ACEP US Section Discussion Forums

If you aren’t a member of the Ultrasound Section or ACEP this is a great reason to become one.

 

 

Mike Stone with help from Phil Perera and no doubt others have built a forum where you can find all of the most pertinent discussions from the section list-serve. There are a few choice topics available for your perusal and comment right now, but I’m sure this will be built into an even better resource in the future. Great Job.

 

To find the forums, head to the acep ultrasound section page and look for “ultrasound forum”.

The FALLS-protocol

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.

 

Sonocloud

On July First, while most of us were busy meeting new interns, Mike and Matt from the ultrasound podcast along with Mike Stone have released into the wild their newest creation, sonocloud.

 

Sonocloud Logo
Sonocloud is awesome.  It is a copyright free compendium of all the clips you wish you had in your ultrasound quiver.  So next time you are a) putting a talk together and you can’t find you old clip of biceps tendonitis, or b) you get a really cool high quality clip yourself, head over to sonocloud to a) download an open-source clip or b) upload your own for others to use…

Top ultrasound scanning tips

Welcome new interns across the land! You will be receiving lots and lots of advice from many sources, so I’d like to pour some ultrasound scanning tips into the information deluge.

Most of these tips were posted here at SinaiEM.us a few years ago, yet they are so classic they they still ring true!

These are mainly directed towards novices, but there may be something useful in there for everyone to remember. Note that I used self-restraint and did NOT list “clean the machine” among the tips. I assume everyone has already built up an impressive list of excuses for not cleaning the machine. That sounds like another post in itself!

  • Start with one indication and become comfortable with it, then expand your repertoire
  • Before picking up the probe, think about how the results of the scan will change your management and clarify your clinical question (good advice for any diagnostic test)
  • Familiarize yourself with the most useful buttonsfirst (every machine has these):
    • Power, probe selection, depth, gain, save/print
  • Remember you are scanning three-dimensional structures- be sure to fan the ultrasound beam through several planes to visualize the full anatomy
  • Practice, and keep practicing. Ultrasound IS operator dependent, just like everything else you do in your practice. So get good at it, just as you became proficient in EKG interpretation or laceration repair.
  • When you can’t see anything:
    • Use more gel, find a better acoustic window, and check the common buttons (transducer, depth, gain)
  • Proper hand position is crucial- hold the probe so you are comfortable and stable
  • Check follow-up studies if they are performed, and compare your bedside results to CT scan, operative findings, etc.
  • Position the patient, the machine, and yourself for optimal visibility and comfort whenever possible
  • Share positive findings with your colleagues! Although pregnancies and gallstones are common, sharing aortic aneurysms or deep vein thromboses will be appreciated.
  • Share ‘saves’ with your colleagues! Although most applications for bedside ultrasound are evidence-based, never underestimate the power of the anecdote in changing practice patterns.

Please leave YOUR best scanning tip in the comments.

SAEM newsletter

The current issue of SAEM’s resident newsletter features an interview with Bret Nelson regarding ultrasound training. He and Beatrice Hoffman, MD, PhD, RDMS (Director of Ultrasound Education for the Department of Emergency Medicine at Johns Hopkins School of Medicine) are featured.

They describe their path towards emergency ultrasound, the value of fellowship training, advice for residents, the role of research, and more.

Aneurysm screening

Sweep through large AAA from Sinai EM Ultrasound on Vimeo.

Abdominal aortic aneurysm (AAA) affects 5-10% of males age 65-79, and among males over 55 years of age represents the 14th leading cause of death. Ruptured aortic aneurysm is associated with a very high mortality rate. Up to 80% of patients die by the time they reach the hospital, and half die during emergent operative repair.

Evaluation of the abdominal aorta by emergency physicians using point-of-care sonography has been a core indication since ACEP’s first ultrasound guidelines were published in 2001. Several studies have demonstrated sensitivity and specificity for aneurysm which approach those of Radiology Department performed ultrasounds, and even CT scans.

While many providers have adopted a point-of-care assessment strategy in patients where AAA is suspected, it is debatable whether emergency physicians should engage in screening asymptomatic patients for AAA. Several ED-based studies have found aneurysms in 5-7% of asymptomatic male patients over the age of 65. Screening has been shown to reduce mortality from AAA, and is recommended by the U.S. Preventive Services Task Force. A single screening examination for asymptomatic males over age 65 is covered by many insurers in the United States including Medicare (Medicare requires that you have smoked over 100 cigarettes or have a family history of AAA to qualify for coverage).

