Download article PDF – POCUS Journal 2026;11(1):6

DOI: https://doi.org/10.24908/pocusj.v11i01.20878

Dear Readers,

In clinical medicine, we course correct constantly: re-evaluating a diagnosis, revising a management plan, acknowledging that new data no longer support our original conclusions. It is part of the work. In academic medical publishing, these same practices must also apply. This month, POCUS Journal publishes its first Corrigendum: Normal Anatomy Mimicking an Abdominal Aortic Dissection, Kee et al. on page 50. There is a particular kind of humility in publishing a correction. Not because something went terribly wrong, but because something went right: the system worked and the community came together. The conclusions in a case report from last year were re-evaluated by Dr. Tanping Wong of our editorial board and the authors graciously accepted the feedback. The POCUS community has a lot of integrity and everyone who helped make this corrigendum possible represents our unwavering commitment to accurate image interpretation; a fascinating mimic of abdominal aortic dissection was attributed to artifact but later concluded to be due to the way that the crus of the diaphragm appears in today’s high-resolution scans. 

Publishing this corrigendum reflects POCUS Journal’s value for prioritizing transparency and we hope that the corrected case report published in the April issue strengthens—not weakens—the trust our readers place in the POCUS journal. We are grateful that the authors eagerly accepted the opportunity to correct their case report, which will enable anyone who reads it to properly understand how normal anatomy can create a mimic of abdominal aortic dissection on POCUS examination.

Beyond this milestone, the April issue reflects the continued maturation of POCUS as both a clinical tool and an academic discipline. The contributions in this issue move comfortably between bedside application and broader systems thinking. In addition to riveting cases with high-quality images, the April issue contains exciting new applications for POCUS as well as novel POCUS curricula. Please Enjoy.

Sincerely,

Benjamin T. Galen, MD

Professor of Medicine

Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA

Editor-in-Chief,

POCUS Journal

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Download article PDF – POCUS Journal 2026;11(1):9

DOI: https://doi.org/10.24908/pocusj.v11i01.20826

Introduction by Conference Chair

On October 25, 2025, the 5^th annual Séguin Canadian POCUS Education Conference (SCPEC) was held over Zoom. SCPEC is an annual student-led conference that unites Canadian medical students, residents, and staff physicians to collaborate and advance POCUS education across all medical schools. This year’s conference was the largest to date, bringing together over 150 attendees at all levels of training. We were pleased to host our inaugural case competition this year, titled “Breaking Barriers in POCUS Education – Innovate to Educate.” The case competition featured 32 teams of medical students and their creative proposals to improve POCUS training at their medical school. With the expertise of our resident and staff MD judges, the top three case competition teams were awarded the SCPEC 2025 Grant to support the implementation of their POCUS initiative at their home school. We especially thank The POCUS Journal for this partnership to publish the winning teams’ abstracts – showcasing the innovative ideas by Canadian medical students to improve POCUS education.

Congratulations once again to all 150 medical students who participated in SCPEC 2025! We hope you will continue to lead change in POCUS training at your medical school.

I would like to sincerely thank everyone who made SCPEC 2025 possible. To my incredible team of 21 medical student leaders across Canada: thank you for five months of hard work to re-design SCPEC to host a new and successful case competition and conference. A huge thank you to Dr. Tsoutsoulas for his outstanding supervision and mentorship with SCPEC. Many thanks to our keynote speaker, judges, and workshop leaders for their engaging sessions. Finally, thank you to our sponsors; your support makes this national collaboration happen every year.

It has been my absolute privilege to chair SCPEC 2025, and I am so proud of all the medical students across the country who are changing the landscape of POCUS education. We cannot wait to hear of all your successes next year at SCPEC 2026 (https://seguincpec.wixsite.com/scpec).

Sincerely,

Dr. Selina Chow

Conference Chair, SCPEC 2025

PGY1 Resident Physician, Family Medicine, University of Toronto

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Recommendations for POCUS Curriculum in Canadian Undergraduate Medical Education: Consensus from the Inaugural Seguin Canadian POCUS Education Conference The PEGASUS Games: Physical Exam, Gross Anatomy, phySiology and UltraSound Games for Preclinical Medical Education Team-Based Learning & Point of Care Ultrasound (POCUS) to Augment a Preclinical Cardiovascular Physiology Course

Schulich School of Medicine & Dentistry, Western University, London, ON, Canada

*Corresponding Author: Sarah Bilgasem (email: sbilgasem2028@meds.uwo.ca)

Download article PDF – POCUS Journal 2026;11(1):10-11

DOI: https://doi.org/10.24908/pocusj.v11i01.20506

Conference Abstract – Séguin Canadian POCUS Education Conference 2025

Identification and Rationale for the Chosen Barrier

Across Canadian medical schools, integration of point of care ultrasound (POCUS) in undergraduate medical education remains inconsistent and insufficiently standardized. A national review found that only half of undergraduate medical education programs offer formal ultrasound teaching, and typically under five hours per year [1]. Meanwhile, 76% of internal medicine trainees report using POCUS in clinical practice despite minimal training, revealing a disconnect between undergraduate preparation and clinical expectations [2]. Although the Canadian Medical Student Ultrasound Curriculum (CMSUC) outlines national competencies, few schools have implemented standardized instruction or validated assessment [3]. This gap limits competency development and prevents students from applying ultrasound diagnostically.

Proposed Initiative

This initiative embeds POCUS directly into system-based Clinical Skills, taught alongside traditional examination maneuvers. During the Respiratory block, students pair auscultation with lung ultrasound to identify pleural effusion and pulmonary edema—conditions with >90% sensitivity and specificity, outperforming both percussion and auscultation [4–8]. Emphasizing high-yield, high–pretest-probability conditions such as left ventricular dysfunction, pericardial effusion, and abdominal aortic aneurysm, enables learners to apply ultrasound to answer diagnostic questions and integrate imaging into bedside reasoning [4]. Competence will be evaluated using the Objective Structured Assessment of Ultrasound Skills (OSAUS)—a validated global rating scale for ultrasound performance and diagnostic integration [9–12].

Implementation Plan

We will coordinate with block leads, secure ultrasound machines from institutional inventory, and train clinical skills teaching assistants (senior students/residents) as near-peer instructors. The pilot will launch in the Respiratory block, dedicating one hour per session to hands-on POCUS teaching. Feedback from students and facilitators will guide evaluation and integration into the team observed structured clinical examination (TOSCE), where students perform targeted scans to answer diagnostic questions. Findings will inform refinement and expansion to Cardiovascular and Abdominal systems. The initiative will leverage existing resources and infrastructure [14,15].

Evaluation Strategy and Scalability

Within the TOSCE, OSAUS will assess diagnostic scanning and interpretation, with success defined as a mean score of ≥3.5/5, a validated competency threshold [9,13]. Pre- and post-session knowledge assessments will measure improvement, while anonymous surveys will evaluate confidence. Curriculum effectiveness will be determined by the proportion of students meeting the competency standard and inter-rater reliability (ICC > 0.8) [13,16]. Findings will guide expansion toward a sustainable, evidence-based framework for POCUS education in undergraduate medicine.

References

1. Steinmetz P, Dobrescu O, Oleskevich S, Lewis J. Bedside ultrasound education in Canadian medical schools: a national survey. Can Med Educ J. 2016;7(1):e78-e86.

2. Ailon J, Mourad O, Nadjafi M, Cavalcanti R. Point-of-care ultrasound as a competency for general internists: a survey of internal medicine training programs in Canada. Can Med Educ J. 2016;7(2):e51-e69.

3. Ma IWY, Steinmetz P, Weerdenburg K, Woo MY, Olszynski P, Heslop CL, Miller S, Sheppard G, Daniels V, Desy J, Valois M, Devine L, Curtis H, Romano MJ, Martel P, Jelic T, Topping C, Thompson D, Power B, Profetto J, Tonseth P. The Canadian Medical Student Ultrasound Curriculum: a statement from the Canadian Ultrasound Consensus for Undergraduate Medical Education Group. J Ultrasound Med. 2020;39(7):1279-1287. doi: 10.1002/jum.15218

4. Moore CL, Copel JA. Point-of-care ultrasonography. N Engl J Med. 2011;364(8):749-757. doi: 10.1056/NEJMra0909487.

5. Andersen CA, Holden S, Vela J, Rathleff MS, Jensen MB. Point-of-care ultrasound in general practice: a systematic review. Ann Fam Med. 2019;17(1):61-69. doi: 10.1370/afm.2330

6. Arnold MJ, Jonas CE, Carter RE. Point-of-care ultrasonography. Am Fam Physician. 2020;101(5):275–285.

7. Ultrasound Guidelines: Emergency, Point-of-Care, and Clinical Ultrasound Guidelines in Medicine. Ann Emerg Med. 2023;82(3):115-155. doi: 10.1016/j.annemergmed.2023.06.005

8. Al Deeb M, Barbic S, Featherstone R, Dankoff J, Barbic D. Point-of-care ultrasonography for the diagnosis of acute cardiogenic pulmonary edema in patients presenting with acute dyspnea: a systematic review and meta-analysis. Acad Emerg Med. 2014;21(8):843-852. doi: 10.1111/acem.12435

9. Tolsgaard MG, Ringsted C, Dreisler E, Klemmensen A, Loft A, Sorensen JL, Ottesen B, Tabor A. Reliable and valid assessment of ultrasound operator competence in obstetrics and gynecology. Ultrasound Obstet Gynecol. 2014;43(4):437-443. doi: 10.1002/uog.13198

10. Todsen T, Tolsgaard MG, Olsen BH, Henriksen BM, Hillingsø JG, Konge L, Jensen ML, Ringsted C. Reliable and valid assessment of point-of-care ultrasonography. Ann Surg. 2015;261(2):309-315. doi: 10.1097/SLA.0000000000000552

11. Todsen T, Melchiors J, Charabi B, Henriksen B, Ringsted C, Konge L, von Buchwald C. Competency-based assessment in surgeon-performed head and neck ultrasonography: a validity study. Laryngoscope. 2018;128(6):1346-1352. doi: 10.1002/lary.26841

12. Gomes SH, Trindade M, Petrisor C, Costa D, Correia-Pinto J, Costa PS, Pêgo JM. Objective structured assessment ultrasound skill scale for hyomental distance competence: psychometric study. BMC Med Educ. 2023;23(1):177. doi: 10.1186/s12909-023-04146-y

13. Höhne E, Recker F, Dietrich CF, Schäfer VS. Assessment methods in medical ultrasound education. Front Med (Lausanne). 2022;9:871957. doi: 10.3389/fmed.2022.871957

14. Winter L, Neubauer R, Weimer J, Dietrich CF, Wittek A, Schiestl L, Marinova M, Schäfer VS, Strizek B, Recker F. Peer teachers as ultrasound instructors? a systematic literature review of peer teaching concepts in undergraduate ultrasound education. BMC Med Educ. 2024;24(1):1369. doi: 10.1186/s12909-024-06345-7

15. hockalingam L, Hammar D, Ortiz-Lopez C, Fleshner M, Keniston A, McBeth L, Baduashvili A. Developing point-of-care ultrasound curricula for internal medicine residency programs: consensus-based recommendations on skills, teaching methods, and evaluation strategies. Ann Intern Med. 2025;178(11):1624-1631. doi: 10.7326/ANNALS-25-02271

16. Schober P, Mascha EJ, Vetter TR. Statistics from A (agreement) to Z (z score): a guide to interpreting common measures of association, agreement, diagnostic accuracy, effect size, heterogeneity, and reliability in medical research. Anesth Analg. 2021;133(6):1633-1641. doi: 10.1213/ANE.0000000000005773

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McGill University, Montreal, QC, Canada

*Corresponding Author: Juliette Begin (email: juliette.begin@mail.mcgill.ca)

Download article PDF – POCUS Journal 2026;11(1):12-13

DOI: https://doi.org/10.24908/pocusj.v11i01.20481

Conference Abstract – Séguin Canadian POCUS Education Conference 2025

While national recommendations for point of care ultrasound (POCUS) integration in undergraduate medical education (UGME) are outlined by Canadian POCUS leaders, a critical barrier remains: the absence of standardized national objectives for POCUS teaching and evaluation [1].

To address this gap, we propose an outcome-driven approach to learning—the entrustable professional activity (EPA). This tool evaluates a student’s competency and progression in performing clinical tasks [2–7]. In Canada, EPAs are used to document key clerkship competencies, making it readily accessible.

We suggest a series of POCUS-specific EPAs spanning the UGME curriculum. Establishing EPAs across the program’s entirety reinforces a longitudinal educational framework, enhancing skill retention[8–11]. Our proposed EPAs include a 10-domain checklist assessing common POCUS competencies. Each EPA builds on skills developed in completed ones, creating a coherent progression that mirrors learners’ evolving clinical responsibilities.

To align with national standards, EPAs will be derived from the Canadian POCUS Acute Care Core curriculum [12]. Due to its high scalability, the ultrasound applications within this EPA-based program can be updated without modifying the assessment framework, allowing the curriculum to remain current with medical advancements. Pre-clerkship EPAs will emphasize foundational physics, knobology, anatomical landmark recognition, and supervised image acquisition. Clerkship EPAs will focus on independent image acquisition and their integration in clinical contexts.

To test this method, an initial phase will be conducted in entering cohorts in Quebec’s four medical schools. Evaluation will be based on learner performance, measured through completion rates, entrustment scores, and student and faculty feedback on usability and educational value. EPAs will occur during existing practical sessions or clinical rotations, thus requiring no additional equipment nor instructor. Costs will be related to administrative and technical tasks, including EPA form incorporation into existing electronic systems. The following year, after fine-tuning, Quebec schools will extend the framework to incoming cohorts, after which the system can be expanded nation-wide. 

The educational impact will be assessed by comparing learner progression across Canadian cohorts and institutions. Residents and physicians will monitor POCUS preparedness of incoming clerks and residents via surveys. Stakeholders include medical students, UGME curriculum committees, and national bodies such as cPOCUS and the Medical Council of Canada.

This EPA-based model offers a feasible and scalable strategy to standardize UGME POCUS education nationally, ensuring all medical graduates possess the foundational skills required for clinical practice.

References

1. Ma IWY, Steinmetz P, Weerdenburg K, et al. The Canadian Medical Student Ultrasound Curriculum: A Statement From the Canadian Ultrasound Consensus for Undergraduate Medical Education Group. J Ultrasound Med. 2020;39(7):1279-1287. doi:10.1002/jum.15218

2. Ten Cate O, Taylor DR. The recommended description of an entrustable professional activity: AMEE Guide No. 140. Med Teach. 2021;43(10):1106-1114. doi:10.1080/0142159X.2020.1838465

3. Pangaro L, ten Cate O. Frameworks for learner assessment in medicine: AMEE Guide No. 78. Med Teach. 2013;35(6):e1197-e1210. doi:10.3109/0142159X.2013.788789

4. Shorey S, Lau TC, Lau ST, Ang E. Entrustable professional activities in health care education: a scoping review. Med Educ. 2019;53(8):766-777. doi:10.1111/medu.13879

5. Violato C, Englander R, Dale E, Gauer JL. Implementing Core Entrustable Professional Activities in Undergraduate Medical Education: A Psychometric Study. Acad Med. 2025;100(5):585-591. doi:10.1097/ACM.0000000000005907

6. Brown DR, Moeller JJ, Grbic D, et al. Comparing Entrustment Decision-Making Outcomes of the Core Entrustable Professional Activities Pilot, 2019-2020. JAMA Netw Open. 2022;5(9):e2233342. Published 2022 Sep 1. doi:10.1001/jamanetworkopen.2022.33342

7. Shorey S, Lau TC, Lau ST, Ang E. Entrustable professional activities in health care education: a scoping review. Med Educ. 2019;53(8):766-777. doi:10.1111/medu.13879

8. Recker F, Schäfer VS, Holzgreve W, Brossart P, Petzinna S. Development and implementation of a comprehensive ultrasound curriculum for medical students: The Bonn internship point-of-care-ultrasound curriculum (BI-POCUS). Front Med (Lausanne). 2023;10:1072326.10.3389/fmed.2023.1072326.

9. Kelm DJ, Ratelle JT, Azeem N, Bonnes SL, Halvorsen AJ, Oxentenko AS, et al. Longitudinal Ultrasound Curriculum Improves Long-Term Retention Among Internal Medicine Residents. J Grad Med Educ. 2015;7(3):454-7.10.4300/jgme-14-00284.1.

10. Zeitouni F, Matejka C, Boomer M, Lee VH, Brower GL, Hewetson A, et al. Integration of point of care ultrasound into undergraduate medical education at Texas Tech University Health Sciences Center school of medicine: a 6 year review. BMC Med Educ. 2024;24(1):1476.10.1186/s12909-024-06483-y.

11. Steinmetz P, Oleskevich S, Lewis J. Acquisition and Long-term Retention of Bedside Ultrasound Skills in First-Year Medical Students. J Ultrasound Med. 2016;35(9):1967-75.10.7863/ultra.15.09088.

12. Society CPoCUS. CPoCUS Tracks – Acute Care CORE (AC CORE)  [Available from: https://cpocus.ca/acute-care-core/.

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Michael G. DeGroote School of Medicine, McMaster University, ON, Canada

*Corresponding Author:  Natalia Mangos (email: mangosn@mcmaster.ca)

Download article PDF – POCUS Journal 2026;11(1):14

DOI: https://doi.org/10.24908/pocusj.v11i01.20482

Conference Abstract – Séguin Canadian POCUS Education Conference 2025

Structured point of care ultrasound (POCUS) education remains limited across Canadian undergraduate medical programs, despite its growing clinical relevance. At our institution, where no formal POCUS curriculum exists, 84% of surveyed students (n = 71) rated POCUS education as “lacking” or “severely lacking,” with many seeking costly, external training. To address this gap, we designed InSiGHT-US—the Interdisciplinary and Simulation-Guided Hands-on Training in Ultrasound curriculum—an evidence-informed, two-phase program introducing foundational skills and reinforcing them through spaced, simulation-based application.

Phase 1, POCUS Day, launches the initiative with an interdisciplinary, full-day, multi-station workshop providing intensive, hands-on training in core applications, including diagnostic scanning (Focused Assessment with Sonography for Trauma (FAST), cardiac, lung, obstetric) and ultrasound-guided procedures (vascular access, thoracentesis, paracentesis, blocks). This phase leverages evidence-based pedagogical methods—small group learning, active learning, and near-peer teaching—delivered by interdisciplinary resident instructors to maximize skill acquisition and resource efficiency [1–4]. Several months later, Phase 2, a Hybrid Simulation Session, allows learners to apply their training to realistic case scenarios. Students perform real-time scanning on standardized patients while preceptors integrate digital ultrasound clips displaying corresponding pathological findings. This innovative format bridges image acquisition with diagnostic reasoning, enabling students to practice technical skills, interpret both normal and abnormal findings, and use these insights to guide management. Integrating simulation-based learning and spaced reinforcement enhances procedural retention and knowledge consolidation [5].

InSiGHT-US is designed for high feasibility and cost efficiency. By leveraging existing institutional infrastructure (ultrasound equipment, models, and protected teaching time for residents), expenses are largely limited to standardized patients and preceptor honoraria (~$6000 annually for a class of 200; <$30 per student). The program will be piloted with voluntary participation in Year 1 (estimated cost: $200), followed by full implementation in Year 2 upon successful evaluation. The evaluation employs a rigorous pre- and post-intervention design [6–8]. It will use primary metrics of objective knowledge gain (multiple choice question assessments) and self-reported competence (Likert surveys) to ensure data-driven quality improvement and scalability. This model is highly adaptable; it can be tailored for institutions with varying resources by adjusting scanning stations, substituting virtual cases, or tailoring content to local needs. InSiGHT-US offers a robust, sustainable, and scalable model for embedding essential POCUS education into undergraduate training nationwide.

References

1. Recker F, Schäfer VS, Holzgreve W, Brossart P, Petzinna S. Development and Implementation of a Comprehensive Ultrasound Curriculum for Medical Students: The Bonn Internship Point-of-Care-Ultrasound Curriculum (BI-POCUS). Front Med. 2023;10:1072326. doi:10.3389/fmed.2023.1072326.

2. Celebi N, Griewatz J, Malek NP, et al. Development and Implementation of a Comprehensive Ultrasound Curriculum for Undergraduate Medical Students – A Feasibility Study. BMC Med Educ. 2019;19(1):170. doi:10.1186/s12909-019-1611-1.

3. Recker F, Neubauer R, Dong Y, et al. Exploring the Dynamics of Ultrasound Training in Medical Education: Current Trends, Debates, and Approaches to Didactics and Hands-on Learning. BMC Med Educ. 2024;24(1):1311. doi:10.1186/s12909-024-06092-9.

4. Anazor FC, Grech M. The Impact of Near-Peer Teaching Methods in Undergraduate and Postgraduate Surgical Education Using the Kirkpatrick Evaluation Model: A Systematic Review. J Surg Educ. 2025 Oct;82(10):103618. doi: 10.1016/j.jsurg.2025.103618.

5. Cook DA, Hatala R, Brydges R, et al. Technology-Enhanced Simulation for Health Professions Education: A Systematic Review and Meta-analysis. JAMA. 2011;306(9):978-988. doi:10.1001/jama.2011.1234.

6. Wykowski JH, Starks H. What Type of Self-Assessment Is Best for Your Educational Activity? A Review of Pre-Post, Now-Then, and Post-Only Designs. J Gen Intern Med. 2025;40(5):1010-1015. doi:10.1007/s11606-024-09176-w.

7. Baernstein A, Liss HK, Carney PA, Elmore JG. Trends in Study Methods Used in Undergraduate Medical Education Research, 1969-2007. JAMA. 2007;298(9):1038-1045. doi:10.1001/jama.298.9.1038.

8. Belfield C, Thomas H, Bullock A, Eynon R, Wall D. Measuring Effectiveness for Best Evidence Medical Education: A Discussion. Med Teach. 2001;23(2):164-170. doi:10.1080/0142150020031084.

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(1) Departments of Internal Medicine and Pediatrics, Division of Hospital Medicine, University of North Carolina, Chapel Hill, NC, USA

(2) Department of Medicine, Division of Geriatric Medicine, University of North Carolina, Chapel Hill, NC, USA

(3) Internal Medicine and Pediatrics Residency Program, University of North Carolina, Chapel Hill, NC, USA

*Corresponding Author: Dr. Erin M. Finn (email: erin.finn@unchealth.unc.edu)

Download article PDF – POCUS Journal 2026;11(1):15-21

DOI: https://doi.org/10.24908/pocusj.v11i01.20051

Abstract

Background: While professional societies acknowledge the importance of point of care ultrasound (POCUS), a minority of internal medicine (IM) residencies have a formal curriculum. This study aims to 1) describe the implementation of a longitudinal POCUS curriculum for first-year IM trainees and 2) assess the effectiveness of the curriculum in improving knowledge and confidence. Methods: We implemented a longitudinal curriculum for IM interns, with didactic and hands-on sessions throughout the year. We assessed curriculum effectiveness through knowledge tests and confidence surveys at the beginning and end of the intern year. Trainees who took our POCUS elective were given the same tests to assess knowledge retention. Results: Between 2021 and 2024, 87 interns completed the curriculum; 37 (42.5%) completed pre- and post-test questionnaires. Mean scores for knowledge tests improved from 44.4% to 62.9% (mean difference 18.5%, 95% CI 14.9-22.1, p < 0.001). Confidence in using POCUS to identify pathologic findings and apply it in clinical scenarios improved for all 17 measures (p < 0.001). Of the 37 interns who completed the knowledge assessments, 15 (40.5%) took the upper-level elective and completed knowledge assessments. There were no differences between first-year post-curriculum and elective pre-curriculum scores. Conclusions: Knowledge scores and confidence in POCUS improved following a longitudinal curriculum for internal medicine interns. Residents participating in a subsequent POCUS elective maintained their knowledge scores.

Introduction

Point of care ultrasound (POCUS) is defined as an ultrasound exam performed at the bedside by a healthcare provider to answer a diagnostic question or to guide an invasive procedure [1]. There is much evidence that POCUS improves the safety and success of procedures, expedites and improves diagnosis and treatment, and improves patient satisfaction [2–8].  Both the Alliance for Academic Internal Medicine (AAIM) and the American College of Physicians (ACP) have formally acknowledged the important role of POCUS in internal medicine (IM) and support the integration of POCUS into graduate medical education [9,10]. 

LoPresti et al. reviewed the current use of POCUS among IM residency programs using the 2020 Association of Program Directors in Internal Medicine (APDIM) program directors’ survey [11]. They found that of the existing United States IM residency programs that responded to the survey, greater than 95% reported that their residents are exposed to diagnostic POCUS, but only 35% provide formal teaching to all residents. While POCUS curricula have been described for trainees in a number of disciplines, relatively few published studies have described curricula within the field of IM [12–19].

At our institution, we have developed the “Basal-Bolus POCUS Curriculum,” which consists of a mandatory curriculum that spans the first year of training (the “basal” component), which can be followed by intensive 2-week electives in diagnostic and procedural POCUS offered to second- through fourth-year residents (the “bolus” components). We describe the implementation and outcomes of our longitudinal IM curriculum for first-year residents (“interns”).

Methods

Setting and participants

Our longitudinal intern POCUS curriculum was implemented at the University of North Carolina IM Residency program at the beginning of the academic year 2021. The residency program has 95–98 residents total, with 29–30 interns per year. Every categorical intern participates in the curriculum. 

Study design

We performed a retrospective analysis of curriculum implementation, comparing pre- and post-curriculum measures. This study was exempted from review by the Institutional Review Board of the University of North Carolina (IRB 19-1013).

Curriculum development

The longitudinal curriculum spanned the academic year, and interns participated in 7 sessions (Figure 1) focusing on abdominal (liver, spleen, kidneys, bladder, deep pelvis), pleural/lung, vascular (deep vein and aorta), cardiac 1 (parasternal long and short axis views), cardiac 2 (apical and subcostal 4 chamber views and inferior vena cava), and procedural POCUS (focusing on 2 procedures chosen by the trainees, such as paracentesis, central lines, thoracentesis, knee arthrocentesis, or lumbar punctures). The seventh and final session was a review and integration session, during which interns demonstrated the POCUS exams they would use to assist in the diagnosis and management of simulated patient cases. The session topics were chosen based on high-yield clinical application to internal medicine, informed by the clinical and teaching experiences of the faculty. Each distinct teaching session was taught three times to accommodate three intern cohorts, which follow an X+Y model, and allowed an optimal instructor-to-learner ratio [20].

Each teaching session lasted 2.5 hours and began with 15–30 minutes of didactic instruction focused on sonographic anatomy. This was followed by 1 hour of hands-on practice and 1 hour of abnormal image review, where the interns learned to systematically evaluate and interpret ultrasound images.

There were typically 9–10 interns per session. Two course directors were each supported with 15% full-time equivalent (FTE) and about five other POCUS-competent core faculty were incentivized to teach. Upper-level residents who had completed the intern longitudinal curriculum were invited to provide near-peer teaching under faculty supervision. To optimize hands-on learning, we maintained a 3:1 learner-to-instructor ratio. The ultrasound machines used for teaching were cart-based machines (Sonosite XPorte or PX, FUJIFILM Sonosite Inc., Bothell, WA, USA) that were either designated for teaching or borrowed from inpatient units. Interns scanned each other on a voluntary, opt-in basis as they typically have optimal imaging windows and normal anatomy. The course was prefaced with the stipulation that all incidental findings would be referred for comprehensive imaging and further evaluation. 

Image review consisted of a slide deck of abnormal ultrasound videos facilitated by one of the course directors. For each image, an intern systematically approached the ultrasound clip to comment on the transducer used, the exam type, the appropriateness of the depth and gain of the image, the organ or organs being imaged, the anatomy, and any notable pathology.

Finally, autonomous learning was encouraged outside of the curriculum in several formats. Residents were provided with course lectures and previously-recorded abnormal image sessions to review and test themselves. Additionally, we used a shared POCUS group on a group messaging application to provide a platform to share  Health Insurance Portability and Accountability Act (HIPAA)-compliant POCUS images and videos for real-time feedback from experts and as a venue for POCUS instructors to teach learners by guiding them through clinical cases to reinforce teaching points.

Outcomes and evaluation

We developed a knowledge assessment tool consisting of 56 multiple-choice questions (Supplementary Material S1) with ultrasound clips or still images accompanying each question. The test was created by one of the authors, RD, who was also one of the experts tasked to create the final knowledge assessment exam for the Society of Hospital Medicine and American College of Chest Physicians (CHEST) national POCUS certificate of completion (COC) [21,22]. Our exam was patterned after the COC exam; a challenging and comprehensive exam designed to be taken at the end of a training program geared towards the development of expertise in POCUS.

The assessment was given at the beginning of the intern year and again at the end of the year. Questions were based on a review of literature and ranged from lower-order thinking skills, such as pitfalls in image acquisition and identification of artifacts and structures, to higher-order skills that required image interpretation and clinical integration. Interns were highly encouraged to complete the assessments but are not penalized for failing to do so. Testing was conducted entirely online using Research Electronic Data Capture® (REDCap, Vanderbilt University, Atlanta, GA, USA) and took about 30 minutes for individuals to complete.

We also administered confidence assessments at the beginning and end of the intern year to evaluate resident confidence in simple identification of 14 POCUS findings (e.g., identifying a pericardial effusion, lung consolidation, ascites) and in clinical integration (e.g., using POCUS to evaluate the cause of hypotension, hypoxia, or acute kidney injury). Residents were asked to rate their confidence on a scale of 0 to 100 (Supplementary Material S2). After completing the curriculum, residents were surveyed regarding their attitudes toward POCUS (e.g., how much they agree or disagree with the statement that POCUS adds time to their clinical work or whether it adds value to bedside diagnosis), whether they anticipate continuing to utilize POCUS, and the barriers that might prevent this (Supplementary Material S3). These questions were novel at the time of survey creation but were considered important balancing measures. The tool was reviewed by a statistician with experience in survey creation. Finally, we sought feedback on the curriculum itself and how satisfied residents were with the education provided. For each outcome measure, we only included subjects with complete data for all questions/measures (e.g., all 56 questions for the knowledge test).

Trainees who subsequently participated in our upper-level POCUS elective were retested with the same assessment tools to assess decay in knowledge.

Data analysis

We calculated summative statistics, including proportions, medians and interquartile ranges as appropriate. We used paired t tests, two-tailed, to compare pre- and post-curriculum knowledge test scores and confidence with POCUS use, with a p-value < 0.05 considered significant. All calculations were performed using Microsoft Excel™ (Redmond, WA).

Results

Curriculum implementation and outcomes

Over the course of 3 years, we taught 87 categorical IM interns in our longitudinal curriculum; 37 (42.5%) trainees completed all pre- and post-knowledge test questions.

POCUS knowledge 

Knowledge assessment scores improved significantly post-curriculum. Pre-curriculum, the average score was 44.4% compared to 62.9% after the curriculum, with a mean difference of 18.5% (95%CI 14.9-22.1, p < 0.001).

Confidence assessments 

Thirty-four interns completed all pre- and post-curriculum confidence assessments. These trainees demonstrated significant improvement in confidence for both simple identification of pathology (Table 1) and clinical integration (Table 2). Post-curriculum, interns reported the highest confidence in identifying ascites (86.5 out of max 100, mean difference 37.9, 95% CI 29.3-46.5) and the lowest confidence in identifying an abdominal aortic aneurysm (AAA) (45.4 out of 100, mean difference 14.2, 95% CI 6.6-21.9). Pre- and post-curriculum confidence in using POCUS for evaluating hypotension, hypoxia or dyspnea, and acute kidney injury increased significantly for all three clinical scenarios (Table 2). 

POCUS satisfaction and barriers to POCUS use 

Thirty-five interns completed all post-curriculum satisfaction questions (Table 3). While 53.2% agreed that the use of POCUS adds significant time to clinical work, 86.1% agreed that the use of POCUS for bedside diagnosis adds significant value, and 79.4% agreed that POCUS increased satisfaction with their clinical work. Most (94.3%) indicated that they were either likely or very likely to continue to use POCUS in clinical practice. Barriers to POCUS use, in order of most to least selected, included lack of time, equipment availability, training, and patient factors.

POCUS curriculum satisfaction

Overall, interns strongly agreed that they were satisfied with the curriculum (mean 91.2 out of 100, SD 9.7) and that it provided the skill set needed to successfully perform POCUS examinations (mean 84.2 out of 100, SD 13.3). Suggestions to improve the curriculum included having even more sessions and more opportunities for clinical integration.

Knowledge decay

Of the 37 interns included in our assessment, there were 15 who subsequently participated in our 2-week upper-level POCUS elective and completed a repeat pre-elective knowledge test (40.5%). The median time between assessments was 14 months (IQR 6.25, 17). There was no statistically significant difference between the knowledge assessments of the 15 residents who completed the intern curriculum and then opted to take the upper-level elective (mean intern post-test score was 68.6% with mean elective pre-test 66.3%; mean difference 2.3%, 95%CI -3.4-8.0, p = 0.41).

Discussion

In this study of the first three years of experience following the implementation of a longitudinal POCUS curriculum for IM interns, trainees demonstrated significant gains in POCUS knowledge. Post-curriculum, participants also reported improved confidence in their ability to use POCUS to identify specific pathologies and apply this to clinical scenarios. Among those who subsequently participated in the intensive POCUS elective as upper-level residents, there was no decrease in knowledge comparing post-intern curriculum to pre-elective knowledge tests, despite a median 14-month gap between assessments. This suggested good knowledge retention. Lastly, interns reported high levels of satisfaction with the curriculum and planned to incorporate POCUS in their future clinical practice. Our curriculum structure, with sessions spaced every six weeks through the academic year, may be more feasible than shorter, intensive curricula for Accreditation Council for Graduate Medical Education (ACGME) programs to incorporate within standardized training requirements and thus may be able to serve as a model for other programs.

For knowledge acquisition and retention to be replicated in future POCUS or medical education curricula, we posit a few mechanisms for our success. First, the longitudinal structure allowed for knowledge application and had been shown to be superior to single-session or short-term POCUS curricula [18,19]. Second, the spaced teaching sessions, which presented new concepts each time while also reinforcing key concepts, provided opportunities for informal repetition of fundamental material. Third, the curriculum structure provided tools for autonomous learning outside of the dedicated curriculum time, which is a fundamental tenet of adult learning theory and may have contributed to increased confidence in POCUS knowledge after the curriculum [23]. Importantly, the intern longitudinal curriculum was only a part of our Basal-Bolus POCUS curriculum. Between sessions, interns rotated through the medicine procedure service and intensive care units which served as “boluses” of opportunities to engage in deliberate practice of newly acquired skills under the guidance of POCUS and procedural faculty in real-world clinical scenarios.

Several prior POCUS curricula for IM trainees have been described [15–19]. While a number of prior curricula were also longitudinal, some were elective throughout or part of the curriculum implementation rather than being required for all trainees [15,17–19]. Additionally, two of the longitudinal curricula were implemented over a six-month time frame rather than the whole academic year [18,19]. The study most similar to ours was by Faiella et al., though the curriculum was implemented in a Canadian academic center [17]. The Canadian curriculum also included training for all interns, with spaced sessions through the academic year. However, they implemented 30 shorter sessions more frequently, compared with our material. The majority of the studies reported results of pre- and post-curricular knowledge tests [15–17,19]. It should be noted that, as of yet, there is not one accepted standard for post-curriculum POCUS knowledge, which is reflected by the fact that the four studies above each created their own test, ranging from 11 to 30 questions in length. The mean post-test score range in prior studies (70.2–82.8%) was higher than our post-curriculum mean of 62.9% [15–17,19]. This is likely due in part to the difficulty of our 56-question assessment, consciously aligned with Society of Hospital Medicine (SHM) and American College of Chest Physicians (CHEST) POCUS certification standards, which are more stringent than in previous studies.

Limitations of our study include relatively low response rates for post-curriculum assessments of knowledge, confidence, and retention. Non-responders may differ from those who participated in subsequent assessments. We plan to address this by continuing the curriculum to increase the sample size of completed assessments. Adding dedicated in-person time at the beginning and end of the curriculum for the residents to take the knowledge test could improve response rates. Additionally, the assessment of knowledge retention was conducted among upper-level residents who took the POCUS elective and thus may have more baseline interest and knowledge of POCUS compared with trainees who did not opt to participate in this elective. We also did not assess skill acquisition and retention for the intern longitudinal curriculum; although, hands-on skills testing is an important part of the upper-level POCUS elective. Haptic competency will be a necessary component for developing a POCUS curriculum if IM follows emergency and family medicine in making POCUS a required graduate medical education competency. Relatedly, we should note that while important, the confidence in use of POCUS that we measured does not necessarily correlate with competence. Lastly, our study was conducted in a large university setting with multiple faculty members trained in POCUS and thus may not be generalizable to other training centers, particularly given the capital equipment and number of POCUS-competent faculty required to successfully implement a similar program.

Conclusions

Our year-long intern longitudinal POCUS curriculum led to improved knowledge and confidence in POCUS applications and was well received by trainees, though hands-on competency was not directly assessed. Additionally, our data revealed minimal decay in knowledge and confidence between the completion of the intern curriculum and the beginning of the more intensive upper-level elective. We propose this basal component as the foundation of a successful residency-long POCUS curriculum that can serve as a framework for other programs seeking to incorporate POCUS training. At our institution, POCUS education throughout 3 years of residency includes bolus components (such as our upper-level elective) in addition to the basal component described in this study. Continued education after the intern year is essential to reinforce skills, and it is important that formal teaching does not cease after completion of the intern curriculum. We intend to describe the second half of our basal-bolus curriculum in future publications. Other areas for future study could include assessment of hands-on competency or measurement of patient care metrics, such as length of stay or earlier detection of patient decompensation for providers before and after completion of POCUS training. Finally, as POCUS education expands among IM residencies in different formats, defining “competency” will need to be addressed further to provide clear benchmarks for graduating physicians.

Acknowledgements

We would like to acknowledge the following individuals who have helped teach and support this curriculum over the years: Maxwell Diddams, MD, William Kwan, MD, Jessica Guidici, MD, Robert A. Campbell, MD, Ryan Bonner, MD, Stephanie Pavlovich, MD, Jonathon Heath, MD, and many residents from the University of North Carolina. We also acknowledge Eric Zwemer, MD, for his assistance with reviewing and editing this manuscript.

Ethics Statement

This study was exempted from review by the Institutional Review Board of the University of North Carolina (IRB 19-1013).

Disclosure Statement

An abstract from this project has been previously presented as a poster at the Society of Hospital Medicine national conference in 2023. RD is a consultant for Lippincott Procedures, Wolters-Kluwer publishing and an associate editor for the 3rd edition of Point of Care Ultrasound, Elsevier publishing. None of the other authors have any conflicts of interest.

Funding

There was no funding for this project.

Author Contributions

EMF: conceptualization, methodology, investigation, formal analysis, data curation, writing – original draft, writing – review & editing. JRS: methodology, investigation, formal analysis, data curation, writing – review & editing. HS: methodology, investigation, writing – review & editing. MF: methodology, formal analysis, data curation, writing – original draft, writing – review & editing. OH: formal analysis, writing – original draft, writing – review & editing. RD: conceptualization, methodology, investigation, formal analysis, data curation, writing – review & editing.

References

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2. Soni NJ, Franco-Sadud R, Schnobrich D, Dancel R, Tierney DM, Salame G, Restrepo MI, McHardy P. Ultrasound guidance for lumbar puncture. Neurol Clin Pract. 2016;6(4):358-368.

3. Dancel R, Schnobrich D, Puri N, Franco-Sadud R, Cho J, Grikis L, Lucas BP, El-Barbary M, Society of Hospital Medicine Point of Care Ultrasound Task F, Soni NJ. Recommendations on the Use of Ultrasound Guidance for Adult Thoracentesis: A Position Statement of the Society of Hospital Medicine. Journal of hospital medicine : an official publication of the Society of Hospital Medicine. 2018;13(2):126-135.

4. Cho J, Jensen TP, Reierson K, Mathews BK, Bhagra A, Franco-Sadud R, Grikis L, Mader M, Dancel R, Lucas BP, Society of Hospital Medicine Point-of-care Ultrasound Task F, Soni NJ. Recommendations on the Use of Ultrasound Guidance for Adult Abdominal Paracentesis: A Position Statement of the Society of Hospital Medicine. Journal of hospital medicine : an official publication of the Society of Hospital Medicine. 2019;14:E7-E15.

5. Franco-Sadud R, Schnobrich D, Mathews BK, Candotti C, Abdel-Ghani S, Perez MG, Rodgers SC, Mader MJ, Haro EK, Dancel R, Cho J, Grikis L, Lucas BP, Soni NJ. Recommendations on the Use of Ultrasound Guidance for Central and Peripheral Vascular Access in Adults: A Position Statement of the Society of Hospital Medicine. Journal of hospital medicine : an official publication of the Society of Hospital Medicine. 2019;14(9):E1-E22.

6. Tierney DM, Rosborough TK, Sipsey LM, Hanson K, Smith CS, Boland LL, Miner R. Association of Internal Medicine Point of Care Ultrasound (POCUS) with Length of Stay, Hospitalization Costs, and Formal Imaging: a Prospective Cohort Study. POCUS J. 2023;8(2):184-192.

7. Mourad M, Auerbach AD, Maselli J, Sliwka D. Patient satisfaction with a hospitalist procedure service: is bedside procedure teaching reassuring to patients? Journal of hospital medicine : an official publication of the Society of Hospital Medicine. 2011;6(4):219-224.

8. Mathews BK, Miller PE, Olson APJ. Point-of-Care Ultrasound Improves Shared Diagnostic Understanding Between Patients and Providers. Southern medical journal. 2018;111(7):395-400.

9. LoPresti CM, Jensen TP, Dversdal RK, Astiz DJ. Point-of-Care Ultrasound for Internal Medicine Residency Training: A Position Statement from the Alliance of Academic Internal Medicine. The American journal of medicine. 2019;132(11):1356-1360.

10. ACP Statement in Support of Point-of-Care Ultrasound in Internal Medicine. https://www.acponline.org/meetings-courses/focused-topics/point-of-care-ultrasound-pocus-for-internal-medicine/acp-statement-in-support-of-point-of-care-ultrasound-in-internal-medicine. Published 2018. Accessed March 20, 2026.

11. LoPresti CM, Schnobrich D, Novak W, Fondahn E, Bardowell R, O’Connor AB, Uthlaut B, Ortiz J, Soni NJ. Current Point of Care Ultrasound Use and Training Among Internal Medicine Residency Programs from the 2020 APDIM Program Director’s Survey. The American journal of medicine. 2022;135(3):397-404.

