Practical Tips on Emergent Transcutaneous and Transvenous Pacing

Originally Published; 2013-Mar-01

Was one of the faculty for a simulation day with some lecture stations.  The station I had was a short lecture on the setting up of emergent transcutaneous and transvenous pacing followed by some hands on.  Figured I would record the lecture and post it up for whoever was interested.  I did have to put in some echo guided pacemaker insertion clips since I was giving the presentation.

As a side note some of the discussion points may not be applicable depending on what kind of equipment your facility regularly stocks.

Clearing the Memory on a SonoSite Turbo

It is that time of year again with new residents and fellows for ultrasound programs.  Many Emergency Medicine programs are now using digital arching solutions for their ultrasound studies.  Also becoming popular are the use of middleware and/or PACS systems for quality assurance and education/feedback.

One problem that occurs if you are using a SonoSite system is that the studies are saved to the hard drive or internal memory before transmission to the middleware system, such as Q-Path.  Eventually the internal memory of the ultrasound unit will fill up.  When the memory is full the boot time can be longer and performance may suffer.  Most importantly you will NOT be able to save further studies to the hard drive in order to transmit to the arching solution you use.

Someone has to clear the memory periodically.  Unfortunately if you have several sites this could become a problem with schedules and new people in the program.  This short video is a walk through of how to clear the memory on the M-Turbo system from SonoSite, it also works for the Edge system.  Feel free to distribute the link to you people in your program or if you get that late night call asking how to clear the memory.

To make things easier to distribute you can also use this shortened link that will take you directly to the YouTube video:  http://bit.ly/clearturbo and is easier to remember.  Or you can use this QR Code:

Central Line Kit Walkthrough and Line Placement

Originally Published: 2013-Jul-02

This video is a walk through of placing an ultrasound guided internal jugular central line in  a sterile fashion.  The technique and individual steps will depend on the brand of kit and how it has been customized for your institution.

This video was originally created as a review for the residents at my institution.  It focuses on the process of placing the line and less so on the ultrasound guidance.

Twitter Use During Emergency Medicine Conferences

Originally Published: 2012-Apr-26

This research letter is published online ahead of print in the American Journal of Emergency Medicine.  It reviews some of the Twitter statistics from the American College of Emergency Physicians 2010 Scientific Assembly and the Society for Academic Emergency Medicine 2011 Annual meeting.

It also raises the idea of the metric of individual user, original tweets, and original tweet per individual user for evaluating Twitter volume during conferences.

The citation and a pre-production pdf version for those who do not have journal access is: Nomura JT, Genes N, Bollinger HR, Bollinger M, Reed JF 3rd. Twitter Use During Emergency Medicine Conferences. Am J Emerg Med. Epub ahead of print. PMID 22424992.

Point of Care Ultrasound for Hernias

Originally Published: 2012-Feb-21

**This post was originally part of the ACEP Emergency Ultrasound Section’s Newletter in the Tips and Tricks section . The newsletter is located on the member only section of the site so I am posting here to make it more available.**

Patients commonly present with complaints of abdominal hernias and are frequent incidental findings in the emergency department. Incarcerated hernias can cause swelling, pain, and may require emergent surgical consultation if strangulated.

While an incarcerated hernia can be found on physical exam, ultrasound can assist in the management of these cases. Imaging the incarcerated hernia to identify the contents of hernia sac can help differentiate bowel from adipose tissue. As well, one can identify concomitant pathology such as free fluid, bowel wall thickening, pneumotosis coli, aperistalsis, and abnormal blood flow.

Diagnostic imaging is commonly described in many texts and articles; however, an additional step in the imaging protocol can help with the management of incarcerated hernias. Scan through the hernia sac and pay special attention to the abdominal wall for the break in the wall or the neck of hernia sac, this will allow planning for reduction. Identification of the neck allows the operator to direct the hernia contents toward the neck during manual reduction. It also allows the clinician to identify the size of the neck compared to the hernia contents.

Figure 1 shows an incarcerated ventral hernia containing small bowel. The neck can be identified by the defect in the abdominal wall. This hernia was successfully reduced by applying pressure from the lateral edge of the bowel loop toward the neck. Figure 2 shows the hernia post reduction containing only fat; the fascial defect is still visible.

