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Emergency Ultrasound Section Newsletter - August 2012

circle_arrowAnnouncements - Emergency Ultrasound Section Newsletter, August 2012
circle_arrowUpdates from the Chair - Emergency Ultrasound Section Newsletter, August 2012
circle_arrowCase Report: FAST Detection of a Rare Colonoscopy Complication - Emergency Ultrasound Section Newsletter, August 2012
circle_arrowPediatric Ultrasound: Do you have the Heart? - Emergency Ultrasound Section Newsletter, August 2012
circle_arrowTips and Tricks: Ultrasound Guided Regional Anesthesia - Emergency Ultrasound Section Newsletter, August 2012
circle_arrowJournal Watch - Emergency Ultrasound Section Newsletter, August 2012
circle_arrowACEP EUS Listserve Summary - Emergency Ultrasound Section Newsletter, August 2012
circle_arrowAsk the Expert: One More Year? The Real Value of Ultrasound Fellowship Training - Emergency Ultrasound Section Newsletter, August 2012

Announcements - Emergency Ultrasound Section Newsletter, August 2012

  • ACEP Emergency Ultrasound Section Meeting at the Scientific Assembly in Denver is scheduled for Tuesday, October 9th, 1-4 PM. Annual awards and section business will be followed by breakout sessions focusing on Image Archival and Workflow Solutions, Troubleshooting EUS Program Obstacles, Designing EUS Research, Ultrasound Fellowships, and Resident Education.
  • Available spots for the ACEP Emergency Ultrasound Management Course and Ultrasound Workshops are filling up fast. Register today at https://www.acep.org/sa/

 

The ACEP Emergency Ultrasound Section strongly endorses the candidacy of Dr. Alex. M. Rosenau for the office of ACEP President-Elect. 

Dr. Rosenau tirelessly supports the section in its myriad of EUS issues (eg, accreditation, fellowship, training, and policy development). He is consistently available to provide guidance and always responds to section leaders in a timely manner. Dr. Rosenau was instrumental in furthering the section's relationship with AIUM. We believe that Dr. Rosenau's administrative, clinical practice, academic, and leadership experience has produced a well-rounded candidate capable of understanding the needs of the College. 

Michael Stone, MD
Chair, Emergency Ultrasound Section


Updates from the Chair - Emergency Ultrasound Section Newsletter, August 2012

Michael Stone, MD, RDMS

Section Members -

I hope that everyone's enjoying their summer and that you're making plans to attend Scientific Assembly in Denver this October 8-11 (https://www.acep.org/sa/). I wanted to take this opportunity to update you on the ACEP Ultrasound Section's activities, and encourage you to attend the ACEP Emergency Ultrasound Section annual meeting on October 9th from 1pm-4pm during Scientific Assembly in Denver. Here's a look at some of our current projects, activities, and achievements:

  • As of June our Section grew to over 1,000 members! This is a great testament to the commitment and dedication of our membership, and the importance of the work we all do.
  •  
  • The ACEP ultrasound website at www.acep.org/ultrasound continues to evolve and improve. We listened to your feedback about private and public sections of the site and changes have been made. The "Policy Statements" and "Education and Training" sections are now completely open to the public, and the private areas have a more streamlined login process. Keep an eye out for continued improvements and a formal update on the completed redesign and functionality at Scientific Assembly.
  •  
  • Thanks to the SAEM Academy of Emergency Ultrasound for collaborating with our Section and obtaining approval of the ACEP EUS Fellowship guidelines from the SAEM Board of Directors! These guidelines will continue to serve as the basis for ensuring a quality educational experience for Emergency Ultrasound Fellowships.
  •  
  • Congratulations to Jim Tsung, MD and his co-applicants for being awarded a Section Grant for "Creation of an Educational Ultrasound Guide for Pediatric emergency Medicine Practitioner." This was a joint Section grant with the Pediatric Emergency Medicine Section and we look forward to seeing the final product!
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  • The online ACEP ultrasound exam (http://www.emsono.com/acep) is being updated and revised and will have some great new features. More on this at Scientific Assembly!
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  • More details of the Emergency Medicine Foundation/Mindray Ultrasound Grant for $20,000 should be coming soon, so get your research ideas ready for a summer 2013 funding cycle!

