Deep venous thrombosis (DVT) is a common condition that appears in the emergency department and outpatient settings. Clinical diagnosis is unreliable due to the infrequency of the classic findings of edema, warmth, erythema, pain, and tenderness, which are present in 23% to 50% of patients. When a patient presents with findings consistent with DVT, it is important to make an accurate diagnosis, as the risk of failing to treat the condition involves pulmonary embolism (PE), superior vena cava syndrome (SVCS), and associated complications up to and including death. However, empiric treatment with anticoagulation also comes with a high risk and cost to the patient. Venogram remains the gold standard for diagnosis of DVT. However, ultrasound is the most accurate non-invasive test to diagnose DVT. There are two main ways that ultrasound can be used to diagnose a DVT. The classic method is elective ultrasound performed by trained ultrasound technologist and ready by radiology. Recently, a few studies have demonstrated that well-trained emergency physicians can complete bedside ultrasonography for lower extremity DVT with sensitivities and specificities of 95% and 96%, respectively. If this is possible, this would significantly be able to improve emergency department throughput times for the most common type of DVT. Two-point compression has been widely accepted as a rapid way to assess for DVT in patients with a low pretest probability, making this an even more rapid way to assess for DVT than the complete assessment at the bedside.

Audience: This low-cost, reusable ultrasound pericardiocentesis simulation model is designed to instruct emergency medicine residents and emergency medicine-bound students.Section break fluid-filled balloon inside a press and seal bag that is covered with pork or beef ribs.Research Methods: To evaluate the model's efficacy and learner experience, we created a 5-point Likert scale survey to determine whether respondents believed the model was realistic enough to improve their comfort with performing an ultrasound-guided pericardiocentesis.The survey assessed prior experience with the simulation model, whether different models had been used, and individual experience including its utility in representing both subxiphoid and parasternal approaches to the procedure.Results: From a total of 16 completed surveys, one respondent had performed the procedure clinically, and two had used other simulation models.On a 5-point scale, average comfort level to model usage significantly increased 1.38 points from pre-to post-simulation (P<0.0001).On average, respondents rated the model useful in learning the anatomy and ultrasound image acquisition of the procedure and felt better prepared to perform the procedure post-simulation.Discussion: Our model provided learners the opportunity to practice ultrasound-guided pericardiocentesis with very little cost or effort to create.Users were able to glean feedback in real-time from the images shown on the ultrasound, as well as from the fluid collected in the syringe.The model differed from others by allowing users to practice in two different views with true anatomical landmarks.Survey results indicate the model was effective in improving learner experience since 87.5% of respondents felt more comfortable with performing the procedure post-simulation.Overall, this model proved useful in offering learners a realistic and cost-effective training model for the practice of a rare but important procedure.Emergency medicine residency programs will benefit from the ability to teach and practice ultrasound-guided pericardiocentesis in a controlled environment with immediate opportunities for feedback.

Introduction: Pediatric obesity threatens the efficacy of medications given intramuscularly. In anaphylactic patients, epinephrine auto-injector needle lengths are potentially too short to reach the muscle compartment in patients with elevated body habitus. The objective of the study was to determine needle-length requirements for intramuscular injections in pediatric patients. Methods: We used ultrasound to measure the distance from skin to muscle compartment of the thigh in 200 pediatric patients of various weight and body mass index who presented to the emergency department. Results: Patients with higher body mass index had an increased distance to muscle and bone. If current recommendations were followed, 5% of patients within the EpiPen adult weight category and 11% of patients within the Centers for Disease Control and Prevention weight category would have potentially used a needle inadequate in length for intramuscular injections. Conclusion: With the increase in childhood obesity, needle lengths may be too short to effectively deliver medications to the intramuscular compartment. Needle length should be evaluated to accommodate pediatric patients with increased skin to muscle distance.

ObjectivesEmergency ultrasound (EUS) has been recognized as integral to the training and practice of emergency medicine (EM). The Council of Emergency Medicine Residency-Academy of Emergency Ultrasound (CORD-AEUS) consensus document provides guidelines for resident assessment and progression. The Accredited Council for Graduate Medical Education (ACGME) has adopted the EM Milestones for assessment of residents' progress during their residency training, which includes demonstration of procedural competency in bedside ultrasound. The objective of this study was to assess EM residents' use of ultrasound and perceptions of the proposed ultrasound milestones and guidelines for assessment.MethodsThis study is a prospective stratified cluster sample survey of all U.S. EM residency programs. Programs were stratified based on their geographic location (Northeast, South, Midwest, West), presence/absence of ultrasound fellowship program, and size of residency with programs sampled randomly from each stratum. The survey was reviewed by experts in the field and pilot tested on EM residents. Summary statistics and 95% confidence intervals account for the survey design, with sampling weights equal to the inverse of the probability of selection, and represent national estimates of all EM residents.ResultsThere were 539 participants from 18 residency programs with an overall survey response rate of 85.1%. EM residents considered several applications to be core applications that were not considered core applications by CORD-AEUS (quantitative bladder volume, diagnosis of joint effusion, interstitial lung fluid, peritonsillar abscess, fetal presentation, and gestational age estimation). Of several core and advanced applications, the Focused Assessment with Sonography in Trauma examination, vascular access, diagnosis of pericardial effusion, and cardiac standstill were considered the most likely to be used in future clinical practice. Residents responded that procedural guidance would be more crucial to their future clinical practice than resuscitative or diagnostic ultrasound. They felt that an average of 325 (301-350) ultrasound examinations would be required to be proficient, but felt that number of examinations poorly represented their competency. They reported high levels of concern about medicolegal liability while using EUS. Eighty-nine percent of residents agreed that EUS is necessary for the practice of EM.ConclusionsEM resident physicians' opinion of what basic and advanced skills they are likely to utilize in their future clinical practice differs from what has been set forth by various groups of experts. Their opinion of how many ultrasound examinations should be required for competency is higher than what is currently expected during training.