Nejmra 1916062

The n e w e ng l a n d j o u r na l of m e dic i n e
Review Article
Julie R. Ingelfinger, M.D., Editor
Point-of-Care Ultrasonography
José L. Díaz‑Gómez, M.D., Paul H. Mayo, M.D., and Seth J. Koenig, M.D.
P
oint-of-care ultrasonography (POCUS) is defined as the acquisi- From the Baylor College of Medicine,
tion, interpretation, and immediate clinical integration of ultrasonographic Houston (J.L.D.-G.); and the Donald and
Barbara Zucker School of Medicine at
imaging performed by a treating clinician at the patient’s bedside rather Hofstra/Northwell, Hempstead (P.H.M.),
than by a radiologist or cardiologist. POCUS is an inclusive term; it is not limited and the Albert Einstein College of Medi-
to any specialty, protocol, or organ system.1 With the advent of smaller and more cine, New York (S.J.K.) — both in New
York. Address reprint requests to Dr.
affordable ultrasound machines, combined with evidence that nonradiologists and Díaz-Gómez at the Division of Cardiovas-
noncardiologists can become competent in the performance of POCUS, it is now cular Anesthesiology and Critical Care
used in many practice settings and in all phases of care — from screening and Medicine, Baylor College of Medicine,
6720 Bertner Ave., Suite O-520, Hous-
diagnosis to procedural guidance and monitoring — and has become associated ton, TX 77030, or at jose.diaz-gomez@
with changes in clinical decision making in medical practice.2,3 A recent study bcm.edu.
showed that POCUS facilitated confirmation of the suspected clinical diagnosis in N Engl J Med 2021;385:1593-602.
up to 50% of cases and supported a change in the initial diagnosis in 23% of DOI: 10.1056/NEJMra1916062
cases.4 In this review, we discuss key trends in POCUS technology, advances in its Copyright © 2021 Massachusetts Medical Society.
clinical applications, and the overlap and complementarity of POCUS and consul- CME
tative ultrasonography in primary imaging specialties, as shown in Figure 1. at NEJM.org
P O CUS a nd C onsultat i v e Ult r a sono gr a ph y

As a point-of-care imaging technique, POCUS requires direct interaction between
the clinician and the patient to establish a clinical diagnosis or guide a procedure.
Thus, it differs from consultative ultrasonography, in which the test is ordered by
the clinician, typically performed by a technician, and then interpreted by a
consultant who is not directly involved with the care of the patient.5 Since POCUS
challenges the traditional approach to ultrasonography and involves the clinician
directly, it may well result in a reduction in the use of consultative ultrasono-
graphic services.6-8
A 2015 retrospective study showed that the introduction of point-of-care echo-
cardiography performed by intensivists led to a decreased number of comprehensive
diagnostic echocardiographic studies overall but led to a recommendation to per-
form full diagnostic echocardiographic studies in 10.7% of patients who had un-
dergone the point-of-care studies.9 This change in practice occurred without ad-
verse clinical outcomes.9 However, such practice changes may engender concern in
the radiology and cardiology communities about reduced reimbursement and po-
tential quality issues. Professional societies such as the American Society of Echo-
cardiography10 have provided guidance on the use of POCUS, and there is evidence
that consultative diagnostic and therapeutic ultrasonography can be complemen-
tary to POCUS.6,10
The American Society of Echocardiography, in concert with multiple specialties
that use POCUS in clinical practice, recommends that, to ensure high-quality care,
both cardiologists and sonographers facilitate the education and direct training of
clinicians who perform cardiac ultrasonography.10 North American radiology
n engl j med 385;17 nejm.org October 21, 2021 1593

The New England Journal of Medicine
Downloaded from nejm.org by Sebastián Camilo Medina Rivera on November 30, 2021. For personal use only. No other uses without permission.
Copyright © 2021 Massachusetts Medical Society. All rights reserved.
2011 2016 2019 2021

Recognition of Effect of POCUS Improved, low-cost Deep-learning
change in clinical in cardiac arrest handheld algorithms
management management ultrasound systems for prescriptive
imaging
guidance
2015 2018 2020

Use of POCUS as Certification in Overlap and
a hemodynamic advanced critical care complementarity
monitoring tool in echocardiography by of POCUS and
the trauma bay the National Board consultative
of Echocardiography ultrasonography
Figure 1. Evolution of Point-of-Care Ultrasonography (POCUS) during the Past Decade.

The leading areas of research on POCUS have been cardiothoracic ultrasonography and ultrasound-guided procedures. Most of the studies
have been published in critical care medicine and emergency medicine journals.
societies have delineated what they consider the affects cost. One handheld ultrasound system
proper scope and use of POCUS and have advo- uses silicon-chip array microsensors instead of
cated the adoption of a framework that defines piezoelectric crystal elements, which means that
POCUS as a tool that enhances evaluation and a single probe can be used for both vascular and
management. These professional societies em- body imaging.13,14 Another design features a
phasize the finite nature of POCUS and recom- double-ended probe with traditional piezoelectric
mend its use by well-trained operators.2,11 crystals, so the probe can be used for both vas-
cular and body imaging. Combining vascular
and body imaging capability in one probe re-
K e y T r ends in P O CUS Technol o gy
duces acquisition costs related to the device.
Handheld Ultrasound Systems Several handheld ultrasound systems can per-
Low-cost handheld ultrasound systems that con- form linear measurements and have full-spec-
nect to a smartphone or tablet by means of so- trum Doppler, M-mode, analytics, and quantita-
phisticated wireless technology, the Internet, and tion features to facilitate POCUS applications in
a cloud-based system have become readily avail- multiple subspecialty settings.13,15 In 2020, the
able to the frontline clinician. Thus, video con- Food and Drug Administration cleared for use a
ferencing and peer imaging evaluation (in which handheld ultrasound system that has full-spec-
an experienced peer can evaluate POCUS imag- trum Doppler capability, which had not previous-
ing remotely on a real-time basis) for clinical, ly been available in any handheld system. This
training, or mentoring purposes are now feasible.12 capability allows for a variety of quantitative
The number of probes necessary for studies measurements. Clinicians who use handheld
1594 n engl j med 385;17 nejm.org October 21, 2021

