Midclavicular Line Research Articles

Local infiltration versus laparoscopic-guided transverse abdominis plane block in laparoscopic cholecystectomy: double-blinded randomized control trial.

Transverse abdominal plane block (TAP) is a new technique of regional block described to reduce postoperative pain in laparoscopic cholecystectomy (LC). Recent reports describe an easy technique to deliver local anesthetic agent under laparoscopic guidance. This randomized control trial was designed to compare the effectiveness of additional laparoscopic-guided TAP block against the standard full thickness port site infiltration. 45 patients were randomized in to each arm after excluding emergency LC, conversions, ones with coagulopathy, pregnancy and allergy to local anesthetics. All cases were four ports LC. Interventions-Both groups received standard port site infiltration with 3-5ml of 0.25% bupivacaine. The test group received additional laparoscopic-guided TAP block with 20ml of 0.25% bupivacaine subcostally, between the anterior axillary and mid clavicular lines. As outcome measures the pain score, opioid requirement, episodes of nausea and vomiting and time to mobilize was measured at 6 hourly intervals. The two groups were comparable in the age, gender, body mass index, indication for cholecystectomy difficulty index and surgery duration. The pain score at 6h (P = 0.043) and opioid requirement at 6h (P = 0.026) was higher in the TAP group. These were similar in subsequent assessments. Other secondary outcomes were similar in the two groups. Laparoscopic-guided transverses abdominis plane block using plain bupivacaine does not give an additional pain relief or other favorable outcomes. It can worsen the pain scores. Pre registration: The trial was registered in Sri Lanka clinical trial registry-SLCTR/2016/011 ( http://www.slctr.lk/trials/357 ).

Using a Cadaveric Model to Map the Epigastric Artery [39O

INTRODUCTION: Injury of the vessels of the anterior abdominal wall occurs in 0.2-2% of laparoscopic surgeries. The purpose of this study is to use surface landmarks on the abdominal wall of cadaver models to map out areas of safe trocar placement to avoid the inferior and superior epigastric arteries. METHODS: The inferior and superior epigastric arteries were dissected bilaterally in twenty formalin fixed cadavers. The rectus sheath was divided for adequate exposure of the entire length of the arteries from the pubic bone to the costal margin. Two reference points were defined. Point A was halfway between the umbilicus and the anterior superior iliac spine. Point B was 3cm below the costal margin on the midclavicular line (known as Palmer’s point on the left side). The distance from point A and point B to the inferior epigastric artery and superior epigastric artery, respectively, were measured bilaterally. RESULTS: Twenty formalin-fixed cadavers were dissected, for a total of forty epigastric arteries. Twelve female and eight male cadavers were included. The mean distance from point A to the inferior epigastric artery was 1.6 +/- 1.0 cm. The artery was always on or medial to point A. The mean distance from point B to the superior epigastric artery was 1.1 +/- 0.6 cm. The artery was always on or medial to point B. CONCLUSION: In trocar placement during laparoscopic surgery, staying lateral to a vertical line drawn from point A to point B is very likely to avoid the inferior and superior epigastric artery.

