- Email: [email protected]
ALS conformed use of echocardiography or ultrasound in resuscitation management
Resuscitation (2008) 77, 270—275
available at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/resuscitation
LETTERS TO THE EDITOR
Lack of lung sliding on ultrasound does not always indicate a pneumothorax
2. Kirkpatrick W, Sirois M, Laupland KB, et al. Hand-held thoracic sonography for detecting post-traumatic pneumothoraces: the extended focused assessment with sonography for trauma (EFAST), J. Trauma 2004;57:288—95.
Sir, We enjoyed the recent article by Hernandez et al. C.A.U.S.E.: cardiac arrest ultra-sound exam1 —–a better approach to managing patients in primary nonarrythmogenic cardiac arrest. Resuscitation 2007, discussing the use of bedside ultrasound to aide in the treatment of critically ill patients. Integrating bedside ultrasound into the evaluation of the critically ill patient can be a helpful tool allowing the clinician to rapidly determine reversible causes of serious pathology. We are concerned about one specific point that was made in this article. It is correct that bedside ultrasound has been shown to be more sensitive than supine radiographs in detecting a pneumothorax. However, a lack of ‘‘lung sliding’’ is not always indicative of pneumothorax. Kirkpatrick et al.2 reported two cases of false positive left-sided pneumothorax in patient’s who were later found to have right mainstem intubations. This concept is extremely important in the evaluation of critically ill intubated patients. Incorrect tracheal tube placement in the right mainstem bronchus (right mainstem intubation) will reduce aeration of the left lung leading to lack of ‘‘lung sliding’’ on ultrasound examination. For intubated patients, caution must be taken before performing definitive interventional procedures solely based on lack of lung sliding by ultrasound examination. Furthermore, implicit association of lack of lung sliding with pneumothorax in intubated patients may lead the clinician down the wrong management pathway.
Conflict of interest None of the authors have any conflicts of interest. No financial obligations exist between the authors.
References 1. Hernandez C, Shuler K, Hannan H, Sonyika C, Likourezos A, 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;76:198—206.
Michael Murphy Arun Nagdev ∗ Craig Sisson The Department of Emergency Medicine, The Rhode Island Hospital, The Warren Alpert School of Medicine at Brown University, United States ∗ Corresponding author at: The Warren Alpert School of Medicine of Brown University, Emergency Medicine, 593 Eddy Street, Davol 141, Providence, RI 02903, United States . Tel.: +1 401 444 6480. E-mail address: [email protected] (A. Nagdev)
30 October 2007 doi: 10.1016/j.resuscitation.2007.10.026
ALS conformed use of echocardiography or ultrasound in resuscitation management Sir, In a recent review of the use of ultrasound in resuscitation the authors describe an ultrasound-based test for detecting treatable causes during cardiac arrest.1 This is an important approach as the use of ultrasound can improve diagnostic accuracy in life-threatening situations. Currently it is felt that there is an inadequate evidence-base to justify routine incorporation of ultrasound into the Advanced Life Support (ALS) resuscitation guidelines and may be limited to trained experts.2 Nonetheless, the ALS guidelines recommend the identification of treatable causes in PEA/asystole but do not explain how this should be done. Of note, however, echocardiography is already advocated as a Class 1 recommendation in the American College of Cardiology/Emergency Cardiac Care 2003 guidelines for suspected pericardial effusion and unexplained hypotension and is mentioned in the ERC guidelines for CPR in special circumstances.3 In May 2007 we
0300-9572/$ — see front matter © 2007 Elsevier Ireland Ltd. All rights reserved.
Letters to the Editor published in the journal ‘‘Critical Care Medicine’’ our concept on the use of focused echocardiography in resuscitation as an ALS-conformed algorithm,4 the Focused Echocardiographic Evaluation in Resuscitation (FEER) protocol. In this paper, we described a method of integrating echocardiography into the ALS guidelines and gave supporting scientific and clinical information. The practical and educational requirements of such an approach were also illustrated. The current paper of Hernandez et al., does not reference this previous publication, and in addition several points raise concerns in our group.
