ACEP Policy Statement on Emergency Ultrasound by External Entities

Approved by the ACEP Board of Directors, June 2014

The American College of Emergency Physicians (ACEP) believes that certification by non-emergency medicine external bodies, organizations, societies or other medical specialties or upon short course completion is inadequate to demonstrate comprehensive training, knowledge, and skill in the practice of emergency ultrasound.

Emergency ultrasound comprises a set of focused applications utilized to diagnose life-threatening conditions, guide invasive procedures, and treat emergency medical conditions. Both residency-based and practice-based pathways exist for emergency physicians to demonstrate competency in emergency ultrasound as detailed in the ACEP policy statement, “Emergency Ultrasound Guidelines.”

Any non-emergency medicine external certification process would impede the use of this critical clinical skill and adversely affect patient care.

ACEP strongly opposes the use of any non-emergency medicine external certification process to validate competency in the use of emergency ultrasound. Furthermore, any such process should not be utilized as a requirement for hospital privileges or credentialing, nor for reimbursement by accountable care organizations (ACOs), managed care organizations (MCOs), the Centers for Medicare and Medicaid Services (CMS) or other third-party payers.

Hertz so Good – Sonogames 2014

Congratulation, Raashee, Jeremy and George,

Sinai’s team “Hertz so Good” finally made it past the first round, finishing seventh out of thirty-six teams!!

Sinai Sonogames

For the past two years, Boston University has taken home the Sonocup.  This year we are dedicated to at least coming a little bit closer to bringing the cup home. Hertz so Good, our sonoteam, is George Lim, Raashee Kedia and Jeremy Faust.  Indomitable.

Except in Round one of our Mock Sonogames, where the Sonoteam answered fewer multiple choice questions correctly than the three teams that tied for first: the Endocavitary Probes, The Spice Girls and R2D2.

Round 2 brought us to the 8th floor conference room, where Amy Sanghvi, Dan Lakoff, Liz Dei Rossi, Tish Harper and Raashee Kedia had set up four hands on challenge stations.

George Lim dominating Dan Lakoff in Beat the Expert.

2014-05-07 10.38.18

Aldo Gutierrez with some pericompetition in-line vascular access teaching for Jeremy Kim.2014-05-07 10.38.31

Head to Head Blinded team v-scanning  by Brendan Milliner (i think)2014-05-07 10.39.08

After Round 2 the Spice Girls jumped out to a big lead with 42 points.  But the head to head competition favored the prepared.  The Sono Team, who memorized the five articles distributed for the national sonogames competition, rocketed past all adversaries to win the grand prize of a dinner in Dallas.

Congratulations Raashee, George and @jeremyfaust.  Now bring home the cup.


2014 Emergency and Critical Care Ultrasound CME Course

The Mount Sinai Department of Emergency Medicine hosted its annual ultrasound CME conference on April 25. Faculty, fellows, nurses and PAs from a number of institutions and specialties took part in our tenth annual course.

The course was directed by Bret Nelson, MD who introduced ultrasound physics and machine controls, followed by lectures on assessment of  airway and breathing (Jim Tsung, MD, MPH), cardiovascular ultrasound (Jennifer Huang, DO), trauma evaluation (Phil Andrus, MD) and procedure guidance (Amy Sanghvi, MD).

After lunch an intensive hands-on session with live models, task simulators and sim cases rounded out the experience.

Is it time?


Every year in December my ARDMS renewal would arrive.  It was only $75 to renew, so I did.  My enthusiasm for this badge steadily declined from the early heady days after taking the Edelman course (which I thought was awesome).  But this year, I burned my card.  Resa Lewiss and Mike Stone have a great “clinical controversies” editorial in this month’s Annals of Emergency Medicine.

You should read it… and then burn your card.*

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* unless you are Bret Nelson MD RDMS FACEP and you’ve embroidered RDMS on all of your custom white coats.

Cardiac Arrest Ultrasound AIUM 2014

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As promised, references from today’s lecture.


1. Arntfield RT, and Millington SJ. Point of care cardiac ultrasound applications in the emergency department and intensive care unit–a review. Curr Cardiol Rev. 2012, May;8(2): 98-108.
2. Bocka JJ, Overton DT, and Hauser A. Electromechanical dissociation in human beings: an echocardiographic evaluation. Ann Emerg Med. 1988, May;17(5):450-2.

