Emergency Ultrasound Section Newsletter - August 2011
Letter from the Chair - Emergency Ultrasound Section Newsletter, August 2011
Vicki Noble, MD, FACEP
I wanted to make sure people were aware of a few announcements...
We will be electing a new chair-elect, councilor and alternate councilor as well as the section newsletter editor this fall. We will be sending out calls for nominations this summer to the listserv and then holding an electronic vote this fall before the San Francisco meeting. As always we rely solely on the efforts of our amazing section members for everything we do and so please consider running! If anyone has questions please contact me.
Current officers for 2010-2011 are:
- Chair: Vicki E. Noble, MD, FACEP
- Chair-elect: Michael Stone, MD, RDMS
- Secretary/Newsletter Editor: Joel M. Schofer, MD, RDMS
- Councilor: Rajesh N. Geria, MD, RDMS, FACEP
- Alternate Councilor: Robert J. Tillotson, DO, RDMS, FACEP
- Board Liaison: Alexander M. Rosenau, DO, FACEP
We will also be sending out a list of the subcommittee chairs and chair-elects this fall as well as short statements of what each committee is working on. Again, we always need help and members are encouraged to contact the subcommittee chairs to get involved. Below is a list of the subcommittees and current chairs:
- Accreditation: Will Manson
- Community Practice: Bob Tillotson
- Critical Care: Keith Boniface
- Fellowship: Jerry Chiricolo
- Industry Communications: MacLong Tran
- International Ultrasound: Sachita Shah
- Media/Gov't Relations: Paul Sierzenski
- Medical Student Education: Teresa Liu
- Military/Tactical Ultrasound: Brooks Laselle/Jeremy Johnson
- Pediatric Ultrasound: Jason Levy
- Reimbursement: Jess Resnick
- Residency Education: Dan Theodoro
- Safety: Brian Euerle
- Reporting Guidelines: Steve Leech/Alfredo Tirado
- Subspecialty Organization: Resa Lewiss
- US Management Course: Troy Foster
- Website Development: Mike Stone
Keith Boniface (George Washington University) and Haney Mallemat (University of Maryland) were awarded a section grant (this grant was co-awarded with ACEP’s critical care section) to develop a training curriculum for point of care ultrasound to be used in critical care fellowship programs offered by emergency medicine programs.
Hamid Shokoohi (George Washington University) was awarded a section grant that will perform a survey of the administrative solutions for running a point of care ultrasound program.
We look forward to hearing the results of their work!
SECTION MEETING AT SA
We are going to change the format slightly of the section meeting at the ACEP Annual meeting this year. We are going to abbreviate the committee presentations (using the updates by email to communicate most of the committee work) and try to keep the presentations to 90 minutes or so - we will then break into smaller groups focused on some of the more pressing issues the section is working on so there can be a bit more networking and interaction and so that we can utilize the opportunity of having everyone in one place a bit more effectively.
IMPORTANT though is the vote on whether to pursue ACGME accreditation for ultrasound fellowships will be a paper vote and will be part of the main meeting.
The small groups will be:
- an update and call to action on how health care reform is/will impact point of care ultrasound
- a review of image management solutions and developing a wish list for industry
- a panel discussing medical school ultrasound curriculum how to’s - the politics, how to approach and a review of people's experience
- a discussion of resident competency assessments - how are we doing and could we do better?
More to come on the listserv this summer....
Ask the Expert - Emergency Ultrasound Section Newsletter, August 2011
Michael Blaivas, MD
Question #1 “What do you feel are the most useful non-core ultrasound applications in the emergency department setting?”
Question #2: “What areas of research should be a focus for emergency ultrasound investigators in the upcoming 5 years?”
