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Emergency Ultrasound Section Newsletter - April 2009, Vol 13, #2

Emergency Ultrasound Section

circle_arrow From the Chair
circle_arrow Color Doppler Ultrasound in the Evaluation of Suspected UVJ Stones
circle_arrow Case Report - Intraluminal Cannula Location Revealed by Power Doppler
circle_arrow The Stimulus Package, National Institutes of Health (NIH) Funding, and Ultrasound Research & Networking
circle_arrow Journal Watch – March 2009
circle_arrow AIUM Forum 2008 Report


Newsletter Index


Emergency Ultrasound Section

 

 

From the Chair

Lawrence A. Melniker, MD, MS, FACEP
Vice Chair for Quality Management
Department of Emergency Medicine
New York Methodist Hospital

The first 4 months of my tenure as the Emergency Ultrasound Section Chair have been eventful.

  • Sonoguide continues to be a highly visited website and now has its first corporate sponsor, Ultrasonix. We owe much appreciation to the company and the work of our colleagues at the College, notably Peggy Brock, for completing the deal. This sponsorship and, hopefully more to follow, guarantees that Sonoguide will remain a living resource with regular additions and refinements. Beatrice Hoffman will be contacting the membership regarding new chapters and updates. Those with ideas to improve Sonoguide may contact Dr. Hoffman directly.
  • Starting at Scientific Assembly and over the past 3 months, there has been considerable interest in taking Data Management to the next level through the development of industry-wide specification for image and video archiving and transmission, as well as, reporting and billing requirements. Now, weaving our needs in the EM clinical sonography community with the process of Integrating the Healthcare Enterprise (IHE) has been proposed. The IHE movement is a major undertaking to bring Healthcare into the 21st century from an Information Technology perspective. This issue will require a lot of expertise and maximal effort; it will be coordinated by Chris Moore and involve several members of the Section.
  • Discussions have been underway on the development of an Annotated Bibliography to be added to the Section website. This would continue and expand the work of the Section Secretary Gary Quick’s journal reports that are a regular part of our quarterly newsletter. Such a bibliography would serve the Section and our community in many ways as an online resource for all members. A point-person will be recruited soon to begin this new project.
  • The ACEP Board of Directors gave final approval to the Emergency Ultrasound Section’s new Operational Guidelines. The Board endorsed our preliminary plan for the Accreditation Process for Emergency Ultrasound Services; fully recognized these issues as a matter of the protection of the integrity of Emergency Medicine practice– under no circumstances will the College allow another specialty to accredit any aspect of the provision of emergency care by emergency physicians.
  • The ACEP and the American Society for Echocardiography (ASE) have drafted a Consensus Document on Bedside Cardiac Ultrasound and it is under review by both Boards. Congratulations to Vicki Noble for shepherding this process through many iterations and refinements.
  • Finally, the further Development and Maturation of the Section will continue to be my principle focus over the next several months. Under Dr. Vivek Tayal’s leadership in 2007-8, several important Committees and Subcommittees were enshrined in the Operational Guidelines of the Section. Starting in February, there will be quarterly conference calls with the Chairs to discuss progress towards the Goal & Objectives of each group and how the Section & College leadership may assist. Finally, in order to facilitate the development of the next generation of Section leaders, all Chairs are requested to identify a member of the group to become the new Committee or Subcommittee Chair in October.

Listed below are the groups and their current membership; anyone wishing to join may contact the group’s Chair.

 o Accreditation

        • Jerry Chiricolo, MD, FACEP, Chair
        • Anthony J. Dean, MD
        • Lawrence Melniker, MD, MS, FACEP
        • Vicki E. Noble, MD, FACEP
        • Andrew Sama, MD, FACEP
        • Paul R. Sierzenski, MD, FACEP
        • Vivek S. Tayal, MD, FACEP

 o Community Practice

        • Robert J. Tillotson, DO, FACEP, Chair
        • Mike Blaivas, MD, FACEP
        • Evelyn E. Cardenas, MD, FACEP
        • Jim Fedinec, MD, RDMS, FACEP
        • Steffen "Hazzy" Fletcher, MD
        • Robert A. Jones, DO, FACEP
        • Mike Overfield, MD
        • Mike Pallaci, DO, FACEP
        • Geoffrey E. Renk, MD, FACEP
        • Mike Roshon, MD, PhD, FACEP
        • Greg Snead, MD
        • Rita A. Sweeney, MD, MPH
        • Irving V. Westney, MD, FACEP 

o Critical Care in Emergency Ultrasound

        • Anthony J. Dean, MD, Chair
        • Mike Blaivas, MD, FACEP
        • Keith Boniface Jr, MD, FACEP
        • Anthony Weekes, MD

