MatthewL.Lutynski,DOLieutenantCommander,MedicalCorps,USNavy

Radiologist,WRNMMC

AssistantProfessorDepartmentofRadiology,USUHS

Point of Care Ultrasound

(POCUS)

≠POTUSPOCUS

Disclosure

• Nofinancialdisclosures

• Productnameslistedduringthispresentationdonotimplyendorsement

•  ThethoughtsandviewsofthispresentationdonotinanywayreflecttheofficialviewpointoftheDepartmentofDefenseortheUnitedStatesNavy

Goals and Objectives

• Discussabriefhistoryofultrasoundandthepathtowardcurrentapplications

• Discusssomepitfallswiththeultrasoundmodality

• Discussafewwaystooptimizeultrasoundimages

1895X-ray 1940’s

Ultrasound Early1970’sCT Late1970’s

MRI

http://www.ob-ultrasound.net/history1.html

The Somascope Life Magazine 1954

The “Pan-Scanner” 1957

http://www.ob-ultrasound.net/history1.html

Nothingtoeatordrink4hoursbefore

yourtest.

Bringabathingsuitandtowel.

Obstetrics

• Routine20weekanatomicsurvey

•  Troubleshooting:•  1sttrimesterdating•  1sttrimesterbleeding•  Size/datemismatch

TwoofthestrongestriskfactorsforDDHareafemalenewbornwithafrankbreechpresentationatbirthandafamilyhistoryofaparentand/orsiblingwithDDH.Itisrecommendedthatthesepatientsundergoultrasoundscreeningat4to6weeksafterbirth.

https://www.aium.org/resources/guidelines/hip.pdf

Addinghand-heldorAutomatedBreastUltrasound(ABUS)tomammographyinwomenwithdensebreastsincreasescancerdetectionrate(alsoincreasesfalse-positiverate)

Cardiology

TraumaSurgery

Pediatrics

Radiology “owned” ultrasound versus POCUS?

• Diverseapplications

• Miniaturizationofequipment

•  Lessequipmentoverheadcosts

•  Incorporationintotrainingprograms

NEJM 370;12. March 20, 2014

NEnglJMed2011;364:749-57

Agency for Healthcare Research and Quality

2013updateon2001report

http://www.ob-ultrasound.net/history1.html

"Further results of the Ultrasonic Investigation of Brain illnesses" September 1952

Dussik’s Apparatus 1946

Karl Dussik Andpleasebringyoursnorkel.

1946

http://www.ob-ultrasound.net/history1.html

Modern Ultrasound

http://www3.gehealthcare.com

“Thenextstethoscope”

1st year Medical Students vs

Board Certified Cardiologists

Sensitivity Specificity

MedicalStudents+POCUS

75% 87%

Cardiologists+PhysicalExam

49% 76%

AmJCardiol2005;96:1002-6.

Abilitytoidentifysignificantcardiacabnormalities

Consequence of Early Exposure?

Inmyexperience…

Old Dog NewTrick

What are appropriate case volumes for competency? •  Cardiologyfellowstypicallyrequire4to6weekstolearnthebasicechocardiographicexamination

NEJM370;12.March20,2014

•  SAEMrequiresinvolvementinonly150sonographicexaminations•  Only50%ofthesestudiesrequiredtobeonpatientswithclinicalindicationsfor

sonographyAnnEmergMed1994;23:95–102

•  FamilyPracticesuggeststhatonly25–75examinationsareneededforcompetencytoperformfetalbiometryandfetalanatomicsurveys

ClinUltrasound1991;19:479–483JFamPract1990;30:163–168JFamPract1992;34:186–200

•  10firstyearradiologyresidents

AJR:174, May 2000

False-positives•  Traineereportedafindingnotseenbysonographerandattendingphysicianteam

False-negatives•  Traineefailedtoidentifyafinding

Interpretiveerrors•  Traineeaccuratelysawfindingsbutincorrectlyinterpretedthem

AJR:174, May 2000

Take-Aways:•  Studyencompassesarangeofdifferentexams(versusasingleexamthataspecialistmayperform)

• Performancevariationfrom1residenttoanother• Progressiveimprovement

•  Thosethatstartedwithhighperformancetendedtocontinuetooutpacepeers(operatordependence)

• Riskofclinicallysignificanterrors(falsenegatives)withexposureto200orlessstudies

AJR:174, May 2000

Practical Considerations for POCUS Implementation •  No“risk”ofradiation

•  Competencyrequirements

•  How/Whethertorecordfindings(PACS)•  Whatobligationtomakeimagesandinterpretationofimagesavailabletopatientsandotherproviders

•  How/Whethertobillfortheseprocedures•  Bedsidetoollikethestethoscope•  Formalultrasound

