Echo in Life Support

One of the competencies we have to get is echo in life support. I've floated around with echo for a while - but now it's time to knuckle down and be 100% excellent at what we need to do to be level one competent.

- Subxiphoid + one other view, normally parasternal long axis
- Identifies pericardial space
- Look at LV RV (?dilated)
- Identifies IVC, looks at diameter and assesses collapsibility

The Probe
If you are using a cardiac probe, the marker (dot) needs to be on the right to give you the views you are used to. This means that mostly, the probe is near the apex of the heart If you are using an abdominal probe (as many of us have to, especially for the subcostal view) the dot will be on the left.

The Anatomy
Remember that the heart doesn't lie exactly vertically. It lies tilted, and slanted. This helps you to think about what you are seeing.

Subxiphoid or Subcostal View

This is similar to an apical view, but everything is rotated 90 degrees. You can use a curved probe to get this view. Imagine you are shining a torch on the heart. Point it down, and to the patient's left. Remember, the right hand side of the heart is next to the liver.

Because the heart is tilted slightly, the probe hits the liver first, then the right hand side of the heart, and then the left hand side - hence the view you get with the right side of the heart at the top, and the left at the bottom.

Fluid normally collects posteriorly. This view is really good for looking at fluid.

Parasternal Long axis
Aim the probe perpendicular to the chest, just to the left of the sternum in the 4-5th IC space (although I was told that the third is better). The marker should be pointing to the top of the patient. Point towards the patient's right shoulder.

This is really good for looking at LV function, and also shows effusions well.

Remember that the right atrium is likely to be hiding behind the aortic outlet.

Parasternal Short Axis
Rotate the probe to look at the patient's left shoulder, keeping the probe marker on the patient's left. This gives you a view at the bottom of the heart - looking at the ventricles.

If you scan at the level of the mitral valve, you get the croissant and doughnut appearance. You also get the fish mouth. This is the view we are aiming to get.

Apical Four and Five Chamber Views
Both of these views have the probe in the same sort of position. To get a five chamber view, you point the probe down a little more to be able to see the aorta. The probe marker is on the patient's left.

IVC
Remember that this will be affected by your probe. Start with a subxiphoid view. Rotate the probe vertically, with the probe marker (using a cardiac probe) at the top. Slide 1-2 cm to the right, and tilt towards the heart. This will give you a view of the liver, with the IVC below it, entering the right atrium.
Measure the heart where the hepatic vein is, or 2-3 cm from the heart edge.

Turn into M mode.

The IVC  should collapse on inspiration. If it doesn't, ask the patient to sniff. Measure this as a percentage. If it collapses 25- 50%, they will be fluid tolerant. >50% very likely to be fluid responsive, some say >30%.

I was really struggling to get my head around this anatomy, and one of my collegues drew this brilliant picture for me - and it's mostly clicked. The key I think is thinking about how the heart lies (ie not straight!) and how your probe is looking.

References
http://emergencyultrasound.org.uk/resources/03+Cardiac+views+web.pdf
http://www.rcem.ac.uk/Training-Exams/Training/Ultrasound%20training
http://www.rcem.ac.uk/code/document.asp?ID=5447
https://www.youtube.com/watch?v=oMwgUo6sbyY
https://web.stanford.edu/group/ccm_echocardio/cgi-1bin/mediawiki/index.php/Subcostal_4_chamber_view
http://www.fate-protocol.com/130067GE_Fate_Card.pdf
http://www.smacc.net.au/sonowars-chicago/
http://lifeinthefastlane.com/own-the-echo/

Sore Throat - Tonsillitis

Most sore throats are not caused by a bacterial infection. Make sure there is no epiglottitis or scarlet fever. Scarlet fever would be seen with a rough textured macular rash, with Pastia's lines, and red cheeks with perioral sparing.
There could also be Lemierre's syndrome, retropharyngeal abscess, diptheria, bacterial tracheitis, Ludwig's angina or angioedema.

Red flags for sore throat including significant systemic upset, severe pain, stridor, severe neck stiffness, inability to swallow or tripod position.

Causes
Group A β haemolytic streptococcus - 5-15%
Can cause rheumatic fever in some patients, toxic shock syndrome, necrotising fascitis and post-strep glomerulonephritis. GABHS can be carried asymptomatically - mostly between 3 and 15yrs old (carriage rates 5 - 21%). Adults have much lower carriage rates.
Complications can be suppurative (otitis media, sinusitis, peritonsillar abscess) or non-suppurative (rheumatic fever).
Treat with pen V, 500mg QDS for 10 days.

Viral Tonsillitis
Tonsillitis/pharyngitis are: rhinovirus; coronavirus; adenovirus; herpes simplex; parainfluenza; echovirus; coxsackie A; Epstein-Barr; CMV.

Epstein-Barr Virus
This causes infectious mononucleosis which presents with malaise, headache, fever, pharyngitis, posterior cervical node enlargement, splenomegaly and hepatomegaly. There is a lethargy lasting for six to eight weeks, with suffers being infective for weeks to months. Glandular fever causes anterior and posterior chain lymphadenopathy - bacterial is normally just the upper anterior cervical chain.
Diagnosis is supported by monospot, and there may be atypical lymphocytes and deranged liver enzymes.
90% of patients get an amoxicillin rash with EBV - 5% do with no EBV.

Viral Pharyngitis
Viral infection will often affect immunocompromised and elderly patients. You normally see a unilateral erythema with ulceration. The lesions are often mirrored in the distribution of the glossopharyngeal nerve.

CMV Tonsillitis
This presents very similarly to EBV, and if symptoms persist but the monospot remains negative it should be considered. There is a lot of fever and malaise.

