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Hamid Shokoohi

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National University of "Kyiv-Mohyla Academy"

University College Cork

Armando Marques-Guedes

UNL - New University of Lisbon

Ucla

Università di Bologna

Iolanda Craifaleanu

Technical University Of Civil Engineering, Bucharest

Fabián Hoyos Patiño

Universidad Nacional de Colombia (National University of Colombia)

Universitat Oberta de Catalunya

Robert Kozinets

University of Southern California

ESSEC Business School

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Papers by Hamid Shokoohi

A cruise ship emergency medical evacuation triggered by handheld ultrasound findings and directed by tele-ultrasound

International Maritime Health, 2020

Cruise ships travel far from shoreside medical care and present a unique austere medical environm... more Cruise ships travel far from shoreside medical care and present a unique austere medical environment. For the cruise ship physician, decisions regarding emergency medical evacuation can be challenging. In the event that a passenger or crew member becomes seriously ill or is injured, the use of point-of-care ultrasound may assist in clarifying the diagnosis and stratifying the risk of a delayed care, and at times expedite an emergent medical evacuation. In this report we present the first case reported in the literature of an emergency medical evacuation from a cruise ship triggered by handheld ultrasound. A point-of-care ultrasound performed by a trained cruise ship physician, reviewed by a remote telemedical consultant with experience in point-of-care ultrasound, identified an ectopic pregnancy with intraabdominal free fluid in a young female patient with abdominal pain and expedited emergent helicopter evacuation from a cruise ship to a shoreside facility, where she immediately underwent successful surgery. The case highlights a medical evacuation that was accurately triggered by utilising a handheld ultrasound and successfully directed via a tele-ultrasound consultation. American College of Emergency Physicians (ACEP) health care guidelines for cruise ship medical facilities should be updated to include guidelines for point-of-care ultrasound, including training and telemedical support.

Delayed Diagnosis of Shoulder Septic Arthritis and Osteomyelitis During the COVID-19 Pandemic: The Role of Point-of-Care Ultrasound

Cureus, Feb 25, 2023

The diagnosis and treatment of septic arthritis are complex and require collaboration among multi... more The diagnosis and treatment of septic arthritis are complex and require collaboration among multiple medical services, especially in the emergency department (ED). This case report highlights the difficulties in diagnosing shoulder septic arthritis, which is a rare condition in adults and can present with subtle symptoms. The patient was eventually diagnosed with septic arthritis of the left shoulder. However, the diagnosis was delayed due to the impact of the COVID-19 pandemic on obtaining an outpatient MRI and a previous shoulder injury that added confusion. Delays in diagnosis and treatment can lead to a rapid destruction of the affected joint, causing significant morbidity and mortality. This case report also highlights the importance of alternative diagnostic tools, such as point-of-care ultrasound (POCUS), which is quick, inexpensive, and may lead to earlier detection of joint effusions and prompt arthrocentesis.

P147: International scope of emergency ultrasound: barriers to utilizing ultrasound to guide central venous catheter placement by providers in Kenya

CJEM, 2016

Introduction: While ultrasound (U/S) use for internal jugular central venous catheter (CVC) place... more Introduction: While ultrasound (U/S) use for internal jugular central venous catheter (CVC) placement is standard of care in many institutions in North America, most developing countries have not adopted this practice. Previous surveys of American physicians who are not currently using U/S to place CVCs have identified lack of training and equipment availability as the most important barriers to the use of U/S. We sought to identify Kenyan physicians’ perceived barriers to the use of U/S to guide CVC insertion in a resource-constrained environment. Methods: The study was conducted at the Aga Khan University Hospital in Nairobi, Kenya. Physicians participating in a one-hour course teaching U/S guided CVC placement were asked to complete a survey before beginning training, which was used to assess previous experience with U/S, and evaluate perceived barriers to U/S. Survey responses were analyzed using summary statistics and the Rank-Sum test to compare the difference between particip...

