Indications For Bedside Ultrasonography in The Critically-Ill Adult Patient - UpToDate (Completo)

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Indications for bedside ultrasonography in the

critically-ill adult patient
Authors: John T Huggins, MD, Paul Mayo, MD
Section Editor: Scott Manaker, MD, PhD
Deputy Editor: Geraldine Finlay, MD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Feb 2022. | This topic last updated: Jun 14, 2021.
INTRODUCTION
Portable bedside ultrasonography is being increasingly used by clinicians in patients who are
critically ill [1,2]. Critical care ultrasonography (CCUS) is most commonly used in the
emergency department and the intensive care unit. It can also be used in the operating
room and postoperative care unit when evaluating patients who become acutely ill in the
hospital. CCUS is commonly divided into four separate elements: thoracic (lung and pleural),
abdominopelvic, vascular, and cardiac (basic and advanced).
This section will review the clinical utility of these four separate elements of CCUS. Details
regarding bedside ultrasonography for trauma patients, thoracic ultrasonography in non-
critically-ill patients, and transcranial ultrasonography in stroke patients are discussed
separately. (See "Emergency ultrasound in adults with abdominal and thoracic trauma" and
"Bedside pleural ultrasonography: Equipment, technique, and the identification of pleural
effusion and pneumothorax" and "Imaging of pleural effusions in adults" and "Ultrasound-
guided thoracentesis" and "Neuroimaging of acute ischemic stroke", section on 'Ultrasound
methods'.)
TERMINOLOGY AND DEFINITION
Critical care ultrasonography (CCUS) refers to the use of ultrasonography in patients who are
critically ill. Multiple terms are used to describe various elements of CCUS. These include
terms that refer to the bedside application of ultrasonography (eg, point-of-care
ultrasonography [POCUS]), and terms that refer to the organs imaged with ultrasonography
including multiorgan ultrasonography, thoracic ultrasonography (TUS; lung, pleural, and/or
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heart), lung ultrasonography (LUS), abdominopelvic ultrasonography, vascular

ultrasonography, and cardiac ultrasonography (basic and advanced critical care
echocardiography [CCE]).
Protocols that describe the use of CCUS in critically-ill patients who present with shock or
trauma have been described including rapid ultrasound in shock (RUSH), abdominal and
cardiac evaluation with sonography in shock (ACES), focused assessment with sonography
for trauma (FAST), and focused cardiac ultrasound (FOCUS). These protocols are discussed
separately. (See "Emergency ultrasound in adults with abdominal and thoracic trauma",
section on 'Focused Assessment with Sonography for Trauma'.)
A widely accepted definition of the elements of CCUS that are required for competence has
been published and constitutes a reasonable definition of the scope of practice of CCUS [1].
CHOOSING CONSULTATIVE OR CRITICAL CARE ULTRASONOGRAPHY
For critical care ultrasonography (CCUS), the critical care clinician is directly responsible for
all aspects of image acquisition and interpretation, and integration of the results into the
management plan at the point of care. This differs from standard ultrasonography
performed by the consultative radiology and cardiology services where there is a delay in
these processes. The choice between using consultative ultrasonography or CCUS is
dependent upon the available equipment, expertise, and the indication for the examination.
● Consultative ultrasonography – In critically-ill patients, consultative radiology- or

cardiology-performed ultrasonography is typically done at the bedside or in a radiology
suite using large expensive machines; it is usually performed by skilled technicians and
later interpreted by radiologists or cardiologists with ultrasonography expertise. Thus,
consultative ultrasonography assessment is useful for hemodynamically stable patients
with complex disorders that require high level of expertise at image acquisition and
interpretation (eg, detailed assessment of the hepatobiliary system,
obstetric/gynecologic applications, testicular disease, detailed assessment of valvular
heart disease). Another major indication for consultative ultrasonography is when the
critical care clinician identifies an abnormality beyond their level of expertise to assess
(eg, splenic lesions, complex renal or hepatic cysts).
● Critical care ultrasonography – CCUS uses portable equipment that is compact and
relatively inexpensive. Image acquisition and interpretation are performed by the
intensivist at the bedside, so the imaging results can be immediately actionable and
integrated into a comprehensive management plan. CCUS is typically best suited for
patients with imminently life threatening processes, to categorize shock and

respiratory failure, to check for coexisting diagnoses and complications of therapy, and
to track the evolution of the critical illness by serial examinations.
Although useful as a standalone bedside tool, CCUS should not eliminate the need for
standard imaging tools, particularly when CCUS is not helpful or when confirmation of
a diagnosis is important or complex (eg, mitral valve rupture, complicated
pneumothorax). When appropriately used, CCUS can reduce the use of other imaging
modalities such as chest CT, chest radiography, and pulmonary artery catheter use [3].
In many scenarios, it is best used as a complimentary diagnostic tool to standard
pathways. In support of this concept, point of care ultrasonography (POCUS) has been
shown to be of value in the evaluation of acute dyspnea in the emergency department
and inpatient hospital setting. One meta-analysis of 49 studies reported that the
inclusion of POCUS (namely thoracic, cardiac, and vascular US), led to more correct
diagnoses in patients with acute dyspnea than standard diagnostic pathways [4].
Specifically, POCUS improved the sensitivities of standard diagnostic testing for the
detection of heart failure (88 percent), pneumonia, pneumothorax, pleural effusion,
and pulmonary embolism (two to three studies; 78 to 95 percent versus 50 to 64
percent). In-hospital mortality and length of stay were not impacted by POCUS.
THORACIC ULTRASONOGRAPHY
Thoracic ultrasonography (TUS; lung and pleural), is a key component of critical care
ultrasonography (CCUS) and for the purposes of this topic does not include cardiac
ultrasonography. In critically-ill patients, TUS can be used to evaluate patients with dyspnea
due to acute cardiopulmonary respiratory failure, pleural effusion, and pneumothorax [5],
the details of which are discussed below. (See 'Evaluation of the etiology of cardiopulmonary
failure' below and 'Evaluation and treatment of pleural effusion' below and 'Evaluation for
pneumothorax' below and 'Investigational' below.)
An algorithmic approach to evaluation of acute respiratory failure that recommends

examination of three well defined points on the thorax (anterior, lateral, and posterolateral)
bilaterally (the BLUE protocol) [6,7]. Based upon the ultrasonography findings derived from
these examination points, the etiology of the respiratory failure may be identified in a high
proportion of cases. This algorithm is distinguished by its simplicity and ease of use but
other protocols exist with no study demonstrating superiority of one over the other.
Additional techniques used to obtain lung and pleural ultrasonography images, the
advantages and disadvantages of TUS compared with traditional radiographic imaging of
the lung (chest radiography and computed tomography [CT]), and the value of emergency
ultrasonography in adults with thoracic trauma, a probes used for imaging are discussed
separately. (See "Bedside pleural ultrasonography: Equipment, technique, and the
identification of pleural effusion and pneumothorax" and "Emergency ultrasound in adults

with abdominal and thoracic trauma".)
Evaluation of the etiology of cardiopulmonary failure — Data from observational studies

suggest that TUS in critically-ill patients can identify abnormalities associated with acute
cardiopulmonary failure:
● Presence or absence of pneumothorax – Pneumothorax is suggested by the absence

of lung sliding and or lung pulse, and verified by the presence of a lung point, the
details of which are discussed separately [8-10]. (See "Bedside pleural ultrasonography:
Equipment, technique, and the identification of pleural effusion and pneumothorax"
and "Clinical presentation and diagnosis of pneumothorax", section on 'Diagnostic
imaging'.)
● Normal aeration pattern versus alveolar/interstitial abnormality – An A line

pattern with lung sliding indicates a normal aeration pattern [11]. The presence of B
lines indicates an alveolar or interstitial abnormality [12]. Profuse bilateral B lines with
smooth pleural morphology are characteristic of cardiogenic pulmonary edema;
whereas focal B lines with irregular pleural morphology are characteristic of a primary
lung injury process such as acute respiratory distress syndrome (ARDS) or pneumonia
[13]. In a systematic review of three studies of patients with suspected ventilator-
associated pneumonia (VAP), although lung ultrasonography was more useful for
ruling out pneumonia, useful signs of VAP included subpleural consolidations and
dynamic air bronchograms [14]. In another systematic review of 25 studies, lung
ultrasonography had a sensitivity of 0.82 and specificity of 0.94 for consolidation, 0.90
and 0.93 for heart failure, and 0.78 and 0.94 for acute exacerbations of pneumonia [15].
In patients with ARDS, lung ultrasound compared favorably with chest CT (diagnostic
sensitivity ranged from 82 to 92 percent), and performed best when abnormal findings
reached the pleural surface [16]. In another study of 67 patients, a nine-point bedside
ultrasonography protocol outperformed routine chest radiography in the evaluation of
intubated patients with acute respiratory failure [17]. (See "Bedside pleural
ultrasonography: Equipment, technique, and the identification of pleural effusion and
pneumothorax".)
● Pleural effusion – An effusion is suggested by an anechoic area surrounded by typical

anatomic boundaries, the details of which are described separately [18]. (See "Bedside
pleural ultrasonography: Equipment, technique, and the identification of pleural
effusion and pneumothorax".)
From a diagnostic perspective, TUS compares well with CT and may be superior to chest
radiography when performed by experienced operators. As examples:

