Ultrasound Guidelines: Emergency, Point-of-Care, and Clinical Ultrasound Guidelines in Medicine

Section 1—Introduction

Clinical ultrasound (CUS) has become an integral aspect of emergency care in the United States for over 2 decades. Since the last update of these guidelines in 2016, the role of ultrasound has expanded throughout clinical medicine. The wide breadth of recognized CUS applications offers both diagnostic and therapeutic benefits to patients around the world. Benefits of bedside imaging with ultrasound include its relatively low cost, lack of ionizing radiation, portability, and ease of use. Data have demonstrated that CUS can improve diagnostic accuracy in numerous common clinical presentations, including dyspnea,¹ abdominal pain,² and joint dislocations.³ Ultrasound guidance has also been incorporated into bedside procedures, improving success and decreasing inadvertent complications.4, 5, 6

Emergency physicians have been leaders in innovation and education in the CUS space both nationally and internationally. This has led to increased integration and improved standardization at the undergraduate, postgraduate, and continuing medical education levels. Emergency medicine leaders have also leveraged their extensive knowledge and teaching to educate other specialties seeking to enhance their ultrasound training and expertise. Specifically, CUS curricula in undergraduate medical education are growing exponentially because of the leadership and advocacy of emergency physicians, integrating CUS into the education of the next generation of clinicians. In fact, CUS in emergency medicine residency training has been codified in the Model of the Clinical Practice of Emergency Medicine, a joint policy collaboration between 7 organizations. Moreover, CUS fellowship has advanced, with fellowships now eligible for accreditation by the Emergency Ultrasound Fellowship Accreditation Council (EUFAC) and fellowship graduates being recognized with certification as a focused practice designation by American Board of Emergency Medicine (ABEM). Leaders in CUS have created the foundation of a subspecialty of ultrasonography that provides the expertise for establishing clinical practice, educating across the educational spectrum, and researching a wide range of applications. The CUS leaders have also become instrumental in bringing health care systems into the future through championing and often running system-wide programs. As CUS continues to evolve and access to ultrasound machines becomes increasingly widespread, it is critical to understand the current field and provide national guidelines to inform education and practice. This guideline update is intended to provide a framework for new and established programs using CUS.

Section 2—Scope of Practice

Clinical ultrasound is the medical use of ultrasound technology for the bedside clinical evaluation of acute or critical medical conditions.⁷ It is used for diagnosis of any emergency condition, such as the resuscitation of the critically ill patient, during guidance of procedures, and monitoring of certain pathologic states. The CUS examinations are typically performed and interpreted by emergency physicians or those under the supervision of emergency physicians in the setting of the emergency department or a non-ED emergency setting hospital unit (out-of-hospital, battlefield, space, urgent care, clinic, remote, or other settings). It may be performed as a single examination, repeated serially based on clinical need or patient deterioration or used for monitoring of physiologic or pathologic changes.

Other medical specialties may wish to use this document if they perform CUS in the manner described above. However, guidelines that apply to ultrasound examinations or procedures performed by consultants, especially consultative imaging in ultrasound laboratories or departments or in alternative settings, may not be applicable to emergency physicians.

Emergency ultrasound (EUS) is an emergency medicine procedure and should not be considered in conflict with exclusive “imaging” contracts that may be in place with consultative ultrasound practices. In addition, EUS should be reimbursed as a separate billable procedure.⁹ (See Section 7—Value and Reimbursement.)

The CUS is a separate entity distinct from the physical examination that adds anatomic, functional, and physiologic information to the care of the acutely ill patient.¹⁰ It provides clinically significant data not obtainable by inspection, palpation, auscultation, or other components of the physical examination.¹¹ The ultrasound used in this clinical context is also not equivalent to use in the training of medical students and other clinicians in training looking to improve their understanding of anatomic and physiologic relationships of organ systems.

• 1.

  Resuscitative: ultrasound use directly related to an acute resuscitation

• 2.

  Diagnostic: ultrasound used in an emergency diagnostic imaging capacity

• 3.

  Symptom or sign-based: ultrasound used in a clinical pathway based on the patient’s symptom or sign (eg, shortness of breath)

• 4.

  Procedure guidance: ultrasound used as an aid to guide a procedure

• 5.

  Therapeutic and Monitoring: ultrasound use in therapeutics or in physiological monitoring

Within these broad functional categories of use, 15 core emergency ultrasound applications have been identified as Aorta, Bowel, Cardiac/Hemodynamic assessment, Deep Venous Thrombosis (DVT), Hepatobiliary, Musculoskeletal (MSK), Ocular, Pregnancy, Procedural Guidance, Skin and Soft-tissue, Testicular, Thoracic/Airway, Trauma, Ultrasound-Guided Nerve Blocks, and Urinary Tract. Evidence for these core applications may be found in Appendix 1. The criteria for a core application are widespread use, significant evidence base, uniqueness in diagnosis or decisionmaking, importance in primary emergency diagnosis and patient care, or technological advance.

Alternatively, symptom and sign-based ultrasound pathways, such as Shock or Dyspnea, may be considered an integrated application based on the skills required in the pathway. In such pathways, applications may be mixed and used in a format and order that maximizes medical decisionmaking, outcomes, efficiency, and patient safety tailored to the setting, resources, and patient characteristics. See Figure 1.

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Figure 1. The ACEP 2023 Emergency Ultrasound Guidelines scope of practice.

Emergency physicians should have a basic education in ultrasound physics, knobology, instrumentation procedural guidance, and Focused Assessment with Sonography in Trauma (FAST) as part of emergency medicine practice. It is not mandatory that every clinician performing EUS examinations use or be an expert in each core application, but it is understood that each core application is incorporated into common EUS practice nationwide. The descriptions of these examinations may be found in the American College of Emergency Physicians (ACEP) policy, Emergency Ultrasound Imaging Criteria Compendium.¹² Many other ultrasound applications or advanced uses of these applications may be used by emergency physicians. Their noninclusion as a core application does not diminish their importance in practice nor imply that emergency physicians are unable to use them in patient care.

Each EUS application represents a clinical bedside skill that can be of great advantage in a variety of emergency patient care settings. In classifying an emergency ultrasound, a single application may appear in more than one category and clinical setting. For example, focused cardiac ultrasound may be used to identify a pericardial effusion in the diagnosis of an enlarged heart on a chest radiograph. The focused cardiac ultrasound may be used in a cardiac resuscitation setting to differentiate true pulseless electrical activity from profound hypovolemia. The focused cardiac US can be used to monitor the heart during resuscitation in response to fluids or medications. If the patient is in cardiac tamponade, the cardiac ultrasound can also be used to guide a pericardiocentesis. In addition, the same focused cardiac study can be combined with one or more additional emergency ultrasound types, such as the focused abdominal, the focused aortic, or the focused chest/thoracic ultrasound, into a clinical algorithm for an undifferentiated hypotensive patient. See Figure 1.

Ultrasound guidance provides added safety to a wide variety of procedures ranging from vascular access (eg, central venous access) to drainage procedures (eg, thoracentesis pericardiocentesis, paracentesis, arthrocentesis) to localization procedures like ultrasound-guided nerve blocks. These procedures may provide additional benefits by increasing patient safety and helping alleviate acute pain.

Other ultrasound applications are performed by emergency physicians and may be integrated depending on the setting, training, and needs of that particular ED or emergency medicine group.