Ascending Thoracic Aortic Dissection: A Case Report of Rapid Detection Via Emergency Echocardiography with Suprasternal Notch Views.

Aortic dissection is a life-threatening, time-sensitive emergency. Conventional diagnostic imaging modalities such as computed tomography (CT) can be time-consuming to obtain, and require that the patient leave the emergency department (ED); as such, they are unsuitable for unstable patients. Emergency focused transthoracic echocardiography (ETTE) is commonly performed in the ED as part of the evaluation of a patient presenting with chest pain, but the suprasternal notch view (SSNV) is much less well-known and infrequently included in this assessment. We present a case of a 51-year-old previously healthy man who presented to the ED complaining of chest pain that had resolved prior to arrival, and a mild headache. His vital signs were notable for hypotension, but physical exam was unremarkable. Chest x-ray revealed a borderline widened mediastinum. A standard ETTE was within normal limits, but additional SSNV demonstrated a dissection flap in the aortic arch. The patient was taken to the operating room for surgical repair 75 minutes after the ED ultrasound was performed; the operation was successful, and the patient was discharged to home post-operatively with good outcome. Standard ETTE has limited ability to visualize the ascending aorta and aortic arch. Addition of SSNV allows visualization of these structures and may improve diagnostic accuracy and time to diagnosis of proximal aortic dissection. Topics: Aortic dissection, emergency echocardiography, point-of-care ultrasound, POCUS, emergency ultrasound, suprasternal notch view.

A Comprehensive Course for Teaching Emergency Cricothyrotomy.

Audience: This curriculum was developed for emergency medicine (EM) residents at the post-graduate year (PGY) 1-4 level, and attending EM physicians. It may be adapted for training of any healthcare provider or learner who might be required to perform an emergency cricothyrotomy, including emergency medical technicians, senior medical students, and advanced practice providers (ie, nurse practitioners and physician assistants); however, we did not specifically validate it for these providers. Introduction: Emergency cricothyrotomy (EC) is a lifesaving surgical procedure, often the option of last resort, used to secure the airway when other methods of airway control have failed or are not feasible. It is a high-risk procedure since it is infrequently performed, but it is time-sensitive and critical for survival when needed.1,2 Time-sensitive procedural skills such as EC are subject to relatively rapid decay,3,4 and unlike other high-risk procedures, in which just-in-time training (JITT) may improve real time procedural performance, the extreme time sensitivity of cricothryotomy precludes JITT as a feasible educational intervention to improve EC performance.5 As such, clinicians must periodically review the essential concepts and practice the physical actions of the procedure in order to build and maintain familiarity with the steps involved and to develop and maintain the muscle memory necessary to perform it quickly and confidently. Previous studies have shown that simulation-based training improves both confidence and competence in the performance of the simulated procedures,6,7 and that small group learning situations are effective for procedural learning.8,9Commercially produced mannequins are available to simulate cricothyrotomy. However, being made of plastic materials, they suffer from unrealistic "tissue" feel that is radically different from that of biologic tissue.10,11 Additionally, because they are mass-produced, they tend to be fairly homogeneous in their anatomic representations, lacking the variability encountered in the human population.We developed an inexpensive procedure simulator using commercially available porcine byproduct that more closely mimics the feel of cricothyrotomy in real life, and a comprehensive curriculum for instruction in, or review of, EC, intended for implementation in a small-group format. This publication is intended to provide interested educators with a comprehensive suite of materials for teaching EC at their own institution. Included are instructions for how to construct the simulator, an EC case scenario with discussion points, a PowerPoint didactic module covering the fundamental concepts of EC, and sample course evaluation forms that may be implemented directly or adapted to meet institutional requirements. Educational Objectives: After completing this activity, the learner will be able to:correctly describe the indications for and contraindications to emergency cricothyrotomycorrectly describe and identify on the simulator the anatomic landmarks involved in emergency cricothyrotomycorrectly list the required equipment and the sequence of the steps for the "standard" and "minimalist" variations of the proceduredemonstrate proper technique when performing a cricothyrotomy on the simulator without prompts or pauses. Educational Methods: Small group activity combining didactic learning, case-based learning, and procedural simulation. The didactic component may be delivered in an asynchronous learning or "flipped classroom" format. Research Methods: The cricothyrotomy simulator was initially pilot-tested on a group of emergency medicine attending faculty, who were asked to evaluate the simulator, with results demonstrating that it was felt to be superior to typical plastic mannequin simulators. This simulator was then subsequently integrated into our airway workshops teaching EC, which include hands-on practice, didactic, and discussion components. The content and delivery of these workshops were assessed by the learners via standardized evaluation forms after completion of each workshop, and the overall clinical relevance, appropriateness of content, and satisfaction with the workshop format were highly rated (mean score 4.87 on a 5-point scale, with 5 denoted as "Excellent"). Discussion: The real-tissue model to simulate the procedure was well liked by course participants, and the learning environment was felt to be conducive to asking questions and discussion. Overall, the instructors and the learners felt that the workshops were effective in improving understanding of the procedure and increasing the comfort level and skill of the emergency physician learners in performing the procedure. Topics: Cricothyrotomy, cricothyroidotomy, emergency airway, surgical airway, failed airway, rescue airway, can't intubate can't ventilate, small group activity, simulation.

