Test Characteristics of Emergency Medicine-Performed Point-of-Care Ultrasound for the Diagnosis of Acute Cholecystitis: A Systematic Review and Meta-analysis.

Acute cholecystitis accounts for up to 9% of hospital admissions for acute abdominal pain, and best practice entails early surgical management. Ultrasound is the standard modality used to confirm diagnosis. Our objective was to perform a systematic review and meta-analysis to determine the diagnostic accuracy of emergency physician-performed point-of-care ultrasound for the diagnosis of acute cholecystitis when compared with a reference standard of final diagnosis (informed by available surgical pathology, discharge diagnosis, and radiology-performed ultrasound). We completed a systematic review and meta-analysis, registered in PROSPERO, in adherence to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched 7 databases as well as gray literature in the form of select conference abstracts from inception to February 8, 2023. Two independent reviewers completed study selection, data extraction, and risk of bias (QUADAS-2) assessment. Disagreements were resolved by consensus with a third reviewer. Data were extracted from eligible studies to create 2 × 2 tables for diagnostic accuracy meta-analysis. Hierarchical Summary Receiver Operating Characteristic models were constructed. Of 1855 titles/abstracts, 40 were selected for full-text review. Ten studies (n=2356) were included. Emergency physician-performed point-of-care ultrasound with final diagnosis as the reference standard (7 studies, n=1,772) had a pooled sensitivity of 70.9% (95% confidence interval [CI] 62.3 to 78.2), specificity of 94.4% (95% CI 88.2 to 97.5), positive likelihood ratio of 12.7 (5.8 to 27.5), and negative likelihood ratio of 0.31 (0.23 to 0.41) for the diagnosis of acute cholecystitis. Emergency physician-performed point-of-care ultrasound has high specificity and moderate sensitivity for the diagnosis of acute cholecystitis in patients with clinical suspicion. This review supports the use of emergency physician-performed point-of-care ultrasound to rule in a diagnosis of acute cholecystitis in the emergency department, which may help expedite definitive management.

Test Characteristics of Chest Ultrasonography for Rib Fractures Following Blunt Chest Trauma: A Systematic Review and Meta-analysis.

STUDY OBJECTIVE: Chest ultrasonography has been reported as an accurate imaging modality and potentially superior to chest radiographs in diagnosing traumatic rib fractures. However, few studies have compared ultrasonography to the reference standard of computed tomography (CT), with no systematic reviews published on the topic to date. Our objective was to summarize the evidence comparing the test characteristics of chest ultrasonography to CT in diagnosing rib fractures. METHODS: This study was performed and reported in adherence to PRISMA guidelines. We searched 5 databases plus gray literature from inception to October 2021. Two independent reviewers completed study selection, data extraction, and a QUADAS-2 risk of bias assessment. Summary measures were obtained from the Hierarchical Summary Receiver Operating Characteristic model. RESULTS: From 1,660 citations, we identified 7 studies for inclusion, of which 6 had available 2×2 data for meta-analysis (n = 663). Of the 6 studies, 3 involved emergency department-performed ultrasonography and 3 radiology-performed ultrasonography. Chest ultrasonography had a pooled sensitivity of 89.3% (95% confidence interval [CI], 81.1 to 94.3) and specificity of 98.4% (95% CI, 90.2 to 99.8) compared with CT imaging for the diagnosis of any rib fracture. The finding of a fracture on ultrasonography, defined as an underlying cortical irregularity, was associated with a +likelihood ratio (LR) of 55.7 (95% CI, 8.5 to 363.4) for CT diagnosed rib fracture, while the absence of ultrasonography fracture held a -LR of 0.11 (95% CI, 0.06 to 0.20). We were unable to detect a difference in test characteristics between emergency department- and radiology-performed ultrasonography (P=.11). The overall risk of bias of included studies was high, with patient selection identified as the highest risk domain. CONCLUSION: Chest ultrasonography is both sensitive and highly specific in diagnosing rib fractures following blunt trauma.

Diagnostic Accuracy of Lung Point-Of-Care Ultrasonography for Acute Heart Failure Compared With Chest X-Ray Study Among Dyspneic Older Patients in the Emergency Department.

