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Ask the Expert - Emergency Ultrasound Section Newsletter - January 2011
Question: Ultrasound guidance (USG) for central line placement has become standard of care at many institutions. What criteria should be used for physician credentialing and why?
Paul R. Sierzenski, MD, RDMS, FACEP
Member, CMS MedCAC
Member, ACEP QPC & FGA Committees
Director, EM, Trauma & Critical Care Ultrasound
Director, Emergency Ultrasound Fellowship
Christiana Care Health System, Delaware
Past-Chair, ACEP & SAEM US Sections
Edited by John T. Powell, MD, Emergency Ultrasound Fellow, Christiana Care Heath System
My first response is, “Wow...way to set me up guys. There is no fixed consensus on this topic, and I am sure this will foster some discussion and debate!” The prime reason for potential controversy is the concept that ultrasound is an adjunct to an established skill set such as central venous cannulation (CVC), so why would distinct credentialing in ultrasound guidance be required. First allow me to provide some key background and build the case for some proposed USG-Procedure/CVC credentialing criteria and education.
It is important to note that though physician credentialing and privileging has been around for decades, the metrics and rules have changed. The concept of see-one, do-one, teach-one is no longer valid or accepted by governing bodies or the public. Also gone, is the sense of no harm-no foul.1 Evidence of performance competency with continuous evaluation is the expectation and mandate by The Joint Commission (TJC) and has been adopted by the Accreditation Council for Graduate Medical Education (ACGME).
In 2007, T JC, previously the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), revamped its recommendations and standards for physician credentialing and privileging (great reading for those with insomnia). This document highlights the importance of carefully monitoring volume and performance of each procedure in which a particular practitioner is privileged. Doing so in an ongoing fashion is essential.
Per TJC; “before the/any core/bundle (credential) is granted, the organization must evaluate each applicant's education, training and current competence to perform each activity listed in the core/bundle, and any that are assigned outside the core/bundle.”2
According to TJC 2007 Standards on Credentialing and Privileging,3 organizations must:
- Conduct an ongoing professional practice evaluation for each practitioner and collect data on good performance, not just outlier or trending data
- Use the data to trigger a focused professional practice evaluation when issues affecting care are identified
- Use the ongoing review and focused review data to determine the status of each practitioner’s privileges
This process is fairly straight-forward for a residency graduate that has faculty and leadership who perform these evaluations and validate competency. This is not generally the case in the community ED setting, especially as new skills are learned and new credentials are requested.
The argument that USG is an adjunct to an already credentialed skill set in central venous cannulation (CVC) is factually true. However, there is a strong argument that sufficient differences in USG-CVC warrant either core/bundled credentialing for USG procedures or even USG-CVC. Some differences to note are:
- USG-CVC site location selection varies from traditional approaches
- Sonographic approaches may vary (eg, a posterior approach to the internal jugular vein is often more common with USG-CVC, and this can place the carotid posterior to the internal jugular vein)
- Threshold for performing USG-CVC on high risk patients is lower (we have all placed an USG internal jugular line in a coagulopathic patient)
- USG affords the user sonographic findings/differences in critical steps when performing the USG-CVC versus landmark techniques, for example:
- Confirmation of target vessel and critical structures to avoid
- Visual confirmation of vein patency (absence of deep venous thrombosis)
- Visual confirmation of vein diameter and path
- Confirmation of needle tip location
- Identification of spontaneous hematoma development
- Confirmation of wire location and direction prior to dilatation
- Multiple USG approaches are possible including in-plane, out-of-plane, short axis, long axis, etc.
A potential financial reason may exist as well. Just as some (eg, American College of Radiology) have argued that emergency ultrasound (EUS) is “an extension of the physical exam (PE)...and thus should not be reimbursed,” defining USG as simply an adjunct to CVC may paint us into a corner respective to performing USG-CVC as an unfunded mandate. The rationalization that EUS is an exam extender may aid in defusing controversy when gaining the technology or reducing clinician “hoop-jumping” for credentialing, but it has a potential downside: denial of reimbursement or bundling of charges. Credentialing reaffirms that USG-Procedures/CVC is a unique and separate privilege from non-USG CVC, and as such, should be billed and reimbursed separately.
Changes in residency training driven by ACGME and the Residency Review Committee-Emergency Medicine and expanded mandates for competency assessment are driving credentialing metrics to the right. Many residencies have a competency-based progression for USG-CVC. A standard structure includes initial didactic education, practical training, simulation with competency thresholds prior to live patient performance, then proctored live performance with outcomes tracking. This process will likely compel community physician credentialing to be more rigorous.
The revised ACEP Emergency Ultrasound Guidelines,4 pertinent to community and academic settings, state:
- “As a class of ultrasound procedures, each emergency ultrasound application represents a clinical bedside skill that can be of great advantage in a variety of emergency settings.”
- “Emergency ultrasound requires emergency physicians to become knowledgeable in the indications for ultrasound applications, competent in image acquisition and interpretation, and able to integrate the findings appropriately in the clinical management of his or her patients.”
- “These various aspects of the clinical use of emergency ultrasound all require proper education and training. The ACGME mandates procedural competency for all EM residents in emergency ultrasound as it is considered a ‘skill integral to the practice of Emergency Medicine’ as defined by the 2007 Model of Clinical Practice of Emergency Medicine.”
