The first and most important step in paracentesis is confirming there is ascites to begin with!

Physical examination findings can be misleading, and inserting a needle blindly into the abdomen can cause complications unnecessarily. Note the black free fluid in the image, with echogenic bowel loops floating within.

Several approaches are commonly used. Each one starts with an assessment for peritoneal fluid, localization of area suitable for paracentesis (no nearby vessels, large enough pocket, etc.). Next, measure the distance from skin to peritoneum to establish a sense of how far the needle lust penetrate before expecting to yield ascites. This is followed by either:

1. Real time (dynamic) ultrasound guidance. Probe held in non-dominant hand (or by assistant); dominant hand guides needle with real-time guidance using short- or long-axis technique
2. Static guidance: Mark the location for paracentesis (use a pen, pressure from a pen cap or fingernail, or even using a nearby mole/skin blemish as a landmark!), and then proceed with the tap using that mark as a guide. It is critical that the mapping is performed immediately before the paracentesis, and the patient remains in the same position. If the patient moves or is re-positioned,  the patient must be scanned again because the pocket of fluid would have shifted due to the highly mobile floating bowel loops.

As the needle is inserted into the abdomen using either technique, it is wise to hold slight negative pressure on the plunger of the syringe. This way, as soon as fluid or blood is encountered, the operator will note both a pressure change and a flash of fluid into the syringe.

The official language for the conference is English, and it will be held in Tuscany!

This is an EFSUMB accredited Euroson school event. For more information please visit here.

1. In this Cochrane review, the authors’ conclusion was that there was insufficient evidence for the use of ultrasound-based clinical pathways in the initial diagnostic workup of patients with blunt abdominal trauma. Ultrasound was not sensitive and lacked diagnostic accuracy. However, the use of ultrasound did reduce the use of CT scans. The take-home message is that ultrasound should not be used as a single rule-out test for significant intra-abdominal injury and the ED resident should be aware of ultrasound’s limitations.

Stengel D, Bauwens K, Sehouli J, Rademacher G, Mutze S, Ekkernkamp A, Porzsolt F. Emergency ultrasound-based algorithms for diagnosing blunt abdominal trauma (Review). The Cochrane Collaboration. February 18th, 2008.

2. Interestingly, this review used the same methodology as the Cochrane review and found that an adequately performed FAST exam can predict the need to send a patient to the operating room, with a high degree of sensitivity (98.9%) and specificity (98.1%).

Melniker LA. The value of focused assessment with sonography in trauma examination for the need for operative intervention in blunt torso trauma: a rebuttal to “emergency ultrasound-based algorithms for diagnosing blunt abdominal trauma (review)”, from the Cochrane Collaboration. Critical Ultrasound Journal. 2009;1:73-84.

3. Thoracic ultrasound has become part of the standard assessment of the trauma patient. Ultrasound has been shown to be much more sensitive than CXR in the detection of pneumothorax when compared to CT as the gold standard. There are many studies proving this point and this is a good example.

Blaivas M, Lyon M, Duggal S. A prospective comparison of supine chest radiography and bedside ultrasound for the diagnosis of traumatic pneumothorax. Acad Emerg Med. Sep 2005;12(9):844-849

Some of the topics discussed are supported by plenty of evidence (ie the use of RSI as an intubation technique), some were simply fun to discuss (holding your breath while intubating) and some remain quite reasonably controversial (the use of etomidate for RSI in sepsis).

I highly recommend visiting Dr. Reuben Strayer’s blog for a brief and enlightening discussion of the use of rocuronium for RSI. Also, Dr. Scott Weingart’s EMCrit blog and podcasts are an excellent source for ED critical care topics. Finally, The Airway Site contains links to key airway management references as well as information on the Difficult Airway Course.

Selected References:

• Farmery AD, Roe PG: A model to describe the rate of oxyhemoglobin desaturation during apnoea. Br J Anaesth 1996; 76:284-91
• Naguib et al. Optimal dose of succinylcholine revisited. Anesthesiology 2003; 99:1045-1049
• Bozeman et al. A comparison of rapid sequence intubation and etomidate-only intubation in the prehospital air medical setting. Prehosp Emerg Care: 2006; 10:8-13
• Sackles et al. Airway management in the emergency department: a one-year study of 610 tracheal intubations. Ann Emerg Med 1998; 31:325-332
• Li J et al. Complications of emergency intubation with and without paralysis. AJEM 1999: 17(2); 141-143
• Mallon WK et al. Rocuronium vs. succinylcholine in the emergency department: A critical appraisal. JEM 37(2); 183-188
• Strayer RJ. Rocuronium vs. succinylcholine revisited. JEM 2010 Apr 22. [Epub ahead of print]
• Cardiopulmonary resuscitation by bystanders with chest compression only (SOS-KANTO): an observational study, Lancet 369 (2007), pp. 920–926.
• Bobrow et al. Passive oxygen insufflation is superior to bag-valve-mask ventilation for witnessed ventricular fibrillation out-of-hospital cardiac arrest. Ann Emerg Med. 2009;54:656-662.
• Brimacombe JR and Berry JM. Cricoid pressure. Can J Anaesth. 1997 Apr;44(4):414-25

