Student ultrasound education - current views and controversies.

As an extension of the clinical examination and as a diagnostic and problem-solving tool, ultrasound has become an established technique for clinicians. A prerequisite for high-quality clinical ultrasound practice is adequate student ultrasound training. In light of the considerable heterogeneity of ultrasound curricula in medical studies worldwide, this review presents basic principles of modern medical student ultrasound education and advocates for the establishment of an ultrasound core curriculum embedded both horizontally and vertically in medical studies.

[Perspectives and Challenges of hand-held Ultrasound]. / Entwicklungen, Herausforderung und Perspektiven des Handheld-Ultraschalls (HHUS).

The use of handheld ultrasound devices from a technical and data protection point of view, device properties, functionality, documentation, indications, delegation of performance, applications by doctors, students and non-medical staff is examined and discussed.

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 However, most curricula only define these tasks as non-binding and in general terms or use outdated measures, such as length of training and self-reporting of achieved examinations with variable oversight, or administrative measures to create educational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.

EFSUMB Clinical Practice Guidelines for Point-of-Care Ultrasound: Part One (Common Heart and Pulmonary Applications) SHORT VERSION.

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. Following 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 75 % 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 75 %. 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.

EFSUMB Clinical Practice Guidelines for Point-of-Care Ultrasound: Part One (Common Heart and Pulmonary Applications) LONG VERSION.

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. Following 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 75 % 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 75 % 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 Ultrasound-History, Current and Evolving Clinical Concepts in Emergency Medicine.

Point-of-care ultrasound (PoCUS) has become an indispensable standard in emergency medicine. Emergency medicine ultrasound (EMUS) is the application of bedside PoCUS by the attending emergency physician to assist in the diagnosis and management of many time-sensitive health emergencies. In many ways, using PoCUS is not only the mere application of technology, but also a fusion of already existing examiner skills and technology in the context of a patient encounter. EMUS practice can be defined using distinct anatomy-based applications. The type of applications and their complexity usually depend on local needs and resources, and practice patterns can vary significantly among regions, countries, or even continents. A different approach suggests defining EMUS in categories such as resuscitative, diagnostic, procedural guidance, symptom- or sign-based, and therapeutic. Because EMUS is practiced in a constantly evolving emergency medical setting where no two patient encounters are identical, the concept of EMUS should also be practiced in a fluid, constantly adapting manner driven by the physician treating the patient. Many recent advances in ultrasound technology have received little or no attention from the EMUS community, and several important technical advances and research findings have not been translated into routine clinical practice. The authors believe that four main areas have great potential for the future growth and development of EMUS and are worth integrating: 1. In recent years, many articles have been published on novel ultrasound applications. Only a small percentage has found its way into routine use. We will discuss two important examples: trauma ultrasound that goes beyond e-FAST and EMUS lung ultrasound for suspected pulmonary embolism. 2. The more ultrasound equipment becomes financially affordable; the more ultrasound should be incorporated into the physical examination. This merging and possibly even replacement of aspects of the classical physical exam by technology will likely outperform the isolated use of stethoscope, percussion, and auscultation. 3. The knowledge of pathophysiological processes in acute illness and ultrasound findings should be merged in clinical practice. The translation of this knowledge into practical concepts will allow us to better manage many presentations, such as hypotension or the dyspnea of unclear etiology. 4. Technical innovations such as elastography; CEUS; highly sensitive color Doppler such as M-flow, vector flow, or other novel technology; artificial intelligence; cloud-based POCUS functions; and augmented reality devices such as smart glasses should become standard in emergencies over time.

Point-of-Care Ultrasound: A Multimodal Tool for the Management of Sepsis in the Emergency Department.

Sepsis and septic shock are life-threatening emergencies associated with increased morbidity and mortality. Hence, early diagnosis and management of both conditions is of paramount importance. Point-of-care ultrasound (POCUS) is a cost-effective and safe imaging modality performed at the bedside, which has rapidly emerged as an excellent multimodal tool and has been gradually incorporated as an adjunct to physical examination in order to facilitate evaluation, diagnosis and management. In sepsis, POCUS can assist in the evaluation of undifferentiated sepsis, while, in cases of shock, it can contribute to the differential diagnosis of other types of shock, thus facilitating the decision-making process. Other potential benefits of POCUS include prompt identification and control of the source of infection, as well as close haemodynamic and treatment monitoring. The aim of this review is to determine and highlight the role of POCUS in the evaluation, diagnosis, treatment and monitoring of the septic patient. Future research should focus on developing and implementing a well-defined algorithmic approach for the POCUS-guided management of sepsis in the emergency department setting given its unequivocal utility as a multimodal tool for the overall evaluation and management of the septic patient.

