Point-of-care ultrasound helps in emergency diagnosis
Point-of-care ultrasound helps in emergency diagnosis
Interview with Dr. Achim Ehrt, Medical Center (Klinikum) Ingolstadt, Executive Medical Director for the Department of Anesthesia, Critical Care, and Pain Management
Medical emergencies require quick action and prompt decisions: Point-of-care ultrasound (POCUS) is a valuable diagnostic tool available to the emergency physician. Rather than relying on his/her gut feeling, the device answers specific clinical questions that narrow differentials. The question is, in which settings does POCUS deliver the biggest benefits?
Dr. Achim Ehrt
In this MEDICA-tradefair.com interview, Dr. Achim Ehrt explains situations where POCUS is especially helpful, describes the latest innovations in this area, and predicts the future of this technology.
Dr. Ehrt, when is the use ofpoint-of-care ultrasound(POCUS) necessary?
Dr. Achim Ehrt: First, we need to distinguish between the use of this imaging modality in clinical and preclinical settings. When it comes to clinical use, POCUS is a common approach in the intensive care unit, in clinical anesthesia and in emergency medicine, because it answers many clinical questions or guides a procedure quickly at bedside and eliminates long patient transport.
It is somewhat more difficult to substantiate its importance in preclinical scenarios: The question here is always whether its application may contribute to delays since onsite ultrasound may waste precious time or whether it is particularly relevant to the treatment of the patient. For example, a preclinical ultrasound is a time waster if a patient is transported to the nearest tertiary care hospital after a traffic accident anyway.
That being said, I believe POCUS is of utmost importance in patients with life-threatening conditions, because the device quickly delivers answers to questions that used to require extensive diagnostic exams (CT, X-Ray imaging).
Why is POCUS becoming more and more significant?
Ehrt: I think the main reason its reach is increasing is because the devices are getting smaller, better, more adaptable, and more powerful with premium image quality. An ultrasound machine used to be as big as a refrigerator, sat in the ultrasound laboratory and could not be moved. Today's devices are portable and compact with battery power that allows forty-five minutes of continuous scanning.
The latest innovation is an ultrasound transducer that is connected to a smartphone or tablet, making it portable like a stethoscope. In my opinion, this is the key why POCUS has been increasingly adopted by a wide variety of users: the devices are more accessible and increasingly affordable, allowing even smaller hospitals to purchase them, which increases the number of people who get training to use them. One thing leads to another: the more people become fans of this technology, the more devices are being purchased. And the more devices are being purchased, the more people seek training and education – creating a beautiful perpetual cycle.
Do you need a different technology than the one that is already present at hospitals or do you just need new equipment?
Ehrt: The technology is the same, but it is getting more and more compact, with devices getting smaller and handier thanks to very powerful chips. This marks the end of the old-fashioned refrigerator-sized ultrasound units. The ultrasound transducers still convert electrical energy into mechanical (sound) energy and back again, based on the piezoelectric effect.
One company has now developed an innovative ultrasound transducer that generates the sound waves via the circuit board so that you can simulate different types of transducers with a single transducer platform. If this technology takes off and works as well as recent tests suggest, it is set to revolutionize ultrasound practice again, because the device will then only need one transducer versus the three common ones popular POCUS tools require today.
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Emergency sonographies can help with diagnosis at the scene.
How is point-of-care ultrasound used in the emergency department?
Ehrt: In an emergency, physicians perform a Focused Assessment with Sonography for Trauma (FAST) and Focused Echocardiography Evaluation in Life Support (FEEL) scan. These assessments include defined steps and sectional views: FAST identifies free fluid in the abdominal and pelvic cavity that should not be there: meaning in the space between liver and lungs, liver and kidneys, spleen and lungs, spleen and kidney, and behind the bladder. POCUS is an excellent tool in this setting to detect abdominal free fluid in the patient's abdomen.
FEEL uses the same principle but explores the heart area: subcostal scanning can detect pericardial effusion (the buildup of extra fluid in the space around the heart) and assess the heart's function and structure. Fewer sectional views, fast exam, narrowing and expediting the diagnosis – crucial steps to ensure the patient's survival.
What do medical professionals learn in emergency medicine ultrasound training courses?
Ehrt: Whether it is doctors or non-certified personnel, everyone first learns the basics in these courses: How does an ultrasound work? This is important to understand the types of images that can be generated and learn about common pitfalls. Then they study cross-sectional images, which are illustrated using test subjects. Those are the basic, simple ultrasound images.
A new trend is to use ultrasounds for pulse checks: an ultrasound image is more accurate to directly visualize the carotid artery to determine the presence of a pulse than placing your fingers to feel for a pulse under stress. If this technology is further optimized and becomes cheaper, it can be used by emergency medical services, subsequently allowing paramedics to use it as a criterion to initiate resuscitation: utilizing an ECG to measure cardiac rhythm plus carotid ultrasound to check the blood flow through the carotid artery. But we are still a long way off from this particular application.
Speaking of the future, what is your prediction for the future of point-of-care technology?
Ehrt: I believe point-of-care technologies will advance and see worldwide growth in the future. More and more manufacturers offer compact, portable devices. In the not-too-distant future – let's say within five to ten years – anesthesiologists will probably no longer wear a stethoscope around their necks but carry a small transducer, because it can provide far more information and facilitate differently types of exams. Not all situations in a hospital require a time critical diagnosis, which means you could also use the tool to perform an ultrasound of the stomach to check if the patient has fasted, for example. I am confident we will see a significant increase in use and application of this technology in the coming years.
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