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Emergency Ultrasound Section Newsletter - December 2016

Sonic Boom: Cases that Count, Studies that Stick, US News that you need to Hear!

 

Chair’s Corner

Many thanks to Co-Editors Laleh Gharahbaghian and Michael Zwank on another great year of educational and entertaining ACEP US Newsletters. Congratulations to Dr. Sandy Schneider on her promotion to Associate Executive Director of Practice, Policy and Academic Affairs. Julie Rispoli is our Ultrasound Section Staff Liaison.

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Ask The Expert

Interview with Marek A. Radomski, DO, FACEP
Associate Chief of Emergency Services, UPMC-Presbyterian/Shadyside - Shadyside Campus
Director of Ultrasound Services, Department of Emergency Medicine - University of Pittsburgh Physicians
Assistant Professor of Emergency Medicine, University of Pittsburgh School of Medicine

Clinical Ultrasound: How do I work with other specialties?

Questions often arise among on how best to navigate the potential minefields that can exist between specialists and Emergency Physicians when performing clinical ultrasound studies in the point-of-care setting. The field of clinical ultrasound has expanded drastically over the course of the last several years with nearly all specialties using ultrasound in one capacity or another. The sentiment that only certain specialists should be performing ultrasound studies is obsolete and antiquated, but I find it especially important to have a good working relationship with as many other specialties as possible. Emergency Medicine as a discipline has outlined a specific fellowship in the field of clinical ultrasound, performs nearly every type of clinical ultrasound study, and has been performing these point-of-care studies as long as any other specialty -- positioning us to be leaders in the field.

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Cases That Count: I Spy a Swollen Eye

SwollenEye1Chief Complaint: Eye trauma

Clip 1 - Ocular Ultrasound

Questions:

  1. Identify the structures in Image 1 and Clip 1. What are the important landmarks to identify?
  2. What are your differential diagnoses and how do you differentiate between them?
  3. What are the potential complications of this clinical entity?
  4. In what other ways can point-of-care bedside ultrasound (POCUS) be helpful in the setting of ocular trauma?

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Cases that Count: Use of POCUS for the Diagnosis and Management of Hypertrophic Obstructive Cardiomyopathy

Introduction
Hypertrophic obstructive cardiomyopathy (HOCM) is an occasionally encountered and under-recognized clinical entity in the critical and emergency care environment. Point-of-Care Ultrasound (POCUS) can be utilized to better recognize HOCM and tailor resuscitation.

Case Description
A 49-year-old man with a history of decompensated cirrhosis secondary to alcoholic liver disease, complicated by hepatic encephalopathy, hepatorenal syndrome, recurrent pleural effusions, and ascites was admitted to the medical intensive care unit (ICU) for septic shock. The patient eventually required mechanical ventilation, blood transfusions, IR embolization, multiple vasopressor support and broad-spectrum antibiotics. Physical exam was notable for a systolic murmur, prompting further investigation. POCUS findings were consistent with HOCM.

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FOAM Ultrasound: #FOAMus Highlight

Point-of-Care OB Ultrasound iBook
A product of an ACEP ultrasound section grant, the new ACEP Point-of-Care OB ultrasound book is bursting with crucial information that will be a huge aid to any bedside provider. This book bypasses the traditional method of book publishing by being available exclusively in iBook format

Ultrasound GEL podcast
Ultrasound G.E.L. (Gathering Evidence from the Literature) is a new medical podcast featuring reviews of recent studies in point-of-care ultrasound (POCUS).

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International Ultrasound: A view from the frontlines of international ultrasound: Interview with Dr. Laura Diegelmann

Q: Tell me about the path you have taken to become the physician you are today.

After completing residency at University of Maryland, I learned about a post-grad position to work with CareFlight in Australia. CareFlight employs physicians who work for aeromedical retrieval services, including the rotary wing Emergency Medicine Queensland (EMQ) and the fixed wing Royal Flying Doctor Services (RFDS). After that year working in remote parts of Australia without access to any reliable diagnostic imaging, I came back with a clear interest in ultrasound.

