Nick Smallwood Consultant Acute Medicine Surrey and Sussex Healthcare NHS Trust. September 2017

Transcription

1 Nick Smallwood Consultant Acute Medicine Surrey and Sussex Healthcare NHS Trust September 2017

2 Overview When to use it How to use it Why use it (+lots of images) Summary

3 When to use it How to use it Why use it (+lots of images) Summary

4 When to use it Vascular access DVT assessment Shocked patient Breathless patient Chest pain patient Swollen abdomen patient?pe patient Renal failure patient Pleural effusion patient Abdominal pain/abnormal LFTs patient Trauma patient

5 When to use it How to use it Why use it (+lots of images) Summary

6

7 FAMUS Practical course followed by on the job scanning Thoracic ultrasound Abdominal/renal ultrasound DVT/peripheral vascular ultrasound

8 Other standards are available RCEM Core and Advanced RCR focussed ultrasound standards CUSIC FICE and FEEL for echo

9 When to use it How to use it Why use it (+lots of images) Summary

10 Why use it Why wouldn t you? Reduce time to (correct) diagnosis CVCs, Pleural procedures (?why not ascitic) Maintain care between 4pm Fri and 8am Mon

11 But is there any evidence? Sensitivity of CXR for diagnosing pleural effusion? 39% 74% 39% 88% 24% Ultrasound? 92% Sensitivity of auscultation for diagnosing pulmonary oedema? Ultrasound? 34% 68% 90% 34% 49% 93%

12 Why use it Vascular access DVT assessment Shocked patient Breathless patient Chest pain patient Swollen abdomen patient?pe patient Renal failure patient Pleural effusion patient Abdominal pain/abnormal LFTs patient (Trauma patient)

13 Why use it Unfortunately, not all of our patients look like this

14

15

16 Why use it (+lots of images) Vascular access DVT assessment Shocked patient Breathless patient Chest pain patient Swollen abdomen patient?pe patient Renal failure patient Pleural effusion patient Abdominal pain/abnormal LFTs patient Trauma patient

17 Rule in DVT protocol Can be learnt easily and consistently within 60 minutes (evidenced) 98% agreement with vascular technicians 3 point compression approach

18 Common femoral vein

19

20

21 Femoral vein

22

23

24 Popliteal vein

25

26

27 Why use it (+lots of images) Vascular access DVT assessment Shocked patient Breathless patient Chest pain patient Swollen abdomen patient?pe patient Renal failure patient Pleural effusion patient Abdominal pain/abnormal LFTs patient Trauma patient

28 Shocked patient

29

30

31

32

33

34 Shocked patient Time for a case Medical registrar on call 86, F Admitted with chest pain, subtle ECG changes, trop rise?acs?pe treat as such and repeat trop, consider CTPA Asked to review as persistent hypotension No particular new signs/symptoms found

35 Shocked patient Time for a case Echo limited, but LV appeared reasonable No clear evidence PE Lung fields appeared ok Some abdominal pain on subcostal views

36

37 Shocked patient Point of care ultrasound allowed us to expedite urgent CT-A Confirmed leaking AAA Facilitated urgent transfer to vascular centre (unfortunately didn t prevent her death)

38 Why use it (+lots of images) Vascular access DVT assessment Shocked patient Breathless patient Chest pain patient Swollen abdomen patient?pe patient Renal failure patient Pleural effusion patient Abdominal pain/abnormal LFTs patient Trauma patient

39 Breathless patient (BLUE protocol) Lung ultrasound is more than just pleural fluid!

40 Lichtenstein D et al.comparative diagnostic performances of auscultation, chest radiography, and lung ultrasonography in acute respiratory distress syndrome. Anesthesiology. 2004; 100:

41 The BLUE protocol Lichtenstein, D and Mezière G (2008). Relevance of Lung Ultrasound in the diagnosis of Acute Respiratory Failure: The BLUE Protocol. Chest 134;

42

43

44

45

46

47

48 Why use it (+lots of images) Vascular access DVT assessment Shocked patient Breathless patient Chest pain patient Swollen abdomen patient?pe patient Renal failure patient Pleural effusion patient Abdominal pain/abnormal LFTs patient Trauma patient

49

50

51

52 Why use it (+lots of images) Vascular access DVT assessment Shocked patient Breathless patient Chest pain patient Swollen abdomen patient?pe patient Renal failure patient Pleural effusion patient Abdominal pain/abnormal LFTs patient Trauma patient

53 Evidence suggests that success rate increases and complication rate decreases when using US to guide ascitic procedures

54

55

56

57

58 Why use it (+lots of images) Vascular access DVT assessment Shocked patient Breathless patient Chest pain patient Swollen abdomen patient?pe patient Renal failure patient Pleural effusion patient Abdominal pain/abnormal LFTs patient Trauma patient

59

60

61

62 Why use it (+lots of images) Vascular access DVT assessment Shocked patient Breathless patient Chest pain patient Swollen abdomen patient?pe patient Renal failure patient Pleural effusion patient Abdominal pain/abnormal LFTs patient Trauma patient

63 Renal failure patient Time for another case study 72 year old man referred generally unwell with marked deterioration in renal function Well enough to come to ambulatory care A little tired, minimal other symptoms Creatinine 443, urea 22.4 (normal baseline 3 months ago)

64 What would you do? (remember this is an ambulatory patient)

65

66

67 And there s your decision Admit for urgent IP investigation of obstructive renal failure Request CT KUB (no need to await departmental renal US) *NO NEED FOR (UNNECESSARY) iv FLUIDS* Ultimately diagnosed with midline lymphoma which encased both ureters (among many other structures)

68 Why use it (+lots of images) Vascular access DVT assessment Shocked patient Breathless patient Chest pain patient Swollen abdomen patient?pe patient Renal failure patient Pleural effusion patient Abdominal pain/abnormal LFTs patient Trauma patient

69

70

71

72

73

74 Why use it (+lots of images) Vascular access DVT assessment Shocked patient Breathless patient Chest pain patient Swollen abdomen patient?pe patient Renal failure patient Pleural effusion patient Abdominal pain/abnormal LFTs patient Trauma patient

75 53, F, referred as?pe

76

77 Why use it (+lots of images) Vascular access DVT assessment Shocked patient Breathless patient Chest pain patient Swollen abdomen patient?pe patient Renal failure patient Pleural effusion patient Abdominal pain/abnormal LFTs patient Trauma patient

78 Silver trauma at it s finest GIM on call, overnight, midnight 100yr old admitted that morning having fallen out of bed CT head and neck NAD Mild abdominal pain, soft abdomen O/A Asked to review as BP and UO poor

79 Trauma patient Nil to find on examination Hb drop on bloods (110-86) Creatinine rise To CT or not to CT?

80

81 US gave me the evidence CT with contrast agreed Grade 4 splenic tear with significant intra-abdominal blood Don t forget the elderly don t get peritonitic!

82 When to use it Vascular access DVT assessment Shocked patient Breathless patient Chest pain patient Swollen abdomen patient?pe patient Renal failure patient Pleural effusion patient Abdominal pain/abnormal LFTs patient Trauma patient

83 Summary Point of care ultrasound adds significant value to your standard assessment of the acutely unwell patient Lung ultrasound is more than just pleural fluid FAMUS provides a basis for assessment of the medical patient (don t forget atypical presentations in the elderly)

84 Questions?

85

86

87

88

89 Renal failure patient

90 Abdominal pain/abnormal LFTs patient

91