OBJECTIVE: The objective of this study is to identify the top five most influential papers published on the use of point-of-care ultrasound (POCUS) in cardiac arrest and the top five most influential papers on the use of POCUS in shock in adult patients. METHODS: An expert panel of 14 members was recruited from the Canadian Association of Emergency Physicians (CAEP) Emergency Ultrasound Committee and the Canadian Ultrasound Fellowship Collaborative. The members of the panel are ultrasound fellowship trained or equivalent, are engaged in POCUS research, and are leaders in POCUS locally and nationally in Canada. A modified Delphi process was used, consisting of three rounds of sequential surveys and discussion to achieve consensus on the top five most influential papers for the use of POCUS in cardiac arrest and shock. RESULTS: The panel identified 39 relevant papers on POCUS in cardiac arrest and 42 relevant papers on POCUS in shock. All panel members participated in all three rounds of the modified Delphi process, and we ultimately identified the top five most influential papers on POCUS in cardiac arrest and also on POCUS in shock. Studies include descriptions and analysis of safe POCUS protocols that add value from a diagnostic and prognostic perspective in both populations during resuscitation. CONCLUSION: We have developed a reading list of the top five influential papers on the use of POCUS in cardiac arrest and shock to better inform residents, fellows, clinicians, and researchers on integrating and studying POCUS in a more evidence-based manner.
RéSUMé: OBJECTIF: L'objectif de cette étude est d'identifier les cinq articles les plus influents publiés sur l'utilisation de l'échographie au point de soin (POCUS) dans l'arrêt cardiaque et les cinq articles les plus influents sur l'utilisation de POCUS dans le choc chez les patients adultes. MéTHODES: Un comité d'experts composé de 14 membres a été recruté par le Comité d'échographie d'urgence de l'Association canadienne des médecins d'urgence (ACMU) et le Canadian Ultrasound Fellowship Collaborative. Les membres du comité sont formés en échographie ou l'équivalent, participent à la recherche sur le POCUS et sont des chefs de file du POCUS à l'échelle locale et nationale au Canada. Un processus Delphi modifié a été utilisé, consistant en trois séries de sondages séquentiels et de discussions pour parvenir à un consensus sur les cinq articles les plus influents pour l'utilisation de POCUS dans les arrêts cardiaques et les chocs. RéSULTATS: Le panel a identifié 39 articles pertinents sur le POCUS en arrêt cardiaque et 42 articles pertinents sur le POCUS en état de choc. Tous les membres du panel ont participé aux trois cycles du processus Delphi modifié, et nous avons finalement identifié les cinq articles les plus influents sur le POCUS en arrêt cardiaque et aussi sur le POCUS en état de choc. Les études comprennent des descriptions et des analyses de protocoles POCUS sûrs qui ajoutent de la valeur d'un point de vue diagnostique et pronostique dans les deux populations pendant la réanimation. CONCLUSION: Nous avons dressé une liste de lecture des cinq principaux articles influents sur l'utilisation du POCUS en cas d'arrêt cardiaque et de choc afin de mieux informer les résidents, les boursiers, les cliniciens et les chercheurs sur l'intégration et l'étude du POCUS d'une manière plus factuelle.
Cardiopulmonary Resuscitation , Heart Arrest , Shock , Adult , Humans , Point-of-Care Systems , Canada , Point-of-Care Testing , Heart Arrest/therapy , Heart Arrest/etiology , Ultrasonography/methods , Cardiopulmonary Resuscitation/methods
Objective The objective of this study is to identify the top five influential papers published on renal point-of-care ultrasound (POCUS) and the top five influential papers on biliary POCUS in adult patients. Methods A 14-member expert panel was recruited from the Canadian Association of Emergency Physicians (CAEP) Emergency Ultrasound Committee and the Canadian Ultrasound Fellowship Collaborative. All panel members have had ultrasound fellowship training or equivalent, are actively engaged in POCUS scholarship, and are involved with POCUS at their local site and nationally in Canada. We used a modified Delphi process consisting of three rounds of sequential surveys and discussion to achieve consensus on the top five influential papers for renal POCUS and biliary POCUS. Results The panel identified 27 relevant papers on renal POCUS and 30 relevant papers on biliary POCUS. All panel members participated in all three rounds of the modified Delphi process, and after completing this process, we identified the five most influential papers on renal POCUS and the five most influential papers on biliary POCUS. Conclusion We have developed a list, based on expert opinion, of the top five influential papers on renal and biliary POCUS to better inform all trainees and clinicians on how to use these applications in a more evidence-based manner. This list will also be of interest to clinicians and researchers who strive to further advance the field of POCUS.