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Tips & Tricks: Volume Status - Using the Internal Jugular Vein

Central venous pressure (CVP) is crucial for evaluating the patient’s intravascular volume and hemodynamics, which has important indications on management for sepsis, congestive heart failure, pulmonary edema, trauma, and surgery.1-5 Over or under fluid resuscitation can both be detrimental to critically ill patients or those with cardiovascular diseases.1-3 The gold standard was invasive monitoring with a central venous catheter, but due to the procedure’s inherent risks and potential to delay resuscitation, there has been ongoing research for noninvasive methods.1,4,6,7 Sonographic measurement of the inferior vena cava (IVC) has been widely studied and accepted as a tool to assess intravascular volume status.2,8-10 Multiple studies have demonstrated that respiratory variations of IVC measurements at 2cm from the right atrial-caval junction reliably reflects the central venous pressure.2,8-10 However, this technique is limited by body habitus, bowel gas, ascites, surgical scars, and wound dressing, thus providers have been searching for alternatives.3,6,8

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Pediatric Emergency Ultrasound Update: Point-of-Care Ultrasound Evaluation for “Whiteout” Lung

Fussiness1Chief Complaint: Fussiness

Questions

  1. What are common indications for lung ultrasound in the pediatric patient?
  2. What sonographic features are found with pleural effusions, and which features suggest simple vs. complex pleural effusion?
  3. What are common pitfalls encountered with lung ultrasound?

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Welcome the New Chair -The Year Ahead

Dear EUS Community,

I am extremely honored to be your section chair for 2016-2017! I look forward to working with you all to continue the tradition of excellence and productivity our section has produced for decades. Hats off to John Bailitz on an incredible 2015-2016!

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

In 1999, in response to Resolution 802 introduced by the American College of Emergency Physicians and the American College of Obstetricians and Gynecologists, the American Medical Association House of Delegates passed the following: 

               Resolved that our American Medical Association (AMA) affirm that ultrasound imaging is within the scope of practice of appropriately trained physicians; and be it further 

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ACEP Subcommittee Highlights - System-Wide Clinical Ultrasound Director Subcommittee

There were a number of subcommittees that were able to meet at ACEP16. We will bring you highlights from several of these subcommittees over the coming months. A subcommittee that was developed over the past year to meet an evolving need of the POCUS community is the System Wide Clinical Ultrasound Director Subcommittee (SWCUD). Individuals attending the meeting represented all stages in the development of a SWCUD from early interest to fully developed and operational directors.

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Want to Get Involved?

Many thanks to all our incredible section editors! If you have a great case, an article review, commentary, or tech update to contribute to the next newsletter, then please contact Michael Zwank and Laleh Gharahbaghian.

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Journal Summary

Emergency department point-of-care ultrasound in out-of-hospital and in-ED cardiac arrest
Review by Michael Boniface, MD

Corrected flow time: a noninvasive ultrasound measure to detect preload reduction by nitroglycerin
Review by Michael Boniface, MD

Point-of-care ultrasonography for the management of shoulder dislocation in ED
Review by Tomislav Jelic, MD

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Cardiac Journal Summary

Transthoracic Echocardiography in Chest Pain and Dyspnea
Have you ever had this sign out, “I have this guy with PE that I am admitting. Just keep an eye on him. He is a little hypoxic, but 99% on 2 L nasal cannula.” You dutifully listen to the sign out but remember an older article that you read where the authors found that a room air pulse oximetry <95% was associated with a worsened in-hospital outcome for patients with acute PE and that vital signs change only when the patient has a greater than 50% pulmonary artery occlusion (1). And you also recall a newer article you read just last month that looked at the different echocardiographic findings in patients with acute PE’s (2).

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Fellow’s Spotlight: A look at EUS Fellows’ Projects

Tim Gleeson, MD
Emergency Medicine Ultrasound Fellow
University of Massachusetts, Worchester MA

Prior to training, Tim worked for the Peace Corps and was living in Africa. At UMass, Tim has a special interest in the critical care and global health aspects of Emergency Medicine.

Sally Graglia, MD
Emergency Medicine Ultrasound Fellow
Mass General Hospital, Boston, MA

Sally recently returned from a month long trip to Uganda, where she was working with Trish Henwood's non-profit organization PURE (Point-of-care Ultrasound in Resource-Limited Environments). 

Alex Brevil, MD
Emergency Medicine Ultrasound Fellow
Brigham and Women’s Hospital, Boston, MA

Alex is currently in his first of two years as an ultrasound fellow in Boston at Brigham and Women’s hospital. In addition to obtaining a master’s degree his fellowship project involves the development of an ultrasound training, QA and credentialing project in Haiti.

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Peter’s Pet Peeves: Ultrasound Proficiency

Ultrasound has been used in the Emergency Department for decades, yet still many EPs are uncomfortable with performing them. And our Rebel Alliance of Emergency Medicine continues to be assailed by the Dark Side led by Darth Rader (ologist) citing poor image quality or inadequate imaging of our studies. Unfortunately, many in our Rebel Alliance, have not attained the status of a POCUS Knight, much less Master.

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