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Emergency Ultrasound Section Newsletter - August 2009, Vol. 13, #3


circle_arrow From the Chair
circle_arrow Physician Extenders Use US in the ED; It Works for Us!
circle_arrow The Success of a Disaster
circle_arrow Office of the Inspector General and CMS Defines Characteristics to Monitor and Investigate Ultrasound Claims
circle_arrow Final Citywide Grand Rounds of the Academic Year
circle_arrow From Picture to Payment: Coding and Reimbursement of a FAST Examination
circle_arrow Journal Watch
circle_arrow Assistant Director, Emergency Ultrasound Fellowship Opportunity in NY
circle_arrow Open Position: Director of Emergency Ultrasound

Newsletter Index

Emergency Ultrasound Section



From the Chair

Lawrence A. Melniker, MD, MS, FACEP

I hope the new academic year started well for everyone and your new class of residents and new faculty are happily scanning. Spring 2009 was a very active time for the ACEP Emergency Ultrasound Section, and we are now the 3rd largest Section in the College – keep recruiting new members please.

  • The political winds have been whipping with threats to credentialing and reimbursement for bedside sonography performed in the ED in Massachusetts and Pennsylvania brought to the Section Leadership. ACEP staff has worked hard and our president, Nicholas Jouriles, MD, has strenuously opposed these threats.
  • In Massachusetts, as a result of a battle with MA Blue Cross/Blue Shield demanding EP’s be "signed off" by the Chair of Radiology to be allowed to bill for EUS, the Section has submitted 2 resolutions for Council consideration (See attached) to make it the policy of ACEP to oppose with all necessary resources any requirements for credentialing, accrediting, certifying, or signing-off by any other specialty prior to privileging of any Emergency Physician to perform bedside ultrasound or any other action defined within the scope of Emergency Medicine.(See attached)
  • The American Board of Radiology Foundation is hosting a Summit August 6-7 on the "crucial challenge" of medical imaging: Addressing Overutilization; I will be in attendance representing ACEP and will report back to the Section in the pre-SA newsletter. This Summit will likely focus on non-radiologist use of imaging, but we will have a voice at the table and try to steer things toward a meaningful dialogue.
  • A formal response to the Cochrane Review on FAST has been submitted to the new Journal of Critical Ultrasound.
  • The Section will endorse a Council Resolution to request the Board to develop a process by which National ACEP will come to the financial assistance of State Chapters which become enmeshed in battles involving issues of importance to the practice of Emergency Medicine throughout the country (ie, reimbursement for ultrasound services).
  • The SAEM Annual Meeting featured a combined Interest Group and Section meeting
  • Beatrice Hoffman, MD (developer of the SonoGuide Website) was elected IG Chair-elect 2009-2010.
  • The Interest Group will spearhead the development of a new Clinical Sonography Research Consortium, which will prepare a Program Grant for submission and begin active research in the late summer.
  • In Washington, health care reform is the #1 domestic policy issue for President Obama; a universally insured population would be highly beneficial to Emergency Medicine and Emergency Physicians everywhere. In addition, the Stimulus Package includes considerable funds for medical research and a number of Section members have applied for "Challenge Grants" – best of luck!

 As we prepare for the summer months, please mark 2 important conferences on your calendars:

  • The 5th World Congress on Ultrasound in Emergency & Critical Care Medicine, September 3-7, 2009 in Sydney, Australia. The WCU has become the premier event for clinical sonography education, research, and collaboration. The Sydney Congress will be the best ever and airfares are at all-time lows – so come on down under!
  • The ACEP Scientific Assembly, October 5-9 in Boston. This year the educational program offerings and research presentations in Emergency Ultrasound look outstanding. The Section meeting will be held on Monday, October 5th at 1PM, with an Interest Group update to follow. We will also conduct an Industry Roundtable still to be scheduled.