- “Procedural guidance represents one of five Core Categories defined for emergency ultrasound.”
- “If a number of examinations for USG procedure is required (for credentialing), we would recommend 10 US-guided procedures examinations or completion of a module on ultrasound guided procedures with simulation on a high quality ultrasound phantom.”
- “The ED medical director or his/her designate (Emergency Ultrasound Director) is responsible for the periodic assessment of clinical privileges of emergency physicians.”
- “..the American Medical Association (AMA) House of Delegates in 1999 passed a resolution (AMA HR. 802) recommending hospitals’ credentialing committees follow specialty specific guidelines for hospital credentialing decisions related to ultrasound use by clinicians.”
- “Emergency medicine departments should either list emergency ultrasound within their core emergency medicine privileges, or as a single separate privilege for “emergency ultrasound” without further designation. - this is often not possible due to specific departmental or hospital processes or politics.
- Specific to procedural ultrasound:
- Describe the indications and limitations when using ultrasound to assist in bedside procedures.
- Understand the 2D approaches of transverse and longitudinal approaches to procedural guidance with their advantages and disadvantages.
- Define the relevant local anatomy for the particular application.
- Understand the standard protocols when using ultrasound to assist in procedures. These procedures may include: central and peripheral vascular access
- Recognize the relevant focused finding when performing ultrasound for procedural assistance.
Regardless if you plan to have a core, or bundled set of credentials in EUS, you should list “procedural ultrasound” per ACEP’s EUS Guidelines. This will address credentialing either within the “emergency department delineation of privileges,” if physicians are globally credentialed in the hospital in “Emergency Ultrasound” or specifically at the hospital credentialing level such as in “Ultrasound Guided Procedures.”
The Joint Commission’s comments regarding credentialing for new privileges also note “before the core/bundle is granted, the organization must evaluate each applicant's education, training and current competence to perform each activity listed in the core/bundle, and any that are assigned outside the core/bundle.”
- It cannot be assumed that every applicant can do every activity listed.
- There needs to be a clearly defined method for the applicant to request deletion of specific activities.
- If they don't wish for them to be granted or if organization's evaluation determines that the applicant is not competent to perform certain activities, then the organization must modify the core/bundle that is granted to the applicant
- In accordance with the medical staff standards the applicant and all appropriate internal and/or external persons or entities (as defined by the organization and applicable law) are notified as to the granting decision, ie, whether the full core/bundle or a modified bundle has been granted.
- If the core/bundle was modified, the notification must detail the specific modifications.
In conclusion, I promote the following specialty specific training and credentialing concepts:
- USG procedures or USG-CVC should be delineated either in the departmental or hospital emergency ultrasound credentialing documents. This is really based on the history and politics of the institution. Either method is appropriate, but a specialty-specific approach is key.
- USG-Procedure/CVC education must include didactic, practical and supervised training, gained through either American Board of Emergency Medicine/American Osteopathic Board of Emergency Medicine residency training or American Medical Association Category 1 Continuing Medical Education supported education. This training should cover sonographic findings (anatomy, landmarks, needle tracking, sonographic findings of increased risk - clot, small size, hematoma, etc.).
- Training and supervision should only be provided by practitioners who actually perform the procedure. USG-CVC training by sonographers or practitioners who do not actually perform USG-CVC does not meet training standards and does not meet the credentialing threshold in my opinion....and this may lead to medical liability concerns.
- Competency assessment is critical and can be performed through many mechanisms, including simulation, direct visualized supervision, image reviews, outcome assessment, etc. Many residencies have moved to a “certification” pathway for procedures with numerical thresholds such as 5 internal jugular, 5 subclavian and/or 3 femoral CVCs. Although numerical thresholds alone are not ideal, ample data supports that proficiency and competency increases with the volume of procedures; the issue is at what volume. For the practicing physician these number thresholds are not a practical reality, but concomitant direct or indirect review is sufficient.
- Image retention, either static or dynamic, should be maintained. For most, I support an image of the “wire in the vein” as evidence that the user identified the landmarks and confirmed appropriate vessel prior to dilatation for the catheter.
- Committee on Quality of Health Care in America, Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. The National Academies Press, 2001.
- The Joint Commission Credentialing and Privileging Conference Call, April 30, 2007. Transcript available at http://www.jointcommission.org/NR/rdonlyres/8AB389E2-412D-49F0-BAC9- 996D7EF098B1/0/audio_conference_043007.pdf
- American College of Emergency Physicians. Emergency Ultrasound Guidelines [policy statement]; 2008, 2010. https://www.acep.org/WorkArea/DownloadAsset.aspx?id=32878
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Case Report - Emergency Ultrasound Section Newsletter - January 2011
John Bailitz, MD, ARDMS
Emergency US Co-Director
Cook County Hospital
Karen Cosby, MD
Emergency US Co-Director
Cook County Hospital
Chief Complaint: Worsening low back pain
Summary: A 57 year old male with a history of hypertension and herniated disk disease presented to the ED complaining of “acute on chronic” low back pain x 1 day. The pain was described as a constant “deep strong ache” in the mid and lower back radiating around to the lower abdomen bilaterally. Vital signs were significant for a BP of 230/110. In the resuscitation bay, an emergency ultrasound was immediately performed (Figures 1-3).
