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PRACTICAL GUIDE TO EMERGENCY ULTRASOUND Second Edition Karen S Cosby, MD, FACEP Director, Emergency Ultrasound Fellowship Senior Attending Physician Department of Emergency Medicine Cook County Hospital (Stroger) Associate Professor Rush Medical College Chicago, Illinois John L Kendall, MD, FACEP Director, Emergency Ultrasound Denver Health Medical Center Associate Professor Department of Emergency Medicine University of Colorado School of Medicine Denver, Colorado Executive Editor: Rebecca S Gaertner Product Manager: Ashley Fischer Vendor Manager: Bridgett Dougherty Manufacturing Manager: Beth Welsh Marketing Manager: Lisa Lawrence Design Coordinator: Teresa Mallon Production Service: S4Carlisle Publishing Services © 2014 by LIPPINCOTT WILLIAMS & WILKINS, a WOLTERS KLUWER business Two Commerce Square 2001 Market Street Philadelphia, PA 19103 USA LWW.com All rights reserved This book is protected by copyright No part of this book may be reproduced in any form by any means, including photocopying, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews Materials appearing in this book prepared by individuals as part of their official duties as U.S government employees are not covered by the abovementioned copyright Printed in China Library of Congress Cataloging-in-Publication Data Practical guide to emergency ultrasound / editors, Karen S Cosby, John L Kendall.—2nd ed    p ; cm   Includes bibliographical references and index   ISBN 978-1-4511-7555-4 (alk paper)   I.  Cosby, Karen S.  II.  Kendall, John L   [DNLM: 1.  Ultrasonography—methods.  2.  Emergencies WN 208]  RC78.7.U4  616.07'543—dc23 2013012308 Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication Application of the information in a particular situation remains the professional responsibility of the practitioner The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accordance with current recommendations and practice at the time of publication However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions This is particularly important when the recommended agent is a new or infrequently employed drug Some drugs and medical devices presented in the publication have Food and Drug Administration (FDA) clearance for limited use in restricted research settings It is the responsibility of the health care provider to ascertain the FDA status of each drug or device planned for use in their clinical practice To purchase additional copies of this book, call our customer service department at (800) 638-3030 or fax orders to (301) 223-2320 International customers should call (301)223-2300 Visit Lippincott Williams & Wilkins on the Internet: at LWW.com Lippincott Williams & Wilkins customer service representatives are available from 8:30 am to pm, EST 10 To our families Whose patience and tolerance make everything possible To our contributors Who have given us countless hours and valuable expertise To our students, residents, and fellows Who test our ideas and sharpen our skills To our patients Who hopefully benefit from all our labor Contributors Srikar Adhikari, MD, MS, RDMS Associate Professor Department of Emergency Medicine University of Arizona Medical Center Tucson, AZ Eric J Adkins, MD, MSc Lead Administrative Physician Director of Emergency Medicine Critical Care Assistant Professor of Emergency Medicine & Internal Medicine Department of Emergency Medicine Department of Internal Medicine Division of Pulmonary, Allergy, ­Critical Care & Sleep Medicine Wexner Medical Center at The Ohio State University Columbus, OH David P Bahner, MD, RDMS Associate Professor Director of Ultrasound Founder Ultrasound Academy Department of Emergency Medicine The Ohio State University Medical Center Columbus, OH Caitlin Bailey, MD Emergency Medicine Alameda County Medical Center Oakland, CA John Bailitz, MD, FACEP, RDMS Emergency US Director Department of Emergency Medicine Cook County Hospital (Stroger) Chicago, IL Aaron E Bair, MD, MSc Associate Professor Emergency Medicine Medical Director, Center for Health and Technology Medical Director, Center for Virtual Care University of California Davis Health System Sacramento, California Gregory R Bell, MD Assistant Clinical Professor Director of Emergency Ultrasound University of Iowa Hospital Iowa City, IA Michael Blaivas, MD Professor of Medicine University of South Carolina School of Medicine Columbia, SC Keith P Cross, MD, MS, MSc Assistant Professor of Pediatrics Department of Pediatrics University of Louisville Kosair Children’s Hospital Louisville, KY Anthony J Dean, MD Associate Professor of Emergency Medicine Associate Professor of Emergency Medicine in Radiology Director, Division of Emergency Ultrasonography Department of Emergency Medicine University of Pennsylvania Medical Center Philadelphia, PA Joy English, MD University of Utah Visiting Instructor Department of Surgery, Division of Emergency Medicine Fellow, Primary Care Sports Medicine Salt Lake City, UT Ashraf Fayad, MBBCh, FRCPC, FACC, FASE Associate Professor Director, Perioperative Echocardiography for Non-cardiac Surgery The Ottawa Hospital Department of Anesthesiology University of Ottawa Ottawa, ON Matthew Flannigan, DO, FACEP Assistant Ultrasound Program Director Department of Emergency Medicine Michigan State University-Grand Rapids Spectrum Health Hospital System Grand Rapids, MI J Christian Fox, MD, RDMS, FACEP, FAAEM, FAIUM Professor of Clinical Emergency Medicine Department of