Emergency Ultrasound Course

Huntington Beach, CA November 8-10, 2019

Ocular Ultrasound

Debia Kim, MD Co-Director, Emergency Ultrasound

TPMG, South Sacramento(no disclosures)

Huntington Beach, CA November 8-10, 2019

Eye Can See You!ocular ultrasound for

common ED complaints

ObjectivesWhy do EYE need POCUS?

When will EYE use this? (Indications)

Trauma Vision loss/change Eye pain Suspected elevated ICP

Normal & Abnormal Anatomy

Techniques and practice

Why grab the ultrasound?

❖ More information, faster, and more safely! ❖ External eye exams are not always diagnostic

❖ Eye complaints make up 1.5-3% of ED visits ❖ POCUS is quick and the eye is an excellent fluid medium ❖ Patient satisfaction

... which all adds up to make YOU a better provider.

ObjectivesWhy do EYE need POCUS?

When will EYE use this? (Indications)

Trauma Vision loss/change Eye pain Suspected elevated ICP

Normal Anatomy

Techniques and practice

ANATOMY REVIEW

ObjectivesWhy do EYE need POCUS?

When will EYE use this? (Indications)

Trauma Vision loss/change Eye pain Suspected elevated ICP

Normal & Abnormal Anatomy

Techniques and practice

Technique ...❖ Use a high-frequency, linear transducer ❖ Check your EXAM settings for ALARA

Technique ...❖ Use barrier protection (like a Tegaderm) ❖ Use lots of cold gel or a gel pad

Technique ...❖ Hold the probe like a

pencil and lay the rest of your hand on the patient to maintain position

❖ Scan in 2 planes ❖ Scan the

contralateral structure to compare

Eye Trauma: look for…Extra ocular movements

Pupillary reflexes

Ruptured globe

Retrobulbar hematoma

Lens dislocation

Ruptured GlobeControversy: Concern for use in suspected rupture

Possible vitreous humor extrusion? Ultrasound findings:

Decrease in globe size Anterior chamber collapse Scleral “buckling” Vitreous hemorrhage

Retrobulbar HematomaFacial trauma, post-surgical, spontaneous Time-sensitive diagnosis Presentation:

Painful proptosis Vision change/loss Impaired extra-ocular movements

Ultrasound: hypo echoic region posterior to globe

Lens DislocationTrauma, post-surgical, spontaneous (Marfan’s) Most common: lens is posterior to normal location Other ultrasound findings of ocular trauma are usually present (retinal detachment, globe rupture, etc.)

Retinal vs Vitreous Disorders

Retinal detachment: Macula ON vs Macula OFF Retinal versus Vitreous detachments Vitreous hemorrhage

Retinal vs Vitreous Disorders

Retinal DetachmentTime sensitive!

Macula ON vs Macula OFF Presentation

Floaters and flashers, curtains or shade Painless vision loss

Ultrasound:

Retinal vs Vitreous Disorders

Vitreous DetachmentStill time sensitive… because it can become a retinal detachment Presentation

Floaters and flashers, NOT so much curtains or shade Painless vision loss

Ultrasound: because the vitreous is NOT tethered at the optic nerve, the “wavy white line” can come off the back of the eye

Vitreous HemorrhageMost commonly from traction in the back of the eye acutely or chronically

Retinal tear, PVD, trauma, DM retinopathy Presentation

Floaters, shadows, cobwebs Blurring/Loss of visual acuity

Ultrasound: often nonlinear echogenicities

Intracranial Pressure?The optic nerve communicates directly with the brain, and increased intracranial pressure can cause swelling of the optic nerve sheath Measured 3mm behind (below) the eye

<5mm is normal 5-6 mm …. ? >6mm is abnormal, suggesting ICP elevation

Concurrent papilledema also helps make the diagnosis

Papilledema WITH increased ONSD

ANATOMY REVIEW

Pitfalls❖ Too much pressure while scanning can cause more harm to the

traumatic eye

❖ Artefact galore and ALARA! Please adjust your exam settings

❖ ONSD and US findings of papilledema are still being investigated … clinical correlation

“Nuts and Bolts”

❖ Linear probe ❖ “Eye” exam setting ❖ Optic Nerve: >6mm, 3mm below ❖ Scan in 2 orthogonal planes and don’t squish!

