Background: Traditional water baths for ultrasound exams place a hand into a pan of water and submerge an ultrasound probe into the water. While this improves ultrasound transmission and moves structures into the focal zone to make higher resolution images, this method does have limitations. Patients must be manipulated directly under the probe, which can be limited by pain or normal movement restrictions. The probe must also be held very still in water to minimize motion artifact. The lateral approach water bath method addresses such limitations by imaging through the side of a thin -walled plastic container without submerging the probe. This reduces much need for patient manipulation by imaging through the side of a column-shaped bath, which has 360 degrees of imaging freedom. It also stabilizes the probe directly against the flat, firm container to reduce image degrading motion artifact. We hypothesized that because of these improvements the lateral approach water bath might create higher quality images than traditional water baths. Methods: We compared twenty images from each method, which were obtained with the same model and ultrasound operator at the same time. Two ultrasound fellowship trained blinded reviewers rated the images for quality and adequacy for clinical decision making on a scale from 1 to 5. Results: Image quality was better for the lateral water bath, with an average rating of 4.2 compared to the traditional bath's 2.6 (p < 0.001). Adequacy to aid clinical decision making was better for the lateral approach bath with an average rating of 4.0 compared to the traditional bath's 2.6 (p < 0.001). The lateral bath also had a smaller range for image quality and thus greater consistency. Conclusions: The lateral approach water bath is a method of hand imaging that produces higher quality, more consistent, and more clinically useful images than traditional water bath imaging. (c) 2023 Published by Elsevier Inc.

BlockchainBlockchain is a distributed ledgerDistributed ledger where “write once, never erase” is the mantra for this digitalDigital recordRecord keeping. Physician and practitioner credentialingCredentialing is the arduous, often repetitive processProcess of verifying medical schoolSchool diplomas, residency completion, and successful board certificationCertification and continued educationEducation. From medical board licensing to obtaining hospitalHospital privileges, the processProcess is time-consuming, expensiveExpensive and frequently requires an unseemly amount of blind trustTrust regarding performancePerformance competencyCompetency. This processProcess has grown as non-physician providersProvider expanded scope of practicePractice and telemedicineTelemedicine lawsLaw loosened. Point-of-carePoint-of-Care ultrasoundUltrasound is an example of a procedural skill that can be learned and practiced in medicineMedicine. To practicePractice it well is an essential physician and practitioner skill that has historically demonstrated significant variation between operators with varied experiences from medical schoolSchool, residency, and hospitalHospital use. Block chainChain technologyTechnology offers a solution by providing a natural ledgerLedger for standardized reportingReporting of these various documents of competencyCompetency but also a recordRecord of the quality of proceduresProcedure performed, including ultrasoundUltrasound. It also provides a direct means for universal distribution of credentialingCredentialing for each providerProvider by simplifying the processProcess, making it more efficient with a new level of integrityIntegrity.

Aims: At the Ohio State University College of Medicine, medical students have the option to train in ultrasound and take part in global electives where they can utilize clinical ultrasound. This presents the opportunity for medical students to engage in bidirectional sharing of medical and ultrasound knowledge in geographic regions with limited resources. We developed Bringing Ultrasound Internationally for Long-term development (BUILD), a longitudinal course, to provide standardized ultrasound education to students planning to enroll in global health electives. Material and methods: This was a pilot study of the BUILD curriculum. Third-year medical students planning to complete a global health elective were invited to participate. Enrolled students completed an online curriculum, hands-on scanning, and pathology sessions, which augmented the pre-departure Global Health course work. Students received two resource assessments: one to be completed by the student, and one to be completed by the on-site preceptor. Main outcomes measured were number of enrolled students, primary indications for imaging, and number of scans per-day. Results: In total, 152 students participated in the study and traveled to 22 different global sites in Low-Income Countries (LIC's). All enrolled students completed the curriculum. Between 3 and 25 scans were performed per day and the leading indication for ultrasound imaging was obstetric and abdominal pain evaluation. Conclusions: The BUILD curriculum is a feasible construct to prepare students for using ultrasound during global electives. Students successfully performed proctored scans in a variety of settings. This format can be adopted by other institutions to further support student and global ultrasound programs.

OBJECTIVES Medieval yoga texts claim that a special exercise of the muscles of the anterior abdominal wall, called agnisara, improves digestive function. Main objective of the study was to demonstrate change in the blood flow through superior mesenteric artery (if any) after performance of agnisara. METHODS Ultrasound examination of the linear and volumetric indicators of blood flow in the superior mesenteric artery (SMA) before and after performing the agnisara yoga exercise 100 times was carried out in 12 healthy volunteers of both sexes (8 of them women). RESULTS A significant increase in the diameter of the SMA, peak systolic and diastolic velocities, and blood flow in the superior mesenteric artery after performing the agnisara exercise 100 times was found, which contrasts with the established data on a decrease in splanchnic blood flow in humans in response to normal physical activity. CONCLUSION Properly performed agnisara increases blood flow to the splanchnic region, registered by the SMA, which should contribute to adequate blood supply to the gastrointestinal tract for successful performance of digestive function.

Ultrasound imaging provides unique opportunities to study the physiology and pathology of the musculoskeletal (MSK) system. This chapter begins by describing the molecular and histological features that give bones, muscles, tendons, and ligaments their characteristic appearance, or echotexture, in ultrasound imaging. Examples of changes in normal echotexture that indicate pathology are then given. Next, dynamic imaging of structures of the MSK system is described as the capability to observe a body part as it is moved actively by the patient, or passively by the person performing the imaging. The chapter concludes with four laboratory exercises that are examples of how ultrasound imaging can be used to enhance the understanding of concepts underlying the normal physiology of the MSK system: (1) visualization and measurement of the pennation angle in a muscle before and after contraction; (2) demonstration of increased blood perfusion in a muscle after exercise; (3) operation of the calf venous pump, and (4) demonstration of differences in flow patterns in arteries before and after exercise.

