ACEP Updates Emergency Ultrasound Guidelines

ACEP News
March 2009

By Vivek Tayal, M.D

The ACEP Board of Directors recently approved new emergency ultrasound guidelines, which will be of particular interest to anyone who has an ultrasound program in the emergency department, is interested in starting one, or wants to expand its applications.

Since 2001, tremendous growth and developments have occurred in the field of emergency ultrasound that required a new update. The new guidelines were approved in October 2008.

Setting the stage for present and future uses, a new overall classification of the way emergency physicians use ultrasound is described in the guidelines. Included applications are resuscitation, diagnostic, symptom- or sign-based, monitoring, and therapeutic categories that more closely describe the multiple clinical uses of ultrasound.

For example, an emergency physician can apply cardiac ultrasound for resuscitation during a code, as a diagnostic tool for pericardial effusion, for a patient with hypotension, to monitor the patient's inferior vena cava, or for guidance for pericardiocentesis.

Adding to the seven applications from the 2001 guidelines (trauma, pregnancy, abdominal aorta, cardiac, biliary, urinary tract, and procedural), four new applications--thoracic, DVT, ocular, and soft tissue/musculoskeletal--were added as core emergency applications. These applications recognize the new realities of clinical issues such as soft tissue infection (MRSA), new applied research (pneumothorax, DVT), and diagnostic utility (ocular).

Emergency physicians use ultrasound in the emergency department and also in critical care, pediatric, pre-hospital, international, disaster, remote, and military settings. With this recognition that physicians use ultrasound in various settings, the guidelines describe the innovation and limitations of these settings.

In coordination with the CORD Consensus Conference, there are now new recommendations for ultrasound training in residency, including initial courses, rotations, testing, resources, and competency definitions. For residents or medical students, there are curricula and objectives that should be included in their training. There is an expanded core curriculum of emergency ultrasound for residency or community training.

Examples of how the post-instructional phase can be implemented are included in ACEP's new guidelines, and the issue of continuing education in ultrasound is also addressed.

Teaching ultrasound in the undergraduate curriculum is one of the latest exciting developments in emergency ultrasound, and the guidelines outline a curriculum for a 1-month rotation in emergency medicine or a 1-month rotation in emergency ultrasound.

The emergency department and its role in navigating the politics and mechanism of credentialing ultrasound's many new applications are described with a continued emphasis on specialty-specific guidelines. The focus of the new credentialing process in the emergency department is to help organize and forward credentialed providers to the hospital level.

ACEP's new guidelines also focus on the role of the ultrasound director, proper documentation for emergency ultrasound, the quality assurance process for an emergency ultrasound program, and risk management in emergency ultrasound. Finally, the guidelines also outline evidence and research in emergency ultrasound.

There are tremendous resources in these new guidelines, as well as explicit explanations and an assertive but clear spirit of the growth, depth, and maturity of emergency ultrasound.

ACEP's new emergency ultrasound guidelines (presented in a 38-page pdf file) are available at www.acep.org by clicking on "practice resources," then "issues by category."

Dr. Tayal is a past chair of the ACEP Emergency Ultrasound Section.

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