Test characteristics of thoracic point of care ultrasonography for the diagnosis of acute congestive heart failure in the emergency department

The test characteristics of thoracic Point of Care Ultrasonography (PoCUS) for the diagnosis of acute congestive heart failure (CHF) are not well known, and no prior study evaluated the diagnostic impact of pleural effusions. We sought to determine the test characteristics of thoracic PoCUS when performed within 2 hours of initial emergency physician (EP) assessment by combining sonographic B-lines and pleural effusion to diagnose acute CHF.

Background: The ultrasound in the ICU has proved to be a non invasive and economic technique that helps the approach in the diagnosis and management of the critical patient. Echocardiography permits diagnosis such as coronary syndrome, pericardial effusion or valvulopathies and brings us the possibility of monitoring the different aspects of shock, like cardiac function or volume respond. Furthermore, lung ultrasound allows us to approach the diagnosis of pneumothorax, pleural effusion, pulmonary edema, consolidation or interstitial disease. For all the abovementioned reasons, we believe intensive residents ought to train in this aspect. Objective: To evaluate the resident´s ability to determine the hemodynamic, cardiac and respiratory situation with a basic training in ultrasound. Methods: We use VSCAN and lineal transducer probe to do lung ultrasounds in five different areas in each hemithorax. First we examine the parasternal area and then we use the axillar line to divide the lateral of the hemitorax in four parts: anterosuperior, anteroinferior, posteroinferior and postero superior; we are trying to evaluate the possible presence of: pleural sliding, pleural effusion, consolidation, A or B lines, and the correlation with the clinical aspects and X-rays or TC. We use VSCAN for echocardiography and evaluating the cardiac function, to check for the presence of segmentary contractility alterations, valvulopathies and cava vein variability. We are presented with a 73-year-old patient with previous arterial hypertension, atrial fibrillation, and chronic bronchitis who is admitted in the ICU for septic shock secondary to anastomotic rupture in the postoperative of a colon disease. Thirty-two days later, he is extubated without vasoactive drugs. On the 35th day he started having respiratory problems, fever and hypotension, needing intubation and vasoactive drugs. After a subclavian access, we suspected it to be a left pneumothorax. In the X-rays, both hemithorax bases were observed with an augment of density, mostly in the right lung. A Lung ultrasound was done in the parasternal line of the right lung and we observed pleural sliding with B lines pattern. It was not present in the left lung and we were not able to do the echocardiography because of window absence. TC confirmed the presence of anterior pneumothorax, and a thorax tube was inserted. The clinical situation did not improve. ECG demonstrated a new Q wave in the septal face and negative T in the lateral face. An echocardiography was done and moderate biventricular dysfunction, left ventricle dilated with dyskinetic movement were observed. We also noticed pericardial effusion with a dubious tamponade of the right ventricle, nonetheless this was dismissed because this collapse movement occurred in systole. There were mitral and tricuspid insufficiencies. The cava vein was dilated without variability. At a later time, another lung ultrasound was done where pleural sliding was observed in both hemithorax, with a B line pattern at the parasternal line. Pleural effusion and heterogenic consolidation were noticed at the decline parts of both lungs. Discussion: It is a difficult patient with multiple complications that render his hemodynamic situation worse. We were not able to diagnose with certainty the presence of pneumothorax, it is true that M mode could not be done and this had increased the probability of diagnosis of it, but the ultrasound improved the chances and confirmed the drainage of the pneumothorax. We can say that it is a shock with septic and cardiac characteristics with a dilated cava vein and B lines that indicate pulmonary edema. Also bilateral consolidation lung was observed with pleural effusion that makes the pneumonia more likely, bearing in mind the fever and the respiratory problems of the patient. Conclusion: Portable ultrasound technology is able to assist physicians in the assessment of the cardiovascular and respiratory system at the bedside of the patient. Use of the ultrasound can lead to considerable savings of cost and time, as physicians will be able to more selectively order tests based on what is found during the physical examination and after completing a brief ultrasound study. Thus, the ultrasound has the potential to help promote better and more efficient health-care delivery. The ultrasound is a technology observed-dependent and this is the reason for which a good training is important. More studies are necessary to evaluate the training of the residents on it. marker of increased intracranial pressure (ICP). Only few studies were made correlating MRI measurment of ONSD with ultrasound measurment of ONSD. Overall lower standard values of the ONSD for ultrasound measurment compared to MRI measurment were found. That might be atribbuted to variable interpretation of ultrasound anatomywhat are we really measuring? Objective: We performed a proof of concept study to evaluate the accuracy of measurments of the ONSD for contrast enhanced ultrasound (CEUS) and magnetic resonance imaging (MRI). Second generation contrast agent (Sonovue™, Bracco SpA) was used to enhance the ultrasound recognition of relevant anatomy and conduct transbulbar ONSD measurments. Patients and methods: Nine healthy volunteers were examined with CEUS with transbulbar approach and MRI. CEUS and MRI examinations were recorded on the PACS system. Measurments of the ONSD were performed on the collected images using DICOM viewing software (OsiriX™, Pixmeo SARL). Statistical analysis was performed and included the calculation of the agreement of measurment between both methods. Statistical software was used (IBM SPSS Statistics ver. 20™, IBM Corp). Results: Good correlation of measurment values was found between CEUS and MRI (ICC 0.98, 95% CI, 0.74 -0.99), MRI being regarded as a gold standard. Conclusion: Using CEUS significantly aids the identification and recognition of the relevant structures sorrounding the optic nerve. Measuring a small structure as ONSD with ultrasound is a demanding task. By using CEUS the exact measuring points can be quickly and easilly identified, making a measurment more exact using transbulbar sonography on living subjects. The measurment can be quickly performed, can be repeated, the introduced contrast agent is nontoxic References 1. Beare NAV, Kampondeni  The two leading causes of IJVT are iatrogenic trauma secondary to jugular vein catheterization, and repeated IV injections by drug users. Lemierre syndrome is a complex and unusual clinical entity, characterized by septic thrombophlebitis of internal jugular vein. Lemierre syndrome was thought to be a rare and forgotten disease with suggested incidence of approximately one per million. However, an increase in frequency over the past years has been suggested due to changes in antibiotic usage. Unfortunately, wide spread antibiotic usage has also changed clinical picture of Lemierre syndrome and it is often difficult to recognize this unusual ilness in the Emergency Department (ED). Systemic septic complications may range from deep neck infection over septic arthritis to brain infections. Every organ system may be involved. Delays in diagnosis ranging up to 11 days after admission have been reported. When recognized and treated in early phase patients recover completely but other vise condition may be lethal. In emergency settings accurate and prompt diagnosis is crucial in satisfactory patient management. Diagnosis of Lemierre's syndrome is simple with Doppler ultrasonography but it mostly requires a high degree of clinical suspicion. It has been suggested that bedside ultrasound of the internal jugular vein in ED before other radiologic imaging, may lead to rapid diagnosis and treatment of Lemierre syndrome. In last two years we treated five patients with Lemierre's syndrome in our department. In one case young woman died because of sepsis and multiorgan failure due to delayed diagnosis. Rapid ultrasound examination of neck veins is discussed as a part of ED evaluation of patients.

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Accuracy Methods: This study investigated male patients in whom standard urethral catheterization attempted by an emergency nurse or emergency physician failed in our institution or who were transferred from other hospitals or nursing homes following failure of the procedure and subsequent urethral bleeding. Patients with a history of urological surgery were excluded. Transabdominal ultrasonography was performed using a portable device with a 2-5 MHz convex probe. First, an emergency physician placed the probe on the suprapubic region longitudinally and observed the possible course of the prostatic to bulbar urethra, and tried to detect the tip of a catheter advanced by a nurse until progress was obstructed. To detect the tip more easily, the physician asked the nurse to oscillate the catheter and moved the tip when necessary. After the tip was detected, the nurse withdrew 2-3 cm. The physician then inserted the index finger of the opposite side into the rectum and kept pushing the site of the previous resistance ventrally while simultaneously holding the probe. After following these procedures, the nurse advanced the catheter again. Results: Five patients (age range, 56-93 years) were enrolled between March 2011 and April 2012. The tip of the catheter was observed in the bulbomembranous urethra or the false passage with transabdominal ultrasonography in four of the five patients. In these four patients, the false passage was compressed or the curve of the bulbomembranous urethra became gentle by pushing the regions ventrally from the rectum, and the tip was advanced smoothly to the bladder.
