2nd Italian WINFOCUS Congress, Milan, Italy, 10–13 December 2008 ACCURACY OF CHEST SONOGRAPHY IN THE EMERGENCY DEPARTMENT TO DETECT CONGESTIVE HEART FAILURE IN ACUTE DYSPNEIC PATIENTS (EUCAD 1) EMERGENCY DIAGNOSIS OF PULMONARY EDEMA BY LUNG ULTRASOUND LIMITED TO THE ANTERIOR CHEST

Background : Dyspnea is one of the most common cause of admit- tance in the Emergency Department (ED). The real challenge is understanding which is the cause of this symptom in order to begin a right management. Recent studies report that extravascular lung water can be accurately assessed with ultrasound lung comets (ULCs) by chest sonography (US) [1–3]. Objective : The aim of this study is to validate chest US in detecting congestive heart failure in patients admitted to ED complaining acute dyspnea. Patients and methods : From 01/02 to 30/11/2007 we performed chest US in 65 pts admitted to ED complaining acute dyspnea of uncertain origin. We used an Acuson X150TM System (Siemens, Erlangen Germany) with a 3–5 MHz convex probe, and we examined three different lung windows (the upper, the middle and the basal ﬁelds following an oblique line from the lung’s apex) of each lung. A widespread interstitial-alveolar syndrome was deﬁned when were found more than three B lines for each windows in at least two windows for each side. Pleural effusion was conﬁrmed by the presence of an anechoic area in the costo-phrenic sinus. Echocardiogram was performed in all pts. The diagnosis was independently made by a different physician, according to the clinical presentation, laboratory data, EKG, chest X-ray, Echocardiogram and from the response to therapy. Results : Congestive heart failure was found in 38/65 pts (prevalence 58%). Chest US resulted really conﬁdent to detect cardiac dyspnea, with sensibility 97%, speciﬁcity 85%, PPV 96%, NPV 90% and accuracy 92%. Conclusion : Chest US performed in pts complaining acute Background : B-lines are vertical echogenic artifacts seen on lung ultrasound that allow bedside diagnosis of pulmonary edema. The ‘‘BLUE’’ protocol, recently published by Lichtenstein and Mezie`re, suggests that cardiogenic pulmonary edema is sufﬁciently ruled out in the ICU setting when B-lines are not predominant in the anterior chest (the ‘‘B proﬁle’’). Objective : Our analysis sought to evaluate the accuracy of the B proﬁle for ruling out pulmonary edema in the ED patient population. Patients methods The ultrasound lung scans of patients with conﬁrmed ofﬁcial diagnoses of acute decompensated heart failure (ADHF) from two ED databases were retrospectively analyzed. acutely dyspneic patients had complete studies (130 from one data- base and the other). The scans were reviewed using the B proﬁle deﬁnition for ruling out pulmonary edema and comparing that to an alternate scanning protocol that includes ultrasound evaluation of the lateral and anterior chest. Results : Of the 170 ED patients with ADHF Background : Pleuritic pain in the ED elicits a long list of possible pleural and lung conditions. In case of negative chest radiography (CXR), other routine bedside diagnostic tools, including history, physical signs and laboratory data, can be useful to differentiate between pleuropulmonary diseases and parietal chest pain. Lung ultrasound (LUS) has the advantage of being easily performed bedside, and it could be useful in the diagnostic process. Objective : Comparing the usefulness of LUS with other bedside diagnostic tools commonly used in the ED in the differential diag- nosis of pleuritic pain with silent CXR. Material and methods : We studied 54 patients complaining of pleuritic pain who showed non-diagnostic CXR. All patients were submitted to history recording, clinical examination, blood sample and blinded LUS. Results were compared with ﬁnal ofﬁcial diag- nosis, conﬁrmed by other conclusive image techniques and follow-up. Results : In 34 cases ﬁnal diagnosis was muscoloskeletal parietal chest pain. The other 20 patients (37%) were diagnosed a pleuro- pulmonary condition (15 pneumonia, 4 pulmonary embolism, 1 lung cancer). Diagnostic accuracy of LUS, routine blood tests and symptoms in predicting any pleural and/or pulmonary radioccult condition is shown in the following table (data are expressed as percentage; WBC white blood cells count; CRP C-reactive protein; * at least one positive blood WBC, CRP D-dimer; # at one symptom including fever, cough hemoptysis; § positivity parietal is crucial the correct subsequent of Background : Chest ultrasonography (US) is able to detect different kind of peripheral lung pathologies such as infectious and neoplastic, other than traumatic and cardiac ones [1]. An infectious pathogenesis, expanding the subpleural septa, can provoke an interstitio-alveolar syndrome [2], which should not be evident in neoplastic. Moreover, air bronchogram is considered typical X-ray and US ﬁnding in pneumonia but not in neoplasm. Objective : To distinguish between infectious alveolar consolidation from neoplastic ones by researching the following US ﬁndings: (1) the interstitial pattern all around the lesion (comet tail artifacts or B and C lines); (2) the presence of air bronchogram. Patients and methods : We selected 25 patients (pts) Patients We following for CVC placement: after US evaluation of the internal jugular vein (IJV), the brachiocephalic vein (BCV), the subclavian vein (SV) and the axillary vein (AV) on both sides, one of the following US guided approaches was chosen: (1) low lateral ‘Jernigan’ approach to the IJV, (2) lateral approach to the BCV, (3) supraclavicular approach to the SV, (4) infraclavicular approach to the SV or AV. Correct position of the tip was controlled either by intraoperative EKG guidance or by chest X-ray. Results : In 12 months, 607 CVC were inserted; the chosen approach was either BCV ( n = 360), or IJV ( n = 203), or supraclavicular SV ( n = 32), or infraclavicular SV/AV ( n = 12). In eight procedures (two IJV, four supraclavicular SV, two infraclavicular SV/AV), the operator decided to shift to another approach (BCV in most cases, except one shift to controlateral IJV). Complications were: arterial punture 1%, (six cases: ﬁve with IJV, one with supraclavicular SV); malposition 0.6% (four cases, all from the left side, two with IJV and two with infraclavicular SV/AV). Conclusions : (a) The US approach to the central veins is characterized by an overall minimal incidence of complications; (b) preoperative US evaluation allows to choose the venous approach most likely to be successful and uneventful; (c) the US guided can- nulation of the BCV appears to be particularly safe. with a very short learning curve; (f) the better results of USG as compared to USA prompted