Discordance Between Pulse Palpation And Focused EchocardiographyFindings In Adult Cardiopulmonary Arrest Patients
BY Dr Michael Blaivas, MD, MBA
Department of Emergency Medicine
St. Francis Hospital
Columbus, Georgia, USA
Objectives: Define the frequency of agreement between focused bedside
echocardiography (Echo) and pulse checks during cardiopulmonary resuscitation (CPR).
Methods: This was a retrospective review of multi-year quality assurance logs on cardiac
arrest patients evaluated with point-of-care Echo during CPR, over a seven year period.
All patients in cardiopulmonary arrest that presented when physicians trained in Echo
were availabile and had quality assurance documentation completed, were eligible for
enrollment. Patients for whom incomplete data was present in the logs were excluded
from the study. This study took place at a busy emergency medicine department with a
large cardiac population and an approximate annual census of 80,000 visits per year.
Emergency physicians (EPs), with hospital credentialing in point-of-care Echo, routinely
used ultrasound as part of their standard management of CPR patients. During all pulse
checks, nurses and physicians attempted to locate pulses while one EP performed a brief
Echo of the heart with a compact ultrasound machine. Echo checks were limited to the
time available during pulse checks and ended when the treating EP ordered resumption of
chest compressions. Myocardial function was graded into normal ejection fraction (EF),
mildly, moderately, severely depressed, negligible function and asystole as previously
defined in the literature. If Echo suggested sufficient EF to generate blood flow but pulse
check was negative, the carotid arteries were evaluated with Doppler when interference
with resuscitative efforts could be avoided. Statistical analysis included descriptive
statistics and Cohen Kappa coefficient for agreement analysis.
Results: A total of 693 pulse checks occurred concomitantly with Echo checks in 226
patients. Of the 226 patients, 59 (26.1%) had resumption of spontaneous circulation at some point in their resuscitation based on pulse palpation and electrocardiographic
monitor tracing. A total of 178 (25.7%) Echo checks revealed an EF felt to likely
generate a detectable blood pressure. In 47% (84) of those Echo checks, no pulses were
palpable. Conversely, in 31 (6%) pulse checks (when electrical cardiac activity was noted
on the monitor) and a healthcare provider felt palpable pulses, the echo showed either
myocardial standstill or negligible EF. Echo results and pulse palpation during pulse
checks showed poor correlation with a Kappa of 0.52.
Conclusions: In this study, Echo findings and pulse palpation results periodically
disagreed when myocardial activity was present. When Doppler analysis of carotid flow
was possible in patients with adequate EF but no pulses, flow was always noted. Very
concerning, in 6% of patients apparent palpable pulses occurred when Echo showed no
myocardial contraction or negligible EF.
Evaluation and treatment of patients in cardiopulmonary arrest has progressed
significantly in the last four decades with the advent of cardiac resuscitation protocols,
endotracheal intubation, central line placement and electric cardioversion. 1-4 However,
clinicians managing cardiopulmonary resuscitations are typically doing so blindly. While
electrocardiographic monitoring provides a glimpse of the electrical activity of the heart,
it tells the clinician little about actual myocardial function. 5 Thus, pulse checks are critical
and help determine if spontaneous circulation has resumed. In addition pulse checks will
typically decide whether chest compressions continue or not and if resuscitation is
Typically, invasive arterial blood pressure monitoring is not available in patients
arriving to an emergency department or resuscitation area. Similarly, hospitalized
patients that are not in an intensive care unit are unlikely to have any invasive monitoring
in place. Since pneumatic blood measuring devices are inaccurate, slow to result and
have difficulty picking up low blood pressures, physicians typically have to rely on
manual pulse palpation during resuscitation. 6 However, there is growing evidence that our
ability of accurately palpate a pulse is quite poor in these critically ill patients. 7,8 Some
studies indicate that physicians may accurately palpate a pulse in as low as 50% of
patients. 9 This likely results from the innate inaccuracy of pulse palpation, the tense
environment of a cardiac arrest and also the trend toward obesity and morbid obesity in
westernized countries. In addition, low blood pressure and low flow states which require
vasopressor support, but not continued chest compressions, may be too difficult to detect
by human hands in many cases.
Many intensivists, emergency physicians, surgeons and other clinicians have
found great utility in utilizing bedside echocardiography during cardiopulmonary arrest
management. 10-12 This reflects the ability of ultrasound to identify treatable causes of
arrest as well as aid in managing patient resuscitation. 13 Anecdotal experience, as well as
previous published studies suggest that there may be a discordance between
echocardiographic findings and electrocardiographic findings as well as detection of
pulses. 14 This study sought to evaluate the frequency of apparent discordance between
pulse detection by manual palpation and finding on echocardiography.
