ultrasound in emergency medicine...• logbook with minimum: – 10 fast scans – 5 vascular access...
TRANSCRIPT
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UltrasoundinEmergencyMedicine
DrBillCoodeConsultantinEmergencyMedicineNewhamUniversityHospital
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Welcome
• Faculty
• Courseaims– Level1theory– Level1skills– BeyondLevel1
• Howtogetstarted
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CourseFormat• Day1
– physics,knobology,optimisingimages,buyingkit– Level1– eFAST,AAA
• Day2– Level1- peri-arrest/shock,vascularaccess– Beyondlevel,softtissueFB,DVT
• Lecture/Practical/CasePresentations
• Stationswithmodels&patients
• Assessment forms
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WhatCanWeUseUltrasoundFor?• Newpossibilitieseveryday
• Differentrequirementsbetweenspecialities• CannotreplaceRadiologists/Sonographers• Trytoanswerfocusedquestion– ‘istherefreefluidinthe
abdomen?’Y/N• Understandsensitivity/specificitywithintheclinical
context• Acceptthatimageacquisitionmaybesuboptimal
• Safeplacementofneedleandtubes– ‘THEREISNOBODYCAVITYTHATCANNOTBEREACHEDWITHA#14GNEEDLEANDAGOODSTRONGARM’
• UseUltrasoundasanextensionofHx /Examination• ‘Afoolwithastethoscopewillstillbeafoolwithan
ultrasoundprobe’
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RCEM• From2010,thehigherspecialtycurriculumforemergencymedicineincorporated
PoCUS asamandatoryelement.Thismeansthatfrom2013traineesneedtobesignedoffatCORElevelpriortoCCTbeingawarded.
• FocusedAssessmentwithSonographyinTrauma(FAST)• AssessmentoftheAbdominalAortaforAneurysm(AAA)• FocusedEchocardiographyinLifeSupport(ELS)• UltrasoundGuidedVascularAccess(VA)
• From2014theUSSCpreferredmethodofassessmentwillbeviaOSCEorFinishingSchoolformat
• ThereareallfourCOREcompetencesassessmentdocumentsontheRCEMePortfolioportal.
• RCEM/UniversityofTeessideUltrasoundRegistry.
• Enhancedpractice• RCEMUSLevel2guidance
• RCEMGovernanceStatement
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CEMLevel1• Goaliscompetency,notrigidnumberofscans
• Reviewofevidence• AttendanceatLevel1USorlocalmodularcourse• Completionof6RCEMUSmoduleswww.rcemlearning.co.uk (orevidenceof
modulescompletedinpastonEnlightenme/e-lfh)
• Logbookwithminimum:– 10FASTscans– 5vascularaccess– 10focusedECHO,5inperi-arrest/cardiac arrest ifpossible– 10abdominal aortascans
• (50%ofallscansshouldbesupervised)
• Pictorialrecordwithillustrateddescriptionof10casesinwhichcandidatehasbeenpersonallyinvolved.Themostimportantthinghereistosee10reflectivecases.Imagesarenotamust,asnoteverycandidateisabletoprintimagesattheirhospitals.Casestudies,however,mustbeproperlypresentedandshowthatthecandidatehasaclearunderstandingoftheuseofUSinaclinicalscenario.
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Level1CEM Position
• CurriculumST4-6
• Theory– Level1CourseandEnlightenMemodulesonline
• UltrasoundviewofAnatomy
• Physics&setupofUSsystem
• Imagerecording
• Artefacts
• Safety&consent
• Limitations
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Medicine
• Respiratory- Pleuralultrasoundtraining(2010curriculumtolevel1)
• Cardiology– formalECHO
• AcuteGeneralMedicine– nogeneralultrasoundcurriculum
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IntensiveCareMedicine
• CoreUltrasoundIntensiveCare(CUSIC)
• FocusedIntensiveCareEcho (FICE)
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RCR View
• “Allwhoprovideanultrasoundserviceareethicallyandlegallyvulnerableiftheyhavenotbeenadequatelytrained.
• NationalHealthService(NHS)TrustsintheUK,whichprovideprofessionalindemnitytopractitioners,areunlikelytobeabletomountanydefencetoanactionbroughtagainstanuntrainedpractitioner”
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Howtogetstarted?
• Findasupervisor
• Nominateadepartmentlead
• MakefriendswithRadiology/Cardiology/ED
• Attendaregisteredcoursee.g.Infomed
• GetanUSmachine– cheap!
• Keepalogbook
• Gastroward/Renal/AAAscreening/SIM/ECHOlist…………………….
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Training/Competency• Easytogoonacourse
• Difficulttogain/maintaincompetency
• Trainer
• Portfolio
• FinishingSchool
• OngoingCPD
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Level1- SkillMaintenance
• CPD
• DOPS
• Dept - governance,trainingmeetings,nominatedlead
• Regionaltrainer
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Practicalities\ Kit• Chooseyourmachinecarefully
• Storeitsafely• Workoutwhoisgoingtosupportyourtraining
• Remembertologallscans• QualitycontrolCTresults/Clinicalfollowup
• Harddrive+passwordsvprintedscans
• PACSintegration=ideal
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Medico-Legal
• Writeinnotesaccordingtoleveloftraining
• Explaintopatientnotaformalscan
• Storeimagesforreview
• Deptprotocol&framework
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FAST/AAA
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LinePlacement/Periarrest
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?DVT /RUQ Pain
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ForeignBody/1st Trimester
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VolumeStatus
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Chest
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CardiacPerformance/Hydronephrosis
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Pneumothorax
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LungRockets
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More?• JointEffusions- e.g.childirritablehip
• Proceduralguidance - nerveblocks,LPs
• Undifferentiated hypotension
• Softtissue-e.g.Achillestendonrupture
• Fractures
• ECHO
• Peripherallines/ALines
• Jointinjections/Aspirations
• Bladder?PreSuprapubiccatheter
• Abscess/LymphNodes
• Testicularmass/Bloodflow
• ARF– Obstruction/Kidneysize
• Pneumothorax/pleuraleffusion
• RaisedICP
• LungWetness
• Ascites
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‘ShockScan’
FASTAAAPTXHTX
FocusedEcho
IVCassessment
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Summary
• Enjoythecourse• Askquestions• Workoutwhatwouldbenefityourclinicalpractice
• Planyourportfolio/accreditation• MakefriendswithRadiology/Cardiology• Knowyourlimitations– FocussedUS• Beproactiveinfindingcasestoscan
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Questions?