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Emergency Ultrasound Section Newsletter - October 2017

Machine Purchase, Femoral Nerve Blocks, and Pediatric FAST

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

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Ask The Expert: “What do I need to consider when purchasing a new ultrasound system for my ED?”

To start off, there is simply no perfect answer or perfect device for Emergency Department (ED) use. That’s not to say there are not great devices that meet the needs of clinicians in the ED but getting emergency physicians amongst different sites or even within the same institution to agree on a device or features is a challenge. The variety of devices from high end radiology ultrasound equipment to hand held devices allows for options for all tastes however there should be a few basic requirements and items for consideration while evaluating possible systems for your institution.

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FOAM Ultrasound: #FOAMus Highlight

Have you listened to all your podcasts? Caught up on EMRAP? Check out the brainchild of Dr. Michael Prats (@PratsEM) and Dr. Creagh Bulger (@CreaghB), the Ultrasound G.E.L Podcast. In this podcast, they Gather Evidence from the Literature (G.E.L) and discusses important ultrasound literature as it applies to the clinician-sonographer. You can find topics from cardiopulmonary ultrasound to the evidence on confirming your next shoulder reduction by ultrasound at the bedside. Drs. Prats and Bulger abide by the spirit of FOAM, making their podcast free for all potential listeners.

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Cardiac Journal Summary

Ma WYM, Caplin JD, Azad A, et al. Correlation of carotid blood flow and corrected carotid flow time with invasive cardiac output measurements. Crit Ultrasound J. 2017; 9:10.

Scenario: 58 year-old female arrives to you with post arrest, but with a questionable cause of whether it was after seizure activity, drug induced, or actual cardiac induced arrest. She is tachycardic, hypotensive, and unresponsive. She is a former smoker, obese and with poor cardiac windows during her initial EFAST and TTE. How much fluid to give? How best to find the answer? A classic question, but what is the right answer?

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Pediatric Emergency Ultrasound Update: The Unique Pediatric FAST

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

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Chair’s Corner

Really? Summer is over? October is nearly here? I feel like I just got started!

I imagine we all feel like we can’t tell where the time goes, but for me this year was way outside the norm. (Note to self - Don’t take a new position, drive cross country with wife and dogs and be section chair all in the same year).

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Cases That Count: Right upper quadrant (RUQ) pain: An unusual presentation for an unusual finding

A 27-year-old healthy female on Depo-Provera presented to the ED with constant, sharp, non-radiating right upper quadrant (RUQ) pain for three days. The pain was unchanged with food intake, and was associated with nausea and one episode of non-bloody, non-bilious emesis on the day prior to presentation. She also reported pleuritic right lower chest pain, lightheadedness, and chills. On further review of systems, she denied sore throat, shortness of breath, cough, rash, urinary changes, diarrhea, and bloody stools. Social history was unremarkable.

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Journal Summary

Holmes JF, Kelley KM, Wootton-Gorges SL, et al. Effect of Abdominal Ultrasound on Clinical Care, Outcomes, and Resource Use Among Children With Blunt Torso Trauma A Randomized Clinical Trial. JAMA. 317(22) 2290-96.

We all know that there are plenty of situations in which a FAST exam can provide useful and even life-saving information. A group of investigators at the University of California Davis wanted to examine this ultrasound application in a previously unstudied group - stable pediatric blunt trauma patients.

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Tips & Tricks: Ultrasound guided “3 in 1” nerve block

Hip fractures, defined as fractures to the femur from the femoral neck to 6 cm distal to the lesser trochanter, are a significant source of morbidity and mortality in the elderly.1-3 The mainstay of pain control in the acute setting is parenteral opiate medications, which also carry significant risks, namely: increased incidence of respiratory depression, hypotension, and delirium. That makes it pretty tough to obtain surgical consent, communicate about the plan of care, and to get true pain control. Regional anesthesia has been a mainstay in the perioperative and post-operative care of these patients.4 In an effort to decrease morbidity for these patients in the acute setting and improve patient experience, the femoral nerve block or “3 in 1” nerve block, so called as it promotes diffusion of local anesthetic to the femoral, obturator, and lateral femoral cutaneous nerve, has gained traction with institutions including this as part of hip fracture protocols.

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Special Contribution - Peter’s Pet Peeves: “The ultrasound shows appy but I need a CT to confirm it”

A 22 year-old healthy female with abdominal pain presents to your ED at 3 am. Her pain began periumbilical yesterday evening and has gotten worse, localizing to the right lower quadrant. The ride over was “rough.” Each bump sending a shockwave of pain that also made her nausea worse. She is not pregnant and has no vaginal bleeding or discharge.

Her physical exam is unremarkable, except for the guarding and rebound tenderness of her RLQ. Even her pelvic exam is unconcerning for TOA, PID, torsion or other gynecologic pathology. The CT scanner is backed up and your radiologist still believes in needing a full oral contrast prep, so you wheel in the ultrasound machine, ask her to point to where it hurts the most. and see a tubular structure, without peristalsis, measuring 1.2cm in diameter. She tenses and winces as you push the probe on her abdomen and note that the structure is non-compressible.

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