This was a retrospective quality assurance log review using de-identified patient
data of ultrasound findings during cardiac arrest pulse palpation breaks. The study was
conducted at busy emergency department with a large high acuity cardiac population and
annual census of approximately 80,000 patients. This study was IRB exempted due to its
retrospective quality assurance nature and use of de-identified data.
All patients arriving in, or experiencing cardiopulmonary arrest while in the
emergency department, without an indwelling arterial pressure monitor, were eligible for
enrollment if they had complete data in the quality assurance logs. As part of standard
practice all cardiopulmonary resuscitations were managed with bedside emergency
echocardiography, when hospital credentialed physicians were available. Patients with
incomplete quality assurance log data were excluded from the study. Quality assurance
logs were reviewed for cardiac arrest entries with completed EF estimate and
corresponding pulse check results by an experienced point of care ultrasound program
Arrest Echo Protocol
Each patient in cardiopulmonary arrest was scanned by a study physician during
pulse breaks. The treating physician was advised of echo finding as part of standard
practice, but the study physician did not make treatment recommendations. Bedside
ultrasound examinations were performed only during pulse checks, which were
conducted by a nurse and treating physician or second nurse. In all cases, at least two
healthcare providers assessed for pulses at the same time. All pulse checks were made
either at carotid artery or femoral artery locations. All efforts at performing an echo were
ceased when the pulse check was stopped by the treating physician. Echo checks
continued during pulse checks for the duration of the resuscitation as long as they did not
interfere with resuscitation efforts.
Left ventricular function on echocardiography was graded into distinct categories:
normal ejection fraction (EF), mildly (approximately 40 to 50%), moderately
(approximately 20 to 40%), severely depressed (approximately 10 to 20%) and negligible
function (EF below 10%) as previously defined in the literature. 15 If Echo suggested
sufficient EF to generate blood flow but pulse check revealed no palpable pulses, the
carotid arteries were evaluated with Doppler, color and pulse wave, when interference
with resuscitative efforts could be avoided.
All ultrasound examinations of the heart during pulse checks were videotaped
using either SVHS video tape or DVD and stored for quality assurance review. In
addition, ultrasound quality assurance logs were filled out with ultrasound findings and
clinical outcome as part of standard practice. Emergency sonologists utilized phased
array transducers with a range of 2.5 to 4 MHz using either as SonoSite 180 Plus, Titan,
Micromaxx or M-Turbo compact ultrasound machines. Standard echocardiography
windows were utilized to image the heart. The subxiphoid window was utilized
preferentially in order to avoid interference with resuscitation, the parasternal long and
apical four chamber views were used if no useful subxiphoid image was obtainable.
Transesophageal echocardiography was used when available, either on a Sonosite
Micromaxx or M-Turbo.
Main Outcome Measures
Physicians filled out standardized quality assurance logs. They recorded the
results of the pulse checks by team members and the corresponding emergency echo
findings. For secondary measures, if left ventricular ejection fraction was felt to be above
10% in the setting of absent pulses on palpation and the study physician was able to
Doppler a carotid artery, presence of absence of flow was recorded. In addition, when
pulse wave Doppler was used the peak systolic velocity was recorded. Sonologists also
recorded when manual pulse palpation revealed a palpable pulse, but emergency echo
showed either negligible that could not generate flow or complete absence of myocardial
Data were kept in an Access database (Microsoft Corporation, Seattle
Washington). Prior to analysis, data were exported to an Excel spreadsheet and
commercially available statistical software was used to perform analyses. Statistical
analysis included descriptive statistics and agreement analysis using Cohen Kappa
A total of 693 pulse checks occurred concomitantly with Echo checks in 226 patients. Of
the 226 patients, 59 (26.1%) had resumption of spontaneous circulation at some point in
their resuscitation based on pulse check and electrocardiographic monitor tracing. A total
of 178 (25.7%) Echo checks revealed EF of severely depressed or better and were felt to
likely generate a detectable blood pressure. In 47% (83.66) of these Echo checks, no
pulses were palpable. Conversely, in 31 (6%) pulse checks on when electrical cardiac
activity was noted on the monitor and a healthcare provider felt palpable pulses, the echo
showed either myocardial standstill or negligible EF.
