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.

Objectives: There is a paucity of data about emergency ultrasound (EUS) training in emergency medicine (EM) residency programs accredited by the Royal College of Physicians and Surgeons of Canada (Royal College) and the College of Family Physicians of Canada (CFPC). Historically the progress of EUS in Canada has been different from that in the United States. We describe the current state of EUS training in both Royal College and CFPC-EM programs.Methods: All Royal College EM program directors and all CFPC-EM program directors were invited to participate in a website-based survey. Main outcome measures were characteristics of currently offered EUS training.Results: The response rate of the survey was 100% (30 ⁄ 30). EUS is part of the formal residency curriculum in 100% (13 ⁄ 13) of Royal College EM programs and in 88% (15 ⁄ 17) of CFPC-EM programs. EM resident rotations in ultrasound (US) are provided by 77% (10 ⁄ 13) of Royal College programs but only 47% (8 ⁄ 17) of CFPC-EM programs. There are specific requirements for numbers of EUS exams to be completed by graduation in 77% (10 ⁄ 13) of Royal College programs and 47% (8 ⁄ 17) of CFPC-EM programs. EM faculty and residents make clinical decisions and patient dispositions based on their EUS interpretation without a consultative study by radiology in 100% (13 ⁄ 13) of Royal College programs and 88% (15 ⁄ 17) of CFPC-EM programs. However, 69% (9 ⁄ 13) of Royal College programs and 53% (9 ⁄ 17) of CFPC-EM programs have no formal quality assurance program in place.Conclusions: EUS training in Canadian EM programs is prevalent, but there are considerable discrepancies among residency programs in scope of training, curricula, determination of proficiency, and quality assurance. These findings suggest variability in both the level and the quality of EUS training in Canada.

Objectives: As ultrasonography is increasingly used in the emergency department (ED), ultrasound equipment has become a potential threat to infection control. Improperly cleaned ultrasound probes may serve as a vector for pathogens such as methicillin-resistant Staphylococcus aureus (MRSA). The primary objective of this study was to determine the prevalence of MRSA colonization on ultrasound probes used in a busy, urban ED. It was hypothesized that cultures of our ED ultrasound probes would yield a significant number of positive results for MRSA. Methods: In this observational study, 11 ED ultrasound probes were randomly sampled on 10 different occasions. Samples were taken using a RODAC plate method and were cultured for MRSA and methicillin-sensitive Staphylococcus aureus (MSSA). On half of the randomly assigned sampling occasions, a visual inspection of each ultrasound probe for general cleanliness was conducted and recorded. Data were stratified by ultrasound location in the ED and analyzed using the Fisher exact test, with p , 0.05 deemed to be statistically significant. Results: Of 110 samples, no isolates of MRSA were cultured. One probe yielded a positive culture for MSSA. Probes in the medicine, trauma, and pediatrics areas were found to be clean 65%, 33%, and 70% of the time, respectively. This variability in probe cleanliness by ED location was found to be statistically significant (p , 0.01). Conclusions: Contrary to our hypothesis, MRSA contamination of ultrasound probes was not found. This finding suggests that the spread of MRSA by ED ultrasound machines in a high-volume urban ED is unlikely. Further research at different centres with larger sample sizes is required before these results can be generalized. RÉ SUMÉObjectifs : Les services des urgences (SU) utilisent de plus en plus l'é chographie; or, ces appareils sont devenus des menaces potentielles dans la lutte contre l'infection. Des sondes é chographiques mal nettoyé es peuvent en effet servir de vecteurs aux pathogè nes comme le Staphylococcus aureus ré sistant à la mé thicilline (SARM). Cette é tude avait donc comme principal objectif de dé terminer la pré valence de colonisation par le SARM des sondes é chographiques utilisé es dans un SU en milieu urbain à grande affluence. On a é mis l'hypothè se que des cultures des sondes é chographiques du SU donneraient un nombre important de ré sultats positifs quant au SARM. Mé thodes : Dans cette é tude par observation, onze sondes é chographiques ont é té é chantillonné es au hasard en dix occasions diffé rentes. Les é chantillons ont é té pré levé s au moyen de la mé thode en boîte Rodac et cultivé s afin d'y dé tecter la pré sence de SARM et de SASM (Staphylococcus aureus sensibles à la mé thicilline). Lors de la moitié des é chantillonnages au hasard, une inspection visuelle de la propreté globale de chaque sonde é chographique a é té mené e et consigné e. Les donné es ont é té stratifié es par site d'é chographie au SU et analysé es au moyen de la mé thode exacte de Fisher, où p , 0,...

Retrobulbar hemorrhage is a rare complication of blunt ocular trauma. Without prompt intervention, permanent reduction in visual acuity can develop in as little as 90 minutes. We report a novel bedside ultrasound finding of conical deformation of the posterior ocular globe: the ''guitar pick'' sign. In our elderly patient, the ocular globe shape normalized post-lateral canthotomy and inferior cantholysis. Identifying this sonographic finding may add to the clinical examination when deciding whether to perform decompression. RÉ SUMÉUne hé morragie ré trobulbaire est une complication rare d'un traumatisme oculaire pé né trant. Si l'on n'intervient pas rapidement, une ré duction permanente de l'acuité visuelle peut se produire en aussi peu que 90 minutes. Nous pré sentons un nouveau cas d'é chographie au chevet du patient pré sentant une dé formation conique du segment posté rieur du globe oculaire que nous avons baptisé le signe du « pic de guitare ». Chez notre sujet â gé , le globe oculaire a repris sa forme normale aprè s une canthotomie laté rale et une cantholyse infé rieure. L'utilisation de l'é chographie pour identifier ce signe peut constituer un outil complé mentaire à l'examen clinique visant à dé terminer l'indication de dé compression.