What is the diagnostic efficacy of Point-of-Care Ultrasound (POCUS) in the Emergency Department (ED)?

From the Guidelines

Point-of-care ultrasound (POCUS) is a highly effective diagnostic tool in the Emergency Department (ED), likely increasing the proportion of correct diagnoses and improving patient outcomes, as evidenced by moderate-certainty evidence showing an absolute risk difference of 31.9% [95% CI, 22.4% to 53.8%) 1.

Key Findings

• The diagnostic efficacy of POCUS in the ED is supported by moderate-certainty evidence, which shows that it probably increases the proportion of correct diagnoses from 59% to 91% 1.
• Low-certainty evidence suggests that the sensitivities of POCUS range from 79% to 100% and specificities range from 63% to 100%, compared to the standard diagnostic pathway alone 1.
• POCUS has been shown to be effective in various clinical scenarios, including the diagnosis of acute dyspnea, with the ability to identify underlying conditions such as cardiogenic pulmonary edema, pneumonia, and pulmonary embolism 1.

Clinical Applications

• POCUS can be used to rapidly diagnose life-threatening conditions, such as pneumothorax, although no evidence was available to assess its test accuracy for this specific condition 1.
• It can also be used to guide procedures, such as central line placement, thoracentesis, and paracentesis, reducing complications and improving patient outcomes.

Limitations and Future Directions

• The primary limitations of POCUS include operator dependence and the need for ongoing skill maintenance 1.
• Quality assurance programs should be established to maintain diagnostic standards and ensure that emergency physicians receive appropriate training and supervision to achieve competency in POCUS.

From the Research

Diagnostic Efficacy of Point-of-Care Ultrasound (POCUS) in the Emergency Department (ED)

The diagnostic efficacy of POCUS in the ED has been evaluated in several studies, which have reported varying degrees of sensitivity and specificity for different conditions.

• The sensitivity and specificity of POCUS for various conditions, as reported in a systematic review and meta-analysis 2, are:
  • Appendicitis: 65% and 89%
  • Hydronephrosis: 82% and 74%
  • Small bowel obstruction: 93% and 82%
  • Cholecystitis: 75% and 96%
  • Retinal detachment: 94% and 91%
  • Abscess: 95% and 85%
  • Foreign bodies: 67% and 97%
  • Clavicle fractures: 93% and 94%
  • Distal forearm fractures: 97% and 94%
  • Metacarpal fractures: 94% and 92%
  • Skull fractures: 91% and 97%
  • Pleural effusion: 91% and 97%
• A diagnostic accuracy study 3 found that POCUS showed good concordance with the final composite diagnosis for patients with acute dyspnea, with a sensitivity of 94% for retinal detachment and 91% for pleural effusion.
• A systematic review and meta-analysis 4 evaluated the role of different POCUS protocols in diagnosing deep vein thrombosis (DVT) in the ED, and found that the pooled sensitivity and specificity for the 2-point POCUS protocol were 92.32% and 96.86%, respectively.
• A prospective observational study 5 found that POCUS was performed as a diagnostic tool in 88.2% of cases and as procedural guidance in 11.8% of cases, with the majority of diagnostic POCUS cases indicated for abdominal pain, chest pain, and trauma.
• A randomized controlled trial protocol 6 aims to determine the effect of a POCUS-driven diagnostic pathway on the proportion of patients having a hospital stay of less than 24 hours, compared to the standard diagnostic pathway, in adult ED patients with dyspnea.

Conditions Diagnosed using POCUS

POCUS has been used to diagnose a wide range of conditions in the ED, including:

• Appendicitis
• Hydronephrosis
• Small bowel obstruction
• Cholecystitis
• Retinal detachment
• Abscess
• Foreign bodies
• Clavicle fractures
• Distal forearm fractures
• Metacarpal fractures
• Skull fractures
• Pleural effusion
• Deep vein thrombosis (DVT)
• Acute dyspnea

POCUS Protocols

Different POCUS protocols have been evaluated for diagnosing DVT in the ED, including:

• 2-point POCUS protocol
• 3-point POCUS protocol
• Complete compression ultrasound
• Whole-leg duplex ultrasound

Time to Diagnosis

POCUS has been shown to significantly reduce the time to diagnosis, with a median time to make a POCUS diagnosis of 16 minutes, compared to 170 minutes for the final composite diagnosis 3.