IFEM Consensus Statement – SHoC – PoCUS use in Undifferentiated Hypotension and Cardiac Arrest

International Federation for Emergency Medicine Consensus Statement: Sonography in hypotension and cardiac arrest (SHoC): An international consensus on the use of point of care ultrasound for undifferentiated hypotension and during cardiac arrest.

Paul Atkinson, MB, MA*†; Justin Bowra, MB‡§; James Milne, MD¶; David Lewis, MB*†; Mike Lambert, MD**; Bob Jarman, MB, MSc†††‡‡; Vicki E. Noble, MD§§¶¶; Hein Lamprecht, MB***; Tim Harris, BM†††‡‡‡; Jim Connolly, MB†† on behalf of the International Federation of Emergency Medicine Sonography in Hypotension and Cardiac Arrest working group: Romolo Gaspari, MD, PhD; Ross Kessler, MD; Christopher Raio, MD; Paul Sierzenski, MD; Beatrice Hoffmann, MD; Chau Pham, MD; Michael Woo, MD; Paul Olszynski, MD; Ryan Henneberry, MD; Oron Frenkel, MD; Jordan Chenkin, MD; Greg Hall, MD; Louise Rang, MD; Maxime Valois, MD; Chuck Wurster, MD; Mark Tutschka, MD; Rob Arntfield, MD; Jason Fischer, MD; Mark Tessaro, MD; J. Scott Bomann, DO; Adrian Goudie, MB; Gaby Blecher, MB; Andrée Salter, MB; Michael Rose, MB; Adam Bystrzycki, MB; Shailesh Dass, MB; Owen Doran, MB; Ruth Large, MB; Hugo Poncia, MB; Alistair Murray, MB; Jan Sadewasser, MD

Canadian Journal of Emergency Medicine (CJEM) 

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.

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.

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 CoreSupplementary, 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: fluidformfunctionfilling. An international consensus on sonography in hypotension and cardiac arrest is presented. Future prospective validation is required.

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Resident Clinical Pearl – A New Focus for PoCUS

A New Focus for PoCUS

Elective Resident Clinical Pearl – December 2016

Heather Flemming, PGY4 Emergency Medicine, Dalhousie University, Saint John, New Brunswick

Reviewed by Dr. David Lewis


A 70 year old female presents to the emergency department with central abdominal pain and one episode of vomiting.  Her vital signs are stable, but she appears uncomfortable.

You bring the ultrasound machine to the bedside to assess her abdominal aorta. Your exam is challenged by the presence of bowel gas, causing scattering of your ultrasound beam, but is ultimately negative for an abdominal aortic aneurysm. You note that the patient has a midline scar, which she states is from a remote hysterectomy. With increased suspicion for bowel obstruction, you move the curvilinear probe across the abdomen and generate the following images: (Video Below)

The images demonstrate dilated loops of bowel and alternating peristalsis (a ‘to and fro movements’ of bowel contents). This confirms your suspicion for a small bowel obstruction (SBO).



Bedside ultrasound is a useful tool in evaluating any patient with abdominal pain, and has shown to be more sensitive and more specific than abdominal xray in diagnosing SBO1. Additional advantages of ultrasound include lack of radiation to the patient, bedside availability and potential to improve ED flow2. Treatments, such as nasogastric tube insertion, and early consultation to general surgery can be expedited by rapid identification. In individuals with recurrent sub-acute SBO, PoCUS may become the investigation of choice, reducing radiation exposure for this group of patients.


Pearls for performing a bedside ultrasound for SBO:

Multiple regions of the abdomen should be assessed, including the epigastrium, bilateral colic gutters, and suprapubic regions2. (Image 2).

