TRAIN CERTIFY MAINTAIN
Community Paramedic CORE
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CURRICULUM
Review the curriculum to achieve IP certification
Earn CME credits at the same time via the MOC program
POCUS basics
All CPoCUS-certified Independent Practitioners (CPoCUS IPs) must be able to use the following controls on their ultrasound system:
Power:
Provides power to ultrasound machine. Ideally, all systems should be kept in sleep mode if there is a long start up time (i.e. longer than 30 seconds) so that there is always immediate PoCUS capability in emergency situations.
Depth:
Magnifies the area of interest and centers it in the vertical plane. The default for beginners is to maximize the depth for most scans (see detailed text for recommended starting depths for each specific scan). This control should be continually adjusted while scanning.
Gain:
Modifies the brightness on the screen and is used to ensure that the area of interest is clear enough to interpret correctly and to compensate for differences in tissue density and reflectivity as well as ultrasound artifacts. Should be continually adjusted while scanning.
Frequency:
Modifies the frequency of sound waves emitted from the ultrasound probe. Most modern ultrasound
systems will have variable frequency probes and allow the operator to change the probe frequency to one
of three settings:
- General mode for scanning most tissues (3.5 MHz for the curvilinear probe)
- Resolution mode for scanning near-surface structures or low-density tissues (5 MHz for the curvilinear probe)
- Penetration mode for scanning deeper structures or high-density tissues (2.5 MHz for the curvilinear probe)
M-mode:
Measures movement along a vertical line (from near field to far field) on the ultrasound screen and graphs this over time. May be used to measure fetal heart rate in first trimester scanning, to detect movement along the pleural line in pneumothorax scanning, and to help estimate fractional shortening in the sub-xiphoid cardiac scan. The use of this control is NOT required for CPoCUS CORE IP certification.
Exam presets:
Provides pre-determined optimal settings for specific scans. Used before starting a scan to optimize the ultrasound system for a specific type of scan, such as abdominal, cardiac, or lung. Although the use of appropriate exam presets will enhance the ultrasound images produced, use of this control is NOT required for CPoCUS certification.
Freeze:
Freezes the image on the screen to allow the operator to identify essential anatomy and perform other functions such as measurements.
Focus:
Optimizes lateral resolution by ‘bending’ the ultrasound beams closer to one another and thus increasing their ability to distinguish whether what appears to be a single object is really two objects side by side at the same depth. Focus is usually represented by a marker on the side of the screen (often a triangle) that can be moved either towards the near field or the far field. Some machines will automatically set the focus at the mid-point of the screen, emphasizing that one should always center the area of interest at the mid-point of the screen with the depth function. Placing the focus at the level of the area of interest should be standard practice to optimize lateral resolution.
Calipers:
Produces electronic markers (i.e. calipers) when the image is frozen. These can be placed in two locations on the screen to output the true body distance between the markers. Can be used to measure the diameter of the abdominal aorta, the length of the fetal pole, the width of the myometrial mantle and the size of other structures.
Cineloop:
Allows one to review several seconds of a scan, going back in time from the moment the freeze button was pushed. Most systems use a trackpad or trackball to scroll back and forth through images. This function is helpful to review essential anatomy and physiology, especially during very dynamic scans and with moving tissues (e.g. the heart).
Save image/video:
Allows the operator to save a still image as well as video clips of a scan. This function is particular to each ultrasound manufacturer, and the user manual should be consulted to learn how to perform this. Although image archiving and recording is not explicitly required for CPoCUS certification, it is often necessary for local or jurisdictional quality assurance or billing systems.
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Advanced skills for certification
Primary author
Stéphane Rhein
Contributing author / Editor
Chau Pham
Publishing
Sharon Oleskevich
© Canadian Point of Care Ultrasound Society 2024
Reproduction or distribution without express written permission is prohibited
Accéder à la version française
Advanced skills for certification
Probe(s)
Knobology
Patient positioning:
Probe orientation:
Probe grip:
External landmark(s):
- Anterior scan: Midclavicular line, immediately inferior to clavicle.
- Lateral scan: Intersection between the xiphoid process and the posterior axillary line.
Internal landmark(s): - Rib(s) and acoustic shadow(s) to identify pleura. Diaphragm and/or physiologic lung points (cardiac, liver and spleen) to identify the endpoint of the scan.
Relevant anatomy: - Pleural line, liver, spleen, heart, stomach, diaphragm, spine and lung.
Area of interest(s): - Pleura and lung parenchyma
Image Interpretation:
- Normal: smooth and regular pleura
- A lines
- Lung sliding, comet tails, lung pulse
- Cardiac and liver lung points Positive finding:
- 3 or more B-lines at a single rib interspace
- Consolidation
- Absent lung sliding or lung point
- Pleural effusion
- Air bronchograms
Image generation:
- All severely dyspneic patients should be scanned in the anterior and lateral lung zones, bilaterally. This entire protocol should be performed rapidly and efficiently and should take no longer than 60 seconds to complete.
