Emergency and Critical Ultrasound Course

Organized By:

PERSATUAN SONOGRAFI KECEMASAN DAN KRITIKAL MALAYSIA (SUCCES)

Table of Contents
Chapter 1 2 Introduction to Emergency Ultrasound 3 Physics and Technical Facts for the Beginner 7 Ultrasound in Trauma - The FAST Exam 25 Focused Assessment with Sonography in Trauma Abdominal Aorta Ultrasound Basic Emergency Echocardiography 65 6 89 7 Renal Ultrasound 107 Gallbladder Ultrasound 51

4 5

Pelvic Ultrasound 122 Deep Venous Thrombosis 142

10 149 11

Small Parts - Ocular Ultrasound

Ultrasound Guided Procedures in Emergency Medicine Practice - Vascular Access 159 Ultrasound Guided Procedures in Emergency Medicine Practice Pericardiocentesis 169 Ultrasound Guided Procedures in Emergency Medicine Practice Thoracentesis 174 Ultrasound Guided Procedures in Emergency Medicine Practice Paracentesis 179 Ultrasound Guided Procedures - V. Foreign Body Localization 183

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Chapter 1 Introduction to Emergency Ultrasound

Chapter 1: Introduction to Emergency Ultrasound

Scientists have been fascinated by the mechanisms of acoustics, echoes and sound waves for many centuries. Numerous famous individuals, including Aristotle, Leonardo da Vinci, Galileo Galilei, Sir Isaac Newton and Leonard Euler studied these phenomena. However, it was not until 1877 that Lord Rayleigh published a description of sound as a mathematical equation in The Theory of Sound. A few years later Jacques and Pierre Curie discovered the piezo-electric effect, that is, an electric potential is generated when mechanical pressure is applied to a quartz crystal. (1,2) 4

Interestingly, these findings date several years before the discovery of X-rays by Conrad Roentgen 1895. (3) Around 1900, with the invention of the Diode and Triode, powerful electronic amplification became possible, leading to the development of a high frequency ultrasonic device by scientists Langvin and Chilowsky. (4) This machine, called hydrophone, sent and received ultrasonic signals underwater. The Titanic disaster in 1912 and World War I accelerated investigations of underwater and airborne echo- ranging systems and antisubmarine warfare research, which lead to the beginning of SONAR (Sound Navigation and Ranging) and RADAR (Radio Detection and Ranging, using electromagnetic waves). The main industrial application of ultrasonic waves in the 1930s and 1940s became the detection of metal flaws. The first application of ultrasound as a medical diagnostic tool was published in 1942 by Karl and Friederich Dussik in Vienna. The Austrian brothers attempted to locate brain tumors and the cerebral ventricles by measuring ultrasound transmission through the skull. They concluded that if imaging of the ventricles was possible, the interior of the human body could also be visualized using ultrasound. This marked the beginning of diagnostic ultrasonography in the medical field. (5,6)

Over the next five decades, researchers improved and perfected ultrasound into a sophisticated diagnostic technology. Advances in computer science and electronics made the development of real-time ultrasound imaging possible. Diagnostic ultrasound is now used in two-, three- and even four-dimensional applications. It can be combined with color and power Doppler flow or other ultrasound modes and the exam can be performed with a portable machine. The portability of real-time bedside diagnosis has made ultrasound an attractive tool for emergency medicine. More and more emergency physicians have made bedside sonography part of their clinical practice and research activities (Figure 1).

Figure 1: Increase in research activity 1987- 2004 shown by the number of publications using PubMed search terms emergency medicine ultrasound. Implementing this diagnostic test into our daily practice can reduce morbidity and mortality for many medical and surgical emergencies while improving patient throughput and satisfaction. In addition, emergency ultrasound education has become part of our specialty training. Residents are required to practice and implement this tool early in their careers and strict credentialing guidelines exist for emergency physicians. (7)

The purpose of this web-based ultrasound guide is to expose more emergency physicians to this great diagnostic tool. It was initially developed for the beginner (the medical student) with little ultrasound experience. However, it also includes advanced concepts and skills for those with more ultrasound skill. We hope this guide will encourage more physicians to implement ultrasound in their everyday clinical practice. Ultrasound is an extremely valuable diagnostic tool and with the appropriate knowledge, physicians might be able to improve its utilization compared to other diagnostic tests such as CT or MRI. (8) References

1. Lord Rayleigh JWS. The theory of sound. (1896). Macmillan, London, 2nd edition. Dover Publications: New York. Reprinted 1945. 2. Curie J, Curie P. Dveloppement par compression de llectricit polaire dans les cristaux hmidres faces inclines. Bulletin de la Socit Minralogique de France.1880;3:90-93. 3. Rntgen WC. ber eine neue Art von Strahlen. Mitteilung vom 28. Dezember 1895 an die Physikalisch-Medizinische Gesellschaft in Wrzburg. Sitzungsbericht der PhysikalischMedizinischen Gesellschaft Wrzburg,137,1895. 4. Chilowsky CM, Langvin MP. Procds et appareil pour production de signaux sousmarins dirigs et pour la localisation distances d'obstacles sons-marins. French patent no. 502913;1916. 5. Dussik KT. ber die Mglichkeit hochfrequente mechanische Schwingungen als diagnostisches Hilfsmittel zu verwenden. Z Ges Neurol Psych.1942;174:153-168. 6. Woo J. A short history of the development of ultrasound in obstetrics and gynecology. 7. ACEP Policy Statement Ultrasound guidelines.

Chapter 2 Physics and Technical Facts for the Beginner

Chapter 2: Physics and Technical Facts for the Beginner

This chapter is designed to introduce the ultrasound beginner to basic concepts in ultrasound physics along with managing and manipulating a machine. Further reading material can be found in a variety of great ultrasound books, publications and on the internet. Only some basic and universal ultrasound machine functions will be explained every novice sonographer should spend time with the specific ultrasound machine used during his or her rotation in the emergency department. I. Basic Ultrasound Physics Sound is a mechanical wave, which requires a medium in which to travel. More accurately, it is a series of pressure waves propagating through a medium. One cycle of the acoustic wave is composed of a complete positive and negative pressure change. The wavelength is the distance traveled

during one cycle, the frequency of the wave is measured in cycles per second or Hertz (Cycles/s, Hz, illustration 1)

Illustration 1: The illustration shows a schematic drawing of wave length, pressure and amplitude.

For humans audible sound ranges between 16 Hz and 20.000 Hz (20 kHz). The hearing range of other species can be much higher than 20 kHz and is inaudible for us. These higher wave frequencies are referred to as ultrasound (Illustration 2).

Illustration 2: Hearing range in various animals and humans. The speed with which an acoustic wave travels through a medium is determined by the density and stiffness of the medium. The greater the stiffness, the faster the wave will travel. This means that sound waves travel faster in solids than liquids or gases. Acoustic waves are calculated to travel through human tissue at body temperature at approximately 1540 m/s (about one mile per second). When traveling through a medium the sound waves' intensity and amplitude decreases. This is called 'attenuation' and is the reason why echoes from deeper structures are weaker than echoes from superficial areas. The major cause of attenuation in soft tissue is absorption, which is the conversion of acoustic energy into heat. Other mechanisms are reflection, refraction and scatter. The sound wave encounters a boundary between two different media. Some of the wave bounces back towards the source as an echo (reflection). The angle of incidence is identical to the angle of the reflection. The remaining sound wave travels through the second medium (or tissue), but is 'bent' from its path. The angle of incidence will be different from the angle of transmission. The amount of deflection is proportional to the difference in the two tissues' stiffness. Scatter occurs when ultrasound waves encounter a medium with a nonhomogeneous surface. A small portion of the sound wave is scattered in random directions while most of the original wave continues to travel in its original path. 10

Illustration 3: Absorption, reflection, refraction. Scatter between the unhomogeneos border of two different mediums. The production of ultrasound waves is based on the so-called pulse echo' principle. The source of the ultrasound wave is the piezoelectric crystal, which is placed in the transducer. This crystal has the ability to transform an electrical current into mechanical pressure waves (ultrasound waves) and vice versa. Once the ultrasound wave is generated and travels through the medium, the crystal switches from sending into listening mode and awaits returning ultrasound echoes. Actually, over 99% of the time is spent 'listening'. This cycle is repeated several million times per second. This principle is called 'pulse echo' principle. Returning sound waves are converted into images on the ultrasound monitor. Diagnostic ultrasound used for common medical imaging uses frequencies between 2 and 20 million Hertz (Megahertz, MHz). Lower frequencies are able to penetrate deeper into tissue but show poorer resolution. On the other hand, higher frequency ultrasound will display more detail with a higher resolution in exchange for less depth 11

penetration. This trade-off between resolution and penetration is a very important principle when choosing your probes and frequencies.
(1-8)

II.

Ultrasound Modes The most important mode for the ultrasound-beginner is the B-mode. B-mode stands for brightness mode and provides structural information utilizing different shades of gray (or different brightness) in a two-dimensional image (Figure 1).

Figure 1: Sample of B-Mode image. M-mode stands for motion mode. It captures returning echoes in only one line of the B-mode image but displays them over a time axis. Movement of structures positioned in that line can now be visualized. Often M-mode and B-mode are displayed together on the ultrasound monitor. (Figure 2)

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Figure 2: M-Mode (lower portion of the image) combined with B-Mode image. In this still image the M-mode captures the movement of a particular part of the heart.

The Doppler mode follows very sophisticated and complex laws of physics. It utilizes a phenomenon called Doppler shift, which is a change in frequency from the sent to the returning sound wave. These changes or shifts are generated by sound waves reaching moving particles. The change of frequency/amount of shift correlates with the velocity and direction of particle motion. In simplified terms, the Doppler mode examines the characteristics of direction and speed of tissue motion and blood flow and presents it in audible, color or spectral displays. Color Doppler ultrasound is also called 'color-flow ultrasound'. It is able to show blood flow or tissue motion in a selected two-dimensional area. Direction and velocity of tissue motion and blood flow are color coded and superimposed on the corresponding B-mode image (Figure 3).

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Figure 3: Color Doppler image. Power Doppler: Unlike color Doppler, common power Doppler does not examine flow velocity or the direction of flow. It looks at the amplitudes of the returning frequency shifts and is able to detect even states of very low flow (Figure 4). This is of use when evaluating vascular emergencies such as testicular or ovarian torsion.

Figure 4: Power Doppler image. Spectral Doppler consists of a continuous and pulsed-wave form. Continuous wave Doppler is often available as a separate small hand14

held unit containing discrete transmitting and receiving piezo-electric crystals. This allows for simultaneous transmitting of ultrasound waves and receiving of returning Doppler shift signals, which are converted to audible frequencies over a loudspeaker. No image is produced. This technique is often utilized at the bedside to demonstrate patent vessels or fetal heart tones in pregnancy. Pulsed-wave spectral Doppler shows the spectrum of the returned Doppler frequencies in a characteristic two-dimensional display. Venous flow demonstrates a more continuous, band like shape. Arterial flow shows a more triangular shape (Figure 5). (1-8)

Figure 5: Sample image of pulsed wave Doppler showing arterial flow. III. Artifacts Artifacts refer to findings seen on the ultrasound image that do not exist in reality. An artifact can be helpful when interpreting the image or it can confuse the examiner. Several commonly encountered artifacts are mentioned below. Attenuation Artifacts: Shadowing: This artifact is caused by partial or total reflection or absorption of the 15

sound energy. A much weaker signal returns from behind a strong reflector (air) or sound-absorbing structure (gallstone, kidney stone, bone, figure 6).

Figure 6: Attenuation (shadowing) artifact caused by gallstones. Posterior Enhancement: In posterior enhancement, the area behind an echo-weak or echo-free structure appears brighter (more echogenic) than its surrounding structures. This occurs because neighboring signals had to pass through more attenuating structures and return with weaker echoes (Figure 7).

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Figure 7: Posterior enhancement, side lobe and mirror artifact. Edge Shadowing: The lateral edge shadow is a thin acoustic shadow that appears behind edges of cystic structures. Sound waves encountering a cystic wall or a curved surface at a tangential angle are scattered and refracted, leading to energy loss and the formation of a shadow.

Figure 8: Edge artifact.

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Propagation Artifacts: Reverberation: Reverberation occurs when sound encounters two highly reflective layers. The sound is bounced back and forth between the two layers before traveling back. The probe will detect a prolonged traveling time and assume a longer traveling distance and display additional reverberated images in a deeper tissue layer (Figure 9).

Figure 9: Sample of reverberation artifact.

Comet Tail: A comet tail artifact is similar to reverberation. It is produced by the front and back of a very strong reflector (air bubble, BB gun pellet). The reverberations are spaced very narrowly and blend into a small band (Figure 10).

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Figure 10: Comet tail artifact. Mirror Imaging: If a structure is located close to a highly reflective interface (such as the diaphragm), it is detected and displayed in its normal position. However, the strong reflector causes additional sound waves to bend towards the neighboring anatomy, from where they are bounced back towards the strong reflector and return to the transducer. These sound waves have a longer travel time and are perceived as an additional anatomic structure. The image is duplicated on the other side of the strong reflector (see figure 7). Miscellaneous Artifacts: Ring Down: The artifact is caused by a resonance phenomenon from a collection of gas bubbles. A continuous emission of sound occurs from the resonating structure causing a long and uninterrupted echo. It appears very similar to the comet tail artifact. Side Lobe: This artifact is caused by low energy side lobes of the main ultrasound beam. When an echo from such a side lobe beam becomes strong enough and returns to the receiver, it is assigned to the main 19

beam and displayed at a false location. Side-lobe artifacts are usually seen in hypoechoic or echo-free structures and appear as bright and rounded lines (see figure 7). IV. Probes Several different types of probes are commonly used in emergency departments. These transducers consist of the active element (the piezoelectric crystal), damping material and a matching layer. Different arrangements and forms of activation of the active element have lead to a variety of probes. The most common transducers utilized in the emergency department are listed below: Large Convex Probe: Main ED utilization is transabdominal sonography. Produces a sector image with a large curved top (see figure 1 and 9). The active element is arranged in a 'large curved line', also called large curved probe or transducer. Microconvex Probe: Utilized for transabdominal or transthoracic sonography. Produces a sector shaped image with a small curved top (see figure 68). The active element is arranged in a small curved or 'convex line', the probe can be called small curved transducer. Linear Probe: Main utilization is vascular sonography or evaluation of superficial soft tissue structures. It produces a rectangular image. The active element is arranged in a straight line. Intracavity Probe: Basically a microconvex probe on a large handle, its main utilization is endovaginal ultrasound. Sector Probe: Sector probes are also utilized in the emergency department, especially for transthoracic sonography. They produce a pie-shaped image with an angulated top (Figure 2). The active element is arranged in a circle and only parts of it are activated at a time and steered into the direction needed. This arrangement provides the sector probe with 20

an overall lower resolution as fewer 'crystals' are activated at one time. It has the advantage of requiring only very minimal skin contact or a very small sonographic window to obtain an image.(1-8)

Figure 11: Samples of probes commonly used in the emergency department. V. Common Terminology **The beginner needs to be familiar with a few commonly used terms: Image Interpretation:

Anechoic / Echolucent - Complete absence of returning sound waves, area is black. Hypoechoic - Structure has very few echoes and appears darker than surrounding tissue. Hyperechoic / Echogenic - Opposite of hypoechoic, structure appears brighter than surrounding tissue.

Image Acquisition / Probe Positions:

Transverse Plane - Also known as an axial plane or cross section, separates the superior from the inferior, or, the head from the feet. Sagittal Plane - Oriented perpendicular to the ground, separating left from right. The "midsagittal plane" is a sagittal plane that is exactly in the middle of the body. 21

Coronal Plane - Also known as the frontal plane, separates the anterior from the posterior or the front from the back. Oblique Plane - The probe is oriented neither parallel to, nor at right angles from, coronal, sagittal or transverse planes. Longitudinal Plane - The longitudinal plane is perpendicular to the transverse plane an can be either the coronal plane or sagittal plane.

Illustration 4: Spatial orientation.

VI. Your Machine Functions This section lists several important machine functions. They are more or less universal to all ultrasound equipment. Information is kept as general as possible to make it applicable to most machines. Make every effort to be as familiar as possible with most of these functions.

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On / Off - Remember how to switch the machine on before going into the patients room! Select / Change Probes - Select a specific probe. Set - Press to select from an activated menu; press to select/fixate a measurement point. Preset Menu - Select from preset menus such as general abdominal / vascular / procedures / OB or others. Use the scroll ball to navigate the menu. Scroll - Use the scroll ball (or in some machines a touch pad) to move the curser within the image or navigate through menus. After freezing an image-moving the scroll ball will display the last few images just before you pushed the freeze button (these images are called cineloops) Gain - Changes overall strength of returning echoes, functions as an amplifier. TGC - Changes strength of returning echoes in a certain depth. Depth Adjustment - Increases or decreases the depth of the ultrasound beam. Freeze - Push to freeze the current image. Print / Save - Will print a frozen image and/or save an image to a hard drive. Measurement / Cursor - After activating the first measurement button, a marker will appear on the screen. Use the scroll ball (or sometimes this is a touch pad) to place it over the desired area. By pushing set or mark - the first cursor will be placed there and second cursor will appear. Use the scroll ball and the set button to complete the process. Additional measurements can be obtained by pushing the cursor button again. Some machines will have extra measurement buttons.

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Change Mode - Pushing the 'M-mode' button will change the machine to M-mode, 'Doppler' button to Doppler mode, 'color Doppler' to color, etc. Most machines are set up so that a 'dual' screen appears when certain modes are selected (B-Mode combined with Doppler or M-Mode etc.; see figure 2 and 5 as examples). Focus - Will change or add focal zones to the image (Figure 12).

Figure 12: Display of focal zones on ultrasound monitor. Change Paper - Most printers are designed in a very similar way: Push open button on printer and insert new roll as shown inside the printer door, manually close the printer. Start printing! VII. References 1. Block B. The Practice of Ultrasound, A Step by Step Guide to Abdominal Scanning.Thieme: New York;2004. 2. Nielsen TJ, Lambert MJ. Physics and instrumentation. In: Ma OJ, Mateer JR., eds., Emergency Ultrasound. McGraw-Hill: New York; 2003:45-66. 3. Heller M, Jehle D. Fundamentals. In: Heller M , Jehle D, eds., Ultrasound in Emergency Medicine. Center Page: West Seneca, NY, 2nd edition,2002:1-40. 4. Hofer M. In: Hofer M, eds., Sono-Grundkurs. Ein Arbeitsbuch fr den Einstieg. 2nd edition, Thieme: Stuttgart,1997:6-10. 5. Msgen D. Physikalische und technische Grundlagen. In: Frst G, Koischwitz D, eds., Moderne Sonographie. Thieme: Stuttgart,2000:1-23. 24

6. Odwin CS, Dubinsky T, Fleischer AC. Appleton & Langes Review for the Ultrasonography Examination . 2nd edition, Appleton & Lange Reviews. McGraw-Hill: New York, 1997. 7. Kremkrau FW. Diagnostic Ultrasound. 6th edition, W. B. Saunders Company: New York,2002. 8. Smith RS, Fry WR. Ultrasound instrumentation. Surg Clin N Am.2004;84:953-971.