The Section continues its work on subspecialty development, quality assurance and educational resources for practitioners of all levels. There are many active subcommittees and we can always use more participation: please contact me with any suggestions, feedback or interest in becoming more involved with the Section's efforts. Thanks and have a great and productive remainder of 2012!

 


Case Report: FAST Detection of a Rare Colonoscopy Complication - Emergency Ultrasound Section Newsletter, August 2012

By Ian Medoro, MD; Christian Molstrom, MD; and Meghan Herbst, MD

Chief Complaint: Abdominal pain and syncope. 

Questions:

1. What anatomy and pathology are shown in the images below?

2. What are the indications for the FAST exam?

3. How does this injury occur in the setting of colonoscopy? 

      Image One - Click for Video]    Image Two - Click for Video]
   casereportimage1august   image2august

Case presentation:

An 84-year-old female presented with abdominal pain and hypotension one day following colonoscopy. Shortly following the procedure she complained of diffuse abdominal pain. Over the course of the evening she developed bloating and distension despite her continued ability to eat. She denied nausea or vomiting, and had passed gas but no stool. The pain was constant and without any aggravating or alleviating factors. Prior to arrival, the family reported that when the patient attempted to stand, she fainted. She denied fever, chills, bleeding, dysuria, chest pain or any focal neurological abnormality. On arrival to the ED she was alert with a blood pressure of 84/45. Her abdomen was distended with diffuse tenderness to palpation. 

Bedside ultrasound demonstrated free fluid in the right upper quadrant, which was highly suspicious for blood originating from a peritoneal source. The patient was resuscitated with IV fluids and blood products. The surgical service was emergently consulted. CT of the abdomen revealed a 9 cm x 5 cm subcapsular splenic hematoma. The patient was admitted to the ICU for observation and discharged without surgical intervention. 

The Role of Emergency Ultrasound in the Hypotensive Patient:

In the setting of hypotension, bedside ultrasound of the heart and abdomen allows direct visualization of pathology and differentiates different shock states. Hemoperitoneum is best evaluated with the FAST exam, which is a simple and validated study that can be performed in under four minutes.[1] The FAST exam traditionally includes four windows: right flank (Morison's Pouch), left flank (perisplenic space), subxyphoid (heart), and suprapubic region (Pouch of Douglas). The overall sensitivity and specificity of the FAST exam for intraperitoneal fluid collections have been reported as 79% and 99% respectively.[2] Morison's pouch and the pouch of Douglas are the most sensitive of these views.[3,4] In this case, the patient presented with both unexplained hypotension and undifferentiated abdominal pain, which the ED team quickly diagnosed as abdominal bleeding with the help of bedside ultrasound. While utility of bedside ultrasound for detecting free fluid is well established, the accuracy for detecting solid-organ injuries is not established. In one study the overall sensitivity of ultrasound for any splenic injury was 69% but rose to 86% for grade III or higher injuries.[5]

Answers to Questions:

1. In the first image, there is significant free fluid present in Morison's pouch. The liver has a smooth border, making ascites less likely, especially without a history of liver disease. The liver and right kidney make up the borders for Morison's pouch. In the second image, there are heterogenous echoes consistent with clotted blood in the perisplenic region. The kidney is seen inferiorly in this coronal view.

2. Indications for the FAST exam are abdominal trauma, undifferentiated abdominal pain, and unexplained hypotension. The exam has been incorporated into many trauma protocols. In the unstable trauma patient, the FAST carries high specificity for intraperitoneal fluid and can obviate the need for CT.

3. Splenic injury due to colonoscopy (SIDC) is a rare but serious complication of colonoscopy. Injury is thought to occur from traction placed on the splenic capsule via the splenocolic ligament during instrumentation. The largest review of SIDC found a total of fifty-nine reports published since 1974. [6] In contrast to most traumatic splenic injuries, patients with SIDC have delayed presentations, although symptom onset is typically within 24 hours of the procedure.[6,7] Often, early recognition leads to successful outcomes,[7] and as in this case, bedside ultrasound may be a helpful noninvasive tool in diagnosing this entity.

