Ultrasound in the field

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.

pseudoknot

Full Member
Lifetime Donor
15+ Year Member
Joined
Jan 1, 2004
Messages
2,923
Reaction score
6
http://northeast2.tbo.com/content/2009/nov/04/ne-local-paramedics-get-new-diagnosis-tool/

From the article:
Having experienced first-hand the life-saving potential of ultrasound machines when he worked several years ago in Tampa General Hospital's emergency room, he dreamed of possessing similar transportable tools for the city's 45-member team of firefighter-paramedics.

His vision recently turned into reality when his department received three such interior body scan machines, each valued at $18,000. They were funded through a state Emergency Medical Services grant and the county's Community Investment Tax.

The cutting-edge technology allows paramedics to do on-the-spot patient diagnoses to check for internal bleeding or lacerations to the kidneys, liver or spleen. If life-threatening injuries are found, patients are transported to Tampa General, a Level 1 trauma center.

The Temple Terrace department is the first in the state to equip its rescue units with the portable machines commonly used in combat situations by American troops.

"We may even be the first department in the Southeast to have these tools," Chapman said. "I have no doubt, however, they will catch on because they can make a difference in the outcome of trauma patients."

Dean Christensen, the department's medical director, helped write the protocol for the paramedics' pre-hospital use of the technology. Charlotte Derr, ultrasound director at TGH and an assistant professor of internal medicine at the University of South Florida, provided the training. Prior to taking the machines out on the road, every paramedic was required to complete 25 scans.

"They basically went through the same process TGH's medical staff does," Chapman said.

He would like his rescue crews to get into a routine of doing ultrasound scans on all blunt trauma patients who experience abdominal pain, whose pulse rates are high or are otherwise unstable.

All scans are saved and made available to emergency room personnel. They are also kept by the department for quality assurance purposes.

I'll be interested to see what happens with this. I imagine it could help reduce overtriage of trauma patients, but I also would be concerned about the effects on scene times.

Members don't see this ad.
 
I would be interested to see what the goal is wrt how this changes management in the prehospital setting.
 
If this is done in the back of the bus while on the way to the hospital, okay but how good an image can you get with that? Otherwise I'm afraid this will be just another excuse to waste time on-scene (A la medics doing a full 'work-up' on an obvious STEMI while idling on scene).

Changing managment? Well, per current evidence, as far as I know, transport on major trauma/MOI should be to the nearest level 1 or 2 center anyway. Do you really think any EMS provider is going to allow their medics to take the risk of mistriaging someone to a non trauma center based on their FAST exam?

So are we going to allow them to do pericardiocentesis? What else could this be used for then. Uhh, heart murmurs?

Edit: here's an article that sums up the current evidence.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2657261/?tool=pubmed

Seems like most of the evidence comes from flight physicians performing FAST in the heli. I'm sorry but I honestly don't see the point of doing one mid-flight. You're already headed to the Level 1 Trauma center where you can do an accurate ultrasound without the vibrations/seat belt constraints and unless you suspect tamponade, how is mgmt going to change?
 
Last edited:
Members don't see this ad :)
...yes continue on to the level 1 trauma center...
 
As many here know, I'm a huge EMS advocate (and remain a current paramedic) but I just don't see the benefit of US in the field as currently available and discussed.

I did see a handy-dandy little toy at NAEMSP that MIGHT become useful if the price drops low enough. It is an all-in-one single hand-holdable unit designed for US guided IV starts.

I think this is a technology in search of a field application at present.

Take care,
Jeff
 
I did see a handy-dandy little toy at NAEMSP that MIGHT become useful if the price drops low enough. It is an all-in-one single hand-holdable unit designed for US guided IV starts.

I think this is a technology in search of a field application at present.

Take care,
Jeff
I seem to recall an article in the EM literature that U/S did not significantly change IV start success... but anyway...

Most progressive communities work pulseless cardiac arrests in the field rather than transport them lights and sirens, at least until they get a pulse back. Most of us have seen the studies how terrible all providers are at palpating a pulse.

In the ED I've been ready to call a code when the ultrasound demonstrated coordinated cardiac activity. We continued and the patient eventually had a return of spontaneous circulation and went to the cath lab, (35 yo woman with LAD lesion). She would have been dead if we had been in the field.

Still not sure if we can justify trying to train all those medics, but worth considering, especially at our program where EM residents respond to all cardiac arrests.
 
