Crit Care Nurs Q

Vol. 41, No. 2, pp. 94–101

Copyright  c 2018 Wolters Kluwer Health, Inc. All rights reserved.

Point-of-Care Ultrasonography
in Emergency and Critical Care
Medicine
Leon Chen, DNP, AGACNP-BC, CCRN, CEN;
Tony Malek, MS, NP-C, CEN, RDMS, RDCS, RVT

To stabilize critically ill patients, emergency and critical care medicine providers often require
rapid diagnosis and intervention. The demand for a safe, timely diagnostic device, alongside tech-
nological innovation, led to the advent of point-of-care ultrasonography (POCUS). POCUS allows
the provider to gain invaluable clinical information with a high level of accuracy, leading to bet-
ter clinical decision-making and improvements in patient safety. We have outlined the history of
POCUS adaptation in emergency and critical care medicine and various clinical applications of
POCUS described in literature. Key words: critical care, emergency medicine, point of care,
shock protocol, ultrasonography

U TILIZATION OF ULTRASONOGRAPHY
(US) by practitioners other than radi-
ologists and cardiologists first started in the
sential in the trauma bay to quickly screen
for intra-abdominal hemorrhage and in the
right clinical context, determined the need
late 1980s to early 1990s. At that time, it for the operating room, without having to
was primarily used by trauma surgeons and move an unstable patient to CT scan or to re-
emergency medicine physicians in cases of sort to invasive tests such as diagnostic peri-
penetrating trauma. Focused assessment us- toneal lavage. Point-of-care US (POCUS) or fo-
ing sonography in trauma or “FAST,” was es- cused US allows the practitioner to rapidly
gain time-sensitive information and conduct
serial examinations without having to expose
patients to harmful radiation or contrast.1-3
Author Affiliations: Critical Care Medicine Service, Cardiologists and radiologists were initially
Department of Anesthesiology and Critical Care skeptical of the competency of emergency
Medicine, Memorial Sloan Kettering Cancer Center,
and NYU Rory Meyers College of Nursing, New York
medicine providers in conducting POCUS,
(Dr Chen); and Emergency Department, Bellevue acquiring proper images, and interpret-
Hospital Center, NYU School of Medicine, New York ing images in the right clinical context;
(Mr Malek).
therefore, they pushed back in the use of
The authors thank Nalini Saxena, MBA, for manuscript POCUS. Following several years of education,
editing.
demonstration of competency, publication
Supported by MSK Cancer Center Support Grant/Core of relevant literatures, and improvement in
Grant (P30 CA008748).
technology and communication between the
The authors have disclosed that they have no signif- involved professional organizations, in 2010,
icant relationships with, or financial interest in, any
commercial companies pertaining to this article.
the American College of Echocardiography
and the American College of Emergency
Correspondence: Leon Chen, DNP, AGACNP-BC, CCRN,
CEN, Critical Care Medicine Service, Department of
Physicians released a consensus statement
Anesthesiology and Critical Care Medicine, Memorial that emergency physicians have the proper
Sloan Kettering Cancer Center, New York, NY 10065 training and knowledge to conduct and inter-
([email protected]).
pret POCUS.4,5 In 2011, a group of experts
DOI: 10.1097/CNQ.0000000000000190 from the European Society of Intensive Care
94

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 Ultrasonography in Critical Care 95