Teaching Points: Emergency Ultrasound of the Aorta (EUA) rapidly answers the clinical question, “Does this patient have an abdominal aortic aneurysm (AAA)?” In the low risk stable patient with vague back pain, EUA reliably rules out AAA without the need for additional diagnostic testing.1 In the high risk unstable patient, EUA reliably rules in AAA without the need for potentially dangerous trips out of the ED to the CT scanner.2,3
The structure shown is a 7 cm AAA with intraluminal thrombus extending into the iliacs bilaterally. Make sure to always measure the outer wall of the AAA, not just the lumen, to accurately determine AAA size.4 Arrows in Figure 3 are pointing to retroperitoneal hemorrhage secondary to initial rupture.
Take Home Points:
- EUS is a reliable screening test for the presence of AAA in low-risk and high-risk patients.
- Pathognomonic findings are rare. The classic triad of pain, hypotension, and a pulsatile mass is found in only 25% of patients with a ruptured AAA.
- Measure anterior to posterior diameter from outer wall to outer wall in the transverse scanning plane to avoid the underestimating the AAA size.
- Eckstein H, Bocker D, Flessenkamper I, et al. Ultrasonographic screening for the detection of abdominal aortic aneurysms. Dtsch Arztebl Int. 2009;106(41):657-663.
- Tayal VS, Graf CD, Gibbs MA. Prospective study of accuracy and outcome of emergency ultrasound for abdominal aortic aneurys, over two years. Acad Emerg Med. 2003;10(8):867-871.
- Constantino TG, Bruno EC, Handly N, et al. Accuracy of emergency medicine ultrasound in the evaluation of abdominal aortic aneurysm. J Emerg Med. 2005;29(4):455-460.
- Thapar A, Cheal D, Hopkins T, et al. Internal or external wall diameter for abdominal aortic aneurysm screening? Ann R Coll Surg Engl. 2010;92(6):503-505.
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More OIG Attention on Emergency Department Imaging - Emergency Ultrasound Section Newsletter - January 2011
Peter J. Mariani, MD, FACEP
The 159 page, 2011 “Work Plan” of the U.S. Dept of Health & Human Services Office of the Inspector General (OIG) was published1 on October 1st. This annually issued document enumerates those health care services on which the OIG will focus new or heightened regulatory attention during the upcoming fiscal year.
On page I-7, the OIG describes intent to investigate payments made for emergency department (ED) diagnostic imaging. Specifically discussed are…
“…concerns about the increasing cost of imaging services for Medicare beneficiaries and potential overuse of diagnostic radiology services. In 2008, Medicare reimbursed physicians about $227 million for imaging interpretations performed in emergency departments. We will determine whether diagnostic radiology interpretations and reports contributed to the diagnoses and treatment of beneficiaries receiving care in emergency departments.”
Rendering judgments to such a degree of medical sophistication will almost certainly require individual chart review. As emergency physicians (EPs) bill bedside ultrasounds using the same CPT codes utilized by radiologists, records of ED patients receiving ultrasounds from either can be easily flagged for scrutiny. In making bedside interpretations and in recording them to the medical record, the “reports” of EPs could be subject to government judgment as to whether and by how much the ultrasound actually contributed to the care of a particular patient.
This is not the first time in recent history that ultrasound, inclusive of that performed by EPs, has attracted OIG interest. In July 2009, the OIG issued a report on high use and questionable use of ultrasound.2,3 In its subsequent semi-annual report to congress, enforcement methods recommended in the July document were confirmed, and included delaying reimbursement of questionable claims.4
The 2011 Work Plan further confirms ongoing government anti-fraud and anti-abuse interest potentially involving ED bedside ultrasound. It now additionally benefits EPs to not only record a clear focused diagnostic impression within the ultrasound note, but to also have the record more clearly reflect an explicit ultrasound contribution to medical decision making.
- Office of Inspector General Work Plan for Fiscal Year 2011. US DHHS. http://oig.hhs.gov/publications/workplan/2011/
- Sierzenski PR. OIG and CMS Define Characteristics to Monitor and Investigate Ultrasound Claims. ACEP Ultrasound Section Newsletter, August 2009. https://www.acep.org/ACEPmembership.aspx?id=45963#story4
- Mariani PJ. Ultrasound Use and “Overuse.” West J Emerg Med. 2010;11(4):319-321. http://escholarship.org/uc/item/3g60p7bm
- DHHS OIG. Semiannual Report to Congress. September 30, 2009. http://oig.hhs.gov/publications/docs/semiannual/2009/semiannual_fall2009.pdf
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Emergency Ultrasound Tips and Tricks - Emergency Ultrasound Section Newsletter - January 2011
Christiana Care Health System Emergency Medicine Ultrasound Fellowship Program
David T. Cook MD, Jennifer T. Mink MD, John Powell MD, Paul R Sierzenski MD RDMS, and Jason T. Nomura MD RDMS
Placement of a central line is a common procedure in the resuscitation of critically ill patients in the Emergency Department. Real-time ultrasound guidance can reduce mechanical complications associated with central venous cannulation. This includes decreasing arterial puncture and increasing the rate of first pass success.
