Novel Approach to Ultrasound-Guided Thoracostomy.

OBJECTIVES: Thoracostomy is often a required treatment in patients with thoracic trauma; however, performing a thoracostomy using traditional techniques can have complications. Ultrasound can be a beneficial tool for identifying the correct thoracostomy insertion site. We designed a randomized prospective study to assess if ultrasound guidance can improve thoracostomy site identification over traditional techniques. METHODS: Emergency medicine residents were randomly assigned to use palpation or ultrasound to identify a safe insertion site for thoracostomy placement. The target population comprised of hemodynamically stable trauma patients who received an extended focused assessment with sonography for trauma (EFAST) and a chest computed tomography (CT) exam. The resident placed a radiopaque marker on the skin of the patient where a safe intercostal space was believed to be located, either by palpation or ultrasound. Clinical ultrasound faculty reviewed the CT to confirm marker placement relative to the diaphragm. A Fischer's exact test was used to analyze the groups. RESULTS: One hundred and forty-seven patients were enrolled in the study, 75 in the ultrasound group and 72 in the landmark group. This resulted in the placement of 271 total thoracostomy site markers, 142 by ultrasound and 129 by palpation and landmarks. The ultrasound group correctly identified thoracostomy insertion sites above the diaphragm in 97.2% (138/142) of patients, while the palpation group identified a safe insertion site in 88.4% (114/129) of patients (P = .0073). CONCLUSION: This study found that emergency medicine residents are more likely to identify a safe tube thoracostomy insertion site in trauma patients by using ultrasound, as compared to using landmarks and palpation.

Feasibility of focused cardiac ultrasound during cardiac arrest in the emergency department.

BACKGROUND: Focused cardiac ultrasound (FOCUS) can aid in evaluation and management of patients with cardiac arrest, but image quality in this population has been questioned. Our goal was to determine how often adequate imaging can be obtained in cardiac arrest patients. METHODS: We conducted a prospective cohort study to examine the utility of FOCUS in cardiac arrest. All patients who presented to the Emergency Department (ED) in cardiac arrest or who had cardiac arrest while in the ED over 6 months were prospectively identified. FOCUS images were obtained as part of routine clinical care. Patients with images obtained were paired with age- and gender-matched controls who underwent FOCUS for another indication during the study period. Image quality was scored by two blinded reviewers using a 0-4 scale, with a score of ≥ 2 considered adequate. RESULTS: There were 137 consecutive cardiac arrests, 121 out-of-hospital and 16 in-hospital, during the study period. FOCUS images were recorded in 126 (92%), who were included in the analysis. The average age was 58 years, and 45% were female. Ninety-seven studies (77%) were obtained during advanced cardiac life support while 29 (23%) were obtained after return of spontaneous circulation. The controls were appropriately matched. Of the cardiac arrest studies, 106 (84%) were rated adequate, compared to 116 (92%) in controls (p = 0.08). When compared to control FOCUS studies, the scores given to studies of cardiac arrest patients were lower (p = 0.001). CONCLUSIONS: FOCUS can reliably be used during cardiac arrest to obtain images adequate to answer clinical questions and guide therapies.

Focused Cardiac Ultrasound in Dyspnea of Unclear Etiology in the Emergency Department: Utility of the FLUID Score.

