Crit Care Nurs Q

Vol. 41, No. 2, pp. 94–101

Copyright  c 2018 Wolters Kluwer Health, Inc. All rights reserved.

Point-of-Care Ultrasonography
in Emergency and Critical Care
Medicine
Leon Chen, DNP, AGACNP-BC, CCRN, CEN;
Tony Malek, MS, NP-C, CEN, RDMS, RDCS, RVT

To stabilize critically ill patients, emergency and critical care medicine providers often require
rapid diagnosis and intervention. The demand for a safe, timely diagnostic device, alongside tech-
nological innovation, led to the advent of point-of-care ultrasonography (POCUS). POCUS allows
the provider to gain invaluable clinical information with a high level of accuracy, leading to bet-
ter clinical decision-making and improvements in patient safety. We have outlined the history of
POCUS adaptation in emergency and critical care medicine and various clinical applications of
POCUS described in literature. Key words: critical care, emergency medicine, point of care,
shock protocol, ultrasonography

U TILIZATION OF ULTRASONOGRAPHY
(US) by practitioners other than radi-
ologists and cardiologists first started in the
late 1980s to early 1990s. At that time, it
was primarily used by trauma surgeons and
emergency medicine physicians in cases of
penetrating trauma. Focused assessment us-
ing sonography in trauma or “FAST,” was es-
Author Affiliations: Critical Care Medicine Service,
Department of Anesthesiology and Critical Care
Medicine, Memorial Sloan Kettering Cancer Center,
and NYU Rory Meyers College of Nursing, New York
(Dr Chen); and Emergency Department, Bellevue
Hospital Center, NYU School of Medicine, New York
(Mr Malek).
The authors thank Nalini Saxena, MBA, for manuscript
editing.
Supported by MSK Cancer Center Support Grant/Core
Grant (P30 CA008748).
The authors have disclosed that they have no signif-
icant relationships with, or financial interest in, any
commercial companies pertaining to this article.
Correspondence: Leon Chen, DNP, AGACNP-BC, CCRN,
CEN, Critical Care Medicine Service, Department of
Anesthesiology and Critical Care Medicine, Memorial
Sloan Kettering Cancer Center, New York, NY 10065
(ChenL@mskcc.org).
DOI: 10.1097/CNQ.0000000000000190
94
sential in the trauma bay to quickly screen
for intra-abdominal hemorrhage and in the
right clinical context, determined the need
for the operating room, without having to
move an unstable patient to CT scan or to re-
sort to invasive tests such as diagnostic peri-
toneal lavage. Point-of-care US (POCUS) or fo-
cused US allows the practitioner to rapidly
gain time-sensitive information and conduct
serial examinations without having to expose
patients to harmful radiation or contrast.1-3
Cardiologists and radiologists were initially
skeptical of the competency of emergency
medicine providers in conducting POCUS,
acquiring proper images, and interpret-
ing images in the right clinical context;
therefore, they pushed back in the use of
POCUS. Following several years of education,
demonstration of competency, publication
of relevant literatures, and improvement in
technology and communication between the
involved professional organizations, in 2010,
the American College of Echocardiography
and the American College of Emergency
Physicians released a consensus statement
that emergency physicians have the proper
training and knowledge to conduct and inter-
pret POCUS.4,5 In 2011, a group of experts
from the European Society of Intensive Care

Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

Medicine and 11 other professional critical
care societies released a consensus statement
endorsing the necessity of incorporating
critical care ultrasonography into the cur-
riculum of critical care medicine physicians.6
With such steps in standardization, POCUS’
utilization in emergency and critical care
medicine is not novel or an adjunct, but
rather the standard of care.7,8
SCOPE OF POINT-OF-CARE
ULTRASONOGRAPHY
A common misconception of POCUS is that
it replaces the need for official US or echocar-
diogram. In fact, POCUS is conducted with a
focus on answering a specific clinical ques-
tion in the given time and clinical situation. It
is not meant to be diagnostic nor is it meant to
replace an official US or echocardiogram. The
clinical questions that POCUS is looking to an-
swer are often binary, meaning “yes” or “no.”7
For example, a patient whose clinical presen-
tation suspicious for pericardial tamponade
begs the question “Is there a pericardial ef-
fusion?” is eligible for a POCUS. Information
acquired from a POCUS is interpreted qual-
itatively rather than quantitatively.7 There-
fore, in a patient with suspected congestive
heart failure exacerbation, the frontline prac-
titioner conducting POCUS will use the exam-
ination to look for decreased heart function,
rather than for a specific numerical ejection
fraction.
This is in contrast to an official US that is
done by licensed technicians, cardiologists,
or radiologists.7 Official US contains detailed
measurements of an organ of which values
will be interpreted by the radiologist or the
cardiologist. The practitioner who ordered
the test will then correlate this interpretation
within the clinical context. This process is of-
ten time-consuming and cannot be initiated
at all hours of the day. For clinically unstable
patients, this is simply not feasible. However,
the POCUS performer should also recognize
the limitation of a focused examination and
be ready to seek help from official ultrasono-
graphers when more detailed measurements
Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Ultrasonography in Critical Care 95
are needed since POCUS is not meant to re-
place official ultrasound.6,8
CLINICAL APPLICATIONS
Invasive procedures
Invasive procedures such as central line,
thoracentesis, and paracentesis prior to the
advancement of US usage were typically done
using landmark identifications. Such “blind”
methods carry an increased risk of compli-
cation such as pneumothorax, organ punc-
ture, infection, and multiple attempts. Land-
mark methods cannot account for anatomical
variations in the general population.9 With US
guidance, complication rates decreased, and
now US guidance for invasive procedures is
the standard of care recommended by mul-
tiple professional organizations.10–13 With US
guidance, procedures that traditionally have
been thought as high risk, such as thoracente-
sis on a mechanically ventilated patient, have
been demonstrated to be safe.14
Respiratory insufficiency
In the past, lung US was viewed as not fea-
sible since air in aerated lungs deflects US
beams; therefore, such an image would be
filled with artifact. This changed after Daniel
Lichtenstein, an intensivist who started to cat-
egorize different artifacts, and based on those
images, discovered that the artifacts can re-
veal underlying pathology.15 From this, Dr
Lichtenstein developed the Bedside Lung Ul-
trasound in Emergency (BLUE) protocol to
rapidly narrow down differentials in cases of
respiratory insufficiency or failure.16 In the
protocol, clinicians are guided through differ-
ent pathways based on the bedside US find-
ing. At the end of each different pathway, pa-
tients are categorized into different profiles,
with the most likely pulmonary pathology
that explains the presenting dyspnea. With
the protocol, novel terms such as “A lines,”
“B lines,” and “lung sliding” made it into the
US lexicon.16 A full description of the BLUE
protocol is beyond the scope of this review,
but a few of the terms are worth discussing
96 CRITICAL CARE NURSING QUARTERLY/APRIL–JUNE 2018
insofar, as they are popularly used by all clini-
cians who perform POCUS.
“Lung sliding” is the description of the
bright shimmering line under the ribs, which
shows the movement between visceral and
parietal pleura. When this is seen, pneumoth-
orax can be safely ruled out.16 Lung US has
been shown to be more sensitive in detecting
pneumothorax than chest x-rays in multiple
studies.17–20 Notably, although the presence
of lung sliding effectively rules out pneumoth-
orax, the absence of lung sliding does not rule
in pneumothorax since many other patholo-
gies can present with the absence of lung
sliding (eg, severe chronic obstructive pul-
monary disease, pleurodesis, and right main-
stem intubation).21
“A lines” are multiple horizontal lines that
are equal distances below the pleural line. “A
lines” are reverberation artifacts of the pleu-
ral line. When US waves penetrate through
the thick pleura, it captures the image and re-
flects off the air below which produces the
mirror image of the pleural line seen below.
When seen, this represents air in the lung,
which can be interpreted as normal aeration
when lung sliding is present. When lung slid-
ing is absent however, this sign may be in-
terpreted as possible pneumothorax since air
will be present in the thorax even with col-
lapsed lungs.15–16
“B lines” are vertical bright lines that be-
gin from the pleura line and extend to the
bottom of US screen. Other features of “B
lines” are that it should efface underlying “A
lines,” and move with the movement of pleu-
ral sliding. When seen, “B lines” represent the
loss of aeration within the lung whether in
the interstitium or in the alveoli.15–16 Three
or more “B lines” seen between 2 rib spaces
are highly associated with cardiogenic pul-
monary edema, and the number of “B lines”
seen is correlated with the degree of inter-
stitial syndrome.20 Other conditions that the
BLUE protocol can help with diagnosing are
pleural effusion, lung consolidation, and deep
vein thrombosis, which in the right setting in-
creases the pretest probability of pulmonary
embolism.15–16 In experienced hands, the
Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
BLUE protocol can be completed in min-
utes and can be extremely effective in help-
ing the bedside clinician make time-sensitive
decisions.
Undifferentiated shock
Recognizing the numerous causes of shock
in critically ill patients in the emergency de-
partment (ED) or the intensive care unit (ICU)
is difficult mostly due to poor or limited med-
ical history, a wide array of differential diag-
nosis, and the necessity of early and fast inter-
vention needed to save patients from impend-
ing death.22 There are many different types
of shock, such as hypovolemic, cardiogenic,
septic, neurogenic, and obstructive. These
subtypes of shock are unique and require dif-
ferent approaches. Clinicians in the ED/ICU
may even face tougher situations when
shock is of the mixed type or of an etiology
that is “not defined.”23 Usually, intravenous
fluid therapy is an essential component in
managing patients with shock. However, at
times it is crucial to assess volume status
prior to flooding the patient with fluids.24
Assessing volume status is achievable via
invasive monitoring, which might not be
readily available during an emergency.25
Incorrect fluid therapy may lead to persistent
hypovolemia or fluid volume; in either case
it may deteriorate the patient’s status and
causes more complications.25–26 Managing
conditions such as shock or undifferentiated
hypotension in the ED is common, and
these symptoms are a predictor of inhospital
mortality. Clinicians may have a very limited
time window in dealing with shock patients
for whom they must choose the right inter-
ventions depending on the kind of shock and
the management of hypotension.24,26 Signs
point to the usage of only intravenous fluid
while monitoring vital signs as no longer
sufficient.24,26
US enables providers everywhere in the
ED or the ICU to visualize inside the body
without having to perform invasive proce-
dures. Physical examination alone cannot
provide the information that US is capa-
ble of revealing.27 US has an instant impact

