|Year : 2020 | Volume
| Issue : 1 | Page : 1-11
Point-of-care ultrasound for the acute abdomen in the primary health care
Moien A B. Khan1
, Fikri M Abu-Zidan2
1 Department of Family Medicine, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
2 Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
|Date of Submission||11-Sep-2019|
|Date of Acceptance||07-Oct-2019|
|Date of Web Publication||28-Jan-2020|
Dr. Fikri M Abu-Zidan
Department of Surgery, College of Medicine and Health Sciences, UAE University, PO Box: 17666 Al-Ain, United Arab Emirates
United Arab Emirates
Source of Support: None, Conflict of Interest: None
Point-of-care ultrasound (POCUS) is a focused examination, which is performed and interpreted at the bedside by the treating physician answering a specific clinical question. It is currently utilized as an essential adjunct to physical examination in many medical specialties. Recent advances in technology have made POCUS machines portable, affordable, and could be used with minimal training even by nonradiologists. This review aims to cover the fundamental physics of POCUS and its applications for diagnosing the acute abdomen in the primary health care including the most common causes encountered by family physicians. These are acute appendicitis, acute cholecystitis, renal colic, ectopic pregnancy, acute diverticulitis, bowel obstruction, and abdominal aortic aneurysm. We hope to encourage primary care physicians to incorporate POCUS in their routine clinical practice. We also highlight challenges encountered when using POCUS in the primary health care including limited availability and the need for proper training. Furthermore, we review the POCUS results when performed by primary health-care physicians. Integrating POCUS in primary health care empowers primary health-care physicians to provide high-quality, safe, and cost-effective care to the patients.
Keywords: Abdominal pain, acute abdomen, point-of-care ultrasound, primary care
|How to cite this article:|
B. Khan MA, Abu-Zidan FM. Point-of-care ultrasound for the acute abdomen in the primary health care. Turk J Emerg Med 2020;20:1-11
| Introduction|| |
Primary health care is an early patient's encounter to a proper health-care system., Primary care physicians should provide timely comprehensive care at this point of time,,, including urgent and after-hours management., Abdominal pain is the third most common out of hour's emergency presentation seen by primary care physicians and accounts for 2%–4% of all consultations in primary health care.,,,, The acute abdomen is defined as a sudden onset of abdominal pain which requires urgent medical care. It is a diagnostic challenge with many differential diagnoses that can vary from a self-limiting illness to a life-threatening condition., Patients with acute abdomen are usually referred to hospitals for further workup. Nevertheless, half of these patients do not require hospital admission., Investigations for these patients can be resource demanding. Accordingly, an initial workup at the primary health care facility can be useful.
Point-of-care-ultrasound (POCUS) is now more frequently performed in the primary health care. Nevertheless, only 6% of family physicians use nonobstetric POCUS in their practice. Only 2% of family medicine postgraduate programs in America include POCUS training. POCUS allows primary care physicians to make an appropriate and accurate diagnosis during consultations.
In this review, we aim to lay down the basic principles of using POCUS in diagnosing the acute abdomen and highlight its findings in the most common acute abdominal presentations encountered by the primary health-care physicians.
| Point-Of-Care Ultrasound|| |
Point-of-care ultrasound (POCUS) is defined as a targeted ultrasound examination performed and interpreted by the physician at the bedside as part of the clinical examination. POCUS answers a specific clinical question and does not replace routine detailed ultrasound studies. When combined with clinical examinations, POCUS improves diagnostic accuracy and patient's care.
POCUS is a physiological study (can define the cause of shock), an on-spot clinical decision-making tool, an extension of the clinical examination that is unique (studying different regions at the same time) and safe (can be done repeatedly).,,,, When using POCUS, primary care physicians can interpret the achieved information immediately on the bedside to guide further management.
| The Utility of Point-Of-Care Ultrasound for Diagnosing the Acute Abdomen|| |
POCUS is the initial imaging diagnostic tool for the acute abdomen., The common causes of abdominal pain presenting to primary care physicians include acute appendicitis, cholecystitis, renal colic, ectopic pregnancy, diverticulitis, bowel obstruction, and abdominal aortic aneurysm (AAA).,
POCUS is a dynamic examination which can demonstrate bowel motility and blood flow., Furthermore, it can be focused at the maximum point of abdominal tenderness which is defined by the patient. This has a sensitivity of 85% in diagnosing acute appendicitis. The graded compression technique entails slow and sustained compression at the point of maximum tenderness of the bowel loops to displace intraluminal gas and visualize the underlying structures., Furthermore, inability to compress the bowel indicates an abnormal pathology including appendicitis, intussusception, or malignancy., POCUS could reach the diagnosis in 35%–65% of patients presenting with acute abdomen, and changed the management plan in 47% of them.
| Basic Physics|| |
Understanding the basic physics of ultrasound allows physicians to properly interpret ultrasound images., Ultrasound is a high frequency sound wave which can be transmitted through different media such as fluids and soft tissues. The number of ultrasound waves per se cond defines the ultrasound frequency. Ultrasound machines send high-frequency ultrasound waves (2–15 MHz) through their piezoelectric crystals located in their probes and then receive the reflected waves., High-frequency waves have low penetration but excellent resolution compared with low-frequency waves which have more deep penetration but low resolution. The brightness (B) mode produces 1 mm thin slices of black and white two-dimensional images. The images can be altered by changing the frequency of the waves, the shape of the probe, the size of the probe, and the timing of waves' emission.,,
Acoustic impedance varies according to the density of different media. With increased density, particles of the media are tightly attached, leading to more reflection of ultrasound waves. Hence, an anechogenic black image represents fluids such as blood and urine, whereas soft tissue such as the liver is gray, fibrous tissue such as the diaphragm is white without a shadow (hyperechoic), and bones/stones such as gallstones are white with a shadow [Figure 1].,
|Figure 1: Denser materials reflect more ultrasound waves. Accordingly, fluid (like ascites) is black (anechoic), soft tissue (like the liver) is gray, fibrous tissue (like the diaphragm) is white without a shadow, and stones are white (hyperechoic) with a shadow. The air is very hyperechoic having reverberation artifacts. (This figure was reproduced from the study of Abu-Zidan and Cevik), which is distributed under the terms of the Creative Commons Attribution 4.0 International License|
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| Free Fluid|| |
Traumatic bleeding, ascites, bile leak, urinary leak, and ruptured ectopic pregnancy can cause the presence of intraperitoneal free fluid. POCUS can detect up to 10 ml free intraperitoneal fluid (IPF) by experienced hands.,, The common abdominal locations for free IPF are the 3 Ps, which are (a) perihepatic space (Morison's pouch), (b) perisplenic space (Koller's pouch), and (c) pelvis (pouch of Douglas). Fluids are usually anechoic (black) [Figure 2]. Nevertheless, clotted blood can be gray and difficult to visualize. The sensitivity and specificity of ultrasonography in the detection of free IPF is over 90%., However, one of the critical challenges with POCUS is the inability to define the type of fluid (urine, bile, blood, or ascites). Hence, correlating the sonographic findings with the clinical findings would give an accurate bedside diagnosis.
