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Emergency Ultrasound Section Newsletter - September 2010, Vol 14, #3

Emergency Ultrasound Section

circle_arrow Emergency Ultrasound Section Meeting at Scientific Assembly
circle_arrow From the Chair
circle_arrow From the Editor’s Desk
circle_arrow Tips on applying for emergency ultrasound fellowship from a recent graduate
circle_arrow City-wide Grand Rounds - 2010
circle_arrow Ultrasound Guided IV Access: Hip or Hype?? 
circle_arrow Breaking New Ground for Emergency Ultrasound
circle_arrow NQF passes two ACEP Ultrasound quality & patient safety measures!
circle_arrow Probe Humor
circle_arrow The Rise and Future of Bedside Echocardiography 
circle_arrow Emergency Ultrasound Diagnosis of Quadriceps Tendon Tear
circle_arrow Standards versus Suggestions
circle_arrow WINFOCUS Update – 2010
circle_arrow Journal Watch 
circle_arrow Thoracic Aortic Dissection Diagnosed on Bedside Ultrasound with Associated Pericardial Effusion 
circle_arrow Sonoguide Update 


Newsletter Index


Emergency Ultrasound Section

Emergency Ultrasound Section Meeting at Scientific Assembly

Make plans to attend the Emergency Ultrasound Section Meeting!   

Tuesday, September 28, 2010
11:00 am – 2:30 pm
Room: Ballroom H
Mandalay Bay Resort & Casino

The Convention Center and Hotel are all one complex.
Be sure to check the schedule on-site as meeting time and location could change.

    


 

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From the Chair

Gerardo Chiricolo, MD, RDMS, FACEP

Dear Colleagues, 

Soon we will have our annual meeting in Las Vegas where there will be no drinking, no gambling, and no fun to be had. I hear Vegas is a pretty boring place. Anyway, I look forward to seeing all of you. Obviously an update on the section activities will take place then. Among the topics we will discuss are the reimbursement issues we have faced this year, an update on the accreditation system, suggestive reporting fields, the fellowship guidelines, and section activities.  

As my last “From the Chair” is upon me, I wanted to appraise you all as to what I’ve learned this year serving as chair of the section. I learned that we are a remarkable community. I’ll begin with our young leaders. Early in the year I made a call for help. I asked you, our section members, to get involved. So many of you responded. You joined subcommittees, participated in conference calls and list-serve discussions, and many will continue to lead us in the future. 

I also appreciate our past leaders. I have always admired our previous leaders and respected all that they have done. I never realized until this year how that leadership never ends. There have been many issues affecting the section and its integrity this year. They came together to help the section through it all.  

Finally, I would like to thank one of those leaders publicly. Dr. Gary Quick has been the Secretary/Newsletter Editor for the section since 2000. This is his 37th newsletter and he has dedicated countless hours to the section. He has been instrumental in relaying political, educational, and entertaining information to our entire community. And he has done this all through great adversity. I thank him and want him to know that we truly appreciate all that he has done.


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From the Editor’s Desk

Gary Quick, MD, FACEP 

In 1999, the Section of Emergency Ultrasound presented me with the opportunity and privilege to perform a service as Newsletter Editor for the Section. The task was something which I was able to continue for a decade with some measure of success. Now, at age 65 years and climbing, I have determined that the time has come for my departure, so that the Emergency Ultrasound Section might chronicle its remarkable history through the pen of another Editor. I need not boast of our accomplishments together because they are so obvious and utilized every day as we make diagnostic and therapeutic decisions for our emergency patients. I will refer you to the growing list of foundational documents and publications listed on our section Web page. These documents have been developed and deployed by our colleagues over the years and represent the integrity and quality which our section has insisted we include in our work and structure.

Some of the fruits of our labor mark the maturation of emergency ultrasound. You will find the WINFOCUS report in this issue of the newsletter. This is an international organization to foster world-wide development of bedside ultrasound. The Sonoguide educational product on the website is an exquisite reminder of the volume and bulk of specific precepts constituting the practice of emergency ultrasound. Not only are the EM residencies now incorporating emergency ultrasound into their respective curricula, but we have, by my count, forty emergency ultrasound fellowships functioning in the section at this time. The most recent accomplishment of the section is receiving the award as the best Web page within ACEP based upon number of unique visitors and quality of content. These accomplishments have occurred in the past decade. I would remind us that they have been accomplished by hard work and collaboration among our members. 

Along the way I wrote an editorial using the analogy of a hockey game and the comments of the phenomenal Wayne Gretzky relating how he was able to score such a large number of goals and with solid consistency. Gretzky attributed his success to the concept of “skating to where the puck would be.” As the Great Gretzky was able to accomplish his feats with such finesse, so emergency ultrasound has managed to “skate to where the puck would be.” 

I have been honored and privileged to serve as your Newsletter Editor these past several years. My work has been almost effortless due to the willingness of the Emergency Ultrasound Section to provide the articles and copy which go to form the content of the Newsletter. I also wish to profusely thank Julie Williams at ACEP for handling with such expertise and accuracy the content which arrived on her desk as Editorial Assistant. Julie’s effort has been indispensable to the success of the newsletter. 

I wish every success to the next Secretary/Newsletter Editor and would leave this advice to our body. “Find a place where you can help by your participation and help us ‘skate to where the puck will be’.” 

Mike Heller, at one point about 8 years ago, nominated me for the position of Perennial

Newsletter Editor. The encouragement of the Section has been much appreciated. I have done what I could do. It is time for another to fill the slot. Thank you all very much for your wonderful support.


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Tips on applying for emergency ultrasound fellowship from a recent graduate

J. Matthew Fields, MD

So you’ve decided to give up a year of your life and chunk of your potential earnings for the noble cause of emergency ultrasound training. Having done it myself, I’ll give you some good news – it’s definitely worth it! Not only does it give you unique expertise and skill, but it garners respect amongst your peers. I cannot count the number of times another provider has approached me for help in resolving diagnostic dilemmas and performing therapeutic maneuvers with bedside ultrasound. 

