Bedside ultrasound case: Fibroids, Syncope and Dyspnea. #FOAMed, #FOAMus, #FOAMcc

So today, a 33F presented following syncope. She was mildly tachypneic wiyh a HR of 135 and BP of 130/80. I’m inserting the clip of my bedside ultrasound evaluation, as this takes place essentially simultaneously with my history-taking:

So this clip runs thru a few views, starting with an IVC long axis, showing a relatively plethoric IVC with minimal variation. This is not normal. Tells me to expect something abnormal downstream, unless someone has flooded the patient with IV fluids. The next view is the parasternal long, then short axis, showing an increased RV to LV ratio, and a small, hypercontractile LV, with septal flattening consistent with RV pressure overload, the “D” sign.  The apical 4 chamber follows with little else to add (difficult to measure TAPSE well in that segment).

So this is sure looking like pulmonary embolism, and I’m already toying with a half dose TPA, MOPETT-style, until the reveals that the cause of her starting oral contraceptives two months ago was to control heavy menses associated with large uterine fibroids… So I figure I’ll buy myself some decision time anyhow by ordering the CT angio – unless in pre-arrest, I don’t thrombolyse without formal confirmation – but I did start IV heparin on the echo findings. Here is the CT:

So this indeed confirms submissive embolism, particularly to the left PA.

Next?  I work in a community hospital, and although I’m totally comfortable thrombolysing PE, in this case, I was concerned about bleeding related to the fibroids, and I haven’t yet figured out a way to embolize bleeding vessels at the bedside, so I felt that the safest thing was to transfer her to a tertiary care center with a solid interventional radiology program. So off she went. I’ll update if anything funky was done like a catheter suction and I can get some clips.

So in terms of POCUS, I think this illustrates how speedily a diagnosis can be made, and although in this case the pre-test probability and index of suspicion was pretty high, it isn’t always!

cheers!

 

Philippe

 

For more POCUS tips, see here!

POCUS in cardiac arrest: Great, but avoid Pitfalls! #FOAMed, #FOAMus

So just wanted to briefly review POCUS technique during arrest. What I like to do is to position my probe for a subxiphoid view while CPR is ongoing, and try to see what I can. It may look like this:

 

The best is to record a loop and review it immediately, in order to be able to focus properly on each important area and let CPR continue. For instance, in the clip above, there is a lot of information. There is a pericardial effusion, but clearly visible cardiac chambers make tamponade as the sole reason of the arrest unlikely (atrial pressures > pericardial pressure). The RV is not huge and crushing the LV, so massive PE – although not ruled out – probably isn’t the cause of arrest. 

Be wary, however, of making calls based on RV appearance or RV to LV ratios as representing PE in a nonbeating heart, as this is not necessarily representative of the state of the RV or RV/LV ratio immediately pre-arrest.

More Posts to come on the topic of peri-arrest POCUS…

Cheers,

For more POCUS tips, see here!

Philippe

CCUS Institute Mini-Fellowships: A Highlight and CME Update!

First of all, I just wanted to share some feedback I just received today, which to me exemplifies the impact that exposure can have. It’s now been about fifteen years since I independently picked up a probe (the cardiology department was decimated in my shop when I started there, and there was an unused full-sized echo machine that no one noticed or cared if I took), and maybe twelve years since the development of the first POCUS courses (shout out to my friend Dr. Yannick Beaulieu, intensivist-sonographer-inventer extraordinaire who started the first FOCUS course – now run by CAE), and although the FOAMed world is full of POCUS, the real world is still lagging behind.  But I think that’s about to change, and we should see the second generation of clinician-sonographers getting into the trenches soon. I’d call it a very slow explosion. But I have a feeling there is a lot brewing under the surface…

So, back to the feedback. A young internist, Dr. Alexandre Lafleur, joined me for a 2 or 3 day Mini-Fellowship in the ICU at Scarborough General Hospital a few years ago, and I remember he had quite a few “lightbulb” moments, where he clearly saw the immense clinical application of POCUS.  I just recently asked him for some feedback which he was kind enough to give me:

« I have had the chance to participate in a shadowing experience with Dr Rola at the Scarborough General Hospital ICU during two days in 2013. As a general internist and assistant program director, this experience really opened my eyes regarding the use of bedside ultrasound in general internal medicine and for IM residents. I think I would have benefited more of this experience if I had done more training previously, and I encourage future participants to do so. However, I came back from this experience with a very clear idea of the benefit of CUSE for my patients and for our residency training program. I really saw how ultrasound was used ‘in action’, in a much more realistic way than what is usually shown in CPD meetings. I also saw its limitations and the skills I needed to develop to generate good images (not something you can learn over the weekend!). Since then, I participated in formal trainings and licensing activities (more than 250 supervised US on acute care patients) and now practice bedside ultrasound autonomously. We now offer a bedside ultrasound training for our residents with the help of the emergency medicine department and an ultrasound-guided procedural simulation lab. Nothing in CPD has improved my practice and benefited the health of my patients as much as bedside ultrasound training. »

Alexandre Lafleur, MD, MSc (Ed.), FRCPC
Spécialiste en médecine interne
CHU de Québec – CHUL
alexandre.lafleur.1@ulaval.ca

Wow. So I can’t see a better scenario. From someone who had minimal ultrasound ability in 2013, to now an educator and policy decision-maker in the field. Absolutely fantastic. I am honoured to have triggered this domino effect. I am certain he has now countless tales of how POCUS saved the day.

 

CME now available!

So, great news, finally went thru the CME process and lo and behold, the Mini-Fellowships qualify for 25 Section 2 credits (regardless of the length) and 3 hours of Section 3 credits (per day of fellowship). For you americans:

Through an agreement between the Royal College of Physicians and Surgeons of Canada and the American Medical Association, physicians may convert Royal College MOC credits to AMA PRA Category 1 Credits™. 

See here for more info about the Mini-Fellowships.

Bedside Ultrasound Case: Control the source. #POCUS #FOAMed, #FOAMcc, #FOAMus

So this morning a 65yr old man with shock and respiratory failure was admitted to the ICU, hypotensive on levophed and vasopressin, with a lactate over 10.

So, as usual, my first reflex was to reach for the probe to assess hemodynamics. He had been well resuscitated by a colleague, and the IVC was essentially normal, somewhere around 15 mm and still with some respiratory variation. However, scanning thru the liver, my colleague had noted a large hepatic lesion, which on CT scan (non-infused since patient had acute renal failure) the two radiologists argued whether it was solid, vascular or fluid filled.

image

Having the advantage of dynamic ultrasound, you can tell that there is some fluid motion within the structure, very suggestive of an abcess, especially in the context of severe septic shock:

So the next step was source control:

 

Pretty nasty. Pardon my french!

We got over 1.5 L of exceedingly foul pus.

imageimage

Within a couple of hours the lactate dropped to 3 and the levophed was down by more than half.

I think this case illustrates once again, the power of POCUS in the hands of clinicians.  While I am certain that the diagnosis would have been made without POCUS, it probably would have taken additional time as the radiologists themselves were debating its nature, and without POCUS, bedside drainage in the ICU would have been out of the question. That liter might still be in there tonight…

For those interested in how to integrate POCUS in their daily rounds, I think I put together a fair bit of clinical know-how and tips in this little handbook.

 

Cheers!

 

Philippe

Bedside Ultrasound: a primer for clinical integration. #POCUS

screen-shot-2016-10-28-at-1-11-48-am

So I had a lot of people ask me over the years to put to paper (or screen) a POCUS book, but I figured there were so many good ones out there, like my original Bible, General Ultrasound in the Critically Ill by my good friend Daniel Lichtenstein, or Vicky & Bret’s book, Emergency and Critical Care Ultrasound, that I would be trying to re-invent the wheel, and probably not doing as good a job.

But then I remembered Dubin’s EKG book, the kind of book you could almost read in a single sitting, and certainly over a few days, and get a decent grasp of the concepts and actually have some skill at the end of it.  So I figured maybe I could put together something like that for POCUS from the standpoint of clinical integration. Not so much a protocol, but how you fit your findings together in clinical syndromes, and inserting as many tips and pearls as possible.