Emergency Medicine University of California Irvine, CA Bradley W Frazee, MD Department of Emergency Medicine Alameda County Medical Center – Highland Hospital Oakland, CA Clinical Professor of Emergency Medicine University of California San Francisco San Francisco, CA Andrew J French, MD Associate Director, Emergency Ultrasound Department of Emergency Medicine Denver Health Medical Center Assistant Professor University of Colorado School of Medicine Denver, CO v vi   Contributors Richard Gordon, MD Ultrasound Fellow, Emergency Medicine Georgia Health Sciences University Augusta, GA John Gullett, MD Assistant Professor Co-Director of Emergency Ultrasound Department of Emergency Medicine University of Alabama at Birmingham Birmingham, AL Michael Heller, MD Professor of Clinical Emergency Medicine Albert Einstein School of Medicine Director Emergency Ultrasound Beth Israel Medical Center New York, NY Stephen R Hoffenberg, MD, FACEP President, CarePoint Medical Group Attending Emergency Physician Rose Medical Center Denver, CO Russ Horowitz, MD, RDMS Director Emergency Ultrasound Emergency Department Ann & Robert H Lurie Children’s Hospital of Chicago Assistant Professor, Northwestern University Feinberg School of Medicine Chicago, IL Calvin Huang, MD, MPH Ultrasound Fellow Department of Emergency Medicine Massachusetts General Hospital Boston, MA Nicole Danielle Hurst, MD Emergency Physician and Emergency Ultrasound Fellow Denver Health Denver, CO Jeanne Jacoby, MD Vice Chair Emergency Department, Pocono Medical Center East Stroudsburg, PA Timothy Jang, MD Associate Professor of Clinical Medicine Director of Emergency Ultrasonography Harbor-UCLA Medical Center David Geffen School of Medicine at UCLA Los Angeles, CA Medical College of Georgia Georgia Regents University Augusta, GA Dietrich Jehle, MD, ACEP, RDMS Director of Emergency ­Ultrasonography and Professor of Emergency Medicine SUNY Buffalo, School of Medicine Associate Medical Director Erie County Medical Center Buffalo, NY Daniel Mantuani, MD/MPH Ultrasound Fellow Department of Emergency Medicine Alameda County Medical Center Oakland, CA Ken Kelley, MD Assistant Professor Fellowship Director, Emergency Ultrasound Department of Emergency Medicine University of California Davis Sacramento, CA R Starr Knight, MD Emergency Ultrasound Fellow Department of Emergency Medicine University of California, San Francisco San Francisco, CA Brooks T Laselle, MD, FACEP Fellowship Director, Emergency Ultrasound Ultrasound Director, Emergency Medicine Residency Department of Emergency Medicine Madigan Army Medical Center Tacoma, WA Clinical Instructor, U of Washington School of Medicine, Seattle, WA Stephen J Leech, MD, RDMS Ultrasound Director, Graduate Medical Education Orlando Health, Orlando FL Assistant Clinical Professor, University of Central Florida College of Medicine Andrew S Liteplo, MD, RDMS Emergency Ultrasound Fellowship Director, Department of Emergency Medicine Massachusetts General Hospital Boston, MA Matthew Lyon, MD, FACEP Professor Vice Chairman for Academic Programs Director, Section of Emergency and Clinical Ultrasound Department of Emergency Medicine David J McLario, DO, MS, FACEP, FAAP Department of Pediatrics University of Louisville Louisville, KY Jacob C Miss, MD Resident Physician Department of Emergency Medicine University of California, San Francisco and San Francisco General Hospital San Francisco, CA Matthew A Monson, DO Assistant Professor of Radiology University of Colorado School of Medicine Denver Health Medical Center Denver, CO Children’s Hospital Colorado Aurora, CO Christopher L Moore, MD, RDMS, RDCS Associate Professor Department of Emergency Medicine Yale University School of Medicine New Haven, CT Arun Nagdev, MD Director, Emergency Ultrasound Alameda County Medical Center Highland General Hospital Clinical Assistant Professor University of California San Francisco School of Medicine San Francisco, CA Bret P Nelson, MD, RDMS, FACEP Director, Emergency Ultrasound Associate Professor of Emergency Medicine Department of Emergency Medicine Mount Sinai School of Medicine New York, NY Vicki E Noble, MD Director, Division of Emergency Ultrasound Massachusetts General Hospital Contributors   vii Associate Professor Harvard Medical School Boston, MA David C Pigott, MD, RDMS, FACEP Co-Director of Emergency Ultrasound Associate Professor and Vice Chair for Academic Development Department of Emergency Medicine The University of Alabama at Birmingham Birmingham, AL John S Rose, MD, FACEP Professor, Department of Emergency Medicine University of California, Davis Health System Sacramento, CA Sachita P Shah, MD, RDMS Assistant Professor, University of Washington School of Medicine Division of Emergency Medicine Harborview Medical Center Seattle, WA Paul R Sierzenski, MD, RDMS, FACEP, FAAEM Director, Emergency, Trauma and Critical Care Ultrasound Assoc Dir, Emergency Medicine Ultrasound Fellowship Christiana Care Health Center Newark, DE Michael B Stone, MD, FACEP Chief, Division of Emergency Ultrasound Department of Emergency Medicine Brigham & Women’s Hospital Boston, MA Richard Andrew Taylor, MD Clinical Instructor, Department of Emergency Medicine Yale University School of Medicine New Haven, CT Amanda Greene Toney, MD Assistant Professor, Department of Pediatrics Section of Emergency Medicine University of Colorado Denver Aurora, CO Negean Vandordaklou, MD Clinical Instructor/Fellow of ­Emergency Ultrasound Emergency Department University