Prehospital point-of-care emergency ultrasound: a cohort study

Abstract

BackgroundIn the prehospital situation, the diagnostic armamentarium available to the rescue physician is limited. Emergency ultrasound has proven to be a useful diagnostic tool, providing crucial information for the management of critically ill and injured patients. The proportion of performed ultrasound scans in all patients attended to by the rescue service team, the quality of the findings and the ultrasound-related changes in management approach and patient transport were evaluated.MethodsIn this prospective 18-month observational study, we documented all missions performed by rescue physicians with special training in emergency ultrasound (expert standard). These data were than analysed with regard to the ultrasound examinations. The ultrasound protocols used comprised Focussed Assessment with Sonography for Trauma (FAST), Prehospital Lung Ultrasound (PLUS) and Focused Echocardiography in Emergency Life support (FEEL). The quality of prehospital examinations was assessed by comparing the findings and diagnoses at the emergency site with those established in hospital. The changes in patient management and transport were documented using a standardized protocol.ResultsA total of 99 (18.1%) emergency ultrasound examinations were performed during 546 callouts. The most common indications for prehospital emergency ultrasound were dyspnoea (n = 38; 38.4%), during cardiac arrest (n = 17/17.2%), fall (n = 12/12.1%) and high-speed trauma (n = 11/11.1%). The combinations of ultrasound examination protocols in the trauma group (n = 31; 31.3%) were: 1. FAST+FEEL+PLUS (n = 17; 54.8%). 2. FAST+PLUS (n = 11; 35.5%) 3. FAST alone (n = 3; 9.7%). In the non-trauma group (n = 68; 68.7%), the following combinations were used: 1. FEEL+PLUS (n = 36; 52.9%), 2. FEEL alone (n = 21/30.9%). 3. PLUS alone (n = 6/8.8%) 4. FAST alone (n = 2; 2.9%) 5. FAST+FEEL+PLUS (n = 2; 2.9%). 6. FAST+FEEL (n = 1/1.5%). The emergency ultrasound findings impaired left ventricular contractile function (sensitivity 89.4%), right ventricular stress (85.7%), lung interstitial syndrome (100%), ruling out pneumothorax (specificity 100%), ruling out intraabdominal fluid (97,1%) were verified at the receiving hospital using ultrasonography, CT scan or x-rays; the prehospital diagnosis was confirmed in 90.8% of cases, the difference between the prehospital and in-hospital findings were not significant(p-values from p = 0.688 to p = 0,99). Ultrasound-related changes in patient management occurred in 49.5% of patients; in 33.3%, these were transported-related.ConclusionsEmergency ultrasound was as often used in the prehospital situation as it is in hospital. The ultrasound findings correlated well with in-hospital diagnostic results. Significant pathology changed patient-management, without prolonging the mission time.

An evaluation of the accuracy of prehospital eFAST in the assessment of polytrauma by a physician-staffed helicopter emergency medical service

“…The sensitivities found for IPFF, PTx and HTx were lower than other prehospital studies that used small sample sizes [11][12][13] , but similar to recent prehospital studies using larger sample sizes for pneumothorax 8 and eFAST 9 . This highlights the challenge with deploying and interpreting PH eFAST when it is used as a primary assessment tool because the majority of scans are likely to be negative.…”

Prehospital point-of-care ultrasound: A transformative technology

“… 34 – 36 Echocardiography is another common application of PHUS, as it allows to assess for cardiac standstill during cardiac arrest resuscitation and can help identify pericardial and myocardial disease, such as tamponade, decreased left ventricular ejection fraction, or right ventricular dysfunction. 37 – 39 Ultrasound can be utilized for procedural guidance, for example, peripheral or central vascular access or confirmation of endotracheal tube placement. 40 Rapid assessment protocols that combine different ultrasound exams to rapidly rule in or out life-threatening causes of hypotension or respiratory distress, such as the Rapid Ultrasound in SHock (RUSH) and Bilateral Lung Ultrasound in Emergency (BLUE) protocols and their modifications, are of particular interest for prehospital use.…”

Hemorrhagic Shock

“…The ultrasound protocols used comprised focused assessment with sonography for trauma (FAST), prehospital lung ultrasound (PLUS), and focused echocardiography in emergency life support (FEEL). By combining the standard examination according to the FAST protocol (detection of internal bleeding) with pleural and lung ultrasound (PLUS) and echocardiography (FEEL), important life-threatening conditions, such as pneumothorax and cardiac tamponade, can be ruled out [53].…”