- Email: [email protected]
215 Prevalence of the “Double-Line” Sign When Performing Focused Assessment With Sonography For Trauma Exams
Research Forum Abstracts defined as a palpable pulse and a measurable blood pressure for a minimum of thirty minutes. Data was analyzed using descriptive statistics and students. Results: Fifty-nine patients were enrolled (14 EDCA and 45 OHCA) with complete data. Age was similar between the 2 groups (mean 65.3). There was 10 ROSC in EDCA (71.4%) and 10 ROSC in OHCA (22.2%). Initial rhythm for EDCA was PEA, 58%m VF 8%, VT 17%. In OHCA the initial rhythm was PEA, 35%, VF 31% Asystole 33.3%. Initial ETCO2 was on average higher in the OHCA 27.9 (21.1) compared to EDCA 18.3 (7.3); however, this was not statistically significant (p⫽0.012). Any ETCO2 ⬎30 at anytime during resuscitation were similar between EDCA 8 (57.1%) and OHCA 33 (73.3%). There was a difference in the time of sustained ETCO2 ⬎ 30 in minutes prior to ROSC or Death 0.62 EDCA and 2.63 OHCA, (p ⫽ 0.007) and the degree of rise prior to ROSC was greater in EDCA than OHCA, (7.14 v 2.67, p ⫽ 0.266). CereOx ⬎30 at any time during resuscitation was higher in EDCA 78.6% compared to 31.1% OHCA (p⫽0.005). CereOx change from 3mins before ROSC/Death was statistically different between groups, having a delta of 12.28 for EDCA and 1.6 for OHCA. Groups were statistically significant in number of epinephrine given, OHCA 4.99 and EDCA 2.71 (p⫽0.003). Conclusions: Not surprisingly, EDCA was different than OHCA with respect to initial rhythm, percent ROSC, and required less epinephrine in comparison to the OHCA. ETCO2 initial was lower in the EDCA; however, the rise was greater and time ⬎ 30 was less than in OHCA. Similarly, the duration of CereOx ⬎30 and the elevation prior to ROSC was greater in EDCA than OHCA. These differences may represent the earlier monitoring, shorter downtimes and better CPR in EDCA.
212
End Tidal CO2 versus Cerebral Oximetry for Monitoring CPR Quality and Determination of Return of Spontaneous Circulation
Engel II TW, Medado P, Thomas C, Wilburn J, Scott T, O’Neil B/Wayne State University School of Medicine, Detroit, MI
Background: There are over 330,000 deaths due to cardiac arrest (CA) per year in the US. The American Heart Association (AHA) recommends monitoring the quality of cardiopulmonary resuscitation (CPR) primarily through the use of End Tidal CO2 (ETCO2). The level of ETCO2 is significantly dependant on minute ventilation and altered by pressors and bicarbonate administration. Cerebral Oximetry (CereOx) utilizes near infrared spectroscopy to non-invasively measure regional oxygen saturation of the frontal lobes of the brain. CereOx has been correlated with cerebral blood flow and jugular vein bulb saturation. Study Objectives: The objective of this study is to compare the simultaneous measurement of ETCO2 and CereOx to investigate which monitoring method provides the best measure of CPR quality as defined by return of spontaneous circulation (ROSC). Methods: A prospective study on a convenience sample of subjects suffering from out-of-hospital and ED CA from 2 large EDs. Subjects had simultaneous monitoring of ETCO2 and CereOx during CPR. Patient demographics and arrest data was collected utilizing the Utstein criteria. All patients were monitored throughout the resuscitation efforts. ROSC was defined as a palpable pulse and a measurable blood pressure that was maintained for a minimum of ten minutes. Results: Fifty-nine encounters were included in the analysis. 33.9% of the subjects attained ROSC. Average down time with ROSC until ED arrival was 10.2 minutes (SD⫾14.3) and 24.2 minutes (SD⫾14.4) without ROSC. The inability to obtain a value of 30 either for ETCO2 or CereOx was 30.8% and 79.5% specific and had a NPV of 66.6% and 91.2% respectively for predicting lack of ROSC. Obtaining a value of 30 for either ETCO2 or CereOx was 70% and 85% sensitive with a PPV of 34.1% and 68% respectively for predicting ROSC. Subjects with ROSC had sustained values above 30 for 1.9 (SD⫾2.37) minutes on CereOx and 1.67 (SD⫾2.17) minutes on ETCO2 prior to ROSC. The change in values during the 3-minute period prior to ROSC was 12.15 (SD⫾14.03) for the ETCO2 and 13.35 (SD⫾15.7) for the CereOx. Conclusions: The inability to obtain a value of 30 on either the ETCO2 or CereOx strongly predicted lack of ROSC. CereOx and ETCO2 were comparable in their elevation and sustainability prior to obtaining ROSC. Attaining a value of 30 on CereOx was more predictive of ROSC than ETCO2.