of California Irvine ­Medical Center Orange, CA Ralph C Wang, MD, RDMS Assistant Professor Director of Emergency Ultrasound Fellowship Department of Emergency Medicine University of California, San Francisco San Francisco, CA Juliana Wilson, DO Ultrasound Fellow, University of Buffalo Emergency Medicine Residency Erie County Medical Center Buffalo, NY Michael Y Woo, MD, CCFP (EM), RDMS Associate Professor Director and Fellowship Director Emergency Medicine Ultrasonography Department of Emergency Medicine University of Ottawa and The Ottawa Hospital Ottawa, ON Preface Emergency ultrasound has expanded well beyond most expectations of even a decade ago This text too has changed in significant ways The scope of the book is unapologetically expansive We are well aware of the need for innovation to keep pace with the rapid rate of change in medical knowledge and technology Our goal is to make as much information as possible accessible to the reader As ultrasound finds its way into undergraduate education, and as it spreads to other medical disciplines, we believe the potential for ultrasound will only continue to grow This book differs from many in our approach to scanning Rather than present only a traditional region- or organ-specific approach, we have added sections with a problem/symptombased approach The opening section on “Resuscitation of Acute Injury or I­ llness” describes use of ultrasound in solving clinical questions to r­esuscitate patients with shock or acute dyspnea In addition, we present material in the manner in which we understand ultrasound is used; thus, content on procedural assistance is placed adjacent to sections on related diagnosis Increasingly, we find that as ultrasound is incorporated into the physical exam, one application melds into another At first, a diagnosis is considered, possibly excluded, then another one entertained Therapeutic interventions are made (possibly with ultrasound assistance), and then the patient reassessed (again with u­ ltrasound) Thus, ultrasound becomes an integral tool for the dynamic process of diagnosis, treatment, and reassessment In order to make the content relevant for both adults and children, we have added special highlighted inserts (“Pediatric Considerations”) for helpful guidance to modify technique or improve interpretation and use of ultrasound for children when content differs from adults This revised edition adds video clips that display more realistic three-dimensional views of anatomy We have ­increased the number and variety of images that are included in the electronic version of the book The result is a rich ­resource with a library of images to learn from In an increasingly digital era, many readers might question if textbooks are even necessary Our answer rests with this book In one place we have condensed expertise across emergency ultrasound, complete with photos, images, and videos that demonstrate a wide range of pathology We have focused on technique and recognition of images without ­repeating content on pathophysiology that can be gained from general medical sources Point of care ultrasound can improve the ability to make rapid decisions and optimize care in many settings ranging from the high-tech environment of critical care to the frontline of disaster relief in third world countries By arming the bedside clinician with rapid access to information, we believe ultrasound improves both quality and safety for patients in situations where either time or resources are limited Even in routine situations, ultrasound can augment the physical exam and help decisions about diagnosis and care to be made earlier and with greater certainty The ability to take advantage of ultrasound technology has changed the nature of frontline medicine We are thrilled to participate in spreading this skill to clinicians Karen S Cosby, MD John L Kendall, MD ix 438   Section X / Implementing Ultrasound into the Clinical Setting to which it will be exposed in the developing world, machine maintenance programs and plans should be negotiated up front when considering machine purchase or acceptance of a donation for use in a low-resource, remote setting Consider requesting loaner ultrasound machines if long delays are expected during transport and repair of ultrasound equipment Quality Assurance To ensure the safety and success of any global health intervention, including ultrasound, quality assurance and monitoring is essential This can be achieved by remote image review by an ultrasound expert, with most images undergoing quality reviews initially, and then over time when high quality is the norm, selected images may be sent for review Prompt and easily accessible feedback on how to integrate ultrasound into the clinical patient care plan or difficult-tointerpret images allows local providers using ultrasound to have a greater impact on patient outcomes Scheduled ultrasound refresher trainings are very useful, especially if there is staff turnover CASES FROM THE FIELD While an exhaustive review of each indication for bedside ultrasound in low-resource settings would fill an entire textbook on its own, we review here some key conditions and their ultrasound findings that are common in developing countries but uncommon in other areas and are not covered elsewhere in the text The top disease-related mortality in the developing world is commonly known to be related to infectious diseases, maternal mortality, and dehydration/malnutrition for children