Mount Sinai Emergency Medicine Ultrasound

Welcome to the Emergency Ultrasound Division website! 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

The first and most important step in paracentesis is confirming there is ascites to begin with!

Physical examination findings can be misleading, and inserting a needle blindly into the abdomen can cause complications unnecessarily. Note the black free fluid in the image, with echogenic bowel loops floating within.

Several approaches are commonly used. Each one starts with an assessment for peritoneal fluid, localization of area suitable for paracentesis (no nearby vessels, large enough pocket, etc.). Next, measure the distance from skin to peritoneum to establish a sense of how far the needle lust penetrate before expecting to yield ascites. This is followed by either:

1. Real time (dynamic) ultrasound guidance. Probe held in non-dominant hand (or by assistant); dominant hand guides needle with real-time guidance using short- or long-axis technique
2. Static guidance: Mark the location for paracentesis (use a pen, pressure from a pen cap or fingernail, or even using a nearby mole/skin blemish as a landmark!), and then proceed with the tap using that mark as a guide. It is critical that the mapping is performed immediately before the paracentesis, and the patient remains in the same position. If the patient moves or is re-positioned,  the patient must be scanned again because the pocket of fluid would have shifted due to the highly mobile floating bowel loops.

As the needle is inserted into the abdomen using either technique, it is wise to hold slight negative pressure on the plunger of the syringe. This way, as soon as fluid or blood is encountered, the operator will note both a pressure change and a flash of fluid into the syringe.

The Adriatic Vascular Ultrasound Society will host its 7th annual meeting and CME conference September 23-25 in Montecatini Terme.

The official language for the conference is English, and it will be held in Tuscany!

This is an EFSUMB accredited Euroson school event. For more information please visit here.

The FAST exam is the prototypical application of emergency ultrasound. However, it is important to know that there are limited randomized controlled trials assessing the utility of the FAST exam. Despite this, let’s look at three good articles that  all emergency residents should know.

1. In this Cochrane review, the authors’ conclusion was that there was insufficient evidence for the use of ultrasound-based clinical pathways in the initial diagnostic workup of patients with blunt abdominal trauma. Ultrasound was not sensitive and lacked diagnostic accuracy. However, the use of ultrasound did reduce the use of CT scans. The take-home message is that ultrasound should not be used as a single rule-out test for significant intra-abdominal injury and the ED resident should be aware of ultrasound’s limitations.

Stengel D, Bauwens K, Sehouli J, Rademacher G, Mutze S, Ekkernkamp A, Porzsolt F. Emergency ultrasound-based algorithms for diagnosing blunt abdominal trauma (Review). The Cochrane Collaboration. February 18th, 2008.

2. Interestingly, this review used the same methodology as the Cochrane review and found that an adequately performed FAST exam can predict the need to send a patient to the operating room, with a high degree of sensitivity (98.9%) and specificity (98.1%).

Melniker LA. The value of focused assessment with sonography in trauma examination for the need for operative intervention in blunt torso trauma: a rebuttal to “emergency ultrasound-based algorithms for diagnosing blunt abdominal trauma (review)”, from the Cochrane Collaboration. Critical Ultrasound Journal. 2009;1:73-84.

3. Thoracic ultrasound has become part of the standard assessment of the trauma patient. Ultrasound has been shown to be much more sensitive than CXR in the detection of pneumothorax when compared to CT as the gold standard. There are many studies proving this point and this is a good example.

Blaivas M, Lyon M, Duggal S. A prospective comparison of supine chest radiography and bedside ultrasound for the diagnosis of traumatic pneumothorax. Acad Emerg Med. Sep 2005;12(9):844-849

As promised, here are selected references from today’s talk on Airway Management Mythology. Thanks to the organizers of the International Conference on Emergency Medicine (ICEM) for the invitation to speak.

Some of the topics discussed are supported by plenty of evidence (ie the use of RSI as an intubation technique), some were simply fun to discuss (holding your breath while intubating) and some remain quite reasonably controversial (the use of etomidate for RSI in sepsis).

I highly recommend visiting Dr. Reuben Strayer’s blog for a brief and enlightening discussion of the use of rocuronium for RSI. Also, Dr. Scott Weingart’s EMCrit blog and podcasts are an excellent source for ED critical care topics. Finally, The Airway Site contains links to key airway management references as well as information on the Difficult Airway Course.

Selected References:

• Farmery AD, Roe PG: A model to describe the rate of oxyhemoglobin desaturation during apnoea. Br J Anaesth 1996; 76:284-91
• Naguib et al. Optimal dose of succinylcholine revisited. Anesthesiology 2003; 99:1045-1049
• Bozeman et al. A comparison of rapid sequence intubation and etomidate-only intubation in the prehospital air medical setting. Prehosp Emerg Care: 2006; 10:8-13
• Sackles et al. Airway management in the emergency department: a one-year study of 610 tracheal intubations. Ann Emerg Med 1998; 31:325-332
• Li J et al. Complications of emergency intubation with and without paralysis. AJEM 1999: 17(2); 141-143
• Mallon WK et al. Rocuronium vs. succinylcholine in the emergency department: A critical appraisal. JEM 37(2); 183-188
• Strayer RJ. Rocuronium vs. succinylcholine revisited. JEM 2010 Apr 22. [Epub ahead of print]
• Cardiopulmonary resuscitation by bystanders with chest compression only (SOS-KANTO): an observational study, Lancet 369 (2007), pp. 920–926.
• Bobrow et al. Passive oxygen insufflation is superior to bag-valve-mask ventilation for witnessed ventricular fibrillation out-of-hospital cardiac arrest. Ann Emerg Med. 2009;54:656-662.
• Brimacombe JR and Berry JM. Cricoid pressure. Can J Anaesth. 1997 Apr;44(4):414-25

Here are some key references from today’s lecture on Status Epilepticus at ICEM:

FERNE’s seizure and status epilepticus management guide

Key practice guidelines related to seizures:

Special thanks to Professor Andy Jagoda (Department of Emergency Medicine, Mount Sinai, New York)