V09-05 SIX-WEEK-OLD INFANT ROBOTIC PYELOPLASTY: KEY POINTS FOR SAFETY AND PROFICIENCY

You have accessJournal of UrologyPediatric Urology1 Apr 2018V09-05 SIX-WEEK-OLD INFANT ROBOTIC PYELOPLASTY: KEY POINTS FOR SAFETY AND PROFICIENCY Maria Veronica Rodriguez, Nimrod Barashi, Joseph Rodriguez, and Mohan S Gundeti Maria Veronica RodriguezMaria Veronica Rodriguez More articles by this author , Nimrod BarashiNimrod Barashi More articles by this author , Joseph RodriguezJoseph Rodriguez More articles by this author , and Mohan S GundetiMohan S Gundeti More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.2177AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Ureteropelvic junction obstruction (UPJO) is one of the most common pediatric urologic congenital anomalies. Anderson-Hynes dismembered pyeloplasty has been the gold standard for the intervention of this pathology. Nowadays, robotic surgery has provided a safe alternative to manage these patients with minimally invasive surgery and, even though the procedure is frequently performed by pediatric urologists across the US, there is still a steep learning curve to perform infant robotic pyeloplasty. We aim to describe a robotic-assisted laparoscopic pyeloplasty in a 6-week-old patient with grade 4 hydronephrosis and UPJO in addition to key technical points for safety and proficiency. METHODS The crucial points are patient positioning, proper port placement; particularly the inferior working ports, given the close proximity to the bladder, instrumentation and docking and the inherent bowel distension that children usually have. We present a robotic pyeloplasty in a 6-week old infant with UPJO. The patient was placed in a lateral position, close to the edge of the table. With an open Hassan technique approach, a 12-mm umbilical camera port and two 8-mm ports were placed in the midline in addition to a 5-mm assistant port that was positioned on the lower midclavicular line. There was a distended bowel, therefore an orogastric tube was placed to improve visualization and avoid bowel injury. The Gerota's fascia was incised and the pelvis was hitched with a subcutaneous suture. Then, the narrow ureteropelvic junction was recognized and the pelvis was transected just below the renal hilum vessels, which was followed by ureter spatulation. Ultimately, the anastomosis of the posterior wall with the spatulated ureter was performed in a continuous fashion and subsequently, a double J stent was placed percutaneously to complete the anterior wall anastomosis. RESULTS The patient tolerated the procedure well and was discharged on postoperative day 2 without any complications. Operative time was 143 minutes and, estimated blood loss was found to be less than 5 mL. The Foley catheter was removed prior to discharge. At 1 month follow-up, the patient had well healed abdominal surgical incisions, the double J stent was removed and, his renal bladder ultrasound scan showed improvement of the hydronephrosis. CONCLUSIONS We emphasize the key points for safety and proficiency when performing a robotic infant pyeloplasty, given our long-term institutional experience doing robotic surgery in such young patients to optimize outcomes and prevent complications. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e904 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Maria Veronica Rodriguez More articles by this author Nimrod Barashi More articles by this author Joseph Rodriguez More articles by this author Mohan S Gundeti More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Lung ultrasound surface wave elastography for assessing interstitial lung disease

A lung ultrasound surface wave elastography (LUSWE) technique is developed for assessing interstitial lung disease (ILD). In LUSWE, a 0.1 second harmonic vibration is generated on the chest wall of a subject using a handheld vibrator. An ultrasound probe is aligned with the vibration indenter in the same intercostal region to measure the generated surface wave speed of the lung. A human subject is examined in a sitting position. The lung is tested at the total lung volume. The upper anterior lungs are tested through the second intercostal space in the mid-clavicular line. The lower lateral lungs are tested in the mid-axillary line and the lower posterior lungs are tested in the mid-scapular line. In a prospective clinical study, we measure both lungs through the six intercostal regions for patients and healthy controls. The surface wave speed is measured at 100 Hz, 150 Hz, and 200 Hz. Significant differences of wave speed between patients and controls were found in all lung regions at all frequencies. We also found positive correlation between LUSWE and CT analyses. LUSWE is a safe and noninvasive technique for generating and measuring surface wave propagation on the lung. LUSWE may be useful for assessing ILD.A lung ultrasound surface wave elastography (LUSWE) technique is developed for assessing interstitial lung disease (ILD). In LUSWE, a 0.1 second harmonic vibration is generated on the chest wall of a subject using a handheld vibrator. An ultrasound probe is aligned with the vibration indenter in the same intercostal region to measure the generated surface wave speed of the lung. A human subject is examined in a sitting position. The lung is tested at the total lung volume. The upper anterior lungs are tested through the second intercostal space in the mid-clavicular line. The lower lateral lungs are tested in the mid-axillary line and the lower posterior lungs are tested in the mid-scapular line. In a prospective clinical study, we measure both lungs through the six intercostal regions for patients and healthy controls. The surface wave speed is measured at 100 Hz, 150 Hz, and 200 Hz. Significant differences of wave speed between patients and controls were found in all lung regions at all frequencies. We ...

Robotic choledocoduodenostomy

Background: This video documents a robotic choledocoduodenstomy undertaken in a 59-year- old woman. Methods: The patient presented with chronic right upper abdominal visceral pain and elevated bilirubin. Preoperative workup, including a CT scan and MRI, uncovered the existence of a mild to moderate dilation of the common bile duct (11 mm) with debris present in the distal common bile duct. Results: The patient was taken to the operating room and prepared for the procedure. An 8 mm trocar was placed through the umbilicus for the robotic camera and two 8 mm robotic ports were placed at the right and left midclavicular lines on the same level as the umbilicus. The operation began with the lysis of adhesions followed by an extended Kocher maneuver. Next, a small incision was made along the length of the common bile duct on its ventral side. A biliary Fogarty was placed up the common bile duct toward the common hepatic duct, into the left hepatic duct, and then into the right hepatic duct. Then a choledocoscope was a placed up both the left and right hepatic duct and then down into the duodenum. Then the anastomosis was constructed. Conclusion: The patient tolerated the operation well and went home on postop day 1.

