Fall ECCU Fest 2018 – PoCUS Conference Workshop and ECCU2 Course

September 27th – 28th 2018

The Algonquin Resort in St. Andrews by-the-Sea, New Brunswick, Canada

Atlantic Canada’s top PoCUS event

UPDATE

 

Now open for applications/booking – Only a few places still available

 

The ECCU Conference is being held in conjunction with the ECCU2 Advanced Applications Course in order to provide those attending the course and other delegates with an opportunity to access an update in the hottest clinical PoCUS topics. The focus will be on presenting the best emerging evidence, strategies for developing a local PoCUS program and developing competencies.

Includes:

  • International PoCUS experts
  • Clinical PoCUS hot topics and updates
  • Top PoCUS research
  • IP2 Diagnostic stream lectures

Conference delegates will have access to the Diagnostic stream lectures of the ECCU2 Advanced Applications Course, which will include an Gallbladder, Renal, DVT and Ocular

Invited Faculty – 2018

Dr. Hein Lamprecht – South Africa – (ECCU Fest 2018) – PoCUS Educator Extraordinaire – IFEM – WinFocus

Dr. Peter Croft – USA – (ECCU Fest 2018) – New England PoCUS disrupter –past MGH PoCUS Fellow

Dr. David Mackenzie – USA – (ECCU Fest 2018) – Canadian New Englander, PoCUS innovator – past MGH PoCUS Fellow

 

Also our top Dalhousie Faculty of PoCUS Experts

 


 

Open for applications and booking: More Information Here

 

There are only 2 places left on the 2 day Advanced Apps ECCU 2 course, however we still have good availability for the 1 day conference workshop

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RCP – Regional anesthesia of the hand

Regional anesthesia of the hand: ultrasound-guided vs tumescent anesthesia

Resident Clinical Pearl (RCP) – February 2018

Sean Hurley Emergency Medicine PGY1 (FRCPC), Dalhousie University, Halifax, Nova Scotia

Reviewed by Dr. David Lewis

 

The goal of this resident clinical pearl is to discuss two different methods of achieving complete anesthesia of the hand. Hopefully, by the end of this article, you will have the knowledge to perform both methods in the emergency department. The first method is ultrasound (US)-guided nerve blocks of the ulnar, median, and radial nerves. The second method is the “tumescent anaesthesia” approach used by many hand surgeons around the world for wide-awake hand surgery, including local, local anesthetic guru and plastic surgeon, Dr. Donald Lalonde who provided many of the clinical pearls in this article.

 

Method 1:  Ultrasound-guided nerve block

In a recent article by Amini et al. (2016), 84% of 121 emergency medicine residency programs surveyed in the United States reported that US-guided nerve blocks are performed at their institution. Of the 16 different nerve blocks reported, forearm blocks were the most commonly performed (74%) (Table 1). The main indications for nerve blocks are outlined in Table 2 1.

Table 1 and 2 from Amini et al., 2016 1

 

Three major nerves, median, ulnar, and radial, provide sensory innervation of the hand (Figure 1). Each nerve needs to be blocked in a simple straightforward approach, which was shown to to be quick, safe and effective. After a 1-hour training session, residents, fellows, and staff emergency physicians had 100% success rate with no rescue anesthesia on 11 hand pathology patients presenting to the ED. The blocks were performed in a median time of 9 minutes with no complications 2.

 

Figure 1. Cutaenous innervation of the hand. https://www.nysora.com/wrist-block

 

Figure 2. Indications for different nerve blocks of the hand http://highlandultrasound.com/forearm-blocks/

 

Radial Nerve: Palpate the radial artery in the volar aspect of distal forearm then place the US probe over the artery in a transverse orientation. Move the probe proximally until you clearly identify the radial nerve (Figure 3), which is located at the radial aspect of the radial artery. Insert your needle using an in-line approach (Figure 4). Inject 5-10cc of 1% lidocaine with epinephrine until you can clearly see the nerve bathed in lidocaine.