OBJECTIVES: We evaluated the utility of focused cardiac ultrasound to predict the length of stay in patients presenting to the emergency department with dyspnea of unclear etiology. METHODS: Patients with focused cardiac ultrasound examinations performed in the emergency department for dyspnea over a 34-month period were retrospectively identified. Patients were excluded if they had a prior diagnosis of heart failure, dialysis requirement, or an etiology of dyspnea unrelated to the volume status. Left ventricular function was categorized as normal or reduced, and the inferior vena cava was categorized as normal or increased volume. A fast limited ultrasound to investigate dyspnea (FLUID) score was calculated by adding 1 point for reduced left ventricular function and 1 point for increased volume, producing a score of 0, 1, or 2. RESULTS: There were 123 patients included. There was a significant correlation between the FLUID score and length of stay, with longer stays for higher scores (FLUID score 0, 7.4 hours median; FLUID score 1, 2.34 days; FLUID score 2, 5.56 days; analysis of variance P < .001). Of the other variables collected, only age, hypertension, diabetes, heart rate, and brain natriuretic peptide were significantly correlated with the length of stay. A multivariate analysis including those variables and the FLUID score showed that the FLUID score was the strongest independent predictor of the length of stay. CONCLUSIONS: Focused cardiac ultrasound and calculation of a FLUID score for patients with undifferentiated dyspnea can be a powerful tool to predict the hospital length of stay.

Central Venous Catheter Confirmation by Ultrasonography: A Novel Instructional Protocol.

OBJECTIVES: Ultrasound (US)-only confirmation of central venous catheter (CVC) placement has proven to be accurate and fast when compared with the current standard chest radiograph. This procedure depends on the detection of appropriately timed atrial bubbles during central line flushing, called the rapid atrial swirl sign (RASS). The most obvious barrier to increasing the use of this technique is appropriate education and training; therefore, we proposed a novel educational approach to training emergency department (ED) physicians in the confirmation of CVC location using US and then tested its effectiveness. METHODS: Using an online educational model, participants were taught the background and procedural steps to confirm CVC placement using US. Subsequently, they were asked to use this knowledge to place central lines in simulation and confirm them using US. They were tested with various scenarios, including correctly and incorrectly placed lines. Their accuracy was measured, and a survey was used to assess their satisfaction with the training and applicability to practice. RESULTS: A total of 47 ED physicians completed the online training module and 24 completed the simulation testing that followed. Results showed 100% accuracy in detecting appropriately timed RASS (<2 seconds), delayed RASS (>2 seconds), and no RASS in simulation. All of the participants "agreed" or "strongly agreed" that the didactic and simulation sessions improved their understanding of US confirmation of central line placement. CONCLUSIONS: The use of US to confirm central line placement can be effectively taught to ED physicians using short didactic and simulation-based training. This is a reasonable approach to integrate this protocol into practice, and allow for more widespread use of this emerging technique.

Comparison of Ultrasound-Guided and Landmark-Based Lumbar Punctures in Inexperienced Resident Physicians.

OBJECTIVES: We sought to determine whether US-guided lumbar puncture reduced the rate of lumbar puncture failures for providers at an academic teaching hospital with variable lumbar puncture and US experience compared to the traditional landmark-based technique. METHODS: We conducted a prospective randomized controlled trial to compare US-guided lumbar puncture to the traditional landmark technique in an academic emergency department. Thirty-five patients were randomized to either have their lumbar puncture performed either via the landmark or US-guided technique. All procedures were completed by an emergency medicine resident with variable lumbar puncture and US experience. Procedural failures, the number of attempts, the time to completion, and patient pain scores were all recorded. RESULTS: The adjusted odds ratio of successfully obtaining cerebrospinal fluid (CSF) in the US-guided lumbar puncture group was 2.31 compared to the landmark-based lumbar puncture group (P = .377). It took 1.54 times more attempts to obtain CSF in the landmark group as it did in the US group (P = .046). It seemed to have no effect on postprocedural pain or the time to obtain CSF. CONCLUSIONS: The use of US guidance to assist in lumbar punctures did not improve the procedural success rate over traditional landmark techniques in an academic setting with novice providers. Although using US for procedural guidance significantly decreased the number of attempts, it seemed to have no effect on postprocedural pain or the time to obtain CSF.

Diagnostic Yield and Accuracy of Bedside Echocardiography in the Emergency Department in Hemodynamically Stable Patients.