Expert: Michael Blaivas, MD
- Professor of Emergency Medicine
Associate Professor of Internal Medicine
Department of Emergency Medicine, Northside Hospital Forsyth, Atlanta, Georgia
- Vice President, Society of Ultrasound in Medical Education
- Editor-in-Chief, Critical Ultrasound Journal
- Chair, AIUM Emergency and Critical Care Ultrasound Section
- Immediate Past President, WINFOCUS
- Editorial Board, Journal of Ultrasound in Medicine
- Past Chair, ACEP Ultrasound Section
- ACEP liaison for Critical Care Medicine
Answer #1: I think the uses that come to mind the most are lung ultrasound and regional nerve blocks. Obviously, there are arguments for many different applications, but I think these two are near the top. Why lung ultrasound? First and simplest, lung ultrasound has tremendous potential in emergency medicine practice. It is being utilized heavily in Europe and is exploding in the hands of our critical care colleagues here at home as well. Starting in academic settings, but soon more and more in private practice, we will see the physicians we probably work with most (critical care) utilizing a number of lung ultrasound techniques. It started with ruling out pneumothorax, but emphysema, pneumonia and pulmonary edema evaluation are of great interest to intensivists. Lung ultrasound even has tremendous potential in the office setting and will eventually spread to internists and family physicians. This is important especially for hospitalists whose interest in point-of-care ultrasound is growing rapidly. Second, a recent consensus conference on lung ultrasound has been completed and is being written up now. It was an international, multi-specialty effort that will further define evidence based standards and techniques for lung ultrasound, thus accelerating its spread. There are multiple applications showing near replacement potential for many chest x-ray and some CT indications. This is a point-of-care test performed rapidly and accurately that saves time and cuts down on radiation exposure. Even if reimbursement ebbs in the near future, there is considerable financial and risk management justification for lung ultrasound use. Third, the role of lung ultrasound in emergency practice is being better defined as we speak. It has applications from the mildly to the critically ill patient and even makes sense in the pre-hospital setting. The pediatric emergency literature is growing with evidence of ultrasound accuracy in identifying and ruling out pneumonia and this is a population especially vulnerable to ionizing radiation. In time, it may be standard to do a point-of-care lung ultrasound examination in pediatric patient in whom you are suspicious of pneumonia. In fact, while we are talking about pneumonia and ultrasound, it is becoming ever clearer that chest x-rays miss a lot of pneumonias. Not just the early ones, but also in the patients that are potentially critically ill and are dehydrated enough that the chest x-ray misses the tri-lobe pneumonia until the next day. There are one or two obvious directions to go to with pneumonia to improve diagnostic imaging accuracy, CT all patients with possible pneumonia (crazy and expensive at best) or consider ultrasound given its apparent superiority in sensitivity and specificity for pneumonia detection when compared to chest x-ray.
Nerve blocks have a special utility for us. Almost everyone in EM has been affected by the insane conscious sedation requirements. (I was recently told giving a patient 25 mg of diphenhydramine to calm a patient in MRI was conscious sedation, and I lost a nurse for 45 minutes to monitor for the deadly effects of this dreaded ultra-potent barbiturate.) At the same time, there is a recent paucity of patients tough enough to let you reduce a joint, fracture or perform an extensive extremity repair without conscious sedation. This means we are tying up nurses and rooms for extra hours and driving staff crazy with additional paperwork and hoops to jump through. There is a great way to avoid a large portion of such incidences - regional nerve blocks. It is true no one is really excited about doing them blindly like our brave anesthesia colleagues have done for years using only an electrical nerve stimulating device as a guide. However, under ultrasound most nerve blocks are a breeze! Common ones that are useful in the EM setting include interscalene, supraclavicular, axillary, femoral, popliteal and sciatic nerve blocks. Obviously most distal and focused versions of the extremity blocks can be quite helpful as well. The potential for good future applications include abdominal wall blocks (for post op pain) and epidurals. I do think these last two will take some time. In my setting I am effectively in competition with other physicians and the clock for patients and there is never enough space. When I can get a patient blocked and reduced with effectively no nursing involvement my troops keep moving and doing work and are not bogged down. When I have to do a conscious sedation everything stops. This is especially evident when you are not working with residents and also to some degree with mid-levels (who typically cannot push sedation medications). In the trenches, this all means higher productivity at the end of the day. Not to mention, right now, about two trees worth less paperwork.
Answer #2: The key, big, remaining question we have not quite answered to the critics’ satisfaction is the effect of ultrasound on patient outcome and costs. Think about it, why has everyone not jumped on the bandwagon? Yes, there are dinosaurs out there that have not realized a large rock has hit the Yucatan Peninsula, a lot of small fury mammals are running around everywhere, and things are changing in a big way, but this is nothing new. There is still not enough proof for power brokers such as the government and hospital CEOs to force the non-adopters to use ultrasound. Relatively convincing proof that ultrasound makes an impact for the individual patient, for the physician, the ED, the hospital and society would clinch it in our favor. Every level must be shown to benefit and save. Thus, the individual’s outcome is improved, lives are saved and morbidity cut down, the ED functions more efficiently with throughput time decreased and money is made. The hospital must save money, see decreased liability and improved patient satisfaction. Society must see benefit by lives saved per capita and money saved. Such proof will immunize us against waning reimbursement for point-of-care ultrasound studies that is likely to come. Justification for machine purchase and ultrasound use will depend less and less of making money from billing. Studies like this, which prove the multi-level benefit of point-of-care ultrasound are really the zenith of research over the next 5 to 7 years and would change practice the most.
