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Ultrasound in Emergency Medicine Dr Bill Coode Consultant in Emergency Medicine Newham University Hospital

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Page 1: Ultrasound in Emergency Medicine...• Logbook with minimum: – 10 FAST scans – 5 vascular access – 10 focused ECHO, 5 in peri-arrest/cardiac arrest if possible – 10 abdominal

UltrasoundinEmergencyMedicine

DrBillCoodeConsultantinEmergencyMedicineNewhamUniversityHospital

Page 2: Ultrasound in Emergency Medicine...• Logbook with minimum: – 10 FAST scans – 5 vascular access – 10 focused ECHO, 5 in peri-arrest/cardiac arrest if possible – 10 abdominal

Welcome

• Faculty

• Courseaims– Level1theory– Level1skills– BeyondLevel1

• Howtogetstarted

Page 3: Ultrasound in Emergency Medicine...• Logbook with minimum: – 10 FAST scans – 5 vascular access – 10 focused ECHO, 5 in peri-arrest/cardiac arrest if possible – 10 abdominal

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

Page 4: Ultrasound in Emergency Medicine...• Logbook with minimum: – 10 FAST scans – 5 vascular access – 10 focused ECHO, 5 in peri-arrest/cardiac arrest if possible – 10 abdominal

WhatCanWeUseUltrasoundFor?• Newpossibilitieseveryday

• Differentrequirementsbetweenspecialities• CannotreplaceRadiologists/Sonographers• Trytoanswerfocusedquestion– ‘istherefreefluidinthe

abdomen?’Y/N• Understandsensitivity/specificitywithintheclinical

context• Acceptthatimageacquisitionmaybesuboptimal

• Safeplacementofneedleandtubes– ‘THEREISNOBODYCAVITYTHATCANNOTBEREACHEDWITHA#14GNEEDLEANDAGOODSTRONGARM’

• UseUltrasoundasanextensionofHx /Examination• ‘Afoolwithastethoscopewillstillbeafoolwithan

ultrasoundprobe’

Page 5: Ultrasound in Emergency Medicine...• Logbook with minimum: – 10 FAST scans – 5 vascular access – 10 focused ECHO, 5 in peri-arrest/cardiac arrest if possible – 10 abdominal

RCEM• From2010,thehigherspecialtycurriculumforemergencymedicineincorporated

PoCUS asamandatoryelement.Thismeansthatfrom2013traineesneedtobesignedoffatCORElevelpriortoCCTbeingawarded.

• FocusedAssessmentwithSonographyinTrauma(FAST)• AssessmentoftheAbdominalAortaforAneurysm(AAA)• FocusedEchocardiographyinLifeSupport(ELS)• UltrasoundGuidedVascularAccess(VA)

• From2014theUSSCpreferredmethodofassessmentwillbeviaOSCEorFinishingSchoolformat

• ThereareallfourCOREcompetencesassessmentdocumentsontheRCEMePortfolioportal.

• RCEM/UniversityofTeessideUltrasoundRegistry.

• Enhancedpractice• RCEMUSLevel2guidance

• RCEMGovernanceStatement

Page 6: Ultrasound in Emergency Medicine...• Logbook with minimum: – 10 FAST scans – 5 vascular access – 10 focused ECHO, 5 in peri-arrest/cardiac arrest if possible – 10 abdominal

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.

Page 7: Ultrasound in Emergency Medicine...• Logbook with minimum: – 10 FAST scans – 5 vascular access – 10 focused ECHO, 5 in peri-arrest/cardiac arrest if possible – 10 abdominal
Page 8: Ultrasound in Emergency Medicine...• Logbook with minimum: – 10 FAST scans – 5 vascular access – 10 focused ECHO, 5 in peri-arrest/cardiac arrest if possible – 10 abdominal

Level1CEM Position

• CurriculumST4-6

• Theory– Level1CourseandEnlightenMemodulesonline

• UltrasoundviewofAnatomy

• Physics&setupofUSsystem

• Imagerecording

• Artefacts

• Safety&consent

• Limitations

Page 9: Ultrasound in Emergency Medicine...• Logbook with minimum: – 10 FAST scans – 5 vascular access – 10 focused ECHO, 5 in peri-arrest/cardiac arrest if possible – 10 abdominal

Medicine

• Respiratory- Pleuralultrasoundtraining(2010curriculumtolevel1)

• Cardiology– formalECHO

• AcuteGeneralMedicine– nogeneralultrasoundcurriculum

Page 10: Ultrasound in Emergency Medicine...• Logbook with minimum: – 10 FAST scans – 5 vascular access – 10 focused ECHO, 5 in peri-arrest/cardiac arrest if possible – 10 abdominal

IntensiveCareMedicine

• CoreUltrasoundIntensiveCare(CUSIC)

• FocusedIntensiveCareEcho (FICE)

Page 11: Ultrasound in Emergency Medicine...• Logbook with minimum: – 10 FAST scans – 5 vascular access – 10 focused ECHO, 5 in peri-arrest/cardiac arrest if possible – 10 abdominal
Page 12: Ultrasound in Emergency Medicine...• Logbook with minimum: – 10 FAST scans – 5 vascular access – 10 focused ECHO, 5 in peri-arrest/cardiac arrest if possible – 10 abdominal

RCR View

• “Allwhoprovideanultrasoundserviceareethicallyandlegallyvulnerableiftheyhavenotbeenadequatelytrained.

• NationalHealthService(NHS)TrustsintheUK,whichprovideprofessionalindemnitytopractitioners,areunlikelytobeabletomountanydefencetoanactionbroughtagainstanuntrainedpractitioner”

Page 13: Ultrasound in Emergency Medicine...• Logbook with minimum: – 10 FAST scans – 5 vascular access – 10 focused ECHO, 5 in peri-arrest/cardiac arrest if possible – 10 abdominal

Howtogetstarted?