us to adopt the former technique as the procedure of choice both in clinical as well as in teaching practice. Background : After the insertion of a central venous catheter, chest radiograph is usually obtained to ensure correct positioning of the catheter tip. Objective : To determine the usefulness of conventional B-mode (US) plus real-time contrast-enhanced (CEUS) ultrasonography to evaluate central catheter misplacements and tip positioning (i.e., right atrium, superior vena cava-atrium junction, or superior vena cava) in mechanically ventilated adults, thus obviating the need for a post-procedural radiograph. Materials and methods : A prospective study of 74 consecutive central venous access procedures using landmark technique was conducted in an adult intensive care unit. The preferred catheterization site was the right subclavian one. At the end of the procedure a B-mode US was ﬁrst performed to assess catheter position and then CEUS was used to exactly detect the catheter tip position, avoiding unknown RA placing. CEUS studies were performed using a commercially available US system and 3.5 MHz transducers on epigastric window. The contrast agent was prepared by mixing ten times 1 mL of air and 9 mL of saline into two syringes connected by a three-way stopcock to an indwelling catheter placed in the central line. The bubble con- taining saline was then injected as bolus. A post-procedural chest radiograph was obtained in all patients and was considered as reference technique. Results : In seven cases US examination was impossible for physical limitations. In 50/67 patients post-procedural US and CEUS showed catheter and tip position inside in the vena cava. Among 16 patients expected to have a complication, US detected 4 catheter malpositioning and CEUS 12 tip misplacements into the right atrium. US plus CEUS showed a 96% sensitivity and 93% speciﬁcity, with a 98% positive predictive value and 88% negative predictive value in the detection of catheter malpositioning and right atrium tip misplacement. In 64/67 (96%) cases there was concordance between US plus CEUS and chest radiography. Conclusions : The close concordance between US plus CEUS and chest radiography in detection of tip malpositioning and catheter misplacement justiﬁes the use of sonography as a reference technique to ensure the correct positioning of catheter tip after central venous cannulation in order to optimize hospital resources utilization and minimize time-consumption and radiation. Chest radiography may be still necessary when sonographic examination is limited by metheo- rism, deep traumatic or surgical wound, low echogenicity transmission or technical limitations at insertion site, such as presence of neck sterile drainage in oral or maxillar surgery. Background : To prospectively compare the diagnostic value of ultrasound (US) and contrast-enhanced ultrasound (CE-US) with computed tomography (CT) for detection of renal injuries in blunt abdominal trauma patients. Patients and methods : US, CE-US and CT were performed to assess possible abdominal organ injuries in 152 non consecutive hemody- namically stable patients with blunt abdominal trauma and a strong clinical suspicion of abdominal lesions. US and CE-US ﬁndings were compared with CT ﬁndings, the reference standard technique. 24 out of 152 patients (15.7%) had renal lesions, the severity of which was graded according to the organ injury severity scale of the American Association for the Surgery of Trauma (AAST). Results : Eleven out of 24 traumatic parenchymal lesions had perirenal ﬂuid collection at baseline US. 27 renal parenchymal lesions, with or without perirenal or retroperitoneal haematoma, were identiﬁed at contrast-enhanced US. The sensitivity and speciﬁcity of US were 45.8 and 91.4% respectively. CE-US had a sensitivity of 96.4%, a speciﬁcity of 100% and a positive and negative predictive value of 100 and 92.5% respectively. Conclusion : CE-US was found to be more sensitive than US and almost as sensitive as CT in the detection of traumatic renal traumatic injuries. It can therefore be proposed as a useful tool in the assessment of blunt abdominal trauma. CE-US reduced radiation exposure and can be used also in patients with reduced renal function and/or with previous adverse reaction to iodinated contrast media. Case report : We presented a case of swelling neck in a 65 year old Caucasian man observed in Emergency Department. No other masses or lymphadenopathy could be felt in the neck. The toid improvement both of the echo- radiographic features and of the symptomatology. conﬁrmed the signiﬁcant increase of Constant Score, which is the most used index to quantify the pain and the functional inability of the shoulder. In some cases the procedure was repeated because of the recurrence of the symptomatology but the ﬁnal outcome good anyway with the increase of Constant Score. In the MR controls at 6 months only tendon structural alterations in the site of were percutaneous ablation treatment tendinous calciﬁcations the valid alternative to tradi- tional therapies: beneﬁt electively the bursa. neither contraindications Background : Detection of a superﬁcial foreign body (FB) may be difﬁcult, especially if non-radiopaque. The accuracy of ultrasonography (US) in detecting radiopaque and non-radiopaque FBs in soft tissues and possible complications is well established both in vitro1 and in vivo studies. Objective : US assessment of spontaneous disappearance of the air bubbles can distinguish a harmless traumatic nature of the wound from a life-threatening gas-producing bacterial infection. Background Emergency Objective : Evaluation of the performance of a pocket US (P-US) (Siemens P10–Germany) for point-of-care US in emergency settings (ED, ICUs), in comparison with a standard portable US machine (SP-US). Patients and Methods : From October 1st to November 1, 2008, 4 US-trained acute care surgeons performed 135 focused US with both P10 and SP-US on 62 pts. P10 is a P-US equipped with a unique micro-convex probe (2–4 MHz). In EDSP-US machine was always available; in ICUs not immediately. The following data were analyzed: time of indication for US, time of accomplishment, inﬂuence on patient man- agement. Focused questions were classiﬁed in basic (pleural and abdominal effusion, gallstones, abdominal aneurysm, pneumothorax (ptx), hydronephrosis, bladder retention, CUS) and advanced (IVC diameter, cardiac motility and load, lung interstitial syndrome, acute appendicitis, diverticulitis). When SP-US was immediately available, the time required for P10 exam was subtracted in analysis. Results : US scan was performed to search for 25 peritoneal effusions, 21 pleural