Objectives: The purpose of this study is to provide expert consensus recommendations to establish a global ultrasound curriculum for undergraduate medical students. Methods: 64 multi-disciplinary ultrasound experts from 16 countries, 50 multi-disciplinary ultrasound consultants, and 21 medical students and residents contributed to these recommendations. A modified Delphi consensus method was used that included a systematic literature search, evaluation of the quality of literature by the GRADE system, and the RAND appropriateness method for panel judgment and consensus decisions. The process included four in-person international discussion sessions and two rounds of online voting. Results: A total of 332 consensus conference statements in four curricular domains were considered: (1) curricular scope (4 statements), (2) curricular rationale (10 statements), (3) curricular characteristics (14 statements), and (4) curricular content (304 statements). Of these 332 statements, 145 were recommended, 126 were strongly recommended, and 61 were not recommended. Important aspects of an undergraduate ultrasound curriculum identified include curricular integration across the basic and clinical sciences and a competency and entrustable professional activity-based model. The curriculum should form the foundation of a life-long continuum of ultrasound education that prepares students for advanced training and patient care. In addition, the curriculum should complement and support the medical school curriculum as a whole with enhanced understanding of anatomy, physiology, pathophysiological processes and clinical practice without displacing other important undergraduate learning. The content of the curriculum should be appropriate for the medical student level of training, evidence and expert opinion based, and include ongoing collaborative research and development to ensure optimum educational value and patient care. Conclusions: The international consensus conference has provided the first comprehensive document of recommendations for a basic ultrasound curriculum. The document reflects the opinion of a diverse and representative group of international expert ultrasound practitioners, educators, and learners. These recommendations can standardize undergraduate medical student ultrasound education while serving as a basis for additional research in medical education and the application of ultrasound in clinical practice.

A 20-year-old female presented to the emergency department (ED) with a sore throat and progressive discoloration to her uvula that were first noticed 2 days ago. Three days prior, she underwent uncomplicated endoscopic sinus surgery for chronic rhinosinusitis. Intubation was performed by direct laryngoscopy using a Macintosh 4 blade and a size 7.0 cuffed endotracheal tube, requiring a single attempt, followed by an uneventful extubation. The patient was intubated a total duration of 127 minutes. On ED presentation her vital signs were within normal limits. Oropharyngeal examination revealed a demarcated white coating to the inferior third of the uvula (Figure 1). Uvular necrosis is an uncommon adverse event resulting from impingement by airway devices or vigorous suctioning during surgical procedures.1, 2 Patients may experience sore throat, foreign body sensation, coughing, and, in severe cases, infection or airway obstruction.3, 4 Uvular necrosis is a clinical diagnosis, often made with direct observation of an elongated, inflamed uvula with white exudates at the necrotic tip.5 Treatment course is usually conservative with antibiotics, corticosteroids, topical anesthetics, and nebulized epinephrine with sloughing of the necrotic tissue within 2 weeks.3 Rarely, severe cases require excision of the necrotic tissue.6 Ear, nose, and throat (ENT) surgeons were consulted and recommended conservative management with a 7-day course of amoxicillin-clavulanic acid and nystatin mouthwash. No uvular lesions were noted at ENT follow-up 9 days later, and the patient reported resolution of throat discomfort.