 o Industry Communications

        • Chris Moore, MD, RDMS, FACEP, Chair
        • Jim Hwang, MD
        • Peter Kumasaka, MD
        • Rich Limperos, MD
        • Lawrence Melniker, MD, MS, FACEP 

o International Emergency Ultrasound

o Media/Government Relations

        • Paul R. Sierzenski, MD, FACEP, Chair
        • Gregory M. Press, MD 

o Medical Student Education

        • Michael B. Stone, MD, Chair
        • Thomas P. Cook, MD, FACEP
        • J. Chris Fox, MD, FACEP
        • Beatrice Hoffman, MD
        • Lawrence Melniker, MD, MS, FACEP
        • Phil Perera, MD, FACEP
        • Alfredo Tirado-Gonzalez, MD

 o Military Emergency Medicine

        • Rob Blankenship, MD, FACEP, Chair
        • Rob Ferre, MD
        • Sumeru Mehta, MD, FACEP

o Pediatric Ultrasound

        • Jim Tsung, MD, Chair
        • Jason Levy, MD 

o Reimbursement

        • Steve Hoffenberg, MD, Chair
        • Tom Ashar, MD
        • Eitan Dickman, MD, RDMS
        • Mila L. Felder, MD
        • Bret P. Nelson, MD, FACEP
        • Jessica Resnick, MD, FACEP 

o Residency Education

        • Dan Theodoro, MD, RDMS, Chair
        • Srikar R. Adhikari, MD
        • Keith Boniface Jr, MD, FACEP
        • Michael A. Peterson, MD
        • Chris C. Raio, MD
        • Sarah Stahmer, MD, FACEP
        • Sandy Werner, MD, FACEP

 o Safety

        • Arun Nagdev, MD, Chair
        • Chalene Corinaldi, MD
        • Brian D. Euerle, MD, FACEP  

o Subspecialty Future Organization

        • Resa E. Lewiss, MD, Chair
        • Deepak Chadwani, MD
        • Jerrica L. Chen, MD
        • John L. Kendall, MD, FACEP
        • Lawrence Melniker, MD, MS, FACEP
        • Michael Roshon, MD, PhD, FACEP
        • Sonali C. Ruder, DO
        • Paul R. Sierzenski, MD, FACEP
        • Barry C. Simon, MD
        • Vivek S. Tayal, MD, FACEP

 o US Management Course

        • Troy R. Foster, MD, FACEP, Chair
        • Rajesh N. Geria, MD
        • Bret P. Nelson, MD, FACEP
        • Vivek S. Tayal, MD, FACEP

o US Section Web Page

        • Thomas Mailhot, MD, Chair
        • David P. Bahner, MD, RDMS, FACEP
        • Beatrice Hoffman, MD
        • Diku P. Mandavia, MD, FACEP  

Back to Top

Color Doppler Ultrasound in the Evaluation of Suspected UVJ Stones

William T. Hosek MD, FACEP
Johns Hopkins University

Case: A 26 year old female presented with nausea, vomiting and severe right flank pain. She was afebrile and had stable vital signs. She was treated with intravenous fluids, antiemetics and pain medication. A non-contrast renal CT revealed right hydronephrosis and hydroureter compressing her inferior vena cava (image A). The CT also showed a 3 mm stone at the ureteropelvic junction (not shown in the image). Because a 3 mm stone would not likely lead to such severe pathology, a ureteral stricture was also suspected. She was therefore scheduled for a percutaneous nephrostomy tube. Images B and C are from a bedside ultrasound performed while she awaited transfer to the OR. Image B is a long axis view of the bladder through the right UVJ and image C is a transverse view of the bladder. The images clearly show a previously undetected large stone in the UVJ which was thought to explain her symptoms and CT findings.

 

0309ColorDopplerUltrasoundA
Image A 

 

0309ColorDopplerUltrasoundB
Image B

0309ColorDopplerUltrasoundC
Image C

 

 

Discussion: The ureterovesicular junction (UVJ) is the most common location for a ureteric stone to become impacted and the most likely region for a stone to be visualized by ultrasound. Although a full bladder provides an excellent sonographic window, the large degree of enhancement can actually obscure the presence of a stone. Additionally, ureteral stones don’t always cast a significant shadow (image B). The likelihood of stone detection can be maximized by decreasing the gain (to reduce enhancement) and by using color Doppler to identify stone artifact and urine flow. The twinkling sign1 is a color Doppler artifact that appears as a rapidly changing mixture of colors behind a strongly reflective object such as a stone. Image C shows blue color lighting-up distal to an echogenic structure in the right UVJ, confirming the presence of a stone. Color Doppler is also used to detect urine flow at the ureteral orifice (ureteral jet). Ureteral jets are normally directed in an anteromedial direction and are best evaluated in the transverse plane at the level of the trigone.2 While ureteral jets may not always be seen in normal or low flow states, the presence of a jet confirms that a suspected obstruction is not complete. In the above case, the ureteral jet clearly seen just above the UVJ stone (image C) proved that the patient’s obstruction was only partial. 

