Erratum: This Article Corrects: "Systemwide Clinical Ultrasound Program Development: An Expert Consensus Model".

[This corrects the article on p. 649 in vol. 19, PMID: 30013699.].

Systemwide Clinical Ultrasound Program Development: An Expert Consensus Model.

Clinical ultrasound (CUS) is integral to the practice of an increasing number of medical specialties. Guidelines are needed to ensure effective CUS utilization across health systems. Such guidelines should address all aspects of CUS within a hospital or health system. These include leadership, training, competency, credentialing, quality assurance and improvement, documentation, archiving, workflow, equipment, and infrastructure issues relating to communication and information technology. To meet this need, a group of CUS subject matter experts, who have been involved in institution- and/or systemwide clinical ultrasound (SWCUS) program development convened. The purpose of this paper was to create a model for SWCUS development and implementation.

Successful use of intra-arrest thrombolysis for electrical storm due to acute myocardial infarction.

Acute vascular thrombotic disease, including acute myocardial infarction and pulmonary embolism, accounts for 70% of sudden outpatient cardiac arrest. The role of intra-arrest thrombolytic administration aimed at reversing the underlying cause of cardiac arrest remains an area of debate with recent guidelines advising against routine use. We present a case of prolonged refractory ventricular fibrillation electrical storm in a patient who demonstrated intra-arrest electrocardiographic and sonographic markers confirming acute myocardial infarction. Return of spontaneous circulation was rapidly achieved after rescue intra-arrest bolus thrombolysis.Highlights of this case are discussed in the context of the current evidence for thrombolytic therapy in cardiac arrest with specific attention to the issue of patient selection.

The core content of clinical ultrasonography fellowship training.

The purpose of developing a core content for subspecialty training in clinical ultrasonography (US) is to standardize the education and qualifications required to provide oversight of US training, clinical use, and administration to improve patient care. This core content would be mastered by a fellow as a separate and unique postgraduate training, beyond that obtained during an emergency medicine (EM) residency or during medical school. The core content defines the training parameters, resources, and knowledge of clinical US necessary to direct clinical US divisions within medical specialties. Additionally, it is intended to inform fellowship directors and candidates for certification of the full range of content that might appear in future examinations. This article describes the development of the core content and presents the core content in its entirety.

Ultrasound-guided oblique approach for peripheral venous access in a phantom model.

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.

The effect of weight-based volume loading on the inferior vena cava in fasting subjects: a prospective randomized double-blinded trial.

OBJECTIVES: Inferior vena cava ultrasound (IVC-US) assessment has been proposed as a noninvasive method of assessing volume status. Current literature is divided on its ability to do so. The primary objective was to compare IVC-US changes in healthy fasting subjects randomized to either 10 or 30 mL/kg of intravenous (IV) fluid administration versus a control group that received only 2 mL/kg. METHODS: This was a prospective randomized double-blinded trial set in emergency department (ED) clinical care rooms. Volunteer subjects with no history of cardiac disease or hypertension fasted for 12 hours. Subjects were randomly assigned to receive IV 0.9% saline bolus of 2 (control group), 10, or 30 mL/kg over 30 minutes. IVC-US was performed before and 15 minutes after each fluid bolus. RESULTS: Forty-two fasting subjects were enrolled. Analysis of variance (ANOVA) comparison showed that IVC-US was unable to detect any significant difference between the control group and those given either 10 or 30 mL/kg fluid, whether using maximum or minimum IVC diameter or caval index (IVC-CI). The groups receiving 10 and 30 mL/kg each had a statistically significant change in IVC-CI; however, the 30 mL/kg group had no significant change in either of the mean IVC diameters. CONCLUSIONS: Overall, there were statistically significant differences in mean IVC-US measurements before and after fluid loading, but not between groups. Fasting asymptomatic subjects had a wide intersubject variation in both baseline IVC-US measurements and fluid-related changes. The degree of IVC-US change in association with graded acute volume loading was not predictably proportional between our subjects.

Ultrasound measurements of the saphenous vein in the pediatric emergency department population with comparison to i.v. catheter size.