Medicine and 11 other professional critical are needed since POCUS is not meant to re-
care societies released a consensus statement place official ultrasound.6,8
endorsing the necessity of incorporating
critical care ultrasonography into the cur- CLINICAL APPLICATIONS
riculum of critical care medicine physicians.6
With such steps in standardization, POCUS’
Invasive procedures
utilization in emergency and critical care
medicine is not novel or an adjunct, but Invasive procedures such as central line,
rather the standard of care.7,8 thoracentesis, and paracentesis prior to the
advancement of US usage were typically done
SCOPE OF POINT-OF-CARE using landmark identifications. Such “blind”
ULTRASONOGRAPHY methods carry an increased risk of compli-
cation such as pneumothorax, organ punc-
A common misconception of POCUS is that ture, infection, and multiple attempts. Land-
it replaces the need for official US or echocar- mark methods cannot account for anatomical
diogram. In fact, POCUS is conducted with a variations in the general population.9 With US
focus on answering a specific clinical ques- guidance, complication rates decreased, and
tion in the given time and clinical situation. It now US guidance for invasive procedures is
is not meant to be diagnostic nor is it meant to the standard of care recommended by mul-
replace an official US or echocardiogram. The tiple professional organizations.10–13 With US
clinical questions that POCUS is looking to an- guidance, procedures that traditionally have
swer are often binary, meaning “yes” or “no.”7 been thought as high risk, such as thoracente-
For example, a patient whose clinical presen- sis on a mechanically ventilated patient, have
tation suspicious for pericardial tamponade been demonstrated to be safe.14
begs the question “Is there a pericardial ef-
fusion?” is eligible for a POCUS. Information Respiratory insufficiency
acquired from a POCUS is interpreted qual- In the past, lung US was viewed as not fea-
itatively rather than quantitatively.7 There- sible since air in aerated lungs deflects US
fore, in a patient with suspected congestive beams; therefore, such an image would be
heart failure exacerbation, the frontline prac- filled with artifact. This changed after Daniel
titioner conducting POCUS will use the exam- Lichtenstein, an intensivist who started to cat-
ination to look for decreased heart function, egorize different artifacts, and based on those
rather than for a specific numerical ejection images, discovered that the artifacts can re-
fraction. veal underlying pathology.15 From this, Dr
This is in contrast to an official US that is Lichtenstein developed the Bedside Lung Ul-
done by licensed technicians, cardiologists, trasound in Emergency (BLUE) protocol to
or radiologists.7 Official US contains detailed rapidly narrow down differentials in cases of
measurements of an organ of which values respiratory insufficiency or failure.16 In the
will be interpreted by the radiologist or the protocol, clinicians are guided through differ-
cardiologist. The practitioner who ordered ent pathways based on the bedside US find-
the test will then correlate this interpretation ing. At the end of each different pathway, pa-
within the clinical context. This process is of- tients are categorized into different profiles,
ten time-consuming and cannot be initiated with the most likely pulmonary pathology
at all hours of the day. For clinically unstable that explains the presenting dyspnea. With
patients, this is simply not feasible. However, the protocol, novel terms such as “A lines,”
the POCUS performer should also recognize “B lines,” and “lung sliding” made it into the
the limitation of a focused examination and US lexicon.16 A full description of the BLUE
be ready to seek help from official ultrasono- protocol is beyond the scope of this review,
graphers when more detailed measurements but a few of the terms are worth discussing