One complication of central venous catheter placement that may be detected by ultrasound guidance of vessel cannulation is misdirection of the catheter. We have all had internal jugular (IJ) catheters that travel into the subclavian or flip in a retrograde direction. We can employ ultrasound to gauge direction of the needle, location of the bevel and direction of the guidewire J-Tip.
When cannulating the IJ you can evaluate the placement of the guidewire to ensure it is placed correctly. The first step is to make certain that the wire has been placed in the IJ without puncture of the posterior wall. As described in several publications visualization of the wire should occur in a transverse and sagittal plane to ensure its location of prior to dilation.
You can then angle the transducer and trace the IJ and wire to the brachiocephalic vein (Figure 1). Depending on the maximal depth and frequency of your probe you may or may not be able to visualize the superior vena cava. The next step is to evaluate the ipsilateral subclavian vein to ensure the wire is not directed laterally (Figure 2). You have now ensured that the wire is at least directed to the ipsilateral brachiocephalic.
If you prep widely enough you can also repeat this on the contralateral side to ensure that you have not directed the wire to the contralateral subclavian or IJ.
Figure 1: View of the wire in the brachiocephalic vein. This probe does not have a low enough frequency and maximal depth to adequately view the superior vena cava in this patient. The probe is placed lateral and posterior to the clavicular head of the sternocleidomastoid muscle and directed toward the contralateral nipple.
Figure 2: The subclavian artery and vein are visualized without wire present in the subclavian vein. The probe is placed superior the clavicle and lateral to the clavicular head of the sternocleidomastoid muscle.
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Listserve Topics: Transvaginal Probe Disinfection - Emergency Ultrasound Section Newsletter - January 2011
J. Matt Fields, MD
A commonly discussed listserve topic is the appropriate method of transvaginal probe (TVP) cleaning and disinfection. Below is a summary of the current guidelines, brief review of the literature and a brief discussion on the debate between high- and low-level disinfection.
Definitions: (adapted from CDC Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008)1
Cleaning - The process of removal of visible contaminants from objects. In regards to transvaginal ultrasound this includes removing the probe cover, wiping it down with a damp cloth, and washing it with running water and liquid soap to remove all ultrasound gel and visible debris. Cleaning before disinfection is essential for successful disinfection.
Disinfection - The process of eradication of many or all pathologic microorganisms, except bacterial spores, on inanimate objects. Three categories of disinfection include:
High-Level Disinfection (HLD) - The eradication of all organisms except bacterial spores.
Mid-Level Disinfection (MLD) - The eradication of most bacteria, viruses, and fungi including Mycobacterium tuberculosis and some bacterial spores.
Low-Level Disinfection (LLD) - The eradication of most bacteria, some viruses, and some fungi. It is often ineffective against Mycobacterium tuberculosis and bacterial spores.
Recommendations & Evidence:
Currently, the CDC and American Institute of Ultrasound in Medicine (AIUM) consider the TVP a semi-critical device, a device that comes in contact with mucous membranes, and recommend HLD. The CDC supports this recommendation, despite the use of probe covers, citing evidence of high probe cover perforation rates. One of the main studies the CDC cites for this recommendation is from 1995 by Hignett and Claman 2, in which three different types of commercially available probe sheaths were examined before and after oocyte retrieval for perforation. To determine perforation the probe covers were filled with water and checked for leaks. They found perforation rates of 25%, 75%, and 81% post procedure and 25%-65% pre-procedure. A study by Rooks et al3 randomized patients to a different commercially available cover vs a condom and found that condoms had a significantly lower perforation rate 1.7% (vs 8.3% for the probe covers). A study by Amis et al4 also found a low rate of condom perforation (0.9%). In this study post-procedural swabs for bacteria and HSV were performed and only one of a total of 46 for bacteria was positive and all probe samples were negative for HSV. The largest study of condom perforation rates was by Milki and Fisch5 including 840 consecutive transvaginal ultrasounds and found a perforation rate of 2%, however a large portion of perforations were not distal enough to pose a risk of intravaginal contamination.
Despite these studies demonstrating potential failure of probe covers and condoms, there is a lack of clinical data showing actual transmission of organisms or any case reports of negative clinical outcomes. The controversy surrounding the CDC recommendation is that it is based on surrogate data points and not on hard clinical evidence of organism transmission. While perforation may occur, contamination may not. Even if one assumed that perforation leads to contamination then two separate perforations must occur during the life of the organism for patient to patient cross contamination to occur from a TVP. In addition, many of the studies suffer from small sample size and test only selected products fifteen years ago.
The major downside of HLD is the time and resources required to implement it, which is often difficult in a busy emergency department. 2% glutaraldehyde (Cidex ®) is the most studied and one of the more affordable agents; however, it has a pungent odor and requires a hood to prevent respiratory irritation. The manufacturer recommends a contact time of at least 20 minutes for HLD. In addition, the probe must be grossly decontaminated and cleaned prior to placement in glutaraldehyde. Other potential chemical HLDs include hydrogen peroxide (7.5%), peracetic acid (0.2%), and ortho-phthalaldehyde (OPH).
