SonoProcedures: Review of ultrasound-guided procedures, technique, and videos

In the most recent addition of Emergency Medicine Clinics of North America (yup, you’ll need to register to view), some big wigs in bedside ultrasound (Tirado, Teresa Wu, Resa Lewiss, Vicki Noble, Adam Sivitz) published an article reviewing the ultrasound – guided techniques (with images) of procedures where an ultrasound machine can make all the difference in decreasing complications, increasing patient satisfaction, and decreasing time of procedure. From pericardiocentesis, thoracentesis, abscess drainage to lumbar puncture, arthrocentesis, and foreign body removal, these physicians discuss it all. “Bedside ultrasound is an extremely valuable and rapidly accessible diagnostic and therapeutic modality in potentially life- and limb-threatening situations in the emergency department. In this report, the authors discuss the role of ultrasound in quick assessment of pathologic conditions and its use to aid in diagnostic and therapeutic interventions”

In the same issue, Drs. Tirado, Nagdev and others discuss ultrasound-guided venous central and peripheral venous access and nerve blocks (a topic near and dear to Arun Nagdev’s heart – given how many publications he has done on the topic – a true expert!). “Ultrasound has rapidly become an essential tool in the emergency department, specifically in procedural guidance. Its use has been demonstrated to improve the success rate of procedures, while decreasing complications. In this article, we explore some of these specific procedures involving needle guidance and structure localization with ultrasound.”

And, in the same issue, Drs. Lewis, Crapo, and Williams discuss more procedural guidance using bedside ultrasound for central venous access as well as a review of other procedures, like IO lines an arterial lines. “The venous and/or arterial vasculature may be accessed for fluid resuscitation, testing and monitoring, administration of blood product or medication, or procedural reasons, such as the implantation of cardiac pacemaker wires. Accessing the vascular system is a common and often critically important step in emergency patient care. This article reviews methods for peripheral, central venous, and arterial access and discusses adjunct skills for vascular access such as the use of ultrasound guidance, and other forms of vascular access such as intraosseus and umbilical cannulation, and peripheral venous cut-down. Mastery of these skills is critical for the emergency medicine provider.”

A great review of pericardiocentesis, thoracentesis, paracentesis, vascular access, foreign body localization, abscess drainage, and nerve blocks can be found on Sonoguide as well.

Here are some great videos on how-to perform the varying procedures:

Pericardiocentesis:

Thoracentesis:

Paracentesis:

Abscess drainage:

Central venous access: internal jugular

Central venous access – supraclavicular approach to the subclavian vein:

Ultrasound Podcast on the Subclavian and Supraclavicular venous access in only the way they know how.

Central venous access – axillary vein cannulation

Peripheral venous access:

A great video on US guided Peripheral IV can be found here, by HQMedEd

Lumbar puncture:

Foreign Body removal:

Femoral nerve block:

Axillary Nerve block:

Distal Sciatic nerve block:

Nerve blocks of all kinds can be found here on SonicNerve.

Other procedures:

US guided fracture reduction

 

SonoTutorial: Musculoskeletal Ultrasound of the Tendon – an AIUM Sound Judgement Series

In the recent entry of the Journal of Ultrasound in Medicine, Dr. Ken Lee (MSK radiology), discusses how ultrasound of the tendon can add to your clinical work up of a patient with pain in that area. it is the most common sports-related injury and we see it in the emergency department all.the.time.  In a prior post, we highlighted how Dr. Brita Zaia evaluated a patient with knee pain and tenderness who came to the ED for an arthrocentesis, showing the patellar tendon abnormality on her ultrasound image, making her diagnosis without the need of that invasive procedure (Published in WestJEM).

“Common tendon abnormalities include tendinopathy and tendon tears, which impose a substantial cost to society in the United States and abroad. According to the American Public Health Association, tendon disorders account for approximately $850 billion per year in health care costs and indirect lost wage expenditures.4 Accurate and timely diagnosis of musculoskeletal tendon injuries is critical to ensure proper treatment and thus minimize societal costs. Magnetic resonance imaging (MRI) has been the imaging standard for musculoskeletal injuries. However, MRI is costly and overused.5 Improvements in ultrasound technology have made sonography a rapidly growing imaging alternative and complementary tool to MRI for the diagnosis of common tendon injuries.6…..The most defining advantage of sonography over MRI is its real-time imaging capability, which allows for dynamic evaluation of the tendon using a variety of stress maneuvers.16,17 For example, in the neutral position, the long head of the biceps tendon may lie normally in the bicipital groove (Figure 3), only to dislocate medially once the arm, with elbow flexed, is externally rotated (Figure 4). In addition to tendon subluxation, other tendon abnormalities diagnosed dynamically include tendon snapping, friction between two structures such as in shoulder impingement,18 and increasing conspicuity of tendon tears while stressing the tendon or with sonopalpation.17 Real-time dynamic sonographic evaluation provides this unique diagnostic ability using controlled movements.”

