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PRACTICAL GUIDE TO

EMERGENCY ULTRASOUND
Second Edition

Karen S. Cosby, MD, FACEP
Director, Emergency Ultrasound Fellowship
Senior Attending Physician
Department of Emergency Medicine
Cook County Hospital (Stroger)
Associate Professor
Rush Medical College
Chicago, Illinois
John L. Kendall, MD, FACEP
Director, Emergency Ultrasound
Denver Health Medical Center
Associate Professor
Department of Emergency Medicine
University of Colorado School of Medicine
Denver, Colorado


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Library of Congress Cataloging-in-Publication Data
Practical guide to emergency ultrasound / editors, Karen S. Cosby, John L. Kendall.—2nd ed.
   p. ; cm.
  Includes bibliographical references and index.
  ISBN 978-1-4511-7555-4 (alk. paper)
  I.  Cosby, Karen S.  II.  Kendall, John L.
  [DNLM: 1.  Ultrasonography—methods.  2.  Emergencies. WN 208]
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2013012308
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To our families
Whose patience and tolerance make everything possible
To our contributors
Who have given us countless hours and valuable expertise
To our students, residents, and fellows
Who test our ideas and sharpen our skills
To our patients
Who hopefully benefit from all our labor.



Contributors
Srikar Adhikari, MD, MS, RDMS
Associate Professor
Department of Emergency Medicine
University of Arizona Medical
Center
Tucson, AZ
Eric J. Adkins, MD, MSc
Lead Administrative Physician
Director of Emergency Medicine

Critical Care
Assistant Professor of Emergency
Medicine & Internal Medicine
Department of Emergency Medicine
Department of Internal Medicine
Division of Pulmonary, Allergy,
­Critical Care & Sleep Medicine
Wexner Medical Center at The Ohio
State University
Columbus, OH
David P. Bahner, MD, RDMS
Associate Professor Director of
Ultrasound
Founder Ultrasound Academy
Department of Emergency Medicine
The Ohio State University Medical
Center
Columbus, OH
Caitlin Bailey, MD
Emergency Medicine
Alameda County Medical Center
Oakland, CA
John Bailitz, MD, FACEP, RDMS
Emergency US Director Department
of Emergency Medicine
Cook County Hospital (Stroger)
Chicago, IL
Aaron E. Bair, MD, MSc
Associate Professor Emergency
Medicine

Medical Director, Center for Health
and Technology

Medical Director, Center for
Virtual Care
University of California Davis
Health System
Sacramento, California
Gregory R. Bell, MD
Assistant Clinical Professor
Director of Emergency Ultrasound
University of Iowa Hospital
Iowa City, IA
Michael Blaivas, MD
Professor of Medicine
University of South Carolina School
of Medicine
Columbia, SC
Keith P. Cross, MD, MS, MSc
Assistant Professor of Pediatrics
Department of Pediatrics
University of Louisville
Kosair Children’s Hospital
Louisville, KY
Anthony J. Dean, MD
Associate Professor of Emergency
Medicine
Associate Professor of Emergency
Medicine in Radiology
Director, Division of Emergency

Ultrasonography
Department of Emergency
Medicine
University of Pennsylvania Medical
Center
Philadelphia, PA
Joy English, MD
University of Utah Visiting
Instructor
Department of Surgery, Division of
Emergency Medicine
Fellow, Primary Care Sports
Medicine
Salt Lake City, UT

Ashraf Fayad, MBBCh, FRCPC,
FACC, FASE
Associate Professor
Director, Perioperative Echocardiography for Non-cardiac Surgery
The Ottawa Hospital Department
of Anesthesiology
University of Ottawa
Ottawa, ON
Matthew Flannigan, DO, FACEP
Assistant Ultrasound Program
Director
Department of Emergency Medicine
Michigan State University-Grand
Rapids
Spectrum Health Hospital System

Grand Rapids, MI
J. Christian Fox, MD, RDMS,
FACEP, FAAEM, FAIUM
Professor of Clinical Emergency
Medicine
Department of Emergency Medicine
University of California
Irvine, CA
Bradley W. Frazee, MD
Department of Emergency Medicine
Alameda County Medical Center –
Highland Hospital
Oakland, CA
Clinical Professor of Emergency
Medicine
University of California
San Francisco
San Francisco, CA
Andrew J. French, MD
Associate Director, Emergency
Ultrasound
Department of Emergency Medicine
Denver Health Medical Center
Assistant Professor University of
Colorado School of Medicine
Denver, CO
v


vi  

Contributors

Richard Gordon, MD
Ultrasound Fellow, Emergency
Medicine
Georgia Health Sciences
University
Augusta, GA
John Gullett, MD
Assistant Professor
Co-Director of Emergency Ultrasound
Department of Emergency Medicine
University of Alabama at Birmingham
Birmingham, AL
Michael Heller, MD
Professor of Clinical Emergency
Medicine
Albert Einstein School of Medicine
Director Emergency Ultrasound Beth
Israel Medical Center
New York, NY
Stephen R. Hoffenberg, MD,
FACEP
President, CarePoint Medical Group
Attending Emergency Physician
Rose Medical Center
Denver, CO
Russ Horowitz, MD, RDMS
Director Emergency Ultrasound
Emergency Department

Ann & Robert H. Lurie Children’s
Hospital of Chicago
Assistant Professor, Northwestern
University Feinberg School of
Medicine
Chicago, IL
Calvin Huang, MD, MPH
Ultrasound Fellow
Department of Emergency Medicine
Massachusetts General Hospital
Boston, MA
Nicole Danielle Hurst, MD
Emergency Physician and Emergency
Ultrasound Fellow
Denver Health
Denver, CO
Jeanne Jacoby, MD
Vice Chair Emergency Department,
Pocono Medical Center
East Stroudsburg, PA
Timothy Jang, MD
Associate Professor of Clinical
Medicine
Director of Emergency
Ultrasonography
Harbor-UCLA Medical Center

David Geffen School of Medicine at
UCLA
Los Angeles, CA

Medical College of Georgia
Georgia Regents University
Augusta, GA

Dietrich Jehle, MD, ACEP, RDMS
Director of Emergency
­Ultrasonography and Professor of
Emergency Medicine
SUNY Buffalo, School of Medicine
Associate Medical Director
Erie County Medical Center
Buffalo, NY

Daniel Mantuani, MD/MPH
Ultrasound Fellow
Department of Emergency Medicine
Alameda County Medical Center
Oakland, CA

Ken Kelley, MD
Assistant Professor
Fellowship Director, Emergency
Ultrasound
Department of Emergency Medicine
University of California Davis
Sacramento, CA
R. Starr Knight, MD
Emergency Ultrasound Fellow
Department of Emergency Medicine

University of California, San
Francisco
San Francisco, CA
Brooks T. Laselle, MD, FACEP
Fellowship Director, Emergency
Ultrasound
Ultrasound Director, Emergency
Medicine Residency
Department of Emergency Medicine
Madigan Army Medical Center
Tacoma, WA
Clinical Instructor, U of Washington
School of Medicine, Seattle, WA
Stephen J. Leech, MD, RDMS
Ultrasound Director, Graduate
Medical Education
Orlando Health, Orlando FL
Assistant Clinical Professor,
University of Central Florida
College of Medicine
Andrew S. Liteplo, MD, RDMS
Emergency Ultrasound Fellowship
Director, Department of Emergency
Medicine
Massachusetts General Hospital
Boston, MA
Matthew Lyon, MD, FACEP
Professor
Vice Chairman for Academic
Programs

