World J Emerg Med, Vol 3, No 2, 2012 85

An overview of emergency ultrasound in the United

States
Jeremy A. Michalke
Emergency Ultrasound, Upper Chesapeake Health System, Bel Air, MD 21014, USA
Corresponding Author: Jeremy A. Michalke, Email: foxhollow8525@gmail.com

BACKGROUND: As emergency ultrasound use explodes around the world, it is important to

realize the path its development has taken and learn from trials and tribulations of early practitioners
in the field.
METHODS: Approaches to education, scanning, documentation, and organization are also
described.
RESULTS: Machines have reduced in price and once purchased further material costs are low.
Staffing costs in terms of training, etc have yet to be assessed, but indications from elsewhere are that
these are low. Length of stay in the emergency department dramatically decreases, thus increasing
patient satisfaction while maintaining an even higher standard of care.
CONCLUSION: Emergency screening ultrasound is now a nationally accepted tool for the rapid
assessment of the emergency patient.
KEY WORDS: Emergency ultrasound; United States
World J Emerg Med 2012;3(2):85-90
DOI: 10.5847/ wjem.j.issn.1920-8642.2012.02.001

INTRODUCTION other Asian countries, the United States, and Germany to

Ultrasound has long been recognized as a powerful evaluate the utility of ultrasound in trauma patients,
tool for use in the diagnosis and evaluation of many specifically for the detection of hemoperitoneum and
clinical entities. Before the development of real-time hemopericardium. This research culminated in the
ultrasound, the complexity of acquiring images prevented description of the Focused Assessment with Sonography
the practical application of ultrasound for most injured for Trauma, or the FAST examination.[1-8] In most trauma
or emergency patients and was an absolute barrier to use centers, the FAST examination has replaced diagnostic
at the bedside. Significant time and effort was devoted to peritoneal lavage as the preferred method of initial
improving ultrasound devices throughout the 1980s and evaluation and been fully integrated into Advanced
1990s. This resulted in the units being smaller, faster, Trauma Life Support (ATLS). Consequently, the FAST
and more portable. Other technological advancements examination is the initial ultrasound examination for
included the trans-vaginal transducer, multi-frequency trauma victims performed by trauma surgeons and
probes, and color Doppler. These improvements emergency physicians and is the prototype of emergency
accelerated the movement of technology from the ultrasonography.
domain of a specific specialty to the bedside, where Ultrasound is no longer limited to radiology but
clinicians could use it for the immediate evaluation of is being utilized by at least 8 different specialties.
their patients. One specialty which has contributed new research
From the late 1980s through the mid 1990s, regarding ultrasound's multiple clinical applications
significant investigations were conducted in Japan and is emergency medicine. The attraction of immediate

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 86 Michalke et al World J Emerg Med, Vol 3, No 2, 2012

