https://www.medschool.lsuhsc.edu/emergency_medicine/docs/RUSH%20protocol.pdf

The RUSH Exam: Rapid Ultrasound in SHock in the Evaluation of the Critically lll

Over the past 25 years, research performed by emergency physicians (EPs) demonstrates that bedside ultrasound (US) can improve the care of emergency department (ED) patients. At the request of the Council of Emergency Medicine Residency Directors (CORD), leaders in the field of emergency medicine (EM) US met to delineate in consensus fashion the model "US curriculum" for EM residency training programs. The goal of this article is to provide a framework for providing US education to EM residents. These guidelines should serve as a foundation for the growth of resident education in EM US. The intent of these guidelines is to provide minimum education standards for all EM residency programs to refer to when establishing an EUS training program. The document focuses on US curriculum, US education, and competency assessment. The use of US in the management of critically ill patients will improve patient care and thus should be viewed as a required skill set for all future graduating EM residents. The authors consider EUS skills critical to the development of an emergency physician, and a minimum skill set should be mandatory for all graduating EM residents. The US education provided to EM residents should be structured to allow residents to incorporate US into daily clinical practice. Image acquisition and interpretation alone are insufficient. The ability to integrate findings with patient care and apply them in a busy clinical environment should be stressed.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1553-2712.2009.00589.x

Resident training in emergency ultrasound: consensus recommendations from the 2008 Council of Emergency Medicine Residency Directors Conference.

Assessment of hemodynamic status in a shock state remains a challenging issue in Emergency Medicine and Critical Care. As the use of invasive hemodynamic monitoring declines, bedside-focused ultrasound has become a valuable tool in the evaluation and management of patients in shock. No longer a means to simply evaluate organ anatomy, ultrasound has expanded to become a rapid and noninvasive method for the assessment of patient physiology. Clinicians caring for critical patients should strongly consider integrating ultrasound into their resuscitation pathways.

/pdf/bedside-ultrasound-in-resuscitation-and-the-rapid-ultrasound-20wepano7u.pdf

Bedside Ultrasound in Resuscitation and the Rapid Ultrasound in Shock Protocol

Ultrasound of the lung and quantification of B lines was recently introduced as a novel tool to detect overhydration. In the present study, we aimed to evaluate a four-region protocol of lung ultrasound to determine the pulmonary fluid status in ventilated patients in the intensive care unit. Fifty patients underwent both lung ultrasound and transpulmonary thermodilution measurement with the PiCCO system. An ultrasound score based on number of single and confluent B lines per intercostal space was used to quantify pulmonary overhydration. To check for reproducibility, two different intensivists who were blinded as to the ultrasound pictures reassessed and classified them using the same scoring system. The results were compared with those obtained using other methods of evaluating hydration status, including extravascular lung water index (EVLWI) and intrathoracic blood volume index calculated with data from transpulmonary thermodilution measurements. Moreover, chest radiographs were assessed regarding signs of pulmonary overhydration and categorized based on a numeric rating scale. Lung water assessment by ultrasound using a simplified protocol showed excellent correlation with EVLWI over a broad range of lung hydration grades and ventilator settings. Correlation of chest radiography and EVLWI was less accurate. No correlation whatsoever was found with central venous pressure measurement. Lung ultrasound is a useful, non-invasive tool in predicting hydration status in mechanically ventilated patients. The four-region protocol that we used is time-saving, correlates well with transpulmonary thermodilution measurements and performs markedly better than chest radiography.

/pdf/simplified-lung-ultrasound-protocol-shows-excellent-4vjogiae7n.pdf

Simplified lung ultrasound protocol shows excellent prediction of extravascular lung water in ventilated intensive care patients

Background 

The use of ultrasound (US) to diagnose an abdominal aortic aneurysm (AAA) has been well studied in the radiology literature, but has yet to be rigorously reviewed in the emergency medicine arena.



Objectives 

This was a systematic review of the literature for the operating characteristics of emergency department (ED) ultrasonography for AAA.



