Damali Nakitende

Comparison of Static versus Dynamic Ultrasound for the Detection of Endotracheal Intubation

Introduction In the emergency department setting, it is essential to rapidly and accurately confirm correct endotracheal tube (ETT) placement. Ultrasound is an increasingly studied modality for identifying ETT location. However, there has been significant variation in techniques between studies, with some using the dynamic technique, while others use a static approach. This study compared the static and dynamic techniques to determine which was more accurate for ETT identification. Methods We performed this study in a cadaver lab using three different cadavers to represent variations in neck circumference. Cadavers were randomized to either tracheal or esophageal intubation in equal proportions. Blinded sonographers then assessed the location of the ETT using either static or dynamic sonography. We assessed accuracy of sonographer identification of ETT location, time to identification, and operator confidence. Results A total of 120 intubations were performed: 62 tracheal intubations and 58 esophageal intubations. The static technique was 93.6% (95% confidence interval [CI] [84.3% to 98.2%]) sensitive and 98.3% specific (95% CI [90.8% to 99.9%]). The dynamic technique was 92.1% (95% CI [82.4% to 97.4%]) sensitive and 91.2% specific (95% CI [80.7% to 97.1%]). The mean time to identification was 6.72 seconds (95% CI [5.53 to 7.9] seconds) in the static technique and 6.4 seconds (95% CI [5.65 to 7.16] seconds) in the dynamic technique. Operator confidence was 4.9/5.0 (95% CI [4.83 to 4.97]) in the static technique and 4.86/5.0 (95% CI [4.78 to 4.94]) in the dynamic technique. There was no statistically significant difference between groups for any of the outcomes. Conclusion This study demonstrated that both the static and dynamic sonography approaches were rapid and accurate for confirming ETT location with no statistically significant difference between modalities. Further studies are recommended to compare these techniques in ED patients and with more novice sonographers.

Ultrasound-Guided Peripheral Intravenous Line Placement: A Narrative Review of Evidence-based Best Practices

Peripheral intravenous line placement is a common procedure in emergency medicine. Ultrasound guidance has been demonstrated to improve success rates, as well as decrease complications and pain. This paper provides a narrative review of the literature focusing on best practices and techniques to improve performance with this procedure. We provide an evidence-based discussion of preparation for the procedure, vein and catheter selection, multiple techniques for placement, and line confirmation.

Ultrasound for confirmation of thoracostomy tube placement by emergency medicine residents

Introduction Thoracostomy tubes are placed in the Emergency Department for numerous indications, including hemothoraces, pneumothoraces, and empyemas. After insertion, a portable single view chest radiograph is typically performed minutes later to confirm thoracostomy tubes position. However, up to 2.6% of thoracostomy tubes are ultimately determined to be misplaced. Failure to adequately drain the chest in a timely manner may have disastrous consequences. Ultrasonography by expert sonographers has been previously described to evaluate thoracostomy tubes position. The purpose of this study was to assess the accuracy of ultrasound for confirmation of thoracostomy tubes placement by Emergency Medicine residents. Methods We conducted a prospective, randomized, blinded study using a cadaveric model for ultrasound confirmation of thoracostomy tube placement by resident physicians. Thirty-five Emergency Medicine residents performed a total of 140 confirmations. The primary outcome of the study was the sensitivity and specificity of EM resident-performed ultrasonography to correctly confirm thoracostomy tube placement. Secondary outcomes included time to identification, operator confidence, and subgroup analysis by resident training level. Results The study demonstrated an overall sensitivity of 100% (95% CI 94–100%) and specificity of 96% (95% CI 87–99%) for intrathoracic placement. Post-graduate year (PGY) 1 EM residents demonstrated 100% (95% CI 76–100%) sensitivity and 100% (95% CI 76–100%) specificity. PGY 2 EM residents demonstrated 100% (95% CI 87–100%) sensitivity and 94% (95% CI 79–99%) specificity. PGY 4 EM residents demonstrated 100% (95% CI 80–100%) sensitivity and 95% (95% CI 75–100%) specificity. The total time to identification was 16 seconds (95% CI 13–19). Overall operator confidence was 4.0/5.0 (95% CI 3.8–4.1). Conclusion Emergency medicine residents were able to quickly identify thoracostomy tube location using ultrasound with a high degree of accuracy in a cadaveric model after a brief educational session.

