Date: November 2nd, 2019

Reference: Lee and Yun. Diagnostic Performance of Emergency Physician-Performed Point-of-Care Ultrasonography for Acute Appendicitis: A Meta-Analysis. AJEM 2019.

Guest Skeptic: Chip Lange is an Emergency Medicine Physician Assistant (PA) working primarily in rural Missouri in community hospitals. He also hosts a great #FOAMed blog and podcast called TOTAL EM. Chip is the CEO of an ultrasound education company called Practical POCUS which is based in the United States but is expanding into an international market.

Case: A 6-year-old boy comes into your emergency department at around midnight with his parents complaining of abdominal pain.  His mother reports that the symptoms began a couple of days ago and he did not eat today.  Now, the patient has been vomiting for the last couple of hours.  Initially, he would point to the periumbilical area, but his father says that now he points to the right lower portion of the abdomen as his area of pain.  You do not have an ultrasound tech available at night and you are thinking of using your point of care ultrasound (POCUS) skills to look for a possible appendicitis, but you are unsure how accurate this test would be especially compared to other modalities such as radiology performed ultrasound.

Background: We have reviewed papers on POCUS many times over the years on the SGEM. This has included performing lumbar punctures, diagnosing acute abdominal aneurysms, acute heart failure, pediatric fractures, retinal detachments and endotracheal tube placement.

* SGEM#41: Ultra Spinal Tap (Ultrasound Guided Lumbar Puncture)

* SGEM#94: You Better Think Ultrasound for Acute Abdominal Aneurysm

* SGEM#97: Hippy Hippy Shake – Ultrasound Vs. CT Scan for Diagnosing Renal Colic

* SGEM#119: B-Lines (Diagnosing Acute Heart Failure with Ultrasound)

* SGEM#124: Ultrasound for Skull Fractures – Little Bones

* SGEM#153: Simulation for Ultrasound Education

* SGEM#177: POCUS –A New Sensation for Diagnosing Pediatric Fractures

* SGEM#245: Flash-errrs (POCUS for Retinal Detachments)

* SGEM#249: Ace in the Hole –Confirming Endotracheal Tube Placement with POCUS

Ultrasound, especially in the pediatric population, has been a common form of imaging for the diagnosis of appendicitis.  It avoids the concerns for radiation and contrast that is seen with CT.  MRI is not practical in many situations, especially in rural or remote environments.

However, ultrasound does have its limitations especially in obese patients or those unable to comply with the exam for reasons such as pain.

Clinical Question: What are the diagnostic performance of point of care ultrasonography (EP-POCUS) for diagnosing acute appendicitis?

Reference: Lee and Yun. Diagnostic Performance of Emergency Physician-Performed Point-of-Care Ultrasonography for Acute Appendicitis: A Meta-Analysis. AJEM 2019.

* Population: Patients in original research articles with right-lower quadrant (RLQ) abdominal pain with EP-POCUS being performed as the index test and the use of surgical or pathological findings as the reference standard for acute appendicitis. There had to be sufficient information to reconstruct a 2×2 contingency table regarding sensitivity and specificity.

* Excluded: Case reports, case series, review articles, guidelines, consensus statements letters, editorials, clinical trial, and conference abstracts. Additionally, studies that did not pertain to the field of interest, insufficient data to create the 2×2 tables, POCUS was not performed by emergency physicians (EPs), and studies that only used the radiologists’ final report.