Mount Sinai Emergency Medicine Ultrasound

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

• Tutorials on the FAST exam, cardiac ultrasound, obstetrics, pneumothorax assessment, etc. as well as how to use the S-Cath and M-Turbo ultrasound machines.
• Information on our ultrasound division Faculty
• Ultrasound CME course information
• Selected faculty Publications
• Information about the ultrasound Rotation and Manual

We are very pleased to welcome the newest member of the Mount Sinai Emergency Ultrasound Division, Dr. Jennifer Huang!

Dr. Huang completed her residency training at Highland Hospital in Oakland, California and an emergency ultrasound fellowship at the SUNY Downstate / Kings County Hospital in Brooklyn, New York.  She has led emergency ultrasound courses and lectured both nationally and internationally.  She has also been an instructor for the ultrasound guided regional anesthesia course at ACEP since 2010.  Her interests include ultrasound education, ultrasound guided regional anesthesia, and critical care ultrasound.

The inaugural SonoGames were held at the SAEM Scientific Assembly in Chicago this week. Thirty-eight residency programs were represented at the event, organized by Resa Lewiss and SAEM’s Academy of Emergency Ultrasound. Three rounds separated the dabblers from the master sonographers. In order to win, teams had to demonstrate ultrasound knowledge on tests and then complete feats such as blindfolded scanning and replicating sample images.

Here are the results:

Winner: Boston Medical Center

Team members: Derek Wayman, Joseph Pare, and Neil Hadfield. Faculty: Kristin Carmody.

They share The Cup, and each take home a copy of The Manual of Emergency and Critical care Ultrasound

Runner-up: University of Texas-Houston

Semi-Finalists: University of Michigan, University of Connecticut, Carolinas Med Center

Arcuate vessels are commonly seen on ultrasound evaluation of the uterus. Occasionally they can be confused with subchorionic hemorrhage, ovaries, and other structures so it’s worth looking at their characteristic appearance.

Once again, thanks to Dr. Gray for his lovely, copyright-free images:

Here we see the Uterine venous plexus giving rise to the helicine branches, aka arcuate vessels. They run circumstantially through the outer margin of the myometrium.

In the images below, anechoic areas are visible in the posterior aspect of the myometrium (arrows in top two images). The bottom two images reveal the same structures with and without color flow, demonstrating their vascularity. These vessels are normal anatomic variations, and can become more engorged during pregnancy as uterine bloodflow increases.

This is again visible posteriorly in this video of a gravid uterus:

Rounding out our recent trifecta of biosafety posts is a description of cavitation. Cavitation is the formation of microbubbles in liquid which has been subjected to rapid pressure changes. This can happen from a variety of causes from beating Dolphin tails, propellers, cracking your knuckles, and with ultrasound. The Mechanical Index is used to represent the risk of cavitation in tissue during ultrasound evaluation, though most authorities do not think cavitation occurs in the normal operating parameters of diagnostic ultrasound.

During rarefaction (the low pressure portion of the ultrasound pressure wave) air-filled structures expand. They then quickly contract again during the remaining phases of the sound wave. Cavitation is deliberately employed in lithotrypsy, as well as non-medical applications such as metal cleaning.

According to Wikipedia:

The physical process of cavitation inception is similar to boiling. The major difference between the two is the thermodynamic paths that precede the formation of the vapor. Boiling occurs when the local vapor pressure of the liquid rises above its local ambient pressure and sufficient energy is present to cause the phase change to a gas. Cavitation inception occurs when the local pressure falls sufficiently far below the saturated vapor pressure, a value given by the tensile strength of the liquid at a certain temperature.

So there are two major bioeffects of ultrsound: Heat and cavitation. The risks of either are vanishingly small with normal diagnostic ultrasound use. No studies have demonstrated any ill effects of diagnostic ultrasound in humans or even fetuses. But understanding these processes at least helps us recognize the issues behind bioeffect concerns.

Notes from Grand Rounds on Cardiac Arrest Ultrasound this morning.

Screencast (in process)

Handout

RUSH in Arrest Algorithm

References:

Atkinson, P R T, D J McAuley, R J Kendall, O Abeyakoon, C G Reid, J Connolly, and D Lewis. “Abdominal and Cardiac Evaluation with Sonography in Shock (ACES): An Approach by Emergency Physicians for the Use of Ultrasound in Patients with Undifferentiated Hypotension.” Emergency medicine journal : EMJ 26, no. 2 (2009): doi:10.1136/emj.2007.056242.

Blaivas, M, and J C Fox. “Outcome in Cardiac Arrest Patients Found to Have Cardiac Standstill on the Bedside Emergency Department Echocardiogram.” Academic emergency medicine : official journal of the Society for Academic Emergency Medicine 8, no. 6 (2001): 616-21.

Breitkreutz, Raoul, Susanna Price, Holger V Steiger, Florian H Seeger, Hendrik Ilper, Hanns Ackermann, Marcus Rudolph, and others. “Focused Echocardiographic Evaluation in Life Support and Peri-Resuscitation of Emergency Patients: A Prospective Trial.” Resuscitation 81, no. 11 (2010): doi:10.1016/j.resuscitation.2010.07.013.

Hernandez, C, K Shuler, H Hannan, C Sonyika, A Likourezos, and J Marshall. “C.A.U.S.E.: Cardiac Arrest Ultra-Sound Exam–A Better Approach to Managing Patients in Primary Non-Arrhythmogenic Cardiac Arrest.” Resuscitation 76, no. 2 (2008): 198-206.

Jones, A E, V S Tayal, D M Sullivan, and J A Kline. “Randomized, Controlled Trial of Immediate Versus Delayed Goal-Directed Ultrasound to Identify the Cause of Nontraumatic Hypotension in Emergency Department Patients*.” Critical care medicine 32, no. 8 (2004): doi:10.1097/01.CCM.0000133017.34137.82.

Lichtenstein, Daniel A, and Gilbert A Mezière. “Relevance of Lung Ultrasound in the Diagnosis of Acute Respiratory Failure: The BLUE Protocol.” Chest 134, no. 1 (2008): doi:10.1378/chest.07-2800.

Rose, J S, A E Bair, D Mandavia, and D J Kinser. “The UHP Ultrasound Protocol: A Novel Ultrasound Approach to the Empiric Evaluation of the Undifferentiated Hypotensive Patient.” The American journal of emergency medicine 19, no. 4 (2001): 299-302.

Salen, Philip, Larry Melniker, Carolyn Chooljian, John S Rose, Janet Alteveer, James Reed, and Michael Heller. “Does the Presence or Absence of Sonographically Identified Cardiac Activity Predict Resuscitation Outcomes of Cardiac Arrest Patients?” The American journal of emergency medicine 23, no. 4 (2005): 459-62.

Weingart, Scott, Daniel Duque and Bret Nelson. “The RUSH Exam – Rapid Ultrasound for Shock / Hypotension.” http://www.webcitation.org/5vyzOaPYU (accessed January 9, 2011).