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BACKGROUND: Accurately determining the fluid status of a patient during resuscitation in the emergency department (ED) helps guide appropriate fluid administration in the setting of undifferentiated hypotension. Our goal was to determine the diagnostic utility of point-of-care ultrasound (PoCUS) for inferior vena cava (IVC) size and collapsibility in predicting a volume overload fluid status in spontaneously breathing hypotensive ED patients. METHODS: This was a post hoc secondary analysis of the SHOC-ED data, a prospective randomized controlled trial investigating PoCUS in patients with undifferentiated hypotension. We prospectively collected data on IVC size and collapsibility for 138 patients in the PoCUS group using a standard data collection form, and independently assigned a fluid status (volume overloaded, normal, volume deplete) from a composite clinical chart review blinded to PoCUS findings. The primary outcome was the diagnostic performance of IVC characteristics on PoCUS in the detection of a volume overloaded fluid status. RESULTS: One hundred twenty-nine patients had completed determinant IVC assessment by PoCUS, with one hundred twenty-five receiving successful final fluid status determination, of which one hundred and seven were classified as volume deplete, thirteen normal, and seven volume overloaded. A receiver operating characteristic (ROC) curve was plotted using several IVC size and collapsibility categories. The best overall performance utilized the combined parameters of a dilated IVC (> 2.5 cm) with minimal collapsibility (less than 50%) which had a sensitivity of 85.7% and specificity of 86.4% with an area under the curve (AOC) of 0.92 for predicting an volume overloaded fluid status. CONCLUSION: IVC PoCUS is feasible in spontaneously breathing hypotensive adult ED patients, and demonstrates potential value as a predictor of a volume overloaded fluid status in patients with undifferentiated hypotension. IVC size may be the preferred measure.

RéSUMé: CONTEXTE: La détermination précise de l'état du liquide d'un patient pendant la réanimation au service des urgences (SU) aide à guider l'administration appropriée du liquide dans le cadre d'une hypotension indifférenciée. Notre objectif était de déterminer l'utilité diagnostique de l'échographie au point de soins (PoCUS) pour la taille de la veine cave inférieure (IVC) et l'collapsibilité dans la prédiction d'un état de liquide de surcharge volumique chez les patients souffrant d'une hypotension respiratoire spontanée. MéTHODES: Il s'agissait d'une analyse secondaire post-hoc des données SHOC-ED, un essai contrôlé randomisé prospectif examinant PoCUS chez des patients atteints d'hypotension indifférenciée. Nous avons collecté prospectivement des données sur la taille et la collapsibilité des IVC pour 138 patients du groupe PoCUS à l'aide d'un formulaire de collecte de données standard, et attribué indépendamment un état de fluide (volume surchargé, normal, épuisement du volume) à partir d'une revue de dossier clinique composite mise en aveugle aux résultats PoCUS. Le résultat principal était la performance diagnostique des caractéristiques IVC sur PoCUS dans la détection d'un état de fluide surchargé en volume. RéSULTATS: 129 patients avaient terminé l'évaluation IVC des déterminants par PoCUS, dont 125 ont reçu une détermination finale du statut hydrique, dont 107 ont été classés comme étant une diminution du volume, 13 normaux et 7 surchargés. Une courbe des caractéristiques de fonctionnement du récepteur (ROC) a été tracée en utilisant plusieurs catégories de taille et d'affaissement IVC. La meilleure performance globale a utilisé les paramètres combinés d'une IVC dilatée (> 2,5 cm) avec une collapsibilité minimale (moins de 50%) qui avait une sensibilité de 85,7% et une spécificité de 86,4% avec une zone sous la courbe (AOC) de 0,92 pour prédire un état de fluide surchargé en volume. CONCLUSION: IVC PoCUS est faisable chez les patients adultes souffrant d'une hypotension respiratoire spontanée et démontre une valeur potentielle en tant que prédicteur d'un état de liquide surchargé en volume chez les patients atteints d'hypotension indifférenciée. La taille IVC peut être la mesure préférée.

