Ultrasound in Emergency Medicine

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Ultrasound in Emergency Medicine

• Martin A. Bazi, MD

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• The clinical application of ultrasonography by
  emergency physicians has greatly expanded over
  the past decade.
• The American College of Emergency Physicians
  (ACEP) has firmly supported the concept of
  emergency ultrasound.

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INDICATIONS

• Blunt or penetrating trauma to the torso
• 4 views
• Rt flank hepatorenal space
• Lt flank Perisplenic area
• Subcostal pericardium
• Pelvic retrovesical or retrouterine

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The FAST examination  

• The Focused Assessment with Sonography for Trauma
  is a rapid, bedside, ultrasound examination
  performed to identify intra-peritoneal
  haemorrhage or pericardial tamponade.
• FAST examines four areas for free fluid
• Perihepatic hepato-renal space
• Perisplenic
• Pelvis
• Pericardium

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Perihepatic Scanning

• The hepatorenal space (pouch of
  Rutherford-Morison) is the most dependent part of
  the upper peritoneal cavity and small amounts of
  intra-peritoneal fluid may collect in this region
  first. Blood shows as a hypoechoic black stripe
  between the capsule liver and the fatty fascia of
  the kidney.
• The probe is placed in the right mid- to
  posterior axillary line at the level of the 11th
  and 12th ribs. 

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Perisplenic Scanning

• The left upper quadrant examination visualises
  the spleen and perisplenic areas.
• The transducer is placed on the left posterior
  axillary line region between the 10th and 11th
  ribs.

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Pelvic Scanning

• The pelvic examination visualises the cul-de-sac
  the Pouch of Douglas in females and the
  rectovesical pouch in the male. It is the most
  dependent portion of the lower abdomen and
  pelvis, hence where fluid will collect.
• The transducer is placed midline just superior to
  the symphysis pubis.

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Pericardial Scanning

• The pericardial examination screens for fluid
  between the fibrous pericardium and the heart,
  and hence possible cardiac tamponade.
• The transducer is placed just to the left of the
  xiphisternum and angled upwards under the costal
  margin.

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Advanced Trauma Scanning

• Looks for fluid
• Look for non-homogenous appearing regions with in
  solid organs parenchyma which may represent
  injury
• Consist of Diamond abdominal examinations and 2
  discrete thoracic windows

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DIAMOND EXAMINATION
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Emergency US in pregnancy

• Indicated in first trimester pregnant patient
  presenting with pain, bleeding, near syncope or
  shock
• Asymptomatic pregnant patient with risk factors
  for ectopic pregnancy
• Look for
• Location of the pregnancy
• Fetal heart rate

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US in pregnancy

• Transabdominal
• Intravaginal
• For second third trimester
• Detecting fetal cardiac movement
• Pregnant trauma patient

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Emergency echocardiography

• Trauma
• Cardiac arrest shock
• Pulseless electrical activity

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Procedural US

• Intravenous lines
• Bladder size aspiration
• Abscess location aspiration
• Thoracentesis paracentesis
• Foreign body localization
• Pacemaker
• IUD
• Soft tissue FB

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ACEP recommended training and proficiency
numerical goals per emergency ultrasound
application.
Primary Application Minimum Range of Documented and Outcome Reviewed Ultrasound Needed for Proficiency
Trauma 25 25-50
IUP 25 25-50 25 Endovaginal (if only doing EV) 25 Transabdominal (if only doing TA)
Emergency cardiac 25 25-50
AAA 25 25
Biliary 25 25-50
Renal 25 25
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Pathway for EUS training for Practicing Physician

• Attends introductory emergency ultrasound course
  or courses
• Performs ultrasounds under supervision over
  reads, gold standards confirmatory testing, or
  patient outcome review within departmental
  ultrasound plan
• Ultrasounds are obtained with documentation and
  review to meet ACEP emergency ultrasound
  proficiency guidelines. Ultrasound available for
  departmental and hospital examination
• Acquired at local hospital setting within
  departmental privileges
• Quality review of ultrasound performed
  continuously. CME attended in accordance with
  specialty guidelines

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Examples of levels of proficiency

• Level I This level is for the practitioner
  who has completed the introductory training.
• Level II This level is for the practitioner
  who is in the process of completing credentialing
  examinations. Credentialing examinations must be
  recorded and contain follow-up documentation.
  Each examination is to be reviewed by the ED
  ultrasound coordinator. Straightforward
  examinations may be used in some clinical
  situations if reviewed by a Level III
  sonographer. In general, these examinations will
  not be used to make patient care decisions unless
  reviewed by a Level III Sonographer
• Level III This level is for the practitioner
  who is approved to use emergency ultrasound in
  the ED for patient-care decisions. This physician
  may supervise Level I and II examiners.

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Future potential applications of Emergency US
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Application Rationale
Musculoskeletal Musculoskeletal injuries Arthrocentesis Fracture detection Fracture reduction guidance
Deep venous thrombosis Detection of deep venous thrombosis
Airway Intubation detection in the apneic patient
Head and neck Peritonsillar abscess detection and drainage
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Testicular ultrasound Rule out torsion
Cardiac (transthoracic) Use for left ventricular function and hypotension
Orbital ultrasound Orbital hematoma and retinal detachment
Transesophageal Cardiac function and aortic disease
Obstetric second- and third-trimester bleeding Placenta previa