Take Home Points:

  1. Ultrasound should be used as an adjunct for assessing patients with undifferentiated abdominal pain and/or hypotension.
  2. Of the four FAST views, free fluid tends to settle more commonly in Morison's pouch and/or in the pouch of Douglas.
  3. Consider splenic injury in patients with hypotension or pain after colonoscopy.

References:

  1. Ma OJ, Mateer JR, Ogata M, et al. Prospective analysis of a rapid trauma ultrasound examination performed by emergency physicians. J Trauma. 1995;38:879.
  2. Jehle D, Stiller G, Wagner D. Sensitivity in detecting free intraperitoneal fluid with the pelvic views of the FAST exam. Am J Emerg Med. 2003;21(6):476-478.
  3. Jehle D, Abrams B, Sukumvanich P, et al. Ultrasound for the detection of intraperitoneal fluid: the role of Trendelenburg positioning. Acad Emerg Med. 1995;2:407.
  4. Branney SW, Wolfe RE, Moore EE, et al. Quantitative sensitivity of ultrasound in detecting free intraperitoneal fluid. J Trauma. 1995;39:375-380.
  5. Richards JR, McGahan JP, Jones CD, et al. Ultrasound detection of blunt splenic injury. Injury. 2001;32(2):95-103.
  6. Michetti CP, Smeltzer E, Fakhry SM. Splenic injury due to colonoscopy: analysis of the world literature, a new case report, and recommendations for management. Am Surg. 2010; 76(11): 1199-1204.
  7. Lalor PF, Mann BD. Splenic rupture after colonoscopy. JSLS. 2007; 11(1): 151-156.


Pediatric Ultrasound: Do you have the Heart? - Emergency Ultrasound Section Newsletter, August 2012

By Russ Horowitz, MD and Samuel Lam, MD, FACEP

Our second article in the pediatric ultrasound series aims to shine some light on bedside echocardiography in children. The standard questions that a focused ED echo addresses are the same in children and adults but the diseases and conditions for which pediatric echo are utilized are dramatically different. The common adult cardiac complaints of crushing midsternal chest pain and progressive shortness of breath with a history of congestive heart failure are unusual in pediatrics. 

Pediatric echo is most often indicated in crashing children and those with unexplained tachycardia, syncope, and respiratory distress unresponsive to bronchodilators. Bedside echo is not intended to diagnose congenital heart disease or rule it out. These lesions are very difficult to visualize in the ED setting. 

A neonate with altered mental status and respiratory distress may suffer from a ductal dependent cardiac lesion. Many of these including coarctation of the aorta, interrupted aortic arch and transposition of the great vessels are extra-cardiac and are best seen with transesophageal echo. Other conditions are valvular abnormalities and typically outside the current scope of the emergency physician. That being said, evidence of congestive heart failure - poor systolic function, dilated and noncollapsing inferior vena cava (IVC), suggest the general diagnosis of cardiac dysfunction and necessitate a complete exam by a pediatric echo sonographer and cardiologist. 

Tips to Improve Your View:

  • Start high. Begin imaging more cephalad on the chest than standard landmarks suggest. The younger the child, the higher you should start searching for good windows. The heart resides slightly more cephalad because of the unique pediatric anatomy.
  • Go right. Perform parasternal imaging from the right side of the chest in kids less than a few months old. Both parasternal long and parasternal short views will be improved from this side of the chest. In these young children the heart is more midline and visualization will be improved from this unusual position. For the apical four chamber view begin halfway between the sternum and nipple instead of at the nipple itself.
  • Don't worry about the ribs. The ribs and sternum aren't fully ossified and therefore provide little sonographic resistance. You can scan right through them.
  • Take baby steps. Kids hearts are small, therefore small adjustments will make dramatic changes in the windows. Think "fan and tilt" more than slide. The heart may go completely out of view with big movements. Use a small phase array probe. You may use either a cardiac or abdominal preset. By convention most pediatric cardiologists use an inverted image - i.e. the US beam begins on the bottom of the screen.
  • Don't chase a beating heart. There may be dramatic change in cardiac position with respirations. Find the best view and keep your hand still. With respirations the heart will come in and out of view. With recorded clips you will be able to fully evaluate the heart.
  • Slow it down. Normal pediatric heart rates can reside in the 150s and may even be higher when children are febrile, dehydrated or upset. Assessing cardiac details in real time at these rates is often difficult. Record a clip and play it back at half speed directly on the ultrasound machine for an easier assessment.
  • Be gentle. Children often don't tolerate the pressure from a subxiphoid imaging position particularly if the probe is placed directly under the xiphoid process. In adults and large children it is necessary to place the probe here because of limited depth capability. Remember kids are little so depth of view isn't a big concern. Place the probe lower on the abdomen and flatten in the standard fashion for this view. The kids will be more comfortable and your images will be better.
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Tips and Tricks: Ultrasound Guided Regional Anesthesia - Emergency Ultrasound Section Newsletter, August 2012