Point-of-Care Ultr asonogr aphy
systems that have these new algorithms for sonographic training with immediate and direct
quantitation can obtain an automated measure- feedback to learners has been shown to shorten
ment of the left ventricular ejection fraction, the learning curve, a potential step in the develop-
estimate the volume of pleural effusions or uri- ment of new training models for POCUS and in-
nary bladder volume, and detect valvular heart creased interoperator reproducibility of results.3,18
disease. Handheld POCUS systems are useful in
telemedicine and triage and directly affect length Clinical Documentation
of stay.16,17 Contemporary POCUS machines store images in
Careless use of handheld ultrasound systems the digital imaging and communications in med-
could lead to violations of the Health Insurance icine (DICOM) format, which allows them to be
Portability and Accountability Act (HIPAA) in uploaded to a picture archiving and communica-
the United States (or similar regulations in other tion system or to commercially available, stand-
countries). Clinicians who use these systems alone digital storage systems. Such storage of
should anticipate concern on the part of their images facilitates quality assurance processes,
information technology colleagues about Internet standardized documentation, and billing.23 Graph-
connectivity and the need for technical solutions ic communication, a recent advance in telemedi-
to prevent HIPAA violations. cine and clinical documentation,24 allows provid-
ers in different locations to engage in continuous
Artificial Intelligence and POCUS quality assurance, education, and clinical deci-
Deep-learning approaches are revolutionizing sion making while using the same server.
decision making in medical imaging. Ultraso-
nography provides ideal data for these transfor- Use of P O CUS for Guida nce
mative approaches because of its widespread in Per for ming Pro cedur e s
availability, even in low-resource environments
and prehospital settings.18 Despite technological Imaging-guided diagnostic and therapeutic pro-
advances in machine design, there is still limited cedures are a mainstay of contemporary clinical
artificial intelligence that is based on quantita- practice to reduce morbidity and to improve
tive analysis. Implementation of fully automated safety, operator effectiveness, and immediate
machine-learning algorithms — for example, for symptom relief after thoracentesis,3,25 paracente-
left and right ventricular systolic function, pres- sis,26 lumbar puncture,27 central venous access,28
ence of pericardial effusion, prediction of fluid peripheral venous and arterial access,29,30 pericar-
responsiveness or severity of acute lung disease, diocentesis,31 abscess drainage,32 and joint aspi-
detection of free abdominal fluid, and prescrip- ration.33 The availability of portable machines per-
tive imaging guidance — is an active area of mits POCUS to be used for procedural guidance
development and research.19-21 on site by office-based clinicians, hospitalists,
Classification of benchmark ultrasound imag- emergency medicine clinicians, and intensivists.
es is a requirement for training a convolutional Use of ultrasonography to guide procedures
neural network (a type of artificial neural net- requires that the clinician be competent in its
work based on the pattern of connectivity of use for specialty-specific functions. Clinicians
neurons in the human brain and used in deep can develop technical competence with task
learning); a new convolutional neural network trainers (simulators that integrate ultrasonogra-
has already been trained to classify multiorgan phy with the physical aspects of a specific pro-
POCUS examinations, with promising results.22 cedure and allow repeated practice before an
In combination with clinician expertise, clinical encounter with a patient). On the basis of expert
ly relevant decision making may become more consensus, 25 to 50 examinations are required
effective with this deep-learning trajectory. In to ensure basic competence in performing most
the case of prescriptive POCUS guidance, one diagnostic ultrasonographic procedures. The ac-
study showed that novice operators were able to quisition of competence in ultrasonography for
obtain a 10-view echocardiographic image set guidance during procedures appears to have a
that was similar in quality to that obtained by shorter learning curve (10 procedures).34-36 How-
skilled cardiac sonographers.19 Automated ultra- ever, a numerical standard alone cannot be used

to determine competence in POCUS-driven probe associated with potentially treatable condi-

