Emergency ultrasonography and error reduction.

You are working an overnight shift in the critical care area of your emergency department (ED). Paramedics bring in an elderly patient from a nursing home with fever, shortness of breath, and a presumptive diagnosis of sepsis. She has a history of multiple medical problems and was recently admitted to your hospital for pneumonia. As you examine the patient, you observe that she is febrile, tachypneic, hypoxemic, tachycardic, and hypotensive. There are diffuse rhonchi on examination and decreased breath sounds at the right base. A stat portable chest radiograph shows a moderate right pleural effusion and consolidation of the left lower lobe. The patient remains hypotensive despite boluses of crystalloid. You decide to place central venous access and an arterial catheter to assess her central venous pressure and mean arterial pressures. You consider thoracentesis to improve her respiratory status. Should you reach for the ultrasonography machine? A decade has passed since Sankoff and Keyes proclaimed the importance of diagnostic emergency ultrasonographic training. In 2000, the Institute of Medicine’s sobering report To Err is Human prompted both legislative and regulatory initiatives to reduce medical errors. One year later, the federal Agency for Healthcare Research and Quality published a set of evidencebased patient safety guidelines that included the use of realtime ultrasonographic guidance for central venous catheter placement among the highest-rated patient safety practices. In the setting of accumulating evidence that ultrasonographic guidance improves patient safety and procedural success, we review the emergency medicine ultrasonographic data, with an emphasis on procedural guidance. Any discussion of error reduction and emergency ultrasonography must begin with central venous catheterization, where the superiority of ultrasonographic guidance to the landmark technique has been demonstrated. The complications from attempted central venous catheter placement depend on the anatomic site and include hematoma formation, arterial puncture, pneumothorax, hemothorax, chylothorax, and air embolus. Traditionally, central venous catheter insertion was guided by surface anatomy estimates of vessel position. Ultrasonographically guided central venous access allows identification of vascular anatomy, visualization of the needle tip approaching and penetrating the target vein, and