The CDC and AIUM recommend HLD, however, true evidence of harm from LLD has never been shown. Further studies are needed. Due to the current lack of evidence it may seem reasonable to take either approach and will likely vary from institution to institution until a consensus is reached.
- Rutala WA, Weber DJ. Guideline for disinfection and sterilization in healthcare facilities, 2008. Centers for Disease Control and Prevention, Division of Healthcare Quality Promotion, 2008. http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Disinfection_Nov_2008.pdf
- Hignett M, Claman P. High rates of perforation are found in endovaginal ultrasound probe covers before and after oocyte retrival for in vitro fertilization-embryo transfer. [Internet]. J Assist Repro Genet. 1995; 12(9):606-609.
- Rooks VJ, Yancey MK, Elg SA, et al. Comparison of probe sheaths for endovaginal sonography. [Internet]. Obstet Gynecol. 1996;87(1):27-9.
- Amis S, Ruddy M, Kibbler CC, et al. Assessment of condoms as probe covers for transvaginal sonograpy. [Internet]. J Clin Ultrasound. 2000;28(6):295-8.
- Milki AA, Fisch JD. Vaginal ultrasound probe cover leakage; implications for patient care [Internet]. Fertil Steril. 1998;69(3):409-11.
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Summary of the New York City-Wide Grand Rounds - Emergency Ultrasound Section Newsletter - January 2011
St. Luke’s - Roosevelt Hospital Center, Ultrasound Division
Katja Goldflam, MD
On September 22, 2010, St. Luke’s - Roosevelt Hospital Center’s Ultrasound Division hosted its first City-Wide Grand Rounds of the academic year. The focus of discussion, facilitated by Dr. Adam Sivitz was bedside pediatric ultrasound. Participating programs included Lincoln Medical Center, Penn State, Albany Medical Center, North Shore Medical Center, Metropolitan Hospital Center, Kings County Hospital Center, Maimonides Medical Center, Long Island Jewish Hospital, New York Hospital Queens, Newark Beth Israel Medical Center and Mount Sinai Medical Center.
The evening’s presentation began with a didactic lecture on ultrasound in the evaluation of the pediatric abdomen, including the pediatric focused assessment with sonography in trauma (FAST) and the diagnosis of intussusception, appendicitis and pyloric stenosis.
The value of the FAST examination in children was debated, given that the test characteristics of the pediatric abdominal sonographic evaluation differ from those for adults. The sensitivity of the FAST is thought to be decreased in children due to the differing nature of blunt traumatic injuries sustained in this population. This includes a greater incidence of solid organ injuries that may not be readily apparent on ultrasound and also a decreased occurrence of hemoperitoneum. In contrast, the lower amount of mesenteric fat in pediatric patients may improve sonographic imaging when compared to adult patients.
Newer studies suggest that the FAST examination, possibly in combination with laboratory testing such as liver enzymes, may be useful as an adjunct to the evaluation of pediatric blunt abdominal trauma.
The second main point of discussion focused on how pediatric emergency medicine (PEM) physicians can attain ultrasound education. There are only a small number of PEM physicians with formal ultrasound training and there is increasing momentum to develop a solution, such as adding an extra year of fellowship versus formal integration into the current PEM fellowship curriculum. Several ultrasound fellowship directors expressed interest in opening up their fellowships to PEM trained physicians. This proposition was well received by the pediatric fellows in attendance.
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Journal Watch - Emergency Ultrasound Section Newsletter - January 2011
Ang SH, Lee SW, Lam KY. Ultrasound-guided reduction of distal radius fractures. Am J Emerg Med. 2010;28(9):1002-1008.
Reviewers: Brian Euerle, MD, RDMS, Ultrasound Fellowship Director, and Sarah Sommerkamp, MD, Emergency Medicine Ultrasound Fellow, University of Maryland
Objective: This study was designed to determine if ultrasound guidance can effectively aid in the reduction of a distal radius fracture. Another aim was to investigate if ultrasound can be used to assess the traditional radiographic indices of adequate fracture reduction.
Methods: The study was conducted in the emergency department of a regional hospital in Singapore with an annual census of 140,000. It was a before-and-after study, based on the introduction of ultrasound-guided fracture reduction in their emergency department. Patients studied were adults with displaced acute distal radius fractures that required manipulation and reduction. In the retrospective control group, fracture reduction was done in the traditional manner using manual palpation and post-reduction x-ray images to guide the adequacy of reduction. In the ultrasound group, two longitudinal views were obtained, along the dorsal and lateral surfaces of the radius, and could be repeated as often as necessary during the reduction. All reductions were performed by a mix of junior- and senior-level emergency physicians. Ultrasound guidance was performed only by senior-level emergency physicians, who had been trained by the use of a short video and lecture.
Results: There were 102 patients in the control (traditional) group and 62 in the ultrasound group. One patient (1.6%) in the ultrasound group and nine patients (8.8%) in the control group required repeat manipulation and reduction (P=0.056). Both groups were found to be similar when the post-reduction radiographic indices were compared.