Director, Section of Emergency and
Clinical Ultrasound
Department of Emergency
Medicine

David J. McLario, DO, MS,
FACEP, FAAP
Department of Pediatrics
University of Louisville
Louisville, KY
Jacob C. Miss, MD
Resident Physician
Department of Emergency
Medicine
University of California, San Francisco and San Francisco General
Hospital
San Francisco, CA
Matthew A. Monson, DO
Assistant Professor of Radiology
University of Colorado School of
Medicine
Denver Health Medical Center
Denver, CO Children’s Hospital
Colorado
Aurora, CO
Christopher L. Moore, MD, RDMS,
RDCS
Associate Professor
Department of Emergency Medicine
Yale University School of Medicine

New Haven, CT
Arun Nagdev, MD
Director, Emergency Ultrasound
Alameda County Medical Center
Highland General Hospital
Clinical Assistant Professor
University of California
San Francisco School of Medicine
San Francisco, CA
Bret P. Nelson, MD, RDMS, FACEP
Director, Emergency Ultrasound
Associate Professor of Emergency
Medicine
Department of Emergency Medicine
Mount Sinai School of Medicine
New York, NY
Vicki E. Noble, MD
Director, Division of Emergency
Ultrasound
Massachusetts General Hospital


Contributors   vii

Associate Professor
Harvard Medical School
Boston, MA
David C. Pigott, MD, RDMS,
FACEP
Co-Director of Emergency Ultrasound

Associate Professor and Vice Chair
for Academic Development
Department of Emergency Medicine
The University of Alabama at
Birmingham
Birmingham, AL
John S. Rose, MD, FACEP
Professor, Department of Emergency
Medicine
University of California, Davis Health
System
Sacramento, CA
Sachita P. Shah, MD, RDMS
Assistant Professor, University of
Washington School of Medicine
Division of Emergency Medicine
Harborview Medical Center
Seattle, WA
Paul R. Sierzenski, MD, RDMS,
FACEP, FAAEM
Director, Emergency, Trauma and
Critical Care Ultrasound

Assoc Dir, Emergency Medicine
Ultrasound Fellowship
Christiana Care Health Center
Newark, DE
Michael B. Stone, MD, FACEP
Chief, Division of Emergency
Ultrasound

Department of Emergency Medicine
Brigham & Women’s Hospital
Boston, MA
Richard Andrew Taylor, MD
Clinical Instructor, Department of
Emergency Medicine
Yale University School of Medicine
New Haven, CT
Amanda Greene Toney, MD
Assistant Professor, Department of
Pediatrics
Section of Emergency Medicine
University of Colorado Denver
Aurora, CO
Negean Vandordaklou, MD
Clinical Instructor/Fellow
of ­Emergency Ultrasound
Emergency Department
University of California Irvine
­Medical Center
Orange, CA

Ralph C. Wang, MD, RDMS
Assistant Professor
Director of Emergency Ultrasound
Fellowship
Department of Emergency
Medicine
University of California, San
Francisco

San Francisco, CA
Juliana Wilson, DO
Ultrasound Fellow, University of
Buffalo Emergency Medicine
Residency
Erie County Medical Center
Buffalo, NY
Michael Y. Woo, MD, CCFP (EM),
RDMS
Associate Professor
Director and Fellowship Director
Emergency Medicine
Ultrasonography Department
of Emergency Medicine
University of Ottawa and The Ottawa
Hospital
Ottawa, ON



Preface
Emergency ultrasound has expanded well beyond most expectations of even a decade ago. This text too has changed in significant ways. The scope of the book is unapologetically expansive.
We are well aware of the need for innovation to keep pace with
the rapid rate of change in medical knowledge and technology.
Our goal is to make as much information as possible accessible to the reader. As ultrasound finds its way into undergraduate education, and as it spreads to other medical disciplines, we
believe the potential for ultrasound will only continue to grow.
This book differs from many in our approach to scanning.
Rather than present only a traditional region- or organ-specific
approach, we have added sections with a problem/symptombased approach. The opening section on “Resuscitation of
Acute Injury or I­ llness” describes use of ultrasound in solving

clinical questions to r­esuscitate patients with shock or acute
dyspnea. In addition, we present material in the manner in
which we understand ultrasound is used; thus, content on procedural assistance is placed adjacent to sections on related diagnosis. Increasingly, we find that as ultrasound is incorporated
into the physical exam, one application melds into another. At
first, a diagnosis is considered, possibly excluded, then another
one entertained. Therapeutic interventions are made (possibly
with ultrasound assistance), and then the patient reassessed
(again with u­ ltrasound). Thus, ultrasound becomes an integral tool for the dynamic process of diagnosis, treatment, and
reassessment. In order to make the content relevant for both
adults and children, we have added special highlighted inserts
(“Pediatric Considerations”) for helpful guidance to modify
technique or improve interpretation and use of ultrasound for
children when content differs from adults.

This revised edition adds video clips that display more
realistic three-dimensional views of anatomy. We have
­increased the number and variety of images that are included
in the electronic version of the book. The result is a rich
­resource with a library of images to learn from.
In an increasingly digital era, many readers might question if textbooks are even necessary. Our answer rests with
this book. In one place we have condensed expertise across
emergency ultrasound, complete with photos, images, and
videos that demonstrate a wide range of pathology. We have
focused on technique and recognition of images without
­repeating content on pathophysiology that can be gained
from general medical sources.
Point of care ultrasound can improve the ability to
make rapid decisions and optimize care in many settings
ranging from the high-tech environment of critical care to
the frontline of disaster relief in third world countries. By

arming the bedside clinician with rapid access to information, we believe ultrasound improves both quality and
safety for patients in situations where either time or resources are limited. Even in routine situations, ultrasound
can augment the physical exam and help decisions about
diagnosis and care to be made earlier and with greater
certainty. The ability to take advantage of ultrasound
technology has changed the nature of frontline medicine.
We are thrilled to participate in spreading this skill to
clinicians.
Karen S. Cosby, MD
John L. Kendall, MD

ix



Preface to First Edition
Change comes slowly. The first paper pertaining to emergency ultrasound appeared more than 15 years ago, and while
the concept of physicians performing a “limited” ultrasound
examination took root and gained favor from clinicians and
educators, the growth of this imaging modality has been
slower than expected. Formal teaching in ultrasound is now a
part of most Emergency Medicine residencies, yet, as educators, we find that there is a dramatic drop-off in the application of ultrasound skills once residents leave their academic
training grounds and enter practice. There are many barriers
that impede the widespread acceptance and use of bedside
ultrasound in real-life practice. This book was born from our
efforts to identify and understand these difficulties, and written with the intent to empower the reader to surmount them.
From an educator’s perspective, the ability to incorporate
ultrasound into clinical practice requires at least four critical elements. First, the skill must be seen as valuable, one
worth learning. Secondly, the skill itself requires specialty
knowledge, awareness of ultrasound-relevant anatomy and

