Point-of-care ultrasound (PoCUS) has become an indispensable standard in emergency medicine. Emergency medicine ultrasound (EMUS) is the application of bedside PoCUS by the attending emergency physician to assist in the diagnosis and management of many time-sensitive health emergencies. In many ways, using PoCUS is not only the mere application of technology, but also a fusion of already existing examiner skills and technology in the context of a patient encounter. EMUS practice can be defined using distinct anatomy-based applications. The type of applications and their complexity usually depend on local needs and resources, and practice patterns can vary significantly among regions, countries, or even continents. A different approach suggests defining EMUS in categories such as resuscitative, diagnostic, procedural guidance, symptom- or sign-based, and therapeutic. Because EMUS is practiced in a constantly evolving emergency medical setting where no two patient encounters are identical, the concept of EMUS should also be practiced in a fluid, constantly adapting manner driven by the physician treating the patient. Many recent advances in ultrasound technology have received little or no attention from the EMUS community, and several important technical advances and research findings have not been translated into routine clinical practice. The authors believe that four main areas have great potential for the future growth and development of EMUS and are worth integrating: 1. In recent years, many articles have been published on novel ultrasound applications. Only a small percentage has found its way into routine use. We will discuss two important examples: trauma ultrasound that goes beyond e-FAST and EMUS lung ultrasound for suspected pulmonary embolism. 2. The more ultrasound equipment becomes financially affordable; the more ultrasound should be incorporated into the physical examination. This merging and possibly even replacement of aspects of the classical physical exam by technology will likely outperform the isolated use of stethoscope, percussion, and auscultation. 3. The knowledge of pathophysiological processes in acute illness and ultrasound findings should be merged in clinical practice. The translation of this knowledge into practical concepts will allow us to better manage many presentations, such as hypotension or the dyspnea of unclear etiology. 4. Technical innovations such as elastography; CEUS; highly sensitive color Doppler such as M-flow, vector flow, or other novel technology; artificial intelligence; cloud-based POCUS functions; and augmented reality devices such as smart glasses should become standard in emergencies over time.

Sepsis and septic shock are life-threatening emergencies associated with increased morbidity and mortality. Hence, early diagnosis and management of both conditions is of paramount importance. Point-of-care ultrasound (POCUS) is a cost-effective and safe imaging modality performed at the bedside, which has rapidly emerged as an excellent multimodal tool and has been gradually incorporated as an adjunct to physical examination in order to facilitate evaluation, diagnosis and management. In sepsis, POCUS can assist in the evaluation of undifferentiated sepsis, while, in cases of shock, it can contribute to the differential diagnosis of other types of shock, thus facilitating the decision-making process. Other potential benefits of POCUS include prompt identification and control of the source of infection, as well as close haemodynamic and treatment monitoring. The aim of this review is to determine and highlight the role of POCUS in the evaluation, diagnosis, treatment and monitoring of the septic patient. Future research should focus on developing and implementing a well-defined algorithmic approach for the POCUS-guided management of sepsis in the emergency department setting given its unequivocal utility as a multimodal tool for the overall evaluation and management of the septic patient.

E-FAST (Extended-Focused Assessment with Sonography for Trauma) is now a widely utilized and internationally recognized standard exam in trauma care. It is highly accepted by emergency physicians and trauma surgeons alike. Thanks to the popularity of PoCUS (point-of-care ultrasound), it has continued to evolve over the last years and can now improve trauma diagnosis at all stages of the primary ABCDE. This review article summarizes key observations made over recent years and also highlights the extension of FAST into E-FAST in the context of PoCUS and CT developments for modern trauma management. Time has come to learn the lessons from 25 years of FAST and 15 years of E-FAST. We should redefine and position ultrasound in the primary ATLS survey (Advanced Trauma Life Support) on two levels: 1. Basic ATLS with new clinical questions, six additional abdominal image sections and one or more follow-up examinations depending on the clinical situation, and 2. Advanced ATLS with ultrasound applications for the entire trauma ABCDE.

Emergency Medicine Point-of-Care Ultrasound (EMPoCUS) is a convincing concept. It has spread rapidly because of its intuitive, simple applicability and low equipment costs. The speed of its emerging growth frequently outpaces the development of quality assurance and education. Indeed, education standards vary worldwide, and in some cases seem to neglect the principles of modern competence-based education. Additional challenges are encountered such as remote or low resource medical practice. Here, EMPoCUS might be the only ad-hoc imaging modality available. Once mastery of EMPoCUS is achieved, emergency physicians should be able to independently and efficiently care for their patients using a variety of PoCUS skills. However, most curricula only define these tasks as non-binding and in general terms or use outdated measures, such as length of training and self-reporting of achieved examinations with variable oversight, or administrative measures to create educational milestones. This threatens to take quality assurance down the wrong path. It created a scenario in which concrete EMPoCUS skill outcome measures that would realistically reflect the training objectives and simultaneously would be easily observable and verifiable are lacking. In view of the dangers of poorly controlled EMPoCUS dissemination and the current lack of European guidelines, we would like to set central standards for European EMPoCUS stewardship based on a critical review of the current situation. This position paper, which was jointly developed by EuSEM and EFSUMB and endorsed by IFEM and WFUMB, is also intended to accompany the EFSUMB/EuSEM guidelines on PoCUS currently being prepared for publication.

