Question Of The Day #67

December 10, 2021November 20, 2021 ~ Joseph Ciano, USA ~ Leave a comment

Which of the following is the most likely cause of this patient’s condition?

Explanation

This patient arrives in the Emergency Department after sustaining penetrating chest trauma and is found to be hypotensive, tachycardic, and with a low oxygen saturation on room air. The first step in evaluating any trauma patient involves the primary survey. The primary survey is also known as the “ABCDEFs” of trauma. This stands for Airway, Breathing, Circulation, Disability, Exposure, and FAST exam (Focused Assessment with Sonography in Trauma). Each letter should be assessed in alphabetical order to avoid missing a time sensitive life-threatening condition. The primary survey should be conducted prior to taking a full history. After the primary survey, a more detailed physical exam (secondary survey) is conducted, followed by interventions and a focused patient history.

The FAST exam is a quick sonographic exam that requires the practitioner to look at 4 anatomical areas for signs of internal injuries. The 4 areas are the right upper abdominal quadrant, left upper abdominal quadrant, pelvis, and subxiphoid (cardiac) areas. The addition of views for each lung (1 view for each lung) is known as an E-FAST, or extended FAST exam. The presence of an anechoic (black) stripe on ultrasound indicates the presence of free fluid. In the setting of trauma, free fluid is assumed to be blood. The presence of free fluid on a FAST exam is considered a “positive FAST exam”. This patient’s ultrasound shows fluid in the pericardiac sac which in combination with the patient’s hypotension and tachycardia, this supports a diagnosis of cardiac tamponade. See the image below for labelling.

Cardiac tamponade is considered a type of obstructive shock. As with other types of obstructive shock, such as pulmonary embolism and tension pneumothorax, there is a state of reduced preload and elevated afterload. This causes a reduction in cardiac output (Choice C) which leads to hypotension, tachycardia, and circulatory collapse. High cardiac preload (Choice A), low cardiac afterload (Choice B), and high cardiac output (Choice D) do not occur in cardiac tamponade. Treatment for cardiac tamponade includes IV hydration to increase preload, bedside pericardiocentesis, and ultimately, a surgical cardiac window performed by cardiothoracic surgery. Correct Answer: C

References

Avila, J. (2020). Pericardial tamponade. Core ultrasound. https://www.coreultrasound.com/pericardial-tamponade/
Simon, E. (2017). EM@3AM – Cardiac tamponade. EmDocs. http://www.emdocs.net/em3am-cardiac-tamponade/

Cite this article as: Joseph Ciano, USA, "Question Of The Day #67," in International Emergency Medicine Education Project, December 10, 2021, https://iem-student.org/2021/12/10/question-of-the-day-67/, date accessed: March 24, 2023

Question Of The Day #66

December 3, 2021November 20, 2021 ~ Joseph Ciano, USA ~ 1 Comment

Which of the following is the most likely diagnosis of this patient’s condition?

Explanation

This man presents to the Emergency Department with pleuritic chest pain, shortness of breath after a penetrating chest injury. He has tachypnea and low oxygen saturation on exam, but he is not hypotensive or tachycardic. The first step in evaluating any trauma patient involves the primary survey. The primary survey is also known as the “ABCDEFs” of trauma. This stands for Airway, Breathing, Circulation, Disability, Exposure, and FAST exam (Focused Assessment with Sonography in Trauma). Each letter should be assessed in alphabetical order to avoid missing a time sensitive life-threatening condition. The primary survey should be conducted prior to taking a full history. After the primary survey, a more detailed physical exam (secondary survey) is conducted, followed by interventions and a focused patient history.

