4/2/14 Conference notes

Dr. Girzadas is at CORD, poor substitution by C Kulstad

8-9: CV Study guide by Dr. C Kulstad

9-930: Safety lecture by Dr. Balogun

Presentation of 4 cases with various chief complaints united by delayed urine testing. 89% of patients with GI/GU complaints have documented UCG at ACMC. Takes 2.5-4 hours after registration to get UCG performed here.  Reasons UCG is delayed- patient can’t urinate, sample there but not processed, not considered important, or ED busy (staff overwhelmed, sample lost).

Important to avoid delay in imaging, psychiatric placement, medication choices.

Ideas for improvement 1) expand and enforce triage UCG orders 2) order UCG for patient of childbearing years who might need medications or imaging before you see them 3) talk with nurse/tech 4) give pt urine cup and instructions and/or perform urine hcg 5) straight cath when UCG is critical to management

Pushback- physicians don’t need to take on additional roles unless emergent need. Compromise- give cup and instructions then notify tech/RN that pt is giving sample

930-12 U/S lecture and workshop- Dr. Lambert

Lambert finds 1^st trimester pelvic ultrasound most meaningful ED ultrasound  for patient management.

Anatomy reminders- pelvis tilted 45 degrees anteriorly when upright. Just behind symphysis pubis will be the bladder. Uterus tends to be horizontal. There is peritoneal reflection between bladder and uterus- not normal to have fluid here. Another peritoneal reflection between uterus and rectum (aka pouch of Doulgas)- very common to have small amount of fluid here in normal patient.

 

Ovaries are next to external iliac vessels, just anterior to ureters.  Bowel gas can obscure visualization of uterus, helps if bladder is distended.

Yolk sac should be visible by 5 wks. Often see cardiac flicker just afterwards, at  5-6 wks.

Ways to image pelvis- Transabdominal- place probe just above symphysis pubis. Use bladder as acoustic window. Less invasive and good field of view. Lower frequency probe means lower image quality. Uncomfortable to press on distended bladder.

Obtain transverse and sagittal views. Sagittal- indicator points to umbilicus. You will see bladder (triangular at top of screen) then uterus (pear shaped). At inferior part of screen- see vaginal stripe towards left screen. Should see endometrial and vaginal stripe in one view, that shows you are in midline. Transverse- Indicator to right. Top of screen will show bladder (rectangular) with uterus (oval) posterior. Ovaries may be seen inferior to bladder at edges of uterus (often are not seen).  

 

Sagittal                                                                            Transverse

 Transvaginal- better because probe is closer to organ of interest, and the high frequency probe gives better images. Not than uncomfortable, especially compared to pressing on full bladder. Get wide field of view but not as much depth. Anatomic relationships can be confusing. Obtain sagittal and coronal views.

Sagittal- indicator up. Think of flipping the sagittal transabdominal view 90 degrees counterclockwise. See long axis of uterus with cervix towards right of screen (opposite of indicator side). May need to tilt probe by moving back of handle down (tip of probe to ceiling). Bladder may be visible at top, left of screen.

Coronal- see slices of uterus from cervix to fundus in short axis- back of handle down to see fundus. May get better images by backing probe out a little bit (make sure you don’t allow air gap which would degrade image quality a lot).

Ovary – 2 x2 x3 cm- should be oval and have peripheral follicles, may have to slide probe lateral to cervix and a bit deeper. They should be inferior/medial to iliac vessels (can use color flow to identify vessels).

Cystic structure on ovary in pregnant patient is corpus luteum- usually a couple of cm but can get up to 6 cm. Starts regressing at 6 wks

Endometrial stripe- hyperechoic inner part of the uterus, has 3 layers. Decidua is the same thing as endometrium, just in a pregnant patient. Double decidual sac is endometrium over embryo, seen at 4 wks.

At 5 wks, see yolk sac which looks triangular inside decidual sac.

60% of u/s done in ED for r/o ectopic in first trimester will show IUP clearly. Greatly decrease time to patient dispo. Improve patient satisfaction as you spend more time with patient. Plus, unstable ruptured ectopic patients can’t go to ultrasound.

Diagnostic criteria for 1^st trimester ultrasound

Live IUP- gestational sac at least 5 mm internal diameter within the endometrial echo of uterus with 1) fetal pole and 2) heart beat

IUP- same criteria but without cardiac activity.

Abnormal IUP- same criteria but 1) gestation sac > 10 mm w/o yolk sac or 2) gestational sac > 16 mm and no fetal pole or 3) obvious fetal pole w/o cardiac activity

Extrauterine gestation- gestational sac at least 5 mm internal diameter- outside endometrial echo and one of the following 1) yolk sac or 2) fetal pole.  This is why landmarks are so important! Ectopic pregnancies often look like they’re in the uterus if you do a cursory ultrasound.

No definitive pregnancy- 1) normal uterus or 2) sac that isn’t big enough yet or 3) gestational sac with yolk sac or fetal pole.

15-20% of ultrasounds end up being no definitive IUP. About 30% of those will end of being ectopic- rate increases with free fluid or mass seen. Must have good follow-up arranged.

Hands-on practice