Ultrasound Case: Syncope in PE
Correspondence should be addressed to Stephanie Stapleton, MD at snstaple13@gmail.com
DOI: https://doi.org/10.21980/J8.52365
ABSTRACT:
Audience: This certifying exam practice ultrasound case is intended for emergency physicians (EP) in training.
Introduction: Point-of-care ultrasound (POCUS) has become an essential tool in the practice of Emergency Medicine (EM). EM physicians routinely use POCUS to expedite diagnostic evaluations, guide resuscitative efforts, enhance the safety and success of bedside procedures, and reassess critically ill patients in real-time. Furthermore, POCUS is listed in the Model of the Clinical Practice of Emergency Medicine from ABEM, including diagnostic, resuscitative, and procedural components.1 Training during residency, however, remains variable while POCUS continues to grow in importance.2 Incorporating structured, competency-based ultrasound education into EM training has the potential to standardize skill with image acquisition, enhance image interpretation, improve confidence with clinical integration, and ultimately lead to better patient care in the acute setting.
Educational Objectives: By the end of the session, learners will be able to: 1) obtain and interpret the parasternal short-axis view of the heart to assess right ventricular size and function, 2) identify ultrasound findings suggestive of pulmonary embolism (PE) on cardiac short-axis view, including right ventricular dilation and septal bowing, 3) demonstrate appropriate probe selection and positioning to obtain optimal images of the heart and inferior vena cava (IVC), 4) evaluate the IVC using a subxiphoid or longitudinal view to assess distension and lack of respiratory collapse as supportive findings for elevated right heart pressures, 5) identify the anatomy of the neck vasculature, differentiate between the internal jugular vein and carotid artery, and select the appropriate puncture site, 6) describe ultrasound-guided central venous catheterization via the right internal jugular vein, using a sterile technique and real-time guidance.
Educational Methods: We developed a single-station Objective Structured Clinical Examination (OSCE) focused on point-of-care ultrasound (POCUS) in the evaluation of a patient with syncope and suspected pulmonary embolism (PE).3 This format aligns with the American Board of Emergency Medicine’s (ABEM) newly implemented certification examination, emphasizing real-time clinical reasoning and ultrasound skills in a simulated encounter.4 The OSCE features a simulated participant and a standardized examiner script mirroring the ABEM certification exam format to ensure realism and consistency.5,6 ABEM has not released specific scoring elements to our knowledge. As a result, a novel set of grading criteria was developed based on patient-centered care, image acquisition, and image interpretation. The case was co-developed by experts in emergency ultrasound and simulation-based education, and then peer-reviewed to ensure clinical accuracy, clarity, and educational value.
During the station, the examinee is presented with a focused clinical case involving a patient with syncope and is expected to demonstrate foundational POCUS knowledge, including image acquisition, optimization, and interpretation to assess for signs of PE, such as right ventricular strain or plethoric inferior vena cava.7 The examiner follows a structured and standardized script that evaluates the participant using a checklist, including de-identified images and clips of pathology. This tool assesses image acquisition, interpretation, and the integration of ultrasound findings into clinical decision-making. This OSCE provides a standardized method to assess diagnostic and procedural competence in a common application of ultrasound.
Research Methods: This simulation case can be used as a standalone scenario or part of an ABEM Certifying Exam practice. For best results, residents should complete it individually, with some assigned as facilitators to better understand the examiner’s role. The case runs for about 10 minutes, followed by a 10-minute debrief. Optimal setup includes examiner control over room lighting and ultrasound display. The case was trialed with EM residents across multiple sites using an iterative process. Feedback was collected via anonymous Qualtrics surveys using Likert scales and open-ended comments. The Boston University Institutional Review Board reviewed the project and deemed it exempt.
Results: Initial testing with two residents and a facilitator showed the case was clear, easy to use, and valuable for exam prep. A second round at the 2025 SAEM Annual Meeting included four learners and one facilitator. Feedback led to case revisions. Survey scores were consistently positive, with high ratings for clarity, usability, and relevance to ABEM exam preparation.
Discussion: The development and implementation of a syncope-focused ultrasound case for ABEM certification preparation highlights the growing integration of POCUS into emergency medicine training and assessment. Syncope is a high-yield chief complaint in the emergency department and serves as a common clinical context in which critical diagnoses like PE may be encountered.8 In this case, the use of bedside ultrasound to identify right heart strain consistent with PE not only mirrors real-world clinical practice but also reinforces the diagnostic reasoning and image interpretation skills essential for contemporary emergency physicians.9,10 The favorable reception from learners underscores the value of ultrasound-based cases in exam preparation and supports the continued development of high-quality, board-style ultrasound assessments in emergency medicine training programs.
Topics: Ultrasound, cardiac, inferior vena cava, vascular, pulmonary embolism.
