Authors: Betül Gülalp, Prof.
Date: 3 August 2017

Appreciation and Respect To

Authors,

Ultrasound Users In Survival of Patients

 Emergency Medicine

All Who Walk Together Heartily With Emergency Ultrasound in the World

 

Although a serious path has been taken, there is currently a lack of research conducted on patients in the Emergency Department (ED) related to the heart and the vasculature with Point of Care Ultrasound (Pocus).

The primary responsibilities of Emergency Medicine are patient survival and the differential diagnosis and intial treatment of the patient’s condition.  With this in mind, there are two issues to discuss regarding use of Doppler to evalute the heart and vasculature of patients admited to the ED.

1. Doppler measurements are not used during point-of-care ultrasonography. However, identification of heart conditions such as diastolic heart failure, pulmonary artery pressure etc is essential to plan treatments in the ED.  

2. Blood vessels abnormalities can be a sign or cause of a number of disease states. Evaluation of the blood flow patterns within heart and the vessels could provide clues to several life-threatening conditions.

Finally, there have been reports of lawsuits resulting from perceived faulty point-of-care ultrasonography performed by Emergency Physician (EP ) in the ED; the few cases that exist are grounded on accusations of failure to perform ultrasonography, delayed ultrasonography, or ultrasonography that did not evaluate the vasculature of the patient’s extremities, all of which resulted in death of the patient.

Thus, more focus should be placed on evaluating the heart and main vasculature, including the use of focused doppler measurements, even for those patients who are stable but present to the ED with new symptoms.

Here we will summarize a few manuscripts describing evaluation of the vasculature of the extremities of patients in the ED. 

*Images of manuscripts are not shared; Manuscripts were chosen from free accesible articles on pubmed.

 

 

Shaukat NM, Taha F, Vortsman E, Desai P, Kindschuh M.

Diagnosis of abdominal mural aortic thrombus following discovery of common femoral artery and vein thrombosis by point-of-care ultrasound.

J Ultrasound. 2015 Oct 6;18(4):415-20.

 

Who?

A 79-year-old female, morbid obesity, with diabetes mellitus type 2, hypertension, atrial fibrillation on Varfarin, had a past surgical history of left femoral-popliteal bypass graft with a below-the-knee amputation presented to the emergency department (ED) with a poor appetite and pain in the right leg for 3 days.

 

Physical Examination?

First vital signs were in normal range at presentation except; Pulse was 108 beats/min,

respirations were 18 breaths/min, SatO2 was 92 %.

The lungs demonstrated wheezing bilaterally.

The abdomen was mildly tender diffusely, without rebound or guarding.

Right lower extremity was pale and cold.

At 30th min, the patient was decompansated and increased tenderness was found on abdomen.  

An echogenic material was seen in the right common femoral artery (CFA) by transverse B-mode ultrasound image.

Partial flow was visualized on the common femoral (CFV) and great saphenous veins (GSV), while no flow on common femoral arterial (CFA) by transverse color flow Doppler ultrasound image.

 

 

Montorfano MA, Pla F, Vera L, Cardillo O, Nigra SG, Montorfano LM.

Point-of-care ultrasound and Doppler ultrasound evaluation of vascular injuries in penetrating and blunt trauma.

Crit Ultrasound J. 2017 Dec;9(1):5.

 

Point-of-care ultrasound and Color flow duplex Doppler ultrasound are widely available, noninvasive, sensible and specific techniques used at bedside. The study reviewed the point-of care ultrasound and Doppler of penetrating and blunt trauma-related vasculary injuries on extremities and neck.

 

Immediate surgical intervention indications in extremities and neck trauma;

 

* Mentioned as pulsatile external bleeding,

* Expanding haematoma,

* Absent distal pulses,

* Cold/pale limb,

* Palpable thrill, or audible bruit, called  “Hard Signs” on physical examination

 

Which Probe?

The suitable probe is the linear one with high-frequency and low-penetration. If you can’t reach the lesion, curve linear probe is preferable.

 

Steps in looking for vascularities;

* 2 plane scanning is required; Transvers and longitudinal axis with B-mode.

* Proximal and distal flows should be confirmed with Color Doppler and duplex Doppler.

 

Clues of distinction in structures;

Veins;

* Generally oval shaped

* Anechoic,

* Definitely and completely compressible with probe.

* The pulsed wave Doppler shows a continuous and spontaneous flow at rest and the velocity increasing during inspiration, while decreasing in expiration or with Valsalva maneuver.

* Augmentation Test; Active compression of distal veins provides the increase the velocity of the venous flow.

