

All rights are reserved. Except as permitted under the United States Copyright Act of 1976, no part of this publication maybe reproduced or distributed in any form or by any means, or stored in a data base or retrieval system, without the prior written per-mission of the lead authors and publisher.http://www.henryfordultrasounduniversity.com

Contact info@medicalimagineering.com

Third Edition © 2013 by Keith Killu, Scott Dulchavsky, Victor Coba

This work is registered for copyrights at the Library of Congress. Registration Number: TXu 1-811-043

First Edition 2010 © by Keith Killu, Scott Dulchavsky, Victor Coba

ISBN-13

978-0-9856551-9-8 Print Edition

978-0-9897205-0-2 Electronic Edition

At the time of publication, every effort has been made to make sure of the accuracy of the information provided. The authors, editors and publishers are unable to warrant that the information provided is free from error, since clinical standards change constantly. The authors, editors and publishers disclaim all liability for direct or consequential damages resulting from the use of material in this book.

Art/Design/Photography, Surgical Imagineers at Butler Graphics, Inc.

3D Modeling, Butler Graphics/VitalPxl Collaboration

Male/Female 3D Model, Zygote

Dedication

I dedicate this small measure of work to

My Mother, for all your sacrifices

My Wife, for always being there

And

All Ultrasound enthusiasts on earth and in space.

Keith Killu MD, Detroit

To those ultrasound explorers who inspired us and to the future generations who will show us new enabling possibilities with this remarkable tool.  Scott A. Dulchavsky MD PhD, Detroit

To my wife and family for their love, support and patience throughout the entire project and the inspiration for upcoming future endeavors.  Victor Coba MD, Detroit

Leads

Keith Killu MD,FCCM, RDMS, RDCS

Clinical Assistant Professor/Wayne State University School of Medicine

Critical Care medicine/Dept. of Surgery, Henry Ford Hospital, Detroit, Michigan

Scott A. Dulchavsky MD, PhD

Professor/Wayne State University School of Medicine

Chairman/Dept. of Surgery, Henry Ford Hospital

Victor Coba MD

Critical Care Medicine/Emergency MedicineStaff Physician/Dept. of Emergency MedicineHenry Ford Hospital

Authors

Karthikeyan Ananthasubramaniam MD, FACC,FASE

Associate Professor of Medicine/Wayne State University School of Medicine. Director of Nuclear Cardiology and Echo cardiography Lab/Dept. of cardiology, Henry Ford Hospital

David Amponsah MD, RDCS

Assistant Clinical Professor/Wayne State University School of Medicine Ultrasound Director/ Dept. of Emergency Medicine, Henry Ford Hospital

J. Antonio Bouffard MD

Senior Staff Radiologist/Bone Radiology DivisionDepartment of Diagnostic Radiology,Sinai Grace Hospital, Detroit, Michigan

Abigail Brackney MD, RDMS

Staff Physician

Dept. of Emergency Medicine

Beaumont Hospital, Detroit, Michigan

Brian M. Craig MD

Ultrasound Section LeaderDept. of Radiology,Henry Ford Hospital

Mark Favot MD

Assistant Clinical Professor/Wayne State University. Ultrasound Director/Dept. of Emergency Medicine, Sinai Grace Hospital, Detroit, Michigan

Kathleen Garcia FASE, RVT

Wyle Integrated Science & EngineeringHouston, Texas

Patrick R. Meyers BS, RDMS,RDCS, RVT

OwnerMusculoskeletal Ultrasound of Wisconsin

Michael Mendez MD, RDCS

Associate Director Medical ICU

Pulmonary/Critical Care. Henry Ford Hospital

Jennifer Milosavljevic MD

Staff PhysicianDept. of OB/GYN,Henry Ford Hospital

Luca Neri, MD

Professor/USCME Project DirectorPast President, WINFOCUSCritical CareA. O. Niguarda Ca' Granda HospitalMilano, Italy

Kathleen O'Connell

Medical StudentWayne State University School of MedicineDetroit, Michigan

Ashot Sargsyan, MD

Wyle Integrated Science & EngineeringHouston, Texas

Amy Sisley, MD, MPH

Division Chief, Acute Care SurgeryHenry Ford Hospital

Enrico Storti, MD

USCME Project Codirector, WINFOCUSCritical Care. A. O. Niguarda Ca' Granda Hospital. Milano, Italy

Guillermo Uriarte RN,RDCS,RCVT

Technical Director, Lead Echo SonographerDept. of Noninvasive CardiologyHenry Ford Hospital

Gabriele Via, MD

Editorial Board/Critical Ultrasound JournalDepartment of Anesthesia & Intensive CareUniversity of Pavia • Pavia, Italy

Contributors

Jack Butler

Media Specialist, Surgical ImagineerDept. of Surgery/Henry Ford HospitalButler Graphics, Inc., CEO

Neil Rudzinski

Media Specialist 3D VisualizationDept. of Surgery/Henry Ford Hospital

Volunteers

Peter Altshuler

Daniel Berardo

Alexandria Dulchavsky

Jessica Ede

Michael NowakCaitlin ReddyElizabeth Watchowski

Table of Contents

Foreward / Preface  .............. 7

Getting Started /

Equipment, Terminology

and Knobology  .................. 10

Cardiac Exam  ..................... 27

FAST, Extended

FAST/Abdominal Exam ...... 90

Evaluation of the Aorta .....136

Vascular ............................. 146

Lung Exam  ....................... 181

Optic Nerve Exam  ............ 204

OB/GYN  ............................ 212

Musculoskeletal (MSK)

& DVT ................................ 226

Procedures ........................ 242

Clinical Protocols  ............ 260

Abbreviations

AO

Aorta

AV

Aortic Valve

CCA

Common Carotid Artery

CBD

Common Bile Duct

CCW

Counterclockwise

CF

Color Flow

CFA

Common Femoral Artery

CFV

Common Femoral Vein

CHD

Common Hepatic Duct

CW

Clockwise

DCM

Dilated Cardiomyopathy

DFV

Deep Femoral Vein

ET

Endotracheal

FV

Femoral Vein

GB

Gallbladder

GSV

Greater Saphenous Vein

HOMC

Hypertrophic Obstructive Cardiomyopathy

IJV

Internal Jugular Vein

Inn

Innominate

IVC

Inferior Vena Cava

IVS

Interventricular Septum

LA

Left Atrium

LLQ

Left Lower Quadrant

LUQ

Left Upper Quadrant

LV

Left Ventricle

LVOT

Left Ventricular Outflow Tract

MV

Mitral Valve

ON

Optic Nerve

ONSD

Optic Nerve Sheath Diameter

PAP

Pulmonary Artery Pressure

PE

Pulmonary Embolus

PEA

Pulseless Electrical Activity

PFA

Profunda Femoris Artery

PI

Pulmonary Incompetence

PR

Pulmonary Regurgitation

PV

Pulmonary Valve

PW

Pulsed Wave Doppler

RA

Right Atrium

RAP

Right Atrial pressure

RLQ

Right Lower Quadrant

RUQ

Right Upper Quadrant

RV

Right Ventricle

RVIT

Right Ventricular Inflow Tract

RVOT

Right Ventricular Outflow

Tract

SCV

Subclavian Vein

SFA

Superficial Femoral Artery

SFV

Superficial Femoral Vein

SVC

Superior Vena Cava

TV

Tricuspid Valve

US

Ultrasound

PREFACE

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Preface & Foreword

PREFACE

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Preface

The ICU Ultrasound pocket book is far and above the most concise, targeted reference source to enable the novice or advanced emergency or ICU clinician to incorporate point of care ultrasound into their practice. This book effectively teams internationally recognized sonologists with NASA researchers developing just in time ultrasound training methods for astronauts on the International Space Station, to provide a rapid ultrasound diagnostic and procedural guide for the ICU. The comprehensive sections included in this book cover the ever expanding array of clinical indications for non-radiologist performed ultrasound and provide a novel addition to this field.

Scott A. Dulchavsky MD PhD

PREFACE

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Foreword

Bedside intensivist-performed ultrasonography easily qualifies as one of the most, if not the most important paradigm shifting technology developed in critical care in recent years. The availability of less expensive, smaller machines with better resolu-tion has made bedside examination by the intensivist feasible. What is it about bedside ultrasonography that is so compelling for the ICU physician? Ultrasonography permits the "ultimate" physical examination. It allows immediate assessment of vital cardiopulmonary, abdominal, renal, and vascular structural and functional elements in the unstable patient. Considerably less diagnostic guess work results in a more precise workup, with less unnecessary, and potentially hazardous, transports to radiol-ogy. Furthermore it replaces "blind" or landmark guided procedures with defined anatomic visualization that translates into safer, faster, and less painful procedures.

Critical Care physicians have been slower than their Emergency Medicine colleagues to adopt this technology, but this is changing rapidly. There is an expanding literature on the use of ultrasonography in critically ill patients. Recent consensus guidelines outlining specific elements of knowledge that define competency in critical care ultrasound have been published. Training guidelines and examinations designed to demonstrate proficiency in critical care ultrasonography are the next steps to fully establishing intensivist-performed ultrasound.

This book succeeds outstandingly in one important part of that process: the creation of educational materials designed to be used at the ICU bedside to guide image acquisition, image interpretation, and procedural ultrasound. As such "The ICU Ultrasound Pocket Book" is a valuable resource for medical students, nurses, physician extenders, residents, and fellows, as well as practicing intensivists.

John M. Oropello, MD, FCCM, FCCP, FACP Program Director, Critical Care Medicine Professor of Surgery & Medicine Mount Sinai School of Medicine New York, N.Y.

PREFACE

AORTA

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KNOBOLOGY

VASCULAR

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10

Getting Started

Equipment, Knobology & Terminology

Ashot Sargsyan, MD

Kathleen Garcia, FASE, RVT

Contents

Physics  ...................11

Transducers .................. 14

Ultrasound Machine ............. 16

Definitions  ................. 17

Modes  .................. 18

Controls  .................. 20

Image Orientation .................. 21

Terminology  .................. 23

Transducer Orientation .........25

Advantages of Ultrasound

Noninvasive

Highly feasible

Rapid, versatile & repeatable

Time saving

Be familiar with your ultrasound machine

Knobology may be presented differently in dif-ferent machines, but the principle is the same.

Setting the machine initially to obtain the best sonographic picture is of ultimate importance.

The learning curve is usually steep

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Wave Length

The distance an US wave travels in one cycle

Frequency

The number of times the wave is repeated

in one second. 1 Hz= 1 wave cycle/sec. US frequency is usually 2-12 million (mega) Hz, (MHz)

Velocity

The speed the US wave travels through a medium

depends on the medium density.

Speed in soft tissue is 1540 m/s

Amplitude

The peak pressure of the US wave (The higher

the amplitude, the brighter the returning wave)

Wavelength

Time

Pressure/Amplitude

High Frequency

Low Frequency

Wavelength

Physics

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Reflection

Redirection of portion of the US wave to its source. Reflection is the foundation upon which US scanning is  based. The more perpendicular the US beam is to the structure, the better is the reflection and visualization

Refraction

Redirection of the US wave as it crosses a boundary between two mediums with different densities (acoustical  properties)

Acoustic Power

The amount of energy emitted by the transducer. This energy should be the minimum needed. ALARA (As Low

As Reasonably Achievable) is a principle that must be followed to minimize the probability of bio-effects of the

acoustical energy on tissues

Medium 1

US Beam

Reflected US

Transmitted/Refracted US

Medium 2

Reflected US

US Beam

Physics

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Resolution

Axial Resolution

The ability to differentiate between two closely spaced structures that lie parallel to the US beam. Can be  improved by using a higher frequency transducer

Lateral Resolution

The ability to differentiate between two closely spaced structures at the same depth. Can be improved with  adjusting the focal zone

Lateral resolution

Axial resolution

Focal Zone

Physics

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Piezoelectric effect

The US transducer has crystals made of piezoelectric material. When an electric wave is applied, the crystal will deform in shape forming an US wave (pressure) which will travel through the tissue. When an US wave is reflected back hitting the trans-ducer (crystal surface), the crystal will deform in shape changing this mechanical energy (pressure) into electrical signals

The new transducers are array transducers that contain crystals or groups of crystals arranged along the footprint. Sequential array transducers refer to sequential activation of each crystal (emitting an US wave and waiting for its return before the next crystal fires). The linear and curvilinear transducers are usually of this type.

Phased array transducers use a group of crystals and using every element with each US pulse (A group of crystals sends an US wave, waits for its return before changing angle slightly to send another wave. This action is repeated until a full sector is scanned). The cardiac transducer is an example of this type.

Linear Array

Phased Array

Curvilinear

Transducers

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Microconvex

Phased Array

Linear

Curvilinear

Frequency ranges 2-5 MHzLarger, curved footprint with excellent penetration for deeper structures and great lateral resolutionUsually used for abdominal exam

Frequency ranges 7-13 MHzHigh resolution for superficial structures. Poor penetration for deep structuresUsed for vascular, lung, musculoskeletal, nerves and optic exams

Frequency ranges 2.5-5 MHzSmaller flat footprint and a better penetration for deeper structuresUsed for cardiac, lung and abdominal exams

Frequency ranges about 4-11 MHzSmaller footprint and a better penetration for deeper structuresGeneral use in adult patients is for abdominal, lung and vascular exams

Transducers

PREFACE

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Basic US Machine Layout

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US Machine/Controls Definitions

1. Power Turn Power on and off

2. Patient Select, enter and edit Patient data

3. Preset To select a preprogrammed setting for a given type of exam and transducer

4. TGC Time Gain Compensation. Adjusts the gain at different depths

5. B-mode (default mode) Brightness mode. Live gray scale image of all structures. Also known as 2D modes

6. Color Flow (CF) Also known as Color Doppler mode. Detects fluid flow and direction

7. Pulsed Wave (PW) Doppler Displays live blood flow spectrum vs. time at the PW Cursor site (in the heart or a vessel), to reveal flow direction, laminarity, velocities and indices

8. M-mode The motion mode. Displays motion of anatomical structures in time along the M-mode cursor.

9. Gain Amplifies the US wave brightness

10. Depth Adjust the depth to focus on the organ being examined . For deeper structures, increase the depth

11. Freeze Display shows image snapshot

12. Set/Pause Acts similar to a computer mouse button

13. Measurement Initiates measurement by bringing up calipers (mode- and preset-specific)

14. Scroll Track ball

15. Cursor Press to make the cursor appear and disappear

16. Print & Media Transfer button Save and transfer data to media keys

17. Reverse Switch screen indicator to the right and left of the screen

18. Focus Focuses the US beam at the depth of interest for better resolution and image quality

Wave length: The distance an US wave travels in one cycle

Frequency: The number of times a wave is repeated per second 1 Hz= 1 wave cycle/secCommon diagnostic US frequency is 2-12 million (mega) Hz ,(MHz)

Acoustic power: The amount of energy emitted by the transducer

ALARA: As Low As Reasonably Achievable. This principle must be followed to minimize the probability of bio-effects of acoustical energy on tissues

Grayscale: The principle of assigning levels of gray (usually 256 levels from white to black) to the returning US pulses according to their intensity. Strongly reflecting anatomical structures are more echogenic, while non-reflecting areas are non-echogenic.

Reflection: Redirection of portion of the US wave to its source

Refraction: Redirection of the US wave as it crosses a boundary between two mediums with different densities (acoustical properties)

Spatial ResolutionAbility of the machine to image finer detail. Measured by the ability to identify closely spaced structures as separate entities.

Axial Resolution: The ability to differentiate between two closely spaced structures that lie parallel to the US beam. Can be improved by using a higher frequency transducer

Lateral resolution:The ability to differentiate between two closely spaced structures at the same depth. Can be improved with adjusting the focal zone

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Modes

Gray scale

Focus

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Color Flow orientation

When applying Color Flow, the top of the box on the left or right of the screen will indicate the color of the flow towards the transducer, and the bottom of the box indicates the color of the flow away from the transducer. In this example the flow towards the transducer is red, and the flow away from the transducer is blue.

Flow towards the transducer

Flow away from the transducer

Modes

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Low gain

Depth

Too much depth > 20 cm

Not enough depth < 3cm

Structure

Structure

Gain

Adequate gain

High gain

Controls

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Structures should be examined in two orthogonal planes, commonly transverse (axial, horizontal) and longitudinal (either sagittal or coronal).

If a transverse image (cross section) is being obtained, place the transducer marker towards the patient's right, and make sure the US monitor indicator is in default position (to the left of the screen)

Structures located near the transducer marker will appear near the marker on the screen

This US image project structures on the right side of the patient to the left side of the screen, similar to a CT image

Transducer Marker

IVC

IVC

AO

AO

Spine

Patient's Right

Patient's Left

ScreenIndicator

Image Orientation

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If a longitudinal image (sagittal) is being obtained, place the transducer marker towards the patient's head (cephalad) and make sure the US monitor indicator is in default position (to the left of the screen)

This will project structures closest to the patient's head on the left side of the screen.

