Death occurring in emergency departments mainly concerned elderly patients with multiple chronic diseases and was frequently preceded by a decision to withdraw and/or withhold life-support therapies. Training of future ED physicians must be aimed at improving the level of care of dying patients, with particular emphasis on collegial decision-taking and institution of palliative care.
BackgroundPoint-of-Care Ultrasound (PoCUS) is recommended by emergency medicine societies for the detection of hydronephrosis. Training of certified Emergency Physicians (EP) without prior ultrasound experience remains debated. We investigate performance of a brief training session for the detection of hydronephrosis with PoCUS performed by EP without previous ultrasound experience.Patients and methodsThis was a prospective observational study of a convenience sample of patients older than 18 years with presumed renal colic, acute pyelonephritis or documented acute renal failure. Exclusion criteria were pregnancy and documented end of life.After inclusion and informed consent, a PoCUS was performed. A radiologist’s renal ultrasound (RRUS) was then conducted, the radiologist being blind to PoCUS result.The objective was to determine the diagnostic performance of PoCUS performed by EP for the detection of hydronephrosis using RRUS as gold standard.ResultsSix EP participated in this study. 55 patients were included, five secondary excluded for lack of RRUS. Age was 47 ± 22 years, sex ratio 1. Hydronephrosis prevalence was 38% (CI 95% [26–52%]). Sensitivity of PoCUS was 100% (CI 95% [82–100%]) while its specificity was 71% (CI 95% [52–86%]) with a NPV of 100% (CI 95% [85–100%]) and a 68% (CI 95% [48–84%]) PPV. Kappa coefficient was 0.65 (CI 95% [0.45–0.85]).DiscussionWe demonstrated that a short training program enables EP without previous ultrasound skills to rule out hydronephrosis with satisfactory performances. The main limitation was the absence of collection of the number of PoCUS by EP. After this didactic course, an experiential phase must be carried out.
Background and ImportanceEarly identification of the cause of shock is associated with better prognosis.Objective The aim of this study was to explore the performances of an ultrasound protocol (echoSHOCK) to diagnose the cause of shock in the emergency department (ED).
Design, settings and participantsThis was a prospective study performed in two EDs. Included patients were older than 18 years admitted with shock. After routine workup strategy, the suspected cause of shock and the planned treatment were reported. The echoSHOCK protocol, using only B mode, was then performed. After performing echoSHOCK, the investigator reported the same two items.Intervention echoSHOCK protocol that assessed: compressive pericardial effusion (tamponade), right ventricle dilatation and flattening of the septum, left ventricle dimension and systolic function, indices of hypovolemia.
Outcomes measure and analysisWe defined four different causes for shock (tamponade, acute cor pulmonale, cardiogenic and hypovolemia). The primary endpoint was the degree of agreement of the routine workup and echoSHOCK with an expert panel.
Main Results85 patients [mean age of 73 ( 14) years] were included. Kappa coefficients between routine strategy and echoSHOCK for the cause of shock, with the expert panel were 0.33 (95% CI, 0.26-0.4) and 0.88 (95% CI, 0.83-0.93), respectively. Likewise, for the planned treatment, kappa were 0.21 (95% CI, 0.14-0.28) and 0.9 (95% CI, 0.85-0.94), respectively. The physician's confidence increased from 3.9 (2.1) before echoSHOCK to 9.3 (1.1) after, (P < 0.001).
ConclusionThis study suggested that echoSHOCK significantly increased the ability to determine the cause of undifferentiated shock in the ED.
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