effusions, 11 hydronephrosis, 18 gallstone diseases, 7 aortic aneurysm, 4 CUS. Some patients had more than a district examined (mean 2.1). Accordance between portable and pocket US results was respectively 96% for peritoneal effusion, 95.2% for pleural effusion, 91% for hydronephrosis, 95% for gallbladder disease, 100% for abdominal aorta and bladder retention. Feasibility and accuracy of P10 midbrain 9 by CT Focal hypodense lesions : focal hypodense lesions in CT scan were visualized in the 25% of the cases with ultrasonography. They appeared like hypoecogenic lesions in 45% of cases and hyperecogenic in the 55% of cases. In patients with DC, there is a good correspondence between CT scan and ultrasounds regarding the focal hypodense Background : Transcranial Doppler ultrasonography can be per- formed by conventional method (TCD) or by color-coded sonography (TCCS). TCCS can follow the vessel along its length, and can analyze mean velocity at different depth. Furthermore, angle-corrected ﬂow velocities in basal cerebral arteries can be obtained only by TCCS. After subarachnoid hemorrhage, vasospasm is often focal, localized in the proximal portion of cerebral arteries. In these cases, it may be missed by TCD. Results : we describe three cases of segmental vasospasm in three patients with subarachnoid hemorrhage. In all cases, the increase of mean velocities in middle cerebral artery above 120 cm/sec was observed by TCCS, but not by TCD. Conclusions : TCD can miss segmental vasospasm. Current recom- mendations do not give us indications about the method to perform transcranial Doppler. TCCS can decrease mistakes giving a more accurate diagnosis. General Hospital (Turin, Italy) with acute dyspnea (i.e. dyspnea appeared or worsened in the last 48 h). In all patients, we performed lung ultrasound and evaluated the presence of diffuse interstitial syndrome using three antero-lateral thoracic windows, as well as the presence of pleural effusion using a basal window on both sides of the thorax. The ﬁnal diagnosis (cardiogenic or not cardiogenic dyspnoea) was conﬁrmed, in a retrospective way, by two expert physicians (an emergency medicine specialist and a cardiologist), not aware of the scope of the study, using all available data (clinical ﬁndings, EKG, chest X-ray, echocardiog-raphy—carried out in all patients—response to therapy), but not lung ultrasound results. Results : The ﬁnding of diffuse interstitial syndrome by lung ultrasound was highly predictive for cardiogenic dyspnea (sensi-tivity 94%, speciﬁcity 96%, negative predictive value 93%, positive predictive value 97%, LR - 0.06, LR +24.57). On the contrary, detection of pleural effusion was not helpful in differ- ential diagnosis. The reproducibility of the lung ultrasound performed in an emergency setting was very good ( k between 0.93 and 0.96). Conclusion : In patients presenting to the ED with acute dyspnea, lung ultrasound, performed with the purpose of identifying diffuse interstitial syndrome, is a very accurate technique for discriminating cardiogenic from not-cardiogenic causes. Background Making the right diagnosis in patients with cardiac arrest or peri-arrest (shock and severe respiratory failure) is often difﬁcult when based only on the clinical evaluation. Objective To study the feasibility and the diagnostic-therapeutic impact of integrated ultrasound in patients with cardiac arrest or peri- arrest in the ED. Patients and methods : We enrolled 30 patients admitted to the ED of the Pinerolo General Hospital (Turin, Italy), 14 with cardiac arrest (PEA 12, V-Fib 1, asystolia 1), and 16 in peri-arrest. All patients were managed according to ALS and ATLS guidelines; in addition, they underwent extensive ultrasonographic evaluation, primarily focused on heart or lungs, then extended to other body districts, if needed. We evaluated: feasibility, diagnostic-therapeutic impact and potential support in procedure execution. Results : The integrated ultrasound approach was feasible in all patients, in a short time and without interfering with other proce- dures. Heart was evaluated in 30 patients (100%), lungs in 11 (37%), inferior vena cava (IVC) in 9 (30%), and other districts in 11 (37%). In 19 out of 30 patients (63%) the diagnosis was deﬁned based on ultrasound results: pulmonary embolism 7, cardiac tam- ponade 1, acute pulmonary oedema 2, myocardial infarction 1, aortic valve endocarditis 1, aortic dissection 1, pneumothorax 1, ARDS 1, hypovolemia 4. Ultrasonography ﬁndings led to therapeutic changes in 13 out of 30 patients (43%): thrombolysis 6, discontinuation of chest compressions during pseudo-PEA 2, ﬂuid resuscitation 1, pericardiocentesis 1, chest tube 1, antibiotics 1, anticoagulation 1. In 9 out of 30 patients (30%) invasive procedures were performed with ultrasound support. Conclusion : In patients with cardiac or peri-arrest, a short time and high diagnostic-thera-peutic impact, leading to better diagnostic deﬁnition and/or therapeutic variations in over a half of the patients. Background Lung ultrasound has elevated accuracy in discrimi- nating cardiogenic from not-cardiogenic causes of dyspnea, but it does not allow to deﬁne the underlying cardiac pathophysiology, which often can be only presumed. Background : Lung ultrasound has elevated accuracy in the diag- nostic evaluation of patients with dyspnea. However, no data concerning the diagnostic-therapeutic impact of this technique in patients with acute dyspnoea in the setting of Emergency Department (ED) are currently available. Objective : To study the diagnostic-therapeutic impact of lung ultrasound in patients with acute dyspnoea in the ED. Patients and methods : Between June and October 2008, we prospectively enrolled 33 patients admitted to the ED of the Pinerolo General Hospital (Turin, Italy) with acute dyspnea Background : About 70% of patients accessing Emergency Depart- ment (ED) require the placement of a venous vascular access. The venous access placement may be difﬁcult due to anatomical/somatic patient’s tissue characteristics or to the changes induced by the disease, or because of other variables related to the patient’s physiological state. Repeated attempts at inserting the peripheral venous catheter may cause patient’s discomfort resulting in dissatis- faction and distrust towards the operators; sometimes ED nurse has to refer to a medical specialist who can provide peripheral or central line. Another solution is ﬁnally represented by the nursing staff usage of ultrasound guidance, which allows you to ‘‘see’’ the goal and to increase the percentage of ﬁnding the line single-shot (SS). Objective deﬁned and/or ﬁnd the the complications of the posterior