Transducer Marker

Liver

IVC

IVC

Liver

Heart

Image Orientation

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Echoic

A relative characteristic of an US image area that contains echos .

The Liver image is often used as a reference to describe adjacent image areas as "hypoechoic" or "hyperechoic"

Anechoic/Black

Image areas with no echos (black)

Usually representing structures filled with uniform fluid.

"Acoustical shadows" from a bone or calculus may also be

anechoic

Hypoechoic/Light Grey

Darker gray areas, as compared to the liver image as reference

Isoechoic/Grey

The level of gray equals to the reference area or the sur-rounding tissue.

Often compared to the liver image as a reference

Hyperechoic/White

Lighter gray areas as compared to the reference area or the surrounding tissue

Often compared to the liver image as a reference

Examples are fascial layers, calcified areas and bone surfaces, reverberation from gas-containing structures and some image artifacts

Artifact

Spurious patterns on the US image (often hyperechoic) that do not correspond topographically to anatomical structures

Usually extends to the top of the screen

Interrupted by air and bony structures

Moves with the movement of the transducer

Acoustic shadow

Anechoic or hypoechoic shadow in the projected path of the US beam after it encounters a highly reflective surface (e.g. calculus or bone)

Mirror Image

A duplicate image of the structure appearing on both sides of a strong reflector (e.g., diaphragm)

Reverberation Artifact

An abnormal recurrent hyperechoic pattern of equal dis-tances

Occurs when the US wave is "trapped" and bounces be-tween two reflective interfaces

Terminology

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Artifact/Reverberation

Gallstone

Acoustic Shadow

Ring-down artifact

MirrorImage

Diaphragm/Hyperechoic

Anechoic

Liver/Echoic

Terminology

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Transducer Orientation

Perpendicular on the skin

Rotating

Tilting

Panning

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Operating the US machine has the same basic principles with all manufacturers. Familiarize yourself with your machine

Formulate a question to be answered by the US examination, for example:

Is there pleural effusion?

What is the LVED volume status?

Is there an increase in the ICP?

What is the safest path for a vein access?

Prepare the US machine, the transducer needed, gel and sterile sheath if needed before starting the examPlace the US machine by the bedside with the screen in comfortable visual contact

Avoid excessive lighting

Getting Started

Turn on the machine

Enter Patient data

Select a transducer (Preset Button)

Start with all TGC sliders in the midline as a standard and change as neede

Start in B Mode. All machines have the B Mode (2D) as default

Place the screen indicator to the left of the screen (default), except in cardiac exam it should be on the right. Apply enough gel on the transducer

Start US exam

Adjust the Gain

Adjust the Depth so that the structure examined fits the view and fills the center of the screen. Note the depth on the right of the screen

Use the focus to improve the image quality of the desired structure

Continue US scanning and have fun

Getting Started

Cardiac Exam

Keith Killu, M.D.

Karthikeyan Ananthasubramaniam, MD

Guillermo Uriarte, RN

Primary indications

Evaluation of global cardiac function

Estimation of intravascular volume status

Detection of Pericardial Effusion and Cardiac

Tamponade

LV & RV systolic function evaluation

Evaluation of wall motion

Evaluation of valve function

Extended Indications

Evaluation of CVP

Evaluation of IVC

Evaluation of PAP

Evaluation of the proximal aorta for dissection/aneurysm

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Contents

Terminology  ........................28

Transducer Type & Positions  ........29

Echocardiographic Windows  ....30

Left Parasternal

Long Axis  .............................31

Short Axis  ............................35

Apical .........................................42

Subcostal  ...................................48

IVC Evaluation 50

Suprasternal/Aorta exam ...............53

LV Systolic Function  ................ 56

Right Heart Assessment ............ 62

Pericardial Effusion ................... 67

Cardiac Tamponade  .................. 69

Cardiac Arrest  ........................72

Hemodynamic Assesment .............73

Worksheet  ........................89

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Terminology

2D image (B mode): Brightness mode for anatomical assessment

M mode: motion assessment of a structure over time. Distance & depth measurements are usually done with this mode

Color flow Doppler (CF): For hemodynamic and anatomical information

Continuous Wave (CW) and

Pulsed Wave (PW) Doppler: For hemodynamic assessment, calculating velocity and pressure gradients

Cine loop: frame to frame assessment

Cardiac Package: Usually included with the software for calculations

B Mode

B Mode

M Mode

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Patient position/Control Settings/Transducers

 04-cardiaccombo-sono.png)

Patient Position

Most critically ill patient have to be examined in a supine position. If possible a left lateral position will improve the cardiac window in the parasternal and apical views by pushing the heart closer to the chest wall

Control Settings

The Screen indicator is placed to the "Right" of the screen

The depth should be set at about 15 cm then adjust as needed

Start with the B Mode

Transducer Type

Phased Array (Cardiac) transducer

2.5-5 MHz. Small and can fit between the ribs

Curvilinear (abdominal) transducer

2-5 MHz. Mostly for subcostal view during the FAST exam

Phased Array transducer

Curvilinear/Abdominal transducer

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Echocardiographic Windows

Transducer Positions/ C = Cardiac

The following windows should be considered only as a guide for transducer position and marker orientation. They can vary from patient to patient and by patient position

C1= Parasternal Window

About the 3rd or 4th intercostal space, left sternal border

Footprint pointing towards the spine

Long axis= Transducer marker at 10 o'clock

Short axis= Transducer marker at 2 o'clock

C2= Apical Window

About the 5th or 6th intercostal at the point of maximal impulse

Footprint pointing towards the right shoulder

4 chamber= Transducer marker at 3 o'clock

5 chamber = Transducer marker at 3 o'clock with slight tilting of the footprint upward

2 chamber= Transducer marker at about 12 o'clock

C3= Subcostal Window

Below the Xiphoid process

Footprint towards the left shoulder

4 chamber= Transducer marker at 3 o'clock

Short axis= Transducer marker at 6 o'clock

IVC= Footprint towards the spine and the transducer marker at 6 o'clock, in cardiac presets or 12 o'clockin abdominal/general presets

C4= Suprasternal Window

At the Suprasternal notch

Footprint towards the back of the sternum (Inferior & Posterior)

Long axis= Transducer marker at 2 o'clock

Short axis= Transducer marker at 3 \- 5 o'clock

C1

C2

C3

C4

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Parasternal Window/Long Axis View

Left Parasternal Long Axis View

This is usually the first window and somewhat easier to obtain

Transducer Position

C1

Transducer marker pointing towards the patient'sright shoulder

LA

RV

LV

AO

Marker

3

4

RV

LV

AV

LA

MV

1

2

2

Descending AO

Marker

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Parasternal Window/Long axisMyocardial segments

Sonographic Findings

Note the overall activity of the heart and anygross abnormality

Note any pericardial effusion especially belowthe posterior wall

Examine the cardiac segments motion and structure

Posterior basal and middle

Apical inferior and anterior

Septal

RV Wall

Myocardial segments may be dysfunctionalduring acute myocardial infarction

3

4

RV

LV

AV

LA

MV

1

2

2

Descending AO

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Parasternal Window/Long axisValvular function

Sonographic Findings (cont.)

Use Color Flow (CF) to identify and evaluate the mitral and aortic valve function and detect any abnormality

Note any valvular dysfunction, note any significant stenosis or regurgitation

Blood moving in multiple directions will display variance and different multiple colors

Note any papillary muscle or chordae tendineae rupture

Large valve vegetations can be seen

AV

MV

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Parasternal Window/Long axisValvular function

AV Regurgitation

MV Normal Flow

AV Normal Flow

MV Regurgitant

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Parasternal Window/Short axis View

Transducer Placement

Start location: C1

From the long axis view turn the marker towards left shoulder [i.e. turn 90° CW]

Start with the transducer footprint perpendicular to the skin to obtain the round shaped "Donut" image of the Short axis

LV

Marker

RV

RV

LV

Donut Image

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Parasternal Window/Short axis View – Apex

Transducer Placement

Start location: C1

Transducer tilted downward with the footprint pointing towards the left thigh to obtain a short axis image at the apical level

Sonographic Findings

To evaluate the myocardial segments and note any apicaL hypokinesis

Anterior Wall

Lateral/Posterior Wall

Inferior Wall

Apical Segment

Marker

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Parasternal Window/Short axis View – Papillary M

Transducer Placement

Start location: C1

From the apical position, tilt the transducer upward moving towards the right shoulder to obtain a papillary muscle view "Donut". The footprint will be almost perpendicular to the skin

Sonographic Findings

This view is used to assess the fluid status and EF by the "eyeballing" method

Posterior Papillary Muscle

Anterior Papillary Muscle

RV

LV

Marker

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Parasternal Window/Short axisPapillary M/Myocardial segments

Sonographic Findings (cont.)

Examine the myocardial segments and wall motion

Anterior

Septal

Inferior

Posterior/Lateral

3

4

1

2

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Parasternal Window/Short axis View – Mitral Valve

Transducer Placement

Start location: C1

From the position of the papillary muscles, by tilting the transducer upward towards the right shoulder, a view of the mitral valve can be obtained

RV

MV Closed

Septum

Ant. Wall

MV Open

Sonographic Findings

Note the "Fish Mouth"

Examine MV function

Note any severe stenosis

Examine the wall segments

Marker

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Parasternal Window/Short axis View – AV & RVOT

Transducer Placement

Start location: C1

From the position of the MV, angling the transducer upward with the footprint towards

the right shoulder, a view of the Aortic valve and the RVOT can be obtained

Mercedes-Benz

sign

Sonographic Findings

Examine AV and PV function and note any severe stenosis

Note the Mercedes-Benz sign representing the AV

Marker

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Parasternal Window/Short axis AV & RVOT

Sonographic Findings (cont.)

Examine the AV, RVOT and the PV

Use CF to examine for any PI, which can help in the measurement of the Pulmonary artery pressure (PAP) by Doppler method

Examine the main PA for regurgitation

Examine the right and left PA

May be able to detect a large pulmonary embolus

Pulmonary Artery Flow

AV Open

RA

PV

LA

RVOT

Rt & Lt Pulmonary Artery

AO

Rt PA

Lt PA

PA

Normal

PR

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Apical Window / 4 Chamber View

LV

RA

RV

LA

Marker

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Apical Window/4 Chamber View – Myocardial segments

Transducer Placement

Start location: C2

Place the transducer at the apex with the footprint towards the patient's head or right shoulder. Transducer marker is rotated to approximately 3 o'clock position

Sonographic Findings

Examine the overall cardiac contractility

Note any wall motion abnormality in different segments, Lateral, Apical, Septal

Can be used to estimate the EF – Evaluate the RV function

Septal

Apical

Lateral

RV

RA

LA

LV

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Apical Window/4 Chamber View – MV & TV Function

Sonographic Findings (cont.)

Use CF to examine the MV and TV function and detect any significant flow abnormality

Note any significant MV, TV stenosis or regurgitation

Normal TV Flow

Normal MV Flow

Regurgitant TV Flow

Regurgitant MV Flow

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RA thrombus (Arrow)

LVH/Thick IVS

Dilated LA, RA & RV

LV

RA

LA

RV

RV

LV

Echo Abnormalities

IVS

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Apical Window/ 5 Chamber View

Transducer Placement

Start location: C2

5 Chamber: Tilting the transducer upward at the apex to open up the LVOT and Aortic valve (the 5th chamber)

CF/LVOT

LVOT

RV

LV

RA

LA

Sonographic Findings

Using the CF can help identify the 5th chamber

Using CF and PW Doppler to calculate the stroke volume (SV) as well as any significant regurgitation

Normal

AR

Marker

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Sonographic Findings

Examine myocardial segments

Anterior

Posterior

Apical

Evaluate MV function and abnormalities

Apical Window/ 2 Chamber View

Transducer Placement

Start location: C2

Rotate the transducer 45° CCW from the 4 Chamber view. Transducer marker at about 12 o'clock

Anterior

MV

Apical

Posterior

LV

LA

Marker

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Subcostal Window/4 Chamber View

Transducer Placement

Start location: C3

4 Chamber: Below the xiphoid process, the footprint pointing towards the left shoulder.The marker is at about 3 o'clock position

Sonographic Findings

Evaluate the function of all chambers

Note any wall motion abnormality

Good view to detect any pericardial effusion

Liver

RV

RA

LA

LV

Marker

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Subcostal Window/Short axis

Transducer Placement

Start location: C3

Short axis: From the 4 chamber view, rotate the transducer 90° CW so that the transducer marker is pointing at about 6 o'clock or 12 o'clock

Sonographic Findings

Similar to the parasternal short axis view

Can show the heart segments at different levels

Used for IVC assessment

Liver

RV

LV

Marker

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Subcostal/Inferior Vena Cava (IVC)

Transducer Placement

Start location: C3

Curvilinear transducer can be used

Depth 15-20 cm

Subcostal, the footprint pointing towards the spine and the transducer marker is pointing cephalad

Liver

IVC

RA

Marker

RA

IVC

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Subcostal/IVC

Sonographic Findings

To evaluate the volume status: Note the IVC diameter and its changes with the respiratory cycle

Normal IVC diameter is 1.5-2.5 cm during expiration in a spon-taneously breathing patient, just distal to the hepatic vein

Change in IVC diameter is an accurate predictor of fluid respon-siveness

Change in IVC diameter > 50% indicates that the patient is possibly hypovolemic

Change of less than 20%, the patient will probably not respond to fluid challenge

Liver

RA

Hepatic Vein

IVC diameter measurement during expiration

IVC diameter measurement during inspiration

Normal

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Subcostal/IVC

By using the M Mode, the IVC diameter measurement is more accurate

Remember that the diameter change during the respiratory cycle is reversed in Mechanically ventilated patients (i.e. Smaller during expiration and larger during inspiration)

Sometimes in quiet respiration, the IVC may not change in diam-eter. A "sniff test" can be done to observe the change

IVC diameter < 1.5 cm and collapsing, indicates hypovolemia.

Inspiritory phase

Spontaneous breathing

Expiratory phase

Collapsing IVC/M Mode

Inspiratory Collapse

Spontaneous breathing

Partial collapse

Collapse

Spontaneous breathing

Expiratory Phase

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Suprasternal View / Evaluation of Aorta

Transducer Position

Start location: C4

Place the transducer in the Suprasternal notch with the footprint pointing towards the back of the sternum. The patient's head is turned to the side

Long axis = Transducer marker at about 2 o'clock

Short axis = Transducer marker at about 5 o'clock

Marker

Marker

Short Axis

Long Axis

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Suprasternal View / Evaluation of Aorta

Sonographic Findings

Long Axis

The ascending aorta, aortic arch, descending aorta, the right pulmonary artery and the brachycephalic vessels will be in view

Examine for the presence of any dissection or moving flap

Arch

Ascending AO

Descending

AO

AO

Suprasternal/Long Axis

Suprasternal/Long Axis

Brachiocephalic

Vessels

PA

Rt. PA

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Suprasternal View / Evaluation of Aorta

Sonographic Findings

Short Axis

The aortic arch (in short axis), Superior Vena Cava (SVC) and the right pulmonary artery in its long axis

Examine for the presence of any dissection or moving flap

Use CF to help visualize the flow and false lumen if present

AO

LA

SVC

Rt PA

AO

SVC

PA

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LV Systolic Function EvaluationEjection Fraction (EF)

Indications

Useful in managing hypotensive patients to differentiate cardio-genic from non-cardiogenic shock

LV systolic function can be accurately assessed by critical care physicians using ultrasound in hypotensive patients

EF can be assessed by:

Simpson's Method or modified Simpson's Method

Apical 4 chamber and/or 2 chamber view should be obtained

The software divides the LV volume into 20 slices of equal height

Volume size=Slice area X Slice thickness

EF=LVEDV-LVESV/LVEDV X 100%

B Mode (Eyeballing)

Visual estimation of LV EF

M Mode

Software compares LV diameter in systole and end diastole

Normal EF=50-70%

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EF (cont.)

Simpson's Method Steps

Acquire an apical 4 chamber and 2 chamber view and store the loops and images

With the tracking ball, trace the LV cavity at end diastole, and then at end systole for both the 4 and 2 chamber views

EF=LVEDV-LVESV/LVEDV X 100%

Cardiac package will calculate the average results

LVESV

LVEDV

LV Systolic Function EvaluationEF

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EF (cont.)

Eyeballing, in the experienced eye, is as accurate as formal measurements

Best to obtain a parasternal short axis view at the papillary muscle level, or an Apical 4 chamber view and estimate the EF

Parasternal Short Axis/Papillary Muscle Level

Apical 4 Chamber

Normal

<40% EF

15% EF

Normal

<40% EF

Apical Hypokinesia

LV Systolic Function EvaluationEyeballing

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LV systolic Function Evaluation

EF

EF (cont.)

