BackgroundLung ultrasound is an effective tool for diagnosing pneumonia in developed countries. Diagnostic accuracy in resource-limited countries where pneumonia is the leading cause of death is unknown. The objective of this study was to evaluate the sensitivity of bedside lung ultrasound compared to chest X-ray for pneumonia in adults presenting for emergency care in a low-income country.MethodsPatients presenting to the emergency department with suspected pneumonia were evaluated with bedside lung ultrasound, single posterioranterior chest radiograph, and computed tomography (CT). Using CT as the gold standard, the sensitivity of lung ultrasound was compared to chest X-ray for the diagnosis of pneumonia using McNemar’s test for paired samples. Diagnostic characteristics for each test were calculated.ResultsOf 62 patients included in the study, 44 (71%) were diagnosed with pneumonia by CT. Lung ultrasound demonstrated a sensitivity of 91% compared to chest X-ray which had a sensitivity of 73% (p = 0.01). Specificity of lung ultrasound and chest X-ray were 61 and 50% respectively.ConclusionsBedside lung ultrasound demonstrated better sensitivity than chest X-ray for the diagnosis of pneumonia in Nepal.Trial registrationClinicalTrials.gov, registration number NCT02949141. Registered 31 October 2016.

Objective Ultrasound guided intravenous catheter (USGIV) insertion is increasingly being used for administration of intravenous contrast for computed tomography (CT) scans. The goal of this investigation was to evaluate the risk of contrast extravasation among patients receiving contrast through USGIV catheters. Methods A retrospective observational study of adult patients who underwent a contrast-enhanced CT scan at a tertiary-care emergency department during a recent 64-month period was conducted. The unadjusted prevalence of contrast extravasation was compared between patients with an USGIV and those with a standard peripheral IV inserted without ultrasound. Then, a two-stage sampling design was used to select a subset of the population for a multivariable logistic regression model evaluating USGIVs as a risk factor for extravasation while adjusting for potential confounders. Results In total, 40,143 patients underwent a contrasted CT scan, including 364 (0.9%) who had contrast administered through an USGIV. Unadjusted prevalence of extravasation was 3.6% for contrast administration through USGIVs and 0.3% for standard IVs (relative risk: 13.9, 95% CI: 7.7 to 24.6). After adjustment for potential confounders, CT contrast administered through USGIVs was associated with extravasation (adjusted odds ratio: 8.6; 95% CI: 4.6, 16.2). No patients required surgical management for contrast extravasation; one patient in the standard IV group was admitted for observation due to extravasation. Conclusions Patients who received contrast for a CT scan through an USGIV had a higher risk of extravasation than those who received contrast through a standard peripheral IV. Clinicians should consider this extravasation risk when weighing the risks and benefits of a contrast-enhanced CT scan in a patient with USGIV vascular access.

Background Medical treatment for acute heart failure (AHF) has not changed substantially over the last four decades. Emergency department (ED)-based evidence for treatment is limited. Outcomes remain poor, with a 25% mortality or re-admission rate within 30 days post-discharge. Targeting pulmonary congestion, which can be objectively assessed using lung ultrasound (LUS), may be associated with improved outcomes. Methods BLUSHED-AHF is a multicenter, randomized, pilot trial designed to test whether a strategy of care that utilizes a LUS-driven treatment protocol outperforms usual care for reducing pulmonary congestion in the ED. We will randomize 130 ED patients with AHF across 5 sites to: a) a structured treatment strategy guided by LUS vs. b) a structured treatment strategy guided by usual care. LUS-guided care will continue until there are ≤ 15 B-lines on LUS or 6 hours post enrollment. The primary outcome is the proportion of patients with B-lines ≤ 15 at the conclusion of 6 hours of management. Patients will continue to undergo serial LUS exams during hospitalization, to better understand the time course of pulmonary congestion. Follow up will occur through 90 days, exploring days-alive-and-out-of-hospital between the two arms. The study is registered on ClinicalTrials.gov (NCT03136198). In conclusion, if successful, this pilot study will inform future, larger trial design on LUS driven therapy aimed at guiding treatment and improving outcomes in patients with AHF.

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Incomplete documentation and submission to the electronic health record of performed point-of-care ultrasound (POCUS) studies is problematic from a patient care, medicolegal, and billing standpoint. Positive and negative financial incentives may be used to motivate physicians to complete documentation workflow. The most efficacious route to improve POCUS workflow completion remains to be determined. Materials and methodsA retrospective analysis of POCUS documentation in an academic emergency department during four distinct six-month blocks was performed. POCUS workflow completion was assessed without incentives (Baseline), with financial bonus (Incentive), interim period (Washout), and with a negative financial incentive (Penalty) to determine the effect of these incentives on workflow completion. ResultsThere was an appreciable increase in the rate of POCUS studies documented between the "Baseline" (no incentive) and "Incentive" (small financial bonus) time periods. The improvement remained stable during the "Washout" (interim) period, and then increased further in the "Penalty" (negative financial incentive) period. This improvement was relatively diffuse among the providers studied. A similar patternimprovements in the Incentive and Penalty periods with stability in the Washout -was also observed in the POCUS volume data (number of studies performed). ConclusionsThis study reveals a positive association between the implementation of both financial incentives and financial penalties, which increases in POCUS documentation among attending physicians at an academic emergency department.