Aortic Stenosis in the Emergency Department 

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A Resident Pearl by Dr. Eric Plant

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Dr. Eric Plant, FM PGY1

Dalhousie Medicine New Brunswick, Saint John

Reviewed By Dr. David Lewis

Copyedited by Dr. David Lewis

The Quick Pearls You Came Here For

  • Aortic stenosis (AS) is very common and severe AS, especially when paired with an acute drop in preload or new onset tachydysrhythmia, can cause cardiogenic shock.
  • Features of severe AS can and should be caught on a routine emergency department (ED) cardiac exam
  • Differentiating from mitral regurgitation (MR) is clinically important and can be aided by PoCUS.
  • Management of cardiogenic shock from severe AS is challenging and relies on achieving euvolemia, normotension, optimizing oxygenation, and maintaining perfusion with a heart rate on the lower end of normal.
  • Dropping the preload of someone with severe AS can cause them to go into cardiogenic shock so everyone who gets nitroglycerine should have their heart auscultated first
  • Goals of managing severe AS in the ED are identification and stabilization until definitive care from a mechanical assist device and or valve replacement can be offered.
  • Identification of symptomatic AS and early referral can be lifesaving whether the patient is in cardiogenic shock or not.


  • Overview of aortic stenosis
  • Overview of shock and cardiogenic shock
  • Differential diagnosis
  • History features
  • Physical exam
  • Diagnostics
  • Treatment
  • Conclusion

Brief Overview of Aortic Stenosis

AS is the most common valvular heart disease, and in Canada, typically develops from chronic calcification over a course of decades.5

Typically, people will develop progressive exertional symptoms which can ultimately lead to heart failure, syncope, and acute myocardial infarctions. While not commonly discussed in emergency medicine resources, valvular disease is very common and can either be the primary reason for an ED visit or complicate another presenting cardiac complaint. 3 Nearly 30% of people over 65 have some degree AS and 2-9% of patients greater than 75 have severe AS.6 Congenital bicuspid valves are the most common etiology in the developed world in patients less than 65.6 Finally, in the developing world, Rheumatic valve disease is the most common cause.6

Calcified AS progressively increases afterload over the course of decades which causes left ventricular hypertrophy.6 The compensatory hypertrophy causes the ventricle to become stiffer and less contractile. As heart failure slowly develops from this progressive left ventricular (LV) outflow obstruction, a person’s ability to maintain cardiac output becomes more and more dependent on synchronicity of the heart and preload. As a heart with AS becomes more larger and stiffer due to compensatory changes, it develops both diastolic and systolic dysfunction.4


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GIF 1 from


It is important to note that severity of AS has a wide range from having low clinical significance to life-threatening. While it is not necessary to try to accurately grade the severity of aortic stenosis in the ED, it is important to know that most patients with aortic stenosis are asymptomatic. For those patients who are asymptomatic, without typical symptoms of decreased exercise tolerance or an audible murmur, their AS is very unlikely to be the etiology of any cardiogenic shock they develop. However, AS should be considered as the etiology of cardiogenic shock for those patients who have known severe aortic stenosis and/or who have a loud characteristic murmur.

Full grading criteria for AS are complicated and can be found here. A more simplified chart is provided below.


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Figure 1 From the European Society of Cardiology, 2018


Cardiogenic shock in severe AS can cause a spiralling of instability.7 An acute episode of cardiogenic shock due to AS is typically because a there has been an exacerbating incident that decreases the heart’s ability to overcome the increased afterload that AS causes.7 Most commonly this is a loss of preload (sepsis, DKA, sever dehydration, excessive nitroglycerine spray) or an episode of a tachydysrhythmia (most commonly rapid atrial fibrillation).3 The spiral begins when the resulting heart failure leads to a drop in coronary perfusion pressure, which causes myocardial ischemia and infarct, which further impede the heart’s ability to overcome the afterload and ultimately causes the patient to crash.


PEARL: AS is very common and severe AS, especially when paired with an acute drop in preload or new onset tachydysrhythmia, can cause cardiogenic shock.


If you prefer a good video to learn cardiac physiology, I’d recommend one of the following:

Brief Overview of Cardiogenic Shock

Shock is most simply defined as impairment in end organ perfusion.7 Cardiogenic shock takes place when the heart fails to provide the necessary pressure to maintain this perfusion. There are several variations of the definition of cardiogenic shock that rely on specific values and metrics. Unfortunately, these definitions were developed as inclusion/exclusion criteria in academic studies and too cumbersome to be utilized at the bedside in a resuscitation.


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Figure 2 (left) from the Taming the SRU Blog, Figure 3 (right) from the Journal of Cardiovascular Pharmacology and Therapeutics


In an emergent resuscitation many of these numbers are not available and/or somewhat unreliable therefore it is easiest to evaluate perfusion clinically with a combination of basic vitals, physical exam, and PoCUS. The simplest ways to assess end organ perfusion is simply to examine the patient’s mental status and skin. Extremities in cardiogenic shock will be cool, with pale or mottled skin, and peripheral pulses will be weak or absent. An altered mental status without another cause suggests that the brain is not receiving adequate perfusion. In the case that either of these features are present, the patient is in serious trouble, and you should assume that all end organs are currently ischemic and being damaged.

Many of us remember the classic chart depicting the Forrester classifications of heart failure. Cardiogenic shock is represented in the bottom, higher mortality, half of the graphic.


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Figure 4 from


As we see represented in figure 1, true cardiogenic shock typically takes place in the highest mortality area of “wet and cold,” meaning that the patient’s skin is cold and systolic dysfunction is causing pulmonary edema. Some cardiogenic shock patients can exist in the cold and dry lower left box but this requires volume depletion or the elusive euvolemic state.


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Figure 5 from the Handbook of ICU Therapy

Assessment: History

Many people with severe AS will know they have a history of aortic valve disease. If they’re not aware or able to give you the history, they may have previous echocardiogram reports on record demonstrating AS. Without these history features being gifted to you in one of the previous ways, people with severe AS may present with typical history of angina, decreased exercise tolerance or exertional dyspnea, and presyncope/syncope.6 Syncope is a particularly important history feature as patient with severe aortic stenosis and a history of syncope have a poorer prognosis.6

Given that AS develops slowly over time while the heart compensates, cardiogenic shock caused by AS requires an acute insult to precipitate a crisis.3 Typically, these insults come as either a sudden onset of an arrythmia (namely atrial fibrillation) or an acute drop in preload.3 Common causes of a sudden drop in preload could be sepsis, dehydration (secondary to DKA, diarrheal illness, etc.), excessive use of nitroglycerine for treatment of angina, or acute hemorrhage.


