Transcript Ultrasound in Emergency Medicine

Ultrasound in
Emergency Medicine
Martin A. Bazi, MD
 The clinical application of ultrasonography
by emergency physicians has greatly
expanded over the past decade.
 The American College of Emergency
Physicians (ACEP) has firmly supported the
concept of emergency ultrasound.
INDICATIONS
 Blunt or penetrating trauma to the torso
 4 views




Rt flank: hepatorenal space
Lt flank:
Perisplenic area
Subcostal : pericardium
Pelvic :
retrovesical or retrouterine
The FAST examination
Focused Assessment with Sonography for

The

performed to identify intra-peritoneal haemorrhage or
pericardial tamponade.
FAST examines four areas for free fluid:
Trauma is a rapid, bedside, ultrasound examination
3.
Perihepatic & hepato-renal space
Perisplenic
Pelvis
4.
Pericardium
1.
2.
Perihepatic Scanning
 The hepatorenal space
(pouch of RutherfordMorison) is the most
dependent part of the upper
peritoneal cavity and small
amounts of intra-peritoneal
fluid may collect in this
region first. Blood shows as
a hypoechoic black stripe
between the capsule liver
and the fatty fascia of the
kidney.
 The probe is placed in the
right mid- to posterior
axillary line at the level of
the 11th and 12th ribs.
Perisplenic Scanning
 The left upper
quadrant
examination
visualises the
spleen and
perisplenic areas.
 The transducer is
placed on the left
posterior axillary
line region
between the 10th
and 11th ribs.
Pelvic Scanning
 The pelvic
examination
visualises the cul-desac: the Pouch of
Douglas in females
and the rectovesical
pouch in the male. It
is the most dependent
portion of the lower
abdomen and pelvis,
hence where fluid will
collect.
 The transducer is
placed midline just
superior to the
symphysis pubis.
Pericardial Scanning
 The pericardial
examination screens
for fluid between the
fibrous pericardium
and the heart, and
hence possible cardiac
tamponade.
 The transducer is
placed just to the left
of the xiphisternum
and angled upwards
under the costal
margin.
Advanced Trauma Scanning
 Looks for fluid
 Look for non-homogenous appearing
regions with in solid organs parenchyma
which may represent injury
 Consist of Diamond abdominal
examinations and 2 discrete thoracic
windows
DIAMOND EXAMINATION
Emergency US in pregnancy
 Indicated in first trimester pregnant
patient presenting with pain, bleeding,
near syncope or shock
 Asymptomatic pregnant patient with risk
factors for ectopic pregnancy
Look for
 Location of the pregnancy
 Fetal heart rate
US in pregnancy
 Transabdominal
 Intravaginal
For second & third trimester
 Detecting fetal cardiac movement
 Pregnant trauma patient
Emergency echocardiography
 Trauma
 Cardiac arrest & shock
 Pulseless electrical activity
Procedural US
 Intravenous lines
 Bladder size & aspiration
 Abscess location & aspiration
 Thoracentesis & paracentesis
 Foreign body localization
Pacemaker
IUD
Soft tissue FB
ACEP recommended training and proficiency numerical
goals per emergency ultrasound application.
Primary Application
Minimum
Range of Documented and
Outcome Reviewed
Ultrasound Needed for
Proficiency
Trauma
25
25-50
IUP
25
25-50
25 Endovaginal (if only
doing EV)
25 Transabdominal (if only
doing TA)
Emergency cardiac
25
25-50
AAA
25
25
Biliary
25
25-50
Renal
25
25
Pathway for EUS training for
Practicing Physician
 Attends introductory emergency ultrasound course or
courses
 Performs ultrasounds under supervision over reads, gold
standards confirmatory testing, or patient outcome review
within departmental ultrasound plan
 Ultrasounds are obtained with documentation and review to
meet ACEP emergency ultrasound proficiency guidelines.
Ultrasound available for departmental and hospital
examination
 Acquired at local hospital setting within departmental
privileges
 Quality review of ultrasound performed continuously. CME
attended in accordance with specialty guidelines
Examples of levels of proficiency
 Level I
This level is for the practitioner who has completed the
introductory training.
 Level II
This level is for the practitioner who is in the process of
completing credentialing examinations. Credentialing examinations must be
recorded and contain follow-up documentation. Each examination is to be
reviewed by the ED ultrasound coordinator. Straightforward examinations
may be used in some clinical situations if reviewed by a Level III
sonographer. In general, these examinations will not be used to make
patient care decisions unless reviewed by a Level III Sonographer
 Level III
This level is for the practitioner who is approved to use
emergency ultrasound in the ED for patient-care decisions. This physician
may supervise Level I and II examiners.
Future potential applications of
Emergency US
Application
Rationale
Musculoskeletal
Musculoskeletal injuries
Arthrocentesis
Fracture detection
Fracture reduction guidance
Deep venous thrombosis
Detection of deep venous thrombosis
Airway
Intubation detection in the apneic
patient
Head and neck
Peritonsillar abscess detection and
drainage
Testicular ultrasound
Rule out torsion
Cardiac (transthoracic)
Use for left ventricular function
and hypotension
Orbital ultrasound
Orbital hematoma and retinal
detachment
Transesophageal
Cardiac function and aortic
disease
Obstetric second- and
third-trimester bleeding
Placenta previa