landmarks. The clinician must have technical knowledge
and skill to acquire the image. Lastly, the clinician must be
able to take the information and use it in real-time decision
making. This text is organized around these four goals. Each
chapter begins with indications for ultrasound, then focuses
on a review of normal ultrasound anatomy, techniques for
acquiring the image, and guidelines for using the information
to make clinical decisions.
The emergency physician faces other challenges as well,
factors that ultimately may limit his/her ability to incorporate ultrasound into clinical practice. There are administrative pressures to be efficient. There are financial pressures
to optimize billing and reimbursement. There are political
pressures within each institution that influence the ability to
change clinical practice, especially when it entails interaction
with other specialties. We have attempted to address these
challenges up front, with guidelines for introducing emergency ultrasound into a new practice, suggestions for quality
assurance and credentialing, and practical ideas for making
ultrasound efficient and accurate.
As this text enters production, we face an interesting
paradox. The widespread integration of ultrasound into clinical practice has occurred relatively slowly, while the technology and potential applications are expanding at a rapid

rate. New applications for bedside ultrasound are continually
­being found, and keeping up with and predicting these trends
in a textbook is nearly impossible. Recognizing that limitation, this text includes sections pertaining to many of the
applications that are currently considered cutting-edge. Our
goal is to narrow the gap between where we stand ­today and
where we hope to be in the next decade of growth. Besides,
it is becoming increasingly apparent that bedside ultrasound
is not an imaging modality specific to emergency medicine,
but rather one that is useful to many different clinicians
(­physicians, nurses, and prehospital personnel) across a variety of specialties (surgeons, intensivists, cardiologists, and

internists). While the authors of this textbook are all practicing emergency physicians, the content of this text is applicable to many different practitioners who seek to realize the
benefits of bedside ultrasound.
Bedside ultrasound is an evolving standard. In the early
years, the use of ultrasound by emergency physicians was
viewed as an encroachment into an area that belonged to
other specialists. This is no longer the case. Emergency
medicine has adopted the technology and developed it for
our own purpose, just as other specialties have done. We have
contributed significantly to the ultrasound literature. We have
developed it for practical bedside applications, applying it to
many types of exams not traditionally performed by radiologists. Ultrasound manufacturers have introduced equipment
that is designed specifically for bedside use, with increased
portability, rapid boot-up times, and improved versatility
appropriate for a wide range of applications. Emergency
ultrasound can no longer be considered a borrowed skill,
nor even an alternative to consultative scans; rather, it has
become a discipline in itself.
Change is inevitable. Emergency medicine has a history
and philosophy accepting of change and a drive to continually raise the standard of care. We are proud to continue
that tradition with this book. Our hope is that this text will
help bedside clinicians, regardless of their specialty or level
of training, to acquire or improve basic bedside ultrasound
skills, enhance their clinical practice, and ultimately raise the
standard of care for our patients.
Karen S. Cosby, MD
John L. Kendall, MD

xi

Contents
Contributors...................................................................................... v
Preface............................................................................................. ix
Preface to First Edition..................................................................... xi
Index to Procedures.........................................................................xv

SECTION I

Getting Started with Bedside Ultrasound
1 The History and Philosophy
of Emergency Ultrasound.............................................. 1
Stephen R. Hoffenberg
2 Fundamentals of Ultrasound....................................... 10
Ken Kelley, John S. Rose, and Aaron E. Bair

SECTION II

10 Abdominal Aorta........................................................ 156
Anthony J. Dean
11Kidneys...................................................................... 172
Michael Blaivas
12 Bedside Sonography of the Bowel............................. 186
Timothy Jang
13 Abdominal Procedures.............................................. 195
Gregory R. Bell

SECTION IV

Evaluation of Pelvic Complaints

14 Pelvic Ultrasound in the Nongravid Patient................ 202
Jeanne Jacoby and Michael Heller

Ultrasound in the Resuscitation of Acute Injury or Illness

15 First Trimester Pregnancy.......................................... 218
Ralph C. Wang and R. Starr Knight

3Trauma........................................................................ 21
Brooks T. Laselle and John L. Kendall

16 Second and Third Trimester Pregnancy..................... 236
John Gullett and David C. Pigott

4Echocardiography....................................................... 55
Richard Andrew Taylor and Christopher L. Moore

SECTION V

5 Lung and Thorax......................................................... 75
Calvin Huang, Andrew S. Liteplo, and Vicki E. Noble
6 Inferior Vena Cava....................................................... 84
Richard Gordon and Matthew Lyon
7A Problem-Based Approach to
Resuscitation of Acute Illness or Injury:
Resuscitative Ultrasound............................................ 96
John Bailitz
8 Critical Procedures for Acute Resuscitations............ 108
Michael Y. Woo and Ashraf Fayed

SECTION III

Vascular Emergencies
17 Lower Extremity Venous Studies............................... 254
J. Christian Fox and Negean Vandordaklou
18 Arterial Emergencies.................................................. 264
Caitlin Bailey, Daniel Mantuani, and Arun Nagdev

SECTION VI

Scrotal Emergencies
19 Scrotal Emergencies.................................................. 271
Paul R. Sierzenski and Stephen J. Leech

Evaluation of Abdominal Conditions

SECTION VII

9 Right Upper Quadrant: Liver,
Gallbladder, and Biliary Tree...................................... 133
Karen S. Cosby and John L. Kendall

20 Skin and Soft Tissue.................................................. 284
Jacob C. Miss and Bradley W. Frazee

Soft Tissue and Musculoskeletal Conditions

xiii

xiv  
Contents

21Musculoskeletal......................................................... 303
Joy English

28 Pediatric Procedures.................................................. 407
Amanda Greene Toney and Russ Horowitz

22 Soft Tissue and Musculoskeletal Procedures............. 319
Andrew J. French, Joy English, Michael B. Stone,
and Bradley W. Frazee

SECTION X

SECTION VIII

29 Implementing Ultrasound into the Community
­Emergency Department............................................. 413
Bret P. Nelson and Stephen R. Hoffenberg

Problems of the Head and Neck
23 Eye Emergencies........................................................ 350
Matthew Flannigan, Dietrich Jehle,
and Juliana Wilson
24 Infections of the Head and Neck................................ 365
Srikar Adhikari
25 Head and Neck Procedures........................................ 383
Srikar Adhikari

SECTION IX

Pediatric Ultrasound
26 General Pediatric Problems....................................... 388
Russ Horowitz
27 Pediatric Abdominal Emergencies............................. 394
Keith P. Cross, Matthew A. Monson,
and David J. McLario

Implementing Ultrasound into the Clinical Setting

30 Implementing Ultrasound into the
Academic Emergency Department............................. 421
David P. Bahner, Eric J. Adkins,
and John L. Kendall
31 Implementing Ultrasound in the
Prehospital Setting.................................................... 428
Nicole Danielle Hurst
32 Implementing Ultrasound in
Developing Countries................................................. 435
Sachita Shah
Index............................................................................................. 441
Highlighted Sections on Pediatric Considerations
authored by Russ Horowitz.