Technical Updates - Emergency Ultrasound Section Newsletter, August 2011
Mark Byrne, MD
Emergency Ultrasound Fellow
Brigham & Women’s Hospital
How to intelligently streamline your credentialing, billing, and quality assurance
Anyone who has embarked on the endeavor of running a busy emergency ultrasound program understands the time and effort involved. A significant portion of this may be spent on activities such as image review and quality assurance (QA) as well as maintaining a database of ultrasound scans for credentialing and archiving purposes. Not long ago, many emergency ultrasound programs relied upon thermal prints for image archiving. Even now, with most programs shifting to digital images, paper worksheets are still frequently used for clinician interpretations and reviewer QA, which subsequently may need to be manually entered into a separate electronic database. Extensive amounts of paperwork can quickly accumulate and redundancy in tasks required to maintain a scan database results in inefficiency and wasted time.
Fortunately, companies have recognized the need for more sophisticated and elegant workflow solutions to streamline the image archiving, QA review, and credentialing processes. Automating tasks such as image transfer directly from the ultrasound machine wirelessly to a central server and maintaining a single database to collect scan images, clinician interpretations, reviewer over-reads, and physician scan numbers offers the potential for tremendous time savings. Most workflow solutions include the capabilities to generate automated QA emails to residents and staff, export scan interpretations into the electronic medical record, and generate customized billing reports. Several companies even offer the possibility for clinicians to enter scan interpretations directly into ultrasound machines at the point-of-care.
The following is a brief overview of several of the most prominent workflow solutions currently tailored for the emergency ultrasound environment.
Sonosite Workflow Solutions
(Click here for the vendor website)
(Click here for a video demonstration)
As one of the most popular ultrasound machine manufacturers in the emergency department setting, Sonosite offers the Sonosite Workflow Solutions (SWS) to address many of the issues described above. Some key features include: capability for wireless transfer of images from your ultrasound machine to the server; create customizable, exam-specific worksheets for image interpretation; generate reports for email, billing, and HL7 (Health Level 7) communication with the electronic medical record (EMR); and exporting of physician scan numbers and statistics into Excel spreadsheets. Sonosite Workflow Solutions supports Sonosite M-Turbo, S Series, MicroMaxx, and NanoMaxx ultrasound systems and is compatible with both PC and Mac computers.
SonixHUB from Ultrasonix
(Click here for the vendor website)
(Click here for a video demonstration)
Another manufacturer specifically marketed at emergency medicine and other point-of-care ultrasound providers, Ultrasonix offers SonixHUB as its integrated workflow solution. While it shares many of the same functions with SWS in terms of credentialing, billing, and QA, several unique features of SonixHUB include: electronic worksheets that can be filled out at the point-of-care using Ultrasonix machine touchscreens; educational scans can be separated from clinical scans within the exam database; exams of interest can be tagged for compiling a teaching library; and patient identity information can be removed when exporting scan images and clips. SonixHUB supports all Sonix series products and can be accessed anywhere using a standard web browser and internet connection.
Q-path from Telexy Healthcare
(Click here for the vendor website)
(Click here for a video demonstration)
While not directly affiliated with any ultrasound machine manufacturer, Q-path nonetheless is designed specifically for the point-of-care ultrasound market. Q-path incorporates most of the features already discussed, including: wired or wireless transfer of images; user customizable exam worksheets; electronic worksheet integration (currently only available on Zonare ultrasound machines); separate educational from billable exams; generate reports for QA emails, billing, and transfer to the LMR; track physician scan number statistics; tag exams of interest for a teaching library; and single step export of all images and clips from an exam, with masks to automate elimination of patient-specific identifiers. Q-path supports DICOM (Digital Imaging and Communications in Medicine) enabled ultrasound systems from multiple manufacturers. It is a web-based application that can be accessed from any internet connection.
