The Venous Excess Ultrasound (VExUS) exam integrates IVC, portal, hepatic, and renal vein findings to assess venous congestion and guide management, such as diuresis, in critically ill patients.
Technique:
Tips:
Interpretation:
Sometimes when other clinical information is contradictory, having the extra data point of the VExUS exam can be extremely useful to determine the best plan for a patient. Practice looking for the portal/hepatic veins and getting the waveforms on patients with a CLEAR clinical picture of venous congestion, then practice on more difficult cases.
This prospective observational study looked at patients with liver lacerations and active contrast extravasation who either had immediate embolization vs. observation. After matching for age, injury score etc. the observation first approach did as well as those who had immediate embolization.
This study tried to expand upon what they describe as the classic triad of signs to diagnose ruptured AAA “(1) abdominal pain, (2) hypotension and (3) a pulsatile abdominal mass”. They tested these against the _modified abdominal aortic aneurysm rupture signs. “_The MARS-signs encompassed (1) the registered pain-associated symptoms or signs, (2) all hypovolemic associated signs, and (3) pulsatile abdominal mass and/or ultrasound finding”. The MARS did slightly better in identifying ruptured AAA retrospectively. For me, this doesn’t add a great deal of help in making this can’t miss diagnosis and further work is necessary.
Background:
Ultrasound-guided subclavian central venous catheter (CVC) placement has become a preferred site due to low risk of infection and a low risk of complication. Complications include arterial puncture, pneumothorax, chylothorax, and malposition of the catheter. Ultrasound guidance can significantly reduce the risk of these complications aside from catheter malposition. The most common sites of malposition are in the ipsilateral internal jugular vein or the contralateral brachiocephalic vein. This study sought to evaluate the rate of catheter malposition between left-and right-sided subclavian vein catheter placement using ultrasound guidance with an infraclavicular approach.
Study:
Results:
Take Home:
For infraclavicular ultrasound-guided subclavian CVC placement, consider using the left-side over the right if no contraindications for left-sided access exist.
Early treatment of congestive heart failure (CHF) exacerbations is associated with improved mortality rates and shorter hospital length of stay. Lung ultrasound is a valuable tool in diagnosing CHF exacerbations. Recently, several studies have explored the use of lung ultrasound in the prehospital settings to expedite diagnosis and treatment.
A recent systematic review and meta-analysis evaluated the diagnostic accuracy and clinical impact of prehospital lung ultrasound. The authors found similar test characteristics to point-of-care ultrasound (POCUS) performed in the emergency department.
The eight studies included in the analysis utilized varying lung ultrasound protocols, analyzing between 2 and 8 lung zones. Notably, only two studies involved paramedics performing the ultrasounds, yet no significant difference in diagnostic accuracy was observed.
Further research is needed to evaluate the training requirements for prehospital providers and the broader impact of prehospital lung ultrasound on treatment strategies and patient outcomes.
Fall from a height of 6 feet with back pain. Plain film shown. What is the diagnosis? Any further imaging indicated? Treatment? Disposition?
As a reminder, prescribing medications to older patients should be done with caution because of changed physiology, co-morbid conditions and other currently used medications. The Beers Criteria is a helpful list of medications that may cause trouble for your older patients. https://www.guidelinecentral.com/guideline/340784/#section-2776198 is a list of medications to either avoid or prescribe carefully in this patient population.
Pay particular attention to medications that have anticholinergic properties as they cause change in mental status and increase the risk for falls.
From all of us at UMEM, Happy Thanksgiving!!
We are incredibly Thankful for each of you and all that you do to care for patients and their families.
We are Thankful for those legends who have blazed the path in EM like Greg Henry who the EM community lost yesterday. Our thoughts are with his family. Thank you Dr. Henry for inspiring so many of us. Our pearls today are two of his famous quotes:
“Medicine is show business for ugly people.”
“You don’t go to Disney and see Mickey taking a smoke break. You have to be on when you are on shift”
Gooble, gooble,… gulp, some food for thought on the eve of Thanksgiving.
The development of artificial intelligence (AI) in emergency medicine is well under way. The schematic below and accompanying reference presents the anticipated stages in the process of AI development, including important features, considerations, and challenges as we move towards increased integration of AI in our practice of EM.
It’s the age-old question. We’ve read studies comparing propofol vs. etomidate, ketofol vs. etomidate, and now a meta-analysis about ketamine vs. etomidate. Etomidate is the staple induction agent for RSI, mostly used by Emergency Medicine, and to a degree in the Intensive Care Unit. However, the question about adrenal suppression was initiated in the early 2000s and researchers have been looking for other alternatives. This meta analysis attempted to look for another answer.
Settings: A meta-analysis of randomized controlled trials
Participants: 2384 patients who needed emergent intubation were included.
Outcome measurement: Peri-intubation instability
Study Results:
Compared with etomidate, ketamine was associated with higher risk of hemodynamic instability and moderate certainty (RR 1.29, 95% CI 1.07-1.57).
Ketamine was associated with lower risk of adrenal suppression, again, with moderate uncertainty (RR 0.54, 95% CI 0.45-0.66).
Ketamine was not associated with differences and risk of first successful intubation nor mortality.
Discussion:
Most studies were single center and involved small-moderate sample size, ranging from 20 patients to 700 patients.
For adrenal suppression, there were only 3 studies and a total of 1280 patients, thus, the results are still not definitive.
For an academic exercise, the Number Needed to Harm for both hemodynamic instability and adrenal suppression are calculated here.