Image 2 (overlapping survey of all quadrants)


Typical SBO ultrasound finding include:

  • ≥3 bowel loops dilated >25mm (Measurements taken at 90° to bowel wall)
  • Transition point – dilated peristalsing small bowel visualized adjacent to non-peristalsing collapsed bowel
  • Increased intraluminal fluid
  • Abnormal peristalsis: Hyperdynamic, alternating or absent peristalsis
  • Abdominal free fluid may also be present


Credit: ACEP.org



  1. Jang, Timothy B. Schindler, Danielle. Kaji, Amy H. Bedside ultrasonography for the detection of small bowel obstruction in the emergency department. Emerg Med J 2011 28:676-678.
  2. Chao, Gharahbaghian. Tips and Tricks: Clinical Ultrasound for Small Bowel Obstruction – A Better Diagnostic Tool? https://www.acep.org/content.aspx?id=100218
  1. http://www.emdocs.net/ultrasound-small-bowel-obstruction/
  1. A video on Ultrasound in Small Bowel Obstruction by the Academy of Emergency Ultrasound can be found here: https://vimeo.com/69551555
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SJRHEM congratulates it’s two newest CEUS certified PoCUS practitioners

Dr Jacqueline Mackay and Dr Kyle McGivery have both completed their CEUS Core IP Certification.

Both recently assisted with the ECCU IP school here in Saint John. The ECCU IP school is now in it’s 3rd year and has given many physicians an opportunity to receive expert supervision in completing the required portfolio. Next year the ECCU IP school will be on April 29th 2017.



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NB Emergency Medicine Research Day 2016

NB EM Research Rounds

5DN Amphitheatre, Saint John Regional Hospital

November 8th 2016

Research plays an important role in advancing everyday clinical practice. Questions such as what drug to order; do guideline improve outcomes; and how can we evaluate system processes that impact patient care. Over the past year, our Emergency Medicine Research Program has undertaken projects that attempt to answer such questions that impact our department. Today, you will hear about some of these projects and publications.

Today’s session provides medical learners the opportunity to present and receive feedback in a friendly format. We will present a prize to acknowledge the best research presentation. The other goal is to encourage formation of a collaborative research network in emergency departments throughout the province of New Brunswick.

Dr. Paul Atkinson MB MA FCEM CFEU Professor, Department of Emergency Medicine Dalhousie University
Horizon Health Network
Saint John Regional Hospital
Saint John, New Brunswick

The program including all the abstracts can be viewed / downloaded below:

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The Reason Study – How do the results affect care?

Earlier this month we reported the publication in Resuscitation Journal of the Reason study. Thanks to Dr. Atkinson (one of the authors of this study) for providing us with this explainer.



Point-of-Care Ultrasound in Cardiac Arrest

Resuscitation Journal, Sept 2016


Absence of cardiac activity on point of care ultrasound during PEA and asystole, is associated with very poor survival rates.


Some clinicians use a lack of cardiac activity on ultrasound as a reason to terminate resuscitation efforts. We at the Saint John Regional Hospital Emergency Department (ED) participated in this prospective observational study at 20 EDs across North America. We assessed the association between cardiac activity on point of care ultrasound (PoCUS) during advanced cardiac life support (ACLS) and survival to hospital discharge in patients with pulseless electrical activity (PEA) or asystole. Patients were included if they received at least one round of ACLS resuscitation after the initial ultrasound. Patients were excluded if they presented with a shockable rhythm, had immediate return of spontaneous circulation (ROSC), or the resuscitation was terminated immediately after the initial ultrasound.

Of 793 patients with out-of-hospital cardiac arrest enrolled, 26% had ROSC, 14% survived to hospital admission, and 1.6% survived to discharge. Among 530 patients without cardiac activity on PoCUS, only 0.6% survived to discharge (compared with 3.8% of those with cardiac activity).


Cardiac activity on PoCUS and an initial rhythm of PEA on ECG were associated with ROSC (odds ratios, 3.0 and 2.8, respectively) and with survival to hospital admission (ORs, 3.6 and 2.1, respectively). Cardiac activity was associated with survival to discharge (OR, 5.7).