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Chapter 3 Ultrasound in Trauma The FAST Exam Focused Assessment with Sonography in Trauma

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Chapter 3: Ultrasound in Trauma - The FAST Exam Focused Assessment with Sonography in Trauma
I. Introduction and Indications Many trauma patients have injuries that are not apparent on the initial physical exam. Patients can present with distracting injuries or altered mental status. Significant bleeding into the peritoneal, pleural, or pericardial spaces may occur without obvious warning signs. The purpose of bedside ultrasound in trauma is to rapidly identify free fluid (usually blood) in the peritoneal, pericardial, or pleural spaces. Physicians in Germany and Japan began using routine bedside ultrasound for trauma patients in the 1970's.(1) In the United States emergency physicians started using this tool in the 1980s (2,3) and it has now become the initial imaging test of choice for trauma care in the United States and is part of the Advanced Trauma Life Support (ATLS) protocol developed by the American College of Surgeons. FAST is an acronym for Focused Assessment with Sonography in Trauma and has become synonymous with beside ultrasound in trauma.(14,15) The FAST exam, per ATLS protocoll, is performed immediately after the primary survey of the ATLS protocol. Ultrasound is the ideal initial imaging modality because it can be performed simultaneously with other resuscitative cares, providing vital information without the time delay caused by radiographs or computed tomography (CT). The concept behind the FAST exam is that many life-threatening injuries cause bleeding. Although ultrasound is not 100% sensitive for identifying all bleeding, it is nearly perfect for recognizing intraperitoneal bleeding in hypotensive patients who need an emergent laparotomy and for diagnosing cardiac injuries from penetrating trauma.(6-9) Recently, research studies have shown that bedside ultrasound is equivalent to, or better than, chest radiography for identifying a hemothorax or pneumothorax in trauma patients.(10-13) For this reason some trauma centers have begun performing an extended FAST exam (EFAST), evaluating for pneumo- and hemothorax in addition to intraperitoneal injuries.(10,11,16) Emergency physicians are trained to practice in a variety of different settings. Depending on the skill of the operator and the practice 27

setting, the FAST exam can be used in a variety of different ways to guide clinical decision-making.(16,17) Physicians should understand the potential applications of trauma ultrasound as well as the common pitfalls and their own technical limitations. It is important to recognize the imperfect nature of such exams, but sonographers who master this challenge, will find it an invaluable tool in the care of trauma patients.
(16-18)

Specific Indications: Penetrating Cardiac Trauma Bedside ultrasound performed by emergency physicians significantly decreases mortality in patients with penetrating cardiac injuries.(9) Many patients with stab wounds to the heart dont suffer significant blood loss because the wound in the pericardium seals, creating a pericardial effusion. Cardiac tamponade will usually develop, but may be delayed by several minutes or even hours. Prior to the development of tamponade patients will be relatively asymptomatic. When symptoms eventually develop, clinical decompensation occurs rapidly resulting in shock and then cardiac arrest. The classic signs of Becks triad are not commonly present and are difficult to appreciate by physical exam alone. The key to managing penetrating chest trauma is to identify a developing pericardial effusion as early as possible, before tamponade and cardiac arrest occurs. All patients with penetrating chest injury should be screened for a potential pericardial effusion. If an effusion is present cardiac injury is assumed until proven otherwise and the patient should go directly to the operating room for a pericardial window or sternotomy. Blunt Cardiac Trauma Significant blunt cardiac injury is relatively uncommon. Most patients who suffer severe cardiac injury such as rupture of the free ventricular wall die quickly. One research report described patients with blunt cardiac rupture who were rapidly diagnosed and aggressively managed because of early bedside ultrasound. The authors stressed the importance of prompt cardiac ultrasound in all patients with significant blunt chest trauma.(19) Cardiac rupture causes a pericardial effusion, which will be easily recognized during the FAST exam. Severe global ventricular dysfunction may also be noted during the FAST exam, more likely the result of severe acidosis from hypovolemic shock than blunt

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cardiac injury. Although blunt cardiac rupture is rare, the cardiac portion of the FAST exam should still be performed on all patients with significant blunt chest trauma, especially those who are hypotensive.
(19)

Blunt Abdominal Trauma During the last decade, the most commonly studied use of the FAST exam and most of the trauma ultrasound research was performed on patients with blunt abdominal injuries. Intraperitoneal bleeding after blunt trauma is common. It is usually the result of a spleen or liver injury and difficult to diagnose on physical exam. The FAST exam is an ideal initial screening modality for early recognition of intraperitoneal blood since it is rapid, safe and sensitive and can be repeated if the patients status changes. Penetrating Abdominal Trauma Although many studies limit analysis of the FAST exam to the setting of blunt trauma, it appears to be equally sensitive for detecting hemoperitoneum in patients with penetrating trauma.(4,23-25) In addition it can be used to help prioritize initial management in patients with multiple penetrating injuries or an unknown missile trajectory.(26) Within minutes it allows clinicians to know to concentrate initial efforts on a cardiac, chest and or intraperitoneal injury. The sensitivity of the FAST exam for determining the need for laparotomy is only about 50%.(27) Bowel injuries are very common in penetrating trauma and the FAST exam does not detect most of these injuries. Some clinicians think that this low sensitivity makes the FAST exam less useful in penetrating trauma, but others advocate it as a valuable tool to help assess for significant hemoperitoneum and to help prioritize management when multiple penetrating injuries are present.(4,5,17,24,26) Chest Trauma Hemothorax Bleeding into the pleural space, called a hemothorax, is common in both blunt and penetrating trauma. It can usually be managed with placement of a simple chest tube. About 200 mL of pleural fluid is required before it can be detected with a plain CXR.(29) Ultrasound is much more sensitive for detecting pleural fluid and can

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identify as little as 20mL in the pleural space.(30) It was found to be equivalent to CXR in detecting hemothoraces in trauma and also showed to be a much quicker procedure, taking about 1 minute versus 15 minutes for chest radiography.(12,13) Chest radiographs are still necessary in trauma patients to evaluate the mediastinum, lung parenchyma and several other anatomic features. Ultrasound can be used during the initial minutes of the trauma evaluation to determine if urgent chest tube placement is necassary. A chest radiograph can then be obtained after chest tube placement. This approach saves valuable time when managing an unstable multiple-trauma patient.(13,17,28) Pneumothorax Using ultrasound to evaluate for a pneumothorax is a relatively new concept but it is easy to learn. Pneumothoraces are common in trauma and more than half are missed on a supine chest radiograph. (31) Bedside ultrasound has been shown to be equal or more sensitive than CXR for detecting this lung injury.(10,11,31-34) Using ultrasound to look for occult pneumothoraces is most important in situations where missing one could result in significant deterioration, especially patients requiring positive pressure ventilation or helicopter transport. Computed Tomography (CT) has many advantages over the FAST exam. CT of the abdomen is better than ultrasound for showing parenchymal injury and the source of intraperitoneal bleeding. CT is useful to differentiate solid organ injury from bowel injury or other causes of hemoperitoneum and it is far superior demonstrating retroperitoneal bleeding. Modern CT scanners can also use abdominal/pelvic images to reconstruct bone windows and rule-out fractures of the spine and pelvis. Unfortunately, CT is very expensive, exposes patients to radiation and usually requires a bolus of IV contrast material. Because of these problems ultrasound will always have certain advantages over CT. When is Trauma Ultrasound Most Useful? Since CT has better accuracy for diagnosing torso injuries, the FAST exam is most useful in situations where CT is not practical due to time constraints or when CT scan can be reasonably avoided.

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Clinical scenarios where the FAST is most useful: 1. Hemodynamically unstable patients, when the cause of hypotension is unclear. 2. Patients who need an emergent bedside procedure. 3. Patients at a community hospital who require transfer to a trauma center. Consider pericardiocentesis if a pericardial effusion is found, consider early blood transfusion for significant hemoperitoneum, and consider a chest tube if a hemothorax or pneumothorax is discovered, especially if aeromedical transport is planned 4. Intoxicated patients who can be observed and re-examined. 5. Patients with penetrating trauma with multiple wounds or unclear trajectory, especially with wounds in upper abdomen or lower chest 6. Patients with a concerning mechanism of injury but no indication for CT. Consider a period of observation and serial FAST exams. III. Anatomy See illustrations 1a,b and 2 for overview of anatomical structures examined with the FAST scan:

Illustration 1a

Illustration 1b

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Illustration 1a: Subxiphoid view of cardiac anatomy. Illustration 1b: Parasternal long axis view of cardiac anatomy.

Illustration 2a

Illustration 2b

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Illustration 2a & Illustration 2b This shows an overview of potential intraabdominal and thoracic spaces. These spaces are examined during the FAST exam to detect blood from organ or vascular injuries. IV. Scanning Technique and Normal Findings The FAST exam is often the first ultrasound exam that a novice clinician-sonographer will learn. Of course it is important to know relevant anatomy and have a good understanding of the standard scanning planes. Modern grayscale (B-mode) ultrasound images are 2 dimensional representations. Comprehensive ultrasound studies require scanning of every organ in 2 different planes, each plane at a 90-degree angle to the other. Fortunately, the FAST exam can be effectively performed with limited scanning planes, since we are only trying to find free fluid and not do a comprehensive survey of the involved organs. This approach makes the FAST exam easier to learn and less time consuming. The exam is performed in the supine position, normal findings show regular anatomy and no intraperitoneal or intrathoracic fluid. V. Abnormal Findings The purpose of the FAST exam is to find free fluid (usually blood) in the pericardial, pleural, or intraperitoneal spaces. Free fluid is jet black and tends to collect in the most dependant areas and surround the organs Learning to perform the FAST exam simply involves learning how to visualize the heart, diaphragms, liver, spleen and bladder. Interpretation of the FAST exam involves learning where free fluid commonly collects adjacent to these organs. The volume of intraperitoneal blood that can be detected using the FAST exam depends on the skill of the operator and which views are obtained. To optimize sensitivity to detect the smallest amount of free fluid possible, it is important to obtain good images of multiple intraperitoneal sites.(20) A good quality FAST can probably reliably detect about 200 mL of free intraperitoneal fluid.(1) If good images of the pelvis are obtained, requiring more technical skill, even smaller volumes may be detected.(20,21) Placing a patient in the Trendelenburg position improves the sensitivity for detecting free fluid in the Morison's pouch view.(22) Trendelenburg positioning is reasonable

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when the pelvic view is indeterminate or difficult to visualize. Overall, the FAST exam is about 90% sensitive for detecting any amount of intraperitoneal free fluid. (4) As noted previously, and most importantly, the FAST exam is nearly perfect for detecting intraperitoneal bleeding that causes shock and requires an emergent laparotomy. (6,7) Cardiac Views There are two different cardiac views that can be performed with the FAST exam. One of the two is usually sufficient to evaluate for a pericardial effusion. It is important to learn both views, because one of the views may be easily obtained and the other impossible in any given patient. Subxiphoid Four-Chamber View: Place the probe in the subxiphoid region with the marker-dot toward the patients right side or right shoulder. Angle the probe toward the left shoulder (Figure 1). This view shows the right ventricle immediately adjacent to the left lobe of the liver (Figures 2, video clip 1). A pericardial effusion will be easily recognized between the liver and the heart (Video clip 2). Increasing the depth of the image and having the patient take a deep breath will improve chances of obtaining a good image.

Figure 1

Figure 2

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Figure 1: Position of the ultrasound probe for the subxiphoid view. Figure 2: Subxiphoid view. Parasternal Long-Axis View: Place the probe just to the left of the sternum in about the 4th or 5th intercostal space, directly over the center of the heart, with the marker-dot toward the 4 oclock position (Figure 3). This view shows the anterior and the posterior pericardium (Video clip 3). Sliding the probe toward the cardiac apex (toward the 4 oclock position) provides a good look at the apex. This view requires less depth and is easier to obtain in uncooperative patients.

Figure 3

Video clip 3

Figure 3: Parasternal long axis-view. Video clip 3: Parasternal long axis-view.

Abdominal and Lower Thoracic Views: When a patient is in the supine position the most dependant area in the upper peritoneum is Morison's pouch (between the liver and right kidney) and the most dependant area in the lower peritoneum is posterior to the bladder in the male and the pouch of Douglas (posterior to the uterus) in the female (see also illustration 2). Right Coronal and Intercostal Oblique Views: The easiest abdominal view to obtain is the view of Morisons pouch. To obtain this view place the probe in the mid-axillary line at about the 8th to 11th intercostal

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space with the marker-dot pointed cephalad (Figure 4). This gives a coronal view of the interface between the liver and kidney (Figure 5). It is important to follow the lower edge of the liver caudally until a good view of the tip is obtained (Figure 6).

Figure 4

Figure 5

Figure 4: Shows probe position. Figure 5 and 6: Morisons pouch view with focus on the liver tip (6).

Free fluid is usually seen in Morisons pouch or along the lower edge of the liver and around the lower tip of the liver (Figures 7-9 and video clip 4). Rib shadows may be prominent when the marker-dot is pointed directly cephalad. Shadows can be minimized by rotating the probe very slightly counter-clockwise, so the marker-dot is pointed toward the posterior axilla and giving an intercostal oblique view.

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Figure 7

Figure 8

Figure 7 8: Right upper abdominal view with fluid in Morisons pouch.

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Slide the probe cephalad to obtain a view of the diaphragm and look for pleural fluid (Figures 10, 11). Pleural fluid will appear as a jet black triangle just superior to the diaphragm (Figure 12). Also, this view may reveal free intraperitoneal fluid superior to the liver (Figure 13), between the liver, diaphragm and around the liver tip (Figure 14).

Figure 10

Figure 11

Figure 10: Probe position for left sided pleural fluid evaluation. Figure 11: Normal view right pleura and lung.

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Figure 12 Figure 12: Pleural fluid (red).

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Figure 13

Figure 14

Figure 13: Positive FAST scan with fluid between superior aspect of liver and diaphragm. Figure 14: Positive FAST with fluid at superior, anterior and inferior margin of the liver.

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Left Coronal and Intercostal Oblique Views: This is often the most difficult abdominal view to obtain. Place the probe in the posterioraxillary line at about the 6th to 9th intercostal space with the markerdot pointed cephalad, producing a coronal view. From this position the interface between the spleen and left kidney can be found. Free fluid is rarely seen between the spleen and the kidney but rather surrounding all other parts of the spleen or between spleen and diaphragm. To get rid of rib shadows, and to get a better view of the spleen, slide the probe cephalad and rotate it very slightly clockwise, producing an intercostal oblique view, so that the spleen (not the kidney) is seen (Figure 15 shows the probe position, figure 16 a normal left upper quadrant - LUQ - FAST view). The marker-dot will be pointed toward the posterior axilla. This view will allow good images of the lower tip and superior surface of the spleen, where intraperitoneal free fluid is most likely to collect. The diaphragm will also be seen in this view, just superior to the spleen (Figure 17). A pleural effusion will appear as a jet black stripe or triangle just superior to the diaphragm .

Figure 15

Figure 16

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Figure 15: Probe position for LUQ FAST. Figure 16: Normal perisplenic view.

Figure 17 Figure 17: Fluid surrounding the spleen. Video clip 5: Pleural effusion next to left diaphragm and spleen. Pelvic Views: Pelvic views are not as easy to obtain as right upper quadrant views, but since the pelvis is the most dependent part of the peritoneal space, it is the most likely place to see abdominal free fluid. It is a good idea to obtain both longitudinal and transverse views of the pelvis. If the longitudinal view is performed first, it is often easier to understand the anatomy and obtain good images. Place the probe in the midline just cephalad to the pubic bone with the marker-dot pointed cephalad.

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Figure 18: Probe position for longitudinal view of the bladder. Make sure the probe position is correct by actually placing the probe on the pubic bone and noting a bone shadow on the image. From this position sliding the probe slightly cephalad will produce a good longitudinal pelvic view. The bladder will be found just cephalad to the pubic bone, and can usually be found even if it is nearly empty. A full bladder will be triangular in shape. The lower angle of the bladder marks the border between the intraperitoneal space (left side of the image) and the true pelvic structures (right side of the image). In a male, free fluid will be seen along the intraperitoneal portion of the posterior to the wall of the bladder (Pic 6).

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Pic 6: Significant amount of free fluid posterior to the bladder. In a female, the body of the uterus sits in the intraperitoneal space just posterior to the bladder (Figure 19), so free fluid will be seen just posterior to the uterus. This space is often called the pouch of Douglas and sometimes just small amounts can be detected (Figure 20). Free fluid may also be seen completely surrounding the edges of the uterus (Figure 21). If the bladder is empty, it is very difficult to recognize pelvic free fluid in a male. In a female, the pouch of Douglas may still be identifiable, even when the bladder is empty.

Figure 19

Figure 19: Normal longitudinal view of bladder and uterus.

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Figure 20

Figure 20: Small amount of free fluid in pouch of Douglas. Figure 21: Large amount of free fluid (black) surrounding the uterus.

Figure 21

To obtain transverse views, simply rotate the probe 90 degrees, pointing the probe marker to the patients' right side (Figure 22). In

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transverse pelvic views, free fluid may be seen posterior to the bladder or uterus, or adjacent to the corners of the full bladder (Figure 23).

Figure 22

Figure 23

Figure 22: Probe position for transverse pelvic view. Figure 23: Small amount of free fluid posterior to the bladder.

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Anterior Thoracic Views: When using ultrasound to evaluate for a pneumothorax, the probe is usually placed on the anterior chest in the 3-4th intercostal space and midclavicular line. This is a starting point and a likely place to find a pneumothorax when the patient is in the supine position. Subsequent imaging can be done on any part of the chest wall if there is concern for a very small or loculated pneumothorax. A high frequency vascular/small parts probe can be used for this exam, but a standard curvilinear abdominal probe will also work well. The most important part about this exam is decreasing the depth setting, so that the ultrasound image shows a maximum depth of about 4 cm. The probe is placed in a longitudinal position with the marker-dot pointed cephalad. In this orientation rib shadows can be used to find the pleural plane. It is best to adjust the probe linearly until two ribs are apparent, one on each side of the image. Between the ribs the pleural interface will be apparent at the posterior border of the ribs. It is important to anchor the probe and hold it very still while looking for the sliding motion of the visceral pleura against the parietal pleura. If the sliding sign is not present, a pneumothorax is suspected. Comparing one side of the chest to the other may be helpful. Clip 7 shows this comparison between a normal sliding sign and an abnormal anterior thoracic view without pleural movement. Occasionally one may visualize the lead point of a pneumothorax, with visceral and parietal pleural movement inferior to an area without movement (Video clip 8).

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clip 7 Clip 7: Shows normal lung sliding

V. Pearls and Pitfalls

If the initial FAST exam is negative and clinical suspicion remains high, consider a repeat FAST exam after a short time period. Trendelenburg position may be required to visualize free fluid during perihepatic and perisplenic examination. Consider reverse Trendelenburg position while evaluating for hemothorax or pelvic free fluid. It is important to visualize as much perihepatic and perisplenic area as possible, not just one quick view. Multiple windows may be required to fully evaluate for free fluid. If visualization of the perisplenic view is inadequate, moving the probe caudad and posterior may improve the window. Subcutaneous emphysema may obscure visualization of underlying structures. Pericardial anechoic or hypoechoic stripes that are circumferential usually represent pericardial fluid, whereas a focal anterior hypoechoic region may be normal pericardial fat. A focal posterior effusion, seen on the parasternal long axis view, may be a left pleural effusion rather than a pericardial effusion. The hypoechoic stripe of a pericardial effusion usually wraps around the apex of the heart. Perinephric fat, especially in obese patients, may be misinterpreted as intraperitoneal free fluid. Consider comparison views between each kidney. Free fluid isnt always blood; consider ascites, fluid related to a ruptured ovarian cyst, ruptured bladder or peritoneal dialysis. Not all abdominal injuries produce free fluid. Bowel injury and solid organ injury without significant bleeding will not be detected by ultrasound.

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Clotted blood can generate various degrees of echogenicity and may be mistaken for normal surrounding soft tissue. The pelvic view should be completed prior to placement of a Foley catheter. Chest ultrasound can only detect a pneumothorax which is directly under the probe, so consider looking in several sites on the anterior chest. Lack of pleural sliding may indicate a pneumothorax, mainstem intubation or just poor ventilation. Comparing one side of the chest to the other is helpful but may be confusing if bilateral pneumothoraces are present. Dimming the lights in the exam room may provide the examiner with an improved display of ultrasound findings.

VI. References: 1. Tiling T, Bouillon B, Schmid A. Ultrasound in blunt abdomino-thoracic Trauma. in: Border J, Allgoewer M, Hansen S (eds.), Blunt Multiple Trauma: Comprehensive Pathophysiology and Care. Marcel Dekker: New York,1990;415-433. 2. Plummer D. Principles of emergency ultrasound and echocardiography. Ann Emerg Med,1989;18:1291-7. 3. Jehle D, Davis E, Evans T, Harchelroad F, Martin M, Zaiser K, Lucid J. Emergency department sonography by emergency physicians. Am J Emerg Med,1989; 7:605-11. 4. Ma OJ, Mateer JR, Ogata M, Kefer MP, Wittmann D, Aprahamian C. Prospective analysis of a rapid trauma ultrasound examination performed by emergency physicians. J Trauma,1995;38:879-85. 5. Rozycki GS, Ochsner MG, Schmidt JA, Frankel HL, Davis TP, Wang D, Champion HR. A prospective study of surgeon-performed ultrasound as the primary adjuvant modality for injured patient assessment. J Trauma,1995;39:492-500.

