We are very pleased to welcome the newest member of the Mount Sinai Emergency Ultrasound Division, Dr. Jennifer Huang!

Dr. Huang completed her residency training at Highland Hospital in Oakland, California and an emergency ultrasound fellowship at the SUNY Downstate / Kings County Hospital in Brooklyn, New York.  She has led emergency ultrasound courses and lectured both nationally and internationally.  She has also been an instructor for the ultrasound guided regional anesthesia course at ACEP since 2010.  Her interests include ultrasound education, ultrasound guided regional anesthesia, and critical care ultrasound.

Here are the results:

Winner: Boston Medical Center

Team members: Derek Wayman, Joseph Pare, and Neil Hadfield. Faculty: Kristin Carmody.

They share The Cup, and each take home a copy of The Manual of Emergency and Critical care Ultrasound

Runner-up: University of Texas-Houston

Semi-Finalists: University of Michigan, University of Connecticut, Carolinas Med Center

Once again, thanks to Dr. Gray for his lovely, copyright-free images:

Here we see the Uterine venous plexus giving rise to the helicine branches, aka arcuate vessels. They run circumstantially through the outer margin of the myometrium.

In the images below, anechoic areas are visible in the posterior aspect of the myometrium (arrows in top two images). The bottom two images reveal the same structures with and without color flow, demonstrating their vascularity. These vessels are normal anatomic variations, and can become more engorged during pregnancy as uterine bloodflow increases.

This is again visible posteriorly in this video of a gravid uterus:

Rounding out our recent trifecta of biosafety posts is a description of cavitation. Cavitation is the formation of microbubbles in liquid which has been subjected to rapid pressure changes. This can happen from a variety of causes from beating Dolphin tails, propellers, cracking your knuckles, and with ultrasound. The Mechanical Index is used to represent the risk of cavitation in tissue during ultrasound evaluation, though most authorities do not think cavitation occurs in the normal operating parameters of diagnostic ultrasound.

During rarefaction (the low pressure portion of the ultrasound pressure wave) air-filled structures expand. They then quickly contract again during the remaining phases of the sound wave. Cavitation is deliberately employed in lithotrypsy, as well as non-medical applications such as metal cleaning.

According to Wikipedia:

The physical process of cavitation inception is similar to boiling. The major difference between the two is the thermodynamic paths that precede the formation of the vapor. Boiling occurs when the local vapor pressure of the liquid rises above its local ambient pressure and sufficient energy is present to cause the phase change to a gas. Cavitation inception occurs when the local pressure falls sufficiently far below the saturated vapor pressure, a value given by the tensile strength of the liquid at a certain temperature.

So there are two major bioeffects of ultrsound: Heat and cavitation. The risks of either are vanishingly small with normal diagnostic ultrasound use. No studies have demonstrated any ill effects of diagnostic ultrasound in humans or even fetuses. But understanding these processes at least helps us recognize the issues behind bioeffect concerns.

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Handout

RUSH in Arrest Algorithm

References:

Atkinson, P R T, D J McAuley, R J Kendall, O Abeyakoon, C G Reid, J Connolly, and D Lewis. “Abdominal and Cardiac Evaluation with Sonography in Shock (ACES): An Approach by Emergency Physicians for the Use of Ultrasound in Patients with Undifferentiated Hypotension.” Emergency medicine journal : EMJ 26, no. 2 (2009): doi:10.1136/emj.2007.056242.

Blaivas, M, and J C Fox. “Outcome in Cardiac Arrest Patients Found to Have Cardiac Standstill on the Bedside Emergency Department Echocardiogram.” Academic emergency medicine : official journal of the Society for Academic Emergency Medicine 8, no. 6 (2001): 616-21.

Breitkreutz, Raoul, Susanna Price, Holger V Steiger, Florian H Seeger, Hendrik Ilper, Hanns Ackermann, Marcus Rudolph, and others. “Focused Echocardiographic Evaluation in Life Support and Peri-Resuscitation of Emergency Patients: A Prospective Trial.” Resuscitation 81, no. 11 (2010): doi:10.1016/j.resuscitation.2010.07.013.

Hernandez, C, K Shuler, H Hannan, C Sonyika, A Likourezos, and J Marshall. “C.A.U.S.E.: Cardiac Arrest Ultra-Sound Exam–A Better Approach to Managing Patients in Primary Non-Arrhythmogenic Cardiac Arrest.” Resuscitation 76, no. 2 (2008): 198-206.

Jones, A E, V S Tayal, D M Sullivan, and J A Kline. “Randomized, Controlled Trial of Immediate Versus Delayed Goal-Directed Ultrasound to Identify the Cause of Nontraumatic Hypotension in Emergency Department Patients*.” Critical care medicine 32, no. 8 (2004): doi:10.1097/01.CCM.0000133017.34137.82.

Lichtenstein, Daniel A, and Gilbert A Mezière. “Relevance of Lung Ultrasound in the Diagnosis of Acute Respiratory Failure: The BLUE Protocol.” Chest 134, no. 1 (2008): doi:10.1378/chest.07-2800.

Rose, J S, A E Bair, D Mandavia, and D J Kinser. “The UHP Ultrasound Protocol: A Novel Ultrasound Approach to the Empiric Evaluation of the Undifferentiated Hypotensive Patient.” The American journal of emergency medicine 19, no. 4 (2001): 299-302.

