November 19, 2020

Background Information: Central venous catheterization is a common procedure performed in the ICU for the purposes of drug administration and resuscitation. The subclavian vein is the more preferred access site given its fixed puncture location, ease for nursing access and low incidence of infections.1 Landmark guided catheterization has a widely variable success rate and has been shown to increase the risk of complications such as hematoma formation and pneumothoraxes.2,3 The use of real-time ultrasound guidance has thus led to more central lines being placed in the internal jugular and femoral lines, however there is substantial debate regarding its use in subclavian vein catheterization.4,5 The authors of this study sought to compare the efficacy and safety of static ultrasound-guided puncture with traditional anatomic landmark guided subclavian vein puncture.

November 16, 2020

Background Information:

US vs Landmark for Radial Arterial LinesUltrasound guided peripheral and central venous access has become more common while simultaneously decreasing complications and increasing first pass success. Landmark guided palpation has historically been considered the standard of care when placing arterial lines, however the use of ultrasound is challenging that notion as anatomic landmarks are not helpful in 30% of patients.1 Additionally, increasing obesity and hemodynamic instability can make radial arterial line placement even more difficult when using landmark-guided palpation alone. The literature comparing the different methods of arterial line placement is limited to two prospective studies. The first assessed second- and third-year emergency medicine residents while the second study evaluated only four emergency medicine attendings, all with extensive ultrasound training and experience.2,3 The authors of this study sought to compare radial arterial line placement using ultrasound vs landmark guided palpation performed by novice emergency medicine interns with respect to overall success.

February 7, 2019

Welcome back to REBELCast.  In this episode we talked with Jacob Avila about US guided PIVs. Difficult IV access in an already busy department can be a frustrating thing, but it doesn’t have to be.  Patients and providers are often frustrated for different reasons.  Patients for multiple IV attempts and providers because of the time it can take to perform the procedure, delays in care, or lack of success. If you want to get better at this all-important procedure, read/listen on.

January 31, 2019

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.

August 20, 2015

As we have discussed in previous posts, the care of patients with cardiac arrest is a key skill for Emergency Providers. ACLS provides a foundation for care but is rife with shortcomings including, but not limited to, reliance on outdated data and inability to adapt in the face of improved understanding of cardiac arrest pathophysiology. The incorporation of technological advances and skills is another massive limitation of ACLS. One of these technologies is point of care ultrasound (POCUS).

Over the last two decades, POCUS has become a integral part of Emergency Medicine training and practice. POCUS allows for rapid, bedside diagnosis of a number of conditions including cholecystitis, urinary retention and ectopic pregnancy. Additionally, it is becoming a greater component in the management of the critical patient where it can be used to assess cardiac contractility, wall motion abnormalities, intraperitoneal free fluid and more. Application of POCUS in all patients with cardiac arrest is simply the next step. This diagnostic modality is not highlighted in the current iteration of ACLS but is a practice changer. The bottom line is that application of POCUS in cardiac arrest allows the emergency provider to guide resuscitation with a direct look into the body - we are no longer blind.

For this post, I want to discuss two ways that we can use ultrasound in cardiac arrest patients, specifically in pulseless electrical activity (PEA), in the Emergency Department:

  1. Assessment for the presence or absence of cardiac output and
  2. As an alternate framework to the Hs and Ts.
A quick disclaimer - I am not an ultrasound expert, I did not do a fellowship but I am passionate about it’s application in our sickest patients.