Summary
Objective:
The study aimed to determine how a brief educational intervention could enable emergency medicine (EM) residents to use point-of-care ultrasound (POCUS) effectively to diagnose and manage shoulder dislocations in the emergency department (ED).
Methods:
Conducted at an academic teaching hospital in Miami, Florida.
Twenty EM residents (PGY1–PGY4) with no prior shoulder ultrasound training participated.
Residents received <1 hour of in-service training, including a short lecture, video instruction, and hands-on practice using a Sonosite M-Turbo ultrasound device.
Over one year (2016–2017), residents prospectively enrolled 78 adult patients with suspected shoulder dislocation.
POCUS findings were compared with x-rays (the gold standard) for accuracy.
Time to diagnosis and reduction confirmation were recorded.
Results:
55 of 78 patients were diagnosed with dislocation; 53 anterior, 1 posterior, 1 inferior.
POCUS achieved 100% sensitivity and specificity for diagnosing and confirming successful reductions compared to x-ray.
Ultrasound results were available ~22 minutes faster for diagnosis and ~27 minutes faster for reduction confirmation than x-rays (p < 0.0001).
Residents across all training years performed equally well.
POCUS also identified 14 fractures (12 confirmed by x-ray, 2 seen only on ultrasound).
Discussion:
A short educational session enabled residents to accurately use POCUS for shoulder dislocation diagnosis and management.
POCUS reduced diagnostic time, avoided radiation exposure, and may improve ED workflow and patient comfort.
Findings support including shoulder ultrasound as a core component of EM training, filling a current gap in national ultrasound education guidelines.
Limitations:
Convenience sample and single-center design.
Some selection bias and inherent limitations of POCUS-based studies.
Conclusion:
Emergency medicine residents can learn to diagnose and manage shoulder dislocations with excellent accuracy after brief ultrasound training. POCUS should be integrated into EM residency curricula as a core skill for musculoskeletal emergencies.
POCUS can be performed at the bedside to evaluate for acute scrotal conditions, including testicular torsion and inflammatory processes such as epididymo-orchitis.
A high-frequency linear transducer is typically used to scan the scrotum in two different planes. Additionally, a coronal "buddy view"—displaying both testes side by side—can aid in comparing echogenicity and vascularity.
On B-mode imaging, both testicular torsion and inflammatory conditions may present with testicular swelling and decreased homogeneity. However, color and power Doppler imaging can help to differentiate:
Inflammatory conditions (e.g., epididymo-orchitis) typically show increased vascular flow on color and power Doppler.
Testicular torsion usually demonstrates reduced or absent flow in the affected testis. However, in cases of intermittent torsion-detorsion, vascular flow may appear preserved or even increased. In such scenarios, repeat Doppler imaging after one hour may help clarify the diagnosis.
Summary:
This study evaluated whether the line-of-sight approach improves the speed and accuracy of ultrasound-guided needle placement into the subdeltoid bursa among novice operators, compared to the side approach. A secondary aim was to assess the usefulness of the APPLES mnemonic (Angle, Position, Perpendicular, Line up, Entry, Sweep) as a teaching aid.
Methods:
Medical students and residents were randomized to perform the procedure using both approaches in a crossover design. Two blinded reviewers measured procedure time, and participants completed a survey on their preferences and perceptions of APPLES. Statistical tests (paired t test, McNemar test) compared performance time and accuracy.
Results:
The line-of-sight approach significantly reduced procedure time (mean 14.4 s vs. 18.6 s; P = .00029).
Participants were more likely to hit the target within 30 s using the line-of-sight approach (P = .035).
72.7% preferred the line-of-sight approach.
88.2% found the APPLES mnemonic helpful.
Conclusions:
The operator’s positioning plays a key role in ultrasound-guided procedures. The line-of-sight approach improves both speed and accuracy for novice users, and the APPLES mnemonic is a valuable educational tool for teaching these techniques.
Kerith Joseph MD, RMSK
Clinical Associate Professor
University of Maryland School of Medicine
Baltimore Veterans Affairs Medical Center, Emergency Department
E-point septal separation (EPSS)—the distance between the anterior mitral valve leaflet and the interventricular septum during early diastole—is a well-established marker of left ventricular (LV) systolic function in adults. A threshold of 7.0 mm is commonly used to screen for severely depressed LV function. But how well does this cutoff translate to pediatric populations?
A recent retrospective study set out to explore this very question. Researchers reviewed 770 pediatric echocardiograms, including 148 with abnormal LV function and a 4:1 random sample of normal studies. Using post-exam ultrasound software, blinded operators measured EPSS across three age groups: 0-3 years, 4-12 years and 13-18 years.
