More than just another stethoscopeMark Bromley Emergency Medicine PGY3

Undifferentiated Hypotension - EchoLV functionVolume StatusJVPProceduresGuided Lumbar PunctureAbscess DrainagePleural effusion/ThoracentesisParacentesisSuprapubic aspirationVascular AccessJoint taps

GalbladderDVTOcularFracture DetectionFracture Management Renal Pneumothorax Intubation

...for the cardiologist in you

67 Hx of CAD and CHFUnwell over last 2-3 daysHypotensive Tachycardic SOB

Urgent diagnostic evaluation TimelyLimited diagnostic options due to the clinical condition transportation of sick patientsAllow appropriate intervention and improve the course of disease

Cardiogenic shock Hypovolemia - DistributiveRight ventricular infarct/large PETamponade

As a clinician trying to choose between inotropy, fluid resuscitation, or a needleThe ventricle is either moving well or notThe RV is dilated or notThere is an effusion or there is notThe IVC is full or notThe JVP is up or not

Fractional shortening Look at the black (i.e. blood) in the left ventricle Systole: the black decreases in size The in size with systole is fractional shortening

Normal ejection fraction is ~ 60%Mathematically single dimension (diameter rather than volume)Change of diameter 30% Gr 1 fxnChange of diameter

LV dilatation Mid-LV diameter 5.2cm at end-diastole If diameter >5.2cm LV dilatation

shortening fractionLV Dilatation

End-diastole LV chamber unusually small Systole virtually all LV blood ejected

Cardiac Activity hyperdynamic fast heart ratevery vigorous contractions Ejection fraction exceeds 70%

IVC low CVP

RV is usually 2/3 the size of the LVRV function is less formally quantified (mathematically) complex shape

PE RV diameter can exceed the LV diameter

Such a finding may guide diagnosis and management in the acutely dyspneic or hypotensive patient

Identify the IVC:Just anterior to the spine To the right of the aorta in > 99.9%. Thin-walled (vs. the thicker-walled aorta) Compressible with pressure Size varies with respiration

Diameter 1.5cm possibly c/w CVPDiameter 1.0 cm definitely c/w CVP

inspiratory in IVC (>25%) chance pt is dry

Methods:84 consecutive patients referred for right-sided cardiac catheterizationRA pressure was acquiredInternal residents underwent 4h of formal US training and performed 20 supervised studiesBlinded to cath results examined the IVC 10mm Hg was 82% with US and 14% from JVP inspection

why should medicine residents have all the fun?

How long does it take?Does it change what we do?

Methods: Prospective, observational study4 EP investigators with prior US experience focused echo trainingA convenience sample of 51 adult pts with hypotensionExclusion criteria:History of traumaChest compressionsEKG diagnostic of acute MIEchocardiogram was recorded by an EP investigator - estimated EF and categorized LVF as normal, depressed, or severely depressed. Blinded cardiologist reviewed all 51 studies for EF, categorization of function, and quality of the studyA second cardiologist reviewed 20 of the tapes to assess inter-observer variability between cardiologists

Pearsons correlation coefficient for EP and cardiologist estimation was R=0.86

Pearsons correlation coefficient for the two cardiologists estimations was R=0.84

Agreement between EPs in the convenience subset of eight patients who underwent echo by two EPs yielded an R = 0.94

Methods: Prospective observational study of a convenience sample of patients admitted to ICUAll patients underwent BLEEP followed by an independent formal echocardiogram by an experienced paediatric echocardiography provider (PEP)EPs had 3 hours of focused cardiac US training including 5-proctored BLEEP examinations on unenrolled patients

IVC volume was assessed by measurement of the maximal diameter of the IVCLVF was determined by calculating shortening fraction (SF)Estimates of SF and IVC volume obtained on the BLEEP were compared with those obtained by the PEP

Results:N=31 Mean age=5.1 years (range: 23 days16 years)Agreement between the EP and the PEP for estimation of SF (r = 0.78)The mean difference in the estimate of SF between the providers was 4.4% (95% CI: 1.6%7.2%) This difference in estimate of SF was not thought to be clinically significant

Agreement between the EP and the PEP for estimation of IVC volume (r = 0.8). The mean difference in the estimate of IVC diameter by the PEP and the EP was 0.068 mm (95% CI: 0.16 to 0.025 mm).

