Adeyinka A. Adedipe

Impact of point-of-care ultrasound training on surgical residents' confidence.

OBJECTIVE Point-of-care ultrasound (POCUS) is a vital tool for diagnosis and management of critically ill patients, particularly in resource-limited settings where access to diagnostic imaging may be constrained. We aimed to develop a novel POCUS training curriculum for surgical practice in the United States and in resource-limited settings in low- and middle-income countries and to determine its effect on surgical resident self-assessments of efficacy and confidence. DESIGN We conducted an observational cohort study evaluating a POCUS training course that comprised 7 sessions of 2 hours each with didactics and proctored skills stations covering ultrasound applications for trauma (Focused Assessement with Sonography for Trauma (FAST) examination), obstetrics, vascular, soft tissue, regional anesthesia, focused echocardiography, and ultrasound guidance for procedures. Surveys on attitudes, prior experience, and confidence in point-of-care ultrasound applications were conducted before and after the course. SETTING General Surgery Training Program in Seattle, Washington. PARTICIPANTS A total of 16 residents participated in the course; 15 and 10 residents completed the precourse and postcourse surveys, respectively. RESULTS The mean composite confidence score from pretest compared with posttest improved from 23.3 (±10.2) to 37.8 (±6.7). Median confidence scores (1-6 scale) improved from 1.5 to 5.0 in performance of FAST (p < 0.001). Residents reported greater confidence in their ability to identify pericardial (2 to 4, p = 0.009) and peritoneal fluid (2 to 4.5, p < 0.001), to use ultrasound to guide procedures (3.5 to 4.0, p = 0.008), and to estimate ejection fraction (1 to 4, p = 0.004). Both before and after training, surgical residents overwhelmingly agreed with statements that ultrasound would improve their US-based practice, make them a better surgical resident, and improve their practice in resource-limited settings. CONCLUSIONS After a POCUS course designed specifically for surgeons, surgical residents had improved self-efficacy and confidence levels across a broad range of skills.

Carotid Doppler blood flow measurement during cardiopulmonary resuscitation is feasible: A first in man study

OBJECTIVE High quality chest compressions are the cornerstone of effective cardiopulmonary resuscitation (CPR). There is no available method of real time noninvasive hemodynamic measurement and feedback to inform rescuers of the efficacy of compressions. Ultrasound-based measures of blood flow may provide immediate, noninvasive hemodynamic information. Our objective was to determine the feasibility and safety of using ultrasound to measure blood flow on patients with cardiac arrest. METHODS Study design This was a prospective cohort study in an emergency department setting. Subjects Included were patients receiving ongoing manual chest compressions for cardiac arrest. Excluded were those less than 18 years of age, incarcerated, pregnant, with neck injury, or obvious traumatic cause of arrest. Scan protocol Physicians recorded blood flow over the common carotid arteries during chest compressions with transverse and longitudinal color flow and Doppler using a portable ultrasound machine (CX30, Philips Healthcare., Andover, MA). Measurements Duration of scan time, and the median values for peak systolic (PSV), end-diastolic (EDV) and mean diastolic (MDV) carotid blood flow velocities were captured. Feasibility was defined as the proportion of eligible subjects upon whom ultrasound was initiated Safety was defined as availability of at least 5 min of scanning time. RESULTS Nineteen patients (56% of eligible) where enrolled and had ultrasound measurements attempted during manual compressions. In one patient, scanning was not initiated because ongoing CPR efforts were terminated. Three patients were enrolled but had no images available for review. A total of 15 patients (78% of attempted) had ultrasound imaging saved. Most (n=10, 66%) had scanning times greater than 5 min (median 5 min 59s, interquartile range 3 min 15s to 8 min 25s), median PSV was 67 cms(-1) (IQR 55-106), median EDV was 18 cms(-1) (IQR 12-27), and median MDV was 14 cms(-1) (IQR 9-18). CONCLUSIONS Ultrasound measurement of common carotid artery blood flow during CPR is feasible. Further studies are necessary to correlate carotid blood flow to other hemodynamic measures and its effects on patient outcomes.

Sepsis mimicking thyroid storm in a patient with methimazole-induced agranulocytosis

Agranulocytosis is a rare yet life-threatening complication of methimazole therapy for hyperthyroidism. We present the case of a 37-year-old female recently started on methimazole for hyperthyroidism who presented to our facility for evaluation of suspected thyroid storm. In addition to having abnormal thyroid indices, she was noted to have an odontogenic abscess, and was septic with profound neutropenia. Her symptoms resolved quickly following incision and drainage of her abscess and treatment with broad-spectrum antibiotics. Her neutrophil count improved significantly following cessation of methimazole and administration of granulocyte colony-stimulating factor. Diagnosis was initially confounded by the similarity between symptoms of early sepsis and those of thyroid storm. This case report discusses the factors leading to diagnostic delay and highlights the dangerous manifestations of neutropenia in patients on methimazole therapy.