QUESTIONS?

References & ThanksNoble, Vicki E., Nelson, Bret P. Manual of Emergency and Critical Care Ultrasound, 2nd ed. New York, N.Y.: Cambridge University Press, June 2011 Ma, O.J., Mateer, James R., Blaivas, Michael. Emergency Ultrasound, 2nd ed. New York, N.Y.: McGraw Hill, 2008 Vaziri K, Schwartz SG, Flynn HW, Kishor KS, Moshfeghi AA. Eye-related Emergency Department Visits In the United States, 2010. Ophthalmology. 2016;123(4):917-919. doi:10.1016/j.ophtha.2015.10.032. HARRIES Am J Emerg Med. 2010 Oct;28(8):956-9. doi: 10.1016/j.ajem.2009.06.026. Epub 2010 Jan 28. KNIESS J Emerg Med. 2015 Jul;49(1):58-60. doi: 10.1016/j.jemermed.2014.12.074. Epub 2015 Mar 18. TAYAL 2007 DUBOURG 2011 VENKATAKRISHNA 2011

sonoguide sonocloud.com THE INTERNET FOR PICTURES

special thanks to: Dr K. Kelley, Dr. C. Jones

Emergency Ultrasound Course

Huntington Beach, CA November 8-10, 2019

DVT Ultrasound

Debia Kim, MD Co-Director, Emergency Ultrasound

TPMG, South Sacramentono disclosures

Huntington Beach, CA November 8-10, 2019

DVTBedside ultrasound in the ED

With special thanks to

Drs Ken Kelley & Lisa Rapoport!

Background & Indications Anatomy, Technique & Common Pitfalls Image Interpretation

OBJECTIVES

DVT: What are the stakes?Prevalence in symptomatic outpatients is ~20%

ICU patient incidence ~9.6-12% despite prophylaxis

500,000 screening US exams are done in the US every year

US is 95% Sn and 98% Sp for DVT in symptomatic patients

Withholding anticoagulation in patients with a negative US has been shown to be safe

Who is at risk?

Mechanical ventilation Pressors

CVC (including PICC) Trauma

Immobilization Surgery/general

anesthesia Known thrombophilic

disorders ESRD (chronic)

Platelet transfusion Prior personal or family hx of VTE

… so really, everyone in the ED who is sick

Traditionally: Venogram 1990s - Ultrasound

visualization compression doppler augmentation

Duplex Ultrasonagraphy is a screening exam — can we abbreviate this?

History of Imaging

DVT distribution

Prospective, RCT, n=2465 First episode of suspected DVT randomized to 2-Point lower extremity ultrasound versus whole-leg ultrasound CONCLUSION: 2-Point ultrasound is as good as whole-leg ultrasound for detecting DVT in symptomatic outpatients

TRADITIONAL VS. 2-POINT:

Compression is performed at the level

of the inguinal ligament to the bifurcation of

the popliteal vein, marching all the way

through the superficial femoral canal

TRADITIONAL VS. 2-POINT:

Compression is performed from junction of GSV & CFV distally 5cm

Compression is performed from

insertion of proximal pop distal to bifurcation

Limited Duplex US performed at CFV and POP by ED, followed by complete exam done by radiology 112 patients with 34 DVTs, agreement was 98% (kappa = 0.9)

Median time for ED exams: 3mins 28 secs

[

?

LEG VEINS: ANATOMY

Don’t get hung up on names!

