Life Saving Pocket_guide

An IllustratedStep-By-StepPocket Guide

Perfect for Beginner &

Expert Users

Critical Care MedicineEmergency Medicine

Trauma Surgery

Liver

Ao

GB

IVC

Spine

BowelGas

Hepatic Splenic

Celiac

2-D Image

M-Mode Image

Pleural Line

Chest Wall

No Lung Sliding

M-Mode Cursor

stephen j. Leech md rdms

Life-savingpoint-of-care

ULtrasoUnd appLicationsAorta, Cardiac, FAST/Trauma, Pneumothorax, Pelvic, US-Guided Access

EmergencyUltrasoundConsultants

Life-Saving Point-Of-Care Ultrasound ApplicationsA Step-By-Step Pocket GuideBy Stephen J. Leech MD RDMS

Disclaimer

This education material provides a general overview and is not intended to replace formal

training through CME courses or other programs. This material does not constitute

professional medical advice or a complete course of training. You should not perform an

ultrasound examination solely in reliance upon the information in this education material.

Copyright © 2008 by Emergency Ultrasound Consultants, LLC

All rights reserved. No part of this publication may be reproduced or distributed in any

form or by any means without the prior written permission of Emergency Ultrasound

Consultants, LLC.

Stephen J. Leech MD RDMSDirector, Emergency Ultrasound, Department of Emergency Medicine

Director, Emergency Ultrasound Fellowship, Department of Emergency Medicine

Orlando Regional Medical Center, Orlando, Florida

Director, Southeast Region, Emergency Ultrasound Consultants, LLC

Acknowledgements Author would like to thank Paul R. Sierzenski MD RDMS, Michael Blaivas MD

RDMS, L. Connor Nickels MD, Eike Flach MD, SonoSite Inc., and L2Designs.com

for their assistance with the development of this publication.

Emergency Ultrasound Consultants, LLCEUS Consultants, LLC is the industry leader in point-of-care ultrasound

specializing in education, business practices, risk managment, and billing. Our

faculty are board certified, fellowship trained physicians who are both nationally

and internationally recognized. They have authored or contributed to major

emergency and bedside ultrasound policy including societal (ACEP, AAEM, SAEM),

national (ABEM, AIUM), international (World Congress) and governmental (CMS

and MEDPAC). We guarantee that all of our ultrasound courses, consultations,

management services and products will be provided by attending physicians who

are fellowship trained and expert diagnostic medical sonographers.

Paul R. Sierzenski MD RDMS

President, Emergency Ultrasound Consultants, LLC

Michael Blaivas MD RDMS

Vice-President, Emergency Ultrasound Consultants, LLC

Learn more about Emergency Ultrasound Consultants by visiting www.eusconsultants.com.

SonoSite, Inc.SonoSite, Inc., the world leader and specialist in hand-carried ultrasound, is

pleased to provide an unrestricted education grant to Emergency Medicine

Residents Association (EMRA) for the production of this reference guide.

Learn more about SonoSite by visiting www.sonosite.com.

TRv

PROx

TRv

MID

TRv

DIS

TAL

SAG

PROx

SAG

DIS

TAL

AORTA

I n D I C AT I O n S

Suspected Abdominal Aortic Aneurysm (AAA)•

Suspected Aortic Dissection•

aorta POCkET GUIDE

G E n E R A L P O I n T SUse either the • C60 curved or P21 phased array transducerSelect the • Abdominal preset from exam typeScan the aorta in BOTH transverse and sagittal planes• Aorta should taper and become more anterior moving distally• Aorta can be differentiated from the IVC by:•

Location - aorta on patient’s left, IVC on patient’s right• Position relative to liver - aorta runs behind liver, IVC runs through liver• Brightness and thickness of walls - aorta has brighter and thicker walls• IVC runs into right atrium •

