Tag Archives: Nick Mancuso

Using Ultrasound in Central Line Placement

This week, we have a post from regular contributor Nick Mancuso on how to excel when performing a procedure common in the ED as well as upstairs: ultrasound guided central line placement.

 

The three most common veins used in central line placement are the internal jugular (IJ), subclavian (SV), and femoral (FV). I will focus on IJ placement and the use of dynamic ultrasound.

Procedure:

  • Sterile technique is paramount (if time permits).
  • Linear array probe is used with a sterile probe cover, and sterile gel. A CVC kit is obviously required, along with sterile personal protective equipment. This procedure can be done with one person, but two can be helpful especially during training.
  • Operator on the isiplateral side of the pt, pt in Trendelenburg, probe indicator to the left of operator, in transverse position.
  • Place probe superior to clavicle, IJV usually larger, lateral to carotid artery.
  • The IJV will compress with pressure, vs. the artery. If hypotensive or dehydrated, may disappear with inspiration.
  • Center vein on screen, lidocaine can be used to anesthetize pt. Use center of probe as guide, while not looking at monitor, stick pt skin with entry needle.
  • Look at monitor after puncture. Visualize needle or tissue compression. Puncture vein looking at monitor.
  • If needle can’t be visualized, a long-axis (longitudinal) view can help
  • It is extremely important to visualize the needle tip and not proceed with advancement of the needle without visualization of the tip.  The tip can be followed with slow fanning or sliding of the probe distally as you advance.  The most common mistake is not following the tip of the needle and letting the needle get “ahead of” the probe.  This leads to visualization of the proximal portion of the needle while the tip is in a different location in the neck, possibly causing complication.
Ultrasound visualization of neck vasculature

Ultrasound visualization of neck vasculature (Source)

Top: Internal jugular vein (IJV) and carotid artery (CA) in the transverse view with the transducer held on the skin without pressure (left) and with pressure (right). Note that with pressure, IJV appears compressed while the CA has retained its shape. Bottom: These blood vessels in the longitudinal plane. (Source: http://pie.med.utoronto.ca/OBAnesthesia/OBAnesthesia_content/OBA_ultrasonographyBasics_module.html)

Top: Internal jugular vein (IJV) and carotid artery (CA) in the transverse view with the transducer held on the skin without pressure (left) and with pressure (right). Note that with pressure, IJV appears compressed while the CA has retained its shape. Bottom: These blood vessels in the longitudinal plane. (Source)

Video: Ultrasound Guidance for Central Venous Access – SonoSite

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It’s ALSO that time of year: Respiratory Syncytial Virus

Symptoms: Over 2 to 3 days development of wheezing, a so called “tight” wheezy cough, fever (usually low grade), cyanosis, tachypnea, retraction, fatigue.

Diagnosis:

Upon physical exam the above symptoms are noted, on auscultation inspiratory crackles and wheezing are usually present. Hydration status should be noted, as RSV is a diffuse small airway disease, leading to bronchiolitis.

Non-specific lab tests such as ABGs, CBC, and O2 sat., and age of child help determine candidates for admittance. Secretions can be analyzed using PCR but are expensive, a sophisticated virology lab is required in terms of antigen detection.

Imaging X-Ray is commonly ordered, revealing (nonspecific) hyperinflated lung fields, diffuse interstitial infiltrates, and in more advanced cases focal atelectasis.

DDx: Asthma, bronchitis, adenovirus, pneumonia, metapnuemovirus, influenza.

Treatment:  See part 2 coming soon!

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It’s that time of year: Flu QuickHits (part 1)

Part one (written by second year Nick Mancuso) will cover the important basics about the flu epidemic this season. Great summary!

The 2012/13 vaccine contains the typical triad against an H1N1, H3N2, and an influenza B variant.

  • A/California/7/2009 (H1N1)-like virus
  • A/Victoria/361/2011 (H3N2)-like virus
  • B/Wisconsin/1/2010-like virus.

Symptoms overlap with many URI’s, however the classics:

Abrupt onset, Chills, Varying fever temps, Myalgias, Frontal/retro-orbital headache, Sore throat, Nausea/Vomiting

Diagnosis

can be difficult because samples are sent to labs and take time to get results. A nasopharyngeal culture is taken. Most diagnosis is done at the bedside based on clinical criteria. Rapid tests are not accurate and results vary. (Check continue reading for more info about diagnostic tests!)

Treatment:

Read part 2!

For some cool data and graphs from the CDC continue reading…

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Disseminated Intravascular Coagulation (DIC)

Pathophys of DIC. Source: Lippincotts

Pathophys of DIC. Source: Lippincotts

DIC is a pathological process where tissue factor or other thromboplastic substances from endothelial cell injury are released into circulation-Leads to paradoxical formation of 1) microthrombi leading to organ failure and 2) hemorrhaging.

 Associated Clinical Causes

-Sepsis
-Trauma (especially neurotrauma)
-Cancer
-Shock
-Major Surgery
-Immunologic (transfusion/transplant reaction)
-Obstetric complications

Diagnosis

Can be complicated by the underlying causes, lab tests indicating DIC:

– Platelets <100,000 or recent rapid large decrease in number
– Prolonged PT and aPTT
– Elevated D-Dimer (>.5ug/ml)
– Schistocytes in blood smear
– Fibrinogen -if obtainable <1g/L (only in ~28% of pts)

A scoring system has been developed (click continued reading)

DDx: DIC, Hemolytic Uremic Syndrome, Liver Disease, Thrombotic Thrombocytopenic Purpura, Heparin-induced thrombocytopenia, HELLP syndrome in pregnancy

Treatment

Treat the underlying cause, platelet and blood factor replacement to treat bleeding can be used but won’t correct DIC. Heparin used when fibrin deposition is excessive and no risk of hemorrhage present (no petechiae or bruising).

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Herpes Simplex Encephalitis (HSE)

Clinical presentation of HSE in children over 3 months and adults is typically is HSV-1, acute, or subacute, and generally has non-specific signs such as:

  • Alteration of conscious (97%)
  • CSF Pleocytosis (97%)
  • Fever (90%),
  • Personality Change (85%)
  • Headache (81%)
  • Seizures(67%)
  • Vomiting (46%)

In newborns it typically presents 6-12 days after birth with general lethargy, poor feeding, and/or seizures and is HSV-2.

Diagnosis

CSF should be taken immediately when HSE is suspected and sent for a PCR study. This is the gold standard and is sensitive 94-98% and specific 98-100%.

Lab studies are non-specific. Imaging (CT and MRI) and Electroencephalography abnormalities can take days to a week to appear on scans.

  • CSF in patient with HSE will have elevated WBC, RBC, elevated protein, and normal glucose level with lymphocytic pleocytosis
  • MRI findings if present would demonstrate temporal lobe lesions
  • Electroencephalography (EEG) has characteristic periodic high-voltage spike wave activity emanating from the temporal lobes and slow wave complexes are highly suggestive of HSE.

Treatment

IV acyclovir should be started immediately , before PCR results confirm, because its toxicity is rather low and HSE prognosis is poor untreated. In adults 10-15mg/kg q8h x14-21days, 3 months-12years 20mg/kg x10 days, neonates 30mg/kg/day.

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