| |

Received: 18 May 2019    Revised: 16 July 2019    Accepted: 18 July 2019

DOI: 10.1111/echo.14451

REVIEW

Point‐of‐care ultrasound with pocket‐size devices in emergency

department

Costantino Mancusi MD1  | Maria Viviana Carlino MD2 | Alfonso Sforza MD2

1
Hypertension Research Center, Department
of Advanced Biomedical Science, Federico II Abstract
University Hospital, Naples, Italy Point‐of‐care ultrasound is a useful tool for clinicians in the management of patients.
2
Emergency Department, CTO Hospital,
Particularly in emergency department, the role of point‐of‐care ultrasound is strongly
Naples, Italy
increasing due to the need for a rapid assessment of critically ill patients and to speed
Correspondence
up the diagnostic process. Hand‐carried ultrasound devices are particularly useful in
Costantino Mancusi, MD, Hypertension
Research Center, Federico II University emergency setting and allow rapid assessment of patient even in prehospital setting.
Hospital, Via Pansini 5 80131, Naples, Italy.
This article will review the role of point‐of‐care ultrasonography, performed with
Email: costantino.mancusi@unina.it
pocket‐size devices, in the management of patients presenting with acute onset of
undifferentiating dyspnea, chest pain, and shock in emergency department.

KEYWORDS
chest pain, dyspnea, handheld ultrasound, lung ultrasound, POCUS, shock

1 |  BAC KG RO U N D
Point‐of‐care ultrasonography (POCUS), performed at bedside with
portable instruments, allows physician to have a real‐time diagnostic
approach, gaining rapidly diagnostic clues necessary for the manage‐
ment of the patients.1 In the emergency department (ED) and critical
care settings, POCUS is used to guide clinical decision‐making and
critical care interventions with time‐saving approach.2 Its principal
role is to answer a precise clinical question that comes after a compre‐
hensive clinical examination. A presumptive diagnosis that comes from
patient's history and clinical assessment can be easily validated or re‐
fused after a rapid echographic scanning protocol.1 Different studies
have suggested that the use of POCUS can improve the accuracy of
cardiac physical examination done by medical specialists, residents,
and even medical students.3,4 The images are obtained directly at
bedside in real‐time modes, allowing direct correlations with patient's
signs and symptoms.5 Particularly useful is the possibility to repeat the
scanning each time it is required so that success or failure of the ther‐
apeutic approach can be prompt recognized.6 The clinical application
of POCUS is widely recognized across different medical specialties for
diagnostic assessment, procedural guidance, and screening.1
Many different echo machines have been developed during
the last 10 years, with substantial improvement of image quality
and hardware miniaturization. Nowadays, different hand‐carried
devices are available and have been validated for daily clinical prac‐
tice. Particularly, pocket‐size devices have been recently introduced
and have now reached good image quality and resolution, compa‐
rable to traditional echographic apparatus.7,8 The ability of combin‐
ing small size with high‐resolution imaging has led to a widespread
use of small apparatus. Different applications of pocket‐size devices
have been recently introduced, particularly in the setting of ED and
critical care units.9-13 In outpatients setting the use of pocket‐size
devices have demonstrated its usefulness when used by doctors,
nurses, and medical students.14 In low resources settings, the use of
small devices is time saving and has demonstrated its clinical appli‐
cations and impact on patients’ management.15-18
This review explores the role of point‐of‐care ultrasonography,
performed with pocket‐size device, in the management of patients
presenting with acute onset of undifferentiating dyspnea, chest
pain, and shock in emergency department.
2 | FE A S I B I LIT Y O F P O I NT‐ O F ‐ C A R E
U LTR A S O U N D PE R FO R M E D W ITH P O C K E T‐
S IZE D E V I C E S
The widespread use of echography in ED is increasing due to the val‐
uable assistance in the management of critically ill patients. Standard