 

Arteries;

* Round shaped,

* Echogenic wall,

* Noncompressibility

* A triphasic pattern with pulsed Doppler. (Systole of left ventricle-closure of aortic valve-elasticty)

 

             The absence of this triphasic pattern can be both in acute and chronic.

             In any suspician, compare the image within another healthy extremity.

 

Venous injuries;

Traumatized veins may suffer;

*Partial or complete disruption,

*Intimal injury,

*Post-traumatic thrombosis; After minutes or hours after the trauma

Acute thrombosis; Dilated vein and uncompressible.

Chronic thrombosis; More echogenic thrombus, undilated vein, partially collapsible.

Color Duplex Doppler; Differentiation of the presence or absence of blood flow and the direction and velocity of the flow.

Partial thrombosis; Normal or pathologic flow, loss of variability in respiration.

Total thrombosis; Absence of flow both in color and PWD.

 

Arterial injuries

Generally a slight wall irregularity are occured. Intimal detachments, pseudoaneurysms, or arteriovenous fistula are seen in serious injury.

 

Intimal flaps;

*Appear as thin, echogenic structures

* Swimming within the vessel

* Sometime changes in PWD and CFD

* Sometimes turbulence and irregular flow

 

Pseudoaneurysm;

* Partial rupture of an artery wall

* Surrounded by the adventitia, hematomas, or soft tissue.

* Presence of a pseudoaneurysm neck

 

The most common cause is an interventional medical procedure, and then 

penetrating trauma, by gunshot or stab wound are another causes.

 

Arteriovenous fistula

* Anechoic or hypoechoic image, similar to a hematoma,

* Arterialization

* Containing moving echoes

* Pulsatile hematoma

* Swell during systole.

* Swirling motion; A colorized yin–yang sign; Aliasing

* Turbulent flow

* “To-and-Fro.” on the neck

* Bidirectional

* A murmur and thrill may be present

* Hemodynamic alterations may be.

* Presence of a color mosaic (aliasing)

* High flow turbulence.

* High systolic and diastolic velocities with loss of systolic windows

 

 

Mennitt K, Deol M, Gao J.

Emergency color Doppler sonography of the extremity artery: A pictorial essay.

Clin Imaging. 2017 Mar - Apr; 42:240-248.

 

Introduction

It is a review conclude in suspicion of traumatic arterial injuries and acute arterial ischemia on extremities in emergency department.

Methods

This study was included a total of 500 adult retrospective cases performed arterial Doppler US vascular color duplex sonography (CDUS) could assess the arterial morphology and hemodynamy.

Clinical indications; Extremity pain, swelling, trauma, peripheral vascular abnormality following cardiac catheterization, cold limb, and weakness or absence of pulse.

The required training is take part of the residency programs both radiology and emergency physicians.

Performer was an ultrasound technologist in conjunction with an emergency radiologist.

Initial point for upper extremity is the nearest to the aortic arch with scaning of

the brachiocephalic (right) or subclavian (left) arteries to the distally. For lower extremities, it was the inguinal ligament through ankle.

Gray scale; Shape, size, plaques, thrombus (sometimes could be seen, not necessary)

Color flow; Abnormal blood flow as indicated by increased velocity,

flow turbulence, and decreased flow.

Spectral analysis; Velocity measurements

Doppler waveform patterns; Patency of the artery and vein, the severity

of arterial stenosis (peak systolic velocity), and the direction of flow in both arteries and veins.

Sound beam of transducer; Should be 0-60 degree to the flow direction for spectral analyses. The most ideal one is getting beam to paralel to the flow.

Results

The common diagnosis are:

*Atherosclerotic disease;

*Pseudoaneurysm; The common site is the right femoral artery. Treatment; Ultrasound-guided compression, percutaneous ultrasound-guided thrombin injection, or surgical repair

*Arterial aneurysm; Appearance of a dilated native artery or an arterial

graft. Complications; Thrombosis and rupture. Treatment: Stent placement, or surgical repair.

*Arteriovenous fistula; Mixed arterial and venous Doppler waveform, increased flow rate, turbulence.

*Arterial occlusion (Thrombosis or Embolism); Echogenicity, extension of arterial plaques, narrowed arterial lumen,  increased wall echogenicity, irregularity on the wall, abnormal blood flow, elevated velocity, turbulence, reduction in flow velocity. Increased luminal echogenicity can be seen with thrombosis embolus.

 

 

Infinite Respect To

All Emergency Medicine in the World,

Presenting their life to save patients’

&

Everyone who values and supports ​​Emergency Medicine cordially

 

 

Betül Gülalp, Prof.

EMATUS web coordinator. Anyone...Behind the passion and heart...

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