Introduction: Determining fluid status prior to resuscitation provides a more accurate guide for appropriate fluid administration in the setting of undifferentiated hypotension. Emergency Department (ED) point of care ultrasound (PoCUS) has been proposed as a potential non-invasive, rapid, repeatable investigation to ascertain inferior vena cava (IVC) characteristics. Our goal was to determine the feasibility of using PoCUS to measure IVC size and collapsibility. Methods: This was a planned secondary analysis of data from a prospective multicentre international study investigating PoCUS in ED patients with undifferentiated hypotension. We prospectively collected data on IVC size and collapsibility using a standard data collection form in 6 centres. The primary outcome was the proportion of patients with a clinically useful (determinate) scan defined as a clearly visible intrahepatic IVC, measurable for size and collapse. Descriptive statistics are provided. Results: A total of 138 scans were attempted on 138 patients; 45.7% were women and the median age was 58 years old. Overall, one hundred twenty-nine scans (93.5%; 95% CI 87.9 to 96.7%) were determinate. 131 (94.9%; 89.7 to 97.7%) were determinate for IVC size, and 131 (94.9%; 89.7 to 97.7%) were determinate for collapsibility. Conclusion: In this analysis of 138 ED patients with undifferentiated hypotension, the vast majority of PoCUS scans to investigate IVC characteristics were determinate. Future work should include analysis of the value of IVC size and collapsibility in determining fluid status in this group.

Introduction: Patients presenting to the emergency department (ED) with hypotension have a high mortality rate and require careful yet rapid resuscitation. The use of cardiac point of care ultrasound (PoCUS) in the ED has progressed beyond the basic indications of detecting pericardial fluid and activity in cardiac arrest. We examine if finding left ventricular dysfunction (LVD) on emergency physician performed PoCUS reliably predicts the presence of cardiogenic shock in hypotensive ED patients. Methods: We prospectively collected PoCUS findings performed in 135 ED patients with undifferentiated hypotension as part of an international study. Patients with clearly identified etiologies for hypotension were excluded, along with other specific presumptive diagnoses. LVD was defined as identification of a generally hypodynamic LV in the setting of shock. PoCUS findings were collected using a standardized protocol and data collection form. All scans were performed by PoCUS-trained emergency physicians. Final shock type was defined as cardiogenic or non-cardiogenic by independent specialist blinded chart review. Results: All 135 patients had complete follow up. Median age was 56 years, 53% of patients were male. Disease prevalence for cardiogenic shock was 12% and the mortality rate was 24%. The presence of LVD on PoCUS had a sensitivity of 62.50% (95%CI 35.43% to 84.80%), specificity of 94.12% (88.26% to 97.60%), positive-LR 10.62 (4.71 to 23.95), negative-LR 0.40 (0.21 to 0.75) and accuracy of 90.37% (84.10% to 94.77%) for detecting cardiogenic shock. Conclusion: Detecting left ventricular dysfunction on PoCUS in the ED may be useful in confirming the underlying shock type as cardiogenic in otherwise undifferentiated hypotensive patients.

Introduction: Bleeding in the first trimester of pregnancy is a common presentation to the Emergency Department (ED) with half going on to miscarry. Currently there is no local consensus on key quality markers of care for such cases. Point of Care Ultrasound (PoCUS) is increasingly utilized in the ED to detect life threating pathology such as an ectopic pregnancy or fetal viability. PoCUS leads to improved patient satisfaction, quicker diagnosis and treatment. The purpose for this study was to examine the rates of formal ultrasound and PoCUS when compared to reported and recommended rates, and also to understand the use of other diagnostic tests. Methods: A retrospective cohort study of pregnant females presenting to the ED with first trimester bleeding over one year (June 2016 – June2017) was completed. A sample size of 108 patients was required to detect a moderate departure from baseline reported rates (67.8 – 77.6%). The primary outcome was the PoCUS rate in the ED. The main secondary outcome was the formal ultrasound rate. The literature recommends PoCUS in all early pregnancy bleeding in the ED, with a target of 100% of patients receiving PoCUS. Additional data recorded included the live birth rate, pelvic and speculum examination rate and lab tests. There is no clearly defined ideal practice for the additional data so these rates will be recorded without comparison. Results: Records of 168 patients were screened for inclusion. 65 cases were excluded because they were not pregnant or had confirmed miscarriage or other, leaving a total of 103 patients included in the analysis. The PoCUS rate was 51.5% (95% CI 42%-61%), lower than previously reported PoCUS rates of 73% (67.8 – 77.6%). The formal ultrasound rate was 67% (57%-75%). Both approaches were significantly lower than the recommended rate of 100% (95.7 – 100%). Rates for other key markers of care will also be presented. Conclusion: Fewer PoCUS exams were performed at our centre compared with reported and recommended rates for ultrasound. Further results will explore our current practice in the management of first trimester pregnancy complications. We plan to use this information to suggest improvements in the management of this patient population.

