Ultrasound at the Point of Care
By Robert Tillotson, DO, RDMS, FACEP, FAAEM
Medical Director, Emergency Department, Emergency Ultrasound Director
Ministry Saint Michael’s Hospital, Stevens Point, WI
A 15-year-old presents to the Emergency Department after a smoke bomb blew up in his face. His cornea is opacified from burns, making it impossible to see his anterior chamber, iris, lens, vitreous or retina. As in most trauma cases, this patient presents with a potential life or limb (eye) threatening complaint with a clear barrier to a correct diagnosis; whether it is an opacified cornea or the skin, the definitive diagnosis is hidden, leaving the emergency physician in the dark.
Coming out of the Darkness
The introduction of point-of-care ultrasound into the frontline of emergency medicine has had a tremendous impact on patient care. From the immediate, life-saving diagnosis of pericardial tamponade or ruptured ectopic pregnancy, to the reassurance of a frightened pregnant patient with vaginal bleeding, point-of-care ultrasound in emergency medicine has proved invaluable.
Since its initial introduction into emergency medicine as the “FAST” exam in trauma, the indications for point-of-care ultrasound have become wide-sweeping and continue to evolve. It has become a core educational component of all ACGME Emergency Medicine Residencies. As a result, bedside ultrasound is now the new standard of care in emergency medicine.
Evolution of the FAST Exam
The “FAST” (Focused Abdominal Sonography in Trauma) exam’s primary purpose is the identification of blood in the abdomen or pericardial sac in the trauma patient. Trauma algorithms utilize the FAST examination for trauma triage, the decision for surgical exploration in the unstable patient and identification and treatment of pericardial tamponade. It has virtually eliminated diagnostic peritoneal lavage. In recent years the literature has shown that ultrasound surpasses X-rays and approaches the sensitivity and specificity of CT scan for the diagnosis of pneumothorax. The FAST exam has incorporated this technique into the enhanced FAST (or eFAST) examination by adding the two lung views for evaluation of pneumothorax. Pericardial tamponade and tension pneumothorax can present with similar clinical findings. Ultrasound can noninvasively differentiate the two at the bedside, directing the appropriate clinical intervention.
The AHRQ (Agency for Healthcare Research and Quality), in report 43, identified 11 items that would have a major impact on patient safety. Ultrasound-guided central venous access was number eight on the list. There is significant literature showing that ultrasound improves the success rate of catheter placement and reduces complications like carotid puncture.
Into the Spotlight
Ultrasound has provided a way for the Emergency Physician to make rapid life- and limb-saving diagnoses right at the bedside. It has brought the emergency physician out of the darkness by shining a spotlight on bedside diagnoses hidden from us in the past.