WINFOCUS 2019 – Dubai

By | 23/02/2019

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

  1. A lines
  2. B lines
  3. 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)

www.resuscitativetee.com

How?

Standardised TEE views/approach

Transesophageal echocardiography during cardiopulmonary arrest in the emergency department.

Focused transesophageal echocardiography for emergency physicians—description and results from simulation training of a structured four-view examination

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.

ACEP 2017 Guidelines for the Use of Transesophageal Echocardiography (TEE) in the ED for Cardiac Arrest

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)

www.sonoabcd.org

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

Focus cardiac ultrasound core curriculum and core syllabus of the European Association of Cardiovascular Imaging 

US-CAB protocol for ultrasonographic evaluation during cardiopulmonary resuscitation: Validation and potential impact.

*Disclaimer – AW does not and would not use ultrasound to confirm ETT position in his practice

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.

Measuring diaphragm thickness with ultrasound in mechanically ventilated patients: feasibility, reproducibility and validity. 

Diaphragmatic ultrasonography for predicting ventilator weaning: A meta-analysis

Can diaphragmatic ultrasonography performed during the T-tube trial predict weaning failure? The role of diaphragmatic rapid shallow breathing index

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

Lung ultrasound integrated with clinical assessment for the diagnosis of acute decompensated heart failure in the emergency department: a randomized controlled trial.

  • 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

  1. LUS/POCUS saves time
  2. The worse the situation, the more important it is to utilise POCUS
  3. Integrated cardiopulmonary ultrasound assessment
  4. Master all the lung signs
  5. Remember the different types of congestion
Haemodynamic vs pulmonary 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.

Integrating eFAST in the initial management of stable trauma patients: the end of plain film radiography

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.

Ultrasound-Guided Percutaneous Dilational Tracheostomy: A Systematic Review of Randomized Controlled Trials and Meta-Analysis.

Comparison of percutaneous tracheostomy methods in intensive care patients: blind, fibreoptic bronchoscopy and fibreoptic bronchoscopy plus ultrasound

Comparison of 3 techniques in percutaneous tracheostomy: Traditional landmark technique; ultrasonography-guided long-axis approach; and short-axis approach – Randomised controlled study.

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

Consensus summary statement of the International Multidisciplinary Consensus Conference on Multimodality Monitoring in Neurocritical Care

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.

Diagnostic Accuracy of the Aortic Dissection Detection Risk Score Plus D-Dimer for Acute Aortic Syndromes: The ADvISED Prospective Multicenter Study.

  • RebelEM has broken it down here