Conclusion: This transabdominal ultrasound-guided method with digital rectal examination performed by emergency medical personnel appears useful for overcoming difficult urethral catheterization in some male patients. Results: Of 195 respondents, 85% were board certified in emergency medicine with a mean age of 40 years. 69% practiced in academic hospitals, 27% in community, and 4% in military. 83% worked in departments with annual volumes >40,000 visits and 92% had an emergency ultrasound director. Credentialing mechanisms existed for 96% of respondents; 51% of hospitals used ACEP guidelines for credentialing. Credentialed respondents were credentialed in: FAST (78%), Vascular (74%), Aorta (68%), OB/Gyn (66%), Gallbladder (55%), Renal (53%), and DVT (40%). Non-credentialed respondents most commonly cited "lack of experience" (35%) and "too busy" (29%) as barriers. Academic and community physicians were credentialed at the same rate. Those who completed training prior to 2001 were less likely to be credentialed than those trained after in all areas except gallbladder ultrasound. Financial incentive (34%) and hands on experience (31%) were most often cited as reasons to pursue credentialing. This was true for those trained before or after 2001, and for academic or community practice.  Background: Studies conducted in adults have revealed that ultrasound (US) guidance for peripherally inserted central catheter (PICC) placement may improve success rate and reduce procedural complications. However, this is still not sufficiently studied in children. Objective: To study the safety and efficacy of US-guidance for bedside PICC placement in children. Patients and methods: Prospective observational study in which 50 USguided PICC placement attempts are analyzed. Patient clinical data, procedural details, and infectious and thrombotic complications of the catheters are described. Results: Median age and weight of the patients were 55 months (7-288) and 15 kg (3.2-80), respectively. The veins selected for PICC placement were basilic vein in 73% patients, brachial vein in 14.5%, cephalic vein in 6.3% and external yugular vein in 6.2%. Intravenous sedo-analgesia was administered in 93% of the patients. Successful PICC placement was achieved in 96% of attempts. Success rate was 42% in the first attempt, 58% in the second, and 79% in the third. Procedural complication rate was very low (8%), with moderate local hemorrhage and accidental arterial puncture incidence of 6% and 2%, respectively. The median time spent on the procedure was 28 minutes (15-90). The median cannulation time was 3.5 minutes (0.5-60). Median PICC dwell time was 17 days (4-59). Central line-associated bloodstream infection (CLABSI) was suspected in three cases but it was finally not confirmed in any case. Weekly echo-doppler exploration of the cannulated veins detected superficial vein thrombosis in 6.3% of the patients and deep vein thrombosis in 2%. No patients showed clinical signs of venous thrombosis. Conclusion: Ultrasound-guided PICC cannulation is safe, rapid, and has a high success rate in children.
Background: There is limited data on the sonographic evaluation of normative physeal plate measurements in healthy, uninjured children. Objectives: To determine the baseline measurements for physeal plate widths in healthy, uninjured children.