But, I don’t need to convince you. You’ve already chosen this pathway and you are now deciding which of the roads (ie, fellowships) to take. This is not an easy choice as there are over fifty fellowship choices. Unfortunately, I won’t be able to tell you which choice is correct for you. Just like anything else, college match, medical school match, residency match, life partner match, etc … everyone’s match is different. That being said, you should keep in mind that this is also a match and there is a wide variety of personality and character between programs. Here are a few tips to finding and landing your best fellowship match. 

  1. Start early – While there has been some push in recent years to standardize the dates of the ultrasound fellowship application process, this has not happened. Each fellowship takes applications, interviews, and makes offers on its own calendar. The earlier you start, the more likely you are to be considered by all programs you apply to and have a chance to visit while they are still interviewing.
  2. Go to www.eusfellowships.com - Thanks to Drs. Hunt and Gaspari who manage this website, it has become a must for anyone considering an ultrasound fellowship. You’ll find program and contact information to get you started. In addition, you can submit your applications via the website at no cost! Be sure to check out the SAEM ultrasound fellowship listings as well.
  3. Make individual contact with fellowship directors. Utilize the upcoming ACEP conference as an opportunity to meet people in different programs or even schedule an informal interview. Interview early if possible. Give yourself plenty of time to evaluate your options. The last thing you want is to have a deadline for the first place you interviewed before you have completed your last interview.
  4. Have a plan. Think about why it is you are pursing ultrasound fellowship. Sure you like emergency ultrasound, but dig deeper. What do you want to get out of the year? Where do you want to be in five years? Questions like this will be will be most helpful in determining the program that might suit you best and get you where you want to be.
  5. Research. Does the program fit you? Will it offer you the opportunities you desire in terms of training in EUS applications? Research opportunities? Teaching opportunities? Make a point of talking with the previous fellows. If possible try to not only speak with last year’s grads but also graduates from 2-3+ years back. What are they doing now? Is it what you want to be doing? 

Remember, it’s your year, and it should be a great one. By following the simple steps above, you will be able to find the program that is the best match for you. Best of luck, and welcome to the world of emergency ultrasound!


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City-wide Grand Rounds - 2010

Stanley Wu, MD
Resa Lewiss, MD, RDMS
Turan Saul, MD, RDMS

St. Luke’s Roosevelt Ultrasound Division 

On June 9th, 2010, the St. Luke’s Roosevelt Hospital Ultrasound Division hosted its final City-wide Grand Rounds of the academic year. Dr. Penelope Chun, Director of Emergency Ultrasound and Emergency Ultrasound Fellowship Director at New York Hospital Queens facilitated the 2-hour discussion “Ultrasound Infection Control.” 

The evening’s round-table discussion began with Dr. Chun updating the group on the microbiology and infectious disease literature regarding ultrasound machines, probes and transmission gel as vectors of infection. The four other participating programs (Mount Sinai Medical Center, New York Hospital Queens, Albany Medical Center, and Penn State Hershey) each shared their practices of disinfection at their home institutions. 

A wide variety of disinfection procedures exist eg, alcohol and non-alcohol based cleaning wipes, soap-water-paper towel and Cidex®. A noted major stumbling block to the correct use of Cidex® and the disinfection of probes, cords, gel bottles, keyboards, and the machines themselves, appears to be the lack of ownership by other emergency medicine colleagues. A commonly appreciated scenario is finding an ultrasound machine with transmission gel coating multiple probes and dried blood from a patient on the footprint. Seemingly across institutions, much of the actual care, cleanliness and disinfection is the responsibility of the EM ultrasound enthusiasts ie, directors and fellows. 

The Australasian Society for Ultrasound in Medicine (AIUM) published guidelines for the disinfection of transducers. Last revised in 2007, these are being used by some. Lack of uniformity for ultrasound disinfection will likely remain until a more significant body of evidence is published, and guidelines by ACEP or other national or society standards are established.


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Ultrasound Guided IV Access: Hip or Hype??

Michael B. Heller, MD, FACEP
Director Emergency Ultrasound
Clinical Professor of Emergency Medicine
Beth Israel Medical Center
New York, New York

The use of ultrasound guidance to aid intravenous access has exploded in recent years. Since most interventions that are adopted enthusiastically in medicine turn out to be wrong or at least wildly overstated (MAST suits, Swan-Ganz lines, theophylline for asthma, and-I’m sure, hypothermia for post-cardiac arrest), I wonder if this could be just another example of that phenomenon? Is it just possible that US guidance for central line insertion does as much-or more- harm than good? First of all, experienced clinicians are pretty terrific doing central lines using the landmark approach so the potential for benefit is pretty small (and not all studies have demonstrated one: Balls, A, et al. Am J Emerg Med. 2010;28 (5):561-7). More importantly, the availability of ultrasound very likely encourages us to insert these lines when they are not truly needed. The infectious complications of femoral and internal jugular lines has not been lessened one whit by the use of ultrasound and the widespread availability of the newer intraosseous devices (almost painless and virtually no infections at all) has obviated the need for the central route in many cases. Finally, the fact that this route was recommended as a quality indicator by our beloved regulatory agencies (the same folks who gave us blood cultures for everything and antibiotics before diagnosis) should alone give us pause. 

How about peripheral access? I was never as impressed as some. First, it’s not so easy; I would guess it takes at least 30 attempts to get proficient and more than that to become an expert. Second, the procedure takes some specialized equipment, including sterile sets, needle holders and extra long needles to really perform properly. Even more disturbing, we’re now starting to see articles suggesting that cannulating the small veins of the upper arm is not easy and the smaller, the harder (Panebianco, NL, et al. Acad. Emerg. Med. 2009;16(12):1298). Finally, even when these are successfully cannulated, survival of the IV is less than 24 hours in half the patients (!) with complications ranging from hematoma to arterial puncture occurring in 15%. (Dargin JM, et al. Am J Emer Med. 2010;28(1):1.)  

