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|
Abrahams MS, Aziz MF, Fu RF. et al. Ultrasound guidance compared with electrical neurostimulation for peripheral nerve block: a systematic review and meta-analysis of randomized controlled trials. Br J Anaesth 2009 Mar;102(3): 408-417. Epub 2009 Jan 26.
Bansal R, Agarwal SK, Tiwari SC, et al. A prospective randomized study to compare ultrasound-guided with nonultrasound-guided double lumen internal jugular catheter insertion as a temporary hemodialysis access. Ren Fail 2005;27 (5):561-564.
Barnes TW, Morgenthaler TI, Olson EJ, et al. Sonographically guided thoracentesis and rate of pneumothorax. J Clin Ultrasound 2005 Dec;33(9):442-446.
Bassler D, Snoey ER, Kim J. Goal-directed abdominal ultrasonography: Impact on real-time decision making in the emergency department. J Emerg Med 2003 May; 24(4):375-378.
Bauman M, Braude D, Crandall C. Ultrasound-guidance vs. standard technique in difficult vascular access patients by ED technicians. Am J Emerg Med 2009 Feb;27(2):135-140.
Baumann B, McCans K, Stahmer S, et al. Volumetric bladder ultrasound performed by trained nurses increases catheterization success in pediatric patients. Am J Emerg Med 2008 Jan;26(1):18-23.
Baumann BM, McCans K, Stahmer SA, et al. Caregiver and health care provider satisfaction with volumetric bladder ultrasound. Acad Emerg Med 2007 Oct;14(10):903-907.
Blaivas M, Harwood RA, Lambert MJ. Decreasing length of stay with emergency ultrasound examination of the gallbladder. Acad Emerg Med 1999 Oct;6(10):1020-1023.
Blaivas M, Theodoro D, Sierzenski PR. A study of bedside ocular ultrasonography in the emergency department. Acad Emerg Med 2002 Aug;9(8):791-799.
Blaivas M, Lambert MJ, Harwood RA, et al. Lower-extremity Doppler for deep venous thrombosis — can emergency physicians be accurate and fast? Acad Emerg Med 2000 Feb;7(2):120-126.
Brenner DJ, Hall EJ. Computed tomography – an increasing source of radiation exposure. N Engl J Med 2007 Nov;357(22):2277-2284.
Buzzard AK, Linklater DR. Pediatric retinal detachment due to Coats’ disease diagnosed with bedside emergency department ultrasound. J Emerg Med 2009; 37(4):390-392.
Chan VW, Perlas A, McCartney CJ, et al. Ultrasound guidance improves success rate of axillary brachial plexus block. Can J Anaesth 2007 Mar;54(3):176-182.
Chan SS. Emergency bedside ultrasound for diagnosis of rib fractures. Am J Emerg Med 2009 Jun;27(5):617-620.
Chen L, Hsiao A, Moore C, Santucci K. Utility of bedside bladder ultrasound prior to urethral catheterization in infants. Acad Emerg Med 2004 May;11(5):598 Abstract.
Chen L, Hsiao AL, Moore CL, et al. Utility of bedside ultrasound before urethral catherization in young children. Pediatrics 2005 Jan;115(1):108-111.
Chen L, Baker MD. Novel applications of ultrasound in pediatric emergency medicine. Pediatr Emerg Care 2007 Feb;23(2):115-123; quiz 124-126.
Chen L, Kim Y, Moore CL. Diagnosis and guided reduction of forearm fractures in children using bedside ultrasound. Pediatr Emerg Care 2007 Aug;23(8):528-531.
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.
Doniger SJ, Ishimine P, Fox JC, et al. Randomized controlled trial of ultrasound-guided peripheral intravenous catheter placement versus traditional techniques in difficult-access pediatric patients. Pediatr Emerg Care 2009 Mar;25(3):154-159.
Dubois L, Leslie K, Parry N. FACTS Survey: focused assessment with sonography in trauma use among Canadian residents training in general surgery. J Trauma 2010 Oct;69(4):765-769.
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.
Feller-Kopman D. Ultrasound-guided thoracentesis. Chest 2006 Jun;129(6):1709-1714.
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.
