Focus cardiac ultrasound core curriculum and

core syllabus of the European Association of

Cardiovascular Imagingdagger

Aleksandar N Neskovic1 Henry Skinner2Dagger Susanna Price3para Gabriele Via4sect

Stefan De Hert5|| Ivan Stankovic1 Maurizio Galderisi6 Erwan Donal7 Denisa

Muraru8 Erik Sloth9 Luna Gargani10 Nuno Cardim11 Alexandros Stefanidis12

Matteo Cameli13 Gilbert Habib1415 Bernard Cosyns16 Patrizio Lancellotti17

Thor Edvardsen18 and Bogdan A Popescu19

Reviewers This document was reviewed by members of the 2016ndash2018 EACVI Scientific Documents Committee

Victoria Delgado Alessia Gimelli Frank A Flachskampf Pier Giorgio Masci and by external reviewers Nina

Ajmone Marsan Giovanni Di Salvo Kevin Fox Ruxandra Jurcut

1Department of Cardiology Clinical Hospital Center Zemun Vukova 9 11080 Belgrade Faculty of Medicine University of Belgrade Serbia 2Department of AnaesthesiologyNottingham University Hospitals Hucknall Rd Nottingham NG5 1PB UK 3Adult Intensive Care Unit Royal Brompton and Harefield NHS Foundation Trust Sydney StreetLondon SW3 6NP UK 4Department of Anesthesia and Intensive Care Cardiocentro Ticino Via Tesserete 48 6900 Lugano Switzerland 5Department of Anesthesiology andPerioperative Medicine Ghent University Hospital Ghent University Corneel Heymanslaan 10 B-9000 Ghent Belgium 6Department of Advanced Biomedical Sciences FedericoII University Hospital Via S Pansini 5 80131 Napoli Italy 7Department of Cardiology University Hospital of Rennes rue H Le Guillou ndash Hopital Pontchaillou 35000 RennesFrance 8Department of Cardiac Thoracic and Vascular Sciences University of Padua Via Giustiniani 2 35128 Padua Italy 9Department of Anaesthesiology and Intensive CareMedicine Operation and Intensive Care East Section Aarhus University Hospital Skejby 99 Palle Juul-Jensens Boulevard 8200 Aarhus N Denmark 10Institute of ClinicalPhysiology - National Research Council Via Moruzzi 1 56124 Pisa Italy 11Cardiology Department Hospital da Luz Av Lusıada n 100 - 1500-650 Lisbon Portugal 121stDepartment of Cardiology Nikea Hospital 3 P Mela str 18454 Athens Greece 13Department of Cardiovascular Diseases University of Siena Viale Bracci 1 Policlinico LeScotte 53100 Siena Italy 14APHM La Timone Hospital Cardiology Department Boulevard Jean Moulin 13005 Marseille France 15Aix Marseille Univ IRD APHM MEPHI IHU-Mediterranee Infection Boulevard Jean Moulin 13005 Marseille France 16Centrum voor Hart en Vaatziekten (CHVZ) Unversitair Ziekenhuis Brussel Laarbeeklaan 101 1090Brussel Belgium 17Department of Cardiology University of Liege Hospital Domaine Universitaire du Sart Tilman - B35 ndash 4000 Liege Belgium 18Department of CardiologyOslo University Hospital Rikshospitalet and University of Oslo Sognvannsveien 20 NO-0027 Oslo Norway and 19Cardiology Department University of Medicine andPharmacy lsquoCarol Davilarsquo - Euroecolab Institute of Cardiovascular Diseases lsquoProf Dr C C Iliescursquo Sos Fundeni 258 sector 2 022328 Bucharest Romania

Received 3 January 2018 editorial decision 5 January 2018 accepted 8 January 2018 online publish-ahead-of-print 26 February 2018

There is a growing trend of using ultrasound examination of the heart as a first-line diagnostic tool for initial patient evaluation in acutesettings Focus cardiac ultrasound (FoCUS) is a standardized but restricted cardiac ultrasound examination that may be undertaken by arange of medical professionals with diverse backgrounds The intention of this core curriculum and syllabus is to define a unifying frame-work for educational and training processesprogrammes that should result in competence in FoCUS for various medical professionalsdealing with diagnostics and treatment of cardiovascular emergencies The European Association of Cardiovascular Imaging prepared thisdocument in close cooperation with representatives of the European Society of Anaesthesiology the European Association ofCardiothoracic Anaesthesiology the Acute Cardiovascular Care Association of the European Society of Cardiology and the WorldInteractive Network Focused On Critical Ultrasound It aims to provide the key principles and represents a guide for teaching and training

Corresponding author Tel (+381) 64 12 16 359 E-mail neskovichotmailcomdagger The document is endorsed by the Acute Cardiovascular Care Association (ACCA) of the European Society of Cardiology the European Association of CardiothoracicAnaesthesiology (EACTA) the European Society of Anaesthesiology (ESA) and the World Interactive Network Focused On Critical Ultrasound (WINFOCUS)Dagger Representative of the European Association of Cardiothoracic Anaesthesiology (EACTA)para Representative of the Acute Cardiovascular Care Association (ACCA) of the European Society of Cardiologysect Representative of the World Interactive Network Focused On Critical Ultrasound (WINFOCUS)k Representative of the European Society of Anaesthesiology (ESA)

Published on behalf of the European Society of Cardiology All rights reserved VC The Author(s) 2018 For permissions please email journalspermissionsoupcom

European Heart Journal - Cardiovascular Imaging (2018) 19 475ndash481 EACVI CONSENSUSDOCUMENTdoi101093ehjcijey006

Dow

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of FoCUS We offer this document to the emergency and critical care community as a reference outline for teaching materials andcourses related to FoCUS for promoting teamwork and encouraging the development of the field

Keywords echocardiography bull focus bull cardiac ultrasound bull point-of-care ultrasound bull emergency bull education

bull training bull teaching bull limited bedside cardiac ultrasound bull syllabus bull curriculum

Background

Cardiac ultrasound can provide important often life-saving informa-tion in criticalemergency settings Data acquisition depends on spe-cific imaging targets conditions or scenarios the ultrasoundequipment used techniques and protocols applied and related tothe level of training and skill of the operator and the individual opera-torrsquos profile Ideally these examinations should always be performedby an experienced acuteintensive care practitioner appropriatelytrained both in echocardiography and acuteintensive cardiovascularcare12 Although historically cardiologists were almost exclusivelyresponsible for performingsupervising and interpreting echocardio-graphic examinations in acuteemergency settings fully trained cardi-ologists are not always available where medical emergencies occur

The European Association of Cardiovascular Imaging (EACVI) haslong recognized that a range of medical professionals are involved inthe management of cardiovascular emergencies on a daily basis andnot only cardiologists13 These include emergency physicians inten-sive care specialists anaesthesiologists sonographerscardiac physiol-ogists and fellows in training13 Despite their diverse medicalbackgrounds all of them are able to recognize important findings and

obtain key answers in emergency settings by using cardiac ultrasoundprovided they have the appropriate training Indeed from the ethicalpoint of view emergency ultrasound examination of the heart shouldbe performed by any properly trained medical professional and avoiddelay in diagnosis13

There is a growing trend for using cardiac ultrasound as a first-linediagnostic tool for initial patient evaluation in acute settings13

To make critical decisions the attending physician does not necessa-rily need the whole data set of cardiac morphology and function thatis required for a comprehensive echocardiographic exam4 Instead inthe majority of emergency situations restricted information may beused to understand underlying pathophysiology narrow the differen-tial diagnosis initiate therapy andor to trigger further diagnosticwork-up Since the introduction of transthoracic echocardiographyin the hands of non-cardiologists in the late 80 s it has been convinc-ingly demonstrated that relevant information regarding the heart andcirculation in acutely ill patients can be collected by means of rapidechocardiographic scanning protocols5 Current evidence supportsthe contention that operators do not need always to be fully trainedin comprehensive echocardiography in order to obtain crucial diag-nostic information6ndash29

1

3

2

PLAX

PSAX

A4CH

1

1

2SIVC S4CH33

Figure 1 Basic FoCUS examination views From the parasternal window (1) parasternal long-axis (PLAX) and short-axis (PSAX) views can beobtained apical 4-chamber view (A4CH) is obtained from the apical window (2) subcostal inferior vena cava (SIVC) and subcostal 4-chamber(S4CH) views can be obtained from subcostal window (3)

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of FoCUS We offer this document to the emergency and critical care community as a reference outline for teaching materials andcourses related to FoCUS for promoting teamwork and encouraging the development of the field