UltraLinq Healthcare Solutions
(Click here for the vendor website)
(Click here for a video demonstration)
UltraLinq is directed towards a more general ultrasound market, from emergency departments to vascular labs to echocardiography suites. It provides many important features required of a work flow solution, including: creation of pre-populated exam worksheets for scan interpretation; completed reports can be emailed to designated recipients or sent to the EMR via HL7 transfer; and tracking of physician scans within the database for credentialing purposes. One unique feature of UltraLinq is the ability to access the image database via an app available on iOS devices. UltraLinq, an FDA 510(k)-approved system for viewing medical images, is entirely web-based and can be accessed anywhere there is an internet connection.
New York City-Wide Grand Rounds - Emergency Ultrasound Section Newsletter, August 2011
St. Luke’s - Roosevelt Hospital Center Ultrasound Division
Katja Goldflam, MD
On March 9th, St. Luke’s - Roosevelt Hospital Center’s Ultrasound Division hosted its third City-wide Grand Rounds of the academic year. The focus of discussion, facilitated by Dr. Jacob Goertz, Emergency Ultrasound director at Long Island Jewish Medical Center, was “Interacting with Other Services that Perform Ultrasound”. Participating programs included North Shore Medical Center, Metropolitan Hospital Center, Long Island Jewish Hospital, University of New England, NYU Medical Center/Bellevue Hospital, Newark Beth Israel Medical Center and Mount Sinai Medical Center.
The evening began with a brief didactic lecture introducing the complexities of interacting with other specialties that provide ultrasound services to patients, including e.g. radiology and cardiology. The point was made that the American Medical Association acknowledges that ultrasound is within the scope of any “appropriately trained physician.” Ample literature now exists to demonstrate that emergency physicians are capable of performing and interpreting various point-of-care ultrasound scans. Furthermore, a recent joint consensus statement between ACEP and the American Society of Echocardiography shows that acceptance of this is starting to mount in other specialties.
Other points of the discussion revolved around anecdotes illustrating similar battles fought in multiple institutions and how respect on a personal level through consistency in scan interpretation can aid in acceptance by other services. Participants also debated the utility of uploading point-of-care imaging onto the hospital PACS system. While making images available to other services opens up the opportunity for critique of scan quality, it does provide access to those scans performed in the emergency department. The importance of terminology was also emphasized, e.g. calling scans performed by radiologists “official” may delegitimize those performed by emergency physicians, while terms such as “focused” or “limited” vs. “complete” or “comprehensive” might be more accurate.
The discussion concluded with agreement amidst the participants that while interactions with other services might not always be smooth, being an advocate for the patient remains our primary responsibility.
Journal Watch - Emergency Ultrasound Section Newsletter, August 2011
Article: Ahern M, Mallin MP, Weitzel S, Madsen T, Hunt P. Variability in ultrasound education among emergency medicine residencies.West J Emerg Med. 2010;11(4):314-318.
Reviewer: Seth Oskie, MD, Emergency Ultrasound Fellow, Harbor-UCLA Medical Center
Objective: To evaluate current ultrasound education practices among Emergency Medicine programs and assess the need for further formalization in training.
Methods: This observational study used an online survey consisting of 25 questions regarding residency programs’ Emergency Ultrasound (EUS) requirements, curriculum structure, number of faculty credentialed to perform ultrasound in the ED, method of quality assurance, and overall perceptions of the curriculum. A link to the survey was emailed to program and ultrasound directors at all 149 American College of Graduate Medical Education Emergency Medicine residency programs. Data was anonymous and analyzed using descriptive statistics.
Results: A total of 65 out of the 149 (44%) contacted ACGME Emergency Medicine residencies responded to the survey. A disproportionate number of programs responding, 26/65 (40%), offered an ultrasound fellowship. The average number of ultrasound exams required by programs for resident emergency ultrasound competency was 137 scans. Most programs, 42/65 (67%), required greater than 150 scans and 9/65 (13.8%) required greater than 200 scans. The requirement ranged between 25 and 300 scans. However, four programs had no specified number of scans for competency. Most of the reporting programs, 51/64 (79%), had a structured ultrasound curriculum. The rest of the programs indicated that training was primarily resident directed. A formal ultrasound rotation was offered at 62/65 (95%) of residencies and required by 44/65 (72%) of these programs.