Index to Procedures
Ultrasound Guided Procedures

Lumbar puncture...................................................... Chap 22

Arthrocentesis.......................................................... Chap 22

Nerve blocks............................................................ Chap 22

Bladder, suprapubic aspiration................................. Chap 28

Pacemaker, placement................................................ Chap 8

Endotracheal intubation, confirmation of ................. Chap 8

Paracentesis.............................................................. Chap 13

Foreign body, localization........................................ Chap 20

Pediatric procedures................................................. Chap 28

Foreign body, removal ............................................ Chap 22

Pericardiocentesis...................................................... Chap 8

Fracture reduction.................................................... Chap 22

Thoracentesis............................................................. Chap 8

Hernia reduction....................................................... Chap 13

Venous access, central................................................ Chap 8

Incision and drainage of abscess

Cutaneous....................................................... Chap 20
Head and neck................................................ Chap 25
Pediatric.......................................................... Chap 28
Peritonsillar.................................................... Chap 25

Venous access, central (peds)................................... Chap 28
Venous access, peripheral.......................................... Chap 8
Venous access, peripheral (peds)............................. Chap 28

xv



1

The History and Philosophy
of Emergency Ultrasound
Stephen R. Hoffenberg

INTRODUCTION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
THE HISTORY OF EMERGENCY ULTRASOUND. . . . . . . . . . . . .
GROWTH OF EMERGENCY ULTRASOUND . . . . . . . . . . . . . . . .
Recognition of Ultrasound’s Value . . . . . . . . . . . . . . . . .
Timely Access to Imaging. . . . . . . . . . . . . . . . . . . . . . . .
Imaging Availability. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Improving Technology. . . . . . . . . . . . . . . . . . . . . . . . . . .
Specialty Endorsement by Emergency Medicine. . . . . . .
THE PARADIGM OF EMERGENCY ULTRASOUND . . . . . . . . . . .
CHARACTERISTICS OF THE EMERGENCY ULTRASOUND. . . . .
CORE DOCUMENTS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

ACEP and SAEM Policy Statements on Emergency
Ultrasound. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1
1
2
2
2
2
3
3
3
4
5
5

INTRODUCTION
Emergency ultrasound is a standard emergency physician
skill (1,2). It is taught in emergency medicine residencies
(3,4), tested on board examinations (5,6), and is endorsed by
emergency medicine professional societies (1,2,7). The use
of ultrasound performed by the treating emergency physician, interpreted as images are displayed and immediately
used for diagnosis or for procedural assistance, differs significantly from the traditional approach of consultative imaging services. Bedside emergency ultrasound has proven to be
an appropriate use of technology demonstrated to speed care
(8–10), enhance patient safety (11,12), and save lives (13).

THE HISTORY OF EMERGENCY ULTRASOUND
Ultrasound became available for clinical use in the 1960s
following more than a decade of investigation. The technology was initially found only in specialized imaging
laboratories; however, by the 1970s, ultrasound was being

adopted in diverse settings by a variety of clinical specialties.
Ultrasound technology and devices improved rapidly, and
real-time ultrasound was developed in the early 1980s that
allowed the viewing of ultrasounds without an appreciable

ACEP Emergency Ultrasound Guidelines. . . . . . . . . . . . .
The Core Content for Emergency Medicine and the
Model of the Clinical Practice of Emergency Medicine. .
Model Curriculum for Physician Training in
Emergency Ultrasonography . . . . . . . . . . . . . . . . . . .
AMA Approach to Ultrasound Privileging . . . . . . . . . . . .
Additional Positions – AIUM, ASE, and ACR. . . . . . . . . .
American Institute of Ultrasound Medicine. . . . . . . . . . .
American Society of Echocardiography. . . . . . . . . . . . . .
American College of Radiology. . . . . . . . . . . . . . . . . . . .
EMERGENCY ULTRASOUND AS AN EVOLVING
STANDARD OF CARE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
CONCLUSION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5
5
6
6
6
6
6
6
7
7

delay between signal generation and display of the image.
In addition, sufficient images were generated by real-time
ultrasound to allow the visualization of continuous motion.
Prior to the development of real-time ultrasound the complexity of acquiring images prevented the practical application of ultrasound for most emergency patients and was an
absolute barrier to use at the bedside. Real-time scanning
changed how ultrasound would be used, who would use
ultrasound, and where studies would be performed.
Ultrasound devices continued to improve, and during the
1980s and 1990s, smaller, faster, and more portable ultrasound equipment was developed in accompaniment with
other enhancements, such as the transvaginal transducer,
multi-frequency probes, and color Doppler. These improvements accelerated the movement of technology from the
ultrasound suite to the bedside for immediate use in emergency patients.
The growth in clinical applications paralleled technological advancements. As early as 1970, surgeons in
Germany were the first to experiment with ultrasound for
the detection of free fluid in the abdomen (14,15). In 1976,
an American surgeon used ultrasound to describe and grade
splenic injuries (16). Emergency physicians began investigating the clinical use of ultrasound in the late 1980s,
1


2  
Section I / Getting Started with Bedside Ultrasound

while the first emergency ultrasound publication appeared
in 1988, which addressed the utility of echocardiography
performed by emergency physicians (17). From the late
1980s through the mid 1990s significant investigation was
done in both the United States and Germany on the detection of hemoperitoneum and hemopericardium in trauma
victims. This research ultimately led to the description of
the Focused Assessment with Sonography for Trauma or

the FAST examination (13,18–22). The FAST examination has essentially replaced diagnostic peritoneal lavage in
all but a handful of patients, and has been fully integrated
into Advanced Trauma Life Support (ATLS) teaching. This
examination remains the standard initial ultrasound examination for trauma victims by emergency physicians and
trauma surgeons, and is often equated with “emergency
ultrasonography.”
The American College of Emergency Physicians (ACEP)
offered its initial course in the emergency applications of
ultrasound in 1990. In 1991, both ACEP and the Society of
Academic Emergency Medicine (SAEM) published position
papers recognizing the utility of ultrasound for emergency
patients (1,7). These documents endorsed not only the clinical use of ultrasound, but also ongoing research and education. The SAEM policy added that resident physicians should
receive training leading to the performance and interpretation of emergency ultrasound examinations. In 1994, SAEM
published the Model Curriculum for Physician Training in
Emergency Ultrasonography outlining recommended training standards for emergency medicine residents (23). Shortly
following the development of this curriculum, the first textbook dedicated to emergency ultrasound was published in
1995 (24).
In 2001, ACEP published the Emergency Ultrasound
Guidelines more clearly defining the scope of practice and
clinical indications for emergency ultrasonography (2). This
policy statement advanced recommendations for credentialing, quality assurance, and the documentation of emergency
ultrasounds, as well as representing current best practices
and standards for ultrasound provided by emergency physicians. These guidelines were updated in 2008, reflecting
the broader adoption, maturation, and expanded use of emergency ultrasound. A comprehensive approach to training,
quality, documentation, and credentialing is provided in this
document, as well as evidence-based additions to the list of
core applications.
Over the past two decades, results of emergency physicianperformed ultrasound have been examined for a wide spectrum of clinical conditions and applications, including trauma
(13,18–22,25,26), intrauterine pregnancy (8,27–31), abdominal aortic aneurysm (AAA) (32–34), cardiac (13,35–39),
biliary disease (40–43), urinary tract (44–46), deep venous

thrombosis (DVT) (10,47,48), soft–tissue/musculoskeletal
(49–58), thoracic (59), ocular (60–63) and procedure guidance (11,12,64–72). Each of these is now considered a primary
indication for emergency ultrasound. Ongoing research will
likely establish the efficacy of additional emergency applications (Table 1.1).