Keywords echocardiography bull focus bull cardiac ultrasound bull point-of-care ultrasound bull emergency bull education

bull training bull teaching bull limited bedside cardiac ultrasound bull syllabus bull curriculum

Background

Cardiac ultrasound can provide important often life-saving informa-tion in criticalemergency settings Data acquisition depends on spe-cific imaging targets conditions or scenarios the ultrasoundequipment used techniques and protocols applied and related tothe level of training and skill of the operator and the individual opera-torrsquos profile Ideally these examinations should always be performedby an experienced acuteintensive care practitioner appropriatelytrained both in echocardiography and acuteintensive cardiovascularcare12 Although historically cardiologists were almost exclusivelyresponsible for performingsupervising and interpreting echocardio-graphic examinations in acuteemergency settings fully trained cardi-ologists are not always available where medical emergencies occur

The European Association of Cardiovascular Imaging (EACVI) haslong recognized that a range of medical professionals are involved inthe management of cardiovascular emergencies on a daily basis andnot only cardiologists13 These include emergency physicians inten-sive care specialists anaesthesiologists sonographerscardiac physiol-ogists and fellows in training13 Despite their diverse medicalbackgrounds all of them are able to recognize important findings and

obtain key answers in emergency settings by using cardiac ultrasoundprovided they have the appropriate training Indeed from the ethicalpoint of view emergency ultrasound examination of the heart shouldbe performed by any properly trained medical professional and avoiddelay in diagnosis13

There is a growing trend for using cardiac ultrasound as a first-linediagnostic tool for initial patient evaluation in acute settings13

To make critical decisions the attending physician does not necessa-rily need the whole data set of cardiac morphology and function thatis required for a comprehensive echocardiographic exam4 Instead inthe majority of emergency situations restricted information may beused to understand underlying pathophysiology narrow the differen-tial diagnosis initiate therapy andor to trigger further diagnosticwork-up Since the introduction of transthoracic echocardiographyin the hands of non-cardiologists in the late 80 s it has been convinc-ingly demonstrated that relevant information regarding the heart andcirculation in acutely ill patients can be collected by means of rapidechocardiographic scanning protocols5 Current evidence supportsthe contention that operators do not need always to be fully trainedin comprehensive echocardiography in order to obtain crucial diag-nostic information6ndash29

1

3

2

PLAX

PSAX

A4CH

1

1

2SIVC S4CH33

Figure 1 Basic FoCUS examination views From the parasternal window (1) parasternal long-axis (PLAX) and short-axis (PSAX) views can beobtained apical 4-chamber view (A4CH) is obtained from the apical window (2) subcostal inferior vena cava (SIVC) and subcostal 4-chamber(S4CH) views can be obtained from subcostal window (3)

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Focus cardiac ultrasound (FoCUS) is defined as a point-of-care car-diac ultrasound examination performed according to a standardizedbut restricted scanning protocol (Figure 1) as an extension of theclinical examination It is undertaken by an operator not necessarilytrained in comprehensive echocardiography but appropriately trainedin FoCUS who is usually responsible for immediate decision-making andor treatment367 When compared with comprehensiveechocardiography FoCUS is limited by a number of factors includingtime-constraints restricted image acquisition protocol the experienceof the operator and the technical capabilities of available equipment(eg pocket-sized imaging devices) Accordingly there is a risk ofmissing potentially important abnormalities andor misreadingmisinterpretation of an incomplete data set3 These concerns havebeen expressed and addressed in detail by the EACVI in the documenton FoCUS which emphasized the need for specific education and train-ing in FoCUS in order to fully exploit its advantages and mitigate poten-tial risks3 The EACVI viewpoint on FoCUS is summarized in Table 13

Since cardiovascular diseases are often associated with pulmonaryabnormalitiesmanifestations (such as pulmonary oedema and pleuraleffusions) lung ultrasound examination (LUS) is considered in theFoCUS core curriculum17 We believe that LUS limited to the recog-nition of pleural effusions and interstitial syndrome should be per-formed in each case as an integral part of FoCUS examination inanalogy with the physical examination of the patient that alwaysentails auscultation both of the heart and the lungs In addition sinceFoCUS may reveal key information in cardiac arrest that may directlychange the management it is currently integrated in the advancedcardiovascular life support (ACLS) algorithm30ndash32

By definition therefore the content and duration of education andtraining programmes and competency requirements are substantiallydifferent comparing FoCUS with comprehensive echocardiography3

Currently recommendations statements and protocols foreducation and training in FoCUS are defined by a range of diversesocietiesorganizations who are fully responsible for organizingteaching courses and ensuring final competenceskillset of practi-tioners35ndash717ndash2733ndash35 The EACVI recognized that both cardiologists

and non-cardiologists can perform either echocardiography orFoCUS depending on their backgroundtraining the clinical circum-stances existing equipment and expertise3 Indeed the question isnot whether FoCUS should be used by non-cardiologists in situationswhen critical information is needed to direct patient managementbut rather how to define standards for training and education inorder to secure safe and efficient use of FoCUS in emergency cardiaccare3 If FoCUS is performed by an operator not formally authorizedfor clinical decision-making (eg sonographers fellows in training) itis essential to ensure that the findings are promptly communicated tothe physician responsible for patient care

Rationalescopesaims of thiscurriculum and syllabus

Whereas respecting the complexity of the topic and diversity of med-ical professionals who undergo training in FoCUS there is a growingneed to set standards in educationtraining in FoCUS by the EACVI intheir role as a reference echocardiography community The EACVITask Force members believe that the development of defined rec-ommendations for educationtraining and knowledgeskills require-ments is essential to achieve full integration of FoCUS into themanagement of the critically illemergency patient The EACVI TaskForce members also believe that this activity should be coordinatedbetween professional societiesorganizations already involved in edu-cationtraining in FoCUS3 Thus the current document is prepared inclose cooperation with representatives of the European Society ofAnaesthesiology (ESA) the European Association of CardiothoracicAnaesthesiology (EACTA) the Acute Cardiovascular CareAssociation (ACCA) of the European Society of Cardiology and theWorld Interactive Network Focused On Critical Ultrasound(WINFOCUS) This document should therefore provide a goodfoundation for a future collaboration between the EACVI and therespective societiesassociationsorganizations involved in FoCUSeducational and training activities by means of preparing

Table 1 Summary of the EACVI viewpoint on FoCUS

FoCUS should only be used as a point-of-care cardiac ultrasound examination aimed to detect a limited number of critical cardiac conditions

FoCUS may provide key clinical information regarding the presence of pericardial effusioncardiac tamponade left and right ventricular size and

function intravascular volume status and may aid decision-making during cardiopulmonary resuscitation

FoCUS should never be considered or reported as echocardiographic examination

Educational curriculum and training programme for FoCUS should be designed and conducted by the specialty professional organizationssocieties

involved in treating medical emergencies including cardiac with continual collaboration with reference echocardiographic communities

FoCUS should only be used by the operators who have completed appropriate education and training programme and who fully understand and

respect its scope and limitations

Whenever the information about cardiovascular abnormalities provided by the FoCUS exam is insufficient for the immediate or definitive care of

patients these should be referred to a comprehensive echocardiographic examination as soon as possible and as compatible with clinical priorities

FoCUS examinations should be recorded and permanently stored and reports issued in a timely manner

Continual supervision and quality control of the FoCUS examinations are essential provided preferably by accredited echocardiographic laborato-

ries and emergency echocardiography services

Reference echocardiographic community representatives should actively follow developments in the field and whenever appropriate work on improving

educational and training curricula in concert with respective specialities professional societiesorganizations to deliver the best possible care for the patients

Modified from reference 3

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recommendations and consensus documents67 endorsing docu-ments adjusting educational and training programmes organizingresearch projects and joint professional and scientific meetings3 Weoffer this document to the emergency and critical care community asa reference outline for teaching materials and courses related toFoCUS for promoting teamwork and encouraging discussions andthe development of the field

The intention of this core curriculum and syllabus is to define a unify-ing framework for educational and training processesprogrammes thatshould result in competence in FoCUS for various medical professionalsdealing with diagnostics and treatment of cardiac or cardiac-like emer-gencies It aims to provide the key principles and represents a guide forteaching and training of FoCUS providing a platform for a structuredapproach to certification and sources for preparing educational material