HIV Tonsillitis
Uncommon but should be considered if there is no exudate, tonsillar hypertrophy, rash and mucocutaneous ulceration.

Globus Pharyngeus
This is painless, and patients complain of having "something in the throat", with symptoms improved by swallowing.

Agranulocytosis
Can present with a sore throat, and can be caused by a number of drugs, carbimazole in particular.

Quinsy - peritonsillar abscess
Full, erythematous appearance of the peritonsilar area.
-Deviation of the uvular
-Trismus
- Lateralising pain
- Fullness of the soft palate on the affected side
- Reduction in neck mobility
There is a risk of re-accumulation after drainage. There is no evidence for antibiotics after drainage, but they are generally given.
Quinsy can spread to the parapharyngeal abscess which can be fatal if not treated. Signs can be subtle, and underlying masses might not be fluctuant.

Treatment
Single doses of prednisolone or dexamethasone can be very helpful in major cases - in minor cases they decrease pain by six hours.

Despite their regular use, antibiotics are rarely indicated. Even the SIGN guidelines suggest we use CENTOR guidelines!

The Centor Score - sensitive 97% and specificity 78%
History of fever or temperature > 38oC              +1
Absence of cough                                               +1
Tender anterior cervical lymphadenopathy         +1
Tonsillar swelling or exudates                             +1

Age ≥45 years                                                     -1
A score of 4-5 means that antibiotics should be prescribed.

Antibiotics should be given if there is an increased risk of complications - immuo-suppressed patients, history of valvular heart disease, history of rheumatic fever. If there is an outbreak of GABHS infection within an institution, and a history of repeated episodes of proven GABHS infection.

Streptococcal Score Card - for children 
5 to 15 years
Season (late autumn, winter, early spring)
Fever (≥38.3°C)
Cervical lymphadenopathy
Pharyngeal erythema, oedema, or exudate
No symptoms of a viral upper respiratory infection (conjunctivitis, rhinorrhoea, or cough)

If 5 of the criteria are met, a positive culture for GABHS is predicted in 59% of children; if 6 of the criteria are met, a positive culture is predicted in 75% of children.

Tonsillectomy
Patients with seven attacks in one year, five in two consecutive years, or three attacks in three consecutive years warrant referral to an ENT department.

References
http://www.annemergmed.com/article/S0196-0644(13)00687-2/pdf
http://rebelem.com/patients-strep-throat-need-treated-antibiotics/
http://www.smartem.org/podcasts/treatment-acute-pharyngitis
http://radiopaedia.org/cases/tonsillitis
http://lifeinthefastlane.com/ent-equivocation-002/
http://www.ncbi.nlm.nih.gov/pubmed/?term=Hayward+G%2C+Thompson+MJ%2C+Perera+R%2C+et+al.+Corticosteroids+as+standalone+or+add-on+treatment+for+sore+throat.+Cochrane+Database+Syst+Rev.+2012%3B10%3ACD008268.+http%3A%2F%2Fdx.doi.org%2F10.1002%2F14651858.CD008268.pub2
http://learning.bmj.com/learning/module-intro/sore-throat-diagnostic-picture-tests.html?moduleId=6058292&searchTerm=%E2%80%9Cthroat%E2%80%9D&page=1&locale=en_GB
http://www.sign.ac.uk/guidelines/fulltext/117/index.html
http://www.rcemlearning.co.uk/modules/acute-sore-throat/
http://dontforgetthebubbles.com/tonsillitis/
http://www.rcemlearning.co.uk/references/acute-sore-throat/
http://www.rcemlearning.co.uk/modules/psor-throat/
http://www.rcemlearning.co.uk/modules/sore-throat-with-a-fruity-appearance/

http://www.rcemlearning.co.uk/modules/holiday-sore-throat-are-antibiotics-required/
http://www.aliem.com/modern-em-case-1-and-2-strep-throat/
http://www.aliem.com/paucis-verbis-card-strep-pharyngitis/

e-FAST - Pneumothorax

We've talked about FAST...now we need to put the "E" into it. The E wasn't taught to me in my course, and isn't mentioned on the college e-learning module, but it is on their checklist to be assessed for competence...

How
- Ideally you need a linear probe
- Place the probe in the 2nd or 3rd IC space, midclavicular line, and slide caudally.
Bat Sign - the top rib looks like a bat flying out of the screen
- Then look in the 6th IC space, ant axillary line


Normal
Comet Tails - artifacts from the pleural line. Sliding lung and comet tails are normal.
Seashore Sign or waves on a sandy beach- normal lung sliding on M mode.
 - from http://www.intechopen.com/books/hot-topics-in-echocardiography/lung-ultrasound-comet-tails-technique-and-clinical-significance

  - from https://sonospot.wordpress.com/2012/06/19/sonoapp-lung-ultrasound-the-down-low-of-pneumo-with-the-help-of-lichtenstein-of-course/


Pneumothorax
Loss of pleural sliding/ loss of the seashore sign in a spontaneously breathing patient.
This leads to the stratosphere or bar code sign.
No comet tails
 - from https://sonospot.wordpress.com/2012/06/19/sonoapp-lung-ultrasound-the-down-low-of-pneumo-with-the-help-of-lichtenstein-of-course/

References
https://www.acep.org/Clinical---Practice-Management/Focus-On--EFAST---Extended-Focused-Assessment-With-Sonography-for-Trauma/
https://www.youtube.com/watch?v=Yg78aU93SZE
https://www.youtube.com/watch?v=EVQTI7ivhFM
https://sonospot.wordpress.com/2012/06/19/sonoapp-lung-ultrasound-the-down-low-of-pneumo-with-the-help-of-lichtenstein-of-course/