ACEP 2010- Ultrasound for pediatric appendicitis

On September 28 Dr. Suzanne Bentley presented the abstract:

Ultrasound evaluation for appendicitis in children: Can we safely reduce CT scan utilization?

Bentley S, Nelson BP, Zahn L

at ACEP in Las Vegas. Data on using ultrasound as a first-line diagnostic modality (instead of CT scan) were discussed, with implications for diagnostic accuracy, radiation exposure, and length of stay. This was abstract #001, which carries no more prestige than #998 but we will be proud anyway.

A great deal of attention has recently focused on radiation exposure risks, and many organizations have allied to reduce necessary imaging. The Image Gently Alliance for example boasts dozens of member organizations and has done a great deal to educate providers about the risks of ionizing radiation in imaging. A brief article on the study was published by Reuters Health:

For pediatric appendicitis, ultrasound cuts radiation, saves time over CAT scans (subscription only)

Emergency Medicine has advocated the use of ultrasound for quite some time. As point-of-care ultrasound as well as radiology department ultrasound gain ground we hope to make informed diagnostic decisions while minimizing risks.

Lutheran Medical Center Course

The Mount Sinai Division of Emergency Ultrasound was proud to visit Lutheran Medical Center today for a critical care ultrasound workshop. Many thanks to Dr. Bonnie Simmons, Chair of Emergency Medicine and Dr. Gloria Tsan, Director of Medical Student and Resident Education for inviting us and hosting the course.

The course was well-attended by faculty and residents representing Emergency Medicine, Critical Care, Surgery, Cardiology, and other departments. Multi-specialty courses are a fantastic opportunity to share knowledge and common ground among colleagues, and it is a pleasure to work with a group with diverse interests and talents.

Focusing on high-yield topics for acute care, we discussed on algorithms for Rapid Ultrasound in Shock/Hypotension (RUSH) as well as ultrasound for venous access. We look forward to future collaborations!

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.