Emergency Medicine Resident Assessment of the Emergency Ultrasound Milestones and Current Training Recommendations.

OBJECTIVES: Emergency ultrasound (EUS) has been recognized as integral to the training and practice of emergency medicine (EM). The Council of Emergency Medicine Residency-Academy of Emergency Ultrasound (CORD-AEUS) consensus document provides guidelines for resident assessment and progression. The Accredited Council for Graduate Medical Education (ACGME) has adopted the EM Milestones for assessment of residents' progress during their residency training, which includes demonstration of procedural competency in bedside ultrasound. The objective of this study was to assess EM residents' use of ultrasound and perceptions of the proposed ultrasound milestones and guidelines for assessment. METHODS: This study is a prospective stratified cluster sample survey of all U.S. EM residency programs. Programs were stratified based on their geographic location (Northeast, South, Midwest, West), presence/absence of ultrasound fellowship program, and size of residency with programs sampled randomly from each stratum. The survey was reviewed by experts in the field and pilot tested on EM residents. Summary statistics and 95% confidence intervals account for the survey design, with sampling weights equal to the inverse of the probability of selection, and represent national estimates of all EM residents. RESULTS: There were 539 participants from 18 residency programs with an overall survey response rate of 85.1%. EM residents considered several applications to be core applications that were not considered core applications by CORD-AEUS (quantitative bladder volume, diagnosis of joint effusion, interstitial lung fluid, peritonsillar abscess, fetal presentation, and gestational age estimation). Of several core and advanced applications, the Focused Assessment with Sonography in Trauma examination, vascular access, diagnosis of pericardial effusion, and cardiac standstill were considered the most likely to be used in future clinical practice. Residents responded that procedural guidance would be more crucial to their future clinical practice than resuscitative or diagnostic ultrasound. They felt that an average of 325 (301-350) ultrasound examinations would be required to be proficient, but felt that number of examinations poorly represented their competency. They reported high levels of concern about medicolegal liability while using EUS. Eighty-nine percent of residents agreed that EUS is necessary for the practice of EM. CONCLUSIONS: EM resident physicians' opinion of what basic and advanced skills they are likely to utilize in their future clinical practice differs from what has been set forth by various groups of experts. Their opinion of how many ultrasound examinations should be required for competency is higher than what is currently expected during training.

Perceived barriers in the use of ultrasound in developing countries.

