Category Archives: Uncategorized

Physical exam

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Is ultrasound the stethoscope of the future? Is it an extension of the physical examination? Will it replace the physical exam?

No.

Point-of-care ultrasound is a diagnostic test. It is a rapid, bedside, noninvasive, accurate, diagnostic test, but still a diagnostic test. It can certainly augment data obtained through physical examination and medical interviews, and adds to information obtained by blood assays and radiology studies.

It is performed using FDA-approved medical devices by clinicians with specialized training. Images used for medical decision-making may be archived and shared with colleagues from multiple specialties. Quality assurance programs improve clinician accuracy and accountability. These are not physical examination characteristics. These are qualities of good diagnostic tests.

There is and will continue to be debate about this issue. Whether we think about point-of-care ultrasound as a diagnostic test or part of the physical examination has ramifications for training, documentation, archiving, and billing.

We recommend checking the guidelines relevant to your specialty and making up your own mind on this issue. In either camp some things remain constant: train well and use ultrasound to enhance the care you provide your patients.

 

Ultrasound First

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usFirst 500x104 Ultrasound FirstWe previously reported on AIUM’s Ultrasound First initiative back in March. Since then a number of helpful articles have been published in the Journal of Ultrasound in Medicine, each highlighting the utility of ultrasound as the primary imaging modality.

Thus far, topics include:

Sonography in Postmenopausal Bleeding – Steven R. Goldstein, MD

Think Ultrasound When Evaluating for Pneumothorax – Vicki E. Noble, MD

Sonography Should Be the First Imaging Examination Done to Evaluate Patients With Suspected Endometriosis – Beryl R. Benacerraf, MD, and Yvette Groszmann, MD

Sonography of Adenomyosis – Khaled Sakhel, MD, and Alfred Abuhamad, MD

Lung Ultrasound in Evaluation of Pneumonia – Michael Blaivas, MD

Ultrasound-Guided Interscalene Blocks – Andrew Gorlin, MD, and Lisa Warren, MD

Sonography for Surveillance of Patients With Crohn Disease – Kerri L. Novak, MSc, MD, FRCPC, and Stephanie R. Wilson, MD, FRCPC

Sonography as the First Line of Evaluation in Children With Suspected Acute Appendicitis – Leann E. Linam, MD, and Martha Munden, MD

Shoulder Sonography: Why We Do It – Sharlene A. Teefey, MD

Sonographically Guided Enema for Intussusception Reduction: A Safer Alternative to Fluoroscopy – Thomas Ray S. Sanchez, MD, Aaron Potnick, MD, Joy L. Graf, MD, Lisa P. Abramson, MD and Chirag V. Patel, MD

Sonography First for Subcutaneous Abscess and Cellulitis Evaluation – Srikar Adhikari, MD, RDMS, and Michael Blaivas, MD

Sonography in the Treatment of Calcific Tendinitis of the Rotator Cuff – Gregory R. Saboeiro

More articles on best evidence are forthcoming- please check out Ultrasoundfirst.org for more information!

On November 11-12, AIUM will host its first Ultrasound First Forum in New York City.

Intubation devices

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Many new developments in ultrasound were demonstrated at the ACEP conference in Denver this week. Since airway management rivals ultrasound as my academic interest, I’d like to focus for a moment on an intubating device I saw demonstrated at an ultrasound vendor booth.  I’ve seen lots of organs on my ultrasound screen- hearts, gallbladders, eyeballs, prostates. I’ve even seen airway structures, but not like this:

VividTrac Intubation devices

The VividTrac is a single use, USB video intubation device. It is a channeled blade video laryngoscope similar in concept to the King Vision or the AirTraq Optical Laryngoscope. The channel is designed to pass the endotrachel tube through. This is in contrast to non-channeled video laryngoscopes like the Storz C-MAC or the Verathon Glidescope, where the endotracheal tube is guided with a stylet and not directed through the video device itself.

What is interesting about the Vivid device is it hooks up to a monitor using a standard USB cable. Thus, it can be connected to different types of monitors, PDAs or tablets which accept USB input, or… an ultrasound machine monitor! Theoretically one could use an existing ultrasound machine with a variety of probe types as well as a device like this.

There are many device manufacturers involved in R&D of devices which might lead to a technology convergence. Ultrasound probes, video intubation devices, cardiac monitoring equipment, etc. could all transmit images to a monitor, via wires or wirelessly. Thus, pluripotent monitors could be used with a variety of devices depending on the needs of any given patient. This could increase the amount of information relayed via the monitors, and even what is transmitted to the electronic medical record. Importing vital signs, ultrasound images, EKGs, or other clinical images could all be captured in this way. It will be interesting to see how many other devices can learn to communicate with each other as the technology develops.

The FALLS-protocol

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In critically ill septic shock patients, assessments of hemodynamic function, fluid status and improvement of clinical status are challenging.  As a consequence of critical illness and large volume administration of crystalloids as recommended by Early Goal-Directed Therapy, comes the potential of acute (respiratory distress/failure) and long-term sequelae  (ARDS, prolonged endotracheal intubation, anasarca, bedsores, poor IV access, increased resource utilization).