Clinician-performed ultrasound diagnosis of ruptured interstitial pregnancy.

An interstitial pregnancy is a rare type of ectopic pregnancy located within the proximal portion of the fallopian tube in the muscular wall of the uterus. They are more likely to result in significant or fatal hemorrhage because of the increased vascularity. Diagnosis of interstitial pregnancy is challenging but critical to facilitate prompt and appropriate intervention. Ultrasound performed by an emergency physician is commonly used to assess early pregnancy, but little has been published in the emergency medicine literature regarding its use in assessing for presence of interstitial pregnancy. We describe a case of a ruptured interstitial pregnancy diagnosed by emergency ultrasonography in the emergency department and review the literature regarding the sonographic findings of interstitial pregnancies.

Randomised controlled trial to assess the effect of a Just-in-Time training on procedural performance: a proof-of-concept study to address procedural skill decay

Background A subset of high-risk procedures present significant safety threats due to their (1) infrequent occurrence, (2) execution under time constraints and (3) immediate necessity for patient survival. A Just-in-Time (JIT) intervention could provide real-time bedside guidance to improve high-risk procedural performance and address procedural deficits associated with skill decay. Objective To evaluate the impact of a novel JIT intervention on transvenous pacemaker (TVP) placement during a simulated patient event. Methods This was a prospective, randomised controlled study to determine the effect of a JIT intervention on performance of TVP placement. Subjects included board-certified emergency medicine physicians from two hospitals. The JIT intervention consisted of a portable, bedside computer-based procedural adjunct. The primary outcome was performance during a simulated patient encounter requiring TVP placement, as assessed by trained raters using a technical skills checklist. Secondary outcomes included global performance ratings, time to TVP placement, number of critical omissions and System Usability Scale scores (intervention only). Results Groups were similar at baseline across all outcomes. Compared with the control group, the intervention group demonstrated statistically significant improvement in the technical checklist score (11.45 vs 23.44, p<0.001, Cohen’s d effect size 4.64), the global rating scale (2.27 vs 4.54, p<0.001, Cohen’s d effect size 3.76), and a statistically significant reduction in critical omissions (2.23 vs 0.68, p<0.001, Cohen’s d effect size −1.86). The difference in time to procedural completion was not statistically significant between conditions (11.15 min vs 12.80 min, p=0.12, Cohen’s d effect size 0.65). System Usability Scale scores demonstrated excellent usability. Conclusion A JIT intervention improved procedure perfromance, suggesting a role for JIT interventions in rarely performed procedures.

Emergency department utilization by a jail population

Background Incarcerated individuals represent a significant proportion of the US population and face unique healthcare challenges. Scarce articles have been published about emergency department (ED) care of these patients. We studied the ED visits from one urban jail to better describe this population. Methods A cohort study design was used, identifying patients who were sent to the ED from a city jail in 2015. Demographics, triage information, length of stay, number of studies, billing codes, diagnoses, and disposition data were collected. These were compared to the overall ED patient population in the same year. Results 868 ED visits by jail patients occurred, representing 1.3% of the ED census. Compared to the general population, incarcerated patients were younger (32.1 years vs. 44.0 years, p < .01), healthier based on Elixhauser comorbidity scores (0.71 vs. 0.98, p < .01), and had lower admission rates (11.29% vs. 21.54%, p < .01). An abnormal vital sign was noted in 25% of incarcerated patients. Laboratory (61% vs. 57%, p < .02) and radiologic (63% vs 45%, p < .001) testing was more frequent for inmates and length of stay was longer (271 vs. 225 min, p < .01). Conclusion ED visits from jail were common, involving a relatively young and healthy population with a low incidence of abnormal vital signs and admission. Given the high costs associated with ED care and the medical resources available at some jails, further study should evaluate if increased jail medical capabilities could improve care and decrease costs by decreasing ED visits.

Clinical paperCarotid Doppler blood flow measurement during cardiopulmonary resuscitation is feasible: A first in man study☆

