Hemodynamically unstable, sick patient have high mortality and morbidity. Their physical exam findings can be misleading and the diagnosis still broad or unclear even after examination. When time counts and your patient is sick, bedside ultrasound can quickly make the diagnosis to help you provide appropriate and definitive care when it matters most. This is the basis for the SonoSave series, which examines ultrasound saves and the critically ill patients alive today because of point of care ultrasound.
Intro
Ultrasound is a lifesaver and luckily for a recent patient I mean this literally. Thanks to the early use of ultrasound a life was saved that would have been lost. A critical diagnosis was made within 5 minutes of arrival, preventing investment of precious time in ineffective treatments or delaying definitive care and making me look real slick in the process. The patient was successfully treated and admitted to the ICU. When I walk into work the next day, I find out the patient is not only alive but sitting up in bed talking to the team! With some simple ultrasound views and less than 2 minutes, the direction of our treatment completely changed and a man lived to see his family that I doubt would have otherwise. Two minutes to save a life… that’s some good stuff and even better ultrasound! These are the moments that make medicine worth it.
There are a few cases I could talk about… Ultrasound guided LPs have turned out to be a surprisingly useful skill. Lucky for you, I’ve restrained myself.
The first time I heard about ultrasound guided LPs was during a spectacular yearlong ultrasound elective in medical school. I was sitting in the doctor’s pod with THE ultrasound attending of ultrasound attendings. He casually asked “Have you ever heard of ultrasound guided LPs?” Never. “Do you want to see one?” Obviously. He explained how ultrasound guided LPs follow the principle of “Measure twice. Cut once.” He spent a minute (and I mean literally just one minute) visualizing the spinal landmarks and marking them on a somewhat altered, seriously chunky patient. He proceeded to get the LP in one stick! I remember thinking he was a wizard in that moment, a wizard who uses ultrasound to elevate patient care to another level; and that I want to be the badass attending that gets LPs on obese, altered patients in one stick. I had to learn this skill… Continue reading Getting to the Point of Ultrasound Assisted Lumbar Punctures→
The latest SonoMojo ultrasound cheat sheet has arrived! The Soft Tissue Ultrasound Cheat Sheet is a brief review of soft tissue ultrasound and it’s applications. Use it to quickly review the essentials before performing a scan or as an overview of soft tissue ultrasound before diving into the Soft Tissue Ultrasound Module.
In case you haven’t heard of “Ultrasound Cheat Sheets”… they’re all the basic info you need to review before performing (or teaching) a specific ultrasound scan. They are 1-2 pages long and consist of an brief check list of information on the application, image acquisition, and interpretation of a scan.
That’s right! The Life in The eFAST Lane series is back!Last time we reviewed eFAST basics and half of the eFAST technique. Hopefully you’ve been practicing the heart, RUQ, and LUQ scans like my friend below. So without further adieu…. I give you eFAST Part Deux!
Figure 1 – An eFAST Rockstar in Action
Figure 1 – An eFAST Rockstar in Action
How to Do I Perform an eFAST? (Continued from Part 1)
Pelvis
Probe position
Probe marker towards patient’s head (longitudinal view) or towards patient’s right (transverse view).
Place the probe just above the pubic symphysis and look for the bladder in men and both the bladder and uterus in women.
If it’s not awkward, it’s not right and you’re not low enough.
Once you’ve completed the longitudinal view, turn your probe 90° for the transverse view. Both views should be evaluated to avoid false positives.
This is the first of a three part series reviewing the eFAST scan in detail. The goal of this series is to aid new ultrasound users to perform their first eFAST scan correctly and improve existing sonographer’s understanding of the eFAST.
The Case
There are just too many eFAST cases to choose from. Which one to tell you…? Should I talk about my first eFAST patient, the supposed-to-be-simple-but-really-wasn’t, coumadin guy who laid out his motorcycle? What about the lady from the rollover down a twenty foot embankment? Or the teenager from a horseback riding accident? Should I tell you about the night I hung out in resuscitation and did an eFAST on every patient that came through? A December night in medical school I like to think of as Ultrasound Christmas. A night when a trauma alert rolled in and before I knew what was happening, the resident put the ultrasound probe in my hand and said “Go for it!” Needless to say it was AWESOME! Like do-a-secret-happy-dance-in-the-hallway-afterwards kind of awesome. I definitely loved my ultrasound elective, especially once I became competent at eFASTs. So what’s an eFAST you ask? It’s simple really. It’s a systematic ultrasound scan to check for pneumothorax and free fluid (usually blood) in the abdomen and chest. It’s quick, easy, and incredibly useful. You don’t have to be a genius for this stuff. My first year med students can do this and so can you! If you’re going to spend time in the Emergency Department or with critically ill patients, you should learn the eFAST. End of story. So now that you’re convinced… just how do you do an eFAST?
A new SonoMojo Ultrasound Cheat Sheet is here! The DVT cheat sheet is a brief review of DVT bedside ultrasound. You can use it for a quick review of the essentials before performing a scan or an overview of the key points before diving into learning DVT ultrasound.