12. Brant JA, Orsborn J, Good R, Greenwald E, Mickley M, Toney AG. Evaluating a longitudinal point-of-care-ultrasound (POCUS) curriculum for pediatric residents. BMC Med Educ. 2021;21(1):64.

13. Filler L, Orosco D, Rigdon D, Mitchell C, Price J, Lotz S, Stowell JR. Evaluation of a novel curriculum on point-of-care ultrasound competency and confidence. Emerg Radiol. 2020;27(1):37-40.

14. Bornemann P. Assessment of a Novel Point-of-Care Ultrasound Curriculum’s Effect on Competency Measures in Family Medicine Graduate Medical Education. J Ultrasound Med. 2017;36(6):1205-1211.

15. Mellor TE, Junga Z, Ordway S, Hunter T, Shimeall WT, Krajnik S, Tibbs L, Mikita J, Zeman J, Clark P. Not Just Hocus POCUS: Implementation of a Point of Care Ultrasound Curriculum for Internal Medicine Trainees at a Large Residency Program. Military medicine. 2019;184(11-12):901-906.

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(1) Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology and Women’s Health, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA

(2) Department of Anesthesia, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA

*Corresponding Author: Dr. Celia A. Muoser (email: celia.muoser@gmail.com)

Download article PDF – POCUS Journal 2026;11(1):22-26

DOI: https://doi.org/10.24908/pocusj.v11i01.19976

Supplementary Materials: S1

Abstract

Background: The importance of cardiopulmonary point of care ultrasound (POCUS) for the assessment of the acute obstetric patient is increasingly recognized. Obstetricians are well-versed in ultrasound and may be able to perform POCUS with brief training. Objective: To implement and assess a hands-on basic training program in cardiopulmonary POCUS for obstetric trainees. Methods: Obstetric residents participated in a basic training program for cardiopulmonary POCUS run by maternal-fetal medicine and cardiac anesthesia specialists. A pre- and post-survey on confidence and self-perceived likelihood to utilize learned skills was administered. Results: Twenty-seven trainees participated in our program. Participants showed improved confidence in obtaining cardiac and lung views, as well as using the cardiac probe. They felt more comfortable making clinical decisions based on POCUS findings and reported they were more likely to use POCUS on obstetric patients. Conclusions: Our study demonstrated the feasibility of a POCUS training program for obstetric residents.

Introduction

Cardiopulmonary point of care ultrasound (POCUS) has emerged as a useful and efficient imaging modality for timely diagnosis and enhanced medical decision-making. In 2004, the American Institute of Ultrasound in Medicine (AIUM) introduced the idea of using the “ultrasound as a stethoscope” or adjunct to a clinician’s bedside clinical exam [1]. Subsequently, guidelines for POCUS exams have been established by the Society of Critical Care Medicine [2,3]. As opposed to conventional formal ultrasound, POCUS is conducted in a focused fashion with emphasis on views and findings that can guide differential diagnosis and treatment in medically acute patients.

POCUS has been used extensively in emergency medicine and critical care settings [4,5]. More recently, it has been utilized by internal medicine, family medicine, and pediatric providers [6–8]. The importance of cardiopulmonary POCUS for assessment of the acute obstetric patient is increasingly recognized, particularly in the setting of acute cardio-respiratory failure or to assist with peripartum fluid management [9–11]. While critical care or anesthesia providers may be available for consultation, obstetricians are also well versed in ultrasound as an imaging modality and may be able to perform cardiopulmonary POCUS with brief training [12,13]. Additionally, an obstetric ultrasound probe is readily available on labor and delivery units, making POCUS for the obstetric provider a quick and feasible tool while awaiting additional imaging or subspecialist assistance. The American College of Obstetricians and Gynecologists (ACOG) recently acknowledged the role of POCUS in pregnancy [14]. Leaders in the field of maternal-fetal medicine issued a call for maternal POCUS techniques and skills to be incorporated into obstetric training curricula [15]. In obstetric care, cardiopulmonary POCUS has particular clinical value for rapid evaluation of dyspnea, assessment of peripartum cardiomyopathy and cardiopulmonary complications of severe preeclampsia, identification of pulmonary edema, and guidance of volume status during hemorrhage resuscitation [9–11,15].

Previous basic training programs for POCUS in internal medicine and family medicine residencies have shown that proficiency and competence in cardiopulmonary POCUS can be achieved, particularly when hands-on training is used [16–18]. With the proposed benefit of expedited diagnosis and treatment in the acute labor and delivery setting, obstetrics should also consider the feasibility of such training. This study aimed to implement and assess a hands-on basic training program in cardiopulmonary POCUS for obstetric residents.

Methods

Obstetric residents at a large, academic, urban medical center (Montefiore Medical Center/Albert Einstein College of Medicine in the Bronx, NY) participated in a basic training program for cardiopulmonary POCUS. This was a pre-post intervention study with survey assessment of participants before and after the training (Figure 1). Sessions were conducted in small groups from April 2023 through March 2024. Participation was voluntary, and informed consent was obtained from all participants. Inclusion criteria for participation included current enrollment in our Obstetrics & Gynecology residency program (post-graduate years 1–4) and consent to participate, while exclusion criteria included any prior formal cardiopulmonary POCUS training.

The program consisted of a one-hour lecture with educational handouts (Supplementary Material S1), followed by a simulation session with an ultrasound-compatible mannequin and hands-on practice of lung and heart views (Figure 2). The training program was run by maternal-fetal medicine and cardiac anesthesia specialists with prior clinical POCUS experience. All participants had the opportunity to use the HeartWorks (Surgical Science Sweden AB, Göteborg, Sweden) mannequin for cardiac views, as well as practice live cardiac and pulmonary views on one another. Participants of all post-graduate years received the same training.

Basic knowledge of ultrasound is already part of the obstetric skill set, so training focused on the use of the cardiac probe and obtaining specific heart and lung views and interpretation. Five views commonly used in cardiac and pulmonary ultrasonography were taught as the foundation of cardiac POCUS . These views are adapted from those previously outlined in the CLUE (Cardiac Limited Ultrasound Examination) and RACE (Rapid Assessment of Competency in Echocardiography) protocols used for established POCUS training protocols [7,19]:

1. Parasternal – long and short axis

2. Apical – 4 chamber view

3. Subcostal – 4 chamber view and inferior vena cava

4. Lung apex – left and right

5. Lung base – left and right

The objective of the training was for obstetric residents to be able to obtain views adequate for image interpretation and to identify pathologies that may change acute medical management in the  labor and delivery unit, including abnormal cardiac dilation and ventricular function, pulmonary edema, pericardial effusion, and intravascular volume depletion. The goal of the program was to build foundational POCUS awareness and build pattern recognition. Only gross abnormalities were expected to be recognized with POCUS as a tool to escalate care, while complex or structural cardiac disease was not expected to be diagnosed.

A survey on level of confidence and self-perceived likelihood to utilize learned skills was administered before and after the training session. The survey collected responses to statements on a 5-point Likert scale ranging from 1 (not at all confident/likely) to 5 (very confident/likely). The Wilcoxon Signed Rank Sum test was used to compare pre- and post-training responses and compensate for non-normality. A p-value of <0.05 was considered statistically significant. A subset of participants answered additional questions about their experience with the use of POCUS in real-time on the labor and delivery unit.

Results

Twenty-seven obstetric residents participated in our POCUS training program. All residents completed both the lecture and simulation/hands-on portions of the training. Residents of all experience levels were included and completed the training. Seven were post-graduate year 4 (PGY4), eleven were PGY3, four were PGY2, and five were PGY1.

For the pre-training confidence statements, participants were most confident in the use of the obstetric probe and the appropriate clinical setting in which to use POCUS based on median scaled responses. They were not at all confident in using the cardiac probe or obtaining either cardiac or pulmonary views (Table 1).

Significant improvements in confidence were seen in all survey responses post-training, except confidence with the obstetric probe. Participants gained confidence in obtaining both cardiac and pulmonary views. Additionally, participants were significantly more likely to feel they could use POCUS on the labor and delivery unit after the training, and significantly more likely to feel they could teach another provider POCUS (Table 1).

A subset of 10 participants was asked about subsequent use of POCUS on the labor and delivery unit. Four out of the ten reported using POCUS in real-time for patient care after the training program. Three out of those four reported that POCUS decreased the time to rule out or diagnose cardiopulmonary disorders in a clinical setting. Additional work-up prompted by POCUS use included chest X-rays and computed tomography imaging. Interventions prompted by POCUS use included critical care evaluation, diuretic administration, and discontinuation of intravenous magnesium.

Discussion

This study demonstrated the feasibility of a basic training program for cardiopulmonary POCUS for obstetric residents. Through a structured curriculum, we were able to increase confidence in using bedside ultrasound to obtain cardiac and lung views, similar to prior studies done in other medical specialties [18]. This is the inception of an established universal program to train obstetric trainees, which is an ultimate goal for the obstetric community. We found that residents were able to adapt technical ultrasound skills already in their repertoire with the cardiac probe. Our residents have had some exposure to POCUS on the labor and delivery unit as performed by maternal-fetal medicine providers, so it is not surprising that there was already some comfort level about the appropriate clinical setting in which to use POCUS—for example, a preeclamptic patient with shortness of breath. Our training sessions allowed them to take the next step and develop their own acquisition and interpretation skills for cardiopulmonary POCUS, increasing the likelihood that they would feel comfortable using these skills for critically ill obstetric patients. Additionally, we found that some residents were able to employ the skills they learned in training in patient care.

To our knowledge, this is the first study to describe and assess a POCUS training program for obstetric residents. With the recent call for maternal POCUS technique and skills to be incorporated into obstetric training curriculum [15], we expect further programs and research in this emerging topic in the coming years. Our program’s strengths include standardization of training for small groups of residents within a single program, incorporation of simulation and hands-on training, and interdisciplinary collaboration between maternal-fetal medicine and cardiac anesthesiology.

Limitations of the study include the small number of participants, a lack of a validated survey instrument, and a lack of objective measurement of POCUS skills. Our survey instrument was adapted from prior similar studies aimed at teaching POCUS to residents [17]. However, we were unable to identify a standardized or validated survey tool to use in this setting. Additionally, in this first phase of our program, we could not test the proficiency and accuracy of obstetric residents in obtaining images. To fully evaluate a training program, an objective assessment of image acquisition, image quality, and diagnostic accuracy is vital. Studies in internal and family medicine have assessed resident-obtained images after POCUS training to help determine competency [16,18]. This is something we hope to implement and examine in the future.

Furthermore, a formalized assessment of clinical decisions based on POCUS use is needed. As described by Easter et al. in a 2023 expert review, POCUS can be used to guide clinical management in the setting of acute obstetric emergencies, assist with decisions for fluid management, and help to narrow a differential diagnosis [15]. Future studies should examine the use of POCUS by obstetric trainees under faculty supervision in labor and delivery units over time and ideally assess the time to clinical intervention and final diagnosis both with and without POCUS use.

Our program, as described here, is just a starting point for introducing cardiopulmonary POCUS into the obstetric training curriculum. We hope to continue training residents at our institution and begin to examine objective measures of proficiency after completing the training. Additionally, we need to examine the usefulness of the resident training on care provided to critically ill patients on the labor and delivery unit in a meaningful way. Perhaps examining the time to diagnosis of cardiopulmonary disorders or intervention with and without POCUS can help to demonstrate the utility of such training in the obstetric setting. Ideally, our program curriculum and materials could be adapted for use with a larger audience of obstetric providers and trainees.

Conclusion

Our study demonstrated the feasibility and benefits of a cardiopulmonary POCUS training program for obstetric residents. This is a skill that is valuable for expedited diagnosis and treatment of acute obstetric patients. Further work should objectively assess the proficiency of obstetric trainees with POCUS and evaluate its use in the labor and delivery setting.

Ethics Statement

Institutional Review Board approval was obtained for this study (IRB 2022-14057). Consent was obtained for identifiable individuals in the images that were included in this manuscript.

Disclosure Statement

The authors report no conflicts of interest.

Funding

The authors report no sources of funding.

Author Contributions

CAM: conceptualization, methodology, investigation, resources, data curation, formal analysis, project administration, writing – original draft, visualization, writing – review & editing. AA: conceptualization, methodology, investigation, resources, visualization, writing – review & editing. JI: conceptualization, methodology, investigation, resources, supervision, visualization, writing – review & editing. DSW: conceptualization, methodology, investigation, resources, data curation, formal analysis, project administration, supervision, visualization, writing – review & editing.

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6. Fischer EA, Kinnear B, Sall D, Kelleher M, Sanchez O, Mathews B, Schnobrich D, Olson APJ. Hospitalist-Operated Compression Ultrasonography: a Point-of-Care Ultrasound Study (HOCUS-POCUS). J Gen Intern Med. 2019;34(10):2062–2067. https://doi.org/10.1007/s11606-019-05120-5.

7. Kimura BJ, Shaw DJ, Amundson SA, Phan JN, Blanchard DG, DeMaria AN. Cardiac Limited Ultrasound Examination Techniques to Augment the Bedside Cardiac Physical Examination. J Ultrasound Med, 2015;34(9):1683–1690. https://doi.org/10.7863/ultra.15.14.09002.

8. Conlon TW, Nishisaki A, Singh Y, Bhombal S, De Luca D, Kessler DO, Su ER, Chen AE, Fraga MV. Moving Beyond the Stethoscope: Diagnostic Point-of-Care Ultrasound in Pediatric Practice. Pediatrics. 2019;144(4):e20191402. https://doi.org/10.1542/peds.2019-1402.

9. Zieleskiewicz L, Bouvet L, Einav S, Duclos G, Leone M. Diagnostic point-of-care ultrasound: applications in obstetric anesthetic management. Anaesthesia. 2018;73(10):1265–1279. https://doi.org/10.1111/anae.14354.

10. Neumann KE, Banayan JM. (2021). Point of care ultrasound on Labor and Delivery. Anesthesiol Clin. 2021;39(4):811–837. https://doi.org/10.1016/j.anclin.2021.08.014.

11. Algodi M, Wolfe DS, Taub CC. The utility of maternal point of care ultrasound on labor and delivery wards. J Cardiovasc Dev Dis. 2022;9(1):29. https://doi.org/10.3390/jcdd9010029.

12. Yassa M, Mutlu MA, Kalafat E, Birol P, Yirmibeş C, Tekin AB, Sandal K, Ayanoğlu E, Yassa M, Kılınç C, Tug N. How to perform and interpret the lung ultrasound by the obstetricians in pregnant women during the SARS-CoV-2 pandemic. Turk J Obstet Gynecol. 2020;17(3):225–232. https://doi.org/10.4274/tjod.galenos.2020.93902.

13. Pachtman S, Koenig S, Meirowitz N. Detecting pulmonary edema in obstetric patients through point-of-care lung ultrasonography. Obstet Gynecol. 2017;129(3):525–529. https://doi.org/10.1097/aog.0000000000001909.

14. ACOG Practice Bulletin No. 211: Critical Care in Pregnancy. Obstet Gynecol. 2019;133(5):e303-e319. https://doi.org/10.1097/AOG.0000000000003241.

15. Easter SR, Hameed AB, Shamshirsaz A, Fox K. Point of care maternal ultrasound in obstetrics. Am J Obstet Gynecol. 2023;228(5):509.e1-509.e13. https://doi.org/10.1016/j.ajog.2022.09.036. 

16. Kimura BJ, Amundson SA, Phan JN, Agan DL, Shaw DJ. Observations during development of an internal medicine residency training program in cardiovascular limited ultrasound examination. J Hosp Med. 2012;7(7):537–542. https://doi.org/10.1002/jhm.1944.

17. Wong F, Franco Z, Phelan MB, Lam C, David A. Development of a pilot family medicine hand-carried ultrasound course. WMJ. 2013;112(6):257–261. https://wmjonline.org/wp-content/uploads/2013/112/6/257.pdf.

18. Yao G, Hong TP, Lee P, Newbigging J, Wolfrom B. Point-of-Care Ultrasound Training for Family Medicine Residents: Examining the outcomes and feasibility of a pilot ultrasound curriculum. POCUS J, 2019;4(2):22–26. https://doi.org/10.24908/pocus.v4i2.13692.

19. Millington SJ, Arntfield RT, Hewak M, Hamstra SJ, Beaulieu Y, Hibbert B, Koenig S, Kory P, Mayo P, Schoenherr JR. (2016). The Rapid Assessment of Competency in Echocardiography Scale: Validation of a Tool for Point-of-Care Ultrasound. J Ultrasound Med. 2016;35(7):1457–1463. https://doi.org/10.7863/ultra.15.07083.

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(1) Adult Critical Care Unit, Royal London Hospital, Barts Health NHS Trust, London, UK

(2) Department of Anaesthesiology and Intensive Care, Khoo Teck Puat Hospital, NHG Health, Singapore

(3) Department of Cardiology, Barts Heart Centre, Saint Bartholomew’s Hospital, Barts Health NHS Trust, London, UK

(4) Department of Perioperative Medicine, Barts Heart Centre, Saint Bartholomew’s Hospital, Barts Health NHS Trust, London, UK

*Corresponding Author: Dr. Olusegun Olusanya (email: Olusegun.olusanya@nhs.net)

Download article PDF – POCUS Journal 2026;11(1):27-29

DOI: https://doi.org/10.24908/pocusj.v11i01.19963

Supplementary Materials: S1, S2

Abstract

We report a case of an elderly gentleman with recurrent episodes of flash pulmonary edema, initially attributed to hypertensive episodes. Cardiac point of care ultrasound (POCUS) revealed severe mitral regurgitation (MR), a finding underappreciated on transthoracic echocardiography and likely responsible for his repeated episodes of deterioration. Early recognition of dynamic MR expedited and guided targeted management of his valvular pathology. This case report highlights how serial cardiac POCUS can complement transthoracic echocardiography.

Introduction

Dynamic mitral regurgitation (MR) is challenging to diagnose, as severity may vary significantly according to loading conditions [1]. Thus, it can be difficult to accurately recognize and assess on routine transthoracic echocardiograms. Serial cardiac point of care ultrasound (POCUS) examinations can address this diagnostic gap, capturing a transient phenomenon during symptomatic episodes [2]. Proper training with advanced cardiac POCUS techniques is required [3–5].

Case Presentation

A 69-year-old man with a history of cerebrovascular disease, type 2 diabetes mellitus, hypertension, and hyperlipidaemia presented to the emergency department (ED) with sudden onset acute shortness of breath for 2 hours. He then deteriorated rapidly within 10 minutes of arrival to the hospital and suffered a witnessed cardiac arrest with return of spontaneous circulation after 4 minutes of resuscitation. He was intubated and sedated.

A 12-lead electrocardiogram showed new left bundle branch block. Cardiac and lung POCUS showed poor left ventricular contractility and bilateral B-lines pattern, respectively. Laboratory investigations revealed the first Troponin T level was 55 ng/L, which subsequently rose to 18,415 ng/L (reference range <14 ng/L). There were severe respiratory and metabolic acidosis and hypoxemia with a pH of 6.67, pCO₂ of 9.69 KPa, pO₂ of 11.5 KPa (FiO₂ 1.0), bicarbonate of 8 mmol/L and lactate of 10.3 mmol/L. The chest X-ray was consistent with fluid overload. The impression was acute pulmonary edema from a non-ST-elevation myocardial infarction.

On the second day of admission, a transthoracic echocardiogram demonstrated the left ventricle to be normal in size with impaired systolic function (ejection fraction of 45%). There were multiple regional wall motion abnormalities with akinesia of all the apical segments and the mid-anteroseptal segment. The remaining walls were contracting normally. The mitral valve appeared structurally normal with mild MR.

Over the course of 2 days, fluid removal was initially achieved via haemodialysis and thereafter with furosemide. He was extubated on day 2 and transferred to the general ward on day 6 of admission with plans for an inpatient coronary angiogram.

On the general ward, there was a repeat episode of flash pulmonary edema. He was receiving oxygen at 2 L/min when his oxygen saturation rapidly declined to 50%, requiring a 100% non-rebreather mask. He was subsequently re-intubated and mechanically ventilated. Repeat cardiac POCUS demonstrated left ventricular impairment and regional wall motion abnormalities similar to the recent transthoracic echocardiogram. It further showed a significant MR jet that was posteriorly directed, occupying 50% of the left atrium and reaching the left atrial wall (Figure 1).

He was stabilized again and transferred to a cardiac center, where he was extubated on their intensive care unit. He continued to have recurrent episodes of flash pulmonary edema related to increases in heart rate and blood pressure. These episodes were managed with inotropic support, diuretics, and continuous positive airway pressure (CPAP). A repeat transthoracic echocardiogram showed impaired left ventricular function but only mild MR. This led to the presumption that the episodes were purely afterload related. There were large bilateral pleural effusions noted; drainage of the right-sided pleural effusion was performed with minimal improvement in symptoms. The pleural fluid was transudative in nature according to Light’s criteria [6].

A coronary angiogram revealed severe diffuse disease in the left anterior descending coronary artery, critical in mid-vessel, and proximal-mid right coronary artery disease and further posterior descending artery disease. Medical therapy was recommended as no stents were placed.

On day 10 of admission, cardiac POCUS was repeated as part of teaching rounds. Prior to the examination, the patient’s blood pressure was 80/50 mmHg with a heart rate of 70 beats/min, supported by milrinone and adrenaline infusions. During the POCUS examination, his blood pressure rose to 110/60 mmHg and his heart rate increased to 90 beats/min as he became increasingly aggravated while sharing his frustrations about his prolonged hospitalization. Interestingly, the posteriorly directed mitral regurgitant jet occupying 50% of the left atrium was seen again, which was visually quantified as severe by the supervising intensive care unit consultant (Supplementary Material S1).

Based on his history, lab findings, and review of the POCUS findings, a multidisciplinary team comprising cardiologists, intensivists, and cardiothoracic surgeons concluded that the patient had dynamic MR, which was the leading cause of his deterioration. In view of his medical background, both percutaneous and surgical interventions for his coronary artery disease were deemed extremely risky, and the recommendation was for ongoing medical optimisation for his coronary artery disease. Mitral valve intervention in the form of transcatheter edge-to-edge repair with MitraClip™ (Abbott, 3200 Lakeside Dr, Santa Clara, 95054, U.S.A) was discussed with and accepted by the patient.

The patient was transferred to the cardiac catheterization laboratory, anaesthetised, and had a baseline trans-esophageal echocardiogram (TEE) performed. This demonstrated moderate-severe secondary MR due to tethering of the posterior mitral valve leaflet (Supplementary Material S2). Two clips were successfully placed under fluoroscopic and TEE guidance, and the patient was stepped down to the general ward 4 days post procedure, where guideline directed medical therapy for heart failure was optimised. There were no further episodes of flash pulmonary edema.

Discussion

Advanced cardiac POCUS examination with Doppler assessment of the mitral valve was pivotal in diagnosing dynamic MR that was underappreciated on initial transthoracic echocardiogram [7,8]. Secondary MR remains a challenge to diagnose, as it is characteristically dynamic in nature and sensitive to changes in ventricular geometry and loading conditions [9].In diseased ventricles, the delicate balance of tethering and closing forces that is necessary for optimal mitral valve leaflet coaptation is often disrupted, resulting in MR. Both volume overload and increase in afterload, provoked either physiologically or pharmacologically, can result in further changes in left ventricular geometry and hence, worsening of MR [10]. Therapies for secondary MR should thus aim at reducing the dynamic component of the valvular lesion [9].

Current guidelines recommend modalities such as TEE, exercise stress echocardiography, cardiac magnetic resonance imaging and cardiac computed tomography to complement two-dimensional echocardiography in the evaluation of MR. These are not without risk or additional cost or time; particularly in our patient who was CPAP and inotrope-dependent. In patients whose clinical presentation is is not fully explained by their resting echocardiography findings, exercise stress echocardiography is recommended to elicit severe MR [11].This is, however, not practical in critically ill patients. In such a setting, the worsening on the MR can be provoked either physiologically or pharmacologically via vasopressors or fluid infusion.

In this case, POCUS enabled the team to identify findings which only became evident in situations where the patient was hemodynamically stressed. This facilitated a more rapid diagnosis and allowed for timely intervention, which could potentially translate to a shorter length of stay and reduced healthcare costs [12].

Conclusion

This case demonstrates that advanced cardiac POCUS can hasten the diagnosis of dynamic MR. Without POCUS, this patient might have required further investigations such as a repeat transthoracic echocardiogram or TEE for diagnosis, which would have resulted in significant delays.

Ethics Statement

The above case report and details were provided with written consent from the patient, taken on 4/7/2025.

Disclosure Statement

The authors declare no conflicts of interest. This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Funding

The authors received no financial or material support related to the research.

Author Contributions

SW: writing – original draft, data curation, writing – review & editing. DH: data curation, writing – review & editing. SA: writing – review & editing. OO: conceptualization, writing – original draft, data curation, writing – review & editing.

References

1. Lancellotti P, Zamorano JL, Vannan MA. Imaging challenges in secondary mitral regurgitation: unsolved issues and perspectives. Circ Cardiovasc Imaging. 2014;7(4):735-746.

2. Expert Round Table on Echocardiography in ICU. International consensus statement on training standards for advanced critical care echocardiography. Intensive Care Med. 2014;40(5):654-666.

3. Miller A, Peck M, Clark T, Conway H, Olusanya S, Fletcher N, Coleman N, Parulekar P, Aron J, Kirk-Bayley J, Wilkinson JN, Wong A, Stephens J, Rubino A, Attwood B, Walden A, Breen A, Waraich M, Nix C, Hayward S. FUSIC HD. Comprehensive haemodynamic assessment with ultrasound. J Intensive Care Soc. 2022;23(3):325-333.

4. Boyd S, Nix C, McDermott C, Doolan A, Hastings J, Keane S, Moran P, McCarthy C, Mohammed A. Echocardiography Training Pathway for Intensive Care Trainees: A Comparison with International Guidelines. Ir Med J. 2025;118(3):35.

5. Tierney DM, Rosborough TK, Sipsey LM, Hanson K, Smith CS, Boland LL, Miner R. Association of Internal Medicine Point of Care Ultrasound (POCUS) with Length of Stay, Hospitalization Costs, and Formal Imaging: a Prospective Cohort Study. POCUS J. 2023;8(2):184-192.

6. Light RW. Clinical practice. Pleural effusion. N Engl J Med 2002;346(25):1971-1977.

7. Bhagra A, Tierney DM, Sekiguchi H, Soni NJ. Point-of-Care Ultrasonography for Primary Care Physicians and General Internists. Mayo Clin Proc. 2016;91(12):1811-1827.

8. Núñez-Ramos JA, Duarte-Misol D, Petro MAB, Pérez KJS, Echeverry VPG, Malagón SV. Agreement of point of care ultrasound and final clinical diagnosis in patients with acute heart failure, acute coronary syndrome, and shock: POCUS not missing the target. Intern Emerg Med. 2024;19(6):1585-1592.

9. Bertrand PB, Schwammenthal E, Levine RA, Vandervoort PM. Exercise Dynamics in Secondary Mitral Regurgitation: Pathophysiology and Therapeutic Implications. Circulation. 2017;135(3):297-314.

10. Wong N, Tan WCJ, Widodo WA, Ong BC, Ding ZP, Ewe SH, Tang HC, Yeo KK. Dynamic mitral regurgitation treated with MitraClip. Ann Acad Med Singap. 2021;50(3):280-282.

11. Camaj A, Thourani VH, Gillam LD, Stone GW. Heart Failure and Secondary Mitral Regurgitation: A Contemporary Review. J Soc Cardiovasc Angiogr Interv. 2023;2(6):101195

12. B Núñez-Ramos JA, Aguirre-Acevedo DC, Pana-Toloza MC. Point of care ultrasound impact in acute heart failure hospitalization: A retrospective cohort study. Am J Emerg Med. 2023;66:141-145.

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(1) Memorial Healthcare System, Hollywood, FL, USA

(2) Mount Sinai Medical Center, Miami Beach, FL, USA

*Corresponding Author:  Dr. Eric Boccio (email: eric.boccio@msmc.com)

Download article PDF – POCUS Journal 2026;11(1):30-33

DOI: https://doi.org/10.24908/pocusj.v11i01.19751

Supplementary Materials: S1, S2, S3

Abstract

A 44-year-old man with a history of intravenous drug use presented to the emergency department in cardiac arrest. Point of care ultrasound (POCUS) revealed a pericardial effusion with tamponade physiology. Initial landmark-guided pericardiocentesis returned blood but failed to confirm guidewire placement via POCUS. A repeat, ultrasound-guided pericardiocentesis yielded purulent fluid. Subsequent drainage of 50 mL of fluid improved cardiac contractility and hemodynamics. The patient was admitted to the intensive care unit, and pericardial fluid cultures grew Streptococcus pneumoniae. This case highlights the diagnostic and procedural utility of POCUS in managing purulent pericardial tamponade as a cause of cardiac arrest.

Case presentation

A 44-year-old man with a history of type I diabetes mellitus, cocaine abuse, and alcohol abuse presented to the emergency department (ED) in cardiac arrest after collapsing in the shower. The patient had been complaining of right upper quadrant abdominal pain radiating to the right shoulder for two weeks prior to the event. He received a total of 6 mg epinephrine, 1 g calcium gluconate, 50 mEq sodium bicarbonate, and 2 mg naloxone by emergency medical services (EMS). The patient was intubated prior to ED arrival. Endotracheal tube placement was confirmed prior to and after patient transfer from the EMS stretcher. Mechanical compressions were provided via a Lund University Cardiopulmonary Assist System (LUCAS) device. Upon initial pulse check, a carotid pulse was palpated and return of spontaneous circulation (ROSC) was noted. Initial post-ROSC vital signs were remarkable for hypothermia (33.3°C, axillary), tachycardia (127 beats per minute), and hypotension (66/40 mmHg). During resuscitation, cardiac point of care ultrasound (POCUS) examination was performed which revealed a pericardial effusion with concern for tamponade (Figure 1).

Emergent pericardiocentesis was performed by interventional cardiology at bedside using a landmark approach with return of a scant volume of blood. Cardiac POCUS was employed by the emergency physician but failed to confirm visualization of the guidewire in the pericardial sac (Supplementary Material S1). The initial attempt was aborted, and pericardiocentesis was repeated under dynamic ultrasound guidance which yielded 50 mL of purulent fluid during aspiration (Figure 2). The pericardiocentesis needle tip was visualized using POCUS to be properly positioned within the pericardial sac (Supplementary Material S2).

Repeat cardiac POCUS following aspiration of 50 mL of purulent fluid revealed a decrease in the volume of pericardial effusion and improved heart contractility which corresponded with an improvement in blood pressure to 128/106 mmHg (Figure 3, Supplementary Material S3).

Laboratory results revealed leukocytosis (white blood cell count, 42.5 x 103 cells/µL), hyperkalemia (6.0 mEq/ L), elevated serum creatinine (3.36 mg/ dL), hyperlactatemia (16.0 mmol/L), hyperglycemia (serum glucose, 554 mg/dL), and an anion gap (25 mEq/L). A chest X-ray revealed satisfactory endotracheal tube positioning, a right lower lobe infiltrate, small pericardial effusion, and a left-sided pleural effusion. The electrocardiogram (EKG) revealed wide complex tachycardia (Figure 4).

Empiric vancomycin and piperacillin/tazobactam were administered for septic shock presumed secondary to pyogenic pericarditis and community-acquired pneumonia. Given the clinical suspicion of diabetic ketoacidosis and hyperkalemia with EKG changes, an insulin infusion and continuous albuterol nebulization were initiated. The patient was admitted to the medical intensive care unit. Computed tomography of the chest revealed multifocal pneumonia and a moderate sized left hydropneumothorax. A left-sided thoracostomy with chest tube insertion was performed by the interventional pulmonology team. The pericardial fluid culture and subsequently collected blood cultures both grew Streptococcus pneumoniae. Following a “goals of care” discussion with the patient’s family, the patient’s code status was revised to Do Not Resuscitate, and the patient died on hospital day 4.

Diagnosis

Pericardial tamponade secondary to pyogenic pericarditis

Pyogenic pericarditis can rapidly progress to pericardial tamponade and precipitate cardiac arrest. The pathophysiology involves accumulation of pus within the pericardial space which increases intrapericardial pressure [1]. When this pressure exceeds the cardiac chambers’ filling pressures, diastolic filling is impaired, leading to a drop in cardiac output and ultimately circulatory collapse [2]. Rapid accumulation is particularly dangerous because the pericardium cannot stretch quickly enough to accommodate the increased volume, resulting in a dramatic rise in intrapericardial pressure and acute hemodynamic compromise. This is in contrast to slowly accumulating effusions, where compensatory mechanisms may delay tamponade physiology [3,4]. In pyogenic effusions, the inflammatory process also causes pericardial thickening and may promote systemic illness, further exacerbating hemodynamic instability [1,2]. Clinically, patients present with hypotension, elevated jugular venous pressure, and muffled heart sounds (Beck’s triad), which may rapidly progress to cardiac arrest if untreated [5–7]. The mortality rate is high, even with prompt intervention, due to the fulminant nature of infection and the risk of rapid decompensation.

Discussion

Pyogenic pericarditis is a rare but potentially life-threatening condition due to its rapid progression to sepsis, pericardial tamponade, and hemodynamic collapse. The diagnosis is confirmed through culturing of pericardial fluid [8]. Pericardiocentesis may be performed using the landmark approach. However, POCUS-guided pericardiocentesis is recommended as it is associated with higher success rates and fewer complications [9]. In this case, the landmark approach was believed to have been successful due to aspiration of blood, however, proper placement of the needle could not be verified using POCUS. The second attempt at pericardiocentesis was successfully confirmed by real-time POCUS visualization of the needle in the pericardial space, aspiration of purulent fluid, improved hemodynamics, and a post-procedural reduction in the size of the pericardial effusion with reversal of radiographic tamponade on POCUS.

In the setting of cardiac arrest, the application of POCUS is essential for assessing cardiac motion, identifying potentially reversible etiologies, facilitating procedural guidance, and providing dynamic feedback on the efficacy of ongoing resuscitation efforts [10]. POCUS-guidance has become the standard of care for pericardiocentesis because it dramatically improves both safety and success rates compared to the blind landmark approach [11]. The most critical benefit is minimizing complications, as real-time visualization allows the proceduralist to avoid vital surrounding structures such as the lungs, internal thoracic vessels, and cardiac chambers. Furthermore, ultrasound excels at optimizing the insertion site by locating the area with the maximal fluid accumulation, ensuring the distance from the skin to the fluid is the shortest [12]. While the subxiphoid approach is classic, POCUS guidance allows for the safe use of alternative approaches such as the apical and parasternal when they offer more direct access to a non-uniform fluid collection. Real-time procedure monitoring is also a key advantage, as continuous visualization confirms the correct path of the needle and proper catheter placement in the pericardial space [13].

Needle and catheter placement during pericardiocentesis may be confirmed through a combination of aspiration, diagnostic imaging, and physiological reassessment. The first sign of correct needle placement is the ability to freely aspirate pericardial fluid into the syringe, often achieved after advancing the needle 1–2 mm past an initial partial entry where aspiration was intermittent. Once a guidewire is advanced, confidence regarding correct positioning in the pericardial space is achieved if the wire appears to span multiple cardiac chambers on imaging. Proceduralists must remain vigilant for signs of cardiac puncture, which include movement of the needle with each cardiac cycle, the presence of premature ventricular complexes on telemetry, brisk blood return from the needle lumen, flailing movement of the wire during systole, or wire tracking along the pulmonary artery or aorta. After the needle is exchanged for a catheter, correct placement is confirmed using two primary methods: transducing a non-ventricular pressure waveform on a monitor and confirmation on imaging. When using POCUS, placement confirmation involves injecting agitated saline bubbles into the catheter and then visualizing them in the pericardial space. Bubbles in the atria or ventricles are highly suggestive of cardiac puncture and ectopic catheter placement. In very large or loculated effusions, inadequate bubble visualization may necessitate the use of additional imaging views for accurate confirmation [14].

Pericardial tamponade secondary to pyogenic pericarditis is a true cardiac emergency with a high risk of death if it is not managed expeditiously. Immediate drainage of the pericardial effusion and administration of broad-spectrum antibiotics are essential to improve hemodynamics and treat the underlying infection. When performing emergent pericardiocentesis, POCUS-guidance is recommended over the landmark technique, as it provides real-time visual confirmation of proper needle, guidewire, and catheter positioning thereby increasing procedural success rates and reducing complications related to ectopic needle placement.

Ethics Statement 

Patient consent requirements were satisfied per the affiliate Institutional Review Board.

Disclosure Statement

The authors report no conflicts of interest regarding the referenced work.

Funding

No funding was provided in support of this research.

Author Contributions

NA: conceptualization, data curation, writing – original draft. BK: conceptualization, data curation, writing – review & editing, supervision. PD: conceptualization, data curation, writing – review & editing, supervision. EB: methodology, resources, writing – review & editing, supervision, project administration.

References

1. Patel H, Patel C, Soni M, Patel A, Banda V. Acute Primary Pneumococcal Purulent Pericarditis With Cardiac Tamponade: A Case Report and Literature Review. Medicine (Baltimore). 2015;94(41):e1709. doi: 10.1097/MD.0000000000001709

2. Zmora I, Wiener-Well Y, Alpert EA. A case of purulent pneumococcal pericarditis. Am J Emerg Med. 2019;37(5):1006.e5-1006.e7. doi: 10.1016/j.ajem.2019.02.013

3. Adler Y, Ristić AD, Imazio M, Brucato A, Pankuweit S, Burazor I, Seferović PM, Oh JK. Cardiac tamponade. Nat Rev Dis Primers. 2023;9(1):36. doi: 10.1038/s41572-023-00446-1

4. Cremer PC, Klein AL, Imazio M. Diagnosis, Risk Stratification, and Treatment of Pericarditis: A Review. JAMA. 2024;332(13):1090-1100. doi: 10.1001/jama.2024.12935

5. Troughton RW, Asher CR, Klein AL. Pericarditis. Lancet. 2004;363(9410):717-27. doi: 10.1016/S0140-6736(04)15648-1

6. Roy CL, Minor MA, Brookhart MA, Choudhry NK. Does this patient with a pericardial effusion have cardiac tamponade? JAMA. 2007;297(16):1810-8. doi: 10.1001/jama.297.16.1810

7. Bodson L, Bouferrache K, Vieillard-Baron A. Cardiac tamponade. Curr Opin Crit Care. 2011;17(5):416-24. doi: 10.1097/MCC.0b013e3283491f27

8. Adler Y, Charron P, Imazio M, Badano L, Barón-Esquivias G, Bogaert J, Brucato A, Gueret P, Klingel K, Lionis C, Maisch B, Mayosi B, Pavie A, Ristic AD, Sabaté Tenas M, Seferovic P, Swedberg K, Tomkowski W; ESC Scientific Document Group. 2015 ESC Guidelines for the diagnosis and management of pericardial diseases: The Task Force for the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology (ESC)Endorsed by: The European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2015;36(42):2921-2964. doi: 10.1093/eurheartj/ehv318

9. Blanco P, Figueroa L, Menéndez MF, Berrueta B. Pericardiocentesis: ultrasound guidance is essential. Ultrasound J. 2022;14(1):9. doi: 10.1186/s13089-022-00259-5

10. Magon F, Longhitano Y, Savioli G, Piccioni A, Tesauro M, Del Duca F, Napoletano G, Volonnino G, Maiese A, La Russa R, Di Paolo M, Zanza C. Point-of-Care Ultrasound (POCUS) in Adult Cardiac Arrest: Clinical Review. Diagnostics (Basel). 2024;14(4):434. doi: 10.3390/diagnostics14040434

11. Salem K, Mulji A, Lonn E. Echocardiographically guided pericardiocentesis – the gold standard for the management of pericardial effusion and cardiac tamponade. Can J Cardiol. 1999;15(11):1251-5

12. Callahan JA, Seward JB, Tajik AJ. Cardiac tamponade: pericardiocentesis directed by two-dimensional echocardiography. Mayo Clin Proc. 1985;60(5):344-7. doi: 10.1016/s0025-6196(12)60541-2

13. Tsang TS, Enriquez-Sarano M, Freeman WK, Barnes ME, Sinak LJ, Gersh BJ, Bailey KR, Seward JB. Consecutive 1127 therapeutic echocardiographically guided pericardiocenteses: clinical profile, practice patterns, and outcomes spanning 21 years. Mayo Clin Proc. 2002;77(5):429-36. doi: 10.4065/77.5.429

14.Tsang TS, Freeman WK, Sinak LJ, Seward JB. Echocardiographically guided pericardiocentesis: evolution and state-of-the-art technique. Mayo Clin Proc. 1998;73(7):647-52. doi: 10.1016/S0025-6196(11)64888-X

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*Corresponding Author:  Dr. Taryn Hoffman (email: taryn_hoffman@teamhealth.com)

Download article PDF – POCUS Journal 2026;11(1):34-36

DOI: https://doi.org/10.24908/pocusj.v11i01.19500

Supplementary Material: S1

Abstract

Background: ST segment elevation myocardial infarction (STEMI) is a common cause of death and disability in the United States. A rare, though highly morbid complication of STEMI is a rupture of the left ventricular free wall. Prompt recognition and action by emergency physicians is essential. This report describes a case of left ventricular free wall rupture in the setting of a STEMI, diagnosed by point of care ultrasound (POCUS) in the emergency department (ED). Case Presentation: A 72-year-old man presented with severe chest pain and STEMI on his electrocardiogram (ECG), days after an untreated episode of chest pain. Cardiac POCUS revealed a complex pericardial effusion with partially clotted blood, which raised concern for a rupture of the left ventricular free wall. Conclusion: Cardiac POCUS enabled providers to quickly recognize a complex pericardial effusion and cardiac tamponade in a patient presenting with a STEMI.

Introduction

The Centers for Disease Control and Prevention (CDC) estimate a total of 750,000 cases of ST elevation myocardial infarction (STEMI) in the United States each year [1]. Of these 750,000 cases, only about 0.01 to 0.5% result in left ventricular free wall rupture, though that number is likely higher as patients with this complication can expire without a known diagnosis. The overall mortality of left ventricular free wall rupture is high. It is responsible for 20% of in-hospital STEMI-related deaths, and can have a mortality of up to 90% if managed conservatively [2]. In this report, we describe a case in which cardiac POCUS was used by emergency physicians to quickly identify the complex pericardial effusion and presumed left ventricular free wall rupture in the setting of recent recurrent STEMI.

