This was a prospective observational study (n=80) comparing emergency medicine (EM) physician performed mitral valve EPSS to formal TTE LVEF estimation. A convenience sample of unselected hospitalized patients undergoing comprehensive TTE for any indication was used. While EPSS > 7 mm was noted to be 100% sensitive for predicting severe systolic dysfunction (EF < 30%), a second cutoff of 8 mm was used for assessing any systolic dysfunction. The sensitivity and specificity of an EPSS > 8 mm for any systolic dysfunction were 83.3% (95% CI, 62.6-95.2) and 50.0% (95% CI, 29.2-70.9), respectively. The corresponding positive LR was 1.67, and the negative LR was 0.33.
This was a small systematic review (n = 201) that evaluated the utility of emergency department (ED) performed ocular ultrasound. A total of 3 studies were included in the final analysis and overall the data was low risk for bias. Operating characteristics were not pooled. One limitation to note is that among the 3 studies included, there was not a clear definition for a positive test result. In one of the included studies, no positive test definition was provided.
This was a systematic review, which including 12 studies (n = 478) using ultrasound measurement of optic nerve diameter (cut point of 5 mm for adult studies, 4.5 mm for age 1–17 years, and 4 mm for age <1 year) to evaluate for increased intracranial pressure (ICP). There was moderate to high heterogeneity among these studies given multiple patient populations. This resulted in wide confidence intervals: sensitivity of 95.6% (95% CI, 87.7%–98.5%), specificity of 92.3% (95% CI, 77.9%–98.4%), positive likelihood ratio of 12.5 (95% CI, 4.2–37.5), and a negative likelihood ratio of 0.05 (95% CI 0.016–0.14). It is also important to mention that the gold standard in this review was CT, which is not as accurate as invasive ICP monitoring. Overall their conclusions were that ocular sonography had a very low LR- (0.05) making it a good test for ruling out raised ICP in a low-risk group, and a high LR+ (12.4) making it a good test for ruling in raised ICP in a high-risk group.
This was a systematic review evaluating the operating characteristics of emergency department (ED) performed ultrasonography for abdominal aortic aneurysm (AAA). A total of 7 studies (n = 655) were included in the analysis, all of which were prospective studies which enrolled adult patients with symptoms/signs suggestive of AAA. The reference standard was varied among studies including CT, MRI, aortography, radiology performed ultrasound, exploratory laparotomy, or autopsy results. AAA was defined as > 3 cm dilation of the aorta. Individual sensitivity and specificity for AAA detection among studies were as follows: sensitivity 97.5-100%, specificity 94.1-100%, LR+ 10.8 - infinite, and LR- 0.00-0.025.
This was a large systematic review and meta-analysis (57 studies, n = 17,893) of the operating characteristics for diagnostic elements available to the emergency physician for diagnosing acute heart failure (AHF) including the history and physical, ECG, chest radiography, BNP/NT-proBNP (NPs), bedside echocardiography, lung ultrasound, and bioimpedance. They concluded that bedside lung US and echocardiography appear to the most useful tests for affirming the presence of AHF while NPs are valuable in excluding the diagnosis. Reduced ejection fraction was determined to have the highest +LR compared to other elements of the exam. However, the studied included in the final pooling appear to have only used "visual estimation" of reduced EF. With regards to lung US, a positive finding was defined in every study by the presence of at least three B lines in two bilateral lung zones.
This was a prospective observational study at 20 hospitals in the US and Canada evaluating patients presenting with out-of-hospital arrest or in-ED arrest. Patients with pulseless electrical activity or asystole were included. An ultrasound was performed at the beginning and end of ACLS. Clinicians were not blinded to the ultrasound results. Patients with short resuscitation time ( < 5 minutes) were excluded to avoid including patients with resuscitation efforts stopped because of a negative ultrasound. Their findings demonstrated that patients in asystole without cardiac activity are unlikely to benefit from prolonged resuscitation as survival rate is dismal. Note that Positive Predictive Value was used in provided table as this is easier to interpret with respect to their data. Positive predictive value is the probability that subjects with a positive screening test truly have the disease. With respect to the study data, positive predictive value represents the probability that a patient WILL NOT survive if they have no cardiac activity on bedside echo and are in asystole (or PEA).
