Intensivist bedside ultrasound (INBU) for volume assessment in the intensive care unit: a pilot study.

BACKGROUND: Estimation of volume status in the high-acuity surgical population can be challenging. The use of intensivist bedside ultrasound (INBU) to rapidly assess volume status in the surgical intensive care unit (SICU) was hypothesized to be feasible and as accurate as invasive measures. METHODS: Clinician sonographers (CSs) were trained to perform basic cardiac ultrasound and sonographic assessment of the inferior vena cava (IVC). A convenience sample of general surgery and trauma patients was enrolled in the SICU. The CS interpreted IVC and cardiac parameters and then categorized the subject as hypovolemic or not hypovolemic. Intensivists caring for the patients were blinded to the INBU findings and made a real-time expert clinical judgment (ECJ) of the patient's volume status (hypovolemic vs. not hypovolemic) using all available traditional data. RESULTS: A total of nine CSs performed 70 studies; three of the CSs performed the majority of the studies (86%). Adequate ultrasound (US) views for cardiac and IVC assessment were obtained in 96% and 89% of studies, respectively. The ECJ was considered to be the standard to which comparisons were made. The concordance rate between ECJ and central venous pressure was 62%. ECJ concordance with sonographic measures were similar (cardiac US = 75%, IVC US = 67%, and IVC collapse index = 65%). All pairwise comparisons against the ECJ/CVP agreement were not significantly different. CONCLUSIONS: INBU is feasible in the SICU and is equivalent to central venous pressure in assessing volume status. Noninvasive methods to assess volume status may decrease the need for invasive procedures.

Directed bedside transthoracic echocardiography: preferred cardiac window for left ventricular ejection fraction estimation in critically ill patients.

BACKGROUND: Bedside transthoracic echocardiography (TTE) performed by emergency physicians (EPs) is valuable in the rapid assessment and treatment of critically ill patients. We sought to determine the preferred cardiac window for left ventricular ejection fraction (LVEF) estimation by EP sonographers in a critically ill patient population. METHODS: Prospective investigator-blinded study of focused bedside TTE in a convenience sample of surgical intensive care patients. Investigators were faculty, fellows, or residents from an academic emergency medicine department. Five standard cardiac views were performed: parasternal long axis (PSLA), parasternal short axis (PSSA), subxiphoid 4-chamber, subxiphoid short axis, and apical 4-chamber (AFC). LVEF was determined using at least 1 cardiac view. Investigators rated their preference for each cardiac view on a 5-point Likert scale. RESULTS: A total of 70 studies were performed on 70 patients during a 6-month period. Users rated the PSLA as the most useful view for estimation of LVEF (mean 4.23; 95% confidence interval, 3.95-4.51). Pairwise comparisons of cardiac ultrasound views revealed PSLA was preferred over all other views (P < .05) except PSSA (P = .23). Complete 5 view examinations were not achieved in all patients (PSLA in 98%, PSSA in 96%, apical 4-chamber in 74%, subxiphoid 4-chamber in 35%, and subxiphoid short axis in 18%). Interobserver correlation of LVEF estimation was good (r = 0.86, r2 = 0.74, P < .0001). CONCLUSION: Parasternal long axis and PSSA are the preferred echocardiographic windows for EP estimation of LVEF using focused bedside TTE in critical care patients. This may be an important consideration in patients who often have physical barriers to optimal echocardiographic evaluation, are relatively immobile, and have unstable conditions requiring rapid assessment and intervention.

Laryngeal view during laryngoscopy: a randomized trial comparing cricoid pressure, backward-upward-rightward pressure, and bimanual laryngoscopy.

