Emergency Point-of-Care Ultrasound Stewardship - A Joint Position Paper by EuSEM and EFSUMB and Endorsed by IFEM and WFUMB.

Emergency Medicine Point-of-Care Ultrasound (EMPoCUS) is a convincing concept. It has spread rapidly because of its intuitive, simple applicability and low equipment costs. The speed of its emerging growth frequently outpaces the development of quality assurance and education. Indeed, education standards vary worldwide, and in some cases seem to neglect the principles of modern competence-based education. Additional challenges are encountered such as remote or low resource medical practice. Here, EMPoCUS might be the only ad-hoc imaging modality available. Once mastery of EMPoCUS is achieved, emergency physicians should be able to independently and efficiently care for their patients using a variety of PoCUS skills. However, most curricula only define these tasks as non-binding and in general terms or use outdated measures, such as length of training and self-reporting of achieved examinations with variable oversight, or administrative measures to create educational milestones. This threatens to take quality assurance down the wrong path. It created a scenario in which concrete EMPoCUS skill outcome measures that would realistically reflect the training objectives and simultaneously would be easily observable and verifiable are lacking. In view of the dangers of poorly controlled EMPoCUS dissemination and the current lack of European guidelines, we would like to set central standards for European EMPoCUS stewardship based on a critical review of the current situation. This position paper, which was jointly developed by EuSEM and EFSUMB and endorsed by IFEM and WFUMB, is also intended to accompany the EFSUMB/EuSEM guidelines on PoCUS currently being prepared for publication.

Acquisition and interpretation of focused diagnostic ultrasound images by ultrasound-naive advanced paramedics: trialling a PHUS education programme.

OBJECTIVE: This trial investigated whether advanced paramedics from a UK regional ambulance service have the ability to acquire and interpret diagnostic quality ultrasound images following a 2-day programme of education and training covering the fundamental aspects of lung ultrasound. METHOD: The participants were tested using a two-part examination; assessing both their theoretical understanding of image interpretation and their practical ability to acquire diagnostic quality ultrasound images. The results obtained were subsequently compared with those obtained from expert physician sonographers. RESULTS: The advanced paramedics demonstrated an overall accuracy in identifying the presence or absence of pneumothorax in M-mode clips of 0.94 (CI 0.86 to 0.99), compared with the experts who achieved 0.93 (CI 0.67 to 1.0). In two-dimensional mode, the advanced paramedics demonstrated an overall accuracy of 0.78 (CI 0.72 to 0.83), compared with the experts who achieved 0.76 (CI 0.62 to 0.86). In total, the advanced paramedics demonstrated an overall accuracy at identifying the presence or absence of pneumothorax in prerecorded video clip images of 0.82 (CI 0.77 to 0.86), in comparison with the expert users of 0.80 (CI 0.68 to 0.88). All of the advanced paramedics passed the objective structured clinical examination and achieved a practical standard considered by the examiners to be equivalent to that which would be expected from candidates enrolled on the thoracic module of the College of Emergency Medicine level 2 ultrasound programme. CONCLUSION: This trial demonstrated that ultrasound-naive practitioners can achieve an acceptable standard of competency in a simulated environment in a relatively short period of time.

Is point-of-care ultrasound a reliable predictor of outcome during atraumatic, non-shockable cardiac arrest? A systematic review and meta-analysis from the SHoC investigators.

