Ultrasound in the ICU handout edition 1

Ultrasound in the ICU Doug Franzen, MD, M.Ed, FACEP Asst Professor, Associate Residency Director VCU Department of Emergency Medicine Objectives • Demonstrate how to perform and the potential findings of various limited bedside ultrasound studies that can be performed in the critical care setting • Get you more interested in incorporating ultrasound into your practice! You’ve Come a Long Way, Baby You’ve Come a Long Way, Baby Why Learn Ultrasound? Everybody’s doing it: • Providers of the near-future will be incorporating bedside ultrasound as part of an “extended physical exam” • Has been part of EM residency training since 1994; now required by ACGME • Medical Students are learning it as part of their exam • Even EMS providers are using ultrasound in the field! Why Learn Ultrasound? Outperforms our usual tests: • Better than a decubitus xray for pleural effusion! • Better than an AP xray for pneumothorax! • Better than your standard physical exam for a whole host of things – M1’s outperformed board-certified cardiologists “The students were significantly more accurate than the cardiologists in the recognition of LV dysfunction, valvular disease (96% vs 68%) and in the recognition of lesions that cause systolic or diastolic murmurs” Why Learn Ultrasound? • Improves safety & speed of procedures – In one study of proceduralists in a pulmonology group (i.e people who a LOT of thoracentesis), the pneumothorax rate dropped from 8.6% to 1.1% after they incorporated US – A metaanalysis showed that using US for placement of central lines led to decreases in: • Placement failure - by 64% • Complications - by 78% • Need for multiple attempts - by 40% • Randolph, Cook, Gonzales et al Ultrasound guideance for placement of central venous catheters: a metaanalysis of the literature Crit Care Med 1996; 24:2053-2058 Why Learn Ultrasound? “ [For placing central lines,] Ultrasound assistance was superior to landmark techniques Dynamic ultrasound outperformed static ultrasound but may require more training and personnel All central cannula placement should be conducted with ultrasound assistance.” (italics added) Milling TJ Jr, Rose J, et.al Randomized, controlled clinical trial of point-of-care limited ultrasonography assistance of central venous cannulation: the Third Sonography Outcomes Assessment Program (SOAP-3) Trial Crit Care Med 2005 Aug;33(8):1764-9 Evaluation of Resuscitation • Circulation – – – – – – Organized activity during cardiac arrest Pericardial Effusion / Tamponade Pulmonary Embolus (RV strain) (estimated) LVEF / Cardiac Output Aortic Root & Abdominal Aorta Volume status (IVC) • Airway – Endotracheal tube placement • Breathing – Pneumothorax – Pulmonary Edema – Pleural Effusion Endotracheal Tube Placement • There should only be air-filled structure in the neck if the tube is in the right place Good In the Goose Thoracic US • “Lung US scans carried out in the ED detect occult PTX and its extension with an accuracy that is almost as high as the reference standard (CT scanning).” – Chest 2008; 133:204-11 • Normal pleura creates “comet tail” artifacts (AKA Blines), and motion between the two layers of pleura can be seen as the patient breathes • In a pneumothorax, these normal findings are lost because air (which doesn’t play well with US) is between the two pleural layers Normal Pleural US Pneumothorax in M-mode Normal – the mixture of air and soft tissue in the lung below the pleura cause scatter of US, creating the “sand” of the seahore Pneumothorax – air between the two layers of pleura sets up a reverberation artifact, creating the “barcode sign” Pulmonary Edema Pleural Effusion Other Fun Stuff • Line Placement – Central Venous, Peripheral IV, arterial line • Other Procedures – Thoracentesis, Paracentesis, Suprapubic catheter – Confirm Pacer wire, foley placement • • • • • DVT evaluation Cholecystitis evaluation Intracranial Pressure (optic nerve sheath) (transcranial doppler / brain death !?) (Maxillary sinusitus !?) Are you sure you’re in? DVT Evaluation DVT evaluation Optic Nerve Sheath Diameter (ONSD) Optic Nerve Sheath • Optic Nerve sheath diameter has been shown to correlate with ICP – as ICP goes up, ONSD will go up • Problem is, the correlation is not the same from patient to patient • Some studies say >5mm is abnormal, some >7mm – A CVP >20 causes ONSD >7mm • J Trauma, Sep 2011 What questions you have? What about credentialling? AMA Resolution 802 – 1999 – “Ultrasound privileges based on criteria (that) are in accordance with recommended training and education standards developed by each physician’s respective specialty society.” Selected References • • • • • • • Beaulieu, Y and Marik, P Bedside Ultrasonography in the ICU, Part Chest 2005; 128:17661781 Melamed, R, Sprenkle, M, Ulstad, V et al Assessment of LV function by Intensivists Using Hand-Held Echocardiograph Chest 2009; 135:1416-1420 Gunst, M, Ghaemmaghami, V, Sperry, M et al Accuracy of Cardiac Function and Volume Status Estimates using Bedside Echocardiographic Assessment in Trauma/Critical Care J Trauma 2008; 65:509-516 Chou, H, Tseng, W, Wang, C, et al Tracheal rapid ultrasound exam (T.R.U.E.) for confirming endotracheal tube placement during emergency intubation Resuscitation 82 (2011) 1279– 1284 Litelpo A, Marill, K, Villen, T, et al Emergency Thoracic Ultrasound in the Differentiation of Shortness of Breath (ETUDES): Sonographic B-lines and Pro-BNP in Diagnosing CHF Acad Emerg Med 2009; 16:201-210 Burnside, P, Brown, M and Kline, J Systematic Rview of Emergency Physician-performed Ultrasonography for Lower-Extremity DVT Acad Emerg Med 2008; 15:493-498 Cammarata, G, Ristagno, G, et al Ocular Ultrasound to Detect Intracranial Hypertension in Trauma Patients J Trauma 2011, 71; 779-781 ... perform and the potential findings of various limited bedside ultrasound studies that can be performed in the critical care setting • Get you more interested in incorporating ultrasound into your... Endotracheal Tube Placement • There should only be air-filled structure in the neck if the tube is in the right place Good In the Goose Thoracic US • “Lung US scans carried out in the ED detect occult... Learn Ultrasound? Everybody’s doing it: • Providers of the near-future will be incorporating bedside ultrasound as part of an “extended physical exam” • Has been part of EM residency training since