PEARL: Dropping the preload of someone with severe aortic stenosis can cause them to go into cardiogenic shock so make sure to auscultate before administering nitroglycerine to a patient with suspected angina or CHF exacerbation.


Finally, a patient with severe AS may present with new onset or an exacerbation of heart failure. These patients can pose a treatment dilemma that we will discuss later. If the patient is on heart failure medications, hopefully you’ll be able to find an echo report at least!

Risk factors for disease progression include many of the classic cardiac risk factors: age, smoking, hypertension, obesity, dyslipidemia, and renal insufficiency.5

History Pearls:

  • Aortic stenosis presents with typical features of angina, exertional dyspnea, and presyncope/syncope.
  • Cardiogenic shock from aortic stenosis requires an insult which is typically a new arrythmia (particularly rapid atrial fibrillation) or a sudden drop in preload.
  • Aortic stenosis takes time to develop, and the patient may be aware of their condition.

Assessment: Physical Exam


A simple glimpse can tell a lot about a patient’s perfusion status. People in cardiogenic shock do not look well. On general inspection they are pale, look distressed, may be lethargic with abnormal eye opening, probably experiencing dyspnea, and may be visually diaphoretic. It is important to assess for volume status by examining mucous membranes. You may also see:

  • Skin mottling
  • Elevated or decreased JVP (elevated indicating heart failure, decreased indicating a possible hypovolemia precipitating the crisis)


The highest yield exam for assessing cardiogenic shock will simply be assessing the skin of the extremities for temperature and peripheral pulses.6 People with cool and clammy extremities with weak or absent peripheral pulses are in shock until proven otherwise. You may also start to assess volume status with crude indicators like skin turgor or axillary moisture. Finally, if you have the hands of a cardiologist, you may also feel:

  • Pulsus parvus (slow) et tardus (late)
  • Displacement of apex from 5th intercostal space in midclavicular
  • Heaves or thrills


Auscultating murmurs is difficult, and while most of us are happy to be able to distinguish systolic from diastolic in the ED, it is especially important clinically to distinguish AS from MR as our goals of resuscitation are different. Both conditions have a systolic murmur and differentiating in an emergency is difficult. Below are some links to videos which demonstrate these differences.

  • Aortic stenosis: harsh, crescendo-decrescendo, mid-late systolic, best heard at right upper sternal border, that radiates bilaterally to the carotids, decrease in intensity with increased afterload, increase in intensity with increased preload

Aortic Stenosis - Heart Sounds - MEDZCOOL

Video 1 from the MEDZCOOL YouTube channel


  • Mitral regurgitation: soft, decrescendo, holosystolic, best heard at cardiac apex, does not radiate, increase in intensity with increased afterload, decrease in intensity with increased preload

Mitral Regurgitation (MR) - Heart Auscultation - Episode 4

Video 2 from the AMBOSS: Medical Knowledge Distilled YouTube channel

  • You may also hear:
  • Pulmonary edema (crackles)
  • S3 or S4 – S3 vs S4 Heart Sound
  • Early systolic ejection “click”
  • A softer S2

Special tests: Getting the patient to perform a two-hand grip test for 30 seconds while auscultating a patient’s murmur may help distinguish between aortic stenosis and mitral regurgitation. The two-hand grip test is supposed to increase afterload which should increase regurgitant murmurs and decrease stenotic murmurs.

Assessment: PoCUS

While this article will not go into detail on the ultrasound features of AS, it is useful to know the basic of features of AS on PoCUS. As you place your probe on the patient it is always important to remember the 5 F’s of ED echocardiography because ruling out other common causes of cardiogenic shock is just as valuable as identifying potential aortic valve disease.1 The graphic below from provides an excellent summary but a full PDF of the The Five F’s of Focused Echocardiography in Shock publication from Dr. Atkinson, Dr. Peach, and Dr. Lewis in the Just the Facts section of CJEM can be found here.


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Figure taken from Just the Facts: The Five F’s of Focused Echocardiography in Shock


It is important to note that aortic stenosis should not be ruled in or out with ER PoCUS at our level. Proper measurements need to be taken from a transthoracic echocardiogram and interpreted by an expert. For our purposes, PoCUS is being used as an extension of the physical exam and to help see some features that further support your diagnosis. For a more comprehensive overview of the PoCUS features of AS you can watch these two excellent videos by Dr. Katie Wiskar. The following GIF images were made from clips from the first video.

Point-of-Care Echo: Aortic Stenosis vs. Sclerosis (9mins)

Basic Valve Evaluation with POCUS (20mins)

For comparison’s sake, below is an example of normal aortic valve function in a parasternal long-axis view. You can see that the hypogenic valve leaflets are thin and mobile with a wide lumen when they open.


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GIF created with frames from Point-of-Care Echo: Aortic Stenosis vs. Sclerosis, Parasternal long-axis graphic from Introduction to transthoracic echocardiography by Philips Ultrasound


In the two images below, we can see that the valve leaflets are thick and surrounded by sclerotic tissue. In the second more zoomed in image the opening of the valve is very narrow.


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GIFs created with frames from Point-of-Care Echo: Aortic Stenosis vs. Sclerosis


The above images only evaluate the valve in 2D however it is important to note that more experienced practitioners will add doppler, either colour flow or spectral, to examine for regurgitant jets and attempt to measure gradients across the valves. This is not addressed in this article as it is an advanced skill which is prone is error without the appropriate training.

While assessing the heart for AS, it is clinically important to look for MR. As stated before, distinguishing between AS and MR is tricky during a resuscitation but clinically important.4 Features of MR on PoCUS that are pertinent negatives would be left atrial enlargement or a poorly functioning/prolapsing mitral valve. Although a proper diagnosis of MR also requires formal echocardiography, finding an obvious regurgitant jet as seen below could explain that systolic murmur you think you’ve found when auscultating.

PEARL: Differentiating from mitral regurgitation is clinically important and can be aided by PoCUS.

This is an obvious regurgitant jet seen in the parasternal long-axis view. It is worth noting that MR is commonly underestimated in parasternal long view.