Based on this curriculumsyllabus educational and training pro-grammes in FoCUS should

bull enable individuals after appropriate training to identify relevantcritical cardiovascular and lungthoracic pathologies in order todirect andor facilitate immediate patient management

bull clearly state the scope and limitations of FoCUSbull set the basis for development of educational materialsbull set the basis for continuing education in the fieldbull set the basis for individual certification in FoCUS by the EACVI in

the near future

Training candidates

FoCUS utilizes a highly restricted protocol that represents a small partof the standard comprehensive echocardiographic examinationHowever being trained in comprehensive echocardiography does notnecessarily mean that a cardiologistsonographer will inevitably be ableto provide the specific answers demanded by the critical clinical scenariounless they are familiar with this setting This is particularly important incertain aspects of cardiovascular evaluation in particular in the contextof critical care interventions (for example positive pressure ventilationthe use of inotropes or mechanical circulatory support and response tovolume loading) Although cardiologists who have completed basicechocardiography training outlined in the EACVI recommendations36

are qualified to perform echocardiography in all emergency situationsfor optimal use of FoCUS they should be familiar with the FoCUSscope approach and Core Curriculum In this regard they could alsobenefit from additional training in basic LUS and the use of cardiac ultra-sound in cardiac arrest in ACLS-compliant manner and knowledge onthe effects of critical care interventions on ultrasound findings

The educational and training requirements presented in this docu-ment are therefore aimed for both non-cardiologists and cardiologistswho intend to use FoCUS in the emergency setting These require-ments could be recognized and accepted as a standard guide for educa-tion and training for all medical professionals intending to use FoCUS inmedical emergencies irrespective of their speciality This includes (butis not limited to) cardiologists with insufficient formal training in echo-cardiography intensivists anaesthesiologists emergency medicinephysicians traineesfellows in the aforementioned specialties and gen-eral practitioners This document is intended also to serve as the basisfor preparation of the future EACVI certification exam in FoCUS

Training and competence forperformance and interpretationof FoCUS

All education and training programmes on FoCUS should result infull understanding and respect of the scope and limitations ofFoCUS3 Only in this way FoCUS can improve emergency cardiovas-cular care

Basic theoretical knowledge oncardiovascular diseaseSince various medical professionals who intend to use FoCUS mayhave relatively limited knowledge of cardiovascular diseases com-pared with cardiologists additional theoretical learning might beneeded to enable trainees with different medical backgrounds tounderstand interpret and fully integrate cardiac ultrasound findingsinto the clinical context13 The cardiovascular diseasesconditionsproposed by the EACVI for additional learning programmes for non-cardiologists undergoing training on emergency echocardiography1

are addressed in the theoreticalteaching part of FoCUS training pro-grammes (Part 1 in Table 2)3

Learning technique for performingFoCUSFoCUS does not equate to comprehensive echocardiographicexamination1336ndash39 Furthermore FoCUS should be distinguishedfrom lsquogoal-orientedrsquo (targeted) echocardiographic examination per-formed by the fully trained echocardiographer attempting to obtainan answer to a specific often critical and frequently complex clinicaldilemmas (eg failure to wean from mechanical ventilation exclusionof inter-ventricular dyssynchrony echocardiography in mechanicalcirculatory support) In comparison to comprehensive echocardiog-raphy the learning curve for FoCUS is relatively rapid as the contentand duration of training can be simplified and narrowed3 It is impor-tant to appreciate however that the inherently limited approachlinked to FoCUS scanning protocols does not imply substandardimaging technical simplicity and easily achievable competence inFoCUS We believe that full competence in performing FoCUS can-not be achieved in few days no matter how well a particular courseis organized andor how skilled the teachers are Thus although therelevant courses can be delivered in one or a few days they are thestarting point of additional supervised practice until competence inFoCUS is achieved It is especially important to understand thathigher technical skills are often needed for optimal image acquisitionsby FoCUS in unfavourable emergency settings typically using a port-able or pocket size imaging device compared to elective scanning ofstable patients in the echocardiography laboratory with a high-endimaging system low-level lighting and in the left lateral position140

Of note due to the logistics related to emergency cardiovascularcare and due to its limited scope the FoCUS examination providesmostly qualitative assessment of cardiac morphology and functionTherefore widely available low-cost portable hand-held andpocket-size imaging devices are likely to be used more frequently byFoCUS operators instead of fully equipped echocardiographicmachines9ndash16 While in this way FoCUS can be performed in virtually

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all situations where it is needed the inherent limitations of such devi-ces must be considered Trainees should master not only the exami-nation technique but also the interpretation of findings andprofessional communication in a time-sensitive manner This shouldbe clearly explained during the training process and fully appreciatedby both teachers and trainees

Suggested teaching and training targets for FoCUS are listed inTable 3332 Studies demonstrate that identification of these basic but

critical cardiovascular conditions and pathologies by FoCUS332 maybeneficially modify patients management3141ndash51 and predict out-come52ndash56 Any attempt to expand this list of teaching and trainingtargets for FoCUS should be discouraged due to increased risk ofinappropriate use and errors31232 Thus only a simple detection ofabnormally enlarged cardiac chambers signs of severe left and rightventricular dysfunction large pericardial effusion andor extremelyaltered intravascular volume status should be the part of FoCUSexam Although trained FoCUS operators may occasionally identifygross valvular abnormalities large intracardiac masses or strikingregional wall motion abnormalities such patients should be referredto an expert for a comprehensive echocardiographic evaluation3 Inall cases where a cardiac cause is suspected but FoCUS findings arenegative (lsquonormalrsquo) patients should be immediately referred for

Table 2 Minimal educationtraining requirements forachieving competence for performing FoCUS

Part 1 Basic theoretical knowledge on cardiovascular diseasea

Acute coronary syndromeacute myocardial infarction

Mechanical complications of acute myocardial infarction

Acute aortic syndromeaortic dissection

Acute pulmonary embolism

Acute heart failurecardiogenic shock

Acute pericarditis

Cardiac tamponade

Acute myocarditis

Cardiomyopathies

Aortic stenosis

Acute valvular regurgitation

Ventricular hypertrophy

Pneumothorax

Endocarditis

Cardiac sources of embolism (tumours and masses)

Traumatic injuries of the heart

Part 2 Pre-recorded cases review (25 cases)b

LV dilatationdysfunction 4

RV dilatationdysfunction 4

Pericardial effusion 4

Tamponade 3

Hypovolemia 3

Cardiac arrest 3

Pleural effusion 2

LUS B-lines 2

Part 3 Mastering technique for performing FoCUSmdashlog-book (50

cases) to include minimum number of the following conditionsc

LV dilatationdysfunction 5

RV dilatationdysfunction 5

Pericardial effusion or tamponade 3

Hypovolemia 5

Cardiac arrest or peri-arrest 2

Pleural effusion 2

LUS B-lines 3

Competency evaluation should be incorporated in the ongoing training processand required numbers increased if needed to achieve competence of eachtraineeaEssential information of practical clinical importance only (lectures web-basede-learning) (modified from the reference 1)bPattern recognition by online teaching with self-evaluation or reading withexpertscAt least one case in each category must be performed by the trainee underdirect expert supervision the rest of the cases trainee can perform unsupervisedbut the images and reports must be reviewed together with the supervisorLUS lung ultrasound LV left ventricular RV right ventricular

Table 3 Suggested targets of FoCUS examination andrelated emergency cardiovascular scenariosconditionsthat might be addressed

Targets

Global LV systolic function and size

Global RV systolic function and size

Pericardial effusion tamponade physiologya

Intravascular volume assessment

Gross signs of chronic cardiac diseaseb

Gross valvular abnormalitiesc

Large intracardiac massesd

Scenarios

Circulatory compromiseshock

Cardiac arrest

Chest paindyspnoeae

ChestCardiac trauma

Respiratory compromise

Syncopepresyncope

Conditions

Ischaemic LVRV dysfunction

Mechanical post-MI complications

Cardiomyopathies (ie DCM HCM Takotsubo)

Myocarditis

Cardiac tamponade

Pulmonary embolism

Hypovolaemiashock

Modified from references 3 and 32aBased on detection of 2D signs of compression of right-sided chambers (systoliccollapse of the right atrium diastolic collapse of the right ventricle) rather thanDoppler-based study of intracardiac flowsbMajor LV dilatation or severe hypertrophy right ventricular hypertrophy majoratrial dilatationcRecognizable by FoCUS without the use of Doppler-based techniques (eg mas-sive disruption or marked thickening of leaflets flail anatomic gaps)dLarge valve vegetations or visible intracardiac or inferior vena cava massesthrombieSubtle regional wall motion abnormalities as well echocardiographic signs ofacute aortic syndrome are not evidence-based targets for FoCUS thereforedespite actual FoCUS findings all patients with chest pain and suspected acutecoronary syndrome or acute aortic syndrome should be referred as soon as pos-sible to comprehensive echocardiographyDCM dilated cardiomyopathy HCM hypertrophic cardiomyopathy LV left ven-tricular MI myocardial infarction RV right ventricular