OBJECTIVE High quality chest compressions are the cornerstone of effective cardiopulmonary resuscitation (CPR). There is no available method of real time noninvasive hemodynamic measurement and feedback to inform rescuers of the efficacy of compressions. Ultrasound-based measures of blood flow may provide immediate, noninvasive hemodynamic information. Our objective was to determine the feasibility and safety of using ultrasound to measure blood flow on patients with cardiac arrest. METHODS Study design This was a prospective cohort study in an emergency department setting. Subjects Included were patients receiving ongoing manual chest compressions for cardiac arrest. Excluded were those less than 18 years of age, incarcerated, pregnant, with neck injury, or obvious traumatic cause of arrest. Scan protocol Physicians recorded blood flow over the common carotid arteries during chest compressions with transverse and longitudinal color flow and Doppler using a portable ultrasound machine (CX30, Philips Healthcare., Andover, MA). Measurements Duration of scan time, and the median values for peak systolic (PSV), end-diastolic (EDV) and mean diastolic (MDV) carotid blood flow velocities were captured. Feasibility was defined as the proportion of eligible subjects upon whom ultrasound was initiated Safety was defined as availability of at least 5 min of scanning time. RESULTS Nineteen patients (56% of eligible) where enrolled and had ultrasound measurements attempted during manual compressions. In one patient, scanning was not initiated because ongoing CPR efforts were terminated. Three patients were enrolled but had no images available for review. A total of 15 patients (78% of attempted) had ultrasound imaging saved. Most (n=10, 66%) had scanning times greater than 5 min (median 5 min 59s, interquartile range 3 min 15s to 8 min 25s), median PSV was 67 cms(-1) (IQR 55-106), median EDV was 18 cms(-1) (IQR 12-27), and median MDV was 14 cms(-1) (IQR 9-18). CONCLUSIONS Ultrasound measurement of common carotid artery blood flow during CPR is feasible. Further studies are necessary to correlate carotid blood flow to other hemodynamic measures and its effects on patient outcomes.

Carotid Doppler blood flow measurement during cardiopulmonary resuscitation is feasible

OBJECTIVE High quality chest compressions are the cornerstone of effective cardiopulmonary resuscitation (CPR). There is no available method of real time noninvasive hemodynamic measurement and feedback to inform rescuers of the efficacy of compressions. Ultrasound-based measures of blood flow may provide immediate, noninvasive hemodynamic information. Our objective was to determine the feasibility and safety of using ultrasound to measure blood flow on patients with cardiac arrest. METHODS Study design This was a prospective cohort study in an emergency department setting. Subjects Included were patients receiving ongoing manual chest compressions for cardiac arrest. Excluded were those less than 18 years of age, incarcerated, pregnant, with neck injury, or obvious traumatic cause of arrest. Scan protocol Physicians recorded blood flow over the common carotid arteries during chest compressions with transverse and longitudinal color flow and Doppler using a portable ultrasound machine (CX30, Philips Healthcare., Andover, MA). Measurements Duration of scan time, and the median values for peak systolic (PSV), end-diastolic (EDV) and mean diastolic (MDV) carotid blood flow velocities were captured. Feasibility was defined as the proportion of eligible subjects upon whom ultrasound was initiated Safety was defined as availability of at least 5 min of scanning time. RESULTS Nineteen patients (56% of eligible) where enrolled and had ultrasound measurements attempted during manual compressions. In one patient, scanning was not initiated because ongoing CPR efforts were terminated. Three patients were enrolled but had no images available for review. A total of 15 patients (78% of attempted) had ultrasound imaging saved. Most (n=10, 66%) had scanning times greater than 5 min (median 5 min 59s, interquartile range 3 min 15s to 8 min 25s), median PSV was 67 cms(-1) (IQR 55-106), median EDV was 18 cms(-1) (IQR 12-27), and median MDV was 14 cms(-1) (IQR 9-18). CONCLUSIONS Ultrasound measurement of common carotid artery blood flow during CPR is feasible. Further studies are necessary to correlate carotid blood flow to other hemodynamic measures and its effects on patient outcomes.

BE-SAFE: Bedside sonography for assessment of the fetus in emergencies: educational intervention for late-pregnancy obstetric ultrasound.

Introduction Late obstetric emergencies are time critical presentations in the emergency department. Evaluation to ensure the safety of mother and child includes rapid assessment of fetal viability, fetal heart rate (FHR), fetal lie, and estimated gestational age (EGA). Point-of-care (POC) obstetric ultrasound (OBUS) offers the advantage of being able to provide all these measurements. We studied the impact of POC OBUS training on emergency physician (EP) confidence, knowledge, and OBUS skill performance on a live model. Methods This is a prospective observational study evaluating an educational intervention we designed, called the BE-SAFE curriculum (BEdside Sonography for the Assessment of the Fetus in Emergencies). Subjects were a convenience sample of EP attendings (N=17) and residents (N=14). Prior to the educational intervention, participants completed a self-assessment survey on their confidence regarding OBUS, and took a pre-test to assess their baseline knowledge of OBUS. They then completed a 3-hour training session consisting of didactic and hands-on education in OBUS. After training, each subject’s time and accuracy of performance of FHR, EGA, and fetal lie was recorded. Post-intervention knowledge tests and confidence surveys were administered. Results were compared with non-parametric t-tests. Results Pre- and post-test knowledge assessment scores for previously untrained EPs improved from 65.7% [SD=20.8] to 90% [SD=8.2] (p<0.0007). Self-confidence on a scale of 1–6 improved significantly for identification of FHR, fetal lie, and EGA. After training, the average times for completion of OBUS critical skills were as follows: cardiac activity (9s), FHR (68.6s), fetal lie (28.1s), and EGA (158.1 sec). EGA estimates averaged 28w0d (25w0d-30w6d) for the model’s true gestational age of 27w0d. Conclusion After a focused POC OBUS training intervention, the BE-SAFE educational intervention, EPs can accurately and rapidly use ultrasound to determine FHR, fetal lie, and estimate gestational age in mid-late pregnancy.