Volume , . : October
213
Family Presence During Cardiopulmonary Resuscitation
Jabre P, Belpomme V, Jacob L, Bertrand L, Broche C, Pinaud V, Assez N, Beltramini A, Normand D, Adnet F/APHP, PARIS, France; Montauban Hospital, MONTAUBAN, France; Nantes Hospital, NANTES, France; Lille Hospital, LILLE, France; Dreux Hospital, DREUX, France
Study Objectives: Family presence during cardiopulmonary resuscitation (CPR) of a loved one remains controversial. The principal aim of this trial was to determine if offering a relative the choice to observe CPR of a family member might reduce his or her psychological impact 90 days later. We also assessed the impact of family presence on medical efforts at resuscitation, the wellbeing of the health care team, and on the occurrence of medicolegal claims. Methods: This study was a multicenter prospective, cluster randomized, controlled trial. We enrolled 570 relatives of patients who were in cardiac arrest in 17 out-of-hospital emergency medical services. Centers were randomized either to 1) systematically offer the family member the opportunity to observe CPR (intervention group), or 2) to a habitual practice regarding family presence (control group). The primary endpoint was the proportion of relatives having post-traumatic stress disorder (PTSD)-related symptoms by an Impact of Event Scale (IES) ⬎30 at 90 days. Secondary endpoints included the presence of anxiety and depression symptoms by the Hospital Anxiety and Depression Scale (HADS) and the impact of family presence on medical efforts at resuscitation, the wellbeing of the health care team, and on the occurrence of medicolegal claims. For pyschological assessment analyses, inorder to take into account the cluster structure of the design, Generalized Estimating Equations (GEE) were used. Results: In the intervention group, 211/266 (79%) relatives witnessed CPR compared to 131/304 (43%) relatives in the control group. In the intention-to-treat analysis, family members had PTSD-related symptoms significantly more frequently in the control group (adjusted odds ratio, 1.7; 95% confidence interval [CI], 1.2 to 2.5; P⫽0.004) and when they did not witness CPR (adjusted odds ratio, 1.6; 95% CI, 1.1 to 2.5; P⫽0.02). According to family presence, relatives who did not witness CPR had more frequently symptoms of anxiety and depression. Family-witnessed CPR did not affect resuscitation characteristics, patient survival, medical team stress or result in medicolegal claims. Conclusion: Our results promote family presence during CPR. This experience was associated with positive results on psychological parameters and neither interfered with medical efforts or health care team stress nor resulted in medicolegal conflicts.