cedures, given the level of the data. At present, tions.43,44 Current CPR guidelines recommend
there is no widely accepted method of determin- that the duration of pulse checks be limited to
ing competence in the performance of ultraso- 10 seconds, since minimizing interruptions is
nography to guide procedures. associated with improved rates of return of
spontaneous circulation and survival to hospital
discharge. This arouses concern that using
P O CUS E x a minat ions
for Cl inic a l Moni t or ing POCUS for characterization of cardiac arrest
might prolong the time to the pulse check. One
Clinicians who become proficient in POCUS can study showed that this was the case.41 However,
use it to track clinical conditions that may this finding was contradicted in a subsequent
progress rapidly — for example, acute respira- study, which showed that the use of POCUS dur-
tory failure, intracranial hypertension, and hemo- ing the pulse check reduced the duration of pulse
dynamic failure and resuscitation from traumatic checks.41,42 Another benefit of using POCUS dur-
shock.37-39 A prospective, randomized, controlled ing CPR is the reliable detection of a carotid
study of the value of limited transthoracic echo- pulse.45
cardiography as a monitoring tool in patients A multicenter, prospective, protocol-driven
with severe injuries and hypotension who were observational study involving 793 cases of out-
seen in the trauma section of an emergency de- of-hospital or emergency-department cardiac
partment showed that the use of this form of arrest documented organized cardiac activity on
POCUS reduced mortality and the time to opera- POCUS in some cases, which was associated
tive intervention.40 Monitoring applications that with an increased likelihood of survival from the
use POCUS require repeat examinations and use initial resuscitation to hospital discharge.46 An
semiquantitation or quantitation when indicat- absence of cardiac activity on POCUS was associ-
ed.38 For instance, a POCUS assessment of pa- ated with a very low rate of survival. POCUS was
tients with decompensated heart failure or coro- useful in identifying pericardial effusion that
navirus disease 2019 (Covid-19) can facilitate responded to pericardiocentesis.46 POCUS may
clinical decision making during triage, evalua- also provide clinical guidance in deciding
tion of implemented therapeutic interventions, whether to cease or continue CPR when the cap-
and tracking of disease activity (see Video S1 in nographic values are very low or gas is present
the Supplementary Appendix, available with the in the hepatic vein.47,48
full text of this article at NEJM.org).39
POCUS can be useful as a monitoring tool A dva nce s in the Cl inic a l
during the performance of cardiopulmonary A ppl ic at ion of P O CUS
resuscitation (CPR). To use this approach during
CPR, a POCUS operator is tasked with assessing Diagnostic Accuracy
cardiac function serially, during the brief periodic How POCUS compares with other imaging tech-
interruptions of chest compressions that are part niques in general use, apart from its low cost,
of the standard CPR sequence. This application time efficiency, and ease of use, is a key ques-
of POCUS requires the operator to be competent tion. The accuracy of POCUS supports its benefit
in rapid image acquisition in the 10-second peri- in the evaluation of common medical conditions
od that is conventionally used to perform a pulse (Fig. 2).49-54 POCUS is effective as a screening
check (i.e., seek a palpable pulse) during CPR.41,42 tool for the identification of certain disorders,
Serial POCUS images during these 10-second such as abdominal aortic aneurysm.49
pulse checks facilitate the recognition of pseudo– A relevant example of the diagnostic accuracy
pulseless electrical activity, which is defined as of POCUS is its value in characterizing non
organized cardiac activity identified by echocar- specific clinical conditions, including respiratory
diography in the absence of a detectable pulse. distress and chest pain, as compared with chest
In contrast, pulseless electrical activity is charac- radiography. In a prospective study involving
terized by a lack of cardiac activity on echocar- 2683 patients evaluated for dyspnea in the emer-
diography. Pseudo–pulseless electrical activity may gency department, there were no significant

Acute Pulmonary Edema Pneumonia
Sensitivity: 88% Sensitivity: 88%

Specificity: 90% Specificity: 93%
Pneumothorax Left Ventricular Dysfunction Thoracoabdominal Trauma
Sensitivity: 81% Sensitivity: 69–94% Sensitivity: 74%

Specificity: 100% Specificity: 88–96% Specificity: 96%
Figure 2. Diagnostic Accuracy of POCUS for Common Medical Conditions.

POCUS is useful and safe for diagnosing acute pulmonary edema,49 pneumonia,49,50 pneumothorax,49-51 left ventricular
dysfunction,50,52 and thoracoabdominal trauma.53
differences in accuracy between POCUS and ic obstructive pulmonary disease and pulmonary
standard evaluation that included chest radiog- embolism.50 In another prospective study, involv-
raphy for the diagnosis of an acute coronary ing 128 patients presenting to the emergency
syndrome, pneumonia, pleural effusion, pericar- department with dyspnea and chest pain, a chest
dial effusion, pneumothorax, or dyspnea from radiograph did not add actionable clinical informa-
other causes.50 POCUS was more sensitive for the tion for patients with a normal thoracic POCUS
diagnosis of heart failure, but standard evalua- study.55
tion performed better in the diagnosis of chron- Using an expedited, modified Delphi consen-