A Low-Cost Ultrasound Phantom for Peritonsillar Abscess Drainage Training.

BACKGROUND: Peritonsillar abscesses (PTAs) are encountered routinely in clinical practice. Ultrasound-guided aspiration has been proven both safe and effective in treating this condition. However, to date, there are no easily produced, low-cost models that enable the practice of point-of-care ultrasound-guided PTA aspiration and PTA diagnosis. OBJECTIVES: The objective was to create a low-cost, easy-to-produce, ultrasound phantom to train emergency physicians on ultrasound-guided PTA drainage. METHODS: We improved on previous work with ultrasound phantoms by creating a refillable phantom that approximates the oral cavity. This enabled learners to gain the manual dexterity necessary to operate an intraoral ultrasound probe while also aspirating a PTA. RESULTS: We have created a low-cost ultrasound phantom that is amenable to repeated ultrasound-guided aspirations for the purpose of training both resident- and attending-level physicians. CONCLUSION: With minimal lead time and readily available equipment, we successfully created a low-cost ultrasound phantom for the purpose of PTA identification and drainage.

A Multicenter, Prospective Study Comparing Subxiphoid and Parasternal Views During Brief Echocardiography: Effect on Image Quality, Acquisition Time, and Visualized Anatomy.

BACKGROUND: Recent literature has suggested echocardiography (echo) may prolong pauses in chest compressions during cardiac arrest. OBJECTVES: We sought to determine the impact of the sonographic approach (subxiphoid [SX] vs. parasternal long [PSL]) on time to image completion, image quality, and visualization of cardiac anatomy during echo, as performed during Advanced Cardiac Life Support. METHODS: This was a multicenter, randomized controlled trial conducted at 29 emergency departments (EDs) assessing the time to image acquisition and image quality between SX and PSL views for echo. Patients were enrolled in the ED and imaged in a simulated cardiac arrest scenario. Clinicians experienced in echo performed both SX and PSL views, first view in random order. Image quality and time to image acquisition were recorded. Echos were evaluated for identification of cardiac landmarks. Data are presented as percentages or medians with interquartile ranges (IQRs). RESULTS: We obtained 6247 echo images, comprising 3124 SX views and 3123 PSL. Overall time to image acquisition was 9.0 s (IQR 6.7-14.1 s). Image acquisition was shorter using PSL (8.8 s, IQR 6.5-13.5 s) compared with SX (9.3 s, IQR 6.7-15.0 s). The image quality was better with the PSL view (3.86 vs. 3.54; p < 0.0001), twice as many SX images scoring in the worst quality category compared with PSL (8.6% vs. 3.7%). Imaging of the pericardium, cardiac chambers, and other anatomic landmarks was superior with PSL imaging. CONCLUSIONS: Echo was performed in < 10 s in > 50% of patients using either imaging technique. Imaging using PSL demonstrated improved image quality and improved identification of cardiac landmarks.

Emergency Ocular Ultrasound - Common Traumatic and Non-Traumatic Emergencies Diagnosed with Bedside Ultrasound.

Point-of-care ocular ultrasound (POCOUS) in the ambulatory and critical care setting has become an invaluable diagnostic tool for patients presenting with traumatic or atraumatic vision and ocular complaints. Sonographic bedside evaluation is intuitive and easy to perform and can accurately diagnose a variety of pathologies. These include detachment or hemorrhage of the retina or vitreous, lens dislocation, retrobulbar hematoma or air, as well as ocular foreign bodies, infections, tumors, and increased optic nerve sheath diameter that can be assessed in the setting of suspected increased intracranial pressure. The ocular anatomy is easy to visualize with sonography, as the eye is a superficial structure filled with fluid. Over the last two decades, a large number of scientific publications have documented that POCOUS in emergent or critical care settings is an accurate diagnostic tool and expands and improves emergency diagnosis and management. This article will review POCOUS exam techniques as well as normal sonographic findings and common pathologies.