It’s a light read, it’s irreverent, it’s kinda like #FOAM. So I hope I did a decent enough job, and I was pretty happy with the comments from a couple of respected colleagues:

Philippe has created a fantastic real-time reference for the busy practicing clinician who wishes to adopt point of care ultrasound into their working cinical armamentarium. The strength of this work is it’s immediate applicability to the clinical scenario. Dr. Rola’s extensive experience in clinical practice and teaching shines through with a concise and clinically minded approach to each scanning modality. The work is greatly enriched by many practical tips and tricks and that are often missing from larger, more formal texts. The sum of these “truths” is an important part of what transforms a clinician to an expert in the field. A final unique feature of this resource is it’s focus on integration. In Philippe’s mind, findings of differing ultrasound modalities are blended together with the patient’s clinical picture to derive a true ultrasound enhanced understanding of the patient’s pathophysiology. With characteristic plain language and descriptions, the book succeeds in taking the reader closer to that vision.

Dr. Edgar Hockmann, MD, FRCP

Dr. Rola has created the ideal compendium for contemporary healthcare professionals. Bedside Ultrasound: a primer for clinical integration concisely and intuitively describes the essentials of examining a patient in the 21st century. The guide is both unique and useful because it speaks to all levels of training for all professionals caring for patients within multiple hospital environments – the emergency department, general medical ward, operating room and intensive care unit. Dr. Rola’s succinct account of ultrasound examination leads the reader through a patient’s anatomical and physiological underpinnings using the ultrasound probe as his guide; it is a resource to be found in the pocket – virtual or otherwise – of all those interested in the future of the physical exam.

Jon-Emile Kenny M.D.

The first print run just got off the press, is on Amazon here, as is our casebook, and on our website http://www.ccusinstitute.org. The iPad version is available on iTunes here! Please give me feedback as it is important, so that the second edition just gets better!

cheers!

Philippe

Canadian Society of Internal Medicine does Lung Ultrasound!

ccus-logo

csim-logo

Happy to be hosting a satellite event for the CSIM Annual meeting taking place in Montreal.  As an internist, I’ve been long wanting to see my colleagues working on the wards integrate bedside ultrasound into their practice. After all, as an ICU guy, i try to catch the patients spiralling down. However, bedside ultrasound in the care of hospitalized patients should actually have a greater impact! Wait, I hope I’m not promoting myself out of a job here… Oh well it is for the patients’ benefit.

But it’s true, preventing deterioration is best done well…prior to the deterioration.

Anyhow, looks like we’re gonna have a pretty good day, focused on lung ultrasound:

 

csim-bedside-lung-ultrasound-program-2016-local-registration-only

 

The faculty – besides me – is excellent: Andre Denault and Georges Desjardins are pros at doing and teaching, and workshop instructors Ian Ajmo and Philippe St-Arnaud, intensivist colleagues from my shop’s team, are great too.

I’m hoping that the echo-naive participants leave fully convinced that practicing acute care without ultrasound is essentially unethical, given today’s accessibility to the technology.  I hope they can see that it out-does the most educated guesses we can muster, most of the time. Because that is what we do when held to the limitations of physical exam, even if DeGowin, Bates and Shapira were doing the physical exams themselves…

cheers!

 

Philippe

 

MOPOCUS: A great synopsis by Ha & Toh. #FOAMed, #FOAMcc, #FOAMus

Just came across this review and figured I should share. The authors make a great synopsis and review of POCUS in acute illness:

MOPOCUS Review by Ha &To

The only thing I would add to this is a more physiological way to assess the IVC, which I’ve blogged about here.  Sadly, I’ve heard a few people stating how they didn’t want to get into the dogma of IVC ultrasound, that it wasn’t reliable, etc.  The IVC doesn’t lie. It’s just not a recipe. The IVC findings have to be integrated into the rest of the echo graphic and clinical examination.  Trying to use it as a single value is akin to using serum Na+ as a diagnostic test for volume. It works only sometimes.

Please spread among the POCUS non-believers. We’ll convert them, slowly but surely. But the sooner, the better for the patients. Again, there’s no excuse to practice acute care without ultrasound. It’s not right. I’m not saying every probe-toting MD is better than one without, but everyone would up their game by adding POCUS, once past the learning curve!

cheers!

 

Philippe