MEDIA REVIEWS

CHALLENGER FUNDAMENTALS: EM ULTRASOUND.FUNDAMENTALS FOR EMERGENCY AND ACUTE CARE

PHYSICIANS

By John L. Kendall, MD, Sarah A. Stahmer, MD,and Mark Deutchman, MD.Memphis, TN: Challenger Corp., 2008; $395(one instruction CD).Up to 20.0 AMA Category 1 CME from The Universityof Colorado School of Medicine.

Challenger Fundamentals: EM Ultrasound. Fundamen-tals for Emergency and Acute Care Physicians is aCD-ROM–based course intended to teach the basictechniques of emergency ultrasound. It uses a combina-tion of stills and video segments coupled with anima-tions and diagrams to illustrate key concepts includingprobe position and sonographic images. The programperforms admirably in providing a concise yet thor-ough introduction to ultrasound technology, physics,and sonographic anatomy, along with instruction onbasic image acquisition and standard emergency ultra-sound applications.

The CD opens with a dialog box, which providesinstructions on applying appropriate computer settingsto best visualize the ultrasound images. The table ofcontents introduces the 10 chapters, which are dis-cussed below in sequence. It begins with an introduc-tory chapter (four slides) that provides a brief overviewof the program and its goals with a focused historylesson on ultrasound.

Physics and orientation are covered in the secondchapter (39 slides). The goals of this chapter are tointroduce the physics of ultrasonography and provideinstruction on probe and patient orientation. The phys-ics discussion provides valuable information to improveunderstanding of the variables affecting image qualityand acquisition, including probe selection, sound wavetransmission, acoustic windows, and artifacts. Buildingon the physics discussion, patient and probe orientationare reviewed to establish the conventions of ultraso-nography, providing a universal language for effectivecommunication. This chapter does an excellent job ofproviding the knowledge and basic understanding ofphysics and songraphic image acquisition to beginholding the probe and acquiring images.

Trauma is presented in the third chapter (84 slides).There is a full description of the use of ultrasound forthe trauma patient including the indications, acousticwindows, pitfalls, and a synopsis of the relevant litera-ture. The use of interactive videos and diagrams dem-onstrates the techniques for complete interrogation ofthe sonographic windows and illustrates the appear-ance of normal and abnormal findings including theappearance of free fluid. The chapter provides a greatintroduction into the skills and knowledge necessary toperform a FAST (focused assessment with sonographyin trauma) exam.

The fourth chapter includes the evaluation of theright upper quadrant (69 slides). This section presents athorough review of pertinent anatomy of the liver, bili-ary system, and relevant vasculature. The section goeson to discuss pathology of the biliary system and liver,with a focus on gallstones and associated normal andabnormal sonographic findings. The review of liverpathology is extensive and generally beyond the scopeof point of care emergency ultrasound, as it detailssonographic findings through a range of hepaticpathology from cancer to hepatitis.

Chapter 5 covers the aortic exam (31 slides). A thor-ough review of abdominal vasculature is presented.There is discussion of the aorta and its branches withfull interrogation through two planes: transverse andsagittal views. The review of the abdominal vasculatureis extended to include the hepatic veins and the inferiorvena cava, as well as further discussion of the portalvein and its contributory vessels. Pathologic conditionsthat alter the sonographic appearance of the abdominalvessels are introduced with a brief discussion of the useof color and power Doppler to illustrate abnormal flowpatterns. This is an excellent introduction to the keyconcepts for evaluating the aorta for both the noviceand more advanced users with the discussion of colorand power Doppler.

The renal exam is described in Chapter 6 (30 slides).The focus is on renal anatomy, renal calculi, and hydro-nephrosis providing an excellent introduction to thetraditional emergency ultrasound application of renalultrasonography. The section goes on to moreadvanced assessments, including measurements of kid-ney size, renal pathology, congenital anomalies, andbladder pathology. With a detailed approach to the dis-cussion of renal ultrasound, this chapter provides bothintroductory and advanced sonographic findings,making it educational for both beginners and moreexperienced sonographers.

