Publications by authors named "Shadi Lahham"

58 Publications

Point of Care Ultrasound in the Diagnosis of Necrotizing Fasciitis.

Am J Emerg Med 2022 Jan 29;51:397-400. Epub 2021 Oct 29.

University of California Irvine, Department of Emergency Medicine, United States.

Background: Necrotizing fasciitis (NF) is a severe, life-threatening soft tissue infection requiring prompt diagnosis and immediate surgical debridement. Imaging, including a computed tomography (CT) scan, can often aid in the diagnosis, though it can prolong time to treatment and diagnosis. Point-of-care ultrasound (POCUS) is often used in the ED to identify soft tissue infections. The objective of this study is to evaluate the use of POCUS to identify NF in patients presenting to the emergency department.

Methods: We prospectively enrolled patients who presented to the emergency department (ED) with suspected soft tissue infection who received a computed tomography and/or surgical consult. POCUS images of the suspected site of infection were obtained by the emergency medicine physician and interpreted based on sonographic findings of NF. These findings were compared with CT scan or surgical impression.

Results: We enrolled 64 patients in this study. Eight were determined to be at high risk of having NF based on CT scan and/or surgical impression. All of these patients also had POCUS images interpreted as concerning for NF. Furthermore, 56 patients were classified as being low risk for having NF based on CT scan and/or surgical impression. All but one of these patients had POCUS images interpreted as not concerning for NF.

Conclusions: Our data indicates that POCUS can be used to identify NF with a high sensitivity and specificity.
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http://dx.doi.org/10.1016/j.ajem.2021.10.033DOI Listing
January 2022

Diagnosis of Bladder Diverticula with Point-of-Care Ultrasound.

Clin Pract Cases Emerg Med 2021 Nov;5(4):466-467

University of California, Irvine, Department of Emergency Medicine, Orange, California.

Case Presentation: A 65-year-old male presented to the emergency department with symptoms including fever, abnormal urinalysis, and elevated post-void residual. Point-of-care ultrasound was used to rapidly diagnose a bladder diverticulum. The patient was subsequently seen by urology for outpatient bladder repair.

Discussion: Bladder diverticula, an out-pouching of the bladder, may occur congenitally or as a result of various bladder conditions and/or surgery. Although bladder diverticula are rare and often asymptomatic, severe complications including frequent recurring urinary tract infections may arise depending on the patient.
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http://dx.doi.org/10.5811/cpcem.2021.7.53199DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8610476PMC
November 2021

A Case Report on Distinguishing Emphysematous Pyelitis and Pyelonephritis on Point-of-care Ultrasound.

Clin Pract Cases Emerg Med 2021 Feb;5(1):35-38

University of California, Irvine, Department of Emergency Medicine, Orange, California.

Introduction: Point-of-care ultrasound (POCUS) in the emergency department (ED) is being performed with increasing frequency. The objective of this study was to demonstrate how utilization of POCUS can help the emergency physician recognize emphysematous pyelitis (EP) and emphysematous pyelonephritis (EPN).

Case Report: A 60-year-old female presented to the ED with normal vital signs and intermittent left-sided flank pain that radiated to her groin. She also had a history of obstructive nephrolithiasis. Within 20 minutes of arrival she became febrile (101.2°Fahrenheit), tachycardic (114 beats per minute), tachypneic (21 breaths per minute), and had a blood pressure of 114/82 millimeters mercury. POCUS was conducted revealing heterogeneous artifact with "dirty shadowing" within the renal pelvis, which was strongly suggestive of air. The emergency physician ordered a computed tomography (CT) to confirm the suspicion for EP and started the patient on broad-spectrum antibiotics. The CT showed a 1.3-centimeter calculus and hydronephrosis with foci of air. The patient received intravenous antibiotics and had an emergent nephrostomy tube placed. Urine cultures tested positive for pan-sensitive Escherichia Coli. Urology was consulted and a repeat CT was obtained to show correct drainage and decreased renal pelvis dilation.

Conclusion: Distinctly different forms of treatment are used for EP and EPN, despite both having similar pathophysiology. In EP, air can be seen in the renal pelvis on POCUS, as in this case study, which distinguishes it from EPN. In the case of our patient, the use of POCUS was useful to aid in rapid differentiation between EP and EPN.
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http://dx.doi.org/10.5811/cpcem.2020.11.49892DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7872620PMC
February 2021

Point-of-care Ultrasound in the Evaluation of Mitral Valve Regurgitation and Mitral Annular Calcification.

Clin Pract Cases Emerg Med 2020 Nov;4(4):628-629

University of California, Irvine, Department of Emergency Medicine, Orange, California.

Case Presentation: A 77-year-old female presented to the emergency department (ED) with chest pain. Cardiac point-of-care ultrasound (POCUS) was performed and demonstrated a hyperechoic structure on the posterior leaflet of the mitral valve. Admission to cardiology and echocardiogram revealed moderately decreased mobility of the posterior leaflet, mitral annular calcification, and severe mitral regurgitation.