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6. Rozycki GS, Ballard RB, Feliciano DV, Schmidt JA, Pennington SD. Surgeon-performed ultrasound for the assessment of truncal injuries: lessons learned from 1540 patients. Ann Surg,1998;228:557-67. 7. Wherrett LJ, Boulanger BR, McLellan BA, Brenneman FD, Rizoli SB, Culhane J, Hamilton P. Hypotension after blunt abdominal trauma: the role of emergent abdominal sonography in surgical triage. J Trauma,1996;41:81520. 8. Rozycki GS, Feliciano DV, Ochsner MG, Knudson MM, Hoyt DB, Davis F, Hammerman D, Figueredo V, Harviel JD, Han DC, Schmidt JA. The role of ultrasound in patients with possible penetrating cardiac wounds: a prospective multicenter study. J Trauma,1999;46:543-52. 9. Plummer D, Brunette D, Asinger R, Ruiz E. Emergency department echocardiography improves outcome in penetrating cardiac injury. Ann Emerg Med,1992;21:709-12. 10. Dulchavsky SA, Schwarz KL, Kirkpatrick AW, Billica RD, Williams DR, Diebel LN, Campbell MR, Sargysan AE, Hamilton DR. Prospective evaluation of thoracic ultrasound in the detection of pneumothorax. J Trauma,2001;50:201-5. 11. Kirkpatrick AW, Sirois M, Laupland KB, Liu D, Rowan K, Ball CG, Hameed SM, Brown R, Simons R, Dulchavsky SA, Hamiilton DR, Nicolaou S. Hand-held thoracic sonography for detecting post-traumatic pneumothoraces: the Extended Focused Assessment with Sonography for Trauma (EFAST). J Trauma,2004;57:288-95. 12. Ma OJ, Mateer JR. Trauma ultrasound examination versus chest radiography in the detection of hemothorax. Ann Emerg Med, 1997;29:312-6. 13. Sisley AC, Rozycki GS, Ballard RB, Namias N, Salomone JP, Feliciano DV. Rapid detection of traumatic effusion using surgeon-performed ultrasonography. J Trauma,1998;44: 291-7. 14. Scalea TM, Rodriguez A, Chiu WC, Brenneman FD, Fallon WF Jr, Kato K, McKenney MG, Nerlich ML, Ochsner MG, Yoshii H. Focused Assessment with Sonography for Trauma (FAST): results from an international consensus conference. J Trauma,1999;46:466-72.

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15. Rozycki GS, Shackford SR. Ultrasound, what every trauma surgeon should know. J Trauma,1996;40:1-4. 16. Reardon R, Moscati R. Beyond the FAST Exam: Additional Applications of Sonography in Trauma. in: Jehle D, Heller M (eds.) Ultrasonongraphy in Trauma: The FAST Exam, American College of Emergency Physicians: Dallas,TX. 2003;107-126. 17. Moscati R, Reardon R. Clinical Application of the FAST Exam. in: Jehle D, Heller M (eds.) Ultrasonography in Trauma: The FAST . American College of Emergency Physicians: Dallas,TX.2003;39-60. 18. Mandavia D, Kendall J. Pitfalls in Trauma Ultrasonography. in: Jehle D, Heller M (eds.),Ultrasonography in Trauma: The FAST Exam. American College of Emergency Physicians: Dallas,TX.2003;87-105. 19. Schiavone WA, Ghumrawi BK, Catalano DR, Haver DW, Pipitone AJ, L'Hommedieu RH, Keyser PH, Tsai AR. The use of echocardiography in the emergency management of nonpenetrating traumatic cardiac rupture.Ann Emerg Med,1991;20:1248-50. 20. Ma OJ, Kefer MP, Mateer JR, Thoma B. Evaluation of hemoperitoneum using a single- vs multiple-view ultrasonographic examination.Acad Emerg Med,1995;2:581-6. 21. Von Kuenssberg Jehle D, Stiller G, Wagner D. Sensitivity in detecting free intraperitoneal fluid with the pelvic views of the FAST exam. Am J Emerg Med, 2003;21:476-8. 22. Abrams BJ, Sukumvanich P, Seibel R, Moscati R, Jehle D. Ultrasound for the detection of intraperitoneal fluid: the role of Trendelenburg positioning. Am J Emerg Med,1999;17:117-20. 23. [No authors listed] Here's what new ED ultrasound guidelines say. ED Manag,2002;14: 5-7; suppl 1-9. 24. Boulanger BR, Kearney PA, Tsuei B, Ochoa JB. The routine use of sonography in penetrating torso injury is beneficial. J Trauma,2001;51:320-5. 25. Rozycki GS, Ochsner MG, Jaffin JH, Champion HR. Prospective evaluation of surgeons' use of ultrasound in the evaluation of trauma patients. J Trauma,1993;34:516-27.

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26. Tayal VS, Beatty MA, Marx JA, Tomaszewski CA, Thomason MH. FAST (focused assessment with sonography in trauma) accurate for cardiac and intraperitoneal injury in penetrating anterior chest trauma. J Ultrasound Med,2004;23:467-72. 27. Soffer D, McKenney MG, Cohn S, Garcia-Roca R, Namias N, Schulman C, Lynn M, Lopez P. A prospective evaluation of ultrasonography for the diagnosis of penetrating torso injury. J Trauma,2004;56:953-9. 28. Ma OJ, Mateer. Trauma, in: Ma OJ, Mateer J (eds.), Emergency Ultrasound, McGraw-Hill: New York.2003;67-88. 29. Juhl J. Diseases of the pleura, mediastinum, and diaphragm., in: Juhl J, Crummy A (eds.), Essentials of Radiologic Imaging.JB Lippincott: Philadelphia, PA. 1993;1026. 30. Rothlin MA, Naf R, Amgwerd M, Candinas D, Frick T, Trentz O. Ultrasound in blunt abdominal and thoracic trauma. J Trauma,1993;34:488-95. 31. Ball CG, Kirkpatrick AW, Laupland KB, Fox DL, Litvinchuk S, Dyer DM, Anderson IB, Hameed SM, Kortbeek JB, Mulloy R. Factors related to the failure of radiographic recognition of occult posttraumatic pneumothoraces. Am J Surg,2005;189:550-6. 32. Lichtenstein DA, Menu Y. A bedside ultrasound sign ruling out pneumothorax in the critically ill. Lung sliding. Chest,1995;108:1345-8. 33. Lichtenstein D, Goldstein I, Mourgeon E, Cluzel P, Grenier P, Rouby JJ. Comparative diagnostic performances of auscultation, chest radiography, and lung ultrasonography in acute respiratory distress syndrome. Anesthesiology,2004;100:9-15. 34. Lichtenstein D, Meziere G, Lascols N, Biderman P, Courret JP, Gepner A, Goldstein I, Tenoudji-Cohen M. Ultrasound diagnosis of occult pneumothorax. Crit Care Med,2005;33:1231-8.

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Chapter 4

Abdominal Aorta Ultrasound

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Chapter 4: Abdominal Aorta Ultrasound

I. Introduction and Indications A ruptured abdominal aortic aneurysm (AAA) is a vascular catastrophe responsible for 1-3% of deaths in men from the age 65-85 in developed countries. (1) AAA is the 13th leading cause of death in the United States, causing about 15,000, or 0.8% of all deaths annually. (2,3) Rupture from an AAA is the 10th leading cause of death in males over 50 and the incidence of AAA continues to increase.(1) Currently, the U.S. Preventative Services Task Force recommends that men from the age of 65-75 years who have ever smoked be screened once for an AAA by sonography. (4) The lethality of a ruptured AAA is devastating; the mortality rate after rupture approaches 90%. (3) Therefore, it is essential for the emergency medicine physician to recognize the presence of an AAA in an expeditious manner. A patient who presents with a ruptured AAA will usually not have the classic triad of hypotension, back pain, and a pulsatile abdominal mass. Wrong diagnoses such as gastrointestinal bleed, nephrolithiasis, and diverticulitis are often made. Delayed diagnosis can obviously prove detrimental to the patient with a symptomatic AAA. The physical exam is often unreliable in detecting the presence of an AAA and should never be used to rule it out. Abdominal palpation has been shown to have a moderate sensitivity of 68% in diagnosing an AAA. (5) Other modalities for detecting an AAA include conventional radiography, ultrasonography, computed tomography (CT), magnetic resonance imaging (MRI), and arteriography. Ultrasound, utilized since the 1980s to inspect the abdominal aorta, is an ideal method for detecting AAAs due to its accuracy combined with low cost, rapid 54

deployment, non-invasiveness, and avoidance of contrast material. (6) Multiple studies have demonstrated that physicians from varied disciplines outside of radiology can be highly accurate in finding an AAA using ultrasonography. (7,8,9) Kuhn et al. showed that emergency physicians can identify an AAA with 100% accuracy with only a brief 3 day training course. (7) The current indications by the American College of Emergency Physicians (ACEP) for obtaining an emergency medicine based ultrasound to detect an AAA include the presence of syncope, shock, hypotension, abdominal pain, abdominal mass, flank pain, or back pain especially in the older population. (10)

II. Anatomy The aorta passes through the diaphragm at the level of the 12th thoracic vertebral body. It lies slightly to the left of the midline and bifurcates at the level of the 4th lumbar vertebral body. The surface anatomy landmarks corresponding to these two points are the xiphoid process and the umbilicus. The length of the abdominal aorta is about 13 cm (6 inches) which is less than the length of iliac arteries from the bifurcation to the inguinal ligament. Most scanning of the aorta will therefore take place in the short distance between the sternum and the umbilicus. Immediately below the diaphragm, the celiac trunk is the first major vessel to arise from the aorta in the midline anteriorly. This short (usually less than 1 cm) vessel can often be seen sonographically in the transverse plane, dividing in a wide Y. The fork on the patients right is the common hepatic artery, heading to the porta hepatis; the fork on the patients left, is the splenic artery. This sonographic view is known as the seagull sign. About 1 cm inferior to the celiac trunk, again in the midline, arises the superior mesenteric artery (SMA), which often runs in a caudal direction immediately anterior and parallel to the aorta. Measurements of the proximal aorta to use as a comparison with distal measurements are made at this level. One centimeter below the SMA, the renal arteries arise on either side. Although these cannot be seen on a sagittal view of the aorta, they can sometimes be identified with careful transverse scanning. Thus, these three major vessels occur within about 3 centimeters of the

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diaphragm. 90% of all AAAs will occur distal to this point. With experience, it is easy to distinguish the aorta from the IVC, but initially they can be confused. Distinguishing features are listed in Table 1.

Illustration 1: Overview of the main branches of the abdominal aorta (CT= celiac trunk, SMA = superior mesenteric artery, IMA = inferior mesenteric artery).

IVC On patients right Compressible Thinner walls Usually respiratory variation Usually larger (can

Aorta On patients left Non-compressible Thick walls No respiratory variation Usually smaller (unless 56

depend on hydration AAA) status) Not pulsatile Pulsatile (simple) (or displays doublepulsatile swing = transmitting the cardiac atrial and ventricular pressure wave) Table 1: Sonographic features of the aorta vs. IVC.

Figure 1: A transverse image of the aorta shows a classic example of the seagull sign. The celiac trunk branches into the hepatic and splenic (S) arteries. The inferior vena cava (IVC) is seen to the left of the aorta.

III. Scanning Technique, Normal Findings and Common Variants Sonographic Technique A 3.5 MHz transducer is adequate for most abdominal scanning, including imaging of the aorta. A lower frequency may be needed in large patients, and a higher frequency will give more detail in thin

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ones. The aorta and iliac arteries are measured from outer wall to outer wall. The steps for aorta scanning are outlined in Table 2.

Table 2. Technique for ultrasound scanning of the aorta 1. Orientation. Start in the transverse plane (pointer to 9 oclock), high in the epigastrium, using the liver as a sonic window. Identify the vertebral body (a dark, rounded shape, with dense shadow). 2. Identify the aorta on the patients left, and the IVC (patients right) above the vertebral body on the ultrasound image. (If the patient is hypovolemic, use light probe pressure in order to avoid effacement of the IVC). 3. In real time obtain transverse images of the aorta from the celiac to the bifurcation. 4. If the gas-filled transverse colon obscures the aorta move the probe until you find a sonographic window between loops of bowel: rock the probe up and down without moving it across the patients skin to maximize the information attained through the window. 5. Frequently identifiable sonic windows in the upper abdomen include: 1. high in the epigastrium. Ask the patient to take a deep breath and hold to lower the liver margin. 2. above or around the umbilicus. 6. Obtain views of the iliacs if possible. 7. Rotate the probes pointer clockwise from the "9 o' clock" to the 12 oclock position for sagittal views from the celiac to the bifurcation.

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8. Attempt to obtain: 1. at least 3 transverse views, labeled, high, middle, low, with calipers. One view should show the maximal aortic diameter. 2. Sagittal view(s) from the celiac to the bifurcation 9. If an AAA is identified... 1. Does probe pressure reproduce symptoms? 2. Is there free fluid?

Figure 2 Figure 2: Transverse image of the normal proximal aorta (A) shown in its relationship to the vertebral body (arrow). IVC = inferior vena cava; H = hepatic artery; L= liver.

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Figure 2

Figure 3

Figure 3: Transverse image of the normal mid to distal aorta (A) and inferior vena cava (IVC) before the bifurcation into the iliac arteries. The vertebral body (arrow) causes a characteristic shadowing artifact.

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Figure 4: Longitudinal view of the normal proximal aorta showing the branches of the celiac artery and SMA. SMA = superior mesenteric artery; VB = vertebral body.

Special Techniques for Ultrasound Evaluation If bowel gas makes it difficult to obtain images, some or all the following can help: 1. Jiggle the probe, while applying gentle pressure. This sometimes allows the bowel to be gently moved aside. 2. Reposition the patient. 3. Obtain coronal views, using the liver as a window. The probe is placed in the 12 oclock position in the mid axillary line at or below the costal margin, directed slightly anterior. With practice, both the IVC and aorta can be seen running parallel in this view, with the aorta lying deep on the screen to the IVC. 4. Try imaging from below the umbilicus with the probe directed cephalad. 5. Try imaging the aortic bifurcation from an oblique angle with the probe placed lateral to the umbilicus (right or left) and pointing towards the spinal column (Figure 5).

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Figure 5: Longitudinal-oblique view of a normal lower aorta and bifurcation. (Image courtesy of B. Hoffmann, M.D.)

IV. Pathology An AAA is described as being a focal dilatation of the abdominal aorta of 150% of normal.(11,12,13) Although there is no established definition of aneurysm size, conventionally, an AAA is diagnosed when the diameter exceeds 3.0 cm. (1) It has been demonstrated that the risk of rupture for an AAA of 3.0 cm is less than 4% over 5 years; this risk, however, substantially increases for AAAs with larger diameters. (14) A true aneurysm by definition involves dilation of all three layers of the aorta: Intima, media, and adventitia. The majority of aneurysms are fusiform, affecting the entire circumference of the vessel. Saccular aneurysms are uncommon and affect only part of the aortic circumference. Treatment of AAA is entirely surgical. The first resection was performed in Paris in 1951. Prior to that, patients lived with their aneurysms until they ruptured, at which time they usually died. Aneurysms sometimes reached enormous size. In his description, Osler reports on AAAs in living patients, as well as pathological

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specimens where the tumour mass [was] as large as the adult head. (15)

Figure 6: Transverse image of a nearly 6 cm AAA with calipers measuring the aorta in the anterior-posterior direction.

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Figure 7: Transverse image of an AAA with an intraluminal thrombus. This figure demonstrates the importance of measuring the aorta from the outer walls.

V. Pearls and Pitfalls

Obtain measurements of the aorta from outer wall to outer wall. Since aneurysms will often contain a thrombus, one may accidentally mistake the inner rim of the thrombus for the aortic wall. Doing this will lead a falsely decreased measurement of the true aortic diameter. Avoid oblique or angled cuts if possible, especially with a tortuous aorta, which will exaggerate the true aortic diameter. Since images are often obtained from paramedian probe positions, and the aorta may be tortuous, it is simpler (and more accurate) to speak of longitudinal rather than sagittal sections of the aorta. Although axial resolution is usually greater than lateral resolution, transverse views are needed because many AAAs have larger transverse than AP diameter. (16) A small aneurysm does not preclude rupture: (17,18) Any symptoms consistent with rupture in a patient with an aortic diameter greater than 3.0 cm should have this diagnosis (or alternative vascular catastrophes) ruled out. Scanning should be systematically performed in real-time from the diaphragmatic hiatus to the bifurcation in order to avoid missing small, localized saccular aneurysms.

VI. References

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1. Sakalihasan N, Limet R, Defawe OD. Abdominal Aortic Aneurysm. Lancet.2005;365:1577-89. 2. Wilmink AB, Quick CG. Epidemiology and potential for prevention of abdominal aortic aneurysm. Brit J Surg.1998;85:5562. 3. Ernst CB. Abdominal Aortic Aneurysm. N Engl J Med.1993;328:1167-72. 4. U.S. Preventive Services Task Force. Screening for abdominal aortic aneurysm: recommendation statement. Ann Inter Med.2005;142(3):198-202. 5. Fink HA, Lederle FA, Roth CS, Bowels CA, Nelson DB, Haas MA. The accuracy of physical examination to detect abdominal aortic aneurysm. Arch Intern Med.2000;160(6):833-6. 6. Hermsen K, Chong WK. Ultrasound evaluation of abdominal aortic and iliac aneurysms and mesenteric ischemia. Radiol Clin N Am.2004;42:365-81. 7. Kuhn M, Bonnin RL, Davey MJ, Rowland JL, Langlois SL. Emergency department ultrasound scanning for abdominal aortic aneurysm: accessible, accurate, and advantageous. Ann Emerg Med.2000;36(3):219-23. 8. Lin PH, Bush RL, McCoy SA, Felcai D, Pasnelli TK, Nelson JC, Watts K, Lam RC, Lumsden AB. A prospective study of a hand-held ultrasound device in abdominal aortic aneurysm evaluation. Am J Surg.2003;186(5):455-9. 9. Riegert-Johnson DL, Bruce CJ, Montori VM, Cook RJ, Spittell PC. Residents can be trained to detect abdominal aortic aneurysms using personal ultrasound imagers: a pilot study. J Am Soc Echocardiogr.2005;18(5)394-7. 10. American College of Emergency Physicians. Policy Statement. 2001:Emergency Ultrasound Guidelines. 11. Johnston KW, Rutherford RB, Tilson MD, Shah DM, Hollier L, Stanley JC. Suggested standards for reporting on arterial aneurysms. Subcommittee on reporting standards for arterial aneurysms, Ad Hoc committee on reporting standards, Society for Vascular Surgery and North American Chapter, International Society of Cardiovascular Surgery. J Vasc Surg.1991;13:44450.

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12. Sox HJ, Huber JM (eds.) Guide to Clinical Preventive Services, Second Edition, Section I, Chapter 6. Copyright, Columbia-Presbyterian Medical Center. 13. Patel MI, Hardman DT, Fisher CM, Appleberg M. Current views on the pathogenesis of the abdominal aortic aneurysms. J Am Coll Surg.1995;181:371 82. 14. Vardulaki KA, Prevost TC, Walker NM, Day NE, Wilmink AB, Quick CR, Ashton HA, Scott RA. Growth rates and risk of rupture of abdominal aortic aneurysms. Br J Surg.1998;85:1674-1680. 15. Osler W. Aneurysm of the abdominal aorta. Lancet.1905;2:108996. 16. Cronenwett JL, Murphy TF, Zelenock GB, Whitehouse WM Jr, Lindenauer SM, Graham LM, Quint LE, Silver TM, Stanley JC. Actuarial analysis of variables associated with rupture of small abdominal aortic aneurysms. Surgery.1985;98:47282. 17. Miller J, Grimes P, Miller J. Case report of an intraperitoneal ruptured abdominal aortic aneurysm diagnosed with bedside sonography. Acad Emerg Med.1999;6(6),6614. 18. Darling RC, Messina CR, Brewster DC, Ottinger LW. Autopsy study of unoperated abdominal aortic aneurysms. Circulation.1977;56(3) Supp II:161 4.