Procedural concerns Detection of spontaneous wall motion There are many considerations where ultrasound is used to detect wall motion during chest compressions. When assuming usual chest compression rates of 100 min−1 , distinguishing between passive ‘‘squeezing’’ of the chambers and organized contractions of the heart may be challenging in parallel to regular chest compressions where there is profound hypokinesis and/or bradycardia. As we have already published, where compressions are interrupted briefly as part of the ALS guidelines, e.g., for rhythm analysis, the presence or absence of spontaneous cardiac motion may be seen. Therefore, in the FEER protocol, practitioners are trained to obtain visual diagnoses in bradycardia/asystole within regular pauses to check rhythm or pulse and with a time limit of 10 s at a maximum in order to keep ALS-compliant and not further interrupt cycles of chest compressions. In trained hands, this may be used to provide early detection of wall motion, to diagnose PEA and return of spontaneous circulation, and thereafter to detect any treatable cause.
Detection of pulmonary embolism (PE) and pneumothorax (PTX) The use of this technique to detect PE and PTX is questionable because the sensitivity and specificity of echocardiography to differentiate between abnormalities of right ventricular function is inadequate.4 With respect to tension PTX, we would strongly suggest that should there be any suspicion of tension pneumothorax during mechanical CPR, a needle aspiration should be attempted. During chest compressions and cardiac arrest major diagnostic criteria for detecting PTX such as gliding sign, moving comet tail artefacts, lung pulse or lung point are likely to be absent. The use of US to detect occult PTX may be more valuable in unstable patients before or after a mechanical CPR.
Assessment of intravascular volume The IVC imaging by eye-balling in a longitudinal plane can be misleading in hypovolaemia and while performing regular compressions because a paramedian plane may be obtained and hypovolaemia over-estimated. It is more accurate to obtain a transverse view of the IVC during a brief interruption in chest compressions. Further, descriptions of
271 ‘‘flattened right and left ventricles’’ are meaningless in echocardiography, because they could be caused by either external compression or hypovolaemia.
Educational concerns The lack of standardized emergency echocardiography or ultrasound exam in the peri-resuscitation setting is a significant gap in our patient care. Untrained staff should be prevented imaging a patient undergoing CPR in an ad hoc manner because this will disturb the regular CPR cycles and prolong the no-flow intervals. It is thus dangerous to propose applying a flow diagram1 or a pocket card5 if it is not integrated into the ALS universal algorithm or insufficient explanation on how to apply this in practice.4 We think any simplification to help detect1,5 the four reversible causes tells only half of the story. Our solution is a detailed practical description of the procedure4 and its training in a level 1 (basic) level course program on focused echocardiography for non-cardiologist intensivists and emergency physicians or physicians who are involved in shock room management or as members of outreach medical emergency teams. In our experience a simple 8-h educational course including an ALS-compliant simulation on a manikin, together with a fully trained educational team, may bridge this educational gap and produce excellent results.4 Such a module can be easily attached or integrated into a basic level echocardiography training course and e.g. run in addition to an ALS-provider or ALSinstructor course.4 Finally, we recommend that the concept of incorporating goal-directed ultrasound in peri-resuscitation is only a small part of the procedure, and do not support the use of this technique as a tool to terminate resuscitative efforts. We would emphasize that well-defined expert ALS-compliant guidelines may help improve resuscitation efforts, and hope that in future this will be supported by more scientific data when available.
Conflict of interest None to declare.
References 1. Hernandez, et al. C.A. U. S. E. : Cardiac arrest ultra-sound exam-A better approach to managing patients in primary nonarrhythmogenic cardiac arrest. Resuscitation 2008;76:198—206. 2. Soar J, Nolan JP. Use of ultrasound to detect and treat reversible causes during CPR. Resuscitation 2007;74:199. 3. Soar J, Deakin CD, Nolan JP, et al. European Resuscitation Council Guidelines for Resuscitation 2005 Section 7: cardiac arrest in special circumstances. Resuscitation 2005;67(Suppl. 1): S135—70. 4. Breitkreutz R, Walcher F, Seeger FH. Focused echocardiographic evaluation in resuscitation management: concept of an advanced life support-conformed algorithm. Crit Care Med 2007;35(Suppl. 5):S150—61. 5. Sloth E, et al. The resuscitation guidelines in force–time for improvement towards causal therapy? Resuscitation 2007;74: 198—9.
