Background Focused cardiac ultrasound (FoCUS) is a simplified, clinician-performed application of echocardiography that is rapidly expanding in use, especially in emergency and critical care medicine. Performed by appropriately trained clinicians, typically not cardiologists, FoCUS ascertains the essential information needed in critical scenarios for time-sensitive clinical decision making. A need exists for quality evidence-based review and clinical recommendations on its use. Methods The World Interactive Network Focused on Critical UltraSound conducted an international, multispecialty, evidence-based, methodologically rigorous consensus process on FoCUS. Thirty-three experts from 16 countries were involved. A systematic multiple-database, double-track literature search (January 1980 to September 2013) was performed. The Grading of Recommendation, Assessment, Development and Evaluation method was used to determine the quality of available evidence and subsequent development of the recommendations. Evidence-based panel judgment and consensus was collected and analyzed by means of the RAND appropriateness method. Results During four conferences (in New Delhi, Milan, Boston, and Barcelona), 108 statements were elaborated and discussed. Face-to-face debates were held in two rounds using the modified Delphi technique. Disagreement occurred for 10 statements. Weak or conditional recommendations were made for two statements and strong or very strong recommendations for 96. These recommendations delineate the nature, applications, technique, potential benefits, clinical integration, education, and certification principles for FoCUS, both for adults and pediatric patients. Conclusions This document presents the results of the first International Conference on FoCUS. For the first time, evidence-based clinical recommendations comprehensively address this branch of point-of-care ultrasound, providing a framework for FoCUS to standardize its application in different clinical settings around the world.

International Evidence-Based Recommendations for Focused Cardiac Ultrasound

In 2011, the role of Point of Care Ultrasound (POCUS) was defined as one of the top five research priorities in physician-provided prehospital critical care and future research topics were proposed; the feasibility of prehospital POCUS, changes in patient management induced by POCUS and education of providers. This systematic review aimed to assess these three topics by including studies examining all kinds of prehospital patients undergoing all kinds of prehospital POCUS examinations and studies examining any kind of POCUS education in prehospital critical care providers. By a systematic literature search in MEDLINE, EMBASE, and Cochrane databases, we identified and screened titles and abstracts of 3264 studies published from 2012 to 2017. Of these, 65 studies were read in full-text for assessment of eligibility and 27 studies were ultimately included and assessed for quality by SIGN-50 checklists. No studies compared patient outcome with and without prehospital POCUS. Four studies of acceptable quality demonstrated feasibility and changes in patient management in trauma. Two studies of acceptable quality demonstrated feasibility and changes in patient management in breathing difficulties. Four studies of acceptable quality demonstrated feasibility, outcome prediction and changes in patient management in cardiac arrest, but also that POCUS may prolong pauses in compressions. Two studies of acceptable quality demonstrated that short (few hours) teaching sessions are sufficient for obtaining simple interpretation skills, but not image acquisition skills. Three studies of acceptable quality demonstrated that longer one- or two-day courses including hands-on training are sufficient for learning simple, but not advanced, image acquisition skills. Three studies of acceptable quality demonstrated that systematic educational programs including supervised examinations are sufficient for learning advanced image acquisition skills in healthy volunteers, but that more than 50 clinical examinations are required for expertise in a clinical setting. Prehospital POCUS is feasible and changes patient management in trauma, breathing difficulties and cardiac arrest, but it is unknown if this improves outcome. Expertise in POCUS requires extensive training by a combination of theory, hands-on training and a substantial amount of clinical examinations – a large part of these needs to be supervised.

