Download Novel Uses for ED Ultrasound

More than just another stethoscope
Mark Bromley
Emergency Medicine PGY3
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Undifferentiated Hypotension - Echo
 LV function
 Volume Status
 JVP
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Procedures
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Guided Lumbar Puncture
Abscess Drainage
Pleural effusion/Thoracentesis
Paracentesis
Suprapubic aspiration
Vascular Access
Joint taps
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Galbladder
DVT
Ocular
Fracture Detection
Fracture Management
Renal
Pneumothorax
Intubation
...for the cardiologist in you
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67 ♂
Hx of CAD and CHF
Unwell over last 2-3 days
Hypotensive Tachycardic SOB
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Urgent diagnostic evaluation
Timely
Limited diagnostic options due to the clinical
condition → transportation of sick patients
Allow appropriate intervention and improve
the course of disease
1.
2.
3.
4.
Cardiogenic shock
Hypovolemia - Distributive
Right ventricular infarct/large PE
Tamponade
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As a clinician → trying to choose between
inotropy, fluid resuscitation, or a needle
 The ventricle is either moving well or not
 The RV is dilated or not
 There is an effusion or there is not
 The IVC is full or not
 The JVP is up or not
Fractional shortening
 Look at the black (i.e. blood) in the left ventricle
 Systole: the black decreases in size
 The ↓in size with systole is fractional shortening
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Normal ejection fraction is ~ 60%
Mathematically → single dimension
 (diameter rather than volume)
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Change of diameter ≥30% → Gr 1 fxn
Change of diameter <30% → ↓LV systolic fxn
LV dilatation
 Mid-LV diameter ≤5.2cm at end-diastole
 If diameter >5.2cm → LV dilatation
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↓ shortening fraction
LV Dilatation
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End-diastole → LV chamber unusually small
Systole → virtually all LV blood ejected
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Cardiac Activity → hyperdynamic
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 fast heart rate
 very vigorous contractions
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Ejection fraction → exceeds 70%
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IVC → low CVP
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RV is usually 2/3 the size of the LV
RV function is less formally quantified
 (mathematically) complex shape
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PE → RV diameter can exceed the LV
diameter
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Such a finding may guide diagnosis and
management in the acutely dyspneic or
hypotensive patient
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Identify the IVC:
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Just anterior to the spine
To the right of the aorta in > 99.9%.
Thin-walled (vs. the thicker-walled aorta)
Compressible with pressure
Size varies with respiration
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Diameter ≤ 1.5cm→ possibly c/w ↓CVP
Diameter ≤ 1.0 cm definitely c/w ↓CVP
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↑inspiratory ↑ in IVC (>25%) → ↑ chance pt is dry
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Methods:
 84 consecutive patients referred for right-sided cardiac catheterization
 RA pressure was acquired
 Internal residents underwent 4h of formal US training and performed 20
supervised studies
 Blinded to cath results examined the IVC <1h before catheterization
 RA pressure was also estimated by JVP in 40 patients before right-sided
cardiac catheterization
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Results:
 RA pressure was successfully estimated from US images of the IVC in 90% of
patients, compared with 63% from JVP examination
 The sensitivity for predicting RA pressure >10mm Hg was 82% with US and
14% from JVP inspection
…why should medicine residents have all the fun?
How long does it take?
Does it change what we do?
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Methods:
Prospective, observational study
4 EP investigators with prior US experience → focused echo training
A convenience sample of 51 adult pts with hypotension
Exclusion criteria:
 History of trauma
 Chest compressions
 EKG diagnostic of acute MI
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Echocardiogram was recorded by an EP investigator - estimated EF and
categorized LVF as normal, depressed, or severely depressed.
Blinded cardiologist reviewed all 51 studies for EF, categorization of
function, and quality of the study
A second cardiologist reviewed 20 of the tapes to assess inter-observer
variability between cardiologists
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Pearson’s correlation coefficient for EP and
cardiologist estimation was R=0.86
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Pearson’s correlation coefficient for the two
cardiologists’ estimations was R=0.84
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Agreement between EPs in the convenience subset of
eight patients who underwent echo by two EPs
yielded an R = 0.94
Methods:
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Prospective observational study of a convenience sample of patients admitted to ICU
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All patients underwent BLEEP followed by an independent formal echocardiogram by an experienced paediatric
echocardiography provider (PEP)
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EPs had 3 hours of focused cardiac US training including 5-proctored BLEEP examinations on unenrolled patients
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IVC volume was assessed by measurement of the maximal diameter of the IVC
LVF was determined by calculating shortening fraction (SF)
Estimates of SF and IVC volume obtained on the BLEEP were compared with those obtained by the PEP
Results:
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N=31
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Mean age=5.1 years (range: 23 days–16 years)
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Agreement between the EP and the PEP for estimation of SF (r = 0.78)