Optimizing Lung Ultrasound: The Effect of Depth, Gain and Focal Position on Sonographic B-Lines

Ultrasound in Medicine & Biology

Point-of-Care Ultrasonography: Clearly More Than a Pretty Picture

JAMA Internal Medicine, 2022

Sonographic Assessment of the Effects of Mechanical Ventilation on Carotid Flow Time and Volume

Cureus, 2021

Background Corrected carotid flow time (CFTc) and carotid blood flow (CBF) are sonographic measur... more Background Corrected carotid flow time (CFTc) and carotid blood flow (CBF) are sonographic measurements used to assess fluid responsiveness in hypotension. We investigated the impacts of mechanical ventilation on CFTc and CBF. Materials and methods Normotensive patients undergoing cardiac surgery were prospectively enrolled. Carotid ultrasound (US) was performed pre and post-intubation. Post-intubation measurements took place after the initiation of mechanical ventilation. To measure CFTc and CBF, a sagittal carotid view was obtained with pulse wave-Doppler (maximum angle 60°). CFTc was calculated with the Bazett formula (CFTc = systolic time/√cycle time). CBF was calculated using CBF (mL/min) = area (cm 2 ) x time average mean velocity (TAMEAN) (cm/sec) x 60 (sec/min). The maximum carotid diameter was measured at the level of the thyroid. Results Twenty patients were enrolled. Mean CFTc pre-intubation was 328 ms (SD 43.9 ms) compared to CFTc post-intubation 336 ms (SD 36 ms). There...

Racial and sex disparities in difficult intravenous access

The American Journal of Emergency Medicine, 2021

Ultrasound and Influenza: The Spectrum of Lung and Cardiac Ultrasound Findings in Patients with Suspected Influenza A and B

Ultrasound in Medicine & Biology, 2021

In patients with influenza, cardiac and lung ultrasound may help determine the severity of illnes... more In patients with influenza, cardiac and lung ultrasound may help determine the severity of illness and predict clinical outcomes. To determine the ultrasound characteristics of influenza and define the spectrum of lung and cardiac findings in patients with suspected influenza A or B, we conducted a prospective observational study in patients presenting to the emergency department at a tertiary care academic institution. An ultrasound protocol consisting of cardiac, lung and inferior vena cava scans was performed within 6 h of admission. We compared the ultrasound findings in cases with positive and negative influenza polymerase chain reaction, while controlling for comorbidities. We enrolled 117 patients, 41.9% of whom (49/117) tested positive for influenza. In those with influenza, ultrasound confirmed preserved left ventricular and right ventricular (RV) function in 81.3% of patients. The most common cardiac pathology was RV dilation (10.4%), followed by left ventricular systolic dysfunction (8.3%). Patients with negative influenza polymerase chain reaction with RV dysfunction demonstrated higher hospital admission than those those with normal RV function (45.1%, 23/51, vs. 17.9%, 5/28; p = 0.016). B-lines were prevalent in both influenza and non-influenza groups (40.8% and 69.1%, respectively; p = 0.013). Lung consolidation was identified in only 8.25% of patients with influenza. In conclusion, in patients with influenza we were unable to define distinct ultrasound features specific to influenza A or B, suggesting that ultrasound may not be beneficial in diagnosing influenza nor in evaluating its severity.

Left Ventricular Dysfunction Correlates With Mortality in Pulmonary Embolism

The Journal of Emergency Medicine, 2021

Background: Risk stratification of patients with pulmonary embolism (PE) is essential to guide ad... more Background: Risk stratification of patients with pulmonary embolism (PE) is essential to guide advanced interventional management and proper disposition. Objectives: In this study, we sought to assess individual echocardiographic markers of right ventricular (RV) strain and left ventricular (LV) function in patients with high-risk PE and identify their association with the need for advanced intervention (such as thrombolysis) and 30-day mortality. Methods: This was a retrospective study of ED patients with PE who were subject to a pulmonary embolism response team activation over a 5-year period. Cardiac point-of-care ultrasound studies were performed as part of patient care and later assessed for septal bowing, RV hypokinesis, McConnell sign, RV enlargement, tricuspid annular place systolic excursion, and LV systolic dysfunction. Outcome variables included need for advanced intervention and 30day mortality. Results: The pulmonary embolism response team was activated in 893 patients, of which 718 had a confirmed PE. Of these, 90 had adequate cardiac point-ofcare ultrasound images available for review. Patients who needed an advanced intervention were more likely to have septal bowing (odds ratio [OR] 8.69, 95% confidence interval [CI] 2.37-31.86), RV enlargement (OR 4.02, 95% CI 1.43-11.34), and a McConnell sign (OR 2.79, 95% CI 1.09-7.13). LV dysfunction was the only statistically significant predictor of 30-day mortality (OR 9.63, 95% CI 1.74-53.32). Conclusion: In patients with PE in the ED, sonographic findings of RV strain that are more commonly associated with advanced intervention included septal bowing, McConnell sign, and RV enlargement. LV dysfunction was associated with a higher 30-day mortality. These findings can help inform decisions about ED management and disposition of patients with PE.