This patient should immediately be given supplemental oxygen for his low oxygen saturation. The history of penetrating chest trauma and hypoxemia also should raise concern for a traumatic pneumothorax, and oxygen supplementation is part of the treatment for all pneumothoraces. The patient’s chest X-ray shows a large left sided pneumothorax indicated by the absence of left sided lung markings. There is some left to right deviation of the heart and the primary bronchi. There is no large left sided pleural effusion in the costodiaphragmatic recess to indicate a pneumo-hemothorax. There is also no deviation of the trachea, hypotension, or tachycardia to indicate a tension pneumothorax (Choice B). The patient is hemodynamically stable, so he cannot be in hemorrhagic shock (Choice A) or have cardiac tamponade (Choice C). Although the pneumothorax is large with mild deviation of the heart, the lack of hemodynamic instability supports the diagnosis of a traumatic non-tension pneumothorax (Choice D). The treatment for this would include 100% oxygen supplementation and placement of a chest tube. A CT scan of the chest is more sensitive imaging test than a chest X-ray and should be considered to evaluate for additional injuries (blood vessel injuries, rib fractures, etc.). Correct Answer: D

References

Bartels, B. (2020). EM@3AM: Pneumothorax. EMDocs. http://www.emdocs.net/em3am-pneumothorax/

Cite this article as: Joseph Ciano, USA, "Question Of The Day #66," in International Emergency Medicine Education Project, December 3, 2021, https://iem-student.org/2021/12/03/question-of-the-day-66/, date accessed: March 24, 2023

Question Of The Day #65

November 26, 2021November 20, 2021 ~ Joseph Ciano, USA ~ Leave a comment

Which of the following is the most appropriate next step in management for this patient’s condition?

Explanation

This patient arrives in the Emergency Department after an assault with penetrating abdominal trauma and is hemodynamically stable on exam. The first step in evaluating any trauma patient involves the primary survey. The primary survey is also known as the “ABCDEFs” of trauma. This stands for Airway, Breathing, Circulation, Disability, Exposure, and FAST exam (Focused Assessment with Sonography in Trauma). Each letter should be assessed in alphabetical order to avoid missing a time sensitive life-threatening condition. The primary survey should be conducted prior to taking a full history. After the primary survey, a more detailed physical exam (secondary survey) is conducted, followed by interventions and a focused patient history.

The FAST exam is a quick sonographic exam that requires the practitioner to look at 4 anatomical areas for signs of internal injuries. The 4 areas are the right upper abdominal quadrant, left upper abdominal quadrant, pelvis, and subxiphoid (cardiac) areas. The addition of views for each lung (1 view for each lung) is known as an E-FAST, or extended FAST exam. The presence of an anechoic (black) stripe on ultrasound indicates the presence of free fluid. In the setting of trauma, free fluid is assumed to be blood. The presence of free fluid on a FAST exam is considered a “positive FAST exam”. This patient has no free fluid between the right kidney and liver. There also is no free fluid above the diaphragm to indicate a hemothorax. The question stem notes that all other FAST exam views are nonremarkable. Therefore, this patient has a negative FAST exam. See labelling of the FAST exam image below.

An exploratory laparotomy (Choice A) would be indicated in a patient with penetrating or blunt trauma, a positive FAST exam, and hemodynamic instability. This patient has a negative FAST exam and is hemodynamically stable. Packed red blood cell infusion (Choice B) would be indicated in the setting of hemodynamic instability and trauma, as this is assumed to be hemorrhagic shock. This patient is not tachycardic or hypotensive. A urinalysis to check for hematuria (Choice D) may be a helpful adjunctive investigation to evaluate for renal or bladder injury, but it is not the most crucial next step in management. Performing a CT scan of the abdomen and pelvis (Choice C) is the best next step as the patient is hemodynamically stable with a negative FAST exam and a penetrating abdominal injury. The CT scan will help further evaluate for any internal injuries that may require operative repair. See the algorithm below for further detail on an abdominal trauma work flow. Correct Answer: C

References

Avila, J. (2020). E-FAST exam. Core Ultrasound. https://www.coreultrasound.com/efast/
Gadhok, K, Fairbrother, H. (2015). Abdominal trauma: Is there anything we can be doing better? EmDocs. https://www.emdocs.net/abdominal-trauma-anything-can-better/

Cite this article as: Joseph Ciano, USA, "Question Of The Day #65," in International Emergency Medicine Education Project, November 26, 2021, https://iem-student.org/2021/11/26/question-of-the-day-65/, date accessed: March 24, 2023

Out of Proportion: Acute Leg Pain

October 18, 2021August 25, 2021 ~ J. Austin Lee, USA ~ Leave a comment

Case Presentation

A 48-year-old male, with history of hypertension and diabetes and prior intravenous drug use (now on methadone) presents with acute onset right leg pain from his calf to the ankle, that woke him from sleep overnight. The pain has been constant, with no modifying or relieving factors. He hasn’t taken anything other than his daily dose of methadone. He hasn’t had any fevers or chills and denies any recent trauma or injuries.

