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   Here’s comes another heaping helping of ultrasound highlights from our winter symposium’s echo extravaganza! In this serving, Dr. Mindy Lipsitz, MD shares some pearls about the suprasternal notch view to assess for trauma, coarctation, aortic root regurgitation, and aortic aneurysm.  Mindy Lipsitz, MD Ultrasound FellowBrigham and Women’s HospitalBoston, MA   Edited and Posted by Jeffrey A. Holmes, MD ..read more
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   Here’s comes another heaping helping of ultrasound highlights from our winter symposium’s echo extravaganza! In this serving, Dr. Mindy Lipsitz, MD shares some pearls about the suprasternal notch view to assess for trauma, coarctation, aortic root regurgitation, and aortic aneurysm.  Mindy Lipsitz, MD Ultrasound FellowBrigham and Women’s HospitalBoston, MA   Edited and Posted by Jeffrey A. Holmes, MD ..read more
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   When you're intubating a patient, twiddling your thumbs, and waiting for your induction/paralytic meds to work, do you ever ask yourself "hmm, should I be bagging this patient?"In this podcast we talk about that very question and the new data from the PREVENT trial.Check out the Podcast by clicking here.Casey JD et al. Bag-Mask Ventilation during Tracheal Intubation of Critically Ill Adults. N Engl J Med 2019 Feb 28; 380 (9): 811-821. [Pubmed} ..read more
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   Here’s comes another heaping helping of ultrasound highlights from our winter symposium’s echo extravaganza! In this serving, Dr. Heidi Kimberly teaches us how to identify and characterize the 5 E’s of echocardiography: effusion, ejection fraction, equality of the right and left ventricle, exit (aortic root) and entrance (IVC).   Heidi Kimberly, MD Director of Emergency UltrasoundDepartment of Emergency MedicineBrigham and Women’s HospitalBoston, MA@sonocurious   Edited and Posted by Jeffrey A. Holmes, MD ..read more
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In this blog post we talk ear infections, or Acute Otitis Media (AOM) - a common disease commonly diagnosed... and probably commonly done ..read more
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Which central venous catheter (CVC) is best for our patients? Is it the internal jugular (IJ), subclavian, or femoral? We all have our go- ..read more
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  https://commons.wikimedia.org/wiki/File:Apical_4_chamber_view.png ..read more
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   We apologize that it has been so long since our last blog post . . . we were busy preparing for our annual Winter Symposium. What a fantastic year it was! It included an amazing point of care echocardiography extravaganza by the course’s ultrasound faculty. We covered core content, the 5 E’s of echocardiography, mastering the suprasternal notch, unlocking the apical four chamber view and tricuspid annular plane systolic excursion … phew! We are excited to roll out this content to you over the coming weeks, starting with Dr. Kring’s core content on point of care echocardiography.  Randy Kring, MD Ultrasound Fellow, Department of Emergency MedicineMaine Medical Center, Portland Maine  @EMRMK  ..read more
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    THE CASE A 25 year old female presents as a trauma activation after a motor vehicle accident. EMS reports the patient was the belted passenger of a motor vehicle which sustained a passenger side impact versus a tree at 25 mph. The airbags did not deploy, the patient did not lose consciousness, and she did not self extricate. Initial vitals were HR 100, BP of 126/80, RR 22, and SpO2 96% on room air. The patient is complaining of right arm pain and is noted to have a grossly deformed and open right distal forearm fracture. WHAT’S YOUR NEXT MOVE?In the chaos of the critical care bay you force yourself to march through ATLS. The patient’s primary survey is unremarkable - her airway is