Keith Boniface

Ultrasound-guided peripheral intravenous access program is associated with a marked reduction in central venous catheter use in noncritically ill emergency department patients.

STUDY OBJECTIVE We examine the central venous catheter placement rate during the implementation of an ultrasound-guided peripheral intravenous access program. METHODS We conducted a time-series analysis of the monthly central venous catheter rate among adult emergency department (ED) patients in an academic urban ED between 2006 and 2011. During this period, emergency medicine residents and ED technicians were trained in ultrasound-guided peripheral intravenous access. We calculated the monthly central venous catheter placement rate overall and compared the central venous catheter reduction rate associated with the ultrasound-guided peripheral intravenous access program between noncritically ill patients and patients admitted to critical care. Patients receiving central venous catheters were classified as noncritically ill if admitted to telemetry or medical/surgical floor or discharged home from the ED. RESULTS During the study period, the ED treated a total of 401,532 patients, of whom 1,583 (0.39%) received a central venous catheter. The central venous catheter rate decreased by 80% between 2006 (0.81%) and 2011 (0.16%). The decrease in the rate was significantly greater among noncritically ill patients (mean for telemetry patients 4.4% per month [95% confidence interval {CI} 3.6% to 5.1%], floor patients 4.8% [95% CI 4.2% to 5.3%], and discharged patients 7.6% [95% CI 6.2% to 9.1%]) than critically ill patients (0.9%; 95% CI 0.6% to 1.2%). The proportion of central venous catheters that were placed in critically ill patients increased from 34% in 2006 to 81% in 2011 because fewer central venous catheterizations were performed in noncritically ill patients. CONCLUSION The ultrasound-guided peripheral intravenous access program was associated with reductions in central venous catheter placement, particularly in noncritically ill patients. Further research is needed to determine the extent to which such access can replace central venous catheter placement in ED patients with difficult vascular access.

ED technicians can successfully place ultrasound-guided intravenous catheters in patients with poor vascular access☆☆☆

OBJECTIVE The objective of the study was to assess the success rate of emergency department (ED) technicians in placing ultrasound (US)-guided peripheral intravenous (i.v.) catheters. METHODS In this prospective, observational trial, 19 ED technicians were taught to use US guidance to obtain i.v. access. Training sessions consisted of didactic instruction and hands-on practice. The ED technicians were then prospectively followed. The US guidance for i.v. access was limited to patients with difficult access. The primary outcome was successful peripheral i.v. placement. RESULTS A total of 219 attempts were recorded, with a success rate of 78.5% (172/219). There was a significant correlation between operator experience and success rate. Complications were reported in 4.1% of patients and included 5 arterial punctures and 1 case of a transient paresthesia. CONCLUSIONS Emergency department technicians can be taught to successfully place US-guided IVs in patients with difficult venous access. Teaching this skill to ED technicians increases the pool of providers available in the ED to obtain access in this patient population.

Accuracy of radiographic readings in the emergency department

OBJECTIVES A review of radiology discrepancies of emergency department (ED) radiograph interpretations was undertaken to examine the types of error made by emergency physicians (EPs). METHODS An ED quality assurance database containing all radiology discrepancies between the EP and radiology from June 1996 to May 2005 was reviewed. The discrepancies were categorized as bone, chest (CXR), and abdomen (AXR) radiographs and examined to identify abnormalities missed by EPs. RESULTS During the study period, the ED ordered approximately 151 693 radiographs. Of the total, 4605 studies were identified by radiology as having a total of 5308 abnormalities discordant from the EP interpretation. Three hundred fifty-nine of these abnormalities were not confirmed by the radiologist (false positive). The remainder of the discordant studies represented abnormalities identified by the radiologist and missed by the EP (false negatives). Of these false-negative studies, 1954 bone radiographs (2.4% of bone x-rays ordered) had missed findings with 2050 abnormalities; the most common missed findings were fractures and dislocations. Of the 220 AXRs (3.7% of AXRs ordered) with missed findings, 240 abnormalities were missed; the most common of these was bowel obstruction. Of the 2431 CXRs (3.8% of CXRs ordered), 2659 abnormalities were missed; the most common were air-space disease and pulmonary nodules. The rate of discrepancies potentially needing emergent change in management based solely on a radiographic discrepancy was 85 of 151 693 x-rays (0.056%). CONCLUSIONS Approximately 3% of radiographs interpreted by EPs are subsequently given a discrepant interpretation by the radiology attending. The most commonly missed findings included fractures, dislocations, air-space disease, and pulmonary nodules. Continuing education should focus on these areas to attempt to further reduce this error rate.