Methods 

The authors searched PubMed and EMBASE databases for trials from 1965 through November 2011 using a search strategy derived from the following PICO formulation: Patients—patients (18+ years) suspected of AAA. Intervention—bedside ED US to detect AAA. Comparator—reference standard for diagnosing an AAA was a computed tomography (CT), magnetic resonance imaging (MRI), aortography, official US performed by radiology, ED US reviewed by radiology, exploratory laparotomy, or autopsy results. AAA was defined as ≥3 cm dilation of the aorta. Outcome—operating characteristics (sensitivity, specificity, and likelihood ratios [LR]) of ED abdominal US. The papers were analyzed using Quality Assessment of Diagnostic Accuracy Studies (QUADAS) guidelines.



Results 

The initial search strategy identified 1,238 articles; application of inclusion/exclusion criteria resulted in seven studies with 655 patients. The weighted average prevalence of AAA in symptomatic patients over the age of 50 years is 23%. On history, 50% of AAA patients will lack the classic triad of hypotension, back pain, and pulsatile abdominal mass. The sensitivity of abdominal palpation for AAA increases as the diameter of the AAA increases. The pooled operating characteristics of ED US for the detection of AAA were sensitivity 99% (95% confidence interval [CI] = 96% to 100%) and specificity 98% (95% CI = 97% to 99%).



Conclusions 

Seven high-quality studies of the operating characteristics of ED bedside US in diagnosing AAA were identified. All showed excellent diagnostic performance for emergency bedside US to detect the presence of AAA in symptomatic patients.


Resumen
Revision Sistematica: La Ecografia a la Cabecera del Paciente en la Sospecha Diagnostica de Aneurisma de Aorta Abdominal

Introduccion 

El uso de la ecografia para el diagnostico de un aneurisma de aorta abdominal (AAA) se ha estudiado de forma extensa en la literatura radiologica, pero todavia debe ser revisada rigurosamente en el area de la medicina de urgencias y emergencias.



Objetivos 

Se realizo una revision sistematica de la literatura de las caracteristicas operativas de la ecografia en el servicio de urgencias (SU) para el AAA.



Metodologia 

Se busco en las bases de datos de Pubmed y EMBASE estudios desde 1965 hasta noviembre de 2011 mediante una estrategia de busqueda derivada de la formulacion PICO como se describe a continuacion. Pacientes: pacientes (18 o mas anos) con sospecha de AAA. Intervencion: ecografia a la cabecera del paciente en el SU para detectar AAA. Comparacion: el estandar de referencia para diagnosticar un AAA fue la tomografia computarizada (TC), la resonancia magnetica (RM), la aortografia, la ecografia revisada o realizada por un radiologo, la laparotomia exploratoria o los resultados de la autopsia (el AAA se definio como dilatacion de la aorta ≥ 3 cm). Resultado: caracteristicas operativas (sensibilidad, especificidad, y razones de probabilidad) de la ecografia abdominal en el SU. Los articulos se analizaron mediante las guias QUADAS.



Resultados 

La estrategia de busqueda inicial identifico 1.238 articulos; tras la aplicacion de los criterios de inclusion/exclusion quedaron incluidos en siete estudios con 655 pacientes. La media ponderada de la prevalencia del AAA en pacientes sintomaticos por encima de la edad de 50 anos es de un 23%. En la historia, el 50% de los pacientes con AAA carecera de la triada clasica de hipotension, dolor de espalda y masa pulsatil abdominal. La sensibilidad de la palpacion abdominal para el AAA aumenta segun se incrementa el diametro del AAA. Las caracteristicas operativas de la ecografia en el SU fueron: sensibilidad 99% (IC 95% = 96% a 100%) y especificidad 98% (IC 95% = 97% a 99%) para la deteccion de un AAA. No existe una combinacion de historia clinica, examen fisico y hallazgos de ecografia que descarten el diagnostico de AAA.