Ultrasound guided IV access may well have its place, just like credit default swaps, adjustable mortgages and deep water oil wells. But maybe it’s time our enthusiasm was tempered for all these things.


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Breaking New Ground for Emergency Ultrasound

Dr. Rob Ferre has prepared an excellent case report on a head-injured patient whose elevated intracranial pressure was detected by optic nerve sheath measurement. 

To access this case report, click the following link http://ultrasound.seecontent.com/5921445060

 


 

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NQF passes two ACEP Ultrasound quality & patient safety measures!

Paul Sierzenski MD, RDMS, FACEP
Chair, GA/PR Committee, ACEP US Section

It is my pleasure to inform you that the National Quality Forum (NQF) has passed the following ultrasound measures proposed by the ACEP Quality and Performance Committee (QPC). Of interest, the CVC US guidance measure generated the most discussion respective to implementation and market penetration. Though there are still some hoops to jump through this is a significant step in moving EUS as the standard of care by measuring its utilization as a goal to chance practice. 

 #ACP-002-10 – Ultrasound determination of pregnancy location for pregnant patients with abdominal pain. Percentage of pregnant patients who present to the ED with a chief complaint of abdominal pain and or vaginal bleeding who receive a trans-abdominal or trans-vaginal ultrasound. 

 #ACP-043-10 – Ultrasound guidance for Internal Jugular central venous catheter placement. Percent of adult patients aged 18 years and older with an Internal Jugular central venous catheter placed in the emergency department (ED) under ultrasound guidance. 

All the best and greetings from the Florida Keys.


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Probe Humor

Michael B. Heller, MD, FACEP
Director Emergency Ultrasound
Clinical Professor of Emergency Medicine
Beth Israel Medical Center
New York, New York

All of us involved in ultrasound education have noticed that there are certain phrases that keep coming up when teaching at the bedside or reviewing ultrasound images. I’d like to respectfully submit a few. 

  • What organ is that supposed to be? 
  • I believe the aorta is usually to the Left of the vena cava 
  • They’re not cysts; they’re renal pyramids. 
  • It’s where Gerota’s fascia meets Glisson’s capsule 
  • It’s really a coronal view, if you think about it 
  • Yes, you can use KY jelly but it’s not as good. 
  • You have to press down harder to see the aorta with all that bowel gas. 
  • It doesn’t matter if it looks like a septum or a fold or Lincoln’s nose; there are only 5 things that matter when looking at the gall bladder 
  • Do you know who the Phrygians were? 
  • Use the word “intracavitary probe” when looking for a peritonsillar abscess. 
  • Yes, the gel goes on both the inside and outside of the condom. 
  • Red and blue just tells you the direction of blood flow; the machine doesn’t know about arteries and veins. 
  • To some people it looks like a chocolate chip cookie; to me it looks like the Sinai Peninsula. 
  • There are a lot better ways to tell if the tube’s in the trachea. 
  • The textbooks say the cysts don’t hurt unless it’s more than 3 cm; the textbooks are written by men. 
  • Hold the probe like a pencil, not like a klutz. 
  • What! You forgot the formula for the volume of a sphere?(4/3 pi R cubed). I’m calling your 11th grade solid geometry teacher right NOW! 
  • Don’t call it a “small parts probe” when you’re examining the testicle or penis.
  • When the echo shows the heart is not moving but you’re feeling a pulse, it’s good news. It means you are alive but the patient isn’t. 
  • Sir, that’s the first time in history any male has made that joke while having an abdominal ultrasound. No, I don’t see a baby in there but your prostate’s enormous. 

Ed. A clear mark of maturity of a specialty is the development of specialty-specific humor. I confess I miss the humor in a few of the statements, but we are making progress in the development of probe humor.


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The Rise and Future of Bedside Echocardiography

Michael Mallin, MD
Matthew Dawson, MD
University of Utah Division of Emergency Medicine

Over the last several years we have seen echocardiography gain popularity in the hands of the bedside user. Initially, we thought of echo as simply a means to a quick diagnosis of pericardial effusion or asystole. As more critical care and emergency medicine physicians have adopted echo as a means of non-invasive monitoring we appear to be entering an age where advanced echo is no longer the exclusive property of cardiology. A new form of echo is evolving. One that assesses hemodynamics in the critically ill patient including response to fluids, volume status, and many other clinical questions that we have historically attempted to answer subjectively with physical exam, or through invasive monitoring with central lines, cardiac catheters, and arterial lines.

Will echo replace the stethoscope? To some degree it already has. Most ultrasound-trained EM docs I know are quick to reach for the ultrasound in search of cardiac pathology. Besides, who can really identify a valvular lesion in a busy emergency department? Seeing is much easier than hearing, and true novices can be easily and quickly taught to identify regurge with color flow imaging.

The fall of the ECG? It seems unavoidable that emergency physicians will become more familiar with strain imaging and stress echocardiography. We are the front line in cardiac disease, and these modalities are becoming hot diagnostic tools in the early detection of cardiac disease, even before a full negative troponin rule-out. True ischemia is occasionally seen on ECG, but it may be even more visible on echo. Wall thickening is diminished within seconds of an ischemic event and is visible even before the patient experiences pain.1 Strain-rate imaging uses computerized algorithms to measure the systolic deformation of specific wall segments. This can not only identify the presence of ischemia but also the specific artery involved.2

Noninvasive monitoring. Recent research has suggested that critical care monitoring may be feasible with cardiac echo replacing invasive monitoring.3 We have all heard of CVP assessments of preload, but the story goes deeper. More pertinent assessment of preload may be hidden in the diastolic function of the right and left ventricle - an area of echo many cardiologists are not comfortable with. The diastolic function of the left ventricle has been proven to be a surrogate for the pulmonary capillary wedge pressure and left ventricular end diastolic pressure - two parameters much more helpful than CVP.4 Furthermore, systolic function and CO can easily be assessed with echo and optimized in the critical care setting. We may soon see real-time echo in the ICUs with wearable probes allowing for constant hemodynamic evaluation of the critical patient. This could replace the cardiac monitor.

