The ability of emergency nurses to detect simulated long bone fractures with portable ultrasound.

Fractures are a common emergency department (ED) diagnosis. Ultrasound is a useful tool to evaluate for the presence of long bone fractures and can be performed by minimally trained individuals. We examined the ability of ED nurses to sonographically detect long bone fractures using a recently described training model. The fracture model consisted of a turkey long bone within a firm gelatin matrix. Emergency nurses examined five fracture models with a portable ultrasound machine to determine the presence or absence of a fracture. Overall accuracy was compared via chi-square analysis to the ability of physicians to complete the same assessment. Thirty nurses sonographically assessed the models. An overall sensitivity of 98% (95% confidence interval: 92-99%) and specificity of 93% (95% confidence interval: 76-99%) was observed for the detection of a fractured model. No difference in fracture detection accuracy (p>0.05) was revealed compared to an evaluation by 30 ED physicians. While the clinical impact of this ability remains uncertain, future utilization of nursing ability to detect fractures by ultrasound may improve patient care in ways such as more efficient triaging of radiographs and the mobilization of resources for fracture reduction.

The ultrasound detection of simulated long bone fractures by U.S. Army Special Forces Medics.

INTRODUCTION: U.S. Army Special Forces Medics (18Ds) operate in austere environments where decisions regarding patient management may be limited by available resources. Portable ultrasound may allow for the detection of fractures in environments where other imaging modalities such as radiography are not readily available or practical. OBJECTIVE: We used a simulation training model for the ultrasound diagnosis of long bone fractures to study the ability of 18Ds to detect the presence or absence of a fracture using a portable ultrasound. METHODS: The fracture simulation model is composed of a bare turkey leg bone that is mechanically fractured and housed in a shallow plastic container within an opaque gelatin base solution. Five fracture patterns were created: transverse, segmental, oblique, comminuted, and no fracture. After a brief orientation session, twenty 18Ds evaluated the models in a blinded fashion with a SonoSite M-Turbo portable ultrasound device for the presence or absence of a fracture. RESULTS: 18Ds demonstrated 100% sensitivity (95% CI: 94.2% to 100%) in fracture detection and an overall specificity of 90% (95% CI: 66.8-98.2%) due to two false positive assessments of the no fracture model. CONCLUSIONS: Using a portable ultrasound device, 18Ds were able to correctly detect the presence or absence of a simulated long bone fracture with a high degree of sensitivity and specificity. Future studies are needed to investigate the clinical impact of this diagnostic ability.

The ultrasound identification of simulated long bone fractures by prehospital providers.

OBJECTIVE: In austere environments, patient management decisions are often limited by obtainable resources. Portable ultrasound may allow for the detection of fractures when imaging modalities such as radiography are unavailable. We used a simulation training model in a pilot study to examine the ability of emergency medical technicians (EMTs) to detect the presence or absence of a variety of simulated fracture patterns with portable ultrasound. METHODS: The fracture simulation model is composed of a mechanically fractured bare turkey leg bone housed in a shallow container within a completely opaque gelatin solution. Five different fracture patterns were created. Twenty EMTs sonographically evaluated these models with a portable ultrasound device to determine the presence or absence of a fracture. RESULTS: EMTs correctly identified the presence or absence of a fracture in the no fracture, transverse fracture, and oblique fracture models 95% of the time. They always correctly identified the presence of a fractured model when assessing the comminuted and segmental fracture models. Across all fracture patterns, a final detection sensitivity of 97.5% (95% confidence interval [CI]: 94.1%-100.0%) and a specificity of 95.0% (95% CI: 85.4%-100.0%) were observed. CONCLUSIONS: Using portable ultrasound, EMTs correctly detected the presence or absence of simulated long bone fractures with a high degree of sensitivity and specificity. Future studies may evaluate the ability of other groups to use ultrasound to assist in the diagnosis of fractures and examine the clinical impact of this skill in environments where conventional imaging modalities are limited or unavailable.

A simulation model for the ultrasound diagnosis of long-bone fractures.

INTRODUCTION: Ultrasound is emerging as a promising tool for the diagnosis of skeletal fractures, particularly in environments where conventional radiography may be absent or limited. This article presents a high-fidelity, practical simulation model for the ultrasound diagnosis of long-bone fractures and also examines the ability of physicians to diagnose the presence or absence of different fracture patterns using this model. METHODS: The bony component of the model is a bare turkey leg bone that is mechanically fractured and housed in a shallow plastic container within a gelatin-based solution. Twenty physicians sonographically evaluated five models with different fracture patterns for the presence or absence of a fracture and were then queried regarding their opinion of this model as a teaching tool. RESULTS: Physicians were able to correctly identify the presence or absence of a fractured model with 100% sensitivity and 100% specificity across all fracture patterns and expressed agreement that this would be a useful teaching model. CONCLUSIONS: This high-fidelity, practical model is simple to construct, and the creation of a variety of fracture patterns is possible. Physicians found this to be a potentially useful teaching tool and correctly identified the presence or absence of different simulated fractures. Further studies may validate this simulation model as a teaching tool in the sonographic assessment of long bones for the presence of fractures and examine the potential clinical impact of this trainer.

Use of ultrasound to assess acute fracture reduction in emergency care settings.

OBJECTIVE: There is a need to develop tools for the rapid diagnosis and treatment of fractures and intraosseous pathology in remote and austere environments. Several emergency and orthopedic studies have demonstrated ultrasound to be a reliable tool in diagnosing these conditions in both adult and pediatric patients. The purpose of this pilot study is to assess the ability of the ultrasound to assess in "real-time" the success of fracture reduction in adult patients in the emergency department (ED), in comparison with the accepted standard, plain film radiography, for the purposes of future application in austere environments. DESIGN: Case series. SETTING: Emergency department at an academic medical center. PATIENTS/PARTICIPANTS: Convenience sample of five patients presenting to an ED with clinical evidence of fractures (three radial, one phalangeal, and one metacarpal). INTERVENTIONS: A Sonosite Titan portable ultrasound system with L38/10-5:38-mm broadband linear array transducer was used to assess prereduction and postreduction angulations and alignment. Alignment was reconfirmed with use of fluoroscopy and plain radiography. RESULTS: The ultrasound confirmed proper reduction and realignment in all five cases, from an average prereduction angle of alignment of 37.4 degrees to an average postreduction angle of 4.4 degrees. The use of the ultrasound resulted in adequate visualization of the reduction in all cases. Regional anesthesia or sedation and limited pressure with the probe resulted in no verbalization of pain by any of the subjects. CONCLUSIONS: In this pilot study, emergency physicians demonstrated the use of ultrasound in place of traditional radiography to either confirm adequate reduction or assess the need for further manipulation. Our pilot study suggests that ultrasound has a possible future role in fracture reduction management in both the ED as well as "austere"prehospital locations.

Anesthetic and procedural sedation techniques for wound management.

Emergency physicians come across a wide variety of painful conditions and perform a large number of uncomfortable procedures on a typical shift. This article describes the local anesthetic agents and their potential applications. The peripheral nerve blocks that are regularly done in the emergency department are described. Lastly, procedural sedation and analgesia are covered, to include general principles and specific agents for its use in the emergency department.