Discussion: The authors conclude that ultrasound guidance is effective and recommended for routine use in the reduction of distal radius fractures. Fluoroscopy can be used for this purpose, but it is not commonly available in the emergency department setting. The authors mention two other possible ways in which ultrasound can be used in fracture reduction. In one, if the ultrasound scan shows good reduction, the post-reduction x-ray films can be eliminated and obtained instead at 1-week follow-up (this is unlikely to be acceptable in the U.S. practice environment). In the other scenario, ultrasound alone is used initially to diagnose the fracture and then guide the reduction, and post-reduction x-ray images are obtained.
Barillari A, Fioretti M. Lung ultrasound: a new tool for the emergency physician.Intern Emerg Med. 2010;5(4):335-340.
Reviewer: Lisa D Mills, MD, Director, Emergency Ultrasound, University of California-Davis
Summary: This is a review article of lung ultrasound (US) in the dyspneic patient. Chest radiographs and physical examinations are criticized for low accuracy in the setting of critical illness. Lung ultrasound can be performed quickly and efficaciously. High- and low-frequency transducers are used. Longitudinal and transverse scanning is considered acceptable. US of the lung involves artifact interpretation, as the lung itself is not visualized directly in much of the study. Artifacts and combinations of artifacts are interpreted to rule in or rule out the presence of disease.
Discussion: This is an excellent, compact review of the essentials of emergency lung US. Explanations of common artifacts are accompanied by high-quality images as examples. Clear, simple explanations of the physics of the findings are provided to ensure reader comprehension rather than simple memorization. This article is an excellent introduction to lung US.
Heegaard W, Hildebrandt D, Spear D, et al. Prehospital ultrasound by paramedics: results of field trial. Acad Emerg Med. 2010;17(6):624-630.
Reviewers: Russ Horowitz, MD, Emergency Medicine Ultrasound Fellow, and John Bailitz, MD, RDMS, Fellowship Director, Emergency Ultrasound, Stroger Hospital of Cook County
Objective: To determine if prehospital paramedics trained in ultrasound (US) could perform Focused Assessment Sonography for Trauma (FAST) and abdominal aortic aneurysm (AAA) US exams under real conditions.
Methods: This prospective, observational study examined the accuracy of FAST and AAA exams performed by paramedics. Twenty-five paramedics in two Minnesota cities completed a standard 6-hour US training course that included lectures, written evaluations, practical experience, and an objective structured clinical examination. A 1-hour refresher course was completed at 3 and 8 months. Paramedics followed detailed protocols describing indications and procedural steps for both FAST and AAA US exams. FAST exams were documented with 6-second video clips of the standard regions. AAA exams were documented with video clips and measurements of still images. All exams were done in an ambulance, at the scene, or during transit and did not interfere with standard medical care. US images were reviewed by a blinded emergency physician with extensive sonographic experience at a major teaching hospital. Positive US scans were confirmed operatively or by CT imaging.
Results: A convenience sample of 104 patients was imaged during the 1-year study. The mean number of US scans was 4.6 per paramedic. Twenty AAA and 84 FAST scans were performed. The mean time to perform the FAST exam was 156 seconds. Adequate images were obtained in 100% of AAA and 92% of FAST cases.
There was 100% agreement between the paramedics and the reviewing physician. All AAA exams were negative. Of the 76 adequate FAST studies, 6 were positive for intraperitoneal or pericardial fluid, as interpreted by both the paramedic and the reviewing physician.
Discussion: With a standard focused training program, prehospital paramedics are capable of performing AAA and rapid FAST exams in real-life settings with a high degree of accuracy. Limitations of the study include small sample size and small number of true positive scans. Future research is needed as to the utility of prehospital US performed by paramedics in different settings as well the optimal method of establishing and maintaining competency with limited training resources.
Jang TB, Ruggeri W, Dyne P, et al. The learning curve of resident physicians using emergency ultrasonography for cholelithiasis and cholecystitis. Acad Emerg Med. 2010;17(11):1247-1252.
Reviewer: Molly E.W. Thiessen, MD, Emergency Ultrasound Fellow, Denver Health Medical Center
Objective: To evaluate the “learning curve” of residents in performing right upper-quadrant emergency ultrasound examinations and to determine if identification of sonographic findings of cholelithiasis and cholecystitis improve relative to the number of scans performed.
Methods: This prospective study involved a convenience sample of patients presenting to the emergency department with abdominal pain or nausea/vomiting. They were enrolled in the study if their physicians ordered an abdominal ultrasound for biliary disease and a resident was available to obtain patient consent and perform an emergency ultrasound. The participating physicians were residents in the PGY 2-4 EM program or a PGY 1-5 combined emergency medicine/internal medicine program, who had undergone this institution’s standard PGY-2 ultrasound introductory training. After consent was obtained, an emergency ultrasound was performed by the resident, looking for cholelithiasis, common bile duct dilation, gallbladder wall thickening, the presence of pericholecystic free fluid, and the presence of sludge. Patients underwent a second ultrasound examination in the radiology department. The ED results were entered into a data sheet, and trained research assistants blinded to the ED results reviewed the results of the second ultrasound read by board-certified radiologists. Ultrasounds done with an attending physician or for “training purposes” were excluded.