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96 CRITICAL CARE NURSING QUARTERLY/APRIL–JUNE 2018

insofar, as they are popularly used by all clini- BLUE protocol can be completed in min-
cians who perform POCUS. utes and can be extremely effective in help-
“Lung sliding” is the description of the ing the bedside clinician make time-sensitive
bright shimmering line under the ribs, which decisions.
shows the movement between visceral and
parietal pleura. When this is seen, pneumoth- Undifferentiated shock
orax can be safely ruled out.16 Lung US has Recognizing the numerous causes of shock
been shown to be more sensitive in detecting in critically ill patients in the emergency de-
pneumothorax than chest x-rays in multiple partment (ED) or the intensive care unit (ICU)
studies.17–20 Notably, although the presence is difficult mostly due to poor or limited med-
of lung sliding effectively rules out pneumoth- ical history, a wide array of differential diag-
orax, the absence of lung sliding does not rule nosis, and the necessity of early and fast inter-
in pneumothorax since many other patholo- vention needed to save patients from impend-
gies can present with the absence of lung ing death.22 There are many different types
sliding (eg, severe chronic obstructive pul- of shock, such as hypovolemic, cardiogenic,
monary disease, pleurodesis, and right main- septic, neurogenic, and obstructive. These
stem intubation).21 subtypes of shock are unique and require dif-
“A lines” are multiple horizontal lines that ferent approaches. Clinicians in the ED/ICU
are equal distances below the pleural line. “A may even face tougher situations when
lines” are reverberation artifacts of the pleu- shock is of the mixed type or of an etiology
ral line. When US waves penetrate through that is “not defined.”23 Usually, intravenous
the thick pleura, it captures the image and re- fluid therapy is an essential component in
flects off the air below which produces the managing patients with shock. However, at
mirror image of the pleural line seen below. times it is crucial to assess volume status
When seen, this represents air in the lung, prior to flooding the patient with fluids.24
which can be interpreted as normal aeration Assessing volume status is achievable via
when lung sliding is present. When lung slid- invasive monitoring, which might not be
ing is absent however, this sign may be in- readily available during an emergency.25
terpreted as possible pneumothorax since air Incorrect fluid therapy may lead to persistent
will be present in the thorax even with col- hypovolemia or fluid volume; in either case
lapsed lungs.15–16 it may deteriorate the patient’s status and
“B lines” are vertical bright lines that be- causes more complications.25–26 Managing
gin from the pleura line and extend to the conditions such as shock or undifferentiated
bottom of US screen. Other features of “B hypotension in the ED is common, and
lines” are that it should efface underlying “A these symptoms are a predictor of inhospital
lines,” and move with the movement of pleu- mortality. Clinicians may have a very limited
ral sliding. When seen, “B lines” represent the time window in dealing with shock patients
loss of aeration within the lung whether in for whom they must choose the right inter-
the interstitium or in the alveoli.15–16 Three ventions depending on the kind of shock and
or more “B lines” seen between 2 rib spaces the management of hypotension.24,26 Signs
are highly associated with cardiogenic pul- point to the usage of only intravenous fluid
monary edema, and the number of “B lines” while monitoring vital signs as no longer
seen is correlated with the degree of inter- sufficient.24,26
stitial syndrome.20 Other conditions that the US enables providers everywhere in the
BLUE protocol can help with diagnosing are ED or the ICU to visualize inside the body
pleural effusion, lung consolidation, and deep without having to perform invasive proce-
vein thrombosis, which in the right setting in- dures. Physical examination alone cannot
creases the pretest probability of pulmonary provide the information that US is capa-
embolism.15–16 In experienced hands, the ble of revealing.27 US has an instant impact

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 Ultrasonography in Critical Care 97

on the management of shock by allowing uation and Management of Shock (RECES)

