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Point of Care Ultrasound A key skill for the Emergency Surgeon Ioannis Gerogiannis MD, PFICS, FRCS, MFSTEdMLM, FACS, Specialist Interest in Upper Gastrointestinal, Bariatric & Abdominal Wall Surgery Department of Surgery, Kingston Hospital London (KHFT) Honorary Senior Lecturer - St George's University London (SGUL) College Tutor - Royal College of Surgeons of England (RCSEng) Educational Committee Member - European Society for Trauma & Emergency Surgery (ESTES) Educational Committee Member - European Hernia Society (EHS) ATLS, PHTLS, DSTC, CCrISP, BSS, MUSEC InstructorUSS & Emergency Surgery • Trauma Surgery • FAST • e-FAST • Non trauma Surgery • Abdominal/visceral USS • Soft tissue USS • Vascular USS • Interventional USSUSS • Many applications • In UK, it is performed by ultrasonographers and radiologists POCUS • Accident & Emergency physicians • Not popular in surgical community • I use it in my everyday practice in Emergency Surgery • Challenging situation (medicolegal & acceptance from colleagues)Case Scenario 1Case Scenario 1 • One Tuesday morning… • Cirrhotic, obese, 65 yo patient with ascites – Under Medics • Multiple attempts of ascitic paracentesis Rt abdomen • Sample taken but patient became septic after • Transferred to ITU Case Scenario 1 Wednesday early in the morning… • Surgical opinion was requested ?perforation • Patient with sepsis and ongoing respiratory failure • ↑ Ascites – ↑ intrabdominal pressure • ITU asked for ascitic drainage catheter under IRCase Scenario 1 Wednesday 08:30… • Surgical Ward Round in ITU • Patient seen and examined • Still waiting confirmation from IR…Case scenario 1 - What would you do? 1. Request a CT abdomen & pelvis 2. Re attempt paracentesis 3. Exploratory laparotomy 4. Bedside USS and position of a drain 5. Request an Erect Chest XR 6. Wait for Interventional radiology to position a drain 7. Conservative management with antibiotics and respiratory supportCase Scenario 1 • Decision for bedside USS abdomen • Insertion of catheter with Seldinger technique under direct vision and LA • 500 mls of clear ascitic fluid was initially drained (IAP) • Fluid sent to labs for Leucocytes, WBC and cultures • Gastro opinion was asked • Patient started to improve (respiratory) • Fluid did not show high leucocytes and WBC • No further surgical inputSo… POCUS Fast – avoids delays (?life threatening) Safe – “under vision” technique Bedside procedureCase Scenario 2Case Scenario 2 • 87 yo female presented to A&E with acute onset abdominal pain • Vomiting for 12 hours, loss of appetite, feeling unwell • PMH: Hypertension, liver cirrhosis, hypothyroidism, osteoarthritis, no previous operations, recurrent urinary infections • O/E: abdomen soft, mildly distended, generalised tenderness, bowel sounds present • BP: 95/60 HR:107 T:37.3 INR: 2.1 • WBC: 16.7 CRP:71 • Urine dip: Leu: 1+, Prot:1+, Nitrites: -Case scenario 2 - What would you do? 1. Request a CT abdomen & pelvis 2. Request an abdominal XR and an Erect Chest XR 3. Perform a FAST scan 4. Conservative management with antibiotics and analgesia 5. Palliative care (just analgesia) 6. No need for a surgeon - ask a gastroenterologist (hepatologist) to see the patientCase Scenario 2 • CT abdomen – pelvis was requested • Reported free intrabdominal fluid in 4 quadrants – no free air – thickened wall small bowel – SMA & SMV patentCase scenario 2 - What would you do next? 1. Exploratory laparotomy 2. Diagnostic laparoscopy 3. Paracentesis of the abdomen with USS guidance 4. Diagnostic Peritoneal Lavage (DPL) under LA 5. Conservative management with antibiotics and analgesia 6. Palliative care (just analgesia) 7. No further surgical input - ask a gastroenterologist (hepatologist) to see the patient Case Scenario 2 • POCUS was performed confirming the fluid • Paracentesis under USS guidance Case Scenario 2 • Peritoneal fluid was aspirated (looked ascitic) and sent to the lab • Decision to proceed with conservative management with antibiotics and ask for a gastro team opinion later • Patient started improving from the next day. Discharged after 4 daysSo… POCUS Can save patient from a laparotomy/laparoscopy May facilitate early diagnosis Safe – “under vision” technique Bedside procedureUltrasound: Is it a useful skill for the ES? • Adjunct to the surgical practice • No operational cost/ no radiation • We can use it as many times we want! • Dynamic Scan • Portable – Bedside • Pre – intra – post operative use – no limitations • More sensitive for specific pathologies • To use it, you have to believe it's of value!Thank you