272
Letters to the Editor
Raoul Breitkreutz a,∗ Felix Walcher b Florian H. Seeger c a Department of Anesthesiology, Intensive Care and Pain Therapy, Hospital of the Johann-Wolfgang Goethe University, Theodor-Stern Kai 7, 60590 Frankfurt am Main, Germany b Department of Trauma Surgery, Intensive Care and Pain Therapy, Hospital of the Johann-Wolfgang Goethe University, Theodor-Stern Kai 7, 60590 Frankfurt am Main, Germany c Department of Cardiology, Intensive Care and Pain Therapy, Hospital of the Johann-Wolfgang Goethe University, Theodor-Stern Kai 7, 60590 Frankfurt am Main, Germany ∗
Corresponding author. Tel.: +49 69 61995357; fax: +49 69 6301 5889. E-mail address: [email protected] (R. Breitkreutz) 20 October 2007
doi: 10.1016/j.resuscitation.2007.10.025
Reply: ALS conformed use of echocardiography or ultrasound in resuscitation management Sir, Thank you for the opportunity to reply formally to the questions raised by Drs. Breitkreutz, Walcher and Seeger, after reading our paper published in your journal.1 The first question they raise is why their publication was not included in our review of the literature involving bedside ultrasound during cardiac arrest. Our answer to this question is that their paper was not available at the time we submitted our paper for review. Our paper was submitted in the month of February 2007 and was accepted in June of that same year. The paper written by Drs. Breitkreutz, Walcher and Seeger was not published until May 2007, 4 months after our paper was submitted for review. Regrettably, whenever a group of authors sets out to write a review involving the available literature on a subject, some excellent papers may become available after the review is finished and for this reason may not be included. The remainder of the questions addressed procedural concerns with our paper. The first of these was related to detection of spontaneous wall motion, and Drs. Breitkreutz, Walcher and Seeger describe the method they use to determine spontaneous wall motion in cardiac arrest victims using the FEER protocol. We feel their method is very thorough. We suppose that these authors felt our method of detecting spontaneous wall motion was not thorough enough as they later stated ‘‘we. . .do not support the use of this technique as a tool to terminate resuscitative efforts.’’ We would like to point out that two studies have looked into this question in depth and found that absence of recognisable cardiac activity is observed to have a total inverse correlation with any spontaneous return of cardiac activity.2,3
The second procedural question was in regard to using ultrasound to detect pneumothorax and pulmonary embolism during cardiac arrest resuscitation. Obviously we agree that needle aspiration should be performed for suspected tension pneumothorax. However, Drs. Breitkreutz, Walcher and Seeger state that our method of detection has questionable sensitivity and specificity and refer their own paper to defend this statement. As noted in our study, there is a published body of evidence regarding the specificities and sensitivities of ultrasound for the detection of pneumothorax and pulmonary embolism.4—11 The third procedural question was in regard to the assessment of intravascular volume. Drs. Breitkreutz, Walcher and Seeger feel that our method of visualising the longitudinal plane of the inferior vena cava has the potential for over-estimating hypovolemia, and such ‘‘eye-balling’’ may result in examination of a paramedian plane. Our feeling on this is that a trained sonographer would always examine a positive finding in more than one plane. However, if our method is ultimately prone to over-estimating hypovolemia, we would prefer this during cardiac arrest resuscitation, rather than under-treat a patient with true hypovolemia, as most causes of PEA respond well to increased preload. The final question was related to educational concerns. Drs. Breitkreutz, Walcher and Seeger state that ‘‘untrained staff should be prevented from imaging a patient undergoing CPR in an ad hoc manner’’. We agree. Training in emergency ultrasonography has well-defined processes in the United States. A full description of these can be found at the website for the American College of Emergency Physicians.12 Indeed basic ultrasound training is a requirement for all emergency medicine residents. In place of the 8-h course described by Drs. Breitkreutz, Walcher and Seeger, we provide our resident physicians a full-day comprehensive introduction to emergency ultrasonography including ultrasound physics, clinical applications, and practice on live models. Over the next 3 years of graduate medical education, the residents receive 2 months of dedicated sonography training, one on one with a mentoring physician who has completed a fellowship in emergency ultrasound application. In addition to this training there is daily emergency ultrasound exposure throughout the course of their clinical training as well as refresher didactic sessions and formal training in additional advanced ultrasound applications. All of this training is recorded onto video tape which is reviewed meticulously for quality assurance. We thank Drs. Breitkreutz, Walcher and Seeger for taking an interest in our paper, and agree fully with them that more scientific data is needed on this important topic. We are grateful that our paper is generating discussion over the use of ultrasound to impact management of patients during cardiac arrest. We feel that greater the marketplace for ideas, the higher the ultimate quality of care provided to our patients when they need our assistance.
