The Role of Point-of-Care Ultrasonography in Medicine

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

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

  • 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)

  • 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)

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

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

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

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

  • 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)

  • 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)

  • 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)

  • 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)

  • 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)

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

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


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Costantino TG, Parikh AK, Satz WA, et al. Ultrasonography-guided peripheral intravenous access versus traditional approaches in patients with difficult intravenous access. Ann Emerg Med 2005 Nov;46(5):456-461.

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Engin G, Yekeler E, Güloglu R, et al. US versus conventional radiography in the diagnosis of sternal fractures. Acta Radiol 2000 May;41(3):296-299.

Ferre RM, Sweeney TW. Emergency physicians can easily obtain ultrasound images of anatomical landmarks relevant to lumbar puncture. Am J Emerg Med 2007 Mar;25(3):291-296.

Freeman K, Dewitz A, Baker WE. Ultrasound-guided hip arthrocentesis in the ED. Am J Emerg Med 2007 Jan;25(1):80-86.

Froehlich CD, Rigby MR, Rosenberg ES, et al. Ultrasound-guided central venous catheter placement decreases complications and decreases placement attempts compared with the landmark technique in a pediatric intensive care unit. Crit Care Med 2009 Mar;37(3):1090-1096.

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Gunst M, Ghaemmaghami V, Sperry J, et al. Accuracy of cardiac function and volume status estimates using the bedside echocardiographic assessment in trauma/critical care. J Trauma 2008 Sep;65(3):509-516.

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Jones PW, Moyer JP, Rogers JT, et al. Ultrasound-guided thoracentesis: is it a safer method? Chest 2003 Feb;123(2):418-423.

Karabinis A, Fragou M, Karakitsos D. Whole-body ultrasound in the intensive care unit: a new role for an aged technique. J Crit Care 2010 Sep;25(3):509-513.

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Kimberly HH, Shah S, Marill K, et al. Correlation of optic nerve sheath diameter with direct measurement of intracranial pressure. Acad Emerg Med 2008 Feb;15(2):201-204.

Kirkpatrick AW, Sirois M, Laupland KB, et al. Hand-held thoracic sonography for detecting post-traumatic pneumothoraces: the Extended Focused Assessment with Sonography for Trauma (EFAST). J Trauma 2004 Aug;57(2):288-295.

Knudston JL, Dort JM, Helmer SD, et al. Surgeon-performed ultrasound for pneumothorax in the trauma suite. J Trauma 2004 Mar;56(3):527-530.

Kobal SL, Trento L, Baharami S, et al.  Comparison of effectiveness of hand-carried ultrasound to bedside cardiovascular physical examination. Am J Cardiol 2005 Oct 1;96(7)1002-1006.

Kuhn M, Bonnin RL, Davey MJ, et al. Emergency department ultrasound scanning for abdominal aortic aneurysm: accessible, accurate, and advantageous. Ann Emerg Med 2000 Sep;36(3):219-223.

Lanoix R, Leak LV, Gaeta T, et al. A preliminary evaluation of emergency ultrasound in the setting of an emergency medicine training program. Am J Emerg Med 2000 Jan;18(1):41-45.

LaRocco BG, Zlupko G, Sierzenski P. Ultrasound diagnosis of quadriceps tendon rupture. J Emerg Med 2008 Oct;35(3):293-295.

Leung J, Duffy M, Finckh A. Real-time ultrasonographically-guided internal jugular vein catheterization in the emergency department increases success rates and reduces complications: a randomized, prospective study. Ann Emerg Med 2006 Nov; 48(5):540-547.

Levy JA, Noble VE. Bedside ultrasound in pediatric emergency medicine. Pediatrics 2008 May;121(5):e1404-1412.

Liebmann O, Price D, Mills C, et al. Feasibility of forearm ultrasonography-guided nerve blocks of the radial, ulnar, and median nerves for hand procedures in the emergency department. Ann Emerg Med 2006 Nov;48(5):558-562.

Lyon M, Blaivas M. Intraoral ultrasound in the diagnosis and treatment of suspected peritonsillar abscess in the emergency department. Acad Emerg Med 2005 Jan;12(1):85-88.

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Malcolm GE 3rd, Raio CC, Del Rios M, et al. Feasibility of emergency physician diagnosis of hypertrophic pyloric stenosis using point-of-care ultrasound: a multi-center case series. J Emerg Med 2009 Oct;37(3):283-286.

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Mateer JR, Valley VT, Aiman EJ, et al. Outcome analysis of a protocol including bedside endovaginal sonography in patients at risk for ectopic pregnancy. Ann Emerg Med 1996 Mar;27(3):283-289.

Melniker LA, Leibner E, McKenney MG, et al. Randomized controlled clinical trial of point-of-care, limited ultrasonography for trauma in the emergency department: the first sonography outcomes assessment program trial. Ann Emerg Med 2006 Sep;48(3):227-235.

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Miller AH, Roth BA, Mills TJ, et al. Ultrasound guidance versus the landmark technique for the placement of central venous catheters in the emergency department. Acad Emerg Med 2002 Aug;9(8):800-805.

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Milling TJ, Jones M, Khan T, et al. Transtracheal 2-d ultrasound for identification of esophageal intubation. J Emerg Med 2007 May;32(4):409-414.

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Nagdev AD, Merchant RC, Tirado-Gonzalez A, et al. Emergency department bedside ultrasonographic measurement of the caval index for noninvasive determination of low central venous pressure. Ann Emerg Med 2010 Mar;55(3):290-295.

Nazeer SR, Dewbre H, Miller AH. Ultrasound-assisted paracentesis performed by emergency physicians vs the traditional technique: a prospective, randomized study. Amer J Emerg Med 2005 May;23(3):363-367.

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