Module 1 - Ultrasound physics, knobology, data storage and clinical governance
Understand the basics of ultrasound physics, including but not limited to the piezoelectric effect, wave characteristics, Doppler effect, echogenicity and attenuation
Understand instrumentation, including but not limited to probe characteristics, probe selection, labelling, and image storage and export
Understand and comply with the Australian Government practice accreditation standards for diagnostic imaging
Two hours pre-reading
One hour education and practical workshop
Read ACEM document numbers G25, P21 and the position statement on probe disinfection to familiarise yourself with ACEM expectations regarding POCUS.
Read the Diagnostic Imaging Accreditation Scheme document produced by the Australian Department of Health.
Describe and document the ways in which a POCUS provider can ensure their use of imaging complies with national legislation. Bring your responses along to the workshop.
Module 2 - abdomen and lung
- Understand superficial and sonographic anatomy of the lungs and abdominal viscera
- Perform a standardised lung ultrasound study in the supine patient.
- Understand the ultrasound appearance of lung pathology and its limitations.
- Perform a standardised renal tract ultrasound study.
- Understand the ultrasound appearance of renal tract pathology and study limitations.
- Perform a standardised biliary tract ultrasound study.
- Understand the ultrasound appearance gallbladder pathology and study limitations.
- Three hours pre-reading/viewing
- One and a half hours of workshop and practical with formative and summative assessment
module 3 - efast
- Understand the anatomy relevant for eFAST
- Describe the relevant sonoanatomy
- Perform the technique of eFAST
- Outline the clinical benefits and indications for eFAST
- Summarise the evidence for eFAST including limitations.
- One hour pre-reading
- Two hours workshop education and practical with formative and summative assessment
- Read chapter 1 in Introduction to Bedside Ultrasound (Vol 1)
- Listen to audio file in your course material on eFAST
module 4 - vascular and procedural
- Describe the probe types and general principles of imaging vessels for cannulation.
- Describe imaging of the radial, jugular, subclavian and femoral vessels
- Describe imaging of the arm veins for PICC lines.
- Describe the sonographic appear of foreign bodies in tissue
- Perform cannulation of phantom vessels using central lines and PICCs
- Understand the sonoanatomy of the abdominal aorta, inferior vena cava, and vertebral bodies
- Perform a standardised study of the abdominal aorta and understand its limitations.
- Three hours pre-reading
- Two hours workshopped AAA education and practical with formative and summative assessment
- Two hours workshopped ultrasound procedures with formative and summative assessment
- One hour workshopped VTE education and practical with formative and summative assessment
- Read chapter 3 in Introduction to Bedside Ultrasound (Vol 1)
- Read chapters 8, 9 and 12 In Introduction to Bedside Ultrasound (Vol 2)
- Read the systematic review on the test characteristics of ED ultrasound for detection of AAA. Read the following two research articles on emergency ultrasound diagnosis of VTE, as well as the systematic review snapshot. Describe the strengths, limitations, and relevance to clinical practice of both papers. How should we apply the findings of these studies to our practice?
Rubano et al, Systematic Review: Emergency Department Bedside Ultrasonography for Diagnosing Suspected Abdominal Aortic Aneurysm, Academic Emergency Medicine 2013; 20, 128–138
Crisp JG, Lovato LM, Jang TB. Compression ultrasonography of the lower extremity with portable vascular ultrasonography can accurately detect deep venous thrombosis in the emergency department. Ann Emerg Med. 2010; 56:601-10
Zitek et al. Mistakes and pitfalls associated with two-point compression ultrasound for DVT. West J Emerg Med. 2016;17(2):201–208
West et al. What Is the Accuracy of Emergency Physician–Performed Ultrasonography for Deep Venous Thrombosis? Ann Emerg Med, Vol 65, 6: 699 - 701
module 5 - haemodynamic assessment
- Understand the concept of “haemodynamic state”
- Estimate LV preload
- Estimate LV ejection fraction
- Understand the effects of loading conditions on evaluation of LV systolic function
- Qualitative evaluation
- Quantitative evaluation
- M mode
- 2D echo
- Combine information to determine the appropriate haemodynamic state
- Understand how echocardiography interpretation can guide clinical management
- Errors and limitations
- Two hours pre-reading
- Two hours education and practical session with formative and summative assessment
- Read pre-workshop preparatory article on ultrasound-guided haemodynamic assessment.
Colin Royse, Ultrasound-guided haemodynamic state assessment, Best Practice & Research: Clinical Anaesthesiology, 2009-09-01, Volume 23, Issue 3, Pages 273-283
MODULE 6 - DIASTOLIC FUNCTION, VALVE INTERROGATION
- Define diastole and review the normal process of cardiac relaxation.
- Categorise the causes of diastolic dysfunction.
- Outline the clinical features of diastolic heart failure.
- Be aware of the different methods of assessing diastolic function
- Perform tissue Doppler to quantify diastolic function.
- Understand the basic sonoanatomy of the cardiac valves
- Perform colour Doppler analysis of valves to identify regurgitation flow.
- Three hours pre-reading
- Two hours education and practical sessions with formative and summative assessment
Godfrey G, Peck M. Diastolic dysfunction in anaesthesia and critical care. BJA Education 2016. 16 (9): 287–291
Aneman A, Vieillard-Baron A. Cardiac dysfunction in sepsis. Intensive Care Medicine. Published online 20 August 2016. DOI 10.1007/s00134-016-4503-4
Lanspa et al. Application of a simplified definition of diastolic function in severe sepsis and septic shock. Critical Care 2016. 20:243
Marik P, Bellomo R. A rationale approach to fluid therapy in sepsis. British Journal of Anaesthesia 2016, 116 (3): 339–49
module 7 - pulmonary embolus, pericardial effusion
- Describe the conventional acoustic windows required for optimal evaluation of the right heart.