Any thoughts on what else you might want to ask or know?

Any recent travel or prolonged immobilization?
Have you ever had a blood clot?
Are you on any blood thinners?
Have you used IV drugs recently?
Any numbness or weakness in your leg?
Any associated rash or color change?
Any back pain or abdominal pain? Any bowel or bladder incontinence?
Any recent antibiotics (or other medication changes)?
Have you ever had anything like this before?

[all of these are negative/normal]

Pause here -- what is your initial differential diagnosis looking like?

Deep vein thrombosis
Superficial vein thrombosis
Pyomyositis
Necrotizing fasciitis
Muscle sprain or tear
Arterial thromboembolism
Bakers cyst
Achilles tendonitis, Achilles tendon rupture

What are some key parts of your targeted physical exam?

VITAL SIGNS! [BP was slightly hypertensive, and he is slightly tachycardic, normothermic]
Neurologic exam of the affected extremity (motor and sensory)
Vascular exam of the affected extremity (femoral/popliteal/posterior tibialis/dorsalis pedis)
Musculoskeletal exam including ranging the hip, knee, ankle and palpating throughout the entire leg
Skin exam for signs of injury or rashes etc.
Consider a cardiopulmonary and abdominal exam, particularly the lower abdomen

On this patient’s exam, he was overall uncomfortable appearing and had slight tachycardia (110s, EKG shows normal sinus rhythm), normal cardiopulmonary exam, normal abdominal exam. He had a 2+ right femoral pulse and faintly palpable DP pulse that had a good biphasic waveform on doppler. His hip/knee/ankle all have painless range of motion. The compartments are soft in the upper and lower leg. He does have some diffuse calf tenderness and the medial aspect feels slightly cool compared to the contralateral side, but his foot is warm and well perfused. There isn’t any spot that is most tender. There is no rash, no crepitus, no bullae or bruising or other evidence of injury.

What diagnostic studies would you like to send?

CBC, BMP
CPK, lactate
DVT ultrasound?
Anything else?

What treatments would you like to provide?

Analgesia (mutli-modal)?
Maybe a bolus of IV fluids to help with the tachycardia?

The patient is having a lot of pain despite already getting NSAIDs, acetaminophen, and a dose of morphine. You decide to re-medicate the patient with more morphine and send him for DVT ultrasound. As soon as he gets back, he’s frustrated that you still haven’t treated his pain “at all” and he really does look uncomfortable and in a lot of pain. You start to wonder if he’s faking it giving his history of IV drug use.

His DVT ultrasound comes back as normal. The lab work is also coming back and unrevealing. A normal CBC, metabolic panel, normal CPK, normal lactate. His pain is not really improving. You reexamine the leg, and the exam is unchanged. It really seems like his pain is out of proportion to the exam.

Pain is out of proportion to the exam should catch your attention every time. While we always need to keep malingering and less emergent causes for pain that seems to be more than expected in the back of our minds. But! Several emergent diagnoses have patients presenting in pain in a way that doesn’t fit what you can objectively identify as a cause. Diagnoses like compartment syndrome and mesenteric ischemia can be erroneously dismissed by emergency providers, and it is crucial you don’t just stop looking for the cause of pain out of proportion. In fact, it’s important you dig in deeper and rule out all potentially life and limb threatening causes.

In this case, the pain was recalcitrant to multiple doses of IV opiates and several other modes of treatment. The patient was getting so frustrated that he pulled out his IV and threatened to leave the ED. After talking with him further, he agreed to stay and a new IV was placed, more pain medication given, and a CTA with lower extremity run-off was performed, which showed the acute thrombus of the proximal popliteal artery, just below the level of the knee.

