ACEP Emergency Ultrasound Suggested Reporting Guidelines 2011 - Comprehensive Notes

FORMAT

All diagnostic examinations should include:

• Patient/exam demographics
• Indications for examination
• Views
• Findings
• Interpretation
• Quality assurance

Exams included in this draft:

• FAST
• Focused Abdominal Aorta
• Focused Pelvic Ultrasound (Obstetrical)
• Focused Pelvic Ultrasound (Non-obstetrical)
• Focused Biliary
• Focused Thoracic
• Focused Renal/Urinary Tract
• Focused Lower Extremity Venous
• Focused Cardiac (Echo)
• Focused Soft Tissue/MSK
• Focused Ocular

In development:

• Ultrasound guided procedures
• Testicular
• Symptom-based exams (hypotension, dyspnea, abdominal pain, chest pain)

FORMAT DETAILS

• All diagnostic examinations should include:
  • Patient/exam demographics
  • Indications for examination
  • Views
  • Findings
  • Interpretation
  • Quality assurance
• The first and last portions should be consistent across exam types and are presented in this document
• The bolded elements represent the core emergency ACEP views, findings, and interpretations for each application
• Exams aim to be compatible with non-proprietary reporting and computer databases; potential integration with DICOM and IHE initiatives
• The document is a guideline resource for clinicians with a wide range of experience; not all fields are required in every situation

EXAMS INCLUDED (overview)

• FAST: Focused assessment with sonography for trauma
• Focused Abdominal Aorta: Screening for aneurysm
• Obstetrical Pelvic Ultrasound: Evaluation of intrauterine and early pregnancy
• Non-obstetrical Pelvic Ultrasound: Gynecologic evaluation in the ED
• Focused Biliary: Gallbladder and biliary tree assessment
• Focused Thoracic: Pleural and pulmonary ultrasound
• Focused Renal/Urinary Tract: Kidney and bladder evaluation
• Focused Lower Extremity Venous: DVT assessment
• Focused Cardiac Ultrasound: Cardiac function and pathologies
• Soft Tissue/Musculoskeletal: Soft tissue and musculoskeletal evaluation
• Ocular: Focused ocular ultrasound

In development/other notes

• Testicular ultrasound; ultrasound-guided procedures; broader symptom-based modules
• The guidelines emphasize core ACEP views and standardized interpretation language to facilitate communication and coding

FAST EXAM

Patient/ exam demographics

• Patient name
• Patient gender: MF (M/F)
• DOB
• MR# / Bar Code / Patient Identifier
• Hospital Name
• Date and time of exam
• Exam type:
  • ☐ Diagnostic
  • ☐ Educational
  • ☐ Procedural
• Clinical category:
  • ☐ Resuscitative
  • ☐ Symptom based
  • ☐ Therapeutic
  • ☐ Unknown/ other
• Initial exam / Repeat exam
• Primary person obtaining/interpreting images
• Secondary person obtaining/interpreting images
• Additional person(s) obtaining/interpreting images

Indication(s) for exam

• ☐ blunt trauma
• ☐ penetrating trauma
• ☐ abdominal pain
• ☐ chest pain
• hypotension
• ☐ tachycardia
• ☐ dyspnea
• ☐ altered mental status
• pregnancy
• ☐ educational
• ☐ other

Views

• Hepatorenal
• Perisplenic
• Suprapubic
• Pericardial
• R thorax for fluid
• R thorax for lung sliding
• L thorax for fluid
• L thorax for lung sliding
• adequacy indicators: ☐ adequate ☐ limited ☐ not obtained (per view as applicable)
• other views may be added as needed

Findings

• Hepatorenal free fluid: ☐ present ☐ absent ☐ indeterminate
• Perisplenic free fluid: ☐ present ☐ absent ☐ indeterminate
• Suprapubic free fluid: ☐ present ☐ absent ☐ indeterminate
• Right thoracic fluid: ☐ present ☐ absent ☐ indeterminate
• Right lung sliding: ☐ present ☐ absent ☐ indeterminate
• Left thoracic fluid: ☐ present ☐ absent ☐ indeterminate
• Left lung sliding: ☐ present ☐ absent ☐ indeterminate
• Lung point sign: ☐ yes ☐ no ☐ indeterminate
• Pericardial effusion: ☐ present (size: ☐ small ☐ moderate ☐ large) ☐ indeterminate
• Pericardial tamponade signs: ☐ present ☐ absent ☐ indeterminate
• Peritoneal free fluid: ☐ present ☐ absent ☐ indeterminate
• Right/Left hemithorax pleural effusion: details above
• Lung findings: pneumothorax status by side if applicable