M Mode

Measure the LVIDd (LV internal dimension end diastole)

LVIDd range about 3.5-6.5 cm

Measure the LVIDs (LV internal diameter end systole)

LVIDs range about 2.0-3.8 cm

Cardiac package will calculate the EF & SV as well asfractional shortening

M-Mode Parasternal LA

M-Mode Parasternal SA

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SV Measurement

Simpson's Method or modified Simpson's will be used

Simpson's Method Steps

Acquire an apical 4 chamber and 2 chamber view

With the track ball, trace the LV cavity at end diastole, and then at end systole for both the 4 and 2 chamber views

SV= LVEDV-LVESV

Normal= 60-70 ml

End Diastole

End Systole

LV systolic Function Evaluation

Stroke Volume (SV)

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LV systolic Function EvaluationSV Measurement

SV Measurement (cont.)

Aortic Root method (2 steps)

Measure diameter of the aorta by M Mode or 2 D Echo

CSA (Cross Sectional Area) = 2 (Diameter)² X 0.78

Normal CSA 1.8-2.2 cm

Measure flow velocity, VTI (Velocity Time Index) from the LVOT at peak systole by PW Doppler

Calculate the volume of flow (SV)

SV= Cross sectional area X Velocity

SV= CSA X VTI

Cardiac package will do calculations

How to obtain VTI

Remember that the transducer angle is critical

Obtain a 5 chamber apical view

Use CF to help identify the 5th chamber (LVOT)

Use PW Doppler and point the marker to the LVOT

Using the track ball, track the systolic Doppler wave

Velocity of flow from the LVOT at peak systole by 2D echo (VTI) will be calculated by the cardiac package

Parasternal LA

LV

AO

LA

LVOT

Tracking the Doppler Wave

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Right Heart Assessment

Transducer Placement

The right heart can be assessed through different windows, C1,C2 and C3

Start location: C1

From the parasternal long axis view of the LV, tilt the transducer with the footprint pointing slightly towards the right thigh

RV assessment

Examine the RV inflow tract (RVIT) and any significant TV regurgitation

RV

RA

RV

RA

Parasternal long axis RVIT with TR

RV

RA

Marker

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Sonographic Findings

C3/Subcostal

Examine the wall motion and contractility, any paradoxical septal movement

EF in RV is normally less than LV

RVED area is usually < 2/3 of the LVED area

Note any RV dilation or collapse

Good view to detect any pericardial effusion

Liver

RV

RA

LV

LA

Subcostal 4 Chamber View

Right Heart Assessment

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Transducer Placement

C2/Apical 4 chamber view

Sonographic Findings/Steps

Assuming TR is present in most patients (over 75% of normal adults), Turn color flow and continuous wave Doppler across the Tricuspid valve. Align cursor along TV regurgitation jet when noted

Mark the maximum TR jet

Normal TR Velocity is 1.7-2.3 m/s

The signal reflects the pressure gradient between the RV and RA

A higher velocity usually means a higher PAP

TR Flow

Apical 4 Chamber

Pulmonary Artery Pressure (PAP) Assessment

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Sonographic Findings/Steps (cont.)

PA pressure = 4 X (peak TR velocity )2 \+ RA pressure (usually 5-10 mmHg)

RA pressure or CVP can be estimated from

Jugular Venous Pressure

Respiratory variation of the IVC

TR Velocity of 3.75 m/s

PAP Assessment

Example:

If peak TR velocity is 3.75 m/s and the estimated RA pressure is 10 mmHg

PA pressure = 4 X (3.75 )2 \+ 10 = 66.25 mmHg

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Transducer Placement

Start Location: C1/Left Parasternal Short axis View of the RVOT. Apply continuous Doppler

Sonographic Findings

Pulmonary Incompetence is common

PAEDP=4 X(Pulmonary Regurgitation End Diastolic Velocity PREDV)2 \+ RAP

Estimation of the RAP is as mentioned before

Continuous Wave Doppler

PREDV

PA

RVOT

AO

RA

LA

C1 / RVOT and Color Flow PR

Pulmonary Artery End Diastolic Pressure (PAEDP) Assessment/Wedge Pressure

Example:

If PAREDV was 2 m/s and RAP was 10 then

PAEDP= 4 X (2)2 \+ 10= 26 mmHg

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Transducer Placement

C3/Subcostal/The better view

C1/Parasternal

C2/Apical

Sonographic Findings

C3/Subcostal

Detection of echo-free rim around the heart within the hyperechoic parietal pericardium

False positive

Pleural effusion

Epicardial fat pad (usually anterior)

Measure the pericardial space in systole and diastole

Subcostal View/Pericardial Effusion

RV

RA

LA

LV

Pericardial Effusion

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Sonographic Findings (cont.)

C1/Parasternal View

A pericardial effusion will accumulate between the heart and the descending aorta.

A pleural effusion will accumulate beyond the descending aorta and will not separate it from the heart

Physiological effusion measures < 1 cm and is posterior only

Moderate is < 1 cm and large is > 1 cm in measurement and circumferential

RV

LV

LA

Posterior

Pericardial

Effusion

Pleural Effusion

DescendingAO

C1/Long Axis View

LV

LV

RV

RV

Anterior Pericardial Effusion

Posterior Pericardial Effusion

Pleural Effusion

M-Mode/left Parasternal View

Pericardial Effusion

Pericardial and Pleural Effusion

Pericardial Effusion

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Transducer Placement

Start location: C3/ Subcostal

Sonographic Findings

RA and RV diastolic collapse

RV free wall moves towards the RV cavity early in diastole [normally it moves away]

RA moves inwards at the end of diastole and the beginning of systole.

Small amounts of pericardial effusion, when accumulating acutely, can lead toTamponade features

C3 View/Cardiac Tamponade with RA & RV wall collapse

RV

RA

LA

LV

Liver

Early Tamponade

Tamponade

Cardiac Tamponade

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Sonographic Findings (cont.)

Obtaining an M-Mode with the cursor across the RV free wall, will show the collapse

Preserved reactivity of the IVC (changing with the respiratory cycle), strongly argues against hemodynamically significant cardiac Tamponade.

This can be examined by the IVC 2D or M-Mode images

M-Mode/IVC

IVC Plethora

RV Wall

Liver

LV

M-Mode across the RV showing Wall Collapse

Cardiac Tamponade

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Sonographic Findings

The heart will display a "swinging motion", which is an ominous sign of cardiac tamponade

By applying the Doppler, MV and TV flows will show exaggerated velocity features with respiration

Exaggerated Doppler Waves of the MV

Swinging Motion

Cardiac Tamponade

B Mode MV Doppler

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Echocardiography can be performed during cardiac arrest and CPR

Helps detect cardiac motion, dilated RV, pericardial effusion, cardiac tamponade and PEA

An image of the heart can be obtained in C3 (Subxiphiod 4 chamber) or C1 (Left parasternal long axis)

View Cardiac contractility and wall motion

Detect any intra-cardiac thrombi (associated with poor prognosis)

Exam should be done during pulse checks, lasting no more than 5-7 seconds

Cardiac arrest with intra-cardiac thrombus

Cardiac Arrest

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Introduction to Hemodynamic Assessment

Some technical factors and anatomical variations may lead to difficul-ties in ultrasound assessment. In most instances the ultrasound can be used for initial assessment and revaluation of the patient status and reassessment. It is an easy, non-invasive and reproducible modality for henodynamic assessment

Discussed below are the following exams for hemodynamic assessment using ultrsound:

Limited Cardiac exam

Inferior Vena Cava (IVC)

Lung/Pleural exam

Internal Jugular Vein (IJV)

Hemodynamic assessment by limited Trans-esopha-geal Echo (TEE)

Further evaluations like examining the Aorta, Focused Assessment with Sonography for Trauma (FAST) and the Extended FAST (E-FAST) is also recommended.

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Limited Cardiac exam

The goal of cardiac function assessment is to determine if the heart is the cause of hemodynamic instability of a patient at a certain time. The main focus of point of care ultrasound cardiac evaluation is to estimate the overall function of the heart, including:

Ejection fraction (EF)

Wall motion abnormality

Moderate to severe Valvular dysfunction

Pericardial effusion and tamponade

Please, refer to the corresponding cardiac section in the chapter for full details

Introduction to Hemodynamic Assessment

Cardiac Windows

Left Parasternal Long and Short Axis

Apical

Subcostal

C1

C2

C3

C4

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Limited Cardiac exam

Introduction to Hemodynamic Assessment

Left parasternal long axis

Note the overall activity of the heart and anygross abnormality

Note any pericardial effusion especially belowthe posterior wall

Note the valvular function and any significant regurgitation

Examine the cardiac segments motion and structure

Posterior basal and middle

Apical inferior and anterior

Septal

RV Wall

Myocardial segments may be dysfunctionalduring acute myocardial infarction

3

4

RV

LV

AV

LA

MV

1

2

2

Descending AO

Normal EF

AV Reguritation

AV Normal

MV Regurgitation

MV Normal

Low EF

Hyperkinetic

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Limited Cardiac exam

Introduction to Hemodynamic Assessment

Left parasternal short axis

Note the overall activity of the heart and any gross abnormality

Examine the cardiac segments motion and structure

1. Anterior wall

2. Septal wall

3. Inferior wall

4. Posterior/Lateral wall

Myocardial segments may be dysfunctional during acute myo-cardial infarction

This view is used to assess the fluid status and EF by the "eyeballing" method

Posterior Papillary Muscle

Anterior Papillary Muscle

RV

LV

EF < 15%

EF < 40%

Normal EF

Hyperkinetic

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Limited Cardiac exam

Introduction to Hemodynamic Assessment

Apical

Examine the overall cardiac contractility. Note any wall motion abnormality in different segments, Lateral, Apical, Septal segments. The apical view can be used to estimate the EF and Evaluate the RV function

Septal

Apical

Lateral

RV

RA

LA

LV

Apical hypokinesia

EF < 40%

Normal EF

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Limited Cardiac exam

Introduction to Hemodynamic Assessment

Subcostal

Examine the wall motion and contractility, any paradoxical septal movement

EF in RV is normally less than LV

RVED area is usually < 2/3 of the LVED area

Good view to detect any pericardial effusion

Collapse in the RV and/or RA may indicate Tamponade physiology

Liver

RV

RA

LA

LV

Tamponade physiology

Circumfrential pericardial effusion

Normal EF

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Limited Cardiac exam

Introduction to Hemodynamic Assessment

Ejection Fraction Estimation:

LV systolic function can be accurately assessed by critical care physicians using ultrasound in hypotensive patients.

Eye Balling:

Eyeballing, in the experienced eye, is as accurate as formal measurements. Best to obtain a parasternal short axis view at the papillary muscle level, or an Apical 4 chamber view and estimate the EF discussed before

M Mode:

Obtain a parasternal long axis view

Measure the LVIDd (LV internal dimension end diastole)

LVIDd range about 3.5-6.5 cm

Measure the LVIDs (LV internal diameter end systole)

LVIDs range about 2.0-3.8 cm

Cardiac package will calculate the EF & SV

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Inferior Vena Cava (IVC)

Introduction to Hemodynamic Assessment

The IVC is used to evaluate the intravascular volume status in hemodynamicaly unstable patients. Change in IVC diameter during respiration is an accurate predictor of fluid responsiveness.

Normal:

Normal IVC diameter is 1.5-2.5 cm during expiration in a spontaneously breathing patient, just distal to the hepatic vein, with respiratory variation. Asking the patient to "Sniff", can illustrate the respiratory variations in the IVC.

Hypovolemia:

A small IVC < 1.5 cm in diameter with a change > 50% or collapsing indicates that the patient is possibly hypovolemic

Hypervolemia:

An IVC of 1.5-2.5 cm with a change of less than 20%, indicates that the patient will prob-ably not respond to fluid challenge

Tamponade:

An IVC diameter of > 2.5 cm with no change with respiratory variation (IVC Plethora), indicates a possible tamponade physiology

Remember that the diameter change during the respiratory cycle is reversed in Mechani-cally ventilated patients (i.e. Smaller during expiration and larger during inspiration)

Estimating Right Atrial pressure (CVP) from the IVC size:

Normal (5-10 mmHg)= Normal size IVC with respiratory variation and collapse with sniff.

15 mmHg= Dilated IVC with collapse with sniff.

20 mmHg= Dilated IVC with no collapse.

Liver

RA

IVC

Hepatic Vein

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Inferior Vena Cava (IVC)

Introduction to Hemodynamic Assessment

IVC Diameter during expiration

IVC Diameter during inspiration

Spontanouse breathing

Spontanouse breathing

M Mode IVC plethora

Inspiratory

Expiratory

M Mode IVC diameter variation

IVC Plethora

Collapsed IVC

Normal IVC respiratory variation

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Lungs/Pleura

Introduction to Hemodynamic Assessment

Lung ultrasound is an integral part of hemodynamic as-sessment. The focus will be on identifying pulmonary edema and pneumothorax

Lung Examination Zones

Always examine both lungs and all zones. The trans-ducer should be perpendicular to the chest wall

Lung Zone 1/L1= Upper Anterior chest wall

Lung Zone 2/L2= Lower Anterior chest wall

Lung Zone 3/L3= Upper Lateral chest wall

Lung Zone 4/L4= Lower Lateral chest wall

L1

L2

L3

L4

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Lungs/Pleura

Introduction to Hemodynamic Assessment

B-lines (Commet tail sign)

Vertical lines, extending from the pleural line to the edge of the screen without fading. They have synchronized move-ment with lung sliding. The B lines represents thickening interlobular septa and extravascular lung water as in alveolar interstitial disease (pulmonary edema, ARDS...)

The higher the number of the B lines, the more severe is the interstitial process. Decrease or disappearance of the B lines occur after treatment of the underlying disorder (e.g diuresis for pulmonary edema)

Pleural Line

Comet Tail Artifacts/B Lines (arrows)

Pulmonary Edema after treatment

B Lines/Pulmonary Edema

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Internal Jugular Vein (IJV)

Introduction to Hemodynamic Assessment

Internal Jugular Vein (IJV)

Assessment of the IJV is easy and may give the operator an idea about the fluid status of the patient. The IJV diameter changes with respiration as the IVC, and significant variation and collapse can point to possible low volume status and fluid responsiveness. Using the M Mode can help measure the IJV more accurately.

Spontanouse breathing

Inspiratory

Expiratory

M Mode IJV diameter variation

IJV Collapse

IJV Respiratory variation

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limited TEE

Introduction to Hemodynamic Assessment

In certain patient populations, obtaining a transthorasic Echo window can be challenging secondary to patient habitus, position or limitations due to injury and dressings. Using a TEE can be very helpful in such conditions, where it is easy to use and interpret. Using TEE has been traditionally limited to cardiology or anesthesia specialists, but lately, specially with the introduction of the "mini", disposable transducer, the use of a limited TEE exam has been available to most acute care professionals.

Anatomy and structures will be displayed differently, since the trans-ducer will be placed through the esophagus behind the heart.

Three main views:

Superior Vena Cava (SVC) view

Transesophagel Four chamber view (4C)

Trans-gastric short axis view (SA)

SVC

4C

SA

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The transducer usually advanced through the esophagus to about 30 cm. Screen depth is usually about 15 cm.

Position the transducer just above the aortic valve.

Visualize the SVC.

This view helps to observe the size of the SVC and its collapsibility and responsiveness to fluids.

TEE Probe

PA

AO

S

V

C

RA

AO

SVC

limited TEE

Introduction to Hemodynamic Assessment

SVC View

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limited TEE

Introduction to Hemodynamic Assessment

4 Chamber (Long Axis) View

TEE Probe

PA

AO

S

V

C

RA

RV

LV

LV

LA

RV

RA

The transducer usually advanced through the esophagus to about 30 cm. Can advance another 1-2 cm from the SVC position.

Position the transducer just below the aortic valve. Retroflex the transducer.

Good window to view all chambers.

Observe the LV function and contractility. Note any wall motion abnormality. Good view to estimate the EF.

Apply CF to evaluate for any significant valvular regurgitation.

Very good view to evaluate the RV function.

Note any pericardial effusion.

Normal

CF

Hypokinetic

Hyperkinetic

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limited TEE

Introduction to Hemodynamic Assessment

Trans-Gastric (Short Axis) View

TEE Probe

PA

AO

S

V

C

RA

RV

LV

RV

LV

Posterior

Papillary Muscle

Anterior

Papillary

Muscle

The transducer usually advanced through the esophagus to about 40 cm, into the stomach. Anteflex the transducer.

Observe the LV function and contractility. Note any wall motion abnormality. Good view to estimate the EF.

Can evaluate the apex by slight retroflexion of the transducer.