Femoral artery and Deep femoral artery start paired next to the

Common femoral vein

Deep femoral vein — NOT seen on ultrasound (too small)

Groin Crease

Let’s start in the groin…

Femoral VesselsLaterality matters

Supine patient

CFVDFA

SFA

Femoral VesselsAs you travel away from the groin you will see the

confluences disappear

FVFA

Popliteal VesselsLaterality does not matter Supine vs prone vs sitting

patient

PA

PV

Ready to scan?Grab a linear probe (save the curvilinear probe for large patients)

Choose your DVT exam setting on the machine

Position your patient

March your compressions every along the femoral and popliteal positions

How far apart do I compress?

It is not necessary to compress every continuous millimeter of the venous lumen searching for a clot

In symptomatic patients, clot usually involves whole or multiple venous segments

It is generally adequate to compress every 1 cm of the femoral and popliteal leg veins

COMPRESSION = NORMAL

Compress until the vein walls touch, then let go

and watch for the “wink back”

NON-COMPRESSABILTY

= DVT

Common Pitfalls:Cannot interrogate the iliac veins

Beware the lymph node!

Color can help you, but can also fool you

Non-laminar flow creates artefact

Common Pitfalls:Clinical correlation:

need to repeat that US in 5-7 days for those high risk negative studies

Morbid obesity

Uncooperative patient

So … what is this?

Popliteal Pitfalls:

Getting hung up on hamstring tendons

Interrogating/mistaking superficial vessels

Baker’s cysts

The POP is on TOP!

PITFALL: superficial popliteal vessels

PITFALL: Baker’s Cyst

What about Doppler?

“Duplex” term refers to ability to simultaneously perform gray scale imaging with superimposed color flow from structures containing moving RBCs The body of published literature suggests compression ultrasound alone is satisfactory as a diagnostic technique for lower extremity DVT

What about Doppler?

“Spontaneity” - flow observed in larger vessels at quiescence “Phasic Variation” - fall in venous flow velocity at inspiration, rise at expiration

What about Augmentation?Compress a more distal part of the leg Normal vein should fill with color while thrombus appears as a filling defect Augmentation indicates patency between the point of compression and the sampling site

Primary Criterion Secondary Criterion

Noncompressibility of a vein

Echogenic ThrombusVenous Distention

Filling DefectLoss of PhasicityLoss of Valsalva

Loss of Augmentation

Diagnosis made.

“Nuts and Bolts”It’s only a deep vein if there’s an artery next to it Need to scan 2 regions:

1. The femoral triangle, CFV, GSV 2. The popliteal vein and its trifurcation

If it’s normal, the vein walls have to touch If it’s abnormal, the artery needs to collapse

RECAP:SCANNING: 2 locations (add

the CFV/mid-thigh for better sensitivity)

VISUALIZATION: recognize anatomy, fanning

COMPRESSION: press and look

43 yo M after ACL injury: suspicious?

47 yo F with Obesity and Chronic Pain

64 yo female with recurrent DVTsreturns with left leg swelling, dimer > 4000

References & Thanks!

Noble, Vicki E., Nelson, Bret P. Manual of Emergency and Critical Care Ultrasound, 2nd ed. New York, N.Y.: Cambridge University Press, June 2011 Ma, O.J., Mateer, James R., Blaivas, Michael. Emergency Ultrasound, 2nd ed. New York, N.Y.: McGraw Hill, 2008 PALLADIO study, Ageno et al., Lancet Haematology, 2015 Bernardi, JAMA, 2008 Coco Arch Intern Med 1993 Blaivas, Lambert, Harwood, Wood, Konicki at Christ Hospital; Acad Emerg Med. 2000 Feb;7(2):120-6 Crisp GJ et al, Ann Emerg Med 2010 Kory PD, Chest 2011

and special thanks to Drs. Lisa Rapoport and Kenneth Kelley THE INTERNET FOR PICTURES sonocloud.com, sonoguide.com

Emergency Ultrasound Course

Huntington Beach, CA November 8-10, 2019

MSK Ultrasound

Debia Kim, MD Co-Director, Emergency Ultrasound

TPMG, South Sacramentono disclosures

Huntington Beach, CA November 8-10, 2019

Musculo-Skeletal Miscellany

ultrasound tips and tricks!

