The point of care ultrasound protocol population. Time to tie the room together?

Αυτό το κείμενο υπάρχει μόνο στα Αγγλικά Αμερικής.

Author: Theodoros Aslanidis

MD, PhD, Anesthesiology/ Critical Care-Prehospital Emergency Medicine

Intensive Care Unit, Saint Paul (“Agios Pavlos”) General Hospital, Thessaloniki, Greece

Correspondence: Doridos str 4, PC 54633, Thessaloniki, Greece, e-mail: , Tel.: +306972477166.

ABSTRACT

Point-of-care ultrasound has earned a place as a reliable clinical tool. Examination protocols are growing fast, both in number and in complexity and more specialties adopt beside ultrasound. The parties involved in the health care should also catch up with this vast progress and set the frame within bedside ultrasound could reveal its maximum potency.

Point-of-care (POC) was a term initially adopted to describe beside or near-to-patient medical activities, mainly diagnostic testing. This approach aims at minimising time waist for diagnosis and early targeted therapy, especially in emergency, austere, prehospital and critical care settings¹. With the progress of technology and evolution of personalised medicine POC care has become a valuable tool in daily clinical practice.

Ultrasound (US) is one of the diagnostic methods that has fully integrated POC approach. Currently, POCUS (point-of-care ultrasound) is used by almost every medical specialty. “Traditional” or “formal” ultrasound exam (carried out by radiologists -in Greece- or medical sonographers) remains the reference imaging method; yet POCUS has become the new stethoscope². The latter is a fast beside evaluation while the first is a comprehensive more complex examination.

The dynamic is so rapid that in many countries the legal frame struggle to keep up with the new clinical reality. There are no standardised international rules about its implementation, so, the regulatory landscape for POCUS is currently evolving and varies across different regions and professions. Many professional societies have already included US training in their official specialty training curriculum. In Greece the legal frame is currently under evaluation for change: the current legislation is outdated, and, in many cases, it creates confrontations between (paradoxically) the Radiology Society and the rest of the medical societies^3-4. Medico-legal literature analyses have not yet identified any cases where performing diagnostic POCUS has resulted in civil-legal action^5-7. Instead, all cases have arisen from failure to perform POCUS when clinically indicated^5-7. Still, there is need for further standardization of training and certification. Since POCUS is used for answering specific clinical questions, a plethora of protocols have been developed. (Table 1).

Name	Abbreviation	Goal/description.
Focused Advanced Sonography in Trauma⁸	FAST	Detect life-threatening internal bleeding (abdomen, heart) in locations: Hepatorenal space (Morrison pouch), Splenorenal space, suprapubic (Douglas pouch) and subxiphoid.
Extended FAST	eFAST	The same as FAST plus pneumothorax (PTX) Right (R) and Left (L) anterior chest.
Tactical FAST⁹	tacFAST	First subxiphoid IVC check and then prioritize small IVC, scan below diaphragm, large IVC- scan above diaphragm. Includes ONSD measurement for possible increased ICP. Also includes US-guided procedures.
Cardiac arrest US exam¹⁰	CAUSE	Check for PTX, pulmonary embolism (PE), tamponade. Scan during pulse check (R and L ant. chest, subxiphoid).
Cardiac arrest sonographic assessment¹¹	CASA	Check for PE, tamponade and heart activity. Same as CAUSE, May perform eFAST during CPR and inferior vena cava (IVC) check
Focused Echocardiographic evaluation in life support¹²	FEEL	Uses SICV, AP4CH, PLAX, PSAX and subcostal 4 chamber view to evaluate heart function during advanced life support.
POCUS pulse check during CPR¹³	PURPAS	Pulse US checks (Doppler) at either the carotid artery or the femoral artery for confirming circulation in case of PEA or ROSC.
Lungs, IVC, Cardiac and Extra regions as indicated¹⁴	SLICE	US in shocked or dyspnoeic patient
US Hypotension protocol¹⁵	UHP	Seek for evaluation of reversible causes of hypotension.
Bed Lung US exam¹⁶	BLUE	Differential diagnosis (DDg) of acute respiratory failure: PTX, PE, pneumonia, COPD or asthma.
Fluid administration limited by lung US.¹⁷	FALLS	DDg of shock type (cardiogenic, septic, hypovolemic)
Rapid US for shock and hypotension¹⁸	RUSH	DDg of shock type. Follows “Pump, tank and pipes” view concept: heart (AP4CH, PLAX), IVC, FAST views, Aorta below the renal artery (4 views) and search for PTX.
RUSH- velocity time integral¹⁹	RUSH- VTI	Same as RUSH plus the calculation of stroke volume or its surrogates.
Focused assessed transthoracic echocardiography²⁰	FATE	Goal: exclusion of the obvious causative pathology, assessing contractility of the left ventricle (LV), estimation of wall thickness and chamber dimensions, exclusion of pleural pathology. Includes: Subcostal view (SIVC), Apical four-chamber view (AP4CH), Parasternal long-axis view (PLAX), Parasternal short-axis view (PSAX), Pleura scanning.
Extended FATE²⁰	eFATE	Includes: Subcostal vena cava view, Apical two-chamber viewApical three-chamber or long-axis view, Apical five-chamber view, Parasternal short-axis mitral plane view, Parasternal aortic short-axis view.
Venous excess US²¹	VEXUS	Uses IVC measurement and Doppler US of intrahepatic, portal and renal vein to assess venous congestion, especially in critical ill patients with heart and kidney problems.
Focus assessment in STEMI²²	FASTEMI	Early evaluation and detection of complications.
Point-of-care US protocol for Hepatitis²³	PUSH	Check for signs of cirrhosis and hepatocellular carcinoma in the liver of people with chronic hepatitis B