Methods: This is a prospective observational study of a convenience sample of healthy patients between ages 0 and 12 years presenting to the pediatric emergency department. A focused ultrasound of the distal tibia, fibula, radius and ulna were performed bilaterally (8 total). Measurements were taken at the physeal plates in the longitudinal plane at the widest distance. The degree of variance of physeal plate widths within an individual and the average values of physeal plates for each bone were calculated. Results: A total of 60 patients were enrolled in this study. The mean age of enrolled patients was 6 years 3 months, 38% of who were female. Mean physeal plate diameters for the averaged measurement of each bone were: tibia 0.33 cm (95% CI 0.29 -0.36), fibula 0.31 cm (95% CI 0.28 -0.34), radius 0.27 cm (95% CI 0.24 -0.30) and ulna 0.32 cm (95% CI 0.27 -0.36). Mean values for the absolute difference in physeal plate diameters were: tibia 0.06 cm (95% CI 0.04 -0.07), fibula 0.06 cm (95% CI 0.04 -0.07), radius 0.05 cm (95% CI 0.04 -0.07), and ulna 0.1 cm (95% CI 0.05 -0.16). When measurements were stratified by age, the confidence intervals for each averaged measurement narrowed with increasing age while the absolute difference in physeal plate diameters remained consistent.
Conclusion: This pilot study demonstrated that there was no statistically significant difference in physeal plate diameters between contralateral extremities and the degree of variation between contralateral extremities was minimal. Results of this study elucidate normative growth plate variance in healthy children and demonstrate that mean plate measurements and absolute differences are narrow. This study suggests that sonographic detection of significant disparities in physeal plate diameters of injured children may have the potential for earlier detection of Salter Harris injuries with subsequent appropriate referral and management. Background: A variety of animal models have been used for research into the sonographic evaluation of soft tissue foreign bodies. The wide range of reported accuracies in FB detection in these studies may be due to some tissue models being easier to image than human tissue. Objective: To determine which among commonly used animal tissue models for FB detection most closely approximates human soft tissue. Methods: 99 sonographic images (59 still, 40 video clips) of soft tissues from healthy humans, chicken breasts and thighs, turkey thighs, beef chops and pork feet were obtained using a high frequency linear transducer. Video clips were 6 seconds and the scanning depth was 1.5 to 3.3 cm. Clips and images were grouped separately in random order, and consisted of hand (4 stills, 6 clips), arm (3,2), foot (6,3), leg (4, 2), flank (2,4), chicken breasts (5, 5), chicken thighs (7, 2), turkey thighs (8,6), beef chops (8,3), and pork feet (13,7). 7 experienced ED sonologists reviewed images and rated as "human tissue", "non-human tissue", or "don't know". Responses were converted into a binary variable, and raw percentages per sonologist and per animal type were calculated. To determine which animal tissue was most frequently identified as human, logistic regression was used clustering on sonologist. Results: Correct identification rate was 67% for the trunk, 57% for the hand and leg, 37% for the arm, and 17% for the foot. For animal tissue models, the rate of identification as human tissue was 61% for the pork feet, 35% for the chicken thighs, 26% for the beef chops, 23% for the turkey thighs, and 13% for the chicken breasts. Pork feet were the most likely animal tissue to be identified as human tissue (p<0.0001, OR=1.9, 95% CI 1.2-3.0), and chicken breasts were the least (p<0.0001, OR=0.16, 95% CI 0.07-0.35). Conclusion: Among animal tissues, pork feet most closely approximate human tissues. Experienced sonologists performed poorly in distinguishing human from animal tissue. Educational programs and future studies might be optimized by the use of this animal soft tissue model. Background: Ultrasound (US) has been shown to be useful in the diagnosis of pediatric skeletal injuries. It can be performed accurately and reliably by emergency department (ED) physicians with focused US training. Objective: To determine the test performance characteristics for point-ofcare US performed by pediatric emergency medicine (PEM) physicians compared to radiographic diagnosis of elbow fractures and to compare inter-rater agreement between enrolling physicians and an experienced PEM sonologist. Patients and methods: This was a prospective study of children up to 21 years old presenting to the emergency department with elbow injuries requiring X-rays. Before obtaining X-rays, PEM physicians performed a focused elbow US. A positive US for fracture at the elbow was defined as the PEM physician's determination of an elevated posterior fat pad (PFP) and/or lipohemarthrosis (LH) of the PFP. All patients received an elbow X-ray in the ED and clinical follow-up. The gold standard for fracture was fracture on initial or follow-up X-rays. Results: One hundred thirty patients with a mean age of 7.5 years were enrolled by 26 sonologists. Forty-three (33%) patients had an X-ray positive for fracture. A positive elbow US had a sensitivity of 98% (95% CI 88-100%), specificity of 70% (95% CI 60-79%), positive likelihood ratio of 3.3 (95% CI 2.4-4.5), and negative likelihood ratio of 0.03 (95% CI 0.01-0.23) for fracture. The inter-rater agreement (kappa) was 0.77. The use of elbow US would reduce X-rays in 48% of patients but would miss 1 fracture.
