Point-of-care ultrasound-guided regional anaesthesia in older ED patients with hip fractures: a study to test the feasibility of a training programme and time needed to complete nerve blocks by ED physicians after training.

OBJECTIVES: Point-of-care ultrasound-guided regional anaesthesia (POCUS-GRA) provides safe, rapid analgesia for older people with hip fractures but is rarely performed in the emergency department (ED). Self-perceived inadequate training and time to perform POCUS-GRA are the two most important barriers. Our objective is to assess the feasibility of a proposed multicentre, stepped-wedge cluster randomised clinical trial (RCT) to assess the impact of a knowledge-to-practice (KTP) intervention on delirium. DESIGN: Open-label feasibility study. SETTING: An academic tertiary care Canadian ED (annual visits 60 000). PARTICIPANTS: Emergency physicians working at least one ED shift per week, excluding those already performing POCUS-GRA more than four times per year. INTERVENTION: A KTP intervention, including 2-hour structured training sessions with procedure bundle and email reminders. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary feasibility outcome is the proportion of eligible physicians that completed training and subsequently performed POCUS-GRA. Secondary outcome is the time needed to complete POCUS-GRA. We also test the feasibility of the enrolment, consent and randomisation processes for the future stepped-wedge cluster RCT (NCT02892968). RESULTS: Of 36 emergency physicians, 4 (12%) were excluded or declined participation. All remaining 32 emergency physicians completed training and 31 subsequently treated at least one eligible patient. Collectively, 27/31 (87.1%) performed 102 POCUS-GRA blocks (range 1-20 blocks per physician). The median (IQR) time to perform blocks was 15 (10-20) min, and reduction in pain was 6/10 (3-7) following POCUS-GRA. There were no reported complications. CONCLUSION: Our KTP intervention, consent process and randomisation were feasible. The time to perform POCUS-GRA rarely exceeded 30 min, Our findings reinforce the existing data on the safety and effectiveness of POCUS-GRA, mitigate perceived barriers to more widespread adoption and demonstrate the feasibility of trialling this intervention for the proposed stepped-wedge cluster RCT. TRIAL REGISTRATION NUMBER: Clinicaltrials.gov #02892968.

Is B-mode ultrasound alone a sufficient screening tool for carotid stenosis? A pilot study.

BACKGROUND: Carotid ultrasound is performed solely in hospital ultrasound departments or outpatient labs, using both B- and Doppler modes. We hypothesize that B-mode without Doppler can be used to classify patients as having carotid stenosis (CS) above or below 50%. Our objective is to determine the frequency with which a CS >50% is found using Doppler when no such stenosis was visible using B-mode. METHODS: This was a retrospective study of 100 patients referred to the stroke clinic and 100 patients referred for carotid endarterectomy (CEA). All patients had an elective carotid ultrasound done at Health Sciences North. The ultrasound reports were mixed together and blinded. Investigators determined if there was a CS of greater or less than 50% based on the carotid diagram. These results were compared to the degree of CS found on Doppler. RESULTS: In the CEA group, there were 198 ultrasounds, with 153 showing a CS of >50%. Only one case of CS >50% was missed by B-mode. In the clinic group, 32 of 192 ultrasounds showed a CS of >50%. None were missed by B-mode. B-mode had a sensitivity and negative predictive value of 100% and a specificity of 65%. CONCLUSION: This study supports the theory that it may be possible to use B-mode ultrasound without Doppler to reliably determine if there is CS above or below 50%. Further research is required before carotid ultrasound using B-mode alone can be recommended.

Acrometastasis and the potential benefits of early positron emission tomography scanning.

A case report of a rare proximal phalanx metastasis from a primary lung carcinoma is described. The presenting symptom of the patient was pain in the proximal phalanx of the index finger. Radiographs at the time of presentation were unremarkable, and no diagnosis was provided. Because of increasing pain and eventual swelling, the patient presented for emergency assessment. Radiographs, less than 3 months after initial assessment, demonstrated a large lytic lesion within the proximal phalanx. Biopsy of the lesion documented a large cell malignancy consistent with a poorly differentiated adenocarcinoma. Subsequent investigations documented an occult lung neoplasm. The patient underwent palliative ray resection followed by the initiation of palliative chemotherapy for the primary carcinoma. A brief review of literature regarding acrometastases is provided and the potential benefit of early positron emission tomography scanning is discussed.