I seem to recall an article in the EM literature that U/S did not significantly change IV start success... but anyway...
There was one study in Annals that showed no difference with and without ultrasound. However, the study randomized U/S vs non at the outset, rather than selecting difficult sticks after a set number of attempts. Since most IV starts are not difficult, it would be hard to find any utility in such a study. A number of other studies have found that U/S does help with difficult IV access.

Most progressive communities work pulseless cardiac arrests in the field rather than transport them lights and sirens, at least until they get a pulse back. Most of us have seen the studies how terrible all providers are at palpating a pulse.

In the ED I've been ready to call a code when the ultrasound demonstrated coordinated cardiac activity.
I don't know how many "progressive communities" there are. I suspect we would do better by encouraging the use of rational field termination protocols and working codes on scene. Actually, I'd think the benefit from U/S in codes might be earlier termination, not the reverse. Interesting idea.
 
U/S is big in Irag and Afghanistan b/c it can triage serious abd or lung penetrations from injuries that are non-penetrating, but just look bad. And, there are many more applications where x-ray and CT are not available.

In the civilian setting, the applications are obvious for remote hospitals, or long transit times when the decision has to be made whether to call for medivac or not.

In urban settings, an EFAST to eval for pneumo and free fluid can change immediate mgmt or trigger the surgery team earlier.
 
I think a huge problem with EMS U/S even if there is a use for it is that it will only go to wealthy urban areas with 10 minute transport times. How will this change management in such a setting? The military is quite different in terms of infrastructure, acuity, and type of trauma.
 
I had a small sonosite with me in rural haiti last summer. we used it mostly for pregnancy issues( r/o ectopic, position at term, single or twins, etc) as well as for help in the triage of pts with abd pain as our referal hospital was > 3 hrs away over a very bumpy road in the back of a pickup truck. in that setting it was nice to have.
having worked as a medic before pa school I don't think field u/s would be all that helpful for urban ems:
difficult vascular access? just use an IO instead.
trauma evals? it would be very operator dependent...it would suck to downgrade a pts triage status and take them to a non-trauma receiving facility due to a "nl" fast exam only to realize later that something important was present and missed.
non-trauma abd pain evals? why bother? they are all going to the hospital anyway regardless of how their gb looks or whether or not they have an ectopic or a AAA...
dvt r/o? still going in so why bother?
 
I give this the thumb's down. No utility. EMS already wastes massive amounts of time and money. This would just increase the waste.
 
I give this the thumb's down. No utility. EMS already wastes massive amounts of time and money. This would just increase the waste.

I second that. FAST scan is useful for ruling in injuries, not ruling them out.
 
Members don't see this ad :)
I was just at a Texas EMS conference when I heard a presentation about a rural EMS agency using U/S on trauma patients to decide if the helo was called or not. This was not the only criteria for activating the helicopter. They had a 1 hr transport by ground to the nearest level 1 trauma center or they could go to the local level 4. If the patient had a positive fast, they were activating the helo to fly the pt to the level 1. Interesting. They had some nice fancy U/S mounted in their rigs. Don't know where they hell the money for that came from in rural EMS.
 
I practice in a trauma level 4 center (at least I guess that is probably what we are, I really don't know or care). I have a problem with the idea of truly rural EMS providers having ultrasound. The paramedics here in town are, for the most part, great. I think they are dedicated enough to the profession to take it upon themselves to get adequate training.

Most of their transports are withing 15 minutes of us. There is no way that a helicopter could get there in time to make it worth them bipassing us. Most often, if they think that the helicopter needs to be called, they meet them in our ER for help with stabilization. Even though my ER is small, it is a much better place to stabilize than in the back of a helicopter, or on scene.

There are times that a REALLY rural unit has to respond and the helicopter is sometimes called and we are bipassed. The guys that respond to these calls are usually basic EMT, and don't even have the expertise to place IVs, let alone the training, resources, time, or motivation to become clinically competent in FAST exams.

