Focused Emergency Department Sonography (FEDS) Mark Mensour MD

Transcription

1 Focused Emergency Department Sonography (FEDS) Mark Mensour MD CCFP EM ANAES FCFP Assistant Professor of Emergency Medicine Northern Ontario School of Medicine Chief of Emergency Medicine Muskoka Algonquin Healthcare

2 Conflicts of Interest Founding Faculty Co-Developer Instructor Chief of Emergency Medicine

3 Andrew Healey MD RCPS EM Program McMaster University Assisted with this presentation and is co founder of EBR

4 Literature Review Bedside ED ultrasound currently recognized by: Canadian Association of Emergency Physicians American College of Emergency Physicians Society for Academic Emergency Medicine American Academy of Emergency Medicine Part of ACEP Model of Clinical Practice Planned competency for EM in Canada

5 FEDS how it all began Our Success Collaborative effort Diagnostic imaging Radiologist Same patients Better care 1970s Germany 1980s USA, Japan 1990s Canada 2000s Ontario (Muskoka)

6 Focused Questions FAST Is there free fluid? AAA Is there an aneurysm? Cardiac Is there cardiac activity? Is there a pericardial effusion? Pelvic/IUP Is there an IUP? CVC insertion

7 How long does it take to learn? Nobody really knows this answer Regardless of population All requirements are empiric 8-10 hour course Minimum 10 scans per question 50 supervised scans in each modality AAA / cardiac / FAST / pelvic = 200 scans

8 Ultrasound Education in RCPS EM Programs in Canada Andrew Healey MD PGY 4 RCPS EM Mark Mensour MD CCFP (EM, ANAES) FCFP

9 Survey Results 100% response, 13/13 programs 13 programs have dedicated ultrasound for ED 13/13 11/13 2 /13 Provide ED ultrasound by EPs Teach ultrasound formally Plans to teach by end of Remainder of information only of those who currently teach ultrasound*

10 QA/QI Results Amount of probe time to achieve competence for residents unknown Most (8/11) believe 50 scans per domain necessary to achieve competence Credentialing process CAEP Interest Group Guidelines CEUS IP Status Other * (1 = both, 1 = unknown, 1 = none) N / We are not interested in providing credentialing or certification. We don t do it for procedures, nor for reading head CTs.

11 QA/QI Results QA/QI Program for Bedside ED US All pts referred for formal with discrepancies reviewed All tapes later reviewed by qualified faculty No formal QA/QI program Limited experience thus far No chance to set one up yet N / 11* *Can select more than one response

12 National survey of CCFP(EM) Programs 18/18 15/18 16/18 11/18 Provide ED ultrasound by EPs Teach ultrasound formally EMUS should be scope of practice Residents can learn in residency Woo NY, Nussbaum C, Lee AC. National survey of CCFP(EM) Program Directors regarding emergency medicine ultrasonography. Abstract presented at ICEM /CAEP

13 What s the evidence?

14 Likelihood Ratios +LR -LR Comment > < Generate large and often conclusive changes from pre- to post-test probability Generate moderate shifts in pre- to posttest probability Generate small, sometimes important changes in probability Alter probability to a small degree, rarely important Guyatt G, Rennie D. Users Guides to the Medical Literature.

15 What is the evidence? FAST AAA Pericard Effusion Rule in IUP* +LR 66 (33-115) 15 (2-90) 48 (22-110) 98 LR 0.20 ( ) 0.06 ( ) 0.04 ( ).22 *Improved LOS in one study ~60 mins

16 CVC Insertion Improved patient safety Who could say no to this?

17 Outcome Successful insertion Prevent one complication Prevent one failure NNT 6 (95% CI 3-26) 8 (95% CI 4-54) 5 (95% CI 4-7) Leung J, Duffy M, Finckh A (2006). Real-time Ultrasonographically-Guided Internal Jugular Vein Catheterization in the Emergency Department Increases Success Rates and Reduces Complications. Ann Emerg Med 48: Hind D, Calvert N, McWilliams R (2003). Ultrasonic locating devices for central venous cannulation: a meta-analysis. BMJ 327:

18 Improved patient safety Who could say no to this? Outcome Prevent one failure NNT 5 (95% CI 4-7) Hind D, Calvert N, McWilliams R (2003). Ultrasonic locating devices for central venous cannulation: a meta-analysis. BMJ 327:

19 Future Directions Ocular Sonography ONSD for EICP Lens Dislocation Foreign Body Retinal detachment Cellulitis Sonography Abscess/management Pneumothorax (Sliding Lung) FB location/assessment Sonographically assisted procedures paracentesis US guided Arterial line And others

20 Important Conclusions Anything in medicine can be done poorly Challenge is to do FEDS well