Background Focused cardiac ultrasound (FoCUS) is a simplified, clinician-performed application of echocardiography that is rapidly expanding in use, especially in emergency and critical care medicine. Performed by appropriately trained clinicians, typically not cardiologists, FoCUS ascertains the essential information needed in critical scenarios for time-sensitive clinical decision making. A need exists for quality evidence-based review and clinical recommendations on its use. Methods The World Interactive Network Focused on Critical UltraSound conducted an international, multispecialty, evidence-based, methodologically rigorous consensus process on FoCUS. Thirty-three experts from 16 countries were involved. A systematic multiple-database, double-track literature search (January 1980 to September 2013) was performed. The Grading of Recommendation, Assessment, Development and Evaluation method was used to determine the quality of available evidence and subsequent development of the recommendations. Evidence-based panel judgment and consensus was collected and analyzed by means of the RAND appropriateness method. Results During four conferences (in New Delhi, Milan, Boston, and Barcelona), 108 statements were elaborated and discussed. Face-to-face debates were held in two rounds using the modified Delphi technique. Disagreement occurred for 10 statements. Weak or conditional recommendations were made for two statements and strong or very strong recommendations for 96. These recommendations delineate the nature, applications, technique, potential benefits, clinical integration, education, and certification principles for FoCUS, both for adults and pediatric patients. Conclusions This document presents the results of the first International Conference on FoCUS. For the first time, evidence-based clinical recommendations comprehensively address this branch of point-of-care ultrasound, providing a framework for FoCUS to standardize its application in different clinical settings around the world.

International Evidence-Based Recommendations for Focused Cardiac Ultrasound

LUS is normally performed in supine patients. Operator should firstly locate the diaphragm and the lungs. Lung consolidation or pleural effusion is found predominantly in dependent and dorsal lung regions and can be easily distinguished from liver or spleen once the diaphragm has been identified. By using the anterior and posterior axillary lines as anatomical landmarks, three areas per hemithorax (anterior, lateral, and posterior) can be iden-tified. Each area is divided in two, superior and inferior. In a given region of interest, lung surface of all adjacent inter-costal spaces must be explored by moving the probe trans-versally.

Ultrasound for "lung monitoring" of ventilated patients.

Over the last decade, the way to monitor hemodynamics at the bedside has evolved considerably in the intensive care unit as well as in the operating room. The most important evolution has been the declining use of the pulmonary artery catheter along with the growing use of echocardiography and of continuous, real-time, minimally or totally non-invasive hemodynamic monitoring techniques. This article, which is the result of an agreement between authors belonging to the Cardiovascular Dynamics Section of the European Society of Intensive Care Medicine, discusses the advantages and limits of using such techniques with an emphasis on their respective place in the hemodynamic management of critically ill patients with hemodynamic instability.

Less invasive hemodynamic monitoring in critically ill patients

Background Developing countries face the dual burden of high rates of cardiovascular disease and barriers in accessing diagnostic and referral programs. The aim of this study was to test the feasibility of performing focused echocardiographic studies with long-distance Web-based assessments of recorded images for facilitating care of patients with cardiovascular disease. Methods Subjects were recruited using newspaper advertisements and were prescreened by paramedical workers during a community event in rural north India. Focused echocardiographic studies were performed by nine sonographers using pocket-sized or handheld devices; the scans were uploaded on a Web-based viewing system for remote worldwide interpretation by 75 physicians. Results A total of 1,023 studies were interpreted at a median time of 11:44 hours. Of the 1,021 interpretable scans, 207 (20.3%) had minor and 170 (16.7%) had major abnormalities. Left ventricular systolic dysfunction was the most frequent major abnormality (45.9%), followed by valvular (32.9%) and congenital (13.5%) defects. There was excellent agreement in assessing valvular lesions (κ = 0.85), whereas the on-site readings were frequently modified by expert reviewers for left ventricular function and hypertrophy (κ = 0.40 and 0.29, respectively). Six-month telephone follow-up in 71 subjects (41%) with major abnormalities revealed that 57 (80.3%) had improvement in symptoms, 11 (15.5%) experienced worsening symptoms, and three died. Conclusions This study demonstrates the feasibility of performing sonographer-driven focused echocardiographic studies for identifying the burden of structural heart disease in a community. Remote assessment of echocardiograms using a cloud-computing environment may be helpful in expediting care in remote areas.