Measure aortic diameter from outer wall to outer wall • Measure proximal (above celiac), mid (at SMA), and distal (just above bifurcation) • sectionsAAA is defined as any measurement > 3 cm or any distal segment that is > 50% • larger than the more proximal segmentUltrasound accurately detects AAAs but does not accurately detect rupture• An intimal flap will appear as an echogenic line within the aortic lumen and suggests • aortic dissectionBowel gas may limit study•

Steady downward pressure should move gas out of the way• Scanning patient from RIGHT flank using the liver as a window may be used as • an option

A O R TA T R A n S v E R S ETransducer in epigastrium, just below xiphoid process• Transducer indicator aimed toward patient’s RIGHT in transverse plane• Identify the spinal shadow as key landmark•

Bright echogenic crescent shaped reflection with shadow in far field• Aorta is just anterior and to the left of the spine•

Identify the aorta, IVC, celiac, SMA, left renal vein, splenic vein• Scan down length of aorta through bifurcation into iliac arteries•

A O R TA S A G I T TA LReturn the transducer to the epigastrium• Transducer indicator aimed toward patient’s HEAD in sagittal plane• Identify spine, celiac, and SMA as key landmarks• Scan down length of aorta through bifurcation•

R E C O M M E n D E D I M A G E S T O S A v ETransverse view above the SMA with measurement of aortic diameter• Transverse view at SMA with measurement of aortic diameter• Transverse view above or at the bifurcation with measurement of aortic diameter• Sagittal view of the proximal aorta with measurement of aortic diameter• Sagittal view of the distal aorta with measurement of aortic diameter• Include any additional views showing pathology•

AORTA

POCkET GUIDE aorta

CARDIAC

cardiac POCkET GUIDE

SUBx

4C

SUBx

IvC

SAG

PSLA

xPS

SAx

A4C


Determination of Cardiac Activity in Cardiac Arrest•

Suspected Pericardial Effusion and Tamponade•

Estimation of LV Function•

Estimation of Preload and RV Filling Pressure•

CARDIAC

POCkET GUIDE cardiac

G E n E R A L P O I n T SUse the • P21 phased array transducerSelect the • Cardiac preset from exam typeCardiac orientation orients the image toward patient’s HEAD or LEFT side• Rolling the patient into the LLD position can help imaging by bringing the heart against • the chest wallPress • Clip button to save video clips instead of saving still imagesFIndings suggestive of tamponade include a pericardial effusion with diastolic collapse • of the RA/RV and dilation of the IVC with no respiratory variation

S U B x I P h O I D 4 C h A M B E R ( S U B x 4 C )Transducer in subxiphoid region• Transducer indicator aimed toward patient’s LEFT side• Aim US beam toward patient’s LEFT shoulder at a shallow angle• Identify liver, cardiac silhouette, RV, LV, RA, LA, and pericardial space• Easiest 4 chamber view to obtain, best view during CPR• Shallow angle, lots of depth required for visualization•

S U B x I P h O I D I v C ( S U B x I v C )Transducer in subxiphoid region• Transducer indicator aimed toward•

patient’s HEADSweep into RUQ to find IVC running•

through liver in a longitudinal planeMeasure IVC diameter just distal to •

hepatic veins to estimate CVP

P A R A S T E R n A L L O n G A x I S ( P S L A x )Transducer perpendicular to chest wall in LEFT 4-6th parasternal space• Transducer indicator aimed toward patient’s RIGHT shoulder• Identify RV, LV, LA, mitral valve, aortic valve, aortic root, and descending thoracic aorta • behind the LABest view for measurement of aortic root diameter (normal < 3.8 cm) • Best view for LV function estimation• Assess LV wall thickening, change in size of LV cavity, force and speed of valve opening•

P A R A S T E R n A L S h O R T A x I S ( P S S A x )Transducer perpendicular to chest wall in LEFT 4-6th parasternal space• Transducer indicator aimed toward patient’s LEFT shoulder• Rotated 90 degrees clockwise from PSLAX• Identify RV, LV, and papillary muscles indenting the LV• Best view for regional LV function (SALPI going clockwise around LV from septum)•