214 215
Abstract Withdrawn
Prevalence of the “Double-Line” Sign When Performing Focused Assessment With Sonography For Trauma Exams
Patwa AS, Lomibao A, Aziz-Bose R, Abo A, Nelson M, Bramante R, Modayil V, Haines C, Raio CC/North Shore-LIJ Health System, Manhasset, NY
Study Objectives: This study aims to determine the prevalence of the doubleline sign, a finding that can be mistaken for free intraperitoneal fluid during clinically indicated focused assessment with sonography in trauma (FAST) exams. The study also investigates the relationship between the presence of a double-line sign and BMI, sex, age, and positive FAST exam for free fluid. Methods: This was a prospective, observational, institutional review boardapproved study at an 85,000 visit/year, academic Level 1 Trauma Center. A convenience sample of adult patients (ⱖ18 years) was enrolled when a FAST exam was performed as part of patients’ clinical management. Each exam was performed by an RDMS-eligible or -certified ultrasonographer. The double-line sign (DLS) was defined to be an ultrasonographic finding of a wedge-shaped hypoechoic region in Morison’s pouch bound on the hepatic and renal sides by echogenic lines. In real time, the sonographer established the presence or absence of the DLS, and recorded the subject’s sex, age, height, and weight. If a patient received additional imaging (CT scan or radiography ) or went to surgery, presence or absence of free fluid in the abdomen was recorded as a “gold standard” measurement. The 2 sample t-test was used to compare presence of DLS against continuous variables, and the Fisher’s exact test was used to compare groups for categorical data.
Annals of Emergency Medicine S77
Research Forum Abstracts Results: In total, 49 patients (mean age 46⫾23 years, mean BMI 28.1⫾7.5, 47% female) were enrolled. The DLS was present in 32.7% of all exams (n⫽16). There was no significant difference in BMI between DLS-positive and DLS-negative groups (26.9 [inter-quartile range 22.2-30.5] versus 28.8 [IQR 24.1-30.5]; p⫽0.18). However, there was a significant difference in age between DLS-positive and DLSnegative groups (54 years [IQR 31-73] versus 42 years [IQR 23-52]; p⬍0.05). In the DLS-positive cases, 56.3% had negative FAST exams for free fluid (false positives). There was a significant difference in the proportion of false-positive readings in the over-65 and under-65 subject groups (50% versus 8.8%, p⬍0.005); however, no significant differences were found for sex, height, or weight. When follow-up imaging was done (n⫽22), findings for free fluid were consistent with results from the FAST exam in 86% of cases. Conclusion: The double-line sign was a common finding in adult FAST exams. No significant relationship was found between BMI and false-positive DLS findings. However, a relationship was found between age and the prevalence of false-positive readings: false-positive DLS were more likely to be visualized for patients over 65. For this group, therefore, it is particularly important to verify the presence of free fluid in DLS-positive FAST exams using other confirmatory imaging. Ultrasonography training should address the implications of a positive DLS in FAST exams - especially in those under 65 - to improve patient care and avoid unnecessary costs.
216
Medical Student Assessment of Point of Care Ultrasonography Training as Part of the Emergency Medicine Clerkship
Favot M, Amponsah D, Manteuffel J/Henry Ford Hospital, Detroit, MI
Study Objectives: The purpose of this study was to evaluate whether or not 4th year medical students felt that dedicated point-of-care ultrasonography training was a useful addition to the standard emergency medicine clerkship curriculum. Methods: This was an 8-month prospective cohort study of medical students during an emergency medicine clerkship at a large urban academic medical center, from July 2011 to February 2012. A total of 40 medical students participated in the study, with an average of 5 students per month. As part of the standard 1-month emergency medicine clerkship, students were introduced to the Focused Assessment with Sonography for Trauma (FAST) exam, and ultrasonography-guided vascular access. They all completed a 2-hour ultrasonography didactic and hands-on session on live models and phantoms on day one of the elective. They also had 3-4 hours of individual dedicated scanning sessions with the ultrasonography fellow during the 1-month elective. They completed a 10-item multiple choice exam at the end of the rotation, and were surveyed via email one month after the rotation regarding their ultrasonography experience (figure 1). The investigators were aware of the chosen specialties of all the subjects. Results: 29/40 (72.5%) students completed the email survey. 14 (48.3%) of the students were applying to emergency medicine residencies, 5 (17.2%) to internal medicine, and 3 (10.3%) to family medicine. No other specialty had more than 2 prospective applicants amongst the students. Other specialties represented were surgery, radiology, neurology, anesthesiology and ophthalmology. 24/29 (82.8%) respondents said they had used ultrasonography during subsequent clinical rotations and 27/29 (93.1%) respondents said they foresaw using ultrasonography in some capacity during residency. Other themes that were frequently mentioned by the students in their responses were: finding the knowledge helpful on non-emergency medicine rotations (17/29, 58.6%), finding the scanning shift with the ultrasonography fellow highly valuable (16/29, 55.2%), getting to train on patients with actual pathology rather than models or volunteers (7/29, 24.1%) wanting more than 1 dedicated scanning shift (15/29, 51.7%) and also wanting bedside echocardiography to be a part of the curriculum (7/29, 24.1%) (table 1). There was a wide variation in the rotations the students mentioned using the ultrasonography skills they learned during the emergency medicine clerkship including CCU, PICU, OB, MICU, radiology, family medicine, internal medicine and surgery. Conclusions: Our study demonstrates that medical students find dedicated point-of-care ultrasonography training to be a useful adjunct to the emergency medicine clerkship curriculum, and that they feel the skills they acquire during this time will serve to benefit them on future clerkships and during residency training.