Conclusions: PEP sonographers are capable of accurate assessment of LVF and IVC volumeBLEEP can be performed with focused training and oversight by a pediatric cardiologist

Design: Randomized, controlled trial of immediate vs. delayed ultrasound.Urban, tertiary emergency department, census >100,000.Non-trauma emergency department patients, aged >17 yrs, and initial emergency department vital signs consistent with shock (SBP1.0), and agreement of two independent observers for at least one sign and symptom of inadequate tissue perfusionInterventions: Group 1 (immediate ultrasound) received standard care plus goal-directed US at time 0Group 2 (delayed ultrasound) received standard care for 15 min and goal-directed US b/w 15-30 min

Results: Outcomes included the number of viable physician diagnoses at 15 mins and the rank of their likelihood of occurrence at both 15 and 30 mins. N=184 Group 1 (n = 88) had a smaller median number of viable diagnoses at 15 mins (median = 4) than did group 2 (n = 96, median = 9, Mann-Whitney U test, p < .0001). Physicians indicated the correct final diagnosis as most likely among their viable diagnosis list at 15 mins Group 1 80% (95% confidence interval, 7087%) of group 1 subjects Group 2 50% (95% confidence interval, 4060%) in group 2...difference of 30% (95% confidence interval, 1642%)

7 viewsEach intended to answer a binary question:Pericardial effusionPericardial tamponadeLeft ventricular dysfunction Right ventricular dilationIntravascular volume depletionIntraperitoneal fluidAortic aneurysm

On average, this information was obtained in < 6 min

Conclusions: Incorporation of a goal-directed ultrasound protocol in the evaluation of nontraumatic, symptomatic, undifferentiated hypotension in adult patients results in fewer viable diagnostic etiologies. More accurate physician impression of final diagnosis.

We can do easilyWe can do safely

...when you need the bariatric needleAccurate identification of landmarks by palpation is impaired in obese patients

At least 65% of adults in the US are overweight or obese

Increasing the accuracy of landmark identification for LP may be useful

Objective: The objective of the study was to determine EPs ability to apply a standardized US technique for visualizing landmarks surrounding the dural space

Methods: 2 EPs sought to identify relevant anatomy in emergency patientsVisualization time for 5 anatomical structures (spinous processes or laminae, ligamentum flavum, dura mater, epidural space, subarachnoid space), BMI, and perception of landmark palpation difficulty

Results: N=76 Soft tissue and bony anatomical structures were identified in all subjectsMean BMI was 31.4 (95% confidence interval, 29.1 - 33.6). High-quality images were obtained in < 1 minute in 153 (87.9%) scans < 5 minutes in 174 (100%) scansMean acquisition time was 57.19 seconds; SD, 68.14 seconds; range, 10 to 300 seconds.

Conclusion: In this cohort, EPs were able to rapidly obtain high-quality ultrasound images relevant to lumbar puncture

Methods: Cross-sectional studyPatients categorized by BMIRecorded the difficulty in palpating traditional LP landmarksIdentification and measurement of the spatial relationships of the sacrum; spinous processes of L3, L4, L5; ligamentum flavum; and the spinal canal by US

Results: Difficulty in palpating landmarks Normal BMI - 5% Overweight 33%Obese - 68% ( P .0001)Successful identification of pertinent structures Normal BMI 100%Overweight 95%Obese -- 74% ( P = .011)

In subjects with difficult-to-palpate landmarks, US identified pertinent structures in 16/21 (76%; 95%CI 53-92) The average distance from skin to ligamentum flavum was 44 mm - normal BMI 51 mm - overweight 64 mm - obeseConclusion:As people get bigger they are harder to landmarkUltrasound is helpful in this population but not perfect

...wheres the pus

Cellulitis vs AbscessAbscesses may not be clinically obvious

Is there an abscess?What is the best area for I&D?Are there structures near the abscess(i.e. vessels or nerves) risk?

