SonoStudy: Ultrasound of heart and lungs identify preeclamptic pregnant patients at risk

In anesthesiology literature (not yet on pubmed), heart and lung ultrasound has entered the mix to identify pregnant patients at risk for respiratory failure – looking for hypocontractile heart and B lines! Oh yeah! It has received a lot of press, see here, here and here :

“Chicago — (March 18, 2014)

An ultrasound of the lungs could help doctors quickly determine if a pregnant woman with preeclampsia is at risk for respiratory failure, suggests preliminary research published in the April issue of Anesthesiology.

About 60,000 women worldwide die as a result of preeclampsia, which causes severely high blood pressure. Potential complications include stroke, bleeding and excess fluid in the lungs – called pulmonary edema – which can lead to respiratory failure.  The study suggests a lung ultrasound can help doctors easily learn whether a woman with preeclampsia is suffering from pulmonary edema and ensure she receives the correct treatment.

“Lung Ultrasound is fast, safe, noninvasive and easy to use,” said Marc Leone, M.D., Ph.D., lead author of the study and vice chair of the department of anesthesiology and critical care medicine, Hopital Nord, Marseille, France. “We found it allowed us to quickly assess whether a woman with preeclampsia had pulmonary edema and confirm the severity of the condition.”

Doctors often measure urine output to determine if a woman needs fluid administration, but the results are wrong about half of the time. “Lung ultrasound enables the medical team to identify which women really need the fluid treatment,” noted Dr. Zieleskiewicz, the study’s  first author.

Pulmonary edema is typically caused by heart failure, but also can be caused by lung inflammation. Researchers analyzed the use of lung ultrasounds, which can assess lung  edema, are easier to use than cardiac ultrasound and can be performed with devices commonly found in maternity wards. Lung ultrasound highlights white lines mimicking comet tails, irradiating from the border of the lungs. These lines are the reflection of water in the lungs.  The detection of three or more lines strongly suggests the diagnosis of pulmonary edema.

Researchers performed both cardiac and lung ultrasounds before and after delivery in 20 women with severe preeclampsia.  Five of the 20 women (25 percent) had pulmonary edema prior to delivery according to lung ultrasound, while four (20 percent) had the condition according to the cardiac ultrasound. The lung ultrasound identified a patient with non-cardiac pulmonary edema, which the cardiac ultrasound did not detect.

The test results could help ensure that pregnant women with pulmonary edema not be given intravenous or excess fluids, which worsens the condition and can lead to respiratory failure.  Typically, women with pulmonary edema are treated with oxygen and medication to lower the blood pressure or rid the body of excess fluid.  In real time, lung ultrasound also serves to observe improvement or worsening of pulmonary edema.”

SonoCase: Thoracic aortic aneurysms – and a review of the literature #FOAMed

Thoracic aortic aneurysms are much less common than abdominal aortic aneurysms. And, to top it off, the measurements of the thoracic aorta are different than the abdominal aorta, especially in the ascending thoracic aorta. It’s good to know how to look at the thoracic aorta when you need to, and what the normal measurements are so that you can make that immediate decision when a thoracic aneurysm (or dissection) is detected.

Drs. Daignault, Saul, and Lewiss published 2 great case reports in the Journal of EM Aug 2013 issue (subscription needed) on thoracic aortic aneurysms. One patient was a 60 year old male who had blunt trauma to his back by a heavy piece of plaster while at work. He had a BP of 140/80 mm Hg and HR of 90 beats/min. The FAST was negative for free fluid but the aortic root was found to be 5.49cm. This caused them to order a CT angio confirming their findings.  Another patient was an 82 year old male with 1 month of chest pain radiating to his back with history of aortic valve repair and HTN on coumadin. BP was 210/90 mm Hg. A bedside echo was performed and showed descending thoracic aorta aneurysm measuring 4.82cm.  This had a CT Angio done confirming descending thoracic aneurysm.  The abstract is found here, and a prior post on these case reports can be found here.

These cases bring up an excellent reason to review the thoracic aorta. The best cardiac echo view to see visualize the thoracic aorta, if you could only pick one, would be the parasternal long view.