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emergency echocardiography examination to be undertaken by anechocardiographer trained to the level of independent operator(Figure 2)1

Numerous high-quality FoCUS courses and programmes are widelyavailable They may have different characteristics (eg not all haveACLS-compliance as a part of syllabus) but several commonalitiesAll of them aim to enable individuals to undertake a focused scan andidentify basic cardiac conditions and pathologies after a short intensiveand narrowly-targeted training51735 These courses should be consid-ered as an introductorystarting point for educationtraining processoffering theoreticaldidactic learning (Table 2 Part 1) reviews of pre-recorded cases together with experts (pattern recognition) (Table 2Part 2) and initial hands-on training on live models or patientsHowever we believe that in order to achieve full competence inFoCUS it is essential that practical training is extended to post-courseproctored ultrasound examinations in real-life scenarios according tothese requirements (Table 2 Part 3) Although it seems unlikely that

strictly predefined minimal number of hours of hands-on image acquisi-tion training or the number of performedinterpreted cases wouldever fit all36717ndash27 the EACVI proposes minimal requirements that iffulfilled should result in competence in performing FoCUS by the vastmajority of trainees (Table 2) Competency evaluation should be incor-porated into the ongoing training process and if needed the proposednumbers in Table 2 may be increased to achieve full competence inFoCUS in all trainees3

Examination technique should be learned first on virtual echo-cardiography simulators live models or stable elective patientsand then mastered in real-life clinical scenarios where FoCUS istypically performed For training not only fully equipped echocar-diographic machines but also portable and pocket-size imagingdevices should be used37 Initially scanning should be performedunder direct proctored supervision Later this can be partiallyreplaced with supervised review of recorded material andreports Every attempt should be made to expose trainees to a

Figure 2 The FoCUS examination by on-call physician did not reveal a potential cause of a cardiac murmur in a young febrile patient(A) Comprehensive echocardiography showed a small ventricular septal defect (B arrow) along with suspicious tricuspid valvevegetation (C arrow) which was confirmed by transoesophageal echocardiography (D arrow) Apical 4-chamber view is shown in panelsA B and C

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case mix that includes a wide range of clinical scenarioscondi-tions that might be addressed by FoCUS3

LUS is a logical companion of FoCUS in everyday clinical practicesince it may help in the differential diagnosis of acute dyspnoeaand hemodynamic instability57ndash60 Thus detection of B-lines(lsquolung cometsrsquo) (Figure 3) and pleural effusion is encompassed in theFoCUS core curriculum

There are not many situations in medicine with such a vital need foraccurate extra information to be used for guiding life-saving patientmanagement as it occurs in cardiac arrest and in the peri-arrest settingIt has been shown that in this scenario FoCUS is more accurate thanECG and physical examination for determining mechanical cardiacfunction and diagnosing the cause of cardiac arrest32 FoCUS may alsodetect the lack of mechanical activity in pulseless electrical activitydirect management change and improve the clinical ability to predictoutcome32 It is essential however that brief FoCUS assessment isfully integrated into ACLS algorithm in a time-sensitive manner with-out interruption of chest compressions (ie every 2 min within thepulse-check time ideally from the subcostal viewmdashat least as astart)306162 There is an evidence that even highly-experienced echo-cardiographers require specific training in this regard303161ndash64

Trainees should be taught to record and store FoCUS examina-tions whenever possible and to issue the reports in a timely manner3

Stored data can then be used for documentation case reviews andconsultations but also for quality control and medico-legal purposes3

Trainees should be advised to never consider or report FoCUS asa standard echocardiographic examination to always specify in thereport the clinical setting and the indication for examination and toensure that they practice within the defined governance structures oftheir institution2

Trainers (proctors) and supervisors can be practitioners with cardi-ology intensive care anaesthesiology or emergency medicine back-ground either fully trained and preferably certified in echocardiographyby national or international authorities (ie EACVI) or fully trained inFoCUS with significant experience in emergency andor critical care

Core syllabus

The FoCUS Core Syllabus of the EACVI describes the fundamentalknowledge required for the accurate practice of FoCUS and providesa framework for FoCUS education and training Additionally it repre-sents part of the recently updated Echocardiography Core Syllabusof the EACVI3738 modified according to the restricted scope ofFoCUS and in line with existing documents proposed by respectivespecialty societiesassociationsorganizations already engaged inFoCUS education and training173265

It is strongly recommended that all FoCUS practitioners undertakespecific training in the use of FoCUS as a part of ACLS algorithm (ieFocus Assessed Transthoracic EchocardiographymdashFATE5 FocusedEchocardiography in Emergency Life SupportmdashFEEL66 or similar) inorder to achieve necessary proficiency

It should be recognized that all individuals who have undergone fulltraining in echocardiography andor have successfully passed theEACVI certification process may be considered able to performFoCUS in a competent way with three provisions First that they arefamiliar with FoCUS scope approach and Core Curriculum Secondthat they have completed additional training in basic LUS Third thatthey have undertaken specific training in the use of FoCUS as a part ofACLS algorithm with a focus on the expected pathologies communi-cation of findings to the resuscitation team and ACLS compliance

Focus Cardiac Ultrasound(FoCUS) Core Syllabus of theEuropean Association ofCardiovascular Imaging 2018

BasedModifiedAccording to

(1) Cosyns B Garbi M Separovic J Pasquet A Lancellotti P EducationCommittee of the European Association of Cardiovascular Imaging

Figure 3 Lung ultrasound in a patient with incipient pulmonary oedema showing multiple bilateral vertical white lines (B-lines arrows) consistentwith extravascular lung water Left panel left lung right panel right lung

Focus cardiac ultrasound core curriculum and core syllabus 481D

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Association (EACVI) Update of the echocardiography core syllabusof the European Association of Cardiovascular Imaging (EACVI)Eur Heart J Cardiovasc Imaging 201314837ndash9

(2) Via G Hussain A Wells M Reardon R El Barbary M Noble VE et alInternational Liaison Committee on Focused Cardiac UltraSound(ILC-FoCUS) International Conference on Focused CardiacUltraSound (IC-FoCUS) International evidence-based recommenda-tions for focused cardiac ultrasound J Am Soc Echocardiogr 2014Jul27(7)683e1ndashe33 (Supplement BASIC ECHO (WBE) FocusedCardiac Ultrasound Competence-based CURRICULUM)

(3) Core Ultrasound Intensive Care (CUSIC) Accreditation pack(4) Focused Echocardiography in Emergency Life Support (FEEL)

Resuscitation Council (UK) httpswwwresusorgukinformation-on-coursesfocused-echocardiography-in-emergency-life-support(28 January 2018 date last accessed)

(5) Breitkreutz R Walcher F Seeger FH Focused echocardiographicevaluation in resuscitation management concept of an advanced lifesupport-conformed algorithm Crit Care Med 200735(5Suppl)S150-61

(6) Price S Via G Sloth E Guarracino F Breitkreutz R Catena E et alWorld Interactive Network Focused On Critical UltraSoundECHO-ICU Group Echocardiography practice training and accred-itation in the intensive care document for the World InteractiveNetwork Focused on Critical Ultrasound (WINFOCUS)Cardiovasc Ultrasound 2008649 doi1011861476-7120-6-49

(7) Fletcher SN Grounds RM Critical care echocardiography clearedfor take up BJ Anaesth 2012109440ndash2

(8) Jensen MB Sloth E Larsen KM Schmidt MB Transthoracic echocar-diography for cardiopulmonary monitoring in intensive care Eur JAnaesthesiol 200421700ndash7

(9) Focused Intensive Care Echo (FICE) httpwwwicsacukICSficeaspx (28 January 2018 date last accessed)

I General principles of Focus Cardiac Ultrasound (FoCUS)(1) Scientific background supporting the use of FoCUS(2) Differences between FoCUS and comprehensive

echocardiography(3) Indications for FoCUS

h Targetsbull Global LV systolic functionbull Global right ventricle (RV) systolic functionbull Pericardial effusion tamponade physiologybull Intravascular volume assessment and fluid

responsivenessbull Signs of pre-existing cardiac disease (marked ventric-

ular dilatation or hypertrophy atrial dilatation)bull Gross valvular abnormalitiesbull Large intracardiac masses

h Scenariosbull Circulatory compromiseshockbull Cardiac arrestperi-arrestbull Chest painDyspnoeabull Chestcardiac traumabull Respiratory compromisebull PresyncopePresyncope