approach of ultra- sonographically-guided internal jugular vein catheterization. Objective : Incidence of early and late complications due to infra- clavicular subclavian vein catheterization (iS) relative to echo-guided internal jugular vein by anterior (aIJ) or posterior (pIJ) approach. Patients and methods : 87 patients have been cannulated with a CVC with the approach in which the operator was most conﬁdent. All the precautions for infection prevention have been strictly observed and the subsequent management has been uniformly done in the three groups. The early and late complications have been evaluated and the differences between the three groups have been examined by the one way variance analysis (ANOVA). Results : The CVCs positioned have been: 22 iS, 31 aIJ and 34 pIJ. The early complications have been: 4.5% in the iS group (one pneumothorax), 0% in the ultrasound-guided aIJL and pIJ. The late complications have been: 4.5% in the iS group (vein thrombosis), 6.4% in the aIJ group (cetheter-related infection and vein thrombosis), 2.9% in the pIJ group (skin redness without catheter-related infec-tion). Multiple incannulation attempts have been made with the iS approach. The difference in late complications has reached statistical signiﬁcance between the pIJ group and either iS and aIJ groups. Conclusion : The posterior ultrasound-guided approach is associated with small percentage of early and late complications and as such is better than the subclavian approach. These results are the consequence of the use of ultrasound (reduced incannulation attempts) and of the ease of dressing of the posteriorly positioned internal jugular catheter. Objective : The reproducibility of the evaluation of jCVP and corre- lation with invasive CVP (iCVP) respect to inferior caval CVP was studied. Patients and methods : 91 patients have been studied, ﬁrst with jugular and then caval ultrasonography, ﬁnally with iCVP measure- ment. cCVP was evaluated with a score system, jCVP was the result of the measurement of the vertical from the 4th intercostal anterior axillary space to the edge of blood column in jugular vein. iCVP was measured in end-diastole. Measurements were repeated after different loading conditions by experienced operators. A linear regression analysis and correlation with t test has been done. Results : The following mean M (standard deviation SD) values, in cmH 2 O, and tendency lines R 2 have been obtained: iCVP M = 12 (SD 4.1), R 2 = 0.91; jCVP M = 12.28 (SD 4.25), R 2 = 0.86; cCVP M = 13.18 (SD 5.97), R 2 = 0.62. The correlation between iCVP and jCVP has been r = 0.96, between iCVP and cCVP r = 0,82 ( P \ 0.05). The interobserver variability has been: 5% for iCVP, 7% for jCVP,11% for cCVP. Conclusion : The ultrasonography of the internal jugular vein for CVP is valid and reproducible and constitutes a good alternative to CVP invasively measured. Background : The peritoneal dialysis is a treatment of the chronic renal failure alternative to the haemodialysis, in which some amount of a deﬁned solution come exchanged inside of the peritoneal cavity by means of a transcutaneous catheter. The patient in peritoneal dialysis constitutes an interesting model for the practical training on the FAST. Objectives : To test a didactic model for (a) the acknowledgment and (b) the semiquantitative appraisal of the free ﬂuid in a program of abbreviated training for the FAST. Patients and methods : Eight doctors with none (group 1, n = 3 doctors), beginning (group 2, n = 3 doctors) and [ 3 years (group 3, n = 2 doctors) experience in abdominal ultrasound have carried out a proctored FAST on patients submitted to peritoneal dialysis, 3 months after a FAST theoretical course of 6 h. The proof consisted of three tests, breaking in peritoneal cavity of 500, 1000 and 1500 cc of ﬂuid respectively. After every ﬁlling, an expert examiner previ-ously executed a test standard: (1) four scannings for: pericardic ( ± ), peritoneal ( ± ) and pleuric ( ± ) effusion and (2) a semiquantitative appraisal of ﬂuid amount (light, moderated and abundant), with which they have been compared the results of the students.

Background: Pleuritic pain in the ED elicits a long list of possible pleural and lung conditions. In case of negative chest radiography (CXR), other routine bedside diagnostic tools, including history, physical signs and laboratory data, can be useful to differentiate between pleuropulmonary diseases and parietal chest pain. Lung ultrasound (LUS) has the advantage of being easily performed bedside, and it could be useful in the diagnostic process. Objective: Comparing the usefulness of LUS with other bedside diagnostic tools commonly used in the ED in the differential diagnosis of pleuritic pain with silent CXR. Material and methods: We studied 54 patients complaining of pleuritic pain who showed non-diagnostic CXR. All patients were submitted to history recording, clinical examination, blood sample and blinded LUS. Results were compared with final official diagnosis, confirmed by other conclusive image techniques and followup. Results: In 34 cases final diagnosis was muscoloskeletal parietal chest pain. The other 20 patients (37%) were diagnosed a pleuropulmonary condition (15 pneumonia, 4 pulmonary embolism, 1 lung cancer). Diagnostic accuracy of LUS, routine blood tests and symptoms in predicting any pleural and/or pulmonary radioccult condition is shown in the following table (data are expressed as percentage; WBC = white blood cells count; CRP = C-reactive protein; * at least one positive blood test, including WBC, CRP and D-dimer; # at least one symptom in the history, including fever, cough and hemoptysis; § positivity of any blood test or any symptom). Conclusion: commonly reported symptoms, CXR and blood tests may be inadequate in the diagnostic process of pleuritic pain, especially in differentiating a parietal chest pain from a pleuropulmonary condition. In case of silent CXR, bedside lung ultrasound is crucial for the correct diagnosis and subsequent management of the patient.

DIFFERENT ULTRASONOGRAPHIC FINDINGS IN PERIPHERAL LUNG CONSOLIDATION
A. Testa, R. Giannuzzi, A. M. Meloni, G. Pignataro, N. Gentiloni Silveri Emergency Department, A. Gemelli University Hospital, Roma, Italy Background: Chest ultrasonography (US) is able to detect different kind of peripheral lung pathologies such as infectious and neoplastic, other than traumatic and cardiac ones [1]. An infectious pathogenesis, expanding the subpleural septa, can provoke an interstitio-alveolar syndrome [2], which should not be evident in neoplastic. Moreover, air bronchogram is considered typical X-ray and US finding in pneumonia but not in neoplasm.
