Comparison of Commonly Carried Liquids Against Commercial Ultrasound Gel for Use in the Backcountry Setting.

INTRODUCTION: Point-of-care ultrasound (POCUS) is utilized in austere environments because it is lightweight, durable, battery powered, and portable. In austere settings, weight and space constraints are limitations to carrying dedicated ultrasound gel. Few studies have assessed commonly carried liquids as gel alternatives. The study objective was to assess the suitability of common food and personal care products as ultrasound coupling agents compared with that of commercial gel. METHODS: A noninferiority study compared 9 products to commercial gel. Each substance was independently tested on 2 subjects by 2 sonographers covering 8 standardized ultrasound windows. Clips were recorded, blinded, and independently graded by 2 ultrasound fellowship-trained physicians on the ability to make clinical decisions and technical details, including contrast, resolution, and artifact. A 20% noninferiority margin was set, which correlates to levels considered to be of reliably sufficient quality by American College of Emergency Physicians' guidelines. The substances included water, soap, shampoo, olive oil, energy gel, maple syrup, hand sanitizer, sunscreen, and lotion. RESULTS: A total of 300 of 318 (94%) clips met the primary endpoint of adequacy to make a clinical decision. All media, except sunscreen, were noninferior to commercial gel in the ability to make a clinical decision (α=0.05). In terms of secondary outcomes, resolution, artifact, and contrast, all substances were noninferior to commercial gel (α=0.05). The sonographers concluded that all gel alternatives' usability performed similarly to commercial gel, with the exception of energy gel. CONCLUSIONS: Of the 9 substances tested, 8 were noninferior to commercial gels for clinical decisions. Our study indicates that several POCUS gel substitutes are serviceable to produce clinically adequate images.

Clinical utilization of a sous vide device in the acute rewarming of frostbitten extremities.

The current standard of care for acute frostbite rewarming is the use of a circulating warm water bath at a temperature of 37 °C to 39 °C. There is no standardized method to achieve this. Manual management of a warm water bath can be inefficient and time consuming. This case describes the clinical use of a sous vide cooking device to create and maintain a circulating warm water bath to rewarm acute frostbite. A 34 year-old male presented to the emergency department with acute frostbite. Each of the patient's feet were placed in a water bath with a sous vide device attached to the side of the basin and set to 38 °C. Temperatures were recorded every 2 m from 2 thermometers. Once target temperature was achieved, the extremities were rewarmed for 30 m. The water baths required an average of 25 m to reach target temperature and maintained the target temperature within ±1 °C for the duration of the rewarming. The extremities were clinically thawed in one session and there were no adverse events. The patient was seen by plastic and vascular surgery and admitted to the hospital for conservative management. He was discharged on hospital day 3 and did not require any amputations. A sous vide device can be used clinically to heat and maintain a water bath and successfully rewarm frostbitten extremities in one 30 m cycle. No adverse events were reported and providers rated this as a convenient method of water bath management.

Witnessed Cardiac Arrest in a Hypothermic Avalanche Victim Completely Buried for 2 Hours.

A 34-y-old skier triggered a wind slab avalanche and was completely buried for over 2 h. After extrication by rescuers, the victim was breathing and conscious. Despite directions from the rescuers against standing up, the victim struggled to free himself and ultimately stood upright before collapsing in cardiac arrest. The rescuers performed cardiopulmonary resuscitation during transport to a nearby trailhead, where a helicopter emergency medical services crew found that the victim was in ventricular fibrillation. After further resuscitative efforts, including advanced life support, the victim was declared dead at the scene. Afterdrop and circumrescue collapse were the most likely triggers of cardiac arrest. This case highlights a need for rescuers, emergency medical services, and hospitals to be prepared to care for victims with hypothermia. To prevent circumrescue collapse, victims with hypothermia should be extricated gently, should not be allowed to stand, and should be placed flat. This may be difficult or impossible, as in this case. Hypothermic victims in cardiac arrest may require prolonged cardiopulmonary resuscitation, preferably with mechanical compressions, during transport to a hospital that has protocols for rewarming using extracorporeal life support. Resuscitation from hypothermic cardiac arrest should not be terminated before the victim has been rewarmed.