Methods: Prospective observational ED study of adult patients with clinical STI without obvious abscess The treating physicians pretest opinions need for drainage procedures probability of subcutaneous fluid collectionEmergency US of the infected areaEffect on management plan was recorded

Results: Ultrasound changed the management in 71/126 (56%) of cases Pretest Groupbelieved not to need drainage - US changed management in 39/82 (48%)(33 drained and 6 more imaging or consultation) believed drainage to be needed, US changed the management in 32/44 (73%) (16 not drained and 16 more diagnostics)US had a management effect in all pretest probabilities for fluid from 10% to 90%

ConclusionUS changes ED managementHopefully for the better

Methods:Prospective, convenience sample of adult patients with ?cellulitis +/- abscess US was performed by EPs or residents who had attended a h training session in soft tissue USyes/no assessment (of abscess) I&D was the standard when performedResolution on 7d follow-up was the standard when I&D was not performedResultsN=10764/107 patients had I&Dproven abscess17/107 had negative I&D26/107 improved with antibiotic therapy alone (clinically negative)Clinical examinationSensitivity of : 86% (95% [CI] = 76% to 93%)Specificity: 70% (95% CI = 55% to 82%). USSensitivity: 98% (95% CI = 93% to 100%)Specificity was 88% (95% CI = 76% to 96%)

Of 18 cases in which US disagreed with the clinical examination, US was correct in 17 (94%) (x2=14.2, p = 0.0002)

Clinical examinationSensitivity of : 86%Specificity: 70%USSensitivity: 98%Specificity was 88%

Of 18 cases in which US disagreed with the clinical exam, US was correct in 17 (94% of cases with disagreement, x2 = 14.2, p = 0.0002)

Conclusions: ED bedside US improves accuracy in detection of superficial abscesses

The probe should be perpendicular to the chest to ensure an accurate assessment of pleural fluid collection size, shape, and depth

Identify the diaphragm and liver or spleen

Slide the probe in the longitudinal plane towards the head and feet and then anterior-posterior or medial-lateral to locate the largest pocket of fluid

With the largest pocket of fluid in the centre of the screen, mark that point on the skin under the centre of the probe just above the lower rib

Rotate the probe 90o into the transverse plane. Ensure that the largest pocket of fluid is still under the centre of the probe and corresponds to the mark made on the skin

Note the location of the diaphragm, lung, liver and spleen, etc. Also note the depth that you could insert the needle into the fluid before hitting one of these structures

Preparation for thoracentesis, thoracentesis technique, and aftercare are otherwise performed in the usual fashion.

PneumothoraxSolid organ insertionDry tap insufficient tap

Prospective randomized trial (not blinded)US guided vs Needle Catheter vs Needle onlyPopulationSpontaneously breathingCooperative patients Effusions obliterating > the hemidiaphragm on X-rayResultsN=52US guided 0/19 serious complicationsNeedle catheter 9/18 serious complications (7PTx)Needle only 5/15 serious complications (3PTx)Conclusion:Thoracentesis method significantly influenced complicationsUS guided method was the safestDonna R. Grogan; Richard S. Irwin; Richard Channick; Vassilios Raptopoulos; Frederick J. Curley; Thaddeus Bartter; R. William CorwinArch Intern Med. 1990;150(4):873-877

Objective: To determine the safety of ultrasound-guided thoracentesis performed by critical care physicians on patients receiving mechanical ventilation

Design: Prospective and observationalSetting: ICUs in a teaching hospitalPatients: 211 serial patients receiving mechanical ventilation with pleural effusion requiring diagnostic or therapeutic thoracentesis

Interventions: 232 separate USTs were performed by critical care physicians without radiology support. AP CXRs were reviewed for possible post-procedure pneumothorax

Results: PTx occurred in 3/232 USTs (1.3%)

Conclusions: UST performed in patients receiving mechanical ventilation without radiology support results in an acceptable rate of pneumothorax

Paracentesis is performed for diagnostic and therapeutic reasonsComplications - rareBowel perforationArtery punctureUS makes paracentesis safer and dry taps

Is there fluid in the abdomen?