Case Presentation

A 72-year-old man with a medical history only significant for tobacco abuse presented to the emergency department (ED) as a STEMI alert activated by paramedics. The patient had originally developed chest pain about 5 days prior to presentation. He did not seek medical care at that time and his pain resolved the following day. He continued having episodes of pain over the next couple of days until 3 hours prior to presentation, when he developed acute worsening of his symptoms. He described feeling sudden, severe, substernal chest pain that radiated across both of his shoulders. This pain was also associated with nausea but not with dyspnea, leg swelling, or other symptoms. Paramedics performed a 12-lead electrocardiogram (ECG) which showed ST elevations in anterolateral leads. They activated a prehospital STEMI alert and administered 162 mg aspirin during transport. Vitals were stable on their initial assessment, but blood pressure began down trending during transport.

Upon arrival at the ED, the patient had an initial blood pressure of 90/63 mm Hg, a heart rate of 99 beats per minute, and an oxygen saturation on room air of 99%.  He appeared to be in moderate distress. Pertinent exam revealed clear lungs, unlabored respirations, benign abdomen, and mild pitting edema of the lower extremities. The patient had delayed capillary refill and weak but symmetric pulses in his extremities.

A 12-lead ECG was rapidly performed on arrival (Figure 1). A STEMI alert was reactivated in the ED and the patient was given an additional 162 mg aspirin (for a total of 324 mg), along with an intravenous heparin bolus of 5000 units. ED physicians performed a cardiac POCUS examination (Figure 2, Supplementary Material S1) that revealed a large, mixed-echogenic fluid collection encircling the heart, most consistent with clotted blood. This raised concern for left ventricular free wall rupture, given the history of several days of chest pain. Chest X-ray was performed and read as negative for acute cardiopulmonary abnormality. He started to become more hypotensive, so intravenous fluids were administered and norepinephrine was initiated to maintain adequate blood pressure. Cardiology brought him to the catheterization suite, where he was found to have 60–70% mid-segment stenosis of the left anterior descending artery (LAD) with 100% occlusion of the first diagonal branch. They were unable to pass the wire through the fully occluded vessel, so no stent was placed. Cardiac POCUS in the catheterization lab showed worsening of the pericardial effusion and development of signs of cardiac tamponade. Ultrasound-guided pericardiocentesis was performed which removed 600 cc of blood. This was initially dark red but transitioned to bright red blood. The patient then suffered pulseless electrical activity (PEA) cardiac arrest and massive transfusion protocol was initiated. He was intubated, received multiple doses of epinephrine, 4 units of packed red blood cells, 2 units of fresh frozen platelets, and multiple vasopressors. A pericardial drain was placed. Ultimately, the patient had return of spontaneous circulation (ROSC) after 75 minutes of resuscitation. 

Cardiothoracic surgery then took him to the operating room. He went into asystole after draping for surgery, so they initiated cardiopulmonary resuscitation  and performed an emergent sternotomy. Upon opening the pericardium, he had 1L of blood with large amounts of clots evacuated, as well as 6.5 L of hemothorax removed. Internal cardiac massage was performed until he was placed on cardiopulmonary bypass. He regained cardiac activity once on bypass, and further repair was done while the heart was beating. The patient was found to have a blowout-type left ventricular free wall rupture with a large anterior tear of infarcted myocardium beginning at the origin of the diagonal arteries. Surgeons repaired the ruptured myocardium with felt strips and suture, but then further rupture occurred so they needed to place an additional patch. Each procedure that was performed yielded further rupture as the myocardium was quite friable. Once hemostasis was achieved at the patch site, the patient was weaned from cardiopulmonary bypass briefly but went back into cardiac arrest and was placed on bypass again. Despite all aggressive measures taken to resuscitate him, the patient’s cardiac function was less than 10% and did not improve despite high doses of inotropes and epinephrine. Ultimately, he expired in the operating room.

Discussion

Left ventricular free wall rupture, though uncommon, is a devastating and often fatal complication of myocardial infarction, most frequently occurring three to five days after the initial infarct. Cardiac POCUS has tremendous benefit when evaluating patients who are at risk for having a left ventricular free wall rupture [3]. As in this case, the use of cardiac POCUS allows an emergency provider to quickly identify an immediate threat to life. The classic finding that is commonly associated with wall rupture is pericardial effusion, from which a patient may rapidly decompensate into cardiac tamponade with right atrial systolic collapse and right ventricular diastolic collapse [3,4]. It is not uncommon to also visualize a papillary muscle rupture in these cases, seen as a hyperechoic structure that prolapses from the left ventricle into the left atrium during systole [5]. As patients with left ventricular free wall rupture are typically unstable, it may be necessary to perform pericardiocentesis to temporarily improve hemodynamics while arranging for emergent surgical intervention for definitive management. Surgical management is the first-line management for this condition. Conservative treatment involves fluid replacement, pressor support, pericardiocentesis as needed, and potentially insertion of an intra-aortic balloon pump, though none of these treatments actually repair the underlying problem [6]. Left ventricular wall rupture is associated with an exceedingly high morbidity and mortality, and early recognition is paramount in improving clinical outcomes and for increasing the chance of a patient’s survival.

Ethics Statement

The authors attest that their institution requires neither Institutional Review Board approval, nor patient consent for publication of this case report.

Disclosure Statement

The authors declare no conflict of interest. This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare affiliated entity. The views expressed in this publication represent those of the author(s) and do not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.

Funding

No funding or financial support received by any author.

Author Contributions

JA: writing – original draft. SO: conceptualization, supervision. ED: conceptualization, supervision. TH: writing – review & editing, supervision.

References

1. Fang J, Luncheon C, Ayala C, Odom E, Loustalot F. Awareness of Heart Attack Symptoms and Response Among Adults – United States, 2008, 2014, and 2017. MMWR Morb Mortal Wkly Rep. 2019;68(5):101-106. doi:10.15585/mmwr.mm6805a2

2. Yan L, Wang H, Su B, Fan J, Wang M, Zhao X. Survival after left ventricular free wall rupture following acute myocardial infarction by conservative treatment. Am J Emerg Med. 2021;39:21-23. doi: 10.1016/j.ajem.2020.08.035.

3. Lee BW, Cha YS, Hwang SO, Kim YS, Kim SJ. Echocardiographic features of myocardial rupture after acute myocardial infarction on emergency echocardiography. Clin Exp Emerg Med 2023;10(4):393-399.

4. Alerhand S, Adrian RJ, Long B, Avila J. Pericardial tamponade: A comprehensive emergency medicine and echocardiography review. Am J Emerg Med. 2022;58:159-174. doi: 10.1016/j.ajem.2022.05.001

5. Pujari SH, Sharma S, Agasthi P. Left Ventricular Rupture. In: StatPearls. StatPearls Publishing; 2025. Accessed May 26, 2025. http://www.ncbi.nlm.nih.gov/books/NBK559271/

6. Matteucci M, Fina D, Jiritano F, Meani P, Blankesteijn WM, Raffa GM, Kowaleski M, Heuts S, Beghi C, Maessen J, Lorusso R. Treatment strategies for post-infarction left ventricular free-wall rupture. Eur Heart J Acute Cardiovasc Care. 2019;8(4):379-387. doi: 10.1177/2048872619840876

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(1) Department of critical care, Hospital Nossa Senhora da Conceição, Porto Alegre, Brazil

(2) Department of critical care, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil

(3) Universidade La Salle, Canoas, Brazil

*Corresponding Author:  Dr. Marcio Manozzo Boniatti (email: mboniatti@hcpa.edu.br)

Download article PDF – POCUS Journal 2026;11(1):37-44

DOI: https://doi.org/10.24908/pocusj.v11i01.19496

Supplementary Material: S1

Abstract

Background: Ventilator weaning failure is a significant challenge in critically ill patients, and venous congestion has emerged as a potentially modifiable factor influencing weaning outcomes. This study aimed to investigate the association between venous congestion identified by the modified venous excess ultrasound (mVExUS) score and ventilator weaning failure in critically ill patients. Methods: We prospectively enrolled patients aged 18 years or older who had received mechanical ventilation (MV) for at least 48 hours. A mVExUS score, excluding the intrarenal component, and a lung point of care ultrasound (POCUS) assessment were performed before a spontaneous breathing trial (SBT). The primary outcome was weaning failure, defined as a failed SBT or the need for MV (invasive or non-invasive) within 72 hours. Results: Among 111 patients, 57 (51.4%) experienced ventilator weaning failure. Ventilator weaning failure occurred in 63.9% of patients with mVExUS scores of 2–3, compared to 45.3% with scores of 0–1 (p = 0.067). In adjusted analyses, mVExUS scores of 2–3 were independently associated with weaning failure (OR 2.756, p = 0.03). A post-hoc analysis combining mVExUS and lung POCUS scores showed a weaning failure incidence of 76.5% in patients with mVExUS scores of 2–3 and lung POCUS scores ≥7, compared to 34.1% in patients with mVExUS scores of 0–1 and lung POCUS scores <7 (p = 0.002). Conclusion: mVExUS scores of 2–3 are significantly associated with a higher risk of weaning failure and post-extubation respiratory failure. Combining VExUS and lung POCUS scores may enhance the assessment of weaning readiness in critically ill patients.

Introduction

The liberation of patients from mechanical ventilation (MV) remains a significant challenge in the management of critically ill individuals. Failure to successfully wean from MV is associated with adverse clinical outcomes [1,2]. Multiple mechanisms contribute to extubation failure, among which an inadequate cardiovascular response plays a central role [3–5]. During the ventilator weaning process, the withdrawal of positive pressure ventilation functions as a cardiovascular stress test, and can trigger a weaning-induced pulmonary edema (WIPO) [6]. Recently, Shi et al. reported that WIPO accounted for over one-third of weaning failure cases, particularly among patients with pre-existing heart disease or chronic obstructive pulmonary disease [7]. Consequently, identifying patients at risk for cardiovascular dysfunction during MV weaning using a cost-effective, non-invasive, and widely accessible method is of great clinical importance.

Lung point of care ultrasound (POCUS)  has emerged as a valuable tool for detecting WIPO. Several studies have demonstrated that higher lung POCUS scores are associated with ventilator weaning failure [8–10]. While lung POCUS is well established in assessing pulmonary congestion during the weaning process, its ability to evaluate systemic venous congestion is limited. In contrast, the venous excess ultrasound (VExUS) score provides a more comprehensive assessment of systemic congestion by integrating measurements of inferior vena cava (IVC) diameter with pulsed-wave Doppler patterns of the hepatic, portal, and intrarenal veins [11]. A modified version of the VExUS score (mVExUS), which excludes the intrarenal component, offers a simplified alternative while maintaining good diagnostic performance in identifying venous congestion. This integrated approach allows the VExUS score to quantify systemic congestion and to reflect the severity of underlying cardiovascular dysfunction [12,13]. Given that patients with systemic venous congestion are at increased risk of developing WIPO, the VExUS score may provide complementary insights to lung POCUS [14,15]. This can enhance the assessment of patients during the ventilator weaning process.

Therefore, this study aimed to investigate the association between venous congestion identified by the mVExUS score and ventilator weaning failure in critically ill patients undergoing a spontaneous breathing trial (SBT), independent of the lung POCUS score.

Methods

We conducted a prospective cohort study in the intensive care unit (ICU) of a tertiary hospital in Porto Alegre, Brazil, from July 5, 2022 to July 13, 2023. The study was conducted in accordance with the principles of the Declaration of Helsinki. The research protocol was approved by the institutional ethics committee, and written informed consent was obtained from each participant or their legally authorized representative.

We prospectively enrolled patients aged 18 years or older who received MV for at least 48 hours and were deemed ready for a SBT. Exclusion criteria included liver cirrhosis, portal vein thrombosis, presence of a tracheostomy, or a do-not-reintubate order. Patients with a do-not-reintubate order would not be eligible for reintubation and therefore could not meet one of the components of the primary outcome. The decision to initiate the SBT was made by the attending physician based on routine clinical judgment. All eligible patients were systematically screened, but because a single investigator performed all ultrasound assessments, patients were only enrolled on days when the investigator was avaliable. Therefore, a convenience sampling strategy was applied.

Before the initiation of the SBT, both mVExUS and lung POCUS assessments were performed by one of the investigators (THMM), a clinician with extensive experience in critical care ultrasonography who was not involved in patient management. All ultrasound images were subsequently reviewed by a senior ICU physician (MMB), also highly experienced in critical care ultrasonography and blinded to clinical outcomes, to ensure data quality and objectivity.

mVExUS assessments were performed using a portable ultrasound machine (M-Turbo, Sonosite, Seattle, USA) equipped with a 2–5 MHz curved-array transducer. Patients were positioned in the dorsal decubitus position with the head of the bed elevated to 30 degrees. The diameter of the IVC was initially measured in its intrahepatic segment, approximately 2 cm from the junction with the hepatic veins, using both short- and long-axis views from a subxiphoid window. If the subxiphoid view was inadequate, the probe was repositioned laterally on the right side of the abdomen over the liver to obtain a suitable image. The maximal IVC diameter during the respiratory cycle was recorded.

If the IVC was nonplethoric (<2 cm), the patient was classified as mVExUS 0. If the IVC was plethoric (diameter ≥2 cm), further Doppler evaluations of the hepatic vein and portal vein were performed, preferably from the mid- to posterior axillary line. Electrocardiogram (ECG) monitoring was used concurrently to aid in waveform interpretation, and all images were analyzed offline.

Hepatic vein Doppler was obtained using pulsed-wave (PW) Doppler to identify A, S, and D waves. The patterns were classified as follows [11]: Normal: S >D; Mild abnormality: S <D; Severe abnormality: reversed S wave. Portal vein Doppler was also assessed using PW Doppler. Peak (V_max) and nadir (V_min) velocities during the cardiac cycle were recorded, and the pulsatility fraction was calculated using the formula: Pulsatility fraction = (V_max – V_min) / V_max. Interpretation followed the criteria proposed by Beaubien-Souligny et al. [11]: Normal: <0.3; Mild abnormality: 0.3 to <0.5; Severe abnormality: ≥0.5.

We did not include the intrarenal vein Doppler (IRVD) in our mVExUS protocol. This decision was intentional as we aimed to simplify the examination for routine bedside application in critically ill patients. Previous studies have shown that the exclusion of IRVD does not substantially compromise the score’s ability to detect clinically significant systemic congestion [16 –18].

mVExUS was applied, based on the VexUS; a scheme originally described by Beaubien-Souligny et al. and used by Bhardwaj et al. [11,16,18]. This simplified classification excludes the IRVD component and defines mVExUS 0 as IVC <2 cm; mVExUS 1 as IVC ≥2 cm with normal Doppler waveforms; mVExUS 2 as IVC ≥2 cm with at least one mild Doppler abnormality (in the hepatic or portal vein); and mVExUS 3 as IVC ≥2 cm with at least one severe Doppler abnormality. The decision to adopt this simplified protocol was made to facilitate bedside assessment and align with prior studies using similar approaches.

Lung POCUS was performed using the same curved-array probe. A comprehensive scan was performed in eight zones—four for each hemithorax (superior and inferior regions in both the anterior and lateral areas) using the anterior axillary line as the landmark. A scoring system based on aeration patterns was applied as follows: A-lines (0 points), separated B-lines (1 point), coalescent B-lines (2 points), and lung consolidation (3 points) [10]. The total lung POCUS score ranged from 0 (normal aeration) to 24 (most severe aeration loss) [19,20].

The SBT was performed using either a T-piece connected to an oxygen source or low-level pressure support (8 cm H₂O) with positive end-expiratory pressure (PEEP) ≤5 cm H₂O and FiO₂ ≤40%. SBT failure was defined by the occurrence of any of the following criteria: agitation; decreased level of consciousness (Glasgow Coma Scale <13); respiratory rate >35 breaths/min or use of accessory muscles; oxygen saturation <90%; heart rate >140 beats/min or a >20% increase from baseline; systolic blood pressure <90 mmHg; or onset of arrhythmias. Patients who failed the SBT were reconnected to MV. Those who successfully completed the SBT were extubated at the discretion of the attending physician, independent of the investigators. Prophylactic non-invasive ventilation (NIV) was defined as its immediate initiation following extubation, maintained for 4 hours, and used preemptively to reduce respiratory distress.

The primary outcome was ventilation weaning failure, defined as either SBT failure or the need for MV (invasive or non-invasive) within 72 hours following extubation. The secondary outcome was post-extubation respiratory failure, defined by the presence of at least two of the following criteria: respiratory acidosis; oxygen saturation <90% with FiO₂ ≥50%; respiratory rate >35 breaths/min for two consecutive hours; or clinical signs of respiratory fatigue.

Statistical analysis

Categorical variables were presented as absolute and relative frequencies, while continuous variables were summarized using means and standard deviations or medians and interquartile ranges, as appropriate. The distribution of continuous variables was assessed using the Kolmogorov-Smirnov test. Comparisons of continuous variables were performed using either Student’s t-test or the Mann-Whitney U test, depending on the distribution. Categorical variables were compared using the χ² test when the expected frequency in each cell was ≥5, and Fisher’s exact test was used when this assumption was not met. There were no missing data for any of the variables included in the analysis.

A multivariate binary logistic regression model was constructed to identify variables independently associated with the primary and secondary outcomes, both of which were binary. The mVExUS score was retained as a variable of interest in the multivariable analysis. Additional covariates were defined a priori based on their plausible association with the primary outcome: SAPS 3, duration of MV, lung POCUS score, and cumulative fluid balance prior to the SBT. Linearity of continuous variables with the logit was tested using the Box-Tidwell procedure, and multicollinearity was assessed using variance inflation factors.

Based on the study by Ferré et al., a ventilator weaning failure rate of 45% was assumed for the congestive group [9]. For the non-congestive group, we estimated a failure rate of 15%, reflecting clinical expectations in less congested patients. Assuming a 2:1 ratio between non-congestive and congestive patients, with a two-sided alpha of 0.05 and 80% power, the required sample size was estimated at 55 patients without congestion and 28 with congestion, totaling 83 patients. After adding 20% to account for potential losses or missing data, the final required sample size was approximately 100 patients. Although this calculation provided a minimum target, all eligible patients assessed during the predefined study period were enrolled whenever the investigator was available.

The mVExUS grade was categorized into two groups: 0–1 (no or mild congestion) and 2–3 (moderate or severe congestion). Similarly, the lung POCUS score was dichotomized. The optimal cutoff point for the lung POCUS score in predicting the primary outcome was determined using the Youden index. Statistical significance was set at p <0.05, and all analyses were conducted using SPSS software, version 20.0.

Results

During the study period, 116 patients underwent a SBT. Five were excluded due to inadequate image quality for score determination, resulting in a final cohort of 111 patients. Their clinical characteristics are presented in Table 1. Among them, 57 patients (51.4%) experienced ventilator weaning failure. Specifically, 18 patients (16.2%) failed the SBT, while 93 completed the SBT and were subsequently extubated. Of note, one patient who initially failed the SBT was later extubated by the attending physician during the following shift. Among the 94 extubated patients, 28 (29.8%) required NIV due to respiratory dysfunction, and 19 (20.2%) required reintubation within 72 hours. Some of the reintubated patients initially received NIV before progressing to invasive support.

The distribution of mVExUS scores was as follows: 33 patients (29.7%) were classified as mVExUS 0; 42 (37.8%) as mVExUS 1; 28 (25.2%) as mVExUS 2, and 8 (7.2%) as mVExUS 3. Patient characteristics stratified by VExUS score are detailed in Table 2.

Primary outcome

The incidence of weaning failure was higher among patients with mVExUS scores of 2–3 (63.9%) compared to those with scores of 0–1 (45.3%), although the difference did not reach statistical significance (p = 0.067). For individual components of the primary outcome, the mVExUS 2–3 group had an SBT failure rate of 16.7%, NIV use of 40.0%, and extubation failure rate of 23.3%, compared to 16.0%, 25.0%, and 18.8%, respectively, in the mVExUS 0–1 group (p-values: 0.929, 0.138, and 0.606, respectively).

In a multivariable analysis adjusted for SAPS 3 score, the duration of MV, cumulative fluid balance prior to SBT, lung POCUS score, and mVExUS scores of 2–3 were independently associated with ventilator weaning failure (Table 3). Model assumptions were adequately met. All tolerance values were above 0.923 and variance inflation factors were below 1.083, indicating low multicolinearity. Interaction terms between each continuous predictor and its natural logarithm were non-significant (SAPS 3, p = 0.914; duration of MV, p = 0.629; cumulative fluid balance prior to the SBT, p = 0.710).

Secondary outcome

Patients with mVExUS scores of 2–3 had a significantly higher incidence of post-extubation respiratory failure compared to those with scores of 0–1 (70.0% vs. 43.8%; p = 0.018). This association remained significant in an adjusted analysis, controlling for SAPS 3, duration of MV, cumulative fluid balance, and lung POCUS score (Table 3).

Additionally, we performed an exploratory analysis using a composite outcome that included either weaning failure or post-extubation respiratory failure. mVExUS remained significantly associated with this composite outcome after adjustment (Supplementary Material S1).

Lung POCUS score

A lung POCUS score ≥7.0 was significantly associated with both primary and secondary outcomes in both unadjusted and adjusted analyses (Table 3). Patients with lung POCUS scores ≥7.0 had a weaning failure rate of 68.8%, compared to 40.7% among those with scores <7.0 (p = 0.004). Among patients with lung POCUS scores ≥7.0, 22.9% experienced SBT failure, 50.0% required NIV, and 23.7% had extubation failure, compared to 11.9%, 17.3%, and 19.2%, respectively, in those with scores <7.0 (p = 0.128, 0.001, and 0.609).

For the secondary outcome, the incidence of post-extubation respiratory failure was significantly higher in patients with lung POCUS scores ≥7.0 (71.1%) compared to those with scores <7.0 (38.5%; p = 0.002).

Combined mVExUS and lung POCUS scores

In a post hoc exploratory analysis, the combination of mVExUS and lung POCUS scores was significantly associated with ventilator weaning failure (Figure 1). Patients with both mVExUS scores of 2–3 and lung POCUS scores ≥7.0 had a high incidence of weaning failure (76.5%), with an odds ratio (OR) of 8.3 (95% confidence interval [CI]: 2.114–32.739; p = 0.002). In contrast, patients with mVExUS scores of 0–1 and lung POCUS scores <7.0 had a substantially lower incidence of weaning failure (34.1%).

Discussion

We identified a significant association between mVExUS scores of 2–3 and an increased incidence of both weaning failure and post-extubation respiratory failure. Additionally, our exploratory analysis suggests that combining mVExUS and lung POCUS scores may enhance the evaluation of weaning readiness in critically ill patients.

An inadequate cardiovascular response is a key contributor to weaning failure [3–5]. The transition from MV to spontaneous breathing induces a sudden increase in venous return and left ventricular afterload. This hemodynamic shift can overwhelm patients with subclinical or residual congestion, precipitating WIPO [5,21]. In critically ill populations, occult cardiac dysfunction is common and may compromise compensatory cardiovascular mechanisms [20]. Therefore, identifying patients with clinically relevant systemic congestion remains a priority—albeit a challenging one—in optimizing weaning strategies.

The VExUS score has emerged as a practical and non-invasive bedside tool for assessing systemic venous congestion [11]. It has shown correlations with cardiac filling pressures and associations with the development of acute kidney injury [16,23,24]. Additionally, VExUS has been used to guide decongestion strategies in patients with renal dysfunction [18,25]. Of particular relevance, Longino et al. demonstrated a correlation between VExUS scores and pulmonary capillary wedge pressure, indicating the score’s ability to detect elevated left atrial pressure even before overt venous congestion is evident [23]. These findings support our observation that the mVExUS score was independently associated with weaning failure, regardless of lung POCUS findings.

The rationale for combining VExUS and lung POCUS lies in achieving a more comprehensive evaluation of the hemodynamic spectrum of congestion. While VExUS is specifically designed to assess venous congestion, it does not capture interstitial or pulmonary congestion [25]. Conversely, lung POCUS effectively detects pulmonary congestion and has been previously associated with weaning failure [10]. By integrating both tools, clinicians may identify a broader range of congestion phenotypes, potentially improving risk stratification during the weaning process. In our study, we chose to use a lung POCUS score that is well established in the prediction of ventilator weaning failure, rather than limiting the analysis to findings specifically associated with cardiogenic pulmonary edema. This approach allowed us to investigate whether the identification of systemic venous congestion through mVExUS could provide additional prognostic information beyond the pulmonary findings already captured by lung POCUS, even if these are not exclusively attributable to cardiovascular dysfunction.

If validated in future studies, the combined use of VExUS and lung POCUS scores could enhance the early identification of patients at high risk for weaning failure due to cardiovascular dysfunction. This, in turn, could inform tailored management strategies such as judicious use of diuretics, control of hypertension, vasodilator therapy, or the prophylactic application of NIV in the post-extubation period [22]. Similar to the role of B-type natriuretic peptide and echocardiography-guided therapy, the VExUS score may become a useful adjunct in guiding decongestive management during weaning [26,27].

This study had several limitations. First, it was conducted at a single center with a relatively small sample size, which may affect the generalizability of the results. Second, invasive hemodynamic monitoring was not included to confirm the cardiac origin of respiratory failure. Third, a modified version of the VExUS score was applied, which excluded the IRVD component. Although this version is less extensively validated than the original VExUS C score, it has been used in previous studies and has demonstrated good performance in identifying clinically significant venous congestion [16–18]. However, the absence of IRVD may have led to underestimation of congestion in patients with isolated intrarenal abnormalities, while the use of the VExUS A classification—where mild abnormalities are categorized as moderate congestion—may have overestimated severity in others. These classification differences may affect internal validity and limit the comparability of our results with studies using the full VExUS C protocol. Fourth, the cutoff point for the lung POCUS score was derived using Youden’s index based on the study dataset, which may overestimate the model’s discriminative performance. Although this threshold is consistente with prior literature, such data-driven cutoffs should be interpreted with caution. Fifth, the ventilator weaning failure rate observed in our cohort (51.7%) was relatively high. This may limit the generalizability of our findings to less severely ill populations. However, our definition of weaning failure included SBT failure, reintubation, and the need for NIV within 72 hours, whereas some previous studies used narrower definitions. Moreover, the high severity of illness in our population may have contributed to the elevated failure rate. Finally, the study may be subject to selection bias, as inclusion depended on the availability of a single investigator to perform ultrasound assessment. In addition, despite multivariable adjustment, residual confounding cannot be excluded due to the observational nature of the study. In particular, we did not account for potentially relevant confounders such as detailed comorbidities or treatment strategies, which could influence both venous congestion, lung aeration, and weaning outcomes. This omission should be considered when interpreting our results.

Conclusions

We observed a significant association between higher mVExUS scores (2–3) and increased incidence of ventilator weaning failure, independent of the lung POCUS score. These findings underscore the importance of evaluating systemic congestion during the weaning process. Furthermore, our exploratory analysis supports the potential utility of combining mVExUS and lung POCUS scores to improve the assessment of weaning readiness. Future research should explore the synergistic application of these tools to optimize patient outcomes during the critical transition from MV.

Ethics Statement

The study was approved by the institutional Review Board of Hospital Nossa Senhora da Conceicao, in accordance with the ethical standards of the committee and with the Helsinki Declaration of 1975. Written informed consent was obtained from each patient or their legal representative prior to inclusion.

Disclosure Statement

The authors have no relevant financial or non-financial interests to disclose.

Funding

The authors declare that no funds, grants, or other support were received during the preparation of this manuscript.

Author contributions

THMM: conceptualization, methodology , data curation , writing – original draft, writing – review & editing. WLN: conceptualization, methodology and writing – review & editing. MMB: conceptualization, data curation, writing – original draft, writing – review & editing.

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7. Shi R, Ayed S, Beuzelin M, Persichini R, Legouge M, Vita NDE, Levy B, Beurton A, Mangal K, Hullin T, Labbe V, Guillot M, Harrois A, Cecconi M, Anguel N, Osman D, Moretto F, Lai C, Pham T, Teboul JL, Monnet X. Incidence and risk factors of weaning-induced pulmonary oedema: results from a multicentre, observational study. Crit Care 2025;29:140.

8. Song J, Luo Q, Lai X, Hu W, Yu Y, Wang M, Yang K, Chen G, Chen W, Li Q, Hu C, Gong S. Combined cardiac, lung, and diaphragm ultrasound for predicting weaning failure during spontaneous breathing trial. Ann Intensive Care 2024;14:60

9. Ferré A, Guillot M, Lichtenstein D, Mezière G, Richard C, Teboul JL, Monnet X. Lung ultrasound allows the diagnosis of weaning-induced pulmonary oedema. Intensive Care Med 2019;45:601–8.

10. Soummer A, Perbet S, Brisson H, Arbelot C, Constantin J-M, Lu Q, Rouby JJ; Lung Ultrasound Study Group. Ultrasound assessment of lung aeration loss during a successful weaning trial predicts postextubation distress*. Crit Care Med 2012;40:2064–72.

11. Beaubien-Souligny W, Rola P, Haycock K, Bouchard J, Lamarche Y, Spiegel R, Denault AY. Quantifying systemic congestion with Point-Of-Care ultrasound: development of the venous excess ultrasound grading system. Ultrasound J 2020;12:16.

12. Argaiz ER, Rola P, Gamba G. Dynamic Changes in Portal Vein Flow during Decongestion in Patients with Heart Failure and Cardio-Renal Syndrome: A POCUS Case Series. Cardiorenal Med 2021;11:59–66.

13. Guinot PG, Bahr PA, Andrei S, Popescu BA, Caruso V, Mertes PM, Berthoud V, Nguyen M, Bouhemad B. Doppler study of portal vein and renal venous velocity predict the appropriate fluid response to diuretic in ICU: a prospective observational echocardiographic evaluation. Crit Care 2022;26:305

14. Dres M, Teboul J-L, Anguel N, Guerin L, Richard C, Monnet X. Passive leg raising performed before a spontaneous breathing trial predicts weaning-induced cardiac dysfunction. Intensive Care Med 2015;41:487–94.

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16. Bhardwaj V, Vikneswaran G, Rola P, Raju S, Bhat RS, Jayakumar A, Alva A. Combination of Inferior Vena Cava Diameter, Hepatic Venous Flow, and Portal Vein Pulsatility Index: Venous Excess Ultrasound Score (VEXUS Score) in Predicting Acute Kidney Injury in Patients with Cardiorenal Syndrome: A Prospective Cohort Study. Indian J Crit Care Med 2020;24:783–9.

17. Martin KC, Gill EA, Douglas IJ, Longino AA. Evaluation of a modified venous excess ultrasound (VExUS) protocol for estimation of venous congestion: a cohort study. Ultrasound J 2025;17:7. 18. Rihl MF, Pellegrini JAS, Boniatti MM. VExUS Score in the Management of Patients With Acute Kidney Injury in the Intensive Care Unit: AKIVEX Study. J Ultrasound Med 2023;42:2547–56.

18. Rihl MF, Pellegrini JAS, Boniatti MM. VExUS Score in the Management of Patients With Acute Kidney Injury in the Intensive Care Unit: AKIVEX Study. J Ultrasound Med 2023;42:2547–56.

19. Lichtenstein DA, Mezière GA. Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. Chest 2008;134:117–25.

20. Bouhemad B, Mojoli F, Nowobilski N, Hussain A, Rouquette I, Guinot PG, Mongodi S. Use of combined cardiac and lung ultrasound to predict weaning failure in elderly, high-risk cardiac patients: a pilot study. Intensive Care Med 2020;46:475–84.

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26. Dessap AM, Roche-Campo F, Kouatchet A, Tomicic V, Beduneau G, Sonneville R, Cabello B, Jaber S, Azoulay E, Castanares-Zapatero D, Devaquet J, Lellouche F, Katsahian S, Brochard L. Natriuretic peptide–driven fluid management during ventilator weaning. Am J Respir Crit Care Med 2012;186:1256–63.

27. Goudelin M, Champy P, Amiel J-B, Evrard B, Fedou A-L, Daix T, François B, Vignon P. Left ventricular overloading identified by critical care echocardiography is key in weaning-induced pulmonary edema. Intensive Care Med 2020;46:1371–81.

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The Prevalence of Systemic Venous Congestion Post Kidney Transplant Detected by Point of Care Ultrasound (POCUS) Venous Excess Ultrasound (VExUS) Grading to Assess Perioperative Fluid Status for Noncardiac Surgeries: a Prospective Observational Pilot Study Subclinical Congestion Evaluated by Point of Care Ultrasound (POCUS) at Discharge Predicts Readmission in Patients with Acute Heart Failure: Prognostic Cohort Study

Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA

*Corresponding Author: Dr. William Hui (email: whui@stanford.edu)

Download article PDF – POCUS Journal 2026;11(1):45-49

DOI: https://doi.org/10.24908/pocusj.v11i01.20246

Abstract

Background: Lower extremity deep vein thrombosis (DVT) requires prompt diagnosis to prevent pulmonary embolism (PE). DVT point of care ultrasound (POCUS) is shown to be effective in emergency department (ED) settings, though few studies have demonstrated impact in primary care settings. This quality improvement (QI) project aimed to establish a primary care DVT POCUS pathway to reduce ED visits. Methods: From June 2024 to August 2025, a POCUS fellowship-trained physician at an academic family medicine clinic received referrals from other primary care clinicians for suspected DVTs and performed POCUS evaluations and DVT management. Patient outcomes and clinician feedback were collected via chart review and surveys to assess the project’s feasibility and acceptability. Results: Eighty patients were evaluated, with a positive DVT rate of 5% (4/80). The pathway potentially avoided ED visits for 46% of patients (37/80), translating to an estimated cost savings of $85,100. With a 98% (43/44) response rate, most referring clinicians strongly agreed that the DVT pathway improved patient safety and access, reduced their cognitive burden, and reduced ED referrals. Conclusions: The DVT POCUS pathway effectively managed patients with suspected DVT in the primary care setting, demonstrating feasibility and acceptability with clinicians, as well as potential cost savings. This model warrants further research as a framework for integrating DVT POCUS into primary care, enhancing diagnostic capabilities and patient care, while alleviating pressures on EDs.

Introduction

Deep vein thrombosis (DVT) has an annual incidence of 5 per 10,000 people and requires prompt diagnosis to prevent pulmonary embolism (PE), a complication that develops in up to 50% of untreated cases with a mortality rate up to 30% [1,2]. Venous thromboembolism (VTE) costs the United States healthcare system an estimated $5-10 billion annually [3,4].

DVT point of care ultrasound (POCUS) has been effectively utilized in the emergency department (ED) and hospital settings, particularly after hours when radiology services are unavailable, leading to faster patient disposition and reduced time to diagnosis [5–7]. Incorporating DVT POCUS into clinical protocols can result in a 27% reduction in imaging and 67% reduction in D-dimer testing [5]. The proximal DVT POCUS examination demonstrates 90% sensitivity and 97–99% specificity [8–11]. Combining POCUS with risk stratification allows clinicians to diagnose over 80% of DVTs independently [12].

Although DVT POCUS can be effective in ED settings, there are few studies demonstrating its impact in primary care. At our institution from September 2024 to August 2025, urgent outpatient radiology ultrasound had a mean wait time of 2.2 days, extending to 3.7 days for Thursday and Friday orders. In our ED during the same time period, 85 low acuity ED visits were made for urgent DVT ultrasound, resulting in 6 positive DVT and 1 positive PE, and were subsequently discharged home. This project was initiated after an internal chart review revealed low-risk DVT assessments in the ED, likely due to limited outpatient radiology availability during weekday hours. Value-based care is a healthcare delivery model that reimburses providers based on patient health outcomes, quality of care, and efficiency, rather than volume of services rendered. As part of our institution’s value-based care initiative, we aimed to establish a DVT POCUS pathway in primary care with the hypothesis that it could provide timely diagnostics, be feasible to use by referring clinicians, and decrease DVT-related ED visits and costs.

Methods

Pilot Intervention

This QI project was conducted at a single family medicine clinic within a large academic medical center in Palo Alto, California, USA, from June 2024 to August 2025. The pathway employed an ultrasound-fellowship trained physician for urgent DVT evaluations seen within 2 days on average (Figure 1). Primary care clinicians referred patients via staff messaging to the ultrasound-fellowship-trained physician. This physician managed scheduling and conducted evaluation, POCUS, and management in the same visit. The pilot was advertised through meetings and emails.

POCUS examination: Scans were performed using a Sonosite Xporte (Fujifilm Sonosite, Bothell, WA, USA) with curvilinear and/or linear probes. The 2-zone POCUS DVT compression ultrasound was utilized [13]. First, the patient was positioned supine with the affected leg externally rotated, in the frog-leg position. The common femoral vein (CFV) and femoral vein (FV) were evaluated from the inguinal ligament to the distal thigh, including the junctions of the great saphenous vein (GSV)-CFV, and the FV and deep femoral vein (DFV). Then, the patient was positioned in the lateral decubitus or standing position to evaluate the popliteal vein and its trifurcation. The compression ultrasound was complete if there was adequate compression of the vein at every 1 cm. Indeterminate studies prompted a full leg radiology ultrasound evaluation.

Patient selection

Patients were referred to the DVT POCUS pathway by primary care clinicians. Inclusion criteria were unilateral leg pain and swelling. Exclusion criteria included recurrent DVT and signs suggestive of a PE.

Diagnostic algorithm

Using Wells’ criteria, patients were categorized into low (<2) or intermediate/high (≥2) pre-test probability. A D-dimer test was used at the clinician’s discretion. DVT was excluded in low risk with a negative POCUS. In moderate/high risk, a negative POCUS was followed by a repeat radiology ultrasound in one week to rule out proximal extension of a distal DVT [9,14–16]. Patients with positive DVT POCUS received immediate treatment, with a non-urgent radiology ultrasound ordered [17] (Figure 1).

Data collection

Data were collected prospectively, including date of exam request and visit, history, Wells’ criteria, radiology, lab results, presumed diagnosis, and treatment. Follow-up data were collected at 3 months to check for VTE diagnoses after a negative DVT POCUS scan. A 5-point Likert scale survey was sent to all referring clinicians to assess attitudes towards the new pathway.

Results

Patient Outcomes

Eighty patients (Table 1) were evaluated in the POCUS DVT pathway. They had a mean wait time of 2.1 days, comparable to our institution’s average of 2.2 days for urgent radiology DVT studies. Two patients were diagnosed with a positive proximal DVT.

Additionally, two patients were found to have a DVT on follow-up imaging within 1 week. The first patient had a proximal DVT identified as a distal popliteal DVT extending from the calf veins at 1 week after the initial visit. This suggested that a DVT may have extended from a distal to a proximal DVT within the 2 days between the POCUS and radiology scan, or suggested that it was a falsely negative POCUS proximal DVT scan. The second patient had a distal DVT identified on follow-up 1 week after the initial visit, which resolved without treatment.

After the initial evaluation, two additional patients had VTE diagnosed within 3 months. One patient with active cancer developed a proximal DVT that was likely due to their ongoing clotting risk factors. The second patient had a distal DVT detected on radiology ultrasound due to persistent leg symptoms (Figure 2).

Estimated Financial Impact

From the study, 46% (37/80) of cases were potentially avoidable ED visits (defined as requesting an exam on Thursday/Friday). This saved an average ED level 4 or 5 cost of $2,300 per patient, or a total of $85,100, along with the indirect cost savings of freeing up an ED slot for a higher level of care.

The outpatient POCUS pathway costs approximately $239.69 per case (Using the CMS Medicare Physician fee schedule for 2025: $114.51 (93971 limited DVT POCUS) + $125.18 (99214 office visit)).

Referring Provider Perspectives

A survey was sent to all 44 referring clinicians, with a response rate of 98% (43/44). Most providers indicated that the POCUS DVT clinic improved patient safety and access, reduced cognitive burden, and avoided unnecessary ED referrals (Figure 3).

Discussion

To our knowledge, this is the first QI study demonstrating the impact of a referral-based DVT POCUS pathway in outpatient primary care. The pathway effectively managed patients with suspected DVT, demonstrating feasibility and acceptability with clinicians and potential cost savings.

The establishment of the DVT POCUS pathway had slow initial uptake, but through advertising and collaborations with registered nurses, the service has spread organically, reaching a rate of about one referral per week. Yearly advertisement is planned to sustain this project. There may be additional opportunities to scale to the broader ambulatory setting, including subspecialty care. However, despite its utility, clinician referrals remain low, possibly due to insufficient provider education on the benefits and limitations of POCUS. DVT assessment is high-stakes, and clinicians may be hesitant to refer for a limited POCUS study over traditional methods. In addition, the average wait time for the POCUS pathway and our institution’s urgent radiology DVT orders were similar at about 2 days. The POCUS pathway wait time is related to the availability of clinic slot scheduling. It is worth pointing out that the POCUS pathway is particularly useful towards the end of the week, as wait times  for radiology ultrasound lengthen to 3.7 days on Thursday and Friday, as no available outpatient radiology services are available over the weekend. It is helpful to have an adjunct POCUS service to help offload radiology pressures and ED visits.

Limitations

This project was conducted by a single US-fellowship-trained family physician, limiting generalizability. Referrals are manually scheduled, which can be time intensive. Future steps include involving the medical assistant scheduling team and exploring integration into an automatic electronic medical record referral.

Additionally, the chart review utilized the academic institution’s electronic medical record (Epic Systems, Verona, Wisconsin, USA). Therefore, VTE cases occurring outside of this system may have been missed in the retrospective review.

In this study, a DVT prevalence of 5% (4/80) was seen, as compared to the 19% prevalence rate for outpatient DVTs [18]. This may suggest an inadequate sample size. However, the majority of the patients were low risk, which matches the prevalence rate for low pretest probability of 3.5-8.1% [9].

Conclusions

Utilizing POCUS in the primary care setting effectively triages patients with suspected DVT, serving as an adjunct to traditional radiology services.

Though POCUS is usually an examination done at the time of initial visit, our pilot demonstrated that a referral-based DVT POCUS pathway was safe and effective, deemed feasible and acceptable by clinicians, and generated potential cost savings. This model warrants further research as a framework for integrating DVT POCUS into primary care, enhancing diagnostic capabilities and patient care, while alleviating pressures on EDs.

Acknowledgements

The authors thank the Stanford Value-Based Care team. Special thanks to Amy Bui and Valentyn Golovko for providing cost estimates and data on radiology appointments and low acuity ED visits occurring for urgent imaging. The authors also thank Dr. Sang-ick Chang for supporting the development of the POCUS program.