The Use of Angle-Independent M-Mode in the Evaluation of Diaphragmatic Excursion: Towards Improved Accuracy

Cureus, 2021

Assessment of diaphragmatic function has been well described in the intensive care setting as wel... more Assessment of diaphragmatic function has been well described in the intensive care setting as well as in emergency medicine and pediatrics. Conventional M-mode evaluation of diaphragmatic excursion is frequently associated with over and under-estimations of diaphragmatic excursion. Angle-independent M-mode allows free rotation and movement of the analysis line to obtain M-mode images in a direction that more accurately reflects diaphragmatic excursion. In order to provide a standardized approach to the evaluation of diaphragmatic excursion with angle-independent M-mode, we propose a landmark-based approach utilizing the spine in order to target the same diaphragmatic segment consistently throughout the diaphragmatic analysis. While the proposed approach is not intended to replace current methods, it may improve accuracy and inter-rater reliability. The relevant background, as well as three patient cases, are presented demonstrating the use of a landmark-based approach in the emergen...

140 Patient Performed Thoracic Lung Ultrasound

Annals of Emergency Medicine, 2021

Detecting Ventilator‐Induced Diaphragmatic Dysfunction Using Point‐of‐Care Ultrasound in Children With Long‐term Mechanical Ventilation

Journal of Ultrasound in Medicine, 2020

Long‐term mechanical ventilation (MV) is defined as the use of MV for more than 6 hours per day f... more Long‐term mechanical ventilation (MV) is defined as the use of MV for more than 6 hours per day for at least 3 weeks. Children requiring long‐term MV include those with neuromuscular disease, central dysregulation, or lung dysfunction. Such children with medical complexity may be at risk for ventilator‐induced diaphragmatic dysfunction. Ventilator‐induced diaphragmatic dysfunction has been described in adult patients requiring acute MV with ultrasound (US). At this time, diaphragmatic US has not been evaluated in the pediatric post–acute care setting or incorporated into weaning strategies. We present 24 cases of children requiring long‐term MV who underwent diaphragmatic US examinations to evaluate for ventilator‐induced diaphragmatic dysfunction.

232 National Cost Savings, Length of Stay Reduction and Preventable Cancer from Expanded Use of Point-of-Care Ultrasound for Small Bowel Obstruction

Annals of Emergency Medicine, 2020

Background: Activating point mutations of GNAS at codon 201 have been detected in approximately t... more Background: Activating point mutations of GNAS at codon 201 have been detected in approximately two thirds of intraductal papillary mucinous neoplasms (IPMNs) of the pancreas. Intraductal papillary neoplasms of the bile ducts (IPNBs) morphologically resemble pancreatic IPMNs. This study sought to assess the mutational status of GNAS at codon 201 in IPNBs. Methods: Thirty-four patients were included. DNA from microdissected IPNBs was subjected to a polymerase chain reaction and ligation method for the detection of GNAS mutations at codon 201 and of KRAS mutations at codon 12. Mutational status was compared with clinical and pathologic data. Results: The IPNBs had a median diameter of 3.5 cm and were located intrahepatically (n = 6), extrahepatically (n = 13), both intra-and extrahepatically (n = 4) or in the gallbladder (intracystic papillary neoplasms, n = 11). Most exhibited pancreatobiliary differentiation (n = 20), high-grade dysplasia (n = 26) and an associated adenocarcinoma (n = 20). Analysis of GNAS codon 201 identified only one mutant sample in a multifocal intestinal subtype intrahepatic IPNB with high-grade dysplasia. Six lesions harboured a KRAS codon 12 mutation. Conclusions: GNAS codon 201 mutations are uncommon in IPNBs, by contrast with pancreatic IPMNs. More comprehensive molecular profiling is needed to uncover the pathways involved in IPNB development.