Conclusiones 

Se identificaron siete estudios de gran calidad de las caracteristicas operativas de la ecografia a la cabecera del paciente en el SU para el diagnostico de un AAA. Todos mostraron resultados diagnosticos excelentes para la ecografia a la cabecera del paciente en urgencias para detectar la presencia de un AAA en pacientes sintomaticos.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/acem.12080

Systematic review: emergency department bedside ultrasonography for diagnosing suspected abdominal aortic aneurysm.

Objective: Abdominal aortic aneurysm (AAA) is a deadly but often clinically silent disease. Patients at increased risk are elderly men with risk factors for vascular disease who may not have adequate screening through primary care. We sought to examine the prevalence and feasibility of screening for AAA in at-risk patients presenting for unrelated complaints using emergency physician–performed bedside ultrasound. Methods: At-risk patients presenting with unrelated complaints were screened for AAA by emergency physician–performed ultrasound. Scan was rated as complete, limited, or inadequate, and time to complete scan noted. Patients with identified AAA were provided with appropriate follow-up and were followed to look at confirmatory imaging and clinical course. Results: A total of 179 patients were screened, with 12 AAAs discovered (6.7%; 95% confidence interval, 3.9%-11.4%). Average time to perform the screening ultrasound was 141 ± 135 seconds. Average discrepancy between emergency ultrasound and formal imaging was 3.9 mm. Of 12 (92%) patients, 11 were followed up, with repair recommended in 3 patients. Conclusion: The emergency department represents a potential opportunity for screening at-risk patients for AAA. Emergency ultrasound is a fast and accurate method for identifying patients with AAA who may benefit from follow-up or intervention. © 2008 Elsevier Inc. All rights reserved.

/pdf/screening-for-abdominal-aortic-aneurysm-in-asymptomatic-at-rr1sm9cbw8.pdf

Screening for abdominal aortic aneurysm in asymptomatic at-risk patients using emergency ultrasound

Objective: This study sought to correlate the presence of pleural-based B-lines seen by emergency department ultrasound performed with the linear transducer with B-type natriuretic peptide (BNP) level in patients with suspected congestive heart failure. Methods: The study was a prospective convenience sample on adult patients in an academic, urban emergency department with over 100,000 annual patient visits. Adult patients with a BNP level ordered by the treating physician were prospectively enrolled by one of four physicians, blinded to the BNP level. The enrolling physicians included an emergency ultrasound director, two emergency ultrasound fellows, and a senior emergency medicine resident. Bedside ultrasound was performed using a 3-12 MHz linear broadband transducer in four lung fields. The serum BNP level was correlated with bilateral B-lines, defined as three or more comet-tail artifacts arising from the pleural line extending to the far field without a decrease in intensity on the right and left thorax. Results: Sixty three patients were consented and enrolled during a four-month period. Fifteen patients had the presence of bilateral B-lines. The median BNP in patients with bilateral B-lines was 1560 pg/mL (95% confidence interval (CI) 1141-3706 pg/mL), compared with 538 pg/mL (95% confidence interval 310-1917 pg/mL) in patients without B-lines. The distributions in the two groups differed significantly (p=0.0006). Based on the threshold level of BNP 500 pg/mL, the sensitivity of finding bilateral B-lines on ultrasound was 33.3% (95% CI: 0.19-0.50), and the specificity was 91.7% (95% CI: 0.73-0.99). In addition, bilateral B-lines were absent in all patients with a BNP 500. Further research may show that it can be applied to quickly assess patients with undifferentiated dyspnea. [West J Emerg Med. 2011;12(1):102-106.]

/pdf/identification-of-sonographic-b-lines-with-linear-transducer-x0yvo3q4lz.pdf

Michael Osborne

Papers

Screening for abdominal aortic aneurysm in asymptomatic at-risk patients using emergency ultrasound

Identification of Sonographic B-lines with Linear Transducer Predicts Elevated B-Type Natriuretic Peptide Level