Ethics Statement

Stanford University’s Institutional Review Board (IRB) determined that this project does not meet the definition of human subjects research (Protocol #85891).

Disclosure Statement

The authors have no competing interests to disclose .

Funding

The authors received no financial support for the study.

Author Contributions

WH: conceptualization; investigation; methodology; project administration; visualization; writing – original draft; writing – review & editing. SL: conceptualization; methodology; project administration; visualization; writing – review & editing. JS: methodology; project administration; visualization; writing – review & editing.

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(1) School of Medicine, University of Louisville, Louisville, KY, USA

(2) Department of Emergency Medicine, School of Medicine, University of Louisville, Louisville, KY, USA

*Corresponding Author: Dr. Kahra Nix (email: Kahra.nix@louisville.edu)

Download article PDF – POCUS Journal 2026;11(1):50-53

DOI: https://doi.org/10.24908/pocusj.v11i01.20821

Supplementary Materials: S1, S2, S3, S4, S5, S6

This article is a corrigendum to: Klee O, Buechler J, Fears M, Gosser C, Nix K. A Point of Care Ultrasound (POCUS) Artifact Mimicking an Aortic Dissection: A Case Series. POCUS J. 2025 Apr 15;10(1):88-91. doi: https://doi.org/10.24908/pocusj.v10i01.18498.

In the original article, the authors highlighted a key POCUS mimic of abdominal aortic dissection in a series of young patients who were later referred for diagnostic radiology imaging and found to have normal aortas. This was attributed to artifact in the case series, however, it was later determined that this “pseudo-dissection” finding on POCUS is a result of how the echogenic line of a normal diaphragmatic crus tricks the POCUS user into interpreting the normal aortic wall as a possible dissection flap. This corrigendum provides a corrected interpretation of the original findings.

Abstract

Point-of-care ultrasound is often taught to learners at the bedside using standardized patients. Just as in clinical practice, there is the potential for coming across incidental findings or even pathology mimics. We describe a series of four cases where normal anatomy mimicked an abdominal aortic dissection. We clarify normal anatomy and probe maneuvers to prevent from mistaking this from pathology.

Introduction

Point of care ultrasound (POCUS) is evaluated along with other knowledge, skills, attitudes, and attributes in the Emergency Medicine Milestones, as defined by the American College of Graduate Medical Education [1]. In a policy statement, the American College of Emergency Physicians acknowledged POCUS as a fundamental part of Emergency Medicine (EM) training [2]. In order to achieve these goals, EM residents have discrete and longitudinal POCUS training. Often, medical students are included in bedside teaching both in the operator role and as standardized patients. When acting as a standardized patient, verbal consent is obtained. The potential for incidental findings is acknowledged as a possibility with a clear plan for next steps [3]. In this case series, we describe normal anatomy that mimics a dissection involving the abdominal aorta that was found on a young, healthy, thin female medical student who was acting as a standardized patient. This same abdominal aortic dissection mimic was subsequently seen on three additional young, healthy, thin, female medical students.

Methods

Each of the standardized patients in this case series provided written, informed consent for the POCUS images to be obtained after a full explanation was provided. The abdominal aortas from four standardized patients were evaluated using a Sonosite curvilinear (5-1 MHz) (Sonosite, Bothwell, WA, USA) or a Mindray curvilinear (C6-1s) transducer (Mindray, Mahwah, NJ, USA) by placing the probe in the sagittal and transverse planes along the abdominal aorta. Clips and stills of both the sagittal and transverse views of the abdominal aorta were recorded. Additional clips with color Doppler were obtained on the initial standardized patient and one other. This case series was completed after the University of Louisville Institutional Review Board determined it was exempt. Each standardized patient consented to this case series.

Case Presentation and Results

Case 1

A POCUS examination of the abdominal aorta was performed on a 22-year-old medical student acting as a standardized patient. Grayscale sagittal-plane images on POCUS showed the abdominal aorta but did not clearly distinguish which of two neighboring structures represented the true aortic wall (Figure 1, Supplementary Material S1). The transverse view showed expected anatomy with no overt pathology.

Case 2

A POCUS examination of the abdominal aorta was performed on a 25-year-old medical student acting as a standardized patient. Grayscale sagittal-plane images on POCUS showed the abdominal aorta but did not distinguish which of two neighboring structures represented the true aortic wall (Figure 2, Supplementary Material S2). The transverse view showed expected anatomy with no overt pathology.

Case 3

A POCUS examination of the abdominal aorta was performed on a 27-year-old medical student acting as a standardized patient. Grayscale sagittal-plane images on POCUS showed the abdominal aorta but did not distinguish which of two neighboring structures represented the true aortic wall (Figure 3, Supplementary Material S3). The transverse view showed expected anatomy with no overt pathology.

Case 4

A POCUS examination of the abdominal aorta was performed on a 25-year-old medical student acting as a standardized patient. Grayscale sagittal-plane images on POCUS showed the abdominal aorta but did not distinguish which of two neighboring structures represented the true aortic wall (Figure 4, Supplementary Material S4). The transverse view showed expected anatomy with no overt pathology.

Additional Images

Additional still images of the abdominal aorta in the sagittal plane with color Doppler were obtained from the standardized patients from Case 1 (Figure 5) and Case 3 (Figure 6), including measurements of the filled lumen along the visualized aorta. Within a margin of error, the measurements of the aorta’s anterior-posterior dimension at two locations were congruent. Lastly, additional clips surveying the abdominal aorta from proximal to distal in the transverse plane were obtained from the standardized patients in Case 1 (Supplementary Material S5) and Case 3 (Supplementary Material S6).

Discussion

POCUS mimics and artifacts are frequently encountered in both clinical and educational settings. Case 1 showed a sagittal view of the aorta that was confused for a possible and unexpected abdominal aortic dissection. This asymptomatic, healthy, standardized patient was sent for a radiology-performed ultrasound of her abdomen that confirmed her abdominal aorta as normal. Artifacts within vessels are known to occur as a result of mirroring and reverberation and can mimic both dissection and thrombus [4–7]. These resolve with rotation and/or translation of the probe. Our initial proposed etiology was that this was side-lobe artifact, which is known to occur within vessels as a result of the appearance of an echogenic structure that did not actually originate from within the vessel. As with other examples of side-lobe artifact, the linear, hyperechoic structure in these four cases disappeared when rotating the probe from the sagittal to the transverse plane (Figures 1–4).

However, there are multiple findings that point away from artifact as the explanation and toward normal anatomy that can mimic a dissection. Dissection flaps often undulate, and these did not. Also, color Doppler revealed the true wall (Figures 5 and 6) as there was continuous, uniform flow that filled the vessel lumen. A true dissection should exist in both planes, so the same maneuver of looking in both sagittal and transverse was essential. Furthermore, measurement of the aortic lumen, with overlying color Doppler confirming the true lumen, showed a uniform diameter (within a margin of error), as would be expected in young, healthy, asymptomatic patients (Figures 5 and 6). Most important to discerning fact from fiction, however, is understanding the normal anatomy neighbouring the abdominal aorta. The paired diaphragmatic crura are muscular fibers that originate on the lumbar spine and course anteriorly, creating a triangular retrocural space in which the abdominal aorta sits [8–9].  In this series of images, a trick of the “ultrasound eye” attempted to confuse the operators into thinking that the diaphragmatic crus that sits anterior to the abdominal aorta was a dissection flap inside of the vessel lumen (Figures 1–4, white star) instead of normal anatomy neighboring the abdominal aorta.

Conclusion

POCUS users must be aware of the potential for both artifacts and normal anatomy that that mimic pathology. They must have enough understanding of both normal anatomy and probe maneuvers to distinguish pathology from artifact or mimic. Diaphragmatic crura can mimic an aortic dissection by confusing which structure is the true wall of the aorta. Both color Doppler and scanning the aorta in multiple planes can provide clarity to this confusion.

Ethics Statement

The University of Louisville Institutional Review Board determined this case series to be exempt. All standardized patients gave their informed consent for images to be obtained and to be part of this case series. The material is the authors’ own original work in collaboration with the journal editors.

Disclosure Statement

There are no conflicts of interest for any author listed.

Funding

There are no grants or other sources of funding to be acknowledged.

Author Contributions

OK: investigation, data curation, formal analysis, visualization, writing – original draft, writing – review & editing. MF: investigation, data curation, formal analysis, visualization, writing – original draft, writing – review & editing. CG: investigation, data curation, formal analysis, visualization, writing – original draft, writing – review & editing. JB: investigation, data curation, formal analysis, visualization, writing – original draft, writing – review & editing. KN: conceptualization, investigation, data curation, formal analysis, visualization, writing – original draft, writing – review & editing.

References

1. Accreditation Council for Graduate Medical Education. Emergency medicine milestones. Published 2021. Accessed April 18, 2024. https://www.acgme.org/globalassets/pdfs/milestones/emergencymedicinemilestones.pdf

2. American College of Emergency Physicians Emergency Ultrasound Section Writing Committee. Ultrasound guidelines: emergency, point-of-care and clinical ultrasound guidelines in medicine. Ann Emerg Med. 2017;69(5):e27-e54.

3. Dietrich CF, Fraser AG, Dong Y, Guth S, Hari R, Hoffmann B, Prosch H, Walter R, Abramowicz JS, Nolsøe CP, Blaivas M. Managing incidental findings reported by medical, sonography and other students performing educational ultrasound examinations. Ultrasound Med Biol. 2022;48(2):180-187. doi:10.1016/j.ultrasmedbio.2021.09.015

4. Crotty JM, Timken MJ. Pseudodissection of the abdominal aorta on color Doppler imaging. J Ultrasound Med. 1995;14(11):853-857.

5. Rosenberry C, Ball V. False positive aortic dissection on abdominal ultrasound. West J Emerg Med. 2010;11(1):110-111.

6. Mann GS, Robinson AJ, LeBlanc JG, Heran MKS. Abdominal aortic pseudomass in a child. J Ultrasound Med. 2008;27(2):307-310.

7. Toepfer NJ, Racadio JM, Adams JM, Babcock DS, Holland CK. Aortic pseudothrombus. J Diagn Med Sonogr. 2006;22(2):131-134.

8. Block B. Stomach, duodenum, and diaphragm. In: Telger TC, ed. Abdominal Ultrasound: Step by Step. 3rd ed. Thieme; 2015:178-192. doi:10.1055/b-004-140255

9. Block B. Vessels. In: Telger TC, Leube K, eds. Color Atlas of Ultrasound Anatomy. 3rd ed. Thieme; 2022:16-71.

Related posts:

A Point of Care Ultrasound (POCUS) Artifact Mimicking an Aortic Dissection: A Case Series Two cases of aortic emergency presenting with neurologic manifestations, aided by POCUS Acute Type A Aortic Dissection Diagnosed by POCUS in a 29-year-old Man

(1) Division of Critical Care Medicine, Montefiore Medical Center, New York, NY, USA

(2) Division of Nephrology, Medical College of Wisconsin, Milwaukee, WI, USA

*Corresponding Author:  Dr. Abhilash Koratala (email: akoratala@mcw.edu)

Download article PDF – POCUS Journal 2026;11(1):54-61

DOI: https://doi.org/10.24908/pocusj.v11i01.19348

Abstract

Persistent congestion in decompensated heart failure predicts poor outcomes. The Venous Excess Ultrasound (VExUS) score, which integrates hepatic, portal, and intrarenal Doppler waveforms, provides a dynamic, noninvasive measure of venous congestion and outperforms right atrial pressure alone. Its utility during mechanical circulatory support remains largely unexplored. We report a case of right ventricular failure requiring venoarterial extracorporeal membrane oxygenation (VA ECMO) and intra-aortic balloon pump (IABP). Despite changes in arterial waveform with IABP settings, venous Doppler signals remained stable, suggesting minimal impact on congestion. In contrast, clamping the ECMO circuit led to marked worsening of portal and intrarenal waveforms, highlighting the drainage cannula’s role in right-sided offloading. Hepatic vein Doppler remained unchanged due to severe tricuspid regurgitation (TR). This case illustrates the value of VExUS in monitoring venous congestion during advanced cardiac support and its potential in guiding decongestion strategies, weaning decisions, and right heart support. Further research is needed to validate these observations.

Introduction

Persistent congestion in decompensated heart failure predicts worse outcomes. Doppler ultrasonography provides real-time assessment of venous flow alterations indicative of congestion and has recently garnered increasing attention. The Venous Excess Ultrasound (VExUS) score, introduced in 2020 from cardiac surgery data, quantifies venous congestion using hepatic, portal, and intrarenal vein Doppler [1]. Figure 1 illustrates the grading system. Given that congestion results from the interplay of fluid overload, elevated right atrial pressure (RAP), and venous compliance, VExUS provides better predictive value for congestive organ injury compared to RAP alone [2]. These waveforms also change dynamically with treatment, making them useful for ongoing monitoring. Recent evidence suggests that the VExUS score enhances the prediction of in-hospital mortality in heart failure patients compared to conventional models [3]. In patients with severe tricuspid regurgitation (TR), hepatic vein systolic reversal may persist despite decongestion, which is considered a limitation of VExUS. Portal vein flow patterns still improve in these cases, which serve as a progress marker [4]. However, data on VExUS in mechanical circulatory support, particularly venoarterial extracorporeal membrane oxygenation (VA ECMO), is lacking. This case file highlights the effects of VA ECMO and intra-aortic balloon pump (IABP) on venous waveforms. To ensure consistency, all images were acquired by a single operator (author AK), who has performed over 500 documented VExUS studies. All images were also taken  using the same ultrasound machine (Philips 5500P).

Case Presentation

Briefly, this case describes a 50-year-old man with a history of aortic root aneurysm repair and coronary re-implantation, who developed intraoperative right ventricular dysfunction, likely due to myocardial infarction. He underwent single-vessel coronary artery bypass grafting (saphenous vein graft to the right coronary artery) with IABP placement. However, he deteriorated despite dual inotropes (dobutamine, epinephrine) and was cannulated for VA ECMO three days later. The patient also developed acute kidney injury that required continuous renal replacement therapy.

The images were obtained while the patient was receiving both IABP and VA ECMO support. The IABP was set to a 1:1 configuration. At the time, pulmonary artery catheter measurements demonstrated a central venous pressure (CVP) of 16 mmHg and pulmonary artery pressures (PAP) of 31/20 mmHg. The ECMO circuit configuration was right femoral vein drainage and left femoral artery return, with a flow rate of 3 L/min. Transthoracic echocardiography revealed severe right ventricular (RV) dysfunction and qualitatively severe TR, though imaging was limited by suboptimal acoustic windows (Supplementary Material S1). The left ventricular systolic function was mildly reduced, with regional wall motion abnormalities in the right coronary artery territory.

The inferior vena cava (IVC) appeared plethoric, measuring >2.1 cm in diameter. Supplementary Material S2 demonstrates a right upper quadrant lateral view, revealing the ECMO drainage cannula within the IVC and the intra-aortic balloon pump positioned in the abdominal aorta. Hepatic vein Doppler demonstrated systolic flow reversal, indicative of severe venous congestion (Figure 2). Although a built-in electrocardiogram was not available on the ultrasound machine to definitively identify systolic and diastolic waves, interpretation was supported by the concurrently recorded CVP waveform from the pulmonary artery catheter, which showed a prominent y descent. Additionally, impaired tricuspid annular excursion along with severe TR likely contributed to the reversal of hepatic vein systolic flow.

Portal vein Doppler exhibited mild pulsatility, with a pulsatility fraction of approximately 40%. Intrarenal venous Doppler demonstrated mildly pulsatile flow with minor flow interruptions (Figures 3 and 4).

Adjusting the IABP operational mode to 1:2 and 1:3 frequency resulted in no significant changes to the intrarenal venous flow, despite clear alterations in the arterial waveform reflecting native and augmented flow. Similarly, no appreciable changes were observed in the hepatic vein waveform (Figures 5-7).

However, clamping of the ECMO circuit led to a marked deterioration in venous congestion. Portal vein pulsatility increased to 100%, with pronounced flow interruptions (Figure 8). A similar increase in flow interruptions was observed in the intrarenal venous Doppler, consistent with worsening systemic congestion (Figure 9). Hepatic vein flow remained unchanged, likely because it was already at its most severe state (Figure 10). These  findings were accompanied by a modest increase in CVP of 3 mmHg and a rise in PAP to 34/23 mmHg, as measured by the pulmonary artery catheter. Of note,  clamping was carried ut by a trained perfusionist in the presence of a cardiac intensivist, with careful attention to safety and appropriate duration.

Discussion

While recognizing the limitations of a single case study and the operator-dependent nature of image acquisition, this case provides a few key insights that may have future research implications:

While IABP altered arterial flow dynamics, it did not appear to have a significant effect on venous congestion as assessed by Doppler ultrasound. This suggests that IABP and other LV venting strategies may have limited immediate impact on right-sided venous congestion.

The VA ECMO drainage cannula effectively offloaded the right atrium. This reduced venous congestion despite persistent RV failure, while clamping led to an instantaneous worsening of congestion. This finding may help predict the risk of congestive organ injury post-decannulation, guide the need for mechanical right heart support, and assess ECMO weanability.

The dynamic nature of venous Doppler waveforms enables real-time monitoring of treatment response, offering additive value to invasive pressure measurements, which are prone to errors from transducer positioning and zeroing. Notably, while hepatic vein Doppler may be affected by impaired RV excursion and TR—making the pursuit of a normal waveform potentially unsafe in this context—portal and intrarenal venous Doppler waveforms remain reliable indicators of systemic venous congestion. These findings open new avenues for further research in this area.

Ethics Statement

This case report was conducted in accordance with the principles of the Declaration of Helsinki. Institutional review board (IRB) approval was not required for single-patient case reports according to our institution’s policy. All identifying information has been omitted to ensure patient confidentiality.

Disclosure Statement

The authors have no conflicts of interest to disclose.

Funding

No funding was received for this work.

Author Contributions

AB: conceptualization; methodology; investigation; data curation; visualization; acquisition of POCUS images; writing – original draft. MJ: investigation; data curation; visualization; writing – review & editing. UG: investigation; writing – review & editing. AS: investigation; writing – review & editing. AAN: investigation; writing – review & editing. AC: supervision; writing – review & editing.

References

1. Beaubien-Souligny W, Rola P, Haycock K, Bouchard J, Lamarche Y, Spiegel R, Denault AY. Quantifying systemic congestion with Point-Of-Care ultrasound: development of the venous excess ultrasound grading system. Ultrasound J. 2020;12(1):16. doi: 10.1186/s13089-020-00163-w.

2. Rola P, Haycock K, Spiegel R, Beaubien-Souligny W, Denault A. VExUS: common misconceptions, clinical use and future directions. Ultrasound J. 2024;16(1):49. doi: 10.1186/s13089-024-00395-0.

3. Anastasiou V, Peteinidou E, Moysidis DV, Daios S, Gogos C, Liatsos AC, Didagelos M, Gossios T, Efthimiadis GK, Karamitsos T, Delgado V, Ziakas A, Kamperidis V. Multiorgan Congestion Assessment by Venous Excess Ultrasound Score in Acute Heart Failure. J Am Soc Echocardiogr. 2024;37(10):923-933. doi: 10.1016/j.echo.2024.05.011.

4. Alday-Ramírez SM, Leal-Villarreal MAJ, Gómez-Rodríguez C, Abu-Naeima E, Solis-Huerta F, Gamba G, Baeza-Herrera LA, Araiza-Garaygordobil D, Argaiz ER. Portal vein Doppler tracks volume status in patients with severe tricuspid regurgitation: a proof-of-concept study. Eur Heart J Acute Cardiovasc Care. 2024;13(7):570-574. doi: 10.1093/ehjacc/zuae057.

Related posts:

Venous Excess Ultrasound (VExUS) Grading to Assess Perioperative Fluid Status for Noncardiac Surgeries: a Prospective Observational Pilot Study The Prevalence of Systemic Venous Congestion Post Kidney Transplant Detected by Point of Care Ultrasound (POCUS) Subclinical Congestion Evaluated by Point of Care Ultrasound (POCUS) at Discharge Predicts Readmission in Patients with Acute Heart Failure: Prognostic Cohort Study

(1) Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA

(2) Department of Emergency Medicine, Stanford University School of Medicine, Stanford, CA, USA

(3) Department of Anesthesiology, Stanford University School of Medicine, Stanford, CA, USA

*Corresponding Author: Dr. Andre Kumar (email: akresearchcorrespondence@gmail.com)

Download article PDF – POCUS Journal 2026;11(1):62-67

DOI: https://doi.org/10.24908/pocusj.v11i01.19439

Supplementary Materials: S1

Abstract

Background: Lung point of care ultrasound (POCUS) offers advantages over traditional imaging for diagnosing pulmonary conditions, with superior accuracy compared to chest X-ray and lower cost compared to computed tomography. Despite these benefits, widespread adoption is limited by operator dependency, moderate interrater reliability, and training requirements. Deep learning (DL) could potentially address these challenges, but the development of effective algorithms is hindered by the scarcity of comprehensive image repositories with proper metadata. Methods: We created an open-source dataset of lung POCUS images derived from a multi-center study involving 226 adult patients presenting to emergency departments with respiratory symptoms between March 2020 and April 2022. Images were acquired using a standardized scanning protocol (12-zone or modified 8-zone) with various POCUS devices. Three blinded researchers independently analyzed each image following consensus guidelines, with disagreements adjudicated to provide definitive interpretations. Videos were preprocessed to remove identifiers, and frames were extracted and standardized to 512×512 pixels using letterboxing to maintain aspect ratios. Results: The dataset contained 1,871 video clips comprising 324,027 frames extracted and standardized to 512×512 pixels. Half of the participants (50%) had COVID-19 pneumonia. Among all clips, 66% contained no abnormalities, 18% contained B-lines, 4.5% contained consolidations, 6.4% contained both B-lines and consolidations, and 5.2% had indeterminate findings. Pathological findings varied significantly by lung zone, with anterior zones more frequently normal and less likely to show consolidations compared to lateral and posterior zones. Discussion: This dataset represents a large, annotated lung POCUS repository and includes patients with and without COVID-19. The repository metadata and expert interpretations enhance its utility for DL applications. Despite limitations including potential device-specific characteristics and COVID-19 predominance, this repository provides a valuable resource for developing artificial intelligence tools to improve lung POCUS acquisition and interpretation.

Introduction

Lung point of care ultrasound (POCUS) offers significant advantages as a bedside tool to diagnose several pulmonary conditions, including pneumonia, pulmonary edema, pleural effusion, pneumothorax, and interstitial disease. It can be expediently performed at the point of care to enhance diagnostic accuracy and monitor disease progression [1,2]. Lung POCUS has demonstrated superior diagnostic accuracy compared to chest X-ray for identifying pneumonia, pulmonary edema, pleural effusion, and pneumothorax [1,3–5]. When compared to computed tomography (CT), lung POCUS often demonstrates similar diagnostic performance for these conditions [6–8]. Lung POCUS devices are more cost-effective than traditional imaging equipment such as X-ray or CT machines, making them particularly valuable in resource-limited settings or overwhelmed clinical environments. Despite these advantages, widespread lung POCUS adoption faces several challenges, including operator dependency for image acquisition, moderate interrater reliability for interpreting pathological findings, and the need for standardized provider training [9,10].

Deep learning (DL), a subfield of artificial intelligence (AI), has the potential to address many obstacles hindering lung POCUS adoption [11]. DL utilizes machine learning to automatically characterize features from raw data [11–13]. By analyzing large repositories of POCUS images, DL can make predictions about new images [13]. Potential applications of DL in POCUS include aiding examiners in image acquisition, providing anatomical labelling of structures, assessing image quality, identifying pathological findings, and assisting with interpretation [11–14]. Through these capabilities, DL may improve lung POCUS image quality, automate analysis, and help healthcare professionals make more accurate and timely clinical decisions [11–13].

Despite the potential benefits of combining lung POCUS with DL applications, there is a scarcity of high-quality image repositories needed to develop effective DL algorithms [15–17]. There is a critical need to create open-source image libraries that can be used for current and future applications of POCUS. Many existing databases derive primarily from inpatients, and relatively few datasets contain healthy controls [15,16]. Furthermore, these repositories often lack important metadata such as patient characteristics, scan locations, expert interpretations, and assessments of image quality [15].

In this manuscript, we describe the creation of an open-source dataset of lung POCUS images derived from 226 patients, comprising 303,977 individual video frames. This dataset is one of the largest lung POCUS repositories to date and includes metadata regarding patient information, expert interpretations of findings, and control cases. Our dataset includes additional metadata to further aid in applications of DL as applied toward lung POCUS.

Methods

Dataset Derivation

All patient images were collected as part of a multi-center prospective cohort study between 3/2020 and 4/2022 (Clinicaltrials.gov Registration: NCT04384055) [18]. Inclusion criteria were adults presenting to the emergency department with respiratory symptoms concerning for COVID-19. For healthy controls, patients presenting to the emergency department or clinic without known pulmonary disease or symptoms were included. Patients were excluded if they did not receive a lung POCUS examination. Patient demographics and clinical information were collected. This study received institutional review board approval, including for the creation of the de-identified image database (Protocol 74680).

Scanning Protocol

All images were acquired utilizing a previously-published standardized scanning protocol [18]. Physicians were instructed to use a 12-zone scanning protocol for lung POCUS views. If a 12-zone protocol could not be performed due to the patient’s condition (inability to turn, patient discomfort), then a modified 8-zone protocol capturing the anterior and lateral lung fields was performed. The probe marker was oriented cranially. The 12-zone lung POCUS protocol involved obtaining two anterior, two lateral, and two posterior views obtained on each hemithorax. The 8-zone protocol involved two anterior and two lateral zones on each hemithorax. The two views for each location (e.g., the two anterior views) were obtained as cranial and caudal views, with the nipple line as a bisecting line to distinguish between the two areas. Scans were obtained in supine or semi-recumbent position.

This study utilized several cart-based and handheld POCUS devices, including Butterfly IQ^TM (Burlington, MA), Vave^TM (Santa Clara, CA), Fujifilm Sonosite LX^TM (Bothell, WA), GE Venue^TM (Chicago, IL) and Echonous^TM (Redmond, WA), which represent the commercially available POCUS devices at our institutions. All devices used a phased array probe and were set to the “lung” preset. The lung preset varied between machines, but in general, this preset provided optimal depth, gain, and frame rate to visualize lung artifacts (B-lines, consolidations, and effusions). A total of 226 participants were enrolled in the study.

Interpretation

Physician interpretation of the images was performed using a previously developed consensus guideline for lung POCUS images [19]. Briefly, B-lines were defined as vertically oriented artifacts originating from the pleura that extend at least 12 cm and erase A-lines as they move over them. Subpleural consolidations included irregular or thickened pleura and hyper echogenicity inferior to the pleura. Lobar consolidations were defined as dense, “hepaticized” lung. Physicians who interpreted the images met the following criteria: 1) at least five years of faculty experience, 2) previously credentialed in POCUS at our institution, and 3) completed a POCUS certificate program or advanced fellowship in POCUS. Three researchers (AK, JK, YD), who were blinded to any patient information, independently analyzed each image and provided their interpretation on separate electronic spreadsheets (sample provided in Supplementary Material S1). When disagreements occurred, the researchers met to discuss their interpretations and the underlying imaging features to reach consensus through dialogue. If no consensus could be reached, the interpretation for that image was marked as “indeterminate.” Previous investigations have demonstrated moderate to substantial interrater reliability for lung POCUS across different experience levels and probe types [20,21]. Within this dataset, there was initial agreement in 77% of the clips (N = 1,445), with 23% (N = 426) requiring adjudication, which is consistent with our previous findings where our interpretation protocol had moderate-to-substantial interrater reliability for the lung POCUS findings included in this study (k = 0.79 for normal scans, k = 0.79 for B-lines, k = 0.57 for consolidations) [10].

Image Preprocessing

All 1,871 video clips underwent systematic preprocessing to create a standardized dataset suitable for DL applications (Figure 1). Videos were first reviewed to identify and remove patient identifiers. Using OpenCV (version 3.12.0) [22], we extracted individual frames from each video at the native frame rate. Template masking was applied to remove device-specific annotations and identifiers while preserving the ultrasound image field. Frames were then standardized to 512×512 pixels using letterboxing to maintain aspect ratios, resulting in 324,027 total frames (Figure 1). Each frame was saved in .jpg format with a standardized nomenclature indicating participant identification, lung zone, and frame number (e.g., P001_Zone1_Frame005.jpg). This preprocessing created a dataset suitable for convolutional neural network architectures, for image classification tasks.

Variable Definitions

All patient diagnoses were determined through retrospective chart reviews of the primary treating physician’s discharge summary or emergency department note. COVID-19 infection testing was obtained via nasopharyngeal polymerase chain reaction (PCR) in all patients presenting to the emergency department.

Results

The open access lung POCUS repository and associated metadata can be found at: https://github.com/kumarandre/OpenPOCUS.

The dataset consisted of 1,871 video clips (324,027 frames) derived from 226 patients (Table 1). Of these participants, 114 (50%) were diagnosed with COVID-19 pneumonia at the time of their scan. Additional diagnoses are presented in Table 1. The mean body mass index (BMI) was 28.4 (SD 6.8), and 90 patients (40%) were female.

Regarding scanning protocols, 70 patients (31%) had scans obtained using the 12-zone protocol, while 156 patients (69%) had scans using the 8-zone protocol. Among all scans, 1,233 clips (66%) contained no abnormal findings, 338 clips (18%) contained any count of B-lines, 84 clips (4.5%) contained consolidations, 119 clips (6.4%) contained both B-lines and consolidations, and 97 clips (5.2%) had indeterminate findings (Supplementary Material S1).

The dataset included additional metadata such as COVID-19 status, normal versus abnormal interpretation, and expert interpretation of each video clip for a given lung zone (Table 2).

Discussion

We describe the creation of a large lung POCUS dataset derived from adult patients with annotated metadata for each lung clip. This dataset encompasses patients with various pulmonary diseases as well as healthy controls. With over 320,000 individual frames, this open-source repository is among the largest available. The dataset can be used to aid in future applications of AI as applied toward lung POCUS and medical imaging. Specific applications include the development of neural network models to classify and segment lung POCUS images for pathology detection and the determination of normal versus abnormal. Additionally, it represents a dataset that can be used for individuals to test their current models to provide verification of their accuracy.

Previous investigations have found moderate to substantial interrater reliability for lung POCUS findings, which is an important consideration given the expert over-reads of this study [10,20,21]. Within our group, we have observed similar interrater reliability for the lung POCUS findings in this database [10]. For this project, we implemented an adjudication process to provide a single interpretation for future DL applications. Imaging findings that have poor interrater reliability may result in difficulty establishing a singular ground truth, as human labellers are needed to train these models. Therefore, models developed around findings with higher reliability (e.g., normal findings with κ = 0.79 or B-lines with κ = 0.79) are more likely to achieve greater accuracy than models targeting less reliable findings. We report on interrater reliability for our dataset to inform future applications of these images and highlight potential accuracy limitations. As DL and neural network integration become more prominent in POCUS, determining how these technological advances can aid providers in image acquisition and interpretation will be crucial [11,13]. It will be equally important to compare the accuracy of these models with expert physicians, given that interpretations among providers vary [10,21,23].

Although other open-source lung POCUS databases have been described, our dataset represents the largest to date [24]. Our dataset offers unique advantages over other existing open-source lung POCUS databases [15–17,23]. For example, the COVIDx-US dataset (v1.5) contains 242 videos and more than 29,000 preprocessed images with video-level annotations. Our dataset provides a larger number of source videos (1,871 clips) with frame-level preprocessing (324,027 frames at 512×512 pixels), comprehensive metadata including COVID-19 status, and most importantly, a balanced mix of COVID-19 (50%) and non-COVID-19 pathologies. While COVID-19-predominant datasets face declining clinical relevance as the pandemic evolves, the heterogeneous manifestations of SARS-CoV-2 on lung parenchyma (including B-lines, consolidations, pleural irregularities, and mixed patterns) make it an ideal teaching model for lung POCUS interpretation. The pathophysiologic findings of COVID-19 pneumonia overlap substantially with other acute respiratory conditions, providing a rich substrate for training computer vision models to recognize fundamental lung POCUS artifacts. Furthermore, approximately half of our participants had non-COVID-19 conditions, providing broader generalizability than purely COVID-focused datasets [15–17,23].

It is important to note that there may be subtle differences in lung POCUS findings between COVID-19 and other conditions. Models trained primarily on COVID-19 may miss these distinctions, particularly if used for diagnostic purposes [12,23,24]. For example, cardiogenic pulmonary edema (due to heart failure) and non-cardiogenic pulmonary edema (related to acute respiratory distress syndrome) present differently on lung POCUS [25]. Since COVID-19 typically causes imaging findings consistent with non-cardiogenic pulmonary edema, overreliance on COVID-19-derived models may reduce reliability in future imaging applications [25].

Limitations

This study has several limitations. We utilized only three reviewers for the interpretation of each video clip, which may reduce the accuracy of findings. Analysis was performed at the clip level rather than the frame level, requiring caution when extrapolating metadata to individual frames. Approximately half of the scans were derived from patients with COVID-19, which potentially limits generalizability to specific disease models. The majority of scans (59%) were obtained using a single device (Butterfly IQ™) in a phased array setting without the use of a linear probe, which has additional diagnostic benefits in lung POCUS. Despite preprocessing to remove device-specific markings, each ultrasound probe has unique characteristics (scan angle, frame rate, gray-scaling), potentially limiting model generalizability across devices. The predominance of scans from a single device (59% Butterfly IQ™) may introduce device-specific characteristics despite our preprocessing efforts to remove identifying markers. Future work should validate models across diverse ultrasound platforms.

Conclusions

We present a large, open-source lung POCUS database derived from diverse patients, including healthy controls. The methods used in creating this dataset can serve as a template for future datasets. Importantly, imaging datasets should be built on well-defined patient populations, which in this study included adults presenting to the emergency department with respiratory symptoms. Images should be reviewed by experts to label findings, and diagnoses should be assigned whenever possible. With the addition of similar lung POCUS databases, it is possible to develop image interpretation tools powered by DL to assist in the acquisition and interpretation of lung POCUS.

Ethics Statement

This study was approved by the Stanford University IRB (Protocol 74680).

Disclosure Statement

Dr. Kumar reports receiving consultant fees from Vave Health and GE Healthcare, which are two of the POCUS devices used in this study. The other study authors do not have any disclosures.

Funding

None

Author Contributions

AK: conceptualization, data curation, methodology, supervision, writing – original draft, writing – review & editing. PN: methodology, formal analysis, writing – original draft. AG: data curation, formal analysis, writing – original draft. EB: data curation, formal analysis, writing – original draft. JM: data curation, formal analysis, writing – original draft. YD: data curation, formal analysis, writing – original draft. JK: conceptualization, data curation, methodology, supervision, writing – original draft, writing – review & editing.

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18. Kumar A, Weng Y, Duanmu Y, Graglia S, Lalani F, Gandhi K, Lobo V, Jensen T, Chung S, Nahn J, Kugler J. Lung Ultrasound Findings in Patients Hospitalized With COVID-19. J Ultrasound Med. 2021 Mar 5;41(1):89–96.

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20. Gullett J, Donnelly JP, Sinert R, Hosek B, Fuller D, Hill H, Feldman I, Galetto G, Auster M, Hoffmann B. Interobserver agreement in the evaluation of B-lines using bedside ultrasound. J Crit Care. 2015 Dec;30(6):1395–9.

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Handheld Lung Ultrasound to Detect COVID-19 Pneumonia in Inpatients: A Prospective Cohort Study Role of Point of Care Ultrasonography in Patients with COVID-19 Associated Acute Kidney Injury Machine Learning in Point of Care Ultrasound

(1) Division of General Internal Medicine, Section of Hospital Medicine, Weill Cornell Medical Center, New York City, NY, USA

(2) Department of Medicine, Division of Hospital Medicine, Kings County Hospital and SUNY Downstate Medical University, Brooklyn, NY, USA

*Corresponding Author:  Dr. Jessie Huang (email: jeh4028@med.cornell.edu)

Download article PDF – POCUS Journal 2026;11(1):68-71

DOI: https://doi.org/10.24908/pocusj.v11i01.19785

Supplementary Material: S1

Abstract

Point of care ultrasound (POCUS) is an increasingly common tool used in patient evaluation. Rapid interpretation of POCUS findings rely on the operator’s familiarity with POCUS patterns. However, over-reliance on heuristics can result in misdiagnosis. We describe a case involving a patient who exhibited characteristic lung POCUS in the abdominal region. This case emphasized the importance of anatomic correlation and the limitations of pattern recognition in isolation.

Case Presentation

A 58-year-old man with locally advanced hepatocellular carcinoma and portal vein thrombosis presented to the emergency department with one day of severe right-sided abdominal pain, hematemesis, and melena. The patient had multiple recent hospitalizations for upper gastrointestinal bleeding and biliary infections due to a duodenal ulcer with contained perforation and fistulization into the biliary tree. On arrival, he was afebrile, hypotensive to 89/73 mmHg, tachycardic to 132 bpm, and had an oxygen saturation of 100% on 2 L supplemental oxygen.

The abdomen was diffusely tender without peritoneal signs, and the lungs were clear to auscultation. Laboratory studies were notable for hemoglobin of 7.6 g/dL (baseline), white blood cell count of 30 × 10³/µL with 20% bands and lactic acid of 7 mmol/L. The leading differential diagnoses for the patient’s shock were hemorrhagic shock from a gastrointestinal bleed or septic shock from an intra-abdominal source. The patient received 2 L of intravenous fluids and 2 units of packed red blood cells. Intravenous vancomycin, ertapenem and micafungin were also started empirically. The Rapid Ultrasound for Shock and Hypotension (RUSH) exam was performed to assess for the cause of undifferentiated hypotension as the patient was initially too unstable to proceed to computed tomography (CT).

The patient was scanned with a curvilinear probe in the supine position. The right flank was interrogated at the posterior axillary line in the coronal plane, with the probe marker oriented cephalad. This showed a curved hyperechoic line at the center of the image, which was initially misinterpreted as the diaphragm (Figure 1, Supplementary Material S1). The liver was not seen caudal to the presumed diaphragm. However, two common POCUS patterns were seen cephalad: (1) several hyperechoic foci on the background of soft tissue density, and (2) an irregular hyperechoic line with distal reverberation artifact. These patterns were recognized as “air bronchograms” and “shred sign” of lung POCUS, respectively. These two signs, when seen in the thorax, indicate the presence of a lung consolidation [1,2]. Although not one of the initial differential diagnoses, septic shock from pneumonia became the leading diagnosis. However, this diagnosis was incorrect.

Subsequent CT angiography of the chest, abdomen, and pelvis demonstrated new focal areas of air within the patient’s known liver masses, raising concern for an infected necrotic liver tumor versus hepatic abscesses (Figure 2A). There was also new pneumoperitoneum, suspected to be an extension of the infected liver tumor/abscess. Finally, there were new bilobar branching tracks of air in the liver, which was suggestive of portal venous gas (PVG). No pulmonary consolidations were present (Figure 2B). General surgery and gastroenterology were consulted; however, the patient was not a candidate for procedural interventions given his advanced metastatic disease. The patient was admitted to the medical intensive care unit and continued receiving broad-spectrum antibiotics. On hospital day 1, the patient’s blood cultures returned positive for Clostridium perfringens. The patient was transitioned to comfort care on hospital day 2 and passed away on hospital day 4.

Discussion

POCUS is a valuable tool that allows clinicians to acquire and interpret images in real time, supporting rapid diagnosis and informed clinical decision-making. Image interpretation often relies on fast, intuitive pattern recognition, especially in high-acuity situations. Research suggests that such heuristics are a fundamental part of human decision-making [3]. However, as this case illustrated, pattern recognition alone comes with a trade-off between speed and accuracy. A deliberate and systematic interpretation should take place in addition to the initial impression to ensure accurate image interpretation.

In this case, the initial appearance of a hyperechoic line with adjacent air bronchograms and a shred sign was misinterpreted as the diaphragm with adjacent lung consolidation. On review, a kidney was seen deep to the curved hyperechoic line, necessitating reinterpretation of the superficial soft-tissue density as the liver instead of a lung consolidation (Figure 3). Thus, the air bronchograms and shred sign seen on POCUS were generated not by a consolidation in the lung, but by air in the liver.

POCUS patterns represent radiographic syndromes rather than specific disease entities. Common lung POCUS syndromes such as air bronchograms and shred sign are created by the interface between air and surrounding soft tissue. Differences in acoustic impedance generate these artifacts [4]. Large air pockets can produce hyperechoic lines with distal reverberation artifacts. The shred sign is an example of this, because it is generated by the interface between consolidated lung and aerated lung in a non-translobar consolidation [1]. In contrast, smaller air bubbles may create bright, punctate foci within hypoechoic structures, as seen with air bronchograms [2]. Any pathology that creates interfaces between air and soft tissue can generate these POCUS signs. In this case, the presence of air in the liver and the portal vein resulted in the shred sign and air bronchograms seen in the abdominal space.

Hoffmann et al. proposed a classification system for abnormal abdominal air based on its location. The categories include extraluminal air, intraluminal air, intraparenchymal air, and intramural air [5]. This framework helps contextualize our patient’s findings as a combination of PVG (intraluminal) and air within the hepatic parenchyma (intraparenchymal).

Supplementary Material S1 demonstrates hyperechoic, non-shadowing speckles arranged in a linear pattern, consistent with the appearance of intraluminal air. In the upper right quadrant, this finding is suggestive of pneumobilia or PVG. These pathologies can be difficult to distinguish on ultrasound. Air is typically more centrally located in pneumobilia and peripherally located in PVG [3]. Our POCUS findings most closely align with PVG due to the presence of peripherally located air. M-mode and pulsed wave Doppler can also be used to distinguish PVG. In M-mode, the line of interrogation is placed through the portal vein to track the movement of hyperechoic air bubbles, which resemble a “meteor shower” [6,7]. In pulsed wave Doppler, the sample gate is placed within the portal vein. As air bubbles flow through the sample gate, they generate a hyperechoic vertical spike on the spectral tracing [6,7]. In addition to intraluminal air, Supplementary Material S1 also demonstrates hyperechoic lines with ring-down artifacts within the liver parenchyma, suggestive of intraparenchymal air. This appearance likely represents pyogenic liver abscesses or a necrotic air-filled tumor [8,9]. There are few reports in the POCUS literature on the appearance of air in the abdomen, and even fewer still that describe air so extensive that it produces POCUS signs closely associated with lung POCUS, but in the abdomen.