sus approach, an international, multispecialty ex- assess patients with hypotension, as compared
pert panel evaluated clinically integrated, multi- with conventional clinical management without
organ POCUS for management of Covid-19. The POCUS.63 However, the study suggested that
results led the panel to suggest that POCUS was POCUS can improve diagnostic accuracy and
useful in nine clinical domains (diagnosis of characterization of arterial hypotension in the
severe acute respiratory syndrome coronavirus 2 emergency department. Methodologic limita-
[SARS-CoV-2] infection, initial triage and risk tions of the study included the use of a limited
stratification, diagnosis of Covid-19 pneumonia, POCUS examination, early termination of pa-
diagnosis of cardiovascular disease, screening tient enrollment, and lack of information about
for venous thromboembolic disease, respiratory whether the use of POCUS to establish diagno-
support strategies, management of fluid therapy, ses resulted in appropriate management deci-
clinical monitoring of patients with Covid-19, sions. However, a systematic review partially
and infection control to reduce the environmen- supported the use of POCUS to guide fluid re-
tal spread of infection and risk of infection for suscitation in surgical patients and septic non-
health care providers).39 surgical patients with shock, reducing adverse
effects, organ failure, and mortality.64
Efficiency and Cost-Effectiveness
Several studies indicate that POCUS is more C ompe tence a nd T r a ining
cost-effective and time-efficient than traditional in P O CUS
ultrasonography in obtaining data that may
decrease the length of stay in the emergency It is self-evident that the clinician who uses
department (for evaluation of nephrolithiasis, un- POCUS must be competent in its use. Clinicians
complicated biliary disease, early intrauterine preg- who have not been adequately trained may harm
nancy, and soft-tissue infection).56-59 Implemen- patients by making an inaccurate diagnosis or
tation of POCUS for a broad range of clinical using POCUS inappropriately. In 2020, the Joint
conditions in general medical practice has led to Commission on Accreditation of Healthcare Or-
a measurable reduction in planned referrals.60 ganizations and the Emergency Care Research
Similar findings have been reported by cardiolo- Institute identified the adoption of POCUS with-
gists and trainees who use POCUS in the triage out necessary safeguards as a major health tech-
of patients with suspected cardiac disease.16 nology hazard.65
For peritonsillar abscess, the use of POCUS in With the widespread availability of lower-cost
evaluation and management resulted in more handheld ultrasound systems, training large num-
efficacious aspiration and decreased subspecial- bers of clinicians to become competent in POCUS
ist consultation, less computed tomographic im- poses a challenge. The development of training
aging, fewer return visits, and a shorter length curricula and methods to assess competence is
of stay, as compared with the conventional imperative for the safe and effective use of such
clinical approach.61 POCUS can be efficiently systems.66 At the medical school level, 35% of
used in patients receiving palliative care to ad- 222 medical schools in the United States have
dress symptoms such as severe dyspnea due to implemented a focused ultrasound training pro-
malignant pleural effusions and has benefits gram.66-68 In one study, integrating POCUS into
with regard to triage, patient satisfaction, and the abdominal physical examination improved the
cost-effectiveness.26,62 ability of medical students to accurately identify
abnormalities.69 Also, after POCUS training, med-
Morbidity and Mortality ical students found new diagnoses and decreased
Evidence that the use of POCUS reduces morbid- triage time with a high concordance with attend-
ity and mortality remains elusive. The first ran- ing physicians.70 On the basis of collaborative
domized clinical trial evaluating the effect of research, the American Society of Echocardiogra-
early POCUS on hospital discharge and 30-day phy and the Canadian Society of Echocardiogra-
mortality showed little benefit (with respect to phy have created a cardiovascular POCUS curricu-
survival, length of stay, fluid administration, lum for medical students.71,72 It is not known
and use of inotropes) when POCUS was used to how widely this curriculum has been adopted.

Table 1. Comparison of Point-of-Care Ultrasonography (POCUS) and Consultative Ultrasonography.*
POCUS Performed by Nonradiologists Consultative Ultrasonography Performed by Radiologists

Point of Comparison and Noncardiologists and Cardiologists
Scope of practice and POCUS, combined with history taking and physical exam Clinician directly responsible for medical management
ultrasonographic ination, performed for specific clinical conditions by the orders ultrasonographic evaluation, performed by
workflow clinician directly responsible for medical management sonographer and interpreted by radiologist or car
diologist
Examples of training ACGME core competency for general surgery residency, ACGME core competency for radiology residency:
requirements for anesthesiology residency, critical care fellowship† ≥350 abdominal or pelvic ultrasound examinations,
competency ACEP clinical ultrasound accreditation: emergency med ≥25 image-guided drainage procedures
icine residency training pathway — residency program ACGME core competency for cardiology fellowship: 3 mo
director assesses competence of board-eligible or of dedicated echocardiographic training
certified physician in specific components of ultraso- NBE certification for independent performance of ad-
nography — or practice pathway involving >16 hr of vanced perioperative TEE after completion of cardiac
didactics and >25 high-quality examinations for each anesthesia fellowship or practice pathway for appli-
application or >150 total ultrasound procedures in a cants who finished core residency before July 1, 2009:
wide variety of applications 150 TEE procedures performed, 300 interpreted
EDEC requirements for advanced critical care echocardiog- NBE certification for independent performance and
raphy: 100 TTE and 30 TEE procedures performed and interpretation of echocardiography after completion
interpreted, written examination designed by ESICM of adult cardiovascular disease fellowship or practice
NBE certification in critical care echocardiography: written pathway with specific board requirements: level II
examination designed by NBME, 150 TTE examina- competence — 150 TTE procedures performed and
tions performed and interpreted 300 interpreted, 50 TEE procedures performed and
ASUM requirements: 300 TTE and 50 TEE procedures per- interpreted; level III competence — 150 TTE proce-
formed and interpreted, 50 vascular or lung ultrasound dures performed and 750 interpreted, 150 TEE pro
procedures, no written examination cedures performed and interpreted
Possible limitations Inadequate training and lack of competence, with potential Delay in performance, interpretation, and communica-
for false positive and false negative examinations tion of results to physician directly responsible for
Heterogeneous documentation of training, quality assur- management, compounded by consultant’s lack of
ance, and credentialing standards across hospital full knowledge of clinical situation
and clinic medical practices Increased health care costs and lack of immediate avail-
ability of consultative services
* ACEP denotes American College of Emergency Physicians, ACGME Accreditation Council for Graduate Medical Education, ASUM Australasian
Society for Ultrasound in Medicine, EDEC European Diploma in Advanced Critical Care Echocardiography, ESICM European Society of
Intensive Care Medicine, NBE National Board of Echocardiography, NBME National Board of Medical Examiners, TEE transesophageal
echocardiography, and TTE transthoracic echocardiography.
† Training is required but without the requirement of a dedicated training period.
Specialty-specific training in POCUS and meth- specific POCUS. In the United States and Canada,
ods that test for competence are important for the National Board of Echocardiography offers
postgraduate medical training. The Accreditation national certification in advanced critical care
Council for Graduate Medical Education defines echocardiography (Table 1),66,74,75 and the Euro-
requirements for ultrasonographic training in pean Society of Intensive Care Medicine offers a
emergency medicine and anesthesiology residen- similar certification. Both certifications are open
cies. An innovative approach to fellowship-level to international physicians. Advanced critical care
training has been the development of regional, echocardiography, a recent addition to POCUS in
multiday cooperative courses that provide a stan- critical care, comprises all relevant components
dard initial training sequence followed by on-site of echocardiography, with additional elements
training during critical care fellowships.73 In the specific to critical care.
United States and Canada, training standards
have been formulated for specialty-specific Una ns w er ed Que s t ions
POCUS, but national-level postgraduate certifica- a bou t P O CUS
tion is generally not available for the many ap-
plications of POCUS. The United Kingdom and Two questions about POCUS remain unanswered.
Australia and New Zealand have well-designed First, does POCUS affect patient-centered end
national standards for certification in specialty- points such as functional status, morbidity, and