|Figure 2: A heavy plywood fell on the right side of the abdomen of a 34-year-old male laborer. The patient complained of severe abdominal pain. On clinical examination, blood pressure was 110/57 mmHg and pulse rate was 66 beats/min. Point-of-care ultrasound examination (a) showed significant intraperitoneal fluid and floating fibrinous band (arrow heads). Computed tomography scan with intravenous contrast (b) confirmed the presence of liver injury (yellow arrow head). The patient was treated conservatively, but his abdomen continued to distend. Laparotomy confirmed the presence of bile leak which was successfully treated by suction drainage. K = Kidney, S = Spleen (Point-of-care ultrasound study was performed by Professor Fikri Abu-Zidan)|
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| Intestinal Obstruction|| |
Intestinal obstruction accounts for approximately 15% of acute abdominal pain presenting to the emergency department. Complications of intestinal obstruction include bowel ischemia and perforation. POCUS can determine the etiology of small-bowel obstruction. Small-bowel loops are scanned starting from the epigastrium to the pelvis in a sweeping fashion using the linear probe (10–12 MHz). With obstruction, there is the possibility of air–fluid levels of the bowel. Gentle but graded compression can be used to displace gas and bowel contents to evaluate the bowel wall.
Ultrasound has a sensitivity of 95% and specificity of 84% in diagnosing small-bowel obstruction. POCUS is a real-time examination that can detect dynamic changes of bowel movements and show blood flow [Figure 3]. Its findings include dilated bowel loops and increased bowel wall thickness (>3 mm) with increased or decreased peristalsis., The level of small-bowel obstruction is dependent on the visibility of the valvulae conniventes. They are more prominent in jejunal obstruction and less in the obstruction at the level of the ileum.
|Figure 3: Point-of-care ultrasound of a strangulated epigastric hernia using a linear probe (10–12 MHZ). The hernia contained a small bowel (B). The color Doppler showed that there was no flow in the mesentery (M). Urgent surgery showed that the bowel was ischemic. (Point-of-care ultrasound study was performed by Professor Fikri Abu-Zidan)|
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| Free Intraperitoneal Air|| |
Reverberation artifacts occur when waves bounce between two interface media having high tissue impedance., The waves moves forward and backward between these interfaces. This occurs when the ultrasound waves bounce between the probe and free intraperitoneal air. The ultrasound machine recognizes these waves as parallel lines with equal distance between them, resulting in a striped pattern with alternating dark and bright lines at regular intervals. There is decreased echogenicity for the deeper lines because the reflected waves become gradually less [Figure 4].
|Figure 4: Classical point-of-care ultrasound findings of free intraperitoneal air. An enhanced peritoneal stripe sign (arrow heads) is a white increased echogenicity stripe located under the abdominal wall fascia in the supine position which does not move with respiration. The reverberation artifact consists of hyperechogenic parallel lines with equal distance between them (arrows). (Point-of-care ultrasound study was performed by Professor Fikri Abu-Zidan)|
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Bowel gas is normally confined within the gut lumen. Gas may leak into the peritoneal cavity through a bowel perforation, which needs urgent treatment. POCUS can precisely detect free intraperitoneal air. The sensitivity of detecting free intraperitoneal air by POCUS is superior to an abdominal X-ray (86% compared with 76%). Ultrasound is superior to upright chest and left lateral decubitus abdominal X-rays which can miss hollow viscus perforations in 20% to 62%.,, The sonographic signs of intraperitoneal air include (a) enhanced peritoneal stripe sign, (b) peritoneal stripe reverberations, and (c) focal air collections visualized as ring down artifacts. The enhanced peritoneal stripe sign is a white increased echogenicity stripe under the abdominal wall fascia in supine position. The free intraperitoneal air can move when changing the patients' position (shifting phenomenon). However, there are some challenges related to sonographic detection of free intraperitoneal air including rib shadows and artifacts from air-filled lungs or colon.
| Acute Appendicitis|| |
Acute appendicitis is a common disease seen by primary care physicians. It is caused by obstruction of the appendicular lumen leading to inflammation, ischemia, necrosis, and perforation of the appendix. It has a lifetime risk of 8.6% in males and 6.7% in females. Approximately one-third of acute appendicitis perforate. Physicians should balance the risk of misdiagnosis against the risk of perforation. POCUS is advised to be the first diagnostic modality for acute appendicitis., Difficulty in visualizing the appendix may be encountered due to pain, obesity, and bowel gas. If the appendix is visualized, POCUS has a diagnostic sensitivity of almost 100% and a specificity of 85%. The appendix is better visualized in thin patients having more pain and higher Alvarado scores. There is a low threshold in general practice to refer patients to the hospital when suspecting acute appendicitis. The referrals are done not to miss the diagnosis, which results in more surgery. Accordingly, negative appendectomies have increased up to 40%.
Fat and bowel covering the appendix can be slowly displaced using the gradual compression technique. Noncompressibility of the appendix is an indication of inflammation. Computed tomography (CT) scan is more accurate in diagnosing appendicitis. Nevertheless, it carries a risk of radiation, especially in children and younger patients. A step-wise approach starting with POCUS before CT scan is advised.
