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PoCUS: Just because we can doesn't mean we should

PoCUS has found its place as an invaluable tool in a number of clinical scenarios: one, in helping guide the resuscitation of critically ill patients and determining underlying etiology; two, in supplementing clinical history and findings to help narrow a differential diagnosis; and three, to provide procedural guidance for common bedside procedures including vascular access, thoracentesis, lumbar puncture, and endotracheal intubation, among others.1,2 PoCUS has also been shown to be costeffective in the emergency department (ED) setting.3 The systematic review and metaanalysis published in Academic Emergency Medicine evaluated the accuracy of clinical signs and symptoms, computed tomography (CT) with angiography, and PoCUS for the diagnosis of ruptured abdominal aortic aneurysms (rAAA). Pooled sensitivities were 27.8%– 61.7% for clinical symptoms, 30.9%– 47.1% for examination findings, and 91.4% for CT with angiography; while PoCUS did not have the fidelity to detect rAAAs, its pooled sensitivity and specificity for AAAs in patients with suspected ruptures was 97.8% and 97.0%, respectively. The authors concluded: “CTA has reasonable accuracy, but misses some cases of rAAA. PoCUS is a valuable tool that can help guide the need for urgent transfer to a vascular center in patients suspected of having rAAA.”4 Where PoCUS is increasingly seen as an extension of the stethoscope in clinching critical diagnoses, it has important caveats. First, its diagnostic yield is operatordependent; while it is commonly used at the bedside by nonechocardiographers and nonradiologists, it requires mastery of skills in image generation through appropriate transducer manipulation, accurate interpretation of findings, and integration into clinical decisionmaking.1 Second, widespread adoption of the tool has been challenged due to gaps in structured training across medical curricula and faculty development programs, lack of clear competency standards, and variable resource availability. Third, while it may improve diagnostic accuracy, its utility in impacting patientimportant outcomes have not yet been clearly established.5 A recent systematic review of studies evaluating PoCUS as a diagnostic tool to determine the underlying cause of acute dyspnea found significant improvement in diagnostic sensitivities and significantly more correct diagnoses, but no clear benefit in terms of inhospital mortality and length of hospital stay. Fourth, the tool has been recommended as an adjunct to standard testing for acute presentations like dyspnea, rather than as a replacement; thus, PoCUS has generally not been recommended as a standalone diagnostic tool.6