3. Giraud R, Siegenthaler N, Schussler O, Kalangos A, Müller H, Bendjelid K, and Banfi C. The LUCAS 2 Chest Compression Device Is Not Always Efficient: An Echographic Confirmation. Ann Emerg Med. 2014, Feb 12;
4. Hollister N, Bond R, Donovan A, and Nicholls B. Saved by focused echo evaluation in resuscitation. Emerg Med J. 2011, Nov;28(11):986-9.

5. Niendorff DF, Rassias AJ, Palac R, Beach ML, Costa S, and Greenberg M. Rapid cardiac ultrasound of inpatients suffering PEA arrest performed by nonexpert sonographers. Resuscitation. 2005, Oct;67(1):81-7.
6. Rich S, Wix HL, and Shapiro EP. Clinical assessment of heart chamber size and valve motion during cardiopulmonary resuscitation by two-dimensional echocardiography. Am Heart J. 1981, Sep;102(3 Pt 1):368-73.

7. Werner A, Greene L, Janko L, and Cobb A. Visualization of cardiac valve motion in man during external chest compression using two-dimensional echocardiography. Implications regarding the mechanism of blood flow. Circulation. 1981, Jun 1;63(6):1417-1421.

Prognosis in Cardiac Arrest Ultrasound

1. Aichinger G, Zechner PM, Prause G, Sacherer F, Wildner G, Anderson CL, et al. Cardiac movement identified on prehospital echocardiography predicts outcome in cardiac arrest patients. Prehosp Emerg Care. 2012;16(2):251-5.
2. Breitkreutz R, Price S, Steiger HV, Seeger FH, Ilper H, Ackermann H, et al. Focused echocardiographic evaluation in life support and peri-resuscitation of emergency patients: a prospective trial. Resuscitation. 2010, Nov;81(11):1527-33.

3. Cohn B. Does the absence of cardiac activity on ultrasonography predict failed resuscitation in cardiac arrest? Ann Emerg Med. 2013, Aug;62(2):180-1.
4. Cureton EL, Yeung LY, Kwan RO, Miraflor EJ, Sadjadi J, Price DD, and Victorino GP. The heart of the matter: utility of ultrasound of cardiac activity during traumatic arrest. J Trauma Acute Care Surg. 2012, Jul;73(1):102-10.

5. Hayhurst C, Lebus C, Atkinson PR, Kendall R, Madan R, Talbot J, et al. An evaluation of echo in life support (ELS): is it feasible? What does it add? Emerg Med J. 2011, Feb;28(2):119-21.
6. Kudenchuk PJ, Cobb LA, Copass MK, Cummins RO, Doherty AM, Fahrenbruch CE, et al. Amiodarone for resuscitation after out-of-hospital cardiac arrest due to ventricular fibrillation. N Engl J Med. 1999, Sep 16;341(12):871-8.

7. Nelson BP, Patel VR, Norris MM, and Richardson BK. The utility of cardiac sonography and capnography in predicting outcome in cardiac arrest. International journal of emergency medicine. 2008;1(3):213-5.
8. Salen P, O’Connor R, Sierzenski P, Passarello B, Pancu D, Melanson S, et al. Can cardiac sonography and capnography be used independently and in combination to predict resuscitation outcomes? Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 2001;8(6):610-5.

9. Salen P, Melniker L, Chooljian C, Rose JS, Alteveer J, Reed J, and Heller M. Does the presence or absence of sonographically identified cardiac activity predict resuscitation outcomes of cardiac arrest patients? Am J Emerg Med. 2005, Jul;23(4):459-62.

10. Schuster KM, Lofthouse R, Moore C, Lui F, Kaplan LJ, and Davis KA. Pulseless electrical activity, focused abdominal sonography for trauma, and cardiac contractile activity as predictors of survival after trauma. J Trauma. 2009, Dec;67(6):1154-7.

11. Schuster KM, and Davis KA. Response to “Pulseless electrical activity focused abdominal sonography for trauma, and cardiac contractile activity as predictors of survival after trauma”. J Trauma. 2010, May;68(5):1270.

12. Tayal VS, and Kline JA. Emergency echocardiography to detect pericardial effusion in patients in PEA and near-PEA states. Resuscitation. 2003, Dec;59(3):315-318.
13. Tomruk O, Erdur B, Cetin G, Ergin A, Avcil M, and Kapci M. Assessment of Cardiac Ultrasonography in Predicting Outcome in Adult Cardiac Arrest. Journal of International Medical Research. 2012, Apr 1;40(2):804-809.