Introduction: Evidence suggests that prehospital point of care ultrasound (POCUS) may improve outcomes. It serves as an aid in physical examination, triage, diagnosis, and patient disposition. The rate of adoption of POCUS among aeromedical services (AMS) throughout Canada is unknown. The objective of this study was to describe current POCUS use among Canadian AMS providers. Methods: This is a cross-sectional observational study. A survey was emailed to directors of government-funded AMS bases in Canada. Data was analyzed using descriptive statistics. Results: The response rate was 88.2% (15/17 AMS directors) and accounted for 42 out of 46 individual bases. POCUS is used by AMS in British Columbia, Alberta, Saskatchewan, and Manitoba. New Brunswick, Nova Scotia, Prince Edward Island, and Yukon are planning to introduce POCUS within the next year. Ontario, Quebec, and Newfoundland are not utilizing POCUS and are not planning to introduce it. BC is the only province currently using POCUS on fixed-wing aircraft. POCUS is used in <25% of missions, most frequently at sending hospital and in flight. Most useful applications were assessment for pneumothorax, free abdominal fluid, and cardiac standstill. Most common barrier to POCUS use was cost of training and maintenance of competence. Conclusion: Prehospital POCUS is available in Western Canada with one third of the Canadian population having access to AMS utilizing ultrasound. The Maritimes and the Yukon Territory will further extend POCUS use on fixed-wing aircraft. While there are barriers to POCUS use, those bases that have adopted POCUS consider it valuable.

Introduction: According to the International Evidence-Based Recommendations for Point-of-Care Lung Ultrasound published in 2012, the sonographic technique for evaluating a patient for a pneumothorax (PTX) “consists of exploration of the least gravitationally dependent areas progressing more laterally” in the supine patient. However, there is a wide variety of scanning protocols in the literature with varying accuracy and complexity. We sought to derive an efficient and accurate scanning protocol for diagnosing pneumothorax using point of care ultrasound in trauma. Methods: We performed a retrospective chart review of a tertiary care trauma registry from Nov 2006 to Aug 2016. We included patients with a PTX diagnosed on computed tomography (CT). Patients were excluded if they did not have an identifiable PTX on the CT scan or if they underwent a tube thoracostomy prior to the CT scan. Penetrating and blunt trauma were eligible. Data were extracted with a standardized data collection tool and 20% of charts reviewed by two reviewers. Pre defined zones were used to map area of PTXs on CT. Sensitivity, specificity and 95% CI are reported for presence of PTXs in each individual or combination of lung zones as identified on CT scan. Results: Data were collection yielded 170 traumatic PTX on chest CT with an average age of 44.2 and 77.8% male. The kappa for data extraction was 0.88. 19.4% of patients had bilateral PTX leading to a total sample size of 203. The average ISS score was 20.7 and 93% of patients survived to discharge. The length of ICU stay and hospital stay was 3.7 and 11.2 days respectively. The most accurate and efficient protocol would involve scanning the inferior border of the clavicle at the para-sternal border and again at the mid-clavicular line down to the cardiac (left hemithorax) and liver lung points (right hemithorax). The sensitivity of this scanning area in the detection of PTXs was 91.6% (95% CI 86.9-95%,). Limiting the area to the most anterior point of the chest wall increased the risk of missing a PTX (Sensitivity 89.7% (95%CI 84.6-93.5)). Conclusion: We have derived an evidence-based standardized accurate and efficient scanning protocol to rule out a pneumothorax on point of care ultrasound.