 It has been a very dynamic time for the Section’s many subcommittees, the chairs of which are mentoring future leaders for the Section. Highlights of subcommittee activities are below: 

  • SonoGuide, Beatrice Hoffman, MD, Chair
    • The SonoGuide site has secured corporate sponsorship from Ultrasonix and Sonosite, which will provide the needed revenue stream to allow updating and revision of current components, as well as new segments.
    • There will be discussion on adding an annotated bibliography and a case library to the site.
  • Accreditation, Jerry Chiricolo, MD, FACEP, Chair
    • The ACEP Emergency Ultrasound Accreditation Process has been approved and the online, voluntary component will be available to members soon.
    • The Section Leadership urges all programs to make use of the online system as soon as it is operational.
  • Community Practice, Robert J. Tillotson, DO, FACEP, Chair
    • The "Toolkit" for Emergency Ultrasound Education is in development and will be made available to all members.
    • The ACEP National Chapter Relations Committee is eager to assist in the production and dissemination of the product.
  • Critical Care in Emergency Ultrasound, Anthony J. Dean, MD, Chair
    • Through WINFOCUS and multiple liaisons we continue to enhance collaboration between the specialties of Emergency Medicine and Critical Care Medicine.
    • Numerous educational and research collaboration have been developed.
  • Industry Communications, Chris Moore, MD, RDMS, FACEP, Chair
    • Will conduct a second Industry Roundtable at the Scientific Assembly in Boston.
    • Will assist Industry leaders in the development of minimum standards and requirements for storage and reporting of ultrasound scans.
  • International Emergency Ultrasound, Dan D. Price, MD, Chair
    • Several committee members are on the faculty of the 5th World Congress in Sydney and the WINFOCUS educational mission.
    • There is increasing international interest in clinical sonography as a cost-effective means to promote health and decrease health disparities in the developing world.
  • Media/Government Relations, Paul R. Sierzenski, MD, FACEP, Chair
    • As usual Paul has been keenly aware of what’s going on "on the Hill."
    • The Section Leadership has become aware of several bills passed in State Capitols and, with ACEP Leadership, will develop a system to monitor these events as they develop.
  • Medical Student Education, Michael B. Stone, MD, Chair
    • ACEP is about to receive the magnificent fruits of another Section grant; as SonoGuide before it, the Emergency Ultrasound Testing System developed by Dr. Stone will become a vital tool in Medical Student and Residency Training.
  • Pediatric Ultrasound, Jim Tsung, MD, Chair
    • While the American Academy of Pediatrics apparently did not meet this year, the Pediatric academic society (SAEM equivalent) had a very large workshop in bedside sonography and plans more educational offerings for future meetings.
  • Reimbursement , Steve Hoffenberg, MD, Chair
    • Look for new and better codes and coding in the near future.
    • This committee will remain central in the battles over reimbursement approval/denial and keeping us informed which ICD codes support which CPT codes.
  • Safety, Arun Nagdev, MD, Chair
    • Completed a review of the various policies on the proper care of endocavity probes and found considerable variability in this area.
    • It will remain the policy of the College and Section to support the local institutional policy on this matter. 

Look forward to seeing everyone in Sydney and Boston – happy scanning!

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

Proposed Council Resolution

ACEP Opposes Credentialing, Certification, Or "Signing-Off" Processes by Other Specialties for Core Skills with the Scope of Practice of Emergency Medicine

WHEREAS, Emergency Medicine is a broad based specialty involving the practice of many procedures that are primarily within the practice domain of other specialties, including, but not limited to the administration of thrombolytics (Cardiology and Neurology), the administration of Paralytic agents, conscious sedation agents, and endotracheal intubation (Anesthesiology), utilization of the nasopharyngoscope (Otolaryngology), placement of thoracostomy tubes (Surgery); and

WHEREAS, previous attempts to "certify" or "sign off" on emergency physicians use of these components of emergency medicine practice that are primarily within the practice domain of other specialties have been demonstrated to undermine the best interests of patients requiring emergency care at times when such specialists are not available in the hospital, and are contrary to the autonomous stature of the Specialty of Emergency Medicine as recognized American Board of Medical Specialties; and

WHEREAS, The imposition upon the specialty of Emergency Medicine of a requirement of any credentialing, certification, or "signing-off" process by other specialties represents a clear and present danger to the independence of the practice of Emergency Medicine and is a violation of American Medical Association (AMA) Resolution 802 et al; and

WHEREAS, credentialing, certification, or "signing-off" processes by other specialties, other specialty-associated groups, or healthcare institutions, which are used or proposed for use in the granting of privileges or by third-party payors and Medicare for reimbursement for any other core skill within the scope of practice of Emergency Medicine, including the performance and interpretation of imaging studies provided by emergency physicians are extremely unfriendly to Emergency Medicine and, specifically, harm the ability of emergency physicians to use emergency ultrasound, a core skill; therefore be it 

RESOLVED, That ACEP, in cooperation with all established College liaisons and relationships with other medical specialty societies, the American Medical Association, the Alliance for Specialty Medicine, the Coalition for Patient-Centric Imaging, and other interested parties actively and fully opposes the imposition upon the specialty of Emergency Medicine of a requirement of any credentialing, certification, or "signing-off" process by other specialties for any core skill within the scope of practice of Emergency Medicine. 

