Skin to Intramuscular Compartment Thigh Measurement by Ultrasound in Pediatric Population.

INTRODUCTION: Pediatric obesity threatens the efficacy of medications given intramuscularly. In anaphylactic patients, epinephrine auto-injector needle lengths are potentially too short to reach the muscle compartment in patients with elevated body habitus. The objective of the study was to determine needle-length requirements for intramuscular injections in pediatric patients. METHODS: We used ultrasound to measure the distance from skin to muscle compartment of the thigh in 200 pediatric patients of various weight and body mass index who presented to the emergency department. RESULTS: Patients with higher body mass index had an increased distance to muscle and bone. If current recommendations were followed, 5% of patients within the EpiPen adult weight category and 11% of patients within the Centers for Disease Control and Prevention weight category would have potentially used a needle inadequate in length for intramuscular injections. CONCLUSION: With the increase in childhood obesity, needle lengths may be too short to effectively deliver medications to the intramuscular compartment. Needle length should be evaluated to accommodate pediatric patients with increased skin to muscle distance.

Emergency Medicine Resident Assessment of the Emergency Ultrasound Milestones and Current Training Recommendations.

OBJECTIVES: Emergency ultrasound (EUS) has been recognized as integral to the training and practice of emergency medicine (EM). The Council of Emergency Medicine Residency-Academy of Emergency Ultrasound (CORD-AEUS) consensus document provides guidelines for resident assessment and progression. The Accredited Council for Graduate Medical Education (ACGME) has adopted the EM Milestones for assessment of residents' progress during their residency training, which includes demonstration of procedural competency in bedside ultrasound. The objective of this study was to assess EM residents' use of ultrasound and perceptions of the proposed ultrasound milestones and guidelines for assessment. METHODS: This study is a prospective stratified cluster sample survey of all U.S. EM residency programs. Programs were stratified based on their geographic location (Northeast, South, Midwest, West), presence/absence of ultrasound fellowship program, and size of residency with programs sampled randomly from each stratum. The survey was reviewed by experts in the field and pilot tested on EM residents. Summary statistics and 95% confidence intervals account for the survey design, with sampling weights equal to the inverse of the probability of selection, and represent national estimates of all EM residents. RESULTS: There were 539 participants from 18 residency programs with an overall survey response rate of 85.1%. EM residents considered several applications to be core applications that were not considered core applications by CORD-AEUS (quantitative bladder volume, diagnosis of joint effusion, interstitial lung fluid, peritonsillar abscess, fetal presentation, and gestational age estimation). Of several core and advanced applications, the Focused Assessment with Sonography in Trauma examination, vascular access, diagnosis of pericardial effusion, and cardiac standstill were considered the most likely to be used in future clinical practice. Residents responded that procedural guidance would be more crucial to their future clinical practice than resuscitative or diagnostic ultrasound. They felt that an average of 325 (301-350) ultrasound examinations would be required to be proficient, but felt that number of examinations poorly represented their competency. They reported high levels of concern about medicolegal liability while using EUS. Eighty-nine percent of residents agreed that EUS is necessary for the practice of EM. CONCLUSIONS: EM resident physicians' opinion of what basic and advanced skills they are likely to utilize in their future clinical practice differs from what has been set forth by various groups of experts. Their opinion of how many ultrasound examinations should be required for competency is higher than what is currently expected during training.

Comparison of procedural sedation for the reduction of dislocated total hip arthroplasty.