In patients with asystole, lack of cardiac activity had a sensitivity of 90% and predictive value of 99% for non–survival to hospital discharge (death).


PoCUS identified pericardial effusion in 34 patients and suspected pulmonary embolism in 15 who received thrombolytic therapy.


How does this affect care?

There is always an argument that the association between dismal survival and lack of cardiac activity is just a self-fulfilling prophecy, if absence of cardiac activity led to early termination of salvageable resuscitations. In this study, resuscitation had to continue until at least 2 scans were completed.

So, unless there are very special circumstances, such as significant hypothermia, or post defibrillation, it seems safe to terminate resuscitation for most patients with asystole on ECG and without cardiac activity on ultrasound.



Gaspari R, Weekes A, Adhikari S, Noble VE, Nomura JT, Theodoro D, Woo M, Atkinson P, Blehar D, Brown SM, Caffery T, et al. Emergency department point-of-care ultrasound in out-of-hospital and in-ED cardiac arrest. Resuscitation. 2016;109:33-9. http://dx.doi.org/10.1016/j.resuscitation.2016.09.018


Daniel M. Lindberg reviewing Gaspari R et al. Resuscitation 2016. Journal Watch. www.jwatch.org/na42452/2016/10/03/point-care-ultrasound-cardiac-arrest

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SJRHEM associated publication – The Reason Study

The Reason Study group, which included researchers from SJRHEM and involved may of SJRHEM physicians contributing data, has just published the results of the biggest prospective study to determine whether cardiac activity on ultrasound during ACLS is associated with improved survival.

The paper: Emergency department point-of-care ultrasound in out-of-hospital and in-ED cardiac arrest, was published in Resuscitation (http://dx.doi.org.ezproxy.library.dal.ca/10.1016/j.resuscitation.2016.09.018) reported that “Cardiac activity on ultrasound was the variable most associated with survival following cardiac arrest. Ultrasound during cardiac arrest identifies interventions outside of the standard ACLS algorithm.”



Point-of-care ultrasound has been suggested to improve outcomes from advanced cardiac life support (ACLS), but no large studies have explored how it should be incorporated into ACLS. Our aim was to determine whether cardiac activity on ultrasound during ACLS is associated with improved survival.


We conducted a non-randomized, prospective, protocol-driven observational study at 20 hospitals across United States and Canada. Patients presenting with out-of-hospital arrest or in-ED arrest with pulseless electrical activity or asystole were included. An ultrasound was performed at the beginning and end of ACLS. The primary outcome was survival to hospital admission. Secondary outcomes included survival to hospital discharge and return of spontaneous circulation.


793 patients were enrolled, 208 (26.2%) survived the initial resuscitation, 114 (14.4%) survived to hospital admission, and 13 (1.6%) survived to hospital discharge. Cardiac activity on US was the variable most associated with survival at all time points. On multivariate regression modeling, cardiac activity was associated with increased survival to hospital admission (OR 3.6, 2.2–5.9) and hospital discharge (OR 5.7, 1.5–21.9). No cardiac activity on US was associated with non-survival, but 0.6% (95% CI 0.3–2.3) survived to discharge. Ultrasound identified findings that responded to non-ACLS interventions. Patients with pericardial effusion and pericardiocentesis demonstrated higher survival rates (15.4%) compared to all others (1.3%).


Cardiac activity on ultrasound was the variable most associated with survival following cardiac arrest. Ultrasound during cardiac arrest identifies interventions outside of the standard ACLS algorithm.


A very good critique of this paper has been published on the well-known EM Blog – St. Emlyns – JC: Is this the REASON to use USS in cardiac arrest? St.Emlyn’s

St. Emlyn’s Bottom Line: A lack of cardiac activity on initial USS is very probably associated with a worse prognosis. The role of USS in improving outcome as an intervention in cardiac arrest is less certain


We will be asking our Research Director (Dr Paul Atkinson), who was closely involved in this study, for his take on the results and how they should be interpreted/incorporated into practice. This has been posted here.

