Abstracts surgical exploration is advised in patients with Acute scrotal pain unless a definitive diagnoses of causes other than torsion can be made. In about 30 - 50 % cases the different underlying pathological conditions cannot be distinguished by clinical exam or lab tests .Ultrasound offers timely and accurate differentiation of the causes of scrotal pain. The Spectrum of differentials Torsion of the Testis. 30% Epididymo-Orchitis. 37% Torsion of Testicular appendage. 11% Idiopathic scrotal edema. 09% Incomplete Torsion & de-torsion. Acute hydrocele. Strangulated Hernia. Henoch Schonlein purpura. Hemorrhage into a testicular neoplasm. Testicular Torsion 20-30% of patients with Acute scrotal pain. Haste is essential as testicular salvage rate reduces with passage of time in Ac. Torsion Testicular torsion occurs due to twisting of the testis on cord due to an underlying Bell and Clapper anomaly. Initially the testis swells up due to venous compression, later as the arterial flow is compromised ischemia sets in and tissue necrosis may occur. Sonography and color Doppler ultrasound reflect these developments. On gray scale ultrasound the testis appears slightly enlarged. Color Doppler scan will reveal reduced or absent flow. Careful examination of cord must be performed to look for the whirlpool sign – confirming the twisting of the cord. Torsion of Testicular appendage In a child torsion of the testicular appendage is a more common cause of acute scrotum as compared to torsion of the testis itself. Sonography reveals a small focal hypoechoic mass adjacent to the epididymis. The epididymis and testis appear normal in size and reveal normal vascularity. This is often a diagnosis of exclusion. Acute Epididymo-Orchitis Epididymo-orchitis is a more common cause for Acute scrotum, particularly in young children. Gray scale ultrasound reveals enlarged epididymis and testis. Echostructure is usually altered and hypoechoic. Testicular involevement is often later and lesser. Color Doppler reveals increased vascular flow signals in epididymis and testis. Some studies have shown that increased vascularity on color Doppler may be the only sign of Acute Epididymitis or Orchitis in 20-40%. Trauma Trauma can cause bleeding in the tunical sac producing a hematocele, or it can cause a rupture of the testis itself. Testicular conturs may become irregular, but more often rupture is seen as focal areas of altered echogenecity in the testis. Difficulties & Pitfalls Partial Torsion – some flow may still occur. Spontaneous detortion – flow may be normal or increased. Orchitis may cause sudden swelling and global ischemia of testis T8-13-IN06 Musculoskeletal Ultrasound in Acute Care and MSK Emergency P. K. Srivastava, Prof., M.B.B.S., M.D.(Radiology), FICR, FICMU Professor, Dept. Of Radiodiagnosis, King George’s Medical University, Lucknow High resolution ultrasound is an excellent modality in MSK emergency conditions. The role of ultrasound starts in acute MSK infection to MSK trauma. It is very useful to differentiate between cellulitis verses abscess, necrotizing fascitis and cutaneous masses. It can easily locate the foreign bodies. Ultrasounds can pickup bony fractures and helps
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in identifying non healing fracture and mal union of the bones. Acute tendon ruptures, joint effusion, muscle rupture, crush injury evaluation can be easily done with high resolution ultrasound. High resolution ultrasound is very useful in compartment syndromes and vascular compromise for locating the vessels and assess the vascular insert. It is also very useful in nerve entrapment and can tell with confidence about shearing of the nerve, compression of the nerve and entrapment of the nerve. Large wound assessment can be done with high resolution ultrasound for proper healing. High resolution ultrasound is also first lie of investigation in acute soft tissue trauma involving muscles, ligaments, tendons and cartilage injury which are not easily picked up on conventional X-ray or CT scan. The main advantage of ultrasound on CTAND MRI that it can be done in emergency room without shifting the patient to CT or MR room. T8-13-IN07 Ultrasound-Assisted Resuscitation Wei-Tien Chang, MD, PhD National Taiwan University Hospital Cardiac arrest and cardiopulmonary resuscitation (CPR) is the most critical condition in emergency and critical care medicine. Prompt recognition followed by effective diagnosis and management are the keys to successful resuscitation. In recent years ultrasound