There is little debate that ultrasound-guided central lines are safer, faster, and more reliable compared to a landmark technique; there is some debate, however, as to whether the short axis (SA) or long axis (LA) approach is the best (see clips below).
The referenced study compared the SA and the LA technique for both the internal jugular (IJ) and subclavian (SC) venous approach. The authors measured number of skin breaks, number of needle redirections, and time to cannulation for each method.
This study demonstrated that the LA technique for subclavian placement had fewer redirections, decreased cannulation time, and fewer posterior wall punctures as compared to the SA. With respect to the IJ approach, the LA was also associated with fewer redirections than the SA view.
Bottom line: Consider the long-axis technique the next time you place an ultrasound guided central line.
40 year-old male sustains a blunt force injury the left side of his lead. What's the diagnosis and what structure was injured?
70 year-old female presents from a nursing home with fever and abdominal pain. A right upper quadrant ultrasound is shown, what's the diagnosis?
You see the following on a parasternal long-axis view; what's the diagnosis and what coronary distribution is involved?
You decide to do a R.U.S.H. exam on your hypotensive patient and perform an apical four-chamber view.You see one of the two clips below; are there any tricks to figure out which is the left ventricle and which is the right ventricle?
Patient presents with leg and ankle pain after a fall 3 weeks earlier. Initial ankle Xrays were negative. Patient presents today with persistent leg and ankle pain. What's the diagnosis and what other imaging would you perform and why?
25 year-old male with the acute onset of right flank pain. Ultrasound of the right flank is shown. What's the diagnosis?
35 year-old male presents with increasing difficulty swallowing and tenderness in the floor of him mouth. What's the diagnosis?
25 year-old male with autoimmune enteropathy presents with intractable vomiting and diarrhea for 7 days. What's the diagnosis?
The results of a multi-center trial from the UK, the ProMISe trial, were just released and it confirms what two prior studies (i.e., ProCESS and ARISE) have already shown; there does not appear to be any difference in mortality when septic patients are treated with a strategy of early-goal directed therapy as compared to usual care.
Patients were included in the ProMISe trial if they were in septic shock and were then randomized to either the EGDT group (630 patients) or the usual care group (630 patients); a total of 1,260.
The primary end-point was all cause mortality at 90 days and there was no difference shown in the primary outcome. There were no differences found in the measured secondary outcomes (e.g., serious adverse events)
This trial adds to the evidence that septic patients may not benefit from protocolized (i.e., EGDT) care versus usual care. One explaination why, is that our "usual care" in 2015 has significantly changed since the introduction of EGDT in 2001.
35 year-old female presents with acute leg pain and swelling. What's the diagnosis?
6 day-old child is brought in by parents with 1 day of reduced oral intake and 4 hours of rapid breathing. The child has no fever and no significant birth history. The child is tachycardic, hypotensive, and hypoxic. What’s the diagnosis?
45 year-old male complains of pleuritic chest pain following a "long" flight. What's the diagnosis and what's this sign called?
As the cold and snow rips through the United States, hypothermia is a major concern because each year approximately 1,300 Americans die of hypothermia.
Classification of hypothermia:
The risk of cardiac arrest increases when the core temperature is less than 32 Celsius and significantly rises when the temperature is less than 28 Celsius. Rapid rewarming is required as part of resuscitation should cardiac arrest occur.
A rescue therapy to consider (when available) is extra corporeal membrane oxygenation (ECMO). ECMO not only provides circulatory support for patients in cardiac arrest, but allows re-warming of patients by 8-12 Celsius per hour.
Some studies quote survival rates of 50% with hypothermic cardiac arrest patients receiving ECMO versus 10% in similar patients who do not receive ECMO.
As winter lingers in the United States, consider speaking to your cardiac surgeons now to plan an Emergency Department protocol for hypothermic patients that may require ECMO.
Patient presents with right shoulder pain following minor trauma. What's the diagnosis....and what's the Cunningham technique?
Elderly male presents with the skin findings below. He is also on a medication for atrial fibrillation. What's the diagnosis?
