Treating critically ill patients poses a unique and difficult challenge. Often, decisions about treatment must be made quickly, and patients may be in life-threatening situations. In recent years, point-of-care ultrasound has emerged as a popular and efficacious tool for answering specific clinical questions and evaluating patients in critical care.
Point-of-care ultrasound is a technique which involves using ultrasound technology to identify and assess internal trauma. Within the past decade, point-of-care ultrasound has been increasingly integrated into healthcare settings, particularly when it comes to critical care. This trend can be primarily attributed to improvements in ultrasound technology, as well as the development of more portable and cost-effective devices. By providing visualization of internal damage, point-of-care ultrasound can be informative of the severity of a patient’s condition, thus indicating the extent of necessary medical intervention. Research has shown that the time it takes to triage and treat critically ill patients is one of the most important factors in determining morbidity and mortality;1 thus, rapid and accurate assessments are essential to patient welfare.
Currently, point-of-care ultrasound is most commonly used to identify intraperitoneal hemorrhage, pericardial tamponade, and hemothorax/pneumothorax. Given these considerations, a standard trauma ultrasound exam will focus on the hepatorenal, perisplenic, and subcostal space, as well as the pelvis and each hemi-thorax. While abdominal ultrasounds are unlikely to isolate a specific site of internal bleeding, they are highly informative as to which anatomical areas require surgical intervention, thus expediting the patient’s delivery to the operating room for an exploratory laparotomy.2,3
In addition to providing standard exams for on-site care, point-of-care ultrasound may also be used to explain vague yet serious symptoms often seen in critical care. For example, if a patient reports abdominal pain, a few plausible explanations are acute renal colic, cholelithiasis, abdominal aortic aneurysm, or acute intestinal obstruction, all of which require different types of medical intervention. In order to distinguish these conditions from one another, an ultrasound device can be used to detect hydronephrosis, common bile duct dilatation, gallbladder wall thickening and pericholecystic fluid, and an abdominal aorta of over three centimeters in diameter, which are signs of the first three conditions respectively.4-6 Point-of-care ultrasound can also be used to distinguish between different catastrophic cardiac events. By providing visualization of pericardial fluid, chamber size, pleural sliding, and the aortic root, point-of-care ultrasound allows emergency medical personnel to distinguish between a pulmonary embolism, aortic dissection, pericardial effusion, and several other primary pulmonary processes.7,8 Moreover, studies done on both medical and trauma patients with pericardial effusion have reported that point-of-care ultrasound is both a highly specific and highly sensitive diagnostic tool compared to other assessment methods.9,10
Given these considerations, point-of-care ultrasound can be considered the gold standard for patient assessment and diagnosis in critical care. Moreover, the portability and overall accessibility of ultrasound technology create a prime opportunity to raise the standard of care in historically underserved communities. Thus, it is anticipated that point-of-care ultrasound exams will continue to be integrated as common practice in emergency departments throughout the United States.
References
1. Rooney KD, Schilling UM. Point-of-care testing in the overcrowded emergency department–can it make a difference? Crit Care 2014;18:692. doi: 10.14219/jada.archive.2010.0281
2. American Institute of Ultrasound in Medicine, American College of Emergency Physicians. AIUM practice guideline for the performance of the focused assessment with sonography for trauma (FAST) examination. J Ultrasound Med 2014;33:2047-56. doi: 10.7863/ultra.33.11.2047
3. Körner M, Krötz MM, Degenhart C, Pfeifer KJ, Reiser MF, Linsenmaier U. Current Role of Emergency US in Patients with Major Trauma. Radiographics 2008;28:225-42. doi: 10.1148/rg.281075047
4. Smith-Bindman R, Aubin C, Bailitz J, et al. Ultrasonography versus computed tomography for suspected nephrolithiasis. N Engl J Med 2014;371:1100-10. doi: 10.1007/s11739-015-1192-x
5. Fox CJ, Harry RA, Cairns SR. A prospective series of out-patient endoscopic retrograde cholangiopancreatography. Eur J Gastroenterol Hepatol 2000;12:523-7. doi: 10.1097/00042737-200012050-00008
6. Hoffmann B, Bessman ES, Um P, Ding R, McCarthy ML. Successful sonographic visualisation of the abdominal aorta differs significantly among a diverse group of credentialed emergency department providers. Emerg Med J 2010;28:472-6. doi: 10.1136/emj.2009.086462
7. Amsterdam EA, Kirk JD, Bluemke DA, et al. Testing of low-risk patients presenting to the emergency department with chest pain: a scientific statement from the American Heart Association. Circulation 2010;122:1756-6. doi: 10.1161/CIR.0b013e3181ec61df
8. Labovitz AJ, Noble VE, Bierig M, et al. Focused cardiac ultrasound in the emergent setting: a consensus statement of the American Society of Echocardiography and American College of Emergency Physicians. J Am Soc Echocardiogr 2010;23:1225-30. doi: 10.1016/j.echo.2010.10.005
9. Mayron R, Gaudio FE, Plummer D, Asinger R, Elsperger J. Echocardiography performed by emergency physicians: impact on diagnosis and therapy. Ann Emerg Med 1988;17:150-4. doi: 10.1016/s0196-0644(88)80301-9
10. Jones AE, Tayal VS, Kline JA. Focused training of emergency medicine residents in goal-directed echocardiography: a prospective study. Acad Emerg Med 2003;10:1054-8. doi: 10.1111/j.1553-2712.2003.tb00574.x
