Interscalene brachial plexus nerve block in the emergency department: an effective and practice-changing workshop.

BACKGROUND: The interscalene brachial plexus nerve block (ISNB) is a potentially useful method of regional analgesia for humerus fracture and shoulder dislocation reduction in the Emergency Department (ED). We examined the effectiveness of an ISNB workshop given to emergency medicine (EM) residents. We also explored complication rates and effectiveness of ISNBs performed in the ED. METHODS: One-hour evidence-based ISNB workshops were conducted with EM residents. Participants were given pre-, post-, and 3-month post-workshop knowledge and technical assessments. Results were analyzed using descriptive statistics. A pre- and post-workshop chart review examined ISNB utilization, complications, post-ISNB opiate administration, and post-ISNB procedural sedation. RESULTS: 41 residents enrolled in the workshop. Pre-workshop pass rate: knowledge assessment 22%. Immediate post-workshop pass rates: knowledge assessment 100%, image acquisition 93%, needle placement 100%. Three months post-workshop pass rates: knowledge assessment 73%, image acquisition 76%, needle placement 100%. Areas of poorest knowledge retention were anatomical landmarks, block distribution, and early signs of LAST. In the chart review, 2 ISNBs were performed in the pre-workshop period, and 12 in the post-workshop period. No serious complications were recorded. 78.5% of attempted ISNBs were successful, without need for procedural sedation. Of the 11 successfully performed ISNBs, 91% received no opiates after the procedure. CONCLUSIONS: Our study suggests that EM residents can learn the ISNB, perform it safely in the emergency department, and that the ISNB may be an alternative to procedural sedation and opiate use for shoulder dislocation. Residents are adept at ISNB technical skills but demonstrate some deficits in knowledge retention.

Does oral radiocontrast affect image quality of abdominal sonography?

OBJECTIVE: Emergency Department patients with abdominal pain may require both an ultrasound (US) and computed tomography (CT) for an accurate diagnosis. Patients are often asked to drink oral radiocontrast while awaiting ultrasound, in order to better expedite a CT in the case of a non-diagnostic US. The impact of oral radiocontrast on US image quality has not been studied. We compared the quality of US images obtained before and after the ingestion of oral radiocontrast in healthy adult volunteers. METHODS: This was a prospective study in which adult volunteer subjects underwent sonographic studies of the aorta, the right upper quadrant, the right lower quadrant, and the Focused Assessment with Sonography in Trauma (FAST) examination. Initial studies were performed prior to ingestion of oral radiocontrast, with subsequent imaging occurring at 1 and 2hour post-ingestion. All of the images from the sonographic exams were randomized and subsequently scored for quality by two emergency ultrasound fellowship trained emergency physicians with extensive experience in performing and interpreting US. RESULTS: 638 images from 240 exams were obtained from 20 subjects at three time points. Six exams were not scored due to inadequate images. There were no significant differences in image quality for any of the US exam types after the ingestion of oral radiocontrast at 1 and 2h. CONCLUSION: Ingestion of oral radiocontrast did not affect image quality of four common abdominal ultrasound examinations.

Inflating the endotracheal tube cuff with saline to confirm correct depth using bedside ultrasonography.

Although bedside ultrasonography can accurately distinguish esophageal from tracheal intubation, it is not used to establish the correct depth of endotracheal tube insertion. As indirect sonographic markers of endotracheal tube insertion depth have proven unreliable, a method for visual verification of correct tube depth would be ideal. We describe the use of saline to inflate the endotracheal cuff to confirm correct endotracheal tube depth (at the level of the suprasternal notch) by bedside ultrasonography during resuscitation. This rapid technique holds promise during emergency intubation.

Point-of-care ultrasound detection of acute scaphoid fracture.

In cases of traumatic wrist pain, emergency physicians must maintain a high index of suspicion for scaphoid fractures due to their potential for serious complications. A growing body of literature supports the use of point-of-care ultrasonography by emergency physicians in the evaluation of potential fractures. We report a case of a pediatric scaphoid fracture that was initially not visualized on x-ray and was subsequently detected using point-of-care ultrasound in the ED.

Tracheal rapid ultrasound saline test (T.R.U.S.T.) for confirming correct endotracheal tube depth in children.

OBJECTIVE: We evaluated the accuracy of tracheal ultrasonography of a saline-inflated endotracheal tube (ETT) cuff for confirming correct ETT insertion depth. METHODS: We performed a prospective feasibility study of children undergoing endotracheal intubation for surgery. Tracheal ultrasonography at the suprasternal notch was performed during transient endobronchial intubation and inflation of the cuff with saline, and with the ETT at a correct endotracheal position. Ultrasound videos were recorded at both positions, which were confirmed by fiberoptic bronchoscopy. These videos were shown to two independent blinded reviewers, who determined the presence or absence of a saline-inflated cuff. The primary outcome was accuracy of tracheal ultrasonography for appropriate ETT insertion depth. RESULTS: Forty-two patients were enrolled. For correct endotracheal versus endobronchial positioning, pooled results from the reviewers revealed a sensitivity of 98.8% (95% CI=90-100%), a specificity of 96.4% (95% CI=87-100%), a PPV of 96.5% (95% CI=87-100%), a NPV of 98.8% (95% CI=89-100%), a positive likelihood ratio of 32 (95% CI=6-185), and a negative likelihood ratio of 0.015 (95% CI=0.004-0.2). Agreement between reviewers was high (kappa co-efficient=0.93; 95% CI=0.86 to 1). The mean duration of the ultrasound exam was 4.0s (range 1.0-15.0s). CONCLUSIONS: Sonographic visualization of a saline-inflated ETT cuff at the suprasternal notch is an accurate and rapid method for confirming correct ETT insertion depth in children.