emergency ultrasound course · emergency ultrasound course. huntington beach, ca . november 8-10,...
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Emergency Ultrasound Course
Huntington Beach, CA November 8-10, 2019
Ocular Ultrasound
Debia Kim, MD Co-Director, Emergency Ultrasound
TPMG, South Sacramento(no disclosures)
Huntington Beach, CA November 8-10, 2019
Eye Can See You!ocular ultrasound for
common ED complaints
ObjectivesWhy do EYE need POCUS?
When will EYE use this? (Indications)
Trauma Vision loss/change Eye pain Suspected elevated ICP
Normal & Abnormal Anatomy
Techniques and practice
Why grab the ultrasound?
❖ More information, faster, and more safely! ❖ External eye exams are not always diagnostic
❖ Eye complaints make up 1.5-3% of ED visits ❖ POCUS is quick and the eye is an excellent fluid medium ❖ Patient satisfaction
... which all adds up to make YOU a better provider.
ObjectivesWhy do EYE need POCUS?
When will EYE use this? (Indications)
Trauma Vision loss/change Eye pain Suspected elevated ICP
Normal Anatomy
Techniques and practice
ANATOMY REVIEW
ObjectivesWhy do EYE need POCUS?
When will EYE use this? (Indications)
Trauma Vision loss/change Eye pain Suspected elevated ICP
Normal & Abnormal Anatomy
Techniques and practice
Technique ...❖ Use a high-frequency, linear transducer ❖ Check your EXAM settings for ALARA
Technique ...❖ Use barrier protection (like a Tegaderm) ❖ Use lots of cold gel or a gel pad
Technique ...❖ Hold the probe like a
pencil and lay the rest of your hand on the patient to maintain position
❖ Scan in 2 planes ❖ Scan the
contralateral structure to compare
Eye Trauma: look for…Extra ocular movements
Pupillary reflexes
Ruptured globe
Retrobulbar hematoma
Lens dislocation
Ruptured GlobeControversy: Concern for use in suspected rupture
Possible vitreous humor extrusion? Ultrasound findings:
Decrease in globe size Anterior chamber collapse Scleral “buckling” Vitreous hemorrhage
Retrobulbar HematomaFacial trauma, post-surgical, spontaneous Time-sensitive diagnosis Presentation:
Painful proptosis Vision change/loss Impaired extra-ocular movements
Ultrasound: hypo echoic region posterior to globe
Lens DislocationTrauma, post-surgical, spontaneous (Marfan’s) Most common: lens is posterior to normal location Other ultrasound findings of ocular trauma are usually present (retinal detachment, globe rupture, etc.)
Retinal vs Vitreous Disorders
Retinal detachment: Macula ON vs Macula OFF Retinal versus Vitreous detachments Vitreous hemorrhage
Retinal vs Vitreous Disorders
Retinal DetachmentTime sensitive!
Macula ON vs Macula OFF Presentation
Floaters and flashers, curtains or shade Painless vision loss
Ultrasound:
Retinal vs Vitreous Disorders
Vitreous DetachmentStill time sensitive… because it can become a retinal detachment Presentation
Floaters and flashers, NOT so much curtains or shade Painless vision loss
Ultrasound: because the vitreous is NOT tethered at the optic nerve, the “wavy white line” can come off the back of the eye
Vitreous HemorrhageMost commonly from traction in the back of the eye acutely or chronically
Retinal tear, PVD, trauma, DM retinopathy Presentation
Floaters, shadows, cobwebs Blurring/Loss of visual acuity
Ultrasound: often nonlinear echogenicities
Intracranial Pressure?The optic nerve communicates directly with the brain, and increased intracranial pressure can cause swelling of the optic nerve sheath Measured 3mm behind (below) the eye
<5mm is normal 5-6 mm …. ? >6mm is abnormal, suggesting ICP elevation
Concurrent papilledema also helps make the diagnosis
Papilledema WITH increased ONSD
ANATOMY REVIEW
Pitfalls❖ Too much pressure while scanning can cause more harm to the
traumatic eye
❖ Artefact galore and ALARA! Please adjust your exam settings
❖ ONSD and US findings of papilledema are still being investigated … clinical correlation
“Nuts and Bolts”
❖ Linear probe ❖ “Eye” exam setting ❖ Optic Nerve: >6mm, 3mm below ❖ Scan in 2 orthogonal planes and don’t squish!