161 Cardiopulmonary Ultrasound in Risk Stratification of Patients With Influenza

Annals of Emergency Medicine, 2020

Background: While chronic pulmonary hypertension is a known manifestation of cocaine intoxication... more

155 Using Point-of-Care Ultrasound to Predict Clinical Outcomes in Patients With COVID-19

Annals of Emergency Medicine, 2020

Background: The optimal duration of triple anti-platelet therapy (DTAP) remains unclear in patien... more Background: The optimal duration of triple anti-platelet therapy (DTAP) remains unclear in patients with acute myocardial infarction (AMI). Methods: We retrospectively analyzed 716 AMI patients who received TAP (aspirin, clopidogrel, and cilostazol) after drug-eluting stent (DES) implantation from November 2005 to May 2008. Mean age was 61.9 ± 11.70 years (male gender 74.1%) and mean duration of TAP was 98.1 ± 115.34 days. We compared the major adverse cardiovascular events [MACE, defined as the composite of cardiac death, non-fatal AMI, stent thrombosis, and target vessel revascularization (TVR)] between the group of DTAP ≥3 months (n = 497) and those of <3 months (n = 219). Results: There were no significant differences in the incidences of cardiac death, non-fatal AMI, stent thrombosis, and TVR at 1-year follow-up between the two groups. However, the group of DTAP ≥3 months had lower incidence of MACE than those <3 months (5.9% vs. 10.7%, p = 0.044). The rate of bleeding complications was similar between the two groups. By Cox regression analysis with propensity score adjustment, Killip class IV and DTAP ≥3 months were

Remodeling Point‐of‐care Ultrasound Education in the Era of COVID‐19

AEM Education and Training, 2020

INSPIRED (Instruction of Sonographic Placement of IVs by RNs in the Emergency Department): The Learning Curve for Peripheral IV Placement

Annals of Emergency Medicine, 2013

ED TVU, their anxiety before the exam compared to after the ED TVU was unchanged (D ¼ 2, p¼0.8). ... more ED TVU, their anxiety before the exam compared to after the ED TVU was unchanged (D ¼ 2, p¼0.8). Conclusions: Most ED patients getting TVU for complications of first trimester pregnancy have little embarrassment or anxiety about ED TVU. They don't have a significant preference for operator sex, and are willing to wait only 60 minutes to avoid the possibility of repeat exams. The majority would agree to another ED TVU in the future under similar circumstances and reported that their experience either resulted in no change or in improvement in their perception of ED TVU.

Ultrasound Assessment of Postprocedural Arterial Pseudoaneurysms: Techniques, Clinical Implications, and Emergency Department Integration

Cureus

Temporal Artery Ultrasound for the Diagnosis of Giant Cell Arteritis in the Emergency Department

Cureus

Point-of-care Ultrasound in Morbidity and Mortality Cases in Emergency Medicine: Who Benefits the Most?

Western Journal of Emergency Medicine, 2020

Point-of-care ultrasound (POCUS) is an essential tool in the timely evaluation of an undifferenti... more Point-of-care ultrasound (POCUS) is an essential tool in the timely evaluation of an undifferentiated patient in the emergency department (ED). Our primary objective in this study was to determine the perceived impact of POCUS in high-risk cases presented at emergency medicine (EM) morbidity and mortality (M&M) conferences. Additionally, we sought to identify in which types of patients POCUS might be most useful, and which POCUS applications were considered to be highest yield. Methods: This was a retrospective survey of cases submitted to M&M at an EM residency program that spans two academic EDs, over one academic year. Postgraduate year 4 (PGY) residents who presented M&M cases at departmental sessions were surveyed on perceived impacts of POCUS on individual patient outcomes. We evaluated POCUS use and indications while the POCUS was used. Results: Over the 12-month period, we reviewed 667 cases from 18 M&M sessions by 15 PGY-4 residents and a supervising EM attending physician who chairs the M&M committee. Of these cases, 75 were selected by the M&M committee for review and presentation. POCUS was used in 27% (20/75) of the cases and not used in 73% (55/75). In cases where POCUS was not used, retrospective review determined that if POCUS had been used it would have "likely prevented the M&M" in 45% (25/55). Of these 25 cases, the majority of POCUS applications that could have helped were cardiac (32%, 8/25) and lung (32%, 8/25) ultrasound. POCUS was felt to have greatest potential in identifying missed diagnoses (92%, 23/25), and decreasing the time to diagnosis (92%, 23/25). Patients with cardiopulmonary chief complaints and abnormal vital signs were most likely to benefit. There were seven cases (35%, 7/20, 95% CI 15-59%) in which POCUS was performed and thought to have possibly adversely affected the outcome of the M&M. Conclusion: POCUS was felt to have the potential to reduce or prevent M&M in 45% of cases in which it was not used. Cardiac and lung POCUS were among the most useful applications, especially in patients with cardiopulmonary complaints and in those with abnormal vital signs. [