- This scan will incorporate comprehensive lung methods as well, as areas of pathology will be interrogated more closely with the “lawnmower” approach: sliding cephalad-caudad, sliding a probe-width aside, and repeating.
- Sweep to optimize the pleural line.
- Heel the probe near the apex of the lung.
- Decrease the depth to magnify the pleural line.
- Modify the gain.
- Adjust the focus.
- Adjust probe frequency. A higher frequency will allow better resolution of a shallow pleural line.
- Rotate the probe to elongate the pleural line.
- Change to linear array probe.
- Allowing a PoCUS finding to supersede clinical judgement.
- Depth too shallow
- Not waiting three respiratory cycles.
- Not properly identifying external landmarks and starting too inferior with the potential to miss a small pneumothorax at the lung apex.
- Not scanning to the lung base on both the right and left sides.
- Not interrogating the pleura line at 90 degrees.
- In older patients and those with pleural disease either chronically (pulmonary fibrosis, recurrent pneumonia, asbestosis etc.), or acutely (pneumonia, ARDS, etc.), the pleura will be thickened and irregular. In these patients, the practitioner will never see a nice crisp pleural line. But, sweep until the thinnest, crispest pleural line is achieved.
- Declaring a pneumothorax based only on the absence of lung sliding.
- Mistaking a physiologic lung point for a true lung point.
- Stopping at the cardiac lung point. This may often miss some lung tissue that is caudal to the heart Declaring a false positive for ADHF. Other conditions can cause pathologic B-lines and could be misidentified as ADHF.
- Maintain a supple wrist when scanning to allow an easy sweep to ensure interrogation of the pleura at 90 degrees.
- Pleural effusions may have echogenic areas within the black pleural fluid.
- Spine sign: In the lateral approach, always keep the spine on the screen to identify a spine sign.
- Lung point: The location of the lung point can be used to estimate the size of a pneumothorax in the supine patient.
- Flash pulmonary edema might present as interstitial syndrome without pleural effusions.
- Some patients with ADHF may have pathologic B-lines and pleural effusions that are more prominent on one side.
- Patients with partially treated or spontaneously ADHF may have patchy interstitial syndrome.
- Bilateral
- Anterior lung from start point immediately inferior to clavicle to end point at costal margin (physiologic lung point), in the mid-clavicular line.
- Lateral lung from start point at the level of the diaphragm to the axilla, in the posterior axillary line.
- Images stored digitally with patient identifiers
- Documentation of views obtained
- Documentation of findings (positive, negative, indeterminate)
- If positive, documentation of location. Documentation is based on clinical suspicion and positive findings.
- Prerequisites: Completion of CPoCUS-approved introductory course
- Logged scans: Minimum 10 scans during training
- Proctored scans: Minimum 5 unassisted proctored scans with IP instructor
- Examinations: Written, visual, and practical assessment
Probe(s)
Knobology
Patient positioning:
Probe orientation:
Probe grip:
External landmark(s):
- External landmark(s): just cephalad to the umbilicus
- Internal landmark(s): liver
- Relevant anatomy: Liver, inferior pericardium, right ventricle, interventricular septum, left ventricle, mitral valve and leaflets, and any positive findings (fat pad and/or pericardial effusion).
- Area of interest(s): Inner walls of the left ventricle at the mid-ventricular level (i.e. just beyond the mitral valve leaflets) to assess for gross estimation of cardiac activity.
- Entire inferior pericardium to intersection with interventricular septum for the detection of a pericardial effusion (PCE).
- Starting just cephalad to the umbilicus, keeping the probe in the midline and flat, CPoCUS-IPs must slide the probe slowly cephalad, aiming at the patient’s head, with the goal of achieving good contact between the probe, skin, and liver.
- Using the liver as both the internal landmark and an acoustic window, IPs must attempt to visualize the entire heart to assess for cardiac activity. At a minimum, the left ventricular inner walls at the mid-point of the ventricle (i.e. just beyond the mitral valve leaflets) must be visible. This location is then utilized to estimate cardiac activity, categorizing it as either absent, poor, good or indeterminate (see below for specifics of each category).
- Assessment for a pericardial effusion is then attempted by visualizing the entire inferior pericardium to the intersection with the interventricular septum. The pericardium should be swept first anteriorly and then posteriorly, maintaining continuous contact with the liver, using the disappearance of the heart in both directions as the end-points of sweeping. During this part of the sub-xiphoid cardiac scan, the pericardium may be magnified, as needed, by decreasing the depth.
- Ensure constant firm contact between probe and liver. This maneuver often involves pushing firmly.
- Bend patient’s knees/flex hips.
- Slide the probe to the patient’s right and heel medially.
