Core review: physician-performed ultrasound: the time has come for routine use in acute care medicine.

The use of ultrasound in the acute care specialties of anesthesiology, intensive care, emergency medicine, and surgery has evolved from discrete, office-based echocardiographic examinations to the real-time or point-of-care clinical assessment and interventions. "Goal-focused" transthoracic echocardiography is a limited scope (as compared with comprehensive examination) echocardiographic examination, performed by the treating clinician in acute care medical practice, and is aimed at addressing specific clinical concerns. In the future, the practice of surface ultrasound will be integrated into the everyday clinical practice as ultrasound-assisted examination and ultrasound-guided procedures. This evolution should start at the medical student level and be reinforced throughout specialist training. The key to making ultrasound available to every physician is through education programs designed to facilitate uptake, rather than to prevent access to this technology and education by specialist craft groups. There is evidence that diagnosis is improved with ultrasound examination, yet data showing change in management and improvement in patient outcome are few and an important area for future research.

Limited transthoracic echocardiography assessment in anaesthesia and critical care.

The use of echocardiography in anaesthesia and critical care started with transoesophageal echocardiography, whereas transthoracic echocardiography was largely the domain of the cardiologist. In recent times, there has been a change in focus towards transthoracic echocardiography owing to the development of small and portable, yet high-fidelity, echocardiography machines. The cost has reduced, thereby increasing the availability of equipment. A parallel development has been the concept of limited transthoracic echocardiography that can be performed by practitioners with limited experience. The basis of these examinations is to provide the practising clinician with immediate information to help guide management with a focus on haemodynamic evaluation, and limited structural (valve) assessment to categorise whether there is a valve disorder that may or may not cause haemodynamic instability. The limited examination is therefore goal directed. A number of named examinations exist which differ in their scope and views. All of these require a limited knowledge base, and are designed for the clinician to recognise patterns consistent with haemodynamic or anatomical abnormalities. They range from very limited two-dimensional assessments of ventricular function to more complex (yet presently limited) studies such as HEART (haemodynamic echocardiography assessment in real time) scan, which is designed to provide haemodynamic state, as well as basic valvular and pericardial assessment. It is suitable for goal-directed examination in the operating theatre, emergency department or intensive care unit (ICU) and for preoperative screening.