Erector spinae plane block (ESPB) for intractable, non-surgical abdominal pain: a scoping review.

Abdominal pain is one of the most common presenting chief complaints in the emergency department (ED). Erector spinae plane block (ESPB) is an ultrasound-guided nerve block with proven effectiveness in treating visceral and somatic abdominal pain. Despite the increasing popularity of ESPB, its role in the management of non-surgical abdominal pain has not yet been characterized. Our scoping review aims to review the current literature on the safety and efficacy of ESPB in the management of patients experiencing intractable, non-surgical abdominal pain. We searched PubMed and Scopus to evaluate the existing literature on ESPB for non-surgical abdominal pain. Reviewers screened 30 titles and abstracts that met the predefined inclusion and exclusion criteria. Following initial screening, 24 articles underwent full-text review. Two reviewers also screened references included in each study. A total of 14 journal articles were reviewed, including 12 case-based studies, one systematic review, and one narrative review of ESPB in the treatment of non-surgical abdominal pain. All cases described the successful use of ESPB in treating abdominal pain refractory to oral or intravenous analgesic medications, and each case reported no complications. This scoping review provides support for ESPB in the management of intractable, non-surgical abdominal pain. ESPB demonstrates efficacy in alleviating various conditions such as functional abdominal pain, renal colic, pancreatitis, herpetic pain, and cancer-related pain. Theoretical risks such as pneumothorax, bleeding, and infection are possible, although the studies reviewed did not report such complications.

Block Time: A Multispecialty Systematic Review of Efficacy and Safety of Ultrasound-guided Upper Extremity Nerve Blocks.

INTRODUCTION: Ultrasound-guided peripheral nerve blockade is a common pain management strategy to decrease perioperative pain and opioid/general anesthetic use. In this article our goal was to systematically review publications supporting upper extremity nerve blocks distal to the brachial plexus. We assessed the efficacy and safety of median, ulnar, radial, suprascapular, and axillary nerve blocks by reviewing previous studies. METHODS: We searched MEDLINE and Embase databases to capture studies investigating these nerve blocks across all specialties. We screened titles and abstracts according to agreed-upon inclusion/exclusion criteria. We then conducted a hand search of references to identify studies not found in the initial search strategy. RESULTS: We included 20 studies with 1,273 enrolled patients in qualitative analysis. Both anesthesiology (12, 60%) and emergency medicine (5, 25%) specialties have evidence of safe and effective use of radial, ulnar, median, suprascapular, and axillary blocks for numerous clinical applications. Recently, multiple randomized controlled trials show suprascapular nerve blocks may result in lower pain scores in patients with shoulder dislocations and rotator cuff injuries, as well as in patients undergoing anesthesia for shoulder surgery. CONCLUSION: Distal upper extremity nerve blocks under ultrasound guidance may be safe, practical strategies for both acute and chronic pain in perioperative, emergent, and outpatient settings. These blocks provide accessible, opioid-sparing pain management, and their use across multiple specialties may be expanded with increased procedural education of trainees.

Using a Linear Probe Ultrasound for the Detection of First-Trimester Pregnancies in the Emergency Department.

Linear probe point-of-care ultrasound (LPUS) presents a less invasive alternative for identifying intrauterine pregnancies (IUPs) compared to usual practice (transabdominal (TAUS) or transvaginal (TVUS) ultrasound). TAUS and TVUS can be invasive or produce lower-resolution images than LPUS. The purpose of this study is to determine whether a linear probe alone can identify first-trimester IUPs. A convenience sample of 21 patients were enrolled at the University of California Irvine ED during a 7-month period. The inclusion criteria were English- or Spanish-speaking women (≥18 years) in their first trimester of pregnancy (≤12 weeks pregnant) with a body mass index (BMI) of <35. The exclusion criteria were psychiatric, incarcerated, or cognitively impaired patients. An ED physician performed LPUS and ordered a confirmatory ultrasound. The 21 patients enrolled had a mean age of 28.6 ± 6.60 years, BMI of 26.6 ± 5.03, and gestational age of 7.4 ± 2.69 weeks. Considering the 95% confidence interval, we are 97.5% confident that the sensitivity and specificity of LPUS to identify IUPs does not exceed 67.1% and 93.2%, respectively. Our pilot data did not demonstrate that LPUS can independently visualize IUPs in first-trimester patients.

