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Intensively Ultrasonic

Intensively Ultrasonic . An introduction to the clinical use of ultrasound in the critical care environment. Dr. Daniel Rankmore - 2011. Talk Outline. t he physics t he equipment n ovel clinical uses v ascular access f inal words. t he physics. Ultrasound Physics.

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Intensively Ultrasonic

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  1. Intensively Ultrasonic An introduction to the clinical use of ultrasound in the critical care environment. Dr. Daniel Rankmore - 2011

  2. Talk Outline • the physics • the equipment • novel clinical uses • vascular access • final words

  3. the physics

  4. Ultrasound Physics

  5. Pulse Echo & Piezoelectrics

  6. Basic Principles

  7. Basic Principles

  8. Artifacts

  9. Knobology

  10. the equipment

  11. The Machine Sonosite M-Turbo SonositeS-Series

  12. which probe to use

  13. Frequency

  14. Pattern

  15. Special Purpose

  16. The Probes Linear10-5MHz 38mm Linear13-6MHz 25mm Phase Array5-1MHz 21mm Curvy-linear5-2 Mhz 60mm

  17. Linear Freq – 13-6Mhz Max Depth – 6cm Applications: Vascular Access, Pneumothorax Nerve Blockade, Muscloskeletal

  18. Curved Freq – 5-2 Mhz Max Depth – 30cm Applications: FAST, Major vessel ?AAA, Hemothorax Pleurocentesis, Peracentesis, Bladder Hepatobiliary, Obstetrics

  19. Phased Freq – 5-1 Mhz Max Depth – 35cm Applications: Echocardiography

  20. novel clinical uses

  21. http://resusme.em.extrememember.com/ Cliff Reid’s Blog

  22. extensions to FAST

  23. Pneumothorax Extended focused assessment with sonography for trauma (EFAST) in the diagnosis of pneumothorax: experience at a community based level I trauma center. • Injury. 2011 May;42(5):511-4. Epub 2010 Feb 10. • 204 Patients. Clinical examination was positive in 17 patients (true positive in 13/21, 62%; 4 were false positive and 8 were false negative), CXRwas positive in 16 (true positive in 15/19, 79%; 1 false positive, 4 missed and 2 CXR not performed before chest tube) patients and EFASTwas positive in 21 patients (20 were true positive [95.2%], 1 false positive and 1 false negative). In diagnosing pneumothorax EFAST has significantly higher sensitivity compared to the CXR (P=0.02).

  24. hqmeded.org • 23 yo male stabbed with a cooking fork (6min) (Link) • Thoracic ultrasound for pneumothorax (Link)

  25. Pelvic Fractures • Ultrasonic detemination of pubic symphyseal widening in trauma: FAST-PS. J Emerg Med 2011 May 40(5):528-33 • STUDY OBJECTIVES: We hypothesized that an ultrasound image of the PS as part of the FAST examination (FAST-PS) would be an accurate method to determine if pubic symphysis diastasis was present. • RESULTS: Twenty-three trauma patients were evaluated with both plain radiographs and US (11 PM, 12 ED). Four patients had radiographic PS widening (3 PM, 1 ED) and 19 patients had radiographically normal PS width; all were correctly identified with US. US measurements were compared with plain X-ray study by Bland-Altman plot. With one exception, US measurements were within 2 standard deviations of the radiographic measurements and, therefore, have excellent agreement. The only exception was a patient with pubic symphysis wider than the US probe. • CONCLUSION: Bedsidultrasound examination may be able to identify pubic symphysis widening in trauma patients. This potentially could lead to faster application of a pelvic binder and tamponade of bleeding.

  26. vascular

  27. Art Line Insertion Ultrasound-guided catheterization of the radial artery: a systematic review and meta-analysis of randomized controlled trials. • Chest. 2011 Mar;139(3):524-9. Epub 2010 Aug 19. • Conclusion: Four trials with a total of 311 subjects were included in the review, with 152 subjects included in the palpation group and 159 in the ultrasound-guided group. Compared with the palpation method, ultrasound guidance for arterial catheterization was associated with a 71% improvement in the likelihood of first-attempt success (relative risk, 1.71; 95% CI, 1.25-2.32).

