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ACEP Emergency Ultrasound Imaging Criteria Compendium

Policy
Statement
Approved by ACEP This compendium contains the following criteria:
Board of Directors ! Aorta
April 2006 ! Biliary
! Echocardiography
! Pelvic Ultrasound
! Renal
! Trauma
! Ultrasound-Guided Procedures
! Venous Thrombosis

Aorta
1. Introduction
The American College of Emergency Physicians (ACEP) has
developed these criteria to assist practitioners performing emergency
ultrasound studies (EUS) of the abdomen and retroperitoneum in
patients suspected of having an acute abdominal aortic aneurysm
(AAA).

Ultrasound has been shown to be accurate in identifying both


aneurysmal and normal abdominal aortas. In most cases, EUS is used
to identify or exclude the presence of infrarenal AAA. In some cases,
EUS of the abdominal aorta can also identify the presence of
suprarenal AAA or of distal dissection. If thoracic aortic aneurysm or
proximal dissection is suspected, these may be detected using
transthoracic techniques or may require additional diagnostic
modalities. Patients in whom AAA is identified also need to be
assessed for free intraperitoneal fluid.

EUS evaluation of the aorta occurs in conjunction with other EUS


applications and other imaging and laboratory tests. It is a clinically
focused examination, which, in conjunction with historical and
laboratory information, provides additional data for decision-making.
It attempts to answer specific questions about a particular patient’s
condition. While other tests may provide information that is more
detailed than EUS, have greater anatomic specificity, or identifies
alternative diagnoses, EUS is non-invasive, is rapidly deployed and
does not entail removal of the patient from the resuscitation area.
Further, EUS avoids the delays, costs, specialized technical
personnel, the administration of contrast agents and the biohazardous

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ACEP Policy Emergency Ultrasound Imaging Criteria Compendium
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potential of radiation. . These advantages i. When bowel gas or other technical


make EUS a valuable addition to available factors prevent a complete systematic
diagnostic resources in the care of patients real-time scan through all tissue
with time-sensitive or emergency conditions planes, these limitations should be
such as acute AAA. identified and documented. Such
limitations may mandate further
2. Indications/Limitations evaluation by alternative methods, as
a. Primary clinically indicated.
i. The rapid evaluation of the abdominal ii. A small aneurysm does not preclude
aorta from the diaphragmatic hiatus to rupture. A patient with symptoms
the aortic bifurcation for evidence of consistent with acute AAA and an
aneurysm. aortic diameter greater than 3.0 cm
should have this diagnosis (or
b. Extended alternative vascular catastrophes)
i. Abdominal aortic dissection ruled out.
ii. Thoracic aortic dissection iii. The absence of free intraperitoneal
iii. Intraperitoneal free fluid in the event fluid does not rule out acute AAA as
that AAA is identified most acute AAAs presenting to the
iv. Iliac artery aneurysms ED do not have free peritoneal fluid.
iv. The presence of retroperitoneal
c. Contraindications hemorrhage cannot be reliably
i. There are no absolute identified by EUS.
contraindications to abdominal aorta v. If an AAA is identified, it still may
EUS. There may be relative not be the cause of a patient’s
contraindications based on specific symptoms.
features of the patient’s clinical vi. While most aneurysms are fusiform,
situation. extending over several centimeters of
aorta, saccular aneurysms are confined
d. Limitations to a short focal section of the aorta,
i. EUS of the aorta is a single making them easily overlooked. This
component of the overall and ongoing may be avoided by methodical,
resuscitation. Since it is a focused systematic real-time scanning through
examination EUS does not identify all all tissue planes.
abnormalities or diseases of the aorta. vii. Oblique or angled cuts exaggerate the
EUS, like other tests, does not replace true aortic diameter. Scanning planes
clinical judgment and should be should be obtained that are either
interpreted in the context of the entire exactly aligned with, or at exact right
clinical picture. If the findings of the angles to, the main axis of the vessel.
EUS are equivocal additional viii. With a tortuous or ectatic aorta
diagnostic testing may be indicated. “longitudinal” and “transverse” views
ii. Examination of the aorta may be should be obtained with respect to the
technically limited by axis of the vessel in order to avoid
1. Obese habitus artifactual exaggeration of the aortic
2. Bowel gas diameter.
3. Abdominal tenderness ix. Large para-aortic nodes may be
confused with the aorta and/or AAA.
e. Pitfalls They usually occur anterior to the
aorta, but may be posterior, displacing

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the aorta away from the vertebral image of the vertebral body is identified.
body. They can be distinguished by an The aorta is a circular structure
irregular nodular shape, identifiable in identified as tubular in real-time
real-time. If color flow Doppler is adjacent to the left anterior surface of
utilized nodes will not demonstrate the vertebral body.
luminal flow. ii.Real-time scanning technique.
3. Qualifications and Responsibilities in the 1. Overview. The abdominal aorta
performance and interpretation of EUS of the extends from the diaphragmatic
aorta hiatus to the bifurcation. The
EUS of the aorta provides information that is surface anatomy corresponding to
the basis of immediate decisions about further these points are the xiphoid
evaluation, management, and therapeutic process and the umbilicus. If
interventions. Because of its direct bearing on possible, the probe is held at right
patient care, the rendering of a diagnosis by angles to the skin and slid from
EUS represents the practice of medicine, and the xiphoid process down the
therefore is the responsibility of the abdominal midline to the
supervising physician. umbilicus, providing real-time
systematic scanning through all
Due to the time-critical and dynamic nature of planes from the diaphragm to the
acute AAA, emergent interventions may be bifurcation. The probe is then
mandated by the diagnostic findings of EUS of rotated 90 degrees and real-time
the aorta. For this reason, EUS of the aorta images are obtained of all
should occur as soon as the clinical decision is longitudinal planes by rocking or
made that the patient needs a sonographic sliding the probe from side to
evaluation. side.

2. Details of technique. In the


Physicians of a variety of medical specialties
subxiphoid area the liver often
may perform EUS of the aorta. Training
provides a sonographic window.
should be in accordance with specialty or
A cooperative patient may be
organization specific guidelines. Physicians
asked to take a deep breath, which
should render a diagnostic interpretation in a
augments this window by
time frame consistent with the management of
lowering the diaphragm and liver
acute AAA, as outlined above.
margin. Frequently, gas in the
transverse colon obscures the
4. Specifications for the performance and
midsection of the aorta in a
interpretation of EUS of the aorta
roughly 5-centimeter band
a. General – Simultaneously with other
between the xiphoid process and
aspects of resuscitation, ultrasound images
the umbilicus. This precludes a
are obtained demonstrating the abdominal
systematic sliding movement of
aorta from the diaphragmatic hiatus to the
the probe from xiphoid to
bifurcation.
umbilicus. In order to circumvent
the gas filled transverse colon, it
b. Technique
is necessary to use a rocking
i. Identification. The aorta is most easily
technique in the windows above
identified and most accurately measured
and below this sonographic
in the transverse plane. The transverse
obstacle. This may give rise to a

American College of Emergency Physicians ! PO Box 619911 ! Dallas, TX 75261-9911 ! 972-550-0911 ! 800-798-1822
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slightly exaggerated measurement aneurysm can be performed using


of the AP aortic diameter because parasternal and suprasternal
the scanning plane is not windows. These are discussed in
completely at right angles to the the section on emergency cardiac
tubular axis of the aorta. ultrasound.
However, it is necessary to use
this technique since it often allows 4. Measurements. The aorta and
for real-time systematic scanning iliacs are measured from the
through all planes of the organ of outside margin of the wall on one
interest, and will diminish the side to the outside margin of the
possibility of missing a small other wall. The maximum aortic
saccular aneurysm. diameter should be measured in
both transverse and longitudinal
After a systematic real-time scan planes.
in transverse planes, the aorta
should be scanned longitudinally. For technical reasons, when
In this view, abnormalities in the scanning in the transverse plane,
lateral walls may be missed, but the anterior and posterior walls
focal abnormalities in the anterior are usually more sharply defined
or posterior walls and absence of than the lateral walls, allowing for
normal tapering are more easily more precise measurements in this
appreciated. direction. However, due to the
fact that many AAAs have larger
3. Additional windows. If bowel gas side-to-side than AP diameter,
and/or truncal obesity interfere measurements are obtained in
with visualization of the aorta in both directions when possible.
the anterior midline, the
emergency physician should use 5. Additional technical
any probe position that affords considerations – If an AAA is
windows of the aorta. In identified, evaluation of the
particular, two additional peritoneal cavity for free fluid
windows can be used. First, in the (using the approach of the
right midaxillary line intercostal Focused Assessment by
views using the liver as a window Sonography in Trauma) should be
can sometimes provide images of made. If a high clinical index of
the aorta. To optimize this suspicion persists despite a normal
approach, the patient may be EUS exam of the aorta, an attempt
placed in a left decubitus position. may be made to evaluate the iliacs
On this view the aorta will appear for aneurysm.
to be lying “deep” to the inferior 5. Documentation
vena cava. Second, the distal aorta EUS of the aorta are interpreted by the treating
can sometimes be most easily physician as they are performed and are used
visualized with the probe placed to guide contemporaneous clinical decisions.
in a left paraumbilical region. Such interpretations should be documented in
the medical record as a dictated, hand-written,
Evaluation of the ascending aorta or templated note. Documentation should
and aortic arch for dissection or include the indication for the procedure, a

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description of the organs or structures studied causes of the patient’s symptoms. If biliary
and an interpretation of the findings. disease is identified, EUS also guides
Whenever feasible images should be stored as disposition by helping to distinguish emergent,
a part of the medical record and done so in urgent, and expectant conditions.
accordance with facility policy requirements.
Given the often emergent nature of such
EUS of the RUQ occurs as a component of the
ultrasound examinations the timely delivery of
overall clinical evaluation of a patient with
care should not be delayed by the archiving of
abdominal pain. It is a clinically focused
ultrasound images.
examination, which, in conjunction with
historical and laboratory information, provides
6. Equipment Specifications
additional data for decision-making. It
Curvilinear abdominal or phased array
attempts to answer specific questions about a
ultrasound probes can be utilized. A 2 - 5
particular patient’s condition. While other
MHz multi-frequency transducer is ideal. The
tests may provide information that is more
lower end of this frequency range may be
detailed than EUS, have greater anatomic
needed in larger patients, while the higher
specificity, or identifies alternative diagnoses,
frequency will give more detail in thin
EUS is non-invasive, is rapidly deployed and
patients. Both portable and cart-based
does not entail removal of the patient from the
ultrasound machines may be used, depending
resuscitation area. Further, EUS avoids the
on the location and setting of the examination.
delays, costs, specialized technical personnel,
the administration of contrast agents and the
7. Quality Control and Improvements, Safety,
biohazardous potential of radiation. These
Infection Control and Patient Educations
advantages make EUS a valuable addition to
Policies and procedures related to quality,
available diagnostic resources in the care of
safety, infection control and patient education
patients with time-sensitive or emergency
should be developed in accordance with
conditions such as acute biliary colic or
specialty or organizational guidelines. Specific
cholecystitis, as well as other causes of
institutional guidelines may be developed to
abdominal pain.
correspond with such guidelines.
2. Indications/Limitations
Biliary a. Primary
1. Introduction i. Identification of cholelithiasis
The American College of Emergency b. Extended
Physicians (ACEP) has developed these i. Cholecystitis
criteria to assist practitioners performing ii. Common bile duct abnormalities,
emergent ultrasound (EUS) studies of the right including dilatation and
upper quadrant (RUQ) in patients suspected of choledocholithiasis
having acute biliary disease. iii. Liver abnormalities, including tumors,
abscesses, intrahepatic cholestasis,
Abdominal pain is a common presenting pneumobilia, hepatomegaly
complaint in the emergency department. iv. Portal vein abnormalities
Biliary disease is frequently a consideration v. Abnormalities of the pancreas
among the possible etiologies. In many cases, vi. Other gallbladder (GB) abnormalities,
EUS of the right upper quadrant may be including tumors
diagnostic for biliary disease, may exclude vii. Unexplained jaundice
biliary disease, or may identify alternative viii. Ascites

