Point-of-Care Ultrasound for Central Venous Assessment in the Emergency Department: A Prospective Study Comparing the Femoral and Internal Jugular Veins.

OBJECTIVES: The objective of this study was to estimate the width, height, and depth of the femoral vein (FV) and internal jugular vein (IJV), both sites of potential central line placement in children, using point-of-care ultrasound. METHODS: This was a prospective observational study. Point-of-care ultrasound was used to measure the width, height, and depth of the right FV and IJV in 100 children. The primary outcome was a comparison of the widths of the FV and the IJV in the same child. Our primary hypothesis was that the IJV would be wider than the FV. Secondary outcome measures included comparison of the heights and depths the FV and IJV and description of vessel overlap frequency between the 2 sites. RESULTS: A total of 106 children were enrolled, with 6 subjects excluded, and equally divided into 5 age groups (0-30 days, 1-24 months, 2-5 years, 6-11 years, and 12-17 years). The FV/IJV width ratios (95% confidence interval) by age were 0.58 (0.49-0.68), 0.53 (0.43-0.66), 0.57 (0.49-0.67), 0.68 (0.55-0.85), and 0.73 (0.62-0.85), all P < 0.002. The FV/IJV height ratios were <1 in all age groups, with P < 0.003 in the 4 youngest age groups. The FV/IJV depth ratios were >1 in 6 to 11 years (P = 0.018) and 12 to 17 years (P < 0.001). CONCLUSIONS: The IJV was significantly wider and taller than the FV in the same child in all age groups. The FV was significantly deeper than the IJV in children 6 years and older. This supports the use of the IJV as a potential site when placing ultrasound-guided central lines in children.

The Effect of Catheter Length Placed Into the Vein on Peripheral Ultrasound-Guided Catheter Survival Time: A Prospective Observational Study.

INTRODUCTION: Establishing and maintaining peripheral intravenous access in patients with no visible or palpable veins can be arduous. Intravenous catheters placed with ultrasound do not survive as long as traditionally placed catheters. This study was performed to determine the relationship between the catheter length placed into the lumen of the vein using ultrasound and catheter survival. METHODS: This was a nonrandomized prospective observational study of admitted patients with difficult intravenous placement in 2017. Subjects had ultrasound-guided peripheral intravenous placement in the emergency department or intensive care unit. The main outcome was the time of catheter survival. Data were analyzed using descriptive statistics and Cox regression. RESULTS: A total of 98 patients with an average age of 63 years were enrolled. The total number of cases examined was 97 (N = 97), of which 29 intravenous catheters were removed for catheter-related problems (events). The mean (SD) survival time for catheters placed using ultrasound was 3,445 minutes (2,414) or 2.39 days. Peripheral catheter survival was not significantly related to the in-vein length of the catheter (X2 = 0.03, P = 0.86) nor was it significantly related to any of the covariates. DISCUSSION: The survival time of ultrasound-guided intravenous access doubled in the present study from 1674 minutes in a previous 2013 study. The results may have been due to clinician expertise and experience with the peripheral ultrasound-guided method and the use of updated equipment.

Intubation of the Right Atrium During an Attempted Modified Surgical Airway in a Pig.

In modern medicine, the surgical cricothyrotomy is an airway procedure of last resort. In austere environments, however, its simplicity may make it a more feasible option than carrying a full complement of laryngoscopes. To create a Transportation Security Agency-compliant compact first-response bag, we attempted to establish a surgical cricothyrotomy in a pig, using trauma shears, basic medical scissors, a pocket bougie, and an endotracheal tube. Bougies can provide tactile feedback via the "tracheal ring sign" and "stop sign" to indicate positive tracheal placement during orotracheal intubation. We report on a previously unknown serious potential complication that questions the use of scissors to establish a surgical airway and the reliability of tactile bougie signs when translated into certain surgical airways.

Can novice sonographers accurately locate an endotracheal tube with a saline-filled cuff in a cadaver model? A pilot study.

BACKGROUND: No single confirmatory device can accurately distinguish between endotracheal, endobronchial, and esophageal intubation. Bedside ultrasound (US) shows promising potential for endotracheal tube (ETT) verification. Image acquisition depends on the approach used and the experience of the sonographer. Air within the trachea remains a challenge for interpretation of US images. Insufflation of the ETT cuff with saline helps overcome this difficulty and allows easy visualization of the cuff. This novel approach has not been studied in ETT verification among novice sonographers. OBJECTIVES: The objective was to evaluate the accuracy of novice sonographers in identifying proper ETT location and depth using US visualization of a saline-filled cuff. METHODS: Eight pediatric emergency medicine (PEM) fellows without prior training in airway bedside US participated in this prospective pilot study. Baseline US knowledge was assessed using a pretraining questionnaire. Fellows received a 20-minute didactic training session focused on airway US, followed by a 30-minute practice session. Using a linear US probe placed at the suprasternal notch, fellows identified the saline-filled cuff of an ETT in both the trachea and the esophagus. Following training, the ETT was placed in either the esophagus or the trachea of the cadaver model by the principal investigator. ETT depth (adequacy) was confirmed by chest radiograph. Each PEM fellow, blinded to the placement of the ETT, used bedside US to determine ETT location and depth. If placement was determined to be tracheal, the fellow was asked to comment on adequacy of tube placement. Adequate placement was defined as complete visualization of the ETT cuff within the trachea at the suprasternal notch. This was used as a surrogate for correct depth. This study sequence was repeated five times for each trainee, following varying placement of the ETT in the trachea or esophagus. RESULTS: The PEM fellows displayed limited baseline knowledge of US prior to receiving the training module (average score of 50% on pretest questionnaire). None had any prior airway bedside US experience. Following training, PEM fellows correctly identified ETT location in 39 of 40 scans, with a sensitivity of 96% (23 of 24) for identifying tracheal location. The tube depth was correctly identified in 22 of 23 scans identified as tracheal intubations. CONCLUSIONS: PEM fellows, lacking formal airway bedside US training, were able to identify the location and depth of a saline-filled ETT above or at the suprasternal notch in an adult cadaver model following a 50-minute teaching module. Filling the ETT cuff with saline allowed novice sonographers to accurately visualize the ETT within the trachea.