Sounding out the future of ultrasound education.

As in so many other fields, the internet has revolutionised medical education. It has done this by circumventing the traditional constraints of medical education, in particular the availability of local resources such as teachers and textbooks. This "education revolution" has been most successful in the areas of theoretical knowledge. This article explores the available resources, and the challenges that arise when attempting to teach point-of-care ultrasound via the internet, such as the visuomotor and visuospatial skills required to create a diagnostic image. This article also describes the progress to date in this field.

Relationship between Trendelenburg tilt and internal jugular vein diameter.

OBJECTIVES: To evaluate the relationship between Trendelenburg tilt and internal jugular vein (IJV) diameter, and to examine any cumulative effects of tilt on the IJV diameter. METHODS: Using a tilt table, healthy volunteers were randomised to Trendelenburg tilts of 10 degrees, 15 degrees, 20 degrees, 25 degrees, and 30 degrees. Ultrasound was used to measure and record the lateral diameter of the right IJV at the level of the cricoid cartilage. Following each reading the table was returned to the supine position. Balanced randomisation was used to assess cumulative tilt effects. RESULTS: A total of 20 healthy volunteers were recruited (10 men, 10 women). Mean supine IJV diameter was 13.5 mm (95% CI 12.8 to 14.1) and was significantly greater at 10 degrees (15.5 mm, 95% CI 14.9 to 16.1). There was no significant difference between 10 degrees and greater angles of tilt. The effect of the previous angle of tilt did not prove to be statistically significant. CONCLUSION: Increasing the degree of Trendelenburg tilt increases the lateral diameter of the IJV. Even a 10 degrees tilt is effective. The cumulative effect of tilt (that is, the effect of the previous angle) is not significant. Ultrasound guided cannulation is ideal, but in its absence Trendelenburg tilt will increase IJV diameter and improve the chance of successful cannulation. While 25 degrees achieved optimum distension, this may not be practical and may be detrimental (for example, risk of raised intracranial pressure).

Survey of attitudes of senior emergency physicians towards the introduction of emergency department ultrasound.

INTRODUCTION: Emergency department ultrasound (EDU) is widely practised in the USA, Australia, parts of Europe, and Asia. EDU has been used in the UK since the late 1990s but as yet, few areas have established a practice. OBJECTIVES: To assess the current climate of opinion with respect to the practice, constraints, and establishment of EDU among emergency department (ED) consultants on the island of Ireland. METHODS: A postal questionnaire was formulated, piloted, and assessed for ambiguity by a sample of ED consultants and an independent non-ED consultant, prior to being mailed to all ED consultants in Ireland. RESULTS: Of the 58 consultants canvassed 46 (79%) responded. Of the respondents, 40 (87%) strongly agreed/agreed that EDU is appropriate and should be performed in the ED. Of these, 3 (7%) are currently performing EDU; 37 (80%) have not had formal training in EDU, however 42 (91%) support the establishment of national guidelines for training in focused ultrasound in the ED. Problems instituting EDU were often multifactorial. Commonly highlighted difficulties included financial issues (24 respondents, 52%) and radiology department support (16 respondents, 34%). Other cited problems include varying interdepartmental practices (15 respondents, 33%) and (for some EDs) low numbers of patients requiring EDU, with projected difficulties in skills maintenance. CONCLUSION: Despite the vast majority of ED consultants being in favour of EDU, very few actually perform it on a regular basis or have had any formal training. Highlighted difficulties in EDU implementation included financial constraints, lack of support from radiology departments, and lack of formal training.

Emergency department ultrasound (EDU): clinical adjunct or plaything?

BACKGROUND: Emergency department ultrasound (EDU) is a physician performed ultrasound service aimed at improving patient flow and diagnosis in the emergency department. METHODS: This paper describes the initial phase of the introduction of EDU with three illustrative case reports and a discussion on the pitfalls and benefits of EDU. RESULTS AND DISCUSSION: In three cases discussed here, the use of EDU facilitated treatment and reduced the need for formal radiological scanning. While there are drawbacks to EDU, we believe these are far outweighed by the advantages, and in a recent survey of emergency medicine consultants throughout Ireland, the vast majority were in favour of its introduction. CONCLUSION: EDU has become a routine part of our clinical practice, and although we are still on a learning curve with regard to its use, we have experienced significant benefits in patient care. With technological advances (such as improved image resolution and teleradiology) the potential for EDU will continue to expand, but training, practice, accreditation, and audit are essential.

Use of propofol infusion in Australian and New Zealand paediatric intensive care units.

Despite the risk of propofol infusion syndrome, a rare but often fatal complication of propofol infusion in ventilated children and possibly adults, propofol infusion remains in use in paediatric intensive care units (PICU). This questionnaire study surveys the current pattern of use of this sedative infusion in Australian and New Zealand PICUs. Thirty-three of the 45 paediatric intensive care physicians surveyed (73%), from 12 of the 13 intensive care units, returned completed questionnaires. The majority of practitioners (82%) use propofol infusion in children in PICU, the main indication being for short-term sedation in children requiring procedures. 39% of respondents consider propofol infusion useful in ventilated children requiring longer-term sedation. 67% of paediatric intensivists use maximum infusion doses that may be considered dangerously high (> or = 10 mg/kg/h). Nineteen per cent use propofol infusion for prolonged periods (> 72 hours). A smaller proportion (15%) of respondents indicate that they may use both higher doses and prolonged periods of infusion, a practice likely to lead to a greater chance of serious adverse events. Knowledge of local protocols for the use of propofol infusion is associated with a significantly greater level of monitoring for possible adverse events. We suggest that national guidelines for the use of propofol infusion in children should be developed. These should include clear indications and contraindications to its use, a maximum dose rate and maximum period of infusion, with a ceiling placed on the cumulative dose given and clearly stated minimum monitoring requirements.