Positional relationship between the pectoralis major and external abdominal oblique muscles for consideration during dual-plane breast augmentation.

During dual plane breast augmentation (DPBA), the costal origin of the pectoralis major (the PM) should be cut to ensure appropriate coverage and positioning of an implant. However, surgeons sometimes make inappropriate planar incisions and insufficient muscular incisions because the external abdominal oblique (the EAO) muscle partially overlaps the lateral portion of the PM. The goal of this study was to clarify the positional relationship between the PM and EAO with the aim of improving the accuracy of implant and muscular incisions during DPBA. Forty sides of 20 embalmed and fresh cadavers were dissected. The midline and midclavicular line (MCL) were used as reference lines for measurements. We clarified the overlapping patterns between the PM and EAO, and measured the distances from the MCL to the borders of those two muscles. The costal part of the PM originated from the 5th (25%), 6th (70%), or 7th rib (5%), respectively. The distances from the MCL to the lateral border of the PM at the 4th, 5th, and 6th ribs were 49.8 mm, 30.5 mm, and 6.3 mm, respectively. In 90% of the specimens, the PM and the EAO overlapped near the MCL. The width of the overlapping portion between the PM and EAO was about 25 mm. This study is one of the first to suggest an innovative approach for explaining the positional relationships between the PM and EAO. Our findings can be useful for surgeons attempting to produce optimal outcomes in DPBA, especially in procedures that involve patients of different races. Clin. Anat. 31:339-346, 2018. © 2018 Wiley Periodicals, Inc.

Ultrasound B-lines for detection of late lung fibrosis in breast cancer patients after radiation therapy.

Radiation therapy (RT) for breast cancer after conservative surgery can be life-saving but remains associated with significant late side effects, including lung fibrosis, detected by chest CT. Aim of this study was to assess whether lung ultrasound (LUS) may detect late lung fibrosis through the biomarker of B-lines. We evaluated 30 women (median age 67 years, range 46-80 years) about 3-8 years after RT (follow up 38-101 months, median 58 months) for left (n = 12) or right (n = 18) breast cancer (stage 1, n = 24; stage 2, n = 6), treated with total dose 40.5 - 50.00 Gy with/without boost dose). In all, both treated and contralateral hemithorax were evaluated. LUS was performed and B-lines evaluated with a 28-region antero-lateral scan, from second to fifth intercostal spaces, along the mid-axillary, anterior axillary, mid-clavicular, and parasternal lines. In each space, the B-lines were counted from 0 = black lung to 10 = white lung. The sum of B-lines in all spaces generated the B-line score of each hemithorax. Median B-line score was higher in the irradiated site than in the contralateral control hemithorax (9, 1st-3rd quartiles: 2-23 vs 3, 1st-3rd quartiles: 1-4; P < 0.05). In the treated hemithorax, higher mean lung doses ( > median value of 2.7 Gy) were associated with more B-lines when compared to lower doses (< 2.7 Gy): 9 vs 5, p <0.001. RT in female breast cancer survivors is associated with increase in B-lines in the targeted hemithorax, likely due to lung fibrosis, and related to the lung mean dose. LUS can provide a simple "echo-marker" of lung fibrosis.

Optimal Initial Trocar Placement for Morbidly Obese Patients.

