Timothy W. Sweeney

Bedside sonography by emergency physicians for the rapid identification of landmarks relevant to cricothyrotomy

INTRODUCTION Cricothyrotomy is a difficult, infrequently performed lifesaving procedure. OBJECTIVES The objectives of the study were to develop a standardized ultrasound technique to sonographically identify the cricothyroid membrane (CM) and to evaluate the ability of emergencyphysicians (EPs) to apply the technique in a cohort of Emergency Department (ED) patients. METHODS Four cadaveric models were used to develop a technique to accurately identify the CM. Two EPs then sonographically imaged 50 living subjects. Time to visualization of the CM and relevant landmarks, as well as perception of landmark palpation difficulty, were recorded. RESULTS Fifty subjects were enrolled, and relevant structures were identified in all participants. The mean time to visualization of the CM was 24.32 +/- 20.18 seconds (95% confidence interval, 18.59-30.05 seconds). Although a significant relationship between palpation difficulty and body mass index was noted, body mass index did not impact physician ability to identify the CM. CONCLUSIONS Emergency physicians were able to develop and implement a reliable sonographic technique for the identification of anatomy relevant to performing an emergent cricothyrotomy.

Orthopedic pitfalls in the ED: neurovascular injury associated with posterior elbow dislocations

Posterior elbow dislocations are the most common type of elbow dislocation and are usually caused by a fall on an outstretched hand. Although the incidence of elbow dislocation complications is rare, the emergency physician is responsible for evaluation and identification of concomitant neurovascular injuries. Failure to identify neurovascular compromise after elbow dislocation or reduction can potentially lead to severe morbidity with limb ischemia, neurologic changes, compartment syndrome, and potential loss of limb. Cyanosis, pallor, pulselessness, and marked pain should suggest vascular injury or compartment syndrome, both requiring immediate intervention. Patients in whom it is not clear if there is vascular injury should undergo further imaging with angiography, considered the gold standard for evaluation of arterial damage. It is important for the emergency physician to maintain a high level of suspicion and evaluate for neurovascular compromise on every patient with elbow dislocation despite the low overall incidence of severe injury.

Ultrasound identification of landmarks preceding lumbar puncture: a pilot study

Aim: To assess the utility of bedside ultrasound performed by an emergency physician in adults undergoing diagnostic lumbar puncture. Method: Ultrasound was used as the primary means of determining the site of skin puncture, angle of needle advancement and depth needed to access the subarachnoid space. Results: Cerebrospinal fluid was obtained from 36 of 39 patients (92.3%) in the first interspinous space attempted. Conclusions: The ultrasonographically measured depth of the dura mater correlates strongly with the final needle depth.

Visual diagnosis in emergency medicineUrethral Calculus

A 27-year-old man with one previous episode of ureterolithiasis presented to our Emergency Department with 5 days of colicky right flank pain radiating toward his genitalia without associated fever. A computed tomography (CT) scan was performed, which showed right-sided hydronephrosis, but no stone (Figure 1). On return from the CT scan, the patient reported that his pain was now “in his penis” and increasing in intensity. He was unable to void, and bedside ultrasound showed 800 cc of urine. On repeat examination, the patient had a tender mass in his mid corpus cavernosa. Bedside ultrasound of his penis is shown below (Figure 2).