Emergency Ultrasound Section Newsletter - May 2007, Vol 11, #2
From the Chair
Slowly But Surely
Robert A. Jones, DO, RDMS, FACEP
As I returned from the American Institute of Ultrasound in Medicine (AIUM) meeting in New York City last month, I reflected on the meeting and my experiences there. Overall, my experiences were quite positive. It was apparent that we were getting the recognition we deserve as a specialty for our work within the ultrasound community. However, one area that seemed to come up over and over was in regard to our training guidelines. Many were enthusiastic that we were using ultrasound at the bedside, but they felt that we should adopt AIUM’s training guidelines.
In the last newsletter I reported that we had stalled in our negotiations with AIUM in the creation of a joint AIUM-ACEP FAST exam document. The concerns AIUM had were all centered on our training guidelines. I am now happy to report that we have moved forward here through the hard work of members within our section and the document has been approved.
At this point I would like to thank the emergency physicians who have worked so hard on the joint ACEP-AIUM document (Vivek S. Tayal, MD, FACEP; David P. Bahner MD, RDMS, FACEP; Michael Blaivas, MD, FACEP; John L. Kendall, MD, FACEP; John Christian Fox, MD, FACEP; Stephen Hoffenberg, MD, FACEP; and Paul R. Sierzenski, MD, FACEP). I would encourage those of you who are not members of AIUM to join today. We now have an emergency physician (Dr. Bahner) on the AIUM Board of Governors. This is a huge step forward for us and will allow us to continue to have our voice heard. For those of you who couldn’t make the AIUM meeting, it was decided at their emergency ultrasound section meeting to combine the section with the newly formed critical care section. Therefore, if you know of any critical care physicians who are interested in bedside ultrasound, encourage them to join too. Remember, there is strength in numbers.
Does this now mean that we have won the hearts and minds of all and can now sit back comfortably knowing we have reached our destination? The answer once again to this question is unfortunately: NO. However, this does show that we are on the right track in this area. Unfortunately, we will never be able to win the approval of all physicians from other specialties, but the good news is that we are continuing to win the support of the key individuals in organizations like AIUM that are capable of impacting change. It is essential that we continue to work with AIUM since they are the recognized multi-specialty leader in the area of ultrasound. As the leading specialty in the use of bedside ultrasound, it appears AIUM also realizes the importance of continuing to work with us.
The process of getting to our destination is far from over. We still have to tackle the issues of accreditation and certification. However, I want to reiterate that we are on the right track here as well. The leading multi-specialty ultrasound organization (AIUM) is showing that they are willing to work with us and we need to continue to take advantage of this open door. I am cautiously optimistic here. Understand, however, that the section and ACEP are committed to ensuring that the practice rights of emergency physicians are fully protected. If negotiations with AIUM fail, be assured that ACEP will be there for us. We will continue to remain proactive in making certain that emergency medicine has a solid position from both a clinical and billing perspective within the ultrasound community. We will continue to keep you aware of our progress here and will seek input from the section as discussions move forward. I would encourage everyone to get involved in the ultrasound community. For those of you who signed up for one of the subcommittees, please be patient. It will take some time to get these subcommittees running smoothly, but I expect that a lot of good things will come from these subcommittees.
In future issues of the newsletter, I would like to have articles from other sections (uniformed services, pediatrics, critical care, EMS) within ACEP that are currently using ultrasound, since this would be of interest to our members and would potentially open avenues for us to support them. How many of you are aware that there is now a Tactical Ultrasound Course for docs in the military? In addition, we are working with the critical care section to put out a special joint newsletter that would focus on critical care ultrasound.
If anyone has any questions, comments or concerns, please feel free to email me c/o ultrasound.section @acep.org.
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A Welcome to the AIUM Board of Governors
David P. Bahner, MD, RDMS, FACEP
The American Institute of Ultrasound in Medicine (AIUM) was founded in 1951 by a group of 24 physiatrists who used therapeutic ultrasound. The organization has changed over the years but continues to highlight the practice of ultrasound in modern medicine. The administrative governance of this organization includes a president, the first being Disraeli Kobak, MD in 1952. There is an executive committee that includes the CEO of the AIUM, the president, president elect, immediate past-president, 1st and 2nd vice presidents, secretary and treasurer. The executive committee reports to the Board of Governors, which represents 3 groups of five individuals who serve 3-year terms. Additionally there are ex officio members from the American Medical Association (AMA), the Journal of Ultrasound in Medicine (JUM) editor, and the CEO of the AIUM. Finally there are official liaison members from the American College of Radiology (ACR), American College of Obstetrics and Gynecology (ACOG), Society of Diagnostic Medical Sonography (SDMS), Society for Vascular Ultrasound (SVU), Society of Radiologists in Ultrasound (SRU), Society of Maternal Fetal Medicine (SMFM) and the National Electrical Manufacturers Association (NEMA). The board meets twice a year, once in the spring at the annual meeting and once again in the fall.