ObjectivesWhy do I need MSK POCUS?

When will I use this? (Indications)

Normal Anatomy

Techniques and practice:

Nerve Blocks Cellulitis vs. Abscess Tendons & Fractures Foreign Bodies

ObjectivesWhy do I need MSK POCUS?

When will I use this? (Indications)

Normal Anatomy

Techniques and practice:

Nerve Blocks Cellulitis vs. Abscess Tendons & Fractures Foreign Bodies

Why grab the ultrasound?❖ More information, faster, and more safely!

❖ X-rays are awful for soft tissue. ❖ in 2010, an epidemiological study found the most

common ED malpractice claims were: AMI (5%), fractures (6%), and appendicitis (2%)*

❖ Procedures are safer and more effective with real-time guidance ... reduce the need for procedural sedation*

❖ Patient satisfaction... which all adds up to make YOU a better doc.

ObjectivesWhy do I need MSK POCUS?

When will I use this? (Indications)

Normal Anatomy

Techniques and practice:

Nerve Blocks Cellulitis vs. Abscess Tendons & Fractures Foreign Bodies

ObjectivesWhy do I need MSK POCUS?

When will I use this? (Indications)

Normal Anatomy

Techniques and practice:

Nerve Blocks Cellulitis vs. Abscess Tendons & Fractures Foreign Bodies

When Do I Use This?

❖ Trauma (direct and indirect, blunt & penetrating) ❖ Effusions, fractures, tendinopathies ❖ Nerve blocks for pain control

❖ Inflammation, infection, masses ❖ Abscess vs. cellulitis ❖ Hematomas, glands, foreign bodies

ObjectivesWhy do I need MSK POCUS?

When will I use this? (Indications)

Normal Anatomy

Techniques and practice:

Nerve Blocks Cellulitis vs. Abscess Tendons & Fractures Foreign Bodies

ObjectivesWhy do I need MSK POCUS?

When will I use this? (Indications)

Normal Anatomy

Techniques and practice:

Nerve Blocks Cellulitis vs. Abscess Tendons & Fractures Foreign Bodies

Your meat... aka Normal Anatomy

ACROSS THE GRAIN

ALONG THE GRAIN

Tendons are ... ANISOTROPIC, tricky things

so you MUST scan through them carefully. Don’t mistake anisotropy for pathology.

What about vessels & nerves?

B...O...N...E...S

Technique ...

❖ Use a high-frequency, linear transducer ❖ Hold the probe like a pencil and lightly lay the rest of

your hand on the patient to maintain position ❖ Start where it hurts and scan over the area of

interest in 2 planes ❖ Scan the contralateral limb/structure to compare ❖ Use a stand-off pad or water bath if needed

ObjectivesWhy do I need MSK POCUS?

When will I use this? (Indications)

Normal Anatomy

Techniques and practice:

Nerve Blocks Cellulitis vs. Abscess Tendons & Fractures Foreign Bodies

ObjectivesWhy do I need MSK POCUS?

When will I use this? (Indications)

Normal Anatomy

Techniques and practice:

Nerve Blocks Cellulitis vs. Abscess Tendons & Fractures Foreign Bodies

What are we looking at?

Where will the abscess show up?

To cut or not to cut ...

107 skin infection ED patients prospectively enrolled. Clinical exam: Sn 86%, Sp 70% US exam: Sn 98%, Sp 88% Conclusions: ED bedside US improves accuracy in detection of superficial abscesses.

Abscess vs Cellulitis

Abscess vs Cellulitis

Abscess vs. Cellulitis

Cut? No cut?

Abscess vs Cellulitis

Tendonremember what normal tendon looks like?

Tendon

red, hot, symmetrically swollen

held in flexion

pain on tendon percussion

pain on passive stretch

27 year old female with a “spider bite” on her finger...

Ortho is unimpressed.

Tenosynovitis?

