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05/10/2018

Conio: Echo, cela se confirme

Ultrasound Is Superior to Palpation in Identifying the Cricothyroid Membrane in Subjects with Poorly Defined Neck Landmarks: A Randomized Clinical Trial.

Siddiqui N1, et Al. Anesthesiology. 2018 Sep 26.

 

 

BACKGROUND: Success of a cricothyrotomy is dependent on accurate identification of the cricothyroid membrane. The objective of this study was to compare the accuracy of ultrasonography versus external palpation in localizing the cricothyroid membrane.

METHODS:

In total, 223 subjects with abnormal neck anatomy who were scheduled for neck computed-tomography scan at University Health Network hospitals in Toronto, Canada, were randomized into two groups: external palpation and ultrasound. The localization points of the cricothyroid membrane determined by ultrasonography or external palpation were compared to the reference midpoint (computed-tomography point) of the cricothyroid membrane by a radiologist who was blinded to group allocation. Primary outcome was the accuracy in identification of the cricothyroid membrane, which was measured by digital ruler in millimeters from the computed-tomography point to the ultrasound point or external-palpation point. Success was defined as the proportion of accurate attempts within a 5-mm distance from the computed-tomography point to the ultrasound point or external-palpation point.

RESULTS:

The percentage of accurate attempts was 10-fold greater in the ultrasound than external-palpation group (81% vs. 8%; 95% CI, 63.6 to 81.3%; P < 0.0001). The mean (SD) distance measured from the external-palpation to computed-tomography point was five-fold greater than the ultrasound to the computed-tomography point (16.6 ± 7.5 vs. 3.4 ± 3.3 mm; 95% CI, 11.67 to 14.70; P < 0.0001).

US Crico.jpeg

Analysis demonstrated that the risk ratio of inaccurate localization of the cricothyroid membrane was 9.14-fold greater with the external palpation than with the ultrasound (P < 0.0001). There were no adverse events observed.

CONCLUSIONS:

In subjects with poorly defined neck landmarks, ultrasonography is more accurate than external palpation in localizing the cricothyroid membrane.

| Tags : airway, coniotomie

30/09/2018

US: Mieux que la main pour la conio

A multicentre prospective cohort study of the accuracy of conventional landmark technique for cricoid localisation using ultrasound scanning

 

Cricoid pressure is employed during rapid sequence induction to reduce the risk of pulmonary aspiration. Correct application of cricoid pressure depends on knowledge of neck anatomy and precise identification of surface landmarks. Inaccurate localisation of the cricoid cartilage during rapid sequence induction risks incomplete oesophageal occlusion, with potential for pulmonary aspiration of gastric contents. It may also compromise the laryngeal view for the anaesthetist. Accurate localisation of the cricoid cartilage therefore has relevance for the safe conduct of rapid sequence induction.

We conducted a multicentre, prospective cohort study to determine the accuracy of cricoid cartilage identification in 100 patients. The cranio‐caudal midpoint of the cricoid cartilage was identified by a qualified anaesthetic assistant using the conventional landmark technique and marked. While maintaining the patient in the same position, a second mark was made by identifying the midpoint of the cricoid cartilage using ultrasound scanning.

The mean (SD) distance between the two marks was 2.07 (8.49) mm. In 41% of patients the midpoint was incorrectly identified by a margin greater than 5 mm. This error was uniformly distributed both above and below the midpoint of the cricoid cartilage. The Pearson correlation coefficient of this error with respect to body mass index was 0.062 (p = 0.539) and with age was −0.020 (p = 0.843). There were also no significant differences in error between male and female patients.

Identification of cricoid position using a landmark technique has a high degree of variability and has little correlation with age, sex or body mass index. These findings have significant implications for the safe application of cricoid pressure in the context of rapid sequence induction.

| Tags : airway, coniotomie

22/09/2018

Echo pour l'intubation

Integration of Point-of-care Ultrasound during Rapid Sequence Intubation in Trauma Resuscitation.

Mishra PR et Al. J Emerg Trauma Shock. 2018 Apr-Jun;11(2):92-97

Introduction:

Airway and breathing management play critical role in trauma resuscitation. Early identification of esophageal intubation and detection of fatal events is critical. Authors studied the utility of integration of point-of-care ultrasound (POCUS) during different phases of rapid sequence intubation (RSI) in trauma resuscitation.

