Faculty group photo

SonoSweden 2014 course

At the end of January, Bret Nelson joined an incredible team of international a faculty for the largest SonoSweden course to date. Course director Christofer Muhr hosted this unique, intensive hands-on conference at the scenic Yasuragi hotel in Stockholm, Sweden. Over thirty faculty and one hundred participants took part in this three-day course.

Among the faculty were lung ultrasound pioneer Vicki Noble, Matt Dawson and Mike Mallin (creators of the Ultrasound Podscast) and others from around the globe.

Registration is not yet open for the 2015 course, but check out the SonoSweden website for a countdown timer- there were over 100 people on the waiting list for this year’s course!

Last days of the stethoscope?

GH TOC 500x381 Last days of the stethoscope?In the current issue of Global Heart (journal of the World Heart Foundation), several Mount Sinai authors have published articles on the use of point-of-care ultrasound. Phil Andrus wrote about focused cardiac ultrasound, Jennifer Huang co-authored a review of ultrasound use in IVC assessment, Daniel Lakoff described ultrasound incorporation into rapid response teams in inpatient wards, and Bret Nelson and Amy Sanghvi wrote a review of non-cardiologist use of cardiac ultrasound.

Bret Nelson and Global Heart Editor-in-Chief Jagat Narula wrote the editorial for the issue, which focused on improvements in ultrasound technology creating new opportunities and markets for ultrasound use. One theme of the editorial was whether ultrasound could replace the stethoscope, and as you may imagine the press has picked up on that thread!
CBS news visited Mount Sinai and interviewed Drs. Nelson and Narula.
And a number of media outlets have covered the story, including Popular Mechanics, the Huffington Post and others.
Mount Sinai has incorporated ultrasound into medical student education in Gross Anatomy since 2006, and last year began a curriculum in focused ultrasound as part of the physical examination course.

January 23rd NYC RESUS Rounds

Spectacular rounds this week lead by Sahar Ahmad of Stonybrook and hosted by Pierre at BI.

 January 23rd NYC RESUS RoundsSahar gave a great presentation on her didactic program for the critical care fellows at Stonybrook.  She then presented a series of discussion inducing cases.  Carl Kaplan (of Stonybrook not RUSH) presented an interesting case of ONSD ultrasound for hydrocephalus.  Sam Parnia gave a presentation on the cardiopulmonary resuscitation research being done at Stonybrook on cerebral oximetry.

Some of the articles (with pmid and link) that came up in discussion were:

  • The Lung US Consensus Recommendations: 22392031
  • Copetti ARDS vs Pulmonary Edema: 18442425
  • NASA MRI Optic Nerve sheath: 22416248
  • Louis Eisen Optic Nerve sheath: 21519957
  • Flawed Pediatric Optic nerve sheath article 19167786 
  • re “reverse” FALLS protocol – Vicki Noble’s on bline resolution at dialysis 19188552

See you next time.

Aortic dissection

Aortic Dissection – A Covert Killer

Aortic dissections are insidious killers that are often undetectable by history and physical exam alone. Obviously, providers must have a high index of suspicion for these as their presentations are highly variable. CT angiography, and less often, transesophageal echocardiography are classically the diagnostic modalities that providers use to identify this rare, deadly diagnosis. However, getting a patient over to CT can sometimes be delayed whether it is for transportation, or stabilizing the patient before CT scan.

cartoon ninja 8 300x300 Aortic Dissection   A Covert Killer

Case:

A 73 year old lady with only a past medical history of hypertension that presented to our emergency department with intermittent focal left upper extremity numbness and weakness, and bilateral lower extremity pain. She presented hypotensive and tachycardic. The astute clinician had a high index of suspicion of dissection and while the patient was getting prepared to go to CT scan obtained the following clip of the parasternal long axis of the heart:

It is obvious here that the aortic outflow tract is dilated (usually, it should be the size of the left atrium).

Then the physician obtained a suprasternal view of the aortic arch and obtained the following clip:

Then, given the focal neurologic symptoms, she got the following images of the right carotid, in which you can see an intimal flap and also more distally, a blood clot in the carotid:

To investigate the distal extension of the clot, the following views were obtained of the abdominal aorta with an actual intimal flap:


Finally, at the level of the bifurcation, extension of the dissection into the bilateral iliacs is visualized

CT surgery was notified before the CT scan and the patient was taken directly from the CT scanner (which revealed the image below) to the OR..

Screen shot 2013 11 19 at 1.49.48 AM 300x281 Aortic Dissection   A Covert Killer

Tips on POCUS for aortic dissection:

  1. A parasternal long axis view can be helpful to visualize a dilated aortic root and/or a pericardial effusion in the setting of a suspected dissection
  2. Evaluating carotid arteries, the distal aorta, or the iliac arteries can help diagnose an extensive dissection.
  3. Point of care ultrasound should be used to quickly make a diagnosis, speed further imaging, or get a consultant involved expeditiously. Similar to much of what we do with point of care ultrasound, this tool should be used to rule in a diagnosis, rather than to rule out a diagnosis.
  4. Point of care ultrasound can be used to make a quick diagnosis at the bedside before more consultative imaging, making it an invaluable tool in identifying this covert killer.

