Emergency Ultrasound

Contents

Preface: Emergency Ultrasound xiii

Srikar Adhikari and Michael Blaivas

History, Progress, and Future of Emergency Ultrasound 119

Srikar Adhikari and Michael Blaivas

The use of point-of-care ultrasound by emergency physicians is rapidly becomingstandard of care. With the incorporation of ultrasound training into emergencymedicine residency core curriculum and inclusion of emergency ultrasound intoemergency medicine milestones, it has become a mandatory skill for graduatingemergency medicine residents. In addition, there is growing interest to integrateultrasound into medical school curriculum and in many institutions emergency phy-sicians are leading the way in providing emergency ultrasound education to studentsthroughout 4 years of medical school.

Pitfalls and Pearls in Emergency Point-of-Care Sonography 123

Nadim Mike Hafez, Michael Gottlieb, and John Bailitz

Clinicians in different medical specialties now use point-of-care sonography (POCS)to improve the efficiency and safety of patient care. For nearly 2 decades, POCS hasbeen used in the emergency and critical care settings. This article reviews challeng-ing pitfalls and key pearls to help the busy clinician use Emergency POCS in a safeand efficient manner.

Focused Cardiac Ultrasonography in the Emergent Patient 143

Anthony J. Weekes, James Hwang, and Sama Ghali

Videos of abnormal chambers, pericardial disease, myocardial and valvedysfunction, dissection, and other interesting findings accompany this article

Focused cardiac ultrasonography provides emergency and critical care providerswith a bedside modality to assess for immediate life threats and to gather essential,time-sensitive information. The clinical usefulness of focused cardiac ultrasonogra-phy is greatest in patients with dyspnea/hypoxia, hypotension/shock, tachycardia,and periarrest states. The core applications of focused cardiac ultrasonographyinclude assessing left and right ventricular function, detecting the presence orabsence of pericardial fluid, and assessing volume status/volume responsiveness.Routine practice and clinical integration of these applications is critical. Understand-ing the various limitations of focused cardiac ultrasonography is important and a keystep toward realizing its many benefits.

Point-of-Care Pelvic Ultrasonography in Emergency Medicine 173

Lori A. Stolz and Refky Nicola

Point-of-care (POC) pelvic ultrasonography by emergency physicians allows fora rapid and safe diagnosis of a multitude of abnormalities, and allows for constantmonitoring of both obstetric and nonobstetric patients without mobilization duringthe acute phase of disease. Assessment of intrauterine pregnancy, ectopic preg-nancy, subchorionic hemorrhage, and fetal heart rate is possible with POC pelvicultrasonography in the obstetric patient, in addition to diagnosis of pathologic

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conditions in any patient presenting with acute pelvic pain. This review discusses thesonographic techniques, findings, and guidelines for the use of POC pelvic ultraso-nography in the emergency setting.

Emergency Ultrasonography: Vascular Applications 185

Christopher Vaughn and James Moak

Videos identifying the deep venous system of the lower extremities as well as theabdominal aorta and inferior vena cava accompany this article

Specific vascular ultrasound applications have been shown to be useful, quick, andaccurate when applied in the emergency department. Evaluation of deep venousthrombosis is indicated in symptomatic patient and relies on compression. Abdom-inal aortic aneurysms have a highmortality rate, often present with nonspecific symp-toms, and may be quickly identified on bedside ultrasound. Evaluation of the inferiorvena cava and its collapsibility may be useful in the evaluation of hemodynamicallyunstable patients particularly in the setting of sepsis. Further applications, includingcarotid intima-media thickness and evaluation for septic thrombophlebitis, may showpromise when applied to emergency department patients in the future.

Pediatric Emergency Ultrasound 199

Lorraine Ng and Jennifer R. Marin

Videos of picture frame and lawnmower scanning of the abdomen forintussusception accompany this article

The use of point-of-care ultrasound (POCUS) in emergency medicine is rapidlyexpanding to include pediatric-specific applications that aid in the diagnosis of pe-diatric clinical conditions and guidance of invasive procedures. POCUS has demon-strated diagnostic utility in common pediatric complaints, such as vomiting andabdominal pain, minor head trauma, and limping. This article highlights novelPOCUS applications relevant to pediatric emergency care.