• Findasupervisor

• Nominateadepartmentlead

• MakefriendswithRadiology/Cardiology/ED

• Attendaregisteredcoursee.g.Infomed

• GetanUSmachine– cheap!

• Keepalogbook

• Gastroward/Renal/AAAscreening/SIM/ECHOlist…………………….

Page 14: Ultrasound in Emergency Medicine...• Logbook with minimum: – 10 FAST scans – 5 vascular access – 10 focused ECHO, 5 in peri-arrest/cardiac arrest if possible – 10 abdominal

Training/Competency• Easytogoonacourse

• Difficulttogain/maintaincompetency

• Trainer

• Portfolio

• FinishingSchool

• OngoingCPD

Page 15: Ultrasound in Emergency Medicine...• Logbook with minimum: – 10 FAST scans – 5 vascular access – 10 focused ECHO, 5 in peri-arrest/cardiac arrest if possible – 10 abdominal

Level1- SkillMaintenance

• CPD

• DOPS

• Dept - governance,trainingmeetings,nominatedlead

• Regionaltrainer

Page 16: Ultrasound in Emergency Medicine...• Logbook with minimum: – 10 FAST scans – 5 vascular access – 10 focused ECHO, 5 in peri-arrest/cardiac arrest if possible – 10 abdominal

Practicalities\ Kit• Chooseyourmachinecarefully

• Storeitsafely• Workoutwhoisgoingtosupportyourtraining

• Remembertologallscans• QualitycontrolCTresults/Clinicalfollowup

• Harddrive+passwordsvprintedscans

• PACSintegration=ideal

Page 17: Ultrasound in Emergency Medicine...• Logbook with minimum: – 10 FAST scans – 5 vascular access – 10 focused ECHO, 5 in peri-arrest/cardiac arrest if possible – 10 abdominal

Medico-Legal

• Writeinnotesaccordingtoleveloftraining

• Explaintopatientnotaformalscan

• Storeimagesforreview

• Deptprotocol&framework

Page 18: Ultrasound in Emergency Medicine...• Logbook with minimum: – 10 FAST scans – 5 vascular access – 10 focused ECHO, 5 in peri-arrest/cardiac arrest if possible – 10 abdominal

FAST/AAA

Page 19: Ultrasound in Emergency Medicine...• Logbook with minimum: – 10 FAST scans – 5 vascular access – 10 focused ECHO, 5 in peri-arrest/cardiac arrest if possible – 10 abdominal

LinePlacement/Periarrest

Page 20: Ultrasound in Emergency Medicine...• Logbook with minimum: – 10 FAST scans – 5 vascular access – 10 focused ECHO, 5 in peri-arrest/cardiac arrest if possible – 10 abdominal

?DVT /RUQ Pain

Page 21: Ultrasound in Emergency Medicine...• Logbook with minimum: – 10 FAST scans – 5 vascular access – 10 focused ECHO, 5 in peri-arrest/cardiac arrest if possible – 10 abdominal

ForeignBody/1st Trimester

Page 22: Ultrasound in Emergency Medicine...• Logbook with minimum: – 10 FAST scans – 5 vascular access – 10 focused ECHO, 5 in peri-arrest/cardiac arrest if possible – 10 abdominal

VolumeStatus

Page 23: Ultrasound in Emergency Medicine...• Logbook with minimum: – 10 FAST scans – 5 vascular access – 10 focused ECHO, 5 in peri-arrest/cardiac arrest if possible – 10 abdominal

Chest

Page 24: Ultrasound in Emergency Medicine...• Logbook with minimum: – 10 FAST scans – 5 vascular access – 10 focused ECHO, 5 in peri-arrest/cardiac arrest if possible – 10 abdominal

CardiacPerformance/Hydronephrosis

Page 25: Ultrasound in Emergency Medicine...• Logbook with minimum: – 10 FAST scans – 5 vascular access – 10 focused ECHO, 5 in peri-arrest/cardiac arrest if possible – 10 abdominal

Pneumothorax

Page 26: Ultrasound in Emergency Medicine...• Logbook with minimum: – 10 FAST scans – 5 vascular access – 10 focused ECHO, 5 in peri-arrest/cardiac arrest if possible – 10 abdominal

LungRockets

Page 27: Ultrasound in Emergency Medicine...• Logbook with minimum: – 10 FAST scans – 5 vascular access – 10 focused ECHO, 5 in peri-arrest/cardiac arrest if possible – 10 abdominal

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

Page 28: Ultrasound in Emergency Medicine...• Logbook with minimum: – 10 FAST scans – 5 vascular access – 10 focused ECHO, 5 in peri-arrest/cardiac arrest if possible – 10 abdominal

‘ShockScan’

FASTAAAPTXHTX

FocusedEcho

IVCassessment

Page 29: Ultrasound in Emergency Medicine...• Logbook with minimum: – 10 FAST scans – 5 vascular access – 10 focused ECHO, 5 in peri-arrest/cardiac arrest if possible – 10 abdominal

Summary

• Enjoythecourse• Askquestions• Workoutwhatwouldbenefityourclinicalpractice

• Planyourportfolio/accreditation• MakefriendswithRadiology/Cardiology• Knowyourlimitations– FocussedUS• Beproactiveinfindingcasestoscan

Page 30: Ultrasound in Emergency Medicine...• Logbook with minimum: – 10 FAST scans – 5 vascular access – 10 focused ECHO, 5 in peri-arrest/cardiac arrest if possible – 10 abdominal

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