Discussion: These findings highlight the role of POCUS in identifying mitral valve pathology in the ED, ultimately leading to appropriate disposition and management. Mitral annular calcification can lead to significant manifestations including mitral stenosis or regurgitation, and advanced cases have been associated with an increased risk of infective endocarditis, thrombosis, and arrhythmia.
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http://dx.doi.org/10.5811/cpcem.2020.7.48117DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7676781PMC
November 2020

A Case Report on Paget-Schroetter Syndrome Presenting as Acute Localized Rhabdomyolysis.

Clin Pract Cases Emerg Med 2020 Aug;4(3):358-361

University of California, Irvine Medical Center, Department of Emergency Medicine, Orange, California.

Introduction: The life- or limb-threatening differential diagnosis for upper extremity swelling can include deep vein thrombosis (DVT), infectious processes, and compartment syndrome. Chronic anatomic abnormalities such as axillary vein stenosis are rarely a consideration in the emergency department.

Case Report: We present a 26-year-old female with history of Chiari type 1 malformation who presented with acute left arm swelling. Initial workup, including point-of-care ultrasound, revealed the presence of significant soft tissue swelling without evidence of DVT.

Conclusion: Further workup revealed an early, localized rhabdomyolysis secondary to axillary vein stenosis or venous thoracic outlet syndrome, also known as Paget-Schroetter syndrome.
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http://dx.doi.org/10.5811/cpcem.2020.6.47335DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7434234PMC
August 2020

Point-of-care Ultrasound Detection of Cataract in a Patient with Vision Loss: A Case Report.

Clin Pract Cases Emerg Med 2020 Aug;4(3):355-357

University of California, Irvine Medical Center, Department of Emergency Medicine, Orange, California.

Background: Point-of-care ocular ultrasound in the emergency department (ED) is an effective tool for promptly evaluating for several vision-threatening etiologies and can be used to identify more slowly progressing etiologies as well, such as cataract formation within the lens.

Case Report: A 62-year-old female presented to the ED with a two-day history of painless vision loss of the left eye as well as reduced vision for the prior 30 days.

Conclusion: Point-of-care ultrasound was performed and showed calcification of the lens consistent with cataract.
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http://dx.doi.org/10.5811/cpcem.2020.4.46597DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7434286PMC
August 2020

Role Of Point Of Care Ultrasound In The Diagnosis Of Retinal Detachment In The Emergency Department.

Open Access Emerg Med 2019 13;11:265-270. Epub 2019 Nov 13.

University of California, Irvine, Department of Emergency Medicine, Orange, CA 92868, USA.

Ocular complaints represent up to 3% of all emergency department (ED) visits. These presentations can result in permanent vision loss if not promptly diagnosed and treated. Recently, point of care ultrasound (POCUS) has been investigated for the evaluation of ocular pathology in the ED. Multiple studies have investigated the role that ultrasound may play in the early diagnosis of these patients. Ocular ultrasound can be used to visualize the structures of the eye and evaluate for pathology such as retinal detachment, vitreous hemorrhage and vitreous detachment. This comprehensive review aims to present current evidence for the efficacy and reliability of ED ocular ultrasound use in the detection of retinal detachment and additional ocular pathologies.
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http://dx.doi.org/10.2147/OAEM.S219333DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6859292PMC
November 2019

Tricuspid Annular Plane of Systolic Excursion (TAPSE) for the Evaluation of Patients with Severe Sepsis and Septic Shock.

West J Emerg Med 2020 Jan 13;21(2):348-352. Epub 2020 Jan 13.

University of California, Irvine; Department of Emergency Medicine, Orange, California.

Introduction: Sepsis is a systemic infection that can rapidly progress into multi organ failure and shock if left untreated. Previous studies have demonstrated the utility of point of care ultrasound (POCUS) in the evaluation of patients with sepsis. However, limited data exists on the evaluation of the tricuspid annular plane of systolic excursion (TAPSE) in patients with sepsis.

Methods: We prospectively enrolled patients who presented to the emergency department (ED) with concern for severe sepsis or septic shock in a pilot study. In patients that screened positive, the treating physician then performed POCUS to measure the TAPSE value. We compared the intensive care unit (ICU) admission rate, hospital length of stay, and morbidity with their respective TAPSE values.

Results: We enrolled 24 patients in the study. Eight patients had TAPSE values less than 16 millimeters (mm), two patients had TAPSE values between 16mm-20mm, and fourteen patients had TAPSE values greater than 20mm. There was no statistically significant association between TAPSE levels and ICU admission (p=0.16), or death (p=0.14). The difference of length of stay (LOS) was not statistically significant in case of hospital LOS (p= 0.72) or ICU LOS.

Conclusion: Our pilot data did not demonstrate a correlation between severe sepsis or septic shock and TAPSE values. This may be due to several factors including patient comorbidities, strict definitions of sepsis and septic shock, as well as the absence of septic cardiomyopathy (SCM) in patients with sepsis and septic shock. Future large-scale studies are needed to determine if TAPSE can be beneficial in the ED evaluation of patients with concern for SCM.
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http://dx.doi.org/10.5811/westjem.2019.11.44968DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7081860PMC
January 2020

Retrospective analysis of eFAST ultrasounds performed on trauma activations at an academic level-1 trauma center.

World J Emerg Med 2020 ;11(1):12-17

Department of Emergency Medicine, University of California, Irvine, Orange, CA 92868, USA.

