Medical Student Clinical Pearl – PoCUS and Clavicle Fractures

Using PoCUS to diagnose clavicular fractures

Medical Student Pearl – May 2018

Danielle Rioux – Med III Class of 2019, Dalhousie Medicine New Brunswick 

Reviewed by Dr. Mandy Peach and Dr. David Lewis

Case: A 70 year-old man presented to the emergency department with pain in his left shoulder and clavicular region following a skiing accident. He slipped and fell on his left lateral shoulder while he was on skis at the ski hill. He has visible swelling in his left shoulder and clavicular region, and was not able to move his left arm.

On exam: The patient was in no sign of distress. He was standing and holding his left arm adducted close to his body, supporting his left arm with his right hand. There was swelling and ecchymosis in the left clavicle, mid-shaft region, with focal tenderness. On palpation, there was crepitation, tenderness, swelling, and warmth in this region. He was unable to move his left shoulder due to pain. His neurovascular exam on his left arm was normal. Auscultation of his lungs revealed normal air-entry, bilaterally and no adventitious sounds.

Point of Care Ultrasound (PoCUS): We used a linear, high-frequency transducer and placed it in the longitudinal plane on the normal right clavicle (see Image 1.), and the fractured left clavicle (see Image 2.). Image 3 shows the fractured clavicle in the transverse plane.


Image 1. PoCUS of normal right clavicle along the long axis of the clavicle (arrows depict the hyperechoic superficial cortex with deep acoustic shadowing).



Clip 1. PoCUS of normal right clavicle along the short axis of the clavicle. The transducer is moving from the lateral to medial, note the visible hyperechoic curved superficial cortex and the subclavian vessels at the end of the clip. 


Image 2. PoCUS of normal right clavicle along the short axis of the clavicle (arrows depict the hyperechoic superficial cortex with deep acoustic shadowing).



Image 3. PoCUS of a fracture in the left clavicle along the long axis of the clavicle



Clip 2. PoCUS of a fracture of the left clavicle, viewed in the long axis of the clavicle. Compare this view with image 1.




Clip 3. PoCUS of a fracture in the left clavicle viewed in the short axis of the clavicle. Compare this view with Clip 1. Note the fracture through the visible cortex and the displacement that becomes apparent halfway through the clip.


Radiographic findings: Radiographic findings of the left clavicle reveal a mid-shaft spiral clavicular fracture.  (Image 4).

Image 4. Radiographic image of fractured left clavicle.


Take home point: Research has shown that Ultrasonography is a sensitive diagnostic tool in the evaluation of fractures (Chapman & Black, 2003; Eckert et al., 2014; Chen et al., 2016).

This case provides an example of how PoCUS can be used to diagnose clavicle fractures in the emergency department. In a rural or office setting where radiography is not always available, PoCUS can be used to triage patients efficiently into groups of those with a fracture and those with a low likelihood of a fracture. This would enable more efficient medical referrals while improving cost-effectiveness and patient care.



Chapman, D. & Black, K. 2003. Diagnostic musculoskeletal ultrasound for emergency physicians. Ultrasound, 25(10):60

Eckert, K., Janssen, N., Ackermann, O., Schweiger, B., Radeloff, E. & Liedgens, P. 2014 Ultrasound diagnosis of supracondylar fractures in children. Eur J Trauma Emerg Surg., 40:159–168

Chen, K.C., Chor-Ming, A., Chong, C.F. & Wang, T.L. 2016. An overview of point-of-care ultrasound for soft tissue and musculoskeletal applications in the emergency department, Journal of Intensive Care, 4:55


This post was copyedited by Dr. Mandy Peach



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Fall ECCU Fest 2018 – PoCUS Conference Workshop and ECCU2 Course

September 27th – 28th 2018

The Algonquin Resort in St. Andrews by-the-Sea, New Brunswick, Canada


Atlantic Canada’s top PoCUS event


Now open for applications/booking



The ECCU Conference is being held in conjunction with the ECCU2 Advanced Applications Course in order to provide those attending the course and other delegates with an opportunity to access an update in the hottest clinical PoCUS topics. The focus will be on presenting the best emerging evidence, strategies for developing a local PoCUS program and developing competencies.


