Background Information: The successful placement of an endotracheal tube (ETT) is a necessary skill all emergency physicians must possess. Performing life-saving interventions are understandably stressful as their failure can lead to morbid consequences and expedited patient death.1,2 The intensive training of emergency physicians, the availability of multiple alternative airway adjuncts and the use of rapid-sequence intubation has helped reduce the intubation complication rate among trauma and medical patients.3-5 Confirmatory methods to ensure the placement of the endotracheal tube are ever changing with no single method being infallible.6. Physical exam findings such as auscultation of the chest and epigastrium, visualization of thoracic movement and fogging of the ETT are not sufficiently reliable to confirm placement.7,8 The use of end-tidal CO2 detection has been shown to have a cumulative false-positive and false-negative failure rate of 10% in accurately confirming the ETT’s location according to the authors of this paper (The paper referenced is a bit dated).6 Furthermore, the usage of these devices may contribute to the complications as they frequently require up to 5 ventilations to obtain an accurate reading.9-11 This puts the patient at risk for aspiration especially if the tube is in the esophagus. No.12 Despite a post-intubation CXR taking time, exposing the patient to more radiation and adding to the cost of treatment, it still continues to remain the standard of care.12-14 The authors of this study wished to better understand the test characteristics of utilizing ultrasound to confirm ETT placement. They conducted a systematic review and meta-analysis to quantify the accuracy of this ETT confirmatory method. Read more →
Tag Archive for: POCUS
Background: Focused use of ultrasound in resuscitation of patients with shock and cardiac arrest has become increasingly embraced in both the emergency department (ED) as well as in the prehospital setting. Application of ultrasound, particularly of echocardiography, has the potential to identify treatable causes of shock and arrest, identify shockable rhythms and identify the presence of mechanical activity. All of these can affect management decisions and, potentially effect outcomes. Recent studies have led to concerns that integration of point of care ultrasound (POCUS) in cardiac arrest increases pauses in compressions. Thus, it is important to establish what POCUS adds to shock and arrest management. Read more →
I was working a busy shift in the ED, like many of us do, and the next patient I was going to see was a 57 year old male with no real medical problems complaining of chest pain. I remember thinking as I walked into the room this guy looks ashen and diaphoretic….he doesn’t look well. He is a paramedic telling me how he has been having off and on chest pain for the past several months. He just had a stress test two months ago that was “negative”. Today he was working on his pool and developed the same chest discomfort as he had been having off and on the past several months, but today, the pain would just not go away. In his mind, he thought this might be an ulcer and just needed some Pepcid to help. He got put on the monitor and an ECG was run…
The patient involved in this case has given permission to share the story, and relevant images with the knowledge that this information will be used for the purposes of education.
Background: The provision of high-quality compressions with minimal interruptions is central to the management of cardiac arrest. Along with defibrillation, high-quality compressions are the only interventions proven to improve patient-oriented outcomes. Recently, point-of-care ultrasound (POCUS) has gained greater use in cardiac arrest care for determination the cause of arrest as well as guiding the resuscitation and interventions. Performance of POCUS during arrest can be challenging particularly in terms of obtaining cardiac windows. Among these challenges is obtaining images of the heart during compressions. As a result, cardiac POCUS is often performed during rhythm checks when there is a scheduled pause in compressions. Despite the potential benefit from POCUS in cardiac arrest, prolonged interruptions in compressions while attempting to get optimal windows is unlikely to benefit the patient and, may be harmful. Read more →
Background: Point of Care Ultrasound (POCUS) has gained wider use in resuscitation of patients presenting with cardiac arrest. POCUS can play an important role in determining the etiology of arrest as well as being used to determine the presence or absence of mechanical activity. The REASON study demonstrated that patients with PEA or asystole without cardiac activity on POCUS are extremely unlikely to survive to hospital discharge though this study did not investigate the more important question of a survival with a good neurologic outcome. (Gaspari 2016). In light of this as well as other evidence, some have proposed that the absence of cardiac activity may be adequate to declare resuscitation futility and stop resuscitative efforts. However, there is a lack of agreement on what defines cardiac activity (see table 1). Due to this, and other factors, the level of agreement between physicians in interpretation of cardiac standstill is unknown. Read more →