Novel Uses for ED Ultrasound

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Novel Uses for ED Ultrasound

• More than just another stethoscope

Mark Bromley Emergency Medicine PGY3
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Intubation
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Ocular
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Ultrasound in the ED - Outline

• Undifferentiated Hypotension - Echo
• LV function
• Volume Status
• JVP
• Procedures
• Guided Lumbar Puncture
• Abscess Drainage
• Pleural effusion/Thoracentesis
• Paracentesis
• Suprapubic aspiration
• Vascular Access
• Joint taps

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Other Novel Uses

• Galbladder
• DVT
• Ocular
• Fracture Detection
• Fracture Management
• Renal
• Pneumothorax
• Intubation

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Undiferentiated Hypotension

• ...for the cardiologist in you

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Case

• 67 ?
• Hx of CAD and CHF
• Unwell over last 2-3 days
• Hypotensive Tachycardic SOB

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Why US? Why us?

• Urgent diagnostic evaluation
• Timely
• Limited diagnostic options due to the clinical
  condition ? transportation of sick patients
• Allow appropriate intervention and improve the
  course of disease

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Unexplained Hypotension

1. Cardiogenic shock
2. Hypovolemia - Distributive
3. Right ventricular infarct/large PE
4. Tamponade

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Unexplained Hypotension

• As a clinician ? trying to choose between
  inotropy, fluid resuscitation, or a needle
• The ventricle is either moving well or not
• The RV is dilated or not
• There is an effusion or there is not
• The IVC is full or not
• The JVP is up or not

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LV Failure fractional shortening

• 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 fxn
• Change of diameter lt30 ? ?LV systolic fxn

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LV Failure fractional shortening
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LV Failure LV dilatation

• LV dilatation
• Mid-LV diameter 5.2cm at end-diastole
• If diameter gt5.2cm ? LV dilatation

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Specific Diagnoses
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LV Failure

• ? shortening fraction
• LV Dilatation

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Hypovolemic or Distributive Shock

• End-diastole ? LV chamber unusually small
• Systole ? virtually all LV blood ejected
• Cardiac Activity ? hyperdynamic
• fast heart rate
• very vigorous contractions
• Ejection fraction ? exceeds 70
• IVC ? low CVP

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Massive Pulmonary Embolus

• RV is usually 2/3 the size of the LV
• RV 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

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Bottom Line
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IVC how to

• Identify the IVC
• Just anterior to the spine
• To the right of the aorta in gt 99.9.
• Thin-walled (vs. the thicker-walled aorta)
• Compressible with pressure
• Size varies with respiration
• Diameter 1.5cm? possibly c/w ?CVP
• Diameter 1.0 cm definitely c/w ?CVP
• ?inspiratory ? in IVC (gt25) ? ? chance pt is dry

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IVC
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JVP How Good Are We

• Methods
• 84 consecutive patients referred for right-sided
  cardiac catheterization
• RA pressure was acquired
• Internal residents underwent 4h of formal US
  training and performed 20 supervised studies
• Blinded to cath results examined the IVC lt1h
  before catheterization
• RA pressure was also estimated by JVP in 40
  patients before right-sided cardiac
  catheterization
• Results
• RA pressure was successfully estimated from US
  images of the IVC in 90 of patients, compared
  with 63 from JVP examination
• The sensitivity for predicting RA pressure gt10mm
  Hg was 82 with US and 14 from JVP inspection

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JVP

• why should medicine residents have all the fun?

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JVP image generation
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JVP
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Case
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Case
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Can we do it?

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

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• Methods
• Prospective, observational study
• 4 EP investigators with prior US experience ?
  focused echo training
• A convenience sample of 51 adult pts with
  hypotension
• Exclusion criteria
• History of trauma
• Chest compressions
• EKG diagnostic of acute MI
• Echocardiogram 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 study
• A second cardiologist reviewed 20 of the tapes to
  assess inter-observer variability between
  cardiologists

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• Pearsons correlation coefficient for EP and
  cardiologist estimation was R0.86
• Pearsons correlation coefficient for the two
  cardiologists estimations was R0.84
• Agreement between EPs in the convenience subset
  of eight patients who underwent echo by two EPs
  yielded an R 0.94

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• Methods
• Prospective observational study of a convenience
  sample of patients admitted to ICU
• All 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 IVC
• LVF 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
• N31
• Mean age5.1 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 1.67.2)
• 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).

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• Design
• Randomized, controlled trial of immediate vs.
  delayed ultrasound.
• Urban, tertiary emergency department, census
  gt100,000.
• Non-trauma emergency department patients, aged
  gt17 yrs, and initial emergency department vital
  signs consistent with shock (SBPlt100 mm Hg or
  shock index gt1.0), and agreement of two
  independent observers for at least one sign and
  symptom of inadequate tissue perfusion
• Interventions
• Group 1 (immediate ultrasound) received standard
  care plus goal-directed US at time 0
• Group 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.
• N184
• 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 lt .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)

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• 7 views
• Each intended to answer a binary question
• Pericardial effusion
• Pericardial tamponade
• Left ventricular dysfunction
• Right ventricular dilation
• Intravascular volume depletion
• Intraperitoneal fluid
• Aortic aneurysm
• On average, this information was obtained in lt 6
  min

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• 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.