3D Echo in the ED? As machines improve and technology becomes cheaper. 3D echo will become a reality. Square, matrix array probes can recreate the heart in real time and allow for quicker diagnosis of valvular and wall motion abnormalities. The complexity of orientation in cardiac echo is absolved with 3D echo.  

The reality is that medicine has classically evaluated the heart with electrical and pressure measurements. These modalities, while widely accepted, are clearly inferior and often more invasive than direct visualization through echo. Emergency medicine has always been on the front lines pushing the diagnostic envelope.  Echo will be no exception. The time to learn is now. 

References:

  1. Sigwart U, Gerbic M, Payot M, et al. Ischemic events during coronary artery balloon occlusion. In: Rutishauser W, Roskamm H, eds. Silent Myocardial Ischemia. Berlin: Springer-Verlag; 1984: 29–36.
  2. Voigt JU, Exner B, Schmiedehausen K, et al. Strain-rate imaging during dobutamine stress echocardiography provides objective evidence of inducible ischemia. Circulation. 2003;107(16):2120-2126.
  3. Pittman JE, Grissom C, Brown S, et al. Advanced critical care transthoracic echocardiography in severe sepsis and septic shock. Chest. 2009 136: 128S-c-129.
  4. Nagueh SF, Middleton KJ, Kopelen HA, et al. Doppler tissue imaging: a noninvasive technique for evaluation of left ventricular relaxation and estimation of filling pressures. J Am Coll Cardiol. 1997;30: 1527-1533.

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Emergency Ultrasound Diagnosis of Quadriceps Tendon Tear

Michael A.Secko MD, RDMS
Michelle Diaz MD
Lorenzo Paladino MD
From the Department of Emergency Medicine
SUNY Downstate/Kings County Hospital Center
Brooklyn, NY 11203

Corresponding Author: Dr. Secko 

Case Report  

A 38-year-old man presented to the ED complaining of pain to his left knee and inability to ambulate after being tackled to the ground. He stated that he had been drinking alcohol that day and got into a physical altercation that ended when police tackled him to the ground. His past medical history consisted of schizophrenia for which he was compliant with his medications. 

The vital signs were all within normal limits and the Glasgow Coma Score (GCS) was 15. The patient appeared intoxicated and was uncooperative with certain elements of the physical exam. His left knee demonstrated a large effusion with ecchymosis over the anterior, superior portion of his knee. Bony landmarks of the knee were difficult to palpate because of the large effusion. Distal peripheral pulses were palpable. The patient was resistant to allow both active and passive range of motion of the knee, and refused assessment for ligamentous instability. The remainder of his physical exam was unremarkable. 

Standard 3-view radiography of the knee was performed and did not reveal any foreign bodies, fracture, or subluxation. Given their diagnostic uncertainty, the authors performed a bedside ultrasound of the knee using a 10-5 MHz linear transducer (SonoSite M-Turbo, Bothell WA). Ultrasound examination demonstrated an anechoic area at the distal end of the quadriceps tendon at its attachment to the superior pole of the patella, suggestive of a quadriceps tendon rupture (Figures 1 & 2). A comparison view of the right knee revealed no such abnormality (Figure 3).  

 

Figure10910
 Figure 1

  

Figure20910
 Figure 2 - T: quad tendon; P: patella; F: femur;* tendon rupture with effusion

  

figure30910
 Figure 3 - T: quad tendon; P: patella; F: femur

After the diagnosis was made, the patient was placed in a knee immobilizer; the leg was elevated; ice and analgesia were given; and the orthopedic surgeons were notified. The patient was admitted to the orthopedic service and underwent operative repair of a complete quadriceps tendon rupture the following day. The patient was later discharged to rehabilitation facility and had an uneventful recovery.

Discussion: 

Quadriceps tendon rupture (QTR) is a rare cause of knee pain. QTR is more common in the elderly, and often related to a slip or fall, as opposed to a patella tendon rupture, which is often a sports related injury in younger patients.1 Unilateral rupture is more frequent than bilateral ruptures. QTR is either traumatic, idiopathic, or due to a variety of systemic diseases, including gout, rheumatoid arthritis, lupus erythematosus, chronic renal failure, obesity, infections, diabetes mellitus, hyperparathyroidism, and multiple steroid injections.2,3  

Complete tears can often be diagnosed clinically. Loss of active leg extension, a palpable suprapatellar depression, and knee pain are common findings. Partial tendon tears may be more difficult to detect since some degree of function is maintained. Misdiagnosis is common, ranging between 10-50%,3 because the physical examination is often limited by pain and swelling. Hence, imaging is often necessary. Plain radiographs are of limited utility in the diagnosis of QTR.4 Ultrasound (US) and magnetic resonance imaging (MRI) are more suitable imaging modalities because they allow for more detailed examination of the soft tissues. MRI is highly sensitive and specific for QTR and therefore the imaging study of choice. However, it is expensive and time consuming. Ultrasound is rapid, easily accessible, and relatively inexpensive. 

Ultrasound can differentiate between complete and partial tears, as well as demarcate the location of the tear.1,2 When visualizing the quadriceps tendon on US, one usually sees a 6 to 11mm3 thick structure with linear, parallel echoes running its length representing the convergence of 4 muscle tendons: the rectus femoris, vastus medialis, vastus intermedius, and vastus lateralis. These tendons form 3 laminae: rectus femoris forms the superficial lamina; vastus medialis and lateralis form the middle lamina; and the vastus intermedius forms the deep lamina.5 Partial tears may affect single or multiple layers, while a complete tear represents rupture of all 3 layers.  