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c. Contraindications portal vein, the inferior vena cava, and


ii. There are no absolute hepatic or renal cysts or even
contraindications to RUQ EUS. There loculated collections of fluid. These
may be relative contraindications can be more accurately identified with
based on specific features of the careful scanning in multiple planes.
patient’s clinical situation. iv. Measurement of posterior GB wall
d. Limitations thickness may be difficult due to the
i. EUS of the RUQ is a single frequent presence of closely apposed
component of the overall and ongoing loops of bowel. Measurement of GB
evaluation. Since it is a focused wall thickness should be made on the
examination EUS does not identify all anterior wall, where the GB is
abnormalities or diseases of the RUQ. adjacent to the hepatic parenchyma.
EUS, like other tests, does not replace v. Small gallstones may be overlooked
clinical judgment and should be or mistaken for gas in an adjacent loop
interpreted in the context of the entire of bowel. In questionable cases, gain
clinical picture. If the findings of the settings should be optimized, the area
EUS are equivocal additional should be scanned from several
diagnostic testing may be indicated. directions, and the patient should be
ii. The primary focus of RUQ EUS is to repositioned to check for the mobility
identify or exclude gallstones. Other of gallstones.
entities, including hepatic tumors, vi. Gas in loops of bowel adjacent to the
abnormalities of the pancreas or posterior wall of the GB may be
abnormalities of the portal system mistaken for stones. The two may be
would not usually be identified by a distinguished by optimizing gain to
limited and focused exam. identify shadowing, by the presence of
iii. Examination of the RUQ may be peristalsis in bowel, and by the
technically limited by absence of gravitational effect when
1. Obese habitus the patient is repositioned.
2. Bowel gas vii. Small stones in the GB neck may
3. Abdominal tenderness easily be overlooked or mistaken for
e. Pitfalls lateral cystic shadowing artifact (edge
i. When bowel gas or other technical shadows). It may be necessary to
factors prevent an adequate image this area from several directions
examination, these limitations should to avoid this pitfall.
be identified and documented. As viii. Common bile duct stones may only be
usual in emergency practice, such identified by the shadowing they
limitations may mandate further cause.
evaluation by alternative methods. ix. Cholesterol stones are often small,
ii. Failure to identify the GB may occur less echogenic, may float, and may
with chronic cholecystitis particularly demonstrate “comet tailing.”
when filled with stones. Or, would not x. Pneumobilia and emphysematous
be identified in the rare instances of cholecystitis are subtle finding and
GB agenesis. Failure to identify the may produce increased echogenicity
GB would warrant additional and comet-tailing caused by gas in the
diagnostic testing. biliary tree and GB wall.
iii. The GB may be confused with other
fluid filled structures including the

American College of Emergency Physicians ! PO Box 619911 ! Dallas, TX 75261-9911 ! 972-550-0911 ! 800-798-1822
ACEP Policy Emergency Ultrasound Imaging Criteria Compendium
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xi. Polyps may be mistaken for


gallstones. The former are non-mobile 4. Specifications for performance and
and do not shadow. interpretation of biliary EUS
xii. GB wall thickening may not represent a. General –Organs and structures evaluated
biliary pathology, but may be in the RUQ are scanned systematically in
physiological, as in the post-prandial real time through all tissue planes in at
state, or with non-surgical conditions least two orthogonal directions. The
such as hypoproteinemia, congestive primary focus of the biliary EUS
heart failure. examination is the identification of
xiii. The presence of gallstones or other gallstones. Evaluation of the GB for
findings consistent with cholecystitis evidence of cholecystitis and examination
does not rule out the presence of other of the liver and biliary tree, as described in
life-threatening causes of epigastric “Extended Indications”, are performed
pain such as aortic aneurysm or based on the clinical situation and
myocardial infarction. appropriate emergency physician’s
xiv. Except for emergency physicians with sonographic experience.
extensive experience in EUS, b. Technique
evaluations of the liver, pancreas and i. Identification
Doppler examination of the portal 1. Gallbladder. The normal GB is
venous system are not part of the highly variable in size, shape,
normal scope of EUS of the RUQ. axis, and location. It may contain
folds and septations, and may lie
3. Qualifications and Responsibilities of the anywhere between the midline
Performing Medical Professional and the midaxillary line. The axis
Biliary EUS is the basis of immediate and location of the porta hepatis
decisions concerning further evaluation, are also highly variable.
management, and therapeutic interventions. Orientation of images of the GB
Because of its direct bearing on patient care, and common bile duct are
the rendering of a diagnosis by biliary EUS conventionally defined with
represents the practice of medicine, and respect to their axes as
therefore is the responsibility of the longitudinal, transverse, and
supervising physician. oblique, rather than standardized
anatomic planes such as sagittal,
Due to the time-critical and dynamic nature of coronal, oblique and transverse.
many causes of abdominal pain and biliary
pathology, emergency interventions may be In most cases, the GB lies
undertaken based upon findings of the EUS immediately posterior to the
exam. For this reason, EUS should occur as inferior margin of the liver in the
soon as the clinical decision is made that the mid-clavicular line. In some
patient needs a sonographic exam. patients, the fundus may extend
Physicians of a variety of medical specialties several centimeters below the
may perform biliary ultrasound. Training costal margin; in others, the GB
should be in accordance with specialty or may be high in the hilum of the
organization specific guidelines. Physicians liver, almost completely
should render a diagnostic interpretation in a surrounded by hepatic
time frame consistent with the management of parenchyma. In order to avoid
acute GB disease, as outlined above. confusing it with fluid-filled

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tubular structures, the entire plane of the probe parallel to the


extent of the GB is scanned in real ribs and the indicator directed
time in its long and short axes. toward the vertebral end of the
rib. This plane is about 45 degrees
2. Common bile duct. It is usually counter-clockwise from the long
located by identifying the portal axis of the patient’s body. The
vein in the porta hepatis, which it probe is swept laterally from the
reliably accompanies. sternal border to the midaxillary
line until the GB is located.
ii. Real-time scanning technique 4. When the GB has been located, its
1. Overview: A general-purpose long and short axes are identified.
curved array abdominal probe In the long axis, images are
with a frequency range of between obtained, by convention, with the
2-5 MHz is generally used. A GB neck on the left of the screen,
small footprint or phased array and the fundus on the right. The
probe may facilitate scanning GB is scanned systematically in
between the ribs. As with other real time through all tissue planes
EUS, the organs of interest are in both long and short axis views.
scanned methodically in real-time In many patients a combination of
through all tissue planes in at least subcostal and intercostal windows
two orthogonal directions. allows for views of the GB from
multiple directions and may help
2. In most patients, the inferior in identifying small stones,
margin of the liver provides a resolving artifacts, and examining
sonographic window for the GB the gall bladder neck.
below the costal margin. In many
cases, this window can be 5. The common bile duct is most
augmented by asking the patient easily located sonographically by
to take and hold a deep breath. It finding and identifying the portal
may also be helpful to place the vein, which, with the hepatic
patient in a left decubitus position. artery and CBD, comprise the
The transducer is placed high in porta hepatis. Several techniques
the epigastrium with the indicator can be used to locate the CBD in
in a cephalad orientation. The addition to anatomic location.
probe is swept laterally while These include tracking the hepatic
being held immediately adjacent artery from the celiac axis,
to the costal margin. The liver tracking the portal vein from the
margin should be maintained confluence of the splenic and
within the field of view on the superior mesenteric veins, and
screen. following the portal vessels in the
liver to the hepatic hilum. In a
3. In patients whose liver margin transverse view of the porta
cannot be visualized below the hepatis, the CBD and hepatic
costal margin, an intercostal artery are typically seen anterior
approach is necessary. In order to to the portal vein. The CBD is
minimize rib shadowing, the usually more lateral than the
transducer is oriented with the hepatic artery or more to the left

American College of Emergency Physicians ! PO Box 619911 ! Dallas, TX 75261-9911 ! 972-550-0911 ! 800-798-1822
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on the screen. It can also be shadowing. Optimization of gain,


distinguished by its absence of a frequency and focal zone settings
color-flow Doppler signal if this may be necessary to identify small
modality is employed. gallstones and to differentiate
their shadows from those of
iii. Key components of the exam. The GB adjacent bowel gas.
is systematically scanned as described, 2. Cholecystitis - This diagnosis is
with particular attention to the neck. based on the entire clinical picture
For patients with low hanging GB, the in addition to the findings of the
fundus may be obscured by gas-filled EUS. The following sonographic
colon. Decubitus positioning or findings support the diagnosis of
exhalation may help provide adequate cholecystitis.
windows in this situation. The a. Thickened, irregular, or
principal abnormal finding is heterogeneously echogenic
gallstones that are echogenic with GB wall is measured along
distal shadowing. Measurements of the anterior surface. Thickness
the GB wall thickness, if performed, greater than 3 millimeters is
are made on the anterior wall between considered abnormal.
the lumen and the hepatic b. Pericholecystic fluid may
parenchyma. Measurements of GB appear as hypo- or an-echoic
size are rarely helpful in EUS, regions seen along the
although gross increases in transverse anterior surface of the GB
diameter or overall size may be within the hepatic
evidence of cholecystitis and hydrops, parenchyma and suggests
respectively. A qualitative assessment acute cholecystitis.
of the wall and pericholecystic regions c. A Sonographic Murphy’s sign
should also be made, looking for is tenderness reproducing the
mural irregularity, breakdown of the patient’s abdominal pain
normal trilaminar mural structure, and elicited by probe compression
fluid collections. directly on the gall bladder,
combined with the absence of
The common bile duct, like other similar tenderness when it is
tubular structures, is most accurately compressed elsewhere.
measured when imaged in a transverse d. Increased transverse GB
plane. It is most reliable to measure diameter greater than 5 cm
the intraluminal diameter (inside wall may be evidence of
to inside wall). Evaluation of the CBD cholecystitis.
may reveal shadowing suggesting 3. Common bile duct dilatation - The
stones and/or comet-tail artifact normal upper limit of CBD
suggesting pneumobilia. The question diameter has been described as 3
of such findings would warrant mm, although several studies have
additional diagnostic testing. demonstrated increasing diameter
with aging in patients without
iv. Pathologic findings evidence of biliary disease. For
1. Cholelithiasis - Gallstones are this reason, many authorities
often mobile (move with patient consider that the normal CBD
positioning) and usually cause may increase by 1 mm for every

American College of Emergency Physicians ! PO Box 619911 ! Dallas, TX 75261-9911 ! 972-550-0911 ! 800-798-1822
ACEP Policy Emergency Ultrasound Imaging Criteria Compendium
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decade of age. criteria to assist practitioners performing


4. Pathologic findings of the liver emergency ultrasound studies (EUS) of the
and other structures are beyond heart in patients suspected of having emergent
the scope of the EUS. pericardial or cardiac disease.