- Understand the sonoanatomy of the RV.
- Perform quantitative functional RV assessment using tissue Doppler
- Measure tricuspid annular plane systolic excursion.
- Understand the normal physiology of the right ventricle and pulmonary circulation.
- Identify the advantages and disadvantages of measurements and techniques used to assess right heart function, specifically in relation to pulmonary embolus and pericardial effusions.
- Explain the clinical and prognostic significance of right ventricular assessment as it pertains to pulmonary embolus and pericardial effusion.
- Two hours pre-reading
- Half hour educational video
- Two hours interactive discussion and practical session
- Watch the case discussion video on pericardial effusion (password: tamponade).
- Read pages 985-991of the ASE guideline on pericardial disease (subsection pericardial effusion) and the opinion piece in EHJ on a triage strategy for the management of pericardial tamponade. Be prepared to describe how your clinical experiences related to the proposed triage strategy/scoring system.
- Read the two studies (Kjaergaard et al, Weekes et al) on test characteristics of ultrasound for diagnosing PE. Be prepared to describe your thoughts on what this means for sensitivity of ED ultrasound in haemodynamically stable patients whom you suspect may have PE.
- ASE/EAE guidelines on right ventricular assessment, and a systematic review and meta-analysis on the role of TTE for diagnosing PE are provided for reference only.
Klein et al. American Society of Echocardiography Clinical Recommendations for Multimodality Cardiovascular Imaging of Patients with Pericardial Disease. J Am Soc Echocardiogr 2013; 26:965-1012.
Rudski et al. Guidelines for the Echocardiographic Assessment of the Right Heart in Adults: A Report from the American Society of Echocardiography. J Am Soc Echocardiogr 2010;23:685-713.
Kjaergaard et al. Quantification of right ventricular function in acute PE: relation to V/Q defects. European Journal of Echocardiography 2008; 9: 641-645
Ristic et al. Triage strategy for urgent management of cardiac tamponade: a position statement. European Heart Journal 2014. 35: 2279-2284
Weekes et al. Diagnostic Accuracy of Right Ventricular Dysfunction Markers in Normotensive Emergency Department Patients with Acute Pulmonary Embolism. Annals of Emergency Medicine 2016. Vol 88 No 3: 277-291
Fields et al. Transthoracic Echocardiography for Diagnosing Pulmonary Embolism: A Systematic Review and Meta-Analysis. J Am Soc Echocardiogr 2017; 30: 714-723
MODULE 8 - RESUSCITATING THE RIGHT VENTRICLE
- Understand the effects of pressure and volume overload on RV function.
- Understand the effects of intrathoracic pressure on RV function.
- Recognise the common clinical scenarios in which RV dysfunction contributes to haemodynamic instability.
- Understand the principles of the management of RV dysfunction.
- One hour pre-reading
- Read the following paper and then reflect of clinical practice in your workplace. Describe and document three similarities or differences you've observed between management of RV dysfunction in your workplace and what is described in the paper. Bring these points to the workshop session.
Price et al. Pulmonary vascular and right ventricular dysfunction in adult critical care: current and emerging options for management: a systematic literature review. Critical Care 2010, 14:R169 http://ccforum.com/content/14/5/R169
module 9 - undifferentiated critical illness
- Undertake a sequenced approach to ultrasound in the critically ill shocked or hypotensive patient.
- Understand the limitations of focused sonography in assessing deranged physiology and guiding treatment.
- Two hours pre-reading
- One hour education and practical workshop
- Read Chapter 5 in Introduction to Bedside Ultrasound (Vol 1)
- Read the original articles describing the RUSH and SEARCH 8ES protocols, as well as the review article published in Journal of Intensive Care on multi-organ ultrasound. Bring a list of 5 limitations of the SEARCH 8S and RUSH protocols to discuss at the practical workshop.
Ha and Toh, Clinically integrated multi-organ point-of-care ultrasound for undifferentiated
respiratory difficulty, chest pain, or shock: a critical analytic review, Journal of Intensive Care (2016) 4:54
Perera et al, The RUSH Exam: Rapid Ultrasound in Shock in the evaluation of the critically ill, Emerg Med Clin N Am 28 (2010) 29–56
Ahn JH, Jeon J, Toh H-C, Noble VE, Kim JS, Kim YS, et al. (2017) SEARCH 8Es: A novel point of care ultrasound protocol for patients with chest pain, dyspnea or symptomatic hypotension in the emergency department. PLoS ONE 12(3): e0174581.
module 10 - administration
- Identify experiential themes within the group based on scanning experience thus far to guide future POCUS mentorship
- Understand the process of submitting imaging studies for accreditation
- One and half hours of facilitated discussion
- No pre-reading requirements
Be prepared to discuss the challenges and successes which have stemmed from your POCUS experiences thus far.
- Ensure an adequate level of baseline knowledge prior to commencing the MUSKETEER program.
- Identify knowledge gaps to enable focuses further study
- Set a minimum standard of knowledge required for POCUS practitioners
- One hour per assessment
- Complete the pre-course assessment prior to commencement of the course.
- Complete the post-course assessment at end of your scanning assessments on day three.