GIF created with frames from Point-of-Care Echo: Aortic Stenosis vs. Sclerosis


Therefore, it is ideal to achieve a good apical four-chamber view and evaluate the mitral valve from there. Below is another obvious regurgitant jet seen from the apical four-chamber view


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GIF created with frames from Point-of-Care Echo: Aortic Stenosis vs. Sclerosis , Apical four-chamber graphic from Introduction to transthoracic echocardiography by Philips Ultrasound

Assessment: Investigations

Below are some of the investigations that you should order for work up a person presenting with aortic stenosis and/or cardiogenic shock.

CXR: Boot-shaped heart, pulmonary edema

ECG: LVH, possible STE elevation or depression with concomitant infarct/ischemia

Labs: troponin, BNP, extended electrolytes including magnesium and calcium, blood gas, creatinine, and blood cultures if you suspect sepsis as the culprit of dropping the patient’s preload.

Echocardiogram: Definitive diagnosis is made from a formal cardiac echo.

Angiogram: Many patients presenting in cardiogenic shock will be sent to the cath lab with ACS in mind. Conveniently the left ventriculogram will allow for measurement of LVEDP and aortic valve gradients during the same procedure.

Differential Diagnosis

Once we have identified cardiogenic shock, our differential diagnosis has eliminated the other causes of shock: obstructive, distributive (sometimes subdivided into septic and neurogenic), and hypovolemic. However, there are still numerous etiologies of cardiogenic shock with some important differences in clinical management. Below are the three most important differential diagnoses to consider:

Mitral regurgitation: Severe MR can cause a systolic murmur and cardiogenic shock. Additionally, these patients may tell you that they have “valve problems” on history. Careful physical exam and PoCUS can help differentiate these two but ultimately, they will need a formal echocardiogram.

Acute coronary syndrome: When a patient presents in cardiogenic shock the first thing on everyone’s mind is acute coronary syndrome. Furthermore, patients in cardiogenic shock from severe AS can suffer an acute myocardial infarction secondary to their cardiogenic shock. On initial assessment it can be difficult to determine whether the etiology of their ischemia is atherosclerosis or the decrease in coronary perfusion pressure resulting from severe AS. Therefore, someone with severe AS and normal coronary arteries can still present with increase troponins and ST changes due to myocardial injury.

Hypertrophic cardiomyopathy: Another presentation of LVOT obstruction, this can also present with cardiogenic shock or syncope. Although possible, a systolic murmur is much less common in HOCM. Luckily the demographics of people presenting with HOCM may help eliminate this as they are typically younger than even the younger aortic stenosis patients that present with a bicuspid etiology.

Extended differential diagnosis:

  • Congestive heart failure
  • COPD
  • Pulmonary embolism
  • Supravalvular and subvalvular LVOT pathologies

Treatment: Severe AS with Cardiogenic Shock

Patients with severe AS causing cardiogenic shock are very sick and tricky to manage. Primary goals of resuscitation are:

  • Oxygen: Simple intervention but optimizing O2 in these patients is a great first step. In the state of cardiogenic shock, it is ok to aim for high SPO­­­2 because our concern is oxygen delivery to ischemic end organs and not O2 toxicity. Once resuscitated they can be titrated back to normal SPO­2.
  • Euvolemia: Given that a sudden drop in preload is a common precipitating factor for cardiogenic shock in severe AS, correcting a decreased volume status should improve their shock status. Unfortunately, someone with severe AS is always in danger of heart failure from fluid overload, so the goal should be careful fluid resuscitation with frequent reassessments.3
    • Bolus of fluid with frequent reassessments
  • Normal Sinus Rhythm: Sudden onset of arrythmia can put someone with severe aortic stenosis into cardiogenic shock because the lack of synchronicity between the atria and ventricle deprives the left ventricle of the atrial kick.7
    • Rhythms such as SVT or rapid afib should be corrected aggressively with electrical cardioversion
  • Normotension: People with aortic stenosis do not tolerate hypotension or hypertension very well. Hypertension increases the afterload so peripheral vasoconstrictors should be used sparingly. Unfortunately, soft BPs are also a huge problem because can reduce preload and drop coronary perfusion pressure which can cause the final collapse. The goal is once again, in the middle.
    • Aim for MAP of 65-80
    • In a crashing patient, lifting their legs and administering phenylephrine can be good first steps.
    • Norepinephrine is a good first choice in a case of that doesn’t improve with fluid administration
  • Lower end of normal heart rate: Even those severe AS patients in NS rhythm will do better with lower HRs rather than high rates. This is because the longer the diastolic cycle, the greater the left ventricular preload will be. High HRs with short diastolic periods can have trouble overcoming the increased afterload of AS.3
  • Improving cardiac contractility: Inotropes like dobutamine or milrinone can be added but the above avenues of resuscitation should be explored first.


PEARL: Management of cardiogenic shock from severe AS is challenging and relies on achieving euvolemia, normotension, optimizing oxygenation, and maintaining perfusion with a heart rate on the lower end of normal. Early consultation with cardiology/cardiac surgery is key and arterial and central line insertion should be priorities after initial resuscitation.


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Figure 5 From: EM Crit 327 – Acute Valve Disasters Part 2 – Management of Critical Aortic Stenosis


Definitive treatment of these patients is aortic valve replacement. Some may require mechanical assistance from a device like an intra-aortic balloon pump to bridge them until this procedure can be done. Either way early consultation from cardiology/cardiac surgery and critical care should be prioritized. Once resuscitated, they should have early insertion of arterial and central lines to allow for more accurate and frequent assessment of their hemodynamics.

A full breakdown of treatment and resuscitation for these patients is beyond the scope of this article but can be found at these two excellent resources below:

Treatment: Hemodynamically Stable

Identification of AS as the reason for a person’s syncope, angina, or heart failure in a hemodynamically stable patient can still save their life. Referral to the appropriate service in your system (cardiac surgery or cardiology) is the best thing you can do for these patients.5 People with symptomatic AS have a poor prognosis and should be referred urgently for aortic valve replacement.5 These patients are at risk for sudden cardiac death and their pathology can be missed completely if simple things like auscultation are not done. Prognosis is improved significantly with aortic valve replacement and the increasing prevalence of transcatheter aortic valve implantation (TAVI) is expanding access to valve replacement into older and more complicated patient populations.5 Therefore, identification and referral for further evaluation itself can significantly improve patient care.


PEARL: Identification of symptomatic AS and early referral can be lifesaving whether the patient is in cardiogenic shock or not.



