Michael J. Vitto

Perceived Difficulty and Success Rate of Standard Versus Ultrasound-Guided Peripheral Intravenous Cannulation in a Novice Study Group A Randomized Crossover Trial

To our knowledge, no previous studies have evaluated the perceived levels of difficulty between traditional and ultrasound (US)‐guided peripheral intravenous (IV) access in the novice provider. We attempt to show that, in a group of medical students who have limited peripheral IV experience, US‐guided peripheral IV cannulation can be achieved more effectively and with a lesser degree of difficulty than standard peripheral IV cannulation.

Emergency Physician-performed Transesophageal Echocardiography in Simulated Cardiac Arrest

Introduction Transesophageal echocardiography (TEE) is a well-established method of evaluating cardiac pathology. It has many advantages over transthoracic echocardiography (TTE), including the ability to image the heart during active cardiopulmonary resuscitation. This prospective simulation study aims to evaluate the ability of emergency medicine (EM) residents to learn TEE image acquisition techniques and demonstrate those techniques to identify common pathologic causes of cardiac arrest. Methods This was a prospective educational cohort study with 40 EM residents from two participating academic medical centers who underwent an educational model and testing protocol. All participants were tested across six cases, including two normals, pericardial tamponade, acute myocardial infarction (MI), ventricular fibrillation (VF), and asystole presented in random order. Primary endpoints were correct identification of the cardiac pathology, if any, and time to sonographic diagnosis. Calculated endpoints included sensitivity, specificity, and positive and negative predictive values for emergency physician (EP)-performed TEE. We calculated a kappa statistic to determine the degree of inter-rater reliability. Results Forty EM residents completed both the educational module and testing protocol. This resulted in a total of 80 normal TEE studies and 160 pathologic TEE studies. Our calculations for the ability to diagnose life-threatening cardiac pathology by EPs in a high-fidelity TEE simulation resulted in a sensitivity of 98%, specificity of 99%, positive likelihood ratio of 78.0, and negative likelihood ratio of 0.025. The average time to diagnose each objective structured clinical examination case was as follows: normal A in 35 seconds, normal B in 31 seconds, asystole in 13 seconds, tamponade in 14 seconds, acute MI in 22 seconds, and VF in 12 seconds. Inter-rater reliability between participants was extremely high, resulting in a kappa coefficient across all cases of 0.95. Conclusion EM residents can rapidly perform TEE studies in a simulated cardiac arrest environment with a high degree of precision and accuracy. Performance of TEE studies on human patients in cardiac arrest is the next logical step to determine if our simulation data hold true in clinical practice.

Comparison of Ultrasound-Guided and Landmark-Based Lumbar Punctures in Inexperienced Resident Physicians: Ultrasound-Guided Lumbar Puncture in Resident Physicians

We sought to determine whether US‐guided lumbar puncture reduced the rate of lumbar puncture failures for providers at an academic teaching hospital with variable lumbar puncture and US experience compared to the traditional landmark‐based technique.

Ultrasound-guided thoracostomy site identification in healthy volunteers

BackgroundTraditional landmark thoracostomy technique has a known complication rate up to 30%. The goal of this study is to determine whether novice providers could more accurately identify the appropriate intercostal site for thoracostomy by ultrasound guidance.Methods33 emergency medicine residents and medical students volunteered to participate in this study during routine thoracostomy tube education. A healthy volunteer was used as the standardized patient for this study. An experienced physician sonographer used ultrasound to locate a site at mid-axillary line between ribs 4 and 5 and marked the site with invisible ink that can only be revealed with a commercially available UV LED light. Participants were asked to identify the thoracostomy site by placing an opaque marker where they would make their incision. The distance from the correct insertion site was measured in rib spaces. The participants were then given a brief hands-on training session using ultrasound to identify the diaphragm and count rib spaces. The participants were then asked to use ultrasound to identify the proper thoracostomy site and mark it with an opaque marker. The distance from the proper insertion site was measured and recorded in rib spaces.ResultsThe participants correctly identified the pre-determined intercostal space using palpation 48% (16/33) of the time, versus the ultrasound group who identified the proper intercostal space 91% (30/33) of the time. On average, the traditional technique was placed 0.88 rib spaces away (95 CI 0.43–1.03), while the ultrasound-guided technique was placed 0.09 rib spaces away (95 CI 0.0–0.19) [P = 0.003].ConclusionsThe ability to accurately locate the correct intercostal space for thoracostomy incision was improved under ultrasound guidance. Further studies are warranted to determine if this ultrasound-guided technique will decrease complications with chest tube insertion and improve patient outcomes.

Medication mismanagement using the rivaroxaban demonstration pack

A 65-year-old woman arrived at our emergency department (ED) via emergency medical services with a chief complaint of acute dyspnea. The patient’s medical history of bipolar disorder, schizophrenia, and mild dementia with a recent inpatient psychiatric admission was noted. She was admitted to an

Iliac Pseudoaneurysm from Endoleak.

A 65-year-old male presented to the emergency department complaining of two hours of severe lower abdominal pain radiating into his left testicle. The patient described a vascular procedure in the past but did not recall the details. An emergent bedside ultrasound was performed to evaluate the abdominal aorta. During the exam an echogenic object consistent with a prior endovascular stent was discovered in the distal aorta prompting further ultrasound evaluation of the iliac artery (Figure). A true lumen (thin black arrow) was visualized with evidence of leak (white arrows) during color Doppler evaluation. The patient was taken emergently to computed tomography and the diagnosis of an iliac artery pseudoaneurysm from an endoleak was confirmed. Figure Ultrasound of the left iliac (left) with color Doppler flow (right) showing the true lumen (thin black arrow) and evidence of the leak (white arrows) creating a pseudoaneurysm (thick black arrow). A pseudoaneurysm is formed after a disruption causes a saccular expansion at the site of injury that is contained by adventitia or perivascular soft tissue. Rupture is common in patients with iliac artery pseudoaneurysm, with associated mortality rates of approximately 50%.1 An endoleak is a potential complication of endovascular stenting that involves blood leaking around or through the graft site.2 Presenting symptoms of a pseudoaneurysm are variable, based on the location, and are often caused by pressure on adjacent organs. Symptoms that have been described include abdominal pain, urinary symptoms, renal failure, lumbosacral pain, groin pain, rectal bleeding, or constipation.1 Our patient had prior endovascular stenting of an iliac artery aneurysm that extended into the distal aorta. He had developed a pseudoaneurysm (thick black arrow) arising from the medial aspect of the left iliac artery at the juncture of two metallic stents with active extravasation suggestive of an endoleak (white arrows). The patient underwent endovascular repair with endograft placement to repair the leak and subsequent coil embolization of the pseudoaneurysm cavity.