Methods:

It was prospective, randomized single-centered study conducted at the Emergency Department of a level one trauma center. Patients were divided into ultrasonography (USG) and clinical examination (CE) arm. The objectives were to study the utility of POCUS in endotracheal tube placement and confirmations and identification of potentially fatal conditions as tracheal injury, midline vessels, paratracheal hematoma, vocal cord pathology, pneumothorax, and others during RSI. Patient >1 year of age were included. Time taken for procedure, number of incorrect intubations, and pathologies detected were noted. The data were collected in Microsoft Excel spread sheets and analyzed using Stata (version 11.2, Stata Corp, Texas, U. S. A) software.

Results:

One hundred and six patients were recruited. The mean time for primary survey USG versus CE arm was (20 ± 10.01 vs. 18 ± 11.03) seconds. USG detected four pneumothorax, one tracheal injury, and one paratracheal hematoma. The mean procedure time USG versus CE arm was (37.3 ± 21.92 vs. 58 ± 32.04) seconds. Eight esophageal intubations were identified in USG arm by POCUS and two in CE arm by EtCO2 values.

Conclusion:

Integration of POCUS was useful in all three phases of RSI. It identified paratracheal hematoma, tracheal injury, and pneumothorax. It also identified esophageal intubation and confirmed main stem tracheal intubation in less time compared to five-point auscultation and capnography.

| Tags : airway

21/09/2018

Airway Ultrasound

Upper Airway US.jpeg

Clic sur l'image pour accéder au docment

| Tags : airway

01/02/2017

Echo: Pour le thorax surtout

Traumatic cardiac injury: Experience from a level-1 trauma centre

Mishra B. et Al. Chin J Traumatol. 2016 Dec 1;19(6):333-336.

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Disposer d'un appareil d'échographie est d'un grand intérêt. Encore faut-il maîtriser cette technique (1) sous peine de se tromper dans les priorités de prise en charge. Le recours a cette technique reste débattu pour la prise en charge de traumatismes pénétrants. L'échographie thoracique est probablement à valeur ajoutée tant sur l'imagerie pleurale que péricardique. C'est ce que présente ce travail. Ce document rapporte également l'inefficacité en terme de survie de péricardocentèse pourtant prôné par l'ATLS.

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Traumatic cardiac injury (TCI) is a challenge for trauma surgeons as it provides a short thera- peutic window and the management is often dictated by the underlying mechanism and hemodynamic status. The current study is to evaluate the factors influencing the outcome of TCI.

METHODS:

Prospectively maintained database of TCI cases admitted at a Level-1 trauma center from July 2008 to June 2013 was retrospectively analyzed. Hospital records were reviewed and statistical analysis was performed using the SPSS version 15.

RESULTS:

Out of 21 cases of TCI, 6 (28.6%) had isolated and 15 (71.4%) had associated injuries. Ratio be- tween blunt and penetrating injuries was 2:1 with male preponderance. Mean ISS was 31.95. Thirteen patients (62%) presented with features suggestive of shock. Cardiac tamponade was present in 12 (57%) cases and pericardiocentesis was done in only 6 cases of them. Overall 19 patients underwent surgery. Perioperatively 8 (38.1%) patients developed cardiac arrest and 7 developed cardiac arrhythmia. Overall survival rate was 71.4%. Mortality was related to cardiac arrest (p = 0.014), arrhythmia (p = 0.014), and hemorrhagic shock (p =0.04). The diagnostic accuracy of focused assessment by sonography in trauma (FAST) was 95.24%.

CONCLUSION:

High index of clinical suspicion based on the mechanism of injury, meticulous examination by FAST and early intervention could improve the overall outcome.

02/12/2016

Echo préhospitalière: Expertise à construire svp!

Prehospital ultrasound of the abdomen and thorax changes trauma patient management: A systematic review

O’Dochartaigh D et Al. Injury, Int. J. Care Injured 46 (2015) 2093–2102

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L'échographie tend à prendre une place de plus en plus importante dans notre quotidien. L'existence d'appareils portables, à l'ergonomie et la performance sans cesse améliorée, procède à la généralisation de cet outil d'évaluation dont on comprend bien l'intérêt. Pour autant qu'apporte réellement ce moyen d'exploration et tout particulièrement en préhospitalier ? Et bien les choses ne sont pas si évidentes que cela. Sauf à être mis en oeuvre par des mains expertes et pour des pathologies ciblées et malgré l'engouement général l'intérêt réel reste à prouver. Ce travail n'est pas isolé (1, 2) et devrait nous pousser à une certaine pondération et surtout à des efforts de formation des praticiens ayant recours à cette technique (3).

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Background: Ultrasound examination of trauma patients is increasingly performed in prehospital services. It is unclear if prehospital sonographic assessments change patient management: providing prehospital diagnosis and treatment, determining choice of destination hospital, or treatment at the receiving hospital.

