Conflict of interest informationers.snapuptickets.com/ers/event-files/680/TA05-Scan-the... ·...

37
Summary of presentation points included for each slide. Contact info: Dr. Greg Hall [email protected] Cell: 519-572-099 Brantford General Hospital 200 Terrace Hill Street Brantford ON N3R 1G9 1 2 2 Conflict of interest information

Transcript of Conflict of interest informationers.snapuptickets.com/ers/event-files/680/TA05-Scan-the... ·...

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Summary of presentation points included for each slide. Contact info: Dr. Greg Hall [email protected] Cell: 519-572-099 Brantford General Hospital 200 Terrace Hill Street Brantford ON N3R 1G9

1 2 2

Conflict of interest information

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3 3

Blah blah blah

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You know the irony of conflict disclosure is that there is literature showing those who disclose significant conflicts of interest are MORE likely to be believed than those who do not have conflicts to disclose.

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Brief discussion of new tech and evolution of POCUS. Introduction to some leading edge applications. Discuss some applications that may come to the ED soon Credentialling for all these new applications? Where are we at?

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POCUS provides immediate, time-sensitive, dynamic clinical information. Non-ionizing radiation. Data points generated often superior to clinical exam.

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Let’s begin with a little history of POCUS. Because it gives us an idea of where we are heading as we explore more clinical applications of ultrasound in the ED.

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Much EM tech is from other specialties. The evolution of this tech to serve EM needs reflects this with features designed for non-EM needs.

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1st generation of U/S interpretable only by highly trained radiologists Each subsequent generation provides better imaging that can be interpreted by non-radiologists. Newer tech also improves the need for dynamic or live-motion imaging that radiologists traditionally don’t use but is in demand by other specialties like cardiology.

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Medical ultrasound began to take of in the 1970s but the resolution was so poor that it was beyond the clinical practioner’s domain. To interpret these images truly took the eyes of a highly trained radiologist. The machines were large, expensive and not portable.

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Resolution and removal of artifact improved significantly by the 2000s. Also more portable and less expensive.

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The latest generation of machines have resolution so good that you can image the fingerprint or digital artery in a finger tip. Much more portable and inexpensive. Images now interpretable by most clinicians

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Let’s talk about where things are headed as technology continues to improve.

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Similar to 3D reconstruction of CT imaging U/S can also have 3D reconstruction making interpretation of images easier 4D U/S is 3D imaging video (not just a 3D single image)

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3D imaging may allow superior imaging of some structures such as blood vessels

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Cardiac valves are hard to assess in 2D. With the newer 3D reconstruction it is becoming much easier to determine the functional degree of regurgitation and/or stenosis to better decide on treatment.

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New, high intensity, high resolution ultrasound can track the tiny movements of tissue as it compresses and differentiate the behaviour of tumour tissues from surrounding normal soft tissue. Another method is to measure other waves created by the original as it travels through a different tissue type

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What if the ultrasound machine could immediately colour code soft tissues to highlight an abscess or foreign body making use of its different elasticity properties compared to surrounding tissue?

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In development now for echocardiology. In the near future you could apply a probe to a patient with chest pain and immediately note areas of infarcting tissue as it will demonstrate a stiffness different from non-ischemic tissue.

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Differences in elasticity may better elicit plaque development in blood vessels.

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Speckle tracking locates all the tiny echos coming from a structure and maps them image to image generating information on how the tissue is moving. Segmental wall abnormalities can be detected much more accurately.

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Non-ionizing laser pulses delivered to tissue generate heat and thus expansion. This expansion generates ultrasound waves that can be detected by transducers. Certain tissues such as blood contain hemoglobin molecules in high amounts that will generate a greater amount of echo making them easy to image. Certain tumors will likewise light up. It is conceivable that this technology may eventually be incorporated into bedside machines to detect or monitor skin tumors and evaluate response to therapy.

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The latest generation of ultrasound machines uses artificial intelligence to analyze the tissue being imaged and help with interpretation of things like wall motion.

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Of more interest to EM physicians is the first generation of wireless probes have now been produced. An end to running over cables?

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Traditional U/S is limited by the piezoelectric crystals in the transducer Expensive to make Easy to break Physical limit to how many crystals can be packed into probe head, limiting image resolution

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Newest tech uses silicone wafers and nanotechnology manufacturing methods instead of crystals. Termed “CMUT”=Capacitive Micromachined Ultrasonic Transducers

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CMUT eventually cheaper to make Can pack a lot more sensors into probe head to increase resolution Tougher Shape of transducer can be almost any shape desired

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Miniaturization of electronics is allowing a new category of U/S machines, the ultraportable or hand-held version Less expensive Easy for the individual to carry with them Trade-offs in power and flexibility of use Small screen harder to interpret

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Tablet and smartphone based systems now available. Probes sold separately that can be plugged into a regular notebook as well. Image quality inferior to current generation portables.