Sonographic finding of acute appendicitis include (a) noncompressible tubular structure with a target sign having a diameter of more than 6 mm at the location of the appendix, (b) distorted irregular mucosa, (c) presence of IPF, (d) thickened omentum, and (e) presence of a fecalith [Figure 5].
|Figure 5: A 19-year-old male presented with pain in the right upper quadrant of the abdomen of 1-day duration. Abdominal examination revealed tenderness and guarding in the right upper quadrant. The patient had no fever and no leukocytosis. The patient was suspected to have acute cholecystitis. Routine ultrasound was performed by a radiologist and reported as normal. Repeated point-of-care ultrasound 12 h later (a) using a high-frequency linear probe of the abdomen showed a noncompressible tubular structure in the subhepatic region having a target sign (arrow heads). Point-of-care ultrasound (b) using a small print convex array probe with a frequency of 3–5 MHz showed minimum amount of free fluid in the pelvis (yellow arrow). Laparoscopy confirmed the presence of subhepatic acute appendicitis. (Point-of-care ultrasound study was performed by Professor Fikri Abu-Zidan)|
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| Acute Cholecystitis|| |
Gallstones can be detected in 10% to 15% of the adult population and majority are asymptomatic., Acute cholecystitis is caused by gallstones in 95% of cases whereas 5% has no gall stones., A curvilinear low-frequency (2–5 MHz) transducer is used when examining the gall bladder. During examination, the patient should be in supine position. The probe will be moved from medial to lateral on the right side of the abdomen starting from the xiphoid and following the right subcostal margin laterally. After the liver is seen, the gallbladder is localized and scanned in different planes. The diameter of the common bile duct should be measured. When doubt exists whether the structures seen are gallstones or a gall bladder wall irregularity, the patient is asked to gradually move to his/her right or left side while the probe is stable in its position in relation to the abdominal wall. The gallstones could be seen moving within the gallbladder confirming the diagnosis.
Gallstones produce a posterior acoustic shadow and an echogenic rim. Gall stones of <5 mm in diameter can be echogenic without a shadow. Detecting gallbladder stones along with increased wall thickness of the gall bladder >3 mm, pericholecystic fluid, and positive Murphy's sign are diagnostic of acute cholecystitis [Figure 6]. Finding gallstones during POCUS which is associated with tenderness when the gallbladder is compressed with the ultrasound probe (sonographic Murphy's sign) has a 92% positive predictive value for acute cholecystitis. A study on 1690 patients having abdominal pain showed that POCUS had 88% sensitivity, 87% specificity, 91% positive predictive value, and 83% negative predictive in diagnosing gall stones. Patients having a negative POCUS were unlikely to require surgery or admission for cholecystitis within 2 weeks of the study.
|Figure 6: A 61-year-old male presented with abdominal pain, fever, rigors, and jaundice. Abdominal examination revealed tenderness and guarding in the right upper quadrant. The patient had no leukocytosis and his bilirubin was high (60 μmol/L). Serum amylase was normal. Point-of-care ultrasound examination (a) showed the presence of gall stones (white arrow) with a shadow (arrow heads), thickened wall of the gall bladder, normal diameter of the common bile duct (5 mm), and a normal pancreas. Magnetic resonance cholangiopancreaticography (b) showed a suspected filling defect in the distal end of the common bile duct (white arrow) with no significant dilatation. There was diffuse thickening of the wall of the gallbladder associated with multiple small gall stones. Laparoscopic cholecystectomy confirmed the presence of acute cholecystitis. The intraoperative cholangiogram was normal. (Point-of-care ultrasound study was performed by Professor Fikri Abu-Zidan)|
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| Renal Colic|| |
The most common cause of renal colic is urolithiasis, which is more in males between 20 and 50 years of age. Between 3% and 15% of adults experience renal colic in their lifetime., The main objective of POCUS when evaluating a flank pain is to detect obstructive uropathy and not stones [Figure 7]. Depending on the patient's habitus and operator's experience, sensitivity of POCUS for detecting hydronephrosis is 72% to 97% whereas the specificity is 73% to 98%., Patients with ureteral calculi of >5 mm are more likely to have hydronephrosis., Stones of <10 mm in size are likely to be managed conservatively if patients have no signs of sepsis, if the stone is unilateral, if the renal function is normal, and if the pain is controlled with analgesia. Patients with hydronephrosis are more likely to have a stone >5 mm. Goertz and Lotterman correlated the POCUS with CT scan findings in 129 patients having renal colic and they concluded that patients with mild or no hydronephrosis were unlikely to have stones. Majority of those who have moderate-to-severe hydronephrosis had stones >5 mm in diameter.
|Figure 7: A 27-year-old male presented with pain in the right iliac fossa of 1-day duration with tenderness and guarding. He did not have fever or leukocytosis. There was no loin tenderness. He was admitted as a case of acute appendicitis and planned for surgery. Point-of-care ultrasound (a) has shown a dilated pelvis of the right kidney (arrows). Computed tomography abdomen without contrast (b) confirmed the presence of hydronephrosis on the right side (arrow head) with traceable ureter due to a stone in the lower ureter close to the urinary bladder with a diameter of 3.4 mm (yellow arrow). The stone was removed using endoscopic ureteroscopy and the patient was discharged in a good condition. L = Liver, K = Kidney (Point-of-care ultrasound study was performed by Professor Fikri Abu-Zidan)|
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CT scan without contrast is the gold standard imaging modality for patients with suspected renal stones. Renal POCUS has a poor negative predictive value for urolithiasis in the absence of hydronephrosis compared with CT scan. Hydration with 500 ml to 1000 ml of fluid increases the chances of identifying hydronephrosis although it may increase the pain. In general, POCUS has poor sensitivity in detecting stones. Stones that can be visualized are mainly those proximal to the ureteropelvic junction or distal to the ureterovesical junction where there is an acoustic window. It is difficult to visualize the retroperitoneal ureter between the kidney and the bladder. Occasionally, the ureter can be seen dilated indicating distal obstruction when correlated with acute abdominal pain.
| Ectopic Pregnancy|| |
Family physicians can provide first trimester care evaluating complications arising in early pregnancy. It is always essential to exclude ectopic pregnancy and pregnancy loss in women of childbearing age if presenting with abdominal pain and missed periods. A full assessment of the first-trimester pregnancy using POCUS helps identify the cause of early pregnancy bleeds. The American College of Emergency Physicians approves the use of bedside ultrasound for the detection of intrauterine or ectopic pregnancy during all stages of pregnancy. In a suspected ectopic pregnancy, testing urine for pregnancy along with POCUS would be the best method to get an accurate diagnosis and appropriate management [Figure 8]. POCUS is mainly done to look for free IPF and its volume and also the presence or absence of intrauterine pregnancy. Viability of early pregnancy can be confirmed by POCUS in women having vaginal bleeding. Combining POCUS with the clinical findings, measuring the inferior vena cava diameter, and evaluating the heart define the hypovolemic or septic nature of the shock if present., Abnormal adnexal findings such as tubal rings, complex masses, or live extra uterine embryos can be occasionally seen.