sooner identification of the cause, and it is protocol.
quickly becoming essential to diagnose and
manage trauma in today’s health care.28,29
The use of US in emergency situations is RUSH protocol
growing at a rapid state and continuously One of the most used protocols is RUSH.
evolving.29 This protocol aims at evaluation of the heart,
POCUS greatly aids the clinician in narrow- the intraperitoneal spaces, the aorta, and the
ing down the list of differentials, thus improv- IVC. An US examination evaluates the heart
ing patient outcomes, especially in patients for left ventricular function, right ventricular
with undifferentiated shock/hypotension.30 strain, and tamponade. In addition, the prac-
POCUS should be aimed at ruling out any titioner evaluates the great vessels to estimate
emergent life-threatening condition as a result central venous pressure, aortic dissection or
of hemodynamic instability, and it involves aneurysm, and finally evaluation of the ab-
a simple and quick sonographic examination dominal quadrants for any signs of free fluid
of the heart, lungs, abdomen, large vessels, (ie, bleeding).26 In other words, the practi-
and peripheral veins.29,31 It has been proven tioner is using US to examine the pump, the
that it can improve the specificity of early tank, and the pipes.22
recognition of hypovolemia, and in a patient Most of the examinations can be done us-
with possible shock, timely detection of tam- ing a phased array transducer while the pa-
ponade, massive pleural effusion, abdominal tient is commonly supine. The traditional car-
bleed, or cardiac wall-motion abnormality of diac chamber views are obtained, followed by
the heart is crucial and, indeed, life-saving.22 parasternal long- and short-axis views, subx-
iphoid and apical 4-chamber views. Linear or
curvilinear array probes may be utilized for
PROTOCOLIZED POINT-OF-CARE evaluation of the peripheral vessels to rule
ULTRASONOGRAPHIC EXAMINATIONS out deep vein thrombosis or to evaluate jugu-
lar veins.26
Since FAST has become a regular element A prospective study by Ghane et al30 con-
of advanced trauma life support, its use has cluded that the RUSH protocol showed very
provided real-time evaluation of patients with promising results in diagnosing undifferen-
undifferentiated shock.22 Like the FAST pro- tiated shock. It has excellent sensitivity in
tocol, the rapid ultrasound in shock (RUSH) patients with hypovolemic, cardiogenic, and
is also a valuable tool in diagnosing and obstructive types of shock. The RUSH pro-
managing undifferentiated shock that may tocol also had good specificity in the latter
not be caused by trauma.26 For example, by 3 types of shock as well as in distributive
measuring the left ventricular end-diastolic and mixed etiology shock.30 Overall, the au-
area, or visualizing an underfilled left ventri- thors praised this protocol in the care of pa-
cle, the provider can identify the reduction tients with undifferentiated shock. Another
in intravascular volume in minutes.30 Recent prospective study by Bagheri-Hariri et al32 uti-
research has shown that inferior vena cava lized the RUSH protocol on patients with un-
(IVC) assessment can be a valuable tool to differentiated shock and compared the proto-
help determine a patient’s volume status.22,30 col results with the patient’s final diagnosis.
Many protocols exist and this review will The study found that the RUSH protocol has
addresses the Rapid Ultrasound Assessment 88% sensitivity and 96% specificity when ex-
for Shock (RUSH) protocol, the Abdominal amined with the final diagnosis. Therefore, it
and Cardiac Evaluation with Sonogra- concluded that the RUSH examination is an
phy in Shock (ACES) protocol, and the apt tool to diagnose undifferentiated shock in
Resuscitative Echocardiography for the Eval- critically ill patients.32

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98 CRITICAL CARE NURSING QUARTERLY/APRIL–JUNE 2018

ACES protocol ficity. The next step is the evaluation of the

Another evolving protocol is ACES, which global systolic function via visual estimate (ie,
is also utilized in undifferentiated shock. This eyeballing) rather than exact calculated ejec-
protocol is conducted by acquiring 6 views, tion fraction resulting from the chambers’
which include focused views of the heart, measurements.26 The third, fourth, and fifth
IVC diameter with the index of respiropha- components aim to assess responsiveness to
sic collapse, abdominal aorta views, right and treatment by examining the size of the IVC
left upper quadrant views to evaluate for peri- in a similar fashion as the ACES protocol,
toneal or pleural fluid, and transverse pelvic as well as by evaluating left ventricular con-
view for bladder volume and abdominal free tractility, left ventricular outflow tract veloc-
fluid.23 This protocol incorporates the basic ity changes, and the presence or absence of
idea of the caval index, which operates on the left ventricular diastolic dysfunction.23 The
premise that the change in the diameter of presence of left ventricular diastolic dysfunc-
the IVC during the respiratory cycle is corre- tion can be a cause of pulmonary edema
lated with the volume status of the patient.33 or congestion from volume overload. On the
The caval index can be calculated by the dif- other hand, “kissing” papillary muscles may
ference between expiratory IVC diameter and be linked with hypovolemia. The sixth and
inspiratory IVC diameter, divided by the ex- seventh components of the RECES protocol
piratory IVC diameter, and multiplied by 100 are evaluations of the walls of the ventri-
to achieve a percentage in variation.25 Data cles, specifically the right ventricular wall. A
obtained are not only diagnostic for volume wall motion abnormality can be an indication
status but a good indicator of the responsive- of a concurrent myocardial ischemia, which
ness for volume loading.33 Overall, the ACES might be the underlying cause of shock in
protocol was found to be a good adjunct to a particular case. A careful evaluation of the
a physical examination in patients with undif- systolic function of the right ventricle re-
ferentiated shock. veals a great deal of information regarding
the pulmonary pressure and the expecta-
tion of right ventricular failure. The eighth
RECES protocol and last item on the list that is unique to
RECES is also an emerging protocol devel- this protocol is the evaluation of the cardiac
oped to provide immediate diagnostic infor- valves for blatant mitral, tricuspid, or aortic
mation as to the cause of undifferentiated valve insufficiency. An acute papillary mus-
shock. What is different about this protocol cle rupture may precipitate various types of
is that it continues to guide the clinician dur- complications.23
ing ongoing resuscitation. The RECES proto-
col targets 8 aspects of the human cardio- DEMONSTRATION OF COMPETENCY
vascular system to evaluate the cause of the
hypotension or shock as well as the status of US competency in critical care has been
the patient during and posttreatment.26 This hard to measure. Unlike emergency medicine
protocol requires training to acquire and in- in which US training is built into the resi-
terpret the findings. It is not intended to re- dency curriculum and in which a specialty
place an echocardiographic examination, but US fellowship has been well developed, not
it is designed to be performed in emergency every critical care program institutionalized
situations by qualified emergency or intensive critical care US (CCUS) as part of its core
care clinicians to rapidly delineate potential curriculum.34–37 However, this is changing
causes of a patient’s undifferentiated shock. after consensus statements made by large
The RECES protocol starts with the evalua- professional organizations such as the Amer-
tion of the presence of pericardial effusion, ican College of Chest Physicians (ACCP)
with US sensitivity of 96% and 98% speci- and other international expert panels. Based

