Mount Sinai Emergency Medicine Ultrasound

Although we tend to suspect torsion only in cases where there is ovarian enlargement, cyst, etc., there are a number of studies that show these are not reliable (sensitive or specific) indicators of torsion. Radiology reports often seem to hedge and note that ovarian torsion is a clinical diagnosis because the test characteristics of ultrasound are not that great even when you include flow, adnexal size, free fluid, and other factors in combination.

Children (<15 years old) are at greater risk of torsing normal ovaries (up to 50% of torsion cases), but even in women of childbearing age 8-19% of cases are associated with normal ovaries. Doppler flow has demonstrated great sensitivity and specificity for torsion by some authors but was much less valuable in this retrospective study.

In this recent study, abnormal ovarian location, abnormal flow and free fluid were the best predictors of torsion; ovarian mass or cyst actually didn’t help rule in or out the diagnosis.

Bottom line: normal ovaries do not rule out torsion. Doppler flow may not be sensitive or specific enough either. So use (dare we say it?) clinical judgement.

Many of our lectures reference the same pantheon of literature on ultrasound in the acutely hypotensive patient. For ease of reference here they are, with appropriate links to the original publications:

• UHP protocol
  • Rose JS et al,  Am J Emerg Med 2001 (PMID: 11447518)
• Trinity Protocol
  • Bahner D,  JDMS 2002
• RCT of ultrasound in hypotension
  • Jones AE et al, Crit Care Med 2004 (PMID: 15286547)
• FATE:Focused Assessed Transthoracic Echocardiography
  • Jensen et al, Eur J Anaesthesiol 2004 (PMID: 15595582)
• FEER:Focused Echocardiographic Evaluation in Resuscitation
  • Breitkreutz et al, Crit Care Med 2007 (PMID: 17446774)
• CAUSE:Cardiac Arrest Ultrasound Exam
  • Hernandez et al, Resuscitation 2008 (PMID: 17822831)
• RUSH: Rapid Ultrasound in Shock and Hypotension
  • Weingart et al, emcrit.org 2008, EMedHome 2009
• ACES:Abdominal and Cardiac Evaluation with Sonography in Shock
  • Atkinson et al, Emerg Med J 2009 (PMID: 19164614)
• RUSH: Rapid Ultrasound in Shock
  • Perera P et al, Emerg Med Clin N Am 2010 (PMID: 19945597)

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:

International evidence-based recommendations for point-of-care lung ultrasound.

PMID: 22392031

One common source of confusion or false positives in the FAST exam is the assessment of the left upper quadrant. We’ve already covered some tips on improving your view of the spleen. This post will illustrate how the stomach can mimic free fluid to the unprepared.

The first image shows a perisplenic (left upper quadrant) view on ultrasound. Note the spleen (S), kidney (K), and diaphragm (D).

As the operator fans anterior and posterior to assess for fluid, anechoic fluid with some dirty shadows and slightly irregular margins is seen (bounded by arrows). This structure is often visualized anterior and medial to the spleen, and represents fluid within the stomach.

The video better illustrates fanning through a sagittal plane and encountering this common artifact.

Scan through the area carefully to ensure this fluid is all accounted for within the confines of the stomach, and does not layer out around the kidney, spleen, or highlight bowel loops at its margins.

On March 22, 2012 the Division of Emergency Ultrasound will host its annual hands-on CME course at Mount Sinai. Targeted at clinicians in emergency and critical care settings, the course consists of presentations by national faculty and plenty of hands-on scanning with live models.

Course highlights:

• Basic to advanced topics covered
• Organ system-based approach to bedside ultrasound use
• Faculty with international experience in ultrasound education
• Diagnostic applications as well as procedure guidance covered

Both experienced sonographers and neophytes will benefit from small group sizes and an interactive course design.

Additional information is available on the CME Course Page, or download our Mount Sinai Ultrasound CME course brochure 2012.

Registration for the course is open!