BACKGROUND: Access to ultrasound has increased significantly in resource-limited settings, including the developing world; however, there remains a lack of sonography education and ultrasound-trained physician support in developing countries. To further investigate this potential knowledge gap, our primary objective was to assess perceived barriers to ultrasound use in resource-limited settings by surveying care providers who practice in low- and middle-income settings. METHODS: A 25-question online survey was made available to health care providers who work with an ultrasound machine in low- and middle-income countries (LMICs), including doctors, nurses, technicians, and clinical officers. This was a convenience sample obtained from list-serves of ultrasound and radiologic societies. The survey was analyzed, and descriptive results were obtained. RESULTS: One hundred and thirty-eight respondents representing 44 LMICs including countries from the continents of Africa, South America, and Asia completed the survey, with a response rate of 9.6 %. Ninety-one percent of the respondents were doctors, and 9 % were nurses or other providers. Applications for ultrasound were diverse, including obstetrics (75 %), DVT evaluation (51 %), abscess evaluation (54 %), cardiac evaluation (64 %), inferior vena cava (IVC) assessment (49 %), Focused Assessment Sonography for Trauma (FAST) exam (64 %), biliary tree assessment (54 %), and other applications. The respondents identified the following barriers to use of ultrasound: lack of training (60 %), lack of equipment (45 %), ultrasound machine malfunction (37 %), and lack of ultrasound maintenance capability (47 %). Seventy-four percent of the respondents wished to have further training in ultrasound, and 82 % were open to receiving distance learning or telesonography training. Subjects used communication tools including Skype, Dropbox, emailed photos, and picture archiving and communication system (PACS) as ways to communicate and receive feedback on ultrasound images. CONCLUSIONS: Health care providers in the developing world identify lack of training as a primary barrier to regular use of ultrasound in their practice. While equipment requirements including maintenance and cost of machines are also important factors, future research is warranted on best practices for training methods, including telesonography and distance learning to enhance ultrasound use in low-resource settings.

Impact of point-of-care ultrasound training on surgical residents' confidence.

OBJECTIVE: Point-of-care ultrasound (POCUS) is a vital tool for diagnosis and management of critically ill patients, particularly in resource-limited settings where access to diagnostic imaging may be constrained. We aimed to develop a novel POCUS training curriculum for surgical practice in the United States and in resource-limited settings in low- and middle-income countries and to determine its effect on surgical resident self-assessments of efficacy and confidence. DESIGN: We conducted an observational cohort study evaluating a POCUS training course that comprised 7 sessions of 2 hours each with didactics and proctored skills stations covering ultrasound applications for trauma (Focused Assessement with Sonography for Trauma (FAST) examination), obstetrics, vascular, soft tissue, regional anesthesia, focused echocardiography, and ultrasound guidance for procedures. Surveys on attitudes, prior experience, and confidence in point-of-care ultrasound applications were conducted before and after the course. SETTING: General Surgery Training Program in Seattle, Washington. PARTICIPANTS: A total of 16 residents participated in the course; 15 and 10 residents completed the precourse and postcourse surveys, respectively. RESULTS: The mean composite confidence score from pretest compared with posttest improved from 23.3 (±10.2) to 37.8 (±6.7). Median confidence scores (1-6 scale) improved from 1.5 to 5.0 in performance of FAST (p < 0.001). Residents reported greater confidence in their ability to identify pericardial (2 to 4, p = 0.009) and peritoneal fluid (2 to 4.5, p < 0.001), to use ultrasound to guide procedures (3.5 to 4.0, p = 0.008), and to estimate ejection fraction (1 to 4, p = 0.004). Both before and after training, surgical residents overwhelmingly agreed with statements that ultrasound would improve their US-based practice, make them a better surgical resident, and improve their practice in resource-limited settings. CONCLUSIONS: After a POCUS course designed specifically for surgeons, surgical residents had improved self-efficacy and confidence levels across a broad range of skills.

BE-SAFE: Bedside sonography for assessment of the fetus in emergencies: educational intervention for late-pregnancy obstetric ultrasound.