This case highlights a high-acuity scenario in which using only heuristics in POCUS image interpretation resulted in a significant diagnostic error. The initial recognition of shred sign and air bronchograms without assessment of the surrounding structures led to the incorrect diagnosis of septic shock from pneumonia. A more deliberate review of the images allowed for identification of all the surrounding structures, including the kidneys, which suggested that the pathology was within the abdomen rather than the thorax.

Conclusion

We report a case of significant abdominal air that produced POCUS images commonly associated with lung POCUS, resulting in misdiagnosis. This case has several major learning points. Firstly, familiarity with the appearance of air in the abdomen on POCUS imaging is crucial in recognizing intra-abdominal pathology. Secondly, common POCUS signs are created by sonographic phenomena and are not pathognomonic for specific pathologies. Finally, clinicians should be cognizant of the role heuristics play in medical judgement, including POCUS image interpretation, and maintain the cognitive flexibility to employ a slower, analytical approach to image interpretation.

Ethics Statement

Written informed consent was obtained from the patient’s family by the authors. The patient’s family has consented to the use of deidentified images, video clips, and health information to be published within the journal.

Disclosure Statement

The authors have no disclosures related to this work.

Funding

The authors have no sources of funding related to this research.

Author Contributions

JH: writing – original draft, writing – review & editing, visualization. JB: writing – original draft, writing – review & editing, visualization. TC: writing – review & editing. GM: conceptualization, writing – review & editing.

References

1. Lichtenstein DA. Lung ultrasound in the critically ill. Ann Intensive Care. 2014;4(1):1.

2. Lichtenstein D, Meziere G, Seitz J. The dynamic air bronchogram. A lung ultrasound sign of alveolar consolidation ruling out atelectasis. Chest. 2009;135(6):1421-1425.

3. Kahneman D. Thinking, Fast and Slow. Farrar, Straus and Giroux, New York, 2013.

4. Bakhru RN, Schweickert WD. Intensive care ultrasound: I. Physics, Equipment, and image quality. Ann Am Thorac Soc. 2013;10(5):540-548.

5. Hoffman B, Nurnberg D, Westergaard MC. Focus on abnormal air: diagnostic ultrasonography for the acute abdomen. Eur J of Emerg Med. 2012;19(5):284-291.

6. Bitar R, Kaur M, Crandall I, McNamara R, Revzin MV. Ultrasound evaluation of portal venous gas and its mimics. Abdom Radiol. 2024;49:2756-2769.

7. Cheong I, Tamagnone FM. The role of different ultrasound modes in hepatic portal venous gas diagnosis, including a novel method using color M-mode. J Ultrasound. 2024;27(4):1009-1013.

8. Chin WV, Khaw MJ. Gas Forming Pyogenic Liver Abscess Diagnosed by Point of Care Ultrasound. POCUS J. 2024;9(1):41-43.

9. Webb GJ, Chapman TP, Cadman PJ, Gorard DA. Pyogenic liver abscess. Frontline Gastroenterol. 2014;5:60-67.

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Bilateral Lung Points without Pneumothorax: Exploring “Lung Point” Mimics Diagnosis of Pneumoperitoneum Using POCUS Comparison of Six Handheld Ultrasound Devices by Pediatric Point of Care Ultrasound (POCUS) Experts

(1) Pediatric Emergency, Kaplan Medical Center, Rehovot, Israel

(2) Faculty of Medicine, Hebrew University of Jerusalem, Israel

(3) Department of Pediatrics, Kaplan Medical Center, Rehovot, Israel

*Corresponding Author:  Dr. Eric Scheier (email: eric.scheier@gmail.com)

Download article PDF – POCUS Journal 2026;11(1):72-76

DOI: https://doi.org/10.24908/pocusj.v11i01.19441

Abstract

Background: Point of care ultrasound (POCUS) has proven utility in confirming the diagnosis of skin and soft tissue abscesses. We studied the characteristics of 50 dental abscesses on pediatric POCUS examinations and their outcomes. Methods: This was a convenience sample of cases collected in the pediatric emergency department from December 2020 to December 2024. All included patients were examined by an oromaxillofacial specialist and hospitalized. All cases had POCUS imaging performed at initial assessment by the first author. Results: The median age of the patients was 7 years (IQR = 5 years), and 31 (62%) were male. Forty (80%) received antibiotic prior to arrival. Thirty-five (70%) presented within 3 days from onset of pain, and 36 (72%) were referred to the pediatric emergency department by a dentist for oromaxillofacial evaluation. Four children (8%) experienced spontaneous drainage while inpatient, and eleven children underwent surgical drainage (22%). There was a significant correlation between maximal abscess height from bone and the need for surgical drainage (p = 0.011). A cutoff of 4.5 mm yielded a sensitivity of 72.7% and specificity of 69%, indicating that abscesses measuring greater than 4.5 mm are more likely to need surgical drainage. Conclusions: This was the first known study to describe POCUS findings in children determined to have dental abscess by an oromaxillofacial specialist and hospitalized for treatment. POCUS may have utility in identifying dental abscess, and may be useful in following the progress of abscesses under treatment. The majority of dental abscesses will resolve with antibiotic therapy, but abscesses above 4.5 mm may require drainage early in the course of treatment.

Introduction

Point of care ultrasound (POCUS) has proven utility in confirming the diagnosis of skin and soft tissue abscess. Limited evidence suggests that skin and soft tissue abscesses with a diameter greater than 1.3 cm are likely to fail medical management [1]. Further, POCUS can differentiate between odontogenic fascial space cellulitis and abscess [2]. The utility of POCUS in guiding therapy of pediatric dental (periapical and periodontal) abscesses is unclear. Here, we describe our experience using POCUS in the pediatric emergency department. We evaluated children with dental abscess in order to determine whether there were characteristics of these POCUS examinations that are associated with subsequent drainage.

Methods

This study was a retrospective review of POCUS examinations acquired at a tertiary care pediatric emergency department with 27,000 visits annually. Our pediatric emergency department receives children from birth to 18 years of age.

Children with odontogenic facial swelling are referred to the pediatric emergency department by their pediatrician or dentist to confirm a diagnosis of abscess and, if confirmed, inpatient treatment. In our facility, children with odontogenic facial swelling are examined in the pediatric emergency department  and followed inpatient by an oromaxillofacial specialist. If the specialist believes the child has failed intravenous antibiotic, drainage is performed under deep sedation. The first author performed all inpatient sedations for these children, as sedation for an oral procedure presents an airway risk that may not be suitable for junior physicians to manage.

Children with odontogenic facial swelling are routinely examined in the pediatric emergency department  by the first author with POCUS. We included children of all ages who had an abscess confirmed on POCUS and were then hospitalized. Children who received POCUS but were discharged from the pediatric emergency department  were excluded as we had no way to examine outpatient dental records. POCUS was performed by the first author—a pediatric emergency physician with seven years of experience with POCUS—from December 2020 to December of 2024. Measurements were made during review of the images for the study. Hospital charts were reviewed to extract details of emergency department and hospital course. Children who were not seen by an oromaxillofacial specialist and discharged from the pediatric emergency department  were excluded. The country-wide Ofek electronic medical record database, which includes all outpatient visits as well as all hospitalizations, was reviewed to verify that the children in our series were not seen in another emergency department for dental abscess.

Statistics

Descriptive statistics were utilized to summarize the data. Categorical variables are presented as frequencies and percentages, whereas continuous variables are expressed as medians with interquartile range (IQR). Comparisons of categorical variables were performed using the Chi-square test. The normality of continuous variables was assessed using the Shapiro-Wilk test; if the data followed a normal distribution, an independent t-test was used, and if not, the Mann-Whitney U test was employed. Additionally, a receiver operating characteristic (ROC) analysis was conducted. All statistical analyses were performed using SPSS version 29.0, and a p-value below 0.05 was considered statistically significant.

POCUS Technique

All images were acquired with a high frequency linear probe on a Zonare z.1 ultrasound (Mindray, Mahwah, NJ). We started by examining the contralateral side to adjust gain and depth, and to demonstrate to the child that the examination should not be painful. Images were collected in the sagittal plane over the area of swelling (Figure 1). Copious gel was applied and a video sweep in the coronal axis over the area of interest was recorded. Anechoic fluid collections were defined as abscess. After fanning through the abscess, the maximum height of the anechoic fluid pocket from lateral cortex of maxilla or mandible to facial soft tissue was recorded (Figure 2). In contrast with a subcutaneous abscess, which is generally round or ovoid, a periodontal abscess is elliptical within a well-defined anatomic space. In our experience, severity is associated with the height of abscess from bone, which should be identical in coronal and in transverse views. This method of measuring effusion by height rather than volume is commonly used to measure hip effusion on pediatric ultrasound [3]. We therefore recorded abscess height from maxilla or mandible, rather than volume.

Results

Sixty-one children underwent POCUS examination, of whom eleven were not seen by an oromaxillofacial specialist and were discharged from the pediatric emergency department. None presented after pediatric emergency department discharge to an outside hospital pediatric emergency department. Thus, 50 children with dental abscess treated by an oromaxillofacial specialist were studied. The mean age of this group was 7 years (IQR = 5 years), and 31 (62%) were male. The average duration of pain prior to presentation was just under 4 days, and 40 cases (80%) received antibiotics prior to arrival (Table 1). Seven children had panoramic dental radiography while hospitalized. Four children experienced spontaneous drainage while inpatient and eleven children underwent surgical drainage (22%).

There were no statistically significant associations in white blood cell (WBC), absolute neutrophil (ANC), and C-reactive protein (CRP) counts between operative and non-operative cases (Table 2). All children received intravenous (IV) amoxicillin/clavulanate, except for two who were treated with IV clindamycin due to penicillin allergy. All IV antibiotic courses and drainage were successful. No child re-presented to the pediatric emergency department with recurrent dental abscess. There was no significant association between antibiotic administration prior to pediatric emergency department presentation and either abscess drainage or duration of hospitalization.

There was no statistically significant correlation between duration of symptoms prior to POCUS or between any laboratory parameter and the need for surgical drainage. There was a significant correlation between mean maximal abscess height from bone and the need for surgical drainage (not drained, 0.39 cm; drained, 0.57 cm; p = 0.011). Based on the ROC analysis, the area under the curve (AUC) was 0.749, which suggested moderate accuracy in predicting which abscesses might require drainage.

A cutoff of 4.5 mm yielded a sensitivity of 72.7% and specificity of 69%, indicating that there may be an association between abscesses measuring above 4.5 mm and the need for surgical drainage. Including the 11 children who were discharged from the pediatric emergency department and therefore excluded from the initial analysis slightly reduced the model’s discriminatory power (AUC decreased from 0.749 to 0.727) and increased the significance level from p = 0.012 to p = 0.019. Importantly, the optimal cutoff of 0.45 cm remained unchanged, with stable sensitivity and specificity. These findings suggested that the inclusion of milder, non-hospitalized cases did not enhance prediction performance, though it slightly improved generalizability.

Maximal abscess diameters below 0.25 cm had 100% sensitivity for predicting that no surgical intervention was necessary, at the cost of a sharp decline in specificity to 25.6%. While a definitively safe prognostic threshold cannot be established from our data, values below 0.25 cm may support a decision to discharge without intervention if clinical judgment supports that disposition.

Discussion

Prior small case series in the dental literature have shown that ultrasound can detect odontogenic abscesses [4]. However, this is the first study to describe POCUS findings in children with dental abscess, determined by a pediatric emergency physician. Moreover, all children in our study had a POCUS diagnosis confirmed by an oromaxillofacial specialist, and all were followed through hospitalization. Our study demonstrated that a cutoff of approximately 0.45 cm yields a sensitivity of 72.7% and specificity of 69%, indicating that abscesses measuring 0.45 cm or greater may be associated with need for surgical drainage.

Prior research suggests that a skin abscess diameter above 1.3 cm or depth greater than 0.4 cm is likely to fail antibiotic therapy [1]. While odontogenic periapical abscesses are usually apparent on physical examination, clinical signs alone may not reliably distinguish between cellulitis and true abscess formation in odontogenic infections [2,5]. There is no guidance in the literature regarding the need for drainage of odontogenic abscesses.

Several of our patients underwent panoramic dental radiography. Panoramic radiography can evaluate the dental root and surrounding bone and can demonstrate focal apical lucencies associated with infections originating from the root apices [6,7]. Ultrasound, in contrast with conventional radiographic imaging, has no radiation. Several studies of adult patients with facial pain and swelling have found ultrasound to be more sensitive for abscess than panoramic radiography [8,9]. Barton et al. described two techniques to improve clarity of the image: the first was to have the patient fill their mouth with water and perform a “cheek puff” to push the water between gingiva and buccal mucosa, simulating a water bath. The second was to have the patient use their tongue to point to the area of tenderness [10].

Previous studies have shown that inflammatory markers, such as WBC count and CRP, are frequently elevated in odontogenic abscesses, with elevations less marked in pediatric patients compared to adults [11]. Our study did not find a significant difference in inflammatory markers between children treated surgically (i.e., with drainage) or medically. POCUS allows for early identification of abscess without bloodwork, enabling early treatment. There is a lack of evidence regarding the use of systemic antibiotics in the pediatric population [12,13]. However, early treatment in the outpatient setting may reduce hospitalization [14]. Early treatment is important to prevent dehydration that may result from dental pain and more serious sequelae such as sepsis that has been reported in pediatric dental abscess [15,16]. Thus, early POCUS may obviate the need for laboratory evaluation and systemic antibiotics, and may inform the need for early drainage.

Limitations

This was a single-center retrospective convenience sample collected by a single physician. While POCUS of a periodontal abscess is a straight-forward examination, we cannot exclude inter-operator variability. POCUS was performed at point of contact and not when the abscess was opened, which in most cases was during hospitalization. The abscess was fanned through in only the sagittal orientation rather than in two orthogonal planes, and height of abscess from cortex rather than abscess volume was measured. The potential space that might contain a dental abscess is limited by the smaller potential space than exists for other subcutaneous abscesses. Because of this, we saw little utility in a second view. While our data can help guide clinical judgment alongside other clinical and laboratory findings, the results are limited by the small sample size, the single-center, retrospective design, and operator-dependent ultrasound measurements. Additional prospective, multicenter studies are needed to validate and refine these recommendations.

Conclusion

POCUS can be useful for identifying dental abscess and may be useful in following the progress of abscesses under treatment. A POCUS-determined abscess diameter of 4.5 mm is associated with the need for surgical drainage. Larger, prospective studies are required to determine which dental abscesses will require surgical drainage as opposed to medical management, either inpatient or outpatient.

Ethics statement

This study was approved by the Kaplan Medical Center institutional review board (KMC 146-23). Patient consent was not required due to the retrospective nature of the study.

Disclosures statement

The authors declare no conflict of interest. The authors received no funding and have no financial relationships relevant to this article to disclose.

Funding

The authors received no funding and have no financial relationships relevant to this article to disclose.

Author Contributions

EC: conceptualization, methodology, formal analysis, investigation, writing – original draft, writing – review & editing. BG: formal analysis, investigation, data curation, writing – review & editing.

References

1. Menegas S, Moayedi S, Torres M. Abscess Management: An Evidence-Based Review for Emergency Medicine Clinicians. J Emerg Med. 2021;60(3):310-320. doi: 10.1016/j.jemermed.2020.10.043

2. Shah N, Patel S, Rupawala T, Makwana S, Mansuri S, Bhimani K. Evaluation of Efficacy of Ultrasonography as an Additional Diagnostic Tool for Deciding Management Protocol of Odontogenic Superficial Fascial Space Infections: A Prospective Clinical Study. J Maxillofac Oral Surg. 2022;21(4):1148-1154. doi: 10.1007/s12663-021-01560-x

3. Jones RM, Malia L, Snelling PJ, Riera A, Mak W, Moote D, Brimacombe M, Chicaiza H. Diagnostic Accuracy of Point-of-Care Ultrasound for Hip Effusion: A Multicenter Diagnostic Study. Ann Emerg Med. 2025:S0196-0644(25)00279-3. doi: 10.1016/j.annemergmed.2025.04.033

4. Pallagatti S, Sheikh S, Puri N, Mittal A, Singh B. To evaluate the efficacy of ultrasonography compared to clinical diagnosis, radiography and histopathological findings in the diagnosis of maxillofacial swellings. Eur J Radiol. 2012;81(8):1821-7. doi: 10.1016/j.ejrad.2011.04.065

5. Bertossi D, Barone A, Iurlaro A, Marconcini S, De Santis D, Finotti M, Procacci P. Odontogenic Orofacial Infections. J Craniofac Surg. 2017;28(1):197-202. doi: 10.1097/SCS.0000000000003250

6. Sklavos A, Beteramia D, Delpachitra SN, Kumar R. The panoramic dental radiograph for emergency physicians. Emerg Med J. 2019;36(9):565-571. doi: 10.1136/emermed-2018-208332

7. Sams CM, Dietsche EW, Swenson DW, DuPont GJ, Ayyala RS. Pediatric Panoramic Radiography: Techniques, Artifacts, and Interpretation. Radiographics. 2021;41(2):595-608. doi: 10.1148/rg.2021200112

8. Adhikari S, Blaivas M, Lander L. Comparison of bedside ultrasound and panorex radiography in the diagnosis of a dental abscess in the ED. Am J Emerg Med. 2011;29(7):790-5. doi: 10.1016/j.ajem.2010.03.005

9. Jaswal S, Patil N, Singh MP, Dadarwal A, Sharma V, Sharma AK. A Comparative Evaluation of Digital Radiography and Ultrasound Imaging to Detect Periapical Lesions in the Oral Cavity. Cureus. 2022;14(10):e30070. doi: 10.7759/cureus.30070

10. Barton MF, Al Jalbout N, Barton BL, Alnuaimi M, Shokoohi H. Novel techniques in performing extraoral ultrasound in diagnosing dental abscesses. Am J Emerg Med. 2023;70:57-60. doi: 10.1016/j.ajem.2023.05.002

11. Mair M, Mahmood S, Fagiry R, Mohamed Ahmed M, Rajaram K, Baker A, Avery C. Comparative analysis of paediatric and adult surgically drained dental infections at a university teaching hospital. Br J Oral Maxillofac Surg. 2020;58(10):e307-e311. doi: 10.1016/j.bjoms.2020.08.043

12. Welti R, Ravindra D, Teoh L, Sloan A, Burgner D, Silva M. The use of antibiotics in the management of odontogenic facial swellings in children and adolescents: A scoping review. J Dent. 2025;153:105523. doi: 10.1016/j.jdent.2024.105523.

13. Leroy R, Bourgeois J, Verleye L, Carvalho JC, Eloot A, Cauwels R, Declerck D. Are systemic antibiotics indicated in children presenting with an odontogenic abscess in the primary dentition? A systematic review of the literature. Clin Oral Investig. 2021;25(5):2537-2544. doi: 10.1007/s00784-021-03862-3

14. Thikkurissy S, Rawlins JT, Kumar A, Evans E, Casamassimo PS. Rapid treatment reduces hospitalization for pediatric patients with odontogenic-based cellulitis. Am J Emerg Med. 2010;28(6):668-72. doi: 10.1016/j.ajem.2009.02.028

15. Lin YT, Lu PW. Retrospective study of pediatric facial cellulitis of odontogenic origin. Pediatr Infect Dis J. 2006;25(4):339-42. doi: 10.1097/01.inf.0000216202.59529.3d

16. Holmberg P, Hellmich T, Homme J. Pediatric Sepsis Secondary to an Occult Dental Abscess: A Case Report. J Emerg Med. 2017;52(5):744-748. doi: 10.1016/j.jemermed.2016.12.034

Related posts:

Gas Forming Pyogenic Liver Abscess Diagnosed by Point of Care Ultrasound  Comparison of Six Handheld Ultrasound Devices by Pediatric Point of Care Ultrasound (POCUS) Experts Evaluating a Lung Abscess in a Pediatric Patient using Point of Care Ultrasound (POCUS)

(1) Attending Physician, Assistant Professor, Department of Anesthesiology and Critical Care, George Washington School of Medicine and Health Sciences, Washington DC, USA

(2) Resident Physician, Department of Anesthesiology and Critical Care Medicine, The George Washington School of Medicine and Health Sciences, Washington DC, USA

(3) Medical Student, The George Washington School of Medicine and Health Sciences, Washington DC, USA

(4) Resident Physician, Department of Otolaryngology, George Washington School of Medicine and Health Sciences, Washington DC, USA

(5) Professor, Department of Anesthesiology and Critical Care, George Washington School of Medicine and Health Sciences, Washington DC, USA

(6) Attending Physician, Associate Professor, Department of Anesthesiology and Critical Care, George Washington School of Medicine and Health Sciences, Washington DC, USA

*Corresponding Author:  Dr. Jevaughn Davis (email: jevdavis@mfa.gwu.edu)

Download article PDF – POCUS Journal 2026;11(1):77-81

DOI: https://doi.org/10.24908/pocusj.v11i01.19821

Abstract

Background: Multiple assessment tools are available to evaluate for difficult mask ventilation. Obstructive sleep apnea (OSA) is a known risk factor. In this observational study, patients were screened using the STOP-BANG questionnaire. Submandibular point of care ultrasound (POCUS) was performed to determine the correlation between ultrasound findings and difficult mask ventilation. Methods: POCUS was performed to measure tongue thickness (TT), geniohyoid muscle thickness (GMT), distance between lingual arteries (DLA), lateral pharyngeal wall thickness (LPW), hyomental distance (HMD), and oral cavity height (OCH). The results were analyzed to determine the correlation with difficult mask ventilation scores. Results: TT, GMT, DLA, and HMD were larger in those with STOP-BANG scores ≥ 3. OCH was larger for those with STOP-BANG score ≥ 5. TT was greater when mask ventilation required oral airway adjunct (p = 0.044) or management by two anesthesia practitioners (p = 0.006). The DLA was higher when mask ventilation required management by two anesthesia practitioners (p < 0.001) and higher when an oral airway adjunct was required (p = 0.056). Increased TT was associated with a higher mask ventilation score (odds ratio [OR] 1.152, 95% confidence interval [95%CI] 1.011–1.314, p = 0.034). A larger DLA was associated with increased odds of difficult mask ventilation (OR 1.207, 95% CI 1.1–1.324, p < 0.001). Conclusions: Submandibular POCUS could potentially be used to identify difficult mask ventilation in patients suspected of having OSA based on the STOP-BANG questionnaire.

Introduction

Mask ventilation of an apneic patient is an essential component of airway management. The American Society of Anesthesiologists (ASA) considers mask ventilation difficult when an anesthesiologist cannot maintain an oxygen saturation of greater than 90% using 100% oxygen during positive pressure ventilation without assistance [1]. Assessment tools such as the Mallampati classification, mouth opening, and upper lip bite are widely used to evaluate the airway to predict difficulty in airway management. These tools have variable predictive value, and unanticipated difficult mask ventilation may still occur despite thorough use during preoperative clinical evaluation.

Certain patient conditions, such as obstructive sleep apnea (OSA), may increase the risk for difficult mask ventilation [2,3]. Patients with OSA are three to four times more likely to experience difficult mask ventilation, intubation, or both compared to patients without OSA [4]. Most cases of OSA are undiagnosed and untreated despite a high prevalence in the population [5]. The STOP-BANG questionnaire is a validated screening tool used to identify individuals at high risk for OSA. The presence of snoring, daytime somnolence, observed apnea, hypertension, body mass index (BMI) greater than 35 kg/m², age over 50 years, neck circumference greater than 40 cm, and male gender have been positively correlated with an OSA diagnosis [6]. Scores range from 0 to 8 and scores of 0 to 2 are considered low risk, scores 3 to 4 moderate risk, and scores of 5 or higher are considered high risk for moderate to severe OSA [7]. The STOP BANG questionnaire has been validated for identifying patients at risk for OSA in the perioperative period as well [8].

Point of care ultrasound (POCUS) is increasingly used perioperatively for airway assessment but the techniques are novel and studies are limited [8,9]. Previous studies have suggested that submandibular POCUS measurements of the oral cavity can help predict difficult mask ventilation, particularly tongue thickness (TT) and the distance between lingual arteries (DLA) [10,11]. Other studies have found a correlation between TT, geniohyoid muscle thickness (GMT), lateral pharyngeal wall thickness (LPW), and the DLA with the severity of OSA [11,12].

To test these observations, patients were screened for OSA using the STOP-BANG questionnaire and those at high risk were identified based on their STOP-BANG score. Anatomical airway measurements were then assessed using POCUS. We hypothesized that patients with increased submandibular POCUS measurements are correlated with a higher risk for OSA and, consequently, for difficult mask ventilation. The goal of this study was to determine if point of care airway ultrasonography is a reliable diagnostic tool for identifying patients who will have difficult mask ventilation.

Methods

This study was approved by the George Washington Institutional Review Board as a prospective observational study. Patients aged 18 years or older undergoing planned elective surgery with planned utilization of general anesthesia requiring positive pressure ventilation by mask were included. Exclusion criteria included patients with relative contraindications to mask ventilation, such as known recent food ingestion, pregnancy, severe gastroesophageal reflux, severe hiatal hernia, or those undergoing an emergency procedure. Recorded demographic information included age, sex, BMI, neck circumference, history of OSA, continuous positive airway pressure (CPAP) use, Mallampati classification, STOP-BANG score, and comorbid conditions.

Ultrasonographic images were obtained using a 3 to 8 MHz curvilinear probe and a SonoSite X-porte ultrasound system (FujiFilm, Philips Healthcare, Bothell, WA). Patients were scanned preoperatively in the supine position and had six airway dimensions evaluated. The six measurements taken were TT, GMT, DLA, LPW, hyomental distance (HMD), and oral cavity height (OCH). Measurements were made in real time while examining the patients, and the images were saved.

Patients were preoxygenated and underwent intravenous (IV) induction. Agents used for induction were not standardized and were determined by the anesthesia provider. Mask ventilation was initiated by the anesthesia provider, and the level of difficulty was evaluated. Mask ventilation difficulty level was determined using the scoring system proposed by Han et al [2]. A score of 1 was assigned for successful mask ventilation without assistance, 2 for mask ventilation requiring an airway adjunct, 3 for mask ventilation requiring two providers, and 4 for unable to mask ventilate [13]. Successful mask ventilation was defined as the sustained presence of end tidal carbon dioxide (ETCO₂) and capnography waveform.

De-identified data were recorded using Microsoft Excel (Microsoft Corp, Redmond, WA). Descriptive analyses, including frequency and measures of central tendency such as mean and standard deviations, were performed using Statistical Product and Service Solutions (International Business Machines, Armonk, NY), version 28. Chi-square and Pearson’s correlation were used to determine the association between categorical patient characteristics (e.g., sex, BMI by category, and STOP-BANG score by cut score) and mask ventilation score. The Kruskal-Wallis test was used to examine the relationship between airway POCUS measurements and STOP-BANG scores as seen in Tables 1 and 2. Multivariable logistic regression was used to determine the association between independent variables and ventilation score. A p-value of less than 0.05 was considered significant.

Results

There were 92 patients enrolled in the study, and 91 patients were included in the final analysis. One patient was excluded after consenting to participate, but preoperative POCUS was not performed. The mean age of enrolled patients was 51.3 years, standard deviation (SD) 17.3 years (Table 3). Of those enrolled, 62% were female and 18% had a history of OSA. Nearly half (48%) were obese (BMI ≥ 30), 26% were overweight (BMI 25–30), and 25% had a BMI between 18.5 and 25. There was a 50% prevalence of a STOP-BANG score of 3 or greater.In the cohort, 66% of patients had a mask ventilation difficulty score of 1, 28% had a score of 2, and 7% had a score of 3. No patients had a score of 4.

Age and sex were not significantly associated with difficult mask ventilation (p = 0.2 and p = 0.5, respectively). A STOP-BANG score greater than 3, representing higher risk of OSA, was associated with a higher mask ventilation score (p < 0.01).

Patients with STOP-BANG scores indicating moderate or higher risk of OSA (≥ 3) had significantly increased TT, GMT, DLA, and HMD (Table 4 and 5). Those with a STOP-BANG score ≥ 5 had significantly increased OCH, compared to those with STOP-BANG scores between 0 and 4.

Patients with a mask ventilation score of 2 or 3 had significantly greater TT and LPW (Table 6). Patients with mask ventilation scores of 2 or greater also had significantly increased DLA compared to those with a score of 1.

Increased BMI, TT, and DLA were associated with significantly increased probability of a higher mask ventilation score in a multivariate logistic regression model (Table 6). A BMI score greater than 30 was significantly associated with a mask ventilation score of ³2 (odds ratio [OR] 1.02, 95% confidence interval [95%CI] 1.01–1.03, p < 0.01). TT greater than 0.134 was associated with higher odds of mask ventilation score 2 (OR 1.15, 95%CI 1.01–1.31, p = 0.03). DLA greater than 0.188 was also associated with mask ventilation score 2 (OR 1.21, 95%CI 1.1–1.32, p < 0.01).

Discussion

Difficulty in airway management can occur when there is an inability to mask ventilate, inability to intubate, or both. Inadequate mask ventilation may require an oral or nasal airway adjunct and/or a second practitioner to facilitate a two-handed technique. Our findings suggest POCUS may be useful in predicting difficult mask ventilation.

We demonstrated that preoperative submandibular POCUS can be used to measure several oral cavity parameters that correlate with increased difficulty in mask ventilation. Greater TT, DLA, and LPW measurements were observed among patients who experienced increased difficulty with mask ventilation. TT, DLA, and elevated BMI were independently associated with increased odds for difficult ventilation. Lin et al. have also studied ultrasound measurements and difficult mask ventilation, but found a correlation with higher tongue-base thickness and longer DLA, which were similar to our findings [11]. Similarly, Padhy et al. found that a DLA above 30.78 mm was the single most important predictor of difficult mask ventilation [14,15].

Beyond the current understanding of airway ultrasound evaluation and prediction of difficult mask ventilation, we found that GMT and HMD are increased in patients with mask ventilation scores of 2 compared to those with a score of 1. We did not find a difference when analyzing the entire group, including those with a mask ventilation score of 3. This could be due to a small sample size of four patients with a mask ventilation score of 3. A larger sample size would be needed to make a concrete statement on predictability of these variables for difficult ventilation. Further studies with larger sample sizes are needed for validity and generalizability to the general populace.

In addition to predicting difficulty with mask ventilation, it is important to evaluate for OSA in the perioperative period. While only TT and DLA were associated with increased risk for difficult mask ventilation, all airway POCUS measurements that were evaluated in this study correlated with a STOP-BANG score of 3 and increased risk for OSA. Prior studies showed that increased tongue base thickness was associated with increased OSA severity [16]. Our results suggest the clinical utility of airway POCUS may exceed just predicting difficulty with mask ventilation. POCUS evaluation of the airway in the preoperative period may help identify patients with OSA who are prone to airway collapse and obstruction throughout the perioperative period.

Airway POCUS can be time consuming and requires expertise compared to utilizing the STOP-BANG questionnaire to screen patients. STOP-BANG has been validated to predict difficult mask ventilation [9]. Similarly, in our study, we found a correlation between STOP-BANG and mask ventilation scores (p = 0.002). Khan et al. found that the STOP-BANG score has a high negative predictive value, which can be used to rule out difficult mask ventilation. In their study, 39.5% of patients with a STOP-BANG score of 3 or more were difficult to mask ventilate, compared to 7.5% in patients with a score less than 3 [16]. While a STOP-BANG evaluation is highly valuable and requires less skill and time, it is somewhat dependent on the reliability of patients self-reporting, which may be limited if patients are unaware of certain symptoms. Given the high incidence of OSA and the potential for patients to misreport symptoms, airway POCUS may have value. The additional time and expertise required for airway POCUS compared to utilizing the STOP-BANG questionnaire may yield a greater ability to screen for OSA.

Our study has some limitations. There is often anatomical variation between patients and obtaining an ideal view of the oral cavity (i.e., a clear outline of the tongue) may not always be possible. Moreover, experience levels of sonographers vary, which can affect the measurements that are obtained. In addition, we only looked at difficult mask ventilation which may not translate to difficult intubation. In fact, a recent study by Lin et al. suggested that submental ultrasound (i.e., using TT and DLA) was effective in predicting difficult mask ventilation but not difficult direct laryngoscopy [10]. Future studies will need to enroll a larger and more heterogeneous sample size to determine validity and applicability of our findings in the general population.

Conclusion

Submandibular POCUS is a simple technique that can be used to assess upper airway anatomy. Higher scores on the STOP-BANG screening tool, an indicator of moderate-severe OSA, and higher measurements of certain airway parameters—specifically GMT and HMD—obtained on submandibular POCUS are correlated with difficult mask ventilation. Our report suggests there may be more parameters that can be used for identifying potential difficulty with mask ventilation. We also suggest airway POCUS may be valuable in screening for OSA in the perioperative period.

Acknowledgements

We acknowledge the support of George Washington University Department of Anesthesiology and Critical Care and the contributions of all participants who made this research possible.

Ethics Statement

The study protocol was reviewed and was approved by the Institutional Review Board, NCR: 203147.

Disclosure Statement

No potential conflict of interest relevant to this article was reported.

Funding

There is no external funding to be declared.

Author Contributions

JD: data curation, formal analysis, investigation, methodology, writing – original draft, writing – review & editing. EC: data curation, formal analysis, writing – original draft, writing – review & editing. DL: data curation, writing – original draft. EL: data curation, formal analysis, writing – review & editing. MD: formal analysis, supervision, writing – original draft, writing – review & editing. RK: formal analysis, supervision, writing – original draft, writing – review & editing. AV: data curation, resources, supervision, writing – original draft, writing – review & editing. EH: conceptualization, data curation, formal analysis, supervision, writing – original draft, writing – review & editing.

References

1. Practice guidelines for management of the difficult airway: a report by the American Society of Anesthesiologists’ task force on management of the difficult airway. Anesthesiology. 1993;78(3):597-602.

2. Kheterpal S, Han R, Tremper KK, Shanks A, Tait AR, O’Reilly M, Ludwig TA. Incidence and predictors of difficult and impossible mask ventilation. Anesthesiology. 2006;105(5):885-91.

3. Leong SM, Tiwari A, Chung F, and Wong DT. Obstructive sleep apnea as a risk factor associated with difficult airway management – a narrative review. J Clin Anesth. 2018;45:634-68.

4. Chung F, Yegnesswaran Pu L, Chung SA, Vairavanathan S, Islam S, Khajehdehi A, Shapiro CM. STOP questionnaire: a tool to screen patients for obstructive sleep apnea. Anesthesiology. 2008;108(5):812-21.

5. Singh M, Liao P, Kobah S, Wijeysundera DN, Shapiro C, and Chung F. Proportion of surgical patients with undiagnosed obstructive sleep apnoea. Br J Anaesth. 2013;7(2):155-159.

6. Chung F, Abdullah HR, Liao P. STOP-Bang Questionnaire: A Practical Approach to Screen for Obstructive Sleep Apnea. Chest. 2016;149(3):631-8.

7. Chung F, Subramanyam R, Liao P, Sasaki E, Shapiro C, Sun Y. High STOP-Bang score indicates a high probability of obstructive sleep apnoea. Br J Anaesth. 2012;108(5):768-75.

8. Hwang M, Nagappa M, Guluzade N, Saripella A, Englesakis M, Chung F. Validation of the STOP-Bang questionnaire as a preoperative screening tool for obstructive sleep apnea: a systematic review and meta-analysis. BMC Anesthesiol. 2022;22(1):366.

9. Carsetti A, Massimiliano S, Adrario E, Donati A, Falcetta S. Airway Ultrasound as Predictor of Difficult Direct Laryngoscopy: A Systematic Review and Meta-analysis. Anesth Analg. 2022;134(4):740-750.

10. Austin DR, Chang MG, Bittner EA. Use of Handheld Point-of-Care Ultrasound in Emergency Airway Management. Chest. 2021;159(3):1155-1165.

11. Bianchini A, Nardozi L, Nardi E, Scuppa MF. Airways ultrasound in predicting difficult face mask ventilation. Minerva Anestesiol. 2021;87(1):26-34.

12. Lin HY, Tzeng IS, Hsieh YL, Kao MC, Huang YC. Submental Ultrasound Is Effective in Predicting Difficult Mask Ventilation but Not in Difficult Laryngoscopy. Ultrasound Med Biol. 2021;47(8):2243-2249.

13. Bilici S, Engin A, Ozgur Y, Ozlem Onerci C, Ahmet Gorkem Y, Aytul Hande Y. Submental Ultrasonographic Parameters among Patients with Obstructive Sleep Apnea. Otolaryngol Head Neck Surg. 2017;156(3):559-566.

14. Khan MN, Ahmed A. Accuracy of STOP-Bang Questionnaire in Predicting Difficult Mask Ventilation: An Observational Study. Cureus. 2021;13(6):e15955. doi: 10.7759/cureus.15955

15. Padhy S, Pady N, Patro A, Kar AK, Jonnavithula N, and Durga P. Submental ultrasound for assessment of difficult mask ventilation in patients with obstructive sleep apnoea posted for surgery under general anaesthesia. A prospective observational study. Trends in Anaesth and Crit Care. 2021;41:61-68.

16. Han R, Tremper KK, Kheterpal S, O’Reilly M. Grading scale for mask ventilation. Anesthesiology. 2004;101(1):267.

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(1) Master’s Program, Paulo Picanço School of Dentistry, Fortaleza, CE, Brazil

(2) Postgraduate Program in Dentistry, Federal University of Ceará, Fortaleza, CE, Brazil

(3) Paulo Picanço School of Dentistry, Fortaleza, CE, Brazil

*Corresponding Author: Rachel Brazuna Solidonio (email: rachelsolidonio27@gmail.com)

Download article PDF – POCUS Journal 2026;11(1):82-85

DOI: https://doi.org/10.24908/pocusj.v11i01.19968

Abstract

Point of care ultrasound (POCUS) is becoming an essential tool in aesthetic medicine, allowing clinicians to evaluate tissues in real time and respond promptly to complications. We present the case of a 42-year-old woman with diabetes who developed swelling, pain, and purulent drainage shortly after undergoing nonsurgical rhinoplasty with hyaluronic acid and polydioxanone (PDO) threads. POCUS quickly revealed an abscess surrounding a thread knot as well as additional fluid collections along the nasal dorsum. These findings guided the surgical plan and enabled real-time visualization during thread removal, improving safety and ensuring complete extraction. Histology later confirmed granulomatous inflammation. The patient recovered without further issues. This case illustrates how POCUS can assist in diagnosing and guiding the treatment of aesthetic complications, reinforcing its value as a simple, non-invasive tool that enhances patient safety and outcomes in everyday clinical practice.

Introduction

The rising popularity of minimally invasive aesthetic treatments has sparked a surge in the use of barbed polydioxanone (PDO) threads, especially for subtle enhancements like shaping the nose. These threads provide a non-surgical option that comes with benefits such as being absorbable, biocompatible, and generally well tolerated by patients. They come in both smooth and barbed varieties, encouraging collagen production and, in the case of the barbed threads, offering mechanical lifting and gradual skin tightening [1].

While PDO threads are generally considered safe, they can still lead to some adverse effects, which may range from minor issues to more serious complications like infections or tissue damage. In such cases, point of care ultrasound (POCUS) has proven to be an invaluable tool for both diagnosis and intervention. POCUS allows for accurate, real-time localization of threads and precise assessment of surrounding anatomical structures, directly at the patient’s bedside. This case report discusses a complication that arose after using PDO threads for nasal tip projection, highlighting the POCUS-assisted removal technique and the histopathological findings, thereby emphasizing the critical role of this imaging modality in enhancing patient safety and optimizing outcomes in aesthetic medicine.

Case Presentation

The patient was a 42-year-old woman with diabetes. She sought care after undergoing a nasal remodeling procedure that involved the application of hyaluronic acid and the insertion of three PDO threads for nasal support. Three days after the procedure, she began experiencing intense pain, redness, and purulent discharge in the nasal region. Clinical examination confirmed the presence of discharge.

Initial treatment included the application of hyaluronidase, as well as antibiotic therapy with cephalexin (500 mg, every 8 hours for 7 days) and dexamethasone (2 mg, every 6 hours for 2 days). Laser therapy was also performed (Therapy XT, DMC Equipamentos, São Carlos – Brazil), using 3 joules distributed at specific points on the nose, root, dorsum, and tip, with 30 seconds of application at each site. The therapy combined red and infrared wavelengths, aiming to promote healing, reduce inflammation, and drainage.

To complement the evaluation, POCUS was used (SAEVO – EVUS 5, Alliage S/A Dental Medical Industries, Ribeirão Preto – Brazil). POCUS showed a poorly defined area, compatible with fluid accumulation (abscess). It involved a dense and highly reflective structure at the center of the lesion, suggesting a PDO thread knot encapsulated by pus (Figure 1A, 1B). Additionally, it was possible to identify the three threads aligned along the nasal dorsum using POCUS, located in the subcutaneous layer and surrounded by hypoechoic areas, reinforcing the diagnosis of an inflammatory process along the thread paths (Figure 1B). This information was essential for surgical planning.

Given the situation, surgical removal of the threads with real-time POCUS guidance was chosen. POCUS allowed for monitoring the introduction of the cannula and the removal of the threads, making the procedure safer and more precise.

Anesthesia was performed by blocking the infraorbital foramen with 2% mepivacaine with epinephrine 1:100,000 (DFL Indústria e Comércio S.A, Rio de Janeiro – Brazil), in addition to extraoral local anesthesia with mepivacaine without vasoconstrictor applied to the nasal dorsum. Incisions were made with a No. 15 scalpel blade (Solidor, Itaipava – Brazil) on the columella and nasal dorsum, at points previously identified by POCUS. Through these openings, the PDO threads were visualized and carefully removed with surgical forceps (Golgran, São Caetano – Brazil) (Figure 1C, Figure 2). Continuous POCUS guidance helped to minimize tissue damage and ensure complete removal.

After surgery, the thread surrounded by granulomatous tissue was fixed in 10% formalin (EXODO CIENTÍFICA – Sumaré/SP – Brazil) and processed for a histological slide stained with hematoxylin and eosin (Dinâmica Química Contemporânea LTDA, Indaiatuba/SP – Brazil). This allowed for microscopic analysis of the inflammatory process (Figure 3A, 3B).

