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To evaluate the frequency of unsuspected posterior vessel wall penetration of the internal jugular vein during ultrasound-guided needle cannulation.Prospective, single-blinded observational study.Urban level I emergency department with an annual census of 80,000.Residents who had previously completed a 2-day ultrasound course including a 3-hr didactic and hands-on session on ultrasound-guided central venous cannulation.Residents were asked to place an ultrasound-guided catheter on a human torso mannequin. Residents used a short-axis approach for ultrasound guidance. During the procedure, an 8-4 MHz convex (endocavity) transducer was used to observe the path of the resident's needle without interference with the placement procedure.Unknown to residents, researchers tracked the frequency of posterior wall penetration and the final needle location when the resident felt that optimal needle placement was achieved in the lumen of the internal jugular. Residents were also asked to rate their confidence regarding appropriate final needle position on a 10-point Likert scale. Statistical analysis consisted of descriptive statistics and Spearman correlation analysis. A total of 25 residents participated. All had placed at least one ultrasound-guided central catheter previously. The median number of previous ultrasound-guided cannulations was 8.0. Sixteen (64%) residents accidentally penetrated the posterior wall of the internal jugular vein during cannulation. The median number of posterior wall penetrations was 1.0 for all residents. In six cases the final location of the needle was through the posterior wall and deep to the venous lumen. In five of these cases the carotid artery was actually mistakenly penetrated. Median confidence by residents regarding appropriate needle placement was 8.0 out of 10. More training and more ultrasound-guided catheters placed were associated with fewer posterior wall penetrations (p = .04).In this study, residents accidentally penetrated the posterior vessel wall of the internal jugular in a lifelike vascular access mannequin in the majority of cases. These results suggest that care must be taken even with ultrasound-guided central catheter placement and that alternative ultrasound guidance techniques, such as visualization of the vein and needle in longitudinal axis, should be considered.

BACKGROUND: Ultrasonography use is increasing in emergency departments, and ultrasound education is now recommended in resident training. Ultrasound phantoms are used in many institutions for training purposes. The purpose of this study is to describe an inexpensive and simple method to create ultrasound-imaging models for the purpose of education and practice using clear ballistic gel. METHODS: Clear ballistic gel is used to simulate tissue for firing practice and other military evaluations. RESULTS: The transparent and durable ultrasound phantom we produced was clear and contained four vessel lumens. The images obtained using the phantom were of high quality and compared well to normal sonographic anatomy. CONCLUSIONS: The clear ballistic brand gel is unique because it is inexpensive, does not dry out, does not decay, is odorless, and is reusable. The ultrasound images obtained using the phantom are realistic and useful for ultrasound education.

Objectives The objective of this study was to describe diagnosis and management of ectopic pregnancy using bedside transvaginal ultrasound (US) in an established emergency US program. Methods This was a retrospective study on patients presenting over a 2-year period performed at a level I urban academic emergency department (ED). The ED sees 78000 patients annually and has a residency and active US program. Patients were eligible for inclusion if they were pregnant, seen in the ED for a first-trimester complication, and underwent a bedside emergency US suggesting an ectopic pregnancy. Emergency department US logs were reviewed for findings suggestive of ectopic pregnancy. Medical records were reviewed for history, physical examination findings, laboratory results, additional diagnostic testing, management, hospital course, and a discharge diagnosis by the admitting obstetric service (OB). Patients with incomplete data were excluded from analysis. Statistical analysis consisted of descriptive statistics. Results Seventy-four patients ranging in age from 16 to 39 years (mean, 25 years) were included in the study. Eight patients with incomplete data were excluded from analysis. Emergency-physician US diagnoses included definite ectopic pregnancy (6/74), probable ectopic pregnancy (28/74), and possible ectopic pregnancy (40/74). Forty-seven (64%) of these patients were eventually diagnosed with definite ectopic pregnancy by the OB. During initial consultation, the OB disagreed with the diagnosis of ectopic pregnancy in 15 (32%) of the 47 eventual patients with ectopic pregnancy, calling them miscarriages. Other eventual diagnoses included 9 (12%) patients with possible ectopic pregnancy, 11 (14%) patients with miscarriage, and 7 (9%) with intrauterine pregnancy. Emergency sonologists found tubal rings in 9 (19%) patients with eventual ectopic pregnancy, complex adnexal mass in 29 (61%) patients, and a large amount of echogenic fluid in the cul-de-sac in 10 (21%) patients. Six (13%) patients had live ectopic pregnancy. The OB ordered a radiology US in 10 cases but did not change the diagnosis or management. β -Human chorionic gonadotropin ( β -hCG) levels ranged from 41 to 59846 mIU/mL (mean, 4602 mIU/mL), but for live ectopic pregnancy, the range was 2118 to 59846 mIU/mL (mean, 36341 mIU/mL). Seventeen (36%) patients had β -hCG levels of lower than 1000 mIU/mL. Of 47 eventual ectopic pregnancies, 29 (62%) patients underwent operative intervention, 17 (36%) patients received methotrexate, and 1 patient left against medical advice. Five (11%) of these patients with definite ectopic pregnancy were initially managed by emergency physicians with follow-up ED visits and serial US examinations without OB consultation. Conclusion Our study demonstrates that with increased experience, emergency sonologists can accurately diagnose ectopic pregnancy. Furthermore, patients at risk for ectopic pregnancy should not be denied US examinations if their β -hCG levels fall below an arbitrary discriminatory zone.