Aortic stenosis is common and can be the primary etiology of a person’s presenting complaint or a complicating factor. Identification of the characteristic murmur in a hemodynamically stable patient who presents after an episode of angina or syncope should prompt an urgent consult to cardiology/cardiac surgery and echocardiogram. Some of these patients will have severe AS and valve replacement will significantly improve their length and quality of life. Patients in cardiogenic shock secondary to severe AS have probably undergone a recent insult that has dropped their preload or caused asynchrony of the cardiac rhythm and can be very tricky to manage. It is clinically important to try to differentiate quickly between AS and MR because patients with MR tolerate tachycardia well while patients with AS do much better with lower heart rates. Resuscitation of patients in cardiogenic shock due to severe AS should target euvolemia, aggressive correction of arrythmias, and normotension.


  1. Atkinson, P., Peach, M., & Lewis, D. (n.d.). Just the facts: The five F S of focused echocardiography in shock – CAEP. Canadian Association of Emergency Physicians. Retrieved September 25, 2022, from
  2. Helman, A. Hedayati, T, Tillmann, B. Cardiogenic Shock. Emergency Medicine Cases. January 2022. Accessed July 7th, 2022
  3. Lebowitz, D. (2017, April 21). Management of the crashing aortic stenosis patient. – Emergency Medicine Education. Retrieved September 25, 2022, from
  4. Messika-Zeitoun, D., & Lloyd, G. (n.d.). Aortic valve stenosis: Evaluation and management of patients with discordant grading. European Society of Cardiology. Retrieved September 25, 2022, from
  5. Pujari, S. H., & Agasthi, P. (n.d.). Aortic stenosis – statpearls – NCBI bookshelf. Retrieved September 25, 2022, from
  6. Pellikka, P.A., Otto, C. M., Yeon, S. B, Natural history, epidemiology, and prognosis of aortic stenosis. In: UpToDate, Shefner JM (Ed), UpToDate, Waltham, MA. (Accessed on September 25, 2022)
  7. White, C. W., Freed, D. H., Zieroth, S. R., & Singal, R. K. (2015). Heart Failure. In Handbook of ICU therapy. essay, Cambridge University Press. Retrieved from Media
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EM Journal Club – The BUCKLED Trial

Presenter: Dr. Casey Jones (RCPSC EM PGY1)
Host: Dr. David Lewis 

Ultrasonography or radiography for suspected pediatric distal forearm fractures

Snelling et al., for the BUCKLED trial group

NEJM, 2023; 388:2049-2057.


  • Research Question: Is ultrasonography non-inferior to X-ray with respect to ..
  • Population: Children and adolescents between 5–15 years old presenting to an ED with an isolated, acute, clinically non-deformed distal forearm injury
  • Intervention: Randomization to either POCUS by a trained ED practitioner or radiography for injury evaluation
  • Comparison: POCUS vs Radiography
  • Outcome: Self-reported physical function of affected arm at 28 days



  • Forearm fractures represent 40-50% of all childhood fractures
  • Distal third of forearm accounts for ~75% forearm fractures and 20-25% of all pediatric fractures
  • Most fractures are buckle fractures, treated conservatively with a wrist splint
  • Other pediatric fracture patterns include greenstick, Monteggia, Galeazzi, and Salter-Harris fractures
  • POCUS for distal forearm fractures is accurate, timely, and confers no radiation.
  • Ultrasonography may be more accessible in low and middle-income countries.
  • Is POCUS just as good as x-ray in diagnosing distal forearm fractures in pediatric patients?



  • Bedside Ultrasound Conducted in Kids with Distal Upper Limb Fractures in the Emergency Department (BUCKLED) trial
  • Study Design: Multi-center, open-label, noninferiority, randomized controlled trial
  • Setting: Four centers in Queensland, Australia (large tertiary pediatric hospital, two large mixed academic hospitals with dedicated pediatric treatment areas within their emergency departments, and one mixed hospital without a dedicated pediatric treatment area)
  • Inclusion criteria
    • Age 5-15
    • Distal forearm injury requiring radiological evaluation
    • Ability to follow up (distance from centre, telephone, internet access)
  • Exclusion criteria – many, but namely:
    • Obvious angulation
    • Injury sustained >48 hr prior to presentation
    • Compound / open fracture, neurovascular compromise, known bone disease
    • Suspicion of non-accidental injury, additional injuries
  • Imaging modalities
    • X-Ray – minimum 2 views performed by radiography. Classified by treating clinician (not radiologist) into either: no fracture, buckle fracture, other fracture
    • POCUS – 6-view forearm POCUS protocol with assessment of secondary signs (Snelling et al., 2020, BMJ)


  • POCUS credentialling
    • Scans in the study were done by either: nurse practitioner, physiotherapist, or emergency physician
    • Training course – 2 hour simulated course with lectures and staged learning (scanning)
    • 3 proctored scans on actual patients
    • Logbook of total 20 patients with a mix of at least 10 buckle and cortical breach fractures, then image interpretation quiz
  • Outcome measures:

  • Statistical analysis

    • Assumed true between-group difference in PROMIS score of 0 at 4 weeks, with noninferiority margin of 5 points (chosen by experts from trial group)
    • Power: 300 participant enrollment  outcome data for 224 participants (112 per group)  90% power with one-sided alpha of 0.025
    • Primary outcome of PROMIS score at 4 weeks was analyzed for noninferiority of ultrasonography to radiography
    • Primary analysis was with linear regression modeling to assess noninferiority of POCUS to radiography


  • Participant characteristics (Table 1)
    • Well randomized groups for ultrasound and radiography (n=135 each group)
  • Primary outcome:
    • PROMIS (physical function score) at four weeks showed no difference between ultrasonography and radiography

  • Secondary outcomes:
    • No difference in physical function scores at week 1 or 8 between POCUS/X-ray
    • Parent / caregiver-reported satisfaction (5-point likert scale) appeared to be greater in POCUS group vs X-ray at 4 weeks (0.19 points) and 8 weeks (0.20 points)
    • Patients in POCUS group had shorter length of stay in the ED (median difference: 15 minutes), and shorter treatment time (median difference: 28 minutes) versus X-ray group
    • No substantial difference between groups in number of follow-up radiography films obtained up to week 8


Authors Discussion and Conclusions

  • The authors show that point-of-care ultrasound can be used as an initial diagnostic test in distal forearm injury in pediatric patients, with XR reserved for features suggestive of a diagnosis that leads to casting and follow-up (i.e. POCUS best suited for diagnosing buckle fractures)
  • Reduced initial radiography at initial ED presentation, especially in patients with buckle fracture or no fracture.
  • A diverse group of health care practitioners (physicians, nurse practitioners, physiotherapists) were trained to use ultrasound for this purpose
  • “The present randomized trial examined the feasibility, safety, acceptability, and timeliness of using an ultrasonography-first approach to the diagnosis of clinically non-angulated distal forearm injury in children and adolescents who presented to the emergency department.”