  28. airway

  29. Peadiatric ETT Size Prediction of pediatric endotracheal tube size by ultrasonography. • ActaAnaesthesiol Scand. 2011 Apr;55(4):422-8. doi: 10.1111/j.1399-6576.2010.02372.x. Epub 2011 Feb 2. • Conclusion: Measuring subglottic airway diameter with ultrasonography facilitates the selection of appropriately sized ETTs in pediatric patients. This selection method better predicted optimal outer ETT diameter than standard age- and height-based formulas.

  30. brains

  31. Pre-hospital Transcranial Doppler Pre-hospital transcranial Doppler in severe traumatic brain injury: a pilot study. • ActaAnaesthesiol Scand. 2011 Apr;55(4):422-8. doi: 10.1111/j.1399-6576.2010.02372.x. Epub 2011 Feb 2. • 18 patients. Matched GCS/MAP. 9 abnormal. Link with pupil changes and mortality. • Conclusion: Our preliminary study suggests that TCD could be used in pre-hospital care to detect patients whose cerebral perfusion may be impaired

  32. Post Crainectomy Use of ultrasonography in hemicraniectomized patients: a report of two cases. • Intensive Care Med. 2010 Jun;36(6):1091-2. • Zampieriand colleagues from Brazil report the use of brain ultrasound in two ICU patients who had had hemicraniectomies. ‘using the hemicraniectomy as an insonation window could be useful as a noninvasive triage tool and reduce the need for patient transport to the imaging center.’

  33. Optic Nerve Ultrasound measurement of optic nerve sheath diameter in patients with a clinical suspicion of raised intracranial pressure. • Emerg Med J. 2011 Aug;28(8):679-81. Epub 2010 Aug 15. • To assess if ultrasound measurement of the optic nerve sheath diameter (ONSD) can accurately predict the presence of raised intracranial pressure (ICP). 26 patients.  For any acute intracranial abnormality the value of ONSD was 100% specific (95% CI 76% to 100%) and 60% sensitive (95% CI 27% to 86%). 

  34. vascular access Introduction…

  35. Transverse • Keeps other structures in view • Easiest to find vessel

  36. Longitudinal • Can be better for deeper structures • Allows visualisation of needle & wire advancing within the vessel

  37. Which is the vein?1. Know the anatomy

  38. Which is the vein?2. Static views on Ultrasound • Arteries have thicker walls • Arteries are rounder

  39. Which is the vein?3. Dynamic views on Ultrasound • Compressibility • Collapse vs. Winking 2. Doppler • BART – Blue Away Red Towards • Flow – Pulsatile vs. Continuous

  40. vascular ultrasound how I use ultrasound for vascular access…

  41. Preparation • Equipment • Sonosite S Series – Linear 25mm – Gel/ Sock/ Opsite • Tourniquet • Gown/ Gloves • Skin Prep – Chlorhex • Local – 2-3ml 1% Lignocaine • Line (IVC/ CVC/ PICC/ Vascath/ Art line) • Flush – 20ml 0.9% N-Saline • Dressing (Opsite/ Statlock/ Suture) • Staff • Patient

  42. sßcanthe vessel • Confirms the direction of the vessel • Reveals anatomical variations (and other structures) • Gives insight into patency (ie. thrombus)

  43. identify the target • Prep the skin • Hold the probe low • Orientate the probe • Adjust depth and gain • Vessel central • Local anesthetic

  44. advance on target • Pencil grip @ 30-45degrees • Advance needle • ‘I can’t see the needle!’ • Stay midline • Bright echogenic circle • Shadow • Do the jiggle • Tenting • Move the probe • Flashback • Check the wire

  45. hqmeded.org • Ultrasound Guided Intravenous Peripheral Placement (7min) - Link • Ultrasound Guidance for Central Venous Catheter - Link • 2 yo with DKA - Link

  46. some final words…

  47. think in three dimensions

  48. Simplify the angles

  49. Prior Preparation Prevents Piss Poor Performance • Optimise position (you & the patient) • Have an assistant (& talk to them) • Get the right equipment • Understand the equipment • Understand the anatomy • Know the complications (& what to do) • Practice

  50. References • Ma JO, Mateer JR. Emergency Ultrasound. McGraw Hill. 2003. • Sangers RC, Winter R. Clinical Sonography: A practical guide. Fourth Edition. Lippincott Williams & Wilkins. 2007. • Wikipedia • Google Images

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