● In a prospective study of 32 patients with acute respiratory distress syndrome (ARDS),

the diagnostic accuracy of bedside chest radiography and TUS was compared with that
of thoracic computed tomography as the gold standard [19]. TUS was superior to chest
radiography for the diagnosis of pleural effusion (93 versus 47 percent), alveolar
consolidation (97 versus 75 percent), and alveolar-interstitial syndrome (95 versus 55
percent).
● In a prospective study of 42 mechanically ventilated patients, the sensitivity and

specificity of TUS was reported as 100 and 78 percent for consolidation, 94 and 93
percent for interstitial syndromes, 75 and 93 percent for pneumothorax, and 100 and
100 percent for pleural effusion [20]. In contrast, the sensitivity of chest radiography in
the same population was significantly lower: 38 and 89 percent for consolidation, 46
and 80 percent for interstitial syndrome, 0 and 99 percent for pneumothorax, and 65
and 81 percent for pleural effusion. However, this study is flawed, likely due to the
small numbers, since in practice the sensitivity of chest radiography compared with CT
is not likely to be zero.
● In a study of 404 patients who presented to the emergency department (ED) with acute
dyspnea, the performance of TUS was similar to chest radiography for the identification
of pulmonary edema, pneumothorax, and consolidation and was superior for the
identification of pleural effusion [21].
● In a review of 16 studies, the sensitivity of ultrasound for the diagnosis of pneumonia

ranged from 57 to 100 percent with no alteration of sensitivity in critically-ill versus
non-critically-ill subgroups [22].
● In a prospective study of 177 patients who underwent chest radiograph and lung
ultrasound, lung ultrasound detected 90 percent of postoperative pulmonary
complications compared with 61 percent with chest radiograph imaging [23].
Postoperative complications were also detected earlier.
TUS may be associated with reduced imaging time and a reduction in the number of
imaging studies used during care [3,21,24]. As examples:
● In a study of 404 ED patients with acute dyspnea, ultrasound interpretation was

completed during the scan at bedside (ie, within minutes), while the average time
between a chest radiograph request and its final interpretation was 1 hour and 35
minutes [21]. Similarly, in another prospective cohort study of over 2000 ED patients
with acute dyspnea, the time to formulate a diagnosis was lower in patients in whom
point of care ultrasonography was used when compared with standard ED care (24
versus 186 minutes) [25].

● In another retrospective chart review that compared use of imaging studies in two
intensive care units (ICUs; one used all CCUS elements and the other used
ultrasonography for vascular access only), multiorgan ultrasonography (thoracic,
cardiac, lung, abdominal, vascular) reduced the number of chest radiographs
performed per patient (0.04 versus 0.10) and chest CTs (0.05 versus 0.17), as well as
other imaging studies performed per patient [3].
Evaluation and treatment of pleural effusion — TUS can easily identify and quantify the
size of an effusion at the bedside. In addition, the use of ultrasonography-guidance is
becoming commonplace for guidance of thoracentesis and other pleural access procedures,
because of the considerable inaccuracy of the physical examination and chest radiograph in
selecting a safe site for needle or catheter insertion. TUS reduces the complications
associated with thoracentesis, and in particular, allows safe thoracentesis in patients on
mechanical ventilatory support [26], an important consideration given that visceral pleural
laceration may result in a tension pneumothorax in this population. A detailed discussion of
the indications and contraindications of ultrasonography guided pleural access procedures
is presented separately. (See "Ultrasound-guided thoracentesis".)
Few data describe its value in critically-ill patients. However, one study suggested that free-
flowing effusions can be readily identified and quantified by residents after a focused
training session [27].
Evaluation for pneumothorax — Portable ultrasonography is used to detect

pneumothorax in several situations, such as after pleural or vascular access procedures, in
the evaluation of patients with chest trauma, and following chest tube placement to assess
resolution of a pneumothorax. Data indicate that TUS may be superior to standard chest
radiography for detection of pneumothorax [28-39]. TUS may also be used to guide timing of
chest tube removal following treatment of a pneumothorax [40]. Data to support these
applications are presented separately. (See "Bedside pleural ultrasonography: Equipment,
technique, and the identification of pleural effusion and pneumothorax" and "Clinical
presentation and diagnosis of pneumothorax", section on 'Pleural ultrasonography'.)
Investigational — Single-center observational studies describe several investigational

applications of TUS that have not been validated in larger studies. These include the
following:
● Titration of positive end-expiratory pressure (PEEP) in ARDS – Lung recruitment in

response to increasing levels of PEEP may be followed by imaging the aeration pattern
with lung ultrasonography (LUS) at various levels of PEEP [41]. (See "Ventilator
management strategies for adults with acute respiratory distress syndrome", section
on 'Recruitment maneuvers'.)

● Weaning Failure – Weaning failure may be predicted by the pattern of lung aeration
with bedside LUS that occurs during a spontaneous breathing trial [42]. Ultrasound can
also be used to evaluate diaphragm function in patients who are ready to wean,
although its ability to predict successful extubation is variable [43]. (See "Initial weaning
strategy in mechanically ventilated adults".)
● Resolution of ventilator associated pneumonia – The resolution of ventilator associated

pneumonia may be tracked with ultrasonography [44,45].
● Diagnosis of pulmonary embolism – In the evaluation of hemodynamically stable

patients with suspected peripheral pulmonary embolism, lung ultrasonography can
identify peripheral wedge-shaped abnormalities or alternate etiologies (eg, alveolar
consolidation) [46,47]. (See "Clinical presentation, evaluation, and diagnosis of the
nonpregnant adult with suspected acute pulmonary embolism", section on
'Investigational'.)
● Assessment of pulmonary artery occlusion pressure (PAOP) – TUS that includes analysis
of A- and B-lines correlates with the PAOP and may distinguish patients with
cardiogenic pulmonary edema (elevated PAOP) from those with acute lung injury
(normal PAOP) [13,48]. (See "Acute respiratory distress syndrome: Clinical features,
diagnosis, and complications in adults", section on 'Initial diagnostic evaluation'.)
● Predicting the development of ARDS after blunt chest trauma – The quantification of
lung contusion identified by LUS in one study predicted the occurrence of ARDS [49].
ABDOMINOPELVIC ULTRASONOGRAPHY
Abdominopelvic ultrasonography is an integral component of critical care ultrasonography

(CCUS) [1,50]. CCUS of the abdomen and pelvis most commonly evaluates patients for a
possible source of sepsis and for acute undifferentiated abdominal pain. This includes
patients suspected of having gallstones or acute cholecystitis, urinary tract obstruction, free
fluid suggestive of vessel rupture or abscess, or free air suggestive of a ruptured viscus or
gas-producing organism, all of which are discussed in this topic (see 'Detection of abdominal
free fluid' below and 'Detection of abdominal free air' below). The value of emergency
abdominal ultrasound in adults with abdominal trauma (focused assessment with
sonography for trauma [FAST]) is described separately. (See "Emergency ultrasound in adults
with abdominal and thoracic trauma".)
Critically-ill patients are generally in the supine position for abdominal ultrasonography
examinations. Focused areas to scan include the hepatorenal recess (Morrison's pouch),
splenorenal recess, right upper quadrant, left upper quadrant, left paracolic gutter, right

paracolic gutter, and suprapubic area with attention to the bladder, rectovesicular, and
rectouterine areas. Either a phased-array (1 to 5 Mhz) or a curvilinear (1 to 3 Mhz) probe can
be used for abdominal scanning. (See "Transabdominal ultrasonography of the small and
large intestine", section on 'Technical considerations'.)
Detection of gallbladder disease — Ultrasonography is a valuable modality for the

evaluation of right upper quadrant abdominal pain suspicious for symptomatic gallstones
and acute cholecystitis. Examination of the common bile duct (CBD) requires a higher level of
scanning expertise than is typically achieved with CCUS.
Certain maneuvers can help optimize gallbladder visualization; however, it may be limited in
the intensive care unit (ICU) when patients are not able to follow commands or are
mechanically ventilated. These maneuvers include holding a deep breath to descend the
gallbladder below the costal margin and placing the patient in a left lateral decubitus
position to move any gas-containing bowel away from the gallbladder.
Studies that support value of CCUS for the evaluation of gallbladder disease in critically-ill
patients include the following:
● Gallstones – Several studies of bedside CCUS report that the sensitivity and specificity
for the diagnosis of symptomatic cholelithiasis is 90 percent when performed by non-
radiologists (mostly emergency department physicians) [51-55]. (See
"Choledocholithiasis: Clinical manifestations, diagnosis, and management", section on
'Transabdominal ultrasound'.)
● Acute cholecystitis – In a retrospective study of 666 cases of acute cholecystitis and 111
cases of choledocholithiasis, few cases of cholecystitis were missed on bedside CCUS
when the following findings were present: gallstones, gallbladder wall thickening,
pericholecystic fluid, positive sonographic Murphy's sign, and cholestatic liver function
testing abnormalities [56]. The prevalence of isolated CBD dilation was less than 1
percent, suggesting that of the CBD measurement is not critical in this setting to detect
clinically significant disease of the gallbladder. (See "Acute calculous cholecystitis:
Clinical features and diagnosis", section on 'Ultrasonography'.)
Detection of urinary tract obstruction — Renal failure is a common feature of critical

illness. The differential diagnosis of renal failure includes urinary tract obstruction. Although
much less common than other causes of renal failure in the critically ill patient, it is
mandatory to consider obstructive uropathy in the differential; given that it is an eminently
treatable cause. The examination of the kidneys for hydronephrosis and bladder for
distension can be performed rapidly at the bedside with CCUS.

