1
50M, MVA patient, HR 130bpm, BP 70/40
Internal bleeding ?
85M, sudden onset right flank pain, 8/10
Renal colic or AAA ?
48F, RUQ pain with fever
Cholecystitis ?
28F, low abdominal pain with shock, EIA (+)
Ectopic pregnancy ?
3
Cardiovascular Assessment
Heart Anatomy
Thoracic Cavity
Cardiac Axes
Transducer consideration
Classic routes of heart
Subxiphoid Four-Chamber View
Subxiphoid Short-Axis View
Subxiphoid Long-Axis View (IVC view)
Central Venous Pressure
IVC size for volume assessment IVC size (cm) <1.5 1.5-2.5 1.5-2.5 >2.5 >2.5 Resp. change Total collapse >50% collapse <50% collapse <50% collapse No change RA pressure (cm) 0-5 5-10 11-15 (>10) 16-20 >20
IVC size assessment
Parasternal Long-Axis View
Parasternal Short-Axis View
Parasternal Short-Axis View papillary muscle level
Parasternal Short-Axis View mitral valve level
Parasternal Short-Axis View aortic valve level
Mercedes Benz sign
Apical Four-Chamber View
Primary Indications
Detection of pericardial effusion and/or tamponade Evaluation of gross cardiac activity during CPR
Evaluation of global LV systolic function
Secondary Indications
Gross evaluation of intravascular volume status and cardiac preload Indentify acute RV dysfunction and/or acute pul. HTN for chest pain / dyspnea/or
hemodynamic instability
Pericardiocentesis guidance
Limitations for EUS
Focal wall motion abnormality Diastolic dysfunction Valvular abnormalities and function Intracardiac mass or thrombus, ventricular aneurysm, septal defect, AD, myocarditis, HCM, and vegetation
Technical limitations
Thorax abnormalities Pulmonary hyperinflation Obesity Patient cant cooperate Subcutaneous emphysema
Key component
Evaluation of pericardial effusion
Anechoic or hypoechoic fluid Complex echogenicity: inflammation, infection, malignancy, hemorrhage
Classification
None Small, <10 mm in width in dastole, noncircumferential Moderate, circumferential, not greater than 10 mm Large, 10-20mm in width Very large, > 20 mm and/or evidence of tamponade
Pericardial Effusion
Pericardial Effusion
Key component
Echocardiographic evidence of tamponade
Diastolic collapse of any chamber in the presence of moderate or large effusion Hemodynamic instability with a moderate or large pericardial effuion
Cardiac Tamponade
US Guided- Pericardiocentesis
Subcostal approach
Traditional approach Blind Increased risk of injury to liver, heart
Echo-guided
Left parasternal preferred for needle entry or Largest area of fluid collection adjacent to the chest wall
Technique
Pericardial Effusion / Tamponade
Tamponade
Clinical diagnosis Circulatory collapse due to pericardial effusion
Subxiphoid approach is the best window
Effusion location inferior & posterior
Echo evidence of tamponade
Diastolic collapse of the right side of the heart Plethoric IVC without inspiratory collapse
Chest
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Why such a delay for lung ultrasound to become popular ?
Principles of Lung Ultrasound
1. 2. 3. 4. 5. 6. 7. Dependent versus Nondependent disorders Lung surface is extensive All lung signs arise from the pleural line Analyze artifacts Dynamic signs Acute disorders contact the thorax surface A simple & 2-D device meets this task
Earth-Sky Axis
Fluids want to descent, gases to rise. Lung disorders
Dependent: PLE, consolidation, . Non-dependent: PTX, interstitial syndrome, .