OBJECTIVES: The goal of this study was to determine the diagnostic yield of focused cardiac ultrasound (FOCUS) in hemodynamically stable patients in the emergency department and secondarily to confirm the accuracy of these studies when compared to formal echocardiography. METHODS: All hemodynamically stable adult patients who had an emergency physician-performed FOCUS examination completed over a 1-year period were identified using our electronic ultrasound database. Hemodynamic stability was defined as presenting systolic blood pressure higher than 90 mm Hg and not requiring any form of positive pressure ventilation. RESULTS: There were 1198 FOCUS examinations performed: 976 in hemodynamically stable patients who were included in our analysis. Twenty-seven percent of patients had new findings, including 154 (16%) new diagnoses of reduced left ventricular function, 105 (11%) new pericardial effusions, and 44 (5%) new diagnoses of RV dilatation. Dyspnea as an indication for the FOCUS examination was the strongest predictor of a positive study. Of patients included, 28% underwent formal echocardiography within 2 days and were analyzed for concordance with regard to left ventricular function and the presence of pericardial effusion. Of 270 studies, 208 were accurate, and 62 were inaccurate, for raw agreement of 77% (κ = 0.53). When stratified by sonographer experience, there was no impact on accuracy. CONCLUSIONS: Focused cardiac ultrasound in the emergency department for hemodynamically stable patients revealed new findings in 27% of studies, with a modest correlation with formal echocardiography. In stable patients, FOCUS has the potential for rapid diagnosis of cardiac disease, particularly in patients with dyspnea.

Perceived Difficulty and Success Rate of Standard Versus Ultrasound-Guided Peripheral Intravenous Cannulation in a Novice Study Group: A Randomized Crossover Trial.

OBJECTIVES: To our knowledge, no previous studies have evaluated the perceived levels of difficulty between traditional and ultrasound (US)-guided peripheral intravenous (IV) access in the novice provider. We attempt to show that, in a group of medical students who have limited peripheral IV experience, US-guided peripheral IV cannulation can be achieved more effectively and with a lesser degree of difficulty than standard peripheral IV cannulation. METHODS: We performed a randomized crossover study of 61 first- and second-year medical students. After a 1-hour training session, participants were randomized to either standard cannulation on a standard peripheral IV trainer or US-guided cannulation on a standard US IV trainer. RESULTS: One hundred percent (61 of 61) of the participants in the US-guided IV group successfully achieved cannulation versus 56% (34 of 61) of the participants in the standard IV group (P < .001). The average number of attempts to obtain access in the US-guided IV group was 1.31 versus 2.16 in the standard IV group (P < .001). The average difficulty score assigned to US-guided cannulation was 2.81 of 10 versus 3.90 of 10 in the standard IV group (P = .003). CONCLUSIONS: Our study shows a decrease in perceived difficulty and a concomitant increased ability to cannulate a vein using US versus traditional landmark guidance techniques, even in the novice phlebotomist.

Inter-rater reliability of optic nerve sheath diameter measurement using real-time ultrasonography.

OBJECTIVES: Ultrasound measurement of the optic nerve sheath diameter (ONSD) is a rapid, non-invasive means to indirectly assess intracranial pressure. Previous research has demonstrated the ability of emergency physicians to measure ONSD accurately with bedside ultrasound when compared to CT scan or MRI, however the reliability of this measurement between two or more operators has been called into question (Hassen et al. in J Emerg Med 48:450-457, 2015; Shirodkar et al. in Ind J Crit Care Med 19:466-470, 2015). Given the need for accurate and precise measurement to use this as a screening exam, we sought to determine the inter-rater reliability between ONSD measurements obtained in real time by fellowship-trained emergency ultrasound physicians. METHODS: Three ultrasound fellowship-trained emergency physicians measured bilateral ONSD of 10 healthy volunteers using a high-frequency linear transducer. The physicians were blinded to the other scanners' measurements, and no instructions were given other than to obtain the ONSD. Each sonographer measured the ONSD in real time and it was recorded by a research coordinator. All measurements were recorded in millimeters. Intraclass correlation coefficients (ICCs) were calculated to estimate the inter-rater reliability. RESULTS: A total of 60 measurements of ONSD were obtained. The average measurement was 4.3 mm (3.83-4.77). Very little variation was found between the three physicians, with a calculated ICC of 0.82 (95% confidence interval 0.63-0.92). CONCLUSIONS: ONSD measurement obtained by ultrasound fellowship-trained emergency medicine physicians is a reliable measurement with a high degree of correlation between scanners.