The majority of programs (80%) had a lecture-based component of their ultrasound education curriculum and 36% of reporting residencies use some form of online education. Fifteen programs responded to indicate that residents received an average of 34 hours of ultrasound-specific lectures during their training. Of the 15 programs that reported faculty involvement in ultrasound education, residents received an average of 46 hours of dedicated hands-on ultrasound training with faculty at patient bedside. The data indicates 29/62 (47%) of residency programs have greater than 50% of faculty credentialed to provide ultrasound in the emergency department. Furthermore, 62/64 (96%) of credentialed faculty reported using ultrasound in patient care decisions on a regular basis. A majority of programs, 47/64 (73%), indicated little or no perceived institutional opposition to training residents in emergency ultrasound. Over half, 34/63 (54%), of programs reported meeting all of their goals for resident Emergency Ultrasound education. Only 5/63 (7.9%) reported not meeting their ultrasound program goals. The authors observed a trend toward residency programs covering more advanced applications beyond those initially identified by ACEP as core modalities.
Discussion: The investigators point out that although the majority (64%) of programs report competency requirements that exceed the ACEP recommended minimum of 150 scans, the data average of 137 is bellow this standard for proficiency and does not account for the effect of observer bias, which they suggest likely inflated the data average. It is unclear whether the number of ultrasound exams documented in residency or the amount of hours dedicated to training correlate with competency. Standardized competency testing has been proposed to address the apparent variability in ultrasound education reported by emergency medicine residency programs.
Article: Jorgenson H, Jensen C, Dirks J. Does prehospital ultrasound improve treatment of the trauma patient? A systematic review. Eur J Emerg Med. 2010;17(5):249-253.
Reviewer: Aliasgher Hussain, MD, Emergency Ultrasound Fellow, Harbor-UCLA Medical Center
Objective: The objective of this study is to systematically search the literature to determine if prehospital US of the thorax and abdomen increases survival of trauma patients.
Methods: A Medline and EMBASE search was done by the three authors to identify relevant studies. A relevant study was either a randomized trial in which prehospital US is compared with no US in trauma patients or descriptive studies or case reports on US performed in the prehospital setting. Outcome measures assessed included whether prehospital US is feasible, increases survival, alters time to hospital, changes primary diagnosis, changes therapy, or influences choice of receiving hospital. All three review authors independently assessed the methodological quality of the reports. The review authors were not blinded to study authors, institution, or journal when performing quality assessment. The three authors decided, in full agreement, which studies to exclude.
Results: 24 articles were identified, of which 14 were included in the study. There were no prospective RCTs identified. All studies included patients undergoing prehospital US in broad terms and included FAST exams, invasive procedures (pericardiocentesis) or US-guided access to large central veins. Pooled together, 885 patients were included. All studies show that US is feasible. Some of these studies intersect and show that US leads to early diagnosis, potential change of admittance and a time delay of 0-6 min.
Discussion: The authors conclude that because of the heterogeneity of the studies, a comparison was not done and that it is not possible to answer the objective question. They do state that the data may indicate that prehospital management is altered by the use of US in respect to early and precise diagnosis, treatment, and visitation. The limitation of the study is that no comparison was done and the study question was unable to be answered, which the authors do address in their discussion.
Article: Markowitz JE, Hwang JQ, Moore CL. Development and validation of a web-based assessment tool for the extended focused assessment with sonography in trauma examination.J Ultrasound Med. 2011;30(3):371-375.
Reviewers: Sam Hsu, MD, RDMS, Assistant Professor, and Sarah Sommerkamp, MD, Emergency Ultrasound Fellow, Department of Emergency Medicine, University of Maryland School of Medicine
Objectives: The eFAST exam is widely used in EDs and trauma centers. ACEP guidelines recommend 25-50 FAST studies for competency; however, recently the ACGME removed the number of exams from residency requirements in favor of a subjective measure of competency. The study’s primary goal was to develop and validate a web-based multiple-choice test that could be used to assess competency of practitioners of the eFAST examination.
Methods: The researchers and experts developed a 41-question multiple-choice test that included still images and video clips as well as vignettes based on NBME standards. Questions evaluated image interpretation and management decisions. The pass rate was set at 70%. The residents and fellows at the study institutions were asked to participate on a voluntary basis. Test results were correlated to level of training, number of eFAST exams performed, and total number of ultrasound scans performed.
Results: There were 66 participants: 64 residents and 2 fellows. Passing scores were achieved by post-graduate year (PGY) 4 residents (mean score 73.2%), fellows (mean score 86.6%), and those who met the ACEP criteria of having completed an ultrasound course and performed >25 eFAST exams (mean score 70.4%). Passing scores were not achieved until >75 eFAST exams when those who had not completed an ultrasound course were included. Scores were better between PGY1 and PGY2 who completed an ultrasound course (63.4%) vs. those who had not (44%), although neither group achieved a passing score.