This past election, one of the board seats was opened up to two emergency physicians for the first time. Michael Blaivas, MD, FACEP and David P Bahner, MD, RDMS, FACEP, were nominated and ran for a board position that consisted of an online election. There are roughly 7500 members within the AIUM and all members are allowed to vote online. Each candidate for the board position posts academic positions, AIUM contributions and goals for the AIUM on a personal web page. The voting closed on January 31, 2007.
I received notice from then AIUM President Lennard Greenbaum, MD that I had been elected to the board and was invited to attend the 2007 AIUM board meeting as a guest on March 19, 2007. At the conclusion of the board meeting I would begin my three-year term 2007-2010 as a member of the Board of Governors.
I graduated from medical school in 1995 and entered into an emergency medicine residency. I was exposed to ultrasound between my first and second year of medical school when I worked in the Radiology Department at Cincinnati’s Children’s hospital. During residency I became interested in emergency ultrasound and took some courses and learned to scan. I graduated and took more courses as I stayed on as faculty at Ohio State. I immersed myself in the sonography community by joining multiple ultrasound and emergency medicine organizations. After all, activism begins with membership. I went to national and international meetings and met those that practice, research and teach diagnostic ultrasound. I listened and learned about how ultrasound was changing in medicine and watched as miniature machines became prevalent. This paradigm shift of the practice of ultrasound has caused the AIUM to reconsider its politics within the house of medicine. After the AMA resolution in December of 1999 (HR 802), the AIUM leadership reached out to the emergency medicine community by forming an emergency ultrasound section. This section met in 2001 and elected joint leadership from the emergency medicine community and radiology. The section has prospered as it contributed to the AIUM with regional courses, categorical courses, pre-convention courses, and section meetings. The current section has changed its title to the Emergency and Critical Care Medicine section to reflect the role of bedside ultrasound within the critical care community. The role of focused bedside ultrasound continues to evolve as devices become portable, affordable and more non-traditional imaging specialists learn to use these tools.
The current AIUM membership on 12/31/06 stood at 7421 members. A total of 1264 members joined in 2006. The breakdown of membership includes OB/GYN (2161), Radiology (1537), Maternal Fetal Medicine (933), Internal Medicine (156), Reproductive endocrinology (149), Nuclear medicine (142), Surgery (104) and 17 other groups with less than 100 members. Emergency medicine has 75 members within AIUM which represents 1% of total membership.
I attended the 2007 AIUM Board of Governors meeting in New York. Many issues were discussed concerning the Annual meeting as well as hearing reports from the different liaisons. The focus was always an attempt to improve the practice of ultrasound in medicine. Each of the members brought experience and a belief in the clinical practice of ultrasound to this diverse group of ultrasound specialists. Each member has influenced the recent history of ultrasound and now meets with the confidence to shape the future of ultrasound within this AIUM organization. One topic of discussion at this year’s board meeting made highlight of the expanding role of ultrasound in emerging specialties. The utilization of ultrasound in medicine is changing, and I listened to top-level discussions on how this organization resolved its role to promote ultrasound in the practice of medicine. The board supports the AIUM sponsorship of the Ultrasound Practice Forum to be held in Baltimore, MD, on April 23, 2007. This forum continues to convene those from all areas in the ultrasound community to address the future of training, practice, accreditation and other important sonographic issues that affect the safety of our patients.
My agenda as a Board of Governor is simple. I have been very active in medical student ultrasound training and consider this the ultimate answer to competency issues. There are answers to the challenges of the day in regard to the practice and quality of ultrasound. The answers lie with the collaborative and developing training for medical students who will eventually become residents. Residents then become attending physicians who will use ultrasound in their practice. Once a proficiency path has been defined that includes the entire educational spectrum, it will be more efficient at producing competent practitioners.
I began my term as a member of the AIUM Board of Governors as of March 19, 2007. I am a physician, a sonographer, an emergency practitioner, and an educator. I consider ultrasound underutilized in medicine and recognize a great need for more coordination among those practicing this specialized skill. I want to encourage those who are interested in making a difference to contact me to let me know how I can stay in touch with the issues facing those that utilize ultrasound in emergency and critical care. The future is bright in regard to ultrasound in medicine and the challenges that are present can be addressed and solved through consistent resolve to improve the quality of our patient’s lives. The AIUM defines itself as an umbrella organization that encompasses specialist from many fields and ultrasound disciplines. It has been imperative to have an emergency medicine voice within this organization. I am privileged to represent our specialty and will continue to promote the principles of emergency ultrasound within the AIUM.