5. Documentation The primary applications of cardiac EUS are


EUS of the RUQ is interpreted by the treating in the diagnosis or exclusion of pericardial
physician as they are performed and are used effusion, cardiac tamponade and the
to guide contemporaneous clinical decisions. evaluation of gross cardiac function. Cardiac
Documentation of the RUQ EUS should be EUS is an integral component of patient
incorporated into the medical record as a evaluation and/or resuscitation. It is a
dictated, hand-written, or templated note. clinically focused examination, which, in
Documentation should include the indication conjunction with historical and laboratory
for the procedure, the views obtained, a information, provides additional data for
description of the organs or structures studied decision-making. It attempts to answer
and an interpretation of the findings. specific questions about a particular patient’s
Whenever feasible, images should be stored as condition. Other diagnostic or therapeutic
a part of the medical record and in accordance interventions may take precedence or may
with facility policy requirements. Given the proceed simultaneously with the cardiac EUS
often emergent nature of such ultrasound evaluation. While other tests may provide
examinations the timely delivery of care information that is more detailed than EUS,
should not be delayed by the archiving of have greater anatomic specificity, or identifies
ultrasound images. alternative diagnoses, EUS is non-invasive, is
rapidly deployed and does not entail removal
6. Equipment specifications of the patient from the resuscitation area.
A curvilinear abdominal transducer with Further, EUS avoids the delays, costs,
frequencies of 2.0-5 MHz is appropriate. A specialized technical personnel, the
small footprint curved array probe or phased administration of contrast agents and the
array probe facilitates intercostal scanning. biohazardous potential of radiation. These
Both portable and cart-based ultrasound advantages make EUS a valuable addition to
machines may be used, depending on the available diagnostic resources in the care of
location and setting of the examination. patients with time-sensitive or emergency
conditions such as acute cardiac disease. In
7. Quality Control and Improvements, Safety, addition cardiac EUS is an integral component
Infection Control and Patient Education of the trauma EUS evaluation.
Policies and procedures related to quality,
safety, infection control and patient education 2. Indications/ Limitations
should be developed in accordance with a. Primary
specialty or organizational guidelines. Specific i. Detection of pericardial effusion
institutional guidelines may be developed to and/or tamponade
correspond with such guidelines. ii. Evaluation of gross cardiac activity in
the setting of cardiopulmonary
Echocardiography resuscitation
1. Introduction iii. Evaluation of global left ventricular
The American College of Emergency systolic function
Physicians (ACEP) has developed these

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b. Extended identified on cardiac EUS, these are


i. Gross estimation of intravascular beyond the scope of the cardiac EUS
volume status and cardiac preload. exam.
ii. Identification of acute right vii. Cardiac EUS is technically limited by:
ventricular dysfunction and/or acute 1. Abnormalities of the boney thorax
pulmonary hypertension in the setting 2. Pulmonary hyperinflation
of acute and unexplained chest pain, 3. Massive obesity
dyspnea, or hemodynamic instability. 4. The patient’s inability to
iii. Identification of proximal aortic cooperate with the exam
dissection or thoracic aortic aneurysm. 5. Subcutaneous emphysema
iv. Procedural guidance of e. Pitfalls
pericardiocentesis, pacemaker wire i. When technical factors prevent an
placement and capture. adequate examination, these
c. Contraindications limitations should be identified and
There are no absolute contraindications to documented. As usual in emergency
cardiac EUS. There may be relative practice, such limitations may
contraindications based on specific mandate further evaluation by
features of the patient’s clinical situation. alternative methods, as clinically
indicated.
d. Limitations
ii. The measured size of a pericardial
i. Cardiac EUS is a single component of effusion should be interpreted in the
the overall and ongoing evaluation. context of the patient’s clinical
Since it is a focused examination EUS situation. A small rapidly forming
does not identify all abnormalities or effusion can cause tamponade, while
diseases of the heart. EUS, like other extremely large slowly forming
tests, does not replace clinical effusions may be tolerated with
judgment and should be interpreted in minimal symptoms.
the context of the entire clinical iii. Acute hemopericardium with clotted
picture. If the findings of the EUS are blood may be isoechoic with the
equivocal additional diagnostic testing myocardium or hyperechoic, so that it
may be indicated. can be overlooked if the examining
ii. Assessment of focal wall motion physician is expecting it to be
abnormalities is typically outside of anechoic as are most effusions.
the scope of cardiac EUS iv. Sonographic evidence of cardiac
iii. The evaluation of diastolic standstill should be interpreted in the
dysfunction is typically outside of the context of the entire clinical picture.
scope of cardiac EUS. v. Cardiac EUS may reveal sonographic
iv. Analysis of valvular abnormalities and evidence of right ventricular strain in
function is typically outside the scope cases of massive pulmonary embolus
of cardiac EUS. sufficient to cause hemodynamic
v. While sonographic evidence of a instability. However, a cardiac EUS
variety of cardiac conditions, may not demonstrate the findings of
including intracardiac thrombus or right ventricular strain and a normal
mass, ventricular aneurysm, septal EUS does not exclude pulmonary
defects, aortic dissection, myocarditis, embolism.
vi. hypertrophic cardiomyopathy and vi. Evidence of right ventricular strain
valvular vegetations, are occasionally may be due to causes other than

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pulmonary embolus. These include Training should be in accordance with


acute right ventricular infarct, specialty or organization specific guidelines.
pulmonic stenosis, and chronic Physicians should render a diagnostic
pulmonary hypertension. interpretation in a time frame consistent with
vii. Small or loculated pericardial the management of acute cardiac disease, as
effusions may be overlooked. As with outlined above.
other EUS, the heart should be
scanned in real-time through multiple 4. Specifications for Individual Examinations
tissue planes in two orthogonal a. General - Images are obtained and
directions. interpreted in real time without removing
viii. Pleural effusions may be mistaken for the patient from the clinical care area.
pericardial fluid. Evaluation of other Images are ideally obtained in a left-semi-
areas of the chest usually reveals their decubitus position, although the clinical
characteristic shape and location. situation often limits the patient to lying
ix. Occasionally, hypoechoic epicardial supine. Images may be captured for
fat pads may be mistaken for documentation and/or quality review.
pericardial fluid. Epicardial fat usually Recording of moving images, either in
demonstrates some internal echoing is video or cine loops, may provide more
not distributed evenly in the information than is possible with still
pericardial space. cardiac EUS images. However, capturing
x. The descending aorta may be moving images may be impractical in the
mistaken for a posterior effusion. This course of caring for the acutely ill patient.
can be resolved by rotating the probe
into a transverse plane. b. Technique
i. Overview
3. Qualifications and Responsibilities of the Both patient habitus and underlying
Performing Medical Professional pathological conditions affect the
Cardiac EUS provides information that is the accessibility of the heart to
basis of immediate decisions about further sonographic evaluation. For example,
evaluation, management, and therapeutic patients with causes of pulmonary
interventions. Because of its direct bearing on hyperinflation (e.g. emphysema or
patient care, the rendering of a diagnosis by intubation) are likely to have poor
cardiac EUS represents the practice of parasternal windows, while patients
medicine, and therefore is the responsibility of with abdominal distension or pain
the supervising physician. may have an inaccessible subcostal
window. For this reason, familiarity in
Due to the time-critical and dynamic nature of evaluating the heart from a number of
cardiac disease, emergent interventions may cardiac windows and planes increases
be mandated by the diagnostic findings of the likelihood of successful EUS.
EUS examination. For this reason, cardiac
ii. Orientation
EUS should be performed as soon as the
In certain views, cardiologists have
clinical decision is made that the patient needs
traditionally reversed the orientation
a sonographic evaluation.
of the viewing screen. In this
orientation, a transverse image of a
Physicians of a variety of medical specialties structure with the probe marker
may perform focused cardiac ultrasound. directed to the patient’s right would

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show right-sided body structures on them. As with other EUS the heart is
the left hand side of the screen. Since scanned in real-time through all tissue
reversing the screen for certain images planes.
and/or parts of an EUS exam can be
1. Subcostal four-chamber view or
time-consuming and confusing,
subxiphoid view
especially under the exigent
This view is obtained by placing
conditions typical of cardiac EUS,
the probe just under the rib cage
most emergency physicians have
or xiphoid process with the
adopted the convention of not
transducer directed towards the
adjusting the screen orientation in
patient’s left shoulder and the
views where the screen is reversed by
probe marker directed towards the
cardiologists, and have adopted
patient’s right (9-o’clock). The
reversing the direction of the probe
liver is used as a sonographic
marker instead. The resulting images
window. The heart lies
appear the same as those in traditional
immediately behind the sternum,
echocardiography texts. Throughout
so that it is necessary, in a supine
this document, this EUS convention
patient, to direct the probe in a
will be followed so that to obtain the
plane that is almost parallel with
views described, the emergency
the horizontal plane of the
physician will not need to reverse the
stretcher. This requires firm
orientation of the screen. The
downward pressure, especially in
approximate orientation of the probe
patients with a protuberant
marker in the various classic cardiac
abdomen. Structures imaged in
views is described in terms of a clock
the subcostal four-chamber view
face where 12 o’clock is directed to
include the right atrium, tricuspid
the head, 6 o’clock is directed to the
valve, right ventricle, left atrium
feet, 9 o’clock is directed to the
and left ventricle. The pericardial
patient’s right, and so on.
spaces should be examined both
iii. The primary cardiac views anterior and posterior to the heart.
Throughout the following discussion By scanning inferiorly, the
“windows” refer to locations that inferior vena cava may also be
typically afford sonographic access to visualized as it drains into the
the heart. Conversely, “views” refer to right atrium. This can help with
cardinal imaging planes of the heart, orientation, as well as giving
defined by specific structures that they information about the patient’s
demonstrate. In the following preload and intravascular volume
discussion, typical surface anatomical status.
locations are described for the cardiac
2. Parasternal long axis view
windows, but these are subject to
This view is typically obtained
significant individual variation based
using the third, fourth, and fifth
on the location and lie of the heart.
intercostal spaces, immediately to
The emergency physician should
the left of the patient’s sternum.
focus on identifying the key features
Structures imaged on this view
of the primary cardiac views,
include the pericardial spaces
regardless of the window where the
(anterior and posterior), the right
probe needs to be positioned to obtain
ventricle, the septum, the left

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atrium and left ventricular inflow muscles, the mitral valve, the
tract, the left ventricle in long aortic outflow tract, the aortic
axis, the left ventricular outflow valve, the aortic root and the left
tract, the aortic valve, and the atrium. The view at and
aortic root. immediately below the mitral
valve may be particularly helpful
The probe marker is directed to
for determining overall left
the patient’s left hip
ventricular systolic function.
(approximately 4-o’clock). In this
view the aortic outflow and left 4. Apical four-chamber view
atrium will be on the right side of This view is obtained by placing
the screen as it is viewed and the the probe at the point of maximal
cardiac apex will be on the left impulse (PMI) as determined by
side of the screen. physical exam. Normally this is in
the fifth intercostal space and
Alternately, the probe may be
inferior to the nipple, however this
directed to the patient’s right
location is subject to great
shoulder (approximately 10-
individual variation. The probe is
o’clock). This will provide a view
directed up along the axis of the
that is reversed 180 degrees from
heart toward the right shoulder,
that seen in cardiology texts, but
with the marker oriented towards
is consistent with orientation in
the patient’s right or 9-o’clock,
the rest of emergency ultrasound,
which is towards the ceiling in a
with the apex (a leftward
supine patient. The apex of the
structure) on the right side of the
heart is at the center of the image
screen as it is viewed. In this
with the septum coursing
probe position the orientation will
vertically also in the center of the
appear very similar to the
screen. The left ventricle and left
subcostal view, only slightly
atrium will be on the right side of
higher so that the aortic outflow
the screen, and the right ventricle
tract is seen instead of the right
and atrium will be on the left side
atrium.
of the screen. This view
3. Parasternal short axis view demonstrates both the mitral and
This view is obtained by rotating tricuspid valves and gives a clear
the probe 90 degrees clockwise view of the relative volumes of
from the parasternal long axis, so the two ventricular cavities, the
that the marker is directed in an motions of their free walls, and
approximately 8-o’clock the interventricular septum.
direction. By rocking the probe in
iv. Secondary cardiac views
these interspaces, images can be
1. Subxiphoid short axis view
obtained from the apex of the left
This view is obtained by placing
ventricle inferiorly up to the aortic
the probe in the same location as
root superiorly. Intervening
the subxiphoid four-chamber
structures which can be identified,
view, but rotating the probe
all in cross-section, include the
marker 90 degrees clockwise into
entire left ventricular cavity, the
a cephalad direction at 12-o’clock.
right ventricle, the papillary
This provides a short axis view of