TABLE 1.1  Core Emergency Ultrasound Applications

GROWTH OF EMERGENCY ULTRASOUND

Imaging Availability

A number of factors have driven the development of emergency ultrasound. They include a growing recognition of the
utility of ultrasound information, a need for timely access

Patients present to the emergency department 24 hours a
day, 7 days a week, and a predictable subset require ultrasound evaluation. While recognition of the positive impact

Trauma
Intrauterine pregnancy
AAA
Cardiac
Biliary
Urinary tract
DVT
Soft-tissue/musculoskeletal
Thoracic
Ocular
Procedural guidance

to diagnostic imaging, declining access to consultative services, improved ultrasound technology, and the endorsement of immediate ultrasound by the specialty of emergency

medicine.

Recognition of Ultrasound’s Value
A key factor contributing to the growth of emergency ultrasound is an increased recognition of ultrasound’s clinical
utility. The primary indications for diagnostic emergency
ultrasound are now well established. Where immediate ultrasound is available, it has essentially replaced invasive techniques such as peritoneal lavage and culdocentesis, as well as
obviating the need for blind pericardiocentesis. Use for procedure guidance, such as central venous access, has become
a standard of care in many practice settings. Interestingly, the
management of cardiac arrest assisted by diagnostic ultrasound (36,39) or the evaluation of patients with nontraumatic
hypotension (73,74) are examples of ultrasound usage not
contemplated prior to the growth of emergency ultrasound.

Timely Access to Imaging
For many emergency conditions, ultrasound is needed on
an immediate basis. Immediate may mean within minutes
of patient presentation. Examples include central line placement under ultrasound guidance in the hypotensive patient,
or hemodynamically unstable patients with suspected aortic
aneurysm or blunt trauma. In addition, patients in cardiac
arrest, with penetrating chest injuries, or those with undifferentiated hypotension are all candidates for immediate
bedside ultrasound. These examinations are extremely time
dependent, and typically they cannot be supplied in a clinically useful time-frame by even the best-staffed radiology
departments or echocardiography laboratories. For some of
these conditions, both diagnostic ultrasound (e.g., abdominal) and echocardiography are required for the same patient,
but in most hospitals these studies are supplied by separate
consulting services. The ultrasound-trained emergency physician is typically in the best position to utilize immediate
ultrasound for a number of emergency conditions.


Chapter 1 / The History and Philosophy of Emergency Ultrasound   3

of ultrasound imaging on patient care has grown, consulting
imaging services have become progressively less available for
emergency patients. This has been particularly true at night
and on weekends. The reasons most often cited for decreasing
access include higher costs incurred by the imaging service
for “off-hours” studies and the lack of an adequate number
of sonographers to perform these examinations. As a result,
emergency physicians may be asked to hold patients that
require imaging until the following day, to treat patients prior
to diagnostic testing, or to send patients home with potentially life-threatening conditions pending a scheduled outpatient study. Common examples include holding a patient with
undiagnosed abdominal pain pending a right upper quadrant
study, treating a patient with anticoagulants prior to a deep
venous ultrasound exam, or sending home a patient with suspected ectopic pregnancy prior to pelvic imaging.
Delays and decreased access to consultative imaging
increase the medical risk to patients, can result in emergency
department overcrowding, and increase medical liability
for the emergency physician. Immediate imaging by the
emergency physician can provide needed data, significantly
decrease requirements for costly consultative studies, and
avoid associated delays (8–10,42,75–77).

Improving Technology
Technology improvements in ultrasound devices have made
an essential contribution to the development of emergency
ultrasound programs. The stationary and operationally complex devices historically associated with ultrasound have
been replaced with a variety of highly portable and more
intuitive devices. Hardware improvements have been accompanied by software enhancements resulting in increased
speed, flexibility, image quality, and ease of use. These technological advancements have increased the practical utility
of ultrasound and have allowed the movement of this technology from the laboratory to the bedside.

Specialty Endorsement by Emergency
Medicine
The use of emergency ultrasound has been endorsed by
emergency medicine professional societies, such as ACEP
and SAEM (1,2,7). Assumptions underlying these endorsements are that specialists in emergency medicine are in the
best position to recognize the needs of emergency patients
and, in addition, have an obligation to utilize available technologies that have been demonstrated to improve patient
care. Finally, since ultrasound training has been included in
residency education (3,4), emergency specialists now enter
practice with the reasonable expectation of utilizing this
standard emergency physician skill (1,2,5,6).

THE PARADIGM OF EMERGENCY
ULTRASOUND
The approach to ultrasound performed by the emergency
physician differs significantly from that embraced by consultative imaging services. Who performs the study, where
the examination is conducted, how quickly it is accomplished, and how study results are communicated all differ.
In addition, the scope of the examination and study goals
may be quite different. Physician work associated with the

examination, the expense of test performance, and how data
is integrated into patient care are also unique to each of these
approaches. Understanding and communicating the paradigm of emergency ultrasound is an essential step in program
implementation.
The paradigm of emergency ultrasound is reflected in
the 2001 ACEP policy on Use of Ultrasound Imaging by
Emergency Physicians (1).
Ultrasound imaging enhances the physician’s ability
to evaluate, diagnose, and treat emergency department patients. Because ultrasound imaging is often
time-dependent in the acutely ill or injured patient, the

emergency physician is in an ideal position to use this
technology. Focused ultrasound examinations provide
immediate information and can answer specific questions about the patient’s physical condition. Such bedside ultrasound imaging is within the scope of practice
of emergency physicians.
The paradigm of emergency ultrasound begins with ultrasound performance by the treating physician at the patient’s
bedside. The examination is contemporaneous with patient
care and is performed on an immediate basis. In this context, immediate means within minutes of an identified need.
Interpretation of images is done by the treating physician
and occurs as the images are generated and displayed. In
this approach, permanent images document what has already
been interpreted by the emergency physician, rather than
becoming a work-product for delayed interpretation by a
consultant. Finally, the scope of the examination is focused,
or limited, in nature. The treating physician is seeking an
answer to a specific question for immediate use that will
drive a clinical decision, or is utilized to guide a difficult
or high-risk procedure. In this paradigm, the work-product
is care of the patient that is improved by the appropriate
use of ultrasound technology, and it is not the image or a
report. It should be emphasized that the focused examinations performed in this paradigm meet the medical needs of
the patient without providing unnecessary services.
The paradigm of consultative ultrasound imaging begins
when a treating physician requests a study. The patient is
usually transported to an ultrasound suite where a sonographic technician images the patient. The completed study
is presented, or transmitted, to an interpreting physician who
documents the study results and communicates these results
to the treating physician. The treating physician incorporates
reported data into clinical decision making. Ultrasound guidance of emergent procedures is rarely pursued or available
under this paradigm. Diagnostic studies are stored as hard
copies in file rooms or in a digital format. The consulting

physician’s work product is an image and a report.
The paradigm of the consulting imaging service represents a complex system that involves multiple providers,
movement of the patient, and several steps in a chain of
communications. Delays, high costs, and the opportunity for
miscommunication are inherent in this approach. For example, one must wait for a sonography technician who may be
remotely located in the hospital, completing a study in progress, summoned from home, or not available for emergency
studies. All this must occur before the study is obtained,
interpreted, or reported for clinical use. Delays associated
with this paradigm predictably negate many of the clinical
benefits of ultrasound. Finally, consulting studies are usually


