Transcript Some example PPT Slides (12.3 Megs)

Prehospital
Ultrasound
“The future stethoscope”
Peter Bonadonna, EMT-P CI/C
June 2011
Disclosure: No financial or other benefit is provided to me, my family or
my place of work for advancing and promoting this material at this time.
Presentation Goals
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To introduce the practicing paramedic to a
technology that will revolutionize the way we
examine and treat our patients in the near future.
To excite you about the utility of ultrasound.
To give a short introduction about the numerous
medical and trauma ultrasound uses in EMS.
To dispel fear and misinformation that is holding
this technology back.
To leave you supporting this technology.
What is ultrasound?
The use of high frequency
sound waves (> 20 kHz) to
accomplish a task such as
echolocation or US imaging
These frequencies are far
above the human hearing
range. 1-20 MHz is typical
medical ultrasound range
Therapeutic Ultrasound
This is not what we are going to talk about
Ultrasound energy is applied to generate
heat energy to promote muscle
relaxation and improved circulation.
Diagnostic Ultrasound
Now you
can take a
look
inside.
Paramedics tend to be very visual
learners. This is perfect for
learning and using Ultrasound. A
picture is worth 1000 words.
It will
definitely
change
your care.
Prehosptial
Focused
Assessment with
Sononography in
Trauma.
Dynamic assessments
See the size, shape and function in real time !
So Peter, “Why are you so interested in
advancing field ultrasonography?”
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I see once-valued EMS treatments are now deemed
questionable or injurious (Trendelenburg, MAST, ET,
IV fluids, some medications). The value of the old style
paramedic is in peril.
I have been observing many misses and wrong Dxs by
good providers who relied on physical exam.
I have noticed declining physician confidence in
paramedics.
I recognize that this technology is a real game-changer
for paramedics. It would empower us to be far more
accurate, give better care and shift the paradigm from
educated guessing and treatment to accurate diagnosis
and accurate treatment.
How can ultrasound help Paramedics?
 Educationally
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Students can see actual anatomy and real-time function on classmates and
themselves. It provides another reason to really learn anatomy well.
Students can appreciate the variability of human anatomy.
It’s fun, which helps in the learning and retention process.
Even if they work where no US is available students will be better providers.
 Clinically
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Can see inside the body, far more accurate diagnosis and trending.
More exacting treatments are possible and increased documentation.
Better triage of our patients to Aeromedical, ED, CT or the OR.
 Professionally
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A chance for the Paramedic profession to elevate its abilities and accuracies.
Better patient care will immediately be recognized by the medical community
as well as by the public.
Better self-esteem when accuracy improves.
Why now ?
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The price has dropped substantially and the technology has
reached the point of “will be smaller, cheaper and
clearer from here on in”.
Physio/Sonosite collaboration – Your next heart monitor
may have ultrasound built in.
Several leading physicians are promoting EMT-P’s use
ultrasound but most paramedics are oblivious (or resistant)
to the notion.
Initial entry-level exams, like P-FAST, are easy to learn,
easy to do, accurate, noninvasive, feasible, rapid, versatile,
repeatable, time saving and very safe.
Better for patients (early accurate Dxs = more timely care).
Why now ?
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Cont.
Takes less time to perform than a 12 lead EKG and can
be done in transit (unlike 12 Lead). Easier to teach how
to “read”.
US can significantly increase diagnostic accuracy and
therefore treatment accuracy.
US can increase skills success – ET, IV, needle
thoracostomy, pericardiocentesis, external pacing.
The need for accuracy in diagnosis and treatment is
greater than ever before i.e. for physician trust & the
medicolegal climate of today.
Serial ultrasounds may be as valuable to the Physician as
serial 12 lead ECGs have been.
Because if we don’t do it, someone else will.
You have had many of these cases. How often
did you make the correct call ? Not suspected
– actually called it in as these ?
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AAA or ruptured AAA
Thoracic bleeding (hemothorax)
Pericardial effusion from cancer, uremia, heart failure, s/p cardiac
procedure or trauma
Intraperitoneal bleeding
Ectopic pregnancy or ruptured ectopic pregnancy
Pneumothorax
Cardiogenic shock from low EF (pump failure)
Obstructive uropathy (kidney stone, bladder distention, Foley obstruction)
Pleural effusions as the cause of SOB
These aren’t rare. They’re just always missed by EMS
The physical exam fallacy
So you think that history and physical exam will make
you pretty accurate in your assessments?
 AAA (>50% missed on physical exam by Drs)
 Cardiac Tamponade (Impossible to Dx w/o imaging)
 TNT (Recent studies show many EMS misDx)
 Shock (fluid or pressors, if you guess wrong pt. is harmed)
 Internal Bleeding (can have normal VS until too late)
 OB (paramedics have never been able to really examine)
 SOB Cardiac Asthma vs. Asthma/COPD.
NTG, CPAP, diuretics vs. β2 , Hydration
The reasons it has not taken off
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So new that you may have not heard about it.