Echocardiography. 2019;00:1–10. © 2019 Wiley Periodicals, Inc. |  1

wileyonlinelibrary.com/journal/echo  
 |
2       MANCUSI et al.
echocardiographic machines may be difficult to handle in this set‐
ting, even if more accurate information might be obtained. Starting
from early 2000 miniaturized echo machines have become widely
available, introducing a new era in the echographic approach in ED.
Used in outpatient's clinical setting, these machines have demon‐
strated to be reliable in terms of assessment of cardiac size and func‐
tion, inferior vena cava (IVC) evaluation, and detection of pleural and
pericardial effusion.19 Of course, the higher is the expertise of the
physician performing echo, the higher is the accuracy of the informa‐
tion gathered from the pocket‐size device when compared to tradi‐
tional echographic apparatus. 20
Focused cardiac ultrasound (FoCUS) is a noninvasive and repro‐
ducible examination that has great diagnostic and prognostic value
in patients with heart failure, major valve disease, cardiac tampon‐
ade, significant reduction in left ventricular function, and massive
pulmonary embolism. 21 The concordance between PUDs (pocket ul‐
trasound devices) and standard echocardiography has been recently
assessed, and the use of PUDs confirmed to be feasible and reliable
even by medical residents. 22
Different studies have demonstrated that either medical resi‐
dents or medical students, after a short training period, are able to
obtain accurate information with pocket‐size devices, when com‐
pared to traditional echocardiography. 23,24 Specialized nurses in the
management of patients with heart failure have demonstrated to be
able to assess volume status of patients with good accuracy compa‐
rable to that of traditional echocardiography, and this information
has been used in patient's management with improvement in clin‐
6
ical outcome. Even right heart can be assessed using pocket‐size
device, obtaining information regarding right atrium, right ventri‐
cle, and IVC25 that have good diagnostic agreement with standard
echocardiography, even if only expert sonographers have been in‐
volved. 26 Using pocket‐size device with combined linear probe has
been demonstrated to be useful and accurate in the detection of
27
deep vein thrombosis in outpatients clinic setting.
In emergency department different validation studies have been
performed to assess the feasibility and accuracy of pocket‐size de‐
vices compared to high‐end ultrasound system, demonstrating good
28-31
diagnostic agreement between small‐ and high‐level apparatus.
In prehospital emergencies, despite feasibility of echocardiography
using pocket‐size device, the diagnostic accuracy is mainly limited by
the operator's experience.32,33
To assess the role of point‐of‐care ultrasound with pocket‐size
devices in emergency department a systematic research in PubMed
has been done lasting the word (“point of care systems” or “porta‐
ble” or “pocket” or “hand‐held”) and (“echography”) and (“emergency
department”) for all literature published from January 1990 to April
2019. The search was limited to “human studies” and those available
in English.
As a result, 1348 items were found. The following selection cri‐
teria were followed to identify the studies to include:
1. Using a truly handheld device;
2. Performed in the setting of ED;
3. Focused on management of patients with acute dyspnea, chest
pain, and shock.
Studies involving medical students as operator or involving pediatric
population have been excluded. After reading abstract of all clinical
studies, 21 relevant studies have been included.
Clinical impact of handheld ultrasound use in emergency set‐
ting has been demonstrated in several studies, as detailed in
Table 1.17,18,34-44 The potential advantages and disadvantages in the
use of handheld ultrasound devices, in patient's managements, are
shown in Table 2.
3 | A S S E S S M E NT O F PATI E NT S W ITH
ACU TE DYS PN E A
Acute dyspnea is one of the most common reasons for admission in
ED. Rapid and accurate diagnosis and management can be lifesav‐
ing in this specific clinical setting.45 Initial assessment in dyspneic
patients includes clinical history, physical examination, chest X‐ray,
12‐lead electrocardiogram, arterial blood gas analysis, and routine
blood tests including brain natriuretic peptides. Lung and cardiac ul‐
trasound examination during acute dyspnea allow to gather impor‐
tant diagnostic information useful to establish correct therapeutic
approach, particularly in complex clinical cases. The integrated ultra‐
sound examination (IUE) of lung–heart–IVC with pocket ultrasound
devices is an extension of the clinical examination,46 increasing ef‐
ficiency, and speed in the differential diagnosis of acute dyspnea in
ED.47,48
Large amount of informations can be obtained using lung ultra‐
sound (LUS), especially in the identification of pulmonary diseases,
pleural effusion, and extravascular lung water.49-51 In patients hos‐
pitalized for heart failure, quantification of extravascular lung water
is feasible and comparable with that obtained with high‐end ultra‐
sound system.52 We have recently proposed a validated protocol
for the evaluation of dyspneic patients using a PUD that allows to
correctly identify patients with dyspnea of cardiac and noncardiac
origin47 (Movie S1). Thorax should be examined in two scans at each
side (4 zones): anteriorly on the II intercostal space, mid‐clavicular
line and laterally on the V intercostal space, mid‐axillary line, to
sample upper and lower lungs. The presence or the absence of in‐
terstitial syndrome (IS, defined as the presence of ≥3 comet tail ar‐
tifacts/B‐lines for field, Movie S2) and the presence or the absence
of pleural effusion (defined as a hypo‐anechoic space between the
parietal and visceral pleura, Movie S3) need to be evaluated. LUS
is defined positive for bilateral IS and/or effusion if any IS and/or
effusion is present in at least 1 scan per side and symmetrically.53
By symmetrical, we mean the presence of IS and/or effusion in the
same scans in both sides of the lungs. FoCUS includes at least two
views (parasternal long‐axis and apical) allowing qualitative eval‐
uation of left ventricular (LV) systolic function and left atrial size.
Ejection fraction (EF) is estimated visually and categorized as pre‐
served if >40% or reduced if ≤40%, based on cut point provided by
TA B L E 1   Clinical impact of handheld ultrasound use in emergency setting

Authors/ Type of
references Journal Year Title article Device Chief complaint Key findings
18
MANCUSI et al.

Blaivas M et al Wilderness and 2005 Change in differential Original Sonosite Abdominal and pelvic In 25 ultrasound scans performed, handheld ultrasound altered patients’
Environmental diagnosis and patient Research 180 Plus pain management in 7 cases, allowing recognition of intra‐abdominal hemorrhage,
Medicine management with the use pregnancy complications, hepatobiliary and renal diseases.
of portable ultrasound in
a remote setting
Filipiak‐Strzecka The 2018 Brief cardiovascular imag‐ Original Vscan Dyspnea, chest pain, In 100 patients suspected to have pulmonary embolism, supplementation of
D et al34 International ing with pocket‐size ultra‐ Research suspected pulmonary the initial bedside assessment of patients with four‐point compression venous
Journal of sound devices improves embolism ultrasonography and right ventricular size assessment with handheld device
Cardiovascular the accuracy of the initial positively influence the accuracy of clinical predictions.
Imaging assessment of suspected
pulmonary embolism
Filopei J et al35 Journal of 2014 Impact of pocket ultra‐ Original Vscan Dyspnea In 69 patients presenting with dyspnea handheld lung ultrasound improve diag‐
Hospital sound use by internal Research nostic accuracy of the clinical examination alone.
Medicine medicine Housestaff in
the diagnosis of Dyspnea
Howard BG36 Archives of 2018 The utility of handheld Case Vscan Heart Failure Handheld ultrasound was used to provide serial central venous pressure estima‐
Medicine ultrasound in the manage‐ Series tions by inferior vena cava evaluations in patients with heart failure.
ment of patients with
congestive heart failure
Hu H et al37 American 2014 Streamlined focused as‐ Original Vscan Torso trauma Handheld ultrasound with FAST protocol was used for triage purpose in 45
Journal of sessment with sonog‐ Research nonambulatory patients with blunt torso trauma, allowing recognition of intra‐
Emergency raphy for mass casualty abdominal hemorrhage, pericardial effusion and pneumothorax.
Medicine prehospital triage of blunt
torso trauma patients
Lapostolle F American 2006 Usefulness of handheld Original Sonosite Pleural, peritoneal, peri‐ In 270 ultrasound examination performed in 158 out‐of‐hospital patients, hand‐
et al38 Journal of ultrasound devices in Research 180 Plus cardial effusion, deep held ultrasound improved diagnostic accuracy in 67% of the cases.
Emergency out‐of‐hospital diagnosis venous thrombosis, ar‐
Medicine performed by emergency terial flow interruption
physicians
Lisi M et al39 Interactive 2012 Incremental value of Original Vscan Pleural effusion Handheld ultrasound was used in the evaluation of 73 patients suspected to
CardioVascular pocket‐sized imaging Research have pleural effusion and allowed recognition of abundant effusion and guided
and Thoracic device for bedside diag‐ thoracentesis.
Surgery nosis of unilateral pleural
effusions and ultrasound‐
guided thoracentesis
Mancuso FJN Arquivos 2014 Focused cardiac ultrasound Original Vscan Chest pain, dyspnea, Handheld ultrasound was used in the evaluation of 100 patient presenting with
et al40 Brasileiros de using a pocket‐size device Research shock different cardio‐pulmonary complaints, allowing recognition of heart failure,
Cardiologia in the emergency room pulmonary embolism, cardiac tamponade and aortic dissection and changing
initial diagnosis in 17 cases.
Reynolds TA PLOS ONE 2018 Impact of point‐of‐care Original Sonosite Trauma, respiratory In 784 patients, the use of handheld ultrasound changed either diagnostic im‐
et al41 ultrasound on clinical de‐ Research M‐Turbo failure, abdominopel‐ pression or disposition plan in 29% of all cases and rates of change in diagnostic
cision‐making at an urban vic pain, chest pain, impression or disposition plan increased to 45% in patients for whom more than
emergency department in shock, cardiac arrest, one ultrasound study type was performed.
Tanzania pregnancy
|
      3