(4) Limitations of FoCUS (compared to comprehensiveechocardiography)h Inferiority of the imaging devices typically used for FoCUS

examination

h Narrow list of detectable evidence-based targetsh Limited data set due to restricted image acquisition

protocolh Typically unfavourable settings (emergencies critically ill

time constrains)h lsquoAbsentPresentrsquo or lsquoYesNorsquo reporting styleh SubtleComplex cardiac abnormalities difficult to assess

II Basic ultrasound instrumentation and knobology(1) Digital ultrasound machines

h High-end ultrasound systemsh Portable ultrasound machinesh Pocket-size ultrasound devices

(2) Image display analysis and storageh Pixelsmdasheffect on image resolutionh Display devicesmdashdigital monitors flat screenh Display controlsmdashbrightness contrasth Off-line image analysisreportingh Storagemdashtemporarypermanent

(3) Probes suitable for FoCUS and their differencesh Transthoracic cardiac phased-array transducer is the pre-

ferred probe for FoCUSh Microconvex and abdominal transducers are not ideal for

FoCUS although their use may be considered when noother probes are available

h Vascular linear probes are not suitable for FoCUS(4) Setting up the ultrasound machine

h Default settingsbull Cardiacnon-cardiac (abdominal obstetricsgynaecol-

ogy vascular) presetsh Frequency

bull The relation between the frequency image qualityand penetration

h Depthh Sector widthh Gain

bull Overall gain and image brightnessbull Choosing gain in different imaging environments

h Time-gain compensationbull Changing the brightness in different regions of the

imageh Focus

bull Positioning the focus pointbull Dual- and multi-focal imaging

h Frame ratebull Temporal versus lateral resolution

h Zoomh Acoustic power

bull Definitionbull The trade-off between improved image quality and

the risk of biological effectsh Harmonic vs fundamental imaging

bull Definitionbull Image quality vs image resolution

h Machine settings affecting spatial (axial and lateral)resolution

h Machine settings affecting temporal resolutionIII Anatomy and physiology of the heart and great vessels

(1) Left ventricleh Dimensionsh Wall thickness

481a AN Neskovic et alD

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h Global LV systolic functionh Gross regional wall motion abnormalities

(2) RVh Dimensionsh Global RV systolic functionh Echo findings of RV volumepressure overloadh Moderator band

(3) Left atriumh Dimensions

(4) Right atriumh Dimensions

(5) Interventricular septummdashmorphology and motion [ie septalflattening in the short-axis (SAX) view]

(6) Interatrial septummdashmorphology and motion (ie septalbowing to the left or right)

(7) Inferior vena cava (IVC)h Dimensions (end expiration)h Collapsibility on inspiration (spontaneous breathing)h Distensibility at inspiration (mechanical ventilation)

(8) Great vesselsh Aorta

bull Ascending aortah Pulmonary artery

(9) Mitral valve apparatush Leaflets (anterior posterior) commisuresh Chordae tendineaeh Annulush Papillary muscles

(10) Aortic valveh Cusps commissures annulus

(11) Tricuspid valveh Leaflets (anterior septal posterior)

(12) Pulmonary valve(13) Pericardium

h epicardial fat (vs pericardial effusion)IV The FoCUS exam

(1) Image acquisition principlesh Technical considerations

bull Appropriate use of equipment controlsbull Recognition of technical artefactsbull Recognition of setup errors

(2) Standard FoCUS scanningh ECG monitoring (whenever possible)h Respiratory cycle monitoring (constriction tamponade)h Standard FoCUS windows2D views

bull Parasternal Long-axis (LAX) view of the LV SAX view of the LV (at the level of the papillary

muscles)bull Apical

4-chamber view (4CH)bull Subcostal

IVC view Subcostal 4CH view

(3) Principles of echo measurementsh Timing (end-diastoleend-systole)h 2D echo (current recommendations)

bull 2D still end-diastolicend-systolic frameh M-modemdashonly if it is feasible to align cursor perpendicular

to the measured structure

h Pitfalls and limitationsbull Image quality drop-outs poor cavity outlinebull Worse border delineation on frozen frames vs

moving 2D imagebull Poor RV borders delineation including IVS right side

border

V Targets of the FoCUS exam(1) Screening for signs of chronic pre-existing cardiac disease

Qualitative (eye-balling) assessment of heart chamber size and sizevariation (relevant LA and LV dilatation marked LV hypertrophyRA dilatation RV dilatation with hypertrophy relevant valvecalcifications)

(2) Global LV systolic function1 FoCUS measures of global LV systolic function

h Visual ejection fractionh Visual fractional area change (mid-papillary SAX view)

2 Conditions requiring caution in global LV systolic functioninterpretation (afterload and preload dependence)h Bradycardia and tachycardiah Severe hypotension and hypertensionh Mitralaortic regurgitationh Aortic stenosissevere hypertrophyh Mitral stenosish Ventricular septal defecth Severe anaemia hyperthyroidism other hyperdynamic

states (sepsis)h LV underfillingh Inotropes

3 Regional LV systolic functionh Myocardial segmentation and coronary territories of

distributionh Wall motion analysismdashgross wall motion abnormalitiesh Qualitative

bull Endocardial motion with concomitant myocardialthickening

bull Hyperkinesis Normokinesis Hypokinesis AkinesisDyskinesis

bull Scar recognition (wall thinning hyperechogenicity)h Awareness of limitations related to limited scanning views

and expertiseh Awareness of need for referral to comprehensive echocar-

diography in patients with detectedsuspected abnormalities(3) Basic assessment of global RV systolic function

1 Visual estimation of global RV ejection fractionh Hallmarks of RV failure

bull dilatationbull free wall hypokinesiabull septal dyskinesiaflattening

2 Acute vs chronic cor pulmonaleh morphological clues towards chronic pulmonary hypertension

(marked RV hypertrophy RV dilatation)(4) Assessment of volume status

1 Severe hypovolemia and volume responsivenessh Rationale for the use of FoCUS to assess volume statush Echocardiographic features of severe hypovolemia

bull small hyperkinetic LV (visual assessment)bull small hyperkinetic RV (visual assessment)bull small IVC (lt12 mm)

h Effect of positive pressure mechanical ventilation on IVC size

Focus cardiac ultrasound core curriculum and core syllabus 481bD

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h Expected changes of IVC and LV size upon volume status

manipulationbull 2D indices of volume responsivenessbull 2D dynamic indices of volume responsiveness IVC

collapsibility IVC distensibilitybull criteria of applicability of dynamic indices of volume

responsivenessh Vasodilation vs hypovolaemia

bull In both cases end-systolic area will be small In caseof vasodilation end-diastolic area will be either nor-mal or only slightly reduced In case of hypovolemiaend-diastolic area will be much reduced

h Challenging situations for volume status assessmentbull Non-passive mechanical ventilationbull Concurrent cardiac disease (arrhythmia valve dis-

ease acute RV myocardial infarction chronic cor pul-monale dilated cardiomyopathy)

2 Volume overloadh FoCUS features of systemic venous congestionh Interpretation of a systemic venous congestion IVC patternh Interatrial septum position

(5) Assessment of pericardial effusion and cardiac tamponade1 Pericardial effusion

h Diagnosis of pericardial effusionh Differential diagnosis

bull Pericardial effusion vs pleural effusionbull Pericardial effusion vs epicardial fatbull Pericardial effusion vs hematomaclot

h Semi-quantitation of pericardial fluid2 2D signs of cardiac tamponade

h Irrelevance of effusion amount for the diagnosis of tamponadeh Echocardiographic signs supporting the diagnosis of

(impending) cardiac tamponade (heart chambers compres-sion systemic venous congestion)bull RA systolic collapsebull RV diastolic collapsebull LA collapse (rare)bull IVC plethorabull Swinging heart

h Cardiac tamponade despite no detectable echocardio-graphic features (clinical basis of tamponade diagnosis)

h Localized collectionsmdashpericardial hematoma (after cardiacsurgery interventional cardiology procedures)mdashcannot beruled out by FoCUS

(6) Gross assessment of heart valves1 Goals and limitations of cardiac ultrasound valves assessment

by FoCUSh FoCUS aim trigger formal comprehensive echocardiography

once gross heart valve abnormalities are suspected2 Mitral valve

h Normal mitral valve morphology and functionbull thin leaflets complete opening complete closure at

annulus levelh Mitral valve findings associated with severe dysfunction

bull morphological (marked leaflet thickening calcifica-tions masses lsquoholesrsquo)

bull functional (hypermobility hypomobility)h Clues towards chronic mitral valve disease

bull marked calcifications LA enlargement LV enlarge-ment RV dilatation and hypertrophy