mortality? The effect of POCUS on patient out- to the success of a training sequence for POCUS
comes is a challenge to study, given the hetero- also relates to the skill and motivation of the
geneity of the patient populations, the lack of faculty, particularly with regard to hands-on train-
standardized therapeutic plans based on POCUS ing. This is an unexamined area of research.
results, the difficulty in standardizing scanning
protocols, the confounding effect of concurrent C onclusions
therapeutic interventions, variation in skill levels
on the part of the clinicians performing POCUS, The use of POCUS is not limited to one specialty,
and the difficulty in finding clinicians with protocol, or organ system. POCUS provides the
clinical equipoise regarding POCUS. It is not treating clinician with real-time diagnostic and
likely that focusing on POCUS as the primary monitoring information and can be used to en-
variable determining the outcome will be a pro- hance the safety of standard ultrasound-guided
ductive approach to research. procedures. The introduction of POCUS curri-
Second, what specific training is required for cula and training at the medical school and
a clinician to become competent in POCUS? The postgraduate levels, the increasing level of evi-
field needs information to identify the hours of dence of its effect in clinical practice, and ad-
training required to achieve mastery of image vances in handheld systems all point toward the
acquisition, image interpretation, and the cogni- possibility that POCUS will become a standard
tive base; the course design; the usefulness of tool of the frontline clinician. However, it will be
simulators and training programs embedded in critical to determine which, if any, applications
the ultrasonography machine; the design of sum- ultimately benefit patient care.
mative examinations of skill; and the ongoing Disclosure forms provided by the authors are available with
assessment of maintenance of skill. A key aspect the full text of this article at NEJM.org.
References
1. Moore CL, Copel JA. Point-of-care ultra- tic protocol at early intensive-care stay: J Cardiothorac Vasc Anesth 2020;34:3139-
sonography. N Engl J Med 2011;364:749- a randomized-controlled trial. Ultrasound 45.
57. J 2019;11:24. 14. Lee L, DeCara JM. Point-of-care ultra-
2. Patel MD, Horrow MM, Kamaya A, 8. Oks M, Cleven KL, Cardenas-Garcia J, sound. Curr Cardiol Rep 2020;22:149.
et al. Mapping the ultrasound landscape et al. The effect of point-of-care ultraso- 15. Austin DR, Chang MG, Bittner EA.
to define point-of-care ultrasound and di- nography on imaging studies in the med- Use of handheld point-of-care ultrasound
agnostic ultrasound: a proposal from the ical ICU: a comparative study. Chest 2014; in emergency airway management. Chest
Society of Radiologists in Ultrasound and 146:1574-7. 2021;159:1155-65.
ACR Commission on Ultrasound. J Am 9. Alherbish A, Priestap F, Arntfield R. 16. Kobal SL, Liel-Cohen N, Shimony S,
Coll Radiol 2021;18:42-52. The introduction of basic critical care et al. Impact of point-of-care ultrasound
3. Riishede M, Laursen CB, Teglbjærg LS, echocardiography reduces the use of di- examination on triage of patients with
et al. Diagnostic value of whole-body- agnostic echocardiography in the inten- suspected cardiac disease. Am J Cardiol
focused ultrasonography in high-acuity sive care unit. J Crit Care 2015;30(6):1419. 2016;118:1583-7.
patients in the emergency department: e7-1419.e11. 17. Galusko V, Bodger O, Ionescu A. A sys-
a prospective single-center cross-sectional 10. Kirkpatrick JN, Grimm R, Johri AM, tematic review of pocket-sized imaging
study. Ultrasound J 2019;11:11. et al. Recommendations for echocardiog- devices: small and mighty? Echo Res Pract
4. Baker DE, Nolting L, Brown HA. Im- raphy laboratories participating in car- 2018;5:113-38.
pact of point-of-care ultrasound on the diac point of care cardiac ultrasound 18. Shokoohi H, LeSaux MA, Roohani YH,
diagnosis and treatment of patients in (POCUS) and critical care echocardiogra- Liteplo A, Huang C, Blaivas M. Enhanced
rural Uganda. Trop Doct 2021;51:291-6. phy training: report from the American point-of-care ultrasound applications by
5. Marbach JA, Almufleh A, Di Santo P, Society of Echocardiography. J Am Soc integrating automated feature-learning sys-
et al. A shifting paradigm: the role of fo- Echocardiogr 2020;33(4):409-422.e4. tems using deep learning. J Ultrasound
cused cardiac ultrasound in bedside pa- 11. Chawla TP, Cresswell M, Dhillon S, Med 2019;38:1887-97.
tient assessment. Chest 2020; 158:
2107- et al. Canadian Association of Radiolo- 19. Narang A, Bae R, Hong H, et al. Util-
18. gists position statement on point-of-care ity of a deep-learning algorithm to guide
6. Kaplan SL, Chen AE, Rempell RG, ultrasound. Can Assoc Radiol J 2019;70: novices to acquire echocardiograms for
Brown N, Velez-Florez MC, Khwaja A. Im- 219-25. limited diagnostic use. JAMA Cardiol 2021;
pact of emergency medicine point-of-care 12. Salerno A, Tupchong K, Verceles AC, 6:624-32.
ultrasound on radiology ultrasound vol- McCurdy MT. Point-of-care teleultrasound: 20. Roy S, Menapace W, Oei S, et al. Deep
umes in a single pediatric emergency de- a systematic review. Telemed J E Health learning for classification and localiza-
partment. J Am Coll Radiol 2020;17:1555- 2020;26:1314-21. tion of COVID-19 markers in point-of-care
62. 13. Baribeau Y, Sharkey A, Chaudhary O, lung ultrasound. IEEE Trans Med Imag-
7. Pontet J, Yic C, Díaz-Gómez JL, et al. et al. Handheld point-of-care ultrasound ing 2020;39:2676-87.
Impact of an ultrasound-driven diagnos- probes: the new generation of POCUS. 21. Sjogren AR, Leo MM, Feldman J, Gwin