(Continues)
 4       | MANCUSI et al.

the ESC guidelines.54 Left atrium (LA) dilation is also eyeball evalu‐

shock, peri‐operative cardiac assessment of systolic function and volume status,

patients allowing detection of intra‐abdominal fluid, pericardial effusion, pleural

and infectious complications of abdominal trauma in 142 victims of earthquake.
In 50 examined patients, handheld ultrasound influenced management decisions
ated.19 Whenever possible, LA is considered dilated if anteroposte‐

performed to determine presence or absence of hemoperitoneum and led to a

Handheld ultrasound allowed rapid identification of potentially life‐threatening

change in either prehospital therapy or management in 30% of patients, and a

injuries like pneumothorax, intra‐peritoneal and intra‐thoracic hemorrhage,

Handheld ultrasound using FAST in 202 patients with abdominal trauma was

effusion, pneumothorax, volume status thus modifying their management.

rior diameter (in the parasternal long‐axis view) is visually estimated

Handheld ultrasound with FAST protocol was used for triage purpose in 38
to be >4 cm in both genders.55,56 The combined presence of bilateral
interstitial syndrome and/or effusion and either dilated left atrium or
ejection fraction ≤ 40% or both has excellent accuracy for identifica‐
tion of patients with acute heart failure. Particularly, in the presence
of LUS positivity, evidence of EF ≤ 40% identifies acute heart failure
(HF) with reduced EF, while evidence of LA dilatation identifies pa‐
tients with acute HF with preserved EF,57 (Figure 1).
Simplified lung ultrasound, using only anterior scanning (2 zones)

change to admitting hospital in 22%.

can be useful in patients with severe‐critical hypoxemia, while in
general at least 4 zone scanning needs to be performed with good
accuracy for the diagnosis of acute HF.58
In patients with acute dyspnea, a diffuse B profile pattern can
in 70% of the cases.

be attributable to traditional interstitial syndrome conditions (acute

cardiogenic pulmonary edema, acute respiratory distress syndrome,
Key findings

interstitial pneumonia, and pulmonary fibrosis) 49 but can be also

a marker of multiple pulmonary metastases.59 POCUS can be also
used to detect anterior mediastinal mass, in patients presenting to
the ED for dyspnea.60 Suprasternal or parasternal approach is use‐
thrombosis, pulmonary

chest pain, procedural

ful to assess mediastinum involvement. Left atrial compression,

Hypotension, trauma,
pregnancy, abdomi‐

embolism, dyspnea,
nal pain, deep vein

Blunt torso trauma,

by extra‐cardiac structures, increases pulmonary venous pressure

extremities injury
Abdominal trauma
Chief complaint

causing dyspnea or even pulmonary edema and can be detected by

FoCUS performed with PUDs.61
Trauma

Symptom presentations for a cardiac tumor depend on its loca‐

tion. Dyspnea can be due to pulmonary embolization or congestive
heart failure from intracardiac obstruction. A pulmonary embolism
HandyScan
Micromax

due to neoplastic mass infiltrating the inferior vena cava and the
Device

Signos

Vscan

right atrium can be detected by POCUS performed with PUDs.62

The role of bedside ultrasound evaluation of patients present‐
ing to the ED with signs and symptoms of pulmonary embolism is
Research

Research

Research

Research
Original

Original

Original

Original
Type of

crucial.63 There are multiple sonographic findings that support the

article

diagnosis of acute pulmonary embolism and can be broken down

into two major categories: direct and indirect signs. Direct signs in‐
sound in trauma care after

ment of abdominal trauma

Prehospital ultrasound im‐
environments: use in the

aging improves manage‐

cluded visualization of a free‐floating thrombus in the right heart or

Impact of portable ultra‐

the Haitian earthquake

management triage of
ultrasound in Austere

Utility of point‐of‐care
ultrasound in acute

pulmonary artery (Movie S4). Indirect signs include right ventricular

earthquake injury
Portable handheld

dilation, D‐shaped left ventricle, right ventricular systolic dysfunc‐

Haiti disaster

tion, McConnell's sign, pulmonary hypertension, and inferior vena

of 2010

cava dilation without inspiratory collapsibility. Deep vein thrombosis

Title

can be present. McConnell sign is defined as hypo/akinesis of the

right ventricular free wall with hyperdynamic motion of the right
2005
2012
2010

2014
Year

ventricular apex, D‐shaped left ventricle refers to left ventricular

shape in parasternal short‐axis caused by flattening or bowing of the
intraventricular septum into the left ventricle due to acute pulmo‐
British Journal
and disaster
Emergency

Emergency
of Surgery
Prehospital

nary pressure overload. The specificity of sonographic findings of

Journal of

Journal of
Medicine

Medicine

Medicine
American

American
Journal
TA B L E 1   (Continued)

pulmonary embolism has been shown to be higher than the sensitiv‐

ity.64 Right ventricular dilatation with D‐shaped left ventricle,40 right
heart thrombus,65 McConnell's sign,66 and deep vein thrombosis67
Zhang S et al44

can be detected by ultrasound examination performed with hand‐

Shah S et al42
references

Shorter M

Walcher F

held devices. Echographic findings of absence of pleural sliding and

Authors/

et al43
et al17

presence of lung point may help in identification of pneumothorax

and can be detected using handheld thoracic sonography.68
MANCUSI et al.
4 | A S S E S S M E NT O F PATI E NT S W ITH
C H E S T PA I N
Chest pain is one of the main reasons for admission to the ED with a
broad spectrum of possible causes, some of which may be life‐threat‐
69
ening. Causes of chest pain are acute coronary syndromes, aortic
syndromes, pulmonary embolism, pericardial diseases, pleuro‐pul‐
monary conditions, and musculo‐skeletal causes. The usefulness of
integrated lung–heart ultrasound evaluation to determine chest pain
70
etiology is established but there is lack of standardized protocols.
      5|
In patients with chest pain and no certain diagnosis, after assess‐
ment of the medical history, physical examination, and ECG, focused
echocardiography with pocket‐size equipment may allow a prompt
diagnosis and, consequently, an earlier initiation of the therapy.40
Bedside handheld echocardiography may allow diagnosis of
aortic dissection by detection of intimal flap into the aortic lumen
(Movie S5).71 In this setting focused echocardiography is also im‐
portant to detect aortic dilatation and/or aortic valve abnormalities
(regurgitation and/or stenosis and/or bicuspid valve). It should be
underlined that handheld echocardiography may allow imaging only