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The mean difference in the estimate of SF between the providers was 4.4% (95% CI: 1.6%–7.2%)
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This difference in estimate of SF was not thought to be clinically significant
Agreement between the EP and the PEP for estimation of IVC volume (r = 0.8).
The mean difference in the estimate of IVC diameter by the PEP and the EP was 0.068 mm (95% CI: –0.16 to 0.025 mm).
Conclusions:
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PEP sonographers are capable of accurate assessment of LVF and IVC volume
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BLEEP can be performed with focused training and oversight by a pediatric cardiologist
Design:
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Randomized, controlled trial of immediate vs. delayed ultrasound.
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Urban, tertiary emergency department, census >100,000.
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Non-trauma emergency department patients, aged >17 yrs, and initial emergency department vital signs
consistent with shock (SBP<100 mm Hg or shock index >1.0), and agreement of two independent
observers for at least one sign and symptom of inadequate tissue perfusion
Interventions:
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Group 1 (immediate ultrasound) received standard care plus goal-directed US at time 0
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Group 2 (delayed ultrasound) received standard care for 15 min and goal-directed US b/w 15-30 min
Results:
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Outcomes included the number of viable physician diagnoses at 15 mins and the rank of their likelihood
of occurrence at both 15 and 30 mins.
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N=184
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Group 1 (n = 88) had a smaller median number of viable diagnoses at 15 mins (median = 4) than did group
2 (n = 96, median = 9, Mann-Whitney U test, p < .0001).
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Physicians indicated the correct final diagnosis as most likely among their viable diagnosis list at 15 mins
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Group 1 80% (95% confidence interval, 70–87%) of group 1 subjects
Group 2 50% (95% confidence interval, 40–60%) in group 2
...difference of 30% (95% confidence interval, 16–42%)
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7 views
Each intended to answer a binary question:
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Pericardial effusion
Pericardial tamponade
Left ventricular dysfunction
Right ventricular dilation
Intravascular volume depletion
Intraperitoneal fluid
Aortic aneurysm
On average, this information was obtained in < 6 min
Conclusions:
 Incorporation of a goal-directed ultrasound protocol in the evaluation of nontraumatic,
symptomatic, undifferentiated hypotension in adult patients results in fewer viable
diagnostic etiologies.
 More accurate physician impression of final diagnosis.
We can do easily
We can do safely
...when you need the bariatric needle
•Accurate identification of landmarks by palpation is impaired in obese patients
•At least 65% of adults in the US are overweight or obese
•Increasing the accuracy of landmark identification for LP may be useful
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Objective:
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Methods:
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2 EPs sought to identify relevant anatomy in emergency patients
Visualization time for 5 anatomical structures (spinous processes or laminae, ligamentum
flavum, dura mater, epidural space, subarachnoid space), BMI, and perception of landmark
palpation difficulty
Results: N=76
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The objective of the study was to determine EPs’ ability to apply a standardized US technique
for visualizing landmarks surrounding the dural space
Soft tissue and bony anatomical structures were identified in all subjects
Mean BMI was 31.4 (95% confidence interval, 29.1 - 33.6).
High-quality images were obtained in < 1 minute in 153 (87.9%) scans
< 5 minutes in 174 (100%) scans
Mean acquisition time was 57.19 seconds; SD, 68.14 seconds; range, 10 to 300 seconds.
Conclusion:
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In this cohort, EPs were able to rapidly obtain high-quality ultrasound images relevant to
lumbar puncture
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Methods:
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Results:
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Cross-sectional study
Patients categorized by BMI
Recorded the difficulty in palpating traditional LP landmarks
Identification and measurement of the spatial relationships of the sacrum; spinous processes of L3, L4, L5; ligamentum flavum;
and the spinal canal by US
Difficulty in palpating landmarks
Successful identification of pertinent structures
Normal BMI - 5%
Overweight – 33%
Obese
- 68%
Normal BMI – 100%
Overweight – 95%
Obese
-- 74%
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( P = .011)
In subjects with difficult-to-palpate landmarks, US identified pertinent structures in 16/21 (76%; 95%CI 53-92)
The average distance from skin to ligamentum flavum was 44 mm - normal BMI
51 mm - overweight
64 mm - obese
Conclusion:
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( P .0001)
As people get bigger they are harder to landmark
Ultrasound is helpful in this population – but not perfect
...where’s the pus
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Cellulitis vs Abscess
Abscesses may not be clinically obvious
Is there an abscess?
What is the best area for I&D?
Are there structures near the abscess
(i.e. vessels or nerves) risk?
Methods:
 Prospective observational ED study of adult patients with clinical STI without
obvious abscess
 The treating physician’s pretest opinions
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need for drainage procedures
probability of subcutaneous fluid collection
Emergency US of the infected area
Effect on management plan was recorded
Results:
 Ultrasound changed the management in 71/126 (56%) of cases
 Pretest Group
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believed not to need drainage - US changed management in 39/82 (48%)
▪