In complete tears, a hypoechoic or anechoic area between the tendon fibers is usually seen, and is usually representative of a hematoma. Partial tears may display a focal hypoechoic defect in the tendon. If the patient cannot flex their knee, gentle traction on the patella may lead to better visualization of the tendon defect.  

Ultrasound is an operator-dependent imaging modality and tendon sonography can be technically challenging. One must be aware that tendons on US display anisotropy, and therefore the probe should be kept perpendicular to the tendon to obtain the best resolution and to avoid false-positive exams. 

In conclusion, ultrasound is an imaging modality that should not be overlooked by an emergency physician when examining a patient with a painful swollen knee.

References:

  1. Samuel L, Fessell DP, Femino JE. Sonography of partial-thickness quadriceps tendon tears with surgical correlation. J Ultrasound Med. 2003;22:1323-1329.
  2. Bianchi S, Zwass A, Abdekwahab IF, et al. Diagnosis of tears of the quadriceps tendon of the knee: value of sonography. Am J Roentgenol. 1994; 162:1137-1140.
  3. LaRocco BG, Zulpko G, Sierzenski P. Ultrasound diagnosis of quadriceps tendon rupture. J Emerg Med. 2008; 35:293-295.
  4. Kaneko K, Demouy EH, Brunet ME, et al. Radiographic diagnosis of quadriceps tendon rupture: analysis of diagnostic failure. J Emerg Med. 1994; 12:225-229.
  5. Zeiss J, Saddemi SR, Ebraheim NA. MR imaging of the quadriceps tendon: normal layered configuration and its importance in cases of tendon rupture. Am J Roentgenol. 1992; 159:1031-1034.

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Standards versus Suggestions

Like the Accreditation Program, the publication of “Minimum Standards for Reporting” for both end-users and for industry is an obvious and logical responsibility for the ACEP Emergency Ultrasound Section – no one else is going to do it, nor would we want anyone else to do so. 

Lawrence A. Melniker, MD, MS, FACEP 

The American College of Emergency Physicians is the leading advocate for the use of Clinical Sonography in Emergency Medicine. ACEP has endorsed and published the Training Guidelines, the Imaging Criteria, and a guide to Coding & Reimbursement. The College has liaised with numerous governmental and specialty organizations to promote and protect our interests. Soon, it will accredit Emergency Ultrasound Programs. No other organization in the United States has shown the commitment or capacity to do what ACEP has done and will do. 

A committee of the Emergency Ultrasound Section (EUS) of ACEP has been tasked with developing “Minimum Standards for Reporting” of clinical ultrasound scans. There are two distinct goals within this mandate: first to define in the key elements that should be contained in the sonologist’s report of a scan; and, secondly, define the fields which should be employed in data management systems of the various manufacturers going forward – so all machines will “speak the same language” and report in a similar fashion. There has been considerable debate and, I believe, some confusion about these tasks. 

On the first component, establishing key elements which should be included in all reports, the questions have been raised whether we will be held to such reporting standards and, potentially, have bills rejected if these standards are not met? The answers are – YES and YES – and I say, bring it on! We are the authority on these issues; we should define standards, we should be held to those standards, and we should not be reimbursed for substandard provision of care. 

WINFOCUS is conducting a series of Consensus Conferences; the first is on the topic of Lung Sonography. The CC resulted in good to excellent consensus on over 80% of the issues discussed – a superb result considering the relative newness of this application. For well-established applications, is agreeing on minimum reporting standards so difficult – if ACEP-EUS cannot do it, who can? Would anyone report on a pelvic scan in early pregnancy without mentioning the presence or absence of an IUP? Would anyone scan an aorta without measuring and reporting the diameter? 

The more troubling question raised regarding reporting asked whether malpractice attorneys would use published standards against us? While this is possible or even probable, we cannot kowtow to this fear– publishing “suggested” terminology would be useless. The day we refuse to define best practices out of fear of being sued is the day we should quit. “If you can’t stand the heat, get out of the kitchen” – Harry S Truman, ca. 1948. Standards define defensibility and protect us, not the other way around. To the contrary, defensiveness hurts both patients and care providers – attorneys will make any argument, anytime; regardless of facts or common sense or standards. 

The second component of the committee’s efforts, establishing industry-wide fields for reporting, seems to be mired in a debate between a “KISS principle’ basic schema and taking a comprehensive approach. My first inclination was the latter - to be broad and thorough – get it done right the first time and not have to revisit the issue anytime soon – and let everyone pick and choose which elements worked for them, while hiding others from view. 

Now, I have been assured that the system to be put in place will be highly malleable, easily customizable, and faster to establish agreement around. More advanced fields and elements for research purposes could be readily added as needed. Thus, starting with the basic template approach would seem to make the most sense.


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WINFOCUS Update – 2010

Lawrence A. Melniker, MD, MS, FACEP
Past Chair, ACEP Emergency Ultrasound Section
WINFOCUS, Board of Directors

The World Interactive Network Focused on Critical Ultrasound (WINFOCUS) was founded upon three basic pillars. The first, ultrasound education, started with the first World Congress in 2005 in Milan. In all, it has conducted 5 successful World Congresses and many exceptional national/regional congresses. WINFOCUS leadership has met with government representatives of many nations to assist in the creation of country-wide educational programs and curricula. In 2010, for the second year in row, WINFOCUS faculty presented and, this year demonstrated, the benefits of clinical sonography at the United Nations. Under the leadership of Luca Neri, Mike Blaivas, and Enrico Storti with contributions from scores of extraordinary faculty, WINFOCUS provided many basic, advanced, and instructor-level courses on 6 continents over the past five years, thereby establishing itself as the world leader in clinical ultrasound education. 

