Applications of Transcranial Color‐Coded Sonography in the Emergency Department

Transcranial color‐coded Doppler sonography is a noninvasive bedside ultrasound application that combines both imaging of parenchymal structures and Doppler assessment of intracranial vessels. It may aid in rapid diagnoses and treatment decision making of patients with intracranial emergencies in point‐of‐care settings. This pictorial essay illustrates the technical aspects and emergency department applications of transcranial color‐coded Doppler sonography, and provides some rationale for implementation of this technique into the emergency department practice.     

Focused assessment with sonography for trauma patients by clinicians: Initial experience and results

Objectives: To describe the establishment of a service to provide bedside focused assessment sonography in trauma and to evaluate the service to date. Setting: Emergency department of an urban trauma centre. Methods: A prospective study of trauma patients who received a focused assessment sonography in trauma examination performed by a clinician managing the trauma in the emergency department. Accuracy was determined by comparing the scan interpretation with abdomino‐pelvic computerized tomography, laparotomy or postmortem examination. Results: The study period ran from 1 January 2000 to 11 September 2001 inclusive (20 months). One hundred and forty patients were included, with a final diagnosis established by computerized tomography (n = 124) and/or laparotomy (n = 18). There were 26 true‐positives, 101 true‐negatives, two false‐positives and 11 false‐negatives. Ten of the false‐negative studies were performed by clinicians who had not reached accreditation. The sensitivity of focused assessment sonography in trauma was 70%, specificity 98% and diagnostic accuracy 91%. Conclusions: We have described the implementation of a clinician‐based focused assessment sonography in trauma service within the emergency department with the support of radiology/ultrasound and trauma service. Processes for credentialling, quality assurance and training need to be in place. Significant issues exist with the length of time it takes clinicians to reach accreditation, in order that a critical mass of clinicians exists to provide a consistent service. The credentialling process should mandate a minimum number of supervised examinations.     

Asteroid Hyalosis Masquerading as Vitreous Hemorrhage on Point‐of‐Care Sonography

Point‐of‐care ocular sonography is frequently used in the emergency department to evaluate patients with vision disorders. We describe a case series of 3 patients who ultimately had a diagnosis of asteroid hyalosis, a lesser‐known condition that on point‐of‐care sonography may be mistaken for vitreous hemorrhage. Asteroid hyalosis is considered a benign degenerative condition. In contrast, vitreous hemorrhage may be an ocular emergency that warrants an urgent ophthalmologic consultation if there is an underlying retinal tear or detachment. Although similar in appearance on sonography, recognition of the subtle pathognomonic sonographic features along with their clinical presentations can differentiate these diseases, with vastly different management strategies and dispositions.     

Five Cases of Axillary Lymph Node Metastatic Breast Cancer on Contrast‐Enhanced Sonography

This study was performed to determine the importance of contrast‐enhanced sonography for axillary lymph node metastatic breast cancer. Contrast‐enhanced sonographic findings in 5 patients with breast cancer and axillary lymph node metastasis are discussed, and imaging‐pathologic correlations are also presented in 3 cases. In all 5 cases, lymph nodes showed a perfusion defect in the late phase. Rapid arterial enhancement and wash‐out were observed in 2 cases in which we performed second injections. Contrast‐enhanced sonography may be effective for identifying metastatic lesions in lymph nodes, especially in the early stages.     

Evaluation of extremity trauma with sonography.

OBJECTIVE: To report on the use of bedside sonography in the diagnosis and treatment of penetrating extremity trauma. METHODS: Sonography was performed in the emergency department of a level 1 trauma center with both curved and linear array transducers. RESULTS: In both cases, foreign bodies and fractures resulting from gunshot wounds to the extremities were found. In addition, intra-abdominal and thoracic injuries were evaluated for using sonography. CONCLUSIONS: The increasing mobility and portability of sonography has led to its increasing use at the patient' bedside to diagnose a variety of conditions. It provides potential immediate diagnosis and has the flexibility for evaluating a multitude of injuries normally requiring several different imaging technologies. In circumstances in which conventional radiography is unavailable, such as at trauma scenes, mass casualty situations, or at the bedside with unstable patients, sonography can provide unique and essential information about these patients.     