S78 Annals of Emergency Medicine
217
Midaxillary Option for Measuring IVC: Prospective Comparison of the Right Midaxillary and Subxiphoid IVC Measurements
Howard ZD, Gharahbaghian L, Steele BJ, Foy S, Williams SR/Stanford University, Stanford, CA
Study Objectives: Subxiphoid (SX) bedside ultrasonography measurements of the inferior vena cava (IVC) as a reflection of volume status and the variability of IVC diameter with anatomical location has been well described in the literature; however, trauma patients commonly have thoracoabdominal pathology that often limits this sonographic window. The right midaxillary (RMA) IVC view may offer a good alternative, obtained with the probe in the same window as the Morison’s pouch evaluation for the FAST exam and in many ultrasonography protocols for a patient in undifferentiated shock. The primary objective is to assess the accuracy of the RMA IVC view compared to the SX IVC view. Secondary objectives include evaluating emergency physicians’ ease of obtaining the RMA view, prior clinical judgment of volume status compared to each IVC view and whether a concurrent static versus dynamic trend of vital signs correlates with IVC volume status measurement. Methods: A prospective convenience sample of adult patients at a large urban academic Level-1 trauma center emergency department were enrolled over a 6-month period in 2011-2012. Emergency physicians trained in the protocol visualized the longitudinal IVC in in both SX and RMA windows. Measurements of maximal and minimal diameter located 2cm from the caval-atrial junction or diaphragm were recorded during passive respiration utilizing both 2D clips, still images and M-mode functionality. Sonosite M-Turbo systems were used exclusively for this study deemed exempt by the IRB. Euvolemia was defined by prior studies as an IVC diameter of 1.5-2.5cm with 50% or less respiratory variation in the SX view. Patients’ initial and concurrent vital signs, physician perceptions of volume status who were blinded to IVC measurement, and ease of obtaining the RMA views were noted in a random subset of cases. Mean and standard deviations of the measurements were compared using a paired t-test with scientific significance given to those with p values ⬍ 0.05.