While this large hernia had a midline neck, that is not always the case as demonstrated in Figure 3. The neck is visible and the hernia sac is laterally located. Evaluation of the hernia contents and neck location can aid in planning the reduction. Practice visualizing known hernias and the fascial defect or neck on patients with hernias that are not incarcerated or strangulated.

Figure 1: Incarcerated hernia with bowel and neck visualized

Figure 1: Incarcerated hernia with bowel and neck visualized

Figure 2: Post reductions fat containing hernia and neck are visualized

Figure 2: Post reductions fat containing hernia and neck are visualized

Figure 3: Small hernia lateral to the neck

Figure 3: Small hernia lateral to the neck

Tips and Tricks for the Pelvic Views during the FAST Exam

Originally published: 2011-Apr-18

This is a short article that my colleagues and I wrote for the American College of Emergency Medicine Emergency Medicine Ultrasound Section April Newsletter.

The full newsletter can be found here.

The Focused Assessment with Sonography in Trauma or FAST exam is one of the most common Point of Care Ultrasound exams performed in the Emergency Department.  As discussed in numerous forums, the FAST (or E-FAST) exam can be used in multiple clinical scenarios beyond the traumatically injured patient.  We will discuss two common errors that can lead to the misdiagnosis of subtle findings.

The pelvic windows in the FAST exam are often scanned hastily if the RUQ and LUQ do not show free fluid; however, subtle pathology can be missed if the windows are not surveyed in a thorough manner.

The urine-filled bladder results in posterior acoustic enhancement, which can obscure pelvic structures and pathology posterior to the bladder.  This will be amplified if the far field gain is not appropriately adjusted.  Structures may appear significantly more hyperechoic, and free fluid can be missed due to wash-out from an overgained far field image.  Figure 1 is an example of missed pelvic free fluid due to posterior acoustic enhancement.  The overgained far field obscures the free fluid.

Sagittal view of the bladder with free fluid.  The posterior acoustic enhancement leads to an overgained far field despite the appropriate gain settings of the near field.  This small amount of free fluid, caused by a liver injury, was missed on initial evaluation.

Sagittal view of the bladder with free fluid.  The posterior acoustic enhancement leads to an overgained far field despite the appropriate gain settings of the near field.  This small amount of free fluid, caused by a liver injury, was missed on initial evaluation.

Figure 2 demonstrates a similar transverse view of the bladder, but with improved far field gain.  Internal echoes are visible within the free fluid due to posterior acoustic enhancement; however, further reduction in far field gain may reduce visualization of anatomic structures.  Sonographers must strike a balance between adjusting the far field gain to adequately visualize free fluid while still identifying posterior structures and boundaries.  This highlights the need to remain vigilant in looking for small amounts of free fluid or other subtle findings.  Despite the reduced far field gain and improved image, the persistent artifact within the fluid could mask this pathology.  Appropriate imaging and assessment in the suprapubic window requires an understanding of both the pitfalls of posterior acoustic enhancement, as well as any limitations that can be encountered when correcting for this artifact.

Sagittal view of the bladder with subtle free fluid.  Although the far field gain is better than Figure 1, there are still echoes within the free fluid due to posterior acoustic enhancement.  This highlights the need to be vigilant for subtle findings in the FAST exam.

Sagittal view of the bladder with subtle free fluid.  Although the far field gain is better than Figure 1, there are still echoes within the free fluid due to posterior acoustic enhancement.  This highlights the need to be vigilant for subtle findings in the FAST exam.

The second common error occurs while imaging the bladder in the transverse plane.   Sonographers commonly fail to adequately visualize the lateral edges of the structure.  One of the goals of transverse imaging is to evaluate for free fluid that is lateral to the bladder and may not be apparent on sagittal imaging.  Figure 3 demonstrates this potential pitfall.

Transverse view of the bladder with free fluid located laterally to the bladder.

Transverse view of the bladder with free fluid located laterally to the bladder.

Figure 4 shows a transverse view in which the lateral edges are not visualized.  This occurs most commonly either when the bladder is distended or when a small footprint transducer, such as the phased array or small curved array, is used.  If this occurs, the lateral edges need to be evaluated by scanning each half of the bladder separately on transverse imaging.

Transverse image of the bladder using a phased array transducer.  Due to the small footprint, the lateral edges of the bladder are not visualized and free fluid may not be visualized.

Transverse image of the bladder using a phased array transducer.  Due to the small footprint, the lateral edges of the bladder are not visualized and free fluid may not be visualized.