Comparison of color flow with standard ultrasound for the detection of endotracheal intubation

Introduction: Intubation is a frequently performed procedure in emergency medicine that is associated with significant morbidity and mortality when unrecognized esophageal intubation occurs. However, it may be difficult to visualize the endotracheal tube (ETT) in some patients. This study assessed whether the addition of color Doppler was able to improve the ability to visualize the ETT location. Methods: This study was performed in a cadaver lab using three different cadavers chosen to represent varying neck circumference. Cadavers were randomized to tracheal or esophageal intubation. Blinded sonographers then assessed the location of the ETT using either grayscale or color Doppler imaging. Accuracy of sonographer identification of ETT location, time to identification, and operator confidence were assessed. Results: One hundred and fifty intubations were performed and each was assessed by both standard and color Doppler techniques. There were 78 tracheal intubations and 72 esophageal intubations. The standard technique was 99.3% (95% CI 96.3 to 99.9%) accurate. The color flow technique was also 99.3% (95% CI 96.3 to 99.9%) accurate. The mean operator time to identification was 3.24 s (95% CI 2.97 to 3.51 s) in the standard approach and 5.75 s (95% CI 5.16 to 6.33 s) in the color flow technique. The mean operator confidence was 4.99/5.00 (95% CI 4.98 to 5.00) in the standard approach and 4.94/5.00 (95% CI 4.90 to 4.98) in the color flow technique. Conclusion: When added to standard ultrasound imaging, color flow did not improve accuracy or operator confidence for identifying ETT location and resulted in a longer examination time.

Variation in the accuracy of ultrasound for the detection of intubation by endotracheal tube size

Introduction: Rapid and accurate confirmation of endotracheal tube (ETT) placement is a fundamental step in definitive airway management. Multiple techniques with different limitations have been reported. Recent studies have evaluated the accuracy, time to performance, and physician confidence for ultrasound in both cadaveric models and live patients. However, no study to date has measured the effect of ETT size. Our study is the first to measure the accuracy of ultrasound for ETT confirmation based on ETT size. Methods: This study was performed in a cadaver lab using three different cadavers chosen to represent varying neck circumferences. Cadavers were intubated in a random sequence with respect to both the location of intubation (i.e., tracheal vs esophageal) and sizes of ETT. Three ETT sizes were utilized: 6.0‐, 7.0‐, and 8.0‐mm. Blinded sonographers assessed the location of the ETT using the static technique. Accuracy of sonographer identification, time to identification, and operator confidence were assessed. Results: 453 assessments were performed. Overall, ultrasound was 99.1% (95% CI 97.8% to 99.7%) accurate in identification of correct location of intubation. The mean time to placement was 6.45 s (95% CI 5.62 to 7.28). The mean operator confidence level was 4.72/5.0 (95% CI 4.65 to 4.78). There was no significant difference between ETT sizes with respect to any of the outcomes. Conclusion: The diagnostic accuracy of ultrasound for ETT confirmation did not vary with the use of different ETT sizes. Further studies are needed to determine if the accuracy would change with more novice providers or in specific patient populations.

Comparison of Tamsulosin, Nifedipine, and Placebo for Ureteric Colic.

Clinical question Do calcium channel blockers or alpha blockers improve renal stone passage when compared with placebo? Article chosen Pickard R, Starr K, MacLennan G, et al. Medical expulsive therapy in adults with ureteric colic: a multicentre, randomised, placebo-controlled trial. Lancet 2015;386(9991):25-31, doi: 10.1016/S0140-6736(15)60933-3.

