An audit was conducted of 1,750 emergency ultrasound scans performed over 7 months at a hospital. The most common scans were abdominal (32%), vascular (22%), and echocardiography (10%). The majority (53%) of abdominal scans found relevant pathology such as gallstones, kidney stones, appendicitis. Vascular scans commonly detected deep vein thromboses (9%) and aortic aneurysms (2%). Echocardiograms often had normal results (44-71%) but also found things like pulmonary embolisms, pericardial effusions and heart wall motion abnormalities. The audit demonstrated emergency ultrasound's value in rapidly diagnosing many acute and urgent conditions.

1. Emergency Ultrasound
James Rippey & the Sonoboys
An audit of 1750
sequential DDU ED Cases
7 months

2. Background
• The Vision
– Ultrasound is user dependent
– DDU vs CCPU
– The Roster
• Why the audit?
– Financial accountability
– Hospital Politics

3. Background
• Method
– Only DDU scans counted
– Relied on the Sonoboys to enter the cases
Date DD
U
UMR
N
Study
Description
Indication Diagnostic Impact Management
impact
Disposition Actual
diagnosis
Qualit
y
Abdominal
- upper
pain
- lower pain
- rif pain
- flank pain
- hernia
- other
Echo
- arrest
- SOB
- hypoten.
- chest pain
…..
Resus
Classic
Procedural
Equivocal
Confirmed suspicion
Excluded suspicion
Alternative diagnosis
Incidental finding
Not useful
Major
Minor
No impact
Impeded Mx
Assisted admission
Assisted discharge
No effect
(obstructed adm)
(obstructed disc)
Free text 1-5

4. TOTAL 1750
• Trauma Ultrasound 130 7%
• AAA 34 2%
• Abdominal ultrasound 554 32%
• Gynaecological ultrasound 104 6%
• Renal ultrasound 119 7%
• Vascular ultrasound (exc AAA) 183 10%
• Echocardiography 181 10%
• Testes 36 9%
• Ocular 16 1%
• Musculoskeletal 153 9%
• Procedural ultrasound 193 11%

5. Trauma - Major
Trauma 130 = 7% of workload
EFAST normal 109 (84%)
Free fluid 5
Free air 2
Splenic rupture & free fluid 1 (indication actually LUQ pain)
Renal injury 1
Sternal or rib fracture 9
Pneumothorax 2
Haemothorax 2
Retroperitoneal haemorrhage 1

6. Abdominal Aorta
Total scans 35 = 2% of workload
Normal scans 25 (71%)
Ruptured AAA 1
Ruptured iliac aneurysm 1
Aortic Dissection 1
AAA (not ruptured) new diagnosis 2
AAA (known – not bigger) 2
Repaired AAA 2
Inadequate images 1 (3%)

7. Echo - Indication
Total 181 = 10% of workload
Cardiac arrest 26
Chest pain 45
SOB 36
Hypotension 20
Sepsis & shock 32
Other (e.g. collapse, endocarditis,
murmur)
22
Normal 61

8. Echo - Arrest
Total 26 (11 ROSC)
No reversible cause evident 19
PE 1 (saddle, heparinised)
Dissection and then Tamponade 1 (died)
RWMA 5 (to cath lab)

9. Chest pain
Total 45
Tamponade 2
Type A dissection 2
Pericarditis with effusion 2
Pleural effusion 1
Acute MI 1 pericarditis vs RWMA (young pt)
1 Takutsubo vs RWMA (young pt)
1 inferior STEMI
Shoulder haemarthrosis (new LBBB) 1
HOCM, SAM, severe MR 1
Myopericarditis 1 (impaired LV young pt, trop 3000)
Pericarditis (pericardial thickening) 1
Normal 32 (71%)
12 ?PE; 12 ?pericarditis; 3 ?tamponade
post procedure, ?dissection, ?HOCM; Abn
ECG; abn CXR

10. Short of Breath
Total 36
APO 11
Pulmonary embolism 3
Pneumonia 1
Pleural effusion 2
Pericardial effusion 2 tamponade
1 no tamponade
Normal 16 (44%)
1 later shown to have endocarditis
1 had multiple bilateral PE on CTPA

11. Hypotension
Total 21
Biventricular failure 2
Pulmonary embolism 1
Hypovolaemia 4 (3 blood loss, 1 gastroenteritis)
Sepsis relatively underfilled 4 (given fluids)
Hypotension despite adequate filling 7 5 Sepsis, 1 DKA, 1 OD (given inotropes)
Other 1 moderate to severe MS
1 moderate to severe AS
Normal 1 (5%)