A cruise ship emergency medical evacuation triggered by handheld ultrasound findings and directed by tele-ultrasound

International Maritime Health, 2020

Cruise ships travel far from shoreside medical care and present a unique austere medical environm... more Cruise ships travel far from shoreside medical care and present a unique austere medical environment. For the cruise ship physician, decisions regarding emergency medical evacuation can be challenging. In the event that a passenger or crew member becomes seriously ill or is injured, the use of point-of-care ultrasound may assist in clarifying the diagnosis and stratifying the risk of a delayed care, and at times expedite an emergent medical evacuation. In this report we present the first case reported in the literature of an emergency medical evacuation from a cruise ship triggered by handheld ultrasound. A point-of-care ultrasound performed by a trained cruise ship physician, reviewed by a remote telemedical consultant with experience in point-of-care ultrasound, identified an ectopic pregnancy with intraabdominal free fluid in a young female patient with abdominal pain and expedited emergent helicopter evacuation from a cruise ship to a shoreside facility, where she immediately underwent successful surgery. The case highlights a medical evacuation that was accurately triggered by utilising a handheld ultrasound and successfully directed via a tele-ultrasound consultation. American College of Emergency Physicians (ACEP) health care guidelines for cruise ship medical facilities should be updated to include guidelines for point-of-care ultrasound, including training and telemedical support.

Delayed Diagnosis of Shoulder Septic Arthritis and Osteomyelitis During the COVID-19 Pandemic: The Role of Point-of-Care Ultrasound

Cureus, Feb 25, 2023

The diagnosis and treatment of septic arthritis are complex and require collaboration among multi... more The diagnosis and treatment of septic arthritis are complex and require collaboration among multiple medical services, especially in the emergency department (ED). This case report highlights the difficulties in diagnosing shoulder septic arthritis, which is a rare condition in adults and can present with subtle symptoms. The patient was eventually diagnosed with septic arthritis of the left shoulder. However, the diagnosis was delayed due to the impact of the COVID-19 pandemic on obtaining an outpatient MRI and a previous shoulder injury that added confusion. Delays in diagnosis and treatment can lead to a rapid destruction of the affected joint, causing significant morbidity and mortality. This case report also highlights the importance of alternative diagnostic tools, such as point-of-care ultrasound (POCUS), which is quick, inexpensive, and may lead to earlier detection of joint effusions and prompt arthrocentesis.

P147: International scope of emergency ultrasound: barriers to utilizing ultrasound to guide central venous catheter placement by providers in Kenya

CJEM, 2016

Introduction: While ultrasound (U/S) use for internal jugular central venous catheter (CVC) place... more Introduction: While ultrasound (U/S) use for internal jugular central venous catheter (CVC) placement is standard of care in many institutions in North America, most developing countries have not adopted this practice. Previous surveys of American physicians who are not currently using U/S to place CVCs have identified lack of training and equipment availability as the most important barriers to the use of U/S. We sought to identify Kenyan physicians’ perceived barriers to the use of U/S to guide CVC insertion in a resource-constrained environment. Methods: The study was conducted at the Aga Khan University Hospital in Nairobi, Kenya. Physicians participating in a one-hour course teaching U/S guided CVC placement were asked to complete a survey before beginning training, which was used to assess previous experience with U/S, and evaluate perceived barriers to U/S. Survey responses were analyzed using summary statistics and the Rank-Sum test to compare the difference between particip...

Optimizing Lung Ultrasound: The Effect of Depth, Gain and Focal Position on Sonographic B-Lines

Ultrasound in Medicine & Biology

Point-of-Care Ultrasonography: Clearly More Than a Pretty Picture

JAMA Internal Medicine, 2022

Sonographic Assessment of the Effects of Mechanical Ventilation on Carotid Flow Time and Volume

