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Emergency Ultrasound Section Newsletter - April 2011

circle_arrowFrom the Chair - Newsletter update - Emergency Ultrasound Section Newsletter, April 2011
circle_arrowAsk the Expert Column - Emergency Ultrasound Section Newsletter, April 2011
circle_arrowCitywide Grand Rounds, December 2010 - Emergency Ultrasound Section Newsletter, April 2011
circle_arrowFrom the American College of Emergency Physicians - Emergency Ultrasound Section Newsletter, April 2011
circle_arrowNews from Beyond: Bedside Ultrasound Reaches the Farthest Corners of the Globe - Emergency Ultrasound Section Newsletter, April 2011
circle_arrowCase Study #1 - Emergency Ultrasound Section Newsletter, April 2011
circle_arrowTechnical Updates - Emergency Ultrasound Section Newsletter, April 2011
circle_arrowJournal Watch – April 2011 - Emergency Ultrasound Section Newsletter, April 2011
circle_arrowEmergency Ultrasound Tips and Tricks - Emergency Ultrasound Section Newsletter, April 2011
circle_arrowCase Study #2 - Emergency Ultrasound Section Newsletter, April 2011
circle_arrowDr. Harvey Nisenbaum, president of AIUM responds to an article in Diagnostic Imaging - Emergency Ultrasound Section Newsletter, April 2011

From the Chair - Newsletter update - Emergency Ultrasound Section Newsletter, April 2011

Vicki Noble MD FACEP 

Section Members -  

I would like to take this opportunity to review what the ACEP ultrasound section is working on and how we hope to further point of care ultrasound both for the section, for emergency medicine as a whole and for the broader users community. ACEP will continue to provide leadership - as it always has - in promoting point of care ultrasound. Here are some of our priorities..... 

First - One of the section's priorities this year is to support and advance research and publications in point of care ultrasound as much as possible. I truly believe that the way to convince others of ultrasound's utility and efficacy is to demonstrate this in academic and professional publications. We are lucky to have a new grant (see below) to help promote outcomes research and encourage applications. But the case reports, practice experience and outcomes of our members are an enormous resource. Regardless of your practice environment, the world is interested in your experience and if we can help provide support to get your articles in print please contact the section leadership. Publish!

EMF and Siemens sponsored ultrasound research grant - Due April 1
http://www.emfoundation.org/emf.aspx?id=108  

Second - As more hospitals and programs develop point of care ultrasound within their department, the section has worked to increase the accessibility of point of care ultrasound management courses. There are two courses scheduled for the Northeast in the next few months and we are actively working to increase course offerings in all regions of the country. Most importantly though for any members just starting a clinical ultrasound program, attending ACEP’s management course in October at the Scientific Assembly is strongly encouraged. 

May 11, 2011            Newport RI             http://newenglandultrasound.com  - Dr Romolo Gaspari 
September 2011      New York CityNorth Shore Hospital, Dr Chris Raio (details to follow)
October 14, 2011San FranciscoACEP Ultrasound Management Course

We are actively working on developing courses in other regions - stay tuned. 

Third - It is also essential as we grow that we don't sacrifice quantity for quality. Mandatory resident education is now a reality thanks to the efforts at CORD and through ACEP and SAEM advocacy, but we want good resident education that meets ACEP training guidelines and that graduates residents who integrate point of care ultrasound seamlessly and effectively into their practice. The section is developing resources for resident education programs to improve training and monitor competency. In addition, the new fellowship training guidelines for emergency ultrasound are about to be published - maintaining high standards for fellowship training will only serve to elevate the educational experience of all emergency medicine residents. 

Fourth - There are an enormous amount of documents and resources out there for both community and academic physicians learning point of care ultrasound and managing point of care ultrasound programs - but the way to access this information and communication has been challenging. ACEP is in the process of redesigning our Section Web page and our website subcommittee is putting together the list of FAQs and resources in a (hopefully) more accessible way. In addition we are working on suggested reporting templates and reviewing technology solutions (what are the electronic medical record solutions available that help with point of care ultrasound image management and documentation) that we hope to put on the Web page this year. 

There are many other active subcommittees (developing an emergency medicine based critical care ultrasound training pathway, providing ultrasound training resources to international development efforts, advocacy for reimbursement as part of healthcare reform) and we can always use your help and ideas so please contact me with offers of either. Thanks and happy scanning.


Ask the Expert Column - Emergency Ultrasound Section Newsletter, April 2011

Question: 

Should all emergency medicine residents be required to pass a test in emergency ultrasound (EUS) as part of their training? If so, what format or combination of formats should that test consist of? 

Expert:  

Michael B. Stone, MD, RDMS

  • Faculty and Director of Emergency Ultrasound Research, Department of Emergency Medicine, Alameda County Medical Center- Highland Hospital, Oakland, California
  • Chair-Elect ACEP Ultrasound Section
  • Former Chair ACEP Emergency Ultrasound Section Subcommittee on Medical Student Education
  • Recipient of 2008 ACEP Section Grant to develop an online interactive ultrasound examination

Answer:  

First of all, I have to say I’m somewhat (or maybe extremely) biased on this issue as I recently worked with a great group of ACEP EUS Section members on an online interactive examination for students of EUS. My short answer is that testing residents on EUS is of significant value and importance, and that testing should assess general EUS knowledge, image interpretation, image acquisition, and incorporation of EUS into clinical decision-making. Though my opinion is just that, it fortunately happens to mirror ACEP’s recommendations on training and proficiency as described in the 2008 ACEP Policy Statement on Emergency Ultrasound Guidelines1 as well as the Consensus Recommendations from the 2008 Council of Emergency Medicine Residency Directors (CORD) Conference on Resident Training in Emergency Ultrasound.2 I’ll summarize those recommendations, focusing particularly on Appendix 3 from the 2008 ACEP document, “Emergency Medicine Residency Ultrasound Education Guidelines,” and will wrap up by discussing some of my own thoughts on the topic of EUS testing for EM residents.

Why should our residents undergo competency assessment?  

As described in the guidelines, the goal of competency assessment is to make sure that graduating residents possess the necessary skills to integrate EUS appropriately into their independent clinical practice. 

What types of competency assessment are recommended? 

  1. Assessment of ultrasound technique.
  2. This covers image acquisition, systems operation, disinfecting the system and transducers, appropriate patient interaction, documentation, etc. Common validated educational tools such as the Objective Structured Clinical Examination (OSCE) or Standardized Direct Observation Tool (SDOT) may be used for this purpose.
  3. Assessment of image interpretation.
  4. Each EM residency program should have an educational program that includes image or video (preferred) review to assess the residents’ ability to perform and interpret focused EUS examinations.
  5. A multiple-choice examination.
  6. ACEP recommends a nationwide question bank be made available to EUS directors to use when assessing their residents EUS knowledge and clinical decision-making based on interpretation of images and video. The resource our working group of EUS Section members helped to develop offers this service for students and EUS directors in the form of an interactive, modular exam available to anyone at: http://emsono.com/acep  

When should testing of EM residents occur? 