This past year marked the establishment of the second pillar, a series of International Consensus Conferences (ICC) to systematically review the state of the evidence, grade that evidence, and define areas in need of further investigation for each of the many applications for clinical sonography. The ICC are designed to bring content expertise from the many well-published investigators on the WINFOCUS faculty in each application together with process expertise from members with advanced training in research methodology and the “science of consensus,” using a modified-Delphi methodology; led by Mahmoud El-Barbary, MD. They will result in the publication of a series of Consensus Statements stating the level of consensus, recommendations on the most evidenced-based ways to use each application, and research questions regarding specific areas where consensus is lacking. 

The first 2 ICC have started and a third will convene this fall. The 1st ICC, convened in Bologna and Pisa, Italy, was devoted to Lung Sonography in deference to the pioneering work of our colleague, Daniel Lichtenstein. Though a difficult topic on which to “field test” our consensus assessment methods, the effort met with great success resulting in good to excellent consensus reached on more than 80% of the statements – a remarkable achievement. The 2nd ICC, addressing the issue of ultrasound-assisted vascular access, peripheral and central venous cannulation, met in Amsterdam. Both ICC will present drafts of their Consensus Statements in October in Rome at the 6th World Congress. The 3rd ICC will convene in Rome and address the use of Focused Cardiac Ultrasound/ECHO. The ECHO ICC will conclude in 2011 following meetings in Boston and Milan. Future ICC are planned for eFAST, Resuscitation, Medical Education, and many more. 

The series of ICC will result in a collection of evidenced-based “roadmaps” of the many applications of clinical sonography. They will deploy multiple formats to present diagnostic algorithms, symptom-driven and syndromic assessment tools, and others. At a glance, clinicians will be able to appreciate the strength of the evidence for using ultrasound for a given condition and investigators will see where the evidentiary hunt should be directed. The algorithms will serve as both clinical and research tools. 

This brings us to the final founding pillar of WINFOCUS: the establishment of an international infrastructure for world-wide research collaboration. The spectrum of ideas brought together by WINFOCUS is breathtaking. No one specialty group or national/regional organization has employed clinical sonography in the various ways presented by the WINFOCUS faculty over the past 5 years. In addition a multitude of clinicians are also looking at the same questions. WINFOCUS can support global expansion of clinical sonography by functioning as a warehouse for knowledge and promoting the accumulation of knowledge. It can direct like-minded individuals to joint collaboration and turn around to then facilitate the ensuing collaboration. Finally, WINFOCUS can make existing evidence and new knowledge of greater impact by authoritative publication and assertive publicizing of the many benefits of clinical sonography. The cost-effectiveness of clinical sonography has barely been elucidated and, once well-defined, will have multinational implications. WINFOCUS must take an active role in promoting the accrual and dissemination of current and future knowledge. The new Critical Ultrasound Journal (Editor-in-Chief, Michael Blaivas, MD) will play a vital role. 

This year, the World Congress returns to Italy; it will convene October 4-9 in Rome. Drs. Neri, Blaivas, and Storti and the entire WINFOCUS faculty cordially invite you all to attend. The program begins with numerous pre-congress courses and boasts a robust agenda. The meetings and ICC presentations will be historic. Please go to www.winfocus.org for all the details and registration. 

Hope to see you all in Roma!


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Journal Watch

Seth Oskie, MD
Ultrasound Fellow 

Timothy Jang, MD
Director, Emergency Ultrasound
Assistant Professor of Medicine
David Geffen School of Medicine at UCLA
Harbor-UCLA Medical Center

Hoyer HX, Vogl S, Schiemann U, et al. Prehospital ultrasound in emergency medicine: incidence, feasibility, indications and diagnoses. Eur J Emerg Med. 2010; 17(5):254-9. 

Objective: This was s multicenter prospective observational study investigating the use of handheld technology for bedside ultrasound in European emergency system prehospital setting. 

Methods: Four different handheld ultrasound devices in 4 helicopters and one emergency vehicle were used over a cumulative period of 3 years. The participating helicopters and emergency vehicles served various urban, suburban and rural areas of Germany. On 971 consecutive missions ultrasound systems were available for use by a physician experienced in ultrasound. All sonographers had received a minimum of 1 hour training on the handheld devices. The emergency physician responsible for the mission decided when and where to use ultrasound and ultimately determined the incidence, indication and feasibility of prehospital ultrasound in this study. Ultrasound was excluded if it was likely to slow or hinder workflow. Following the mission, the physician reported whether sonographic examination was indicated to find an essential diagnosis. They also reported whether it influenced priority and destination of transport or therapy. An independent researcher documented how long the ultrasound study took and also hospital results and patient outcome. A symptom guided “point-of-care” approach to ultrasound examination was utilized by the physician that focused on answering specific clinical questions. A standard scanning protocol was not outlined. 

Results: Ultrasound equipment was available during the prehospital management of 971 consecutive emergency patients. Ultrasound was considered valuable in 178 cases (18.3%). Of note, in some of the cases where ultrasound was determined valuable sonography was excluded. Prehospital ultrasound was actually performed on 144 (14.8%) patients. Clinically useful information was provided by ultrasound examination in 130 (90%) cases. Many examples of important pathology were reveled in this study such as traumatic free fluid, pneumothorax, pericardial effusion and pleural effusion, cardiac dysfunction and standstill. In 110 patients examined (76.5%) confirmatory results or outcome data was available. There were no reported false positive findings in the study resulting in a specificity and positive predictive value of 100%. The sensitivity was 85%, accuracy was 96% and the negative predictive value was 95%. Examination time with ultrasound averaged less than 2 minutes. 

Discussion: The use of prehospital ultrasound was reported as valuable and the data provided in this study suggest that it can be a reliable and accurate tool for diagnosis in a challenging environment. There is insufficient information to conclude that patient triage or patient outcome is improved by the availability of prehospital ultrasound technology, especially since the studies were done by physicians and not paramedics. 