  • International PoCUS experts
  • Clinical PoCUS hot topics and updates
  • Top PoCUS research
  • IP2 Diagnostic stream lectures

Conference delegates will have access to the Diagnostic stream lectures of the ECCU2 Advanced Applications Course, which will include an Gallbladder, Renal, DVT and Ocular

Invited Faculty – 2018

Dr. Hein Lamprecht – South Africa – (ECCU Fest 2018) – PoCUS Educator Extraordinaire – IFEM – WinFocus

Dr. Darryl Wood – UK/South Africa – (ECCU Fest 2018) – PoCUS bushcraft on the frontline

Dr. Peter Croft – USA – (ECCU Fest 2018) – New England PoCUS disrupter –past MGH PoCUS Fellow

Dr. David Mackenzie – USA – (ECCU Fest 2018) – Canadian New Englander, PoCUS innovator – past MGH PoCUS Fellow


Also our top Dalhousie Faculty of PoCUS Experts



Open for applications and booking: More Information Here

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New – Dal SJRHEM PoCUS Fellowship/Elective

The Dalhousie University (DU) Emergency Point of Care Ultrasound Elective and Fellowship Program at Saint John Regional Hospital (SJRH) with an optional up to 1 month placement in Pediatric PoCUS at the IWK Health Centre Pediatric Emergency Department


There are four primary components to the mini-fellowship and fellowship programs:


  1. Clinical: optimizing image acquisition and interpretation skills for both core and advanced emergency and point of care ultrasound applications
  2. Education: developing lecturing and teaching skills by developing an emergency ultrasound lecture portfolio and contributing to the program’s educational mission. Acquiring expertise at bedside ultrasound teaching and assessment.
  3. Administration: understanding the critical components required to run an emergency ultrasound program, set up and deliver educational events/courses and how to best utilize information technologies for image archiving, database management, and quality assurance.
  4. Research: understanding the state of emergency ultrasound research by participating in ultrasound journal club activities and developing an independent research project from its inception to publication.


For more information click here

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Dalhousie DEM SJRHEM/IWK PoCUS Fellowship/Elective


Dalhousie University

Emergency Point of Care Ultrasound

Clinical-Academic Fellowship

Department of Emergency Medicine,

Dalhousie University,

Saint John Regional Hospital.

Ultrasound and Research Programs

Dr. David Lewis FCEM, Ultrasound Program Director

Dr. Paul Atkinson FRCPC, Research Director



Member of the Canadian Society of EM-PoCUS Fellowships –




Fellowship Director, Dalhousie University, Saint John – Dr. David Lewis

Fellowship Director (Research), Dalhousie University, Saint John – Dr. Paul Atkinson

Fellowship Director, Dalhousie University, IWK – Dr. Kirstin Weerdenburg




  1. Overview and Objectives

Welcome to the Dalhousie University (DU) Emergency Point of Care Ultrasound (PoCUS) Elective and Fellowship Program at Saint John Regional Hospital (SJRH) with an optional up to 1-month placement in Pediatric PoCUS at the IWK Health Centre Pediatric Emergency Department.  We are very proud of our program and excited that you are considering joining us. This document outlines the nature and scope of the elective and fellowship options, with a breakdown of the individual components that comprise your educational experience. Particular attention is paid to how we plan on providing you with the tools you need to succeed in your career in each discipline, and on the expectations we have of you.

The Emergency PoCUS Program began in 2009 and has been a leading program in Canada. We offer a one-month elective, a three-month mini-fellowship, as well as 6 and 12 month fellowships to be completed either during the 4th year of the Royal College Residency Program in Emergency Medicine (or equivalent level international Emergency Medicine training program) or for graduates of emergency medicine residency programs who wish to improve their skills and knowledge to become ultrasound program directors or leaders in the field of emergency ultrasound.

The elective program is designed to provide additional scanning experience in the clinical setting as well as provide an introduction to ultrasound education.

There are four primary components to the mini-fellowship and fellowship programs:


  1. Clinical: optimizing image acquisition and interpretation skills for both core and advanced emergency and point of care ultrasound applications
  2. Education: developing lecturing and teaching skills by developing an emergency ultrasound lecture portfolio and contributing to the program’s educational mission. Acquiring expertise at bedside ultrasound teaching and assessment.
  3. Administration: understanding the critical components required to run an emergency ultrasound program, set up and deliver educational events/courses and how to best utilize information technologies for image archiving, database management, and quality assurance.
  4. Research: understanding the state of emergency ultrasound research by participating in ultrasound journal club activities and developing an independent research project from its inception to publication.