According to a german study where they looked at the thoracic aorta throughout life from 17 to 89 yrs of age  via helical CT with the following methods and results: “Methods: Seventy adults, 17 to 89 years old, without any signs of cardiovascular disease were investigated with helical computed tomography. Aortic diameters were measured at seven predefined thoracic levels. Results: Aortic diameters (mean ± SD) were 2.98 ± 0.46 cm at the aortic valve sinus, 3.09 ± 0.41 cm at the ascending aorta, 2.94 ± 0.42 cm proximal to the innominate artery, 2.77 ± 0.37 cm at the proximal transverse arch, 2.61 ± 0.41 cm at the distal transverse arch, 2.47 ± 0.40 cm at the isthmus, and 2.43 ± 0.35 cm at the diaphragm. Men had slightly longer diameters than did women. All diameters increased with age. There was no influence of weight, height, or body surface area.”

More recently, Medscape authors state that the thoracic aorta dimensions are larger than the abdominal aorta dimensions and that aneursymal definition occurs when it is greater than 50% of the normal size.

Another study in the radiology literature with many more subjects more recently, had the following methods and results: “Methods: 1442 consecutive subjects who were referred for evaluation of possible coronary artery disease underwent coronary CT angiography (CTA) and coronary artery calcium scanning (CACS) (55+11 years, 65% male) without known coronary heart disease, hypertension, chronic pulmonary and renal disease, diabetes and severe aortic calcification. The ascending aortic diameter, descending aortic diameter (DAOD), pulmonary artery (PAD) and chest anterioposterior diameter (CAPD), posterior border of sternal bone to anterior border of spine, were measured at the slice level of mid right pulmonary artery by using end systolic trigger image. The volume of four chambers, ejection fraction of left ventricle, and cardiac output were measured in 56% of the patients. Patients demographic information, age, gender, weight, height and body surface area (BSA), were recorded. The mean value and age specific and gender adjusted upper normal limits (mean + 2 standard deviations) were calculated. The linear correlation analysis was done between AAOD and all parameters. The reproducibility, wall thickness and difference between end systole and diastole were calculated. Result: AAOD has significant linear association with age, gender, descending aortic diameter and pulmonary artery diameter (P<0.05). There is no significant correlation between AAOD and body surface area, four chamber volume, LVEF, CO and CAPD. The mean Intra-luminal AAOD was 31.1 ± 3.9mm and 33.6 ± 4.1 mm in females and males respectively. The upper normal limits (mean + 2 standard deviations) of Intra-luminal AAOD, mean+ standard deviation, was 35.6, 38.3 and 40 mm for females and 37.8, 40.5 and 42.6 mm for males in age group 20 to 40, 41 to 60, above 60 year respectively. Intra-luminal should parallel echocardiography and invasive angiography. Traditional cross sectional imaging (with computed tomography and magnetic resonance imaging) includes the vessel wall. The mean total AAOD was 33.5mm and 36.0 mm in females and males respectively. The upper normal limits (mean + 2 standard deviations) of Intra-luminal AAOD, mean+ standard deviation, was 38.0, 40.7 and 42.4 mm for females and 40.2, 42.9 and 45.0 mm for males in age group 20 to 40, 41 to 60, above 60 year respectively. The inter and intra observer, scanner and repeated measurement variability was low (R value >0.91, P<0.001, coefficient variation <3.2%). AAOD was 1.7 mm less in end-diastole than end systole(P<0.001).” Below is their table illustrating the various measurements by others:

Screen Shot 2013-09-03 at 10.59.27 AM

As Dr Lewiss and colleagues state in their case reports, “The most recent consensus statement by the American Society of Echocardiography (ASE) and the American College of Emergency Physicians (ACEP) recognized that the thoracic aortic pathology can be identified on EP-performed focused cardiac ultrasound (3). Transthoracic echocardiography was shown to be consistent with TEE for measurement of the ascending aorta (21). Taylor et al. demonstrated that EP-performed focused cardiac ultrasound was consistent with CTA measurements for maximal thoracic aortic diameter (2). In these cases, an EP with considerable experience in ultrasound performed these studies, but many EP are trained in the use of focused ultrasound for evaluation of the abdominal aorta. Principals used in this application, such as avoiding measurements in oblique planes, measuring from outer wall to outer wall (for the descending thoracic aorta), and the use of Doppler also may be utilized in the evaluation of the thoracic portion of the aorta.”