Walcher F, Kirschning T, Müller MP, et al. Accuracy of prehospital focused abdominal sonography for trauma after a 1-day hands-on training course. Emerg Med J. 2010;27:345-349.  

Objective: To establish a training course for Prehospital Focused Abdominal Sonography for Trauma (P-FAST) and evaluate the accuracy of the participants after the course and at the trauma scene. 

Methods: This was a prospective study that evaluated procedural accuracy after a 1-day hands-on training course on the prehospital FAST exam. The intervention included an instructional presentation on P-FAST exam technique and a hands-on course component with supervised practice scanning both healthy volunteers with a negative FAST exam and patient volunteers with positive FAST exam findings of abdominal free fluid form peritoneal dialysis or ascities. There were nine participants in the experimental group (five emergency physicians and four paramedics) who underwent the training course. Afterward they performed P-FAST on-scene with trauma patients as part of this multicenter study. The accuracy of P-FAST on-scene was verified using FAST and CT scanning in the emergency department as the gold standard. There were two control groups not exposed to the 1-day P-FAST course. One group consisted of 9 emergency physicians working on a helicopter who used P-FAST occasionally. The other control group consisted of 10 trauma surgeons who used FAST daily for over three years working in an ambulance station or helicopter unit. The results of all P-FAST exams were compared to confirmatory emergency department FAST exam or computed tomography studies. 

Results: There was no significant difference between groups in the multi center trial on prehospital trauma patients 

Discussion: This study evaluates accuracy of prehospital FAST exam after focused training in the procedure. The results suggest no significant difference between groups. Perhaps the 1-day course brought novice sonographers up to speed and enabled them to incorporate P-FAST into the care of trauma patients at a level similar to practitioners with prior experience.  However, control group members all had experience with the FAST exam and none were paramedics without exposure to the 1-day course. Conclusions on accuracy are limited by the fact that there were only a few true positive exams on the actual trauma patients in this study. 

Dan D, Mingsong L, Jie L, et al. Ultrasonographic applications after mass casualty incident caused by Wenchuan earthquake. J Trauma. 2010; 68(6):1417-1420. 

Objective: This study describes how bedside ultrasound was utilized by the Chengdu Military General Hospital during medical rescue efforts the first 6 weeks following the 2008, Wenchuan earthquake in China.

Over 90,000 deaths are attributed to this mass casualty incident and an additional 370,000 people were injured. 

Methods: Retrospective case series reported by the Department of Ultrasound at Chengdu Military Hospital, PR China. Of the 3,307 wounded patients evaluated by the hospital, 1,207 were examined by ultrasound. Patients were screened by FAST exam mostly outdoors in the early stages after the earthquake. Selection criteria included unstable hemodynamics, change in consciousness, hematuria or oliguria and suspected chest or abdominal trauma. Later on ultrasound was also used to examine patients with suspected soft tissue hematoma or peripheral vascular injury. Major indications for ultrasound-guided procedures included effusion, soft tissue hematoma and traumatic intraabdominal abscess.  Positive findings on screening ultrasound were variably confirmed with exploratory surgery, computed tomography, serial ultrasound, or medical observation based on assessment of clinical condition. 

Results: Bedside ultrasound was performed on 1,207 patients with ages ranging between 2 days and 102 years old. The sample included 98 patients < 14 years old and 14 pregnant women. A total of 1,286 ultrasound examinations were performed. Ultrasound screening detected

23 cases of hemoperitoneum, 45 patients with pleural effusion, 1 case of traumatic femoral artery intimal tear, 3 patients with deep vein thrombosis of a lower extremity, and 12 with deep-part, soft tissue hematoma. In five patients with negative screening ultrasound exam, visceral injury was confirmed later by surgery, computed tomography or contrast-enhanced ultrasonography. The detection rate of trauma-related ultrasound findings was reported to be 6.96% (84 of 1,207). The study reports no false positive exams but calculate the false negative rate at 5.6% based on 5 patients with confirmed injury out of 89 cases with a negative screening ultrasound that later had a follow up study or exploratory surgery. One hundred fifteen patients received ultrasound-guided procedural interventions including drainage of hematomas, abscesses, pleural and pericardial effusions. Ultrasound guided-vascular access is not mentioned. Of the ultrasound-guided procedures, no adverse complications are reported. 

Discussion: This article provides an account of how bedside ultrasound can play an integral role in the care or patients after a mass casualty incident. For the Chengdu Military General Hospital it proved invaluable to triage, diagnosis and treatment of injured patients after the Wenchuan earthquake. It is difficult to draw conclusions about accuracy from this study. Interestingly, pneumothorax is not a reported finding and vascular access is not described. Data on the sonographer is not clearly provided and this could limit generalizability, as the studies may have been done by radiologists rather than emergency physicians. 

Windish R, Ungar T, Backlund B, et al. Use of sterile saline as a conduction agent for ultrasound visualization of central venous structures. Emerg Med Australas. 2010;22(3): 232-235 

Objective: To determine whether sterile saline as a conduction agent provides adequate visualization of anatomic structures to attempt ultrasound-guided access of the internal jugular vein. 

Methods: Prospective observational study involving a convenience sample of 47 adult patients who presented to an urban academic ED during a 3-month period. Each patient had three 6-second ultrasound video clips obtained of the right internal jugular vein utilizing each of three different conduction agents, water-based gel, sterile saline and nothing.  Two emergency physicians with ultrasound expertise who were blinded to the conduction agent reviewed the video clips independently. They determined whether the video image was adequate to perform ultrasound guided vascular access and also rated the overall quality of visualization on a 100 mm visual analog scale. 