Conclusion: Point-of-care US is highly sensitive for elbow fractures, and a negative US may reduce the need for X-rays in children with elbow injuries. Elbow US may be useful in settings where radiography is not readily accessible or time-consuming to obtain. Background: Ultrasound is not used to take part in the clinical approach of body-packers in the Emergency Department. Its usefulness in the evaluation of these kind of patients has not been sufficiently studied. Sometimes, specially in liquid-filled packs, the identification can be specially challenging. Objective: To assess the diagnostic accuracy of bedside ultrasound detecting body packers among a small size of body packers and health volunteers.
Methods: This was a prospective study, in which 29 people were enrolled. In each patient, a 6 seconds retrospective clip of each 9 abdomen anatomical division was recorded. In order to ensure adequate blinding, the clips were reviewed days after its obtention and the reviewer was blinded to all significative data as medical record number or the sonographer that saved the clip. A possitive case consists on the detection of a pack, as an hyperechoic stripe just below the peritoneum line with accoustic shadow and without peristalsis motion and/or air reverberation artifacts. The gold standard was expulsion of at least 10 packs after the scan, and we asume that healthy volunteers enrolled had no packs in their digestive tracts. Results: 27 of 29 patients enrolled were included to analysis, due to a failure to save all the clips. 15 patients were body packers brought in to the Emergency Department under arrest from Madrid Barajas International Airport, and 12 were healthy volunteers. After the review, the accuracy obtained was (with a 95% Confidence Interval): Sensitivity 0.

Conclusion:
The study shows an acceptable value of sensitivity of ultrasound in the body packers detection. Due to the small sample size and the problems related to blinding (mainly impossibility of make pressure over the bowel loops in order to distinguish them from packs) further studies are neccesary to assess the real accuracy of ultrasound among these kind of patients.

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Evaluation of formal training in clinical ultrasonography and its utility in identifying treatable causes of PEA Ramon Nogué Bou * , J Fabregat, R Vilella, A Encinas, T Villen, R Campos Hospital Montserrat, University of Lleida, Alcalde Sol, Nº 6-3, Lleida, Spain E-mail: rnogueb@gmail.com Critical Ultrasound Journal 2012, 4(Suppl 1):A21 Background: Ultrasonography performed by the clinical physician should be a diagnostic tool, associated with anamnesis and physical examination of the patient, in order to increase security in the diagnoses, procedures, initial treatments and the following monitorization. Critical Ultrasound Journal 2012, Volume 4 Suppl 1 http://www.criticalultrasoundjournal.com/supplements/4/S1 The medical areas that benefit most from this concept are those in which the time factor is important. The present study examines aspects of standardized training clinical ultrasonography performed at the Faculty of Medicine, University of Lleida, in order to know the characteristics of the students, know their capacity to identify serious or fatal heart disease and the suitability of the view used in the videos (subcostal), all of them for the course and for clinical application. Material and methods: Standardized training in clinical ultrasonography, with a duration of 25 hours, for physicians without experience in ultrasonography and who attend patients with acute, urgent and critical conditions. The teaching methodology consists in a brief theoretical presentations followed by practical sessions in small groups (4-5 students) about ultrasonography, different benefits, monitor expert. They used live models and simulators. One hour of theory and two of practice are dedicated to echocardiography. The course is assessed with a standardized practical and theoretical examination. Before an after de course all students respond a survey related to their previous knowledge, use and availability of this technique. A part of the evaluation consists of four videos of echocardiography in a subcostal view, 3 of them with life-threatening disease and a normal one, for 10 seconds. They had no available prior information of the case and only the image must be interpreted by the student and suggest a diagnosis. Data was analyzed using SPSS v.17.
