Ultrasound-guided nerve blocks in emergency medicine practice: 2022 updates.

OBJECTIVES: In the Emergency Department (ED), ultrasound-guided nerve blocks (UGNBs) have become a cornerstone of multimodal pain regimens. We investigated current national practices of UGNBs across academic medical center EDs, and how these trends have changed over time. METHODS: We conducted a cross-sectional electronic survey of academic EDs with ultrasound fellowships across the United States. Twenty-item questionnaires exploring UGNB practice patterns, training, and complications were distributed between November 2021-June 2022. Data was manually curated, and descriptive statistics were performed. The survey results were then compared to results from Amini et al. 2016 UGNB survey to identify trends. RESULTS: The response rate was 80.5% (87 of 108 programs). One hundred percent of responding programs perform UGNB at their institutions, with 29% (95% confidence interval (CI), 20%-39%) performing at least 5 blocks monthly. Forearm UGNB are most commonly performed (96% of programs (95% CI, 93%-100%)). Pain control for fractures is the most common indication (84%; 95% CI, 76%-91%). Eighty-five percent (95% CI, 77%-92%) of programs report at least 80% of UGNB performed are effective. Eighty-five percent (95% CI, 66%-85%) of programs have had no reported complications from UGNB performed by emergency providers at their institution. The remaining 15% (95% CI, 8%-23%) report an average of 1 complication annually. CONCLUSIONS: All programs participating in our study report performing UGNB in their ED, which is a 16% increase over the last 5 years. UGNB's are currently performed safely and effectively in the ED, however practice improvements can still be made. Creating multi-disciplinary committees at local and national levels can standardize guidelines and practice policies to optimize patient safety and outcomes.

Prospective Evaluation of Venous Excess Ultrasound for Estimation of Venous Congestion.

BACKGROUND: Venous excess ultrasound (VExUS) is a novel ultrasound technique previously reported as a noninvasive measure of venous congestion and predictor of cardiorenal acute kidney injury. RESEARCH QUESTION: Are there associations between VExUS grade and cardiac pressures measured by right heart catheterization (RHC) and cardiac biomarkers and clinical outcomes in patients undergoing RHC? STUDY DESIGN AND METHODS: We conducted a prospective cohort study at the Denver Health Medical Center from December 20, 2022, to March 25, 2023. All patients undergoing RHC underwent a blinded VExUS assessment prior to their procedure. Multivariable regressions were conducted to assess relationships between VExUS grade and cardiac pressures, biomarkers, and changes in weight among patients with heart failure, a proxy for diuretic success. Receiver operating characteristic curve and area under the curve (AUC) were derived for VExUS, inferior vena cava (IVC) diameter, and IVC collapsibility index (ICI) to predict right atrial pressure (RAP) > 10 and < 7 mm Hg. RESULTS: Among 81 patients, 45 of whom were inpatients, after adjusting for age, sex, and Charlson Comorbidity Index, there were significant relationships between VexUS grade of 2 (ß = 4.8; 95% CI, 2.6-7.1; P < .01) and 3 (ß = 11; 95% CI, 8.9-14; P < .01) and RAP, VExUS grade of 2 (ß = 6.8; 95% CI, 0.16-13; P = .045) and 3 (ß = 15; 95% CI, 7.3-22; P < .01) and mean pulmonary artery pressure, and VExUS grade of 2 (ß = 7.0; 95% CI, 3.9-10; P < .01) and 3 (ß = 13; 95% CI, 9.5-17; P < .01) and pulmonary capillary wedge pressure. AUC values for VExUS, IVC diameter, and ICI as predictors of RAP > 10 mm Hg were 0.9 (95% CI, 0.83-0.97), 0.77 (95% CI, 0.68-0.88), and 0.65 (95% CI, 0.52-0.78), respectively. AUC values for VExUS, IVC diameter, and ICI as predictors of RAP < 7 mm Hg were 0.79 (95% CI, 0.70-0.87), 0.74 (95% CI, 0.64-0.84), and 0.62 (95% CI, 0.49-0.76), respectively. In a subset of 23 patients with heart failure undergoing diuresis, there was a significant association between VExUS grade 3 and change in weight between time of RHC and discharge (P = .025). INTERPRETATION: Although more research is required, VExUS has the potential to increase diagnostic and therapeutic capabilities of physicians at the bedside and increase our understanding of the underappreciated problem of venous congestion.

Application of Focused Assessment with Sonography for Trauma in the Intensive Care Unit.

The Extended-Focused Assessment with Sonography for Trauma (E-FAST) allows clinicians to rapidly diagnose traumatic thoracoabdominal injuries at the bedside without ionizing radiation. It has high specificity and is extremely useful as an initial test to rule in dangerous diagnoses such as hemoperitoneum, pericardial effusion, hemothorax, and pneumothorax. Its moderate sensitivity means that it should not be used alone as a tool to rule out dangerous thoracoabdominal injuries. In patients with a concerning mechanism or presentation, additional imaging should be obtained despite a negative FAST examination.

Disaster Preparedness for Clinics - Further Study from Haiti.

OBJECTIVE: This team created a manual to train clinics in low- and middle-income countries (LMICs) to effectively respond to disasters. This study is a follow-up to a prior study evaluating disaster response. The team returned to previously trained clinics to evaluate retention and performance in a disaster simulation. BACKGROUND: Local clinics are the first stop for patients when disaster strikes LMICs. They are often under-resourced and under-prepared to respond to patient needs. Further effort is required to prepare these crucial institutions to respond effectively using the Incident Command System (ICS) framework. METHODS: Two clinics in the North East Region of Haiti were trained through a disaster manual created to help clinics in LMICs respond effectively to disasters. This study measured the clinic staff's response to a disaster drill using the ICS and compared the results to prior responses. RESULTS: Using the prior study's evaluation scale, clinics were evaluated on their ability to set up an ICS. During the mock disaster, staff was evaluated on a three-point scale in 13 different metrics, grading their ability to mitigate, prepare, respond, and recover in a disaster. By this scale, both clinics were effective (36/39; 92%) in responding to a disaster. CONCLUSION: The clinics retained much prior training, and after repeat training, the clinics improved their disaster response. Future study will evaluate the clinics' ability to integrate disaster response with country-wide health resources to enable an effective outcome for patients.

Point-of-care Ultrasonography of a Rare Cause of Hemoperitoneum.

A young woman presented to the emergency department with lethargy, hemodynamic instability, and diffuse abdominal tenderness. On point-of-care ultrasound (PoCUS), she was found to have intraperitoneal free fluid and a large pelvic mass, which were discovered intraoperatively to be hemoperitoneum due to ruptured vessels of a uterine leiomyoma. Although rare, a life-threatening, ruptured leiomyoma may be treated surgically if recognized in an expedient fashion. A PoCUS can aid the emergency clinician in prompt diagnosis.