BACKGROUND: Acute heart failure and exacerbation of chronic obstructive pulmonary disease (COPD) are sometimes difficult to differentiate in the emergency department (ED). OBJECTIVES: We sought to determine the classification performance of lung point-of-care ultrasound (POCUS) compared with chest x-ray study to identify acute heart failure in an older population. METHODS: We conducted a cohort study with additional health records review between March and September 2017. We included consecutive patients aged 50 years and older with shortness of breath from suspected acute heart failure or COPD. The reference standard was discharged diagnosis, ED diagnosis with confirmation by another physician, or diagnosis made by health record reviews. We calculated the classification performance of lung POCUS to diagnose acute heart failure as well as that of chest x-ray study, and compared them by exact McNemar test. RESULTS: There were 81 patients evaluated with lung POCUS, and 67 had acute heart failure. Emergency physicians identified acute heart failure by lung POCUS with sensitivity of 92.5% (95% confidence interval [CI] 83.4-97.5%) and specificity of 85.7% (95% CI 57.2-98.2%). The radiology reading of chest x-ray study had sensitivity of 63.6% (95% CI 50.9-75.1%) and specificity of 92.9% (95% CI 66.1-99.8%). The sensitivity of lung POCUS was significantly higher than that of chest x-ray study (p = 0.0003). CONCLUSIONS: Lung POCUS in a real clinical setting was highly sensitive and specific in identifying acute heart failure, and performed better than chest x-ray in an older population.

The Canadian Medical Student Ultrasound Curriculum: A Statement From the Canadian Ultrasound Consensus for Undergraduate Medical Education Group.

OBJECTIVES: This study sought to establish by expert review a consensus-based, focused ultrasound curriculum, consisting of a foundational set of focused ultrasound skills that all Canadian medical students would be expected to attain at the end of the medical school program. METHODS: An expert panel of 21 point-of-care ultrasound and educational leaders representing 15 of 17 (88%) Canadian medical schools was formed and participated in a modified Delphi consensus method. Experts anonymously rated 195 curricular elements on their appropriateness to include in a medical school curriculum using a 5-point Likert scale. The group defined consensus as 70% or more experts agreeing to include or exclude an element. We determined a priori that no more than 3 rounds of voting would be performed. RESULTS: Of the 195 curricular elements considered in the first round of voting, the group reached consensus to include 78 and exclude 24. In the second round, consensus was reached to include 4 and exclude 63 elements. In our final round, with 1 additional item added to the survey, the group reached consensus to include an additional 3 and exclude 8 elements. A total of 85 curricular elements reached consensus to be included, with 95 to be excluded. Sixteen elements did not reach consensus to be included or excluded. CONCLUSIONS: By expert opinion-based consensus, the Canadian Ultrasound Consensus for Undergraduate Medical Education Group recommends that 85 curricular elements be considered for inclusion for teaching in the Canadian medical school focused ultrasound curricula.

Point-of-Care Ultrasound Performed by a Medical Student Compared to Physical Examination by Vascular Surgeons in the Detection of Abdominal Aortic Aneurysms.

BACKGROUND: The use of point-of-care ultrasound (POCUS) has become increasingly prevalent in medical practice as a non-invasive tool for focused bedside diagnosis. Consequently, some medical schools have begun implementing POCUS training as a standard in their medical school curriculum. The feasability and value of introducing POCUS training at the medical student level to screen for abdominal aortic aneurysms (AAA) should be explored. Given this, the objective of our study was to determine the test characteristics of point-of-care ultrasonography performed by a medical student versus physical examination by vascular surgeons compared to a gold standard reference scan for the detection of AAAs. METHODS: We conducted a prospective, observer-blinded study recruiting patients from an outpatient vascular surgery clinic. Participants were screened for AAAs by standardized physical examination by a blinded vascular surgeon, followed by a POCUS examination by a blinded medical student. The student underwent prior training by a vascular sonographer and emergency physician on 60 patients (16 were supervised). Ultrasonography was used to visualize and measure the proximal, mid, and distal aortic diameters. The maximal aortic diameter was noted and compared with measurements obtained by the reference scan (computed tomography scan or vascular sonographer-performed ultrasound). Reference scans were completed within 3 months of the recruitment visit. RESULTS: A total of 57 patients were enrolled over a 5-month period between October 2015 and March 2016. Mean age of recruited patients was 71 years, and 61% were male. Mean body mass index was 27.9 ± 4.3, and mean waist-to-hip ratio was 0.96 ± 0.10. Sixteen AAAs were detected by the reference scan, with an average maximal aortic diameter of 44.9 mm. Physical examination by a vascular surgeon detected 11 of 16 AAAs with 2 false positives (sensitivity and specificity of 66.7% [95% confidence interval [CI], 38.4-88.2] and 94.4% [95% CI, 81.3-99.3], respectively). POCUS detected 15 of 16 AAAs (sensitivity and specificity of 93.3% [95% CI, 68.1-99.8] and 100% [95% CI, 88.4-100], respectively). Seven of the 64 POCUS scans were indeterminate (>1 cm of the aorta was not visualized). Average time to conduct the physical examination was 35 sec versus 4.0 min for point-of-care ultrasonography. There was a strong linear correlation (R2 = 0.95) between maximal aortic diameter measured by point-of-care ultrasonography versus reference scan with a mean absolute difference of 2.6 mm. CONCLUSION: Point-of-care ultrasonography performed by a medical student is highly accurate and more effective in detecting AAAs than physical examination by vascular surgeons. The introduction of POCUS training at the medical student level and its wide-scale implementation as an extension to physical examination may lead to improved detection of AAAs.