patent, breath sounds are equal bilaterally, she has strong femoral pulses and no external evidence of hemorrhage. Repeat vitals are HR 105, BP 130/74, RR 20, SpO2 97% on room air. GCS is 15. The secondary survey doesn’t give you any big surprises. You, of course, note the open right distal forearm fracture. The patient has a very minimal amount of diffuse abdominal tenderness with no external evidence of injury. The secondary survey is otherwise unremarkable. Concerned about the patient’s diffuse abdominal tenderness and tachycardia, you decide to do a FAST exam … What is the FAST exam?We know this ultrasound study well. The FAST exam, or Focused Assessment with Sonography in Trauma, is one of the most common applications of point of care ultrasound in the Emergency Department. The goal of the FAST exam is to detect free fluid in the abdomen, typically hemoperitoneum in the unstable trauma patient. The “extended” (E)-FAST exam also looks for pneumothorax, pleural effusion and pericardial fluid. The EFAST exam can quickly evaluate the unstable trauma patient and direct emergent management of hemoperitoneum, hemopericardium, hemothorax, and pneumothorax.[1]To evaluate for free intra-abdominal, pleural and pericardial fluid, the following views are obtained using the curvilinear probe. Free fluid characteristically has sharp edges and will dive between structures, as seen in the clips below.    Right Upper Quadrant Look for free fluid in Morison’s pouch between the liver and kidney, around the inferior liver tip, around the inferior pole of the kidney, and between the liver and the diaphragm. Then visualize the diaphragm and spine; the spine will be visible above the diaphragm only if pleural fluid is present.Right upper quadrant ultrasound with no free fluidRight Upper Quadrant Ultrasound with free fluid in the hepatorenal space Right upper quadrant ultrasound with pleural effusion visualized in the right chest and a positive “spine sign”Left Upper QuadrantLook for free fluid between the spleen and kidney, inferior aspect of the spleen, and between the spleen and the diaphragm. Then visualize the diaphragm and spine; the spine will be visible above the diaphragm only if pleural fluid is present.Left upper quadrant ultrasound with no free fluid visualizedLeft upper quadrant ultrasound with free fluid at the inferior aspect of the spleen extending into the splenorenal space SuprapubicLook for free fluid adjacent to the bladder. It is essential to fan through the entirety of the bladder in a transverse and longitudinal axis.Suprapubic ultrasound through the bladder in transverse orientation with no free fluid visualizedSuprapubic ultrasound through the bladder in longitudinal orientation with free fluid visualized deep to the bladderEvaluate for Pericardial EffusionSubxiphoid: The curvilinear probe is placed inferior to the xiphoid process, angled towards the patient’s left shoulder with the probe flattened to provide a view into the chest. The hyperechoic pericardium is visualized; pericardial effusion will appear as a hypoechoic line between the pericardium and the myocardium.Subxiphoid ultrasound of the heart with no pericardial effusion seenSubxiphoid ultrasound of the heart showing pericardial effusionParasternal: If a subxiphoid view does not provide an adequate view, a parasternal view can be obtained using the phased array probe. Place the probe just to the left of the sternum and slide up and down until you visualize the heart between the ribs.Parasternal long axis ultrasound of the heart with no pericardial effusion seenParasternal long axis ultrasound of the heart showing pericardial effusion To evaluate for pneumothorax, place the curvilinear or linear probe in a longitudinal orientation along the anterior chest wall. Visualize the pleura between rib shadows. Absence of pleural sliding--the “shimmering” or “ants marching” appearance - is characteristic of a pneumothorax.Curvilinear probe on the anterior chest with lung sliding seenLinear probe on the anterior chest with no lung sliding seen, characteristic of