3 Aortic valveh Normal aortic valve morphology and function

bull Thin leaflets complete opening complete closure atannulus level

h Aortic valve findings associated with severe dysfunctionbull Morphological (marked cusps thickening calcifica-

tions masses lsquoholesrsquo)bull Functional [(hypermobility hypomobility prolapse

into left ventricular outflow tract (LVOT)]h Clues towards chronic aortic valve disease

bull marked calcifications LV Hypertrophy LV dilationLA enlargement

(7) Large intracardiac massesh Large valve vegetations or visible intracardiac or inferior

vena cava massesthrombih FoCUS aim with the exception of right heart thrombus

suspected in the context of cardiac arrest detectionof masses should trigger formal comprehensiveechocardiography

VI FoCUS in cardiac arrest and peri-arrest(1) Rationale and indications of the use of FoCUS in cardiac arrest

and peri-arrest scenarios (non-shockable rhythms)(2) Specific goals of the use of FoCUS in cardiac arrest (differen-

tiation of electro-mechanical dissociation (lsquoTrue PEArsquo) fromorganized mechanical contraction with no pulse (lsquoPseudo-PEArsquo) early detection of return of spontaneous circulationidentification of potentially treatable causes)

(3) PEA conditions detectable with FoCUS in cardiac arrest(mechanical causes of PEA severe hypovolemia massive pul-monary embolism cardiac tamponade dramatic LV dysfunc-tion pneumothorax)

(4) Asystole confirmation (cardiac standstill)(5) The FEEL protocol

h Advanced cardiovascular life support (ACLS) complianceof FoCUS in cardiac arrest

h The FEEL protocol [cardiopulmonary resuscitation (CPR)and preparation execution CPR resumption interpreta-tion and management]

VII FoCUS in shock andor dyspnoea(1) FoCUS patterns in shock

h Acute LV failureh Acute RV failureh Acute biventricular failureh Hypovolemiavasodilatationh Cardiac tamponadeh Suspected acute valve disease

(2) Interpretation of FoCUS findings in clinical context(3) Immediate referral for comprehensive echocardiography in

situations going beyond FoCUS diagnostic capabilityh Doubtfulinconclusive findingsh Acute chest painmdashsuspected acute coronary syndromeh Suspected acute aortic syndromeh Chronic heart diseaseh Suspected valve diseaseh Findings not matching with the clinical context

(4) Simplified FoCUS reporting(5) Wet lungs patternmdashmultiple diffuse bilateral B-lines (lung

lsquocometsrsquo) by LUSVIII Lung ultrasound (LUS)

(1) Pleural effusionh Ultrasound appearances of pleural fluid

481c AN Neskovic et alD

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h Assessment of size of effusionh Distinguishing between pleural pericardial and abdominal

fluid collection(2) Wet lungs pattern (B-linesmdashlung lsquocometsrsquo)

h Recognition of interstitial syndromebull Recognition of B-linesbull Differentiating between physiological and pathological

B-lines (multiple diffuse bilateral B-lines)IX Acknowledged competence in FoCUS after completion of training

process(1) Understanding of basic instrumentation of ultrasound

machines(2) Optimization of depth sector width zoom frequency har-

monics focus overall gain sectorial gain reject compres-sion dynamic range m-mode sweep speed

(3) Ability to obtain 2D FoCUS scan views(4) Ability to recognize basic ultrasound anatomy of heart cham-

bers valves great vessels and pericardium(5) Application of M-Mode on LV [parasternal long-axis veiw

(PLAX) or parasternal short axis view (PSAX)] and IVC (sub-costal inferior vena cava (SIVC) view]

(6) Correct qualitative assessment of the size of LV RV LA RA(screening for signs of chronic cardiac disease LV dilatationhypertrophy LA dilatation RV dilatationhypertrophy RAdilatation)

(7) Correct linear measure of RV free wall thickness (for detec-tion of signs of chronic RV diseasemdashchronic cor pulmonale)

(8) Correct linear measure of heart chambers size(9) Digital storage of images and clips and digital archive

management(10) Ability to differentiate normal from abnormal global LV sys-

tolic function(11) Ability to detect large wall motion abnormalities(12) Understanding of potential causes of a global and regional

wall motion abnormalities(13) Ability to appreciate dynamic changes of LV systolic function

(improvement deterioration) due to evolution of the diseaseandor effects of treatment

(14) Differentiation of normal from abnormal RV systolic function(15) Understanding of potential causes of RV failure(16) Ability to appreciate dynamic changes of RV systolic function

(improvement deterioration) due to evolution of the diseaseandor effects of treatment

(17) Visual estimation of LV size (PSAX subcostal short axisviews)

(18) Visual estimation of IVC size (SIVC view)(19) Measurement of IVC size (SIVC view)(20) Recognition of the lsquoclassicalrsquo hypovolemic profile in the spon-

taneously breathing patient (hyperdynamic LV and RV smallIVC)

(21) Recognition of the lsquoclassicalrsquo hypovolemic profile in themechanically ventilated patient (hyperdynamic LV and RVsmall IVC)

(22) Measurement of IVC collapsibility index (SIVC viewmdash2Dand M-Mode)

(23) Measurement of IVC distensibility index (SIVC viewmdash2Dand M-Mode)

(24) Correct interpretation of IVC findings in light of ongoingmechanical ventilation and potential concurrent cardiacdisease

(25) Recognition for the need of volume responsiveness assess-ment tools other than FoCUS

(26) Understanding of potential causes of hypovolemia and sys-temic venous congestion

(27) Ability to visually appreciate LV size and IVC variations uponvolume status manipulations

(28) Understanding of potential causes of vasodilation and differ-ential diagnosis of vasodilatation vs hypovolemia

(29) Detection of pericardial effusion assessment of its echoge-nicity (fluid vs clothematoma) amount estimation

(30) Differentiation of pericardial effusion from pericardial fat padand pleural effusion

(31) Recognition of RA systolic collapse (A4CH and S4CH views)RV diastolic collapse [PLAX A4CH and subcostal four cham-ber (S4CH) views] and LA systolic collapse (PLAX andA4CH views)

(32) Recognition of tamponade effects on IVC(33) Clinical diagnosis of tamponade recognition of confounding

factors potentially sustaining a diagnosis of tamponadedespite no clear echo features (post-surgical setting pulmo-nary hypertension RV failure RV hypertrophy)

(34) Indication to pericardiocentesis(35) Visualization of the mitral valve in more than one plane

(PLAX apical 4CH)(36) Recognition of 2D signs potentially associated with severe

mitral regurgitation (eg flail prolapse masses missed coap-tation disruption)

(37) Recognition of 2D signs potentially associated with severemitral stenosis (eg marked thickening diastolic hypomobil-ity LA enlargement)

(38) Visualization of the aortic valve (PLAX)(39) Recognition of 2D signs potentially associated with severe

aortic regurgitation (eg cusp prolapse into LVOT missedcoaptation masses disruption)

(40) Recognition of 2D signs potentially associated with severeaortic stenosis (eg marked cusps thickening andor calcifica-tions systolic hypomobility LV hypertrophy)

(41) Understanding of potential causes of severe mitral disease(post-infarction papillary muscle rupture acute endocarditissevere regurgitationstenosis in the setting of chronic valvedisease)

(42) Understanding of potential causes of severe aortic disease(acute endocarditis severe stenosisregurgitation in the set-ting of chronic valve disease)

(43) Appropriately referring the patient with suspected valve dis-ease to comprehensive echocardiographic assessment

(44) Application of FoCUS in cardiac arrest according to correctindication (non-shockable rhythms) along with execution ofCPR according to ACLS guidelines

(45) Recognition of FoCUS findings of PEA (cardiac standstill)(46) Correct preparation of FoCUS for FEEL(47) Timely execution of FoCUS in cardiac arrest (after minimum

5 CPR cycles within the pulse check time anticipated conclu-sion when required)

(48) Correct execution of FoCUS in cardiac arrest (subcostalview first video clips acquisition and storage)

(49) Appropriate interaction and communication with ACLSteam during FoCUS examination in cardiac arrest

(50) Appropriate action plan generation upon FoCUS findings incardiac arrest and simplified FoCUS reporting (delayed)

Focus cardiac ultrasound core curriculum and core syllabus 481dD

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ehjcimagingarticle-abstract1954754909812 by guest on 06 February 2019

(51) Approaching shock (and dyspnoea) systematically recog-

nition of tamponade LV failure RV failure biventricularfailure hypovolemia severe (acute) valve disease wetlungs