Background: Point-of-care ultrasound (POCUS) has become increasingly integrated into the practice of emergency medicine. A common application is the extended focused assessment with sonography in trauma (eFAST) exam. The American College of Emergency Physicians has guidelines regarding the scope of ultrasound in the emergency department and the appropriate documentation. The objective of this study was to conduct a review of performed, documented and billed eFAST ultrasounds on trauma activation patients.

Methods: This was a retrospective review of all trauma activation patients during a 10-month period at an academic level-one trauma center. A list comparing all trauma activations was cross-referenced with a list of all billed eFAST scans. Medical records were reviewed to determine whether an eFAST was indicated, performed, and appropriately documented.

Results: We found that 1,507 of 1,597 trauma patients had indications for eFAST, but 396 (27%) of these patients did not have a billed eFAST. Of these 396 patients, 87 (22%) had documentation in the provider note that an eFAST was performed but there was no separate procedure note. The remaining 309 (78%) did not have any documentation of the eFAST in the patient's chart although an eFAST was recorded and reviewed during ultrasound quality assurance.

Conclusion: A significant proportion of trauma patients had eFAST exams performed but were not documented or billed. Lack of documentation was multifactorial. Emergency ultrasound programs require appropriate reimbursement to support training, credentialing, equipment, quality assurance, and device maintenance. Our study demonstrates a significant absence of adequate documentation leading to potential revenue loss for an emergency ultrasound program.
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http://dx.doi.org/10.5847/wjem.j.1920-8642.2020.01.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6885586PMC
January 2020

Evaluation of a point-of-care ultrasound curriculum taught by medical students for physicians, nurses, and midwives in rural Indonesia.

J Clin Ultrasound 2020 Mar 26;48(3):145-151. Epub 2019 Dec 26.

Department of Emergency Medicine, University of California, Irvine, California.

Purpose: In the Indonesian health-care system, nurses and midwives often serve as the primary health-care providers due to physician shortages. Seeking to address the need for medical care in resource-limited environments, some have advocated for portable equipment in the hands of health-care providers. We hypothesized that medical students are able to effectively teach point-of-care ultrasound (POCUS) to physicians, nurses, and midwives in rural Indonesia.

Methods: We conducted a prospective, observational study using health-care practitioners from a clinic and accredited school for nursing and midwifery in Mojokerto, East Java, Indonesia. Enrolled practitioners took part in a 4-week POCUS course followed by postinstructional testing.

Results: A total of 55 health-care practitioners completed the course. This included 19 physicians, 13 nurses, and 19 midwives. Of the 55 clinicians, 43 (72%) passed the course and 12 (28%) failed.

Conclusions: Physicians, nurses, and midwives in rural Indonesia showed significant acquisition of ultrasound (US) knowledge and skills following a 4-week US course. Following training, all three groups displayed skills in practical US use during a postcourse practical examination. This is one of the first studies to assess the efficacy of medical students teaching POCUS to midwives and nurses.
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http://dx.doi.org/10.1002/jcu.22809DOI Listing
March 2020

The association of smoking with ultrasound-measured kidney dimensions
.

Clin Nephrol 2020 Jan;93(1):9-16

Purpose: Ultrasound is considered a preferred first-line imaging technique for the assessment of kidney function. The potential relationship between tobacco smoke exposure and ultrasound-measured renal characteristics has yet to be explored. We hypothesized that exposure to tobacco smoke would be associated with reduced kidney dimensions.

Materials And Methods: This was a cross-sectional study that included all individuals over age 18 at a single site in Mojokerto, Indonesia. A questionnaire was used to assess prior history and environmental exposure, and blinded evaluators performed ultrasound assessments. Six kidney parameters (length, width, and parenchymal thickness of each kidney) were considered as dependent variables, and statistical relationships were assessed using multivariate analysis. Echogenicity was evaluated using a 5-point grading scale described previously.

Results: Of the 445 participants assessed, a total of 138 male and 269 female subjects were included in the final analysis. There was a statistically significant association between kidney measures and the following independent variables: pack years smoking (p < 0.001), height (p < 0.001), weight (p < 0.001), and beginning to smoke at the age of 25 or younger (p < 0.001). There was not a statistically significant association between kidney measures and hypertension (p > 0.05) or diabetes (p > 0.05). Echogenicity was similar among all smoking groups.

Conclusion: Kidney dimensions were decreased in individuals with increased smoking history. This association is notable, particularly given that statistically significant associations were not observed between renal dimensions and hypertension or diabetes. The null findings using echogenicity are consistent with previous studies.
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http://dx.doi.org/10.5414/CN109854DOI Listing
January 2020

Evaluation of a Standardized Cardiac Athletic Screening for National Collegiate Athletic Association (NCAA) Athletes.

West J Emerg Med 2019 Aug 14;20(5):810-817. Epub 2019 Aug 14.

University of California, Irvine Medical Center, Department of Emergency Medicine, Orange, California.

Introduction: Sudden cardiac death is a rare cause of death in young athletes. Current screening techniques include history and physical exam (H and P), with or without an electrocardiogram (ECG). Adding point of care cardiac ultrasound has demonstrated benefits, but there is limited data about implementing this technology. We evaluated the feasibility of adding ultrasound to preparticipation screening for collegiate athletes.

