Top 3 Articles: Pelvic US

Miscarriage in progress from Sinai EM Ultrasound on Vimeo.

Pelvic ultrasound is one of our core US applications. It has been incorporated within many emergency departments and it is a bread and butter skill for the EP. So, how do we fare in our performance?

This early study showed that ED ultrasound was very similar to radiology department findings (or final outcome, or both) in 96% of the study cohort. Also, when ED ultrasound accurately identified IUPs, ectopic pregnancies were effectively ruled out with a NPV of 100%.

1. Durham, B., Lane, B., Burbridge, L., & Balasubramaniam, S. (1997). Pelvic ultrasound performed by emergency physicians for the detection of ectopic pregnancy in complicated first-trimester pregnancies. Annals of Emergency Medicine, 29(3), 338-47.

Also, why do we do it in the first place, and not send all the cases to radiology for ultrasound? The answer lies in the reduction of both ED length of stay as well as cost. Any means to reduce ED overcrowding and decrease spending are welcome!

2. Shih, C. H. (1997). Effect of emergency physician-performed pelvic sonography on length of stay in the emergency department. Annals of Emergency Medicine, 29(3), 348-51; discussion 352.

Lastly, when ectopic pregnancy is suspected, remember to perform a FAST exam as a positive finding (free fluid in Morison’s pouch) can predict the need for operative intervention.

3. Moore C, Todd WM, O’Brien E, Lin H. Free fluid in Morison’s pouch on bedside ultrasound predicts need for operative intervention in suspected ectopic pregnancy. Acad Emerg Med. 2007;14:755-758.



WINFOCUS Bangkok 2010

On August 20-21, King Chulalongkorn Hospital Memorial Hospital was host to the WINFOCUS course:
Essential Ultrasound Guided Invasive Procedures in Emergency and Critical Settings

Dr. Suthaporn Lumlertgul was the director of this course, held at the hospital’s cutting edge surgical training center. Faculty including Mount Sinai’s Bret Nelson, as well as Luca Neri (past president of WINFOCUS), Yuen Chi Kit, Henry Cheng and Mok Ka Leung.

Left to right: Luca Neri, Bret Nelson, Suthaporn Lumlertgul, Henry Cheng, Mok Ka Leung, Yuen Chi Kit

The course covered ultrasound guidance for procedures such as venous access, pericardiocentesis, thoracentesis, nerve blocks, foreign body localization, and others. Physicians from many countries were in attendance.

Upcoming WINFOCUS training courses around the world are listed here.

Artifacts 2 – What’s missing?

A middle-aged male presented to the ED with 2 weeks history of increasing exertional dyspnea. Air entry was reduced clinically. A focused bedside ultrasound demonstrated the above findings. What artifact is missing?

Continue reading “Artifacts 2 – What’s missing?”

2010-11 Fellow

The Mount Sinai Division of Emergency Ultrasound is pleased to welcome their fellow for the 2010-2011 academic year. Dr. Rob Arntfield joins Sinai from London, Ontario, Canada where he was an attending emergency physician at The University of Western Ontario.

Rob has also completed a two-year critical care medicine fellowship in addition to his EM training. Rob sees a particular role for bedside ultrasound in further uniting these two specialties. He brings advanced training in focused transthoracic and transesophageal echocardiography to Sinai.

He has a strong background in ultrasound education internationally and has served as advisor and instructor with ICCU Imaging, Inc.  Among other academic pursuits this year, Rob is excited to examine possible role for transesophageal echocardiography in the ED. Beyond ultrasound, Rob has particular interests in ED-based critical care, sepsis and organ donation after cardiac death.

Rob has brought his family from the North and is grateful for the hospitality shown by his new ED colleagues and support staff at Sinai.

Tips and Tricks: Paracentesis

The first and most important step in paracentesis is confirming there is ascites to begin with!

Physical examination findings can be misleading, and inserting a needle blindly into the abdomen can cause complications unnecessarily. Note the black free fluid in the image, with echogenic bowel loops floating within.

Several approaches are commonly used. Each one starts with an assessment for peritoneal fluid, localization of area suitable for paracentesis (no nearby vessels, large enough pocket, etc.). Next, measure the distance from skin to peritoneum to establish a sense of how far the needle lust penetrate before expecting to yield ascites. This is followed by either:

  1. Real time (dynamic) ultrasound guidance. Probe held in non-dominant hand (or by assistant); dominant hand guides needle with real-time guidance using short- or long-axis technique
  2. Static guidance: Mark the location for paracentesis (use a pen, pressure from a pen cap or fingernail, or even using a nearby mole/skin blemish as a landmark!), and then proceed with the tap using that mark as a guide. It is critical that the mapping is performed immediately before the paracentesis, and the patient remains in the same position. If the patient moves or is re-positioned,  the patient must be scanned again because the pocket of fluid would have shifted due to the highly mobile floating bowel loops.

As the needle is inserted into the abdomen using either technique, it is wise to hold slight negative pressure on the plunger of the syringe. This way, as soon as fluid or blood is encountered, the operator will note both a pressure change and a flash of fluid into the syringe.

Adriatic Vascular Ultrasound Society Meeting

The Adriatic Vascular Ultrasound Society will host its 7th annual meeting and CME conference September 23-25 in Montecatini Terme.

The official language for the conference is English, and it will be held in Tuscany!

This is an EFSUMB accredited Euroson school event. For more information please visit here.

Top 3 Articles: FAST

The FAST exam is the prototypical application of emergency ultrasound. However, it is important to know that there are limited randomized controlled trials assessing the utility of the FAST exam. Despite this, let’s look at three good articles that  all emergency residents should know.

1. In this Cochrane review, the authors’ conclusion was that there was insufficient evidence for the use of ultrasound-based clinical pathways in the initial diagnostic workup of patients with blunt abdominal trauma. Ultrasound was not sensitive and lacked diagnostic accuracy. However, the use of ultrasound did reduce the use of CT scans. The take-home message is that ultrasound should not be used as a single rule-out test for significant intra-abdominal injury and the ED resident should be aware of ultrasound’s limitations.

Stengel D, Bauwens K, Sehouli J, Rademacher G, Mutze S, Ekkernkamp A, Porzsolt F. Emergency ultrasound-based algorithms for diagnosing blunt abdominal trauma (Review). The Cochrane Collaboration. February 18th, 2008.

2. Interestingly, this review used the same methodology as the Cochrane review and found that an adequately performed FAST exam can predict the need to send a patient to the operating room, with a high degree of sensitivity (98.9%) and specificity (98.1%).

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.

3. Thoracic ultrasound has become part of the standard assessment of the trauma patient. Ultrasound has been shown to be much more sensitive than CXR in the detection of pneumothorax when compared to CT as the gold standard. There are many studies proving this point and this is a good example.

Blaivas M, Lyon M, Duggal S. A prospective comparison of supine chest radiography and bedside ultrasound for the diagnosis of traumatic pneumothorax. Acad Emerg Med. Sep 2005;12(9):844-849