ACEP recommends that (at a minimum) testing should occur at the end of each EUS rotation and in the last year of residency training, with the option of performing different aspects of competency assessment at separate intervals to allow easy integration into the general EM residency education schedule. Repeat testing is encouraged as these skills may degrade over time. 

What is my personal opinion on testing EM residents on EUS? 

First, I have to confess that the thought of having to perform formal testing of the residents (there were 72 EM residents at my last job where I served as EUS director), can occasionally seem overwhelming. The good news is that they do not have to be tested at the same time, and that a standard 3 or 4 year EM residency offers ample time during which testing can be performed. From my own experience, I’d say that all three types of competency assessment outlined above are of great value, as they offer the EUS director a unique opportunity to identify residents who need work on particular areas. Direct observation of scanning technique is the most fundamental: if a resident can’t obtain the appropriate images, they can’t be expected to interpret them correctly or incorporate them appropriately into clinical decision-making. Image interpretation skills are also critical, but are often adequately developed during routine QA/QI sessions of image and video review; and this is an activity that should be happening anyway at an EM residency with an EUS program. Finally, teaching residents how to integrate their EUS findings into their clinical decision-making process is, in my opinion, the most important part of EUS training. We perform focused, goal-directed point-of-care ultrasound examinations to help us take better care of patients when time really matters; applying the results of these exams appropriately is the final critical action, without which the rest of it doesn’t matter much.  

  1. American College of Emergency Physicians.Emergency ultrasound guidelines [policy statement]. Ann Emerg Med. 2009 Apr;53(4):550-70. Available for download at: https://www.acep.org/workarea/downloadasset.aspx?id=32878 
  2. Akhtar S, Theodoro D, Gaspari R, et al. Resident training in emergency ultrasound: consensus recommendations from the 2008 Council of Emergency Medicine Residency Directors Conference.Acad Emerg Med. 2009 Dec;16 Suppl 2:S32-6. Available for download at: http://onlinelibrary.wiley.com/doi/10.1111/j.1553-2712.2009.00589.x/pdf 


Citywide Grand Rounds, December 2010 - Emergency Ultrasound Section Newsletter, April 2011

St. Luke’s Roosevelt Emergency Ultrasound Division
Katja Goldflam, MD, Ultrasound Fellow
Diana Kim, MD, PGY-2 Emergency Medicine
 

On December 15th, St. Luke’s-Roosevelt Hospital’s Emergency Ultrasound Division hosted the second Citywide Grand Rounds of the academic year. The featured topic was “Ultrasound Education in Emergency Medicine Residencies.” Dr. Roger Chirurgi, the Associate Director of Metropolitan Hospital’s Emergency Medicine Residency facilitated the 2-hour discussion on the difficulties of training emergency medicine (EM) residents in ultrasound without ultrasound fellowship trained faculty. Participating programs included Newark Beth Israel, Metropolitan Hospital, North Shore University Hospital, Long Island Jewish Hospital, New York Hospital Queens, University of New England and Penn State/Hershey. 

The evening’s presentation began with an introduction by Dr. Chirurgi discussing emergency ultrasound education at Metropolitan Hospital, and the implementation of the ACEP and CORD ultrasound guidelines in emergency ultrasound. 

The ensuing round-table discussion focused on resident education, faculty credentialing, and the difficulties of both having and lacking a dedicated ultrasound division within an EM residency program. There was general consensus that the numbers of scans used for credentialing was often arbitrary and that the amount of scanning needed to become “competent” is highly individual. Some interesting questions raised were, “Why should residents need “positive” scans? Should we only require them to know what is “normal” so that an “abnormal” scan will dictate further imaging and workup?” 

One challenge faced by many of the city’s ultrasound divisions is a lack of faculty interest in becoming credentialed in emergency ultrasound. Cited barriers included the number of scans required for credentialing, and the attitude that ultrasound would not change practice or patient management. 

Overall, the evening’s discussion highlighted the difficulties facing programs both with and without ultrasound divisions. Several of the current ultrasound fellows who graduated from programs without established ultrasound divisions are feeling the pressure to return to their programs of training to help build the faculty. On a similar note, current EM senior residents who have completed ultrasound graduation requirements are commonly in demand as they go into the job market. They are often the most experienced sonographer to join a practice and consequently are being offered positions as the ultrasound director without fellowship training.


From the American College of Emergency Physicians - Emergency Ultrasound Section Newsletter, April 2011

ACEP's New grassroots effort aims to influence health care reform’s regulatory implementation.

With changes in the health care system already underway, a new initiative is looking to positively impact the regulations that will be written and implemented under this sweeping reform.

The Emergency Medicine Action Fund, launched by ACEP in February, will pool contributions from individual emergency physicians and groups, ACEP Sections of Membership, and anyone else interested in advancing emergency care to provide financial support for advocacy activities in the regulatory arena.

“This is probably the most important, defining moment for emergency medicine in our lifetime,” said ACEP President Dr. Sandra Schneider. “The decisions that are made now will set the course for us for years to come and we must positively influence the regulatory agenda. This Action Fund will help us do that and create a practice environment we can thrive in.”

The Emergency Medicine Action Fund will pursue a regulatory agenda that supports emergency physicians and quality emergency care. For example, evolving practice models and demonstration projects, such as accountable care organizations and bundled payments, are two areas of the Patient Protection and Affordable Care Act where the Action Fund might be able to wield some influence.

“We need to be out there with the rule writers, working to ensure that emergency medicine’s perspective is valued,” said Dr. Angela Gardner, ACEP Past President who first proposed a national grassroots initiative focused on federal regulatory affairs. “It is critical that we be involved in these decisions regarding the formation of the future of health care delivery. This is our opportunity to be part of it.”

The following organizations have been invited to designate representatives to the initial Board of Governors – American Academy of Emergency Medicine (AAEM), Association of Academic Chairs of Emergency Medicine (AACEM), American College of Osteopathic Emergency Physicians (ACOEP), Emergency Department Practice Management Association (EDPMA), Emergency Medicine Residents’ Association (EMRA), and Society for Academic Emergency Medicine (SAEM).

One of the unique features of the Emergency Medicine Action Fund is that multiple Sections can band together to form coalitions that would be eligible to have a seat on the Board of Governors. Or Sections can organize their individual members for collective representation. The first 10 groups of contributors at $100,000 will be granted seats on the Action Fund’s Board of Governors.

“We are encouraging Sections, chapters and small to mid-sized groups to combine their resources,” Dr. Schneider said. “This is intended to be an inclusive effort, and everyone’s contributions are needed.”