Utilization of point-of-care ultrasound among graduates of a 4-year longitudinal medical school ultrasound curriculum.

OBJECTIVE: In 2011, School of Medicine, University of California, Irvine was among the first schools to implement a 4-year ultrasound curriculum. We aimed to find the point-of-care ultrasound (POCUS) utilization pattern among University of California, Irvine alumni. METHODS: We surveyed University of California, Irvine alumni from the class of 2011 and beyond. Survey questions included POCUS reliance, frequency of use, and comfort with image acquisition and interpretation compared with peers. The primary outcomes were self-reported comfort and reliance on POCUS. RESULTS: We received 93 responses from 624 surveyed alumni (response rate, 14.9%), of which 87 were analyzed. Although 46 respondents (52.9%) reported more reliance on POCUS, three (3.4%) relied on it less than their peers. At the same time, 72 (82.7%) and 67 (77.0%) felt more comfortable than their colleagues in obtaining and interpreting POCUS, respectively. No respondents felt less comfortable obtaining or interpreting POCUS than their peers. The frequency of POCUS use correlated directly with the frequency with which POCUS changed the responder's case management (rho, 0.860; P<0.001). POCUS reliance also correlated with respondents' comfort level in obtaining (rho, 0.321; P<0.001) and interpreting (rho, 0.378; P<0.001) POCUS results. CONCLUSION: University of California, Irvine graduates had higher reliance on POCUS than peers in their respective specialties. Their POCUS findings frequently changed their case management.

Assessment of clinical dehydration using point of care ultrasound for pediatric patients in rural Panama.

BACKGROUND: Dehydration and its associated symptoms are among the most common chief complaints of children in rural Panama. Previous studies have shown that intravascular volume correlates to the ratio of the diameters of the inferior vena cava (IVC) to the aorta (Ao). Our study aims to determine if medical students can detect pediatric dehydration using ultrasound on patients in rural Panama. METHODS: This was a prospective, observational study conducted in the Bocas del Toro region of rural Panama. Children between the ages of 1 to 15 years presenting with diarrhea, vomiting, or parasitic infection were enrolled in the study. Ultrasound measurements of the diameters of the IVC and abdominal aorta were taken to assess for dehydration. RESULTS: A total of 59 patients were enrolled in this study. Twenty-four patients were clinically diagnosed with dehydration and 35 were classified to have normal hydration status. Of the 24 patients with dehydration, half (n=12) of these patients had an IVC/Ao ratio below the American threshold of 0.8. Of the remaining asymptomatic subjects, about half (n=18) of these subjects also had an IVC/Ao ratio below the American threshold of 0.8. CONCLUSION: Our study did not support previous literature showing that the IVC/Ao ratio is lower in children with dehydration. It is possible that the American standard for evaluating clinical dehydration is not compatible with the rural pediatric populations of Panama.

Feasibility study of minimally trained medical students using the Rural Obstetrical Ultrasound Triage Exam (ROUTE) in rural Panama.

BACKGROUND: Maternal and infant mortality rates reported in rural Panama are greater than those in urban regions. Bocas del Toro is a region of Panama inhabited by indigenous people at greater risk for pregnancy-related complications and deaths due to geographic isolation and limited access to health care. Portable ultrasound training programs have recently been implemented in low-resource settings to increase access to diagnostic imaging. The goal of this study is to determine the feasibility of teaching first-year medical students the Rural Obstetrical Ultrasound Triage Exam (ROUTE) to help identify pathology in pregnant women of the Bocas del Toro region of Panama. METHODS: Eight first-year medical students completed ROUTE training sessions. After training, the students were compared to professional sonographers to evaluate their accuracy in performing the ROUTE. Students then performed the ROUTE in mobile clinics within Bocas del Toro. They enrolled women pregnant in their 2nd or 3rd trimesters and measured biparietal diameter, head circumference, amniotic fluid index, fetal lie and placental position. Any abnormal measurement would be further analyzed by the lead physician for a potential hospital referral. RESULTS: A total of 60 women were enrolled in the study. Four women were detected as having a possible high-risk pregnancy and thus referred to a hospital for further evaluation. CONCLUSION: Based on our data, first-year medical students with additional training can use the ROUTE to identify complications in pregnancy using ultrasound in rural Panama. Additional studies are required to determine the optimal amount of training required for proficiency.

