Overly Traumatic: A Teenager Elbowed in the Stomach
A 17 yo healthy M presents with abdominal pain and a syncopal episode several hours after getting elbowed in the stomach at a soccer game.
PMH: Intermittent asthma
ROS: Sore throat, cough and fatigue x 1 week.
VS: T 98.3 °F | HR 90 | BP 129/60 | RR 16 | SpO2 100%
Pale but comfortable and alert. Abdomen diffusely tender, guarding in the upper quadrants. Exam otherwise unremarkable.
RUQ: Free fluid in Morrison’s pouch & at the tip of the liver
LUQ: Free fluid in splenorenal recess & bowel floating in free fluid
Transverse Bladder: Large amount of fluid & clotted blood anterior to the bladder
Click ahead to reveal diagnosis
An elderly patient is in the RIH Critical Care bay with severe sepsis and needs central access. Luckily, Drs. Adam “Hyperechoic” Haag and Eddie “Rule ‘Em Out” Ruhland are on shift. They settle on the right Internal Jugular vein, but traditional sternocleidomastoid muscle (SCM) and clavicular bone landmarks are not apparent. So a linear-array probe is correctly placed transversely over the triangle formed by the bifurcation of the SCM, to where the IJ and Carotid are seen in parallel…but there is some sort of hyperechoic, noncompressible mass…
They identify the thrombus, and instead find the Femoral vein, where CIV access is successfully achieved on the first attempt with no immediate complications. The use of US to guide this procedure changed this patient’s course and potentially saved a complication.
But exactly how much safer, faster, and more reliable is US-guided CIV placement?
- Vascular access is critical in emergent situations
- Body habitus, dehydration, poor perfusion, anatomical abnormalities, or history of IVDU can cause difficulties and delays when using landmark-based techniques
- Complications of CIV placement include arterial puncture, excessive bleeding, vessel laceration, pneumothorax, hemothorax, and necessitation of multiple attempts
- US guidance was identified in 2001 by United States Agency for Healthcare Research and Quality as one of the top 11 means of increasing patient safety, but this was based on one study of subclavian lines at one large urban center (1)
The “SOAP-3” Trial (2005)
- A concealed, randomized, controlled study of 201 patients
- Studies dating back to the 1990s in EM and Anesthesia (4) had demonstrated the efficacy of ultrasound-guidance, but this was the first study in the ED setting comparing the anatomical landmark method, the static “quick look” US-guided method, and dynamic “real time” US-guided method
- In the “quick look” group, US was used to identify landmarks, the skin was marked, and the catheter was placed without real-time US guidance
- EM residents and Attendings passed a 1h training course, then placed 10 CIVs with dynamic US guidance to qualify to participate
|Anatomical Landmarks Method|
(OR vs LM)
|Avg # of Attempts||1.7||1.6||3.2|
|Avg Total Sec||30||20||150|
- Dynamic guidance is superior but requires the most training
- Static guidance is vastly superior to Landmark, and while slightly inferior to Dynamic, it requires less training
- 10% of the study patients had “extremely narrow” (<5mm) IJs bilaterally, which could explain the inferior performance of the LM technique, even with experienced practitioners
- All the complications were arterial punctures, and these were not statistically significant
- Agency for Health Care Research and Quality (AHRQ). Evidence Report/Technology Assessment: Number 43. Making Health Care Safer. A Critical Analysis of Patient Safety Practices: Summary 2001. 2007.
- Milling, et al. Randomized, controlled clinical trial of point-of-care limited ultrasonography assistance of central venous cannulation: The Third Sonography Outcomes Assessment Program (SOAP-3) Trial. Critical Care Medicine, 2005, Aug;33(8); 1764-9.
- Sulek et al. A Randomized Study of Left versus Right Internal Jugular Vein Cannulation in Adults. J Clin Anesth, 2000, Mar; 12(2): 142-5
Jon and I did this awesome ultrasound-guided superficial cervical plexus nerve block the other day for a R IJ central line placement– taught to us by none other than the amazing Dr. Otto Liebmann.
It was so neat we made a video about it. Check it out!