Results: The study group consisted of 1,837 patients, who underwent emergency ultrasound exams performed by 127 physicians. The sensitivity and specificity for all ultrasounds in detecting cholelithiasis were 84% (95% CI, 81-86%) and 86% (95% CI, 83-88%). The sensitivity for sonographic signs of cholecystitis (common bile duct [CBD] dilation, gallbladder wall thickening, pericholecystic fluid, and sludge) overall were less than 60%; however, the specificity for these were all over 92%. Ultrasounds were also studied based on whether the resident had performed 1-10, 11-20, 21-30, 21-40, or 40-75 ultrasound exams. The authors found no statistically significant difference in the identification of cholelithiasis based on the number of studies performed. The true negative rate of CBD dilation, the true positive rate for pericholecystic fluid, and the true negative rate for pericholecystic fluid all demonstrated increasing trends with number of studies performed; however, once corrected for correlation, only detection of pericholecystic fluid was found to be related to the number of exams performed.
Discussion: These findings indicate that the number of scans performed does not correlate with competency. The authors suggest that alternative methods of assessing competency are likely indicated.
Louwers MJ, Sabb B, Pangilinan PH. Ultrasound evaluation of a spontaneous plantar fascia rupture. Am J Phys Med Rehabil. 2010;89(11):941-944.
Reviewer: Gregory Bell, MD, FACEP, Clinical Assistant Professor, University of Iowa Health Care
Discussion: This is a case study of spontaneous exercise-induced medial plantar fascia rupture confirmed by ultrasound. The case is unique in the patient’s lack of prior symptoms or use of steroid injections causing weakening of the fascia. The authors provide a detailed description of plantar fasciitis along with findings from this patient’s presenting examination and ultrasound examination. They reference the ultrasound criteria for plantar fasciitis from a review and meta-analysis by McMillian et al in patients with chronic plantar fascia pain. Those authors defined plantar fascia thickening and fascia hypoechoic areas as consistent findings representing plantar fasciitis. In this case study, Louwer et al suggest that a 1.5-mm hypoechoic area of the affected proximal thickened fascia on longitudinal view represented an acute tear of the medial fascia. The ultrasound scan of this patient was obtained on the day of presentation (2 days after injury and onset of pain, when he appreciated a painful “pop”). The small hypoechoic finding on imaging may not be a tear; it might represent focal hypodensity seen in fasciitis, not a rupture. The pictorial review by Jeswani et al for rupture of the entire fascia (also referenced in the article) is quite different from the image in this case report; however, Louwer et al isolated their lesion to just the medial portion of the fascia. Future study is needed to define the ultrasound criteria for plantar fascia tears, both partial and complete.
Mallin M, Lewis H, Madsen T. A novel technique for ultrasound-guided supraclavicular subclavian cannulation. Am J Emerg Med. 2010;28(8):966-969.
Reviewers: Sarah Sommerkamp, MD, Emergency Medicine Ultrasound Fellow, and Brian Euerle, MD, RDMS, Ultrasound Fellowship Director, University of Maryland
Objective: To introduce ultrasound guidance using the endocavitary probe for placement of supraclavicular subclavian lines after evaluating EM residents’ ability to identify the anatomy and comfort with the technique after an educational session.
Methods: Fifteen residents with varying degrees of ultrasound experience (none of whom had placed a supraclavicular subclavian line) were given a questionnaire to compare their comfort with the technique before and after an educational session. They were also evaluated by study team members during a practical session for their ability to correctly identify the subclavian vein.
Results: All 15 participants correctly identified the subclavian vein from the supraclavicular fossa using the endocavitary probe. Participants rated their understanding of the supraclavicular anatomy before and after the training. The average score was 2.9 before training and 4.4 after the teaching session. Participants reported their comfort level with attempting an US-guided supraclavicular central line placement with an average score of 1.9 before the teaching session and 3.7 after the session.
Discussion: This article presents a novel solution to the difficulties encountered using ultrasound for central cannulation of the subclavian vein when the traditional infraclavicular approach is attempted. Ultrasound-guided supraclavicular subclavian venous anatomy can be assessed using the endocavitary probe. A brief training session can prepare EM residents to feel comfortable before attempting the procedure. However, the study does not include actual placement of the catheter. Further research will be needed to fully assess this technique.
Socransky S, Wiss R, Bota G, et al. How long does it take to perform emergency ultrasound for the primary indications?Crit Ultrasound J. 2010;2(2):59-63.
Reviewer: Gregory Bell, MD, FACEP, Clinical Assistant Professor, University of Iowa Health Care
Objective: Socransky and colleagues looked at the duration of critical emergency ultrasound (EUS) studies performed by emergency physicians (EPs) certified by the Canadian Emergency Ultrasound Society. These physicians worked at trauma and tertiary care facility that saw 60,000 patients per year in a Canadian metropolitan area of 160,000.
Methods: This was a prospective time-motion study of a convenience sample of patients at Sudley Regional Hospital ED, conducted from June to August 2006. The EUS exams were timed by stopwatch during day and evening hours by a research assistant, who recorded from onset of the physician’s interaction with either the machine or the patient in preparation for the study. The exams were done for the following indications: cardiac arrest, rule-out cardiac effusion, rule-out intra-peritoneal free fluid in trauma, rule-out abdominal aortic aneurysm, and rule-in intrauterine pregnancy. Results were recorded as positive, negative, or indeterminate if adequate views were not obtained or if findings were equivocal.