Interpretation

• Narrative interpretation of the above findings in the context of the presenting concern
• Quick dichotomies commonly used: No acute findings vs acute pathology suspected; specific etiologies suggested by findings

Quality assurance

• Grading Scale (see below)
• Accuracy of interpretation (versus gold standard when available, e.g., CT or operative report)
• Comments

QUALITY ASSURANCE (GENERAL)

Grading Scale

• 1: No recognizable structures, no objective data can be gathered
• 2: Minimally recognizable structures but insufficient for diagnosis
• 3: Minimal criteria met for diagnosis, recognizable structures but with some technical or other flaws
• 4: Minimal criteria met for diagnosis, all structures imaged well and diagnosis easily supported
• 5: Minimal criteria met for diagnosis, all structures imaged with excellent image quality and diagnosis completely supported

Definitions and interpretation guidelines (for both image quality and accuracy of interpretation):

• Image quality: 1–5 scale as above
• Accuracy of interpretation: comparison of interpretation to gold standard (e.g., CT, operative report) where available
• TP, TN, FP, FN categories may be used in QA to denote true positives, true negatives, false positives, false negatives

FOCUSED ABDOMINAL AORTA

Demographics

• Patient name, gender, DOB, MR#, Bar Code/Patient Identifier, Hospital Name, Date/time, Exam type (Diagnostic/Educational/Procedural), Clinical category (Resuscitative/Symptom based/Therapeutic/Unknown/other), Initial/Repeat exam
• Primary/Secondary/Additional personnel

Indication(s) for exam

• ☐ abdominal pain
• ☐ syncope
• ☐ chest pain
• ☐ hypotension
• ☐ tachycardia
• ☐ back pain
• ☐ flank pain
• ☐ pulsatile abdominal mass
• ☐ other

Views

• Proximal Transverse view: visualized / not visualized / inadequate
• Distal Transverse view: visualized / not visualized / inadequate
• Sagittal view: visualized / not visualized / inadequate
• Celiac artery: visualized / not visualized / inadequate
• Bifurcation: visualized / not visualized / inadequate

Findings

• Aneurysm: ☐ present ☐ absent
• If present: ☐ suprarenal ☐ infrarenal ☐ both; iliac involvement; indeterminate
• Maximal aortic diameter: D ext{ cm}
• Other: ☐ other findings as applicable

Interpretation

• Sonographic evidence for aneurysm: ☐ present ☐ absent ☐ indeterminate
• If present: diameter value: D_{ ext{max}} ext{ cm}

FOCUSED OBSTETRICAL PELVIC ULTRASOUND

Demographics

• Patient name, gender, DOB, MR#, Bar Code/Patient Identifier, Hospital, Date/time, Exam type, Clinical category, Initial/Repeat exam, Personnel

Indication(s) for exam

• Qualitative hCG positive
• Quantitative hCG positive
• Pregnant by history
• Abdominal pain
• Pelvic pain
• Back pain
• Vaginal bleeding
• Syncope
• Hypotension
• Trauma
• Educational
• Other

Views obtained

• Endovaginal sagittal
• Endovaginal coronal
• Transabdominal sagittal
• Transabdominal transverse
• Adequacy: ☐ adequate ☐ limited
• Cul-de-sac: ☐ adequate ☐ limited
• Left adnexa: ☐ adequate ☐ limited
• Right adnexa: ☐ adequate ☐ limited
• Hepatorenal space: ☐ adequate ☐ limited
• Other: ☐ not obtained

Findings

• Uterus: ☐ anteverted ☐ retroverted ☐ fluid present ☐ no significant fluid ☐ indeterminate
• If fluid present: ☐ small ☐ moderate ☐ large
• Intrauterine pregnancy (IUP):
  • If present: Yolk sac ☐ present ☐ absent; Yolk sac diameter: d ext{ mm}; Fetal pole: ☐ present ☐ absent; Fetal heart: ☐ present ☐ absent; FHR: f ext{ bpm}; Gestational sac diameter: D ext{ mm}; Crown-rump length (CRL): CRL ext{ mm}; Gestational age: GA ext{ weeks/days}; Fetal motion: ☐ present
  • If no IUP: Intrauterine contents: ☐ other
• R adnexa / L adnexa: ovaries—size, cysts (simple/complex), ovarian mass, endometrial stripe status, other adnexal findings
• Ovarian measurements and descriptions: diameter(s), simple/complex; cysts, masses
• Endometrial stripe: thickness; presence of heterogeneous material
• Intervening adnexal fluid, cul-de-sac fluid

Interpretation

• Overall interpretation for pregnancy status (e.g., intrauterine pregnancy, live intrauterine pregnancy, abnormal intrauterine pregnancy, ectopic pregnancy, etc.)

