Background: Computed tomography coronary angiography is used to assess for coronary artery disease but can also pick up non-cardiac pathology. Previous studies have assessed the frequency of non-cardiac pathology. We investigated the non-cardiac findings and resulting follow up in a District General Hospital. Methods: All computed tomography coronary angiography scans for 1 year were retrospectively collected. Basic demographics and the non-cardiac findings were recorded from electronic health records. The significant respiratory findings and the respiratory follow up of these non-cardiac findings were recorded. Results: A total of 503 scans were carried out in one year. Of these scans, 24% had non cardiac findings present. Older patients were more likely to have non cardiac findings. The most common non cardiac findings were lung nodules, emphysema and hiatus hernias. Significant respiratory findings were present in 35 cases, which generated 24 episodes of respiratory follow up. Some patients who met criteria for follow up had not been referred. Conclusions: Non cardiac findings are common on computed tomography coronary angiography and in our hospital these findings led to significant follow up in respiratory services.

BACKGROUND:Coronavirus disease 2019 has had a dramatic impact on the delivery of acute care globally. Accurate risk stratification is fundamental to the efficient organisation of care. Point-of-care lung ultrasound offers practical advantages over conventional imaging with potential to improve the operational performance of acute care pathways during periods of high demand. The Society for Acute Medicine and the Intensive Care Society undertook a collaborative evaluation of point-of-care imaging in the UK to describe the scope of current practice and explore performance during real-world application.METHODS:A retrospective service evaluation was undertaken of the use of point-of-care lung ultrasound during the initial wave of coronavirus infection in the UK. We report an evaluation of all imaging studies performed outside the intensive care unit. An ordinal scale was used to measure the severity of loss of lung aeration. The relationship between lung ultrasound, polymerase chain reaction for SARS-CoV-2 and 30-day outcomes were described using logistic regression models.RESULTS:Data were collected from 7 hospitals between February and September 2020. In total, 297 ultrasound examinations from 295 patients were recorded. Nasopharyngeal swab samples were positive in 145 patients (49.2% 95%CI 43.5-54.8). A multivariate model combining three ultrasound variables showed reasonable discrimination in relation to the polymerase chain reaction reference (AUC 0.77 95%CI 0.71-0.82). The composite outcome of death or intensive care admission at 30 days occurred in 83 (28.1%, 95%CI 23.3-33.5). Lung ultrasound was able to discriminate the composite outcome with a reasonable level of accuracy (AUC 0.76 95%CI 0.69-0.83) in univariate analysis. The relationship remained statistically significant in a multivariate model controlled for age, sex and the time interval from admission to scan Conclusion: Point-of-care lung ultrasound is able to discriminate patients at increased risk of deterioration allowing more informed clinical decision making.

We read with interest the paper from Knight et al in Acute Medicine1 in particular the use of a lung ultrasound (LUS) score to predict outcome in patients with suspected COVID-19. LUS has been shown to be useful in the diagnosis and prognosis for COVID-19 by other authors. We have carried out a service evaluation project on our data from East Surrey Hospital looking into prognostic and diagnostic performance of LUS in suspected COVID-19. In contrast to the data used by Knight et al we had discharge diagnosis data available which allowed us to split the cohort into patients with COVID-19 and patients with other diagnoses and compare the LUS score between the two groups.

Introduction The Society for Acute Medicine and the Intensive Care Society developed a collaborative evaluation of point-of-care lung ultrasound (LUS) in the UK to describe the scope of current practice and explore performance during real-world application. All participating hospitals have established expertise in point-of-care imaging. https://ics.ac.uk/ICS/ICS/FUSIC/Documents/National_COVID_POCUS_service_evaluation.aspx describes the project. Methods We report the evaluation of all imaging studies performed outside the intensive care unit. An ordinal scale measured the severity of loss of lung aeration. The relationship between this score and adverse outcomes was explored using generalised linear models. A composite diagnostic score was used to describe diagnostic performance compared against polymerase chain reaction (PCR) results as a reference standard. Results 297 ultrasound examinations from 295 patients were recorded, between February and September 2020, from 7 sites. Nasopharyngeal swab samples were positive in 145 patients (49.2% 95%CI 43.5–54.8). A multivariate model combining three ultrasound variables had an AUC of 0.79 (95%CI 0.73–85) to predict PCR positivity. The composite outcome of death or intensive care admission at 30 days occurred in 83 (28.1%, 95%CI 23.3–33.5). Lung ultrasound was able to discriminate the composite outcome with a reasonable level of accuracy (AUC 0.76 95%CI 0.69–0.83) in univariate analysis. The relationship remained statistically significant in a multivariate model controlled for age, sex, the time interval from admission to scan and the severity of hypoxia. Conclusions LUS discriminates between patients at increased risk of deterioration. The ultrasound severity score appears to be best calibrated with risk in patients receiving oxygen therapy. The evaluation provides further evidence of the clinical utility of LUS which combined with the potential practical advantages provide a strong argument for wider adoption and integration of the practice.