Methods: We prospectively enrolled 42 collegiate athletes randomly selected from several sports. All athletes were screened using a 14-point H and P based on 2014 American College of Cardiology (ACC) and American Heart Association (AHA) guidelines, ECG, and cardiac ultrasound.

Results: We screened 11 female and 31 male athletes. On ultrasound, male athletes demonstrated significantly larger interventricular septal wall thickness (p = 0.002), posterior wall thickness (p <0.001) and aortic root breadth (p = 0.002) compared to females. Based on H and P and ECGs alone and a combination of H and P with ECG, no athletes demonstrated a positive screening for cardiac abnormalities. However, with combined H and P, ECG, and cardiac ultrasound, one athlete demonstrated positive findings.

Conclusions: We believe that adding point of care ultrasound to the preparticipation exam of college athletes is feasible. This workflow may provide a model for athletic departments' screening.
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http://dx.doi.org/10.5811/westjem.2019.7.43190DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6754195PMC
August 2019

A Prospective Evaluation of Point of Care Ultrasound Teaching in Switzerland.

J Med Ultrasound 2019 Apr-Jun;27(2):92-96. Epub 2019 Feb 26.

Department of Emergency Medicine, University of California Irvine, Irvine, California, USA.

Context: As the utility of point-of-care ultrasound (POCUS) continues to expand in the medical field, there is a need for effective educational methods. In Switzerland, medical education follows the European model and lasts 6 years, focusing on preclinical training during the first 2 years. No previous studies have evaluated the optimal time for teaching ultrasound in European medical education.

Aims: The aim of this study is to provide ultrasound training to medical students in Switzerland at varying times during their clinical training to determine if the level of training plays a role in their ability to comprehend and to apply basic POCUS skills.

Methods: We performed an observational study utilizing a convenience sample of Swiss medical students between July 11, 2016 and August 6, 2016. They were taught a 2-day POCUS course by five American-trained 1-year medical students. Following this course, students were evaluated with written and clinical examination.

Results: 100 Swiss medical students were enrolled in the study. A total of 59 of these students were early clinical students, and 41 students were late clinical students. A two-tailed -test was performed and demonstrated that the late clinical students performed better than the early clinical students on the written assessment; however, no difference was found in clinical skill.

Conclusion: Our data suggest that Swiss medical students can learn and perform POCUS after a 2-day instructional taught by trained 1-year American medical students. No difference was found between students in early clinical training and late clinical training for the ability to perform POCUS.
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http://dx.doi.org/10.4103/JMU.JMU_57_18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6607874PMC
February 2019

A comparison of simulation versus didactics for teaching ultrasound to Swiss medical students.

World J Emerg Med 2019 ;10(3):169-176

Department of Emergency Medicine, University of California Irvine, Irvine, USA.

Background: Point-of-care ultrasound is an increasingly common imaging modality that is used in a variety of clinical settings. Understanding how to most effectively teach ultrasound is important to ensure that medical students learn pre-clinical content in a manner that promotes retention and clinical competence. We aim to assess the effectiveness of simulation-based ultrasound education in improving medical student competence in physiology in comparison to a traditional didactic ultrasound curriculum.

Methods: Subjects were given a pre and post-test of physiology questions. Subjects were taught various ultrasound techniques via 7 hours of lectures over two days. The control group received 2 additional hours of practice time while the experimental group received 2 hours of case-based simulations. A physiology post-test was administered to all students to complete the two-day course.

Results: Totally 115 Swiss medical students were enrolled in our study. The mean pre-course ultrasound exam score was 39.5% for the simulation group and 41.6% for the didactic group (>0.05). The mean pre-course physiology exam score was 54.1% for the simulation group and 59.3% for the didactic group (>0.05). The simulation group showed statistically significant improvement on the physiology exam, improving from 54.1% to 75.3% (<0.01). The didactic group also showed statistically significant improvement on the physiology exam, improving from 59.3% to 70.0% (<0.01).

Conclusion: Our data indicates that both simulation curriculum and standard didactic curriculum can be used to teach ultrasound. Simulation based training showed statistically significant improvement in physiology learning when compared to standard didactic curriculum.
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http://dx.doi.org/10.5847/wjem.j.1920-8642.2019.03.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6545372PMC
January 2019

Point-of-care Ultrasound Diagnosis of Cholecystitis vs. Adenomyomatosis.

Clin Pract Cases Emerg Med 2019 May 27;3(2):158-159. Epub 2019 Mar 27.

University of California-Irvine, Department of Emergency Medicine, Orange, California.

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http://dx.doi.org/10.5811/cpcem.2019.2.40798DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6497195PMC
May 2019

Aortic Dissection with Subsequent Hemorrhagic Tamponade Diagnosed with Point-of-care Ultrasound in a Patient Presenting with STEMI.

Clin Pract Cases Emerg Med 2019 May 26;3(2):103-106. Epub 2019 Feb 26.

University of California, Irvine, Department of Emergency Medicine, Orange, California.

