The AHRQ recently published an update to its landmark 2001 report, Making Health Care Safer: A Critical Analysis of Patient Safety Practices (AHRQ Evidence Report No. 43). This report advocated evidence-based practices such as root cause analysis, hand hygiene, ID bracelets for high risk patients, and time-outs prior to procedures.
The 2013 update analyzed 41 patient safety practices and identified 22 which were deemed ready for adoption. Ten were selected as “strongly encouraged” for adoption based on the strength and quality of evidence. Number nine on that list was “Use of real-time ultrasound for central line placement.”
A special supplement to the March issue of Annals of Internal Medicine features articles related to many of these patient safety strategies, and is available for free online.
Looking through the top ten list, most interventions are implemented at most major hospitals, and JCAHO surveyors track adherence to guidelines such as these. Now that ultrasound use has made the top ten in two iterations of these AHRQ safety practices, it may be more difficult to argue that lack of availability or proper training absolves providers of the need to provide this service.
This symposium is always worth the trip. See you there.
It’s been out awhile now, but if you haven’t seen it yet, take a look at Mike and Matt’s Introduction to Bedside Ultrasound. The ultrasound pocast guys have released this excellent overview of point of care ultrasound through the iTunes Store. This is certainly convenient as most of us have 3-12 iDevices on our person at any one time. Caveats are that this means that it is available only on an iPad using iBooks 2 or later, and ios 5 or later. Right now it is $29.99.
There is a lot of good content, but I think the best chapter in the book, is probably the RUSH chapter. :)
More lung ultrasound tips and examples from Drs. Jim Tsung and Brittany Pardue Jones!
Bacterial pneumonia will manifest as lung consolidation with air bronchograms. The A-line pattern of normal lung will begin to be replaced by B-lines in the area of affected lung:
Here we’ve highlighted the consolidation from the above video as well:
In contrast, subpleural consolidations and confluent B-lines are more suggestive of viral pneumonia.
So what do these look like?
and another example:
occur when multiple B-lines coalesce. In contrast, the next example demonstrates multiple discrete B-lines.
And now for something completely different
Z-Lines: Comet tails that arise from the pleural line but DO NOT make it to the bottom of the ultrasound screen. These are not B-lines. These artifacts have not been associated with any pathology, and they do not obliterate A-lines.
For more details on the sonographic appearance of viral lung pathology, check out this article by Jim Tsung.
The FAST exam is generally described as a trauma assessment (hence the acronym). But it is often used as a metanym to mean any assessment of the peritoneum for fluid. In fact when I was a resident folks would often say, “let’s FAST that gallbladder,” or “get the FAST machine so we can put that central line in.” And we didn’t have Twitter.
Anyway, here are a few cases where the “FAST” was used in a non-trauma patient to assess the peritoneum:
Cirrhotic with abdominal pain and tenderness:
who was found to have ascites, and spontaneous bacterial peritonitis
Lower abdominal pain in pregnancy:
who was found to have hemoperitoneum from a ruptured ectopic pregnancy
Diffuse abdominal tenderness in a healthy ten-year-old:
who was found to have idiopathic seromas of the peritoneum, pleura, and pericardium!
Shortness of breath and abdominal distension:
which turned out to be massive abdominal abscesses
Diffuse abdominal tenderness and distension after hysteroscopy:
which was complicated by a bowel perforation; hence fecal material throughout the peritoneum
Take home points:
- Assessment of the peritoneum greatly aids medical and surgical diagnoses
- Fluid appears black (anechoic) on ultrasound. Very difficult to tell what TYPE of fluid by appearance alone
- Your clinical assessment must guide the differential diagnosis for your ultrasound findings
Here’s a quick trick:
When the Transeptic spray bottle won’t spray, it is often because the pump has become disconnected from the plastic tubing within the bottle. Instead of trying to fish it out with forceps, just turn the whole bottle upside-down.
Disinfectant Spray Bottle Troubleshooting from Sinai EM Ultrasound on Vimeo.
I hope this takes away just one small annoyance on your next shift. Unfortunately this will leave room for another, larger annoyance to occupy the space.
Counter-intuitively, when insonating the lungs of healthy patients, we don’t “see” lung tissue. Instead we see and interpret artifacts arising from the pleural lines and the diaphragm. These artifacts change with pulmonary disease processes. In pneumonia, the airway spaces become inspissated with bacterial byproducts and consequently the sonographic appearance of lung tissue changes.
The transformation of lung tissue is termed hepatization: the lung tissue now appears similar to liver tissue.
This can be confusing in the lower lung fields, especially adjacent to the diaphragm because we use the mirror image artifact of the liver and spleen to indicate that lung tissue is normal. This mirrored, artifactual splenic or liver appearance could then be called pseudo-hepatization.
So, how do we differentiate hepatized lung versus pseudo-hepatized lung?
- Never use a single image for your diagnosis, scan through area and convince yourself (then save a representative image or clip for QA).
- Be systematic and scan down from the lung apices to the diaphragm.
- Hunt for the diaphragm and use it as a dividing line between the lung and the abdominal organs.
- Hepatized lung will often have a rim of fluid around it.
Image 1: Normal lung with visible diaphragm
Ultrasound of lung and spleen from Sinai EM Ultrasound on Vimeo.
Image 2: Normal lung with obscured diaphragm
Lung and Spleen Interface on ultrasound from Sinai EM Ultrasound on Vimeo.
Image 3: Hepatized lung at the lower lung field