Background

Point of care ultrasound (POCUS) or Clinical Ultrasound has become a critical piece of patient care with the advent of newer, cost-effective, and more efficient technology. Over the past 10 years, POCUS has expanded both within and across specialties, including pediatrics.  It has become the standard of care when it comes to procedures that were previously done blindly.  It is part of the ATLS trauma protocol for blunt abdominal trauma.  It is advantageous to have a robust POCUS program in order to accommodate the push for decreased patient wait times, increased patient satisfaction, earlier recognition of critical illness, and improve first-pass success rates of procedures, especially when resources can be limited (such as during night shifts).

Significance

Having an imaging modality such as POCUS readily available allows for the benefit of immediately detecting the most common causes of critical illness, allowing for more rapid intervention and better patient outcomes. POCUS has modified the clinical practice of many subspecialties.  It does so to the extent that it functions as the clinician’s eyes, hands, and brain as an extension of the physical exam, often leading to calling POCUS “the new stethoscope”.  Similar to the stethoscope, the information obtained by the use of POCUS is a function of the expertise residing between the operator’s ears.  This where it becomes essential to have a well-organized, rigorous, and thorough training program and QA for POCUS providers across the institution to ensure that one’s capabilities with POCUS are not exceeded.   This includes the ability to archive and review images with software that is practical to do so, which in this case, is QPATH, which is used across the country as the ideal program of choice by the most well-established POCUS programs. In addition, it will be necessary to upgrade the outdated equipment currently in use, because the field of POCUS has grown exponentially over the past 10 years and the newer models allow for the full capabilities that POCUS offers that the older machines have not been engineered to provide. 

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How is POCUS different than radiology-performed ultrasound?

Highly specialized, diagnostic US performed by specialists (e.g. radiologists, cardiologists) in an ED is beyond the scope of these recommendations, since these areas generally have their own guidelines and recommendations. Clinical US is also an emergency medicine procedure and should not be considered in conflict with other US procedures performed by other specialists. Clinical US in the ED is used for bedside diagnosis, resuscitation, monitoring and procedural guidance of the critically ill or injured patient. US is performed, interpreted and integrated in a rapid manner directed by the clinical scenario.  The spectrum of clinical ultrasound for use in critically-ill patients can be divided into the following categories:

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1. Resuscitative: Ultrasound use directly related to resuscitation

2. Diagnostic: Ultrasound utilized in an emergent diagnostic imaging capacity

3. Symptom or sign-based: Ultrasound used in a clinical pathway based upon the patient’s symptom or sign (e.g. trauma, red swollen leg)

4. Procedure guidance: Ultrasound used as an aid to guide a procedure

5. Therapeutic and Monitoring: Ultrasound use in therapeutics or in physiological monitoring

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Therefore, the indication for performing clinical ultrasound for a patient is not limited to a particular exam type, rather it is directly related to the clinical question for which we are looking for an answer (e.g. why is this patient hypotensive?).

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