Prehospital Ultrasounds?

[blindsideflank]

http://www.hhmglobal.com/knowledge-...sound-could-improve-stroke-diagnosis-and-care

3D ultrasound could improve stroke diagnosis and care
Enquiry
Research says, 3D ultrasound can compensate for the thickness of the skull and image the brain’s arteries in real time.

Experts believe that these advances will ultimately improve the treatment of stroke patients, giving emergency medical technicians (EMTs) the ability to quickly scan the skulls of stroke victims while inside the ambulance.

Senior study author Stephen Smith said: “This is an important step forward for scanning the vessels of the brain through the skull, and we believe that there are now no major technological barriers to ultimately using 3D ultrasound to quickly diagnose stroke patients.”

“Speed is important because the only approved medical treatment for stroke must be given within three hours of the first symptoms.”

The team injected 17 people with contrast dye to enhance the images then aimed ultrasound “wands” into the brain.

The researchers found that 3D ultrasound sensors could compensate for the skulls thickness and for the first time provide real-time clear ultrasound images of the brain arteries.

Stephen Smith added: “It’s safe to say that within five to 10 years, the technology will be minaturised to the point where EMTs in an ambulance can scan the brain of a stroke patient and transmit the results ahead to the hospital.”



Neato

Edit. Here is the more complete article
http://www.hoise.com/vmw/08/articles/vmw/LV-VM-05-08-40.html

This would be great for rural hospitals where a ct is hours away, this is an old article btw. I have no follow up on it's use

 

[WestMetroMedic]

Then don't bother (not saying I disagree with how you handle traumas btw). U/S is difficult with a completely still patient. Trying to get a clean picture bouncing down the road is a complete waste of time.

We are doing a Sliding Lung Sign U/S study right now, not a FAST, and I haven't received any training on the FAST, so I can't speak to its use in a moving ambulance, but Sliding Lung signs are not difficult at all to obtain in a moving vehicle in my experiences with a SonoSite.

Obviously Sliding Lung Signs don't achieve a Cost/Benefit ratio that makes U/S useful, but they are a good tool.

Our goal of 6 minutes of scene time with high acuity trauma patients wouldn't allow for a FAST, but obviously high acuity patients perhaps may not be the best venue for out of hospital U/S.

As I see it, a good ultrasound program will focus on routine scans of every trauma patient, perceived to be sick or not. I think you will find more value in it if you are trying to find patients who have injury and are compensating well and without obvious findings who would normally go to a lower acuity facility or even be placed in a lower acuity bed at a Trauma center. We all know that the patient who is obviously profoundly injured needs to go to the doctor place without discussion, but it is those patients who have easily missed injuries, who will actually see benefit.

 

[zmedic]

We are doing a Sliding Lung Sign U/S study right now, not a FAST, and I haven't received any training on the FAST, so I can't speak to its use in a moving ambulance, but Sliding Lung signs are not difficult at all to obtain in a moving vehicle in my experiences with a SonoSite.

I work in a busy level 1 trauma center, I do a lot of ultrasound. And I haven't picked up a pneumothorax on US yet. And I see a lot more patients with penumothoracies in a year than a paramedic does (I saw 17 patients today, about average for me, and I do 20 of those a month).

I'm not bragging, but here is the question.
How many trauma patients does the average medic see in a year?
How many patients have a pneumothorax?
Now how many of those pneumothoracies are missed by a paramedic on exam with a stethoscope? And how many of those patients go on to have a bad outcome because of it?

I really think that in an average population of trauma patients you would have to scan hundreds if not thousands of patients with ultrasound to prevent one bad outcome. And you have to ask how many medics are going to stick in needle in the chest of a patient with a questionable ultrasound who are breathing fine with a good pulse ox.

Now I think lung ultrasound may have a place prehospitaly, mainly with flight medics who are seeing much higher acuity than the average medic, have more training, and are in a very noisy chopper where a stethoscope is pretty useless.

Just remember how much money the ultrasound companies stand to make if they can convince your medical director to put a machine on every ambulance.

 

[ditchdoc125]

For the sake of academic discussion, how would you go about implementing TXA into prehospital treatment?

What would be the criteria?

Alberta Health Service EMS has recently announced a protocol to come into effect in July which encompasses tranexamic acid. The drug is given only with on-line consultation with a physician, but the inclusion criteria are any patient >16 y/o who has severe external hemorrhage from an injury <3 hours old who have a HR >100/min or systolic BP <90mmHg.