● Detection of hydronephrosis – Hydronephrosis results in a dilated pelvicaliceal

junction that is evident with renal CCUS ( image 1). The sensitivity and specificity of
comprehensive renal ultrasonography for the detection of hydronephrosis and the
grading system that can be applied clinically to hydronephrosis is discussed separately.
(See "Clinical manifestations and diagnosis of urinary tract obstruction and
hydronephrosis", section on 'Diagnosis'.)
Several studies in patients with abdominal pain from suspected obstructive

hydronephrosis report that renal CCUS may be of value [57-60]. In one prospective
observational study of 104 patients in the emergency department suspected as having
renal colic, bedside ultrasonography had an overall sensitivity and specificity of 88 and
85 percent, respectively for the detection of hydronephrosis [58].
Although many of the causes of hydronephrosis including obstructive stones

(parenchymal, uteropelvic, and ureterovesicular), tumors, lymphadenopathy,
abdominal aortic aneurysm, and pregnancy can be appreciated with ultrasonography,
consultative ultrasonography or other advanced imaging modalities are often needed
for full evaluation. Similarly, although renal cysts and complex renal masses can be
readily visualized with CCUS, they warrant further investigation and expert
consultation.
● Detection of bladder distension – A qualitative assessment of bladder distension is

performed by noting the location of the bladder dome to the umbilicus. When the
bladder dome extends at least halfway to the umbilicus, the majority of patients will
have urinary retention. This finding should prompt a renal CCUS evaluation to assess
for hydronephrosis. (See "Acute urinary retention", section on 'Diagnosis'.)
Bladder volume that correlates with catheterized volume can be calculated by the
following formula [61,62]:
Bladder volume = 0.75 x width x length x height
The width and length is measured in a transverse plane and the height in a sagittal
plane.
Although not absolute, bladder volumes greater than 600 mL are concerning for
bladder outlet obstruction [63]. Case reports indicate that bladder ultrasonography can
detect a range of abnormalities associated with urinary retention including bladder
masses, enterovesical fistulae, and bladder rupture [60,64-68]. Bladder masses may
appear as irregular, echogenic projections from the bladder wall or as localized bladder
wall thickening. Although the bladder wall thickness varies with the degree of filling,
the wall thickness is normally between 3 to 6 mm. In addition to malignancy, the

differential of bladder masses includes diverticula, bladder wall thickening due to

chronic cystitis, foreign bodies, stones, and blood clots. If the bladder mass disappears
with irrigation, the cause of the bladder mass was likely due to a blood clot.
Detection of abdominal aorta aneurysm rupture — The value to CCUS in the diagnosis of

a ruptured aortic aneurysm is discussed separately. (See 'Abdominal aortic syndromes' below
and "Clinical features and diagnosis of abdominal aortic aneurysm", section on 'Imaging
symptomatic patients'.)
Detection of abdominal free fluid — CCUS may be used for the assessment of free fluid to
support the presence of blood due to trauma or ruptured abdominal aortic aneurysm,
similar to that described for the FAST examination. The right and left upper quadrant is
scanned with attention to the hepatorenal and splenorenal recess, as well as the right and
left paracolic gutters, and the rectouterine (pouch of Douglas) and rectovesicular pouch.
Non-complicated collections of fluid often appear as an anechoic collection. With complexity,
fluid collections may appear as a complex non-septated collection, a homogenous complex
collection, and/or a septated collection. The presence of blood may give the appearance of
an ultrasound "hematocrit sign" (an anechoic layer interfaced with an increased echogenic
dependent layer due the gravitational effects on blood). Details regarding the role of FAST
and ultrasonographic appearance of fluid in patients with trauma are discussed separately.
(See "Emergency ultrasound in adults with abdominal and thoracic trauma", section on
'Intraperitoneal free fluid'.)
Commonly, free fluid from ascites due to a medical cause such as cirrhosis may also be
detected by CCUS and, if indicated, may guide paracentesis.
Detection of abdominal free air — Although not a well-established modality for imaging

abdominal free air, several studies have reported that abdominal free air can be identified
using ultrasonography [69]. For the sonographic examination for abdominal free air, high
frequency linear probes and curved array transducers (2.6 to 5 MHz range), are preferred to
better visualize the peritoneal layer and associated free air ( movie 1). The patient should
be positioned at an incline of 10 to 20 degrees or placed in the semi-left lateral decubitus
position to maximize the detection of air.
Ultrasonography can be used to detect the following types of abdominal free air:
● Pneumoperitoneum – The identification of free intraperitoneal air is found most

consistently over the ventral aspect of the liver when the patient is supine or in a semi-
left lateral decubitus position (also known as the enhanced peritoneal stripe sign
[EPSS]) [70,71]. EPSS consists of a superficial single or double echogenic line that
denotes the interface of the abdominal wall with the peritoneal surface. With more free
air, multiple layers of air bubbles create reverberation artifacts referred to as "Comet
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tails" and "ring-downs." Another reverberation artifact seen in pneumoperitoneum is

called A-lines. When echogenic lines run parallel to the peritoneal stripe, this is termed
"A-lines." The identification of abdominal organs, such as liver and bowel structures,
rules out pneumoperitoneum at the site of the probe position, as air blocks
transmission of ultrasonography. The detection of pneumoperitoneum has a reported
sensitivity and specificity ranging from 85 to 100 percent and 99 to 100 percent
respectively [70-78].
● Pneumoretroperitoneum – This is a rare complication of trauma, cancer, infection, or

invasive procedures. The typical ultrasonography findings include air around the right
kidney creating a "veiling" appearance, air ventral to the aorta and inferior vena cava
creating the appearance of a vanishing vessel, and air collections around the
retroperitoneal duodenum, pancreatic head, and posterior to the gallbladder [79-82].
In contrast to free intraperitoneal air, shifting of gas does not occur with positional
changes in the patient.
● Intraluminal free air – Air within lumens of non-bowel structures can be observed
within the biliary system, gallbladder, bladder, vascular structures, and pancreatic
ducts. The interpretation of these findings depends upon the clinical context, with
iatrogenic manipulation, trauma, and infection being the typical causes. Air in the
portal venous system is associated with significant morbidity and mortality and is often
the result of bowel necrosis.
● Intraparenchymal free air – Intraparenchymal free air refers to the identification of

gas within an organ (eg, liver, kidney). This most commonly occurs in the setting of
infection with abscess formation but can also be due to trauma and neoplasms. The
identification of emphysematous pyelonephritis can be made with ultrasonography,
and when found, emergency nephrectomy is often indicated.
VASCULAR ULTRASONOGRAPHY
The vascular system is an essential area of critical care ultrasonography (CCUS) application.
Key components of this area are focused on the evaluation of the following:
● Deep venous thrombosis (DVT) in the upper and lower extremity

● Venous access for central and peripheral vein catheter placement
● Arterial access for catheter placement
● Abdominal aortic syndromes
Detection of deep venous thrombosis — DVT of the upper and lower extremity is a

common cause of morbidity and mortality in critically-ill patients. Ultrasonography identifies

thrombus as non-compressibility of the imaged vein. The value of compression

ultrasonography in the diagnosis of upper and lower extremity DVT is discussed separately.
(See "Clinical presentation and diagnosis of the nonpregnant adult with suspected deep vein
thrombosis of the lower extremity", section on 'Diagnostic ultrasonography suspected first
DVT' and "Overview of thoracic central venous obstruction".)
A high frequency (5 to 10 MHz) linear transducer is used for the assessment of DVT.
Compression ultrasonography is performed in a transverse orientation since error can be
introduced when the transducer is oriented in a longitudinal axis. A firm, rapid compression
with the probe should be used with minimal to no distortion to the corresponding artery.
Compressible veins are considered patent and without thrombus, while non-compressible
veins are diagnostic of thrombus. If a thrombus is visible within the vein, the compression
component of the examination is not required and may be rarely associated with
dislodgement of the thrombus.
● Lower extremity – For the lower extremity, the patient should be in the supine
position in order to image the femoral veins. As the critically-ill patient cannot usually
assume a prone position, the popliteal vein is examined by flexing the knee with
outward rotation of the hip and placement of the linear probe in the popliteal fossa. A
compression exam with the ultrasound probe begins in the groin at the proximal
common femoral vein. Compressibility of the vein is assessed at the following five sites:
• The proximal common femoral artery and vein