INTRODUCTION: Late obstetric emergencies are time critical presentations in the emergency department. Evaluation to ensure the safety of mother and child includes rapid assessment of fetal viability, fetal heart rate (FHR), fetal lie, and estimated gestational age (EGA). Point-of-care (POC) obstetric ultrasound (OBUS) offers the advantage of being able to provide all these measurements. We studied the impact of POC OBUS training on emergency physician (EP) confidence, knowledge, and OBUS skill performance on a live model. METHODS: This is a prospective observational study evaluating an educational intervention we designed, called the BE-SAFE curriculum (BEdside Sonography for the Assessment of the Fetus in Emergencies). Subjects were a convenience sample of EP attendings (N=17) and residents (N=14). Prior to the educational intervention, participants completed a self-assessment survey on their confidence regarding OBUS, and took a pre-test to assess their baseline knowledge of OBUS. They then completed a 3-hour training session consisting of didactic and hands-on education in OBUS. After training, each subject's time and accuracy of performance of FHR, EGA, and fetal lie was recorded. Post-intervention knowledge tests and confidence surveys were administered. Results were compared with non-parametric t-tests. RESULTS: Pre- and post-test knowledge assessment scores for previously untrained EPs improved from 65.7% [SD=20.8] to 90% [SD=8.2] (p<0.0007). Self-confidence on a scale of 1-6 improved significantly for identification of FHR, fetal lie, and EGA. After training, the average times for completion of OBUS critical skills were as follows: cardiac activity (9s), FHR (68.6s), fetal lie (28.1s), and EGA (158.1 sec). EGA estimates averaged 28w0d (25w0d-30w6d) for the model's true gestational age of 27w0d. CONCLUSION: After a focused POC OBUS training intervention, the BE-SAFE educational intervention, EPs can accurately and rapidly use ultrasound to determine FHR, fetal lie, and estimate gestational age in mid-late pregnancy.

Use of ultrasound guidance for central venous catheter placement: survey from the American Board of Emergency Medicine Longitudinal Study of Emergency Physicians.

OBJECTIVES: The objective was to survey practicing emergency physicians (EPs) across the United States regarding the frequency of using ultrasound (US) guidance in central venous catheter (CVC) placement and, secondarily, to determine factors associated with the use or barriers to the use of US guidance. METHODS: This was a cross-sectional survey mailed to presumed practicing EPs as part of the American Board of Emergency Medicine (ABEM)'s longitudinal study of EPs. The selection process used stratified, random sampling of cohorts thought to represent four different stages within the development of the specialty of emergency medicine (EM). Multivariable logistic regression was used to identify independent factors associated with both high comfort using US guidance and high-percentage usage of US guidance. RESULTS: The survey was mailed to 1,165 subjects, and the response rate was 79%. The median number of years of practice was 20 (interquartile range [IQR]=7 to 28 years). As their primary practice setting, 64% work in private or community hospitals, 60% received training in US-guided vascular access, and 44% never use US guidance in placing CVCs. Barriers differed in those who never use US and those who sometimes or always used US guidance. In those who never use US, top barriers were insufficient training (67%) and lack of equipment (25%). In those who use US, top barriers were the perceptions that US was too time-consuming (27%) and that the preferred site was not amenable to US (24%). Independent factors associated with high comfort and high-percentage use of US guidance were training in US-guided vascular access (adjusted odds ratio=5.1 [high comfort]; 95% confidence interval [CI]=2.6 to 10.1; adjusted odds ratio 11.1=(high percentage); 95% CI=5.0 to 24.8) and being a recent residency graduate. CONCLUSIONS: Among EPs, the translation of evidence to clinical practice regarding the benefits of US guidance for CVC placement is poor and still faces many barriers. Training and education are potentially the best ways to overcome such barriers.

Ultrasound guidance for central venous access by emergency physicians in colorado.

INTRODUCTION: To survey emergency physicians (EP) regarding the frequency of use of ultrasound guidance for placement of central venous catheters (UGCVC) and to assess their perceptions regarding the technique and barriers to its implementation. METHODS: A 25-question Web-based survey was e-mailed to all members of the Colorado chapter of the American College of Emergency Physicians with a listed e-mail address. A total of 3 reminders were sent to nonresponders. RESULTS: Responses were received from 116 out of 330 invitations. Ninety-seven percent (n = 112) of respondents indicated they have an ultrasound machine available in their emergency department, and 78% indicated they use UGCVC. Seventy-seven percent (n = 90) agreed with the statement, "Ultrasound guidance is the preferred method for central venous catheter placement in the emergency department." However, 23% of respondents stated they have received no specific training in UGCVC. Twenty-six percent (n = 28) of respondents stated they felt "uncomfortable" or "very uncomfortable" with UGCVC, and 47% cite lack of training in UGCVC as a barrier to performing the technique. CONCLUSION: Although the majority of surveyed EPs feel UGCVC is a valuable technique and do perform it, a significant percentage reported receiving no training in the procedure and also reported being uncomfortable performing it. Nearly half of those surveyed cited lack of training as a barrier to more widespread implementation of UGCVC. This suggests that there continues to be a need for education and training of EPs in UGCVC.