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Chapter 5

67

Basic Emergency Echocardiography

Chapter 5: Basic Emergency Echocardiography

I. Introduction and Indications Cardiac ultrasound is a valuable skill set for medical professionals in multiple clinical scenarios including trauma, hypotension and cardiac arrest. The proper techniques to image the heart can be mastered with practice and familiarity with the ultrasound machine. Familiarity with the common echocardiographic windows provides a foundation upon which to interrogate these structures and make clinical decisions. As technology continues to improve, the education of future clinical providers becomes the rate-limiting step to fully implement the true potential of ultrasound. The twenty first century emergency physician may soon utilize bedside ultrasound to differentiate critical cardiac patient presentations by answering focused questions such as: Is there a pericardial effusion? Is tamponade present? What is the cardiac contractility? What is the intravascular volume status of my patient? This chapter will attempt to guide an emergency department medical provider in the necessary skills to acquire and interpret sonographic

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images of the heart and great vessels in the emergency medicine setting. II. Anatomy The appearance of cardiac anatomy on ultrasound can sometimes be confusing. It is difficult to derive a three-dimensional mental construct utilizing 2 dimensional images. The best way to learn anatomy is by reviewing the sonographic shapes and patterns displayed in 2 dimensions and continuously relate that to the 3 dimensional configuration. It is important to find sonographic landmarks to provide spatial orientation when viewing the heart from multiple planes. Echocardiography is a dynamic assessment and it is important to examine structures through the entire cardiac cycle. The normal heart sits in the left chest with its base anchored by the great vessels: the aorta, superior vena cava, and main pulmonary artery. The cardiac apex points anterior inferior and about 60 degrees to the left. The heart consists of two thicker walled ventricles, two thinner walled atria and four valves that separate flow between the chambers. The left heart is filled by 4 pulmonary veins draining into the left atrium. Blood flows between the anterior and posterior leaflets of the mitral valve into the thick walled left ventricle. The left ventricle (LV) is thicker walled and is the largest of the four chambers in the normal heart. The LV is by far the main focus in echocardiography and learning nuances of its appearance aids the experienced sonographer. The cardiac apex provides a distinctive landmark from which to orient the image. In the longitudinal (long) parasternal (LPS) view the cardiac apex is on the left side of the screen while the apex is on the right side of the screen in the subxiphoid (SUX) view. From the LV, blood flows into the tubular ascending aorta and into the systemic circulation. The ascending aorta, otherwise known as the Left Ventricular outflow tract (LVOT), is shaped like a tube on long axis. The aortic valve can be seen in this plane as two of the three aortic leaflets (typically the non coronary cusp and right coronary cusp) mark diastole (closed) and systole (open). Occasionally the left coronary cusp is seen in this imaging plane. In the short axis parasternal view, tilting the probe cephalad can image the aortic valve in cross section. This is the

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so-called Mercedes Benz sign where all three valves are displayed at the ascending aortic root. Superior and inferior vena cava drain into the right atrium and can help orient the sonographer. These structures lead the operator to the right side of the heart. In the subxiphoid view of the heart, the left lobe of the liver is used as an acoustic window to image the three hepatic veins draining into the IVC as it passes through the diaphragm and drains into the right atrium. From there, blood flows through the tricuspid valve into the triangular shaped right ventricle. The right ventricle size is determined by forces influencing preload (e.g. intravascular volume, right atrial and tricuspid function) and afterload (e.g. pulmonary artery pressure). It can assume many shapes depending on the disease state. The pulmonary arteries are difficult to see yet can be visualized in the short axis parasternal view. The right heart normally carries deoxygenated blood to the lungs and is separated from the left heart by the interatrial septum and the thick walled interventricular septum. A variety of congenital cardiac malformations are common and should be considered when normal patterns deviate. Cardiac anomalies have varying prevalence among differing populations. The normal heart will change morphology and function with age and comorbid conditions.

III. Scanning Technique and Normal Sonographic Findings Probe selection: Typically, cardiac imaging requires the use of intercostal acoustic windows. This necessitates the use of probes with small footprints. Phased or microconvex arrays are utilized for this reason. Imaging in adults requires the use of lower frequencies (typically 2-4 MHz). Curvilinear probes can be used to image the heart, especially in the subxiphoid view. However, rib shadows impede the use of these larger footprint probes with transthoracic imaging. Orientation: To image the heart utilizing ultrasound, one must approach the acquisition and interpretation of the heart from various 70

orthogonal planes based on the hearts position within the chest. Traditional imaging planes for anatomic structures are transverse (short axis) and sagittal (long axis) planes. The picture on the monitor is essentially a displayed version of the ultrasound beam that emanates from the transducer face. Structures closest to the transducer are displayed at the top of the image deemed the near field. The deeper structures are displayed at the bottom of the screen in the far field. The focal zone is that area of greatest resolution (usually marked with a carat) that indicates the transition from the near to far field. All probes have an indicator that demarcates the leading edge of the beam that corresponds to a mark on the monitor. This orientation in cardiac imaging has created much controversy on how to position the probe on the chest wall to obtain the necessary standard images of the heart. Standard cardiology teaching positions the probe pointing to the right shoulder in the long parasternal view or to the left shoulder in the short parasternal view with the indicator on the right side of the monitor. Other methods have been described such as rotating the probe 180 degrees and reversing the image on the monitor so the indicator is on the left side of the image (standard for abdominal presets). The confusion in the cardiac display is best explained and clarified at the bedside by touching one side of the probe and watching the resultant image on the display. Standard display of cardiac anatomy in the long and short axis, subxiphoid and apical views are the goal for cardiac imaging. Scanning Methods: Scanning the patient incorporates the 3 Ps, Patient, Probe and Picture. The anatomy of the patient is interrogated with an ultrasound probe that then displays the returning echoes (ultrasound beam) on a picture display according to the probes orientation. The chest can be imaged from a series of acoustic windows and tissue planes. First of all, make sure to document the right patient and medical record number. Ensure that there is a recording device (analog-thermal paper, Super VHS, or digital- Picture Archiving Communication System-PACS) and set the correct cardiac preset application. Cardiac settings enhance the image for optimal motion detection. Scan the patient from the patients right and hold the probe comfortably as a pen or gently in a cupped hand. Apply generous amount of warm gel and position the patient in left lateral decubitus if tolerated. The heart sits in the chest at an angle and can be approached through the intercostal muscles. These intercostals

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and structures such as the liver (gray or black structures in the near field) act as acoustic windows to allow sound waves to penetrate to the underlying heart and chest cavity. Comparatively, strong reflectors such as ribs or gas in the stomach obscure visualization into the far field. The ribs obscure the beam from penetrating, therefore it is important to rotate the cardiac probe to align the beam parallel to the ribs in the space and eliminate rib shadows. Common Cardiac Ultrasound Windows

Illustration 1: Probe direction for subxiphoid and parasternal views.

Long Axis Parasternal: The heart sits obliquely in the left chest with the apex pointing toward the left hip. To obtain the long parasternal view, begin to sweep the probe across the parasternal area in the third or fourth intercostal space. If the mark on the monitor is on the left, than point the probe to the left hip, if the mark on the monitor is on the right, point the probe to the right shoulder. Either way the image is displayed in the same manner for convenience with the curved apex on the left side of the monitor (See Illustration 1,2, and 3 and Figures 1 and 2). Look for the landmark mitral valve and rotate the probe to image the aortic and mitral valve in the same long axis plane.

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Illustration 2: Drawing illustrating sonographic capture of a long axis parasternal view.

Figure 1 Figure 1: Long axis parasternal view of the left ventricle (LV), aorta (Ao), mitral valve (MV, closed) and interventricular septum (S).

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Figure 2

Illustration 3

Figure 2 and Illustration 3: This split screen shows a long axis parasternal view of the heart. It displays the change in left ventricular (LV) size during systole and diastole. Sonographically watching the beating heart can demonstrate systolic and diastolic function marked by the opening and closing of the mitral and aortic valves. Short Axis Parasternal: The short axis is in plane ninety degrees from the long axis and points the probe toward 8 oclock (mark on left) or the left shoulder (mark on right). After adjusting the probe to obtain a circular short axis view of the left ventricle, the structures along the endocardial border help to determine the segmental position of the heart (Mitral Valve = base, Papillary Muscle = mid section, small diameter = apex). The short axis focuses on obtaining an image of the LV in a circular pattern and then angling through the various positions to interrogate the respective wall segments. (See Figure 3-5, Illustration 3). Angling through the short axis views allows the operator to visualize the LV from the smaller caliber apex past the base to the aortic valve in the superior mediastinum. The short axis beam can be aimed cephalad to image the aortic valve in cross section. This image can provide insight into the right ventricular outflow tract, as it is oriented anterior to the aorta (Figure 7).

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Figure 3 Figure 3: Short Axis view of left ventricle (LV) at the mitral valve (base). The hyperechoic mitral valve (MV) spans the left ventricle unlike the mid level papillary muscles that abut the left ventricle (Figure 4)

Figure 4

Figure 4: Short axis parasternal image at papillary muscle mid section (PM) of the left ventricle.

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Figure 5 Figure 5: In this image the various short axis segments of the cardiac wall are labeled. Very often the lateral wall of the ventricle can be obscured by lung tissue. Using a probe with a smaller footprint (e.g. phased array instead of curvilinear) or positioning the patient in left lateral decubitus, may provide better image quality.

Illustration 4: Diagram outlining the wall segments of the left ventricle. There are typically 15 or 16 wall segments with the apex partitioned into 3 or 4 segments. In this 16 segment model displays the base and mid section of the heart 6 segments each while the apex has four segments. The areas of the left ventricle (anteroseptal 1,7,13,anterior free wall 2,8,14, lateral wall 3,9, posterior 4,10,15, 76

inferior 5,11,16, and inferoseptal 6,12) are then demarcated according to sonographic landmarks, notably the presence of the MV (base) or the papillary muscles (mid).

Figure 6a Figure 6a: This shows a cardiac short axis view at the level of the aortic root in diastole. It displays the circular aorta (Ao) in the center with the left atrium (LA) directly posterior and the right ventricle (RV) anteriorly. The egress of the right ventricular outflow tract into the pulmonary arteries can sometimes be seen, yet in this image is obscured by artifact from air in adjacent lung tissue

Figure 6c: A parasternal short axis view is shown at the level of the apex with some visible papillary muscles (PM).

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Subxiphoid: A common approach to critically image the heart is the subxiphoid view. Unlike other cardiac views, this view is dependent on the left lobe of the liver as an acoustic window in the near field. With the probe aimed to the right, angle cephalad toward the thorax and then center the heart onto the screen with a rock and slide maneuver. The operator should first identify the starry sky appearance to the liver. Next the anechoic IVC in the far field abuts the hyperechoic diaphragm. As the operator angles up into the chest, the IVC will transition into the right atrium. Measurements taken at this IVC/RA junction have been described as rough estimates of central venous pressure (Table 1). (1) Table 1 IVC measured Percent collapse (IVC) during inspiration >50% >50% <50% Little phasicity CVP (mm Hg)

<1.5 cm 1.5-2.5 cm 1.5-2.5 cm >2.5 cm

0-5 5-10 10-15 15-20

Relation Between IVC/RA junction and Central Venous Pressure (CVP) Adapted from Jones Handbook of Ultrasound in Trauma and Critical Care Illness, 2003 (9).

Figure 7: Note the operator is holding the probe from a cephalad position. This allows for a flattening of the probe face to image up into the chest.

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Figure 8 Figure 8: This sonographic image demonstrates the three hepatic veins (HV) emptying into the posterior located anechoic IVC. The heart will come into view on the right side of the screen (heart). The key to the subxiphoid view is to fill the near field with liver tissue by aiming toward the right shoulder, identifying the IVC posteriorly, and then aiming superiorly as the IVC empties into the right atrium.

Figure 9

Figure 9: The atrial (AS) and ventricular septum (VS) is seen clearly oblique to the beam. The right heart structures are juxtaposed to the liver. The left heart structures are in the far field as the beam is

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angled under the rib cage. The apex (yellow) is a morphological landmark with its curved surface and hyperechoic pericardial lining.

Figure 10 Figure 10: The same subxiphoid view is shown with the four heart chambers labeled. Adjacent to the liver are the right atrium (RA) and right ventricle(RV), while the left heart (left ventricle LV, left atrium LA) lies in the far field and right side of the screen.

Figure 11: This long axis view of the IVC shows an example of a hepatic vein (HV) draining into the inferior cava, which then

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immediately drains into the right atrium (RA). Standard measurements of the IVC caliber at this juncture and its response to respiration can help the clinician to determine volume status. (Table 1).

Figure 9 Figure 12: This is a split screen image of a B-mode and corresponding M-mode ultrasound. The B-mode shows a long axis view of the IVC entering the right atrium (RA). The dotted green line depicts the area of measurement for the M-mode. On the right, these measurements (e.g. IVC width) are shown over the course of time. (HV = hepatic vein).

Apical: On physical exam the point of maximal intensity on the chest wall demarcates the cardiac apex. An ultrasound probe can be placed lateral to the nipple line there and rotated between the three apical views (Apical four chamber, apical two chamber, apical long). The apical four-chamber view displays the ventricular septum in the middle with the right heart displayed on the left side of the screen and the larger left heart on the right of the screen. The atria are seen in the far field (Figure 13). 81

Figure 13

Figure 13: This is a phased array sector image displaying all four heart chambers. The probe is placed over the tip of the heart and shows an apical four-chamber view (apex on top of the image). By convention, the left heart is displayed on the right side and the right heart is on the left side. The atria and AV-valves are in the far field.

IV. Pathology Indications: If the technology is available at the bedside, the following patients can benefit from cardiac ultrasound: the trauma patient, the hypotensive patient, and the patient in cardiopulmonary arrest. Chest pain and pulmonary embolism are attractive diagnoses to experienced sonologists, but are difficult to interpret without advanced training. A focused approach to the patient in shock can utilize ultrasound to provide key information on the critically ill patient (1) . Differentiating between the presence/absence of effusion, state of

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contractility (absent/poor/normal), and chamber size (large/small) can provide key bedside data in a variety of critical patient scenarios. Trauma and Tamponade: The trauma patient may have injury to the chest that can be interrogated with ultrasound. Specifically penetrating trauma has a high likelihood of having a pericardial effusion and resultant tamponade. Remember, cardiac pressure rises quicker over smaller volumes during acute time periods and thus develops tamponade physiology earlier than in chronic effusions that develop over a longer time period. Sonographic tamponade is a combination of pericardial effusion and right heart diastolic collapse. The heart usually moves inward at systole and expands during diastole. During this time of low pressure, increased pressures around the heart (pericardial effusion) can cause paradoxical wall movement (collapse). In the presence of a pericardial effusion, observing the right heart for diastolic collapse is diagnostic of tamponade physiology.

Figure 14 Figure 14: In this image a large circular pericardial effusion (black) is distinguished from the left ventricle (LV, blue).

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Figure 16

Figure 17 Figure 16 and 17: These subxiphoid images display additional samples of circular pericardial effusions (PE). The right heart

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chambers do not exhibit diastolic collapse (LA = left atrium, LV left ventricle, LVOT = left ventricular outflow tract, RA = right atrium, RV = right ventricle). Shock: Shock is a common presentation to many disease states and can be classified according to etiology (e.g hypovolemic, obstructive, cardiogenic, distributive). The hypotensive patient can be a conundrum as far as fluid resuscitation and timely administration of pressors. The circulatory collapse of a patient has many patterns from the elderly patient with urosepsis, to the accident victim with ruptured spleen and hypovolemic shock. Bedside echocardiography makes it easier for clinicians to differentiate shock etiology. Ultrasound of the patient in shock can be used to interrogate the heart (contractility and effusion), search for blood loss (FAST exam), and interrogate the great vessels for aneurysm. The patient in shock with or without pericardial effusion, with or without normal cardiac contractility, and with or without evidence of adequate preload (2), can be quickly differentiated using common echographic views of the heart.

Figure 18: A synthesized hypotensive protocol (3) uses common acoustic windows into the torso to image those structures important in maintaining blood pressure. Probe placement at area 1-long axis parasternal, 2-short axis parasternal and 3- subxiphoid, allow common windows into imaging the heart during hypotension. Views 4 and 5 image the aorta, while images 6-8 encompass a modified FAST exam.

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Cardiac Motion and Contractility: Clearly the first step is to image the heart and determine if there is cardiac wall motion. There are 15 to 16 wall segments described within the left ventricle and each can be scored individually or globally for wall motion (4) (Table 2). Moore et al described emergency physicians accurately utilizing echo to predict LV ejection fraction in three broad terms (Normal >55%, depressed 3050%, severely depressed <30%) in those patients presenting with hypotension. (5) Cardiac ultrasound allows the operator to assess depressed cardiac function by investigating thickening of the myocardium and further elucidating the hypotensive state. Table 2 Scor e 0 1 2 3 4 Cardiac Wall Motion Hyperkinesis Normal Hypokinesis Akinesis Dyskinesis
(4)

Adapted from Otto. Echocardiography. 2004

Cardiac Arrest: Advanced cardiopulmonary life support systematically assesses and manages patients in arrest with energy (joules) and pharmacology (epinephrine, atropine, vasopressin, etc.) while monitoring the electrical rhythms of the heart. Echocardiography enables the bedside clinician to image the heart during a pulse check (subxiphoid or parasternal view) and objectively assess cardiac function, chamber size and the presence of effusion. In a study of 169 cardiac arrest victims presenting without a pulse, cardiac standstill on ultrasound was predictive of death (6). Another study looked at adding end tidal CO2 to focused cardiac ultrasound in patients in arrest to predict resuscitation outcome. The investigators found that cardiac motion was associated with survival, as was capnography > 16 torr, however in combination there was no statistical enhancement.(7) Ultrasound can be useful to determine if there is cardiac motion or no motion in the arrest patient (8,9) and combined with clinical parameters can help define futility of resuscitation efforts.

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Cardiac motion or lack of motion can be documented using M-mode (Figure 19 and 20).

Figure 19: Split-screen image of B-and M-mode ultrasound. The subxiphoid view shows a patient in cardiac arrest. M-mode is activated within the Bmode image (dotted green line). The different gray tones of the M-mode waveform correspond (orange

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arrows) to the anatomic structures detected. Their change in position is shown in the morphology of the waveform. Here a flat line represents no cardiac activity (no motion of the underlying anatomy).

Figure 20: This displays an ultrasound B/M-mode screen captured during simulated cardiac activity. The chest compressions during CPR cause a displacement of the cardiac chambers, changing the flat line to a significant waveform.

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V. Pearls and Pitfalls

Always try and position something gray or black in the near field. Acoustic windows involve areas conducive to ultrasound transmission such as the liver, intercostal muscles and chest wall. These structures are hypoechoic and when placed in the near field, facilitate sound transmission (little attenuation or weakening of the signal). In contrast, the ribs and sternum can be challenging to image through as they are strong reflectors and prevent sound transmission. Scan in a systematic fashion. Moving the probe in a coordinated fashion allows access to cardiac windows as the operator manipulates the transducer in 4 main motions. The first is to sweep the probe from side to side in the short axis plane of the probe. The second is to rock and slide in the long axis plane of the probe (indicator), and the third is to rotate in a clockwise or counterclockwise direction. Finally angling or pivoting the probe is key for orienting the beam to other degrees (< 60 degrees for vascular) of insonation. Find sonographic landmarks that can be used as points of reference to identify surrounding anatomy. The main views of the heart for cardiologists and bedside clinicians are the long and short parasternal views, the apical and the subxiphoid. Pattern recognition of key cardiac shapes (especially the location of the apex, valves, and papillary muscles) help the novice sonographer anchor their scanning and adjust the angle of the probe to recreate the intended standard images. Improve the quality of the exam by appropriating depth and gain. Remember to change the depth, as the heart is usually 22 cm from the probe

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surface in the subxiphoid view but closer in the parasternal and apical view. Make the image of interest as large as possible that encompasses the structures of interest. Lower the gain to identify the sliding of the visceral and parietal pericardium and assess for effusion. Adjust the gain higher to more clearly image the cardiac walls.

Identify effusions based on their relation to key thoracic structures. Pericardial fluid collects in the dependent posterior pericardial space and can be seen surrounding the myocardium anterior to the descending aorta. A left sided pleural effusion will be located posterior to the descending aorta.

VI. References 1. Hendrickson RG, Dean AJ, Costantino TG. A Novel use of ultrasound in pulseless electrical activity: The diagnosis of an acute abdominal aortic aneurysm rupture. J Emerg Med.2001;21:141-144. 2. Kircher BJ, Himelman RB, Schiller NB. Noninvasive estimation of right atrial pressures from the inspiratory collapse of the inferior vena cava. Am J Cardiol.1990;66:493-496. 3. Bahner DP. Trinity, A hypotensive ultrasound protocol. JDMS.2002;18:193198. 4. Otto CM. Textbook of Clinical Echocardiography.W.B. Saunders: Philadelphia,3rd ed. 2004. 5. Moore CL, Rose GA, Tayal VS, Sullivan DM, Arrowood JA, Kline JA. Determination of left ventricular function by emergency physician echocardiography of hypotensive patients. Acad Emerg Med.2002;9:186-193.

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6. Blaivas M, Fox JC. Outcome in cardiac arrest patients found to have cardiac standstill on the bedside emergency department echocardiogram. Acad Emerg Med.2001;8:616-621. 7. Salen P, O'Connor R, Sierzenski P, Passarello B, Pancu D, Melanson S, Arcona S, Reed J, Heller M. Can cardiac sonography and capnography be used independently and in combination to predict resuscitation outcomes. Acad Emerg Med.2001;8:610-615. 8. Varriale P, Maldonado JM. Echocardiographic observations during in hospital cardiopulmonary resuscitation. Crit Care Med.1997;25:1717-20. 9. Jones R, Blaivas M. The handbook of ultrasound in trauma and critical illness. Ohio ACEP,2003.

