SonoSweden 2014 course

At the end of January, Bret Nelson joined an incredible team of international a faculty for the largest SonoSweden course to date. Course director Christofer Muhr hosted this unique, intensive hands-on conference at the scenic Yasuragi hotel in Stockholm, Sweden. Over thirty faculty and one hundred participants took part in this three-day course.

Among the faculty were lung ultrasound pioneer Vicki Noble, Matt Dawson and Mike Mallin (creators of the Ultrasound Podscast) and others from around the globe.

Registration is not yet open for the 2015 course, but check out the SonoSweden website for a countdown timer- there were over 100 people on the waiting list for this year’s course!

Last days of the stethoscope?

Global Heart Title PageIn the current issue of Global Heart (journal of the World Heart Foundation), several Mount Sinai authors have published articles on the use of point-of-care ultrasound. Phil Andrus wrote about focused cardiac ultrasound, Jennifer Huang co-authored a review of ultrasound use in IVC assessment, Daniel Lakoff described ultrasound incorporation into rapid response teams in inpatient wards, and Bret Nelson and Amy Sanghvi wrote a review of non-cardiologist use of cardiac ultrasound.

Bret Nelson and Global Heart Editor-in-Chief Jagat Narula wrote the editorial for the issue, which focused on improvements in ultrasound technology creating new opportunities and markets for ultrasound use. One theme of the editorial was whether ultrasound could replace the stethoscope, and as you may imagine the press has picked up on that thread!
CBS news visited Mount Sinai and interviewed Drs. Nelson and Narula.
And a number of media outlets have covered the story, including Popular Mechanics, the Huffington Post and others.
Mount Sinai has incorporated ultrasound into medical student education in Gross Anatomy since 2006, and last year began a curriculum in focused ultrasound as part of the physical examination course.

January 23rd NYC RESUS Rounds

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.  She then presented a series of discussion inducing cases.  Carl Kaplan (of Stonybrook not RUSH) presented an interesting case of ONSD ultrasound for hydrocephalus.  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:

  • The Lung US Consensus Recommendations: 22392031
  • Copetti ARDS vs Pulmonary Edema: 18442425
  • NASA MRI Optic Nerve sheath: 22416248
  • Louis Eisen Optic Nerve sheath: 21519957
  • Flawed Pediatric Optic nerve sheath article 19167786 
  • re “reverse” FALLS protocol – Vicki Noble’s on bline resolution at dialysis 19188552

See you next time.

Aortic Dissection – A Covert Killer

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.

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Case:

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:

https://gmep.org/media/14976

https://gmep.org/media/15046

It is obvious here that the aortic outflow tract is dilated (usually, it should be the size of the left atrium).

Then the physician obtained a suprasternal view of the aortic arch and obtained the following clip:

https://gmep.org/media/15047

Then, given the focal neurologic symptoms, she got the following images of the right carotid, in which you can see an intimal flap and also more distally, a blood clot in the carotid:

https://gmep.org/media/14981

To investigate the distal extension of the clot, the following views were obtained of the abdominal aorta with an actual intimal flap:

https://gmep.org/media/14978

Finally, at the level of the bifurcation, extension of the dissection into the bilateral iliacs is visualized

https://gmep.org/media/14979

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..

Screen shot 2013-11-19 at 1.49.48 AM

Tips on POCUS for aortic dissection:

  1. 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
  2. Evaluating carotid arteries, the distal aorta, or the iliac arteries can help diagnose an extensive dissection.
  3. 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.
  4. 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.