Discussion at journal club


  • Well powered trial to study their question of non-inferiority of POCUS to XR
  • Feasible approach to imaging distal radius, and transferrable to many health professions
  • Showed that simple fractures can be initially imaged with POCUS only


  • Children with features of a more concerning fracture (i.e. anything more than a buckle) received x-ray anyway (122 films were obtained in POCUS group vs 375 in XR group)
    • To that end, does this study show that POCUS may only be appropriate for simple fractures?

Bottom Line

This was a well-designed and executed study by this group in Australia. This method of diagnosing distal forearm injuries would be helpful in rural or resource-limited settings that don’t have readily accessible X-ray. I will certainly be using this more at the bedside in children with this injury pattern!

Further Reading

Quick Take NEJM Video

View the author’s webinar here


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EMSJ – Transesophageal Echo (TEE) Protocol

Please refer to our TEE introduction and video guides in the resources at the bottom of this page

EMSJ MD Protocol

Download (PDF, 2.16MB)

Information for Nursing and Respiratory Therapy

Download (PDF, 741KB)


  • Please ensure the probe is sent for sterilization at the end of the procedure
  • Please ensure it is returned to the Walmart HEPA cupboard when it returns (usually takes 1 hr)
  • Please save the clips to Path and ensure it is coded as a TEE – for our database


  • Resuscitative TEE requires 2 MDs. One to run the code, the other to exchange the EMS airway for an ETT and perform the TEE
  • The TEE probe only works with the XPORTE
  • Attach TEE probe and place the XPORTE at the head of the bed before the patient arrives
  • Exchange Intubate the patient during first pulse check, immediately followed by passing the TEE
  • Laryngoscopy can assist with directing TEE posterior to ETT, but the blade will need to be removed prior to advancing into esophagus (it gets in the way)
  • Stand at the head of the bed to control the probe.
  • Advance probe until the first view is obtained (ME4C)
  • Follow protocol
  • Defibrillation can be done with probe in situ
  • Communicate findings with the team


Introduction to TEE Guide

Introduction to Transesophageal Echo – Basic Technique

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PoCUS For Maxillary Sinusitis

PoCUS Clinical Pearl by Dr. Chew Kiat Yeoh



DalEM PoCUS Fellow

Reviewed by: Dr. David Lewis





  • Acute rhinosinusitis is an inflammatory disease of nasal mucosa and paranasal sinuses. It is one of the most common ED presentations and fifth most common diagnosis for which antibiotics are prescribed (1).
  • It affects more than 30 million adult each year (2).
  • Accurate diagnosis of acute maxillary sinusitis based on clinical examination is unreliable (3) because the signs/symptoms are nonspecific.
  • Although radiographic imaging improves diagnostic accuracy, it is not recommended in uncomplicated sinusitis (4) due to radiation risk, additional costs, and time.


How accurate is PoCUS in identifying maxillary sinusitis?

  • Gold standard for diagnosing maxillary sinusitis is positive fluid culture obtained from sinus puncture (5). However, this method is invasive, unnecessary, and often not easily accepted by patient.
  • Ultrasound has been used to diagnose acute maxillary sinusitis as it is rapid, safe, and non-invasive.
  • Ultrasound is very sensitive in identifying fluid in sinus cavities, with accuracies more than 90% for the diagnosis of maxillary sinusitis have been reported in otolaryngology (ENT) practices.
  • While the result from ENT practices might not be applicable to the ED setting due to different patient demographic and severity of disease. When PoCUS performed by Emergency Physician compared to CT in ED patients with suspected maxillary sinusitis, the sensitivity and specificity are 81% and 89%, respectively, for diagnosis of maxillary sinusitis (7). The agreement between the two methods was 86%.
  • Study using MRI as gold standard, ultrasound was found to have 64% sensitivity and 95% specificity, compared to 73% sensitivity and 100% specificity for plain XR (6).
  • Overall – ultrasound is sensitive in detecting fluid in sinus cavities and highly accurate (>90%) in diagnosing maxillary sinusitis.


Scanning Technique

  • Position: sitting upright or lean slight forward to ensure sinus fluid if present, would layer out against the anterior wall.
  • Probe: High frequency (4 to 12 MHz) linear array transducer with adequate depth penetration (5-7cm) to visualize the entire sinus cavity Or phased-array probe if depth required.
  • Scan the maxillary sinus in between lateral nose and zygoma in at least two planes: transverse & sagittal (Figure 1).
  • Always scan the contralateral normal side is for comparison.

Ultrasound Features

Normal Ultrasound Appearance of Maxillary Sinus



The Ultrasound Appearance of Maxillary Sinusitis

  • If the sinus cavity is fluid filled (complete or partial), the ultrasound signal will be able to penetrate through the thin hyperechoic anterior wall, and the surrounding walls (posterior, medial, lateral) of the sinus will be visualized and seen as a bright echogenic line.
  • Positive Ultrasound finding : Presence of posterior wall echo >3.5 cm from the initial echo (3) (anterior maxillary wall)


Partially Filled: Partial Sinusogram


Completely Filled: Complete Sinusogram



The significance of the Pathology and how can PoCUS add value?

  • More than 1 in 5 antibiotics prescribed in adults are for sinusitis. It is the fifth most common diagnosis which antibiotics is prescribed.
  • Rhinosinusitis is a common disorder, however, only 50% of patients presenting to the acute care setting with sinus symptoms have acute bacterial sinusitis.
  • Although, ultrasound is not accurate as CT and MRI, it is a more practical adjunct bedside tool that can be rapidly, safely and routinely used to assess those with sinus symptoms and for diagnosing uncomplicated sinusitis in acute care settings and could potentially reduce unnecessary over prescription of antibiotic use.


Pearls and Pitfalls

  • Ultrasound is not helpful in differentiating between a viral and or bacterial sinusitis.
  • Positive sinusogram can also be caused by significant mucosal thickening, polyps, fluid-filled cysts, masses and blood from facial trauma or sinus fractures. All these can be mistaken for acute sinusitis.
  • Technical failure includes inadequate depth setting to properly visualize the posterior wall and improper position(supine).