SonoCase: 46yo c/o abdominal pain h/o cocaine use – sup mesenteric art dissection #FOAMed

Drs. Davis and Kendall write up a very interesting case in the Aug 2013 issue of Journal of EM where the ultrasound made the diagnosis, quite easily too. They discuss a 46 year old male with a history of current cocaine use AND a prior history of an aortic dissection, of course, who was complaining of sudden onset of abdominal pain and found to be severely hypertensive. The diagnosis on the top of their list was aortic dissection/aneurysm/rupture – and when they looked, they saw even more. Below is the abstract:

Background

A timely diagnosis of aortic dissection is associated with lower mortality. The use of emergent bedside ultrasound has been described to diagnose aortic dissection. However, there is limited literature regarding the use of bedside ultrasound to identify superior mesenteric artery dissection, a known high-risk feature of aortic dissection.

Objective

Our aim was to present a case of superior mesenteric artery dissection identified by bedside ultrasound and review the utility of bedside ultrasound in the diagnosis of aortic emergencies.

Case Report

We report a case of superior mesenteric artery dissection found on emergent bedside ultrasound in a 46-year-old male complaining of abdominal pain with a history of cocaine abuse and prior aortic dissection. Bedside ultrasound in the emergency department revealed an intimal flap in the descending aorta with extension into the superior mesenteric artery prompting early surgical consultation before computed tomography because of concern for acute mesenteric ischemia.

Conclusion

Superior mesenteric artery dissection is a high-risk feature of aortic dissection and can be identified with emergent bedside ultrasound.

Just one of their images is displayed below – but take a look at the video in JEM to truly see the awesomeness. A subscription and password is required, but it’s a great journal with lots of cool ultrasound cases published almost every month.

Screen Shot 2013-09-03 at 9.54.59 AM

SonoCase: 60yo blunt chest trauma, 82yo with chest pain- in JEM by @ultrasoundREL

In a recent article in the Journal of Emergency Medicine, Dr. Resa Lewiss and friends, discuss 2 cases of thoracic aortic aneurysm identification by focused cardiac ultrasound. It is a great case report that highlights the need to include the aortic root and descending thoracic aorta in the parasternal long view of your focused cardiac echo.

“A 60-year-old man presented to the emergency department (ED) after a blunt traumatic injury to his back while at work. During the focused cardiac ultrasound examination, the aortic outflow tract distal to the aortic valve appeared enlarged and the aortic root measured 5.49 cm.

Screen Shot 2014-03-04 at 9.16.55 AM

“An 82-year-old man with hypertension presented to the ED with 1 month of chest pain radiating to the back. The focused cardiac ultrasound examination demonstrated enlargement of the descending thoracic aorta at 4.82 cm.”

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SonoMedStudent: Integrating in Ultrasound into the First year of Med school by Dr Tarina Kang #FOAMed

Dr, Tarina Kang, the Ultrasound Director at USC, wrote to the Editor of Advances in Medical Education and Practice in the Aug 2013 journal . She poses quite a good argument for ultrasound in medical education ( with references ) and also discusses how she found it to be best done in the first year – a great read:

Dear editor,

For over 100 years, medical schools throughout the United States have typically followed a standardized curriculum that clearly delineates the preclinical (basic and clinical sciences) and clinical years (patient encounters and care).1 However, the transfer of learning that is derived from isolated data of basic science to clinically relevant information has been a topic of much debate and study throughout the years.

Recently, educators have attempted to unite the preclinical and bedside principles in an effort to make the basic sciences more relevant to medical practice. Basic, clinical, and social sciences are taught simultaneously to reaffirm “the importance of the relationship between the practitioner and patient. Further, the practitioner should focus [on the patient] as a whole, be informed by evidence, and make use of all appropriate therapeutic approaches, health care professionals, and disciplines to achieve optimal health and healing.”2 Although implementation of an integrated learning curriculum in medical school poses political, logistical, and financial challenges, its rewards for the student may be profound.

The ideal approach to integrating basic science material with the practice of medicine is complex in that educators often have to incorporate innovative and pertinent student experiences, without compromising the existing curriculum requirements. The sheer amount of information that first year medical students are required to learn makes inclusion of additive curriculum difficult. However, it behooves course directors to constantly test, change, and expand course curriculums to maximize the educational benefit to students.