The Emergency Medicine Action Fund is modeled on a successful initiative sponsored by CAL/ACEP, CAL/AAEM, EDPMA, and rural emergency physicians in California that has raised several million dollars for state advocacy since 2004.

Wes Fields, chair of the California Emergency Medicine Advocacy Fund, said their program doubled the size of the CAL/ACEP advocacy staff, increased the number of lobbyists and consultants, and engaged in legal activities related to physician payment practices. He has been appointed by Dr. Schneider as the founding chair of the new national Action Fund.

“I view this as the best form of free speech on behalf of emergency physicians and our patients,” Dr. Fields said. “It is not partisan. It is not political.

“The rule writers and the policy makers will hear emergency medicine speaking with one voice, with one set of goals, one approach,” he added. “We need wide and deep support, even from those who are not members of the College.”

CEP America, the nation’s largest emergency medical partnership, will be the inaugural donor to the Emergency Medicine Action Fund, pledging $100,000.

Activities planned by the Emergency Medicine Action Fund are intended to enable participants to make contributions that would be tax-deductible business expenses (tax deductibility can be determined only by participants’ tax advisors).

NEMPAC, the National Emergency Medicine Political Action Committee of the ACEP, gives contributions to candidates who have listened to the needs of emergency medicine and made a positive change. However, NEMPAC may be used only to support candidates.

The Action Fund can enhance regulatory advocacy with policy makers to ensure emergency physicians receive fair payment for their services. It can also fund numerous meetings with regulators to help guarantee that patients receive the best care, and provide funding for studies to demonstrate the value of emergency medicine.

“With the new Congressional session upon us, it is as important as ever to be active on both the legislative and regulatory fronts,” Dr. Schneider said. “We will depend on all of these funds to make our case. This will be the year we ask everyone to dig a little deeper. In these challenging times, we need contributions to both the Action Fund and NEMPAC.”

Find out more about the Emergency Medicine Action Fund at www.acep.org/EMActionFund

 How is the Emergency Medicine Action Fund Different from NEMPAC? 

Both are valuable tools that need our continued support, but the Emergency Medicine Action Fund serves a different purpose than NEMPAC.  

 

NEMPAC 

EM Action Fund 

Gives campaign contributions to Congressional candidates 

YES 

 

Funds meetings with regulators and policy makers

 

YES 

Enhances emergency medicine advocacy efforts 

YES 

YES 

 


News from Beyond: Bedside Ultrasound Reaches the Farthest Corners of the Globe - Emergency Ultrasound Section Newsletter, April 2011

Sachita Shah, MD 

There has been incredible effort put forth by so many in our section to help train our colleagues around the world in clinician-performed, bedside ultrasound and to study its impact. As ultrasound becomes more widely available in resource-poor settings, we hope more of you will consider sharing your skills and contributing to these ongoing efforts around the globe. A few ongoing projects that might be of interest are summarized here: 

  • PURE (Physician’s Ultrasound in Rwanda Education Initiative) is a new venture spearheaded by Dr. Elizabeth Krebs . The goal of this project is to partner with the Rwandan Ministry of Health to develop an ultrasound training program for clinicians in district hospitals that could be replicated throughout Rwanda. For more information, please visit www.ultrasound-rwanda.org.
  •  
  • Partners in Health continues to include ultrasound as an integral part of patient care in their district hospitals in Haiti and Rwanda. Research from Rwanda on clinician-performed ultrasound in evaluation of dehydration in children was published in the October 2010 issue of Academic Emergency Medicine by Dr. Adam Levine. The PIH Manual of Ultrasound for Resource Limited Settings is available for free at http://www.pih.org/publications/c/manual . For more information, please contact Dr. Sachita Shah .   
  •  
  • A recent research project launched by the Massachusetts General Hospital, Department of Emergency Medicine, Division of Global Health and Human Rights with partners from Highland Hospital/ACMC Emergency Medicine will study ultrasound training of health care providers in several health clinics in western Kenya. The group plans to evaluate the effect of ultrasound on patient management and the possible magnet effect of ultrasound in drawing patients to medical care. For more information please contact Dr. Daniel Price.
  •  
  • The International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) Outreach Program, under the leadership of Dr Alfred Abuhamad, sends medical volunteers to underserved regions in order to provide training in women’s ultrasound as part of the end goal of reducing maternal mortality rates around the world. ISUOG’s Outreach in Somaliland launches next month in partnership with Doctors Without Borders and the Edna Adan Maternity Hospital in Somaliland, and promises to be the start of an exciting and fruitful long-term partnership with both organizations. To read more about the Outreach Program, please click here: http://www.isuog.org/EducationAndTraining/Outreach+Program/ . If you are a physician, midwife or sonographer with Ultrasound expertise and would like to participate in ISUOG’s Outreach Program, or would like more information, please contact Manna at ISUOG. 
  •  
  • WINFOCUS (World Interactive Network Focused on Critical Ultrasound) will hold their world congress this year in New Delhi, India, Nov 22-27, 2011. For more information about this organization and their ongoing courses around the world, please visit www.winfocus.org    
  •  
  • sidHARTe is a non-profit organization focused on strengthening emergency medicine in 5 regions in Ghana. As part of their efforts, ultrasound training of medical providers has been ongoing by Dr. Resa Lewiss and Dr. Arun Nagdev. For more information about their programs in Ghana and plans for expansion to other nations, see www.sidharte.org.
  •  
  • Faculty from UCSF’s Dept of Emergency Medicine are providing a 4 week ultrasound training course for the staff physicians of Hospital San Carlos located in the southern state of Chiapas, Mexico. The training curriculum will cover all the principal emergency medicine applications of bedside ultrasound and will be followed by a post-training examination and subsequent image review to ensure adequate skill acquisition. The training will be part of a larger study to assess the feasibility and impact of providing training in bedside ultrasound in resource poor settings. For further details, please contact Dr. Jeanne Noble.

Emergency physicians from around the world are aiding in the movement to bring bedside ultrasound to the places where it is arguably needed the most. We look forward to further research and productivity in this relatively new niche within emergency ultrasound.


Case Study #1 - Emergency Ultrasound Section Newsletter, April 2011

Michael Pallaci, DO, FACEP
Director, Emergency Medicine Residency Program
Grandview Medical Center 
 

Clyde Watson, MD
Attending Physician
Grandview Medical Center
 

Chief Complaint: Flank pain s/p fall 

casestudy1-1of3 casestudy12of3r2  

casestudy13of3
Questions:
  

What do these images show?

Why did this case initially result in a false negative ultrasound for the condition shown?