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Chapter 6

Gallbladder Ultrasound

Chapter 6: Gallbladder Ultrasound

I. Introduction and Indications Gallbladder disease affects 8 % of men and 17 % of women in the United States resulting in over 600,000 surgeries each year.(1,2) Cholecystitis, the most common emergent surgical condition of the gallbladder, is diagnosed in up to 10 % of total patients and 21 % of 92

elderly patients presenting to the emergency department with acute abdominal pain.(3-5) Overall, biliary tract disease is the 3rd most common cause of acute abdominal pain presenting to the emergency department. The associated annual costs total $5.8 billion and result in more than 5000 deaths a year.(6,7) In the acute presentation of biliary tract disease, the priority is to discriminate between biliary pain (also called biliary colic) and more serious diseases such as acute cholecystitis that require hospital admission, intravenous antibiotic therapy, and possibly emergent surgery. Unfortunately, no combination of clinical symptoms, signs, and laboratory values can reliably make that differentiation. Classically, patients with symptomatic biliary disease present with severe, steady pain in the epigastrium or right upper quadrant and may radiate to the right scapular region.(8,9) Dyspeptic symptoms such as nausea, vomiting, bloating, belching, acid regurgitation, and heartburn are not uncommon but do not add to the diagnostic certainty.(10,11) Self-resolving biliary pain generally lasts 15-minutes to 5-hours, but may persist up to 24 hours. Right upper quadrant tenderness is typically present on physical examination in both biliary pain and cholecystitis. Murphys sign, the arrest of inspiration on deep palpation of the right upper quadrant, is present in 90% of patients with acute cholecystitis. Fever and leukocytosis are common, but the combination of both does not occur in one-third of patients with cholecystitis.(12) Due to the difficulty in confirming the appropriate diagnosis on clinical grounds, imaging is used in most cases. Ultrasound is the initial imaging study for the diagnosis of acute cholecystitis because it is performed relatively quickly and does not expose the patient to radiation.(13) Adjusting for verification bias, sensitivity is 88 % and specificity is 80 %.(14) Ultrasound does not expose the patient to radiation and is much more accurate than plain film radiographs or computed tomography. Furthermore, the modality is faster and more generally more readily available than cholescintigraphy or MRI. It is important to note, however, that ultrasound is not the most accurate imaging modality for the diagnosis of acute cholecystitis. Cholescintigraphy, usually in the form of the HIDA scan, is 97 % sensitive and 90 % specific (after adjusting for verification bias).(14) Radionucleotide material is injected intravenously and is excreted through the bile. A nuclear study is then performed to evaluate the filling of the gallbladder. If the cystic duct is obstructed, as in the case

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of acute cholecystitis, the gallbladder will not fill and the test is considered positive. Cholescintigraphy should be considered in patients with a high clinical suspicion and a negative ultrasound. II. Anatomy The gallbladder is an elongated, pear shaped organ that functions to concentrate and store bile. Along with the liver, it is an embryologic derivative of the foregut. It normally lies on the visceral surface of the liver between the quadrate and right hepatic lobes covered by a continuation of the hepatic peritoneum. The gallbladder consists of the fundus, body, and neck. The fundus is the most caudal portion of the gallbladder and often will protrude from under the inferior margin of the liver and contact the anterior wall of the abdomen. The body of the gallbladder tapers cranially, eventually becoming the neck of the gallbladder, which continues to narrow to the junction with the cystic duct. At its neck, the gallbladder makes a sharp turn away from the parenchyma of the liver into the peritoneal cavity where it becomes the cystic duct. The cystic duct carries bile to and from the gallbladder and common bile duct into the duodenum. It is up to 5 cm long, and it joins the common hepatic duct to create the common bile duct (CBD). The CBD courses along the free border of the lesser omentum along with the hepatic artery and the portal vein. It passes behind the duodenum and into the head of the pancreas where it meets the ampulla of Vater at the duodenal papilla. The sphincter of Oddi functions at the ampulla to inhibit the flow of biliary and pancreatic secretions into the duodenum, until it is relaxed by cholecystokinin in response to the ingestion of food.

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Illustration 1a: Anatomical overview of upper abdomen.

Illustration 1b: Overview of porta hepatis.

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Bile is produced by hepatocytes and passes down through the biliary ducts of the liver. When the ampulla of Vater is open, bile flows freely into the duodenum. When closed, bile backs up into the cystic duct and into the gallbladder. The smooth muscle of the gallbladder aids flow toward the duodenum by contracting with stimulation by cholecystokinin. Within the abdominal cavity, the gallbladder most commonly lies anterior to the first and second portion of the duodenum, hepatic flexure, and stomach. Variations in gallbladder shape are common. Folds within the body of the gallbladder occur frequently. Septations and duplication of the gallbladder are rare and make diagnoses in pathologic conditions difficult. III. Scanning Technique and Normal Findings Gallbladder: Curvilinear abdominal probes with a frequency ranging from 2-5 MHz are ideal for examination of the gallbladder. The lower end of this range may be necessary for sufficient penetration in larger patients. However, sonographers should increase the frequency whenever possible as the evaluation of wall thickness, pericholecystic fluid, and gallstones is significantly improved with better resolution. The gallbladder is identified with three basic approaches: The subscostal sweep , the X minus 7 and the "flattening the probe" approach. The subcostal sweep is generally the most effective window and is usually attempted first. Start the scan with the probe in longitudinal orientation and the probe-indicator oriented toward the patients head and instruct the patient to take a deep breath. Sweep the probe inferiorly and laterally along the subcostal margin.

Clip 1: Subcostal sweep video

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The X-Minus 7 approach is an intercostal window. Find the xiphoid process and move laterally to the right approximately 7 centimeter. Place the probe perpendicular to the skin between the ribs. In most cases, the gallbladder will be found posterior to the liver parenchyma immediately beneath the probe. In the few instances where the gallbladder is not identified, move the probe laterally, sweeping through the liver In many young patients in a supine position, the gallbladder will be very anterior and cranial. In these cases, it is often helpful to point the indicator toward the patients right and flatten the probe against the abdomen while aiming the beam toward the right shoulder. Fan the beam anterior to posterior to identify the gallbladder With any of the three views, once the gallbladder is identified, stop moving the probe and make small adjustments to create the best longaxis view. In the long-axis, the gallbladder will usually appear as a pear-shaped, hypoechoic structure with a hyperechoic wall.

Clip 4: Gallbladder long axis: Note the main hepatic fissure extending from the tapered end of the gallbladder to the cross-section of the portal vein. The entire complex resembles an exclamation point. Because the gallbladder sits in the fossa created by the right and left main lobes of the liver, the main hepatic fissure appears as an echogenic line that extends from the neck of the gallbladder to the portal vein and serves as a landmark. The complex of the gallbladder, main hepatic fissure, and portal vein (in the short-axis) has the

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appearance of an exclamation point (Video 4). Fan the ultrasound beam through the entirety of the gallbladder to identify any pathology. As with any organ of the body, the gallbladder should be viewed in two planes. After the long-axis is thoroughly examined, pivot the probe 90 degrees and demonstrate the short-axis (Video 5). In the short-axis, the gallbladder will appear spherical. Again, scan through the entire organ in the short axis The gold standard to evaluate the g allbladder wall thickness is evaluated from the short-axis. Measure the anterior gallbladder wall at its most narrow point. It is important to obtain a view while the probe and ultrasound beam are perpendicular to the gallbladder wall. If an oblique section of the wall is measured, the reading will be falsely

elevated Clip 7: Measuring the gallbladder wall: To properly measure the gallbladder wall, view the organ in the short-axis and freeze the image on the narrowest portion of the wall. Importantly, the normal gallbladder may be contracted. The lumen of the gallbladder will appear very narrow in these cases and the wall will be thickened with a characteristic three layer appearance. The inner and outer walls are echogenic while the middle layer is relatively hypoechoic .

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Clip 8: Contracted gallbladder wall: This image demonstrated the classic appearance of the contracted gallbladder wall. Note the three distinct layers of the wall. The wall is thickened, but pathologic thickening will not demonstrate the three layers of the wall. Common Bile Duct (CBD): The CBD is most easily identified through its association with the portal vein and the portal vein is most easily identified in the long axis of the gallbladder. It is the point of the exclamation point that is created with the gallbladder in the long-axis. Follow the main lobar fissure from the neck of the gallbladder to the porta hepatis. The portal vein will appear as a large, hypoechoic circle with echogenic walls. The CBD and hepatic artery will appear as two smaller circles anterior to the portal vein. Often times, it gives the appearance of a face with two ears also called a Mickey Mouse sign.The CBD and hepatic artery form the ears of the Mickey Mouse sign. With the indicator directed toward the patients right, the right ear will be the common bile duct and the left ear the hepatic artery. The best way to evaluate the CBD is in the long axis as gallstones, strictures, or external compression may occur at any point in the tubular structure. Maintain the Mickey Mouse sign in the center of the screen and rotate the probe 90 degrees without changing the location of the probe on the patients skin. In the long axis, three echogenic lines will stretch across the screen. The line closest to the probe will be the anterior wall of the common bile duct. The second line is the

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shared anterior wall of the CBD and portal vein. Finally, the third line is the posterior wall of the portal vein. If there is confusion differentiating between the CBD and portal vein, color flow or power Doppler can be used. The portal vein will demonstrate flow and the CBD will not.

Video clip 10: Measuring the CBD: This video demonstrates the porta hepatis in the long-axis with power flow Doppler. The CBD lies in the long-axis just anterior to the portal vein. The Doppler is not absolutely necessary, but it is helpful as the hepatic artery is sometimes visualized instead. This CBD is not measured in the video, but is of normal caliber. Follow the CBD as far distally as possible by moving the probe medial in relation to the patient. It is very difficult to follow the CBD, as it passes posterior to the second portion of the duodenum. It is often identified within the head of the pancreas medially. Keep in mind that pathology other than choledocholithiasis can result in a dilated CBD and remain suspicious for tumors in the head of the pancreas. The CBD should be measured at its largest diameter in the long-axis. Calipers should be used to measure from the interior margin of the anterior wall to the interior margin of the posterior wall. IV. Pathology There are five major pathologic findings in the ultrasonographic diagnosis of acute cholecystitis: 1. Gallstones/Sludge: Gallstones are evident in 90-95 % of acute cholecystitis and likely play a role in the development of gallbladder 100

cancers as well. They are demonstrated on ultrasound with a thin, echogenic rim with pronounced shadowing obscuring the tissues behind. Small gallstones may not shadow. In such cases, increasing the frequency will improve resolution and shadowing may become apparent. Most often, gallstones are mobile and will roll to the most dependant portion of the gallbladder. This phenomenon may be demonstrated on ultrasound by maintaining a view of the gallbladder while a patient is rolled to a new position such as left lateral decubitus. Note the location of the gallstones in relation to the neck of the gallbladder. Stones in the neck of the gallbladder may be more likely to cause cholecystitis. Gallstones come in many shapes and sizes. Some will be only a couple of millimeters in diameter while others will grow to larger than 2 centimeters. Sometimes only a single gallstone will be present, while other patients will have multiple stones.

clip 12

clip 13

Clip 12: Large gallstone: The video shows a large gallstone within the lumen of the gallbladder. The gallstone reflects virtually all of the sound waves. Therefore, the edge of the stone is very bright on the screen and the tissues behind the stone are obscured by shadows because no sound waves make it past the stone. Clip 13: Multiple gallstones: Multiple echogenic foci within the gallbladder lumen with shadowing behind..

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Video clip 15

Video clip 16

Clip 15: Full of stones: This gallbladder is full of stones. Many echogenic foci with shadowing are seen within the lumen of the gallbladder. Video clip 16: Layer of stones: Notice the very bright line of stones at the lower left aspect of the gallbladder with shadowing behind. Gallbladder wall polyps may be confused with gallstones. They are soft tissue masses attached to the wall of the gallbladder and differentiated from gallstones by their lack of mobility and shadowing The position of polyps in the gallbladder is important as they may cause acute cholecystitis if they lodge in the neck of the gallbladder. Gallbladder sludge is likely made up of very small stones making the bile viscous and giving the bile echogenicity. Sludge is identified on ultrasound as slightly hyperechoic material forming a meniscus within the gallbladder lumen. Sludge may be a precursor to gallstones and has been related to pathology such as acute cholecystitis and acute pancreatitis

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2. Sonographic Murphys Sign: The sonographic Murphys sign differs from Murphys sign identified on physical exam (arrest of inspiration on deep palpation of the right upper quadrant). Sonographic Murphys sign is positive when the point of maximal tenderness is identified in the right upper quadrant while the gallbladder is identified on the ultrasound monitor. Multiple points in the epigastrium and right upper quadrant must be tested with the ultrasound probe when the gallbladder is not demonstrated in order to properly evaluate this sign. The sensitivity of the sonographic Murphys sign is reported from 75-86 % with a positive predictive value of 92 % when combined with the finding of gallstones.(15,17) 3. Gallbladder Wall Thickness: The normal gallbladder wall measures less than 4 mm. As detailed above, the gallbladder wall is measured at the most narrow point of the anterior wall in the shortaxis. Care must be taken to not measure the wall at an oblique angle

The gallbladder wall may be thickened in many disease states. Acute cholecystis is the most common of these. Ascites and congestive heart failure are the second and third most common cause of gallbladder wall thickening. Hepatitis may also cause gallbladder wall edema. Gallbladder wall cancers may show a thickened and/or calcified gallbladder wall. 4. Pericholecystic Fluid: Pericholecystic fluid (PCCF) is generally found in wedges around the acutely inflamed gallbladder wall. It is most often seen posterior to the gallbladder at the around the neck, but may also be seen layering on the anterior wall. Ascites makes evaluation of pericholecystic fluid due to gallbladder inflammation impossible, as the patient will have free fluid throughout their abdomen, including around their gallbladder

5. Dilated Common Bile Duct: The CBD may dilate when obstructed by a stone, a mass, or a stricture. The normal width of the CBD is 4 mm. Older patients may have a normally dilated duct up to 1mm for every decade past the age of 40. The CBD may be dilated up to 1cm normally after cholecystectomy 103

In the setting of acute cholecystitis, the common hepatic duct may be dilated due to inflammation of the gallbladder wall neck and cystic duct causing external pressure. This is a rare complication termed Mirizzi syndrome and may lead to hyperbilirubinemia. Gangrenous and emphysematous cholecystitis are serious complications of acute cholecystitis that may be identified with ultrasound by the presence of air within the gallbladder wall or lumen (Video 25). Air on ultrasound is represented by comet-tail artifacts. Gallbladder perforation may also be diagnosed by ultrasound. Findings of perforation include significant amounts of pericholecystic fluid that may contain echogenic material which may be walled off from the rest of the abdomen.

Clip 25: Air in the GB wall: There are comet-tail artifacts extending down from this gallbladder wall indicating air due to emphysematous cholecystitis.

V. Pearls and Pitfalls 1. Duodenal Air: Because the second portion of the duodenum lies just behind the posterior wall of the gallbladder, air in the duodenum can inhibit the ability to successfully image the gallbladder.

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Furthermore, this slice of sound actually has a thickness of 1.5 mm. As it is directed towards the posterior wall of the gallbladder, some of this sound is reflected off the duodenum and the image produced is a combination of the two organs. Because air can cause shadowing, it can appear that there is a gallstone lying on the posterior wall when in reality this is air in the second portion of the duodenum (Video clip 26 and 27). 2. Renal Cyst: The kidney is closely related to the gallbladder and cysts in the superior pole of the kidney may be confused for the gallbladder. This is one reason why it is important to view the gallbladder in both a short and long axis. The renal cyst will appear the same in both axes, while the gallbladder elongates in a long axis. 3. Ascites: Free intraperitoneal fluid, regardless of the etiology, will appear anechoic. Be careful not to mistake ascitic fluid for pericholecystic fluid. Ascitic fluid is typically located throughout the peritoneum, including Morrisons pouch, whereas pericholecystic fluid is localized to the anterior side of the gallbladder. Patients with ascites also have markedly thickened gallbladder walls not associated with an inflammatory process. Keep in mind that fluid that is found posterior to the gallbladder can be the result of a ruptured gallbladder. 4. WES Sign- Wall-Echo-Shadow: When a gallbladder is contracted around a gallstone, sometimes the only visualization of this is a shadow coming out of the liver. This is due to the stones reflection that obscures the rest of the gallbladder. The three layers of the gallbladder wall of the anterior gallbladder are generally seen, followed by the echogenic stone which is followed by the shadow caused by the stone. 5. Patient Positioning: Typically the images are best obtained with the patient in a supine position, although rolling the patient into a left lateral decubitus position may be helpful. This is thought to move the second portion of the duodenum away from the posterior wall of the gallbladder reducing the negative effect of duodenal air. 6. Obtain Multiple Windows: The X minus 7 approach refers to using an intracostal window in probes that have smaller footprints. This approach is especially useful in the morbidly obese patient. Furthermore, it is important to view the gallbladder in both the short and long axes. This can help in not mistaking the gallbladder for the IVC, renal cyst, or portal vein. In general the gallbladder will appear in a perpendicular axis to the portal vein. The exclamation point sign

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helps to draw this concept home. When the gallbladder is in the long axis (the top of the exclamation point), the portal vein is in the short axis (the point of the exclamation point). 7. Probe Orientation: With the indicator aimed towards the patients head the gallbladder is generally shown in the long axis. As anatomical variation is common with the biliary system, this orientation may need to be adjusted in order to obtain this window. Keep in mind that with biliary scanning the orientation of the gallbladder is with respect to how the organ appears on the screen, not necessarily the position of the probe on the patient. The short axis of the gallbladder is typically found with the indicator towards the patients right

Clip 26: Duodenum mimicking gallbladder filled with stones: The duodenum adjoins the posterior aspect of the liver. At times, it may appear as the gallbladder filled with stones. The air in the duodenum appears as dirty shadowing .The shadows are very indistinct, rather than the clean shadows behind stones.

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Clip 27: Gallstone vs. Duodenum: The duodenum sits very close to the gallbladder. So close that the thickness of the ultrasound beam may pick up parts of both, superimposing the duodenum onto the gallbladder in the image. This can cause problems because the duodenum may shadow due to air leading the sonographer to believe there is a gallstone within the gallbladder. VI. References 1 Everhart JE, Khare M, Hill M, Maurer KR. Prevalence and ethnic differences in gallbladder disease in the United States. Gastroenterology,1999;117(3):632-9. 2 Go V, Everhart JE. Gallstones. In: Digestive diseases in the United States: Epidemiology and impact US Department of Health and Human Service. Public Health Service, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases,1994.NIH Publication no. 94-1447. 3 Powers RD, Guertler AT. Abdominal pain in the ED: stability and change over 20 years. Am J Emerg Med.1995;13(3):301-3. 4 de Dombal FT. The OMGE acute abdominal pain survey. Progress report, 1986. Scand J Gastroenterol.Suppl,1988;144:35-42.