A 58-year-old male with no past medical history presented to the emergency department with sudden onset left lower extremity weakness and central chest pain with radiation to his back. Electrocardiogram revealed an acute inferior and posterior ST-segment elevation myocardial infarction (STEMI). Point-of-care ultrasound (POCUS) demonstrated right ventricular akinesis consistent with infarction, and an intimal defect consistent with an aortic dissection. We determined that cardiothoracic surgery was indicated rather than left-heart catheterization and anticoagulation. Using POCUS we were able to immediately diagnose a dissection of the aortic arch and considerably alter treatment in a patient presenting with STEMI.
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http://dx.doi.org/10.5811/cpcem.2019.1.40869DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6497200PMC
May 2019

Point-of-Care Ultrasonography in the Diagnosis of Retinal Detachment, Vitreous Hemorrhage, and Vitreous Detachment in the Emergency Department.

JAMA Netw Open 2019 04 5;2(4):e192162. Epub 2019 Apr 5.

Department of Emergency Medicine, University of California, Irvine.

Importance: Ocular symptoms represent approximately 2% to 3% of all emergency department (ED) visits. These disease processes may progress to permanent vision loss if not diagnosed and treated quickly. Use of ocular point-of-care ultrasonography (POCUS) may be effective for early and accurate detection of ocular disease.

Objective: To perform a large-scale, multicenter study to determine the utility of POCUS for diagnosing retinal detachment, vitreous hemorrhage, and vitreous detachment in the ED.

Design, Setting, And Participants: A prospective diagnostic study was conducted at 2 academic EDs and 2 county hospital EDs from February 3, 2016, to April 30, 2018. Patients who were eligible for inclusion were older than 18 years; were English- or Spanish-speaking; presented to the ED with ocular symptoms with concern for retinal detachment, vitreous hemorrhage, or vitreous detachment; and underwent an ophthalmologic consultation that included POCUS. Patients with ocular trauma or suspicion for globe rupture were excluded. The accuracy of the ultrasonographic diagnosis was compared with the criterion standard of the final diagnosis of an ophthalmologist who was masked to the POCUS findings. Seventy-five unique emergency medicine attending physicians, resident physicians, and physician assistants performed ocular ultrasonography.

Exposure: Point-of-care ultrasonography performed by an emergency medicine attending physician, resident physician, or physician assistant.

Main Outcomes And Measures: Sensitivity and specificity of POCUS in identifying retinal detachment, vitreous hemorrhage, and vitreous detachment in patients presenting to the ED with ocular symptoms.

Results: Two hundred twenty-five patients were enrolled. Of these, the mean age was 51 years (range, 18-91 years) and 135 (60.0%) were men; ophthalmologists diagnosed 47 (20.8%) with retinal detachment, 54 (24.0%) with vitreous hemorrhage, and 34 (15.1%) with vitreous detachment. Point-of-care ultrasonography had an overall sensitivity of 96.9% (95% CI, 80.6%-99.6%) and specificity of 88.1% (95% CI, 81.8%-92.4%) for diagnosis of retinal detachment. For diagnosis of vitreous hemorrhage, the sensitivity of POCUS was 81.9% (95% CI, 63.0%-92.4%) and specificity was 82.3% (95% CI, 75.4%-87.5%). For vitreous detachment, the sensitivity was 42.5% (95% CI, 24.7%-62.4%) and specificity was 96.0% (95% CI, 91.2%-98.2%).

Conclusions And Relevance: These findings suggest that emergency medicine practitioners can use POCUS to accurately identify retinal detachment, vitreous hemorrhage, and vitreous detachment. Point-of-care ultrasonography is not intended to replace the role of the ophthalmologist for definitive diagnosis of these conditions, but it may serve as an adjunct to help emergency medicine practitioners improve care for patients with ocular symptoms.
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http://dx.doi.org/10.1001/jamanetworkopen.2019.2162DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6481597PMC
April 2019

Detection of Inferior Vena Cava Thrombosis Extending into the Right Atrium Using Point-of-care Ultrasound.

Clin Pract Cases Emerg Med 2019 Feb 23;3(1):67-68. Epub 2019 Jan 23.

University of California, Irvine, Department of Emergency Medicine, Irvine, California.

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http://dx.doi.org/10.5811/cpcem.2019.1.41041DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6366377PMC
February 2019

Left Ventricular Thrombus in a 34-year-old Female Seen on Point-of-care Ultrasound.

Clin Pract Cases Emerg Med 2019 Feb 22;3(1):65-66. Epub 2019 Jan 22.

University of California, Irvine, Department of Emergency Medicine, Orange, California.

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http://dx.doi.org/10.5811/cpcem.2019.1.40801DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6366381PMC
February 2019

Point-of-care Ultrasound Diagnosis of Pulmonary Embolism with Thrombus in Transit.

Clin Pract Cases Emerg Med 2019 Feb 4;3(1):11-12. Epub 2019 Jan 4.

University of California, Irvine, Department of Emergency Medicine, Orange, California.