Objective: This review aims to assess and grade the evidence that specifically examines whether prehospital ultrasound (PHUS) of the thorax and/or abdomen changes management of the trauma patient.

Methods: A systematic review was conducted of trauma patients who had an ultrasound of the thorax or abdomen performed in the prehospital setting. PubMed, MEDLINE, Web of Science (CINAHL, EMBASE, Cochrane Central Register of Controlled Trials) and the reference lists of included studies were searched. Methodological quality was checked and risk of bias analysis performed, a level of evidence grade was assigned, and descriptive data analysis performed.

Results: 992 unique citations were identified, which included eight studies that met inclusion criteria with a total of 925 patients. There are no reports of randomised controlled trials. Heterogeneity exists between the included studies which ranged from a case series to retrospective and prospective nonrandomised observational studies. Three studies achieved a 2+ Scottish Intercollegiate Guidelines Networks grade for quality of evidence and the remainder demonstrated a high risk of bias. The three best studies each provided examples of prehospital ultrasound positively changing patient management.

Conclusion: There is moderate evidence that supports prehospital physician use of ultrasound for trauma patients. For some patients, management was changed based on the results of the PHUS. The benefit of ultrasound use in non-physician services is unclear.

31/08/2016

Echo et voies aériennes: Mais oui, à maîtriser

The Role of Airway and Endobronchial Ultrasound in Perioperative Medicine

Vortrua J et Al. Biomed Res Int. 2015; 2015: 754626

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Certainement UN APPORT IMPORTANT à la gestion des voies aériennes et de la ventilation non seulement dans les blocs opératoires mais dans les situations critiques y compris hors de l'hôpital.

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Recent years have witnessed an increased use of ultrasound in evaluation of the airway and the lower parts of the respiratory system. Ultrasound examination is fast and reliable and can be performed at the bedside and does not carry the risk of exposure to ionizing radiation. Apart from use in diagnostics it may also provide safe guidance for invasive and semi-invasive procedures. Ultrasound examination of the oral cavity structures, epiglottis, vocal cords, and subglottic space may help in the prediction of difficult intubation. Preoperative ultrasound may diagnose vocal cord palsy or deviation or stenosis of the trachea. Ultrasonography can also be used for confirmation of endotracheal tube, double-lumen tube, or laryngeal mask placement. This can be achieved by direct examination of the tube inside the trachea or by indirect methods evaluating lung movements. Postoperative airway ultrasound may reveal laryngeal pathology or subglottic oedema. Conventional ultrasound is a reliable real-time navigational tool for emergency cricothyrotomy or percutaneous dilational tracheostomy. Endobronchial ultrasound is a combination of bronchoscopy and ultrasonography and is used for preoperative examination of lung cancer and solitary pulmonary nodules. The method is also useful for real-time navigated biopsies of such pathological structures.

 

 

| Tags : airway

30/08/2016

Crico et Echo: Pensez TACA

Ultrasonographic identification of the cricothyroid membrane: best evidence, techniques, and clinical impact

Kristensen MS et Al. Br. J. Anaesth. (2016) 117 (suppl 1):i39-i48

 

Inability to identify the cricothyroid membrane by inspection and palpation contributes substantially to the high failure rate of cricothyrotomy. This narrative review summarizes the current evidence for application of airway ultrasonography for identification of the cricothyroid membrane compared with the clinical techniques. We identified the best-documented techniques for bedside use, their success rates, and the necessary training for airway-ultrasound-naïve clinicians.

F1.medium.gif

After a short but structured training, the cricothyroid membrane can be identified using ultrasound in difficult patients by previously airway-ultrasound naïve anaesthetists with double the success rate of palpation. Based on the literature, we recommend identifying the cricothyroid membrane before induction of anaesthesia in all patients. Although inspection and palpation may suffice in most patients, the remaining patients will need ultrasonographic identification; a service that we should aim at making available in all locations where anaesthesia is undertaken and where patients with difficult airways could be encountered.

| Tags : airway

05/08/2016

Echo pour abord vasculaire: Intérêt modéré ?

Ultrasound guidance versus anatomical landmarks for subclavian or femoral vein catheterization

Cochrane Database Syst Rev. 2015 Jan 9;1:CD011447. doi: 10.1002/14651858.CD011447.