Conflict of interest None.
available at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/resuscitation
LETTERS TO THE EDITOR
Lack of lung sliding on ultrasound does not always indicate a pneumothorax
2. Kirkpatrick W, Sirois M, Laupland KB, et al. Hand-held thoracic sonography for detecting post-traumatic pneumothoraces: the extended focused assessment with sonography for trauma (EFAST), J. Trauma 2004;57:288—95.
Sir, We enjoyed the recent article by Hernandez et al. C.A.U.S.E.: cardiac arrest ultra-sound exam1 —–a better approach to managing patients in primary nonarrythmogenic cardiac arrest. Resuscitation 2007, discussing the use of bedside ultrasound to aide in the treatment of critically ill patients. Integrating bedside ultrasound into the evaluation of the critically ill patient can be a helpful tool allowing the clinician to rapidly determine reversible causes of serious pathology. We are concerned about one specific point that was made in this article. It is correct that bedside ultrasound has been shown to be more sensitive than supine radiographs in detecting a pneumothorax. However, a lack of ‘‘lung sliding’’ is not always indicative of pneumothorax. Kirkpatrick et al.2 reported two cases of false positive left-sided pneumothorax in patient’s who were later found to have right mainstem intubations. This concept is extremely important in the evaluation of critically ill intubated patients. Incorrect tracheal tube placement in the right mainstem bronchus (right mainstem intubation) will reduce aeration of the left lung leading to lack of ‘‘lung sliding’’ on ultrasound examination. For intubated patients, caution must be taken before performing definitive interventional procedures solely based on lack of lung sliding by ultrasound examination. Furthermore, implicit association of lack of lung sliding with pneumothorax in intubated patients may lead the clinician down the wrong management pathway.
Conflict of interest None of the authors have any conflicts of interest. No financial obligations exist between the authors.
References 1. Hernandez C, Shuler K, Hannan H, Sonyika C, Likourezos A, 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;76:198—206.
Michael Murphy Arun Nagdev ∗ Craig Sisson The Department of Emergency Medicine, The Rhode Island Hospital, The Warren Alpert School of Medicine at Brown University, United States ∗ Corresponding author at: The Warren Alpert School of Medicine of Brown University, Emergency Medicine, 593 Eddy Street, Davol 141, Providence, RI 02903, United States . Tel.: +1 401 444 6480. E-mail address: [email protected] (A. Nagdev)
30 October 2007 doi: 10.1016/j.resuscitation.2007.10.026
ALS conformed use of echocardiography or ultrasound in resuscitation management Sir, In a recent review of the use of ultrasound in resuscitation the authors describe an ultrasound-based test for detecting treatable causes during cardiac arrest.1 This is an important approach as the use of ultrasound can improve diagnostic accuracy in life-threatening situations. Currently it is felt that there is an inadequate evidence-base to justify routine incorporation of ultrasound into the Advanced Life Support (ALS) resuscitation guidelines and may be limited to trained experts.2 Nonetheless, the ALS guidelines recommend the identification of treatable causes in PEA/asystole but do not explain how this should be done. Of note, however, echocardiography is already advocated as a Class 1 recommendation in the American College of Cardiology/Emergency Cardiac Care 2003 guidelines for suspected pericardial effusion and unexplained hypotension and is mentioned in the ERC guidelines for CPR in special circumstances.3 In May 2007 we
0300-9572/$ — see front matter © 2007 Elsevier Ireland Ltd. All rights reserved.
Letters to the Editor published in the journal ‘‘Critical Care Medicine’’ our concept on the use of focused echocardiography in resuscitation as an ALS-conformed algorithm,4 the Focused Echocardiographic Evaluation in Resuscitation (FEER) protocol. In this paper, we described a method of integrating echocardiography into the ALS guidelines and gave supporting scientific and clinical information. The practical and educational requirements of such an approach were also illustrated. The current paper of Hernandez et al., does not reference this previous publication, and in addition several points raise concerns in our group.