So there is evidence that emergency physicians are capable of screening for aneurysm, and there is evidence to support that someone should be screening selected elder patients. Whether emergency physicians should engage in screening will depend on ED resources available. Many departments across the country have screening programs for HIV, abuse, and other pathology. There is a balance between using limited resources to diagnose and treat acute illness and deploying resources to impact the long-term health of a population which might otherwise be lost to follow up.

So you decide!

Further reading:

  • Tayal VS, Graf CD, Gibbs MA. Prospective study of accuracy and outcome of emergency ultrasound for abdominal aortic aneurysm over two years. Acad Emerg Med 2003 (PMID: 12896888)
  • Costantino TG, Bruno EC, Handly N, Dean AJ. Accuracy of emergency medicine ultrasound in the evaluation of abdominal aortic aneurysm. J Emerg Med 2005 (PMID: 16243207)
  • Knaut AL, Kendall JL, Patten R, Ray C. Ultrasonographic measurement of aortic diameter by emergency physicians approximates results obtained by computed tomography. J Emerg Med 2005 (PMID: 15707804)
  • Salen P, Melanson S, Buro D. ED screening to identify abdominal aortic aneurysms in asymptomatic geriatric patients. Am J Emerg Med 2003 (PMID: 12671815)
  • Moore CL, Holiday RS, Hwang JQ, Osborne MR. Screening for abdominal aortic aneurysm in asymptomatic at-risk patients using emergency ultrasound. Am J Emerg Med 2008 (PMID: 18926345)
  • Cosford PA, Leng GC. Screening for abdominal aortic aneurysm. Cochrane Database Syst Rev. 2007 (PMID: 17443519)
  • Hoffmann B, Um P, Bessman ES, Ding R, Kelen GD, McCarthy ML. Routine screening for asymptomatic abdominal aortic aneurysm in high-risk patients is not recommended in emergency departments that are frequently crowded. Acad Emerg Med. 2009 (PMID: 20053243)

Haiti 2012

 

In early May, emergency ultrasound fellow Leila PoSaw and two Mount Sinai senior Emergency Medicine residents on the ultrasound track, Swathi Nadindla and Micah Nite, traveled to Haiti for an ultrasound education project.

This project was at the Bernard Mevs/ Project Medishare hospital in Port-au-Prince, which is the only trauma, critical care, and rehabilitation hospital in an entire country of ten million people. This hospital is responsible for providing lifesaving care to Haiti’s sickest adults, children and premature infants. The hospital treats 200 to 300 patients daily in the outpatient clinic and 50 inpatients daily.  Two years after the earthquake of Jan 12, 2010, Project Medishare has moved to a capacity-building stage of empowering Haitians to create and sustain their own healthcare system through training, education, and employment of local medical professionals.

 

The goals of the project were to assess the feasibility of a permanent ultrasound program run by Haitian doctors.  In such a program, Haitian doctors would use point of care bedside ultrasound to make life-changing medical decisions for their patients.

Is there a need? Is this possible?

We aimed to perform a needs assessment as an important part of the planning process to clarify and identify appropriate interventions. We also aimed to teach a mini-ultrasound course to any and all who might be interested to learn.

Two years after the earthquake we found the city to still be in a state of disrepair. We developed a flat tire on this extremely bumpy road strewn with debris.  This was formerly the busy down town area. Now it looks like a ghost town.

Though there are still tents around the destroyed National Palace (which is due for demolition), many of the tents have been moved away from the center to the outskirts.

There is a single guarded gate that leads into the Bernard Mevs hospital.  The clinics are open weekdays and have long wait lines. Not surprisingly, we found that the OB clinic could use an ultrasound machine!

The ultrasound course was a huge success. It was held in the cafeteria/dining hall. A total of 14 medical students and 7 staff doctors attended, including Drs. Marlon and Jerry Bitar in the blue surgical caps, and Dr. Toni Eyssallenne, the medical director.

Special thanks to Dr. Marc Jean-Baptiste, driver and navigator, Dr. Alice Baptiste, Dr. Julie Kanter, Dr. Swathi Nadindla and Dr. Micah Nite, without whom this project would never have happened.

There is no doubt that ultrasound has a lot of potential in resource-limited settings. We used ultrasound to diagnose and confirm several interesting cases, which will be highlighted on this site soon!