Results: A total of 289 students attended to this course. 4 has been removed from or study because didn't answered the exam or the survey, leaving a sample of 285 students. In the survey 95.5% rated as high the need for ultrasound in emergency services. There is a significant relationship (p < 0.05) between the availability of radiologist in the hospital and the need to use ultrasound in the ED. 86.7% achieved optimal viewing at subcostal point. The 80.7% of students committed one or none error in the questions videos about heart disease. The following tables summarizes the number of students which correctly respond each video an in the response in that students who didn't answered correctly. Tables 1 and 2. Discussion and conclusions: 95% of physicians who work in ED found useful the knowledge and use of ultrasonography. Those who work in hospitals considered more basic found the knowledge of this technique more useful. Most of the students achieved a correct visualization from the subcostal point, which correlates with other studies and publications in the bibliography. Would therefore be recommend as the initial view in a situation of AESP. The videos with a major percentage of errors are the severe hypocontractiblity and the healthy hearth, in contrast a more than 90% of students identified the pericardial effusion and the dilatation of right ventricle, which are potentially treatable diseases in CPR contexts. These results support the thesis that a short course can help to identify potentially treatable pathology in a PEA context.

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The pericardium horror show Ramon Nogué Bou * , J Fabregat, R Vilella, A Encinas, T Villen, R Campos Hospital Montserrat, University of Lleida, Alcalde Sol, Nº 6-3. Lleida, Spain E-mail: rnogueb@gmail.com Critical Ultrasound Journal 2012, 4(Suppl 1):A22 We describe three cases where the ultrasonography "point of care" was decisive. Case 1: 83 year old woman with a history of hypertension and stroke, who were admitted to our hospital for right hemiplegia with an evolution of more than 3 hours. She shows us a report that two days earlier was admitted in another center for an episode of atrial fibrillation at 150 bpm of less than 48 hours of evolution, where he underwent electrical cardioversion reverting to sinus rhythm at 72 bpm and anticoagulation with heparin of low molecular weight was started. Given the presence of jugular venous distention, echocardiography was decided, objectifying pericardial effusion. In ultrasound guided pericardiocentesis a transparent liquid was extracted. In biochemistry showed an ion concentration similar to physiologic saline. Diagnostic judgment: Central line catheter complication. Treatment: Given the findings fluid infusion was suspended, and central line retired 3 cm, presenting hemodynamic improvement. It is therefore assumed that the central line was placed in the pericardium, being the cause of the effusion. Conclusions: The three cases have exposed three facts in common: first, the presence of pericardial effusion initially unsuspected. Second, the difficulty to suspect this condition without ultrasonography. And third, its easy detection by bedside echocardiography, which changed the treatment, avoiding potential aggravation. Critical Ultrasound Journal 2012, Volume 4 Suppl 1 http://www.criticalultrasoundjournal.com/supplements/4/S1 This highlights the important role of ultrasonography and its progressive introduction in the emergency services, enabling rapid detection of diseases by the staff using protocols.
