Ever wondered what the ultrasound boys do in the ‘sonocave‘?

…tonsillar ultrasound of course!

The guys from UltrasoundVillage provide insight into the procedure of tonsillar ultrasound.

Rationale

Clinically differentiating peritonsillar abscess (quinsy)  from uncomplicated tonsillitits can be difficult. Traditional teaching dictates the uvula should be displaced away from the side of a quinsy, and that a quinsy tends to obliterate the palatoglossal fold.

In reality we find clinical assessment is relatively unreliable…

Tonsillar Ultrasound Technique

• Chose either a sterilised endocavity transducer or a hockey stick transducer for this procedure.
• Cover it with an unused condom.
• Explain the procedure to the patient, reassuring them it is not as bad as it looks!

• Spray the oropharynx with a local anaesthetic ENT spray. Now introduce the transducer carefully with the imaging plane transversely oriented.
• Gently push the transducer against the enlarged tonsil watching for any flow within the area of interest. Add colour Doppler. Record images measuring the size of any collection in both the transverse and longitudinal planes.
• Noting the depth from mucosal surface to collection, and from mucosal surface to carotid gives the proceduralist a sense of relative depths.

Uncomplicated Tonsillitis - Left Tonsillar fossa

Peritonsillar Abscess - Right Tonsillar fossa

Differentiation between solid enlarged tonsil and peritonsillar abscess is made by close observation of the heterogenous predominantly hypoechoic material within the tonsillar area.

• If an abscess has formed subtle movement of the probe will cause the pus to flow within the collection.
• If the tonsillar enlargement remains solid, no such flow occurs.

The addition of colour Doppler also assists. There is no flow within an abscess, whereas an inflamed enlarged but solid tonsil tends to be hyperaemic. In the first case note the vascular flow within the solid tonsil.
In the second case the flash of blue within the image is artefact, not hyperaemia

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

The S-CUT is the ultimate tool for removing clothes/leathers from that critically ill trauma patient. The S-CUT gives you the ability strip patients naked in seconds, saving you time, and allowing you get complete exposure with-out moving the patient minimising further injury and pain.

About the S-CUT:

• S-CUT is designed for use on patients in rescue situations as well as emergency situations in hospitals.
• It is a fast way to remove the patient’s clothes in order to expose injuries without needing to change the patient’s position which could inflict further injury or unnecessary pain.
• S-CUT replaces scissors, knifes and similar tools. Ordinary fabrics as well as leather belts, zippers and heavy outerwear can be easily cut.
• All you need is a free edge of the clothes where you can start the cut.
• S-CUT is designed for optimal ergonomics and provides an excellent grip.
• Using scissors in heavy materials will most often require a lot of effort. The S-CUT is used with a pulling action requiring minimal effort.

Check out the video and see how this device actually works:

http://www.youtube.com/watch?v=XLOOoTC1C-A

• Hat Tip: Impactednurse
• Disclaimer: LITFL has no financial interest or ties with the company who manufactures the S-CUT.

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

aka Ruling the Resus Room 002

A 28 year-old male is brought in by paramedics with ongoing generalised tonic/clonic seizures. They have continued for 35 minutes. The paramedics have given 15mg of Midazalam IM with no effect, and were unable to gain IV access due to extensive track marks over the patient’s veins from extensive IV drug use.

Vascular access is urgently needed to terminate this state of status epilepticus and to prevent further neurological sequelae. You consider placing a central line but don’t like the idea of even a few minutes delay, nor the idea of a moving target…

You decide to reach for the EZ-IO to obtain intraosseous access in seconds.

Image used with permission from: www.regval.com

Questions

Q1. Describe the history of the intraosseous catheter?

Answer and interpretation

Q2. What are the indications for intraosseous catheter/infusion?

Answer and interpretation

Q3. What are the advantages of the EZ- IO over central venous access?

Answer and interpretation

Q4. What medications/fluids can be infused through an intraosseous catheter?

Answer and interpretation

Q5. What anatomical locations and catheter sizes can be used with the EZ-IO?