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Introduction: The African Federation of Emergency Medicine (AFEM) recommends the use of emergency point-of-care ultrasound (ePOCUS) as a core skill for health care practitioners in Africa. The study explored the use of ePOCUS by health care practitioners among AFEM members who work across Africa. Methods: An anonymous online survey was distributed to individual members of AFEM and affiliated organisations. The questionnaire was tested by the AFEM Scientific Committee for potential content modifications prior to distribution. Summary statistics are presented. Results: Of the 220 participants that were analysed, 148 (67.3%) were using ePOCUS. The mean age was 36 years; 146 (66%) were male; and 198 (90%) obtained their primary medical qualification in Africa. In total, 168 (76%) were doctors, and most participants (n = 204, 93%) have worked in Africa during the last 5 years. Reasons for not using ePOCUS mainly related to lack of training and problems with ultrasound machines or consumables. Most ePOCUS users (116/148, 78%) attended courses with hands-on training, but only 65 (44%) participants were credentialed (by 18 different organizations). The median score for self-perceived level of ePOCUS skills was 75 in credentialed users versus 50 in those that were not credentialed. Ultrasound in trauma was the most frequently used module (n = 141, 99%), followed by focused cardiac assessment (n = 128, 90%) and thoracic (including lung) assessment (n = 128, 90.1%). The FASH-module (Focused Assessment with Sonography for HIV/TB) was the least used (n = 69, 49%). Conclusion: Access barriers to ePOCUS training, mentorship, equipment and consumables are still relevant in Africa. The low credentialing rate and the potential discordance between local burden of disease and ePOCUS training requires further investigation.

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Early identification of the shock type and correct diagnosis is associated with better outcomes. Previous studies have suggested that point-of-care ultrasound (POCUS) increases the diagnostic accuracy of patients in undifferentiated shock. However, a complete overview of the diagnostic accuracy of POCUS and the related treatment changes when compared to standard care is still limited. Our objective was to compare POCUS against standard practice regarding the diagnostic accuracy and specific therapeutic management changes (fluid volume administration and vasopressor use) in patients with undifferentiated shock in the emergency department (ED). We conducted a systematic review in concordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. A systematic search was performed using Embase, PubMed, Cochrane Central Register for Controlled Trials, and clinicaltrials.gov. Two physicians independently selected the articles and assessed the quality of the studies independently with the Quadas-2 tool. All included studies used POCUS in adult patients in undifferentiated shock and described diagnostic accuracy or specific therapeutic management changes (fluid volume administration or vasopressor use) and compared this to standard care. The primary outcome was diagnostic accuracy. Secondary outcomes were the amount of fluid administered and vasopressor use in the ED. Only articles published after 1996 were included. There were 10,805 articles found of which 6 articles were included. Four out of six studies reported diagnostic accuracy, three reported on fluid administration and vasopressors. We found that the diagnostic accuracy improved through the use of POCUS when compared to the standard care group, increasing overall diagnostic accuracy from 45-60% to 80-89% when combined with clinical information. There was no significant difference in fluid administration or vasopressor use between the groups. In our systematic review, we found that the use of POCUS in patients that presented with undifferentiated shock in the ED improved the diagnostic accuracy of the shock type and final diagnosis. POCUS resulted in no changes in fluid administration or vasopressor use when compared to standard care. However, the results should be interpreted within the limitations of some of the studies that were included in the review.