STUDY OBJECTIVE: External cricoid and thyroid cartilage manipulations are commonly taught to facilitate laryngeal view during intubation. We compare the laryngeal views during laryngoscopy with 4 manipulations (no manipulation, cricoid pressure, backward-upward-rightward pressure [BURP], and bimanual laryngoscopy) to determine the method that optimizes laryngeal view. METHODS: This was a randomized intervention study involving emergency physicians participating in airway training courses from December 2003 to November 2004. Direct laryngoscopies were performed with curved blades on fresh, non-fixed cadavers by using each of the 4 methods. The percentage of glottic opening (POGO), a validated scoring scale, was recorded for each laryngoscopy. Scores for bimanual laryngoscopy were recorded before the assistant applied external pressure. RESULTS: A total of 1,530 sets of comparative laryngoscopies were performed by 104 participants. One thousand one hundred eighteen of 1,530 sets (73%) had POGO scores less than 100 with no manipulation. Compared to no manipulation, mean POGO scores with bimanual laryngoscopy improved by 25 (95% confidence interval [CI] 23 to 27); mean POGO score improvement with cricoid pressure and BURP were 5 (95% CI 3 to 8) and 4 (95% CI 1 to 7), respectively. POGO scores with bimanual laryngoscopy were higher compared to cricoid pressure (mean difference 20, 95% CI 17 to 22) and BURP (mean difference 21, 95% CI 19 to 24). Among laryngoscopies with no manipulation in which the POGO score greater than 0 (n=1,434), laryngeal view worsened in 60 cases (4%, 95% CI 3% to 5%) with bimanual laryngoscopy, in 409 cases (29%, 95% CI 26% to 31%) with cricoid pressure, and in 504 cases (35%, 95% CI 33% to 38%) with BURP. CONCLUSION: Using a cadaver model, we found pressing on the neck during curved blade laryngoscopy greatly affects laryngeal view. Overall, bimanual laryngoscopy improved the view compared to cricoid pressure, BURP, and no manipulation. Cricoid pressure and BURP frequently worsen laryngoscopy. These data suggest bimanual laryngoscopy should be considered when teaching emergency airway management.

Preevent vaccination against smallpox: a survey of pediatric emergency health care providers.

BACKGROUND: In January 2003, smallpox vaccinations were offered to health care workers to create hospital-based teams prepared to care for patients with smallpox as part of national bioterrorism preparedness activities. METHODS: An anonymous survey of pediatric emergency health care workers was conducted in November and December 2002. Two mailings were sent to physicians, nurses and ancillary staff at five academic pediatric emergency departments in major US cities. We assessed the willingness to receive preevent smallpox vaccine. In addition we measured the prevalence of vaccine contraindications, perceived likelihoods of a local smallpox outbreak or a vaccine-related adverse event and reasons for or against wanting to receive the vaccine. RESULTS: Overall 72% of respondents were willing to receive the smallpox vaccine. Individuals who were willing to receive the smallpox vaccine, compared with those not willing, believed a local outbreak was more likely to occur (odds ratio, 1.29; 95% confidence interval, 1.16 to 1.44). One-fifth of respondents reported a contraindication to smallpox vaccine; however, more than half indicated they would still be willing to receive vaccine. Individuals who perceived themselves at high risk for vaccine-related adverse events were less willing to receive the preevent smallpox vaccine. Self-protection was the most common reason cited for wanting to receive the vaccine. CONCLUSIONS: A majority of pediatric healthcare workers were willing to receive preevent smallpox vaccine before the onset of Phase I of the CDC Smallpox Vaccination Program. A greater understanding of the knowledge, attitudes and beliefs of pediatric health care workers toward preevent smallpox vaccination will assist in the development of future bioterrorism preparedness programs.

Limitations of difficult airway prediction in patients intubated in the emergency department.

STUDY OBJECTIVE: Physiognomic assessment of difficult laryngoscopy before rapid sequence intubation has been advocated for all emergency department (ED) intubations. The study objectives were to evaluate whether Mallampati scores, thyromental distance, and neck mobility could have been assessed in non-cardiac arrest ED-intubated patients and determine whether such tests would have been feasible in our rapid sequence intubation-associated laryngoscopy failures. METHODS: We retrospectively reviewed 37 months of ED intubations using prospectively collected data from electronic medical records, critical care flow sheets, and a trauma registry. All non-cardiac arrest ED-intubated patients were included for analysis. Mallampati scoring was deemed unobtainable if patients could not follow simple commands. Neck mobility and thyromental measurement were deemed unobtainable with cervical spine precautions. RESULTS: Eight hundred fifty intubations met the inclusion criteria, and 838 patients underwent rapid sequence intubation. Laryngoscopy failed in 3 patients who underwent rapid sequence intubation. Eight patients had awake nasal intubation, and 4 oral intubations were done without rapid sequence intubation. Four hundred fifty-two (53%) patients could not follow simple commands, and cervical spine immobilization was present in 370 (44%) patients. Only 32% of patients could follow simple commands and were not cervical spine immobilized. Among the 3 rapid sequence intubation laryngoscopy failures, no patients were following commands. CONCLUSION: Mallampati scoring, neck mobility testing, and measurement of thyromental distance could have been done in only one third of our non-cardiac arrest ED intubations and in none of the rapid sequence intubation failures. The inability to widely obtain these assessment tools, coupled with the low incidence of failed rapid sequence intubation, indicates limitations to using these screening tests in the ED setting.