A P I C A L 4 C h A M B E R ( A 4 C )Transducer at PMI• Transducer indicator aimed toward patient’s LEFT axilla• Aim US beam toward patient’s RIGHT shoulder at a shallow angle• Identify LV, mitral valve, LA, RV, tricuspid valve, and RA• Best view for RV dilation (normal RV : LV ratio is < 0.6 : 1 measured at valve leaflets)•

R E C O M M E n D E D I M A G E S T O S A v ESave AT LEAST 3 of the above views• Include any additional views showing pathology•

IvC Size Respiratory Change Estimated CvP

< 1.5 cm Total Collapse 0 - 5 mm hg

1.5 - 2.5 cm > 50% Collapse 5 - 10 mm hg

1.5 - 2.5 cm < 50% Collapse 11 - 15 mm hg

> 2.5 cm < 50% Collapse 16 - 20 mm hg

> 2.5 cm no Change > 20 mm hg

FAST / TRAUMA

fast / trauma POCkET REFEREnCE GUIDE

SUBx

4C

RU

qLU

qPE

LvIS

SA

GPE

LvIS

TR

v


Identification of Free Fluid in the setting of:•

Blunt Trauma•

Penetrating Trauma•

Unexplained Hypotension•

Trauma in Pregnancy•

FAST / TRAUMA

POCkET REFEREnCE GUIDE fast / trauma

G E n E R A L P O I n T SUse either the • C60 curved or P21 phased array transducerSelect the • Abdominal preset from exam type

CARDIAC v IE WS (ChOOSE OnE v IE W FROM BELOW ) SUBxIPhOID 4 ChAMBER (SUBx 4C)

Transducer in subxiphoid region• Transducer indicator aimed toward patient’s RIGHT side• Aim US beam toward patient’s LEFT shoulder at a shallow angle• Identify liver, cardiac silhouette, RV, LV, RA, LA, and pericardial space• Look for free fluid in pericardial space• Shallow angle, lots of depth required for visualization•

PARASTERnAL LOnG AxIS (PSLAx) (nOT PICTURED - SEE CARDIAC GUIDE)Transducer perpendicular to chest wall in LEFT 4-6th parasternal space• Transducer indicator aimed toward patient’s RIGHT shoulder• Identify RV, LV, LA, mitral valve, aortic valve, and aortic root• Look for free fluid in pericardial space•

R U q v I E WTransducer on patient’s RIGHT flank, mid-axillary line, 10-12th rib space• Transducer indicator aimed toward patient’s HEAD in coronal plane• Identify liver, kidney, and diaphragm• Sweep transducer anterior and posterior to visualize all potential spaces• Look for free fluid above diaphragm, in Morison’s pouch between liver and kidney, • and in the pericolic gutter at the inferior pole of the kidney

L U q v I E WTransducer on patient’s LEFT flank, posterior axillary line, 10-12th rib space• Transducer indicator aimed toward patient’s HEAD in coronal plane• Identify spleen, kidney, and diaphragm• Sweep transducer anterior and posterior to visualize all potential spaces• Look for free fluid above diaphragm, between diaphragm and spleen, between • spleen and kidney and in the pericolic gutter at the inferior pole of the kidneyGas shadow means transducer placement is too anterior or inferior•

P E L v I S v I E W S ( P E R F O R M B O T h v I E W S B E L O W ) SAGITTAL

Transducer just above the pubic symphysis• Start in a sagittal plane, transducer indicator aimed towards patient’s HEAD• Identify the bladder and sweep through pelvis from side to side• Look for free fluid anterior, posterior, or lateral to the bladder•

TRAnSvERSERotate transducer indicator to the patient’s RIGHT• Sweep through pelvis from superior to inferior• Look for free fluid superior, inferior, or lateral to the bladder•

R E C O M M E n D E D I M A G E S T O S A v ECardiac showing all 4 chambers and view of pericardial space• RUQ showing liver, kidney, diaphragm, and potential spaces • LUQ showing spleen, kidney, diaphragm, and potential spaces • Pelvis in sagittal and transverse planes showing bladder and potential spaces• Include any additional views showing pathology•