Harbison H, Shah S, Noble V. Validation of ocular nerve sheath diameter measurements with ultrasound. Acad Emerg Med 2006;13:S198-b-199S-b Abstract.
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.
Karakitsos D, Labropoulos N, De Groot E, et al. Real-time ultrasound-guided catheterisation of the internal jugular vein: a prospective comparison with the landmark technique in critical care patients. Crit Care 2006;10(6):R162.
Kendall JL, Hoffenberg SR, Smith RS. History of emergency and critical care ultrasound: the evolution of a new imaging paradigm. Crit Care Med 2007 May;35(5 Suppl):S126-S130.
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.
Ma G, Davis DP, Schmitt J, et al. The sensitivity and specificity of transcricothyroid ultrasonography to confirm endotracheal tube placement in a cadaver model. J Emerg Med 2007 May;32(4):405-407.
Madill JJ. In-flight thoracic ultrasound detection of pneumothorax in combat. J Emerg Med 2010 Aug;39(2):194-197.
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.
Marshburn TH, Legome E, Sargsyan A, et al. Goal-directed ultrasound in the detection of long-bone fractures. J Trauma 2004 Aug;57(2):329-332.
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.
Miletic D, Fuchkar Z, Mraovic B, et al. Ultrasonography in the evaluation of hemoperitoneum in war casualties. Mil Med 1999 Aug;164(8):600-602.
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.
Milling TJ Jr, Rose J, Briggs WM, et al. Randomized, controlled clinical trial of point-of-care limited ultrasonography assistance of central venous cannulation: the Third Sonography Outcomes Assessment Program (SOAP-3) Trial. Crit Care Med 2005 Aug;33(8):1764-1769
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.
Moore CL, Gregg S, Lambert M. Performance, training, quality assurance, and reimbursement of emergency physician-performed ultrasonography at academic medical centers. J Ultrasound Med 2004 Apr;23(4):459-466.
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.
Nomura JT, Leech SJ, Shenbagamurthi S, et al. A randomized controlled trial of ultrasound-assisted lumbar puncture. J Ultrasound Med 2007 Oct;26(10):1341-1348.
Nomura JT, Sierzenski PR. Ultrasound diagnosis of penile fracture. J Emerg Med 2010 Apr;38(3):362-365.
O’Donnell BD, Ryan H, O’Sullivan O, et al. Ultrasound-guided axillary brachial plexus block with 20 milliliters local anesthetic mixture versus general anesthesia for upper limb trauma surgery: an observer-blinded, prospective, randomized, controlled trial. Anesth Analg. 2009 Jul;109(1):279-283.
Palepu GB, Deven J, Subrahmanyam M, et al. Impact of ultrasonography on central venous catheter insertion in intensive care. Indian J Radiol Imaging. 2009 Jul-Sep;19(3):191-198.
Palese A, Buchini S, Deroma L, et al. The effectiveness of the ultrasound bladder scanner in reducing urinary tract infections. a meta-analysis. J Clin Nurs 2010 Nov;19(21-22):2970-2979.
Park CH, Joung HH, Lee JH, et al. Usefulness of ultrasonography in the treatment of nasal bone fractures. J Trauma 2009 Dec;67(6):1323-1326.
Patel DD, Blumberg SM, Crain EF. The utility of bedside ultrasonography in identifying fractures and guiding fracture reduction in children. Pediatr Emerg Care 2009 Apr;25(4):221-225.
Peterson MA, Abele J. Bedside ultrasound for difficult lumbar puncture. J Emerg Med 2005 Feb;28(2):197-200.
Plummer D, Brunnette D, Asinger R, et al. Emergency department echocardiography improves outcome in penetrating cardiac injury. Ann Emerg Med 1992 Jun;21(6):709-712.
Raptopoulos V, Davis LM, Lee G, et al. Factors affecting the development of pneumothorax associated with thoracentesis. AJR Am J Roentgenol 1991 May;156(5):917-20.
Rozycki GS, Feliciano DV, Ochsner M, et al. The role of ultrasound in patients with possible penetrating cardiac wounds: a prospective multicenter study. J Trauma 1999 Apr;46(4):543-552.
