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Emerg Med J. 2009 Feb;26(2):87-91. doi: 10.1136/emj.2007.056242.

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

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Addenbrooke's Hospital, Cambridge University Teaching Hospitals NHS Foundation Trust, Cambridge, UK.



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.


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.


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


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.

[Indexed for MEDLINE]

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