FERNE’s seizure and status epilepticus management guide

Key practice guidelines related to seizures:

Special thanks to Professor Andy Jagoda (Department of Emergency Medicine, Mount Sinai, New York)

The gallbladder:

• has a bright (echogenic) wall
• is surrounded by liver
• attaches to the middle hepatic ligament
• is a contained structure
• can be traced to the portal vein

The duodenum:

• has a darker (hypoechoic) wall
• is next to the liver, not in it
• cannot be traced to the middle hepatic ligament
• is a tubular structure
• does not connect to the portal vein

More images and explanation after the break!

Also, because of the presence of air within the duodenum, it often casts a ‘dirty’ shadow rather than a ‘clean, dark’ shadow from the acoustic shadowing of a classic gallstone. Check out the following images and see if you agree with the findings as labeled.

Some may argue that these pictures demonstrate the WES (wall-echo-shadow). There’s the hyperechoic wall, the anechoic bile and the stone is casting the shadow… however, the shadow’s all wrong. The “shadow” is NOT an anechoic area extending to the edge of the screen. Instead, it represents a ring-down artifact.

Therefore, going by all of the above criteria, the images are not that of a gallbladder/stone, but more likely the duodenum.

1. The presence of some artifacts can help us to identify anatomy:  e.g. “an aorta” is  “the aorta” because it’s resting on the spine, which is “the spine” because it casts a shadow (what if the spine does not cast a shadow….?)

2. The absence of artifacts can also reveal pathology:  e.g. in  FAST with right hemothorax, loss of the mirror image of the liver above the diaphragm not only reveals the blood and superior aspect of the diaphragm, it also allows  the vertebral column (above the diaphragm) to show up! The spine above the diaphragm is never seen because the normal aerated lung scatters all of the ultrasound energy above the diaphragm.

3. Both the real image and artifact arise because of certain assumptions that that ultrasound machine makes. When they are all met, you get a real image; when any assumption is not, well, you get an artifact. And thankfully, there are only four such assumptions. Here’s a quick review of them as we begin this series of what’s real and what’s not.

Assumption ONE:

A pulse of ultrasound beam emitted by the transducer travels in a straight line, is reflected at an interface, and travels back to the transducer (exactly along the path it was emitted, only in the reverse direction)

Assumption TWO:

All the returning echoes of the beam are presumed to have arisen only from the center (i.e. axis) of the beam and hence are displayed as such (i.e. along a vertical line on the screen that represents the axis)

Assumption THREE:

The speed of ultrasound beam (emitted and/or reflected) is always and exactly 1540m/s

Assumption FOUR:

The intensity of the displayed echo is dependent on the acoustic properties and size of the interface where it is being reflected

And with that, we’ll make good use of what’s not really there to find out what’s really going on.

Three DVT articles that every emergency physician should know. What are they?

1) If there is any “must know” article for DVT or PE, this is it: commonly known as the Well’s Criteria, it provides a framework for the EP to approach any patient presenting with the the suspicion of DVT or PE. It is the ability to categorize patients into the different risk categories that we’re able to effectively use pre-test and post-test probability of a negative D-dimer to rule out the disease.

Wells PS, Anderson DR, Rodger M, et al. Evaluation of D-dimer in the diagnosis of suspected deep-vein thrombosis. N Engl J Med. 2003;349:1227.

2) With the introduction of bedside clinician performed ultrasound, EPs now have a tool to evaluate the proximal lower extremity veins themselves. While there is abundant literature suggesting the feasibility of an EP performed bedside ultrasound, this review article showed that properly trained EPs can accurately diagnose DVTs with a pooled overall sensitivity and specificity of 95% and 96% respectively. However, several limitations were highlighted with regards to the available literature – there is no standardization of the technique used, and the studies involved EPs already highly trained in ultrasound and so the results cannot be generalized to all EPs.

Burnside PR, Brown MD, Kline JA. Systematic review of emergency physician-performed ultrasonography for lower-extremity deep vein thrombosis. Acad Emerg Med. 2008;15:493-498.

3) This large RCT compares 2 point compression ultrasonography plus D-dimer with formal ultrasonography in symptomatic patients with suspected DVT. The rates of  confirmed DVT at 3 months were similar in the 2 groups. This suggests that EPs can manage symptomatic patients suspected of having DVT with just 2-point compression ultrasound and D-dimer.

Bernardi E, Camporese G, Büller HR, et al. Serial 2-point ultrasonography plus D-dimer vs whole-leg color-coded Doppler ultrasonography for diagnosing suspected symptomatic deep vein thrombosis: a randomized controlled trial. JAMA. 2008;300:1653-1659.

Do you have other suggestions for studies? Comment below!

Visual Diagnosis Case from JEM.  Bret and Ted discuss a case of appendicitis confirmed with ultrasound after CT was not conclusive.