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the right and left ventricles. With 4. Apical two chamber view
side to side rocking motion, a This view is obtained by rotating
longitudinal view of the inferior the probe clockwise 90 degrees
vena cava draining into the right from the apical four chamber
atrium can be seen. This view is view, so that the probe marker is
the preferred subxiphoid view for directed in a cephalad direction or
many trauma surgeons in the 12-o’clock. This allows
evaluation of blunt truncal trauma. visualization of the anterior and
inferior left ventricular walls as
2. Venous windows
well as the mitral and aortic
The inferior vena cava (IVC) may
valves. This view is infrequently
be traced by following hepatic
utilized in the cardiac EUS.
veins in a subcostal window.
Comparing the maximal IVC v. Relationship of the cardiac views
diameter in exhalation with the Several of the cardiac views provide
minimal IVC diameter in images of the same planes of the
inhalation may provide a heart from different angles. This is
qualitative estimate of preload. true of the following pairs of views:
Collapse of 50 - 99% is normal; the parasternal long axis and apical
complete collapse may indicate two-chamber views; the apical four-
volume depletion and <50% chamber and sub-xiphoid four-
collapse may indicate volume chamber views; and the parasternal
overload, pericardial tamponade short axis and the subxiphoid short
and/or right ventricular failure. axis views.
Additionally, an estimation of
preload may be obtained by c. Key components of the cardiac EUS
measuring the height of the evaluation
meniscus sonographically in the
i. Evaluation of pericardial effusion.
internal jugular from the sternal
Pericardial effusion usually images as
notch and adding 5 cm.
an anechoic or hypoechoic fluid
3. Suprasternal notch view collection within the pericardial space.
This view is obtained by placing With inflammatory, infectious,
the probe in the suprasternal malignant or hemorrhagic etiologies
notch, directed inferiorly into the this fluid may have a more complex
mediastinum. The marker is echogenicity and not appear anechoic
usually directed obliquely or uniform. Fluid tends to collect
between the patient’s right and dependently, but may be seen in any
anterior since this is the plane portion of the pericardium. Very small
followed by the aortic arch as it amounts of pericardial fluid can be
crosses from right anterior to left considered physiologic and are seen in
posterior of the mediastinum. A normal individuals. A widely used
bolster under the patient’s system classifies effusions as none,
shoulders with the neck in full small (< 10 mm in diastole, often non-
extension will facilitate this view circumferential), moderate
used to visualize the aortic arch (circumferential, no part greater than
and great vessels. 10 mm in width in diastole), large (10-
20 mm in width), and very large (>20

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mm and/or evidence of tamponade include the indication for the procedure, a


physisiology). description of the organs or structures studied
and an interpretation of the findings.
ii. Echocardiographic evidence of
Whenever feasible images should be stored as
tamponade. Diastolic collapse of any
a part of the medical record and done so in
chamber in the presence of moderate
accordance with facility policy requirements.
or large effusion is indicative of
Given the often emergent nature of such
tamponade. Hemodynamic instability
ultrasound examinations the timely delivery of
with a moderate or large pericardial
care should not be delayed by the archiving of
effusion, even without identifiable
ultrasound images.
diastolic collapse, is suspicious for
tamponade physiology.
6. Equipment Specifications
iii. Evaluation of gross cardiac motion in A phased array cardiac transducer is optimal,
the setting of cardiopulmonary since it facilitates scanning through the narrow
resuscitation. Terminal cardiac intercostal windows, and is capable of high
dysfunction typically progresses frame rates which provide better resolution of
through global ventricular rapidly moving cardiac structures. If this is not
hypokinesis, incomplete systolic valve available a 2-5 MHz general-purpose curved
closure, absence of valve motion, array abdominal probe, preferably with a small
absence of ventricular motion, finally foot-print, will suffice. The cardiac presets
culminating in intracardiac gel-like available on most equipment may be activated
densities. The lack of mechanical to optimize cardiac images. Doppler capability
cardiac activity, or true cardiac may be helpful in certain extended emergency
standstill, demonstrated by EUS has echo indications but is not routinely used for
the gravest of prognoses. The decision the primary cardiac EUS indications. Both
to terminate resuscitative efforts portable and cart-based ultrasound machines
should be made on clinical grounds in may be used, depending on the location and
conjunction with the sonographic setting of the examination.
findings.
iv. Evaluation of global cardiac function. 7. Quality Control and Improvements, Safety,
Published investigations demonstrate Infection Control and Patient Education
that emergency physicians with Policies and procedures related to quality,
relatively limited training and safety, infection control and patient education
experience can accurately estimate should be developed in accordance with
cardiac ejection fraction. Left specialty or organizational guidelines. Specific
ventricular systolic function is institutional guidelines may be developed to
typically graded as normal (EF>50%), correspond with such guidelines.
moderately depressed (EF 30-50%), or
severely depressed (EF<30%). Pelvic Ultrasound
1. Introduction
5. Documentation The American College of Emergency
EUS of the heart are interpreted by the treating Physicians (ACEP) has developed these
physician as they are performed and are used criteria to assist practitioners performing
to guide contemporaneous clinical decisions. emergency ultrasound studies (EUS) of the
Such interpretations should be documented in pelvis in emergency patients to evaluate for
the medical record as a dictated, hand-written, evidence of acute pathology including ectopic
or templated note. Documentation should

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pregnancy, ovarian cysts and tubo-ovarian when modifying factors such as


abscess. infertility treatment are not present.
b. Extended
First trimester pregnancy complications such i. Ovarian cysts
as abdominal pain and vaginal bleeding are ii. Fibroids
common presenting complaints in the iii. Tobu-ovarian abscess
emergency department. Ultrasound finding of iv. Ruling out ovarian torsion by ruling
a clear intrauterine pregnancy, in many out cyst or mass
instances, minimizes the possibility of ectopic v. Identifying suspected ectopic
pregnancy and can decrease ED throughput pregnancy
time and decrease morbidity. The scope of
practice for pelvic ultrasound in ED will vary c. Limitations
depending on individual experience, i. Infertility patients or other with
comfort/skill level and departmental policies. specifically known risk factors for
However, some centers may chose to evaluate heterotopic pregnancy.
the ovaries and seek to identify tubo-ovarian ii. Assessing pelvic sonographic anatomy
abscess, fibroids, and pelvic masses. after vaginal-rectal surgery
iii. Evaluation of fetal health outside of
EUS of the pelvis occurs as a component of fetal heart rate determination
the overall clinical examination of a patient
presenting with symptoms related to the pelvic d. Pitfalls
area. It is a clinical focused examination, i. Ovarian torsion evaluation in the
which, in conjunction with historical and presence of ovarian, para-ovarian,
laboratory information, provides additional tubal or para-tubal mass
data for decision-making. It attempts to ii. Ovarian mass evaluation for presence
answers specific questions about a particular of malignancy versus benign mass
patient’s condition. Other diagnostic tests may iii. Interstitial pregnancy
provide more detailed information than EUS, iv. Presence of ovarian torsion due to a
show greater anatomic detail, or identify mass or cyst in first trimester patient
alternative diagnoses. However, EUS is non- with identified intrauterine pregnancy
invasive, rapidly deployed, allows the patient
to remain in the ED, and avoids delays, costs, 3. Qualifications and Responsibilities of the
specialized technical personnel, and bio- Performing Medical Professional
hazardous potentials of radiation and contrast Pelvic EUS provides information that is the
agents. These advantages make it a valuable basis of immediate decisions concerning
addition to the diagnostic resources available further evaluation, management, and
to the emergency physician caring for patients therapeutic interventions. Because of the
with time-sensitive or emergency conditions direct bearing on patient care, the rendering of
such as ectopic pregnancy and other causes of a diagnosis by EUS represents the practice of
acute pelvic pain. medicine, and therefore is the responsibility of
the supervising physician.
2. Indications/Limitations:
a. Primary Due to the time-critical and dynamic nature of
i. To evaluate for the presence of ectopic pregnancy and other pathologic
intrauterine pregnancy, minimizing conditions of the pelvis, emergency
the likelihood of an ectopic pregnancy interventions may be mandated by the
diagnostic findings of the EUS of the pelvis.

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For this reason, EUS of the pelvis should 5 to 7 mm (exact minimum


occur as soon as the clinical decision is made normal distance varies from
that the patient needs a sonographic reference to reference) from the
evaluation. edge of the myometrium is
concerning for being an interstitial
Physicians of a variety of medical specialties ectopic pregnancy.
may perform EUS of the pelvis. Training 2. Cul-de-sac. The cul-de-sac or
should be in accordance with specialty or pouch of Douglas may contain a
organizational specific guidelines. Physicians small to moderate amount of fluid
should render a diagnostic interpretation in a in the healthy female pelvis
time frame consistent with the management of depending on her point in the
acute presentations related to the pelvic area, menstrual cycle. Large amounts of
as outlined above. fluid are abnormal but may not be
tied to significant pathology.
4. Specifications for the performance and When an ectopic pregnancy is of
interpretation of EUS of the pelvis concern, a significant amount of
a. General – Organs and structures evaluated fluid in the pouch of Douglas
by pelvic EUS are scanned systematically raises the concern for rupture.
in real time through all tissue planes in at Echogenic fluid in the pelvis may
least two orthogonal directions. The be consistent with either pus or
primary focus of the pelvic EUS is the blood.
identification on an intrauterine 3. Ovaries. The ovaries should also
pregnancy. Pelvic sonographic evaluations be scanned in at least two planes,
for other pelvic pathology, as described in short and long axis, completely
“Extended Indications”, are performed through each of the paired organs.
based on the clinical situation and This should provide a good view
appropriate emergency physician’s of possible masses next to an
sonographic experience. ovary as well as cysts located on
the periphery of an ovary. In the
b. Technique first trimester patient with pain
i. Identification evaluating the ovaries may
1. Uterus. The uterus should be identify an unexpected cause for
examined in at least two planes, pain despite having an intrauterine
the short and long axis, to avoid pregnancy. For instance ovarian
missing important findings that masses or cysts that may in
may lie off of the center or themselves cause pain or have led
endometrial canal, such as in an to torsion of the ovary.
interstitial pregnancy or fibroids. 4. Fallopian tubes. The normal
The uterus should be traced from fallopian tube can be visualized as
the fundus to the cervix, it originates from the cornua of
confirming that it is actually the the uterus. Visualization can be
uterus that is being scanned rather limited by significant bowel gas
than a gestational reaction from a or enhanced when distended by
large ectopic pregnancy. Fibroids, fluid such as in hyrosalpinx or
which can cause significant pain tubo-ovarian abscess.
and even bleeding, should be
noted. A pregnancy that is with in ii. Real-time scanning technique

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1. Overview. The pelvic ultrasound provides the best overview of the


examination can be performed at pelvis.
the patient’s bedside and when
possible, immediately following 3. Transvaginal. For the transvaginal
the pelvic examination portion of examination, the best imaging is
the physical examination to limit achieved with an empty bladder.
the time a patient spends in the Two possible patient positions
lithotomy position. A chaperone will facilitate endovaginal
should also be present for all scanning. In the first, the patient is
endovaginal examinations. In supine on a stretcher or bed with
most instances, the her legs flexed. Folded sheets or
transabdominal portion of the pads are placed under her buttocks
ultrasound exam should precede to elevate her pelvis above the
the transvaginal component as examination table to allow room
information regarding bladder for transducer manipulation.
fullness, position of the uterus, Alternatively, the patient may be
and anatomic variations can be examined on a pelvic examination
appreciated. As well, in a certain table with her feet in stirrups. The
percentage of patients, an probe may be placed in the vagina
intrauterine pregnancy will be by the patient or the examiner.
documented, thereby minimizing The uterus is examined entirely in
the need to perform the two planes. When in the sagittal
endovaginal ultrasound exam. plane, the examiner sweeps the
transducer laterally to sides to
2. Transabdominal. The patient lies visualize the uterus in its entirety,
supine on the examination table. because it is often deviated to one
The transducer is placed on the side. The transducer is then
lower abdomen just above the rotated 90 degress
symphysis pubis and the pelvic counterclockwise to obtain a
organs are examined through a coronal view. The transducer can
window of the distended bladder. then be angled anteriorly,
Bladder filling is ideal when the posteriorly, and to each side to
bladder dome is just above the obtain a full assessment of the
uterine fundus. Underdistention uterus.
limits visualization. Images are
obtained in sagittal and transverse After the sagittal and coronal
planes. To optimally image the planes of the uterus have been
uterus, the transducer is aligned fully interrogated, other structures
with the long axis of the uterus, in the pelvis can be visualized,
which is often angled right or left such as the cul-de-sac, fallopian
of the midline cervix. The ovaries tubes, and ovaries. The cul-de-sac
and adnexa are best seen by is inferior to the uterus and the
sliding the transducer to the ovaries are located lateral to the
contralateral side and angling uterus and usually lie anterior to
back toward the ovary of interest. the internal iliac veins and medial
The transabdominal technique to the external iliac vessels.

