If you're as old as I am, you probably learned how to place an internal jugular (IJ) line using landmarks. I was in my third year of residency when I first used ultrasound. Flash forward to today and putting in an IJ without using ultrasound is pretty unusual, for good reason: Its use reduces complications, time to success, and the number of attempts.
What about other procedures? Do you use ultrasound to guide paracentesis or thoracentesis? A lot of us are at least using ultrasound to mark the spot in these procedures. What about arthrocentesis? How many of us are using ultrasound to routinely guide joint aspiration in the ED? A point-counterpoint in the Annals of Emergency Medicine on using routine arthrocentesis in the ED provides some answers.
Gottlieb and Alerhand argued for routinely using ultrasound for arthrocentesis. (Ann Emerg Med. 2020;75:261.) They began their argument by reminding us that ultrasound is better for diagnosing a joint effusion than a traditional physical exam and that it can alter the decision to perform the procedure in the first place. These authors cited multiple studies in which using ultrasound improved success rates in joint aspiration of knees, shoulders, and particularly hips. Not surprisingly, ultrasound reduced damage to surrounding structures as well. A couple of studies demonstrated reduced pain with the ultrasound-guided technique. The authors also emphasized that the technique is easy to learn and quick to perform.
Long, April, and Koyfman argued against routinely using ultrasound for arthrocentesis. (Ann Emerg Med. 2020;75:262.) They conceded that some literature supports using ultrasound, but noted that many of these studies were done in other environments (an orthopedics clinic, for example) and may not be as applicable to the ED. They emphasized that the joint being aspirated plays a role as well: The hips seem more likely to benefit from ultrasound guidance than the knees, for example. The authors also pointed out the possible increased cost and time of using ultrasound because some additional training is needed.
Both sets of authors cited literature supporting their positions, so where do I fall on this one? Ultrasound has been critical in my practice in identifying joint effusions, even in “easy” joints like the knee. Not every patient's anatomy is easily discerned on physical exam alone. Being able to differentiate between superficial causes of swelling (such as bursitis) and a tappable effusion has saved me unnecessary procedures. Even when I wind up putting the probe down for the actual procedure itself, it's only because I've used ultrasound to assess the joint and know where I want to put my needle. To me, it's a no-brainer.
Dr. Buttsis the director of the division of emergency ultrasound and a clinical assistant professor of emergency medicine at Louisiana State University at New Orleans. Follow her on Twitter@EMNSpeedofSound, and read her past columns athttp://bit.ly/EMN-SpeedofSound.