Rodgerson JD, Heegaard WG, Plummer D, et al. Emergency department right upper quadrant ultrasound is associated with a reduced time to diagnosis and treatment of ruptured ectopic pregnancies. Acad Emerg Med 2001 Apr;8(4):331-336.
Salen P, Melniker L, Chooljian C, et al. Does the presence or absence of Sonographically identified cardiac activity predict resuscitation outcomes of cardiac arrest patients? Am J Emerg Med 2005 Jul;23(4):459-462.
Shiver SA, Lyon M, Blaivas M, et al. Prospective comparison of emergency physician-performed venous ultrasound and CT venography for deep venous thrombosis. Am J Emerg Med 2010 Mar;28(3):354-358.
Sivitz AB, Lam SH, Ramirez-Schrempp D, et al. Effect of bedside ultrasound on management of pediatric soft-tissue infection. J Emerg Med 2010 Nov;39(5):637-643.
Squire BT, Fox JC, Anderson C, et al. ABSCESS: applied bedside sonography for convenient evaluation of superficial soft tissue infections. Acad Emerg Med 2005 Jul;12(7):601-606.
Stamilio DM, McReynolds T, Endrizzi J, et al. Diagnosis and treatment of a ruptured ectopic pregnancy in a combat support hospital during Operation Iraqi Freedom:
ase report and critique of a field-ready sonographic device. Mil Med 2004 Sep;169(9):681-683.
Stiffler KA, Jwayyed S, Wilber ST, et al. The use of ultrasound to identify pertinent landmarks for lumbar puncture. Am J Emerg Med 2007 Mar;25(3):331-334.
Stone MB, Price DD, Wang R. Ultrasound-guided supraclavicular block for the treatment of upper extremity fractures, dislocations, and abscesses in the ED. Am J Emerg Med 2007 May;25(4):472-475.
Stone MB, Nagdev A, Murphy MC, et al. Ultrasound detection of guidewire position during central venous catheterization. Am J Emerg Med 2010 Jan;28(1):82-84.
Stone MB, Moon C, Sutijono D, et al. Needle tip visualization during ultrasound-guided vascular access: short-axis vs long-axis approach. Am J Emerg Med 2010 Mar;28(3):343-347.
Sztajnkrycer MD, Baez AA, Luke A. Utility of ultrasonography in the triage of patients in the disaster setting: a preliminary study. Ann Emerg Med 2004 Oct;44(4):S36 Abstract.
Tayal VS, Hasan N, Norton HJ, et al. The effect of soft-tissue ultrasound on the management of cellulitis in the emergency department. Acad Emerg Med 2006 Apr;13(4):384-388.
Tayal VS, Neulander M, Norton HJ, et al. Emergency department sonographic measurement of optic nerve sheath diameter to detect findings of increased intracranial pressure in adult head injury patients. Ann Emerg Med 2007 Apr; 49(4):508-514.
Tayal VS, Graf CD, Gibbs MA. Prospective study of accuracy and outcome of emergency ultrasound for abdominal aortic aneurysm over two years. Acad Emerg Med 2003 Aug;10(8):867-871.
Tayal V, Pariyadath M, Norton J. Randomized controlled trial of ultrasound-guided peripheral non-knee arthrocentesis in the emergency department. Acad Emerg Med 2006;13:S122-b-123S-b Abstract.
Theodoro DL, Blaivas M, Duggal D, et al. Emergency physician-performed lower extremity doppler results in significant time savings. Acad Emerg Med 2002;9:541 Abstract.
Titus MO, White SJ. Suprapubic bladder tap aspiration in an elderly female. J Emerg Med 2006 May;30(4):421-423.
Vieira RL, Levy JA. Bedside ultrasonography to identify hip effusions in pediatric patients. Ann Emerg Med 2010 Mar;55(3):284-288.
Warren JW. Catheter-associated urinary tract infections. Int J Antimicrob Agents 2001 Apr;17(4):299-303.
Wu TS, Leech SJ, Rosenberg M, et al. Ultrasound can accurately guide gastrostomy tube replacement and confirm proper tube replacement at the bedside. J Emerg Med Apr 2009;36(3):280-284.
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