Emergency Physicians commonly perform invasive procedures. These procedures have traditionally been taught using surface landmarks, with the assumption that anatomy is reliably similar from patient to patient. The increasing use of ultrasound (US) to assist in procedural guidance has demonstrated that this is not the case. Utilizing US to assist with procedures has numerous benefits.1–9 It is safer for patients as it has been shown to reduce complications. US improves patient comfort and satisfaction. This is due primarily to decreased attempts at the procedure. The use of US usually decreases the duration of the procedure.
This chapter reviews the basic information regarding the use of US to assist or guide procedures in the Emergency Department (ED). US can assist in many commonly performed ED procedures (Table 4-1). The specific US technique for a procedure is described in the chapter for the particular procedure.
Table 4-1 Common ED Procedures that Use US Assistance or Guidance |Favorite Table|Download (.pdf)
Table 4-1 Common ED Procedures that Use US Assistance or Guidance
|Abdomen and pelvis|
Suprapubic bladder aspiration
Suprapubic bladder catheterization
|Bones and joints|
Closed fracture reduction
Cardiac pacing (transvenous and transthoracic)
Peritonsillar abscess incision and drainage
Peripheral nerve blocks
|Soft tissue and musculoskeletal|
Abscess incision and drainage
Foreign body identification and removal
Arterial line placement
Central venous access
Peripheral venous access
The sonographer must make several decisions prior to beginning a procedure using US. Will the procedure be performed under real-time US guidance or will US only be used to map the anatomy? Will one person (the sonographer) or two people (the sonographer and an assistant) be necessary? Which US probe is the most appropriate for the procedure? Should the instrument or needle be imaged in the long-axis view or the short-axis view? Are needle guides necessary? What is the ideal location of the US machine in relation to the sonographer and patient? These general questions must be kept in mind when using US for invasive procedures and are discussed below.
US can be used in one of the two ways for procedural assistance: the dynamic technique or the static technique. The dynamic technique is also known as US guidance. The sonographer uses US guidance in real time during the procedure to survey the anatomy, to confirm a diagnosis, and to visualize the needle or instrument as it enters tissue and reaches the target. The static technique is also known as US mapping. The sonographer uses US mapping prior to starting the procedure to map the local anatomy, to confirm a diagnosis, and to mark the site of needle entry. The US probe is then put away and the procedure performed in the traditional fashion without real-time US.