Introduction: Hydronephrosis is the de facto measure of obstructive uropathy (OU) and can be evaluated using renal Point of Care Ultrasound (rPOCUS). This educational initiative aimed to develop an effective one-day rPOCUS curriculum and evaluate if feedback/quality assurance (QA), leads to an improvement in image acquisition and interpretation of hydronephrosis as well as comfort with the technique. Methods: Physicians were randomized into a QA or control group (NQA) and all attended a one day training session which involved acquiring rPOCUS scans with one-on-one instruction. Participants then performed POCUS scans on all ED patients where formal renal US was deemed clinically indicated. The QA group received feedback on every scan from qualified ED physicians. Overall sensitivity and specificity were calculated compared to formal scans using a chi-square test. Written QA was reviewed for future improvements. Crossover occurred at 10 weeks to allow for equal learning opportunity but analyses focused on pre-crossover data. Participants completed surveys at study start and end focusing on initiative effectiveness and barriers/comfort with POCUS measured with a likert scale (Not at all (1)-Very (7)). Results: Fourteen ED physicians participated. The most common cited barrier to utilizing rPOCUS was lack of knowledge/training (78.6%). A total of 63 POCUS scans were reviewed. Common feedback included breath-holding (69.7%), use of color doppler (48.5%) and including a transverse sweep (36.4%). Sensitivity and specificity were better in the QA versus NQA group though the difference was not significant (Se- 75.0% vs 50.0%, 95%CI: −34.0-73.4%; Sp- 89.3% vs 73.9%, 95% CI: 8.2-39.2%). Ten physicians completed the post survey; all reported improved comfort with rPOCUS in assessment of hydronephrosis (median [IQR]: Δ+2 [1-3]). At study end, the comfort rating for using only POCUS and not formal scan remained low (median [IQR]: 3.50 [1.8-4.2]). The training initiative was rated highly with a median [IQR] rating of 5.50 [4.8-7.0]. Conclusion: Although the initiative was rated highly effective and resulted in improved comfort with renal POCUS, physicians did not feel comfortable solely using POCUS without formal scan to diagnose OU. Despite the initiative's success, further educational programs are needed before rPOCUS can be safely used as the primary investigation. In the future, a greater emphasis should be placed on the commonly noted areas of improvement.

Introduction: Undifferentiated hypotension remains one of the most life-threatening presentations to emergency departments (ED) around the world. An accurate and rapid initial assessment is essential, as shock carries a high mortality with multiple unique etiologies and management plans. Point of care ultrasound (PoCUS) has emerged as a promising tool to improve these diagnostic and management challenges, yet its reliability in this setting remains unclear. Methods: We performed a systematic review of Medline, EMBASE, CINAHL, Cochrane, and clinicaltrials.gov databases from inception to June 8, 2018. Databases were reviewed by two independent researchers and all languages were included. The methodological quality of included studies were evaluated using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. Our primary outcome was diagnostic accuracy of PoCUS in hypotension, with secondary outcomes including patient outcomes and changes to management. Results: Our literature search revealed 5345 articles after duplicates were removed, leaving 235 articles for full article review. Following full article review, 9 studies remained and were included in the systematic review. There were 2 randomized control trials, 6 prospective cohort trials, and 1 retrospective cohort trial. For our primary outcome of diagnostic accuracy, eight studies were included; we extracted Kappa values ranging from 0.70 to 0.971, pooled sensitivity ranging from 69% to 88%, and pooled specificity ranging from 88% to 96%. Four studies reported on management change including results reporting shorter time to disposition, change in diagnostic test ordering (18% to 31%), change in consultation (13.6%), change in admission location (12%) and change in management plan (25% to 40%). Only one study reported on patient outcomes, which revealed no survival or length of stay benefit. Conclusion: When assessing for the diagnostic accuracy of PoCUS in the setting of undifferentiated hypotension presenting to the emergency department, we found fair consistency between PoCUS and final diagnosis with high Kappa values, fair to good pooled sensitivities, and good to excellent specificities. There was no strong evidence indicating improved outcomes. However, the large amount of heterogeneity amongst studies has limited our ability to make a strong conclusion except that future research should focus on a uniform study design and patient focused outcomes.