Attenuation

FeldmanMK,KatyalS,BlackwoodMS.“USArtifacts.”RadioGraphics2009;29:1179-1189

Artifacts in Ultrasound

Reverberation

Reverberation“A-Line”artifactinlungultrasoundRadiology: Volume 283: Number 1—April 2017

Anisotropy • Appearsmorehyperechoicwhenbeamisperpendicular

• Appearsmorehypoechoicwhenthebeamisdirectedawayfromthetransducer

• Correction:•  Rocktransducertodifferentiatefatorsuspectedtendinosisfromanormalfibrillarstructure

https://radiopaedia.org/articles/anisotropy

Focused Assessment with Sonography in Trauma (FAST)

Radiology: Volume 283: Number 1—April 2017

•  Sensitivitytodetecthemoperitoneumbetween69-98%

•  Sensitivitytodetectsolidorganinjury63%

Thoracic Ultrasound

•  Therearemanyprotocolsforthoracicultrasoundevaluation

•  ExtendedFAST(eFAST)•  BedsideLungUltrasoundinEmergency(BLUE)

•  RapidAssessmentofDyspneainUltrasound(RADIUS)

•  Etc…

•  DetectionofpneumothoraxUltrasoundsensitivityof48.8%Chestx-raysensitivity20.9%

Radiology: Volume 283: Number 1—April 2017

ExtendedFAST(eFAST)

Radiology: Volume 283: Number 1—April 2017

Abdominal Ultrasound

2of2

CoronalT2 AxialLAVAwithFatSaturationNon-contrast

Differential Diagnosis •  “Physiologic”

•  Abscess/Hemorrhage•  Ascites•  Peritonealdialysis/VP

shunt•  EpithelialOvarianNeoplasm•  Post-operativeLymphocele

LEFTOVARY,BENIGNSEROUSCYSTADENOMA(5Liters)

Abdominal Ultrasound Pearls

•  “Physiologic”freefluidinfemalesshouldbe<50mL

• Hyperacutehemoperitoneummaybenearlyanechoicandcanincreaseincomplexityovertime

•  Lookforfloatingbowelloopsormesentericfatinthecaseofascites

Vascular Ultrasound

VV

V

TransverseSagittal

Sternocleidomastoid

CCA

Axial Longitudinal

Vascular Ultrasound Pearls

• Veinsshouldcompress

•  Echogenicthrombus,wallabnormalities,orvalves(veins)cancauseintraluminalfillingdefects

Superficial Ultrasound

AxialT1

AxialT1PostContrastwithFatSat

AxialT2withFatSaturation

RightThyroid

Trachea

CommonCarotid

Superficial Ultrasound Pearls

•  Lipomaisnotaccuratelydiagnosedwithultrasound

• Applygenerousamountsofgeloruseawaterbathtopreventcompressionofsuperficiallesions

• Don’tjustfocusonyour“areaofinterest”

• Befamiliarwithvariousultrasoundartifacts•  Anisotropy•  DirtyShadowing•  Reverberation

Summary

•  Discussabriefhistoryofultrasoundandthepathtowardcurrentapplications

•  Discusssomepitfallswiththeultrasoundmodality

•  Discussafewwaystooptimizeultrasoundimages

References •  CarraBJ,Bui-MansfieldLT,O’BrienSD,ChenDC.SonographyofMusculoskeletalSoft-TissueMasses:Techniques,Pearls,andPitfalls.AJR2014;202:1281–1290.

•  Hertzberg,BS.etal.PhysicianTrainingRequirementsinSonography:HowManyCasesAreNeededforCompetence?AJR2000;174:1221–1227.

•  KobalSL,TrentoL,BaharamiS,etal.Comparisonofeffectivenessofhand-carriedultrasoundtobedsidecardiovascularphysicalexamination.AmJCardiol2005;96:1002-6.

•  Moore,CL.CopelJA.CurrentConcepts:Point-of-CareUltrasonography.NEnglJMed2011;364:749-57.

•  RichardsJR,McGahanJP.FocusedAssessmentwithSonographyinTrauma(FAST)in2017:WhatRadiologistsCanLearn.Radiology:Volume283:Number1—April2017

•  Solomon,SD.Saldana,F.Point-of-CareUltrasoundinMedicalEducation–StopListeningandLook.NEnglJMed370;12.March20,2014.

•  MakingHealthCareSaferII:AnUpdatedCriticalAnalysisoftheEvidenceforPatientSafetyPractices.AgencyforHealthcareResearchandQualityPublication.2013.

•  PrimaryCareScreeningforAbdominalAorticAneurysm:ASystematicEvidenceReviewfortheU.S.PreventiveServicesTaskForce.AgencyforHealthcareResearchandQuality.PublicationNo.14-05202-EF-1.Rockville,MD.2014.