Page 1 : Introduction

 2024 

Updated POCUS training Whangarei Emergency Department 

Ultrasound lead : Mick Killeen , FACEM 

Bedside ultrasound training has evolved in Emergency Medicine over the course of the last decade. 

ACEM has moved away from prescribed credentialing based on other organisations (eg ASUM ) and formally credentialed workshops and courses . The guidelines can be accessed on the side bar of this blog. To summarise ACEM and the Ultrasound steering committee have made the following recommendations: 

1) Credentialing of POCUS is the responsibility of the local hospital and health organisation , not ACEM 

2) The traditional stepwise process of training is maintained but there is no governing body outside ACEM , although organisations such as ASUM are recognised  sources of reference and training . The training steps are outlined below 

3) Ongoing maintenance of credentialing involves continuined practice  of the various POCUS modalities +/- logging of this . 

Stepwise POCUS training  

1. Workshop attendance . There are various resources such as the eBooks Introduction to bedside ultrasound vol 1 and 2 , Websites such as POCUS 101 , Sonomojo.org will lead you modules that are easy to access and understand . Coreultrasound.com is also to be recommended . Although workshop attendance should be 2 hrs per module , this time can be greatly reduced by accessing the websites and resources above . We feel that didactic one on one instruction during the six months a trainee is in Whangarei hosptial , they should be able to get sufficient teaching if they also use these free online resources 
2. Log scans ( for most modules , the required number to log is 15 ( 25 for EFAST and 50 for cardiac )  At least 2 of these logged scans in a module must be supervised with feedback ( these are called formative scans ) .There needs to be some positive pathology demonstrated on some of the images  . Many of the images can be obtained outside the clinical setting eg , at a course 
3. On completion of at least the majority of the log book,  an “exit” or “ summative scan” should be supervised and signed off , completing the initial training process . Examples of what a summative scan looks like can be seen by following the link to ASUM and scrolling through the details of each module to the end . 
4. Ongoing maintenance of POCUS skills involves continued logging of images . 

In the up coming posts I will review  the details of each of the modules 

The following are recommended apps for logging images although a simple excel or google sheet would also suffice .

Echo log 

Tidy ultrasound 

The following posts will run through various scanning protocols , in particular focussed cardiac echo , early pregnancy , hepatobiliary and soft tissue / small parts / MSK ultrasound at the point of care. It is up to the reader to look at various resources on the side bar to learn some of basics ( eg POCUS 101 and introduction to beside ultrasound Vol 1 / 2 ) . The next step is to gets someone on the “shop floor” to give you some  instruction and then get some formative scans supervised ( see forms attached to each module )  and then a final summative scan demonstrating competency . 

A summative scan demonstrates competency , a log book with required scans confirms credentialing requirements. Without credentialing it is difficult to report on a POCUS scan without a supervisor present and it is to be discouraged . 

LINK TO INTRODUCTION TO BEDSIDE ULTRASOUND VOLUME 1 

LINK TO POCUS 101 

PLEASE FOLLOW LINKS ON SIDE BAR FOR MORE USEFUL LINKS 

Page 2 AAA and EFAST resources

 Page 2 : 

AAA and EFAST 

These are the original topics / modalities in ED point of care Ultrasound 

This page will cover AAA and EFAST at some point . 

In the meantime to learn everything there is to know about EFAST and AAA there are a multitude of sources 

-EFAST and AAA modules via ACEM 

-EFAST and AAA modules via POCUS 101 

-Introduction to bedside USS volumes 1 (via I tunes free or via UTEC NSW )

-Core Ultrasound / 5 minutes sono also has free open access teaching modules 

Prior to the AAA and EFAST teaching sessions there will be some basic mcqs that are based on the information in these sights 

AAA

EFAST 

 

Page 3 : Focussed cardiac ultrasound - Based on the views acquired using a BSI level 1 Echo

 Cardiac Ultrasound 

Focussed Cardiac Ultrasound describes echocardiography performed  by non cardiologist , non echocardiographer . There are various protocols , FELS , RACE, EGLS FEEL   etc . In my opinion, the most recognisable across specialties is the BSE level 1 echo .  This is a 17 image protocol using the standard views ( PSLAX , PS short axis x 3 , apical 4 and 5 chamber views and subcostal / IVC ) .The echo taught here is based on the BSE level one echo, but will be called Focussed cardiac Ultrasound 

The indications for focussed cardiac ultrasound include the following 

1) shock ? cause 

2) Shortness of breath ? cause 

3) haemodynamic status ( ie ? hypovolaemia vs vasodilation vs systolic dysfunction  vs diastolc dysfunction ) - useful in deciding whether an unwell patient needs inotropes or fluids 

4) ? pericardial effusion ( also ? tamponade physiology) 

5) Is there obvious valvular dysfunction that might be contributing to patients clinical presentation 

Often one single view can be misleading and several views need to be looked at to put together and useful interpretation 

Tips and tricks 

The PSLAX is the 'cardiologist view '

It gives the most information about the LV , including 

- LV End diastolic diameter LVEDD - the upper limit of normal is about 5 ( 5.1-6.0 depending on BMI , sex  ) For focussed Echo a rough estimate of  normal is acceptable. Normal ranges can be looked up later 

This is best measured at the tips of the MV ( anterior leaflet ) during diastole or the widest you can see on scrolling back the still image.  Another option is to  save it a M mode cut through this level ( anterior leaflet ) 

The wall thickness of the septum can be measured ( avoiding measuring the “knuckle” at the base of the septum and and also the lateral wall.  The upper limit of normal  LV wall and septum is about1 cm ( 0.9 mm in a female and 1.1 in a male . 