Pearl: The radial nerve is often difficult to visualize in the forearm. The radial nerve is more easily visualized above the elbow along the spiral groove of the humerus. Place the probe in a transverse orientation along the lateral aspect of the humerus between the brachioradialis and brachialis muscles. This block is more proximal and will require longer time to peak anesthesia.

 

Ulnar nerve: Use the exact same 2-step approach but on the ulnar side of the forearm. The ulnar nerve is located at the ulnar aspect of the ulnar artery (Figure 3).

 

Median nerve: The median nerve lies between the palmaris longus and the flexor carpi radialis. Position the probe in the transverse plane over this location. Insert your needle from either side using an in-plane or out-of-plane approach

 

Pearl: the median nerve and the many tendons of the distal forearm can be difficult to distinguish. You can identify the nerve by tilting the probe, which causes the tendons to disappear, as the US waves are no longer reflected back to probe, while the median nerve fibers still reflect waves back to the probe. Alternatively, you can slide the probe proximally where the tendons transition to muscle fibers, allowing the median nerve to be easily distinguishable.

Pearl: The palmar cutaneous branch of the median nerve that supplies the thenar eminence branches off before the carpal tunnel. Make sure you move the probe proximally before blocking the nerve so you don’t miss this important sensory branch.

Pearl: The more local anesthetic, the better! Some resources recommend 3-5cc of 1% lidocaine per nerve. Why not use 10cc or more for each nerve? You will still be safely under 7mg/kg limit.

 

Figure 3. Ultrasound identification of the ulnar nerve (left), median nerve (middle), and radial nerve (right). (Figure from Liebemann et al, 2006) 2.

 

Figure 4. Ultrasound guided ulnar nerve block using an in-plane technique (Figure from Sohoni et al., 2016) 3.

 

Please see link to excellent descriptions and videos of ulnar, radial, and median US-guided nerve blocks in the ED. www.highlandultrasound.com/forearm-blocks/

 

Method 2: Tumescent anesthesia

Tumescent means “Swollen”. In relation to local anaesthesia, Dr. Lalonde provides the following definition in his textbook Wide-Awake Hand Surgery: “Injecting a large enough volume of local anesthetic that you can see it plump up the skin and feel its slightly firm consistency with your finger through the skin” 4. The tumescent anesthesia approach has been described in depth for a variety of hand surgeries 4-6.

Using a 10cc syringe, aim for the space directly between the median and ulnar nerve (figure 5 and Video 1).  As you puncture the skin, Inject 3-5cc in the subcutaneous space. This is critical to block superficial nerves in this region, including the palmar cutaneous branch of the median nerve. Then, move your needle >3-4mm deeper through the superficial fascia in the forearm compartment where the median and ulnar nerves reside. Inject the remainder of your 10cc syringe into this space. With a single poke, the ulnar and median nerve distributions should be completely anesthetized.

Now, all that remain are the superficial branches of radial nerves and the posterior interosseus nerve. The superficial branches of radial nerve lie over the anatomical snuffbox. Insert your needle within 1cm of your previously anesthetized skin and blow local anesthesia into the subcutaneous space as you slowly move your needle towards the radial aspect of the wrist until you have a tumescent area of local anesthesia over the snuffbox. For the PIN, which is primarily a motor branch of radial nerve but has some sensory contribution, palpate the distal radial ulnar joint  of the dorsal aspect of the wrist. The PIN runs along the interosseous membrane so the needle needs to pass through the deep fascia of the forearm. Inject another 5cc of lidocaine in this location.

 

Figure 5. Tumescent anesthesia of the median and ulnar nerve 5.

 

Video 1. Tumescent anesthesia of the hand (courtesy of S. Hurley).

 

Which approach is better?

No studies have directly compared the two approaches discussed in this article. A recent Cochrane review article reviewed compared US-guided vs. anatomical landmark technique vs. trans-arterial vs. peripheral nerve stimulation for lower and upper limb blocks by trained anaesthetists. They found US-guided had greater success rates, less conversions to general anesthetic, lower rates of parathesias and vascular puncture 7.

A recent small randomized control trial compared US-guided nerve blocks of the forearm to anatomical landmark-based technique and found 14 of 18 ultrasound-guided forearm blocks were successful, as opposed to 10 of 18 for the anatomical technique 3.