 By Zoe Howard, MD and Laleh Gharahbaghian, MD, FACEP

 

 Image One:
Honeycomb Nerve
 tipstricksaugust1

Regional anesthesia under ultrasound guidance is yet another application that is rapidly acceptance due to its many benefits - namely the reduction of large doses of oral narcotics or even avoiding procedural sedation, not to mention potential for decreased length of stay and increased patient satisfaction. We can use ultrasound to identify the target nerve and adjacent structures and vessels as well as use real-time guidance for anesthetic delivery, increasing the safety and success of the procedure.   

A number of bedside ultrasound devotees are leading the field with interscalene, clavicular, and axillary blocks, however, the most common indications are femoral and popliteal nerve anesthesia in the setting of femur and lower leg fractures, lacerations and wound exploration, soft tissue infection or foreign body retrieval. 

Pre-Procedure Exam

Prior to performing your nerve block, you should confirm the neurovascular status of the affected extremity. If the patient is altered or you cannot perform a complete neurologic exam, you should not perform the procedure as the exam will change and the ability to identify pre-existing deficit becomes difficult. You should also reconsider performing a nerve block if there is vascular or nerve injury or if the patient has a severe bleeding disorder or coagulopathy. Confirm your anesthetic dose and keep its toxicity levels in mind. Intralipid is a handy thing to have close should you need it. Clean the site to prevent infection. 

Nerve Identification

You should know your nerve and its function and area of distribution. Classically described as "honeycomb" in appearance in the short axis, the hyperechoic nerve can appear round, triangular or oval. It is always helpful to trace the course of the nerve for confirmation, or pulse wave/color doppler can also be invoked to identify nearby vessels. 

Technique  

   Image Two Humeral Fracture
  Nerve Block - Click for Video
  tipstricksaugustr3

Use the in-plane approach for increased safety due to greater direct visualization of the needle and its tip. Using the high frequency linear probe, identify the target nerve and with real time guidance, insert the needle at the side of the probe opposite of where the vessels are in order to minimize vessel puncture and inject the local anesthetic when the tip is at the nerve site, ideally bathing the nerve. Always avoid injecting into or making contact with the nerve and frequently aspirate to prevent intravascular injection. If resistance is ever encountered, this can suggest intraneural injection and should be avoided. The injection of the anechoic fluid will further outline and frame the intended nerve, confirming your placement.  

As with all procedures, patients must be consented on the risks (hematoma, infection, residual anesthesia and the possibility of unintended intraneural or intravascular injection). 

 Image Three Popliteal Nerve
Block - Click for Video
tipstricksaugust3r2   



Post-Procedure Exam:  

Confirm that your block worked, that there has been no change in vascular status, and document your procedure and estimated length of action of your anesthetic. Communication with the surgical and admitting teams is key in post-procedure assessment. Follow up care and post-procedure return to function should be assessed as the residual anesthesia leaves the patient without motor function for a number of hours, possibly requiring splinting, crutches and specific precautions.

 

 

 

 

 


Journal Watch - Emergency Ultrasound Section Newsletter, August 2012

By Brian Euerle, MD, FACEP and Gregory Bell, MD

Article: Ko DR, Chung YE, Park I, et al. Use of bedside sonography for diagnosing acute epiglottitis in the emergency department: a preliminary study. J Ultrasound Med. 2012;31(1):19-22.

Reviewer: Jehangir Meer, MD, RDMS, Director of Emergency Ultrasound, Saint Agnes Hospital

Objective: The purpose of this pilot study was to investigate whether bedside ultrasound could identify acute epiglottitis in adult patients in the emergency department. 