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Introduction Patients that present to the emergency department (ED) with undifferentiated hypotension have a high mortality rate. Hypotension can be divided into four categories: obstructive, hypovolemic, distributive, and cardiogenic. While it is possible to have overlapping or concomitant shock states, being able to differentiate between cardiogenic shock and the other categories is important as it entails a different treatment regime and extra cautions. In this secondary analysis, we investigate if using focused cardiac ultrasonography (FOCUS) to determine left ventricular dysfunction (LVD) can serve as a reliable test for cardiogenic shock. Methods We prospectively collected FOCUS 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 the identification of a generally hypodynamic left ventricle in the setting of shock. FOCUS findings were collected using a standardized protocol and data collection form. All scans were performed by emergency physicians trained in ultrasound. Final shock type was defined as cardiogenic or noncardiogenic by independent specialist blinded chart review. Results In our findings, 135 patients had complete records for assessment of left ventricular function and additional follow-up data and so were included in this secondary analysis. The median age was 56 years and 53% of patients were male. Disease prevalence for cardiogenic shock was 12% and the mortality rate was 24%. The presence of LVD on FOCUS had a sensitivity of 62.50% (95% confidence interval 35.43% to 84.80%), specificity of 94.12% (88.26% to 97.60%), positive likelihood ratio (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 FOCUS may be useful in the early identification of cardiogenic shock in otherwise undifferentiated hypotensive adult patients in the emergency department.

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Introduction Point of Care Ultrasound (PoCUS) protocols are commonly used to guide resuscitation for patients with undifferentiated hypotension, yet there is a paucity of evidence for any outcome benefit. We undertook an international multicenter randomized controlled trial (RCT) to assess the impact of a PoCUS protocol on key clinical outcomes. Here we report on resuscitation markers.  Methods Adult patients presenting to six emergency departments (ED) in Canada and South Africa with undifferentiated hypotension (systolic blood pressure (SBP) <100mmHg or a Shock Index >1.0) were randomized to receive a PoCUS protocol or standard care (control). Reported physiological markers include shock index (SI), and modified early warning score (MEWS), with biochemical markers including venous bicarbonate and lactate, at baseline and four hours.  Results A total of 273 patients were enrolled, with data collected for 270. Baseline characteristics were similar for each group. Improvements in mean values for each marker during initial treatment were similar between groups: Shock Index; mean reduction in Control 0.39, 95% CI 0.34 to 0.44 vs. PoCUS 0.33, 0.29 to 0.38; MEWS, mean reduction in Control 2.56, 2.22 to 2.89 vs. PoCUS 2.91, 2.49 to 3.32; Bicarbonate, mean reduction in Control 2.71 mmol/L, 2.12 to 3.30 mmol/L vs. PoCUS 2.30 mmol/L, 1.75 to 2.84 mmol/L, and venous lactate, mean reduction in Control 1.39 mmol/L, 0.93 to 1.85 mmol/L vs. PoCUS 1.31 mmol/L, 0.88 to 1.74 mmol/L. Conclusion We found no meaningful difference in physiological and biochemical resuscitation markers with or without the use of a PoCUS protocol in the resuscitation of undifferentiated hypotensive ED patients. We are unable to exclude improvements in individual patients or in specific shock types.

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Ultrasound is becoming a fundamental first-line diagnostic tool for most medical specialties and an innovative tool to teach anatomy, physiology and pathophysiology to undergraduate and graduate students. However, availability of structured training programs during medical school is lagging behind and many physicians still acquire all their ultrasound skills during postgraduate training.There is wide variation in medical student ultrasound education worldwide. Sharing successful educational strategies from early adopter medical schools and learning from leading education programs should advance the integration of ultrasound into the university medical school curricula. In this overview, we present current approaches and suggestions by ultrasound societies concerning medical student educa-tion throughout the world. Based on these examples, we formulate a consensus statement with suggestions on how to integrate ultrasound teaching into the preclinical and clinical medical curricula.

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Introduction Our 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. Methods A 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. Conclusion Despite 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.