• The junction of the saphenous vein and the common femoral vein
• The bifurcation of the common femoral artery and deep femoral artery
• The bifurcation of the common femoral vein into the superficial and deep femoral
vein
• The popliteal vein
Some examiners extend the examination to include the superficial femoral vein.
Whether this increases the yield compared to the standard five point examination is
debatable. Extending the examination adds very little time to the test.
In a retrospective chart review, multiorgan ultrasonography (thoracic, cardiac, lung,

abdominal, vascular) reduced the number of radiology-service-performed DVT studies
per patient (0.02 versus 0.2) [3]. In another study, bedside ultrasonography had a
sensitivity and specificity of 86 and 93 percent, respectively, compared with standard
compression ultrasonography; in addition standard compression ultrasonography was
associated with a 14 hour time delay [83].
● Upper extremity – For the upper extremity, the patient should be supine with the arm
externally rotated and abducted 90 degrees from the chest. The patient's head is

rotated to the contralateral side and elevated above the extremity to avoid external
compression of the distal subclavian vein between the first rib and clavicle. The target
vein is imaged in a transverse plane in multiple sites with a similar compression
technique to that described for the lower extremity.
Central venous access — The use of ultrasonography guidance is commonplace for

placement of central venous catheters. Several studies have shown reduced complications,
mainly arterial puncture and pneumothorax with ultrasonography-guidance. Further details
are provided separately. (See "Principles of ultrasound-guided venous access" and "Overview
of central venous access in adults" and "Central catheters for acute and chronic hemodialysis
access and their management".)
Peripheral venous and arterial access — Most peripheral venous catheters do not require
ultrasonography-guidance for successful placement. However, ultrasonography is preferred
for the placement of a peripherally inserted central venous catheter (PICC line) for patients
with veins that are not readily visualized. Similar to central venous access, pre-procedural
scanning and understanding the anatomy of the upper and lower extremity venous system
is required for the success of PICC line placement. (See "Peripheral venous access in adults",
section on 'Ultrasound guided'.)
Ultrasonography guidance for arterial guided catheters also improves success and reduces
complication rates, the details of which are provided separately. (See "Arterial blood gases",
section on 'Technical challenges' and "Intra-arterial catheterization for invasive monitoring:
Indications, insertion techniques, and interpretation", section on 'Use of ultrasound
guidance'.)
Abdominal aortic syndromes — Abdominal aortic syndromes, including ruptured

abdominal aortic aneurysms (AAA) and dissection are identified with ultrasonography
assessment. In hemodynamically unstable patients, ultrasound is the imaging modality of
first choice for the diagnosis of a ruptured AAA. Expected findings include an enlarged aorta
with or without a fluid collection in the abdomen. In the emergency department, several
studies report high sensitivity (97.5 to 100 percent) and specificity (94.1 to 100 percent) for
AAA detection using bedside ultrasonography compared with computed tomography (CT)
and magnetic resonance imaging [84-87]. Similarly, the ultrasonography detection of
abdominal aorta dissection has comparable sensitivity when compared to CT. Detailed
discussion of ultrasonography for the diagnosis of AAA and aortic dissection is provided
separately. (See 'Abdominopelvic ultrasonography' above and "Emergency ultrasound in
adults with abdominal and thoracic trauma" and "Clinical features and diagnosis of acute
aortic dissection", section on 'Diagnosis' and "Clinical features and diagnosis of abdominal
aortic aneurysm", section on 'Imaging symptomatic patients'.)

BASIC CRITICAL CARE ECHOCARDIOGRAPHY
Critical care echocardiography (CCE) can be classified as basic and advanced. Basic CCE,
which is discussed in this topic, utilizes a limited number of standard echocardiographic
views which include the parasternal long axis, parasternal short axis, apical four chamber,
subcostal long axis, and inferior vena cava long axis views. The technical aspects of
consultative transthoracic echo is discussed separately. (See "Emergency ultrasound in
adults with abdominal and thoracic trauma" and "Transthoracic echocardiography: Normal
cardiac anatomy and tomographic views".)
Patient-specific factors such as obesity, heavy musculature, surgical dressings, and chest
drains may limit image acquisition. On occasion, image quality will not be adequate for
clinical purposes. In this case, transesophageal echocardiography may be indicated,
although requiring a higher level of training. Independent of patient specific factors, the
examiner may have difficulty in obtaining an effective scanning position due to equipment
that surrounds the patient or the patient may be difficult to position for optimal image
acquisition. (See "Transesophageal echocardiography: Indications, complications, and
normal views".)
The basic CCE examination does not include Doppler measurements of cardiac pressures or
flows, or other standard views used for a full echocardiography examination. Competence in
basic CCE includes training in when to call for a complete examination that needs to be
performed by a clinician who is fully trained in advanced critical care echocardiography
including transesophageal echocardiography.
Limited cardiac ultrasound is not a replacement for routine echocardiography. A meta-

analysis of nine studies that compared focused cardiac ultrasound (FoCUS)-assisted clinical
assessment with clinical assessment alone reported that while FoCUS examination of the left
ventricle and mitral valve was more sensitive than clinical assessment alone (84 versus 43
percent), its specificity was similar (89 versus 81 percent) [88].
Evaluation of shock — Basic CCE is useful for evaluating patients with undifferentiated

shock ( algorithm 1) [89]. Basic CCE is most often used in combination with thoracic,
abdominal, and/or vascular elements of critical care ultrasonography (CCUS). In published
protocols that promote multiorgan ultrasonography in patients with shock (eg, rapid
ultrasound in shock [RUSH] or abdominal and cardiac evaluation with sonography in shock
[ACES]) [90-92], the heart is typically examined first, followed by ultrasound of the chest and
abdomen and major blood vessels; however, other protocols such as focused cardiac
ultrasound (FOCUS) examine the heart only [93]. Details regarding point of care
ultrasonography in shock are provided separately. (See "Evaluation of and initial approach to

the adult patient with undifferentiated hypotension and shock", section on 'Point-of-care
ultrasonography'.)
In brief, in patients with undifferentiated shock, multiorgan CCUS that includes basic CCE is
useful for the following:
● Classification of shock – CCE helps to categorize shock into hypovolemic, obstructive,

cardiogenic, or distributive shock. This guides the intensivist in establishing initial
management strategy with volume resuscitation, vasopressors, inotropes, and/or
mechanical circulatory support. (See "Definition, classification, etiology, and
pathophysiology of shock in adults" and "Evaluation of and initial approach to the adult
patient with undifferentiated hypotension and shock", section on 'Point-of-care
ultrasonography'.)
● Identification of life-threatening cardiac causes of shock – These include pericardial

tamponade, acute cor pulmonale, hyperdynamic left ventricle (LV) with outflow
obstruction due to hypovolemia and inappropriate use of inotropes, LV outflow
obstruction following aortic valve replacement surgery, catastrophic left sided valve
failure, very severe LV dysfunction, or acute RV dysfunction. (See "Evaluation of and
initial approach to the adult patient with undifferentiated hypotension and shock",
section on 'Point-of-care ultrasonography'.)
● Tracking evolution of disease and response to therapy using serial CCE examinations.
Data supporting the use of CCE is mostly derived in studies in the emergency department
and intensive care unit setting. These studies demonstrate that a multiorgan scanning
approach that includes basic CCE is useful to narrow the differential diagnosis, to confirm a
clinically suspected diagnosis, to prompt changes in management, and/or to detect a
complication from a therapeutic procedure. There is no study that has examined any effect
on mortality. These data are described separately. (See "Evaluation of and initial approach to
the adult patient with undifferentiated hypotension and shock", section on 'Point-of-care
ultrasonography'.)
Evaluation of acute cardiopulmonary failure — CCE alone may also be useful for the
diagnosis of cardiogenic pulmonary edema [94,95]. A meta-analysis of seven prospective
cohort studies reported that in patients who present to the emergency department with a
moderate to high pretest probability of acute pulmonary edema, bedside CCE showing B-
lines had a sensitivity and specificity of 94 and 92 percent, respectively [94].
The addition of CCE to other elements of CCUS improves the diagnostic ability of
ultrasonography for evaluation of acute respiratory failure. In a prospective study of 136
patients with acute respiratory failure, adding CCE to thoracic ultrasonography (TUS)

improved diagnostic accuracy for cardiogenic pulmonary edema, pulmonary embolism, and
pneumonia, when compared with TUS alone [96].
The use of CCE as part of a multiorgan assessment strategy may decrease the use of
comprehensive echocardiography assessments. In a retrospective chart review, multiorgan
ultrasonography (thoracic, cardiac, lung, abdominal, vascular) reduced the number of
consultative echocardiography studies per patient (0.07 versus 0.18) [3].
Cardiopulmonary resuscitation — In patients undergoing cardiopulmonary resuscitation,