on the management of shock by allowing
sooner identification of the cause, and it is
quickly becoming essential to diagnose and
manage trauma in today’s health care.28,29
The use of US in emergency situations is
growing at a rapid state and continuously
evolving.29
POCUS greatly aids the clinician in narrow-
ing down the list of differentials, thus improv-
ing patient outcomes, especially in patients
with undifferentiated shock/hypotension.30
POCUS should be aimed at ruling out any
emergent life-threatening condition as a result
of hemodynamic instability, and it involves
a simple and quick sonographic examination
of the heart, lungs, abdomen, large vessels,
and peripheral veins.29,31 It has been proven
that it can improve the specificity of early
recognition of hypovolemia, and in a patient
with possible shock, timely detection of tam-
ponade, massive pleural effusion, abdominal
bleed, or cardiac wall-motion abnormality of
the heart is crucial and, indeed, life-saving.22
PROTOCOLIZED POINT-OF-CARE
ULTRASONOGRAPHIC EXAMINATIONS
Since FAST has become a regular element
of advanced trauma life support, its use has
provided real-time evaluation of patients with
undifferentiated shock.22 Like the FAST pro-
tocol, the rapid ultrasound in shock (RUSH)
is also a valuable tool in diagnosing and
managing undifferentiated shock that may
not be caused by trauma.26 For example, by
measuring the left ventricular end-diastolic
area, or visualizing an underfilled left ventri-
cle, the provider can identify the reduction
in intravascular volume in minutes.30 Recent
research has shown that inferior vena cava
(IVC) assessment can be a valuable tool to
help determine a patient’s volume status.22,30
Many protocols exist and this review will
addresses the Rapid Ultrasound Assessment
for Shock (RUSH) protocol, the Abdominal
and Cardiac Evaluation with Sonogra-
phy in Shock (ACES) protocol, and the
Resuscitative Echocardiography for the Eval-
Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Ultrasonography in Critical Care 97
uation and Management of Shock (RECES)
protocol.
RUSH protocol
One of the most used protocols is RUSH.
This protocol aims at evaluation of the heart,
the intraperitoneal spaces, the aorta, and the
IVC. An US examination evaluates the heart
for left ventricular function, right ventricular
strain, and tamponade. In addition, the prac-
titioner evaluates the great vessels to estimate
central venous pressure, aortic dissection or
aneurysm, and finally evaluation of the ab-
dominal quadrants for any signs of free fluid
(ie, bleeding).26 In other words, the practi-
tioner is using US to examine the pump, the
tank, and the pipes.22
Most of the examinations can be done us-
ing a phased array transducer while the pa-
tient is commonly supine. The traditional car-
diac chamber views are obtained, followed by
parasternal long- and short-axis views, subx-
iphoid and apical 4-chamber views. Linear or
curvilinear array probes may be utilized for
evaluation of the peripheral vessels to rule
out deep vein thrombosis or to evaluate jugu-
lar veins.26
A prospective study by Ghane et al30 con-
cluded that the RUSH protocol showed very
promising results in diagnosing undifferen-
tiated shock. It has excellent sensitivity in
patients with hypovolemic, cardiogenic, and
obstructive types of shock. The RUSH pro-
tocol also had good specificity in the latter
3 types of shock as well as in distributive
and mixed etiology shock.30 Overall, the au-
thors praised this protocol in the care of pa-
tients with undifferentiated shock. Another
prospective study by Bagheri-Hariri et al32 uti-
lized the RUSH protocol on patients with un-
differentiated shock and compared the proto-
col results with the patient’s final diagnosis.
The study found that the RUSH protocol has
88% sensitivity and 96% specificity when ex-
amined with the final diagnosis. Therefore, it
concluded that the RUSH examination is an
apt tool to diagnose undifferentiated shock in
critically ill patients.32
98 CRITICAL CARE NURSING QUARTERLY/APRIL–JUNE 2018
ACES protocol