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Many of you likely have bladder ultrasound systems In your departments that your nurses use. That is just the beginning for simplified, dedicated application machines. Here is an interesting specialized ultrasound machine that is placed on the arm and outlines where blood vessels are for cannulation.

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After surgeons figured out they could use ultrasound on their trauma patients looking for free abdominal fluid, the EM world realized “Hey we see far more trauma patients than anyone else, maybe we could use this too”. By the early 2000’s we had expanded our use of ultrasound for other conditions that were life saving such as vascular access, AAA, PCE, 1st TM pregnancy. In Canada courses like EDE and EDTU were born.

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After the basic applications came the next wave of POCUS in the ED for diagnostic purposes which have taken root in the past three years RUQ scans for biliary obstruction Hemodynamic assessment using IVC and LVF Pneumothorax Retinal detachment, vitreous bleed, vitreous detachment Proximal leg DVT Fracture Renal obstruction

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The newer procedural applications include Joint aspiration Regional anesthesia of the femoral and forearm nerves Fracture reduction Para, pleuro, and pericardiocentesis

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The newest wave of applications is now here Pulmonary edema, COPD, pneumonia More advanced regional blocks Scrotal ultrasound for torsion/ischemia GI ultrasound for obstruction, diverticulitis, appendicitis MSK ultrasound for tendon rupture,

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Here is the 3 min summary of lung scans. To scan the pleura you can use a linear probe for the best detail. However the abdominal probe works for most people in visualizing the pleura and both this probe and the microconvex are low frequency probes that can interrogate the deeper lung for other pathology.

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Lung ultrasound studies the artifacts created by the interaction of air and fluid in the lung. Thus pleural effusions and consolidation which tend to be rich in water create artifacts that are more posterior. Pneumothorax and interstitial edema tend to have more air involved and are found more anterior in the supine patient.

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Looking for pneumothorax: sliding pleural lines, comet tails means no pneumo. To confirm pneumothorax look for the lung point between lung sliding and no lung sliding

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When fluid builds up in the alveolae it creates a type of artifact on ultrasound called B-lines that looks like comet tails extending down the entire screen. It’s normal to have one or two of these lines from the small amount of fluid in the interstitial tissue. But lots of B-lines, or a confluence of these lines into a big wide line, indicates edema. Recent evidence suggests pulmonary ultrasound is superior to CXR for diagnosing pulmonary edema even in trainees with minimal ultrasound exposure. Martindale, Noble, Liteplo. Diagnosing pulmonary edema: lung ultrasound versus chest radiography Eur J Emerg Med. 2013 Oct;20(5):356-60

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When the lung becomes consolidated it takes on a solid tissue like appearance, often looking like liver. That’s why it is sometimes called hepatization of the lung. Within these solid areas can be seen bright lines and artifact caused by the air-filled bronchi that moves with respiration. Atelectasis on the other hand lacks these bronchial artifacts.

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UHN is one of the world leaders in ultrasound guided regional blocks and there are many conferences and workshops on this topic annually in Toronto though they tend to be aimed at anesthesia. Vincent Chan and his team have an excellent handbook on this topic. (see refs) Femoral blocks for femur fractures is rapidly gaining ground in the ED. Forearm blocks for hand procedures. Some newer blocks include the popliteal sciatic for ankle fractures and foot procedures. Interscalene and supraclavicular for arm procedures are also possible with POCUS.

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With EDE it is now possible to do an effective and simple block for procedures involving the foot. Almost the entire plantar surface will be anesthetized by a block of the sciatic nerve at the popliteal level. Only a small medial portion is innervated by the saphenous nerve. At this level the sciatic nerve is relatively superficial and easy to locate as it runs close to the popliteal artery.

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Start with the probe in transverese across the popliteal artery. Indicator to operator left. Locate the popliteal artery. If it isn’t easy to find, move cephalad as it may have already branched. Look superficial and lateral to the artery to locate the nerve. “High and outside”. Sometimes the sciatic nerve has already branched into tibial and common peroneal. You can either inject local around both branches or follow them until they join more proximally.

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Here is a video clip showing the popliteal artery and nerve. You would Inject 20ml of anesthetic. Beware that motor as well as sensory block may occur so these patients should be carefully evaluated before discharge.

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Brachial plexus blocks can be done at various levels. The two most popular are interscalene and supraclavicular. The supraclavicular is good for procedures involving anything distal to the shoulder. The interscalene is good for procedures of the shoulder and humerus but does not reliably affect the ulnar nerve.

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The interscalene block involves locating the nerve roots between the anterior and middle scalene muscles. Nerves above the clavicle are HYPOechoic. Approximately 10-15 ml of anesthetic is injected around the nerves.

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For testicular conditions patients will usually show up complaining of pain, swelling, or a mass.

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[click] Unfortunately up to 50% of acute scrotal cases cannot be differentiated on history and physical alone. [click] Bedside ultrasound done by EPs has been found in some series to be 95% sensitive and specific in diagnosis and [click] 100% sensitive in identifying urgent surgical emergencies.