Background and Objectives:Rates of morbid obesity are skyrocketing worldwide. Not only bariatric surgeons, but also general surgeons are often operating on morbidly obese patients. Many general surgeons still use the same anatomic landmarks for patients with body mass index (BMI) over 35 mg/kg2 as they do for patients of normal weight and can therefore find accessing the morbidly obese abdominal organs difficult. This paper will describe a technique that is easily reproducible and applicable in a wide range of laparoscopic cases.Method:The xiphoid process is the only landmark referenced. From the xiphoid process, the surgeon puts 2 fists together and places the first trocar inferiorly 2 cm lateral to the midline in either direction. The umbilicus is not used as a landmark. This placement is 15–18 cm inferior to the xiphoid process, but allows adequate visualization for any foregut case. An optical trocar is used.Results:In over 1400 bariatric cases, the initial trocar was safely placed with this technique. Most of these cases were performed with the method, but some had one modification: the first trocar was placed in the midclavicular line in the subcostal area if there were previous midline scars. In no cases was an extra-long, or bariatric, trocar used.Conclusions:Laparoscopic access in morbidly obese patients does not have to be difficult. Using an optical trocar off the midline 15–18 cm below the xiphoid process will provide reliable, safe access in the morbidly obese patient, with excellent visualization of the target anatomy.

Management of Suspected Tension Pneumothorax in Tactical Combat Casualty Care: TCCC Guidelines Change 17-02

This change to the Tactical Combat Casualty Care (TCCC) Guidelines that updates the recommendations for management of suspected tension pneumothorax for combat casualties in the prehospital setting does the following things: (1) Continues the aggressive approach to suspecting and treating tension pneumothorax based on mechanism of injury and respiratory distress that TCCC has advocated for in the past, as opposed to waiting until shock develops as a result of the tension pneumothorax before treating. The new wording does, however, emphasize that shock and cardiac arrest may ensue if the tension pneumothorax is not treated promptly. (2) Adds additional emphasis to the importance of the current TCCC recommendation to perform needle decompression (NDC) on both sides of the chest on a combat casualty with torso trauma who suffers a traumatic cardiac arrest before reaching a medical treatment facility. (3) Adds a 10-gauge, 3.25-in needle/ catheter unit as an alternative to the previously recommended 14-gauge, 3.25-in needle/catheter unit as recommended devices for needle decompression. (4) Designates the location at which NDC should be performed as either the lateral site (fifth intercostal space [ICS] at the anterior axillary line [AAL]) or the anterior site (second ICS at the midclavicular line [MCL]). For the reasons enumerated in the body of the change report, participants on the 14 December 2017 TCCC Working Group teleconference favored including both potential sites for NDC without specifying a preferred site. (5) Adds two key elements to the description of the NDC procedure: insert the needle/ catheter unit at a perpendicular angle to the chest wall all the way to the hub, then hold the needle/catheter unit in place for 5 to 10 seconds before removing the needle in order to allow for full decompression of the pleural space to occur. (6) Defines what constitutes a successful NDC, using specific metrics such as: an observed hiss of air escaping from the chest during the NDC procedure; a decrease in respiratory distress; an increase in hemoglobin oxygen saturation; and/or an improvement in signs of shock that may be present. (7) Recommends that only two needle decompressions be attempted before continuing on to the "Circulation" portion of the TCCC Guidelines. After two NDCs have been performed, the combat medical provider should proceed to the fourth element in the "MARCH" algorithm and evaluate/treat the casualty for shock as outlined in the Circulation section of the TCCC Guidelines. Eastridge's landmark 2012 report documented that noncompressible hemorrhage caused many more combat fatalities than tension pneumothorax.1 Since the manifestations of hemorrhagic shock and shock from tension pneumothorax may be similar, the TCCC Guidelines now recommend proceeding to treatment for hemorrhagic shock (when present) after two NDCs have been performed. (8) Adds a paragraph to the end of the Circulation section of the TCCC Guidelines that calls for consideration of untreated tension pneumothorax as a potential cause for shock that has not responded to fluid resuscitation. This is an important aspect of treating shock in combat casualties that was not presently addressed in the TCCC Guidelines. (9) Adds finger thoracostomy (simple thoracostomy) and chest tubes as additional treatment options to treat suspected tension pneumothorax when further treatment is deemed necessary after two unsuccessful NDC attempts-if the combat medical provider has the skills, experience, and authorizations to perform these advanced interventions and the casualty is in shock. These two more invasive procedures are recommended only when the casualty is in refractory shock, not as the initial treatment.

Ultrasound measurement of liver longitudinal length in a North Anatolian population: A community-based study.