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5. Documentation Renal
EUS of the pelvis are interpreted by the 1. Introduction
treating physician as they are performed and The American College of Emergency
are used to guide contemporaneous clinical Physicians (ACEP) has developed these
decisions. Such interpretations should be criteria to assist practitioners performing
documented in the medical record as a emergency ultrasound studies (EUS) of the
dictated, hand-written, or templated note. kidneys and bladder in patients suspected of
Documentation should include the indication having diseases involving the urinary tract.
for the procedure, a description of the organs
or structures studied and an interpretation of Emergency ultrasound of the kidneys and
the findings. Whenever feasible, images urinary tract may identify both normal and
should be stored as part of the medical record pathological conditions. The primary
and done so in accordance with facility policy indications for this application of EUS are in
requirements. Given the often emergent nature the evaluation of obstructive uropathy and
of such ultrasound examinations, the timely acute urinary retention. The evaluation of
delivery of care should not be delayed by the perirenal structures and the peritoneum for
archiving of ultrasound images. perirenal fluid is considered in the criteria for
Trauma EUS.
6. Equipment specifications
A curved linear array abdominal transducer EUS of the kidneys and urinary tract occurs as
with a range of approximately 3 to 5 MHz as a component of the overall clinical evaluation
well as an endovaginal transducer with an of a patient with possible urinary tract disease.
approximate range of 4 to 8 MHz is used for It is a clinically focused examination, which,
pelvic EUS. Color or power Doppler and in conjunction with historical and laboratory
pulsed wave Doppler are critical if an information, provides additional data for
assessment of blood flow will be made. Both decision-making. It attempts to answer
portable and cart-based ultrasound machines specific questions about a particular patient’s
may be used, depending on the location and condition. While other tests may provide
setting of the examination. There is no information that is more detailed than EUS,
indication to interrogate the fetus with pulsed have greater anatomic specificity, or identifies
wave Doppler, consequently high energy alternative diagnoses, EUS is non-invasive, is
ultrasound use should be avoided. Further, all rapidly deployed and does not entail removal
pelvic ultrasound studies should be kept to a of the patient from the resuscitation area.
reasonably limited amount of time when Further, EUS avoids the delays, costs,
sensitive tissue such as the fetus is involved. specialized technical personnel, the
administration of contrast agents and the
7. Quality Control and Improvements, Safety, biohazardous potential of radiation. These
Infection Control, and Patient Educations and advantages make EUS a valuable addition to
Concerns available diagnostic resources in the care of
Policies and procedures related to quality, patients with time-sensitive or emergency
safety, infection control, and patient education conditions such as acute renal colic and
should be developed in accordance with urinary retention.
specialty or organizational guidelines. Specific
institutional guidelines may be developed to 2. Indications/Limitations
correspond with such guidelines. a. Primary

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i. The rapid evaluation of the urinary i. When bowel gas or other technical
tract for sonographic evidence of factors prevent a complete real-time
obstructive uropathy and/or urinary scan through all tissue planes, the
retention in a patient with clinical limitations of the examination should
findings suggestive of these diseases. be identified and documented. As is
customary in emergency practice,
b. Extended such limitations may mandate further
i. Causes of obstructive uropathy evaluation by alternative methods, as
ii. Causes of acute hematuria clinically indicated.
iii. Causes of acute renal failure ii. Hydronephrosis may be mimicked by
iv. Infections and abscesses of the several normal and abnormal
kidneys conditions including dilated renal
v. Renal cysts and masses vasculature, renal sinus cysts, and
vi. Gross bladder and prostate bladder distension. Medullary
abnormalities pyramids may mimic hydronephrosis,
vii. Renal trauma especially in young patients.
iii. Presence of obstruction may be
c. Contraindications: No absolute masked by dehydration.
contraindications exist. Contraindications iv. Absence of hydronephrosis does not
are relative, based on specific features of rule out a ureteral stone. Many
the patient’s clinical condition. ureteral stones, especially small ones,
do not cause hydronephrosis.
d. Limitations v. Patients with an acutely symptomatic
i. EUS of the kidney and urinary tract is abdominal aortic aneurysm may
a single component of the overall and present with symptoms suggestive of
ongoing evaluation. Since it is a acute renal colic.
focused examination EUS does not vi. Both kidneys should be imaged in
identify all abnormalities or diseases order to identify the presence of either
of the urinary tract. EUS, like other unilateral kidney or bilateral disease
tests, does not replace clinical processes.
judgment and should be interpreted in vii. The bladder should be imaged as part
the context of the entire clinical of EUS of the kidney and urinary
picture. If the findings of the EUS are tract. Many indications of this EUS
equivocal additional diagnostic testing exam are caused by conditions
may be indicated. identifiable in the bladder.
ii. Examination of the kidneys and viii. Variations of renal anatomy are not
collecting system may be technically uncommon and may be mistaken for
limited by: pathologic conditions. These include
1. Patient habitus including obesity, reduplicated collection systems,
paucity of subcutaneous fat, unilateral, bipartite, ectopic and horse-
narrow intercostal spaces shoe kidney.
2. Bowel gas ix. Renal stones smaller than 3 mm are
3. Abdominal or rib tenderness usually not identified by current
4. An empty bladder sonographic equipment. Renal stones
of all sizes may be missed and are
e. Pitfalls usually identified by the shadowing
they cause as their echogenicity is

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similar to that of surrounding renal axis. They are paired structures that lie
sinus fat. oblique to every anatomic plane and at
different levels on each side. Their
3. Qualifications and Responsibilities in the inferior poles are anterior and lateral
performance and interpretation of EUS of the to their superior poles. Both hila are
renal system. also directed obliquely. Orientation is
EUS of the kidneys and urinary tract provides defined with respect to the axes of the
information upon which immediate decisions organ of interest (longitudinal,
for further evaluation, management and transverse, and oblique), rather than
interventions are based. Rendering a diagnosis standardized anatomic planes (sagittal,
by EUS impacts patient care directly and coronal, oblique and transverse). The
qualifies as the practice of medicine. long axis of the kidney approximates
Therefore, performing and interpreting EUS is the intercostal spaces and longitudinal
the responsibility of the supervising physician. scans may be facilitated by placing the
transducer plane parallel to the
Due to the time-critical and dynamic nature of intercostal space. By convention the
many conditions of renal pathology, probe indicator is always toward the
emergency interventions may be undertaken head or the vertebral end of the rib on
based upon findings of the EUS exam. For this both the right and left sides.
reason, EUS should occur as soon as the Transverse views of the kidneys are
clinical decision is made that the patient needs therefore usually also transverse to the
a sonographic exam. ribs, resulting in prominent rib
shadows that may make visualizing
Physicians of a variety of medical specialties the kidneys more difficult unless a
may perform renal ultrasound examinations. small footprint or phased array probe
Training should be in accordance with is available. Transverse views are
specialty or organization specific guidelines. obtained on both sides by rotating the
Physicians should render a diagnostic probe 90 degrees counter-clockwise
interpretation in a time frame consistent with from the plane of the longitudinal
the management of acute renal pathology, as axis.
outlined above.
ii. Real-time scanning technique
4. Specifications for EUS of the kidneys and 1. Overview. The kidneys are
urinary tract retroperitoneal in location and are
a. General. An attempt should be made to usually above the costal margin of
image both kidneys and the bladder in the flanks in the region of the
patients with suspected renal tract costovertebral angle. A general-
pathology undergoing EUS. In addition, purpose curved array abdominal
hydronephrosis and urinary retention are probe with a frequency range of
frequently unsuspected causes of between 2-5 MHz is generally
abdominal pain and may be recognized in used. A small footprint or phased
the course of other abdominal or array probe may facilitate
retroperitoneal EUS examinations. scanning between the ribs, but
may require several windows in
b. Technique the longitudinal plane if the
i. Identification. The kidneys are more kidney is long, or superficial.
easily identified in their longitudinal Images of both kidneys should be

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ACEP Policy Emergency Ultrasound Imaging Criteria Compendium
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obtained in the longitudinal and transducer can be moved


transverse planes for purposes of superiorly and medially, or
comparison and to exclude inferiorly and laterally to locate
absence of either kidney. The the renal hilum. Images cephalad
bladder should be imaged to to the hilum represent the superior
assess for volume, evidence of pole and those caudad represent
distal ureteral obstruction and for the inferior pole. The left kidney
calculi. As with other EUS, the lacks the hepatic window,
organs of interest are scanned in necessitating an intercostal
real-time through all tissue planes approach similar to the one
in at least two orthogonal described above for the right
directions. flank.

2. Details of technique. The right The bladder is imaged from top to


kidney may be visualized with an bottom and from side to side, in
anterior subcostal approach using transverse and sagittal planes,
the liver as a sonographic respectively. While a full bladder
window. Imaging may be facilitates bladder scanning,
facilitated by having the patient in distension may be a cause of
the left lateral decubitus position artifactual hydronephrosis and is
or prone. Asking the patient to therefore to be avoided in
take and hold a deep breath may scanning the kidneys. Ideally the
serve to extend the liver window bladder is scanned prior to
so that it includes the inferior pole voiding (and again post-void, if
of the kidney. Despite these outlet obstruction is a
techniques, parts or the entire consideration), and kidney
kidney may not be seen in this scanning performed after voiding.
view due to interposed loops of Such ideal conditions are rarely
bowel, in which case the kidney met with the exigencies of EUS
should be imaged using an and emergency care.
intercostal approach in the right
flank between the anterior axillary 3. Key components of the
line and midline posteriorly. For examination. The kidneys should
this approach the patient can be be studied for abnormalities of the
placed in the decubitus position renal sinus and parenchyma.
with a bolster under the lower side Under normal circumstances, the
with the arm of the upper side renal collecting system contains
fully abducted, thus spreading the no urine, so that the renal sinus is
intercostal spaces. Separate views a homogeneously hyperechoic
of the superior and inferior poles structure. A distended bladder can
are often required to adequately cause mild hydronephrosis in
image the entire kidney in its normal healthy adults. Several
longitudinal plane. To obtain classifications of hydronephrosis
transverse images, the transducer have been suggested. One that is
is rotated 90 º counter-clockwise easily applied and widely utilized
from the longitudinal plane. Once is Mild or Grade I (any
in the transverse plane, the hydronephrosis up to Grade II),