QUESTIONS?
References & ThanksNoble, Vicki E., Nelson, Bret P. Manual of Emergency and Critical Care Ultrasound, 2nd ed. New York, N.Y.: Cambridge University Press, June 2011 Ma, O.J., Mateer, James R., Blaivas, Michael. Emergency Ultrasound, 2nd ed. New York, N.Y.: McGraw Hill, 2008 Vaziri K, Schwartz SG, Flynn HW, Kishor KS, Moshfeghi AA. Eye-related Emergency Department Visits In the United States, 2010. Ophthalmology. 2016;123(4):917-919. doi:10.1016/j.ophtha.2015.10.032. HARRIES Am J Emerg Med. 2010 Oct;28(8):956-9. doi: 10.1016/j.ajem.2009.06.026. Epub 2010 Jan 28. KNIESS J Emerg Med. 2015 Jul;49(1):58-60. doi: 10.1016/j.jemermed.2014.12.074. Epub 2015 Mar 18. TAYAL 2007 DUBOURG 2011 VENKATAKRISHNA 2011
sonoguide sonocloud.com THE INTERNET FOR PICTURES
special thanks to: Dr K. Kelley, Dr. C. Jones
Emergency Ultrasound Course
Huntington Beach, CA November 8-10, 2019
DVT Ultrasound
Debia Kim, MD Co-Director, Emergency Ultrasound
TPMG, South Sacramentono disclosures
Huntington Beach, CA November 8-10, 2019
DVTBedside ultrasound in the ED
With special thanks to
Drs Ken Kelley & Lisa Rapoport!
Background & Indications Anatomy, Technique & Common Pitfalls Image Interpretation
OBJECTIVES
DVT: What are the stakes?Prevalence in symptomatic outpatients is ~20%
ICU patient incidence ~9.6-12% despite prophylaxis
500,000 screening US exams are done in the US every year
US is 95% Sn and 98% Sp for DVT in symptomatic patients
Withholding anticoagulation in patients with a negative US has been shown to be safe
Who is at risk?
Mechanical ventilation Pressors
CVC (including PICC) Trauma
Immobilization Surgery/general
anesthesia Known thrombophilic
disorders ESRD (chronic)
Platelet transfusion Prior personal or family hx of VTE
… so really, everyone in the ED who is sick
Traditionally: Venogram 1990s - Ultrasound
visualization compression doppler augmentation
Duplex Ultrasonagraphy is a screening exam — can we abbreviate this?
History of Imaging
DVT distribution
Prospective, RCT, n=2465 First episode of suspected DVT randomized to 2-Point lower extremity ultrasound versus whole-leg ultrasound CONCLUSION: 2-Point ultrasound is as good as whole-leg ultrasound for detecting DVT in symptomatic outpatients
TRADITIONAL VS. 2-POINT:
Compression is performed at the level
of the inguinal ligament to the bifurcation of
the popliteal vein, marching all the way
through the superficial femoral canal
TRADITIONAL VS. 2-POINT:
Compression is performed from junction of GSV & CFV distally 5cm
Compression is performed from
insertion of proximal pop distal to bifurcation
Limited Duplex US performed at CFV and POP by ED, followed by complete exam done by radiology 112 patients with 34 DVTs, agreement was 98% (kappa = 0.9)
Median time for ED exams: 3mins 28 secs
[
?
LEG VEINS: ANATOMY
Don’t get hung up on names!