Liver size can be influenced by various factors, including malignant diseases, infective processes, and anthropometric variations among individuals from different geographical locations and races. Therefore, the exact definition of hepatomegaly in the ultrasonographic measurement of liver size is controversial. Moreover, the majority of studies regarding the study of liver size are not community-based. The aim of this study is to establish a range of normal liver sizes by ultrasonography with respect to age and sex in healthy individuals and to identify factors affecting liver size. This was a prospective, community-based study. Liver size was measured ultrasonographically from the midclavicular line in 822 individuals, of which 49.3% (n = 405) were male and 51.7% (n = 417) were female. Following physical examination, all participants provided blood samples. Height, weight, and waist circumference were recorded. The mean liver length was calculated for males, females, and for the whole study group. It was also determined whether there was an association between liver size and age, weight, height, body mass index (BMI), body surface area, alanine aminotransferase (ALT), and aspartate aminotransferase (AST) enzyme levels. Results: The mean liver length was significantly different between males (150.04 ± 14.84) and females (147.57 ± 18.32, P = 0.034). Weight and BMI were the most strongly associated with liver size. There was a significant difference between liver size in individuals with normal and elevated levels of AST and ALT enzymes (P < 0.01). In a northern Anatolian Turkish population, liver size was greater among males than females. In light of these data, we believe our study may serve as a reference source for the evaluation of liver size.

Treatment Outcome of Children With Multisystem Langerhans Cell Histiocytosis: The Experience of a Single Children's Hospital in Shanghai, China.

We reported the outcome of 150 children newly diagnosed with multisystem langerhans cell histiocytosis following a langerhans cell histiocytosis-II-based protocol (arm B). However, the continuation treatment was extended to 56 weeks and etoposide was omitted from the continuation treatment. Risk organ (RO) involvement was defined as: liver (≥3 cm with or without functional impairment); spleen (≥2 cm below the costal margin in the midclavicular line); hematopoietic system (hemoglobin <100 g/L, and/or white blood cell count <4.0×10/L, and/or platelets <100×10/L). The lungs are not considered a RO in the current study. For the 59 patients with RO involvement (RO+), the rapid response rate (week 6) was 61.0% and the 3-year overall survival 73.4%±5.9%. Rapid responders had a better 3-year survival rate than poor responders (90.9%±5.0% vs. 45.7%±11.0%, P<0.001). Ninety-one patients without RO involvement (RO-) had a relatively low 3-year cumulative reactivation rate (10.7%). No deaths occurred in this subgroup and the 3-year overall survival of RO- patients was 100%. Poor responders of RO+ patients had an extremely poor prognosis. An effective salvage therapy is essential for this high-risk group. The initial treatment intensity and duration of continuation therapy both impact disease reactivation in RO- patients.

Intercostal Nerve to Long Thoracic Nerve Transfer for the Treatment of Winged Scapula: A Cadaveric Feasibility Study.

There are very few surgical options available for treating a patient with winged scapula caused by a long thoracic nerve (LTN) injury. Therefore, we devised a novel technique based on a cadaveric dissection whereby regional intercostal nerves (ICN) were harvested and transposed to the adjacent LTN in 10 embalmed cadavers (20 sides). The LTN was identified along the lateral border of the serratus anterior and ICNs were identified at the mid-axillary line inferior to the lower edge of the pectoralis major muscle. Along the mid-clavicular line, each ICN was transected and transposed to the adjacent LTN. The length and diameter of each ICN available for mobilization to the LTN were measured. All measurements were made with microcalipers. Within the operative site, the mean proximal and distal diameters of the LTN were 1.6 and 1.1 mm, respectively. The adjacent ICN had a mean diameter of 1.3 mm. On all sides, the ICN branches were easily transposed to the adjacent LTN without any tension. Anastomosis to the LTN was performed to the third through sixth ICN provided each intercostal was preserved and mobilized anteriorly at least as far as the midclavicular line. The end to end size match between donor and LTN was appropriate on all sides. We found that it is feasible to harvest adjacent ICNs and move these to the adjacent LTN. Such a procedure, after being confirmed in patients, might offer a new technique for restoring protraction following an LTN injury.