Dilated right coronary sinus identified on point-of-care ultrasound

Point-of-care cardiac ultrasound (POCUS) is a common application in Emergency Medicine. Here we present a case of an incidentally discovered dilated right coronary sinus on ultrasound. This case involved a 55-year-old female who presented with chest pain, shortness of breath, and lightheadedness. Her initial presentation was concerning for congestive heart failure (CHF) exacerbation. A bedside ultrasound was performed to assess cardiac function, where a dilated right coronary sinus was discovered. The right coronary sinus is the vein that serves as the venous return for the coronary system. It is a tubular structure located at the posterior atrioventricular groove and it is generally not visible unless it is pathologically dilated. Identification of a dilated right coronary sinus can assist the clinician in making the diagnoses of CHF exacerbation, as well as alter the approach to specific procedures. To the best of our knowledge, this is the first case report describing the identification of a dilated right coronary sinus using POCUS.

Utilization of ultrasound for the evaluation of small bowel obstruction: A systematic review and meta-analysis

Introduction Small bowel obstruction (SBO) is a common presentation to the Emergency Department (ED). While computed tomography (CT) is frequently utilized to confirm the diagnosis, this modality is expensive, exposes patients to radiation, may lead to time delays, and is not universally available. This study aimed to determine the test characteristics of ultrasound for the diagnosis of SBO. Methods PubMed, CINAHL, Scopus, the Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials were assessed for prospective trials evaluating the accuracy of ultrasound for the detection of SBO. Data were double extracted into a predefined worksheet and quality analysis was performed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS‐2) tool. Results This systematic review identified 11 studies comprising 1178 total patients. Overall, ultrasound was found to be 92.4% sensitive (95% CI 89.0% to 94.7%) and 96.6% specific (95% CI 88.4% to 99.1%) with a positive likelihood ratio of 27.5 (95% CI 7.7 to 98.4) and a negative likelihood ratio of 0.08 (95% CI 0.06 to 0.11). Discussion The existing literature suggests that ultrasound is a valuable tool in the diagnosis of SBO with a sensitivity and specificity comparable to that of CT. Ultrasound may save time and radiation exposure, while also allowing for serial examinations of patients to assess for resolution of the SBO. It may be particularly valuable in settings with limited or no access to CT. Future studies should include more studies in the Emergency Department setting, comparison of probe choices, and inclusion of more pediatric patients.

Frequency of Fractures Identified on Post-Reduction Radiographs After Shoulder Dislocation.

Introduction Most emergency physicians routinely obtain shoulder radiographs before and after shoulder dislocations. However, currently there is limited literature demonstrating how frequently new fractures are identified on post-reduction radiographs. The primary objective of this study was to determine the frequency of new, clinically significant fractures identified on post-reduction radiographs with a secondary outcome assessing total new fractures identified. Methods We conducted a retrospective chart review using appropriate International Classification of Diseases, 9th Revision (ICD-9) codes to identify all potential shoulder dislocations that were reduced in a single, urban, academic emergency department (ED) over a five-year period. We excluded cases that required operative reduction, had associated proximal humeral head or shaft fractures, or were missing one or more shoulder radiograph reports. All charts were abstracted separately by two study investigators with disagreements settled by consensus among three investigators. Images from indeterminate cases were reviewed by a radiology attending physician with musculoskeletal expertise. The primary outcome was the percentage of new, clinically significant fractures defined as those altering acute ED management. Secondary outcomes included percentage of new fractures of any type. Results We identified 185 total patients meeting our study criteria. There were no new, clinically significant fractures on post-reduction radiographs. There were 13 (7.0%; 95% CI [3.3%–10.7%]) total new fractures identified, all of which were without clinical significance for acute ED management. Conclusion Post-reduction radiographs do not appear to identify any new, clinically significant fractures. Practitioners should re-consider the use of routine post-reduction radiographs in the ED setting for shoulder dislocations.