The FALLS-protocol, developed by Daniel Lichtenstein introduces novel clinical parameters useful in the assessment of fluid status dynamically.  It aims to define the critical point when fluid administration is becoming deleterious to the patient (lung saturation), and we must start considering the use of vasopressors as well as the potential for respiratory failure.

Review: Lung Ultrasound basics

Utilizing a decision tree that obligates several simple cognitive and sonographic steps in the evaluation of shock, the true protocol begins when septic shock remains the most likely etiology and resuscitation has already been initiated.  By evaluating the lung parenchyma at the Blue Points, we begin with the A-profile in healthy patients.  Patients with fluid overload however demonstrate a B-profile (lung rockets emanating from the pleural line) indicative of interstitial edema.  In combination with vital signs, as we are administering fluids, we can evaluate the profile in either intervals of time or fluid aliquots.  At any of these intervals, if the patient remains hypotensive but has an A profile, we can feel confident that we can continue to administer fluids with little risk for respiratory compromise.  However, if the profile transitions to B-profile, we must consider vasopressors and advanced airway management.

Fluid administration is often guided by clinical judgment, with no clearly defined end point other than a normalized blood pressure. However, blood pressures can be corrected by vasopressors and are often given as a last ditch effort.  With the current emphasis on sepsis management in the US, EDs are coming under scrutiny for our role.  Although the FALLS-protocol still requires exhaustive study, it has the potential to allow a more finessed management of acute circulatory failure.

Reference:

Lichtenstein, D.  (2010) Wholebody Ultrasonography in the Critically Ill.  London: Springer-Verlag Berlin Heidelberg

Fluid Administration limited by lung sonography: the place of lung ultrasound in assessment of acute circulatory failure (The FALLS-protocol).  Expert Rev Respir Med. 2012 Apr;6(2):155-62.

 

Gel Contamination

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other sonic Gel Contamination

On April 18 the FDA released an alert regarding Other-Sonic Generic Ultrasound Transmission Gel, manufactured by Pharmaceutical Innovations Inc. The ultrasound gel was found to be contaminated with Pseudomonas aeruginosa and Klebsiella oxytoca.

According to the FDA Press Announcement,

U.S. Marshals, acting at the request of the Food and Drug Administration, have seized Other-Sonic Generic Ultrasound Transmission Gel located at Pharmaceutical Innovations Inc. in Newark, N.J., after an FDA analysis found that product samples contained dangerous bacteria. The seizure included all lots of the gel product manufactured between June 2011 and December 2011….The FDA received a report involving 16 surgical patients infected with Pseudomonas aeruginosa. The patients had transesophageal ultrasound procedures, while undergoing heart valve replacement, using Other-Sonic Generic Ultrasound Transmission Gel.

Yes, that first line said “U.S. Marshals.” The FDA does not mess around. So take a minute and check your gel! Maybe a good time to wipe the whole machine down while you are at it.

Low Frequency US

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Ear Low Frequency USApril 1, 2012:

Researchers presented exciting new data on the use of extremely low-frequency ultrasound for the bedside diagnosis of a wide range of pathology.

“We’re very excited by the technique,” remarked Bret Nelson as he described a method he has used for many years. With conventional ultrasound, sound waves above the range of human hearing transmitted from a transducer into the patient. These waves are then reflected back to the transducer, creating an image on the ultrasound screen.

“By using sound waves within the range of human hearing, we have been able to create an image directly into the mind of the operator. This obviates the need for special equipment, and does not require the use of gel.” Dr. Nelson demonstrated the technique:

“So what brings you here today?” At this point, sound waves were transmitted from Dr. Nelson into the patient.

“I’m having an allergic reaction.” New sound waves were then transferred from the patient to Dr. Nelson.

“Why do you say that?” The cycle repeats with a new pulse.

“I’m allergic to shrimp, and I ate some shrimp, and now I have a rash.”

“I agree. You seem to be having an allergic reaction.” Diagnosis confirmed! Now treatment can begin.

The research team warned that this technique is quite operator dependent, and can often involve multiple cycles before the diagnosis is confirmed. But they hope that someday this technique can augment information gained from traditional ultrasound, CT scan, and MRI.

 

International Space Station Ultrasound

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In case your department doesn’t have the funds to get you a new ultrasound machine on a regular basis, don’t despair. The ultrasound machine on the International Space Station has just been swapped out with a newer model, after a ten-year stint in space. The story was reported in this week’s issue of AIUM’s newsletter:

 

Obituaries are sad, but a good one makes us remember the deceased with respect and admiration. This is as true for a person as it is for the ultrasound machine on the International Space Station (ISS), which survived for 10 years without requiring service. The Philips HD15000 was brought home to rest on shuttle flight STS-135. Without the STS-135, the ultrasound system would have been sent to burn up in the atmosphere in a discarded supply vessel.

David Martin, BS, RDMS, RDCS, RVT, who is NASA’s lead sonographer, spent many hours talking astronauts through ultrasound studies on the historic machine, often during stressful situations and with challenging protocols. These sessions usually took place during the very early morning hours to accommodate the Greenwich Mean Time schedule of the ISS.

But just because the Philips machine has been laid to rest doesn’t mean that ultrasound studies on the ISS are finished. A new system, a GE Vivid Q, arrived on the ISS with the last shuttle flight. We hope that it will continue to provide invaluable information for the next decade and beyond.