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This executive summary will provide a brief overview of consensus statements on sonography in hypotension and cardiac arrest (SHoC) recommended by the International Federation for Emergency Medicine (IFEM) for use in emergency medicine (EM). PurposeAs point of care ultrasound (PoCUS) has become an established tool in the initial management of patients with undifferentiated hypotension and during cardiac arrest, the Ultrasound Special Interest Group (USIG) of IFEM was tasked to provide consensus guidance for use in EM that was designed to be widely implementable internationally, and which was targeted at likely etiologies as well as guiding resuscitation. The protocols were also aimed at minimizing interruption of ongoing resuscitation. A hierarchical model was proposed, to be developed by expert consensus based upon disease incidence, previously published protocols, and the medical literature. A practical checklist was to be developed, along with a standardized approach to the performance of scans based upon a "4 F" approach: fluid, form, function, filling. Consensus approachWe summarized the recorded incidence of PoCUS findings from two international multicentre prospective studies

IntroductionOur previously reported randomized-controlled-trial of point-of-care ultrasound (PoCUS) for patients with undifferentiated hypotension in the emergency department (ED) showed no survival benefit with PoCUS. Here, we examine the data to see if PoCUS led to changes in the care delivered to patients with cardiogenic and non-cardiogenic shock.MethodsA post-hoc analysis was completed on a database of 273 hypotensive ED patients randomized to standard care or PoCUS in six centres in Canada and South Africa. Shock categories recorded one hour after the ED presentation were used to define subcategories of shock. We analyzed initial intravenous fluid volumes, as well as rates of inotrope use and procedures.Results 261 patients could be classified as cardiogenic or non-cardiogenic shock types. Although there were expected differences in the mean fluid volume administered between patients with non-cardiogenic and cardiogenic shock (p-value<0.001), there was no difference between the control and PoCUS groups (mean non-cardiogenic control 1881mL (95% CI 1567-2195mL) vs non-cardiogenic PoCUS 1763mL (1525-2001mL); and cardiogenic control 680mL (28.4-1332mL) vs. cardiogenic PoCUS 744mL (370-1117mL; p= 0.67). Likewise, there were no differences in rates of inotrope administration nor procedures for any of the subcategories of shock between the control group and PoCUS group patients.ConclusionDespite differences in care delivered by subcategory of shock, we did not find any difference in key elements of emergency department care delivered between patients receiving PoCUS and those who did not. This may help explain the previously reported lack of outcome differences between groups.

IntroductionPoint of care ultrasound (PoCUS) has become an established tool in the initial management of patients with undifferentiated hypotension. Current established protocols (RUSH and ACES) were developed by expert user opinion, rather than objective, prospective data. PoCUS also provides invaluable information during resuscitation efforts in cardiac arrest by determining presence/absence of cardiac activity and identifying reversible causes such as pericardial tamponade. There is no agreed guideline on how to safely and effectively incorporate PoCUS into the advanced cardiac life support (ACLS) algorithm. We wished to report disease incidence as a basis to develop a hierarchical approach to PoCUS in hypotension and during cardiac arrest.MethodsWe summarized the recorded incidence of PoCUS findings from the initial cohort during the interim analysis of two prospective studies. We propose that this will form the basis for developing a modified Delphi approach incorporating this data to obtain the input of a panel of international experts associated with five professional organizations led by the International Federation of Emergency Medicine (IFEM). The modified Delphi tool will be developed to reach an international consensus on how to integrate PoCUS for hypotensive emergency department patients as well as into cardiac arrest algorithms.ResultsRates of abnormal PoCUS findings from 151 patients with undifferentiated hypotension included left ventricular dynamic changes (43%), IVC abnormalities (27%), pericardial effusion (16%), and pleural fluid (8%). Abdominal pathology was rare (fluid 5%, AAA 2%). During cardiac arrest there were no pericardial effusions, however abnormalities of ventricular contraction (45%) and valvular motion (39%) were common among the 43 patients included.ConclusionsA prospectively collected disease incidence-based hierarchy of scanning can be developed based on the reported findings. This will inform an international consensus process towards the development of proposed SHoC protocols for hypotension and cardiac arrest, comprised of the stepwise clinical-indication based approach of Core, Supplementary, and Additional PoCUS views. We hope that such a protocol would be structured in a way that enables the clinician to only perform views that are clinically indicated, which limits exposure to the frequent incidental positive findings that accompany the current “one size fits all” standard protocols.

BackgroundUltrasound is being used increasingly to diagnose pathological free fluid accumulation at the bedside. In addition to the detection of peritoneal and pericardial fluid, point-of-care ultrasound allows rapid bedside diagnosis of pleural fluid.FindingsIn this short report, we describe the sonographic observation of the vertebral or ‘V-line’ to help confirm the presence of pleural fluid in the supine patient. The V-line sign is a result of the fluid acting as an acoustic window to enable visualization of vertebral bodies and posterior thoracic wall, thus confirming the presence of pleural fluid.ConclusionsThe V-line is a useful sonographic sign to aid the diagnosis of pleural free fluid.