For physicians who have graduated residency and who wish to undertake a 12-month fellowship, the position may include an appointment (pending Nominations / Privileges agreement) as a locum part-time attending physician in the Department of Emergency Medicine in the Saint John region group of hospitals including Sussex, St Josephs UCC, Charlotte County and Saint John Regional Hospitals, and as such, it is available only to individuals meeting requirements for medical licensure in New Brunswick.

Residents will need to come with their own funding preferably via their own Residency Program. We may be able to direct residents towards other areas of funding such as educational grants, but all application requirements will be their responsibility.

International applications are welcome; however, these need to be fully funded and all the immigration requirements will need to be organized by the applicant. In addition a Fellowship fee may be required, depending on the circumstances of the application.

Expressions of interest are made in writing via email or letter to the Dr. David Lewis at the address below. An application form will be sent for completion. Appointment to a Fellowship will be decided by the Fellowship Nominations committee. Locum part-time attending physician appointments will be decided by the SJRHEM Nominations committee.


  1. Electives (one month)


Your weekly schedule requirements are approximately 36 hours per week and are very variable from week to week. In general, you should expect to spend approximately:


  • 32 hours/week clinical shifts (approximately)


During your one month elective in emergency ultrasound, you will work as a resident in the emergency department, following a regular schedule of 4 clinical shifts per week. These will be supervised by faculty with advanced ultrasound skills. The purpose of this elective is to enhance your sonographic skills in a clinical setting. You will be expected to provide clinical care for patients with a focus on the integration of point of care ultrasound in emergency medicine.

  • Scanning

You will save and log all scans performed and will aim to complete 50 scans in each of the following Core areas of Emergency Point of Care Ultrasonography (PoCUS)


  • Abdominal/FAST
  • Basic Cardiac
  • Lungs and Thorax
  • Abdominal Aorta
  • IVC / Shock
  • First Trimester Pregnancy
  • Vascular Access



  • For Residents with a documented prior Core level PoCUS competency, we will provide training and supervision in selected advanced applications. The nature of theses will be tailored to the individual’s requirements (e.g critical care, sports medicine, pediatrics etc).
  • You will be required to teach and assist with ultrasound courses run by the SJRH program.
  • You will present at journal club and rounds as required.
  • You will contribute at least one referenced pictorial case discussion per month to the Resident Pearls / PoCUS Rounds series on the website



  1. Mini-fellowship and fellowship (3-12 months)

The expectations outline below will be adjusted to the duration of your fellowship.



Your weekly schedule requirements are approximately 36 hours per week and are very variable from week to week. In general, you should expect to spend approximately:

  • 16 hours/week supervised clinical shifts in the Emergency Department (approximately)
  • 20 hours/week fellowship responsibilities; including scanning, education and research/administrative work. Vacation will be determined by your residency program guidelines.
  • Courses – you will be required to teach and assist with ultrasound courses run by the SJRH program.
  • You will present at journal club and rounds as required.

III. Education

You are expected to read provided materials to enhance your knowledge in the field. The topics to be covered are outlined below. You will be provided with material to cover all of these topics.

A. Ultrasound Physics and Instrumentation


  1. Units and Measurement
  2. Sound
  3. Pulsed Ultrasound
  4. Intensity
  5. Interaction of Sound and Media
  6. Range Equation
  7. Transducers
  8. Sound Beams
  9. Axial and Lateral Resolution
  10. Display modes
  11. Two-dimensional Imaging
  12. Temporal Resolution
  13. Pulsed Echo Instrumentation
  14. Displays
  15. Image Processing and Dynamic Range
  16. Hemodynamics
  17. Doppler
  18. Image Characteristics and Artifacts
  19. Quality Assurance
  20. Bioeffects

B. Emergency Point of Care Ultrasonography (PoCUS)

a. Core applications

  1. Abdominal/FAST
  2. Basic Cardiac
  3. Lungs and Thorax
  4. Abdominal Aorta
  5. IVC / Shock
  6. First Trimester Pregnancy
  7. Vascular Access

b. Advanced applications

  1. Advanced Cardiac
  2. Gallbladder
  3. DVT
  4. Renal
  5. Musculoskeletal
  6. Soft tissue
  7. Pediatric applications
  8. Regional anesthesia/nerve blocks
  9. Procedural guidance
  10. Ocular
  11. Bowel
  12. Doppler