Hypokinetic LV

Apex

Normal EF

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Worksheet

Patient Name:  _______________________

MRN: _______________________

Date:  _______________________

Echo Performer:  _______________________

LV & LA

Global LV Size Normal Dilated

Wall Motion Abnormality Y N

Segment  _________________

LA Normal Dilated

LV Function (EF) >40% <40% ____%

RV & RA

Global LV Size Normal Dilated

RVEDA/LVEDA 0.6-1 >1

Paradoxical Septal Motion Y N

Dilated RA Y N

Valve Abnormality (Moderate-Severe) Y N

MVR Y N

AVR Y N

TVR Y N

PVR Y N

Pericardial Effusion Y N

Small <1 cm Posterior only Y N

Moderate <1 cm circumferencial Y N

Large >1 cm circumferential Y N

Tamponade  Y N

RA/RV collapse  Y N

Dilated non-collapsible IVC (IVC Plethora) Y N

IVC Size and Collapsibility Index Y N

< 1.5 cm & collapse Y N

1.5-2.5 cm Y N

>2.5 cm Y N

>50% diameter change Y N

<50% diameter change Y N

Estimated RAP (CVP) ____

Aortic Dissection Y N

Intimal Flap Y N

Pericardial Effusion Y N

Aortic Regurgitation Y N

Cardiac Arrest Y N

Cardiac Standstill Y N

Pericardial Tamponade Y N

Intracardiac Thrombus Y N

Dilated RV & RA Y N

Impressions, Comments and Recommendations

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Abdominal Exam

Amy Sisley MD, MPHVictor Coba MD

Contents

Transducer Placement ............ 91

FAST* ................... 93

Subxiphoid  ......94

RUQ  ................97

LUQ  ...............100

Suprapubic  ....104

Extended Fast (E-FAST) ......107

Lung & Pleural space  ............108

IVC  ................113

Biliary .................117

GB/CBD ........ 118

Pancreas...............127

Renal ....................130 Worksheet  ........... 135

* Focused Assessment with Sonography for Trauma

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Abdominal Exam

Transducer Placement

Views may vary with anatomy, type of injury, body habitus and position

A1-A4 are used for the FAST exam

A1: Subxiphoid

Cardiac, IVC, Aorta

A2: Right mid to posterior Axillay line at  the level of 7th Intercostal space to the flank  area

Liver, Kidney, Diaphragm, Lung, Bowel

A3: Left mid to posterior Axillay line at  the level of 7th Intercostal space to the flank  area

Spleen, Kidney, Diaphragm, Lung, Bowel

A4: Suprapubic

Bladder, Uterus, Bowel

A5: Abdominal Midline

Aorta, IVC, Pancreas

A6: Right subcostal anterior Axillary line and  transthoracic

Liver, GB, Diaphragm

A7: Left subcostal anterior Axillary line and  transthoracic

Spleen, Diaphragm

A1

A2

A3

A4

A5

A6

A7

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Transducer Type & Orientation

Curvilinear transducer, 2 \- 5 MHz or a phased array transducer

Transducer marker pointing cephalad (for sagittal plane) or towards the patient's right (for transverse plane)

Screen marker on the left side of the screen

Depth about 15-20 cm

Patient Position

Supine

Curvilinear Transducer

Abdominal Exam

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Transducer Placement

A1 Subxiphoid view/Pericardial

A2  RUQ/Hepatorenal recess (Morrison's pouch)

A3  LUQ/Splenorenal recess

A4 Suprapubic/Pelvic

FAST exam results should only complement the clinical exam and other diagnostic modalities to reach a final decision

A1

A2

A4

A3

FAST Exam

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FAST/Sub-xiphoid view

Patient position

Supine

Transducer Placement

A1 Subxiphoid, pointing towards the left shoulder with the transducer marker pointing towards the patient's right

Structures to be identified

Heart, Liver, IVC

Sonographic Findings

Able to detect any significant pericardial effusion or Tamponade

Pericardium is hyperechoic

The pericardial space is anechoic or hypoechoic space between the heart and Pericardium

Normally, minimal pericardial fluid is present

False positive: pleural effusion and epicardial fat pad

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FAST/Sub-xiphoid view

RA

RV

Liver

Liver

RV

RA

LV

LA

Pericardium

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FAST/Sub-xiphoid view

Sonographic Findings (cont.)

Acute minimal fluid accumulations can lead to hemodynamic compromise

Assess the general cardiac function

Evaluate

RV function

RA collapse (in the case of Tamponade)

IVC diameter and respiratory variation to determine the effect of the pericardial effusion on the cardiac function (Discussed later in the chapter)

RV

RA

LV

LA

Pericardial Effusion (Arrows)

Pericardial Effusion with RA and RV Collapse

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FAST/RUQ/Hepatorenal Recess (Morrison's View)

Patient position

Supine

Trendelenburg position may give a better view of the RUQ structures

Transducer Placement

A2 About mid axillary line, 7th intercostal space to the right flank area

Marker cephalad

A2 CCW rotation and oblique positioning will help eliminate the rib shadows

Angle of the transducer can be moved more cephalad to examine the diaphragm, lungs and pleura

A2

A2 with oblique angle

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Structures to be identified

Liver

Lung, Pleura and Diaphragm

Kidney

Morrison's Pouch

Sonographic Findings

Hepatorenal recess (Morrison's Pouch)Found more posteriorly

Sliding the transducer downward will expose the lower edge of the liver where free fluid tends to accumulate

Sliding the transducer upward will expose the right diaphragm, pleural space and lungs

FAST/RUQ/Hepatorenal Recess (Morrison's View)

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FAST/RUQ/Hepatorenal Recess(Morrison's View)

Liver

Liver

Rib Shadow

Morrison's Pouch

Lung

Lung

Diaphragm

Kidney

Kidney

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FAST/RUQ/Hepatorenal Recess(Morrison's View)

Sonographic Findings (cont.)

The RUQ is the most common location to identify intra-abdominal free fluid or blood

Anechoic or hypoechoic space between the liver and kidney indicates free fluid, which also tends to accumulate in the subdia-phragmatic region or near the inferior pole of the kidney

Measure the width of the anechoic stripe in Morrison's pouch

Width in cm= Abdominal fluid in Liters

Free Fluid

Liver

Kidney

Liver

Lung

Diaphragm

Free fluid above the diaphragm

Free fluid below the diaphragm

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FAST/LUQ/Perisplenic

Patient position

Supine

Transducer Placement

A3 About the mid – posterior axillary line, 7th intercostal space \- left flank area

Marker cephalad

Oblique Position with CW rotation can help eliminate the rib shadows

A3

A3/Oblique

Structures to be Identified

Spleen, Kidney, Lung, Diaphragm and Pleura. Splenore-nal Recess

Sonographic Findings

Locate the splenorenal recess

Sliding the transducer downward will expose the lower tip of the spleen where free fluid tends to accumulate

Sliding the transducer upward will expose the left diaphragm and pleural space

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FAST/LUQ/Perisplenic

Kidney

Spleen

Spleen

Splenorenal recess

Lung

Diaphragm

Kidney

Rib Shadow

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FAST/LUQ/Perisplenic

Sonographic Findings (cont.)

Fluid can collect between the diaphragm and the spleen in the left upper quadrant.

Fluid will present as hypoechoic or anechoic strip

Measure the width of the anechoic stripe

Width in cm= Abdominal fluid in Liters

Hemothorax will present as a hypoechoic strip above the diaphragm

Spleen

Spleen

Kidney

Kidney

Free Fluid

Free Fluid

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FAST/Suprapubic

Structures to be identified

Bladder, Uterus or Prostate (as applicable), Cul De Sac and Retrovesical space

Sonographic Findings

Better to perform the US on a full bladder

Obtain a long and short axis views

Accumulated free fluid will be found as a hypoechoic strip in the cul de sac or retrovesicular space on either side of the bladder

A4/Short Axis

A4/Long Axis

Patient position

Supine

Transducer Placement

A4 Above pubis angled inferiorly

Obtain both the transverse and longitudinal views

Transverse View: marker pointing towards the patient's right

Longitudinal view: marker pointing cephalad

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FAST/Suprapubic

Retrovesicular pouch site

Bladder/Short Axis

Bladder/Short Axis

Bladder/Long Axis

Bladder/Long Axis

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FAST/Suprapubic

Sonographic Findings (cont.)

Less than 20 ml of fluid is considered normal in an adult.

Bladder volume measurement can be estimated:

Height X Width X Depth X 0.5

By measuring the long and short axis, the ultrasound software will estimate the volume

Normal Measurements

Long axis: 10-12 cm, Short axis: 5 cm

Cul De Sac Fluid

Uterus

Bladder

Cul De Sac Fluid

Retrovesical Fluid

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Extended FAST (E-FAST) Examination

Extended FAST

Lungs & Pleural interface

To detect the presence of pneumothorax or pleural effusion

IVC

To evaluate the fluid status and guide resuscitation efforts

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E-FAST/Lung

Extended FAST (cont.)

Patient position

Supine

Structures to be identified

Lungs, Diaphragm, Pleural interface, Ribs, Liver & Spleen

L1

L2

L3

L4

Transducer Type & Placement

Phased array or Curvilinear. Sometimes a linear transducer is used to examine the pleural interface closely.

Transducer marker pointing cephalad. Depth about 15-20 cm. The exam should be performed bilaterally

L1= Upper anterior chest wall

L2= Lower anterior chest wall

L3= Upper lateral chest wall

L4= Lower lateral chest wall

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E-FAST/Lung

Sonographic Findings

First, identify the lung, the diaphragm and the liver interface

Sliding the transducer downward in L4 can give a good view of the lungs and diaphragm

Look for normal and abnormal lung signs

Diaphragm

Lung ultrasound using Phased Array Transducer

Liver

Lung

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E-FAST/Lung

Sonographic Findings (cont.)

"Lung Sliding" Sign/Normal

Two echogenic pleural lines sliding with respiration and heart motion. Tend to be slightly hyperechoic. Best in L1 & L2

Color Flow (CF) can help identify lung sliding. Color will be present at the pleural interface with respiration

The presence of lung sliding rules out pneumothorax

Perform the US exam bilaterally in L1, L2, L3 and L4

Pleural Line

Rib

Rib

Lung

CF with Pleural movement

Pleural and lung ultrasound using Linear Transducer

Chest Wall

Lung sliding

No Lung sliding

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E-FAST/Lung

Sonographic Findings (cont.)

Seashore Sign (sand on the beach)/Normal

Start with the B Mode and identify the lung sliding

Switch to M-Mode and place the cursor on the pleural line

The soft tissue and the pleural structures will appear as horizontal lines.

The presence of the seashore sign rules out pneumothorax

Seashore Sign

Sea

Shore/Sand

Pleural Line

Stratosphere Sign/No Sea Shore

Pneumothorax

No  "Lung Sliding" Sign

Air will prevent the visceral pleura from being visualized, and the sliding motion will not be seen

No color will be present at the pleural interface when CF is applied

M-Mode

Stratosphere Sign/sand on the beach is not seen.

Perform the US exam bilaterally and in all lung areas

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E-FAST/Lung

Sonographic Findings (cont.)

Pleural Effusion

Best detected in L4 area in a supine patient

Anechoic space separating the parietal and visceral pleura

Note the lung movement with respiration (Jelly Fish Sign)

Liver

Lung

Diaphragm

Chest Wall

InferiorLung Pole

Pleural fluid thickness

Fluid Volume

Measure the fluid depth at the lung base or the level of the 5th intercostal space

Measurement starts approximately 3 cm from the inferior pole of the lung to the chest wall

> 5 cm fluid thickness indicate pleural effusion > 500 ml

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CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

113

E-FAST/Inferior Vena Cava (IVC)

E-FAST (cont.)

Patient position

Supine

Transducer

Curvilinear 2-5 MHz or Phased Array 2.5-5 MHz

Transducer Position

A1, A5

Marker Cephalad

Structures to be identified

IVC, Right Atrium, Liver, Hepatic veins and the Aorta

Sonographic findings

Start from A1 or A5 position and slide the transducer towards the patient's right

Identify the IVC, right atrium and the liver

Make sure to differentiate the IVC from the Aorta, which has thicker walls, gives the SMA and celiac branches and is pulsatile

A1/A5

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

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MSK & DVT

114

E-FAST Exam/IVC

Liver

RA

IVC

A

O

Liver

RA

Hepatic Vein

Diaphragm

IVC

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

115

E-FAST Exam/IVC

Sonographic Findings (cont.)

To evaluate the volume status

The IVC diameter changes during the respiratory cycle, smaller during inspiration, larger during expiration. In mechanically ventilated patients, this relationship is reversed

In the case of RVF/ RV infarct, massive PE, TR or cardiac Tamponade, there will be a distended IVC, and no variation with respiration (IVC Plethora)

During spontaneous breathing, the normal IVC diameter is 1.5-2.5 cm during expiration, just distal to the hepatic vein

Small IVC diameter and > 50% change during respiration usually indicate hypovolemia

Less than 20% change during respiration, the patient probably will not respond to fluid challenge

Spontaneous Breathing/Expiration

Spontaneous Breathing/Inspiration

Liver

IVC Collapse

Hepatic Vein

IVC diameter measurement

IVC collapse

IVC normal variation

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

116

E-FAST/IVC

Inspiratory phase

Expiratory phase

Spontaneous breathing

By using the M Mode, the IVC diameter measurement is more accurate

IVC diameter change during the respiratory cycle is reversed in mechanically ventilated patients(i.e. smaller in expiration and larger during inspiration)

Sometimes in quiet respiration, the IVC may not change in diameter. A "sniff test" can help observe the change

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

117

Gallbladder (GB) & Common Bile Duct (CBD)

Indications

Right upper quadrant or epigastric pain

Suspicion of cholecystitis, cholangitis

Patient Position

Supine

Deep breath can help push the GB down

Left lateral decubitus helpspush the gallbladder down

The GB is not a fixed organ and its position can vary

A6/Long Axis GB

A6/Short Axis GB

Transducer type & Placement

Curvilinear 2-5 MHz or Phased Array 2.5-5 MHz

A6

Long Axis

Marker pointing cephalad

Short Axis

Marker pointing towards the patient's right

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

118

GB & CBD

Structures to be identified

GB, Liver, CBD, Portal Vein, Hepatic artery and the IVC

Portal Triad (portal vein, hepatic artery and bile duct)

Sonographic Findings

The GB is generally found between the nipple line and anterior axillary line

Scan the inferior edge of the liver, medial to the kidney, and lateral to the IVC

Kidney

I

V

C

GB

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

119

GB & CBD

Kidney

Liver

GB

Pancreas

Liver

Anterior Wall of GB

Main Lobar fissure

Portal Vein

GB/Long Axis View

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

120

GB & CBD

Sonographic Findings (cont.)

Long Axis/GB

Transduceer Placement

Start with the transducer at A6 with the marker cephalad. May need to go towards the right axilla (transhepatic)

Scan the entire GB from the neck to the fundus by panning the transducer

The main lobar fissure connects the Portal vein to the bladder neck

Adding CF will help identify blood vessels. GB has no flow

Note the presence of any sludge or stones

GB

Portal Vein

Main lobar fissure

A6/Long Axis GB

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

121

GB & CBD

Sonographic findings (cont.)

Short Axis/GB

Transducer Placement

A6 From the Long Axis view rotate the transducer CCW so the marker is pointed towards the patient's right or Right Axilla

In many instances the position of the transducer may vary with the anatomy

Tilt the transducer from cephalad to caudal orientation to visualize the fundus of the gallbladder to the neck toward the portal triad

Liver

GB

Diaphragm

Lung

GB/Short Axis View

A6/Short Axis GB

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

122

Sonographic Findings (cont.)

Anterior wall thickness measurement

From the middle of the anterior wall

Inner to outer surface measurement

Normal <3 mm

GB & CBD

GB/Short Axis Anterior Wall Measurement

GB/Long Axis Anterior Wall measurement

+

+

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

123

Sonographic Findings (cont.)

Cholecystitis/Gall Stones

Thickened anterior wall > 4 mm

Measurement is taken (in a long and short axis) from the outer to the inner surface.

Presence of pericholecystic fluid

Sonographic Murphy's sign

Pushing on the GB while in view by US will produce pain

Note the presence of any stones or sludge. The stones are hyperechoic and have acoustic shadowing which is absent with sludge

GB short Axis

Acoustic Shadow

Acoustic Shadow

Gall Stones

Gall Stones

Liver

GB Long Axis

GB & CBD

Cholecystitis

GB stones

GB stones

GB short Axis

GB Sludge

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

124

CHD & CBD

Transducer Placement

A6

Sonographic Findings

More difficult to detect

From the long axis view of the GB, follow the anterior wall medially and try to find the connection to the CHD

Locate the portal vein at the neck of the gallbladder. The CHD is part of the portal triad along with the portal vein and the hepatic artery.

Rotate the transducer 90º CCW into a longitudinal axis view of the portal vein

The CBD is found anterior and parallel to the portal vein. Sliding the transducer medially can help identify the CBD.

A6/Marker to the right

A6/Marker cephalad

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

125

CHD & CBD

Liver

GB

CHD

Portal vein

Sonographic Findings (cont.)

