Spectacular rounds this week lead by Sahar Ahmad of Stonybrook and hosted by Pierre at BI.
Sahar gave a great presentation on her didactic program for the critical care fellows at Stonybrook. Â She then presented a series of discussion inducing cases. Â Carl Kaplan (of Stonybrook not RUSH) presented an interesting case of ONSD ultrasound for hydrocephalus. Â Sam Parnia gave a presentation on the cardiopulmonary resuscitation research being done at Stonybrook on cerebral oximetry.
Some of the articles (with pmid and link) that came up in discussion were:
Aortic dissections are insidious killers that are often undetectable by history and physical exam alone. Obviously, providers must have a high index of suspicion for these as their presentations are highly variable. CT angiography, and less often, transesophageal echocardiography are classically the diagnostic modalities that providers use to identify this rare, deadly diagnosis. However, getting a patient over to CT can sometimes be delayed whether it is for transportation, or stabilizing the patient before CT scan.
A 73 year old lady with only a past medical history of hypertension that presented to our emergency department with intermittent focal left upper extremity numbness and weakness, and bilateral lower extremity pain. She presented hypotensive and tachycardic. The astute clinician had a high index of suspicion of dissection and while the patient was getting prepared to go to CT scan obtained the following clip of the parasternal long axis of the heart:
CT surgery was notified before the CT scan and the patient was taken directly from the CT scanner (which revealed the image below) to the OR..
Tips on POCUS for aortic dissection:
A parasternal long axis view can be helpful to visualize a dilated aortic root and/or a pericardial effusion in the setting of a suspected dissection
Evaluating carotid arteries, the distal aorta, or the iliac arteries can help diagnose an extensive dissection.
Point of care ultrasound should be used to quickly make a diagnosis, speed further imaging, or get a consultant involved expeditiously. Similar to much of what we do with point of care ultrasound, this tool should be used to rule in a diagnosis, rather than to rule out a diagnosis.
Point of care ultrasound can be used to make a quick diagnosis at the bedside before more consultative imaging, making it an invaluable tool in identifying this covert killer.
The American College of Emergency Physicians awarded its annual National Faculty Teaching award in Seattle this year during the Academic Affairs committee meeting.
Bret Nelson, Director of the Emergency Ultrasound Division at Mount Sinai, was one of four faculty honored nationally.
According to ACEP,
The American College of Emergency Physicians sponsors a national faculty teaching and junior faculty teaching award to honor outstanding educators in emergency medicine. These awards are designed to support emergency medicine faculty in their efforts to achieve academic advancement, as well as support the continued academic development of the specialty. The awards recognize superior teaching activities including didactic lectures, clinical instruction, the development of innovative educational programs, as well as the endorsement by faculty, residents, and students.
A 51 year old female with a history of diabetes presented to the ED with acute onset of left eye painless blurry vision.Â Vitals were within normal limits.Â Fingerstick was 450.
On exam : Visual acuity was 20/30 in the right eye but could only count fingers in left eye at 1 foot. There were no external signs of trauma, conjunctivitis or proptosis. Pupils were equal and reactive to light.Â Ocular ultrasound of her right and left eyes were performed and shown below:
IN the left eye a bright echogenic linear structure can be seen floating in the posterior aspect of the globe. Â This was concerning for retinal detachment, which is a clear ocular emergency. Ophthalmology evaluated the patient in the emergency department and diagnosed a vitreous hemorrhage. The patient was discharged home.
How do you tell the difference between a vitreous hemorrhage and a retinal detachment?
First, a little anatomy of the eye:
The vitreous is a clear, gelatinous, and avascular substance, filling the space bound by the lens, retina, and optic disc. The retina is composed of multiple layers that form the posterior wall of the globe behind the vitreous. A retinal detachment occurs when these layers separate.
There is an internal membrane that separates the retina from the vitreous. This forms a potential space between the membrane and the vitreous called the subhyaloid space.
A vitreous hemorrhage occurs when blood extravasates into the vitreous or in the subhyaloid space. If bleeding has occurred in the subhyaloid space, it can appear boat-shaped on the surface of the retina, forming a superior straight line in an upright patient but changing with the position of the patient.
Ocular ultrasound is a quick and accessible way to assess ocular pathology. In patients with acute visual change, evaluation for retinal detachment is important to prevent complete and possibly permanent visual loss.
Ocular ultrasound is highly sensitive in the detection of retinal detachment in the ED.
With ocular ultrasound it can be difficult to distinguish between vitreous hemorrhage and retinal detachment. However, it is important to distinguish between these pathologies as they carry two different treatments and a different sense of urgency.
In an intact globe, the retina cannot be differentiated from the other choroidal layers on ultrasound.
Ultrasound of retinal detachment will show a thick hyperechoic membrane floating in the posterior globe. It never detaches from the optic nerve posteriorly.
Vitreous hemorrhage may layer and form a hyperdense linear density that can mimic a retinal detachment.
Decrease the gain to help differentiate between the two.
Vitreous hemorrhage is usually less dense and will fade as the gain is decreased. It usually layers inferiorly with gravity. Ocular movements produce a rapid, staccato motion of the hemorrhage, unlike a retinal detachment that is stiffer and slower in movements.
Schott, M, Pierog, J.,Williams, S. â€œPitfalls in the use of ocular ultrasound for evaluation of acute vision loss.â€ Journal of Emergency Medicine, Vol 44. Nov 2012.
Yanoff M, Duker JS. Opthalmology. 3rd ed. St Louis, MO: Mosby, An Imprint of Elsevier; 2008.
DiBernardo C, Greenberg E. Opthalmic ultrasound: A diagnostic atlas. 2nd ed. New York: Thieme MEidcal Publisers; 2007.
The University of South Carolina once again hosted the incredible World CongressÂ on Ultrasound in Medical Education in Columbia. Dean Richard Hoppmann hosted over 100 faculty and hundreds of attendees, with dozens of countries represented.
Mount Sinai emergency ultrasound director Bret Nelson gave a plenary talk on the use of ultrasound in remote environments, from the battlefield to the International Space Station.
Pediatric emergency medicine ultrasound director Jim Tsung led a well-attended course on pediatric ultrasound, along with Ee Tay.
Mount Sinai emergency ultrasound fellow Amy Sanghvi presented an abstract on a novel interdepartmental ultrasound education project. Obstetric and emergency medicine interns learned pelvic ultrasound through a combination of didactics, online tutorials, hands-on skill stations with live models and several types of simulators, then underwent an OSCE for competency assessment and completed an online interactive question bank.
There were far too many ultrasound visionaries to list them all here. Here we have Mike Mallin and Matt Dawson (of Ultrasound Podcast fame) and Vicki Noble (ultrasound director at MGH and thoracic ultrasound guru) making sure Bret’s seersucker was for real.
Check out the World Congress website for the final program, images and videos from the conference, and more!
The first annual Tri-State Ultrasound Fellow Conference kicked off today at Lenox Hill Hospital in New York City. The first day of this two-day course focused on administrative issues in ultrasound, featuring nationally recognized speakers from all around the area.
Bret Nelson from the Icahn School of Medicine at Mount Sinai discussed faculty development, including: