Challenger Fundamentals: EM Ultrasound. Fundamentalsfor Emergencyand Acute Care Physicians By John L. Kendall, MD , Sarah A. Stahmer, MD , and Mark Deutchman, MD. Memphis, TN : Challenger Corp. , 2008 ; $395 (one instruction CD ).

Up to 20.0 AMA Category 1 CME from The University of Colorado School of Medicine.

Challenger Fundamentals: EM Ultrasound. Fundamentals for Emergency and Acute Care Physicians is a CD-ROM–based course intended to teach the basic techniques of emergency ultrasound. It uses a combination of stills and video segments coupled with animations and diagrams to illustrate key concepts including probe position and sonographic images. The program performs admirably in providing a concise yet thorough introduction to ultrasound technology, physics, and sonographic anatomy, along with instruction on basic image acquisition and standard emergency ultrasound applications.

The CD opens with a dialog box, which provides instructions on applying appropriate computer settings to best visualize the ultrasound images. The table of contents introduces the 10 chapters, which are discussed below in sequence. It begins with an introductory chapter (four slides) that provides a brief overview of the program and its goals with a focused history lesson on ultrasound.

Physics and orientation are covered in the second chapter (39 slides). The goals of this chapter are to introduce the physics of ultrasonography and provide instruction on probe and patient orientation. The physics discussion provides valuable information to improve understanding of the variables affecting image quality and acquisition, including probe selection, sound wave transmission, acoustic windows, and artifacts. Building on the physics discussion, patient and probe orientation are reviewed to establish the conventions of ultrasonography, providing a universal language for effective communication. This chapter does an excellent job of providing the knowledge and basic understanding of physics and songraphic image acquisition to begin holding the probe and acquiring images.

Trauma is presented in the third chapter (84 slides). There is a full description of the use of ultrasound for the trauma patient including the indications, acoustic windows, pitfalls, and a synopsis of the relevant literature. The use of interactive videos and diagrams demonstrates the techniques for complete interrogation of the sonographic windows and illustrates the appearance of normal and abnormal findings including the appearance of free fluid. The chapter provides a great introduction into the skills and knowledge necessary to perform a FAST (focused assessment with sonography in trauma) exam.

The fourth chapter includes the evaluation of the right upper quadrant (69 slides). This section presents a thorough review of pertinent anatomy of the liver, biliary system, and relevant vasculature. The section goes on to discuss pathology of the biliary system and liver, with a focus on gallstones and associated normal and abnormal sonographic findings. The review of liver pathology is extensive and generally beyond the scope of point of care emergency ultrasound, as it details sonographic findings through a range of hepatic pathology from cancer to hepatitis.

Chapter 5 covers the aortic exam (31 slides). A thorough review of abdominal vasculature is presented. There is discussion of the aorta and its branches with full interrogation through two planes: transverse and sagittal views. The review of the abdominal vasculature is extended to include the hepatic veins and the inferior vena cava, as well as further discussion of the portal vein and its contributory vessels. Pathologic conditions that alter the sonographic appearance of the abdominal vessels are introduced with a brief discussion of the use of color and power Doppler to illustrate abnormal flow patterns. This is an excellent introduction to the key concepts for evaluating the aorta for both the novice and more advanced users with the discussion of color and power Doppler.

The renal exam is described in Chapter 6 (30 slides). The focus is on renal anatomy, renal calculi, and hydronephrosis providing an excellent introduction to the traditional emergency ultrasound application of renal ultrasonography. The section goes on to more advanced assessments, including measurements of kidney size, renal pathology, congenital anomalies, and bladder pathology. With a detailed approach to the discussion of renal ultrasound, this chapter provides both introductory and advanced sonographic findings, making it educational for both beginners and more experienced sonographers.

The following (seventh) chapter covers the cardiac evaluation (33 slides). The instruction for this section involves the acquisition and interpretation of cardiac images with endpoints of pericardial effusion, cardiac tamponade, and use in cardiopulmonary resuscitation. There is no mention of the evaluation of global left ventricular function. The images and diagrams illustrate probe position and desired image acquisition. The evaluation for pericardial effusion and pitfalls leading to false-positive and -negative exams are presented. Included in the discussion of pericardial effusions are the sonographic findings consistent with the clinical diagnosis of cardiac tamponade, including the evaluation of the inferior vena cava. Finally, there is a brief introduction to the use of bedside echocardiography in cardiopulmonary resuscitation. Echocardiography is a relatively broad field with a large amount of complex information, which is narrowed significantly when discussing emergent or point-of-care ultrasound. Overall, this chapter adequately introduces basic sonographic evaluation of the heart, covering most key concepts, although absent is the discussion of global left ventricular function.

Chapter 8 introduces the pelvic exam (70 slides). Pelvic sonography, using both the transabdominal and the transvaginal approaches, is introduced with stills, animations, videos, and interactive sessions. Review of the anatomy includes sonographic views of the uterus, ovaries, and posterior cul-de-sac. The concept of identifying intrauterine pregnancy (IUP) versus no IUP is well illustrated. There is in-depth discussion on dating with multiple dating measurements, including dating in the second and third trimesters, which is typically beyond the scope of emergency ultrasound. Emergency pelvic ultrasound focuses primarily on the presence or absence of an IUP in the first trimester and fetal well-being thereafter. The concept of an IUP is well presented in this chapter, and the learner should come away with a firm grasp of this concept.

The evaluation of the lower extremity venous system for deep venous thrombosis (DVT) is discussed in the ninth chapter (17 slides). There is an initial review of anatomy covering the venous system extending from the common femoral vein to the trifurcation of the popliteal vein. There is discussion of the two protocols for venous compression: full compression versus limited compression. Adjuncts and common pitfalls for the compression study for DVT are introduced. The interactive videos provide demonstration of probe position with the corresponding image as instruction for appropriate image acquisition. The lower extremity evaluation for DVT is well introduced here, and the learner should acquire the knowledge to complete a basic point of care DVT examination.

The final chapter covers sonographic procedural guidance (70 slides). Approaches to procedural ultrasound are introduced with discussion of the two-person versus free-hand and dynamic vs. static approaches. There are nine procedural topics covered: venous cannulation, pericardiocentesis, transvenous pacemaker placement, thoracentesis, paracentesis, foreign body retrieval, abscess drainage, joint aspiration, and bladder aspiration. With each topic, the important steps to identification of structures and approach to the procedure are covered. Ultrasound guidance generally improves the safety and efficiency of most procedures. With this chapter, the learner is given the knowledge necessary for a safer and more efficient approach to standard emergency procedures. It provides an excellent introduction to the novice user and a thorough review for the more experienced user.

In summary, this is an educational CD introducing the concepts and applications of emergency ultrasound. Emergency ultrasound encompasses a wide spectrum of applications, which have been divided into 10 convenient and easy-to-follow chapters. With interactive images, videos, and animations, the CD thoroughly introduces emergency ultrasound. The CD would be an excellent introduction to emergency ultrasound for novice learners including medical students, residents, or practicing providers looking to learn the basic concepts and gain comfort performing beside sonographic examinations. It would also work well for those providers with some experience looking for a review or more detailed understanding of the concepts and approaches to emergency ultrasound. The learner should come away with the necessary knowledge to acquire and interpret basic emergency ultrasound images.