PnEUMOThORAx

Pneumothorax POCkET GUIDE

ThO

RA

CIC

SAG

CPD

SLI

DE

nO

CPD

SLI

DE

M-M

OD

E“S

EASh

OR

E”M

-MO

DE

“STR

ATO

SPh

ERE”


Suspected Pneumothorax•

Confirmation of Endotracheal Tube Placement•

PnEUMOThORAx

POCkET GUIDE Pneumothorax

G E n E R A L P O I n T SUse either the • L38 linear, C60 curved or P21 phased array transducerSelect the • Small Parts (L38) or Abdominal (C60, P21) preset from exam type

T h O R A C I C S A G I T TA LTransducer on upper chest, 2nd to 3rd rib space, mid-clavicular line•

Sampling additional sites along thorax will increase sensitivity, specificity, and • allow for determination of size if a PTX is present

Transducer indicator aimed toward patient’s HEAD in sagittal plane• Identify the ribs and rib shadows the key landmarks• Identify the PLEURAL LINE just below ribs•

Echogenic line formed by visceral and parietal pleura• Watch the pleural line for LUNG SLIDING•

Horizontal sliding motion will be seen if the pleural surfaces are opposed• Identify COMET TAIL artifacts if present•

Vertical reverberation artifacts arising from pleural line • When a PTX is present, air trapped between the pleural surfaces will scatter US waves • and lead to a LOSS of lung sliding and comet tail artifacts

C O L O R P O W E R D O P P L E R S L I D E ( C P D )Color Power Doppler can be used to accentuate lung sliding and save still images• Select Color from scan modes in right lower portion of keyboard• Toggle to CPD from Color mode using soft keys• Straddle the CPD box across pleural line• In normal cases, the chest wall will remain stationary while the lung slides below the • pleural line, leading to CPD slide artifact in the portion of the box below the pleural lineWhen a PTX is present, no CPD slide artifact will be present below the pleural line•

M - M O D EM-Mode can be used to accentuate lung sliding and save still images • Select M-Mode from scan modes in right lower portion of keyboard• Use track pad to toggle the M-Mode cursor across the pleural line between ribs• Push Update or the M-Mode key a second time to enter M-Mode• In normal cases, the chest wall will remain stationary while the lung slides below the • pleural line, leading to the “SEASHORE” signWhen a PTX is present, no motion will be seen below the pleural line, leading to the • “STRATOSPHERE” sign

R E C O M M E n D E D I M A G E S T O S A v EVideo clip of lung sliding and comets tails if present• Color Power Doppler slide if present• M-Mode image showing “SEASHORE” or “STRATOSPHERE” sign• Include any additional views showing pathology•

PELvIC

Pelvic POCkET GUIDE

Ev U

T SA

GEv

UT

COR

Ev A

Dx

SAG

TA S

AG

TA T

Rv


Identification of an Intrauterine Pregnancy•

Suspected Ectopic Pregnancy•

Suspected Ovarian Cyst and Ovarian Torsion•

G E n E R A L P O I n T SUse either the • ICT (EV), C60 curved or P21 phased array (TA) transducersSelect the • OB preset if HCG positive, GYN preset if HCG negative from exam typeEV approach allows earlier visualization of findings of pregnancy by about 1 week• Order of appearance of pregnancy findings:•

Double decidual sign, gestational sac, yolk sac (earliest reliable sign of IUP), • fetal pole, fetal cardiac activity

E n D O v A G I n A L ( E v )Introduce the ICT transducer into the vagina in a sagittal plane•

Transducer indicator aimed toward • CEILINGIdentify bladder, uterus, endometrial stripe in uterus, and cervix• Sweep transducer from side to side through lateral boundaries of uterus• Rotate the transducer 90 degrees counterclockwise to coronal plane•