Procedural concerns Detection of spontaneous wall motion There are many considerations where ultrasound is used to detect wall motion during chest compressions. When assuming usual chest compression rates of 100 min−1 , distinguishing between passive ‘‘squeezing’’ of the chambers and organized contractions of the heart may be challenging in parallel to regular chest compressions where there is profound hypokinesis and/or bradycardia. As we have already published, where compressions are interrupted briefly as part of the ALS guidelines, e.g., for rhythm analysis, the presence or absence of spontaneous cardiac motion may be seen. Therefore, in the FEER protocol, practitioners are trained to obtain visual diagnoses in bradycardia/asystole within regular pauses to check rhythm or pulse and with a time limit of 10 s at a maximum in order to keep ALS-compliant and not further interrupt cycles of chest compressions. In trained hands, this may be used to provide early detection of wall motion, to diagnose PEA and return of spontaneous circulation, and thereafter to detect any treatable cause.
Detection of pulmonary embolism (PE) and pneumothorax (PTX) The use of this technique to detect PE and PTX is questionable because the sensitivity and specificity of echocardiography to differentiate between abnormalities of right ventricular function is inadequate.4 With respect to tension PTX, we would strongly suggest that should there be any suspicion of tension pneumothorax during mechanical CPR, a needle aspiration should be attempted. During chest compressions and cardiac arrest major diagnostic criteria for detecting PTX such as gliding sign, moving comet tail artefacts, lung pulse or lung point are likely to be absent. The use of US to detect occult PTX may be more valuable in unstable patients before or after a mechanical CPR.
Assessment of intravascular volume The IVC imaging by eye-balling in a longitudinal plane can be misleading in hypovolaemia and while performing regular compressions because a paramedian plane may be obtained and hypovolaemia over-estimated. It is more accurate to obtain a transverse view of the IVC during a brief interruption in chest compressions. Further, descriptions of
271 ‘‘flattened right and left ventricles’’ are meaningless in echocardiography, because they could be caused by either external compression or hypovolaemia.
Educational concerns The lack of standardized emergency echocardiography or ultrasound exam in the peri-resuscitation setting is a significant gap in our patient care. Untrained staff should be prevented imaging a patient undergoing CPR in an ad hoc manner because this will disturb the regular CPR cycles and prolong the no-flow intervals. It is thus dangerous to propose applying a flow diagram1 or a pocket card5 if it is not integrated into the ALS universal algorithm or insufficient explanation on how to apply this in practice.4 We think any simplification to help detect1,5 the four reversible causes tells only half of the story. Our solution is a detailed practical description of the procedure4 and its training in a level 1 (basic) level course program on focused echocardiography for non-cardiologist intensivists and emergency physicians or physicians who are involved in shock room management or as members of outreach medical emergency teams. In our experience a simple 8-h educational course including an ALS-compliant simulation on a manikin, together with a fully trained educational team, may bridge this educational gap and produce excellent results.4 Such a module can be easily attached or integrated into a basic level echocardiography training course and e.g. run in addition to an ALS-provider or ALSinstructor course.4 Finally, we recommend that the concept of incorporating goal-directed ultrasound in peri-resuscitation is only a small part of the procedure, and do not support the use of this technique as a tool to terminate resuscitative efforts. We would emphasize that well-defined expert ALS-compliant guidelines may help improve resuscitation efforts, and hope that in future this will be supported by more scientific data when available.
Conflict of interest None to declare.
References 1. Hernandez, et al. C.A. U. S. E. : Cardiac arrest ultra-sound exam-A better approach to managing patients in primary nonarrhythmogenic cardiac arrest. Resuscitation 2008;76:198—206. 2. Soar J, Nolan JP. Use of ultrasound to detect and treat reversible causes during CPR. Resuscitation 2007;74:199. 3. Soar J, Deakin CD, Nolan JP, et al. European Resuscitation Council Guidelines for Resuscitation 2005 Section 7: cardiac arrest in special circumstances. Resuscitation 2005;67(Suppl. 1): S135—70. 4. Breitkreutz R, Walcher F, Seeger FH. Focused echocardiographic evaluation in resuscitation management: concept of an advanced life support-conformed algorithm. Crit Care Med 2007;35(Suppl. 5):S150—61. 5. Sloth E, et al. The resuscitation guidelines in force–time for improvement towards causal therapy? Resuscitation 2007;74: 198—9.