Intravenous drug users are at high risk for developing skinor subcutaneousabscesses and septic thrombophlebitis of peripheral veins. Septic thrombophlebitis is a condition characterized by inflammation and thrombosis of the vein (1). The clinical manifestations of peripheral vein septic thrombophlebitis include fever, erythema, tenderness, and purulent drainage at the site of the affected vein (2–4). The diagnosis is made based on a combination of clinical manifestations, imaging findings, and culture results. Surgical resection of the involved peripheral venous segment is usually recommended (5).

To compare images obtained using two linear transducers with a different range of frequencies, and to determine if there is a significant difference in the quality of images between the two transducers for medical decision-making. This was a single-blinded, cross-sectional study at an academic medical center. Twenty-five emergency medicine clinical scenarios with ultrasound images (using both 10–5 and 14–5 MHz transducers) covering a variety of point-of-care ultrasound applications were presented to four emergency physician sonographers. They were blinded to the study hypothesis and type of the transducer used to obtain the images. On a scale of 1–10, the mean image quality rating for 10–5 MHz transducer was 7.09 (95 % CI 6.73–7.45) and 6.49 (95 % CI 5.99–6.99) for 14–5 MHz transducer. In the majority of cases (84 %, 95 % CI 75.7–92.3 %), sonographers indicated that images obtained with a 10–5 MHz transducer were satisfactory for medical decision-making. They preferred images obtained with a 10–5 MHz transducer over 14–5 MHz transducer in 39 % (95 % CI 30–50 %) of cases. The images obtained with a 14–5 MHz transducer were preferred over 10–5 MHz transducer in only 16 % (95 % CI 7.7–24.3 %) of the cases. The 14–5 MHz transducer has a slight advantage over 10–5 MHz transducer for ocular, upper airway, and musculoskeletal (tendon) ultrasound applications. A 10–5 MHz linear transducer is adequate to obtain images that can be used for medical decision-making for a variety of point-of-care ultrasound applications.

Patients with acute Achilles tendon injuries from sport related activities are frequently seen in the emergency department (ED). Missed or delayed diagnosis of an Achilles tendon rupture can result in significant patient morbidity. However, the diagnosis of an Achilles tendon rupture is not always clear clinically. Physical examination maneuvers to assess for a tendon injury can be limited by pain and soft tissue swelling. Ultrasound has been shown to be very sensitive in detecting an Achilles tendon rupture.We report a case of a 39-year-old woman who presented to the ED with severe left ankle and leg pain. Her physical examination was limited by pain. However, a point-of-care ultrasound examination helped in making a prompt and accurate diagnosis of acute Achilles tendon rupture. This case demonstrates that point-of-care ultrasound can be a useful diagnostic tool in the assessment of patients with suspected Achilles tendon rupture, particularly when the physical examination is limited.