Eitan Dickman

Identification of congestive heart failure via respiratory variation of inferior vena cava diameter

INTRODUCTION Rapid diagnosis of volume overload in patients with suspected congestive heart failure (CHF) is necessary for the timely administration of therapeutic agents. We sought to use the measurement of respiratory variation of inferior vena cava (IVC) diameter as a diagnostic tool for identification of CHF in patients presenting with acute dyspnea. METHODS The IVC was measured sonographically during a complete respiratory cycle of 46 patients meeting study criteria. Percentage of respiratory variation of IVC diameter was compared to the diagnosis of CHF or alternative diagnosis. RESULTS Respiratory variation of IVC was smaller in patients with CHF (9.6%) than without CHF (46%) and showed good diagnostic accuracy with area under the receiver operating characteristic curve of 0.96. Receiver operating characteristic curve analysis showed optimum cutoff of 15% variation or less of IVC diameter with 92% sensitivity and 84% specificity for the diagnosis of CHF. CONCLUSION Inferior vena cava ultrasound is a rapid, reliable means for identification of CHF in the acutely dyspneic patient.

LEARNING CURVE OF BEDSIDE ULTRASOUND OF THE GALLBLADDER

Existing guidelines for the number of ultrasounds required before clinical competency are based not on scientific study but on consensus opinion. The objective of this study was to describe the learning curve of limited right upper quadrant ultrasound. This was a prospective descriptive study. Ultrasounds collected over 1 year were reviewed for interpretive and technical errors. Possible errors during bedside ultrasound of the gallbladder include incorrect interpretation, incomplete image acquisition, and improper or poor imaging techniques resulting in poor image quality. The ultrasound image quality was rated on a 4-point scale, with 1 = barely interpretable and 4 = excellent image quality. Required images were rated on an additional 4-point scale, with 4 = all required images were included and 1 = minimal images were recorded. There were 352 patients enrolled by 42 emergency physicians (35 residents and 7 attendings). Gallstones were identified in 13.9% of the patients, and 4.3% of the ultrasounds were indeterminate. Interpretive and technical error rates decreased as the clinician gained experience. The number of poor quality ultrasounds decreased after an average of seven ultrasounds. Inclusion of all required images increased after 25 ultrasounds. Sonographers who had performed over 25 ultrasounds showed excellent agreement with the expert over-read, with only two disagreements, both from a single individual. It was concluded that clinicians are clinically competent after performing 25 ultrasounds of the gallbladder.

Ultrasound-Guided Fascia Iliaca Compartment Block for Hip Fractures in the Emergency Department

BACKGROUND Hip fracture (HFx) is a painful injury that is commonly seen in the emergency department (ED). Patients who experience pain from HFx are often treated with intravenous opiates, which may cause deleterious side effects, particularly in elderly patients. An alternative to systemic opioid analgesia involves peripheral nerve blockade. This approach may be ideally suited for the ED environment, where one injection could control pain for many hours. OBJECTIVES We hypothesized that an ultrasound-guided fascia iliaca compartment block (UFIB) would provide analgesia for patients presenting to the ED with pain from HFx and that this procedure could be performed safely by emergency physicians (EP) after a brief training. METHODS In this prospective, observational, feasibility study, a convenience sample of 20 cognitively intact patients with isolated HFx had a UFIB performed. Numerical pain scores, vital signs, and side effects were recorded before and after administration of the UFIB at pre-determined time points for 8h. RESULTS All patients reported decreased pain after the nerve block, with a 76% reduction in mean pain score at 120 min. There were no procedural complications. CONCLUSION In this small group of ED patients, UFIB provided excellent analgesia without complications and may be a useful adjunct to systemic pain control for HFx.

Ultrasonography for confirmation of endotracheal tube placement: A systematic review and meta-analysis ☆