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From the Editor's Desk: Musings on a Rail Fence and a Clematis
Gary Quick, MD, FACEP
Two benchmarks of excellent clinical practice reside in the capability of the practitioner and in the structure of the organization to provide a salutary practice and support for the practitioner. An example from the landscape garden will help to develop the truth of my premise on benchmarks.
If I wish to display a rail fence standing in full sun covered with a clematis vine as a focal point of one area of a property, the clematis or practitioner must possess certain qualities in order to pull off the concept. First, the clematis must be of a variety which thrives in full sun. A shade-loving clematis simply will not survive the blazing intensity of the mid-summer solar cooker of the sun. Likewise, the vine must possess the intrinsic size and vigor to climb the fence scaffold and cover it with profuse blooms. Third, we must have a source of good quality mulch to protect the roots of our vine. Clematises are known to grow vigorously in full sun if the soil is maintained in a moist and cool condition beneath an appropriate mulch layer. Next the scaffold of the fence might require modification to accommodate the climbing vine. The clematis climbs best on a mesh or grid structure such as hardware cloth, chicken wire or criss-crossed lattice. These materials accommodate the nature of the vine’s tendrils by which the clematis fastens itself to the structure upon which it is to climb. Finally our vine must have a source of water to preserve its life and keep it growing.
The analogy of the clematis vine allows some comparison to the Emergency Ultrasound Section, especially as we look at the content of this newsletter issue. We are a clematis that thrives in full sun. As emergency physicians, our practice environment, including our triumphs and our errors, are visible to all our colleagues. We practice daily in a fishbowl. Almost all of our patients end up in another physician’s practice, permitting disclosure of our errors and inspection of our work. Our emergency ultrasound clematis has demonstrated over the years of our existence that we are bred of vigorous stock. We have the nature, the energy, and the instinct to cover the fence with a profuse mantle of bloom as noted in our output of work as an ACEP Section.
As Dr. Jones mentions in "From the Chair," ACEP covers our roots as a thick and insulating layer of mulch to secure the critical roots of our vine, roots which continue to pump vigor into the vine resulting in continued opportunity for growth. The trellis or support for our vine is the product of the collective work of our leaders over the years working to build the structure of the section. Simultaneous they integrated the Emergency Ultrasound Section into ACEP. Next came our efforts to become part of AIUM and other ultrasound organizations and even within the house of medicine itself. We are building a strong, effective and desirable structure.
Finally there is the water. Ah yes, the water! Whence cometh our water? The water of this Section is you, the membership. The three-legged stool of clinical practice, education and research comprise the lifeblood of the Section. Every time you pick up the probe and perform an exam, each course you take, every time you share a bit of technique or share a case, every time you review results or collect data in a formal or informal trial, you are providing an infusion of new water into our Section’s vine. As you watch this process over years as some of us have, you see the centerpiece vine becoming fuller.
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AIUM Liaison Report
Vivek S. Tayal, MD, FACEP
ACEP Liaison to AIUM
I attended the AIUM annual meeting held in New York, NY on March 15-18, 2007 on behalf of ACEP. There were several developments pertinent to emergency medicine as described below. Most importantly, continued discussions were held regarding accreditation and partnering with other like-minded organizations.
AIUM Emergency Medicine Board Member – One Board position was designated for emergency medicine, and David P. Bahner, MD, RDMS, FACEP, of Ohio State was elected to that position. Dr. Bahner has been very involved with ACEP Section on Emergency Ultrasound, and will be a proponent for emergency physicians.
New President of AIUM – the new president of AIUM is an obstetrician, Joshua Copel, MD. It is too soon to tell if he will change the direction of the organization to accept the potential of clinical physicians who perform ultrasound.
- AIUM Emergency Ultrasound Section Leaders
- Chris Moore, MD, FACEP – Dr. Moore, the previous vice-chair, has ascended to the Chair of the Section.
- Michael Blaivas, MD, FACEP – Dr. Blaivas is the Secretary of the Section.
- The Section sponsored a pre-course on the Critically Ill patient, which was well-attended.
- Several emergency medicine members including Michael Osborne, MD, Christopher C. Raio, MD, Dr. Bahner, Vicki E. Noble, MD, FACEP, and Arun Nagdev, MD spoke at the meeting.
ACEP Leadership - Many present and former leaders of the ACEP Section on Emergency Ultrasound attended the meeting including Robert A. Jones DO, RDMS, FACEP (present chair), Paul R. Sierzenski, MD, RDMS, FACEP (past chair), Michael Blaivas, MD, FACEP (past chair), Larry Melniker, MD, FACEP (Section Councilor) and many other section members.