Ultrasonography for the prediction of urological surgical intervention in patients with renal colic.

CONTEXT: There are no clear indicators of which ultrasound findings in an emergency department (ED) renal colic population are predictive of urological surgical intervention. OBJECTIVE: To determine the sonographic findings of renal colic that predict surgical intervention. METHODS: We conducted a retrospective cohort study of 500 consecutive ED patients with a diagnosis of renal colic that had ultrasonography (performed by radiology) during their ED visit. Our main outcome was urological surgical intervention. This was defined as extracorporeal shock wave lithotripsy, percutaneous nephrostomy or ureteroscopy performed within 16 weeks of the initial ED presentation. RESULTS: Of the 500 identified patients, 483 met our eligibility criteria. Of this group, 67 (13.9%) received a surgical intervention. Ultrasound (US) findings were 97% (95% CI 88.7% to 99.5%) sensitive and 28.1% (23.9% to 32.8%) specific in 'diagnosing' the requirement for surgery when the ultrasound (US) showed either at least a stone present or showed moderate to severe hydronephrosis. The presence of stone and moderate to severe hydronephrosis had a + likelihood ratio (LR) 3.86 (2.46 to 6.07) and a -LR 0.72 (0.60 to 0.86). Having a stone ≥6 mm had a sensitivity of 77.6% (65.5% to 86.5%), a specificity of 73.6% (69.0% to 77.7%), a +LR of 2.94 (2.39 to 3.6) and a -LR 0.30 (0.19 to 0.48). CONCLUSIONS: Radiology performed ultrasonography is a valuable tool for identifying renal colic that will go on to receive a surgical intervention in the 16 weeks following an ED visit. Further studies are needed to confirm the utility of ultrasound findings of stone visualisation, stone size and moderate to severe hydronephrosis in determining which patients need outpatient urology follow-up.

Sonography of the Optic Nerve Sheath Diameter for Detection of Raised Intracranial Pressure Compared to Computed Tomography: A Systematic Review and Meta-analysis.

OBJECTIVES: The diagnosis of raised intracranial pressure (ICP) is important in many critically ill patients. The optic nerve sheath is contiguous with the subarachnoid space; thus, an increase in ICP results in a corresponding increase in the optic nerve sheath diameter. The objective of this study was to assess the diagnostic accuracy of sonography of the optic nerve sheath diameter compared to computed tomography (CT) for predicting raised ICP. METHODS: We searched PubMed, EMBASE, and the Cochrane database from 1986 to August 2013 and performed hand searches. Two independent reviewers extracted data. Study quality was assessed by using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool. We calculated κ agreement for study selection and evaluated clinical and quality homogeneity before the meta-analysis. RESULTS: From 1214 studies, we selected 45 for full review. Twelve studies with 478 participants were included (κ = 0.89). Ocular sonography yielded sensitivity of 95.6% (95% confidence interval [CI], 87.7%-98.5%), specificity of 92.3% (95% CI, 77.9%-98.4%), a positive likelihood ratio of 12.5 (95% CI, 4.16-37.5), and a negative likelihood ratio of 0.05 (95% CI, 0.02-0.14). Average quality according to the QUADAS tool was 7.4 of 11. There was moderate to high heterogeneity based on the prediction ellipse area and variance logit of sensitivity (2.1754) and specificity (2.6720). CONCLUSIONS: Ocular sonography shows good diagnostic test accuracy for detecting raised ICP compared to CT: specifically, high sensitivity for ruling out raised ICP in a low-risk group and high specificity for ruling in raised ICP in a high-risk group. This noninvasive point-of-care method could lead to rapid interventions for raised ICP, assist centers without CT, and monitor patients during transport or as part of a protocol to reduce CT use.

Test characteristics of point-of-care ultrasonography in patients with acute kidney injury.