Bedside Ultrasound Reduces Diagnostic Uncertainty and Guides Resuscitation in Patients With Undifferentiated Hypotension.

Objectives:Utilization of ultrasound in the evaluation of patients with undifferentiated hypotension has been proposed in several protocols. We sought to assess the impact of an ultrasound hypotension protocol on physicians’ diagnostic certainty, diagnostic ability, and treatment and resource utilization. Design:Prospective observational study. Setting:Emergency department in a single, academic tertiary care hospital. Subjects:A convenience sample of patients with a systolic blood pressure less than 90 mm Hg after an initial fluid resuscitation, who lacked an obvious source of hypotension. Interventions:An ultrasound-trained physician performed an ultrasound on each patient using a standardized hypotension protocol. Differential diagnosis and management plan was solicited from the treating physician immediately before and after the ultrasound. Blinded chart review was conducted for management and diagnosis during the emergency department and inpatient hospital stay. Measurements and Main Results:The primary endpoints were the identification of an accurate cause for hypotension and change in physicians’ diagnostic uncertainty. The secondary endpoints were changes in treatment plan, use of resources, and changes in disposition after performing the ultrasound. One hundred eighteen patients with a mean age of 62 years were enrolled. There was a significant 27.7% decrease in the mean aggregate complexity of diagnostic uncertainty before and after the ultrasound hypotension protocol (1.85–1.34; –0.51 [95% CI, –0.41 to –0.62]) as well as a significant increase in the absolute proportion of patients with a definitive diagnosis from 0.8% to 12.7%. Overall, the leading diagnosis after the ultrasound hypotension protocol demonstrated excellent concordance with the blinded consensus final diagnosis (Cohen k = 0.80). Twenty-nine patients (24.6%) had a significant change in the use of IV fluids, vasoactive agents, or blood products. There were also significant changes in major diagnostic imaging (30.5%), consultation (13.6%), and emergency department disposition (11.9%). Conclusions:Clinical management involving the early use of ultrasound in patients with hypotension accurately guides diagnosis, significantly reduces physicians’ diagnostic uncertainty, and substantially changes management and resource utilization in the emergency department.

Serious injuries related to the Segway® personal transporter: a case series.

STUDY OBJECTIVE We describe a case series of emergency department (ED) visits for injuries related to the Segway® personal transporter. METHODS This was a retrospective case review using a free-text search feature of an electronic ED medical record to identify patients arriving April 2005 through November 2008. Data were hand extracted from the record, and further information on admitted patients was obtained from the hospital trauma registry. RESULTS Forty-one cases were included. The median age was 50 years, and 30 patients (73.2%) were women. Twenty-nine (70.7%) of the patients resided outside the District of Columbia, Maryland, and Virginia, and 32 (78.1%) arrived between June and September. Seven (17.1%) patients had documented helmet use. Ten (24.4%) were admitted. Four patients (40% of admitted patients) required admission to the ICU. CONCLUSION The severity of trauma in this case series of patients injured by the use of the self-balancing personal transporter is significant. Further investigation into the risks of use, as well as the optimal length and type of training or practice, is warranted. A distinct E-code and Consumer Product Safety Commissions product code is needed to enable further investigation of injury risks for this mode of transportation.

Ultrasonography Versus Landmark for Peripheral Intravenous Cannulation: A Randomized Controlled Trial

STUDY OBJECTIVE Randomized controlled trials report inconsistent findings when comparing the initial success rate of peripheral intravenous cannulation using landmark versus ultrasonography for patients with difficult venous access. We sought to determine which method is superior for patients with varying levels of intravenous access difficulty. METHODS We conducted a 2-group, parallel, randomized, controlled trial and randomly allocated 1,189 adult emergency department (ED) patients to landmark or ultrasonography, stratified by difficulty of access and operator. ED technicians performed the peripheral intravenous cannulations. Before randomization, technicians classified subjects as difficult, moderately difficult, or easy access according to visible or palpable veins and perception of difficulty with a landmark approach. If the first attempt failed, we randomized subjects a second time. We compared the initial and second-attempt success rates by procedural approach and difficulty of intravenous access, using a generalized linear mixed regression model, adjusted for operator. RESULTS The 33 participating technicians enrolled a median of 26 subjects (interquartile range 9 to 55). The initial success rate was 81% but varied significantly by technique and difficulty of access. The initial success rate by ultrasonography was higher than landmark for patients with difficult access (48.0 more successes per 100 tries; 95% confidence interval [CI] 35.6 to 60.3) or moderately difficult access (10. 2 more successes per 100 tries; 95% CI 1.7 to 18.7). Among patients with easy access, landmark yielded a higher success rate (10.6 more successes per 100 tries; 95% CI 5.8 to 15.4). The pattern of second-attempt success rates was similar. CONCLUSION Ultrasonographic peripheral intravenous cannulation is advantageous among patients with difficult or moderately difficult intravenous access but is disadvantageous among patients anticipated to have easy access.