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Power doppler is applied to the B-mode image to determine if there is any flow, regardless of direction. It is 3-4 times more sensitive to low flow than colour doppler.

49 50

In the longitudinal view the probe marker is towards the patient’s head, thus nearfield will be [click] patient anterior. Farfield will [click] be patient posterior. Screen left will besuperior [click] and screen right will be [click] inferior. Scanning through the testis looking for inhomogeneity, masses, fluid.

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The second view is the coronal comparison view where both testes are imaged at the same time from the inferior poles with probe marker to patient right

Power doppler is applied to the B-mode image to determine if there is any flow, regardless of direction. It is 3-4 times more sensitive to low flow than colour doppler.

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In B-mode we are looking for homogenous tissue. Here is an example of an infarcted testis. Note the inhomogeneity of the testicular tissue. It is important to confirm blood flow on power doppler and confirm there is both venous and arterial flow using spectral doppler which analyzes wave forms. As with formal ultrasound any patient with a high pretest probability of torsion should receive urological consultation. It can be very helpful to have the urologist come to the bedside and observe you do the scan, particularly after hours where there may be a delay in getting further imaging. Demonstrating lack of flow or signs of infarction can help speed up the decision to go to the OR.

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Looking for appendicitis first with POCUS can help speed up patient care. Use it as a rule-in test only however. If you see a swollen appendix or appendicolith this may help the surgeon decide on operating. However, it is often the case that the appendix is not clearly seen in which case further investigation or consultation should be done before considering discharge. To find the appendix orient yourself by finding the cecum region as shown here. Scan across the area of maximum tenderness using compression in transverse and longitudinal planes.

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POCUS can diagnose diverticulitis. Scan across the proximal, distal and transverse colon.

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The pseudo-kidney sign indicates bowel wall edema.

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Look for fecoliths in the bowel wall which are echogenic and can shadow.

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POCUS can be very useful for SBO. Some studies suggest it is superior to plain films in sensitivity. Look for bowel lumen greater than 25mm in diameter, loss of peristalsis, and a transition point.

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At the transition point you will see a region of peristalsis adjacent to an area with no movement. This is highly specific for obstruction.

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Rather than just listening for the murmur of MR, applying doppler to the 4 chamber view of the heart is a simple way to look for severe regurgitation. Blood flow towards the probe is red, away from the probe is blue. If you see a lot of blue hitting the back of the atrium, the patient likely has significant regurg.

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Work is ongoing into other bedside applications. In acute cerebral ischemia, changes in blood-flow can be seen with transcranial doppler that might eventually help us decide who would most benefit from TPA or angioplasty. Rapid screening of the carotids at the bedside could potentially rule out the majority of CVA patients who do not have significant stenosis. Only those with a stenosis of perhaps 50% on screening would go on to definitive carotid doppler ultrasound. The latest POCUS systems even have carotid intimal layer automated calculators.

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We still base a lot of our acute intervention decisions on ST changes on EKG and troponin changes. What if we could rapidly assess segmental wall motion changes to further stratify who should be admitted to a CCU and who can go home?

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NASA and the National Space Biomedical Research Team have helped pioneer the use of telemetry-based ultrasound. The non-clinician user can do a scan as directed by a physician elsewhere and the images interpreted real time as well.

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With greater portability and dropping prices POCUS is rapidly becoming an ideal modality for resource poor regions. A self-contained unit with minimal maintenance requirements that can be powered by solar batteries. Teleradiology will enable midwives and various mid-level providers to generate images and get expert help with interpretation when necessary. Rapid diagnoses can be made in a village clinic and assistance with procedures and maternal assessment done.

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The key to true ultrasound proficiency may lie in learning the modality from day one of medical school. Just as students are introduced to the stethoscope and incorporate their findings with problem based learning and studies in anatomy and physiology, so can ultrasound be integrated. All 288 1st year students at U of T received 3 hours of US training in small groups this year Western has had an optional US workshop for 1st year students the past two years NOSM has an introductory program for their 1st year. American schools like U of South Carolina, UC Irvine, and Wayne State have had programs for up to 6 years.

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http://chec-cesc.afmc.ca Aium.org

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Certification in POCUS is still evolving. First issue is training-based on numbers vs competency assessment. Groups like the Canadian Emergency Ultrasound Society have put forth certification processes for the basic applications that require a minimum number of scans and examinations. Many residency programs are developing their own processes that are based on competency assessment vs numbers. Poor literature to support either approach. CEUS is now looking at certification for advanced applications. CAEP and ACEP have general position statements about requirements. Second issue: How many positive findings must be imaged in real or simulated patients? Third issue: How do we define the various levels of ability in POCUS? i.e.Basic application competence. Basic application educator. Advanced application competence, subset vs comprehensive. Advanced application educator. Forth issue: How to recognize those who have done significantly more

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POCUS is being considered in clinical decision aids. Data points generated by POCUS can be far superior to those generated by the clinical exam for some conditions like PE.

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