Define the scanning situation
Patient position
Landmarks of the chest wall
Lung surface: 1500cm2 Position: as stethoscope 9 areas
Anterior zone (1-4) Lateral zone (5,6) Posterior zone (S,M,L)
4 stages
1. anterior 2. lateral 3. portion of posterior 4. posterior
Landmarks of the chest wall
Lung surface: 1500cm2 Position: as stethoscope 9 areas
Anterior zone (1-4) Lateral zone (5,6) Posterior zone (S,M,L)
4 stages
1. anterior 2. lateral 3. portion of posterior 4. posterior
Degree of aeration and US signs Key concepts: Air versus Water
Degree Pathologic disorder
100% 98% 95% 80% 10% 5% 0% Pneumothorax Normal lung Ground-glass areas Alveolar consolidation Atelectasis Pleural effusion
Ultrasound pattern
A lines & Lung sliding (-) A lines & Lung sliding (+) B3 lines Hepatization & air bronchograms (++) Hepatization & air bronchograms (-) Anechoic collection
Thickening of the interlobular septa B7 lines
Normal Landmark Bat sign
Rib
Pleural line A-line
Normal dynamic lung pattern Lung sliding: all-or-nothing rule Seashore sign
Rule out pneumothorax
Normal static lung pattern A line & B line
A lines and B lines cannot be visible at the same location
Comet-tail artifact Lung rockets
B-line
Rule out pneumothorax Indicate interstitial syndrome
88F with respiratory failure
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Normal versus APE
Comet-tail artifact
E-line
Parietal emphysema
Pneumothorax
Rule out pneumothorax all-or-nothing rule
Stratosphere sign (Barcode Sign)
Lung sliding (-) Sensitivity 100% Specificity 78% A line sign (No B line) Sensitivity 100% Specificity 60%
Pneumothorax
Sensitivity 66% Specificity 100%
Lung point
Pneumothorax
Lichtenstein DA, et al. Inten Care Med 2000;26:1434-1440
Explanation of lung point
Sensitivity 66% Specificity 100%
Lung point
Pneumothorax
Lichtenstein DA, et al. Inten Care Med 2000;26:1434-1440
Signs of PTX
No lung sliding No B line No lung pulse Presence of lung point
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MSK
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Outlines
US anatomic considerations Skin and soft tissue infection Long Bony fracture evaluation
Skin Subcutaneous tissue Fascial planes Muscles Tendon
Echogenic Hypoechoic Traverse by irregular strands of hyperechoic connective tissue Hyperechoic; regular thickness Striated appearance on long axis scan Fibrillar; echogenic Anechoic (Artery versus Vein) Irregular, circular, echogenic; with hypoechoic rim Echogenic cortices and dense acoustic shadows
Vascular structures Lymph nodes Bones
(5-10MHz) (depth)(focus) (longitudinal & transverse) & (Split screen)
Stand-off pad Water/gel-filled glove Water bath technique
Water/gel-filled glove
EUS &
&
Cellulitis Subcutaneous abscess
Cobblestone-like appearance Variable appearance Most: hypoechoic; spherical mass Content:
Hyperechoic sediment Septae Gas Isoechoic or hyperechoic Liquefied pus
induced motion of the content
Necrotizing fasciitis
Marked thickened of SC layer A layer of anechoic fluid, Subcuatneous gas
greater than 4 mm adjacent to deep fascia Acoustic shadow Reverberation artifact
Cellulitis
Nonspecific Indicative of edema Skin Subcutaneous tissue Compare to unaffected side
Normal v.s. Cellulitis
EUS improves accuracy of superficial abscess detection
Squire BT, et al. AEM. 2005;12:601-606
NTUH experience
diffuse thickening of the SC tissue a layer of fluid accumulation more than 4 mm in depth along the deep fascial layer 66 patients (17,NF) Sensitivity: 88.2% Specificity: 93.3% PPV: 83.3% NPV: 95.4% Accuarcy: 91.9
Yen ZS, et al. AEM. 2002;9:1448-1451
FASTER
Rib
Rib fracture
Rib fracture
Normal sternum
Sternal body fracture
Femur
Femoral shaft fracture
Tibial shaft fracture
JUICE BAR Juice119.pixnet.net
juice119@gmail.com
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