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ED Ultrasound

ED Ultrasound. Rob Hall MD Oral Presentation PGY4 Emergency Medicine October 30 th , 2003. ED echo ( “ Eddie ” ) ED ultrasound . WHY SHOULD WE?.

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ED Ultrasound

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  1. ED Ultrasound Rob Hall MD Oral Presentation PGY4 Emergency Medicine October 30th, 2003

  2. ED echo (“Eddie”)ED ultrasound WHY SHOULD WE?

  3. Ultrasound imaging enhances the physician's ability to evaluate, diagnose, and treat emergency department (ED) patients. Because ultrasound imaging is often time-dependent in the acutely ill or injured patient, the emergency physician is in an ideal position to use this technology. Focused ultrasound examinations provide immediate information and can answer specific questions about the patient's physical condition. Such bedside ultrasound imaging is within the scope of practice of emergency physicians.

  4. CAEP Position Statement:Feb 1999 • Ultrasound should be available 24 hours per day for emergency patients, particularly for those being evaluated for cardac tamponade, abdominal aortic aneurysm, abdominal trauma, and ectopic pregnancy. A focused or limited bedside Emergency Department ultrasound should be available, performed by technicians, radiologists, or appropriately trained, qualified and experienced Emergency Physicians.

  5. Who is doing ED ultrasound in the USA? • Counselman. Acad Emerg Med 2000 • Mail out survery • 80% response rate • 95% of emergency medicine training programs teaching and using ultrasound • Accounting for response bias --------- 75% of programs • Conclusion: ED ultrasound is mainstay in US emerg programs

  6. Winnipeg Lethbridge Kelowna Lillooet Abbotsford Vancouver Victoria Nanaimo Fredericton Sacre’ Coeur Granby St-Paul Monmagny Montreal Ottawa Torondo Windsor Brampton Sarnia Kingston Parry Sound Huntsvile Sault Sainte Marie What do all these places have in common?

  7. What do all of these specialists have in common?

  8. Main objective: literature review of ED ultrasound Pregnancy AAA 4 Primary Indications Cardiac FAST

  9. Main objective: literature review of ED ultrasound Pregnancy AAA 4 Primary Indications Cardiac FAST

  10. Is there literature supporting ED ultrasound to detect AAAs? How much training is required be accurate? AAA: objectives

  11. AAA: general information • Ultrasound done by radiology is nearly 100% sensitive for the detection of AAA • Ultrasound measurements correlate with CT and laparotomy measurements w/I 2-3mm • Physical examination is unreliable: Lederle JAMA 1999 • 3.0-3.9cm 29% sensitivity • 4.0-4.9cm 50% sensitivity • > 5.0cm 75% sensitivity

  12. AAA: 6 prospective studies

  13. AAA: 6 prospective studies

  14. AAA • Jones. Emergency Medicine 2003. • Prospective • N=66 scans for AAA • Initial training was an 8 hour course covering four primary indications • Gold standard = CT or laparotomy • Results • Sensitivity 98% (86-100) • Specificity 100% (87-100) • Accuracy 99% (90-100)

  15. AAA • Khun. Ann Emerg Med 2000 • Prospective, N=68 • Training was 3 days (2hrs for AAA) • Gold standard = radiologist review of video • Results • Sensitivity 100% (87-100) • Specificity 100% (91-100) • Accuracy 100% (no CI)

  16. AAA: conclusions • Emergency Physicians can achieve accuracy in detection of AAAs with limited training • Our scans should aim to be 95% accurate

  17. Main objective: literature review of ED ultrasound Pregnancy AAA 4 Primary Indications Cardiac FAST

  18. Can ED ultrasound be used to predict survival post cardiac arrest? Is there literature supporting ED ultrasound for the detection of pericardial effusions? LV function? Cardiac: objectives

  19. Blaivas Acad Emerg Med 2001 Prospective, N=166 Cardiac standstill 0/136 survival Cardiac activity 20/33 survival Salen Acad Emerg Med 2001 Prospective, N=102 Standstill: 2/61 survival Cardiac activity: 11/41 survival ETC02 production was a better predictor Cardiac arrest and ED ultrasound

  20. Cardiac: conclusions • There is insufficient evidence to prove that cardiac standstill is a reliable indicator of cardiac arrest survival • Cardiac standstill should be considered in the decision to terminate resuscitation but should not be the sole criterion

  21. Moore. Acad Emerg Med 2002 Looked at atraumatic hypotensive patients Prospective, N=51, cardiology as gold standard Ratings: normal (1), mod depressed (2), severely depressed (3) Kappa 0.61 (0.39-0.83) EP ratings Cardiologist ratings Cardiac: LV function

  22. Cardiac: pericardial effusions

  23. Cardiac: pericardial effusions

  24. Cardiac: pericardial effusions • Mandavia. Ann Emerg Med 2001 • Prospective study, N=515 • Training = 16hrs, 5hrs dedicated to echo • Gold standard = blinded cardiologist interpretation • All scans were clinically indicated • Results: • Technically adequate in 93% • Sensitivity 96% (90-99) • Specificity 98% (96-99) • Accuracy 97.5% (95-99)

  25. Cardiac: conclusions • Emergency Physicians can achieve accuracy in detection of pericardial effusion with limited training • Our scans should aim to be 95% accurate • Determination of LV function requires further study

