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Emergency Ultrasound Section Newsletter - April 2012

circle_arrowEmergency Ultrasound Tips and Tricks - Ocular Ultrasound - Emergency Ultrasound Section Newsletter, April 2012
circle_arrowJournal Watch – April 2012 - Emergency Ultrasound Section Newsletter - April 2012
circle_arrowSummary of Listserve Discussions - Emergency Ultrasound Section Newsletter - April 2012
circle_arrowWhat was it like bringing ultrasound into the emergency department back in the 80's? - Emergency Ultrasound Section Newsletter - April 2012
circle_arrowCase Report: Surprise Bedside Ultrasound Finding in Dyspneic Emergency Department Patient - Emergency Ultrasound Section Newsletter - April 2012
circle_arrowHow to Start an Ultrasound Program - Emergency Ultrasound Section Newsletter - April 2012

Emergency Ultrasound Tips and Tricks - Ocular Ultrasound - Emergency Ultrasound Section Newsletter, April 2012

Zoe Howard, MD
Laleh Gharahbaghian, MD
 

Ocular ultrasound can provide us with critical diagnostic information even when our physical exam is limited by the disease process itself (when there is trauma, swelling, cataracts, a hyphema or when a patient is altered or intubated).

The Normal Eye:

Using a linear array high-resolution transducer, apply a generous amount of gel to the closed eyelid and have the patient move their eye in all directions. By slowly fanning through the motionless eye in both transverse and sagittal planes, the overall integrity and inner structures of the eye can be evaluated. Take care to apply gentle pressure, especially to the traumatic eye. See Image 1 Extraocular Movements (Click Image for Video)

Tips: You can apply a tegaderm patch over the closed eyelid and apply gel over it in order to prevent gel from getting on the eyelid to maximize patient comfort. With the linear transducer in transverse view, have the patient look left and right; with the linear transducer in sagittal view, have the patient look up and down. The amount of movement to each side should be symmetric: a good test for extraocular movement.

Image 1: Extraocular Motion (Click Still Image for Video) 

 Image14-12 

 Image 2: Normal Eye 

 Image2 

The anterior chamber, filled with aqueous humor, will provide an excellent acoustic window. The orbit containing the anterior and posterior chamber should appear circular separated by the ciliary muscles and lens. The iris and ciliary body are echogenic and can be visualized during testing for pupillary constrictions when a light is shined in the contralateral eye. See Image 2 Normal Eye - Anterior chamber, ciliary muscles, lens, posterior/vitreous chamber, retina, optic nerve sheath

Tip: Placing the linear transducer in transverse view, have the patient look downward. Decrease your depth in order to focus on the longitudinal view of the ciliary musculature and pupil. Once the ciliary muscles are seen as a thick echogenic structure, shine a light on the contralateral eye. This will optimize your visualization of pupillary constriction. See Video. Another way to perform this is to place the linear transducer on the lower eyelid to attempt a coronal view of the eye. The pupil will be seen as a circular image and constrict when light is shines on the opposite eye. See Image 3 Pupillary Constriction (Click Still Image for Video).

Image 3: Pupil Constriction (Click Still Image for Video) 
 
Image 3 

 
Image 4: Retinal Detachment 

 Image 4    

Ocular Pathology 

The retina appears posteriorly as a hyperechoic membrane, which when detached, is seen as a ribbon, but always anchored near the optic disk. Having the patient look at different planes of sight and fanning through each area of the retina will increase your sensitivity of picking up pathology. See Image 4 Retinal Detachment

It is critical to increase the gain for the highest sensitivity of picking up vitreous hemorrhage. With the patient moving their eye, you will see movement of granular or linear echogenic material in the posterior chamber (although depending on age, vitreous hemorrhage can also appear as layered). See Image 5 Vitreous hemorrhage. 

Image 5: Vitreous Detachment

Image 5 

Image 6: ONSD 

 Image 6 

From traumatic head injury to benign intracranial hypertension to SAH, an estimation of elevated ICP obtained rapidly at the bedside using the ONSD (optic nerve sheath diameter) has been well established and can mean a significant change to the management of a patient. The most accurate measurements on ONSD are obtained 3mm posterior to the globe (the best contrast interface) and the average of 2 measurements obtained there should be obtained, with >5mm indicating increased ICP. See Image 6 IONSD -a hypoechoic column exiting the retina

Tip: Decrease your gain and increase your depth then slowly fan through the orbit in order to improve your visualization of the optic nerve sheath.