Slide the probe caudally down the flankIdentify the ideal site of insertion by following the fluid with your probe in all directions. Chose the largest pocket of fluid, away from the bowel, liver, spleen, and bladder

Once the largest pocket of fluid has been identified the site of insertion is marked with indelible ink Paracentesis is performed as usual

Study objective: To determine if emergency center ultrasound (ECUS) can be of value to emergency physicians in the evaluation of possible ascites and accompanying decisions to perform emergent paracentesis.

Methods: Randomized ED StudyInclusion:18 yrs, suspected of having ascites and potentially requiring paracentesisExclusion: kids and pregnant womenRandomized to traditional or US-assisted paracentesis coin tossParticipating physicians had received a minimum of 1 hour of formal didactic ultrasound training

Results: 100 enrolled patients56 received the ECUS-assisted technique. Of 42 patients with ascites, 40 (95%) were successfully aspirated and 14 (25%) did not receive paracentesis because no ascites or insignificant amount of ascites was visualized. One patient was noted to have a large cystic mass in the left lower quadrant and another patient had a ventral hernia.

Of the 44 patients randomized to the traditional technique, 27 (61%) were successfully aspirated. In 17 (39%) of these patients, fluid could not be obtained using traditional methods. Of these 17 failed attempts by traditional methods, 15 patients received ECUS in a break from the study protocolAscitic fluid was obtained in 13 of these 15 patients; of the 2 remaining patients, 1 did not have enough fluid to be sampled and the other had no fluid visualized.

Did it help? avoid complicationsIncrease efficiencyEnhance knowledge of anatomy

1AM at FMCElderly gentleman presents with urinary retntionFoley cant be passedUrology is helpful over the phone but doesnt want to see tonight

EDE ensures that the bladder is large enough to access and that there is no bowel in the way of your target

Place the probe in the midline just above the symphysis pubis in the longitudinal plane with the indicator pointed towards the head

Aim the beam into the pelvis by tilting the probe caudally

Identify the bladder in transverse and longitudal planesNote the overall shape and dimensions of the bladder

Mark the overlying skinPerform aspiration-catheterization in the usual manner

Prospective case series17 consecutive patients Acute urinary outflow obstruction Urethral cath was not possible or contraindicatedIntervention:Emergent real-time ultrasound-guided suprapubic cystostomy in the ED

Results:Successful 17/17 (100%, 90100% CI: 95%) cases 1st pass 17/17Technically challenging 4/17No complications reported 2week FU

A peripheral vein will look like a small IVCThin-walledBlackCircular structureNon-pulsatile Compressible with very little pressure

Look with US in both forearms for a target If no good vein is visible, move to upper arm

Methods: Prospective, randomized study of all adult patients who presented to the Emergency Department (ED) between June and December 2007. Inclusion criteria were failed nursing attempts at peripheral access (at least three)EPs were 2nd- or 3rd-year residents who had previously performed > five EJs and USIVsRandomized into either an initial EJ or USIV approach.

Results: 60 pts enrolled32 in the ultrasound group28 in the EJ groupInitial Success: USIV 84% (95% CI 6893%) vs. EJ 50% (95% CI 3367%) p 0.006Success if EJ visible: USIV 84% vs. EJ 66% (p 0.18)Overall success (including crossover): 41 lines were successfully placed by US out of 46 attempts (89%) vs. 18 out of 33 for EJ (55%), p 0.001Total: 59/60 patients (98%) had a peripheral IV successfully placed

Rob HallKyle McLaughlin

X-rays are pretty good

Possibility of detecting hematoma and periosteal elevation in subtle fracturesDecrease radiation loadConvenience

Double Blinded Randomized Educational Study13 EPs / 4ER US fellows / 2 Residents24 chicken drumsticks (14 c # and 10 c/o)Each given a 2 min tutorial on fracture ID

Results312 examsSensitivity 91% (CI 85%-95%)Specificity84% (CI 76%-89%)