Read more in this article to learn about what it means and what happens when the tendon goes from looking like this:

Screen shot 2012-12-03 at 12.58.39 PM

..to looking like this:

Screen shot 2012-12-03 at 12.58.55 PM

or like this….

Screen shot 2012-12-03 at 12.59.10 PM

with plenty more examples of it, illustrating how awesome it is and why we should use bedside ultrasound to evaluate tendons more.

SonoStudy: US-guided lines by nurses (& docs) reduce need for physician intervention (& central lines!) for difficult access

A recent study, from the Journal of Emergency Medicine, by Weiner et al at Tufts University, in addition to so many of the prior studies, proves that nurses SHOULD perform ultrasound guided peripheral line placement. they are good at it, they do it right, and they do it well. Oh, and patients love it.

“Emergency physicians (EPs) have become facile with ultrasound-guided intravenous line (USIV) placement in patients for whom access is difficult to achieve, though the procedure can distract the EP from other patient care activities…..A prospective multicenter pilot study: Interested emergency nurses (ENs) received a 2-h tutorial from an experienced EP. Patients were eligible for inclusion if they had either two failed blind peripheral intravenous (i.v.) attempts, or if they reported or had a known history of difficult i.v. placement. Consenting patients were assigned to have either EN USIV placement or standard of care (SOC).” 50 patients enrolled, 29 assigned to USIV and 21 to SOC. “Physicians were called to assist in 11/21 (52.4%) of SOC cases and 7/29 (24.1%) of USIV cases (p = 0.04). Patient satisfaction was higher in the USIV group, though the difference did not reach statistical significance (USIV 86.2% vs. SOC 63.2%, p = 0.06). “

And, even more recently, another study:

Ultrasound-Guided Peripheral Intravenous Access Program Is Associated With a Marked Reduction in Central Venous Catheter Use in Noncritically Ill Emergency Department Patients.

by Shokoohi et al from George Washington University published in the Annals of Emergency Medicine has been getting quite a bit of press – particularly from MedwireNews: “Training emergency department (ED) staff in use of ultrasound to guide difficult peripheral intravenous catheter placement appears to reduce the unnecessary use of central venous lines, a study suggests. The reduction in central venous line use after the introduction of ultrasound training was particularly notable for patients who were not critically ill, report Hamid Shokoohi (George Washington University, DC, USA) and colleagues…..They say that this has “potentially major implications for patient safety,” noting that around 15% of the 5 million central venous catheters placed in the USA annually result in complications, which can include blood infections, thrombosis, vessel damage, and hematomas.”

The study itself was: “….a time-series analysis of the monthly central venous catheter rate among adult emergency department (ED) patients in an academic urban ED between 2006 and 2011. During this period, emergency medicine residents and ED technicians were trained in ultrasound-guided peripheral intravenous access. We calculated the monthly central venous catheter placement rate overall and compared the central venous catheter reduction rate associated with the ultrasound-guided peripheral intravenous access program between noncritically ill patients and patients admitted to critical care. Patients receiving central venous catheters were classified as noncritically ill if admitted to telemetry or medical/surgical floor or discharged home from the ED. RESULTS: During the study period, the ED treated a total of 401,532 patients, of whom 1,583 (0.39%) received a central venous catheter. The central venous catheter rate decreased by 80% between 2006 (0.81%) and 2011 (0.16%). The decrease in the rate was significantly greater among noncritically ill patients (mean for telemetry patients 4.4% per month [95% confidence interval {CI} 3.6% to 5.1%], floor patients 4.8% [95% CI 4.2% to 5.3%], and discharged patients 7.6% [95% CI 6.2% to 9.1%]) than critically ill patients (0.9%; 95% CI 0.6% to 1.2%). The proportion of central venous catheters that were placed in critically ill patients increased from 34% in 2006 to 81% in 2011 because fewer central venous catheterizations were performed in noncritically ill patients. CONCLUSION: The ultrasound-guided peripheral intravenous access program was associated with reductions in central venous catheter placement, particularly in noncritically ill patients. Further research is needed to determine the extent to which such access can replace central venous catheter placement in ED patients with difficult vascular access.”