There are a number of ways to implement clinical practice into the first year courses of medical school, with the theoretically most successful ones being those that can be brought to the student during class, where other students and instructors are present for more in-depth and collaborative discussion. Point-of-care ultrasound was developed by emergency physicians in an effort to better evaluate the patient at the bedside. More recently, ultrasound has become an important educational and clinical tool across all specialties due to its ease of use, portability, and applicability at the bedside. Many institutions have integrated bedside ultrasound teaching into the clinical years of medical school. Several US institutions such as Wayne State, Ohio State, and the University of South Carolina have implemented ultrasound curriculums that span from the first year to the entire 4 years of medical school.35 In 2012 Fox et al6at the University of California (Irvine, CA, USA) implemented a novel medical curriculum which integrated web-based lectures and peer instruction for Year I students. They were successfully able to maximize teaching and practice time and integrate practical medicine into the basic science courses. Given the success of these programs and the potential educational benefit they afford students, a seamless introduction of ultrasound into the first year courses at our affiliated medical school seemed like a natural progression.

The goal of the project was to integrate ultrasound, a practical clinical modality, into the preclinical educational experience, specifically, during the anatomy and histology classes and laboratory sessions. The ultrasound instructors successfully completed a 10-week course which combined anatomy and histology laboratory sessions, small group sessions, and lectures. After a year of planning, we successfully integrated ultrasound into the course in a way which emphasized how teaching in a dynamic and safe manner with the ultrasound can illuminate the structural relativity of human anatomy.

The novelty of this curricular change in a course that has never had this type of teaching before was itself an impediment. I think that, in retrospect, the adage “There is strength in numbers” is a proverb one should follow when attempting to implement a new course at a medical school. The more people you know who represent different specialties and ranks in both the hospital and the medical school, the higher the likelihood for continued success of the course.

When I started this project, I was naive to the accepted conduct and decorum that one is expected to follow when trying to introduce unprecedented ideas into the medical school curriculum. I had an idea worthy of pursuing, I created a plan to implement it, and I spoke to the directors of the course, but I did not attempt to gain crucial allies in the medical school who could have accelerated its acceptance. The legacy of new projects and teaching initiatives at medical schools will constantly be endangered unless there is consistent support at the administrative level. As a result, although I had the full support from the course directors, I did not have the complete acceptance of the laboratory professors and instructors who taught the course. This disconnection manifested in frustration and bewilderment by some students attending our course during their teaching time. In addition, because there was no formal explanation of our pilot to the students, some were unable to fully grasp the concept of an integrated educational forum, and noted on course feedback their lack of understanding as to why, and how, point-of-care ultrasound correlates with anatomy and histology. This problem could have been curtailed, at least in some part, by a formal acknowledgment made by not only the course directors but also the administration. With this knowledge, we reached out to several medical school administrators, and we are in talks with them to gain valuable insight and input for further direction for next year’s course. In addition, we are recruiting physicians from different specialties to broaden the type of expertise in our curriculum.

Although I encountered barriers, the experience was invaluable. It helped me understand, with startling clarity, the political structure of medical education. I have since moved to another academic medical center, and we are scheduled to begin talks to create an integrated curriculum with first year medical students. The next time I introduce myself though, I think I’ll bring my friends.”

Go to this article’s link for a list of the references as well.

To read posts on US in Medical Education done at AIUM and other institutions, and see what others are doing and saying about it, go here.

SonoMetaAnalysis: Errors in Emergency Ultrasound – When/What/Why & the lawsuits #FOAMed

In the July 2013 issue of Critical Ultrasound Journal, the authors did a meta-analysis of all studies relating to emergency ultrasound and the diagnostic errors that occur and Ill explain why It’s fascinating. When you read through the details, the reasons are clear and the issues may be obvious. The authors (from Italy who practice ultrasound in different settings with description of emergency ultrasound a bit different than the way we do it here) searched utilizing different association of the following terms from 1990-2013: (1) emergency ultrasonography, (2) error, (3) malpractice and (4) medical negligence –  restricted to human studies and to English-language literature. The abstract of 171 articles appeared appropriate while other articles were recognized by reviewing the reference lists of significant papers. The full text of 48 selected articles was reviewed.