Case Discussion: A 47 year-old male with multiple ED visits for psychiatric disease, as well as recurrent pneumothoraces, presented complaining of pleuritic right flank pain after a fall. The ED attending ordered a CT to evaluate for the possibility of renal injury. After reviewing the CT images, the ED attending suggested that we perform an ultrasound (US) to review a “true positive” exam. Surprisingly, we were unable to visualize the CT abnormality with the patient supine. After reviewing the CT scan ourselves, we went back to the room and repeated the US with the patient lying prone, and now were able to visualize the CT findings. 

The M-mode anterior US image demonstrates the M-mode seashore sign representing a normal hemithorax. The CT image reveals a posterior pneumothorax. The air does not rise to the anterior chest wall, likely due to scar tissue from the patient’s previous chest tubes. A known limitation of the FAST (Focused Assessment with Sonography in Trauma) exam is the possibility of a false negative in patients with prior abdominal surgery, due to adhesions preventing the free flow of intraperitoneal fluid into the dependent portions of the abdomen. This case illustrates an analogous limitation of the thoracic US exam. US for pneumothorax depends on air rising anteriorly in the supine patient. In patients with a history of prior pneumothorax or thoracic procedures, scar tissue can prevent the movement of air anteriorly, resulting in a false negative thoracic US. The posterior US image demonstrates the barcode or stratosphere sign suggestive of a pneumothorax. 

Take Home Points:  

  1. US for pneumothorax depends on the free flow of air between the visceral and parietal pleura to the anterior chest wall in the supine patient.
  2. Scar tissue from previous thoracic procedures may cause a false negative thoracic US by preventing movement of air anteriorly.
  3. With a high clinical suspicion, consider obtaining US images both anteriorly and posteriorly in patients with a history of prior thoracic procedures.

Additional Reading:  

  1. Volpicelli G, Noble VE, Liteplo A, et al. Decreased sensitivity of lung ultrasound limited to the anterior chest in emergency department diagnosis of cardiogenic pulmonary edema: a retrospective analysis. Crit Ultrasound J. 2010.
  2. Barillari A, Kiuru S. Detection of spontaneous pneumothorax with chest ultrasound in the emergency department. Intern Emerg Med. 2010;5(3):253-255.
  3. Havelock T, Teoh R, Laws D, et al. Pleural procedures and thoracic ultrasound. British Thoracic Society Pleural Disease Guideline 2010. Thorax. 2010;65 Suppl 2:ii61-76.
  4. Simon BC, Paolinetti L. Two cases where bedside ultrasound was able to distinguish pulmonary bleb from pneumothorax. J Emerg Med. 2005;29(2):201-205.
  5. Monti JD, Younggren B, Blankenship R. Ultrasound detection of pneumothorax with minimally trained sonographers: a preliminary study. J Spec Oper Med. 2009;9(1):43-46.
  6.  


Technical Updates - Emergency Ultrasound Section Newsletter, April 2011

Mark Byrne, MD
Emergency Ultrasound Fellow
Brigham & Women’s Hospital 
 

Needle guidance technologies: 

Potential solutions to current limitations in ultrasound-guided vascular access 

Introduction 

It has been well established that ultrasound guidance during central venous catheter insertion improves success rates, eases performance, and reduces the risk of mechanical complications such as arterial puncture and pneumothorax. However, there is still debate as to which approach (ie, in-plane versus out-of-plane) should be used. The in-plane (long axis) approach provides excellent visualization of the needle tip although may require more manual dexterity to perform and risks losing track of the needle in the axial plane, potentially leading to arterial puncture. The out-of-plane (short axis) approach provides better guidance of the needle towards the target vessel in the axial plane, although it is easier to lose track of the needle tip, risking passage through the back wall of the vein. 

Several recently introduced and upcoming needle guidance technologies promise to improve the ease of ultrasound-guided vascular access, overcoming some of the limitations described above. (See the referenced websites to view video demonstrations of how each product works.)

 

Advanced Needle Visualization software by Sonosite 
www.sonosite.com 
 

 technicalupdates1of7  technicalupdates2of7 

 

When using the in-plane (long axis) approach, the entire length of the needle can be seen, most importantly the needle tip. However, as the angle between the needle tract and the ultrasound transducer becomes steeper, the needle becomes increasingly more difficult to visualize. Clinicians often attempt to compensate for this limitation by “jiggling” the needle and looking for movement of surrounding soft tissue as an indirect sign of the needle’s location. Sonosite’s Advanced Needle Visualization technology seeks to overcome this limitation by significantly improving needle echogenicity even at steep angles. This feature comes as an additional software purchase for existing Sonosite M-Turbo and S Series systems but does not require the purchase of any new equipment or specialized needles. 

 

ExactTrackTM vascular access probe by SOMA Access Systems 
www.somaaccesssystems.com 

                    technicalupdates307r2                                        technicalupdates4of7                       

SOMA Access Systems takes another approach to the “disappearing” needle problem. Using a specially designed (ExactTrackTM) transducer with integrated needle guide and position sensor, a virtual representation of the needle appears superimposed on the ultrasound image (Virtual Needle TechnologyTM). The trajectory of the needle path is seen as a blue dotted line while the needle itself appears as a blue cylindrical structure. As a result, the entire needle (including the tip) can be visualized in real-time throughout the procedure, from skin puncture until cannulation of the desired vessel. Seeing the needle trajectory prior to skin puncture also helps to choose the optimal angle of entry and needle insertion site prior to actual needle insertion. The ExactTract is limited to investigational use at this time and is not yet available for purchase.

 

SonixGPS Guidance Positioning System by Ultrasonix
www.ultrasonix.com  

technicalupdates5of7 technicalupdates6of7 

SonixGPS Guidance Positioning System describes itself as a truly freehand needle guidance technology. The mobile GPS arm (left image) is moved into the vicinity of the patient. One sensor is embedded in the ultrasound transducer and a second sensor is inside the needle. Red marks the tract of the needle, “X” is the point where the needle intersects with the ultrasound image plane, and green represents the trajectory the needle is following. The lower right hand corner shows the position and angle of the needle in relation to the ultrasound transducer. SonixGPS provides real-time needle guidance at any angle and can be used with both in-plane (long axis) and out-of-plane (short axis) approaches. It works with both linear array and curvilinear transducers on Ultrasonix SonixTOUCH systems. 


Simultaneous visualization of short & long axis using 4D probes 

technicalupdates7of7While not specifically marketed for this purpose, the advent of “real-time 3D” (often referred to as 4D) represents another solution to the current limitations in ultrasound-guided vascular access. Several authors have written case reports and review articles describing their experiences using 4D probes during central line insertion. 4D systems provide the ability to view both short and long axes simultaneously on the ultrasound monitor, thus combining the advantages of both the in-plane and out-of-plane approach. Some authors do note that 4D probes are bulkier than current 2D transducers, frame rates can be choppy, and the cost of such transducers currently may be prohibitive. They also point out that these issues are likely to be mitigated as the technology continues to progress. 