We present the case of a patient, 60 years old, which has been carrying multiple central venous catheters for hemodialysis. We recived consultation: the patient need a central vascular access. He has malfunctioning of femoral dialysis catheter, central catheter in left internal jugular vein removed a week ago, the right jugulosubclavian territory with thrombosis. We try cannulation of left internal jugular vein, with ultrasound and radiologic guidance. During the procedure, the patient experienced sudden and intense chest pain, which disappear spontaneously in a few seconds. At the end of the procedure one of the catheter´s lights was malfunctioning. Before starting hemodialysis the chest pain is reproduced by serum injection. Rx appropriate check. Chest CT is performed and it shown the vascular perforation. The patient suffer mediastinic perforation due to catheter of 14'5F, into the left brachiocephalic vein. The vascular perforation is in the same area of permcath kink previous. Discussion: Several mechanical complications associated with central venous catheters, even using ultrasonography and radiology during the procedure, are reported. It is essential to have a high index of suspicion in patients with known vascular diseases, carriers of thick catheters for long periods, especially left approaches. This creates particular vulnerability to serious complications as vascular perforation.
A 50 year old woman, with breast cancer undergoing chemotherapy. Login to removal because of the disconnection between the catheter and the subcutaneous port, diagnosed in routine check. In this case the X-ray showed the disconnection between the catheter and the subcutaneous port. And the consequent migration of the catheter, through cardiac cavities, into the pulmonary artery. Embolized catheter was removed by interventional radiology, under local anesthesia and intravenous sedation. The retrieval of the fragment was performed successfully using a snare catheter passed through the right femoral vein. Discussion: The central venous cannulation and placement of permanent vascular access is a common technique in cancer patients. This is an invasive procedure, non-therapeutic or curative in itself, which can lead to serious complications, even death. The iconography of this case demonstrates a mechanical complication, potentially severe and rare placement of a port-a-cath. Embolized catheters can be removed by interventional radiology without significant adverse affects. The patient recovered without complications.
Background: For several years modern technology allows the manufacturing of anatomical models that accurately simulate the features anatomical human body, their pathologies and in some cases their physical properties in what regards to the ultrasound. Today exist in the market a variety of anatomical models called Phantoms, created with the purpose of increasing the skills of the emergency physician in the use of the ultrasound as diagnostic and therapeutic tool. But on the other hand, these phantoms is not within the reach of all stakeholders, due to its high cost.
Objective: This poster summarizes the development of a low cost phantom of the human eye for ultrasound, with the purpose of obtaining a useful and economical alternative for training, teaching and learning in ultrasonographic diagnosis of the more often ocular patholology seen in emergency services. The method to make this kind of models of gelatine has already been described before, but which is described in this poster provides as a novelty, the manufacture and use of metal molds, as well as other details that give the phantom a great detail as to the quality of the ultrasound image, finish end and therefore to its practical purpose. Materials and ingredients: Unflavored gelatin, ethanol at 70%, plastic microwave-safe bowl or Tupperware, bowl with measurement, aluminum paper, any lubricating oil to the skin, approximately 1 mm thick aluminum rod, 1.5 cm wide and 40 cm long (you can use a splint of Zimmer that withdraws the foam), spoon, electric hand mixer. Mixing bowl. Elaboration: Mix in a large bowl, a concentrated solution of unflavored gelatin, water and ethanol. For 500 ml of hot water, add 100 grams of gelatin and 30 ml of ethanol as a preservative. To obtain greater or lesser amount of mixture you will only need to make the corresponding conversion ratios using a simple rule of three and if required you can add clothing artificial colorant to give desired color to the phantom. Mix it with the electric mixer for 2 minutes, allow to stand 30 minutes. Then remove the foam on the surface with a spoon. Fill the bowl or tupperware with the mix and let it cool for 2 hours in the fridge. Meanwhile a metal rod is used to shape the mold of the eyeball, making a circle with a small mound that will simulate the shape of the cornea, which will represent the sagittal plane to view it with the ultrasound. In the same way and with smaller pieces of metal, will be made molds of smaller structures as the lens, iris, the retina detached etc. Can be used as guide, ultrasound of normal eye or a drawing fron an anatomy book. In order to increase echogenicity of the shapes made, use the body oil to  Results: Advantages: A block of transparent and durable gelatin in the medium-term (in cooling not freezing) is obtained, economic in which can be put into practice the handling of the probe, such as training in the recognition and ultrasonographic diagnosis of the more frequently eye pathology seen in emergency services. Each and every one of these molds are perfectly recyclable, so they can be melted again in the microwave for 3 to 4 minutes and then make new prints in the resulting gelatin block. Disadvantages: do not have long term durability and required store in cool place (fridge), as that the ambient temperature In the material rises handling can become friable. Eye ultrasound exploration is static and not dynamic, due to the eyeball does not move as in a real patient, the scan is performed only in the axial plane. Conclusion: It is possible to achieve a training on ultrasound phantom of the eyeball with a better quality in terms of anatomy, physical and echographic properties, with acceptable durability, recyclable, economic, which allows the physicians to improve their skills in recognition of the most frequently emergency ocular pathology and therefore to improve the chances of patients to receive an accurate diagnosis and timely treatment. Background: Acute appendicitis (AA) is the most frequent abdominal emergency surgery and the perforation, is mainly due to a delay in the diagnosis. The use of ultrasound (US) in Emergency Department (ED), could avoid delays in the diagnosis of this entity. When there is a perforation surgical morbidity multiplies by 15 and 50 the deaths. Objective: We present a case of AA, diagnosed at ED, through the use of US scanning used by Emergency Physicians (EP), and promoting their use.