- Joint FAST Guideline
- ACEP has its own FAST guideline under the ACEP Imaging Criteria – Trauma approved by the Board in 2006.
- ACEP and AIUM had worked cooperatively over the last 3 years to develop a joint FAST guideline.
- A working document was finished right after the AIUM meeting in March 2006 in Washington, D.C.
- However, in the fall of 2006, I was notified by Dr. Greenbaum that the AIUM wanted the negotiated document changed to a different format with references to ACEP only at the beginning of the document and references to ACEP documents within the text of the document deleted.
- We objected to this change on the basis of the following:
- We had negotiated for 2 years in a good faith effort to an agreed document with appropriate references within the text.
- Only citing ACEP at the beginning of the document without references to ACEP documents within the joint guideline would weaken the document.
- Specific references to physician training and QA would have only referenced current AIUM policies, which we already oppose.
- We are trying to work with the AIUM standards committee to resolve issues, but are firm on references to ACEP US documents and policies, so ACEP members will not be stuck with current AIUM policies as a default for hospital credentialing and QA committees.
There was continued discussion of the possible threat of the need to be accredited by third-party agencies to be paid for emergency ultrasound.
- MedPac threatened this in 2005-2006 but Congress did not move on due to other issues
- United Healthcare and others have sent a letter to all outpatient facilities performing CT, MRI, diagnostic ultrasound, and echocardiography stating that they must be certified by ACR, ICAEVL, or other certifying entity.
- Hospital based imaging per se has not been affected but we are very concerned that the threat of mandatory accreditation will choke off the continued growth and practice of emergency physicians who perform ultrasound.
- In particular these accreditation guidelines require significant paperwork, fees (into the thousands of dollars), and standards that do not fit the typical practice of emergency ultrasound.
- Partnering with Other Organizations
Critical Care – We feel critical care, particularly the ACCP, is where we were in bedside ultrasound eight years ago. They are running into the same political and reimbursement battles. We are networking and making contacts with specialties that use ultrasound like we do.
Dr. Blaivas and I will be attending the 2nd US Practice Forum on April 23, 2007 on behalf of ACEP, and I will report on that meeting.
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Resident Echoes - "Dirty Shadows"
Mechanisms of Resident Feedback, Their Pros and Cons
Amit Bahl, MD, MPH
Chief Resident, North Shore University Hospital
Feedback is a crucial component for each resident’s learning experience. Within an emergency ultrasound educational program, feedback can be given on several different levels. First, hands-on bedside teaching where each resident scans directly with qualified, credentialed faculty is vital to skill development. This feedback should transition appropriately through each level of resident training. At the intern level, feedback may be as simple as demonstrating appropriate maneuvers of the transducer or identification of an organ or structure. As the resident advances, objectives of training will mature to more subtle methods of image quality optimization, use of Doppler, etc. At each step the resident should feel comfortable reproducing the specific learning objective, or at least walk away from the interaction confident that he or she has improved his technical skill. The most beneficial and productive characteristic of the hands-on learning experience is the questions that come up for discussion with each patient encounter. However variable, the dialogue that arises from bedside interaction leads to the integration of ultrasound skill with real clinical problems, cases, and complications: a fundamental goal of each teaching session. The disadvantage of bedside teaching is that there is no way to guarantee the consistency and availability for each learning objective. One cannot predict what patients will present on a given shift. Thus it is clearly important to have multiple credentialed faculty members able to instruct residents on a daily basis. One would hope that over the course of a 3- or 4-year residency program that each resident’s patient exposures would be fairly consistent. This bedside teaching should also be supplemented with other forms of resident feedback.
Next, workshops combined with informal or formal evaluation make up another important method of resident feedback. This process is particularly helpful when focusing on the indications, techniques, and implications of specific ultrasound examinations. For example, when learning about the evaluation of the aorta, residents may first learn from a formal lecture and subsequently practice this skill in a group setting with teaching faculty. During the group sessions, faculty may formally evaluate each resident’s ability to fulfill the requirements of the scan. This method is useful because it uses objective criteria for performing specific examinations. It can offer great insight into the resident’s strengths and weaknesses and may serve as a comparison to evaluate his or her improvement over time. This may directly correlate to the residents’ understanding of the learning material and their ability to reproduce these scans in the clinical setting. Although very helpful, this form of objective evaluation is useful only to assure basic competency. Scans are done for the most part on a select group of normal volunteers. This experience must be combined with subjective feedback from the teaching faculty to appropriately evaluate various qualitative measures that rely on scanning maneuvers to obtain quality images in difficult patients and the interpretation of those images. This approach may not be embraced by some residents because there may be a "grade" or "test" at the completion of the session. Faculty should emphasize that the exercise is purely a learning experience.