Point of care ultrasound is associated with decreased ED length of stay for symptomatic early pregnancy.

INTRODUCTION: Emergency physicians (EP) can accurately rule out ectopic pregnancy with pelvic point of care ultrasound (PPOCUS). Multiple studies have suggested that PPOCUS may decrease length of stay (LOS) for emergency department (ED) patients presenting with early symptomatic pregnancy compared to comprehensive ultrasound (CUS). This systematic review and meta-analysis examines the association between the use of PPOCUS vs CUS and ED LOS. METHODS: A systematic review of the literature was performed. Patients with symptomatic early pregnancy receiving EP-performed PPOCUS were compared to patients receiving CUS without PPOCUS. Keywords and search terms were generated for PPOCUS, ED LOS and CUS. Two independent reviewers screened abstracts for inclusion. A third reviewer was used when conflicts arose to gain consensus. Formal bias assessment was performed on included studies. Meta-analysis was carried out, pooling the mean differences between studies using a random-effects model. RESULTS: 2980 initial articles were screened, 32 articles underwent detailed review, 8 underwent bias assessment, and 6 were included in the final meta-analysis. There were 836 patients in the study group and 1514 in the control group. All studies showed a decreased LOS in the PPOCUS group with a mean decrease of 73.8 min (95% CI 49.1, 98.6). Two studies not included in the meta-analysis also showed significantly decreased LOS with PPOCUS. CONCLUSION: Use of PPOCUS in the evaluation of patients with symptomatic early pregnancy is associated with decreased LOS in patients ultimately diagnosed with intrauterine pregnancy. This review suggests that this finding is generalizable to a variety of practice settings.

New Perspectives for Modern Trauma Management - Lessons Learned from 25 Years FAST and 15 Years E-FAST.

E-FAST (Extended-Focused Assessment with Sonography for Trauma) is now a widely utilized and internationally recognized standard exam in trauma care. It is highly accepted by emergency physicians and trauma surgeons alike. Thanks to the popularity of PoCUS (point-of-care ultrasound), it has continued to evolve over the last years and can now improve trauma diagnosis at all stages of the primary ABCDE. This review article summarizes key observations made over recent years and also highlights the extension of FAST into E-FAST in the context of PoCUS and CT developments for modern trauma management. Time has come to learn the lessons from 25 years of FAST and 15 years of E-FAST. We should redefine and position ultrasound in the primary ATLS survey (Advanced Trauma Life Support) on two levels: 1. Basic ATLS with new clinical questions, six additional abdominal image sections and one or more follow-up examinations depending on the clinical situation, and 2. Advanced ATLS with ultrasound applications for the entire trauma ABCDE.

Examiner Position in Ocular Point-of-Care Ultrasound: A Proposed Technique.

BACKGROUND: Ocular point-of-care ultrasound (POCUS) is a fast and safe non-invasive procedure used to evaluate the structural integrity and pathology of the eye. Ocular POCUS can be used for evaluation of posterior chamber and orbital pathology, including retinal detachment, vitreous detachment or hemorrhage, foreign body, lens dislocation, and increased intracranial pressure. DISCUSSION: The purpose of this brief communication is to describe a technique for conducting an ocular POCUS that may in some cases be easier and more comfortable by adjusting the position of the sonographer relative to the patient. CONCLUSIONS: To our knowledge, this proposed technique has not been described in previous literature and may result in greater comfort for both sonographer and patient.

Bedside sonography for the diagnosis of esophageal food impaction.

BACKGROUND: Esophageal foreign body (EFB) and impaction are common gastrointestinal emergencies. Detection with standard imaging can be challenging. Computed tomography is a commonly used non-invasive imaging modality, but is not 100% sensitive and not always feasible. Sensitivity of plain film x-ray varies widely and the addition of a barium swallow can obscure evaluation by subsequent esophagogastroduodenoscopy (EGD). Use of emergency ultrasound (EUS) for detection of EFB in adults has not been previously studied. OBJECTIVE: To evaluate the role of EUS in detection of EFB and to characterize sonographic findings. METHODS: A case control series of five patients with clinical suspicion of EFB underwent EUS, and findings were compared to five healthy controls. Patients were evaluated for persistent air-fluid levels after swallowing, esophageal dilatation, and visualization of EFB. RESULTS: All patients with suspected EFB had esophageal dilatation (17.5mm vs 9.3mm in healthy controls; p=0.0011) and persistent air-fluid levels after swallowing. EFB was visualized on EUS in 60% of patients. All patients had EFB confirmed on EGD except one, who vomited a significant food bolus during EUS and prior to EGD. CONCLUSION: In patients with suspected EFB, point-of-care ultrasound may identify those with impaction. Suggestive findings include cervical esophageal dilatation and persistent intraluminal air-fluid levels after swallowing. EUS is a rapid, convenient test with the potential to expedite definitive management while decreasing cost and radiation exposure in this patient population.

