EM Ultrasound

BACKGROUND: Pulmonary ultrasound plays a key role in the diagnosis of pneumothorax in emergency and intensive-care medicine. The lung point sign has been generally considered a pathognomonic diagnostic sign. Recently, several other situations have been published that can mimic the lung point, as well as a few different variants of the true lung point sign. MATERIALS AND METHODS: Based on years of monitoring the literature and collecting our database of ultrasound findings, we prepared a review of ultrasound findings mimicking the lung point sign and ultrasound variants of the true lung point sign...

BACKGROUND: Recent meta-analyses failed to support the reliability of ultrasound assessment of the inferior vena cava (IVC) to predict fluid responsiveness. However, the techniques utilized were heterogeneous. We hypothesized that the variability of the elliptic section and caliber of the IVC along its course may influence ultrasound evaluation. Therefore, we investigated IVC size and shape at four levels, before and after a fluid challenge. METHODS: Twenty mechanically-ventilated adult patients who received a fluid challenge after cardiac surgery were enrolled...

Ultrasound assessment of patients in shock is becoming the standard of care in emergency and critical care settings worldwide. One of the most common protocols used for this assessment is the rapid ultrasound in shock (RUSH) examination. The RUSH protocol is a rapid evaluation of cardiac function, key vascular structures, and likely sources of hypotension. Stroke volume is an established important value to assess in the setting of shock, allowing the provider to predict the patient's response to treatment. However, the calculation of stroke volume or its surrogates is not part of any protocol, including RUSH...

Accurate assessment of volume status is critical in the management of patients with heart failure (HF). We studied the utility of a pocket-sized ultrasound device in an outpatient cardiology clinic as a tool to guide volume assessment. Inferior vena cava (IVC) size and collapsibility were assessed in 95 patients by residents briefly trained in focused cardiac ultrasound (FCU). Cardiologist assessment of volume status and changes in diuretic medication were also recorded. Patients were followed for occurrence of 30-day events...

PURPOSE OF REVIEW: To present the practical aspects of transcranial Doppler (TCD) and provide evidence supporting its use for the management of traumatic brain injury (TBI) patients. RECENT FINDINGS: TCD measures systolic, mean, and diastolic cerebral blood flow (CBF) velocities and calculates the pulsatility index from basal intracranial arteries. These variables reflect the brain circulation, provided there is control of potential confounding factors. TCD can be useful in patients with severe TBI to detect low CBF, for example, during intracranial hypertension, and to assess cerebral autoregulation...

PURPOSE OF REVIEW: When a condition of hypoperfusion has been identified, clinicians must decide whether fluids may increase blood flow or whether other therapeutic approaches are needed. For this purpose, several tests and parameters have been introduced in clinical practice to predict fluid responsiveness and guide therapy. RECENT FINDINGS: Fluid challenge is the gold standard test to assess the preload dependence of the patients. Moreover, several parameters and tests avoiding fluid administration are now available...

BACKGROUND: The evaluation of fluid responsiveness in patients with hemodynamic instability remains to be challenging. This investigation aimed to determine whether respiratory variation in carotid Doppler peak velocity (ΔCDPV) predicts fluid responsiveness in patients with septic shock and lung protective mechanical ventilation with a tidal volume of 6 ml/kg. METHODS: We performed a prospective cohort study at an intensive care unit, studying the effect of 59 fluid challenges on 19 mechanically ventilated patients with septic shock...

Extravascular lung water (EVLW) is a key variable in heart failure management and prognosis, but its objective assessment remains elusive. Lung imaging has been traditionally considered off-limits for ultrasound techniques due to the acoustic barrier of high-impedance air wall. In pulmonary congestion however, the presence of both air and water creates a peculiar echo fingerprint. Lung ultrasound shows B-lines, comet-like signals arising from a hyper-echoic pleural line with a to-and-fro movement synchronized with respiration...

Despite multiple advantages, subclavian vein (SCV) cannulation via the traditional landmark approach has become less used in comparison to ultrasound (US) guided internal jugular catheterization due to a higher rate of mechanical complications. A growing body of evidence indicates that SCV catheterization with real-time US guidance can be accomplished safely and efficiently. While several cannulation approaches with real-time US guidance have been described, available literature suggests that the infraclavicular, longitudinal "in-plane" technique may be preferred...

