Over forty participants joined Sinai faculty Jim Tsung, Ee Tay, Bret Nelson, Joshua Guttman, Jacob Goertz, Turan Saul, Jenny Sanders, Kimberly Kahne, Michelle Vazquez, Joe Sorravit, and Rupi Mudan. Course Directors Ee Tay and Joshua Guttman organized great didactic content and lost of hands-on training (HOT) with pediatric models.
Participants from many pediatric and acute care specialties attended. They left with greater scanning skills, reduced reliance on CT scans, a multi-tool, and one lucky winner received Kaushal Shah’s new junior medical detective book, My Tummy Hurts
Our next hands-on ultrasound course will be in Ponte Vedra, Florida on June 17 at the Clinical Decision Making conference.
The Mount SinaiÂ DepartmentÂ of Emergency Medicine hosted its annual ultrasound CME conference on April 25.Â Faculty, fellows, nurses and PAs from a number of institutions and specialties took part in our tenth annualÂ course.
The course was directed by Bret Nelson, MD who introducedÂ ultrasound physics and machine controls, followed by lectures on assessment ofÂ airway and breathing (Jim Tsung, MD, MPH), cardiovascular ultrasoundÂ (JenniferÂ Huang, DO), trauma evaluationÂ (Phil Andrus, MD) and procedure guidance (Amy Sanghvi, MD).
After lunch an intensive hands-on session with live models, task simulators and sim cases rounded out the experience.
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-lineÂ patternÂ of normal lung will begin to be replaced by B-lines in the area ofÂ affectedÂ lung:
Here we’ve highlighted the consolidation from the above video as well:
In contrast, subpleural consolidations and confluent B-lines are more suggestive ofÂ viral pneumonia.
So what do these look like?
andÂ anotherÂ example:
occur when multiple B-lines coalesce. In contrast, theÂ next example demonstrates multiple discrete B-lines.
And now for something completely different
Z-Lines:Â Comet tails thatÂ arise from the pleural lineÂ 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.
Thoracic sonography is one of the most rapidly growing areas of emergency and critical care ultrasound. One very important emerging indication is to assess for lung consolidation. The characteristic appearance of consolidated lung is very sensitive and specific for pneumonia, but novices should heed some important pitfalls in making the diagnosis.
Special thanks to Jim Tsung, MD, MPH and Brittany Jones, MD for their tips, videos, and ongoing research in this important field! For further reading on this topic, please see this article.
Pitfall #1 – confusing thymus for a consolidation
Normal thymus in sagittal view:
Thymus (top half of screen) and heart (bottom right). Don’t confuse thymus for lung consolidation. Note there are no air bronchograms, but thymus has a faint speckled appearance.
Normal thymus in transverse view:
Thymus (top half of screen) and heart (bottom right). Don’t confuse thymus for lung consolidation. Note there are no air bronchograms, but thymus has a faint speckled appearance
Pneumonia adjacent to Thymus in transverse view:
Lung consolidation with air bronchograms (top left) adjacent to normal thymus (speckled appearance on top right) with heart (bottom right)
Pitfall #2 – mistaking spleen for consolidation.
This is an important pitfall for everyone to know about. The same issue applies to the liver & stomach. The sensitivity of lung US for pneumonia rises >90% if this mistake is avoided.
Left lower chest- sagittal view:
Be careful scanning the left lower chest (left anterior and left axillary line) – air in stomach and spleen may look like pneumonia if you don’t realize that you have scanned inferior to the diaphragm and past the end of the pleural line. Most common error by novices.
Left lower chest- transverse view:
Be careful scanning the left lower chest (left anterior and left axillary line) – air in stomach and spleen may look like pneumonia if you don’t realize that you have scanned inferior to the diaphragm and past the end of the pleural line.
Pitfall #3- missing pleural effusion
Here are a few examples to refresh your memory.
Left pleural effusion:
Pleural effusion (anechoic wedge just beneath ribs and pleura)
Air in stomach
Do not confuse spleen and air in stomach for pneumonia.
Congratulations to Sinai’s own Dr. Jim Tsung, who recently coauthored a major evidence-based consensus guideline on point-of-care lung ultrasound. The manuscript is the result of a multi-national effort by pioneering clinician-sonographers, and was just published in the journal Intensive Care Medicine:
Volpicelli G, Elbarbary M, Blaivas M, Lichtenstein DA, Mathis G, Kirkpatrick AW, Melniker L, Gargani L, Noble VE, Via G, Dean A, Tsung JW, Soldati G, Copetti R, Bouhemad B, Reissig A, Agricola E, Rouby JJ, Arbelot C, Liteplo A, Sargsyan A, Silva F, Hoppmann R, Breitkreutz R, Seibel A, Neri L, Storti E, Petrovic T; International Liaison Committee on Lung Ultrasound (ILC-LUS) for the International Consensus Conference on Lung Ultrasound (ICC-LUS).
Intensive Care Med. 2012 Mar 6. [Epub ahead of print]
Sinai’s own Dr. Lana Friedman, Pediatric Emergency Medicine Fellow, was just named one of three recipients of the prestigious SPR Fellow Clinical Research Award. Her abstract entitled, â€œAccuracy of Point-of-Care Ultrasound (PoCUS) by Novice Pediatric Emergency Sonologists in the Diagnosis of Skull Fractures,â€ was selected from a very competitive pool of submissions. She will present the abstract at the PAS meeting in Denver in April.
Congratulations to Dr. Friedman and her research advisor, Dr. Jim Tsung!