pneumothorax  BAck to the case . . . You quickly perform an EFAST on your patient, with the following images obtained below.Right Upper Quadrant Interpretation: No free fluid in the RUQ abdomen or chestLeft Upper Quadrant Interpretation: No free fluid in the chest… but what’s that next to the spleen? Suprapubic Interpretation: No free fluid in the pelvis; uterus is seen at the end of the clipParasternal Long Axis View of the Heart Interpretation: No pericardial effusion Right Anterior Chest Interpretation: No pneumothoraxLeft Anterior Chest Interpretation: No pneumothorax What’s the deal with that LUQ view? Is that a splenic laceration?There is a thick walled, heterogeneous filled structure in the anterior field of the LUQ view which does not persist with posterior fanning. This is characteristic of the stomach and its gastric contents - NOT a splenic laceration! Case ResolutionBased on the mechanism of injury, patient’s diffuse abdominal tenderness, and distracting injury, you ordered a CT scan of the patient’s chest, abdomen, and pelvis to assess for intrathoracic and intra-abdominal injury.  This revealed no evidence of acute traumatic injury in the chest, abdomen, or pelvis.  The stomach was, of course, visualized on CT with a similar appearance to what you saw on your bedside ultrasound:Left upper quadrant ultrasound with stomach and gastric contents visualized next to the spleen  CT of the abdomen and pelvis in coronal plane showing the stomach filled with gastric contents adjacent to the spleenanOther EFAST Fake-Out In addition to visualization of gastric contents in the LUQ, there is another common FAST exam finding that can be easily confused with a positive exam: the double line sign.The double line sign refers to the appearance of a perinephric fat pad (especially in the RUQ), which can easily be misinterpreted as free fluid in Morison’s pouch. Both perinephric fat and free fluid will appear as hypoechoic structures separating fascial planes. However, only a perinephric fat pad will have hyperechoic lines both superficial and deep to the hypoechoic structure - hence the double line sign. These double lines are fascial planes that are visible because of perinephric fat. The double line sign is present in at least 30% of normal exams. There doesn’t appear to be a correlation with BMI, although age does seem to increase the incidence.[2,3]In contrast, when free intraperitoneal fluid is present, only one echogenic line will be visible bounding the fluid. Pathologic free fluid does not highlight fascial planes, unlike perinephric fat.  Compare the two clips below: Right upper quadrant view of the FAST exam showing the double line sign, indicative of perinephric fat between the liver and kidneyRight upper quadrant view of the FAST exam with free fluid seen between the liver and the kidney; no double line sign is seen  This case demonstrates how tricky the EFAST exam can be. In the stressful situation of managing an acute trauma patient, take the time to obtain adequate views as described above. Remember that free fluid characteristically has sharp edges and will dive between structures; it does NOT have smooth edges and walls like physiologic structures (such as vasculature). Be aware of the double line sign and appearance of the stomach on ultrasound so that you don’t call false positives. Ultimately remember that the EFAST exam is a rule-in test, not a rule-out test - it can rule in free fluid and pneumothorax, but a negative EFAST exam doesn’t rule out injury. If you are concerned about an intrathoracic or intra-abdominal injury in a trauma patient in spite of a negative EFAST exam, proceed to comprehensive imaging with CT!Written by Evan Gill, MD & Randy Kring, MDEdited and Posted by Jeffrey A. Holmes, MDReferences:1. The American Institute For Ultrasound In Medicine. (2015). Focused Assessment With Sonography in Trauma (FAST) Examination. Retrieved from https://www.aium.org/resources/guidelines/fast.pdf2. Patwa, A.S. et al.Prevalence of the “Double-Line” Sign When Performing Focused Assessment With Sonography For Trauma Exams. Intern Emerg Med. 2015 Sep;10(6):721-4. [ ..read more