Quality assurance

• Grading scale and comments

FOCUSED NON-OBSTETRIC PELVIC ULTRASOUND

Demographics

• As above (name, DOB, MR#, etc.)

Indication(s) for exam

• Qualitative (urine) hCG negative
• Quantitative hCG negative
• Abdominal pain
• Pelvic pain
• Back pain
• Vaginal bleeding
• Syncope
• Hypotension
• Trauma
• Educational
• Other

Views obtained

• Transabdominal sagittal / transverse
• Endovaginal sagittal / coronal
• Cul-de-sac
• Left adnexa / Right adnexa
• Hepatorenal space
• Adequacy: ☐ adequate ☐ limited
• Not obtained: ☐ yes

Findings

• Uterus
• Endometrium / Endometrial stripe: thickness and content
• Fluid in cul-de-sac: ☐ none ☐ small ☐ moderate ☐ large
• R adnexa / L adnexa: ovarian size, cysts (simple/complex), ovarian mass, indeterminate
• Interperitoneal fluid: ☐ present ☐ absent ☐ indeterminate
• Uterine fibroids: ☐ present ☐ absent
• Interpretation of adnexa and gynecologic pathology

Quality assurance

• Grading scale and comments

FOCUSED BILIARY

Demographics

• As above

Indication(s) for exam

• Abnormal labs
• Abdominal pain
• Jaundice
• Pancreatitis
• Fever
• Educational
• Other

Views obtained

• Gallbladder long axis: ☐ adequate ☐ limited ☐ not visualized
• Gallbladder short axis: ☐ adequate ☐ limited ☐ not visualized
• Common bile duct: ☐ adequate ☐ limited ☐ not visualized
• Main lobar fissure: visualized / not visualized
• Portal vein: visualized / not visualized

Findings

• Gallstone(s): ☐ present ☐ single ☐ absent ☐ indeterminate ☐ multiple; Largest measured: L ext{ mm}; Mobility: ☐ mobile ☐ non-mobile; Location: ☐ in fundus
• Gallbladder wall thickness: W ext{ mm}; Wall thickened: ☐ yes ☐ no ☐ indeterminate
• Pericholecystic fluid: ☐ present ☐ absent
• Sonographic Murphy's sign: ☐ present
• Common bile duct diameter: D ext{ mm}; Diameter status: ☐ normal ☐ enlarged ☐ indeterminate
• Biliary sludge: ☐ present ☐ absent
• Polyp: ☐ present ☐ absent
• Adenomyomatosis: ☐ present ☐ absent ☐ indeterminate
• Transverse gallbladder diameter: DT ext{ mm}; Longitudinal gallbladder diameter: DL ext{ mm}

Interpretation

• No significant biliary pathology identified
• Cholelithiasis without sonographic evidence of cholecystitis
• Cholelithiasis with evidence of cholecystitis
• Sonographic evidence of acalculous cholecystitis
• Choledocholithiasis
• Polyps / other findings

Quality assurance

• Grading scale and comments

FOCUSED RENAL/URINARY TRACT

Demographics

• As above

Indication(s) for exam

• Abdominal pain
• Flank pain
• Back pain
• Hematuria
• Urinary retention
• Dysuria
• Acute renal failure
• Anuria
• Post-void
• Educational
• Other

Views obtained

• Right kidney long axis (coronal): ☐ adequate ☐ limited
• Right kidney short axis: ☐ adequate ☐ limited
• Left kidney long axis (coronal): ☐ adequate ☐ limited
• Left kidney short axis: ☐ adequate ☐ limited
• Transverse bladder: ☐ adequate ☐ limited
• Sagittal bladder: ☐ adequate ☐ limited
• Other: ☐ not obtained

Findings

• Right kidney hydronephrosis: ☐ present ☐ absent ☐ indeterminate; if present, degree: d ext{ (mild/moderate/severe)}
• Hydoureter: ☐ present ☐ absent ☐ indeterminate
• Kidney stones: ☐ present ☐ absent ☐ indeterminate; Size of largest stone: s ext{ mm}
• Renal Cyst: ☐ left ☐ right ☐ bilateral; Type: ☐ simple ☐ complex; Diameter: D ext{ mm}
• Extra-renal pelvis: ☐ present ☐ absent
• Duplicated Ureteral System: ☐ present ☐ absent
• Bladder dimensions: width W ext{ mm}; volume V ext{ mL}
• Right/Left ureteral jets: ☐ present ☐ absent ☐ indeterminate
• Interrogation of renal pelvis, UPJ/UVJ/ureteral segments