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La mise en place d'un abord veineux central est une éventualité peu fréquente en médecine tactique. La maîtrise de l'abord vasculaire périphérique et l'apport de la perfusion intraosseuse suffisent le plus souvent à répondre aux besoins. Néanmoins ce besoin ne peut être écarté. Alors que la majorité des sociétés savantes recommandent le recours à la pose échoguidée, il semblerait qu'une analyse critique de l'intérêt d'une telle pratique ne soit pas encore complètement en faveur de telles recommandations (???). Même si de très grandes avancées technologiques ont lieu et permettent de disposer d'appareil et de sondes adhoc utilisables hors de l'hôpital, dans nos conditions d'exercice et donc in fine de notre aptitude à cette pratique sans échographe.

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BACKGROUND:

Central venous catheters can help with diagnosis and treatment of the critically ill. The catheter may be placed in a large vein in the neck (internal jugular vein), upper chest (subclavian vein) or groin (femoral vein). Whilst this is beneficial overall, inserting the catheter risks arterial puncture and other complications and should be performed in as few attempts as possible.In the past, anatomical 'landmarks' on the body surface were used to find the correct place to insert these catheters, but ultrasound imaging is now available. A Doppler mode is sometimes used to supplement plain 'two-dimensional' ultrasound.

OBJECTIVES:

The primary objective of this review was to evaluate the effectiveness and safety of two-dimensional ultrasound (US)- or Dopplerultrasound (USD)-guided puncture techniques for subclavian vein, axillary vein and femoral vein puncture during central venous catheter insertion in adults and children. We assessed whether there was a difference in complication rates between traditional landmark-guided and any ultrasound-guided central vein puncture.When possible, we also assessed the following secondary objectives: whether a possible difference could be verified with use of the US technique versus the USD technique; whether there was a difference between using ultrasound throughout the puncture ('direct') and using it only to identify and mark the vein before starting the puncture procedure ('indirect'); and whether these possible differences might be evident in different groups of patients or with different levels of experience among those inserting the catheters.

SEARCH METHODS:

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2013, Issue 1), MEDLINE (1966 to 15 January 2013), EMBASE (1966 to 15 January 2013), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1982 to 15 January 2013), reference lists of articles, 'grey literature' and dissertations. An additional handsearch focused on intensive care and anaesthesia journals and abstracts and proceedings of scientific meetings. We attempted to identify unpublished or ongoing studies by contacting companies and experts in the field, and we searched trial registers. We reran the search in August 2014. We will deal with any studies of interest when we update the review.

SELECTION CRITERIA:

Randomized and quasi-randomized controlled trials comparing two-dimensional ultrasound or Doppler ultrasound versusan anatomical 'landmark' technique during insertion of subclavian or femoral venous catheters in both adults and children.

DATA COLLECTION AND ANALYSIS:

Three review authors independently extracted data on methodological quality, participants, interventions and outcomes of interest using a standardized form. We performed a priori subgroup analyses.

MAIN RESULTS:

Altogether 13 studies enrolling 2341 participants (and involving 2360 procedures) fulfilled the inclusion criteria. The quality of evidence was very low (subclavian vein N = 3) or low (subclavian vein N = 4, femoral vein N = 2) for most outcomes, moderate for one outcome (femoral vein) and high at best for two outcomes (subclavian vein N = 1, femoral vein N = 1). Most of the trials had unclear risk of bias across the six domains, and heterogeneity among the studies was significant. For the subclavian vein (nine studies, 2030 participants, 2049 procedures), two-dimensional ultrasound reduced the risk of inadvertent arterial puncture (three trials, 498 participants, risk ratio (RR) 0.21, 95% confidence interval (CI) 0.06 to 0.82; P value 0.02, I² = 0%) and haematoma formation (three trials, 498 participants, RR 0.26, 95% CI 0.09 to 0.76; P value 0.01, I² = 0%). No evidence was found of a difference in total or other complications (together, US, USD), overall (together, US, USD), number of attempts until success (US) or first-time (US) success rates or time taken to insert the catheter (US). For the femoral vein, fewer data were available for analysis (four studies, 311 participants, 311 procedures). No evidence was found of a difference in inadvertent arterial puncture or other complications. However, success on the first attempt was more likely with ultrasound (three trials, 224 participants, RR 1.73, 95% CI 1.34 to 2.22; P value < 0.0001, I² = 31%), and a small increase in the overall success rate was noted (RR 1.11, 95% CI 1.00 to 1.23; P value 0.06, I² = 50%). No data on mortality or participant-reported outcomes were provided.

AUTHORS' CONCLUSIONS:

On the basis of available data, we conclude that two-dimensional ultrasound offers small gains in safety and quality when compared with an anatomical landmark technique for subclavian (arterial puncture, haematoma formation) or femoral vein (success on the first attempt) cannulation for central vein catheterization. Data on insertion by inexperienced or experienced users, or on patients at high risk for complications, are lacking. The results for Doppler ultrasound techniques versus anatomical landmark techniques are uncertain.