BACKGROUND: Preoperative imaging for suspected acute appendicitis (AA), such as ultrasonography (US), was shown to improve diagnostic accuracy and patient outcomes. Criteria for diagnosis of AA by US are well established and reliable. In previous studies, US assessments were always performed by skilled radiologist physicians. However, a radiologist and computed tomography scanning equipment are not always available in the community hospitals or remote sites of developing countries. OBJECTIVE: Our aim was to assess a diagnostic pathway using clinical evaluation, routine US performed by an emergency physician, and clinical re-evaluation for patients suspected of having AA...

OBJECTIVE: Diagnosis of bone fractures by ultrasonography is becoming increasingly popular in emergency medicine practice. We aimed to determine the diagnostic sensitivity and specificity of point-of-care ultrasonography (PoCUS) compared with plain radiographs in proximal and middle phalanx fractures. METHODS: Between August 2012 and July 2013, adult patients presenting to our emergency department with a possible (by clinical evaluation) proximal or middle phalanx fracture of finger were invited to participate in this prospective cohort study...

OBJECTIVES: Ultrasound-guided interscalene brachial plexus blocks are commonly used to provide anesthesia for the shoulder and proximal upper extremity. Some reviews identify a sheath that envelops the brachial plexus as a potential tissue plane target, and current editorials in the literature highlight the need to establish precise and reproducible injection targets under ultrasound guidance. We hypothesize that an injection of a local anesthetic inside the brachial plexus sheath during ultrasound-guided interscalene nerve blocks will result in enhanced procedure success and provide a consistent tissue plane target for this approach with a reproducible and characteristic local anesthetic spread pattern...

No abstract text is available yet for this article.

A shortcut review was carried out to establish whether ultrasound is an effective diagnostic tool for the diagnosis of sternal fractures. 27 papers were found of which 4 presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are tabulated. The clinical bottom line is that in patients with blunt thoracic injury and suspected isolated sternal fracture, ultrasound seems superior to conventional radiology to diagnose sternal fracture...

STUDY OBJECTIVE: Ascending aortic dissection (AAD) is an uncommon, time-sensitive, and deadly diagnosis with a nonspecific presentation. Ascending aortic dissection is associated with aortic dilation, which can be determined by emergency physician focused cardiac ultrasound (EP FOCUS). We seek to determine if patients who receive EP FOCUS have reduced time to diagnosis for AAD. METHODS: We performed a retrospective review of patients treated at 1 of 3 affiliated emergency departments, March 1, 2013, to May 1, 2015, diagnosed as having AAD...

BACKGROUND: Ventilator-induced lung injury is a form of mechanical damage leading to a pulmonary inflammatory response related to the use of mechanical ventilation enhanced by the presence of atelectasis. One proposed mechanism of this injury is the repetitive opening and closing of collapsed alveoli and small airways within these atelectatic areas-a phenomenon called tidal recruitment. The presence of tidal recruitment is difficult to detect, even with high-resolution images of the lungs like CT scan...

STUDY OBJECTIVE: We determine whether renal point-of-care limited ultrasonography (PLUS) used in conjunction with the Sex, Timing, Origin, Nausea, Erythrocytes (STONE) clinical prediction score can aid identification of emergency department (ED) patients with uncomplicated ureteral stone or need for urologic intervention. METHODS: This was a prospective observational study of adult ED patients undergoing computed tomography (CT) scan for suspected ureteral stone...

No abstract text is available yet for this article.

Appropriate fluid resuscitation has been a major focus of critical care medicine since its inception. Currently, the most accurate method to guide fluid administration decisions uses "dynamic" measures that estimate the change in cardiac output that would occur in response to a fluid bolus. Unfortunately, their use remains limited due to required technical expertise, costly equipment, or applicability in only a subset of patients. Alternatively, point-of-care ultrasound (POCUS) has become widely used as a tool to help clinicians prescribe fluid therapy...

There is evidence to suggest that point-of-care ultrasound assessment of the lungs has a higher sensitivity and specificity than chest radiography for the diagnosis of pneumonia. It is unknown if the same is true for pneumonia complications. We present and discuss the case of a 61-year-old woman who presented to the emergency department with confusion, decreased level of consciousness, and signs of sepsis. A chest x-ray revealed a right sided infiltrate. An ultrasound of the patient's lungs was performed, and revealed a complex loculated fluid collection consistent with an empyema...