Randomized study of effectiveness of computerized ultrasound simulators for an introductory course for residents in Brazil.

PURPOSE: This study aimed to assess the impact of ultrasound simulation (SonoSim) on educational outcomes of an introductory point-of-care ultrasound course compared to hands-on training with live models alone. METHODS: Fifty-three internal medicine residents without ultrasound experience were randomly assigned to control or experimental groups. They participated in an introductory point-of-care ultrasound course covering eight topics in eight sessions from June 23, 2014 until July 18, 2014. Both participated in lecture and hands-on training, but experimental group received an hour of computerized simulator training instead of a second hour of hands-on training. We assessed clinical knowledge and image acquisition with written multiple-choice and practical exams, respectively. Of the 53 enrolled, 40 participants (75.5%) completed the course and all testing. RESULTS: For the 30-item written exam, mean score of the experimental group was 23.1±3.4 (n=21) vs. 21.8±4.8 (n=19), (P>0 .05). For the practical exam, mean score for both groups was 8.7 out of 16 (P>0 .05). CONCLUSION: The substitution of eight hours of ultrasound simulation training for live model scanning in a 24 hour training course did not enhance performance on written and image acquisition tests in an introductory ultrasound course for residents. This result suggests that ultrasound simulation technology used as a substitute for live model training on an hour-for-hour basis, did not improve learning outcomes. Further investigation into simulation as a total replacement for live model training will provide a clearer picture of the efficacy of ultrasound simulators in medical education.

Ranking Practice Variability in the Medical Student Performance Evaluation: So Bad, It's "Good".

PURPOSE: To examine the variability among medical schools in ranking systems used in medical student performance evaluations (MSPEs). METHOD: The authors reviewed MSPEs from U.S. MD-granting medical schools received by the University of California, Irvine emergency medicine and internal medicine residency programs during 2012-2013 and 2014-2015. They recorded whether the school used a ranking system, the type of ranking system used, the size and description of student categories, the location of the ranking statement and category legend, and whether nonranking schools used language suggestive of rank. RESULTS: Of the 134 medical schools in the study sample, the majority (n = 101; 75%) provided ranks for students in the MSPE. Most of the ranking schools (n = 63; 62%) placed students into named category groups, but the number and size of groups varied. The most common descriptors used for these 63 schools' top, second, third, and lowest groups were "outstanding," "excellent," "very good," and "good," respectively, but each of these terms was used across a broad range of percentile ranks. Student ranks and school category legends were found in various locations. Many of the 33 schools that did not rank students included language suggestive of rank. CONCLUSIONS: There is extensive variation in ranking systems used in MSPEs. Program directors may find it difficult to use MSPEs to compare applicants, which may diminish the MSPE's value in the residency application process and negatively affect high-achieving students. A consistent approach to ranking students would benefit program directors, students, and student affairs officers.

Ultrasound diagnosis of malaria: examination of the spleen, liver, and optic nerve sheath diameter.

