Physicians

The Role of Point-of-Care Ultrasonography in Medicine

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While traditional methods of performing a physical examination are of critical importance, healthcare practitioners that become skilled in the use of point-of-care ultrasonography become uniquely empowered. Conditions such as cardiac valvular disorders that are inferred by auscultation can be visualized and quantified by ultrasound. Time-sensitive definitive diagnoses, such as ruptured abdominal aortic aneurysms, are made in minutes rather than hours. The differential diagnosis of undifferentiated shock is narrowed in a matter of minutes through the use of ultrasound to evaluate cardiac ejection fraction, noninvasive estimation of central venous pressures by visualizing the diameter and variation in the inferior vena cava, and assessing for right heart overload, pericardial effusion, and intracorporal blood loss in major body cavities.

The range of clinical applications that point-of-care ultrasound is being utilized for is rapidly expanding on a continuous basis. A variety of clinical care efficiencies have been reported. (Table 1) (Bassler) Examples include patients with flank pain or hematuria, where the kidneys can be evaluated for the presence of hydronephrosis, renal cysts, or distortion of the renal architecture consistent with a renal mass. In addition, the bladder can be assessed with ultrasound to estimate the volume and confirm ureteric expulsion of urine into the bladder using Doppler. The presence of these bladder jets confirms patency of the ureters, avoiding an unnecessary computed tomography (CT) scan.

The intimal-medial thickness of the carotid artery can be measured as a screening for atherosclerosis.  Ultrasound has 100% sensitivity for the diagnosis of abdominal aortic aneurysms. In patients with a swollen arm or leg, a deep vein thrombosis can easily be screened for at the bedside without having to anticoagulate the patient while waiting for an ultrasound. Differentiating simple cellulitis from the need to surgically drain an abscess has been shown to be superior with ultrasound. Long-bone fractures can be diagnosed and reduced under ultrasound guidance. Many times foreign bodies can be localized and removed without the need for fluoroscopic guidance. Needle-based procedures can be made safer and timelier when done under ultrasound guidance. This includes paracentesis, thoracentesis, arthrocentesis, pericardiocentesis, lumbar puncture, regional anesthesia, and vascular access.

Portable ultrasound technology at the bedside means that this virtually risk-free technology is immediately accessible throughout the hospital and community clinics. This will decrease reliance on CT scans as initial imaging tests, and reduce the exposure of patients to ionizing radiation. Ultrasound is of critical importance in pediatric care, as children are particularly susceptible to the long-term risks of ionizing radiation. (Chen, Levy, Brenner) By conducting an initial assessment of the patient with ultrasound, physicians will be inclined to use focused rather than full-body CT scans. It will also lead to early detection of certain pathologic conditions that might not otherwise be possible, and provide cost-effective healthcare.

 

Table 1: Clinical Benefits of Point-of-Care Ultrasonography
ANESTHESIA/PAIN MANAGEMENT

  • Improved ability to provide regional anesthesia with image-guidance (Stone 2007, Liebmann, Chan 2007)
CRITICAL CARE

  • Improve imaging efficiency and decrease resource utilization in an ICU  (Karabinis, Karakitsos, Palepu)
  • Noninvasive method of estimating central venous pressure (Nagdev)
  • Assessment of endotracheal tube placement (Ma, Milling 2005)
  • Noninvasive method of estimating cardiac index and central venous pressure (Gunst)
EMERGENCY MEDICINE

  • Decreased length of stay (LOS) in the ED by 22 to 52 minutes for acute cholecystitis cases (presenting during regular hours and afterhours, respectively) (Blaivas 1999)
  • Decreased LOS in the ED from 225 minutes to 95 minutes following bedside deep venous thrombosis (DVT) evaluation in the ED (Theodoro, Blaivas 2000)
  • Decreases average time to diagnosis of ruptured AAA in the ED from 83 minutes to 5.4 minutes and reduces mortality from 72 percent to 40 percent. (Plummer)
  • Improved ability to detect retinal detachment (Buzzard), vitreous body detachment and hemorrhage, intraocular foreign body, and elevated intracranial pressures (Blaivas 2002)
  • Improved ability to rapidly screen for pneumothorax (Kirkpatrick, Knudtson)
  • Rapid assessment of resuscitation outcomes in cardiac arrest patients (Salen)
  • Assessment of endotracheal tube placement (Ma, Milling 2007)
INFECTIOUS DISEASE

  • Improved noninvasive diagnostic ability for discriminating cellulitis versus abscess (Squire, Tayal & Hasan 2006)
NEUROLOGY/NEUROSURGERY

  • Provides a noninvasive method of measuring intracranial pressure (Tayal 2007, Harbison, Kimberly)
OBSTETRICS

  • Improves management and reduces time to operative care in the setting of ectopic pregnancy by 69 percent  (Mateer, Rodgerson)
OROMAXILLOFACIAL/OTOLARYNGOLOGY

  • Diagnosis and real-time assessment of nasal bone fractures and reduction (Park)
  • Improved diagnosis and drainage of peritonsillar abscess (Lyon)
MUSCULOSKELETAL

  • Ability to image-guide arthrocentesis (Freeman)
  • Rapid diagnosis of rib fractures (Chan 2009)
  • Detection of tendon ruptures (LaRocco)
  • Allows for rapid diagnosis of fractured bones and enables a radiation-free method for real-time image-guided fracture reduction (Engin, Patel, Marshburn, Chen & Kim 2007)
PEDIATRICS

  • Improved efficacy of bladder catheterization of infants and young children (Chen 2005, Baumann 2008) and improved caregiver satisfaction with care (Baumann 2007)
  • Successful documentation of g-tube replacement without the use of ionizing radiation (Wu)
  • Improved rates of vascular access in difficult-to-access pediatric patients (Doniger, Froehlich)
  • Improved management of pediatric soft-tissue infection (Sivitz)
  • Bedside detection of hip effusion in the child with a limp (Vieira)
  • Bedside detection of pyloric stenosis (Malcolm)
  • Rapid diagnosis and reduction of fractures (Chen)
PRIMARY CARE

  • Provides a reliable and efficient method of AAA screening (Kuhn, Tayal 2003)
  • Reduces the incidence of failed nerve blocks by 86 percent and reduces time-to-discharge (compared to general anesthesia) by 75 percent. (Abrahams, O’Donnell)
PROCEDURAL GUIDANCE

  • Improved efficacy, efficiency, and safety for a variety of procedures including central venous line placement, difficult peripheral vascular access patients (Stone & Nagdev 2010, Bauman), paracentesis (Nazeer), thoracentesis (Barnes, Feller-Kopman, Jones), arthrocentesis, lumbar puncture (Ferre, Peterson, Stiffler), suprapubic bladder aspiration (Titus) among others (Tayal V, Leung, Nomura, Costantino, Milling)
  •  Decreased rate of iatrogenic pneumothorax following thoracentesis from 18 to 3 percent (Raptopoluos)
TRAUMA

  • Reduced time to diagnosis of pericardial effusion following chest trauma (Plummer, Rozycki)
  • Reduced time to operative care in the setting of trauma and decreased overall hospital length of stay by 29 percent (Melniker, Nelson)
UROLOGY

  • Noninvasive method of measuring bladder volumes  (Baumann 2007 & 2008, Palese)
  • Noninvasive method of detecting penile fractures (Nomura 2010)
VASCULAR

  • Provides a rapid and efficient method of bedside DVT screening (Shiver)

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References

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