Emergency department targeted ultrasound: 2006 update

CAEP Position Statements

CJEM 2006;8(3):170-171

Introduction

Emergency department targeted ultrasound (EDTU) is a proven aid in the evaluation and treatment of emergency patients with a variety of medical and traumatic conditions.

Immediate access to bedside EDTU enhances patient care and safety by expediting the management of critical illness and by avoiding transfer of potentially unstable patients outside the emergency department for diagnostic testing.1–8

Emergency departments should strive to have EDTU immediately available, 24 hours per day, 7 days per week.

CAEP supports the following principles:

• EDTU is a focused, limited, bedside diagnostic tool. EDTU can also be used as a guide for certain invasive procedures.
• Applications for EDTU include, but are not limited to cardiac arrest,8–10 pericardial effusion,8,11–14 thoracoabdominal trauma,2,15–18 ectopic pregnancy,3,5–7,19–21 abdominal aortic aneursym,22,23 undifferentiated shock,24,25 and guidance for venous access.26
• In emergency departments with EDTU capability, ultrasound machines should be immediately available in the emergency department and possess appropriate functionality and quality for EDTU.
• EDTU training should be incorporated into emergency medicine residency programs of the Royal College of Physicians and Surgeons of Canada and the College of Family Physicians of Canada.
• EDTU training for emergency physicians already in practice is strongly encouraged.
• Training guidelines should be developed using both available evidence17,18,27–30 and the experience of EDTU experts.
• EDTU training should focus on both cognitive (indication and interpretation) and psychomotor skills.
• Physicians entering an EDTU training path should possess a sound foundation of knowledge and skill in the provision of emergency medical care.
• EDTU research is strongly encouraged.
• A strong quality improvement program is integral to the safe practice of EDTU, and should be incorporated into the overall emergency department quality improvement program.31
• EDTU findings should be documented in writing.
• Routine image capture is unnecessary for documentation, although image capture may be used for quality improvement.
• Documentation should only include findings relevant to the specific indication for the scan.
• Scans that are indeterminate should be so documented and should not be used in clinical decision-making.
• Continuing medical education in EDTU is strongly encouraged.31
• It is preferable that at least one local leader supervise the development and maintenance of the EDTU program at their institution.