He was started on a heparin infusion and vascular surgery was consulted; the patient was admitted from the ED and taken for thrombectomy. No source of embolism was identified, and his occlusion was presumed to be thrombotic (most commonly from a ruptured atheromatous plaque leading to activation of the coagulation cascade), with particular attention to his history of diabetes and hypertension raising his risk for this. He had a fair amount of collateralization from other arteries around the occlusion, such that his foot wasn’t cold, and he had a doppler-able DP pulse.

Remember

Go with your gut and don’t minimize pain that is out of proportion to the exam. Keep hunting for a reasonable explanation or you may miss a life or limb threatening cause of an atypical emergency presentation.

Question Of The Day #5

July 22, 2020July 21, 2020 ~ Joseph Ciano, USA ~ Leave a comment

Which of the following is the most appropriate next step in management for this patient‘s condition?

Explanation

This patient has sustained blunt abdominal trauma from his seat belt. This is indicated by the linear area of ecchymoses, known as a “seat belt sign”. This is a worrisome physical exam finding that should raise a concern about a severe intra-abdominal injury. All trauma patients presenting to the emergency department should be assessed using an organized approach, including a primary survey (“ABCs”) followed by a secondary survey (more detailed physical examination). The FAST (Focused Assessment with Sonography in Trauma) examination is part of the primary survey in a trauma patient. Some sources abbreviate the primary survey in trauma as “ABCDEF”, which stands for Airway, Breathing, Circulation, Disability, Exposure, FAST exam. The primary survey attempts to identify any life-threatening diagnoses that need to be addressed in a time-sensitive manner. Examples include cardiac tamponade, tension pneumothorax, and intra-abdominal bleeding. The FAST exam includes 4 basic views: the right upper quadrant view (liver and right kidney), pelvis view (bladder), left upper quadrant view (spleen and left kidney), and cardiac/subxiphoid view (heart). An E-FAST, or extended FAST, includes the four standard FAST views plus bilateral views of the lungs to evaluate for pneumothorax. An abnormal FAST exam demonstrates the presence of free fluid on ultrasound. In the setting of trauma, free fluid is assumed to be blood. Free fluid on ultrasound appears black, or anechoic (indicated by yellow arrows in below image).

The space between the liver and right kidney (“Morrison’s Pouch”) is often the first location or blood to accumulate in a patient with intra-abdominal bleeding. Trauma patients who are hemodynamically unstable with a positive FAST exam (this patient) should go to the operating room for emergent exploratory laparotomy (Choice C) to determine the source of their bleeding. Performing a CT scan of the abdomen and pelvis (Choice A) would be the correct answer if the patient was hemodynamically stable and had a positive FAST exam. Allowing this patient to leave the emergency department for a CT scan would be dangerous as this patient could rapidly decompensate. Performing a Diagnostic Peritoneal Lavage (Choice B) would be the correct answer if the patient was hemodynamically stable but had a normal FAST exam. An emergent thoracotomy (Choice D) is more typically performed in patients with penetrating trauma who have cardiac arrest shortly before presenting to the emergency department. This intervention attempts to identify and treat any reversible causes of cardiac arrest. Correct Answer: C

Compare your answer with others in Twitter

Which of the following is the most appropriate next step in management for this patient’s condition?
— iem-student (@iem_student) July 21, 2020

References

Butler, M. (2015). “Boring question: What is the role of the FAST exam for blunt abdominal trauma?” Canadiem. https://canadiem.org/boring-question-what-is-the-role-of-the-fast-exam-for-blunt-abdominal-trauma/

Franzen, D. (2016). “FAST examination”. SAEM. https://www.saem.org/cdem/education/online-education/m3-curriculum/bedside-ultrasonagraphy/fast-exam

Cite this article as: Joseph Ciano, USA, "Question Of The Day #5," in International Emergency Medicine Education Project, July 22, 2020, https://iem-student.org/2020/07/22/question-of-the-day-5/, date accessed: March 24, 2023

Triads in Medicine – Rapid Review for Medical Students

June 12, 2020June 7, 2020 ~ Sumaiya Hafiz, UAE ~ Leave a comment

One of the most convenient ways of learning and remembering the main components of disease and identifying a medical condition on an exam are Triads, and medical students/interns/residents swear by them.