370 The Relationship Between Adult Body Mass Index and Anticipated Failure Rate of Needle Decompression Using a 5 cm Needle for Tension Pneumothorax

Tension pneumothorax is traumatic injury that can lead to rapid circulatory collapse and death. Emergent needle thoracostomy can quickly treat tension pneumothorax, but the best anatomic location and catheter length necessary to perform the intervention has been questioned in the recent years given the increasing rates of obesity in our population. We conducted a retrospective review of a convenience sample of all trauma patients admitted to our level 1 trauma center in Minneapolis, MN who underwent chest computed tomography (CT) during their admission between 2011 and 2012. Using these CT radiographs, chest wall thickness was measured bilaterally at the 2nd intercostal space (ICS) at the midclavicular line, and at the 4th and 5th intercostal spaces at the anterior axillary line. Baseline demographic data including age, sex, BMI, ISS and associated chest wall trauma were collected from medical chart review. Needle thoracostomy failure was defined as chest wall thickness (CWT) of > 5cm, based on the length of commonly used needle decompression needles. 141 patients who met all inclusion criteria were identified. There were no significant differences in mean CWT at any of the anatomic sites. CWT was similar between males and females. BMI > 30 was associated with an adjusted odds ratio of 13.8 (confidence interval 4.8-39.8) for failure with a standard 5cm catheter needle decompression. In the increasingly obese general population, needle thoracostomy with a standard 5cm needle may be more prone to failure. Adult BMI > 30 is a significant risk factor for anticipated failure of needle tube decompression. Alternative anatomic sites for needle decompression did not appear to increase the anticipated success of the intervention.

B-lines with Lung Ultrasound: The Optimal Scan Technique at Rest and During Stress

Various lung ultrasound (LUS) scanning modalities have been proposed for the detection of B-lines, also referred to as ultrasound lung comets, which are an important indication of extravascular lung water at rest and after exercise stress echo (ESE). The aim of our study was to assess the lung water spatial distribution (comet map) at rest and after ESE. We performed LUS at rest and immediately after semi-supine ESE in 135 patients (45 women, 90 men; age 62 ± 12 y, resting left ventricular ejection fraction = 41 ± 13%) with known or suspected heart failure or coronary artery disease. B-lines were measured by scanning 28 intercostal spaces (ISs) on the antero-lateral chest, 2nd–5th IS, along with the midaxillary (MA), anterior axillary (AA), mid-clavicular (MC) and parasternal (PS) lines. Complete 28-region, 16-region (3rd and 4th IS), 8-region (3rd IS), 4-region (3rd IS, only AA and MA) and 1-region (left 3rd IS, MA) scans were analyzed. In each space, the B-lines were counted from 0 = black lung to 10 = white lung. Interpretable images were obtained in all spaces (feasibility = 100 %). B-lines (>0 in at least 1 space) were present at ESE in 93 patients (69%) and absent in 42. More B-lines were found in the 3rd IS and along AA and MA lines. The B-line cumulative distribution was symmetric at rest (right/left = 1.10) and asymmetric with left lung predominance during stress (right/left = 0.67). The correlation of per-patient B-line number between 28-S and 16-S (R2 = 0.9478), 8-S (R2 = 0.9478) and 4-S scan (R2 = 0.9146) was excellent, but only good with 1-S (R2 = 0.8101). The average imaging and online analysis time were 5 s per space. In conclusion, during ESE, the comet map of lung water accumulation follows a predictable spatial pattern with wet spots preferentially aligned with the third IS and along the AA and MA lines. The time-saving 4-region scan is especially convenient during stress, simply dismissing dry regions and focusing on wet regions alone.

Desperate times call for desperate measures

It is 5 pm on New Year’s Eve and you are on service as an emergency physician in training for the London Helicopter Emergency Medical Service (HEMS). The London Ambulance Service Control informs you of a stabbing incident in the town of Watford, England. Your helicopter arrives on the scene 10 minutes after the call and 13 minutes after the incident, along with land ambulance and police. After the scene is declared safe, you are directed to the patient, JJ, a 24-year-old male who has suffered a stabbing outside of a local bar. His friend, who made the call to EMS, tells you JJ lost consciousness about 3 minutes after the insult. The patient has no signs of life, with no palpable carotid pulse or measurable blood pressure. He is apneic and his pupils are fixed and dilated. You notice a 2-cm wound in the midclavicular line, just superior to the left nipple, consistent with a penetrating stab wound. Cardiac monitors are attached and show an initial rhythm of asystole. Closed cardiac massage is undertaken immediately with rescue breaths given using bag-valve-mask. Simultaneously, the patient is cannulated in both antecubital fossae and is administered 1 mg adrenaline with 1000 mL 0.9% saline. Emergent decompressive needle thoracotomy is performed on the left chest by placing a 14-gauge, 3.5-inch angiographic catheter into the chest cavity at the midclavicular line in the second interspace. There is no release of air but periodic bubbles and blood appear to come from the left lung. After 2 minutes of unsuccessful CPR, there is still no palpable pulse and you notice the patient’s neck veins are distended, with normal air entry and no dullness to percussion in the left hemithorax. Your helicopter is about 10 minutes away from the nearest major trauma centre.