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   Prompt, safe, and effective pain management is a core competency of the emergency provider. Unfortunately, traditional strategies for administering analgesics for acute pain have shown poor success rates. In this podcast episode, Dr. Matthew Delaney shares a few evidence based pain management pearls you can use on your next shift.  THE TRADITIONAL APPROACH TO ADMINISTERING IV MORPHINE AND HYDROMORPHONE WORKS POORLYThe “text book” doses of morphine and hydromorphone underperform for pain control when given as a single dose. [1]   PROTOCOLS FOR THE TIMING AND DOSING OF IV MORPHINE AND HYDROMORPHONE CAN INCREASE YOUR SUCCESSCurrent re-dosing protocols for IV analgesics can be logistically challenging.[2]One simple protocol by Chang et al. asked the patient every 30 minutes if they needed additional doses of IV hydromorphone (up to 3 doses). This protocol provided adequate analgesia in 99% of cases.[3]  CHANG eT AL.  ORAL OVER THE COUNTER COMBINATIONS OUTPERFORM MOST OTHER ANALGESICSCombinations of acetaminophen and ibuprofen at varying doses provide superior pain relief to most commonly prescribed oral analgesics.[4,5] NUMBER NEEDED TO TREAT FOR >/= 50% REDUCTION IN PAIN mOORE ET AL  CONSIDER TOPICAL NSAIDS FOR PAIN CONTROLTopical NSAIDs combine the analgesic properties of oral NSAIDs with the placebo effect from the use of a lotion.This may be a good option for patients who report intolerance (or may be at higher risk of adverse effects) to oral NSAIDs.Patients experienced moderate rates of skin irritation but have essentially no GI or systemic adverse effects. [6,7] TOPICAL NSAIDs - NUMBER NEEDED TO TREAT FOR >/= 50% REDUCTION IN PAIN  The only topical NSAID available in the US is diclofenac sodium gel (Voltaren).A reasonable dosing strategy is to instruct the patient to apply an almond size amount of gel to the affected area 3 x daily.     . Edited and Posted by Jeffrey A. Holmes, MD Original content and authorship by Matthew Delaney, MDDr. Delaney has no disclosures or conflicts of interest.References1. Bijur PE, Kenny MK, Gallagher EJ. Intravenous morphine at 0.1 mg/kg is not effective for controlling severe acute pain in the majority of patients. Ann Emerg Med. 2005 Oct;46(4):362-7. PubMed PMID: 16187470. [Pubmed]2. Lvovschi V, Aubrun F, Bonnet P, Bouchara A, Bendahou M, Humbert B, Hausfater P, Riou B. Intravenous morphine titration to treat severe pain in the ED. Am J Emerg Med. 2008 Jul;26(6):676-82. doi: 10.1016/j.ajem.2007.10.025. PubMed PMID: 18606320.[Pubmed]3. Chang AK, Bijur PE, Holden L, Gallagher EJ. Efficacy of an Acute Pain Titration Protocol Driven by Patient Response to a Simple Query: Do You Want More Pain Medication? Ann Emerg Med. 2016 May;67(5):565-72. doi: 10.1016/j.annemergmed.2015.04.035. Epub 2015 Jun 11. PubMed PMID: 26074387.[Pubmed]4. Moore RA, Derry S, Aldington D, Wiffen PJ. Single dose oral analgesics for acute postoperative pain in adults - an overview of Cochrane reviews. Cochrane Database Syst Rev. 2015 Sep 28;(9):CD008659. doi: 10.1002/14651858.CD008659.pub3. Review. PubMed PMID: 26414123.[Pubmed]5. Moore RA, Wiffen PJ, Derry S, Maguire T, Roy YM, Tyrrell L. Non-prescription (OTC) oral analgesics for acute pain - an overview of Cochrane reviews. Cochrane Database Syst Rev. 2015 Nov 4;(11):CD010794. doi:10.1002/14651858.CD010794.pub2. Review. PubMed PMID: 26544675.[Pubmed]6. Tugwell PS, Wells GA, Shainhouse JZ. Equivalence study of a topical diclofenac solution (pennsaid) compared with oral diclofenac in symptomatic treatment of osteoarthritis of the knee: a randomized controlled trial. J Rheumatol. 2004 Oct;31(10):2002-12. PubMed PMID: 15468367.[Pubmed]7. Klinge SA, Sawyer GA. Effectiveness and safety of topical versus oral nonsteroidal anti-inflammatory drugs: a comprehensive review. Phys Sportsmed. 2013 May;41(2):64-74. doi: 10.3810/psm.2013.05.2016. Review. PubMed PMID: 23703519.[Pubmed] ..read more

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