Use of sterile saline as a conduction agent for ultrasound visualization of central venous structures.

OBJECTIVE: To determine whether sterile saline as a conduction agent provides adequate visualization of anatomic structures to attempt ultrasound-guided vascular access. METHODS: This prospective study involved a convenience sample of adult patients (18 years and older) who presented to an urban academic ED during a 3-month study period. Each patient had three six-second ultrasound video clips obtained of the right internal jugular vein and surrounding structures utilizing three different conduction agents, water-based gel (the control), sterile saline or no conduction agent. Video clips were randomized and assigned a numeric code to blind reviewers to the conduction agent. They were then independently reviewed by two experts who determined whether anatomic structures were visualized with enough detail to perform ultrasound-guided vascular access. The reviewers also rated the overall image quality of each video clip using a 100 mm visual analogue scale (VAS). RESULTS: Forty-seven patients were included in the final analysis. The raw agreement was 100% (95% confidence intervals [CI]: 93-100%) with a kappa of 1.0 between the two reviewers in assessing whether they would be able to perform vascular access using the images obtained using saline as a conduction agent. The median VAS for gel across both reviewers was 92 (95% CI: 90-93) and the median VAS differences for saline and no medium were -3 (95% CI: -1 to -3) and -46 (95% CI: -22 to -61), respectively. CONCLUSIONS: The use of sterile saline as a conduction agent allows adequate visualization of anatomic structures to attempt ultrasound-guided vascular access.

Pilot study to determine the feasibility of training Army National Guard medics to perform focused cardiac ultrasonography.

OBJECTIVE: To assess the ability of Army National Guard combat medics to perform a limited bedside echocardiography (BE) to determine cardiac activity after a brief training module. METHODS: Twelve Army National Guard health care specialists trained to the level of emergency medical technician-basic (EMT-B) underwent an educational session consisting of a 5-minute lecture on BE followed by hands-on practical training. After the training session, each medic performed BEs, in either the subxiphoid (SX) or parasternal (PS) location at his or her discretion, on four healthy volunteers. The time required to complete the BE and the anatomic location of the examination (SX vs. PS) was documented. A 3-second video clip representing the best image was recorded for each BE. These clips were subsequently reviewed independently by two of the investigators with experience performing and interpreting BE; each BE was graded on a six-point scale designed for the study, the Cardiac Ultrasound Structural Assessment Scale (CUSAS). A score of 3 or greater was considered to be adequate to assess for the presence of cardiac activity. Where there was disagreement on the CUSAS score, the reviewers viewed the clip together and agreed on a consensus CUSAS score. We calculated the median time to completion and interquartile range (IQR) for each BE, the median CUSAS scores and IQR for examinations performed in the SX and PS locations, and kappa for agreement between the two reviewers on the CUSAS. RESULTS: A total of 48 BEs were recorded and reviewed. Thirty-seven of 48 (77%) were obtained in the SX location, and 11 of 48 (23%) were obtained in the PS location. Forty-four of 48 (92%) were scored as a 3 or higher on the CUSAS. Median time to completion of a BE was 5.5 seconds (IQR: 3.7-10.9 seconds). The median CUSAS score in the SX location was 4 (IQR: 4-5), and the median CUSAS score in the PS location was 4 (IQR: 4-4). Weighted kappa for the CUSAS was 0.6. CONCLUSION: With minimal training, the vast majority of the medics in our study were able to rapidly perform a focused BE on live models that was adequate to assess for the presence of cardiac activity.