Answer and interpretation

Currently recommended sites (from the manufacturer) for the EZ-IO are the:

1. Proximal humerus – (Palpate the anterior mid-shaft humerus, and continue palpating proximally up the anterior surface of the humerus until the greater tubercle is met. Palpate the coracoid and acromion, then imagine a line between them. The insertion point is about 2cm from its midpoint).
2. Proximal tibial – (In adults, two fingers’ breadths below and medial to the tibial tuberosity)
3. Distal tibia – (In adults, two fingers’ breadths proximal to the tip pf the medial malleolus)

However any bone with an intraosseous space can be used to place an intraosseous catheter. Current literature and studies seem to favour the proximal humerus as the preferred site, as it is close to the heart and allows the quickest absorption of fluids/medications into the central circulation.

Image From: www.regval.com

Selecting catheter size is similar to an IV with different sizes, for different ages and bone size:

• Pink — paediatric patients 3-39kg
• Blue — Patients >39kg
• Yellow — for patients with extensive soft tissues of insertion site.

Image used with permission from: www.regval.com

Q6. What are the contraindications for intraosseous use?

Answer and interpretation

Q7. What complications can occur from intraosseous catheters?

Answer and interpretation

Q8. How does the EZ-IO compare to CVC/IVC for medication delivery?

Answer and interpretation

Q9. What ongoing care do intraosseous infusion require?

Answer and interpretation

My Presentation to 2011 CENA Conference:

Disclosure

• The LITFL team have no financial or commercial interest in any product mentioned during this post.
• Lisa Owens from www.vidacare.com kindly provided images for use in this post.

References

• Burgert, J. (2009). Intraosseous infusion of blood products and epinephrine in an adult patient in haemorrhagic shock. AANA Journal. PMID: 19911645
• Chatterjee, D. et.al. (2011). Resuscitation in massive obstetric haemorrhage using an intraosseous needle. Anaesthesia. 66, 306-310. PMID: 21401545
• Fenwick, Rob. (2010). Intraosseous approach to vascular access in adult resuscitation. Emergency Nurse. 18(4), 22-25. PMID: 20662405
• Knuth, T. Paxton, J. & Myers, D.(2011). Intraosseous injection of iodinated computed tomography agent in an adult blunt trauma patient. Annals of Emergency Medicine. PMID: 21111513
• Langley, D. Moran, M. (2008). Intraosseous needles: They’re not just for kids anymore. Journal of Emergency Nursing. 34(4), 318-319. PMID: 18640412
• Luck, R. Haines, C. & Mull, C. (2010). Intraosseous Access. The Journal of Emergency Medicine. 39(4), 468-475. PMID: 19545966
• Mac Kinnon, K. (2009). Intraosseous vascular use at signature healthcare Brockton hospital department of emergency services. Journal of Emergency Nursing. 35(5), 425-428. PMID: 19748022
• Ngo, A. et.al. (2009). Intraosseous vascular access in adults using the EZ-IO in an emergency department. International Journal of Emergency Medicine. 2, 155-160. PMID: 20157465
• Ong, M. et.al. (2009). An observational, prospective study comparing tibial and numeral intraosseous access using the EZ-IO. American Journal of Emergency Medicine. 27, 8-15. PMID: 19041528
• Phillips, L. et.al. (2010). Recommendations for the use of intraosseous access for emergency and non-emergent situations in various healthcare settings: A consensus paper. Journal of Emergency Nursing. 36(6), 551-556. PMID: 21030876
• Ruiz-Hornillos, P. et.al. (2011). Systemic fibrinolysis through intraosseous vascular access in ST-segment elevation myocardial infarction. Annals of Emergency Medicine. PMID: 29047209
• Von Hoff, D. et.al. (2008). Does intraosseous equal intravenous? A pharmacokinetic study. American Journal of Emergency Medicine. 26, 31-38. PMID: 18082778

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

aka Trauma Tribulation 008

A 26 year-old male was BIBA after falling off his stationary motorbike at a set of traffic lights. C-spine precautions were removed following palpation of his neck and assessment of his sphincter tone. Initially, his only complaint was pain to his right thumb, presumably from a hyperextension injury. However a detailed secondary survey located a palpable deformity underlying the patient’s left jacket pocket.