c. Indications

d. Limitations

e. Literature-based evidence

f. Algorithms for incorporation of ultrasound into clinical practice



  • Become familiar with the operations of the Sonosim simulator or Vimedix simulator. Utilise the available learning packages on both simulators. Develop teaching methods that utilize these simulators in the education of others.
  • Complete all the online Emergency Ultrasound Exams at ACEP and other formative assessments as directed by the Fellowship directors.
  • Stay up-to-date with current literature, reading and reviewing ultrasound-related articles. Maintain the library of articles that we review.
  • You will be given support to prepare, acquire eligibility for and to take the Canadian Point of Care Society (CPoCUS) exam for the CPoCUS Core IP or Expanded Applications certification track (depending on level of competency at start of Fellowship).
  • Optionally – If you meet the eligibility requirements, you will be given support to adjust the components of this Fellowship to support an application for recognition of a Royal College of Physicians and Surgeons of Canada Area of Focused Competence Diploma in Acute are Point of Care Ultrasonography.

IV. Scanning

Paramount to all else in your fellowship, you must become an expert user of PoCUS. The skills you acquire in doing so will be invaluable to your career in emergency medicine and will make you a better clinician. Your skills need to reach a level where you feel confident in your own scans, both in identifying and ruling out pathology, and in knowing when the exams are inadequate to do so.

We will directly observe your scanning when possible and assess your images and interpretations for adequacy when not. You will have scanning shifts with an Emergency Physican PoCUS faculty, both when they are working clinically, and when they are not.


  • Perform a minimum of 250 scans per 3 month block.

These should consist of primary emergency ultrasound applications (FAST, echo, aorta, biliary, renal, 1st trimester ultrasound, DVT, procedural, soft tissue, thoracic), but may include some advanced applications. You should have an appropriate mix of both applications and findings (both positive and negative scans).

  • Log each of your scans and interpretations in a datasheet (We use Q-Path for this purpose).
  • Have a sample of your scans reviewed by the Fellowship Directors for both adequacy of image acquisition and interpretation.
  • Do your own external QA. Record when a patient that you scan has an “official” study performed (i.e. a formal echo, ultrasound, CT scan, operative report) and compare your findings to that study.
  • Spend approximately 4-8 hours a week scanning. If there are rotating residents during that week, your scanning time should be spent with them. If there are no residents or students, you should schedule your scanning time when an Emergency Physican PoCUS faculty is working clinically when possible.
  • Keep a log of the dates and times of your scanning shifts.
  • Assure that your scans are entered into Q-Path or equivalent database. Q-Path serves as our tool for tracking scanner numbers and accuracy.
  • Seek out pathology and novel applications of ultrasound when possible. Your scanning should not be limited to established applications.
  • Know how to acquire video clips as well as still images, and when each is appropriate.
  • Adhere to and enforce departmental policies regarding machine cleanliness and maintenance.

There is also an option to perform up to 1 month of scanning in pediatric applications at the IWK Health Centre Pediatric Emergency Department. The expectations would be the same as stated above.


V. Teaching

Learning to teach ultrasound is a fundamental portion of your fellowship. The most important component to superlative teaching is a strong grasp of the fundamentals of ultrasound. Your teaching experience will consist of both lecturing and hands-on teaching. We feel this is an essential component to your ultrasound fellowship experience.

We will provide you with background information, literature review, and access to image and video clip databases to help you prepare for your lectures, as well as review them for quality and presentation style pointers. You will have ample hands-on experience scanning with us, in preparation for your independent teaching.


  • Develop your own emergency ultrasound lecture portfolio consisting of at 2-4 lectures (depending on the duration of your fellowship). These need to be high-level case-based lectures covering at least scanning technique, normal and abnormal findings, treatment algorithms, and most importantly a critical review and appraisal of the current literature related to that application.
    • One of your lecture topics should be from the list of core applications: Abdominal/FAST, Basic Cardiac Echo, Lungs and Thorax, Abdominal aorta, IVC / Shock, First Trimester Pregnancy, or Vascular access
    • One of your lecture topics should cover an advanced application, such as Advanced cardiac echo, Gallbladder, DVT, Renal, Musculoskeletal/Soft tissue, Pediatric applications, Regional anesthesia/nerve blocks, Procedural guidance, Optic, Bowel or Doppler
    • Your other lecture topics can be of your choosing, from the lists above, or on another original subject (with prior approval from the fellowship directors)
  • Prior to presentation, you must review your lecture with an Emergency Physican PoCUS faculty. This should be done no less than a week before your talk is scheduled.
  • Present a minimum of 1 lecture at ED Rounds.
  • Spend individual time doing hands-on scanning with rotating residents.
  • Participate in teaching of EM staff when the opportunities arise.
  • Contribute at least one referenced pictorial case discussion per month to the Resident Pearls / PoCUS Rounds series on the website


Emergency ultrasound is at the cutting edge of clinical research in emergency departments across Canada and worldwide. New applications and uses are being frequently being studied and tested and can make immediate impact on clinical practice. We feel strongly that Dalhousie University Department of Emergency Medicine can and should be among the leaders in this field. Participation in research is an integral component of your fellowship.