Case Outcome: The patient was observed for the possibility of spontaneous stone passage but her symptoms continued into the next day. Since the ultrasound had localized the stone to the UVJ, the patient underwent cystoscopy (as opposed to percutaneous nephrostomy) and a 6 mm stone was easily removed.

References:

  1. Rahmouni A, Bargoin R, Herment A, et al. Color doppler twinkling artifact in hyperechoic regions. Radiology. 1996;199:269-271.
  2. Burge HJ, Middleton WD, McClennan BL, et al. Ureteral jets in healthy subjects and in patients with unilateral ureteral calculi: comparison with color doppler US. Radiology. 1991:180(2):437-442. 

Back to Top

Case Report - Intraluminal Cannula Location Revealed by Power Doppler

Peter J. Mariani MD
SUNY Upstate Medical University, Syracuse NY

Scott A. Bloch MD
Amy J. Bloch MD
Medical College of Georgia, Augusta GA

A 73 year old dehydrated male presented to the ED with a chronic pancreatitis exacerbation and poor peripheral venous access. He underwent placement of a triple lumen cannula into his right femoral vein. Venipuncture was attained under ultrasound guidance and the procedure was completed in standard Seldinger fashion. Lumens flushed easily but blood could not be easily aspirated. 2D gray scale insonation with linear probe at several frequencies failed to visualize the cannula.

A sterile saline flush of the cannula was performed under power doppler (Figure 1).

0309CaseReport1

No extravascular doppler signals were evident on repeat flushes with insonation further superiorly. Image series was interpreted as indicating intravenous cannula location (Figure 2). Blood specimens were thereafter obtained with gentle persistence, and a saline infusion under gravity into the cannula proceeded without complication.

0309CaseReport2

Discussion

Not all vascular cannulas are sufficiently echogenic as to be easily visualized by 2D gray scale imaging. Difficult resolution is compounded by transducers that have seen their share of ED wear and tear.

Power doppler can reveal the location of difficult to see fluid conduits, including those manmade. In the present case, an otherwise sonographically invisible cannula was revealed. In attempting to so visualize a cannula coursing presumptively parallel to a vessel’s long axis within its lumen, a transverse (short axis) view should be first used to assure cannula capture somewhere within the vessel’s imaged cross section. As with any 2-D imaging in a three dimensional world, the caveat should be kept in mind that a cannula seen intraluminally at the location of a single image is no guarantee against vessel wall transgression further downstream. Multiple images along the course of the cannula should be obtained.

For a subsequent patient in whom cannulation of the right internal jugular was performed, link to the below video to observe real time flow synchronous with cannula injection. Here again, note absence of perceptible cannula were it not for the doppler signal. 

 

 


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The Stimulus Package, National Institutes of Health (NIH) Funding, and Ultrasound Research & Networking

Lawrence A. Melniker, MD, MS, FACEP

As written in the September 2008 EUS Newsletter (Vol 12, #3) with respect to an Ultrasound Research Network, "The question is: where should we go from here? We must take this effort to the next step and develop a formal network with the infrastructure and accountability the task necessitates and which can procure the funding to complete the work. The leadership and members of the ACEP US Section and the SAEM US Interest Group must consider this question carefully. We should discuss and decide soon, whether to build upon and remake what we have [a SOAP 2.0, if you will] or begin a new research network; under the auspices of a Steering Committee established from our ranks.

"Several robust Emergency Care Research Networks (ECRN) now exist, which we could pattern our group after. The critical feature is to facilitate working together towards our common goal: to demonstrate the effectiveness and efficiency of clinical sonography, and its ability to improve the quality of care and safety of our patients."

The Stimulus Package passed and signed this past week has a boat-load of money for medical research over the next 2 years (see below). After this 2-year period, funds may be sparse for a while. The last section on Comparative Effectiveness Research is most germane to Clinical Ultrasonography.