TA B L E 2   Advantages and
Advantages
disadvantages of handheld ultrasound
systems use Low‐weight and low‐size hardware, to keep
in your pocket, portable at the bedside
Rapid qualitative assessment of structures
and functions
Little time to start the ultrasound
examination
Less expensive compared to larger ultra‐
sound scanners
Suitable for prehospital use especially during
maxi‐emergencies
Useful in the emergency room with a high
number of hospitalized people and a
reduced number of standard ultrasound
scanners available to every doctor
Disadvantages
Small screen size, lower 2D resolution, and
lower color Doppler quality compared to
larger machines
More probing and less reliable quantitative
evaluation compared to standard machines,
no spectral Doppler
Not suitable for long examinations due to
relatively fast overheating
Lower quality–price ratio compared to larger
systems
Not suitable in contexts where a more detailed
examination is required
Need for adequate training for image acquisi‐
tion and interpretation

Acute Dyspnea

Lung Ultrasound

Bilateral Interstitial Syndrome and/or Effusion?

No
Non-AHF
Yes

Focused Cardiac Ultrasound

Left Ventricular Ejection Fraction Left Atrial Dimension

EF≤40% EF>40% LA≤4 cm LA>4 cm

F I G U R E 1   Interpretation of integrated
ultrasound examination in patients
presenting to the emergency department Both
for acute dyspnea. AHF = acute heart AHF AHF
failure; EF = ejection fraction; LA = left
atrial dimension Non-AHF
 |
6       MANCUSI et al.
Left
ventricle
Left atrium
Pericardial
effusion
F I G U R E 2   Pericardial effusion
the first part of the aorta and its negative predictive value in patient
suspect of aortic dissection is really low. Thus, a negative finding
does not allow to exclude acute aortic syndrome and a more ad‐
vance imaging modality should be used.72
The role of point‐of‐care echocardiography in the management
of patients suspected to have acute coronary syndromes is to assess
the presence and the extension of regional wall‐motion abnormal‐
ities. Normal resting echocardiography cannot definitively rule out
an episode of ischemia but the absence of wall‐motion abnormalities
has a good negative predictive value for the presence of major myo‐
cardial ischemia in patients with ongoing and/or prolonged (>45 min‐
utes) chest pain.73-75 It is important to remember that segmental
wall‐motion abnormalities are not synonymous with ischemia76 and
can also occur in case of myocarditis, Takotsubo cardiomyopathy,
left ventricular pre‐excitation, left bundle branch block, pressure
overload states, and in the presence of paced rhythm. Furthermore,
bedside echocardiography is important in early detection of acute
myocardial infarction complications such as myocardial rupture (free
wall or inter‐ventricular septum) and acute mitral regurgitation.77
These abnormalities can be detected using portable ultrasound
device.40,78
Pericardial effusion is an abnormal accumulation of fluid in the
pericardial cavity and can be present in case of chest pain due to
pericarditis. It is defined as a hypo‐anechoic space between the two
pericardial layers and can be detected and monitored by handheld
echocardiography (Figure 2).79
Pleural effusion is an abnormal accumulation of fluid in the pleu‐
ral cavity, it can be present in case of chest pain due to pleuritis and/
or pneumonia and it can be detected by handheld lung ultrasound.80
In case of chest pain due to pneumonia, lung ultrasound performed
with handheld device can reveal lung consolidation with fluid and
air bronchograms.81 Absence of pleural sliding and presence of lung
point can be detected by handheld thoracic sonography in case of
chest pain due to pneumothorax.68 A protocol for integrated lung–
heart ultrasound evaluation for patients presenting with chest pain
is proposed in Table 3.
5 | A S S E S S M E NT O F PATI E NT S W ITH
SHOCK
Shock is the clinical expression of circulatory failure that results in
inadequate cellular oxygen delivery. It results from four potential,
and not exclusive, pathophysiological mechanisms: hypovolemia
(from internal or external fluid loss), cardiogenic factors (acute my‐
ocardial infarction, end‐stage cardiomyopathy, advanced valvular
heart disease, cardiac masses), obstruction (pulmonary embolism,
cardiac tamponade, tension pneumothorax), and distributive fac‐
tors (sepsis, anaphylaxis, spinal cord injury). Type and cause of
shock may be looked from the medical history, physical examina‐
tion, clinical investigations, and point‐of‐care echocardiography
that should be performed as soon as possible in any patient pre‐
senting with shock. 82 Focused cardiac goal‐oriented ultrasound
examination is required in this specific clinical setting. 83 Cardiac
ultrasound provides information on left and right ventricular sys‐
tolic function, chambers dimensions, and shape, valvular dysfunc‐
tions, aortic root and ascending aorta, pericardial diseases, inferior
vena cava dimension, and collapsibility. 84 Goal‐directed echocar‐
diography can be combined with thoracic and abdominal ultra‐
sound imaging to improve diagnostic accuracy. 85
5.1 | Hypovolemic shock
In this type of circulatory shock, there is significantly reduced end‐
diastolic chamber size and “kissing” of left ventricular walls during
systole, central venous pressure is low (inferior vena cava of small
dimension and totally collapsing during inspiration).84 In this type
of shock, integration with thoracic and abdominal ultrasound per‐
formed with a handheld device is important to detect the source of
blood loss (hemothorax,86 hemoperitoneum,87 and ruptured abdom‐
inal aortic aneurysm88).
5.2 | Cardiogenic shock
In this type of circulatory shock left ventricle is generally dilated with
poor contractility and significantly reduced ejection fraction, central ve‐
nous pressure is generally high (inferior vena cava dilated with hyporeac‐
tivity during inspiration).83 Causes of cardiogenic shock can be detected
by ultrasound examination performed with pocket‐size device and are
MANCUSI et al. |
      7

TA B L E 3   Proposed protocol for ultrasound evaluation of fluid administration. 85,92 All of this information can be detected by
patients with chest pain handheld device ultrasonography.47,93 A specific anatomic side of

A Aorta: aneurysm and/or dissection flap and/or valvular infection can be detected by point‐of‐care ultrasound examination
abnormalities performed with handheld device in case of septic shock.94,95