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INTRODUCTION: Unrestricted access to journal publications speeds research progress, productivity, and knowledge translation, which in turn develops and promotes the efficient dissemination of content. We describe access to the 500 most-cited emergency medicine (EM) articles (published between 2012 and 2016) in terms of publisher-based access (open access or subscription), alternate access routes (self-archived or author provided), and relative cost of access. METHODS: We used the Scopus database to identify the 500 most-cited EM articles published between 2012 and 2016. Access status was collected from the journal publisher. For studies not available via open access, we searched on Google, Google Scholar, Researchgate, Academia.edu, and the Unpaywall and Open Access Button browser plugins to locate self-archived copies. We contacted corresponding authors of the remaining inaccessible studies for a copy of each of their articles. We collected article processing and access costs from the journal publishers, and then calculated relative cost differences using the World Bank purchasing power parity index for the United States (U.S.), Germany, Turkey, China, Brazil, South Africa, and Australia. This allows costs to be understood relative to the economic context of the countries from which they originated. RESULTS: We identified 500 articles for inclusion in the study. Of these, 167 (33%) were published in an open access format. Of the remaining 333 (67%), 204 (61%) were available elsewhere on the internet, 18 (4%) were provided by the authors, and 111 (22%) were accessible by subscription only. The mean article processing and access charges were $2,518.62 and $44.78, respectively. These costs were 2.24, 1.75, 2.28 and 1.56 times more expensive for South African, Chinese, Turkish, and Brazilian authors, respectively, than for U.S. authors (p<0.001 all). CONCLUSION: Despite the advantage of open access publication for knowledge translation, social responsibility, and increased citation, one in five of the 500 EM articles were accessible only via subscription. Access for scientists from upper-middle income countries was significantly hampered by cost. It is important to acknowledge the value this has for authors from low- and middle-income countries. Authors should also consider the citation advantage afforded by open access publishing when deciding where to publish.

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AIMS: To evaluate the accuracy of PoCUS in predicting return of spontaneous circulation (ROSC), survival to hospital admission (SHA), and survival to hospital discharge (SHD) in adult non-traumatic, non-shockable out-of-hospital or emergency department cardiac arrest. METHODS: Medline, EMBASE, Cochrane, CINAHL, ClinicalTrials.gov and the World Health Organization Registry were searched for eligible studies. Data analysis was completed according to PRISMA guidelines. A random-effects meta-analysis model was used with I-squared statistics for heterogeneity. RESULTS: Ten studies (1486 participants) were included. Cardiac activity on PoCUS had a pooled sensitivity of 60.3% (95% confidence interval 38.1%-78.9%) and specificity of 91.5%(80.8%-96.5%) for ROSC. The sensitivity of cardiac activity on PoCUS for predicting ROSC was 26.1%(7.8%-59.6%) in asystole compared with 76.7% (61.3%-87.2%) in PEA. Cardiac activity on PoCUS, compared to absence, had odd ratios of 16.90 (6.18-46.21) for ROSC, 10.30(5.32-19.98) for SHA and 8.03(3.01-21.39) for SHD. Positive likelihood ratio (LR) was 6.87(3.21-14.71) and negative LR was 0.27(0.12-0.60) for ROSC. CONCLUSIONS: Cardiac activity on PoCUS was associated with improved odds for ROSC, SHA, and SHD in non-traumatic, non-shockable cardiac arrest. We report a lower sensitivity and higher negative likelihood ratio, but greater heterogeneity compared to previous systematic reviews. PoCUS may provide valuable information in the management of non-traumatic PEA or asystole, but should not be viewed as the sole predictor in determining outcomes.

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STUDY OBJECTIVE: Point-of-care ultrasonography protocols are commonly used in the initial management of patients with undifferentiated hypotension in the emergency department (ED). There is little published evidence for any mortality benefit. We compare the effect of a point-of-care ultrasonography protocol versus standard care without point-of-care ultrasonography for survival and clinical outcomes. METHODS: This international, multicenter, randomized controlled trial recruited from 6 centers in North America and South Africa and included selected hypotensive patients (systolic blood pressure <100 mm Hg or shock index >1) randomized to early point-of-care ultrasonography plus standard care versus standard care without point-of-care ultrasonography. Diagnoses were recorded at 0 and 60 minutes. The primary outcome measure was survival to 30 days or hospital discharge. Secondary outcome measures included initial treatment and investigations, admissions, and length of stay. RESULTS: Follow-up was completed for 270 of 273 patients. The most common diagnosis in more than half the patients was occult sepsis. We found no important differences between groups for the primary outcome of survival (point-of-care ultrasonography group 104 of 136 patients versus standard care 102 of 134 patients; difference 0.35%; 95% binomial confidence interval [CI] -10.2% to 11.0%), survival in North America (point-of-care ultrasonography group 76 of 89 patients versus standard care 72 of 88 patients; difference 3.6%; CI -8.1% to 15.3%), and survival in South Africa (point-of-care ultrasonography group 28 of 47 patients versus standard care 30 of 46 patients; difference 5.6%; CI -15.2% to 26.0%). There were no important differences in rates of computed tomography (CT) scanning, inotrope or intravenous fluid use, and ICU or total length of stay. CONCLUSION: To our knowledge, this is the first randomized controlled trial to compare point-of-care ultrasonography to standard care without point-of-care ultrasonography in undifferentiated hypotensive ED patients. We did not find any benefits for survival, length of stay, rates of CT scanning, inotrope use, or fluid administration. The addition of a point-of-care ultrasonography protocol to standard care may not translate into a survival benefit in this group.