Femoral artery and Deep femoral artery start paired next to the
Common femoral vein
Deep femoral vein — NOT seen on ultrasound (too small)
Groin Crease
Let’s start in the groin…
Femoral VesselsLaterality matters
Supine patient
CFVDFA
SFA
Femoral VesselsAs you travel away from the groin you will see the
confluences disappear
FVFA
Popliteal VesselsLaterality does not matter Supine vs prone vs sitting
patient
PA
PV
Ready to scan?Grab a linear probe (save the curvilinear probe for large patients)
Choose your DVT exam setting on the machine
Position your patient
March your compressions every along the femoral and popliteal positions
How far apart do I compress?
It is not necessary to compress every continuous millimeter of the venous lumen searching for a clot
In symptomatic patients, clot usually involves whole or multiple venous segments
It is generally adequate to compress every 1 cm of the femoral and popliteal leg veins
COMPRESSION = NORMAL
Compress until the vein walls touch, then let go
and watch for the “wink back”
NON-COMPRESSABILTY
= DVT
Common Pitfalls:Cannot interrogate the iliac veins
Beware the lymph node!
Color can help you, but can also fool you
Non-laminar flow creates artefact
Common Pitfalls:Clinical correlation:
need to repeat that US in 5-7 days for those high risk negative studies
Morbid obesity
Uncooperative patient
So … what is this?
Popliteal Pitfalls:
Getting hung up on hamstring tendons
Interrogating/mistaking superficial vessels
Baker’s cysts
The POP is on TOP!
PITFALL: superficial popliteal vessels
PITFALL: Baker’s Cyst
What about Doppler?
“Duplex” term refers to ability to simultaneously perform gray scale imaging with superimposed color flow from structures containing moving RBCs The body of published literature suggests compression ultrasound alone is satisfactory as a diagnostic technique for lower extremity DVT
What about Doppler?
“Spontaneity” - flow observed in larger vessels at quiescence “Phasic Variation” - fall in venous flow velocity at inspiration, rise at expiration
What about Augmentation?Compress a more distal part of the leg Normal vein should fill with color while thrombus appears as a filling defect Augmentation indicates patency between the point of compression and the sampling site
Primary Criterion Secondary Criterion
Noncompressibility of a vein
Echogenic ThrombusVenous Distention
Filling DefectLoss of PhasicityLoss of Valsalva
Loss of Augmentation
Diagnosis made.
“Nuts and Bolts”It’s only a deep vein if there’s an artery next to it Need to scan 2 regions:
1. The femoral triangle, CFV, GSV 2. The popliteal vein and its trifurcation
If it’s normal, the vein walls have to touch If it’s abnormal, the artery needs to collapse
RECAP:SCANNING: 2 locations (add
the CFV/mid-thigh for better sensitivity)
VISUALIZATION: recognize anatomy, fanning
COMPRESSION: press and look
43 yo M after ACL injury: suspicious?
47 yo F with Obesity and Chronic Pain
64 yo female with recurrent DVTsreturns with left leg swelling, dimer > 4000
References & Thanks!
Noble, Vicki E., Nelson, Bret P. Manual of Emergency and Critical Care Ultrasound, 2nd ed. New York, N.Y.: Cambridge University Press, June 2011 Ma, O.J., Mateer, James R., Blaivas, Michael. Emergency Ultrasound, 2nd ed. New York, N.Y.: McGraw Hill, 2008 PALLADIO study, Ageno et al., Lancet Haematology, 2015 Bernardi, JAMA, 2008 Coco Arch Intern Med 1993 Blaivas, Lambert, Harwood, Wood, Konicki at Christ Hospital; Acad Emerg Med. 2000 Feb;7(2):120-6 Crisp GJ et al, Ann Emerg Med 2010 Kory PD, Chest 2011
and special thanks to Drs. Lisa Rapoport and Kenneth Kelley THE INTERNET FOR PICTURES sonocloud.com, sonoguide.com
Emergency Ultrasound Course
Huntington Beach, CA November 8-10, 2019
MSK Ultrasound
Debia Kim, MD Co-Director, Emergency Ultrasound
TPMG, South Sacramentono disclosures
Huntington Beach, CA November 8-10, 2019
Musculo-Skeletal Miscellany
ultrasound tips and tricks!