This was a prospective observational study (n=116) of consecutive normotensive patients with confirmed pulmonary embolism, assessing the diagnostic accuracy of biomarkers, CT, and goal-directed echocardiography for right ventricular dysfunction. Emergency physicians, blinded to clot burden and biomarkers, performed qualitative goal-directed echocardiography for right ventricular (RV) dysfunction: RV enlargement (RV diameter greater than or equal to that of the left ventricle), severe RV systolic dysfunction (RV free wall hypokinesis or TAPSE < 1.0 cm), and/or interventricular septum flattening or bowing into the left ventricle. If any one of these were present, right ventricular dysfunction was diagnosed. Goal-directed echocardiography results were compared to comprehensive echocardiography as the gold-standard.
This was a systematic review including 7 prospective case control or cohort studies (n=1075) evaluating the sensitivity and specificity of B-lines in diagnosing acute cardiogenic pulmonary edema (ACPE). The included studies recruited patients presenting to the hospital with acute dyspnea, or where there was a clinical suspicion of congestive heart failure. The setting was either the emergency department (ED) , ICU, or inpatient wards. Ultrasound examinations were performed by any non-radiologist physician. *Various lung ultrasound protocols were used, including the Volpicelli method, the Lichtenstein protocol, and the Comet Score. All involved using B-lines to make the diagnosis of ACPE. The varied protocols used for diagnosis may explain the increased sensitivity noted in this study compared to other meta-analysis. Gold standard was heterogeneous amongst studies with 'final diagnosis from clinical follow-up' being an acceptable reference standard.
This was a systematic review of 8 prospective studies (n=1048) of adult patients. Included manuscripts evaluated for traumatic or iatrogenic pneumothorax. No studies that screened for spontaneous pneumothorax were included. Examiners were surgeons, radiologists, or emergency providers. Reference standard was pneumothorax found on CT or a rush of air upon tube thoracostomy. All studies but one used the ultrasonographic signs of lung sliding and comet tail to rule out pneumothorax. Although the exact technique used to perform the ultrasound examination is not reported with enough detail in some studies, most agree on requiring the examination of more than one intercostal space in both the midclavicular line and laterally and inferiorly at the anterior or midaxillary lines. Lastly, this data does not evaluate whether the pneumothoraces identified were clinically significant.
This was a meta-analysis including 12 retrospective and prospective studies (n=1554) of adults and pediatric patients. Ultrasound was used to diagnose pleural effusion, with the reference standard either CT, surgery, or a more formal “high quality ultrasound in conjunction with expert end diagnosis.” Ultrasound examinations were performed by a variety of operators including emergency physicians, intensivists, radiologists, and nurses. Exact criteria for diagnosis of a pleural effusion by ultrasound was not defined.
The was a systematic review including 20 prospective adult and pediatric studies (n=2513) with varied settings including the emergency department, inpatient wards, or ICU. A positive finding on ultrasound was identified as an alveolar and interstitial pattern or consolidation, although this is not further expanded upon. Gold standard was either CT, chest radiography, or “clinical diagnosis” depending on the study. One large caveat of this study is that it has a very large degree of heterogeneity, with ultrasound examinations performed by emergency physicians, intensivists, and radiologists of varying levels of expertise, on patients ranging from ambulatory to critically ill.
This was a systematic review including 17 prospective studies (n=5108) evaluating the operating characteristics of lung ultrasound for pneumonia in adult patients seen in the emergency department with a clinical suspicion for this diagnosis. Reference standard was either chest radiograph or CT. Included studies varied with regards to which and how many lung fields were evaluated. The operators performing ultrasound examinations were exclusively emergency physicians or radiologists. *Subpleural consolidation and/or focal B-lines were the diagnostic criteria in the majority of manuscripts included, however in 4 studies, no clear positive findings were specified.
This was a systematic review including 4 prospective studies evaluating the operating characteristics of bedside ultrasound for acute cholecystitis (AC) in adult patients seen in the emergency department with a clinical suspicion for AC or right upper quadrant pain. Sample size of the studies varied from 30 to 193 subjects. Reference standard was surgical pathology. The experience of the sonographers varied between the studies and in one study no documentation of sonographer experience was noted. There was significant heterogeneity across the included studies precluding the authors ability to pool the results hence a range is noted in the operating characteristics table.