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ACEP Policy Emergency Ultrasound Imaging Criteria Compendium
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Moderate or Grade II (the calices


are confluent resulting in a “bear’s 7. Quality Control and Improvements, Safety,
paw” appearance), or Severe or Infection Control and Patient Education
Grade III (the hydronephrosis is Policies and procedures related to quality,
sufficiently extensive to cause safety, infection control and patient education
effacement of the renal should be developed in accordance with
parenchyma). Other abnormalities specialty or organizational guidelines. Specific
identified including cysts, masses institutional guidelines may be developed to
and bladder abnormalities may correspond with such guidelines.
require additional diagnostic
evaluation. Measurements may be Trauma
made of the dimensions of 1. Introduction
abnormal findings and the length The American College of Emergency
and width of the kidneys. Such Physicians (ACEP) has developed these
measurements are rarely relevant criteria to assist practitioners who are
in the focused EUS examination. performing emergency ultrasound studies
(EUS) of the torso of the injured patient and
5. Documentation commonly referred to as the Focused
EUS of the kidneys and urinary tract are Assessment by Sonography in Trauma (FAST)
interpreted by the treating physician as they exam.
are performed and are used to guide
contemporaneous clinical decisions. Such Trauma ultrasound is used to evaluate the
interpretations should be documented in the peritoneal, pericardial or pleural spaces in
medical record as a dictated, hand-written, or anatomically dependent areas by combining
templated note. Documentation should include several separate focused ultrasound
the indication for the procedure, a description examinations of the chest, heart, abdomen and
of the organs or structures studied and an pelvis. Since a variety of formats and content
interpretation of the findings. Whenever have been advocated for the FAST exam, and
feasible images should be stored as a part of because this document considers some
the medical record and done so in accordance applications of trauma ultrasonography that
with facility policy requirements. Given the are beyond the scope of the FAST, this
often emergent nature of such ultrasound document will refer to such examinations as
examinations the timely delivery of care “Emergency Ultrasound (EUS) in Trauma,” or
should not be delayed by the archiving of “Trauma EUS.”
ultrasound images.
The primary indication for this application is
6. Equipment Specifications in the identification of pathologic free fluid
A general purpose curved array abdominal released from injured organs or structures.
transducer with a frequency range of between Trauma EUS is performed at the bedside to
2-5 MHz is generally used. A small footprint assess for hemopericardium, hemothorax,
or phased array probe may facilitate scanning hemoperitoneum or other abnormal fluids such
between the ribs. A higher frequency 5.0-7.0 as urine or bile. Free fluid is a marker of
MHz transducer may give better resolution in injury, not the injury itself. Since certain
children and smaller adults. Both portable and important traumatic conditions such as hollow
cart-based ultrasound machines may be used, viscus injury, mesenteric vascular injury,
depending upon the location of the patient and diaphragmatic rupture may cause minimal
the setting of the examination.

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hemorrhage, they can be easily be overlooked and/or emergent conditions associated with
by trauma EUS. Trauma EUS also may not torso trauma.
differentiate between different types of
pathological fluid such as urine and blood. 2. Indications/Limitations
These characteristics of trauma EUS have a. Primary
implications for management of patients in i. To rapidly evaluate the torso for
whom these injuries are a consideration. evidence of traumatic free fluid
suggestive of injury in the peritoneal,
Trauma EUS is performed as an integral pericardial, and pleural cavities.
component of trauma resuscitation. Other
diagnostic or therapeutic interventions may b. Extended
take precedence or may proceed i. Pneumothorax
simultaneously with the EUS evaluation. It is ii. Solid organ injury
a clinically focused examination, which, in iii. Triage of multiple or mass casualties
conjunction with historical and laboratory
information, provides additional data for c. Contraindications
decision-making. It attempts to answer i. There are no absolute
specific questions about a particular patient’s contraindications to trauma EUS.
condition. While other tests may provide There may be relative
information that is more detailed than EUS, contraindications based on specific
have greater anatomic specificity, or identifies features of the patient’s clinical
alternative diagnoses, EUS is non-invasive, is situation, e.g. extensive abdominal or
rapidly deployed and does not entail removal chest wall trauma.
of the patient from the resuscitation area. ii. The need for immediate laparotomy is
Further, EUS avoids the delays, costs, often considered a contraindication to
specialized technical personnel, the trauma EUS; however, even in this
administration of contrast agents and the circumstance, EUS evaluation for
biohazardous potential of radiation. These pericardial tamponade or
advantages make EUS a valuable addition to pneumothorax may be indicated prior
available diagnostic resources in the care of to transfer to the operating room.
patients with time-sensitive or emergency
conditions such as acute thoracic and d. Limitations
abdominal trauma. i. Trauma EUS is a single component of
the overall and ongoing resuscitation.
Trauma EUS is well suited to mass casualty Since it is a focused examination EUS
situations where it can be used to rapidly does not identify all abnormalities
triage multiple victims. It can be performed on resulting from truncal trauma. EUS,
the patient with spinal immobilization and like other tests, does not replace
with portable equipment, allowing it to be clinical judgment and should be
used in remote or difficult clinical situations interpreted in the context of the entire
such as aeromedical transport, wilderness clinical picture. If the findings of the
rescue, expeditions, battlefield settings, and EUS are equivocal additional
space flight. Finally, serial trauma EUS exams diagnostic testing may be indicated.
can be repeated as frequently as is clinically ii. EUS in trauma is technically limited
indicated. These advantages make it a valuable by
addition to diagnostic resources available in 1. Bowel gas
the care of patients with the time-sensitive 2. Obesity

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3. Subcutaneous emphysema viii. Blood clots form rapidly in the


iii. Trauma EUS is likely to be less peritoneum. Clotted blood has
accurate in the following settings sonographic qualities similar to soft
1. Pediatric patients tissue, and may be overlooked.
2. Patients with other reasons for ix. Perinephric fat may be mistaken for
free fluid such as prior diagnostic hemoperitoneum.
peritoneal lavage, ascites, x. Fluid in the stomach or bowel may be
ruptured ovarian cyst, pelvic mistaken for hemoperitoneum.
inflammatory processes xi. Small hemothoraces may be missed in
e. Pitfalls the supine position.
i. When bowel gas or other technical xii. In the evaluation of the pericardium,
factors prevent a complete or adequate epicardial fat pads, pericardial cysts,
exam, these limitations should be and the descending aorta have been
identified and documented. As usual mistaken for free fluid.
in emergency practice, such xiii. Patients with peritoneal or pleural
limitations may mandate further adhesions with significant hemorrhage
evaluation by alternative methods, as may not develop free fluid in the
clinically indicated. normal locations.
ii. Most studies show that peritoneal free xiv. In the suprapubic view, posterior
fluid is not identified by EUS until at acoustic enhancement caused by the
least 500 ml is present. Thus, a bladder can result in pelvic free fluid
negative exam does not preclude early being overlooked. Gain settings
or slowly bleeding injuries. should be adjusted accordingly.
iii. Some injuries may not give rise to free
fluid and may therefore easily be 3. Qualifications and Responsibilities in the
missed by trauma EUS. These include performance and interpretation of Trauma
contained solid organ injuries, EUS
mesenteric vascular injuries, hollow Trauma EUS provides information that is the
viscus injuries, and diaphragmatic basis of immediate decisions about further
injuries. evaluation, management, and therapeutic
iv. Non-traumatic fluid collections such interventions. Because of its direct bearing on
as ascites, or pleural and pericardial patient care, the rendering of a diagnosis by
effusions, which are due to antecedent trauma ultrasound represents the practice of
medical conditions, may be medicine, and therefore is the responsibility of
mistakenly ascribed to trauma. the supervising physician.
Credible history and associated
clinical findings, as well as the Due to the time-critical and dynamic nature of
sonographic features of the free fluid traumatic injury, emergent interventions may
may suggest such conditions. be mandated by the diagnostic findings of
v. Trauma EUS does not specifically EUS examination. For this reason, trauma
identify most solid organ injuries. EUS should be performed as soon as possible
vi. EUS does not identify retroperitoneal (usually minutes) following the decision that
hemorrhage. the patient needs a sonographic evaluation.
vii. A negative trauma EUS is not
accurate in excluding intra-abdominal
Physicians of a variety of medical specialties
injury after isolated penetrating
may perform the FAST examination. Training
trauma.

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ACEP Policy Emergency Ultrasound Imaging Criteria Compendium
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should be in accordance with specialty or quadrant, and suprapubic views. As


organization specific guidelines. Physicians with other EUS, the potential spaces
should render a diagnostic interpretation in a being examined should be scanned
time frame consistent with the management of methodically in real-time through all
acute traumatic injury, as outlined above. tissue planes. If possible, they should
be evaluated in at least two orthogonal
directions. Identification of the
4. Specifications for performance and
potential spaces in a single still image
interpretation of EUS in trauma
or plane is likely to result in early
a. General Trauma EUS is performed
injuries, or those with small volumes
simultaneously with other aspects of
of free fluid, being overlooked.
resuscitation. The transducer is placed
ii. Real-time scanning technique
systematically in each of 4 general regions
1. The right flank. Also known as
with known windows to the peritoneum,
the perihepatic view, Morison’s
pericardium and pleural spaces for
pouch view or right upper
detection of fluid and other sonographic
quadrant view. Four potential
abnormalities. The precise location of
spaces for the accumulation of
these regions varies from patient to
free fluid are examined in this
patient, and is only used as a means to the
region (listed in a cephalad to
real goal of identifying specific potential
caudad direction): the pleural
spaces where pathological collections of
space, the subphrenic space, the
free fluid are known to collect. The
hepatorenal space (Morison’s
transducer is placed in each of the regions
pouch), and the inferior pole of
consecutively and then tilted, rocked and
the kidney, which is a
rotated to allow for real-time imaging of
continuation of the right paracolic
the underlying potential space(s). The
gutter.
ultrasound images obtained are interpreted
in real-time as the exam is being
In this region, the liver usually
performed. If possible, images may be
provides a sonographic window
retained for purposes of documentation,
for all four potential spaces. If the
quality assurance, or teaching.
liver margin is sufficiently low,
the probe can be placed in a
b. Technique
subcostal location in the mid-
i. Overview. The trauma EUS exam
clavicular line. Cooperative
evaluates 4 general regions or “views”
patients may facilitate this by
for free fluid in defined potential
being asked to “take a deep breath
spaces. The order in which the regions
and hold” while the four potential
are examined may be determined by
spaces are examined. In the
clinical factors such as the mechanism
majority of patients the liver does
of injury or external evidence of
not afford an adequate window
trauma. Since scientific investigations
with a subcostal probe position, so
have shown that the single most likely
an intercostal approach is
site for free fluid to be identified is the
necessary. In order to minimize
right upper quadrant, many
rib shadowing, the transducer
practitioners start with this view, and
should be placed in an intercostal
then progress in a clockwise rotation
space in a location between the
through the sub-xiphoid, left upper
mid-clavicular and posterior

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ACEP Policy Emergency Ultrasound Imaging Criteria Compendium
Statement Page 28

axillary lines, with the plane of stretcher. This requires firm


the probe parallel with the ribs. downward pressure, especially in
This plane is about 45 degrees patients with a protuberant
counter-clockwise from the long abdomen, in order to obtain a
axis of the patient’s body. The view posterior to the sternum
probe indicator, by convention, is (“under” the sternum) in the
always directed toward the head supine patient. Both sagittal and
(the vertebral end) of the rib. By transverse planes may be used.
angling the probe superiorly, the Many find the transverse plane
subhepatic space and the right easier, especially in obese
pleural space may be visualized patients, since it requires slightly
for fluid. Abnormal fluid less compression of the abdominal
collections in the pleural space are wall to obtain adequate views.
visualized as anechoic or The potential space of the
hypoechoic collections above the pericardial sac is examined for
diaphragm. fluid both inferiorly (between the
diaphragmatic surface and the
Angling inferiorly allows inferior myocardium) and
visualization of Morison’s pouch posteriorly. Slight angulation in a
and may show the inferior pole of caudal direction when the probe is
the right kidney. In many patients, held in a transverse orientation
bowel gas is interposed between allows visualization of the IVC
the liver and the inferior pole of and hepatic veins including their
the kidney, necessitating a more normal respiratory variability. In
posterior approach to visualize some patients, a subxiphoid view
this space. is not possible due to anterior
abdominal trauma, or body
Gain settings should be adjusted habitus. In this case, other
so that the diaphragm and renal routinely used cardiac windows
sinus fat appear white, and known such as the parasternal or apical
hypoechoic structures (such as the four-chamber views may be used.
inferior vena cava, GB, or renal These are described in the
vein) appear black. Guideline to Cardiac EUS.