I do disagree with some of the way the authors described emergency ultrasound. I believe in their effort to show their study’s importance, they state: “Emergency US is particularly susceptible to errors, more than any other diagnostic imaging technique: in fact, the misinterpretation of sonographic images should be considered as a serious risk in US-based diagnosis [8]”  - they are referencing an article by radiologists on US artifacts on clinical sonography. So, that’s weird.

Another item that I felt was strange was that many of the references to emergency ultrasound were actually those done by radiologists. I couldnt find one emergency medicine ultrasound article. Thi sis likely due to the practice differences between europeans and Americans with emergency ultrasound, but ….hmmm, it gets even more interesting, and I will likely get even more critical. Im sure the radiologists did an outstanding job in their (or their lab tech’s) image acquisition, but the reasons for diagnostic errors stated by the authors of this study now make sense when you take into account the above:

Reasons for Errors in Emergency Ultrasound: “Causes of error in emergency ultrasonography are multifactorial, frequently exist in combination as in other diagnostic imaging techniques [9,10] and include: lack of attention to the clinical history and examination, lack of communication with the patient (who may be uncooperative), lack of knowledge of the technical equipment, use of inappropriate probes, inadequate optimization of the images, failure of perception, lack of knowledge of the possible differential diagnoses, over-estimation of one’s own skill, failure to suggest further ultrasound examinations or other imaging techniques (such as CT or MRI) [11-16]“

The authors then go on to further describe the errors. The discuss the importance of the amount of gel, the correct probe used, the adequate technique, and how artifacts can get in the way. They also state something that i completely agree with – it also depends on the operator. But, they use the example of:  “Modern ultrasound equipment is certainly adequate for producing images that permit diagnosis of anomalies such as open lumbosacral spina bifida or atrioventricular septal defect. However, such diagnoses can only be made if considerable operator skill is associated with knowledge and experience.” So, not sure how to put this, but that’s NOT emergency ultrasound. So, I cannot relate. But, good on those who do it in emergency practice…who am I to say differently – you never know, as our scope of practice continues to increase.

The authors finally discuss errors in the emergency setting, again done by radiologists with references authored in radiology literature from over 10-15 years ago…. and state what we all know and can appreciate: “Quick diagnosis and treatment of patients with whom we have had no previous contact, and who, quite often, may be uncooperative, and/or under the influence of alcohol or drugs creates an environment with significant risk [27]. The frequency of reported “missed diagnoses” depends on how the frequency of error was assessed: based on trauma registries, error rates were approximately 2% [28], while retrospective chart review found approximately 40% [29], and retrospective review of all admissions revealed missed or delayed diagnoses of approximately 8%-10% [28-30]……Moreover, the sonographer should evaluate the patient in terms of physical constitution (in obese patients, the thickness of subcutaneous fat and the sound-attenuating properties of fat present challenges) and the presence of conditions potentially limiting the examination (such as obliged decubitus, scars, etc.). The sonographer should be aware of the limitations of the technique in the evaluation of the traumatized patients, asking for other diagnostic imaging procedures (Multidetector row Computed Tomography).” – The authors dont state the errors made nor any litigation made in the emergency setting – interesting, right? That may be because the studies that were queried were not including those of emergency medicine bedside, limited, focused, goal directed, – or whatever you want to call it – ultrasound. There was something interesting though:

As far as litigation is concerned, the authors state ” The earliest litigation related to diagnostic ultrasound occurred in 1974 and involved obstetric measurements. Before 1974, images were so difficult to interpret that ultrasonography was considered of little value apart from obstetric measurement data and for characterizing masses as cysts [19]” They reference an article by J Ultrasound in Medicine done by ObGyn and is a fascinating read on ObGyn litigation as relating to ultrasound, but also does not necessarily speak about emergency ultrasound and our limited studies that we perform. That article states (in relation to ObGyn litigation): “There has been a change in the main target of litigation over time: in the 1980s, ectopic pregnancy was the most common reason for litigation; today, litigation related to a missed fetal anomaly is the most frequent indication. Invented lesions, often seen in past years, almost never occur today. With greater adherence to guidelines, failure to perform sonography for a recognized indication has become a cause of litigation. Well-recognized obstetric ultrasound guidelines, in one respect, provide protection for those who perform faultless series and yet find no abnormalities when they are present and, in another respect, cause problems for those who do not document all the images required by the guidelines when abnormalities are subsequently found.”   Why is this interesting? Well, one of the best studies to date on true emergency medicine ultrasound litigation comes from Dr. Michael Blaivas and Dr. Pawl. First off, there were no law suits on emergency physicians who performed and interpreted bedside ultrasound studies in their review of 659 cases. But, there was one on a physician who chose not to perform it when it was available and indicated – and ectopic pregnancy case.