JT. Image segmentation and machine 34. Frankel HL, Kirkpatrick AW, Elbar- arrest, predict survival? Ann Emerg Med
learning for detection of abdominal free bary M, et al. Guidelines for the appropri- 2018;71:208-10.
fluid in focused assessment with sonog- ate use of bedside general and cardiac 48. Ramamurti P, Yamane D, Desai S,
raphy for trauma examinations: a pilot ultrasonography in the evaluation of criti- Boniface K, Drake A. Mortality in patients
study. J Ultrasound Med 2016;35:2501-9. cally ill patients. I. General ultrasonogra- with hepatic gas on point-of-care ultra-
22. Blaivas M, Arntfield R, White M. DIY phy. Crit Care Med 2015;43:2479-502. sound in cardiac arrest: does location
AI, deep learning network development 35. Blehar DJ, Barton B, Gaspari RJ. Learn- matter? J Clin Ultrasound 2021;49:205-11.
for automated image classification in a ing curves in emergency ultrasound edu- 49. Sorensen B, Hunskaar S. Point-of-care
point-of-care ultrasound quality assurance cation. Acad Emerg Med 2015;22:574-82. ultrasound in primary care: a systematic
program. J Am Coll Emerg Physicians 36. Arbelot C, Dexheimer Neto FL, Gao Y, review of generalist performed point-of-
Open 2020;1:124-31. et al. Lung ultrasound in emergency and care ultrasound in unselected popula-
23. Flannigan MJ, Adhikari S. Point-of- critically ill patients: number of super- tions. Ultrasound J 2019;11:31.
care ultrasound work flow innovation: im- vised exams to reach basic competence. 50. Zanobetti M, Scorpiniti M, Gigli C, et al.
pact on documentation and billing. J Ultra- Anesthesiology 2020;132:899-907. Point-of-care ultrasonography for evalua-
sound Med 2017;36:2467-74. 37. Yic CD, Prada G, Paz SI, et al. Com- tion of acute dyspnea in the ED. Chest
24. Cohen GI. A practical guide to graph- parison of ultrasonographic versus infra- 2017;151:1295-301.
ic communication for quality assurance, red pupillary assessment. Ultrasound J 51. Chan KK, Joo DA, McRae AD, et al.
education, and patient care in echocardiog- 2020;12:38. Chest ultrasonography versus supine chest
raphy. Echocardiography 2019;36:1747-54. 38. Porter TR, Shillcutt SK, Adams MS, radiography for diagnosis of pneumotho-
25. Helgeson SA, Fritz AV, Tatari MM, et al. Guidelines for the use of echocar- rax in trauma patients in the emergency
Daniels CE, Diaz-Gomez JL. Reducing iat- diography as a monitor for therapeutic department. Cochrane Database Syst Rev
rogenic pneumothoraces: using real-time intervention in adults: a report from the 2020;7:CD013031.
ultrasound guidance for pleural proce- American Society of Echocardiography. 52. Kimura BJ. Point-of-care cardiac ultra-
dures. Crit Care Med 2019;47:903-9. J Am Soc Echocardiogr 2015;28:40-56. sound techniques in the physical exami-
26. Wang J, Khan S, Wyer P, et al. The role 39. Hussain A, Via G, Melniker L, et al. nation: better at the bedside. Heart 2017;
of ultrasound-guided therapeutic para- Multi-organ point-of-care ultrasound for 103:987-94.
centesis in an outpatient transitional care COVID-19 (PoCUS4COVID): international 53. Stengel D, Leisterer J, Ferrada P,
program: a case series. Am J Hosp Palliat expert consensus. Crit Care 2020;24:702. Ekkernkamp A, Mutze S, Hoenning A.
Care 2018;35:1256-60. 40. Ferrada P, Evans D, Wolfe L, et al. Point-of-care ultrasonography for diag-
27. Abraham A, Breiner A, Katzberg HD, Findings of a randomized controlled trial nosing thoracoabdominal injuries in pa-
Lovblom LE, Bril V. Ultrasound-assisted using limited transthoracic echocardio- tients with blunt trauma. Cochrane Data-
lumbar puncture in a neuromuscular clin- gram (LTTE) as a hemodynamic monitor- base Syst Rev 2018;12:CD012669.
ic has a high success rate and less pain. ing tool in the trauma bay. J Trauma Acute 54. Javali RH, Loganathan A, Srinivasa-
Can J Neurol Sci 2019;46:79-82. Care Surg 2014;76:31-7. rangan M, et al. Reliability of emergency
