Ultrasound examination is basically done to corroborate the clinical findings. routine advise and referral for investigations is taking toll on the quality of emergency medical care. Bed side ultrasound examination may be done by the internee himself if he suspects any abdominal emergency to rule out perforation or infiltration. Ultrasound examination rarely helps patients to overcome emergency rather it is the clinical acumen and presence of mind that saves them.

most of the referred cases coming to the emergency department have been mismanaged or ill treated.

even an unconscious person will leave behind signs to be seen and understood, a standard protocol will help.

Im not a radiologist nor a physician but I have dealt with emergencies as a doctor.

Of course it is not routine. This is a case of people requesting invesatigations for which there is no scientific reason and most importantly without thinking. It is a waste of everyone's time and money. A good history and examination is far more important. Unfortunately once one person starts this nonsensical approach to patient management it can be difficult to reverse it. My advice is to nip it in the bid before it becomes an ongoing problem.

Ultrasound is a high-end diagnostic (and not a simple screening) tool with a very high spatial resolution and specific applications to help to narrow the differential diagnosis.

When it is used in the combination with information from a thorough anamnesis and physical exam, and with the information of biochemical and hematological results, it can help to rule out or confirm specific pathology.

But it is only helpful when it is performed by a trained physician, preferable a radiologist who is trained to judge the usefulness of the suggested exam.

Routine screening of the abdomen is (as already stated) a waste of time and money. Imaging should always be specific and dedicated to the patient.

So my advice: ask the radiologist and help your patient.

Abdominal ultrasound is not mandatory in all patients presenting to ED. It should be asked for only in problematic cases to conserve resources. It can give specific diagnosis in many cases - for example in differentiating between urinary tract obstruction and acute appendicitis in cases with right lower abdominal pain. If the emergency physician is well trained in performing and interpreting ultrasound studies it can significantly add to the clinical information immediately, thus helping in triaging in many instances. In this case (when performed by ED physician) it can very well become a part of the clinical examination. In my view, if the examination is to be done by a radiologist, clinical examination should be given more importance and abdominal ultrasound may be asked for in selected cases only.

@Mostafa Soliman. Please define "urgent".

In an ED the physician attending can be

A). Sure of diagnosis:

he may may not need usg but may rush the patient the patient to Emg OR. In such cases ultrasound/ radiologist will confirm the findings and none mind such investigations unless it is wastage of precious time.

B). Suspects something but needs confirmation:

these are the cases where radiology/us plays a vital role in guiding the further treatment plan. this definitely helps the patient. But this 'suspicion' is a subjective issue ( as mentioned earlier, skill of the attending doctor) and plays an important role both in asking a specific query and the maximum out of the investigation or making things more vague by being gross while ordering an usg. Usg may be helpful in many of the conditions but as pointed out earlier its important to decide when to get it done, in ED or in routine because in ED a minute saved is a minute earned. here triage of the patients is needed. Developing a standard protocol will be of enormous help to the doctors and patients as well.

3). Do not suspects anything but just send the patient to get something:

this is the part which is the burden and medical audit can take care of it ( if it is there).the reason for such investigations is to be double sure as far as the doc or the patient is concerned, after all everyone is afraid of law suites.

with upcoming trends, the ultrasound is more and more being used by physicians, i personally foresee ultrasound becoming an integral part of the routine general physical examination. Hence referrals to radiology will reduce but the use of ultrasound in ED will still continue and those cases with positive findings will be considered while rest will not be counted anywhere.

A rational approach is all that is neede.

If the clinical indications exists such as abdominal pain and white count, abdominal ultrasound in ER is a preferred choice than CT. Without clinical indications, probing abdomen just to find an incidental cause could be a waste. However, in my experience, even in the absence of clinical indications (like white), ER US exams have revealed pathologies (Hernia,pancreatic tumor, CBD blockage), otherwise would have been missed. So making a choice when not to have US exam is difficult. But US exam is much easier, less expensive, lot more safe compared to otherwise CT exam.

