0
Editorial |

The Ultrasound Corner Series: A Reverberating Success FREE TO VIEW

Seth Koenig, MD, FCCP; Viera Lakticova, MD
Author and Funding Information

Northwell Long Island Jewish Medical Center, New Hyde Park, NY

CORRESPONDENCE TO: Seth Koenig, MD, FCCP, 410 Lakeville Rd, Ste 107, New Hyde Park, NY 11040


Copyright 2016, American College of Chest Physicians. All Rights Reserved.


Chest. 2016;150(3):483-484. doi:10.1016/j.chest.2016.06.010
Text Size: A A A
Published online

Point-of-care critical care ultrasound is finally receiving the attention it deserves. Let's define it just once again so there is no ambiguity to its usefulness for the critically ill. Critical care ultrasound performed at the bedside allows the intensivist to categorize the etiology of all forms of cardiopulmonary failure and/or multiorgan failure, allowing immediate interpretation of the results without the time or clinical dissociation inherent in consultative radiology or echocardiography. This interpretation is then integrated into the clinical picture, along with the history and surface physical examination, and may allow a more complete treatment plan that could reduce the need for ionizing radiation and transport of the patient. CHEST, and all other major international critical care societies, have endorsed critical care ultrasound, and it is hard to find an issue of this Journal without at least 1 article on its usefulness., The utility and ease of point-of-care ultrasound (POCUS) use has spread among other subspecialties, confirmation of which is seen in a recent endorsement of POCUS, including echocardiography, by the president of the American Society for Echocardiography. What a long way we have come. For years, the ultrasound machine, if a critical care unit had one, would sit idle in the corner, hibernating, with its occasional use to guide central line placement or help in distinguishing into which intercostal space the fellow would put the thoracentesis needle. Well, the ultrasound revolution has begun, but like all revolutions, success cannot be based on ideology alone.

The successful integration of critical care ultrasound into routine use requires up-front education and continuous quality assurance. Although many academic institutions have created formal ultrasound curricula for fellows and attending physicians, with mentoring and regularly scheduled ultrasound didactics and hands-on training, this is by no means universal. Ultrasound education, for many, relies on critical care ultrasound courses such as the ones offered at CHEST. We have trained more than 2,200 intensivists over the past 10 years and have great data suggesting that all who attend learn many of the skills, including image acquisition and image interpretation, necessary to become competent at their institutions. However, even today, not all intensivists interested in critical care ultrasound have the ability to receive personalized training, mentorship, and experiential learning. With the explosion of online education and social media, and the ability to view high-quality videos in virtually all areas of medicine, at least some of the obstacles of personalized training for ultrasound may be mitigated. An example of such learning is the Ultrasound Corner, an online video-based educational series published in this Journal, of real patient cases, where POCUS proved vital for the diagnosis and management of all types of disease processes. The series began in 2013 and has been very successful. Since the beginning, more than 70 cases have been submitted and the number of submissions is increasing every year. Each case outlines a clinical scenario encountered routinely in the critical care setting. Along with the clinical history and physical examination, a set of unknown ultrasound videos is available to view. The authors challenge the reader to use the videos to help organize a diagnosis for the “patient.” The discussion section focuses on the image acquisition and interpretation of each video and how it was clinically integrated to ultimately render a diagnosis and management strategy. A unique part of each Ultrasound Corner is the narration by the section editor, which accompanies the discussion video section. The narration not only identifies the key points of each video, but also adds a poetic essence to the case entitled reverberations.

In real life, POCUS is always integrated into the complete patient evaluation alongside the clinical history and physical examination. The intensivist who performs POCUS does not do so in a vacuum. All aspects of the patient’s case are known before the POCUS, allowing the intensivist to ask and answer specific questions about the patient. Why is my patient hypotensive? Goal-directed echocardiography may answer this question. Goal-directed echocardiography categorizes the shock state accurately and immediately, allowing potentially life-saving therapeutics to be given (eg, thrombolysis in massive pulmonary embolus, pericardiocentesis in tamponade). Why is my patient in hypoxemic respiratory failure? Does he or she have a pneumothorax? A massive pleural effusion or pneumonia? In this way, the intensivist uses a whole body ultrasound approach to help answer an ICU daily question: Why is my patient critically ill? The Ultrasound Corner cases illustrate how POCUS adds to daily patient evaluation and challenges readers to test their level of competence in interpreting the video images. The cases demonstrate how to use POCUS in all aspects of critical care from the diagnosis and management of shock and respiratory failure to the help with procedural guidance such as chest tube placement and pericardiocentesis. Less common applications of ultrasound are also explored, such evaluating optic nerve diameter for identification of increased intracranial pressure. However, make no mistake: becoming competent in critical care ultrasound requires hands-on training, starting with being trained by someone experienced in POCUS, whether at a course or personalized mentoring, and continuing with individual, at the bedside, “on-the-job training.” But as a trusty companion, Ultrasound Corner will provide the learner with reassurance in image interpretation and clinical integration with high-quality cases and just may make some of you authors. We encourage all who perform POCUS to submit both “the bread and butter” critical care cases, such as left and right ventricular failure cases, commonly encountered in daily ICU practice, and cases where POCUS allowed a timely diagnosis of less common disease processes. We have recently received submissions that outline POCUS for intracerebral hypertension, septic pulmonary emboli, pyopneumothorax, and diaphragmatic dysfunction. These cases highlight the remarkable creativity that physicians possess when faced with a critically ill patient and no diagnosis. They say necessity is the mother of invention; therefore, we look forward to reviewing all your ultrasound cases.

References

Schmidt G.A. . Expert consensus on advanced critical care echocardiography: opportunity to do it right. Chest. 2014;145:1188-1189 [PubMed]journal. [CrossRef] [PubMed]
 
Mayo P.H. .Beaulieu Y. .Doelken P. .et al Consensus Statement. American College of Chest Physicians/La Société de Réanimation de Langue Française Statement on Competence in Critical Care Ultrasonography. Chest. 2009;135:1050-1060 [PubMed]journal. [CrossRef] [PubMed]
 
Wiegers S.E. . The point of care. J Am Soc Echocardiogr. 2016;29:A19- [PubMed]journal
 

Figures

Tables

References

Schmidt G.A. . Expert consensus on advanced critical care echocardiography: opportunity to do it right. Chest. 2014;145:1188-1189 [PubMed]journal. [CrossRef] [PubMed]
 
Mayo P.H. .Beaulieu Y. .Doelken P. .et al Consensus Statement. American College of Chest Physicians/La Société de Réanimation de Langue Française Statement on Competence in Critical Care Ultrasonography. Chest. 2009;135:1050-1060 [PubMed]journal. [CrossRef] [PubMed]
 
Wiegers S.E. . The point of care. J Am Soc Echocardiogr. 2016;29:A19- [PubMed]journal
 
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

Find Similar Articles
CHEST Journal Articles
PubMed Articles
  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543