Lastly, I do agree with this : “Ultrasound scanners, however, are relatively inexpensive and highly effective in the hands of a trained operator. More importantly, ultrasound is a “sustainable technology” for developing and impoverished nations because of its relatively low cost of purchase, low cost for maintenance and supplies, portability, and durability in comparison with all other imaging modalities [47]. Moreover, early education of operators is a priority that can begin to be addressed in medical school. The practice of ultrasound has clearly been shown to be operator-dependent, and the way to train better operators is to start early, provide opportunities for practice, and standardize curriculum that will ultimately align with residency requirements in the various specialties [48]” – This latter reference was the first emergency medicine one I saw – Nice job Dr. David Bahner ! (who was the coordinator of the Ultrasound in Medical Education at AIUM in April 2013).

Other great articles relevant to this and what we should do about incidental findings:

Blaivas M, Pawl R. Analysis of lawsuits filed against emergency physicians for point-of-care emergency ultrasound examination performance and interpretation over a 20-year period. Am J Emerg Med. 2012 Feb;30(2):338-41. doi: 10.1016/j.ajem.2010.12.016. Epub 2011 Jan 28.

Lanitis S, Zacharioudakis C, Zafeiriadou P, Armoutides V, Karaliotas C, Sgourakis G. Incidental findings in trauma patients during focused assessment with sonography for trauma. Am Surg. 2012 Mar;78(3):366-72

Fox JC, Richardson AG, Lopez S, Solley M, Lotfipour S. Implications and approach to incidental findings in live ultrasound models. West J Emerg Med. 2011 Nov;12(4):472-4. doi: 10.5811/westjem.2011.2.2054.

SonoCase: 60yo in cardiac arrest in @EPMonthly by @TeresaWuMD @TheSafetyDoc #FOAMed

In the recent issue of Emergency Physician’s Monthly (one of my favorite EM magazines), Drs. Teresa Wu and Brady Pregerson once again hit the ultrasound wave and start soaring in their newest insert describing the utility of bedside ultrasound during cardiac arrest and post-mortem.

They describe it best: ” ….60-year-old male who collapsed at work and remained unresponsive. They state that there was bystander CPR and a lot of freaking out by coworkers. The only past history they have was from a coworker who thought he had high blood pressure. There was also a witness who told them he was just walking, then doubled over and collapsed without saying a thing. No one knew if he had any symptoms earlier in the day. Paramedics state he was initially in a PEA rhythm at a rate of 120 bpm on the monitor. They started an IV, gave him a 500cc saline bolus, intubated him, and have given three rounds of epi. They estimate a 15 minute down time prior to their arrival and a 10 minute transport time with no return of spontaneous circulation. In fact, things are going in the opposite direction as he has been in asystole for the past five minutes.

They move him onto the bed where your EMT takes over CPR. You note good and symmetric assisted breath sounds via the ET tube, but minimal palpable femoral pulse despite what appears to be good CPR to the tempo of the Bee Gees hit “Staying Alive”. On the monitor there is asystole in two leads. Pupils are fixed and dilated despite no atropine having been received. Things are not looking promising.

You request saline wide open and a final round of epinephrine while you take a look for cardiac motion with the ultrasound machine. To minimize interruption of CPR you don’t have the EMT pause until you are completely ready to look. You also have the RT hold respirations to avoid any artifact. There is no cardiac motion. You verbalize this to your team. The heart does not appear dilated and there is no pericardial effusion. You ask aloud, “anyone have any other suggestions” prior to calling the time of death.

Of course you next wonder what did him in: MI, PE, something else… His belly looks pretty protuberant, so you decide to take a quick look at his abdomen to check for free fluid. What you see is shown in the two images below. “

Screen Shot 2013-08-27 at 6.26.16 PM

What do you think killed this gentleman? Trust me, you want to read more and see what exactly the ultrasound image is  - as it is quite an interesting finding: go here.

For a discussion from a prior post on ultrasound during cardiac arrest, go here.