  1. Summary E. Otolaryngology – Head and Neck Surgery Antimicrobial treatment guidelines for acute bacterial rhinosinusitis. 2004;130(January):1-45. doi:10.1016/j.otohns.2003.12.003
  2. Rosenfeld RM, Andes D, Bhattacharyya N, et al. Clinical practice guideline : Adult sinusitis. Published online 2007:1-31. doi:10.1016/j.otohns.2007.06.726
  3. Varonen H, Mäkelä M, Savolainen S, Läärä E, Hilden J. Comparison of ultrasound , radiography , and clinical examination in the diagnosis of acute maxillary sinusitis : a systematic review. 2000;53:940-948.
  4. Aring ANNM, Chan MM. Acute Rhinosinusitis in Adults. Published online 2011:1057-1063.
  5. Carolina S, Sur- N, Hospital HF, Cen- HM, Carolina S. Maxillary sinus puncture and culture in the diagnosis of acute rhinosinusitis : The case for pursuing alternative culture methods. Published online 2000:7-12. doi:10.1067/mhn.2002.124847
  6. Puhakka T, Heikkinen T, Makela MJ, et al. Validity of Ultrasonography in Diagnosis of Acute Maxillary Sinusitis. Arch Otolaryngol Head Neck Surg 126(12):1482–1486, 2000.
  7. Price D, Park R, Frazee B, et al. Emergency department ultrasound for the diagnosis of maxillary sinus fluid. Acad Emerg Med. 2006;13(3):363-4


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PoCUS Guided Nerve Blocks in EM

Recommended resources  for PoCUS Guided Nerve Blocks in EM

This page is under maintenance – future updates will include a ‘Plan A‘ list of blocks with associated guides.

EMSJ Resources

Collection of our nerve block guidelines, clinical pearls and rounds

Fascia Iliaca Block

Serratus Anterior Plane Block

Dental Block

Regional Anesthesia of the Hand

Other Resources

Local Anesthetic Dose


Overview of Common Nerve Blocks in the ED

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Unvexing the VExUS Score – An Overview

Unvexing the VExUS Score – An Overview


PoCUS Clinical Pearl

Dr Steven Chen

DalEM PoCUS Elective

PGY2 Internal Medicine, University of Toronto

Reviewed: Dr David Lewis

Copyedited: Dr David Lewis


The pursuit of a rapid and objective measure of volume status has always been a vexing problem for clinicians as proper fluid management is pivotal for patient outcomes. In recent years, there has been increased attention towards the concept of “fluid-responsive” as liberal fluid boluses can often be associated with poor outcomes as a result of systemic congestion. 1

In the POCUS community, while Inferior Vena Cava (IVC) measurements have promise in assessing central venous pressure, the subsequent translation towards “volume responsiveness” has been met with many other limitations. For one, it did not account for venous congestion at other organ levels such as the pulmonary, renal, or hepatic systems. 2,3

Venous excess ultrasound (VExUS) is a growing bedside ultrasound-based approach that aims to provide a more comprehensive assessment of venous congestion. This was initially described by Beaubien-Souligny et al. (2020) from a post-hoc analysis correlating ultrasound grading parameters with risk in development of AKI in cardiac surgery patients.4 The protocol serves to assess multiple sites of venous congestion, including the IVC, hepatic veins, portal veins and intrarenal veins. By assessing congestion in these multiple sites, the VExUS score has gained attraction in providing a more comprehensive assessment of systemic congestion. 4,5

View Acquisition:

The VExUS protocol is composed of four main components outlined below:

  • IVC diameter
  • Hepatic Vein Doppler Assessment
  • Hepatic Portal Vein Doppler Assessment
  • Intrarenal Vein Doppler Assessment

This can be performed using either the curvilinear probe (preferred) or the phased array probe. The patient should be positioned flat and supine on the bed to acquire the views. The table below depicts some suggested views where larger regions of the veins may be accessible for pulse wave doppler gating in reference to standardized sonography protocols. 6,7

Note: Reviewing the basics of pulse wave doppler will be needed prior to completing VExUS scans (not covered in this article).







Interpretation of the VExUS grading system is well summarized in diagram below (sourced from POCUS1018) and takes some practice to differentiate normal from abnormal waveforms. Pulse wave doppler assessment is pursued only if the inferior vena cava is found plethoric, defined as greater or equal to 2cm. 4,5

Each of the hepatic, portal and renal veins are subsequently examined and classified as normal, mildly congested, or severely congested. The VExUS system has four grades: Grade 0 represents no congestion in any organ, Grade 1 represents only mild congestive findings, Grade 2 represents severe congestive findings in only one organ, and Grade 3 represents severe congestive findings in at least two out of three organ systems. 4,5

Source: POCUS1018

Some sample waveforms are shown below with comments to help with distinguishing normal from abnormal waveforms.



VExUS has also been shown to be reliable and reproducible, with good interobserver agreement in trained individuals and correlation with other measures of volume status such as central venous pressure.4,5 As the technique is growing in the POCUS literature, below is a table summarizing several recent studies exploring its application across numerous settings.

Study Purpose Results
Beaubien-Souligny W, et al. (2020)4


Post-hoc analysis of a single centre prospective study in 145 patients




Initial model of VExUS grading system looking at association in development of AKI in cardiac surgery population Association with subsequent AKI:


HR: 3.69 CI 1.65–8.24 p = 0.001;

+LR: 6.37 CI 2.19–18.50 when detected at ICU admission, which outperformed central venous pressure measurements


Bhardwaj V, et al. (2020)9


Prospective cohort study of 30 patients in ICU setting


Prospective study on application of VExUS scoring on staging of AKI in patients with cardiorenal syndrome Resolution of AKI injury significantly correlated with improvement in VExUS grade (p 0.003).


There was significant association between changes in VExUS grade and fluid balance (p value 0.006).

