**5. Conclusion**

diagnose pericardial effusion and tamponade and can help in its immediate management. Ultrasound guidance allows visualization of the area of maximum fluid accumulation and real-time needle guidance to decrease complications such as inadvertent puncture of the internal mammary artery or the neurovascular bundle at the inferior edge of the ribs [11, 75, 76]. The traditional technique involved a subxiphoid approach and blind needle advancement until blood or fluid was withdrawn. Using ultrasound, the initial approach in over 80% of patients was changed to an apical puncture site due to better fluid accumulation

The procedure is performed with the curvilinear or phased array transducer and can be placed either subxiphoid or in the parasternal position for viewing the pericardial effusion. The ideal site for needle placement is where the effusion has maximal depth, is closest to the skin and farthest from structures the needle could damage, such as the liver or lung. The ultrasound beam is used to simulate the needle tract, so if the liver or lung lies above the pericardium on the screen, the needle will penetrate these structures [11]. The placement of the pericardiocentesis catheter can be confirmed using ultrasound. After the needle or catheter is deemed likely to be in the pericardial sac, a syringe filled with agitated saline can be connected and injected while viewing with the ultrasound. A "snow-storm" of bubbles, showing as white dots, will be seen within the pericardial sac if the catheter is correctly placed, or may be apparent within

The complication rate for lumbar punctures is exceedingly low; yet in patients with increased body-mass-index and excess soft tissue, the success rates can vary greatly. Anesthesia literature from Russia first mentioned the concept of ultrasound guidance used during lumbar punctures in 1971 [78]. Following this publication, further anesthesia literature has documented a reduced number of unsuccessful attempts, fewer interspaces punctured, and decreased needle repositioning within the skin when using pre-procedure ultrasound guidance [79–81]. Ultrasound was recently demonstrated to be a preferred rescue method in failed neonatal lumbar punctures [82]. Likewise, a 2005 case series demonstrated its utility in localization in three failed adult lumbar punctures performed by experienced physicians [83]. In patients with difficulty to palpate landmarks, ultrasound has proven value to identify the lumbar vertebral landmarks as well as other relevant structures that help to guide a lumbar

As the best utility in ultrasound guidance is experienced in patients with a high amount of overlying soft tissue, a curvilinear transducer will typically be the choice probe to gain a greater amount of depth. The transducer is placed parallel to the vertebral column at first to view the spinous processes and the desired para-vertebral space. The spinous processes will be hyperechoic and rounded, and there will be a notable gap where the space occurs. Ultrasound allows alignment in both the vertical as well as the horizontal axis, providing an exact point for needle puncture to optimize success. Real-time guidance is generally not performed given the difficulty of needle insertion with one hand while holding the probe, and

typically static guidance and skin marking are sufficient [11].

the ventricle if the myocardium was penetrated during the procedure [9, 11].

here [75, 77].

158 Essentials of Accident and Emergency Medicine

**4.4. Lumbar puncture**

puncture [84, 85].

Ultrasound has helped to transform the practice of emergency medicine by providing an efficient and powerful tool that allows rapid information acquisition and subsequently informed, quick decision-making. Its utility continues to expand and, with technological advancements, it will continue to become more versatile and widespread in its use, not only in the emergency department, but in the prehospital and more austere settings. It allows the emergency physician to expedite care by decreasing time needed to obtain imaging and speak with consultants or to order additional tests or treatments based on the findings. It decreases procedural complications by allowing real-time guidance of needles along specific tracts, avoiding inadvertent organ or vessel injury.

Ultrasound education is established as an essential part of all emergency medicine residencies, as well as some general surgery residencies, and is offered as an accredited fellowship. As physicians graduate from these training programs, the expectations of their ultrasound skills will grow. Bedside ultrasound is increasingly available, and emergency medicine physicians will continue to refine and optimize its use.

[7] Jakobsen L, Bøtker M, Lawrence L, Sloth E, Knudsen L. Systematic training in focused cardiopulmonary ultrasound affects decision-making in the prehospital setting – Two case reports. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 2014;**22**:29 [8] Ketelaars R, Hoogerwerf N, Scheffer GJ. Prehospital chest ultrasound by a dutch helicopter emergency medical service. The Journal of Emergency Medicine. 2013;**44**(4):811-817 [9] Galdamez LA, Clark JB, Antonsen EL. Point-of-care ultrasound utility and potential for high altitude crew recovery missions. Aerospace Medicine and Human Performance.

The Evolving Role of Ultrasound in Emergency Medicine http://dx.doi.org/10.5772/intechopen.74777 161

[10] Press GM, Miller SK, Hassan IA, Alade KH, Camp E, Del Junco D, et al. Prospective evaluation of prehospital trauma ultrasound during aeromedical transport. The Journal

[12] Noble VE, Nelson BP. Manual of Emergency and Critical Care Ultrasound. 2nd ed. New

[13] Herring W. Learning Radiology: Recognizing the Basics. 2nd ed. Philadelphia, PA:

[14] Perera P, Lobo V, Williams SR, Gharahbaghian L. Cardiac echocardiography. Critical

[15] Labovitz AJ, Noble VE, Bierig M, S a G, Jones R, Kort S, et al. Focused cardiac ultrasound in the emergent setting: A consensus statement of the American Society of Echocardiography and American College of Emergency Physicians. Journal of the American Society of

[16] Yoshino S, Minagoe S, Yu B, Kosedo I, Yamashita M, Ishizawa M, et al. Cardiac tamponade due to rupture of coronary artery fistula to the coronary sinus with giant aneurysm of coronary artery: Usefulness of transthoracic echocardiography. Heart and Vessels.

[17] Guntheroth WG. Sensitivity and specificity of echocardiographic evidence of tamponade: Implications for ventricular interdependence and pulsus paradoxus. Pediatric

[18] Secko MA, Lazar JM, Salciccioli LA, Stone MB. Can junior emergency physicians use E-point septal separation to accurately estimate left ventricular function in acutely dys-

[19] Blyth L, Atkinson P, Gadd K, Lang E. Bedside focused echocardiography as predictor of survival in cardiac arrest patients: A systematic review. Academic Emergency Medicine.

[20] Breitkreutz R, Price S, Steiger HV, Seeger FH, Ilper H, Ackermann H, et al. Focused echocardiographic evaluation in life support and peri-resuscitation of emergency patients: A

pneic patients? Academic Emergency Medicine. 2011;**18**(11):1223-1226

prospective trial. Resuscitation. 2010;**81**(11):1527-1533

[11] Killu K, Dulchavsky S, Coba V. The ICU Ultrasound Pocket Book. 1st ed. 2010

Feb 2017;**88**(2):128-136

Elsevier; 2012

2013;**28**(4):536-540

Cardiology. 2007;**28**:358-362

2012;**19**(10):1119-1126

Care Clinics. 2014;**30**(1):47-92

of Emergency Medicine. 2014;**47**(6):638-645

York, NY: Cambridge University Press; 2011

Echocardiography. 2010;**23**(12):1225-1230