4  
Section I / Getting Started with Bedside Ultrasound

comprehensive or complete in scope and often seemingly
exceed both the treating physician’s requirements as well as
criteria for medical necessary services.
The paradigm of emergency ultrasound has been a difficult concept for many traditional providers of ultrasound
to understand or to accept. Emergency ultrasound is not a
lesser imitation of comprehensive consulting imaging services, but rather it is a focused and appropriate application
of technology that provides essential diagnostic information
and guidance of high-risk procedures. Unfortunately, the
development of emergency ultrasound has been accompanied by a great deal of misunderstanding. Issues of physician credentialing, the ownership of technology, exclusive
contracts, reimbursement, and specialty society advocacy
positions have tended to overshadow clinical evidence and
the practical experience of improved emergency patient
care. Not only does the paradigm of emergency ultrasound
offer tangible benefits in patient care, but it represents a
technology that emergency physicians will continue to utilize and refine.

CHARACTERISTICS OF THE EMERGENCY
ULTRASOUND
Indicated emergency ultrasound studies share a common
set of characteristics that reflect their clinical utility, as well
as the practicality of performance in the emergency department setting. The primary indications for emergency studies
address the clinical conditions of trauma, intrauterine pregnancy, abdominal aortic aneurysm, cardiac, biliary disease,
urinary tract, DVT, soft-tissue/musculoskeletal, thoracic,
ocular, and procedures that would benefit from assistance
of ultrasound (1,2). As research, technology, and experience
grows, indications and standards for emergency ultrasound
will evolve. Characteristics common to effective emergency
ultrasound studies include the following:
1. US examinations should be performed only for defined
emergency indications that meet one or more of the following criteria:
• A life threatening or serious medical condition
where emergency ultrasound would assist in diagnosis or expedite care. An example would be evaluation of a patient with suspected AAA and signs of
instability.
• A condition where an ultrasound examination would
significantly decrease the cost or time associated with
patient evaluation. An example would be locating an
intrauterine pregnancy in a patient with early pregnancy and vaginal bleeding.
• A condition in which ultrasound would obviate the
need for an invasive procedure. An example would be
echocardiography to rule out pericardial effusion and
the need for pericardiocentesis in a patient with pulseless electrical activity.
• A condition where ultrasound guidance would increase patient safety for a difficult or high risk procedure. An example would be ultrasound guidance for
central line placement.
• A condition in which ultrasonography is accepted as
the primary diagnostic modality. An example would

be identifying gallstones in a patient with suspected
biliary colic. Note that establishing a diagnosis may

often obviate the need for additional testing or acute
hospital admission.
2. Emergency physicians conduct focused, not comprehensive examinations.
Emergency ultrasound diagnostic studies are goaldirected and designed to answer specific questions that
guide clinical care. They frequently focus on the presence or absence of a single disease entity or a significant
finding such as hemoperitoneum in the blunt trauma
patient. These studies are quite different from the complete examinations typically performed by consulting
imaging services. Complete studies evaluate all structure and organs within an anatomic region. They are
typically more expensive and time consuming as they
may address issues outside of those medically necessary
for patient management.
3. Emergency ultrasound studies should demonstrate one
or two easily recognizable findings.
Carefully designed indications result in simple questions, straightforward examinations, and useful answers.
For example, free intraperitoneal fluid, a gestational sac,
absence of a heart beat, or the presence of pericardial
fluid are all easily recognizable and have clear and
immediate clinical utility.
4. Emergency ultrasounds should directly impact clinical
decision making.
Patient care algorithms should be developed for each
focused ultrasound indication and the result of the study
should be used to determine subsequent care. Any exam
that will not reasonably be expected to change clinical
decision-making should be performed on an elective
basis.
5. Emergency ultrasounds should be easily learned.

Some findings, such as the presence or absence of
an intrauterine pregnancy with an intracavitary probe,
are relatively easy to learn. Other evaluations such as
evaluation for focal myocardial wall motion abnormalities in ischemic heart disease are more difficult
to learn. A body of evidence has been accumulated by
emergency physicians, which identifies studies that are
most reasonably learned and result in reliable clinical
data (78–82).
6. Emergency physicians should conduct ultrasound studies that are relatively quick to perform.
Emergency physicians have limited time with each
patient, and they generally have responsibility for the
safety of many patients in the department at any given
time. Ultrasound procedures selected by emergency
physicians should be completed in a reasonable amount
of time. Selecting focused examinations that are more
quickly performed does not diminish the value of the
data, intensity of the service, or the positive impact on
patient care. For example, an echocardiography performed in the presence of penetrating cardiac injury may
be quickly performed, yet it provides potentially lifesaving information that cannot be obtained by physical
examination.
7.Emergency departments should have the capacity to
perform ultrasound examinations at the bedside on an
immediate basis for the unstable patient and in a timely
fashion for the stable patient.
This requires that the emergency physician be prepared to conduct and interpret emergency ultrasound


Chapter 1 / The History and Philosophy of Emergency Ultrasound   5

examinations and that equipment is available for immediate use. ACEP policy recommends that optimal patient

care is provided when dedicated ultrasound equipment is
located within the emergency department (1).

CORE DOCUMENTS
An understanding of emergency ultrasound includes a review
of policy statements and clinical guidelines addressing the
use of ultrasound. These documents should be utilized not
only in formulating a program, but should be referenced in
discussions with members of the medical staff and with hospital administration as well as being used to establish guidelines and standards for training, credentialing, and quality
improvement. The core documents include:

ACEP and SAEM Policy Statements
on Emergency Ultrasound
In 1991, the ACEP policy on Ultrasound Use for Emergency
Patients stressed the clinical need for the immediate availability of diagnostic ultrasound on a 24-hour basis (1). In
addition, the policy called for training and credentialing of
physicians providing these services and encouraged research
for the optimal use of emergency ultrasound. This position
was endorsed by the SAEM policy in the same year  (7).
SAEM added language to their policy that encouraged
research to determine optimal training requirements for performance of emergency ultrasound, and suggested that specific training should be included during residency.
The ACEP policy was updated in 1997 and in 2001. The
most recent version of the policy has been incorporated into
the 2008 Emergency Ultrasound Guidelines (Table  1.2).
This ACEP endorsement articulates the value of emergency
ultrasound, outlines the primary diagnostic and procedural
uses of ultrasound, and recognizes ultrasound as a standard
emergency physician skill. In addition, it states that residents
should be trained in ultrasound, EDs should be equipped
with dedicated ultrasound equipment, and that emergency

physicians should be reimbursed for the added work of ultrasound performance. Finally, the policy states that ultrasound

is within the scope of practice of emergency physicians and
that the hospital’s medical staff should grant privileges based
upon specialty-specific guidelines.