For more information about 4D probe use in vascular access, see the following references: 

  • Dowling M, Jlala H, Hardman J, et al. Real-time three-dimensional ultrasound-guided central venous catheter placement. Anesth Analg. 2011;112:378-81. 
  • French JL, Raine-Fenning NJ, Hardman JG, et al. Pitfalls of ultrasound guided vascular access: the use of three/four-dimensional ultrasound. Anaesthesia. 2008;63:806-13. 


Journal Watch – April 2011 - Emergency Ultrasound Section Newsletter, April 2011

Reviewers: Sarah K. Sommerkamp, MD, Emergency Ultrasound Fellow, and Brian D. Euerle, MD, RDMS, Emergency Ultrasound Fellowship Director, University of Maryland 

Article: Afonso N, Amponsah D, Yang J, et al. Adding new tools to the black bag -introduction of ultrasound into the physical diagnosis course. J Gen Int Med. 2010;25(11):1248-52. 

Objective: The goals of this study were to examine the feasibility of teaching ultrasound to medical students as part of a second-year physical diagnosis class and to determine if students had gained demonstrable skills in image acquisition and recognition by the end of the course. 

Methods: Ultrasound was incorporated into the physical diagnosis class at Wayne State University School of Medicine. First-year students were taught multiple organ systems, knobology, and image acquisition. The class then had a 3-hour review and focused instruction on abdominal and cardiovascular ultrasound imaging. Three hundred seven second-year students participated in 2-hour small-group bedside teaching sessions with a standardized patient (SP) and a Logic E ultrasound system. A debriefing session was precepted by physicians who had completed an ultrasound training course. Cases with clinical correlation were given to the students as part of the pathophysiology class that incorporated ultrasound video and was taught concurrently. Participants’ pre- and post-test knowledge was assessed. A final objective structured clinical examination was administered, in which students were asked to obtain one of the following: image of the internal jugular vein, image of the abdominal aorta, the subxiphoid cardiovascular view, or the perihepatic view of the FAST exam. Images were scored individually for correct transducer orientation, labeling the correct structure, proper depth/focal zone adjustment, correct label, and overall image resolution. A percentage was interpreted by multiple physicians in order to verify inter-rater reliability. A satisfaction survey was also completed. 

Results: In a comparison of pre- and post-test scores, significant improvement was noted in nearly all areas, including transducer selection and orientation and recognition of the kidney, gallbladder, heart, abdominal aorta, and internal jugular vein. The diaphragm and urinary bladder were the most easily recognizable structures; the students’ scores showed no significant improvement in before and after testing. The students scored very well on the final exam, with a score of 4 or 5 out of a possible 5 being obtained in 98.4% of the internal jugular vein images, 81.4% of the abdominal aorta images, 74.6% of the heart images, and 75.2% of the FAST view. The satisfaction survey found students to be very satisfied with the incorporation of ultrasound into the course, and 85% felt that ultrasound was a valuable tool that they would use in their medical practice. 

Discussion: Based on this study, the authors conclude that it is feasible and practical to incorporate ultrasound into a physical diagnosis course for second-year medical students. The title of this article, “Adding New Tools to the Black Bag,” is a reference to the concept that a portable ultrasound machine may be similar to the instruments that have traditionally been in a physician’s black bag―the stethoscope, ophthalmoscope, and otoscope. Some study limitations, which the authors point out, are that they did not evaluate whether ultrasound teaching improved competence in the physical examination or the students’ ability to detect abnormalities. Overall, this is a very interesting study that demonstrates some of the exciting possibilities regarding the incorporation of ultrasound into medical education. 

______________________________
 

Reviewer: Seth Oskie, MD, Emergency Ultrasound Fellow, Harbor-UCLA Medical Center 

Article: Christos SC, Chiampas G, Offman R, et al. Ultrasound-guided three-in-one nerve block for femur fractures. West J Emerg Med. 2010;11(4):310-313. 

Objective: This article reviews an ultrasound-guided nerve block that provides regional anesthesia to the femoral, obturator, and lateral cutaneous nerves. The authors discuss their experience with this technique and various considerations used to implement it for emergency department patients with femur fractures. 

Methods: Physicians who were already comfortable with the use of bedside ultrasound in the emergency department underwent a 20-minute didactic training session on the use of the three-in-one nerve block in patients with femur fractures. They then observed the procedure before performing it under supervision.  

The technique is well described in this article. Useful photographs illustrate the important sonographic anatomy. Patients were positioned supine with their legs slightly abducted. With the use of a linear (vascular) probe with a sterile covering for real-time guidance, the hyperechoic femoral nerve was visualized lateral to the femoral artery and vein lying just below the inguinal ligament. The injection was made using a 21-gauge 3.5-inch spinal needle attached to a syringe containing 20 ml of 0.5% bupivacaine. Depending on the operator’s preference, the ultrasound probe was held by an assistant or in the physician’s non-dominant hand while the needle was inserted in a lateral-to-medial direction. Its tip was tracked on the monitor to a position close to the nerve sheath, where the surrounding fascia was infiltrated with anesthetic.  

The authors did not provide a list of inclusion criteria. They did acknowledge that femoral nerve block is commonly used for trochanteric and femoral neck fractures and imply that it is also helpful in the management of more distal injuries of the femur and knee. The contraindications to this technique include systemic or local infection and allergy to anesthetic. The use of nerve block is not advised in patients at risk for neurovascular compromise or compartment syndrome, because serial examinations will be impeded.  

Results: The outcomes described in this study are limited. No complications were reported. All physicians were stated to have been comfortable performing the ultrasound-guided procedure at their first patient encounter. The number of physicians performing the technique and the number of procedures or patients included in the study were not provided. The authors report that the technique has received favorable feedback from their patients, orthopedic surgeons, and the nursing staff.  

Discussion: This study describes the ultrasound-guided three-in-one femoral nerve block and the education of sonographically savvy physicians and residents in its use. No complications were reported. The authors did not describe any method for systemically observing patient outcome. 

______________________________

Reviewer: Aliasgher Hussain, MD, Emergency Ultrasound Fellow, Harbor-UCLA Medical Center 

Article: Enright K, Beattie T, Taheri S. Use of a hand-held bladder ultrasound scanner in the assessment of dehydration and monitoring response to treatment in a paediatric emergency department. Emerg Med J. 2010;27(10):731-733. 

Objective: The objective of this study was to evaluate the use of a handheld bladder ultrasound scanner to monitor urine production in children who present to the emergency department with suspected dehydration. 