We will provide you with all the mentorship, resources, and support that you need to pursue your research endeavors.


  • Actively seek and enroll patients in all ultrasound research projects. When you are on a scanning shift by yourself, research enrollment should be as important as educational scanning.
  • Support and advise other learners with their ultrasound related research projects.
  • Develop at least 1 research project. As the primary investigator, you should undertake all aspects of this research, including but not limited to idea conception, protocol authorship, IRB approval, consent and data forms, advertisement of the study, patient recruitment and enrollment, follow-up, data analysis, statistical analysis, and manuscript authorship.
  • Present at least one project at a regional, national or international conference.
  • Submit at least one project as lead author for publication in a peer-reviewed journal.
  • Meet deadlines for submission of research project abstracts. Be aware that the deadline for the annual CAEP conference (Usually in June) can be as early as December.

VII. Administration

A keen understanding of the administrative aspects of emergency ultrasound is a necessity for successful implementation of an emergency ultrasound program in any emergency department. Administrative issues are primarily but not exclusively financial, medico-legal, or political in nature. We will do our best to ensure exposure and familiarity with each of these topics.



  • Attend all ultrasound interest group meetings, department meetings, ultrasound research meetings.


  • Understand the various medico-legal aspects of performing and documenting emergency ultrasounds.
  • Understand the politics and business behind ultrasound machine companies.
  • Understand the nature of the politics of emergency ultrasound on a national level.
  • Aid in the organization and implementation of a recruitment and selection process for future fellows.
  • Attend a national Emergency Ultrasound Committee meeting—CAEP Emergency Ultrasound Committee.
  • Read the CAEP, CPoCUS and IFEM Emergency Ultrasound Guidelines
  • Participate in setting up ultrasound courses given within or outside of the hospital.
  • Understand the process of marketing, organizing and budgeting for an ultrasound course, dealing with those who have paid to attend and supporting the invited faculty.


VIII. Quality Assurance

Reviewing ultrasound images is an essential skill. To ensure that you are performing high-quality sonography, your images and videos will all be reviewed by the Fellowship Directors or deputy to assure that they support your interpretations. We refer to this as internal QA. In addition, there is external QA which compares your findings to “official” findings. To further hone your skills and prepare you for a directorship of your own, you will review other peoples’ ultrasounds and give them feedback on their scans.


  • Participate in QA of departmental exams. You will learn the QA process in a graduated manner. At first, you will observe how the Fellowship Directors or deputy assess image quality and adequacy and learn the scoring system for image feedback. Once you have become familiar with the process, you will perform the QA with oversight. When your assessment of images correlates well with Fellowship Directors or deputy assessments, you will be granted privileges to perform QA independently. The learning curve is variable, but we expect that within a few months you should be reading scans on your own.


IX. Image Management

As technology progresses, so does sophistication of ultrasound machines and systems. With increased usage of ultrasound in the emergency department, appropriate image storage and management becomes more and more imperative.


  • Aid in the maintenance of an organized image storage and retrieval system (Q-Path). Keep the Teaching Files up to date with appropriate keywords for easy searching.
  • Learn how to configure an ultrasound machine to record video and still images.
  • Understand the process of how to edit and convert digital images and clips from the ultrasound machine into ones that can be used in a presentation.
  • Make Keynote / Powerpoint presentations incorporating video clips.

X. Evaluation

Your scanning technique and images will be reviewed on a continual basis. You will receive verbal feedback on these. At the end of the Fellowship/Elective you will receive a summative assessment of Emergency PoCUS knowledge and competency. The details of this assessment will vary depending on the duration of your Fellowship/Elective and will be provided to you when you start.

You will meet with the Fellowship Directors every six weeks. At each meeting, we will review your performance and progress in line with the listed objectives. You will also have the opportunity to evaluate the Fellowship, the faculty, and your own performance. These evaluations are meant to be constructive, and to help shape the fellowship experience into one that meets your needs.



Address for expressions of interest

Dr. David Lewis –


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RCP – Suprapubic Aspiration PoCUS

Suprapubic aspiration – when the catheter doesn’t cut it.