BACKGROUND: Over 90% of all cases of malaria worldwide occur in Africa. Current methods of diagnosis are time and labor intensive, and could lead to delayed treatment. METHODS: In this study we investigated the effectiveness of measurements of spleen, liver, and optic nerve sheath diameter (ONSD) in identifying patients with malaria or severe malaria through the use of hand-held ultrasound devices. We recruited 40 adult patients with malaria and 16 adult control subjects at two hospitals in Mwanza, Tanzania. Ultrasonographic diagnosis was compared with rapid antigen diagnostic test and peripheral blood smear as the gold standards. An receiver operating characteristic curve test was performed to determine the most optimal diagnostic threshold for malaria and severe malaria, using each of the measurements for liver size, spleen size, and ONSD. The thresholds were determined to be >12 cm for spleen length and >15.1 cm for liver length, whereas ONSD was not significant in this study. RESULTS: The sensitivities for malaria diagnosis were 66.7% and 58.3% for liver and spleen length respectively, suggesting that these measurements may not be suitable for identifying patients with severe malaria. However, the high specificity of 90.9% for spleen length and the acceptable specificity of 75.0% for liver length suggest that these measurements can be used as a method to eliminate false-positive diagnoses (i.e. patients who do not have severe malaria but are classified as having it by a test with a high sensitivity), giving a high positive predictive value. CONCLUSIONS: We report a high specificity for spleen size and a moderate specificity for liver size in the ultrasonographic diagnosis of severe malaria. Thus when paired with a highly sensitive method of malaria diagnosis, ultrasonographic measurement of spleen and liver size is promising as part of a diagnostic algorithm for malaria. It could be used to stratify risk in patients diagnosed with malaria and assist in their triage. If no sensitive tests are available, ultrasound might be useful to suggest malaria as a cause of a patient's constellation of clinical symptoms.

Pelvic ultrasonography and length of stay in the ED: an observational study.

OBJECTIVES: We compared emergency physician-performed pelvic ultrasonography (EPPU) with radiology department-performed pelvic ultrasonography (RPPU) in emergency department (ED) female patients requiring pelvic ultrasonography and their outcomes in relation to ED length of stay, ED readmission, and alternative diagnosis, within a 14-day follow-up period. METHODS: This was a prospective, observational study of female patients of reproductive age who required either an EPPU or RPPU for their ED evaluation. We hypothesized that patients receiving EPPU would have a length of stay reduction greater than or equal to 60 minutes, as compared with RPPU. Statistical analyses included an independent-samples t test and multivariate regression modeling to control for factors associated with ED LOS. RESULTS: Eighteen resident physicians performed EPPU, with 15 attending physicians supervising. Forty-eight patients received only EPPU, and 84 patients received only RPPU. In univariate analysis, those who received EPPU had an ED LOS 162 minutes less than those who received RPPU (95% confidence interval, 106-209 minutes). In multivariate analysis controlling for gynecologist consultation, disposition, and pregnancy status, patients who received EPPU had an ED LOS reduction of 108 minutes when compared with RPPU (95% confidence interval, 38-166 minutes). Five patients (10%) who had received EPPU and were discharged from the ED returned to the ED within 2 weeks, but none had alternative diagnoses. CONCLUSIONS: Patients with EPPU had statistically and clinically significant reductions in ED LOS, even when controlling for disposition, gynecologist consultation in the ED, and pregnancy status. No patients in the study had an alternative diagnosis within 2 weeks of EPPU.

USEFUL: Ultrasound Exam for Underlying Lesions incorporated into physical exam.