Smallpox vaccination: a national survey of emergency health care providers.

UNLABELLED: Concerns about bioterrorism have prompted a national voluntary smallpox (SP) vaccination program in the United States. Although emergency health care providers are among the first targeted for vaccination, little is known about how these providers view the risks and benefits of SP vaccination. OBJECTIVES: To assess the willingness of emergency health care personnel to receive pre-event SP vaccination prior to the start of the national program. METHODS: The authors conducted a national cross-sectional, anonymous survey of 1,701 emergency physicians, nurses, and mid-level practitioners working full time in 13 adult and pediatric academic emergency departments in large U.S. cities in November and December 2002. The main outcome measure was willingness to be vaccinated against SP. Secondary outcomes included the prevalence of self-reported contraindications, and reasons for and against vaccination. RESULTS: 732 emergency health care providers returned questionnaires (response rate 43%). Overall, 73% (95% CI = 66% to 80%) were willing to receive pre-event SP vaccination. 18% (95% CI = 14% to 23%) reported contraindications to vaccination, and 50% (95% CI = 39% to 61%) of these providers were willing to receive pre-event SP vaccination. Self-protection (72%) was the most common reason cited for desiring vaccination against SP; concern about vaccine-related adverse events (54%) was the most common reason cited for not wanting immunization. CONCLUSIONS: Most emergency health care providers express a willingness to receive pre-event SP immunization; self-protection is a principal motivating reason. A subset of health care providers, however, may place themselves at increased risk by desiring vaccination despite contraindications.

Skatepark injuries and the influence of skatepark design: a one year consecutive case series.

Skateboarding and in-line skating are popular activities that attract millions of participants yearly and have spawned the development of skateparks (SPs). This study examined the types and distribution of injuries within a local commercial SP. Subjects were prospectively enrolled in a university Emergency Department (ED) after an injury at a local SP. One hundred subjects were enrolled over 1 year, representing 102 episodes and 106 injuries. Musculoskeletal injuries accounted for 80% of all injuries. Fractures and dislocations were the most frequent injuries (59%); six required operative management. One serious intra-abdominal injury occurred. Head and facial injuries occurred in 17% of subjects; none required operative repair. Admission rate was 9%. Safety equipment use was greater than 91%. Significantly more injuries occurred in the ramp/bars areas compared to the half-pipe and gully areas, suggesting that SP design may significantly influence injury patterns. A substantial number of injuries occurred at the SP, despite controlled conditions and equipment requirements.

Clinician-performed Beside Ultrasound for the Diagnosis of Traumatic Pneumothorax.

INTRODUCTION: Prior studies have reported conflicting results regarding the utility of ultrasound in the diagnosis of traumatic pneumothorax (PTX) because they have used sonologists with extensive experience. This study evaluates the characteristics of ultrasound for PTX for a large cohort of trauma and emergency physicians. METHODS: This was a prospective, observational study on a convenience sample of patients presenting to a trauma center who had a thoracic ultrasound (TUS) evaluation for PTX performed after the Focused Assessment with Sonography for Trauma exam. Sonologists recorded their findings prior to any other diagnostic studies. The results of TUS were compared to one or more of the following: chest computed tomography, escape of air on chest tube insertion, or supine chest radiography followed by clinical observation. RESULTS: There were 549 patients enrolled. The median injury severity score of the patients was 5 (inter-quartile range [IQR] 1-14); 36 different sonologists performed TUS. Forty-seven of the 549 patients had traumatic PTX, for an incidence of 9%. TUS correctly identified 27/47 patients with PTX for a sensitivity of 57% (confidence interval [CI] 42-72%). There were 3 false positive cases of TUS for a specificity of 99% (CI 98%-100%). A "wet" chest radiograph reading done in the trauma bay showed a sensitivity of 40% (CI 23-59) and a specificity of 100% (99-100). CONCLUSION: In a large heterogenous group of clinicians who typically care for trauma patients, the sonographic evaluation for pneumothorax was as accurate as supine chest radiography. Thoracic ultrasound may be helpful in the initial evaluation of patients with truncal trauma.

Evidence-based diagnostics: adult septic arthritis.