Volume , . : October
212
End Tidal CO2 versus Cerebral Oximetry for Monitoring CPR Quality and Determination of Return of Spontaneous Circulation
Engel II TW, Medado P, Thomas C, Wilburn J, Scott T, O’Neil B/Wayne State University School of Medicine, Detroit, MI
Background: There are over 330,000 deaths due to cardiac arrest (CA) per year in the US. The American Heart Association (AHA) recommends monitoring the quality of cardiopulmonary resuscitation (CPR) primarily through the use of End Tidal CO2 (ETCO2). The level of ETCO2 is significantly dependant on minute ventilation and altered by pressors and bicarbonate administration. Cerebral Oximetry (CereOx) utilizes near infrared spectroscopy to non-invasively measure regional oxygen saturation of the frontal lobes of the brain. CereOx has been correlated with cerebral blood flow and jugular vein bulb saturation. Study Objectives: The objective of this study is to compare the simultaneous measurement of ETCO2 and CereOx to investigate which monitoring method provides the best measure of CPR quality as defined by return of spontaneous circulation (ROSC). Methods: A prospective study on a convenience sample of subjects suffering from out-of-hospital and ED CA from 2 large EDs. Subjects had simultaneous monitoring of ETCO2 and CereOx during CPR. Patient demographics and arrest data was collected utilizing the Utstein criteria. All patients were monitored throughout the resuscitation efforts. ROSC was defined as a palpable pulse and a measurable blood pressure that was maintained for a minimum of ten minutes. Results: Fifty-nine encounters were included in the analysis. 33.9% of the subjects attained ROSC. Average down time with ROSC until ED arrival was 10.2 minutes (SD⫾14.3) and 24.2 minutes (SD⫾14.4) without ROSC. The inability to obtain a value of 30 either for ETCO2 or CereOx was 30.8% and 79.5% specific and had a NPV of 66.6% and 91.2% respectively for predicting lack of ROSC. Obtaining a value of 30 for either ETCO2 or CereOx was 70% and 85% sensitive with a PPV of 34.1% and 68% respectively for predicting ROSC. Subjects with ROSC had sustained values above 30 for 1.9 (SD⫾2.37) minutes on CereOx and 1.67 (SD⫾2.17) minutes on ETCO2 prior to ROSC. The change in values during the 3-minute period prior to ROSC was 12.15 (SD⫾14.03) for the ETCO2 and 13.35 (SD⫾15.7) for the CereOx. Conclusions: The inability to obtain a value of 30 on either the ETCO2 or CereOx strongly predicted lack of ROSC. CereOx and ETCO2 were comparable in their elevation and sustainability prior to obtaining ROSC. Attaining a value of 30 on CereOx was more predictive of ROSC than ETCO2.
Volume , . : October
213
Family Presence During Cardiopulmonary Resuscitation
Jabre P, Belpomme V, Jacob L, Bertrand L, Broche C, Pinaud V, Assez N, Beltramini A, Normand D, Adnet F/APHP, PARIS, France; Montauban Hospital, MONTAUBAN, France; Nantes Hospital, NANTES, France; Lille Hospital, LILLE, France; Dreux Hospital, DREUX, France
Study Objectives: Family presence during cardiopulmonary resuscitation (CPR) of a loved one remains controversial. The principal aim of this trial was to determine if offering a relative the choice to observe CPR of a family member might reduce his or her psychological impact 90 days later. We also assessed the impact of family presence on medical efforts at resuscitation, the wellbeing of the health care team, and on the occurrence of medicolegal claims. Methods: This study was a multicenter prospective, cluster randomized, controlled trial. We enrolled 570 relatives of patients who were in cardiac arrest in 17 out-of-hospital emergency medical services. Centers were randomized either to 1) systematically offer the family member the opportunity to observe CPR (intervention group), or 2) to a habitual practice regarding family presence (control group). The primary endpoint was the proportion of relatives having post-traumatic stress disorder (PTSD)-related symptoms by an Impact of Event Scale (IES) ⬎30 at 90 days. Secondary endpoints included the presence of anxiety and depression symptoms by the Hospital Anxiety and Depression Scale (HADS) and the impact of family presence on medical efforts at resuscitation, the wellbeing of the health care team, and on the occurrence of medicolegal claims. For pyschological assessment analyses, inorder to take into account the cluster structure of the design, Generalized Estimating Equations (GEE) were used. Results: In the intervention group, 211/266 (79%) relatives witnessed CPR compared to 131/304 (43%) relatives in the control group. In the intention-to-treat analysis, family members had PTSD-related symptoms significantly more frequently in the control group (adjusted odds ratio, 1.7; 95% confidence interval [CI], 1.2 to 2.5; P⫽0.004) and when they did not witness CPR (adjusted odds ratio, 1.6; 95% CI, 1.1 to 2.5; P⫽0.02). According to family presence, relatives who did not witness CPR had more frequently symptoms of anxiety and depression. Family-witnessed CPR did not affect resuscitation characteristics, patient survival, medical team stress or result in medicolegal claims. Conclusion: Our results promote family presence during CPR. This experience was associated with positive results on psychological parameters and neither interfered with medical efforts or health care team stress nor resulted in medicolegal conflicts.