INTRODUCTION: The Ultrasound Screening Exam for Underlying Lesions (USEFUL) was developed in an attempt to establish a role for bedside ultrasound in the primary and preventive care setting. It is the purpose of our pilot study to determine if students were first capable of performing all of the various scans required of our USEFUL while defining such an ultrasound-assisted physical exam that would supplement the standard hands-on physical exam in the same head-to-toe structure. We also aimed to assess the time needed for an adequate exam and analyze if times improved with repetition and previous ultrasound training. METHODS: Medical students with ranging levels of ultrasound training received a 25-minute presentation on our USEFUL followed by a 30-minute hands-on session. Following the hands-on session, the students were asked to perform a timed USEFUL on 2-3 standardized subjects. All images were documented as normal or abnormal with the understanding that an official detailed exam would be performed if an abnormality were to be found. All images were read and deemed adequate by board eligible emergency medicine ultrasound fellows. RESULTS: Twenty-six exams were performed by 9 students. The average time spent by all students per USEFUL was 11 minutes and 19 seconds. Students who had received the University of California, Irvine School of Medicine's integrated ultrasound curriculum performed the USEFUL significantly faster (p< 0.0025). The time it took to complete the USEFUL ranged from 6 minutes and 32 seconds to 17 minutes, and improvement was seen with each USEFUL performed. The average time to complete the USEFUL on the first standardized patient was 13 minutes and 20 seconds, while 11 minutes and 2 seconds, and 9 minutes and 20 seconds were spent performing the exam on the second and third patient, respectively. CONCLUSION: Students were able to effectively complete all scans required by the USEFUL in a timely manner. Students who have been a part of the integrated ultrasound in medicine curriculum performed the USEFUL significantly faster than students who had not. Students were able to significantly improve upon the time it took them to complete the USEFUL with successive attempts. Future endpoints are aimed at assessing the feasibility and outcomes of an ultrasound-assisted physical exam in a primary care setting and the exam's effect on doctor-patient satisfaction. [West J Emerg Med. 2014;15(3):260-266.].

Prospective analysis of single operator sonographic optic nerve sheath diameter measurement for diagnosis of elevated intracranial pressure.

INTRODUCTION: The accurate diagnosis of elevated intracranial pressure (eICP) in the emergent setting is a critical determination that presents significant challenges. Several studies show correlation of sonographic optic nerve sheath diameter (ONSD) to eICP, while others show high inter-observer variability or marginal performance with less experienced sonographers. The objective of our study is to assess the ability of bedside ultrasound measurement of ONSD to identify the presence of eICP when performed by a single experienced sonographer. We hypothesize that ONSD measurement is sensitive and specific for detecting eICP and can be correlated with values obtained by external ventricular device (EVD). METHODS: This was a prospective blinded observational study conducted in a neurocritical care unit of a level 1 trauma center. ONSD measurement was performed on a convenience sample of 27 adult patients who required placement of an invasive intracranial monitor as part of their clinical care. One certified sonographer/physician performed all ultrasounds within 24 hours of placement of EVD. The sonographer was blinded to the ICP recorded by invasive monitor at the time of the scan. A mean ONSD value of ≥5.2 mm was taken as positive. RESULTS: The sonographer performed 27 ocular ultrasounds on individual patients. Six (22%) of these patients had eICP (EVD measurement of >20 mmHg). Spearman rank correlation coefficient of ONSD and ICP was 0.408 (p=0.03), demonstrating a moderate positive correlation. A ROC curve was created to determine the optimal cut off value to distinguish an eICP greater than 20 mmHg. The area under the receiver operator characteristic curve was 0.8712 (95% confidence interval [CI]=0.67 to 0.96). ONSD ≥5.2 mm was a good predictor of eICP (>20 mmHg) with a sensitivity of 83.3% (95% CI=35.9% to 99.6%) and specificity of 100% (95% CI=84.6% to 100%). CONCLUSION: While the study suggests ONSD measurements performed by a single skilled operator may be both sensitive and specific for detecting eICP, confirmation in a much larger sample is needed. Ocular ultrasound may provide additional non-invasive means of assessing eICP.

Assessment of readiness to change and relationship to AUDIT score in a trauma population utilizing computerized alcohol screening and brief intervention.

Trauma patient readiness-to-change score and its relationship to the Alcohol Use Disorder Identification Test (AUDIT) score were assessed in addition to the feasibility of computerized alcohol screening and brief intervention (CASI). A bilingual computerized tablet for trauma patients was utilized and the data were analyzed using Stata. Twenty-five percent of 1145 trauma patients drank more than recommended and 4% were dependent. As many Spanish-speaking as English-speaking males did not drink, but a higher percentage of Spanish-speaking males drank more than recommended and were dependent. Half of patients who drank more than recommended rated themselves 8 or higher on a 10-point readiness-to-change scale. CASI also provided personalized feedback. A high percentage of trauma patients (92%) found CASI easy and a comfort in use (87%). Bilingual computerized technology for trauma patients is feasible, acceptable, and an innovative approach to alcohol screening, brief intervention, and referral to treatment in a tertiary care university.