Be it a question during rounds, a multiple-choice exam question to be solved, or even in medical practice, the famous triads help physicians recall important characteristics and clinical features of a disease or treatment in an instant.

Since exam season is here, this could serve as a rapid review to recall the most common medical conditions.

While there are a vast number of triads/pentads available online, I have listed the most important (high-yy) ones that every student would be asked about at least once in the duration of their course.

1) Lethal Triad also known as The Trauma Triad of Death
Hypothermia + Coagulopathy + Metabolic Acidosis

2) Beck’s Triad of Cardiac Tamponade
Muffled heart sounds + Distended neck veins + Hypotension

3) Virchow’s Triad – Venous Thrombosis
Hypercoagulability + stasis + endothelial damage

4) Charcot’s Triad – Ascending Cholangitis
Fever with rigors + Right upper quadrant pain + Jaundice

5) Cushing’s Triad – Raised Intracranial Pressure
Bradycardia + Irregular respiration + Hypertension

6) Triad of Ruptured Abdominal Aortic Aneurysm
Severe Abdominal/Back Pain + Hypotension + Pulsatile Abdominal mass

7) Reactive Arthritis
Can’t See (Conjunctivitis) + Can’t Pee (Urethritis) + Can’t Climb a Tree (Arthritis)

8) Triad of Opioid Overdose
Pinpoint pupils + Respiratory Depression + CNS Depression

9) Hakims Triad – Normal Pressure Hydrocephalus
Gait Disturbance + Dementia + Urinary Incontinence

10) Horner’s Syndrome Triad
Ptosis + Miosis + Anydrosis

11) Mackler’s Triad – Oesophageal Perforation (Boerhaave Syndrome)
Vomiting + Lower Thoracic Pain + Subcutaneous Emphysema

12) Pheochromocytoma
Palpitations + Headache + Perspiration (Diaphoresis)

13) Leriche Syndrome
Buttock claudication + Impotence + Symmetrical Atrophy of bilateral lower extremities

14) Rigler’s Triad – Gallstone ileus
Gallstones + Pneumobilia + Small bowel obstruction

15) Whipple’s Triad – Insulinoma
Hypoglycemic attack + Low glucose + Resolving of the attack on glucose administration

16) Meniere’s Disease
Tinnitus + Vertigo + Hearing loss

17) Wernicke’s Encephalopathy- Thiamine Deficiency
Confusion + Ophthalmoplegia + Ataxia

18) Unhappy Triad – Knee Injury
Injury to Anterior Cruciate Ligament + Medial collateral ligament + Medial or Lateral Meniscus

19) Henoch Schonlein Purpura
Purpura + Abdominal pain + Joint pain

20) Meigs Syndrome
Benign ovarian tumor + pleural effusion + ascites

21) Felty’s Syndrome
Rheumatoid Arthritis + Splenomegaly + Neutropenia

22) Cauda Equina Syndrome
Low back pain + Bowel/Bladder Dysfunction + Saddle Anesthesia

23) Meningitis
Fever + Headache + Neck Stiffness

24) Wolf Parkinson White Syndrome
Delta Waves + Short PR Interval + Wide QRS Complex

25) Neurogenic Shock
Bradycardia + Hypotension + Hypothermia

RUSH Course for Medical Students

May 27, 2020July 10, 2020 ~ Arif Alper Cevik ~ Leave a comment

Dear students,

We are pleased to open our third course for you; Rapid Ultrasound in Shock and Hypotension (RUSH).

As a part of our social responsibility initiative, iem-course.org will continue to provide free open online courses related to emergency medicine. We hope our courses help you to continue your education during these difficult times.

Please send us your feedback or requests about courses.

We are here to help you.

Best regards.