Study DesignProspective, blinded, convenience sample study over a 7 month period from May - Nov 2004An urban peds EDMethods: A bedside ultrasound of the forearm bones was performed by a PEM physician US findings were compared with X-ray findings Reductions were performed under US guidance Post reduction X-rays were performedAny need for further reduction was recordedResults: N=68 patientsRadiographs revealed forearm fractures in 48 patientsFractures of radius, ulna, and both U/S identified all patients with fracturesU/S revealed the correct type and location of the fracture in 46 patients (2 missed)

Sensitivity 97% (95% confidence interval [CI], 89%100%) Specificity was 100% (95% CI, 83%100%)26 subjects underwent reduction of their fractures in the ED2 subjects required re-reduction after the initial reductionThe initial success rate of ultrasound-guided reduction was 92% (95% CI, 75%99%)

Methods: After one hour of standardized training, physicians with minimal US experience clinically evaluated patients presenting with pain and trauma to the upper arm or legThe investigators then performed a long-bone US evaluation, recording their impression of fracture presence or absenceResults were compared with X-ray or CT

Results: N=58 patientsPhysical examinationSensitivity 78.6% Specificity 90.0%UltrasoundSensitivity 92.9% Specificity 83.3%

US provided improved sensitivity with less specificity compared with physical examination in the detection of fractures in long bones.

Conclusion: Author: US by minimally trained clinicians may be used to rule out a long-bone fracture in patients with a medium to low probability of fractureImproves on clinical exam

HPI: An 18-month-old boy presented to the ER after a fall 24h previously. Refusing to bear weight on the right leg since the fall.

OE: afebrile, comfortable at rest, and reluctant to transfer weight through his right leg. There was no swelling, bruising, or deformity visible, and his range of motion was normal. There was no focal tenderness, but the examining physician was unable to rule out lower leg tenderness because of inconsistent responses from the child.

X-Ray...

Diagnosis: soft tissue traumaManagement: Analgesia medications 72-hour review was arranged

72h Follow-up: the child was still non-weight-bearing trouble sleeping

*Peri-osteal elevation with underlying fracture hematoma

The leg was immobilized in an above knee cast

2 week follow-up: plain X-ray demonstrated healing oblique fracture of the distal tibia

* Healing fracture

Reduction assessment

8 year girl was referred from the periphery for evaluation of a forearm fractureThe patient had fallen at play about 4h earlier

OE: obvious deformity of the distal forearm N/V exam normal Skin intact

American Journal of Emergency Medicine - Volume 18, Issue 1 (January 2000)

After good anesthesia had been achieved, the EP attempted to reduce the fracture using manipulation, traction, and counter-traction

Swelling of the forearm made it difficult to evaluate the reduction clinically

...repeat US

While anesthesia was still in place and before casting, a second reduction was performed

Repeat US

Hennepin County Medical Center Training video

Confirmation of tube placement

Methods: 13 patients requiring elective intubation under GA, and data from two trauma patients were evaluated. Using a portable, hand-held, ultrasound machine, sonographic recordings of the chest wall visceral-parietal pleural interface (VPPI) were recorded bilaterally in each patient during all phases of airway management: (1) preoxygenation; (2) induction; (3) paralysis; (4) intubation; and (5) ventilation.

Results: The VPPI could be well-imaged for all of the patients. In the two trauma patients, right mainstem intubations were noted in which specific pleural signals were not seen in the left chest wall VPPI after tube placement. These signs returned after correct repositioning of the ETT tube. IAll of the elective surgery patients, signs correlating with bilateral ventilation in each patient were imaged and correlated with confirmation of ETT placement by anesthesiology.

Conclusions: US may be another tool to confirm ETT placement US may have merit in extreme environments, such as in remote, prehospital settings or during aerospace medical transports, in which auscultation is impossible due to noise, or capnography is not availableRequires further evaluation

Methods:Real-time B-mode ultrasound imaging was performed in 24 intubated patients in order to confirm the correct placement of ET tubesThe large acoustic impedance mismatch between the air within the ET tube cuff and the tracheal wall could be bypassed by (1) use of a foam-cuffed Bivona ET tube (2) cuff inflation with saline instead of airOptimal repositioning of the endotracheal tube could be done under direct visualizationImaging of the foam-filled and saline-filled cuffs was easier in the longitudinal (sagittal) than in the transverse view, was enhanced by a slight longitudinal to-and-fro motion of the tubeCases of esophageal intubation were not considered