The following (seventh) chapter covers the cardiacevaluation (33 slides). The instruction for this sectioninvolves the acquisition and interpretation of cardiacimages with endpoints of pericardial effusion, cardiactamponade, and use in cardiopulmonary resuscitation.There is no mention of the evaluation of global left ven-tricular function. The images and diagrams illustrateprobe position and desired image acquisition. The eval-uation for pericardial effusion and pitfalls leading tofalse-positive and -negative exams are presented.Included in the discussion of pericardial effusions arethe sonographic findings consistent with the clinicaldiagnosis of cardiac tamponade, including the evalua-tion of the inferior vena cava. Finally, there is a briefintroduction to the use of bedside echocardiography incardiopulmonary resuscitation. Echocardiography is arelatively broad field with a large amount of complexinformation, which is narrowed significantly when dis-cussing emergent or point-of-care ultrasound. Overall,

ISSN 1069–6563 ª 2012 by the Society for Academic Emergency Medicine

e10 PII ISSN 1069–6563583

this chapter adequately introduces basic sonographicevaluation of the heart, covering most key concepts,although absent is the discussion of global left ventricularfunction.

Chapter 8 introduces the pelvic exam (70 slides). Pel-vic sonography, using both the transabdominal and thetransvaginal approaches, is introduced with stills, ani-mations, videos, and interactive sessions. Review of theanatomy includes sonographic views of the uterus, ova-ries, and posterior cul-de-sac. The concept of identify-ing intrauterine pregnancy (IUP) versus no IUP is wellillustrated. There is in-depth discussion on dating withmultiple dating measurements, including dating in thesecond and third trimesters, which is typically beyondthe scope of emergency ultrasound. Emergency pelvicultrasound focuses primarily on the presence orabsence of an IUP in the first trimester and fetal well-being thereafter. The concept of an IUP is well pre-sented in this chapter, and the learner should comeaway with a firm grasp of this concept.

The evaluation of the lower extremity venous systemfor deep venous thrombosis (DVT) is discussed in theninth chapter (17 slides). There is an initial review ofanatomy covering the venous system extending fromthe common femoral vein to the trifurcation of the pop-liteal vein. There is discussion of the two protocols forvenous compression: full compression versus limitedcompression. Adjuncts and common pitfalls for thecompression study for DVT are introduced. The interac-tive videos provide demonstration of probe positionwith the corresponding image as instruction for appro-priate image acquisition. The lower extremity evalua-tion for DVT is well introduced here, and the learnershould acquire the knowledge to complete a basic pointof care DVT examination.

The final chapter covers sonographic proceduralguidance (70 slides). Approaches to procedural ultra-sound are introduced with discussion of the two-personversus free-hand and dynamic vs. static approaches.There are nine procedural topics covered: venous

cannulation, pericardiocentesis, transvenous pacemakerplacement, thoracentesis, paracentesis, foreign bodyretrieval, abscess drainage, joint aspiration, and bladderaspiration. With each topic, the important steps to iden-tification of structures and approach to the procedureare covered. Ultrasound guidance generally improvesthe safety and efficiency of most procedures. With thischapter, the learner is given the knowledge necessaryfor a safer and more efficient approach to standardemergency procedures. It provides an excellent intro-duction to the novice user and a thorough review forthe more experienced user.

In summary, this is an educational CD introducingthe concepts and applications of emergency ultrasound.Emergency ultrasound encompasses a wide spectrumof applications, which have been divided into 10 conve-nient and easy-to-follow chapters. With interactiveimages, videos, and animations, the CD thoroughlyintroduces emergency ultrasound. The CD would be anexcellent introduction to emergency ultrasound for nov-ice learners including medical students, residents, orpracticing providers looking to learn the basic conceptsand gain comfort performing beside sonographic exam-inations. It would also work well for those providerswith some experience looking for a review or moredetailed understanding of the concepts and approachesto emergency ultrasound. The learner should comeaway with the necessary knowledge to acquire andinterpret basic emergency ultrasound images.doi:10.1111/j.1553-2712.2011.01263.x

Troy Dean, MD(troy.dean@ucdmc.ucdavis.edu)Department of Emergency Medicine,University of California, Davis,Sacramento, CA

Supervising Editor:Peter Sokolove, MD.

ACADEMIC EMERGENCY MEDICINE • February 2012, Vol. 19, No. 2 • www.aemj.org e11