National ACEP Plan for Support for ACEP State Chapters

WHEREAS, Situations arise in which ACEP State Chapters become entangled in battles regarding issues that represent a clear and present danger to the independence of the practice of Emergency Medicine and/or the appropriate reimbursement for emergency care; and

WHEREAS, Some of these entanglements do result in litigation, which may lead to legal fees that may render an ACEP State Chapter or Chapters insolvent or bankrupt; therefore be it

RESOLVED, That the Board of Directors of ACEP submit a comprehensive report to the Council at the 2010 Council Meeting regarding the development, adoption, and execution of a strategic plan for National ACEP to A) declare an issue of National, Specialty-wide importance and B) support (legally, financially, and otherwise) ACEP State Chapters, when they become involved in litigation regarding issues that represent a clear and present danger to the independence of the practice of Emergency Medicine and/or the appropriate reimbursement for emergency care. 


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Physician Extenders Use US in the ED; It Works for Us!

Michael B. Heller, MD, FACEP

At Beth Israel in New York City we have lots and lots of Physician Assistants who work in the ED, more than 2 dozen, I’m told. Mostly they staff an intermediate care area called "Northwest," sometimes with a physician, sometimes not. Basically all women with vaginal bleeding and all pregnant women get triaged to Northwest .For many, many years they were all sent up to Radiology for a formal ultrasound by the ultrasound techs, which took many hours except on the weekends and at nights when there were no techs on duty. The radiology resident did the exams. Then it took forever.

Almost exactly one year ago we gave all the PAs a 2-hour course on how to do pelvic ultrasounds, which was followed by an experiential period in which they each do a defined number of exams with one of our half-dozen credentialed attendings (initially these were transabdominal scans as concerns over nosocomial infection prevented use of the endovaginal probe; no, I am not making this up.) We will tabulate the results and (hopefully) present them next year but the results in terms of time saving are already evident. Hours are saved with every PA-performed exam and the response in terms of both patient and clinician satisfaction is very gratifying. The radiology residents like it, too.

I don’t know for sure if this model of PA-performed, focused ultrasound exams in an ED setting is applicable, or even legal in most places. At least one state specifically bars physician extenders from performing ultrasound exams (maybe Ohio but don’t quote me on that) and I know that it is not included within the "scope of practice" list for many others. I would certainly be interested to hear if others have had experience with this model or are we the only ones?

Dr. Heller may be reached via email

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The Success of a Disaster

Lisa Mills, MD

June 1st marked the beginning of hurricane season for Louisiana and the Gulf Coast. When Gary Quick asked for an update on the state of US at Charity since Hurricane Katrina, I was perplexed as to what I could write. What has changed since the hurricane? As our faculty and residents begin our annual division into disaster and recovery teams in preparation for something that we hope never comes again, I realized that the answer, simply put, is a lot.

Hurricane Katrina washed us out of the historic Charity Hospital. After the storm, the LSU Emergency Medicine Residency program worked from many venues, including, tents, parking lots, and shopping malls, finally settling into the "LSU Interim Hospital." This hospital underwent renovation and restoration before opening its doors in 2006.

Since moving in, the emergency department has been flexible and mobile, operating while the rest of the hospital continued to be under renovation. At each step, we have taken US with us and propagated it throughout the hospital and into the community. Since the days immediately following the hurricane, when we relied exclusively on US for imaging, LSU Emergency Medicine continues to push the limits of bedside US.

Our residents and faculty continue to utilize the machine in novel and established applications to facilitate diagnosis and procedures. Some of our more unique findings since moving into our new hospital include diagnosis of small bowel perforation with the finding of free, mobile air in the scrotum and a large ariepiglottic mass in a patient with hoarseness. Our success with US caught the attention our colleagues in other departments, with resultant increase in the utilization of bedside US throughout the hospital and improved collaboration among the departments.