bedside CCE has been used during pulse checks in order identify potentially reversible
causes of cardiac arrest such as pericardial tamponade, profound hypovolemia, or thrombus
in transit with acute cor pulmonale [97]. Alternatively, the finding of absent cardiac
contractility following a reasonable period of cardiopulmonary resuscitation (CPR) indicates
limited probability for return of spontaneous circulation [98,99]. (See "Advanced cardiac life
support (ACLS) in adults".)
Investigational — Use of CCE has been described for patients undergoing extracorporeal

membrane oxygenation for cannula placement, to follow hemodynamics and to identify
those that can be weaned [100-102].
TRAINING AND COMPETENCE
Acquiring the necessary skills for performing critical care thoracic, abdominal, and vascular
ultrasonography depends upon an understanding of normal and abnormal ultrasonography
anatomy to avoid image misinterpretation. In addition, the clinician should understand the
indications as well as limitations of critical care ultrasonography (CCUS). One standard
definition of competence is available that is supplemented by an expert consensus
statement on training in CCUS [1,50]. One study reported that a three-day course resulted in
improved CCUS skills but further studies are needed to determine whether such courses will
translate into effective clinical practice [103].
Non-cardiologists can achieve competence in basic critical care echocardiography (CCE) with
appropriate training [104-117]. The use of basic CCE is supported by the American College of
Chest Physicians (ACCP), European Society of Intensive Care Medicine, American Society of
Echocardiography, and an international committee on focused cardiac ultrasound
[1,50,93,118,119]. Although requirements for training in basic CCE have not been
standardized, a typical training sequence includes a didactic component for mastery of the
cognitive base of CCE, hands-on training initially with normal human subjects followed by
scanning of patients under the supervision of a capable instructor, and review of a
comprehensive image set representative of a wide range of normal and abnormal findings.
As a guide, one report indicates that a 12-hour learning program blending didactics,
interactive clinical cases, and tutored hands-on sessions is a sufficient training period for
basic CCE [120].
SUMMARY AND RECOMMENDATIONS
● Critical care ultrasonography (CCUS) refers to the use of ultrasonography in patients

who are critically-ill. Compared with consultative ultrasonography, CCUS is a bedside
tool that can be rapidly performed and interpreted simultaneously by the operator,
usually an intensivist or emergency department physician, prompting a diagnosis, a
procedure, and/or a therapy. The most common four elements of CCUS are thoracic,
abdominal, vascular, and cardiac. (See 'Introduction' above and 'Terminology and
definition' above.)
● Choosing consultative radiology- or cardiology -performed ultrasonography or CCUS is

dependent upon available equipment and skill as well as the indication. While
consultative ultrasonography assessment is useful for hemodynamically stable patients
with complex disorders that require skilled expertise, CCUS is typically best suited for
patients with imminently life threatening processes, in whom the result will determine
the administration of a specific or life-saving therapy. (See 'Choosing consultative or
critical care ultrasonography' above.)
● Thoracic ultrasonography (TUS) includes ultrasonography of both the lung and the
pleural space. In the critically-ill patient, TUS can be used to evaluate patients with
acute cardiopulmonary respiratory failure, pleural effusion, and pneumothorax. (See
'Thoracic ultrasonography' above and "Bedside pleural ultrasonography: Equipment,
technique, and the identification of pleural effusion and pneumothorax" and
"Ultrasound-guided thoracentesis".)
● Abdominopelvic CCUS is useful for the evaluation of a possible source of sepsis and
acute undifferentiated abdominal pain. This includes patients suspected as having
gallstones or acute cholecystitis, urinary tract obstruction, free fluid suggestive of
vessel rupture or abscess, or free air suggestive of a ruptured viscus or gas-producing
organism. Emergency abdominopelvic ultrasonography is useful in the evaluation of
patients suspected as having contusion or bleeding from abdominal trauma. (See
'Abdominopelvic ultrasonography' above and "Emergency ultrasound in adults with
abdominal and thoracic trauma", section on 'Abdominal examination'.)
● Vascular CCUS includes the evaluation of upper and lower extremities for deep venous
thrombosis (DVT), imaging of central and peripheral veins and arteries for catheter
placement, and evaluation of the aorta for rupture or dissection. (See 'Vascular
ultrasonography' above and "Clinical features and diagnosis of abdominal aortic
aneurysm", section on 'Diagnosis' and "Principles of ultrasound-guided venous access"

and "Clinical presentation and diagnosis of the nonpregnant adult with suspected deep
vein thrombosis of the lower extremity", section on 'Diagnostic ultrasonography
suspected first DVT'.)
● Critical care echocardiography (CCE) can be classified as basic or advanced. Basic CCE,
which is discussed in this topic, is useful in the evaluation of patients with
undifferentiated shock or acute cardiopulmonary failure; occasionally it can be used to
identify potentially reversible etiologies of cardiopulmonary resuscitation. (See 'Basic
critical care echocardiography' above.)
● Acquiring the necessary skills for performing CCUS depends upon an understanding of
normal and abnormal ultrasonography anatomy to avoid image misinterpretation as
well as a knowledge of the indications and limitations of CCUS. (See 'Training and
competence' above.)
ACKNOWLEDGMENT
The UpToDate editorial staff acknowledges Peter Doelken, MD, FCCP, who contributed to an
earlier version of this topic review.
Use of UpToDate is subject to the Terms of Use.
REFERENCES
1. Mayo PH, Beaulieu Y, Doelken P, et al. American College of Chest Physicians/La Société
de Réanimation de Langue Française statement on competence in critical care
ultrasonography. Chest 2009; 135:1050.
2. Zieleskiewicz L, Muller L, Lakhal K, et al. Point-of-care ultrasound in intensive care units:
assessment of 1073 procedures in a multicentric, prospective, observational study.
Intensive Care Med 2015; 41:1638.
3. Oks M, Cleven KL, Cardenas-Garcia J, et al. The effect of point-of-care ultrasonography

on imaging studies in the medical ICU: a comparative study. Chest 2014; 146:1574.
4. Gartlehner G, Wagner G, Affengruber L, et al. Point-of-Care Ultrasonography in Patients

With Acute Dyspnea: An Evidence Report for a Clinical Practice Guideline by the
American College of Physicians. Ann Intern Med 2021; 174:967.
5. Expert Panel on Thoracic Imaging, Laroia AT, Donnelly EF, et al. ACR Appropriateness
Criteria® Intensive Care Unit Patients. J Am Coll Radiol 2021; 18:S62.
6. Lichtenstein D. Lung ultrasound in the critically ill. Curr Opin Crit Care 2014; 20:315.

7. Lichtenstein DA. BLUE-protocol and FALLS-protocol: two applications of lung ultrasound

in the critically ill. Chest 2015; 147:1659.
8. Lichtenstein DA, Menu Y. A bedside ultrasound sign ruling out pneumothorax in the
critically ill. Lung sliding. Chest 1995; 108:1345.
9. Lichtenstein D, Mezière G, Biderman P, Gepner A. The comet-tail artifact: an ultrasound
sign ruling out pneumothorax. Intensive Care Med 1999; 25:383.
10. Lichtenstein D, Mezière G, Biderman P, Gepner A. The "lung point": an ultrasound sign
specific to pneumothorax. Intensive Care Med 2000; 26:1434.
11. Lichtenstein DA, et al. Relevance of lung ultrasonography in the diagnosis of acute respi
ratory failure: The BLUE protocol Chest 2008; 134:117.
12. Lichtenstein D, Mézière G, Biderman P, et al. The comet-tail artifact. An ultrasound sign
of alveolar-interstitial syndrome. Am J Respir Crit Care Med 1997; 156:1640.
13. Copetti R, Soldati G, Copetti P. Chest sonography: a useful tool to differentiate acute
cardiogenic pulmonary edema from acute respiratory distress syndrome. Cardiovasc
Ultrasound 2008; 6:16.
14. Staub LJ, Biscaro RRM, Maurici R. Accuracy and Applications of Lung Ultrasound to
Diagnose Ventilator-Associated Pneumonia: A Systematic Review. J Intensive Care Med
2018; 33:447.
15. Staub LJ, Mazzali Biscaro RR, Kaszubowski E, Maurici R. Lung Ultrasound for the
Emergency Diagnosis of Pneumonia, Acute Heart Failure, and Exacerbations of Chronic
Obstructive Pulmonary Disease/Asthma in Adults: A Systematic Review and Meta-
analysis. J Emerg Med 2019; 56:53.
16. Chiumello D, Umbrello M, Sferrazza Papa GF, et al. Global and Regional Diagnostic
Accuracy of Lung Ultrasound Compared to CT in Patients With Acute Respiratory
Distress Syndrome. Crit Care Med 2019; 47:1599.
17. Tierney DM, Huelster JS, Overgaard JD, et al. Comparative Performance of Pulmonary
Ultrasound, Chest Radiograph, and CT Among Patients With Acute Respiratory Failure.
Crit Care Med 2020; 48:151.
18. Lichtenstein DA, Lascols N, Mezière G, Gepner A. Ultrasound diagnosis of alveolar

consolidation in the critically ill. Intensive Care Med 2004; 30:276.
19. Lichtenstein D, Goldstein I, Mourgeon E, et al. Comparative diagnostic performances of
auscultation, chest radiography, and lung ultrasonography in acute respiratory distress
syndrome. Anesthesiology 2004; 100:9.
20. Xirouchaki N, Magkanas E, Vaporidi K, et al. Lung ultrasound in critically ill patients:
comparison with bedside chest radiography. Intensive Care Med 2011; 37:1488.