In case you don’t know what an Ultrasound Cheat Sheet is…. they’re all the basic info you need to review before performing (or teaching) a specific ultrasound scan. They are 1-2 pages long and consist of an brief check list of information on the application, image acquisition, and interpretation of a scan.
So be sure check out the newest installment of Ultrasound Cheat Sheets, DVT ultrasound, on the Ultrasound Cheat Sheets page!
There’s a new SonoMojo Ultrasound Cheat Sheet! The eFAST Ultrasound Cheat Sheet is here! In case you don’t know what an ultrasound cheat sheet is…
Ultrasound cheat sheets are all the basic info you need to review before performing (or teaching) a specific ultrasound scan. They are 1-2 pages long and consisting of an brief check list of information on the application, image acquisition, and interpretation of a scan.
Generally, I like to write about positive ultrasound cases. This is not one of those cases. But out of this sad case there was much learning to be had for this med student. At the time of the case, I was on an emergency ultrasound elective. And I couldn’t have be happier! I was learning all sorts of awesome and useful skills. Another perk of being on ultrasound duty was that I got to tag along on all the ultrasound cases I can get my hands on, including the traumas (a big perk in my book). As soon as I heard a trauma called in, I gowned up, gloved up, goggled up, and masked up. I observed the FAST exam (Focused Abdominal Scan for Trauma) and helped however I was instructed. Mostly squeezing IV bags or fetching things, but I was in there; I had a job; and I was learning ultrasound awesomeness. Life was good…. like really, really good. Until it wasn’t. Enter a teenager in an ATV accident. One paramedic cranks out compressions, while the other relays patient information. Car versus ATV. Trouble intubating. And he’s asystolic. Huge bummer. This is not going to be fun and someone somewhere is going to be very sad tonight. Everyone is hustling. I stand at the foot of the bed squeezing fluids into the kid while lines are placed, drugs are pushed, and they figure out what’s wrong. I watch the FAST exam. Looks negative to me, so no visible blood in the pelvis, abdomen, or around the heart. Unfortunately the ultrasound’s heart view also shows no heart movement. There is no electrical activity on the ECG. He’s been down for a long time. Time of death is called. Everyone puts down what they were doing and steps away. I feel heavy. After the room has cleared, the ultrasound attending pulls the ultrasound up to the bedside. There is a valuable teaching opportunity here. He does another FAST exam, explaining it as he goes. Still no free fluid in the pelvis, abdomen, or pericardium. He puts the probe on his chest. No signs of pneumo or hemothorax. This is weird; an ATV versus car with no major bleeding from the neck down. I’m supposed to be learning what an ultrasound exam looks like on a trauma patient, but so far it all looks pretty normal. That’s odd… so what killed this kid? The ultrasound attending agrees it’s unusual and wants to check one more thing. Here’s where things get interesting. The only visible trauma is from the neck up; some bleeding from the ears, eyes, and an open scalp lac. With no helmet that really isn’t a surprise. What is a surprise is the ultrasound attending putting the ultrasound probe on his eye. What are we suppose to tell from this..? Intracranial pressure. Mind blow. Now I’m pretty sure the ultrasound attending is a wizard. On the screen, we see a normal globe with a huge optic nerve and sheath exiting. Before he even measures it, he can tell it’s too big. He measures it and confirms ICP is elevated. So how’d he do this?
Measuring Intracranial Pressure Using Ocular Ultrasound
In a Nutshell
If you suspect elevated intracranial pressure (ICP), ocular ultrasound is a fast and easy method to detect it.
You can measure the optic nerve sheath diameter (ONSD) using ultrasound.ONSD > 5 mm may indicate an ICP > 20 mmHg, especially in symptomatic patients.
Not everyone with ONSD > 5 mm has elevated ICP.
ONSD > 5.7 mm indicates an ICP > 20 mmHg.
All patients with ONSD > 5.7 mm have elevated ICP.
Calling all med students (and their awesome ultrasound faculty mentors)! Are you interested in bedside ultrasound? Do you wish you could have more ultrasound education? Do you want to make a difference and bring ultrasound education to your medical school? Do you wish you could do something to influence ultrasound curriculum integration? If you answered yes to any of these question, you’re a perfect candidate to start your own Ultrasound Interest Group (USIG)!
Seriously, you can use a USIG to accomplish all kinds of awesome things at your medical school, like organizing regular ultrasound education, introducing other medical students to bedside ultrasound, creating an ultrasound community among students and faculty, and using USIG generated student interest in ultrasound to promote ultrasound curriculum integration. It’s not hard and other students, just like you, have founded and run their own USIGs! To make it even easier SonoMojo has put together a USIG Toolbox with all the info you need to start and run your own USIG. It’s got a ton of useful resources, so check it out!
If you’re interested in starting a USIG at your school, please contact us (sonomojoUS@gmail.com). We’re here to help and we’ll get you connected with other students who’ve started their own USIG too! Happy ultrasounding everyone!