|Figure 8: A 23-year-old married female presented with right lower abdominal pain of 1-day duration. Her last menstrual period was 2 weeks before. Her blood pressure was 120/70 mmHg, and her pulse rate was 90 beats/min. On examination, she did not look sick, and her abdomen was soft and lax. There was mild tenderness in the right iliac fossa. Abdominal ultrasound (a) showed free intraperitoneal fluid (black arrow). Pregnancy test was urgently requested and was positive. The patient had a laparotomy which showed one and half liters of blood (b) caused by an ectopic pregnancy located in the right Fallopian tube More Details which was excised (c). The patient had a smooth postoperative recovery. (Courtesy of Professor Fikri Abu-Zidan)|
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One of the challenges of doing POCUS is missing an ectopic pregnancy. Occasionally, interstitial pregnancy, which is an ectopic gestation in the intrauterine part of the fallopian tube, can be missed for an intrauterine pregnancy. Transvaginal ultrasound performed by an expert is advised in doubtful cases of ectopic pregnancy.,
| Diverticulitis|| |
Diverticulitis is a common cause of abdominal pain in adults resulting from inflammation of a colonic diverticulum. Patients can present with fever, acute abdominal pain, bleeding per rectum, or urinary symptoms. Diverticulitis is seen in 15% to 25% of patients having diverticulosis. The accuracy of clinical examination for diverticulitis is low. Taking appropriate history and physical examination along with POCUS improves the diagnosis. The differential diagnosis includes appendicitis, urolithiasis, or urinary tract infection. Liljiegeren et al. in a systematic review recommended ultrasound as the first choice for diagnosing diverticulitis. Similarly, Laméris et al. did a systematic review on graded compression technique of ultrasound in diagnosing diverticulitis and reported a sensitivity and specificity of 90% and 89%, respectively. Nevertheless, CT scan is more accurate than ultrasound in diagnosing diverticulitis.,
Mural thickening of the bowel with a paucity of luminal content may indicate inflammatory bowel disease. The diagnostic findings of the inflamed bowel include (a) thickened bowel wall >4–5 mm, (b) echogenic inflamed fat, (c) noncompressibility, and (d) loss of peristalsis [Figure 9]., Colonic wall layers are usually preserved in diverticulitis compared with malignant tumors in which layers are distorted. Bedside POCUS can also detect other complications of diverticulitis including free IPF, free intraperitoneal air, and abscess formation.,
|Figure 9: A 52-year-old male presented with pain in the left iliac fossa of 3-day duration. He had no history of bleeding or constipation. On clinical examination, there was a tender mass in the left iliac fossa. Point-of-care ultrasound (a) has shown a target sign at the site of the sigmoid colon (arrow heads) suggestive of acute diverticulitis. Sparse gas is seen within the colon (white arrows). Computed tomography scan with IV contrast confirmed the findings (b) with the presence of the mass (arrow head) and inflamed peritoneum (yellow arrows). (Point-of-care ultrasound study was performed by ProfessorFikri Abu-Zidan)|
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| Abdominal Aortic Aneurysm|| |
AAA is found in 2% to 5% of the population above 50 years of age. AAA occurs when the aorta below the renal arteries expands to a diameter of >3 cm. Ruptured AAA is a life-threatening emergency condition having a high mortality. The risk of rupture of an aneurysm increases with its increased diameter. Diagnostic delay occurs because AAA may mimic other pathologies including renal colic or acute diverticulitis. AAAs are often clinically silent; hence, early screening is advised. POCUS examination in patients with cardiovascular risk factors such as age>70 years, smoking, hypertension, peripheral vascular disease, dyslipidemia, or diabetes detected 71% of AAA's.,
Ultrasound is the gold standard for AAA screening and diagnosis having a sensitivity of 94% to 99% and specificity of 98% to 100%.,,,, In a Japanese study of 1731 patients who underwent community screening for AAA, small AAAs were missed by physical examination. In contrast, a study used a hand-held ultrasound device for AAA screening on randomly selected 1010 male patients aged more than 60 years. It found that patients who were diagnosed with AAA had a smaller aortic diameter (3.5 cm) compared with patients diagnosed incidentally (4.7 cm diameter) [Figure 10]. This study supports the use of POCUS for screening AAAs in the primary care setting.
|Figure 10: A 75-year old male presented with severe abdominal pain and an unexplained shock. Blood pressure was 70/50 mmHg. Point-of-care ultrasound in both longitudinal (a) and cross section (b) showed a pulsatile aortic aneurysm of 4.27 cm diameter with fluid leakage around it (yellow arrow). Urgent laparotomy confirmed the presence of a ruptured aortic aneurysm. (Courtesy of Professor Fikri Abu-Zidan)|
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A curvilinear low-frequency (2–5 MHz) probe is used for scanning the aorta. The aorta should be initially scanned longitudinally [Figure 10]a. The marker of the probe is then tilted 90° to the right side to visualize the transverse cross section of the aorta [Figure 10]b. The aorta should be completely scanned starting from the epigastrium till the distal bifurcation. The outer diameter should be included in the measurement. A thrombus can be occasionally seen within the aneurysm. Color Doppler is useful to study the flow within the aneurysm. The presence of free intraperitoneal fluid may indicate a ruptured aortic aneurysm.
AAA imaging by POCUS can be done efficiently by primary care physicians even with minimal training and was highly correlated with the hospital-based studies. It had a sensitivity and specificity of 100% and was done within an average of 3.5 min. Nevertheless, screening for AAA by general practitioners was associated with a high false positive rate of 21.4%. Furthermore, AAA screening can be challenging in obese patients.
| The Importance of Training|| |
POCUS use in general practice is still limited because of the required time, lack of training, and financial constraints. Understanding the basic physics of ultrasound and having proper hands-on training allows primary care physicians to use this useful tool. Providing community-based ultrasound reduces waiting time for having a routine ultrasound. Furthermore, POCUS has the same results when done by general practitioners compared with radiologists. With recent innovations and technological advances, ultrasound machines have become affordable as a point-of-care device. They have become smaller, portable, and easier to use. Accordingly, ultrasound training has been included in many undergraduate and postgraduate training programs.,, Training is important before using POCUS., Structured training allows family physicians to perform abdominal ultrasound with high accuracy. Family physicians became confident in performing POCUS after 16 h of learning. The average time spent by family physicians in performing POCUS studies was <10 min.