Number Needed to Harm for hemodynamic instability: 25.
Number needed to harm for adrendal suppression: 11.
One of the many siginificant complications of cancers we encounter in the ED is cord compression. Here are pearls from a recently published systematic review focused on metastasis-associated spinal cord compression:
It is important for trauma and emergency care providers to understand what our patients experience prior to arrival in our clean, safe, and structured emergency department. It is also vitally important that we are involved in training and education in the pre-hospital environment. A group in the United Kingdom is challenging the age old “wisdom” that post-motor vehicle crash extrication should be slow, methodical, and work to have absolutely no movement in the spinal canal. Spinal immobilization and slow extrication instead of rapid resuscitation appears to be bad for patients. Based on several of their ground breaking papers they have published a 14 point recommendation of patient extrication post motor vehicle collision. Here are two important tenets they propose. For an in-depth discussion check out November 14, 2024 / CPD, Podcasts, Roadside to Resus.
Ankle sprains are frequently lateral.
They occur less frequently to the medial or “high” ankle.
High ankle sprains without fracture occur in 5-6% of ankle injuries presenting to the ED
Rates of injury are much higher in college and professional hockey and football players
The tibiofibular syndesmosis is primarily injured in high ankle sprains
Mechanism: Typically, external rotation or eversion on a dorsiflexed ankle
Example: When a player’s leg is forcefully rotated while foot is planted
Hx: anterior lateral ankle pain. Frequently significant pain with weight bearing.
PE: local tenderness over the syndesmosis ligaments
Two specialized tests may aid in the diagnosis
https://wikism.org/Squeeze_Test#/media/File:Squeeze_test_example.jpg
2. Dorsiflexion-external rotation test – This test attempts to reproduce the forces commonly involved in the original injury. Positive test is reproduction of pain. Position patient similar to above test. Grasp the upper calf with one hand while the other hand grasps the midfoot and places the foot in dorsiflexion and external rotation.
https://www.dralexjimenez.com/wp-content/uploads/2017/07/external-rotation-test-1.png
The authors looked at 51 patients intubated with both anterior and posterior cervical collar in place and measured the degree of movement within the spine during intubation. They repeated this process in 51 additional patients with just the posterior portion of the collar in place. They found there was one degree of difference in movement between the two groups. This adds evidence that removing the anterior portion of the collar is safe when intubating trauma patients.
Achilles tendon injuries are commonly encountered in the emergency department. While MRIs are often unavailable, POCUS offers a quick and effective alternative for evaluating such injuries. In one review, the sensitivity of ultrasound for detecting complete Achilles tendon ruptures was 94.8%.
For the POCUS evaluation of the Achilles tendon:
- Place the patient in a prone position with their foot relaxed.
-Begin distally at the tendon’s insertion on the calcaneus and scan proximally, keeping the probe marker oriented toward the patient’s head.
-Next, obtain a transverse view by rotating the probe marker toward the patient’s right side.
-You can even do a sonographic Thompson’s Test!
Findings:
Complete Rupture: Displays as a full disruption of the tendon fibers.
Partial Tear: Shows intact tendon tissue with surrounding edema.
Tendinitis: Appears as a thickened tendon with increased vascularity on color Doppler imaging.
This retrospective study illustrates that the use of CT scanning to identify injury in gun shot wounds to the abdomen is not sensitive or specific enough to obviate the need for laparotomy. “Admission hypotension, abdominal pain and/or peritonitis, evisceration, and a transabdominal trajectory were considered clear indications for laparotomy.” If there is clear indication to go to the OR, stopping in CT does not add any benefit.
This article was a review of randomized control trials using intranasal (IN) fentanyl. There were 8 studies included that showed IN fentanyl was superior to controlling pain compared to other pain medications at the 15-20 minute mark, but not at the 30 and 60 minute marks. There were less reports of nausea and vomiting with IN fentanyl, but no difference in dizziness or hallucinations compared to the other medications included in the various trials (ie morphine, ketamine, po narcotics, ect)
The bioavailability of IN fentanyl ranges from 71-89% with effects noted in 2 minutes with maximal concentrations noted at 7 minutes. The half life is approximately 60 minutes.
Bottom line: Consider IN fentanyl for quick acute pain management in the pediatric patient.
An out-of-hospital, randomized, placebo-controlled, blinded, parallel group study was conducted in adult patients under the care of the city fire-based emergency medical services and the local level one trauma center. Adult male patients experiencing moderate to severe pain due to traumatic injuries received either 50mg of intranasal ketamine or placebo in addition to fentanyl after randomization in the field by the paramedic (a novel approach). The primary outcome was reduction of pain by 2 points 30 minutes after study drug administration.
199 patients were randomized with 107 receiving ketamine and 92 with placebo. Patients were young (30-40), and had a median weight of 83 kg. Pretreatment pain scores were 10/10 and patients presented to the ED 14 minutes after receiving study medication. The most common injuries were falls, MVC, and GSW. Half of the patients received IV fentanyl but others had IM or IN routes.
Ketamine receipt did not lead to a 2 point reduction in pain scores (36% vs 44.7% p = 0.22). There was no difference in pain at 3 hours, additional medications received, or total amount of analgesia received. Notably, there were no differences in adverse events.
Administration of prehospital TXA was found to improve 28 day mortality and decrease the amount of blood required to be transfused without any increased risk of thromboembolism or seizure. Two grams of TXA was superior to one gram and no TXA.