ObjectivesWhy do I need MSK POCUS?
When will I use this? (Indications)
Normal Anatomy
Techniques and practice:
Nerve Blocks Cellulitis vs. Abscess Tendons & Fractures Foreign Bodies
ObjectivesWhy do I need MSK POCUS?
When will I use this? (Indications)
Normal Anatomy
Techniques and practice:
Nerve Blocks Cellulitis vs. Abscess Tendons & Fractures Foreign Bodies
Why grab the ultrasound?❖ More information, faster, and more safely!
❖ X-rays are awful for soft tissue. ❖ in 2010, an epidemiological study found the most
common ED malpractice claims were: AMI (5%), fractures (6%), and appendicitis (2%)*
❖ Procedures are safer and more effective with real-time guidance ... reduce the need for procedural sedation*
❖ Patient satisfaction... which all adds up to make YOU a better doc.
ObjectivesWhy do I need MSK POCUS?
When will I use this? (Indications)
Normal Anatomy
Techniques and practice:
Nerve Blocks Cellulitis vs. Abscess Tendons & Fractures Foreign Bodies
ObjectivesWhy do I need MSK POCUS?
When will I use this? (Indications)
Normal Anatomy
Techniques and practice:
Nerve Blocks Cellulitis vs. Abscess Tendons & Fractures Foreign Bodies
When Do I Use This?
❖ Trauma (direct and indirect, blunt & penetrating) ❖ Effusions, fractures, tendinopathies ❖ Nerve blocks for pain control
❖ Inflammation, infection, masses ❖ Abscess vs. cellulitis ❖ Hematomas, glands, foreign bodies
ObjectivesWhy do I need MSK POCUS?
When will I use this? (Indications)
Normal Anatomy
Techniques and practice:
Nerve Blocks Cellulitis vs. Abscess Tendons & Fractures Foreign Bodies
ObjectivesWhy do I need MSK POCUS?
When will I use this? (Indications)
Normal Anatomy
Techniques and practice:
Nerve Blocks Cellulitis vs. Abscess Tendons & Fractures Foreign Bodies
Your meat... aka Normal Anatomy
ACROSS THE GRAIN
ALONG THE GRAIN
Tendons are ... ANISOTROPIC, tricky things
so you MUST scan through them carefully. Don’t mistake anisotropy for pathology.
What about vessels & nerves?
B...O...N...E...S
Technique ...
❖ Use a high-frequency, linear transducer ❖ Hold the probe like a pencil and lightly lay the rest of
your hand on the patient to maintain position ❖ Start where it hurts and scan over the area of
interest in 2 planes ❖ Scan the contralateral limb/structure to compare ❖ Use a stand-off pad or water bath if needed
ObjectivesWhy do I need MSK POCUS?
When will I use this? (Indications)
Normal Anatomy
Techniques and practice:
Nerve Blocks Cellulitis vs. Abscess Tendons & Fractures Foreign Bodies
ObjectivesWhy do I need MSK POCUS?
When will I use this? (Indications)
Normal Anatomy
Techniques and practice:
Nerve Blocks Cellulitis vs. Abscess Tendons & Fractures Foreign Bodies
What are we looking at?
Where will the abscess show up?
To cut or not to cut ...
107 skin infection ED patients prospectively enrolled. Clinical exam: Sn 86%, Sp 70% US exam: Sn 98%, Sp 88% Conclusions: ED bedside US improves accuracy in detection of superficial abscesses.
Abscess vs Cellulitis
Abscess vs Cellulitis
Abscess vs. Cellulitis
Cut? No cut?
Abscess vs Cellulitis
Tendonremember what normal tendon looks like?
Tendon
red, hot, symmetrically swollen
held in flexion
pain on tendon percussion
pain on passive stretch
27 year old female with a “spider bite” on her finger...
Ortho is unimpressed.
Tenosynovitis?