Long Axis/GB

CF can help identify the blood vessels. CBD has no flow

Normal CBD Diameter is less than 7 mm

Measurement is between the interior walls

Normal size increases with age and in patients with cholecystectomy

CBD >10 mm is usually pathologic

IVC

Portal Vein

CBD Measurement

CHD

IVC

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

126

Pancreas

Patient Position

Supine

Transducer Type and Placement

Curvilinear 2-5 MHz

Depth 12-15 cm

Long Axis

A5, Transducer marker towards the patient's right

Short Axis

A5, Transducer marker cephalad

A5/Pancreas Long axis (Transverse)

A5/Pancreas Short axis (Sagittal)

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

127

Pancreas

Structures to be identified

Pancreas, Aorta, IVC, Splenic Vein, SMA, Spine

Sonographic Findings

The pancreas is found anterior to the splenic vein with homogenous texture

The pancreatic head is anterior to the IVC and the body is parallel to the splenic vein

The splenic vein is anterior to the SMA and the renal vein is posterior

Pancreatic duct can be visualized horizontally within the gland

Pancreas

Liver

I

V

C

SMA

Splenic Vein

Renal Vein

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

128

Pancreas

Splenic Vein

Pancreas Tail

SMA

Stomach

Liver

IVC

AO

Spine

Pancreas Body

Pancreas Head

Normal Pancreas

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

129

Pancreas

Enlarged Pancreas with a heterogeneous necrotizing pattern

Pseudo cyst

Pancreatitis/Enlarged Pancreas with edema

Sonographic Findings (cont.)

Pancreatitis

The pancreas is larger with a distorted heterogeneous pattern. Decrease echogenicity means interstitial edema

Maximal normal cross section measurements are, head= 2.6 cm and body 2.2 cm

Necrotic area can be identified usually as a hypo-echoic area

Fluid collection may be found within or outside the pancreas

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

130

Renal

Indications

Evaluation of acute flank or abdominal pain

To rule out bilateral obstruction in acute renal failure

To evaluate for the presence of stones

To evaluate the bladder

Transducer type and Placement

Curvilinear 2-5 MHz or Phased Array 2.5-5 MHz

A2, A3

Long Axis: Marker pointing cephalad towards the posterior axilla.

Short Axis: 90° rotation

Patient Position

Supine. Right and left lateral decubitus for left and right kidneys respectively, when possible a deep breath helps the kidney move below the ribs

Structures to be identified

Kidneys

Liver, Spleen & Diaphragm

Morrison's Pouch and splenorenal recess

Kidney border, Calyces and renal pelvis

A3

A3/Long Axis

A3/Short Axis

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

131

Transducer Placement/Right kidney

Long Axis

A2, Right mid axillary line from the 7th intercostal space to the right flank with the marker pointing cephalad

Adjust the transducer according to the kidney's long axis (turn CCW) towards the posterior axilla

Right Kidney Long Axis

Morrison's Pouch

Liver

Kidney

Rib Shadow

Diaphragm

Kidney

Liver

Renal

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

132

Transducer Placement/left kidney

Long Axis

A3, Left mid axillary line from the 7th intercostal space to the left flank with the marker pointing cephalad

Adjust the transducer according to the kidney's long axis (turn CW)

More difficult to obtain images compared to the right kidney

Left Kidney Long Axis

Spleno-renal recess

Spleen

Kidney

Rib Shadow

Diaphragm

Kidney

Spleen

Renal

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

133

Transducer Placement

Short Axis

Rotate the transducer 90°counter CCW for the right kidney and CW for the left. from the long axis position. Tilt the transducer up and down

Sonographic findings

The outer hypoechoic layer consists of the cortex and medulla

The inner layer which is comparatively more echoic consists of the calyces, arteries, veins and the renal pelvis

Kidney Short Axis

Kidney border

Rib Shadow

Rental Pelvis

Calyces

Kidney

Renal

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

134

Sonographic Findings (cont.)

Hydronephrosis

Divided into Grades 1, 2 and 3 depending on the calyceal separation and involvement of the renal pelvis

Normal kidney measurements are length 9-12 cm, and width 4-6 cm

Renal stones appear as hyperechoic structure with shadowing (when larger than 3 mm)

Note any free fluid accumulation in Morrison's pouch or the spleno-renal recess

Hydronephrosis with Dilated Pelvis & Ureter

Dilated Ureter

Dilated Calyces

Dilated Pelvis

Hydronephrosis

Renal

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

135

Work Sheet

Patient Name:  _______________________

MRN: _______________________

Date:  _______________________

Time:  _______________________

History:  _______________________

Vitals: HR PB RR TEMP

US Performer:  _______________________

FAST Exam

Positive Intraperitoneal Fluid: Y N

Estimated Volume/Measured # cm:

Perihepatic: Y N

Perisplenic: Y N

Pelvic: Y N

Positive Subxiphoid view: Y N

Positive FAST Negative FAST

Extended FAST (E-FAST) Exam Lung Exam

Right Pleural Effusion: Y N

Left Pleural Effusion: Y N Pneumothorax Y N

Lung Sliding (right} Y N

Lung Sliding (left) Y N

IVC Diameter ______ cm

Respiratory change: Y N _____% change

Collapse > 50%: Y N

GB & CBD

Gallstones: Y N

Sonographic Murphy's Sign: Y N

Pericholecystic Fluid: Y N

GB Wall thickness ______ cm

Common Bile Duct Size ______ cm

Pancreas

Parenchymal Abnormality: Y N

Head Uncinate Process Body Tail

Peripancreatic Fluid: Y N

Pseudocyst: Y N

Renal

Kidney Measurement (Long Axis): Y N

Hydronephrosis: Y N

Renal Stones: Rt Lt Size ____

Ureter Obstruction: Y N

Impression and comments:

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

136

Evaluation of The Aorta

Victor Coba MD

Mark Favot MD

Contents

Patient position ................. 136

Transducer placement ........... 136

Segments ................. 139

Proximal ...... 139

Middle ...... 141

Distal ...... 142

Aortic Dissection ................. 143

Indications

Suspicion of abdominal aortic aneu-rysm (AAA) with

Abdominal pain

Age >50

Pulsatile mass

Hypotension

Back pain/Flank pain

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

137

Aorta

Patient Position

Supine

Transducer Type and Placement

Curvilinear or Phase Array. Depth 15-20 cm

A5 /see abdominal chapter for transducer placement posi-tions

Long Axis

Transducer marker cephalad

Short Axis

Transducer marker toward the patient's right

A5/Short axis

A5/Long axis

Structures to be identified

Aorta, IVC, Spine, Celiac trunk, SMA, Renal arteries, Iliac arteries, Liver, Pancreas

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

138

Aorta

Sonographic Findings

The Aorta has a thicker wall compared to the IVC and is more circular and pulsatile

CF help identify the aorta and IVC

Normal maximal diameter is < 2 cm using anterior-posterior (AP) measurement (outer wall to outer wall)

The diameter usually tapers down from proximal to distal. Measure the diameter in long and short axis in all segments

SMA

AO

IVC

Celiac Trunk

Splenic Vein

Renal Vein

Dilated aorta is >2 cm

Aneurysm is > 3 cm

Note the presence of a flap if aortic dissection is suspected

US is not sensitive in the diagnosis of rupture

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

139

Sonographic Findings (cont.)/Aortic sweep

Proximal segment

Just below the Xiphoid. Contains the celiac trunk and the superior mesenteric artery (SMA)

long axis

The transducer marker cephalad

Note the celiac trunk and the SMA

Aneurysms in this segment are not common

Aorta/Proximal Segment Long Axis

SMA

Celiac Trunk

Liver

AO

Aorta/Proximal Segment Long Axis

Aorta

Celiac Trunk

SMA

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

140

Sonographic findings (cont.)/Aortic sweep

Proximal segment

Short Axis

Rotating the transducer 90° CCW

Note the celiac trunk

Sliding the transducer downward will show the origin of the SMA (in transverse view)

Measure the maximal A-P diameter, superior to the origin of the SMA

Aorta/Proximal Segment Short Axis

Aorta/Proximal Segment Short Axis

Celiac Trunk

Hepatic Artery

Splenic Artery

Spine

Spine

AO

AO

IVC

SMA

IVC

Aorta/Proximal Segment Short Axis

Aorta

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

141

Aorta

Aorta/middle segment

Sonographic findings (cont.)/Aortic sweep

Middle segment

Distal to the SMA origin

Transducer pointing towards the spine with the marker towards the patient's right, slide transducer downward

No branches recognized

Measure the AP diameter in long and short axis

The renal arteries originate very close to the origin of the SMA

Aorta/Middle Segment CF

Spine

AO

AO

IVC

IVC

Aorta/Middle Segment

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

142

Aorta

Aorta/Level of Iliac bifurcation

Sonographic findings (cont.)/Aortic sweep

Distal Segment

Aorta bifurcating into the iliac arteries, at or just below the umbilicus

Continue same orientation (marker pointing towards patient's right), sliding the transducer downward

More than 90% of AAAs are infrarenal in the distal aorta.

Measure the largest A-P diameter in long and short axis

Bowel loops and gas may interfere with the view, and can be displaced by gentle pressure

Aorta distal segment/Iliac Arteries

Iliac Arteries

IVC

Spine

Aorta Diameter Measurement

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

143

Evaluation of Aorta

Left Parasternal long Axis View

Transducer position

Start location: C1

Sonographic Findings

Examine the aortic valve, root, ascending aorta and part of the descending aorta

Normal aortic root diameter measurement is < 3.4 cm

Examine for the presence of any dissection or moving flap

Use CF to help visualize the flow and false lumen

RV

Aortic Root

Aortic Root

LV withhypertrophy

LA

Descending Aorta with flap

Descending Aorta

Parasternal Long Axis View/Dilated Aortic Root

Parasternal long axis view/ Descending Aortic Dissection

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

144

Evaluation of the Aorta

False Lumen

Aorta/Long Axis with Flap

Aortic dissection color

False Lumen

Aorta/Short Axis with Flap CF

Flap

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

145

Worksheet

Patient Name:  _______________________

MRN: _______________________

Date:  _______________________

Ultrasound Performer:  _______________________

History

AP measurements (short axis)

Proximal ______ cm

Mid ______ cm

Distal ______ cm

AP measurements (long axis)

Proximal ______ cm

Mid ______ cm

Distal ______ cm

Abdominal Aortic Aneurysm Y N

Infrarenal Suprarenal Thoracoabdominal

Common Iliacs Normal Aneurysm

Free Intraperitoneal Fluid Y N

Impression and comments:

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

146

Vascular Access

Keith Killu M.D.

Contents

Equipment  ................ 147

Patient Position  ................ 149

Preprocedure  .................151

Differentiate between artery, vein,

nerves ..................154

Localizing the Vessel  ................ 157

Long vs. Short Axis  ................ 158

Insertion Method  ................ 159

Internal Jugular Vein ................ 160

Subclavian Vein ..................165Femoral Vein & Artery .............. 169

Radial Artery ................ 172

Axillary Artery ................ 174

Peripherally Inserted Central Catheter (PICC) ............. 177

Peripheral Veins ................ 179

Advantages of Vascular US

Identify anatomical variations

Decrease procedure failure rate

Decrease procedure related complications

Decrease procedure time

Decrease the number of attempts

Patient comfort

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

147

Equipment

Equipment

The transducer used in most vascular access procedures is the linear type 7-13 MHz

The higher frequency is for better resolution

Sterile sheath, gel and rubber bands

Needle guide adaptors to guide the approach if desired

Linear Transducer

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

148

Sterile kit usually includes

Sterile sheath, gel, Rubber bands

Needle guides with different angle paths for different depths

Place the gel inside the sterile sheath. Place the sterile sheath on the transducer head and roll the sheath along the entire transducer cable

Place the rubber bands, one near the face and the other near the base of the transducer

Place sterile gel outside the sheath along the transducer head

Use a Needle Guide if desired

The needle guide is to be attached to the transducer head

The needle tip is placed through the guide

Advantages:

Predictable path, depth and angle of the needle

Less hand eye coordination needed

Disadvantages:

Angle is fixed

Deeper structures are hard to reach

Equipment

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

149

Patient Position

Patient Position

Position the patient in the optimal position depending on the location of the vessel accessed and the desired anatomical ap-proach (e.g. Internal Jugular Vein access, place the patient in a Trendelenburg position)

The ultrasound machine placed where the operator can easily visualize the screen

Perform a scan of the vessel before starting the sterilization process to identify the largest diameter, relation to other vessels and the presence or absence of a thrombus

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

150

The Screen marker is placed to the left of the screen. The Transducer marker pointing to the right side of the patient. Make sure the transducer marker side corresponds to the left side of the screen by touching the transducer footprint near the transducer marker

Always maintain universal sterile precautions

Transducer held in the non dominant hand and the needle in the dominant hand

Transducer should be perpendicular and in complete contact with the skin

Transducer Position & Orientation

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

151

Pre-Procedure

Screen marker to the left

Structures on the left of the screen are on the right side of the patient

Depth is usually 3-4 cm

Orient yourself

Obtain transverse and longitudinal views

By placing the vessel in the center of the screen, the transducer will be directly above it

Note the depth of the vessel (The right side of the screen will display the depth in centimeters)

IJV Transverse View

IJV Longitudinal View

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

152

Using color flow (CF), orientation

When applying Color Flow, the top of the box on the right or left of the screen will indicate the color of the flow towards the trans-ducer, and the bottom of the box indicates the color of the flow away from the transducer. In this example the Flow towards the transducer is red, and the flow away from the transducer is blue

Flow towards the transducer

Flow away from the transducer

Pre-Procedure

PREFACE

AORTA

OB/GYN

KNOBOLOGY

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Dynamic (real time )

Sonographic localization and image guided cannulation

More precise

More difficult to maintain sterility

Need hand-eye coordination

One or two operators

The preferred method

Static (prescan. The procedure is done separately)

Ultrasonic localization of landmarks

Cannulation is separate

Easier to maintain sterility

Less technical demand

Less equipment needed

Dynamic vs Static Procedure

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Differentiate the Artery from the Vein

The vein is usually

Oval in shape, thin walled

Compressible with gentle pressure

Non pulsatile

Valsalva maneuver can increase the neck vein size

The artery is usually

Circular in shape, thicker wall

Non compressible, pulsatile

Use CF to demonstrate blood flow direction and pulsation

Color Flow

Artery

Vein

Vein

Artery

Artery

Vein & Artery Transverse View/No Compression

Vein & Artery Transverse View/With Compression

Vein

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Pulse Wave (PW) Doppler generates audible signals and wave forms to help differentiate an artery from a vein

Differentiate the artery from the VeinPulse Wave Doppler (PW)

PW Doppler/ Venous

PW Doppler/ Arterial

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Use blood vessels and bony landmarks to identify adjacent neural structures

Nerves are

generally more difficult to identify. Oval or round in shape, non compressible and has no color flow

More echogenic than blood vessels

Echogenicity depends on the transducer angle and the nerve size (larger nerves are more echogenic)

Note the hypo-echoic Fascicles that look like grapes forming the nerve bundle sur-rounded by hyper-echoic connective tissue sheath

Median nerve near the wrist or in the forearm is a good start and reference for learning

Mid Arm Structures

Brachial Vein

Brachial Artery

Ulnar Nerve

Muscle

Differentiate blood Vessels from Nerves

Median Nerve/Short axis/Forearm

Median Nerve/Long axis/Forearm

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Procedure/Localizing the Vessel

Place the transducer perpendicular to the skin

To prevent transducer sliding, place part of the hand holding the transducer on the skin

View the vessel in a long and short axis view

Note the depth of the vessel

Long Axis

IJV

IJV

CCA

CCA

Short Axis

Vessel Depth 1 cm

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Procedure/Long vs. Short Axis

Long Axis view

Provides a better needle slope positioning and can monitor the needle throughout the procedure

Tip of the needle is easier to localize

More difficult for hand eye coordination

Short Axis view

Preferred for dynamic line placement

Allows for a better lateral positioning of the needle

Tip of the needle is harder to localize

Easier hand eye coordination

Long axis/Needle tip

Short axis/Needle tip

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Procedure/Needle Insertion method

Apply  local anesthetic

Place the needle 1-2 cm behind the transducer with the bevel facing upwards

Angle the needle at about 45°-60° from the skin

Sometimes the angle is steeper when trying to avoid another structure

Perform a mock poke and notice the ring down artifact to locate the needle

Anatomical landmark approach is not always applied since you are in full view of the vessel

Needle should be moved in short slow controlled fashion

Locate the tip of the needle (which may appear as an echo-genic dot)

Place the bevel towards the transducer beam which will produce more echo return and better visualization of the needle tip

If the needle can't be visualized, readjust the transducer, gently wiggle the needle or change its angle

Ringdown artifact

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Patient Position

Place the patient in a supine position for pre procedure scanning, then in a trendelenburg position for the procedure

Transducer Type & Placement

Linear Transducer 7-13 MHz

Short Axis

Transducer marker pointing towards the patient's left (One of the few instances where the marker points towards the patient's left. This is done because the position of the operator is at the head of the bed

Long Axis

Transducer marker pointing cephalad

Screen marker to the left of the screen

Depth 2-4 cm

Internal Jugular Vein (IJV)

External JV

IJV

CCA

Marker

IJV/Short Axis

IJV/Long Axis

Marker

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IJV/Long and Short Axis

IJV

CCA

Thyroid

Right IJV Short Axis

IJV

CCA

IJV Long Axis

Marker

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Apply CF to help differentiate the artery from the vein

IJV

IJV

CCA

Pulse wave (PW) Doppler generates audible signals and waveforms to help differentiate the artery from the vein

IJV PW Doppler

CCA PW Doppler

CCA

Continue the line placement with the standard Seldinger technique

IJV/CF, PW

IJV/Short

IJV/Long

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Post procedure: It is possible sometimes to locate the catheter or it's tip in the superior vena cava (SVC)

Transducer Placement

Place the transducer between the two heads or lateral to the sternocleidomastoid muscle with the ultrasound beam  directed towards the back of the sternum. Depth usually about 8 cm

IJV

SVC

Catheter

Subclavian Vein

Rt. Innominate V.