In patients presenting with eye pain or vision changes, head or facial trauma or headache, we can use ultrasound to rapidly assess and expeditiously diagnose potential ocular emergencies. Besides those described here, many other applications for ocular ultrasound exist from lens dislocation, retrobulbar hematoma, foreign body localization, and globe rupture. Try it out in your ED!

Image 7: Lens Dislocation

Image 7   
 

Image 8: Retrobulbar Hematoma 

 Image 8 

 
Image 9: Foreign Body                                                            

Image 9 


Image 10: Globe Rupture 

 Image 10 

 


Journal Watch – April 2012 - Emergency Ultrasound Section Newsletter - April 2012

Reviewer: Sam Hsu, MD, RDMS, Assistant Professor, Department of Emergency Medicine, University of Maryland School of Medicine  

Article: Doubilet PM, Benson CA. Further evidence against the reliability of the human chorionic gonadotropin discriminatory level.J Ultrasound Med. 2012;30(12):1637-1642. 

Objectives: The “discriminatory level” (DL) is defined as the quantitative HCG above which an intrauterine pregnancy (IUP) should be visible on ultrasound. The typically reported DL is 1000 to 2000 mIU/ml. If no IUP is present when the HCG > DL, a failed or ectopic pregnancy is presumed. Anecdotally, this presumption is not always correct. This study asks: can a pregnancy with a non-diagnostic ultrasound and a HCG > DL go on to become a normal IUP?  

Methods: The study was a retrospective review of cases from 2000 to 2010. The authors sought cases in which the initial transvaginal ultrasound showed an empty uterus, there was a same-day quantitative HCG measurement, and a subsequent ultrasound demonstrated a live IUP. 

Results: Two hundred two cases were identified: 162 (80.2%) had HCG<1000 mIU/ml, 19 (9.4%) had HCG between 1000 and 1499 mIU/ml, 12 (5.9%) had HCG between 1500 and 1999 mIU/ml, and 9 (4.5%) had HCG>2000 mIU/ml. The highest HCG was 6567 mIU/ml. One hundred thirty-five were live born, 18 were spontaneous miscarriages, and the rest lacked outcome information. There was no correlation between initial HCG level and the eventual outcome of the pregnancy. 

Discussion: Normal HCG levels vary widely in early pregnancy, with levels that can exceed the DL as early as 3 or 4 weeks of gestational age, well before ultrasound can demonstrate an IUP. This case series shows that pregnancies with a non-diagnostic ultrasound and an HCG > DL can develop into an IUP and, presumptively, that treating all such cases as ectopic pregnancies runs the risk of terminating a normal pregnancy. This study supports the practice of following stable patients with minimal symptoms with serial HCG and/or ultrasounds every 2 or 3 days, until the state of the pregnancy is evident. The study was not designed to describe the characteristics or proportion of non-diagnostic cases that will become an IUP, so deciding which patients can be followed safely remains the primary challenge. When making this decision, keep in mind that a “non-diagnostic” ultrasound cannot include high-risk findings such as free fluid or an adnexal mass. These findings should trigger a high level of suspicion for ectopic pregnancy. Even without high-risk findings, a non-diagnostic ultrasound with an HCG > DL still deserves careful consideration and a cautious management plan. 



Reviewers:
Laura Diegelmann, MD, Clinical Instructor, Department of Emergency Medicine, University of Maryland School of Medicine, and Sarah Sommerkamp, MD, RDMS, Instructor, Department of Emergency Medicine, University of Maryland School of Medicine 

Article: Figen C, Emine A, Mehmet A, Havva S. Our new stethoscope in the emergency department: handheld ultrasound. Turkish J Trauma Emerg Surg. 2011;17(6):488-492. 

Objective: The objective of this study was to examine the feasibility of using a handheld ultrasound (V scan) to perform a FAST exam and assess for free fluid in the initial evaluation of a trauma patient. 

Methods: The study was done at three hospitals that treat trauma patients. Patients with abdominal trauma had a FAST exam performed by an emergency physician using the V scan. Approximately 10 minutes later, the patient had a study performed by a radiologist using a standard ultrasound machine. Results of the V scan images obtained by the emergency physician were then compared with the images obtained by the radiologist doing abdominal ultrasound or other radiological studies. 

