Correspondence

Impact of portable ultrasound in trauma care after the Haitian earthquake of 2010

To the Editor,

Portable ultrasound in mass casualty disasters has emerged as a useful imaging modality to aid in clinical care and victim triage [1,2]. As portable ultrasound technology has become more durable, and charitable programs can rapidly provide machines to deploy with humanitarian workers, it has become possible to routinely use this imaging modality in disaster triage settings. Although a wide variety of potential ultrasound applications in mass casualty patient care exists [3], prior published studies of use of ultrasound in disaster are limited to abdominal hemoperitoneum [4] and renal Doppler studies in patients with Crush injury [5]. We present here our experience in use of hand-carried ultrasound during care of Earthquake victims after the Haitian earthquake of January 2010.

We describe our observations of ultrasound uses in the care of earthquake victims at St Marc Hospital, Haiti, a district hospital supported by the nonprofit organization Partners in Health. The hospital is located 40 miles north of Port-au-Prince, Haiti, and our team arrived on day 4 after the earthquake to provide clinical care to earthquake victims. During triage and clinical care of surgical ward and emergency department patients, clinically indicated ultra- sound examinations were performed and results recorded in a Microsoft Excel spreadsheet (Microsoft, Redmond, Wash). A Sonosite Micromaxx with phased array and linear array probes was carried by hand to the disaster site by the emergency physician in the group as a charitable loan from the Soundcaring Committee of Sonosite Inc. (Bothell, WA). An extra set of 2 batteries was used to decrease reliance on generator power.

We found that hand-carried ultrasound was used by 2 of 4 anesthesiologists, the trauma surgeon, and the emergency physician in our group during perioperative and emergency care of trauma patients. For 14 days, we recorded 21 different scans in the care of 142 surgical patients who underwent 136 procedures in the operating room.

Four scans on pediatric patients included one US-guided peripheral intravenous catheter on a 2-year-old girl undergo-

ing below-the-knee amputation, one femoral nerve block on an 8-year-old boy undergoing large-wound debridement, abdominal scan of Pediatric appendicitis with abscess (1), and a Focused assessment with sonography in trauma examination

[6] in a 7-year-old girl run over by a car while sleeping in the street. Adult ultrasound examinations performed by an ultrasound-trained emergency physician included focused assessment with sonography in trauma examinations (3: 1 positive and 2 negative), pneumothorax examinations (1 negative and 1 positive but with resumption of Lung sliding after reexpansion post-chest tube thoracostomy), pelvic ultrasound for Tubo-ovarian abscess in a patient with pelvic fracture and vaginal puncture of bony fragments (1 positive for salpingitis), shock examination (1 perioperative patient with tachycardia and hypotension with normal transthoracic echocardiogram , N50% inspiratory collapse of inspi- ratory vital capacity suggesting dehydration), postoperative biliary ultrasound (2 negative), and kidney/bladder ultra- sound (1 patient with rhabdomyolysis and renal failure).

The anesthesiologists found the portable ultrasound extremely useful within the operating room and recovery area to aid in pre- and postoperative pain control through ultrasound-guided regional anesthesia. Specifically, with the language barrier, anesthesiologists were unable to rely on communication with patients regarding paresthesias during nerve blocks, which normally aid placement of local anesthetic, so ultrasonographic guidance aided precision of blocks. n addition, use of motor stimulation in traumatized patients can produce severe pain, which is avoided if ultrasound guidance is used instead of motor stimulation to guide the needle placement. Adult ultrasound-guided proce- dures by our anesthesiologists included interscalene block (1), subclavian perivascular nerve block for ORIF (open reduction and internal fixation) of supracondylar fracture (1), femoral nerve blocks (4) for external fixation of femur, revision of below the knee amputation, above the knee amputation (BKA/AKA) and flap closures of AKA, and internal jugular venous catheter placement (1).

Portable ultrasound proved to be a valuable tool in our experience providing clinical care in this mass casualty disaster. Because of the heavy burden of crush Trauma victims in an earthquake-specific mass casualty incident, rapid identification of potentially life-threatening injuries can

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Correspondence 971

be assisted by the use of ultrasound for pneumothorax, intraperitoneal and intrathoracic hemorrhage, shock, perio- perative cardiac assessment of systolic function and volume status, and infectious complications of abdominal trauma. In addition, ultrasound-guided regional anesthesia for pain control may be performed to increase success when anatomical landmarks may be obscured by trauma, commu- nication regarding paresthesias is limited by the language barrier, and muscle stimulation is not readily available and can be painful. We would recommend hand-carried ultra- sound as an essential tool for clinicians traveling to provide medical relief in the disaster setting.