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believed drainage to be needed, US changed the management in 32/44 (73%)
▪
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(33 drained and 6 more imaging or consultation)
(16 not drained and 16 more diagnostics)
US had a management effect in all pretest probabilities for fluid from 10% to 90%
Conclusion
 US changes ED management
 Hopefully for the better
Methods:
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Prospective, convenience sample of adult patients with ?cellulitis +/- abscess
US was performed by EPs or residents who had attended a ½h training session in soft tissue US
yes/no assessment (of abscess)
I&D was the standard when performed
Resolution on 7d follow-up was the standard when I&D was not performed
Results
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N=107
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Clinical examination
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US
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64/107 patients had I&D–proven abscess
17/107 had negative I&D
26/107 improved with antibiotic therapy alone (clinically negative)
Sensitivity of : 86% (95% [CI] = 76% to 93%)
Specificity: 70% (95% CI = 55% to 82%).
Sensitivity: 98% (95% CI = 93% to 100%)
Specificity was 88% (95% CI = 76% to 96%)
Of 18 cases in which US disagreed with the clinical examination, US was correct in 17 (94%)
(x2=14.2, p = 0.0002)
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Clinical examination
 Sensitivity of : 86%
 Specificity: 70%
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US
 Sensitivity: 98%
 Specificity was 88%
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Of 18 cases in which US disagreed with the clinical exam,
US was correct in 17 (94% of cases with disagreement, x2 =
14.2, p = 0.0002)
Conclusions:
 ED bedside US improves accuracy in detection of
superficial abscesses
1.
The probe should be perpendicular to the chest to ensure an accurate
assessment of pleural fluid collection size, shape, and depth
2.
Identify the diaphragm and liver or spleen
3.
Slide the probe in the longitudinal plane towards the head and feet and
then anterior-posterior or medial-lateral to locate the largest pocket of
fluid
4.
With the largest pocket of fluid in the centre of the
screen, mark that point on the skin under the centre of
the probe just above the lower rib
5.
Rotate the probe 90o into the transverse plane. Ensure
that the largest pocket of fluid is still under the centre of
the probe and corresponds to the mark made on the skin
6.
Note the location of the diaphragm, lung, liver and spleen, etc.
Also note the depth that you could insert the needle into the
fluid before hitting one of these structures
7.
Preparation for thoracentesis, thoracentesis technique, and
aftercare are otherwise performed in the usual fashion.
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Pneumothorax
Solid organ insertion
Dry tap – insufficient tap
Donna R. Grogan; Richard S. Irwin; Richard Channick; Vassilios Raptopoulos; Frederick J. Curley; Thaddeus Bartter; R. William Corwin
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Prospective randomized trial (not blinded)
US guided vs Needle Catheter vs Needle only
Population
 Spontaneously breathing
 Cooperative patients
 Effusions obliterating >½ the hemidiaphragm on X-ray
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Results
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N=52
US guided – 0/19 serious complications
Needle catheter – 9/18 serious complications (7PTx)
Needle only – 5/15 serious complications (3PTx)
Conclusion:
 Thoracentesis method significantly influenced complications
 US guided method was the safest
Arch Intern Med. 1990;150(4):873-877
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Objective: To determine the safety of ultrasound-guided thoracentesis
performed by critical care physicians on patients receiving mechanical
ventilation
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Design: Prospective and observational
Setting: ICUs in a teaching hospital
Patients: 211 serial patients receiving mechanical ventilation with pleural
effusion requiring diagnostic or therapeutic thoracentesis
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Interventions: 232 separate USTs were performed by critical care
physicians without radiology support. AP CXRs were reviewed for
possible post-procedure pneumothorax
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Results: PTx occurred in 3/232 USTs (1.3%)
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Conclusions: UST performed in patients receiving mechanical ventilation
without radiology support results in an acceptable rate of pneumothorax
Paracentesis is performed for diagnostic and
therapeutic reasons
 Complications - rare
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 Bowel perforation
 Artery puncture
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US makes paracentesis safer and ↓ dry taps
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Is there fluid in the abdomen?
1.
2.
Slide the probe caudally down the flank
Identify the ideal site of insertion by following
the fluid with your probe in all directions. Chose
the largest pocket of fluid, away from the
bowel, liver, spleen, and bladder
3.
4.
Once the largest pocket of fluid has been
identified the site of insertion is marked with
indelible ink
Paracentesis is performed as usual
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Study objective:
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To determine if emergency center ultrasound (ECUS) can be of value to emergency physicians in the
evaluation of possible ascites and accompanying decisions to perform emergent paracentesis.
Methods:
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Randomized ED Study
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Inclusion:≥18 yrs, suspected of having ascites and potentially requiring paracentesis
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Exclusion: kids and pregnant women
Randomized to traditional or US-assisted paracentesis – coin toss
Participating physicians had received a minimum of 1 hour of formal didactic ultrasound training
Results:
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100 enrolled patients
56 received the ECUS-assisted technique.
Of 42 patients with ascites, 40 (95%) were successfully aspirated and 14 (25%) did not receive paracentesis