Results: A total of 216 patients with abdominal trauma from motor vehicle crashes, falls, assaults, or work-related incidents were included in the study. Two hundred three patients had a negative FAST exam and 13 had a positive result using the V scan. These results were compared with the radiologists’ images, using this as the gold standard. The V-scan sensitivity for FAST was 88.9%, specificity was 97.6%, negative predictive value was 99.5%, and positive predictive value was 61.5%.   

Discussion: Ultrasound has long been used in the trauma setting for assessing patients. This study illustrates that the V scan is comparable to radiologist-performed ultrasound, with the added benefit of portability. The recent availability of smaller handheld imaging devices has created a promising future for incorporating them into everyday medical exams. Devices such as the V scan, in the hands of a trained emergency physician, have applications beyond the trauma patient. 
 



Reviewers:
Sarah Sommerkamp, MD, RDMS, Instructor, Department of Emergency Medicine, University of Maryland School of Medicine, and Laura Diegelmann, MD, Clinical Instructor, Department of Emergency Medicine, University of Maryland School of Medicine 

Article: Tay E, Stone M, Tsung J. Emergency ultrasound diagnosis of deep venous thrombosis in the pediatric emergency department: a case series. Pediatr Emerg Care. 2012;28(1):90-95. 

Objective: To describe the use of ultrasound in the ED to diagnose DVT in adolescents. 

Methods: Three cases were presented:

Case 1:A 17-year-old girl with neck pain after a MVC, with fractured ribs, orbit and splenic laceration 3 weeks prior. Emergency ultrasound was completed and identified DVT in the left internal jugular vein. CT confirmed the diagnosis and the patient was started on low-molecular-weight-heparin (LMWH). She was later diagnosed with Factor V Leiden mutation.

Case 2: A 16-year-old girl with 3 days of leg pain after starting birth control to control heavy menses was evaluated by emergency ultrasound and found to have lower extremity DVT. Diagnosis was confirmed with radiology ultrasound and the patient was started on LMWH. She was later found to be a carrier for Factor V Leiden gene mutation.

Case 3: An 18-year-old obese male with a history of a knee injury presented with sudden onset of shortness of breath. He was found to be hypoxic and tachycardic. Emergency ultrasound confirmed popliteal DVT. CT shows bilateral PE. The patient was intubated and given TPA. He was discharged to a rehabilitation facility. 

The authors then discuss the technique for using ultrasound to locate thrombi and review published reports on DVT in children. 

Discussion: The discussion focuses on reviewing the relatively low frequency of DVT in the pediatric population and the link with clotting abnormalities and central venous catheters. The authors highlight the importance of ultrasound in limiting radiation compared with the gold standard of contrast venography. However, the gold standard appears to be radiology confirmation by ultrasound in these cases. Extrapolation from adult data notes that the sensitivity of emergency ultrasound for DVT is almost 90%. Given these limitations, there is utility in emergency ultrasound for DVT in the pediatric population. Ultrasound adds critical information about the pediatric patient. Early recognition and diagnosis can lead to early treatment and potentially limit radiation.

 


   

Reviewer: Gregory R. Bell, MD, Assistant Clinical Professor and Director of Ultrasound, University of Iowa 

Article: Taylor RA, Oliva I, Van Tonder R, Elefteriades J, Dziura J, Moore CL. Point-of-care focused cardiac ultrasound for the assessment of thoracic aortic dimensions, dilation, and aneurysmal disease.Acad Emerg Med. 2012;19(2):244-247. 

Objective: To compare point-of-care focused cardiac ultrasound (FOCUS) with chest CT angiography (CTA) in a pilot study of patients to determine the accuracy of transthoracic measurements for aortic dimension and for designation of aortic dilation and aneurysm. 

Method: This is a retrospective pilot study of consecutive ED patients being evaluated for thoracic aortic disease who had both a CTA and a FOCUS exam. The FOCUS studies were reviewed by three ultrasound-fellowship-trained emergency physicians and the CTA images by a radiologist trained in cardiothoracic imaging. All reviewers were blinded to the patients’ clinical presentations (except for the radiolologist, who knew why the CTA was requested), the initial imaging interpretations, and each other’s measurements. A subset of studies was reanalyzed for interobserver and intraobserver variability. Using the largest aortic measurements by CTA as a reference, the study assessed sensitivity and specificity of ultrasound measurements of dilation (diameter > 40 mm) and aneurysm (diameter > 45 mm). Measurements of diameter used the parasternal long view at the sinuses of Valsalva, the sinotubular junction, and the largest visible portion of the aorta. They measured leading edge to leading edge with FOCUS and outer wall to outer wall with CTA. 