03/08/2016

Echographie clinique en médecine d'urgence

Premier niveau de compétence pour l'échographie clinique en médecine d’urgence

Recommandations de la Société française de médecine d’urgence par consensus formalisé.

TEXTE LONG

Société française de médecine d’urgence 2016

800px-SFMU.jpg

clic sur l'image pour accéder au document

| Tags : échographie

05/06/2016

Echographie pour l'intubation: Plutôt oui.

Tracheal ultrasonography and ultrasonographic lung sliding for confirming endotracheal tube placement: Speed and Reliability

Karacabey S. et Al. Am J Emerg Med. 2016 Jan 26. pii: S0735-6757(16)00037-1. doi: 10.1016/j.ajem.2016.01.027.

BACKGROUND:

In this study we aimed to evaluate the success of ultrasonography (USG) for confirming the tube placement and timeliness by tracheal USG and ultrasonographic lung sliding in resuscitation and rapid sequence intubation.

MATERIALS AND METHODS:

This study was a prospective, single-center, observational study conducted in the emergency department of a tertiary care hospital. Patients were prospectively enrolled in the study. Patients who went under emergency intubation because of respiratory failure, cardiac arrest or severe trauma included in the study. Patients with severe neck trauma, neck tumors, history of neck operation or tracheotomy and under 18years old were excluded from the study.

RESULTS:

A total of 115 patients included in the study. The mean age was 67.2±17.1 with age 16-95years old. Among 115 patients 30 were cardiac arrest patients other 85 patients were non-cardiac arrest patients intubated with rapid sequence intubation. The overall accuracy of the ultrasonography was 97.18% (95% CI, 90.19-99.66%), and the value of kappa was 0.869 (95% CI, 0.77-0.96), indicating a high degree of agreement between the ultrasonography and capnography. The ulrasonography took significantly less time than capnography in total.

DISCUSSION:

Ultrasonography achieved high sensitivity and specificity for confirming tube placement and results faster than end-tidal carbon dioxide. Ultrasonography is a good alternative for confirming the endotracheal tube placement. Future studies should examine the use of ultrasonography as a method for real-time assessment of endotracheal tube placement by emergency physicians with only basic ultrasonographic training.

| Tags : airway, échographie

30/10/2015

Echographie: De l'expérience SVP

Does physician experience influence the interpretability of focused echocardiography images performed by a pocket device?

Bobbia X et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2015) 23:52

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Il existe un très grand engouement concernant l'emploi d'échographe dit de poche. Cet article appelle a être plus circonspect. Sil il s'agit bien de faire rentrer l'échographie dans la pratique quotidienne, encore faut il que cela soit assorti d'une qualification réelle.

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Introduction: The use of focused cardiac ultrasound (FoCUS) in a prehospital setting is recommended. Pocket ultrasound devices (PUDs) appear to be well suited to prehospital FoCUS. The main aim of our study was to evaluate the interpretability of echocardiography performed in a prehospital setting using a PUD based on the experience of the emergency physician (EP).

Methods: This was a monocentric prospective observational study. We defined experienced emergency physicians (EEPs) and novice emergency physicians (NEPs) as echocardiographers if they had performed 50 echocardiographies since their initial university training (theoretical training and at least 25 echocardiographies performed with a mentor). Each patient undergoing prehospital echocardiography with a PUD was included. Four diagnostic items based on FoCUS were analyzed: pericardial effusions (PE), right ventricular dilation (RVD), qualitative left ventricular function assessment (LVEF), and inferior vena cava compliance (IVCC). Two independent experts blindly evaluated the interpretability of each item by examining recorded video loops. If their opinions were divided, then a third expert concluded.

Results: Fourteen EPs participated: eight (57 %) EEPs and six (43 %) NEPs. Eighty-five patients were included: 34 (40 %) had an echocardiography by an NEP and 51 (60 %) by an EEP. The mean number of interpretable items by echocardiography was three [1; 4]; one [0; 2.25] in the NEP group, four [3; 4] in EEP (p < .01). The patient position was also associated with interpretable items: supine three [2; 4], “45°” three [1; 4], sitting two [1; 4] (p = .02). In multivariate analysis, only EP experience was associated with the number of interpretable items (p = .02). Interpretability by NEPs and EEPs was: 56 % vs. 96 % for LVF, 29 % vs. 98 % for PE, 26 % vs. 92 % for RVD, and 21 % vs. 67 % for IVCC (p < .01 for all).