There is a great deal of in-house training being done prior to the rollout of this drug, and its largely based on the results of the CRASH-II study. There is a 30-page education module on TXA, an online exam and there is also a classroom portion that must be completed with a clinical educator.

 

[ditchdoc125]

But more related to prehospital US... We are not not currently using it in Alberta, but it is being heavily investigated by both the fixed and rotary wing aeromedical services. I forsee it as a much more pertinent tool for rural practitioners, which in my neck of the woods, are working more and more as an adjunct to the rural hospital, either in place of or alongside a physician as the EM specialist.

Currently... our provincial legislation does not technically allow paramedics to apply non-ionizing radiation except for doppler FHR, but this will hopefully be changing soon.

I am not 100% sure, but we have a number of clinics in the far north on reserves which are staffed by a Paramedic and RN, they MAY be utilizing it, as they are under federal scope and jurisdiction.

 

[blindsideflank]

TXA is used by bc cct's
But they are in a league of their own

 

[jbrayp5]

it would be nice to be able to do a US study and be in communications with a ED doc or radiologist on callso they can see the image as your doing the study.....thats what we use in the hospital setting for emergency cases when radiologist is on call at home

 

[xrsm002]

I know Odessa (Texas) Fire & Rescue (EMS) use ultrasound on their ambulances.

 

[zmedic]

it would be nice to be able to do a US study and be in communications with a ED doc or radiologist on callso they can see the image as your doing the study.....thats what we use in the hospital setting for emergency cases when radiologist is on call at home

My problem with this is that I don't see it as good use of my time as a doctor. In the ER an attending is seeing 2-3 patients an hour. So spending 10-15 minutes looking at prehospital ultrasounds better be pretty important. I'm just not seeing what question I'm going to be answering. I'm not sending trauma patients to the OR based on a pre hospital FAST. Is it going to change destination? I feel like if it's a question that the medic can't answer based on their read on the scene, is it really something that can't wait till the patient gets to the ER? I don't know, but convince me. Tell me what you would want to know when you call up.

 

[Doczilla]

The only thing I can contribute is that F.A.S.T exams were essential for blast trauma in the little mud hut trauma center we built in AFG.

On instance in particular was a land mine victim that suffered a left leg amputation with what appeared to be a severe TBI. Heard strange lung sounds on end-expiration, and by strange, i mean not diminished, and not textbook lung sounds. It was more like a whoopie cushion at the last part of expiration.

"Ppppptthhhhh".....

That seemed suspicious, but with good sats and otherwise unremarkable chest exam, further investigation was needed to justify any type of invasive procedure. Enter portable US.

Sure enough, right sided closed pneumo from blast barotrauma. Hooked up a 10cc flush to a 14 ga needle, saw bubbles when decompressing. Ketamine, intercostal block, chest tube. Done. Pulled about 300ml of blood from the chest. Did portable blood type kit, spun up donors.

Got pics if you wanna check it out, Doc.

 

[Veneficus]

On instance in particular was a land mine victim that suffered a left leg amputation with what appeared to be a severe TBI. Heard strange lung sounds on end-expiration, and by strange, i mean not diminished, and not textbook lung sounds. It was more like a whoopie cushion at the last part of expiration.

"Ppppptthhhhh".....

That seemed suspicious, but with good sats and otherwise unremarkable chest exam, further investigation was needed to justify any type of invasive procedure. Enter portable US

No to be a kill joy, but blast injury with abnormal breath sounds that sound like fluttering?

What do you need an ultrasound for?

That really sounds like somebody lobbied to make portable US a requirement to verify something that doesn't need to be.

Even in Afghanistan, if you decompress a chest and you are wrong, a bandge and some antibiotics should do the trick.

If you don't decompress the chest that needs it, then you will have some more obvious clinical signs in a few minutes.

But everyone should be suspected of hollow organ injury after a blast. (that is why they tell you to exhale in the rocket attack drill)

 

[Doczilla]

Trust me I'm right there with you, brother.

in the heat of the moment, it felt right to verify. Especially with that tool readily accessible.

 

[Doczilla]

To add onto that, a lot of CYA had to do with that. We had already gotten some angry-grams from salty doctors (admin guys, not surgeons) questioning our agressiveness.

As liberally as you can operate over there, getting support becomes difficult if they feel you're doing stuff just for the sake of doing it.