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Emergency Ultrasound

Journal Watch

Michael Zwank, MD

Using Google Glass Remotely To Guide Ultrasound… Cool.

In this pilot study, instruction via Google Glass (a type of wearable video imaging spectacles) achieved ultrasound imaging quality similar to bedside instruction. This is a very cool, very exciting application of new technology that could foreseeably be used in remote locations. At the same time, it is the first step of validating a method of teaching hands-on bedside ultrasound from a distance. It was good that they included a control group of individuals trying to perform ultrasound without any instruction – needless to say this didn’t go so well – “Hey you, go get a good parasternal long-axis view of the heart.”

Russell PM1, Mallin M, Youngquist ST, et al. First “glass” education: Telementored cardiac ultrasonography using Google Glass- a pilot study. Acad Emerg Med. 2014;21(11):1297-1299.

Abstract

OBJECTIVES:
“The objective of this study was to determine the feasibility of telementored instruction in bedside ultrasonography (US) using Google Glass.” Could first-time US users obtain cardiac ultrasound images that were good enough to determine ejection fraction using Google Glass telementoring?

METHODS:
Eighteen second-year medical students were randomized into three groups: Group A received real-time education through Google Glass; Group B received bedside education; Group C (control) received no instruction.

RESULTS:
Groups A and B were perfect with no statistical difference (6 out of 6 obtained adequate images). Group C was very poor (1 out of 6).

CONCLUSIONS:
“In this pilot study, novice US users were able to obtain adequate imaging to determine a healthy patient’s EF through telementored education using Google Glass.”

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Ultrasound is quite sensitive for detecting distal radius fractures

This article looks at ultrasound in detecting distal radius fractures. I don’t think this will be replacing standard radiography any time soon. From a practical standpoint, this can help make a quick diagnosis and help guide a hematoma block and reduction, all perhaps prior to obtaining x-rays. As always, remember that ultrasound is user-dependent so start imaging broken bones with your linear probe. (A nice 2 minute instructional video can be found at: http://youtu.be/sFGhIUsJ3Xs)

Kozaci N1, Ay MO2,Akcimen M1, et al. Evaluation of the effectiveness of bedside point-of-care ultrasound in the diagnosis and management of distal radius fractures. Am J Emerg Med. 2015;33(1):67-71.

Abstract

OBJECTIVE:
“The aim of the study was to compare the effectiveness of point-of-care ultrasound (POCUS) with direct radiography in diagnosis and management of the patients with distal radius fractures (DRFs).”

METHODS:
In this study, patients with suspected DRF were examined with POCUS and x-rays by emergency physicians (EPs). All POCUS exams were performed while blinded to x-ray results.

RESULTS:
83 patients were enrolled. Compared with direct radiography, POCUS yielded 98% sensitivity and 96% specificity with 98% positive predictive value and 96% negative predictive value. POCUS yielded 96% sensitivity and 93% specificity in detecting linear fractures; 78% sensitivity, 98% specificity in detecting torus-type fractures, and 100% specificity and sensitivity for detecting fissure fractures. Specificity of POCUS in the decision for reduction was 100%.

CONCLUSION:
“In our study, it was shown that POCUS could be applied easily by EPs trained in MSK POCUS imaging with success in diagnosing DRF and determining the correct fracture type and required treatment methods.”

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Ultrasound can help guide forearm fracture reduction

This article looked a little more closely at the aspect of forearm fracture reduction. What they show is that when the ultrasound shows good reduction, it is quite accurate. When it shows inadequate reduction, it’s less useful. From a practical standpoint, you can use ultrasound until you get good alignment. If you are struggling to get good alignment by the ultrasound image, consider shooting an x-ray to see if maybe you actually do have a good reduction.

Dubrovsky AS1, Kempinska A2, Bank I3, et al. Accuracy of Ultrasonography for Determining Successful Realignment of Pediatric Forearm Fractures. Ann Emerg Med. 2015;65(3):260-5.

STUDY OBJECTIVE:
“The primary objective of this study is to assess the accuracy of point-of-care ultrasonography compared with blinded orthopedic assessment of fluoroscopy in determining successful realignment of pediatric forearm fractures.”

METHODS:
Children younger than 18 years with forearm fractures requiring reduction of a single bone were enrolled. Physicians performed closed reductions guided by ultrasound until they assessed that they had the best possible reduction. Fluoroscopy was then immediately performed. A blinded orthopedic surgeon reviewed the fluoroscopy x-rays to assess for adequacy of reduction.

RESULTS:
One hundred patients were enrolled (median age 12.1 years). The sensitivity was 50% but the specificity was 89% with positive predictive value of 95%.

CONCLUSION:
“Point-of-care ultrasonography can help emergency physicians determine when pediatric forearm fractures have been adequately realigned, but inadequate reductions should be confirmed by other imaging modalities.”

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The Biggest Legal Risk of Point-of-Care Ultrasound is NOT Doing It

You probably wonder at times about the medical-legal implications of the point-of-care ultrasound that you are doing. You might ask: Am I skilled enough to do this? What if I do this and get something wrong? In this study looking in the recent history of bedside ultrasound in the emergency department, the only cases that could be found in a very large national legal database were those in which bedside ultrasound was not performed. To quote the article, ‘none involved failure to interpret or misdiagnosis when using of POC ultrasound.’ So go ahead and do some ultrasound.

Stolz L, O’Brien KM, Miller ML, et al. Ethical and Legal Issues: A Review of Lawsuits Related to Point-of-Care Emergency Ultrasound Applications. West J Emerg Med. 2015; January, Vol XVI, No. 1: pp 1-4.

INTRODUCTION: “POC ultrasound creates potential legal risk to an emergency physician (EP) either using or not using this tool. The aim of this study was to quantify and characterize reported decisions in lawsuits related to EPs performing POC ultrasound.”

METHODS: The authors examined all reported state and federal cases involved emergency departments or emergency physicians (2008-2012) in the Westlaw database. Ultrasound applications were all within the American College of Emergency Physician (ACEP) ultrasound core applications.
Results: Five cases were identified and all reported a failure to perform an ultrasound or failure to perform it in a timely manner. There were no cases of misdiagnoses.

CONCLUSION: From 2008 to 2012, five malpractice cases involving EPs and ultrasound examinations were documented in the Westlaw database. “All cases were related to failure to perform an ultrasound study or failure to perform a study in a timely manner and none involved failure to interpret or misdiagnosis when using of POC ultrasound.”


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