 

ACEP National Faculty Teaching Award

The American College of Emergency Physicians awarded its annual National Faculty Teaching award in Seattle this year during the Academic Affairs committee meeting.

Bret Nelson, Director of the Emergency Ultrasound Division at Mount Sinai, was one of four faculty honored nationally.

NFTA group 500x332 ACEP National Faculty Teaching Award

Left to right: Federico E. Vaca, MD, MPH; Vicken Y. Totten, MD, MS, FACEP; Bret P. Nelson, MD, RDMS, FACEP; Yashwant Chathampally, MD, MS

According to ACEP,

The American College of Emergency Physicians sponsors a national faculty teaching and junior faculty teaching award to honor outstanding educators in emergency medicine. These awards are designed to support emergency medicine faculty in their efforts to achieve academic advancement, as well as support the continued academic development of the specialty. The awards recognize superior teaching activities including didactic lectures, clinical instruction, the development of innovative educational programs, as well as the endorsement by faculty, residents, and students.

Left eye

Retinal Detachment v Hemorrhage

By Dr. Raashee Kedia

Acute vision change

A 51 year old female with a history of diabetes presented to the ED with acute onset of left eye painless blurry vision. Vitals were within normal limits. Fingerstick was 450.

On exam : Visual acuity was 20/30 in the right eye but could only count fingers in left eye at 1 foot. There were no external signs of trauma, conjunctivitis or proptosis. Pupils were equal and reactive to light. Ocular ultrasound of her right and left eyes were performed and shown below:

R eye Retinal Detachment v Hemorrhage

Leye Retinal Detachment v Hemorrhage

IN the left eye a bright echogenic linear structure can be seen floating in the posterior aspect of the globe.  This was concerning for retinal detachment, which is a clear ocular emergency. Ophthalmology evaluated the patient in the emergency department and diagnosed a vitreous hemorrhage. The patient was discharged home.

How do you tell the difference between a vitreous hemorrhage and a retinal detachment?

First, a little anatomy of the eye:

eyeana 300x229 Retinal Detachment v Hemorrhage

Courtesy: National Eye Institute, National Institutes of Health (NEI/NIH).

The vitreous is a clear, gelatinous, and avascular substance, filling the space bound by the lens, retina, and optic disc. The retina is composed of multiple layers that form the posterior wall of the globe behind the vitreous. A retinal detachment occurs when these layers separate.

There is an internal membrane that separates the retina from the vitreous. This forms a potential space between the membrane and the vitreous called the subhyaloid space.

A vitreous hemorrhage occurs when blood extravasates into the vitreous or in the subhyaloid space. If bleeding has occurred in the subhyaloid space, it can appear boat-shaped on the surface of the retina, forming a superior straight line in an upright patient but changing with the position of the patient.

Ocular ultrasound is a quick and accessible way to assess ocular pathology. In patients with acute visual change, evaluation for retinal detachment is important to prevent complete and possibly permanent visual loss.

Ocular ultrasound is highly sensitive in the detection of retinal detachment in the ED.

With ocular ultrasound it can be difficult to distinguish between vitreous hemorrhage and retinal detachment. However, it is important to distinguish between these pathologies as they carry two different treatments and a different sense of urgency.

In an intact globe, the retina cannot be differentiated from the other choroidal layers on ultrasound.

Ultrasound of retinal detachment will show a thick hyperechoic membrane floating in the posterior globe. It never detaches from the optic nerve posteriorly.

Vitreous hemorrhage may layer and form a hyperdense linear density that can mimic a retinal detachment.

Decrease the gain to help differentiate between the two.

Vitreous hemorrhage is usually less dense and will fade as the gain is decreased. It usually layers inferiorly with gravity. Ocular movements produce a rapid, staccato motion of the hemorrhage, unlike a retinal detachment that is stiffer and slower in movements.

Sources:

Schott, M, Pierog, J.,Williams, S. “Pitfalls in the use of ocular ultrasound for evaluation of acute vision loss.” Journal of Emergency Medicine, Vol 44. Nov 2012.

Yanoff M, Duker JS. Opthalmology. 3rd ed. St Louis, MO: Mosby, An Imprint of Elsevier; 2008.

DiBernardo C, Greenberg E. Opthalmic ultrasound: A diagnostic atlas. 2nd ed. New York: Thieme MEidcal Publisers; 2007.

http://www.nyuemsono.com/wp-content/uploads/2012/10/Pitfalls-in-the-Use-of-Ocular-Ultrasound-for-Evaluation-ofnbspAcutenbspVision-Loss.pdf