B Bi‐ventricular global systolic function: left ventricular EF, right

ventricular TAPSE
C Contractility: left ventricular wall motion, right ventricular
McConnell's sign
D Dimension and shape: LV enlargement, LV D‐shape, LV apical
ballooning, RV dilatation
E Effusion in the pericardial space
F Further cardiac or noncardiac abnormalities: valvulopathies,
LV hypertrophy, atrial dilatation, heart rupture, pneumonia,
pneumothorax, pleural effusion
attributable to acute coronary syndromes or end‐stage cardiomyopa‐
thy,40 severe valvular regurgitation or stenosis89 and cardiac masses.62
5.3 | Distributive shock
In this type of circulatory shock cardiac chambers are generally
normal with preserved contractility except in the case of sepsis‐
related cardiomyopathy. Septic shock is one of the most complex
hemodynamic failure syndromes because it may imply absolute
or relative reduction in central fluid volume, peripheral vasodila‐
tation, and myocardial failure.90 In patients with septic shock,
echocardiography can be used to assess fluid responsiveness by
measuring variation in dimension and collapsibility of the inferior
vena cava or by measuring stroke volume variation and its sur‐
rogates during fluid administration,91 to diagnose sepsis‐induced
myocardial dysfunction and to monitor responses to therapy by
evaluation of myocardial contractility during inotropes and vaso‐
pressors therapy and by evaluation of pulmonary wetness during
5.4 | Obstructive shock
In cardiac tamponade, pericardial effusion is typically abundant
but not necessarily, right chambers and left atrium are generally
collapsed and left ventricular filling is impaired (Movie S6), in‐
ferior vena cava is dilated with no respiratory variation. Cardiac
tamponade can be detected by point‐of‐care echocardiography
performed with handheld device.96 Echocardiography is also im‐
portant in guiding pericardiocentesis. In some cases of massive
pulmonary embolism, point‐of‐care echocardiography could be
the only available diagnostic tool. Typical signs of massive pulmo‐
nary embolism detectable by handheld device echocardiography
are D‐shaped left ventricle with abnormal dilation of right ven‐
tricle,97 McConnell sign and right heart thrombi. 65 In pulmonary
embolism inferior vena cava is generally dilated with poor respira‐
tory variation and signs of deep vein thrombosis can be detected
by handheld device compression ultrasonography. 67 The diagnosis
of tension pneumothorax is clinical but echographic findings of
absence of pleural sliding and presence of lung point may help in
its identification and are detectable by handheld thoracic sonog‐
raphy. 68 A summary of echographic findings in the different types
of shock is proposed in Table 4.
6 | CO N C LU S I O N
The use of pocket‐size device in ED has a pivotal role in the man‐
agement of patients presenting in critical and life‐threatening

TA B L E 4   Echographic findings in the different types of shock

Type of shock

Obstructive

Tension
Echo Hypovolemic Cardiogenic Distributive Tamponade Pulmonary embolism pneumothorax

