Point of care sonography (POCS) done by clinicians has become popular over the past two decades1. Its use has been described as an adjunct to physical examination during resuscitation 2.Ultrasound has also been shown to be useful to emergency care providers with differing levels of training, background, and clinical focus such as trauma and emergency care 3. The Focused Assessment with Sonography in Trauma (FAST) examination has become the standard of care for the diagnosis of post-traumatic pericardial tamponade and hemoperitoneum 4. POCS is also useful in diagnosis of chest, extremity trauma, evaluation of shock states and intravascular volume depletion 4,5,6,7.
Disasters are situations which demands quick triage of large numbers of injured patients, especially in a resource limited setting 8. An immediately deployable, flexible and resource-sparing emergency medical response is key to improve survival during disaster. In disasters, the benefit from early intervention to the injured is often undermined by relative lack of healthcare personnel, a chaotic environment, and deficient stable social infrastructure 6,7.This limits the availability of most modern diagnostic tools, especially imaging modalities, because they are resource intensive and require a high degree of infrastructural integrity. Thus, in a disaster, responders may be forced to rely only on history and clinical examination which is relatively time-consuming and often inaccurate approach in this setting.
Modern ultrasound machines are portable, robust, easy to use, and inexpensive. These advances allow ultrasound to be brought to the patients to acquire diagnostic information in real time. In addition, literature describes its use in remote, austere, and resource-poor settings, including outer space, high altitudes and combat settings9. It can address triage, resuscitation and critical treatment decisions during the disaster 10,11,12,13. Virtual technology such as telemedicine can be integrated with the POCS to make critical management decisions in the field. These qualities of point of care ultrasound makes it uniquely suited for deployment in the care of patients in the setting of a disaster.
References
Kendall JL, Hoffenberg SR, Smith RS. History of emergency and critical care ultrasound: the evolution of a new imaging paradigm. Crit Care Med.2007;35: S126–S130.
Brooks A, Davies B, Smethhurst M, Connolly J. Prospective evaluation of non-radiologist performed emergency abdominal ultrasound for haemoperitoneum. Emerg Med J. 2004;21: e5.
Nelson BP, Chason K. Use of ultrasound by emergency medical services: a review. Int J Emerg Med.2008; 1:253–259.
4 Rozycki GS. Surgeon-performed ultrasound: its use in clinical practice. Ann Surg. 1998; 228:16–28.
Dulchavsky SA, Henry SE, Moed BR, Diebel LN, Marshburn T, Hamilton DR, et al. Advanced ultrasonic diagnosis of extremity trauma: the FASTER examination. J Trauma.2002;53:28–32.
Lyon M, Blaivas M, Brannam L. Sonographic measurement of the inferior vena cava as a marker of blood loss. Am J Emerg Med. 2005; 23:45–50.
Ebrahim A, Yousefifard M , Kazemi H , Rasouli H , Asady H , Jafari A Diagnostic Accuracy of Chest Ultrasonography versus Chest Radiography for Identification of Pneumothorax: A Systematic Review and Meta-Analysis. Tanaffos.2014; 13(4): 29–40.
Burkle FM Jr. Mass casualty management of a large-scale bioterrorist event: an epidemiological approach that shapes triage decisions. Emerg Med Clin North Am.2002; 20:409–436.
Ma OJ, Norvell JG, Subramanian S. Ultrasound applications in mass casualties and extreme environments. Crit Care Med. 2007;35: S275–S279.
Extremity (Musculoskeletal USG): Long bone fracture detection, Nerve Blocks for field amputation
2.25-2.35 pm
Coffee break and Move to Skill station
2.35-3.35 pm
Hands-on Training session: Fracture Detection, Nerve localization (Brachial Plexus, Femoral, Sciatic Nr) live models
3.35-4.15 pm
Traige & Sono triage – Discussion
4.15-5.15 pm
Mega code: Simulated Disaster scenario management with POC ultrasound. (Hands-on Training session)
5.15-5.45 pm
Post-test & Feedback
5.45-6.00 pm
Certification and Closure
Detailed Course Schedule
Topic
Time
Description
Pre-course Evaluation & Introduction of students and Course Faculty
30 min
The participants are given printed baseline knowledge and confidence assessment forms after completion the participants and faculties are formally introduce each other.
Disaster Management: Introduction, Opportunities and challenges
30 min
This topic gives an overview of disaster management its issues and challenges. It focuses on the role of point of care (POC) ultrasonography.
BASICS OF ULTRASOUND:
30 min
Basic physics of ultrasound
Different buttons/knobs, probe orientation, Imaging modes, gain & depth setting, ultrasound artifacts and
Image optimization, recording, reporting and image transfer by cost effective technology.
Airway Ultrasound:
30 min
Ultrasound anatomy of airway,
Identification of Tracheal injury and Threatened airway,
ET- tube confirmation, Dynamic Intubation,
USG guided Procedures- Needle cricothyroidotomy and Tracheostomy.
These topics will have video presentation.
Integration of Airway ultrasound during the period of rescue to resuscitation for empowering triage and critical management decisions (CMG).
Lung Ultrasound:
20 min
Method of doing lung ultrasound & Ultrasound lung signs,
Identification of pneumothorax & hemothorax,
The topics will feature video presentation.
Integration of Lung ultrasound during the period of rescue to resuscitation for empowering triage and critical management decisions (CMG).
Skill Station: Knobology, Airway, Breathing
60 min
Normal Airway anatomy in longitudinal & Transverse view, Identification of esophagus on healthy volunteer.
Dynamic Intubation method
Methodology of lung ultrasound, Normal lung signs and simulation of abnormal lung signs.
Extended FAST & Inferior Vena cava (IVC) :
30 min
E-FAST: Four windows of FAST (subxiphoid, right upper quadrant, left upper quadrant and suprapubic view) & concept of extended FAST.
IVC: Method of Inferior vena cava (IVC) ultrasound, IVC diameter measurement and correlation with volume status of patient. Video demonstration of hypovolemic, rigid and normal IVC.
These will feature normal and pathological video presentation.
Integration of E-FAST & IVC during the period of rescue to resuscitation for empowering triage and critical management decisions (CMG).
Skill Station: E- FAST & IVC
60 min
Four windows of FAST (sub-xiphoid, right upper quadrant, left upper quadrant and supra-pubic view)
How to do E-FAST
Localization of IVC and identification of its variability during inspiration and expiration.
Disability Assessment:
25 min
Identification of skull fracture,
Method of Optic nerve seath diameter assessment and its use for assessment of raised intra-cranial pressure.
Integration of disability assessment during the period of rescue to resuscitation for empowering triage and critical management decisions (CMG).
Extremity [Musculoskeletal (MSK)] Ultrasound:
25 min
Long bone fracture detection,
Nerve Blocks (mainly brachial plexus, Sciatic and Femoral nerve) for field amputation.
Integration of MSK ultrasound during the period of rescue to resuscitation for empowering triage and critical management decisions (CMG).
Skill Station:
60 min
Fracture Detection Metod,
Nerve localization (Brachial Plexus, Femoral and Sciatic Nr) live models
Traige & Sono triage – Discussion
40 min
Participants will be given different case scenarios and will be asked to take the triage decisions without ultrasound and then how integration of POC ultrasound changes the triage decision.
Mega code:
60 min
Simulated Disaster scenario management with POC ultrasound. (Hands-on Training session)
Post-course Evaluation:
30 min
The participants are given printed answer sheets for knowledge assessment done through power point questions (videos and pictures) and confidence assessment.