Carotid Doppler was obtained in 37% of cases when Echo showed severely depressed or
better EF but no pulses were palpable. In these cases, all patients showed flow in the
carotid on both color and pulse wave Doppler. Echo results and pulse palpation during
pulse checks showed poor correlation. Echo results and pulse checks showed poor
agreement with a correlation coefficient of 0.52. Comparing only the 178 patients noted
to have echo based findings of adequate cardiac output the Cohen Kappa decreased to
Cardiopulmonary arrest has many etiologies, some of which are correctable
through interventions such as pericardiocentesis and many that are not. However,
identification of these correctable processes may be difficult simply based on physical
examination and electrocardiographic evidence. The focus of many resuscitation efforts
are patients with apparent electrical activity on a monitor, as they may hold out the
highest hope for successful resuscitation. 16 Over the past two decades, the use of Point of
Care Ultrasound to manage resuscitation has greatly improved the ability of clinicians to
accurately identify correctable causes of cardiac arrest in a variety of settings. 17 Recent
studies suggesting that focused ultrasound checks of the heart during CPR interfere with
quality chest compression are likely to push more providers to relying on pulse palpation
only. 18,19 However, prior data has repeatedly suggested pulse checks are unreliable for
resuscitation management, leaving providers who chose not to use ultrasound blinded to
cardiac function in many cases.
Pulseless electrical activity (PEA) occurs when a patient appears to have electrical
activity on a monitor, but no pulse can be palpated. Once thought to strictly indicate
mechanical asystole in the presence of electrical activity, it is now clear that a portion of
these patients have mechanical cardiac activity with blood pressures too low to result in a
palpable pulse, in that specific individual. One study demonstrated that up to 41% of
patients presenting with electrical activity but no pulse actually had mechanical
contractions of the heart. 20 While survival rates for patients in PEA are poor, with one
large study reporting 11% survival rate with only 62% of survivors having a good
neurological outcome, this group of patients are typically thought to have a higher
likelihood of survival than asystolic patients. 21 As the team managing the patient in
cardiopulmonary arrest strives to resuscitate the patient they are also seeking reversible
causes of cardiac arrest. In PEA patients these include tension pneumothorax,
hypovolemia, toxins, hypoglycemia, hypoxemia, acidosis, hypokalemia, hyperkalemia,
hypothermia, cardiac tamponade, cardiac ischemia, pulmonary embolism, and trauma. 22
Ultrasound can aid the resuscitation team by allowing visual assessment of
cardiac function as well are a more accurate evaluation for some the treatable causes of
PEA that are listed by both the AHA and European Council on Resuscitation. 23 Cardiac
tamponade from pericardial effusion can be readily identified by focused emergency
echo. 24 At the same time the provider can image the inferior vena cava to estimate
intravascular fluid volume and even monitor change in volume during ongoing
resuscitation. Cardiac contractility can be evaluated by emergency echo and may greatly
aid in goal directed resuscitation. Pneumothorax has been proven to be very accurately
ruled out and identified in multiple studies by point of care ultrasound. In cases of large
pulmonary emboli, point of care ultrasound may detect intra-cardiac thrombosis, venous
thrombosis or particular echo findings such as right heart strain on TAPSE and McConell
sign, which may strongly point toward presence of PE. 25 In such cases, the resuscitation
director may be more included to thrombolyse the patient given the evidence provided by
ultrasound. When complete mechanical cardiac stand still is noted on echo despite
several rounds of chest compressions and medications there is strong support that
successful resuscitation is extremely unlikely. Terminating the resuscitative efforts earlier
in such patients may save resources without compromising care.
In most situations of cardiopulmonary resuscitation, the code is continued until
further efforts are deemed futile and the resuscitation stopped or, in the minority, when
resumption of spontaneous circulation is noted. Unless the patient has already been in
the hospital or emergency department for some time and received an indwelling arterial
blood pressure monitor, the only commonly accepted method of determining resumption
of spontaneous circulation is palpating a pulse.