Left Hyperdynamic, Enlarged Commonly normal Impaired D‐shaped Normal

ventricle ventricular kissing with poor except in case diastolic
during systole contractility of sepsis‐related filling
cardiomyopathy
Other Commonly normal Commonly Normal, except in case Collapsing Dilated right ventricle Possible dilation of
chambers enlarged of sepsis‐related with the presence of the right ventricle
cardiomyopathy Mc Connell's sign
Pericardium Normal Commonly Normal Commonly Normal Normal
normal large
effusion
Inferior Small and totally Commonly di‐ Commonly small and Dilated and Commonly dilated Commonly dilated
vena cava collapsing during lated with hypo‐ collapsing during fixed with hyporeactivity with hypore‐
inspiration reactivity during inspiration during inspiration activity during
inspiration inspiration
 |
8       MANCUSI et al.
conditions. Point‐of‐care assessment using handheld devices allows
rapid acquisition of crucial information to speed up the diagnostic
and therapeutic process in patients presenting with dyspnea, chest
pain, and shock.
ORCID
Costantino Mancusi  https://orcid.org/0000-0001-6690-1408
REFERENCES
1. Moore CL, Copel JA. Point‐of‐care ultrasonography. N Engl J Med.
2011;364(8):749–757.
2. Labovitz AJ, Noble VE, Bierig M, et al. Focused cardiac ultrasound
in the emergent setting: a consensus statement of the American
Society of Echocardiography and American College of Emergency
Physicians. J Am Soc Echocardiogr. 2010;23(12):1225–1230.
3. Spencer KT, Anderson AS, Bhargava A, et al. Physician‐performed
point‐of‐care echocardiography using a laptop platform compared
with physical examination in the cardiovascular patient. J Am Coll
Cardiol. 2001;37(8):2013–2018.
4. Kimura BJ. Point‐of‐care cardiac ultrasound techniques in the physical
examination: better at the bedside. Heart. 2017;103(13):987–994.
5. Beaulieu Y. Bedside echocardiography in the assessment of the crit‐
ically ill. Crit Care Med. 2007;35(5 suppl):S235–S249.
6. Gundersen GH, Norekval TM, Haug HH, et al. Adding point
of care ultrasound to assess volume status in heart failure pa‐
tients in a nurse‐led outpatient clinic. A randomised study. Heart.
2016;102(1):29–34.
7. Liebo MJ, Israel RL, Lillie EO, Smith MR, Rubenson DS, Topol EJ.
Is pocket mobile echocardiography the next‐generation stetho‐
scope? A cross‐sectional comparison of rapidly acquired images
with standard transthoracic echocardiography. Ann Intern Med.
2011;155(1):33–38.
8. Gianstefani S, Catibog N, Whittaker AR, et al. Pocket‐size imaging
device: effectiveness for ward‐based transthoracic studies. Eur
Heart J Cardiovasc Imaging. 2013;14(12):1132–1139.
9. Graven T, Wahba A, Hammer AM, et al. Focused ultrasound of the
pleural cavities and the pericardium by nurses after cardiac surgery.
Scand Cardiovasc J. 2015;49(1):56–63.
10. Kjesbu IE, Laursen CB, Graven T, et al. Feasibility and diagnostic
accuracy of point‐of‐care abdominal sonography by pocket‐sized
imaging devices, performed by medical residents. J Ultrasound Med.
2017;36(6):1195–1202.
11. Schleder S, Dendl LM, Ernstberger A, et al. Diagnostic value of
a hand‐carried ultrasound device for free intra‐abdominal fluid
and organ lacerations in major trauma patients. Emerg Med J.
2013;30(3):e20.
12. Coşkun F, Akıncı E, Ceyhan MA, Sahin Kavaklı H. Our new stetho‐
scope in the emergency department: handheld ultrasound. Ulus
Travma Acil Cerrahi Derg. 2011;17(6):488–492.
13. Mark DG, Hayden GE, Ky B, et al. Hand‐carried echocardiogra‐
phy for assessment of left ventricular filling and ejection fraction
in the surgical intensive care unit. J Crit Care. 2009;24(3):470.
e1–e7.
14. Dalen H, Gundersen GH, Skjetne K, et al. Feasibility and reliability
of pocket‐size ultrasound examinations of the pleural cavities and
vena cava inferior performed by nurses in an outpatient heart fail‐
ure clinic. Eur J Cardiovasc Nurs. 2015;14(4):286–293.
15. Godown J, Lu JC, Beaton A, et al. Handheld echocardiography ver‐
sus auscultation for detection of rheumatic heart disease. Pediatrics.
2015;135(4):e939–e944.
16. Lu JC, Sable C, Ensing GJ, et  al. Simplified rheumatic heart dis‐
ease screening criteria for handheld echocardiography. J Am Soc
Echocardiogr. 2015;28(4):463–469.
17. Shorter M, Macias DJ. Portable handheld ultrasound in austere
environments: use in the Haiti disaster. Prehosp Disaster Med.
2012;27(2):172–177.
18. Blaivas M, Kuhn W, Reynolds B, Brannam L. Change in differ‐
ential diagnosis and patient management with the use of por‐
table ultrasound in a remote setting. Wilderness Environ Med.
2005;16(1):38–41.
19. Galderisi M, Santoro A, Versiero M, et al. Improved cardiovascular
diagnostic accuracy by pocket size imaging device in non‐cardio‐
logic outpatients: the NaUSiCa (Naples Ultrasound Stethoscope in
Cardiology) study. Cardiovasc Ultrasound. 2010;8:51.
20. Filipiak‐Strzecka D, John B, Kasprzak JD, Michalski B, Lipiec P.
Pocket‐size echocardiograph–a valuable tool for nonexperts
or just a portable device for echocardiographers? Adv Med Sci.
2013;58(1):67–72.
21. Zanobetti M, Scorpiniti M, Gigli C, et al. Point‐of‐care ultra‐
sonography for evaluation of acute dyspnea in the ED. Chest.
2017;151(6):1295–1301.
22. Mjølstad OC, Andersen GN, Dalen H, et al. Feasibility and re‐
liability of point‐of‐care pocket‐size echocardiography per‐
formed by medical residents. Eur Heart J Cardiovasc Imaging.
2013;14(12):1195–1202.
23. Andersen GN, Graven T, Skjetne K, et al. Diagnostic influence of rou‐
tine point‐of‐care pocket‐size ultrasound examinations performed
by medical residents. J Ultrasound Med. 2015;34(4):627–636.
24. Andersen GN, Viset A, Mjølstad OC, Salvesen O, Dalen H, Haugen
BO. Feasibility and accuracy of point‐of‐care pocket‐size ultraso‐
nography performed by medical students. BMC Med Educ. 2014;
14:156.
25. Goonewardena SN, Gemignani A, Ronan A, et al. Comparison of
hand‐carried ultrasound assessment of the inferior vena cava and
N‐terminal pro‐brain natriuretic peptide for predicting readmission
after hospitalization for acute decompensated heart failure. JACC
Cardiovasc Imaging. 2008;1(5):595–601.
26. Schiano‐Lomoriello V, Esposito R, Santoro C, de Simone G, Galderisi
M. Early markers of right heart involvement in regular smokers by
Pocket Size Imaging Device. Cardiovasc Ultrasound. 2015;13:33.
27. Nakanishi K, Fukuda S, Yamashita H, et al. Detection of deep ve‐
nous thrombosis using a pocket‐size ultrasound examination de‐
vice. JACC Cardiovasc Imaging. 2016;9(7):897–898.
28. Cullen MW, Geske JB, Anavekar NS, Askew JW 3rd, Lewis BR, Oh
JK. Handheld echocardiography during hospitalization for acute
myocardial infarction. Clin Cardiol. 2017;40(11):993–999.
29. Biais M, Carrié C, Delaunay F, Morel N, Revel P, Janvier G. Evaluation
of a new pocket echoscopic device for focused cardiac ultrasonog‐