Further inspection confirmed your suspicions, this patient sustained an irreversible injury to his third most vital organ:

Questions

Q1. How should this case be managed?

Answer and interpretation

Q2. Could this worst case scenario have been avoided?

Answer and interpretation

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

If you’re an ED doc, you probably love the iphone.But now that there are over 10,000 different apps in the App Store listed under “Medical” and “Healthcare & Fitness” you may be a bit bamboozled as to which apps to try.

Not to worry… Houston Neal from SoftwareAdvice.com has an updated list of the best medical apps for doctors and medical students. Here is how the list is created:

It’s worth having a look through the list to see what takes your fancy. Although, there are are no emergency medicine or critical care sub-categories, many of the categories are relevant to our specialties.

Let us know of any ‘must have’ apps you can recommend for use in the ED or the ICU. We’ve mentioned a quite a few ED/ ICU relevant apps before:

• Top ED iPhone Apps
• Smartphone Medical Apps
• iPhone Heart Monitor
• Eponyms for your iPhone
• Smartphone Medical Apps
• Learning CPR with your iphone

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

Scenario:

One of your trainees transfers an intubated patient from your resuscitation room to radiology for a CT scan. They are using a Dräger Oxylog^® 3000 to ventilate the patient.

Following completion of the CT scan, and prior to transfer back to the emergency department, the ventilator alarm was silenced due to a high Paw alarm.

On arrival back in the ER the nursing staff note oxygen saturations of 88% and rapidly falling…

Action:

The patient was disconnected from the ventilator.

Using BVM the patient was easily ventilated and oxygen saturations rapidly returned to 100%

There were no adverse sequele.

Review:

QA review revealed an interesting and potentially worrying alarm system on the Oxylog^® 3000.

If you have an Oxylog® 3000 or Oxylog® 3000 PLUS then try this…

Turn ventilator on

Press alarm silence.

Disconnect oxygen

Wait…

There is no breakthrough alarm for this catastrophic failure.

If you silence the alarm for any reason and there is subsequent oxygen supply failure within the next 2 minutes you will have no audible alarm.

Unlike other ventilators on the market the Oxylog^® 3000 cannot ventilate without an oxygen supply.

This issue has been raised with Dräger but they have elected not to perform a software upgrade as they don’t see the need to offer a breakthrough alarm system for this potentially lethal fault…

Any thoughts?

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

Smartphones have made significant advances over the last year, and with the technological advance a swarm of health based applications have descended upon us.

Despite the potential intervention of the TGA in the iPhone app development field, there are still a good number of well developed, user friendly and increasingly essential smartphone applications being developed. Some of the more useful applications I have tried recently include iDoctor and CPR Pro

iDoctor

In collaboration with developer Stuart Hall of Bonobo, Dr Rhys Clark from Sir Charles Gairdner Hospital in Perth has released “iDoctor”, a software application for Apple iPhone and iPod Touch devices, and also the iPad.

Primarily targeted at junior doctors working in hospital settings, iDoctor offers a suite of five different logging systems that allow clinicians to keep track of their procedures, hours worked, patients seen, education attended and consults given.

“I was struggling to keep track of my surgical logbook and also saw other doctors battling to run clunky spreadsheets on their iPhones. I found I had lots of different pieces of paper and patient stickers in my pockets and was always missing out on cases that needed to be included,” said Dr Clark.

The early version of the app is certainly very useful, and once the colleges MOPS and CME teams are able to accept direct submission of the data it will make the whole process of procedure accreditation much more streamlined.

Part proceeds from the sale of iDoctor will go to Australian Doctors for Africa, a charity providing volunteer doctors and nurses to areas of need in Africa. – The Record

Find iDoctor on [iTunes] [Facebook]

Find Bonobo Labs [Web] [Facebook] [Twitter]

http://www.youtube.com/watch?v=aGaL4fnsQUo

CPR Pro

CPR PRO application offers audio and visual prompts, as well as cardiopulmonary resuscitation (CPR) feedback, for individuals trained in Basic or Advanced Life Support.