Conclusion:Use of a noninvasive imaging modality such as ultrasound will spare selected patients from the radiation exposure associated with a chest x-rayThis is of value in pregnant patients and in those requiring frequent chest radiographs for the sole purpose of confirming correct ET tube placement

Objective. Determining the correct position of ET tubes in critically ill patients may be complicated by external factors such as noise, body habitus, and the need for ongoing resuscitation

Methods We describe the sonographic findings in a case series of endobronchial main stem intubations and obstruction, highlighting the utility of this sonographic application.

ResultsUS detection of the sliding lung sign, the lung pulse, and diaphragmatic excursion can accurately detect main stem bronchial intubation as well as bronchial obstruction

Conclusions. Clinical use of lung sonography may decrease the need for chest radiography and may allow more rapid diagnosis of main stem intubation and bronchial obstruction.J Ultrasound Med 27:785-789 0278-4297

Methods: Cross-sectional observational studyConvenience sample of patients presenting to the ED between Sept 2000 - Feb 2001EP sonographers who had undergone a 3h training session in limited echocardiography, focusing on LVEF and CVP measurement, performed echocardiogramsLVEF was rated as poor (55%) and an absolute %

CVP categories included low (10 cm). Formal echocardiograms were obtained within a four-hour window on all patients and interpreted by a staff cardiologist

Results: A total of 115 patients were assessed for LVEF, and 94 patients had complete information for CVPIndications for echocardiography included chest pain (45.1%), CHF (38.1%), dyspnea (5.7%), and endocarditis (10.6%). LVEF correlation of r=0.712 with 86.1% overall agreement. Subgroup analysis revealed the highest agreement (92.3%) between EP and formal echocardiograms within the normal LVEF category, followed by 70.4% agreement in the poor LVEF category and 47.8% in the moderate LVEF category.

CVP measurements resulted in 70.2% overall raw agreement between EP and formal echocardiograms. Subgroup analysis revealed the highest agreement (83.3%) within the high CVP category followed by 66.6% in the moderate and 20% in the low categories.

Methods: Cross-sectional observational study, Convenience sample of patients presenting to the ED between Sept 2000 - Feb 2001Level III credentialed EP sonographers who had undergone a three hour training session in limited echocardiography, focusing on LVEF and CVP measurement, performed echocardiograms. LVEF was rated as poor (55%) and an absolute %

CVP categories included low (10 cm). Formal echocardiograms were obtained within a four-hour window on all patients and interpreted by a staff cardiologist.

Results: A total of 115 patients were assessed for LVEF, and 94 patients had complete information for CVP. Indications for echocardiography included chest pain (45.1%), CHF (38.1%), dyspnea (5.7%), and endocarditis (10.6%). LVEF correlation of r=0.712 with 86.1% overall agreement. Subgroup analysis revealed the highest agreement (92.3%) between EP and formal echocardiograms within the normal LVEF category, followed by 70.4% agreement in the poor LVEF category and 47.8% in the moderate LVEF category. Central venous pressure measurements resulted in 70.2% overall raw agreement between EP and formal echocardiograms. Subgroup analysis revealed the highest agreement (83.3%) within the high CVP category followed by 66.6% in the moderate and 20% in the low categories.

Conclusions:Experienced EP sonographers with a small amount of focused additional training in limited bedside echocardiography can assess LVEF accurately in the ED

*****************************bedside limited echocardiography by the emergencyphysician************************************************3 drumsticks had skin folds and joints that were mis-interprited.If these were removed the Sens/Specificity would be 100%*The two missed fractures also had radial metaphyseal fractures which were identified*****Peri-osteal elevation with underlying fracture hematoma**

The cast was removed at 3 weeks, and the child rapidly returned to normal activity.***overriding fracture of the distal radius and slight bowing of the ulna ***Repeat ultrasound showing persistent displacement after first reduction attempt**Repeat ultrasound after second reduction showing good alignment*Radiograph after second reduction and splinting, showing good position of the fracture.************