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5 Telfer S, Feny G, Holt PR, de Dombal FT. Acute abdominal pain in patients over 50 years of age. Scand J Gastroenterol. Suppl,1988;144:47-50. 6 Sandler RS, Everhart JE, Donowitz M, Adams E, Cronin K, Goodman C, Gemmen E, Shah S, Avdic A, Rubin R. The burden of selected digestive diseases in the United States. Gastroenterology.2002;122(5):1500-11. 7 Diehl AK. Epidemiology and natural history of gallstone disease. Gastroenterol Clin North Am.1991;20(1):1-19. 8 Berger MY, Olde Hartman TC, Bohnen AM. Abdominal symptoms: do they disappear after cholecystectomy? Surg Endosc.2003;17(11): p. 1723-8. 9 Festi D, Sottili S, Colecchia A, Attili A, Mazzella G, Roda E, Romano F. Clinical manifestations of gallstone disease: evidence from the multicenter Italian study on cholelithiasis (MICOL). Hepatology.1999;30(4):839-46. 10 Thijs C, Knipschild P. Abdominal symptoms and food intolerance related to gallstones. J Clin Gastroenterol.1998;27(3):223-31. 11 Kraag N, Thijs C, Knipschild P. Dyspepsia--how noisy are gallstones? A meta-analysis of epidemiologic studies of biliary pain, dyspeptic symptoms, and food intolerance. Scand J Gastroenterol.1995;30(5):411-21. 12 Singer AJ, McCracken G, Henry MC, Thode HC Jr, Cabahug CJ. Correlation among clinical, laboratory, and hepatobiliary scanning findings in patients with suspected acute cholecystitis. Ann Emerg Med.1996;28(3):267-72. 13 Bree RL, Ralls PW, Balfe DM, DiSantis DJ, Glick SN, Levine MS, Megibow AJ, Saini S, Shuman WP, Greene FL, Laine LA, Lillemoe K. Evaluation of patients with acute right upper quadrant pain. American

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College of Radiology. ACR Appropriateness Criteria. Radiology.2000;215(Suppl):153-7. 14 Shea JA, Berlin JA, Escarce JJ, Clarke JR, Kinosian BP, Cabana MD, Tsai WW, Horangic N, Malet PF, Schwartz JS, et al. Revised estimates of diagnostic test sensitivity and specificity in suspected biliary tract disease. Arch Intern Med.1994;154(22):2573-81. 15 Ralls PW, Colletti PM, Lapin SA, Chandrasoma P, Boswell WD Jr, Ngo C, Radin DR, Halls JM. Real-time sonography in suspected acute cholecystitis. Prospective evaluation of primary and secondary signs. Radiology.1985;155(3):767-71. 16 Bree RL. Further observations on the usefulness of the sonographic Murphy sign in the evaluation of suspected acute cholecystitis. J Clin Ultrasound.1995;23(3):169-72. 17 Kendall JL, Shimp RJ. Performance and interpretation of focused right upper quadrant ultrasound by emergency physicians. J Emerg Med.2001;21(1):7-13. 18 Menakuru SR, Kaman L, Behera A, Singh R, Katariya RN. Current management of gall bladder perforations. ANZ J Surg.2004;74(10):843-6. 19 Fagan SP, Awad SS, Rahwan K, Hira K, Aoki N, Itani KM, Berger DH. Prognostic factors for the development of gangrenous cholecystitis. Am J Surg.2003;186(5):481-5. 20 Contini S, Corradi D, Busi N, Alessandri L, Pezzarossa A, Scarpignato C. Can gangrenous cholecystitis be prevented?: a plea against a "wait and see" attitude. J Clin Gastroenterol.2004;38(8):710-6. 21 Ryu JK, Ryu KH, Kim KH. Clinical features of acute acalculous cholecystitis. J Clin Gastroenterol.2003;36(2):166-9.

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About Us | Site Map | Privacy Policy | Contact Us | Ultrasound Guide for Emergency Physicians 2008

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Chapter 7 Renal Ultrasound

Chapter 7: Renal Ultrasound

I. Introduction and Indications

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Acute flank pain and abdominal pain with hematuria are relatively common presenting complaints in the emergency department. Although urinary obstruction is a likely diagnosis in such patients, the differential diagnosis includes life-threatening disease processes, most importantly an expanding or ruptured abdominal aortic aneurysm. Emergency bedside sonography is a tool that can rapidly confirm the diagnosis of acute urinary obstruction and help exclude life-threatening processes. It is important to know common medical terms used to describe the pathophysiology of urinary retention. The structural impediment to the flow of urine is termed obstructive uropathy. Unless this obstruction develops slowly it is typically painful, which is called renal colic. The most common cause is a kidney stone dislodged into the ureter called ureterolithiasis. Urine flow is blocked by the stone leading to back-up and dilation of the proximal ureter (hydroureter). As the obstruction progresses, more proximal structures like the renal collecting system (renal pelvis and calyces) becomes dilated, termed hydronephrosis. If the hydronephrosis is severe, the renal parenchyma becomes compressed and if lasting long enough (about 2-4 weeks), can cause loss of renal function. As described above, the most common cause of renal colic and hydronephrosis is ureterolithiasis. But in general everything able to obstruct the inner lumen of the collecting system or causing extrinsic compression can block urinary flow and lead to renal colic. Bedside renal sonography in the emergency department is also useful in the patient presenting with decreased urinary output or anuria, acute renal failure or pyelonephritis. Similar to the renal colic patient it allows the examiner to narrow the differential diagnosis by evaluating the retroperitoneal anatomical structures for abnormalities but gives only limited clues for the functional status of the urinary system. II. Anatomy The kidneys are retroperitoneal organs that are protected by the lower ribs posteriorly. The right kidney lies just below the liver, while the left lies just below the spleen. The superior pole of both kidneys is tilted slightly medially and posteriorly (oblique lie). Each kidney has a fibrous outer cortex, a middle layer consisting of medulla (pyramids) with surrounding cortex (columns of Bertin) and an inner renal sinus

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that contains the calyces and renal pelvis with larger blood vessels, lymphatics and fatty tissue. The entrance to the renal sinus is on each medial aspect of the kidneys. It is termed renal hilum and contains the major branches of renal vein, artery, ureter, lymphatics and connective tissue. The whole renal complex including the kidney, adrenal gland, renal hilum and perinephric fat is surrounded by a fascial layer, called Gerotas fascia.

Illustration 1: Overview of kidney anatomy. The ureter leaves the kidney through the renal hilum and is a tubular, muscular structure that travels retroperitoneal and anterior to the psoas muscle towards the bladder. It courses medially then crosses over the iliac vessels and travels along the pelvic sidewalls before turning anteriorly and medially to enter the fundus of the bladder. There are three natural anatomic narrowing of the ureters: The ureteropelvic junction, as the renal pelvis narrows to become the ureter; the crossing of the iliac vessels, due to external bending and compression and the ureteral vesicular junction, due to intrinsic narrowing. The bladder lies just posterior to the pubis and anterior to

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the rectum (males) or uterus (females). It is a muscular structure that, as it distends, expands to fill the pelvis and, eventually, abuts the anterior abdominal wall. III. Scanning Technique, Normal Findings and Common Variants A 3.5-5 MHz probe is typically used to scan the kidney. For the right kidney, have the patient lie supine and place the probe in the right lower intercostal space in the midaxillary line. Use the liver as your acoustic window and aim the probe slightly posteriorly (toward the kidney). Gently rock the probe (up and down or side to side) to scan the entire kidney. If needed, you can have the patient inspire or exhale, which allows for subtle movement of the kidney. Obtain longitudinal (long axis) and transverse (short axis) views (Figure 1-3 and video clip1 and 2).

Figure 1a

Figure 1b

Figure 2

Figure 1a and 1b: Longitudinal images of normal right kidney. Figure 2: Transverse image of normal right kidney. Note the position of the gallbladder (GB) next to the liver and inferior vena cava (IVC).

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Figure 3: Transverse view of renal blood supply of the right kidney. (Color Doppler shows hilum vessels in red and blue). For the left kidney have the patient lie supine or in the right lateral decubitus position. Place the probe in the lower intercostal space on the posterior axillary line. The placement will be more cephalad and posterior than when visualizing the right kidney. Again gently rock the probe to scan the entire kidney. Obtain longitudinal and transverse views Depending on which axis you use to obtain you images, the sonographic shape of the kidney will change. On longitudinal view, the kidney will appear football-shaped and will typically be 9-12 cm in length and 4-5 cm in width (normally within 2 cm of each other). On transverse view, the kidney appears C-shaped. The normal kidney will have a bright area surrounding it which is made up of Gerotas fascia and perinephric fat. The periphery of the kidney will appear grainy gray which is made up of the renal cortex and pyramids. Sometimes you can see the individual pyramids, but this is not always the case. The central area of the kidney, the renal sinus, will appear bright (echogenic) and consists of the calyces, renal pelvis and the renal sinus fat. Always scan both kidneys for comparison and correlation to clinical picture. The ureters are generally not well visualized by ultrasound, but, when distended may appear as a tubular structure extending inferiorly from the kidney (Figure 4). The bladder, when distended with fluid, can be easily visualized in the lower pelvis as a rather thick walled, fluid-filled structure. There are many normal variations in the anatomic structure of the kidneys. Some common ones that you may identify include: Double collecting system, where the renal sinus is divided by a hypertrophied column of Bertin; horseshoe kidney, where the left and right kidney are connected to each other, usually at the lower pole; Renal ectopia, where one or both kidneys are outside the normal renal fossa. (1-4) IV. Pathology The diagnosis of acute renal colic has three major components: 1. The patients clinical presentation. 2. The presence of blood on urinalysis. 89% of patients with ureterolithiasis have > 0 RBC per high power field on urine microscopy. 115

3. Diagnostic imaging, which may include intravenous pyelogram (IVP), CT scan or ultrasound. The goal of bedside renal ultrasonography is to rapidly evaluate the patient presenting to the ED with flank pain, abdominal pain with hematuria or decreased urinary output to answer a few basic questions: Is there hydronephrosis? Unilateral or bilateral? Is there fluid around the kidney? Is the bladder distended? Are stones seen? Is the aorta normal (see abdominal aortic aneurysm) The primary sonographic abnormality you will identify in the patient with suspected acute renal colic is hydronephrosis. The degree of hydronephrosis relates to the degree and extent of obstruction (Illustration 2, figures 5 - 7). The alternative imaging studies that are used to diagnose acute renal colic include IVP and spiral CT scan. In IVP, intravenous contrast is injected and a series of plain abdominal radiographs are obtained. The intravenous contrast agent is filtered by the kidney and appears bright white on the radiographs. The radiographs are reviewed to evaluate for a delay in renal filtering of the intravenous contrast agent and for evidence of hydronephrosis as the contrast is filtered. A delay in filtering of the intravenous contrast along with the presence of hydronephrosis indicates obstruction. With high resolution spiral CT, images are obtained from the kidney to the bladder without the use of IV contrast. This allows the reader to view serial cross sectional images of the kidney and ureter to identify hydronephrosis. In comparison to ultrasound or IVP, CT scan can routinely identify ureteral stones and provide accurate measurements of the stones size. Just remember, no study can identify hydronephrosis or ureteral calculi 100% of the time. The advantages of emergency renal ultrasonography include: Bedside No radiation No IV contrast

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Repeatable Fast The disadvantages of emergency renal ultrasonography are that it does not assess renal function (as IVP does) and it cannot typically identify/size the ureteral stone.

Figure 4: Dilated ureter seen below bladder (transverse view).

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Illu stration 2: Overview of degrees of hydronephrosis.

Figure 5: Longitudinal view of right kidney with mild hydronephrosis.

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Figure 6a

Figure 6b

Figure 6a: Longitudinal axis of kidney with moderate hydronephrosis. Figure 6b: Transverse view of same kidney with moderate hydronephrosis.

Figure 7: Kidney with severe hydronephrosis. Note that the shape of the kidney is completely obliterated by the severe hydronephrosis. Dehydrated patients may not show hydronephrosis if the obstruction is early. After complete obstruction to flow, there is an acute rise in intrarenal pressure. The renal pelvis and calyces dilate first. On ultrasound you will see echo-free areas distending the normal bright white (hyperechoic) central area of the kidney. As obstruction continues, the renal parenchyma becomes compressed and you see thinning of the pyramids. Always scan both kidneys for comparison and correlation to the patients clinical presentation. Renal or ureteral stones may be seen on ultrasonography in the 119

patient with acute renal colic. Look for bright objects that cast a shadow within the kidney (Figures 8 12). If you can, follow the dilated ureter down toward the bladder. A bright object that casts a shadow within the ureter or at the junction of the bladder is consistent with ureteral nephrolithiasis. It is often difficult to identify ureteral stones.

Figure 8

Figure 9

Figure 10

Figure 11

Figure 12

Figure 8 - 12: Several examples of kidney stones are shown. Kidney, kidney stone (blue) with the cast shadow are labeled in each figure. In the evaluation of the patient with anuria, acute renal failure or decreased urinary output look for evidence of bilateral obstruction to flow. You may find a distended, fluid-filled bladder (despite the patients best efforts to void), indicating bladder outlet obstruction, or a normal bladder with bilateral hydronephrosis, indicating a mass lesion compressing both ureters. Other abnormal findings that you may identify when scanning the kidney include: Simple or complex renal cysts: peripheral, smooth, hypoechoic and with or without internal echoes; multiple in polycystic disease (Figure 13 to 19).

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Figure 13

Figure 14

Figure 15

Figure 13 - 15: Several examples of renal cysts. Kidneys with cyst and posterior enhancement are shown.

Figure 16

Figure 17

Figure 18

Figure 19

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Figure 16 -19: Images of polycystic kidneys with multiple cysts.

Pyelonephritis: sonographic appearance is most commonly normal, but you may find hypoechoic cortex and loss of demarcation between the outer cortex and middle pyramids and columns of Bertin. Renal mass: may have any echotexture (hyperechoic, anechoic etc.) and appear anywhere within the kidney (Video Clip 5 and 6) Transplant kidney: a normal echotexture kidney, typically in a pelvic location (Figure 20 and 21).

Figure 20

Figure 21

Figure 20 and 21: Renal transplant in longitudinal view located in the pelvic fossa. Figure 21 shows a small intra-parenchymal bleed after a biopsy (blue area). Chronic renal failure: Kidneys appear small and hyperechoic. Ureteral stents: have a characteristic appearance but can be difficult to visualize due to size and position (Figure 22 and 23).

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Figure 22

Figure 23

Figure 22 and 23: Images showing a ureteral stent (green) in the proximal dilated ureter (blue). Bladder: Stones: bright object within the bladder that casts a posterior shadow. Foreign bodies: Foley catheter in bladder. Bladder mass: hyperechoic or mixed, irregular shaped mass within the bladder (Figure 24-26).

Figure 24a

Figure 24b

Figure 25a

Figure 25b

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Figure 24a, b and 25a, b: Images 24a and 24b show the Foley in the bladder with the balloon deflated. In images 25a and b the balloon is inflated.

Figure 26: Fungating bladder mass.

V. Pearls and Pitfalls

Renal cysts can sometimes be mistaken for hydronephrosis. Cysts are typically single and arise in the periphery of the kidney, but can be multiple as in polycystic kidney disease. A collecting system located outside the kidney is termed extrarenal pelvis. This can mimic early hydronephrosis but is a normal developmental variant. The overhydrated patient may have mild hydronephrosis without obstruction. In this case, both kidneys will show evidence of mild hydronephrosis The underhydrated patient may not have hydronephrosis on initial renal scanning, despite the presence of obstruction and renal colic Mild hydronephrosis may be seen in the pregnant patient or one with a full bladder. Again, both kidneys will appear similar

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Kidneys with chronic disease may not have normal sonographic appearance, making identification difficult In some cases an adjacent structure, such as a fluid-filled gallbladder, may be mistaken as renal (in this case mistaken as a renal cyst). Remember, the patient with multiple renal cysts may also have liver cysts. Perform a quick ultrasound of the liver to screen for liver cysts in these patients. Additionally, certain forms of polycystic kidney disease are associated with intracerebral aneurysms; followup is important in these patients. Be sure to scan the aorta for AAA in the patient who clinically appears to have acute renal colic, but in whom the renal scanning is normal.

VI. References 1. Walsh J, ed., Campbells Urology. Philadelpia, PA, W.B. Saunders, 2002. 2. Ma, OJ and Mateer JR, eds. Emergency Ultrasound, New York, NY: McGrawHill; 2003. 3. Cosby, KS and Kendall JL, eds. Practical Guide to Emergency Ultrasound. Lippincott, Williams & Wilkins: Philadelphia, PA,2006. 4. Simon BC and Snoey ER, eds.Ultrasound in Emergency and Ambulatory Medicine. Mosby: St. Louis, MO,1997.

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Chapter 8

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Pelvic Ultrasound

Chapter 8:

Pelvic Ultrasound

I. Introduction and Indications One in every thirteen women presenting to the emergency department in their first trimester of pregnancy with abdominal or pelvic pain or vaginal bleeding will eventually be diagnosed with an ectopic pregnancy.(1-4) Because the history and physical exam has proven to be unreliable in detecting or excluding the presence of an ectopic pregnancy(2,4), ultrasound has become more than just an adjunctive diagnostic tool. Traditionally, the serum quantitative B-hCG has been the initial test performed in the evaluation for possible ectopic pregnancy. Only if the quantitative B-hCG level was above a certain level was pelvic ultrasound performed.(4) Unfortunately, limiting the use of ultrasound in this way results in delayed diagnosis of ectopic pregnancy, a great number of undiagnosed ectopic pregnancies being released from the ED, and a significant number of ectopic pregnancies rupturing prior to definitive treatment. Ultrasound as the initial step in the evaluation of all women presenting to the ED in their first trimester with abdominal pain or vaginal bleeding provides the best chance of

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early diagnosis of ectopic pregnancy.(5,6,7) Given the financial and logistical challenges of providing resources for around-the-clock immediate ultrasound, clinician-performed pelvic sonography has been incorporated into the practice of emergency medicine.(8) Pelvic ultrasound performed by emergency physicians significantly reduced emergency department length of stay for those women found to have an intrauterine pregnancy and has reduced the incidence of discharged patients with subsequent ectopic pregnancy rupture.(5,9,10) II. Anatomy Uterus The uterus is a pear-shaped organ that lies posterior to the bladder and anterior to the sigmoid colon. The uterus consists of the body, an upper broad fundus and the lower neck or cervix. The size of the uterus in the adult (post-pubertal) female is approximately 8 cm long, 5 cm wide and 3 cm deep. The uterus is composed of three layers which include the outer serosa, a muscular middle layer and the inner endometrium. The uterine fundus may point towards the anterior abdominal wall (anteverted) or back towards the spine (retroverted). When a sharp angle exists between the cervix and fundus, the uterus is said to be flexed. Fallopian Tubes and Ovaries Each fallopian tube is approximately 10 cm in length and consists of four segments (from proximal to distal: the interstitial cornu, isthmus, ampulla and infundibulum). Ovaries are elliptical and approximately 4 cm in length, 3 cm in width and 2 cm in height. Although the location of the ovaries can vary, they are usually anterior to the internal iliac artery.(11) III. Scanning Technique and Normal Findings Transabdominal Ultrasound The goal of pelvic ultrasound is to scan completely through the uterus and adnexal region in both the longitudinal and transverse planes. The transabdominal ultrasound employs ideally a 3.5 MHz curvilinear probe and begins just above the pubic symphysis in a longitudinal axis. It is best performed when the patient has a full bladder, which tends to

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displace overlying bowel away from penetrating ultrasound waves (Figure 1, illustration 1).

Figure 1

Illustration 1

Figure 1: Transabdominal ultrasound in longitudinal plane showing the uterus (fundus) and a distended bladder. Illustration 1: Corresponding medical illustration. The endometrial lining appears as an echogenic line on ultrasound (the endometrial stripe) and identifies the center of the uterus in the longitudinal plane. The ultrasound probe is moved laterally from side to side through the entire width of the uterus in the longitudinal plane looking for evidence of an intrauterine pregnancy. The probe is next placed in the transverse plane just above the pubic symphysis directed down towards the uterus (Figure 2 and illustration 2).

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Figure 2

Illustration 2

Figure 2: Transabdominal ultrasound in a transverse plane showing bladder, uterus and right ovary. Illustration 2: Drawing of corresponding anatomy. Once the endometrial stripe is identified, the uterus is scanned from cervix to fundus in the transverse plane. Finally, although not often visualized in the transabdominal ultrasound, the ovaries are located by sweeping laterally from the uterus. Before moving on to the transvaginal ultrasound, the hepatorenal space should be scanned for the presence of free fluid which appears anechoic when present. It is important to remember that the ultrasound is providing the clinician with one thin slice through a given region. Therefore, free fluid may be missed if a region is not thoroughly scanned.

Transvaginal Ultrasound The transvaginal ultrasound is best performed on patients with an empty bladder because of reduced patient discomfort, reduced uterine distortion from the distended bladder and less artifacts. The transvaginal probe is typically a 5 MHz probe and is covered with a probe condom. Bacteriostatic Surgi-lube is placed inside and outside of the condom to ensure smooth transmission of ultrasound waves. Some patients experience less discomfort when they place the probe into the vaginal canal by themselves. The probe is placed adjacent to 130

the cervix (Illustration 3). A transvaginal ultrasound in the longitudinal axis will appear as shown in figure 3. In this standardized format, a uterine fundus pointing towards the anterior abdominal wall is anteverted. A uterine fundus pointing in the direction of the posterior wall is retroverted (Figure 4, video clip 1). The longitudinal scan begins midline at the endometrial stripe and the uterus is scanned from right to left through its entire length (Video clip 2). The probe is then moved laterally to the adnexal area to view the ovaries.

Figure 3

Illustration 3

Figure 3: Transvaginal ultrasound in a longitudinal plane showing an anteverted uterus. Illustration 3: Drawing of longitudinal view of uterus with pelvic probe in canal.

Figure 4: Transvaginal ultrasound in a longitudinal plane showing a retroverted uterus.