Pearl: The tumescent anesthesia technique blocks both smaller and larger nerves of the hand and will likely achieve faster anesthesia compared to nerve blocks of the ulnar, median, and radial nerve.  Expect up to an hour for the large nerve blocks to take full effect.

 

Conclusions

Both methods, US-Guided nerve blocks and tumescent anesthesia are safe, effective, and relatively easy options to achieve complete anesthesia of the hand. For both techniques, remember basic principles for minimizing pain during injection of local anaesthesia to optimize patient comfort and satisfaction 4-6.

 

References

  1. Amini R, Kartchner JZ, Nagdev A, Adhikari S. 2016. Ultrasound‐Guided nerve blocks in emergency medicine practice. Journal of Ultrasound in Medicine 35: 731-736.
  2. Liebmann O, Price D, Mills C, et al. 2006. Feasibility of forearm ultrasonography-guided nerve blocks of the radial, ulnar, and median nerves for hand procedures in the emergency department. Ann Emerg Med 48: 558-562.
  3. Sohoni A, Nagdev A, Takhar S, Stone M. 2016. Forearm ultrasound-guided nerve blocks vs landmark-based wrist blocks for hand anesthesia in healthy volunteers. Am J Emerg Med 34: 730-734.
  4. Lalonde D. 2016. Wide awake hand surgery, CRC Press, Taylor & Francis Group. Boca Raton, FL.
  5. Lalonde DH. 2010. “Hole-in-one” local anesthesia for wide-awake carpal tunnel surgery. Plast Reconstr Surg 126: 1642-1644.
  6. Farhangkhoee H, Lalonde J, Lalonde DH. 2012. Teaching medical students and residents how to inject local anesthesia almost painlessly. Can J Plast Surg 20: 169-172.
  7. Lewis SR, Price A, Walker KJ, McGrattan K, Smith AF. 2015. Ultrasound guidance for upper and lower limb blocks. The Cochrane Library.

 

This post was copyedited by Kavish Chandra @kavishpchandra

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New – Dal SJRHEM PoCUS Fellowship/Elective

The Dalhousie University (DU) Emergency Point of Care Ultrasound Elective and Fellowship Program at Saint John Regional Hospital (SJRH) with an optional up to 1 month placement in Pediatric PoCUS at the IWK Health Centre Pediatric Emergency Department

 

There are four primary components to the mini-fellowship and fellowship programs:

 

  1. Clinical: optimizing image acquisition and interpretation skills for both core and advanced emergency and point of care ultrasound applications
  2. Education: developing lecturing and teaching skills by developing an emergency ultrasound lecture portfolio and contributing to the program’s educational mission. Acquiring expertise at bedside ultrasound teaching and assessment.
  3. Administration: understanding the critical components required to run an emergency ultrasound program, set up and deliver educational events/courses and how to best utilize information technologies for image archiving, database management, and quality assurance.
  4. Research: understanding the state of emergency ultrasound research by participating in ultrasound journal club activities and developing an independent research project from its inception to publication.

 

For more information click here

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RCP – Suprapubic Aspiration PoCUS

Suprapubic aspiration – when the catheter doesn’t cut it.

Resident Clinical Pearl (RCP) – Guest Resident Edition

Sean Davis MD, PGY2 Family Medicine

Dalhousie University, Yarmouth, Nova Scotia

Reviewed and Edited by Dr. David Lewis

 

Urine is routinely analyzed and cultured as part of a sick child workup, as diagnosis of urinary tract infection can be difficult in pre-verbal children. They are unable to “point where it hurts”, and physical exam can be both difficult and unreliable in an irritable or obtunded infant. Urine may be collected in three ways – by “clean catch” collection, transurethral catheterization (TUC), and suprapubic aspiration (SPA). Given the inherent risk of contamination with local flora (over 25% in one cohort study)1, clean catch urine is typically useful only for ruling out UTI. TUC is more commonly performed as it does not require physician participation, but SPA remains a valid option for obtaining a urine sample for analysis and culture in children under the age of 2. It has been shown to have a significantly lower rate of contamination than TUC (1% versus 12%, respectively)1, although failure rates are higher with SPA4. Use of portable ultrasound has been shown to significantly increase the rate of success of SPA (79% US guided vs 52% blind)5.