In addition to the increased use of US in our own hospital, our residents have taken the technology into the community. During the community rotations and in jobs following graduation, our residents continue to promote US in the ED. The community EDs that host our residents purchased US machines and increased the utilization of US within the ED. In addition, outside of our immediate region, our residents have taken jobs and campaigned for US in the ED. The result of a tragedy is a tremendous increase in the presence of US performed by emergency medicine physicians in our community. 


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Office of the Inspector General and CMS Defines Characteristics to Monitor and Investigate Ultrasound Claims

Paul Sierzenski, MD, RDMS, FACEP

Please note that with the increasing attention of healthcare cost control, as well as waste/fraud reduction, the OIG has issued the attached report on their analysis on billing for ultrasound services. The primary thrust of this report is for that of outpatient services. Please note the criteria for identifying "questionable services." This is to confirm that the rules of engagement for billing and the boundaries for claims investigation have been defined by the OIG.

"Nearly one in five ultrasound claims (Medicare) nationwide had characteristics that raise concerns about whether the claims were appropriate."

Analysis of Billing Patterns

We analyzed our county-level file and our national claims file to describe utilization in the high-use counties and to compare utilization in the high-use counties to that of all other counties. In consultation with a certified fraud examiner and a registered sonographer at a PSC, we identified five characteristics that may indicate questionable ultrasound claims. These characteristics were:

• The absence of a prior service claim from the doctor who ordered the ultrasound service. We identified the ordering doctor reported on each ultrasound claim and determined whether the doctor had a service claim for treating the beneficiary any time from 2006 up to and including the date of the ultrasound service. Such an absence raises questions as to whether the doctor who reportedly ordered the service ever saw the beneficiary.

• Questionable use of ultrasound billing codes, such as suspect combinations of ultrasound services billed for the same beneficiary on the same day by the same provider, or specific procedures that are not effective in adults. An example would be duplicative services, such as billing for both a complete abdominal scan and a concern of unnecessary or inappropriate use of services.

• Instances of more than five ultrasound services provided to the same beneficiary on the same day by the same provider. This raises concerns of excessive utilization of services.

• Beneficiaries who had ultrasound services billed for them by more than five providers in 2007. This raises concerns of misuse of beneficiaries’ Medicare numbers.

• Missing or invalid data in the claim fields that identify the doctor who ordered the service. This raises questions about whether the service was ordered by a physician treating the beneficiary.

We created variables to show the presence or absence of each of these characteristics on each claim. We analyzed them to determine the extent to which ultrasound claims exhibited these characteristics and the extent to which high-use counties and all other counties varied in their prevalence.

Contact Dr. Sierzenski via e-mail


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Final Citywide Grand Rounds of the Academic Year

St. Luke’s Roosevelt Ultrasound Division
William H. Bagley IV, MD

In the final emergency ultrasound citywide grand rounds of the 2008-2009 academic year, on June 3, 2009, the St. Luke’s Roosevelt ultrasound division hosted a roundtable discussion on different methods used to assess sonographer competency at different stages of training. Dr. Robert Rodgers, Director of Emergency Ultrasound at Penn State Hershey facilitated the 2-hour conversation. Participating programs included New York Methodist Hospital, Jacobi Medical Center, Albany Medical Center, Bellevue Hospital Center, Metropolitan Hospital Center, Long Island Jewish, and Penn State Hershey.  

After a discussion about some of the more traditional forms of teaching including lecturing, multiple-choice tests, and the Socratic method, the conversation shifted to the main topic of the evening, self-directed learning. In contrast to a lecture-based format, an efficient method of exposing larger audiences to a set amount of information, self-directed learning is often more tailored to the individual and to personal preferences. The proverb "Tell me and I forget. Show me and I remember. Involve me and I understand." demonstrates how important it is for students to take an active role in the education process. Resources for self-directed learning in ultrasonography may include continuing medical education (CME), online resources, and citywide grand rounds. 

The concepts of formative learning and summative assessment were discussed. A summative assessment is seen in the example of the stereotypical final exam, covering a whole semester’s worth of information in one test; formative learning includes the actual learning process in the assessment. Examples of formative learning could be an objective structured clinical examination (OSCE) or constructing a lecture to give to colleagues. 