A 95-year-old female with a history of dementia and atrial fibrillation (not on anticoagulation) presented to the emergency department (ED) by ambulance from her skilled nursing facility due to hypoxia. Point-of-care ultrasound was performed, and showed evidence of a large mobile thrombus in the right ventricle on apical four-chamber view. Further evidence of associated right heart strain was seen on the corresponding parasternal short-axis view. These ultrasound findings in combination with the patient's clinical presentation are diagnostic of acute pulmonary embolism with right heart strain. Point-of-care transthoracic cardiac ultrasound in the ED is an effective tool to promptly diagnose acute pulmonary embolism with right heart strain and thrombus in transit and guide further treatment.
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http://dx.doi.org/10.5811/cpcem.2018.11.40377DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6366382PMC
February 2019

A Prospective, Multicenter Evaluation of Point-of-care Ultrasound for Small-bowel Obstruction in the Emergency Department.

Acad Emerg Med 2019 08 12;26(8):921-930. Epub 2019 Mar 12.

Department of Emergency Medicine, Wellspan York Hospital, York, PA.

Objective: The main objective of this study was to evaluate the accuracy of emergency physician-performed point-of-care ultrasound (POCUS) for the diagnosis of small-bowel obstruction (SBO) compared to computed tomography (CT).

Methods: We performed a prospective, multicenter, observational study examining a convenience sample of adult patients with potential SBO presenting to the emergency department (ED) between July 2014 and May 2017. Each POCUS was interpreted at the bedside by the performing emergency physician and retrospectively by an expert reviewer. Test characteristics were calculated for POCUS, blinded expert interpretation, and specific POCUS parameters.

Results: A total of 217 subjects were included in the primary analysis with an overall SBO prevalence of 42.9%. For the diagnosis of SBO, POCUS demonstrated an overall sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of 0.88 (95% confidence interval [CI] = 0.80 to 0.94), 0.54 (95% CI = 0.45 to 0.63), 1.92 (95% CI = 1.56 to 2.35), and 0.22 (95% CI = 0.12 to 0.39), respectively. Expert review yielded a similar sensitivity (0.89 [95% CI = 0.81 to 0.95]) with a significantly higher specificity (0.82 [95% CI = 0.74 to 0.88]). The more sensitive sonographic parameters for both POC sonographers and expert reviewers were small-bowel dilation ≥ 25 mm (0.87 [95% CI = 0.79 to 0.93], 0.87 [95% CI = 0.79 to 0.93]) and abnormal peristalsis (0.82 [95% CI = 0.72 to 0.89], 0.85 [95% CI = 0.76 to 0.87]). The more specific parameters for both groups were transition point (0.82 [95% CI = 0.74 to 0.89], 0.98 [95% CI = 0.94 to 1.00]), intraperitoneal free fluid (0.82 [95% CI = 0.74 to 0.89], 0.93 [95% CI = 0.87 to 0.97]), and bowel wall edema (0.76 [95% CI = 0.67 to 0.83], 0.93 [95% CI = 0.87 to 0.97]).

Conclusion: POCUS is moderately sensitive for SBO, although less specific, when performed by a diverse group of emergency physicians across multiple EDs. Interpretation of acquired POCUS images is significantly more accurate when performed by physicians with prior emergency ultrasound fellowship training and familiarity with the sonographic appearance of SBO.
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http://dx.doi.org/10.1111/acem.13713DOI Listing
August 2019

Can an 8 grade student learn point of care ultrasound?

World J Emerg Med 2019 ;10(2):109-113

Department of Emergency Medicine, UC Irvine Medical Center, UC Irvine School of Medicine, Irvine, Orange, California 92868, USA.

Background: Point-of-care ultrasound has gained widespread use in developing countries due to decreased cost and improved telemedicine capabilities. Ultrasound training, specifically image acquisition skills, is occurring with more frequency in non-medical personnel with varying educational levels in these underdeveloped areas. This study evaluates if students without a high school education can be trained to acquire useful FAST images, and to determine if an 8 grade student can teach peers these skills.

Methods: The 8 grade students at a small middle school were divided into two groups. One group received training by a certified medical sonographer, while the other group received training by a peer 8 grade student trainer who had previously received training by the sonographer. After training, each student was independently tested by scanning the four FAST locations. A blinded ultrasound expert evaluated these images and deemed each image adequate or inadequate for clinical use.

Results: Eighty video image clips were obtained. The overall image adequacy rate was 74%. The splenorenal window had the highest rate at 95%, followed by retrovesical at 90%, hepatorenal at 75%, and subxiphoid cardiac at 35%. The adequacy rate of the sonographer-trained group was 78%, while the adequacy rate of the student-trained group was 70%. The difference in image adequacy rate between the two groups was not significant (P-value 0.459).

Conclusion: The majority of 8 graders obtained clinically adequate FAST images after minimal training. Additionally, the student-trained group performed as well as the sonographer-trained group.
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http://dx.doi.org/10.5847/wjem.j.1920-8642.2019.02.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6340824PMC
January 2019

Assessment of clinical dehydration using point of care ultrasound for pediatric patients in rural Panama.

World J Emerg Med 2019 ;10(1):46-50

Department of Emergency Medicine, University of California Irvine, Orange, CA 92868, USA.

Background: Dehydration and its associated symptoms are among the most common chief complaints of children in rural Panama. Previous studies have shown that intravascular volume correlates to the ratio of the diameters of the inferior vena cava (IVC) to the aorta (Ao). Our study aims to determine if medical students can detect pediatric dehydration using ultrasound on patients in rural Panama.