Varudo R, et al. (2022)10


Case report of ICU patient with hyponatremia

Application of VExUS in case report as rapid tool to help with volume status assessment in patient with complex hyponatremia Overall VExUS grade 2, prompting strategy for diuresis with improvement
Rolston D, et al. (2022)11


Observational study of 150 septic patients in single centre

VExUS score performed on ED septic patients prior to receiving fluids with chart review done to determine if there is association with poorer outcomes Composite outcome (mortality, ICU admission or rapid response activation):


VExUS score of 0: 31.6% of patients

VExUS score of 1: 47.6% of patients

VExUS score >1: 67.7% of patients

(p: 0.0015)

Guinot, PG, et al. (2022)12

Prospective observational study of 81 ICU patients started on loop diuretic therapy

Evaluation of multiple scores to predict appropriate diuretic-induced fluid depletion (portal pulsatility index, renal venous impedance index, VExUS) Baseline portal pulsatility index and renal venous impedance index were found to be superior predictors compared to VExUS.


The baseline VExUS score (AUC of 0.66 CI95% 0.53–0.79, p = 0.012) was poorly predictive of appropriate response to diuretic-induced fluid depletion.

Menéndez‐Suso JJ, et al. (2023)13


Cross-sectional pilot study of 33 children in pediatric ICU setting

Association of VExUS score with CVP in pediatric ICU VExUS score severity was strongly associated with CVP (p<0.001) in critically ill children.
Longino A, et al. (2023)14


Prospective validation study in 56 critically ill patients

Validation looking at association of VExUS grade with right atrial pressure. VExUS had a favorable AUC for prediction of a RAP ≥ 12 mmHg (0.99, 95% CI 0.96-1) compared to IVC

diameter (0.79, 95% CI 0.65–0.92).


It should be kept in mind that numerous factors may affect interpretation of VExUS gradings.

For the IVC component, increased intra-abdominal pressure can affect measurements independently of the pressure in the right atrium or may be affected by chronic pulmonary hypertension. The hepatic vein may not show significant changes even in severe tricuspid regurgitation if the right atrium can still expand and contract normally. In thin healthy people and those with arteriovenous malformations, the portal vein can have a pulsatile flow without venous congestion. It is also important to note that for patients with underlying disease renal or liver parenchymal disease, venous doppler recordings may be less reliable. 3-5

Outside of physiologic factors, another limitation is the need for adequate training and familiarity in performing and interpreting the technique. While VExUS is fairly well protocolized, it requires proficiency with pulse wave doppler to perform accurately. As with any new technique, there is a risk of variability in technique and interpretation. To avoid misinterpretation, it is important to consider repeat tracings to ensure consistency of results and to consider findings within the overall clinical context of the patient.

Bottom line:

VExUS is a non-invasive ultrasound method for assessing venous congestion across multiple organ systems. While there are several physiologic limitations and results need to be used in adjunct with the clinical picture, studies have shown promise for VExUS to be incorporated as part of a physician’s toolkit to help with clinical decision making. 3-5


  1. Atkinson P, Bowra J, Milne J, Lewis D, Lambert M, Jarman B, Noble VE, Lamprecht H, Harris T, Connolly J, Kessler R. 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. Canadian Journal of Emergency Medicine. 2017 Nov;19(6):459-70.
  2. Corl KA, George NR, Romanoff J, Levinson AT, Chheng DB, Merchant RC, Levy MM, Napoli AM. Inferior vena cava collapsibility detects fluid responsiveness among spontaneously breathing critically-ill patients. Journal of critical care. 2017 Oct 1;41:130-7.
  3. Koratala A, Reisinger N. Venous excess doppler ultrasound for the nephrologist: Pearls and pitfalls. Kidney Medicine. 2022 May 19:100482.
  4. Beaubien-Souligny W, Rola P, Haycock K, Bouchard J, Lamarche Y, Spiegel R, Denault AY. Quantifying systemic congestion with point-of-care ultrasound: development of the venous excess ultrasound grading system. The Ultrasound Journal. 2020 Dec;12:1-2.
  5. Rola P, Miralles-Aguiar F, Argaiz E, Beaubien-Souligny W, Haycock K, Karimov T, Dinh VA, Spiegel R. Clinical applications of the venous excess ultrasound (VExUS) score: conceptual review and case series. The Ultrasound Journal. 2021 Dec;13(1):1-0.
  6. Mattoon JS, Berry CR, Nyland TG. Abdominal ultrasound scanning techniques. Small Animal Diagnostic Ultrasound-E-Book. 2014 Dec 2;94(6):93-112.
  7. Standardized method of abdominal ultrasound [Internet]. Japanese society of sonographers. [cited 2023Apr12]. Available from:
  8. Dinh V. POCUS101 Vexus ultrasound score–fluid overload and venous congestion assessment.
  9. Bhardwaj V, Vikneswaran G, Rola P, Raju S, Bhat RS, Jayakumar A, Alva A. Combination of inferior vena cava diameter, hepatic venous flow, and portal vein pulsatility index: venous excess ultrasound score (VExUS score) in predicting acute kidney injury in patients with cardiorenal syndrome: a prospective cohort study. Indian journal of critical care medicine: peer-reviewed, official publication of Indian Society of Critical Care Medicine. 2020 Sep;24(9):783.
  10. Varudo R, Pimenta I, Blanco JB, Gonzalez FA. Use of Venous Excess UltraSound (VExUS) score in hyponatraemia management in critically ill patient. BMJ Case Reports CP. 2022 Feb 1;15(2):e246995.
  11. Rolston D, Li T, Huang H, Johnson A, van Loveren K, Kearney E, Pettit D, Haverty J, Nelson M, Cohen A. 204 A Higher Initial VExUS Score Is Associated With Inferior Outcomes in Septic Emergency Department Patients. Annals of Emergency Medicine. 2021 Oct 1;78(4):S82.
  12. Guinot PG, Bahr PA, Andrei S, Popescu BA, Caruso V, Mertes PM, Berthoud V, Nguyen M, Bouhemad B. Doppler study of portal vein and renal venous velocity predict the appropriate fluid response to diuretic in ICU: a prospective observational echocardiographic evaluation. Critical Care. 2022 Dec;26(1):1-1.
  13. Menéndez‐Suso JJ, Rodríguez‐Álvarez D, Sánchez‐Martín M. Feasibility and Utility of the Venous Excess Ultrasound Score to Detect and Grade Central Venous Pressure Elevation in Critically Ill Children. Journal of Ultrasound in Medicine. 2023 Jan;42(1):211-20.
  14. Longino A, Martin K, Leyba K, Siegel G, Gill E, Douglas I, Burke J. Prospective Validation of the Venous Excess Ultrasound “(VExUS)” Score.

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Why are ER wait times so bad in Canadian cities?