The process of assessing sonographers is related to how we have been taught, how we learn, and how we have been taught to teach. Quality assessment will continue to be an important topic as we expand the number of applications we perform and teach physicians at earlier levels of training. We need to continue to evaluate and utilize the many styles of education and assessment to ensure proficiency in ultrasonography.  

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From Picture to Payment: Coding and Reimbursement of a FAST Examination

Jessica Resnick MD

Abstract: This article reviews the steps involved from producing an ultrasound image to collecting a payment for this image. Key steps required for appropriate coding and payor policy edits are reviewed. 

Manuscript: Emergency physicians often outsource coding and billing for charts. While most physicians are familiar with requirements for documenting varying levels of service for evaluation and management codes (E and M codes), physicians are less familiar with the process of billing for procedures such as focused ultrasounds in the emergency department. This article follows the steps involved from producing an ultrasound image to collecting payment for this image.

Ultrasound Documentation and Billing of a FAST Examination

Step One: Excerpt From Emergency Department Physician Documentation:

"68 year old man, fell twenty feet off a ladder onto concrete while cleaning his gutters at home. He is non-verbal and unable to provide a history. EMS transported the patient in full spinal precautions and was bagging the patient en route. Upon arrival he had obvious head injury, he was hypoventilating, and had the following vital signs: BP 90/60, HR 110, RR 16 assisted, 88% Pulse Ox. ATLS protocol was initiated. . .

Procedure note:

A FAST examination was performed by myself on this patient. Focused chest, cardiac and abdominal exams were performed. The indication was fall from height with blunt thoracic and abdominal trauma, hypotension, hypoxia, and an unreliable examination due to altered mental status. Lung sliding was absent on the patient’s right side. Cardiac and abdominal windows were negative for free fluid. The study was limited by an incompletely filled bladder. Impression: Right-sided pneumothorax. Thermal prints of the study images were placed in the patient’s record. The results of the study were conveyed to the trauma surgeon contemporaneously with the study being performed.

A repeat focused abdominal examination was performed by myself on this patient 30 minutes after the first focused abdominal examination. The indication was continued hypotension despite aggressive fluid resuscitation and blunt abdominal trauma with concern for hemoperitoneum. Morison’s pouch was positive for free fluid. Impression: Hemoperitoneum. Thermal prints of the study images were placed in the patient’s record and the trauma surgeon was notified of the results immediately. 

Key Points: The physician documentation above includes the following key points needed for appropriate billing:

  1. What ultrasound procedures were performed? Focused cardiac, abdominal, and chest examinations
  2. Who performed the ultrasound? The emergency physician of record.
  3. What were the indications for the ultrasound? For the initial ultrasounds, fall from height with blunt thoracic and abdominal trauma, and traumatic shock with hypotension. For the repeat ultrasounds, blunt abdominal trauma with continued traumatic shock.
  4. What were the results? The initial focused ultrasounds demonstrated pneumothorax but no hemopericardium and no hemoperitoneum. Repeat abdominal ultrasound was positive for free fluid.
  5. How are the pertinent images being stored for medical records? Thermal prints of pertinent images are in the paper chart. 

Step Two:  Coding Documentation for Ultrasound Procedures:

CPT CODE                                            ICD-9                                                  CHARGE

76604-26                                                959.11, 958.4, 860.4, E881.0, E849.0             *

76705-26                                                959.12, 958.4, E881.0, E849.0                        *

93308-26                                                959.11, 958.4, E881.0, E849.0                        *

76705-26,76                                           959.12, 958.4, 868.00 E881.0, E849.0            *

*Charges vary by region.  

After verification of images accompanying the documentation above, the procedure is coded for Current Procedural Terminology (CPT) code , International Classification of Diseases, 9th Revision (ICD-9 )diagnoses, and associated charges. CPT codes describe what services have been performed. The CPT codes above represent the focused abdominal, cardiac, and repeat ultrasounds performed for the chart above. Each CPT code must be accompanied by an ICD-9 code. ICD-9 codes describe the signs, symptoms, diagnoses, injuries, and health status which support why a procedure was performed. As noted above, multiple ICD-9 codes may be used to support a particular CPT code.