 

RCP – The pee or not the pee: so many questions!

 

Indications:2,3

  • Labial adhesions/edema
  • Phimosis
  • Diarrhea
  • Unsuccessful urethral catheterization
  • Urethral/introital surgery
  • Urethral stricture
  • Urethral trauma
  • Urinary retention
  • Urinalysis/culture in children younger than 2 years
  • Chronic urethral/periurethral gland infection

Contraindications: 2,3

  • Genitourinary abnormalities (congenital or acquired)
  • Empty or unidentifiable bladder
  • Bladder tumor
  • Lower abdominal scarring
  • Overlying infection
  • Bleeding disorders
  • Organomegaly

Complications: 2,3

  • Gross hematuria
  • Abdominal wall cellulitis
  • Bowel perforation

Equipment: 2,3

  • Lidocaine for local anesthesia (1% or 2%, with or without epinephrine)
  • Adhesive bandaid
  • Povidone-iodine or Chlorhexidine prep
  • 25g to 27g 1” needle
  • 22g or 23g 1.5” needle
  • Sterile 5ml and 10ml syringes

Procedure (ultrasound-guided): 2,3

  • Position the patient supine in frog-leg position, using parent or caregiver to assist with immobilization.
  • Using sterile technique, identify the bladder on ultrasound; it appears as an anechoic ovoid structure just below the abdominal musculature.
    • Landmarking: midline lower abdomen, just above the pubic symphysis
  • Mark the area and sterilize; infiltrate local anesthetic into the marked area
  • Insert the needle slightly cephalad, 10-20° off perpendicular while aspirating until urine appears.
  • If the insertion is unsuccessful, do not withdraw the needle fully. Instead, pull back until the needle tip rests in the subcutaneous tissue and then redirect 10° in either direction. Do not attempt more than 3 times.
  • One sufficient urine is obtained, withdraw the needle and place a sterile dressing at the site of the insertion.

 

 

From: Performing Medical Procedures – NEJM

 

References

    1. Contamination rates of different urine collection methods for the diagnosis of urinary tract infections in young children: an observational cohort study. Tosif S; Baker A; Oakley E; Donath S; Babl FE. J Paediatr Child Health. 2012; 48(8):659-64 (ISSN: 1440-1754). Retrieved from https://reference.medscape.com/medline/abstract/22537082 on December 10, 2017
    2. Suprapubic Aspiration. Alexander D Tapper, MD, Chirag Dave, MD, Adam J Rosh, MD, Syed Mohammad Akbar Jafri, MD. Medscape. Updated: Mar 31, 2017. Retrieved from https://emedicine.medscape.com/article/82964-overview#a4 on December 10, 2017
    3. Suprapubic Bladder Aspiration. Jennifer R. Marin, M.D., Nader Shaikh, M.D., Steven G. Docimo, M.D., Robert W. Hickey, M.D., and Alejandro Hoberman, M.D. N Engl J Med 2014; 371:e13September 4, 2014DOI: 10.1056/NEJMvcm1209888. Retrieved from http://www.nejm.org/doi/full/10.1056/NEJMvcm1209888 on December 10, 2017
    4. Suprapubic bladder aspiration versus urethral catheterization in ill infants: success, efficiency and complication rates. Pollack CV Jr, Pollack ES, Andrew ME. Ann Emerg Med. 1994 Feb;23(2):225-30. Retrieved December 10, 2017.
    5. Use of portable ultrasound to assist urine collection by suprapubic aspiration. Gochman RF1, Karasic RB, Heller MB. Ann Emerg Med. 1991 Jun;20(6):631-5. Retrieved December 10, 2017.

 

Other PEM PoCUS Videos Here

 

 

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What we missed in FOAM October 2017

Welcome to SJRHEM’s newest feature, “Best of FOAM”. This is a quick curated list of the best free open access medical education the internet has to offer!