Cureus, 2021

Background Corrected carotid flow time (CFTc) and carotid blood flow (CBF) are sonographic measur... more Background Corrected carotid flow time (CFTc) and carotid blood flow (CBF) are sonographic measurements used to assess fluid responsiveness in hypotension. We investigated the impacts of mechanical ventilation on CFTc and CBF. Materials and methods Normotensive patients undergoing cardiac surgery were prospectively enrolled. Carotid ultrasound (US) was performed pre and post-intubation. Post-intubation measurements took place after the initiation of mechanical ventilation. To measure CFTc and CBF, a sagittal carotid view was obtained with pulse wave-Doppler (maximum angle 60°). CFTc was calculated with the Bazett formula (CFTc = systolic time/√cycle time). CBF was calculated using CBF (mL/min) = area (cm 2 ) x time average mean velocity (TAMEAN) (cm/sec) x 60 (sec/min). The maximum carotid diameter was measured at the level of the thyroid. Results Twenty patients were enrolled. Mean CFTc pre-intubation was 328 ms (SD 43.9 ms) compared to CFTc post-intubation 336 ms (SD 36 ms). There...

Racial and sex disparities in difficult intravenous access

The American Journal of Emergency Medicine, 2021

Ultrasound and Influenza: The Spectrum of Lung and Cardiac Ultrasound Findings in Patients with Suspected Influenza A and B

Ultrasound in Medicine & Biology, 2021

In patients with influenza, cardiac and lung ultrasound may help determine the severity of illnes... more In patients with influenza, cardiac and lung ultrasound may help determine the severity of illness and predict clinical outcomes. To determine the ultrasound characteristics of influenza and define the spectrum of lung and cardiac findings in patients with suspected influenza A or B, we conducted a prospective observational study in patients presenting to the emergency department at a tertiary care academic institution. An ultrasound protocol consisting of cardiac, lung and inferior vena cava scans was performed within 6 h of admission. We compared the ultrasound findings in cases with positive and negative influenza polymerase chain reaction, while controlling for comorbidities. We enrolled 117 patients, 41.9% of whom (49/117) tested positive for influenza. In those with influenza, ultrasound confirmed preserved left ventricular and right ventricular (RV) function in 81.3% of patients. The most common cardiac pathology was RV dilation (10.4%), followed by left ventricular systolic dysfunction (8.3%). Patients with negative influenza polymerase chain reaction with RV dysfunction demonstrated higher hospital admission than those those with normal RV function (45.1%, 23/51, vs. 17.9%, 5/28; p = 0.016). B-lines were prevalent in both influenza and non-influenza groups (40.8% and 69.1%, respectively; p = 0.013). Lung consolidation was identified in only 8.25% of patients with influenza. In conclusion, in patients with influenza we were unable to define distinct ultrasound features specific to influenza A or B, suggesting that ultrasound may not be beneficial in diagnosing influenza nor in evaluating its severity.

Left Ventricular Dysfunction Correlates With Mortality in Pulmonary Embolism

The Journal of Emergency Medicine, 2021

Background: Risk stratification of patients with pulmonary embolism (PE) is essential to guide ad... more Background: Risk stratification of patients with pulmonary embolism (PE) is essential to guide advanced interventional management and proper disposition. Objectives: In this study, we sought to assess individual echocardiographic markers of right ventricular (RV) strain and left ventricular (LV) function in patients with high-risk PE and identify their association with the need for advanced intervention (such as thrombolysis) and 30-day mortality. Methods: This was a retrospective study of ED patients with PE who were subject to a pulmonary embolism response team activation over a 5-year period. Cardiac point-of-care ultrasound studies were performed as part of patient care and later assessed for septal bowing, RV hypokinesis, McConnell sign, RV enlargement, tricuspid annular place systolic excursion, and LV systolic dysfunction. Outcome variables included need for advanced intervention and 30day mortality. Results: The pulmonary embolism response team was activated in 893 patients, of which 718 had a confirmed PE. Of these, 90 had adequate cardiac point-ofcare ultrasound images available for review. Patients who needed an advanced intervention were more likely to have septal bowing (odds ratio [OR] 8.69, 95% confidence interval [CI] 2.37-31.86), RV enlargement (OR 4.02, 95% CI 1.43-11.34), and a McConnell sign (OR 2.79, 95% CI 1.09-7.13). LV dysfunction was the only statistically significant predictor of 30-day mortality (OR 9.63, 95% CI 1.74-53.32). Conclusion: In patients with PE in the ED, sonographic findings of RV strain that are more commonly associated with advanced intervention included septal bowing, McConnell sign, and RV enlargement. LV dysfunction was associated with a higher 30-day mortality. These findings can help inform decisions about ED management and disposition of patients with PE.