Step Three: Payor Verification of Medical Necessity

When the insurance carrier receives the coded bill, the carrier matches CPT codes to the accompanying ICD-9 codes as a first pass edit for appropriate medical necessity. Carriers also have their own list of requirements and exclusions for procedures. For example, many carriers reject "motor vehicle accident" alone as an indication for a focused ultrasound of the abdomen. Carriers also review for payment edits which are payor-policy driven reviews screening for procedures which have a high-probability of being incorrect or medically unnecessary. Examples of codes which may be initially denied based on review of payment edits include the same procedure being repeated during the same visit or a focused ultrasound being performed on the same day as a comprehensive ultrasound.

Step Four: Payment or Denial of Claim

Payment schedule

CPT CODE                                                                                 PAYMENT

76604-26                                                                                    **

76705-26                                                                                    **

93308-26                                                                                    **

76705-26-76                                                                               DENIED

** Payments vary by region.

Payments were made for the initial focused ultrasounds, but were rejected for the repeated ultrasounds due to lack of medical necessity.

Step Five: Letter of Appeal May be Considered

Send a copy of the physician chart along with a letter of appeal. The following is an example of a letter of appeal:

To whom it may concern: The second focused abdominal ultrasound examination (76705-26,-76) was medically necessary because the patient continued to be unstable with an unclear etiology for the traumatic shock. Ultrasound cannot detect hemoperitoneum until about 250 cc of blood is present in the abdomen. Repeat examination was warranted of the abdomen in this situation to evaluate quickly and non-invasively for the cause of the traumatic shock unresponsive to therapy. Attached is a copy of the medical record supporting the medical necessity of the repeat ultrasound of the abdomen.

Step Six: Resolution

With additional information documenting medical necessity, the bill was re-processed and payment was issued.

Note: The appeals process is time-consuming, expensive, and does not always result in successful payment. Appeals should be limited to cases in which a pattern of rejection is seen. Additional evidence for the utility and accuracy of emergency ultrasound can be found in the 2008 Emergency Ultrasound Guidelines Appendix 1 (p 20-21) on the Emergency Ultrasound Section of the ACEP website. The letter of appeal above is by no means a guarantee of payment. Insurance company reimbursements and policies vary by region. Appeals with local carriers have to be negotiated on an individual basis.

For additional information on coding and reimbursement of ultrasound procedures, please see the Emergency Ultrasound Coding and Reimbursement documents on the emergency ultrasound section of the ACEP website. A 2009 update is forthcoming. 

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Journal Watch

Reviewer: Michael Osborne, MD. Associate Ultrasound Director, Assistant Professor of Emergency Medicine, Yale University Medical School

Le A, Hoehn ME, Smith ME, et al. Bedside sonographic measurement of optic nerve sheath diameter as a predictor of increased intracranial pressure in children. Ann Emerg Med. 2009;53(6): 785-791. 

In this recent study from the Annals of Emergency Medicine, Le et al attempted to use the optic nerve sheath diameter to predict elevated ICP in children from 0 to 18 years of age. The optic nerve sheath diameter was measured 3 mm behind the optic disc in both eyes and averaged. An optic nerve sheath average over 4.0 mm in subjects under a year and greater than 4.5 mm in older children was presumed enlarged. This was compared to a standard of either CT scan of the brain or measured opening pressure by LP. Elevated ICP was defined as either CT Scan- midline shift > 3 mm, hydrocephalus, collapsed 3rd Ventricle, effacement of sulci with significant edema or abnormal mesencephalic cistern, or an LP with an opening pressure over 20 cm of water. Sensitivity of the ultrasound for screening for increased ICP was 83% (95% CI 0.097 to 1.79) and specificity was 38% (95% CI 0.23 to 0.54). Positive likelihood ratio was 1.32 and negative likelihood ratio was 0.46 (CI 0.97-1.79 and 0.18 to 1.23 respectively). The conclusion of the authors was that the sensitivity and specificity of bedside ultrasound was inadequate for decision-making in children with suspected elevation of ICP. 

Comments. There are some problems with this study. First it was single-blinded. Next the measurements of the optic sheath were not actually made on the ultrasound machine. Pictures were digitized and then measured from the pictures. This is a very small measurement and this could add an error to that measurement. Without double blinding the expectation of the measuring physicians could have lead to unintentional changes in the actual measurement. 

Of an even greater concern is the use of the "gold standard." Measured opening pressure should correlate well with actual ICP. However use of CT scan is probably not completely accurate, and likely misses some patients with elevated pressures. 