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OBJECTIVES: The study compares experiences of workplace stressors for emergency medicine trainees and specialists in settings where the specialty is relatively well resourced and established (Canada), and where it is newer and less well resourced (South Africa, (SA)). METHODS: We conducted an online cross-sectional survey of emergency medicine trainees and physicians in both countries for six domains (demands, role, support, change, control, and relationships) using the validated Management Standards Indicator Tool (MSIT, Health, and Safety Executive, United Kingdom). RESULTS: 74 SA and 430 Canadian respondents were included in our analysis. SA trainees (n=38) reported higher stressors (lower MSIT scores) than SA specialists (n=36) for demands (2.2 (95%CI 2.1-2.3) vs. 2.7 (2.5-2.8)), control (2.6 (2.4-2.7) vs. 3.5 (3.3-3.7)) and change (2.4 (2.2-2.6) vs. 3.0 (2.7-3.3)). In Canada, specialists (n=395) had higher demands (2.6 (2.6-2.7) vs. 3.0 (2.8-3.1)) and manager support stressors (3.3 (3.3-3.4) vs. 3.9 (3.6-4.1)) than trainees (n=35). Canadian trainees reported higher role stressors (4.0 (95%CI 3.8-4.1) vs. 4.2 (4.2-4.3)) than Canadian specialists. SA trainees had higher stressors on all domains than Canadian trainees. There was one domain (control) where Canadian specialists scored significantly lower than SA specialists, whereas SA specialists had significantly lower scores on peer support, relationships and role. CONCLUSIONS: Work related stressor domains were different for all four groups. Perceived stressors were higher in all measured domains among SA trainees compared with Canadian trainees. The differences between the SA and Canadian specialists may reflect the developing nature of the specialty in SA, although the Canadian specialists reported less control over their work than SA counterparts.

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BACKGROUND: Clinical ultrasound is commonly used in medical practices worldwide due to the multiple benefits the modality offers clinicians. Rigorous credentialing standards are necessary to safeguard patients against operator errors. The purpose of the study was to establish and analyse the barriers that specifically lead to poor credentialing success within a resource-limited clinical ultrasound training programme. METHODS: An electronic cross-sectional survey was e-mailed to all trainees who attended the introductory clinical ultrasound courses held in Cape Town since its inception in 2009 to 2013. All trainees were followed until they completed their training programme in 2015. RESULTS: Only one fifth of trainees (n = 43, 19.7%), who entered the Cape Town training programme, credentialed successfully. Ninety (n = 90, 41.3%) trainees responded to the survey. Eighty-six (n = 86) surveys were included for analysis. Time constraints were the highest ranked barrier amongst all trainees. Access barriers (to trainers and ultrasound machines) were the second highest ranked amongst the non-credentialed group. A combination between access and logistical barriers (e.g. difficulty in finding patients with pathology to scan) were the second highest ranked in the credentialed group. CONCLUSIONS: Access barriers conspire to burden the Cape Town clinical ultrasound training programme. Novel solutions are necessary to overcome these access barriers to improve future credentialing success.

