London USS Level 1
Course
Tim Harris
Emergency Medicine & PHC
Welcome
• Faculty
• Course structure
• Course aims– Level 1 basic knowledge
– After Level 1
– Your folder
• USS is an extension of
Hx Ex - focussed study
USS - History
• Industry to medicine
• Radiology / cardiology to clinical specialties
USS Applications
FAST ?AAA
fluid in Morrissons Pouch
USS Applications
Line PlacementIJ (shown), FV, SCV Pleural & pericardial
effusion
Periarrest - shock
USS Applications
?Cardiac performance Renal tract
– Hydronephrosis (above)
– calculi(Dilated RV shown)
USS Applications
• ?DVT – (compression - here FV)
• RUQ pain - Calculi,
obstruction, infection
Cholelithiasis
USS Applications
• ?FB
– Wood below
• 1st trimester - ?FH,
dates, IUP
free fluid & empty
uterus below
USS applications
• Joint Effusions - eg child irritable hip
• Procedural guidance - nerve blocks, LPs
• Undifferentiated hypotension
• Soft tissue - eg Achilles tendon rupture
• ? tonsillar abscess
RCR - USS training
recomendations
» • urological ultrasound
» • gynaecological ultrasound
» • gastrointestinal ultrasound
» • vascular ultrasound
» • breast ultrasound
» • thoracic ultrasound
» • cranial ultrasound in infants
» • focused emergency ultrasound
» • intensive care ultrasound
» • musculoskeletal ultrasound
RCR USS training
recomendationsLevel 1
SpR 3/4 radiology
- Perform common examns safely
& accurately
- Normal vs pathology
- Dx common abnormalities in
certain organs
- Recognise limitations &
relationship USS vs other
imaging
Level 3
Consultant Radiologist - subspecialty interest
–Tertiary referral
–Complex proceedures
–Teaching / research
Level 2SpR 5 with subspecialty training
- referrals from level1
- recognise almost all pathology
within relevent organ system
- basic USS guided proceedures
- Teach level 1 & research
RCR USS training
recomendations
• Theoretical training
– registered course!!
• Practical Training
– Named supervisor
– Competency assessment & log book
• CPD
RCR Recommendations -
Emergency Medicine at level 1
To be able to use ultrasound in the
context assessment of:
» – focused assessment by sonography for trauma
(FAST)
» – AAA screening/detection in symptomatic
patients
» – peri-arrest scenario for PEA / tamponade/
effusion
» – vascular access
» – pleural and pericardial fluid
RCR Recommendations - ICM /
Critical Care at level 1
• Thorax– Pleural effusions, consolidation & guided
drainage, pericardial effusion
• Abdomen– Free fluid, hydroneprosis, bladder distention
• Vascular– AAA, veins vs arteries & patency, line placement,
features CCF
• Nerve blocks
ICM - Anaesthesia (RCA)
• Focussed on periarrest echo (CCM 2007)
– Identify courses PEA• FEEL 1 day course imported from Germany
• 5 sec look during CPR if ?PEA (at 2 mins with checks)
• Call out findings - large RV, empty heart, effusion etc
– Support ILCOR 2005
– WINFOCUS• FEEL - beginner, FEER (SHOC) - level 1
Level 1- CEM Position
• Std of knowledge EPs expected to have achieved by SpR yr 4
• Knowledge base by 2010
• Theory – Anatomy
– Physics & set up of USS system
– limitations
– Image recording
– Artifacts
– Safety & consent
– Pathology vs normal
Level 1 - Training
• Training with named supervisor
– (ED or Radiology)
• Supervisor - level 2 or
level 1 + 1 yr experience
• Assessment by supervisor
• Registered course
• 5 examns pw
Level 1 training
• Goal is competency not rigid number of scans
• Experience concentrates on
– ? AAA, FAST, vascular access, periarrest
USS
• Nominally 50 logged cases, half supervised,
10 with case histories
– 20 ?AAA, 20 FAST, 10 vascular access
Level 1 - Skill maintainance
• CPD
• All EPs seeking accreditation require assessment within 3/12 of this course
• If > 3/12 elapses between scans reassess with DOPS
• Dept - governance, training meetings, nominated lead
• Keep up to date with literature
• Regional trainer
Medico-Legal
• Write in notes -
date/time/findings/limitations
• Printed image to notes
• Store images for review
• Dept protocol & framework
• Radiology / cardiology
RCR
“All who provide an ultrasound service are ethically and legally vulnerable if they have not been adequately trained. National Health Service (NHS) Trusts in the UK, which provide professional indemnity to practitioners, are unlikely to be able to mount any defence to an action brought against an untrained practitioner”
Course Format
• Day 1– Background - physics, knobology, image acquisition, buying kit
– Level 1 - FAST (pleura), AAA
• Day 2– Level 1 - peri-arrest/shock, vasular access
– Beyond level 1 - GB, renal, soft tissue,
DVT, gynaecology
• Lecture, practical, recap
• Stations– Two stations per session
• Models & Patients
• Assessment forms
Questions?
USS - a few terms
• A (amplitude)
• B (brightness, anatomical imaging)
mode
• M Mode (motion)
• Doppler
• contrast
• …and 3(4)D!
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