Discussion

The use of barbed PDO threads in rhinoplasty has grown in popularity as a minimally invasive alternative to traditional surgical techniques [1]. These threads are capable of reshaping the nasal contour and stimulating collagen production, providing natural and progressive results with shorter recovery times [1]. Nonetheless, their widespread utilization has been paralleled by an increase in reported complications. The most frequent adverse outcomes include skin wrinkling, extrusion, thread breakage, and, on histology, fibrosis and encapsulation [2,3].

Although less prevalent, local infections represent one of the most critical complications due to their potential to progress to granuloma formation, necrosis, and scarring [4,5]. Surowiak et al. described postoperative bacterial infection related to PDO threads, while Goldan et al.  reported cyst formation after thread placement [4,5]. These studies reinforced that although the global incidence of infection is relatively low (2–8.9%), anticipation and early recognition are essential [1,3-6]. This is particularly relevant in high-risk patients, including those with diabetes, who exhibit impaired vascularization and wound healing that may predispose them to more severe outcomes [4,5].

In the present case, clinical findings of purulent drainage were supported by histopathological evidence of necrosis and granulomatous inflammation consistent with a foreign-body reaction, as previously reported [2,6]. Granuloma formation resulting from persistent inflammatory activity has been repeatedly associated with PDO threads and underscores the complexity of management once bacterial contamination occurs.

The most distinctive feature here, however, was the decisive role of POCUS. Previous authors have emphasized that POCUS enables accurate visualization of soft tissues, thread trajectory, and secondary inflammatory changes [7,8]. Mlosek et al. also described how high-frequency ultrasound can characterize nodular and fibrotic complications following thread insertion [9]. In our case, POCUS not only identified an abscess surrounding a central PDO knot, but also delineated fluid collections along the thread pathway, permitting precise mapping of the lesion. During surgery, POCUS provided real-time guidance for cannula introduction and thread removal, enhancing safety and minimizing unnecessary tissue trauma. This practical contribution has also been suggested by Schelke et al., who demonstrated POCUS-guided approaches in the management of filler-related vascular complications [10].

Preventive measures remain a cornerstone in minimizing risks. Bertossi et al. suggested that antibiotic prophylaxis could be considered in patients with systemic comorbidities, although not universally applied [1]. Ryoo et al. further highlighted that improper thread insertion depth increases the likelihood of ischemic complications and subsequent infection [8]. In this case, it is plausible that superficial placement of threads at the nasal tip, compounded by the patient’s diabetic status, provided the substrate for early infectious complications.

In summary, this case reinforces that POCUS is a valuable adjunct in aesthetic practice, both for early diagnosis and for guiding intervention. Incorporating POCUS into clinical protocols for minimally invasive procedures offers the potential to improve diagnostic accuracy, reduce complications, and enhance patient safety, especially in high‑risk groups such as diabetics.

Ethics Statement

This study was approved by the Research Ethics Committee of Faculdade Paulo Picanço (CAAE: 86587825.0.0000.9267), and written informed consent was obtained from the patient for publication of this case report and its accompanying images.

Disclosure Statement

The authors declare no conflicts of interest.

Funding

This research was funded by the authors’ own resources, with no external financial support from public, commercial, or not-for-profit funding agencies.

Author Contributions

RAS: investigation, writing – original draft. RBS: conceptualization, methodology, formal analysis, data curation, writing – original draft, visualization. LBM: writing – review & editing, supervision. DAFB: investigation. TMMB: formal analysis, data curation. DVG: conceptualization, methodology, writing – original draft, Writing – review & editing, supervision. LMS: investigation, formal analysis, data curation, writing – review & editing, supervision.

References

1. Bertossi D, Botti G, Gualdi A, Fundaro P, Nocini R, Pirayesh A, van der Lei B. Effectiveness, longevity, and complications of facelift by barbed suture insertion. Aesthet Surg J. 2019;39(3):241–247.

2. Sardesai MG, Zakhary K, Ellis DA. Thread-lifts: the good, the bad, and the ugly. Arch Facial Plast Surg. 2008;10(4):284–285.

3. Li Y, Zhang Y, Wang Z, Zhang Y, Li Y, Zhang Y. Facial thread lifting complications in China: analysis and treatment. Plast Reconstr Surg Glob Open. 2021;9(9):e3567.

4. Surowiak P. Barbed PDO thread face lift: a case study of bacterial complication. Plast Reconstr Surg Glob Open. 2022;10(3):e4157.

5. Goldan O, Bank J, Regev E, Haik J, Winkler E. Epidermoid inclusion cysts after APTOS thread insertion: case report with clinicopathologic correlates. Aesthet Plast Surg. 2008;32(1):147–148.

6. Carrasco GV, Hiramatsu Azevedo L, da Silva AC, Lobo MM, Kirschner R, Moreira de Freitas P. Antimicrobial photodynamic therapy in the approach of complication after implantation of spiculated polydioxanone threads. Cureus. 2023;15(7):e42418.

7. Qiao J, Jia QN, Jin HZ, Li F, He CX, Yang J, Zhang XY, Zhao ZY. Long-term follow-up of longevity and diffusion pattern of hyaluronic acid in nasolabial fold correction through high-frequency ultrasound. Plast Reconstr Surg. 2019;144(2):189e–196e.

8. Ryoo HJ, Kwon H, Choi JS, Sohn BS, Yoo JY, Shim HS. Prospective analysis of the effectiveness of targeted botulinum toxin type A injection using an ultrasound-guided single-point injection technique for lower face contouring. J Clin Med. 2024;13(17):5337.

9. Mlosek RK, Migda B, Skrzypek E, Sloboda K, Migda M. The use of high-frequency ultrasonography for the diagnosis of palpable nodules after the insertion of PDO threads. J Ultrason. 2021;21(87):e1–e6.

10 Schelke LW, Velthuis P, Kadouch J, Swift A. Early ultrasound for diagnosis and treatment of vascular adverse events with hyaluronic acid fillers. J Am Acad Dermatol. 2023;88(1):79–85.

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Emergency Department, Fundación Instituto Neurológico de Colombia, Medellín, Colombia

*Corresponding Author:  Dr. Felipe Hernández-Restrepo (email: fhr523@gmail.com)

Download article PDF – POCUS Journal 2026;11(1):86-88

DOI: https://doi.org/10.24908/pocusj.v11i01.19937

Abstract

We report the case of a 30-year-old woman with no relevant medical history who presented with a new-onset headache associated with nausea, vomiting, photophobia, phonophobia, and right nasal hemianopsia. Ocular point of care ultrasound (POCUS) examination revealed a hyperechoic lesion adhered to the vascular layer that did not move with eye movements. The patient was referred to ophthalmology, where choroidal melanoma was confirmed. Extension studies showed no metastases, and enucleation was performed. This case highlighted the importance of ocular POCUS in the diagnostic approach to this patient.
 

Introduction

Intraocular neoplastic lesions are uncommonly diagnosed in emergency settings. However, neoplasms such as uveal melanoma can be catastrophic, with a 5-year survival rate of up to 30%, highlighting the importance of timely diagnosis [1,2]. While intraocular neoplastic lesions should be considered in patients with visual symptoms, other conditions such as stroke, acute glaucoma, or retinal detachment, are more common [3].

We report the case of a patient who presented with a headache and nonspecific ocular symptoms whose diagnosis was aided by ocular POCUS examination.

Case Presentation

A 30-year-old woman with no significant medical history presented to the emergency department with a 2-day history of pulsatile occipital headache, associated with nausea, vomiting, photophobia, and phonophobia. She also reported right nasal hemianopsia but denied ocular pain. The symptoms did not improve with nonsteroidal anti-inflammatory drugs and acetaminophen. Of note, the patient did not typically suffer from headaches. On admission, her vital signs were normal and her neurological exam confirmed hemianopsia without focal deficits or other visual disturbances.

As our facility lacked an ophthalmology service, a comparative ocular POCUS was performed (Figures 1 and 2). This examination revealed a normal posterior chamber in the left eye but a hyperechoic lesion in the right eye, adhered to the vascular layer and non-mobile with eye movements. A non-contrast brain computed tomography (CT) scan was ordered, which showed no space-occupying lesions but confirmed the intraocular lesion (Figure 3).

Due to the lack of an ophthalmology service at our facility, the patient was referred to another institution. There, fundoscopic examination described a large, pigmented mass in the inferotemporal retina with orange pigment and surrounding subretinal fluid. Enucleation was proposed, and pathology confirmed a diagnosis of mixed choroidal melanoma.

Discussion

Choroidal melanoma is a malignant lesion of the uveal tract. Despite its relative rarity, it is the most common ocular melanoma, occurring more frequently in younger women [1,4]. The clinical presentation for choroidal melanoma is usually nonspecific, which often leads to consideration of other differential diagnoses in the emergency department, such as acute glaucoma, stroke, or retinal detachment. A well-conducted physical exam and fundoscopic evaluation are critical for diagnosis. Ocular POCUS can complement the physical exam by evaluating the posterior chamber and ruling out common conditions such as retinal detachment, vitreous hemorrhage, lens dislocations, or, as in this case, ruling in a neoplastic lesion [4,5].

Ocular POCUS is relatively easy to perform because the eye’s high liquid content provides an excellent medium for sound transmission. This allows detection of lesions that appear hyperechoic within the aqueous humor, as observed in this case. Some authors have suggested that the learning curve for emergency physicians is relatively short, as this examination is quick, easy to perform, and non-invasive [6].

Timely diagnosis is essential for intraocular neoplastic lesions as they are highly invasive, with a predilection for the liver and skin. Enucleation and chemotherapy are the main treatments to prevent progression and/or metastatic dissemination [7].

Conclusion

Intraocular neoplastic lesions are rare in emergency settings. For patients with nonspecific symptoms, physical examination can be supplemented by ocular POCUS, which can suggest neoplasia when non-mobile solid lesions are detected. In this case, ocular POCUS contributed to the appropriate management of the patient.

Ethics Statement

This manuscript has been approved by the ethics committee.

Disclosure Statement

The authors declare no conflicts of interest.

Funding

The authors received no financial support, funding, or material support for the research, authorship, and/or publication of this manuscript.

Author Contributions

FHR: conceptualization, investigation, data curation, writing – original draft, writing – review & editing. SHM: investigation, data curation, writing – review & editing. ACO: conceptualization, methodology, supervision, validation, writing – review & editing.

References

1. Grin-Jorgensen C, Berke A, Grin M. Ocular melanoma. Dermatol Clin. 1992;10(4):663-8.

2. Shields CL, Manalac J, Das C, Ferguson K, Shields JA. Choroidal melanoma: clinical features, classification, and top 10 pseudomelanomas. Curr Opin Ophthalmol. 2014;25(3):177-85.

3. DeSimone JD, Shields CN, Kalafatis NE, et al. Clinics in Dermatology. Clin Dermatol. 2024;42(1):38-45.

4. Shields CL, Shields JA. Recent developments in the management of choroidal melanoma. Current Opinion in Ophthalmology. 2004;15(3):244-251. doi: 10.1097/01.icu.0000120713.35941.e4

5. Builes SV, Gonzalez VG, Cardozo A. Using point-of-care ultrasound in ocular emergencies: A mini review. J Acute Dis. 2020;9(5):190-3.

6. Calle Morales MI, Duque Hurtado C, Moreira Accame M, Perdomo Amar MA, Rendón Jiménez JC, Soley Gutiérrez L, Saldarriaga Londoño M. Guías para el entrenamiento en ultrasonido de emergencias / Guidelines for emergency ultrasound training. Rev Argent Ultrason. 2013;12(2):86–98.

7. Faretta M, Cardozo L, Rocco C, Schweitzer C, Villalba J, Settecase F, Venancio P, Valeiras A. Melanoma coroideo en paciente joven: a propósito de un caso clínico. Oftalmol Clin Exp. 2024;17(2):e270-e277.

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Terson Syndrome Diagnosed by Ocular Point of Care Ultrasound on the Medical Floor  Acute Traumatic Cataract Diagnosed by Ocular Point of Care Ultrasound (POCUS) in the Emergency Department Asteroid Hyalosis: A Mimicker of Vitreous Hemorrhage on Point of Care Ultrasound: A Case Report.

(1) Department of Emergency Medicine, Nicklaus Children’s Hospital, Miami, FL, USA

(2) Department of Pediatric Urgent Care, Nicklaus Children’s Hospital, Miami, FL, USA

(3) Duke University, Durham, NC, USA

*Corresponding Author: Dr. Paul Khalil (email: Paul.Khalil@nicklaushealth.org)

Download article PDF – POCUS Journal 2026;11(1):89-91

DOI: https://doi.org/10.24908/pocusj.v11i01.20121

Abstract

Achilles tendon injury is uncommon in children but is often caused by direct trauma to the posterior ankle. The diagnosis of Achilles tendon involvement after injury may be inadequate when based solely on physical examination findings. There is limited literature describing the identification of Achilles tendon injury in the pediatric population with point of care ultrasound (POCUS). This case series describes two patients with ankle lacerations in whom Achilles tendon involvement was evaluated using POCUS.

Case Presentation

Case 1

A 9-year-old girl presented in the emergency department with a right foot laceration over the medial calcaneus that occurred three hours prior to arrival. She was performing cartwheels at home when, upon landing, she grazed the medial aspect of her ankle against a door latch. She was unable to bear weight on the right foot secondary to pain. Vital signs included blood pressure 132/86 mmHg, temperature of 98.8°F, heart rate of 92 beats/min, respiratory rate of 24 breaths/min, and oxygen saturation of 99%. A physical exam revealed that she had a 5 cm jagged laceration injury extended laterally from the medial process of the calcaneus towards the lateral process. She had good range of motion of the leg, foot, and phalanges. There was no numbness, tingling, or weakness of the lower extremity. Point of care ultrasound (POCUS) was performed, demonstrating an intact Achilles tendon (Figure 1). The patient followed up as an outpatient for suture removal with good range of motion and without complications.

Case 2

A 10-year-old girl presented for right ankle pain due to sustained injury just prior to arrival, where a metal gate was accidentally closed on her right foot. She was able to walk on her toes but with difficulty secondary to pain. Vital signs included blood pressure 120/85 mmHg, heart rate of 82 beats/min, respiratory rate of 24 breaths/min, and oxygen saturation of 99%. A physical exam showed a 5 x 3 cm triangular-shaped laceration on the posterior aspect of the right ankle, horizontally overlying the Achilles tendon, with active bleeding. She was able to perform dorsiflexion and plantarflexion of the right foot, however, she endorsed pain with movement. The right dorsalis pedis pulse was intact. POCUS showed laceration of the Achilles tendon (Figure 2). Orthopedic surgery was consulted and recommended skin closure, immobilization with crutches, and discharge with follow-up. She later returned to the emergency department for persistent pain and was taken to the operating room for wound washout and repair.

POCUS Findings

In both cases, a high-frequency linear probe (L12-3) on a Sonosite PX ultrasound machine was used to examine the ankle. Case 1 showed a laceration superior to the Achilles tendon with no evidence of tendon involvement on sagittal imaging (Figure 1). Case 2 showed a laceration to the Achilles tendon with a hematoma on sagittal imaging (Figure 2).

Technique

A high-frequency linear transducer should be used to image the laceration and the Achilles tendon. Prior to scanning, the probe should be properly cleaned and covered with either a Tegaderm or a sterile transducer cover, as a laceration is an open wound. Sterile gel should be used. The patient should be scanned while lying in prone position with their feet hanging off the bed, if possible. The wound should be scanned in its entirety, along with the Achilles tendon. The Achilles tendon should be scanned in the transverse and sagittal planes using both static and dynamic imaging techniques. The sagittal view can be obtained by placing the probe maker toward the patient’s head and scanning from the calcaneal tuberosity to the distal calf. The transverse view can be obtained by turning the probe so that it is perpendicular to the Achilles tendon and scanning from the calcaneal tuberosity to the distal calf (Figure 3). During dynamic scanning, the patient should be instructed to dorsiflex the foot. Lacerations to the tendon will have disruption of the fibrillary appearance. 

Discussion

Achilles tendon injury is uncommon in children [1]. In one study, from 2012–2016 in the United States, the largest overall incidence of Achilles tendon ruptures occurred in patients ages 20–39 years [1]. Evaluation was conducted by physical examination and showed that the Thompson test and observation of a gap in the normal contour of the tendon are useful but limited tools. Overlying lacerations of the posterior heel also have the potential to mask tendon injuries [2]. One case report by Vasileff & Moutzouros evaluated a 10-year-old boy in whom a posterior heel laceration masked the diagnosis of Achilles tendon injury and led to a subsequent complete Achilles tendon rupture that required open tendon repair [1]. Early diagnosis of Achilles tendon injury is critical. When Achilles tendon injury goes unrecognized, it can lead to prolonged pain and limitations of activity [3].

Medical resonance imaging (MRI) was long thought to be the imaging modality of choice for evaluating an Achilles tendon injury. Over the past decade, multiple studies have shown that ultrasonography is a reasonable alternative tool. In one systematic review of the literature that included 56 studies, ultrasound was recommended over MRI for diagnosing and monitoring an Achilles tendon injury [4]. The study further noted the utility of POCUS for identifying other clinical information about the injury [4].

Several studies and case reports have examined the use of ultrasonography for the evaluation of an Achilles tendon injury. Adhikari et al. described a case in which Achilles tendon injury was successfully diagnosed by POCUS [5]. High-frequency color Doppler ultrasonography (HFCDU) was studied by Lui et al. in 68 patients with suspected Achilles tendon injury [6]. HFCDU evaluation of the laceration showed the Achilles tendon was swollen and thickened, with reduced echogenicity and blurred fiber texture [6]. Analysis of the data showed a sensitivity of 98% in diagnosis of Achilles tendon injury [6]. Another pediatric POCUS case series described POCUS for Achilles tendon rupture [7]. To our knowledge, no other studies examined use of POCUS after open Achilles tendon injuries or for Achilles tendon lacerations in children.

Conclusion

In our pediatric cases, POCUS was used to evaluate Achilles tendon involvement when direct trauma occurred to the posterior heel secondary to lacerations. Identification of Achilles tendon involvement allowed for the appropriate and timely consultation of orthopedic specialists from the time of injury. There is limited research about the evaluation of Achilles tendon with POCUS, particularly after direct trauma and laceration of the posterior heel. More studies—specifically in the pediatric population—are needed to further evaluate this.

Ethics Statement 

This study was exempt from the Institutional Review Board at Nicklaus Children’s Hospital.

Disclosure Statement

The authors declare that they do not have any relevant or material financial interests to declare.

Funding

This research received no external funding.

Author Contribution

ARC: conceptualization, study design, data acquisition and writing – original draft. GR: conceptualization, study design, data acquisition and writing – original draft. OP: data acquisition and writing – review & editing. PK: conceptualization, study design, data acquisition and writing – review & editing.

References

1. Lemme NJ, Li NY, DeFroda SF, Kleiner J, Owens BD. Epidemiology of Achilles Tendon Ruptures in the United States: Athletic and Nonathletic Injuries From 2012 to 2016. Orthop J Sports Med. 2018;6(11):2325967118808238. doi: 10.1177/2325967118808238

2. Singh, D. (2015). Acute Achilles tendon rupture. BMJ (Clinical research ed.), 351, h4722.

3. Vasileff WK, Moutzouros V. Unrecognized pediatric partial Achilles tendon injury followed by traumatic completion: a case report and literature review. J Foot Ankle Surg. 2014;53(4):485-8. doi: 10.1053/j.jfas.2014.02.016.

4. Dams OC, Reininga IHF, Gielen JL, van den Akker-Scheek I, Zwerver J. Imaging modalities in the diagnosis and monitoring of Achilles tendon ruptures: A systematic review. Injury. 2017;48(11):2383-2399. doi: 10.1016/j.injury.2017.09.013

5. Adhikari S, Marx J, Crum T. Point-of-care ultrasound diagnosis of acute Achilles tendon rupture in the ED. Am J Emerg Med. 2012;30(4):634.e3-4. doi: 10.1016/j.ajem.2011.01.029

6. Liu W, Zhuang H, Shao D, Wang L, Shi M. High-Frequency Color Doppler Ultrasound in Diagnosis, Treatment, and Rehabilitation of Achilles Tendon Injury. Med Sci Monit. 2017;4;23:5752-5759. doi: 10.12659/msm.904186

7. Singh A, Poteh N, Kim J, Starr R, Khalil P. Point-of-Care Ultrasound Diagnosis of Achilles Tendon Rupture in Pediatric Patients. Pediatr Emerg Care. 2022;38(3):e1164-e1165. doi: 10.1097/PEC.0000000000002531

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(1) Medical student, EIA University in Medellín, Colombia

(2) Emergency Physician, Neurological Institute of Colombia

*Corresponding Author: Dr. Alejandro Cardozo Ocampo (email: Galeno026@gmail.com)

Download article PDF – POCUS Journal 2026;11(1):92-95

DOI: https://doi.org/10.24908/pocusj.v11i01.19753

Abstract

Point of care ultrasound (POCUS) of the nontraumatic acute abdomen is limited by its low sensitivity for detecting pneumoperitoneum. However, POCUS signs that suggest the presence of free intraperitoneal air have been described in the literature, such as the enhanced peritoneal stripe. We describe a patient who arrived at our emergency department with an acute abdomen that had been present for several hours. POCUS suggested pneumoperitoneum, which was confirmed by abdominal X-ray and the operative finding of  a perforated peptic ulcer. This case highlights the potential role of POCUS as a rapid, non-invasive bedside diagnostic tool in emergency settings, especially when access to other diagnostic aids may be limited or delayed. Recognizing characteristic POCUS signs, including an enhanced peritoneal stripe and reverberation artifacts, can guide early decision-making and expedite surgical intervention. Timely identification of pneumoperitoneum is crucial, because delays in diagnosis are associated with increased morbidity and mortality. This case report reinforces the value of integrating POCUS into the initial evaluation of acute abdominal pain, suggesting its use as an adjunct to traditional imaging methods in the emergency department.

Introduction

The initial evaluation of patients with nontraumatic acute abdomen in the emergency department can present a diagnostic challenge. This is particularly true when an immediate surgical condition such as visceral perforation is suspected, which manifests as free intraperitoneal air (pneumoperitoneum) on imaging. Traditionally, this diagnosis relies on abdominal radiography or computed tomography (CT); however, the difficulty of interpreting supine radiographs and the limited availability of CT scanners in some emergency departments enhance the value of point of care ultrasound (POCUS) as an initial diagnostic tool.

POCUS has been shown to improve bedside diagnostic accuracy, reduce the need for additional imaging, and expedite clinical decision making [1]. In recent years, its application for identifying pneumoperitoneum has been increasingly described in case series and literature reviews. The main sonographic signs include the enhanced peritoneal stripe sign, A-line–type reverberation artifacts along the hepatic margin, and the gut point—the abdominal analogue of the pulmonary “lung point.” Technical maneuvers such as left lateral decubitus positioning, the “scissors maneuver,” and the “lung curtain sign” can improve the visualization of free intraperitoneal air [2,3].

Here, we report the case of a patient presenting with an acute abdomen in whom POCUS was the first diagnostic tool suggesting pneumoperitoneum and the need for urgent surgery. This case provides four distinctive contributions: (1) early POCUS detection of free air in the context of a perforated peptic ulcer during initial evaluation (POCUS as the first guiding study before radiography or CT), (2) the practical use of the lung curtain sign and dynamic compression maneuvers to differentiate between free gas and intraluminal gas, (3) to our knowledge, the first reported case in Colombia of pneumoperitoneum primarily diagnosed by POCUS, and (4) proposes a practical and reproducible ultrasound approach aimed at improving the consistency of examinations in emergency settings.

Case presentation

A 68-year-old man with a history of high blood pressure and occasional smoking presented to the emergency department. He had sudden onset of epigastric abdominal pain that intensified, reaching a pain score of 10/10 on a pain scale. This pain was associated with nausea without vomiting or other gastrointestinal symptoms. Physical examination revealed a heart rate of 96 bpm, blood pressure of 149/72 mm Hg, afebrile, and no requirement for supplemental oxygen. Physical examination revealed diffuse abdominal pain with guarding and rebound, especially in the upper region.

Due to clinical suspicion of a surgical emergency, Focused Assessment with Sonography for Trauma (FAST) examination was performed and negative for free fluid.  However, in an epigastric and right upper quadrant view, POCUS showed the liver topography, which revealed images like the pulmonary A-line pattern, suggestive of air (Figure 1). In order to differentiate the lung from the liver, the “curtain sign” was verified and the POCUS image was enlarged. This suggested abdominal air not in the thorax (Figure 2). The standing abdominal X-ray (Figure 3) confirmed the POCUS finding so the patient was taken to laparotomy. A perforated peptic ulcer was found; after a five-day period of hospitalization, the patient was discharged without complications.

Discussion

The timely diagnosis of pneumoperitoneum in patients with clinical signs of peritoneal irritation remains a challenge in emergency departments, especially when imaging resources are limited and rapid and accurate evaluation is required. In this context, POCUS has emerged as an accessible, noninvasive, and effective tool for the initial assessment of the acute abdomen [4–7].

In the assessment of possible pneumoperitoneum, the scan can be performed with a convex or phased array transducer, with greater sensitivity in the epigastric and subcostal windows, especially on the right [7–9]. Previous studies of these cases have described POCUS findings of free intraperitoneal air and an A-line pattern similar to that seen in thoracic ultrasonographic semiology, known as the enhanced peritoneal stripe sign [8]. As in our case, this is like a pulmonary A-line pattern but in the peritoneum at its hepatic or splenic border. In this same location, other authors have suggested an artifact reverberation type with a ring down like comet tails that begin in the peritoneum [7]. These findings, like those found in pulmonary evaluation with POCUS, reinforce the value of POCUS as a tool in the early detection of pneumoperitoneum in patients with acute abdomen. Reported  sensitivity and specificity are 95% and 81%, respectively [7]. This supports using POCUS as an initial screening tool for pneumoperitoneum as a rapid, non-invasive, and bedside evaluation.

A key use of POCUS is differentiating the artifacts associated with pneumoperitoneum from dilated bowel loops in intestinal obstruction (Figure 4). On POCUS, these appear as fluid-filled loops, wall thickening, and decreased or absent peristalsis. Whereas in pneumoperitoneum, A-line pattern artifacts are located superficially near the liver, and shift with pressure exerted by a transducer.

Moriwaki et al. provided essential criteria for avoiding a false positive interpretation of pneumoperitoneum. Intraluminal air never overlaps the ventral surface of the liver, unlike free air that collects just below the hepatic peritoneum. Furthermore, air within the gastrointestinal tract maintains continuity with the loops and does not change or shift with transducer compression, whereas free air exhibits mobility and its POCUS pattern can be modified by applied pressure. This distinction helps to identify findings that can mimic pneumoperitoneum and to improve the diagnostic accuracy of POCUS when evaluating the acute abdomen.

Finally, it should be noted that like other POCUS applications in gastroenterology, there are still no standardized protocols or universal training in abdominal POCUS for the detection of pneumoperitoneum [8]. However, we suggest the following approach for detecting pneumoperitoneum during POCUS: with the patient in the supine position and the legs bent to promote abdominal muscle relaxation, begin the examination with a low-frequency convex probe (3.5 MHz). Place it longitudinally in the epigastrium and then slide it toward the right subcostal margin to identify the enhanced peritoneal stripe sign or A-lines as reverberation artifacts along the hepatic margin. Additionally, we recommend performing the scissors maneuver to differentiate air-filled intestinal loops from free intraperitoneal air. In the scissor maneuver, the patient is placed on the left lateral position, thus allowing the peritoneal free air to levitate to the right upper quadrant of the abdomen. A-line pattern reverberation artifacts can then be seen overlying the liver. The disappearance of these A-lines with gentle pressure and their reappearance with the release of pressure indicate the presence of mobile free air within the peritoneal cavity.

Furthermore, structured training in the recognition of specific POCUS signs—such as the enhanced peritoneal stripe—and the use of the lung curtain sign to differentiate the lung from the liver can improve diagnostic accuracy and promote broader adoption of this technique.

In the clinical case presented above, an enhanced peritoneal stripe sign like the pulmonary A-line pattern was identified at the hepatic edge, suggestive of pneumoperitoneum [1,4,7].

These findings reinforce the value of POCUS in the assessment of non-traumatic acute abdomen in the semiology that suggests pneumoperitoneum.

Ethics Statement

The patient gave informed consent for this case report to be written.

Disclosure Statement

The authors declare that they have no competing interests.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Author Contributions

MPMJ: conceptualization, writing – original draft, writing – review & editing. ACO: conceptualization, writing – original draft, writing – review & editing.

References

1. Mateer J, Plummer D, Heller M, Olson D, Jehle D, Overton D, Gussow L. Model curriculum for physician training in emergency ultrasonography. Ann Emerg Med. 1994;23(1):95-102. doi:10.1016/ s0196-0644(94)70014-1

2. Bacci M, Salas M, Perera P. Pneumoperitoneum detected by point-of -care ultrasound: a case report. Cureus. 2020;12(3):e7301. doi:10.7759/ cureus.7301

3. Taylor RA, Bundy A, Smith S. Detection of pneumoperitoneum using bedside ultrasound: case report and review of the literature. Ultrasound J. 2020;12(1):17. doi:10.1186/s13089-020-00195-z

4. Chao A, Gharahbaghian L, Perera P. Diagnosis of pneumoperitoneum with bedside ultrasound. West J Emerg Med. 2015;16(2):302. doi:10.5811/westjem.2014.12.24945

5. Jones R. Recognition of pneumoperitoneum using bedside ultrasound in critically ill patients presenting with acute abdominal pain. Am J Emerg Med. 2007;25(7):838-41. doi:10.1016/j.ajem.2007.02.004. PMID: 17870492.

6. Chen SC, Wang HP, Chen WJ, Lin FY, Hsu CY, Chang KJ, Chen WJ. Selective use of ultrasonography for the detection of pneumoperitoneum. Acad Emerg Med. 2002;9(6):643-5. doi:10.1111/ j.1553-2712.2002.tb02307.x

7. Nazerian P, Tozzetti C, Vanni S, Bartolucci M, Gualtieri S, Trausi F, Vittorini M, Catini E, Cibinel GA, Grifoni S. Accuracy of abdominal ultrasound for the diagnosis of pneumoperitoneum in patients with \acute abdominal pain: a pilot study. Crit Ultrasound J. 2015;7(1):15. doi:10.1186/s13089-015-0032-6

8. Moriwaki Y, Sugiyama M, Toyoda H, Kosuge T, Arata S, Iwashita M, Tahara Y, Suzuki N. Ultrasonography for the diagnosis of intraperitoneal free air in chest–abdominal–pelvic blunt trauma and critical acute abdominal pain. Arch Surg. 2009;144(2):137–141. doi:10.1001/archsurg.2008.553

9. Shankar N, Kuo L, Krugliak Cleveland N, Galen B, Samel NS, Perez- Sanchez A, Nathanson R, Coss E, Echavarria J, Rubin DT, Soni NJ. Point-of-Care Ultrasound in Gastroenterology and Hepatology. Clin Gastroenterol Hepatol. 2025;23(8):1277-1290. doi:10.1016/ j.cgh.2024.09.040.

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Departments of Graduate Medical Education and Cardiology, Scripps Mercy Hospital, San Diego, CA, USA

*Corresponding Author:  Dr. Bruce J. Kimura (email: kimura.bruce@scrippshealth.org)

Download article PDF – POCUS Journal 2026;11(1):96-99

DOI: https://doi.org/10.24908/pocusj.v11i01.19738

Abstract

Hepatocellular carcinoma (HCC) is a leading cause of cancer-related death worldwide, and cardiovascular involvement can occur in advanced cases. An 84-year-old man with subacute dyspnea on exertion and pedal edema was referred to the cardiologist for suspected heart failure. Point of care ultrasound (POCUS) revealed scant ascites, a liver mass, and inferior vena cava (IVC) tumor thrombus extending into the right atrium. Computed tomography confirmed HCC with extensive intravascular spread and pulmonary emboli. This case illustrates a rare phenomenon of HCC masquerading as heart failure and underscores the potential value and challenges of incorporating POCUS into outpatient evaluations for earlier cancer detection.

Introduction

Hepatocellular carcinoma (HCC) poses a major global health burden, with over 850,000 new cases and 750,000 deaths in 2022 alone [1]. Prognosis remains poor, with a five-year survival rate of only 18% [2]. Aggressive tumor biology often leads to vascular invasion: tumor thrombi in hepatic veins and the inferior vena cava (IVC) are common in advanced cases [3]. While cirrhosis is a known risk factor, and biannual surveillance with abdominal ultrasound is recommended in patients with cirrhosis, this screening method is imperfect [4]. Notably, no data support HCC detection via routine in-office examination.

Point of care ultrasound (POCUS) is increasingly utilized across specialties. In internal medicine, focused ultrasonography protocols, such as the cardiac limited ultrasound exam (CLUE), can augment bedside assessment [5]. POCUS improves diagnostic sensitivity by revealing findings that elude traditional examination [5,6]. A growing body of literature shows POCUS can aid in the early detection of occult malignancies during outpatient or emergency evaluations. Reports include tumor findings in the colon, stomach, head and neck, breast, kidney, ovary, and even heart—prompting timely workups [7,8]. Here, we report a patient referred for mild dyspnea, who was found to have extensive HCC on an initial cardiac POCUS exam.

Case presentation

An 84-year-old man with exercise-induced heart block, sick sinus syndrome requiring a dual-chamber pacemaker, and Parkinson’s disease with dysautonomia presented to cardiology on referral from his primary care provider for mild dyspnea on exertion and pedal edema. He had been in his usual health and walking daily, but over several months, developed progressive dyspnea on exertion which limited him to 100 feet. He denied paroxysmal nocturnal dyspnea, orthopnea, pleuritic chest pain, cough, or fever. His routine labs (metabolic panel, blood counts) from a month prior were normal. He had no smoking or drug use history and drank one cocktail nightly. Vital signs and physical exam, including the jugular veins, were unremarkable, aside from 1+ ankle pitting edema bilaterally. As part of the bedside physical examination, a POCUS protocol called CLUE was performed using a standardized six-view protocol (parasternal long-axis, bilateral lung apices, bilateral lung bases, and subcostal/IVC views) to evaluate for left ventricular systolic dysfunction, left atrial enlargement, apical lung B-lines, pleural effusions, and elevated central venous pressure [5]. The CLUE revealed incidental scant ascites instead of pleural effusion on imaging the left lower thorax (Figure 1), and a hyperechoic hepatic mass with absence of hepatic vessels (Figure 2). Imaging of the IVC demonstrated proximal obliteration by an infiltrating mass (Figure 3).

The incidental findings and immediate concern for issues beyond heart failure were discussed with the patient and his family. Instead of a trial of empiric diuretic therapy or referral for echocardiography, the patient was urgently referred for a same-day computed tomography (CT) scan. Imaging revealed a 9 x 8 x 10 cm mass in the haptic dome with vascular invasion, including occlusion of the right portal vein and the right and middle hepatic veins, near occlusion of the left hepatic vein, and tumor thrombus extending into the IVC and right atrium (Figure 4). Acute pulmonary emboli were also seen in the left lower, middle, and right lower lobes. At the time of hospital admission, the alpha-fetoprotein level was elevated at 1,503 (Ref Range: 2 – 8.78 ng/mL). Magnetic resonance imaging (MRI) confirmed necrotic hepatocellular carcinoma with thrombus extending into the hepatic veins, IVC, and right atrium. The tumor was deemed unresectable, and palliative immunotherapy was considered.  However, he developed worsening dyspnea and weight gain with progressive renal/liver failure. Due to clinical decline, he transitioned to comfort care and passed away.

Discussion

This case highlights HCC discovered in an elderly patient referred to cardiology for presumed heart failure, who was ultimately found to have malignancy with extensive intravascular tumor spread. HCC often presents late due to nonspecific or absent early symptoms [2]. Cardiac involvement—via obstruction of venous return or inflow—is rare but can manifest as edema, fatigue, and exertional dyspnea. When HCC is suspected, diagnostic imaging is usually contrast-enhanced CT or MRI [9].^. To our knowledge, this is the first report of initial HCC detection by a POCUS exam and has implications for the value of POCUS in screening for cancer and the scope of POCUS-assisted physical examination.

This case exemplifies the benefit of outpatient practitioners incorporating POCUS into their in-office exams to expedite diagnosis [5]. POCUS-assisted physical examination can improve the centuries-old techniques that often lie at the foundation of current disease detection, referral, and healthcare delivery pathways [10]. In terms of certain cancers, such as HCC in patients with cirrhosis, screening can reduce mortality [11]. There is also growing evidence to suggest that POCUS, when used judiciously, can expedite the diagnosis of various cancers in patients with vague or non-specific complaints when compared to conventional pathways, offering a safe, inexpensive adjunct [7,8,12]. Standardized scanning protocols tailored for oncology have been proposed, such as the Focused Assessment with Sonography in Cancer (FASC) exam, which outlines a six-view POCUS survey for finding fluid in patients with cancer [13]. Future studies are needed to validate whether such protocols can improve patient outcomes when implemented in primary care or survivorship clinics. Technological advances may also enhance POCUS utility. For instance, artificial intelligence (AI) algorithms could assist less experienced operators in identifying abnormal POCUS findings or even perform preliminary scans for common pathology. Although no survival benefit was realized in this case, POCUS enabled an expedited outpatient diagnosis of a deadly disease. This allowed for earlier treatment of the patient’s pulmonary emboli which potentially slowed clinical deterioration and provided more lead time for the patient and family to discuss plans and arrange affairs.

This case reinforces that exertional dyspnea and pedal edema are not always due to congestive heart failure. In this case, the patient’s presentation could be explained by the ominous extracardiac results of an unexpected tumor occluding the IVC and embolizing to the lung. CLUE was performed to evaluate for suspected chronic heart failure, but serendipitously found HCC, technically as an incidental finding. The diagnosis of HCC was not within the scope of the exam, clinical context, or purview of the cardiologist, and its discovery brings to light the medical, legal, and economic complexities of incorporating POCUS into office examination. Accordingly, we do not advocate indiscriminate “head-to-toe” screening with POCUS in asymptomatic patients. Rather, this case supports a cautious, context-driven approach in which focused protocols are anchored to a clear clinical question, and sonographers remain mindful of the downstream implications of indeterminate or incidental findings. Contextual imaging emphasizes POCUS imaging decisions made within specific clinical scenarios or contexts, considering urgency, setting, available equipment, and clinician expertise [14]. This targeted approach, similar to the physical examination, focuses on clinically relevant findings, thus reducing the volume of training or testing that would be necessary to diagnose all incidental or incompletely characterized abnormalities. By streamlining clinical workflows and minimizing documentation burdens, contextual imaging facilitates a broader adoption of POCUS by general practitioners. However, the use of POCUS in the context for oncology screening or general practice comes with challenges. Many clinicians lack POCUS experience, and training programs are still evolving to address this need [15]. Misinterpretation of images could lead to false reassurance or unnecessary alarm. Indeed, widespread use of POCUS in other contexts may increase the incidence of incidental or indeterminate findings that necessitate additional testing. At the current time, clear guidelines on managing incidental POCUS findings are lacking, and clinicians must use judgment on when further evaluation is warranted.

We report a case of an ominous masquerader of chronic heart failure, which was incidentally found by using cardiac POCUS. Ultimately, broader adoption of POCUS may require interdisciplinary consensus on best practices and further outcome-based research to guide its use. Future studies should explicitly incorporate patient-centered outcomes and health-economic endpoints to determine when POCUS-enabled cancer detection improves value, rather than unnecessarily increasing downstream testing and anxiety. Once these challenges are met, a modernized, POCUS-assisted in-office exam could improve the timeliness of cancer diagnosis and care.

Ethics Statement

The authors obtained permission from the patient’s family.

Disclosure Statement

The authors have no conflicts of interest to disclose, and this work had no funding source.

Funding

No funding source.

Author Contributions

LS: conceptualization, writing – original draft. WC: writing – review & editing. BK: conceptualization, writing – review & editing, supervision.