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SJRHEM Photo Contest 2016

We are very excited to announce the 2016 SJRHEM Photo Contest. This photography competition is open to all personel who work in the Saint John Regional Emergency Department in any role including clinical, admin, support, volunteers etc.

The themes of this competition mirror our mission statement and now include a new ‘open’ category:



Our aim is to improve the look and feel of our facility, for both staff and patients, by decorating the walls and corridors with high quality, thought inspiring photographic artwork that reflect the themes above.


Genuine concern for the well-being of others



The dignity of all people



Honest with strong moral principles



Making judgments that are free from discrimination



Landscapes, Architecture, People, Animals etc

2014-03-26 08.46.27

There will be a winner for each category and an overall winner. All will receive a framed print of their winning photo. The overall winner will be awarded the “Winner of the SJRHEM Photo Contest 2016” award.

The closing date for applications is October 10th 2016.

Click Here for More Information (Rules, Entry Forms etc)

Each entry must be accompanied by a separate application form and necessary consent forms.

Each entry must be emailed to :admin@sjrhem.ca  (subject: photo contest) or via online entry below

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Sonography in Hypotension and Cardiac Arrest (SHoC): Rates of Abnormal Findings in Undifferentiated Hypotension and During Cardiac Arrest as a Basis for Consensus on a Hierarchical Point of Care Ultrasound Protocol



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.


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.


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.


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.

See full article at www.cureus.com

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Pediatric Emergency Medicine PoCUS Conference, 29th April 2016

Thanks to Dr Kirstin Weerdenburg, PEM Specialist at the IWK Hospital in Halifax, Nova Scotia, for sharing this invitation to the P2 Network Conference in Baltimore, Maryland on the 29th April 2016.

Information on P2|Network can be found on our website: www.p2network.com

Membership is free, and can be obtained by going to the website listed above, clicking on “Contact” in the upper right hand corner and entering your information under “Membership”.

Also, our annual P2|Network 2016 Conference is right around the corner, preceding the PAS conference. All PEM POCUS enthusiasts are welcome! Registration is now open! Register here: www.bit.ly/p2network2016 

Registration deadline is March 15, 2016.

Date and time: 

Friday, April 29, 2016

8AM – 5PM


University of Maryland, Shock Trauma Auditorium

22 South Greene Street

Baltimore, Maryland USA

Hoping to see you there or as part of P2|Network in the future!

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eFAST – Recommended by NICE

The new NICE major trauma guidelines have recommended the use of eFAST as part of the assessment and management of Major Trauma. See the full recommendations here.

From: NICE guidelines [NG39] Published date:

1.3 Management of chest trauma in pre‑hospital settings

1.3.1 Use clinical assessment to diagnose pneumothorax for the purpose of triage or intervention.

1.3.2 Consider using eFAST (extended focused assessment with sonography for trauma) to augment clinical assessment only if a specialist team equipped with ultrasound is immediately available and onward transfer will not be delayed.

1.3.3 Be aware that a negative eFAST of the chest does not exclude a pneumothorax.

1.3.4 Only perform chest decompression in a patient with suspected tension pneumothorax if there is haemodynamic instability or severe respiratory compromise.

1.3.5 Use open thoracostomy instead of needle decompression if the expertise is available, followed by a chest drain via the thoracostomy in patients who are breathing spontaneously.

1.3.6 Observe patients after chest decompression for signs of recurrence of the tension pneumothorax.

1.3.7 In patients with an open pneumothorax:

  • cover the open pneumothorax with a simple occlusive dressing and
  • observe for the development of a tension pneumothorax.

These guidelines also recommend, where indicated, early endotracheal intubation using RSI within 45 minutes of the EMS call, and preferably at the scene of the incident. More evidence to support the case for Advanced Care Paramedics in New Brunswick?


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