Subscribe to our twitter feed for regular updates and enjoy!

 

EM procedures

 

Clinical summaries

 

Kavish Chandra, R3 FMEM, Dalhousie University, Saint John, New Brunswick

 

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What we missed in FOAM Sept 2017

 

Welcome to SJRHEM’s newest feature, “Best of FOAM”. This is a quick curated list of the best free open access medical education the internet has to offer!

Subscribe to our twitter feed for regular updates and enjoy!

 

EM procedures

Clinical tools

 

Clinical summaries

 

Kavish Chandra, R3 FMEM, Dalhousie University, Saint John, New Brunswick

 

 

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PoCUS – Measurements and Quick Reference

Developed by Dr. Heather Flemming as part of her PG PoCUS Elective at SJRHEM.

A useful Point of Care Ultrasound (PoCUS) guide to common normal values, measurements, pathological values and quick reference tips. A pdf version is also provided in this post which can be downloaded, printed and attached to your ultrasound machine for easy access.

 

 

 


 


Download (PDF, 1017KB)

 

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SJRHEM associated publication – The Reason Study

The Reason Study group, which included researchers from SJRHEM and involved may of SJRHEM physicians contributing data, has just published the results of the biggest prospective study to determine whether cardiac activity on ultrasound during ACLS is associated with improved survival.

The paper: Emergency department point-of-care ultrasound in out-of-hospital and in-ED cardiac arrest, was published in Resuscitation (http://dx.doi.org.ezproxy.library.dal.ca/10.1016/j.resuscitation.2016.09.018) reported that “Cardiac activity on ultrasound was the variable most associated with survival following cardiac arrest. Ultrasound during cardiac arrest identifies interventions outside of the standard ACLS algorithm.”


Abstract

Background

Point-of-care ultrasound has been suggested to improve outcomes from advanced cardiac life support (ACLS), but no large studies have explored how it should be incorporated into ACLS. Our aim was to determine whether cardiac activity on ultrasound during ACLS is associated with improved survival.

Methods

We conducted a non-randomized, prospective, protocol-driven observational study at 20 hospitals across United States and Canada. Patients presenting with out-of-hospital arrest or in-ED arrest with pulseless electrical activity or asystole were included. An ultrasound was performed at the beginning and end of ACLS. The primary outcome was survival to hospital admission. Secondary outcomes included survival to hospital discharge and return of spontaneous circulation.

Findings

793 patients were enrolled, 208 (26.2%) survived the initial resuscitation, 114 (14.4%) survived to hospital admission, and 13 (1.6%) survived to hospital discharge. Cardiac activity on US was the variable most associated with survival at all time points. On multivariate regression modeling, cardiac activity was associated with increased survival to hospital admission (OR 3.6, 2.2–5.9) and hospital discharge (OR 5.7, 1.5–21.9). No cardiac activity on US was associated with non-survival, but 0.6% (95% CI 0.3–2.3) survived to discharge. Ultrasound identified findings that responded to non-ACLS interventions. Patients with pericardial effusion and pericardiocentesis demonstrated higher survival rates (15.4%) compared to all others (1.3%).

Conclusion

Cardiac activity on ultrasound was the variable most associated with survival following cardiac arrest. Ultrasound during cardiac arrest identifies interventions outside of the standard ACLS algorithm.

 


A very good critique of this paper has been published on the well-known EM Blog – St. Emlyns – JC: Is this the REASON to use USS in cardiac arrest? St.Emlyn’s

St. Emlyn’s Bottom Line: A lack of cardiac activity on initial USS is very probably associated with a worse prognosis. The role of USS in improving outcome as an intervention in cardiac arrest is less certain

 


We will be asking our Research Director (Dr Paul Atkinson), who was closely involved in this study, for his take on the results and how they should be interpreted/incorporated into practice. This has been posted here.

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Resident Clinical Pearl – PoCUS for ETT Placement Confirmation

ETT Placement Confirmation During Cardiac Arrest: US for the Win!