Methods: In this small, prospective study, 15 patients with acute epiglottitis confirmed with indirect laryngoscopy by ENT were enrolled, with a comparison group of 15 healthy volunteers. Bedside ultrasound was performed by one experienced emergency physician, with patients scanned in the upright seated position and neck in slight extension. Epiglottis was scanned through the thyrohyoid membrane in the transverse plane. The anteroposterior diameter of the epiglottis at the midpoint and both lateral edges was measured in all participants. 

Results: There was a statistically significant difference (P<0.001) in measurement of the epiglottis between the epiglottitis and healthy groups. Specifically, the lateral edges of the epiglottis in healthy volunteers measured 3.2 mm or less and 3.6 mm or more in epiglottitis patients. 

Discussion: This small pilot study raises the intriguing possibility of using bedside ultrasound to screen for acute epiglottitis. Further study with larger enrollment of subjects is required to validate these findings as well as determine inter-rater reliability. Bedside ultrasound could be yet another adjunct (in addition to laryngoscopy, CT, and neck radiography) available to the clinician to assist in confirming this diagnosis. 

Article: Zaia BE, Briese B, Williams SR, et al. Use of cadaver models in point-of-care emergency ultrasound education for diagnostic applications. J Emerg Med. April 14, 2012 (Epub ahead of print).

Reviewer: Brian Euerle, MD, RDMS, Associate Professor, Department of Emergency Medicine, University of Maryland School of Medicine 

Objective: This study had two objectives. First, to determine what pathology can be successfully simulated and identified by ultrasound in human cadavers. Second, to determine if emergency medicine residents could improve their comfort level with specific ultrasound applications through the use of cadavers. 

Methods: A recently deceased, unembalmed, freshly frozen adult cadaver was used for the study. Ultrasound images were first obtained of the unaltered cadaver. The study team then altered the cadaver to simulate the pathologic conditions of orbital foreign body, retrobulbar hematoma, long bone fracture, joint effusion, and pleural effusion. Ultrasound images were then obtained of the altered cadaver. Phased-array and linear-array transducers were used. The second part of the study involved 22 residents of all levels of training who were first surveyed anonymously about their comfort level with various ultrasound applications using a five-point Likert scale. They were given a brief verbal lecture on each of the ultrasound applications and next attempted to identify the simulated pathology with ultrasound in the cadaver model. After this scanning session, they completed a post-lab survey concerning their change in comfort level with the specific ultrasound applications. 

Results: The investigators were able to successfully simulate orbital foreign body, retrobulbar hematoma, humeral fracture, and joint effusion. The cadaver used had naturally occurring bilateral pleural effusions. Normal and abnormal ultrasound images are included in the paper. The results of the survey showed that the residents felt that they had significant increases in comfort in scanning the normal and abnormal eyes, bones, and joints. They did not have significant improvement scanning for pleural effusions. An additional survey question showed that 100% of residents found ultrasound education using cadavers to be helpful. 

Discussion: One problem with ultrasound education in residency is that some abnormal conditions are infrequently and unpredictably encountered. By using cadavers to teach ultrasound, it is possible to plan sessions and demonstrate specific pathologic conditions. In addition, it would allow all residents to perform specific abnormal scans during their residency. With this article, the authors demonstrate several specific pathologic conditions that can be simulated in a cadaver and used to improve the ultrasound education of our medical students and residents. 

Article: Cortellaro F, Colombo S, Coen D, et al. Lung ultrasound is an accurate diagnostic tool for the diagnosis of pneumonia in the emergency department. Emerg Med J. 2010;29(1):19-23.  

Reviewer: Alisa Sato, MD, Emergency Ultrasound Fellow, Harbor-UCLA Medical Center 

Objective: The goal of this study was to determine the accuracy of lung ultrasound (US) and chest radiography (CXR) in identifying pneumonia compared with CT scan and final diagnosis at discharge. 

Methods: The study incorporated a convenience consecutive sample of 120 patients in a metropolitan emergency department in Milan, Italy, between September 2008 and October 2009. Lung US was performed by a single expert operator on patients with suspected pneumonia. Lung scans were performed in 10 areas of the chest bilaterally and examined for findings such as "B lines," dynamic air bronchograms, and focal interstitial syndrome suggesting pneumonia. CXR was also performed on all of these patients and read officially by a senior radiologist. CT scans were selectively performed on patients if indicated by the senior physician in charge of the patient. Patients were prospectively evaluated until discharge, comparing their US results with their final diagnosis.

