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Risk-Management Pitfalls For Emergency Ultrasound

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“I didn’t know there was so much literature to support the use of ultrasound.” Know the emergency ultrasound literature. For the previously established applications, research has moved beyond the assessment of technical and diagnostic accuracy and toward diagnostic decision-making and patient outcomes research.
“The views weren’t great, but the images I did see looked negative, so I sent the patient home.” Know your limitations. When used appropriately, clinician-performed bedside ultrasound is a powerful tool that can improve patient safety, improve quality of care, and decrease ED lengths of stay. Clinicians put their patients and themselves at risk, however, when they do not recognize the limitations of ultrasound and the limitations of their own ultrasound skills.
“Ultrasound is great because its sensitivity is so high.“ Be focused and specific. The goal of emergency ultrasound is to assess for specific abnormalities with appropriate sensitivity rather than performing comprehensive studies. It is more important for emergency clinicians to be able to recognize, integrate, and act on abnormal ultrasound findings, especially life-threatening ones, than to try and perform consultative ultrasound examinations.
“There wasn’t much space in the room, so I decided to scan the patient from the opposite side and use my non-dominant hand since it was closer.” Develop, perform, and practice your scanning approach the same way every time. Good scanning habits will avoid errors, improve consistency, and increase efficiency.
“The ultrasound looked abnormal, so that must be the problem.” Avoid over-relying on or being overly influenced by information obtained on bedside ultrasound. Clinicians must always remember to integrate findings on ultrasound into the patient’s overall clinical presentation (ie, findings on history and physical examination, laboratory studies, and results of other imaging modalities).
“It looked abnormal on the initial view, so I stopped the exam and then called the consultant.” Remember to confirm or refute findings seen on 1 view with a second or multiple views. Findings seen on a single view may be secondary to artifact or may under- or over-represent an abnormal finding. Be sure to interrogate any abnormal finding from multiple different views in order to confirm and better characterize the finding. Avoid arriving at a final impression until multiple views have been attempted and used.
“The initial ultrasound scan was negative, so I didn’t bother to repeat it.” One of the many benefits of clinician-performed bedside ultrasound is its ability to be repeated. Repeat scans may reveal abnormal findings— which may have taken some time to accumulate —and should be performed when a patient’s clinical course deteriorates.
“It was so busy that I didn’t have time to do the ultrasound.” With appropriate training and practice, emergency ultrasound can be performed rapidly and efficiently integrated into almost any patient work-up. For several of the 11 emergency ultrasound applications, decreased lengths of ED stay and significant time savings have been shown.
“The FAST examination was negative, so I assumed the patient wasn’t bleeding in the abdomen.” While the FAST examination has good sensitivity and excellent specificity for intraperitoneal bleeding, ultrasound is a poor diagnostic test for the detection of hollow viscous injury and retroperitoneal blood.
“The patient had large-volume ascites, so I didn’t need to use ultrasound to guide my paracentesis.” Loops of bowel can be present between the abdominal wall, and the expected location of ascitic fluid based on physical examination and the distribution of ascites may often be variable as well, even in patients with large fluid volumes.¹³⁷