12. Sepsis & Shock
Total 32
Underfilled 12
Reasonably filled 20 (1 rapid AF)
Source / other pathology 1 Pneumonia
2 Infected obstructed kidney
1 Trauma, pancreatitis, free fluid
2 Bowel obstruction
1 Cholecystitis, choledocholithiasis
1 Pyelonephritis & bladder debris
2 Pleural effusions
1 Huge liver cyst
1 AAA

13. STUDY DESCRIPTION - ABDOMINAL 786/1750 = 45% of workload
Abdo
Upper abdo pain
Lower abdo pain
RIF pain
Flank pain
Hernia
Other
563 (72%)
256 (33%)
128 (16%)
92 (12%)
53 (7%)
6 (1%)
28 (4%)
Gynae
1st trimester
Pelvic pain
Other (mainly 2nd and 3rd)
104 (13%)
52
37
15
Renal
Failure
Colic
Haematuria
Infection
Other
119 (15%)
23
39
7
43
7

14. ABDOMINAL RESULTS SUMMARY
Total 786
Relevant pathology 419 (53%)
Incidental findings
Cavernous haemangioma
Dermoid (ovarian)
Horseshoe kidney
20 (2%)
No useful images 4 (0.5%)
Normal scans 353 (45%)

15. BILIARY PATHOLOGY
Cholelithiasis alone 40
Cholecystitis
2 perforated GB; one tract to skin
8 stones in GB neck; 1 acalculous
34
Cholangitis 2
CBD dilation
5 tumours (4 pancreatic, 1 cholangiocarcinoma);
5 stones; 2 pneumobilia
22
GB polyps 1

16. HEPATIC PATHOLOGY
Hepatitis 2
Metastases 3
Abscess 2
Fatty liver 6
Cirrhosis 1
Hepatic adenoma 1
Cavernous haemangioma 3
Simple cysts 2
Portal vein thrombosis 2

17. OTHER ABDOMINAL PATHOLOGY
Pancreatic mass 5
Pancreatic cyst 1
Ascites 5
Free fluid with debris 6
Splenic rupture with free fluid 1
Adrenal adenoma (known) 1

18. RENAL PATHOLOGY
Hydronephrosis 14
Infected obstructed 4
Intrarenal calculi 2
PUJ stone 4
Mid ureteric stone 3
VUJ stone 18
Pyelonephritis 7 (many more with no USS abn)
Ureteric reimplantation 2 (1 obstructed; 1 pyelonephritis)
Nephritis 1
AML 1
Nephrocalcinosis 1
Polycystic kidneys 1
Duplex collecting system 1
Horseshoe kidney 1
JJ stents 3
Nephrostomy tube pulled back too far 1
CRF kidneys 4

19. BLADDER AND PROSTATE PATHOLOGY
Urinary retention and outflow obstruction 9
Full bladder 1
Bladder calculi 3
Bladder tumour 4 (2 with ureteric obstruction)
Large clot 3
Bladder diverticuli 1
IDC in prostate 1
Prostatic abscess 1

20. GYNACOLOGY - UTERUS
Ruptured ectopic 3
PUL 5
Very early pregnancy 2
SLIUP – first trimester 40
2nd and 3rd trimester 17
Miscarriage 7
Post partum empty uterus 1
Adenomyosis 2
Haematometra and cervical stenosis 1
PID 5 (one with bilateral pyosalpinx)
Uterine perforation 1

21. GYNACOLOGY - OVARIES
Simple cyst 8
Haemorrhagic cyst / cyst rupture 15
Ovarian tumour 3 (one advanced, 2 dermoids)
Ovarian torsion 2
Ovarian hyperstimulation 1

22. ABDOMINAL WALL AND OTHER PATHOLOGY
Inguinal hernia 2
Femoral hernia 1
Incisional hernia 1
Umbilical hernia 2
Sister Mary Joseph nodule 1
Rib fracture 1
Abdominal wall abscess 3
Retroperitoneal haematoma 1
AAA 3
Post op collection 3

23. BOWEL PATHOLOGY
Bowel pathology 2
Perforated viscus (DU) 2
Diffusely thickened bowel (enteritis) 7
Bowel obstruction 8 (2 tumours seen; 1 gall stone ileus)
Thickened bowel wall 5 (2 lymphoma, crohns, 2 ca bowel)
Appendicitis 43 (3 in pregnant women, 1 appendiceal
mass, 2 with rupture and abscess)
Diverticulitis 10
Inflammatory bowel mass 2
GI bleed (blood in intestine) 1
Faecal loading 2