You may have already prejudged it.
Someone you respect has told you its bad. *
“Most EMT-Ps haven’t mastered 12 leads and you want
them to do this?!?!” Remember this is easier!
“Show me the supporting studies.”
Still pictures of US can be very hard to interpret and
scare people away. The dynamic image is much easer to
read! The probe location is known and you can look
around.
Fear of having to really make a diagnosis.
Fear of having to learn more. It’s not a lot. I promise.
Prehospital Focused Assessment with
Sonography in Trauma or “P-FAST”
Paracolic gutters
Literally “next to the
colon”. A potential
space where blood or
fluid naturally trickles
into. This is why we
only have to look in
three places with the
probe to detect
bleeding. Detects as
little as 250 mls of
blood in the abdomen
and 20 mls in the chest.
Examples
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Intraperitoneal Bleeding
Morrison’s Pouch
(Hepatorenal pouch)
Normal
Significant intraperitoneal
bleeding
Pneumothorax
Examples
Lung in
M-mode
28 yo ♂with history of blunt trauma
to the left chest
Pt is SOB, has diminished breath sounds on the
left and has a sat of 90% P 90 BP 130/95 R 18
 Point tenderness over several ribs 5-7 on Lt.
 10 minutes into transport patient becomes
This
does short
not ofhave
a pneumo
or
acutelypatient
and severely
breath.
P120 R 32
tension
andsounds
you canhard
nowtoquickly
BP 80/ppneumothorax
Sat. 80% Breath
hear.
hunt for the cause of their distress with your
 ultrasound
Distance to machine
the hospital
minutes This
at bestwould
and20exam.
a paramedic
from ever needling
a normal
 prevent
What would
most paramedics
do?
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chest. Right now this is a 1 in 4 occurrence.
49 yo ♀ with hx of asthma
Mild bilateral wheezing. VS BP 158/90 P 80, RR
30, SpO2 96%, NSR, 12 lead normal, Treatment ?
This patient has heart failure and can be made
worseAfter
by beta
agonists
which
strengthen
the
RV
treatment
with
albuteral
RV
LV
more
thanshe
thefeels
left worse!
increasing pulmonary
she says
congestion. A normal ventricle ejects 50-60
percent of the blood out of the chamber. This
ejection fraction (EF)
LA is about 10 percent.
Does the patient need fluid?
60 yo M. Vomiting, SOB, P 90
BP 130/80 R 20 normal skin turgor
Orthostatic Vital Signs can not be
done on all patients and when they
can be performed, are not always
reliable
Click here to see how you
can answer this question
Looking at the IVC is important
Hypovolemia,
sepsis, neuro
Heart
failure/
pulmonary
embolus,
cardiac
tamponade
Cardiac Arrest
Are you treating all of your arrests the same
way? i.e. Standard ACLS? Do you wonder
why the overall survival has not changed in
25 years?
There are many different causes of cardiac
arrest in addition to arrhythmia. This
requires specific treatment strategies that
could be delivered in the field where it
counts the most.
Incremental training and use
After we master and become comfortable with the simple
P-FAST Exam we can move on to:
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Aorta Assessments (identify AAA or dissection)
ET assessment (can immediately see tube in esophagus)
FEER- Focused Echo Evaluation in Resuscitation / PE/ Pacing
Pregnancy – IUP, Fetal HR, Age, position, Ectopic
IV starts
Ocular (Retinal Detachment, ONSD – elevated ICP)
Lung Ultrasound (easily differentiate CHF vs. COPD)
Kidney/Gall stones
Adult Epiglottitis, Long Bone Fracture, Surgical airway
Are there any EMS systems currently
doing Ultrasound?
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Over 20 agencies in the USA. >200 devices
Boston EMS
Austin and Odessa, Texas
Winnemucca, Nevada
Temple Terrace, Florida
California
HCMC EMS, Minneapolis, Minnesota
Norfolk, Virginia
What are the short-comings?
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Brand new, high end machines are expensive.
Some of the smaller machines are delicate and
have less functionality.
No reimbursement at this time.
Some patients can’t be fully imaged due to body
size or rarely subcutaneous emphysema.
It is operator dependent. (but so is physical exam)
Not all EDs are up to speed on this so they may
be resistant.
Are any Paramedic Programs
teaching it?
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Monroe Community College Paramedic
Program, Rochester, NY
ProEMS Paramedic College, Cambridge, Mass.
Should all paramedics use this?
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I believe the answer should be No. We need to
introduce it carefully into each system.
Only highly motivated, knowledgeable
paramedics should be chosen at first.
High volume or experienced providers first.
Only trained and credentialed providers (can be
local EMS or hospital based credentials).
Only those who participate in USCME.
Only those with medical director approval.
Questions ?
Thank you for your attention
For More Information Visit:
www. ParamedicUltrasound.com
Contact Peter for Intro session like this one or for
training in P-FAST 6 and 24 hour courses