Another evolving protocol is ACES, which
is also utilized in undifferentiated shock. This
protocol is conducted by acquiring 6 views,
which include focused views of the heart,
IVC diameter with the index of respiropha-
sic collapse, abdominal aorta views, right and
left upper quadrant views to evaluate for peri-
toneal or pleural fluid, and transverse pelvic
view for bladder volume and abdominal free
fluid.23 This protocol incorporates the basic
idea of the caval index, which operates on the
premise that the change in the diameter of
the IVC during the respiratory cycle is corre-
lated with the volume status of the patient.33
The caval index can be calculated by the dif-
ference between expiratory IVC diameter and
inspiratory IVC diameter, divided by the ex-
piratory IVC diameter, and multiplied by 100
to achieve a percentage in variation.25 Data
obtained are not only diagnostic for volume
status but a good indicator of the responsive-
ness for volume loading.33 Overall, the ACES
protocol was found to be a good adjunct to
a physical examination in patients with undif-
ferentiated shock.
RECES protocol
RECES is also an emerging protocol devel-
oped to provide immediate diagnostic infor-
mation as to the cause of undifferentiated
shock. What is different about this protocol
is that it continues to guide the clinician dur-
ing ongoing resuscitation. The RECES proto-
col targets 8 aspects of the human cardio-
vascular system to evaluate the cause of the
hypotension or shock as well as the status of
the patient during and posttreatment.26 This
protocol requires training to acquire and in-
terpret the findings. It is not intended to re-
place an echocardiographic examination, but
it is designed to be performed in emergency
situations by qualified emergency or intensive
care clinicians to rapidly delineate potential
causes of a patient’s undifferentiated shock.
The RECES protocol starts with the evalua-
tion of the presence of pericardial effusion,
with US sensitivity of 96% and 98% speci-
Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
ficity. The next step is the evaluation of the
global systolic function via visual estimate (ie,
eyeballing) rather than exact calculated ejec-
tion fraction resulting from the chambers’
measurements.26 The third, fourth, and fifth
components aim to assess responsiveness to
treatment by examining the size of the IVC
in a similar fashion as the ACES protocol,
as well as by evaluating left ventricular con-
tractility, left ventricular outflow tract veloc-
ity changes, and the presence or absence of
left ventricular diastolic dysfunction.23 The
presence of left ventricular diastolic dysfunc-
tion can be a cause of pulmonary edema
or congestion from volume overload. On the
other hand, “kissing” papillary muscles may
be linked with hypovolemia. The sixth and
seventh components of the RECES protocol
are evaluations of the walls of the ventri-
cles, specifically the right ventricular wall. A
wall motion abnormality can be an indication
of a concurrent myocardial ischemia, which
might be the underlying cause of shock in
a particular case. A careful evaluation of the
systolic function of the right ventricle re-
veals a great deal of information regarding
the pulmonary pressure and the expecta-
tion of right ventricular failure. The eighth
and last item on the list that is unique to
this protocol is the evaluation of the cardiac
valves for blatant mitral, tricuspid, or aortic
valve insufficiency. An acute papillary mus-
cle rupture may precipitate various types of
complications.23
DEMONSTRATION OF COMPETENCY
US competency in critical care has been
hard to measure. Unlike emergency medicine
in which US training is built into the resi-
dency curriculum and in which a specialty
US fellowship has been well developed, not
every critical care program institutionalized
critical care US (CCUS) as part of its core
curriculum.34–37 However, this is changing
after consensus statements made by large
professional organizations such as the Amer-
ican College of Chest Physicians (ACCP)
and other international expert panels. Based