McAuley’s study1 published 331 examinations of the optic nerve sheath diameter in 160 children suspected of having hydrocephalus at a single institution from 2000 to 2006. Of children with VP shunts for hydrocephalus, 18 of 19 children with symptoms of increased ICP and ultrasound evidence of increased optic nerve sheath, but with no CT or MRI changes suggestive of high ICP, had a blocked shunt. They found optic nerve sheath diameter useful to assess for hydrocephalus and that in shunted patients it was especially useful to have a baseline sheath diameter for comparison when the patients came in with possible increased pressure. 

Prior study on adults by Tayal et al2 had shown that increased diameter of optic sheath had overlap with normal, but all adult patients with increased ICP were over 5 mm in diameter. May the be question should be phrased differently. Is there a cutoff optic nerve sheath diameter below which only reside patients with normal ICP? In Tayal’s study all adult patients with increased ICP had an optic nerve sheath of 5 or greater. Many normals were above 5, but most were below. From his study, the application could be that in a triage of patients, adults with optic nerve sheaths less than 5 mm in size do not have increased ICP.

Le et al use an average of the optic nerve sheath size right and left eye. Could it be that some compartments will show differing ICP (right or left of the falx)? Certainly unilateral effacement of gyri can be manifest on CT scan. Using the highest and the lowest nerve sheath diameters as independent measurements might yield a different analysis.

I agree that optic nerve sheath diameter is reproducible with limited training. The jury is still out on how to use the data. Certainly in those patients with known hydrocephalus it could be very beneficial to obtain baseline measurements of optic nerve sheath diameter when pressure is definitely at baseline. Recording these on the record as a comparison for when they return to the emergency department or clinic could be very useful. 

  1. McAuley D, Paterson A, Sweeney L. Optic nerve sheath ultrasound in the assessment of paediatric hydrocephalus. Childs Nerv Syst. 2009;25(1):87-90.
  2. Tayal VS, Neulander M, Norton HJ, et al. Emergency department sonographic measurement of optic nerve sheath diameter to detect findings of increased intracranial pressure in adult head injury patients. Ann Emerg Med. 2007;49(4):508-14. 

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Assistant Director, Emergency Ultrasound Fellowship Opportunity in NY



North Shore-Long Island Jewish Health System
North Shore University Hospital
Manhasset, NY

North Shore University Hospital is a suburban Level I Adult and Pediatric Trauma Center, designated Stroke Center, and regional referral center. The state-of-the-art ED sees approximately 75,000 patients per year.

  • 3-year Emergency Medicine residency program with 30 EM residents.
  • Fellowships in Ultrasound, Research, Toxicology, Critical Care and Sports Medicine.
  • New medical school opening in 2010 (Hofstra-NSLIJ); proposal for integrated medical student education in ultrasound has been submitted.

We are in search of an additional fellowship trained physician to join our group as the Assistant Director of our fellowship program. The ultrasound fellowship has been in place since 2001 and currently has 4 fellows. We are very active with fellow, resident, and medical student education as well as research, administration, and faculty development. 

The candidate will be highly motivated and innovative. Compensation and Academic rank are commensurate with experience. NS-LIJ health system offers a comprehensive benefit package. 

If interested, please contact:

Christopher Raio, MD, FACEP, RDMS via e-mail
Jerry Chiricolo, MD, FACEP, RDMS via e-mail 


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Open Position: Director of Emergency Ultrasound



Hackensack University Medical Center is seeking a Director of Emergency Ultrasound for a dynamic emergency department with 26 fulltime board-certified emergency physicians. The setting is a tertiary care teaching community hospital with over 80,000 E.D. visits over two campuses. The hospital is a 753-bed level II county-designated trauma center with a helipad. A strong support staff covers with 95 hours a day of physician coverage.

An excellent benefits package including 6 weeks vacation and 1 week CME with a competitive salary rounds out the offer. Located just 6 miles from NYC.

Contact: Edward Yamin, MD
Vice-Chairman, Emergency Trauma Department
Hackensack University Medical Center
Spectralink 201.996.3759
Phone 201.996.4614
Fax 201.968.1866


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 The ACEP Emergency Ultrasound Section leadership would like to thank and Sonosite www.sonosite.comfor their outstanding underwriting support of the Sonoguide educational resource, a comprehensive guide to emergency ultrasound  Through their underwriting support, the Section is able to maintain the most cutting edge, up-to-date ultrasound resource information in the Sonoguide.


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

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