Introduction: Pain scales are often used in peripheral nerve block studies but are problematic due to their subjective nature. Ultrasound-measured diaphragmatic excursion is an easily learned technique that could provide a much-needed objective measure of pain control over time with serial measurements.

Case Series: We describe three cases where diaphragmatic excursion was used as an objective measure of decreased pain and improved respiratory function after serratus anterior plane block in emergency department patients with anterior or lateral rib fractures.

Conclusion: Diaphragmatic excursion may be an ideal alternative to pain scores to evaluate serratus anterior plane block efficacy. More data will be needed to determine whether this technique can be applied to other ultrasound-guided nerve blocks.

Introduction: 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.

Introduction: Tricuspid annular plane systolic excursion (TAPSE) is an established echocardiographic marker of right ventricular (RV) systolic function. The objective of this study was to evaluate whether emergency clinicians can visually estimate RV function using TAPSE in a set of video clips compared to a reference standard M-mode measurement.

Methods: Emergency clinicians were shown a five-minute educational video on TAPSE. Participants then viewed 20 apical four-chamber point-of-care ultrasound (POCUS) echocardiography clips and recorded their estimate of TAPSE distance in centimeters (cm), as well as whether TAPSE was normal (>1.9 cm), borderline (1.5-1.9 cm), or abnormal (<1.5 cm). We calculated sensitivity, specificity, and overall accuracy of visual TAPSE categorization using M-mode measurement as the criterion standard. Participants also reported their comfort with assessing TAPSE on a five-point Likert scale before and after participation in the study.

Results: Among 70 emergency clinicians, including 20 postgraduate year 1-4 residents, 22 attending physicians, and 28 physician assistants (PA), the pooled sensitivity and specificity for visual assessment of TAPSE was 88.6% (95% confidence interval, 85.4-91.7%) and 81.6% (95% CI, 78.2-84.4%), respectively. The sensitivity and specificity for the clips in which the measured TAPSE was <1.5 cm or >1.9 cm was 91.4% (95% CI, 88.4-94.3%) and 90.8% (95% CI, 87.7-93.9%), respectively. There was no significant difference in sensitivity (p = 0.27) or specificity (p = 0.55) between resident and attending physicians or between physicians and PAs (p = 0.17 and p = 0.81). Median self-reported comfort with TAPSE assessment increased from 1 (interquartile range [IQR] 1-2) to 3 (IQR 3-4) points after participation in the study.

Conclusion: A wide range of emergency clinicians demonstrated fair accuracy for visual estimation of TAPSE on previously recorded POCUS echocardiography video clips. These findings should be considered hypothesis generating and warrant validation in larger, prospective studies.

Introduction: First detected in December 2019, the severe acute respiratory syndrome coronavirus 2 pandemic upended the global community in a few short months. Diagnostic testing is currently limited in availability, accuracy, and efficiency. Imaging modalities such as chest radiograph (CXR), computed tomography, and lung ultrasound each demonstrate characteristic findings of coronavirus disease 2019 (COVID-19). Lung ultrasound offers benefits over other imaging modalities including portability, cost, reduced exposure of healthcare workers as well as decreased contamination of equipment such as computed tomography scanners.

Case Series: Here we present a case series describing consistent lung ultrasound findings in patients with confirmed COVID-19 despite variable clinical presentations and CXR findings. We discuss a triage algorithm for clinical applicability and utility of lung point-of-care ultrasound in the setting of COVID-19 and advocate for judicious and targeted use of this tool.

Conclusion: Lung point-of-care ultrasound can provide valuable data supporting diagnostic and triage decisions surrounding suspected cases of COVID-19. Prospective studies validating our proposed triage algorithm are warranted.

Summary: As space tourism continues to evolve, an organized methodology for POCUS use is advised to best prepare astronauts for space.