John P. Gullett

Ultrasound-Guided Femoral Nerve Blocks.

Abstract Pediatric acute femur fractures are a relatively common major orthopedic injury seen in emergency departments. Providing adequate and safe analgesia is essential while patients await definitive management of these fractures. Opioid medications are typically used to treat fracture-associated pain but have well-known adverse effects including respiratory and central nervous system depression, pruritus, nausea, and allergic reactions. Dose titration of opioids in pediatric patients may be difficult and requires frequent nursing and physician reassessments. Regional anesthesia using ultrasound guidance has been proposed as a reliable and safe method to provide pain relief for this population and to decrease reliance on opioid medications. There is a growing body of literature on the utility and safety of ultrasound-guided femoral nerve blocks for pediatric patients in the acute care setting. This review article covers recent literature on point-of-care ultrasound-guided femoral nerve blocks for pediatric patients, with a discussion of the indications, sonographic anatomy, selection of anesthetics, nerve block technique, and complications. This review supplements the expert supervision and practice required to gain competency.

Ability of pediatric emergency medicine physicians to identify anatomic landmarks with the assistance of ultrasound prior to lumbar puncture in a simulated obese model.

Objectives Lumbar punctures (LPs) are typically performed using anatomical surface landmarks. However, as body mass index increases, identifying surface landmarks becomes more difficult. Ultrasound has been proposed as a tool for identifying these landmarks prior to LP. This study evaluates the effectiveness of a brief training program in ultrasound identification of anatomical landmarks in a simulated obese model prior to completing an LP. Methods Pediatric emergency medicine physicians completed a pretest questionnaire on ultrasound familiarity prior to an educational session. Participants utilized ultrasonography without the assistance of palpation on a simulation LP model saving images for review. Participants attempted LP on phantom models with simulated body mass indices of 35 and 40 kg/m2. Time to image acquisition and successful aspiration of cerebrospinal fluid from the model were recorded. Two expert sonologists independently reviewed all images for correct landmark identification. Results Seven of the 19 participants had previous familiarity with ultrasound. The mean time to lumbar image acquisition significantly improved for all individuals from 176 seconds to 100 seconds (P = 0.003). Comfort level with ultrasound improved (P < 0.001) as well as comfort level in performing a lumbar ultrasound (P < 0.001). Adequate images were obtained in 96% of the attempts (55/57). The success rate at performing LP was 95% (54/57). Conclusions After a brief education intervention, pediatric emergency medicine physicians with little to no previous training in ultrasound can obtain adequate lumbar anatomic images and successfully perform LP in a simulated obese model. Comfort level with ultrasound significantly improves with a short course in ultrasound fundamentals.

Soft Tissue Ultrasound and the Comet Tail Artifact

A 46-year-old man presented with progressive elbow pain following an assault 1 week earlier. He stated that while defending himself, he hit his attacker in the mouth with his elbow. On physical exam, he had a small puncture wound overlying the proximal ulna, 3 cm distal to the olecranon. There was marked erythema and swelling over the elbow joint. Although the site was tender to the touch, there was no fluctuance, crepitus, or joint effusion, and the joint had full range of motion. The patient was afebrile, his white blood cell count was 14,000 ⁄ mm, and all other laboratory tests were normal. Radiographs of the elbow (Figures 1 and 2) did not reveal any fractures, soft tissue foreign bodies, or gas. A bedside ultrasound was then performed using a 7.5-MHz linear transducer and revealed an echogenic area superficial to the ulna (the arrow in Figure 3), casting a bright trail of echoes. These findings were subsequently confirmed by computed tomography, and the patient was hospitalized for intravenous antibiotics, wound exploration, and pain management. The comet tail artifact was first described by Ziskin et al. in 1982 and appears as a dense tapering trail of bright echoes just distal to a strongly reflective structure (Figure 3). In soft tissue, the comet tail is commonly caused by metal, plastic, or air. In this case, the absence of a foreign body on plain radiographs made subcutaneous gas the most likely cause. It is important to note that the ultrasound showed a pronounced comet tail artifact (see Video Clip S1), while the plain films were devoid of findings. Ultrasound is often more sensitive than plain radiographs for the detection of subtle soft tissue collections of air, and the comet tail artifact can thus be an early indicator of anaerobic or necrotic soft tissue infections. Figure 1. Elbow radiograph, anteroposterior view.

Right ventricular fractional area of change is predictive of ventilator support days in trauma and burn patients

Echocardiography has contributed to the care of critically ill patients but there remains a need for more publications about its association with outcomes to confirm its role. We conducted a retrospective review of trauma and burn patients that were admitted to our intensive care unit between 2015 and 2017 that underwent hemodynamic transesophageal echocardiography. Data collected included demographics, clinical and laboratory data. Right ventricle fractional area of change (RVFAC) measurements were performed on still mages obtained from mid-esophageal four-chamber-view clips. There were 74 patients, mean age was 51 years, and were predominantly white and male. Linear regression was used to test for the association between RVFAC and clinical outcomes. Adjusting for age, injury mechanism and injury severity, higher RVFAC was significantly associated with lower ventilator days (p = 0.03). Conclusion, higher right ventricle systolic function is associated with a lower number of ventilator support days in critically injured trauma and burn patients.

Circular right upper quadrant mass, not intussusception.

Abstract Point-of-care ultrasound is fast becoming a routine diagnostic tool in the pediatric emergency department, including in resource-limited settings. We describe a case where a patient was initially diagnosed with intussusception and admitted to a hospital. While serving as a patient model for a point-of-care ultrasound course, he was found to have a liver abscess. We discuss the manner in which the ultrasound study for ileocolic intussusception is performed and potential mimickers of ileocolic intussusception.

Adult Female With Abdominal Pain

A 23-year-old woman with a history of a cholecystectomy 3 years earlier presented with intermittent abdominal pain for 3 days. On physical examination, she was afebrile and had a pulse of 100 beats/min, respiratory rate of 20 breaths/min, blood pressure of 120/70 mm Hg, and a room air oxygen saturation of 98%. She had a soft abdomen with normal bowel sounds and moderate tenderness in the epigastric area. The patient’s WBC count, liver transaminase, serum bilirubin, alkaline phosphatase, amylase, and lipase levels were all normal. Figures 1 and 2 are from her bedside ultrasonogram and were taken with the probe held in a transverse orientation just below the xiphoid. Figure 3 is from her magnetic resonance cholangiography, performed the following morning. Figure 1. Ultrasound of the liver. Figure 2. Ultrasound magnified over the liver with color Doppler.