A while back, a rural EMS squad activated the helicopter on an MVA with poly-trauma, but then headed toward us to stabilize the patient has he was altered, combative and they couldn't even place an IV or secure his airway. So, they got to my place at the same time as the helicopter, and I intubated him, CT scanned him, and put him in the helicopter for transfer to a level 2 trauma center as he had an obvious head-bleed and blood in the belly on my read (I don't have inhouse rads, and official reads take 1-2 hours)

It ended up being kind of a cluster, because the trauma center I usually transfer to wasn't an option per the crew as they had not calculated on fuel to stop at our hospital. I had to call a closer hospital, who said they thought the patient needed a level one trauma and didn't feel comfortable accepting the patient. The helicopter said they knew they had enough fuel to get to their home base (a third level 2 hospital), but the surgeon there said he would cite me for an EMTALA violation if I transferred the patient to him, as the level 2 trauma center giving me grief was closer and the same trauma level status. (Sorry, that scenario has too many hospitals in it to be understandable)

3 points:
1. All trauma centers are NOT equal, despite similar rating.
2. A FAST exam in the field would have had no effect on this scenario.
3. I LOATH EMTALA.
 
There was one study in Annals that showed no difference with and without ultrasound. However, the study randomized U/S vs non at the outset, rather than selecting difficult sticks after a set number of attempts. Since most IV starts are not difficult, it would be hard to find any utility in such a study. A number of other studies have found that U/S does help with difficult IV access.


I don't know how many "progressive communities" there are. I suspect we would do better by encouraging the use of rational field termination protocols and working codes on scene. Actually, I'd think the benefit from U/S in codes might be earlier termination, not the reverse. Interesting idea.

Ah! the ol' Pretest Probability.

Back in 2002, I transported a code into a university-based ED and apparently they were doing a study on US in cardiac arrest. They spent soooo much time doing the US, while I was watching the Lifepack - VT, VT, VT....VT...... VF...VF.....VT.....VF.....VF...VF...asystole. It took all my restraint to not shock the patient myself. Don't most IRBs frown upon withholding standard of care to provide an experimental diagnostic?

I second that. FAST scan is useful for ruling in injuries, not ruling them out.

Thats what I thought.

See, I learned something in medical school.
 
Transport the sick patient, don't waste time trying to get something that probably won't change what is done in the ED anyway.
 
Transport the sick patient, don't waste time trying to get something that probably won't change what is done in the ED anyway.

I agree.

A FAST exam it isn't going to change the medics treatment and will most likely delay transport.
 
I was just at a Texas EMS conference when I heard a presentation about a rural EMS agency using U/S on trauma patients to decide if the helo was called or not. This was not the only criteria for activating the helicopter. They had a 1 hr transport by ground to the nearest level 1 trauma center or they could go to the local level 4. If the patient had a positive fast, they were activating the helo to fly the pt to the level 1. Interesting. They had some nice fancy U/S mounted in their rigs. Don't know where they hell the money for that came from in rural EMS.

Therein lies the problem. People with a positive FAST are likely gonna get a HEMS activation anyway based on other criteria (or no criteria as is the case in many/most HEMS systems...just the whim of a local provider). So why fuddle around with the US? FYI, if you figure in the US time, activation time, transfer to HEMS crew time, and helipad --> trauma bay time, the ground transport isn't much slower.

Wrap and Run.
 
I forgot to ask the question I had when I piped in before.... about central lines.

Is anyone doing central lines in the field? We had to do 2 or 3 in medic school, but didnt do them in the street.

Off the top of my head, I think the literature shows that there's no difference in US guided central lines in the hospital, unless you have an anatomy problem.

Just curious.
 
I forgot to ask the question I had when I piped in before.... about central lines.

Is anyone doing central lines in the field? We had to do 2 or 3 in medic school, but didnt do them in the street.

Off the top of my head, I think the literature shows that there's no difference in US guided central lines in the hospital, unless you have an anatomy problem.

Just curious.

I did them for the first year I was a medic, then our med. director moved to IO access instead of the central lines.
 
I did them for the first year I was a medic, then our med. director moved to IO access instead of the central lines.

Eeewwww.... do you mean those nasty sternum IO lines for adults?
 
HOLY CRAP This is the most disgusting thing ive seen in my life.
 
I thought that once you're over a certain age, access next to the tibial tuberosity doesn't communicate with the nutrient vein any more, so you have to use other parts, like the sternum.
 
By central lines do you mean IJs? My understanding is that ultrasound guided IJ/subclavians are a lot less likely to drop a lung.
 
I thought that once you're over a certain age, access next to the tibial tuberosity doesn't communicate with the nutrient vein any more, so you have to use other parts, like the sternum.

Nope. You can use the tib tube in adults just like in kids.