Cardiac movement identified on prehospital echocardiography predicts outcome in cardiac arrest patients.

INTRODUCTION: The prognostic value of emergency echocardiography (EE) in the management of cardiac arrest patients has previously been studied in an in-hospital setting. These studies mainly included patients who underwent cardiopulmonary resuscitation (CPR) by emergency medicine technicians at the scene and who arrived at the emergency department (ED) still in a state of cardiac arrest. In most European countries, cardiac arrest patients are normally treated by physician-staffed emergency medical services (EMS) teams on scene. Transportation to the ED while undergoing CPR is uncommon. OBJECTIVE: To evaluate the ability of EE to predict outcome in cardiac arrest patients when it is performed by ultrasound-inexperienced emergency physicians on scene. METHODS: We performed a prospective, observational study of nonconsecutive, nontrauma, adult cardiac arrest patients who were treated by physician-staffed urban EMS teams on scene. Participating emergency physicians (EPs) received a two-hour course in EE during CPR. After initial procedures were accomplished, EE was performed during a rhythm and pulse check. A single subxiphoid, four-chamber view was required for study enrollment. We defined sonographic evidence of cardiac kinetic activity as any detected motion of the myocardium, ranging from visible ventricular fibrillation to coordinated ventricular contractions. The CPR had to be continued for at least 15 minutes after the initial echocardiography. No clinical decisions were made based on the results of EE. RESULTS: Forty-two patients were enrolled in the study. The heart could be visualized successfully in all patients. Five (11.9%) patients survived to hospital admission. Of the 32 patients who had cardiac standstill on initial EE, only one (3.1%) survived to hospital admission, whereas four out of 10 (40%) patients with cardiac movement on initial EE survived to hospital admission (p = 0.008). Neither asystole on initial electrocardiogram nor peak capnography value, age, bystander CPR, or downtime was a significant predictor of survival. Only cardiac movement was associated with survival, and cardiac standstill at any time during CPR resulted in a positive predictive value of 97.1% for death at the scene. CONCLUSION: Our results support the idea of focused echocardiography as an additional criterion in the evaluation of outcome in CPR patients and demonstrate its feasibility in the prehospital setting.

Emergency Physician Performed Ultrasound for DVT Evaluation.

Deep vein thrombosis is a common condition that is often difficult to diagnose and may be lethal when allowed to progress. However, early implementation of treatment substantially improves the disease prognosis. Therefore, care must be taken to both acquire an accurate differential diagnosis for patients with symptoms as well as to screen at-risk asymptomatic individuals. Many diagnostic tools exist to evaluate deep vein thrombosis. Compression ultrasonography is currently the most effective diagnostic tool in the emergency department, shown to be highly accurate at minimal expense. However, limited availability of ultrasound technicians may result in delayed imaging or in a decision not to image low-risk cases. Many studies support emergency physiciansas capable of accurately diagnosing deep vein thrombosis using bedside ultrasound. Further integration of ultrasound into the training of emergency physicians for use in evaluating deep vein thrombosis will improve patient care and cost-effective treatment.

Comparison of the visual function index to the Snellen Visual Acuity Test in predicting older adult self-restricted driving.

