Ultrasound (2 weeks,) v PGY 1 & 3

Transcription

1 Ultrasound (2 weeks,) v PGY 1 & 3 PLEASE READ THESE GUIDELI ES CAREFULLY. YOU ARE RESPO SIBLE FOR FAMILIARITY WITH THIS CO TE T A D FOR ACHIEVI G THE GOALS OF THE ROTATIO. PLEASE CO TACT A ULTRASOU D FACULTY MEMBER FOR CLARIFICATIO S AS EEDED. Introduction Emergency ultrasound (EUS) is a critical skill employed for the delivery of highquality emergency care. Emergency physicians use bedside ultrasound in the widest array of clinical applications- more than any other specialty. Its use has revolutionized the way we care for patients and continues to clinical applications for EUS continue to expand. Ultrasound imaging aids in our care of patients with undifferentiated disease in whom complex clinical problems exist. As such, emergency physician performed bedside ultrasound is dynamic process in which real-time information is gathered and immediately effects the course of management strategies. Since Emergency ultrasound is frequently used at a branch point of critical decisions (ectopic vs IUP), a high degree of quality in practice is necessary. Like any test, emergency ultrasound has limitations. Familiarity with ultrasound test characteristics is as critical as performing a quality scan. Both are needed to appropriately guide care influenced by sonographic information. The primary goal of this rotation is to establish a foundation on which to build your ultrasound skills during residency and beyond. Because high quality scans are necessary to guide clinical management, this rotation focuses on the development of excellent skills. High standards will be used to judge the quality of your scans and your ability to make clinically meaningful interpretations of ultrasound studies. Goal and Description of Rotation PGY1 1. Familiarization with the basic principles employed in emergency ultrasonography. 2. Minimum scan requirements: 25 high quality EFAST exams and 25 high quality aorta scans. Additional modalities are welcome and encouraged. Get as much done as possible. All scans must be appropriately saved on the ultrasound machines. Printing is not accepted for credit. 3. Participate in the monthly QA session (see the calendar on NYUEMSONO.com)

2 4. Self-administered test to solidify the understanding gained after completion of the rotation. Go to Complete the tests for aorta and FAST. Print your score. If you fail the test, try again. Prints of passing scores are required. Remember! All ultrasound collected and appropriately saved during the rotation must be HIGH QUALITY to attain credit. Sonography skills improve with practice. A reasonable expectation during the PGY-1 rotation is to collect as many as 3x the number of required scans in order to achieve the appropriate number of high quality scans. PGY-3 1. Familiarization with advanced emergency ultrasonography applications including procedural skills, Doppler, and secondary applications 2. Completion of 175 HIGH QUALITY SCANS (25 in the 7 primary applications) a. Remember! All ultrasound collected and appropriately saved during the rotation must be HIGH QUALITY to attain credit. Sonography skills improve with practice. A reasonable expectation during the PGY-3 rotation is to collect as many as 2x the number of required scans in order to achieve the appropriate number of high quality scans. 3. Participate in the monthly QA session (see the calendar on NYUEMSONO.com) 4. Self-administered test to solidify the understanding gained after completion of the rotation. a. Go to Complete the tests for our 7 primary modalities (see below). If you have taken the PGY-1 rotation, you should have already completed tests for aorta and FAST. Print your scores. If you fail the test, try again. Prints of passing scores are required for all 7 modalities. Mechanics of the rotation 1. Meet with the one of the PGY-4 Ultrasound Coordinators (Louis Cooper, Michael Madland, or Nichole Bosson) at the beginning of your rotation for a brief orientation. This will include basic knobology, probe selection, and saving images. If an ultrasound coordinator is not available, please be sure to contact a faculty member in advance. 2. Be sure to learn how to save images! This should be reviewed with you during your first orientation. In brief:

3 a. All sonographic evaluations must contain your name, the patient s medical record number, the indication of the scan, your interpretation of the exam, and the results of a confirmatory study (confirmatory studies are not necessary if you are scanning with faculty). b. At least half of the ultrasounds should be clinically indicated and compared to a standard imaging study (U/s, CT, CXR, etc). c. Images during the rotation must also be recorded on the data sheet (see below) this will make Tuesday image review an efficient process and it is REQUIRED. 3. Tuesdays are dedicated days for 1:1 scanning and image review with an ultrasound attending. The schedule can be found on the calendar link at YUEMSO O.com. Please contact ultrasound faculty ahead of time to schedule scan and image review meetings. 4. Other days: try to choose scanning shifts (8-4, 11-7, 4-12, etc) based on the presence of an ultrasound faculty. Look at the attending schedule posted in the AES to see when ultrasound faculty are working. Contact Info Dr. Steven Menlove e: Stephen.menlove@nyumc.org Dr. Joseph Novik e: novik911@gmail.com Dr. Uche Blackstock e: ublackstock@gmail.com Dr. Dana Sajed e: dana.sajed@nyumc.org Dr. Rern Lau e: rern@atluri.org Try to contact ultrasound advisors 1-2 weeks before your rotation. Faculty scheduled for Tuesday sessions are listed at NYUEMSONO.com, click on CALENDAR. Remember, it is also helpful to scan during shifts when ultrasound faculty are working, especially in urgent care (see the attending master schedule in the AES). Special Considerations You will be scheduled for sick call during this rotation. You may be assigned to teach ACLS during this rotation. Morning report and Wednesday Conference attendance is mandatory.