OBJECTIVE This study aimed to undertake a systematic review and meta-analysis to summarize evidence on the diagnostic value of ultrasonography for the assessment of endotracheal tube placement in adult patients. METHODS The major databases, PubMed, EMBASE, and the Cochrane Library, were searched for studies published from inception to June 2014. We selected studies that used ultrasonography to confirm endotracheal tube placement. The search was limited to human studies, and had no publication date or country restrictions. Exclusion criteria included case reports, comments, reviews, guidelines and animal studies. Two reviewers extracted and verified the data independently. We summarized test performance characteristics with the use of forest plots, hierarchical summary receiver operating characteristic (HSROC) curves, and bivariate random effect models. Meta-regression analysis was performed to explore the source of heterogeneity. The methodological quality of individual studies was evaluated using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool. RESULTS A total of 12 eligible studies involving adult patients and cadaveric models were identified from 1488 references. For detection of esophageal intubation, the pooled sensitivity was 0.93 (95% CI: 0.86-0.96) and the specificity was 0.97 (95% CI: 0.95-0.98). The area under the summary ROC curve was 0.97 (95% CI: 0.95-0.98). The positive and negative likelihood ratios were 26.98 (95% CI: 19.32-37.66) and 0.08 (95% CI: 0.04-0.15), respectively. CONCLUSIONS Current evidence supports that ultrasonography has high diagnostic value for identifying esophageal intubation. With optimal sensitivity and specificity, ultrasonography can be a valuable adjunct in this aspect of airway assessment, especially in situations where capnography may be unreliable.

Tracheal rapid ultrasound saline test (T.R.U.S.T.) for confirming correct endotracheal tube depth in children.

OBJECTIVE We evaluated the accuracy of tracheal ultrasonography of a saline-inflated endotracheal tube (ETT) cuff for confirming correct ETT insertion depth. METHODS We performed a prospective feasibility study of children undergoing endotracheal intubation for surgery. Tracheal ultrasonography at the suprasternal notch was performed during transient endobronchial intubation and inflation of the cuff with saline, and with the ETT at a correct endotracheal position. Ultrasound videos were recorded at both positions, which were confirmed by fiberoptic bronchoscopy. These videos were shown to two independent blinded reviewers, who determined the presence or absence of a saline-inflated cuff. The primary outcome was accuracy of tracheal ultrasonography for appropriate ETT insertion depth. RESULTS Forty-two patients were enrolled. For correct endotracheal versus endobronchial positioning, pooled results from the reviewers revealed a sensitivity of 98.8% (95% CI=90-100%), a specificity of 96.4% (95% CI=87-100%), a PPV of 96.5% (95% CI=87-100%), a NPV of 98.8% (95% CI=89-100%), a positive likelihood ratio of 32 (95% CI=6-185), and a negative likelihood ratio of 0.015 (95% CI=0.004-0.2). Agreement between reviewers was high (kappa co-efficient=0.93; 95% CI=0.86 to 1). The mean duration of the ultrasound exam was 4.0s (range 1.0-15.0s). CONCLUSIONS Sonographic visualization of a saline-inflated ETT cuff at the suprasternal notch is an accurate and rapid method for confirming correct ETT insertion depth in children.

Resident Experience of Abuse and Harassment in Emergency Medicine: Ten Years Later

BACKGROUND In 1995, a Society for Academic Emergency Medicine in-service survey reported high rates of verbal and physical abuse experienced by Emergency Medicine (EM) residents. We sought to determine the prevalence of abuse and harassment 10 years later to bring attention to these issues and determine if there has been a change in the prevalence of abuse over this time period. OBJECTIVES To determine the prevalence of abuse and harassment in a sample of EM residencies. METHODS We conducted a cross-section survey of EM residents from 10 residencies. EM residents were asked about their experience with verbal abuse, verbal threats, physical threats, physical attacks, sexual harassment, and racial harassment; and by whom. The primary outcome of the study was the prevalence of abuse and harassment as reported by EM residents. RESULTS There were 196 of 380 residents (52%) who completed the survey. The prevalence of any type of abuse experienced was 91%; 86% of residents experienced verbal abuse, 65% verbal threats, 50% physical threats, 26% physical attacks, 23% sexual harassment, and 26% racial harassment. Women were more likely than men to encounter sexual harassment (37% [38/102] vs. 8% [7/92]; p < 0.001). Racial harassment was not limited to minorities (23% [16/60] for Caucasians vs. 26% [29/126] for non-Caucasians; p = 0.59). Senior residents were more likely to have encountered verbal and physical abuse. Only 12% of residents formally reported the abuse they experienced. CONCLUSION Abuse and harassment during EM residency continues to be commonplace and is underreported.

Regional Nerve Blocks Improve Pain and Functional Outcomes in Hip Fracture: A Randomized Controlled Trial.

To compared outcomes of regional nerve blocks with those of standard analgesics after hip fracture.