BACKGROUND: Acute kidney injury is a common disorder that is associated with significant morbidity and mortality. Point-of-care ultrasonography (PoCUS) is an imaging modality performed at the bedside and is used to assess for obstructive causes of acute kidney injury. Little is known about the test characteristics of PoCUS in patients with acute kidney injury. OBJECTIVE: Our primary objective was to describe the test characteristics of PoCUS for the detection of hydronephrosis in patients presenting with acute kidney injury at our centre. Our secondary objective was to describe the current rate of use of PoCUS for this indication. RESULTS: In total, 7873 patients were identified between June 1, 2019 and April 30, 2021, with 4611 meeting inclusion criteria. Of these, 94 patients (2%) underwent PoCUS, and 65 patients underwent both PoCUS and reference standard, for a total of 124 kidneys included in our diagnostic accuracy analysis. The prevalence of hydronephrosis in our cohort was 33% (95% CI 25-41%). PoCUS had a sensitivity of 85% (95% CI 71-94%) and specificity of 78% (95% CI 68-87%) for the detection of hydronephrosis. CONCLUSION: We describe the test characteristics of PoCUS for the detection of hydronephrosis in a cohort of patients with acute kidney injury. The low uptake of this test presents an opportunity for quality improvement work to increase its use for this indication.

Comparison of peer-assisted learning with expert-led learning in medical school ultrasound education: a systematic review and meta-analysis.

INTRODUCTION: Teaching point-of-care ultrasonography (PoCUS) to medical students is resource intensive. Peer-assisted learning, where the teacher can be a medical student, may be a feasible alternative to expert-led learning. The objective of this systematic review and meta-analysis was to compare the PoCUS performance assessments of medical students receiving peer-assisted vs expert-led learning. METHODS: This study was submitted to PROSPERO (CRD42023383915) and reported with PRISMA guidelines. MEDLINE, Embase, ERIC, Education Source, Scopus, and Web of Science were searched from inception to November 2022. Inclusion criteria were studies comparing peer-assisted vs expert-led PoCUS teaching for undergraduate medical students. The primary outcome was performance assessment of PoCUS skills. Two reviewers independently screened citations and extracted data. The Cochrane risk-of-bias tool for randomized trials was used to assess study quality. Studies were included in the meta-analysis if mean performance assessment scores with standard deviations and sample sizes were available. A random-effects meta-analysis was conducted to estimate the accuracy score of practical knowledge test for each group. A meta-regression evaluated difference in mean scores. RESULTS: The search yielded 2890 citations; 1417 unique citations remained after removing duplicates. Nine randomized-controlled studies conducted in Germany, USA, and Israel, with 593 participants, were included in the meta-analysis. The included studies assessed teaching of abdominal, cardiac, thoracic, musculoskeletal, and ocular PoCUS skills. Most studies had some risk-of-bias concerns. The estimate accuracy score after weighting is 0.56 (95% CI [0.47, 0.65]) for peer-assisted learning and 0.59 (95% CI [0.49, 0.69]) for expert-led learning. The regression coefficient estimate is 0.0281 (95% CI [- 0.1121, 0.1683]); P value is 0.69. CONCLUSION: This meta-analysis found that peer-assisted learning was a reasonable alternative to expert-led learning for teaching PoCUS skills to medical students.

RéSUMé: INTRODUCTION: L'enseignement de l'échographie au point d'intervention (PoCUS) aux étudiants en médecine nécessite des ressources importantes. L'apprentissage assisté par les pairs, où l'enseignant peut être un étudiant en médecine, peut être une alternative possible à l'apprentissage dirigé par des experts. L'objectif de cette revue systématique et de cette méta-analyse était de comparer les évaluations de performance PoCUS d'étudiants en médecine bénéficiant d'un apprentissage assisté par des pairs par rapport à un apprentissage dirigé par des experts. MéTHODES: Cette étude a été soumise à PROSPERO (CRD42023383915) et rapportée selon les directives PRISMA. MEDLINE, Embase, ERIC, Education Source, Scopus et Web of Science ont été recherchés depuis leur création jusqu'en novembre 2022. Les critères d'inclusion étaient les études comparant l'enseignement du PoCUS assisté par des pairs à celui dirigé par des experts pour les étudiants en médecine de premier cycle. Le principal résultat était l'évaluation du rendement des compétences PoCUS. Deux évaluateurs ont indépendamment examiné les citations et extrait les données. L'outil Cochrane d'évaluation du risque de biais pour les essais randomisés a été utilisé pour évaluer la qualité des études. Les études ont été incluses dans la méta-analyse si les scores moyens d'évaluation des performances avec les écarts types et la taille des échantillons étaient disponibles. Une méta-analyse à effets aléatoires a été réalisée pour estimer le score de précision du test de connaissances pratiques pour chaque groupe. Une méta-régression a évalué la différence dans les scores moyens. RéSULTATS: La recherche a donné lieu à 2890 citations ; 1417 citations uniques ont été conservées après suppression des doublons. Neuf études contrôlées randomisées menées en Allemagne, aux États-Unis et en Israël, avec 593 participants, ont été incluses dans la méta-analyse. Les études incluses ont évalué l'enseignement des compétences PoCUS abdominales, cardiaques, thoraciques, musculo-squelettiques et oculaires. La plupart des études présentaient des risques de biais. Le score de précision estimé après pondération est de 0,56 (IC à 95 % : [0,47, 0,65]) pour l'apprentissage assisté par les pairs et de 0,59 (IC à 95 % : [0,49, 0,69]) pour l'apprentissage dirigé par des experts. L'estimation du coefficient de régression est de 0,0281 (IC à 95 % : [-0,1121, 0,1683]) ; la valeur P est de 0,69. CONCLUSION: Cette méta-analyse a montré que l'apprentissage assisté par les pairs était une alternative raisonnable à l'apprentissage dirigé par des experts pour enseigner les compétences PoCUS aux étudiants en médecine.