Methods: This was a prospective, observational study conducted in the Bocas del Toro region of rural Panama. Children between the ages of 1 to 15 years presenting with diarrhea, vomiting, or parasitic infection were enrolled in the study. Ultrasound measurements of the diameters of the IVC and abdominal aorta were taken to assess for dehydration.

Results: A total of 59 patients were enrolled in this study. Twenty-four patients were clinically diagnosed with dehydration and 35 were classified to have normal hydration status. Of the 24 patients with dehydration, half (=12) of these patients had an IVC/Ao ratio below the American threshold of 0.8. Of the remaining asymptomatic subjects, about half (=18) of these subjects also had an IVC/Ao ratio below the American threshold of 0.8.

Conclusion: Our study did not support previous literature showing that the IVC/Ao ratio is lower in children with dehydration. It is possible that the American standard for evaluating clinical dehydration is not compatible with the rural pediatric populations of Panama.
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http://dx.doi.org/10.5847/wjem.j.1920-8642.2019.01.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6264979PMC
January 2019

Threatened Respiratory Compromise in the Setting of Isolated Angioedema.

Clin Pract Cases Emerg Med 2018 Nov 28;2(4):291-293. Epub 2018 Sep 28.

University of California, Irvine, Department of Emergency Medicine, Orange, California.

Isolated angioedema of the uvula, or Quincke's disease, is a rare condition that can cause respiratory compromise. Although typically self-limiting, episodes of angioedema may require prompt therapy to prevent obstruction of the proximal airway. In this case report we review the appropriate steps for initial evaluation of patients with suspected angioedema, primary etiologies, and appropriate initial therapy.
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http://dx.doi.org/10.5811/cpcem.2018.9.39548DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6230343PMC
November 2018

Tricuspid annular plane of systolic excursion to prognosticate acute pulmonary symptomatic embolism (TAPSEPAPSE study).

J Ultrasound Med 2019 Mar 4;38(3):695-702. Epub 2018 Sep 4.

Department of Emergency Medicine, University of California, Irvine, Orange, California, USA.

Introduction: The imaging standard for evaluation of acute pulmonary embolism (PE) includes a computed tomography pulmonary angiogram. Ultrasonography has shown promise in obtaining the tricuspid annular plane systolic excursion (TAPSE) measurements, which may be of clinical importance in patients with acute PE. The objective of this study is to evaluate the diagnostic capability of TAPSE measurements for patients with suspicion for acute PE.

Methods: We prospectively enrolled patients who came to the emergency department with suspicion of acute PE. Each patient underwent a point-of-care sonogram where a TAPSE measurement was obtained, followed by computed tomography pulmonary angiogram. Based on the computed tomography pulmonary angiogram findings, patients were grouped into 3 categories: no acute PE, clinically insignificant acute PE, or clinically significant acute PE.

Results: We enrolled 87 patients in this study. Twenty-three (26.4%) of these patients were diagnosed with PE. Of patients with PE, 15 (65%) were found to have a clinically significant acute PE. Analysis of mean TAPSE measurements between patients with clinically significant acute PE and those with insignificant or no PE was 15.2 mm and 22.7 mm, respectively (P ≤ .0001). Following receiver operating characteristic curve analysis, optimum TAPSE measurement to identify clinically significant acute PE is 18.2 mm. A cutoff TAPSE measurement of 15.2 mm shows a sensitivity of 53.3% (95% confidence interval, 26.7%-80%) and a specificity of 100% (95% confidence interval, 100%-100%) for the diagnosis of a clinically significant PE.

Conclusions: Our data suggest that TAPSE measurements less than 15.2 mm have a high specificity for identifying clinically significant acute PE.
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http://dx.doi.org/10.1002/jum.14753DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6628892PMC
March 2019

Adult Male with Leg Swelling after a Fall Two Weeks Prior.

Clin Pract Cases Emerg Med 2018 Feb 18;2(1):86-88. Epub 2018 Jan 18.

University of California, Irvine, Department of Emergency Medicine, Irvine, California.

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http://dx.doi.org/10.5811/cpcem.2017.11.36544DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5965150PMC
February 2018

Management of Complex Facial Lacerations in the Emergency Department.

Clin Pract Cases Emerg Med 2017 Aug 9;1(3):162-165. Epub 2017 May 9.

University of California, Irvine, Department of Emergency Medicine, Orange, California.

Laceration injuries comprise over 8% of all emergency department (ED) visits annually.1 Given that laceration injuries represent a significant volume of ED visits, emergency physicians (EP) should be comfortable treating these types of injuries. We present the case of a 34-year-old male who presented to the ED as a trauma activation who suffered multiple injuries including complex full-thickness lacerations to his face. While there are scenarios in which consulting a specialist is necessary, knowledge and application of basic wound closure principles allows for many complex lacerations to be repaired by EPs. We provide a helpful systematic approach to evaluating and treating complex facial lacerations in the ED.
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http://dx.doi.org/10.5811/cpcem.2017.2.33270DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5965160PMC
August 2017

Feasibility study of minimally trained medical students using the Rural Obstetrical Ultrasound Triage Exam (ROUTE) in rural Panama.

World J Emerg Med 2018 ;9(3):216-222

Department of Emergency Medicine, University of California Irvine, Orange, CA 92868, USA.

