Thomas G. Costantino

Ultrasound-Guided Peripheral Venous Access vs. the External Jugular Vein as the Initial Approach to the Patient with Difficult Vascular Access

BACKGROUND Traditionally, Emergency Physicians (EPs) have used the external jugular (EJ) vein to gain vascular access in patients who have failed nursing attempts at peripheral access. Recently, some EPs have used ultrasound (USIV) to gain peripheral access. STUDY OBJECTIVE This study seeks to determine which initial approach by EPs would lead to greater success. METHODS This was a prospective, randomized study of all adult patients who presented to the Emergency Department (ED) between June and December 2007. Inclusion criteria were failed nursing attempts at peripheral access (at least three). EPs were 2(nd)- or 3(rd)-year residents who had previously performed more than five each of EJs and USIVs. Patients were randomized into either an initial EJ or USIV approach. RESULTS Sixty patients were enrolled, 32 in the ultrasound group, 28 in the EJ group. Fifteen different EPs performed access. Initial Success: USIV 84% (95% confidence interval [CI] 68-93%) vs. EJ 50% (95% CI 33-67%), p = 0.006. Success if EJ visible: USIV 84% vs. EJ 66% (p = 0.18). Overall success, including data from the crossover pathway: a total of 41 lines were successfully placed by ultrasound out of 46 attempts (89%) vs. 18 out of 33 for EJ (55%), p = 0.001. In total, 59/60 patients (98%) had a peripheral i.v. successfully placed. The percentage of functioning lines when the patient left the ED was: USIV 89% (95% CI 72-96%) vs. EJ 93% (95% CI 68-98%), p = 0.88. CONCLUSION As an initial approach to all patients with difficult venous access, ultrasound-guided peripheral lines are superior to the EJ approach. However if the EJ was visible, there was no difference in success among the initial approaches. Both techniques, when used together, could achieve peripheral vascular access in 98% of difficult access patients.

COMPARISON OF ULTRASOUND-GUIDED AND STANDARD LANDMARK TECHNIQUES FOR KNEE ARTHROCENTESIS

BACKGROUND Ultrasound is a useful adjunct to many Emergency Department (ED) procedures. Arthrocentesis is typically performed using a landmark technique but ultrasound may provide an opportunity to improve arthrocentesis performance. OBJECTIVE To assess the success of emergency physicians performing landmark (LM) vs. ultrasound (US)-guided knee arthrocentesis techniques. METHODS This was a prospective, randomized, controlled study of patients requiring knee arthrocentesis who presented to one urban university ED and two community EDs between June 2005 and February 2007. RESULTS There were 66 patients enrolled (39 US-guided, 27 LM). Among all users, there was no difference in arthrocentesis success (US 37/39 vs. LM 25/27); p = 1.0. SECONDARY ENDPOINTS: 1) Patients reported less pain with ultrasound; US-guided 3.71 (95% confidence interval [CI] 2.61-4.80) cm vs. LM 5.19 (95% CI 3.94-6.45) cm; p = 0.02. 2) Providers felt the US-guided technique was easier to perform than LM; 1.67 units on 5-point scale (95% CI 1.37-1.97) vs. 2.11 (95% CI 1.79-2.42) units; p = 0.02. 3) The total procedure time was shorter with the US-guided technique; 10.58 (95% CI 7.36-13.80) min vs. LM 13.37 (95% CI 9.83-16.92) min; p = 0.05. 4) There was no difference in the amount of fluid obtained between techniques; US-guided 45.33 (95% CI 35.45-55.21) mL vs. LM 34.7 (95% CI 26.09-43.32) mL; p = 0.17. CONCLUSION US-guided knee arthrocentesis technique does not improve overall success of obtaining joint fluid aspirate vs. the standard LM and palpation technique. An US-guided approach does not result in more pain for the patient, takes no additional time to perform and, at least for novice physicians, leads to more fluid aspiration and greater novice provider confidence with the procedure. Further studies with more participants and standardization of anesthetic quantity are required to validate these findings.

Randomized Trial Comparing Intraoral Ultrasound to Landmark-based Needle Aspiration in Patients with Suspected Peritonsillar Abscess