ACEP Emergency Ultrasound Guidelines
ACEP published the Emergency Ultrasound Guidelines
in 2001 with a robust revision in 2008 that describes the
scope of practice for emergency ultrasound as well as
providing recommendations for training and proficiency,
­specialty-specific credentialing, quality improvement, and
documentation criteria for emergency ultrasound (2). This
comprehensive 2008 document is the clearest statement
addressing emergency medicine’s approach to diagnostic and
procedural ultrasound, and delineates ultrasound standards
that are broadly accepted by the specialty of emergency medicine. The Emergency Ultrasound Guidelines is an authoritative resource and should be referenced when formulating an
ultrasound program or providing informational materials to
credentials committee, hospital administration, or interested
specialists.

The Core Content for Emergency Medicine
and the Model of the Clinical Practice of
Emergency Medicine
In 1997, a joint policy statement was published by ACEP,
the American Board of Emergency Medicine (ABEM), and
SAEM titled the Core Content for Emergency Medicine (5).
The purpose of this joint policy was to represent the breadth
of the practice of emergency medicine, to outline the content
of emergency medicine at risk for board examinations, and

to serve to develop graduate and continuing medical education programs for the practice of emergency medicine.
Bedside ultrasonography was included in the procedure and
skills section for cardiac, abdominal, traumatic, and pelvic
indications.
In 2001, and most recently in 2009, this document was
updated and published as The Model of the Clinical Practice
of Emergency Medicine (6). This publication includes bedside ultrasound in the list of procedures and skills integral

TABLE 1.2  ACEP Endorsements—Section 8—Emergency Ultrasound Guidelines 2008
This statement originally appeared in June 1991 as ACEP Policy Statement Ultrasound Use for Emergency Patients. This statement was
updated in 1997 and again in 2001 as Use of Ultrasound Imaging by Emergency Physicians. In 2008 this statement was updated and
incorporated into Emergency Ultrasound Guidelines 2008.
ACEP endorses the following statements on the use of emergency ultrasound:
1. Emergency ultrasound performed and interpreted by emergency physicians is a fundamental skill in the practice of emergency medicine.
2. The scope of practice of emergency ultrasound can be classified into categories of resuscitation, diagnostic, symptom or sign-based, procedural guidance,
and monitoring/therapeutics in which a variety of emergency ultrasound applications, including the below listed core applications, can be integrated.
3. Current core applications in emergency ultrasound include trauma, pregnancy, abdominal aorta, cardiac, biliary, urinary tract, deep venous thrombosis,
thoracic, soft-tissue/musculoskeletal, ocular, and procedural guidance.
4. Dedicated ED ultrasound equipment is requisite to the optimal care of critically ill and injured patients.
5. Training and proficiency requirements should include didactic and experiential components as described within this document.
6. Emergency ultrasound training in emergency medicine residency should begin early and be fully integrated into patient care.
7. Emergency physicians after initial didactic training should following competency guidelines as written within this document.
8. Credentialing standards used by EDs and health care organizations should follow specialty-specific guidelines as written within this document.
9. Quality assurance and improvement of emergency ultrasound is fundamental to the education and credentialing processes.
10. Emergency physicians should be appropriately compensated by payors in the provision of these procedures.
11. Emergency ultrasound research should continue to explore the many levels of clinical patient outcomes research.
12. The future of emergency ultrasound involves adaptation of new technology, broadening of education, and continued research into an evolving emergency medicine practice.


6  

Section I / Getting Started with Bedside Ultrasound

to the practice of emergency medicine. These documents
are often used to establish core privileges for emergency
physicians.

Model Curriculum for Physician Training
in Emergency Ultrasonography
In 1994, the SAEM Ultrasound Task Force published the
Model Curriculum for Physician Training in Emergency
Ultrasonography (Model Curriculum) outlining resource
materials, as well as recommended hours of didactic and
hands-on education (23). The model was constructed primarily for residents in training; however, it did address the
practicing emergency physician by stating that instruction,
covering topics that follow the Task Force outline, and a
total of 150 examinations, constitute training in emergency
medicine ultrasonography. The Model Curriculum was
comprehensive and has proven invaluable in guiding the
development of residency training programs as well as the
initial training and continuing education for the practicing
emergency physician. The 2008 Emergency Ultrasound
Guidelines has revisited and updated training and proficiency, including training pathways, continuing education,
and the role of fellowship training (2).

AMA Approach to Ultrasound Privileging
The American Medical Association (AMA) developed a
policy in 1999 on Privileging for Ultrasound Imaging (83).
This policy recognizes the diverse uses of ultrasound
imaging in the practice of medicine. Further, the AMA
recommended that training and educational standards be

developed by each physician’s respective specialty and that
those standards should serve as the basis for hospital privileging. The AMA policy is in full agreement with ACEP
policy and affirms the use of ultrasound by a variety of physician specialties rather than restricting ownership of the
technology of ultrasound.
While the AMA and ACEP’s approach may seem rational, experience in hospital credentialing has demonstrated
opposition to the concept of individual specialties developing
training and education standards for their use of ultrasound.
Providers of consultative ultrasound services, most notably
radiology, have been quite active in developing a policy that
recommends training standards for practitioners outside
their own specialties, and their publications have been used
in debates regarding hospital credentialing as well as third
party reimbursement.

Additional Positions – AIUM, ASE, and ACR
Policy statements regarding physician qualifications and ultrasound training standards have been published by a number
of professional organizations such as the American Institute
of Ultrasound Medicine (AIUM), the American Society of
Echocardiography (ASE), and the American College of
Radiology (ACR). Over the past several years there has been
significant progress in understanding the positive role of clinician performed ultrasound at the patient’s bedside. Current
position statements of the AIUM and ASE are supportive
of the clinical utility of ultrasound performed by qualified
emergency physicians, as well as endorsing ACEP’s education and training requirements for focused emergency
applications. The policy of the ACR remains unchanged and

differs substantially from those published by the specialty of
emergency medicine, the AIUM, and the ASE. In discussions
regarding ultrasound, the emergency physician should be prepared to address these various advocacy positions as they may
be quoted as published and authoritative standards that apply

to emergency practitioners using ultrasound.

American Institute of Ultrasound Medicine
The AIUM is a multidisciplinary association of physicians,
sonographers, and scientists supporting the advancement
of research and the science of ultrasound in medicine. In
2007, they published the AIUM Practice Guideline for the
Performance of the Focused Assessment With Sonography for
Trauma (FAST) Examination in conjunction with ACEP (84).
The AIUM recognized the FAST examination as proven
and useful in the evaluation of both blunt and penetrating
trauma. In addition, the AIUM recognized training in compliance with ACEP guidelines as qualifying a physician for
the performance and interpretation of the FAST examination. Finally, they recommended that credentialing for the
FAST examination be based on published standards of the
physician’s specialty society such as ACEP or the AIUM. In
2011, the AIUM provided a broader endorsement of ultrasound by emergency physicians by officially recognizing
the ACEP Emergency Ultrasound Guidelines education and
training requirements as meeting qualifications for performing focused ultrasounds, and acknowledged the clinical utility of diagnostic and procedural emergency examinations in
clinical practice (85).