Sachita Shah MD

Department of Emergency Medicine

Rhode Island Hospital Providence, RI 02903, USA

E-mail address: [email protected]

Akshay Dalal MD

Department of Anesthesia Critical Care and Pain Management Massachusetts General Hospital

Boston, MA, USA

R. Malcolm Smith MD Department of Orthopedics Massachusetts General Hospital

Boston, MA, USA

Giliane Joseph MD Department of Medicine Division of Infectious Diseases

Albert Einstein College of Medicine Montefiore Medical Center

Bronx, NY, USA

Selwyn Rogers MD Department of Surgery Brigham and Women’s Hospital

Boston, MA, USA

George S.M. Dyer MD Department of Orthopedics Brigham and Women’s Hospital

Boston, MA, USA

doi:10.1016/j.ajem.2010.06.017

References

1. Sztanjnkrycer MD, Baez AA, Luke A. FAST ultrasound as an adjunct to triage using the START mass casualty triage system: a preliminary descriptive study. Prehosp Emerg Care 2006;10:96-102.
2. Beck-Razi N, Fischer D, Michaelson M, Engel A, Gaitini D. The utility of focused assessment with sonography for trauma as a triage tool in

multiple-casualty incidents during the second Lebanon war. J Ultrasound Med 2007;26:1149-56.

1. Ma OJ, Norvell J, Subramanian S. Ultrasound applications in mass casualties and extreme environments. Crit Care Med 2007;35(5): S275-9.
2. Sarkisian AE, Khondkarian RA, Amirbekian NM, et al. Sonographic screening of mass casualties for abdominal and Renal injuries following the 1988 Armenian earthquake. J Trauma 1991;31:247-50.
3. Keven K, Ates K, Yagmurlu B, et al. Renal Doppler ultraSonographic findings in earthquake victims with crush injury. J Ultrasound Med 2001;20:675-9.
4. Ma OJ, Mateer JR, Ogata M, et al. Prospective analysis of a rapid trauma ultrasound examination performed by emergency physicians. J Trauma 1995;38:879-85.

The Airtraq laryngoscope for emergency tracheal intubation without interruption of chest compression

To the Editor,

The 2005 American Heart Association Cardiopulmonary Resuscitation (CPR) Guidelines emphasize minimizing the interruption of chest compression to maximize Coronary and cerebral perfusion pressure [1]. More specifically, these guidelines suggest that skilled operators should be able to secure the airway either without interrupting chest com- pression or with only a brief pause to visualize vocal cords to allow the passage of the tracheal tube (TT). Previous studies have shown that chest compression prolongs the time needed for intubation and increases the risk of Esophageal intubation [2]. Standard direct laryngoscopic tracheal intubation remains the preferred technique to secure the airways. However, sufficient experience is required to be proficient in using this technique. In an emergency situation, airway management is often performed by a less experi- enced physician, in suboptimal conditions. This may affect a patient’s morbidity [3]. Introduction of video laryngoscopes might have benefits in these situations. The Airtraq is a disposable video laryngoscope with an anatomically shaped blade that has 2 parallel conduits: the optical and guiding channels (Fig. 1). A Low Temperature battery-operated light is present at the tip of the blade. The optical channel contains a high definition optics system, which transmits the image to the proximal viewfinder using a combination of lenses and prisms. An antifog system is built into the optical channel, which requires 30 to 45 seconds of warm-up time. To use the Airtraq, the TT is preloaded in a track next to the optical pathway, and the device is inserted in the oropharynx. When the glottis is visualized, the TT is advanced down the track into the trachea and the Airtraq is removed. This device has been favorably evaluated in a number of studies [4]. It has been used in cases of failed conventional intubation [5] and in patients with cervical spine immobilization [6]. We report a case of a 61-year-old man presented to our Medical Emergency Team for in- hospital cardiac arrest in radiology suite. His initial cardiac