Ivor Kovik (blog, twitter) runs Ivor Medical which is currently developing some really interesting and innovative medical devices/applications designed to save lives.

CPR PRO APP

CPR PRO was developed by Ivor Medical in collaboration with professional rescuers who perform CPR on a regular basis. It helps a trained individual to deliver CPR according to guidelines, and offer the best chances of survival and good recovery to the victim. CPR PRO features include:

• Compliance with the latest ILCOR CPR science guidelines
• Instant access to CPR feedback
• Visual and audio prompts
• Metronome to pace chest compressions
• Rate detection of actual compressions
• Detection of number of compressions
• Prompts to give two rescue breaths over 1 second, after the detection of 30 chest compressions
• Prompts to pace ventilation, when the airway is secured (10/minute)
• Stopwatch running continuously, helping you to keep track of time (regularly reassess the victim, deliver defibrillation and drugs, change rescuer roles, etc.)
• Two modes of operation, 30:2 and PRO – to be used when the airway is secured or if unwilling/unable to provide mouth-to-mouth ventilationsE
• Basic Life Support algorithm with photos
• Complete Instructions for Use

CPR PRO Cradle

This cool and space age looking device is designed to allow rescuers to deliver good quality chest compressions during CPR. It primarily allows rescuers to hold their hands in a natural position while performing CPR.

Rescuers grasp the two sides of the device with their palms, so that their hands are in line with their shoulders. Due to this natural hand position, it takes less power to perform accurate compressions and rescuers get tired less quickly. For this reason they can perform good quality compressions for longer periods of time, which is of crucial importance since CPR sometimes results in success after more than 30 or 60 minutes.

CPR PRO Cradle

This cradle and app have the potential to monitor and provide feedback on the regularity of performance of external chest compressions. With the help of accelerometers, such devices can determine the frequency and depth of compressions performed by rescuers and provide them with audio, visual and tactile feedback to enable them to adjust their actions according to international guidelines.

http://www.youtube.com/watch?v=Q-E-B3Pc8mk

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

Software engineers working on the Utopian Waiting Room Medicine Conference at the Symantec Health Institute of Technology have confirmed slugtrails of the Stuxnet worm on several of the UCEM servers. Whilst initial reports suggest that US and Mossad agents might be using the worm to infiltrate the Siemens SCADA Management System of the Bushehr  Nuclear Reactor in Iran (1), Professor Inglebert Struvite Staghorn of UCEM is concerned that a far more sinister motive, aimed at disrupting operations at Emergency Department Waiting Rooms is more likely.

“Most of the computers in our Emergency Departments have been donated to us from Iran. Like Iran, we also use Windows 2.0 and would therefore be extremely vulnerable to any form of Cyber attack targeting this operating system…” – Professor Staghorn

Microsoft has released a Patch, which addresses the ‘zero day vulnerability’ security hole.  The patch (Version 9,568,964,286.2) is available on C-60 Cassette and Floppy Disk, and should prevent redistribution of the worm for the next 5 minutes, by crashing the Windows Operating System for hours.

Despite the worms formidable design in penetrating the WinCC software firewall using compromised Security Certificates (2), Professor Harry Stickler, Chair of Pedantry at the UCEM Council Executive, does not feel the worm has yet been activated.

“It is clear that we have NOT yet seen any compromise to our systems, through the activation of the worm. If the worm were activated we would expect to see…” – Professor Harry Stickler

• Long Emergency Department waiting times, preventing us from meeting our 4-minute rule targets
• Access block from our Waiting Rooms into the main Emergency Departments
• Poor performance of our Emergency Triage Software
• An inability to view radiological images on SUXS (Sonographic Ultrasound and X-Ray Software)
• An inability to download X-rated material from YourTube and BookFace

Software engineers are also sceptical of the depth of penetration of the Stuxnet Worm. The Stuxnet Worm was designed by an advanced, as yet unidentified, third party, with the intention of maliciously taking over large operating systems. Despite the Worm’s status as a ‘Cyber Superweapon’, the creators of the worm failed to identify 2 defensive features of the UCEM Health Information Network. Firstly, all of UCEM’s computers are incapable of propagating the worm, as they do not accept USB memory sticks, key drives or 240 volts.