Results: There were a total of 120 patients, 81 of whom had a final diagnosis of pneumonia. Ultrasound showed a sensitivity of 99% (80/81 patients) and a specificity of 95% (37/39 patients) when comparing the US findings with the final discharge diagnosis. There was one false negative in a patient with both pulmonary edema and pneumonia and two false positives. In comparison, CXR had a sensitivity of 67% (54/81) and a specificity of 85% (33/39). Among the 27 patients with non-diagnostic initial CXR, a second CXR film was obtained 72 hours later and 10 were diagnostic of pneumonia. Chest CT scans were performed in 30 of the 120 patients and was diagnostic for pneumonia in 26 patients. In comparison with a chest CT scan, ultrasound was positive in 25/26 patients with CT-confirmed pneumonia while CXR was positive for only 18/26 patients with CT-confirmed pneumonia. 

Discussion: This study suggests that bedside lung ultrasound is more accurate than CXR in diagnosing pneumonia when using the chest CT scan as the definitive diagnosis. There are several inherent limitations to this study: 1) chest CT was performed only in a limited number of patients (30), so many of the other patients in the study did not have comparison with this gold standard, 2) the patient population was non-randomized, 3) all ultrasounds were performed by a single operator, and 4) the operator was not blinded to the clinical situation of the patient. Nonetheless, this study encourages the use of lung US in the emergency department as a useful clinical tool that may one day even supersede the CXR. 

Article: Brooke M, Walton J, Scutt D. Paramedic application of ultrasound in the management of patients in the prehospital setting: a review of the literature. Emerg Med J. 2010;27:702-707.  

Reviewer: Alisa Sato, MD, Emergency Ultrasound Fellow, Harbor-UCLA Medical Center 

Objective: The aim of this study was to determine if ultrasound (US) performed by paramedics in the United Kingdom (UK) may aid in the management of critically ill patients in the prehospital setting. 

Methods: This was a literature review focusing on clinical trials involving the use of US by non-physicians in the prehospital setting. The literature search extended from scholarly databases to academic and professional journals. Studies were first considered if they involved the use of US in the prehospital setting by physicians, nurses, paramedics, or any combination thereof and then filtered to identify studies directly related to paramedic practice. 

Results: Twenty-eight studies were included in this literature review and all were critiqued by the Critical Appraisal Skills Programme review tool. Four studies that directly addressed prehospital US by non-physicians were identified. These studies were used to assess paramedic capability, training, opportunities, and potential challenges in learning and implementing prehospital US techniques. The authors found that prehospital care providers are capable of learning ultrasound and also retaining the skills necessary for good quality US images. In one of the prospective cohort studies, it was found that both paramedics and physicians showed remarkable specificity, sensitivity, and accuracy compared with assessments using physical examination alone (93%, 99%, and 99% compared with 93%, 52%, and 57%, respectively). 

Discussion: The authors concede that prehospital US performed by paramedics may be helpful in the early detection and management of life-threatening conditions, but further investigation is warranted. These studies collectively imply that paramedics outside the UK are able to obtain adequate US images to identify catastrophic diagnoses; however, these findings may not be directly transferable to the UK emergency medicine system infrastructure. 

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

Reviewer: Alisa Sato, MD, Emergency Ultrasound Fellow, Harbor-UCLA Medical Center 

Objective: The objective of this study was to determine if a hand-held bladder ultrasound scanner may be useful in identifying cases of suspected dehydration in the pediatric emergency department. 

Methods: This was a prospective pilot study conducted in the pediatric emergency department at a tertiary care children's hospital between March and May 2007. A convenience sample of 45 children with "possible dehydration" was obtained, and these patients were classified as mildly, moderately, or severely dehydrated based on the WHO guide. The principle investigator performed serial bladder volume measurements; other details of urine production and decisions about fluid boluses, oral rehydration, admission, and discharge were collected independently of the bladder volume measurements. The primary outcome measure was to demonstrate the utility of the bladder ultrasound scan in documenting serial bladder volumes. The secondary outcome measure was to correlate measured urine production with clinical signs of dehydration, patient disposition, and type of rehydration treatment. 