A retrospective evaluation of point of care ultrasound for acute cholecystitis in a tertiary academic hospital setting.

BACKGROUND: In 2008 the Council of Emergency Medicine Residency Directors delineated consensus recommendations for training in biliary ultrasound for the "detection of biliary pathology". OBJECTIVES: While studies have looked at the accuracy of emergency provider performed clinical ultrasound (ECUS), we sought to evaluated if ECUS could be diagnostic for acute cholecystitis and thus obviate the need for follow-up imaging. METHOD: We reviewed all ECUS performed between 2012 and 2017 that had a matching radiology performed ultrasound (RADUS) and a discharge diagnosis. 332 studies were identified. The sensitivity and specificity of both ECUS and RADUS were compared to the patient's discharge diagnosis. The agreement between the ECUS and RADUS was assessed using an unweighted Cohen's Kappa. The time from patient arrival to diagnosis by ECUS and RADUS was also compared. RESULTS: Using discharge diagnosis as the gold standard ECUS was 67% (56-78%) sensitive, 88% (84-92%) specific, NPV 90% (87-95%), PPV 60% (50-71%), +LR 5.6 (3.9-8.2), -LR 0.37 (0.27-0.52) for acute cholecystitis. RADUS was 76% (66-87%) sensitive, 97% (95-99%) specific, NPV 95% (092-97%), PPV 86% (76-95%), +LR 25.6 (12.8-51.4), and -LR 0.24 (0.15-0.38). ECUS was able to detect gallstones with 93% (89-96%) sensitivity and 94% (90-98%) specificity leading to a NPV 90% (85-95%), PPV of 95% (92-98%), +LR 14.5 (7.7-27.4), -LR 0.08 (0.05-0.13). The unweighted kappa between ECUS and RADUS was 0.57. The median time between obtaining ECUS vs. RADUS diagnosis was 124 min. CONCLUSIONS: ECUS can be beneficial in ruling out acute cholecystitis, but lacks the test characteristics to be diagnostic for acute cholecystitis.

Uvular necrosis after orotracheal intubation.

Most complications from general anesthesia are thought to be minor and require no specific treatment. Throat pain after general anesthesia is a relatively common complaint. However, uvular necrosis is an unusual complication after intubation that has been rarely reported. We describe a case of a 22-year-old man who presented with uvular necrosis 4 days after undergoing general anesthesia.

Ultrasound-guided thoracostomy site identification in healthy volunteers.

BACKGROUND: Traditional landmark thoracostomy technique has a known complication rate up to 30%. The goal of this study is to determine whether novice providers could more accurately identify the appropriate intercostal site for thoracostomy by ultrasound guidance. METHODS: 33 emergency medicine residents and medical students volunteered to participate in this study during routine thoracostomy tube education. A healthy volunteer was used as the standardized patient for this study. An experienced physician sonographer used ultrasound to locate a site at mid-axillary line between ribs 4 and 5 and marked the site with invisible ink that can only be revealed with a commercially available UV LED light. Participants were asked to identify the thoracostomy site by placing an opaque marker where they would make their incision. The distance from the correct insertion site was measured in rib spaces. The participants were then given a brief hands-on training session using ultrasound to identify the diaphragm and count rib spaces. The participants were then asked to use ultrasound to identify the proper thoracostomy site and mark it with an opaque marker. The distance from the proper insertion site was measured and recorded in rib spaces. RESULTS: The participants correctly identified the pre-determined intercostal space using palpation 48% (16/33) of the time, versus the ultrasound group who identified the proper intercostal space 91% (30/33) of the time. On average, the traditional technique was placed 0.88 rib spaces away (95 CI 0.43-1.03), while the ultrasound-guided technique was placed 0.09 rib spaces away (95 CI 0.0-0.19) [P = 0.003]. CONCLUSIONS: The ability to accurately locate the correct intercostal space for thoracostomy incision was improved under ultrasound guidance. Further studies are warranted to determine if this ultrasound-guided technique will decrease complications with chest tube insertion and improve patient outcomes.