(52) Integration of FoCUS findings with available clinical biochem-ical and other findings in order to detect the cause of shockdyspnoea (tamponade hypovolemia cardiomyopathy acutemyocardial infarction acute pulmonary embolism sepsisadult respiratory distress syndrome severe (acute) valve dis-ease myocarditis toxins post-cardiac arrest acute aorticsyndrome trauma)

(53) Acknowledgement of the need for a comprehensive echo-cardiographysecond opinion in shock patient

(54) Acknowledgement of the need for a comprehensive echo-cardiography in patient with acute chest pain and suspectedacute aortic syndrome or acute coronary syndrome

(55) Appropriate action plan generation upon FoCUS findings inshockdyspnoea and simplified FoCUS reporting

(56) LUS diagnosis of pleural effusion(57) LUS diagnosis of pulmonary oedema (wet lung pattern)(58) Understanding of potential role of FoCUS in cardiac arrest

shock and dyspnoea(59) Full understanding of limitations of FoCUS and the need for

referral to comprehensive echocardiographic examination(60) Understanding and full acceptance of the role of supervision

and team work

Core Syllabus Abbreviations list

4CH four chamber (view)2D two-dimensionalA4CH apical four chamber (view)ACLS Advanced Cardiovascular Life SupportARDS adult respiratory distress syndromeCPR cardiopulmonary resuscitationFAC fractional area changeFEEL Focused Echocardiography in Emergency Life SupportFoCUS focused cardiac ultrasoundIVC inferior vena cavaLA left atriumLAX long-axis (view)LV left ventricleLUS lung ultrasoundEF ejection fractionLVOT left ventricular outflow tractPEA pulsless electrical activityPLAX parasternal long axis (view)PSAX parasternal short axis (view)RA right atriumROSC return of spontaneous circulationRV right ventricleS4CH subcostal four chamber (view)SAX short axis (view)SSAX subcostal short axis (view)SIVC subcostal inferior vena cava (view)

Conflict of interest ES is co-founder of USABCD Ltd providinge-learning in ultrasound No conflicts of interest reported by otherauthors

References1 Neskovic AN Hagendorff A Lancellotti P Guarracino F Varga A Cosyns B

Emergency echocardiography the European Association of CardiovascularImaging recommendations Eur Heart J Cardiovasc Imaging 2013141ndash11

2 Lancellotti P Price S Edvardsen T Cosyns B Neskovic AN Dulgheru R et alThe use of echocardiography in acute cardiovascular care recommendations ofthe European Association of Cardiovascular Imaging (EACVI) and the AcuteCardiovascular Care Association (ACCA) Eur Heart J 201543ndash5

3 Neskovic AN Edvardsen T Galderisi M Garbi M Gullace G Jurcut R et alFocus cardiac ultrasound the European Association of Cardiovascular Imagingviewpoint Eur Heart J Cardiovasc Imaging 201415956ndash60

4 Steeds RP Garbi M Cardim N Kasprzak JD Sade E Nihoyannopoulos P et alEACVI appropriateness criteria for the use of transthoracic echocardiography inadults a report of literature and current practice review Eur Heart J CardiovascImaging 2017 doi101093ehjcijew333

5 Jensen MB Sloth E Larsen KM Schmidt MB Transthoracic echocardiography forcardiopulmonary monitoring in intensive care Eur J Anaesthesiol 200421700ndash7

6 Labovitz AJ Noble VE Bierig M Goldstein SA Jones R Kort S et al Focused car-diac ultrasound in the emergent setting a consensus statement of the AmericanSociety of Echocardiography and American College of Emergency PhysiciansJ Am Soc Echocardiogr 2010231225ndash30

7 Spencer KT Kimura BJ Korcarz CE Pellikka PA Rahko PS Siegel RJ Focusedcardiac ultrasound recommendations from the American Society ofEchocardiography J Am Soc Echocardiogr 201326567ndash81

8 Sicari R Galderisi M Voigt J-U Habib G Zamorano JL Lancellotti P et al Theuse of pocket-size imaging devices a position statement of the EuropeanAssociation of Echocardiography Eur J Echocardiogr 20111285ndash7

9 Galderisi M Santoro A Versiero M Lomoriello VS Esposito R Raia R et alImproved cardiovascular diagnostic accuracy by pocket size imaging device innon-cardiologic outpatients the NaUSiCa (Naples Ultrasound Stethoscope inCardiology) study Cardiovasc Ultrasound 20102651

10 Prinz C Voigt JU Diagnostic accuracy of a hand-held ultrasound scanner in routinepatients referred for echocardiography J Am Soc Echocardiogr 201124111ndash6

11 Andersen GN Haugen BO Graven T Salvesen O Mjoslashlstad OC Dalen HFeasibility and reliability of point-of-care pocket-sized echocardiography Eur JEchocardiogr 201112665ndash70

12 Mjoslashlstad OC Andersen GN Dalen H Graven T Skjetne K Kleinau JO et alFeasibility and reliability of point-of-care pocket-size echocardiography per-formed by medical residents Eur Heart J Cardiovasc Imaging 2013141195ndash202

13 Esposito R Ilardi F Schiano Lomoriello V Sorrentino R Sellitto V Giugliano Get al Identification of the main determinants of abdominal aorta size a screeningby Pocket Size Imaging Device Cardiovasc Ultrasound 2017152

14 Scholten C Rosenhek R Binder T Zehetgruber M Maurer G Baumgartner HHand-held miniaturized cardiac ultrasound instruments for rapid and effectivebedside diagnosis and patient screening J Eval Clin Pract 20051167ndash72

15 Liebo MJ Israel RL Lillie EO Smith MR Rubenson DS Topol EJ Is pocketmobile echocardiography the next-generation stethoscope A cross-sectionalcomparison of rapidly acquired images with standard transthoracic echocardiog-raphy Ann Intern Med 201115533ndash8

16 Liu SC Chang WT Huang CH Weng TI Ma Matthew HM Chen WJ The valueof portable ultrasound for evaluation of cardiomegaly patients presenting at theemergency department Resuscitation 200564327ndash31

17 Price S Via G Sloth E Guarracino F Breitkreutz R Catena E et al WorldInteractive Network Focused On Critical UltraSound ECHO-ICU GroupEchocardiography practice training and accreditation in the intensive care docu-ment for the World Interactive Network Focused on Critical Ultrasound(WINFOCUS) Cardiovasc Ultrasound 2008649

18 Mayo PH Beaulieu Y Doelken P Feller-Kopman D Harrod C Kaplan A et alAmerican College of Chest PhysiciansLa Societe de Reanimation de LangueFrancaise statement on competence in critical care ultrasonography Chest 20091351050ndash60

19 American College of Emergency Physicians Emergency Ultrasound Guidelines2008 httpwwwaceporg (10 March 2017 date last accessed)

20 Hellmann DB Whiting-Orsquokeefe Q Shapiro EP Martin LD Martire C ZiegelsteinRC The rate at which residents learn to use hand-held echocardiography at thebedside Am J Med 20051181010ndash8

21 Vignon P Mucke F Bellec F Marin B Croce J Brouqui T et al Basic critical careechocardiography validation of a curriculum dedicated to noncardiologist resi-dents Crit Care Med 201139636ndash42

22 Jones AE Tayal VS Kline JA Focused training of emergency medicine residentsin goal-directed echocardiography a prospective study Acad Emergency Med2003101054ndash8

23 Martin LD Howell EE Ziegelstein RC Martire C Shapiro EP Hellmann DBHospitalist performance of cardiac hand-carried ultrasound after focused train-ing Am J Med 20071201000ndash4

481e AN Neskovic et alD

ownloaded from

httpsacademicoupcom

ehjcimagingarticle-abstract1954754909812 by guest on 06 February 2019

24 Royse CF Seah JL Donelan L Royse AG Point of care ultrasound for basic hae-

modynamic assessment novice compared with an expert operator Anaesthesia200661849ndash55

25 Mayo PH Training in critical care echocardiography Ann Intensive Care 201113626 Expert Round Table on Ultrasound in ICU International expert statement on

training standards for critical care ultrasonography Intensive Care Med 2011371077ndash83

27 Fletcher SN Grounds RM Critical care echocardiography cleared for take upBr J Anaesth 2012109440ndash2

28 Haji DL Ali MM Royse A Canty DJ Clarke S Royse CF Interatrial septummotion but not Doppler assessment predicts elevated pulmonary capillarywedge pressure in patients undergoing cardiac surgery Anesthesiology 2014121719ndash29

29 Alsaddique A Royse AG Royse CF Mobeirek A El Shaer F AlBackr H et alRepeated monitoring with transthoracic echocardiography and lung ultrasoundafter cardiac surgery feasibility and impact on diagnosis J Cardiothorac VascAnesth 201630406ndash12