Spontaneous rectus sheath hematoma diagnosed by point-of-care ultrasonography

Spontaneous rectus sheath hematoma is an uncommon condition that can mimic other conditions associated with an acute abdomen. We report the case of a patient with a spontaneous rectus sheath hematoma due to a ruptured inferior epigastric artery pseudoaneurysm who presented with hypotension and severe abdominal pain and was diagnosed using emergency department point-of-care ultrasonography. Point-of-care ultrasonography has been increasingly used in the evaluation of emergency department patients with acute abdomen and hypotension to expedite the diagnosis and management of aortic aneurysm and intraperitoneal bleeding. Resuscitation and urgent surgical and interventional radiology consultations resulted in the successful embolization of a branch of the inferior epigastric artery and a good outcome.

Ultrasound-guided intra-articular lidocaine block for reduction of anterior shoulder dislocation in the pediatric emergency department

Abstract We report a case of successful reduction of an anterior shoulder dislocation after ultrasound-guided intra-articular lidocaine (IAL) block with subsequent sonographic confirmation of reduction. Current literature suggests that IAL can provide similar levels of analgesia as intravenous sedation, and IAL block is associated with lower complication rates and shorter emergency department stays. However, these studies may be limited by uncertainty about the accuracy of landmark-based glenohumeral injections. The use of beside ultrasound may improve the effectiveness of IAL block for reduction of anterior shoulder dislocation and provide a mechanism for immediate postreduction evaluation of the placement of the humeral head.

Intensive Care Ultrasound: IV. Abdominal Ultrasound in Critical Care

Ultrasound in critical care is distinct from ultrasound performed in radiology. Radiology-performed ultrasound is a comprehensive, anatomical examination that seeks to fully describe the area undergoing investigation. Clinicianperformed ultrasound performed at the bedside of the critically ill patient aims to answer a focused clinical question: Is the systolic function of the heart normal? Is there a deep vein thrombosis? Is there a pneumothorax? As a result, the learning curve for performance of these focused evaluations is much shorter and steeper than it is for more comprehensive examinations (1–3). Intensivistperformed abdominal ultrasound focuses on detecting the presence of intraabdominal fluid, obstructive changes of the kidneys and bladder, acute pathology of the gallbladder, and intraabdominal catastrophes. The examinations that follow use a low frequency (1–5 MHz) curvilinear or phased array transducer, with the orientation mark to the left side of the screen.

Horizontal subxiphoid landmark optimizes probe placement during the Focused Assessment with Sonography for Trauma ultrasound exam.

Objective To introduce an external landmark for optimizing probe placement during Focused Assessment with Sonography for Trauma (FAST) exam. Methods This prospective study was conducted in two phases. First, the students and emergency medicine residents were trained in FAST exam utilizing the horizontal subxiphoid (HS) landmark. The landmark consists of the crossing points of a horizontal line extending from the xiphoid process to the right midaxillary line (H point) and left posterior axillary line (S point). Second, the trained students and residents performed FAST among Emergency Departments patients at two teaching hospitals. The primary outcome was a target organ acquisition score for each view, derived from the number of target organs visualized on an initial probe placement. Secondary endpoints included: time required to obtain the requisite images, and the impact of patient characteristics on landmark prediction rate. Results Forty-eight providers performed 477 exams. The collective prediction rate of the HS landmark was 86.6% for both H and S points upon first attempt without further probe adjustments. Operators visualized all required target structures at the first probe placement site in 430 out of 477 (90.1%) cases at the right upper quadrant, and in 392 out of 474 (82.7%) cases at the left upper quadrant without further probe adjustments. Limited probe adjustment (<2 cm from the initial landmark site) improved the success rate up to 95.6 and 90% to the right upper quadrant and left upper quadrant, respectively. As BMI increased, precision score decreased and image acquisition time increased. Conclusion The HS line is an external landmark that may optimize probe placement and facilitates teaching and performance of FAST examination.