Source-monitoring training: toward reducing rater expectancy effects in behavioral measurement.

The authors developed a source-monitoring procedure to reduce the biasing effects of rater expectations on behavioral measurement. Study participants (N = 224) were given positive or negative information regarding the performance of a group and, after observing the group, were assigned to a source-monitoring or control condition. Raters in the source-monitoring condition were instructed to report only behaviors that evoked detailed memories (remember judgments) and to avoid reporting behaviors based on feelings of familiarity (know judgments). Results revealed that controlling raters' response strategy reduced (and often eliminated) the biasing effects of performance expectations. These findings advance our understanding of the performance-cue bias and offer a potentially useful technique for decreasing rater bias.

Comparison of traditional versus high-fidelity simulation in the retention of ACLS knowledge.

OBJECTIVE: We performed a single-blinded, randomized controlled trial to evaluate the retention of advanced cardiac life support (ACLS) knowledge between high-fidelity simulation training (HFST) and traditional training (TT) in medical students. METHODS: Medical students were randomized to HFST or TT for their ACLS training. Students were then tested on 2 different mega-code scenarios immediately after their training and then 1-year later. A survey was performed asking their satisfaction of ACLS training and confidence of ACLS knowledge with a 10-point rating scale. RESULTS: 93 students were randomized with 86 completing the study (HFST=45, TT=41). The HFST group scored a higher percentage correct on initial testing than the TT group (83% vs. 70%, P<0.0001). However at 1-year follow up, both groups performed the same (66% vs. 66%, P=0.84). Satisfaction with training was higher with the HFST compared to the TT group (9.0 vs. 7.8, P<0.0001). Confidence in ACLS knowledge between HFST and TT groups were similar at baseline (6.9 vs. 6.5, P=0.18) and at 1-year (4.8 vs. 4.5, P=0.46). CONCLUSION: Students demonstrated greater ACLS knowledge initially with HFST than with TT. However, after 1-year, both groups performed the same. Satisfaction with training was higher with HFST compared to TT. Confidence in ACLS knowledge was the same initially and decreased similarly over a 1-year time period regardless of the type of ACLS training. Further studies will need to determine optimal strategies to retain ACLS knowledge.

Design, synthesis and evaluation of bifunctional inhibitors of type II dehydroquinase.

Inhibitors of type II dehydroquinase were designed to straddle the two distinct binding sites identified for the inhibitor (1S,3R,4R)-1,3,4-trihydroxy-5-cyclohexene-1-carboxylic acid and a glycerol molecule in a crystallographic study of the Streptomyces coelicolor enzyme. A number of compounds were designed to incorporate characteristics of both ligands. These analogues were synthesized from quinic acid, and were assayed against type I (Salmonella typhi) and type II (S. coelicolor) dehydroquinases. None of the analogues showed inhibition for type I dehydroquinase. Six of the analogues were shown to have inhibition constants in the micromolar to low millimolar range against the S. coelicolor type II dehydroquinase, while two showed no inhibition. The binding modes of the analogues in the active site of the S. coelicolor enzyme were studied by molecular docking with GOLD1.2. These studies suggest a binding mode where the ring is in a similar position to (1S,3R,4R)-1,3,4-trihydroxy-5-cyclohexene-1-carboxylic acid in the crystal structure and the side-chain occupies part of the glycerol binding-pocket.