Arif Alper Cevik, MD, FEMAT, FIFEM

iEM Course is a social responsibility initiative of iEM Education Project

Hypotension is a high-risk sign which is associated with increased morbidity and mortality rate. The differential diagnosis for hypotension is broad and the treatment depends on the underlying etiology. In most cases of hypotension, patients present with limited history and physical examination may be inaccurate making the management of the condition a great challenge for emergency physicians.

The use of POCUS in undifferentiated hypotension has been shown to help correctly and rapidly identify the etiology and therefore initiate the appropriate management. Since 2001, there are many protocols published describing a systematic approach to the use of POCUS in undifferentiated hypotension.

In this course, we will focus on the Rapid Ultrasound in Shock and Hypotension (RUSH) protocol.

This course aims to provide the necessary information on ultrasonography, its use in a hypotensive patient, and to prepare you for a RUSH practice session.

The course content is prepared and curated from iEM Education chapters, iEM image and video archives, and various FOAMed resources.

At the end of this course, you will be able to;

Describe the basics of ultrasound (terminology, knobology, image acquisition, artifacts, etc.)
Describe indications of RUSH protocol
Describe patient and machine preparations
Describe ultrasound examination views
Recognize normal anatomical structures
Recognize abnormal findings
Feel confident to take a practical session for RUSH protocol

Who can get benefit from this course?

Junior and senior medical students (course specifically designed for these groups)
Interns/Junior emergency medicine residents/registrars

Other Free Online Courses

Cite this article as: Arif Alper Cevik, "RUSH Course for Medical Students," in International Emergency Medicine Education Project, May 27, 2020, https://iem-student.org/2020/05/27/rush-course-for-medical-students/, date accessed: March 24, 2023

eFAST Course for Medical Students

May 18, 2020July 10, 2020 ~ Arif Alper Cevik ~ 6 Comments

Dear students,

We are pleased to open our second course for you; Extended Focused Assessment with Sonography for Trauma (eFAST).

Please send us your feedback or requests about courses.

We are here to help you.

Best regards.

Arif Alper Cevik, MD, FEMAT, FIFEM

iEM Course is a social responsibility initiative of iEM Education Project

Extended Focused Assessment With Sonography In Trauma (eFAST) is one of the most commonly used emergency ultrasound or Point-Of-Care Ultrasound protocols. It is a protocol that we use in trauma patients. However, the eFAST examination can also be a part of another protocol, such as RUSH protocol.

The early diagnosis of a bleeding trauma patient is essential for better patient care. Unfortunately, it is proven that our physical exam findings are not perfect in every case. Therefore, using a bedside tool in addition to the physical examination can improve patient management.

As a 21st-century medical student/young physician, you must learn how to use this tool to provide more comprehensive and accurate care to your patients.

This course aims to provide the necessary information on ultrasonography, its use in a multiply injured trauma patient, and to prepare you for an eFAST practice session.

Cite this article as: Arif Alper Cevik, "eFAST Course for Medical Students," in International Emergency Medicine Education Project, May 18, 2020, https://iem-student.org/2020/05/18/efast-course-for-medical-students/, date accessed: March 24, 2023

Home Made IV Access Ultrasound Phantoms

November 18, 2019November 16, 2019 ~ Masuma Ali Gulamhussein ~ Leave a comment

We recently had the 3rd Tanzanian Conference on Emergency Medicine. Point of Care Ultrasound (PoCUS) training was one of the pre-conference workshops. Ultrasound-guided intravenous cannulation can be very challenging for many doctors in the emergency department.

Therefore, we had a station providing a real-time opportunity to practice IV access using our homemade ultrasound phantoms. And I shall share with you how we came up with this solution.

Ingredients

A plastic container (dimensions used here 8 x 5.5 x 5inches)
Long balloons
Assorted food colors
Gelatin
Metamucil (psyllium)
Powdered household detergent
Spoon, sieve, hand mixer, measuring cup, cooking pot and cooker
Filler syringes
Gloves

How to make your mixture

Take a cooking pot and fill it with 1200 mls of water (we used this as our molding device could accommodate this amount of mls) bring it to a boil (just as it begins to form tiny bubbles on the base add gelatin powder 8 tablespoons and stir with a hand mixer until it completely dissolves. Thereby add 2 tablespoons of Metamucil and 1 tablespoon of detergent and continue stirring with low flame until the mixture begins to thicken. At this point, you will also see foam that sits on top of the mix. Use a sieve to get the foam out. You can, at this point, add any colors that you would want. Let the mixture cool a little before pouring it into the container. As it cools, you will notice it becoming thicker.