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Once scanning is complete in the longitudinal axis, the probe is rotated 90 degrees counterclockwise so that the probe is now in the transverse plane (illustration 4). In this orientation, the left side of the screen corresponds to the patients right side (similar to what is seen with a CT scan). The transverse scan begins with identification of the endometrial stripe and then moves throughout the entire length of the uterus (Figure 5). In order to help locate the ovaries, the cornual flare, the portion of the uterus at the junction of the fallopian tubes, is identified (Figure 6). Once the cornual flare is located, the probe is moved laterally along the fallopian tube to locate the ovary (Video clip 3). Ovaries are often identified by the presence of follicles, which appear hypoechoic or anechoic (Figure 8 and 9).

Illustration 4: Drawing of the transverse view of the uterus with probe in vaginal canal.

Figure 5: Transverse uterus with endometrial stripe. 132

Figure 6

Figure 7

Figure 6: The same transvaginal ultrasound with marking of the cornual flare (uterine fundus at the start of the fallopian tube). Figure 7: Transvaginal ultrasound of the fallopian tube.

Figure 8

Figure 9

Figure 8 and 9: Transvaginal ultrasound of the ovary showing multiple (Figure 8) and a single follicle (Figure 9). Intrauterine Pregnancy The first question to ask when evaluating a patient with pain or bleeding in their first trimester pregnancy is Is there evidence of a definitive intrauterine pregnancy on ultrasound? The presence of an intrauterine pregnancy virtually rules out ectopic pregnancy in patients not receiving fertility medication. Fortunately, this occurs in approximately 70% of cases presenting to the emergency department. The earliest sign of pregnancy on transvaginal ultrasound is the intradecidual sign, an anechoic sac without a distinct chorionic ring. This may be seen as early as four weeks gestation (Figure 10 and 11). However, definitive sonographic evidence of an intrauterine pregnancy is confirmed when a gestational sac containing a yolk sac can be identified in two planes within the endometrium. This occurs around the fifth week of gestation (Figure 12 and 13).

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Figure 10: Transvaginal ultrasound in longitudinal plane showing an anechoic sac within the endometrium.

Figure 11: Transvaginal ultrasound in transverse plane (magnified) showing an anechoic sac with a thin ring (decidual sac).

Figure 12

Figure 13

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Figure 12 and 13: Transvaginal ultrasound in a longitudinal (Figure 12) plane and transverse plane (Figure 13) showing a gestational sac containing a yolk sac within the endometrium (viable IUP). At six weeks gestation, the heart tubes of the embryo fuse and both a fetal heart beat as well as a fetal pole can be identified (Figure 14 and 15). At seven weeks gestation, the fetal head and extremities can be identified. The amniotic sac is often seen as it begins to expand into the chorionic sac (Figure 16). Ten weeks gestation marks the end of the embryonic period, and on ultrasound, the amniotic sac will obliterate the chorionic sac (not quite complete in Figure 17).

Figure 14

Figure 15

Figure 14: Transvaginal ultrasound: gestational sac with yolk sac and fetal pole. Figure 15: Transvaginal ultrasound with Doppler over the fetal pole showing the presence of a fetal heart beat (viable IUP).

Figure 16

Figure 17

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Figure 16: Transvaginal ultrasound at 7 weeks gestation. Figure 17: Transvaginal ultrasound at 10 weeks gestation (end of the embryonic period). The introduction of fertility medications has greatly increased the incidence of multiple gestations. Figure 18 is a transvaginal ultrasound in the transverse plane showing dichorionic, diamniotic twin gestations. The ultrasound shows two separate gestational sacs (i.e. dichorionic), each with its own yolk sac (i.e. diamniotic) and fetal pole. Multiple gestations are by their very nature high risk pregnancies. In addition, the incidence of heterotopic pregnancy (simultaneous intrauterine and ectopic pregnancy) has dramatically risen with fertility treatments. Therefore, early obstetrical consultation should be considered in any patient with either multiple gestations or who has received fertility treatments.

Figure 18: Transvaginal ultrasound showing twin gestations with two separate gestational sacs (dichorionic) and two yolk sacs (diamniotic).

IV. Pathologic Findings Abnormal Pregnancy Signs suggestive of abnormal embryonic development include a gestational sac greater than 8 mm in diameter without a visible yolk sac (Figure 19), a gestational sac greater than 18 mm in diameter without a fetal pole (Figure 20), or a collapsed gestational sac (Figure 21). Additionally, absence of a fetal heart beat in an embryo with a crown rump length of 5 mm (Figure 22) or a fetal heart beat less than 90 beats per minute are poor prognostic signs. Gestational trophoblastic disease (i.e. molar pregnancy) may present with multiple,

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small, irregular cystic lesions within the endometrium (Figure 23 and 24).

Figure 19

Figure 20

Figure 21

Figure 19: Transvaginal ultrasound in a longitudinal plane shows a gestational sac greater than 8 mm diameter without a yolk sac (fetal demise). Figure 20: A gestational sac greater than 18 mm without a fetal pole (fetal demise). Figure 21: Transvaginal ultrasound in a longitudinal plane showing a collapsed gestational sac (fetal demise).

Figure 22: Transabdominal ultrasound with Doppler showing the absence of fetal heart tones in an eight-week gestational pregnancy (fetal demise).

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Figure 23

Figure 24

Figure 23 and 24: Transverse (23) and longitudinal plane ultrasound (24) showing gestational trophoblastic disease. Ectopic Pregnancy Definitive diagnosis of ectopic pregnancy requires visualization of a fetal heart beat outside the uterus. Figure 25 shows a gestational sac with a fetal pole. A fetal heart beat was detected on ultrasound exam. On closer inspection, the gestational sac was clearly outside the endometrial cavity indicating an ectopic pregnancy.

Figure 25: Transvaginal ultrasound in a longitudinal plane showing an ectopic gestational sac. An ectopic fetal heart beat is identified in only a small percentage of the total number of ectopic pregnancies. In approximately 28% of patients presenting to emergency department, neither a definitive intrauterine pregnancy nor a definitive ectopic pregnancy can be visualized by ultrasound. In these cases, diagnosis of ectopic pregnancy is often reached through a combination of abnormal sonographic findings. Absence of a Definitive Intrauterine Pregnancy Once the absence of a definitive intrauterine pregnancy has been established, correlation with a serum B-hCG is the next step. Transvaginal ultrasound should detect the presence of a normal IUP

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when the serum B-hCG exceeds 1000 mIU/ml. Given the incidence of ectopic pregnancy in women presenting early to the ED with pelvic complaints, lack of a definitive IUP is quite concerning. A quantitative B-hCG above 1000 mIU/ml without evidence of a definitive intrauterine pregnancy implies either a recently aborted pregnancy or an ectopic pregnancy. While the presence of an intradecidual sac might indicate an early pregnancy, it could also represent endometrial breakdown in the presence of an ectopic pregnancy (the pseudo-gestational sac). Figure 26 shows a longitudinal view of the uterus with a pseudogestational sac. The endometrial sac does not have a surrounding chorionic ring and free fluid is visible in the posterior culde-sac. This patient had a ruptured ectopic pregnancy.

Figure 26: Transvaginal ultrasound in a longitudinal plane showing pseudo-gestational sac. Free Fluid The presence of free fluid is a frequent normal physiologic finding in women. Figure 27 is a transabdominal ultrasound in the transverse plane across the uterus, which shows a small amount of physiologic free fluid in the pelvic cul-de-sac.

Figure 27: Transabdominal ultrasound in the transverse plane showing free fluid in the pelvic cul-de-sac. However, free fluid is also associated with both ruptured (more commonly) and unruptured ectopic pregnancies. In addition, the

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likelihood of rupture increases with the increase in quantity of free fluid.(12) Since clotted blood in the pelvic cul-de-sac after tubal rupture can sometimes obscure the ultrasound image, a brief scan through the hepatorenal space can often lead to quick identification of active hemorrhage. In the first trimester, the presence of free fluid in the hepatorenal space of a patient without an intrauterine pregnancy is virtually diagnostic of a ruptured ectopic pregnancy.(13) Figure 28 shows a large amount of free fluid in and around the hepatorenal space in a patient with a ruptured ectopic pregnancy. Despite the amount of hemorrhage, free fluid was not readily seen on transvaginal ultrasound because of distorted landmarks from clotted blood (Figure 29).

Figure 28

Figure 29

Figure 28: Ultrasound of the hepatorenal space (ruptured ectopic) demonstrating anechoic (black) free fluid between the liver and right kidney. Figure 29: Transvaginalultrasound in a longitudinal plane (ruptured ectopic). Tubal Rings Figures 30 and 31 are ultrasounds of unruptured tubal ectopic pregnancies. Both ultrasounds show a gestational sac surrounded by a thick chorionic ring outside and immediately adjacent to the myometrium.

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Figure 30

Figure 31

Figure 30: Transvaginal ultrasound in a longitudinal plane with unruptured ectopic.Figure 31: Transvaginal ultrasound showing a ring-like structure situated between the left ovary and uterus. A Complex Adnexal Mass The presence of coagulated blood surrounding a ruptured ectopic can distort the sonogram, making the diagnosis challenging. Even in the absence of hemorrhage, a gestational sac may not be well-defined and a distinct echogenic ring may not be present. Figure 32 is a transverse transvaginal ultrasound of the fallopian tube showing a suspicious adnexal mass found to be an unruptured ectopic pregnancy in the operating room. These findings will usually only be picked up with transvaginal ultrasound.

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Figure 32: Transvaginal ultrasound in a transverse plane showing a suspicious adnexal mass.

An Eccentrically Located Pregnancy A gestational sac surrounded by less than 5 mm of myometrium suggests ectopic pregnancy. In addition, a gestational sac with a marked eccentric location in the uterus is often suggestive of ectopic pregnancy. Figure 33 is a transvaginal ultrasound in the transverse plane showing a large eccentrically located mass in the uterus. This was found to be a left interstitial pregnancy in the operating room.

Figure 33: Transvaginal ultrasound in a transverse plane showing an interstitial pregnancy. Color Doppler The improved capabilities of smaller, more portable ultrasound machines or systems now give emergency physicians the option of color Doppler use in the evaluation of first trimester pregnancy. Since an implanted gestational sac has increased blood supply, identifying vascular asymmetry in the adnexal areas may allow for a specific diagnosis in cases where an ultrasound without color Doppler were previously ruled non-diagnostic. Similarly, color Doppler could potentially aid in distinguishing an early intrauterine gestational sac with its surrounding blood supply from that of a pseudogestational sac. Figure 34 is a transvaginal ultrasound in the transverse plane showing a normal right fallopian tube. Here, color Doppler has 142

identified the fallopian tube just anterior to the iliac vessels. Blood supply above the iliac vessels in the area of the fallopian tube is normal. Marked increase in color flow (blood flow) of the contra lateral adnexal region would suggest the presence of an embedded ectopic pregnancy.

Figure 34: Transvaginal ultrasound of the right fallopian tube in a transverse plane using color Doppler. The use of Spectral Doppler interrogation can also be used to distinguish placental blood flow from maternal blood flow in suspicious adnexal masses, early intrauterine pregnancy, and recent fetal demise with retained intrauterine products of conception. Figure 35 shows spectral Doppler interrogation of a normal ovary. Although large trials with emergency physicians utilizing color Doppler in the evaluation of patients in their first trimester pregnancy are lacking to date, case reports have supported the use of color Doppler in this way. (13)

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Figure 35: Transvaginal ultrasound of the ovary with color Doppler interrogation and pulsed Doppler (= spectral Doppler). It should be noted that although no adverse effects to a fetus have ever been shown, ultrasound does have the potential for mechanical bioeffects. Additionally, color Doppler is considered a higher intensity ultrasound and carries a higher potential risk of adverse effects than ultrasound without color Doppler. Therefore, the goal when using ultrasound is to obtain the most diagnostic information at the lowest possible output level. Fortunately, in the majority of cases a definite intrauterine pregnancy can be established without the need for color Doppler. In cases where ultrasound is non-diagnostic (approximately 28% of the time), color Doppler may prove useful in enhancing the sensitivity of a diagnostic ultrasound.

V. Pearls and Pitfalls

Using the serum quantitative B-hCG to decide when to perform an ultrasound. Not performing the ultrasound. Interpreting an early gestational sac as definitive evidence of an intrauterine pregnancy. Not visualizing the gestational sac in two planes. Not performing an ultrasound of the hepatorenal space for free fluid. Not identifying an eccentrically located gestational sac.

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Diagnostic ultrasound including its use in pregnancy has an impressive safety record. Laboratory studies have shown that diagnostic levels of ultrasound can produce physical effects in tissue, also called bioeffects. These effects include mechanical vibrations, cavitation and heat. Safety guidelines promoting limited exposure time and ultrasound intensity have therefore been implemented to avoid adverse effects, especially in the fetus.(14)

VI. References 1 Stovall TG, Kellerman AL, Ling FW, Buster JE. Emergency department diagnosis of ectopic pregnancy. Ann Emerg Med.1990;19(10):1098-103. 2 Kaplan BC, Dart RG, Moskos M, Kuligowska E, Chun B, Adel Hamid M, Northern K, Schmidt J, Karwadkar A. Ectopic pregnancy: Prospective study with improved diagnostic accuracy. Ann Emerg Med.1996;28:10-17. 3 Buckley RG, King KJ, Disney JD, Gorman JD, Klausen JH. History and physical examination to estimate the risk of Ectopic pregnancy: Validation of a clinical prediction model. Ann Emerg Med.1999;34:589-594. 4 Barnhart K, Mennuti MT, Benjamin I, Jacobson S, Goodman D, Coutifaris C.

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Prompt diagnosis of ectopic pregnancy in an ED setting. Obstet Gynecol.1994;84(6):1010-15. 5 Mateer JR, Valley VT, Aiman EJ, Phelan MB, Thoma ME, Kefer MP. Outcome analysis of a protocol including bedside endovaginal sonography in patients at risk for ectopic pregnancy. Ann Emerg Med.1996;27:283-289. 6 Kaplan BC, Dart RG, Moskos M, Kuligowska E, Chun B, Adel Hamid M, Northern K, Schmidt J, Kharwadkar A. Ectopic pregnancy: Prospective study with improved diagnostic accuracy. Ann Emerg Med.1996;28:10-17. 7 Gracia CR, Barnhart KT. Diagnosing ectopic pregnancy: Decision analysis comparing six strategies. Obstet Gynecol.2001;97:464-70. 8 Mateer J, Plummer D, Heller M, Olson D, Jehle D, Overton D, Gussow L. Model curriculum for physician training in emergency ultrasonography. Ann Emerg Med.1994;23:95-102. 9 Shih CH. Effect of emergency physician-performed pelvic sonography on length of stay in the emergency department. Ann Emerg Med.1997;29(3):348351. 10 Blaivas M, Sierzenski P, Plecque D, Lambert M. Do emergency physicians save time when locating a live IUP with bedside ultrasonography? Acad Emerg Med.2000;7(9):988-93. 11 Reardon RF, Martel ML. First trimester pregnancy. In: Ma OJ, Mateer JR (eds.). Emergency Ultrasound. McGraw-Hill: New York.2003;239-275. 12 Dart R, McLean S, Dart L. Isolated fluid in the cul-de-sac: How well does it predict ectopic pregnancy? Am J Emerg Med.2002;20:1-4.

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13 Blaivas M. Color doppler in the diagnosis of ectopic pregnancy in the emergency department: Is there anything beyond a mass and fluid? J Emerg Med.2002;22(4):379-384. 14 AIUM. Bioeffects and safety of diagnostic ultrasound. AIUM,1993.11200 Rockville Pike, Suite 205, Rockville, Maryland 20852-3139, USA.

Chapter 9
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Deep Venous Thrombosis

Chapter 9: Deep Venous Thrombosis

I. Introduction and Indications The presentation of a swollen or tender lower extremity is common in emergency medicine, and often mandates a work-up to rule out the presence of deep venous thrombosis (DVT). Venous thromboembolism has been shown to have an incidence of more than 1 per 1000 annually in the United States.(1) Patients with a DVT are at risk for morbidity and mortality since a fragment of the thrombus can embolize to the lungs. It has been suggested that about one half of patients with an untreated proximal DVT will develop a pulmonary embolism (PE) within 3 months.(2)

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A variety of diagnostic techniques have been used to identify DVT. These include impedance plethysmography, contrast venography, ultrasonography, computed tomography, and magnetic resonance imaging. In the past, contrast venography was considered to be the gold standard. However, due to its associated expenditure of manpower resources and time, the need for specialized personnel, space and equipment, and its limited availability and associated morbidity (including iatrogenic DVT) (3), contrast venography has been replaced with other tests with more favorable risk / benefit profiles. Among these, ultrasonography is as accurate as any, with many advantages over CT, MRI and plethysmography, including low cost, portability, non-invasiveness, and simplicity. It has become the standard initial test to diagnose a DVT and has proven to be highly accurate and cost-effective. Two distinct protocols have been developed for the sonographic evaluation of the lower extremities: limited compression ultrasonography and duplex ultrasonography. The latter is a comprehensive examination usually requiring 45 minutes or more. It involves a variety of maneuvers as well as color flow and Doppler techniques, and is performed by specialist technicians. The former, employed at the bedside, is a simpler more focused technique readily mastered by practicing clinicians with basic understanding of ultrasonography. Limited compression ultrasonography is directed to identifying clot in the common femoral and/or the popliteal veins. The rationale for this approach is based on specific pathological and anatomic features of DVT. First, thrombi distal to the popliteal vein almost never embolize. This leads to the important clinical distinction between distal and proximal DVTs. While distal DVTs are of limited clinical consequence per se, they may propagate proximally, at which time they are at risk for embolization. For this reason, patients suspected of having distal DVT require repeat ultrasound evaluation in 3-5 days to rule out proximal extension. Second, studies of proximal DVT have demonstrated that isolated superficial femoral vein thrombosis is extremely rare. Clot is almost always present in either the common femoral and/or popliteal veins, or all three.(4) In the technique of compression ultrasonography, the clot is identified by the absence of normal compressibility of the vein. Limited compression ultrasonography has been shown to be as accurate as Duplex ultrasonography and superior to plethysmography, in the detection of

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a proximal DVT. (5) Its use by emergency physicians permits quick and accurate diagnosis with reduced time to disposition of proximal DVT.(6,7) II. Anatomy For the purposes of the emergency ultrasound (EUS) evaluation of the lower extremity, the veins posing a significant risk of PE include the common femoral, superficial femoral, and popliteal veins. It is important to note that the superficial femoral vein is part of the deep system, not the superficial system as the name suggests. Conversely the deep femoral (profunda femoris) vein is not considered to be a source of embolizing thrombi, and is therefore not included in the evaluation for DVT. The popliteal vein is formed by the confluence of the anterior tibial, posterior tibia, and peroneal veins approximately 4-8 cm distal to the popliteal crease. The popliteal vein becomes the superficial femoral vein as it passes through the adductor canal approximately 8-12 cm proximal to the popliteal crease. The superficial femoral vein joins the deep femoral vein to form the common femoral vein approximately 5-7 cm below the inguinal ligament. Prior to passing under the inguinal ligament to form the external iliac vein, the common femoral is joined by the greater saphenous vein (a superficial vein) merging from the medial thigh. In relation to the companion arteries, the common femoral vein lies medial to the artery only in the region immediately inferior to the inguinal ligament. The vein quickly takes a location posterior to the artery within 2 - 4 centimeter of the inguinal crease, and remains posterior to the arteries into the calf.

III. Scanning Technique and Normal Findings Transducer. A linear array vascular probe with a frequency of 6 10 MHz and width of 6 8 cm is often ideal. Narrower transducers may make it harder to localize the veins and to apply uniform compression. For larger patients, a lower frequency or even an abdominal probe will facilitate greater tissue penetration.