Resident Clinical Pearl – November 2015

Kalen Leech-Porter, PGY 1, iFMEM, Saint John NB, Dalhousie University

Reviewed by: Dr Jay Mekwan and Dr David Lewis

 

The AHA has updated their guidelines for CPR and emergency cardiovascular care this year (2015)[i].  Previously, there were insufficient studies to warrant a recommendation for Point of Care Ultrasound (PoCUS) for ETT confirmation, however, a new study has emerged to suggest that PoCUS can be a useful adjunct for ETT placement confirmation.  A 96 patient observational study done on patients during cardiac arrest, found that PoCUS had a sensitivity of 98.9% and a specificity of 100%[ii].  ETT placement was determined by placing the ultrasound transducer transversely above the suprasternal notch to identify endotracheal or esophageal intubation.  It was determined during the study that in using this method ultrasound could be completed without interrupting chest compressions.

As the above study has yet to be replicated, end-tidal CO2 remains the gold standard for ETT placement confirmation (an observational, prospective study of 566 patients found colorimetric to be 95.6% sensitive, 99.8% specific[iii]) during cardiac arrest.  However, AHA has added ultrasound as an additional method for confirmation of endotracheal tube placement, with the caveat that ultrasound should never interfere with the continuous conduction of high-quality CPR.


 

How to confirm ETT with PoCUS:

Video by Haney Mallemat

 

Video by Joseph Minardi


 

Abridged Instructions from ACEP Tips and Tricks [iv]

  • Place the high frequency linear probe transversely just above the sternal notch (Image A); note normal airway anatomy (Image B), prior to ETT placement (if time permits)
Image A

Image A

From: Joseph Minardi’s Video [see above]

 

Image B

Image B

From: Halley Mallemat’s video [see above]

 

Trachea: Hyperechoic, curvilinear with comet-tail artifact

Esophagus: more distal, oval with heyperchoic wall and hypoechoic center


 

  • PoCUS ETT confirmation can be done in real time, as ETT is placed, or done post placement. Successful ETT: there will be a slight increase in artifact/shadowing in trachea region only, known as the “Bullet Sign” (Image C) [v].  The operator should see reverberations in the trachea’s anterior lumen.  To further confirm can slightly shake the ETT, this should only show trachea movement.
Image C

Image C

From: Mark Favot [v]


 

 

  • Esophageal Intubation: will cause a second ‘trachea’ appear (Image D and E), referred to as the “double tract sign”
Untitled4

Image D

From: Halley Mallemat’s video [see above]

Image E

Image E

From ACEP Tips and Tricks [iv]


 

  • Pitfalls: the esophagus may be located directly posterior to the trachea, therefore esophageal intubation may be missed if inadequate depth is used.
  • Additionally, observing bilateral lung sliding while bagging a paralyzed patient also suggest ETT confirmation.

References

[i] Web-based Integrated 2010 & 2015 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care; Part 7: Adult Advanced Cardiovascular Life Support.  (Nov. 25, 2015) https://eccguidelines.heart.org/index.php/circulation/cpr-ecc-guidelines-2/part-7-adult-advanced-cardiovascular-life-support/

[ii] Sun, Jen-Tang, Sim, Shyh-Shyong, et al. “Ultrasonography for proper endotracheal tube placement confirmation in out-of-hospital cardiac arrest patients: two-center experience.”  Critical Ultrasound Journal 6 (2014): A29 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4101346/

[iii] Hayden, SR., and Sciammerella, J., et al. “Colorimetric end-tidal CO2 detector for verification of endotracheal tube placement in out-of-hospital cardiac arrest.” Acad Emerg Med 6 (1995): 499-502 http://www.ncbi.nlm.nih.gov/pubmed/7497049

[iv] Chao, Alice and Ghrahbaghaian, Laleh. “Tips and Tricks: Airway Ultrasound.” American College of Emergency Physicians Emergency Ultrasound Section Newsletter (June, 2015). http://www.acep.org/Content.aspx?ID=102309

[v] Favot, Mark. “Ultrasound for Verification of Endotracheal Intubation.” FOAM EM (March, 2015). http://www.foamem.com/2015/03/02/ultrasound-for-verification-of-endotracheal-tube-location/

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