While patients with no cardiac output receive chest compressions and epinephrine
a hypotensive patient may be taken along a different pathway of resuscitation. Not only is
the treatment of a hypotensive patient different from that of a patient in PEA, but CPR
itself is not a benign intervention and may cause injury to the patient. Unnecessary
trauma to a critically ill patient could further complicate recovery if the patient survives
the resuscitation. Frequent findings in patients having undergone CPR include lesions of
tracheal structures and bony chest fractures. Less frequently encountered are lesions of
the pleura, pericardium, myocardium and other internal organs and vessels. 26
As this data indicates, disagreements between the ultrasound machine monitor
screen and manual pulse palpation are surprisingly common. The concept of actually
checking the carotid artery for blood flow on color and pulse wave Doppler came out of
multiple situations when disagreement occurred between staff that insisted on resuming
chest compressions and physicians who ordered them stopped because of adequate
estimated ejection fraction on focused echo. Such patients are most likely to be treated
with vasopressors and fluids in order to elevate their blood pressure, but may be difficult
to manage if providers are blind to their cardiac function. Our data further supports that
pulse palpation is inaccurate, in arrest situations, suggesting that providers may want to
add focused echo for additional information. In 37% of patients physicians were able to
access the carotid artery after the echo, which reflected an ejection fraction felt to be
consistent with perfusion of the brain. In each case color Doppler confirmed the presence
of spontaneous blood flow with measurement on pulse wave Doppler ranging from 60 to
Vascular ultrasound and neurology literature indicates that normal common
carotid artery peak systolic flow velocities vary considerably, but tend to range from 55
to 100 cm/sec. 27 Mean values in normal patients from the internal carotid are typically 54
to 88 cm/sec, but some normal individuals can have peak systolic velocities up to 120
cm/sec. 28 Values increase considerably for carotid stenosis. Regardless, the typical flow
velocity recorded in this study was quite near normal as previously defined. Multiple
other factors affect carotid peak systolic velocities, such as potential stenosis in the
vertebral arteries or the contralateral carotid. However, such fine details probably have
little bearing in gauging if adequate circulation is produced by a beating heart, while no
pulses are palpable. It is at this point that chest compressions may be terminated and
pressors instituted or adjusted as in any critically ill, hypotensive patient.
Exceedingly shocking was the fact that in 6% of cases a team member called out
“I have a pulse” leading to cessation of chest compressions, when the heart was in
mechanical standstill or had no viable contractile activity. We have noted anecdotally and
repeatedly that such confusion causes delays measured in minutes that may even last until
a pneumatic blood pressure cuff finally fails to obtain a blood pressure and another
provider realizes no pulses are palpable. While additional evidence will need to be
produced, it is more and more compelling that ultrasound should be present at the bedside
of every patient undergoing cardiopulmonary resuscitation whenever possible. This can
be achieved in the most unlikely settings. The introduction of highly compact devices has
enabled clinicians outside of the intensive care units and emergency departments to use
ultrasound for evaluation of cardiopulmonary arrest patients. Focused ultrasound
utilization has been documented in the settings of pre-hospital ground and air ambulances
as well as disaster scenes and even sporting events.
Limitations of the study include no invasive monitoring to compare pulse
palpation to actual arterial blood pressure. The study population was typical of diverse
western body habitus distributions and may not reflect findings in other populations
around the world where pulse palpation may be more or less accurate. The retrospective
nature of the study is also an inherent limitation, although data was collected
prospectively for quality assurance tracking.
In summary, data from this study suggests that disagreement between focused
echo and pulse palpation is a common occurrence. As suggested by previous studies and
resuscitation algorithms hypotension and asystole have different treatment pathways and
there may even be potential harm from unnecessary chest compressions. While more
studies are needed, the inclusion of focused echocardiography into cardiopulmonary
resuscitation may provide valuable additional information not accurately obtained from
palpation of pulses.
In this study, Echo findings and pulse palpation results frequently disagreed when myocardial activity was present. When Doppler analysis of carotid flow was possible in
patients with a gradable EF but no pulses, flow was always noted. In a small percentage of patients apparent palpable pulses occurred when Echo showed no myocardial contraction or negligible EF.
1. Diamond LM. Cardiopulmonary resuscitation and acute cardiovascular life support--a protocol review of the updated guidelines. Crit Care Clin. 2007; 23:873-80
2. Park CB, Shin SD, Suh GJ, Ahn KO, Cha WC, Song KJ, Kim SJ, Lee EJ, Ong ME. Pediatric out-of-hospital cardiac arrest in Korea: A nationwide population-based study. Resuscitation. 2010 Feb 19.
3. Rivers EP, Wortsman J, Rady MY, Blake HC, McGeorge FT, Buderer NM. The effect of the total cumulative epinephrine dose administered during human CPR on hemodynamic, oxygen transport, and utilization variables in the postresuscitation period. Chest. 1994; 106:1499-507.
