© Peakstock – stock.adobe.com
Article • Emergency ultrasound & POCUS
Value or vanity? Experts challenge ultrasound’s expanding role
Point-of-care ultrasound has transformed emergency medicine – but as its use expands beyond critically ill patients, leading clinicians are warning that unchecked enthusiasm could do more harm than good. At a dedicated session during the EUSEM 2026 (European Society of Emergency Medicine) conference, experts examined where the next frontiers in emergency ultrasound may lie – and where its limits should be drawn.
By Mark Nicholls
Photo courtesy of Dr Tabakovic
Dr Senad Tabakovic, Lead Consultant of the Emergency Department at Zürich City Hospital, addressed a question that is gaining urgency as ultrasound skills among emergency physicians continue to grow: does performing Focused Cardiac Ultrasound (FoCUS) on clinically stable patients provide genuine diagnostic value – or has it become a form of clinical ‘vanity’?
‘While the historical utility of FoCUS in unstable critically ill patients is undisputed, its expansion into the routine workup of stable patients introduces significant cognitive and diagnostic risks if not accompanied by stewardship,’ he said.
Tabakovic pointed to what he described as ‘indication creep’ – the progressive use of focused examinations to answer broader clinical questions. ‘From a tool intended to better treat severely ill patients, the emphasis is moving towards making rapid disposition decisions, avoiding time-consuming specialist consultations that prolong the length of stay,’ he explained.
A curriculum that has not kept pace
With an ‘enormous rise’ in the use of emergency ultrasound over the past 20 years, Tabakovic suggested a gap is emerging: the European Emergency Medicine specialty curriculum has failed to reflect this changing reality. In response, the Ultrasound Section of EUSEM recently published a compendium on emergency ultrasound, aiming to better capture the broad range of point-of-care ultrasound applications in European emergency medicine.
To prevent FoCUS from becoming a driver of over-testing, unnecessary costs, patient anxiety, and delays, Tabakovic called for effective POCUS stewardship – with a focus on appropriate indications, accurate interpretation, and integration into the broader clinical workup.
‘Ultimately,’ he said, ‘the future of FoCUS education relies on training Emergency Physicians with a strong emphasis on these cognitive and clinical stewardship aspects.’
Can ultrasound reduce unnecessary CT scans?
Photo courtesy of Professor Osterwalder
Professor Joseph Osterwalder, former Chief Physician at Cantonal Hospital St Gallen, Switzerland, turned to the use of ultrasound in patients with suspected pulmonary embolism (PE) – and its potential to reduce unnecessary computed tomography pulmonary angiography (CTPA).
He outlined how detection of deep vein thrombosis using compression ultrasonography (CUS), right ventricular dysfunction (RVD) on FoCUS, and pulmonary consolidations on lung ultrasound (LUS) are considered indirect diagnostic signs of PE. Drawing on an analysis of 13 meta-analyses and six real-world studies – incorporated into a paper currently under review at the European Journal of Ultrasound – he assessed their diagnostic accuracy.
‘Sensitivity is below 90% in most studies, and in some it is close to 50%, making ultrasound insufficient as a stand-alone rule-out test. Specificity, however, is consistently above 90% in almost all studies, suggesting considerable potential for ruling in pulmonary embolism,’ he said.
A potential game-changer – with caveats
With previous studies described as ‘highly heterogeneous and generally of poor methodological quality’, Osterwalder cautioned that ‘uncritical use of ultrasound in this setting may therefore lead to potentially fatal consequences through inappropriate undertreatment or overtreatment.’
He concluded that ultrasound should only be used in conjunction with clinical probability assessment and D-dimer testing to guide the decision on whether further imaging is warranted, as outlined in the new AHA imaging algorithm published in July 2026.
A stepwise approach to reducing CTPA
Osterwalder pointed to a proposed approach – albeit not yet validated – that could reduce CTPA use by 28–58%. In haemodynamically unstable patients, the initial step is FoCUS. If positive and there are no signs of chronic RVD, treatment can be initiated immediately. If signs of chronic RVD are present, CUS of the lower extremities should be performed next. A positive CUS establishes the diagnosis; if negative, further management should be guided by clinical judgement.
In haemodynamically stable patients, the initial step is CUS. If positive, no further diagnostic imaging is required, although FoCUS should be performed for risk stratification. If CUS is negative, LUS follows. If LUS is positive, FoCUS is then performed for risk stratification. If LUS is negative, FoCUS is also the next step. If FoCUS is positive without signs of chronic RVD, the diagnosis of PE is established.
However, he warned: ‘If all three ultrasound modalities are negative or the findings remain inconclusive, proceed to CTPA.’
Profiles:
Dr Senad Tabakovic is Lead Consultant of the Emergency Department at Zürich City Hospital, Switzerland, and a board-certified specialist in Emergency Medicine (FSSREM). He is a Fellow of EUSEM, currently serving as Co-Chair of the EUSEM Ultrasound Section and a member of its Educational Committee.
Professor Joseph Osterwalder is the former Chief Physician at Cantonal Hospital St Gallen, Switzerland, and Titular Professor at the Faculty of Medicine of the University of St Gallen. Currently CMO at Polipraxis CH-9000, he is a recognised pioneer of point-of-care ultrasound.
11.11.2026