Recommendations for POCUS Curriculum in Canadian Undergraduate Medical Education: Consensus from the Inaugural Seguin Canadian POCUS Education Conference.

Point of care ultrasound (POCUS) in Canadian undergraduate medical education (UGME) is limited. To address this paucity, the inaugural Seguin Canadian POCUS Education Conference hosted 14 of the 17 Canadian medical schools to develop a list of recommendations for POCUS education in Canadian UGME. Attending schools were divided into delegations consisting of a pre-clerkship student, a clerkship student and a staff physician. Recommendations were developed via a modified consensus development panel. Delegations submitted school-specific POCUS education summary documents for roundtable discussions, which yielded an initial set of recommendations. These were then summarized in a large group setting and voted upon for adoption with an a priori agreement threshold of 80%. Conference attendees developed 14 recommendations which 87% of participants agreed to adopt. Conference recommendations reflect the opinions of Canadian trainees and POCUS education experts thus serving as a framework for UGME POCUS education in Canada.

Point-of-Care-ultrasound in undergraduate medical education: a scoping review of assessment methods.

BACKGROUND: Point-of-Care-Ultrasound (POCUS) curricula have rapidly expanded in undergraduate medical education (UME). However, the assessments used in UME remain variable without national standards. This scoping review characterizes and categorizes current assessment methods using Miller's pyramid for skills, performance, and competence of POCUS in UME. A structured protocol was developed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR). A literature search of MEDLINE was performed from January 1, 2010, to June 15, 2021. Two independent reviewers screened all titles and abstracts for articles that met inclusion criteria. The authors included all POCUS UME publications in which POCUS-related knowledge, skills, or competence were taught and objectively assessed. Articles were excluded if there were no assessment methods used, if they exclusively used self-assessment of learned skills, were duplicate articles, or were summaries of other literature. Full text analysis and data extraction of included articles were performed by two independent reviewers. A consensus-based approach was used to categorize data and a thematic analysis was performed. RESULTS: A total of 643 articles were retrieved and 157 articles met inclusion criteria for full review. Most articles (n = 132; 84%) used technical skill assessments including objective structured clinical examinations (n = 27; 17%), and/or other technical skill-based formats including image acquisition (n = 107; 68%). Retention was assessed in n = 98 (62%) studies. One or more levels of Miller's pyramid were included in 72 (46%) articles. A total of four articles (2.5%) assessed for students' integration of the skill into medical decision making and daily practice. CONCLUSIONS: Our findings demonstrate a lack of clinical assessment in UME POCUS that focus on integration of skills in daily clinical practice of medical students corresponding to the highest level of Miller's Pyramid. There exists opportunities to develop and integrate assessment that evaluate higher level competencies of POCUS skills of medical students. A mixture of assessment methods that correspond to multiple levels of Miller's pyramid should be used to best assess POCUS competence in UME.

Start spreading the news: a deliberate approach to POCUS program development and implementation.

While there is an expanding body of literature on Point-of-Care Ultrasound (POCUS) pedagogy, administrative elements that are necessary for the widespread adoption of POCUS in the clinical environment have received little attention. In this short communication, we seek to address this gap by sharing our institutional experience with POCUS program development and implementation. The five pillars of our program, selected to tackle local barriers to POCUS uptake, are education, workflow, patient safety, research, and sustainability. Our program logic model outlines the inputs, activities, and outputs of our program. Finally, key indicators for the monitoring of program implementation efforts are presented. Though designed for our local context, this approach may readily be adapted toward other clinical environments. We encourage others leading the integration of POCUS at their centers to adopt this approach not only to achieve sustainable change but also to ensure that quality safeguards are in place.