Results: Forty-five patients, age 4 months to 10 years, were enrolled in the study. Thirty-three (73%) were mildly dehydrated, eight (18%) were moderately dehydrated, and four (9%) were severely dehydrated based on WHO criteria. Significant differences were found between mild versus moderate/severe dehydration (2.3±1.5 mL/kg/hr vs 0.6±0.7 mL/kg/hr), between admitted versus discharged patients (0.9±1.2 mL vs 1.8±1.5 mL/kg/hr), and between those who received IV fluid boluses and those who did not (0.4±0.46 mL/kg/hr vs 1.9±1.6 mL/kg/hr). Of all the patients, one in four was admitted, and all of those admitted with suspected dehydration had impaired urine production on serial bladder ultrasound scans. 

Discussion: The authors concluded that serial bladder volume ultrasound measurements using the hand-held device is a rapid, non-invasive, and helpful objective tool in managing pediatric patients with suspected dehydration in the emergency department. There were a few limitations to this study: the sample size was small (n=45) and only one principle investigator performed the scans, which may limit the extrapolation of this study to the general community-practicing emergency physician. Nonetheless, this study provides encouraging evidence that bladder ultrasounds may be useful in predicting clinical outcomes of dehydrated pediatric patients. 

Article: Puylaert JB. Ultrasound of colon diverticulitis. Dig Dis. 2012;30:56-59.  

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

Objective: The author presents his observations of ultrasound findings in left- and right-sided diverticulitis. He discusses the natural history of diverticulitis and associated ultrasound findings. 

Method: This is an observational discussion of diverticulitis, which included 110 patients with right-sided diverticulitis, who were examined with ultrasound and CT. 

Results: Ultrasound is used in early uncomplicated diverticulitis. Diverticula are easier to see when the lumen is not filled with feces. Initially there is wall thickening and all three layers (submucosa, mucosa, and muscularis) can be differentiated. The inflamed diverticulum has a fecolith in the neck and the surrounding tissue (the mesentery and omentum) is hyperechoic and noncompressible. This tissue "seals off" the diverticulum at risk of perforation. Inflamed fat is always present in diverticulitis and usually corresponds to the spot of maximal tenderness. With subsequent ultrasound examinations, the fecolith is displaced-it either disintegrates or is expelled to the colonic lumen along with associated pus. This occurs within 1 or 2 days. Small abscesses associated with the inflamed bladder neck usually resorb after 1 or 2 more days. Large diverticular abscesses (>3 cm) usually also evacuate into the colonic lumen. Free perforation without mesenteric sealing off is rare, as is colonic stenosis due to abscess or fistulas to the bladder or vagina. 

Right-sided diverticulitis occurs one time for every 15 cases of left-sided disease. Diverticula on the right tend to be congenital, solitary, and larger, though the muscularis layer does not thicken as it usually does with diverticula on the left side. The author states that right diverticulitis never leads to free perforation or large abscesses. 

Discussion: This is a brief discussion of ultrasound findings (and anatomic changes) of diverticulitis, drawing distinctions between right and left colonic diverticula and providing a timeline for these changes. Some details of ultrasound findings are not discussed here, such as location and extent of diverticulitis wall thickening or appearances of abscesses. The author provides a couple of images to depict acute and convalescent diverticulitis. This article does not discuss the ultrasound technique for diagnosing diverticulitis. 


ACEP EUS Listserve Summary - Emergency Ultrasound Section Newsletter, August 2012

By Tom Kehrl, MD

Lots of specific questions were sent across the EUS Listserve over the past three months, including questions about pediatric echo, nursing placement of peripheral IVs, acquisition of 2.5 inch angiocatheters, ultrasound image banks, digital QA systems, and some billing questions to name a few. Here is a quick summary of a few of the notable discussions: 