bedside sonographic examinations in the evaluation of system. Comprehensive imaging of systems remains the
specific emergent complaints makes it an ideal tool for domain of radiologists and will not be reduced by the
the emergency specialist. implementation of specific ultrasound within the
The social and economic pressures to triage, diagnose emergency department.
and rapidly treat patients have fueled ultrasound's use as
a primary screening tool in the emergency department.
Most institutions now utilizing emergency screening PRIMARY INDICATIONS
ultrasounds report faster turn around times and more Focused assessment with sonography for
expedient diagnosis of potential life-threatening trauma (FAST)
emergencies such as internal hemorrhage following blunt Focused assessment with sonography for trauma
trauma, abdominal emergencies, ectopic pregnancy, has been widely evaluated. [12,13] This allows a timely
pericardial tamponade, and aortic aneurysms. With the examination, takes less than five minutes, and can
use of emergency physician-performed pelvic ultrasound, be performed during resuscitation. [14] It is readily
the length of stay was decreased in the emergency repeatable and noninvasive and has replaced diagnostic
department by a median of 120 minutes.[9] In response to peritoneal lavage as the primary assessment of blunt
this demand, most emergency medicine residencies now abdominal trauma. It will not replace other radiological
train their residents in emergency screening ultrasound procedures, such as computed tomography, but will
as part of their standard curriculum. The individual more effectively triage patients to the operating room,
endorsement statements from both the American College further investigation, or observation. FAST employs a
of Emergency Physicians and the Society for Academic 4 view scan of the abdomen and pericardium purely for
E m e rg e n c y M e d i c i n e c o n t i n u e t o s u p p o r t t h e s e the purpose of detecting free fluid. The standard views
advancements.[10,11] are: Morison's pouch (Figure 1), pericardial (Figure 2),
Incorporation of ultrasound into the emergency perisplenic space (Figure 3), and supra-pubic windows
department has often been fraught with misunderstanding. (Figure 4). Of these, the most useful single view is
Emergency ultrasound is a highly focused, limited, goal of Morison's pouch, but adding other views increases
directed exam with the expressed purpose of answering sensitivity and specificity. [15,16] Limitations of the
a select set of questions. Ultrasound in emergency technique include obesity, subcutaneous emphysema,
medicine in the Untied States acts as a clinical decision and previous abdominal scars. In a series of studies with
support tool and does not replace formal imaging. Only FAST performed by surgeons, sensitivities ranged from
in rare instances will these initial screens not be followed 81.5% to 99% (mean 90.1%), and specificity from 95.0%
by a formal complete radiographic study in the next to 99.7% (mean 97.7%).[17-21] Initially pioneered in the
1-2 days. There are other uses of ultrasound including US by trauma surgeons, there is increasing evidence that
foreign body localization, musculo-skeletal imaging, emergency physicians can perform the scan with similar
and assistance in performing procedures. However, in sensitivity and specificity. There is as yet no consensus
all situations emergency ultrasound remains a specific, as to the minimum training required for performance of
goal directed, focused examination employed to answer FAST. Recent studies have indicated a consistently steep
a single question, rather than fully evaluating a specific learning curve and as few as 15 ultrasound scans may

Morison's
pouch

Liver
R Kidney
Pericardial
effusion

Figure 1. Morison's pouch. Figure 2. Pericardial effusion.

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World J Emerg Med, Vol 3, No 2, 2012 87

be required for clinician ultrasonographers to become of didactic teaching followed by 10-12 patients and
competent in the FAST examination.[14] a sensitivity of 99% and a specificity of 93% were
found for ectopic pregnancy.[26] In another study, when
Abdominal pain and hypotension ultrasound was performed by emergency physicians,
Aortic dimensions can be measured easily and there was a significant reduction in length of stay
although active bleeding cannot be assessed, the presence among patients with a viable intrauterine. [27] These
of a dilated aorta in patients with circulatory instability studies indicate the clear benefit in the early use of both
significantly speeds up diagnosis of a leaking abdominal transabdominal and endovaginal ultrasonography in the
aortic aneurysm (AAA) and referral to the vascular team expedient management of the complicated first trimester
(Figure 5). The time to diagnosis of abdominal aortic pregnancy.
aneurysm is consistently less than 10 minutes with
routine use of bedside ultrasound in unstable patients Echocardiography
with abdominal pain.[22] T h e t w o p r i m a r y i n d i c a t i o n s f o r e m e rg e n c y
department echocardiography are the diagnosis of
Ectopic pregnancy pericardial tamponade (Figure 2) and the confirmation
Clinical assessment alone is inadequate in the (o r refu ta tion ) o f pu lsele ss e lec trica l activity
management of symptomatic women in the first trimester (electromechanical dissociation). Ultrasound also allows
and the early use of endovaginal ultrasound scanning the distinction between "true" electromechanical
is becoming the accepted standard of care. [23,24] In dissociation (EMD) and "clinical" EMD. True EMD is
emergency medicine the goal of the examination is to seen as organized electrical ventricular activity in the
identify a viable intrauterine pregnancy. Endovaginal absence of visual evidence of myocardial contraction
scanning allows visualization of intrauterine structures and carries a prognosis similar to asystole, and stopping
between one and two weeks earlier in gestation than resuscitation is usually justified. Clinical EMD is
transabdominal scans (Figure 6). [25] In one study, diagnosed when myocardial contraction is visualized
six emergency physicians underwent 10-12 hours on ultrasonography and is usually associated with a

