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Register for the Sinai Emergency Critical Care Ultrasound Course here.

Welcome! This is the website for the Mount Sinai Emergency Ultrasound Division. It serves as an information resource for residents, fellows, medical students and others seeking information about point-of-care ultrasound. There is a lot of information here, so please explore the site and send us feedback. To make things easier for new users we’ve condensed some of the highlights here:

Cardiac Arrest Ultrasound AIUM 2014

Screen Shot 2014 03 30 at 1.27.53 PM Cardiac Arrest Ultrasound AIUM 2014

As promised, references from today’s lecture.

Background

1. Arntfield RT, and Millington SJ. Point of care cardiac ultrasound applications in the emergency department and intensive care unit–a review. Curr Cardiol Rev. 2012, May;8(2): 98-108.
2. Bocka JJ, Overton DT, and Hauser A. Electromechanical dissociation in human beings: an echocardiographic evaluation. Ann Emerg Med. 1988, May;17(5):450-2.

3. Giraud R, Siegenthaler N, Schussler O, Kalangos A, Müller H, Bendjelid K, and Banfi C. The LUCAS 2 Chest Compression Device Is Not Always Efficient: An Echographic Confirmation. Ann Emerg Med. 2014, Feb 12;
4. Hollister N, Bond R, Donovan A, and Nicholls B. Saved by focused echo evaluation in resuscitation. Emerg Med J. 2011, Nov;28(11):986-9.

5. Niendorff DF, Rassias AJ, Palac R, Beach ML, Costa S, and Greenberg M. Rapid cardiac ultrasound of inpatients suffering PEA arrest performed by nonexpert sonographers. Resuscitation. 2005, Oct;67(1):81-7.
6. Rich S, Wix HL, and Shapiro EP. Clinical assessment of heart chamber size and valve motion during cardiopulmonary resuscitation by two-dimensional echocardiography. Am Heart J. 1981, Sep;102(3 Pt 1):368-73.

7. Werner A, Greene L, Janko L, and Cobb A. Visualization of cardiac valve motion in man during external chest compression using two-dimensional echocardiography. Implications regarding the mechanism of blood flow. Circulation. 1981, Jun 1;63(6):1417-1421.

Prognosis in Cardiac Arrest Ultrasound

1. Aichinger G, Zechner PM, Prause G, Sacherer F, Wildner G, Anderson CL, et al. Cardiac movement identified on prehospital echocardiography predicts outcome in cardiac arrest patients. Prehosp Emerg Care. 2012;16(2):251-5.
2. Breitkreutz R, Price S, Steiger HV, Seeger FH, Ilper H, Ackermann H, et al. Focused echocardiographic evaluation in life support and peri-resuscitation of emergency patients: a prospective trial. Resuscitation. 2010, Nov;81(11):1527-33.

3. Cohn B. Does the absence of cardiac activity on ultrasonography predict failed resuscitation in cardiac arrest? Ann Emerg Med. 2013, Aug;62(2):180-1.
4. Cureton EL, Yeung LY, Kwan RO, Miraflor EJ, Sadjadi J, Price DD, and Victorino GP. The heart of the matter: utility of ultrasound of cardiac activity during traumatic arrest. J Trauma Acute Care Surg. 2012, Jul;73(1):102-10.

5. Hayhurst C, Lebus C, Atkinson PR, Kendall R, Madan R, Talbot J, et al. An evaluation of echo in life support (ELS): is it feasible? What does it add? Emerg Med J. 2011, Feb;28(2):119-21.
6. Kudenchuk PJ, Cobb LA, Copass MK, Cummins RO, Doherty AM, Fahrenbruch CE, et al. Amiodarone for resuscitation after out-of-hospital cardiac arrest due to ventricular fibrillation. N Engl J Med. 1999, Sep 16;341(12):871-8.

