Lawrence M. Gillman

The ketamine effect on ICP in traumatic brain injury.

Our goal was to perform a systematic review of the literature on the use of ketamine in traumatic brain injury (TBI) and its effects on intracranial pressure (ICP). All articles from MEDLINE, BIOSIS, EMBASE, Global Health, HealthStar, Scopus, Cochrane Library, the International Clinical Trials Registry Platform (inception to November 2013), reference lists of relevant articles, and gray literature were searched. Two reviewers independently identified all manuscripts pertaining to the administration of ketamine in human TBI patients that recorded effects on ICP. Secondary outcomes of effect on cerebral perfusion pressure, mean arterial pressure, patient outcome, and adverse effects were recorded. Two reviewers independently extracted data including population characteristics and treatment characteristics. The strength of evidence was adjudicated using both the Oxford and GRADE methodology. Our search strategy produced a total 371 citations. Seven articles, six manuscripts and one meeting proceeding, were considered for the review with all utilizing ketamine, while documenting ICP in severe TBI patients. All studies were prospective studies. Five and two studies pertained to adults and pediatrics, respectively. Across all studies, of the 101 adult and 55 pediatric patients described, ICP did not increase in any of the studies during ketamine administration. Three studies reported a significant decrease in ICP with ketamine bolus. Cerebral perfusion pressure and mean blood pressure increased in two studies, leading to a decrease in vasopressors in one. No significant adverse events related to ketamine were recorded in any of the studies. Outcome data were poorly documented. There currently exists Oxford level 2b, GRADE C evidence to support that ketamine does not increase ICP in severe TBI patients that are sedated and ventilated, and in fact may lower it in selected cases.

Portable bedside ultrasound: the visual stethoscope of the 21st century.

Over the past decade technological advances in the realm of ultrasound have allowed what was once a cumbersome and large machine to become essentially hand-held. This coupled with a greater understanding of lung sonography has revolutionized our bedside assessment of patients. Using ultrasound not as a diagnostic test, but instead as a component of the physical exam, may allow it to become the stethoscope of the 21st century.

The ketamine effect on intracranial pressure in nontraumatic neurological illness

PURPOSE The purpose of the study was to perform a systematic review of the literature on the use of ketamine in nontraumatic neurological illness and its effects on intracranial pressure (ICP). MATERIALS AND METHODS Articles from MEDLINE, BIOSIS, EMBASE, Global Health, HealthStar, Scopus, Cochrane Library, the International Clinical Trials Registry Platform (inception to January 2014), and gray literature were searched. Two reviewers identified manuscripts on the administration of ketamine in nontraumatic neurological illness that recorded effects on ICP. The strength of evidence was adjudicated using the Oxford and Grading of Recommendation Assessment Development and Education (GRADE) methodology. RESULTS Our search produced a total of 179 citations. Sixteen articles, 15 manuscripts, and 1 meeting proceeding were included in the review. Across all studies, there were 127 adult and 87 pediatric patients described. Intracranial pressure did not increase in any of the adult studies reporting premedication during ketamine administration, with 2 studies reporting a decrease in ICP. No significant non-ICP-related adverse events from ketamine were recorded in any of the studies. CONCLUSIONS There exists Oxford level 2b, GRADE C evidence in adults and level 4, GRADE C in pediatrics to support that ketamine does not increase ICP in nontraumatic neurological illness when patients are sedated and ventilated, and in fact may lower it in selected cases.

Potential Use of Remote Telesonography as a Transformational Technology in Underresourced and/or Remote Settings

Mortality and morbidity from traumatic injury are twofold higher in rural compared to urban areas. Furthermore, the greater the distance a patient resides from an organized trauma system, the greater the likelihood of an adverse outcome. Delay in timely diagnosis and treatment contributes to this penalty, regardless of whether the inherent barriers are geographic, cultural, or socioeconomic. Since ultrasound is noninvasive, cost-effective, and portable, it is becoming increasingly useful for remote/underresourced (R/UR) settings to avoid lengthy patient travel to relatively inaccessible medical centers. Ultrasonography is a user-dependent, technical skill, and many, if not most, front-line care providers will not have this advanced training. This is particularly true if care is being provided by out-of-hospital, “nontraditional” providers. The human exploration of space has forced the utilization of information technology (IT) to allow remote experts to guide distant untrained care providers in point-of-care ultrasound to diagnose and manage both acute and chronic illness or injuries. This paradigm potentially brings advanced diagnostic imaging to any medical interaction in a setting with internet connectivity. This paper summarizes the current literature surrounding the development of teleultrasound as a transformational technology and its application to underresourced settings.