Transducer indicator aimed toward patient’s • RIGHTSweep transducer anterior and posterior though uterus• Look for any free fluid in anterior and posterior cul-de-sacs• Scan any intrauterine contents ONLY AFTER sweeping through uterus in both planes• Take any appropriate fetal measurements (GS diameter, CRL, M-Mode FHR)• Scan laterally into the adnexa in a sagittal plane• Identify iliac vessels as key anatomic landmark• Ovaries usually lie adjacent to iliac vessels• Scan through ovaries in both planes• Use CPD and spectral Doppler to assess ovarian flow•

T R A n S A B D O M I n A L ( TA )Start in a in a sagittal plane just above the pubic symphysis•

Transducer indicator aimed toward patient’s • HEADIdentify bladder, vaginal stripe, cervix, and uterus superior to bladder• Sweep transducer from side to side through lateral boundaries of uterus• Rotate the transducer 90 degrees counterclockwise to transverse plane•

Transducer indicator aimed toward patient’s • RIGHTSweep transducer anterior and posterior though uterus• Look for any free fluid in anterior and posterior cul-de-sacs• Scan any intrauterine contents ONLY AFTER sweeping through uterus in both planes• Take any appropriate fetal measurements (GS diameter, CRL, M-Mode FHR)• Scan laterally into the adnexa in a sagittal plane• Identify iliac vessels as key anatomic landmark• Ovaries usually lie adjacent to iliac vessels• Scan through ovaries in both planes• Use CPD and spectral Doppler to assess ovarian flow•

R E C O M M E n D E D I M A G E S T O S A v EEndovaginal•

Sagittal view showing uterus, endometrium, cervix, and cul-de-sacs• Coronal view showing uterus, endometrium, and cul-de-sacs• Include any additional views showing findings related to IUP and pathology •

Transabdominal• Sagittal view showing bladder, vaginal stripe, cervix, and uterus and cul-de-sacs• Transverse view showing uterus, endometrium, and cul-de-sacs• Include any additional views showing findings related to IUP and pathology•

PELvIC

POCkET GUIDE Pelvic

US-GUIDED vASCULAR ACCESS

us-Guided vascular access POCkET GUIDE

IJ L

On

GPE

RIP

h LO

nG

IJ S

hO

RT

PER

IPh

ShO

RT


Ultrasound-Guided Central Venous Access•

Ultrasound-Guided Peripheral Venous Access•

Ultrasound-Guided Peripheral Arterial Access•

US-GUIDED vASCULAR ACCESS

POCkET GUIDE us-Guided vascular access

G E n E R A L P O I n T SUse either the • L38 or L25 linear array transducerSelect the • Vascular preset from exam typeReal-time dynamic guidance has higher success rates, lower complication rates, and • shorter time to access compared to static guidanceNeedle location is identified in real time by:•

Ring-down artifact - reverberation artifact causing bright reflection with • posterior echoesSoft tissue movement•

Arteries and veins can be differentiated by location, compression, and by Doppler• Deep veins are paired with arteries, peripheral veins run alone• Principles of central and peripheral access are similar• Long axis approach allows better visualization of needle and needle tip throughout • the procedure and is a technically simpler approachShort axis approach allows better visualization of surrounding structures but makes • visualization of the needle and needle tip more difficult

L O n G A x I S ( I n P L A n E )Obtain a long axis view of target vessel• Transducer indicator aimed towards patient’s • HEAD or toward operator Align vessel, transducer, and needle• Use center of the probe as an aiming point• Needle enters from • LEFT side of screenWatch for soft tissue movement and ring-down artifact• Try to keep needle tip and shaft in view•

S h O R T A x I S ( O U T O F P L A n E )Obtain a short axis view of target vessel•

Internal Jugular• Transducer indicator aimed toward patient’s LEFT side•

This allows the operator standing at the head of the bed to correctly • move the needle medially and laterally

Carotid is deep, medial, round, non-compressible • IJ is superficial, lateral, oblong, and compressible•

Femoral (Not Pictured)• Transducer indicator aimed toward patient’s RIGHT side•

This allows the operator standing at the foot of the bed to correctly • move the needle medially and laterally