because no ascites or insignificant amount of ascites was visualized.
One patient was noted to have a large cystic mass in the left lower quadrant and another patient had a
ventral hernia.
Of the 44 patients randomized to the traditional technique, 27 (61%) were successfully aspirated.
In 17 (39%) of these patients, fluid could not be obtained using traditional methods.
Of these 17 failed attempts by traditional methods, 15 patients received ECUS in a break from the study
protocol
Ascitic fluid was obtained in 13 of these 15 patients; of the 2 remaining patients, 1 did not have enough fluid
to be sampled and the other had no fluid visualized.
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Did it help?
 avoid complications
 Increase efficiency
 Enhance knowledge of anatomy
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1AM at FMC
Elderly gentleman presents with urinary retntion
Foley can’t be passed
Urology is helpful over the phone but doesn’t
want to see tonight
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EDE ensures that the bladder is large enough to
access and that there is no bowel in the way of
your target
1.
Place the probe in the midline just above the symphysis pubis in
the longitudinal plane with the indicator pointed towards the
head
2.
Aim the beam into the pelvis by tilting the probe caudally
3.
4.
Identify the bladder in transverse and
longitudal planes
Note the overall shape and dimensions of the
bladder
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Mark the overlying skin
Perform aspiration-catheterization in the
usual manner
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Prospective case series
17 consecutive patients
 Acute urinary outflow obstruction
 Urethral cath was not possible or contraindicated
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Intervention:
 Emergent real-time ultrasound-guided suprapubic cystostomy
in the ED
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Results:
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Successful 17/17 (100%, 90–100% CI: 95%) cases
1st pass 17/17
Technically challenging 4/17
No complications reported – 2week FU
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A peripheral vein will look like a small IVC
 Thin-walled
 Black
 Circular structure
 Non-pulsatile
 Compressible with very little pressure
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Look with US in both forearms for a target
If no good vein is visible, move to upper arm
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Methods:
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Prospective, randomized study of all adult patients who presented to the Emergency
Department (ED) between June and December 2007.
Inclusion criteria were failed nursing attempts at peripheral access (at least three)
EPs were 2nd- or 3rd-year residents who had previously performed > five EJs and USIVs
Randomized into either an initial EJ or USIV approach.
Results:
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60 pts enrolled
32 in the ultrasound group
28 in the EJ group
Initial Success: USIV 84% (95% CI 68–93%) vs. EJ 50% (95% CI 33–67%) p 0.006
Success if EJ visible: USIV 84% vs. EJ 66% (p 0.18)
Overall success (including crossover): 41 lines were successfully placed by US out of 46
attempts (89%) vs. 18 out of 33 for EJ (55%), p 0.001
Total: 59/60 patients (98%) had a peripheral IV successfully placed
Rob Hall
Kyle McLaughlin
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X-rays are pretty good
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Possibility of detecting hematoma and
periosteal elevation in subtle fractures
Decrease radiation load
Convenience
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Double Blinded Randomized Educational Study
13 EPs / 4ER US fellows / 2 Residents
24 chicken drumsticks (14 c # and 10 c/o)
 Each given a 2 min tutorial on fracture ID
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Results
 312 exams
 Sensitivity 91% (CI 85%-95%)
 Specificity84% (CI 76%-89%)
Study Design
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Prospective, blinded, convenience sample study over a 7 month period from May - Nov 2004
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An urban peds ED
Methods:
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A bedside ultrasound of the forearm bones was performed by a PEM physician
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US findings were compared with X-ray findings
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Reductions were performed under US guidance
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Post reduction X-rays were performed
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Any need for further reduction was recorded
Results:
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N=68 patients
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Radiographs revealed forearm fractures in 48 patients
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Fractures of radius, ulna, and both
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U/S identified all patients with fractures
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U/S revealed the correct type and location of the fracture in 46 patients (2 missed)
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Sensitivity 97% (95% confidence interval [CI], 89%–100%)
Specificity was 100% (95% CI, 83%–100%)
26 subjects underwent reduction of their fractures in the ED
2 subjects required re-reduction after the initial reduction
The initial success rate of ultrasound-guided reduction was 92% (95% CI, 75%–99%)
Methods:
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After one hour of standardized training, physicians with minimal US experience clinically
evaluated patients presenting with pain and trauma to the upper arm or leg
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The investigators then performed a long-bone US evaluation, recording their impression of
fracture presence or absence
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Results were compared with X-ray or CT
Results:
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N=58 patients
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Physical examination
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Ultrasound
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Sensitivity 78.6%
Specificity 90.0%