References

1. Bassler D, Snoey ER, Kim J. Goal-directed abdominal ultrasonography: impact on real-time decision making in the emergency department. J Emerg Med 2003;24:375-8.
2. Blaivas M, Sierzenski P, Theodoro D. Significant hemoperitoneum in blunt trauma victims with normal vital signs and clinical examination. Am J Emerg Med 2002;20:218-21.
3. Burgher SW, Tandy TK, Dawdy MR. Transvaginal ultrasonography by emergency physicians decreases patient time in the emergency department. Acad Emerg Med 1998;5:802-7.
4. Durham B. Emergency medicine physicians saving time with ultrasound. Am J Emerg Med 1996;14:309-13.
5. Durston WE, Carl ML, Guerra W, et al. Ultrasound availability in the evaluation of ectopic pregnancy in the ED: comparison of quality and cost-effectiveness with different approaches. Am J Emerg Med 2000;18:408-17.
6. Rodgerson JD, Heegaard WG, Plummer D, et al. Emergency department right upper quadrant ultrasound is associated with a reduced time to diagnosis and treatment of ruptured ectopic pregnancies. Acad Emerg Med 2001;8:331-6.
7. Shih CH. Effect of emergency physician-performed pelvic sonography on length of stay in the emergency department. Ann Emerg Med 1997;29:348-51.
8. Tayal VS, Kline JA. Emergency echocardiography to detect pericardial effusion in patients in PEA and near-PEA states. Resuscitation 2003;59:315-8.
9. Blaivas M, Fox JC. Outcome in cardiac arrest patients found to have cardiac standstill on the bedside emergency department echocardiogram. Acad Emerg Med 2001;8:616-21.
10. Salen P, O'Connor R, Sierzenski P, et al. Can cardiac sonography and capnography be used independently and in combination to predict resuscitation outcomes? Acad Emerg Med 2001;8: 610-5.
11. 11. Blaivas M. Incidence of pericardial effusion in patients presenting to the emergency department with unexplained dyspnea. Acad Emerg Med 2001;8:1143-6.
12. Plummer D, Dick C, Ruiz E, et al. Emergency department two-dimensional echocardiography in the diagnosis of nontraumatic cardiac rupture. Ann Emerg Med 1994;23:1333-42.
13. Plummer D, Brunette D, Asinger R, et al. Emergency department echocardiography improves outcome in penetrating cardiac injury. Ann Emerg Med 1992;21:709-12.
14. Rozycki GS, Feliciano DV, Ochsner MG, et al. The role of ultrasound in patients with possible penetrating cardiac wounds: a prospective multicenter study. J Trauma 1999;46:543-51.
15. 15. Boulanger BR, McLellan BA, Brenneman FD, et al. Prospective evidence of the superiority of a sonography-based algorithm in the assessment of blunt abdominal injury. J Trauma 1999;47: 632-7.
16. 16. Ma OJ, Mateer JR. Trauma ultrasound examination versus chest radiography in the detection of hemothorax. Ann Emerg Med 1997; 29: 312-5.
17. Scalea TM, Rodriguez A, Chiu WC, et al. Focused Assessment with Sonography for Trauma (FAST): results from an international consensus conference. J Trauma 1999;46:466-72.
18. Rose JS. Ultrasound in abdominal trauma. Emerg Med Clin North Am 2004;22:581-99.
19. Durham B, Lane B, Burbridge L, et al. Pelvic ultrasound performed by emergency physicians for the detection of ectopic pregnancy in complicated first-trimester pregnancies. Ann Emerg Med 1997;29:338-47.
20. Mateer JR, Valley VT, Aiman EJ, et al. Outcome analysis of a protocol including bedside endovaginal sonography in patients at risk for ectopic pregnancy. Ann Emerg Med 1996;27:283-9.
21. Mateer JR, Aiman EJ, Brown MH, et al. Ultrasonographic examination by emergency physicians of patients at risk for ectopic pregnancy. Acad Emerg Med 1995;2:867-73.
22. Kuhn M, Bonnin RL, Davey MJ, et al. Emergency department ultrasound scanning for abdominal aortic aneurysm: accessible, accurate, and advantageous. Ann Emerg Med 2000;36:219-23.
23. Tayal VS, Graf CD, Gibbs MA. Prospective study of accuracy and outcome of emergency ultrasound for abdominal aortic aneurysm over two years. Acad Emerg Med 2003;10:867-71.
24. Jones AE, Tayal VS, Sullivan DM, et al. Randomized, controlled trial of immediate versus delayed goal-directed ultrasound to identify the cause of nontraumatic hypotension in emergency department patients. Crit Care Med 2004;32:1703-8.
25. Rose JS, Bair AE, Mandavia D, et al. The UHP protocol: a novel ultrasound approach to the empiric evaluation of the undifferentiated hypotensive patient. Am J Emerg Med 2001; 19: 299-302.
26. Hind D, Calvert N, McWilliams R, et al. Ultrasonic locating devices for central venous cannulation: meta-analysis. BMJ 2003; 327: 361-4.
27. Gracias VH, Frankel HL, Gupta R, et al. Defining the learning curve for the focused abdominal sonogram for trauma (FAST) examination: implications for credentialing. Am Surg 2001;67: 364-8.
28. Shackford SR, Rogers FB, Osler TM, et al. Focused abdominal sonogram for trauma: the learning curve of nonradiologist clinicians in detecting hemoperitoneum. J Trauma 1999;46:553-64.
29. Thomas B, Falcone RE, Vasquez D, et al. Ultrasound evaluation of blunt abdominal trauma: program implementation, initial experience, and learning curve. J Trauma 1997;42:384-8.
30. Gracias VH, Frankel H, Gupta R, et al. The role of positive examinations in training for the focused assessment sonogram in trauma (FAST) examination. Am Surg 2002;68:1008-11.
31. Peterson MA, Lambert MJ. Training and program development. In: Ma OJ, Mateer JR, editors. Emergency ultrasound. New York: McGraw-Hill; 2003. p. 1-14.