Results:
Among children with LV systolic dysfunction, EPSS values increased progressively with severity:
When applying the adult 7.0 mm threshold: Sensitivity: 76.4% (95% CI: 68.5–82.8%) Specificity: 95.8% (95% CI: 93.8–97.2%)
However, the study-derived optimal threshold of 6.0 mm improved sensitivity to 81.8% (95% CI: 74.4–87.4%) while maintaining high specificity at 91.4% (95% CI: 88.9–93.5%).
Special Consideration for the Youngest Patients
In children aged 0–3 years, a lower threshold of 4.9 mm outperformed the adult cutoff: Sensitivity at 4.9 mm: 77.8% (95% CI: 51.9–92.6%) vs sensitivity at 7.0 mm: 55.6% (95% CI: 31.3–77.6%)
While these findings are promising, further research is needed to validate EPSS thresholds in emergency department (ED) settings using point-of-care ultrasound (POCUS), and to assess their feasibility in real-time clinical workflows.
Bottom Line: For older children an EPSS threshold of 7.0 mm appears to be accurate in identifying children with LV systolic dysfunction, but a lower threshold may be needed for children ages 0-3. Further studies are needed.
A recent systematic review compared the timing and diagnostic accuracy of manual pulse check versus point-of-care ultrasound (POCUS) pulse checks (this means placing an ultrasound probe on the carotid or femoral artery to evaluate for a doppler pulse).
The review included seven studies encompassing a total of 469 patients.
Six of the studies assessed the duration of pulse checks, revealing a mean time difference of –1.39 seconds (95% CI: –2.20 to –0.57) in favor of ultrasound.
Three of the studies reported the sensitivity and specificity of POCUS pulse checks, yielding pooled estimates of 99% sensitivity (95% CI: 87%–100%) and 96% specificity (95% CI: 85%–99%). In contrast, two studies evaluated manual pulse checks, with pooled sensitivity of 62% (95% CI: 22%–91%) and specificity of 91% (95% CI: 88%–93%).
As with many systematic reviews, the studies included demonstrated high heterogeneity and generally low methodological quality, indicating that further investigation may still be needed.
If a patient is experiencing issues with their Foley catheter, consider using POCUS.
Using a curvilinear probe over the suprapubic region, you can obtain a transverse view of the bladder by orienting the marker towards the patient’s right side, or a sagittal view by orienting the marker towards the patient’s head.
In a properly functioning Foley, the bladder will appear decompressed, and you may only see the Foley balloon.
In cases of obstruction or malposition, you may notice a distended bladder. The next step is to attempt to visualize the Foley balloon. If you do not see a Foley balloon within the bladder, try deflating the balloon and advancing the catheter.
If you notice debris blocking the foley or heterogenous material in a patient with hematuria, you can attempt to flush the catheter, but if the patient has a large amount of hematuria, you may need to replace the current Foley with a three-way catheter for continuous bladder irrigation.
Early Systolic Notching and Pulmonary Embolism
A prospective multicenter study conducted across four academic emergency departments in Turkey evaluated the diagnostic accuracy of early systolic notching (ESN) in emergency department patients. Among the 183 patients included, 52.5% were diagnosed with pulmonary embolism (PE), while 19.7% exhibited the ESN finding. ESN demonstrated a sensitivity of 34% (95% CI: 25–45%) and a specificity of 97% (95% CI: 90–99%) for PE. Sensitivity increased to 69% in patients classified as high or intermediate-high risk. Overall, ESN exhibits moderate to high specificity but low sensitivity, consistent with other sonographic signs of PE. Notably, ESN may also be present in patients with chronic thromboembolic disease secondary to prior pulmonary hypertension.
How to Obtain ESN
To detect ESN, acquire a parasternal short axis view at the base of the heart to visualize the right ventricular outflow tract and pulmonic valve. Position the pulse wave Doppler gate just proximal to the pulmonic valve, with the cursor traversing the outflow tract. ESN is characterized by a sharp systolic spike with a notch, followed by a dome-shaped waveform
Digital nerve blocks are commonly used to provide anesthesia for finger injuries such as lacerations and dislocations. However, the procedure can be painful, as it often requires multiple injections into sensitive areas.
A recent single-center, unblinded randomized study compared the subjective discomfort and analgesic efficacy of traditional digital nerve blocks with ultrasound-guided peripheral nerve blocks. The study included 106 patients, with 53 in each group.
Results showed that patients in the peripheral nerve block group reported higher satisfaction rates. They also experienced less pain during the initial injection and longer-lasting analgesia compared to those who received digital nerve blocks. While digital blocks had a faster onset of anesthesia, they were associated with a higher rate of block failure.
A hip effusion can cause pain with leg movement in both pediatric and adult patients.