raphy in an emergency setting. Crit Care. 2012;16(3):R82.
3 0. Testuz A, Müller H, Keller PF, et al. Diagnostic accuracy of pocket‐
size handheld echocardiographs used by cardiologists in the acute
care setting. Eur Heart J Cardiovasc Imaging. 2013;14(1):38–42.
31. Blaivas M, Brannam L, Theodoro D. Ultrasound image quality com‐
parison between an inexpensive handheld emergency department
(ED) ultrasound machine and a large mobile ED ultrasound system.
Acad Emerg Med. 2004;11(7):778–781.
32. Charron C, Templier F, Goddet NS, Baer M, Vieillard‐Baron A,
Group of Investigators of SAMU. Difficulties encountered by phy‐
sicians in interpreting focused echocardiography using a pocket
ultrasound machine in prehospital emergencies. Eur J Emerg Med.
2015;22(1):17–22.
33. Bobbia X, Pradeilles C, Claret PG, et al. Does physician experience
influence the interpretability of focused echocardiography images
performed by a pocket device? Scand J Trauma Resusc Emerg Med.
2015;23:52.
MANCUSI et al.
3 4. Filipiak‐Strzecka D, Kasprzak JD, Lipiec P. Brief cardiovascular im‐
aging with pocket‐size ultrasound devices improves the accuracy
of the initial assessment of suspected pulmonary embolism. Int J
Cardiovasc Imaging. 2018;34(10):1595–1605.
35. Filopei J, Siedenburg H, Rattner P, Fukaya E, Kory P. Impact of
pocket ultrasound use by internal medicine housestaff in the diag‐
nosis of dyspnea. J Hosp Med. 2014;9(9):594–597.
36. Howard BG. The utility of handheld ultrasound in the management
of patients with congestive heart failure. Arch Med. 2018;10(3):1.
37. Hu H, He Y, Zhang S, Cao Y. Streamlined focused assessment with
sonography for mass casualty prehospital triage of blunt torso
trauma patients. Am J Emerg Med. 2014;32(7):803–806.
38. Lapostolle F, Petrovic T, Lenoir G, et al. Usefulness of hand‐held
ultrasound devices in out‐of‐hospital diagnosis performed by emer‐
gency physicians. Am J Emerg Med. 2006;24(2):237–242.
39. Lisi M, Cameli M, Mondillo S, et al. Incremental value of pocket‐
sized imaging device for bedside diagnosis of unilateral pleural ef‐
fusions and ultrasound‐guided thoracentesis. Interact Cardiovasc
Thorac Surg. 2012;15(4):596–601.
4 0. Mancuso FJ, Siqueira VN, Moisés VA, et al. Focused cardiac ultra‐
sound using a pocket‐size device in the emergency room. Arq Bras
Cardiol. 2014;103(6):530–537.
41. Reynolds TA, Amato S, Kulola I, Chen CJ, Mfinanga J, Sawe HR.
Impact of point‐of‐care ultrasound on clinical decision‐mak‐
ing at an urban emergency department in Tanzania. PLoS ONE.
2018;13(4):e0194774.
42. Shah S, Dalal A, Smith RM, Joseph G, Rogers S, Dyer GS. Impact of
portable ultrasound in trauma care after the Haitian earthquake of
2010. Am J Emerg Med. 2010;28(8):970–971.
43. Walcher F, Weinlich M, Conrad G, et al. Prehospital ultrasound
imaging improves management of abdominal trauma. Br J Surg.
2006;93:238–242.
4 4. Zhang S, Zhu D, Wan Z, Cao Y. Utility of point‐of‐care ultrasound
in acute management triage of earthquake injury. Am J Emerg Med.
2014;32(1):92–95.
45. Pang PS, Komajda M, Gheorghiade M. The current and fu‐
ture management of acute heart failure syndromes. Eur Heart J.
2010;31(7):784–793.
46. Liu SC, Chang WT, Huang CH, Weng TI, Ma Matthew HM, Chen
WJ. The value of portable ultrasound for evaluation of cardiomeg‐
aly patients presenting at the emergency department. Resuscitation.
2005;64(3):327–331.
47. Sforza A, Mancusi C, Carlino MV, et al. Diagnostic performance of
multi‐organ ultrasound with pocket‐sized device in the manage‐
ment of acute dyspnea. Cardiovasc Ultrasound. 2017;15(1):16.
48. Colclough A, Nihoyannopoulos P. Pocket‐sized point‐of‐care car‐
diac ultrasound devices : role in the emergency department. Herz.
2017;42(3):255–261.
49. Copetti R, Soldati G. Ecografia toracica.III edizione. Turin: Edizioni
Medico-Scientifiche; 2012.
50. Picano E, Pellikka PA. Ultrasound of extravascular lung
water: a new standard for pulmonary congestion. Eur Heart J.
2016;37(27):2097–2104.
51. Sicari R, Galderisi M, Voigt JU, et al. The use of pocket‐size imag‐
ing devices: a position statement of the European Association of
Echocardiography. Eur J Echocardiogr. 2011;12(2):85–87.
52. Platz E, Pivetta E, Merz AA, Peck J, Rivero J, Cheng S. Impact
of device selection and clip duration on lung ultrasound assess‐
ment in patients with heart failure. Am J Emerg Med. 2015;33(11):
1552–1556.
53. Gargani L. Lung ultrasound: a new tool for the cardiologist.
Cardiovasc Ultrasound. 2011;9:6.
54. Ponikowski P, Voors AA, Anker SD, et al. 2016 ESC Guidelines for
the diagnosis and treatment of acute and chronic heart failure: the
Task Force for the diagnosis and treatment of acute and chronic
|
      9
heart failure of the European Society of Cardiology (ESC). Eur J
Heart Fail. 2016;18(8):891–975.
55. Lang RM, Badano LP, Mor‐Avi V, et al. Recommendations for cardiac
chamber quantification by echocardiography in adults: an update
from the American Society of Echocardiography and the European
Association of Cardiovascular Imaging. J Am Soc Echocardiogr.
2015;28:1–39. e14.
56. Canciello G, de Simone G, Izzo R, et al. Validation of left atrial vol‐
ume estimation by left atrial diameter from the parasternal longaxis
view. J Am Soc Echocardiogr. 2017;30:262–269.
57. Carlino MV, Paladino F, Sforza A, et al. Assessment of left atrial
size in addition to focused cardiopulmonary ultrasound improves
diagnostic accuracy of acute heart failure in the Emergency
Department. Echocardiography. 2018;35:785–791.
58. Sforza A, Carlino MV, Guarino M, et al. Anterior vs lateral symmet‐
ric interstitial syndrome in the diagnosis of acute heart failure. Int J
Cardiol. 2019;280:130–132.
59. Carlino MV, Mancusi C, de Simone G, et al. Interstitial syndrome‐
lung ultrasound B lines: a potential marker for pulmonary metasta‐
ses? A case series. Ital J Med. 2018;12:223–226.
60. Carlino MV, Sforza A, D'Amato A, et al. A mediastinal lymphoma
detected by point‐of‐care ultrasound in a young woman with wors‐
ening dyspnea. Hodgkin's Lymphoma: a case report. Italian. J Emerg
Med. 2018;1:1–5.
61. Sforza A, Mancusi C, Carlino MV, et al. Detection of left atrial com‐
pression by focused cardiac ultrasonography in a patient with wors‐
ening dyspnea. ITJEM 3/2017‐Ottobre.
62. Carlino MV, Mancusi C, Sforza A, et al. A cardiac mass diagnosed
using point‐of‐care ultrasound in a dyspneic patient. POCUS J.
2017;2(3):20–21.
63. Nazerian P, Vanni S, Volpicelli G, et al. Accuracy of point‐of‐care
multiorgan ultrasonography for the diagnosis of pulmonary embo‐
lism. Chest. 2014;145(5):950–957.
6 4. Patel AN, Nickels LC, Flach FE, De Portu G, Ganti L. The use of
bedside ultrasound in the evaluation of patients presenting with
signs and symptoms of pulmonary embolism. Case Rep Emerg Med.
2013;2013:312632.