- Ask the patient to take a deep breath and hold it.
Pitfalls a. (Image interpretation)
- Mistaking epicardial fat pad for a PCE.
- Deeming a scan to be determinate when the entire inferior pericardium is not seen.
- Attempting to assess cardiac activity using an inadequate view (i.e. not enough of the LV inner walls seen).
- Missing a very large pericardial effusion by not having the liver on the screen as the internal landmark.
Pitfalls b. (Technique)
- Sweeping too quickly.
- Poor probe grip (i.e. fingers under probe, fingers over the end of the probe, probe marker oriented towards patient left).
- Inadequate contact between the probe, skin and liver.
- Releasing pressure while sweeping, especially anteriorly.
- Sliding up with probe tipped up (i.e. probe not flat).
- Starting scan immediately at the xiphoid process.
- Allowing probe to drift towards patient’s left resulting in image degradation from stomach gas.
- Not completely sweeping through the heart until it disappears in either direction.
- Sweeping too far (i.e. past the point where the heart disappears).
Pitfalls c. (Clinical integration)
- Assuming that a small pericardial effusion is clinically insignificant.
- Assuming that a large pericardial effusion means cardiac tamponade.
- Ceasing resuscitative efforts based solely on PoCUS findings.
- PoCUS use causing prolonged CPR pauses in cardiac arrest.
- Maintain a supple wrist when scanning to allow an easy sweep to ensure interrogation of the pleura at 90 degrees.
- Pleural effusions may have echogenic areas within the black pleural fluid.
- Spine sign: In the lateral approach, always keep the spine on the screen to identify a spine sign.
- Lung point: The location of the lung point can be used to estimate the size of a pneumothorax in the supine patient.
- Flash pulmonary edema might present as interstitial syndrome without pleural effusions.
- Some patients with ADHF may have pathologic B-lines and pleural effusions that are more prominent on one side.
- Patients with partially treated or spontaneously ADHF may have patchy interstitial syndrome.
- Negative scan for PCE: No PCE is seen while the entire inferior pericardium, to where it intersects the interventricular septum, is swept both anteriorly and posteriorly till the heart disappears. The liver must be visible on the screen to declare a negative scan (see Pitfall section).
- Positive scan for PCE: Visible pericardial effusion.
- PCE indeterminate: Unable to adequately visualize and sweep entire inferior pericardium to junction with interventricular septum.
Cardiac activity:
- Cardiac activity is estimated using the ‘eyeball’ method of measuring LV fractional shortening.
- The inner walls of the mid left ventricle (LV) level (just beyond the mitral valve leaflets) must be seen to comment on cardiac activity.
- Definition of fractional shortening: Decrease in the distance between the LV inner walls during systole (when the mitral valve is closed).
- Cardiac activity can be categorized as follows:
- Good: 30% or greater fractional shortening.
- Poor: Much less than 30% LV fractional shortening. By the ‘eyeball’ method, this is a ventricle that is obviously not squeezing well.
- Absent: No movement of the LV inner walls towards each other and no movement of the mitral valve leaflets.
- Indeterminate: Unable to adequately visualize the LV inner walls at the mid-LV level.
- Images stored digitally with patient identifiers
- Documentation of views obtained
- Documentation of findings
Prerequisites: Completion of CPoCUS-approved introductory course
Logged scans: Minimum 50 Subxiphoid Cardiac scans during training
Proctored scans: Minimum 5 unassisted proctored scans with IP instructor
Examinations: Written, visual, and practical assessment
Probe(s)
Knobology
Patient positioning:
Probe orientation:
Probe grip:
External landmark(s):
Internal landmark(s):
Relevant anatomy:
Area of interest(s):
Image Interpretation:
- Urinary retention. Binary answer – present or absent. Using the eyeball method and seeing the dome well above the symphysis pubis either in true transverse or longitudinal strongly suggests the patient is in urinary retention. The location of the dome between the symphysis and the umbilicus will allow you to roughly quantify bladder volume.
- Bladder volume: A more precise calculation of bladder volume is achieved by measuring the bladder in 3 axes:
Bladder volume = H x W x D x 0.6
H (Height): Cephalad caudad dimension from the dome to the neck measured in the longitudinal/sagittal. Corresponds to patient height.
W (Width): Medial lateral dimension from patient left to right measured in the transverse. Corresponds to patient width.
D (Depth): Anteroposterior dimension from patient anterior to posterior measured again in the transverse.
0.6: Coefficient of correlation.
Image generation:
- Place the probe in longitudinal, with the heel of the probe directly against the symphysis pubis.
Centre the image. Slide left to right, +/- heeling caudally for the emptier bladder. - Optimize image. Adjust depth and gain.
