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DOI 10.1186/s13054-016-1399-x
REVIEW
Open Access
Abstract
Introduction
Background
This article aims to review the historical development,
organizational support, scope of practice, and evidence
supporting applications of ultrasonography in the emergency department. A literature search and review was
performed on PubMed and via the Hoftra Northwell
School of Medicine medical library.
* Correspondence: micahwhitson64@gmail.com
Hofstra Northwell School of Medicine, Long Island Jewish Medical Center,
270-05 76th Avenue, New Hyde Park, NY 11040, USA
Point-of-care ultrasonography (POCUS) is a useful imaging technique for the emergency medicine (EM) physician. Comprehensive training in POCUS is presently a
mandatory part of EM training in North America, and is
used extensively by some EM teams in Europe. Because
of its growing use in EM, this article will summarize the
applications of POCUS in the emergency department.
The review will be limited to the use of EM POCUS in
the adult patient. Because of space constraints, the article will not provide instruction on the clinical aspects of
image acquisition, image interpretation, or the cognitive
base of the field; these are well presented in standard
textbooks and literature on the subject. Instead, the
focus will be on reviewing the scope of practice of EM
POCUS.
Consultative ultrasonography versus POCUS
2016 The Author(s). Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
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Emergency department
ultrasonography
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Examination for DVT is a key part of the WBU approach to cardiopulmonary failure, particularly if PE is a
consideration. EM physicians can perform high-quality
2-D venous compression studies with results similar to
those performed by the consultative radiology service
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[37] while avoiding the inevitable delay required to obtain a radiology study [38]. Doppler-based measurements do not add to the yield of the 2-D compression
study [39], so the POCUS DVT examination can be performed rapidly [40].
While a positive DVT study has immediate implication
in the patient who is being evaluated for PE, a negative
DVT study does not rule out PE. If the rest of the WBU
examination reveals another cause for the symptom
complex (e.g., pneumonia, congestive heart failure), it is
very unlikely that the patient has a PE [31]. If lung ultrasonography reveals findings consistent with PE (e.g.,
small subpleural consolidations in lower lobes), it is a
high-probability consideration. Ultrasonography may reduce the need for CT angiography for the detection of
PE [32], but some patients still require CT if ultrasonography is indeterminate.
Screening abdominal ultrasonography
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Ultrasonography in trauma
Ultrasonography is used by the EM physician for guidance of a variety of procedures that are required for
treatment of critical illness or routine management of
the disease process [50, 51]. Ultrasonography increases
the success rate and reduces the complication rate of a
wide variety of procedures that are performed by EM
physicians and intensivists, such as thoracentesis (both
diagnostic and therapeutic requiring chest tube insertion),
paracentesis, regional anesthesia, lumbar puncture [51],
Abdominal ultrasonography
Ultrasonography performed by EM physicians has sensitivity of 96100 % and specificity of 8090 % for the
diagnosis of testicular torsion, and has sensitivity and
specificity of 8090 % for epididymo-orchitis [68, 69].
Many emergency departments do not have ready access
to consultative radiology ultrasonography during all
hours of operation. Ultrasonography for testicular torsion can be performed successfully by emergency physicians [70] and may improve outcome in torsion where
rapid diagnosis leads to increased rates of testicular
salvage.
Soft tissue and musculoskeletal ultrasonography
Ocular ultrasonography is another relatively new application for EM physicians endorsed by the ACEP [4]. Reviews
of anatomy, technique, and pathology are available [75].
Emergency physicians are able to accurately evaluate globe
rupture, foreign bodies, retinal detachment, lens dislocation, and vitreous hemorrhage or detachment with ultrasonography [76]. This allows patient stratification into
emergent, urgent, and routine ophthalmologic consultation.
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Ocular ultrasonography may be used to evaluate intracranial pressure (ICP) by measurement of the optic
nerve sheath diameter. At a cut-off value of 5 mm, ultrasonography has 100 % sensitivity for evaluation of increased ICP when compared with CT and has 84 %
sensitivity for any intracranial injury in the setting of
head trauma [77, 78]. Emergency physicians are able to
accurately measure the optic nerve sheath diameter [79],
and this measurement is highly correlated with direct
ICP measurements with sensitivity and specificity >90 %
[80, 81]. Optic nerve sheath measurements reliably and
rapidly change with changes in ICP [82].
Conclusions
Ultrasonography has become an integral part of EM
over the past two decades. Some aforementioned applications of ultrasonography are well established and practiced routinely, while more research is necessary to
advance the use of ultrasonography in other areas.
Abbreviations
AAA, abdominal aortic aneurysm; ACCP/SRLF, American College of Chest
Physicians/La Societe de Reanimation de Langue Francaise; ACEP, American
College of Emergency Physicians; ACGME, American College of Graduate
Medical Education; CCUS, critical care ultrasonography; CPR, cardiopulmonary
resuscitation; CT, computed tomography; DVT, deep vein thrombosis; EM,
emergency medicine; FAST, focused assessment with sonography in trauma;
GDE, goal-directed echocardiography; ICP, intracranial pressure; IVC, inferior
vena cava; LIS, lung interstitial syndrome; PE, pulmonary embolism; POCUS,
point-of-care ultrasonography; TVUS, transvaginal ultrasonography; WBU,
whole-body ultrasonography
Funding
The authors have no source of funding for this review.
Authors contributions
MRW and PHM were involved in drafting the manuscript and revising it
critically for important intellectual content. They have given final approval of
the version to be published and agree to be accountable for all aspects of
the work in ensuring that questions related to the accuracy or integrity of
any part of the work are appropriately investigated and resolved.
Competing interests
The authors declare that they have no competing interests.
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