American Society of Echocardiography: Remote Echocardiography with Web-Based Assessments for Referrals at a Distance (ASE-REWARD) Study.

Recent technological advances in echocardiography, with progressive miniaturization of ultrasound machines, have led to the development of handheld ultrasound devices (HUD). These devices, no larger than some mobile phones, can be used to perform partial, focused exams as an extension to the physical examination. The European Association of Cardiovascular Imaging (EACVI) acknowledges that the dissemination of appropriate HUD use is inevitable and desirable, because of its potential impact on patient management. However, as a scientific society of cardiac imaging, our role is to provide guidance in order to optimize patient benefit and minimize drawbacks from inappropriate use of this technology. This document provides updated recommendations for the use of HUD, including nomenclature, appropriateness, indications, operators, clinical environments, data management and storage, educational needs, and training of potential users. It also addresses gaps in evidence, controversial issues, and future technological developments.

The use of handheld ultrasound devices: a position statement of the European Association of Cardiovascular Imaging (2018 update).

Introduction
In the emergency setting, focused cardiac ultrasound has become a fundamental tool for diagnostic, initial emergency treatment and triage decisions. A new ultra-miniaturized pocket ultrasound device (PUD) may be suited to this specific setting. Therefore, we aimed to compare the diagnostic ability of an ultra-miniaturized ultrasound device (Vscan™, GE Healthcare, Wauwatosa, WI) and of a conventional high-quality echocardiography system (Vivid S5™, GE Healthcare) for a cardiac focused ultrasonography in patients admitted to the emergency department.

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Evaluation of a new pocket echoscopic device for focused cardiac ultrasonography in an emergency setting.

Introduction: Several series of patient studies have been published on the use of rFVIIa in traumatic haemorrhagic shock, although to date no international recommendations have been produced. France does not currently recognise traumatic haemorrhagic shock as an appropriate indication for the use of rFVIIa. Materials and methods: In this retrospective study, we present our experience in the use of rFVIIa in traumatic haemorrhagic shock. Results: Twenty-seven patients treated with rFVIIa after a traumatic injury between May 2005 and December 2008 were included. Average age was 46 years old. Eighty per cent of patients were polytransfused. Mortality rate was 33%. Adjusted mortality rate, using the Boffard study criteria, was 8.3%. We observed significant differences between the group of patients who died and the group of survivors in pH, PT, Hb, ionised calcaemia, temperature and platelet count. We observed significant differences between the successful rFVIIa group and the failed rFVIIa group in pH, Hb, platelet count and ionised calcaemia. Ten patients had an rFVIIa injection only and 17 patients had an rFVIIa injection combined with a mechanical procedure to stop the bleeding. Two patients presented with thromboembolic complications. We observed a tendency to recommend an rFVIIa injection before radical treatment is applied. Conclusion: It seems to us legitimate to recommend earlier use of rFVIIa in cases of traumatic haemorrhagic shock in the context of haematological damage control combined with the use of an algorithm to predict the risk involved in polytransfusion and a more aggressive transfusion strategy.

G. Janvier

Papers

Evaluation of a new pocket echoscopic device for focused cardiac ultrasonography in an emergency setting.

Advantage of using a recombinant activated factor VII in traumatic haemorrhagic shock: The Bordeaux experience

Angiœdème non histaminique lié aux inhibiteurs de l’enzyme de conversion : le plus difficile est d’y penser !

Transfusion érythrocytaire précoce dans le damage control resuscitation

Évaluation d’un programme de formation à l’échoscopie en médecine d’urgence