Introduction: Although use of point of care ultrasound (PoCUS) protocols for patients with undifferentiated hypotension in the Emergency Department (ED) is widespread, our previously reported SHoC-ED study showed no clear survival or length of stay benefit for patients assessed with PoCUS. In this analysis, we examine if the use of PoCUS changed fluid administration and rates of other emergency interventions between patients with different shock types. The primary comparison was between cardiogenic and non-cardiogenic shock types. Methods: A post-hoc analysis was completed on the database from an RCT of 273 patients who presented to the ED with undifferentiated hypotension (SBP <100 or shock index > 1) and who had been randomized to receive standard care with or without PoCUS in 6 centres in Canada and South Africa. PoCUS-trained physicians performed scans after initial assessment. Shock categories and diagnoses recorded at 60 minutes after ED presentation, were used to allocate patients into subcategories of shock for analysis of treatment. We analyzed actual care delivered including initial IV fluid bolus volumes (mL), rates of inotrope use and major procedures. Standard statistical tests were employed. Sample size was powered at 0.80 (α:0.05) for a moderate difference. Results: Although there were expected differences in the mean fluid bolus volume between patients with non-cardiogenic and cardiogenic shock, there was no difference in fluid bolus volume between the control and PoCUS groups (non-cardiogenic control 1878 mL (95% CI 1550 – 2206 mL) vs. non-cardiogenic PoCUS 1687 mL (1458 – 1916 mL); and cardiogenic control 768 mL (194 – 1341 mL) vs. cardiogenic PoCUS 981 mL (341 – 1620 mL). Likewise there were no differences in rates of inotrope administration, or major procedures for any of the subcategories of shock between the control group and PoCUS group patients. The most common subcategory of shock was distributive. Conclusion: Despite differences in care delivered by subcategory of shock, we did not find any significant difference in actual care delivered between patients who were examined using PoCUS and those who were not. This may help to explain the previously reported lack of outcome difference between groups.

Introduction: Despite widespread use of FAST in trauma, there is a lack of data supporting its usefulness. We sought to identify the impact of FAST on clinical management of blunt trauma patients. Methods: This health records review was conducted at a single large academic Level 1 trauma center emergency department. Patients with a suspicion of acute blunt traumatic abdominal injury were identified from our health records database. Data were collected regarding FAST utilization, CT scan utilization and timing, need for definitive management, disposition, and length of stay (LOS). Results: 285 patients were included, 152 (53.3%) received a FAST examination, with 33 (22%) having a direct impact on clinical management. CT was performed in 112 (73.6%) of the FAST group, with mean time to imaging of 147.4 minutes, time to trauma team assessment of 21.5 minutes, and ED-LOS of 8.6 hours. In the non-FAST group, 33 (24.8%) received a CT, with time to imaging of 133 minutes, time to trauma team assessment of 133 minutes, and ED-LOS of 13.8 hours. 75.6% of the FAST group required admission and 9.2% required definitive management; admission was needed for 38.3% of the non-FAST group and 2.2% required definitive management. Conclusion: This is the first study to assess patient outcomes with respect to FAST in the era of early whole body CT in trauma. Although FAST does not directly impact care for the majority of blunt trauma patients, it demonstrates usefulness in some patients by directing CT utilization and expediting disposition from the ED.

Acute flank pain from suspected urolithiasis is a common presenting complaint in the Emergency Department. Multiple computed tomography (CT) has traditionally been the standard imaging modality used to diagnose obstructive kidney stones, however point of care ultrasound (PoCUS) can play an important role in the diagnostic algorithm and risk stratification of acute flank pain. Here, we present the case of a 29-year-old female with suspected urolithiasis, who underwent PoCUS that revealed right-sided hydronephrosis and normal left kidney, bladder, and aorta. A subsequent KUB was negative. As the clinical course failed to improve with therapy, an abdominal and pelvic CT was ordered revealing a 5 mm distal obstructing ureteric calculus at the right vesico-ureteric junction and another 5 mm left mid ureteric calculus. To the best of our knowledge, this is the first case in which a patient presenting with acute right-sided flank pain demonstrated unilateral hydronephrosis on PoCUS, but had clinically significant bilateral ureteric stones on CT. Emergency physicians who employ PoCUS for evaluation of flank pain must be aware of its benefits and drawbacks and how they apply to each patient. As such, we have developed a script emergency physicians can use for shared decision-making with renal colic patients when deciding on the appropriate imaging modality.