Salen, Philip, Larry Melniker, Carolyn Chooljian, John S Rose, Janet Alteveer, James Reed, and Michael Heller. “Does the Presence or Absence of Sonographically Identified Cardiac Activity Predict Resuscitation Outcomes of Cardiac Arrest Patients?” The American journal of emergency medicine 23, no. 4 (2005): 459-62.

Weingart, Scott, Daniel Duque and Bret Nelson. “The RUSH Exam – Rapid Ultrasound for Shock / Hypotension.” http://www.webcitation.org/5vyzOaPYU (accessed January 9, 2011).

Back to the Mechanical Index. It is defined as the peak negative pressure (PNP) of the ultrasound wave (point of maximal rarefaction) measured in milliPascals divided by the square root of the center frequency (Fc)of the ultrasound wave. Not a very complicated equation, once you know the components:

What the heck is this? Think pressure change divided by time. Lots of pressure change over short periods of time can be damaging. Dr. David Toms, who writes www.fetalultrasoundsafety.net puts this into perspective very nicely. Imagine a MI of 1 in a system using a 4 MHz probe. Pretty typical parameters. That would mean a peak negative pressure of 2 MPa. According to Dr. Toms:

The corresponding positive side of the ultrasound wave would be similar in the other direction, giving an overall pressure difference within half of a 4MHz cycle of 4 MPa, equivalent to being submerged or brought up from 400 metres (1300 feet or ¼ mile) underwater in 1/8 of a microsecond.  Although the 1/8 microsecond in which this 400 metre movement would occur makes the analogy impossible – it would be 10 times the speed of light – the point is to emphasize that pressure fluctuations within the ultrasound pulse are large, rapid and far from intuitively trivial.

The FDA has established a maximum MI of 1.9 for diagnostic imaging. Any machine capable of generating MI greater than 1.0 must display the MI onscreen. The FDA MI limit for obstetric sonography is 1.0.

How does this this affect care in the acute setting?

• Keep scan times to a minimum
• Avoid using pulsed wave Doppler or color flow through the fetus for determination of fetal heart rate
• Use M-Mode instead
• Use Tissue Harmonic Imaging (THI) only when necessary, not as a default setting

Thermal Index (TI) is a biosafety metric used to describe the potential of the ultrasound beam to raise temperature in the path of the beam. It is the ratio of the power used by the machine to the power required to raise tissue temperature by one degree Celsius.  It does not reflect an actual temperature change, and does not correlate with absolute numbers. A TI of 2 is double the output power but does NOT mean a 2-degree Celcius temperature rise.

How much temperature rise is acceptable? According to the AIUM:

For exposure durations up to 50 hours, there have been no significant, adverse biological effects observed due to temperature increases less than or equal to 2°C above normal.

The British Medical Ultrasound Society has great guidelines for the safe use of diagnostic ultrasound equipment which include this graphic:

The subxiphoid four chamber view is commonly used in cardiac assessments and the FAST exam and for many is the initial “go-to” view of the heart. Difficulty obtaining this window can frustrate novice and seasoned operators, and there are a few tips which can help optimize the view.

1. It’s called SUB-xiphoid for a reason. Don’t jam the probe up against the xiphoid process. Imaging through bone is difficult, the patient will be in pain, and the angle is too steep. Instead, place the probe a few centimeters south of the xiphoid process and work up from there.
2. Get a good view of the liver, THEN use that to get a good view of the heart. You may find that starting to the patient’s right of midline gives a better liver window, since the stomach tends to obscure the subxiphoid view as you go further left.

This video illustrates the huge difference that left vs. right can make. It was taken with the probe in a midline subxiphoid position. Starting with the probe angled towards the patient’s left, the entire screen is obscured by gas in the stomach. As the operator changes the angle towards the patient’s right, we see the liver come into view. This yields an excellent window through which the heart can be visualized.

The figure below, taken from the midpoint of the video, illustrates the point a bit more clearly. To the right of the green line (patient left), superficial stomach gas (arrow) obscures everything behind it, creating a terrible view. On the other side of the green line, liver (L) is visualized which creates a good window for viewing the heart behind it.

On April 18 the FDA released an alert regarding Other-Sonic Generic Ultrasound Transmission Gel, manufactured by Pharmaceutical Innovations Inc. The ultrasound gel was found to be contaminated with Pseudomonas aeruginosa and Klebsiella oxytoca.

According to the FDA Press Announcement,

U.S. Marshals, acting at the request of the Food and Drug Administration, have seized Other-Sonic Generic Ultrasound Transmission Gel located at Pharmaceutical Innovations Inc. in Newark, N.J., after an FDA analysis found that product samples contained dangerous bacteria. The seizure included all lots of the gel product manufactured between June 2011 and December 2011….The FDA received a report involving 16 surgical patients infected with Pseudomonas aeruginosa. The patients had transesophageal ultrasound procedures, while undergoing heart valve replacement, using Other-Sonic Generic Ultrasound Transmission Gel.

Yes, that first line said “U.S. Marshals.” The FDA does not mess around. So take a minute and check your gel! Maybe a good time to wipe the whole machine down while you are at it.

The course is held at the beautiful and historic Ponte Vedra Inn and Club.

Please visit here for Registration information

Highlights of the four-hour course include:

1. Cardiac ultrasound
2. Thoracic ultrasound
3. Ultrasound for venous access
4. Assessment of the hypotensive patient

Faculty for this year’s course include:

• Bret Nelson, MD, RDMS (course director)
• Petra Duran, MD
• Joseph Wood, MD, JD, RDMS