21. Zanobetti M, Poggioni C, Pini R. Can chest ultrasonography replace standard chest
radiography for evaluation of acute dyspnea in the ED? Chest 2011; 139:1140.
22. Llamas-Álvarez AM, Tenza-Lozano EM, Latour-Pérez J. Accuracy of Lung Ultrasonography

in the Diagnosis of Pneumonia in Adults: Systematic Review and Meta-Analysis. Chest
2017; 151:374.
23. Touw HR, Parlevliet KL, Beerepoot M, et al. Lung ultrasound compared with chest X-ray
in diagnosing postoperative pulmonary complications following cardiothoracic surgery:
a prospective observational study. Anaesthesia 2018; 73:946.
24. Peris A, Tutino L, Zagli G, et al. The use of point-of-care bedside lung ultrasound
significantly reduces the number of radiographs and computed tomography scans in
critically ill patients. Anesth Analg 2010; 111:687.
25. Zanobetti M, Scorpiniti M, Gigli C, et al. Point-of-Care Ultrasonography for Evaluation of
Acute Dyspnea in the ED. Chest 2017; 151:1295.
26. Mayo PH, Goltz HR, Tafreshi M, Doelken P. Safety of ultrasound-guided thoracentesis in
patients receiving mechanical ventilation. Chest 2004; 125:1059.
27. Begot E, Grumann A, Duvoid T, et al. Ultrasonographic identification and
semiquantitative assessment of unloculated pleural effusions in critically ill patients by
residents after a focused training. Intensive Care Med 2014; 40:1475.
28. Lamb AD, Qadan M, Gray AJ. Detection of occult pneumothoraces in the significantly
injured adult with blunt trauma. Eur J Emerg Med 2007; 14:65.
29. Trupka A, Waydhas C, Hallfeldt KK, et al. Value of thoracic computed tomography in the
first assessment of severely injured patients with blunt chest trauma: results of a
prospective study. J Trauma 1997; 43:405.
30. Soldati G, Testa A, Sher S, et al. Occult traumatic pneumothorax: diagnostic accuracy of
lung ultrasonography in the emergency department. Chest 2008; 133:204.
31. Lichtenstein DA, Mezière G, Lascols N, et al. Ultrasound diagnosis of occult

pneumothorax. Crit Care Med 2005; 33:1231.
32. Sartori S, Tombesi P, Trevisani L, et al. Accuracy of transthoracic sonography in detection

of pneumothorax after sonographically guided lung biopsy: prospective comparison
with chest radiography. AJR Am J Roentgenol 2007; 188:37.
33. Reissig A, Kroegel C. Accuracy of transthoracic sonography in excluding post-
interventional pneumothorax and hydropneumothorax. Comparison to chest
radiography. Eur J Radiol 2005; 53:463.
34. Jalli R, Sefidbakht S, Jafari SH. Value of ultrasound in diagnosis of pneumothorax: a
prospective study. Emerg Radiol 2013; 20:131.

35. Wilkerson RG, Stone MB. Sensitivity of bedside ultrasound and supine anteroposterior
chest radiographs for the identification of pneumothorax after blunt trauma. Acad
Emerg Med 2010; 17:11.
36. Raja AS, Jacobus CH. How accurate is ultrasonography for excluding pneumothorax?
Ann Emerg Med 2013; 61:207.
37. Alrajhi K, Woo MY, Vaillancourt C. Test characteristics of ultrasonography for the
detection of pneumothorax: a systematic review and meta-analysis. Chest 2012;
141:703.
38. Alrajab S, Youssef AM, Akkus NI, Caldito G. Pleural ultrasonography versus chest
radiography for the diagnosis of pneumothorax: review of the literature and meta-
analysis. Crit Care 2013; 17:R208.
39. Chan KK, Joo DA, McRae AD, et al. Chest ultrasonography versus supine chest
radiography for diagnosis of pneumothorax in trauma patients in the emergency
department. Cochrane Database Syst Rev 2020; 7:CD013031.
40. Galbois A, Ait-Oufella H, Baudel JL, et al. Pleural ultrasound compared with chest
radiographic detection of pneumothorax resolution after drainage. Chest 2010; 138:648.
41. Bouhemad B, Brisson H, Le-Guen M, et al. Bedside ultrasound assessment of positive

end-expiratory pressure-induced lung recruitment. Am J Respir Crit Care Med 2011;
183:341.
42. Soummer A, Perbet S, Brisson H, et al. Ultrasound assessment of lung aeration loss
during a successful weaning trial predicts postextubation distress*. Crit Care Med 2012;
40:2064.
43. Llamas-Álvarez AM, Tenza-Lozano EM, Latour-Pérez J. Diaphragm and Lung Ultrasound
to Predict Weaning Outcome: Systematic Review and Meta-Analysis. Chest 2017;
152:1140.
44. Reissig A, Copetti R, Mathis G, et al. Lung ultrasound in the diagnosis and follow-up of
community-acquired pneumonia: a prospective, multicenter, diagnostic accuracy study.
Chest 2012; 142:965.
45. Bouhemad B, Liu ZH, Arbelot C, et al. Ultrasound assessment of antibiotic-induced

pulmonary reaeration in ventilator-associated pneumonia. Crit Care Med 2010; 38:84.
46. Mathis G, Blank W, Reissig A, et al. Thoracic ultrasound for diagnosing pulmonary
embolism: a prospective multicenter study of 352 patients. Chest 2005; 128:1531.
47. Koenig S, Chandra S, Alaverdian A, et al. Ultrasound assessment of pulmonary

embolism in patients receiving CT pulmonary angiography. Chest 2014; 145:818.
48. Lichtenstein DA, Mezière GA, Lagoueyte JF, et al. A-lines and B-lines: lung ultrasound as
a bedside tool for predicting pulmonary artery occlusion pressure in the critically ill.
Chest 2009; 136:1014.
49. Leblanc D, Bouvet C, Degiovanni F, et al. Early lung ultrasonography predicts the
occurrence of acute respiratory distress syndrome in blunt trauma patients. Intensive
Care Med 2014; 40:1468.
50. Expert Round Table on Ultrasound in ICU. International expert statement on training
standards for critical care ultrasonography. Intensive Care Med 2011; 37:1077.
51. Scruggs W, Fox JC, Potts B, et al. Accuracy of ED Bedside Ultrasound for Identification of
gallstones: retrospective analysis of 575 studies. West J Emerg Med 2008; 9:1.
52. Schlager D, Lazzareschi G, Whitten D, Sanders AB. A prospective study of

ultrasonography in the ED by emergency physicians. Am J Emerg Med 1994; 12:185.
53. Durston W, Carl ML, Guerra W, et al. Comparison of quality and cost-effectiveness in the
evaluation of symptomatic cholelithiasis with different approaches to ultrasound
availability in the ED. Am J Emerg Med 2001; 19:260.
54. Rosen CL, Brown DF, Chang Y, et al. Ultrasonography by emergency physicians in
patients with suspected cholecystitis. Am J Emerg Med 2001; 19:32.
55. Kendall JL, Shimp RJ. Performance and interpretation of focused right upper quadrant
ultrasound by emergency physicians. J Emerg Med 2001; 21:7.
56. Becker BA, Chin E, Mervis E, et al. Emergency biliary sonography: utility of common bile
duct measurement in the diagnosis of cholecystitis and choledocholithiasis. J Emerg
Med 2014; 46:54.
57. Rosen CL, Brown DF, Sagarin MJ, et al. Ultrasonography by emergency physicians in
patients with suspected ureteral colic. J Emerg Med 1998; 16:865.
58. Gaspari RJ, Horst K. Emergency ultrasound and urinalysis in the evaluation of flank pain.
Acad Emerg Med 2005; 12:1180.
59. Kartal M, Eray O, Erdogru T, Yilmaz S. Prospective validation of a current algorithm
including bedside US performed by emergency physicians for patients with acute flank
pain suspected for renal colic. Emerg Med J 2006; 23:341.
60. Henderson SO, Hoffner RJ, Aragona JL, et al. Bedside emergency department
ultrasonography plus radiography of the kidneys, ureters, and bladder vs intravenous
pyelography in the evaluation of suspected ureteral colic. Acad Emerg Med 1998; 5:666.
61. Fileni A, Renzetti R, Di Marco G, et al. [Ultrasonographic assessment of bladder volume].
Arch Ital Urol Androl 2002; 74:267.
62. Byun SS, Kim HH, Lee E, et al. Accuracy of bladder volume determinations by
ultrasonography: are they accurate over entire bladder volume range? Urology 2003;
62:656.
63. Purohit RS, Blaivas JG, Saleem KL, et al. The pathophysiology of large capacity bladder. J
Urol 2008; 179:1006.