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Procedures

• We can do easily
• We can do safely

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Guided Lumbar Puncture

• ...when you need the bariatric needle

• Accurate 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

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• 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 patients
• Visualization 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 N76
• Soft tissue and bony anatomical structures were
  identified in all subjects
• Mean BMI was 31.4 (95 confidence interval, 29.1
  - 33.6).
• High-quality images were obtained in lt 1 minute
  in 153 (87.9) scans
• 
  lt 5 minutes in
  174 (100) scans
• Mean 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

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Guided Lumbar Puncture
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• Methods
• Cross-sectional study
• Patients categorized by BMI
• Recorded the difficulty in palpating traditional
  LP landmarks
• Identification 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
  95CI 53-92)
• The average distance from skin to ligamentum
  flavum was 44 mm - normal BMI
• 
  
  51 mm - overweight
• 
  
  64 mm - obese
• Conclusion

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Abscess Drainage

• ...wheres the pus

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Abscess Drainage

• Cellulitis vs Abscess
• Abscesses may not be clinically obvious
• Is there an abscess?
• What is the best area for ID?
• Are there structures near the abscess
• (i.e. vessels or nerves) risk?

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• 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 collection
• Emergency US of the infected area
• Effect on management plan was recorded
• Results
• Ultrasound changed the management in 71/126 (56)
  of cases
• Pretest Group
• believed 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

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• Conclusion
• US changes ED management
• Hopefully for the better

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• Methods
• Prospective, convenience sample of adult patients
  with ?cellulitis /- abscess
• US was performed by EPs or residents who had
  attended a ½h training session in soft tissue US
• yes/no assessment (of abscess)
• ID was the standard when performed
• Resolution on 7d follow-up was the standard when
  ID was not performed
• Results
• N107
• 64/107 patients had IDproven abscess
• 17/107 had negative ID
• 26/107 improved with antibiotic therapy alone
  (clinically negative)
• Clinical examination
• Sensitivity of 86 (95 CI 76 to 93)
• Specificity 70 (95 CI 55 to 82).
• US
• Sensitivity 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)
  (x214.2, p 0.0002)

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• Clinical examination
• Sensitivity of 86
• Specificity 70
• US
• Sensitivity 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

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Thoracentesis
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Thoracentesis How to...

1. The probe should be perpendicular to the chest to
   ensure an accurate assessment of pleural fluid
   collection size, shape, and depth
2. Identify the diaphragm and liver or spleen
3. 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

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Thoracentesis How to...

1. 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
2. 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

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Thoracentesis How to...

• 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.

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Thoracentesis - complications

• Pneumothorax
• Solid organ insertion
• Dry tap insufficient tap

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Complications Associated With Thoracentesis A
Prospective, Randomized Study Comparing Three
Different Methods
Donna R. Grogan Richard S. Irwin Richard
Channick Vassilios Raptopoulos Frederick J.
Curley Thaddeus Bartter R. William Corwin

• Prospective randomized trial (not blinded)
• US guided vs Needle Catheter vs Needle only
• Population
• Spontaneously breathing
• Cooperative patients
• Effusions obliterating gt½ the hemidiaphragm on
  X-ray
• Results
• N52
• US guided 0/19 serious complications
• Needle catheter 9/18 serious complications
  (7PTx)
• Needle only 5/15 serious complications (3PTx)
• Conclusion
• Thoracentesis method significantly influenced
  complications
• US guided method was the safest

Arch Intern Med. 1990150(4)873-877
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• Objective To determine the safety of
  ultrasound-guided thoracentesis performed by
  critical care physicians on patients receiving
  mechanical ventilation
• Design Prospective and observational
• Setting ICUs in a teaching hospital
• Patients 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

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Paracentesis
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Paracentesis

• Paracentesis is performed for diagnostic and
  therapeutic reasons
• Complications - rare
• Bowel perforation
• Artery puncture
• US makes paracentesis safer and ? dry taps
• Is there fluid in the abdomen?

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Paracentesis

• Slide the probe caudally down the flank
• Identify 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

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Paracentesis

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

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• 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 Study
• Inclusion18 yrs, suspected of having ascites
  and potentially requiring paracentesis
• Exclusion kids and pregnant women
• Randomized to traditional or US-assisted
  paracentesis coin toss
• Participating physicians had received a minimum
  of 1 hour of formal didactic ultrasound training
• Results
• 100 enrolled patients
• 56 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 protocol

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Paracentesis

• Did it help?
• avoid complications
• Increase efficiency
• Enhance knowledge of anatomy

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Suprapubic Aspiration
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Suprapubic Aspiration-Catheterization

• 1AM at FMC
• Elderly gentleman presents with urinary retntion
• Foley cant be passed
• Urology 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

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Suprapubic Aspiration-Catheterization

• 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

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Suprapubic Aspiration-Catheterization

1. Identify the bladder in transverse and longitudal
   planes
2. Note the overall shape and dimensions of the
   bladder

