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American Institute of Ultrasound in Medicine <strong>Proceedings</strong> J Ultrasound Med 32(suppl):S1–S134, 2013nals from the saline flush signaled proper catheter tip placement. We comparedthe agreement between BUE results and those of CXR or computedtomography (CT) using a κ statistic.Results—Twenty-seven patients were enrolled, and 26 wereanalyzed. One subject was excluded because his surgery was canceled,and he no longer required CVC. Eight patients were enrolled from the ED,9 from the ICU, and 9 from the OR. On BUE, 1 patient had a technicallylimited study, and 25 demonstrated saline echoes in the right heart. One ofthe 25 demonstrated intracardiac catheter malposition, confirmed by CXR.All 26 patients had CXR, and 2 had additional CT; 25 had confirmedproper CVC placement, including the 1 patient for whom BUE was inconclusive.Timing for BUE was as follows: 20 cases done concurrentlywith CVC placement, 2 done within 1 hour, and 3 done within 24 hours.Of the 25 BUEs that were interpretable, there was 100% agreement betweenBUE and CXR in detecting CVC location (P = .000).Conclusions—Despite the small sample size, this study showspromise for the use of BUE to accurately confirm CVC placement morequickly than CXR. A larger study is needed before we can recommendusing BUE routinely to replace post-CVC CXR.1513191 Bedside Thoracic Ultrasound for Pulmonary Edema:Which Zones Are the Best?Zoe Howard,* Feras Khan, Anne-Sophie Beraud, LalehGharahbaghian, Raymond Balise, Ravi Pamnani, MichaelSchaller, Joelle Barral, Sidhartha Sinha, Sarah WilliamsEmergency Medicine, Stanford University Medical Center,Stanford, California USAObjectives—Thoracic ultrasound (US) has been validated topredict pulmonary edema with high sensitivity and specificity in the presenceof B-lines, a US reverberation artifact caused by interstitial fluid. Ourstudy investigates whether there are specific anatomic zones with a greaterpositive predictive value for pulmonary edema. If so, we could performthis test more rapidly, an important consideration from both a resource utilizationand patient care perspective.Methods—We performed a prospective observational study,scanning a convenience sample of adult emergency department (ED) patientswith shortness of breath at a large tertiary care academic center. Followingpreviously published protocols, the right anterior chest was dividedinto 4 zones with zones 1 and 2 representing an upper and lower midclaviculardistribution, respectively, and 3 and 4 upper and lower midaxillary.The division was mirrored on the left with 5 and 6 anterior and 7 and8 lateral. When there were at least 2 bilateral positive zones, the patient wasenrolled. Compared to a gold standard of chest radiography combinedwith brain natriuretic peptide, echocardiography, and discharge diagnosis,patients were confirmed to have acute pulmonary edema. All imageswere reviewed by 2 US fellowship-trained ED physicians, and each zonewas scored according to an a priori scale.Results—During the initial pilot, 24 patients were analyzed.There was no dominant pattern that emerged among the 8 zones. Thirteenpercent (3/24) were positive in every zone. On the right, zones 2, 3, and 4were positive in 79% (19/24), while on the left, zone 5 was positive in71% (17/24) and zone 7 in 67% (16/24). When the right chest was notedto be positive, the contralateral zone noted to be positive in the greatestnumber of patients was zone 5.Conclusions—While the small number of patients limits thisstudy, trends were noted in specific zones, particularly the right chest andzone 5. However, there is no dominant pattern or statistically significantresults to suggest that any zone is more predictive for diagnosing acutepulmonary edema by B-lines on US. This suggests that it is necessary toscan all 8 zones and perform a thorough but expeditious thoracic US examinationwhen rapid diagnosis of critically ill patients is crucial.1538301 Central Venous Catheterization Location Changes andComplication Rates After the Institution of an EmergencyUltrasound DivisionTahisha Tolbert,* Lawrence Haines, Lucas McArthur,Victoria Terentiev, Antonios Likourezos, Eitan DickmanEmergency Medicine, Maimonides Medical Center, Brooklyn,New York USAObjectives—To look at central venous catheter (CVC) placementpatterns before and after the establishment of an emergency ultrasounddivision (EUSD). We hypothesized that the internal jugular vein(IJ) site would be used more often as familiarity with ultrasound (US)increased. A secondary objective was to compare the mechanical complicationrates associated with CVC placement before and after the establishmentof an EUSD.Methods—This was a retrospective chart review looking at allCVCs placed in an urban tertiary care medical center’s emergency department(ED) with an emergency medicine residency program and115,000 ED visits per year. We queried our electronic medical record forall CVCs placed in the ED between the years 2004 and 2007 and the years2007 and 2010, representing the 3 years before and after the establishmentof the