Intracardiac electrocardiographic assessment of precordial TASER shocks in human subjects: A pilot study

BackgroundCase reports of cardiac arrest in temporal proximity to Conducted Electrical Weapon(CEW) exposure raise legitimate concerns about this as a rare possibility. In this pilot study, we respectfully navigate the oversight and regulatory hurdles and demonstrate the intra-shock electrocardiographic effects of an intentional transcardiac CEW discharge using subcutaneous probes placed directly across the precordium of patients with a previously implanted intracardiac EKG sensing lead. MethodsAdults scheduled to undergo diagnostic EP studies or replacement of an implanted cardiac device were enrolled. Sterile subcutaneous electrodes were placed at the right sternoclavicular junction and the left lower costal margin at the midclavicular line. A standard police issue TASER Model X26 CEW was attached to the subcutaneous electrodes and a 5 s discharge was delivered. Continuous surface and intracardiac EKG monitoring was performed. ResultsA total of 157 subjects were reviewed for possible inclusion and 21 were interviewed. Among these, 4 subjects agreed and completed the study protocol. All subjects tolerated the 5 s CEW discharge without clinical complications. There were no significant changes in mean heart rate or blood pressure. Interrogation of the devices after CEW discharge revealed no ventricular pacing, dysrhythmias, damage or interference with the implanted devices. ConclusionsIn this pilot study, we have successfully navigated the regulatory hurdles and demonstrated the feasibility of performing intracardiac EKG recording during intentional precordial CEW discharges in humans. While no CEW-associated dysrhythmias were noted, the size of this preliminary dataset precludes making conclusions about the risk of such events. Larger studies are warranted and should consider exploring variations of the CEW electrode position in relation to the cardiac silhouette.

Kartagener’s Syndrome: Presenting in Fourth Decade

Kartagener’s Syndrome (KS) is a rare ciliopathic autosomal recessive genetic disorder characterized by a triad of situs inversus, bronchiectasis, and chronic sinusitis. Although Siewart first described this condition in 1904, it was Kartagener -a Swiss pediatrician, who recognized the etiological correlation between elements of the triad and reported four cases in 1933 1. It is a type of Primary Ciliary Dyskinesia (PCD). The frequency of KS is 1:32,000 to 1:50,000 live births. A 40-year-old male patient presented to the emergency department with complaints of fever, productive cough, dyspnea, and headache. He had a history or a recurrent cough for ten years with multiple hospitalizations. The patient had been married for 15 years and still had no offsprings for which he had been investigated previously which was suggestive of azoospermia. He was febrile with normal other vitals accept his respiratory rate which was 28 per minute with 88% saturation on room air. Apex beat could be localized on 5th ics right side on mid clavicular line. On percussion, heart borders were confirmed on the right side with liver dullness on left side. On auscultation, S1S2 were heard on the right side with coarse, leathery crepitations on inspiration and rhonchi on expiration.On investigating further his ECG showed features of dextrocardia and chest roentgenography was suggestive of dextrocardia with aortic arch on right side of the trachea with gastro-hepatic transposition suggestive of situs inversus with bronchietatic changes. Further High resolution computed tomography was done to confirm those findings along with ultrasound of abdomen which showed liver in left upper quadrant and spleen in right upper quadrant. A skull roentgenogram was also done which was suggestive of sinusitis.The ‘nasal saccharin transit time’ test gave mucociliary clearance time of 60 minutes (Normal < 30 minutes). Thus patient was diagnosed with Kartagener’s syndrome clinically and also on the basis of investigations. The patient was treated with oral steroids, bronchodilators, mucolytics, and antibiotics and over the course of 10 days patient gradually recovered and was discharged.

Relative device stability of anterior versus axillary needle decompression for tension pneumothorax during casualty movement: Preliminary analysis of a human cadaver model.