Lastly, a select number of emergency departments (EDs) have a formal tape review process where each ultrasound examination performed in the department is recorded and then viewed on a weekly or bi-weekly basis. Certain programs may utilize review of still images in a similar manner. The tape review process is a very important tool for resident feedback. The scans are reviewed with qualified faculty members and tips on image optimization, locating anatomy, scanning techniques, and clinical pearls are discussed. Residents are able to view not only their own scans but all of the exams performed in the department during a given time period. Even if an individual is not present for the review, process tips can be communicated directly or via email. These tape review sessions are also vital to the quality assurance process of an ultrasound division. In a busy ED more than a hundred scans may be reviewed on a weekly basis which offers a huge learning opportunity for residents.
Each feedback process is important in residency training. Multiple methods, integrating both formal and informal mechanisms, are crucial to effectively educate each resident and foster the growth of their ultrasound skills. Just as feedback from attending to resident is important, so too is the feedback from the individual resident to his or her training program. Only the resident can effectively assimilate and evaluate the efficacy of the feedback. Response to resident opinion is a vital part of every program to ensure that the learning environment is evolving appropriately.
Note: I would like to encourage residents from other programs to get involved with "Resident Echoes." Please contact me firstname.lastname@example.org.
Christopher C. Raio, MD, RDMS
Director, Emergency Ultrasound
North Shore University Hospital
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Ultrasound Journal Watch
Jacoby J, Cesta M, Axelband J, et al. Can emergency medicine residents detect acute deep venous thrombosis with a limited, two-site ultrasound examination? J Emerg Med. 2007; 32(2):197-200.
Reviewer: Matt Solley, MD, RDMS
Introduction: The detection of acute deep venous thrombosis (aDVT) is a task that is often required of the emergency physician. The lack of in-house ultrasound technicians at all hours of the night, and the time required to do a complete examination of the entire leg, can make the diagnostic work-up of suspected aDVT difficult. Previous studies have shown that a limited examination of the leg can be utilized to accurately manage suspected proximal aDVT. The purpose of this study was to evaluate the accuracy of emergency medicine residents in identification of aDVT by performing a limited ultrasound examination of the lower extremity (LE).
Methods: This study was done at a community teaching hospital with an annual census of 55,000. EM residents were eligible to enroll patients after completing a one-day introductory emergency ultrasound course, a 90-minute didactic session on limited compression ultrasound (taught by a teaching faculty and senior resident), and a hands-on component that consisted of three examinations (taught by two senior vascular technicians). A total of six EM residents, two from each year of the three year EM residency, were trained to perform the limited LE ultrasound examinations. The exam was limited to the femoral region (through the bifurcation into the deep and superficial femoral veins) and popliteal region (through the trifurcation into the anterior and posterior tibial and peroneal veins). A positive test was defined as the presence of an acute, non-compressible, occlusive clot in the defined target area above; whereas the exam was considered normal if the vein completely compressed. A 7.5-MHz vascular probe using an ATL 5000 was utilized for all scans, with all exams completed in the vascular lab on patients that may or may not have been referred from the emergency department (ED). The utilization of Doppler, respiratory variation, and augmentation were allowed but not required. A complete scan including both the distal part of the leg and chronic, non-occlusive clots was done afterward by a vascular technician utilizing the same equipment. The vascular technician’s scan was used as the criterion standard for comparison, with only positive findings detected in the limited target area as described above utilized for comparison.
Results: There were 121 symptomatic legs evaluated. Vascular technicians detected nine aDVTs in the target area; of these, eight true positives were identified by the EM residents giving a sensitivity 89%, (95% CI 55-100%). The one clot missed by the EM resident (false negative) was an occlusive popliteal clot. In the 112 patients without aDVT in the target area, there was concordance in 109 patients, with three false positives by the EM residents.
There were eighteen additional clots identified by the vascular technicians in their complete exam that were outside of the target area and/or chronic or non-occlusive. In describing these eighteen clots, one must extrapolate conclusions from the data because the authors describe them in a confusing manner. There were twelve distal clots and seven proximal clots. This adds up to nineteen, so an assumption might be made that one leg had a proximal and distal clot. Ten of these clots were chronic or non-occlusive. It was not entirely clear as to which of the proximal clots were excluded because of being chronic versus being out of the target area.