Resident Clinical Pearl (RCP) – Guest Resident Edition

Sean Davis MD, PGY2 Family Medicine

Dalhousie University, Yarmouth, Nova Scotia

Reviewed and Edited by Dr. David Lewis


Urine is routinely analyzed and cultured as part of a sick child workup, as diagnosis of urinary tract infection can be difficult in pre-verbal children. They are unable to “point where it hurts”, and physical exam can be both difficult and unreliable in an irritable or obtunded infant. Urine may be collected in three ways – by “clean catch” collection, transurethral catheterization (TUC), and suprapubic aspiration (SPA). Given the inherent risk of contamination with local flora (over 25% in one cohort study)1, clean catch urine is typically useful only for ruling out UTI. TUC is more commonly performed as it does not require physician participation, but SPA remains a valid option for obtaining a urine sample for analysis and culture in children under the age of 2. It has been shown to have a significantly lower rate of contamination than TUC (1% versus 12%, respectively)1, although failure rates are higher with SPA4. Use of portable ultrasound has been shown to significantly increase the rate of success of SPA (79% US guided vs 52% blind)5.


RCP – The pee or not the pee: so many questions!



  • Labial adhesions/edema
  • Phimosis
  • Diarrhea
  • Unsuccessful urethral catheterization
  • Urethral/introital surgery
  • Urethral stricture
  • Urethral trauma
  • Urinary retention
  • Urinalysis/culture in children younger than 2 years
  • Chronic urethral/periurethral gland infection

Contraindications: 2,3

  • Genitourinary abnormalities (congenital or acquired)
  • Empty or unidentifiable bladder
  • Bladder tumor
  • Lower abdominal scarring
  • Overlying infection
  • Bleeding disorders
  • Organomegaly

Complications: 2,3

  • Gross hematuria
  • Abdominal wall cellulitis
  • Bowel perforation

Equipment: 2,3

  • Lidocaine for local anesthesia (1% or 2%, with or without epinephrine)
  • Adhesive bandaid
  • Povidone-iodine or Chlorhexidine prep
  • 25g to 27g 1” needle
  • 22g or 23g 1.5” needle
  • Sterile 5ml and 10ml syringes

Procedure (ultrasound-guided): 2,3

  • Position the patient supine in frog-leg position, using parent or caregiver to assist with immobilization.
  • Using sterile technique, identify the bladder on ultrasound; it appears as an anechoic ovoid structure just below the abdominal musculature.
    • Landmarking: midline lower abdomen, just above the pubic symphysis
  • Mark the area and sterilize; infiltrate local anesthetic into the marked area
  • Insert the needle slightly cephalad, 10-20° off perpendicular while aspirating until urine appears.
  • If the insertion is unsuccessful, do not withdraw the needle fully. Instead, pull back until the needle tip rests in the subcutaneous tissue and then redirect 10° in either direction. Do not attempt more than 3 times.
  • One sufficient urine is obtained, withdraw the needle and place a sterile dressing at the site of the insertion.



From: Performing Medical Procedures – NEJM



    1. Contamination rates of different urine collection methods for the diagnosis of urinary tract infections in young children: an observational cohort study. Tosif S; Baker A; Oakley E; Donath S; Babl FE. J Paediatr Child Health. 2012; 48(8):659-64 (ISSN: 1440-1754). Retrieved from on December 10, 2017
    2. Suprapubic Aspiration. Alexander D Tapper, MD, Chirag Dave, MD, Adam J Rosh, MD, Syed Mohammad Akbar Jafri, MD. Medscape. Updated: Mar 31, 2017. Retrieved from on December 10, 2017
    3. Suprapubic Bladder Aspiration. Jennifer R. Marin, M.D., Nader Shaikh, M.D., Steven G. Docimo, M.D., Robert W. Hickey, M.D., and Alejandro Hoberman, M.D. N Engl J Med 2014; 371:e13September 4, 2014DOI: 10.1056/NEJMvcm1209888. Retrieved from on December 10, 2017
    4. Suprapubic bladder aspiration versus urethral catheterization in ill infants: success, efficiency and complication rates. Pollack CV Jr, Pollack ES, Andrew ME. Ann Emerg Med. 1994 Feb;23(2):225-30. Retrieved December 10, 2017.
    5. Use of portable ultrasound to assist urine collection by suprapubic aspiration. Gochman RF1, Karasic RB, Heller MB. Ann Emerg Med. 1991 Jun;20(6):631-5. Retrieved December 10, 2017.