It is currently unknown whether thrombin generation is associated with venous thromboembolism (VTE) recurrence, major bleeding, or mortality in the elderly. Therefore, our aim was to prospectively study the association between thrombin generation and VTE recurrence, major bleeding, and mortality in elderly patients with acute VTE. Consecutive patients aged ≥65 years with acute VTE were followed for 2 years, starting from 1 year after the index VTE. Primary outcomes were VTE recurrence, major bleeding, and mortality. Thrombin generation was assessed in 551 patients 1 year after the index VTE. At this time, 59% of the patients were still anticoagulated. Thrombin generation was discriminatory for VTE recurrence, but not for major bleeding and mortality in non-anticoagulated patients. Moreover, peak ratio (adjusted subhazard ratio 4.09, 95% CI, 1.12–14.92) and normalized peak ratio (adjusted subhazard ratio 2.18, 95% CI, 1.28–3.73) in the presence/absence of thrombomodulin were associated with VTE recurrence, but not with major bleeding and mortality after adjustment for potential confounding factors. In elderly patients, thrombin generation was associated with VTE recurrence, but not with major bleeding and/or mortality. Therefore, our study suggests the potential usefulness of thrombin generation measurement after anticoagulation completion for VTE to help identify among elderly patients those at higher risk of VTE recurrence.

“Point-of-Care Ultrasound” (POCUS) is a term that is currently on everyone’s lips. Its uses vary and it is often equated with focused ultrasound, emergency ultrasound, and pocket ultrasound, for example. The increase in the use of POCUS has resulted not only in a major atmosphere of change and new opportunities for ultrasound but also in a general sense of uncertainty. Some colleagues even view POCUS as a threat with regard to quality assurance. Because POCUS will play a major role in the clinical routine in the future, it seems important to ensure clear understanding and standardized usage of the term. POCUS is a bedside ultrasound method that covers examinations from head to toe. It not only focuses on the macroanatomy and pathology but also allows direct evaluation of functional anatomical aspects, physiology, pathophysiology, and hemodynamics and provides support during interventions. Treating physicians with diverse areas of specialization and an interest in a specific organ pathology, particular diseases/symptoms, or an intervention personally perform examinations in various situations (emergency admission, consultation hours, intensive care unit, operating room, etc.) in real time while determining the scope and interpreting the findings. Another significant component of POCUS is the concept of focused ultrasound. Focused means that the examiner is limited to one or more yes-no ultrasound questions (from simple to complicated) and does not perform a conventional comprehensive organ examination or examination of a region or functional unit. The focus is less on ultrasound as an isolated diagnostic imaging method and more on the expansion of the clinical examination. This provides the examiner with an additional tool for making reliable and optimal management decisions and for monitoring patients as needed. Conventional comprehensive ultrasound, in contrast, is divided into various well-defined anatomical regions, like the abdomen, lung, vessels, nerves, heart, soft tissues, and musculoskeletal system and is performed by a physician specialized in the particular type of imaging at a specialized medical practice or ultrasound department. It includes comprehensive examination of an individual organ, an anatomical or functional unit or a region with reliable criteria to detect or rule out the presence of certain diseases/injuries. 2 articles in this issue provide examples of this. The study on the role of high-resolution ultrasound in the follow-up of cervical lymph nodes after RCT shows that intranodal necrosis and changes in the hilar vascularization pattern can be clearly visualized and accurate control of dynamic changes is possible in sonographic tumor follow-up. A further study shows that US-guided HIFU treatment can be reliably performed even in the case of locally advanced pancreatic cancer with involvement of the mesenteric vessels and extensive collateral circulation. A significant consideration regarding the quality of ultrasound is that the method is highly examiner-dependent. Therefore, a further study in this issue shows that the interobserver agreement for ESCULAP seems better than for CEUS-LI-RADS since the perception of contrast washout can vary greatly between individual examiners. The use of high-resolution ultrasound as an established and validated method thus allows more extensive differentiated diagnosis in the hands of experienced specialists and is also suitable for monitoring therapeutic measures. There are 2 main directions or training programs in ultrasound: 1. Conventional comprehensive ultrasound which is performed by a specialist or at a specialized medical practice usually as a referral and 2. POCUS which is performed by the treating physician as a focused examination in real time at the patient’s bedside with immediate interpretation. Therefore, the differences essentially relate to the examination location, the qualifications of the examiner, and the scope and objective of the examination. In this connection, it is necessary to determine whether POCUS poses a threat to conventional comprehensive ultrasound or represents a risk to the quality of ultrasound examinations. This concern is evidenced by the fact that POCUS is at the bottom of an examiner-expert pyramid. In this regard POCUS is viewed as acceptable for the intended purpose but is of lower quality than a complete ultrasound examination. Consequently, the fear is that POCUS will be used ubiquitously, resulting in a loss in quality and thereby lowering the value of the method. However, this does not take into consideration the fact that a limited examination cannot be equated a priori with a low examination quality in the way that a small circle only differs quantitatively and not qualitatively from a large circle. The learning pyramid is static and does not allow any space for the advantages of POCUS over comprehensive ultrasound. Therefore, for example, the speed and availability of ultrasound examinations are lost. Consequently, there is no doubt that comprehensive ultrasound performed by a specialist is of great importance and cannot be replaced by POCUS. However, it is also correct that ultrasound performed by a specialist is only available on a limited basis and a complete examination is often not necessary or there is insufficient time for such an examination. 6 measures are needed to ensure that traditional comprehensive ultrasound and POCUS complement one another rather than compete with one another: 1. The concept of the conventional US learning pyramid must allow room for recognition of the similarities and differences between the methods and the fact that POCUS represents a new readily available but limited ultrasound method. 2. Standardized, evidence-based training curricula and standards for POCUS must be created and various expert levels for training must be defined. 3. Tutors need to be trained and training centers for those interested in POCUS must be...