Results: Ninety-two patients underwent both FOCUS and CTA for thoracic disease during the study period. Ten were excluded for inadequate test visualization. CTA dilation was present in 26 patients (32%), with 23 of the 26 in the ascending aorta. A diameter of at least 45 mm was present in 14 patients (17%), with 10 of the 14 in the ascending aorta. 

FOCUS sensitivity for dilation was 77% (95% CI, 56%-90%); specificity was 95% (95% CI, 84%-95%). Kappa statistics for agreement between tests was 0.74 (95%CI, 0.58-0.90). For dilation of at least 45 mm, the sensitivity was 64% (95% CI, 35%-86%) and specificity 99% (95% CI, 90%-100%); kappa was 0.71 (95% CI, 0.48-0.90). Mean differences in aortic diameter were 0.6 mm (95% limits of agreement, -5.3-6.5) for the sinus of Valsalva, 4 mm (-2.7-10.7) for the sinotubular junction, 1.5 mm (-5.8-8.8) for the ascending aorta, and 2.2 mm (-5.9-10.3) for the descending aorta. Intraobserver correlation for the ascending aorta FOCUS measurements was 0.83. 

Discussion: This was the first study to investigate FOCUS measurements of thoracic aorta dilation and correlate them with CT angiography findings. The authors found a high specificity for using FOCUS to detect thoracic aorta dilation compared with the use of CTA. The FOCUS exam may prove to be a useful bedside tool for detecting dilation in the appropriate patient. 

The measurements were most consistent for the ascending aorta, though the range of differences was about 1 to 1.5 cm, all points considered. These data suggest that a threshold of 5 to 5.5 cm may be required to detect aortic dilation. The wide variation in measurements may be due to differences in measuring technique used by the emergency physicians compared with the radiologist or to the retrospective nature of the study, as the authors point out. They argue the necessity of a prospective study with defined measuring protocols, which may lessen the range of differences. 


Summary of Listserve Discussions - Emergency Ultrasound Section Newsletter - April 2012

 EUS Functionality in EPIC 

There were a large number of posts and requests for information on emergency ultrasound documentation and storage capabilities of EPIC, the electronic medical record that is being used at an increasing number of institutions. There are a number of institutions that have successfully integrated EUS workflow into EPIC, including computerized physician order entry, integration into PACS, and interpretative reports. The importance of IT support was emphasized, as well as getting requests and processes into the early steps of the EPIC build. More experienced EPIC users discussed the pros and cons of their system. There was discussion on the development of an IT subcommittee as well. 

Hospital Committee to Oversee All Non-Radiology Ultrasound 

A significant amount of comments were posted in response to a proposal by the radiologists at a section member’s institution to create a committee to oversee all non-radiology ultrasound studies. The description of this proposed committee would incorporate EUS, OB-GYN, CCM and any others using ultrasound; radiology would apparently not be involved. Multiple individuals voiced concern, including the right to self-govern, referencing many of our vital documents. Per the original poster’s final response, there were a small number of responses that described the presence of such a committee at their respective institution and the end-results were mixed. Mention was made of the potential for collaboration with other specialties that use clinician-performed imaging.


What was it like bringing ultrasound into the emergency department back in the 80's? - Emergency Ultrasound Section Newsletter - April 2012

For those of us that missed it, what was it like bringing ultrasound into the emergency department back in the 80's?

Dave Plummer, MD
Department of Emergency Medicine
Hennepin County Medical Center
Associate Professor
Department of Emergency Medicine
University of Minnesota
 

It was never our original intention to introduce diagnostic ultrasound into emergency medicine. However, its introduction was almost an inevitable given the state of emergency medicine, faculty support both within and outside of our department and the state of escalating violence in the community. Here is how it happened: 

In the mid 1980's, Minneapolis experienced a sudden increase of penetrating thoracoabdominal trauma. The social economic reasons for this are still debated, but the fact is we experienced a several fold increase of these penetrating injuries arriving to our hospital almost overnight. 