American Recovery & Reinvestment Act (ARRA) – NIH’s Role (*)

Many types of funding mechanisms will be supported, but, in general, NIH will focus scientific activities in several areas:

  1. Fund new R01 applications that have a reasonable expectation of making progress in two years. The adherence to this time frame is in direct response to the spirit of the law.
  2. Accelerate the tempo of ongoing science through targeted supplements to current grants. For example, we may competitively expand the scope of current research awards or supplement an existing award with additional support for infrastructure (eg, equipment) that will be used in the two-year availability of these funds.
  3. NIH anticipates supporting new types of activities that fit into the structure of the ARRA. For example, it will support a reasonable number of awards to jump start the new NIH Challenge Grant program. This program is designed to focus on health and science problems where progress can be expected in two years. The number of awards and amount of funds will be determined, based on the scientific merit and the quality of applications. NIH will support at least $100 to $200 million—but the science will drive the actual level.  

The impact of this stimulus to clinicians and scientists cannot be overstated. Beyond the immediate economic stimulus, the long-term impact from the science funded by the ARRA will have a positive impact upon the health of the nation for years to come. NIH is committed, with the outstanding support that has been given by the White House, the Department, and Congress, to make our decisions based on best scientific opportunity and public need. NIH will seek projects with the broadest impact, work that can be accomplished in two years, that relies heavily on a new streamlined, modernized peer review system.

The stimulus bill provides a total of $10.4 billion, all available for two years--through September 2010. We expect to spend as much as possible in FY 2009 to support the goals of the ARRA and advance scientific priorities. Below is a summary:

  • $8.2 billion in support of scientific research priorities
     
    • $7.4 billion is transferred to the Institutes and Centers and Common Fund (CF), based on a percentage-based formula  
  • $1.1 billion for Comparative Effectiveness Research (CER)

Comparative effectiveness research

  • Establishes the Federal Coordinating Council for Comparative Effectiveness Research (FCC-CER), to be comprised of up to 15 representatives of federal agencies—at least half must be physicians or other experts with clinical expertise.
  • The Agency for Healthcare Research and Quality (AHRQ) will receive $700 million for CER; AHRQ must transfer $400 million to NIH to conduct or support CER.
  • The Secretary will have the discretion to allocate $400 million for CER to accelerate the development and dissemination of research assessing the comparative effectiveness of health care treatments and strategies.
  • The Secretary will also be obligated to meet several requirements, including: contract with the Institute of Medicine (IOM) to produce and submit a report to Congress and the Secretary by June 30, 2009, that includes recommendations on the national priorities for CER; consider any recommendations of the FCC-CER; publish information on grants and contracts awarded with the funds within a reasonable time of the obligation of funds and disseminate research findings from such grants and contracts to clinicians, patients, and the general public, as appropriate; ensure that the recipients of the funds offer an opportunity for public comment on the research; and annually report on the research conducted or supported through the funds.

(*) Summarized from http://www.aamc.org/advocacy/library/laborhhs/22009niharracall.pdf

The emergency ultrasound research community must build on the successes of the 2000's and establish our bona fides now, in order to able to compete for funds in the 2010's. Waves of Request for Applications (RFA) and Program Announcements (PA) are expected in April (for Q2 funding) and October (for Q4 funding). Our community must decide now on how to proceed with an Ultrasound Research Network. With the expertise within our ranks, we can prepare for the multitude of grant opportunities that are about to materialize. The immediate goal would be to create the framework of the new network that would in turn generate a "Chinese menu" of grant application components before the requests and announcements are published; eg, the annotated bibliography mentioned in the Chair’s Update could be the basis for introduction sections of grants, several method sections can be written in advance, and discussion sections can be outlined. With this "menu" in hand, we could mix and match the components to address individual project needs.

As the President discussed before the Congress, out of crisis comes opportunity. This is our golden opportunity to take clinical ultrasonography to the next level – acceptance through evidence – and the time is now.


  Back to Top

Journal Watch – March 2009

Various Reviewers

Reviewer: Lisa D. Mills, MD, FACEP

Grynberg M, Teyssedre J, Andre C, et al. Rupture of ectopic pregnancy with negative serum beta-hCG leading to hemorrhagic shock. Obstet Gynecol. 2009;112(2, part 2):537-539.

The authors present a case in which a 26 yo female presents with a chief complaint of abdominal pain. Last menstrual period was delayed by 2 weeks. Physical exam revealed a pale woman with hypotension, tachycardia, and peritonitis. Two urine pregnancy tests were performed. Both were negative. A serum beta-hCG was negative. CT of the abdomen and pelvis showed massive hemoperitoneum. Subsequent pelvic ultrasound revealed free fluid in the pelvis with a 3.4x2.3x1.8 cm mass in the right adnexa. The patient was taken to the operating room. There was a mass in the fallopian tube consistent with an ectopic pregnancy. Pathologic evaluation confirmed that the mass was an ectopic pregnancy.

