MUSC Internal Medicine Bedside Ultrasound Curriculum Overall objectives: 1. Understand the basic physics of ultrasound technology 2. Appreciate the clinical role for bedside ultrasound 3. Differentiate between types of ultrasound transducers and select correct transducer for particular bedside applications 4. Visualize the normal sonographic appearance of solid organs, soft tissues and vascular structures 5. Recognize abnormalities in the solid appearance of solid organs, soft tissues and vascular structures that can acutely change clinical management 6. Appreciate current literature supporting ultrasound education for IM Residency Programs Useful resources: http://emergencyultrasoundteaching.com/ - Dr. Geoff Hayden s website containing lots of great videos, articles, images, cases, and links to other great resources http://learn-us.vanderbiltem.com/ - ER based lots of great videos http://www.susme.org/learning-modules/learning-modules/ -USC School of Medicine website that has physics lectures, etc http://www.critcaresono.com/ -- tutorials, images, practice clips http://www.nejm.org/multimedia/medical-videos/- procedural videos for paracentesis, thoracentesis, central and peripheral line placement. 1. Knobology Learning Objectives Ultrasound basics 1. Understand orientation of ultrasound probe to the patient 2. Understand orientation of ultrasound probe to the ultrasound screen 3. Identify the appropriate ultrasound probes for various bedside applications: cardiac imaging, pleural imaging, soft tissue imaging, central line placement, and paracentesis 4. Understand how to take and annotate ultrasound images 5. Understand basic ultrasound physics 6. Understand basic ultrasound language (ie hypoechoic, anechoic, hyperechoic) 7. Recognize common ultrasound artifacts acoustic shadowing, mirror image
Moore, C. Point-of-Care Ultrasonography. NEJM. February 24, 2011. http://emergencyultrasoundteaching.com/narrated_lectures.html - Physics and Knobology lecture http://www.susme.org/learning-modules/learning-modules/ 2. Pulmonary Ultrasound Learning Objectives A. Recognize the normal appearance of visceral and parietal pleura using 2D and M-mode imaging 1. Identify ribs, rib shadowing, intercostal space and pleural line 2. Identify A lines 3. Identify lung sliding with respiration 4. Use M-mode to identify normal lung pattern ( seashore sign ) 5. Appreciate the anatomical relationship of lung, diaphragm and liver/spleen and be able to point out all structures B. Recognize common lung abnormalities 1. Identify B lines 2. Assess for pleural effusion 3. Assess for pneumonthorax 4. Assess for consolidation C. Identify Deep Vein Thrombosis Ding et al. Diagnosis of Pneumothorax by Radiography and Ultrasonography:A Meta-analysis. Chest. 2011; 140(4):859 866 Turner, J. Thoracic Ultrasound. Emerg Med Clin N Am 30 (2012) 451-473 Zanobetti et al. Can Chest Ultrasonography Replace Standard Chest Radiography for Evaluation of Acute Dyspnea in the ED? Chest. CHEST 2011; 139(5):1140 1147 http://www.critcaresono.com/page.php?page=27 lung US http://www.critcaresono.com/page.php?page=29 pleural US http://www.sonosite.com/education/learning-center/58/1425 - how to US for pneumothorax http://www.sonosite.com/education/learning-center/58/1441 - US for detection of pleural fluid
3. Cardiac Ultrasound Learning Objectives 1. Obtain 4 views of the heart: parasternal long axis, parasternal short axis, apical 4 chamber, subxyphoid 4 chamber 2. Identify left atrium, mitral valve, left ventricle, aortic valve, aorta, right ventricle, right atrium in each view 3. Obtain qualitative assessment of global LV function (be able to determine <30% vs normal) 4. Obtain qualitative assessment of chamber size and overload https://www.stanford.edu/group/ccm_echocardio/cgi-bin/mediawiki/index.php/main_page http://emergencyultrasoundteaching.com/ - Cardiac Ultrasound www.sonosite.com/education/learning-center - Cardiac Ultrasound Arntfield, R. Point of Care Cardiac Ultrasound Applications in the Emergency Department and Intensive Care Unit a Review. Current Cardiology Reviews, 2012 (8) 2. 4. Soft Tissue Ultrasound Learning Objectives a. Identify the appearance of normal soft tissue b. Recognize the ultrasound appearance of cellulitis c. Differentiate between cellulitis and abscess Squire, et al. ABSCESS: Applied Bedside Sonography for Convenient Evaluation of Superficial Soft Tissue Infections. Acad Emer Med July 2005, 12 (7). http://www.sonoguide.com/abscess.html http://emergencyultrasoundteaching.com/narrated_lectures.html -- Soft tissue lecture 5. Procedural Ultrasound Learning Objectives 1. Identify internal jugular vein and common carotid artery 2. Appreciate the differences between arteries and veins by ultrasound 3. Verify central venous line placement 4. Utilize ultrasound for peripheral venous access
5. Identify ascites 6. Appropriately mark site for paracentesis http://emergencyultrasoundteaching.com/narrated_lectures.html - Venous access lecture http://www.ucdmc.ucdavis.edu/emergency/ultrasound%20cvc%20tutorial/dynamicus_dev29.html - US guided central venous access interactive tutorial www.sonosite.com several videos on central venous line placement, US guided paracentesis 6. Hypotensive patient/volume Assessment Learning Objectives 1. Identify the IVC 2. Identify the junction of the right atrium and IVC 3. Measure the diameter of the IVC 2cm from IVC/right atrial junction 4. Assess for IVC collapse with respiration or sniff test 5. Correlate IVC diameter with estimated RA pressure 6. Obtain qualitative assessment of global LV function (be able to determine <30% vs normal) 7. Obtain qualitative assessment of chamber size and overload Haydar et al. Effect of Bedside Ultrasonography on the Certainty of Physician Clinical Decision making for Septic Patients in the Emergency Department. Ann Emer Med 2012 Byrne, M. Ultrasound in the Critically Ill. Ultrasound Clin 6 (2011) 235-259 Perera, P. The RUSH Exam: Rapid Ultrasound in Shock in the Evaluation of the Critically Ill Patient. Emerg Med Clin North Am. 2010 Feb;28(1):29-56. http://emergencyultrasoundteaching.com/narrated_lectures.html - hypotensive patient and volume assessement lectures Stawicki et al. Intensivist Use of Hand-Carried Ultrasonography to Measure IVC Collapsibility in Estimating Intravascular Volume Status: Correlations with CVP. J Am Coll Surg. 209 (1) July 2009. http://learn-us.vanderbiltem.com/ - hypotensive patient
7. Literature Supporting Ultrasound Education for IM Residency Programs 1. Keddis et al. Effectiveness of an Ultrasound Training Module for Internal Medicine Residents. BMC Medical Education 2011. Mayo Clinic 2. Alba et al. Faculty Staff-guided Versus Self-guided Ultrasound Training for Internal Medicine Residents. Medical Education. 2013. Massachusetts General Hospital. 3. Mourad et al. A Randomized Controlled Trial of the Impact of a Teaching Procedure Service on the Training of Internal Medicine Residents. Journal of Graduate Medical Education. June 2012. U. of California at San Francisco