AIMS: To evaluate the accuracy of PoCUS in predicting return of spontaneous circulation (ROSC), survival to hospital admission (SHA), and survival to hospital discharge (SHD) in adult non-traumatic, non-shockable out-of-hospital or emergency department cardiac arrest. METHODS: Medline, EMBASE, Cochrane, CINAHL, ClinicalTrials.gov and the World Health Organization Registry were searched for eligible studies. Data analysis was completed according to PRISMA guidelines. A random-effects meta-analysis model was used with I-squared statistics for heterogeneity. RESULTS: Ten studies (1486 participants) were included. Cardiac activity on PoCUS had a pooled sensitivity of 60.3% (95% confidence interval 38.1%-78.9%) and specificity of 91.5%(80.8%-96.5%) for ROSC. The sensitivity of cardiac activity on PoCUS for predicting ROSC was 26.1%(7.8%-59.6%) in asystole compared with 76.7% (61.3%-87.2%) in PEA. Cardiac activity on PoCUS, compared to absence, had odd ratios of 16.90 (6.18-46.21) for ROSC, 10.30(5.32-19.98) for SHA and 8.03(3.01-21.39) for SHD. Positive likelihood ratio (LR) was 6.87(3.21-14.71) and negative LR was 0.27(0.12-0.60) for ROSC. CONCLUSIONS: Cardiac activity on PoCUS was associated with improved odds for ROSC, SHA, and SHD in non-traumatic, non-shockable cardiac arrest. We report a lower sensitivity and higher negative likelihood ratio, but greater heterogeneity compared to previous systematic reviews. PoCUS may provide valuable information in the management of non-traumatic PEA or asystole, but should not be viewed as the sole predictor in determining outcomes.

International Federation for Emergency Medicine Consensus Statement: Sonography in hypotension and cardiac arrest (SHoC): An international consensus on the use of point of care ultrasound for undifferentiated hypotension and during cardiac arrest.

Introduction The International Federation for Emergency Medicine (IFEM) Ultrasound Special Interest Group (USIG) was tasked with development of a hierarchical consensus approach to the use of point of care ultrasound (PoCUS) in patients with hypotension and cardiac arrest. METHODS: The IFEM USIG invited 24 recognized international leaders in PoCUS from emergency medicine and critical care to form an expert panel to develop the sonography in hypotension and cardiac arrest (SHoC) protocol. The panel was provided with reported disease incidence, along with a list of recommended PoCUS views from previously published protocols and guidelines. Using a modified Delphi methodology the panel was tasked with integrating the disease incidence, their clinical experience and their knowledge of the medical literature to evaluate what role each view should play in the proposed SHoC protocol. RESULTS: Consensus on the SHoC protocols for hypotension and cardiac arrest was reached after three rounds of the modified Delphi process. The final SHoC protocol and operator checklist received over 80% consensus approval. The IFEM-approved final protocol, recommend Core, Supplementary, and Additional PoCUS views. SHoC-hypotension core views consist of cardiac, lung, and inferior vena vaca (IVC) views, with supplementary cardiac views, and additional views when clinically indicated. Subxiphoid or parasternal cardiac views, minimizing pauses in chest compressions, are recommended as core views for SHoC-cardiac arrest; supplementary views are lung and IVC, with additional views when clinically indicated. Both protocols recommend use of the "4 F" approach: fluid, form, function, filling. CONCLUSION: An international consensus on sonography in hypotension and cardiac arrest is presented. Future prospective validation is required.

International Federation for Emergency Medicine point of care ultrasound curriculum.

To meet a critical and growing need for a standardized approach to emergency point of care ultrasound (PoCUS) worldwide, emergency physicians must be trained to deliver and teach this skill in an accepted and reliable format. Currently, there is no globally recognized, standard PoCUS curriculum that defines the accepted applications, as well as standards for training and practice of PoCUS by specialists and trainees in emergency medicine. To address this deficit, the International Federation for Emergency Medicine (IFEM) convened a sub-committee of international experts in PoCUS to outline a curriculum for training of specialists in emergency PoCUS. This curriculum document represents the consensus of recommendations by this sub-committee. The curriculum is designed to provide a framework for PoCUS education in emergency medicine. The focus is on the processes required to select core and enhanced applications, as well as the key elements required for the delivery of PoCUS training from introduction through to continuing professional development and skill maintenance. It is designed not to be prescriptive but to assist educators and emergency medicine leadership to advance PoCUS education in emergency medicine no matter the training venue. The content of this curriculum is relevant not just for communities with mature emergency medicine systems but in particular for developing nations or for nations seeking to develop PoCUS training programs within the current educational structure. We anticipate that there will be wide variability in how this curriculum is implemented and taught, reflecting the existing educational environment, resources and goals of educational programs.