References

1. Ferlay J, Ervik M, Lam F, Laversanne M, Colombet M, Mary L, Pineros M, Znaor A, Soerjomataram I, Bray F. Global Cancer Observatory: Cancer Today. International Agency for Research on Cancer. 2024. Accessed August 13, 2024. https://gco.iarc.int/today/

2. Villanueva A. Hepatocellular Carcinoma. N Engl J Med. 2019:380(15):1450-1462. doi:10.1056/NEJMra1713263

3. Luo X, Zhang B, Dong S, Zhang B, Chen X. Hepatocellular Carcinoma With Tumor Thrombus Occupying the Right Atrium and Portal Vein: A Case Report and Literature Review. Medicine. 2015;94(34):e1049. doi:10.1097/MD.0000000000001049

4. Demirtas CO, Ozdogan OC. Surveillance of hepatocellular carcinoma in cirrhotic patients: Current knowledge and future directions. Hepatology forum. 2020;1(3):112-118. doi:10.14744/hf.2020.2020.0003

5. Kimura BJ, Shaw DJ, Amundson SA, Phan JN, Blanchard DG, DeMaria AN. Cardiac Limited Ultrasound Examination Techniques to Augment the Bedside Cardiac Physical Examination. J Ultrasound Med. 2015;34(9):1683-1690. doi:10.7863/ultra.15.14.09002

6. Kimura BJ. Point-of-care cardiac ultrasound techniques in the physical examination: better at the bedside. Heart. 2017;103(13):987-994. doi:10.1136/heartjnl-2016-309915

7. Setia G, Kedan I. Case Series of Bedside Renal Cell Carcinoma Detected by Point-of-Care Ultrasound in the Ambulatory Setting. J Prim Care Community Health. 2020;11:2150132720916279. doi:10.1177/2150132720916279

8. Chen W, Teh R, Qurishi A. Point-of-Care Ultrasound for the Diagnosis of Colon Cancer. POCUS journal. 2022;7(2):190-192. doi:10.24908/pocus.v7i2.15657

9. Yu NC, Chaudhari V, Raman SS, Lassman C, Tong MJ, Busuttil RW, Lu DS. CT and MRI improve detection of hepatocellular carcinoma, compared with ultrasound alone, in patients with cirrhosis. Clin Gastroenterol Hepatol. 2011;9(2):161-7. doi:10.1016/j.cgh.2010.09.017

10. Kirkpatrick JN, Panebianco N, Díaz-Gómez JL, Adhikari S, Bremer ML, Bronshteyn YS, Damewood S, Jankowski M, Johri A, Kaplan JRH, Kimura BJ, Kort S, Labovitz A, Lu JC, Ma IWY, Mayo PH, Mulvagh SL, Nikravan S, Cole SP, Picard MH, Sorrell VL, Stainback R, Thamman R, Tucay ES, Via G, West FM. Recommendations for Cardiac Point-of-Care Ultrasound Nomenclature. J Am Soc Echocardiogr. 2024:S0894-7317(24)00222-0. doi:10.1016/j.echo.2024.05.001

11. Yang J, Yang Z, Zeng X, Yu S, Gao L, Jiang Y, Sun F. Benefits and harms of screening for hepatocellular carcinoma in high-risk populations: systematic review and meta-analysis. J Natl Cancer Cent. 2023;3(3):175-185. doi:10.1016/j.jncc.2023.02.001

12. Jamjoom RS, Etoom Y, Solano T, Desjardins MP, Fischer JW. Emergency Point-of-Care Ultrasound Detection of Cancer in the Pediatric Emergency Department. Pediatr Emerg Care. 2015;31(8):602-604. doi:10.1097/PEC.0000000000000512

13. Nauka PC, Galen BT. The Focused Assessment with Sonography in Cancer (FASC) Examination. POCUS journal. 2020;5(2):42-45. doi:10.24908/pocus.v5i2.14428

14. Kimura BJ, Demaria AN. Contextual Imaging: A Requisite Concept for the Emergence of Point-of-Care Ultrasound. Circulation.Lippincott Williams and Wilkins. 2020;142(11):1025-1027. doi:10.1161/CIRCULATIONAHA.120.047903

15. Andersen CA, Holden S, Vela J, Rathleff MS, Jensen MB. Annals Journal Club: Point-of-Care Ultrasound in General Practice: A Systematic Review. Ann Fam Med. 2019;17(1):61. doi:10.1370/AFM.2330

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Point of Care Ultrasound for Diagnosis and Management in Heart Failure: A Targeted Literature Review  A Cardiac Tumor and Liver Masses on Point of Care Ultrasound (POCUS): Implications in a Resource-Limited Setting Case Report: A cardiac mass diagnosed using Point-of-care ultrasound in a dyspneic patient. An integrated ultrasound examination of lung-heart-Inferior Vena Cava

(1) Department of Emergency Medicine, University of Nevada, Las Vegas, NV, USA

(2) Emergency Department, University Medical Center of Southern Nevada, Las Vegas, NV, USA

*Corresponding Author: Dr. Matthew Starr (email: matthew.starr@unlv.edu)

Download article PDF – POCUS Journal 2026;11(1):100-103

DOI: https://doi.org/10.24908/pocusj.v11i01.19770

Abstract

Point of care ultrasound (POCUS) is a helpful tool for supporting the development of a differential diagnosis for testicular and scrotal pain. It can aid in the diagnosis of critical conditions such as Fournier’s Gangrene and testicular torsion. In this case, we describe a 39-year-old man who presented for testicular pain and scrotal swelling who had findings concerning for testicular and epididymal gas on POCUS. This correlated with our computed tomography (CT) findings which were consistent with emphysematous epididymo-orchitis.

Case presentation

A 39-year-old man who was visiting from out-of-state presented to the emergency department with scrotal swelling and pain. The patient reported a “pimple” on the right side of his scrotum one week prior that he attempted to manually squeeze and drain. Afterwards, he began developing significant right-sided testicular and scrotal pain associated with swelling until he was unable to sleep. He had no significant comorbidities—specifically, no history of diabetes or testicular torsion. He had a prior subcutaneous abscess in the same scrotal area in the past for which he received an incision and drainage with improvement in symptoms. In the emergency department, he was afebrile, not tachycardic, and his vital signs were otherwise within normal limits. On examination, his scrotum was significantly swollen with purple skin discoloration severe tenderness to palpation; however, no crepitus was detected and no bullae were observed. Laboratory studies showed CRP of 100.21 mg/L (reference: normal <= 3.00 mg/L), leukocytosis of 21.50 K/mm³ (reference range: normal = 3.10-10.20 K/mm3), and mild hematuria with no evidence of urinary tract infection. The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score was calculated at 5, indicating a mild to moderate risk for possible necrotizing soft tissue infection [1]. POCUS with color Doppler showed normal blood flow to each testicle. It also showed a fluid collection in the right hemiscrotum surrounding the testicle and epididymis. There was hyperechoic debris seen within the fluid collection, as well as dirty shadowing arising from the debris within the fluid collection, suggestive of gas. Importantly, there was no dirty shadowing from the soft tissues of the scrotum itself (Figures 1 and 2). This prompted an emergent CT scan to further characterize the abnormalities seen on POCUS and definitively evaluate for Fournier’s Gangrene. The CT scan (Figures 3 and 4) confirmed gas in the testicle and epididymis suggesting a diagnosis of emphysematous epididymo-orchitis. Furthermore, the CT scan did not show gas in soft tissues of the scrotum, thus making necrotizing fasciitis less likely. In consultation with urology, there was a recommended admission for intravenous antibiotics and a possible need for an orchiectomy if the patient failed to improve with medical therapy within the next 24 hours. The patient unfortunately left the department against medical advice to find care closer to home. He was unable to be reached for further comment after leaving; therefore, further progress regarding his case and outcome were unable to be ascertained.

Discussion

Emphysematous epididymo-orchitis is a rare infection caused by gas-forming bacteria. Its exact etiology is unknown [2]. Some studies suggest that diabetes mellitus is a significant risk factor [3]. Other potential risk factors include concomitant retroperitoneal emphysematous infections adjacent to the origin of the testicular artery or rupture of sigmoid diverticula [3]. Emphysematous epididymo-orchitis is difficult to differentiate from other genitourinary infections as it presents with nonspecific findings such as scrotal swelling, pyuria, bacteriuria, fever, and leukocytosis. POCUS is helpful in evaluating potential causes for the acute scrotum [4,5,6]. We were able to visualize adequate Doppler flow to the testis using POCUS, providing reassurance against testicular torsion in addition to history and physical examination findings. Furthermore, gas arising from the epidermis/fascia of the scrotum and other common sonographic findings for necrotizing fasciitis were not visualized [6]. Crepitus, bullae, and ecchymosis were not seen on physical examination, and the LRINEC score showed only mild-moderate risk for necrotizing infection [1]. Therefore, surgery was not immediately consulted, and we were able to proceed with further diagnostic workup. Gas and debris in and around the epididymis and testicles were apparent on POCUS, which suggested a gas-forming infection of the testicles. This narrowed our differential diagnosis significantly. We were able to  expedite our clinical decision making and form an appropriate treatment plan. We ensured antibiotics included covering gas forming organisms, expedited a CT scan, and consulted with urology. This case could have been missed as scrotal cellulitis or abscess leading to an incorrect discharge on oral antibiotics or unnecessary incision and drainage of the skin. Furthermore, the patient could have been rushed to the operating room for an unnecessary surgical intervention for presumed Fournier’s Gangrene. Current literature delineates epididymo-orchitis as a separate pathological process from Fournier’s Gangrene [7,8]. Unlike Fournier’s Gangrene, emphysematous epididymo-orchitis can be treated conservatively with intravenous antibiotics, escalating to surgery if antibiotics fail and a full orchiectomy is necessary. Management should always be guided in close consultation with a urological specialist [7,8].

Ethics Statement

All information in this case report has been deidentified and approved for publication by the hospital’s clinical research director in the absence of direct patient consent.

Disclosure Statement

The authors declare that they have no competing interests.

Funding

No funding or financial support was received by the authors.

Author Contribution

MS: conceptualization, data collection, formal analysis,, writing — original draft. JB: conceptualization, data collection, formal analysis, project administration, supervision, writing — review & editing.

References

1. Liao CI, Lee YK, Su YC, Chuang CH, Wong CH. Validation of the laboratory risk indicator for necrotizing fasciitis (LRINEC) score for early diagnosis of necrotizing fasciitis. Tzu Chi Medical Journal. 2012;24(2):73-76. doi: https://doi.org/10.1016/j.tcmj.2012.02.009

2. Balani A. Emphysematous epididymo-orchitis. Radiology Reference Article. Radiopaedia.org. Radiopaedia. Published August 2, 2021. Accessed May 5, 2025. https://doi.org/10.53347/rID-33893

3. Hegde RG, Balani A, Merchant SA, Joshi AR. Synchronous infection of the aorta and the testis: emphysematous epididymo-orchitis, abdominal aortic mycotic aneurysm, and testicular artery pseudoaneurysm diagnosed by use of MDCT. Japanese Journal of Radiology. 2014;(7):425-430. doi:10.1007/s11604-014-0313-1

4. Kim DJ, Bell CR, Sheppard G. Genitourinary Ultrasound. Emergency Medicine Clinics of North America. 2024;(4):819-838. doi:10.1016/j.emc.2024.05.007

5. Mori T, Ihara T, Nomura O. Diagnostic accuracy of point-of-care ultrasound for paediatric testicular torsion: a systematic review and meta-analysis. Emergency Medicine Journal. 2022;(2):140-146. doi:10.1136/emermed-2021-212281

6. Gan RK, Sanchez Martinez A, Abu Hasan MA-S, Castro Delgado R, Arcos González P. Point-of-care ultrasonography in diagnosing necrotizing fasciitis—a literature review. Journal of Ultrasound. 2023;(2):343-353. doi:10.1007/s40477-022-00761-5

7. Mathur A, Manish A, Maletha M, Luthra NB. Emphysematous epididymo-orchitis: A rare entity. Indian J Urol. 2011;27(3):399-400. doi:10.4103/0970-1591.85447

8. Greer G, Bechis S. Emphysematous epididymitis following hydrocelectomy. Urol Case Rep. 2020 33:101361. doi: 10.1016/j.eucr.2020.101361

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(1) Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, MA, USA

(2) Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX, USA

(3) Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, MetroHealth System, Case Western Reserve University, Cleveland, OH, USA

(4) Research Service, South Texas Veterans Health Care System, San Antonio, TX, USA

(5) Medicine Service, South Texas Veterans Health Care System, San Antonio, TX, USA

(6) Division of Hospital Medicine, University of Texas Health San Antonio, San Antonio, TX, USA

(7) Division of Pulmonary Diseases & Critical Care Medicine, University of Texas Health San Antonio, San Antonio, TX, USA

*Corresponding Author:  Dr. Megha Gupta (email: mgupta8@bidmc.harvard.edu)

Download article PDF – POCUS Journal 2026;11(1):104-109

DOI: https://doi.org/10.24908/pocusj.v11i01.19484

Supplementary Material: S1, S2

Abstract

Background: Point of care ultrasound (POCUS) has become an invaluable tool in healthcare across multiple disciplines. For the past 30 years, obstetricians and gynecologists in many hospitals have had access to ultrasound equipment and commonly utilize it in labor and delivery suites and emergency rooms for a broad range of conditions. POCUS can be divided into gynecologic and obstetric applications—the latter can be further categorized into fetal POCUS and maternal POCUS. While fetal POCUS primarily assesses the fetus, maternal POCUS is crucial for evaluating conditions that impact a mother’s health during pregnancy, intrapartum, and postpartum, such as cardiopulmonary status. The COVID-19 pandemic highlighted the importance of maternal POCUS for timely diagnosis and management, which can ultimately reduce maternal morbidity and mortality. This study aimed to characterize the current use of maternal POCUS, identify barriers to its adoption, and explore opportunities for greater integration into clinical practice nationally among Women’s Health (WH) departments within the Veterans Affairs (VA) healthcare system. Methods: A prospective observational study was conducted from June 2019 to March 2020 through a web-based survey distributed to all VA medical centers. The survey was first distributed to all chiefs of staff about facility-level POCUS use, training, competency, and policies. A follow-up survey was sent to all WH chiefs to obtain service-level data on diagnostic and procedural POCUS use, training needs, workflows, and equipment availability. Statistical analysis utilized the Chi-squared test to uncover associations between POCUS use and various group characteristics, with a significance threshold of p<0.05. Results: Response rates were 100% among chiefs of staff (n = 130) for the facility-level survey and 77% among WH chiefs (n = 61) for the service-level survey. Diagnostic or procedural POCUS was used by only 30% of all WH groups. The most frequently reported diagnostic applications included assessment of the uterus (23%), ovaries (23%), and intrauterine pregnancy (16%). The most frequently identified procedural application identified was intrauterine device insertion, reported by 23% of the groups. Key barriers to POCUS use included a lack of equipment (56%), lack of trained clinicians (49%), insufficient funding for training (28%), and lack of support staff (26%). While 69% of WH chiefs expressed support for POCUS training, only 23% of chiefs reported having a structured process for obtaining POCUS training for their clinicians. This discrepancy underscores the need for enhanced education and awareness initiatives to align clinician perspectives with the growing benefits of POCUS in clinical practice. Conclusion: This national survey highlighted the low utilization of maternal POCUS among WH clinicians in the VA healthcare system and pointed to critical barriers, including equipment shortages and training gaps. Addressing these barriers through enhanced training, resource allocation, and leadership support is essential to fully leverage the potential benefits of POCUS use in maternal care. Future efforts should focus on evaluating the impact of improved POCUS training and investment in POCUS infrastructure on maternal health outcomes.

Introduction

Since ultrasound was first described in obstetrics and gynecology (OBGYN) in 1958, its primary application has been focused on fetal evaluation with minimal emphasis on peripartum maternal care [1]. By the 1990s, ultrasound equipment was widely available in labor and delivery suites and was utilized to assess a variety of obstetric conditions. In recent years, particularly during the COVID-19 pandemic, the untapped utility of point of care ultrasound (POCUS) in maternal care (maternal POCUS) has been increasingly recognized [2,3]. Maternal POCUS is a focused bedside ultrasound exam performed by a clinician caring for a mother. It can rapidly evaluate maternal conditions related to pregnancy that are not included in traditional obstetric ultrasound exams, such as cardiopulmonary status [4]. With the rising incidence of cardiopulmonary disorders that lead to maternal morbidity and mortality, there is a compelling need to expand maternal POCUS use [1,5].

Obstetricians and gynecologists (OBGYNs) are uniquely poised to incorporate maternal POCUS into their practices [6]. They receive extensive ultrasound training during residency, have access to ultrasound equipment, and have established standard workflows for documentation and image archiving [7,8]. Maternal POCUS can aid in the prompt diagnosis and management of critical obstetric conditions. If untreated, these conditions can lead to severe complications that pose risks to maternal health, such as pulmonary edema in preeclampsia, reduced cardiac function in peripartum cardiomyopathy, and right ventricular failure in amniotic fluid embolism [9].

Despite the potential benefits of maternal POCUS, few obstetricians currently utilize POCUS beyond traditional obstetrical ultrasound [10]. The current use, training needs, and barriers to maternal POCUS adoption among OBGYNs remain largely unknown. To address this knowledge gap, we conducted a national survey of all Women’s Health (WH) departments within the Veterans Affairs (VA) healthcare system to characterize the current landscape of maternal POCUS use and identify opportunities for increased integration into practice. Our findings can guide the implementation of maternal POCUS use in OBGYN, including the development of training and targeted investment in POCUS infrastructure.

Methods

A prospective observational study of all VA medical centers was conducted between June 2019 and March 2020. A multi-disciplinary POCUS Technical Advisory Group with physicians from emergency medicine, internal medicine, hospital medicine, pulmonary medicine, and critical care medicine collaborated with the VA’s Healthcare Analysis and Information Group to develop and disseminate a web-based survey systemwide (Verint Systems, Inc.®, 2019). This study was reviewed by the Institutional Review Board of the University of Texas Health Science Center San Antonio and deemed to be non-research (Protocol Number: HSC20210630NRR).

The survey included questions on current use, barriers, institutional support, equipment, and POCUS training needs—encompassing a wide range of diagnostic and procedural applications categorized by body system (see Supplementary Material S1). Question types were multiple-choice, forced-choice (yes/no), open-ended with numerical or free-text entry, and free-text boxes when “other” was selected. For questions of prevalence, respondents were provided the option to answer as few (1–25%), some (26–50%), many (51–75%), most (76–99%), or all (100%).

The survey was first distributed to all chiefs of staff (n = 130) of VA medical centers nationwide between August and October 2019. The chief of staff survey included ten questions about facility-level POCUS use, training, competency, and policies, and required contact information for all WH chiefs. Next, a follow-up survey with 18 questions was sent to all WH chiefs (n = 79) to obtain service-level data on diagnostic and procedural POCUS use, training needs, workflows, and equipment availability (Supplementary Material S2). The survey period for WH chiefs started in December 2019 but ended early in March 2020 due to the COVID-19 pandemic.

Current POCUS use and training desired were averaged across all diagnostic and procedural applications when reported by body system or category. We used the Chi-squared test to determine associations between POCUS use and group characteristics. A p-value <0.05 was considered statistically significant.

Results

All chiefs of staff (n = 130) of VA medical centers completed the facility-level survey, achieving a 100% response rate. In contrast, 61 WH chiefs  completed the service-level survey (77% response rate). Most WH groups were located in large, urban medical centers with high complexity ratings and had a median of 80 hospital beds (IQR 52–110) (Table 1).

Current use

Diagnostic or procedural POCUS was reported as being used by at least one WH physician in 30% of WH groups. The most common diagnostic applications included assessment of the uterus (23%), ovaries (23%), and intrauterine pregnancy (16%). The most frequently reported procedural application was intrauterine device insertion, cited by 23% of WH groups (Table 2 and Figure 1). There was no reported use of maternal POCUS for critically ill patients.

Barriers

The most commonly reported barriers to POCUS use among WH groups were lack of equipment (56%), insufficient number of trained clinicians (49%), limited funding for training (28%), and inadequate number of support staff (26%) (Table 3). 

Training

Training remains a critical barrier for POCUS use in dedicated WH groups at VA medical centers. Among the WH chiefs surveyed, 49% described encountering at least one training-related barrier. The most frequently cited barrier was the lack of trained clinicians, as reported by 49% of chiefs. Although only 33% of WH chiefs felt their clinicians desired POCUS training, 69% of chiefs indicated they would support sending their clinicians to a VA POCUS training course. This reflected a strong commitment to enhancing clinician training in POCUS. Conversely, only 23% of chiefs reported having a structured process for obtaining POCUS training for their clinicians. Additional training-related barriers included insufficient funding for training (26%), lack of training opportunities (21%), and inadequate travel funding (13%). These further underscored the need for institutional investment in training to standardize POCUS implementation.

Infrastructure

Infrastructure-related barriers were also reported as significant challenges to POCUS adoption in WH groups. Forty-nine percent of chiefs reported at least one infrastructure barrier, with lack of clinician champions and funding for support staff cited by 28% of chiefs. Additional barriers included insufficient funding for simulation space (23%), unclear privileging criteria (16%), and the need for standardized reporting forms and image archiving (18%).

Discussion

Our national survey highlighted both the current landscape of POCUS utilization and significant barriers to its implementation in WH groups within the VA healthcare system. Despite the recognized potential for POCUS to enhance maternal care, our survey revealed that only 30% of WH groups were currently utilizing POCUS. This low adoption rate underscores a critical gap between the capabilities of POCUS and its integration into routine clinical practice by OBGYNs.

To address this gap, it is particularly important to distinguish between gynecological POCUS, which focuses on evaluating the uterus and ovaries, and obstetric POCUS, which is further divided into maternal and fetal applications. Fetal POCUS specifically pertains to the assessment of the fetus and includes standard evaluations, such as confirming intrauterine pregnancy, fetal presentation, fetal number, fetal heart rate, biometry, amniotic fluid volume, biophysical profile, and placental location. In contrast, maternal POCUS involves assessing conditions related to the health and well-being of the mother during pregnancy, encompassing cardiac, pulmonary, abdominal, and lower extremity venous ultrasound. This structured understanding underscores the importance of clarity when discussing POCUS in OBGYN as a specialty, as ambiguity can hinder effective communication and application in clinical settings.

Recognizing the distinctions among POCUS applications highlights a concerning underutilization of POCUS in OBGYN settings. Our survey revealed significant gaps in maternal POCUS use among WH patients. No chiefs reported using POCUS for common clinical scenarios, such as evaluating pulmonary edema in preeclampsia patients on magnesium sulfate, identifying intra-abdominal bleeding or uterine rupture, determining volume status, or ruling out lower extremity deep venous thrombosis. Moreover, 18% of chiefs perceived no benefit from using maternal POCUS, indicating a disconnect between its potential utility and practical application. This may be explained by insufficient awareness or exposure to common maternal POCUS applications that are supported by an ever-increasing body of evidence. Addressing these gaps through case presentations, peer-led workshops, and targeted outreach may enhance awareness, shift perceptions, and increase acceptance of maternal POCUS among OBGYNs [11]. Highlighting the accuracy and manageable learning curve of maternal POCUS in various clinical scenarios can further demonstrate its efficiency and effectiveness, encouraging more OBGYNs to incorporate it into their practices [12,13].

The primary barriers identified—lack of equipment, trained clinicians, and funding for training—reflect health system and institutional challenges that need to be addressed for broad and standardized POCUS adoption across WH settings [14]. Most (56%) WH groups reported significant barriers related to equipment availability. It is unclear whether this refers to availability of machines or specific probe types, or both. Curvilinear probes are generally more accessible, while transvaginal probes require more time for high-level disinfection and patient privacy. This is surprising given that most ultrasound applications are considered standard of care in OBGYN. We suspect these WH groups are obtaining referral ultrasound exams through radiology which cannot be elucidated from our data. Nonetheless, this finding suggests that half of WH groups lack portable ultrasound equipment for various POCUS applications, underscoring the need for health system investment in ultrasound technology to improve women’s care overall.

Training has become a major challenge, and nearly half of WH groups reported a lack of trained clinicians. However, considering only 33% of clinicians expressed interest in POCUS training raises concerns about their perception of its relevance and usefulness in their clinical practice. Previous studies have shown high physician interest in learning POCUS, but the low interest in WH POCUS may be due to historical undervaluation of WH. Given this limited interest, integrating POCUS into routine practice may be difficult if it depends only on clinician-initiated training efforts. These findings emphasize the importance of educational initiatives that showcase POCUS benefits and integrating structured training programs within health systems [15,16]. The strong support from 69% of WH chiefs for sending their clinicians to an internal POCUS training course is encouraging and could serve as a foundational step toward enhancing WH clinicians’ competency and confidence in using POCUS. In the meantime, utilizing dedicated ultrasound consult services might be an effective alternative to increase access and incorporate POCUS in WH.

Additionally, infrastructure-related barriers, including inadequate clinician champions and insufficient funding for support staff, limit integration of POCUS into WH practices [17]. The presence of clinician champions is important for driving change and fostering a culture that embraces innovation. The reported lack of leadership support in some facilities suggests that engagement from both health system and institutional administration is necessary to allocate appropriate resources to champion POCUS initiatives. Further research is needed to evaluate the effectiveness of specific training programs and resource allocation on the adoption of maternal POCUS. Additional studies should explore the impact of integrating POCUS on maternal health outcomes and identify strategies to increase awareness and acceptance of POCUS among WH clinicians.

Our study had both strengths and limitations. A key strength of our survey was the high response rate (100% for chiefs of staff and 77% for WH chiefs). As well, the data are unique, addressing a gap in published national surveys on POCUS use among OBGYNs. However, an important limitation was our use of “POCUS”—a term that needs clearer definition in the context of WH. Chiefs who completed the survey may have been unclear if the survey referred to obstetric (fetal and maternal) POCUS or gynecological POCUS exams, which may have affected their responses. Additionally, the VA system includes many community-based outpatient clinics, and WH clinics in the outpatient setting were not queried in this survey. Another limitation pertained to the timing of data collection. The survey period for WH chiefs started in December 2019 and ended early in March 2020 due to the COVID-19 pandemic. This early termination may have influenced the responses, and the pandemic may have further impacted POCUS utilization in ways not captured by our survey. These factors may limit the generalizability of our findings.

Conclusion

Our study revealed relatively low use of obstetrical (fetal and maternal) and gynecological POCUS among WH clinicians at VA medical centers nationally. However, for all POCUS applications, the desire for training exceeded current usage. Addressing critical barriers, such as the lack of equipment and training opportunities, and fostering a supportive infrastructure will be essential steps to realizing the full potential of both OBGYN and non-OBGYN POCUS applications in WH. Future research should focus on evaluating how POCUS training and equipment provision impacts POCUS implementation and maternal health outcomes. This will pave the way for a more proactive approach to POCUS implementation in WH. By leveraging the unique position of OBGYNs who have access to ultrasound equipment, we can advocate for increased maternal POCUS, ultimately aiming to reduce morbidity and mortality associated with cardiopulmonary and other pregnancy disorders.

Ethics Statement

This study was reviewed and deemed non-research by the Institutional Review Board of the University of Texas Health Science Center San Antonio (Protocol Number: HSC20210630NRR).

Disclosure Statement

Nilam J. Soni receives funding from the Department of Veterans Affairs Quality Enhancement Research Initiative (QUERI) Partnered Evaluation Initiative (I50 HX002263-01A1) and National Center for Patient Safety. This material is the result of work supported with resources and the use of facilities at the South Texas Veterans Health Care System in San Antonio, Texas. The contents of this publication do not represent the views of the U.S. Department of Veterans Affairs or the United States Government.

Funding

Nilam J. Soni receives funding from the Department of Veterans Affairs Quality Enhancement Research Initiative (QUERI) Partnered Evaluation Initiative (I50 HX002263-01A1) and National Center for Patient Safety. This material is the result of work supported with resources and the use of facilities at the South Texas Veterans Health Care System in San Antonio, Texas.

Author contributions

MG: conceptualization, methodology, writing – original draft. SH: writing – review & editing. SW: writing – review & editing. AAS: writing – review & editing. AR: writing – review & editing. MJM: formal analysis, data curation. NJS: conceptualization, methodology, formal analysis, data curation, writing – original draft, supervision.

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(1) PhD Program in Innovative Technologies in Biomedical Sciences, Faculty of Medicine and Surgery, Kore University of Enna, Enna, Italy

(2) Pediatric Pneumoallergology Unit, Department of Pediatrics, A.O.U. Policlinico San Marco, University of Catania, Catania, Italy

(3) Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy

(4) Department of Pediatrics, Faculty of Medicine and Surgery, Kore University of Enna, Enna, Italy

*Corresponding Author: Dr. Salvatore Michele Carnazzo (email: salvatoremichele.carnazzo@unikorestudent.it)

Download article PDF – POCUS Journal 2026;11(1):110-120

DOI: https://doi.org/10.24908/pocusj.v11i01.20031

Abstract

Background: Cranial point of care ultrasound (POCUS) is an emerging bedside tool for rapid evaluation of neurological emergencies in neonates and infants. Although widely used in neonatal intensive care, its application in emergency and critical care remains heterogeneous and lacks standardized protocols. Objective: To synthesize the current literature on cranial POCUS in neonates and infants and propose a structured clinical protocol (KORE Brain POCUS Protocol) to support early diagnosis and management in emergency and critical care settings. Methods: A structured search of PubMed, Scopus, Web of Science, and Cochrane Library (through August 2025) identified studies on cranial POCUS in neonatal and infant acute care. Eligible studies included original research, observational studies, case series, and narrative or systematic reviews. Two reviewers independently screened and extracted data on study characteristics, clinical context, and feasibility. Results: Nine studies met the inclusion criteria. Cranial POCUS was consistently reported as feasible for detecting intracranial hemorrhage (ICH), ventricular dilatation, sinovenous thrombosis, and posterior fossa lesions, and for assessing cerebral hemodynamics using transcranial Doppler. Based on converging findings, we developed the KORE Brain POCUS Protocol, a stepwise framework integrating standardized ultrasound windows and Doppler assessment for pediatric emergency and critical care. Conclusions: Cranial POCUS is a promising, rapid, noninvasive tool for the bedside evaluation of acute neurological conditions in neonates and infants. The proposed KORE Brain POCUS Protocol provides a structured approach to support early diagnosis and clinical decision-making. Prospective studies are needed to validate its diagnostic performance and clinical impact.

Introduction

Point of care ultrasound (POCUS) refers to diagnostically oriented ultrasonography performed and interpreted at the bedside by the treating clinician, enabling immediate, data-informed decisions without reliance on remote radiology support [1]. In emergency and critical care settings, POCUS has revolutionized patient evaluation with established protocols such as Focused Assessment with Sonography for Trauma (FAST) and Extended Focused Assessment with Sonography for Trauma (eFAST) for trauma, Rapid Ultrasound in Shock and Hypotension (RUSH) for circulatory failure, and Bedside Lung Ultrasound in Emergency (BLUE) for undifferentiated respiratory distress [2–4]. However, these protocols are primarily developed for adults and do not always translate to pediatric or neonatal patients, where anatomical and physiological differences—such as smaller size, open fontanelles, and distinct pathologies—necessitate tailored approaches [5]. POCUS is already routinely used in neonatal intensive care settings, but its structured application in pediatric emergency care remains limited [6]. In neonatal and pediatric care, cranial ultrasound offers unique advantages due to the presence of patent fontanelles, which serve as excellent acoustic windows [7]. This enables non-invasive, rapid visualization of intracranial structures, including ventricles, hemorrhages, hydrocephalus, midline shifts, and even cerebral blood flow when combined with Doppler modalities without sedation or radiation exposure [4]. Despite these benefits, there is no standardized “brain POCUS” protocol currently integrated into pediatric emergency pathways, unlike well-established adult POCUS protocols. This gap is noteworthy given the increasingly recognized utility of cranial POCUS in detecting critical pathologies in neonates, such as acute intraventricular hemorrhage (IVH), hydrocephalus progression, or midline shift, with implications for neurodevelopmental outcomes and timely interventions [5]. The intended clinical application of brain POCUS in emergency and critical care is focused on time-critical presentations in neonates and young infants, including seizures, bulging fontanelle with suspected hydrocephalus, selected head trauma, and suspicion of IVH or ventricular enlargement. The protocol is designed as an early bedside triage framework rather than a replacement for definitive neuroimaging. This article aims to (1) review the rationale and current state of cranial POCUS in pediatric critical care, (2) highlight the absence of emergency-focused protocols for brain ultrasound in neonates and children, and (3) propose a structured and scalable brain POCUS protocol tailored for pediatric emergency and critical care, tentatively titled the “KORE Brain POCUS Protocol.”

Methods

Study Design

This review is an evidence-informed, structured literature review that follows the core principles of the PRISMA 2020 statement (Figure 1) [8]. The primary objective was to synthesize current evidence on the use of cranial POCUS in neonatal and pediatric emergency and critical care settings, with particular emphasis on diagnostic and monitoring applications. Given the limited and heterogeneous nature of the available studies, data were synthesized narratively rather than pooled quantitatively.

Search Strategy

A comprehensive search included literature from PubMed/MEDLINE, Embase, Scopus, and Web of Science from inception until August 20, 2025. The following Boolean search strings were applied, tailored to each database syntax:

PubMed :((“point-of-care ultrasound”[tiab] OR POCUS[tiab] OR “bedside ultrasound”[tiab] OR “bedside imaging”[tiab] OR “point-of-care imaging”[tiab]) AND (“cranial ultrasound”[tiab] OR neurosonography[tiab] OR “transfontanelle ultrasound”[tiab] OR “brain ultrasound”[tiab]) AND (neonate*[tiab] OR newborn*[tiab] OR infant[tiab] OR pediatric[tiab] OR child[tiab]) AND (“emergency”[tiab] OR “acute”[tiab] OR “critical”[tiab] OR “resuscitation”[tiab] OR “intensive care”[tiab]))

Scopus (TITLE-ABS-KEY):TITLE-ABS-KEY(“point-of-care ultrasound” OR POCUS OR “bedside ultrasound” OR “bedside imaging” OR “point-of-care imaging”)AND TITLE-ABS-KEY(“cranial ultrasound” OR neurosonography OR “transfontanelle ultrasound” OR “brain ultrasound”)AND TITLE-ABS-KEY(neonate* OR newborn* OR infant OR pediatric OR child*) AND TITLE-ABS-KEY(emergency OR acute OR critical OR resuscitation OR “intensive care”)

Web of Science (TS field):TS=(“point-of-care ultrasound” OR POCUS OR “bedside ultrasound” OR “bedside imaging” OR “point-of-care imaging”) AND TS=(“cranial ultrasound” OR neurosonography OR “transfontanelle ultrasound” OR “brain ultrasound”) AND TS=(neonate* OR newborn* OR infant OR pediatric OR child) AND TS=(“emergency” OR “acute” OR “critical” OR “resuscitation” OR “intensive care”)

Embase (Title/Abstract): ((TI “point-of-care ultrasound” OR AB “point-of-care ultrasound” OR TI POCUS OR AB POCUS OR TI “bedside ultrasound” OR AB “bedside ultrasound” OR TI “bedside imaging” OR AB “bedside imaging” OR TI “point-of-care imaging” OR AB “point-of-care imaging”))AND((TI “cranial ultrasound” OR AB “cranial ultrasound” OR TI neurosonography OR AB neurosonography OR TI “transfontanelle ultrasound” OR AB “transfontanelle ultrasound” OR TI “brain ultrasound” OR AB “brain ultrasound”)) AND ((TI neonate* OR AB neonate* OR TI newborn* OR AB newborn* OR TI infant OR AB infant OR TI pediatric OR AB pediatric OR TI child OR AB child)) AND ((TI emergency OR AB emergency OR TI acute OR AB acute OR TI critical OR AB critical OR TI resuscitation OR AB resuscitation OR TI “intensive care” OR AB “intensive care”))

The search was supplemented by hand-screening of reference lists from included articles and relevant reviews.

Studies were eligible for inclusion if they met the following criteria:

Population: Neonates and children (≤18 years).

Intervention: Cranial ultrasound performed as POCUS (transfontanelle, transtemporal, or other bedside approaches).

Setting: Emergency department, neonatal intensive care unit (NICU) or pediatric intensive care unit (PICU), or perioperative critical care.

Outcomes: Diagnostic accuracy or clinical utility in detecting conditions such as IVH, hydrocephalus, elevated intracranial pressure (ICP), or ischemia, as well as feasibility in acute care scenarios.

Study types: Randomized trials, prospective or retrospective cohorts, cross-sectional studies, case series (≥5 patients), and systematic or narrative reviews relevant to brain POCUS.

Exclusion criteria included studies limited to adult populations, preclinical or technical-only research without clinical application, non-peer-reviewed reports, non-English language publications, and abstract-only sources.

Study Selection

Two reviewers independently screened titles and abstracts using Rayyan QCRI. Full texts of potentially eligible studies were retrieved and assessed against the inclusion criteria. Discrepancies were resolved by discussion or consultation with a third reviewer.

Data Extraction

A standardized data extraction sheet was applied in Excel, recording: first author, year, title, journal; study type, setting, population, sample size; comparator (computed tomography (CT), magnetic resonance imaging (MRI), standard ultrasound); main outcome(s); key findings and relevance to cranial POCUS

Extraction was performed independently by two reviewers.

Risk of Bias Assessment

The methodological quality of the two observational studies was qualitatively appraised using the Newcastle-Ottawa Scale framework [9]. Evaluation focused on three domains: patient selection, comparability, and outcome assessment. Case reports and the narrative review were not formally assessed with standardized tools; however, their inherent methodological limitations, such as small sample size, lack of control groups, and high risk of selection and reporting bias, were acknowledged.

Data Synthesis

Due to heterogeneity in populations, interventions, and outcomes, results were synthesized narratively and tabulated. Key domains of brain POCUS application were identified and mapped. This synthesis informed the development of a conceptual clinical protocol (KORE Brain POCUS Protocol).

Results

Study Selection and Characteristics

The search across databases yielded 36 records. After removing 25 duplicates, 11 records were screened in full; 2 were excluded at eligibility (non-emergency intraoperative focus; not pediatric/POCUS), leaving 9 studies for inclusion. Designs were heterogeneous: 3 narrative reviews/overview pieces [10-12], 1 retrospective case series [13], 1 prospective pilot study in the emergency department [14], 1 cross-sectional cohort in the NICU [15], and 3 single-patient case reports [16–18]. Settings spanned the NICU/PICU (most studies), with one pediatric emergency department cohort [14]. Across the primary studies, a total of 64 neonates/infants were directly evaluated with brain POCUS (n = 6 in the emergency department pilot; n=5 in the neonatal procedure series; n=52 in the NICU cohort; plus 3 single cases).

Populations, Scanning Windows, and Operators

All included works focused on neonates and young infants with open fontanelles, except Rowland (2020), which also covered older children for transcranial Doppler [11]. The anterior fontanelle was the primary window in every bedside series; mastoid/posterolateral and posterior fossa windows were emphasized for posterior fossa and midline lesions [17,18]. Reviews highlighted the role of transcranial Doppler via the anterior fontanelle and transtemporal windows to interrogate waveforms from the anterior cerebral artery (ACA)/middle cerebral artery (MCA)/internal carotid artery (ICA)/basilar arteries (BA) [10,11]. Examinations were performed by neonatologists, pediatric emergency physicians, or intensivists after targeted training [14,15].

Risk of Bias

According to the Newcastle-Ottawa framework [9], both McCormick (2015) [14] and Cizmeci (2018) [13] demonstrated adequate patient selection and outcome assessment through standardized neuroimaging and clinical follow-up. Neither study controlled for potential confounders, resulting in an overall moderate risk of bias. Case reports and the narrative review were considered to have a high inherent risk of bias due to their design limitations.

Diagnostic Applications and Performance

Intracranial Hemorrhage (ICH) and Acute Intracranial Pathology

In the only prospective pilot study conducted in the emergency department, McCormick (2015) evaluated six infants aged ≤3 months presenting with acute neurological concerns [14]. Bedside cranial ultrasound performed by pediatric emergency physicians successfully identified ICH in real time, with complete concordance to radiology findings. This approach avoided the need for sedation or patient transport and contributed to a reduction in CT utilization. Additional diagnostic evidence was provided by several case reports. Halm (2011) described an extremely low birth weight neonate with E. coli meningitis in whom brain POCUS detected evolving parenchymal injury, enabling early intervention [16]. Similarly, Oulego-Erroz (2020) [17] and Lange (2021) [18] reported cases of diffuse intrinsic midline glioma in which the use of mastoid and posterolateral windows was decisive for early suspicion and referral, highlighting the incremental diagnostic value of extended ultrasound windows [19,20]. At a systems level, two narrative reviews emphasized the synergistic role of grayscale cranial ultrasound combined with transcranial Doppler in the early detection of hydrocephalus, midline shift, and hemodynamic compromise [10,11]. These sources underline the potential of brain POCUS to support rapid, bedside neurological assessment in resource-limited or time-sensitive scenarios.

Post-Hemorrhagic Ventricular Dilatation (PHVD)/Hydrocephalus

A recent overview by Dan (2025) consolidated the normative and threshold metrics most commonly applied for the surveillance of PHVD in preterm neonates [12]. In particular, the ventricular index (VI), anterior horn width (AHW), and ratios such as the frontal–occipital horn ratio (FOHR), defined as the ratio between the combined widths of the frontal and occipital horns and the biparietal diameter, and the frontal–temporal horn ratio (FTHR), defined as the ratio between the frontal and temporal horn widths, were highlighted as reliable, reproducible parameters. The review emphasized that these measurements, when obtained serially and plotted over time, can serve as early indicators for neurosurgical referral, thereby directly informing brain POCUS protocols in this population. Additional evidence comes from the cross-sectional cohort study by Yengkhom (2021), which evaluated 52 neonates undergoing late-onset sepsis assessments [15]. In this cohort, cranial ultrasound abnormalities, including ventriculomegaly, IVH, and periventricular leukomalacia (PVL), were identified in 4 of 52 patients (7.7%). These findings contributed meaningfully to clinical decision-making, complementing lung and abdominal POCUS within an integrated multi-organ evaluation pathway.

Hemodynamic Monitoring (Transcranial Doppler)

Reviews detail fontanelle transcranial Doppler as feasible for real-time assessment of cerebral perfusion (peak systolic/end-diastolic velocity; pulsatility index (PI) / resistive index (RI)), autoregulation, and suspected raised ICP in critically ill children [10,11]. These syntheses provide age-aware interpretations and practical scanning tips relevant to emergency pathways.

Procedural Guidance and Impact on Management

The study by Cizmeci (2018) provided one of the few structured evaluations of procedural POCUS in the neonatal neurocritical setting [13]. In this small case series involving five neonates (three with intra-axial and two with extra-axial hemorrhages), ultrasound guidance enabled safe percutaneous needle aspiration directly at the bedside. Procedural success was achieved in all cases, with no infectious complications reported. Importantly, cranial ultrasound was used not only to guide patient selection but also to monitor the immediate post-procedural evolution, illustrating its dual diagnostic and interventional utility. Additional support for expanding brain POCUS applications comes from two illustrative case reports by Oulego-Erroz (2020) and Lange (2021) [17,18]. Both studies demonstrated that incorporating mastoid, posterolateral, and posterior fossa views can reveal lesions that are not accessible through standard anterior coronal and sagittal planes. This extended scanning strategy may therefore play a decisive role in detecting posterior fossa and midline pathologies in time-critical scenarios, broadening the operational value of brain POCUS beyond its conventional applications.

Synthesis of Outcomes Relevant to an Emergency Brain POCUS Protocol

Across the nine included studies, several reproducible elements emerged that can inform the development of a structured brain POCUS protocol for neonatal and pediatric emergency and critical care. These components provide the operational backbone of the proposed KORE Brain POCUS Protocol:

1. Core scanning windows: Routine anterior fontanelle coronal and sagittal sweeps should be systematically performed, with deliberate inclusion of mastoid and posterolateral views when posterior fossa or midline pathology is suspected [10,12,17,18].

2. Structured measurements: In preterm infants at risk of PHVD/IVH, serial assessment of VI, AHW, and FOHR/FTHR ratios against gestational-age–specific reference values allows early recognition of progressive disease and timely neurosurgical discussion [12].

3. Hemodynamic adjuncts: When cerebral perfusion impairment or raised ICP is suspected, transcranial Doppler interrogation of MCA, ACA, ICA, or BA with age-appropriate interpretation of PI and RI provides valuable physiological insight [10,11].

4. Procedural applications: POCUS can be used to guide bedside hematoma aspiration in unstable neonates, supporting both patient selection and procedural monitoring [13].

5. Operational feasibility in the emergency department: Pediatric Emergency Medicine (PEM)-led cranial POCUS has shown the capacity to detect ICH rapidly in young infants, potentially reducing transfers and CT exposure, provided operators have targeted training and escalation pathways [14].

6. Integration into sepsis pathways: Cranial ultrasound can be embedded into multi-organ POCUS workflows to identify neurological complications during late-onset sepsis evaluations [15].