Results: Sixty-six exams were done on 51 patients by 11 EPs. Mean exam duration was 137.8 s (range, 11-465 s; 95% CI, 112.5-163.0). Two examiners with experience of more than 1,000 EUS exams were compared with the other EPs (n=37; duration=129.4 s; 95% CI, 96.4-162.4 vs n=29; duration=148.4 s; 95% CI, 76.3-322.5). Statistical difference was p=0.922. The duration according to outcome was as follows: positive studies (n=8; duration=199.4 s; 95% CI, 76.3-322.5), negative (n=49; duration=123.3 s; 95% CI, 97.3-149.4), and indeterminate (n=9; duration=161.6 s; 95% CI, 79.1-244.1), with a statistical difference of P=0.114.
Discussion: EPs certified in EUS performed the studies in an average of 2 min and 17 s, timed by stopwatch. EUS exam duration has been the focus of several previous papers, all demonstrating a sizable time savings over formal radiology studies. This paper is no different but reports less average time than other studies referenced. It also compares duration according to type of EUS study, experience level of the provider (>1,000 vs <1,000 EUS studies performed), and conclusion of the study EUS (positive, negative, or indeterminant). There was no significant difference in duration for these subgroupings, but the subgroup sizes were too small to draw valid comparisons. This study of exams performed by certified physicians re-demonstrates that performing critical ultrasounds requires little clinical time.
Volpicelli G, Noble VE, Liteplo A, et al. Decreased sensitivity of lung ultrasound limited to the anterior chest in emergency department diagnosis of cardiogenic pulmonary edema: a retrospective analysis. Crit Ultrasound J. 2010;2(2):47-52.
Reviewers: Roderick Roxas, MD, Emergency Medicine Ultrasound Fellow, and John Bailitz, MD, RDMS, Fellowship Director, Emergency Ultrasound, Stroger Hospital of Cook County
Objective: Lichtenstein and Mezière reported a 97% sensitivity and 95% specificity for pulmonary edema utilizing the BLUE protocol’s B Profile of limited anterior lung sonography in ICU patients. In a well-done collaboration between international experts, Volpicelli and colleagues examined the hypothesis that the B Profile is less reliable in ED patients presenting with acute decompensated heart failure (ADHF) compared with more extensive lung sonography examining both the anterior and lateral lungs.
Methods: For this retrospective study, 170 patients were selected from three previous prospective studies performed between 2004 and 2007, which evaluated multiple zone, anterior, and lateral lung sonography.1-3 Inclusion in the analysis required a chief complaint of acute dypsnea with a later confirmed diagnosis of ADHF, without a complicating pulmonary diagnosis. Forty-nine patients were included from Study 1, during which ultrasound was performed within 12 hours for 90% of all patients and within 48 hours of admission for all patients. Eighty-one patients were included from Study 2, during which ultrasound was performed at admission in all patients. Forty patients were included from Study 3, during which ultrasound was performed within 6 hours in 95% of patients and within 12 hours of arrival in all patients.
Initial lung ultrasound images were re-evaluated utilizing the B Profile, solely examining each anterior lung. A positive B profile was defined as bilateral anterior lung zones demonstrating “predominant” B lines with concomitant lung sliding. The finding of three or more B lines, separated by at least 7 mm, was previously described as being significant. The sensitivity of the B profile was calculated in comparison with the study’s gold standard of confirmed diagnosis of ADHF. A subset analysis was then performed on those patients not diagnosed by B Profile criteria.
Results: The overall sensitivity of the B Profile in diagnosing ADHF dropped to 83.5% (95% CI, 77-89%), with similar sensitivities among the individual studies. Seven patients of the 170 (4.1%) total had only lateral B lines. In Studies 1 and 2 (n=130), patients receiving only medical management accounted for all cases missed using B Profile criteria. Patients who required assisted ventilation (CPAP, BIPAP, intubation) were not missed.1,2
Discussion: The sensitivity of the B Profile for the detection of ADHF dropped from 97% in Lichtenstein’s ICU patients to 84% in ED patients from the three earlier studies. The discussion points out that the decreased sensitivity is largely due to the wider spectrum of ADHF disease severity in ED patients. Mild ADHF results in fluid, so B lines appear only in the more dependent lateral zones. Patients with severe ADHF will have B lines in both the lateral and anterior lung zones. The subset analysis confirmed that the B Profile missed no patients with severe disease, as evident by the need for ventilatory support. These findings are similar to studies that demonstrated reduced sensitivity of the FAST exam using only the right upper quadrant or pelvic view. Limited US is adequate in patients with severe disease, but more views are needed to detect more subtle disease. Another source of bias is the timing of sonography. ICU patients were scanned within 20 minutes, while ED patients were scanned up to 48 hours later. Future prospective studies of the focused B Profile and the more extensive anterior and lateral lung US performed at ED arrival are needed to determine the best approach to lung US in ED patients with suspected ADHF.
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