AAA scanning - NSW Agency for Clinical Innovation · Tips & traps bowel gas: try direct pressure...
Transcript of AAA scanning - NSW Agency for Clinical Innovation · Tips & traps bowel gas: try direct pressure...
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AAA scanning
Emergency Ultrasound CourseJustin Bowra
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Abdominal Aortic Aneurysm ultrasound scan
anatomy
definitions
indications
what it tells you
what it doesn’t tell you
How to scan
tips & traps
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Transpyloric plane
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Transpyloric plane
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Abdomen- Renal Hilum and Vessels Transverse Section -Level of L 1- 2 Intervertebral Disc
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When is an aorta aneurysmal?
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Distal calibre change
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When is an aorta aneurysmal?
Complex answer >50% bigger than normal
Simple answer >3cm diameter
But how do you measure the diameter?
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Why is the diameter so important?
It’s very simple1. Electively: urgency of operation depends on
risk of rupture… which depends on diameter2. In ED: same logic. Is it likely to be leaking or
not?
Should I be taking this unstable old guy
to OT or CT? His AAA is only 3cm!
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However…
Any AAA can rupture
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What an AAA scancan tell you..
is there an aneurysm? 98% accurate
is the bladder enlarged?symptoms can mirror ruptured AAA
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What it can’t tell you
is the AAA leaking?
is there any retroperitoneal blood?
what else is going on in the abdomen?
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Top tip #1
You are not a radiologist!
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Top tip #2
Be a binary thinker(AAA yes/no)
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How to scan
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How to scan
ABC first Patient position: supine Probe/settings Probe placement/landmarks Essential views
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Probe
Curved/ phased probe
3.5- 5.0 MHz standard
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Settings
Focus depth 10cm
Image depth 15cm
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Start
Start south of xiphi
Probe is aligned transversely
With mark to patient’s right
ID: vertebral body, liver, IVC
Measure transverse (or A-P) diameter of aorta
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Start: subxiphoid transverse
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VB
IVCA
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IVC versus aorta
IVCTo the rightOvalThin wallsCompressible Larger (unless AAA!)
AortaTo the leftRoundThick walledPulsatileCalcifiedNB Doppler?
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Upper transverse
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Lower transverse
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Then…
scan down to bifurcation
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Bifurcation
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Be very careful when measuring diameter…
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Then…
Longitudinal view
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Longitudinal
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Longitudinal
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Tricks
Pulse wave Doppler versus colour flow Doppler Scan thru liver / loins Change frequency / probe pressure
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Is this a vessel or not?
Xxxxxxxxxxxxxxxxx
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Scan thru liver/ spleen/ loins
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For credentialing:
store 3 images (pref. cineloops) Upper transverse
Lower transverse esp including bifurcation
Longitudinal, or middle transverse
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Top tip #3
You have not ruled out AAA unless you can see the entire length of the aorta.
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But if you see AAA on your 1st
view…
You can stop!
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Tips & traps
bowel gas: try direct pressure with the probe
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Tips & traps
bowel gas: try direct pressure with the probe
Fatties: decr freq, decrease greyscale
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Tips & traps
bowel gas: try direct pressure with the probe
Fatties: decr freq, decrease greyscale
measure outer wall diameter
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Tips & traps
bowel gas: try direct pressure with the probe
Fatties: decr freq, decrease greyscale
measure outer wall diameter
urinary retention may mimic AAA
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Tips & traps
bowel gas: try direct pressure with the probe
Fatties: decr freq, decrease greyscale
measure outer wall diameter
urinary retention may mimic AAA
But assume an old man with ‘renal colic’has AAA
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Tips & traps
bowel gas: try direct pressure with the probe
Fatties: decr freq, decrease greyscale
measure outer wall diameter
urinary retention may mimic AAA
But assume an old man with ‘renal colic’has AAA
unstable AAA patients go to OT, not CT!
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My favourite AAA pic
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Worst aorta pic ever -1
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Worst aorta pic ever -2
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AAA summary
Xiphi to umbi
AAA >3cm
Rupture risk if >5cm
what it tells you
what it doesn’t tell you
technique
tips & traps