Background: Maternal and infant mortality rates reported in rural Panama are greater than those in urban regions. Bocas del Toro is a region of Panama inhabited by indigenous people at greater risk for pregnancy-related complications and deaths due to geographic isolation and limited access to health care. Portable ultrasound training programs have recently been implemented in low-resource settings to increase access to diagnostic imaging. The goal of this study is to determine the feasibility of teaching first-year medical students the Rural Obstetrical Ultrasound Triage Exam (ROUTE) to help identify pathology in pregnant women of the Bocas del Toro region of Panama.

Methods: Eight first-year medical students completed ROUTE training sessions. After training, the students were compared to professional sonographers to evaluate their accuracy in performing the ROUTE. Students then performed the ROUTE in mobile clinics within Bocas del Toro. They enrolled women pregnant in their 2nd or 3rd trimesters and measured biparietal diameter, head circumference, amniotic fluid index, fetal lie and placental position. Any abnormal measurement would be further analyzed by the lead physician for a potential hospital referral.

Results: A total of 60 women were enrolled in the study. Four women were detected as having a possible high-risk pregnancy and thus referred to a hospital for further evaluation.

Conclusion: Based on our data, first-year medical students with additional training can use the ROUTE to identify complications in pregnancy using ultrasound in rural Panama. Additional studies are required to determine the optimal amount of training required for proficiency.
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http://dx.doi.org/10.5847/wjem.j.1920-8642.2018.03.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5962457PMC
January 2018

Ultrasound curriculum taught by first-year medical students: A four-year experience in Tanzania.

World J Emerg Med 2018 ;9(1):33-40

Department of Emergency Medicine, University of California Irvine, Orange, California 92868, USA.

Background: Diagnostic imaging is an integral aspect of care that is often insufficient, if not altogether absent, in rural and remote regions of low to middle income countries (LMICs) such as Tanzania. The introduction of ultrasound can significantly impact treatment in these countries due to its portability, low cost, safety, and usefulness in various medical assessments. This study reviews the implementation of a four-week ultrasound course administered annually from 2013-2016 in a healthcare professional school in Mwanza, Tanzania by first-year allopathic US medical students.

Methods: Participants (=582, over 4 years) were recruited from the Tandabui Institute of Health Sciences and Technology to take the ultrasound course. Subjects were predominantly clinical officer students, but other participants included other healthcare professional students, practicing healthcare professionals, and school employees. Data collected includes pre-course examination scores, post-course examination scores, course quiz scores, demographic surveys, and post-course feedback surveys. Data was analyzed using two-tailed -tests and the single factor analysis of variance (ANOVA).

Results: For all participants who completed both the pre- and post-course examinations (=229, 39.1% of the total recruited), there was a significant mean improvement in their ultrasound knowledge of 42.5%, <0.01.

Conclusion: Our data suggests that trained first-year medical students can effectively teach a point of care ultrasound course to healthcare professional students within four weeks in Tanzania. Future investigation into the level of long-term knowledge retention, impact of ultrasound training on knowledge of human anatomy and diagnostic capabilities, and how expansion of an ultrasound curriculum has impacted access to care in rural Tanzania is warranted.
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http://dx.doi.org/10.5847/wjem.j.1920-8642.2018.01.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5717373PMC
January 2018

Utility of common bile duct measurement in ED point of care ultrasound: A prospective study.

Am J Emerg Med 2018 Jun 20;36(6):962-966. Epub 2017 Nov 20.

University of California, Irvine, Department of Emergency Medicine, 333 The City Boulevard West Suite 640, Orange 92868, CA, USA.

Background: Measurement of the common bile duct (CBD) is considered a fundamental component of biliary point-of-care ultrasound (POCUS), but can be technically challenging.

Objective: The primary objective of this study was to determine whether CBD diameter contributes to the diagnosis of complicated biliary pathology in emergency department (ED) patients with normal laboratory values and no abnormal biliary POCUS findings aside from cholelithiasis.

Methods: We performed a prospective, observational study of adult ED patients undergoing POCUS of the right upper quadrant (RUQ) and serum laboratory studies for suspected biliary pathology. The primary outcome was complicated biliary pathology occurring in the setting of normal laboratory values and a POCUS demonstrating the absence of gallbladder wall thickening (GWT), pericholecystic fluid (PCF) and sonographic Murphy's sign (SMS). The association between CBD dilation and complicated biliary pathology was assessed using logistic regression to control for other factors, including laboratory findings, cholelithiasis and other sonographic abnormalities.

Results: A total of 158 patients were included in the study. 76 (48.1%) received non-biliary diagnoses and 82 (51.9%) were diagnosed with biliary pathology. Complicated biliary pathology was diagnosed in 39 patients. Sensitivity of CBD dilation for complicated biliary pathology was 23.7% and specificity was 77.9%.

Conclusion: Of patients diagnosed with biliary pathology, none had isolated CBD dilatation. In the absence of abnormal laboratory values and GWT, PCF or SMS on POCUS, obtaining a CBD measurement is unlikely to contribute to the evaluation of this patient population.
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http://dx.doi.org/10.1016/j.ajem.2017.10.064DOI Listing
June 2018
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