Emergency Ultrasound Outside the Intensive Care Unit
hospital ultrasound was, to our knowledge, prac- ticed with the described logistics [2]. Using an ultraportable ultrasound unit, the emergency physician directly answered vital clinical questions on site. The aim of this experiment was to analyze the percentage of clinical questions ultrasound answered. Some items such as pneumothorax, hemothorax, hemopericardium, and acute hypov- olemia (inferior vena cava caliper) were investigat- ed and provided the answer to 90.6% of the questions. Therefore and without error, the first pre-hospital ultrasound emergency diagnosis was given in the desert, was for pneumothorax, and was done in January 1996.
Air Medicine
This first experience of pre-hospital ultrasound came in fact from the air [2]. It was performed from a helicopter over Africa. This small helicopter had enough room for our ultraportable ultrasound unit, which in fact fit in a small bag. The local conditions (vibrations, possible interferences) in no way affected the ultrasound examination. In many countries with low-density population, physicians (flying doctors) willingly use the air route, and may feel reinforced by this supplemen- tary tool.
Physician-Attended Ambulances
What was possible in a small helicopter is also pos- sible in an ambulance. Should one be destitute in the full arid desert of Mauritania or highly med- icalized on the road in the heart of Paris, one may feel the need for an immediate diagnosis.When the far-reaching possibilities of ultrasound are consid- ered, it is hard to believe that this will not be part of the future. A traumatized patient will be confi- dently approached, pneumothorax or hemothorax immediately detected, a central venous access promptly inserted in extreme emergency, a dysp- The intensive care unit is only the first step for
practicing and developing emergency ultrasound.
Ultrasound in the Emergency Room
The development of ultrasound in the emergency room can solve many situations. For the moment, the critically ill patient admitted to the ER will be quickly taken in charge by the intensivist. Respira- tory distress, circulatory shock, coma, acute renal failure, drug poisoning, pneumothorax and others are situations where the patient is usually man- aged directly by the intensivist.
On the other hand, countless situations that do not depend on intensive care medicine and are managed by the emergency physician will be sim- plified by the use of ultrasound. Pneumonia, renal colic, venous thrombosis, rib fracture, an impres- sive number of situations can be quickly diag- nosed or quickly ruled out. It is to be expected that a rational use of ultrasound in the emergency room can solve the problem of the accumulation of patients at the emergency room, an important part of the public image of the hospital.
The surgeon called at the ER considers ultra- sound a beneficial tool that will reinforce her clinical sense. Acute appendicitis [1], intestinal obstruction, pneumoperitoneum are some exam- ples among many others.
Note that ultraportable units are a false solution to a real problem: in the ER, there is enough room for the 1978 technology units such as the ADR-4000.
The place for non-ICU emergency ultrasound will not be limited to the ER alone.
Pre-hospital Ultrasound
In a helicopter or an airplane, room is a true
concern, and ultraportable units may be advanta-
geous. The first experiment in emergency extra-
CHAPTER 25neic patient or even a comatose patient properly guided.
A pilot’s license, so to speak, will be indispens- able, more than ever. On the other hand, the devel- opment of sophisticated echocardiography in the ambulance without having first provided the teams with general emergency ultrasound (which includes the main heart emergencies) would be a suboptimal way to exploit ultrasound possibilities.
Pediatric and Neonatal Intensive Care Unit
The use of ultrasound will be highly contributive in pediatric and neonatal ICUs. First, the neonate will benefit from high frequency probes, which means higher diagnostic precision. In fact, the higher the frequency, the better the image. Since the deleterious effects of the ionizing radiation are now established in the child, any noninvasive rou- tine method should be carefully studied [3].
Monitoring the respiratory and cardiac func- tions, mastering the central veins, the transfontanel route are some of the many points of impact to be investigated. An entire chapter will be devoted to the child in the next edition.
Ultrasound of the World
Ultrasound will be as useful in the wealthy ICUs of the affluent world as in the numerous disadvan- taged regions of the world where CT is lacking – or even a simple radiography unit. In this very partic- ular setting, a small unsophisticated device, with a solid padlock, will act as a terminal to make advis- edly therapeutic decisions using extremely simpli- fied logistics.
References
1. Puylaert JBCM (1986) Acute appendicitis: ultrasound evaluation using graded compression. Radiology 158:355–360
2. Lichtenstein D, Courret JP (1998) Feasibility of ultra- sound in the helicopter. Intensive Care Med 24:1119 3. Brenner DJ, Elliston CD, Hall EJ, Berdon WE (2001)
Estimated risks of radiation-induced fatal cancer from pediatric CT. Am J Roentgenol 176:289–296
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