References

FAST/eFAST

• Heron MP, Hoyert DL, Murphy SL, Xu JQ, Kochanek KD, Tejada-Vera B. Deaths: Final data for 2006. National vital statistics reports; vol 57 no 14. Hyattsville, MD: National Center for Health Statistics. 2009.
• Scalea TM, Rodriguez A, Chiu WC, Brenneman FD, Fallon WF Jr, Kato K, McKenney MG, Nerlich ML, Ochsner MG, Yoshii H. Focused Assessment with Sonography for Trauma (FAST): results from an international consensus conference. J Trauma,1999;46:466-72. Price D, Simon BC, Park RS. Evolution of emergency ultrasound. California J Emerg Med.2003;4:82-88.
• Kirkpatrick AW, Sirois M, Laupland KB, Liu D, Rowan K, Ball CG, Hameed SM, Brown R, Simons R, Dulchavsky SA, Hamiilton DR, Nicolaou S. Hand-held thoracic sonography for detecting post-traumatic pneumothoraces: the Extended Focused Assessment with Sonography for Trauma (EFAST). J Trauma,2004;57:288-95.
• Lichtenstein D, Meziere G, Lascols N, Biderman P, Courret JP, Gepner A, Goldstein I, Tenoudji-Cohen M. Ultrasound diagnosis of occult pneumothorax. Crit Care Med,2005;33:1231-8.
• Ma OJ, Mateer JR, Ogata M, Kefer MP, Wittmann D, Aprahamian C. Prospective analysis of a rapid trauma ultrasound examination performed by emergency physicians. J Trauma,1995;38:879-85.
• Rozycki GS, Ochsner MG, Schmidt JA, Frankel HL, Davis TP, Wang D, Champion HR. A prospective study of surgeon-performed ultrasound as the primary adjuvant modality for injured patient assessment. J Trauma,1995;39:492-500.
• Ma OJ, Mateer JR. Trauma ultrasound examination versus chest radiography in the detection of hemothorax. Ann Emerg Med, 1997;29:312-6.
• Abrams BJ, Sukumvanich P, Seibel R, Moscati R, Jehle D. Ultrasound for the detection of intraperitoneal fluid: the role of Trendelenburg positioning. Am J Emerg Med,1999;17:117-20.
• Reardon R, Ultrasound in Trauma – The FAST Exam. In sonoguide. Retrieved 3/1/2010, from http://sonoguide.com/FAST.html.
• V. Noble, B. Nelson and A.N. Sutingco, Focused Assessment with Sonography in Trauma (FAST): Manual of emergency and critical care ultrasound (1st edn), Cambridge University Press, New York (2007).

Ocular Ultrasound

• T Soldatos, K Chatzimichail, M Papathanasiou, et al. Optic nerve sonography: a new window for the non-invasive evaluation of intracranial pressure in brain injury. Emerg Med J 2009 26: 630-634.
• Kevin R. Roth, Gregory Gafni-Pappas, Unique Method of Ocular Ultrasound Using Transparent Dressings, The Journal of Emergency Medicine, In Press, Corrected Proof, Available online 25 January 2010, ISSN 0736-4679, DOI: 10.1016/j.jemermed.2009.10.020.
• Tayal VS, Neulander M, Norton HJ, Foster T, Saunders T, Blaivas M, Emergency Department Sonographic Measurement of Optic Nerve Sheath Diameter to Detect Findings of Increased Intracranial Pressure in Adult Head Injury Patients, Annals of Emergency Medicine, Volume 49, Issue 4, April 2007, Pages 508-514.
• Blaivas M, Theodoro D, Sierzenski P. Elevated intracranial pressure detected by bedside emergency ultrasonography of the optic nerve sheath. Acad Emer Med.2003;10:376-381.
• Blaivas M. Bedside emergency department ultrasonography in the evaluation of ocular pathology. Acad Emerg Med.2000;7:947-950.
• V. Noble, B. Nelson and A.N. Sutingco, Ocular ultrasound: Manual of emergency and critical care ultrasound (1st edn), Cambridge University Press, New York (2007).

Images

• Personal Collection
• sonoguide.com
• trauma.org
• flickr.com
• Visible Human Project

Contact

Phillip Andrus, MD, FACEP
Department of Emergency Medicine
Division of Emergency Critical Care
Division of Emergency Ultrasound
1 Gustave L. Levy Place
New York, NY 10024

email: phillip.andrus@mssm.edu

This month we looked at 2 articles on ultrasound guided regional anesthesia.  To do so, Makini and I started from Elmhurst conference where she had presented the ultrasound case of the month on brachial artery peak velocity variation to predict fluid responsiveness.  While trying to find a spot we could sit and talk we considered La Fusta and Jackson diner.  They didn’t ring true as the place for ultrasound journal club.  So we got on the E train heading west and made a switch to the 6 heading toward Sinai.  Unsure of our destination, we got off at 85th street, still unsure of our destination.  Makini was calm, I started to sweat – where could we go.  To make things worse, Makini had eaten a full share of her conference pizza and yet was still hankering for real food – more than just a coffee.   Mindful of maintaining my waif like figure, I was not at all interested in a second lunch.  What a dilemma!  I pulled out Urban Daddy on my iPhone and hoped for the perfect match, but it’s suggestion was Tevere 84 Italian Glatt Kosher Restaurant.  Part of me liked this thought, the idea of carciofi alla judea took me back to my youth in Rome, but I snapped back to reality — If I couldn’t keep my model like figure, how would I compete with our younger attendings who regularly solicited by modeling agencies.  Lost, though not caught between good and evil on an island, we turned left toward Fifth and stumbled into Cafe Sabarsky.  The perfect fit.  After a once over by the doorman, we were allowed to enter.  Makini ordered the apfelstrudel, I abandoned my fantasy of a healthy BMI and ordered the sachertorte (mit schlag of course).