OBJECTIVES Traditionally, emergency physicians (EPs) have used anatomic landmark-based needle aspiration to drain peritonsillar abscesses (PTAs). If this failed, an imaging study and/or consultation with another service to perform the drainage is obtained. Recently, some EPs have used ultrasound (US) to guide PTA drainage. This study seeks to determine which initial approach leads to greater successful drainage. The primary objective of this study was to compare the diagnostic accuracy of EPs for detecting PTA or peritonsillar cellulitis (PTC) using either intraoral US or initial needle aspiration after visual inspection (the landmark technique [LM]). Secondary objectives included the successful aspiration of purulent material in those patients with a PTA in each arm, the use of computed tomography (CT) scanning in each arm, and the otolaryngology (ENT) consultation rate in each arm. METHODS This was a prospective, randomized, controlled clinical trial of a convenience sample of adult patients who presented to a single, large, urban university hospital. Patients were enrolled if they presented with a constellation of signs and symptoms that were judged to be a PTA. These patients were randomized to receive intraoral US or to undergo LM drainage. The US was performed using an 8-5 MHz intracavitary transducer immediately prior to the procedure. The probe was then withdrawn and the provider who did the US also performed the needle aspiration. The LM was performed using visual landmarks in a superior to inferior approach until pus was obtained or at least two sticks were performed. Anesthesia was standardized. Patients returned for follow-up in 2 days where a final diagnosis was rendered. RESULTS   There were 28 patients enrolled, with 14 in each arm. US established the correct diagnosis more often than LM [(100%, 95% confidence interval [CI] = 75% to 100% vs. 64%, 95% CI = 39% to 84%; p = 0.04)]. US also led to more successful aspiration of purulent material by the EP than LM in patients with PTA [(100%, 95% CI =63% to 100% vs. 50%, 95% CI = 24% to 76%; p = 0.04)]. The ENT consult rate was 7% (95% CI = 0% to 34%) for US versus 50% (95% CI = 27% to 73%) for LM (p = 0.03). The CT usage rate was 0% for US versus 35% for LM (p = 0.04). CONCLUSIONS   An initial intraoral US performed by EPs can reliably diagnose PTC and PTA. Additionally, using intraoral US to assist in the drainage of PTAs with needle aspiration leads to greater success compared to the traditional method of LM relying on physical exam alone.

Diagnosis of patellar tendon rupture by emergency ultrasound.

A 46-year-old man presented to the Emergency Department (ED) with left knee pain after being assaulted and landing on a flexed knee. On physical examination, the patient had a large effusion of his left knee and the patella was retracted proximally. He was unable to bear weight on his left leg, range his knee, or hold his leg up against gravity due to pain. The left extremity was neurovascularly intact. X-ray studies of the knee and femur showed infrapatellar soft tissue swelling but no fracture. A disruption of the extensor mechanism of the knee was suspected, but due to patient discomfort, could not be certainly diagnosed. An ultrasound scan was performed by the emergency physician to evaluate for patellar tendon disruption. It demonstrated a hypoechoic area within the proximal patellar tendon that transversed the entire tendon. Dynamic ultrasound performed while the knee was passively flexed showed a separation of the proximal and distal parts of the patellar tendon with anechoic fluid filling the gap. These findings were consistent with a complete patellar tendon rupture, andOrthopedic Surgery was consulted. Surgery was recommended, and in the operating room, the patella tendon was found to be ruptured near the insertion site on the inferior pole of the patella. After surgical repair, the patient was placed

Ultrasound Competency and Practice: What's in a Number?

Merriam Webster defines the term competency as “the ability to do something well enough to meet a standard.” Upon first impression, this definition seems simple. However, what is meant by “well enough?” Additionally, who sets the “standard” and what is the process for setting the standard? Assessing competency in medical education demonstrates the challenge of applying this essential concept to medical education training and skill maintenance. Whether for initial or recertification processes, these decisions can be difficult and fraught with evidencebased, administrative, and practical issues. The recent decision by the American Board of Internal Medicine (ABIM) to regard its deeply thought-out and debated maintenance of certification process as flawed illustrates the challenge of competency assessment in the medical field. In this case, ABIM elected to suspend implementation of the plan, demonstrating the relevant challenges faced by an established discipline within the medical field. Three articles in this month’s issue of Academic Emergency Medicine address competency assessment in one area of medical education: the teaching and use of point-of-care ultrasound (US) by emergency physicians (EPs). Since the first American College of Emergency Physicians (ACEP) guidelines were published in 2001, the field of emergency medicine (EM) has invested tremendous effort and resources into the teaching of point-of-care US to EPs. These landmark ACEP guidelines have been extremely useful in furthering point of care US use. The guidelines relied on clinical and educational research to support the wise structural concepts for this increasingly essential clinical skill. The guidelines have used the literature to support educational and administrative pathways that define specialty specific guidelines. The article by Hall et al. attempts to provide a mnemonic for the use of limited, focused echocardiography by EPs. The authors first state that EP-performed cardiac US is a unique skill set that is improperly defined even by existing attempts to characterize focused cardiac US. They use their extensive collective experience to present a streamlined approach to teaching focused emergency cardiac US with an easy-to-remember mnemonic, “The Five Es.” This mnemonic helps to support a pathophysiologic basis to emergent cardiac US with characterizations of chamber size and function. This well-written article provides structural aids with a good review of the performance and interpretation of the perceived complexity of cardiac US. The article by Chiem et al. attempts to address the “well enough” aspect for US assessment. In this study, the authors demonstrate that novice practitioners can achieve similar results to experts when dealing with one US scan type. The use of B-lines on thoracic US has been shown to be useful in diagnosing patients with acute decompensated heart failure. Initial studies illustrating this technique were performed by practitioners judged to be expert in emergency US. Chiem et al. sought to expand this concept to a wider US user group, specifically their resident trainees. Their methods use a 30-minute lecture that teaches both image acquisition and technique. The target resident users were individuals who had already completed a 2-week dedicated US rotation. Although 30 minutes is impressively brief to learn a new skill, the majority of EM residents have completed a dedicated emergency US rotation, thus providing a foundation that would seem representative for graduating residents. The Chiem et al. article also demonstrates a limitation of assessing physician competency. Although the novice resident practitioners were trained “well enough” to meet the “standard” of the expert practitioners, neither group achieved admirable diagnostic accuracy for diagnosing acute decompensated heart failure. Additionally, the investigators did not demonstrate changes in patient clinical outcomes through the use of this technology. The article by Blehar et al. attempts to address the means by which we measure competency in US. The authors break down US education into image acquisition and image interpretation. A third component, using those two to guide clinical care, is not included in their review. They point out that many organizations use the number of US examinations performed as a surrogate for experience and, thus, for competency. Their findings demonstrate support for existing national guidelines, finding a plateau effect for skill acquisition. They note these plateaus for both image acquisition and The authors have no relevant financial information or potential conflicts of interest to disclose. Related articles appear on pages 536, 564, 574.