A 21-year-old man presented to the ED via ambulance for unresponsiveness. The patient’s girlfriend had called emergency medical services to the patient’s home after finding him unconscious. On arrival of emergency medical services, the patient was found to be cyanotic with miosis. Initial peripheral capillary oxygen saturation was 78%. He was placed on 10 L/min of oxygen by nasal cannula and given 1 mg of naloxone intravenously. Emergency medical services reported improvement in mental status with these combined interventions; however, bright red hemoptysis had developed in route. In the ED, further history revealed that the patient had a history of using a vaporizer with a frequency of 1 pod per day. He admitted to inhaled marijuana earlier that day as well but denied using THC-containing vaping products for more than a month. He was asymptomatic the day before symptom onset. On physical examination, the patient was afebrile (36.8 ° C ) with a heart rate of 117 beats per minute and a BP of 134/57 mm Hg. He was tachypneic with 28 respirations per minute with increased work of breathing. Lung auscultation revealed coarse breath sounds without overt wheezing. Although the patient initially denied cough, he continued to have hemoptysis in the ED. Initial laboratory values were notable for leukocytosis, elevated lactate, and normal hemoglobin, prothrombin time, and international normalized ratio. Despite a nasal cannula and nonrebreather set to 15 L/min of oxygen, the patient remained hypoxic at 91% with increased work of breathing. He was transitioned to heated high-flow nasal cannula with improvement of his oxygen saturation to 98% but continued to exhibit increased work of breathing. Given the patient's worsening respiratory status despite noninvasive interventions, the decision was made, in conjunction with the pulmonology service, to intubate the patient with a plan to perform emergent bronchoscopy. A focused cardiac and lung ultrasound scan were performed at the bedside. The cardiac ultrasound scan was unremarkable, which included a normal ejection fraction. The lung protocol included bilateral anterior and posterolateral zones of the lung. Lung ultrasound images were obtained (Video 1). What is the differential diagnosis for this patient based on clinical history and imaging findings and what is the next step in diagnosis? Answer: The differential would include electronic vaping associated lung injury (EVALI), ARDS, pulmonary contusion, pneumonia, or cardiogenic pulmonary edema. The next step in diagnosis is chest radiography, CT scanning, or bronchoscopy. The POCUS images performed by the emergency physician showed normal lung sliding in anterior lung fields, with bilateral B-lines in the posterolateral lungs without pleural effusion (Fig 1, Narration Video). There were no secondary findings of pneumoma, such as obvious consolidation or dynamic air bronchograms. A chest radiography showed confluent small nodular opacities favored to reflect extensive airspace disease, with a symmetric basilar predominance (Fig 2). Subsequent CT pulmonary angiography of the chest also showed extensive symmetric multifocal airspace disease (Fig 3). The patient was started on empiric antibiotics for community-acquired pneumonia with ceftriaxone and azithromycin. Methylprednisolone was administered after consultation with pulmonary medicine. On admission to the ICU, the patient underwent bedside bronchoscopy that demonstrated diffuse alveolar hemorrhage. Cultures from BAL washings did not result in subsequent bacterial or fungal growth. Blood cultures likewise showed no growth, and the respiratory viral panel was negative for common viral pathogens. The echocardiogram was read as normal without evidence of systolic or diastolic dysfunction. Autoimmune serology specimens were negative for anti-neutrophil cytoplasmic antibody, anti-myeloperoxidase antibody, anti-proteinase 3 antibody, and anti-glomerular basement membrane antibody. The patient was weaned gradually from the ventilator and extubated on hospital day 3. His work up for cardiac, infectious, and rheumatologic causes was negative, and he subsequently was discharged home. On follow up 14 days after admission and after abstinence from smoking and vaping, the patient underwent repeat CT scanning of his chest that showed complete resolution of previously noted lung changes. He continued to experience dyspnea with significant exertion but was generally asymptomatic and able to perform daily activities without difficulty. EVALI is a relatively recently described phenomenon with high morbidity. As of February 18, 2020, the United States’ Centers for Disease Control and Prevention (CDC) has reported a total of 2,807 hospitalized EVALI cases in the United States, including 68 confirmed deaths with an age range of 15 to 75 years. Components found in electronic cigarettes, vaporizers, electronic hookahs, and electronic nicotine delivery systems are listed as potential causative agents.1Outbreak of Lung Injury Associated with the Use of E-Cigarette, or Vaping, ProductsCenters for Disease Control and Prevention. Accessed March 25, 2020.https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html#latest-informationGoogle Scholar The CDC defines EVALI as a pulmonary infiltrate seen on chest radiography or CT scanning with e-cigarette use within 90 days prior to onset of symptoms. At present, EVALI remains a diagnosis of exclusion because no specific test or marker currently exists for its diagnosis. Respiratory, GI, and constitutional symptoms in combination with a history of recent e-cigarette use should raise clinical suspicion for possible EVALI.2For Healthcare ProvidersCenters for Disease Control and Prevention. Accessed March 25, 2020.https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease/healthcare-providers/index.htmlGoogle Scholar Vaping-associated lung injuries have demonstrated a wide range of lung patterns on radiography and CT scanning. Henry et al3Henry T.S. Kligerman S.J. Raptis C.A. Mann H. Sechrist J.W. Kanne J.P. Imaging findings of vaping-associated lung injury.AJR Am J Roentgenol. 2020; 214: 498-505Crossref PubMed Scopus (47) Google Scholar summarized the imaging findings that included hypersensitivity pneumonitis, diffuse alveolar hemorrhage, acute eosinophilic pneumonia, organizing pneumonia, lipoid pneumonia, and giant cell interstitial pneumonia. A case series presented by Kaliniskiy et al4Kalininskiy A. Bach C.T. Nacca N.E. et al.E-cigarette, or vaping, product use associated lung injury (EVALI): case series and diagnostic approach.Lancet Respir Med. 2019; 7: 1017-1026Abstract Full Text Full Text PDF PubMed Scopus (104) Google Scholar suggested a diagnostic approach that included radiography and CT scanning for initial evaluation of EVALI. To date, however, there have been no documented cases that included the use of ultrasound scanning as an initial modality for evaluation. Ultrasound scanning continues to be recognized as an essential modality to the provision of high-quality, timely and cost-effective patient care, especially in the emergency setting. Beginning with the BLUE protocol described by Lichenstein,5Lichtenstein D.A. BLUE-protocol and FALLS-protocol: two applications of lung ultrasound in the critically ill.Chest. 2015; 147: 1659-1670Abstract Full Text Full Text PDF PubMed Scopus (266) Google Scholar many lung ultrasound protocols have been described in the acute care setting. In our case, we evaluated the anterior and posterolateral lungs bilaterally. Additional views were not feasible in the ED, given the patient’s high acuity; however, more views generally increase the sensitivity for pathologic evaluation. At a minimum, a lung protocol should include an evaluation of the least dependent part of the lung (anterior chest in a supine patient) and the most dependent part of the lung (posterior chest in a supine patient) bilaterally. It should be noted that, in this case, a low frequency curvilinear transducer was used primarily, which allowed for a broad field of view over multiple rib spaces. Tissue harmonic imaging and other artifact-reducing technologies should be turned off to allow for best visualization of the pathologic lung artifacts. A high-frequency linear probe can be useful for further characterizing the pleural line. In this case, detailed evaluation of the pleural line was limited because of the use of a low-frequency probe. From what could be observed, the pleural line was regular and continuous without overt subpleural consolidations. It has been suggested that pleural abnormalities are more indicative of an inflammatory or infectious cause of pulmonary edema as opposed to cardiogenic pulmonary edema, but these findings were not readily apparent in our case.6Copetti R. Soldati G. Copetti P. Chest sonography: a useful tool to differentiate acute cardiogenic pulmonary edema from acute respiratory distress syndrome.Cardiovasc Ultrasound. 2008; 6: 16Crossref PubMed Scopus (334) Google Scholar Patchy B-lines, with spared areas of the lung also, would challenge the possibility of a cardiogenic cause. The patient had few B-lines in the anterior right lung field, whereas there were diffuse B-lines in the bilateral bases of the lungs. It is unclear whether this was indicative of basilar predominance of the edema or a patchiness of the lung ultrasound findings. The bedside cardiac ultrasound scan showed a preserved left ventricular ejection fraction and collapsible inferior vena cava that supports a noncardiogenic cause. These sonographic lung findings together suggest a systemic inflammatory process to be causing increased interstitial edema. This is corroborated by the findings on chest CT scanning. In a patient with vaping-associated diffuse alveolar hemorrhage, these sonographic findings would be expected, based on what has been seen on other imaging modalities.7Agustin M. Yamamoto M. Cabrera F. Eusebio R. Diffuse alveolar hemorrhage induced by vaping.Case Rep Pulmonol. 2018; 2018: 9724530Crossref PubMed Google Scholar,8Edmonds P.J. Copeland C. Conger A. Richmond B.W. Vaping-induced diffuse alveolar hemorrhage.Respir Med Case Rep. 2020; 29: 100996PubMed Google Scholar In previous case reports and case series, chest radiography and CT scanning have been the initial imaging modalities of choice.4Kalininskiy A. Bach C.T. Nacca N.E. et al.E-cigarette, or vaping, product use associated lung injury (EVALI): case series and diagnostic approach.Lancet Respir Med. 2019; 7: 1017-1026Abstract Full Text Full Text PDF PubMed Scopus (104) Google Scholar,8Edmonds P.J. Copeland C. Conger A. Richmond B.W. Vaping-induced diffuse alveolar hemorrhage.Respir Med Case Rep. 2020; 29: 100996PubMed Google Scholar This is consistent with the aforementioned diagnostic criteria set by the CDC. We present a case of EVALI during which point-of-care ultrasound scanning (POCUS) was used during initial resuscitation and diagnostic workup in the ED setting. The sonographic features of this case of EVALI included bilateral B-lines representative of interstitial edema. B-lines are a reverberation artifact that originate from the pleural line caused by a thickening of the interstitium; these findings have been described with other pathologic findings that include cardiogenic pulmonary edema, pulmonary contusion, pneumonia, and ARDS.5Lichtenstein D.A. BLUE-protocol and FALLS-protocol: two applications of lung ultrasound in the critically ill.Chest. 2015; 147: 1659-1670Abstract Full Text Full Text PDF PubMed Scopus (266) Google Scholar,6Copetti R. Soldati G. Copetti P. Chest sonography: a useful tool to differentiate acute cardiogenic pulmonary edema from acute respiratory distress syndrome.Cardiovasc Ultrasound. 2008; 6: 16Crossref PubMed Scopus (334) Google Scholar,9Hosseini M. Ghelichkhani P. Baikpour M. et al.Diagnostic accuracy of ultrasonography and radiography in detection of pulmonary contusion; a systematic review and meta-analysis.Emerg (Tehran). 2015; 3: 127-136PubMed Google Scholar Because this is the first description of lung ultrasound scanning in a patient with EVALI, there are no established guidelines regarding how ultrasound scanning can assist in the diagnostic work up. Given the nonspecific nature of the sonographic findings, we propose that POCUS can be used to increase suspicion for the disease process in a patient with a high pretest probability for EVALI based on history and examination. POCUS has the advantage of being able to be performed rapidly at the bedside of a critically ill patient whose condition may be too unstable to move for CT scanning. In addition, POCUS can be more sensitive for interstitial edema than chest radiography.10Danish M. Agarwal A. Goyal P. et al.Diagnostic performance of 6-point lung ultrasound in ICU patients: a comparison with chest x-ray and CT thorax.Turk J Anaesthesiol Reanim. 2019; 47: 307-319Crossref PubMed Scopus (7) Google Scholar Furthermore, POCUS of the heart and lungs effectively can rule out alternate diagnoses such as pneumothorax, pneumonia, pleural effusion, pericardial effusion, and acute heart failure. Therefore, POCUS can be used early in the course of a patient with suspected EVALI to expedite treatment; however, the diagnosis should be confirmed with further diagnostic testing, given that the sonographic findings are not specific. 1.The sonographic lung findings of EVALI are a regular pleural line and bilateral B-lines with basilar predominance reflective of interstitial edema.2.POCUS can be used to increase suspicion for EVALI in a patient with high pretest probability and to evaluate for alternate causes of acute dyspnea.3.POCUS in isolation should not be used to diagnose EVALI. Due to the nonspecific nature of the findings on lung sonography, the diagnosis should be confirmed with additional diagnostic testing. Financial/nonfinancial disclosures: None declared. Other contributions: CHEST worked with the authors to ensure that the Journal policies on patient consent to report information were met. Additional information: To analyze this case with the Videos, see the online version of this article. https://journal.chestnet.org/cms/asset/f8131159-8813-43b0-8076-07ab6031944f/mmc1.mp4Loading ... Download .mp4 (6.69 MB) Help with .mp4 files Video 1Lung ultrasound images of the anterior chest and bilateral lung bases at the costophrenic angles. Diffuse B-lines are seen in all lung fields.https://journal.chestnet.org/cms/asset/ef2f5b0c-f2e9-4cd8-b864-90077d94ac55/mmc2.mp4Loading ... Download .mp4 (26.32 MB) Help with .mp4 files Narration VideoLabeled video clips of lung ultrasound images of the anterior chest and bilateral lung bases at the costophrenic angles. Diffuse B-lines are seen in all lung fields.