Objective: To distinguish between infectious alveolar consolidation from neoplastic ones by researching the following US findings: (1) the interstitial pattern all around the lesion (comet tail artifacts or B and C lines); (2) the presence of air bronchogram. Patients and methods: We selected 25 patients (pts) with peripheral lung consolidation shown by chest X-ray. 18/25 pts were admitted to the Emergency Department complaining cough, fever and chest pain. In these pts chest X-ray showed an infectious lung consolidation, in agreement with white blood count and the healing after antibiotics. 7/25 pts had peripheral lung consolidation suspected for neoplasm. Chest US was performed by an independent physician to all patient using an Acuson X150 TM System (Siemens, Erlangen Germany) equipped with a 3-5 MHz convex probe, looking for lung consolidation to detect inside air bronchogram and surrounding B and C lines [3]. Results: Among 18 pts that we observed with suspected pneumonia in 15 we were able to recognise alveolar consolidation by US: surrounding B and C lines and inside air bronchogram were found in all patients. 3/7 pts with suspected neoplastic consolidation were excluded because the lesion was undetectable (2) or resulted benign (1). All the remaining 4 pts showed a hypo-anecoic homogeneous lesion without surrounding comet tail artifacts or air bronchogram. Conclusion: Our study suggests that US can help to distinguish between infectious and neoplastic peripheral lung consolidations according to the detection of inside air bronchogram and surrounding comet tail artifacts (B and C lines Patients and methods: We adopted the following protocol for CVC placement: after US evaluation of the internal jugular vein (IJV), the brachiocephalic vein (BCV), the subclavian vein (SV) and the axillary vein (AV) on both sides, one of the following US guided approaches was chosen: (1) low lateral 'Jernigan' approach to the IJV, (2) lateral approach to the BCV, (3) supraclavicular approach to the SV, (4) infraclavicular approach to the SV or AV. Correct position of the tip was controlled either by intraoperative EKG guidance or by chest X-ray. Results: In 12 months, 607 CVC were inserted; the chosen approach was either BCV (n = 360), or IJV (n = 203), or supraclavicular SV (n = 32), or infraclavicular SV/AV (n = 12). In eight procedures (two IJV, four supraclavicular SV, two infraclavicular SV/AV), the operator decided to shift to another approach (BCV in most cases, except one shift to controlateral IJV). Complications were: arterial punture 1%, (six cases: five with IJV, one with supraclavicular SV); malposition 0.6% (four cases, all from the left side, two with IJV and two with infraclavicular SV/AV). Conclusions: (a) The US approach to the central veins is characterized by an overall minimal incidence of complications; (b) preoperative US evaluation allows to choose the venous approach most likely to be successful and uneventful; (c) the US guided cannulation of the BCV appears to be particularly safe. Background: Ultrasound guidance (USG) is gaining widespread acceptance as an essential tool during insertion of central venous catheters (CVC), but its incorporation into clinical practice has met some resistance. One of the reasons is that some training issues, such as learning curve and teaching modalities, are still a matter of controversy. We present the results of our early teaching experience about USG for CVC insertion. Cannulation protocol: (a) US evaluation of the internal jugular vein (IJV) on both sides to assess position, dimension, relationship with carotid artery; classification of IJV as ''easy'' (depth \ 2 cm., diameter [ 5 mm, lateral to the artery) or ''difficult'' (depth [ 2 cm., diameter \ 5 mm. or collapsable during breathing, medial to the artery); (b) decision to stick the vein by US assistance (USA) for ''easy'' veins or under direct US guidance (USG) for ''difficult'' veins. (c) the IJV was always punctured via the low lateral Jernigan approach, both with USA and USG; (d) after two failed USA attempts, USG venipuncture was adopted; during USG procedures, an axial scan of the vein (''short axis'' scan) was obtained, while the needle were introduced parallel to the ultrasound beam (''in plane'' puncture); (e) when IJV was not available, a ''second choice'' USG venipuncture of the following veins was performed: innominate, axillary (infra-clavicular approach); subclavian (supra-clavicular approach); femoral. Teaching protocol: -a total amount of 8 h of formal lessons about US for CVC insertion; -4 h of laboratory training for USG procedures on a biologic simulator, as described elsewhere; -a minimum of 25 procedures observed; -a minimum of 10 procedures performed under direct supervision of an expert operator; -audit after three months of independet activity. Insertions were randomly assigned either to experienced physicians of our resident Team (EP) or to physicians in-training (Non Expert Operators-NEP), i.e. students of the Master. ''Non expert operators'' were defined as operators who had completed a first teaching step of 5 observed and 5 performed procedures. Results: In the study period, 715 CVC were inserted in 695 adult patients (181 short term CVC + 218 tunnelled CVC + 316 ports); 460 procedures were performed by EP, 255 by NEP. The procedure started as USA in 522 and as USG in 299 cases (no significant difference comparing EP vs. EP): a shift from USA to USG was necessary in 8% (7.1% in EP vs. 10% in NEP: n.s.). The IJV was successfully cannulated in most patients, with very few exceptions (innominate vein in 12 cases, axillary vein 2, femoral vein in 1, all by USG). Complications were: failure 0%; pneumothorax 0%; hemothorax 0%; accidental arterial punture 1.1%, (1.7% USA vs. 0.3% USG, p \ .01; no difference EP vs. NEP); hematoma 0.4% (only for USA; no difference EP vs. NEP); malposition (0.8%, exclusively with the left IJV; no difference EP vs. NEP). Conclusions: (a) The ultrasound based approach to the IJV was characterized by an overall minimal incidence of complications; (b) direct USG was associated with a reduced risk of accidental arterial punture and hematoma, if compared to USA; (c) cannulation of the right IJV was associated with a reduced risk of malposition; (d) there was no significant difference in % of complications comparing experienced physicians versus physicians with a very short training; (e) the US technique is easy to learn and associated with a very short learning curve; (f) the better results of USG as compared to USA prompted us to adopt the former technique as the procedure of choice both in clinical as well as in teaching practice. Background: After the insertion of a central venous catheter, chest radiograph is usually obtained to ensure correct positioning of the catheter tip. Objective: To determine the usefulness of conventional B-mode (US) plus real-time contrast-enhanced (CEUS) ultrasonography to evaluate central catheter misplacements and tip positioning (i.e., right atrium, superior vena cava-atrium junction, or superior vena cava) in mechanically ventilated adults, thus obviating the need for a postprocedural radiograph.

PROPOSAL OF A TRAINING MODEL FOR ULTRASOUND GUIDED INSERTION OF CENTRAL VENOUS CATHETERS
Materials and methods: A prospective study of 74 consecutive central venous access procedures using landmark technique was conducted in an adult intensive care unit. The preferred catheterization site was the right subclavian one. At the end of the procedure a B-mode US was first performed to assess catheter position and then CEUS was used to exactly detect the catheter tip position, avoiding unknown RA placing. CEUS studies were performed using a commercially available US system and 3.5 MHz transducers on epigastric window. The contrast agent was prepared by mixing ten times 1 mL of air and 9 mL of saline into two syringes connected by a three-way stopcock to an indwelling catheter placed in the central line. The bubble containing saline was then injected as bolus. A post-procedural chest radiograph was obtained in all patients and was considered as reference technique. Results: In seven cases US examination was impossible for physical limitations. In 50/67 patients post-procedural US and CEUS showed catheter and tip position inside in the vena cava. Among 16 patients expected to have a complication, US detected 4 catheter malpositioning and CEUS 12 tip misplacements into the right atrium. US plus CEUS showed a 96% sensitivity and 93% specificity, with a 98% positive predictive value and 88% negative predictive value in the detection of catheter malpositioning and right atrium tip misplacement. In 64/67 (96%) cases there was concordance between US plus CEUS and chest radiography. Conclusions: The close concordance between US plus CEUS and chest radiography in detection of tip malpositioning and catheter misplacement justifies the use of sonography as a reference technique to ensure the correct positioning of catheter tip after central venous cannulation in order to optimize hospital resources utilization and minimize time-consumption and radiation. Chest radiography may be still necessary when sonographic examination is limited by metheorism, deep traumatic or surgical wound, low echogenicity transmission or technical limitations at insertion site, such as presence of neck sterile drainage in oral or maxillar surgery. Results: Eleven out of 24 traumatic parenchymal lesions had perirenal fluid collection at baseline US. 27 renal parenchymal lesions, with or without perirenal or retroperitoneal haematoma, were identified at contrast-enhanced US. The sensitivity and specificity of US were 45.8 and 91.4% respectively. CE-US had a sensitivity of 96.4%, a specificity of 100% and a positive and negative predictive value of 100 and 92.5% respectively.