Discussion: The number of scans performed is an inexact measure of competency in point-of-care ultrasound. Since the ACGME removed numerical goals for proficiency in ultrasound, new measures must be developed. This study describes a measure using a web-based exam. The results are unsurprising; more didactic training and more scanning lead to higher exam scores. But as the authors acknowledge, the exam does not assess the ability to perform ultrasound exams, so a high score on a written exam does not ensure competency in point-of-care ultrasound. Competency is a combination of the technical skill needed to acquire images and the knowledge base needed to interpret and integrate point-of-care ultrasound into daily practice. The exam described in this study, if externally validated, would be a useful tool for assessing the knowledge component of competency, but no written exam should be used as the sole measure of competency. Bedside assessment of resident and fellow skill remains an important, and by nature subjective, component of competency.
Article: Pacharn P, Ying J, Linam L, et al. Sonography in the evaluation of acute appendicitis: are negative sonographic findings good enough? J Ultrasound Med. 2010;29(12):1749-1755.
Reviewer: Jehangir Meer, MD, Director of Emergency Ultrasound, Saint Agnes Hospital
Objective: The objective of this study was to determine the accuracy of a negative radiological ultrasound on patients referred to a pediatric tertiary hospital for ruling out appendicitis.
Methods: This was a retrospective electronic medical record search at a large children’s hospital in Bangkok, Thailand, looking at patients referred for RLQ sonography to rule out appendicitis between August 2006 and July 2007. Two pediatric radiologists retrospectively reviewed ultrasound exams with images and cine clips. Scans were rated on a 5-point scale, ranging from identification of a normal appendix (score of 1) to obvious appendicitis with enlarged non-compressible appendix with outer diameter greater than 6 mm (score of 5); intermediate scores for appendix not seen, but no inflammatory changes (score of 2); appendix not seen, but inflammatory signs like fecalith, pericecal fluid, or echogenicity (score of 3); and appendix of borderline enlarged diameter 4-5 mm (score of 4). Scores of 4 or 5 were considered consistent with acute appendicitis in this study. Ultrasound findings were compared with subsequent CT, surgical/pathologic findings, or clinical follow-up. Additional tests and surgery were at the discretion of the treating clinicians.
Results: Thirty-seven patients were excluded from the study due to incomplete follow-up information. A hundred and ninety three patients were included in the study and had sonograms done, with ages ranging from 3 to 20 years. Sonography was positive in 49 patients. CT scan was performed in 51 patients; of whom 3 patients with a negative sonogram had positive CT for appendicitis. Forty-three patients were taken to the OR; of which 37 had surgical findings of acute appendicitis. Seven of the patients with acute appendicitis found on surgical pathology had negative sonography, resulting in a sensitivity of 81%, specificity of 87%, PPV 61%, and NPV of 95%.
Discussion: The authors concluded that sonography is a sensitive screening test to exclude acute appendicitis due to NPV of 95%. There are several limitations to the study however. This was a non-randomized retrospective study, so some referral bias was likely inherent (for example, some patients with acute appendicitis probably went directly to OR without imaging). The NPV of 95% was quite good in this study, owing to the fact that the sonograms were read by 2 pediatric radiologists (one of which had extra training in ultrasound) and the sonographers were at a large pediatric center. The results likely would not be as favorable, and may not be applicable to, a typical community ED seeing adults and children.
Case Report #1: Right lower quadrant pain in a 9-year old female - Emergency Ultrasound Section Newsletter, August 2011
Russ Horowitz, MD
Emergency Ultrasound Fellow
Cook County Hospital
John Bailitz, MD, RDMS
Emergency Ultrasound Director
Cook County Hospital
Chief Complaint: Right lower quadrant pain in a 9-year old female.
Figure 1: RLQ Short View Figure 2: RLQ Short Compressed View
Figure 3: RLQ Long View Figure 4: RLQ Color Flow View
What are the structures shown?
Describe the pathology and common ultrasound findings?
What is the current role of ultrasound in the emergency department management?
A 9-year old obese Hispanic female presented to the pediatric emergency department with two days of progressive right lower quadrant abdominal pain and fever. The physical exam was significant for a low grade fever, significant focal tenderness in the right lower quadrant, and a positive psoas sign. After an initial examination and a mildly elevated white blood cell count, surgery requested a CT scan to confirm the suspected diagnosis. While awaiting CT, bedside ultrasound was performed by the Emergency Ultrasound fellow.