Objectives: Accurate communication is an integral component of ultrasound education. In light of the recent global pandemic, this has become even more crucial as many have moved to virtual education out of necessity. Several studies and publications have sought to establish common terminology for cardinal ultrasound probe motions. To date, no studies have been performed to determine which of these terms have been adopted by the ultrasound community at large. Methods: A survey was developed which asked respondents to describe videos of six common probe motions in addition to providing basic demographic and training data. The survey was disseminated electronically across various academic listservs and open access resources. Results: Data were collected over a 6-week period and yielded 418 unique responses. Responses demonstrated significant variation in terminology related to all 6 cardinal probe motions. While some degree of difference in response can be accounted for by discipline of training, inter-group variation still exists in terminology to describe common probe motions. Of the survey respondents, 57.5% felt that inconsistent probe motion terminology made teaching ultrasound more difficult. Conclusions: The results demonstrate that despite efforts to codify probe motions, variation still exists between ultrasound practitioners and educators in the description of cardinal probe motions. This lack of consensus can contribute to challenges in both virtual and in-person ultrasound education.

In medicine, protocols are applied to assure the provision of the treatment with the greatest probability of success. However, the development of protocols is based on the determination of the best intervention for the group. If the group is heterogeneous, there will always be a subset of patients for which the protocol will fail. Furthermore, over time, heterogeneity of the group may not be stable, so the percentage of patients for which a given protocol may fail may change depending on the dynamic patient mix in the group. This was thrown into stark focus during the severe acute respiratory syndrome-2 coronavirus (SARS-CoV-2) pandemic. When a COVID-19 patient presented meeting SIRS or the Berlin Criteria, these patients met the criteria for entry into the sepsis protocol and/or acute respiratory distress syndrome (ARDS) protocol, respectively and were treated accordingly. This was perceived to be the correct response because these patients met the criteria for the “group” definitions of sepsis and/or ARDS. However, the application of these protocols to patients with SARS-CoV-2 infection had never been studied. Initially, poor outcomes were blamed on protocol noncompliance or some unknown patient factor. This initial perception is not surprising as these protocols are standards and were perceived as comprising the best possible evidence-based care. While the academic response to the pandemic was robust, recognition that existing protocols were failing might have been detected sooner if protocol failure detection had been integrated with the protocols themselves. In this review, we propose that, while protocols are necessary to ensure that minimum standards of care are met, protocols need an additional feature, integrated protocol failure detection, which provides an output responsive to protocol failure in real time so other treatment options can be considered and research efforts rapidly focused.