BACKGROUND: Acutely swollen or painful joints are common complaints in the emergency department (ED). Septic arthritis in adults is a challenging diagnosis, but prompt differentiation of a bacterial etiology is crucial to minimize morbidity and mortality. OBJECTIVES: The objective was to perform a systematic review describing the diagnostic characteristics of history, physical examination, and bedside laboratory tests for nongonococcal septic arthritis. A secondary objective was to quantify test and treatment thresholds using derived estimates of sensitivity and specificity, as well as best-evidence diagnostic and treatment risks and anticipated benefits from appropriate therapy. METHODS: Two electronic search engines (PUBMED and EMBASE) were used in conjunction with a selected bibliography and scientific abstract hand search. Inclusion criteria included adult trials of patients presenting with monoarticular complaints if they reported sufficient detail to reconstruct partial or complete 2 × 2 contingency tables for experimental diagnostic test characteristics using an acceptable criterion standard. Evidence was rated by two investigators using the Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS). When more than one similarly designed trial existed for a diagnostic test, meta-analysis was conducted using a random effects model. Interval likelihood ratios (LRs) were computed when possible. To illustrate one method to quantify theoretical points in the probability of disease whereby clinicians might cease testing altogether and either withhold treatment (test threshold) or initiate definitive therapy in lieu of further diagnostics (treatment threshold), an interactive spreadsheet was designed and sample calculations were provided based on research estimates of diagnostic accuracy, diagnostic risk, and therapeutic risk/benefits. RESULTS: The prevalence of nongonococcal septic arthritis in ED patients with a single acutely painful joint is approximately 27% (95% confidence interval [CI] = 17% to 38%). With the exception of joint surgery (positive likelihood ratio [+LR] = 6.9) or skin infection overlying a prosthetic joint (+LR = 15.0), history, physical examination, and serum tests do not significantly alter posttest probability. Serum inflammatory markers such as white blood cell (WBC) counts, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) are not useful acutely. The interval LR for synovial white blood cell (sWBC) counts of 0 × 10(9)-25 × 10(9)/L was 0.33; for 25 × 10(9)-50 × 10(9)/L, 1.06; for 50 × 10(9)-100 × 10(9)/L, 3.59; and exceeding 100 × 10(9)/L, infinity. Synovial lactate may be useful to rule in or rule out the diagnosis of septic arthritis with a +LR ranging from 2.4 to infinity, and negative likelihood ratio (-LR) ranging from 0 to 0.46. Rapid polymerase chain reaction (PCR) of synovial fluid may identify the causative organism within 3 hours. Based on 56% sensitivity and 90% specificity for sWBC counts of >50 × 10(9)/L in conjunction with best-evidence estimates for diagnosis-related risk and treatment-related risk/benefit, the arthrocentesis test threshold is 5%, with a treatment threshold of 39%. CONCLUSIONS: Recent joint surgery or cellulitis overlying a prosthetic hip or knee were the only findings on history or physical examination that significantly alter the probability of nongonococcal septic arthritis. Extreme values of sWBC (>50 × 10(9)/L) can increase, but not decrease, the probability of septic arthritis. Future ED-based diagnostic trials are needed to evaluate the role of clinical gestalt and the efficacy of nontraditional synovial markers such as lactate.

Untreated hypertension and the emergency department: a chance to intervene?

OBJECTIVES: Untreated hypertension (HTN) is a major public health problem. Screening for untreated HTN in the emergency department (ED) may lead to appropriate treatment of more patients. The authors investigated the accuracy of identifying HTN in the ED, the proportion of ED patients with untreated HTN, patient characteristics predicting untreated HTN, and provider documentation of untreated HTN. METHODS: The authors performed a retrospective cross-sectional study on a random sample of 2,061 adults treated at an urban academic ED. The validity of six candidate definitions of HTN in the ED was assessed in a subsample using outpatient clinic records as the reference standard. "Untreated HTN" was HTN without a HTN medication listed in the ED history. "Documentation of untreated HTN was documentation of HTN as a visit problem, specific referral for HTN, or ED discharge with a HTN" information sheet or a HTN medication. Multivariable logistic regression was used to determine associations. RESULTS: The preferred definition of HTN in the ED had sensitivity of 86% (95% confidence interval [CI] = 80% to 90%), specificity of 78% (95% CI = 69% to 85%), and accuracy of 83% (95% CI = 78% to 87%). Of the 42% (95% CI = 40% to 44%) of ED patients with HTN, 43% (95% CI = 39% to 46%) had untreated HTN. Patients who were younger and male, without primary care physicians, with fewer prior ED visits, and without cardiovascular comorbidities, had higher odds of untreated HTN. Of those with untreated HTN, 8% (95% CI = 5% to 11%) had their untreated HTN documented. CONCLUSIONS: Untreated HTN was common in the ED but rarely documented. Providers can use ED blood pressures along with patient characteristics to identify those with untreated HTN for referral to primary care.