Performing an ultrasound by primary care physicians gives patients high satisfaction. We propose the use of POCUS for the initial evaluation of patients presenting with acute abdomen as an adjunct to clinical examination at primary health care. To achieve this, there should be structured educational programs supported by proper credentialing processes.
| Conclusions|| |
POCUS has become an integral part of clinical medicine. There has been limited use of POCUS by primary care physicians despite its accuracy and its affordable costs. POCUS is anticipated to become a standard care diagnostic tool used by primary care physicians in the near future. More training and research is needed to advance the use of POCUS in primary health care. There should be a push to integrate POCUS in the family medicine curricula and support training for the future generation of primary health-care physicians.
Author contribution statement
Moien AB Khan participated in the idea, critically read the literature, drafted the first version of the paper, and approved its final version. Fikri M Abu-Zidan had the idea, critically read the literature, drew and supplied the clincial images, wrote sections of the paper, repeatedly edited the paper and approved its final version.
Ethical Approval and Consent to participate
The images of cases have been collected over a period of 30 years. The paper does not have information or images that can identify any patient. Images are mainly radiological except one operative image for a patient treated 19 years ago. She could not be contacted after this long period of time to get her written consent.
Conflicts of interest
All authors declare that they have no conflict of interest.
| References|| |
Donaldson MS, Yordy KD, Lohr KN, Vanselow NA, editors. Primary Care: America's Health in a New Era. Washington (DC): National Academies Press (US); 1996.
Muldoon LK, Hogg WE, Levitt M. Primary care (PC) and primary health care (PHC). What is the difference? Can J Public Health. 2006;97:409-11.
Banks G, Wingrove P, Petterson SM, Klink K. Family physicians contribute significantly to emergency care of medicare patients in urban and suburban areas. Am Fam Physician 2015;92:445.
Committee Financial Management Rate of Return. ACGME Program Requirements for Graduate Medical Education in Family Medicine. Committee Financial Management Rate of Return; 2011.
Grol R, Giesen P, van Uden C. After-hours care in the United Kingdom, Denmark, and the Netherlands: New models. Health Aff (Millwood) 2006;25:1733-7.
Gerard WA, Staffer A, Bullock K, Pugno P. Family physicians in emergency medicine: New opportunities and critical challenges. Ann Fam Med 2010;8:564-5.
Myhr K, Sandvik H, Morken T, Hunskaar S. Point-of-care ultrasonography in norwegian out-of-hours primary health care. Scand J Prim Health Care 2017;35:120-5.
Frear D, Tilyard MW. Abdominal pain in New Zealand general practice. N Z Med J 1997;110:333-4.
Zantuck N, Wong ML, Mackay S. Surgical causes of upper abdominal pain. Aust Fam Physician 2008;37:614-8.
Speets AM, Kalmijn S, Hoes AW, van der Graaf Y, Mali WP. Yield of abdominal ultrasound in patients with abdominal pain referred by general practitioners. Eur J Gen Pract 2006;12:135-7.
Mengel-Jørgensen T, Jensen MB. Variation in the use of point-of-care ultrasound in general practice in various european countries. Results of a survey among experts. Eur J Gen Pract 2016;22:274-7.
Mayumi T, Yoshida M, Tazuma S, Furukawa A, Nishii O, Shigematsu K, et al.
The practice guidelines for primary care of acute abdomen 2015. Jpn J Radiol 2016;34:80-115.
Mazzei MA, Guerrini S, Cioffi Squitieri N, Cagini L, Macarini L, Coppolino F, et al.
The role of US examination in the management of acute abdomen. Crit Ultrasound J 2013;5 Suppl 1:S6.
Flasar MH, Goldberg E. Acute abdominal pain. Med Clin North Am 2006;90:481-503.
Brekke M, Eilertsen RK. Acute abdominal pain in general practice: Tentative diagnoses and handling. A descriptive study. Scand J Prim Health Care 2009;27:137-40.
Graff LG 4th
, Robinson D. Abdominal pain and emergency department evaluation. Emerg Med Clin North Am 2001;19:123-36.
Hawthorn IE. Abdominal pain as a cause of acute admission to hospital. J R Coll Surg Edinb 1992;37:389-93.
Hickner J. Point-of-care ultrasound: Deploying in primary care. J Fam Pract 2018;67:56.
American Academy of Family Physicians. Clinical Procedures Performed by Physicians at their Practice. American Academy of Family Physicians Member Census; 2016.
Bhagra A, Tierney DM, Sekiguchi H, Soni NJ. Point-of-care ultrasonography for primary care physicians and general internists. Mayo Clin Proc 2016;91:1811-27.
Diprose W, Verster F, Schauer C. Re-examining physical findings with point-of-care ultrasound: A narrative review. N Z Med J 2017;130:46-51.
Abu-Zidan FM, Hefny AF. Point-of-Care Ultrasound in critically-ill patients. In: Di Saverio S, Catena F, Ansaloni L, Coccolini F, Velmahos G, editors. Acute Care Surgery Handbook. First ed. Cham: Springer International Publishing; 2017. p. 335–60.
Abu-Zidan FM. Optimizing the value of measuring inferior vena cava diameter in shocked patients. World J Crit Care Med 2016;5:7-11.
Abu-Zidan FM, Abusharia MI, Kessler K. Surgeon-performed sonographic findings in a traumatic trans-anal rectal perforation. World J Emerg Surg 2011;6:26.
Abu-Zidan FM. Point-of-care ultrasound in critically ill patients: Where do we stand? J Emerg Trauma Shock 2012;5:70-1.
] [Full text]
Zielke A, Hasse C, Bandorski T, Sitter H, Wachsmuth P, Grobholz R, et al.
Diagnostic ultrasound of acute colonic diverticulitis by surgical residents. Surg Endosc 1997;11:1194-7.
Whitson MR, Mayo PH. Ultrasonography in the emergency department. Crit Care 2016;20:227.
Mayumi T, Yoshida M, Tazuma S, Furukawa A, Nishii O, Shigematsu K et al
. The Practice guidelines for primary care of acute abdomen 2015. Jpn J Radiol. 2016;34:80-115.
Stoker J, van Randen A, Laméris W, Boermeester MA. Imaging patients with acute abdominal pain. Radiology 2009;253:31-46.
Cartwright SL, Knudson MP. Evaluation of acute abdominal pain in adults. Am Fam Physician 2008;77:971-8.
