By Michael Zwank, MD
Ultrasound confirmation of central line placement instead of CXR? We are getting there...
It always feels a bit silly to me to order CXR to confirm central line placement when I know it was successful based on US guidance of the procedure. I watched the needle enter the vein and not the lung. However, I do always order CXR as this feels like standard care. This study is a great big step towards ending the practice of CXR confirmation. The authors show excellent performance of the ultrasound — zero errors and much improved time to confirmation. The main limitation of this study is the relatively small number of patients included and the lack of any complications (impressive!). While I’m not sure this is quite ready for standard use, it certainly gives good evidence that turbulent saline in the RV and no pneumothorax on ultrasound gives strong support that the line is good to go.
Gekle R, Dubensky L, Haddad S, Bramante R, Cirilli A, Catlin T, Patel G, D'Amore J, Slesinger TL, Raio C, Modayil V, Nelson M. Saline Flush Test: Can Bedside Sonography Replace Conventional Radiography for Confirmation of Above-the-Diaphragm Central Venous Catheter Placement? J Ultrasound Med. 2015
Ultrasound is useful for evaluating metacarpal fractures but don’t throw out the x-ray yet.
This is an interesting study that describes seemingly good sensitivity and other test characteristics of US for detecting fractures. It has some limitations. Based on the article, it is unclear to me exactly how many fractures were missed by US (three by my calculation). As with many US studies, a very limited number of savvy physicians performed the US - in this case, one. This makes the study very challenging to generalize. Alarming to me was that two patients had scaphoid fractures which I think the average physician would not detect by US (though in this study these were detected by US). I think US has some real utility in the diagnosis and guidance of hematoma block and attempted reduction, but I doubt many orthopedic surgeons following up these patients in clinic would be content to evaluate patients without radiographs.
Kozaci N, Ay MO, Kesapli M, Akcimen M, Sasmaz I, Turhan G, Boz A. The effectiveness of bedside point-of-care ultrasonography in the diagnosis and management of metacarpal fractures. Am J Emerg Med. 2015 Jun 23. pii: S0735-6757(15)00538-0. doi: 10.1016/j.ajem.2015.06.052. [Epub ahead of print] PMID: 26175338