Wars, pandemics and disasters advance medical science and care. Oxygen saturationmonitors were initially only used in anaesthesia and intensive care but are now available from supermarkets and are used for home monitoring of COVID-19. Ultrasound is following a similar path from a specialist investigation to common use in acute care. In the next 10 years, a handheld ultrasound device could be in every medical practitioner’s pocket. Previously, point-of-care lung ultrasound (LUS) was used in acute care for diagnosing causes of hypoxia and so when COVID-19 developed into a global pandemic there was great interest in LUS for this disease. Initial case series from China detailed the LUS findings in COVID-19 with bilateral patchy B-lines, peripheral consolidations and a lack of large effusions. Further studies into diagnostic accuracy and prognostic ability of LUS for COVID-19 were ongoing or awaiting publication. Despite the lack of firm data, it still was useful during the first wave in the UK due to limitations in other diagnostic tests. There was very limited availability of rapid molecular tests and delays of several days for reverse transcriptase polymerase chain reaction (RTPCR). Other imaging methods were limited by poor specificity for disease (chest radiograph) or practical limitations in moving highly infectious patients within the hospital (computed tomography). LUS had a unique advantage, as it could be performed at the bedside giving results within minutes allowing rapid triage and treatment. During the second wave, rapid molecular testing was available in many centres and the turn-around time for RTPCR was significantly reduced. LUS also played a role in the diagnosis of patients with negative molecular tests and high clinical suspicion, particularly as nasopharyngeal RTPCR is only about 70% sensitive. In addition, LUS was used to rule out other causes of hypoxia such as pleural effusion and cardiac failure which can present in tandem with COVID-19. LUS findings consistent with COVID-19 should be treated with caution in times with low prevalence, as false positive rates will be higher. As the pandemic subsides, LUS will still play a key role in diagnosing other causes of hypoxia. The experience learnt in COVID-19 will lead to more practitioners being familiar with LUS and in particular with sonographic findings of a viral pneumonitis. It is unknown whether LUS will be useful in management of long COVID and its advantages over CT imaging of instant results at the bedside are far less important in chronic disease. A lack of equipment and suitably skilled practitioners restrict the availability of point-of-care LUS in the UK. The Society for Acute Medicine and Intensive Care Society are working hard to address this through their established LUS training pathways, while handheld devices provide a cost-effective alternative to cart-based machines. LUS can provide rapid diagnosis of COVID-19 at the bedside and there is now clear evidence to support its use.

A 45-year-old man suffered compartment syndrome of the hands as a complication of prolonged cardiopulmonary resuscitation. He was admitted following a hypothermic out-of-hospital cardiac arrest due to cold-water submersion. The patient was in cardiac arrest for 4 h with mechanical cardiopulmonary resuscitation delivered using the Lund University Cardiac Arrest System (Jolife AB, Lund, Sweden). Cardiopulmonary resuscitation along with aggressive rewarming achieved return of spontaneous circulation. He developed compartment syndrome in his left hand which was likely exacerbated by having his arm strapped to the Lund University Cardiac Arrest System device throughout the resuscitation. The compartment syndrome was managed conservatively. Despite preservation of neurological function the patient died of complications from the cardiac arrest after an extended intensive care unit stay. We recommend healthcare providers unstrap patient's hands during prolonged mechanical cardiopulmonary resuscitation.

Summary Objectives To establish whether blood samples taken from used peripheral intravenous cannulae are clinically interchangeable with venepuncture. Design Systematic review. PubMed, Web of Science and Embase were searched for relevant trials. Setting Trials which compared blood samples from used peripheral intravenous cannulae to venepuncture and provided limits of agreement or data which allowed calculation of limits of agreement. Participants Seven trials with 746 participants. Blood tests included 13 commonly ordered biochemistry, haematology and blood gas measurements. Main outcome measures 95% limits of agreement. Data were pooled using inverse variance weighting and compared to a clinically acceptable range estimated by expert opinion from previous trials. Results Limits of agreement for blood samples from used peripheral intravenous cannulae were within the clinically acceptable range for sodium, chloride, urea, creatinine and haematology samples. Limits of agreement for potassium were ±0.47 mmol/L which exceeded the clinically acceptable range. Peripheral intravenous cannula samples for blood gas analysis gave limits of agreement which far exceeded the clinically acceptable range. Conclusions Blood sampling from used peripheral intravenous cannulae is a reasonable clinical practice for haematology and biochemistry samples. Potassium samples from used peripheral intravenous cannulae can be used in situations where error up to ±0.47 mmol/L is acceptable. Peripheral intravenous cannula samples should not be used for blood gas analysis.

Abstract Background: Central skull base osteomyelitis is clinically difficult to distinguish from malignancy. Method: The computed tomography and magnetic resonance imaging scans of six patients with central skull base osteomyelitis were compared with scans from patients with a range of skull base conditions. Results and conclusion: Computed tomography scans of central skull base osteomyelitis show much less bony destruction relative to the magnetic resonance imaging changes, whereas malignancy cases were associated with similar bony destruction on computed tomography and magnetic resonance imaging. In magnetic resonance imaging scans, it was possible to confirm previous findings of clival hypointensity on T1-weighted images relative to normal fatty marrow. In addition, there were signs of pre- and para-clival soft tissue infiltration, with the obliteration of normal fat planes and frank soft tissue masses in all six central skull base osteomyelitis patients. Signal intensity on T2-weighted images of the clivus was high in five central skull base osteomyelitis patients. With intravenous contrast, fascial plane anatomy appeared restored in central skull base osteomyelitis cases, almost in keeping with that of non-involved areas. This was not a feature in any of the malignant conditions.