7. Nelson BP, Patel VR, Norris MM, and Richardson BK. The utility of cardiac sonography and capnography in predicting outcome in cardiac arrest. International journal of emergency medicine. 2008;1(3):213-5.
8. Salen P, O’Connor R, Sierzenski P, Passarello B, Pancu D, Melanson S, et al. Can cardiac sonography and capnography be used independently and in combination to predict resuscitation outcomes? Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 2001;8(6):610-5.

9. Salen P, Melniker L, Chooljian C, Rose JS, Alteveer J, Reed J, and Heller M. Does the presence or absence of sonographically identified cardiac activity predict resuscitation outcomes of cardiac arrest patients? Am J Emerg Med. 2005, Jul;23(4):459-62.

10. Schuster KM, Lofthouse R, Moore C, Lui F, Kaplan LJ, and Davis KA. Pulseless electrical activity, focused abdominal sonography for trauma, and cardiac contractile activity as predictors of survival after trauma. J Trauma. 2009, Dec;67(6):1154-7.

11. Schuster KM, and Davis KA. Response to “Pulseless electrical activity focused abdominal sonography for trauma, and cardiac contractile activity as predictors of survival after trauma”. J Trauma. 2010, May;68(5):1270.

12. Tayal VS, and Kline JA. Emergency echocardiography to detect pericardial effusion in patients in PEA and near-PEA states. Resuscitation. 2003, Dec;59(3):315-318.
13. Tomruk O, Erdur B, Cetin G, Ergin A, Avcil M, and Kapci M. Assessment of Cardiac Ultrasonography in Predicting Outcome in Adult Cardiac Arrest. Journal of International Medical Research. 2012, Apr 1;40(2):804-809.

Algorithmic approach to Cardiac Arrest Ultrasound

1. Amaya SC, and Langsam A. Ultrasound detection of ventricular fibrillation disguised as asystole. Ann Emerg Med. 1999, Mar;33(3):344-6.

2. Blyth L, Atkinson P, Gadd K, and Lang E. Bedside focused echocardiography as predictor of survival in cardiac arrest patients: a systematic review. Acad Emerg Med. 2012, Oct;19(10): 1119-26.

3. Chardoli M, Heidari F, Rabiee H, Sharif-Alhoseini M, Shokoohi H, and Rahimi-Movaghar V. Echocardiography integrated ACLS protocol versus conventional cardiopulmonary resuscitation in patients with pulseless electrical activity cardiac arrest. Chin J Traumatol. 2012;15(5):284-7.

4. Hernandez C, Shuler K, Hannan H, Sonyika C, Likourezos A, and Marshall J. C.A.U.S.E.: Cardiac arrest ultra-sound exam–a better approach to managing patients in primary non- arrhythmogenic cardiac arrest. Resuscitation. 2008, Feb;76(2):198-206.

5. Horowitz R, Gossett JG, Bailitz J, Wax D, and Pierce MC. The FLUSH Study-Flush the Line and Ultrasound the Heart: Ultrasonographic Confirmation of Central Femoral Venous Line Placement. Ann Emerg Med. 2014, Jan 15;

6. Mallin M, Curtis K, Dawson M, Ockerse P, and Ahern M. Accuracy of ultrasound-guided marking of the cricothyroid membrane before simulated failed intubation. The American Journal of Emergency Medicine. 2014, Jan;32(1):61-63.

7. Nagdev A, and Mantuani D. A novel in-plane technique for ultrasound-guided pericardiocentesis. Am J Emerg Med. 2013, Sep;31(9):1424.e5-9.

8. Pfeiffer P, Rudolph SS, Børglum J, and Isbye DL. Temporal comparison of ultrasound vs. auscultation and capnography in verification of endotracheal tube placement. Acta Anaesthesiol Scand. 2011, Nov;55(10):1190-5.

