Defining an Ultrasound-guided Regional Anesthesia Curriculum for Emergency Medicine.

OBJECTIVES: Ultrasound-guided regional anesthesia (UGRA) can be a powerful tool in the treatment of painful conditions commonly encountered in emergency medicine (EM) practice. UGRA can benefit patients while avoiding the risks of procedural sedation and opioid-based systemic analgesia. Despite these advantages, many EM trainees do not receive focused education in UGRA and there is no published curriculum specifically for EM physicians. The objective of this study was to identify the components of a UGRA curriculum for EM physicians. METHODS: A list of potential curriculum elements was developed through an extensive literature review. An expert panel was convened that included 13 ultrasound faculty members from 12 institutions and from a variety of practice environments and diverse geographical regions. The panel voted on curriculum elements through two rounds of a modified Delphi process. RESULTS: The panelists voted on 178 total elements, 110 background knowledge elements, and 68 individual UGRA techniques. A high level of agreement was achieved for 65 background knowledge elements from the categories: benefits to providers and patients, indications, contraindications, risks, ultrasound skills, procedural skills, sterile technique, local anesthetics, and educational resources. Ten UGRA techniques achieved consensus: interscalene brachial plexus, supraclavicular brachial plexus, radial nerve, median nerve, ulnar nerve, serratus anterior plane, fascia iliaca, femoral nerve, popliteal sciatic nerve, and posterior tibial nerve blocks. CONCLUSIONS: The defined curriculum represents ultrasound expert opinion on a curriculum for training practicing EM physicians. This curriculum can be used to guide the development and implementation of more robust UGRA education for both residents and independent providers.

Ultrasound can accurately guide gastrostomy tube replacement and confirm proper tube placement at the bedside.

BACKGROUND: Malfunctioning or dislodged gastrostomy tubes (G-tubes) often require urgent replacement and reinsertion in the Emergency Department (ED). Few data exist regarding the best technique for bedside catheter replacement and verification, and individual operator preferences vary. Although a few reports have described the use of ultrasound guidance during the initial percutaneous insertion, no data are available concerning its role during subsequent G-tube replacements. OBJECTIVE: We sought to investigate the utility of bedside ultrasonography during G-tube replacements in the ED. METHODS: This was a prospective pilot study conducted at a Level 1 Trauma Center with an annual census of 90,000 patients. Seven adults and three children with malfunctioning G-tubes were enrolled. Three tubes were cracked and leaking, and seven tubes had been dislodged. Under ultrasound, a new G-tube was inserted through the previously fashioned tract. After insertion, color Doppler was applied over the catheter tip to enhance visualization during gentle tube oscillation. RESULTS: Ultrasound successfully visualized G-tube replacement in all 10 patients. Application of color Doppler over the G-tube tip during catheter oscillation enhanced placement confirmation. Sonographic findings were corroborated with gastric content aspiration, contrast-enhanced radiographs, and successful use of the new G-tubes. No false tracts were identified during ultrasound-guided insertion, post-procedure sonographic confirmation, or subsequent radiographs. CONCLUSION: The improper replacement of a G-tube can lead to devastating consequences. Verifying appropriate placement through aspirate evaluation can be misleading, and post-procedure radiographs increase radiation exposure and ED wait times. Bedside ultrasonography can be used to guide catheter insertion while providing a safe and quick adjunct to confirm proper G-tube placement.

A randomized controlled trial of ultrasound-assisted lumbar puncture.

OBJECTIVE: Evidence showing the systematic utility of ultrasound imaging during lumbar puncture (LP) in the emergency department is lacking. Our hypothesis was that ultrasound-assisted LP would increase the success rate and ease of performing LP with a greater benefit in obese patients. METHODS: This was an Institutional Review Board-approved, randomized, prospective, double-blind study conducted at the emergency department of a teaching institution. Patients undergoing LP from January to December 2004 were eligible for enrollment. Patients were randomized to undergo LP using palpation landmarks (PLs) or ultrasound landmarks (ULs). Data collected included age, body mass index, number of attempts, ease of performance and patient comfort on a 10-cm Visual Analog Scale, procedure time, success, and traumatic LP. Statistical analysis of data included relative risk (RR), the Mann-Whitney U test, and the Student t test. RESULTS: A total of 46 patients were enrolled, 22 randomized to PLs and 24 to ULs. There were no differences between the groups in mean age or body mass index. Six of 22 attempts failed with PLs versus 1 of 24 with ULs (RR, 1.32; 95% confidence interval, 1.01-1.72). In 12 obese patients, 4 of 7 PL attempts failed versus 0 of 5 UL attempts (RR, 2.33; 95% confidence interval, 0.99-5.49). The ease of the procedure was better with ULs versus PLs. There were no statistical differences in the number of attempts, traumatic LPs, patient comfort, or procedure length. CONCLUSIONS: The use of ultrasound for LP significantly reduced the number of failures in all patients and improved the ease of the procedure in obese patients.

Impending cardiac tamponade: a case report highlighting the value of bedside echocardiography.

Cardiac tamponade is a life-threatening process that must be diagnosed and treated in a timely fashion. As blood fills the pericardial sac, right ventricular filling is impeded and cardiac output is diminished, ultimately leading to cardiovascular collapse. Fortunately, emergency ultrasonography has improved the way we manage these patients today. In this report, we discuss a patient with hypotension and tachycardia who was found to have a massive loculated posterior pericardial effusion with impending cardiac tamponade. The diagnosis and appropriate treatment of this patient were rapidly ascertained with the use of bedside echocardiography. We review the literature on emergency ultrasonography, and consider the numerous instances in which emergency echocardiography can be life-saving.