Interpretation

• No sonographic evidence of renal tract obstruction
• Hydronephrosis present (left/right/bilateral) with degree specified
• Nephrolithiasis / renal mass / cyst status

Quality assurance

• Grading scale and comments

FOCUSED THORACIC

Demographics

• As above

Indication(s) for exam

• Dyspnea
• Chest pain
• Pleurisy
• Hypoxia
• Other
• Educational

Views obtained

• Right anterior/superior thorax: ☐ adequate ☐ limited ☐ not obtained
• Right lateral/inferior thorax: ☐ adequate ☐ limited ☐ not obtained
• Left anterior/superior thorax: ☐ adequate ☐ limited ☐ not obtained
• Left lateral/inferior thorax: ☐ adequate ☐ limited ☐ not obtained

Findings

• Right thorax: lung sliding ☐ present ☐ absent ☐ indeterminate; Lung point sign: ☐ yes ☐ no ☐ indeterminate; Interstitium: ☐ normal ☐ abnormal; A-lines: ☐ present ☐ absent; B-lines: ☐ present ☐ absent ☐ indeterminate
• Pleural effusion: ☐ present (greater than 3 per view) ☐ absent ☐ indeterminate; Size: ☐ small ☐ large
• Lung consolidation: ☐ present ☐ absent; Air bronchograms: ☐ present ☐ absent
• Left thorax: lung sliding ☐ present ☐ absent ☐ indeterminate; Lung point sign: ☐ yes ☐ no ☐ indeterminate; Interstitium / A-lines / B-lines as above; Pleural effusion details as above
• Thoracic aorta: ☐ normal ☐ dilated ☐ indeterminate
• IVC: ☐ normal ☐ dilated ☐ indeterminate

Interpretation

• No sonographic evidence of acute pulmonary disease
• Pneumothorax (left/right/bilateral) status
• Pleural effusion and pulmonary edema patterns
• RV/LV function notated if applicable

Quality assurance

• Grading scale and comments

FOCUSED LOWER EXTREMITY VENOUS

Demographics

• As above

Indication(s) for exam

• Leg pain
• Leg swelling
• Leg erythema
• Dyspnea
• Tachypnea
• Pleurisy
• Educational
• Other

Views obtained

• Right leg: Saphenofemoral junction ☐ compressible ☐ NOT compressible ☐ indeterminate
• Right common femoral vein: compressible / NOT compressible / indeterminate
• Right femoral vein: compressible / NOT compressible / indeterminate
• Right popliteal vein: compressible / NOT compressible / indeterminate
• Right popliteal trifurcation: ☐ present ☐ absent ☐ indeterminate
• Left leg: Saphenofemoral junction ☐ compressible ☐ NOT compressible ☐ indeterminate
• Left common femoral vein ☐ compressible / NOT compressible / indeterminate
• Left femoral vein ☐ compressible / NOT compressible / indeterminate
• Left popliteal vein ☐ compressible / NOT compressible / indeterminate
• Left popliteal trifurcation ☐ present ☐ absent ☐ indeterminate
• Other: ☐ not obtained

Findings

• Interpretation fields for each segment (compressible vs not compressible) with status

Interpretation

• No sonographic evidence of deep venous thrombosis (DVT)
• If DVT suspected, location(s) and extent documented

Quality assurance

• Grading scale and comments

FOCUSED CARDIAC ULTRASOUND

Demographics

• As above

Indication(s) for exam

• Cardiac arrest
• Chest wall injury
• Hypotension
• Dyspnea
• Shock
• Chest pain
• Shortness of breath
• Tachycardia
• Syncope
• Tachypnea
• Fever
• Educational
• Palpitations
• Other

Views

• Subxiphoid (4 chamber)
• Parasternal long axis
• Parasternal short axis
• Subxiphoid (long axis, IVC view)
• Apical four-chamber
• Additional: ☐ other
• Adequacy per view: ☐ adequate ☐ limited

Findings

• Pericardial effusion: ☐ present (size: small/moderate/large) ☐ absent
• Evidence of tamponade: ☐ present ☐ absent
• IVC size / plethoric status: ☐ present ☐ absent
• R atrial/RV collapse: ☐ present ☐ absent
• Excessive mitral inflow variation: ☐ present ☐ absent
• McConnell's sign: ☐ present ☐ absent
• Tricuspid regurgitation velocity: V_T ext{ (m/s)}
• Global ventricular function: ☐ hyperdynamic ☐ normal ☐ reduced ☐ severely reduced
• RV size: ☐ normal ☐ enlarged ☐ severely enlarged ☐ indeterminate
• Aortic root diameter: D{ ext{aorta}} ext{ mm}; Thoracic aorta diameter: D{ ext{TA}} ext{ mm}
• Cardiac standstill / No cardiac activity: ☐ yes ☐ no