64. Wu TS, Pearson TC, Meiners S, Daugharthy J. Bedside ultrasound diagnosis of a

traumatic bladder rupture. J Emerg Med 2011; 41:520.
65. Daignault MC, Saul T, Lewiss RE. Bedside ultrasound diagnosis of atraumatic bladder
rupture in an alcohol-intoxicated patient: a case report. Crit Ultrasound J 2012; 4:9.
66. Hajiran A, Point DC, Zaslau S. Bedside ultrasound in workup of self-inserted headset
cable into the penile urethra and incidentally discovered intravesical foreign body. Case
Rep Emerg Med 2013; 2013:587018.
67. Vaidyanathan S, Hughes PL, Soni BM. A simple radiological technique for demonstration
of incorrect positioning of a foley catheter with balloon inflated in the urethra of a male
spinal cord injury patient. ScientificWorldJournal 2006; 6:2445.
68. Sutijono D. Point-of-care sonographic diagnosis of an enterovesical fistula. J Ultrasound
Med 2013; 32:883.
69. Hoffmann B, Nürnberg D, Westergaard MC. Focus on abnormal air: diagnostic

ultrasonography for the acute abdomen. Eur J Emerg Med 2012; 19:284.
70. Seitz K, Reising KD. [Ultrasound detection of free air in the abdominal cavity]. Ultraschall
Med 1982; 3:4.
71. Muradali D, Wilson S, Burns PN, et al. A specific sign of pneumoperitoneum on
sonography: enhancement of the peritoneal stripe. AJR Am J Roentgenol 1999;
173:1257.
72. Asrani A. Sonographic diagnosis of pneumoperitoneum using the 'enhancement of the
peritoneal stripe sign.' A prospective study. Emerg Radiol 2007; 14:29.
73. Coppolino F, Gatta G, Di Grezia G, et al. Gastrointestinal perforation: ultrasonographic
diagnosis. Crit Ultrasound J 2013; 5 Suppl 1:S4.
74. Hefny AF, Abu-Zidan FM. Sonographic diagnosis of intraperitoneal free air. J Emerg
Trauma Shock 2011; 4:511.
75. Kim SY, Park KT, Yeon SC, Lee HC. Accuracy of sonographic diagnosis of
pneumoperitoneum using the enhanced peritoneal stripe sign in Beagle dogs. J Vet Sci
2014; 15:195.
76. Marolf A, Blaik M, Ackerman N, et al. Comparison of computed radiography and
conventional radiography in detection of small volume pneumoperitoneum. Vet Radiol
Ultrasound 2008; 49:227.
77. Chen SC, Yen ZS, Wang HP, et al. Ultrasonography is superior to plain radiography in the
diagnosis of pneumoperitoneum. Br J Surg 2002; 89:351.
78. Fujii Y, Asato M, Taniguchi N, et al. Sonographic diagnosis and successful nonoperative
management of sealed perforated duodenal ulcer. J Clin Ultrasound 2003; 31:55.

79. Langfeldt S, Pedersen PR, Nepper-Rasmussen J. [Diagnosis of retroperitoneal air using

ultrasound and radiology in duodenal rupture after blunt abdominal trauma].
Rontgenblatter 1989; 42:478.
80. McWilliams RG, Blakeborough A, Johnson MI, Weston M. Case report: The "veiled right
kidney sign"--an ultrasound finding in retroperitoneal perforation of the duodenum. Br J
Radiol 1996; 69:1061.
81. Oschatz E, Strasser G, Schober E, et al. ["Disappearance" of retroperitoneal vessels - a
case report]. Ultraschall Med 2003; 24:410.
82. Sezgin O, Ulker A, Temuçin G. Retroperitoneal duodenal perforation during endoscopic
sphincterotomy: sonographic findings. J Clin Ultrasound 2000; 28:303.
83. Kory PD, Pellecchia CM, Shiloh AL, et al. Accuracy of ultrasonography performed by
critical care physicians for the diagnosis of DVT. Chest 2011; 139:538.
84. Costantino TG, Bruno EC, Handly N, Dean AJ. Accuracy of emergency medicine
ultrasound in the evaluation of abdominal aortic aneurysm. J Emerg Med 2005; 29:455.
85. Dent B, Kendall RJ, Boyle AA, Atkinson PR. Emergency ultrasound of the abdominal aorta
by UK emergency physicians: a prospective cohort study. Emerg Med J 2007; 24:547.
86. Knaut AL, Kendall JL, Patten R, Ray C. Ultrasonographic measurement of aortic diameter
by emergency physicians approximates results obtained by computed tomography. J
Emerg Med 2005; 28:119.
87. Kuhn M, Bonnin RL, Davey MJ, et al. Emergency department ultrasound scanning for
abdominal aortic aneurysm: accessible, accurate, and advantageous. Ann Emerg Med
2000; 36:219.
88. Marbach JA, Almufleh A, Di Santo P, et al. Comparative Accuracy of Focused Cardiac
Ultrasonography and Clinical Examination for Left Ventricular Dysfunction and Valvular
Heart Disease: A Systematic Review and Meta-analysis. Ann Intern Med 2019; 171:264.
89. Schmidt GA, Koenig S, Mayo PH. Shock: ultrasound to guide diagnosis and therapy.
Chest 2012; 142:1042.
90. Perera P, Mailhot T, Riley D, Mandavia D. The RUSH exam: Rapid Ultrasound in SHock in
the evaluation of the critically lll. Emerg Med Clin North Am 2010; 28:29.
91. Atkinson PR, McAuley DJ, Kendall RJ, et al. Abdominal and Cardiac Evaluation with
Sonography in Shock (ACES): an approach by emergency physicians for the use of
ultrasound in patients with undifferentiated hypotension. Emerg Med J 2009; 26:87.
92. Shokoohi H, Boniface KS, Pourmand A, et al. Bedside Ultrasound Reduces Diagnostic
Uncertainty and Guides Resuscitation in Patients With Undifferentiated Hypotension.
Crit Care Med 2015; 43:2562.

93. Labovitz AJ, Noble VE, Bierig M, et al. Focused cardiac ultrasound in the emergent
setting: a consensus statement of the American Society of Echocardiography and
American College of Emergency Physicians. J Am Soc Echocardiogr 2010; 23:1225.
94. Al Deeb M, Barbic S, Featherstone R, et al. Point-of-care ultrasonography for the
diagnosis of acute cardiogenic pulmonary edema in patients presenting with acute
dyspnea: a systematic review and meta-analysis. Acad Emerg Med 2014; 21:843.
95. Buessler A, Chouihed T, Duarte K, et al. Accuracy of Several Lung Ultrasound Methods
for the Diagnosis of Acute Heart Failure in the ED: A Multicenter Prospective Study.
Chest 2020; 157:99.
96. Bataille B, Riu B, Ferre F, et al. Integrated use of bedside lung ultrasound and
echocardiography in acute respiratory failure: a prospective observational study in ICU.
Chest 2014; 146:1586.
97. Chardoli M, Heidari F, Rabiee H, et al. Echocardiography integrated ACLS protocol versus
conventional cardiopulmonary resuscitation in patients with pulseless electrical activity
cardiac arrest. Chin J Traumatol 2012; 15:284.
98. Blaivas M, Fox JC. Outcome in cardiac arrest patients found to have cardiac standstill on
the bedside emergency department echocardiogram. Acad Emerg Med 2001; 8:616.
99. Cureton EL, Yeung LY, Kwan RO, et al. The heart of the matter: utility of ultrasound of
cardiac activity during traumatic arrest. J Trauma Acute Care Surg 2012; 73:102.
100. Platts DG, Sedgwick JF, Burstow DJ, et al. The role of echocardiography in the
management of patients supported by extracorporeal membrane oxygenation. J Am Soc
Echocardiogr 2012; 25:131.
101. Cavarocchi NC, Pitcher HT, Yang Q, et al. Weaning of extracorporeal membrane
oxygenation using continuous hemodynamic transesophageal echocardiography. J
Thorac Cardiovasc Surg 2013; 146:1474.
102. Aissaoui N, Luyt CE, Leprince P, et al. Predictors of successful extracorporeal membrane
oxygenation (ECMO) weaning after assistance for refractory cardiogenic shock.
Intensive Care Med 2011; 37:1738.
103. Greenstein YY, Littauer R, Narasimhan M, et al. Effectiveness of a Critical Care
Ultrasonography Course. Chest 2017; 151:34.
104. Sabia P, Abbott RD, Afrookteh A, et al. Importance of two-dimensional
echocardiographic assessment of left ventricular systolic function in patients presenting
to the emergency room with cardiac-related symptoms. Circulation 1991; 84:1615.
105. Mandavia DP, Hoffner RJ, Mahaney K, Henderson SO. Bedside echocardiography by
emergency physicians. Ann Emerg Med 2001; 38:377.
106. Moore CL, Rose GA, Tayal VS, et al. Determination of left ventricular function by
emergency physician echocardiography of hypotensive patients. Acad Emerg Med 2002;
9:186.
107. Jones AE, Tayal VS, Kline JA. Focused training of emergency medicine residents in goal-
directed echocardiography: a prospective study. Acad Emerg Med 2003; 10:1054.
108. Vignon P, Chastagner C, François B, et al. Diagnostic ability of hand-held

