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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

Clic ici pour accéder au document

| 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.

 

24/06/2013

Pneumothorax: Echographie

 Husain LF et All. Sonographic diagnosis of pneumothorax.

J Emerg Trauma Shock 2012;5:76-81

Position de la sonde 

Pneumothorax_Sonde.jpg

Images normales

Le glissement pleural        Vidéo

La chauve-souris

Pneumothorax_Images Noramales1.jpg

Le bord de plage

Pneumothorax_Images Normales2.jpg

Les lignes B

Pneumothorax_Images Normales3.jpg

 

Images Anormales attestant du pneumothorax

Pas de glissement                                                        Vidéo 

Le signe du Barcode

Pneumothorax_Images PasNormales1.jpg

Les lignes A

Pneumothorax_Images PasNormales2.jpg

Le point poumon

Pneumothorax_Images PasNormales3.jpg

Le pouls pulmonaire

lung.left-lung-pulse.M-mode-300x225.jpg

 

Pour aller plus loin:

Un cours commenté

Un diaporama du BMP

 

05/05/2013

Echographe: Bien régler pour bien voir

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Reanoxyo_n°28-2_03.jpg

Reanoxyo_n°28-2_04.jpg

| Tags : échographie

06/04/2013

Échographie abdomino-pelvienne d’urgence

L’échographie clinique s’est développée en médecine d’urgence depuis plusieurs années pour devenir incontournable. De nombreuses études ont montré son efficacité et son intérêt en médecine d’urgence tant extrahospitalière qu’intrahospitalière. Un transfert progressif de compétences s’est opéré entre les radiologues d’une part, les spécialistes ayant intégré les ultrasons dans leur pratique courante (cardiologues, gynéco-obstétriciens, etc.) d’autre part et les médecins urgentistes. De fait, la question principale d’aujourd’hui n’est plus « pourquoi faire ? », mais « comment faire ? ». Après avoir choisi le bon appareil et la bonne sonde, une des réponses à cette question consiste à choisir des indications et des incidences précises et focalisées répondant à des besoins cliniques et non pas seulement diagnostiques. Répondre, par exemple, aux questions posées par une douleur abdominale implique un raisonnement médical intégrant de nombreuses variables parmi lesquelles certaines peuvent être explorées par l’échographie d’urgence. Il n’est donc pas question, tout du moins dans un premier temps, de rechercher des lésions fines au chevet du malade, mais plutôt de repérer des anomalies directes ou indirectes s’intégrant dans un syndrome plus général.Du fait de la richesse potentielle des informations fournies par une échographieabdominale, une attitude pragmatique est donc la plus adaptée.

L'article

| Tags : échographie

06/04/2012

Echographie Pulmonaire

Glissement pleural

http://www.sonosite.com/education/learning-center/117/11381

http://www.sonosite.com/education/learning-center/117/11384

Pneumothorax

http://www.sonosite.com/education/learning-center/58/1425

http://www.sonosite.com/education/learning-center/59/1401

Epanchement

http://www.youtube.com/watch?v=X1E7OgOLzw0