Ultrasound-guided nerve blocks for intracapsular and extracapsular hip fractures☆☆☆

OBJECTIVES To compare pain relief between patients with intracapsular and extracapsular hip fractures who received an ultrasound-guided femoral nerve block (USFNB). DESIGN A multicenter, prospective, randomized, clinical trial. SETTING The study was conducted in the emergency departments of 3 academic hospitals located in New York City. SUBJECTS Patients aged ≥60 years presenting to the emergency department with hip fracture. METHODS A subgroup analysis from a larger data set was conducted of patients with intracapsular and extracapsular hip fractures who received an USFNB. We compared pain scores at baseline and then at 2 and 3 hours after the nerve block was performed, and also assessed pain relief at 2 and 3 hours. RESULTS Seventy-seven patients were randomized to receive USFNB, of which 68 had follow-up data at 2 and 3 hours and were included in the data analysis. Thirty-one were diagnosed with intracapsular and 37 with extracapsular hip fractures. In both groups, reductions in pain scores were clinically and statistically significant. In the intracapsular group, mean pain scores decreased from 6.23 to 3.81 (P < .0001) at 2 hours and from 6.23 to 3.87 (P < .0001) at 3 hours. In the extracapsular group, mean pain scores decreased from 6.62 to 3.89 (P < .0001) at 2 hours and from 6.62 to 3.46 (P < .0001) at 3 hours. These differences were similar between the extracapsular and intracapsular groups at 2 hours (P = .92) and at 3 hours (P = .58), thus demonstrating similar reductions in pain in the 2 groups. The differences in pain relief between the intracapsular and extracapsular groups were also similar: 1.61 (confidence interval [CI], 1.14-2.08) vs 1.35 (CI, 0.96-1.75) at 2 hours (P = .39) and 1.68 (CI, 1.21-2.15) vs 1.38 (CI, 0.89-1.87) at 3 hours (P = .38). CONCLUSION Ultrasound-guided femoral nerve block was equally effective in reducing pain for patients with both intracapsular and extracapsular hip fractures.

A Brief Educational Intervention Is Effective in Teaching the Femoral Nerve Block Procedure to First-Year Emergency Medicine Residents

BACKGROUND Hip fractures are a painful condition commonly encountered in the emergency department (ED). Older adults in pain often receive suboptimal doses of analgesics, particularly in crowded EDs. Nerve blocks have been utilized by anesthesiologists to help control pain from hip fractures postoperatively. The use of nerve stimulator with ultrasonographic guidance has increased the safety of this procedure. OBJECTIVES We instituted a pilot study to assess the ability of Emergency Medicine (EM) resident physicians to effectively perform this procedure after a didactic and demonstration session. METHODS First-year EM residents from three urban training programs underwent a 1-h didactic and hands-on training session on the femoral nerve block (FNB) procedure. A written pretest was used to assess baseline knowledge; it was administered again (with test items randomized) at 1 and 3 months post training session. A critical actions checklist (direct observation of procedure steps via simulated patient encounter) was used to assess the residents after the training session and again at 3 months. RESULTS A total of 38 EM residents were initially evaluated. Thirty-three successfully completed 1-month and 3-month written test evaluations; 30 completed all written and direct observation evaluations. The mean written pretest scores were 66% (SD 9); post-test 92% (SD 5), 1-month 74% (SD 8), and 3-month 75% (SD 9). After initial training, 37 of 38 (97%) residents demonstrated competency (completing ≥ 15 of 19 critical actions) in the FNB procedure determined via direct observation. At 3 months, 25 of 30 residents (83%) continued to retain 85% of their initial critical action skills, and 3 of 30 (10%) saw an improvement in their proficiency. CONCLUSION A 1-h training and demonstration module yielded high competency rates in residents performing critical actions related to the FNB; these skills were well maintained at 3 months. An ongoing study will attempt to correlate this competency with procedures performed on patients.

Clinician-performed abdominal sonography

IntroductionPoint-of-care ultrasonography is increasingly utilized across a wide variety of physician specialties. This imaging modality can be used to evaluate patients rapidly and accurately for a wide variety of pathologic conditions.MethodsA literature search was performed for articles focused on clinician-performed ultrasonography for the diagnosis of appendicitis, gallbladder disease, small bowel obstruction, intussusception, and several types of renal pathology. The findings of this search were summarized including the imaging techniques utilized in these studies.ConclusionClinician performed point-of-care sonography is particularly well suited to abdominal applications. Future investigations may further confirm and extend its utility at the bedside.