Beginning over the lateral right lower quadrant, graded compression was applied to displace bowel gas and visualize the iliac vessels overlying the pelvic iliopsoas musculature. The probe was then gradually moved toward the umbilicus and over the identified point of maximum tenderness. A 1.2 cm non-compressible tubular structure was visualized overlying the iliopsoas muscle. On close inspection, hyperechoic material with shadowing was visualized in the distal portion. No peristalsis or significant color flow was detected in either axis. Upon review and discussion of the ultrasound images, the surgical team took the patient to the operating for an exploratory laparoscopy that revealed a gangrenous appendix removed just prior to rupture.
Role of Emergency Ultrasound
The role of ultrasound for the diagnosis of appendicitis remains controversial in the medical literature. Since 1986, studies have reported sensitivities from 44-100% and specificities of 88-100%.1 In trained hands, ultrasound helps to confirm the diagnosis of appendicitis potentially avoiding unnecessary CT scanning.2 Several sonographic findings support the diagnosis of appendicitis. In uncomplicated appendicitis, the classic target or bull’s eye appearance is created by the anechoic fluid filled lumen, hyperechoic mucosa and submucosa, and outer ring of hypoechoic muscularis externa. However, this finding is lost with perforation or mucosal necrosis with gangrenous appendicitis.345 Additional findings include a diameter > 6mm, the lack of normal bowel compressibility and peristalsis, as well as increased color flow. A ring of fire, increased vascularity on color flow imaging, may surround the inflamed appendix.6 However, color flow may again be absent in cases of gangrenous appendicitis.7 The variability of these findings as well as an initial retrospective review demonstrating a sensitivity of 39% and specificity of 90% when performed by emergency physicians illustrate the need to for refined protocols and prospective studies.6
Answers to Questions
Figures 1 and 2 of the right lower quadrant demonstrate an anechoic non-compressible structure (arrowhead) overlying the pelvic iliopsoas musculature (red circle). When rotating the probe into a nearly longitudinal plane (Figure 3) a 6 x 1.2 cm tubular structure with a presumed fecalith (arrow in shadow) is visualized. Figure 4 demonstrates an absence of color flow supporting the confirmed diagnosis of gangrenous appendicitis.
Take Home Points
- Although not sufficiently sensitive to exclude the diagnosis, ultrasound in experienced hands may help confirm the diagnosis of appendicitis.
- Common sonographic findings of early appendicitis, such as the target sign and increased color Doppler, are no longer present in perforated or gangrenous appendicitis.
- Puylaert JB. Acute appendicitis: US evaluation using graded compression. Radiology. 1986;158(2):355-360.
- Krishnamoorthi R, Ramarajan N, Wang NE, et al. Effectiveness of a staged US and CT protocol for the diagnosis of pediatric appendicitis: reducing radiation exposure in the age of ALARA. Radiology. 2011;259(1):231-239.
- Kaneko K, Tsuda M. Ultrasound-based decision making in the treatment of acute appendicitis in children. J Pediatr Surg. 2004;39(9):1316-1320.
- Abu-Yousef M, Bleicher J, Maher J, et al. High-resolution sonography of acute appendicitis. AJR Am J Roentgenol. 1987;149(1):53-58.
- Jeffrey RB, Jain KA, Nghiem HV. Sonographic diagnosis of acute appendicitis: interpretive pitfalls. AJR Am J Roentgenol. 1994;162(1):55-59.
- Fox JC, Hunt MJ, Zlidenny AM, et al. Retrospective analysis of emergency department ultrasound for acute appendicitis. Cal J Emerg Med. 2007;8(2):41-45.
- Birnbaum BA, Wilson SR. Appendicitis at the Millennium. Radiology. 2000;215(2):337 -348.
Case Report #2: Septic ICU Patient - Emergency Ultrasound Section Newsletter, August 2011
Paul Decker, MD
Emergency Medicine Resident
Cook County Hospital
John Bailitz, MD, RDMS
Emergency Ultrasound Director
Cook County Hospital
Chief Complaint: Evaluate for hydronephrosis in a septic ICU patient thirty minutes post “uncomplicated” subclavian line placement.
Figure 1: Left Thorax M Mode Figure 2: Left Thorax Power Doppler
Figure 3: Right Thorax M Mode Figure 4: Right Thorax Power Doppler
Figure 5: Initial Post Procedural Chest Radiograph
Figure 6: Close Up of Repeat CXR following the Bedside US
What is the anatomy shown?
What is the pathology?