4. Meaney PA, Nadkarni VM, Kern KB, Indik JH, Halperin HR, Berg RA. Rhythms and outcomes of adult in-hospital cardiac arrest. Crit Care Med. 2010; 38:101-8.
5. Varriale P, Maldonado JM. Echocardiographic observations during in hospital cardiopulmonary resuscitation. Crit Care Med. 1997; 25:1717-20.
6. Kornø M, Eldrup N, Sillesen H. Comparison of ankle-brachial index measured by an automated oscillometric apparatus with that by standard Doppler technique in vascular patients. Eur J Vasc Endovasc Surg. 2009; 38:610-5.
7. Lundin M, Wiksten JP, Peräkylä T, Lindfors O, Savolainen H, Skyttä J, Lepäntalo M. Distal pulse palpation: is it reliable? World J Surg. 1999; 23:252-5.
8. Myers KA, Scott DF, Devine TJ, Johnston AH, Denton MJ, Gilfillan IS. Palpation of the femoral and popliteal pulses: a study of the accuracy as assessed by agreement between multiple observers. Eur J Vasc Surg. 1987; 1:245-9.
9. Bahr J, Klingler H, Panzer W, Rode H, Kettler D. Skills of lay people in checking the carotid pulse. Resuscitation. 1997; 35:23-6.
10. Salen P, Melniker L, Chooljian C, Rose JS, Alteveer J, Reed J, Heller M. Does the presence or absence of sonographically identified cardiac activity predict resuscitation outcomes of cardiac arrest patients? Am J Emerg Med. 2005; 23:459-62.
11. Klouche K, Weil MH, Sun S, Tang W, Kamohara T. Echo-Doppler observations during cardiac arrest and cardiopulmonary resuscitation. Crit Care Med. 2000; 28(11 Suppl):N212-3.
12. Schuster KM, Lofthouse R, Moore C, Lui F, Kaplan LJ, Davis KA. Pulseless electrical activity, focused abdominal sonography for trauma, and cardiac contractile activity as predictors of survival after trauma. J Trauma. 2009; 67:1154-7.
13. Hernandez C, Shuler K, Hannan H, Sonyika C, Likourezos A, Marshall J. C.A.U.S.E.: Cardiac arrest ultra-sound exam--a better approach to managing patients in primary non-arrhythmogenic cardiac arrest. Resuscitation. 2008; 76:198-206.
14. Bocka JJ, Overton DT, Hauser A: Electromechanical dissociation in human beings: An echocardiographic evaluation. Ann Emerg Med 1988; 17:450-452.
15. Moore CL, Rose GA, Tayal VS, Sullivan DM, Arrowood JA, Kline JA. Determination of left ventricular function by emergency physician echocardiography of hypotensive patients. Acad Emerg Med. 2002; 9:186-93.
16. Testa A, Cibinel GA, Portale G, Forte P, Giannuzzi R, Pignataro G, Silveri NG. The proposal of an integrated ultrasonographic approach into the ALS algorithm for cardiac arrest: the PEA protocol. Eur Rev Med Pharmacol Sci. 2010; 14:77-88.
17. Hernandez C, Shuler K, Hannan H, Sonyika C, Likourezos A, Marshall J. C.A.U.S.E.: Cardiac arrest ultra-sound exam--a better approach to managing patients in primary non-arrhythmogenic cardiac arrest. Resuscitation. 2008; 76:198-206.
18. Huis In 't Veld MA, Allison MG, Bostick DS, Fisher KR, Goloubeva OG, Witting MD, Winters ME. Ultrasound use during cardiopulmonary resuscitation is associated with delays in chest compressions. Resuscitation. 2017;119:95-98.
19. Clattenburg EJ, Wroe P, Brown S, Gardner K, Losonczy L, Singh A, Nagdev A. Point-of-care ultrasound use in patients with cardiac arrest is associated prolonged cardiopulmonary resuscitation pauses: A prospective cohort study. Resuscitation. 2018 Jan;122:65-68.
20. Paradis NA, Martin GB, Getting MC Chest 1992; 101:123-128.
21. Nadkarni VM, Larkin GL, Paberby MA. JAMA 2006; 295:50-57.
22. Desbiens NA. Simplifying the diagnosis and management of pulseless electrical activity in adults: a qualitative review. Crit Care Med. 2008; 36:391-6.
23. Breitkreutz R, Walcher F, Seeger FH. Focused echocardiographic evaluation in resuscitation management: concept of an advanced life support-conformed algorithm. Crit Care Med. 2007; 35(5 Suppl):S150-61.