To push or not to push: manual or mechanical compressions for cardiac arrest?

1824 www.ccmjournal.org July 2013 • Volume 41 • Number 7 Out-of-hospital cardiac arrest is the third leading cause of death in the United States (1). The toll for in-hospital cardiac arrest is of similar magnitude as that of out-of-hospital cardiac arrest (2). Unfortunately, outcomes after out-of-hospital cardiac arrest have not been improved in many communities (3), and there has been limited improvement in outcomes after in-hospital cardiac arrest (4). Thus, critical care practitioners, emergency medicine practitioners, and other healthcare providers continue to seek methods to improve the process and outcome of care for patients with cardiac arrest. Coronary perfusion pressure (CPP) is defined as the difference between aortic diastolic pressure and right atrial pressure. Chest compressions that achieve CPP more than 15 mm Hg during cardiac arrest are associated with increased likelihood of return of spontaneous circulation (5). Once manual compressions are initiated, however, it takes time to develop an adequate CPP. If chest compressions are ineffective or interrupted, CPP decreases rapidly (6). Interruptions in chest compression have a detrimental effect on CPP and reduce the likelihood for a successful outcome (7). The magnitude of CPP achieved during resuscitation is correlated with the quantity and quality of external chest compressions (8). Importantly, high-quality manual chest compressions are difficult to maintain during Campaign guidelines that still recommend targeting a CVP of 8–12 mm Hg for resuscitation (6). What then should the clinician at the bedside do with a patient who is in shock, but with a high CVP? Or the hemodynamically stable patient with a low CVP? With mounting evidence regarding the adverse effects of excessive fluid administration (7, 8), it is hard not to imagine a sense of therapeutic paralysis setting in to most intensivists. Should treatment decisions based on CVP be abandoned? One of the dangers of advocating for this position is the question of what techniques could be used in place of CVP? Unfortunately, blood pressure, heart rate, and urine output are also poor markers of CO and volume status. The utilization of a passive leg raise maneuver in patients with minimally invasive CO monitoring is probably the best predictor of fluid responsiveness, but this type of monitoring has yet to become standard in the operating room or the ICU (9). Marik and Cavallazzi have shown that we should not be utilizing the CVP to predict volume responsiveness or volume status. We need rigorous studies to determine if fluid administration based on minimally invasive CO measurements benefits our patients. Using the CVP alone to guide fluid administration may be unhelpful at best and harmful at worst. REFERENCES 1. Hughes RE, Magovern GJ: The relationship between right atrial pressure and blood volume. AMA Arch Surg 1959; 79:238–243 2. Funk DJ, Jacobsohn E, Kumar A: The role of venous return in critical illness and shock-part I: Physiology. Crit Care Med 2013; 41:255–262 3. Kumar A, Anel R, Bunnell E, et al: Pulmonary artery occlusion pressure and central venous pressure fail to predict ventricular filling volume, cardiac performance, or the response to volume infusion in normal subjects. Crit Care Med 2004; 32:691–699 4. Kumar A, Anel R, Bunnell E, et al: Effect of large volume infusion on left ventricular volumes, performance and contractility parameters in normal volunteers. Intensive Care Med 2004; 30:1361–1369 5. Marik PE, Cavallazzi R: Does the Central Venous Pressure Predict Fluid Responsiveness? An Updated Meta-Analysis and a Plea for Some Common Sense. Crit Care Med 2013; 41:1774–1781 6. Dellinger RP, Levy MM, Rhodes A, et al; Surviving Sepsis Campaign Guidelines Committee including the Pediatric Subgroup: Surviving sepsis campaign: International guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med 2013; 41:580–637 7. Vincent JL, Sakr Y, Sprung CL, et al; Sepsis Occurrence in Acutely Ill Patients Investigators: Sepsis in European intensive care units: Results of the SOAP study. Crit Care Med 2006; 34:344–353 8. Wiedemann HP, Wheeler AP, Bernard GR, et al: Comparison of two fluid-management strategies in acute lung injury. N Engl J Med 2006; 354:2564–2575 9. Cavallaro F, Sandroni C, Marano C, et al: Diagnostic accuracy of passive leg raising for prediction of fluid responsiveness in adults: Systematic review and meta-analysis of clinical studies. Intensive Care Med 2010; 36:1475–1483