BACKGROUND: Saphenous vein cutdown is a rare venous access procedure. Ultrasound (US) can assist with many vascular access procedures. OBJECTIVES: Our objective was to identify the saphenous veins (SVs) using US in pediatric emergency department (ED) patients, and to determine if the SV size allows for potential cannulation by different standard-size intravenous (i.v.) catheters. METHODS: This study was a prospective, observational convenience sample of 60 pediatric patients at an urban, regional referral pediatric ED. Inclusion criteria were children ages 1 through 12 years categorized into four age groups: 1-<2, 2-4, 5-7, and 8-12 years, with informed consent and assent. Investigators performed US examination using a 10-MHz multi-frequency transducer to identify the SV on both legs and measure the SV in short-axis view. The US measurements were then used to calculate the SV areas. Diameters of typical pediatric gauge (G) catheters (24G, 22G, 20G, 18G) were used to calculate catheter areas. RESULTS: Sixty patients were enrolled, with five SVs unable to be measured in 4 patients (1 patient with both SVs). For the remaining 115 (96%) SVs available for further analysis, the median age was 4 years (interquartile range [IQR] 2) and median weight was 22.7 kg (IQR 14.5). Mean area (mm(2)) of the right SV was 2.85 ± 1.9 and for the left SV, 2.88 ± 1.8. For our study group, the compatibility rates of different size i.v. catheters to fit the measured SV areas were as follows: 24G = 100%, 22G = 100%, 20G = 97.3%, and 18G =86.1%. CONCLUSIONS: US can localize the SV in pediatric ED patients. US size of the SV in various pediatric age ranges suggests that the SV may be a potential US venous access site with multiple-size i.v. catheters up to 18G.

Comparison of serial qualitative and quantitative assessments of caval index and left ventricular systolic function during early fluid resuscitation of hypotensive emergency department patients.

OBJECTIVES: The objective was to determine whether serial bedside visual estimates of left ventricular systolic function (LVF) and respiratory variation of the inferior vena cava (IVC) diameter would agree with quantitative measurements of LVF and caval index in hypotensive emergency department (ED) patients during fluid challenges. The authors hypothesized that there would be moderate inter-rater agreement on the visual estimates. METHODS: This prospective observational study was performed at an urban, regional ED. Patients were eligible for enrollment if they were hypotensive in the ED as defined by a systolic blood pressure (sBP) of <100 mm Hg or mean arterial pressure of ≤65 mm Hg, exhibited signs or symptoms of shock, and the treating physician intended to administer intravenous (IV) fluid boluses for resuscitation. Sonologists performed a sequence of echocardiographic assessments at the beginning, during, and toward the end of fluid challenge. Both caval index and LVF were determined by the sonologist in qualitative then quantitative manners. Deidentified digital video clips of two-dimensional IVC and LVF assessments were later presented, in random order, to an ultrasound (US) fellowship-trained emergency physician using a standardized rating system for review. Statistical analysis included both descriptive statistics and correlation analysis. RESULTS: Twenty-four patients were enrolled and yielded 72 caval index and LVF videos that were scored at the bedside prior to any measurements and then reviewed later. Visual estimates of caval index compared to measured caval index yielded a correlation of 0.81 (p < 0.0001). Visual estimates of LVF compared to fractional shortening yielded a correlation of 0.84 (p < 0.0001). Inter-rater agreement of respiratory variation of IVC diameter and LVF scores had simple kappa values of 0.70 (95% confidence interval [CI] = 0.56 to 0.85) and 0.46 (95% CI = 0.29 to 0.63), respectively. Significant differences in mean values between time 0 and time 2 were found for caval index measurements, the visual scores of IVC diameter variation, and both maximum and minimum IVC diameters. CONCLUSIONS: This study showed that serial visual estimations of the respiratory variation of IVC diameter and LVF agreed with bedside measurements of caval index and LVF during early fluid challenges to symptomatic hypotensive ED patients. There was moderate inter-rater agreement in both visual estimates. In addition, acute volume loading was associated with detectable acute changes in IVC measurements.

Important historical efforts at emergency department categorization in the United States and implications for regionalization.

This article is drawn from a report created for the American College of Emergency Physicians (ACEP) Emergency Department (ED) Categorization Task Force and also reflects the proceedings of a breakout session, "Beyond ED Categorization-Matching Networks to Patient Needs," at the 2010 Academic Emergency Medicine consensus conference, "Beyond Regionalization: Integrated Networks of Emergency Care." The authors describe a brief history of the significant national and state efforts at categorization and suggest reasons why many of these efforts failed to persevere or gain wider implementation. The history of efforts to categorize hospital (and ED) emergency services demonstrates recognition of the potential benefits of categorization, but reflects repeated failures to implement full categorization systems or limited excursions into categorization through licensing of EDs or designation of receiving and referral facilities. An understanding of the history of hospital and ED categorization could better inform current efforts to develop categorization schemes and processes.