Ultrasound is being introduced into many medical schools and incorporated into the anatomy curriculum; however, in most cases, this consists of proctored sessions which can be limited by faculty time and availability. Additionally, the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) pandemic has significantly impacted medical education, especially ultrasound education, which has traditionally depended on hands-on practice and instruction. A structured, independent, hands-on learning curriculum using ultrasound would have many benefits. In this study, eight self-guided system-based modules were developed mirroring the undergraduate anatomy curriculum. For each scan, a beginner, intermediate, and advanced component was designed. Each module contains clear, stepwise directions for image acquisition, optimization, and interpretation of the anatomical structures and suggestions for troubleshooting. Students save ultrasound images as part of their digital portfolios for review with ultrasound faculty. This design provides an educational model to increase medical student opportunities for independent, structured, self-directed anatomy learning with ultrasound that can be integrated with existing educational programs.

As ultrasound has gained popularity with improving technology and ease-of-use, a push has been made to integrate ultrasound into the medical school curriculum. Many institutions are reporting one- to four-year integrated ultrasound curricula to augment anatomy and pathophysiology teaching. Our goal was to integrate a thyroid ultrasound scanning session into the endocrinology block of our institution's medical school curriculum to enhance medical student understanding of thyroid anatomy and pathophysiology. We conducted a prospective, single-center cohort (pre-experimental) study to evaluate student performance and knowledge acquisition using a pretest-posttest design. These multimodal sessions, consisting of a didactic, hands-on scanning sessions, and knowledge integration tests, covered ultrasound technique and thyroid evaluation and advanced to diagnosing an abnormal thyroid and working up a thyroid nodule. There were 26 to 27 second-year medical students per session who rotated between three stations proctored by credentialled physicians. Students participated in hands-on scanning of patients with or without thyroid pathology at each station. Out of the 209 students who participated in the ultrasound sessions, 114 (54.5%) consented to participate in the research project and completed both the pretest and posttest. Test data from the 114 students showed a mean pretest score of 57.5% ± 14.6% and the mean posttest score of 73.9% ± 17.4%. They had a 16.5% ± 19.6% (p < 0.001) increase in score between the two tests. Our study demonstrates that a multimodal thyroid ultrasound scanning session is an effective tool to augment the medical school endocrinology curriculum and to improve students' knowledge of thyroid anatomy, pathophysiology, and diagnostic workup of thyroid nodules.

Immersive technology such as virtual, augmented, and mixed reality has been used in entertainment. Applying this technology for educational purposes is a natural extension. We tested the ability of immersive technology to enhance medical education within a scenario about progressively worsening tension pneumothorax using a virtual patient. The goals of the study were 1) to determine whether those in the experimental group were better able to differentiate between normal and abnormal perceptual cues, and 2) to obtain feedback about the Augmented Reality (AR) training experience. For this study, the control group received traditional textbook training about tension pneumothorax. The experimental group received the same textbook training plus the AR tension pneumothorax scenario. An augmented reality headset was used to display a virtual patient on a table for the experimental group participants. All participants completed a pre and post-training knowledge test. Changes in the score of the accuracy from pre-post tests were used to establish whether the experimental group was better able to classify the perceptual cues. All participants responded to questions about the training experience at the end of the session. We discuss whether adding augmented reality training allowed medical students to better discern between abnormal and normal cues, and report our insights for what learning objectives AR can support in simulation-based training.

