Case Based Review (Whew!)
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1 Northern California Emergency Ultrasound Course Case Based Review (Whew!) Martine Sargent, MD Ultrasound Director, Assistant Professor UCSF Department of Emergency Medicine San Francisco General Hospital & Trauma Center No Interests to Disclose :) UC SF
2 Goals To integrate what you have learned so far Work through some cases Time for questions
3 EtoH + car = MVC 30 yo F rear seat passenger, unrestrained cc: back pain, gluteal pain VS field 109/74, 94, 18, 99% RA BP dropped 80/P, 120, 20 95% RA GCS 15
4 Supine CXR insensitive
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6 Normal Abnormal xt Text Text Ultrasound should show pleural movement & artifacts
7 Normal Abnormal ext Text Text
8 Can confirm with M Mode side by side
9 RUQ: Hemoperitoneum Normal Abnormal
10 RUQ: Hemothorax Normal Abnormal
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12 Pelvic View Tranverse Female FF Uterus Abnormal
13 2:30 pm 45 y/o male w/o pmh presents w/abd pain, subjective n/v and diffusely tender abdomen States pain increase with PO intake, crampy and burning in nature, radiates to entire abdomen
14 Objective VS , 110, 14, 140/80, 100%RA Labs - CBC, Chem (LFT and Bili) - WNL PE - in mod distress and mildly dehydrated
15 Sludge Thick Wall Stone Shadow
16 Fluid halo sign
17 Double Barrel Sign - Dispo?
18 Flank Pain 42 yo man c/o left flank pain, radiating to groin denies hematuria, dysuria 168/83 HR 55 T 36.9 RR 14 diaphoretic, in distress abd non-tender, nl BS
19 data UA: RBC> >15<300 nl lytes
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24 more imaging? treatment? follow up? next steps?
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27 AAA -Next Steps? If HD stable Can go to CT Outcomes better with elective surgery If HD unstable Clinical rupture Surgery consult OR
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29 Clot L
30 Dissection
31 Crashing Patient! 42 yo female presents with BP 75/42, HR 135, T 38.2, Sa02 96% RA SOB, epigastric pain, N/V EKG - ST elevations inferolateral leads 5.2 lactate VBG line, labs...p, CXR...P
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33 Text
34 Pericardial Effusion Parasternal Long Parasternal Short RV Thoracic Aorta
35 IVC Plethora
36 Pericardioscentesis Facilitate rapid intervention Choose best approach Avoid unecessary errors
37 Syncope VS: 89/P, 95, 98%, yo F cc: fainting x 2 brief loc at clinic triage. assd sweating, pallor, light headed, VB x 1 day
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44 Next steps Uh oh! No IV access... Still Hypotensive Ordered emergent blood... Need Central Access
45 Follow Up 2L NS, 2L PRBC Stat OR Booking Right Fallopian Ruptured Ectopic
46 Pitfalls Clotted blood Indeterminate scans Failure to do FAST Reliance on discriminatory zone Fertility treatment
47 References American College of Emergency Physicians. Ultrasound Guidelines [policy statement] American College of Emergency Physicians. Emergency Ultrasound Imaging Criteria Compendium [policy statement] Andrulis DP. Study of How Urban Hospitals Address Sociocultural Barriers to Health Care Access : filename=023299s.htm&iaid=133 B. Hoffmann. Ultrasound Guide for Emergency Physicians. Physics and Technical Facts for the Beginner. Edelman, SK. Understanding Ultrasound Physics. 3rd Edition. Moore C, Molina A, Lin H. Ultrasonography in community emergency departments in the United States: Access to ultrasonography performed by consultants and status of emergency physician- performed ultrasonography. Ann Emerg Med. 2006; 47: Moore CL. Utility of portable ultrasound in patient care in a remote area of Nicaragua. Ultrasound Med Biol. 2003; 29:S152 Abstract.
48 Atkinson PRT, et.al. Abdominal & Cardiac Evaluation with Sonography in Shock (ACES): an approach by emergency physicians for the use of ultrasound in patints with undifferentialted hypotension. Emerg Med J (2): Blaivas M, Lyon M, Duggal S. A prospective comparison of supine chest radiography and bedside ultrasound for the diagnosis of traumatic pneumothorax. Acad Emerg Med.2005; 12: Fagenholz P, Gutman J, Murray A, et al. Chest ultrasonography for the diagnosis and monitoring of high-altitude pulmonary edema. Chest. 2007; 131(4): Jones AE, et.al. Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: a randomized clinical trial. JAMA Feb 24; 303(8): Lyon M, Blaivas M, Brannam L. Use of emergency ultrasound in a rural ED with limited radiology services (Letter to Editor). Am J Emerg Med 2005; 23: Perera P, Mailhot T, Riley D, Mandavia D. The RUSH Exam: Rapid Ultrasound in SHock in the Evaluation of the Critically Ill. Emerg Med Clin N Am. 2010; 28: Roberts J, McManus J, Harrison B. Use of ultrasonography to avoid an unnecessary procedure in the prehospital combat environment: A case report. Prehosp Emerg Care. 2006; 10: Soldati G, Testa A, Pignataro G, et al. The ultrasonographic deep sulcus sign in traumatic pneumothorax. Ultrasound Med Biol. 2006; 32: Soldati G, Testa A, Pignataro G, et al. Occult Traumatic Pneumothorax: Diagnositc accuracy of lung ultrasonography in the emergency department. Chest. 2007; Weingart, SD, Duque,D, Nelson, B. Rapid Ultrasound for Shock and Hypotension. EMEDhome.com. April < %20Examfinal.html>
Introduction & Physics of ED Ultrasound. Objectives. What? - Limited Studies. Who? - ED Docs
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