Interpretation

• No significant cardiac dysfunction
• Pericardial effusion present; tamponade suspected or not; impact on hemodynamics described
• RV/LV function assessment and volume status as indicated

Quality assurance

• Grading scale and comments

SOFT TISSUE/MUSCULOSKELETAL

Demographics

• As above

Indication(s) for exam

• Swelling
• Redness
• Mass
• Fever
• Foreign body
• Decreased range of motion
• Deformity
• Educational
• Pain
• Other

Views

• Skin and subcutaneous tissue: ☐ adequate ☐ limited ☐ not obtained
• Muscle: ☐ adequate ☐ limited
• Tendon: ☐ adequate ☐ limited
• Joint: ☐ adequate ☐ limited
• Bone: ☐ adequate ☐ limited
• Other: ☐ not obtained

Findings

• Skin/subcutaneous tissue: tissue thickness, echogenicity, cobblestoning, subcutaneous collections
• Muscle: appearance, echogenicity, thickness, diameter
• Tendon: appearance, defect
• Joint: presence of fluid
• Bone: cortex appearance; disorganized or irregular if present
• Overall interpretation: No sonographic evidence of soft tissue or musculoskeletal abnormality; cellulitis; abscess; joint effusion; tendon injury; fracture; other

Quality assurance

• Grading scale and comments

OCULAR

Demographics

• As above

Indication(s) for exam

• Eye pain
• Eye/orbital trauma
• Vision change / visual loss
• Suspected foreign body
• Head injury
• Educational
• Headache
• Other

Views

• Right eye transverse: ☐ adequate ☐ limited ☐ not obtained
• Right eye longitudinal: ☐ adequate ☐ limited ☐ not obtained
• Left eye transverse: ☐ adequate ☐ limited ☐ not obtained
• Left eye longitudinal: ☐ adequate ☐ limited ☐ not obtained

Findings

• Retina contour: ☐ normal ☐ abnormal/detached ☐ indeterminate
• Lens position: ☐ normally located ☐ dislodged ☐ indeterminate
• Vitreous body: ☐ anechoic ☐ echogenic / hemorrhage ☐ indeterminate
• Optic nerve sheath diameter (ONSD): ext{ONSD} ext{ (mm)} ☐ normal ☐ enlarged ☐ indeterminate
• Other findings: ☐ intraocular foreign body ☐ increased ONSD ☐ retinal detachment ☐ vitreous hemorrhage ☐ lens dislocation

Interpretation

• No acute abnormalities identified
• Retinal detachment (left/right/bilateral)
• Lens dislocation (left/right)
• Vitreous hemorrhage (left/right/bilateral)
• Intraocular foreign body (left/right)
• Increased ONSD (absolute value not specified here)

Quality assurance

• Grading scale and comments

NOTES ON STRUCTURE & INTERPRETATION

• Core ACEP views are indicated by bolded elements in the original document; in these notes, emphasis is conveyed through sectioning and clear labeling of findings
• The guidelines promote consistent reporting in a structured order to facilitate communication, coding, and non-proprietary data exchange
• “Quality assurance” sections provide grading scales and guidance for evaluating image quality and interpretive accuracy relative to reference standards when available
• The document anticipates future integration with DICOM/IHE and non-proprietary reporting methods to standardize POC EUS reporting across EMR systems

REFERENCES TO CORE ELEMENTS

• The bolded elements in the original guidelines represent the core emergency ACEP views, findings, and interpretations for each application
• The fields listed under each exam are designed to be comprehensive and adaptable to a variety of clinical scenarios
• The guidelines acknowledge that many fields may remain unused depending on the clinical situation
• The structure emphasizes: demographics → indications → views → findings → interpretation → quality assurance

SUMMARY OF KEY POINTS

• There is a standardized framework for reporting point-of-care emergency ultrasound across multiple organ systems
• Core elements include demographics, indications, views, findings, interpretation, and QA
• A broad set of exams is provided, with fields for both obligatory data and optional/conditional data to accommodate diverse ED scenarios
• A quality assurance grading scale (1–5) is used to assess image quality and interpretive accuracy
• The guidelines aim to enable better communication, coding, and interoperability, with ongoing development toward non-proprietary reporting standards