Puylaert JB. Ultrasonography of the acute abdomen: Lost art or future stethoscope? Eur Radiol 2003;13:1203-6.
Mazzei MA, Cioffi Squitieri N, Guerrini S, Stabile Ianora AA, Cagini L, Macarini L, et al.
Sigmoid diverticulitis: US findings. Crit Ultrasound J 2013;5 Suppl 1:S5.
Chesbrough RM, Burkhard TK, Balsara ZN, Goff WB 2nd
, Davis DJ. Self-localization in US of appendicitis: An addition to graded compression. Radiology 1993;187:349-51.
Puylaert JB. Acute appendicitis: US evaluation using graded compression. Radiology 1986;158:355-60.
Debnath J, Ram S, Balani S, Chakraborty I, Gupta PD, Bindal RK, et al.
Ultrasonography in patients with suspected acute appendicitis. Med J Armed Forces India 2005;61:249-52.
Walsh PF, Crawford D, Crossling FT, Sutherland GR, Negrette JJ, Shand J. The value of immediate ultrasound in acute abdominal conditions: A critical appraisal. Clin Radiol 1990;42:47-9.
McGrath FP, Keeling F. The role of early sonography in the management of the acute abdomen. Clin Radiol 1991;44:172-4.
Nural MS, Ceyhan M, Baydin A, Genc S, Bayrak IK, Elmali M. The role of ultrasonography in the diagnosis and management of non-traumatic acute abdominal pain. Intern Emerg Med 2008;3:349-54.
Abu-Zidan FM. Basic ultrasound physics, instrumentation, and knobology. In: Zago M, editor. Essential US for trauma: E-FAST. First ed. Italia, Milano: Springer-Verlag; 2014. p. 1–13.
Abu-Zidan FM, Cevik AA. Diagnostic point-of-care ultrasound (POCUS) for gastrointestinal pathology: State of the art from basics to advanced. World J Emerg Surg 2018;13:47.
Abu-Zidan FM, Hefny AF, Corr P. Clinical ultrasound physics. J Emerg Trauma Shock 2011;4:501-3.
] [Full text]
Hangiandreou NJ. AAPM/RSNA physics tutorial for residents. Topics in US: B-mode US: Basic concepts and new technology. Radiographics 2003;23:1019-33.
Muglia V, Cooperberg PL. Artifacts. In: McGahan JP, Goldberg BB, editors. Diagnostic Ultrasound, A logical approach. Philadelphia: Lippincott-Raven Publishers; 1998. pp. 21–37.
Rose JS. Ultrasound physics and knobology. In: Simon BC, Snoey ER, editors. Ultrasound in Emergency and Ambulatory Medicine. St Louis: Mosby-Year book Inc; 1997. p. 10–38.
Rose JS, Bair AE. Fundamentals of ultrasound. In: Cosby KS, Kendall JL (eds). Practical guide to Emergency Ultrasound. Lippincott Willaims and Wilkins, PA, 2006: p. p: 27-41.
Mohammad A, Hefny AF, Abu-Zidan FM. Focused assessment sonography for trauma (FAST) training: A systematic review. World J Surg 2014;38:1009-18.
Paajanen H, Lahti P, Nordback I. Sensitivity of transabdominal ultrasonography in detection of intraperitoneal fluid in humans. Eur Radiol 1999;9:1423-5.
Dietrich CF, Goudie A, Chiorean L, Cui XW, Gilja OH, Dong Y, et al.
Point of care ultrasound: A WFUMB position paper. Ultrasound Med Biol 2017;43:49-58.
Irvin TT. Abdominal pain: A surgical audit of 1190 emergency admissions. Br J Surg 1989;76:1121-5.
Jackson PG, Raiji MT. Evaluation and management of intestinal obstruction. Am Fam Physician 2011;83:159-65.
Schmutz GR, Benko A, Fournier L, Peron JM, Morel E, Chiche L. Small bowel obstruction: Role and contribution of sonography. Eur Radiol 1997;7:1054-8.
Pourmand A, Dimbil U, Drake A, Shokoohi H. The accuracy of point-of-care ultrasound in detecting small bowel obstruction in emergency department. Emerg Med Int 2018;2018:3684081.
Guttman J, Stone MB, Kimberly HH, Rempell JS. Point-of-care ultrasonography for the diagnosis of small bowel obstruction in the emergency department. CJEM 2015;17:206-9.
Suri S, Gupta S, Sudhakar PJ, Venkataramu NK, Sood B, Wig JD. Comparative evaluation of plain films, ultrasound and CT in the diagnosis of intestinal obstruction. Acta Radiol 1999;40:422-8.
Feldman MK, Katyal S, Blackwood MS. US artifacts. Radiographics 2009;29:1179-89.
Lichtenstein DA. Lung ultrasound in the critically ill. Ann Intensive Care 2014;4:1.
Williams H. Perforation: How to spot free intraperitoneal air on abdominal radiograph. Arch Dis Child Educ Pract 2006;91:ep54-7.
Braccini G, Lamacchia M, Boraschi P, Bertellotti L, Marrucci A, Goletti O, et al.
Ultrasound versus plain film in the detection of pneumoperitoneum. Abdom Imaging 1996;21:404-12.
Chen SC, Yen ZS, Wang HP, Lin FY, Hsu CY, Chen WJ. Ultrasonography is superior to plain radiography in the diagnosis of pneumoperitoneum. Br J Surg 2002;89:351-4.
Shaffer HA Jr. Perforation and obstruction of the gastrointestinal tract. Assessment by conventional radiology. Radiol Clin North Am 1992;30:405-26.
Woodring JH, Heiser MJ. Detection of pneumoperitoneum on chest radiographs: Comparison of upright lateral and posteroanterior projections. AJR Am J Roentgenol 1995;165:45-7.
Shokoohi H, S Boniface K, M Abell B, Pourmand A, Salimian M. Ultrasound and perforated viscus; dirty fluid, dirty shadows, and peritoneal enhancement. Emerg (Tehran) 2016;4:101-5.
Chadha D, Kedar RP, Malde HM. Sonographic detection of pneumoperitoneum: An experimental and clinical study. Australas Radiol 1993;37:182-5.
Addiss DG, Shaffer N, Fowler BS, Tauxe RV. The epidemiology of appendicitis and appendectomy in the United States. Am J Epidemiol 1990;132:910-25.
