SonoProcedures: Review of ultrasound-guided procedures, technique, and videos

In the most recent addition of Emergency Medicine Clinics of North America (yup, you’ll need to register to view), some big wigs in bedside ultrasound (Tirado, Teresa Wu, Resa Lewiss, Vicki Noble, Adam Sivitz) published an article reviewing the ultrasound – guided techniques (with images) of procedures where an ultrasound machine can make all the difference in decreasing complications, increasing patient satisfaction, and decreasing time of procedure. From pericardiocentesis, thoracentesis, abscess drainage to lumbar puncture, arthrocentesis, and foreign body removal, these physicians discuss it all. “Bedside ultrasound is an extremely valuable and rapidly accessible diagnostic and therapeutic modality in potentially life- and limb-threatening situations in the emergency department. In this report, the authors discuss the role of ultrasound in quick assessment of pathologic conditions and its use to aid in diagnostic and therapeutic interventions”

In the same issue, Drs. Tirado, Nagdev and others discuss ultrasound-guided venous central and peripheral venous access and nerve blocks (a topic near and dear to Arun Nagdev’s heart – given how many publications he has done on the topic – a true expert!). “Ultrasound has rapidly become an essential tool in the emergency department, specifically in procedural guidance. Its use has been demonstrated to improve the success rate of procedures, while decreasing complications. In this article, we explore some of these specific procedures involving needle guidance and structure localization with ultrasound.”

And, in the same issue, Drs. Lewis, Crapo, and Williams discuss more procedural guidance using bedside ultrasound for central venous access as well as a review of other procedures, like IO lines an arterial lines. “The venous and/or arterial vasculature may be accessed for fluid resuscitation, testing and monitoring, administration of blood product or medication, or procedural reasons, such as the implantation of cardiac pacemaker wires. Accessing the vascular system is a common and often critically important step in emergency patient care. This article reviews methods for peripheral, central venous, and arterial access and discusses adjunct skills for vascular access such as the use of ultrasound guidance, and other forms of vascular access such as intraosseus and umbilical cannulation, and peripheral venous cut-down. Mastery of these skills is critical for the emergency medicine provider.”

A great review of pericardiocentesis, thoracentesis, paracentesis, vascular access, foreign body localization, abscess drainage, and nerve blocks can be found on Sonoguide as well.

Here are some great videos on how-to perform the varying procedures:




Abscess drainage:

Central venous access: internal jugular

Central venous access – supraclavicular approach to the subclavian vein:

Ultrasound Podcast on the Subclavian and Supraclavicular venous access in only the way they know how.

Central venous access – axillary vein cannulation

Peripheral venous access:

A great video on US guided Peripheral IV can be found here, by HQMedEd

Lumbar puncture:

Foreign Body removal:

Femoral nerve block:

Axillary Nerve block:

Distal Sciatic nerve block:

Nerve blocks of all kinds can be found here on SonicNerve.

Other procedures:

US guided fracture reduction


SonoStudy: US-guided lines by nurses (& docs) reduce need for physician intervention (& central lines!) for difficult access

A recent study, from the Journal of Emergency Medicine, by Weiner et al at Tufts University, in addition to so many of the prior studies, proves that nurses SHOULD perform ultrasound guided peripheral line placement. they are good at it, they do it right, and they do it well. Oh, and patients love it.

“Emergency physicians (EPs) have become facile with ultrasound-guided intravenous line (USIV) placement in patients for whom access is difficult to achieve, though the procedure can distract the EP from other patient care activities…..A prospective multicenter pilot study: Interested emergency nurses (ENs) received a 2-h tutorial from an experienced EP. Patients were eligible for inclusion if they had either two failed blind peripheral intravenous (i.v.) attempts, or if they reported or had a known history of difficult i.v. placement. Consenting patients were assigned to have either EN USIV placement or standard of care (SOC).” 50 patients enrolled, 29 assigned to USIV and 21 to SOC. “Physicians were called to assist in 11/21 (52.4%) of SOC cases and 7/29 (24.1%) of USIV cases (p = 0.04). Patient satisfaction was higher in the USIV group, though the difference did not reach statistical significance (USIV 86.2% vs. SOC 63.2%, p = 0.06). ”

And, even more recently, another study:

Ultrasound-Guided Peripheral Intravenous Access Program Is Associated With a Marked Reduction in Central Venous Catheter Use in Noncritically Ill Emergency Department Patients.

by Shokoohi et al from George Washington University published in the Annals of Emergency Medicine has been getting quite a bit of press – particularly from MedwireNews: “Training emergency department (ED) staff in use of ultrasound to guide difficult peripheral intravenous catheter placement appears to reduce the unnecessary use of central venous lines, a study suggests. The reduction in central venous line use after the introduction of ultrasound training was particularly notable for patients who were not critically ill, report Hamid Shokoohi (George Washington University, DC, USA) and colleagues…..They say that this has “potentially major implications for patient safety,” noting that around 15% of the 5 million central venous catheters placed in the USA annually result in complications, which can include blood infections, thrombosis, vessel damage, and hematomas.”