Emergency department operational changes in response to pay-for-performance and antibiotic timing in pneumonia.

BACKGROUND: The percentage of adult patients admitted with pneumonia who receive antibiotics within four hours of hospital arrival is publicly reported as a quality and pay-for-performance measure by the Department of Health and Human Services and is called PN-5b. OBJECTIVES: To determine attitudes among physician leaders at emergency medicine training programs toward using PN-5b as a quality measure for pay for performance, and to determine what operational changes academic emergency departments (EDs) have made to ensure early antibiotic administration for patients with pneumonia. METHODS: The authors administered an online questionnaire to 129 chairpersons and medical directors of 135 academic ED training programs in the United States on attitudes toward performance measurement in pneumonia and changes that academic EDs have made in response to PN-5b; one response was sought from each institution. Respondents were identified through the Society for Academic Emergency Medicine Web site and e-mailed five times to maximize survey participation. RESULTS: Ninety chairpersons and medical directors (70%) completed the survey; 47% were medical directors, 51% were chairpersons, and 2% were medical directors and chairpersons. Forty-five (50%) did not agree that PN-5b was an accurate quality measure, and 61 (69%) did not agree that pay for performance targeting this measure would lead to improved pneumonia care. The most common strategy to address PN-5b was to provide information to providers on the importance of early treatment with antibiotics (n = 63; 70%). For patients with suspected pneumonia, 46 (51%) automate chest radiograph (CXR) ordering at triage, 37 (41%) prioritize patients with suspected pneumonia, and 33 (37%) administer antibiotics before obtaining CXR results. Overall ED changes include improved turnaround time for CXR (n = 33; 37%), prioritized CXRs over other radiographs (n = 13; 14%), and improved inpatient bed availability (n = 12; 13%). Of 13 strategies identified to improve PN-5b, the median number that programs have implemented is five (interquartile range, 5-7). All sites reported engaging in at least three operational changes to address PN-5b. CONCLUSIONS: All EDs in this study have addressed early antibiotic administration with multiple operational changes despite mixed sentiment that these changes will improve care. Future research is needed to measure the impact of pay-for-performance initiatives.

Stylet bend angles and tracheal tube passage using a straight-to-cuff shape.

OBJECTIVES: Malleable stylets improve maneuverability and control during tube insertion, but after passage through the vocal cords the stiffened tracheal tube may impinge on the tracheal rings, preventing passage. The goal of this study was to assess insertion difficulty with styletted tubes of different bend angles. METHODS: Tube passage was assessed with four different bend angles (25 degrees, 35 degrees, 45 degrees, and 60 degrees) using straight-to-cuff-shaped tubes. In two separate airway procedure classes, 16 operators in each class (32 total) placed randomly ordered styletted tubes of the different angles into eight cadavers (16 total). Operators subjectively graded the ease of tube passage as no resistance, some resistance, or impossible to advance. RESULTS: No resistance was reported in 69.1% (177/256) at 25 degrees, in 63.7% (163/256) at 35 degrees, in 39.4% (101/256) at 45 degrees, and in 8.9% (22/256) at 60 degrees. Tube passage was impossible in 2.3% of insertions (6/256) at 25 degrees, in 3.5% (9/256) at 35 degrees, in 11.3% (29/256) at 45 degrees, and in 53.9% (138/256) at 60 degrees. The odds ratios of impossible tube passage for 35 degrees, 45 degrees, and 60 degrees vs. 25 degrees were 1.52 (95% confidence interval [CI] = 0.55 to 4.16), 5.32 (95% CI = 2.22 to 12.71), and 48.72 (95% CI = 21.35 to 111.03), respectively. CONCLUSIONS: Bend angles beyond 35 degrees with straight-to-cuff styletted tracheal tubes increase the risk of difficult and impossible tube passage into the trachea. The authors did not compare different stylet stopping points, stylets of different stiffness, or tracheal tubes with different tip designs, all variables that can affect tube passage.