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RCP – Aortic Dissection

Aortic Dissection

Resident Clinical Pearl (RCP) – October 2017

Luke Taylor, R2 FMEM, Dalhousie University, Saint John, New Brunswick

Edited by Dr Kavish Chandra – @kavishpchandra

Reviewed by Dr. David Lewis


Why should we care?

  • Aortic dissection remains difficult to diagnosis despite improvements in our understanding of the process and its characteristic features
  • Many cases are still missed at the initial ED presentation
  • Dissections occur after some violation of the intimal layer allows blood to enter the media and dissect between the intimal and adventitia. The blood flow entering the tear can extend the dissection proximally, distally, or both
  • With each hour that passes there is a 1-2% increase in mortality as the dissection extends



The presentation is similar across all acute aortic syndromes (AAS)

  • Acute intense chest or back pain (“SAH” of the torso)
  • Ask about:
    • Location
    • Intensity at onset
    • Radiation of pain
  • Aortic dissection can be painless ~5% of the time

IRAD 12 features most associated with acute aortic dissection

  • The characteristic tearing/ripping was not found to be a common descriptor in International Registry of Aortic Dissection (IRAD)

Pear: When assessing a patient with chest pain (CP), think CP+ 1 (see EMCases episode 92)

  • CP+ CVA
  • CP+ paralysis
  • CP+ hoarseness
  • CP+ limb ischemia

These features should drastically increase your suspicion for dissection


Physical examination

  • Keep in mind a large portion of general population have a BP differential >10mmHg
  • Vital signs can be normal but patients may have variation in their pulse or BP in the form a pulse deficit, SBP differential, hypertension or hypotension
    • Pulse Deficit: feel for difference between heart rate and the pulse rate
  • Murmur of aortic insufficiency:
  • Neurological findings: objective focal neurological deficit



  • CXR: Look for a wide mediastinum, loss of aortic knob, calcium sign
    • A normal CXR does not rule out aortic dissection as 1/3 of CXRs in aortic dissection are normal
    • Pearl : Measure the distance from the white line to the outer edge of the aortic knob. A distance >0.5cm is considered a 

positive calcium sign


  • POCUS: If attempting, look for a dissection flap in the parasternal long axis view above the aortic valve. The flap may also be visible in abdominal aorta
    • Low sensitivity, but high specificity

  • Look for pericardial effusion from a retrograde dissection into the pericardium




FOAMED Links and Resources


This post was copyedited by Kavish Chandra @kavishpchandra

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PoCUS – Measurements and Quick Reference

Developed by Dr. Heather Flemming as part of her PG PoCUS Elective at SJRHEM.

A useful Point of Care Ultrasound (PoCUS) guide to common normal values, measurements, pathological values and quick reference tips. A pdf version is also provided in this post which can be downloaded, printed and attached to your ultrasound machine for easy access.





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Resident Clinical Pearl – PoCUS for ETT Placement Confirmation

ETT Placement Confirmation During Cardiac Arrest: US for the Win!

Resident Clinical Pearl – November 2015

Kalen Leech-Porter, PGY 1, iFMEM, Saint John NB, Dalhousie University

Reviewed by: Dr Jay Mekwan and Dr David Lewis


The AHA has updated their guidelines for CPR and emergency cardiovascular care this year (2015)[i].  Previously, there were insufficient studies to warrant a recommendation for Point of Care Ultrasound (PoCUS) for ETT confirmation, however, a new study has emerged to suggest that PoCUS can be a useful adjunct for ETT placement confirmation.  A 96 patient observational study done on patients during cardiac arrest, found that PoCUS had a sensitivity of 98.9% and a specificity of 100%[ii].  ETT placement was determined by placing the ultrasound transducer transversely above the suprasternal notch to identify endotracheal or esophageal intubation.  It was determined during the study that in using this method ultrasound could be completed without interrupting chest compressions.

As the above study has yet to be replicated, end-tidal CO2 remains the gold standard for ETT placement confirmation (an observational, prospective study of 566 patients found colorimetric to be 95.6% sensitive, 99.8% specific[iii]) during cardiac arrest.  However, AHA has added ultrasound as an additional method for confirmation of endotracheal tube placement, with the caveat that ultrasound should never interfere with the continuous conduction of high-quality CPR.