In those days the diagnosis of penetrating cardiac injury remained one of exclusion. After such patients arrived, we would secure their airway, establish intravenous access, begin volume resuscitation, take chest x-rays and start chest tubes when needed. All this took time, and the few patients that were suffering from penetrating cardiac injury would manifest by sudden hemodynamic collapse without other explanation. Sometimes these patients received CPR, followed by pericardiocentesis, and occasionally an emergency department left lateral thoracotomy. But even when this evolved quickly, the patient necessarily demonstrated hemodynamic collapse in order for the physicians to be compelled to action. When we produced a survivor, the patient was often neurologically impaired as a result of prolonged hypotension and shock. 

Dr. Ernest Ruiz approached Dr. Richard Assinger hypothesizing that penetrating cardiac injury in hemodynamically stable victims could be diagnosed more directly and rapidly by demonstrating hemopericardium on echocardiography. The idea held so much promise that he assigned some of his junior people to work on the task, and that’s when my efforts began. 

We began by developing a call list for the echocardiography technicians, but it became clear that they could not be summoned quickly enough. The technicians began on-site call, with a call room just down the hall from a resuscitation area, and again it became clear that for several reasons they could not contribute in these types of chaotic resuscitations in a timely manner. So we asked our cardiologists for some simple instructions - we wanted to learn one window (the subxiphoid) to look at one thing (presence of pericardial fluid) and interpret in only one way (hemopericardium) in one select patient population (penetrating thoracoabdominal injury). 

It took less than one week to “train” the interested physicians, and less than another week before we diagnosed our first traumatic hemopericardium by ultrasonography; this time well before hemodynamic collapse. Cardiology was so impressed that they essentially gave us an ultrasound machine to be positioned at the head of the bed in resuscitation area. The remainder of our faculty quickly recognized its value, became “proficient” and we introduced it into our residency curriculum. 

Once we became proficient at this limited single purpose exam, it was only a matter of time before it expanded, and some say exploded. Again, it was not by design but when you put such a powerful diagnostic tool in the hands of resourceful, intelligent and well-meaning physicians, expansion was inevitable. Quickly, emergency physicians began to recognize conditions by direct visualization such as hemoperitoneum, ruptured ectopic pregnancy, ruptured abdominal aortic aneurysm, massive pulmonary embolism and the list goes on and on. Previously, these could have only been inferred by incomplete or inaccurate histories that were complicated by insensitive and nonspecific physical exams. 

Remember that this was a different time, and it was easier to expand the practice domain of emergency medicine than it is now. It was also before incredible financial pressures would influence turf battles in unspoken ways. These turf battles remain the principal obstacles for many emergency physicians. 

What is the most memorable ultrasound that you've done? Heroic? Life-saving? Bizarre?  

I think the most remarkable ultrasound in my career occurred while caring for a 23-year-old female from a one car motor vehicle collision. While driving on the freeway she became distracted and ran her car into the back end of a parked snowplow. She remained awake and alert and after extrication arrived at the hospital normotensive but tachycardic at 120. Our normal evaluation and treatment (x-rays, IVs, medications) were all uneventful and it was determined that we would observe her in the hospital because of her sustained tachycardia. In that this was before the use, or rather overuse of diagnostic CT scans in trauma patients, we took a quick look at her heart from the subxiphoid window. We were shocked to discover a large amount of fluid in the pericardium. This was completely outside of our paradigm at the time, and after a short and intense discussion with trauma surgery it was elected to perform a subxiphoid window in the operating room. She arrived there with no change in vital signs and the procedure revealed a large amount of pericardial blood with vigorous ongoing bleeding. A median sternotomy was performed and a ruptured left atria was discovered and repaired. On closing it was discovered that the patient had no femoral pulses and subsequent left lateral thoracotomy revealed a ruptured aorta that was also repaired It was astounding to us that the patient could have such a lethal combination of traumatic injuries and present with essentially nonspecific and insensitive physical findings and yet demonstrate such an irrefutable abnormality as pericardial blood that unquestionably led to her timely intervention. She was discharged from the hospital neurologically intact and became an aerobics instructor. This case gained so much attention that it brought all of our faculty on board the emergency ultrasound train. 


