1. Pediatric Hospitalist Skills Day Conference Sept 26 th, 2009 James White, MD Ultrasound Credentialing/Training Department of Emergency Medicine The Permanente Medical Group Sacramento/Roseville

2. Disclosure of Relevant Financial Relationships Dr. White has disclosed that he has no relevant relationships with commercial or industry organizations. The CME Department has reviewed disclosure information for the planners and developers for this program and they do not have relationships that present a relevant conflict of interest.

3. Acknowledgements: Paul-Andre Abboud, MD Assistant Chief of Department Emergency Medicine The Permanente Medical Group, Inc Emergency Medicine Oakland/Richmond

5. Today's Goal Demonstrate how to place an Internal Jugular Central Line under sterile conditions Demonstrate how to place an Internal Jugular Central Line under sterile conditions Discuss double wall phenomena Discuss double wall phenomena Practice Practice

6. Knobology 1) On button in back on the right of machine 2) Gain-amplifies returning echo at the expense of contrast. expense of contrast. 3) Depth-adjusts target location to area of 3) Depth-adjusts target location to area of maximal resolution and minimal scatter. maximal resolution and minimal scatter. Usually in the middle. Usually in the middle.

14. Venous or Arterial? Arterial Arterial Round Round Thick walled Thick walled Pulsatile Pulsatile Not easily collapsible Not easily collapsible Venous May be ovoid or flat on top Thin walled Expand with valsalva Easily collapsible with gentle pressure

17. Two approaches to Interrogation 1) Short axis- Transverse view 1) Short axis- Transverse view 2) Long axis 2) Long axis