Algorithmic approach to Cardiac Arrest Ultrasound

1. Amaya SC, and Langsam A. Ultrasound detection of ventricular fibrillation disguised as asystole. Ann Emerg Med. 1999, Mar;33(3):344-6.

2. Blyth L, Atkinson P, Gadd K, and Lang E. Bedside focused echocardiography as predictor of survival in cardiac arrest patients: a systematic review. Acad Emerg Med. 2012, Oct;19(10): 1119-26.

3. Chardoli M, Heidari F, Rabiee H, Sharif-Alhoseini M, Shokoohi H, and Rahimi-Movaghar V. Echocardiography integrated ACLS protocol versus conventional cardiopulmonary resuscitation in patients with pulseless electrical activity cardiac arrest. Chin J Traumatol. 2012;15(5):284-7.

4. Hernandez C, Shuler K, Hannan H, Sonyika C, Likourezos A, and Marshall J. C.A.U.S.E.: Cardiac arrest ultra-sound exam–a better approach to managing patients in primary non- arrhythmogenic cardiac arrest. Resuscitation. 2008, Feb;76(2):198-206.

5. Horowitz R, Gossett JG, Bailitz J, Wax D, and Pierce MC. The FLUSH Study-Flush the Line and Ultrasound the Heart: Ultrasonographic Confirmation of Central Femoral Venous Line Placement. Ann Emerg Med. 2014, Jan 15;

6. Mallin M, Curtis K, Dawson M, Ockerse P, and Ahern M. Accuracy of ultrasound-guided marking of the cricothyroid membrane before simulated failed intubation. The American Journal of Emergency Medicine. 2014, Jan;32(1):61-63.

7. Nagdev A, and Mantuani D. A novel in-plane technique for ultrasound-guided pericardiocentesis. Am J Emerg Med. 2013, Sep;31(9):1424.e5-9.

8. Pfeiffer P, Rudolph SS, Børglum J, and Isbye DL. Temporal comparison of ultrasound vs. auscultation and capnography in verification of endotracheal tube placement. Acta Anaesthesiol Scand. 2011, Nov;55(10):1190-5.

9. Pfeiffer P, Bache S, Isbye DL, Rudolph SS, Rovsing L, and Børglum J. Verification of endotracheal intubation in obese patients – temporal comparison of ultrasound vs. auscultation and capnography. Acta Anaesthesiol Scand. 2012, May;56(5):571-6.
10. Weingart SW, Duque DD, and Nelson BN. The RUSH Exam – Rapid Ultrasound for Shock / Hypotension [Internet]. ACEP-EMED Home. 2009, Apr 3;[cited 2011, Jan 9] Available from: http://

Future of Cardiac Arrest Ultrasound

1. Abbasi S, Farsi D, Zare MA, Hajimohammadi M, Rezai M, and Hafezimoghadam P. Direct ultrasound methods: a confirmatory technique for proper endotracheal intubation in the emergency department. Eur J Emerg Med. 2014, Jan 16;

2. Blaivas M. Transesophageal echocardiography during cardiopulmonary arrest in the emergency department. Resuscitation. 2008, Aug;78(2):135-40.

3. Copetti R. Clinical Integrated Ultrasound in Peri Cardiac Arrest and Cardiac Arrest. J Clinic Experiment Cardiol S. 2012;102.

4. Doepp Connolly F, Reitemeier J, Storm C, Hasper D, and Schreiber SJ. Duplex sonography of cerebral blood flow after cardiac arrest-A prospective observational study. Resuscitation. 2013, Dec 30;

5. Hogan TS. External cardiac compression may be harmful in some scenarios of pulseless electrical activity. Med Hypotheses. 2012, Oct;79(4):445-7.

6. van der Wouw PA, Koster RW, Delemarre BJ, de Vos R, Lampe-Schoenmaeckers AJ, and Lie KI. Diagnostic accuracy of transesophageal echocardiography during cardiopulmonary resuscitation. J Am Coll Cardiol. 1997, Sep;30(3):780-3.
7. Vieillard-Baron A, Slama M, Mayo P, Charron C, Amiel JB, Esterez C, et al. A pilot study on safety and clinical utility of a single-use 72-hour indwelling transesophageal echocardiography probe. Intensive Care Med. 2013, Apr;39(4):629-35.