has been shown to play increasingly important roles during CPR. In addition to verifying the potential etiologies of cardiac arrest, ultrasound may also help identifying the coexisting confounding factors that hinder the return of spontaneous circulation. Examples are hypovolemia, tension pneumothorax, cardiac tamponade, massive pulmonary embolism, large area myocardial infarction, etc. Moreover, ultrasound also helps in confirming tracheal intubation, assuring adequate bilateral lung ventilation, and monitoring cardiac activity during CPR. In the post-resuscitation phase, ultrasound can be used to evaluate volume status and the presence or severity of post-resuscitation myocardial dysfunction, based on which proper fluid therapy, pharmacological intervention, or mechanical support can be employed. Further, other potential etiologies such as internal bleeding, aortic dissection, ruptured abdominal aortic aneurysm, e.t.c. could be identified through a systemic ultrasound evaluation. In fact, ultrasound has been formally suggested and increasingly incorporated into the advanced cardiac life support (ACLS). With proper training, ultrasound may serve as a powerful tool in the diagnosis and management of cardiac arrest patients undergoing CPR. T8-13-IN08 Ultrasound Assisted Interventions for Regional Blockade Yusef Sayeed, MD, MPH, MEng., CPH, CMRO, CME, DABPM This session is specifically designed for health care providers who are exploring ultrasound to help management of patients with acute injuries that require ultrasound guided interventions for regional blockades. Covering the Superficial Cervical Plexus, Interscalene, Supraclavicular, Femoral and Lateral Femoral Cutaneous, and Posterior Tibial Nerves this course will present a systematic and focused assessment with ultrasound. The session will include when and how to intervene. The participant will develop ultrasound pattern recognition of the nerves for major regional blockades. The case discussions will focus on pathologies that are commonly encountered. T8-13-IN09 Ultrasound-Assisted Sepsis Management Kuo-Chih Chen Department of Emergency & Critical Care Medicine, West Garden Hospital, Taiwan
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Ultrasound in Medicine and Biology
Sepsis is a medical emergency that requires multidimensional and simultaneous efforts for better outcomes. Sepsis definition and management is evolving during previous 20 years. The core concepts for successful management remain the same: early diagnosis and source control, adequate hemodynamic monitoring and supportive cares. Point-of-care ultrasound (POCUS) is getting popular in different challenging settings, such as trauma, emergency medicine and critical care medicine. POCUS is also evolving from focused and single applications to integrated and problem-oriented approaches, such as EFAST, BLUE and RUSH protocols. Currently, there is no universal protocol for sepsis management. The potential benefits of POCUS for sepsis management could be infection control, hemodynamic monitor and treatment guidance. In this section, clinical cases will be used to demonstrate how to use POCUS for septic workup, infection intervention, vascular access, fluid guidance, non-invasive hemodynamic monitoring and respiratory management. Symposium T8-15-IN01 Advanced Eco-FAST. Beyond the FAST S. Jorge Rabat Head of the Department of Surgery, ‘‘Ruiz y Paez’’ Hospital, Eastern University, Bolıvar City, Bolivar State, Venezuela Initial management of trauma patients is one of the greatest challenges in clinical practice, because it requires very quick decision based primarily on clinical criteria. FAST ultrasound has been shown to be useful for the detection of bleeding in the thorax and abdomen, as well as to detect cardiac tamponade in patients with penetrating thoracic trauma and to diagnose the presence of pneumothorax. The FAST A, B, C, D, E is a new approach where the patient is evaluated with ‘‘head to toe’’ Ultrasound, starting from the airway, ventilation, heart, vascular, abdomen, to the System Nervous central (eye). This has made it a valuable tool for therapeutic decision making in trauma patients, as well as for the selection of patients in catastrophic situations. T8-15-IN02 Ultrasound Guided Resuscitation Pathways in the Critically Ill Patient Michael Blaivas, MD, MBA Professor of Medicine, University of South Carolina School of Medicine, Department of Emergency Medicine, Piedmont Hospital Newnan, Atlanta, Georgia, USA Ultrasound is having a tremendous impact on