214 215
Abstract Withdrawn
Prevalence of the “Double-Line” Sign When Performing Focused Assessment With Sonography For Trauma Exams
Patwa AS, Lomibao A, Aziz-Bose R, Abo A, Nelson M, Bramante R, Modayil V, Haines C, Raio CC/North Shore-LIJ Health System, Manhasset, NY
Study Objectives: This study aims to determine the prevalence of the doubleline sign, a finding that can be mistaken for free intraperitoneal fluid during clinically indicated focused assessment with sonography in trauma (FAST) exams. The study also investigates the relationship between the presence of a double-line sign and BMI, sex, age, and positive FAST exam for free fluid. Methods: This was a prospective, observational, institutional review boardapproved study at an 85,000 visit/year, academic Level 1 Trauma Center. A convenience sample of adult patients (ⱖ18 years) was enrolled when a FAST exam was performed as part of patients’ clinical management. Each exam was performed by an RDMS-eligible or -certified ultrasonographer. The double-line sign (DLS) was defined to be an ultrasonographic finding of a wedge-shaped hypoechoic region in Morison’s pouch bound on the hepatic and renal sides by echogenic lines. In real time, the sonographer established the presence or absence of the DLS, and recorded the subject’s sex, age, height, and weight. If a patient received additional imaging (CT scan or radiography ) or went to surgery, presence or absence of free fluid in the abdomen was recorded as a “gold standard” measurement. The 2 sample t-test was used to compare presence of DLS against continuous variables, and the Fisher’s exact test was used to compare groups for categorical data.
Annals of Emergency Medicine S77
Research Forum Abstracts Results: In total, 49 patients (mean age 46⫾23 years, mean BMI 28.1⫾7.5, 47% female) were enrolled. The DLS was present in 32.7% of all exams (n⫽16). There was no significant difference in BMI between DLS-positive and DLS-negative groups (26.9 [inter-quartile range 22.2-30.5] versus 28.8 [IQR 24.1-30.5]; p⫽0.18). However, there was a significant difference in age between DLS-positive and DLSnegative groups (54 years [IQR 31-73] versus 42 years [IQR 23-52]; p⬍0.05). In the DLS-positive cases, 56.3% had negative FAST exams for free fluid (false positives). There was a significant difference in the proportion of false-positive readings in the over-65 and under-65 subject groups (50% versus 8.8%, p⬍0.005); however, no significant differences were found for sex, height, or weight. When follow-up imaging was done (n⫽22), findings for free fluid were consistent with results from the FAST exam in 86% of cases. Conclusion: The double-line sign was a common finding in adult FAST exams. No significant relationship was found between BMI and false-positive DLS findings. However, a relationship was found between age and the prevalence of false-positive readings: false-positive DLS were more likely to be visualized for patients over 65. For this group, therefore, it is particularly important to verify the presence of free fluid in DLS-positive FAST exams using other confirmatory imaging. Ultrasonography training should address the implications of a positive DLS in FAST exams - especially in those under 65 - to improve patient care and avoid unnecessary costs.
