Sonogram of safety: Ultrasound outperforms the fifth intercostal space landmark for tube thoracostomy site selection.

PURPOSE: Identification of tube thoracostomy insertion location is currently performed using a blind, landmark based approach at either the fifth intercostal space (ICS) or inframammary crease in the midaxillary line. A significant percentage of thoracostomies at this site result in complications. This pilot study aimed to assess whether bedside ultrasound could aid in identifying safer tube thoracostomy insertion sites in emergency department patients. METHODS: Fifty emergency department patients were enrolled in this study. Right and left hemidiaphragms were evaluated with ultrasound at the fifth ICS. Observations were made on if the diaphragm was below, above, or crossed the fifth ICS during an entire respiratory cycle. RESULTS: Eighty-one (95% confidence interval 72-82) of the diaphragms were below, 13 (95% confidence interval 8-21) of the diaphragms were at, and 6 (95% confidence interval 3-12) of the diaphragms were above the location marked using traditional landmark techniques. On the right and left hemidiaphragms, 20% (95% confidence interval 19.9%-20.1%) and 18% (95% confidence interval 17.9%-18.1%) of diaphragms were above or crossing the fifth ICS, respectively CONCLUSIONS: Ultrasound identified a significant number of potential chest tube insertion sites at the fifth ICS that would result in subdiaphragmatic insertion or diaphragmatic injury. Based on this data ultrasound can be used to identify safer insertion sites and reduce thoracostomy complications.

A WINning Technique: The Wire-in-Needle Feasibility Study.

BACKGROUND: Dynamic ultrasound guidance reduces complications associated with central venous catheter placement. However, successful central venous cannulation often remains challenging, particularly in hypotensive patients. The new wire-in-needle (WIN) technique can further increase periprocedural safety. Here, a needle is "preloaded" with a guidewire that is then advanced toward the tip of needle. The vein is then cannulated using long-axis ultrasound guidance. OBJECTIVE: To evaluate the feasibility and safety profile of the WIN technique. METHODS: Medical students, and resident and attending physicians participated in this study. After a brief lecture and practice session on the WIN technique, they underwent a skills assessment evaluating different aspects of both techniques. Participants then completed a survey assessing their prior experience regarding procedural ultrasound, and their assessment of the WIN technique. RESULTS: Sixty clinicians participated. The assessment of both techniques revealed no significant differences in the number of needle redirections, cannulation attempts, number of arterial punctures, or overall dexterity with the procedure. The WIN technique was faster (45.9 vs. 61.5 s, p = 0.0005) than the traditional technique. More participants confirmed the accurate position of the guidewire in the vein (75% vs. 95%, p = 0.002). More than 90% of study participants met the predefined safety aspects of the WIN technique. Almost all participants reported that they plan on using the WIN technique in their clinical practice. CONCLUSION: This study demonstrates that the WIN technique can be learned quickly and easily by clinicians with various levels of training. In this study, using manikins, it was as successful and safe as the traditional short-axis approach.

Who watches the WATCHMAN? A rare case of lower extremity paralysis.

We present a case study involving an elderly patient who experienced dislodgement of a recently implanted WATCHMAN device. Initially, the patient exhibited multiple musculoskeletal symptoms, which raised concerns about alternative causes such as cauda equina syndrome or spinal epidural hematoma. Despite vascular surgery removing the device, the patient's condition deteriorated due to ischemia leading to multisystem organ failure. This case highlights the critical need for emergency physicians to promptly diagnose acute aortic obstruction caused by embolization, given the increasing use of the WATCHMAN device in the aging population to reduce the reliance on anticoagulation. The potential for significant ischemic consequences necessitates immediate intervention to mitigate complications.

Wernicke Korsakoff syndrome in a teenage female as a complication of COVID-19.

Wernicke encephalitis (WE) is usually associated with alcohol use disorder and caused by a deficiency in thiamine. Classic findings include confusion, ataxia, and ophthalmoplegia. This case is a unique presentation of WE in a 14-year-old female related to prior coronavirus disease infection. She had persistent dysgeusia and developed thiamine deficiency. She presented with confusion, ataxia, and changes in speech. She had a prolonged hospitalization but was discharged to an inpatient rehab facility with persistent symptoms. It is prudent to include thiamine deficiency in the differential for patients with any symptoms of WE and a history of nutritional deficiency.

An Evaluation of Non-Uniform Grade Distribution with the Emergency Medicine Off-Service Standardized Letters of Evaluation.

Introduction: Standardized Letters of Evaluation (SLOEs) are designed to objectively compare medical students to their peers for completed emergency medicine (EM) rotations to be used in the EM residency match. In an attempt to adapt quickly to the lack of availability of in-person EM rotations due to COVID restrictions, "off-service" SLOEs (OSLOEs) were allowed in place of traditional SLOEs. The purpose of this study was to assess the utility of OSLOEs for candidate selection during the 2020-21 application cycle at a single EM residency. Methods: A retrospective cohort review of all OSLOEs submitted during the 2020-21 academic year to an EM residency program was performed. A total of 270 OSLOES were eligible for review. Summary statistics were calculated for the study variables recorded, including global rank, grade, categorical details, and rank. Results: Of the 270 OSLOEs reviewed, 61.9% ranked candidates in the top 10% of their class, with 95% being ranked in the top two categories. Over 90% of students were graded as honors or high pass and over 75% of students were ranked in the top 1/3 for each specific OSLOE category. Conclusion: Our findings reveal questionable utility of the objective measures in the OSLOE as there are signs it may suffer from non-uniform grade distribution, leading to low utility for candidate selection. Our data shows marked over-ranking within the highest 2 categories. EM program directors and faculty should use caution as the OSLOE may not carry the same weight as a traditional SLOE when objectively evaluating prospective students for a match into EM.

Military trainees can accurately measure optic nerve sheath diameter after a brief training session.

BACKGROUND: Identification of elevated intracranial pressure is important following traumatic brain injury. We assessed the feasibility of educating military trainees on accurately obtaining optic nerve sheath diameter measurements using a brief didactic and hands-on training session. Optic nerve sheath diameter is a noninvasive surrogate marker for elevated intracranial pressure, and may be of value in remote military operations, where rapid triage decisions must be made without access to advanced medical equipment. METHODS: Military trainees with minimal ultrasound experience were given a 5-min didactic presentation on optic nerve sheath diameter ultrasound. Trainees practiced optic nerve sheath diameter measurements guided by emergency physician ultrasound experts. Trainees then measured the optic nerve sheath diameter on normal volunteers. Following this, a trained physician measured the optic nerve sheath diameter on the same volunteer as a criterion standard. An average of three measurements was taken. RESULTS: Twenty-three military trainees were enrolled. A mixed design ANOVA was used to compare measurements by trainees to those of physicians, with a mean difference of - 0.6 mm (P = 0.76). A Bland-Altman analysis showed that the degree of bias in optic nerve sheath diameter measures provided by trainees was very small: d = - 0.004 for the right eye and d = - 0.007 for the left eye. CONCLUSION: This study demonstrates that optic nerve sheath diameter measurement can be accurately performed by novice ultrasonographers after a brief training session. If validated, point-of-care optic nerve sheath diameter measurement could impact the triage of injured patients in remote areas.