Rob Reardon

Ultrasound in HEMS: its role in differentiating shock states.

1already have started using the ultrasound for the focused abdominal sonography for trauma during helicopter transport. Diagnostic ultrasound greatly enhances the evaluation of patients with a variety of presentations. The technology, which evolved rapidly during the previous decade and became widely available in operating suites and emergency departments, 2-7 now is being introduced into the out-of-hospital arena. Many patients who present with unstable or time-critical medical problems require out-of-hospital diagnosis and intervention. These patients benefit from rapid, goal-directed, limited ultrasonography performed and interpreted by the flight clinician. This article describes the indications and interpretation of in-flight ultrasound examination for a select few emergent conditions. INDICATIONS The major use of out-of-hospital ultrasound is to evaluate critically ill or injured patients. This article focuses on the use of ultrasound as an accurate and expedient way to assess and treat hypotension of unknown etiology. We believe that the use of ultrasound as a diagnostic and therapeutic tool is the most immediate contribution it can provide to air medical patient care. Hypotension of Unknown Etiology Patients frequently present with hypotension and shock. Successful resuscitation depends on rapid treatment directed at the primary hemodynamic alteration. The physical examination is often both nonspecific and insensitive in detecting the underlying hemodynamic state. Traditional diagnostic methods, including intra-arterial catheterization, central venous pressure (CVP) measurements, and pulmonary artery catheterization, are invasive, costly, time-consuming, and not easily performed in the prehospital environment. In this setting, portable ultrasonography performed by a single window may rapidly and specifically guide initial resuscitation efforts. Through assessment of the global motion of the heart and chamber size, the patient often can be quickly assigned to 1 of 4 hemodynamic categories: • Cardiogenic shock (left ventricular dysfunction) • Hypovolemia • Cardiac tamponade • Right ventricular dysfunction or outflow obstruction Cardiogenic Shock

Diagnosis of Ascending Aortic Dissection Using Emergency Department Bedside Echocardiogram

A 36-year-old white male with history of hypertension and schizophrenia presented to the emergency department (ED) with several hours of severe throat pain and shortness of breath that began abruptly while climbing stairs. Examination revealed a severely agitated, pale, diaphoretic patient who was vomiting. The patient’s pulse was noted to be 100 beats ⁄ min, with blood pressure 70 ⁄ 35 mmHg. Examination of the oropharynx and neck was unremarkable. Examination of the chest revealed only occasional rales and tachycardia. A chest radiograph revealed cardiomegaly and pulmonary edema. An ED bedside echocardiogram was performed by an emergency physician. Significant aortic root dilatation was seen on a parasternal long axis view (Figure 1). An intimal flap extending around the aortic arch was visualized on a suprasternal view (Figure 2). Surgery was immediately consulted and the patient was taken to the operating room. In this case, early ultrasound diagnosis (videos available as online Data Supplements at http://www.blackwell-synergy. com/doi/suppl/10.1111/j.1553-2712.2008.00106.x) led to prompt operative intervention, and the patient was ultimately discharged from the hospital several weeks later.

Biliary ultrasound instructional video.

Right upper quadrant pain and midepigastric pain are common emergency department complaints. This instructional video (available as supporting information in the online version of this paper) provides a basic review of biliary disease processes and explores the application of bedside ultrasound. Instruction is provided on performing bedside biliary ultrasound, including evaluation of the gallbladder for cholelithiasis (Figure 1) and cholecystitis, as well as evaluation of the common bile duct for signs of choledocholithiasis.