Lt. Innominate V.

Catheter in the SVC

SCV

Rt. Inn

S

V

C

Lt. Inn

IJV

IJV/Catheter Position

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IJV/Post procedure

Check for pneumothorax post procedure

Apply the transducer to the anterior chest wall in the 2nd-8th intercostal spaces mid clavicular line (L1,L2), and 4th-10th spaces (L3,L4) anterior and mid axillary lines

"Lung Sliding" Sign/B-Mode

Two echogenic pleural lines sliding with respiration

Seashore Sign/M-Mode

Presence of lung sliding and the seashore sign usually rules out the presence of pneumothorax

Refer to the lung chapter for more details

B Mode/Lung Sliding

Pleural Line

Chest Wall

Lung

Sea

Shore

M Mode/Seashore Sign

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Subclavian vein

Patient Position

Place the patient in a supine position for pre procedure scanning, then in a trendelenburg position for the procedure

Transducer Type & Position

Linear Transducer 7-13 MHz

Place the transducer perpendicular to the skin, at the lateral aspect of the clavicle outside the thoracic cage

Short Axis View

Transducer marker pointing cephalad

Long axis View

Transducer marker towards the patient's right

Subclavian/Short Axis

Marker

Marker

Subclavian/Long Axis

Subclavian Vein

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Subclavian vein

Clavicle

Subclavian Vein

Subclavian Artery

Pectoralis Major Muscle

Subclavian Vein/Short Axis

Subclavian Vein/Short Axis

Subclavian Vein/Long Axis

SCV

Subclavian Vein/Long Axis

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Subclavian vein

Procedure

The subclavian vein is somewhat difficult to scan

Better to prescan and locate the vessel, then do the procedure separately

Apply CF, PW Doppler and compression to help differentiate the artery from the vein

Obtain a long and a short axis views

Once the vessel is identified, Continue line placement with the standard Seldinger technique

SC Vein/Short Axis

SC Artery

First Rib

Clavicle

Brachial Plexus

SC Vein

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Subclavian vein /Supraclavicular approach

Patient Position

Place the patient in a supine position for scanning, then in a Trendelenburg position with preferably a small towel between the shoulder blades for the procedure

Transducer Type & Placement

Linear Transducer

Place the transducer perpendicular to the skin, at the medial aspect of the clavicle outside the thoracic cage

Short Axis View

Transducer marker pointing cephalad

Long Axis View

Transducer marker towards the patient's right

Clavicle

Subclavian Vein

Subclavian Vein/Supraclavicular approach

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Femoral Vein & Artery

Patient Position

Place the patient in supine position

Transducer Type & Placement

Linear transducer

Transducer placed just inferior to the inguinal ligament and the marker towards the patient's right

Screen marker to the left

Depth 4-6 cm depending on the body habitus

Short Axis

Transducer marker towards the patient's right

Long Axis

Transducer marker cephalad

FV

GSV

SFV

DFV

CFA

PFA

SFA

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Femoral Vein & Artery

Femoral Vein CF/Long Axis

Femoral Artery & Vein/Long Axis

PFA

FV

FA

Femoral Artery & Vein/Short Axis

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Femoral Vein & Artery

Procedure

Vein is medial to the artery

Obtain a long and short axis view

Using CF, PW Doppler and compression can help differentiate between the artery and the vein

Once the vessel is identified, Continue line placement following the standard Seldinger technique

CF/Femoral Artery & Vein

FA

FV

PW/Femoral Artery

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Radial Artery

Patient Position

Place the forearm on a solid surface with the wrist slightly extended

Transducer Type & Placement

Linear transducer

Transducer marker towards the patient's right

Depth 2-3 cm

Prescan and identify the radial artery

Radial Artery

Marker

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Radial Artery

Obtain short and long axis for better orientation specially with narrow vessels

Once the vessel is identified, continue line placement following the standard technique

Radial Artery Short Axis CF/Vessel Depth< 1 cm

Radial Artery Long Axis

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Axillary Artery

Patient Position

Place the patient in supine position

Head turned 30° to the opposite side

Arm abducted 90° and externally rotated with the elbow flexed

Transducer Type & Placement

Linear transducer

Place the transducer close to the axilla to access the 2nd or 3rd part of the axillary artery.

Transducer marker pointing upward

Depth 2-3 cm

Axillary Vein

Axillary Artery

Brachial Artery

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Axillary Artery

Procedure

Access will mostly be in the 2nd & 3rd parts of the axillary artery

Note the pulsating axillary artery, the compressible axillary vein, nerve bundle with the ulnar nerve (infe-rior & medial) and median nerve (superior & lateral)

Apply adequate local anesthesia

Place the needle behind the transducer, puncture the skin and follow the needle's path

Continue the procedure following the standard technique

Axillary Artery Transducer Placement

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Axillary Artery

Axillary Artery

Median Nerve

Muscle

Axillary Vein

Axillary Artery/2nd part

Axillary Artery

Median Nerve

Ulnar Nerve

Axillary Vein

Axillary Artery/3rd part

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Peripherally Inserted Central Catheter (PICC)

Patient Position

Supine

The arm should be abducted 90° and externally rotated with the elbow flexed

Place a tourniquet as close to the axilla as possible

Transducer Type & Placement

Linear transducer

Transducer placed in the short axis of the arm with the marker pointing upwards

Depth 2-3 cm

Brachial Artery

Basilic Vein

Cephalic Vein

Brachial Vein

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PICC

Procedure

Map the entire arm to find the best position for insertion

Basilic (first choice), Cephalic vein, Deep brachial veins

Identify the Arteries

Measure the distance from the insertion site to the acromion process then add 20 cm (this will represent the length of the catheter to be inserted)

Continue line placement following the standard technique

Verify the catheter position in the SVC by fluoroscopy, CXR or ultrasound

Basilic Vein

Biceps Muscle

Brachial Artery

Brachial Vein

Median Nerve

Mid Arm/PICC Placement

PICC placement Transducer Position

Color

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Peripheral Veins

Peripheral vein access using a cannula can be made easy by using ultrasound to locate the vessel

Transducer Type & Placement

Linear transducer

Placed directly over the vein site with the marker towards the patient's right

Depth 1-2 cm

Can perform the procedure in the dynamic or static method

Peripheral Vein

Peripheral Vein Transducer Placement

Marker

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Most veins can be accessed using ultrasound guidance

Locating the vein and determining its depth will help avoid multiple attempts

Using CF and PW Doppler can help differentiate an artery from a vein

Peripheral Vein/PW Doppler

CF Identifying the Superficial Vein and Deeper Structures

Superficial vein/

Note the depth

Radial artery

Radial Vein

Peripheral Veins

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Lung Exam

Scott Dulchavsky, MD, PhDMichael Mendez MD, RDCS

Contents

Lung zones ................. 182

Transducer placement ........... 183

Lung signs ................. 185

Lung & Pleura exam profiles  190

Pleural effusion ................. 191

Pneumothorax ................. 195

Acute interstitial syndrome ................ 198

Diaphragm ................. 201

Worksheet...............................203

Indications

To evaluate patients with respiratory compromise or failure

Pulmonary edema, ARDS, alveolar interstitial disease

Pleural effusion

Pneumothorax

Consolidation

Diaphragmatic dysfunction

Part of the Extended-FAST exam

Procedure guidance

Evaluation of the patient's fluid status

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Lung zones

Lung Examination Zones

Always examine both lungs. The transducer should be perpendicular to the chest wall

Lung Zone 1/L1

Upper anterior chest wall

Lung Zone 2/L2

Lower anterior chest wall

Lung Zone 3/L3

Upper Lateral chest wall, between the anterior & posterior axillary lines

Lung Zone 4/L4

Lower Lateral chest wall, between the anterior & posterior axillary lines

Lung Zone 5/L5

Posterior Chest wall

Different references will give different lung zones. We found these to be the easiest, and most practical to cover most of the clinical applications in the ICU

L1

L2

L3

L4

L5

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Structures to be identified

Chest Wall, Pleura, Lung parenchyma, Diaphragm, Liver & Spleen

Transducer Placement/L1

Transducer Placement/L1

Rib

Chest Wall

Pleural Line

Lung Parenchyma

Patient Position

Supine

Transducer type

Curvilinear, Microconvex or Phased Array

For deeper structures

Linear

For superficial structures (pleura)

Ultrasound screen marker to the Left of the screen, and the depth should be about 10-15 cm

with a curvilinear transducer and 2-4 cm with a linear transducer

Patient Position &Transducer placement

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Transducer placement

Transducer Placement/L4 Long Axis

Liver

Lung

Kidney

Lung

Liver

Kidney

Transducer Placement

Long axis

Place the transducer footprint perpendicular to the chest wall in all zones with the marker pointing cephalad

Short axis

Turn the transducer 90° CCW

Transducer Placement/L4

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Sonographic Findings/Lung Signs

Bat Sign/Normal

Transducer at L1, with the marker Cephalad

The sign is formed by the shadows of two ribs and the pleural line (looks like a bat flying towards you)

Try to obtain this image initially, to avoid artifacts

Pleural Line

Rib

Rib

Chest Wall

Lung Signs

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Sonographic Findings/Lung Signs (cont.)

Lung Sliding/Normal

Movement of pleura with breathing will generate the "lung sliding" sign

Represents the sliding of the visceral pleura against the parietal pleura

Using Color Flow (CF) can help identify the pleural line and its movement

Best seen near the lung bases

Can be absent in pneumothorax, atelectasis, pleurodesis, parietal emphysema or any cause that interrupts the normal pleural movement

Lung Sliding

Lung Parenchyma

Chest Wall

Pleural Line

Pleural Line/ CF

Lung Sliding

Rib Shadow

Rib Shadow

Lung Signs

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Sonographic Findings/Lung Signs

Lung Sliding (cont.)

Lung sliding can sometimes be better evaluated with the M Mode generating the "Sea Shore" sign

The presence of lung sliding and the sea shore sign, mostly rules out pneumothorax

Pleural Interface

Sea Shore Sign

Shore

Sea

Lung Signs

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Sonographic Findings/Lung Signs (cont.)

A Lines/Normal

Can be part of the normal lung signs. Represents normal artifact repetition(s) of the pleural line

Intervals between the A lines are equal to the distance between the skin and the original pleural line

When present without lung sliding, it may indicate the presence of pneumothorax

Pleural Line

A Line

A Line

Lung Signs

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Lung Signs

Sonographic Findings/Lung Signs (cont.)

Comet Tail Artifact/B Lines

Vertical lines, extending from the pleural line to the edge of the screen without fading

Synchronized with lung sliding

When present they will usually overshadow the A lines

Represents thickening interlobular septa and extravascular lung water as in alveolar interstitial disease (pulmonary edema, ARDS...)

Their presence mostly rules out pneumothorax

Pleural Line

Comet Tail Artifacts/B Lines (arrows)

Lung Signs

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Sonographic Findings/Lung Signs (cont.)

Z Lines

Represents artifacts

Originates from the pleural line, fades after few centimeters

Do not extend to the edge of the screen

Do not overshadow the A lines

Pleural Line

Comet Tail Artifacts/Z Lines (small arrows)

Lung and Pleural Profiles Summary

A Profile = designate anterior predominant A lines associated with lung sliding e.g., COPD, asthma, \+ DVT = PE

A' Profile = A profile with abolished lung sliding e.g., pneumothorax

B Profile = Bilateral anterior B lines with lung sliding, e.g., pulmonary edema

B' Profile = B profile with no lung sliding e.g., pneumonia. atelectasis

A/B Profile = B lines on one side, A lines on the other e.g., pneumonia

C Profile = anterior alveolar consolidation e.g., pneumonia, atelectasis

Lung Signs

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Pulmonary regions

Lung Zones L4, L5

Transducer Type & Placement

Phased Array or Curvilinear

The footprint is perpendicular to the skin with the marker pointing cephalad

Start at the lower edge of zone L4 and slide the transducer cephalad to detect the interface between the diaphragm and pleural space

Structures to be identified

Chest Wall, Diaphragm, Lung, Pleural effusion, Liver or spleen

Sonographic Findings

Anechoic space separating the parietal and visceral pleura. Note the lung movement with respiration (Jelly Fish Sign)

Pleural Fluid

Pleural Fluid

Chest Wall

Liver

Lung

Diaphragm

Pleural Effusion

Pleural Effusion

Transducer Placement/L4

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Sonographic Findings (cont.)

Note the Quad sign on 2D, the pleural effusion is delineated by the pleural line (upper border), lung line (lower border) and the two rib shadows

Note the Sinusoid sign on M Mode

Represents movement of the floating lung towards the chest wall with respiration

Specific for pleural effusion

Sinusoid Sign

Chest Wall

Pleural Fluid

Lung

Rib

Rib

Pleural effusion

Quad sign

Pleural Effusion

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Sonographic Findings (cont.)

Fluid Nature

Transudate

Completely anechoic

Exudate

Can be anechoic. Usually echoic with particles

Purulent Pleurisy

Echoic with the presence of septations

Not uncommonly a honey comb pattern

Anechoic Effusion

Pleural Effusion with

septations

Pleural Effusion

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Sonographic Findings (cont.)

Fluid Volume

Measure the fluid depth at the lung base or the level of the 5th intercostal space

Measurement starts 3 cm from the inferior pole of the lung to the chest wall

> 5 cm fluid thickness indicate pleural effusion of > 500 ml

Chest Wall

Inferior Lung Pole

Pleural fluid thickness

Pleural Effusion

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In a critically ill supine patient, air tends to accumulate in the anterior portion of the thorax

The diagnosis is made by detecting the absence of the lung tissue movement beneath the pleural line

Patient Position

Supine

Transducer

Linear 7-13 MHz, for pleural interface for best results

Transducer Placement

Perpendicular to the skin in Zones L1, L2, L3 & L4

Pneumothorax

Transducer Placement/L1

Transducer Placement/L1

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

196

Structures to be identified

Pleura, Lung and Ribs

Sonographic Findings

Lung Sliding is absent . 100% sensitivity

No lung sliding on B Mode

Seashore sign on M Mode is replaced by the Stratosphere sign (no sand, all sea)

Stratosphere Sign/All Sea

Sea

Sea

No Lung Sliding

B Mode

Pneumothorax

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

197

Sonographic Findings (cont.)

Lung Point

A localized transition point from intrapleural air (pneumothorax artifact) to the interparanchymal air is 100% specific for pneumothorax

The transition from the seashore sign to the stratosphere sign on the M Mode is called the Lung Point

Transducer Placement/L3

Lung Point Sign

Transition Point

Lung Point

Sea

Shore

Stratosphere

Lung Point

B Mode

Pneumothorax

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

198

Sonographic Findings

B Lines

Vertical lines extending from the pleural line to the edge of the screen without fading, separated by an average distance of 7 mm or less

To calculate the Comet Tail Score, count the number of the comet tails (B Lines) in lung zones L1, L2, L3 & L4 bilaterally

The higher the number, the more severe is the interstitial process

Has a 93% sensitivity and specificity in patients with pulmonary edema

Disappears after treatment of the underlying disorder

Absent in patients with COPD

Indications

Pulmonary edema, ARDS, Pneumonia/Interstitial disease

Patient Position

Supine

Transducer type & placement

Phased Array, Curvilinear or linear

Perpendicular to the skin in Zones L1, L2, L3 & L4

Acute Interstitial Syndrome

Pleural Line

Comet Tail Artifacts/B Lines (arrows)

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

199

Sonographic Findings

ARDS/Pneumonia

The lung tissue will resemble the hepatic parenchyma

B Lines may be present

In the case of associated pneumonia, Alveolar Consolidations with air bronchogram and possible Shred sign may be seen

In most ICU patients, the area involved will be L4

Alveolar Interstitial Disease

Pleural Effusion

Lung

Liver

Air bronchogram with Consolidations

Acute Interstitial Syndrome

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

200

Sonographic findings (cont.)

Pneumonia

Tissue like image arising from the pleural line

Air bronchogram (hyperechoic artifacts) with dynamic movement with respiration

Shred signs \- Shredded tissue like pattern bordered by the pleural line, lung line and a deep irregular border

Focal B Profile

Shred signs

Lung pulse

Air bronchogram

Lung

Rib

Rib

Acute Interstitial Syndrome

Shred Color

Sonographic findings (cont.)