The study itself was: “….a time-series analysis of the monthly central venous catheter rate among adult emergency department (ED) patients in an academic urban ED between 2006 and 2011. During this period, emergency medicine residents and ED technicians were trained in ultrasound-guided peripheral intravenous access. We calculated the monthly central venous catheter placement rate overall and compared the central venous catheter reduction rate associated with the ultrasound-guided peripheral intravenous access program between noncritically ill patients and patients admitted to critical care. Patients receiving central venous catheters were classified as noncritically ill if admitted to telemetry or medical/surgical floor or discharged home from the ED. RESULTS: During the study period, the ED treated a total of 401,532 patients, of whom 1,583 (0.39%) received a central venous catheter. The central venous catheter rate decreased by 80% between 2006 (0.81%) and 2011 (0.16%). The decrease in the rate was significantly greater among noncritically ill patients (mean for telemetry patients 4.4% per month [95% confidence interval {CI} 3.6% to 5.1%], floor patients 4.8% [95% CI 4.2% to 5.3%], and discharged patients 7.6% [95% CI 6.2% to 9.1%]) than critically ill patients (0.9%; 95% CI 0.6% to 1.2%). The proportion of central venous catheters that were placed in critically ill patients increased from 34% in 2006 to 81% in 2011 because fewer central venous catheterizations were performed in noncritically ill patients. CONCLUSION: The ultrasound-guided peripheral intravenous access program was associated with reductions in central venous catheter placement, particularly in noncritically ill patients. Further research is needed to determine the extent to which such access can replace central venous catheter placement in ED patients with difficult vascular access.”

A great video on the scanning technique and choosing the right vein can be found here by SonoSite and taught by my good friend, Diku Mandavia:

Another great how-to video can be found here: although long, its a good one for a step-by-step, from the New England Journal of Medicine:

SonoReview: US-guided Interscalene nerve blocks

Hope you had a Happy 4th! To all those who received patients with an upper extremity that has been burned, fractured, or blown away from all the “legal” fireworks foreplay……

Pain control. Two words. Patient satisfaction. Two more words. Physician satisfaction. Two MORE words. Nerve blocks are the new procedural sedation for many painful procedures we do in the ED. Takes much less resources and time, and provides immediate pain control for however long your anesthetic will work without concern for respiratory distress, hypotension, hypoxia, and… well… death. So why dont we do it more? Well, in a prior post, we have discussed the ins & outs for performing US guided nerve blocks with the help of some of my colleagues, some of whom are mentioned below.

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SonoNews: ASA Guidelines for central venous access now includes ULTRASOUND!

Now I know that many of you may already be using ultrasound to help guide your needle when obtaining central venous access, but when a governing body announces its importance, it’s a big deal! If any of you are like me, you learned how to place all central lines using the “blind” technique – despite your eyes being wide open – but now that the ultrasound machine is your eyes beneath the skin, there is no longer a reason to be so blind about it! Isn’t it nice to know where “big red” is? Here, I’ll answer for you – Heck YEAH! So why am I excited? Well… Continue reading

SonoStudy: US-Guided Nerve Blocks – in disasters, your ED, and your hearts

Given this memorial day weekend, and the sacrifice of our troops, lets discuss something that the military has used for years – and for good reason. US-guided nerve blocks are becoming more and more utilized in our EDs. Especially when we have the elderly patient who is in severe pain from a humeral fracture or a femoral neck fracture, and you’d rather not have to watch (and chase) their blood pressure after giving systemic opiates. It is also a great resource in resource-poor areas, like the aftermath of the disaster of the Haiti earthquake. This is all clearly discussed in the article in Annals of Emergency Medicine this month by Drs. Suzanne Lippert, Arun Nagdev, Mike Stone, Andrew Herring, and Robert Norris. Continue reading

SonoCase: Motorcycle victim: needs OR! But wait…

So, this case that I just had the other day is an example of an “oldy but goody” reason why bedside ultrasound rocks, especially in the blunt trauma victim with multiple injuries. 40 year-old motorcycle helmeted driver going moderate speed was T-boned by a car and fell onto his left side. He c/o severe left leg pain and mild left lower back pain, with STABLE (and yes, I mean, stable/normal/not worrisome vitals – HR 72, RR 16, BP 148/90, O2 sat 97%RA) with a clear primary trauma survey, and a secondary that revealed a small abrasion on his cheek, no left sided chest wall tenderness, nontender abdomen, no pelvis instability, an obvious deformed open fracture of his left tibia/fibula, and left lower posterior rib cage tenderness without crepitance or bruising. An E-FAST was done… Continue reading