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Emergency Ultrasound

Journal Watch

By Michael Zwank MD

A great review of focused cardiac ultrasound (FOCUS) with a catchy mnemonic to help remember it.

This is a well written review of point-of-care cardiac ultrasound that everybody should read. The authors described a new mnemonic (the five E’s) to help remember the bedside cardiac evaluation. Each ‘E’ describes one component of the exam including Entrance, Exit, Ejection Fraction, Equality of Ventricle Size and Effusion. Each section describes a bit of the history behind the exam and literature review to support the discussion. There are plenty of images to illustrate the concepts and several supplemental videos to help as well. The authors also do a great job of pointing out the limitations of FOCUS and where FOCUS fits into common algorithms of patient evaluation and care. Most practitioners will find some value in this article. Personally, I enjoyed some of the tips regarding pearls and pitfalls – describing common errors that are made.

The "5Es" of Emergency Physician-performed Focused Cardiac Ultrasound: A Protocol for Rapid Identification of Effusion, Ejection, Equality, Exit, and Entrance. Kennedy Hall M, Coffey EC, Herbst M, Liu R, Pare JR, Andrew Taylor R, Thomas S, Moore CL. Acad Emerg Med. 2015 Apr 22. doi: 10.1111/acem.12652. [Epub ahead of print]

Add some confidence to the evaluation and management of peritonsillar abscesses.

The evaluation of patients with sore throat and possible peritonsillar abscess can be intimidating – both because it involves the airway and because the management involves putting a big needle or scalpel in an area with nearby large blood vessels. Ultrasound can help visualize the presence or absence of abscess. In this small cohort, ultrasound performed quite well. There were no ‘misses’ and three false positives. While there are a number of limitations with this study including small sample size and using needle aspiration as the gold standard, it does add to some existing literature that supports point-of-care ultrasound in the evaluation of possible PTA. Using the endocavitary probe, examine the area of suspicion and look for the complex fluid that is typical of abscess. These tend to be fairly superficial and often quite round. The ultrasound can also show you the depth of the carotid artery, thereby taking some of the trepidation out of the drainage procedure.

The use of ultrasound imaging in evaluation of peritonsillar infections
. Nogan S, Jandali D, Cipolla M, DeSilva B. Laryngoscope. 2015 May 6. doi: 10.1002/lary.25313. [Epub ahead of print]

You don’t have to be an expert to perform bedside lung ultrasound for CHF.

This study evaluated a number of aspects of bedside ultrasound for possible pulmonary edema – Can novice sonographers (ie. Interns and residents) with minimal training perform lung ultrasound looking for pulmonary edema? How do they compare to expert sonographers? Does it matter whether you look at a full eight lung zones or is evaluation of two lung zones adequate? While the results were quite complex, the bottom line is that novices performed similarly to experts. Sensitivity was as high as 87% and specificity approached 100% depending on the cutoff for the number of positive lung zones. We need more of this type of study examining how well a group with variable experience performs ultrasound. When evaluating a patient with shortness of breath, use the curved probe and look around the lungs for some b-lines. If you see a lot throughout the lungs, it is very likely CHF as a cause of the patient’s symptoms. If you see a few or none, look some more in other lung fields and take this in context with the patient’s clinical picture.

Comparison of Expert and Novice Sonographers' Performance in Focused Lung Ultrasonography in Dyspnea (FLUID) to Diagnose Patients With Acute Heart Failure Syndrome
. Chiem AT, Chan CH, Ander DS, Kobylivker AN, Manson WC. Acad Emerg Med. 2015 Apr 22. doi: 10.1111/acem.12651. [Epub ahead of print]

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