Case Report: Surprise Bedside Ultrasound Finding in Dyspneic Emergency Department Patient - Emergency Ultrasound Section Newsletter - April 2012

Brian Fort, MD
Emergency Medicine Resident
Advocate Christ Medical Center 
 

Samuel Lam, MD, RDMS
Assistant Emergency Ultrasound Director
Advocate Christ Medical Center
 

Chief Complaint: Chest Pain and Shortness of Breath

Image 1 (Click Still Image for Video)  

  Apical4chamber 


Image 2 (Click Still Image for Video) 

 Parasternalshort
 

 Image 3 (Click Still Image for Video) 

image3subxyphoid 

 
Image 4 (Click Still Image for Video) 

 image4rightatrialthrombus 

 Questions: 

  1. What anatomy is shown?
  2. What is the pathology?
  3. How do these images influence bedside clinical decision making?

Case Presentation: 

An 86-year-old male with multiple medical problems and pacemaker placement 6 days prior to ED visit presented with chest pain and shortness of breath for several hours. On arrival, he was found to be hypoxic and hypotensive. The patient was placed on BiPAP immediately, and EKG showed no ischemic changes. While waiting for x-ray and laboratory results, a bedside echo was performed. The left ventricle was normal in size, and had good overall systolic function. The right ventricle was moderately enlarged with reduced systolic function, and the right atrium also appeared enlarged. Color Doppler showed moderate tricuspid regurgitation but no significant aortic or mitral valvular insufficiency. In addition, multiple mobile echogenic structures were noted in the right atrium that traversed the tricuspid valve into the right ventricle. The differential for these intracardiac masses included thrombus, vegetations, myxoma, and metastatic tumors. Given the recent implantation of the intracardiac pacemaker leads, thrombi were most likely. Since the patient had multiple co-morbidities and his vital signs were relatively stable on BiPAP, conservative management with intravenous heparin was initiated after consultation with cardiology.

A formal comprehensive echocardiographic examination was later performed, which confirmed the bedside ultrasound findings. A V/Q scan showed bilateral pulmonary emboli (the patient was unable to receive a CT exam secondary to acute renal dysfunction). Except for transient hypotension requiring pressor support for 24 hours, the patient had a rather uneventful hospital course, and was discharged on warfarin.

Role of Cardiac Ultrasound in the ED: 

The principle purpose of bedside echocardiography in the ED is a time-sensitive assessment of symptomatic patients. According to the American Society of Echocardiography/American College of Emergency Physicians Consensus Statement on focused cardiac ultrasound (FOCUS) exams in the ED, there are six goals of the bedside echo:

  1. Assessment of the presence of a pericardial effusion
  2. Assessment of global systolic dysfunction
  3. Determine left or right ventricular enlargement
  4. Assistance and guidance for pericardiocentesis
  5. Confirmation of transvenous pacing wire placement
  6. Intravascular status assessment.

Pathologic processes, such as intracardiac masses, aortic dissection, endocarditis, left ventricular thrombus, regional wall motion abnormalities may be suspected on exam, but is beyond the scope of Emergency Physicians alone, and additional evaluation, including formal echocardiographic examination and cardiology consultation is recommended.

In cases of pulmonary embolism, bedside echo may demonstrate right ventricular hypokinesis with sparing of the apex (McConnell’s sign), right ventricular dilation (>1:1 RV/LV ratio), flattening or paradoxical movement of the interventricular septum, or free floating thrombi. Right ventricular dilation is best visualized in the apical 4-chamber window. Comprehensive echocardiography can be used to help risk stratify patients through evaluation of diastolic dysfunction and pulmonary artery pressures.

In our case, identification of intracardiac thrombi led to timely discovery of a rare complication from pacemaker placement, and allowed for early therapeutic decision-making. Bedside echo expedited the diagnosis and treatment of pulmonary embolism in our patient.

Answers to questions: 

  1. The first video image portrays the standard apical 4-chamber view with the ventricles in the near field and the atria in the far field. The left side of the heart is on the right side of the screen with the right atrium and ventricle on the left side of screen. The mitral and tricuspid valves are seen opening and closing on their respective sides. The second video image is an off-axis view displaying the right atrium and ventricle. The liver is seen on the left side of the screen. This view allows for better visualization of the contents within the right atrium and ventricle.
  2. In the second video image, the pacemaker wire can be seen midline on the right side of the heart traversing the tricuspid valve. In the right atrium, there are multiple mobile large echogenic masses surrounding the pacemaker wire. These masses seem to traverse the tricuspid valve as well and are seen within the right ventricle. These findings are seen with greater clarity in the third video image. The second video also shows implantation of the pacemaker wire into the ventricular wall.
  3. Performance of the FOCUS exam allowed the practitioner to narrow his/her differential diagnosis by ruling out pathogenic processes such as pericardial effusions and systolic dysfunction. Furthermore, seeing the mobile echogenic structures in the right atrium and ventricle in fourth video image with evidence of increased right sided pressures on bedside echo, along with clinical signs and symptoms of pulmonary embolism, led to expedited diagnosis and treatment. Additional imaging was still required for proper diagnosis, but treatment could be initiated with confidence.