The Use of Angle-Independent M-Mode in the Evaluation of Diaphragmatic Excursion: Towards Improved Accuracy

Cureus, 2021

Assessment of diaphragmatic function has been well described in the intensive care setting as wel... more Assessment of diaphragmatic function has been well described in the intensive care setting as well as in emergency medicine and pediatrics. Conventional M-mode evaluation of diaphragmatic excursion is frequently associated with over and under-estimations of diaphragmatic excursion. Angle-independent M-mode allows free rotation and movement of the analysis line to obtain M-mode images in a direction that more accurately reflects diaphragmatic excursion. In order to provide a standardized approach to the evaluation of diaphragmatic excursion with angle-independent M-mode, we propose a landmark-based approach utilizing the spine in order to target the same diaphragmatic segment consistently throughout the diaphragmatic analysis. While the proposed approach is not intended to replace current methods, it may improve accuracy and inter-rater reliability. The relevant background, as well as three patient cases, are presented demonstrating the use of a landmark-based approach in the emergen...

140 Patient Performed Thoracic Lung Ultrasound

Annals of Emergency Medicine, 2021

Detecting Ventilator‐Induced Diaphragmatic Dysfunction Using Point‐of‐Care Ultrasound in Children With Long‐term Mechanical Ventilation

Journal of Ultrasound in Medicine, 2020

Long‐term mechanical ventilation (MV) is defined as the use of MV for more than 6 hours per day f... more Long‐term mechanical ventilation (MV) is defined as the use of MV for more than 6 hours per day for at least 3 weeks. Children requiring long‐term MV include those with neuromuscular disease, central dysregulation, or lung dysfunction. Such children with medical complexity may be at risk for ventilator‐induced diaphragmatic dysfunction. Ventilator‐induced diaphragmatic dysfunction has been described in adult patients requiring acute MV with ultrasound (US). At this time, diaphragmatic US has not been evaluated in the pediatric post–acute care setting or incorporated into weaning strategies. We present 24 cases of children requiring long‐term MV who underwent diaphragmatic US examinations to evaluate for ventilator‐induced diaphragmatic dysfunction.

232 National Cost Savings, Length of Stay Reduction and Preventable Cancer from Expanded Use of Point-of-Care Ultrasound for Small Bowel Obstruction

Annals of Emergency Medicine, 2020

Background: Activating point mutations of GNAS at codon 201 have been detected in approximately t... more Background: Activating point mutations of GNAS at codon 201 have been detected in approximately two thirds of intraductal papillary mucinous neoplasms (IPMNs) of the pancreas. Intraductal papillary neoplasms of the bile ducts (IPNBs) morphologically resemble pancreatic IPMNs. This study sought to assess the mutational status of GNAS at codon 201 in IPNBs. Methods: Thirty-four patients were included. DNA from microdissected IPNBs was subjected to a polymerase chain reaction and ligation method for the detection of GNAS mutations at codon 201 and of KRAS mutations at codon 12. Mutational status was compared with clinical and pathologic data. Results: The IPNBs had a median diameter of 3.5 cm and were located intrahepatically (n = 6), extrahepatically (n = 13), both intra-and extrahepatically (n = 4) or in the gallbladder (intracystic papillary neoplasms, n = 11). Most exhibited pancreatobiliary differentiation (n = 20), high-grade dysplasia (n = 26) and an associated adenocarcinoma (n = 20). Analysis of GNAS codon 201 identified only one mutant sample in a multifocal intestinal subtype intrahepatic IPNB with high-grade dysplasia. Six lesions harboured a KRAS codon 12 mutation. Conclusions: GNAS codon 201 mutations are uncommon in IPNBs, by contrast with pancreatic IPMNs. More comprehensive molecular profiling is needed to uncover the pathways involved in IPNB development.