Tension pneumothorax (tPTX) remains a significant cause of potentially preventable death in military and civilian settings. The current prehospital standard of care for tPTX is immediate decompression with a 14-gauge 8-cm angiocatheter; however, failure rates may be as high as 17% to 60%. Alternative devices, such as 10-gauge angiocatheter, modified Veress needle, and laparoscopic trocar, have shown to be potentially more effective in animal models; however, little is known about the relative insertional safety or mechanical stability during casualty movement. Seven soft-embalmed cadavers were intubated and mechanically ventilated. Chest wall thickness was measured at the second intercostal space at the midclavicular line (2MCL) and the fifth intercostal space along the anterior axillary line (5AAL). CO2 insufflation created a PTX, and needle decompression was then performed with a randomized device. Insertional depth was measured between hub and skin before and after simulated casualty transport. Thoracoscopy was used to evaluate for intrapleural placement and/or injury during insertion and after movement. Cadaver demographics, device displacement, device dislodgment, and injuries were recorded. Three decompressions were performed at each site (2MCL/5AAL), totaling 12 events per cadaver. Eighty-four decompressions were performed. Average cadaver age was 59 years, and body mass index was 24 kg/m. The CWT varied between cadavers because of subcutaneous emphysema, but the average was 39 mm at the 2MCL and 31 mm at the 5AAL. Following movement, the 2MCL site was more likely to become dislodged than the 5AAL (67% vs. 17%, p = 0.001). Median displacement also differed between 2MCL and 5AAL (23 vs. 2 mm, p = 0.001). No significant differences were noted in dislodgement or displacement between devices. Five minor lung injuries were noted at the 5AAL position. Preliminary results from this human cadaver study suggest the 5AAL position is a more stable and reliable location for thoracic decompression of tPTX during combat casualty transport. Therapeutic study, level III.

A reappraisal of pediatric thoracic surface anatomy.

Accurate knowledge of surface anatomy is fundamental to safe clinical practice. A paucity of evidence in the literature regarding thoracic surface anatomy in children was identified. The associations between surface landmarks and internal structures were meticulously analyzed by reviewing high quality computed tomography (CT) images of 77 children aged from four days to 12 years. The results confirmed that the sternal angle is an accurate surface landmark for the azygos-superior vena cava junction in a plane through to the level of upper T4 from birth to age four, and to lower T4 in older children. The concavity of the aortic arch was slightly below this plane and the tracheal and pulmonary artery bifurcations were even lower. The cardiac apex was typically at the 5th intercostal space (ICS) from birth to age four, at the 4th ICS and 5th rib in 4-12 year olds, and close to the midclavicular line at all ages. The lower border of the diaphragm was at the level of the 6th or 7th rib at the midclavicular line, the 7th ICS and 8th rib at the midaxillary line, and the 11th thoracic vertebra posteriorly. The domes of the diaphragm were generally flatter and lower in children, typically only one rib level higher than its anterior level at the midclavicular line. Diaphragm apertures were most commonly around the level of T9, T10, and T11 for the IVC, esophagus and aorta, respectively. This is the first study to provide an evidence-base for thoracic surface anatomy in children. Clin. Anat. 30:788-794, 2017. © 2017Wiley Periodicals, Inc.

Evaluation of Monaldi’s approach with regard to needle decompression of the tension pneumothorax—A cadaver study

BackgroundAlthough needle decompression of tension pneumothorax through the second intercostal space in the midclavicular line (Monaldi’s approach) is a life-saving procedure, severe complications have been reported after its implementation. We evaluated the procedure by comparing how it was performed on cadavers by study participants with different training levels. MethodsSix participants including one thoracic surgeon performed bilateral thoracic drainage after Monaldi on 82 torsos. After the thoraces were opened, the distances from the internal thoracic artery (A), the site of the puncture (B) and the midclavicular line (C) were measured bilaterally with reference to the median of the sternum. Further, it was determined whether the participants had correctly identified the second intercostal space. The differences between B-A and C-B were analysed. ResultsThe needle was placed in the second intercostal space in 136 hemithoraces (83%). The thoracic surgeon showed a hit rate of 0% laceration of adjacent vessels. All the other participants had hit rates between 10% and 15%. The interval B-A ranged from 2.88 to 5.06cm in right and from 3.00 to 5.00cm in left hemithoraces. The distance C-B lay between 1.03cm and 1.87cm (right side), and 0.84cm and 2.02cm (left side). ConclusionIn our collective, the main problem was failure to assess correctly the lateral extension of the clavicle. If this fact is emphasized during training, Monaldi’s approach is a safe method for needle decompression of pneumothorax.