Methods: This pilot study was conducted in a pediatric emergency department. A convenience sample of patients presenting with possible dehydration between March and May 2007 were recruited when the principal investigator (KE) was in the department. Patients with possible dehydration were assessed according to standard clinical parameters and the World Health Organization’s guide to dehydration assessment. A handheld ultrasound device, BladderScan BVI-6200, was used for serial bladder scans every 30 to 60 minutes, depending on the level of activity in the emergency department. The primary outcome was the ability to document hourly urine output based on the scanner. Secondary outcomes included relationships between measured urine production and clinical features of dehydration, patient disposition, and rehydration therapy. Decisions about other treatment and disposition were made independently of the urine output measured with the scanner. Results were stored on Microsoft Excel (Microsoft 2005) and analyzed using MedCalc (2005). Unpaired t tests of nonparametric data and Fisher’s exact test were employed. 

Results: Forty-five children ranging in age from 4 months to 10 years were enrolled in the study. Patients were divided into two groups: mildly dehydrated (33 patients) and moderately/severely dehydrated (12 patients). There was a significant difference in urine production between the two groups, as measured on the bladder scan (2.3±1.5 vs 0.6±0.7 ml/kg/hr [p=0.0011]). In addition, there were significant differences between patients who were admitted vs discharged (0.9±1.2 vs 1.8±1.5 ml/kg/hr [p=0.01]) and between those receiving intravenous hydration vs oral rehydration only (0.4±0.46 vs 1.9±1.6 ml/kg/hr [p=0.001]). 

Discussion: The authors state that bladder scanning provides quantitative real-time feedback on urine production in dehydrated children, and they support its use in the ED. Limitations of this study include its small sample size, lack of a control population, lack of comparison of the US finding with measured urine output, and the use of a single operator. 

______________________________

Reviewer: Gregory Bell, MD, FACEP, Clinical Assistant Professor, University of Iowa Health Care 

Article: Ferrada P, Murthi S, Anand RJ, et al. Transthoracic focused rapid echocardiographic examination: real-time evaluation of fluid status in critically ill trauma patients. J Trauma. 2011;70(1):56-64. 

Objective: The focused rapid echocardiographic examination (FREE) correlates bedside cardiac and aortic findings with the clinical picture to allow a better understand of cardiac function and volume status. This paper investigates the benefit of this bedside evaluation in making decisions about volume, pressor, and inotropic support in trauma patients. 

Method: Patients in a trauma intensive care unit (ICU) underwent cardiac and aortic ultrasound examinations performed by fellows trained for 3 months or cardiac sonographers for assessment of ejection fraction, stroke volume, and pre/afterload. The patients’ primary treating physicians were asked if the information was helpful in their hemodynamic decisions.   

Results: Fifty-three patients were studied over a 9-month period. Eighty-five percent were mechanically ventilated. The average age for the women in the group was 77 and, for the men, 54.  

Ejection fraction was estimated in 80% of the patients. Moderate and severe left ventricular dysfunction was diagnosed in 56% and right ventricular dysfunction in 25%. The diameter of the inferior vena cava and respiratory variation were noted in 80%. The time needed for each ultrasound study was 10 minutes or less. 

Eighty-seven percent of the studies answered the clinical question (type of shock, cardiac function, and volume status) being asked by the clinical team. The ultrasound findings changed the management (fluid, pressor, and inotrope use) in 54% of patients. 

Discussion: The FREE uses bedside transthoracic and aortic ultrasound to help intensivists make decisions about hemodynamic care in aging trauma patients. This use of bedside ultrasound has been found reliable for assessing cardiac function and volume status, and the procedure is becoming a favored tool in the ICU. In this study, the FREE answered the team’s hemodynamic question in 87% of cases and changed the treatment plan for slightly more than half of the patients. The study did not address issues of outcome or inter-rater reliability, though this high-yield information has been found to be skillfully acquired by non-cardiologists in previous studies using ultrasound. Evaluation of the aorta by ultrasound becomes more difficult in obese patients and those who have had abdominal surgery.  

______________________________

Reviewer: Sam Hsu, MD, RDMS, Assistant Professor, and Sarah Sommerkamp, MD, Emergency Ultrasound Fellow, Department of Emergency Medicine, University of Maryland School of Medicine 

Article: Jang TB, Ruggeri W, Dyne P, et al. Learning curve of emergency physicians using emergency bedside sonography for symptomatic first-trimester pregnancy. J Ultrasound Med. 2010;29:1423-1428. 

Objective: To prospectively assess the learning curve of emergency physicians using bedside ultrasound to identify complications of first-trimester pregnancy. 

Methods: This prospective study followed the learning curve of resident and attending emergency physicians at an academic center who had not previously met the training guidelines for emergency ultrasound set by the American College of Emergency Physicians or the Society for Academic Emergency Medicine. A convenience sample of pregnant women in their first trimester underwent transabdominal and transvaginal ultrasound examinations by an emergency physician and then went on to have a study performed by the radiology department. Findings were categorized into intrauterine pregnancy (IUP), molar pregnancy, and suspicion for or definite ectopic pregnancy. To track changes in accuracy, the bedside studies were grouped according to the number of previous scans the physician had performed. The first 10 scans of each physician were analyzed together; scans 11 to 20, 21 to 30, 31 to 40 and all scans over 40 were similarly grouped and analyzed. Only physicians who completed more than 25 scans were included in the study. 

Results: Twenty-five of the eligible 137 physicians met the requirement of 25 scans for inclusion in the study. These physicians performed 670 scans over a 7-year period. Sensitivity and specificity improved with experience. The learning curves were asymptotic and exceeded 90% sensitivity and specificity at 21 to 30 scans for IUP and molar pregnancy. Inaccuracies in identifying an IUP tended to occur with pregnancies at <6 weeks’ gestational age. The sensitivity and specificity for ectopic pregnancy did not exceed 90% even in the group with >40 scans. 

Discussion: Although the results of this study may not predict results at other institutions due to differences in training and practice environment, it provides broad answers to the question of how much experience is needed to gain accuracy in bedside first-trimester ultrasound. Novice sonologists should keep in mind that it is relatively easy to gain proficiency in identifying an IUP but that identifying abnormalities such as an ectopic pregnancy is significantly more difficult. The wise emergency sonologist will have a low threshold for ordering a radiology scan when no IUP is present on a bedside ultrasound image.  

______________________________

Reviewer: Molly E.W. Thiessen, MD, Emergency Ultrasound Fellow, Denver Health Medical Center 

Article: Major R, Girling S, Boyle A. Ultrasound measurement of optic nerve sheath diameter in patients with a clinical suspicion of raised intracranial pressure. Emerg Med J. August 15, 2010 [Epub ahead of print]. 

Objective: To assess if measurement of optic nerve sheath diameter (ONSD) by ultrasound can accurately predict the presence or absence of increased intracranial pressure (ICP) and other acute intracranial abnormalities (eg, cerebrovascular accident, subarachnoid hemorrhage, subdural or extradural hemorrhage, tumors). 