4 TABLE 1: ACEP-Defined Core Emergency Ultrasound Applications Indication Abdominal aortic aneurysm Trauma evaluation First trimester pregnancy Cardiac evaluation Obstructive uropathy Gallbladder disease DVT Soft Tissue/Musc-skeletal Thoracic Ocular Procedural Guidance Key Sonographic Finding Aortic diameter > 3 cm Hemoperitoneum Intrauterine pregnancy Cardiac activity / Pericardial fluid Hydronephrosis Stones / thick wall / Sono Murphy s sign. Venous Thrombus Foreign Body / tendon injury Pneumothorax, pleural fluid Retinal detachment Needle visualization TABLE 2: Examples of Secondary Applications for ED Ultrasound 1. Ascites evaluation 2. Cardiac regional wall motion abnormalities 3. Pelvis masses 4. Pleural fluid visualization 5. Procedural applications 6. Abscess localization and drainage 7. Foreign body localization and removal 8. Suprapubic aspiration 9. Vascular access 10. Tendon evaluation

5 TABLE 3: Minimal required image Acquisition and Interpretations for the 7 primary REQUIRED modalities in your residency training Take additional pictures of any pathology Remember to include indications and Interpretations as text on a saved image APPLIC REQUIRED IMAGES I TERPRETATIO S Cardiac 1. Effusion? - MOVIES 2. EF (normal, low, hyper) O LY 1. Any 3 of 4 standard views (MOVIES O LY) - Subxyphoid, parasternal long and short, apical 4 chamber 2. Be able to identify chambers and valves 3. Be able to identify pericardial/myocardial interface Aorta -PICS or movies Renal - PICS or movies Biliary - PICS or movies EFAST - PICS or movies PELVIC - Movies or PICS DVT - MOVIES O LY 1. 3 views - Proximal with major branches - Distal (at bifurcation) - Long axis 2. Identify Aorta and IVC 3. Measure the AP diameter of the aorta (outer wall to outer wall) 4. Try to identify the Celiac and SMA arteries 1. 5 views - Each kidney; sagittal (long) through hilum showing both poles (or 2 clips showing each pole) - Axial (short) through hilum - Bladder 1. 2 Views - GB long and short axis 2. Identify portal vein, GB neck - attempt the CBD 3. Measure the GB anterior wall thickness 1. 6 Views (or as many needed to get the necessary information) - RUQ, LUQ, Cardiac, bladder. - Left and right sliding lung 2. Show the subdiaphragmatic area (common area of blood pooling)***** 3. Be able to identify the peri-myocardial interface 1. 2 views - Uterus long and short axis - Try to measure each ovary with 1 measurement in the greatest diameter 2. If present, show IUP FHR in M-mode (NEVER USE DOPPLER) 1. 4 views w/ compression at: - Common femoral Saphenous v. junction - Superficial femoral Deep femoral v. junction - Popliteal vein - Popliteal vein trifurcation 1. AAA? 1. Hydro- none, mild, moderate, severe 2. Presence of Renal calculi 3. Renal cysts? 1. Cholelithiasis? 2. Cholecystitis? 3. Attempt CBD measurement 1. Hemoperitoneum? 2. Pneumothorax? 3. Hemopericardium? 1. IUP? 2. Ovarian cysts or other mass? 1. DVT?

6 Resources Texts 1. Two copies of EMERGENCY ULTRASOUND (2 rd edition) by Ma, Mateer, and Blavias are available for personal use during the rotation. Please check out a copy from Dr. Novik. This text is also accessible online through ACCESS MEDICINE 2. Ultrasound Guidance for Nerve Blocks by Peter Marhofer. 3. ESP course books for ultrasound physics and abdomen (RDMS test prep) DVD-ROM 1. FOCUS- (focused cardiac ultrasound study) by Yanick Beaulieu. 2. Gulf Coast Ultrasound DVD Useful Links: 1. ACEP s main ultrasound website dedicated to development and teaching OF emergency ultrasound. Probably the best place to start 2. ACEP s ultrasound testing website- see goals and requirements section FROM HCMC (Hennepin County Medical Center) ED. Excellent image bank collection of normal s and abnormals 4. Mount Sinai and St Lukes Roosevelt EM Dept website, image banks and tutorials, journal articles. (The NYU Emergency Medicine Ultrasound webpage will be under development this year) For those interested in musculoskeletal ultrasound: 6. Those interested in Echo: 7. NYUEMSONO.com is under development, thanks to Louis Cooper!

7 DATA Sheet: The data sheet is largely self-explanatory. It may be filled as your go through your scans or at the end of a scan day. Its main purpose is to expedite review your images with the ultrasound faculty, provide a track record of performed studies, and highlight interesting studies.

8 DATE MR# STUDY FINDINGS GOLD STANDARD Pt/ Outcome Aorta Renal EFAST Pelvic/ pregnancy Cardiac Other REVIEWER COMMENTS Cred Yes / No ULTRASOUND RESIDENT NAME Aorta - prox, distal (at iliacs) and long view. AP measurement of each including iliacs - AAA +/-? Biliary - GB short, long - ant wall measure - stone? - cbd diameter - Murphy sign? EFAST - fluid? - pneumo? Cardiac - ¾ views - effusion? - EF L/M/H Renal - each kid long/short + bladder - hydro none, mild, mod, sev DVT -saphenous clot? -common fem clot? -superficial fem clot? -popliteal clot? 1 st trimester pregnancy - IUP? - none, yolk sac, gest sac, fetal pole, - FHR