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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.

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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

Clic sur l'image pour accéder au document

| Tags : échographie

24/03/2015

Airway et Echographie

 

Airway Ultrasound.jpg

Clic sur l'image pour accéder au document

 

 

| 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.

EchoAIrwayBallon.jpg

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.

10/12/2014

Echographie: 10 bonnes raisons POUR

Ten good reasons to practice ultrasound in critical care 

 Lichtenstein D. et AL Anaesthesiol Intensive Ther. 2014 Nov-Dec;46(5):323-35

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Le document proposé est une réflexion faite par un des promoteurs mondial de l'échographie pulmonaire. Il s'agit donc d'un document référence à lire en cliquant sur le lien proposé dans le titre.

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Abstract 

Over the past decade, critical care ultrasound has gained its place in the armamentarium of monitoring tools. A greater  understanding of lung, abdominal, and vascular ultrasound plus easier access to portable machines have revolutionised he bedside assessment of our ICU patients. Because ultrasound is not only a diagnostic test, but can also be seen as a component of the physical exam, it has the potential to become the stethoscope of the 21st century. Critical care ultrasound is a combination of simple protocols, with lung ultrasound being a basic application, allowing assessment of urgent diagnoses in combination with therapeutic decisions. The LUCI (Lung Ultrasound in the Critically Ill) consists of the identification of ten signs: the bat sign (pleural line); lung sliding (seashore sign); the A-lines (horizontal artefact); the quad sign and sinusoid sign indicating pleural effusion; the fractal and tissue-like sign indicating lung consolidation; the B-lines and lung rockets indicating interstitial syndromes; abolished lung sliding with the stratosphere sign suggesting pneumothorax; and the lung point indicating pneumothorax. Two more signs, the lung pulse and the dynamic air bronchogram, are used to distinguish atelectasis from pneumonia. The BLUE protocol (Bedside Lung Ultrasound in Emergency) is a fast protocol (< 3 minutes), also including a vascular (venous) analysis allowing differential diagnosis in patients with acute respiratory failure. With this protocol, it becomes possible to differentiate between pulmonary oedema, pulmonary embolism, pneumonia, chronic obstructive pulmonary disease, asthma, and pneumothorax, each showing specific ultrasound patterns and profiles. The FALLS protocol (Fluid Administration Limited by Lung Sonography) adapts the BLUE protocol to be used in patients with acute circulatory failure. It makes a sequential search for obstructive, cardiogenic, hypovolemic, and distributive shock using simple real-time echocardiography in combination with lung ultrasound, with the appearance of B-lines considered to be the endpoint for fluid therapy. An advantage of lung ultrasound is that the patient is not exposed to radiation, and so the LUCI-FLR project (LUCI favouring limitation of radiation) can be unfolded in trauma patients. Although it has been practiced for 25 years, critical care ultrasound is a relatively young but expanding discipline and can be seen as the stethoscope of the modern intensivist. In this review, the usefulness and advantages of ultrasound in the critical care setting are discussed in ten points. The emphasis is on a holistic approach, with a central role for lung ultrasound.

 

| Tags : échographie

07/12/2014

Echographe et situation isolée: Quid en 2013 ?

Ultrasound in the Austere Environment: A Review of the History, Indications, and Specifications

Russel TC et AL. Military Medicine, 178, 1:21, 2013

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L'échographie s'est très largement démocratisée et du fait des améliorations technologiques continues est en passe de devenir un outil incontournable non seulement en médecine d'urgence (1) mais tout simplement en médecine générale. La maîtrise de cette pratique est donc incontournable pour tout médecin militaire projeté. Cependant connaître une technique et la maîtriser sont deux choses différentes, c'est dire l'importance non seulement de la nature des formations initiales et surtout des modalités de maintien des compétences (2). Intégrer cet outil dans son raisonnement clinique impose une réflexion personnelle sur son niveau d'expertise comme celui de pouvoir réaliser de manière fiable l'acquisition de toutes les coupes d'une FAST Echo en 5 min. D'autres indications plus médicales sont bien réelles voire même plus fréquentes. Très certainement, le recours à des outils de simulation trouvera très rapidement une place (3)

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In the last 10 years, the use of ultrasound has expanded because of its portability, safety, real-time image display, and rapid data collection. Simultaneously, more people are going into the backcountry for enjoyment and employment. Increased deployment for the military and demand for remote medicine services have led to innovative use and study of ultrasound in extreme and austere environments. Ultrasound is effective to rapidly assess patients during triage and evacuation decision making. It is clinically useful for assessment of pneumothorax, pericardial effusion, blunt abdominal trauma, musculoskeletal trauma, high-altitude pulmonary edema, ocular injury, and obstetrics, whereas acute mountain sickness and stroke are perhaps still best evaluated on clinical grounds. Ultrasound performs well in the diverse environments of space, swamp, jungle, mountain, and desert. Although some training is necessary to capture and interpret images, real-time evaluation with video streaming is expected to get easier and cheaper as global communications improve. Although ultrasound is not useful in every situation, it can be a worthwhile tool in the austere or deployed environment.

 

| Tags : échographie

02/12/2014

Echo: Quels requis ?