Point of care ultrasound training in Canadian emergency medicine residency programs.

OBJECTIVES: Point of care ultrasound (POCUS) has been endorsed as an important clinical tool by the Canadian Association of Emergency Physicians (CAEP) and is a training objective of emergency medicine (EM) residency programs accredited by both the Royal College of Physicians and Surgeons of Canada (RCPSC) and the College of Family Physicians of Canada (CFPC). Our objectives are to describe the national state of POCUS training in RCPSC-EM and CFPC-EM residency programs and to evaluate the implementation of the CAEP core POCUS curriculum in these programs. METHODS: This was an online survey study of all POCUS education leads for both RCPSC-EM and CFPC-EM programs. The survey queried participants on program demographics, description of POCUS training, methods of POCUS assessment, and implementation of the CAEP core POCUS curriculum. RESULTS: The response rate was 100% (39/39). All RCPSC-EM and CFPC-EM programs provide POCUS training for their residents, and 100% of RCPSC-EM programs and 91% (20/22) of CFPC-EM programs have a POCUS lead. All programs provide POCUS training for their residents, but there is variability in how POCUS is introduced to residents, ongoing POCUS instruction provided throughout residency, and POCUS assessment. Only 47% (8/17) of RCPSC-EM and 32% (7/22) of CFPC-EM programs have a quality assurance process for the use of POCUS by their residents. POCUS leads believe their residents are proficient in the CAEP core POCUS applications by the end of training except for advanced cardiac and thoracic ultrasound. CONCLUSIONS: POCUS training in Canadian EM programs is prevalent, but there is variability in support for POCUS leads, delivery of training, determination of proficiency, and presence of quality assurance. While almost all programs deliver POCUS education aligning with the CAEP core POCUS curriculum position statement, more support is required both locally and nationally for sharing best practices for POCUS education.

RéSUMé: OBJECTIFS: L'échographie ciblée a été reconnue comme un outil clinique important par l'Association canadienne des médecins d'urgence (ACMU) et constitue un objectif de formation des programmes de résidence en médecine d'urgence (MU) agréés par le Collège royal des médecins et chirurgiens du Canada (CRMCC) et le Collège des médecins de famille du Canada (CMFC). Nos objectifs sont de décrire l'état national de la formation en échographie ciblée dans les programmes de résidence du CRMCC(MU) et du CMFC(MU) et d'évaluer la mise en œuvre du programme d'études en échographie ciblée de base d'ACMU dans ces programmes. MéTHODES: Il s'agissait d'une étude par sondage en ligne auprès de tous les responsables de l'éducation en échographie ciblée pour les programmes CRMCC(MU) et CMFC(MU). L'enquête interrogeait les participants sur les données démographiques du programme, la description de la formation en échographie ciblée, les méthodes d'évaluation en échographie ciblée et la mise en œuvre du programme de base en échographie ciblée d'ACMU. RéSULTATS: Le taux de réponse a été de 100% (39/39). Tous les programmes CRMCC(MU) et CMFC(MU) offrent une formation en échographie ciblée à leurs résidents, et 100 % des programmes CRMCC(MU) et 91 % (20/22) des programmes CMFC(MU) ont un responsable d'échographie ciblée. Tous les programmes offrent une formation en échographie ciblée à leurs résidents, mais la façon dont l'échographie ciblée est présentée aux résidents, l'enseignement continu d'échographie ciblée tout au long de la résidence et l'évaluation de l'échographie ciblée varient. Seulement 47 % (8/17) des programmes CRMCC(MU) et 32 % (7/22) des programmes CMFC(MU) ont un processus d'assurance de la qualité pour l'utilisation d'une échographie ciblée par leurs résidents. Les responsables d'échographie ciblée estiment que leurs résidents maîtrisent les applications de base en échographie ciblée d'ACMU à la fin de la formation, sauf pour l'échographie cardiaque et thoracique avancée. CONCLUSIONS: La formation en échographie ciblée dans les programmes canadiens de MU est répandue, mais il existe une variabilité dans le soutien aux responsables d'échographie ciblée, la prestation de la formation, la détermination de la compétence et la présence d'une assurance qualité. Bien que presque tous les programmes offrent une formation en échographie ciblée qui s'harmonise avec l'énoncé de position du curriculum de base d'ACMU, il faut davantage de soutien à l'échelle locale et nationale pour partager les pratiques exemplaires en matière d'éducation en échographie ciblée.

