Diagnostic Bedside Ultrasound for the Hospitalist Trevor Jensen MD - - PDF document
10/26/2015 Diagnostic Bedside Ultrasound for the Hospitalist Trevor Jensen MD MS Assistant Professor, UCSF Nima Afshar MD Associate Professor, UCSF Diagnostic Bedside Ultrasound AKA Point-of-Care Ultrasound (POCUS) Less common names: AKA
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Trevor Jensen MD MS Assistant Professor, UCSF Nima Afshar MD Associate Professor, UCSF
AKA Point-of-Care Ultrasound (POCUS) Less common names:
AKA Emergency Ultrasound AKA Focused Diagnostic Ultrasound AKA Clinician-performed Ultrasound
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To understand how and why POCUS is being used in hospital medicine To stimulate further study/training NOT to teach you how to use US in your practice (yet)
Requires more in-depth training
1. University Hospital 2. County/General Hospital 3. Veterans Hospital 4. Large HMO (ie. Kaiser) 5. Other nonprofit hospital 6. For Profit Hospital 7. Other
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1. Extensive experience with diagnostic POCUS
2. Limited experience with diagnostic POCUS
3. Experience with procedural POCUS only 4. No experience
Basics & History Diagnostic Bedside Ultrasound for the Hospitalist How to integrate Ultrasound into Clinical Care
Case 1: Leg Swelling Case 2: Hypotension Case 3: AKI
Challenges & how to learn more
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Bedside Focused Goal Directed Easy to learn Quick to perform Done by MD NOT
Organomegaly SOB Hypotension Flank Pain Leg Pain/swelling Chest Pain
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Ultrasound in Medicine
1794 Echolocation 1877 Piezoelectric effect 1915 Sonar (WWI & Titanic) 1920s Soccer Physical Therapy 1940s Brain and Breast Tumors 1953 First echocardiogram 1956 Doppler 1958 First use in OB/GYN 1960 standard in radiology, OB/GYN, cardiology, GI 1990s POC US
Ultrasound in Medicine
1989 First use in ICU & ED 1990s US guided procedures ~1994 First EM US curriculum ~2005 First med school US curricula 2008 Radiology/EM statement on limited cardiac US ~2010 First formal IM US residency curriculum EM program “near boston” circa 1995 ???
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Moore CL, Copel JA. NEJM 2011;364:749-757.
“The larger issue now is to decide whether we believe that building competency in ultrasound among generalist physicians – in this case hospitalists – will enhance patient safety, quality, and value. Personally, I do.”
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Point-of-Care US in Medical Education. NEJM 2014
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Allows earlier diagnosis and treatment Reduces iatrogenic complications (procedures) Reduces radiation exposure Reduces length of stay Reduces cost of stay Increases patient satisfaction (hands-on)
Pleural effusion Pulmonary edema Pneumonia Pneumothorax Volume status DVT Ascites Aortic aneurysm Hydronephrosis Organomegaly LV systolic function Pericardial effusion * Chamber size * Valvular disease
* Advanced uses
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70 year old woman with immobility due to osteoarthritis, breast CA, chronic venous stasis presenting with L>R LE swelling, erythema, tenderness
+ fever, tachypnea, malaise Ddx: cellulitis > other infection + asymmetric edema > DVT
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1. Pomero F et al. Accuracy of emergency physician-performed ultrasonography in the diagnosis of deep-vein thrombosis: a systematic review and meta-analysis. Thromb Haemost. 2013
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54 year old man with COPD, CHF presenting with hypotension
+ sputum, SOB, subjective fevers, missed lasix dose x 4 days CXR, BNP relatively equivocal Ddx: Sepsis from pulmonary source > CHF exacerbation
Many Protocols
CLUE RUSH
Major Components
IVC LV systolic function Lung Ultrasound
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1. Brennan et al. Handcarried ultrasound measurement of the inferior vena cava for assessment of intravascular volume status in the outpatient hemodialysis clinic. Clin J Am Soc Nephrol. 2006 2. DeCara et al. The use of small personal ultrasound devices by internists without formal training in
3. Brennan et al. A comparison by medicine residents of physical examination versus hand-carried ultrasound for estimation of right atrial pressure. Am J Cardiol. 2007 10.
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1. Melamed et al: Assessment of left ventricular function by intensivists using hand-held echocardiography. Chest. 2009 Kimura et al. Usefulness of a hand-held ultrasound device for the bedside examination of left ventricular
2. Vignon et al. Focused training for goal-oriented hand-held echocardiography performed by noncardiologist residents in the intensive care unit. Intensive Care Med. 2007
diagnosis and treatment in undifferentiated shock
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Reduced LVEF video
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1. Xirouchaki et al.: Lung ultrasound in critically ill patients: comparison with bedside chest
pneumothorax
95% vs 49%
94% vs 58%
92% vs 89%
100% vs 69%
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Interstitial syndrome video
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65 year old man with BPH, kidney stones presents with AKI
+ fevers, cough, sputum, decreased UOP, not taking flomax
Ddx: Prerenal > ATN >> obstruction
1. Rosen CL et al. Ultrasonography by emergency physicians in patients with suspected ureteral colic. J Emerg
2. Gaspari RJ et al. Emergency ultrasound and urinalysis in the eval- uation of flank pain. Acad Emerg Med. 2005
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Hydronephrosis video
Training:
Significant time investment
Credentialing and Privileging:
No standards for hospitalists
Hardware:
Few institutions have appropriate POCUS capabilities
Research:
Poorly understood diagnostic algorithms for hospital medicine patients
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Attend a CME course Work with your EM and critical care colleagues Self learning via the many free or cheap online resources Email us for details:
Trevor.Jensen@ucsf.edu Nima.Afshar@ucsf.edu
1. Very likely 2. Likely 3. Unlikely 4. Very unlikely
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Slide 5: http://vscanultrasound.gehealthcare.com/ http://www.cafepress.com/+hocus-pocus+hats-caps Slide 7/8: http://www.jultrasoundmed.org/content/23/1/1/F1.expansion http://www.ob-ultrasound.net/history1.html http://learning.blogs.nytimes.com/2012/04/03/100-years-later-ways-to-teach-about-the-titanic-with-the-times/?_php=true&_type=blogs&_r=0 http://www.ultrasoundschoolsinfo.com/history/ Slide 12: http://www.theobjectivestandard.com/2014/01/portable-ultrasound-the-stethoscope-of-the-21st-century/ Slide 14: Heart: http://www.tophdgallery.com/human-heart-location.html Lungs: http://easyhealthoptions.com/for-healthy-lungs-get-more-of-this-vitamin/ Liver: http://hepcbc.ca/your-liver/ Vasc: http://teachmeanatomy.info/lower-limb/vessels/venous-drainage/ Slide 18/20/28/37: Soni et al. Point of Care Ultrasound. Elsevier. 2015 Slide 24: http://www.fpnotebook.com/cv/rad/InfrVnCvUltrsndFrVlmSts.htm Slide 32: http://www.tomwademd.net/introduction-to-pulmonary-ultrasound-by-critical-care-specialist-liz-turner-md/ Slide 37: http://sinaiem.us/tutorials/kidney