Conclusion: CE-US was found to be more sensitive than US and almost as sensitive as CT in the detection of traumatic renal traumatic injuries. It can therefore be proposed as a useful tool in the assessment of blunt abdominal trauma. CE-US reduced radiation exposure and can be used also in patients with reduced renal function and/or with previous adverse reaction to iodinated contrast media. Case report: We presented a case of swelling neck in a 65 year old Caucasian man observed in Emergency Department. No other masses or lymphadenopathy could be felt in the neck. The medical history of this patient included a tracheostomy followed by decannulation with tracheoplasty, 3 weeks before, because of intracerebral haematoma, T2 diabetes mellitus and mild hypertension. Any modification of vital sign were observed (Oxygen Saturation 97%, BP 120/80). Where the anterior cervical mass was found, a point of care ultrasound scanning identified only presence of air without surrounding subcutaneos emphysema. In fact diffuse horizontal lines (A lines) arising from swelling subcutaneous layers were detected by means of a linear probe (Figs. 2,3,4). No other fluid or tissue ultrasound sign, in spite of objective examination findings, were detected so we could rule out cyst, bleeding, abscess or thyroid mass and lymphadenopathy. Complete decompressions of swelling neck were temporally obtained using a fine needle aspiration until the next breaths. After surgical exploration, a tracheal fistula was found, with a valve mechanism, that needed anterior tracheal wall reinforcement with a new tracheoplasty. The tracheal fistula, late complication of tracheotomy closure, healed by secondary intention after 15 days.

UOS Radiologia Ortopedica Azienda Ospedaliera di Padova, Padova, Italy
Background: The ''aching shoulder'' has a prevalence in the population ranging from 7 to 25% which often induces patients to go to emergency units because of the marked painful symptomatology during the acute phase. In the 45% of the aching shoulder syndromes rotator cuff calcifications are present. During the acute phase the treatment of choice is NSAIDs based pain control or loco-regional infiltrations of corticosteroids. A valid alternative is the use of the percutaneous echo-guided ablation treatment of tendinous calcifications in order to eliminate the main source of pain: this treatment can only be performed in hospitals with interventistic radiology units.Procedural modalities are reported as well as personal experience in a controlled casistic. Patients and Methods: From September 2006 to July 2008 216 treatments were performed at the orthopaedic radiology unit of Padova: 47 patients came from the emergency units of various hospitals. The procedure consists of echo-guided positioning of two 16 or 18 gauge needles with very close points at the calcification under loco-regional anesthesia. A turbulent flux is created thanks to the injection of high pressure physiological solution through one of the needles, which induces the fragmentation of the calcification. The fragments are removed through the other needle. In the second phase of the procedure a corticosteroid infiltration of the subacromial-deltoid bursa is made as well as the washing of the latter with physiological solution if fibro-adhesive bursitis is present. When calcifications are either no more evident or treatable-i.e. only the bursitis is the source of the acute painful symptomatology-only the washing with physiological solution is performed. The follow-up requires an X-ray and an echographic examination at 2 months and even a MR at 6 months. Results: Every patient showed an improvement both of the echoradiographic features and of the symptomatology. This was confirmed by the significant increase of Constant Score, which is the most used index to quantify the pain and the functional inability of the shoulder. In some cases the procedure was repeated because of the recurrence of the symptomatology but the final outcome was good anyway with the increase of Constant Score. In the MR controls at 6 months only tendon structural alterations in the site of treatment were seen. Conclusions: The percutaneous echo-guided ablation treatment of tendinous calcifications of the shoulder is a valid alternative to traditional therapies: it gives immediate benefit and it also permits to treat electively the bursa. It has neither contraindications nor relevant risks. A good knowledge of musculoskeletal echography and manual skills in the operative part are required anyway. It must be therefore considered as a second level echographic procedure for expert clinicians.

ULTRASOUND DETECTION OF SPONTANEOUS GAS GANGRENE IN THE EMERGENCY SETTING
A. Testa 1 , R. Giannuzzi 1 , K. De Gaetano Donati 2 , N. Gentiloni Silveri 1 1 Emergency Department, 2 Infectious Diseases Department, A. Gemelli University Hospital, Rome, Italy Background: Gas gangrene is a rapidly progressive pathology caused by different species of Clostridium that can induce a severe myonecrosis with gas production and sepsis [1]. In rare cases Clostridia disseminate via blood stream, even in absence of wounds as source of departure, this being more frequent in immunodeficients. About onethird of the cases of ''spontaneous'' gas gangrene are caused by Clostridium Septicum [2]. Objective: In emergency setting bedside goal-directed sonography may help in a prompt diagnosis of gas infiltrating soft tissue, avoiding loss of time while organising further investigations. Case report: We report the case of a 51 old women affecting by spontaneous gas gangrene involving the right upper limb due to Clostridium septicum. She suffered of ankylosing spondylitis and had been treated for a long time with immunosuppressors. The source of infection remained unknown and the progression was rapidly lethal, although adequate pharmacological therapy was promptly given and the patient was submitted to surgical debridment. In absence of crepitus the diagnosis was made by the sonographic detection of gas artifacts like comet tails, that had overthrown muscles and subcutaneous tissue. Background: Detection of a superficial foreign body (FB) may be difficult, especially if non-radiopaque. The accuracy of ultrasonography (US) in detecting radiopaque and non-radiopaque FBs in soft tissues and possible complications is well established both in vitro1 and in vivo studies. Objective: US assessment of spontaneous disappearance of the air bubbles can distinguish a harmless traumatic nature of the wound from a life-threatening gas-producing bacterial infection. Case report: A young man arrived at the Emergency Department (ED) complaining of a painful wound in his right forearm. He had been hit by slivers while working with a lawn-mower some hours before. X-ray of the forearm showed a radiopaque object near the radius. US examination using Acuson X150''! ultrasound system (Siemens, Erlangen Germany) and a 10.0 MHz small parts probe, detected the FB retained in the muscle and the gas microbubbles forming a line along the wound track. As it was not clear whether the gas was endogenous (infective) or exogenous (air deriving from the FB), the patient was hospitalized for observation. Their monodimensional arrangement in a line3 and their small size (\1 mm) did not allow the forming of the typical US artifacts (comet tails), but gas was suspected due to spontaneous and pressure provoked movements like ''sparkling-wine microbubbles''. US documented the complete disappearance of the gas, thus ruling out complications due to infection. Background: Bedside emergency ultrasonography leads to a better diagnosis and to a serial, not invasive monitoring of disease evolution.
