A novel inline PEEP valve design for differential multi-ventilation.

BACKGROUND: Ventilator sharing is one option to emergently increase ventilator capacity during a crisis but has been criticized for its inability to adjust for individual patient needs. Newer ventilator sharing designs use valves and restrictors to control pressures for each patient. A key component of these designs is an inline Positive End Expiratory Pressure (PEEP) Valve but these are not readily available. Creating an inline PEEP valve by converting a standard bag-valve-mask PEEP valve is possible with the addition of a 3D printed collar. METHODS: This was a feasibility study assessing the performance and safety of a method for converting a standard PEEP valve into an inline PEEP valve. A collar was designed and printed that covers the exhaust ports of the valve and returns exhaled gases to the ventilator. RESULTS: The collar piece was simple to print and easily assembled with the standard PEEP valve. In bench testing it successfully created differential pressures in 2 simulated expiratory limbs without leaking to the atmosphere at pressures greater than 60 cm of H2O. CONCLUSION: Our novel inline PEEP valve design shows promise as an option for building a safer ventilator sharing system.

A Cost-Effective, Rapidly Constructed Simulation Model for Ultrasound-Guided Pericardiocentesis Procedural Training.

BACKGROUND: Emergent ultrasound-guided pericardiocentesis (USGP) is an uncommonly performed procedure by emergency physicians (EPs). USGP simulation models have previously been developed to increase procedural proficiency, but these models are limited for routine implementation secondary to high-cost, lengthy time to construct, and lack of durability. The objective of this study was to develop an USGP simulation model that is cost-effective, easily and rapidly constructed, and has procedure-specific fidelity. DISCUSSION: We have developed a novel tofu simulation model for USGP training. The model cost per unit was $1.81 and the average construction time was 2.5 ± 0.3 min. The model can withstand upward of 100 needle punctures. Our model provides USGP procedure-specific aspiration of a simulated pericardial effusion. CONCLUSIONS: The tofu USGP model provides a cost-effective and rapidly constructible simulation tool that could be readily integrated in EP procedural training.

Bedside Washout of a Septic Shoulder in the Emergency Department: A Case Report.

We present a case of successful bedside irrigation of a septic joint in the emergency department. Complicating factors prevented the patient from undergoing operative management. With a simple 2 catheter technique the authors irrigated the patient's septic shoulder at the bedside. The patient's pain and range of motion improved immediately following the technique. The patient had complete recovery without open drainage. With further investigation, definitive management of septic joints could begin in the emergency department.

An unusual complication of weightlifting: a case report.

Acute exertional compartment syndrome is an uncommon illness that occurs after a period of strenuous exercise. We present a case of acute exertional compartment syndrome of the bilateral supraspinatus muscles after weight lifting. The diagnosis was made in the emergency department and the patient subsequently underwent successful decompressive fasciotomies of both compartments. We highlight the unusual presentation of this case and the approach to make the diagnosis.

Inline Positive End-Expiratory Pressure Valves: The Essential Component of Individualized Split Ventilator Circuits.

BACKGROUND: As resources are overwhelmed with the coronavirus disease 2019 pandemic, multiple approaches to produce individualized split-ventilator designs have emerged. These designs attempt to address the significant limitations and safety concerns of coventilation practices by allowing practitioners to adjust pressure settings for individual patients connected with specialized circuits to a single ventilator. The critical component in virtually all individualized circuit designs is the adjustable inline positive end-expiratory pressure valve. METHODS: We reviewed the literature on the mechanics of inline positive end-expiratory pressure valve function, the implications and considerations for advanced application of inline positive end-expiratory pressure valves in individualized circuits, available methods of adapting commercial positive end-expiratory pressure valves in the resource-restricted setting, and major caveats of the use of inline positive end-expiratory pressure valves. RESULTS AND CONCLUSIONS: The function of adjustable inline positive end-expiratory pressure valves in advanced individualized ventilator circuits has not been described. Adjustable inline positive end-expiratory pressure valves are critical to individualized circuit reliability and patient safety when attempting to extend ventilator capacity in the setting of extreme ventilator shortages. Adjustable inline positive end-expiratory pressure valves provide a means to reduce delivered peak inspiratory pressure to an individual patient circuit, a method to increase positive end-expiratory pressure for an individual patient circuit, and act as an one-way valve to ensure unidirectional gas flow through the divided circuit. Adjustable inline positive end-expiratory pressure valves can be adapted from commercial valves or printed de novo when commercial options are unavailable. Noncommercial sourcing of ventilator components should only be considered in the setting of extreme ventilator shortages under the supervision of a knowledgeable anesthesiologist or intensivist.

Giant Right Coronary Artery Aneurysm: An Association With Primary Varicose Veins?

Coronary artery aneurysms are rare conditions with potentially devastating consequences. We describe the case of an athletic 40-year-old woman who received a diagnosis of giant right coronary artery aneurysm while she was undergoing a work-up for lower extremity varicose veins. She underwent successful surgical treatment without any complications. (Level of Difficulty: Intermediate.).

Ultrasound-Guided Radial Artery Compression to Assess Blood Pressure.

INTRODUCTION: We proposed using compression sonography to observe the coaptation and collapse of the radial artery as a surrogate for automated cuff blood pressures (BP). We hypothesize that the pressure required to achieve coaptation and complete collapse of the artery would correlate to the diastolic and systolic BP, respectively. This pilot study was to assess the feasibility of ultrasound-guided radial artery compression (URAC) for BP measurement and compare patient comfort levels during automated cuff with URAC measurements. METHODS: This was a prospective cohort pilot study with a convenience sampling of 25 adult patients at a single urban emergency department. URAC pressure was measured, followed by cuff manometry on the same arm. A 100mL normal saline bag was connected to the Stryker pressure monitor and placed on the volar wrist. Pressure was applied to the bag with a linear transducer and the radial artery was observed for coaptation of the anterior and posterior walls and complete collapse. Pressures required for coaptation and collapse were recorded from the Stryker display. Patient level of comfort was also documented during the URAC method, with patients reporting either "more," "same" or "less" comfort in comparison to automated cuffs. We analyzed data using intraclass correlation and paired t-tests. Interrater reliability was calculated using intraclass correlation. RESULTS: The mean cuff systolic BP was 138.6 ± 22.1 mmHg compared to 126.9 ± 19.8 mmHg for the URAC systolic BP (p=0.02). For diastolic BP, there was no significant difference between the cuff BP and the URAC BP (83.7 ± 13.0 cuff vs. 86.5 ± 19.8 URAC, p=0.46). The intraclass correlation (ICC) for systolic BP was 0.48 (p=0.04) and 0.57 (p=0.02) for diastolic BP. The agreement between the two observers was 0.88 for identifying coaptation on ultrasound (diastolic pressure) and was 0.92 for identifying collapse (systolic pressure). Eighty percent (20/25) of subjects found the URAC method more comfortable than the cuff measurement, and the remainder found it the same (5/20). CONCLUSION: This pilot study showed statistically significant moderate correlation between automated cuff diastolic BP and URAC measurements for vessel coaptation. Additionally, most patients found the URAC method more comfortable than traditional cuff measurements. Compression ultrasonography shows promise as an alternative method of BP measurement, though future studies are needed.