Michael G. Allison

A comparison of longitudinal and transverse approaches to ultrasound-guided axillary vein cannulation☆ , ☆☆ , ☆☆☆ , ☆☆☆☆ ,★,★★,★★★

OBJECTIVE The axillary vein is an easily accessible vessel that can be used for ultrasound-guided central vascular access and offers an alternative to the internal jugular and subclavian veins. The objective of this study was to identify which transducer orientation, longitudinal or transverse, is better for imaging the axillary vein with ultrasound. METHODS Emergency medicine physicians at an inner-city academic medical center were asked to cannulate the axillary vein in a torso phantom model. They were randomized to start with either the longitudinal or transverse approach and completed both sequentially. Participants answered questionnaires before and after the cannulation attempts. Measurements were taken regarding time to completion, success, skin punctures, needle redirections, and complications. RESULTS Fifty-seven operators with a median experience of 85 ultrasound procedures (interquartile range, 26-120) participated. The frequency of first-attempt success was 39 (0.69) of 57 for the longitudinal method and 21 (0.37) of 57 for the transverse method (difference, 0.32; 95% confidence interval [CI], 0.12-0.51 [P = .001]); this difference was similar regardless of operator experience. The longitudinal method was associated with fewer redirections (difference, 1.8; 95% CI, 0.8-2.7 [P = .0002]) and skin punctures (difference, 0.3; 95% CI, -2 to +0.7 [P = .07]). Arterial puncture occurred in 2 of 57 longitudinal and 7 of 57 transverse attempts; no pleural punctures occurred. For successful attempts, the time spent was 24 seconds less for the longitudinal method (95% CI, 3-45 [P = .02]). CONCLUSIONS The longitudinal method of visualizing the axillary vein during ultrasound-guided venous access is associated with greater first-attempt success, fewer needle redirections, and a trend of fewer arterial punctures compared with the transverse orientation.

Ultrasound use during cardiopulmonary resuscitation is associated with delays in chest compressions

AIM High-quality chest compressions are a critical component of the resuscitation of patients in cardiopulmonary arrest. Point-of-care ultrasound (POCUS) is used frequently during emergency department (ED) resuscitations, but there has been limited research assessing its benefits and harms during the delivery of cardiopulmonary resuscitation (CPR). We hypothesized that use of POCUS during cardiac arrest resuscitation adversely affects high-quality CPR by lengthening the duration of pulse checks beyond the current cardiopulmonary resuscitation guidelines recommendation of 10s. METHODS We conducted a prospective cohort study of adults in cardiac arrest treated in an urban ED between August 2015 and September 2016. Resuscitations were recorded using video equipment in designated resuscitation rooms, and the use of POCUS was documented and timed. A linear mixed-effects model was used to estimate the effect of POCUS on pulse check duration. RESULTS Twenty-three patients were enrolled in our study. The mean duration of pulse checks with POCUS was 21.0s (95% CI, 18-24) compared with 13.0s (95% CI, 12-15) for those without POCUS. POCUS increased the duration of pulse checks and CPR interruption by 8.4s (95% CI, 6.7-10.0 [p<0.0001]). Age, body mass index (BMI), and procedures did not significantly affect the duration of pulse checks. CONCLUSIONS The use of POCUS during cardiac arrest resuscitation was associated with significantly increased duration of pulse checks, nearly doubling the 10-s maximum duration recommended in current guidelines. It is important for acute care providers to pay close attention to the duration of interruptions in the delivery of chest compressions when using POCUS during cardiac arrest resuscitation.

Alcoholic Metabolic Emergencies

Ethanol intoxication and ethanol use are associated with a variety of metabolic derangements encountered in the Emergency Department. In this article, the authors discuss alcohol intoxication and its treatment, dispel the myth that alcohol intoxication is associated with hypoglycemia, comment on electrolyte derangements and their management, review alcoholic ketoacidosis, and end with a section on alcoholic encephalopathy.

Noninvasive Ventilation for the Emergency Physician

Noninvasive ventilation (NIV) improves oxygenation and ventilation, prevents endotracheal intubation, and decreases the mortality rate in select patients with acute respiratory failure. Although NIV is used commonly for acute exacerbations of chronic obstructive pulmonary disease and acute cardiogenic pulmonary edema, there are emerging indications for its use in the emergency department. Emergency physicians must be knowledgeable regarding the indications and contraindications for NIV in emergency department patients with acute respiratory failure as well as the means of initiating it and monitoring patients who are receiving it.