Structured operative reporting: a randomized trial using dictation templates to improve operative reporting

BACKGROUND Few studies have addressed the quality of dictated operative reports (ORs). This study documents changes in resident dictation after the introduction of a standardized OR template. METHODS Twenty residents dictated an OR based on a surgical procedure video. Residents were randomized to receive an OR template or no intervention. Residents dictated another report 3 months later. Outcomes measures were dictation quality using a previously validated tool and resident comfort with dictation. RESULTS There was no overall difference in quality in the intervention group as measured by the Structured Assessment Form (SAF) (28.6 vs 30.0, P = .36) and Global Quality Ratings Scale (GQRS) (21.7 vs 21.8, P = .96). However, junior resident subgroup analysis revealed an improvement in the intervention group on both the SAF (23.2 vs 28.3, P = .02) and GQRS (17.1 vs 20.4, P = .02). Subjective comfort level improved in the intervention group (P = .02). CONCLUSIONS The operative dictation template can significantly improve resident comfort level with dictation and has the potential to improve the quality of junior resident dictations.

S.T.A.R.T.T.: development of a national, multidisciplinary trauma crisis resource management curriculum-results from the pilot course.

BACKGROUND Most medical errors are nontechnical and include failures in team communication, situational awareness, resource use, and leadership. Other high-risk industries have adopted team-based crisis resource management (CRM) training strategies to address “nontechnical” skills and to improve human error and safety. Here, we describe the development and evaluation of a national multidisciplinary trauma CRM curriculum. METHODS A needs analysis survey was distributed to general surgery program directors across Canada. With the use of this feedback, a course called STARTT [Standardized Trauma and Resuscitation Team Training] was developed and held in conjunction with the Canadian Surgery Forum. Participants completed a precourse and postcourse evaluation exploring changes in attitudes toward simulation and CRM principles using previously validated instruments. RESULTS Twenty surgical residents, 6 nurses, 4 respiratory therapists, and 11 instructors (trauma surgeons, emergency physicians, nurses, and intensivists) participated. Of the participants, 100% completed the survey. Satisfaction was very high, with 97.5% of the participants rating the course as “good” or “excellent” and 97.5% recommending it to others. The presurvey and postsurvey showed statistically significant improvement in attitudes toward simulation and overall CRM principles (136.3 vs. 140.3 of 170, p = 0.004) following the course, primarily in the domain of teamwork (69.1 vs. 72.0 of 85, p = 0.002). CONCLUSION Creation of a national multidisciplinary trauma CRM curriculum is feasible, has high satisfaction among participants, and can improve attitudes toward the importance of simulation and CRM principles with the ultimate goal of improving patient safety and care.

Ultrasound assessment of optic nerve sheath diameter in healthy volunteers.

BACKGROUND Ultrasound assessment of optic nerve sheath diameter (ONSD) has been suggested as a non-invasive measure of intracranial pressure. Numerous small studies suggest its validity; however, discrepancy exists around normal values for ONSD. In this study we sought to define a normal value range for ONSD in a population of healthy adult volunteers. METHODS ONSD was measured in healthy adult volunteers and a normal range was defined using descriptive statistics. A regression analysis was used to determine relationship between ONSD measurements and sex, age, height and weight. RESULTS One hundred twenty adults were recruited (age 18-65 [mean 29.3]) with 55 male and 65 female subjects. Mean ONSD was 3.68 mm (95% confidence interval [CI], 2.85-4.40). Upon regression analysis, mean ONSD did not vary with age, weight, or height but did vary with sex. Mean ONSD measurements for men were 3.78 mm (95% CI, 3.23-4.48) compared with 3.60 mm (95% CI, 2.83-4.11) for women. CONCLUSION This study has defined the range of ONSD in a healthy cohort of volunteers. The lack of relationship to age, weight and height is similar to other studies but this is the first study to find a difference depending on sex suggesting the possible need for separate reference ranges for men and women.