24. Tayal VS, Kline JA. Emergency echocardiography to detect pericardial effusion in patients in PEA and near-PEA states. Resuscitation. 2003; 59:315-8.
25. Pavan D, Nicolosi GL, Antonini-Canterin F, Zanuttini D. Int J Cardiol. Echocardiography in pulmonary embolism disease. 1998:29; 65 Suppl 1:S87-90.
26. Buschmann CT, Tsokos M. Frequent and rare complications of resuscitation attempts. Intensive Care Med. 2009; 35:397-404.
27. Blackshear WM, Phillips JD, Chikos PM et al Carotid artery velocity patterns in normal and stenotic vessels.
28. Zbornikova V, Lassvik G. Duplex scanning in presumably normal persons of different ages. Ultrasound Med Biol. 1986; 12:371-378.
- This is a sponsored post from FUJIFILM SONOSITE -
- This is a sponsored post from Fujifilm Sonosite -
OCULAR Ultrasound by dr luke Philips
FACEM, MBBS, BSC(BIOMED)(HONS), CCPU
EMERGENCY CONSULTANT - ALFRED HEALTH
CO-DIRECTOR OF EMERGENCY MEDICINE TRAINING (THE ALFRED HOSPITAL
CO-CHAIR OF THE EMERGENCY MEDICINE ULTRASOUND GROUP BOARD OF DIRECTORS
75yo Female presents to the ED with sudden onset right visual loss.
I took over from overnight staff and reviewed the patient in the morning. A point of care ocular ultrasound was performed.
The Ultrasound demonstrates a macular off rentinal detachment. The thick undulating hyperechoic membrane in the posterolateral globe is always attached to the optic nerve posteriorly & the ora serrata anteriorly – Almost like a towel pegged on each end to a clothes line. The differential diagnosis is a vitreous detachment which tends to be more mobile, less uniform and is not attached to the optic nerve.
Ultrasound has a 97-100% Sensitivity for detecting retinal detachment & is 83-100% Specific in a recent meta-analysis. Use as a rule in test. If not visualised you may need to investigate further by dilating the pupil and looking at the retina with opthalmoscope or pan-optoscope.
The Time to diagnosis after I saw the patient was less than 10 minutes and the patient was referred for an urgent ophthalmology opinion.
How to Perform an Ocular Ultrasound
Opportunities with UIE in New Zealand
If you are in the planning stages for 2020 and wish to solidify your POCUS skills or are keen to achieve the ASUM and updated ACEM requirements, please check out the workshops we have available on our website www.uie.co.nz.
Auckland Public Hospital on 13 & 14 February
(ASUM AAA, eFAST, ACEM Education Program Guidelines for eFAST, AAA, Procedural Ultrasound and Lung Ultrasound, pending RNZCGP & CICM)
Echo in Waiheke on 21 March
(ASUM BELS and ACEM FELS, pending RNZCGP and CIC
Our workshops cover a number of scanning techniques including MSK, DVT, Biliary, Gallbladder, Cardiac Views, Testicular and Early Pregnancy.
For a copy of the program please email me (email@example.com) noting the workshop you are interested in.
Please feel free to bring along your own ultrasound machine for those with hand-held devices, i.e all Lumify and Butterfly's welcome.
(PAID ADVERTISING POST)
With POCUS handhelds now more readily available, there is an exciting opportunity to embrace the game changing benefits to patient outcomes in acute and urgent care environments beyond the emergency department.
Increased accessibility to POCUS technology comes with a sense of responsibility for ensuring that those with probes in their hands are adequately trained and supervised.
A group of passionate POCUS users lead by Dr Mick Kileen, FACEM and US Clinical Director at Whangarei Hospital in Northland New Zealand, teamed up with Philips in a partnership to meet this need for clinicians in remote or resource restricted environments.
The project was called The Handheld Collaboration.
Together they conducted a feasibility study on bringing safe, comprehensive and not for profit POCUS education and supervision to frontline doctors via distance learning and video interaction using Philips Lumify and Philips Reacts Telehealth platform.
The study ran over three months with 4 supervisors and 5 trainees each supplied with a Lumify and Reacts platform on loan from our friends at Philips.
The study provided Philips with objective insight to the use of the Lumify and Reacts platform is such a setting and provided EMUGs valuable insights to inform the design of future training and supervision pathways with benefits for our Developing Countries programs and beyond.
The trainees thoroughly enjoyed the use of their loaned Lumify pairing them with large screen phones or small tablets.They report that having the Lumify on them meant they scanned more often, resulting in a faster rate of skill development and logged scans and were able to use the probe for everything they would have otherwise use a standard machine for.