  1. There was a question and some discussion about Stark Laws and the issues of self-referral. It seems that there are a number of different opinions about billing practices, particularly regarding billing the technical and / or professional fees. These issues have different implications for the various different models of practice (private group, hospital employee, etc.).
  2.  
  3. ACEP was able to negotiate an industry-sponsored research grant with help from Mindray and the Emergency Medicine Foundation (EMF). $20,000 is available for an Emergency Ultrasound research project. More details to come.
  4.  
  5. In an effort to improve the fellowship application process, the http://www.eusfellowships.com Board of Directors asked fellowships that participate in the site to offer fellowship slots only after November 1st. A job listing board was also created on the site.
  6.  
  7. The ACGME-EM milestones were released. Ultrasound was included as 1 of 24 milestones. The framework for the ultrasound milestone was released as well and will become the competency-based method that residents are evaluated. More to come on this as well.


Ask the Expert: One More Year? The Real Value of Ultrasound Fellowship Training - Emergency Ultrasound Section Newsletter, August 2012

By Michael Zwank, MD, FACEP
Selected Expert:
Rob Ferre, MD, FACEP
Emergency Ultrasound Director
Assistant Professor of Emergency Medicine
Vanderbilt University

Describe Your Career Path  

I completed undergrad at the University of Utah where I essentially paid for school by working part-time. I attended medical school in Milwaukee at the Medical College of Wisconsin. My Dad convinced me to join the Air Force to have them pay for medical school. It seemed like a win-win: Serve my country and have them pay for medical school at the same time. Residency was at Maine Medical Center. Our Ultrasound Director was Tony Owens and it was easy to tell that ultrasound was a fire that burned in his belly; a source of passion that brought enthusiasm to his clinical care. I found that same fire early on in residency and sought out as much experience as I could. I also spent time scanning with sonographers and doing an elective with Vivek Tayal at Carolinas Medical Center. 

I started as a faculty physician at Wilford Hall Medical Center, the Air Force's flagship training hospital. It had a combined Army-Air Force Emergency Medicine Residency program. Within a few months I was made the Emergency Ultrasound Director for the Air Force side of operations, and later the Ultrasound Director for the Residency. 

After finishing my active duty commitment, I completed a fellowship at Palmetto Health in Columbia, South Carolina with Pat Hunt and Tom Cook. I was then hired as the Emergency Ultrasound Director at Vanderbilt University Medical Center, where I work today. 

Why did you choose to do an ultrasound fellowship?  

After finishing residency, I wanted to do an ultrasound fellowship not only because I had a lot more to learn about the technical aspect of scanning, but I also had little experience in regards to starting and directing a program. However, because of my commitments with the Air Force, I had to postpone fellowship plans. I learned as much as I could on my own as an attending. I spent a lot of time teaching residents and coming up with learning material both for the staff and residents in our residency program. Vivek Tayal was a huge help and served as my mentor in learning how to establish and direct a more robust emergency ultrasound program at Wilford Hall. 

When I finished my time in the Air Force, I had experience building and directing an ultrasound program and I felt that I was proficient in all of the core emergency ultrasound exams. However, I still knew there was more to learn and I looked for places to do a fellowship that would augment my experience and teach me more about teaching, research and the business side of emergency ultrasound. 

What do you see as the benefits of completing an ultrasound fellowship?  

There are a multitude of benefits. The obvious being more focused time to become proficient in scanning and to better learn and appreciate the physics and operational knowledge of using an ultrasound machine. Learning how to teach others about performing, interpreting and applying ultrasound is also a key benefit of doing a fellowship. In addition, there are the intangibles: a guided mentorship that teaches you about emergency ultrasound research, directing ultrasound operations, machine purchasing and maintenance, and all the other things that are required to be an expert in the field. 

However, the two benefits that I underestimated the most, but have probably had most impact on me to date are the camaraderie of the emergency ultrasound community and the experience you obtain from working at a different institution with a different patient population and a different residency leadership. It is almost like getting the best of two residencies. It certainly has made me a lot more well rounded as a clinician and educator. 

Do you have any advice to somebody who has been able to gain a fair bit of ultrasound experience (through residency or otherwise) and is contemplating a fellowship?  

Do a fellowship!!! I remember weighing this decision: fellowship or just take a job. I had offers to do both and certainly felt my experience was enough that I really didn't need to do a fellowship. However, doing a fellowship was no doubt the best decision. It continues to reap benefits in ways that I never would have anticipated.


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