The tradition of clinical ultrasound in the hands of physicians who provide critical care to the most acutely ill patients stretches back into the 1980s and is rich with experiences from surgical, emergency medicine, and other practices. Now, as critical care ultrasound explodes around the world, it is important to realize the path its development has taken and learn from trials and tribulations of early practitioners in the field. The development and battles for the right to use ultrasound at the patient's bedside for >20 yrs is described in relation to its emergency medicine and surgical origins. Approaches to education, scanning, documentation, and organization at the national and regional levels are described.

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Students' perception of peer instructors' teaching competency was equivalent to faculty instructors for the majority of sessions. Senior students who have completed an elective ultrasound rotation may serve as a useful resource for circumstances where the availability of skilled instructors is limited. However, further research is required to evaluate their effectiveness.

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Objective To evaluate whether using long axis (LA) or short axis (SA) view during ultrasound-guided internal jugular (IJ) and subclavian (SC) central venous catheterization (CVC) results in fewer skin breaks, decreased time to cannulation, and fewer posterior wall penetrations (PWP). Design Prospective, randomized crossover study. Setting Urban emergency department with approximate annual census of 60,000. Subjects Emergency medicine resident physicians at the Denver Health Residency in Emergency Medicine, a PGY 1-4 training program. Interventions Resident physicians blinded to the study hypothesis used ultrasound guidance to cannulate the IJ and SC of a human torso mannequin using the LA and SA views at each site. Measurements An ultrasound fellow recorded skin breaks, redirections, and time to cannulation. An experienced ultrasound fellow or attending used a convex 8–4 MHz transducer during cannulation to monitor the needle path and determine PWP. Generalized linear mixed models with a random subject effect were used to compare time to cannulation, number of skin breaks and redirections, and PWP of the LA and SA at each cannulation site. Results 28 resident physicians participated: 8 PGY-1, 8 PGY-2, 5 PGY-3, and 7 PGY-4. The median [interquartile range (IQR)] number of total IJ central venous catheters placed was 27 (IQR 9-42) and SC was 6 (IQR 2-20) catheters. The median number of previous ultrasound-guided IJ catheters was 25 (IQR 9-40), and ultrasound-guided SC catheters was 3 (IQR 0-5). The LA view was associated with a significant decrease in the number of redirections at the IJ and SC sites, relative risk (RR) 0.4 (95% confidence interval [CI] 0.2-0.9), and RR 0.5 (95% CI 0.3-0.7), respectively. There was no significant difference in the number of skin breaks between the LA and SA at the SC and IJ sites. The LA view for SC was associated with decreased time to cannulation; there was no significant difference in time between the SA and LA views at the IJ site. The prevalence of PWP was: IJ SA 25%, IJ LA 21%, SC SA 64%, and SC LA 39%. The odds of PWP were significantly less in the SC LA, odds ratio 0.3 (95% CI 0.1-0.9). Conclusions The LA view for the IJ was more efficient than the SA view with fewer redirections. The LA view for SC CVC was also more efficient with decreased time to cannulation and fewer redirections. The LA approach to SC CVC is also associated with fewer PWP. Using the LA view for SC CVC and avoiding PWP may result in fewer central venous catheter-related complications.

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IntroductionPatients are commonly admitted to the hospital for observation following blunt abdominal trauma (BAT), despite initially negative emergency department (ED) evaluations. With the current use of screening technology, such as computed tomography (CT) of the abdomen and pelvis, ultrasound, and laboratory evaluations, it is unclear which patients require observation. The objective of this study was to determine the prevalence of intra-abdominal injury (IAI) and death in hemodynamically normal and stable BAT patients with initially negative ED evaluations admitted to an ED observation unit and to define a low-risk subgroup of patients and assess whether they may be discharged without abdominal/pelvic CT or observation.MethodsThis was a retrospective cohort study performed at an urban level 1 trauma center and included all BAT patients admitted to an ED observation unit as part of a BAT key clinical pathway. All were observed for at least 8 hours as part of the key clinical pathway, and only minors and pregnant women were excluded. Outcomes included the presence of IAI or death during a 40-month follow-up period. Prior to data collection, low-risk criteria were defined as no intoxication, no hypotension or tachycardia, no abdominal pain or tenderness, no hematuria, and no distracting injury. To be considered low risk, patients needed to meet all low-risk criteria.ResultsOf the 1,169 patients included over the 2-year study period, 29% received a CT of the abdomen and pelvis, 6% were admitted to the hospital from the observation unit for further management, 0.4% (95% confidence interval [CI], 0.1%–1%) were diagnosed with IAI, and 0% (95% CI, 0%–0.3%) died. Patients had a median combined ED and observation length of stay of 9.5 hours. Of the 237 (20%) patients who met low-risk criteria, 7% had a CT of the abdomen and pelvis and 0% (95% CI, 0%–1.5%) were diagnosed with IAI or died.ConclusionMost BAT patients who have initially negative ED evaluations are at low risk for IAI but still require some combination of observation and CT. A subgroup of BAT patients may be safely discharged without CT or observation after the initial evaluation.