ABSTRACT
BACKGROUND: Ultrasound (US) vascular guidance is traditionally performed in transverse (T) and longitudinal (L) axes, each with drawbacks. We hypothesized that the introduction of a novel oblique (O) approach would improve the success of US-guided peripheral venous access. We examined emergency physician (EP) performance using the O approach in a gel US phantom. METHODS: In a prospective, case control study, EPs were enrolled from four levels of physician experience including postgraduate years one to three (PGY1, PGY2, PGY3) and attending physicians. After a brief training session, each participant attempted vessel aspiration using a linear probe in T, L, and O axes on a gel US phantom. Time to aspiration and number of attempts to aspiration were recorded. The approach order was randomized, and descriptive statistics were used. RESULTS: Twenty-four physicians participated. The first-attempt success rate was lower for O, 45.83%, versus 70.83% for T (p = 0.03) and 83.33% for L (p = 0.01). The average time to aspiration was 12.5 s (O) compared with 9.47 s (T) and 9.74 s (L), respectively. There were no significant differences between all four groups in regard to total amount of time and number of aspiration attempts; however, a trend appeared revealing that PGY3 and attending physicians tended to aspirate in less time and by fewer attempts in all three orientations when compared with the PGY2 and PGY1 physicians. CONCLUSION: In this pilot study, US-guided simulated peripheral venous access using a phantom gel model in a mixed user group showed that the novel oblique approach was not initially more successful versus T and L techniques.
ABSTRACT
OBJECTIVE: The identification and treatment of critical illness is often initiated by emergency medical services (EMS) providers. We hypothesized that emergency department (ED) patients with severe sepsis who received EMS care had more rapid recognition and treatment compared to non-EMS patients. METHODS: This was a prospective observational study of ED patients with severe sepsis treated with early goal-directed therapy (EGDT).We included adults with suspected infection, evidence of systemic inflammation, and either hypotension after a fluid bolus or elevated lactate. Prehospital and ED clinical variables and outcomes data were collected. The primary outcome was time to initiation of antibiotics in the ED. RESULTS: There were 311 patients, with 160 (51.4%) transported by EMS. Emergency medical services-transported patients had more organ failure (Sequential Organ Failure Assessment score, 7.0 vs 6.1; P = .02), shorter time to first antibiotics (111 vs 146 minutes, P = .001), and shorter time from triage to EGDT initiation (119 vs 160 minutes, P = .005) compared to non-EMS-transported patients. Among EMS patients, if the EMS provider indicated a written impression of sepsis, there was a shorter time to antibiotics (70 vs 122 minutes, P = .003) and a shorter time to EGDT initiation (69 vs 131 minutes, P = .001) compared to those without an impression of sepsis. CONCLUSIONS: In this prospective cohort, EMS provided initial care for half of the patients with severe sepsis requiring EGDT. Patients presented by EMS had more organ failure and a shorter time to both antibiotic and EGDT initiation in the ED.