EF can be estimated by looking at the “squeeze” , although this can be inaccurate. The End point separation from the septum EPSS is the nearest the tip of the anterior leaflet of the mitral 

This can be measured by taking a “B mode” or normal still ( see images below ) and measuring directly on the B mode still or creating an M mode and measuring . 

The values to remember are as follows 

1) normal EPSS < 7 

2) EPSS > 7 mm = reduced EF 

3) EPSS > 14 = severely reduced 

- RV  : Assessing the RV on the pslax involves eye balling the diameter of the rv and seeing if it lines up with the aortic outflow tract and la , meaninf the diameter of each should be about 3.5 cm or less and in a 1:1:1 rario  of the rv appears bigger ( and im particular bigger than 3.5 cm ,then this probably represents right heart strain ( acute if no increase in rv free wall thickness ,more than half a cm, and chronic if there is evidence of rv wall thickening) 

If you think there is right heart strain there is often flattening of the septum that appears as a flat side to the otherwise oval round shape seen on the parasternal short axis view 

The pressure in the right side of the heart also translates to the ivc making it “ plethoric “ with a diameter of >2.1 cm 

The way in which the rv is “stunned” and is essentially akinetic everywhere except the apex is call mconnells sign

If you were to put a cw doppler through the triscupid valve and measure the velocity of the TR jet, this would be greater than 2.8 m/s ( but also no greater than 3.9 m/sec as this can only get that high in chronic processes) 

Not all PEs have reliable echo findings but the majority of submassive PEs  will !

The best app for resourcing normal values is “ECHOQUICK’’

The PSAX ( parasternal short axis view is the second view ) it is actually made of of three views ( see the next post on the BSE level 1 echo . The PSAX is used ( in the Basic echo    ) to look at the Aortic valve and Mtiral valve and LV in cross section . This latter view can also be used for measuring wall thickness and assessing contractility as well as regional wall abnormality . The following images show how you might measure LV wall thickness and assess EF by measuring fractional shortening  

Measuring thickness of LV wall ( not shown but easy to put callipers edge to edge of LV septum and free wall. This image shows how to work out fractional shortening ( normal range 25-45 , this equivalent to EF of 55-70 % ) 

Below is an image of the LV showing the distribution of the RCA, LAD and Cx across the regions of the LV , specifically ( and in order to) inferior wall , septum ,anterior wall and lateral 

Page 4 : BASIC ECHO - BSE level one echo - This is an ideal protocol and is easily understandable and reproducible

 BSE level 1 Echocardiogram (modified to clinical indication and image acquisition) 

15 views 

Images from the following windows 

1) PLAX - Clip to show LV systolic function 

(The BSE protocol also suggests deeper view to view pleural effusion - however our protocol would finish by looking at lung lines and pleural effusions)

Use this view to measure or estimate EPSS (M mode of this optional) 

2)  PLAX still  with measurements (eg LVEDD/septum / Aortic root and RV  / LA diameter ) 

3,4) PLAX clip or still will colour through MV / AV   

5,6,7 ,8) PSAX clips at level of Aortic valve , MV , Papillary muscle and Apex (apex view not shown)

..

.

(Demonstrate valves opening  and RWMA, “D” sign ) 

9,10,11,12 A4C)      clip and stills 

Views including straight forward 4 chamber view , 4 chamber with colour through MV and TV and TAPSE on m mode 

Good 4 chamber view with open LA (measure RV base) 

Colour though MV and TV 

MAPSE (optional) MV CW demonstrating diastolic filling ( also optional ) -

13,14 , 15) ) 2 clips : 2 X A5C view with Aortic valve with and without colour  and subcostal view 

 

( if you have a good CW Doppler tracing  , < 20 degree angle of insonation from Doppler direction , use this to estimate AV max velocity ) 

 

Clinical questions (Must be able to answer  1-4) 

1)LV systolic function estimation - EPSS / visual estimation / fractional shortening . 

Knows pit falls ( particularly valvular pathology / off axis measurements / RWA) 

2)Haemodynamic/volume  status - based on IVC and general signs of overfilled or under filled Left heart ( eg LV Esd , interatrial septal bowing ) -pitfalls 

3) RV systolic function ( size / septal flattening / TAPSe/ visual - McConnell sign) Pitfalls 

4) Pericardial effusion  - 3 signs of Tamponade 

5) Obvious valvular abnormality - pitfalls 

6) Signs of Diastolic dysfunction  - pitfalls 

7) LVOT VTE and significance in assessing volume responsiveness 

8) TR Vmax measurements - significance 

FORMATIVE / SUMMATIVE scan (“+/-“ means optional or additional NOT pass /fail ) 

1. Basics ( eg cleaning principles , depth , patient details , patient position , knowledge of technique and direction of probe )       Pass / fail  .  Feedback 
2. PLAX view . Saves appropriate clips / images . Anatomy knowledge , image acquisition technique , measurements and estimation of LV systolic function , obvious structural abnormality , pericardial effusion , (+/-obvious valvular abnormality ) Pass / fail . Feedback 
3. PSAX . Saves appropriate clips . Comments on D sign, systolic function , +/- RWMA ,+/- LV wall thickness , RV size ,+/- TAPSE , +/- mconells ,  Pass /fail feedback 
4. A4C . Image acquisition ( LA must be open , not foreshortened), saves appropriate clips , RV /LV ration +/-  measures RV base , +/- obvious RWMA , systolic dysfunction of either RV /LV , +/- TAPSE , +- MAPSE , colour through MV and TV , +/- MV CW for diastolic wave form , +/-  CW at TR for measurement of RV peak systolic pressure 
5. Apical 5 C visualisation of AV, saves clip or still  , colour through AV +/- Peak velocity through AV