28. Smit JM, Raadsen R, Blans MJ, Petjak 41. Clattenburg EJ, Wroe PC, Gardner K, department diagnosis in identifying the
M, Van de Ven PM, Tuinman PR. Bedside et al. Implementation of the Cardiac Ar- etiology of nontraumatic undifferentiated
ultrasound to detect central venous cath- rest Sonographic Assessment (CASA) pro- hypotension. Indian J Crit Care Med 2020;
eter misplacement and associated iatro- tocol for patients with cardiac arrest is 24:313-20.
genic complications: a systematic review associated with shorter CPR pulse checks. 55. Buhumaid RE, St-Cyr Bourque J, Sho-
and meta-analysis. Crit Care 2018;22:65. Resuscitation 2018;131:69-73. koohi H, Ma IWY, Longacre M, Liteplo
29. Bhattacharjee S, Maitra S, Baidya DK. 42. Huis In ’t Veld MA, Allison MG, Bos- AS. Integrating point-of-care ultrasound
Comparison between ultrasound guided tick DS, et al. Ultrasound use during car- in the ED evaluation of patients present-
technique and digital palpation technique diopulmonary resuscitation is associated ing with chest pain and shortness of
for radial artery cannulation in adult pa- with delays in chest compressions. Resus- breath. Am J Emerg Med 2019;37:298-303.
tients: an updated meta-analysis of ran- citation 2017;119:95-8. 56. Hilsden R, Leeper R, Koichopolos J,
domized controlled trials. J Clin Anesth 43. Rabjohns J, Quan T, Boniface K, Pour- et al. Point-of-care biliary ultrasound in
2018;47:54-9. mand A. Pseudo-pulseless electrical activ- the emergency department (BUSED): im-
30. Franco-Sadud R, Schnobrich D, ity in the emergency department, an evi- plications for surgical referral and emer-
Mathews BK, et al. Recommendations on dence based approach. Am J Emerg Med gency department wait times. Trauma
the use of ultrasound guidance for central 2020;38:371-5. Surg Acute Care Open 2018;3(1):e000164.
and peripheral vascular access in adults: 44. Zengin S, Yavuz E, Al B, et al. Benefits 57. Lin MJ, Neuman M, Rempell R, Monu-
a position statement of the Society of of cardiac sonography performed by a teaux M, Levy J. Point-of-care ultrasound
Hospital Medicine. J Hosp Med 2019;14: non-expert sonographer in patients with is associated with decreased length of
E1-E22. non-traumatic cardiopulmonary arrest. stay in children presenting to the emer-
31. Maggiolini S, Gentile G, Farina A, et al. Resuscitation 2016;102:105-9. gency department with soft tissue infec-
Safety, efficacy, and complications of peri- 45. Badra K, Coutin A, Simard R, Pinto R, tion. J Emerg Med 2018;54:96-101.
cardiocentesis by real-time echo-moni- Lee JS, Chenkin J. The POCUS pulse 58. Panebianco NL, Shofer F, Fields JM,
tored procedure. Am J Cardiol 2016;117: check: a randomized controlled crossover et al. The utility of transvaginal ultrasound
1369-74. study comparing pulse detection by pal- in the ED evaluation of complications of
32. Gottlieb M, Avila J, Chottiner M, pation versus by point-of-care ultrasound. first trimester pregnancy. Am J Emerg
Peksa GD. Point-of-care ultrasonography Resuscitation 2019;139:17-23. Med 2015;33:743-8.
for the diagnosis of skin and soft tissue 46. Gaspari R, Weekes A, Adhikari S, et al. 59. Metzler IS, Smith-Bindman R, Mogha-
abscesses: a systematic review and meta- Emergency department point-of-care ul- dassi M, Wang RC, Stoller ML, Chi T.
analysis. Ann Emerg Med 2020;76:67-77. trasound in out-of-hospital and in-ED car- Emergency department imaging modality
33. Wu T, Dong Y, Song H, Fu Y, Li JH. diac arrest. Resuscitation 2016;109:33-9. effect on surgical management of nephro-
Ultrasound-guided versus landmark in 47. April MD, Long B. Does spontaneous lithiasis: a multicenter, randomized clini-
knee arthrocentesis: a systematic review. cardiac motion, identified with point-of- cal trial. J Urol 2017;197:710-4.
Semin Arthritis Rheum 2016;45:627-32. care echocardiography during cardiac 60. Andersen CA, Holden S, Vela J, Rath-