Fractures
9 year old male with ankle painfell off his bike
Here’s his US:
Fractures
*often associated with EFFUSIONS*
Effusions
Effusions
Effusions ... in kids
Treasures ... a.k .a. foreign bodies
Treasures ... a.k .a. foreign bodies
Nerve Blocks
Femoral/Fascia Iliaca Ulnar/median Post. tibial Hematoma blocks
Advantagesreduces complications: direct visualization allows avoidance of surrounding vascular, muscular, bony structures improves success rate: blocks done with fewer pokes with faster results
(why would anyone do this without US?)
REMEMBER TO DOCUMENT YOUR NEURO EXAM BEFORE & AFTER EVERY BLOCK!!
Operator-dependent Concern for loss of exam/compartment syndrome
Caveats
Femoral NerveArises from L2-L4, remember NAVL
For femur & knee anesthesia
Direct Fem N block or Fascia Iliaca block
Probe in inguinal crease, needle loaded with 20cc, use in-plane approach
Femoral Block
Femoral Block
Fascia Iliacafind what you know:
Fascia Iliacamove laterally:
Figure 2: panoramic view of ultrasound anatomy of the femoral (inguinal) crease area. May 8th 2018<http://www.nysora.com/updates/3107-ultrasound-guided-fascia-iliaca-block.html>
Fascia Iliacainject!
Figure 2: panoramic view of ultrasound anatomy of the femoral (inguinal) crease area. May 8th 2018<http://www.nysora.com/updates/3107-ultrasound-guided-fascia-iliaca-block.html>
Foot/Ankle Blocks
Dorsal foot: Saphenous, Ant. tibial, Sup. peroneal nerves
Volar foot: Post. tibial, Sural nerves
Posterior Tibial BlockStepped on glass? Nail puncture needs to be explored? FB removal?
Position the patient - knee flexed with towel under. Or, dangle the feet over the bed while prone.
Posterior Tibial, cont’d
Wrist Blocks
Ulnar Nerve Block
Hematoma BlocksPre-scan first - use Doppler freely!
Use appropriate-sized needle to reach the hematoma
Aspirate, and then inject when you see blood
Great for confirmed end-extremity fractures
PROBE NEEDLE
ObjectivesWhy do I need MSK POCUS?
When will I use this? (Indications)
Normal Anatomy
Techniques and practice:
Nerve Blocks Cellulitis vs. Abscess Tendons & Fractures Foreign Bodies
MusculoSkeletal Summary Message!
❖ Linear probe ❖ “Superficial” or “Small Parts” exam ❖ Cobblestoning = edema, irregular hypoechoic
collection = pus ❖ Scan in 2 orthogonal planes
QUESTIONS?
ReferencesNoble, Vicki E., Nelson, Bret P. Manual of Emergency and Critical Care Ultrasound, 2nd ed. New York, N.Y.: Cambridge University Press, June 2011 Ma, O.J., Mateer, James R., Blaivas, Michael. Emergency Ultrasound, 2nd ed. New York, N.Y.: McGraw Hill, 2008 Practical Guide to Emergency Ultrasound, edited by Karen S. Cosby, John L. Kendall. Philadelphia: Lippincott, Williams & Wilkins, 2006 Acad Emerg Med. 2010 May;17(5):553-60. An epidemiologic study of closed emergency department malpractice claims in a national database of physician malpractice insurers., Brown TW, McCarthy ML, Kelen GD, Levy F. Emerg Trauma Shock. 2012 Jan;5(1):28-32. Feasibility and safety of ultrasound-guided nerve block for management of limb injuries by emergency care physicians. Acad Emerg Med. 2005 Jul;12(7):601-6. ABSCESS: applied bedside sonography for convenient evaluation of superficial soft tissue infections. Squire BT, Fox JC, Anderson C. http://www.slredultrasound.com/ImageBank/RegionalAnesthesia.html sonoguide sonocloud.com THE INTERNET FOR PICTURES
special thanks to: Dr Z. Soucy, Dr K. Kelley, Dr. S. Cusick, Dr. L. Bunting, Dr. C. Jones