London USS Level 1

Course

Tim Harris

Emergency Medicine & PHC

Welcome

• Faculty

• Course structure

• Course aims– Level 1 basic knowledge

– After Level 1

– Your folder

• USS is an extension of

Hx Ex - focussed study

USS - History

• Industry to medicine

• Radiology / cardiology to clinical specialties

USS Applications

FAST ?AAA

fluid in Morrissons Pouch

USS Applications

Line PlacementIJ (shown), FV, SCV Pleural & pericardial

effusion

Periarrest - shock

USS Applications

?Cardiac performance Renal tract

– Hydronephrosis (above)

– calculi(Dilated RV shown)

USS Applications

• ?DVT – (compression - here FV)

• RUQ pain - Calculi,

obstruction, infection

Cholelithiasis

USS Applications

• ?FB

– Wood below

• 1st trimester - ?FH,

dates, IUP

free fluid & empty

uterus below

USS applications

• Joint Effusions - eg child irritable hip

• Procedural guidance - nerve blocks, LPs

• Undifferentiated hypotension

• Soft tissue - eg Achilles tendon rupture

• ? tonsillar abscess

RCR - USS training

recomendations

» • urological ultrasound

» • gynaecological ultrasound

» • gastrointestinal ultrasound

» • vascular ultrasound

» • breast ultrasound

» • thoracic ultrasound

» • cranial ultrasound in infants

» • focused emergency ultrasound

» • intensive care ultrasound

» • musculoskeletal ultrasound

RCR USS training

recomendationsLevel 1

SpR 3/4 radiology

- Perform common examns safely

& accurately

- Normal vs pathology

- Dx common abnormalities in

certain organs

- Recognise limitations &

relationship USS vs other

imaging

Level 3

Consultant Radiologist - subspecialty interest

–Tertiary referral

–Complex proceedures

–Teaching / research

Level 2SpR 5 with subspecialty training

- referrals from level1

- recognise almost all pathology

within relevent organ system

- basic USS guided proceedures

- Teach level 1 & research

RCR USS training

recomendations

• Theoretical training

– registered course!!

• Practical Training

– Named supervisor

– Competency assessment & log book

• CPD

RCR Recommendations -

Emergency Medicine at level 1

To be able to use ultrasound in the

context assessment of:

» – focused assessment by sonography for trauma

(FAST)

» – AAA screening/detection in symptomatic

patients

» – peri-arrest scenario for PEA / tamponade/

effusion

» – vascular access

» – pleural and pericardial fluid

RCR Recommendations - ICM /

Critical Care at level 1

• Thorax– Pleural effusions, consolidation & guided

drainage, pericardial effusion

• Abdomen– Free fluid, hydroneprosis, bladder distention

• Vascular– AAA, veins vs arteries & patency, line placement,

features CCF

• Nerve blocks

ICM - Anaesthesia (RCA)

• Focussed on periarrest echo (CCM 2007)

– Identify courses PEA• FEEL 1 day course imported from Germany

• 5 sec look during CPR if ?PEA (at 2 mins with checks)

• Call out findings - large RV, empty heart, effusion etc

– Support ILCOR 2005

– WINFOCUS• FEEL - beginner, FEER (SHOC) - level 1

Level 1- CEM Position

• Std of knowledge EPs expected to have achieved by SpR yr 4

• Knowledge base by 2010

• Theory – Anatomy

– Physics & set up of USS system

– limitations

– Image recording

– Artifacts

– Safety & consent

– Pathology vs normal

Level 1 - Training

• Training with named supervisor

– (ED or Radiology)

• Supervisor - level 2 or

level 1 + 1 yr experience

• Assessment by supervisor

• Registered course

• 5 examns pw

Level 1 training

• Goal is competency not rigid number of scans

• Experience concentrates on

– ? AAA, FAST, vascular access, periarrest

USS

• Nominally 50 logged cases, half supervised,

10 with case histories

– 20 ?AAA, 20 FAST, 10 vascular access

Level 1 - Skill maintainance

• CPD

• All EPs seeking accreditation require assessment within 3/12 of this course

• If > 3/12 elapses between scans reassess with DOPS

• Dept - governance, training meetings, nominated lead

• Keep up to date with literature

• Regional trainer

Medico-Legal

• Write in notes -

date/time/findings/limitations

• Printed image to notes

• Store images for review

• Dept protocol & framework

• Radiology / cardiology

RCR

“All who provide an ultrasound service are ethically and legally vulnerable if they have not been adequately trained. National Health Service (NHS) Trusts in the UK, which provide professional indemnity to practitioners, are unlikely to be able to mount any defence to an action brought against an untrained practitioner”

Course Format

• Day 1– Background - physics, knobology, image acquisition, buying kit

– Level 1 - FAST (pleura), AAA

• Day 2– Level 1 - peri-arrest/shock, vasular access

– Beyond level 1 - GB, renal, soft tissue,

DVT, gynaecology

• Lecture, practical, recap

• Stations– Two stations per session

• Models & Patients

• Assessment forms

Questions?

USS - a few terms

• A (amplitude)

• B (brightness, anatomical imaging)

mode

• M Mode (motion)

• Doppler

• contrast

• …and 3(4)D!