A 59-year-old man came to the ED with out-of-hospital cardiac arrest (CA) after a witnessed convulsive spell. On the scene, he complained of chest pressure and dizziness. En route, he had developed pulseless electrical activity (PEA) and received advanced cardiac life support for 5 min before initial return of spontaneous circulation (ROSC). On arrival, the patient appeared moribund. He had weak central pulses and no evidence of trauma. Initial blood gas was notable for a pH of 6.8 and lactate at 16.6 mmol/L. The patient’s ECG is shown in Figure 1. Bedside point-of-care ultrasound (POCUS) was done within 5 min of arrival (Video 1). Question: On the basis of the sonographic findings, what is the leading differential diagnosis for this patient and the next step if he subsequently arrests? Answer: A transthoracic subxiphoid view of the heart demonstrated a moderate circumferential pericardial effusion with right ventricular collapse, indicative of tamponade physiology Shortly after arrival, the patient again lost pulses. Bedside pericardiocentesis was performed with 15 cm3 of bloody return resulting in ROSC and sonographic resolution of the tamponade physiology (Fig 2). Concern was raised for aortic dissection as the etiology of the hemopericardium. Transesophageal echocardiography (TEE) was performed at the bedside and confirmed acute type A aortic dissection (AADA), extending into the coronary arteries (Video 2). The patient experienced two additional PEA arrests with ROSC subsequent to standard advanced cardiac life support. Massive transfusion and vasopressors were initiated with a goal of permissive hypotension. On the basis of the TEE findings, the patient was taken directly to the cardiac surgery suite for AADA repair. Rapid POCUS is a valuable tool for identifying potentially reversible etiologies of cardiac arrest such as pericardial effusion or right heart strain, especially in PEA.1Long B. Alerhand S. Maliel K. Koyfman A. Echocardiography in cardiac arrest: an emergency medicine review.Am J Emerg Med. 2018; 36: 488-493Abstract Full Text Full Text PDF Scopus (30) Google Scholar, 2Labovitz A.J. Noble V.E. Bierig M. et al.Focused cardiac ultrasound in the emergent setting: a consensus statement of the American Society of Echocardiography and American College of Emergency Physicians.J Am Soc Echocardiogr. 2010; 23: 1225-1230Abstract Full Text Full Text PDF PubMed Scopus (502) Google Scholar, 3Tsou P.Y. Kurbedin J. Chen Y.S. et al.Accuracy of point-of-care focused echocardiography in predicting outcome of resuscitation in cardiac arrest patients: a systematic review and meta-analysis.Resuscitation. 2017; 114: 92-99Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar When performed by trained providers, POCUS may guide life-saving interventions. A prospective study found that POCUS led to treatment changes for 78% patients with shock or CA, including interventions such as pericardiocentesis.4Breitkreutz R. Price S. Steiger H.V. et al.Emergency Ultrasound Working Group of the Johann Wolfgang Goethe-University Hospital, Frankfurt am Main. Focused echocardiographic evaluation in life support and peri-resuscitation of emergency patients: a prospective trial.Resuscitation. 2010; 81: 1527-1533Abstract Full Text Full Text PDF PubMed Scopus (300) Google Scholar Dissection flaps may even be visualized in the transabdominal short and long-axis views (Videos 3, 4, Narration Video). AADA is rare and challenging to diagnose because of its variability in presentation.5Hagan P. Nienaber C. Isselbacher E. et al.The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease.JAMA. 2000; 283: 897-903Crossref PubMed Scopus (2673) Google Scholar The average time from arrival to diagnosis has been reported as high as 200 min.6Cruz I. Stuart B. Caldeira D. et al.Controlled pericardiocentesis in patients with cardiac tamponade complicating aortic dissection: experience of a centre without cardiothoracic surgery.Eur Heart J Acute Cardiovasc Care. 2014; 4: 124-128Crossref Scopus (16) Google Scholar Cardiac tamponade may be present in 18.7% of cases7Gilon D. Mehta R.H. Oh J.K. et al.Characteristics and in-hospital outcomes of patients with cardiac tamponade complicating type A acute aortic dissection.Am J Cardiol. 2009; 103: 1029-1031Abstract Full Text Full Text PDF PubMed Scopus (86) Google Scholar and is associated with more than 90% mortality without early surgical intervention.7Gilon D. Mehta R.H. Oh J.K. et al.Characteristics and in-hospital outcomes of patients with cardiac tamponade complicating type A acute aortic dissection.Am J Cardiol. 2009; 103: 1029-1031Abstract Full Text Full Text PDF PubMed Scopus (86) Google Scholar Because of poor pericardial compliance, acute accumulation of even minimal fluid can cause tamponade physiology. Even with repair, in-hospital mortality is doubled when tamponade is present (44% vs 20.5%).7Gilon D. Mehta R.H. Oh J.K. et al.Characteristics and in-hospital outcomes of patients with cardiac tamponade complicating type A acute aortic dissection.Am J Cardiol. 2009; 103: 1029-1031Abstract Full Text Full Text PDF PubMed Scopus (86) Google Scholar Pericardiocentesis has classically been discouraged in AADA because of concern for clot disruption causing worsening hemorrhage. Multiple case series support controlled pericardiocentesis for temporary stabilization while awaiting definitive surgical treatment in unstable patients.6Cruz I. Stuart B. Caldeira D. et al.Controlled pericardiocentesis in patients with cardiac tamponade complicating aortic dissection: experience of a centre without cardiothoracic surgery.Eur Heart J Acute Cardiovasc Care. 2014; 4: 124-128Crossref Scopus (16) Google Scholar,8Hayashi T. Tsukube T. Yamashita T. et al.Impact of controlled pericardial drainage on critical cardiac tamponade with acute type A aortic dissection.Circulation. 2012; 126: S97-S101Crossref PubMed Scopus (39) Google Scholar Aspiration should be limited to the minimum volume required to restore hemodynamics, typically 40 cm3 or less.6Cruz I. Stuart B. Caldeira D. et al.Controlled pericardiocentesis in patients with cardiac tamponade complicating aortic dissection: experience of a centre without cardiothoracic surgery.Eur Heart J Acute Cardiovasc Care. 2014; 4: 124-128Crossref Scopus (16) Google Scholar,8Hayashi T. Tsukube T. Yamashita T. et al.Impact of controlled pericardial drainage on critical cardiac tamponade with acute type A aortic dissection.Circulation. 2012; 126: S97-S101Crossref PubMed Scopus (39) Google Scholar For facilities without the means to perform cardiothoracic surgery or when prolonged delays are anticipated, insertion of a pericardial drain may be favorable. The differential diagnosis of acute hemopericardium is limited (Table 1). Many of the possible etiologies require immediate intervention for survival.Table 1Differential Diagnosis of Acute Hemopericardium•Free wall rupture (myocardial infarction, left ventricular aneurysm)•Ascending aortic dissection•Pericarditis•Trauma (iatrogenic, blunt/penetrating)•Malignancy•Coronary artery aneurysm Open table in a new tab While prompt POCUS in CA is essential, TEE offers many advantages including assessment of the quality of chest compressions,9Blaivas M. Transesophageal echocardiography during cardiopulmonary arrest in the emergency department.Resuscitation. 