INTRODUCTION: Various types of sedation can be used for the reduction of a dislocated total hip arthroplasty. Traditionally, an opiate/benzodiazepine combination has been employed. The use of other pharmacologic agents, such as etomidate and propofol, have more recently gained popularity. Currently no studies directly comparing these sedation agents have been carried out. The purpose of this study is to compare differences in reduction and sedation outcomes, including recovery times, of these 3 sedation agents. METHODS: We performed a retrospective chart review examining 198 patients who presented with dislocated total hip arthroplasty at 2 academic affiliated medical centers. The patients were grouped according to the type of sedation agent. We calculated percentages of reduction and sedation complications along with recovery times. Reduction complications included fracture, skin or neurovascular injury, and failure of reduction requiring general anesthesia. Sedation complications included use of bag-valve mask and artificial airway, intubation, prolonged recovery, use of a reversal agent, and inability to achieve sedation. We then compared the data for each sedation agent. RESULTS: We found reduction complications rates of 8.7% in the propofol, 24.7% in the etomidate, and 28.9% in the opiate/benzodiazepine groups. The propofol group was significantly different from the other 2agents (p ≤ 0.01). Sedation complications were found 7.3% of the time in the propofol , 11.7% in the etomidate , and 21.3% in the opiate/benzodiazepine group, (p=0.02 propofol vs. others) . Average recovery times were 25.2 minutes for propofol, 30.8 minutes for etomidate, and 44.4 minutes for opiate/benzodiazepine (p = 0.05 for propofol vs. other agents). CONCLUSION: For reduction of dislocated total hip arthroplasty under procedural sedation, propofol appears to have fewer complications and a trend toward more rapid recovery than both etomidate and opiate/benzodiazepine. These data support the use of propofol as first line agent for procedural sedation of dislocated total hip arthroplasty, with fewer complications and a shorter recovery period.

Typed versus voice recognition for data entry in electronic health records: emergency physician time use and interruptions.

INTRODUCTION: Use of electronic health record (EHR) systems can place a considerable data entry burden upon the emergency department (ED) physician. Voice recognition data entry has been proposed as one mechanism to mitigate some of this burden; however, no reports are available specifically comparing emergency physician (EP) time use or number of interruptions between typed and voice recognition data entry-based EHRs. We designed this study to compare physician time use and interruptions between an EHR system using typed data entry versus an EHR with voice recognition. METHODS: We collected prospective observational data at 2 academic teaching hospital EDs, one using an EHR with typed data entry and the other with voice recognition capabilities. Independent raters observed EP activities during regular shifts. Tasks each physician performed were noted and logged in 30 second intervals. We compared time allocated to charting, direct patient care, and change in tasks leading to interruptions between sites. RESULTS: We logged 4,140 minutes of observation for this study. We detected no statistically significant differences in the time spent by EPs charting (29.4% typed; 27.5% voice) or the time allocated to direct patient care (30.7%; 30.8%). Significantly more interruptions per hour were seen with typed data entry versus voice recognition data entry (5.33 vs. 3.47; p=0.0165). CONCLUSION: The use of a voice recognition data entry system versus typed data entry did not appear to alter the amount of time physicians spend charting or performing direct patient care in an ED setting. However, we did observe a lower number of workflow interruptions with the voice recognition data entry EHR. Additional research is needed to further evaluate the data entry burden in the ED and examine alternative mechanisms for chart entry as EHR systems continue to evolve.

Postoperative analgesic effects of a placebo controlled trial of intraarticular morphine sulfate and intraarticular pethidine HCI for patients undergoing anterior cruciate ligament reconstruction using bone patellar graft

Background: Postoperative pain is considered the main cause of morbidity after anterior cruciate ligament (ACL) repair Objectives: This study was designed to determine whether a placebo controlled trial of intraarticular (IA) Morphine sulfate and IA Pethidine HCI would provide postoperative pain relief for patients undergoing ACL reconstruction utilizing bone patellar graft Methods: A randomized, double blind, placebo controlled trial of 60 patients, 18-65 years, ASA I and II scheduled for ACL reconstruction were included in the study. Group I received IA Morphine sulfate 3mg (0.015 percent) solution, Group II received IA Pethidine HCI 30mg (0.15 percent) solution and Group III received IA saline 20 cc solution alone. VAS scores were obtained during the 1st, 2nd, 6th and 24th hour after surgery. Analgesic duration, rescue medication consumption, and occurrence of complications were determined Results: VAS score comparisons were analyzed using Kruskal-Wallis Test and Wilcoxons Matched Pairs Signed Rank test which revealed significant differences among all groups. Analgesic duration and 24-hr rescue medication consumption were also analyzed and results also demonstrated significant differences. However, occurrence of complications was not observed in all clinical trial groups Conclusion: We conclude that IA morphine and IA Pethidine HCI have analgesic effects. IA Pethidine HCI has less analgesic effects as compared to IA morphine sulfate. IA morphine sulfate has the longest analgesic duration and lastly, that IA Morphine sulfate and IA Pethidine HCI offer a well tolerated postoperative pain control with no evidence of complications. (Author)