Object: Emergency ultrasound in patient suffering from undifferentiated fever can reveal insidious pathologies that would require a timely diagnosis and treatment since their potential fatal prognosis. Case report: A 47 year old woman, with history of metrorrhagia from uterine fibromatosis, came to observation for fever from a week with no other signs nor symptoms. Considering the undifferentiated nature of the fever, it was performed a multidistrict, multiple transducer ultrasonography according to the protocol for differential diagnosis of the fever [1]; in this way, multiple liver abscess (maximum diameter 3 cm) were pointed out and then submitted to serial monitoring until their complete regression. Liver abscess is one of the most insidious cause of fever of unknown origin, not directly combined to associated pathologies [2], with rapid evolution towards septic shock and elevated mortality. Laboratoristic findings performed in emergency were globally normal: this reaffirms how ecography has modified the running of the case. We performed a mean number of three brain CT scan for each patient, on the overall 28 CT scan. Before each CT scan, we performed ultrasonography examination. We used a 4 Hz convex probe on the skin of the DC hole, with adequate sterile gel and no pressure on the brain.

Results:
Midline shift: In three patients, CT scan showed midline shift. With 1 mm error, ultrasonography sensitivity and specificity, compared to CT scan, was 100%. Focal hyperdense lesions: ultrasonography showed all thirty-seven focal hyperdense lesions visualized by CT. With 5 mm error, the three main axes correspondence was 85%. Once, the ultrasounds visualized a hyperecogenic lesion in the midbrain of 10 9 10 9 5 mm not shown by CT scan. Focal hypodense lesions: focal hypodense lesions in CT scan were visualized just in the 25% of the cases with ultrasonography. They appeared like hypoecogenic lesions in 45% of cases and hyperecogenic in the remaining 55% of cases. General Hospital (Turin, Italy) with acute dyspnea (i.e. dyspnea appeared or worsened in the last 48 h). In all patients, we performed lung ultrasound and evaluated the presence of diffuse interstitial syndrome using three antero-lateral thoracic windows, as well as the presence of pleural effusion using a basal window on both sides of the thorax. The final diagnosis (cardiogenic or not cardiogenic dyspnoea) was confirmed, in a retrospective way, by two expert physicians (an emergency medicine specialist and a cardiologist), not aware of the scope of the study, using all available data (clinical findings, EKG, chest X-ray, echocardiography-carried out in all patients-response to therapy), but not lung ultrasound results.
Results: The finding of diffuse interstitial syndrome by lung ultrasound was highly predictive for cardiogenic dyspnea (sensitivity 94%, specificity 96%, negative predictive value 93%, positive predictive value 97%, LR -0.06, LR +24.57). On the contrary, detection of pleural effusion was not helpful in differential diagnosis. The reproducibility of the lung ultrasound performed in an emergency setting was very good (k between 0.93 and 0.96).
Conclusion: In patients presenting to the ED with acute dyspnea, lung ultrasound, performed with the purpose of identifying diffuse interstitial syndrome, is a very accurate technique for discriminating cardiogenic from not-cardiogenic causes. Background: Making the right diagnosis in patients with cardiac arrest or peri-arrest (shock and severe respiratory failure) is often difficult when based only on the clinical evaluation.

DIAGNOSTIC-THERAPEUTIC IMPACT OF INTEGRATED
Objective: To study the feasibility and the diagnostic-therapeutic impact of integrated ultrasound in patients with cardiac arrest or periarrest in the ED. Patients and methods: We enrolled 30 patients admitted to the ED of the Pinerolo General Hospital (Turin, Italy), 14 with cardiac arrest (PEA 12, V-Fib 1, asystolia 1), and 16 in peri-arrest. All patients were managed according to ALS and ATLS guidelines; in addition, they underwent extensive ultrasonographic evaluation, primarily focused on heart or lungs, then extended to other body districts, if needed. We evaluated: feasibility, diagnostic-therapeutic impact and potential support in procedure execution. Results: The integrated ultrasound approach was feasible in all patients, in a short time and without interfering with other procedures. Heart was evaluated in 30 patients (100%), lungs in 11 (37%), inferior vena cava (IVC) in 9 (30%), and other districts in 11 (37%). In 19 out of 30 patients (63%) the diagnosis was defined based on ultrasound results: pulmonary embolism 7, cardiac tamponade 1, acute pulmonary oedema 2, myocardial infarction 1, aortic valve endocarditis 1, aortic dissection 1, pneumothorax 1, ARDS 1, hypovolemia 4. Ultrasonography findings led to therapeutic changes in 13 out of 30 patients (43%): thrombolysis 6, discontinuation of chest compressions during pseudo-PEA 2, fluid resuscitation 1, pericardiocentesis 1, chest tube 1, antibiotics 1, anticoagulation 1. In 9 out of 30 patients (30%) invasive procedures were performed with ultrasound support.
Conclusion: In patients with cardiac arrest or peri-arrest, integrated ultrasound is feasible in a short time and has high diagnostic-therapeutic impact, leading to better diagnostic definition and/or therapeutic variations in over a half of the patients. Background: Lung ultrasound has elevated accuracy in discriminating cardiogenic from not-cardiogenic causes of dyspnea, but it does not allow to define the underlying cardiac pathophysiology, which often can be only presumed.

DIAGNOSTIC-THERAPEUTIC IMPACT
Objective: To study the feasibility and the diagnostic-therapeutic impact of echocardiography in patients with acute dyspnea in the ED.
Patients and methods: Between January and June 2006 we prospectively enrolled 50 patients admitted to the ED of the Pinerolo General Hospital (Turin, Italy) with acute dyspnoea (i.e. dyspnea appeared or worsened in the last 48 h). In each patient we performed: physical examination, lung ultrasound, EKG, chest X-ray, and arterial blood gas analysis (ABG). On the basis of the results, the physician examining the patient was invited to define: (a) the main diagnosis (heart failure HF, lung failure LF, or mixed failure MF), (b) the cardiac pathophysiology, and (c) the etiological diagnosis. Immediately after this first evaluation, echocardiography was performed in all patients. We then compared the diagnosis made before and after the performance of echocardiography, and we recorded the therapeutic changes that were introduced based on the ultrasonography findings.
Results: Echocardiography was feasible in all patients. Echocardiography results induced a change in the main diagnosis in 2 out of 50 patients (4%), and in cardiac pathophysiology in 19 out of 50 patients (38%). In addition, ultrasonography findings led to therapeutic changes in 8 patients.
