(1)
Hôpital Ambroise Paré Service de Réanimation Médicale, Boulogne (Paris-West University), France
The intensive care unit is the priority step for developing the BLUE-protocol, but ultrasound is welcome everywhere: the intensivist’s experience can be extrapolated to several disciplines and countless settings. We estimated that a dozen of clinical disciplines would be interested. The best for making it a reality would be to implement lung ultrasound in the medical studies: the shortest way. Not whole body ultrasound, because this would result in making longer medical studies. Just lung ultrasound, because it is the simplest, and because all future doctors dealing with the lung would benefit from it. Another aspect of the paradox of LUCI. Therefore, please expect some decades (hopingly less) for seeing ultrasound a natural component of each of these specialties.
Specialties Dealing with Critical Care
The Intensivist
The book is quite fully dedicated for the frontline critical care physician, from medical intensive care or anesthesiology.
Pediatrics and Critical Care, the Neonatologist, the Neonate Intensive Care Unit
This is our priority target. Although our findings were assessed in adults, our experience showed that the signatures were exactly the same with critically ill neonates, with no adaptation.
Given the potential hazards of radiations, each time a child in less critical settings will have ultrasound instead of CT, his or her long-term health will be preserved. Cough and fever should expedite an ultrasound test, indicating here no need for antibiotics, or there adapted antibiotics, and there again, admission for tight control (if ultrasound shows disseminated lung disorders).
The Trauma Physician
When we wrote our 1992 edition, the road accidents created severe lesions, and CT was an adventure in these patients. Facing countless minutes for image acquisition, many patients never came back from the CT department. The year 1982 (ADR-4000®) was a golden opportunity for critical ultrasound to develop – a revolution for a complete autonomy. Countless stars in the sky are souls that were not saved since these times.
Now, not only road accidents are much less frequent, but also each small hospital counts several ultra-rapid CT units, the doctors have just to push the button and have a whole body analysis in 10 s, which provides a complete study of the deep organs, the skeleton, a functional study by iodine injection that shows vascular ruptures or parenchymal lesions at the liver, spleen, kidneys, etc. Highlighting CT scan as the first tool in trauma is therefore natural – now [1].
We will not underline again CT’s drawbacks. CT is still reserved to the most stable patients, and to be fair, we know some remote villages in the far world that are not yet equipped with hypermodern CTs. We hope that the development of pre-hospital ultrasound will allow more patients to come alive to the hospital. Let us also consider that CT access may become restrained in the future for limiting irradiation – making ultrasound of major interest in focal trauma [2].
We saw about hemothorax, pneumothorax, one lung intubation, etc. Lung contusion [3] yields lung rockets and lung consolidation, better than radiography, only 63 % sensitive [4].
The second principle of lung ultrasound (the sky-Earth axis) will be used if the patient is not strictly supine, but for example a prisoner in an upside down crashed automobile.
We assess the diaphragm using longitudinal scans, an indisputable advantage of ultrasound when compared to the transversal views of CT (see some slides of cupolas in Chaps. 16 and 17 and video in Chap. 36). As usual, radiography lacks specificity. Ultrasound here again plays a role [5]. We put emphasis on indirect signs of rupture: ectopic locations of subphrenic organs – spleen (liver more rarely), GI tract, and abolished lung sliding in spontaneous ventilation.
Pre-hospital Medicine: Lung Ultrasound for Flying Doctors
In an airplane, room is a true concern. Hand-held units are here a providence. We had the privilege to drive in 1996 the first medical experience of pre-hospital ultrasound [6]. It was made from a medical helicopter in a mission over Morocco, Mauritania, Mali, and Senegal – we are glad to see that this princeps paper initiated a wide use in pre-hospital ultrasound. In our pilot study, the physicians answered to vital clinical questions on site. A focus on life-saving traumatic problems (pneumothorax, hemothorax, hemopericardium, abdominal bleeding) provided the answer to 90.6 % of the questions. The local conditions (sun of the desert, sand, vibrations, interferences from rotor in the helicopter) affected in no way the ultrasound examination.