2. The pericardial view. Also known 3. Left flank. In this view, also
as the subcostal or subxiphoid known as the perisplenic or left
view. To examine the upper quadrant view, four
pericardium, the liver in the potential spaces are
epigastric region is most sonographically explored,
commonly used as a sonographic analogous to the right upper
window to the heart. The heart quadrant view. These four spaces
lies immediately behind the are: the pleural space, the
sternum, so that it is necessary, in subphrenic space, the splenorenal
a supine patient, to direct the space, and the inferior pole of the
probe in a direction toward the left kidney, which is a continuation of
shoulder that is almost parallel the left paracolic gutter. This view
with the horizontal plane of the can make some use of the spleen

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as a sonographic window, but, supine position. A full bladder is


being so much smaller, it provides ideal to visualize the potential
a much more limited window than spaces in the pelvis, but adequate
the liver on the right. For this views can often be obtained with a
reason the posterior intercostal partly filled bladder. When the
approach described for the right bladder is empty, large volumes of
upper quadrant is utilized anechoic or hypoechoic free fluid
extensively in the left upper may still be seen, however it is not
quadrant. In order to avoid the gas possible to reliably rule out the
filled splenic flexure and presence of smaller amounts of
descending colon it is usually free fluid. The probe is placed in
necessary to place the probe on the transverse plane immediately
the posterior axillary line or even cephalad to the pubic bone. This
more posteriorly. As is the case on maximizes the sonographic
the right side, the probe indicator, window afforded by the bladder.
by convention, is always directed The probe is rocked from inferior
toward the head (the vertebral to the dome of the bladder in a
end) of the rib. This requires that, systematic manner through all
on the left, the probe is rotated tissue planes. The probe may be
approximately 45 degrees rotated 90 degrees counter-
clockwise from the long axis of clockwise into the sagittal plane
the patient’s body. Angulation for additional visualization of the
superiorly allows visualization of bladder and pelvic peritoneum.
the left pleural space. As on the
right, the pleural spaces are Gain settings usually need to be
investigated for evidence of decreased in this view to account
hemothorax by looking for for the posterior acoustic
anechoic or hypoechoic enhancement caused by the fluid-
collections above the diaphragm. filled bladder.
In order to visualize the inferior
pole of the left kidney and the iii. Additional windows
superior extent of the left 1. Paracolic gutters. These potential
paracolic gutter, it is usually spaces are anatomically
necessary to move the probe one continuous with the hepatorenal
to three rib spaces in a caudal and splenorenal spaces. Windows
direction. In each rib space, the inferior to the level of kidneys and
probe is systematically swept next to the iliac crests may reveal
through all planes in a search for bowel surrounded by fluid.
free fluid. 2. Anterior pleural. In non-collapsed
lung, the anterior visceral and
4. Pelvic. Also known as the parietal pleura are intimately
suprapubic view, retrovesical, and apposed, and slide past one
rectovesical view (in the male), another during respiration.
and the retrouterine, rectouterine, Absence of identifiable pleural
and pouch of Douglas view (in the sliding is indicative of separation
female). This space is the most of the parietal–visceral pleural
dependent peritoneal space in the interface by interposed gas, i.e.

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pneumothorax. In the supine and smaller adults. A small footprint may


position, the anterior pleura are facilitate scanning between the ribs. A depth
examined by placing the probe in of field of up to 25 cm may be required in
a sagittal plane in the rib order to adequately visualize deeper structures
interspaces between the clavicle in the right upper quadrant in large patients.
and diaphragm. The approximate Both portable and cart-based ultrasound
midclavicular line is used on both machines may be used, depending on the
sides. It is necessary to adjust location and setting of the examination.
frequency, depth, focus and gain
settings to optimally image these 7. Quality Control and Improvements, Safety,
superficial structures. Infection Control and Patient Education
iv. Other considerations Policies and procedures related to quality,
Trendelenburg and sitting position safety, infection control and patient education
may increase the sensitivity of the should be developed in accordance with
ultrasound exam for abnormal fluid in specialty or organizational guidelines. Specific
the right upper quadrant and pelvis, institutional guidelines may be developed to
respectively. Serial trauma EUS may correspond with such guidelines.
be performed in response to changes
in the patient’s condition, to check for Ultrasound-Guided Procedures
the development of previously 1. Introduction
undetectable volumes of free fluid or The American College of Emergency
for purposes of ongoing monitoring, Physicians (ACEP) has developed these
as indicated clinically. criteria to assist to practitioners utilizing
emergency ultrasound (EUS) to facilitate the
5. Documentation performance of procedures in the emergency
Trauma ultrasounds are interpreted by the patient.
treating physician as they are performed and
are used to guide contemporaneous clinical Ultrasound has been shown to be helpful in
decisions. Such interpretations should be determining patency of vascular structures and
documented in the medical record as a with the placement of central lines as well as
dictated, hand-written, or templated note. peripheral lines. The Agency for HealthCare
Documentation should include the indication Research and Quality highlighted ultrasound
for the procedure, a description of the organs guided central lines as a key intervention that
or structures studied and an interpretation of should be implemented immediately into
the findings. Whenever feasible, images twenty-first century patient care. This focus on
should be stored as a part of the medical patient safety will promote procedural
record and done so in accordance with facility ultrasound as it enables trained operators
policy requirements. Given the often emergent toward a “one stick” standard. These
nature of such ultrasound examinations the ultrasound examinations are performed at the
timely delivery of care should not be delayed bedside to identify vascular anatomy and
by the archiving of ultrasound images. guide direct visualization and cannulation of
vessels.
6. Equipment Specifications
Generally, a curvilinear abdominal or phased Additional procedural uses include ultrasound
array cardiac ultrasound probe at frequencies to assess for potential abscess formation and to
of 2.0-5 MHz with a mean of 3.5 MHz will be drain fluid collections that accumulate
used for an adult and 5.0 MHz for children

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ACEP Policy Emergency Ultrasound Imaging Criteria Compendium
Statement Page 31

pathologically in various potential spaces. 5. peritoneal fluid (paracentesis)


Confirming fracture reduction and 6. joint effusion (arthrocentesis)
endotracheal tube placement, assessing 7. cerebrospinal fluid (lumbar
bladder volume and directing aspiration, as puncture)
well as facilitating lumbar puncture or ii. To evaluate for and localize with
pacemaker placement are other potential uses ultrasound:
of procedural ultrasound. 1. soft tissue foreign bodies
2. pacemaker placement and capture
The advantages of procedural ultrasound 3. fracture reduction
includes, improved patient safety, decreased 4. endotracheal tube placement
procedural attempts, and decreased time to
perform many procedures in patients whom c. Limitations
the technique would otherwise be difficult. It i. Procedural ultrasound is an adjunct to
is important to recognize that procedural care. No modality is absolutely
ultrasound is a method to identify relevant accurate. Procedural ultrasound
anatomy and pathology before proceeding should be interpreted and utilized in
with invasive procedures while aiding the the context of the entire clinical
accurate execution and minimizing procedural picture.
complications. Procedural ultrasound is an ii. Procedural ultrasound may be
adjunct to emergency care. technically limited by:
1. obese habitus
2. Indications/Limitations 2. subcutaneous air
a. Primary
i. Vascular access d. Pitfalls
1. To identify central venous i. Needle localization and its associated
structures, their relative location artifact must be visualized before
and their patency in facilitating proceeding with any procedure. The
placement of central venous short axis transverse approach allows
catheters. only a cross section of the needle to be
2. To identify peripheral venous visualized by the ultrasound beam and
structures, their relative location may lead to errors in depth perception
and patency in facilitating of the needle. The long axis
placement of peripheral venous orientation allows the operator to trace
access. the entire path and angle of the needle
3. To identify arterial structures, from the entry site at the skin and is
their relative location and flow preferred when this transducer
characteristics in facilitating orientation is possible.
placement of arterial lines. ii. It is important to identify a vessel by
multiple means before attempting
b. Extended cannulation. The difference between
i. To evaluate for and/or drain with veins and arteries can be determined
ultrasound guidance or localization: by compressibility (veins compress),
1. soft tissue abscess shape (arteries tend to be circular in
2. peritonsillar abscess transverse view, with muscular walls)
3. pericardial effusion and flow dynamics if Doppler is
(pericardiocentesis) available and/or utilized.
4. pleural effusion (thoracentesis)

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ACEP Policy Emergency Ultrasound Imaging Criteria Compendium
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iii. Many times abnormal structures can imaging the patient through key
be compared to adjacent tissue or to components of the procedure.
the other normal side. If questions ii. Real-Time: The ultrasound transducer
persist about the sonographic is placed in a sterile covering and the
appearance of a structure, another key components of the procedure are
imaging modality may be warranted. performed with simultaneous
ultrasound visualization during the
3. Qualifications and Responsibilities of the procedure (e.g. using ultrasound to
Performing Medical Professional visualize a needle entering a vessel)
Physicians of a variety of medical specialties
may perform procedural ultrasound. Training c. Procedural ultrasound examinations
should be in accordance with specialty or i. Internal jugular vein
organization specific guidelines. ii. Femoral vein
iii. Subclavian vein
4. Specifications for Individual Examinations iv. External jugular vein
a. General – Ultrasound can be used to both v. Brachial and cephalic veins
localize the relevant anatomy and vi. Arterial cannulation
pathology before executing the procedure
in a sterile manner, or with sterile probe d. Additional Procedures
covers and real-time assessment. All i. Soft tissue abscess drainage
invasive procedures should employ ii. Peritonsillar abscess drainage
standard sterile techniques to diminish the iii. Pericardiocentesis
risk of infection. A high frequency iv. Pleurocentesis
ultrasound probe is placed over the v. Paracentesis.
anatomy of interest in both a sagittal and vi. Arthrocentesis
transverse plane. The probe should be vii. Lumbar puncture
initially placed at the primary window and viii. Fracture reduction
then be tilted, rocked and rotated to allow ix. Endotracheal tube confirmation
for real-time imaging of the area(s) x. Bladder volume assessment-
involved. This may take more time with suprapubic aspiration
difficult windows, challenging patients or
other patient priorities. Interpretation 5. Documentation
should be done at the bedside immediately Procedural ultrasound requires documentation
with performance of the real-time of the ultrasound assisted procedure either as a
examination. dictated, hand-written, or templated note.
Documentation should include the indication
b. Procedural ultrasound techniques- for the procedure, a description of the organs
Ultrasound guidance or ultrasound or structures identified and an interpretation of
assisted procedures can be performed the findings. Whenever feasible, images
using either of two accepted techniques: should be stored as a part of the medical
i. Static: Anatomic structures are record and in accordance with facility policy
identified and an insertion position is requirements. Given the often emergent nature
identified with ultrasound. The of such ultrasound procedures, the timely
procedure then proceeds as it would delivery of care should not be delayed by the
without ultrasound and is not archiving of ultrasound images.
performed with the transducer
6. Equipment Specifications

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Multiple probes can be used yet high focused on the evaluation of proximal lower
frequency (7.0-12 MHz) linear array extremity DVT using this technique. It is
transducers work best to image superficial and recognized that many emergency physicians
vascular structures. Microconvex endoluminal have access to equipment with color flow and
probes can be used to identify abscess Doppler capabilities, and are experienced in its
formation in areas such as the oropharynx. use. It is likely that they will augment their
Portable and cart-based ultrasound machines venous EUS with this technology.
may be used, depending on the location and
setting of the examination. Lower extremity venous EUS is performed
and interpreted in the context of the entire
7. Quality Control and Improvements, Safety, clinical picture. It is a clinically focused
Infection Control and Patient Education examination, which, in conjunction with
Policies and procedures related to quality, historical and laboratory information, provides
safety, infection control and patient education additional data for decision-making. It
should be developed in accordance with attempts to answer specific questions about a
specialty or organizational guidelines. Specific particular patient’s condition. EUS of the
institutional guidelines may be developed to lower extremities does not identify all
correspond with such guidelines. abnormalities or diseases of the deep venous
system. If the findings of lower extremity
Venous Thrombosis venous EUS exam are equivocal, further
1. Introduction imaging or testing may be needed.
The American College of Emergency
Physicians (ACEP) has developed these 2. Indications/Limitations
criteria to assist practitioners performing a. Primary
emergency ultrasound studies (EUS) of the i. Evaluation for acute proximal DVT in
venous system in the evaluation of venous the lower extremities.
thrombosis.
b. Extended
The primary application of venous EUS is in i. Chronic DVT
evaluation of deep venous thrombosis (DVT) ii. Distal DVT
of the proximal lower extremities. Lower iii. Superficial venous thrombosis
extremity venous EUS differs in two iv. Diagnosis of other causes of lower
fundamental aspects from the “Duplex” extremity pain and swelling under
evaluation performed in a vascular laboratory. consideration in the evaluation of
First, its anatomic focus is limited to two DVT such as cellulitis, abscess,
specific regions of the proximal deep venous muscle hematoma, fasciitis, Baker’s
system. Second, its sonographic technique cyst
consists primarily of dynamic evaluation of v. Upper extremity venous thrombosis
venous compressibility in real time. This
approach to lower extremity proximal venous c. Contraindications
EUS is often referred to as “limited i. Known, acute proximal DVT. If an
compression ultrasonography” (LCU). Since ultrasound examination would not
B-mode (gray-scale) equipment is widely have any bearing on clinical decision-
available, and because substantial scientific making, it should not be performed.
evidence supports the use of limited ii. Other contraindications are relative,
compression ultrasonography, this guideline is based on specific features of the
patient’s clinical condition.