Comment/limitations: There are several limitations to this study that are worth mentioning and limit the clinical significance in the ED setting. This study was not done in an ED setting using ED equipment. The use of an ATL 5000 is not an entry-level machine that one would expect to find in the average ED, and hence might increase the sensitivity of the EM resident performance. Additionally, the ultrasounds were done in the vascular lab, which could allow the EM resident more time to dedicate to the exam than would actually be allowed in a typical busy ED setting. Furthermore, patients were not necessarily ED patients but may have been referred to the vascular lab on an outpatient basis. The bulk of the literature we base management decisions on are specific to symptomatic ED patients. Patients referred to a vascular lab might be there to rule out DVT simply based on risk factors and to an acutely swollen extremity. This may have been a contributing factor to lower incidence of positive studies than is reported in the emergency medicine literature.
Allowing but not requiring Doppler, respiratory variation, and augmentation introduces confounding variables into the results. These additional techniques should have either been excluded or utilized on all patients. If one resident was more adept at the utilization of these techniques (which have been shown by other studies to not be necessary), this resident could be altering their sensitivity or specificity. It would also be helpful to know what criteria the EM residents used to determine that a clot was chronic versus acute, since they were clear in their pre-defined criteria that only acute DVTs were considered positive. Another weakness of the study was that a limited ultrasound exam was compared to a complete exam for comparison. Comparing two tests when neither one is 100% accurate has its limitations. It would have been ideal (but probably not feasible) to obtain a criterion standard such as CT Venography.
In their discussion, the authors suggest that a negative study by the ED should be followed-up with a "formal" radiology study because of their sensitivity of 89%. This might indicate that they would advocate anticoagulation based on their positive studies. Looking at the numbers, with 8 true positives and 3 false positives, if one anti-coagulated all of these patients, then 37% would be needlessly anti-coagulated.
Despite some flaws in the methodology of this study that would keep me from changing my clinical practice, the authors should be commended for training their residents to perform this ultrasound application and coordinate the study with their vascular lab. However, as presented, this study does little to add to the body of literature for limited ultrasound examination by emergency physicians to evaluate for suspected aDVT.
Stone MB, Teismann NA, Wang R. Ultrasonographic confirmation of intraosseous needle placement
in an adult unembalmed cadaver model. Ann Emerg Med. 2007; 49:515-519.
Reviewer: Seric Cusick, MD
Methods: A controlled trial was conducted in which intraosseous access was obtained in the bilateral distal tibia of 4 freshly frozen, unembalmed cadavers. In 8 legs, an intraosseous needle (15-gauge Jamshidi) was inserted 1 fingerbreadth superior to the medial malleolus and flushed with 10 mL of crystalloid. Measurements included whether crystalloid was observed to flow by gravity into the drip reservoir of the intravenous tubing and whether color flow was visualized within the intraosseous space of the tibia with a 5- to 10-MHz linear transducer in color power Doppler mode, positioned just cephalad to the intraosseous needle. Intraosseous needles were then intentionally placed into the subcutaneous space just posterior to the distal tibia, and these measurements were repeated. Two blinded observers reviewed ultrasonographic video recordings and rated the presence or absence of color flow within the intraosseous space.
Results: Intraosseous color flow on ultrasonography correctly identified all placements, but flow into the drip reservoir was incorrect for one of the intraosseous lines (P=1.0 versus ultrasonography) and 6 of the subcutaneous lines (P=0.31 versus ultrasonography). There was perfect interobserver agreement (kappa=1) during video review.
Commentary: This study proposes the use of bedside ultrasound to address the question we have all heard during a pediatric resuscitation: ‘Is the IO in?’ Their findings suggest that power doppler may be used to detect flow within the marrow and may be more accurate than the techniques traditionally used to verify correct placement. Once one places the obvious limitations aside – sample size, cadaveric model, single IO site examined – the results offer a novel use of ultrasound that may prove to be of great clinical utility if validated in further studies.
Ultrasound Journal Club: New Directions in Procedure Guidance
Presented by the Emergency Medicine Residency Program
Mount Sinai School of Medicine
For nearly twenty years ultrasound (US) has been used to guide central venous access. In that time we have seen an evolution in the literature from feasibility reports to large, prospective, randomized studies demonstrating changes in outcomes based on the intervention. Each year pioneers in the field expand the role of US as a tool for procedure guidance. We examined recent articles which assess new uses for US to determine how our practice may change in the future and where the next steps in research should be focused.
Bret P. Nelson, MD, RDMS
Director of Emergency Ultrasound
Mount Sinai School of Medicine
Shiver S, Blaivas M, Lyon M. A prospective comparison of ultrasound-guided and blindly placed radial arterial catheters. Acad Emerg Med. 2007;14(1):e15.
