point-of-care ultrasound · • sigel b. a brief history of doppler ultrasound in the diagnosis of...
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Point-of-Care Ultrasound
James H. Moak, MD, RDMS
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History of Ultrasound
Early use of ultrasound focused on therapy
Treatment of gastric ulcers (left) and arthritis (right) in the 1940s.
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History of Ultrasound
• Karl Dussik, 1946
– University of Vienna in
Austria
– Cerebral ventricles
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History of Ultrasound
• Diagnostic ultrasound
– George Ludwig, 1940s
– Classified experiments
with the Navy
– Gall stones
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A-mode
• A-mode ultrasound
• A = amplitude
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History of Ultrasound
• Howry’s somascope
• 2-D images called
“somagrams”
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B-mode
• B-mode ultrasound
• B = brightness
• Intensity of echoes in
grey scale
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M-mode
• Early echocardiogram
– 1953 Edler & Hertz
• M = Motion
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D-mode
• D = Doppler
• Satomura, 1956
– freq returning echoes
≈ velocity of flow
• Moving RBCs create
a Doppler shift
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History of Ultrasound
• 1960s – Commercial machines available
• 1970s – Grey scale becomes common
• 1980s – Use in trauma in Europe & Japan
• 1990s – Introduced into EM curriculum
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Emergency Medicine
Mateer J et al. 1994
• Goal-oriented
• Core applications
– Trauma (FAST)
– Renal
– Cardiac
– Biliary (RUQ)
– Aorta
– Early pregnancy
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Additional applications
• Diagnostic
– DVT
– Soft tissue (abscess)
– Ocular
– Testicular
– Long bone fractures
– Lung (thoracic)
– Joint effusions
– Bladder volume
– IVC diameter
• Procedural
– Vascular access
– Thoracentesis
– Paracentesis
– Arthrocentesis
– Nerve blockade
– Foreign body removal
– Lumbar puncture
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Probe Orientation
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FAST
• Right flank
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FAST
• Left flank
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FAST
• Cardiac
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FAST
• Bladder
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FAST
Free fluid
Hemopericardium
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Extended FAST (with pleural view)
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Cardiac
• Ejection fraction
– Normal or poor?
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Cardiac
• Effusion
– present or absent
• Ejection fraction
– Normal or poor
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Renal
• Ureterolithiasis – Flank pain, N/V
– Hematuria
• Options – KUB, CT, U/S, IVP
– No imaging?
• Ultrasound – Hydronephrosis
– Sensitive for large stones
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Renal
• Hydronephrosis
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Renal
• Moderate hydro
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Biliary
Ultrasound Stones?
Wall thickening? (>3mm)
Fluid around wall?
CBD dilated?
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Biliary
• Transverse view
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• Longitudinal view
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Biliary
• Thickened wall
• Pericholecystic fluid
• Portal vein and
dilated CBD
PV
CBD
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Early Pregnancy
• Ectopic pregnancy
– 2% incidence
– Abdominal pain
– Bleeding
• Goal
– Identify IUP
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Early IUP (6 wks)
Gestational Sac Yolk sac
Fetal pole
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Ultrasound Findings Variations in hCG occur
• Gestational sac hCG (mIU/mL)
– 4-5 weeks TVS 1000
• Fetal pole
– 6 weeks TVS 2000
• Cardiac activity
– 7 weeks TVS 10,000
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Early Pregnancy
• Gestational sac
• Yolk sac
• Fetal pole
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Aorta
• AAA
– 2-4% of population >50
– 10,000 deaths/yr
– Rupture: 80% mortality
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Aorta
• Normal transverse • Normal longitudinal
IVC Aorta
Vertebral body
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Aorta
• AAA transverse
• AAA longitudinal
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Aorta
• AAA
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Aorta
• AAA
True lumen
Mural thrombus
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Rule out DVT
• Two-site compression
– ≈ formal ultrasound
– Misses calf DVTs
– Follow up in 5-7 days
Femoral
Popliteal
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Normal study
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DVT
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DVT
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Ocular
• Retinal detachment
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Ocular
• Vitreous hemorrhage
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Ocular
• Nerve sheath
diameter
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Ocular
• Nerve sheath
diameter
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Procedural Ultrasound
• Standard of care for
IJ vein catheterization
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Procedural Ultrasound
• Standard of care for
IJ vein catheterization
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Future Directions
• Hand-held ultrasound • Vscan (GE)
– $7000-$8000
– One probe
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Future Directions
• MobiUS (Mobisante)
– Connects to cell phone
– $7000-$8000
• Hand-held ultrasound
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Conclusion
• Probe indicator head or right
• Free fluid is hypoechoic
• Standard of care for IJ lines
• Numerous applications – EM: FAST, Cardiac, Renal, Biliary, Aorta, IUP, DVT, Ocular
• Hand-held devices coming soon…
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References
• Mateer J, Plummer D, et al. Model curriculum for physician training in emergency
ultrasonography. Ann Emerg Med 1994; 23(1):95-102.
• Moore CL, Copel JA. Point-of-Care Ultrasonography. NEJM 2011; 364(8):749-757.
• Roelandt JRTC. Seeing the invisible. A short history of cardiac ultrasound. Eur J
Echocardiography 2000; 1(1):8-11.
• Sigel B. A brief history of Doppler ultrasound in the diagnosis of peripheral vascular
disease. Ultrasound in Med and Biol 1998; 24(2):169-176.
• Walcott BM. Mapping the literature of diagnostic medical sonography. Bull Med Libr
Assoc 1999; 87(3):287-291.
• Woo JSK. A short history of the development of ultrasound in obstetrics and
gynecology. www.ob-ultrasound.net/history1.html. Accessed Jan. 6, 2012.