Atelectasis

Lung sliding will be absent

Lung pulse (transmission of heartbeat to the pleural line)

No dynamic movement of the air bronchogram

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

201

Patient Position

Supine

Transducer

Phased Array or Curvilinear

Transducer Placement

L4, marker pointing cephalad

The interface between the diaphragm and lung at about 5th to 8th intercostal space mid-posterior axillary line. Examine both sides

Structures to be identified

Lung, Diaphragm, Liver or spleen

Diaphragm

Transducer Placement/L4

Transducer Placement/L4 Long Axis

Liver

Lung

Kidney

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

202

Sonographic Findings

Inspiratory amplitude in normal spontaneously breathing patient is usually >10mm-20mm

Diaphragmatic Dysfunction

Presence of pleural effusion does not usually affect this amplitude

Amplitude < 5 mm is pathological

There will be a diminished lung sliding and paradoxical movement

M-Mode can be used to detect and measure the diaphragmatic movement

Diaphragm Movement

Diaphragm movement during deep breathing/M-Mode

Lung

Liver

Rupture

Dysfunction

Normal

Diaphragm

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

203

Worksheet

Patient Name:  _______________________

MRN: _______________________

Date:  _______________________

Lung, Pleural & Diaphragm limited exam

Normal Y N

Pleural Effusion Y N

Rt. Y N Estimated Size....Lt. Y N Estimated Size....

Pneumothorax Y N Rt Lt

Lung Sliding Y N

Stratosphere Sign Y N

A lines Y N Lung Point Y N

Acute Interstitial Pattern Y N

Right

B Lines Y N

Consolidation Y N

Bronchograms Y N

Left

B Lines Y N

Consolidation Y N

Bronchograms Y N

Diaphragm Dysfunction  Y N

Impression, Comments and Recommendations:

History:  _______________________

Vitals:  _______________________

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

204

Optic Nerve Exam

Scott Dulchavsky, MD, PhD

Contents

Indications  .......... 205

Patient position  .......... 206 Transducer Type & Position  .......... 206

Optic Nerve Exam .......... 207

Retinal Vessels  .......... 208

Optic Nerve Sheath

Diameter (ONSD) Measurement  . 209

Increased Intracranial

Pressure (ICP)  .......... 210 Pupilary Exam  ...........211

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

205

Optic Nerve Exam

Indications

Evaluation of the optic disc

Evaluation of the Optic Nerve Sheath Diameter (ONSD)

Normal value < 5-5.7 mm

Any cause that may lead to increased ICP > 20 mmHg, will mostly lead to an increase in ONSD > 5.7 mm

Traumatic Brain Injury (TBI)

Intracranial bleeding

Hydrocephalus

Hypertensive emergency

Sclera

Optic Nerve Sheath

Optic Nerve

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

206

Patient Position

Supine

Transducer type and position

Linear 7-13 MHz

Apply the transducer directly to the closed eyelid

Sagittal Axis

Transducer marker cephalad

Horizontal Axis

Transducer marker towards the patient's right

Depth 3-4 cm

Use ALARA principle with the lowest amount of energy pos-sible

Mechanical index (MI) should be < 0.23 in opthalmic applications

Sagittal

Horizontal

Optic Nerve Exam

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

207

Structures to be identified

Cornea, Lens

Choroid & Retina

Optic disk

Optic Nerve

Optic Nerve Sheath (ONS)

Orbital Ultrasound/Sagittal View

Anterior Chamber

Cornea

Lens

Iris

Choroid & Retina

Orbital Ultrasound/Horizontal View

Optic Nerve

Optic Disc

Sclera

Optic Nerve Sheath

Optic Nerve Exam

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

208

Optic Nerve Exam & Retinal vessels

Sonographic findings

Recommended to scan both eyes

Adjust the depth to fill the screen with the entire orbit

The cornea is seen as a thin layer parallel to the eyelid

The normal lens is anechoic

The normal eye appears as a circular hypoechoic structure

The optic nerve is visible posteriorly departing away from the globe and optic disc

Using Color Flow (CF) can help identify the Central retinal vessels

Optic Nerve Sheath

Optic Nerve

Optic Nerve & Sheath/Transverse View

Choroid & RetinaWith CentralRetinal Vessels

Central Retinal Artery & Vein

Sclera

Central Retinal Artery and Vein

Optic Nerve Sheath

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

209

Optic Nerve Exam / ONSD Measurement

Sonographic findings (cont.)

ONSD measurement

Measurement of the ONSD should be done about 3mm posterior to the optic disc

Two measurements averaged in each of the Horizontal and Sagittal planes

A normal ONSD measures < 5-5.7mm

> 5.7mm may be indicative of increased ICP and a head CT is recommended

ONSD dilated

ONSD normal

ONSD measurement

Optic Nerve

Optic Nerve Sheath

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

210

Sonographic findings (cont.)

Other features of Traumatic Brain Injury (TBI) and increased ICP can be identified

Swelling of the optic disk & Papilledema

Retinal detachment can be identified

Vitreous hemorrhage with opacities in the vitreous fluid can sometimes be seen

Choroid & Retinal detachment

Optic disk swelling/

Papilledema

TBI/High ICP

TBI/High ICP

Optic Exam

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

211

Sonographic findings (cont.)

Examination of the pupil can be achieved by placing the transducer on the lower lid of the closed eye and angling superiorly (achieving a coronal plane with the globe and obtaining a view of the iris). This can help measure pupillary reflexes and accurately measure of pupil size by M mode

Dilated pupil/M-mode

Optic Exam

OB/GYN

Abigail Brackney MD, RDMS

Jennifer Milosavljevic MDBrian M. Craig MDKathleen M. O'Connell

Contents

Non-Pregnant Uterus  .......... 213

First Trimester  .......... 215

Fetal Heart Beat  .......... 217

Second & Third Trimester ........... 218

Ectopic pregnancy  .......... 221

Placenta Previa  .......... 224

Placental abruption  .......... 225

Indications

Hypotension and hemodynamic instability

Lower abdominal pain and vaginal bleeding

Trauma

Evaluate the presence of

Intra-uterine pregnancy/Fetal heart beat

Fetal Age

Ectopic pregnancy

Placenta previa

Placental abruption

Ovarian cyst

Pelvic free fluid

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

212

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

213

Non-pregnant uterus

Patient position

Supine

Full bladder if possible

Transducer Type & Placement

Curvilinear 2-5 MHz

Mid line, Suprapubic, angled inferiorly

Screen marker to the left

Depth about 15-20 cm

Longitudinal/Sagittal view

Marker cephalad

Pan the transducer left and right to identify different structures as the uterus and ovaries

Transverse view

Marker towards the patient's right

Pan the transducer up and down to identify the fundus and cervix

Structures to be identified

Bladder

Uterus

Cervix & Vagina

Ovaries

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

214

Sonographic findings

Bladder

Hypoechoic structure, anterior to the uterus

Uterus

Mostly anteflexed and anteverted. Located directly inferior to the bladder with grey appearance

Identify the long axis of the uterus

Normal measurements are less than 10 x 6 cm

Note the endometrial stripe and follow to the cervix

Ovaries

Can be found by panning the transducer to the right or left

Almond shaped, slightly hypo-echoic structures

Follicles can be seen

Normal Measurement is 2 x 2 x 3 cm

Uterus

Vagina

Cervix

Endometrial Stripe

Bladder

Uterus/Sagittal Midline View

Follicles

Ovary

Non-pregnant uterus

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

215

Intrauterine Pregnancy (IUP)

Structures to be identified

Gestational Sac, yolk sac

Fetus, Fetal pole

Placenta and location

Fetal Heart beat

Gestational sac

Appears hypoechoic black inside the uterus (near the fundus) and has thickened surrounding walls

Can be visualized at 5+ weeks gestation

First Trimester

Bladder

Uterus

Gestational Sac

Uterus/Sagittal View

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

216

Intrauterine Pregnancy (IUP)

First Trimester

Sonographic Findings

Fetal pole (FP): seen at 6-7+ weeks gestation

Measure the Crown-Rump Length (CRL) when visible for dating of the pregnancy

CRL= longest measurement of the fetus from head to bottom, not including the extremities

Use up to 12-13 weeks gestation

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

217

IUP/Fetal Heartbeat

Sonographic findings (cont.)

Developed fetus with head, body, and limbs can be seen

Placenta is usually near the fundus of the uterus and has an echo-texture similar to the liver

Confirm live IUP/Fetal Heart Beat

Can be detected from 6 weeks of gestation

Choose M-mode function

DO NOT USE PULSED DOPPLER. It may adversely affect the fetus

Pan the transducer to locate the heart and place the cursor over the heart beat

Measure from peak to peak of one or two cycles. Should be seen by CRL of >5-10mm. Normal HR approx 100 bpm at 5-6 weeks, and 140 by 8-9 weeks

This images demonstrates a fetal heart beat of 153 bpm

A beating heart is also seen without the M-mode in the fetal thorax

Heart

First Trimester

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

218

Placenta

Fetus

Uterus/Sagittal View

Intrauterine Pregnancy (IUP)

Second & Third Trimester

Indications

Determine gestational age and weight

Determine number of fetuses

Presenting fetal part

Placental location

Vaginal bleeding

Cervical length

Trauma – placental abruption

Amount of amniotic fluid

Heart rate measurements are made using M-mode as they were in the first trimester

Determine the present part of the fetus by looking just about the pubic bone by the cervical opening

Assess for oligohydramnios/polyhydramnios

Measure the deepest pocket of fluid, without fetal parts or um-bilical cord, in each of the four quadrants. Add together, normal range from 7-20cm

Amniotic fluid

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

219

Intrauterine Pregnancy (IUP)

OBGYN packages on the US machine will give an estimated gestational age and weight

Accurate within 2 weeks in the second trimester and 3 weeks in the third trimester

Biparietal Diameter (BPD)

Measure from outer edge to inner edge of the calvarium, perpendicular to the falx cerebri

Measure at level of the paired thalami and third ventricle

Head Circumference (HC)

Measure at the same level as the BPD around the outer edge of the calvarium

Second & Third Trimester

BPD Measurement

HC Measurement

Thalamus

3rd ventricle

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

220

Intrauterine Pregnancy (IUP)

Second & Third Trimester

Abdominal Circumference (AC)

Measure in the axial plane where the abdomen is round at the level of the stomach, transverse spine, and where the umbilical vein branches into the right and left portal veins.

Measure around the skin edge

Femur Length (FL)

Measure the ecogenic ossified portions, not the cartilage.

Should be perpendicular to the US beam to avoid foreshortening the bone

FL Measurement

AC Measurement

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

221

Structures to be identified

Adnexal Mass

Ectopic gestational sac

Pseudogestational sac

Fluid in Cul-de-sac or Morrison's pouch

Sonographic findings

Finding an adnexal mass with an empty uterine cavity

Eccentric location of the gestational sac

Ectopic gestational sac and fetus with thickened wall in the fallopian tube or adnexa

The presence of pelvic fluid correlates with a higher possibility of ectopic pregnancy

Ectopic

Pregnancy

Uterus

Ectopic Pregnancy

Ectopic Pregnancy

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

222

Patient position

Supine

Trendelenburg position may give a better view of the RUQ structures

Transducer Placement

About mid axillary line, 7th -11th intercostals. Marker cephalad

Counter clock rotation help eliminate the rib shadows

Sliding the transducer downward will expose the lower edge of the liver, and the kidney, where free fluid tends to accumulate

Sliding the transducer upward will expose the right diaphragm and pleural space

Liver

Liver

Kidney

Kidney

Free Fluid

Morrison's Pouch

Fluid in Morrison's Pouch

Normal RUQ

Ectopic Fluid in Morrison's Pouch

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

223

Ectopic- Fluid in the Posterior Cul-de-sac

Patient Position

Supine

Transducer Placement

Suprapubic, angled inferiorly, marker cephalad (sagittal view)

Sonographic Findings

Fluid in the cul-de-sac tend to accumulate beneath the uterus

Gross amount usually seen with a ruptured ectopic pregnancy

Free Fluid in Cul-De-Sac

Uterus

Free Fluid

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

224

Sonographic findings

Scan is best when there are no uterine contractions

Best to start with a sagittal view to determine if the placenta is extending into the lower uterine segment

Note if the placenta is covering the internal os. If not, can measure the distance between the placenta and the internal os to grade the placenta previa

Uterus

Placenta Previa

Internal Os

Cervix

Placenta Previa

Placenta Previa

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

225

Sonographic findings

Hemorrhage within the placenta causing separation from the uterine wall

Difficult to identify with trans-abdominal ultrasound

Older hemorrhage is easier to identify

Better to start with a sagittal view

Grading is according to the location and degree of separation. Generally is termed, mild, partial and complete. Grading help determine the prognosis

Retro-placental Hemorrhage

Placenta

Placental Abruption

Sonographic findings

Locate the uterus

Pan the transducer to the sides to identify the ruptured ovarian cyst

A large hematoma from a ruptured ovarian cyst is sometimes visible posterior to the uterus

Not all ruptured cysts form hematomas. They could have normal shaped ovary with some fluid collection in the cul-de-sac

Bladder

Uterus

Ruptured Ovarian Cyst

Uterus/Sagittal View

Ruptured Ovarian Cyst

Placental Abruption

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

226

Musculoskeletal

&

DVT

David Amponsah, MD

J. Antonio Bouffard, MD

Contents

Soft tissue  227

Normal soft tissue  .. 228

Cellulitis  .. 229

Abscess  .. 230

Bones 231

Fractures  .. 232

Knee Joint ...233

DVT  235

Three Point Compression  .. 235

Femoral Veins  .. 235

Popliteal Vein  .. 240

Worksheet  .. 241

Indications

Extremity swelling, erythema, pain

Suspicion for abscess / cellulitis

Suspicion of fracture

Aid in procedures for draining abscess

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

227

Soft Tissue

Patient Position

Most critically ill patients are supine

Adjust patient position as tolerated to evaluate the affected area

Transducer type and position

Linear for superficial structures 7-13 MHz or Curvilinear 2-5 MHz for deeper penetration

Transducer marker cephalad or towards the patient's right

Screen marker to the left of the screen

Adjust the depth according to the structure examined

Examination of Soft Tissue

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

228

Exam should include sonographic evaluation of surrounding unaffected areas

Comparison to the opposite extremity

Identify:

Skin: Hyperechoic layer adjacent to the transducer

Subcutaneous tissue: hypoechoic layer of variable thickness with hyperechoic lines resembling a feather

Muscle: Feather like hypoechoic structure

Tendons: hyperechoic fibrillar structure

Skin

Subcutaneous Tissue

Muscle

Tendon

Bone Cortex

Normal Soft Tissue Structures

Tendon

Subcutaneous Tissue

Skin

Muscle

Thenar muscle and tendon

Knee/Patella

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

229

Sonographic findings

Disruption of normal subcutaneous tissue echo texture resulting in cobblestoning

Diffuse thickening with increased echogenicity of the involved soft tissue

Edematous strands representing distended lymphatic channels

Findings are non specific. Skin edema or chronic lymphedema may have similar appearance

Cellulitis

Normal Soft Tissue

Cellulitis

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

230

Sonographic findings

Discrete fluid collection adjacent to a surrounding area of cellulitis

Anechoic or echogenic fluid collection with heterogeneous debris, septations or loculations

Swirling motion during ballottement (with probe compression)

Use Color Flow (CF) to demonstrate surrounding blood flow around periphery

Rule out vascular structures with color or PW Doppler

CF with abscess

Heterogeneous Cellulitis and Abscess

Abscess

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

231

Patient position

Supine

Place transducer at the location of pain

Transducer Type & Placement

Linear 7-13 MHz

Transducer marker pointing cephalad or towards the patient's right

Screen marker located to the left of the screen

Depth 5-10 cm depending on the structure examined or the patient's body habitus

Cortex

Bones

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

232

Sonographic findings

Obtain short and long axis of the bony cortex

Identify the bony acoustic surface (cortex)

Evaluate for any cortical irregularities or interruptions

Evaluate for any hypoechoic hematoma adjacent to the fracture site

Evaluate the opposite extremity if possible for normal variants as comparison.

Bone Cortex

Soft Tissue Swelling

Long Bone Fracture with Bony Fragments

Fractures

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

233

Patient position

Supine. Keep the knee in an extended position, with minimal flexion (pillow to support popliteal region)

Transducer Type & Placement

Linear 7-13 MHz

Place the transducer just above the knee parallel to the Quadreceps Femoris Tendon.Transducer marker pointing cephalad

Screen marker located to the left of the screen

Depth depending on the patient's body habitus, generally 5-10 cm

Move the transducer proximal and distal to be able to see the patella and femur in the same image if possible and view the suprapatellar recess

Knee Joint

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

PROTOCOLS

MSK & DVT

234

Indications

Joint pain, swealling (trauma, crystal arthropathy, tendon rupture...)