leff MS, Jensen MB. Point-of-care ultra- 65. Castro G. Top 10 health technology trainees: a parallel-group randomized trial.
sound in general practice: a systematic hazards for 2020. Oakbrook Terrace, IL: J Hosp Med 2020;15(2):e1-e6.
review. Ann Fam Med 2019;17:61-9. The Joint Commission, January 3, 2020 71. Russ BA, Evans D, Morrad D, et al.
61. Gibbons RC, Costantino TG. Evidence- (https://www.jointcommission.org/en/ Integrating point-of-care ultrasonography
based medicine improves the emergent resources/news-a nd-multimedia/blogs/ into the osteopathic medical school cur-
management of peritonsillar abscesses d ateline-t jc/2020/01/t op-10-health riculum. J Am Osteopath Assoc 2017;117:
using point-of-care ultrasound. J Emerg -technology-hazards-for-2020/). 451-6.
Med 2020;59:693-8. 66. Díaz-Gómez JL, Frankel HL, Hernan- 72. Johri AM, Durbin J, Newbigging J, et al.
62. Breakey N, Osterwalder J, Mathis G, dez A. National certification in critical Cardiac point-of-care ultrasound: state-
Lehmann B, Sauter TC. Point of care ul- care echocardiography: its time has come. of-the-art in medical school education.
trasound for rapid assessment and treat- Crit Care Med 2017;45:1801-4. J Am Soc Echocardiogr 2018;31:749-60.
ment of palliative care patients in acute 67. Wong J, Montague S, Wallace P, et al. 73. Patrawalla P, Narasimhan M, Eisen L,
medical settings. Eur J Intern Med 2020; Barriers to learning and using point-of- Shiloh AL, Koenig S, Mayo P. A regional,
81:7-14. care ultrasound: a survey of practicing cost-effective, collaborative model for
63. Atkinson PR, Milne J, Diegelmann L, internists in six North American institu- critical care fellows’ ultrasonography ed-
et al. Does point-of-care ultrasonography tions. Ultrasound J 2020;12:19. ucation. J Intensive Care Med 2020;35:
improve clinical outcomes in emergency 68. Ultrasound in medical education por- 1447-52.
department patients with undifferentiated tal. Laurel, MD:American Institute of 74. Mayo PH, Koenig S. Advanced critical
hypotension? An international random- Ultrasound in Medicine (http://meded care echocardiography certification: an
ized controlled trial from the SHoC-ED .aium.org/medical-schools). update. Chest 2020;158:48-9.
Investigators. Ann Emerg Med 2018; 72: 69. Wong CK, Hai J, Chan KYE, et al. 75. Panebianco NL, Mayo PH, Arntfield
478-89. Point-of-care ultrasound augments physi- RT, et al. Assessing competence in critical
64. Plurad DS, Chiu W, Raja AS, et al. cal examination learning by undergrad- care echocardiography: development and
Monitoring modalities and assessment of uate medical students. Postgrad Med J initial results of an examination and cer-
fluid status: a practice management guide- 2021;97:10-5. tification processes. Crit Care Med 2021;
line from the Eastern Association for the 70. Kumar A, Weng Y, Wang L, et al. Por- 49:1285-92.
Surgery of Trauma. J Trauma Acute Care table ultrasound device usage and learn- Copyright © 2021 Massachusetts Medical Society.
Surg 2018;84:37-49. ing outcomes among internal medicine


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The n e w e ng l a n d j o u r na l of m e dic i n e

Julie R. Ingelfinger, M.D., Editor

P O CUS a nd C onsultat i v e Ult r a sono gr a ph y

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2011 2016 2019 2021

2015 2018 2020

Figure 1. Evolution of Point-of-Care Ultrasonography (POCUS) during the Past Decade.

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to determine competence in POCUS-driven pro- be associated with potentially treatable condi-

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Acute Pulmonary Edema Pneumonia

Sensitivity: 88% Sensitivity: 88%

Pneumothorax Left Ventricular Dysfunction Thoracoabdominal Trauma

Sensitivity: 81% Sensitivity: 69–94% Sensitivity: 74%

Figure 2. Diagnostic Accuracy of POCUS for Common Medical Conditions.

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Table 1. Comparison of Point-of-Care Ultrasonography (POCUS) and Consultative Ultrasonography.*

POCUS Performed by Nonradiologists Consultative Ultrasonography Performed by Radiologists

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