Fractures

9 year old male with ankle painfell off his bike

Here’s his US:

Fractures

*often associated with EFFUSIONS*

Effusions

Effusions

Effusions ... in kids

Treasures ... a.k .a. foreign bodies

Treasures ... a.k .a. foreign bodies

Nerve Blocks

Femoral/Fascia Iliaca Ulnar/median Post. tibial Hematoma blocks

Advantagesreduces complications: direct visualization allows avoidance of surrounding vascular, muscular, bony structures improves success rate: blocks done with fewer pokes with faster results

(why would anyone do this without US?)

REMEMBER TO DOCUMENT YOUR NEURO EXAM BEFORE & AFTER EVERY BLOCK!!

Operator-dependent Concern for loss of exam/compartment syndrome

Caveats

Femoral NerveArises from L2-L4, remember NAVL

For femur & knee anesthesia

Direct Fem N block or Fascia Iliaca block

Probe in inguinal crease, needle loaded with 20cc, use in-plane approach

Femoral Block

Femoral Block

Fascia Iliacafind what you know:

Fascia Iliacamove laterally:

Figure 2: panoramic view of ultrasound anatomy of the femoral (inguinal) crease area. May 8th 2018<http://www.nysora.com/updates/3107-ultrasound-guided-fascia-iliaca-block.html>

Fascia Iliacainject!

Figure 2: panoramic view of ultrasound anatomy of the femoral (inguinal) crease area. May 8th 2018<http://www.nysora.com/updates/3107-ultrasound-guided-fascia-iliaca-block.html>

Foot/Ankle Blocks

Dorsal foot: Saphenous, Ant. tibial, Sup. peroneal nerves

Volar foot: Post. tibial, Sural nerves

Posterior Tibial BlockStepped on glass? Nail puncture needs to be explored? FB removal?

Position the patient - knee flexed with towel under. Or, dangle the feet over the bed while prone.

Posterior Tibial, cont’d

Wrist Blocks

Ulnar Nerve Block

Hematoma BlocksPre-scan first - use Doppler freely!

Use appropriate-sized needle to reach the hematoma

Aspirate, and then inject when you see blood

Great for confirmed end-extremity fractures

PROBE NEEDLE

ObjectivesWhy do I need MSK POCUS?

When will I use this? (Indications)

Normal Anatomy

Techniques and practice:

Nerve Blocks Cellulitis vs. Abscess Tendons & Fractures Foreign Bodies

MusculoSkeletal Summary Message!

❖ Linear probe ❖ “Superficial” or “Small Parts” exam ❖ Cobblestoning = edema, irregular hypoechoic

collection = pus ❖ Scan in 2 orthogonal planes

QUESTIONS?

ReferencesNoble, Vicki E., Nelson, Bret P. Manual of Emergency and Critical Care Ultrasound, 2nd ed. New York, N.Y.: Cambridge University Press, June 2011 Ma, O.J., Mateer, James R., Blaivas, Michael. Emergency Ultrasound, 2nd ed. New York, N.Y.: McGraw Hill, 2008 Practical Guide to Emergency Ultrasound,  edited by Karen S. Cosby, John L. Kendall. Philadelphia: Lippincott, Williams & Wilkins, 2006 Acad Emerg Med. 2010 May;17(5):553-60. An epidemiologic study of closed emergency department malpractice claims in a national database of physician malpractice insurers., Brown TW, McCarthy ML, Kelen GD, Levy F. Emerg Trauma Shock. 2012 Jan;5(1):28-32. Feasibility and safety of ultrasound-guided nerve block for management of limb injuries by emergency care physicians. Acad Emerg Med. 2005 Jul;12(7):601-6. ABSCESS: applied bedside sonography for convenient evaluation of superficial soft tissue infections. Squire BT, Fox JC, Anderson C. http://www.slredultrasound.com/ImageBank/RegionalAnesthesia.html sonoguide sonocloud.com THE INTERNET FOR PICTURES

special thanks to: Dr Z. Soucy, Dr K. Kelley, Dr. S. Cusick, Dr. L. Bunting, Dr. C. Jones