And ultrasound journal club began in earnest…

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Bret Nelson returned to Singapore this month to join the faculty for a WINFOCUS introductory ultrasound course. Over fifty registrants from all over Singapore were in attendance, representing emergency medicine, critical care, surgery, internal medicine, anesthesia, and nephrology. Many thanks to Dr. Francis Lee, course director as well as Dr. Toh Hong Chuen who organized many of the course logistics.

More pics of the conference and Singapore after the break!

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This month we reviewed two articles on ultrasound guidance for central access.  The first of these was an instructive case series by Mike Blaivas — Video Analysis of Accidental Cannulation with Dynamic Ultrasound Guidance for Central Venous Access: Michael Blaivas: J Ultrasound Med 2009; 28:1239–1244.

At the author’s institution, a continuous recording of ultrasound guidance is usually obtained for each central line placement.  This allowed him to perform a retrospective analysis of the video recording of 6 cases in which arterial cannulation occurred despite the use of ultrasound.   Arterial cannulation in these patients led to serious complication in 4 patients, airway compromise in one, and to death in the sixth.   The findings remind us of what we ought to already know and Dr. Blaivas offers suggestions to decrease the likelihood of these outcomes.

What we know:

• Hypotensive patients are more likely to have collapsible veins – increasing the likelihood of puncturing the posterior wall of the vessel.
• Hypotensive patients  less likely to have the strongly pulsatile arterial flow – rendering this an inadequate measure of confirmation of venous cannulation.
• Hypoxic patients are more likely to have darker arterial blood – making this another inadequate marker of venous cannulation.

The author reminds us that short axis placement may be misleading.  That is, the hyperechoic part of the needle you are imaging inside a vein may actually be the midportion of your needle rather than the tip.  The tip may actually deeper, within unseen structures such as the carotid artery.  He concludes that it may be superior to cannulate the central vein using the long view, or at least to confirm placement of the guidewire in long view to confirm venous placement before dilation.

Would this publication change our practice? This report gave us all food for thought as our current policy regarding prevention of arterial cannulation includes measures which are largely post-dilation.  We agreed that there is little downside to checking the placement of the guidewire in long view prior to dilation.  Coupled with manometry prior to dilation, long view provides the best evidence that your placement is correct.

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Thanks to Eduardo LaCalle for his excellently summary and critique of the second article — Ultrasound localization of central vein catheter and detection of postprocedural pneumothorax: An alternative to chest radiograph: Vezzani et. al. : Crit Care Med 2010 Vol. 38, No. 2.

Dr. Vezzani, et. al., set out to look at confirmation of line placement via another route — CXR vs. US.  This was a prospective diagnostic study performed in the ICU of a large hospital (1200 beds) in Parma, Italy. They looked at all ICU patients older than 18 over 6 months. What they did was to place central line by landmark technique. Then each patient had ultrasound, including contrast enhanced ultrasound (CEUS) as well a cxr. The contrast was provided by agitated saline (9cc saline with 1 cc air). These studies were performed by a single sonographer. Appropriate SVC placement was indicated by laminar flow of bubbles seen in the RV on CEUS via subxyphoid view. RA/IVC placement was indicated by the tip seen in the RA or turbulent flow implying that the agitated saline was being infused directly into the RA. IJ placement was implied by a >2 second delay to appearance of bubbles during CEUS. In addition US was used to check for PTX.

They had 111 cases. 99 were not technically limited. 34 complications were noted on ultrasound vs. 30 on CXR. Ultrasound noted 25 RA placements, 4 IJ placements and 4 Pneumothoraces. CXR noted 24 RA, 4 IJ placements and 2 Pneumothoraces. The authors concluded that CEUS and CXR are at least equivalent and us should replace cxr after central line placement to r/o ptx and confirm tip position.

Would this publication change our practice? Well there are some limitations to this study that give pause. First of all, the CEUS exams were performed by a single sonographer, the first author of the study. This suggests that technical proficiency may play a significant role here – similar results may not be easily achievable by your average EP.   On the other hand, the gold standard for confirming catheter placement or pneumothorax in this study, CXR, is known not to be without fail .  I would be loathe to drop the CXR confirmation based on this single study.  However, there is clearly a role for ultrasound in line confirmation and it probably ought to be added to CXR, especially to look for pneumothorax.

In response to recent confusion:

How can you tell the difference between Ultrasound Gel (used for ultrasound machines) and Electrode Gel (used for defibrillation)?

Answers after the break!

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