Trauma

Suspected joint effusions or septic joint

Sonographic findings

Move the transducer proximal and distal to be able to see the patella and femur in the same image if possible and view the suprapatellar recess

Knee effusions and hemarthrosis can be detected as a hypoechoic area in the suprapatellar recess or bursa where they tend to accumulate

Knee Joint

Anterior surface

of Patella

Femur

Suprapatellar Bursa

Normal Suprapatellar exam

Quadriceps Tendon

Anterior surface

of Patella

Fluid

Osteophyte

Moderate to large Suprapatellar Effusion

Quadriceps Tendon

PREFACE

AORTA

OB/GYN

KNOBOLOGY

VASCULAR

CARDIAC

LUNG

PROCEDURES

ABDOMINAL

OPTIC

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CFV

Great Saphenous Vein

SFV

DFV

Popliteal

Patient Position

Femoral Veins

Supine, hip in slight flexion and external rotation

Popliteal Vein

Supine, leg flexed at the knee with external rotation

Transducer Type & Placement

Linear 7-13 MHz

Transducer marker towards the patient's right

Screen marker on the left side of the screen

Depth 5-10 cm depending on the patient's size

Three Point Compression Technique includes evaluation of areas of the highest turbulence and greatest risk for developing a thrombus

Common femoral vein (CFV) at the saphenofemoral junction

Proximal deep Femoral Vein (DFV) and the superficial femoral vein (SFV)

Popliteal Vein

Non-visualization of a clot does not rule out a DVT (False negative \- may not be echogenic depending on the gain adjustment or auto gain)

Do not confuse a Baker's cyst with a blood vessel (evaluate with color Doppler)

DVT

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Sonographic Findings

Common Femoral Vein (CFV)

Start at the inguinal ligament and scan to the superior calf 2 cm at a time

First find the junction of the saphenous vein and CFV

Differentiate between the artery and the vein, using Color Flow (CF) and Pulse Wave (PW) Doppler if necessary

Apply gentle compression initially, so as not to col-lapse the vein completely (enough pressure is when the artery starts to deform)

Obtain long and short axis views

CFV Scanning

DVT

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Sonographic Findings (cont.)

CFV

Gray scale compression is considered the most use-ful in the diagnosis of DVT

Compression of the vein to the point of collapse

SFV Scanning

DVT

DVT in a Non-Compressed Vein

DVT/Long axis View

DVT

DVT

No DVT

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CFV color flow and PW Doppler

CFV without compression

CFV with compression

Phasic variation

Augmentation

DVT

Sonographic Findings (cont.)

CFV

Involves compression of the calf muscles distal to the vein examined. This will create venous augmentation noted on the gray scale image

Apply the PW Doppler and color Doppler to note the augmentation as a pulse wave or blush of color respectively

Note the Phasic variation: variation in venous flow with respiration. This can be noted by applying PW Doppler

Venous augmentation mostly indicate the vein patency between the level of the compression and the US transducer

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Sonographic Findings (cont.)

DFV & SFV

Identify and scan the DFV and the SFV (the SFV is a deep vein, also known as the femoral vein)

Chronic DVT(s) tend to adhere to the vessel wall

Continue scanning the mid and distal femoral veins

If a DVT is found, it is advisable to measure its extent. Long axis view can help

Store a still image of the DVT

DFV

SFV

DVT

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Sonographic Findings

Popliteal Vein

Place transducer in the transverse orientation in the popliteal fossa and identify the popliteal vein which is superficial to the popliteal artery

Perform Gray Scale Compression with augmentation by pressure on the calf and apply color Doppler and PW Doppler during augmentation

Differentiate from a Baker's cyst by applying CF

Note the phasic variation and augmentation

Popliteal Vein Scanning

Long Axis/Popliteal Vein with color flow and PW Doppler showing phasic variation and positive augmentation

Popliteal Veinwithout compression

Popliteal Veinwith compression

DVT

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Worksheet

Patient Name:  _______________________

MRN: _______________________

Date:  _______________________

History:  _______________________

Common Femoral vein and Proximal Greater Saphenous Vein

Compressible Y N

Color Flow Y N

Augmentation Y N

Proximal Deep Femoral Vein and Superficial Femoral Vein

Compressible Y N

Color Flow Y N

Augmentation Y N

Mid Femoral Vein

Compressible Y N

Color Flow Y N

Augmentation Y N

Popliteal Vein

Compressible Y N

Color Flow Y N

Augmentation Y N

Impression & Comments:

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Procedures

Keith Killu MDVictor Coba MD

Contents

General  ....................................... 243

Sterility  .. 244

Needle Guidance  .. 245

Orientation  .. 245

Procedure  ...246

Thoracentesis ............................ 247

Paracentesis .............................. 249

Suprapubic Bladder Aspiration 251

Lumbar Puncture ....................... 254

Pericardiocentesis ..................... 255

Tracheostomy & Endotracheal (ET) Intubation ........................... 257

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Transducer Types

Choose the transducer according to the structure depth and location. For deeper structures a lower frequency trans-ducer is used.

Higher frequency transducers provide better axial resolution

Procedures/Patient Position & Prescan

Position the patient in the standard optimal position, (e.g. Internal Jugular Vein access, place the patient in Trendelen-burg position)

If using ultrasound to mark a location only, make sure the patient stays in the same position

The ultrasound machine is placed where the operator can easily visualize the screen

Perform a prescan of the structure prior to the sterilization process

Choose a site where the structure is larger and closer to the skin if possible

Adjust the depth and gain

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Sterile kit usually includes

Sterile sheath and gel

Rubber bands

Needle guides with different angle paths for different depths

Place gel inside the sterile sheath

Place the sterile sheath on the transducer head and roll the sheath along the entire transducer cable

Place the rubber bands, one near the head and the other near the base of the transducer

Place sterile gel outside the sheath along the transducer head

Sterility

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Use a Needle Guide if desired

The needle guide is to be attached to the transducer head

The needle tip is introduced through the guide

Advantages:

Predictable path, depth and angle of the needle

Less hand eye coordination is needed

Disadvantages:

The angle is fixed

Deeper structures are hard to reach

The screen marker is placed to the left of the screen. The transducer marker is placed to the right of the patient. Make sure the marker side corresponds to the left side of the screen by touching the transducer footprint near the transducer marker

Needle Guide

Orientation

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General Procedure Steps

Locate the structure to be accessed and apply local anaesthesia

Place the needle behind the transducer at about 1-2 cm

Perform an imitation poke and notice the ring down artifact, acoustic shadowing to locate the needle

Needle angle is usually about 45°-60° from the skin. Can change the angle when trying to avoid another structure

Insertion method

Move the needle in slow short controlled strokes and monitor it's progress

Locate the tip of the needle (which may appear as an echogenic dot)

Place the bevel towards the transducer beam, where this can pro-duce more echo return and better visualization of the needle tip

Ring down Artifact

Needle Tip

Procedure

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Patient Position

Most ICU patients will be in a supine position

Arm abducted and flexed at the elbow

Consider elevating the head of the bed

Transducer type & Placement

Phased Array 2.5-5 MHz

Transducer marker pointing cephalad

Depth about 15 cm

Lung

Liver

Thoracentesis

Transducer Placement and Views

L4/Place the transducer in the mid or posterior axillary line near the RUQ or LUQ to identify the diaphragm

Scan the whole area from the anterior chest to the posterior axillary line

Scan at least 3 intercostal spaces

If the patient can sit, they should face away from the operator and the scan should include the area from the scapula down to the posterior thoracic ribs, and from the paravertebral to the posterior axillary lines (L5). Try to locate the largest area of effusion

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Transducer Placement and Views (cont.)

Locate the diaphragm, liver, or spleen which are excellent land marks for ultrasound

Procedure

Note the depth of the fluid

A 15 mm fluid thickness between the visceral and parietal pleura over three intercostal spaces is usually enough to try a thoracentesis

Mid or posterior axillary line is usually optimal

Supply adequate anesthesia. Practice complete sterility

Thoracentesis

Pleural Effusion

Chest Wall

Liver

Diaphragm

Catheter insidepleural fluid

Procedure (cont.)

Place the needle beside the transducer and follow its path with real time guidance

Real time US guidance is not always necessary

Keep the patient in the same position after the prescan

Perform the procedure following the standard techniques

Catheter tip can be identified inside the pleural fluid

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Paracentesis

Patient Position

Patient in a supine or left lateral oblique position if choosing the LLQ

Consider raising the head of the bed if possible

Transducer type & Placement

Curvilinear 2-5MHz

Transducer marker towards the patient's right

Procedure

Prescan the lower part of the abdomen, identifying the largest fluid accumulation

LLQ not necessarily the best, but usually the better position

Avoid upper quadrants and rectus muscle

Needle angle should be 60-90° to the skin, placed close and behind the transducer

Success rates is about 95%

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Paracentesis

Procedure (cont.)

Identify the free floating bowel and the bladder to avoid injury

A collection of at least 3-4 cm in depth (distance between the abdominal wall and the floating bowel loops) is usually adequate for paracentesis

Scan the fluid collection in long and short axis

Ascitic fluid could have varying degrees of echogenicity characteristics. Bladder fluid is usually anechoeic

Locate the largest pocket of fluid to perform the procedure

Avoid when adhesions are present

Perform the rest of the procedure following the standard technique and sterility with the aid of US guidance and sterile sheath kit

Clear ascitic fluid

Abdominal Wall

Thick Ascitic Fluid

Bowel Loops

Ascites

Ascites with adhesions

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Patient Position

Supine

Head of bed better at 30° if possible

Transducer type & Placement

Curvilinear 2-5 MHz

A4/ Place the transducer directly above the pubic symphysis pointing inferiorly towards the pelvis

Long axis

Transducer marker cephalad

Short axis

Transducer marker towards the patient's right

Suprapubic Bladder Aspiration

A4/Short Axis

A4/Long Axis

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Views and Procedure

Bladder fluid is usually anechoic

Differentiate the bladder from

Any distended bowel, which usually have peristalsis

Identify any large ovarian cysts

Ureteral jets can help differentiate structures by using Color Flow

Success rate increase when transverse diameter is > 3.5 cm

Abdominal Wall, Bladder

Bladder

Abdominal Wall

Procedure (cont.)

Place the needle beside the transducer and follow its path with real time guidance

Real time US guidance is not always necessary

Keep the patient in the same position after the prescan

Perform the procedure following the standard techniques

Suprapubic Bladder Aspiration

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Patient Position

Patient in the lateral decubitus position with the knees and back flexed

If possible a sitting position with the patient leaning forward

Transducer type & Placement

Curvilinear 2-5MHz or linear

Transducer placed over the spinous processes of choosing, L2-L5

Depth about 8 cm

Sagittal Axis

Transducer marker cephalad

Short Axis

Transducer marker towards the patient's right

Long Axis

Short Axis

Lumbar Puncture

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Views and Procedure

Spinous processes above and below the desired space should be identified

Start with a transverse view to identify the midline, then obtain a longitudinal view

The spinous process appears as a hyperechoic round edge structure

Transducer moved superiorly and inferiorly between the spinous processes to identify the interspinous spaces and the path for needle advancement

Between the spaces, the ligamentum flavum (with hyper-echoic thin lines) is followed by the Dura matter

Real time ultrasound guidance is not always needed or preferred. Apply local anasthesia

Perform the rest of the procedure in the standard sterile technique

Spinous Processes

Ligamentum Flavum

Dura matter

Vertebral Body

Vertebral Body

Lumbar Puncture

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Patient Position

Patient in a supine position

Transducer Type & Placement

Curvilinear or phased array transducer

A1/ Subxiphoid is the better view

Left parasternal long axis is best for detecting posterior effusions

Depth about 15 cm

Pericardiocentesis

Views and Procedure

The subxiphoid is commonly used to perform the procedure

Transducer just inferior to the xiphoid process and pointing towards the left costal margin

Choose the site where the effusion is maximal and is closest to the skin

Note the depth of the effusion

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Views and Procedure (cont.)

Make sure the track of the needle is clear. i.e. avoiding the lung and liver

Attention to avoid the internal mammary (3-5 mm on the left of sternal border) and the neurovascular bundle at the inferior edge of the ribs

Use US prior to insertion but not for actual guidance during the procedure

Note the trajectory of the ultrasound beam, which represents the trajectory of the needle

Apply local anesthesia. 18 gauge angiocath is usually used

Procedure to be done following the standard guidelines. Can confirm the angiocath presence in the pericardial sac by ultrasound

Pericardial Effusion

RV

LV

RA

LA

Pericardiocentesis

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Patient Position

Supine

Transducer type & Placement

Linear 7-13 MHz

Short Axis

Marker towards the patient's right

Long Axis

Marker cephalad

Structures to be identified

Thyroid and cricoid cartilage

Thyroid gland (Isthmus)

Tracheal rings

Blood Vessels

Thyroid Cartilage

Cricoid Cartilage

Tracheal Rings

Tracheostomy & Endotracheal (ET) Intubation

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Procedure and Views

Tracheostomy

Procedure to be performed following the standard technique

Pre procedure ultrasound will help

Identify tracheal and paratracheal tissue and blood vessels

Identify the depth of the trachea

Choose best incision site

US can be used during the procedure for guidance

ET intubation

US can be used post intubation to confirm the ET tube inside the trachea

Tracheal Ring

Thyroid Gland

Carotid Artery

Trachea

Trachea/Short Axis

Tracheostomy & Endotracheal (ET) Intubation

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Procedure and Views (cont.)

Inflated cuff

Find the cuff by angling the transducer inferiorly

Appears more echogenic

Acoustic shadowing can be seen

Inflating and deflating the balloon will create a sliding motion

TrachealCartilage

ET tubeballoon

Acousticshadowing

ET Tube

ET Tube/Long Axis

ET Tube/Short Axis

Tracheostomy & Endotracheal (ET) Intubation

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Clinical Protocols

Luca Neri, MDEnrico Storti, MDGabriele Via, MDThanks to Daniel Lichtensteinfor his guidance and inspiration

Contents

Table 1 Ultrasound Life Support WINFOCUS Pathways .. 261

Table A Airway Focused Ultrasound .. 262

Table B Breathing Focused Ultrasound ... 263

Table B.1 Breathing Focused Ultrasound ... 264

Table B.2 Breathing Focused Ultrasound ... 265

Table B.3 Dyspnea Multi-focused Ultrasound ... 266

Table B.3 Dyspnea Multi-focused Ultrasound (cont.) ... 267

Table C Shock Focused Echocardiography ... 268

Table C Shock Focused Echocardiography (cont.) ... 269

Table C1 Shock Multi-focused Ultrasound ... 270

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Table 1 \- Ultrasound Life Support WINFOCUS Pathways

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Table A \- Airway Focused Ultrasound

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Table B Breathing Focused Ultrasound

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Table B.1 \- Breathing Focused Ultrasound

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Table B.2 \- Breathing Focused Ultrasound

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Table B.3 Dyspnea Multi-focused Ultrasound

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Table B.3 Dyspnea Multi-focused Ultrasound (cont.)

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Table C Shock Focused Echocardiography

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KNOBOLOGY

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Table C Shock Focused Echocardiography (cont.)

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Table C1 Shock Multi-focused Ultrasound

Suggested Readings

General Ultrasound in the Critically Ill, D. Lichtenstein

The Echo Manual, Jae K. Oh

Ultrasound Scanning, Principals and Protocols, Betty Tempktin

Diagnostic and Surgical Imaging Anatomy, Ahuja

Emergency Ultrasound, O. John Ma

This handbook of ICU ultrasound is an excellent example of the Earth based benefits of space medical research. The National Space Biomedical Research Institute supports research to develop intuitive educational programs to train astronauts to perform ultrasound examinations on the International Space Station; this handbook is a direct extension of that successful research project and provides a very useful guide to ultrasound use in the Intensive Care Unit.

Jeffrey Sutton, MD, PhD • Director • National Space Biomedical Research Institute

Real-time ultrasound at the point-of-care, has become an invaluable adjunct to the clinical management of critically ill and injured patients both for pre- and in-hospital settings. The rate at which it is spreading, and the continuing development of new applications, may outpace training of adequate numbers of qualified users.

WINFOCUS, the World Interactive Network Focused on Critical UltraSound, is fully committed to enhance and spread quality in the field, through appropriate Education, Clinical Research, Technology Development, Networking, and is eager to support editorial initiatives like this one.

This new handy pocket-book is the ideal reference to consult when making bedside or on-scene interpretations of ultrasound clinical data, mostly when integrated either into time-dependent, crowdy, remote or scarce-resource scenarios. Developed according to a multiple goal–oriented, patient-centred, easy-to-use style, it fully addresses the approach of critical and intensive care professionals, who typically deal with acute, unstable or complex states, rather than individual organ complaints.

This manual is another great tool to make ultrasound accessible worldwide, at the point-of-care of any emergency or critical patient.

Luca Neri, MD • USCME Project Director, WINFOCUS • Past President, WINFOCUS

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  256. 
  257. 
  258. 
  259. 
  260. 
  261. 
  262. 
  263. 
  264. 
  265. 
  266. 
  267. 
  268. 
  269. 
  270. 
  271. 
  272.

## Landmarks

  1. Cover