Sensitivity 92.9%
Specificity 83.3%
US provided improved sensitivity with less specificity compared with physical examination in
the detection of fractures in long bones.
Conclusion:
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Author: US by minimally trained clinicians may be used to rule out a long-bone fracture in
patients with a medium to low probability of fracture
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Improves on clinical exam
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HPI: An 18-month-old boy presented to the ER after a
fall 24h previously. Refusing to bear weight on the
right leg since the fall.
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OE: afebrile, comfortable at rest, and reluctant to
transfer weight through his right leg. There was no
swelling, bruising, or deformity visible, and his range
of motion was normal. There was no focal tenderness,
but the examining physician was unable to rule out
lower leg tenderness because of inconsistent
responses from the child.
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X-Ray...
Diagnosis: soft tissue trauma
Management:
 Analgesia medications
 72-hour review was arranged
72h Follow-up:
 the child was still non-weight-bearing
 trouble sleeping
*Peri-osteal elevation with underlying fracture hematoma
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The leg was immobilized in an above knee
cast
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2 week follow-up: plain X-ray demonstrated
healing oblique fracture of the distal tibia
* Healing fracture
Reduction assessment
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8 year girl was referred from the periphery for
evaluation of a forearm fracture
The patient had fallen at play about 4h earlier
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OE:
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 obvious deformity of the distal forearm
 N/V exam normal
 Skin intact
American Journal of Emergency Medicine - Volume 18, Issue 1 (January 2000)
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After good anesthesia had been achieved, the
EP attempted to reduce the fracture using
manipulation, traction, and counter-traction
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Swelling of the forearm made it difficult to
evaluate the reduction clinically
...repeat US
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While anesthesia was still in place and before
casting, a second reduction was performed
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Repeat US
Hennepin County Medical Center Training video
Confirmation of tube placement
Methods:
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13 patients requiring elective intubation under GA, and data from two trauma patients were evaluated.
Using a portable, hand-held, ultrasound machine, sonographic recordings of the chest wall visceral-parietal
pleural interface (VPPI) were recorded bilaterally in each patient during all phases of airway management:
(1) preoxygenation; (2) induction; (3) paralysis; (4) intubation; and (5) ventilation.
Results:
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The VPPI could be well-imaged for all of the patients.
In the two trauma patients, right mainstem intubations were noted in which specific pleural signals were not
seen in the left chest wall VPPI after tube placement. These signs returned after correct repositioning of the
ETT tube. I
All of the elective surgery patients, signs correlating with bilateral ventilation in each patient were imaged
and correlated with confirmation of ETT placement by anesthesiology.
Conclusions:
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US may be another tool to confirm ETT placement
US may have merit in extreme environments, such as in remote, prehospital settings or during aerospace
medical transports, in which auscultation is impossible due to noise, or capnography is not available
Requires further evaluation
Methods:
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Real-time B-mode ultrasound imaging was performed in 24 intubated patients in order
to confirm the correct placement of ET tubes
The large acoustic impedance mismatch between the air within the ET tube cuff and the
tracheal wall could be bypassed by (1) use of a foam-cuffed Bivona ET tube
(2) cuff inflation with saline instead of air
Optimal repositioning of the endotracheal tube could be done under direct visualization
Imaging of the foam-filled and saline-filled cuffs was easier in the longitudinal (sagittal)
than in the transverse view, was enhanced by a slight longitudinal to-and-fro motion of
the tube
Cases of esophageal intubation were not considered
Conclusion:
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Use of a noninvasive imaging modality such as ultrasound will spare selected patients
from the radiation exposure associated with a chest x-ray
 This is of value in pregnant patients and in those requiring frequent chest radiographs
for the sole purpose of confirming correct ET tube placement
Objective.
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Determining the correct position of ET tubes in critically ill patients may be complicated by
external factors such as noise, body habitus, and the need for ongoing resuscitation
Methods
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We describe the sonographic findings in a case series of endobronchial main stem intubations
and obstruction, highlighting the utility of this sonographic application.
Results
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US detection of the sliding lung sign, the lung pulse, and diaphragmatic excursion can
accurately detect main stem bronchial intubation as well as bronchial obstruction
Conclusions.
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Clinical use of lung sonography may decrease the need for chest radiography and may allow
more rapid diagnosis of main stem intubation and bronchial obstruction.
J Ultrasound Med 27:785-789 • 0278-4297
Methods:
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Cross-sectional observational study
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Convenience sample of patients presenting to the ED between Sept 2000 - Feb 2001
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EP sonographers who had undergone a 3h training session in limited echocardiography, focusing
on LVEF and CVP measurement, performed echocardiograms