VNS for refractory status epilepticus.

BACKGROUND Our goal was to perform a systematic review of the literature on the insertion of vagal nerve stimulators (VNS) for refractory status epilepticus (RSE) and its impact on the control of RSE. METHODS All articles from MEDLINE, BIOSIS, EMBASE, Global Health, HealthStar, Scopus, Cochrane Library, the International Clinical Trials Registry Platform, clinicaltrials.gov (inception to June 2014), reference lists of relevant articles, and gray literature were searched. The strength of evidence was adjudicated using both the Oxford and GRADE methodology by two independent reviewers (FZ and MW). RESULTS Overall, 17 studies were identified, with 7 manuscripts and 10 meeting abstracts. A total of 28 patients were treated. In those with generalized RSE, 76% displayed cessation of RSE with VNS insertion. In cases of focal RSE, 25% responded to VNS insertion. Few adverse effects related to VNS insertion were described. CONCLUSIONS We currently cannot recommend the use of VNS for RSE. Oxford level 4, GRADE D evidence exists to suggest improvement in seizure control with the use of urgent VNS in generalized RSE. No comments can be made on the utility of VNS in focal RSE. Further prospective study is warranted.

A Unique Model for Ultrasound Assessment of Optic Nerve Sheath Diameter

BACKGROUND Ultrasonic assessment of optic nerve sheath diameter (ONSD) as a non-invasive measure of intracranial pressure (ICP) has been evaluated in the literature as a potential valid technique for rapid ICP estimation in the absence of invasive intracranial monitoring. The technique can be challenging to perform and little literature exists surrounding intra-operator variability. OBJECTIVES In this study we describe the creation of a novel model of ONSD to be utilized in ultrasound training of this technique. We demonstrate the realistic ultrasonographic images created utilizing this novel model. METHODS We designed ocular models composed of gelatin spheres and variable three dimensional printed cylinders, which simulate the globe of the eye and variable ONSDs respectively. These models were suspended in a gelatin background and ultrasound of the ONSD was conducted using standard techniques described in the literature. RESULTS This model produces clear and accurate representation of ONSD that closely mimics in vivo images. It is affordable and easy to produce in large quantities, portending its use in an educational environment. CONCLUSIONS Utilizing the standard linear array ultrasound probe for ONSD measurements in our model provided realistic images comparable to in vivo. This provides an affordable and exciting means to test intra- and inter- operator variability in a standardized environment. Knowing this, we can further apply this novel model of ONSD to ultrasound teaching and training courses with confidence in its ability and the techniques ability to produce consistent results.

The "pseudo-lung point" sign: all focal respiratory coupled alternating pleural patterns are not diagnostic of a pneumothorax.

In less than two decades since the introduction of the Focused Assessment with Sonography in Trauma (FAST) examination ultrasound has become ubiquitous in the trauma bay. First used for the identification of abdominal and pericardial fluid, its utility has been expanded to include the detection of pneumothorax; the so-called extended FAST.1 In our case, a 22-year-old man was a restrained passenger involved in a single-vehicle head on collision. On arrival to the trauma bay, he was hemodynamically stable. An extended FAST examination revealed what appeared to be a lung point when the chest was scanned laterally (Fig. 1). These features are best determined through viewing real-time video sequences (see Video, Supplemental Digital Content 1, http://links.lww.com/TA/A20; Author: Lawrence Gillman, Videographer: Andrew Kirkpatrick, Length: 6 seconds, and Size: 0.8 MB, which demonstrates the “pseudolung point” moving across the screen with respiration). Using M-mode imaging, a distinct respiratory coupled pleural sonographic alternation was seen (Fig. 2). A chest radiograph revealed right rib fractures and a right pulmonary contusion with no evidence of pneumothorax, which was corroborated through computed tomography scan of the chest (Fig. 3). The diagnosis of pneumothorax was one of the first clinical applications of lung ultrasound. The lung point was first described by Lichtenstein in 2000.2 The ability to demonstrate the alternating lung sliding and absence of lung sliding within the same ultrasound field has been touted as being diagnostic of a pneumothorax with 100% specificity.2 This is dramatically emphasized using timemotion (M-mode) ultrasonography where one sees alternating patterns of the “seashore” and “stratosphere” signs.