/pdf/the-role-of-point-of-care-ultrasound-in-prehospital-critical-5ca85a23n6.pdf

The role of point of care ultrasound in prehospital critical care: A systematic review

In the prehospital situation, the diagnostic armamentarium available to the rescue physician is limited. Emergency ultrasound has proven to be a useful diagnostic tool, providing crucial information for the management of critically ill and injured patients. The proportion of performed ultrasound scans in all patients attended to by the rescue service team, the quality of the findings and the ultrasound-related changes in management approach and patient transport were evaluated. In this prospective 18-month observational study, we documented all missions performed by rescue physicians with special training in emergency ultrasound (expert standard). These data were than analysed with regard to the ultrasound examinations. The ultrasound protocols used comprised Focussed Assessment with Sonography for Trauma (FAST), Prehospital Lung Ultrasound (PLUS) and Focused Echocardiography in Emergency Life support (FEEL). The quality of prehospital examinations was assessed by comparing the findings and diagnoses at the emergency site with those established in hospital. The changes in patient management and transport were documented using a standardized protocol. A total of 99 (18.1%) emergency ultrasound examinations were performed during 546 callouts. The most common indications for prehospital emergency ultrasound were dyspnoea (n = 38; 38.4%), during cardiac arrest (n = 17/17.2%), fall (n = 12/12.1%) and high-speed trauma (n = 11/11.1%). The combinations of ultrasound examination protocols in the trauma group (n = 31; 31.3%) were: 1. FAST+FEEL+PLUS (n = 17; 54.8%). 2. FAST+PLUS (n = 11; 35.5%) 3. FAST alone (n = 3; 9.7%). In the non-trauma group (n = 68; 68.7%), the following combinations were used: 1. FEEL+PLUS (n = 36; 52.9%), 2. FEEL alone (n = 21/30.9%). 3. PLUS alone (n = 6/8.8%) 4. FAST alone (n = 2; 2.9%) 5. FAST+FEEL+PLUS (n = 2; 2.9%). 6. FAST+FEEL (n = 1/1.5%). The emergency ultrasound findings impaired left ventricular contractile function (sensitivity 89.4%), right ventricular stress (85.7%), lung interstitial syndrome (100%), ruling out pneumothorax (specificity 100%), ruling out intraabdominal fluid (97,1%) were verified at the receiving hospital using ultrasonography, CT scan or x-rays; the prehospital diagnosis was confirmed in 90.8% of cases, the difference between the prehospital and in-hospital findings were not significant(p-values from p = 0.688 to p = 0,99). Ultrasound-related changes in patient management occurred in 49.5% of patients; in 33.3%, these were transported-related. Emergency ultrasound was as often used in the prehospital situation as it is in hospital. The ultrasound findings correlated well with in-hospital diagnostic results. Significant pathology changed patient-management, without prolonging the mission time.

/pdf/prehospital-point-of-care-emergency-ultrasound-a-cohort-3ir7d8v5bn.pdf

Prehospital point-of-care emergency ultrasound: a cohort study.

Effect of prehospital ultrasound on clinical outcomes of non-trauma patients--a systematic review

Stroke is the second common cause of death and the primary cause of early invalidity worldwide. Different from other diseases is the time sensitivity related to stroke. In case of an ischemic event occluding a brain artery, 2000000 neurons die every minute. Stroke diagnosis and treatment should be initiated at the earliest time point possible, preferably at the site or during patient transport. Portable ultrasound has been used for prehospital diagnosis for applications other than stroke, and its acceptance as a valuable diagnostic tool "in the field" is growing. The intrahospital use of transcranial ultrasound for stroke diagnosis has been described extensively in the literature. Beyond its diagnostic use, first clinical trials as well as numerous preclinical work demonstrate that ultrasound can be used to accelerate clot lysis (sonothrombolysis) in presence as well as in absence of tissue plasminogen activator. Hence, the use of transcranial ultrasound for diagnosis and possibly treatment of stroke bares the potential to add to current stroke care paradigms significantly. The purpose of this concept article is to describe the opportunities presented by recent advances in transcranial ultrasound to diagnose and potentially treat large vessel embolic stroke in the prehospital environment.

Prehospital stroke diagnosis and treatment in ambulances and helicopters—a concept paper

ObjectivesTo examine the feasibility and diagnostic value of a novel prehospital chest ultrasound algorithm in patients with dyspnea.MethodsSixty-two patients (32 men, 30 women, mean 67.1 years, range 20–90 years) with acute dyspnea prospectively underwent chest sonography with a portable ultrasound

Prehospital chest emergency sonography trial in Germany: a prospective study.

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Prehospital chest emergency sonography trial in Germany: a prospective study.