Conclusion: In patients with acute dyspnea in the setting of ED, the integration/implementation of clinical evaluation with lung ultrasound allows the correct definition of cardiac pathophysiology only in about 60% of patients. In our experience, echocardiography is feasible in all patients and has high diagnostic (40%) and therapeutic (15-20%) impact. Background: The radiologic diagnosis of pneumonia in ED has a low sensitivity and specificity, often delaying the appropriate therapy and leading to unnecessary examinations.
Objective: Evaluate the diagnostic potential of lung ultrasound in patients admitted in ED with suspected pneumonia and a non-diagnostic first chest XR, using as control the diagnosis at discharge. Patients and methods: We examined 17 pt, between August and October 2008, admitted to our ED with suspected pneumonia (fever, chest/abdominal pain, cough, dyspnoea, increased CRP, WBC) and first chest XR non-diagnostic for pneumonia. All lung ultrasound were performed with a convex 3.5-5 MHz probe, scanning perpendicular, oblique and parallel to the ribs in anterior, lateral and posterior thorax. Lateral position was used to scan the posterior thorax in critical patients. All scans were performed by the same operator and lasted less than 5 min. US signs considered diagnostic of pneumonia: -Lung consolidation containing branching echogenic structures with centrifugal movements during breathing (dynamic bronchograms), anechoic tubular structures with hyperechogenic walls, with no color-Doppler signal (fluid bronchograms) -Interstitial Syndrome (B lines) near the consolidation or isolated asymmetric (early stages), or bilateral early bilater pneumonia, interstitial pneumonia) -Hypoechogenic pleural line with reduced or absent gliding, irregular border between consolidation and normal lung. Results Lung US was positive in 5 pt with pleuritic pain, 6 pt with sepsis of unknown origin, 2 pt with dyspnoea, 4 pt with respiratory failure in chronic lung disease. Lung US showed retrocardiac pneumonia in 8 pt (47%) and in these entire cases first chest XR was performed only in AP. First chest XR was negative in 11 pt, uncertain in 2 pt, positive for pleural effusion in 4 pt. Chest XR was performed only in AP in 14 cases (82%). A second chest XR was controlled in 10 pt resulting positive for pneumonia in 4 cases. Chest CT scan was performed in 6 pt, always confirming the US findings.: 4 consolidations, 1 ground glass pattern(B lines US finding), 1 consolidation with empyema. In the remaining 7 cases the diagnosis of pneumonia was supported by clinical and laboratory evolution. Lung US changed therapy and medical decisions in 16 cases. Conclusions: Lung US is a simple and rapid examination that can be easily repeated bedside and could be a very useful diagnostic tool in ED. Chest XR seems to have a low accuracy, in particular when the exam is performed only in. Lung US could discover pneumonia before chest XR (interstitial pattern in the early stages). We cannot say anything about sensitivity or specificity of lung US, because we did not consider pt with first positive chest XR, or negative lung US. Indications to CVC positioning have been especially superficial veins absence (30% of cases) and the prescription of phlebo-tossic drugs (51%); the most frequently used veins have been right internal jugular vein (30 cases = 44%) and right subclavian vein (28 cases = 41%).
Results: of the 48 procedures performed by the expert physicians, 27 (56%) have been performed with echography and 21 (44%) without echography; of the 21 procedures performed by the less expert ones, 15 (72%) have been performed with and 6 (28%) without echography. A X-ray control has been performed in 55 cases (80%) and has not in 14: 12 (86%) of the latest echo control had been used.
Conclusion: A greater inclination to the ECD use in the less expert group (OR = 1.9) than the expert one (OR = 0.5) results from the mentioned data; it could depend on a lower attitude of the latest toward new technologies. The larger safety that was given to the operator by ECD use brings in the less appeal to X-ray control. Objective: To study the diagnostic-therapeutic impact of lung ultrasound in patients with acute dyspnoea in the ED. Patients and methods: Between June and October 2008, we prospectively enrolled 33 patients admitted to the ED of the Pinerolo General Hospital (Turin, Italy) with acute dyspnea (i.e. dyspoea appeared or worsened in the last 48 h). The presence of 5 fundamental syndromes (consolidation, localized and diffused interstitial syndrome, pneumothorax, and pleural effusion) was evaluated by lung ultrasound by the emergency physician who first evaluated the patient in the ED. We then compared the clinical diagnosis made before and after the performance of lung ultrasound, and we recorded the therapeutic changes that were introduced based on the ultrasonography findings. Results: Lung ultrasound performance induced a change of the initial diagnosis in about 50% of the patients. In particular, the diagnostic hypothesis made after the first evaluation in the ED (main, respiratory pathophysiological and etiological) was modified, as a consequence of lung ultrasound results, in 48, 55, and 61% of the patients, respectively. In addition, ultrasonography findings led to therapeutic changes in 17 out of 33 patients (52%); if we considered only those patients in whom the diagnosis was modified after lung ultrasound, we recorded a therapeutic change in 78% of the patients. Conclusion: Lung ultrasound improves the diagnostic definition in patients with acute dyspnea in the setting of ED. This better diagnosis often leads to change the therapy, which can be oriented to the pathophysiology. Background: Subclavian vein is usually preferred for central vein catheter (CVC) positioning because of its easy accessibility and few infective complications, also relative to anterior ultrasonographically-guided internal jugular vein placement. Little is known about the complications of the posterior approach of ultrasonographically-guided internal jugular vein catheterization.
Objective: Incidence of early and late complications due to infraclavicular subclavian vein catheterization (iS) relative to echo-guided internal jugular vein by anterior (aIJ) or posterior (pIJ) approach. Patients and methods: 87 patients have been cannulated with a CVC with the approach in which the operator was most confident. All the precautions for infection prevention have been strictly observed and the subsequent management has been uniformly done in the three groups. The early and late complications have been evaluated and the differences between the three groups have been examined by the one way variance analysis (ANOVA). Results: The CVCs positioned have been: 22 iS, 31 aIJ and 34 pIJ. The early complications have been: 4.5% in the iS group (one pneumothorax), 0% in the ultrasound-guided aIJL and pIJ. The late complications have been: 4.5% in the iS group (vein thrombosis), 6.4% in the aIJ group (cetheter-related infection and vein thrombosis), 2.9% in the pIJ group (skin redness without catheter-related infection). Multiple incannulation attempts have been made with the iS approach. The difference in late complications has reached statistical significance between the pIJ group and either iS and aIJ groups. Conclusion: The posterior ultrasound-guided approach is associated with small percentage of early and late complications and as such is better than the subclavian approach. These results are the consequence of the use of ultrasound (reduced incannulation attempts) and of the ease of dressing of the posteriorly positioned internal jugular catheter.