161 Cardiopulmonary Ultrasound in Risk Stratification of Patients With Influenza

Annals of Emergency Medicine, 2020

Background: While chronic pulmonary hypertension is a known manifestation of cocaine intoxication... more

155 Using Point-of-Care Ultrasound to Predict Clinical Outcomes in Patients With COVID-19

Annals of Emergency Medicine, 2020

Background: The optimal duration of triple anti-platelet therapy (DTAP) remains unclear in patien... more Background: The optimal duration of triple anti-platelet therapy (DTAP) remains unclear in patients with acute myocardial infarction (AMI). Methods: We retrospectively analyzed 716 AMI patients who received TAP (aspirin, clopidogrel, and cilostazol) after drug-eluting stent (DES) implantation from November 2005 to May 2008. Mean age was 61.9 ± 11.70 years (male gender 74.1%) and mean duration of TAP was 98.1 ± 115.34 days. We compared the major adverse cardiovascular events [MACE, defined as the composite of cardiac death, non-fatal AMI, stent thrombosis, and target vessel revascularization (TVR)] between the group of DTAP ≥3 months (n = 497) and those of <3 months (n = 219). Results: There were no significant differences in the incidences of cardiac death, non-fatal AMI, stent thrombosis, and TVR at 1-year follow-up between the two groups. However, the group of DTAP ≥3 months had lower incidence of MACE than those <3 months (5.9% vs. 10.7%, p = 0.044). The rate of bleeding complications was similar between the two groups. By Cox regression analysis with propensity score adjustment, Killip class IV and DTAP ≥3 months were

Remodeling Point‐of‐care Ultrasound Education in the Era of COVID‐19

AEM Education and Training, 2020

INSPIRED (Instruction of Sonographic Placement of IVs by RNs in the Emergency Department): The Learning Curve for Peripheral IV Placement

Annals of Emergency Medicine, 2013

ED TVU, their anxiety before the exam compared to after the ED TVU was unchanged (D ¼ 2, p¼0.8). ... more ED TVU, their anxiety before the exam compared to after the ED TVU was unchanged (D ¼ 2, p¼0.8). Conclusions: Most ED patients getting TVU for complications of first trimester pregnancy have little embarrassment or anxiety about ED TVU. They don't have a significant preference for operator sex, and are willing to wait only 60 minutes to avoid the possibility of repeat exams. The majority would agree to another ED TVU in the future under similar circumstances and reported that their experience either resulted in no change or in improvement in their perception of ED TVU.

Ultrasound Assessment of Postprocedural Arterial Pseudoaneurysms: Techniques, Clinical Implications, and Emergency Department Integration

Cureus

Temporal Artery Ultrasound for the Diagnosis of Giant Cell Arteritis in the Emergency Department

Cureus

Point-of-care Ultrasound in Morbidity and Mortality Cases in Emergency Medicine: Who Benefits the Most?

Western Journal of Emergency Medicine, 2020

Point-of-care ultrasound (POCUS) is an essential tool in the timely evaluation of an undifferenti... more Point-of-care ultrasound (POCUS) is an essential tool in the timely evaluation of an undifferentiated patient in the emergency department (ED). Our primary objective in this study was to determine the perceived impact of POCUS in high-risk cases presented at emergency medicine (EM) morbidity and mortality (M&M) conferences. Additionally, we sought to identify in which types of patients POCUS might be most useful, and which POCUS applications were considered to be highest yield. Methods: This was a retrospective survey of cases submitted to M&M at an EM residency program that spans two academic EDs, over one academic year. Postgraduate year 4 (PGY) residents who presented M&M cases at departmental sessions were surveyed on perceived impacts of POCUS on individual patient outcomes. We evaluated POCUS use and indications while the POCUS was used. Results: Over the 12-month period, we reviewed 667 cases from 18 M&M sessions by 15 PGY-4 residents and a supervising EM attending physician who chairs the M&M committee. Of these cases, 75 were selected by the M&M committee for review and presentation. POCUS was used in 27% (20/75) of the cases and not used in 73% (55/75). In cases where POCUS was not used, retrospective review determined that if POCUS had been used it would have "likely prevented the M&M" in 45% (25/55). Of these 25 cases, the majority of POCUS applications that could have helped were cardiac (32%, 8/25) and lung (32%, 8/25) ultrasound. POCUS was felt to have greatest potential in identifying missed diagnoses (92%, 23/25), and decreasing the time to diagnosis (92%, 23/25). Patients with cardiopulmonary chief complaints and abnormal vital signs were most likely to benefit. There were seven cases (35%, 7/20, 95% CI 15-59%) in which POCUS was performed and thought to have possibly adversely affected the outcome of the M&M. Conclusion: POCUS was felt to have the potential to reduce or prevent M&M in 45% of cases in which it was not used. Cardiac and lung POCUS were among the most useful applications, especially in patients with cardiopulmonary complaints and in those with abnormal vital signs. [