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Patients and methods: A patient with abdominal pain, with a final diagnosis of an AA assessing ultrasound, performed by EP. We used a Sonosite M Turbo, equipped with probe Convex C60 between 2 and 5 MHz.
Results: A male patient 18 years old, who attends the ED services, with abdominal pain, located all along his right side. No sign of nausea, vomiting or diarrhea, no fever or dysuria. He came in walking in the surgery, conscious and lucid, well hydrated and perfused, afebrile; abdominal tenderness presented an abdomen with voluntary defense in right hemiabdomen, no sign of peritoneal irritation. The rest of the exploration was normal. We have a slight leukocytosis of 10,900 without findings anywhere else in complementary tests. The patient continued with the same pain and the abdominal condition had not changed, so an abdominal US was performed, discovering an enlarged appendix, absence of peristalsis, not compressible, and the thickened wall.
Conclusion: Ultrasound carried out by EP, can be a very useful tool in cases for which clinic and analytics are not clear. The sensitivity of US for the diagnosis of AA is high, vary from 80 to 94%, but is highly browser dependent and it is essential therefore, to have an appropriate training of the MU, to prevent diagnostic errors. To incorporate the US in ED decreases overall care time, since the EP is more efficient and dynamic, providing greater clinical safety and decreasing the complications. Aim: The purpose of this preliminary study is to verify the venipuncture technical using the ecography scanner and compared to the traditional puncture and how this first is beneficial for the patient decreasing the number of attempts and saving the affected puncture area. Inclusion criteria: Including the patient risk and his pathology study: obesity, multipuncturation, respiratory pathology, cardiovascular pathology, patients with warfarina treatment; and convenient area of puncture, defining it as the area between radio-ulnar 1/3 distal and proximal radio-ulnar 1/3. Method: A prospective study in two groups of patients with the abovementioned pathologies: 50 patients receiving traditional puncture and 50 patients receiving ecography guided puncture.
Results: Traditional puncture gets 56% success on the first try, while with ecography guided puncture the success increases to 72%. Traditional puncture on the second attempt we obtain a 34% and with ecography guided puncture we have a 26% of success. We got, with the third attempt in traditional puncture, a 12% of success and through ecography guided puncture we have a 2% of success. Fourth attempt to puncture through the traditional method is done in 2% patients while ecography guided puncture method the result is 0%. Conclusion: The percentage of success in the first ecography guided puncture is greater than the traditional method. The percentage of success increases through the ecography puncture method meanwhile increases in the number of attempts. The area where to place venous catheter is relevant to consider area of comfortable puncture for the patient described above. With the same group of patients the choice of convenient area of puncture site was 92% entering in the above described area between distal radio-ulnar 1/3 and proximal radio-ulnar 1/3. The 8% remaining was in different areas of the upper limb.