ECHO.jpg

 

Conclusion: FoCUS with PUD in prehospital conditions was possible for EEPs, It is difficult and the diagnostic yield is poor for NEPs.

 

| Tags : échographie

25/07/2015

Echo des voies aériennes

Focused ultrasound for airway management

Tutoriel Philips

 

SANS HĖSITER: IL FAUT S'Y METTRE +++

philps.jpg

Clic sur l'image pour accéder au document

Autres sources 1 2 3

Deux exemples

1. Visualisation de l'épiglotte:

- Vue transverse

IJA-55-456-g001.jpg

- Vue parasagittale

IJA-55-456-g002.jpg

2. Repérage du cartilage cricoïdienne en coupe sagittale ou parasagittale

IJA-55-456-g007.jpg

 3. Réalisation d'une coniotomie

airway,échographie


 

 

| Tags : airway, échographie

20/07/2015

Echo en hélico: Avec formation solide !

Prospective evaluation of prehospital trauma ultrasound during aeromedical transport.

Press GM et Al. J Emerg Med. 2014 Dec;47(6):638-45

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L'apport de l'échographie est incontournable pour la prise en charge des traumatisés. Son emploi en prehospitalier est proposé. Pour autant la mise en oeuvre de ce moyen d'exploration n'est pas si simple et demande une grande expertise. Le travail présenté porte sur la mise en oeuvre de ce type d'exploration par technicinens paramédicaux expérimentés et ayant suivi une formation sur une période de deux mois. malgré cela leur performance reste modeste. Un examen négatif de permet pas de conclure. Ceci plaide pour un peu de modération concernant l'engouement actuel. Comme pour tout il faut investir sur la formation pour être performant.

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BACKGROUND:

Ultrasound is widely considered the initial diagnostic imaging modality for trauma. Preliminary studies have explored the use of trauma ultrasound in the prehospital setting, but the accuracy and potential utility is not well understood.

OBJECTIVE:

We sought to determine the accuracy of trauma ultrasound performed by helicopter emergency medical service (HEMS) providers.

METHODS:

Trauma ultrasound was performed in flight on adult patients during a 7-month period. Accuracy of the abdominal, cardiac, and lung components was determined by comparison to the presence of injury, primarily determined by computed tomography, and to required interventions.

RESULTS:

HEMS providers performed ultrasound on 293 patients during a 7-month period, completing 211 full extended Focused Assessment with Sonography for Trauma (EFAST) studies. HEMS providers interpreted 11% of studies as indeterminate. Sensitivity and specificity for hemoperitoneum was 46% (95% confidence interval [CI] 27.1%-94.1%) and 94.1% (95% CI 89.2%-97%), and for laparotomy 64.7% (95% CI 38.6%-84.7%) and 94% (95% CI 89.2%-96.8%), respectively. Sensitivity and specificity for pneumothorax were 18.7% (95% CI 8.9%-33.9%) and 99.5% (95% CI 98.2%-99.9%), and for thoracostomy were 50% (95% CI 22.3%-58.7%) and 99.8% (98.6%-100%), respectively. The positive likelihood ratio for laparotomy was 10.7 (95% CI 5.5-21) and for thoracostomy 235 (95% CI 31-1758), and the negative likelihood ratios were 0.4 (95% CI 0.2-0.7) and 0.5 (95% CI 0.3-0.8), respectively. Of 240 cardiac studies, there was one false-positive and three false-negative interpretations (none requiring intervention).

échographie

CONCLUSIONS:

HEMS providers performed EFAST with moderate accuracy. Specificity was high and positive interpretations raised the probability of injury requiring intervention. Negative interpretations were predictive, but sensitivity was not sufficient for ruling out injury.

| Tags : échographie

21/06/2015

Pneumothorax en vol: Merci l'écho

In-flight thoracic ultrasound detection of pneumothorax in combat

Madill JJ J Emerg Med. 2010 Aug;39(2):194-7

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Ce cas clinique est intéressant car il démontre que le recours à l'échographie est dans ce cas non seulement possible mais indispensable compte tenu des difficultés d'auscultation en vol. Ceci étant dit il faut cependant être bien conscient du caractère opérateur dépendant de l'échographie qui peut être peu parlante et nécessiter donc une pratique réelle au delà d'une simple formation à la FAST échographie

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Background: Ultrasonography is the only portable imaging modality available in the helicopter medical evacuation environment where physical examination is limited, auscultation is impossible, long transport times may occur, and altitude variations are frequent. Although the use of ultrasonography by aviation medical personnel has been documented, minimal literature exists on the contribution of in-flight ultrasonography to patient management. Objectives: This case demonstrates an indication for the use of in-flight ultrasonography. It shows how it can affect in-flight management and direct lifesaving intervention. 