How to set-up your mold/containers

You will need to make a hole on both ends on the container using a hand drill or a hot pointed knife. For this case, since we didn’t have a drill, we used a knife with a pointed tip – heated it up in a burner until it was hot enough and used it to make holes through the plastic container using a circular motion. It is important for the holes not to be too big but estimated to the caliber/ diameter of the long balloons since we need just enough space to pass the balloons across.

For our case, we made 4 holes, 2 on each end. But you can do more if you want. You can arrange balloons in superficial or deeper locations.

To setup the vessels using the long balloons, you will need half cup of water and red color dye. Mix just enough to make a mixture that looks like blood. This can be filled in the balloons with a syringe. Since the color dye can stain your fingers, it is important to use gloves just to prevent your fingers from staining.

Tip: To make an artery, you can fill the balloon much more so that there is minimal compressibility and for the vein, you can fill just enough and have room for compressibility. Don’t fill the balloons before passing it through the container; if you do this, the filled balloon won’t manage to fit into the holes. Once fixed, tie both ends to make knots that are big enough to cover the seal the holes made.
Before pouring the mixture into the container, spray it with some oil, or you can use a cloth dip it in oil and apply it on the inside of the container.

After that, pour your mixture in the container and let it cool. You can place it in the refrigerator and use it the next day. We left ours for 24 hrs prior use.

You can use silicone seals at the holes if you notice to have any leaks. Otherwise, if you don’t have this, you can use plastic food wrap to create a seal between the balloon knots and the container just so the mixture does not leak out until it has set.

And finally, the images that you will have on ultrasound.

Cite this article as: Masuma Ali Gulamhussein, "Home Made IV Access Ultrasound Phantoms," in International Emergency Medicine Education Project, November 18, 2019, https://iem-student.org/2019/11/18/home-made-iv-access-ultrasound-phantoms/, date accessed: March 24, 2023

Interview – Vicky Noble – US training in medical schools

April 15, 2019April 17, 2019 ~ iEM Education Project Team ~ Leave a comment

We interviewed with world renowned emergency and critical care US expert “Vicky Noble” about US training in medical schools.

https://youtu.be/3Bh2uCyESuM

Read US Chapters and Posts

Medical students’ ultrasound training – SURVEY

There are many studies showing benefits of ultrasound training about …

iEM Education Project Team
February 18, 2019

Kunafa Knife and Play Dough for Ultrasound Training

Around two years ago, Prof. Abu-Zidan came with a plastic …

Arif Alper Cevik
February 11, 2019

eFAST

by Ashley Bean, Brian Hohertz and Gregory R. Snead
Introduction
The objective …

iEM Education Project Team
May 2, 2018

PoCUS – RUSH Protocol

by Rasha Buhumaid
Why use POCUS in undifferentiated hypotension?
Hypotension is a …

iEM Education Project Team
May 2, 2018

Bat Sign

February 18, 2019February 11, 2019 ~ iEM Education Project Team ~ Leave a comment

Dear students/interns, learn ultrasonographic anatomy and clinical ultrasound basics to improve your decision making processes.

The bat sign is critical for correct identification of the pleural line. Always begin lung ultrasound by identifying the bat sign before proceeding to look for artifacts and pathologies.

This sign is formed when scanning across 2 ribs with the intervening intercostal space.

The wings are formed by the 2 ribs, casting an acoustic shadow. The body is the first continuous horizontal hyperechoic line that starts below one rib and extends all the way to the other. (see above video) The body is the pleural line, i.e., parietal pleural. Normally, the pleural line is opposed to and hence indistinguishable from the lung line (formed by the visceral pleura).