Want to get your hands on a Lumify?
For the month of December, the ‘dream’ under $5000 price point for a Lumify handheld ultrasound is now a reality (for people who move quickly).
This is a special offer to the EMUGs Community and is available in Australia and New Zealand only and only while in country stocks last.
The offer: inventory clearance sale
$7,999 reduced to
AUD$4,999 per Lumify
with 3 years warranty (AUD, before GST)
To buy: ExDemoLumify2019
In the cart, use voucher code ExDemoLumify2019
Want 5 years warranty? You can add $1000 for this in the cart.
DR THOMAS BROUGH
50yoM P/W exertion chest pain and diaphoresis.
Remote history of whitecoat, no medications; completely healthy until today; worked in business.
Inferior STEMI on ECG with some bradycardia.
450km from cath lab, in an ED where we thrombolyse STEMIs.
Aspirin downrange, about to give ticagrelor, heparin bolus, and 40mg tenecteplase.
Had a look for no reason in particular other than it was my want.
And indeed it was worth a look... (PLAX followed by suprasternal views)
Type A dissection, tPA and heparin withheld, flown to tertiary hospital, arrested a few times, survived neurologically intact
By LUKE PHILIPS: CO-CHAIRPERSON, EMUGs CENTRAL COUNCIL
Dear fellow EMUGers.
2019 has been a huge year for the EMUGS community with a large number of successful events including our Noosa conference and welcoming in both the South Australia and Tasmanian branches of EMUGs.
I’d like to take this opportunity to thank everyone who has helped to organise, assist and teach at these events. Without this grassroots support we wouldn’t be able to push our agenda of advancing Point of Care ultrasound excellence in acute care across Australia and New Zealand.
We have a number of changes at board level with Mark Rewi stepping down from the board and in doing so relinquishing his position as Co-Chairperson. Mark is being replaced as Co-Chairperson by Melody Hiew. Mark has been pivotal in getting EMUGs to where it is today particularly in New Zealand and we are thankful for all his input and support. Allan Whitehead has joined the Central Council, replacing Gaby Blecher, making Allan an official board member, as well as EMUGs secretary and treasurer.
Next year promises to be even bigger with a roadshow of events and our 2nd annual Sonic conference in Queenstown in August. We continue to collaborate and advocate for POCUS with key stakeholders including ACEM and ASUM. As part of this we are looking at how best to make ultrasound education accessible to all trainees and consultants. As part of this process we would like to gauge interest in the development of a focused ultrasound in EM certificate. If you have time and interest, please complete this survey.
In the background, we are developing a set of resources for clinical leads in ultrasound and as part of our outreach/developing country programs we are continuing to offer a scholarships to doctors from developing countries as well as exploring a handheld ultrasound education program.
I look forward to seeing you at a number of events next year and on behalf of the central council we wish you and your families all the best for Christmas and the New Year.
Dr Luke Phillips
Co- Chairperson - EMUGs Central Council
The 2020 Developing Countries Scholarship for POCUS Educators will be made available to a successful applicant and will include:
All taking place in Australia and New Zealand in August 2020.
All made possible by the generous financial support of our Core Partners Istih and our partner AIU – Australian Institute of Ultrasound .
The Selection Process is as follows:
Round 1: Applications Close on January 31st 2020.
All nominations welcome using the below form.
Click Here to Complete the Application Form
A shortlist of candidates will be selected from the first round of applications.
The shortlisted applicants will be required to submit a 2-3 page (recommended) document providing their vision, objectives, strategy and action points for their own and home country Focused Emergency Ultrasound training advancement.
From the shortlist, a small number of candidates will be selected for interview.
From the interviews, one individual will be successful as the 2020 EMUGs Developing Country Scholar.
Two runner-up candidates will be selected in the event of the Scholar being unable to fulfil the Scholarship. The runner-up candidates will automatically be shortlisted for the 2021 Scholarship, pending financial funding of the Scholarship.
Supporting EM in Vanuatu
Thanks to the generosity of our partners AIU – Australian Institute of Ultrasound and Istih, in addition to our annual scholarship we're also able to bring 1 Emergency Physician from Vanuatu over to The Gold Coast to train at AIU-Australian Institute of Ultrasound .
This initiative is of the back of Dr. Jonathan “Jono” Henry's time in Vanuatu after he was asked by the Vanuatu Ministry of Health to assist with emergency services in their country.