Take Home Points 

  • Relevant echo findings in cases of pulmonary embolism include right ventricular hypokinesis with apical sparing (McConnell’s sign), right ventricular dilation (RV/LV ratio greater than 1:1), flattening of the interventricular septum, and free floating thrombi
  • Bedside echocardiography findings tend to be moderately sensitive (~40-50%) and highly specific (~90-95%) in the diagnosis of pulmonary embolism.
  • Intracardiac thrombus/pulmonary embolism is a rare complication of pacemaker placement, but should be in the differential diagnoses of dyspneic patient after the procedure. Prompt identification by bedside echo can be potentially life-saving

Further Reading 

  1. Labovitz AJ, Noble VE, Bierig M, et al. Focused cardiac ultrasound in the emergency setting: a consensus statement of the American Society of Echocardiography and American College of Emergency Physicians. J Am Soc Echocardiogr. 2010; 23: 1225-1230.
  2. Bova C, Greco F, Misuraca G, et al. Diagnostic utility of echocardiography in patients with suspected pulmonary embolism. Am J Emerg Med. 2003; 21: 180-3.
  3. Wright J, Jarman R, Connolly J, et al. Echocardiography in the emergency department. Emerg Med J. 2009; 26: 82-86.
  4. Korkeila P, Mustonen P, Koistinen J, et al. Clinical and laboratory risk factors of thrombotic complications after pacemaker implantation: a prospective study. Europace. 2010; 12: 817-24.
  5. McConnell MV, Solomon SD, Rayan ME, et al. Regional right ventricular dysfunction detected by echocardiography in acute pulmonary embolism. Am J Cardiol. 1996; 78: 469-473.
  6.  


How to Start an Ultrasound Program - Emergency Ultrasound Section Newsletter - April 2012

 Vicki Noble, MD, FACEP  

I am here to tell you that starting an ultrasound program – whether you have residents or are a faculty group only – doesn’t require you break your departments budget or string out all the faculty with reams of new demands. Follow these simple steps and you will be up and running in no time! 

First there are several must-haves: 

  1. A Champion. To get anywhere with any new initiative there must be one person who follows through and is the point person for all the gripes and problems early on (but all the successes and triumphs later on!). While having this person be emergency ultrasound fellowship trained is a plus, it is certainly not necessary and especially for groups with no residents, anyone with a passion for ultrasound can be this champion.
  2. Equipment. The program obviously cannot be successful without equipment but it is also going to be tough going if your only machine is the one you inherited from the OB floor and is now the coat rack in the trauma bay. It is nice to have working machines and some infrastructure for reporting (an EMR with a place where point of care ultrasound findings can be documented and a way to archive images) before you get started…..more on the last two shortly.
  3. Administrative support. If your chair or director are not willing to go to bat for the program, it is going to be tough going. You are going to need to get point of care ultrasound added to your physician privileges and often a hospital’s Privileging Committee is made up of physicians who have never seen the ED. The pushback from the rest of the house of medicine has become less over the years as people from all specialties now recognize the benefit of point of care ultrasound. However, the privileging committee will likely be the first time the rest of the hospital knows what you are up to and if you don’t have the backing of the ED leadership it will be lonely. Likewise, getting a program started is not, sadly, an extra weekend of work. Hopefully by now people realize this but it helps if those people are the ones in charge so the champion can be supported.

So now what next? You have a champion (or if you are reading this you likely are the champion), you have a machine, and your administration says go. What do you do first? 

Training your faculty and creating a documentation/archiving infrastructure. These can happen simultaneously but both need to finish about the same time to keep up your momentum. 

First, faculty training. ACEP’s ultrasound training guidelines have been validated by over two decades of practice and were recently endorsed by the American Institute of Ultrasound of Medicine. The ACEP 2008 Guidelines outline the process in detail and specify the requirements for training. For faculty that graduated before ultrasound was part of residency training, 16 hours of ultrasound CME and logging 25-50 practice ultrasound scans per application is required. For those who graduated with residency training in ultrasound, these requirements should have been met during residency and they should have a letter stating this (there are sample letters on the section’s webpage for those who have to write these). 