Flum DR, McClure TD, Morris A, Koepsell T. Misdiagnosis of appendicitis and the use of diagnostic imaging. J Am Coll Surg 2005;201:933-9.
Matthew Fields J, Davis J, Alsup C, Bates A, Au A, Adhikari S, et al.
Accuracy of point-of-care ultrasonography for diagnosing acute appendicitis: A systematic review and meta-analysis. Acad Emerg Med 2017;24:1124-36.
Mostbeck G, Adam EJ, Nielsen MB, Claudon M, Clevert D, Nicolau C, et al.
How to diagnose acute appendicitis: Ultrasound first. Insights Imaging 2016;7:255-63.
Lam SH, Grippo A, Kerwin C, Konicki PJ, Goodwine D, Lambert MJ. Bedside ultrasonography as an adjunct to routine evaluation of acute appendicitis in the emergency department. West J Emerg Med 2014;15:808-15.
Kaewlai R, Lertlumsakulsub W, Srichareon P. Body mass index, pain score and alvarado score are useful predictors of appendix visualization at ultrasound in adults. Ultrasound Med Biol 2015;41:1605-11.
Hong JJ, Cohn SM, Ekeh AP, Newman M, Salama M, Leblang SD. A prospective randomized study of clinical assessment versus computed tomography for the diagnosis of acute appendicitis. Surg Infect (Larchmt) 2003;4:231-9.
Andersson RE. Meta-analysis of the clinical and laboratory diagnosis of appendicitis. Br J Surg 2004;91:28-37.
Terasawa T, Blackmore CC, Bent S, Kohlwes RJ. Systematic review: Computed tomography and ultrasonography to detect acute appendicitis in adults and adolescents. Ann Intern Med 2004;141:537-46.
Di Saverio S, Birindelli A, Kelly MD, Catena F, Weber DG, Sartelli M, et al.
Wses jerusalem guidelines for diagnosis and treatment of acute appendicitis. World J Emerg Surg 2016;11:34.
Everhart JE, Khare M, Hill M, Maurer KR. Prevalence and ethnic differences in gallbladder disease in the United States. Gastroenterology 1999;117:632-9.
Stinton LM, Shaffer EA. Epidemiology of gallbladder disease: Cholelithiasis and cancer. Gut Liver 2012;6:172-87.
Zenobii MF, Accogli E, Domanico A, Arienti V. Update on bedside ultrasound (US) diagnosis of acute cholecystitis (AC). Intern Emerg Med 2016;11:261-4.
O'Connor OJ, Maher MM. Imaging of cholecystitis. AJR Am J Roentgenol 2011;196:W367-74.
Woo MY, Taylor M, Loubani O, Bowra J, Atkinson P. My patient has got abdominal pain: Identifying biliary problems. Ultrasound 2014;22:223-8.
American College of Emergency Physicians. Emergency ultrasound guidelines. Ann Emerg Med 2009;53:550-70.
Scruggs W, Fox JC, Potts B, Zlidenny A, McDonough J, Anderson CL, et al.
Accuracy of ED bedside ultrasound for identification of gallstones: Retrospective analysis of 575 studies. West J Emerg Med 2008;9:1-5.
Summers SM, Scruggs W, Menchine MD, Lahham S, Anderson C, Amr O, et al.
prospective evaluation of emergency department bedside ultrasonography for the detection of acute cholecystitis. Ann Emerg Med 2010;56:114-22.
Noble VE, Brown DF. Renal ultrasound. Emerg Med Clin North Am 2004;22:641-59.
Pearle MS, Lotan YJ. Urinary lithiasis: Etiology, epidemiology, and pathogenesis. Campbell-walsh urology 2007;2:1363-92.
Dalziel PJ, Noble VE. Bedside ultrasound and the assessment of renal colic: A review. Emerg Med J 2013;30:3-8.
Cox C, MacDonald S, Henneberry R, Atkinson PR. My patient has abdominal and flank pain: Identifying renal causes. Ultrasound 2015;23:242-50.
Goertz JK, Lotterman S. Can the degree of hydronephrosis on ultrasound predict kidney stone size? Am J Emerg Med 2010;28:813-6.
Moak JH, Lyons MS, Lindsell CJ. Bedside renal ultrasound in the evaluation of suspected ureterolithiasis. Am J Emerg Med 2012;30:218-21.
Tsiotras A, Smith RD, Pearce I, O'Flynn K, Wiseman O. British association of urological surgeons standards for management of acute ureteric colic. Journal of Clinical Urology 2018;11:58-61.
Teichman JM. Clinical practice. Acute renal colic from ureteral calculus. N Engl J Med 2004;350:684-93.
Henderson SO, Hoffner RJ, Aragona JL, Groth DE, Esekogwu VI, Chan D. Bedside emergency department ultrasonography plus radiography of the kidneys, ureters, and bladder vs. intravenous pyelography in the evaluation of suspected ureteral colic. Acad Emerg Med 1998;5:666-71.
Avant RF. Spontaneous abortion and ectopic pregnancy. Prim Care 1983;10:161-72.
American College of Emergency Physicians. American College of Emergency Physicians. ACEP emergency ultrasound guidelines-2001. Ann Emerg Med 2001;38:470-81.
Adhikari S, Blaivas M, Lyon M. Diagnosis and management of ectopic pregnancy using bedside transvaginal ultrasonography in the ED: A 2-year experience. Am J Emerg Med 2007;25:591-6.
Liteplo A, Noble V, Atkinson PJ. My patient has no blood pressure: Point-of-care ultrasound in the hypotensive patient-fast and reliable. Ultrasound 2012;20:64-68.
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;28:29-56, vii.
del Campo MR, Lo BM. Diagnostic keys to ectopic pregnancy-abdominal pain, vaginal bleeding, and missed menses can mean many things, but it's important to rule out the life-threatening possibility of ectopic pregnancy. Emerg Med 2009;41:11.
Rastogi R, Gl M, Rastogi N, Rastogi V. Interstitial ectopic pregnancy: A rare and difficult clinicosonographic diagnosis. J Hum Reprod Sci 2008;1:81-2.
] [Full text]
Thorsen MK, Lawson TL, Aiman EJ, Miller DP, McAsey ME, Erickson SJ, et al.
Diagnosis of ectopic pregnancy: Endovaginal vs. transabdominal sonography. Am J Roentgenol 1990;155:307-10.
Condous G, Okaro E, Khalid A, Lu C, Van Huffel S, Timmerman D, et al.