Fluid

Lung Spleen Free fluid

Urinary
bladder

Figure 3. Perisplenic fluid. Figure 4. Suprapubic free fluid.

Uterus

Gestational Sac Yolk

AAA

Figure 5. Abdominal aortic aneurysm. Figure 6. Intrauterine pregnancy.

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 88 Michalke et al World J Emerg Med, Vol 3, No 2, 2012

Stones
Liver

Gortex

Pelvis

Figure 7. Hydronephrosis. Figure 8. Gallstones.

potentially treatable cause.[28] The correct identification Central venous catheter insertion
of ventricular fibrillation masquerading as asystole has Ultrasound technology decreases the number of
also been described and the use of ultrasound allows attempts required to cannulate a central vein and will
early defibrillation as part of successful resuscitation.[29] decrease the amount of time required to cannulate the
vein. These results are especially true for those patients
Renal colic considered to have difficult vascular access.[34]
Ultrasound is used in the assessment of patients
with renal colic to detect hydronephrosis[30] (Figure 7).
The use of early renal ultrasonography by emergency TRAINING
physicians allows a progressive protocol for management The initial providers of the service will be trained
of patients presenting with renal colic and so reduces the through a combination of dedicated courses and
need for radiological imaging with its associated risks cooperation with their local radiology departments or
and inevitable time delays. teaching hospitals. Suitably trained emergency
department personnel will then provide further training
Gall stones in-house.
Ultrasound is the primary diagnostic modality used to One of the most controversial areas is the training
confirm the presence of gallstone disease and it has been required for emergency physicians in this country to
shown that emergency physicians can produce accurate practice ultrasound. The studies cited above show wide
results. A combination of two or more of the following variation in the length of formal training and numbers of
features is highly suggestive of acute gallbladder disease: examinations. Even with brief training periods
the sonographic Murphy's sign (the point of maximal respectable sensitivities and specificities have been
tenderness to transducer pressure is localized to the achieved. The Society for Academic Emergency
sonographically visualized gall bladder), a thickened Medicine has developed a model curriculum suggesting
gallbladder wall, gallbladder sludge, or pericholecystic the adequate training of emergency physicians in the use
fluid (Figure 8).[31] of ultrasound. This recommends 40 hours of teaching
and 150 examinations (at least 50% of these should be
Deep venous thrombosis (DVT) clinically indicated patient studies) across the range of
The place of ultrasound in the diagnosis of DVT indications.[35] Concerns exist regarding skill
is well established but radiographic studies are often maintenance and retention once trained. This has not
available during office hours, while patients attend been adequately investigated and remains an area for
emergency departments 24 hours a day. In one study further evaluation. However, multiple studies have
by emergency physicians using color Doppler the shown the steep learning curve of non-radiologists in
emergency department examination was 100% sensitive performing scans concluding that as few as 10 scans may
and 75% specific.[32] In a study on emergency duplex provide competence.[14,32,33] These findings suggest that
ultrasound by Theodoro et al[33], the mean time from skill maintenance is reasonable but this does require
triage to EP disposition was 95 minutes and the mean time formal evaluation. The combination of primary
from triage to radiology disposition was 220 minutes. indications should mean that ultrasound is used regularly

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World J Emerg Med, Vol 3, No 2, 2012 89

Resuscitative Diagnostic Procedural Symptom or

guidance sign-based Therapeutic
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