Mount Sinai Emergency Medicine Ultrasound

Here are the references and brief overview of Bret Nelson’s talk at the 2011 ACEM conference in Bangkok, Thailand on July 5.

The Focused Assessment with Sonography in Trauma (FAST) was first described decades ago and hundred of citations exist regarding its use. Although it has become a standard part of the evaluation of the trauma patient, there exists some controversy regarding its use. In 2005 a Cochrane Review was published which concluded:

There is currently insufficient evidence from RCTs [randomized controlled trials] to justify promotion of ultrasound-based clinical pathways in diagnosing patients with suspected blunt abdominal trauma.

Stengel D, Bauwens K, Sehouli J, Rademacher G, Mutze S, Ekkernkamp A, Porzsolt F. Emergency ultrasound-based algorithms for diagnosing blunt abdominal trauma. Cochrane Database of Systematic Reviews 2005, Issue 2. Art. No.: CD004446

The review included four RCTs:

1. Arrillaga A, Graham R, York JW, Miller RS. Increased efficiency and cost-effectiveness in the evaluation of the blunt abdominal trauma patient with the use of ultrasound. The American Surgeon 1999; 65:31-5.
2. Boulanger BR, McLellan BA, Brenneman FD, Ochoa J, Kirkpatrick AW. Prospective evidence of the superiority of a sonography-based algorithm in the assessment of blunt abdominal injury. Journal of Trauma 1999; 47:632-7.
3. Melniker LA, Leibner E, McKenney MG, Lopez P, Briggs WM, Mancuso CA. al. Randomized controlled clinical trial of point-of-care, limited ultrasonography  in the emergency department: the First Sonography Outcomes Assessment Program Trial. Academic Emergency Medicine 2006; 48:227-35.
4. Rose JS, Levitt A, Porter J, Hutson A, Greenholtz J, Nobay F, Hilty W. Does the presence of ultrasound really affect computed tomographic scan use? A prospective randomized controlled trial of ultrasound use in trauma. Journal of Trauma 2001; 51:545-50.

Great debate ensued, including a literal debate between Dr. Melniker (author of study #3 above), Dr. Stengel (author of the Cochrane Review on FAST) and other prominent researchers featured during the opening session at the Second World Congress on Ultrasound in Emergency and Critical Care Medicine in New York in 2006.

Dr. Melniker also published the following rebuttal to the Cochrane Review conclusions:

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.

Included in the rebuttal was an analysis of FAST literature focusing on cases which required operative intervention. Dr. Melniker found the FAST exam had a false negative rate (ie. patient required operative intervention despite a negative FAST exam) in 5.8% of cases as they were initially published. Upon further review of those false negative cases (and exclusion of inadequate studies, patients who did not go to the OR during at the time of their initial evaluation, etc.) it may be that the actual false negative rate approaches 1.1%.

Thus, it is critically important to define appropriate outcome measures when we evaluate the utility of a diagnostic test. Do we care about the FAST exam’s ability to detect hemoperitoneum? The ability to detect which patients should go to the OR? And to what extent does the clinical picture (ie. mechanism of injury and hemodynamic stability) determine how we proceed? Few would argue that ultrasound has better test characteristics than CT scan; the utility of sonography is non-invasive, repeatable examinations at the point of care.

This type of discussion is incredibly important, and helps clinicians better determine how to employ the appropriate diagnostic tests in their practice. Non-operative management of blunt abdominal injury is becoming more common, and our interpretation of the FAST as well as other diagnostic tests must evolve:

• Knudson et al. Nonoperative management of solid organ injuries. Past, present, and future. Surg Clin North Am. 1999 Dec;79(6):1357-71.
• Velmahos et al. High success with nonoperative management of blunt hepatic trauma: the liver is a sturdy organ. Arch Surg. 2003 May;138(5):475-80; discussion 480-1.
• Velmahos et al. Nonoperative treatment of blunt injury to solid abdominal organs: a prospective study. Arch Surg. 2003 Aug;138(8):844-51.
• Haan et al. Nonoperative management of blunt splenic injury: a 5-year experience. J Trauma. 2005 Mar;58(3):492-8.
• Yanar et al. Nonoperative treatment of multiple intra-abdominal solid organ injury after blunt abdominal trauma. J Trauma. 2008 Apr;64(4):943-8.

Discussions of the utility of trauma ultrasound are valuable because they force us to consider best practices in terms of clinical management of trauma, appropriate use of diagnostic tests, as well as determining appropriate outcomes-based metrics for quality healthcare delivery.

Please comment below or email me with questions.

The Emergency Ultrasound Interest Group has become an Academy thanks to the hard work of Beatrice Hoffman MD, PhD and James Moak MD, current and past Chairs and many others.  The Word of the Day for the meeting was “Sonopalpation.”  Congratulations to Vicki Noble MD for winning the 2011 SAEM Ultrasound Academy Research Award, and Chris Fox MD for winning the 2011 SAEM Ulltrasound Academy Education Award!

Vicki Noble accepting the AEUS research award.

Chris Fox accepting the AEUS education award

Welcome to the incoming executive board — Matt Fields, secretary; Stan Wu, treasurer; Andrew Liteplo – education officer; Romolo Gaspari – research officer, Resa Lewiss, incoming chair, and Nova Panebianco 2012-2013 chair-elect.

Left to Right: Resa, Nova, Romolo, Andrew, Stan, Matt

The first World Congress on Ultrasound in Medical Education has come to a close.  The event was a great success, with excellent plenary sessions in the morning, hands-on teaching in the afternoon and southern hospitality in the evening.  It was nice to see so many familiar faces, and although we couldn’t capture everyone, we had to record a few for posterity.

Check out the slideshow or click through from the gallery below to download any of these from my flickr account.

Until next time…

Phil, Bret, Jim, Rob and Ee.

The first World Conference on Ultrasound in Medical Education (WCUME) kicks off today in Columbia, South Carolina. We are looking forward to seeing some of Point of Care Ultrasound’s luminaries here.

Richard Hoppmann, the dean of the University of South Carolina school of medicine, the president of the Society of Ultrasound in Medical Education is the principal organizer of the conference. Dr. Hoppmann runs inarguably the most well integrated ultrasound program for undergraduate medical students — we hope to learn a lot from him over the next few days. Abraham Verghese who a frequent contributer to the Atlantic, and nationally recognized for his efforts to return patient care to the bedside will be giving a plenary on “the brave new world of bedside diagnosis”. We always come away enriched from lectures by faculty like: Michael Blaivas, Daniel Lichtenstein, Luca Neri, Tomislav Petrovic, Andrew Kirkpatrick, Vicki Noble, and we are excited to hear from those we haven’t met.

Our own Jim Tsung will be omnipresent. Jim is lecturing on the history of ultrasound and recent advances in technology. Jim will be joined by Sinai faculty Bret Nelson, Phil Andrus and our fellows Rob Arntfield and Ee Tay for hands-on sessions on pediatric ultrasound, ultrasound guided procedures and lung ultrasound.

If you are headed to South Carolina, we’ll see you here.

If you haven’t been reading LITFL, you ought to be. Mike Cadogan and Chris Nickson regularly put out high quality EM/CC posts and offer great resources. The latest of which is the EM/CC Blog database. Not only are the luminaries of EM/CC blogging’s websites listed, but their RSS feeds, twitter feeds and Facebook pages are all there for your perusal.

This is a great table to go through to find out what you may be missing across the web.