How accurate is ultrasound versus traditional evaluation for this condition?
During a recent Critical Care Bedside Ultrasound rounds, our team of Emergency Medicine Ultrasound fellow instructors and critical care staff were asked to evaluate a 56-year-old altered septic patient with a history of cervical cancer for hydronephrosis secondary to ureteral obstruction. Since admission the patient was noted to be febrile and tachycardic, but was now increasingly tachypneic and grabbing at her oxygen mask. A right subclavian line had been placed thirty minutes prior to our evaluation. However, the Initial Post Procedural Chest Radiograph above (Figure 5) was reviewed by an attending radiologist who reported that the “line is in good position without evidence of pneumothorax or other cardiopulmonary disease.”
Role of Bedside Ultrasound
Bedside renal ultrasound was normal, but thoracic sonography (Figures 1-4) quickly confirmed our suspected diagnosis of a right-sided pneumothorax. A repeat CXR (Figure 6) ordered by the critical care staff to confirm our US findings prior to chest tube placement now demonstrated a 2 cm pneumothorax from the right apex to the lung base. A rush of air with tube placement and improvement in the patient’s air hunger further confirmed our team’s US findings.
In busy critical care environments, radiographs may not always be readily available to evaluate for disease or rule out post procedural complications. As this case illustrates, even when available portable chest radiographs may not be sufficiently accurate to exclude a clinically significant pneumothorax. Interest in critical care beside ultrasound has rapidly increased over the past few years creating another potential for Intensivists and Emergency Physicians to collaboratively improve patient care.1
Answers to Questions
The very top of Figure 1, Left Thorax M Mode, is a sagittal view of the normal left thorax demonstrating the bat wing sign of normal thoracic sonographic anatomy. Shadows from rib cross sections are seen on both the left and right side of the image. The pleural line is seen as a horizontal echogenic line immediately inferior to the ribs. M Mode displayed in the bottom demonstrates normal “seashore sign” with straight lines from the relatively fixed chest wall above a “grainy beach” resulting from movement at the interface of the normally closely apposed visceral and parietal pleura. The presence of lung sliding visualized on B mode, color and power Doppler, or M Mode is 100% sensitive in excluding a pneumothorax in the interspace visualized. Figure 2, Left Thorax Power Doppler image, demonstrates the power slide sign of normal pleural movement. Power Doppler is more sensitive than color flow for detecting motion, but does not provide the directional information of color Doppler imaging.2
In contrast, the M Mode in the bottom of the image, Figure 3 - Right Thorax M Mode, demonstrates the stratosphere sign created by the absence of normal movement at the pleural line. Although, an A line represents a normal horizontal reverberation artifact from the parietal pleura, Lichtenstein reported that an A line visualized in the absence of lung sliding (Figure 4) is 95% sensitive and 94% specific for diagnosing an occult pneumothorax in critically ill patients in comparison to CT. Lichtenstein further noted that the visualization of a lung point, where normally apposed pleura is seen at the lateral portion of a pneumothorax, is only 79% sensitive, but 100% specific for the diagnosis3. Likewise, in ED patients with a traumatic pneumothorax, Blaivas reported a sensitivity and specificity of 76% and 100% for CXR and 98% and 99% for US in detecting in comparison to CT4
Take Home Points
- Bedside US is more sensitive than portable CXR in excluding pneumothorax in critically ill patient in both the ED and ICU.
- For the diagnosis of pneumothorax:
- Normal lung sliding rules out a pneumothorax in the interspace being imaged.
- Absent lung slide and the presence of A lines helps confirm a pneumothorax.
- The presence of a lung point rules in a pneumothorax.
- Regularly scheduled multidiscipline educational rounds have the potential to improve patient care, physician training, and collaboration between specialties now utilizing bedside ultrasound.
- Mayo PH, Beaulieu Y, Doelken P, et al. American College of Chest Physicians/La Société de Réanimation de Langue Française statement on competence in critical care ultrasonography. Chest. 2009;135(4):1050-1060.
- Ma, Mateer OJ. Emergency Ultrasound. Second Edition. McGraw Hill; 2008.
- Lichtenstein DA, Mezière G, Lascols N, et al. Ultrasound diagnosis of occult pneumothorax. Crit. Care Med. 2005;33(6):1231-1238.
- Blaivas M, Lyon M, Duggal S. A prospective comparison of supine chest radiography and bedside ultrasound for the diagnosis of traumatic pneumothorax. Acad Emerg Med. 2005;12(9):844-849.