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

AIM: Point-of-care ultrasound (POCUS) has been shown to assist in predicting outcomes in cardiac arrest. We evaluated the test characteristics of POCUS in predicting poor outcomes: failure of return of spontaneous circulation (ROSC), survival to hospital admission (SHA), survival to hospital discharge (SHD) and neurologically intact survival to hospital discharge (NISHD) in adult and paediatric patients with blunt and penetrating traumatic cardiac arrest (TCA) in out-of-hospital or emergency department settings. METHODS: We conducted a systematic review and meta-analysis using the PRISMA guidelines. We searched Clinicaltrials.gov, CINAHL, Cochrane library, EMBASE, Medline and the World Health Organization-International Clinical Trials Registry from 1974 to November 9, 2020. Risk of bias was assessed using QUADAS-2 tool. We used a random-effects meta-analysis model with 95% confidence intervals with I2 statistics for heterogeneity. RESULTS: We included 8 studies involving 710 cases of TCA. For all blunt and penetrating TCA patients who failed to achieve ROSC, the specificity (proportion of patients with cardiac activity on POCUS who achieved ROSC) was 98% (95% CI 0.13 to 1.0). The sensitivity (proportion of patients with cardiac standstill on POCUS who failed to achieve ROSC) was 91% (95% CI 0.67 to 0.98). No patient with cardiac standstill survived. Substantial level of heterogeneity was noted. CONCLUSIONS: Patients in TCA without cardiac activity on POCUS have a high likelihood of death and negligible chance of SHD. The numbers of patients included in published studies remains too low for practice recommendations for termination of resuscitation based solely upon the absence of cardiac activity on POCUS.

Use of Critical Items in Determining Point-of-Care Ultrasound Competence.

We previously developed a workplace-based tool for assessing point of care ultrasound (POCUS) skills and used a modified Delphi technique to identify critical items (those that learners must successfully complete to be considered competent). We performed a standard setting procedure to determine cut scores for the full tool and a focused critical item tool. This study compared ratings by 24 experts on the two checklists versus a global entrustability rating. All experts assessed three videos showing an actor performing a POCUS exam on a patient. The performances were designed to show a range of competences and one included potentially critical errors. Interrater reliability for the critical item tool was higher than for the full tool (intraclass correlation coefficient = 0.84 [95% confidence interval [CI] 0.42-0.99] vs. 0.78 [95% CI 0.25-0.99]). Agreement with global ratings of competence was higher for the critical item tool (κ = 0.71 [95% CI 0.55-0.88] vs 0.48 [95% CI 0.30-0.67]). Although sensitivity was higher for the full tool (85.4% [95% CI 72.2-93.9%] vs. 81.3% [95% CI 67.5-91.1%]), specificity was higher for the critical item tool (70.8% [95% CI 48.9-87.4%] vs. 29.2% [95% CI 12.6-51.1%]). We recommend the use of critical item checklists for the assessment of POCUS competence.

Blinding practices during acute point-of-care ultrasound research: the BLIND-US meta-research study.

OBJECTIVES: Point-of-care ultrasound (POCUS) diagnostic accuracy research has significant variation in blinding practices. This study characterises the blinding practices during acute POCUS research to determine whether research methodology adequately reflects POCUS use in routine clinical practice. DESIGN, SETTINGS AND PARTICIPANTS: A search for POCUS diagnostic accuracy studies published in Emergency Medicine, Anaesthesia and Critical Care journals from January 2016 to January 2020 was performed. Studies were included if they were primary diagnostic accuracy studies. The study year, journal impact factor, population, hospital area, body region, study design, blinding of the POCUS interpreter to clinical information, whether the person performing the POCUS scan was the same person interpreting the scan, and whether the study reported incremental diagnostic yield were extracted in duplicate by two authors. Descriptive statistics were provided and prespecified subgroup analysis was performed. MAIN OUTCOME MEASURES: The primary outcome was the number of studies that blinded the POCUS interpreter to at least some part of the clinical information. Secondary outcomes included whether the person performing the POCUS scan was the same person interpreting it and whether the study reported incremental diagnostic yield. RESULTS: 520 abstracts were screened with 97 studies included. The POCUS interpreter was blinded to clinical information in 37 studies (38.1%), not blinded in 34 studies (35.1%) and not reported in 26 studies (26.8%). The POCUS interpreter was the same person obtaining the images in 72 studies (74.2%), different in 14 studies (14.4%) and not reported in 11 studies (11.3%). Only four studies (4.1%) reported incremental diagnostic yield for POCUS. Inter-rater reliability was moderate (k=0.64). Subgroup analysis based on impact factor, body region, hospital area, patient population and study design did not show significant differences after completing pairwise comparisons. CONCLUSIONS: Although blinding the POCUS interpreter to clinical information may be done in a perceived attempt to limit bias, this may result in accuracy estimates that do not reflect routine clinical practice. Similarly, having a different clinician perform and interpret the POCUS scan significantly limits generalisability to practice as it does not truly reflect 'point-of-care' ultrasound at all. Reporting incremental diagnostic yield from implementing POCUS into a diagnostic pathway better reflects the value of POCUS; however, this methodology was infrequently used. TRIAL REGISTRATION NUMBER: The study protocol was registered on Open Science Framework (https://osf.io/h5fe7/).