OBJECTIVE: In this observational study, a modified version of the Visual Function Index (VF-14) and the Snellen Visual Acuity Test were compared in how well they correlated with self-restricted driving habits in older adults. The VF-14 was originally designed to assess vision in cataract patients; however, in this study, a modified version (mVF-14) was evaluated as a tool for predicting self-restricted driving in older drivers. METHODS: During a 3-month period, 151 drivers over the age of 65 were screened at the local senior center. In addition to the Snellen Visual Acuity Test and mVF-14, each participant was given a questionnaire about their driving habits, previously used in self-restriction studies. RESULTS: Out of 151 total participants, 134 were included and 7 nondrivers and 10 subjects who did not complete all questionnaires were excluded. One hundred one participants exhibited normal visual acuity of 20/40 or better (75%), and 110 scored over 90 on the mVF-14 (82%). Spearman's rank sum correlation coefficient was used to analyze the data and showed significant negative correlation of the mVF-14 and Snellen with self-restricted driving. Individuals with normal vision (20/40 or better on the Snellen eye test) had both high and low mVF-14 scores. CONCLUSIONS: The study shows that poor vision, as indicated by the Snellen scale and low mVF-14 scores, correlates to self-imposed driving limitations. The mVF-14 showed further distinctions of self-restriction between individuals in the same Snellen Visual Acuity category. Therefore, using the mVF-14 in addition to the Snellen Visual Acuity Test can be helpful to further differentiate visual ability within older drivers who appear to have normal vision.

Randomized controlled trial of ultrasound-guided peripheral intravenous catheter placement versus traditional techniques in difficult-access pediatric patients.

OBJECTIVES: We hypothesized that the use of ultrasound guidance would improve the success rate of peripheral intravenous catheter placement in pediatric patients with difficult access in a pediatric emergency department (ED). Our secondary hypotheses were that ultrasound guidance would reduce the number of attempts, the number of needle redirections, and the overall time to catheter placement. METHODS: This was a prospective randomized study of pediatric ED patients younger than 10 years old requiring intravenous access, presenting between August 2006 and May 2007. Inclusion criteria were 2 unsuccessful traditional attempts at peripheral intravenous access or history of difficult access. Exclusion was critical illness or instability. Patients were randomized to undergo peripheral intravenous catheter placement using continued traditional approaches or real-time, dual-operator ultrasound-guided technique. Measured outcomes were success of cannulation, number of attempts, number of needle redirections, and overall time to catheter placement. RESULTS: Fifty patients were enrolled, with 25 patients randomized to each group. The overall success rates for the ultrasound-guided group were 80% and for the traditional-attempts group, 64%, with a difference in proportions of 16% (95% confidence interval, -9% to 38%, P = 0.208). The ultrasound-guided group required less overall time (6.3 vs 14.4 minutes, difference of -8.1 minutes [95% confidence interval, -12.5 to -3.6], P = 0.001), fewer attempts (median, 1 vs 3; P = 0.004), and fewer needle redirections (median, 2 vs 10; P G 0.0001) than traditional approaches. CONCLUSIONS: In a sample of pediatric ED patients with difficult access, ultrasound-guided intravenous cannulation required less overall time, fewer attempts, and fewer needle redirections than traditional approaches.

Associated economic impact of skatepark-related injuries in Southern California.

OBJECTIVE: To correlate the types of skatepark-related injuries with medical expenses and the monetary effects of time missed from work or school. DESIGN: Prospective case series and survey with repeat measures over 1 year. SETTING: Southern California Level I Trauma Center and Emergency Department. PARTICIPANTS: Subjects age 7 years or older who sustained an injury at a local skatepark and treated in the emergency department were included in the study. METHODS: A skatepark-related injury survey was conducted at the time of the subject's emergency department evaluation. Thereafter, subjects were contacted by telephone at 1 week and 1, 3, 6, 9 and 12 months post-injury to assess the extent of ongoing follow-up medical care, time lost from work and school for both the subject and parents, and the degree of self-reported disability. The costs of injury were estimated using accepted econometric methods. The cost of medical care and lost household productivity were estimated using data specific to the nature of the injury and the body part injured. RESULTS: Skatepark-related injuries resulted in a mean loss of 1.1 school days and 5.5 work days to the subject and family. The mean total injury costs were $3,167, of which 64% were medical costs and 28% were wages lost by the subject and family. Costs were much greater for subjects aged 26 years and older than for younger subjects and for those with more severe injuries than for less severe injuries. CONCLUSION: Skatepark injuries resulted in substantial medical costs and lost wages. Injured skatepark users 26 years and older and those with more severe injuries had the highest cost.