  26. Main objective: literature review of ED ultrasound Pregnancy AAA 4 Primary Indications Cardiac FAST

  27. How does ED ultrasound affect patient satisfaction? How does ED ultrasound affect ED flow? Is there literature supporting the accuracy of ED ultrasound in pregnancy? Pregnancy: objectives

  28. Pregnancy: patient satisfaction • Krubel. Am J Emerg Med . 1998 • Prospective; ½ got ED ultrasound • Survey of 96 ED visits • Showed • Improved overall satisfaction with ED care • Improved satisfaction with tests performed • Reduced desire for a second opinion • Reduced anxiety after the ED visit

  29. Pregnancy: ED flow • Remember the chart review we did last year: pregnancy related u/s • Document IUP was found in 72% of initial ultrasounds • ED ultrasound would likely be useful in 72% of patients

  30. Pregnancy: ED flow • Rogerson. Acad Emerg Med • ED RUQ ultrasound is associated with a reduced time to diagnosis and treatment of rupture ectopic pregnancies • Retrospective review • Time ED u/s Radiology u/s • To Dx 58 min (28-87) 197 (162-232) • To OR 111 min (69-153) 322 (270-364)

  31. Pregnancy: ED flow • Blaivas. Acad Emerg Med 2000 • Do emergency physicians save time when locating a live IUP with bedside ultrasound? • Retrospective review of 1419 charts • Length of stays • ED ultrasound 3hr 40min • Rad ultrasound 4hr 39min • Absolute diff 59 min, p=0.0001

  32. Pregnancy: ED flow • Burgher. Acad Emerg Med 1998 • Before and after ED u/s introduction study • Mean L.O.S. before: 234 min • Mean L.O.S. after: 164 min • Difference 70 min, p=0.0003 • Shih. Ann Emerg Med • Prospective; L.O.S. decreased when ultrasound showed an IUP • ED ultrasound: mean L.O.S. 45 min • Radiology ultrasound: mean L.O.S. 177min

  33. Pregnancy: conclusions • ED ultrasound can improve ED flow • ED ultrasound can improve patient satisfaction

  34. Pregnancy: detecting an IUP • How accurate can ER docs be after minimal training? • Is it safe?

  35. Studies look at sensitivity and specificity of detecting an IUP not an ectopic Specificity is therefore more important! Pregnancy: detecting and IUP

  36. Pregnancy: 6 prospective studies

  37. Pregnancy: 6 prospective studies

  38. Pregnancy: detecting an IUP • Shih. Ann Emerg Med 1997 • Prospective, N=125 • Training: 24hrs + 10 proctored exams • Gold standard was formal ultrasound • Some were transvag some transabd • Results • Sensitivity for IUP: 94% (C.I. 82-98%) • Specificity for IUP: 100% (C.I. 83-100)

  39. Pregnancy: detecting an IUP • Durham. Ann Emerg Med 1997 • Prospective, N=136 • Training: 24hrs + 20 proctored exams (variable) • Gold standard: formal ultrasound • Pre-defined possible ultrasound results and correlated ER interpretation vs formal ultrasound result • Results showed overall 97% accurracy (91-97% C.I.)

  40. Pregnancy: detecting an IUP:Durham. Ann Emerg Med 1997

  41. Pregnancy: detecting an IUP • Mateer. Acad Emerg Med • Prospective, N=152 • Training: 12hrs + 12 proctored exams • Gold standard: interpretation by gyne • Also looked at results compared to final outcome • ER interpretation versus gyne interpretation • Correct 94% • Incorrect 4.7% • Inadequate 1.4%

  42. Pregnancy: conclusions • Emergency physicians can accurately detect Intra-uterine pregnancy • Our scans should aim to be 95% accurate • Specificity for IUP needs to be 100% • If you’re not sure it’s an IUP, call it a “NO definitive IUP” and get a formal ultrasound

  43. Main objective: literature review of ED ultrasound Pregnancy AAA 4 Primary Indications Cardiac FAST

  44. What is the learning curve for FAST? Can surgeons use FAST accurately? Can emergency physicians use FAST accurately? FAST: objectives

  45. FAST: general comments • Sensitivity is very dependant on the gold standard • FAST done by RADIOLOGISTS • Laparotomy as gold standard • Sensitivties 93-97% • Specificities 99-100% • CT as gold standard • Sensitivity 89% • Specificity 99%

  46. FAST: variable sensitivity • Melanson. Emerg Med Clinics 1998 • Reviewed 30+ studies • Summarized studies with > 250 scans • Sensitivities ranged from 70-99% • Specificities ranged from 95-99%

  47. FAST: variable sensitivity • Branney. J. Trauma. 1995 • Used CAPD patients and looked at sensitivity with various volumes of dialysate • FAST sensitivity clearly varies with volume of intraperitoneal fluid

  48. FAST: learning curves • Gracias. American Surgeon: showed correlation of sensitivity with experience • Minimal (<30exams): sensitivity 59% • Moderate (30-100): sensitivity 88% • Extensive (>100): sensitivity 100% • Shackford. J Trauma. 1999 • Prospective, N=241 • Surgeons with 8hr training and 10 supervised exams • Gold standard problems

  49. FAST learning curves: Shackford 1999Error rates

  50. FAST: surgeons • Rozycki. J Trauma • Prospective, N=476 • 32hour training (some had more) • Gold standard problems: CT, lap, DPL, or serial exams!!!! • Sensitivity 79%, Specificity 96%, Accuracy 92% • Compared to radiology review of still images • Accuracy 90%, 5% technically inadequate

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