This case report highlights the utility of performing a rapid, bedside evaluation on patients with abdominal pain and unstable vital signs, regardless of the suspected etiology. This patient’s prolonged workup may have been significantly shortened with a focused, emergency physician-performed ultrasound.

_____________

Reviewer: Krishnaraj Jayarama, DO, Carolinas Medical Center

Mulvagh SL, Rakowski H, Vannan MA, et al. American Society of Echocardiography Consensus Statement on the clinical applications of ultrasonic contrast agents in echocardiography. J Am Soc Echocardiogr. 2008;21(11):1179-1201.

Study Design/ Methods: NA

Results/ Findings: The first three pages go in into detail about the various contrast material used for echocardiography establishing a baseline of knowledge about contrast enhanced echocardiography. The following pages go into depth and detail about the various applications of echocardiography and their enhancement with the use of contrast; the most useful of these for emergency physicians being: 1. Assessment of cardiac structure and function especially in critically ill patients, obese or those with lung disease making standard echocardiography sub-optimal. In these patients, a quantification of LV volume and LVEF is extremely important and contrast-enhanced echocardiography has an excellent correlation with radionuclide magnetic resonance or computed tomographic measurements. 2. LV apical anatomy/thrombus can be better visualized with the use of contrast. Left ventricular hypertrophy can be seen more clearly and is seen as a "spadelike" appearance. Also, the ventricular apex is the area most likely to have a thrombus formation and is also the most difficult area to see. However the apex can be visualized using contrast and thrombus is seen as an area of decreased filling. 3. Complications of myocardial infarction such as pseudo-aneurysm, ventricular free wall rupture and VSD which are life threatening to patients post-MI can be better visualized using contrast-enhanced echocardiography, 4. Evidence of regional wall motion abnormalities can also be seen and are of significant importance. Resting echo showing regional wall motion abnormalities in patients with chest pain is predictive of cardiac ischemia. A significant number of these patients will go on to have unstable angina, myocardial infarction and PCI within 48 hours compared to patients with a normal resting echocardiogram. Contrast-enhanced echocardiography enhances and aides in the visualization of the myocardium and evaluation of wall motion and regions of abnormalities.

Conclusions: Overall, this is a well- written article and an in-depth review of contrast-enhanced echocardiography. I feel that its immediate use in the emergency department will be limited by two factors: 1. Physician capability of performing echocardiograms, 2. Time utilization for the contrast study.

_________________

Reviewers: Amanda Czuczman, MD; Andrew Liteplo, MD, RDMS

Blehar DJ, Dickman E, Gaspari R. Identification of congestive heart failure via respiratory variation of inferior vena cava diameter. Am J Emerg Med. 2009; 27:71-75.

Methods: In this prospective study conducted at a single urban emergency department, the investigators attempted to identify pulmonary volume overload in patients presenting with acute dyspnea by using bedside ultrasound to measure respiratory variation of IVC diameter. Forty-six patients were enrolled over a 10-month period in a convenience sample depending upon the availability of one of the study authors to perform the bedside ultrasound, and the ultrasound was performed prior to the initiation of medical care in the ED.

Using the curvilinear probe and an anterior transabdominal approach, the investigators measured the AP diameter of the IVC in a transverse view immediately inferior to the confluence of the hepatic veins and the IVC. Maximum diameter during expiration and minimum diameter during inspiration were then used to calculate the percent of respiratory variation, which is the difference between the maximum and minimum divided by the maximum.

Results: The primary outcome measure was the diagnosis of congestive heart failure (CHF) versus an alternate diagnosis as determined by a standardized chart review performed independently by two physicians blinded to the ultrasound results. Respiratory variation in IVC diameter in the CHF group averaged 9.6% compared to 46% in the non-CHF group (P < .0001). A receiver operating characteristic curve using respiratory variation of the IVC as the diagnostic criteria for CHF demonstrated an area under the curve of 0.96 with an optimum cut-off for respiratory variation of ? 15% (sensitivity of 93%; specificity of 84%). If a 10-mm cutoff for absolute diameter is added to the diagnostic criteria of respiratory variation of ? 15%, the specificity of the test increases to 91%.

Discussion: Acute dyspnea is a common presentation in the ED, and it can be difficult to identify volume overload as the cause of a patient’s shortness of breath because physical exam, radiographic, and laboratory findings can vary. This is a well-designed study describing the use of ultrasound to identify patients with volume overload based on decreased respiratory variation of IVC diameter. Using a relative measure such as respiratory variation as opposed to absolute diameter measurements of the IVC allows one to avoid the pitfall of wide variability of absolute IVC diameters among individual patients. Though this study is limited by its convenience sample format and a small number of patients, it introduces a very feasible and helpful approach to recognizing volume overload in patients with shortness of breath using bedside ultrasonography.