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 Ultrasonography in Critical Care 99

on their recommendation, a curriculum CCUS competency training, has a certificate

consisting of core applications (ie, vascu- of completion program available to all physi-
lar access and thoracic US) and advanced cians and advanced practice practitioners
applications (ie, basic echocardiography) who want to demonstrate competency in
has been proposed for critical care training CCUS. The program consists of 17 hours
programs.36,37 Although a lack of supporting of self-learning modules, 3 live seminars,
data has precluded the standard requirement a portfolio of performed images that is
for the minimum amount of didactic, self- critiqued by faculties, and a final competency
learning modules, or hands-on practice, the examination. The certificate of completion is
ACCP recommends a minimum 10 hours of designed with the recommended CCUS cur-
general CCUS and 10 hours of critical care riculum and can be used to certify minimum
echocardiography; these hours of teaching competency in CCUS.44
are to be divided between lectures on theory Although data are lacking in the efficacy
and image-based teaching.35–36 and accuracy of advanced practice provider-
The minimum number of applications to conducted US applications, a small study
achieve competency in general CCUS is also conducted in the ED does support the nurse
undetermined due to a lack of data; how- practitioners undergoing proper US training
ever, for critical care echocardiography, ap- having high levels of diagnostic accuracy.45
proximately 30 hours is required, based on More research in this specific category is
existing literature.37–40 As such, critical care needed.
programs require completion of the afore-
mentioned curriculum to show competency CONCLUSION
in CCUS prior to graduation.39,40 This is
only applicable to critical care physician fel- With the advancement of technology and
lows and attendings, and not for other criti- training, ultrasonography has been increas-
cal care providers such as advanced practice ingly crossing over to the bedside. It is
nurses and physician assistants (ie, advanced noninvasive, expedient, and of little risk to
practice providers) or noncritical care-trained the patient. With the increasing complex-
physicians. ity of patients, we require a better diag-
A select few postgraduate advanced nostic tool than what is traditionally associ-
practice provider fellowship programs in ated with health care providers: the stetho-
critical care and emergency medicine, such scope. There is strong evidence supporting
as the ones at Emory University Hospital, the use of bedside critical care ultrasonog-
Lehigh Valley Medical Center, and Carillion raphy; therefore, we should embrace it as a
Clinic, include extensive US training in their frontline tool to provide optimal care to our
curriculum.41–43 The ACCP, at the forefront of patients.

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 Ultrasonography in Critical Care 101

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