Introduction: In Canada, family physicians (FPs) provide the majority of early pregnancy care. To receive a same day US, most patients will be sent to the emergency department (ED). FPs are starting to use point of care ultrasound (POCUS) for a variety of indications. The FaMOUS course was modeled after the Canadian Emergency Ultrasound Society (CEUS) ED Echo (EDE) curriculum and adapted with permission for FPs. The objective of this study was to assess the indications for POCUS use in early pregnancy and determine the diagnostic accuracy of POCUS performed by FPs following FaMOUS certification to detect intrauterine pregnancy (IUP) and fetal cardiac activity (FCA). Methods: This was a prospective, observational study conducted in 3 FP clinics from November 2015 to June 2016. Pregnant women <20 weeks gestational age who underwent a focused, transabdominal POCUS by a FaMOUS-certified FP using a handheld GE VScan were enrolled. FPs documented the presence or absence of IUP and FCA. The reference standard was radiologist-interpreted US performed after the FP POCUS. FPs were surveyed to assess provider confidence using POCUS and perceived impact on clinical decision-making. Results: Of 253 eligible patients, 56 (22.1%) underwent POCUS. Of these, 50 (89.3%) had a radiologist-interpreted US following the office-based FP visit. POCUS was used for the following indications: 11 (19.6%) had vaginal bleeding, 5 (8.9%) had abdominal pain, 7 (12.5%) had both vaginal bleeding and abdominal pain, and the indication for 33 (58.9%) patients was unclear. All patients had a documented IUP, resulting in a sensitivity of 94.0% (95% CI: 83.5%, 98.5%) and 100% positive predictive value. FCA resulted in sensitivity of 82.9% (95% CI: 69.2, 92.4%) and specificity of 100% (95% CI: 29.2%, 100.0%). When surveyed, 100% of FPs were confident performing POCUS and reported POCUS had an overall positive impact on clinical practice. 75% agreed the use of POCUS decreased the need for urgent radiologist-interpreted US. Conclusion: Following a certification process modeled after the CEUS EDE curriculum, FPs used POCUS for both CEUS-defined indications and indications that were unclear. FPs trained in early pregnancy POCUS demonstrated excellent diagnostic accuracy identifying IUP and FCA. Future study should assess the clinical impact of office-based POCUS, including whether its use results in decreased ED visits for this patient population.

Introduction: The acute onset of flashes and floaters is a common presentation to the emergency department (ED). The most emergent etiology is retinal detachment (RD), which requires prompt ophthalmologic assessment. Previous studies of point of care ultrasound (POCUS) have reported high sensitivity and specificity for RD, but are limited by small sample size, use of highly trained and experienced sonographers, and referral bias. Our primary objective was to assess the test characteristics of POCUS performed by a large heterogeneous group of emergency physicians (EPs) for the diagnosis of RD. Methods: This was a prospective diagnostic test assessment of POCUS performed by EPs with varying ultrasound experience on a convenience sample of ED patients presenting with the complaint of flashes or floaters in one or both eyes. Participating EPs completed a one hour didactic lecture and were expected to demonstrate appropriate performance of one practice scan before enrolling patients. After standard ED assessment, patients underwent an ocular POCUS scan targeted to detect RD. EPs recorded the presence or absence of RD on the data collection instrument based on their POCUS scan. After completing their ED visit, all patients were assessed by a retina specialist who was blinded to the results of the POCUS scan. We calculated sensitivity and specificity with associated exact binomial confidence intervals (CI) using the retina specialist’s determination of the final diagnosis as the criterion standard. Results: A total of 30 EPs, consisting of 21 staff physicians and 9 residents, participated in this study. These EPs performed a total of 128 POCUS scans. Of these scans, 13 were excluded. Of the remaining 115 enrolled patients, median age was 60 years, and 64% were female. The retina specialist diagnosed RD in 16 (14%) cases. The sensitivity and specificity of POCUS for detecting RD was 75% (95% CI 48% to 93%) and 94% (95% CI 87% to 98%), respectively. The positive likelihood ratio was 12.4 (95% CI 5.4 to 28.3), and negative likelihood ratio was 0.27 (95% CI 0.11 to 0.62). Conclusion: In a heterogeneous group of EPs with varying ultrasound experience, POCUS demonstrates high specificity but only intermediate sensitivity for the detection of RD. A negative POCUS scan is not sufficiently sensitive to rule out RD in a patient with new onset flashes or floaters.