Case Report: A patient with blast injury developed hemodynamic instability of unclear etiology during transport in the combat aviation environment. To our knowledge, this is the first reported case where in-flight thoracic ultrasonography augmented physical examination and diagnosed an untreated pneumothorax when auscultation was impossible. It directed the decision to perform in-flight procedural intervention with tube thoracostomy. This rapidly improved the patient’s hemodynamic stability in a remote and hostile setting.

Conclusion: In-flight thoracic ultrasonography is a portable imaging tool that can be used by aviation medical personnel to detect pneumothorax in environments where physical examination is limited and auscultation is impossible

03/04/2015

Echographiste en quelques heures ?

Limited intervention improves technical skill in focus assessed transthoracic echocardiography among novice examiners.

Frederiksen et al. BMC Med Educ. 2012 Aug 3;12:65

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La généralisation de l'échographie est une avancée majeure. Mais comment apprendre ? La pratique de l'échographie ciblée se développe notamment en médecine d'urgence. A côté des formations classiques de type DU existent de nombreuses formations de courte durée, certaines de quelques heures. Le travail présenté met en évidence qu'un tel type de formation permet une manipulation relativement fiable des équipements et l'obtention de coupes sonographiques propres à être interprétées. On notera que ceci est obtenu A CONDITION qu'au moins 10 examens supervisés soient conduits, ce qui n'est souvent pas fait avec suffisamment de rigueur dans ce que nous pouvons proposer actuellement. Par ailleurs voir et interpréter de manière fiable ne sont pas superposables (1). 

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BACKGROUNDS:

Previous studies addressing teaching and learning in point-of-care ultrasound have primarily focussed on image interpretation and not on the technical quality of the images. We hypothesized that a limited intervention of 10 supervised examinations would improve the technical skills in Focus Assessed Transthoracic Echocardiography (FATE) and that physicians with no experience in FATE would quickly adopt technical skills allowing for image quality suitable for interpretation.

METHODS:

Twenty-one physicians with no previous training in FATE or echocardiography (Novices) participated in the study and a reference group of three examiners with more than 10 years of experience in echocardiography (Experts) was included. Novices received an initial theoretical and practical introduction (2 hours), after which baseline examinations were performed on two healthy volunteers. Subsequently all physicians were scheduled to a separate intervention day comprising ten supervised FATE examinations. For effect measurement a second examination (evaluation) of the same two healthy volunteers from the baseline examination was performed.

RESULTS:

At baseline 86% of images obtained by novices were suitable for interpretation, on evaluation this was 93% (p = 0.005). 100% of images obtained by experts were suitable for interpretation. Mean global image rating on baseline examinations was 70.2 (CI 68.0-72.4) and mean global image rating after intervention was 75.0 (CI 72.9-77.0), p = 0.0002. In comparison, mean global image rating in the expert group was 89.8 (CI 88.8-90.9).

CONCLUSIONS:

Improvement of technical skills in FATE can be achieved with a limited intervention and upon completion of intervention 93% of images achieved are suitable for clinical interpretation.

| Tags : échographie

31/03/2015

Focus assessed transthoracic Echo (FATE)

Un document pdf qui synthétise les données à connaître pour l'examen échographique cardio-respiratoire. Une approche standardisée appelée est visualisable ici.

FATEcardNew01.png

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| Tags : échographie

24/03/2015

Airway et Echographie

 

Airway Ultrasound.jpg

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| Tags : airway, échographie

22/03/2015

L'échographie: Investir de son temps pour avoir une pratique fiable

Ultrafest: A Novel Approach to Ultrasound in Medical Education Leads to Improvement in Written and Clinical Examinations

Connolly K et All. West J Emerg Med. 2015 Jan;16(1):143-8.

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L'apprentissage de l'échographie est un impératif en médecine d'urgence. Cependant une véritable qualification ne peut être obtenue qu'au travers de formations universitaires assorties de pratiques réelles et régulières. La pratique des certains protocoles simplifiés comme le FAST serait d'acquisition plus simples. Aussi sont souvent proposées des formations de courtes durées. Ces dernières semblent en théorie très intéressantes en contexte militaire. Une analyse raisonnée de la réalité doit tempérer cet enthousiasme. Le travail présenté montre que si les connaissances théoriques des étudiants sont améliorées par une formation d'une journée, cette dernière ne permet pas l'acquisition d'une pratique suffisamment fiable. Ainsi la formation de nos personnels, qui repose souvent sur des formations de courtes durée, doit elle vue comme une découverte de cette pratique et non pas comme permettant l'acquisition d'un réel savoir  faire.