In this new Globe and Mail Podcast, we hear from Dr. Paul Atkinson and others who continue to provide their insights into the issues relating to increased Emergency Department wait times and expand on the widely read article “Saving Emergency Medicine: Is less more?”

You can listen to this podcast here:

Further reading and podcasts relating to Saving Emergency Medicine can be accessed here:

Saving EM


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Nursemaid’s Elbow

Nursemaid’s Elbow

Medical Student Pearl


Erika Maxwell


Memorial University Class of 2023

Reviewed by: Dr. David Lewis


A 10-month-old female is brought into the Emergency Department by her mother with a left arm injury. The infant had a fall from standing and the mother reached out to grab her and caught her left forearm. After the incident, the patient’s mother noticed that the infant was no longer using the arm. The child has no medical history and is not taking any medications. She is vitally stable.

On exam, the child’s left arm is limp and extended at her side. She is using her right arm and hand exclusively, including to grasp for items on the left side of her body (pseudoparalysis). There is no deformity, erythema, edema, or ecchymosis. The arm and hand are neurovascularly intact (strong brachial pulse, pink and warm).

Differential Diagnosis

  • Nursemaid’s elbow/pulled elbow/radial head subluxation
  • Elbow fracture
  • Wrist fracture or soft tissue injury
  • Shoulder dislocation


A pulled elbow occurs most frequently in young children with the median age for presentation being 2 years [1]. The reason for this is debated in the literature with some sources saying that the annular ligament is weaker in children [2] and others saying that the radial head is smaller [1], both resulting in a less stable joint.

The most common mechanism of injury is axial traction (i.e. pulling on the arm or hand), but falls or rough play may also be responsible [2].

Anatomical Context

The annular ligament holds the radial head in place next to the ulna. When axial traction is applied by pulling the forearm or hand, the radial head may move underneath the annular ligament and trap it in the radiohumeral joint, against the capitellum [1].

Figure 1: The arm on the left displays a normal elbow, whereas on the right the radius is subluxated and trapping the annular ligament against the capitellum [3].

Signs and Symptoms [3]

  • Pain at elbow
  • Pseudoparalysis of injured arm
  • Extension or light flexion of injured arm, often pronated

Diagnosis and Management

A full examination of the upper limb is required. Leave obviously swollen or deformed areas until the end. Palpate the clavicle, humerus, forearm and gently move the joints (shoulder, wrist, and lastly elbow). Pulled elbows rarely result in joint swelling. If this is present an alternative diagnosis should be considered (e.g., supracondylar fracture).

If a pulled elbow is the only likely diagnosis, then it may be reasonable to proceed to a subluxated radial head reduction manoeuvre. However, when the history is not clear (e.g., unwitnessed mechanism involving siblings or a fall), then it is much safer to perform further diagnostic tests prior to manipulation. These include radiograph of the elbow to rule out fracture or elbow ultrasound to rule out joint effusion [4].

Reduction Technique

 This is done by supporting the elbow with one hand and using your other hand to move the patient’s arm through the recommended maneuvers. There are 2 different maneuvers to try, and they may be used alone or in combination [1-3,5].

  • Supinate the child’s forearm with your hand and flex the elbow


Figure 2: Demonstration of the supination/flexion maneuver [5]

  • Hyperpronate the child’s forearm

Figure 3: Demonstration of the hyperpronation maneuver [5]

Some research has indicated that the hyperpronation maneuver may be more effective and less painful for the patient [2,6], so it may be worth attempting this maneuver first.

If the maneuvers are successful, you may hear a click from the radial head as it moves back into place. The child may briefly cry as the subluxation is reduced. Movement recovery can take anywhere from a few minutes to several hours, but usually occurs within 30 minutes. The greater the delay from injury to presentation and subsequent reduction, the longer it will take for post reduction return to normal movement [2].

If a click is heard or felt during the manoeuvre it can usually be assumed that reduction has occurred. Ideally, it is recommended that the child remain under observation until normal movement returns. However, if delayed, it is reasonable to discharge the child with advice to return.

In any case where an x-ray or ultrasound has not been performed and the child does not rapidly start using their arm post manoeuvre, then imaging is required prior to any further manipulation.


Although a pulled elbow does not result in a permanent injury, it is important to inform the family that their child will be vulnerable to recurrent pulled elbows in the affected arm. Up to 27% of patients with a pulled elbow may experience a recurrence [7-8].

Case continued:

Based on the patient’s history and physical exam, she was diagnosed with a pulled elbow. Using the supination and flexion maneuver followed by the hyperpronation maneuver, an audible click was elicited from the patient’s elbow. Shortly thereafter, she began using the arm again as if no injury had occurred and was discharged home.

Key points:


  1. A pulled elbow is a common upper limb injury in young children presenting to the Emergency Department
  2. Careful assessment may preclude the need for diagnostic imaging however if in any doubt further investigation should be performed prior to manipulation. Many physicians will never forget the time they used a pulled elbow reduction technique in a child with an unexpected supracondylar fracture
  4. Recurrence is common


  1. Aylor, M., Anderson, J., Vanderford, P., Halsey, M., Lai, S., & Braner, D. A. (2014). Reduction of pulled elbow. New England Journal of Medicine, 371(21), e32.
  2. Wolfram, W., Boss, D., & Panetta, M. (2018, December 18). Nursemaid Elbow. Medscape. Retrieved September 6, 2022, from
  3. Boston Children’s Hospital. (2021). Nursemaid’s elbow. Retrieved September 6, 2022, from
  4. Varga, M., Papp, S., Kassai, T., Bodzay, T., Gáti, N., & Pintér, S. (2021). Two- plane point of care ultrasonography helps in the differential diagnosis of pulled elbow. Injury, 52(1), S21-24.
  5. Kilgore, K., & Henry, K. (2021). Nursemaid’s elbow. Society for Academic Emergency Medicine – Clerkship Directors in Emergency Medicine. Retrieved September 6, 2022, from
  6. Lewis, D., Argall, J., & Mackway-Jones, K. (2003). Reduction of pulled elbows. Emergency Medicine Journal, 20, 61-62.
  7. Schunk, J. F. (1990). Radial head subluxation: epidemiology and treatment of 87 episodes. Annals of emergency medicine, 19(9), 1019-1023.
  8. Teach, S. J., & Schutzman, S. A. (1996). Prospective study of recurrent radial head subluxation. Archives of pediatrics & adolescent medicine, 150(2), 164-166.
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