How to confirm ETT with PoCUS:

Video by Haney Mallemat


Video by Joseph Minardi


Abridged Instructions from ACEP Tips and Tricks [iv]

  • Place the high frequency linear probe transversely just above the sternal notch (Image A); note normal airway anatomy (Image B), prior to ETT placement (if time permits)
Image A

Image A

From: Joseph Minardi’s Video [see above]


Image B

Image B

From: Halley Mallemat’s video [see above]


Trachea: Hyperechoic, curvilinear with comet-tail artifact

Esophagus: more distal, oval with heyperchoic wall and hypoechoic center


  • PoCUS ETT confirmation can be done in real time, as ETT is placed, or done post placement. Successful ETT: there will be a slight increase in artifact/shadowing in trachea region only, known as the “Bullet Sign” (Image C) [v].  The operator should see reverberations in the trachea’s anterior lumen.  To further confirm can slightly shake the ETT, this should only show trachea movement.
Image C

Image C

From: Mark Favot [v]



  • Esophageal Intubation: will cause a second ‘trachea’ appear (Image D and E), referred to as the “double tract sign”

Image D

From: Halley Mallemat’s video [see above]

Image E

Image E

From ACEP Tips and Tricks [iv]


  • Pitfalls: the esophagus may be located directly posterior to the trachea, therefore esophageal intubation may be missed if inadequate depth is used.
  • Additionally, observing bilateral lung sliding while bagging a paralyzed patient also suggest ETT confirmation.


[i] Web-based Integrated 2010 & 2015 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care; Part 7: Adult Advanced Cardiovascular Life Support.  (Nov. 25, 2015)

[ii] Sun, Jen-Tang, Sim, Shyh-Shyong, et al. “Ultrasonography for proper endotracheal tube placement confirmation in out-of-hospital cardiac arrest patients: two-center experience.”  Critical Ultrasound Journal 6 (2014): A29

[iii] Hayden, SR., and Sciammerella, J., et al. “Colorimetric end-tidal CO2 detector for verification of endotracheal tube placement in out-of-hospital cardiac arrest.” Acad Emerg Med 6 (1995): 499-502

[iv] Chao, Alice and Ghrahbaghaian, Laleh. “Tips and Tricks: Airway Ultrasound.” American College of Emergency Physicians Emergency Ultrasound Section Newsletter (June, 2015).

[v] Favot, Mark. “Ultrasound for Verification of Endotracheal Intubation.” FOAM EM (March, 2015).

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FAST RUQ Positive

The Saint John Regional Hospital Emergency Department Ultrasound Program was established as one of our priority academic programs. Amongst our physician group are a number of national and international leaders in the field of Point of Care Ultrasound (PoCUS). We run a growing number of PoCUS courses each year in Saint John, including the ECCU 1  course, ECCU IP School and Fall ECCU Fest!

We have 2 Sonosite M-Turbo machines located in Trauma and RAZ and 1 Sonosite X-Porte in Acute.





Fall ECCU Festival

27th-28th September 2018





Ultrasound Program Pages


Ultrasound Resources

Ultrasound Faculty

Dr. Paul Atkinson

Dr. Robin Clouston

Dr. Paul Frankish

Dr. Matt Greer

Dr. Jay Hannigan

Dr. Michael Howlett 

Dr. Joanna Middleton 

Dr. Tushar Pishe 

Dr. Brian Ramrattan

Dr. Peter Ross 

Dr. Jo-Ann Talbot



AAA    ECCU Workshop

Ultrasound Simulation Room

2014-03-26 09.36.19The ultrasound simulation room is located in the back corridor between RAZ and Trauma. They key for this room can be accessed via the ED Admin Office. This room is set up for a variety of ultrasound simulation modalities.

Equipment includes:

  • Sonosite MicroMaxx Ultrasound Machine
  • CAE Vimedix Simulator
  • SonoSim Simulator
  • Blue Phantom – Head and Neck Vascular Access Phantom
  • Blue Phantom – Transvaginal Phantom
  • Blue Phantom – Upper Limb Vascular Access Phantom
  • Blue Phantom – Vascular Access and Nerve block Phantoms

2014-03-26 09.29.582014-03-26 09.28.23

This equipment is available to all staff physicians, residents and medical students. Please contact Dr Lewis for simulator training if required. Simulator instructions can be found in the File Store below. Please ensure that all the equipment in the ultrasound simulation room is turned off and in good condition after use.



Quick Tips

How to Log a Scan – Sonosite SJRHEM – logging a scan web

How to save and Image/Clip – Sonosite SJRHEM – saving a clip or image web


Ultrasound Files



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