A great video on the scanning technique and choosing the right vein can be found here by SonoSite and taught by my good friend, Diku Mandavia:

Another great how-to video can be found here: although long, its a good one for a step-by-step, from the New England Journal of Medicine:

SonoTutorial: The FAST Part 2b: Left Upper Quadrant – More images that could fool you…

Get ready for some more real cases and, just like the prior post, with images of various sections of the left upper quadrant (as you cannot really have all sections in only one 6 second clip). Just like before, think of what is needed to complete the left upper quadrant view:  read the clinical correlate, see the image, and think about what section of the left upper quadrant view is missing (above the diaphragm, below the diaphragm, between the spleen and superior pole of kidney, between the spleen and inferior pole of kidney, or the paracolic gutter), how the image could be improved, and what the interpretation would be. All are stated below the image as well as the actual diagnosis of that particular patient. And, in case any of the below cases stump you as to why the FAST is negative or why it was done in the first place, recall its indications and…. Don’t forget the FAST limitations. Continue reading

SonoTutorial: The FAST Part 2a: Left Upper Quadrant – Images that could fool you…

Get ready for some cases!!! The images and clips below will be a great review to see how much of the information from the prior post on how to perform a complete left upper quadrant view of the FAST scan you recall, while keeping FAST limitations in mind. Remember, in order to be complete and thorough you must evaluate above the diaphragm, below the diaphragm, around the spleen and superior pole of the kidney, and around the spleen and inferior pole of the kidney, and along the left paracolic gutter –  through slow, deliberate, and full fanning between multiple rib spaces, and adjusting your depth as needed.

The images will appear with a clinical correlation first which may give you a certain level of suspicion. Think about what part of the LUQ scan is missing (as there is very few times when you can get all of the above areas in just one clip or in just one rib space), how would you improve the evaluation (changing position of probe, fan more widely or slowly, depth or gain (brightness) adjustment, etc), and what your interpretation of that image would be (positive or negative for free fluid – or is the image just too technically limited to make a statement on it?)- all while thinking of your level of suspicion of injury given the clinical correlate.

These are all real cases: Continue reading

SonoTutorial: The FAST Part 2: Left Upper Quadrant – being right with the left…

No, this isnt a talk about partisan politics (thankfully!), but something that is even more important that you should know and learn well, that could not only change everyone’s life [like politics thinks it does] (by way of how they manage their patients) but also saves a life (by how quickly you help your diagnoses be made). That’s right fellow blogosphere friends. Listen up!

Our SonoTutorial on The FAST: Right Upper Quadrant (RUQ) week was just the beginning of this review on the FAST scan- the most common application done at the bedside at many institutions, and for good reason. It’s used (as a screening study for intraperitoneal free fluid) for any blunt or penetrating chest/abdomen/back trauma as well as the unexplained hypotensive patient (the RUSH exam). The RUQ is the best area to evaluate for free intraperitoneal fluid of all the FAST views, but don’t think you can just do that view and stop there! It is not 100%, and there are enough times for me to see free fluid in the left upper quadrant (LUQ) that was difficult to see in the RUQ that makes it evident that completing the FAST scan is key! The LUQ is, essentially, the not-so-ugly sister to the RUQ. Continue reading

SonoTutorial: The FAST Part 1b: The Right Upper Quadrant: More images that could fool you

Get ready for some more real cases and, just like the prior post, with images of various sections of the right upper quadrant (as you cannot really have all sections in only one 6 second clip). Just like before, think of what is needed to complete the right upper quadrant view:  read the clinical correlate, see the image, and think about what section of the right upper quadrant view is missing (above the diaphragm, below the diaphragm, between the liver and superior pole of kidney, between the left heptaic edge and inferior pole of kidney at the paracolic gutter), how the image could be improved, and what the interpretation would be. All are stated below the image as well as the actual diagnosis of that particular patient. And, in case any of the below cases stump you as to why the FAST is negative or why it was done in the first place, recall  it’s indications and…. Don’t forget the FAST limitations. Continue reading

SonoTutorial: The FAST Part 1a: The Right Upper Quadrant: Images That Could Fool You

Now the fun starts! The images and clips below will be a great test to see how much of the information from the prior post on how to perform a complete right upper quadrant view of the FAST scan you recall, while keeping it’s limitations in mind. Remember, to be complete and thorough, you must evaluate above the diaphragm, below the diaphragm, around the liver and superior pole of the kidney, and around the left liver edge and inferior pole of the kidney (along the right paracolic gutter) through slow and deliberate full fanning between multiple rib spaces, and adjusting your depth as needed.

Continue reading

SonoTutorial: The FAST Part 1: The right upper quadrant – the right way to do it

The FAST scan (focused assessment with sonography for trauma) is probably the most frequent application of bedside ultrasound with a moderate sensitivity and very high specificity. It is done as part of our trauma evaluation for blunt or penetrating chest/abdomen/back/pelvic trauma as well as in the evaluation of the unexplained hypotensive patient as part of the RUSH protocol and the patient with a possible ruptured ectopic pregnancy.

Continue reading

SonoApp & Study: Cellulitis vs Abscess; US more sensitive than CT for soft tissue abscess

A patient comes into your emergency department or outpatient clinic that has a painful red area on their skin:

 -from Medicineo blog

…and you wonder whether its a superficial cellulitis, or if it’s a pus-filled abscess – and if it is an abscess, then how deep is it? how long is it? how loculated is it? Continue reading