In 2012, the Accreditation Council for Graduate Medical Education (ACGME) designated ultrasound (US) as one of 23 milestone competencies for emergency medicine (EM) residency graduates. With increasing scrutiny of medical educational programs and their effect on patient safety and health care delivery, it is imperative to ensure that US training and competency assessment is standardized. In 2011, a multiorganizational committee composed of representatives from the Council of Emergency Medicine Residency Directors (CORD), the Academy of Emergency Ultrasound of the Society for Academic Emergency Medicine (SAEM), the Ultrasound Section of the American College of Emergency Physicians (ACEM), and the Emergency Medicine Residents' Association was formed to suggest standards for resident emergency ultrasound (EUS) competency assessment and to write a document that addresses the ACGME milestones. This article contains a historical perspective on resident training in EUS and a table of core skills deemed to be a minimum standard for the graduating EM resident. A survey summary of focused EUS education in EM residencies is described, as well as a suggestion for structuring education in residency. Finally, adjuncts to a quantitative measurement of resident competency for EUS are offered. 1 Soon thereafter, the Society for Academic Emergency Medicine (SAEM) endorsed this position and recommended the development of a training curriculum.2 In 1994, Mateer and colleagues 3 published the model curriculum for physician training in EUS and by 1996 the EM core content curriculum required EUS competency for residency graduates. A landmark resolution by the American Medical Association in 1999 (Resolution 802 and policy H-230.960) stated that ultrasound (US) is "within the scope of practice of appropriately trained physicians" and that each specialty should decide the necessary training requirements for sonography competency.4 ACEP further developed the standard recognition of EUS as "a skill integral to the practice of EM" in the 2001 Model of the Clinical Practice of Emergency Medicine (EM Model), which resulted in the Accreditation Council for Graduate Medical Education (ACGME) mandating that all EM residents attain competency in the use of EUS by the completion of residency training. 5 In 2008, as an update and revision, ACEP published more comprehensive specialty-specific guidelines as a standard for EUS.6 Subsequently, SAEM, the Council of Emergency Medicine

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The use of ultrasound for LP significantly reduced the number of failures in all patients and improved the ease of the procedure in obese patients.

Objective Develop and validate a prognostic model for clinical deterioration or death within days of pulmonary embolism (PE) diagnosis using point-of-care criteria. Methods We used prospective registry data from six emergency departments. The primary composite outcome was death or deterioration (respiratory failure, cardiac arrest, new dysrhythmia, sustained hypotension, and rescue reperfusion intervention) within 5 days. Candidate predictors included laboratory and imaging right ventricle (RV) assessments. The prognostic model was developed from 935 PE patients. Univariable analysis of 138 candidate variables was followed by penalized and standard logistic regression on 26 retained variables, and then tested with a validation database (N = 801). Results Logistic regression yielded a nine-variable model, then simplified to a nine-point tool (PE-SCORE): one point each for abnormal RV by echocardiography, abnormal RV by computed tomography, systolic blood pressure < 100 mmHg, dysrhythmia, suspected/confirmed systemic infection, syncope, medico-social admission reason, abnormal heart rate, and two points for creatinine greater than 2.0 mg/dL. In the development database, 22.4% had the primary outcome. Prognostic accuracy of logistic regression model versus PE-SCORE model: 0.83 (0.80, 0.86) vs. 0.78 (0.75, 0.82) using area under the curve (AUC) and 0.61 (0.57, 0.64) vs. 0.50 (0.39, 0.60) using precision-recall curve (AUCpr). In the validation database, 26.6% had the primary outcome. PE-SCORE had AUC 0.77 (0.73, 0.81) and AUCpr 0.63 (0.43, 0.81). As points increased, outcome proportions increased: a score of zero had 2% outcome, whereas scores of six and above had ≥ 69.6% outcomes. In the validation dataset, PE-SCORE zero had 8% outcome [no deaths], whereas all patients with PE-SCORE of six and above had the primary outcome. Conclusions PE-SCORE model identifies PE patients at low- and high-risk for deterioration and may help guide decisions about early outpatient management versus need for hospital-based monitoring.

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Potential ultrasound exposure safety issues are reviewed, with guidance for prudent use of point-of-care ultrasound (POCUS). Safety assurance begins with the training of POCUS practitioners in the generation and interpretation of diagnostically valid and clinically relevant images. Sonographers themselves should minimize patient exposure in accordance with the as-low-as-reasonably-achievable principle, particularly for the safety of the eye, lung, and fetus. This practice entails the reduction of output indices or the exposure duration, consistent with the acquisition of diagnostically definitive images. Informed adoption of POCUS worldwide promises a reduction of ionizing radiation risks, enhanced cost-effectiveness, and prompt diagnoses for optimal patient care.

Key PointsQuestionIs the recent use of non–vitamin K antagonist oral anticoagulants (NOACs) associated with increased risk of intracranial hemorrhage among patients with acute ischemic stroke treated with intravenous alteplase?FindingsThis US retrospective cohort study included 163 038 patients with acute ischemic stroke treated with alteplase. Among patients with use of NOACs within 7 days of hospital arrival vs patients with no use of anticoagulants, intracranial hemorrhage occurred in 3.7% vs 3.2%, respectively, a difference that was not statistically significant after multivariable adjustment.MeaningRecent use of NOACs was not significantly associated with increased risk of intracranial hemorrhage among patients with acute ischemic stroke treated with alteplase.

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