__________________

Reviewers: Amy Caron, MD and Michael Y. Woo, MD

Gunst M, Ghaemmaghami V, Sperry J, et al. Accuracy of cardiac function and volume status estimates using the bedside echocardiographic assessment in trauma/critical care. J Trauma. 2008 Sep;65(3):509-16.

Methods: The purpose of this study was to develop and evaluate a tool for non-cardiologists to use for echocardiographic assessment of cardiac function and intravascular volume status in critically ill patients. The group named their assessment the BEAT examination (Bedside Echocardiographic Assessment in Trauma/Critical Care), proposing that this is a tool potentially on par with the Focused Assessment with Sonography in Trauma (FAST) exam.

The study was a prospective observational cohort analysis of consecutively admitted surgical ICU patients at a Level I adult trauma center over a 6 month period. In order to be included in the study, patients had to have had a pulmonary artery catheter (PAC) placed in order to guide resuscitation of shock; the PAC was placed at the discretion of the treating physicians. Six intensivists and trauma surgeons completed a 2-day training course in focused cardiac ultrasound. Using a 2-5MHz cardiac ultrasound probe, the physicians performed protocol-defined examinations after central venous pressure (CVP) and cardiac index (CI) data had been obtained from the PAC. Ultrasonographers were blinded to PAC data. With the patient in the left lateral decubitus position, physicians used the left parasternal long axis view to measure the left ventricular end-systolic and end-diastolic diameters, and from this data the SonoSite® software package derived the left ventricular stroke volume, cardiac output, and cardiac index. Each cardiac index was then categorized as "low," "normal," or "high," based on a normal value of 2.4 L/min/m2 to 4.0 L/min/m2. The BEAT- and PAC- derived categorized cardiac indexes were then compared using a chi-square goodness-of-fit analysis.

Additionally, investigators measured the percentage collapse of inferior vena cava (IVC) diameter at end-inspiration and used this data to estimate the patient's CVP. This BEAT-derived CVP was compared with the PAC-derived CVP in a chi-square goodness-of-fit analysis. The investigators and a group of cardiologists reviewed the images, and only images of good quality were used in the study.

Results: Twenty-two (22) patients were enrolled, and 85 examinations were completed. The BEAT exam took investigators about 25 minutes to complete; the majority of this time was spent waiting for the calculations. Of the 85 examinations, 50 (59%) of the cardiac index examinations contained images of good quality and were included in the analysis. The investigators were unable to identify patient characteristics that were associated with unobtainable images. In the analysis of the categorical CI (low, normal, or high), there was a significant association between the BEAT- and PAC- derived CI (p<=0.021). Of the 85 BEAT examinations, 83 (97%) of the IVC exams contained images of good quality and were included in the analysis. There was a statistically significant association between the BEAT- and PAC-derived CVPs (p<= 0.031).

Discussion: This study supports the idea that non-cardiologists can be trained in focused echocardiography in order to evaluate a patient's CI and CVP by non-invasive methods. Some limitations of the study include the small number of sonographers and the fact that inter-rater variability was not calculated in this highly-operator dependent modality. As only about 59% of images were "good quality," one wonders about the feasibility of including this study into daily practice. Additionally, bias may have been introduced into the study by the fact that PAC placement, a requirement for study inclusion, occurred at the discretion of treating physician, rather than because of previously defined shock parameters. But, as PAC use has fallen out of favor, this non-invasive, inexpensive, FAST-like method of determining volume status could be of great assistance to physicians challenged with resuscitation of a patient in shock.

_____________

Reviewer: Amie H. Woods, MD, George Washington University Medical Center

Gaitini D, Razi NB, Ghersin E, et al. Sonographic evaluation of vascular injuries. J Ultrasound Med. 2008; 27:95-107.

Methods: This descriptive paper provides a discussion regarding the color Doppler duplex sonographic (CDDS) features of iatrogenic and blunt or penetrating traumatic vascular injuries. Procedure-related injuries such as pseudoaneurysms, arteriovenous fistulas (AVF), vascular dissections, and thrombosis are discussed, as well as traumatic vascular injuries in the neck, extremities, and abdomen. Methods of assessing vascular flow in all of the above cases are described, as well as the specific characteristics of each type of injury which make it amenable to or limited by assessment of flow by CDDS. Alternative methods of assessing vascular flow are also described when CDDS is not possible.