OBJECTIVE: To evaluate the evidence and produce a summary and recommendations for the most common heart and lung point-of-care ultrasound (PoCUS). METHODS: We reviewed 10 clinical domains/questions related to common heart and lung applications of PoCUS.âFollowing review of the evidence, a summary and recommendations were produced, including assigning levels of evidence (LoE) and grading of recommendation, assessment, development, and evaluation (GRADE). 38 international experts, the expert review group (ERG), were invited to review the evidence presented for each question. A level of agreement of over 75â% was required to progress to the next section. The ERG then reviewed and indicated their level of agreement of the summary and recommendation for each question (using a 5-point Likert scale), which was approved in the case of a level of agreement of greater than 75â%. A level of agreement was defined as a summary of "strongly agree" and "agree" on the Likert scale responses. FINDINGS AND RECOMMENDATIONS: One question achieved a strong consensus for an assigned LoE of 3 and a weak GRADE recommendation (question 1), the remaining 9 questions achieved broad agreement with an assigned LoE of 4 and a weak GRADE recommendation (question 2), three achieved an LoE of 3 with a weak GRADE recommendation (questions 3-5), three achieved an LoE of 3 with a strong GRADE recommendation (questions 6-8) and the remaining two were assigned an LoE of 2 with a strong GRADE recommendation (questions 9 and 10). CONCLUSION: These consensus-derived recommendations should aid clinical practice and highlight areas of further research for PoCUS in acute settings.
Point-of-Care Systems , Point-of-Care Testing , Humans , Lung , Ultrasonography
AIMS: To evaluate the evidence and produce a summary and recommendations for the most common heart and lung applications of point-of-care ultrasound (PoCUS). METHODS: We reviewed 10 clinical domains/questions related to common heart and lung applications of PoCUS.âFollowing review of the evidence, a summary and recommendation were produced, including assignment of levels of evidence (LoE) and grading of the recommendation, assessment, development, and evaluation (GRADE). 38 international experts, the expert review group (ERG), were invited to review the evidence presented for each question. A level of agreement of over 75â% was required to progress to the next section. The ERG then reviewed and indicated their level of agreement regarding the summary and recommendation for each question (using a 5-point Likert scale), which was approved if a level of agreement of greater than 75â% was reached. A level of agreement was defined as a summary of "strongly agree" and "agree" on the Likert scale responses. FINDINGS AND RECOMMENDATIONS: One question achieved a strong consensus for an assigned LoE of 3 and a weak GRADE recommendation (question 1). The remaining 9 questions achieved broad agreement with one assigned an LoE of 4 and weak GRADE recommendation (question 2), three achieving an LoE of 3 with a weak GRADE recommendation (questions 3-5), three achieved an LoE of 3 with a strong GRADE recommendation (questions 6-8), and the remaining two were assigned an LoE of 2 with a strong GRADE recommendation (questions 9 and 10). CONCLUSION: These consensus-derived recommendations should aid clinical practice and highlight areas of further research for PoCUS in acute settings.
Point-of-Care Systems , Point-of-Care Testing , Humans , Lung , Ultrasonography
Objective The objective of this study is to identify the top five most influential papers published on focused assessment with sonography in trauma (FAST) and the top five most influential papers on the extended FAST (E-FAST) in adult patients. Methods An expert panel was recruited from the Canadian Association of Emergency Physicians (CAEP) Emergency Ultrasound Committee and the Canadian Ultrasound Fellowship Collaborative. These experts are ultrasound fellowship-trained or equivalent, are involved with point-of-care ultrasound (POCUS) research and scholarship, and are leaders in both the POCUS program at their local site and within the national Canadian POCUS community. This 14-member expert group used a modified Delphi process consisting of three rounds of sequential surveys and discussion to achieve consensus on the top five most influential papers for FAST and E-FAST. Results The expert panel identified 56 relevant papers on FAST and 40 relevant papers on E-FAST. After completing all three rounds of the modified Delphi process, the authors identified the top five most influential papers on FAST and the top five most influential papers on E-FAST. Conclusion We have developed a reading list of the top five influential papers for FAST and E-FAST that will benefit residents, fellows, and clinicians who are interested in using POCUS in an evidence-informed manner.
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 Åuvre 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 Åuvre 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.
Emergency Medicine , Internship and Residency , Canada , Curriculum , Emergency Medicine/education , Humans , Point-of-Care Systems , Ultrasonography/methods
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.