Methods: This was a prospective, observational study in which adult patients who presented to the emergency department and were referred for computed tomography (CT) of the brain underwent ultrasound measurement of their ONSD. This measurement was performed by mid-grade emergency medicine physicians who had completed training on measurement of ONSD. The average measurement from both eyes was recorded; a diameter more than 5 mm was considered positive. Patients subsequently underwent CT imaging. The images were reviewed at a later date by two radiologists, one of whom specializes in neuroimaging. Increased ICP on CT was identified by the presence of mass effect with midline shift of 3 mm or more, a collapsed third ventricle, hydrocephalus, effacement of sulci with evidence of significant edema, or abnormal mesencephalic cisterns. The radiologists were blinded to the patient course and ONSD measurements. The primary outcome measure was sensitivity and specificity of the ONSD measurement for increased ICP. The secondary outcome measure was the sensitivity and specificity of the ONSD measurement for any other acute intracranial abnormality detected on CT scan.

Results: Over the 3-month study period, 26 patients were enrolled. Six of them had increased ICP by ONSD measurement, and CT scanning confirmed its presence in all six cases. One patient had a positive CT scan but did not have evidence of increased ICP on ultrasound imaging. With regard to the primary outcome measure, ONSD was found to be 86% sensitive (95% CI, 42%-99%) and 100% specific (99% CI, 79%-100%) for identifying increased ICP. This translates to a positive predictive value of 100% and a negative predictive value of 95%. With regard to the secondary outcome measure, ultrasound measurement of ONSD was 60% sensitive (95% CI, 27%-86%) and 100% specific (95% CI, 75%-100%) for identifying any acute intracranial abnormality seen on CT scan. Kappa values were 0.91 (95% CIs, 0.73-1) for increased ICP on CT and 0.84 (95% CI, 0.62-1) for acute intracranial pathology on CT between radiologists. 

Discussion: The authors conclude that ultrasound measurement of ONSD is specific and sensitive for identification of increased ICP for patients undergoing CT scan in the emergency department. 

______________________________

Reviewers: Roderick Roxas, MD, Emergency Ultrasound Fellow, and John Bailitz, MD, RDMS, Fellowship Director, Emergency Ultrasound, Stroger Hospital of Cook County 

Article: Sivitz AB, Lam SH, Ramirez-Schrempp D, et al. Effect of bedside ultrasound on management of pediatric soft-tissue infection. J Emerg Med. 2010;39(5):637-643. 

Objective: In 2006, Tayal and colleagues found that bedside ultrasound (BUS) changed the management of more than half of adult patients presenting with soft-tissue infections without obvious abscess. In this prospective study, Sivitz and associates investigated the role of BUS in the management of suspected soft-tissue infections in pediatric patients. 

Methods: A convenience sample of 50 patients who were under the age of 18 and in whom soft-tissue infections were suspected were enrolled into the study from two urban teaching hospitals with dedicated pediatric emergency departments. Investigators recorded treating physicians’ rating of the likelihood of a fluid collection and their subsequent management plan. Patients were separated into those receiving solely medical management (n=30) and those undergoing invasive management (n=20). Medical management was defined as administering oral or IV antibiotics. Invasive management was defined as needle aspiration, incision, or surgical consultation. Next, an experienced emergency sonographer performed BUS for signs of fluid collection in the area of interest and reported the findings to the treating physician. Investigators then noted whether the BUS findings changed the management plan of the treating physician. One week later, patients were contacted by telephone or their electronic chart was reviewed to ascertain clinical outcomes.  

Results: Following BUS, clinical management was changed for 11 of the 50 patients (22%). In the medical management group, 4 of the 30 patients underwent drainage procedures, all of which yielded purulent fluid. One patient in the medically managed group was deemed to not have cellulitis and was therefore not treated with antibiotics. In the invasive management group, 4 of the 20 patients were switched to medical management. One of these patients eventually underwent incision and drainage after 5 days of failed antibiotic therapy. Two patients from the invasively managed group had a change in invasive management. The accuracy of BUS to detect subcutaneous fluid collections was compared with results of the clinical assessment, using the results of subsequent drainage as the gold standard in cases of disagreement. BUS was more accurate, with sensitivity of 90% (95% CI, 77%-100%) and specificity of 83% (95% CI, 70%-97%) compared with sensitivity and specificity of 75% (95% CI, 56%-94%) and 80% (95% CI, 66%-94%) for clinical assessment alone. 

Discussion: Despite the small sample size, the authors showed that BUS improves management in a significant proportion of pediatric patients presenting with soft-tissue infections. A subset analysis found the greatest change in management for patients with a moderate pretest probability for underlying fluid collection. These findings are important in two ways. The first and most obvious is the importance of detecting an occult abscess requiring drainage. Conversely, drainage procedures can be extremely stressful and painful for children. The conscious sedation that is often required is resource intensive and poses additional risk. Both procedures can be avoided in patients with cellulitis without sonographic evidence of abscess. 

The authors discussed several limitations of this preliminary study. In 15 of the 50 cases, the sonographer was also the treating physician. All sonographers had performed at least 50 bedside ultrasound exams and at least 5 soft-tissue ultrasound examinations prior to the start of the study. The amount of training required has yet to be determined. Reporting how invasive management was changed in two particular patients may provide additional insight for clinicians. Future studies examining outcomes in a larger group of consecutive patients will clarify these remaining questions. 

In summary, the authors demonstrated that BUS significantly improved management of soft-tissue infections in children without clear-cut evidence of fluid collection on the physical examination.


Emergency Ultrasound Tips and Tricks - Emergency Ultrasound Section Newsletter, April 2011

Jennifer T. Mink MD; John Powell MD; David T. Cook MD; Paul R Sierzenski, MD, RDMS; and Jason T. Nomura, MD, RDMS 

Christiana Care Health System Emergency Medicine Ultrasound Fellowship Program 

The Focused Assessment with Sonography in Trauma or FAST exam is one of the most common Point-of-Care Ultrasound exams performed in the emergency department. As discussed in numerous forums, the FAST (or E-FAST) exam can be used in multiple clinical scenarios beyond the traumatically injured patient. We will discuss two common errors that can lead to the misdiagnosis of subtle findings. 

The pelvic windows in the FAST exam are often scanned hastily if the RUQ and LUQ do not show free fluid; however, subtle pathology can be missed if the windows are not surveyed in a thorough manner. 

The urine-filled bladder results in posterior acoustic enhancement, which can obscure pelvic structures and pathology posterior to the bladder. This will be amplified if the far field gain is not appropriately adjusted. Structures may appear significantly more hyperechoic, and free fluid can be missed due to wash-out from an overgained far field image. Figure 1 is an example of missed pelvic free fluid due to posterior acoustic enhancement. The overgained far field obscures the free fluid.  