Comparison of outcomes between pulseless electrical activity by electrocardiography and pulseless myocardial activity by echocardiography in out-of-hospital cardiac arrest; secondary analysis from a large, prospective study.

OBJECTIVE: To measure prevalence of discordance between electrical activity recorded by electrocardiography (ECG) and myocardial activity visualized by echocardiography (echo) in patients presenting after cardiac arrest and to compare survival outcomes in cohorts defined by ECG and echo. METHODS: This is a secondary analysis of a previously published prospective study at twenty hospitals. Patients presenting after out-of-hospital arrest were included. The cardiac electrical activity was defined by ECG and contemporaneous myocardial activity was defined by bedside echo. Myocardial activity by echo was classified as myocardial asystole--the absence of myocardial movement, pulseless myocardial activity (PMA)--visible myocardial movement but no pulse, and myocardial fibrillation--visualized fibrillation. Primary outcome was the prevalence of discordance between electrical activity and myocardial activity. RESULTS: 793 patients and 1943 pauses in CPR were included. 28.6% of CPR pauses demonstrated a difference in electrical activity (ECG) and myocardial activity (echo), 5.0% with asystole (ECG) and PMA (echo), and 22.1% with PEA (ECG) and myocardial asystole (echo). Twenty-five percent of the 32 pauses in CPR with a shockable rhythm by echo demonstrated a non-shockable rhythm by ECG and were not defibrillated. Survival for patients with PMA (echo) was 29.1% (95%CI-23.9-34.9) compared to those with PEA (ECG) (21.4%, 95%CI-17.7-25.6). CONCLUSION: Patients in cardiac arrest commonly demonstrate different electrical (ECG) and myocardial activity (echo). Further research is needed to better define cardiac activity during cardiac arrest and to explore outcome between groups defined by electrical and myocardial activity.

Quantitative characterization of left ventricular function during pulseless electrical activity using echocardiography during out-of-hospital cardiac arrest.

BACKGROUND: Several prospective studies have demonstrated that the echocardiographic detection of any myocardial activity during PEA is strongly associated with higher rates of return of spontaneous circulation (ROSC). We hypothesized that PEA represents a spectrum of disease in which not only the presence of myocardial activity, but more specifically that the degree of left ventricular (LV) function would be a predictor of outcomes. The purpose of this study was to retrospectively assess the association between LV function and outcomes in patients with OHCA. MATERIALS AND METHODS: Using prospectively obtained data from an observational cohort of patients receiving focused echocardiography during cardiopulmonary resuscitation (CPR) in the Emergency Department (ED) setting, we analyzed 312 consecutive subjects with available echocardiography images with initial rhythm of PEA. We used left ventricular systolic fractional shortening (LVFS), a unidimensional echocardiographic parameter to perform the quantification of LV function during PEA. Regression analyses were performed independently to evaluate for relationships between LVFS and a primary outcome of ROSC and secondary outcome of survival to hospital admission. We analyzed LVFS both as a continuous variable and as a categorial variable using the quartiles and the median to perform multiple different comparisons and to illustrate the relationship of LVFS and outcomes of interest. We performed survival analysis using Cox proportional hazards model to evaluate the hazard corresponding to length of resuscitation. RESULTS: We found a positive association between LVFS and the primary outcome of ROSC (OR 1.04, 95%CI 1.01-1.08), but not with the secondary outcome of survival to hospital admission (OR 1.02, 95%CI 0.96-1.08). Given that the relationship was not linear and that we observed a threshold effect in the relationship between LVFS and outcomes, we performed an analysis using quartiles of LVFS. The predicted probability of ROSC was 75% for LVFS between 23.4-96% (fourth quartile) compared to 47% for LVFS between 0-4.7% (first quartile). The hazard of not achieving ROSC was significantly greater for subjects with LVFS below the median (13.1%) compared to the subgroup with LVFS greater than 13.1% (p < 0.05), with the separation of the survival curves occurring at approximately 40 min of resuscitation duration. CONCLUSIONS: Left ventricular function measured by LVFS is positively correlated with higher probability of ROSC and may be associated with higher chances of survival in patients with PEA arrest.