24. OTHER STUFF FOUND WHIST SCANNING THE ABDOMEN
Pleural effusion 4
Pulmonary embolism 1
Hypovolaemia 1

25. VASCULAR SCANS 218 (12%)
Aorta 35
DVT 158
Other arteries 25

26. DVT scans 158 (9% of workload)
Upper limb 12 (8%)
Normal 6 (6/12 = 50%)
DVT 6 (5 subclavian; 1 basilic) (6/12 = 50%)
Lower limb 146 (146/158 = 92%)
Normal 64 (64/146 = 44%)
DVT (including muscular) 31 (31/146 = 21%)
Other cause found 52 (52/146 = 36%)

27. Lower limb 146
Normal 64
DVT 31
Iliofemoral 5 (1 pregnant)
Common femoral vein 1
Femoral vein 6 (1 new diagnosis ALL)
Popliteal vein 3
Posterior tibial vein 4
Fibular vein 2
Gastrocnemius muscle v 5
Soleus muscle vein 3
Chronic DVT with collaterals 1

28. Lower limb 146
Normal 64
DVT 31
Other case found 52
Varicose vein thrombus 2
Superficial thrombophlebitis 5
Prepatellar bursitis 2
Baker’s cyst 10
Oedema 4
Groin nodes - malignant 4 (lymphoma, SCC, sarcoma, new)
Cellulitis 15
Knee effusion 2 (haemarthrosis, gout)
Haematoma 2
Gastrocnemius tear 8
Myositis 1

29. OTHER ARTERIES
AV fistula thrombus 3
Bilateral CFA occlusion 1
Brachial artery occlusion 2
Femoral artery occlusion 3 (1 site of previous stent)
Popliteal artery occlusion 2
Post procedural review (?complication) 6 (haematoma / seroma)
PVD chronic worsening 3
Varicose veins 1

30. SCROTAL AND PENILE ULTRASOUND
Normal 8
Epididimitis 6
Epididymo-orchitis 11
Orchitis 1
Torsion 1
Atrophic testes 2
Traumatic rupture of testis 1 (haematoma only)
Torted Hydatid of Morgagni 1
Fluid in scrotum - CAPD 1
Fourniers gangrene with gas 1
Penile fracture 1
Dorsal penile vein thrombosis 1

31. PROCEDURAL ULTRASOUND 194 (11% OF WORKLOAD)
Arterial lines 24
Peripheral IV lines 67 (20% in IVDU); (14% >3 prior fails)
Central venous lines 21
Pleural aspiration / Seldinger / ICC 7
Ascites tap / drainage 7
Abscess drainage 6
Foreign body detection & removal 20
Joint aspiration / injection 18 (knee, ankle, elbow, shoulder) / 2
Femoral nerve block / catheter 17
Other nerve blocks 7
Fracture reduction 7 (6 distal radial, 1 femoral)
Urinary catheterisation 5
Lap band port aspiration 3
Blood tests 2

32. OCULAR ULTRASOUND 16
Vitreous detachment 7
Vitreous haemorrhage 4
Retinal detachment 1
Normal 4 (1 IOL)

33. MUSCULOSKELETAL 153 (9% of workload)
Injury 26
Mass 30
Joint Effusion ? 25
Abscess ? 44
Other 28

34. MSK INJURY 26
Achilles rupture 7
Gastrocnemius tear 2
Lipohaemarthrosis 1
Biceps rupture 2
Muscle haematoma 3
Quads rupture 1
Medial collateral of knee rupture 1
Laceration of Palmaris longus 1
Fracture - rib 1
Supraspinatus tear 1
Normal 6

35. MSK ? MASS 30
Haematoma (limb) 7
Rectus sheath haematoma 1
Lymph nodes (1 avascular) 3
Collection post op 5
Baker’s cyst with haemorrhage 1
Lipoma 1
Abscess 2
Parotitis 3
Carpal tunnel syndrome 1
Normal 7

36. MSK ?EFFUSION 25
Knee 7
(5 effusions, 2 of these lipohaemarthroses, 1 Baker’s cyst)
Ankle 6
(no effusions – 1 tenosynovitis; 2 cellulitis)
Hip 5
(2 effusion; 1 fracture; 1 psoas haematoma)
Shoulder 6
(5 effusions, 1 haemarthrosis drained acutely)
Wrist 1
(no effusion)

37. MSK ?ABSCESS 44
Cellulitis 15
Bursitis 5 (3 prepatellar; 2 olecranon)
Abscess 20
Tenosynovitis 1
Thrombophlebitis 1
Tonsillitis 2

38. MSK OTHER 28
Dislocation - shoulder 3
FB detection 6
Post op collection 5
Flexor tendon sheath infection 1
Spina bifida, dermoid, leaking 1
Tenosynovitis 2
Plantar fasciitis 1
Lymph node 1
Baker’s cyst 1
Normal 4

39. The Future
• Who knows?
• What do you want as a potential patient?
• Conveyor belt medicine
• Clinical Emergency Sonologist should be part
of that conveyor belt