The only difference I've ever noticed was the time and effort taken to establish the IO. In kids it takes about 15 seconds to get into the lumen, but in adults it takes quite a bit more force and time to burrow down. We didn't have the easy IO.
 
By central lines do you mean IJs? My understanding is that ultrasound guided IJ/subclavians are a lot less likely to drop a lung.


Either one. I think IJs are preferred in the field. I did a couple in medic school, but never in med school.
 
In the field they do EJs, I've never heard of IJs on an ambulance.
 
I can't think of a good reason for placing a central line in the field.
 
Nope. You can use the tib tube in adults just like in kids.

The only difference I've ever noticed was the time and effort taken to establish the IO. In kids it takes about 15 seconds to get into the lumen, but in adults it takes quite a bit more force and time to burrow down. We didn't have the easy IO.


I've only used the IO twice on real patients. One was a pediatric patient where it ended up infiltrating (medical to tibial tuberosity), the second was an adult, and indeed, the medial tuberosity I couldn't get any marrow, so I went with the distal tibia and got a good marrow flash with suction.

The following is copied and pasted from MDconsult link to Robert's and Hedge's

Sites for IO Needle Placement

The patient's age and size are the two most important factors when choosing the best site for needle penetration. In infants and children younger than 6 years, the proximal tibia is the preferred site, followed by the distal tibia and distal femur. Other sites, such as the clavicle and humerus, have been used, but neither has gained popularity. In adults, the distal tibia has been the most common site for IO access. However, with the introduction of spring-loaded and drill devices, IO locations once reserved only for children are now potential sites in adults as well. In addition, the FAST-1 System makes the sternum a simple and effective location for IO access in adults.[66]

Proximal Tibia

The tibia is a large bone with a thin layer of overlying subcutaneous tissue that allows landmarks to be readily palpated, and insertion here does not interfere with airway management and CPR. On the proximal tibia, the broad, flat, anteromedial surface is used, with the tibial tuberosity serving as a landmark. The site of IO cannulation is approximately 1 to 3 cm (2 fingerwidths) below the tuberosity ( Fig. 25–12A ). This location is far enough from the growth plate to prevent damage but is in an area in which the bone is still soft enough to allow easy penetration of a needle. In adults, penetrating the thick bone in the proximal tibia is much more difficult and requires a 13- to 16-gauge needle. A spring-loaded device such as the BIG or a battery-powered drill such as the EZ-IO can make penetration much easier and allows the use of smaller-gauge needles.

I used a big needle in the adult and buried it to the hub, but still didn't get a flash.

I think Howell's Jollies has a point, based on my N of 1 using it on adults ;)
 
I see no point for central lines in the field.

EZ-IOs are one of the slickest devices I've seen since the bougie (which I use for every intubation). I've used them several times on pts from premi to adult-sized teenager. I get access in <10 seconds with very little problem.

I've done them on proximal tibia and proximal humerus when tib wasn't an option.

The only time I've had it fail was on a newborn resuscitation. I suspect the needle was too long.

I almost never get flash. Just insert it in, make sure it feels right (little to no wobble) and flush. The initial flush may have some resistance but will go. After that, it'll flow well with time to central circulation similar to central lines.

BTW, the initial flush part is, from what I've heard, the most painful part. Consider using a flush with lidocaine included. I've never tried because the folks I'm doing it on were very sick. One of the videos demonstrating it was on a buddy of mine (the model). He said the drilling wasn't too bad but the flush sucked.

BTW, I have no financial stake in the EZ-IO company.

Take care,
Jeff
 
BTW, the initial flush part is, from what I've heard, the most painful part. Consider using a flush with lidocaine included. I've never tried because the folks I'm doing it on were very sick. One of the videos demonstrating it was on a buddy of mine (the model). He said the drilling wasn't too bad but the flush sucked.

BTW, I have no financial stake in the EZ-IO company.

I echo Jeff's non-financially motivated sentiments. I've used the EZ-IO on patients of all ages and also on awake, semi-coherent folks. You should definitely consider a few cc's of lidocaine if the patient is awake--doesn't take much time and the patient will be more, uh, cooperative with your med/fluid administration.
 
Yes flush some lidocaine through that thing before you push anything else. The EZ IO is so fast.
 
Holy cow this got a ton of responses. In terms of my experience we typically did subclavians in the field. Then we moved EZ-IO drills (amazing little piece of equipment if you've never had a chance to use one).
 
Top