Multiparametric Sonography of Hematologic Malignancies of the Testis: Grayscale,Color Doppler,and Contrast‐Enhanced Ultrasound and Strain Elastographic Appearances With Histologic Correlation

Primary testicular lymphoma is rare and appears with nonspecific findings on grayscale and color Doppler sonography. We present 8 patients further examined with contrast‐enhanced sonography, strain elastography, and histologic analysis after orchiectomy. Seven of 8 patients had a diagnosis of large B‐cell lymphoma, and 1 of 8 had a diagnosis of granulocytic sarcoma, with solitary lesions (2 of 8), multiple lesions (3 of 8), or entire testicular involvement (3 of 8). Lesions appeared hypoechoic (7 of 8) or isoechoic (1 of 8), all with increased vascularity on color Doppler sonography and a nonbranching linear pattern of intratumoral vessels (7 of 8). Contrast‐enhanced ultrasound (CEUS) confirmed this pattern and showed increased enhancement in all lesions. On strain elastography, all lesions were hard, with an elasticity score of greater than 4. Multiparametric sonography of testicular lymphoma identifies increased vascularity on color Doppler and contrast‐enhanced ultrasound and increased lesion stiffness on strain elastography.     

Transcranial Doppler Sonography is Useful for the Decision-Making at the Point of Care in Patients with Acute Hepatic Failure: A Single Centre’s Experience

Acute hepatic failure (ALF) is an uncommon disease characterized by a rapid deterioration of the hepatic function with severe derangements of the mental status in previously healthy subjects due to massive hepatocytes necrosis. Neurological impairment, due to intracranial hypertension and cerebral ischemia, is a key factor because it is a main criterion to decide when to proceed to liver transplantation, which is only treatment for these patients. Therefore, neurological monitoring holds an essential role in the clinical management of ALF patients but it needs to be performed at the point-of-care in the majority of the cases as such critically ill patients cannot be moved away from the ICU because they frequently need continuous hemodynamic, ventilatory and renal support. We herein report and discuss our experience relating to the use of transcranial sonography as a neuro-monitoring tool in ALF patients. In our series this technique allowed a repeatable and reliable non-invasive assessment of cerebral blood flow changes at the bedside thus avoiding the complications associated with the use of an intracranial probe to measure intra-cranial pressure and making it possible to correctly evaluate the timing and feasibility of liver transplantation. Bindi ML, Biancofiore G, Esposito M, Meacci L, Bisà M, Mozzo R, Urbani L, Catalano G, Montin U, Filipponi F. Transcranial Doppler sonography is useful for the decision-making at the point of care in patients with acute hepatic failure: a single centre’s experience.     

Contrast‐Enhanced Sonographically Guided Thermal Ablation for Treatment of Solid‐Organ Hemorrhage

The purpose of this series was to preliminarily evaluate the use of contrast‐enhanced sonographically guided percutaneous thermal ablation in the evaluation and treatment of solid‐organ bleeding by retrospectively analyzing 6 cases observed in clinical practice. Six patients who underwent contrast‐enhanced sonographically guided thermal ablation for treatment of solid‐organ bleeding (5 in liver and 1 in spleen) from December 2005 to August 2012 were included in this series. Clinical information, contrast‐enhanced sonograms before and after ablation, and the ablation method were retrospectively collected and analyzed. In 5 of the 6 patients, the location of the bleeding lesion was clearly seen. Hemostasis was successfully achieved in 4 of these 5 patients: 1 by radiofrequency ablation and 3 by microwave ablation. Ablation failed to achieve hemostasis in 1 patient who had postbiopsy splenic arterial bleeding because the bleeding vessel was a thick branch of the splenic artery. In the sixth remaining patient, who had bleeding after liver biopsy, hemostasis failed because contrast‐enhanced sonography did not precisely locate the bleeding lesion; hence, the ablation zone did not cover the whole lesion. Contrast‐enhanced sonographically guided ablation can be an alternative choice for treating solid‐organ bleeding because of its effectiveness and minimal invasiveness. However, it should be carefully investigated for those in whom the bleeding lesion cannot be located by contrast‐enhanced sonography and in those who have bleeding in a large vessel.     

Contrast‐Enhanced Sonographic Follow‐up After Stenting of Visceral Artery Aneurysms

We report 2 cases of exclusion of visceral artery aneurysms. The first was a common hepatic artery aneurysm treated with a multilayer stent; the second was a celiac trunk aneurysm excluded by a covered stent. Computed tomographic angiography was performed at regular intervals after each procedure, together with echo color Doppler imaging and contrast‐enhanced sonography. Computed tomographic angiography and contrast‐enhanced sonography were able to detect endoleaks in both patients and the related inflow vessel; moreover, diameter measurements of the sacs were identical. In our preliminary experience, contrast‐enhanced sonography appeared to be as accurate as computed tomographic angiography after endovascular visceral artery aneurysm exclusion.     