Results: Patient population consisted of both men (55%) and women with a median age of 45 years and median body mass index of 25.1. For ultrasound images in which no conduction agent was used, reviewers determined that visualization was adequate to perform ultrasound-guided vascular access in 19 of 47 studies (40%, 95% CI: 26 ? 56%). Conversely, in 26 of 47 studies done without any conduction agent, reviewers agreed that no visualization of structures was possible (55%, 95 CI: 40 ? 70%). Overall raw agreement was 96% (95% CI

86 ? 99%) with kappa of 0.91 (95% CI: 0.8 ? 1). For images in which saline or gel was used as conduction agent, reviewers agreed in all instances that visualization was sufficient to perform ultrasound-guided vascular access (100%, 95% CI: 93 ? 100%). The median VAS score for gel was 92 (95% CI: 90 ? 93). Using gel as the reference standard, the median VAS difference for saline was -3 (95%

CI: -1 to -3) and the median VAS difference for no conduction medium 

was -46 (-22 to -61). 

Discussion: This study concludes that sterile saline provides adequate visualization of anatomic structures to attempt ultrasound-guided vascular access. While it promotes sterile saline as a possible alternative to traditional water-based gel to obtain visualization of the important anatomy, it does not evaluate conduction agent performance during the actual procedure of central line placement. The statistically inferior quality of the images obtained using saline has unknown implications for the outcomes of ultrasound-guided vascular access procedures.


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Thoracic Aortic Dissection Diagnosed on Bedside Ultrasound with Associated Pericardial Effusion

Patrick Lenaghan, MD
Ralph Wang, MD
Elizabeth Kwan, MD 

A 64-year-old female with a history of hypertension was noted to have a sudden change in mental status during a car ride. The patient complained to EMS of chest pain and back pain. On arrival, the patient’s blood pressure was 115/96, pulse 131, respiration rate 40, and oxygen saturation was 83% with a poor waveform. On exam, the patient was noted to have worsening altered mental status and moaning. A left radial pulse deficit and upper torso and extremities mottling were noted. The neurologic exam revealed a left gaze deviation. At this point, emergency medicine attending performed a bedside ultrasound, as seen above. Approximately 15 minutes after presenting to the emergency department, the patient became pulseless. A cardiothoracic surgery attending and emergency medicine resident performed a pericardiocentesis with minimal blood return. The patient expired thereafter. 

Fig.1 is an ultrasound image of the thoracic aorta obtained through the suprasternal window, coronal oblique plane. The aorta was visualized as a bright walled round structure with a dark lumen. The dissection flap appears as a thin echogenic crescent-shaped line traversing the aorta. Fig.2 is an ultrasound image of the heart obtained through the parasternal long view. A large moderately echogenic pericardial effusion was visualized. Although trans-esophogeal echocardiography, CAT scan, or MRI are far more sensitive for the diagnosis of thoracic aortic dissection[1], emergency physician performed cardiac ultrasound may rapidly confirm this diagnosis in an unstable patient[2]. Furthermore, the serious complication of pericardial tamponade may also be detected at the bedside[3, 4]. 

  1. Cigarroa JE, Isselbacher EM, DeSanctis RW, et al. Diagnostic imaging in the evaluation of suspected aortic dissection. Old standards and new directions. N Engl J Med. 1993;328(1):35-43.
  2. Fotjik JP, Constantino TG, Dean AJ. The diagnosis of aortic dissection by emergency medicine ultrasound. J Emerg Med. 2007;32(2):191-6.
  3. Nienaber CA, von Kodolitsch Y, Nicolas V, et al. The diagnosis of thoracic aortic dissection by noninvasive imaging procedures. N Engl J Med. 1993;328:1-9.
  4. Orzan F, Ottino G, Disumma M, et al. Pericardial effusion simulating aortic dissection. Br Heart J. 1981; 46(2):207-10. 

Figure Legends 

dissection10910
 Fig 1. Ascending thoracic aorta. Intimal flap can be visualized as a
 crescent-shaped echogenic line within the aorta.

  

dissection20910
 Fig 2. Pericardial effusion identified as fluid collection within the pericardial
 space. The effusion is moderately echogenic, suggestive of
hemopericardium.

 


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Sonoguide Update

Beatrice Hoffman, MD, PhD ,RDMS
Matthew Nixon, Web designer and Illustrator

The website continues to attract quite the following; visitor numbers now reach 18,000/month (Figure 1), total page requests are over a million for this calendar year. Sonoguide trivia: Tuesdays and Thursdays are the busiest days on the site, visitors come from 150 countries; about 70% of the traffic is from within the United States. December and the holiday season seems to indicate a paucity of ultrasounds and web surfing for the second year in a row. Somebody should do a study on this. 

sonoguidefigure1

We continue to expand the content of the website. After adding the “Soft Tissue” and “Abscess I&D” chapters last year, we updated and significantly expanded the “Early Pregnancy” chapter. A big Thanks! to authors Brian Earle and Bill Hosek for providing the content. We also added 50 quick cases/images in the new “Image Viewer” section. Some of them are bread and butter cases, others show off the beaten path pathology. If you wish to send us a great case for inclusion in the next group of image viewers, please email me

The work on two brand new chapters “Ultrasound-Guided Nerve Blocks” and “MSK” continues. Both chapters are in finalization by the authors, we have initiated design of web templates and begun illustrating. Authors for future pulmonary and pediatric chapters have been identified, and rumor has it they are already sorting through their images and clips. 

We look forward to keeping the site running and would like to thank you for your continued support!


 

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This publication is designed to promote communication among emergency physicians of a basic informational nature only. While ACEP provides the support necessary for these newsletters to be produced, the content is provided by volunteers and is in no way an official ACEP communication. ACEP makes no representations as to the content of this newsletter and does not necessarily endorse the specific content or positions contained therein. ACEP does not purport to provide medical, legal, business, or any other professional guidance in this publication. If expert assistance is needed, the services of a competent professional should be sought. ACEP expressly disclaims all liability in respect to the content, positions, or actions taken or not taken based on any or all the contents of this newsletter.

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