"Why Ultrasound Belongs in EMS"

While perusing the the twitter sphere I found this tweet...

Ultrasound in every service.My #ECCU2015 pick with Drew Harrell MD @tingles005 @paramedic_al https://t.co/CUAHCNagaI pic.twitter.com/mQs1Tj6eZc

— Word on the Street (@wotsukrobl) December 11, 2015

It really caught my eye thanks to the paper I just wrote and shared here. Point of Care Ultrasound (POCUS) has great utility in acute care and it will probably be the only imaging modality that could reasonably be put in an ambulance. Sonosite and Philips just released pocket/tablet form US devices that could easily be kept next to a cardiac monitor. If Philips is listening they will realize they make EMS cardiac monitors and US probes that could be added together... just an idea.



Anyways! POCUS should be used in cardiac arrest, at least to assure the providers and family that the patient has no cardiac motion(1) and to differentiate PEA and Pseudo-PEA(2).

This figure lays out a new paradigm for PEA management... Which is really the old paradigm for PEA with a functional protocol not just a list of words that (sorta) start with H and T (seriously, Hydrogen ions?).

Prehospital cardiac arrest is one of the few pathologies that may never be evaluated by a physician. Why aren't we using every possible evaluation modality available? Adding ultrasound to the back of an ambulance or specific fly cars could change outcomes in specific patients. Focused Assessment with CardioThoracic Ultrasound can change field treatment decisions.

• Needle decompression (or simple thoracostomy(3,4))
• Need for pericardiocentesis (Prehospital or transporting to nearest ED during CPR)
• Differentiating causes of Dyspnea(COPD Vs. CHF) and monitoring CPAP (5,6)
• Confirming resuscitation futility

Now this is just my personal belief, but what does seeing a STEMI on an ECG change for prehospital management? Maybe destination? What it really helps is the patient's hospital course. If the Cath lab can be activated we can decrease time to definitive treatment. POCUS has the ability to change prehospital management and the hospital course like an ECG. 

As it has been conveyed to me, no one thought ECGs were important when they started in the prehospital setting either.

What do you think? Is it to early for prehospital ultrasound? Should ultrasound be limited to physicians? Comments are always appreciated!

References

1. Aichinger G, Zechner PM, Prause G, et al. Cardiac movement identified on prehospital echocardiography predicts outcome in cardiac arrest patients. Prehosp Emerg Care. 2012;16(2):251-255. doi:10.3109/10903127.2011.640414.

2. Littmann L, Bustin DJ, Haley MW. A simplified and structured teaching tool for the evaluation and management of pulseless electrical activity. Med Princ Pract. 2014;23(1):1-6. doi:10.1159/000354195.

3. Weingart, Scott. Podcast 62 – Needle vs. Knife II: Needle Thoracostomy? December 11, 2011 http://emcrit.org/podcasts/needle-finger-thoracostomy/

4. Massarutti D, Trillò G, Berlot G, et al. Simple thoracostomy in prehospital trauma management is safe and effective: a 2-year experience by helicopter emergency medical crews. Eur J Emerg Med. 2006;13(5):276-280. http://www.ncbi.nlm.nih.gov/pubmed/16969232. Accessed December 20, 2015.

5. Prosen G, Klemen P, Štrnad M, Grmec S. Combination of lung ultrasound (a comet-tail sign) and N-terminal pro-brain natriuretic peptide in differentiating acute heart failure from chronic obstructive pulmonary disease and asthma as cause of acute dyspnea in prehospital emergency setting. Crit Care. 2011;15(2):R114. doi:10.1186/cc10140.

6. Strnad M, Prosen G, Borovnik Lesjak V. Bedside lung ultrasound for monitoring the effectiveness of prehospital treatment with continuous positive airway pressure in acute decompensated heart failure. Eur J Emerg Med. September 2014. doi:10.1097/MEJ.0000000000000205.