High initial tidal volumes in emergency department patients at risk for acute respiratory distress syndrome

PURPOSE Emergency department (ED) patients are at high risk for the acute respiratory distress syndrome (ARDS). Settings only 1 mL/kg above recommended tidal volumes confers harm for these patients. The purpose of this study was to determine whether ED physicians routinely initiate mechanical ventilation with low tidal volumes in patients at risk for ARDS. MATERIALS AND METHODS We retrospectively reviewed the charts of all adult patients who were intubated in an urban, academic ED. The charts were analyzed to identify patients in whom ARDS developed within 48 hours after ED admission. Patients were eligible for inclusion if they had bilateral infiltrates on imaging, had a Pao2/Fio2 ratio less than 300 mm Hg and did not have heart failure contributing to their presentation. The tidal volumes set in the ED were then compared with the recommended tidal volume of 6 mL/kg of predicted body weight. RESULTS The initial tidal volumes set in the ED were higher than recommended by an average of 80 mL (95% confidence interval, 60-110, P < .0001) or 1.5 mL/kg (95% confidence interval, 1.0-1.9). Only 5 of the 34 patients received the recommended tidal volume ventilation setting. CONCLUSIONS In an academic, tertiary hospital, newly intubated ED patients in whom ARDS developed within 48 hours after intubation were ventilated with tidal volumes that exceeded recommendations by an average of 1.5 mL/kg.

Appropriate Antibiotic Therapy

Prescribing antibiotics is an essential component of initial therapy in sepsis. Early antibiotics are an important component of therapy, but speed of administration should not overshadow the patient-specific characteristics that determine the optimal breadth of antimicrobial therapy. Cultures should be drawn before antibiotic therapy if it does not significantly delay administration. Combination antibiotic therapy against gram-negative infections is not routinely required, and combination therapy involving vancomycin and piperacillin/tazobactam is associated with an increase in acute kidney injury. Emergency practitioners should be aware of special considerations in the administration and dosing of antibiotics in order to deliver optimal care to septic patients.

Hematological Issues in Liver Disease

Acute and chronic liver failure are associated with numerous alterations in different features of the coagulation system. Consequently, there is widespread confusion regarding the potential for both bleeding and thrombosis in patients with liver disease. The risk of bleeding is related to the hemodynamic changes in portal pressures and venous congestion whereas the thrombotic risk stems from changes in the coagulation system. Antithrombotic prophylaxis and treatment of patients with hemorrhage and thrombosis requires careful assessment, interpretation of laboratory workup, and attention to coexistent morbidities. A framework for the management of these conditions is presented for clinicians.

Hyperbilirubinaemia and haemolytic anaemia in acute alcoholic hepatitis: there's oil in them thar veins

A Caucasian woman in her late 30s was evaluated after a period of binge drinking and found to have hyperbilirubinaemia for which she was referred for consideration of cholecystectomy. After exclusion of other possibilities, Zieves syndrome was diagnosed. This is a condition of hyperbilirubinaemia, Coombs’ negative haemolytic anaemia and hyperlipidaemia associated with alcoholism. Abstinence from alcohol remains the only known effective treatment, and appreciation of the entity can prevent unnecessary biliary procedures. The patient improved with supportive measures and was discharged in stable condition.

Response to: Do initial tidal volumes impact acute respiratory distress syndrome development in patients intubated in the emergency department?

tion for patients intubated in the ED. We believe the editorial misstates our main conclusion. We primarily found that, in the subset of patients in whom the ARDS developed, initial tidal volumes were higher than the recommended tidal volume of 6 mL/kg of ideal body weight (IBW) [1]. Our study was not designed to show causality between higher initial ventilator settings and the subsequent development of ARDS. Rather, we selected the subset of patients in whom ARDS later developed because they are the patients in whom tidal volumes are felt to be most important. Lung-protective ventilation with a recommended tidal volume of 6 mL/kg has been commonly adopted for all comers since the And Respiratory Management in ARDS (ARMA) trial from the ARDS Network [1] .I n that prospective, randomized trial, the patients seeing a mortality benefit from lung-protective tidal volume ventilation were those who had ARDS. We therefore chose to look at this specific population by including only patients who developed ARDS within 48 hours after intubation. We sought to determine if the ED-initiated ventilator settings in this subset adhered to the goal of 6 mL/kg IBW and found that the volumes were set higher by approximately 1.5 mL/kg of IBW. Importantly, the assertion that the ARMA trial protocol called for an initial tidal volume of 8 mL/kg IBW is somewhat misleading. The protocol does call for an “initial” tidal volume of 8 mL/kg IBW but then states that this tidal volume “will be reduced by 1 mL/kg IBW at intervals of less than or equal to 2 hours until tidal volume equals to 6 mL/kg IBW,” at which point further adjustments would be made for acidosis, hypoxia, and plateau pressures. We did not findthat this titration occurredin our cohort. For patientswho were eventually ventilated at 6 mL/kg IBW, an average of 14 hours passed before they reached this goal. Furthermore, the same protocol states that the tidal volume could be increased above 6 mL/kg only in the setting of severe acidosis (pH b7.15) that persisted despite a respiratory rate of 35

Emergency Care of Patients with Pacemakers and Defibrillators

Devices such as pacemakers and implantable cardioverter-defibrillators (ICDs) are commonly inserted to treat unstable cardiac rhythm disturbances. Despite the benefits of these devices on mortality and morbidity rates, patients often present to the emergency department with complaints related to device insertion or malfunction. Emergency physicians must be able to rapidly identify potential life threats caused by pacemaker malfunction, ICD firing, and complications associated with implantation of the devices.