Reviewer: Jack Choi, MD
Objective: To compare the efficacy of ultrasound-guided versus traditional palpation placement of arterial lines.
Methods: This was a prospective, randomized interventional study at a large academic ED. A convenience sample of patients requiring an arterial line underwent randomization to palpation or US-guided groups.
Patients in either group who had three failed attempts were rescued with the other technique for patient comfort.
Results: 30 patients were randomized to each group. Patients in the US group were cannulated more rapidly (107 vs. 314 seconds; p = 0.0004), had fewer placement attempts (1.2 vs. 2.2; p = 0.001), and fewer sites required for successful line placement (1.1 vs. 1.6; p = 0.001).
Discussion: This prospective, randomized study demonstrated that the use of US resulted in significant improvements in three endpoints compared to the traditional palpation method. The authors acknowledged several limitations. First, all four researchers had ample experience in emergency ultrasound and blind arterial cannulation. Second, the palpation-guided technique may have been more difficult in the hypotensive patients. Although one could argue that the three endpoints were not completely independent, multiple endpoints in this study allow easier comparison to a wide range of prior studies. This study demonstrated improvements in clinically relevant outcomes using US for arterial line placement. Future studies could include operators with varied ultrasound skill levels or more hypotensive patients to determine the difference in outcomes in this subgroup.
Reviewer: Clint Masterson, MD
Blaivas M, Lyon ML. Ultrasound-guided interscalene block for shoulder dislocation reduction in the ED. Am J Emerg Med. 2006; 24:293-296.
Objective: To report on the technique and feasibility of ultrasound-guided nerve block in the setting of shoulder reduction
Methods: This is a case series of four patients undergoing reduction for shoulder dislocation using US-guided interscalene nerve block where conscious sedation was not feasible due to recent oral intake or medical comorbidities. In each case, ultrasound was used to guide a spinal needle to the interscalene position of the brachial plexus. 30 mL of lidocaine or bupivicaine was injected into the space. When adequate anesthesia was achieved, shoulder reduction commenced.
Results: In all four cases presented, the authors report adequate anesthesia was obtained, and needle entry into the brachial plexis nerve sheath was visualized using ultrasound. One elderly patient described hoarseness of voice, left face and neck numbness in addition to arm numbness which resolved after arriving home. There were no other immediate complications reported while patients were in the ED.
Discussion: Nerve blocks of the brachial plexus have long been the domain of anesthesiologists armed with electrical stimulators. As ultrasound demonstrates promise in replacing that technique, both emergency physicians and anesthesiologists may employ US for these procedures. The potential benefits of the procedure include obviating the need for procedural sedation (with the possibility for fewer complications and decreased length of stay) and more targeted anesthesia. It would be interesting to see the technique compared with intracapsular infiltration of anesthetic, another local technique which has been described as having some success. In addition, since this article describes the nerve block as a good alternative in patients who have medical comorbidities, it would be useful to see if larger numbers bear out a low complication rate. The side effects experienced by the elderly patient in this study may be disconcerting to many clinicians without this additional data.
Liebmann O, Price D, Mills C, et al. Feasibility of forearm ultrasonography-guided nerve blocks of the radial, ulnar, median nerves for hand procedures in the emergency department. Ann Emerg Med. 2006;48:558-562.
Reviewer: Thomas Wu, MD
Objective: To evaluate the feasibility of US-guided forearm nerve blocks for hand anesthesia.
Methods: This is a prospective observational study evaluating ultrasonography-guided blocks of the radial, ulnar, and median nerves. Four physicians consisting of an attending, ultrasound fellow, and 2 emergency residents were instructed to perform radial, median, and ulnar-nerve blocks after a brief training session. Each subject underwent various combinations of forearm nerve block to provide hand anesthesia. A high frequency linear array probe was placed at the wrist to identify each nerve/artery pair except for the median nerve where only the nerve was visualized. The probe was moved proximally to the mid-forearm where anesthetic was injected around the nerve under dynamic visualization. The primary outcome measures were reduction in pain and the use of rescue analgesia/anesthetic. Secondary outcomes were complications immediately after the procedure and after 3 months, time required from initial US to completion of last injection, and patient satisfaction with the procedure.
Results: 22 nerve blocks were performed 11 patients over a 3-month period. All presented to the ED with hand injuries necessitating procedural intervention. Using a 100mm visual analog scale, 10 of the 11 patients (92%) reported a clinically significant reduction in their pain after receiving anesthesia. None of the subjects requested additional anesthesia/analgesia. The researchers did not encounter any complications immediately after the procedure or after a 3-month follow up. One patient was lost to follow up. Median time to completion of the nerve block procedure was 9 minutes. Ten of the 11 participants (92%) reported that they would wish to have the procedure again for a similar injury.