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Introduction:

Our objective was to evaluate the effectiveness of hands-on training at a bedside ultrasound (US) symposium (“Ultrafest”) to improve both clinical knowledge and image acquisition skills of medical students. Primary outcome measure was improvement in multiple choice questions on pulmonary or Focused Assessment with Sonography in Trauma (FAST) US knowledge. Secondary outcome was improvement in image acquisition for either pulmonary or FAST.

 

Methods:

Prospective cohort study of 48 volunteers at “Ultrafest,” a free symposium where students received five contact training hours. Students were evaluated before and after training for proficiency in either pulmonary US or FAST. Proficiency was assessed by clinical knowledge through written multiple-choice exam, and clinical skills through accuracy of image acquisition. We used paired sample t-tests with students as their own controls.

 

Results:

Pulmonary knowledge scores increased by a mean of 10.1 points (95% CI [8.9-11.3], p<0.00005), from 8.4 to a posttest average of 18.5/21 possible points. The FAST knowledge scores increased by a mean of 7.5 points (95% CI [6.3-8.7] p<0.00005), from 8.1 to a posttest average of 15.6/ 21. We analyzed clinical skills data on 32 students. The mean score was 1.7 pretest and 4.7 posttest of 12 possible points. Mean improvement was 3.0 points (p<0.00005) overall, 3.3 (p=0.0001) for FAST, and 2.6 (p=0.003) for the pulmonary US exam.

 

US Ultrafest.jpg

 

Conclusion:

This study suggests that a symposium on US can improve clinical knowledge, but is limited in achieving image acquisition for pulmonary and FAST US assessments. US training external to official medical school curriculum may augment students’ education

| Tags : échographie

07/01/2015

Gonflez le ballonnet à l'eau et échographiez le au niveau de la fourchette sternale !

Tracheal rapid ultrasound saline test (T.R.U.S.T.) for confirming correct endotracheal tube depth in children

Tessaro MO et Al. Resuscitation. 2014 Sep 17. pii: S0300-9572(14)00741-2

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On parle beaucoup de l'apport de l'échographie en préhospitalier et plus particulièrement de l'échographie des voies aériennes. Ce travail réalisé dans un contexte de pédiatrie hospitalière est intéressant car il peut peut-être être transposé à nos besoins. Etre rapidement certain du caractère effectif de l'intubation peut être difficile. L'échographie peut être d'un apport important par la visualisation d'un glissement pleural bilatéral. On peut aussi gonfler le ballonnet de la sonde [Ce qui est fait lors de transports aériens non ou mal préssurisés], ce qui permettra d'observer non un cône d'ombre en arriere du ballonnet mais les structures anatomiques du fait de la transmissions des ondes permise par l'eau présente dans le ballonnet.

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OBJECTIVES: 

We evaluated the accuracy of tracheal ultrasonography of a saline-inflated endotracheal tube (ETT) cuff for confirming correct ETT insertion depth.

METHODS:

We performed a prospective feasibility study of children undergoing endotracheal intubation for surgery. Tracheal ultrasonography at the suprasternal notch was performed during transient endobronchial intubation and inflation of the cuff with saline, and with the ETT at a correct endotracheal position. Ultrasound videos were recorded at both positions, which were confirmed by fiberoptic bronchoscopy. These videos were shown to two independent blinded reviewers, who determined the presence or absence of a saline-inflated cuff. The primary outcome was accuracy of tracheal ultrasonography for appropriate ETT insertion depth.

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RESULTS:

Forty-two patients were enrolled. For correct endotracheal versus endobronchial positioning, pooled results from the reviewers revealed a sensitivity of 98.8% (95% CI=90-100%), a specificity of 96.4% (95% CI=87-100%), a PPV of 96.5% (95% CI=87-100%), a NPV of 98.8% (95% CI=89-100%), a positive likelihood ratio of 32 (95% CI=6-185), and a negative likelihood ratio of 0.015 (95% CI=0.004-0.2). Agreement between reviewers was high (kappa co-efficient=0.93; 95% CI=0.86 to 1). The mean duration of the ultrasound exam was 4.0s (range 1.0-15.0s).

CONCLUSIONS:

Sonographic visualization of a saline-inflated ETT cuff at the suprasternal notch is an accurate and rapid method for confirming correct ETT insertion depth in children.