Bedside Ultrasound for Tracheal Tube Verification in Pediatric Emergency Department and ICU Patients: A Systematic Review.

OBJECTIVES: Improper placement of the tracheal tube during intubation can lead to dangerous complications, and bedside ultrasound has been proposed as a method of quickly and accurately identifying tube placement. Recent studies in adults have found it to be accurate, but its applicability in pediatric patients is unclear. This systematic review aims to describe the current available data on the accuracy and feasibility of bedside ultrasound for tracheal tube placement in children. DATA SOURCES: OVID MEDLINE and EMBASE. STUDY SELECTION: Available articles on bedside neck or lung/diaphragm ultrasound for confirmation of tracheal tube placement in children through December 2015. DATA EXTRACTION: Two reviewers screened studies for eligibility and abstracted data independently. The quality of selected articles was evaluated using Quality Assessment of Diagnostic Accuracy Studies statement. DATA SYNTHESIS: A total of nine articles were identified: one study using neck ultrasound, two using lung/diaphragmatic ultrasound, one with both, and five studies looking at direct visualization of the tracheal tube tip met our inclusion criteria. There were 81 intubations evaluated using neck ultrasound, 214 intubations evaluated using diaphragmatic or pleural sliding, and 165 intubations evaluated for feasibility of bedside ultrasound in visualizing tracheal tube tip placement. The sensitivities of transtracheal ultrasound for intubation were overall high ranging from 0.92 to 1.00 with excellent specificities at 1.00. For lung ultrasound, the sensitivities for tracheal placement versus esophageal placement were high at 1.00, but only one study reported esophageal intubations and had a specificity of 1.00. When assessing the appropriate tracheal tube depth for tracheal intubations using lung ultrasound, the sensitivities ranged from 0.91 to 1.00 with specificities ranging from 0.5 to 1.0. Regarding feasibility of direct visualization of tracheal tube tip, visualization ranged from 83% to 100%. CONCLUSION: Bedside ultrasound has been described to be feasible in determining tracheal tube placement in several small single center studies and could be a useful adjunct tool in confirming tracheal tube placement in critically ill pediatric patients, but further studies are needed to assess its accuracy in a randomized multicenter setting.

Real-time optic nerve sheath diameter reduction measured with bedside ultrasound after therapeutic lumbar puncture in a patient with idiopathic intracranial hypertension.

Idiopathic intracranial hypertension (IIH), also referred to as pseudotumor cerebri, is a condition of raised intracranial pressure (ICP) with unknown etiology. Sonographic measurement of optic nerve sheath diameter (ONSD) has been shown to be a reliable, noninvasive method to characterize elevated ICP in a variety of settings. However, little is known about the immediate response of ONSD to an acute reduction in ICP after lumbar puncture. We describe a case of an emergency department patient with IIH in whom we identified real-time change in ONSD correlated with a decrease in cerebrospinal fluid pressure after a therapeutic lumbar puncture. Ocular ultrasound and ONSD measurements were performed by a trained provider using a 9- to 13-MHz linear transducer and an ultrasound machine with ocular software package and low mechanical index settings for data collection (MTurbo; SonoSite Inc, Bothell, WA). The ONSD was measured 30 minutes prior to and 30 minutes after a therapeutic lumbar puncture. Opening and closing pressures were recorded. Optic nerve sheath diameter measurements correlated with ICP as measured by opening and closing lumbar puncture pressures and showed an acute reduction in ONSD within 30 minutes after lumbar puncture. Sonographic measurement of ONSD reduction may be a novel, noninvasive and convenient way to follow acute reductions in ICP. Further investigation is necessary in order to validate this finding.