A recent multicenter, prospective study assessed the diagnostic accuracy of POCUS performed by pediatric emergency physicians in detecting hip effusion.
They found that POCUS had a sensitivity of 89.3% (95% CI 80.6 to 95.0%) and specificity of 99.2% (95% CI 97.0 to 99.9%).
To scan the hip:
-Position the patient supine with the patient’s hip externally rotated.
-Place the probe transversely across the patient’s leg with the marker towards the patient’s right and scan proximally.
-Upon reaching the proximal femur, rotate the probe marker so it points towards the patient’s umbilicus.
-Look for an anechoic stripe at the femoral neck, preceding the femoral head.
An anechoic stripe measuring at least 5 mm in the anterior synovial space or an asymmetry exceeding 2 mm compared to the opposite, asymptomatic hip is diagnostic for hip effusion in BOTH pediatric and adult populations.
When evaluating foreign bodies in soft tissue, an imaging interface- such as a standoff pad- can improve imaging of superficial structures.
Common image interfaces include gel, commercial standoff pads, saline bags, and water baths.
Water baths are primarily used for imaging the hands and feet, but a recent study explored a water-filled patient belongings bag as a novel alternative. This method gives the benefit of the same elevated standoff that water baths provide, while accommodating larger extremities that may not fit in traditional setups.
The study found no significant difference between the patient belonging bag and a water bath for identifying a FB in a porcine model. Saline bags had the lowest image quality.
The normal gallbladder dimensions on ultrasound are approximately 3 cm in width by 10 cm in length.
A recent study evaluated the diagnostic test characteristics of gallbladder distension on POCUS for cholecystitis.
The authors conducted a retrospective cohort study of 227 patients who were admitted to the hospital after undergoing a POCUS biliary study in the emergency department.
They found the prevalence of gallbladder distension to be 30% in their study population. When combined with other sonographic findings, the presence of distension increased the specificity for cholecystitis to 95.6%.
Gallbladder wall distension was associated with the presence of an obstructing stone in the gallbladder neck and with acute cholecystitis.
Additionally, gallbladder wall distension was associated with longer operative times (mean 114 minutes) compared to those without distension (mean 89 minutes; p=0.03), suggesting more severe disease and potentially more complex surgical intervention.
Bottom Line: When gallbladder wall distension is present, it is important to carefully evaluate the gallbladder neck for signs of an obstructing stone.
A recent systematic review and meta-analysis evaluated the diagnostic accuracy of ultrasound in detecting acute diverticulitis. The analysis included 12 studies with a total of 2,056 patients. Ultrasound demonstrated a sensitivity of 92.5% (95% CI: 86.9%–95.8%) and a specificity of 87.7% (95% CI: 75.7%–94.2%).
The most commonly used diagnostic criteria across the studies included:
Similar to prior research on POCUS for nephrolithiasis, these findings support a POCUS-first approach for patients at low risk for serious alternative diagnoses. Ultrasound is a great alternative for patients with contraindications to contrast-enhanced CT, such as those with contrast allergies.
As the authors state, while ultrasound may be effective in identifying acute diverticulitis and its complications, such as abscess, additional imaging with CT may still be required to assess the severity of complications.
On ultrasound, lipohemarthrosis—the presence of blood and fat in the joint cavity—is a key clinical indicator of an intra-articular fracture.
Lipohemarthrosis appears as three distinct layers near the joint line.
A recent study evaluated the accuracy of POCUS in detecting retained products of conception (RPOC) in the emergency department.
In this study, a patient was considered positive for RPOC if they had heterogenous material in the endometrium measuring 10 mm or more. Color Doppler was not used for further evaluation, though it has been cited in obstetric literature as a helpful tool.
Among the 265 patients included, the prevalence of RPOC was 21.5%. POCUS had a sensitivity of 79.0 % and a specificity of 93.8 %.
The authors caution against the use of POCUS to diagnose RPOC in the setting of early pregnancy, as the endometrium can have a variable appearance, increasing the risk of a misdiagnosis. Of the 22 false positives identified, more than half were potentially viable pregnancies. Uterine fibroids can also lead to a heterogenous appearance of the uterus and can be another potential false positive.
Point-of-care ultrasound (POCUS) measurement of the optic nerve sheath diameter (ONSD) has been shown to correlate with increases in intracranial pressure (ICP).
In adults, an ONSD measurement of less than 5 mm is considered normal, while a measurement greater than 6 mm suggests elevated ICP.
How to Measure the Optic Nerve Sheath Diameter:
A small cross-sectional study examined whether ONSD measurements varied when taken at different depths. The findings indicated that ONSD increased by 0.32 mm at a depth of 4 mm and decreased by 0.54 mm at a depth of 2 mm.