Airway and Thoracic Ultrasound 211

Jared T. Marx, Michael Blaivas, and Srikar Adhikari

Videos of the sonographic airway extending from the oropharynx through thoraciccavity to the level of the diaphragm accompany this article

Ultrasound continues to grow in use for rapid diagnosis and assessment within theemergency department. This diagnostic tool aids the physician in early diagnosis forresuscitation of the critical patient. With new emerging research airway ultrasoundshows promise as not only diagnostic but also therapeutic adjunct to a patient’scare. In addition, thoracic ultrasound allows for evaluation of insults to the breathingcomponent of resuscitation and also can diagnostically direct therapy earlier thanpreviously available in critical care areas.

Procedural Guidance with Ultrasound in the Emergency Patient 217

Richard Amini

Videos pertinent to paracentesis, thoracentesis, pericardiocentesis, andtransvenous pacing accompany this article

Successful performance of emergent procedures relies on the experience, compe-tence, and skills of the operator. An ultrasound-aided approach to emergency pro-cedures has been demonstrated to increase patient safety and operator confidenceand is frequently replacing the anatomic landmark approach as the new standard.From the most mundane and simple procedure, such as intravenous catheterplacement, to the most complex and technically challenging procedure, such as

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transvenous pacing, ultrasound provides a means for success. The use of ultra-sound reduces the number of attempts, the complication rates, and the amount ofanesthetic used.

Symptom-Based Ultrasonography 227

Jehangir Meer, Sierra Beck, and Karim Ali

Videos showing heart with large pericardial effusion and tamponade physiology,McConnell’s Sign with RV strain, thrombus in RA/RV, severe mitral regurgitationwith color doppler imaging, pleural effusion, severely reduced LV systolic function,inferior wall motion hypokinesia, calcified aortic valve and absence of pleuralsliding accompany this article

Symptom-based ultrasonography describes 2 approaches to point-of-care ultraso-nography for emergency department patients who present with chest pain anddyspnea, or abdominal pain. The aim of this article is provide a framework to rulein or out life-threatening causes rapidly at the bedside and allow narrowing downof a large list of differential diagnosis while additional tests are being ordered.Although this article is primarily written for the emergency physician, it can also beused in other care settings. In the hands of trained clinicians, bedside ultrasonogra-phy is a truly valuable tool.

Head and Neck Sonography in the Emergency Setting 247

Shannon B. Snyder, Robinson M. Ferre, and Jeremy S. Boyd

This articles is accompanied by supplemental videos demonstrating both thenormal anatomy and pathology illustrated by still ultrasound images

High-resolution sonography is ideal for the evaluation of many oropharyngeal andneck structures because of their superficial nature. Clinicians can use point-of-care ultrasonography to evaluate for different types of infectious and inflammatoryconditions in this area, including cellulitis and/or abscess formation of the superficialsoft tissues, peritonsillar abscess, cervical lymphadenitis, salivary gland inflamma-tion and sialolithiasis, dental abscess, inflammation of the thyroid gland, internaljugular thrombosis and thrombophlebitis, and sinusitis.

Ultrasonography in Musculoskeletal Disorders 269

Eitan Dickman, Marla C. Levine, Shideh Shafie, John Munyak, Jennifer Hashem, Ahmed Saleh,and Eric H. Chou

Ultrasonography has been shown to be an effective imaging modality for the detec-tion of a variety of musculoskeletal conditions, which has led emergency physiciansto increasingly use this technology when assessing patients for possible fractures,joint effusions, tendinopathies, joint dislocations, and soft tissue infections. Clinicalsonography is performed at the patient’s bedside, and in many cases obviates otherimaging studies, including radiography and magnetic resonance imaging. However,future studies will likely further delineate the role of musculoskeletal ultrasonographyin the acute setting.

Ultrasound Protocol Use in the Evaluation of an Unstable Patient 293

Danielle Hallett, Parisa P. Javedani, and Jarrod Mosier

Videos related to pertinent ultrasound findings accompany this article

The use of bedside ultrasound for evaluation and resuscitation of hemodynamicallyunstable patients in the emergency department has become increasingly common.It is supported by a growing number of clinical studies and statement publications

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from various societies. Several ultrasound protocols have been proposed for theassessment of the unstable patient. This article reviews how ultrasound is used byemergency physicians to guide resuscitation of unstable patients and describesdifferent rapid bedside ultrasound protocols that have been proposed.

Index 307