1. Ultrasound in Emergency Medicine Martin A. Bazi, MD

2.  The clinical application of ultrasonography by emergency physicians has greatly expanded over the past decade.  The American College of Emergency Physicians (ACEP) has firmly supported the concept of emergency ultrasound.

3. INDICATIONS  Blunt or penetrating trauma to the torso  4 views Rt flank: hepatorenal space Lt flank: Perisplenic area Subcostal : pericardium Pelvic : retrovesical or retrouterine

4. The FAST examination  The F ocused A ssessment with S onography for T rauma is a rapid, bedside, ultrasound examination performed to identify intra-peritoneal haemorrhage or pericardial tamponade.  FAST examines four areas for free fluid: 1. Perihepatic & hepato-renal space 2. Perisplenic 3. Pelvis 4. Pericardium

5. Perihepatic Scanning  The hepatorenal space (pouch of Rutherford- Morison) is the most dependent part of the upper peritoneal cavity and small amounts of intra-peritoneal fluid may collect in this region first. Blood shows as a hypoechoic black stripe between the capsule liver and the fatty fascia of the kidney.  The probe is placed in the right mid- to posterior axillary line at the level of the 11th and 12th ribs.

6. Perisplenic Scanning  The left upper quadrant examination visualises the spleen and perisplenic areas.  The transducer is placed on the left posterior axillary line region between the 10th and 11th ribs.

7. Pelvic Scanning  The pelvic examination visualises the cul-de- sac: the Pouch of Douglas in females and the rectovesical pouch in the male. It is the most dependent portion of the lower abdomen and pelvis, hence where fluid will collect.  The transducer is placed midline just superior to the symphysis pubis.

8. Pericardial Scanning  The pericardial examination screens for fluid between the fibrous pericardium and the heart, and hence possible cardiac tamponade.  The transducer is placed just to the left of the xiphisternum and angled upwards under the costal margin.

9. Advanced Trauma Scanning  Looks for fluid  Look for non-homogenous appearing regions with in solid organs parenchyma which may represent injury  Consist of Diamond abdominal examinations and 2 discrete thoracic windows

10. DIAMOND EXAMINATION

11. Emergency US in pregnancy  Indicated in first trimester pregnant patient presenting with pain, bleeding, near syncope or shock  Asymptomatic pregnant patient with risk factors for ectopic pregnancy Look for  Location of the pregnancy  Fetal heart rate

12. US in pregnancy  Transabdominal  Intravaginal For second & third trimester  Detecting fetal cardiac movement  Pregnant trauma patient

13. Emergency echocardiography  Trauma  Cardiac arrest & shock  Pulseless electrical activity

14. Procedural US  Intravenous lines  Bladder size & aspiration  Abscess location & aspiration  Thoracentesis & paracentesis  Foreign body localization Pacemaker IUD Soft tissue FB

15. ACEP recommended training and proficiency numerical goals per emergency ultrasound application. Primary ApplicationMinimumRange of Documented and Outcome Reviewed Ultrasound Needed for Proficiency Trauma2525-50 IUP2525-50 25 Endovaginal (if only doing EV) 25 Transabdominal (if only doing TA) Emergency cardiac2525-50 AAA25 Biliary2525-50 Renal25

16. Pathway for EUS training for Practicing Physician  Attends introductory emergency ultrasound course or courses  Performs ultrasounds under supervision over reads, gold standards confirmatory testing, or patient outcome review within departmental ultrasound plan  Ultrasounds are obtained with documentation and review to meet ACEP emergency ultrasound proficiency guidelines. Ultrasound available for departmental and hospital examination  Acquired at local hospital setting within departmental privileges  Quality review of ultrasound performed continuously. CME attended in accordance with specialty guidelines

17. Examples of levels of proficiency  Level I This level is for the practitioner who has completed the introductory training.  Level II This level is for the practitioner who is in the process of completing credentialing examinations. Credentialing examinations must be recorded and contain follow-up documentation. Each examination is to be reviewed by the ED ultrasound coordinator. Straightforward examinations may be used in some clinical situations if reviewed by a Level III sonographer. In general, these examinations will not be used to make patient care decisions unless reviewed by a Level III Sonographer  Level III This level is for the practitioner who is approved to use emergency ultrasound in the ED for patient-care decisions. This physician may supervise Level I and II examiners.

18. Future potential applications of Emergency US

19. Application Rationale MusculoskeletalMusculoskeletal injuries Arthrocentesis Fracture detection Fracture reduction guidance Deep venous thrombosisDetection of deep venous thrombosis AirwayIntubation detection in the apneic patient Head and neckPeritonsillar abscess detection and drainage

20. Testicular ultrasound Rule out torsion Cardiac (transthoracic) Use for left ventricular function and hypotension Orbital ultrasound Orbital hematoma and retinal detachment Transesophageal Cardiac function and aortic disease Obstetric second- and third-trimester bleeding Placenta previa