Emerg Med J 26:87-91 doi:10.1136/emj.2007.056242
  • Original Article

Abdominal and Cardiac Evaluation with Sonography in Shock (ACES): an approach by emergency physicians for the use of ultrasound in patients with undifferentiated hypotension

  1. P R T Atkinson1,
  2. D J McAuley1,
  3. R J Kendall1,
  4. O Abeyakoon1,
  5. C G Reid2,
  6. J Connolly3,
  7. D Lewis4
  1. 1
    Addenbrooke’s Hospital, Cambridge University Teaching Hospitals NHS Foundation Trust, Cambridge, UK
  2. 2
    Basingstoke and North Hampshire NHS Foundation Trust, Basingstoke, UK
  3. 3
    Newcastle Acute Hospitals NHS Foundation Trust, Newcastle, UK
  4. 4
    The Ipswich Hospital NHS Trust, Ipswich, UK
  1. Dr P R T Atkinson, Addenbrooke’s Hospital, Cambridge University Teaching Hospitals NHS Foundation Trust, Cambridge, UK; paul.atkinson{at}
  • Accepted 15 May 2008


Background: Non-traumatic undifferentiated hypotension is a common critical presentation in the emergency department. In this group of patients, early diagnosis and goal-directed therapy is essential for an optimal outcome. The usefulness of focused bedside ultrasound is reviewed and a protocol for Abdominal and Cardiac Evaluation with Sonography in Shock (ACES) is proposed.

Methods: The protocol consists of six windows including cardiac, peritoneal, pleural, inferior vena cava and aortic views, and aims to shorten the time period taken to establish a diagnosis and hence to deliver the most appropriate goal-directed therapy. Its use in seven case examples is described.

Results: In all cases the ACES protocol helped in guiding the initial management while further information was obtained.

Conclusion: The six-view ACES protocol is a useful adjunct to clinical examination in patients with undifferentiated hypotension in the emergency department. A prospective randomised trial or multicentre database/registry is needed to investigate the validity and impact of this protocol on the early diagnosis and management of hypotensive patients.


  • Competing interests: PRTA, RJK, DL and DJMcA organise and teach on emergency ultrasound UK level 1 and advanced ultrasound courses at Addenbrooke’s Hospital and Ipswich Hospital. PRTA and DL co-direct the focused ultrasound websites and CGR organises and teaches on emergency training ultrasound courses in Basingstoke. JC organises and teaches on NEMUS emergency ultrasound courses in the Northern Deanery.

  • Ethics approval: The local ethics committee (Cambridgeshire 2) has approved analysis and publication of the cases included in this paper. No identifiable patient information has been used and all images of scans have been anonymised. Cases are example but typical cases taken from our collective experience.

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Among patients with minor TBI (GCS 13-15) getting CT scans ≥ 24 hours after injury, what proportion have a traumatic finding?


0.5% - 43% response rate
3% - 41% response rate
10% - 16% response rate

Related original article: PCT head imaging in patients with head injury who present after 24 h of injury: a retrospective cohort study

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