Discussion: The wrist block is traditionally performed by locating the median, radial and ulnar nerves by identifying anatomical landmarks.
The authors achieved significant pain reduction with their US-guided technique and were able to directly visualize needle insertion. No complications were associated with the procedure. Although not specifically mentioned by the authors, it would be useful to know if any of the patients received systemic analgesics prior to their nerve blocks which may complicate pain assessments as an endpoint. It would be interesting to see a randomized controlled trial of ultrasound-guided forearm block compared to traditional landmark wrist block technique taking into account operator experience. As it stands, this study demonstrates that forearm ultrasound-guided nerve block shows promise as an alternative to traditional landmark techniques when performed by practitioners with limited bedside ultrasound training.
Ed.:Thanks to Dr. Nelson and his residents from Mount Sinai for sharing this informative and topical Journal Club with us.
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SOAP Update - March 2007
Lawrence A. Melniker, MD, MS
Completed trials to be presented at SAEM 2007:
- Prospective Observational Trial of Vascular PLUS for Suspected DVT: The Fourth Sonography Outcomes Assessment Program (SOAP-4) Trial (E. Leibner)
This prospective, observational cohort study enrolled 124 patients and assessed the accuracy of emergency physician diagnosis of proximal DVT in the ED using a simplified compression technique. SOAP-4 demonstrated a high accuracy for PLUS for proximal DVT in the ED compared with vascular lab studies. Of interest in this trial, no patient with a negative D-Dimer (ELISA) had a clot on either PLUS or Vascular lab studies; and the Well’s Criteria was, both, insensitive and nonspecific in the diagnosis of proximal DVT. A manuscript is in preparation.
- Prospective Observational Trial of a Lung and Cardiac PLUS-Inclusive Protocol for the Evaluation of Acute Dyspnea in the Emergency Department (M. Del Rios-Rivera)
This prospective observational trial enrolled 96 patients to assess the predictive value of a PLUS-inclusive evaluation protocol for dyspneic patients in the ED. The study demonstrated of PLUS for dyspnea to have similar test characteristics as BNP for differentiating patients with acute decompensated heart failure (ADHF), but superior to CXR for identifying interstitial edema. PLUS, in conjunction with a rapid BNP assay, may accelerate the diagnosis of ADHF in the ED. A randomized, controlled trial of PLUS for Dyspnea will be developed and presented to the consortium for evaluation. Dr. Del Rios-Rivera’s Masters thesis and a manuscript are in preparation.
- Predictive Value of Focused Assessment with Sonography in Trauma (FAST) in Assessing the Need for Operative Care: Post-hoc Analysis of the SOAP-1 Trial Database & Cochrane-Methodology Review (114 references)
- Randomized Controlled Trial of PLUS-Assistance of Pediatric Peripheral Intravenous Access (M. Sharma & L. Melniker)
This trial assesses the effectiveness of the availability of PLUS-assistance for the placement of peripheral IVs in pediatric patients. This trial will be completed by April 2007 and the results will be presented to the 2007 ACEP Scientific Assembly.
- Prospective Observational Trial of Common Carotid Intima Media Thickness Assessment in the Evaluation of Patients with Acute Chest Pain in the Emergency Department
This trial is funded by a New York State ECRIP Grant and will evaluate the predictive value of PLUS measurement of the intima-media thickness (IMT) of the carotid arteries in ED patients with suspected Acute Coronary Syndrome. It is being piloted now and will be completed in the Fall 2008 and assess the predictive value of IMT and the resultant calculated vascular age alone and in conjunction with multiple cardiac biomarkers.
- Prospective Observational Trial of Inferior Vena Cava Caliber, Variability, and Indices in Healthy Pediatric Patients: Generating a ‘Growth Curve’ for IVC.
- Prospective Observational Trial of Common Carotid Intima Media Thickness Assessment in the Evaluation of Patients with TIA and CVA in the Emergency Department
- Prospective Observational Trial of Common Carotid Intima Media Thickness Assessment in the Evaluation of Patients with Syncope in the Emergency Department
Trials in Development
- Comparative Trial of Common Carotid Intima Media Thickness Assessment with Coronary Angiography, Cardiac Computerized Tomography, and Cardiac Magnetic Resonance Imaging
- Prospective Observational Trial of Sonographic Confirmation of Endotracheal Tube Placement in the Emergency Department
- Prospective Observational Trial of Sonographic Confirmation of Endotracheal Tube Positioning in the Critical Care Setting
- Randomized Controlled Trial of PLUS for Dyspnea in the Emergency Department
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