resuscitation of critically ill patients from the emergency department to the intensive care unit and surgical suites. Prior to ultrasound introduction in the point of care, clinicians were left with little but pulse palpation and use of any already established invasive monitoring devices to guide resuscitation. Studies have indicated that clinicians could not accurately assess the presence of a pulse and auscultation was not accurate for the assessment of pulmonary or cardiac status in most critical situations. The lack of immediate x-ray availability and other imaging greatly hampers resuscitative efforts in many situations. Fortunately, point of care ultrasound allows clinicians to directly observe anatomy and physiology even in the most critical patient and thereby adjust resuscitative efforts based on real time data that has never been available previously. As a result, multiple resuscitation pathways have been developed to take advantage of
Volume 43, Number S1, 2017 ultrasound bedside capabilities incorporating a symptom based approach and leaving behind single organ scanning approaches. T8-15-IN03 Focused Ultrasound in the Peri-Arrest Setting Adrian Goudie Fiona Stanley Hospital & King Edward Hospital for Women Focused ultrasound can be used in the arrest and peri-arrest setting to distinguish the cause and direct management of critically ill patients. This talk will discuss both the technique, range of potential findings and prognostic information that can be obtained with ultrasound T8-15-IN04 SEARCH (Sonographic Evaluation of Aetiology for Respiratory difficulty, Chest pain, or Hypotension) for 9Es Young-Rock Ha Department of Emergency Medicine, Bundang Jesaeng Hospital, Korea Focused thoracic ultrasound in emergency includes a cardiovascular ultrasound, lung ultrasound, and FAST examination. The critical scenarios for it can be categorized into 3 situations along to the time; pre-cardiac arrest, during the cardiac arrest, and post-resuscitation. When patients are in potential arrest, we need to focus on the patients’ symptoms and signs and perform the ultrasonography right after short history taking and physical examination. Critical symptoms that we should care are like these, acute dyspnea, chest pain, hypotension, or shock-related symptoms and signs such as unresponsiveness, syncope, dizziness, or sweating. However, critical patient’s symptoms and signs frequently show up together. That’s why we should perform a focused thoracic ultrasound for any combination of these indications. We could figure out what happened to the patients and treat them based on their sonographic findings. We named this as SEARCH, which means sonographic evaluation of aetiology for respiratory difficulty, chest pain, or hypotension. Additionally we determined target abnormalities, 9Es to search for with focused thoracic ultrasound. 8Es are mnemonic symbolizing the potentially critical situations which could be diagnosed by SEARCH; Empty thorax (pneumothorax), Edematous or wet lung (pulmonary edema/ alveolar consolidation), E-FAST (pleural and peritoneal effusion), Effusion (pericardial effusion), Equality (pulmonary embolism), EF (LV systolic dysfunction), Exit and entrance (estimation of IVC, aortic dissection, aortic aneurysm, severe valvular heart disease), Endocardial inward motion (Acute coronary syndrome), and lastly E/E’(the ratio of early transmitral flow velocity to early diastolic mitral annular velocity). We can skip the last E, because we can have most of critical information using 8Es and it needs much more experience. Scanning sequence of SEARCH is as follows. After scanning both lung (in the same way of Dr Lichtenstein’s BLUE protocol), we obtain the parasternal long axis view and 4 chamber view on either apex or subxiphoid, and then check abdominal aorta and IVC. We could quickly obtain most of information in those processes. If necessary, In addition to those views, we can look into parasternal short axis view, apical two chamber view and suprasternal view. Those additional views are especially helpful in case of chest pain. During 13 months, we had performed SEARCH 8Es just after history taking and physical examination for ED patients who complained of respiratory difficulty, chest pain, hypotension, or shock-related symptoms and signs and who are admitted to general ward or ICU. We compared diagnosis determined by SEARCH 8Es with final diagnosis at discharge with review of charts. Kappa value between the diagnosis after SEARCH 8Es and final diagnosis was 0.870. The level of confidence