Lung ultrasound in clinical practice: one step forward (G Volpicelli)
Lung ultrasound has been the most impactful new diagnostic tool in the modern emergency medicine during the last 15 – 20 years, together with the advent of troponins… with the difference that lung ultrasound has a wide spectrum of application while troponin has only very few specific
Volpicelli
Ultrasonic Absorption and Reflection by Lung Tissue – By Dunn and Fry, 1961
Lung ultrasound relies on 3 basic patterns
- A lines
- B lines
- Consolidation
Use and look for additional signs…
Integrate information
- Contextualisation
- There is a wide differential diagnosis for B lines BUT with clinical history, the differential can be focussed e.g. localised B-lines in the context of a previously healthy young man who just sustained blunt chest trauma.
- Monitoring
- The re-expansion of a previously atelectatic lung.
- Multiorgan
- The use of lung ultrasound together with echocardiography
TEE-guided resuscitation (F Teran)
How?
Transesophageal echocardiography during cardiopulmonary arrest in the emergency department.
Why TEE?
US is the standard of care – European Resuscitation Council 2015 Guidelines
Whilst TTE is limited by windows and opportunity to get the images, TEE/TOE –> high quality image, no interference, chest compression continues.
Goals of resuscitative TEE
- Identification of presence/absence of cardiac activity
- Identification of cardiac rhythm
- Evaluation of LV function
- Evaluation of RV function
- Identification of pericardial effusion/tamponade
How is TEE impacting care?
- Identify pathology
- Assess intervention
- Improve quality of CPR
- Shorter time off chest
- Optimisation of area of maximal compression
- Understand physiology and the haemodynamics
Shorter time of chest (ref full text)
- TTE – 19s pulse check
- TEE – 9s pulse check
Multiorgan Ultrasound in Cardiac Arrest (R Breitkreutz)
You will find treatable conditions with FEEL
Interruptions for ultrasound are trainable
Emergency department point-of-care ultrasound in out-of-hospital and in-ED cardiac arrest.
- Cardiac activity on US was most associated with survival following cardiac arrest
- US during cardiac arrest identifies interventions outside of the standard ACLS protocol
Diaphragm ultrasound: research to clinical practice (G Ferrari)
Measurements depend on effort and are reproducibility variable
There is no standardised method to assess but broadly speaking 2 most frequently used are Diaphragm Excursion and Diaphragmatic Thickening (Fraction)
The advantages of using ultrasound to evaluate the diaphragm
- Lack of ionising radiation
- Bedside procedure
- Non invasive
- Real-time evaluation of diaphragm movement/thickness
- Fast, easy and reproducible
- Natural window to the critically ill (pleural effusions, consolidation or atelectasis allow an easier identification of the hemidiaphragms)
- Method of choice in the investigation of hemidiaphragmatic paralysis
If subcostal views are difficult to obtain, can use lateral approach but no reference values for this approach
Ultrasonographic diagnostic criterion for severe diaphragmatic dysfunction after cardiac surgery.
Diaphragm dysfunction (DD) in ICU
DD can be present at ICU admission, or may develop during ICU stay
There is increasing evidence that DD is already present at ICU admission in a high % of pts
Evolution of diaphragm thickness during mechanical ventilation: impact of inspiratory effort.
Diaphragmatic ultrasonography for predicting ventilator weaning: A meta-analysis
A new diagnostic approach to heart failure (L Gargani)
Essentially, she means the addition of lung ultrasound to your normal cardiac evaluation. End.
Lung ultrasound has a role in heart failure with regards to –
- diagnosis
- monitoring
- prognostication
- TheBottomLine has broken this down for you here
2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC)
Recommend the use heart and lung ultrasound assessment early (30-60 mins)
Luna’s 5 Laws
- LUS/POCUS saves time
- The worse the situation, the more important it is to utilise POCUS
- Integrated cardiopulmonary ultrasound assessment
- Master all the lung signs
- Remember the different types of congestion
Take-home messages
- LUS can help in the diagnosis, monitoring and prognosis of heart failure
- It helps saves time
- It reveals subclinical congestion
- It differentiates haemodynamic from pulmonary congestion
- It is better placed as part of ‘multiorgan’ ultrasound approach
- It is CLINICAL ULTRASOUND
- It doesn’t replace your brain or medical knowledge
Ultrasound and Trauma (S Ianniello & L Zieleskiewicz)
In Dr Ianniello’s department, a radiologists attends in resus for the arrival of major trauma. An extended-FAST is performed for every unstable (SBP<90mmHg).
For the stable trauma patient, no unrecognised diagnosis with a clinical impact was missed due to lack of chest and pelvic x-ray.
She recommends
- Don’t waste time
- Scan for free fluid and pericardial effusion first
- Second, look for pneumothorax
- (if there is time, look for injuries to solid organs)
- Use eFAST for an overview, not for a definitive diagnosis
- Move the pt on to CT or OR as quickly as possible
The Future?
Strain analysis for cardiac contusion and to better detect pneumothorax?
Ultrasound-guided pericardiocentesis (Dr A Osman)
Multiple approaches – parasternal, apical and subxiphoid
Go for –
- largest fluid
- closest to the probe
- avoid vital structures
Ultrasound-guided pericardiocentesis: a novel parasternal approach
- A description of a parasternal, medial to lateral needling approach
- Main advantages
- Safe, as all surrounding structures are visualised and thus avoided
- High-frequency probe allows for detailed visualisation of needle and wire
- Fast procedural time
Ultrasound guide in tracheostomy (Dr D Govil)
The speaker makes the case that the use of ultrasound completely negates the need for the bronchoscope.
US use and the estimation of intracranial pressure in emergency (F Rasulo)
Ultrasound is useful because its more readily available compared to more invasive methods.
ICP by itself is probably not useful and a multimodal approach should be adopted in order to ‘personalise’ care and treatment
Transcranial Doppler after traumatic brain injury: is there a role?
Neuroultrasound can measure flow (TCD, pulsatility), pressure (ONSD) and midline shift. These can/should be combined.
And coming to you soon – neuropocus competencies….
Integrated approach to aortic rupture (P Nazerian)
Aortic dissection has multiple differentials and hence can be easy to misdiagnosed.
Multiple approaches currently being used
- Aortic dissection detection risk score
- Chest x-ray
- D-dimer
- Bedside TTE (importantly, the suprasternal views)
All are not perfect.
The ADvISED trial aimed to combine all these techniques.
- RebelEM has broken it down here