The Ultrasound‐Only Central Venous Catheter Placement and Confirmation Procedure

The placement of a central venous catheter remains an important intervention in the care of critically ill patients in the emergency department. We propose an ultrasound‐first protocol for 3 aspects of central venous catheter placement above the diaphragm: dynamic procedural guidance, evaluation for pneumothorax, and confirmation of the catheter tip location.     

Contrast‐Enhanced Sonographic Characteristics of Hepatic Inflammatory Pseudotumors

A hepatic inflammatory pseudotumor, which can be misdiagnosed as a malignant tumor, is a relatively uncommon tumor with nonspecific imaging manifestations. As a new diagnostic technique, contrast‐enhanced sonography has become increasingly important in the diagnosis of liver focal lesions. Here we present 3 cases of histologically confirmed hepatic inflammatory pseudotumors diagnosed with contrast‐enhanced sonography. “Fast‐in and centrifugal‐out” may be a characteristic contrast‐enhanced sonographic enhancement pattern in the diagnosis of hepatic inflammatory pseudotumors, which needs confirmation in further studies.     

Evaluation of the abdomen in the critically ill patient: opening the black box

PURPOSE OF REVIEW: Evaluation of the abdomen in critically ill patients can be challenging. This article reviews the available data and proposes evidence-based guidelines for evaluation of the abdomen in the critically ill patient. RECENT FINDINGS: The critically ill are often clinically unevaluable due to distracting injuries, respiratory failure, obtundation, or other conditions. Even when patients can be examined, the clinical exam can be unreliable and misleading. Critically ill patients who are sufficiently stable to undergo imaging benefit from computerized tomography unless biliary sepsis is suspected, when ultrasound is preferred. There is an important role for endoscopy and angiography in the setting of gastrointestinal hemorrhage, as well as magnetic resonance imaging for mesenteric ischemia. Critically ill patients who are too unstable for imaging may require bedside laparoscopy or diagnostic peritoneal lavage. Abdominal compartment syndrome should be considered in the differential diagnosis of the unstable critically ill patient. Empiric laparotomy may still need to be employed in diagnosis and management of unstable patients. SUMMARY: Timely and accurate diagnosis of life-threatening intraabdominal pathology is essential to care for critically ill patients. A multitude of laboratory, radiologic, and interventional modalities are available to evaluate the abdomen in the critically ill.     

床边超声对机械通气患者膈肌功能评估的研究进展

膈肌功能障碍在重症患者中发病率高,是导致患者呼吸衰竭和延迟机械通气撤离的重要原因,且易被忽视。以往传统评估膈肌结构和功能的方法具有创伤性,缺乏特异性,且不便于床旁应用,而超声评估膈肌功能和结构具有准确、安全、无创等优点。床旁超声通过测量膈肌活动度、膈肌厚度和膈肌厚度变化率评估膈肌功能,临床用于鉴定膈肌功能障碍及膈肌功能丧失,监测膈肌萎缩程度和做功能力及人机同步性,并用于预测撤机结果。本文阐述床边超声对机械通气患者膈肌功能评估的进展及存在的问题,为临床采用该技术提供指导和帮助。     

Multiparametric Sonography of Testicular Hematomas

We investigated the appearances of intratesticular hematomas on multiparametric sonography combining grayscale, color Doppler, and contrast‐enhanced sonography and strain elastography. Over a 3‐year period, 17 hematomas in 8 patients were analyzed. Blunt trauma (n = 7) and surgery (n = 1) were preceding events. Grayscale sonography showed well‐defined oval or round predominantly hypoechoic and heterogeneous, peripherally (n = 13) or centrally (n = 4) located lesions. Three showed contrast enhancement of septations, and 4 showed peripheral lesion rim enhancement. On strain elastography, the mean strain ratio was 1.19 (range, 0.41–2.36), and elasticity score were 3 or lower (n = 13) and 5 (n = 4). Multiparametric sonography shows nonenhancement with contrast and predominantly “soft” elastographic properties and aids in the interpretation of the benign nature of intratesticular hematomas.     

Identification and Complications of Cosmetic Fillers

Cosmetic fillers are frequently used these days for enhancing beauty and to treat wrinkles or sagging skin. However, information on the history of injections may be difficult to obtain, and there is a growing number of reports on complications with these agents. In contrast to other imaging techniques, sonography has been successfully used for detecting and identifying common types of cosmetic fillers and has become the first‐line imaging modality to deal with these exogenous components.     

