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CHAPTER 131 ■ ULTRASOUND
JASON LEVY, JOANNA S. COHEN, ALYSSA ABO, RACHEL G. REMPELL, J. KATE DEANEHAN

INTRODUCTION
Point-of-care ultrasound (POCUS) has been used in the emergency department
(ED) for nearly four decades. Its beginnings are rooted in the adult population,
which has well-established, evidence-based applications such as the focused
assessment with sonography in trauma (FAST) and evaluation for abdominal
aortic aneurysm. It is now a required component of emergency medicine
residencies and is considered core content by the American Board of Emergency
Medicine and the American College of Emergency Physicians (ACEP).
Traditionally, ultrasound performed by imaging specialists involves
comprehensive examinations in which entire anatomic areas are evaluated. In
contrast, emergency POCUS is intended to answer a more focused, limited
clinical question (e.g., “Is there cardiac activity or not?”) or assist with a specific
procedure. Consequently, the approach to both training and patient evaluation is
different.
Pediatric emergency medicine has been slower to adopt bedside ultrasound into
clinical practice. In recent years, however, it has gained widespread acceptance as
the body of literature has expanded and training has become more accessible.
There are now consensus educational guidelines for POCUS training in pediatric
emergency medicine fellowship and its inclusion in pediatric emergency medicine
practice is endorsed by the American Academy of Pediatrics (AAP). Besides the
obvious advantage of being done directly at the patient’s bedside, emergency
POCUS offers several other benefits to the pediatric patient. It is painless, readily
available, does not require sedation, and does not expose the patient to ionizing
radiation. Furthermore, published data supports its use with respect to better

patient care, improved patient satisfaction, and decreased wait times. Although a
substantial amount of pediatric-specific research exists, its growing use will
necessitate further investigation to determine which adult applications can be
generalized to children and to develop and implement bedside ultrasound
examinations specific to the pediatric patient.

ADMINISTRATIVE ASPECTS
Starting a Point-of-Care Ultrasound Program


Before implementing a POCUS program, several administrative requirements
should be addressed. First, a point person should be identified who either is
already well trained in POCUS, or is prepared to undertake additional ultrasound
training. This person will ultimately be responsible for the training of staff,
residents, and fellows, as well as assume responsibility for quality assurance and
interdepartmental communication. Second, an ultrasound system should be
purchased designed for the purposes of ED use. Staff and trainees must be able to
put what they have learned into use and only those who perform ultrasound scans
routinely will gain sufficient facility to incorporate it into their practice. There are
now many companies that recognize the need for ED-specific machines and have
products that cater to this niche. Third, starting a program is best done in concert
with hospital leadership and credentialing committees. A collaborative
relationship with Radiology is important. Whenever possible, data should be
employed to justify evidence-based implementation of specific POCUS
examinations with the ultimate goal of improving patient care.
Once the lead person has been identified, teaching of the staff and trainees can
commence. Although there are some published standards for training in
ultrasound, there is still debate among different governing bodies as to minimal
requirements to achieve competency. Guidelines from the American College of
Radiology and the American Institute of Ultrasound in Medicine are geared

toward comprehensive, diagnostic examinations and are not applicable to
POCUS. The AAP and ACEP have published consensus guidelines based on
expert opinion and previously published data which have now become the current
standard for pediatric emergency medicine. In general, programs should establish
a minimum number of didactic hours, a minimum number of overall ultrasound
examinations, and a minimum number of examinations to look for a specific
finding. These requirements will form the basis of the credentialing process for
staff physicians. Despite these baseline requirements, literature would suggest
that there continues to be an ongoing learning curve that plateaus at a
significantly higher number of scans per application.

Equipment Considerations
The ideal equipment for POCUS should have durability, mobility, good image
quality, good battery life, and rapid boot-up time. Most importantly, the
anticipated type of ultrasound scans should guide the purchasing of equipment. If
a machine is being purchased for vascular access only, then one with a highquality cardiac application would not be justified. There are numerous ultrasound
systems that are tailored to the practice of emergency medicine and the
technology is constantly advancing. All machines should be portable and


maneuverable enough to fit into the cramped spaces of an ED. A cart-based
system is ideal for ease of movement, changing of probes, storage space, and
housing considerations. Furthermore, one must consider a device’s ease of use, as
the more complicated systems may intimidate novice users and be a roadblock to
gaining experience. Other factors to consider are initial cost and the ongoing costs
of service plans.
There are numerous types of transducers (probes) from which to choose.
Transducers are generally classified based on frequency, with low-frequency
probes for improved penetration (but poorer image quality) and high-frequency
probes for better image resolution (but weaker penetration into deep tissue).

Transducers should be purchased based on the anticipated type of ultrasound
examinations. For example, if a significant percentage of patients present with
pregnancy-related complaints, an endocavitary probe may be warranted. The
footprint of the probe should also be considered. The footprint is that portion of
the probe that comes into contact with the skin and sends out the ultrasonic
waves. Probes with a large footprint can give a wider field of view but are
difficult to fit into the small intercostal spaces of infants and children. Generally
speaking, at least two probes should be considered essential when purchasing an
ultrasound machine, a low-frequency probe that can be used for abdominal and
cardiac examinations, and a high-frequency linear probe which can be used for
procedural applications and ultrasound of superficial soft tissues (Fig. 131.1 ).