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Emergency Ultrasound Section Newsletter - August 2017

That Sounds Great! Updates, Clinical Cases and Pearls of Emergency Ultrasound

 

Chair's Corner

Dear ACEP Emergency Ultrasound Community,

As we all continue to toil along the path of sono righteousness I wanted to give a few quick updates:

ACEP17 - It’s never too early to plan. Be sure to mark your calendars for the Emergency Ultrasound Section meeting, which is Monday, October 30 from 1-3PM.

APCA - Many more of you are being littered with offers to sign up for APCA, an external ultrasound certification company owned by Inteleos (who also owns RDMS). I’ve already discussed this a number of times in two previous newsletters and e-list messages so I won’t rehash it here. Also look for an article in the July ACEP Now and please share it with your colleagues. Our official stance is that ACEP does not endorse APCA or any other external certification entities. Don’t sign up. 

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Ask The Expert: An interview with a family medicine trained EUS fellow

Section Editor: Robert M. Bramante, MD, FACEP

As a family medicine trained emergency ultrasound (EUS) fellow, what are the challenges and opportunities for family medicine and EUS?

Point-of-care ultrasound (POCUS) is becoming more widely used in all areas of medicine. Emergency medicine is the first specialty to incorporate bedside ultrasound well within its core curriculum for residency training. To enhance education in performing and interpreting POCUS, many emergency ultrasound (EUS) fellowships have been created. A listing of these fellowships could be found on www.eusfellowships.com.

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FOAM Ultrasound: #FOAMus Highlight

It’s summer again and we are now looking back on another fine SMACC conference.  If you are not aware of this already SMACC stands for “Social Media and Critical Care.” It is a conference that has been occurring annually for the last four years and just finished its fifth iteration in Berlin. Previous locations have included Dublin, Chicago, and Australia. While the conference is not free, the podcast certainly is. You can find it on the iTunes store (SMACC Podcast). Now while you’re driving to work or out for a run you can have the SMACC team in your ear and hear from some of medicine’s best speakers on cutting edge topics in Critical Care. These talks are meant to engage and inspire in 20-30 minutes and cover topics including Airway, Prehospital medicine, Education, Ultrasound, and all things Critical Care. You can also find SMACC on social media so take a look and stay up to date on the latest SMACC info and find out where next year’s conference will be held.

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International Ultrasound: Hepatic Vena Cava Syndrome

A 23-y/o male from a Nairobi slum presents with recurrent upper abdominal pain and leg swelling. He has lived in the slum for a long time and has a history of excessive alcohol consumption. He looks older than stated age, his abdomen is slightly distended and he has bilateral lower extremity pitting edema. Ultrasound findings in Figures 1-4 below. 

Fig1 Intl

Fig. 1: Right upper quadrant coronal view. Liver, ascites and pleural effusion

On the differential diagnosis is Hepatic Vena Cava Syndrome (HVCS), a condition that results from chronic stenosis of the IVC close to the outlet of the hepatic veins.1 The disease was initially described in Europe and North America but current disease reports are predominantly from Asia and Africa, where its incidence correlates with areas of poor hygienic conditions.2

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Pediatric Emergency Ultrasound Update: The Unique Pediatric FAST

The Focused Assessment with Sonography for Trauma (FAST) is an important tool for blunt trauma assessment in the Adult Emergency Department (ED). It is widely used to assist the ED provider with medical disposition in a rapid, accurate and cost-effective manner during trauma assessment. Despite its limitations, the FAST has become the standard of care in adult trauma with up to 96% use among adult trauma centers.1,2 The use of FAST in pediatrics is proportionally lower than in adults. There has been interest in enhancing the utilization of FAST in pediatric blunt trauma. It is important, however, to understand that there are many unique factors that differentiate the use of FAST between the adult and pediatric population.

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Update on Drafts of New AMA Resolutions to Promote Point-of-care, Clinical Ultrasound

With the assistance of colleagues from the ACEP Emergency Ultrasound Section, the SAEM Academy for Emergency Ultrasound, and the AMA Section Council on Emergency Medicine, the following 2 resolutions have been drafted for consideration by the Medical Society of the State of New York (MSSNY) House of Delegates next month. Support and co-sponsorship will be sought from other AMA sections and councils, prior to presentation to the AMA House of Delegates in June.

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Cases That Count: 68-year-old female with chest pain

Marsia Vermeulen, DO, FACEP and Meghan Kelly Herbst, MD, FACEP

Case Presentation:

A 68 year old female from Guyana with a history of diabetes, hypertension, and cervical cancer presents to the emergency department (ED) with acute onset chest pain that started while at her gynecology clinic receiving her first cycle of chemotherapy. On arrival, she appeared mildly uncomfortable and diaphoretic. Her vital signs were BP 168/85, HR 84, RR 18 and oxygen saturation 95%. The initial 12-lead EKG demonstrated ST-segment elevations in V2-V6, with ST-segment depression in AVR and mild QT prolongation. A STEMI alert was initiated and the patient was given aspirin, Plavix and morphine for pain control. Repeat EKG approximately 10 minutes later demonstrated resolution of the ST-segment elevations. At that time a cardiac POCUS was performed.

Initial troponin I was elevated to 7 ng/mL and the patient was taken emergently for cardiac catheterization. No culprit lesion was identified for revascularization. Formal transthoracic echocardiogram (TTE) was performed which demonstrated an ejection fraction of 25%, akinesis of the mid inferolateral, apical lateral, mid septum, left ventricular (LV) apex, and an aneurysm of the LV apex.

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Journal Summary

Wells score with POCUS improves accuracy and could decrease advanced imaging orders

Subxyphoid view is best when assessing IVC collapsibility index

 

Cardiac Journal Summary

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Tips & Tricks: Sternal Fractures Diagnosed by POCUS

By Rwo-Wen Huang, MD and Laleh Gharahbaghian, MD, FACEP

Sternal fractures can result from significant blunt thoracic trauma, most commonly motor vehicle accidents.1 It used to be a rare diagnosis, but its prevalence is on the rise with increase in traffic and seat belt legislation.2 While isolated sternal fractures is considered a benign injury treated conservatively, morbidity and mortality can result from associated injuries including aortic disruption, pulmonary contusion, myocardial contusion and laceration, pericardial effusion, rib fractures, flail chest, and bone marrow embolization.3,4 Furthermore, sternal fractures can lead to long term sequelae including pseudoarthroses and overlap deformities that may require surgical intervention.5

 

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Special Contribution: Response to “Who should read point-of-care ED ultrasound exams?” as written by EL Ridley in Auntminnie.com

Erik Ridley’s article in AuntMinnie discusses the research presented by investigators from the ACR's Harvey L. Neiman Health Policy Institute at the American College of Radiology (ACR) meeting (May 2017) in Washington, DC.1   The e-poster presented at the meeting compared downstream imaging utilization after emergency department ultrasound examinations interpreted by radiologists versus non-radiologists.

To answer the question posed in the title: Who should read point-of-care ED ultrasound exams? The answer is simple and clear: emergency medicine physicians who are performing these studies bedside. In fact, this stems back to the 1999 American Medical Association House of Delegates Resolution, which affirmed that ultrasound is within the scope of practice of all appropriately trained physicians, and all medical specialties have the right to use ultrasound in accordance with educational standards developed by their own specialty. For almost two decades, emergency physicians have been performing and interpreting POCUS studies at the patient’s bedside. Real-time ultrasound interpretations are contemporaneously incorporated into medical decision making at bedside. Radiology reads are not compatible with this model of practice.

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