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ACEP Policy Emergency Ultrasound Imaging Criteria Compendium
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lead to both false positive and false


d. Limitations negative results.
i. EUS of the lower extremity deep iv. While thrombus may be directly
venous system is a single component visualized on examination, it is
of the overall and ongoing evaluation. frequently isoechoic to unclotted
Since it is a focused examination EUS blood and failure to see echogenic clot
does not identify all abnormalities or should not be used to exclude the
diseases of the lower extremity veins. diagnosis of DVT.
EUS, like other tests, does not replace v. Inguinal lymphadenopathy may be
clinical judgment and should be mistaken for a non-compressible
interpreted in the context of the entire common femoral vein.
clinical picture. If the findings of the vi. Failure to arrange for repeat venous
EUS are equivocal additional evaluation in patients with suspicion
diagnostic testing may be indicated. for isolated calf or distal DVT.
ii. A prior history of DVT may limit the vii. Failure to consider the possibility of
utility of LCU. The chronic effects of iliac or inferior vena cava obstruction
DVT are highly variable in extent, as a cause for LE pain or swelling.
location, timing and morphology. A While color flow and Doppler
completely normal venous EUS exam techniques may identify the presence
is likely to exclude both acute and of these conditions, they are beyond
chronic DVT. However, the the usual scope of the EUS exam.
interpretation of abnormal findings in viii. A negative scan for a lower extremity
patients with a history of prior DVT DVT does not rule out the presence of
may be outside the scope of a lower pulmonary embolism.
extremity venous EUS examination. ix. Not recognizing that the superficial
iii. Examination can be limited by: femoral vein is part of the deep
1. Obesity venous system. This sometimes
2. Local factors such as tenderness, confusing terminology has resulted in
sores, open wounds, or injuries some authorities referring to the
3. The patient’s ability to cooperate superficial femoral vein as simply the
with the exam femoral vein.

e. Pitfalls 3. Qualifications and Responsibilities of the


i. A non-compressible vein may be Performing Medical Professional
mistaken for an artery, leading to a Limited compression ultrasound of the venous
false negative result. system provides information that is the basis
ii. An artery may be mistaken for a non- of immediate decisions concerning the
compressible vein, leading to a false patient’s evaluation, management, and
positive result. therapy. Because of its direct bearing on
iii. Large superficial veins may be patient care, the rendering of a diagnosis by
mistaken for deep veins. This pitfall is venous EUS represents the practice of
more likely in obese patients and medicine, and therefore is the responsibility of
those with occlusive DVT causing the supervising physician.
distension in the collateral superficial
veins. Depending on the
Due to the potential for life-threatening
compressibility of the vein, this can
complications arising from acute DVT,

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ACEP Policy Emergency Ultrasound Imaging Criteria Compendium
Statement Page 35

emergent interventions may be mandated by cm distal to the popliteal crease.


the diagnostic findings of the EUS exam. For Continuing proximally, the popliteal
this reason, EUS exam should occur as soon as vein becomes the superficial femoral
the clinical decision is made that the patient vein as it passes through the adductor
needs a sonographic evaluation. canal approximately 8-12 cm
proximal to the popliteal crease. The
superficial femoral vein joins the deep
Physicians of a variety of medical specialties
femoral vein to form the common
may perform a lower extremity limited
femoral vein approximately 5-7 cm
compression exam. Training should be in
below the inguinal ligament. Prior to
accordance with specialty or organization
passing under the inguinal ligament to
specific guidelines. Physicians should render a
form the external iliac vein, the
diagnostic interpretation in a time frame
common femoral is joined by the great
consistent with the management of acute
saphenous vein (a superficial vein)
DVT, as outlined above.
merging from the medial thigh. In
relation to the companion arteries, the
4. Specifications for Individual Examinations
popliteal vein is superficial to the
a. General Emergency ultrasound for the
artery. The common femoral vein lies
diagnosis of DVT evaluates for
medial to the artery only in the region
compressibility of the lower extremity
immediately inferior to the inguinal
deep venous system with specific attention
ligament. The vein abruptly runs
directed towards the common femoral and
posterior to the artery distal to the
popliteal veins.
inguinal region.
b. Technique
ii. Compression. The sonographic
i. Identification of veins. For the
evaluation is performed by
purposes of lower extremity EUS, the
compressing the vein directly under
proximal deep veins of the lower
the transducer while watching for
extremity are those in which thrombus
complete apposition of the anterior
poses a significant risk of pulmonary
and posterior walls. If complete
embolization. These include the
compression is not attained with
common femoral, superficial femoral,
sufficient pressure to cause arterial
and popliteal veins. It is important to
deformation, obstructing thrombus is
note that the superficial femoral vein
likely to be present.
is part of the deep system, not the
superficial system as the name
iii. Patient positioning. To facilitate the
suggests. Conversely the deep femoral
identification of the veins and test for
(profunda femoris) vein is not
compression, they need to be
considered to be a source of
distended. This is accomplished by
embolizing thrombi, and is therefore
placing the lower extremities in a
not included in the evaluation for
position of dependency preferably by
DVT.
placing the patient on a flat stretcher
in reverse Trendelenberg. If the
In the distal leg, the popliteal vein is
patient is on a gurney where this is not
formed by the confluence of the
possible, the patient should be placed
anterior and posterior tibial veins with
semi-sitting with 30 degrees of hip
the peroneal vein approximately 4-8
flexion.

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and deep branches and 1 – 2 cm


iv. Transducer. A linear array vascular beyond, since branch points are
probe with a frequency of 6 – 10 MHz particularly susceptible to
and width of 6 – 8 cm is often ideal. thrombosis. If difficulty is
Narrower transducers may make it encountered in following the
harder to localize the veins and to common femoral vein to the
apply uniform compression. For larger bifurcation, or in clearly
patients, a lower frequency or even an identifying the two branching
abdominal probe will facilitate greater vessels, techniques to optimize the
tissue penetration. angle of interrogation should be
used. In equivocal cases,
v. Real-time scanning technique. comparison with the contralateral
1. The common femoral vein. Gel is side may be helpful.
applied to the groin and medial
thigh for a distance about 10 2. The popliteal vein. The patient
centimeters distal to the inguinal can be placed in either a prone or
crease. Filling of the common decubitus position. In the latter
femoral vein might be augmented case, the knee is flexed 10 – 30
by placing a small bolster under degrees, and the side of the leg
the knee resulting in slight (about being examined should be down.
10 degrees) hip flexion. Mild If the patient is prone, placing a
external rotation of the hip (30 bolster under the ankle to flex the
degrees) may also be helpful. The knee to about 15 degrees
vein and artery may have almost facilitates filling of the popliteal
any relationship with one another, vein. Again reverse Trendelenberg
although the vein is frequently positioning promotes venous
seen posterior to the artery. filling. Gel is applied from about
Distinction of the two vessels may 12 centimeters superior, to 5
therefore depend on size (the vein centimeters inferior to the
is usually larger), shape (the vein popliteal crease. The vein usually
is more ovoid) and lies superficial to the artery. Both
compressibility. If color-flow or vessels lie superficial to the boney
Doppler is utilized characteristic structures, which can be used as
signatures can help with landmarks to anticipate the depth
differentiation. of the vessels. If difficulty is
encountered in identifying the
Compressive evaluation of the terminal branches of the popliteal
vessel commences at the highest vein, it is possible that the patient
view obtainable at the inguinal has one of the common variants of
ligament. Angling superiorly, a venous anatomy. In the absence of
short section of the distal common clear anatomic identification of
iliac vein might be scanned. the termination of the popliteal
Systematic scanning, applying vein, the major venous structures
compression every centimeter, should be imaged to
should be continued to the approximately 7 centimeters
bifurcation of the common below the popliteal crease. In
femoral vein into its superficial equivocal cases, comparison with

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ACEP Policy Emergency Ultrasound Imaging Criteria Compendium
Statement Page 37

the contralateral side may be accordance with facility policy requirements.


helpful. Since the LCU exam is a dynamic test,
repeated multiple times over the lengths of the
vi. Additional components of the exam. common femoral vein and popliteal vein, it is
1. The superficial femoral vein. As not practical in the emergency setting to obtain
noted previously, this vein is not a a still image record of each site evaluated with
primary focus of the standard and without compression. If still image
lower extremity EUS evaluation. records are obtained for documentation, one or
In cases where there is a high more representative images of each vein,
suspicion of DVT and an reflecting the key findings with and without
otherwise normal exam of the compression, should be recorded.
common femoral and popliteal
veins, the superficial femoral vein 6. Equipment Specifications
may also be evaluated. A linear array vascular probe with a frequency
2. Color flow and Doppler. Color of 6 – 10 MHz and width of 6 – 8 cm is often
flow and Doppler assessment may ideal. Narrower transducers may make it
be used to localize the vessels, harder to localize the veins and to apply
although the use of this uniform compression. For larger patients, a
technology is beyond the scope of lower frequency or even an abdominal probe
the standard EUS exam. will facilitate greater tissue penetration. Color
or power Doppler capabilities may be of
vii. Gray scale identification of clot. assistance in localizing venous structures.
While thrombus may be hyperechoic, Both portable and cart-based ultrasound
and thus directly visualized on exam, machines may be used, depending on the
it is also frequently isoechoic to location and setting of the examination.
unclotted blood. Consequently, failure
to see echogenic clot should not be 7. Quality Control and Improvements, Safety,
used to exclude the diagnosis of DVT. Infection Control and Patient Education
Policies and procedures related to quality,
5. Documentation safety, infection control and patient education
In performing venous EUS, images are should be developed in accordance with
interpreted by the treating physician as they specialty or organizational guidelines. Specific
are acquired and are used to guide institutional guidelines may be developed to
contemporaneous clinical decisions. Image correspond with such guidelines.
documentation should be incorporated into the
medical record as a dictated, hand-written, or
templated note. Documentation should include
the indication for the procedure, the views
obtained, a description of the structures
studied and an interpretation of the findings.
Limitations of the exam, and impediments to
performing a complete exam should be noted.
The written report of the venous EUS should
document the presence of complete, partial or
absent collapse in each vein examined.
Whenever feasible, images should be stored as
a part of the medical record and done so in

American College of Emergency Physicians ! PO Box 619911 ! Dallas, TX 75261-9911 ! 972-550-0911 ! 800-798-1822