LVEF was rated as poor (<30%), moderate (30%–55%), or normal (>55%) and an absolute %


CVP categories included low (<5 cm), moderate (5–10 cm), and high (>10 cm).
Formal echocardiograms were obtained within a four-hour window on all patients and
interpreted by a staff cardiologist
Results:

A total of 115 patients were assessed for LVEF, and 94 patients had complete information for CVP

Indications for echocardiography included chest pain (45.1%), CHF (38.1%), dyspnea (5.7%), and
endocarditis (10.6%).

LVEF correlation of r=0.712 with 86.1% overall agreement.

Subgroup analysis revealed the highest agreement (92.3%) between EP and formal
echocardiograms within the normal LVEF category, followed by 70.4% agreement in the poor
LVEF category and 47.8% in the moderate LVEF category.

CVP measurements resulted in 70.2% overall raw agreement between EP and formal
echocardiograms. Subgroup analysis revealed the highest agreement (83.3%) within the high
CVP category followed by 66.6% in the moderate and 20% in the low categories.
Methods:

Cross-sectional observational study,

Convenience sample of patients presenting to the ED between Sept 2000 - Feb 2001

Level III – credentialed EP sonographers who had undergone a three hour training session in limited
echocardiography, focusing on LVEF and CVP measurement, performed echocardiograms.

LVEF was rated as poor (<30%), moderate (30%–55%), or normal (>55%) and an absolute %


CVP categories included low (<5 cm), moderate (5–10 cm), and high (>10 cm).
Formal echocardiograms were obtained within a four-hour window on all patients and interpreted by a staff
cardiologist.
Results:

A total of 115 patients were assessed for LVEF, and 94 patients had complete information for CVP.

Indications for echocardiography included chest pain (45.1%), CHF (38.1%), dyspnea (5.7%), and endocarditis
(10.6%).

LVEF correlation of r=0.712 with 86.1% overall agreement.

Subgroup analysis revealed the highest agreement (92.3%) between EP and formal echocardiograms within the
normal LVEF category, followed by 70.4% agreement in the poor LVEF category and 47.8% in the moderate LVEF
category.

Central venous pressure measurements resulted in 70.2% overall raw agreement between EP and formal
echocardiograms. Subgroup analysis revealed the highest agreement (83.3%) within the high CVP category
followed by 66.6% in the moderate and 20% in the low categories.
Conclusions:

Experienced EP sonographers with a small amount of focused additional training in limited bedside
echocardiography can assess LVEF accurately in the ED