Category Archives: SonoExtras

SonoApp: Lung Ultrasound – The down low of pneumo…with the help of Lichtenstein, of course

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Lung ultrasound (aka thoracic US) is one of the currently most popular applications of bedside ultrasound. It was found to be more sensitive and specific than chest XRay for pleural effusion, pulmonary edema, and pneumothorax evaluation (see meta-analysis in Chest here)…. how about them apples?! There have been some recent studies suggesting that in the heat of the moment for trauma patients, the sensitivity may be slightly lower than other studies state, but it is still better than chest Xray! Not only does it take a long time to get that chest Xray done in your ED or in through your ambulatory care practice, but its more expensive than bedside limited ultrasound for the patient as well…. lets not even talk about the radiation (yes, I know, Chest Xray radiation is minimal, but it’s still radiation). The evaluation of the lungs takes no more than 3 minutes, and ultrasound machines can be found in your pocket now (should you want that kind of VERY COOL technology). US machines can also be the size of a laptop with better resolution and multiple probe capabilities – so, needless to say, its easy, portable, fast, and more accurate. Now let’s talk… Continue reading →

SonoStudy: Lung Ultrasound by Blaivas….. yup, there is a God!

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If anyone following SonoSpot does not know who Dr. Michael Blaivas is, you should. As the Greeks have varying Gods for varying reasons, he basically is one of the Gods of point-of-care US. On this current issue of the Journal of US in Medicine by AIUM, he discusses lung ultrasound and its ability to diagnose pneumonia.

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SonoCase: 45 yr old female acute respiratory distress…. RUSH, part deux

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Here’s another crazy case I had in the middle of the night in the ED, a night that was particularly… let’s say… challenging. Lots of patients (about 43 actually) and 2 thankfully great residents, and one other ED attending. We were busy supervising a chest tube placement, while overseeing the trauma next door and finishing our charts on other patients so they can be dispo’d (yup, multi-tasking at its best – [or worst, ya never know]) and we get a ring down of a 45 year old in acute respiratory distress placed on non-rebreather with subsequent vitals:  HR 130s   BP 80s/50    RR 38     90%O2 sat. Continue reading →

SonoStudy: JAMA – use of CT and MRI increased – everyone saying to watch out!… and be careful…

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SonoStudy? well, it’s an indirect sono-related study (and had to interrupt RUSH week) – JAMA article – use of CT and MRI on the rise (CTs have tripled, MRIs have quadrupled!), and thus radiation. The amount of high and very high dose radiation doubled in the last 15 years!! One of the authors stated: “scan rates in the HMOs in the study were a bit lower than in traditional fee-for-service systems, but the growth rates were the same” The reason they suggest: Expanding indications, patient and physician demand, medical uncertainty, and defensive medicine. ok, two words: cancer risk. Plus, in the new era of health care cost control, its time we all start considering the different options: ultrasound (oh yeah!), 1 day rechecks, observation period/stay, or just discharge them with great return precautions if they are low risk/suspicion. This is just insane.  view the article: 

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SonoStudy: an evidence based approach to the RUSH exam…

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Since it’s RUSH week and we have presented a case yesterday of how the RUSH exam helped show the etiology of unexplained shock in critical situations, I thought Id look through the research before during and after the RUSH exam was described to see where its base was, how it was proven, and what the future of RUSH may hold… Continue reading →

SonoCase: 78 yr old, hypotensive, altered…Welcome to “RUSH” week!

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Yup, that’s right, we are going to go through the RUSH exam this week. Its “RUSH” WEEK!!!! To all those in SonoSororities and SonoFraternities out there, this week is going to be dedicated to “rush”ing  to evaluate the patients in shock, and trying to figure out the cause of it by your handy-dandy bedside US machine – especially when the case is not obvious, but you know you need to “rush” to their bedside….ok, Ill stop “rush”ing 🙂

RUSH stands for Rapid US in SHock and written by great friends of mine, namely Phil Perera, Tom Mailhot, D Riley, and Diku Mandavia who coined the terms Pump-Tank-Pipies – with inspiration from an original RUSH protocol by another great friend of mine, Scott Weingart (aka emcrit) who coined the acronym HIMAP (heart, IVC, Morison’s (and other FAST views), Aorta, Pneumothroax (see a great podcast by him here). Both start with the heart, and for good reason – you may find the cause immediately, and you’ll be able to identify if the patient can tolerate fluids. Both also arose from varying research studies by Rose et al. (the UHP protocol) and by Bahner et al (Trinity protocol) and Lichtenstein’s FALLS protocol (see thebluntdiessection’s article). Here, we will discuss the 3 sections to evaluate:

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SonoFiler: Profiling Dr. Arun Nagdev

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The next edition of the Sonofiler – profiling a leader in bedside US – is about a person who is a great friend (and neighbor), an avid researcher in IVC and nerve block US (among other apps), who travels the world teaching US to the masses, and, most importantly, who is just as much of a foodie as I am : Dr. Arun Nagdev. He has plenty of nicknames, none of which I can say publicly (you’re welcome, Arun), but he likes to call himself the “ultrasound dork.” Continue reading →

SonoApp: IVC ultrasound – aka “the gift that keeps on giving.”

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The IVC is a beautiful thing; it returns blood to the heart from all over the body, and without that, we would die – truly is the gift that keeps on giving. It gives so much information about a patient as it gets affected by so many disease processes:

IVC dilation (hypervolemic)- tamponade, PE, CHF exacerbation, severe mitral regurgitation or aortic stenosis, significant renal failure, severe COPD/Cor Pulmonale

IVC collapsed (hypovolemic) – septic shock, hypovolemic shock, dehydration

Now lets talk technique: Continue reading →

SonoStudy (and Case): 53% of septic patients’ treatment plans changed after seeing the IVC and cardiac contractility

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The study coming out in Annals of Emergency Medicine in June done by Haydar et al “found point-of-care ultrasonographic data about cardiac contractility, inferior vena cava diameter, and inferior vena cava collapsibility to be clinically useful in treating adult patients with sepsis” – for those of us who use US regularly to evaluate patients in shock, whether it’s by using the RUSH protocol or evaluating the initial and post-fluid volume status for those we are trying to resuscitate when septic, it’s no big surprise. What is the surprising aspect of this is that 53% of septic patients’ treatment plans had changed due to the findings by ultrasound of cardiac contractility and IVC appearance. Continue reading →

SonoCase: 25 yr old positional, pleuritic, chest pain. “It’s just pericarditis” Really?

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Had a great case the other week of a patient who was previously healthy (“great” because of what it reminds us all to do with this diagnosis) , and other than a girlfriend who he fought with too frequently causing him to go into panic attacks and hyperventilate, he doesn’t have any other stressors in his life – psychologic or drug-induced (yes, I mean cocaine). He came to the ED c/o positional chest pain, worse when lying flat and breathing in, has been persistent for over a week with a recent viral syndrome but no current fever, cough or respiratory distress. He looked well, but felt tired, had no energy to walk a few blocks and that has been worsening over the week, which is when he got into another fight with his girlfriend about coming into the ED for evaluation. Thankfully, he lost and came in.   Continue reading →