So, without mistake, the first pre-hospital ultrasound diagnosis of pneumothorax was made in the Mauritanian desert (January 8, 1996), using a 3.5 kg perfectly portable machine (Fig. 33.1). We then used for our flying missions the 1.9 kg compact machine for more than one decade (Fig. 33.2) then the 0.4 kg machine described in Chap. 2. We would feel really naked without it. Read if needed words about the light units in Chap. 2. We have designed the ULTIMAT-protocol, an ultrasound report dedicated to medical transportation (Table 33.1). The SLAM made some difficulties with the “L” (lump), found it a bit artificial, but eventually accepted the lump acronym.
Fig. 33.1
Portable ultrasound in the desert in 1996. A lot to describe in these coupled figures. At the left, the antique Dymax TM-18, the unit we took in the Sahara desert and the helicopter of the Paris-Dakar rally, i.e., probably the first extra-hospital experience. This unit had five buttons, no lost space for storing any image, only one probe and a battery. This was a fully autonomous “stethoscope,” since December 1995. The pen (arrow) indicates the size of the machine. At the right, we can witness a first: January 8, 1996, in the Saharan desert of Mauritania. A pneumothorax is diagnosed in a crashed biker of the Dakar rally. Maybe the first pre-hospital diagnosis of a life-threatening disorder. The concept we defined in our 1992 textbook is fully illustrated in this image: the exercise of critical ultrasound, the setting of point-of-care ultrasound, and lung (LUCI) as the main target in the critically ill
Fig. 33.2
Air medicine since the year 2000. This machine, which allowed us to conduct countless medical retrievals of critically ill patients through the sky from 2000 to 2012, was devoted to veterinarians, with a smart system for fixing the unit on the forearm, for checking using the other hand whether lady pigs were pregnant. In critical ultrasound, we need our two hands, and we quickly fitted this system into a suitable bag. Using our one-probe philosophy and a light screen, this Tringa unit from Netherlands was clearly one (large) step ahead. Note how small it is (look at the pen). It is perfect for jet medicine. Note on the front pocket of the bag (arrow), material such as this universal 16 G 60 mm catheter, for life-saving procedures (pneumothorax, pericardial tamponade, deep venous line insertion, etc.), making a diagnosis and therapeutic unit. We are approaching the concept of the PUMA (see Fig. 2.2)
Table 33.1
The ULTIMAT-protocol: ultrasound lump test initiating medical airway transportation protocol
Name: | Date: | |
Setting: | ||
Indication: checking for the absence of occult disorders which may influence safety of the air medical transportation | ||
Operator: | Ultrasound unit: Signos RT, 5 MHz probe | |
Technique: two-dimensional technique only | Various parameters (ventilated patient, etc.) | |
Lungs | ||
Screening for pneumothorax (2″ × 2) | ABSENT | PRESENTa |
Screening for hemothorax (10″ × 2) | ABSENT | PRESENTa |
Screening for one lung intubation (5″) | ABSENT | PRESENTa |
Screening for interstitial disorder (6″ × 2) | ABSENT | PRESENTa |
Heart | ||
Screening for pericardial effusion (10″) | ABSENT | PRESENTa |
2D impairment of LV contractility (10″) | ABSENT | PRESENTa |
Abdomen | ||
Screening for pneumoperitoneum (5″) | ABSENT | PRESENTa |
Screening for hemoperitoneum (30″) | ABSENT | PRESENTa |
Screening for mesenteric ischemia (30″) | ABSENT | PRESENTa |
Screening for distended bladder (5″) | ABSENT | PRESENTa
Related posts: The Excluded Patients of the BLUE-Protocol: Who Are They? Did Their Exclusion Limit Its Value?
The BLUE-Protocol and the Diagnosis of Pneumonia
Glossary
 The Ultrasound Approach of an Acute Respiratory Failure: The BLUE-Protocol
 Suggestion for Classifying Air Artifacts
 Which Equipment for the BLUE-Protocol 2. The Probe
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