2008; 78: 135-140Abstract Full Text Full Text PDF PubMed Scopus (80) Google Scholar, 10Fair J. Mallin M. Mallemat H. et al.Transesophageal echocardiography: guidelines for point-of-care applications in cardiac arrest resuscitation.Ann Emergency Med. 2018; 71: 201-207Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar, 11Teran F. Dean A.J. Centeno C. et al.Evaluation of out-of-hospital cardiac arrest using transesophageal echocardiography in the emergency department.Resuscitation. 2019; 137: 140-147Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar shorter pauses during CPR,12Fair III, J. Mallin M.P. Adler A. et al.Transesophageal echocardiography during cardiopulmonary resuscitation is associated with shorter compression pauses compared with transthoracic echocardiography.Ann Emerg Med. 2019; 73: 610-616Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar and early identification of pathology such as AADA in patients too unstable to undergo CT scanning. Although traditionally performed by a cardiologist, use of TEE by trained emergency physicians is increasing and may expedite patient care in undifferentiated CA. One small study of 33 TEEs in CA showed a diagnostic, therapeutic, or prognostic impact in 97% of patients.11Teran F. Dean A.J. Centeno C. et al.Evaluation of out-of-hospital cardiac arrest using transesophageal echocardiography in the emergency department.Resuscitation. 2019; 137: 140-147Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar Another study of 54 ED TEEs found treatment changes affecting CPR, prognostication, volume status, pressor/inotrope titration, and procedural guidance in 78% of patients.13Arntfield R. Pace J. Hewak M. Thompson D. Focused transesophageal echocardiography by emergency physicians is feasible and clinically influential: observational results from a novel ultrasound program.J Emerg Med. 2016; 50: 286-294Abstract Full Text Full Text PDF PubMed Scopus (75) Google Scholar Competency standards by the American College of Emergency Physicians for TEE in the ED and protocols for implementation have been previously published.10Fair J. Mallin M. Mallemat H. et al.Transesophageal echocardiography: guidelines for point-of-care applications in cardiac arrest resuscitation.Ann Emergency Med. 2018; 71: 201-207Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar,14American College of Emergency Physicians Board of DirectorsGuidelines for the use of transesophageal echocardiography (TEE) in the ED for cardiac arrest.Ann Emerg Med. 2017; 70: 442-445Abstract Full Text Full Text PDF Scopus (25) Google Scholar Emergency medicine residents have used TEE in simulated arrest scenarios with a high degree of precision and accuracy.15Byars D. Tozer J. Joyce J. et al.Emergency physician-performed transesophageal echocardiography in simulated cardiac arrest.West J Emerg Med. 2017; 18: 830-834Crossref PubMed Scopus (11) Google Scholar Simplified three-view protocols succinctly direct emergency physicians.10Fair J. Mallin M. Mallemat H. et al.Transesophageal echocardiography: guidelines for point-of-care applications in cardiac arrest resuscitation.Ann Emergency Med. 2018; 71: 201-207Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar After undergoing successful aortic reconstruction, the patient was extubated the next day. Remarkably, he was discharged neurologically intact within 2 weeks, and he returned to independent living and work within 2 months. This patient highlights the benefit of early POCUS in CA, the usefulness of pericardiocentesis to achieve ROSC in tamponade, and the advantages of urgent TEE in the ED. Early multidisciplinary collaboration with cardiology and cardiothoracic surgery is essential for effective treatment of suspected AADA. This patient was in the ED for less than 70 min, a benchmark that never would have been possible without the use of ED POCUS and TEE. 1.Early point-of-care ultrasound in patients with undifferentiated cardiac arrest is effective in guiding resuscitation and may identify the etiology of PEA arrest.2.For decompensating acute type A aortic dissection, controlled pericardiocentesis may be a life-saving temporizing intervention in restoring hemodynamic stability before definitive treatment.3.ED transesophageal echocardiography has significant usefulness in guiding cardiac arrest resuscitations and identifying cardiac pathology. Financial/nonfinancial disclosures: None declared. Other contributions: CHEST worked with the authors to ensure that the Journal policies on patient consent to report information were met. Additional information: The videos can be found in the Supplemental Materials section of the online article. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI4YTM5Yzc5NTE0YWY4ZWIzY2UxZDYyNDlmZGQ1YjBkNSIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc4ODAyMjQyfQ.dGsrF9OD4sCy6LUnbOmeoXUoZ0155zllaVttYXYMIvqV6d8r1GkX5V8IZAh4MH6-CE8uwyKSveySqze9WZIRdnMIiSQD1-Sr5TwP3SRar3qm1YAFAi0dDb1HWP1h2FXbbmcQCPXDKxRO20jrh73nKs6BOjpzw5asOXTejZ1nuUkQU8Deb3JCH5DK86uuQIGT7rrC40oH3tZv622F4HcNKk6gdBCWGXqq_Xs8p7Td0eT3HnXVQw55IQeOGG9HR-m9KbXifs4LqDzyUMrX2LO26pwV6NEmDyVgadLUW6qUgreuaiPKYoSixeSWaYXdSMlfFStuJzBwsJEhli1w7a1rPw Download .mp4 (1.09 MB) Help with .mp4 files Video 1Subxiphoid view showing circumferential pericardial effusion with right ventricular collapse.eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI1ZGE3MjkxZGI2ZjExN2QzNWVlZmY2MDVhYTljZjc5NiIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc4ODAyMjQyfQ.SfHz4xBmz0yg0Ub93W2cMMevOabVE_dK0TUV2p34g9j68G-YJ_Eiv6wD1TSm9Xf5-UIkuPW__oI4tc184ieyc7gqrIsHm8fkuiGtBemxbn2vmL0GcDUPDmxbYUe5YB3Db658YN7vscLWbyh16JUBNZpCyeHithuWIc8aVgWJMn3sric38myJLJnJF85rxZtGdVUrQBMpeH9EIxGGU2-2k1XfM9o1Os4xbMAtMCaGLWDSn6DO2wJPUxuRgRJp2TWhlkdoCEP_ypNf3PjlkK3QYdoSabIdiNIwlp86hT_zhGaw5NT9qLLNX5_OLdSuNU7yu4rBQwrgOXygFXmb-ZZh_Q Download .mp4 (1.42 MB) Help with .mp4 files Video 2Transesophageal echocardiography with aortic dissection flap.eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJlM2U4MmZkYWY1M2RkMmYwMzA2YTUwZjMyMTZlNjRiNCIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc4ODAyMjQyfQ.f9qDyl-6nH6f-q9FfztTUqgpOUvtXa2OxlUQXztlmMBId3LLwf5hF1SUnYp8_npSWtmrnRpzeerRJked6NsZZc5bFPOAxa45j8Q9YoB_oXY74qUdg4JWNuCSUJDqO7EUfyTVxeunG4BMMpj7WlFO0H4uuJJMx9DEeu8H6q_YinnXUdU8lLrJqkneNsdlOYaLz5SM5QHrZuyGNkWJ1C3M8giVmoJgdfF6yUw3XTR4wZa_pbRfp25bRkZOF4c40aFaNeh5IjWvoTII1eB7uoBDjwGgTcqoxhmBPOoE3DlWlf3yZfPdLbswIa8nnLgAlHbS1gv446KX3TTWD70oUmRb2A Download .mp4 (1.31 MB) Help with .mp4 files Video 3Long axis view of the aorta with dissection flap.eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI0ZjA1ZTM2OTBlMjNlMjI0MGFkNTVlNzM1ZWU2NTkwMyIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc4ODAyMjQyfQ.YxW6oZuMBuIbmO_Oj4GU4u1LEwtp2lWTPna3-6o0aN9DtF59T4xpoLMBWN1kzhJCV1sFPvdATcqPLFUWxvk0-5zeKlM_p5E5r-YnJrfAa10PwOxMMo8bl29d3qzev1Pvy33oRcyHP4iW70NIsY-vff9PP0qwglaXV4kqvUyS3wCuvXYp0GyHZEhItDa6E90uXrvqT_MWf7KSzFpKAPD1s0q_UH3B2q5yKFJwaSzoUzSft2R1KF22eVycAR8apBUAfKKui5t99knoeGlECFFHLfotheFurHIWhgkVUZ4JnHiW6PVGU6SRStOT6F6ltyaKVQN9SCuP8SF_5Vff7gL7YA Download .mp4 (1.31 MB) Help with .mp4 files Video 4Short axis view of the aorta with dissection flap.eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiIxYjQzOTMyZmE2NDM3MGJhYWI5NzFhMDk2ZTNkMWViZSIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc4ODAyMjQyfQ.gRdBjS0_vF27o15fFAQefZWX_V_JTpCLNA-9DQsECDs3IinMXPCipwZg9ddSsPjJmDt5i1a7bHZuERbbZCDyqS_3sokP45RDqtLLMLsUL-0cdkZZLu6HejNMiMqnq6C6qgUNEkULpea4KJlvF6sqC8y8PcN0auVSiHEPvr07C6AdckMVUqYiRNpJ_y8-e6Le8bixCb2kRDMFh0oKnU3esE4o1nMLBA16ABoV2gHDlgP-efLhiFupwwexYx2qpV_t53UHkVCELMdf1zPrBD1Hm8p356vd8xjNXCMlWtCWj7hFnVWLSpwhCMF8rCArjd3DQhmU2WD5qLVwqpRV07J2vw Download .mp4 (54.09 MB) Help with .mp4 files Narration Video