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Suprapubic Aspiration-Catheterization

• Mark the overlying skin
• Perform aspiration-catheterization in the usual
  manner

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• Prospective case series
• 17 consecutive patients
• Acute urinary outflow obstruction
• Urethral cath was not possible or contraindicated
• Intervention
• Emergent real-time ultrasound-guided suprapubic
  cystostomy in the ED
• Results
• Successful 17/17 (100, 90100 CI 95) cases
• 1st pass 17/17
• Technically challenging 4/17
• No complications reported 2week FU

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Peripheral Vascular Access
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Peripheral Vascular Access

• A peripheral vein will look like a small IVC
• Thin-walled
• Black
• Circular structure
• Non-pulsatile
• Compressible with very little pressure

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Peripheral Vascular Access

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

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• 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 gt five EJs and USIVs
• Randomized into either an initial EJ or USIV
  approach.
• Results
• 60 pts enrolled
• 32 in the ultrasound group
• 28 in the EJ group
• Initial Success USIV 84 (95 CI 6893) vs. EJ
  50 (95 CI 3367) p 0.006
• Success 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 0.001
• Total 59/60 patients (98) had a peripheral IV
  successfully placed

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Questions
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Thank you

• Rob Hall
• Kyle McLaughlin

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Fracture Identification
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Fracture Identification - Why

• X-rays are pretty good
• Possibility of detecting hematoma and periosteal
  elevation in subtle fractures
• Decrease radiation load
• Convenience

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• Double Blinded Randomized Educational Study
• 13 EPs / 4ER US fellows / 2 Residents
• 24 chicken drumsticks (14 c and 10 c/o)
• Each given a 2 min tutorial on fracture ID
• Results
• 312 exams
• Sensitivity 91 (CI 85-95)
• Specificity84 (CI 76-89)

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• Study Design
• Prospective, blinded, convenience sample study
  over a 7 month period from May - Nov 2004
• An urban peds ED
• Methods
• 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 performed
• Any need for further reduction was recorded
• Results
• N68 patients
• Radiographs revealed forearm fractures in 48
  patients
• Fractures of radius, ulna, and both
• U/S identified all patients with fractures
• U/S revealed the correct type and location of the
  fracture in 46 patients (2 missed)
• Sensitivity 97 (95 confidence interval CI,
  89100)
• Specificity was 100 (95 CI, 83100)

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• 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 leg
• The investigators then performed a long-bone US
  evaluation, recording their impression of
  fracture presence or absence
• Results were compared with X-ray or CT
• Results
• N58 patients
• Physical examination
• Sensitivity 78.6
• Specificity 90.0
• Ultrasound
• Sensitivity 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 fracture
• Improves on clinical exam

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Case

• 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...

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Case

• Diagnosis soft tissue trauma
• Management
• Analgesia medications
• 72-hour review was arranged
• 72h Follow-up
• the child was still non-weight-bearing
• trouble sleeping

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Peri-osteal elevation with underlying fracture
hematoma
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• The leg was immobilized in an above knee cast
• 2 week follow-up plain X-ray demonstrated
  healing oblique fracture of the distal tibia

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Healing fracture
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Fracture Management

• Reduction assessment

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Case

• 8 year girl was referred from the periphery for
  evaluation of a forearm fracture
• The 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)
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Case

• 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

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

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US Guided Reduction - How
Hennepin County Medical Center Training video
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Intubation

• Confirmation of tube placement

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• 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. I
• All 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 available
• Requires further evaluation

99

• Methods
• Real-time B-mode ultrasound imaging was performed
  in 24 intubated patients in order to confirm the
  correct placement of ET tubes
• The 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 air
• Optimal repositioning of the endotracheal tube
  could be done under direct visualization
• Imaging 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 tube
• Cases 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-ray
• This is of value in pregnant patients and in
  those requiring frequent chest radiographs for
  the sole purpose of confirming correct ET tube
  placement

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Point-of-Care Sonographic Detection of Left
Endobronchial Main Stem Intubation and
Obstruction Versus Endotracheal
IntubationMichael Blaivas, MD, RDMS and James W.
Tsung, MD, MPH

• 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.
• Results
• US 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 27785-789 0278-4297
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Cardiac Echo - leftovers
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• Methods
• Cross-sectional observational study
• Convenience sample of patients presenting to the
  ED between Sept 2000 - Feb 2001
• EP sonographers who had undergone a 3h training
  session in limited echocardiography, focusing on
  LVEF and CVP measurement, performed
  echocardiograms
• LVEF was rated as poor (lt30), moderate
  (3055), or normal (gt55) and an absolute
• CVP categories included low (lt5 cm), moderate
  (510 cm), and high (gt10 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 r0.712 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.

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• Methods
• Cross-sectional observational study,
• Convenience sample of patients presenting to the
  ED between Sept 2000 - Feb 2001
• Level 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 (lt30), moderate
  (3055), or normal (gt55) and an absolute
• CVP categories included low (lt5 cm), moderate
  (510 cm), and high (gt10 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 r0.712 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

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