272
Letters to the Editor
Raoul Breitkreutz a,∗ Felix Walcher b Florian H. Seeger c a Department of Anesthesiology, Intensive Care and Pain Therapy, Hospital of the Johann-Wolfgang Goethe University, Theodor-Stern Kai 7, 60590 Frankfurt am Main, Germany b Department of Trauma Surgery, Intensive Care and Pain Therapy, Hospital of the Johann-Wolfgang Goethe University, Theodor-Stern Kai 7, 60590 Frankfurt am Main, Germany c Department of Cardiology, Intensive Care and Pain Therapy, Hospital of the Johann-Wolfgang Goethe University, Theodor-Stern Kai 7, 60590 Frankfurt am Main, Germany ∗
Corresponding author. Tel.: +49 69 61995357; fax: +49 69 6301 5889. E-mail address: [email protected] (R. Breitkreutz) 20 October 2007
doi: 10.1016/j.resuscitation.2007.10.025
Reply: ALS conformed use of echocardiography or ultrasound in resuscitation management Sir, Thank you for the opportunity to reply formally to the questions raised by Drs. Breitkreutz, Walcher and Seeger, after reading our paper published in your journal.1 The first question they raise is why their publication was not included in our review of the literature involving bedside ultrasound during cardiac arrest. Our answer to this question is that their paper was not available at the time we submitted our paper for review. Our paper was submitted in the month of February 2007 and was accepted in June of that same year. The paper written by Drs. Breitkreutz, Walcher and Seeger was not published until May 2007, 4 months after our paper was submitted for review. Regrettably, whenever a group of authors sets out to write a review involving the available literature on a subject, some excellent papers may become available after the review is finished and for this reason may not be included. The remainder of the questions addressed procedural concerns with our paper. The first of these was related to detection of spontaneous wall motion, and Drs. Breitkreutz, Walcher and Seeger describe the method they use to determine spontaneous wall motion in cardiac arrest victims using the FEER protocol. We feel their method is very thorough. We suppose that these authors felt our method of detecting spontaneous wall motion was not thorough enough as they later stated ‘‘we. . .do not support the use of this technique as a tool to terminate resuscitative efforts.’’ We would like to point out that two studies have looked into this question in depth and found that absence of recognisable cardiac activity is observed to have a total inverse correlation with any spontaneous return of cardiac activity.2,3
The second procedural question was in regard to using ultrasound to detect pneumothorax and pulmonary embolism during cardiac arrest resuscitation. Obviously we agree that needle aspiration should be performed for suspected tension pneumothorax. However, Drs. Breitkreutz, Walcher and Seeger state that our method of detection has questionable sensitivity and specificity and refer their own paper to defend this statement. As noted in our study, there is a published body of evidence regarding the specificities and sensitivities of ultrasound for the detection of pneumothorax and pulmonary embolism.4—11 The third procedural question was in regard to the assessment of intravascular volume. Drs. Breitkreutz, Walcher and Seeger feel that our method of visualising the longitudinal plane of the inferior vena cava has the potential for over-estimating hypovolemia, and such ‘‘eye-balling’’ may result in examination of a paramedian plane. Our feeling on this is that a trained sonographer would always examine a positive finding in more than one plane. However, if our method is ultimately prone to over-estimating hypovolemia, we would prefer this during cardiac arrest resuscitation, rather than under-treat a patient with true hypovolemia, as most causes of PEA respond well to increased preload. The final question was related to educational concerns. Drs. Breitkreutz, Walcher and Seeger state that ‘‘untrained staff should be prevented from imaging a patient undergoing CPR in an ad hoc manner’’. We agree. Training in emergency ultrasonography has well-defined processes in the United States. A full description of these can be found at the website for the American College of Emergency Physicians.12 Indeed basic ultrasound training is a requirement for all emergency medicine residents. In place of the 8-h course described by Drs. Breitkreutz, Walcher and Seeger, we provide our resident physicians a full-day comprehensive introduction to emergency ultrasonography including ultrasound physics, clinical applications, and practice on live models. Over the next 3 years of graduate medical education, the residents receive 2 months of dedicated sonography training, one on one with a mentoring physician who has completed a fellowship in emergency ultrasound application. In addition to this training there is daily emergency ultrasound exposure throughout the course of their clinical training as well as refresher didactic sessions and formal training in additional advanced ultrasound applications. All of this training is recorded onto video tape which is reviewed meticulously for quality assurance. We thank Drs. Breitkreutz, Walcher and Seeger for taking an interest in our paper, and agree fully with them that more scientific data is needed on this important topic. We are grateful that our paper is generating discussion over the use of ultrasound to impact management of patients during cardiac arrest. We feel that greater the marketplace for ideas, the higher the ultimate quality of care provided to our patients when they need our assistance.
Conflict of interest None.