EUSD. The locations of these CVCs were compared to assess forany changes. This data set was then queried for patients who had a documentedmechanical complication from the CVC placement.Results—In all, 1876 CVCs were placed between 2004 and2007, and 1707 were placed between 2007 and 2010. Selection of thefemoral vein CVC location changed from 50.8% to 42.5%, subclavianfrom 37.0% to 17.3%, and IJ from 12.2% to 40.2% (P = .0001 for all). Themechanical complication rate decreased from 9.1% to 5.4% (P = .0001).Conclusions—The establishment of an EUSD, with formaltraining in the use of US for CVC placement, is associated with a significantchange in CVC site selection patterns, most notably a sharp increasein selection of the IJ site and a dramatic reduction in the selection of thesubclavian site. In addition, there was a 41% decrease in the complicationrates such as pneumothorax and arterial puncture.Table 1. Specific Complicationsn (%)Complication 2004–2007 2007–2010 PPneumothorax 23 (1.2) 6 (0.4) .004Chest tube 18 (1) 4 (0.2) .005Arterial puncture 47 (2.5) 21 (1.2) .0051539748 Faster = Better? Pilot Sonographic Evaluation of InternalJugular Vein Collapsibility Versus Inferior Vena CavaCollapsibility Indices in Critically Ill PatientsDavid Evans, 1 * Daniel Eiferman, 1 Alistair Kent, 1 CreaghBoulger, 2 Andrew Springer, 3 Eric Adkins, 2 Susan Yeager, 1Geoffrey Roelant, 1 Stanislaw Stawicki, 1 David Bahner 21Surgery, 2 Emergency Medicine, 3 Anesthesiology, Ohio StateUniversity, Columbus, Ohio USAObjectives—Intensivist-performed bedside sonographic assessmentof volume status is a rapidly evolving area. Although the inferiorvena cava collapsibility index (IVC-CI) has been shown to correlatewith both clinical assessment and invasive monitoring of intravascularvolume status, it is limited by difficult visualization of the IVC, interferenceby surgical dressings and tubes, and a relatively steep learning curve.Many physicians already have experience with internal jugular ultrasoundfor vascular access. Due to the ease of the technique and simpler anatomy,we hypothesized that the internal jugular vein collapsibility index (IJV-CI) would be easier to perform than the IVC-CI.Methods—A prospective observational pilot study comparingIVC-CI and IJV-CI was performed in surgical intensive care unit patients.S19
American Institute of Ultrasound in Medicine <strong>Proceedings</strong> J Ultrasound Med 32(suppl):S1–S134, 2013In addition to patient demographics and basic hemodynamic data, simultaneousM-mode measurements of the IVC-CI and IJV-CI were collectedduring each bedside sonographic session. IVC measurements were obtainedusing curvilinear probes. IJV measurements were obtained usinghigh-frequency linear array probes. Statistical comparisons for paired dataincluded linear regression with correlation coefficients and Bland-Altmananalysis with construction of a mean difference plot for bias determination.Results—A total of 16 patients were enrolled (mean age, 52.8years). There were 5 women and 11 men. Acquisition of adequate IJV-CIscans was faster than acquisition of IVC-CI scans (43 vs 105 seconds scanningtime, respectively; P < .01). Thirty-five measurement pairs were obtained,with some correlation noted between paired IVC-CI and IJV-CImeasurements (r = 0.54; r 2 = 0.289). There was a 6% negative measurementbias between IJV-CI and IVC-CI measurements as determined by theBland-Altman method.Conclusions—IJV-CI measurement can be performed significantlyfaster than IVC-CI measurement. In our pilot study, there was minimalmean measurement bias (6%) between the 2 techniques, indicatingthat the IJV-CI tends to overestimate collapsibility. More data are neededto better characterize the correlation between the IJV-CI and IVC-CI anddefine the role of the IJV-CI in clinical practice.1540557 Point-of-Care Ultrasound Evaluation of Central LinePlacementEric Mervis, 1 * Elizabeth Turner, 3 Alan Chiem, 4 Robert Liou, 2Randy Hou, 5 Craig Anderson, 1 Arthur Youssefian, 1 J. ChristianFox 1 1 Emergency Medicine, 2 Pulmonary/Critical Care,University of California Irvine, Orange, California USA; 3 Pulmonary/CriticalCare, University of California Los Angeles,Los Angeles, California USA; 4 Emergency Medicine, Universityof California Los Angeles, Olive View, Los Angeles, CaliforniaUSA; 5 Pulmonary/Critical Care, Kaiser, Fontana, CaliforniaUSAObjectives—In our study we use point-of-care ultrasound(POC-US) to confirm proper central venous catheter (CVC) placementand compare the results of POC-US to chest x-ray (CXR), the current standardof evaluating CVC placement.Methods—This is an ongoing prospective single-center noninferioritystudy comparing the effectiveness of POC-US and CXR inconfirming placement of CVCs. A convenience sample of critically ill patientsthat require emergent CVC placement in the intensive care unit(ICU) or the emergency department at the University of California IrvineMedical Center have been enrolled. Patients who are >18 years old andrequire placement of a subclavian (SC) or internal jugular (IJ) CVC are eligiblefor enrollment in this study. Qualified