Discussion: Iatrogenic injuries – A perivascular hematoma at the puncture site is the most common complication seen in percutaneous procedures, appearing clinically as a focal, nonpulsatile swelling beneath ecchymosed skin, and sonographically as a complex, solid mass adjacent to the injured vessel without flow on Doppler assessment. An AVF will demonstrate a palpable thrill and a bruit on physical exam, and create a mosaic color pattern due to turbulent flow on CDDS. A pseudoaneurysm will demonstrate "yin-yang", or bidirectional color flow and a to-and-fro waveform at the neck due to flow entering during systole and exiting during diastole. Pseudoaneurysms that do not clot spontaneously may be amenable to sonographically-guided thrombin injection. A flow void after thrombin injection confirms successful thrombosis.

Trauma-related vascular injuries are a common component of blunt and penetrating trauma, with 25% of victims of penetrating neck trauma developing vascular injuries, thrombosis being the most common. Although CDDS was sensitive in evaluation of stable patients with zone II neck injuries, CTA with multiplanar reformation remains the standard of care in cases where high clinical suspicion for a vascular injury exists. In vascular injuries involving limbs, CDDS was also less sensitive than arteriography in detection of smaller intimal defects or vessel occlusions, but detected larger lesions such as pseudoaneurysms and AVFs with a specificity of 99%, a sensitivity of 50%, and 96% accuracy when compared with arteriography 1-3.

Conclusion: This review article summarizes the use of color and spectral Doppler in the evaluation of vascular trauma, and contains numerous excellent examples of ultrasound exams that illustrate the pathology described in the text of the article. Limitations to CDDS in assessment of vascular injuries exist, most notably subcutaneous air, hematomas, and skin wounds. Additionally, anatomic areas which are difficult to scan, such as the thoracic inlet and pelvis, as well as the smaller vasculature of the limbs, can decrease the accuracy of assessment of vessel patency and integrity by CDDS. However, with a reported sensitivity of 95-97% and accuracy of 95-98% 4-5, CDDS remains the first-line examination technique when evaluating an anatomic area in which high clinical suspicion for vascular injury exists. When injury is suspected by CDDS or is not amenable to evaluation by this method, magnetic resonance angiography (MRA) and computed tomographic angiography (CTA) are considered useful adjuncts to this type of examination.

References:

  1. Bergstein JM, Blair JF, Edwards J, et al. Pitfalls in the use of color-flow duplex ultrasound for screening of suspected arterial injuries in penetrated extremities. J Trauma. 1992; 33: 395-402.
  2. Bynoe RP, Miles WS, Bell RM, et al. Noninvasive diagnosis of vascular trauma by duplex ultrasonography. J Vasc Surg. 1991; 14: 346-352.
  3. Panetta TF, Sales CM, Marin ML, et al. Natural history, duplex characteristics, and histopathologic correlation of arterial injuries in a canine model. J Vasc Surg. 1992; 16: 867-876.
  4. Schoder M, Prokof M, Lammer J. Traumatic injuries: imaging and intervention of large arterial trauma. Eur Radiol. 2002; 12:1617-1631.
  5. Schwartz M, Weaver F, Yellin A, et al. The utility of color flow Doppler examination in penetrating extremity arterial trauma. Am Surg. 1993; 59:375-378.

  _____________

Reviewer: Vivek Tayal, MD, FACEP, Carolinas Medical Center 

Nagueh SF, Appleton CP, Gillebert TC,et al. Recommendations for the evaluation of left ventricular diastolic function by echocardiography. J Am Soc Echocardiogr. 2009;22(2):107-133 

Study Design: Methods: Review article with ASE Guideline and Standards 

Results/Findings: This article is a good reference for those interested in cardiac diastolic dysfunction. Specifically, the article discusses in 17 separate major sections the following topics: Physiology, Morphologic and Functional Correlates of Diastolic Dysfunction, Mitral Inflow, Valsalva Maneuver, Pulmonary Venous Flow, Color M-Mode Flow Propogation Velocity, Tissue Doppler Annual Early and Late Diastolic Velocities, Deformation Measurements, Left Ventricular Measurements, Estimation of Left Ventricular Relaxation, Estimation of Left Ventricular Stiffness, Diastolic Stress Test, Other Reasons for Heart Failure Symptoms in Patients with Normal Ejection Fractions, Estimation of Left Ventricular Filling Pressures in Special Populations, Prognosis, Recommendations for Clinical Laboratories, Recommendations for Application in Research Studies and Clinical Studies. 

The article is extremely well written, but is very dense, so the reading is slow.  In particular the sections on physiology, mitral inflow, other reasons for heart failure symptoms in patients with normal ejection fractions, and algorithm tables for estimation of filling pressures in patients with depressed and normal EF, and Practical approach to Grade Diastolic dysfunction are helpful. 