These variations highlight the importance of maintaining a consistent measurement depth. To ensure accuracy and avoid misinterpretation, the ONSD should always be measured 3 mm posterior to the retina.
The suprasternal notch view is a valuable tool for assessing the aorta and identifying signs of thoracic aortic dissection. Proper technique is essential to obtain a clear image and improve diagnostic accuracy.
Steps to Obtain the Suprasternal Notch View:
Position the Patient:
Ideally, place the patient in a supine position.
If the patient cannot tolerate lying flat, the scan can be performed with the patient in an upright position.
Probe Selection & Orientation:
Use a phased array probe in cardiac mode.
Direct the probe marker slightly toward the patient’s left shoulder (or right hip if using abdominal mode).
Optimize Patient Positioning:
Ask the patient to extend their neck to improve visualization.
Having the patient rotate their head to the side may further enhance imaging.
Placing a rolled towel under the shoulders can help achieve optimal neck extension.
Probe Manipulation:
Angle the probe inferiorly toward the chest.
Adjust the depth to clearly visualize the aortic arch.
Stellate Ganglion Blocks (SGB) have been reported in case reports as a last-line treatment for patients with refractory ventricular arrhythmias.
A recent multicenter study evaluated the efficacy and safety of SGB in managing refractory ventricular arrhythmias.
The study included 117 critically ill patients, with 9 on ECMO, 5 with Impella devices, and 15 with LVADs.
70% were given long-acting bupivacaine, 28% were given ropivacaine and 1 patient received lidocaine.
SGBs were primarily performed by anesthesiologists during short periods of when the patients were not in ventricular arrhythmia
The median 24-hour episodes of VT/VF decreased from 9.0 (interquartile range [IQR]: 3.0–31.0) pre-SGB to 1.0 (IQR: 0.0–5.0) post-SGB.
2 patients had complications; recurrent laryngeal nerve block with resultant hoarseness and brachial plexus block.
Limitations: This study was conducted in a controlled setting (ie not in active arrest, not in the emergency department) and involved a selective cohort. Randomized controlled trials (RCTs) are needed to validate these findings.
In adult patients, ultrasound-guided long catheter IVs for difficult venous access have been shown to provide increased duration of use, reduced complication rates, and greater cost-effectiveness.
However, there are relatively few studies examining the use of ultrasound for IV access in pediatric patients.
A recent study, the DIAPEDUS study, investigated the success rate of peripheral IV access with and without ultrasound assistance in pediatric patients with difficult venous access.
The study included 110 pediatric patients. IVs were placed by 25 nurses and 6 pediatricians, each of whom had completed departmental training involving at least 20 ultrasound-guided IV placements prior to the study.
The results showed a significantly higher success rate on the first attempt with ultrasound-guided techniques (90% vs. 18%), along with reduced procedural time and fewer attempts overall.
Bottom Line: For patients with known difficult venous access, ultrasound-guided IV placement should be the first-line approach.
Early treatment of congestive heart failure (CHF) exacerbations is associated with improved mortality rates and shorter hospital length of stay. Lung ultrasound is a valuable tool in diagnosing CHF exacerbations. Recently, several studies have explored the use of lung ultrasound in the prehospital settings to expedite diagnosis and treatment.
A recent systematic review and meta-analysis evaluated the diagnostic accuracy and clinical impact of prehospital lung ultrasound. The authors found similar test characteristics to point-of-care ultrasound (POCUS) performed in the emergency department.
The eight studies included in the analysis utilized varying lung ultrasound protocols, analyzing between 2 and 8 lung zones. Notably, only two studies involved paramedics performing the ultrasounds, yet no significant difference in diagnostic accuracy was observed.
Further research is needed to evaluate the training requirements for prehospital providers and the broader impact of prehospital lung ultrasound on treatment strategies and patient outcomes.
Achilles tendon injuries are commonly encountered in the emergency department. While MRIs are often unavailable, POCUS offers a quick and effective alternative for evaluating such injuries. In one review, the sensitivity of ultrasound for detecting complete Achilles tendon ruptures was 94.8%.
For the POCUS evaluation of the Achilles tendon:
- Place the patient in a prone position with their foot relaxed.
-Begin distally at the tendon’s insertion on the calcaneus and scan proximally, keeping the probe marker oriented toward the patient’s head.
-Next, obtain a transverse view by rotating the probe marker toward the patient’s right side.
-You can even do a sonographic Thompson’s Test!
Findings:
Complete Rupture: Displays as a full disruption of the tendon fibers.
Partial Tear: Shows intact tendon tissue with surrounding edema.
Tendinitis: Appears as a thickened tendon with increased vascularity on color Doppler imaging.