216
Medical Student Assessment of Point of Care Ultrasonography Training as Part of the Emergency Medicine Clerkship
Favot M, Amponsah D, Manteuffel J/Henry Ford Hospital, Detroit, MI
Study Objectives: The purpose of this study was to evaluate whether or not 4th year medical students felt that dedicated point-of-care ultrasonography training was a useful addition to the standard emergency medicine clerkship curriculum. Methods: This was an 8-month prospective cohort study of medical students during an emergency medicine clerkship at a large urban academic medical center, from July 2011 to February 2012. A total of 40 medical students participated in the study, with an average of 5 students per month. As part of the standard 1-month emergency medicine clerkship, students were introduced to the Focused Assessment with Sonography for Trauma (FAST) exam, and ultrasonography-guided vascular access. They all completed a 2-hour ultrasonography didactic and hands-on session on live models and phantoms on day one of the elective. They also had 3-4 hours of individual dedicated scanning sessions with the ultrasonography fellow during the 1-month elective. They completed a 10-item multiple choice exam at the end of the rotation, and were surveyed via email one month after the rotation regarding their ultrasonography experience (figure 1). The investigators were aware of the chosen specialties of all the subjects. Results: 29/40 (72.5%) students completed the email survey. 14 (48.3%) of the students were applying to emergency medicine residencies, 5 (17.2%) to internal medicine, and 3 (10.3%) to family medicine. No other specialty had more than 2 prospective applicants amongst the students. Other specialties represented were surgery, radiology, neurology, anesthesiology and ophthalmology. 24/29 (82.8%) respondents said they had used ultrasonography during subsequent clinical rotations and 27/29 (93.1%) respondents said they foresaw using ultrasonography in some capacity during residency. Other themes that were frequently mentioned by the students in their responses were: finding the knowledge helpful on non-emergency medicine rotations (17/29, 58.6%), finding the scanning shift with the ultrasonography fellow highly valuable (16/29, 55.2%), getting to train on patients with actual pathology rather than models or volunteers (7/29, 24.1%) wanting more than 1 dedicated scanning shift (15/29, 51.7%) and also wanting bedside echocardiography to be a part of the curriculum (7/29, 24.1%) (table 1). There was a wide variation in the rotations the students mentioned using the ultrasonography skills they learned during the emergency medicine clerkship including CCU, PICU, OB, MICU, radiology, family medicine, internal medicine and surgery. Conclusions: Our study demonstrates that medical students find dedicated point-of-care ultrasonography training to be a useful adjunct to the emergency medicine clerkship curriculum, and that they feel the skills they acquire during this time will serve to benefit them on future clerkships and during residency training.
S78 Annals of Emergency Medicine
217
Midaxillary Option for Measuring IVC: Prospective Comparison of the Right Midaxillary and Subxiphoid IVC Measurements
Howard ZD, Gharahbaghian L, Steele BJ, Foy S, Williams SR/Stanford University, Stanford, CA
Study Objectives: Subxiphoid (SX) bedside ultrasonography measurements of the inferior vena cava (IVC) as a reflection of volume status and the variability of IVC diameter with anatomical location has been well described in the literature; however, trauma patients commonly have thoracoabdominal pathology that often limits this sonographic window. The right midaxillary (RMA) IVC view may offer a good alternative, obtained with the probe in the same window as the Morison’s pouch evaluation for the FAST exam and in many ultrasonography protocols for a patient in undifferentiated shock. The primary objective is to assess the accuracy of the RMA IVC view compared to the SX IVC view. Secondary objectives include evaluating emergency physicians’ ease of obtaining the RMA view, prior clinical judgment of volume status compared to each IVC view and whether a concurrent static versus dynamic trend of vital signs correlates with IVC volume status measurement. Methods: A prospective convenience sample of adult patients at a large urban academic Level-1 trauma center emergency department were enrolled over a 6-month period in 2011-2012. Emergency physicians trained in the protocol visualized the longitudinal IVC in in both SX and RMA windows. Measurements of maximal and minimal diameter located 2cm from the caval-atrial junction or diaphragm were recorded during passive respiration utilizing both 2D clips, still images and M-mode functionality. Sonosite M-Turbo systems were used exclusively for this study deemed exempt by the IRB. Euvolemia was defined by prior studies as an IVC diameter of 1.5-2.5cm with 50% or less respiratory variation in the SX view. Patients’ initial and concurrent vital signs, physician perceptions of volume status who were blinded to IVC measurement, and ease of obtaining the RMA views were noted in a random subset of cases. Mean and standard deviations of the measurements were compared using a paired t-test with scientific significance given to those with p values ⬍ 0.05.
Volume , . : October