Bret Nelson and Mt. Sinai’s director of Disaster Preparedness and Prehospital Care, Kevin Chason, collaborated on this pilot study on use of Prehospital FAST and Aorta US which showed that paramedics can obtain and interpret these studies.
In this series, we cut to the chase and highlight our choice for the the top three articles on a given topic. Read on for the articles and brief discussion.
Three DVT articles that every emergency physician should know. What are they?
1) If there is any “must know” article for DVT or PE, this is it: commonly known as the Well’s Criteria, it provides a framework for the EP to approach any patient presenting with the the suspicion of DVT or PE. It is the ability to categorize patients into the different risk categories that we’re able to effectively use pre-test and post-test probability of a negative D-dimer to rule out the disease.
2) With the introduction of bedside clinician performed ultrasound, EPs now have a tool to evaluate the proximal lower extremity veins themselves. While there is abundant literature suggesting the feasibility of an EP performed bedside ultrasound, this review article showed that properly trained EPs can accurately diagnose DVTs with a pooled overall sensitivity and specificity of 95% and 96% respectively. However, several limitations were highlighted with regards to the available literature – there is no standardization of the technique used, and the studies involved EPs already highly trained in ultrasound and so the results cannot be generalized to all EPs.
3) This large RCT compares 2 point compression ultrasonography plus D-dimer with formal ultrasonography in symptomatic patients with suspected DVT. The rates of confirmed DVT at 3 months were similar in the 2 groups. This suggests that EPs can manage symptomatic patients suspected of having DVT with just 2-point compression ultrasound and D-dimer.
Bernardi E, Camporese G, Büller HR, et al. Serial 2-point ultrasonography plus D-dimer vs whole-leg color-coded Doppler ultrasonography for diagnosing suspected symptomatic deep vein thrombosis: a randomized controlled trial. JAMA. 2008;300:1653-1659.
Do you have other suggestions for studies? Comment below!
X-Ray Stinks #1: Finger Injury
In this new series we will highlight cases where ultrasound proved more useful than x-ray.
A seven year old boy presented with distal phalanx pain, tenderness after a fall.
The following x-ray was performed:
What is your diagnosis? Can ultrasound help? How would you perform an ultrasound on such a superficial structure?
The following ultrasound of the distal finger was performed (probe marker towards fingertip):
What is your diagnosis now? Continue reading
Bret Nelson recently filmed a webinar on critical care ultrasound at Gulfcoast Ultrasound Institute in Florida. He discussed evaluation of the hypotensive patient, incorporating Scott Weingart’s RUSH exam as well as other literature on acute assessment of the heart, IVC, FAST exam, and pleura.
Information on the webinar is available at Gulfcoast.
References for a variety of hypotension evaluations are included below, as well as a few screenshots from the webinar!
- UHP protocol
- Rose JS et al, Am J Emerg Med 2001 (PMID: 11447518)
- Trinity Protocol
- Bahner D, JDMS 2002
- RCT of ultrasound in hypotension
- Jones AE et al, Crit Care Med 2004 (PMID: 15286547)
- FATE: Focused Assessed Transthoracic Echocardiography
- Jensen et al, Eur J Anaesthesiol 2004 (PMID: 15595582)
- FEER: Focused Echocardiographic Evaluation in Resuscitation
- Breitkreutz et al, Crit Care Med 2007 (PMID: 17446774)
- CAUSE: Cardiac Arrest Ultrasound Exam
- Hernandez et al, Resuscitation 2008 (PMID: 17822831)
- RUSH: Rapid Ultrasound in Shock and Hypotension
- Weingart et al, emCrit.org 2008, EMedHome 2009
- ACES: Abdominal and Cardiac Evaluation with Sonography in Shock
- Atkinson et al, Emerg Med J 2009 (PMID: 19164614)
- RUSH: Rapid Ultrasound in Shock
- Perera P et al, Emerg Med Clin N Am 2010 (PMID: 19945597)
The Emergency and Critical Care community will no doubt benefit from this new journal. The Critical Ultrasound Journal is the official publication of the international ultrasound group WINFOCUS (world interactive network focused on critical ultrasound) . It is new this year, but they are already into their third issue. Headed by Mike Blaivas, the pediatric and neonatology section is edited by none other than our own Jim Tsung.