Cardiopulmonary Resuscitation , Emergency Medical Services , Out-of-Hospital Cardiac Arrest , Adult , Child , Humans , Out-of-Hospital Cardiac Arrest/diagnostic imaging , Out-of-Hospital Cardiac Arrest/therapy , Point-of-Care Systems , Point-of-Care Testing , Ultrasonography
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.
Out-of-Hospital Cardiac Arrest/diagnostic imaging , Point-of-Care Systems/standards , Ultrasonography , Adult , Aged , Aged, 80 and over , Cardiopulmonary Resuscitation/mortality , Female , Humans , Male , Middle Aged , Out-of-Hospital Cardiac Arrest/mortality , Predictive Value of Tests
OBJECTIVES: The main objective of this study was to evaluate the feasibility of emergency department (ED) point-of-care ultrasound (PoCUS) for rib fracture diagnosis in patients with minor thoracic injury (mTI). Secondary objectives were to 1) evaluate patients' pain during the PoCUS procedure, 2) identify the limitations of the use of PoCUS technique, and 3) compare the diagnosis obtained with PoCUS to radiography results. METHODS: Adult patients who presented with clinical suspicion of rib fractures after mTI were included. All patients underwent PoCUS performed by emergency physicians (EPs) prior to a rib view X-ray. A visual analogue scale (VAS) ranging from 0 to 100 was used to ascertain feasibility, patients' pain and clinicians' degree of certitude. Feasibility was defined as a score of more than 50 on the VAS. We documented the radiologists' interpretation of rib view X-ray. Radiologists were blinded to the PoCUS results. RESULTS: Ninety-six patients were included. A majority (65%) of EPs concluded that the PoCUS technique to diagnose rib fracture was feasible (VAS score > 50). Median score for feasibility was 63. Median score was 31 (Interquartile range [IQR] 5-57) for patients' pain related to the PoCUS. The main limiting factor of the PoCUS technique was pain during patient examination (15%). CONCLUSION: PoCUS examination appears to be a feasible technique for a rib fracture diagnosis in the ED.
Emergency Service, Hospital/statistics & numerical data , Point-of-Care Systems/statistics & numerical data , Rib Fractures/diagnostic imaging , Ultrasonography, Doppler , Adult , Aged , Feasibility Studies , Female , Humans , Injury Severity Score , Male , Middle Aged , Quebec , Radiography, Thoracic/methods , Rib Fractures/epidemiology , Rib Fractures/therapy , Sensitivity and Specificity , Tertiary Care Centers , Thoracic Injuries/diagnostic imaging , Thoracic Injuries/physiopathology , Thoracic Injuries/therapy
A short cut review was carried out to establish whether point-of-care abdominal ultrasound could affect the emergency department (ED) length of stay (LOS) of children attending with suspected appendicitis. Using the reported searches, one paper presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of this best paper are tabulated. It is concluded that point-of-care abdominal ultrasound has sufficient specificity to be used to reduce LOS of paediatric patients in the ED with positive results for appendicitis. It is insufficiently sensitive to be used to rule out appendicitis.
Appendicitis/diagnostic imaging , Point-of-Care Systems , Abdominal Pain/diagnostic imaging , Child , Emergency Service, Hospital , Evidence-Based Emergency Medicine , Humans , Length of Stay , Male , Ultrasonography
A shortcut review was carried out to establish whether transtracheal ultrasonography can reliably identify tracheal placement of and endotracheal tube during cardiac arrest. Using the reported searches, 260 papers were found of which one presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of this best paper are tabulated. It is concluded that transtracheal ultrasonography may be a supplementary tool for establishing the correct tracheal tube placement in cardiac arrest. Further work is needed.
Evidence-Based Emergency Medicine , Heart Arrest/diagnostic imaging , Intubation, Intratracheal , Trachea/diagnostic imaging , Ultrasonography, Doppler/methods , Adult , Airway Management/methods , Cardiopulmonary Resuscitation/methods , Heart Arrest/therapy , Humans , Male , Patient Safety
A short cut review was carried out to establish whether ultrasound was better than x-ray at detecting fractured ribs after minor chest trauma. Two papers presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are tabulated. It is concluded that while current studies suggest ultrasonography is better than x-ray at detecting rib fractures, further studies with a well-established gold standard should be completed before ultrasonography is used routinely.
Rib Fractures/diagnostic imaging , Evidence-Based Emergency Medicine , Humans , Radiography , Ultrasonography