The accuracy of transvaginal ultrasonography for the diagnosis of ectopic pregnancy prior to surgery. Hum Reprod 2005;20:1404-9.
Matrana MR, Margolin DA. Epidemiology and pathophysiology of diverticular disease. Clin Colon Rectal Surg 2009;22:141-6.
De Bastiani R, Sanna G, Fracasso P, D'Urso M, Benedetto E, Tursi A. The management of patients with diverticulosis and diverticular disease in primary care: An online survey among italian general pratictioners. J Clin Gastroenterol 2016;50 Suppl 1:S89-92.
Liljegren G, Chabok A, Wickbom M, Smedh K, Nilsson KJ. Acute colonic diverticulitis: A systematic review of diagnostic accuracy 2007;9:480-8.
Laméris W, van Randen A, Bipat S, Bossuyt PM, Boermeester MA, Stoker J. Graded compression ultrasonography and computed tomography in acute colonic diverticulitis: Meta-analysis of test accuracy. Eur Radiol 2008;18:2498-511.
van Randen A, Laméris W, van Es HW, van Heesewijk HP, van Ramshorst B, Ten Hove W, et al.
comparison of the accuracy of ultrasound and computed tomography in common diagnoses causing acute abdominal pain. Eur Radiol 2011;21:1535-45.
Lim JH, Ko YT, Lee DH, Lim JW, Kim TH. Sonography of inflammatory bowel disease: Findings and value in differential diagnosis. AJR Am J Roentgenol 1994;163:343-7.
Ambrosetti P, Jenny A, Becker C, Terrier TF, Morel P. Acute left colonic diverticulitis – Compared performance of computed tomography and water-soluble contrast enema: Prospective evaluation of 420 patients. Dis Colon Rectum 2000;43:1363-7.
O'Malley ME, Wilson SR. US of gastrointestinal tract abnormalities with CT correlation. Radiographics 2003;23:59-72.
Sartelli M, Moore FA, Ansaloni L, Di Saverio S, Coccolini F, Griffiths EA, et al.
proposal for a CT driven classification of left colon acute diverticulitis. World J Emerg Surg 2015;10:3.
Lim JH. Ultrasound examination of gastrointestinal tract diseases. J Korean Med Sci 2000;15:371-9.
Frame PS, Fryback DG, Patterson C. Screening for abdominal aortic aneurysm in men ages 60 to 80 years. A cost-effectiveness analysis. Ann Intern Med 1993;119:411-6.
Fleming C, Whitlock EP, Beil TL, Lederle FA. Screening for abdominal aortic aneurysm: A best-evidence systematic review for the U.S. Preventive services task force. Ann Intern Med 2005;142:203-11.
Basnyat PS, Biffin AH, Moseley LG, Hedges AR, Lewis MH. Mortality from ruptured abdominal aortic aneurysm in wales. Br J Surg 1999;86:765-70.
Macdonald AJ, Faleh O, Welch G, Kettlewell S. Missed opportunities for the detection of abdominal aortic aneurysms. Eur J Vasc Endovasc Surg 2008;35:698-700.
Bailey RP, Ault M, Greengold NL, Rosendahl T, Cossman D. Ultrasonography performed by primary care residents for abdominal aortic aneurysm screening. J Gen Intern Med 2001;16:845-9.
Moore CL, Holliday RS, Hwang JQ, Osborne MR. Screening for abdominal aortic aneurysm in asymptomatic at-risk patients using emergency ultrasound. Am J Emerg Med 2008;26:883-7.
Costantino TG, Bruno EC, Handly N, Dean AJ. Accuracy of emergency medicine ultrasound in the evaluation of abdominal aortic aneurysm. J Emerg Med 2005;29:455-60.
Wilmink AB, Forshaw M, Quick CR, Hubbard CS, Day NE. Accuracy of serial screening for abdominal aortic aneurysms by ultrasound. J Med Screen 2002;9:125-7.
Steinmetz P, Oleskevich S. The benefits of doing ultrasound exams in your office. J Fam Pract 2016;65:517-23.
Blois BJ. Office-based ultrasound screening for abdominal aortic aneurysm 2012;58:e172-8.
Bravo-Merino L, González-Lozano N, Maroto-Salmón R, Meijide-Santos G, Suárez-Gil P, Fañanás-Mastral A. Validity of the abdominal ecography in primary care for detection of aorta abdominal aneurism in male between 65 and 75 years. Aten Primaria 2019;51:11-7.
Fukuda S, Watanabe H, Iwakura K, Daimon M, Ito H, Yoshikawa J, et al.
Multicenter investigations of the prevalence of abdominal aortic aneurysm in elderly japanese patients with hypertension. Circ J 2015;79:524-9.
Sisó-Almirall A, Kostov B, Navarro González M, Cararach Salami D, Pérez Jiménez A, Gilabert Solé R, et al.
Abdominal aortic aneurysm screening program using hand-held ultrasound in primary healthcare. PLoS One 2017;12:e0176877.
Pallan M, Linnane J, Ramaiah S. Evaluation of an independent, radiographer-led community diagnostic ultrasound service provided to general practitioners. J Public Health (Oxf) 2005;27:176-81.
Fu JY, Krause C, Krause R, Mccoy J, Schindler A, Udrea DS, et al.
Integration of point-of-care ultrasound training into undergraduate medical curricula – A perspective from medical students. J Med Educ Curric Dev 2016;3. pii: JMECD.S38240.
Abu-Zidan FM, Cevik AA. Kunafa knife and play dough is an efficient and cheap simulator to teach diagnostic point-of-care ultrasound (POCUS). World J Emerg Surg 2019;14:1.
Monti J. Revolution or evolution? A proposal for the integration of point-of-care ultrasound into physician assistant clinical practice. J Physician Assist Educ 2017;28:27-32.
Barron KR, Wagner MS, Hunt PS, Rao VV, Bell FE, Abdel-Ghani S, et al.
primary care ultrasound fellowship: Training for clinical practice and future educators. J Ultrasound Med 2019;38:1061-8.
Bornemann P, Bornemann G. Military family physicians' perceptions of a pocket point-of-care ultrasound device in clinical practice. Mil Med 2014;179:1474-7.
Pertierra-Galindo N, Salvo-Donangelo L, Salcedo-Joven MI, Román-Crespo B, Froilán Torres MC. [Study of patient satisfaction when performing an ultrasound in Primary Care]. Semergen. 2019;45:239-250.
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