There was a case a few years back that got a lot of attention. 56 year old hypotensive and the providers could have sworn that he had a pericardial effusion, and thus tamponade because they saw the image below on their AP4 and PSL views. They called the cath lab and the cardiology fellow who also performed their echo thought the same and set it up for the patient to get a pericardial window as he was… well….”unstabley stable” – as one of my mentors would say.
AP4:
In the current issue of the Archives of Surgery by Berg et al, through the JAMA network, highlighted in the ACEP news , “To our knowledge, the current study is the most complete examination of injury patterns and outcomes in the largest series of blunt thoracoabdominal trauma patients to date,” wrote study investigators Dr. Regan J. Berg and colleagues in the division of trauma surgery and surgical critical care, Los Angeles County + University of Southern California Medical Center in Los Angeles. Blunt trauma was defined as an Abbreviated Injury Score of 2 or more in both the chest and abdomen) who were admitted to the LAC+USC Medical Center between January 1996 and December 2010. They investigated trauma patterns, resulting injuries, need for operative care, and clinical outcomes – – and found that “In cases of blunt thoracoabdominal trauma, the abdomen should be the initial cavity of exploration in patients requiring emergent surgery without direct radiologic data, based on the results of a trauma registry and medical record review of 1,661 patients.”
A recent study in the journal, Chest by ReiBig et al. that is getting quite a bit of press lately evaluates the accuracy of lung ultrasound in diagnosing community acquired pneumonia. Why this is cool? It highlights the use of lung US for pneumonia, getting closer to decreasing radiation needs for these patients (ALARA). It’s in Chest by a group of multi-disciplinary physicians (intensive care specialists, emergency medicine, radiologists). Specialists who practice in various European countries. All of that = cool!
What they state:… Continue reading
This case highlights an example of how bedside ultrasound can save a life. Period.
It was 330pm. The ring down from EMS was helpful; we knew the equipment we needed to get ready prior to arrival. “75 year old female, last seen normal at 2pm by family found unresponsive on the carpeted ground of her bedroom, O2 sat 94% and placed on 100% non-rebreather (NRB), shallow breaths at 12/min, weak carotid pulses with one IV access and fluids running, HR 120, blood pressure 60/p, ETA 5 minutes.” Intubation equipment, central access kit, arterial line set-up, and ultrasound machine – ready. Upon arrival, EMS states they have no advanced directive (aka full code until proven otherwise – to social worker: “please let us know when family arrives.”
In the ED… Continue reading
This case scares me. Truly. We have all had patients with this chief complaint, maybe on a weekly, if not daily, basis. You know the one – guy comes in, says he has been diagnosed with …. lets see, its usually “herniated disk”, “muscle strain”, “sciatica”, or he may throw out a term that gets more of your attention like “stenosis”, but usually it’s just “I have a bad back” and now on narcotics (because there’s just no other way – ugh!) and just needs a refill. He may even have an empty bottle in hand. He just might ask for the medicine by name : “Norco 10s work really well, but my doctor put me on Oxycontin now. Can you give me enough for a month?” Response: “uh… No.” But I digress…..lets go to our crazy-scary case…
Since the last installment of SonoLinks, there have been several more awesome US related websites/links that 1) I have found in my search for more, 2) are new ones that just came on to the horizon or 3) I totally forgot to add before – – – They are all free! They are all listed on our Blogroll (scroll down, on the right of the screen) that we keep updated. If anyone knows of any other great sites, send them on over!
SonoCloud – a new and excellent website for free and easy visualization, downloading, uploading, and learning of US clips and images – by Matt & Mike (of Ultrasound Podcast) and Mike Stone (current ACEP US Section President). Can you say A-W-E-S-O-M-E! You can help fill up their library of clips by downloading your own on there too.
WikiSpaces to De-identify/Crop/Edit your image/Clip – thanks to Ben Smith for creating and sharing! A great way to post/share your stills and clips without violating HIPAA by cropping out the MRN/patient name. A simple way to keep you out of HIPAA jail.
EchoBasics – Mereles, a cardiologist from Paraguay, has an excellent website of all things cardiac echo, from basic to advanced evaluations, including explanations and clips, and even 3D and 4D clips! very cool.
ICU Sonography – along the same lines as above, there are a couple sites that are worth mentioning for ICU Sonography: Beth Israel’s website and Stanford’s website. Great review/images of critical care US and echo/IVC.
Yale’s Atlas of Echo – a complete site of everything you need to know about cardiac echo
Neuraxiom – A great website for US guided regional nerve blocks!
Sonic Nerve Blocks – another excellent website by Sanjay Sinha, an anesthesiologist at the University of Connecticut, to review all US guided nerve blocks
EFSUMB – free US textbook reviewing US applications (and includes resource limited US utilization and HIV related views)
Partners in Health book – an excellent manual for US use in resource poor/limited settings by Sachita Shah et al.
SonoWorld – an all-inclusive website that has cases, lectures, images, and articles
Ultrasound Village – another all-inclusive site with from our colleagues in Australia filled with lectures, images, and quizzes!
Qstream – a great free way to test your US skills through email question and answers by Sam Ko.
Other organizations that deserve mention in addition to ACEP include: SAEM (who have narrated lectures), AIUM (which is an organizer of the UltrasoundFirst project), WFUMB, and WINFOCUS
Emergency US Fellowships – in the time of application review, I thought I would send out the link for those interested in applying for emergency US fellowships
Emergency US Research articles – Chip Schmier does a GREAT job in sending out the new US related research articles every month; allows us to feel “in the know” when our colleagues ask us questions about it.
And… a website for free medical education testing and media sharing using a social networking and incentive paradigm: GMEP – Global Medical Education Project – as you can see SonoSpot has already created a folder and adding to it with US images of all applications.
Hope you had a Happy 4th! To all those who received patients with an upper extremity that has been burned, fractured, or blown away from all the “legal” fireworks foreplay……
Pain control. Two words. Patient satisfaction. Two more words. Physician satisfaction. Two MORE words. Nerve blocks are the new procedural sedation for many painful procedures we do in the ED. Takes much less resources and time, and provides immediate pain control for however long your anesthetic will work without concern for respiratory distress, hypotension, hypoxia, and… well… death. So why dont we do it more? Well, in a prior post, we have discussed the ins & outs for performing US guided nerve blocks with the help of some of my colleagues, some of whom are mentioned below.
An interesting study in the July issue of the Journal of Trauma and Acute Care Surgery (see full article here) discussing the utility of bedside ultrasound during traumatic cardiac arrest. For anyone who works at a trauma center, or who just so happens to receive a patient dropped off by a friend on the driveway of the ED (we have all had that happen), or who received a patient by ambulance who is in cardiac arrest at a non-trauma center to soon find evidence of trauma upon exposure of the patient….. this study is quite relevant when it comes to survival potential and how bedside ultrasound may help. What they say….
SonoSpot: Topics in Bedside Ultrasound 