Secondly, the worm is designed to infiltrate the newest generation of 21^st Century Browsers, of which Netscape Navigator 3.0 is not one.

UCEM lean-thinking workflow laundering hierarchy blueprint

The College President, Sir Hubert Ignatius Thompson III has remained un-alarmed by the recent security threat, and issued a statement yesterday afternoon.

“The thought that a driven and determined third party, with advanced organizational skills and financial resources has finally taken action, infiltrated our Emergency Department to undermine its current modus operandi, frankly does not scare me. Quite in the contrary, I have looked forward to it for quite some time. This whole place could do with a good de-worming.”

UCEM headquarters under threat

References

• The Economist: “A cyber-missile aimed at Iran?” Sept 26, 2010
• The Christian Science Monitor – CSMonitor.com
• Wild Security Inc [Reference PDF]
• Knowledge Brings Fear: Stuxnet: targeting the iranian enrichment centrifuges in Natanz?

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

It is a situation you, as the UCEM Waiting Room trainee sees every day.

An 86 year old Gold Card holder on a pillow in the Imminent Collapse Unit is looking agitated and psychotic. She is riddled with track marks, and it is clear that she has just shot her last Compo cheque up her arm. She stares in paranoia at the 7 ft, 200 lbs East African HSA guard who is reading the latest Women’s Own weekly wordsearch. The patient slips a Werther’s Original into her mouth and reaches for her handbag with an intent to beat the HSA senselessly into submission.

At that moment, the cardiac monitor on her ICU Pillow goes into VT…

Why should you have to restrict your options to best manage this patient with physical restraint, chemical restraint, the stetho-stun or cardioversion? Now you can have your cake and eat it.

Introducing the all new Defibritazer BP-50KV

The one shot answer to electrical restraint and DC cardioversion. Drop the patient rendering them harmless in less than 0.47 seconds with the Police Grade, twin aeroflex gold tipped electrode ‘stingers’, with a range of up to 200 feet. Then defibrillate the victim out of excited delirium with a synchronized life saving biphasic 50,000 volt shock, and gift them the current of life.

Defibritazer BP-50KV

7 Randomized Double Blind Controlled Trials can’t be wrong! Despite being banned in over 3 States the Defibritazer has been shown to effectively reduce violence towards hospital staff.

“…over 90% of patients are still completely lifeless 2 weeks post defibritazing”, reports a Coronial Inquest last week, “despite active thawing measures”.

The First UCEM Conference in Molvania will provide a 1 day workshop to cover:

• Blindfolded weapon dissassembly and assembly in less than 20 seconds
• Target practice at old people walking outside the lecture hall
• Sniper and close combat engagement techniques
• Avoiding collateral serial circuit electrocution when discharging your treatment in a busy Waiting Room
• Rhythm strip recognition and guess-timation
• Aeroflex gold tipped electrode stinger removal, wound debridement, washout and long term prophylactic antibiotic prophylaxis

Feminists across Australia, the US and the UK are advocating its availability in Football Stadiums across the world. “My husband really deserves it”, responds one wife, whose husband ran amok to the Superfinal for 3 days with his mates without telling her.

Semiautomatic (BP50KSA) and Automatic models (BP50KA) are expected to be rolled out later this year with pink and diamond studded ivory handles.

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

I love trawling the web for educational resources, to see how other people are using technology to translate written text into visual landscapes…

Today I stumbled across what looks to be the first in a series of instructional videos on Ultrasound in the emergency department from a group of ED physicians in Nambour on the Sunshine Coast in Queensland

This video is a great example of an elegant teaching style, recorded and video and shared with the world – great work guys, will be following closely to see what you are up to next.

Ultrasound Guided Venous Access

http://www.youtube.com/watch?v=NQjVlElA8UU

Life in the Fast Lane Medical Blog - Emergency Medicine education blog