Well, it is obvious that abdominal ultrasound is not mandatory in all ED patients. The reasons for that have already been listed or described by others in their comments.

Though, it can be made a part of examination in a certain group of patients. For example, the EM department where I am working has abdominal ultrasound as a part of their protocol for patients coming to ED as trauma alerts after being involved in high-speed motor vehicle accidents. I should be noted that even in such patients, only the physicians trained properly in performing bedside abdominal ultrasound should do the ultrasound exam.

This comment gives one definition of urgent: (life threatening) trauma is an indication for urgent US. In my opinion it is a part of the C in ATLS. Should be done promptly by a radiologist (should be part of the rauma team) if available, if not by a well trained physician.

Of course that is not mandatory but very helpfull. Do not forget that US is very dangerous toll if it is do it by unexperienced and untrained resident. First call senior radiologist to do it instead of you if you are not certain in the diagnosis. And do not forget that US is just a part of a diagnostics in emergency cases. In unstable patient after trauma you can do it, but first of all it is necessery to stabilize patient or to send him with another clinician in OP theatre directly.

Do not waist time in emergency cases with US, use another clinical data and think promptly.

The American College of emergency Physicians (ACEP) came up with policy statement on emergency Ultrasound guidelines in 2008. These guidelines classified ER US into five categories..:

1. Resuscitative: ultrasound use as directly related to an acute resuscitation

2. Diagnostic: ultrasound utilized in an emergent diagnostic imaging capacity

3. Symptom or sign-based: ultrasound used in a clinical pathway based upon 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.

The paper also details the use of ER US in various systems.

This paper can help us define the uses of ER US, which we can adapt to our hospital settings.

I am attaching the article for reference..

My question is: Who is well qualified physicinas to make US in emergency cases?. It is very difficult to see that fact from policy statement. I think that could do it properly just radiologist.

Yes. I think this is very important exam in ED

In the ED, there are a limited number of indications for ultrasound (US) to be performed by the ED clinician. They are done to; (1) provide visualization for an invasive procedure such as a central line, or (2) to answer a specific question such as, "...is there free fluid in the abdomen of this trauma patient...?" They are NOT performed without a specific indication.

Good morning. Here in Malaysia, the ED resident performs the bedside ultrasound and present the finding to the radiology resident. It is part of the ED residents training to be able to perform basic ultrasound of the abdomen to look for free fluid. To be honest, their findings can be very helpful. The ED department has their own ultrasound machine. If the radiology resident has any doubts, we would repeat the ultrasound prior to performing a CT to look for intra abdominal injuries. Imaging are not performed without indication.

Thanks Dr. Netia,

In our centres, a Radiology Resident performs FAST. If positive, a biphasic CECT abdomen is performed for abdominal injuries

Regards

Abdomen ultrasound is not mandatory in all ER patients. Histroy of the patient and physical examination is enough for most of the paitents. In my country, Turkiye, ultrasound is ordered to rule out mostly for trauma patients and conditions need surgery in a short time.

Ultrasound imaging is useful tools in experienced hands , Probably I think, to date,  is the first diagnostic  time, in some and definite conditions,  if the team in ED  have a lot of time for evaluate the patient and if the conditions of patient are not hardly compromised. Is useful also for evaluating in context of trauma if is present a pneumothorax , that is a condition very dangerous and an early diagnosis with ultrasound can be the difference for the life with correct management of patient. It is also correct specify that ultrasounds is dependent for condition of the patient, compliance, mobility or not, and by ability of the operator. Troubles that arise during execution of ultrasound examination by ED Team( without Radiologist)  must been erased by evaluation in radiological setting with optimal and standardized diagnostic tool for evaluation of multifocal trauma: MDCT with i.v mdc.

FAST is a simple bedside adjuncts in trauma assessment that doesn't need radiologist to do it.