American Society of Echocardiography
The ASE is a professional organization of physicians,
cardiac sonographers, nurses, and scientists involved in
echocardiography. In 2010, the ASE published Focused
Cardiac Ultrasound in the Emergent Setting: A Consensus
Statement of the American Society of Echocardiography and
the American College of Emergency Physicians (86). This
statement termed the use of bedside echocardiography an
“indispensible first-line test for the cardiac evaluation of
symptomatic patients” that “has become a fundamental tool

to expedite the diagnostic evaluation of the patient at the bedside and to initiate emergent treatment and triage decisions
by the emergency physician.” Finally, the statement outlined
emergency indications for echocardiography and endorsed
ACEP specialty specific guidelines for training and the performance of focused cardiac ultrasound as described in the
Emergency Ultrasound Guidelines.

American College of Radiology
The ACR-SPC-SRU Practice Guideline for Performing and
Interpreting Diagnostic Ultrasound Examinations (87) was
updated in 2011 and has not evolved from the historical perspective of consultative imaging. This practice guideline
requires that physicians who have not completed a radiology residency interpret and report 500 supervised ultrasound examinations during the previous 36  months and
for each subspecialty they practice in order to be deemed
qualified. Subspecialties as defined in this document reference applications and anatomic regions thus abdomen is
separate from musculoskeletal and each are separate from
echocardiography.


Chapter 1 / The History and Philosophy of Emergency Ultrasound   7

This guideline is designed with the assumption that physicians will perform and interpret comprehensive studies and as
such, the focused ultrasound examinations utilized by emergency physicians have not been contemplated. In addition,
the numbers of studies this policy requires far exceeds training standards accepted by emergency medicine authorities
including ABEM, ACEP, SAEM, the Council of Emergency
Medicine Residency Directors, and the Residency Review
Committee for Emergency Medicine (88), as well as exceeding
those recognized by other relevant professional societies such
as the AIUM and ASE. Finally, this policy is not in agreement
with ACEP, the AMA, the AIUM, the ASE, and others recommending that hospital privileging should be in accordance with
the recommended training and education standards developed
by each physician’s respective specialty (1,83,85,86).

EMERGENCY ULTRASOUND AS AN
EVOLVING STANDARD OF CARE
A frequently asked question is “what is the standard of care
for ultrasound?” Is the standard of care the study performed
by a consultative imaging service or is it the immediate use
of ultrasound at the bedside for indications demonstrated
to improve patient outcomes? How does a standard of care
relate to a best practice? Would the failure of an emergency
physician to utilize ultrasound constitute substandard care?
The simplest definition of a standard of care is how a
similarly-qualified practitioner would manage a patient’s
care under the same or similar circumstances. Standards
are based in peer-reviewed literature and in consensus opinion regarding clinical judgment. They are national in scope
rather than based on community norms and are tested in a
court of law, where they are generally established by expert
witness testimony.
A best practice is a technique that through experience and
research has proven to reliably lead to a desired outcome.
A best practice is based in evidence and represents a commitment to using all the knowledge and technology at one’s
disposal to ensure improved patient care. As best practices
become more broadly adopted, they eventually become recognized as standards of care. Substantial peer-reviewed evidence has demonstrated that emergency physician performed
ultrasound is reliable for each of the primary indications of
emergency ultrasound and would therefore be regarded by
the specialty of emergency medicine as best practices.
Central venous catheter placement facilitated by ultrasound is an interesting example. Ultrasound guidance has
been found to reduce the number of needle passes, the time
to catheter placement and to decrease the complication
rate for central venous access (11,12). Peer-reviewed literature has demonstrated the effectiveness of this technique in
the emergency department where the treatment of critically

ill and injured patients often requires immediate central vascular access (65–67). The Agency for Healthcare Research
and Quality report Making Health Care Safer—A Critical
Analysis of Patient Safety Practices cited the use of real-time
ultrasound guidance during central line insertion to reduce
complications as “one of the most highly rated patient safety
practices based upon potential impact of the practice and the
strength of supporting evidence” (11). This is a best practice
that has been adopted by a growing number of emergency
physicians, and it represents an evolving standard of care.

CONCLUSION
Improvements in technology have allowed the movement
of ultrasound from the imaging laboratory to the patient’s
bedside. Technology enhancements have been accompanied
by an evidence-based recognition of the value of immediate ultrasound in a variety of clinical conditions encountered in the emergency department. The demonstrated value
of emergency ultrasound has led to endorsement by emergency medicine professional organizations, inclusion into
emergency medicine residency training, and integration into
clinical practice. The focused use of emergency ultrasound
and the characteristics of these examinations have been well
described, and there is a broadening acceptance of bedside
ultrasound by the emergency physician. Despite meaningful progress, emergency ultrasound may be misunderstood,
mischaracterized, or undervalued, and clinical issues may
be confused with hospital politics and physician economics. In this context an understanding of a variety of policy
statements by emergency medicine professional societies
and by other professional societies is helpful in discussions
surrounding the use of ultrasound by emergency physicians.
Most importantly, the use of ultrasound by the treating emergency physician represents an advance in the care of emergency patients, an appropriate use of technology, a clinical
best practice, and an evolving standard of care.
REFERENCES
1.ACEP Policy Statement. Ultrasound use for emergency patients. June

1991, updated 1997 and 2001 as: use of ultrasound imaging by emergency physicians. Incorporated into emergency ultrasound guidelines
2008. . Accessed August 21, 2012.
2.ACEP Policy Statement. ACEP emergency ultrasound guidelines. 2001.
Policy #400327. Updated 2008 emergency ultrasound guidelines. http://
www.acep.org/. Accessed August 21, 2012.
3.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;23:459–466.
4.The Accreditation Council for Graduate Medical Education (ACGME);
Emergency Medicine Residency Review Committee. Program
Requirements; Guidelines; Procedures and Resuscitations; Bedside
ultrasound. 2002. .
5.Allison EJ Jr, Aghababian RV, Barsan WG, et al. Core content for
emergency medicine. Task Force on the Core Content for Emergency
Medicine Revision. Ann Emerg Med. 1997;29:792–811.
6.Hockberger RS, Binder LS, Graber MA, et al. The model of the clinical
practice of emergency medicine. Ann Emerg Med. 2001;37:745–770.
7.SAEM. Ultrasound Position Statement. 1991. .
8.Shih CH. Effect of emergency physician-performed pelvic sonography on length of stay in the emergency department. Ann Emerg Med.
1997;29:348–351.
9.Blaivas M, Harwood RA, Lambert MJ. Decreasing length of stay with
emergency ultrasound examination of the gallbladder. Acad Emerg Med.
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10.Theodoro D, Blaivas M, Duggal S, et al. Real-time B-mode ultrasound
in the ED saves time in the diagnosis of deep vein thrombosis (DVT).
Am J Emerg Med. 2004;22:197–200.
11.Agency for Healthcare Research and Quality. Making health care safer:
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12.Hind D, Calvert N, McWilliams R, et al. Ultrasonic locating devices for
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13.Plummer D, Brunette D, Asinger R, et al. Emergency department echocardiography improves outcome in penetrating cardiac injury. Ann
Emerg Med. 1992;21:709–712.


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Section I / Getting Started with Bedside Ultrasound
14.Goldberg BB, Goodman GA, Clearfield HR. Evaluation of ascites by
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Chapter 1 / The History and Philosophy of Emergency Ultrasound   9

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85.AIUM officially recognizes ACEP emergency ultrasound guidelines;
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87.American College of Radiology, Society for Pediatric Radiology and
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