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Significant evidence identifies point-of-care ultrasound (PoCUS) as an important diagnostic and therapeutic tool in resource-limited settings. Despite this evidence, local health care providers on the African continent continue to have limited access to and use of ultrasound, even in potentially high-impact fields such as obstetrics and trauma. Dedicated postgraduate emergency medicine residency training programs now exist in 8 countries, yet no current consensus exists in regard to core PoCUS competencies. The current practice of transferring resource-rich PoCUS curricula and delivery methods to resource-limited health systems fails to acknowledge the unique challenges, needs, and disease burdens of recipient systems. As emergency medicine leaders from 8 African countries, we introduce a practical algorithmic approach, based on the local epidemiology and resource constraints, to curriculum development and implementation. We describe an organizational structure composed of nexus learning centers for PoCUS learners and champions on the continent to keep credentialing rigorous and standardized. Finally, we put forth 5 key strategic considerations: to link training programs to hospital systems, to prioritize longitudinal learning models, to share resources to promote health equity, to maximize access, and to develop a regional consensus on training standards and credentialing.

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Introduction The International Federation for Emergency Medicine (IFEM) Ultrasound Special Interest Group (USIG) was tasked with development of a hierarchical consensus approach to the use of point of care ultrasound (PoCUS) in patients with hypotension and cardiac arrest. METHODS: The IFEM USIG invited 24 recognized international leaders in PoCUS from emergency medicine and critical care to form an expert panel to develop the sonography in hypotension and cardiac arrest (SHoC) protocol. The panel was provided with reported disease incidence, along with a list of recommended PoCUS views from previously published protocols and guidelines. Using a modified Delphi methodology the panel was tasked with integrating the disease incidence, their clinical experience and their knowledge of the medical literature to evaluate what role each view should play in the proposed SHoC protocol. RESULTS: Consensus on the SHoC protocols for hypotension and cardiac arrest was reached after three rounds of the modified Delphi process. The final SHoC protocol and operator checklist received over 80% consensus approval. The IFEM-approved final protocol, recommend Core, Supplementary, and Additional PoCUS views. SHoC-hypotension core views consist of cardiac, lung, and inferior vena vaca (IVC) views, with supplementary cardiac views, and additional views when clinically indicated. Subxiphoid or parasternal cardiac views, minimizing pauses in chest compressions, are recommended as core views for SHoC-cardiac arrest; supplementary views are lung and IVC, with additional views when clinically indicated. Both protocols recommend use of the "4 F" approach: fluid, form, function, filling. CONCLUSION: An international consensus on sonography in hypotension and cardiac arrest is presented. Future prospective validation is required.

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INTRODUCTION: Point 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. METHODS: We 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. RESULTS: Rates 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. CONCLUSIONS: A 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.

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To meet a critical and growing need for a standardized approach to emergency point of care ultrasound (PoCUS) worldwide, emergency physicians must be trained to deliver and teach this skill in an accepted and reliable format. Currently, there is no globally recognized, standard PoCUS curriculum that defines the accepted applications, as well as standards for training and practice of PoCUS by specialists and trainees in emergency medicine. To address this deficit, the International Federation for Emergency Medicine (IFEM) convened a sub-committee of international experts in PoCUS to outline a curriculum for training of specialists in emergency PoCUS. This curriculum document represents the consensus of recommendations by this sub-committee. The curriculum is designed to provide a framework for PoCUS education in emergency medicine. The focus is on the processes required to select core and enhanced applications, as well as the key elements required for the delivery of PoCUS training from introduction through to continuing professional development and skill maintenance. It is designed not to be prescriptive but to assist educators and emergency medicine leadership to advance PoCUS education in emergency medicine no matter the training venue. The content of this curriculum is relevant not just for communities with mature emergency medicine systems but in particular for developing nations or for nations seeking to develop PoCUS training programs within the current educational structure. We anticipate that there will be wide variability in how this curriculum is implemented and taught, reflecting the existing educational environment, resources and goals of educational programs.

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