Read Sonosite's blog about Jono's work in Vanuatu
Aidan completed a Bachelor of paramedic practice at the University of Tasmania in Sydney, followed by a BSc Hons looking at ultrasound guided IV cannulation by paramedics; comparing short and long axis techniques.
Aidan was then the first paramedic in Australia to do a Graduate Certificate in Clinical Ultrasound with specialism in EM at CQ University. After that he spent a year in London as a visiting researcher and lecturer at Kingston University and St Georges University. He also took up the role of Course Director for the PoCUS UK and EU with the Prehospital Care Consultancy Ltd. Now, back home in Sydney, Aidan is a medical student, working casually as a paramedic and lecturer, and freelancing as a POCUS educator.
Aidan is a passionate believer in POCUS, particularly within EM and out of hospital care.
What drives your POCUS passion?
Once you’ve seen the impact POCUS can have, it’s hard to go back.
The first ultrasound Aidan ever did was as a volunteer simulated patient for Sydney’s Air Ambulance retrieval courses where he scanned himself after one of the formal lessons. He became fascinated and ended up learning more. The learning went from informal to formal, the fascination grew and he ended up travelling to exciting places to teach POCUS around the world, and, in a full circle, back home in Australia.
Favourite travel destination…
As yet undecided. The beauty of travel is that everywhere you go is different and doesn’t have to be compared. Too many favourite countries depending on when you ask. Nepal, India, Thailand, Austria, Ireland, and Scotland are definitely up there though
Who are you outside of work?
Aidan was a classically trainer baritone in a previous life and finds himself revisiting singing on rare occasions. He is currently enjoying being a new student to Brazilian Jiu Jitsu. Is sleeping a hobby?
What is your vision for EMUGs?
POCUS needs to become accessible, self regulating, and well governed and audited. Hopefully EMUGs are able to agitate for these changes.
What progress have you seen with regard to POCUS? What would you like to see?
POCUS has come a long way since I first started learning in 2012. The evidence base has exploded, and the technology has become ever more accessible.
‘The POCUS person’ is now a recognised asset in most departments. We need to shift from it being a special skill, to a core skill and standard of care where evidence for benefit exists, of course.
A message from Aidan for those new to POCUS...
Safe point of care ultrasonography requires that one can articulate the pretest probability which justifies the scan, and the positive and negative likelihood ratios of that specific POCUS exam performed. POCUS without a basic understanding of Bayesian clinical decision making is dangerous.
I uses a mental Fagan nomogram every single time I perform a scan.
I believe that you will likely never harm a patient with POCUS if you practice with an honest Bayesian framework.
Safe Scanning y’all.
It's 10pm and the resident comes to me having seen a 61 year old lady who presents with a sudden onset of dizziness on standing.
She is hypertensive, and not in any distress but describes a feeling of significant unsteadiness while standing from a sitting position at home.
She describes a tremor and tingling down her left hand with no complaints of headache or vomiting despite feeling nauseous.
The resident reports a 15mm Hg drop in blood pressure on standing. Other vital signs remain normal and she has a normal ECG with a normal neurological exam.
She says she had a similar episode a month back but thought nothing of it. It was transient at that time and remained transient today but tonight her symptoms persisted a bit longer, making her seek help.
Her FBC/U&E returns within the normal range and after being treated with 500ml of normal saline with 12.5mg of prochlorperazine she appeared well.
Prior to discharge I go to see her and for a sense of completeness decide to use POCUS [point of Care Ultrasound] on her carotids.
After visualising normal vasculature on the right side, it became obvious that there was a significant stenosis in the left carotid artery just distal to its origin after the bifurcation.
Having found this on my unaccredited scan, it then begs the question whether it is just a coincidental finding or the cause of her symptoms. I organised a CT angiogram which confirmed the stenosis without any other pathology.
The options were to then discharge her with an outpatient formal US request and a outpatient vascular appointment after starting her on Aspirin, Statin and an antihypertensive, or admitting her for further investigation.
After discussion with the vascular team it was decided to admit her for a formal Duplex study of her carotids as an inpatient and after quantifying the degree of stenosis a multidisciplinary team discussion can occur in the cold light of day.
She went on to have the Duplex US study the next day and was discharged remaining asymptomatic and is awaiting an outpatient clinic review by the vascular team.
The video can be viewed here.
Another rewarding use of POCUS in emergency medicine.
Dr Ash Mukherjee
Blogs are written by our EMUGs Team from across Australasia.