Objectives: To evaluate the relationship between Trendelenburg tilt and internal jugular vein (IJV) diameter, and to examine any cumulative effects of tilt on the IJV diameter. Methods: Using a tilt table, healthy volunteers were randomised to Trendelenburg tilts of 10˚, 15˚, 20˚, 25˚, and 30˚. Ultrasound was used to measure and record the lateral diameter of the right IJV at the level of the cricoid cartilage. Following each reading the table was returned to the supine position. Balanced randomisation was used to assess cumulative tilt effects. Results: A total of 20 healthy volunteers were recruited (10 men, 10 women). Mean supine IJV diameter was 13.5 mm (95% CI 12.8 to 14.1) and was significantly greater at 10˚(15.5 mm, 95% CI 14.9 to 16.1). There was no significant difference between 10˚and greater angles of tilt. The effect of the previous angle of tilt did not prove to be statistically significant. Conclusion: Increasing the degree of Trendelenburg tilt increases the lateral diameter of the IJV. Even a 10t ilt is effective. The cumulative effect of tilt (that is, the effect of the previous angle) is not significant. Ultrasound guided cannulation is ideal, but in its absence Trendelenburg tilt will increase IJV diameter and improve the chance of successful cannulation. While 25˚achieved optimum distension, this may not be practical and may be detrimental (for example, risk of raised intracranial pressure).T he UK National Institute of Clinical Excellence (NICE) guidelines 1 recommend the use of real time ultrasound guidance for internal jugular vein (IJV) cannulation. However, a recent study has shown that the majority of emergency departments (EDs) in the island of Ireland do not use ultrasound.2 Although strictly speaking these departments do not fall under the jurisdiction of NICE, the pattern of ultrasound usage in EDs is likely similar to that in mainland UK. In the absence of ultrasound guidance the Trendelenburg position is often used in IJV cannulation to increase the diameter of the IJV.Our study aimed to evaluate the relationship between Trendelenburg tilt and the IJV diameter and to examine any cumulative effects of tilt on the IJV diameter. METHODA statistical analysis before the study predicted that 20 subjects would be required for sufficient power, and compared favourably with other similar studies. 3The procedure was carried out by a single examiner (SC) using healthy volunteers selected at random. The subjects had no history of neck problems or previous IJV cannulation.Each subject was placed supine on a tilt table, with an inbuilt clinometer that was raised and lowered on an electric motor. The level of the cricoid cartilage was marked and the right IJV was identified using real time ultrasound (Medison 128 BW high frequency linear probe). Lateral IJV diameter was measured at this level over three respiratory cycles and the maximum diameter was recorded prior to tilt. The subject then was tilted to 10˚, 15˚, 20˚, 25˚, and 30T rendelenburg. For each angle, subjects were kept in position fo...

Introduction: Emergency department ultrasound (EDU) is widely practised in the USA, Australia, parts of Europe, and Asia. EDU has been used in the UK since the late 1990s but as yet, few areas have established a practice. Objectives: To assess the current climate of opinion with respect to the practice, constraints, and establishment of EDU among emergency department (ED) consultants on the island of Ireland. Methods: A postal questionnaire was formulated, piloted, and assessed for ambiguity by a sample of ED consultants and an independent non-ED consultant, prior to being mailed to all ED consultants in Ireland. Results: Of the 58 consultants canvassed 46 (79%) responded. Of the respondents, 40 (87%) strongly agreed/agreed that EDU is appropriate and should be performed in the ED. Of these, 3 (7%) are currently performing EDU; 37 (80%) have not had formal training in EDU, however 42 (91%) support the establishment of national guidelines for training in focused ultrasound in the ED. Problems instituting EDU were often multifactorial. Commonly highlighted difficulties included financial issues (24 respondents, 52%) and radiology department support (16 respondents, 34%). Other cited problems include varying interdepartmental practices (15 respondents, 33%) and (for some EDs) low numbers of patients requiring EDU, with projected difficulties in skills maintenance. Conclusion: Despite the vast majority of ED consultants being in favour of EDU, very few actually perform it on a regular basis or have had any formal training. Highlighted difficulties in EDU implementation included financial constraints, lack of support from radiology departments, and lack of formal training.