Therapeutic endoscopic retrograde cholangiopancreatography without fluoroscopy in four critically ill patients using wire-guided intraductal ultrasound

Emergent endoscopic retrograde cholangiopancreatography cannot be performed at the bedside in critically ill patients in an intensive care unit because of the requirement for fluoroscopy. Moving such patients to a safe location where fluoroscopy is available can pose practical problems, and can lead to delayed intervention, which may adversely affect the outcome. We report the use of intraductal ultrasound to facilitate therapeutic biliary interventions in four critically ill patients in an intensive care unit. Cannulation was performed endoscopically at the bedside using a sphincterotome and a guide wire. Intraductal ultrasound, rather than fluoroscopy, was then used to confirm the location of the wire within the common bile duct prior to performing endoscopic sphincterotomy or stent placement. This technique was successful in all four patients.     

Contrast‐Enhanced Sonography for Monitoring Neoadjuvant Chemotherapy in Soft Tissue Sarcomas

Neoadjuvant chemotherapy is a mainstay in treating soft tissue sarcomas. Soft tissue sarcomas can show an increase in size and central necrosis, with a decrease in the viable tumor, as an initial response to neoadjuvant chemotherapy. Thus, the maximum tumor diameter may not reliably assess the response to this therapy. Contrast‐enhanced sonography may address this limitation. We evaluated 4 patients with soft tissue sarcomas by contrast‐enhanced sonography, performed concomitantly with conventional imaging (computed tomography, magnetic resonance imaging, or positron emission tomography). Quantitative analysis was also performed on 1 sarcoma. A viable, enhancing tumor versus tumor necrosis was nearly identical on contrast‐enhanced sonography and conventional imaging. Preliminary results demonstrate potential for contrast‐enhanced sonographic monitoring of soft tissue sarcomas during neoadjuvant chemotherapy.     

Bedside sonographic control for positioning enteral feeding tubes: a controlled study in intensive care unit patients

BACKGROUND AND STUDY AIM: The correct placement of an enteral feeding tube in the duodenum in critically ill patients is usually controlled radiographically. However, a direct bedside method that obviates the need for exposure to radiation would be preferable. The aim of this study was to demonstrate the usefulness of bedside sonographic position control for placing enteral feeding tubes in critically ill patients. PATIENTS AND METHODS: After placement of the enteral feeding tube, the position of the tip was determined using bedside transabdominal ultrasound. Native ultrasound was enhanced by injection of air bubbles into the feeding tube. The tube was regarded as being correctly positioned when the tube was visualized within the second or third parts of the duodenum. Plain abdominal radiographs with contrast served as the gold standard test. RESULTS: A total of 76 consecutive examinations were analyzed. In 12 patients, access to the upper abdominal wall was not possible because of open wounds; in another 13 patients who had undergone extensive abdominal surgery, the duodenum could not be identified and so no conclusion could be reached regarding the position of the tube. In 51/76 patients (67 %) ultrasound identified the duodenum and it was possible to determine the position of the tube (46 true positives and 2 true negatives); the position was incorrectly diagnosed in three patients. The sensitivity was 96 % (95 %CI 87 % - 98 %) and the specificity was 50 % (95 %CI 36 % - 65 %), with a positive predictive value of 94 %. CONCLUSIONS: Bedside sonographic control of the positioning of enteral feeding tubes is very sensitive and can be a valuable alternative to radiological control, especially in patients without open abdominal wounds, external installations, or extensive abdominal surgery.     

Assessing liver function

PURPOSE OF REVIEW: This is a review on the techniques for assessing liver function in critically ill patients. RECENT FINDINGS: Actually, there is no ideal real-time and bedside technique for assessing liver function in critically ill patients. Though not allowing to differentiate between liver blood flow and cell function, dynamic tests, that is indocyanine green plasma disappearance rate and lidocaine metabolism (monoethylglycinxylidide test), are superior, however, to static tests. Recently, the indocyanine green plasma disappearance rate, which nowadays can be measured reliably by a transcutaneous system in critically ill patients, was confirmed to correlate well with indocyanine green clearance. In general, the indocyanine green plasma disappearance rate is superior to bilirubin, which is still used as a marker of liver function, and comparable or even superior to complex intensive care scoring systems in terms of outcome prediction. Furthermore, indocyanine green plasma disappearance rate is more sensitive than serum enzyme tests for assessing liver dysfunction and early improvement in the indocyanine green plasma disappearance rate after onset of septic shock is associated with better outcome. SUMMARY: Since no ideal tool is currently available, dynamic tests such as indocyanine green plasma disappearance rate and monoethylglycinxylidide test may be recommended for assessing liver function in critically ill patients. The indocyanine green plasma disappearance rate has the advantage, however, of being measurable noninvasively at the bedside and providing results within a few minutes.