L’échographie ciblée en médecine d’urgence. Nouvelles normes et applications avancées. Position conjointe de l’Association des médecins d’urgence du Québec (AMUQ) et de l’Association des spécialistes en médecine d’urgence du Québec (ASMUQ) adoptée le 7 novembre 2012 

La pratique de l'échographie aux urgences est très régulière. Si des formations courtes permettent un apprentissage rapide de techniques de débrouillage comme la FAST Echo, seule une pratique régulière encadrée permet l'acquisition d'une véritable expertise. Le tableau présenté rappelle les prérequis nécessaires à un exercice indépendant chez nos cousins québécois.

EChoREquis.jpeg

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| Tags : échographie

22/11/2014

Echographie en role2/3

Trauma resuscitation using echocardiography in a deployed military intensive care unit

Hutchings Sj et Al. JICS 2013:14, 120-125

Casualties with severe traumatic injury frequently suffer haemodynamic instability. There is interest in the use of transthoracic echocardiography (TTE) to  assess haemodynamic status in intensive care resuscitation. We describe a feasibility study of focused TTE (fTTE) echocardiography in trauma resuscitation in a deployed military setting. fTTE was performed on patients admitted to ICU following severe injury. Data were collected on TTE view availability, LV function, volume status, and inferior vena cava (IVC) dimensions. Doppler of the LV outflow tract was performed to provide a velocity time integer (LVOT VTi) as an indicator of preload. Twenty-three patients were recruited, and 48 individual studies performed. TTE windows available were: parasternal long axis-68%, parasternal short axis-66%, apical 4-chamber-64%, subcostal-66%. IVC imaging was possible in 85%, and LVOT VTi Doppler in 37%. The mean maximal IVC diameter in volume-optimised patients (Group 1, n=19) was 2.07 cm (±0.07), compared with 1.47 (±0.06) in the hypovolaemic cohort (Group 2, n=23). The mean minimum IVC diameter in Group 1 was 1.93(±0.07) vs 1.03(±0.08) in Group 2. IVC collapsibility was 3.16% (±1.61%) in Group 1 vs 30.81%(±1.62) in Group 2. In 12%, profound hypovolaemia with systolic LV cavity obliteration was noted. fTTE suggested hypovolaemia in 69% of patients on admission to the study. Of patients arriving on the ICU following damage-control resuscitation only 31% were volume-optimised. fTTE led to a change in volume management strategy in 47% of cases. This study demonstrates, for the first time in a deployed military setting, that intensivist-delivered fTTE is feasible and changes resuscitation strategy in almost half of patients admitted to a deployed ICU.

30/10/2014

The Blue protocol

Lung ultrasound in the critically ill

Lichtenstein D. Annals of Intensive Care 2014, 4:1

 

Une approche systématisée de l'échographie pulmonaire simpllfie et fiabilise cet examen. C'est ce qu'explique cette publication  

BlueProtocol.jpg 

Lung ultrasound is a basic application of critical ultrasound, defined as a loop associating urgent diagnoses with immediate therapeutic decisions. It requires the mastery of ten signs: the bat sign (pleural line), lung sliding (yielding seashore sign), the A-line (horizontal artifact), the quad sign, and sinusoid sign indicating pleural effusion, the fractal, and tissue-like sign indicating lung consolidation, the B-line, and lung rockets indicating interstitial syndrome, abolished lung sliding with the stratosphere sign suggesting pneumothorax, and the lung point indicating pneumothorax. Two more signs, the lung pulse and the dynamic air bronchogram, are used to distinguish atelectasis from pneumonia. All of these disorders were assessed using CT as the “gold standard” with sensitivity and specificity ranging from 90% to 100%, allowing ultrasound to be considered as a reasonable bedside “gold standard” in the critically ill. The BLUE-protocol is a fast protocol (<3 minutes), which allows diagnosis of acute respiratory failure. It includes a venous analysis done in appropriate cases. Pulmonary edema, pulmonary embolism, pneumonia, chronic obstructive pulmonary disease, asthma, and pneumothorax yield specific profiles. Pulmonary edema, e.g., yields anterior lung rockets associated with lung sliding, making the “B-profile.” The FALLS-protocol adapts the BLUE-protocol to acute circulatory failure. It makes sequential search for obstructive, cardiogenic, hypovolemic, and distributive shock using simple real-time echocardiography (right ventricle dilatation, pericardial effusion), then lung ultrasound for assessing a direct parameter of clinical volemia: the apparition of B-lines, schematically, is considered as the endpoint for fluid therapy. Other aims of lung ultrasound are decreasing medical irradiation: the LUCIFLR program (most CTs in ARDS or trauma can be postponed), a use in traumatology, intensive care unit, neonates (the signs are the same than in adults), many disciplines (pulmonology, cardiology…), austere countries, and a help in any procedure (thoracentesis). A 1992, cost-effective gray-scale unit, without Doppler, and a microconvex probe are efficient. Lung ultrasound is a holistic discipline for many reasons (e.g., one probe, perfect for the lung, is able to scan the whole-body). Its integration can provide a new definition of priorities. The BLUE-protocol and FALLS-protocol allow simplification of expert echocardiography, a clear advantage when correct cardiac windows are missing.