Conclusions: A well written article and in-depth review of diastolic function and dysfunction in echocardiography.  Emergency Physicians, especially US fellows, with special interest in cardiac US may find this educational and a good state-of-art- article for reference.


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AIUM Forum 2008 Report

Vivek S. Tayal, MD, FACEP
Beatrice Hoffman, MD, PhD, RDMS 

We represented ACEP at the AIUM Practice Forum held in Washington, DC on Nov 10, 2008. The Forum in past years had been called the Compact US forum. The forum was divided up into 3 tracks including one on the prenatal exam at 18 weeks (OB track), one on musculoskeletal applications, and one on procedural and vascular access applications. Dr. Mike Blaivas nominated Dr. Tayal to run the procedural track, so he moderated and spoke for EM, while Dr. Hoffman represented EM in the MSK track. The forum included 63 individuals representing 38 professional societies related to medical ultrasound.

  1. Procedural track – This was really a forum for many specialties to discuss procedural US. These included established US specialties such as radiology, interventional radiology and vascular surgery, new US users like IM, critical care, anesthesia, IV team nurses, and specialties in between such as EM, surgery, and nephrology. The focus was what each specialty has done to establish training and guidelines, and discuss cooperative future plans.
  2. MSK track – There are established MSK US guidelines by AIUM, and the emphasis was on getting them accepted by other participating societies including orthopedics, rheumatology, podiatry, and chiropractors. Our efforts to introduce a focused MSK exam in their language failed but there is a possibility of a future agreement on a focused MSK exam like the FAST exam agreement between AIUM and ACEP.
  3. OB track – focused on a late 2nd trimester exam, we did not feel we had EM issues contained within the discussion and did not attend. 

The official proceedings are below: 

Obstetrics: The 76811 Ultrasound Examination
Alfred Abuhamad, MD, Moderator 

The "76811" track participants were charged with defining the components of the 76811 ultrasound examination, the required training for the sonologist performing the ultrasound examination, and the accepted indications. 

Actions

  • Identify additional anatomic findings to be included in the 76811 examination.
  • Develop collaborative practice guidelines for the 76811 and the 76825 ultrasound examinations. 

Musculoskeletal Ultrasound
Levon Nazarian, MD, Moderator 

The Musculoskeletal Ultrasound (MSK) track participants were charged with defining training and practice guidelines specific to musculoskeletal ultrasound examinations. 

Actions

  • Circulate revised "Training Guidelines for the Performance of the Musculoskeletal Ultrasound Examination" to interested societies for comment and/or adoption.
  • Circulate revisions to the "AIUM Practice Guideline for the Performance of the Musculoskeletal Ultrasound Examination" to interested societies for comment and/or adoption. 

Neurology and Vascular Applications
Vivek Tayal, MD, FACEP, Moderator 

Attendees of the Neurology and Vascular Applications track discussed ultrasound procedural guidance; when ultrasound guidance is appropriate; who should be able to perform it; and how practitioners should be educated and trained. The following items were developed during the session:

  • Determined a list of basic conditions that should always be applied to ultrasound procedural guidance.
  • Determined a list of principles that specialties and organizations using ultrasound procedural guidance should consider.
  • Support from the AIUM as a clearing house for the listing of different specialties' use of ultrasound guided procedures
  • AIUM should consider offering ultrasound guided procedure CME courses. 

Action

  • An online forum will be developed to continue discussion of these topics, with the initial goal of determining training criteria for professionals who will be performing ultrasound guided procedures. 

We will continue to work with AIUM and the other societies that use US. EM definitely is a leader in the establishment of the use of US compared to many other prominent clinical specialties, and our prior work has let us be leaders in the new movement of clinical bedside ultrasound. At this point, the MSK guidelines are not inclusive of our "focused" approach, but we will see if we can work with AIUM to agree on a focused exam with appropriate training criteria. In Procedural US, we are significantly lead clinical specialties, and hope to help other specialties who are adopting US. 

If you have any questions, please contact Dr. Tayal at vtayal@carolinas.org or Dr. Hoffman at BHoff19212@aol.com.


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This publication is designed to promote communication among emergency physicians of a basic informational nature only. While ACEP provides the support necessary for these newsletters to be produced, the content is provided by volunteers and is in no way an official ACEP communication. ACEP makes no representations as to the content of this newsletter and does not necessarily endorse the specific conent or positions contained therein. ACEP does not purport to provide medical, legal, business, or any other professional guidance in this publication. If expert assistance is needed, the services of a competent professional should be sought. ACEP expressly disclaims all liability in respect to the content, positions, or actions taken or not taken based on any or all the contents of this newsletter.

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