on their recommendation, a curriculum
consisting of core applications (ie, vascu-
lar access and thoracic US) and advanced
applications (ie, basic echocardiography)
has been proposed for critical care training
programs.36,37 Although a lack of supporting
data has precluded the standard requirement
for the minimum amount of didactic, self-
learning modules, or hands-on practice, the
ACCP recommends a minimum 10 hours of
general CCUS and 10 hours of critical care
echocardiography; these hours of teaching
are to be divided between lectures on theory
and image-based teaching.35–36
The minimum number of applications to
achieve competency in general CCUS is also
undetermined due to a lack of data; how-
ever, for critical care echocardiography, ap-
proximately 30 hours is required, based on
existing literature.37–40 As such, critical care
programs require completion of the afore-
mentioned curriculum to show competency
in CCUS prior to graduation.39,40 This is
only applicable to critical care physician fel-
lows and attendings, and not for other criti-
cal care providers such as advanced practice
nurses and physician assistants (ie, advanced
practice providers) or noncritical care-trained
physicians.
A select few postgraduate advanced
practice provider fellowship programs in
critical care and emergency medicine, such
as the ones at Emory University Hospital,
Lehigh Valley Medical Center, and Carillion
Clinic, include extensive US training in their
curriculum.41–43 The ACCP, at the forefront of
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Ultrasonography in Critical Care 99
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