9. Pfeiffer P, Bache S, Isbye DL, Rudolph SS, Rovsing L, and Børglum J. Verification of endotracheal intubation in obese patients – temporal comparison of ultrasound vs. auscultation and capnography. Acta Anaesthesiol Scand. 2012, May;56(5):571-6.
10. Weingart SW, Duque DD, and Nelson BN. The RUSH Exam – Rapid Ultrasound for Shock / Hypotension [Internet]. ACEP-EMED Home. 2009, Apr 3;[cited 2011, Jan 9] Available from: http:// www.webcitation.org/5vyzOaPYU

Future of Cardiac Arrest Ultrasound

1. Abbasi S, Farsi D, Zare MA, Hajimohammadi M, Rezai M, and Hafezimoghadam P. Direct ultrasound methods: a confirmatory technique for proper endotracheal intubation in the emergency department. Eur J Emerg Med. 2014, Jan 16;

2. Blaivas M. Transesophageal echocardiography during cardiopulmonary arrest in the emergency department. Resuscitation. 2008, Aug;78(2):135-40.

3. Copetti R. Clinical Integrated Ultrasound in Peri Cardiac Arrest and Cardiac Arrest. J Clinic Experiment Cardiol S. 2012;102.

4. Doepp Connolly F, Reitemeier J, Storm C, Hasper D, and Schreiber SJ. Duplex sonography of cerebral blood flow after cardiac arrest-A prospective observational study. Resuscitation. 2013, Dec 30;

5. Hogan TS. External cardiac compression may be harmful in some scenarios of pulseless electrical activity. Med Hypotheses. 2012, Oct;79(4):445-7.

6. van der Wouw PA, Koster RW, Delemarre BJ, de Vos R, Lampe-Schoenmaeckers AJ, and Lie KI. Diagnostic accuracy of transesophageal echocardiography during cardiopulmonary resuscitation. J Am Coll Cardiol. 1997, Sep;30(3):780-3.
7. Vieillard-Baron A, Slama M, Mayo P, Charron C, Amiel JB, Esterez C, et al. A pilot study on safety and clinical utility of a single-use 72-hour indwelling transesophageal echocardiography probe. Intensive Care Med. 2013, Apr;39(4):629-35.

 

 

Faculty group photo

SonoSweden 2014 course

At the end of January, Bret Nelson joined an incredible team of international a faculty for the largest SonoSweden course to date. Course director Christofer Muhr hosted this unique, intensive hands-on conference at the scenic Yasuragi hotel in Stockholm, Sweden. Over thirty faculty and one hundred participants took part in this three-day course.

Among the faculty were lung ultrasound pioneer Vicki Noble, Matt Dawson and Mike Mallin (creators of the Ultrasound Podscast) and others from around the globe.

Registration is not yet open for the 2015 course, but check out the SonoSweden website for a countdown timer- there were over 100 people on the waiting list for this year’s course!

Last days of the stethoscope?

GH TOC 500x381 Last days of the stethoscope?In the current issue of Global Heart (journal of the World Heart Foundation), several Mount Sinai authors have published articles on the use of point-of-care ultrasound. Phil Andrus wrote about focused cardiac ultrasound, Jennifer Huang co-authored a review of ultrasound use in IVC assessment, Daniel Lakoff described ultrasound incorporation into rapid response teams in inpatient wards, and Bret Nelson and Amy Sanghvi wrote a review of non-cardiologist use of cardiac ultrasound.

Bret Nelson and Global Heart Editor-in-Chief Jagat Narula wrote the editorial for the issue, which focused on improvements in ultrasound technology creating new opportunities and markets for ultrasound use. One theme of the editorial was whether ultrasound could replace the stethoscope, and as you may imagine the press has picked up on that thread!
CBS news visited Mount Sinai and interviewed Drs. Nelson and Narula.
And a number of media outlets have covered the story, including Popular Mechanics, the Huffington Post and others.
Mount Sinai has incorporated ultrasound into medical student education in Gross Anatomy since 2006, and last year began a curriculum in focused ultrasound as part of the physical examination course.

January 23rd NYC RESUS Rounds

Spectacular rounds this week lead by Sahar Ahmad of Stonybrook and hosted by Pierre at BI.