30 Breitkreutz R Walcher F Seeger FH Focused echocardiographic evaluation inresuscitation management concept of an advanced life support-conformed algo-rithm Crit Care Med 200735S150ndash61

31 Breitkreutz R Price S Steiger HV Seeger FH Ilper H Ackermann H et alEmergency Ultrasound Working Group of the Johann Wolfgang Goethe-University Hospital Frankfurt am Main Focused echocardiographic evaluation inlife support and periresuscitation of emergency patients a prospective trialResuscitation 2010811527ndash33

32 Via G Hussain A Wells M Reardon R El Barbary M Noble VE et alInternational Liaison Committee on Focused Cardiac UltraSound (ILC-FoCUS)International Conference on Focused Cardiac UltraSound (IC-FoCUS)International evidence-based recommendations for focused cardiac ultrasoundJ Am Soc Echocardiogr 201427683e1ndash683e33

33 Gullace G Demicheli G Monte I Colonna P Carerj S Caso P et alReclassification of echocardiography according to the appropriateness of usefunction- and competence-based profiles and application J Cardiovasc Echogr20122291ndash8

34 Gullace G Demicheli G Monte I Colonna P Carerj S Caso P et al Educationalpathway indication quality process of the novel Echo classification according toappropriateness of use and application J Cardiovasc Med 201415674ndash82

35 Price S Ilper H Uddin S Steiger HV Seeger FH Schellhaas S et alPeriresuscitation echocardiography training the novice practitioner Resuscitation2010811534ndash9

36 Popescu BA Andrade MJ Badano LP Fox KF Flachskampf FA Lancellotti Pet al On behalf of the European Association of Echocardiography EuropeanAssociation of Echocardiography recommendations for training competenceand quality improvement in echocardiography Eur J Echocardiogr 200910893ndash905

37 Update of the Echocardiography Core Syllabus of the European Association ofCardiovascular Imaging (EACVI) httpsacademicoupcomehjcimagingarticle1498372397756Update-of-the-Echocardiography-Core-Syllabus-of (10 March2017 date last accessed)

38 Cosyns B Garbi M Separovic J Pasquet A Lancellotti P Education Committeeof the European Association of Cardiovascular Imaging Association (EACVI)Update of the echocardiography core syllabus of the European Association ofCardiovascular Imaging (EACVI) Eur Heart J Cardiovasc Imaging 201314837ndash9

39 Gillebert TC Brooks N Fontes-Carvalho R Fras Z Gueret P Lopez-Sendon Jet al ESC core curriculum for the general cardiologist (2013) Eur Heart J 2013342381ndash411

40 Popescu BA Stefanidis A Nihoyannopoulos P Fox KF Ray S Cardim N et alUpdated standards and processes for accreditation of echocardiographic labora-tories from the European Association of Cardiovascular Imaging Eur Heart JCardiovasc Imaging 201415717ndash27

41 Rozycki GS Feliciano DV Ochsner MG Knudson MM Hoyt DB Davis F et alThe role of ultrasound in patients with possible penetrating cardiac wounds aprospective multicenter study J Trauma 199946543ndash51

42 Mayron R Gaudio FE Plummer D Asinger R Elsperger J Echocardiography per-formed by emergency physicians impact on diagnosis and therapy Ann EmergMed 198817150ndash4

43 Tayal VS Kline JA Emergency echocardiography to detect pericardial effusion inpatients in PEA and near-PEA states Resuscitation 200359315ndash8

44 Chardoli M Heidari F Rabiee H Sharif-Alhoseini M Shokoohi H Rahimi-Movaghar V Echocardiography integrated ACLS protocol versus conventionalcardiopulmonary resuscitation in patients with pulseless electrical activity cardiacarrest Chin J Traumatol 201215284ndash7

45 Jones AE Craddock PA Tayal VS Kline JA Diagnostic accuracy of left ventricularfunction for identifying sepsis among emergency department patients with non-traumatic symptomatic undifferentiated hypotension Shock 200524513ndash7

46 Joseph MX Disney PJS Da Costa R Hutchison SJ Transthoracic echocardiogra-phy to identify or exclude cardiac cause of shock Chest 20041261592ndash7

47 Leung JM Levine EH Left ventricular end-systolic cavity obliteration as an esti-mate of intraoperative hypovolemia Anesthesiology 1994811102ndash9

48 Zengin S Al B Genc S Yildirim C Ercan S Dogan M et al Role of inferior venacava and right ventricular diameter in assessment of volume status a compara-tive study ultrasound and hypovolemia Am J Emerg Med 201331763ndash7

49 Feissel M Michard F Faller JP Teboul JL The respiratory variation in inferiorvena cava diameter as a guide to fluid therapy Intensive Care Med 2004301834ndash7

50 Barbier C Loubieres Y Schmit C Hayon J Ricome J-L Jardin F et al Respiratorychanges in inferior vena cava diameter are helpful in predicting fluid responsive-ness in ventilated septic patients Intensive Care Med 2004301740ndash6

51 Moore CL Rose GA Tayal VS Sullivan DM Arrowood JA Kline JADetermination of left ventricular function by emergency physician echocardiog-raphy of hypotensive patients Acad Emergency Med 20029186ndash93

52 Blaivas M Fox JC Outcome in cardiac arrest patients found to have cardiacstandstill on the bedside emergency department echocardiogram AcadEmergency Med 20018616ndash21

53 Salen P Orsquoconnor R Sierzenski P Passarello B Pancu D Melanson S et al Cancardiac sonography and capnography be used independently and in combinationto predict resuscitation outcomes Acad Emergency Med 20018610ndash5

54 Prosen G Krizmaric M Zavrsnik J Grmec S Impact of modified treatment inechocardiographically confirmed pseudo-pulseless electrical activity in out-of-hospital cardiac arrest patients with constant end-tidal carbon dioxide pressureduring compression pauses J Int Med Res 2010381458ndash67

55 Plummer D Brunette D Asinger R Ruiz E Emergency department echocardiographyimproves outcome in penetrating cardiac injury Ann Emerg Med 199221709ndash12

56 Tomruk O Erdur B Cetin G Ergin A Avcil M Kapci M Assessment of cardiacultrasonography in predicting outcome in adult cardiac arrest J Int Med Res 201240804ndash9

57 Volpicelli G Elbarbary M Blaivas M Lichtenstein DA Mathis G Kirkpatrick AWet al International Liaison Committee on Lung Ultrasound (ILC-LUS) for theInternational Consensus Conference on Lung Ultrasound (ICC-LUS)International evidence-based recommendations for point-of-care lung ultra-sound Intensive Care Med 201238577ndash91

58 Gargani L Lung ultrasound a new tool for the cardiologist Cardiovasc Ultrasound201196

59 Cortellaro F Ferrari L Molteni F Aseni P Velati M Guarnieri L et al Accuracyof point of care ultrasound to identify the source of infection in septic patients aprospective study Intern Emerg Med 201712371ndash8

60 Volpicelli G Lamorte A Tullio M Cardinale L Giraudo M Stefanone V et alPoint-of-care multiorgan ultrasonography for the evaluation of undifferentiatedhypotension in the emergency department Intensive Care Med 2013391290ndash8

61 Nolan JP Hazinski MF Aickin R Bhanji F Billi JE Callaway CW et al On behalfof the ERC Guidelines 2015 Writing Group European Resuscitation Councilguidelines for resuscitation 2015 Section 1 Executive summary Resuscitation2015951ndash80

62 Link MS Berkow LC Kudenchuk PJ Halperin HR Hess EP Moitra VK et al Part7 Adult advanced cardiovascular life support 2015 American Heart Associationguidelines update for cardiopulmonary resuscitation and emergency cardiovascu-lar care Circulation 2015132S444ndash64

63 Narasimhan M Koenig SJ Mayo PH Advanced echocardiography for the criticalcare physician Part 1 Chest 2014145129ndash34

64 Flato UA Paiva EF Carballo MT Buehler AM Marco R Timerman AEchocardiography for prognostication during the resuscitation of intensive care unitpatients with non-shockable rhythm cardiac arrest Resuscitation 2015921ndash6

65 Neri L Storti E Lichtenstein D Toward an ultrasound curriculum for criticalcare medicine Crit Care Med 200735S290ndash304

66 Focused Echocardiography in Emergency Life Support (FEEL) ResuscitationCouncil (UK) httpswwwresusorgukinformation-on-coursesfocused-echocardiography-in-emergency-life-support (28 January 2018 date last accessed)

Focus cardiac ultrasound core curriculum and core syllabus 481fD

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