Predictive values of triage temperature and pulse for antibiotic administration and hospital admission in elderly patients with potential infection.

To determine how well triage temperature and pulse abnormalities in elderly patients with potential infections predict antibiotic administration and hospital admission. Data from the National Hospital Ambulatory Care Survey (2001-2002), a sample of US emergency departments, were used. Patients (>or=65 years) with a reason for visit suggesting potential infection were included. Of 10,586 patients 65 years or older, 32% had reasons for visit suggesting potential infection. The negative predictive value for predicting intensive care unit admission (n = 154) for triage hyperthermia (temperature >or=38 degrees C) was 96% (95% confidence interval, 95%-96%); hypothermia (temperature

Factors influencing analgesic use for skatepark-related musculoskeletal injuries.

OBJECTIVE: This study was designed to determine the proportion of patients with skatepark-related musculoskeletal injuries who were administered analgesics in the emergency department (ED) or at discharge, and to determine if differences in use of pain medication varied by injury type, anatomic location, or patient age. METHODS: This is a retrospective review of a cohort of consecutive patients with musculoskeletal injuries presenting to a large urban ED from a local skatepark over a 1-year period (1999-2000). Patients with non-musculoskeletal injuries were excluded. The outcome measure was analgesic use either in the ED or at discharge. Data included demographics, activity during injury, disposition, injury type (fracture or non-fracture), and injury location (upper or lower body). Analgesic data was abstracted from the medical records. Multivariable logistic regression was used to identify independent predictors of receipt of analgesic medications. RESULTS: 85 injured patients were enrolled. No differences in age, sex, activity, or disposition were found comparing those who received analgesics (n=68) to those who did not (n=17). Overall, analgesia was administered to 80% (95% CI = 70 to 88%) of patients; 67% (95% CI = 56 to 77%) in the ED and 64% (95% CI = 52 to 74%) at discharge. Fractures were more likely to receive analgesia (adjusted OR = 18.5; 95% CI = 4.0 to 86.1) than non-fracture injuries. Lower body injuries were more likely to receive analgesics compared to upper body injuries (adjusted OR = 9.2; 95% CI = 1.5 to 55.8). Age was not independently associated with analgesic use. CONCLUSIONS: A high proportion of skatepark-related musculoskeletal injuries were treated with pain medications either in the ED or at discharge. In this study analgesic medication use was influenced by injury type and location of the injury, but not age.

A modified approach to supraclavicular subclavian vein catheter placement: the pocket approach.

BACKGROUND: Central venous access is often necessary for the administration of fluids, blood products, and medications. Several approaches to supraclavicular subclavian venous access have been described. This study examines the effectiveness of central venous catheter placement utilizing an alternative set of anatomic landmarks for supraclavicular subclavian vein access. METHODS: This was a two phase study. The first portion involved subclavian vein cannulation using a supraclavicular approach in 28 cadavers. The specific set of anatomic landmarks for the supraclavicular approach, termed the "pocket approach," is described. Cadavers were subsequently dissected to verify appropriate line placement. The second portion was a chart review of Emergency Department (ED) patients who underwent attempted subclavian vein catheter placement utilizing the pocket approach. Charts were extracted following education of the ED faculty and resident staff to determine: 1) Success of subclavian line placement, 2) The incidence of pneumothorax, and 3) The use of supraclavicular subclavian access in the trauma setting, during cardiopulmonary resuscitation (CPR), and in patients who had cervical collars. RESULTS: In 28 cadavers, the success rate of the pocket approach was 100% (34/34; 95% CI 90% to 100%). Chart review of the 68 patients revealed a success rate of 90% (61/68; CI 80% to 96%). No pneumothoraces were recorded (0/68; CI 0% to 5%). The pocket approach was used successfully in 11 patients with cervical collars, (100%, CI 72% to 100%) and in 15 of 16 patients undergoing CPR (94%, CI 70% to 100%). In four fresh cadavers, the average distance from the posterior subclavian vein to the subclavian artery was 0.40cm, and the dome of the pleura was 1.75cm posterior to the vein. CONCLUSION: Our data suggest that the supraclavicular pocket approach to subclavian vein cannulation is a useful and safe method of adult central venous catheterization, with complication and success rates comparable to more common approaches. The anatomic advantage of a great vein that is closer to the skin and farther from the pleural dome makes this an approach worthy of further investigation.