CPR-cardiopulmonary resuscitation, PEA- pulseless electric activity, ROSC- return of spontaneous circulation

Table 1. Selected POCUS protocols.

Yet, the choice of the protocol is not goal-dependent only; but it’s also varying with the ultrasound knowledge and experience of the ultrasound performer. Many protocols have modified variants (e.g. FAST and eFAST, UHP and RUSH and RUSH-VTI, FATE and eFATE, etc), others include scoring systems to answer a specific question (e.g. VEXUS score), other are named differently but the seem to be almost the same protocol (e.g. CAUSE and CASA exam). With the wider application and usage of ultrasound the list of possible POCUS protocol is increasing and the protocols are getting more and more complex and sophisticated. Some (e.g. tac FAST) do not only help diagnostics, but also include US- guided procedures, such as regional nerve blocks. Some are mainly used by certain specialties (e.g. anaesthesiologists use airway and gastric POCUS, for assessing airway and gastric volume respectively) , others are more general (e.g. deep venous thrombosis screening POCUS).

However, the base of POCUS examinations remains; they are mainly unsolicited evaluations, and they do not rely solely on order-based imaging protocols. They rather follow clinician examination: the type and anatomical areas imaged differ and often not – predetermined. If they are performed for clinical reasons, then the serve as adjunct to other evidence/parameters for clinical decision. If they are performed for educational reasons, they do not interfere with clinical care. The latter is often seen in clinical practice; and in those cases, images taken usually are partially or not archived.

Within this frame, essential documents, policies, and protocols and the politics surrounding credentialing and accreditation are still undefined. POCUS is here to stay, along with the “traditional” ultrasound examination. Instead flowing among protocols and debating among specialties, it is time to put serious effort for developing and implementing appropriate governance systems for POCUS application with one goal: widening the safe and quality use of this valuable tool (ultrasound) in our daily practice. There are already suggestions of such governance system, such as the proposal made by the collaboration between the Healthcare Information and Management Systems Society (HIMSS), the Society for Imaging Informatics in Medicine (SIIM), and the American Institute of Ultrasound in Medicine (AIUM)²⁴. Application, education, reimbursement, supplies costs, coding and data/documentation storage, quality assurance issues should be standardised, and all the parties involved in health care are obliged to catch up with the advancement of medical technology and care.

Moreover, POCUS could be seen as a pioneer topic that may be useful for similar “problems” in the future (e.g. imagine if computer tomography or any tool, can be packed to a portable machine, available to be used by a clinician at the bedside…)

Additional materials: No

Acknowledgements: Not applicable

Authors’ contributions: AT: manuscript preparation, primary case-management, literature review. The author read and approved the final manuscript.

Funding: Not applicable

Availability of supporting data: Not applicable

Competing interests: The authors declared no competing interests.

Received: January 2026, Accepted: January 2026, Published: March 2026.

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Citation: Aslanidis Th: The point of care ultrasound protocol population. Time to tie the room together? Greek e j Perioper Med. 2026;25(a):3-9.

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