One tip for the faculty only, non-residency group: There are now 11 applications listed in the ACEP guidelines that are helpful in emergency practice. However, it may not be the right approach to make your faculty get 25-50 scans in all 11 applications from the start. Many places have found that starting with the applications that are the most useful or most common in your department (and maybe also the least politically controversial) may be a good approach. For example, start with FAST, cardiac ultrasound, screening for AAA, and first trimester pregnancy scanning. 

How to organize a CME course: There are lots of options. The people you buy your machine from may have a package that includes a CME course but there are also many fantastic emergency physician run courses. Use the ACEP Ultrasound listserv to get recommendations. A course done at your hospital, using your own machine and with your own colleagues seems to be the most fun and can be bonding for your group. One other tip – if the champion can organize “scan days” where faculty come in and log scans on either models to get their numbers up or on willing patients, momentum for learning to scan can be maintained. A willing patient waiting for an abdominal and/or chest CT is a perfect patient to scan as you can confirm your findings for the aorta, the FAST scan, the cardiac ultrasound and the uterus in one fell swoop! 

Second, documentation in the EMR and image archiving. Luckily this has gotten easier as well. The ACEP Ultrasound Section has sample reports which are free and downloadable on the section webpage. These reports were designed with all the necessary elements required by coders in mind. The minimal elements needed for each application are highlighted and usually you should start there but for the enthusiast the sample reports include all possible findings! Getting these reports into your EMR or on your machine so it can be exported to the medical record can require contacts from your hospital IT department or from your EMR rep. However, most companies have done this before and now know how to set this up. Again use the ACEP ultrasound section listserv and the section webpage as a reference. 

Image archiving has also gotten easier. Having a box of printed thermal pictures in the office of the champion is not a good way to go. Most point of care machine companies now have a way to export digital images – either wirelessly or through a cable – to web-based image archiving systems (there are several now that cater to point-of-care ultrasound), your hospitals PACS (against all odds this is happening more and your hospital IT is probably very familiar with how to get the images from a machine to the PACS) or to an internet portal. Any of these are great solutions and the ACEP ultrasound section has members who are expert in each one – use their expertise and reach out to get tips on how to set this up. This has been a source of frustration in the past but over time much effort has been made to smooth this out. Definitely contact your hospital IT department and see if you can find a friend there – it will pay off a thousand times over.  

Next… 

You have a trained faculty, a documentation system in place and a way to manage your images. You now go to the hospital privileging committee and overwhelm them with your organizational skills. Arm yourself with all the great “look at the lives saved, time saved and money saved” literature you can find – and there is a growing number of these studies so use them! It also helps to do a little prep work if you can ahead of time with recalcitrant committee members if you think there will be difficulties. 

Once you get the hospital to say go you start scanning! In the beginning it is important to have a pretty robust quality assurance program – that is review the scans or at least the reports your colleagues have filled out and make sure what they say they saw jibes with what happened to the patient or other diagnostic imaging reports. When there is an inconsistency look in your archive at the images and see what the problem is. Some extra teaching or scanning help may be all that is needed and like anything we do, demonstrating a conscientious effort to make sure we provide safe care is a must. You will see that over time you will need to do less QA because your faculty gets better. There is never zero QA (most diagnostic imaging requires a 10-20% review rate) but over time people will become proficient and the burden on the champion will get less. 

A few other tips: 

  • *Share cool cases and cool images with the group – either at faculty meeting or by email. It helps keep up interest and re-motivates people to think about ultrasound in unusual cases.
  • In the beginning do your absolute best to make the image documentation and saving process as streamlined and simple as you can. Even your most die-hard clinicians are going to get frustrated if the process adds more than a few steps to their workflow.
  • Make friends with your internists, surgeons and critical care docs. Point of care ultrasound has come to their specialties as well and they are the most likely allies. Invite them to any educational activities or case presentations and share your successes.
  • Don’t isolate the experts – while initially some radiologists or echocardiologists may not be as supportive as you hope, in time they may come around. They have expertise that we will never have as they perform comprehensive scans daily while we do point of care scanning as one small part of our job. Invite them to come discuss interesting cases or to do some education for your group. Usually you can win them over as they start to understand your practice.
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 *Maintain HIPAA compliance and patient confidentiality 


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