echocardiography in ventilated critically ill patients. Crit Care 2003; 7:R84.
109. Randazzo MR, Snoey ER, Levitt MA, Binder K. Accuracy of emergency physician
assessment of left ventricular ejection fraction and central venous pressure using
echocardiography. Acad Emerg Med 2003; 10:973.
110. DeCara JM, Lang RM, Koch R, et al. The use of small personal ultrasound devices by
internists without formal training in echocardiography. Eur J Echocardiogr 2003; 4:141.
111. Lemola K, Yamada E, Jagasia D, Kerber RE. A hand-carried personal ultrasound device
for rapid evaluation of left ventricular function: use after limited echo training.
Echocardiography 2003; 20:309.
112. Pershad J, Myers S, Plouman C, et al. Bedside limited echocardiography by the

emergency physician is accurate during evaluation of the critically ill patient. Pediatrics
2004; 114:e667.
113. Manasia AR, Nagaraj HM, Kodali RB, et al. Feasibility and potential clinical utility of goal-
directed transthoracic echocardiography performed by noncardiologist intensivists
using a small hand-carried device (SonoHeart) in critically ill patients. J Cardiothorac
Vasc Anesth 2005; 19:155.
114. Royse CF, Seah JL, Donelan L, Royse AG. Point of care ultrasound for basic
haemodynamic assessment: novice compared with an expert operator. Anaesthesia
2006; 61:849.
115. Mark DG, Hayden GE, Ky B, et al. Hand-carried echocardiography for assessment of left
ventricular filling and ejection fraction in the surgical intensive care unit. J Crit Care
2009; 24:470.e1.
116. Melamed R, Sprenkle MD, Ulstad VK, et al. Assessment of left ventricular function by
intensivists using hand-held echocardiography. Chest 2009; 135:1416.
117. Prinz C, Dohrmann J, van Buuren F, et al. The importance of training in

echocardiography: a validation study using pocket echocardiography. J Cardiovasc Med
(Hagerstown) 2012; 13:700.
118. Via G, Hussain A, Wells M, et al. International evidence-based recommendations for

focused cardiac ultrasound. J Am Soc Echocardiogr 2014; 27:683.e1.
119. Rajamani A, Galarza L, Sanfilippo F, et al. Criteria, Processes, and Determination of

Competence in Basic Critical Care Echocardiography Training: A Delphi Process
Consensus Statement by the Learning Ultrasound in Critical Care (LUCC) Initiative. Chest
2022; 161:492.
120. Vignon P, Mücke F, Bellec F, et al. Basic critical care echocardiography: validation of a
curriculum dedicated to noncardiologist residents. Crit Care Med 2011; 39:636.
Topic 14867 Version 28.0

GRAPHICS
Ultrasonographic appearance of hydronephrosis
This image of the kidney demonstrates hydronephrosis. The renal

calyces and renal sinus are distended with urine due to downstream
blockage of urine outflow.
Graphic 119827 Version 1.0

Approach to the patient with undifferentiated

hypotension or shock: Initial approach
The shaded boxes indicate the points in the process at which no

further action needs to be taken, a diagnosis has been made, or
continued resuscitation is required.
IV: intravascular; ACLS: advanced cardiac life support; MI: myocardial

infarction; PE: pulmonary embolus.
* The first priority is to stabilize the airway with oxygen and/or

mechanical ventilation. Although most patients are intubated, not
every patient requires mechanical ventilation (eg, those with a
tension pneumothorax).
¶ Aggressive fluids and blood products may be required for those

with hemorrhage. Fluids should not be administered if the etiology
is thought to be due to cardiogenic shock.

Graphic 99357 Version 3.0

Contributor Disclosures
John T Huggins, MD Grant/Research/Clinical Trial Support: Boehringer Ingelheim; Roche/Genentech;
Fibrogen; TORAY; Nitto-Denko [IPF]. Consultant/Advisory Boards: Roche/Genentech; Boehringer
Ingelheim [IPF]. All of the relevant financial relationships listed have been mitigated. Paul Mayo,
MD No relevant financial relationship(s) with ineligible companies to disclose. Scott Manaker, MD,
PhD Other Financial Interest: National Board for Respiratory Care [Director]; Expert witness in workers'
compensation and in medical negligence matters [General pulmonary and critical care medicine]. All of
the relevant financial relationships listed have been mitigated. Geraldine Finlay, MD No relevant
financial relationship(s) with ineligible companies to disclose.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these
are addressed by vetting through a multi-level review process, and through requirements for
references to be provided to support the content. Appropriately referenced content is required of all
authors and must conform to UpToDate standards of evidence.
Conflict of interest policy

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17/03/2022 09:08 Indications for bedside ultrasonography in the critically-ill adult patient - UpToDate

Official reprint from UpToDate®

Indications for bedside ultrasonography in the

TERMINOLOGY AND DEFINITION

heart), lung ultrasonography (LUS), abdominopelvic ultrasonography, vascular

CHOOSING CONSULTATIVE OR CRITICAL CARE ULTRASONOGRAPHY

● Consultative ultrasonography – In critically-ill patients, consultative radiology- or

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An algorithmic approach to evaluation of acute respiratory failure that recommends

identification of pleural effusion and pneumothorax" and "Emergency ultrasound in adults

Evaluation of the etiology of cardiopulmonary failure — Data from observational studies

● Presence or absence of pneumothorax – Pneumothorax is suggested by the absence

● Normal aeration pattern versus alveolar/interstitial abnormality – An A line

● Pleural effusion – An effusion is suggested by an anechoic area surrounded by typical

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● In a prospective study of 32 patients with acute respiratory distress syndrome (ARDS),

● In a prospective study of 42 mechanically ventilated patients, the sensitivity and

● In a review of 16 studies, the sensitivity of ultrasound for the diagnosis of pneumonia

● In a study of 404 ED patients with acute dyspnea, ultrasound interpretation was

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Evaluation for pneumothorax — Portable ultrasonography is used to detect

Investigational — Single-center observational studies describe several investigational

● Titration of positive end-expiratory pressure (PEEP) in ARDS – Lung recruitment in

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● Resolution of ventilator associated pneumonia – The resolution of ventilator associated

● Diagnosis of pulmonary embolism – In the evaluation of hemodynamically stable

Abdominopelvic ultrasonography is an integral component of critical care ultrasonography

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Detection of gallbladder disease — Ultrasonography is a valuable modality for the

Detection of urinary tract obstruction — Renal failure is a common feature of critical

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● Detection of hydronephrosis – Hydronephrosis results in a dilated pelvicaliceal

Several studies in patients with abdominal pain from suspected obstructive

Although many of the causes of hydronephrosis including obstructive stones

● Detection of bladder distension – A qualitative assessment of bladder distension is

Bladder volume = 0.75 x width x length x height

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differential of bladder masses includes diverticula, bladder wall thickening due to

Detection of abdominal aorta aneurysm rupture — The value to CCUS in the diagnosis of

Detection of abdominal free air — Although not a well-established modality for imaging

● Pneumoperitoneum – The identification of free intraperitoneal air is found most

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tails" and "ring-downs." Another reverberation artifact seen in pneumoperitoneum is

● Pneumoretroperitoneum – This is a rare complication of trauma, cancer, infection, or

● Intraparenchymal free air – Intraparenchymal free air refers to the identification of

● Deep venous thrombosis (DVT) in the upper and lower extremity

Detection of deep venous thrombosis — DVT of the upper and lower extremity is a

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thrombus as non-compressibility of the imaged vein. The value of compression

• The proximal common femoral artery and vein

In a retrospective chart review, multiorgan ultrasonography (thoracic, cardiac, lung,

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Central venous access — The use of ultrasonography guidance is commonplace for

Abdominal aortic syndromes — Abdominal aortic syndromes, including ruptured

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BASIC CRITICAL CARE ECHOCARDIOGRAPHY

Limited cardiac ultrasound is not a replacement for routine echocardiography. A meta-

Evaluation of shock — Basic CCE is useful for evaluating patients with undifferentiated

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● Classification of shock – CCE helps to categorize shock into hypovolemic, obstructive,

● Identification of life-threatening cardiac causes of shock – These include pericardial

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Cardiopulmonary resuscitation — In patients undergoing cardiopulmonary resuscitation,