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?

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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

Airway Mythology

As promised, here are selected references from today’s talk on Airway Management Mythology. Thanks to the organizers of the International Conference on Emergency Medicine (ICEM) for the invitation to speak.

Some of the topics discussed are supported by plenty of evidence (ie the use of RSI as an intubation technique), some were simply fun to discuss (holding your breath while intubating) and some remain quite reasonably controversial (the use of etomidate for RSI in sepsis).

I highly recommend visiting Dr. Reuben Strayer’s blog for a brief and enlightening discussion of the use of rocuronium for RSI. Also, Dr. Scott Weingart’s EMCrit blog and podcasts are an excellent source for ED critical care topics. Finally, The Airway Site contains links to key airway management references as well as information on the Difficult Airway Course.

Selected References:

Status Epilepticus

Here are some key references from today’s lecture on Status Epilepticus at ICEM:

FERNE’s seizure and status epilepticus management guide

Key practice guidelines related to seizures:

  • ACEP Clinical Policy: Critical Issues In The Evaluation And Management Of Adult Patients Presenting To The Emergency Department With Seizures
  • Treatment of convulsive status epilepticus. Epilepsy Foundation of America. JAMA 1993; 270:854-859.
  • The neurodiagnostic evaluation of the child with first simple febrile seizure. AAP. Pediatrics 1996; 97:769-775.
  • The role of phenytoin in the management of alcohol withdrawal syndrome. Am Soc Addiction Med 1994 / 1998
  • Evaluating the first nonfebrile seizure in chilren. AAN. Neurology 2000; 55:616-623.
  • Role of antiseizure prophylaxis following head injury. BTF / AANS. J Neurotrauma 2000; 17:549-553.
  • Treatment of the child with a first unprovoked seizure. AAN. Neurology 2003; 60:166-175
  • Antiepileptic drug prophylaxis in severe traumatic brain injury. Neurology 2003; 60:10-16

Special thanks to Professor Andy Jagoda (Department of Emergency Medicine, Mount Sinai, New York)