Xanthogranulomatous Pyelonephritis: A Complicated Febrile Urinary Tract Infection Detected by Point-of-Care Ultrasound in the Emergency Department

BACKGROUND Febrile urinary tract infections (UTIs) include a spectrum of pathologies from uncomplicated pyelonephritis to urosepsis, including xanthogranulomatous pyelonephritis (XGP). Most febrile UTIs are treated with antibiotics alone, but studies indicate nearly 12% of cases of presumed simple pyelonephritis require emergent urologic intervention. How to identify these individuals, while limiting unnecessary advanced imaging and delays in diagnosis, challenges all emergency providers. We review the diagnosis and management of XGP, as well as the evidence regarding the role of renal ultrasound in the identification of complicated presentations of febrile UTIs. CASE REPORT We present a case of XGP, a complicated febrile UTI requiring immediate urologic intervention, diagnosed by point-of-care ultrasound. A 40-year-old female presented in severe sepsis and complaining of flank pain. Prompt bedside ultrasound demonstrated hydronephrosis, expediting definitive urologic treatment via percutaneous nephrostomy tube placement. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: With a mortality rate exceeding 40%, obstructed pyonephrosis requires prompt decompression. Given its exceptional sensitivity for identifying hydronephrosis and ability to detect abscesses and emphysematous changes, we advocate a point-of-care ultrasound-first approach to screen for cases of complicated febrile UTIs in order to expedite treatment and limit radiation in uncomplicated presentations.

Adult Male with Traumatic Eye Pain and Swelling

Case Presentation A 28-year-old male, presented to the emergency department following assault with a fist to the left eye. The patient complained of pain and blurry vision but denied diplopia. Physical examination was significant for left-sided periorbital ecchymosis with a subconjunctival hemorrhage. Both pupils were equal and reactive to light. Visual acuity was 20/30 in the right eye and 20/20 in the left. Eye and intraocular pressures measured 13 and 17 respectively. No proptosis was observed. Point-of-care ocular ultrasound was performed followed by computed tomography (CT) maxillofacial without contrast (Images 1 and 2 respectively).

Ultrasonographic Characteristics of Baker's Cysts: The Sonographic Foucher's Sign

Popliteal cysts, also commonly known as Baker’s cysts, were originally described by Baker in a published case series of synovial cysts of the knee in 1877. However, descriptions of cystic swellings of the popliteal fossa, as well as posterior herniations of the knee joint itself, had both been described in the medical literature since the middle of the 19 century (1). The most common cystic, bursal enlargement of the posterior knee joint is that of the gastrocnemius-semimembranosus bursa, an entity that lies in the medial aspect of the popliteal fossa, just distal to the center of the posterior knee. This is what is commonly referred to as a Baker’s cyst (2). The emergency physician may encounter this physical finding when examining the lower extremity in cases involving pain or swelling of the knee or calf (Table 1). The increasing presence and utilization of ultrasound in the Emergency Department (ED) has led to more frequent and reliable bedside diagnoses of popliteal cysts (3). We describe for the first time the sonographic Foucher’s sign as a characteristic finding of Baker’s cysts on ultrasound of the popliteal fossa; recognition of this entity is