emergency medicine andICU physicians place CVCs into IJ or SC veins. US is then performed toobtain multiple views for confirmation of CVC placement. These includeviews of the CVC within the central vein, the ipsilateral pleural line torule out pneumothorax, and the contralateral IJ vein to rule out malposition.Last, a cardiac view is obtained to show the presence of the tip of thecatheter in the right atrium or turbulence after a 10-mL saline flush, thusconfirming placement of the catheter in the superior vena cava. The timesof US and CXR completion and subsequent review of the CXR by thephysician performing the procedure are recorded.Results—A total of 55 central lines with complete US imagingand comparable CXRs have been obtained to date with a goal of enrolling140 subjects. The US method has identified 2 misplaced lines, and theCXR has shown 5 misplaced lines. Agreement between the 2 methods forconfirming CVC placement is 91% (50/55). The US method thus far hasa negative predictive value of 92.5% (confidence interval, 82%–98%).There is an average 17-minute difference between time to US and time toCXR. There have been no pneumothoraxes identified by either method.Conclusions—Preliminary data suggest that POC-US andCXR have similar agreement for identifying misplaced CVCs. There is a17-minute time difference to POC-US vs CXR, which could translate tomore expeditious use of central lines for intravenous fluids, antibiotics, orvasopressors in potentially unstable patients.1541330 Three-Window Bedside Ultrasound Versus Chest Radiographyfor Confirmation of Endotracheal Tube PlacementArthur Youssefian, 1 * Elizabeth Turner, 3 Shane Breazeale, 2Angelina Amian, 2 Eric Mervis, 1 J. Christian Fox, 1 NegeanVandordaklou, 4 Craig Anderson 1 1 Emergency Medicine,2Pulmonary and Critical Care, University of California Irvine,Orange, California USA; 3 Pulmonary and Critical Care, Universityof California Los Angeles, Los Angeles, California USA;4Department of Emergency Medicine, Long Beach MemorialHospital, Long Beach, California USAObjectives—In our study, we use 3-window bedside point-ofcareultrasound (POC-US) to confirm proper endotracheal tube (ETT)placement and compare the results of POC-US to chest x-ray (CXR), thecurrent standard of evaluation. The hypothesis is that POC-US will benoninferior to CXR for ETT placement and will be more expedient.Methods—This is an ongoing prospective noninferiority studycomparing the effectiveness of 3-window bedside POC-US in confirmingplacement of ETTs. A convenience sample of critically ill patients whorequired emergent endotracheal intubation in the intensive care unit (ICU)or the emergency department (ED) at the University of California IrvineMedical Center have been enrolled. Patients who are >18 years old and requiretracheal intubation are eligible for enrollment. Qualified ED andICU physicians placed ETTs per the usual protocol. US is then performedto obtain multiple views for confirmation of ETT placement. These includeviews of the trachea, bilateral lungs, and diaphragms. The primaryobjective was to compare the sonographer’s ability to predict placementof ETTs based on a 3-window bedside US model compared to the formalinterpretation of the postintubation CXR read by an attending radiologist.The secondary outcome objective was to measure and compare the timefrom the 3-window US exam to the time of the initial availability of postintubationCXR as well as to the time of availability of the radiologist’s formalinterpretation of the film.Results—A total of 136 subjects with complete US imagingand CXRs have been enrolled to date, with a goal of 140 subjects. The 3-window US method correctly identified 124 of 128 ETTs placed in thetrachea (specificity, 94.7%). US correctly identified 1 of 5 ETTs found byCXR to be in a main stem bronchus (sensitivity, 20%), with a positivelikelihood ratio (LR) of 3.74 and a negative LR of 0.845.Conclusions—Preliminary data suggest that 3-window POC-US and CXR have similar agreement for identifying correctly placedETTs. Additional analysis of subjects with false-positive and false-negativeUS impressions will aim to determine factors contributing to thesetype I and II errors.1541487 Transcricothyroid Ultrasound for Confirmation ofEndotracheal Tube Placement by United States MilitaryEmergency Medicine ProvidersMichael Rebener,* Chase Donaldson, Eric Chin EmergencyMedicine, San Antonio Military Medical Center, San Antonio,Texas USAObjectives—The purpose of this study is to assess the accuracyof dynamic transcricothyroid ultrasound for confirming endotracheal tube(ET) placement by military emergency medicine (EM) providers, specificallyphysicians and physician assistants, and to examine the relationshipbetween accuracy and prior ultrasound experience in this application.Methods—A prospective randomized double-blinded validationstudy to identify ET placement in a cadaver model using ultrasoundwas conducted. Twenty-six EM providers with variable ultrasound experiencewere given a brief presentation on how to identify airway land-S20
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