Carbon monoxide (CO) exposure is a prevalent cause of poisoning worldwide. The cardiac effects of CO poisoning are well described and can manifest as angina, myocardial ischemia or infarction, cardiogenic shock, and/or life-threatening arrhythmias. Atrial fibrillation has been associated with severe CO poisoning; however, few cases have described atrial fibrillation in acute CO poisoning with regard to hyperbaric oxygen (HBO2) therapy. Herein, we describe a case of severe CO poisoning that caused atrial fibrillation with successful conversion to sinus rhythm following HBO2 therapy and discuss implications for further research.

INTRODUCTION:The goal of this study was to assess if a neurological disorder ultrasound workshop for the first-year medical students significantly enhanced the students' ability to retain and apply concepts related to neuroanatomy and neurophysiology.MATERIALS AND METHODS:We performed a prospective study to evaluate student performance before and after an optional ultrasound workshop. Data were collected through a within-population pretest-posttest design. Purposive sampling was used to recruit first-year medical students for this study. The six stations were transcranial doppler ultrasound, ocular ultrasound, ultrasound-guided external ventricular drain placement, high-intensity focused ultrasound for brain lesions, carotid artery scan with ultrasound, and ultrasound-guided central line placement. We used a pre-post workshop survey to identify opinions and perceptions about ultrasound and a pre-post workshop test to assess knowledge about neuroanatomy, neurophysiology, and related ultrasound topics.RESULTS:Twenty-two 22 first-year medical students consented to participate in this study. The Wilcoxon signed-rank test showed a statistically significant difference in pre- and posttest scores, suggesting that participants demonstrated higher levels of medical knowledge related to neurological physiology, anatomy, and ultrasound after participating in the workshop. The analysis of the pre-post survey showed participants attributed greater value to ultrasound as a useful tool for their future medical practice after participation in the event (Z = -2.45, P = 0.014).CONCLUSIONS:There is value in integrating experiences with ultrasound into the neurological disorder block of medical school. Future studies, with a larger sample size, are needed to further explore the efficacy of this workshop in enhancing knowledge retention.

Purpose: Document a feasibility study of an interprofessional approach to targeted sonography training (TST) for medical students, incorporating computer-based simulation (CBS). Procedure: Three participants received TST on the abdominal aorta from credentialed sonographers using CBS. Training included didactic instruction, skill demonstration, debrief, and feedback. An assessment template was developed to assess students’ skills and provide structured feedback. Students completed a feedback survey on the learning process that followed the training. Results: Students’ template scores were similar, despite varying prior exposure to CBS. The importance of deliberate practice, direct feedback when a student is struggling, and a debrief session following skill demonstration was evident in this study. Students agreed that this targeted instructional process provided a low-pressure environment where they could learn from mistakes and improve their confidence. Conclusion: This case series demonstrated how readily a TST session can be accomplished using computer-based simulation and the value of structured feedback.

Abstract Venous thromboembolic disease is often a concern for those presenting to the acute care setting. Whether it be a deep venous thrombosis (DVT) or a pulmonary embolism (PE), point-of-care ultrasound (POCUS) can be helpful in the diagnosis and management of these patients. For DVTs, duplex sonography is considered the standard for diagnosis, and studies have shown that POCUS can accurately and quickly make this diagnosis. In addition to ultrasound of the veins, POCUS of the lungs and heart can assist in diagnosing PE. Furthermore, the diagnosis of right heart strain on point-of-care echocardiography can assist with risk stratification of patients with the diagnosis of PE. Overall, POCUS is a valuable modality that can assist in the timely management of this potentially life-threatening disease.

Focused transthoracic echocardiography (TTE) during cardiac arrest resuscitation can enable the characterization of myocardial activity, identify potentially treatable pathologies, assist with rhythm interpretation, and provide prognostic information. However, an important limitation of TTE is the difficulty obtaining interpretable images due to external and patient-related limiting factors. Over the last decade, focused transesophageal echocardiography (TEE) has been proposed as a tool that is ideally suited to image patients in extremis—those in cardiac arrest and periarrest states. In addition to the same diagnostic and prognostic role provided by TTE images, TEE provides unique advantages including the potential to optimize the quality of chest compressions, shorten cardiopulmonary resuscitation interruptions, guide resuscitative procedures, and provides a continuous image of myocardial activity. This review discusses the rationale, supporting evidence, opportunities, and challenges, and proposes a research agenda for the use of focused TEE in cardiac arrest with the goal to improve resuscitation outcomes.