65. Carlino MV, Mancusi C, Sforza A. A right atrial thrombus detected by
transthoracic echocardiography. Vis J Emerg Med. 2018;13:80–81.
66. Andrus P, Dean A. Focused cardiac ultrasound. Glob Heart.
2013;8(4):299–303.
67. Pujol S, Laurent J, Markarian T, et al. Compression with a pocket‐
sized ultrasound device to diagnose proximal deep vein thrombosis.
Am J Emerg Med. 2018;36(7):1262–1264.
68. Kirkpatrick AW, Sirois M, Laupland KB, et al. Hand‐held thoracic
sonography for detecting post‐traumatic pneumothoraces: the
Extended Focused Assessment with Sonography for Trauma
(EFAST). J Trauma. 2004;57(2):288–295.
69. Knockaert DC, Buntinx F, Stoens N, Bruyninckx R, Delooz H. Chest
pain in the emergency department: the broad spectrum of causes.
Eur J Emerg Med. 2002;9(1):25–30.
70. Whitson MR, Mayo PH. Ultrasonography in the emergency depart‐
ment. Crit Care. 2016;20(1):227.
71. Sforza A, Carlino MV, Romano G, Mancusi C. Detection of Stanford
type A aortic dissection by focused cardiac ultrasonography per‐
formed with pocket ultrasound device in a patient with chest pain.
Vis J Emerg Med. 2018;11:14–15.
72. Thomas F, Flint N, Setareh‐Shenas S, Rader F, Kobal SL, Siegel
RJ. Accuracy and efficacy of hand‐held echocardiography
in diagnosing valve disease: a systematic review. Am J Med.
2018;131(10):1155–1160.
73. Roffi M, Patrono C, Collet JP, et  al. 2015 ESC Guidelines for the
management of acute coronary syndromes in patients present‐
ing without persistent ST‐segment elevation: task Force for the
Management of Acute Coronary Syndromes in Patients Presenting
 |
10       MANCUSI et al.
without Persistent ST‐Segment Elevation of European Society of
Cardiology (ESC). Eur Heart J. 2016;37(3):267–315.
74. Weston P, Alexander JH, Patel MR, Maynard C, Crawford L, Wagner
GS. Hand‐held echocardiographic examination of patients with
symptoms of acute coronary syndromes in the emergency depart‐
ment: the 30‐day outcome associated with normal left ventricular
wall motion. Am Heart J. 2004;148(6):1096–1101.
75. Atar S, Feldman A, Darawshe A, Siegel RJ, Rosenfeld T. Utility and
diagnostic accuracy of hand‐carried ultrasound for emergency
room evaluation of chest pain. Am J Cardiol. 2004;94(3):408–409.
76. Kansal M, Kessler C, Frazin L. Hand‐held echocardiogram does not
aid in triaging chest pain patients from the emergency department.
Echocardiography. 2009;26(6):625–629.
77. Lancellotti P, Price S, Edvardsen T, et al. The use of echocardi‐
ography in acute cardiovascular care: recommendations of the
European Association of Cardiovascular Imaging and the Acute
Cardiovascular Care Association. Eur Heart J Acute Cardiovasc Care.
2015;4(1):3–5.
78. Sobczyk D, Nycz K, Andruszkiewicz P. Validity of a 5‐minute fo‐
cused echocardiography with A‐F mnemonic performed by non‐
echocardiographers in the management of patients with acute
chest pain. Cardiovasc Ultrasound. 2015;13:16.
79. Schleder S, Dittmar M, Poschenrieder F, et al. Diagnosis of peri‐
cardial effusion with a new generation hand‐carried ultrasound
device in cardiothoracic intensive care unit patients. Acta Radiol.
2012;53(10):1133–1136.
8 0. Schleder S, Dornia C, Poschenrieder F, et al. Bedside diagnosis of
pleural effusion with a latest generation hand‐carried ultrasound
device in intensive care patients. Acta Radiol. 2012;53(5):556–560.
81. Ellington LE, Gilman RH, Chavez MA, et al. Lung ultrasound as a
diagnostic tool for radiographically‐confirmed pneumonia in low
resource settings. Respir Med. 2017;128:57–64.
82. Vincent JL, De Backer D. Circulatory shock. N Engl J Med.
2014;370(6):583.
83. Walley PE, Walley KR, Goodgame B, Punjabi V, Sirounis D. A practi‐
cal approach to goal‐directed echocardiography in the critical care
setting. Crit Care. 2014;18(6):681.
8 4. Mok KL. Make it SIMPLE: enhanced shock management by focused
cardiac ultrasound. J Intensive Care. 2016;4:51.
85. Copetti R. Clinical integrated ultrasound in peri cardiac arrest and
cardiac arrest. Clin Exp Cardiol. 2012:S;10.
86. Brooks A, Davies B, Smethhurst M, Connolly J. Emergency ul‐
trasound in the acute assessment of haemothorax. Emerg Med J.
2004;21(1):44–46.
87. Brooks A, Davies B, Connolly J. Prospective evaluation of handheld
ultrasound in the diagnosis of blunt abdominal trauma. J R Army Med
Corps. 2002;148(1):19–21.
88. Carlino MV, Sforza A, Paladino F, Mancusi C. Low back pain:
point‐of‐care ultrasound for a rapid diagnosis. Vis J Emerg Med.
2018;12:3–4.
89. Mehta M, Jacobson T, Peters D, et al. Handheld ultrasound versus
physical examination in patients referred for transthoracic echo‐
cardiography for a suspected cardiac condition. JACC Cardiovasc
Imaging. 2014;7(10):983–990.
90. Via G, Price S, Storti E. Echocardiography in the sepsis syndromes.
Crit Ultrasound J. 2011;3:71–85.
91. De Backer D, Fagnoul D. Intensive care ultrasound: VI. Fluid
responsiveness and shock assessment. Ann Am Thorac Soc.
2014;11(1):129–136.
92. Griffee MJ, Merkel MJ, Wei KS. The role of echocardiogra‐
phy in hemodynamic assessment of septic shock. Crit Care Clin.
2010;26(2):365–382.
93. Manasia AR, Nagaraj HM, Kodali RB, et al. Feasibility and poten‐
tial clinical utility of goal‐directed transthoracic echocardiography
performed by noncardiologist intensivists using a small hand‐car‐
ried device (SonoHeart) in critically ill patients. J Cardiothorac Vasc
Anesth. 2005;19(2):155–159.
94. Sforza A, Carlino MV, Guarino M, et al. Implantable device‐­
related endocarditis detected by point‐of‐care echocardiography
in a patient with dyspnea and chest pain. Ital J Med. 2018;12(4):
273–275.
95. Del Medico M, Altieri A, Carnevale‐Maffè G, et al. Pocket‐size ul‐
trasound device in cholelithiasis: diagnostic accuracy and efficacy
of short‐term training. Intern Emerg Med. 2018;13(7):1121–1126.
96. Sforza A, Carlino MV, Guarino M, et al. A case of pulmonary edema:
the critical role of lung‐heart integrated ultrasound examination.
Monaldi Arch Chest Dis. 2018;88:982.
97. Workman A, Lewis G, Currie P. Massive pulmonary embolism di‐
agnosed by focused cardiac ultrasound (V scan). Br J Cardiol.
2016;23(1). https​://doi.org/10.5837/bjc.2016.003
S U P P O R T I N G I N FO R M AT I O N
Additional supporting information may be found online in the
Supporting Information section at the end of the article.
Movie S1. Scans’ acquisition through validated protocol for the eval‐
uation of dyspneic patients using a pocket ultrasound device.
Movie S2. Interstitial syndrome.
Movie S3. Pleural effusion.
Movie S4. A free‐floating thrombus in the right heart.
Movie S5. Intimal flap into the aortic lumen.
Movie S6. Cardiac tamponade.
How to cite this article: Mancusi C, Carlino MV, Sforza A.
Point‐of‐care ultrasound with pocket‐size devices in
emergency department. Echocardiography. 2019;00:1–10.
https​://doi.org/10.1111/echo.14451​