Introduction: Point of care ultrasound (POCUS) has many applications in Emergency Medicine which are proven to improve patient outcomes. Training programs and guidelines for its use are available but its utilization metrics across Canadian Emergency Departments are unknown. This study aims to provide a comprehensive national assessment of POCUS usage, with a key component comparing training with patterns of use. Methods: A survey was distributed via email to all staff adult emergency physician members of the Canadian Association of Emergency Physicians (CAEP). The survey included questions related to training, attitudes towards POCUS, POCUS utilization, and barriers to POCUS use. Standard descriptive statistics were calculated, and differences in mean POCUS usage between groups were measured using a one-way analysis of variance (ANOVA). Results: The survey received 189 responses from emergency physicians from across Canada, 81% of which viewed POCUS as “useful and essential”. Respondents indicated that on average, POCUS was used during 71% (SD 29%) of shifts and on 23% (SD 17%) of patients. POCUS was most commonly used for basic applications, including thoracoabdominal trauma (FAST), cardiac assessment in arrest (trans-abdominal), and assessing for pericardial effusion. The most commonly cited barrier to wider POCUS adoption was a lack of training, with 41% of respondents identifying this as an issue. Correspondingly, formal POCUS training and certification were associated with significantly higher POCUS usage: usage rates ranged from 11.5% (SD 10.5%) of patients for those with formal training but no certification to 39.5% (SD 16.4%) of patients for those with a POCUS fellowship (p <0.001). Conclusion: The presented results from this survey provide an initial overview of the current state of POCUS usage in Canadian Emergency Departments. In summary, a higher level of training was associated with higher POCUS usage, and over a third of the respondents cited lack of training as a barrier to adoption; this suggests that efforts to facilitate POCUS utilization should focus on improving access to formal training and certification. Future work will involve further evaluation of additional barriers preventing POCUS usage in the ED, with the goal of providing information that will encourage changes that support widespread POCUS adoption.

Introduction: Recent studies have shown that point of care ultrasound is a valuable tool in the assessment and management of shock in the Emergency Department (ED). Despite proven utility, data is limited on the current utilization and quality assurance of POCUS in ED management of shock. The aim of this study was to determine the rate of POCUS use, characterize data collection methods and determine rate of quality assurance in both the ED and Intensive Care Unit (ICU) of a tertiary care academic center. Methods: The study included all patients who visited the ED from Jan-Jun 2015 that were transferred to the ICU, and were in shock, as determined by sBP <90, diagnostic code or vasopressor use. Patient charts, as well as wirelessly archived ultrasound studies were reviewed to determine which patients had POCUS performed, and how the results were recorded. By reviewing formal worksheets archived online, it could be determined if a management change was recommended, if studies were over-read for quality assurance and if improvement was recommended to image acquisition or interpretation. Results: Both departments used POCUS in roughly half of patients presenting in shock (53% ED, 41% ICU) with no statistical difference in usage (Δ12, 95% CI −0.01 to 0.25; p=0.06). Most ED studies (87%), had some form of documentation either on paper or online, however few (9%) had a formal worksheet completed. In comparison 71% of ICU studies had a worksheet. There was no difference in the number of performed scans that were saved electronically (66% ED vs 71% ICU; Δ5%, 95%CI −0.13 to 0.21; p=0.60).In the ICU the majority (77%) of the formal reports recommended a management change as a direct result of scan findings. Furthermore, of worksheets submitted for quality assurance (88%), over half the reviews (55%) suggested an improvement in image acquisition or interpretation. Conclusion: To our knowledge, our study is the first to demonstrate that POCUS is only utilized in about half of the shock cases in ED and ICU. Given that the majority of the formally reported studies in the ICU that were over-read for quality assurance found areas for potential improvement and given that the majority of ED studies were reported informally, it stands to reason that POCUS operators in the ED could benefit from a formalized quality assurance program. Future studies should explore potential barriers to implementation of such a program.