Heterogeneity and Evidence Gaps

Marked methodological heterogeneity, including mixed study designs, small prospective cohorts, and several single-patient case reports, precluded any formal meta-analysis. Nevertheless, the convergence of findings across diverse designs supports the overall feasibility and clinical utility of brain POCUS in neonatal and pediatric urgent care settings. The most developed quantitative evidence currently pertains to PHVD surveillance, for which standardized measurement thresholds have been established [12]. In contrast, prospective diagnostic-accuracy data from the pediatric emergency department remain limited to small pilot studies [14]. Multiple narrative reviews consistently emphasize the need for structured training, competency assessment, and the development of outcome-linked protocols to ensure reliable and reproducible implementation [10,11]. Building on these convergent findings, we synthesized the evidence into the KORE Brain POCUS Protocol, a structured bedside algorithm summarizing the recommended scanning sequence, key measurements, and associated clinical actions (Figure 2, Table 1). The KORE Brain POCUS Protocol is designed to provide a structured, stepwise approach to the bedside evaluation of neonates and young infants presenting with acute neurological concerns. It integrates standardized scanning windows, key measurements, and clinical decision points to support rapid diagnosis and management.

Step 1 – Initial Stabilization. The first priority is to assess airway, breathing, and circulation (ABCs) and ensure hemodynamic stability. Typical indications for initiating brain POCUS include altered mental status, bulging fontanelle, seizures, head trauma, and suspected IVH or hydrocephalus. Early stabilization ensures safe and meaningful imaging.

Step 2 – Scanning Windows and Modalities. Imaging begins with the anterior fontanelle, performing coronal and sagittal sweeps to evaluate ventricular size, parenchymal structure, and midline integrity. Mastoid and posterior fontanelle views are added when posterior fossa or cerebellar pathology is suspected. Colour Doppler interrogation of the ACA, MCA, ICA, and BA provides complementary hemodynamic information, while M-mode can be used to assess midline shift dynamically.

Step 3 – Key Measurements. To support structured interpretation, several measurements can be obtained at the bedside:

AHW > 3 mm suggests ventriculomegaly or IVH in preterm infants.

VI > +2 SD for gestational age indicates progressive ventricular dilatation.

FOHR > 0.55 is consistent with hydrocephalus.

RI > 0.85 raises concern for elevated ICP.

Absent or reversed diastolic flow reflects critical cerebral perfusion compromise.

Step 4 – Interpretation and Clinical Action. Normal findings warrant continued observation and, when clinically appropriate, serial monitoring. Ventriculomegaly, IVH, or other structural abnormalities should prompt early communication with neonatology and neurosurgery teams and timely escalation to confirmatory neuroimaging (CT or MRI) when indicated. Doppler abnormalities suggestive of impaired cerebral perfusion should be interpreted cautiously in the clinical context and may support the need for urgent specialist consultation and further diagnostic evaluation. These decision steps are summarized as a structured bedside triage framework (Table 2).

Discussion

This structured evidence synthesis demonstrates that brain POCUS in neonates and children is technically feasible, repeatable at the bedside, and clinically informative across three key domains relevant to acute care: (1) surveillance of ventricular size and hemorrhage (screening and follow-up of IVH/ventriculomegaly), (2) assessment of cerebral hemodynamics (Doppler-based trends in flow velocity and impedance, particularly in unstable physiology), and (3) detection of anatomic “red flags” (e.g., hydrocephalus, extra-axial collections, midline shifts) that can support triage to advanced imaging or prompt neurosurgical consultation. Although the nine included studies were heterogeneous in design and setting (NICU, PICU, intraoperative, and emergency department/acute care), they converge on a consistent signal: Brain POCUS can shorten the time from clinical deterioration to actionable information when the open fontanelle provides an optimal acoustic window, and Doppler is applied with disciplined technique. In neonates and young infants, the anterior fontanelle allows high-quality 2D and Doppler insonation of the ACA, MCA, ICA, and BA with standard portable ultrasound equipment. This aligns with existing neonatal standards and intraoperative literature where transfontanelle ultrasonography has been used to guide decision-making in real time; for example, during cardiac surgery or when cerebral oximetry drops [20]. In older children with closed fontanelles, the evidence is more limited and focuses on transtemporal Doppler windows, consistent with broader transcranial Doppler-based pediatric literature [19]. Importantly, diagnostic feasibility and accuracy decline in late infancy as fontanelles progressively close and acoustic windows become less reliable. Therefore, the KORE Brain POCUS Protocol is expected to perform best in neonates and early infancy, while in older infants, its role should remain limited to selected cases and adjunct assessment. Routine NICU cranial ultrasound protocols establish reliable linear indices such as AHW, VI, and complementary ratios (FOHR/FTHR) that predict disease progression and the need for temporizing cerebral spinal fluid diversion. Importantly, the direction of change over time is more informative than a single absolute value, underscoring the role of serial assessments. This “measure-and-trend” approach is central to the proposed KORE Brain POCUS Protocol and aligns with contemporary neonatal standards [12]. Bedside Doppler adds physiological information to anatomic imaging. Peak systolic velocity, end-diastolic velocity, and derived PI and RI reflect the dynamic balance between cardiac output, PaCO₂, perfusion pressure, and intracranial/venous pressures. Pediatric intraoperative series show that transfontanelle ultrasonography can detect clinically relevant fluctuations in cerebral brain fluid velocity during anesthesia and cardiopulmonary bypass, and guide management in combination with near-infrared spectroscopy [20]. Compared to transtemporal transcranial Doppler, commonly used in adults, the transfontanelle approach offers an optimized insonation angle and improved waveform quality, which is directly translatable to emergency monitoring. Brain POCUS reliably identifies hydrocephalus, intraventricular clots, and extra-axial collections in infants. Doppler detection of high-intensity transient signals has been described intra-operatively, but their clinical significance in pediatrics remains uncertain and should not currently guide independent interventions [19]. In most emergency settings, CT remains the preferred first-line modality when intracranial pathology is strongly suspected. The feasibility of performing comprehensive Doppler-based brain POCUS prior to CT is likely limited to selected stable infants with open fontanelles and immediate operator availability, and it should not delay definitive neuroimaging when urgently indicated. Brain POCUS should therefore be positioned as a rapid bedside triage tool that may accelerate escalation to advanced neuroimaging, neurosurgical consultation, or transfer to higher-level centers, rather than as a replacement for CT or MRI. POCUS has transformed emergency and critical care by introducing structured, high-yield protocols (eFAST, RUSH, BLUE) that sharpen pre-test probabilities and accelerate definitive care. Despite robust neonatal cranial ultrasound standards and growing perioperative evidence, a structured, triage-oriented brain POCUS pathway for emergency pediatrics remains lacking. This synthesis provides sufficient face validity and operational feasibility to justify codification of a protocol, with the important caveat that diagnostic accuracy and patient-centred outcomes still require prospective validation. Building on the evidence above, the KORE Brain POCUS Protocol addresses four time-critical questions that influence immediate management:

Is ventricular pressure/volume likely elevated? Core views include coronal, parasagittal, and posterior horn sweeps; key measures are AHW, VI, and optional FOHR/FTHR. An early neurosurgical consult should be considered when morphology and clinical signs diverge. Serial measurements are more informative than static cut-offs.

Is cerebral perfusion plausibly threatened? Doppler interrogation of ACA/MCA/ICA (peak systolic velocity, end-diastolic velocity, PI, RI) should be interpreted in relation to systemic changes (mean arterial pressure, PaCO₂, ventilation, positioning, sedation). Actions include titrating cardiorespiratory support and repeating scans after interventions.

Is there an urgent structural lesion? Standard 2D scanning identifies IVH, extra-axial collections, and midline shift. Concerning findings should expedite neuroimaging or escalation of care.

Three pragmatic anchors emerged from the review and can inform the safe and effective implementation of brain POCUS in neonatal and pediatric acute care. First, standardizing image acquisition is essential to preserve measurement reliability over time. This includes maintaining an angle correction of less than 20 degrees, ensuring consistent insonation depth, and acquiring images on the same anatomical planes during serial examinations. These measures help protect the integrity of trend-based interpretations, which are central to the proposed protocol. Second, it is important to teach measurement discipline. Examiners should prioritize obtaining AHW and VI as the primary quantitative parameters, and reserve ratios such as FOHR/FTHR for situations in which ventricular geometry is distorted or more complex. Precise documentation of the insonation plane is equally critical to ensure reproducibility across different operators and time points. Finally, brain POCUS findings should always be interpreted in the clinical context. Morphological and Doppler data should be triangulated with hemodynamic parameters, blood gas analyses, neurological examination, and, where available, near-infrared spectroscopy. Together, these principles form the foundation for consistent and safe clinical application.

As with other successful POCUS protocols, structured training, inter-operator reliability assessment, and multicenter validation will be essential to ensure reproducibility and scalability in real-world practice. The findings of this review suggest that the field is ready to move beyond feasibility and towards structured validation of brain POCUS in neonatal and pediatric acute care. Several key research directions emerge as particularly relevant. There is a clear need for prospective, multicenter diagnostic accuracy studies comparing the KORE Brain POCUS Protocol with reference standards such as MRI, CT, or comprehensive NICU cranial ultrasound. These studies should address predefined emergency questions, including the detection of clinically significant ventriculomegaly, large extra-axial collections, and major IVH. Physiology-to-outcome trials are required to determine whether Doppler-guided titration of ventilation and vasoactive therapy can meaningfully reduce secondary brain injury. Relevant endpoints may include the frequency of severe desaturation events, the need for rescue CT imaging, and time to neurosurgical decision-making. Furthermore, establishing measurement reliability is essential. Inter- and intra-rater agreement for key indices such as AHW, VI, and FOHR should be evaluated in real-world emergency and critical care settings to define competency thresholds for credentialing. Research on health service outcomes could clarify the system-level impact of brain POCUS, including its effect on time to diagnosis, radiation exposure, patient transfers, and cost-effectiveness in both high-resource and resource-limited environments. Finally, protocol-refinement studies should delineate when to incorporate adjunct modalities—such as optic nerve sheath diameter assessment in older infants or transtemporal transcranial Doppler when feasible—and when to escalate directly to advanced imaging.

Within its current evidence boundaries, brain POCUS structured by the KORE Brain POCUS Protocol offers a rapid and physiologically anchored framework for the first critical hour of neonatal and early pediatric neurological emergencies. It is not intended to replace comprehensive imaging or neuromonitoring. Instead, its role is to front-load high-value diagnostic information, support triage decisions, guide cardio-respiratory management, and determine who requires advanced imaging, and with what degree of urgency. The convergence between the nine included studies and existing neonatal cranial ultrasound standards supports the feasibility of implementation, provided that operators receive appropriate training and that quality assurance systems are in place. A coordinated prospective validation will be essential to confirm its diagnostic accuracy, clinical impact, and scalability.

Limitations

This review has several limitations that must be acknowledged. First, the number of eligible studies was relatively small, reflecting the nascent nature of this field. Most of the included reports were narrative reviews, case series, or observational studies, with a paucity of randomized or prospective controlled data. Second, there was marked heterogeneity across studies in terms of populations, clinical settings, ultrasound equipment, operators’ expertise, and outcome measures, which limited the ability to conduct a formal meta-analysis. Third, publication bias cannot be excluded, as studies with negative or inconclusive findings may be underrepresented. Finally, although the proposed KORE Brain POCUS Protocol is derived from converging evidence, it remains conceptual and requires rigorous validation before it can be considered a standardized clinical tool.

Conclusion

Cranial POCUS has emerged as a promising modality for the rapid, bedside assessment of critically ill neonates and pediatric patients. The available evidence, although limited, consistently highlights its value in diagnosing IVH, hydrocephalus, elevated ICP, and in guiding clinical decision-making in acute and intensive care settings. To date, however, no structured protocol equivalent to established frameworks such as BLUE or RUSH exists for pediatric neurocritical care. Based on this systematic synthesis, we propose the KORE Brain POCUS Protocol as a conceptual framework to standardize and integrate cranial POCUS into emergency and critical care pathways. Future research should prioritize multicenter, prospective trials to validate the diagnostic accuracy, reproducibility, and clinical impact of brain POCUS in neonatal and pediatric emergencies. Standardization of image acquisition, interpretation criteria, and operator training is urgently needed. Comparative studies evaluating brain POCUS against conventional neuroimaging modalities, as well as its integration with multimodal neuromonitoring, will be essential to establish its role in routine critical care practice. Ultimately, implementing a validated Brain POCUS protocol could improve diagnostic timeliness, optimize resource utilization, and enhance outcomes in vulnerable pediatric populations.

Ethics Statement

This study is a structured synthesis of published literature and did not involve new human or animal research. Ethical approval and informed consent were not required.

Disclosure Statement

The authors declare that they have no conflicts of interest.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Author Contributions

SMC: conceptualization, methodology, formal analysis, writing – original draft, writing – review & editing. DB: methodology, writing – review & editing. SSC: formal analysis, writing – review & editing. ADP: writing – review & editing, supervision.

References

1. Burton L, Bhargava V, Kong M. Point-of-Care Ultrasound in the Pediatric Intensive Care Unit. Front Pediatr. 2022 Feb 1;9:830160. doi: 10.3389/fped.2021.830160

2. Kirkpatrick AW, Sirois M, Ball CG, Laupland KB, Goldstein L, Hameed M, Brown DR, Simons RK, Kortbeek J, Dulchavsky S, Boulanger BB. The hand-held ultrasound examination for penetrating abdominal trauma. Am J Surg. 2004 May;187(5):660-5. doi: 10.1016/j.amjsurg.2004.02.003

3. Perera P, Mailhot T, Riley D, Mandavia D. The RUSH exam: Rapid Ultrasound in SHock in the evaluation of the critically lll. Emerg Med Clin North Am. 2010 Feb;28(1):29-56, vii. doi: 10.1016/j.emc.2009.09.010

4. Lichtenstein DA, Mezière GA. Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. Chest. 2008 Jul;134(1):117-25. doi: 10.1378/chest.07-2800. Epub 2008 Apr 10. Erratum in: Chest. 2013 Aug;144(2):721.

5. Pan S, Lin C, Tsui BCH. Neonatal and paediatric point-of-care ultrasound review. Australas J Ultrasound Med. 2022 Oct 13;26(1):46-58. doi: 10.1002/ajum.12322

6. Stewart DL, Elsayed Y, Fraga MV, Coley BD, Annam A, Milla SS; COMMITTEE ON FETUS AND NEWBORN AND SECTION ON RADIOLOGY; Section on Radiology Executive Committee, 2021–2022. Use of Point-of-Care Ultrasonography in the NICU for Diagnostic and Procedural Purposes. Pediatrics. 2022 Dec 1;150(6):e2022060053. doi: 10.1542/peds.2022-060053

7. Recker F, Kipfmueller F, Wittek A, Strizek B, Winter L. Applications of Point-of-Care-Ultrasound in Neonatology: A Systematic Review of the Literature. Life (Basel). 2024 May 22;14(6):658. doi: 10.3390/life14060658

8. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, Shamseer L, Tetzlaff JM, Akl EA, Brennan SE, Chou R, Glanville J, Grimshaw JM, Hróbjartsson A, Lalu MM, Li T, Loder EW, Mayo-Wilson E, McDonald S, McGuinness LA, Stewart LA, Thomas J, Tricco AC, Welch VA, Whiting P, Moher D. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. Rev Esp Cardiol (Engl Ed). 2021 Sep;74(9):790-799. English, Spanish. doi: 10.1016/j.rec.2021.07.010. Erratum in: Rev Esp Cardiol (Engl Ed). 2022 Feb;75(2):192. doi: 10.1016/j.rec.2021.10.019

9. Wells GA, Shea B, O’Connell D, Peterson J, Welch V, Losos M, Tugwell P. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. Ottawa: Ottawa Hospital Research Institute; 2000.

10. Vinci F, Tiseo M, Colosimo D, Calandrino A, Ramenghi LA, Biasucci DG. Point-of-care brain ultrasound and transcranial doppler or color-coded doppler in critically ill neonates and children. Eur J Pediatr. 2024 Mar;183(3):1059-1072. doi: 10.1007/s00431-023-05388-0

11. Rowland J, Fouchia D, Favot M. Use of Point-of-care Ultrasound for the Seizing Infant: An Adjunct for Detection of Abusive Head Trauma. Clin Pract Cases Emerg Med. 2020 Aug;4(3):485-486. doi: 10.5811/cpcem.2020.6.48207

12. Dan AM, Vasilescu DI, Dragomir I, Vasilescu SL, Voicu D, Cîrstoiu MM. Cranial Ultrasonography-Standards in Diagnosis of Intraventricular Hemorrhage and Ventricular Dilatation in Premature Neonates. Children (Basel). 2025 Jun 13;12(6):768. doi: 10.3390/children12060768

13. Cizmeci MN, Thewissen L, Zecic A, Woerdeman PA, Boer B, Baert E, Govaert P, Dudink J, Groenendaal F, Lequin M, de Vries LS. Bedside Ultrasound-Guided Percutaneous Needle Aspiration of Intra- and Extra-Axial Intracranial Hemorrhage in Neonates. Neuropediatrics. 2018 Aug;49(4):238-245. doi: 10.1055/s-0038-1641568

14. McCormick T, Chilstrom M, Childs J, McGarry R, Seif D, Mailhot T, Perera P, Kang T, Claudius I. Point-of-Care Ultrasound for the Detection of Traumatic Intracranial Hemorrhage in Infants: A Pilot Study. Pediatr Emerg Care. 2017 Jan;33(1):18-20. doi: 10.1097/PEC.0000000000000518

15. Yengkhom R, Suryawanshi P, Murugkar R, Gupta B, Deshpande S, Singh Y. Point-of-care neonatal ultrasound in late-onset neonatal sepsis. J Neonatol. 2021;35(2):59–63. doi:10.1177/09732179211007599

16. Halm BM, Franke AA. Diagnosis of an intraventricular hemorrhage by a pediatric emergency medicine attending using point-of-care ultrasound: a case report. Pediatr Emerg Care. 2011 May;27(5):425-7. doi: 10.1097/PEC.0b013e318217b567

17. Oulego-Erroz I, Ocaña-Alcober C, Jiménez-González A. Point-of-care ultrasound in the diagnosis of neonatal cerebral sinovenous thrombosis. J Clin Ultrasound. 2020 Sep;48(7):428-430. doi: 10.1002/jcu.22859

18. Lange M, Mitzlaff B, Beske F, Koester H, Aumann W, Woitzik J, Mueller HL, Heep A. Extended cranial ultrasound views in infants with acute brain stem/infratentorial lesions: diagnosis of a progressive midline glioma in a 6-week-old infant. J Child Sci. 2021;11:e262–e264. doi:10.1055/s-0041-1736157

19. Millet A, Evain JN, Desrumaux A, Francony G, Bouzat P, Mortamet G. Clinical applications of transcranial Doppler in non-trauma critically ill children: a scoping review. Childs Nerv Syst. 2021 Sep;37(9):2759-2768. doi: 10.1007/s00381-021-05282-w

20. Knieling F, Rüffer A, Cesnjevar R, Regensburger AP, Purbojo A, Dittrich S, Münch F, Neubert A, Meyer S, Strobel D, Rascher W, Woelfle J, Jüngert J. Transfontanellar Contrast-Enhanced Ultrasound for Monitoring Brain Perfusion During Neonatal Heart Surgery. Circ Cardiovasc Imaging. 2020 Mar;13(3):e010073. doi: 10.1161/CIRCIMAGING.119.010073

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Brain Point of Care Ultrasound in Young Children Receiving Computed Tomography in the Emergency Department: A Proof of Concept Study Visualizing an Umbilical Venous Catheter in Malposition Using POCUS Comparison of Six Handheld Ultrasound Devices by Pediatric Point of Care Ultrasound (POCUS) Experts

(1) Atrium Health Wake Forest Baptist, Brenner Children’s Hospital, Winston-Salem, NC, USA

(2) Department of Pediatrics, Neonatology, Wake Forest University School of Medicine, Winston-Salem, NC, USA

(3) Department of Pediatrics, Pediatric Cardiology, Neonatology, Wake Forest University School of Medicine, Winston-Salem, NC, USA

(4) Department of Pediatric Radiology, Wake Forest University School of Medicine, Winston-Salem, NC, USA

*Corresponding Author:  Dr. Ricardo J. Rodriguez (email: rjrodrig@wakehealth.edu)

Download article PDF – POCUS Journal 2026;11(1):121-125

DOI: https://doi.org/10.24908/pocusj.v11i01.19486

Abstract

Point of care ultrasound (POCUS) can be used to diagnose neonatal lung diseases, especially in the setting of a newborn with significant respiratory distress. A neonate was born at 38.4 weeks gestational age to a 36-year-old Gravida 5 Para 3013 woman with prenatal concerns for fetal cardiothoracic anomalies. Fetal echocardiogram demonstrated left atrial compression of unclear etiology. After delivery, the neonate experienced significant respiratory distress. A transthoracic echocardiogram revealed pulmonary hypertension but no structural heart disease. A lung POCUS exam revealed a homogenous echogenic structure within the right pleural cavity consistent with liver parenchyma. The initial diagnosis of right Congenital Diaphragmatic Hernia (CDH) was made and confirmed by a radiology-performed lung ultrasound and a computed tomography (CT) scan of the chest. This case demonstrated the utility of lung POCUS as an initial diagnostic tool in the neonatal intensive care unit (NICU) for CDH.

Introduction

Congenital Diaphragmatic Hernia (CDH) is a structural birth defect characterized by incomplete diaphragm development, which allows abdominal organs to herniate into the chest cavity [1]. CDH affects approximately 1 in 2,500 to 5,000 newborns, with a male-to-female predominance (1.5:1), and can result in significant morbidity and mortality [2-4]. There are multiple anatomic variants of herniation through the diaphragm, each causing a wide array of symptoms that typically relate to the degree of pulmonary hypoplasia and persistent pulmonary hypertension [1]. Antenatal diagnosis accounts for approximately 60% of all cases [5]. While left-sided CDH is more common overall, right-sided defects may cause symptoms of respiratory distress even within the first year of life [2].

Research into developing evidence-based guidelines for lung POCUS in the neonatal intensive care unit (NICU) has recently grown in popularity [6,7]. In neonates with respiratory distress, POCUS can be used to diagnose and assess the severity of different lung pathologies [6,9]. The benefits of lung POCUS in neonatal critical care include decreasing radiation exposure, quick and easy bedside availability, and repeatability for progression monitoring [7]. Using a high frequency linear transducer, a physician can quickly perform lung POCUS using the ribs, pleural lines, and diaphragm as landmarks to assess interactions between air and water on lung function and pathology [10,11]. Lung POCUS has been used for the diagnosis of a variety of conditions, such as congenital pulmonary airway malformations, meconium aspiration syndrome, pneumonia, transient tachypnea, respiratory distress syndrome, and pneumothorax [7,8]. Here, we present a case of a prenatally undiagnosed right CDH which was identified by lung POCUS in a newborn infant with signs of respiratory distress at birth.

Case Presentation

A 36-year-old Gravida 5 Para 3013 woman presented to the Fetal Heart Program at Wake Forest University School of Medicine at 25 weeks gestational age due to concerns for a fetal cardiac anomaly. The maternal screens were unremarkable, and she had good prenatal care. The mother was counseled by pediatric cardiology and a fetal echocardiogram showed an abnormal contour of the left atrium, consistent with extrinsic atrial compression, and abnormal venous flow in the right hemithorax. The right pulmonary artery and right pulmonary veins were not well visualized. The right atrium and ventricle were notably dilated. Pediatric cardiology recommended an echocardiogram following birth to confirm findings. There was no recommended need for further imaging prenatally. The mother continued to be followed by the maternal-fetal medicine team throughout pregnancy. The maternal-fetal medicine team recommended the NICU team at the delivery of the infant with subsequent NICU admission for further work up.

The neonate was born at 38.4 weeks gestational age via repeat cesarean section. In the delivery room, the baby developed respiratory distress and required continuous positive airway pressure (CPAP) at +5 cm H₂O with an FiO₂ up to 70%. The neonate was admitted to the NICU on CPAP support, with FiO₂ gradually weaned down to 21%. Chest X-ray on admission showed near-complete opacification of the right lung (Figure 1). A postnatal transthoracic echocardiogram performed by pediatric cardiology re-demonstrated external compression of the left atrium, dilation of the right atrium and right ventricle, and suprasystemic right ventricular pressure (90 mm Hg plus right atrial pressure, by tricuspid regurgitant jet). There was also improved visualization of right-sided pulmonary veins returning normally to the left atrium. However, the etiology of left atrium compression could not be elucidated.

Due to continued respiratory distress and chest X-ray findings of near-complete opacification of the right lung, a POCUS exam was performed. A Venue Go R2 Portable Ultrasound machine with a linear hockey-stick probe (GE HealthCare, USA) was used to obtain multiple lung views with the neonate lying supine. Both lungs were scanned in three zones: upper front, lower front and lateral for comparison. The left lung demonstrated normal lung sliding, with A lines and non-confluent B lines. The right upper lung zone showed lung sliding, presence of A lines and occasional B lines. The front lower and lateral zones of the right lung showed lack of lung sliding or A lines. Within the right hemithorax, a homogenous echogenic structure consistent with liver parenchyma was visualized extending into the abdomen (Figure 2). Color Doppler and spectral Doppler interrogation demonstrated the presence of blood flow within the structure consistent with portal venous flow (Figure 3). The characteristic hyperechoic line of the right hemidiaphragm was difficult to assess. No bowel loops or effusions were observed in the right hemithorax. These findings lead to the initial diagnosis of a right-sided congenital diaphragmatic hernia. A radiology-performed lung ultrasound was later completed with confirmed herniation of the liver into the right hemithorax. A CT of the chest was then obtained which confirmed the presence of a right-sided diaphragmatic hernia with herniation of the entire liver, a few bowel loops inferior to the hepatic margin, and the superior pole of the right kidney (Figure 4).

On the third day of life, the neonate was electively intubated in the operating room and underwent an exploratory laparotomy for CDH repair. Intraoperative findings included a large liver extending cephalad into the chest cavity with extensive hepato-pulmonary fusion—a finding not visualized on ultrasound or CT. Additionally, there was minimal diaphragm length posteriorly which impeded primary closure. The infant was returned to the NICU on mechanical ventilation with plans to revisit repair in 6–9 months. The immediate postoperative course was complicated by hemodynamic decompensation secondary to pulmonary arterial hypertension. The infant was treated with inhaled nitric oxide, low dose epinephrine, and milrinone infusions resulting in rapid improvement in mean arterial blood pressure and oxygenation index. The patient was eventually extubated and weaned to low flow nasal cannula with low inspired oxygen concentrations and received full enteral feeds by mouth and gastric tube (G-tube). The patient was ultimately discharged home without surgical interventions on full feeds and was then reportedly asymptomatic on room air and was thriving developmentally.

Discussion

POCUS can help neonatal providers with the assessment of critical lung diagnoses, allowing for more prompt treatment and potentially improved outcomes [6]. Previous reports have described POCUS for the diagnosis of CDH in the pediatric emergency department; however, there is a dearth of literature on the use of POCUS for the initial diagnosis of CDH in the NICU [9,10]. This case demonstrates the utility of POCUS in the NICU to assess lung pathology in a symptomatic neonate.

The utility of lung POCUS for the diagnosis of effusions, pneumothorax, and pneumonia continues to be evaluated in literature. In a patient with respiratory distress and complete or near-complete hemithorax opacification, the diagnosis of these conditions can be rapidly performed with POCUS [12]. Furthermore, the evaluation of the diaphragm function may assist in ruling out extrapulmonary causes such as diaphragmatic eventration, paresis, or palsy [9]. In this case, the POCUS finding of liver parenchyma in the chest cavity, the lack of lung sliding, absence of A lines on the affected side in addition to the presence of systemic venous flow on spectral color mapping, and the lack of a clear delineation of the diaphragm anatomy led the medical team to the initial diagnosis of a right CDH. 

POCUS can be useful as a rapid diagnostic tool for NICU providers to evaluate lung anatomy and pulmonary function, especially in the acutely decompensating patient who may not be stable enough for transport to the radiology suite [7]. Moreover, depending on local resources, a dedicated pediatric sonographer may not be readily available to perform a radiology-performed chest ultrasound on a 24-hour basis. Furthermore, the feasibility for sequential studies with no radiation exposure makes lung POCUS an attractive tool for monitoring disease progression, evaluating sudden changes in clinical status, and for rapidly implementing therapeutic maneuvers (e.g., chest tube placement and pericardiocentesis). Recently, Maddaloni et al. proposed a standardized POCUS protocol for the management of neonates with CDH [8]. These authors delineated a very comprehensive multifaceted protocol that included the use of advanced hemodynamic, abdominal, cerebral, lung, and diaphragm POCUS evaluations. However, POCUS has its own limitations—as demonstrated in this case by the inability to identify a hepato-pulmonary fusion. POCUS in the NICU is a growing practice which requires adequate training and understanding of the basic principles to apply diagnostic medical ultrasound. Thus, we cannot overemphasize the importance of continued collaboration with Pediatric Radiology and Pediatric Cardiology to maintain competence and quality assurance.

In summary, the utilization of lung POCUS led to early identification of a right-sided diaphragmatic hernia, which had not been antenatally visualized, and prompted further work-up to better assess and confirm the initial diagnosis. The early identification of the right-sided CDH allowed for collaboration between the medical and surgical teams in addition to changes in the approach to medical management. 

Conclusion

POCUS is a valuable tool for the rapid assessment of lung pathology in the symptomatic neonate. It may help providers implement appropriate and timely therapies and lead to improved outcomes.

Ethics Statement

This case report was prepared in accordance with our institutional policies. Informed parental/guardian consent was obtained. No interventions outside standard clinical care were undertaken. All personal identifiers have been removed or obfuscated to protect confidentiality.

Disclosure Statement

The authors declare that there are no conflicts of interest regarding the publication of this case report. No financial support, sponsorship, or funding was received for this work. The authors have no financial relationships, personal relationships, or affiliations that could be perceived as influencing the content of this report.

Funding

No financial support, sponsorship, or funding was received for this work. The authors have no financial relationships, personal relationships, or affiliations that could be perceived as influencing the content of this report.

Author Contributions

AD: conceptualization; resources; writing – original draft, review & editing. BH: writing – review & editing. MT: writing – review & editing. MW: writing – review & editing. PG: writing – review & editing. RR: conceptualization; resources; supervision, writing – review & editing.

References

1. Oluyomi-Obi T, Van Mieghem T, Ryan G. Fetal imaging and therapy for CDH-current status. Semin Pediatr Surg. 2017;26:140–146.

2. Bagłaj M. Late-presenting congenital diaphragmatic hernia in children: a clinical spectrum. Pediatr Surg Int. 2004;20:658–669.

3. Bagłaj M, Dorobisz U. Late-presenting congenital diaphragmatic hernia in children: a literature review. Pediatr Radiol. 2005;35:478– 488.

4. Clifton MS, Wulkan ML. Congenital diaphragmatic hernia and diaphragmatic eventration. Clin Perinatol. 2017;44:773–779.

5. Garne E, Haeusler M, Barisic I, Gjergja R, Stoll C, Clementi M. Congenital diaphragmatic hernia: evaluation of prenatal diagnosis in 20 European regions. Ultrasound Obstet Gynecol. 2002;19: 329–333. doi: 10.1046/j.1469-0705.2002.00635.x

6. Gallot D, Coste K, Francannet C, Laurichesse H, Boda C, Ughetto S, Vanlieferinghen P, Scheye T, Vendittelli F, Labbe A, Dechelotte PJ, Sapin V, Lemery D. Antenatal detection and impact on outcome of congenital diaphragmatic hernia: a 12-year experience in Auvergne (France). Eur J Obstet Gynecol Reprod Biol. 2006;125:202–205.

7. Corsini I, Parri N, Gozzini E, Coviello C, Leonardi V, Poggi C, Giacalone M, Bianconi T, Tofani L, Raimondi F, Dani C. Lung ultrasonography for the differential diagnosis of respiratory distress in neonates. Neonatology. 2019;115:77–84. doi: 101159/000493001

8. Yousef N, Mokhtari M, Durand P, Raimondi F, Migliaro F, Letourneau A, Tissières P, de Luca D. Lung ultrasound findings in congenital pulmonary airway malformation. Am J Perinatol. 2018;35(12):1222–1227. doi: 10.1055/s-0038-1645861

9. Maddaloni C, De Rose DU, Ronci S, Pugnaloni F, Martini L, Caoci S, Bersani I, Conforti A, Campi F, Lombardi R, Capolupo I, Tomà P, Dotta A, Calzolari F. The role of point-of-care ultrasound in the management of neonates with congenital diaphragmatic hernia. Pediatr Res. 2024;95(4):901-911. doi: 10.1038/s41390-023-02889-4

10. Raimondi F, Yousef N, Migliaro F, Capasso L, De Luca D. Point-of-care lung ultrasound in neonatology: classification into descriptive and functional applications. Pediatr Res. 2021;90(3):524-531. doi: 10.1038/s41390-018-0114-9

11. Desjardins MP, Weerdenburg KD, Fischer JW. Emergency point-of-care ultrasound diagnosis of diaphragmatic hernia in the pediatric emergency department. Pediatr Emerg Care. 2016;32(10):685– 687.

12. Rankin JH, Elkhunovich M, Seif D, Chilstrom M. Point-of care ultrasound diagnosis of diaphragmatic hernia in an infant with respiratory distress. Pediatr Emerg Care. 2016;32:731–733.

13. Berant R, Kwan, C. & Fischer, J. Emergency Point-of-Care Ultrasound Assessment of Whiteout Lung in the Pediatric Emergency Department. Pediatric Emergency Care. 2015;31(12):872-875. doi: 10.1097/PEC.0000000000000635

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(1) Department of Pediatrics, University of Connecticut School of Medicine, Farmington, CT, USA

(2) Division of Neonatology, Connecticut Children’s, Hartford, CT, USA

(3) Departments of Pediatrics and Diagnostic Imaging and Therapeutics, University of Connecticut School of Medicine, Farmington, CT, USA

(4) Division of Pediatric Radiology, Connecticut Children’s, Hartford, CT, USA

*Corresponding Author:  Dr. Jacob Kelner (email: jkelner@connecticutchildrens.org)

Download article PDF – POCUS Journal 2026;11(1):126-129

DOI: https://doi.org/10.24908/pocusj.v11i01.19974

Supplementary Material: S1, S2

Abstract

Umbilical venous catheters (UVCs) are commonly needed in critically ill infants in the neonatal intensive care unit (NICU). However, there is an increased risk for major adverse events with improper positioning. There is a strong argument for using point of care ultrasound (POCUS) to determine catheter tip positioning during and after UVC placement, but X-rays remain the gold standard in many NICUs. This case reports a UVC in malposition in the liver viewed on POCUS after appearing to be in the correct position on both anteroposterior (AP) and lateral X-rays.

Introduction

Umbilical venous catheters (UVCs) are commonly placed in critically ill newborn infants for stable vascular access [1,2]. During insertion and dwell time, tip migration and malposition can lead to major adverse events if they injure the surrounding vessel, tissue, or organs [2]. Radiography remains the typical standard of care for assessing UVC tip positioning [3,4]. At our institution, correct positioning of a UVC is defined as having the catheter tip at the level of the T9 vertebral body—at or just above the diaphragm—on the anteroposterior (AP) X-ray, or if the catheter tip is posterior to the cardiac silhouette—at or just above the diaphragm—on the lateral view.

Several reports raise concerns about the accuracy of radiography for UVC positioning and have proposed ultrasound as an alternative modality [1,5-8]. A prospective observational study using POCUS to detect UVC migration found that among 40 infants with UVCs, 63% migrated within the first 7 days, and 68% of these migrations were in malposition [9]. Most commonly, they were found within the heart. More concerning was that only 11% of the UVCs in malposition were detected by X-ray.

While a limited number of case reports have used POCUS to diagnose an umbilical line in malposition, none have demonstrated a UVC that appeared correctly positioned on both AP and lateral X-rays prior to POCUS assessment by a neonatal provider, as this case report does [10,11].

Case Presentation

A term neonate boy was born at an outside hospital via vaginal delivery, complicated by maternal placental abruption and a shoulder dystocia requiring forceps. Apgar scores were 1, 3, and 3 at 1, 5, and 10 minutes of life, respectively. The cord blood gas indicated severe acidosis (pH of 6.70; base deficit of -18). He was intubated in the delivery room, and a low-lying UVC was secured. Our transport team initiated therapeutic hypothermia for concerns of hypoxic-ischemic encephalopathy, and he was transported to our tertiary academic neonatal intensive care unit (NICU) for further care.

A UVC was reattempted. Based on his birth weight of 3.72 kg, an estimated best predictive insertion length of 10–11 cm was calculated [12,13]. A 5 Fr umbilical catheter was introduced into the umbilical vein and secured at 10 cm. The catheter flushed well but had no blood return. An AP and lateral chest/abdomen radiograph (Figure 1) showed the UVC to be approximately 1 cm lower than the cavo-atrial junction (CAJ), and the catheter was advanced by 1 cm. The radiologist confirmed the catheter was in the correct position in the CAJ on a repeat lateral radiograph (Figure 2).

Since there was no blood return, POCUS was performed by a trained neonatal provider (JK) shortly after the radiograph to assess the position of the UVC tip. A 12s phased array probe  was placed just below the xiphoid process in the sagittal plane, with the probe marker oriented towards the infant’s head. While fanning slightly right (normal UVC positioning in Figure 3), no catheter was found in the ductus venosus (DV), CAJ, or the right atrium (RA), but a catheter was seen within the liver (Figure 4, Supplementary Material S1) [14]. The images were uploaded to the infant’s chart and reviewed with the on-call radiologist, who was concerned the catheter might be positioned anteriorly in the liver parenchyma. A stat radiology department ultrasound of the liver demonstrated an abnormally positioned UVC line terminating in the liver parenchyma, anterior to the hepatic vein/IVC junction region (Figure 5, Supplementary Material S2). During the radiology department ultrasound, the bedside nurse quickly flushed a small volume of normal saline (NS) through the catheter to create bubbles, which were easily visualized at the UVC tip under ultrasound. The catheter was withdrawn to a low-lying UVC.

Discussion and Conclusion

This case report highlights a significant pitfall of radiography for confirming tip positioning while simultaneously promoting the use of POCUS. Here, POCUS outperformed the lateral X-ray, which is often added when UVC tip placement is difficult to evaluate on the AP X-ray. In this case, we used a quick flush of NS to “agitate” the saline and create bubbles at the UVC tip, as this can aid in assessing line placement [15]. However, agitating the saline by flushing 2 mL of saline back and forth between two syringes via a stopcock before flushing has been reported to be safe in neonates and improve visualization compared to NS flush alone [16].

POCUS during UVC placement improves the accuracy of tip positioning, reduces catheter adjustments, and decreases the number of X-rays required during the process [17]. The continued reliance on X-rays is due to the considerable barriers to introducing POCUS into NICUs. A lack of training and resources can be challenging to navigate, compounded by a lack of collaboration with radiology. Previously, 55% of NICUs in the United States reported this as a barrier to adopting POCUS [18]. We want to emphasize that POCUS did not replace radiology department ultrasound; instead, it facilitated faster diagnosis by allowing for a quicker request for radiology department ultrasound.

Fostering a strong relationship between the neonatal POCUS and pediatric radiology teams is vital to improving the quality of neonatal care. Based on our institutional experience, this relationship is built on a mutual understanding of the roles that both POCUS and radiology department ultrasound play in achieving a shared mission of improving patient outcomes. Having standardized protocols for acquiring, interpreting, and documenting POCUS images in patient charts can enable the on-call radiologist to provide quality assurance when needed. Lastly, collaborating on research and quality-improvement projects further improves communication between the two departments and leverages both specialists’ expertise to advance the field of neonatal echography.

In conclusion, this case report contributes to the growing body of evidence supporting the use of POCUS over X-rays for more accurate and safer UVC positioning. It also provides evidence for neonatal POCUS programs to foster a more collaborative relationship with their radiology department, relieving a significant barrier to introducing POCUS in the NICU.

Acknowledgements

We want to thank the University of Connecticut/Connecticut Children’s for supporting this research and the family of this infant for consenting to this case report.

Ethics Statement

Consent for publication has been obtained from the infant’s family.

Disclosure Statement

The authors declare no competing financial interests or other conflicts of interest. This study received no funding.

Funding

This study received no funding.

Author Contributions

JK: POCUS scan, writing – original draft, writing – review & editing . DM: writing – original draft, writing – review & editing, supervision.

References

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2. Gibson K, Sharp R, Ullman A, Morris S, Kleidon T, Esterman A. Risk factors for umbilical vascular catheter-related adverse events: A scoping review. Aust Crit Care. 2022;35(1):89-101.

3. Arunoday A, Zipitis C. Confirming longline position in neonates – Survey of practice in England and Wales. World J Clin Pediatr. 2017;6(3):149-153.

4. Rossi S, Jogeesvaran KH, Matu E, Khan H, Grande E, Meau-Petit V. Point-of-care ultrasound for neonatal central catheter positioning: impact on X-rays and line tip position accuracy. Eur J Pediatr. 2022;181(5):2097-2108.

5. Xie HQ, Xie CX, Liao JF, Xu FD, Du B, Zhong BM, He XG, Li N. Point-of-care ultrasound for monitoring catheter tip location during umbilical vein catheterization in neonates: a prospective study. Front Pediatr. 2023;11:1225087.

6. Franta J, Harabor A, Soraisham AS. Ultrasound assessment of umbilical venous catheter migration in preterm infants: a prospective study. Arch Dis Child Fetal Neonatal Ed. 2017;102(3):F251-f255.

7. Karber BC, Nielsen JC, Balsam D, Messina C, Davidson D. Optimal radiologic position of an umbilical venous catheter tip as determined by echocardiography in very low birth weight newborns. J Neonatal Perinatal Med. 2017;10(1):55-61.

8. Seigel A, Evans N, Lutz T. Use of clinician-performed ultrasound in the assessment of safe umbilical venous catheter tip placement. J Paediatr Child Health. 2020;56(3):439-443.

9. Dubbink-Verheij GH, Visser R, Tan R, Roest AAW, Lopriore E, Te Pas AB. Inadvertent Migration of Umbilical Venous Catheters Often Leads to Malposition. Neonatology. 2019;115(3):205-210.

10. Rajendran G, Sinha AK. Umbilical venous catheter extravasation diagnosed by point-of-care ultrasound. Arch Dis Child Fetal Neonatal Ed. 2021;106(5):549.

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