- Adequate image for interpretation. Not usually an issue unless in retention with a ++ distended bladder, in which case you may need to slide cephalad to see the dome, or sliding caudally for the empty bladder which MAY entail a rescan +/- fluid bolus in the interim, depending upon the clinical scenario.
- Interrogate the bladder – slide or heel looking for the extent of the dome (retention). Rotate into short axis. Slide cephalad looking for the dome in the distended bladder staying in true transverse. Slide back down to the midpoint of the reasonably full bladder and see if you can see the interureteric ridge and the ureteric openings on either side. Be methodical in your approach.
- A completely empty bladder will be difficult or impossible to visualize
- Apply pressure to move bowel gas
Image generation
- Holding transducer too high up. Correction – Hold probe closer to the working end with hypothenar eminence against the patient.
- Sweeping too quickly.
Image interpretation. Urinary retention
- False positive: Older toddlers and children may sometimes hold their urine especially if they have any perineal pain.
Image interpretation. Stones
- False positive: Interposed bowel gas. Ensure the shadowing is clean.
- False negative: Stones are very small, almost always under 1 cm, and often 5 mm or less. As such, shadowing can be very difficult to appreciate. In the setting of a possible stone, be sure to turn the gain down. Additionally, consider using colour Doppler to see if you can get twinkling. See Tips and tricks for details on how to perform this maneuver.
Image interpretation. Ovarian cyst
- A contracted bladder can be misidentified as an ovarian cyst. Ensure the symphysis pubic bone and shadow are identified. These act as internal landmarks to ensure you are looking caudally enough in the abdomen to not miss a small, contracted bladder. If multiple fluid filled structures are visible (most often ovarian cysts), the bladder is the structure that is immediately cephalad-posterior to the symphysis pubis.
Image interpretation. Uterine mass
- An empty bladder can be misidentified as a large uterine mass. Ensure the symphysis pubic bone and shadow are identified. These act as internal landmarks to ensure you are looking caudally enough in the abdomen to not miss an empty bladder.
- Ensure all bladder borders are visualized for accurate measurement
- Use bladder scanning preset if available on machine
- Different factors like age and sex can change normal bladder volumes
- Different shaped bladders should use different coefficients to more accurately calculate volume (lower for more spheroid, higher for more prismatic or rectangular).
- Must visualize entire bladder
- Images stored digitally with patient identifiers
- Documentation of measurements in three dimensions
- Documentation of calculated volume
- Documentation of pre/post void status
- Documentation of findings (negative, positive, indeterminate)
- -negative PVR (normal findings)
- -positive PVR x mL (retention)
- Prerequisites: Completion of CPoCUS-approved introductory course
- Logged scans: Minimum 10 bladder volume scans during training
- Proctored scans: Minimum 5 unassisted supervised scans with IP instructor
- Examinations: Written, visual, and practical assessment
Primary author
Stéphane Rhein
Contributing author / Editor
Chau Pham
Publishing
Sharon Oleskevich
© Canadian Point of Care Ultrasound Society 2024
Reproduction or distribution without express written permission is prohibited
Accéder à la version française
CERTIFY OTHERS
To certify others as an BLADDER Independent Practitioner (IP),
an examiner may submit an IP Request
only if:
The IP candidate has successfully completed BLADDER introductory training, logged scan requirements, and all three examinations
and
If you cannot see the button below, you have not met the examiner certification criteria
SCAN DOCUMENTATION
The summary below is taken from the curriculum Determinate scan requirements and Certification for each module.
For all Prerequisites, the introductory scans do not count towards certification and do not need to be determinate.
For all Logged scan requirements, there is no requirement for a minimum number of positive scans.
***An ‘unassisted’ scan is one in which the learner generates a determinate image and uses appropriate troubleshooting maneuvers without ANY assistance (verbal or physical) from the instructor.
Bladder Basics (BLADDER)
Prerequisites
Appropriate didactic and practical introduction to technique that must include written materials covering all relevant ultrasound physics, anatomy and theory, a minimum of 30 minutes of live or on-line lectures and at least 5 introductory proctored bladder scans.
Logged scan requirements
- 10 bladder determinate scans supervised directly by a CPoCUS instructor for the entirety of the scan.
- Determinate scans are defined in ‘Determinate scan requirements’.
- A minimum of 5 of the last 10 determinate scans must be done ‘unassisted’***.
- There is no requirement for a minimum number of positive scans.
- All scans must be recorded in a CPoCUS logbook.
MAINTAIN YOUR SKILLS
EARN CME CREDITS
Review the BLADDER curriculum
Earn CME credits at the same time
Activity description | Society | Credit category | Credits earned |
|---|---|---|---|
Review the CPoCUS curriculum online | CFPC | Assessment:
Review of learning materials | 1 non-certified credit per hour of review |
RCPSC | Section 2, Self-learning: Planned learning, Traineeship.
Enter Session ID (see table 2). | 2 credits per hour |