“NAVEL” - relationship of structures from lateral to medial • CFA is superficial, lateral, round, non-compressible • CFV is deep, lateral, oblong, and compressible•

Peripheral• Transducer indicator aimed toward patient’s RIGHT side• This allows the operator standing at the foot of the bed to correctly move the • needle medially and laterally

Center the probe over target vessel• Use center of the probe as an aiming point • Needle enters top of screen in center of field• Watch for soft tissue movement and ring-down artifact to identify needle location• Try to keep needle tip in view by fanning, sweeping, and rocking transducer•

R E C O M M E n D E D I M A G E S T O S A v ENeedle entering vein• Passage of guide wire•

AORTAAORTALearn More About EUS Consultants Products and Services

The Ultrasound OracleTM

The Ultrasound Oracle assists physicians, physician groups, hospitals, and

administrators to both understand and estimate the impact of implementing

a clinical bedside ultrasound program. Regardless of your specialty or clinical

practice setting, the Ultrasound Oracle gives you the means to project the return on

investment (ROI) when instituting an ultrasound program into your clinical practice.

Learn more about The Ultrasound Oracle by visiting www.ultrasoundoracle.com.

Case Reviews in Emergency Ultrasound DvDBring the power of point-of-care ultrasound to your clinical practice. Designed

to improve your clinical ultrasound practice, this DVD offers high-quality videos

covering AAA, abscess, cardiac, DVT, ectopic pregnancy, FAST basic, FAST

extended, gallbladder, nerve block, and vascular access. Each case begins with

a picture-in-picture video explaining in detail the scanning technique, followed

by pathology without expert commentary, then with expert commentary by world

renown expert Michael Blaivas MD RDMS.

The video Atlas of Bedside Ultrasounds CD-ROMWhen it comes to bedside ultrasound pathology, if you’ve never seen it, you just

might miss it! The Video Atlas of Abnormal Bedside Ultrasounds is the first CD-

ROM to help you identify, review and study ultrasound (US) pathology from over

10 different US applications, incorporating over 15 organ systems. 85 high quality

videos, compiled by our world renown experts in point-of-care ultrasound.

Other Products and ServicesOn-site ultrasound educational courses•

Program oversight through our “Virtual Ultrasound Director” program (peer •

and QA review of ultrasound images)

Distance learning tools including CD-ROMS, DVDS and internet based •

training with AMA Category 1 CME

Business education, quality assurance, and billing•

Ultrasound program design•

Ultrasound credentialing consultation•

Risk management case review and root cause analysis•

WWW.EUSCOnSULTAnTS.COMPhOnE: 302.832.9054


This guidebook is a “just the facts” reference covering

life-saving and point-of-care ultrasound applications.

It summarizes these critical applications in a compact,

simple, easy to use, pocket reference guide.

PERFECT FOR BEGInnER & ExPERT USERScritical care medicine emergency medicine trauma surgery

Aorta

Cardiac

FAST/Trauma

Pneumothorax

Pelvic

Ultrasound-Guided vascular Access

Transducer and preset choices

Transducer placement and angle

key anatomic landmarks

Scanning technique

Normal findings

Where to look for pathology

Pearls and pitfalls

Recommended images to save

STEP-By-STEPILLUSTRATED GUIDE

APPLICATIOnSCOvERED


EDU00120

An IllustratedStep-By-StepPocket Guide

Perfect for Beginner &

Expert Users

Critical Care MedicineEmergency Medicine

Trauma Surgery

Liver

Ao

GB

IVC

Spine

BowelGas

Hepatic Splenic

Celiac

2-D Image

M-Mode Image

Pleural Line

Chest Wall

No Lung Sliding

M-Mode Cursor

stephen j. Leech md rdms

Life-savingpoint-of-care

ULtrasoUnd appLicationsAorta, Cardiac, FAST/Trauma, Pneumothorax, Pelvic, US-Guided Access


Life Saving Pocket_guide

Documents

Transcript of Life Saving Pocket_guide