Figure 2 demonstrates a similar transverse view of the bladder, but with improved far field gain. Internal echoes are visible within the free fluid due to posterior acoustic enhancement; however, further reduction in far field gain may reduce visualization of anatomic structures. Sonographers must strike a balance between adjusting the far field gain to adequately visualize free fluid while still identifying posterior structures and boundaries. This highlights the need to remain vigilant in looking for small amounts of free fluid or other subtle findings. Despite the reduced far field gain and improved image, the persistent artifact within the fluid could mask this pathology. Appropriate imaging and assessment in the suprapubic window requires an understanding of both the pitfalls of posterior acoustic enhancement, as well as any limitations that can be encountered when correcting for this artifact. 

The second common error occurs while imaging the bladder in the transverse plane. Sonographers commonly fail to adequately visualize the lateral edges of the structure. One of the goals of transverse imaging is to evaluate for free fluid that is lateral to the bladder and may not be apparent on sagittal imaging. Figure 3 demonstrates this potential pitfall. 

Figure 4 shows a transverse view in which the lateral edges are not visualized. This occurs most commonly either when the bladder is distended or when a small footprint transducer, such as the phased array or small curved array, is used. If this occurs, the lateral edges need to be evaluated by scanning each half of the bladder separately on transverse imaging.

 

tipsandtricksfig1  tipstricks2of4 
Figure 1: Sagittal view of the bladder with free fluid. The posterior
acoustic enhancement leads to an overgained far field despite the
appropriate gain settings of the near field. This small amount of free
fluid, caused by a liver injury, was missed on initial evaluation.
Figure 2: Sagittal view of the bladder with subtle free fluid. Although
the far field gain is better than Figure 1, there are still echoes within
the free fluid due to posterior acoustic enhancement. This highlights
the need to be vigilant for subtle findings in the FAST exam.

 

tipstricks3of4 tipstricks4of4 
Figure 3: Transverse view of the bladder with free fluid located
laterally to the bladder.
Figure 4: Transverse image of the bladder using a phased array
transducer. Due to the small footprint, the lateral edges of the bladder
are not visualized and free fluid may not be visualized.

 


Case Study #2 - Emergency Ultrasound Section Newsletter, April 2011

Joseph Minardi, MD, FACEP, RDMS
Director of Emergency Ultrasound
West Virginia University
Department of Emergency Medicine

Chief Complaint:
Right hip pain 

Questions:  

What are the findings in the images below?
 

 casestudy2fig1 casestudy2fig2 

What are the normal sonographic landmarks?
What is the diagnostic procedure of choice for this disease process? 

 

Case Discussion: An 18 year old female presented to the emergency department with 5 days of hip pain that radiated down the anterior thigh and was worse with walking and hip movement. The pain was getting progressively worse and walking was difficult. She denied fevers, injury, or any other symptoms. Physical examination was significant for pain with internal/external rotation of the right hip. An emergency ultrasound was performed and the diagnostic procedure was completed using ultrasound guidance at the bedside. 

Emergency ultrasound rapidly and accurately identifies the presence of a hip effusion and provides guidance for hip arthrocentesis to be performed by the emergency physician. Hip arthrocentesis is a procedure that is traditionally difficult to obtain in the emergency department, leading to significant delays in patient care. The use of emergency ultrasound allows a hip effusion to be quickly and easily identified and provides imaging guidance to allow aspiration to be performed rapidly and safely by the emergency physician for a definitive diagnosis.  

The 1st image shows the right hip with a significant effusion. Arrow 1 points to the femoral head and the arrowhead indicates the femoral neck. Image 2 shows the normal left side for comparison where almost no synovial fluid is visible. The arrows labeled 3 point out to the synovial membrane. 

Take Home Points:  

  1. Emergency ultrasound allows the rapid and accurate identification of a hip effusion without exposing the patient to ionizing radiation.
  2. Synovial fluid analysis is the gold standard for the diagnosis of septic arthritis.
  3. Arthrocentesis of the hip can be safely and rapidly performed by the emergency physician with bedside ultrasound guidance, eliminating the need for fluoroscopy or other special services that may not be routinely available. 

Additional Reading  

  1. Ma J, Mateer J, Blaivas M. Emergency Ultrasound. 2nd ed. McGraw-Hill; 2008.
  2. Freeman K, Dewitz A, Baker WE, et al. Ultrasound-guided hip arthrocentesis in the ED. Am J Emerg Med. 2007;25(1):80-6.
  3. Tsung JW, Blaivas M. Emergency department diagnosis of pediatric hip effusion and guided arthrocentesis using point-of-care ultrasound. J Emerg Med. 2008. Nov;35(4):393-9. Epub 2008 Apr 10.
  4.  


Dr. Harvey Nisenbaum, president of AIUM responds to an article in Diagnostic Imaging - Emergency Ultrasound Section Newsletter, April 2011

The letter below was submitted to the ACEP Emergency Ultrasound (EUS) Section by Dr. Harvey Nisenbaum (AIUM President) in response to the recent discussion on the ACEP EUS listserv about an article that appeared in Diagnostic Imaging. The article is: The Trouble with Ultrasound’s Pervasive Use by Non-Radiologists, by Deborah Abrams Kaplan. March 3, 2011

Dr Nisenbaum asked for the opportunity to address section members directly as he wanted to make sure that his position regarding recent discussions about point of care ultrasound and his support for emergency medicine participation in AIUM was clear. 

Dr. Vicki Noble
Chair, ACEP Ultrasound Section  

To ACEP Community, 

The American Institute of Ultrasound in Medicine (AIUM) is a multidisciplinary association consisting of over 8,500 members including physicians, sonographers, scientists, engineers, other healthcare providers, and manufacturers of ultrasound equipment. The AIUM is modality driven, not specialty driven. One of our central goals is to work with other groups to develop performance and training guidelines so patients receive quality ultrasound (US) studies performed by qualified individuals regardless of physician specialty.

ACEP has a long history of developing US policies and procedures and integrating US into their training programs. You use US protocols that are physiologically and anatomically based to evaluate the patient’s immediate clinical condition. Your US examination is as comprehensive as you feel the clinical situation warrants. The immediacy of being able to perform an US study after your initial evaluation is tremendously valuable to your patient and many times can be life-saving.  

The AIUM values all its ACEP members as demonstrated by having one of our Board of Governors positions allocated to an ACEP member. We have welcomed the emergency ultrasound community through creation of an EM/CC Community of Practice, EM involvement in the course offerings at AIUM national meetings and pre-course conventions, presentation of scientific work in EM POC US at meetings, involvement of EM physicians in the leadership of AIUM, publication of manuscripts in the JUM, joint endorsement of the ACEP FAST guidelines, and opportunities for funding through the AIUM Endowment for Education and Research (EER). 

We look forward to continue working with ACEP on mutually agreeable activities and hopefully seeing many of you in New York in April. 

Harvey L. Nisenbaum, MD
President, AIUM 


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