 January 23rd NYC RESUS RoundsSahar gave a great presentation on her didactic program for the critical care fellows at Stonybrook.  She then presented a series of discussion inducing cases.  Carl Kaplan (of Stonybrook not RUSH) presented an interesting case of ONSD ultrasound for hydrocephalus.  Sam Parnia gave a presentation on the cardiopulmonary resuscitation research being done at Stonybrook on cerebral oximetry.

Some of the articles (with pmid and link) that came up in discussion were:

  • The Lung US Consensus Recommendations: 22392031
  • Copetti ARDS vs Pulmonary Edema: 18442425
  • NASA MRI Optic Nerve sheath: 22416248
  • Louis Eisen Optic Nerve sheath: 21519957
  • Flawed Pediatric Optic nerve sheath article 19167786 
  • re “reverse” FALLS protocol – Vicki Noble’s on bline resolution at dialysis 19188552

See you next time.

Aortic dissection

Aortic Dissection – A Covert Killer

Aortic dissections are insidious killers that are often undetectable by history and physical exam alone. Obviously, providers must have a high index of suspicion for these as their presentations are highly variable. CT angiography, and less often, transesophageal echocardiography are classically the diagnostic modalities that providers use to identify this rare, deadly diagnosis. However, getting a patient over to CT can sometimes be delayed whether it is for transportation, or stabilizing the patient before CT scan.

cartoon ninja 8 300x300 Aortic Dissection   A Covert Killer

Case:

A 73 year old lady with only a past medical history of hypertension that presented to our emergency department with intermittent focal left upper extremity numbness and weakness, and bilateral lower extremity pain. She presented hypotensive and tachycardic. The astute clinician had a high index of suspicion of dissection and while the patient was getting prepared to go to CT scan obtained the following clip of the parasternal long axis of the heart:

It is obvious here that the aortic outflow tract is dilated (usually, it should be the size of the left atrium).

Then the physician obtained a suprasternal view of the aortic arch and obtained the following clip:

Then, given the focal neurologic symptoms, she got the following images of the right carotid, in which you can see an intimal flap and also more distally, a blood clot in the carotid:

To investigate the distal extension of the clot, the following views were obtained of the abdominal aorta with an actual intimal flap:


Finally, at the level of the bifurcation, extension of the dissection into the bilateral iliacs is visualized

CT surgery was notified before the CT scan and the patient was taken directly from the CT scanner (which revealed the image below) to the OR..

Screen shot 2013 11 19 at 1.49.48 AM 300x281 Aortic Dissection   A Covert Killer

Tips on POCUS for aortic dissection:

  1. A parasternal long axis view can be helpful to visualize a dilated aortic root and/or a pericardial effusion in the setting of a suspected dissection
  2. Evaluating carotid arteries, the distal aorta, or the iliac arteries can help diagnose an extensive dissection.
  3. Point of care ultrasound should be used to quickly make a diagnosis, speed further imaging, or get a consultant involved expeditiously. Similar to much of what we do with point of care ultrasound, this tool should be used to rule in a diagnosis, rather than to rule out a diagnosis.
  4. Point of care ultrasound can be used to make a quick diagnosis at the bedside before more consultative imaging, making it an invaluable tool in identifying this covert killer.

 

ACEP National Faculty Teaching Award

The American College of Emergency Physicians awarded its annual National Faculty Teaching award in Seattle this year during the Academic Affairs committee meeting.

Bret Nelson, Director of the Emergency Ultrasound Division at Mount Sinai, was one of four faculty honored nationally.

NFTA group 500x332 ACEP National Faculty Teaching Award

Left to right: Federico E. Vaca, MD, MPH; Vicken Y. Totten, MD, MS, FACEP; Bret P. Nelson, MD, RDMS, FACEP; Yashwant Chathampally, MD, MS

According to ACEP,

The American College of Emergency Physicians sponsors a national faculty teaching and junior faculty teaching award to honor outstanding educators in emergency medicine. These awards are designed to support emergency medicine faculty in their efforts to achieve academic advancement, as well as support the continued academic development of the specialty. The awards recognize superior teaching activities including didactic lectures, clinical instruction, the development of innovative educational programs, as well as the endorsement by faculty, residents, and students.