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Compression. The sonographic evaluation is performed by compressing the vein directly under the transducer while watching for complete apposition of the anterior and posterior walls. If complete venous compression is not attained with pressures sufficient to deform the artery, obstructing venous thrombus is likely to be present. Patient positioning. To facilitate the identification of the veins and test for compression, they need to be distended. This is accomplished by placing the lower extremities in a position of dependency preferably by placing the patient on a flat stretcher in reverse trendelenberg. If the patient is on a gurney where this is not possible, the pt should be placed semi-sitting with 30 degrees of hip flexion Real-Time Scanning Technique: The common femoral vein. (Figure 1) Gel is applied to the groin and medial thigh for a distance about 10 centimeters distal to the inguinal crease. Filling of the common femoral vein might be augmented by placing a small bolster under the knee resulting in slight (about 10 degrees) hip flexion. Mild external rotation (30 degrees) may also be helpful. Many patients do not have the classic anatomic relationship between the vein and artery described above. Distinction of the two vessels may therefore depend on size (the vein is usually larger), shape (the vein is more ovoid) and compressibility, unless color-flow or Doppler is available. In this case the characteristic arterial waveform can help with differentiation. Compressive interrogation of the vessel commences at the highest view obtainable at the inguinal ligament with the probe held transverse to the vein. Angling superiorly, a short section of the distal common iliac vein might be scanned. Systematic scanning, applying compression every centimeter, should be continued to the bifurcation of the common femoral vein into its superficial and deep branches and 1 2 cm beyond, since branch points are particularly susceptible to thrombosis. If difficulty is encountered in following the common femoral vein to the bifurcation, or in clearly identifying the two branching vessels, techniques to optimize the angle of insonation should be used. (The clearest signal will be obtained from the vessel walls when the incidentultrasound beam is at right-angles to the vein. This angle can be identified by rocking the probe in real time.) Other techniques of image adjustment that may be needed include

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decreasing the dynamic range and optimizing the gain. In obese patients it may be necessary to use a widely curved array general abdominal probe with lower frequencies than the vascular probe. In equivocal cases, comparison with the contralateral side may be helpful. If the clinical suspicion is high, the superficial femoral vein can also be evaluated. As noted above, DVT is identified by the absence of normal compressibility of the vein

Figure 1

Figure 1: A still image of the left common femoral vein (V) and artery (A) shows the saphenous vein (SV) merging from medially. Additional Components of the Exam: The superficial femoral vein: As noted previously, this vein is not a primary focus of the standard lower extremity EUS evaluation. In cases where there is a high suspicion of DVT and an otherwise normal exam of the common femoral and popliteal veins, the superficial femoral vein may also be evaluated. Color flow and Doppler: Color flow and Doppler assessment may be used to localize the vessels, although the use of this technology is beyond the scope of the standard EUS exam. Gray scale identification of clot: While thrombus may be hyperechoic and thus directly visualized on exam, it is also frequently isoechoic to unclotted blood. Consequently, failure to see echogenic clot should not be used to exclude the diagnosis of DVT.

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IV.

Pathology

As noted previously, DVT is identified by the absence of normal compressibility of the vein, although occasionally clot can be directly visualized on gray scale. Since this is a dynamic test, it can most clearly be demonstrated in video clips rather than still images.

V. Pearls and Pitfalls

A non-compressible vein may be mistaken for an artery, leading to a false negative result. An artery may be mistaken for a non-compressible vein, leading to a false positive result. Large superficial veins may be mistaken for deep veins. This pitfall is more likely in obese patients and those with occlusive DVT causing distension in the collateral superficial veins. Depending on the compressibility of the vein, this can lead to both false positive and false negative results. Inguinal lymphadenopathy may be mistaken for a non-compressible common femoral vein. Additional scanning in the longitudinal plane will show the extent of the lymph node (usually less than 1 - 2 cm). The possibility of iliac or inferior vena cava obstruction as a cause for lower extremity pain or swelling may be overlooked. While color flow and Doppler techniques may identify the presence of these conditions, they are beyond the usual scope of the EUS exam. A negative scan for a lower extremity DVT does not rule out the presence of pulmonary embolism. The superficial femoral vein is part of the deep venous system. This sometimes confusion terminology has resulted in some authorities referring to the superficial femoral vein as simply the femoral vein.

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VI. References 1. Silverstein MD, Heit JA, Mohr DN, Petterson TM, O'Fallon WM, Melton LJ 3rd. Trends in the incidence of deep vein thrombosis and pulmonary embolism: a 25-year population-based study. Arch Intern Med.1998;158:585-593. 2. Kearon C. Natural history of venous thromboembolism. Circulation.2003;107:I22-30. 3. Fraser JD, Anderson DR. Deep venous thrombosis: recent advances and optimal investigation with US. Radiology.1999;211:9-24. 4. Cogo A, Lensing AW, Prandoni P, Hirsh J. Distribution of thrombosis in patients with symptomatic deep vein thrombosis. Arch Intern Med.1993;153:2777-2780. 5. Lensing AW, Prandoni P, Brandjes D, Huisman PM, Vigo M, Tomasella G, Krekt J, Wouter Ten Cate J, Huisman MV, Bller HR. Detection of deep-vein thrombosis by real-time b-mode ultrasonography. N Engl J Med.1989;320:342-345. 6. Blaivas M, Lambert MJ, Harwood RA, Wood JP, Konicki J. Lower-extremity doppler for deep venous thrombosis-can emergency physicians be accurate and fast? Acad Emerg Med.2000;7:120-126. 7. Theodoro D, Blaivas M, Duggal S, Snyder G, Lucas M. Real-time B-mode ultrasound in the ED saves time in the diagnosis of deep vein thrombosis (DVT). Am J Emerg Med.2004;22:197-200.

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Chapter 10

Small Parts - Ocular Ultrasound

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Chapter 10: Small Parts - Ocular Ultrasound

I. Introduction and Indications Ocular emergencies account for 3% of all emergency department visits. Ocular symptoms remain some of the most challanging to evaluate in a busy emergency department. Ophthalmologic consultation is not available in all settings, which can potentially lead to misdiagnosis and treatment delays. The evaluation of ocular emergencies can be limited by lack of sophisticated tools and training. Direct visualization of intraocular structures is difficult or impossible when the eye lids are swollen shut after injury. Lens opacification and hyphema can also block the posterior view of the chamber. The recent spread of ultrasound technology and adaptation of it at the bedside by emergency physicians has led to exploration of a number of applications. Ocular ultrasonography is a relatively new application in emergency medicine. In 2002, Blaivas et al. published the first series of ED patients presenting with ocular symptoms who were evaluated by bedside emergency department ultrasonography.(1) The ability of ultrasound to evaluate the eye and the adjacent structures in a rapid and noninvasive manner is of tremendous value in the setting of a busy emergency department. ED ultrasound provides a quick, accurate, well-tolerated, noninvasive tool for evaluating potentially vision-threatening conditions at the bedside.(2,3) The need for pupillary dilatation and direct ophthalmoscopy are obviated by the use of bedside ultrasound. Ocular ultrasound can expedite the diagnosis and management of several ocular emergencies including globe perforation, retrobulbar hematoma, retinal detachment, lens subluxation, vitreous hemorrhage, and intraocular foreign body.(4,5,6) Indications: 1. 2. 3. 4. 5. Decreased vision/loss of vision Suspected foreign body Ocular pain Eye trauma Head injury

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II. Anatomy

Illustration 1: Overview of ocular anatomy. III. Scanning Technique and Normal Findings A high-resolution 7.5- 10-MHz or higher linear array ultrasound transducer is used to perform an ocular examination. Emergency ocular ultrasonography is performed using a closed-eye technique. A large amount of standard water-soluble ultrasound transmission gel should be applied to the patients closed eyelid so that the transducer doesnt have to touch the eyelid. Ultrasound gel is not detrimental to eye. The globe should be scanned in both sagittal and transverse planes. Both eyes should be scanned through closed eyelids. The patient is asked to look straight ahead with eyes closed, but without clenching the eyelids. Depth should be adjusted so that the image of the eye fills the screen. Gain should be adjusted to achieve acceptable imaging. Since the eye is a fluid-filled structure, it provides a perfect acoustic window, producing images with excellent detail. The normal eye appears as a circular hypoechoic structure. The cornea is seen as a thin hypoechoic layer parallel to the eyelid. The anterior chamber is 157

filled with anechoic fluid and is bordered by the cornea, iris and anterior reflection of the lens capsule. The iris and ciliary body are seen as echogenic linear structures extending from the peripheral globe towards lens. The normal lens is anechoic. The normal vitreous chamber is filled with anechoic fluid. Vitreous is relatively echolucent in a young healthy eye. Sonographically, the normal retina cannot be differentiated from the other choroidal layers. The evaluation of the retrobulbar area includes optic nerve, extraocular muscles and bony orbit. The optic nerve is visible posteriorly as a hypoechoic linear region radiating away from globe.

Figure 1: A high-resolution linear array ultrasound transducer is being applied to the closed eyelid to perform an ocular examination. (Courtesy of Michael Blaivas, M.D.)

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Figure 2: Ultrasound image of a normal eye with lens. (Courtesy of Michael Blaivas, M.D.)

IV.

Pathology

Globe Rupture Bedside ultrasound has revolutionized the management of a traumatized eye. Evaluation of patients with ocular trauma by ultrasound is of particular value when abnormalities like corneal edema, hyphema, vitreous hemorrhage or cataract make direct visualization of the ocular contents difficult. Traumatic globe rupture is a major ophthalmologic emergency and almost always requires surgical intervention. Ultrasound findings of globe rupture include decrease in the size of the globe, anterior chamber collapse and buckling of the sclera.

Figure 3: Ultrasound of globe rupture. (Courtesy of Michael Blaivas, M.D.)

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Intraocular Foreign Body The utility of ultrasonography in detecting and localizing radiolucent orbital foreign bodies and its clear superiority in the localization of foreign bodies has been clearly established. Intraocular foreign bodies are identified by their bright echogenic acoustic profile and either shadowing or reverberation artifacts seen in the usually echolucent vitreous. Ultrasound patterns of shadowing and comet tails may help differentiate foreign body materials.

Figure 4: A hyperechoic foreign body (blue) in the eye. Note the bright echogenic reverberation artifact. (Courtesy of Michael Blaivas, M.D.) Retinal Detachment Retinal detachment can be difficult to detect on physical examination, especially when the detachment is small. On occasion retinal tears are accompanied by vitreous hemorrhages. A retinal detachment will be seen as a hyperechoic undulating membrane in the posterior to lateral globe (Figure 5). In patients with total retinal detachments, the typically folded surface attaches to the ora serrata anteriorly and the optic nerve posteriorly.

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Illustration 2: Retinal detachment.

Figure 5: Retinal detachment is seen in this image. (Courtesy of Michael Blaivas, M.D.) Elevated Intracranial Pressure Optic Nerve Sheath Measurement The evaluation of the optic nerve sheath diameter is a simple noninvasive procedure, which is a useful tool in the assessment of elevated intracranial pressure. Ocular ultrasound for evidence of increased intracranial pressure has been described in cadavers. Recently, Blaivas et al. described its use among adult patients in the emergency department with suspected elevated intracranial pressure (EICP).(2) Patients with altered level of consciousness may be

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suffering from increased intracranial pressure from a variety of causes. EICP may be present in emergency department patients with head injury and also in those with spontaneous intracranial bleed. Physical examination has significant limitations if the patient is unconscious, or intubated and paralyzed. Papilledema from EICP may be delayed after ICP elevation, by up to several hours. A rapid, bedside and noninvasive means of detecting EICP is desirable when conventional imaging methods are unavailable. The eyes often reflect disease states elsewhere in the body. The optic nerve attaches to the globe posteriorly and is wrapped in a sheath that contains fluid. The optic nerve sheath is contiguous with the dura mater and has a trabeculated arachnoid space through which cerebrospinal fluid slowly percolates. The relationship between the optic nerve sheath diameter (ONSD) and ICP has been well established. Evaluation of the optic nerve sheath diameter (ONSD) can detect EICP. On ultrasound a normal optic nerve sheath measures up to 5.0 mm in diameter. The ONSD is measured 3 mm posterior to the globe for both eyes. A position of 3 mm behind the globe is recommended because the ultrasound contrast is greatest, the results are more reproducible (Figure 6). Two measurements are averaged. An average ONSD greater than 5 mm is considered abnormal and elevated intracranial pressure should be suspected.

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Figure 6: A dilated optic nerve sheath measuring 5.3 mm in a patient with an increased intracranial pressure is shown. One set of calipers measures 3 mm behind the globe and the second measures the diameter of the optic nerve sheath. (Courtesy of Michael Blaivas, M.D.) Vitreous Hemorrhage Vitreous hemorrhage can interfere with vision, and if it is large can cause blindness. It appears as echogenic material in the posterior chamber. The sonographic appearance of vitreous hemorrhage depends on its age and severity. Fresh mild hemorrhages appear as small dots or linear areas of areas of low reflective mobile vitreous opacities, whereas in more severe and older hemorrhages, blood organizes and forms membranes. Vitreous hemorrhages may also layer inferiorly due to gravitational forces.

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Figure 7: Bright echoes in the posterior chamber demonstrating vitreous hemorrhage. (Courtesy of Michael Blaivas, M.D.)

V. Pearls and Pitfalls

If there is any suspicion for globe rupture, copious amounts of gel should be applied to the closed eyelid so that the transducer doesnt actually have to make contact with the eyelid. Any pressure on the traumatic eye could be detrimental. As with fetal ultrasound, it is important to limit the duration of the examination as much as possible, especially when using spectral and color Doppler, which are thought to produce increased levels of mechanical energy. Exposure limit guidelines are almost 50% below the maximum recommended for fetal imaging. Limitations of ocular ultrasound include difficulty in imaging patients with significant orbital emphysema. Various artifacts may interfere with the examination.

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VI. References 1 Blaivas M. Bedside emergency department ultrasonography in the evaluation of ocular pathology. Acad Emerg Med.2000;7:947-950. 2 Blaivas M, Theodoro D, Sierzenski P. Elevated intracranial pressure detected by bedside emergency ultrasonography of the optic nerve sheath. Acad Emer Med.2003;10:376-381. 3 Blaivas M, Theodoro D, Sierzenski P. A study of bedside ocular ultrasonography in the emergency department. Acad Emer Med.2002;9:791-799. 4 Dewitz A. Soft tissue applications. In:Ma OJ, Mateer J, eds. Emergency Ultrasound. McGraw- Hill: New York,2003;385. 5 Whitcomb MB. How to diagnose ocular abnormalities with ultrasound. AAEP Proceedings.2002;48:272-275. 6 Price D, Simon BC, Park RS. Evolution of emergency ultrasound. California J Emerg Med.2003;4:82-88.

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Chapter 11 Ultrasound Guided Procedures in Emergency Medicine Practice - Vascular Access

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Chapter 11: Ultrasound Guided Procedures in Emergency Medicine Practice Vascular Access
Ultrasound guided Vascular Access I. Introduction and Indications Emergency physicians are often called upon to rapidly establish intravenous access for critically ill patients. Depending on the clinical scenario, cannulation of a peripheral vein is first attempted and if unsuccessful, a more central vein is tried. Several factors including body habitus, volume depletion and history of intravenous drug abuse can make this a challenging task. Bedside ultrasound not only provides us with a window of the patients vascular anatomy, but also gives us the ability to visualize the needle as it enters the body. If used correctly, the needle can be successfully guided into the desired vein. The use of ultrasound increases accuracy, limits complications and reduces the number of attempts of venous access. (1-5) Indications: Real-time visualization and anatomical guidance of venous cannulation Minimize number of attempts Decrease complication rates

II. Anatomy It is important to appreciate the sonographic difference between veins and arteries. Veins are thin walled, non-pulsatile, easily compressible, and in a patient with normal hydration status larger than arteries (Figure 1). This principle applies to both the central and peripheral vasculature. In this section we will discuss the basic anatomical landmarks required to perform peripheral and central venous cannulation.

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Central Veins When deciding which central vein to cannulate, we usually think of either the subclavian or internal jugular vein. The femoral vein should only be considered if the above veins are not accessible. As already hinted by its name, the subclavian vein runs for a significant distance under the clavicle. Ultrasound visualization in this area is extremely difficult, as the high acoustic impedance of the clavicle bone causes a large acoustic shadow in most areas of the image. Only in a very lateral or supraclavicular approach imaging can be obtained. This makes it a more difficult choice for cannulation under ultrasound guidance. In contrary, the internal jugular vein traverses the neck virtually unopposed by bone making it an ideal vessel to evaluate using ultrasound. The internal jugular vein runs vertically in the neck lying at first lateral to the internal carotid artery, and then lateral to the common carotid as it eventually unites with the subclavian vein. The internal jugular vein lies underneath the bifurcation of the sternal and clavicular heads of the sternocleidomastoid muscle (SCM), which is used as an external landmark when trying to locate the vein. The common femoral vein is formed by the superficial femoral vein and the deep femoral vein approximately 5-7 cm caudal to the inguinal ligament. It is joined by the greater saphenous vein (a superficial vein) from medial prior to passing under the inguinal ligament to form the external iliac vein. The common femoral vein lies medial to the artery only in the region immediately inferior to the inguinal ligament. It quickly takes a location posterior to the artery within 2 - 4 cm of the inguinal crease and remains posterior to the arteries into the calf (see also DVT chapter).

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Figure 1: Still image of left internal jugular vein in transverse view. Peripheral Veins The antecubital veins of the arm are most commonly used in the emergency setting (Figure 2). Superficial veins that traverse the antecubital fossa include the cephalic and basilic veins. The cephalic vein begins in the radial part of the dorsal venous network and ascends upward within the superficial fascia in front of the elbow in the groove between the brachioradialis and biceps brachii. The basilic vein begins in the ulnar part of the dorsal venous network. It runs up the posterior surface of the ulnar side within the superficial fascia of the forearm in the groove between the biceps brachii and pronator teres. The brachial veins begin at the elbow, by the union of the venae comitantes of the ulnar and radial arteries and lie deep to the superficial veins mentioned above. The deep brachial vein lies adjacent to the pulsatile non-compressible brachial artery. Another common site for peripheral venous access is the external jugular vein (v. jugularis externa). It receives blood from the exterior of the cranium and the deep parts of the face and is being formed by the posterior facial and auricular vein. The v. jugularis externa runs perpendicularly down the neck, in the direction from the angle of the mandible to the middle of the clavicle at the posterior border of the sternocleidomastoideus muscle. In its course it crosses the sternocleidomastoideus muscle obliquely, perforates the deep fascia in

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the subclavian triangle and ends in the subclavian vein,. The external jugular vein varies in size and is occasionally duplicated.

Figure 2: Still image of a peripheral vein. III. Scanning Technique, Normal Findings and Common Variants When attempting to localize these vessels on the ultrasound machine it is important to remember that superficial vessels stand alone while deeper vessels are paired. Procedure Technique: A linear array transducer with frequency ranging from 7.5 to 10 MHz is recommended for ultrasound guided vascular access. Care must be taken to cover the probe with a sterile sheath prior to starting the procedure (Figure 3). The depth, direction and patency of the central or peripheral vein should be examined using ultrasound prior to needle insertion. A proper time-out procedure step should be assured when necessary.

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Figure 3: Linear probe with sterile sheath cover. Central Venous Access Internal Jugular Vein (IJV) The patient is prepped as if you would attempt a traditional line placement. The patients head can be placed in the conventional rotated position or kept in a neutral head position. A potential benefit of a neutral head position is that the internal jugular vein assumes a more lateral position to the carotid artery (it would rotate anterior and over the artery with head movement to the opposite side). Keeping the two major neck vessels in a parallel rather than perpendicular alignment can minimize the risk of arterial puncture should the needle be advanced too far. This is especially important in patients with low venous filling pressures and vein collapse. Ultrasound should also be used to locate the sternoclaidomastoid muscle when choosing a puncture site. Needle insertion through the muscle should be avoided whenever possible. It can lead to bleeding and painful hematoma.

The indicator on the transducer should be oriented in the same direction as the indicator on the screen and located in the upper left hand side of the display. It can be used as a reference point when directing the needle towards the vessel of interest. The transducer is placed in transverse orientation over the triangle formed by the two heads of the SCM. Slowly slide the probe distally, until you find the area of interest, two dark and oval or round appearing vessels. Use the transducer to compress the vein to confirm that it is indeed the vein and not the artery (Video clip 1). Position the vein in the center of your image and place the needle to the midline of 171

the transducer. Estimate or measure the depth of the IJ vein from the skin surface. You can use the same distance when determining how far from the transducer the needle should enter the skin when the angle of insertion is close to 45 degrees (Figure 4 and 5). In this scenario it is also important to remember that the length of the needle should be at least 1.4 times as long as the measured depth of the vein (Illustration 1). Align the needle with the longitudinal axis of the vein while advancing it.

Video clip 1: Shows compression of left internal jugular vessel.

Figure 4

Figure 5

Figure 4: Patient preparation and position for right IJ central line placement. Figure 5: Needle insertion technique right IJ.

Illustration 1: When the needle is inserted in a 45 degree angle, the path of the needle is approximately 1.4 times as long as the measured depth of the vessel. This can be estimated using the Phythagorean theorem, whereby the needle path equals the hypotenuse (c) and

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depth of the vessel and distance from transducer are the legs a and b of the triangle. Advance the needle under direct ultrasound vision (dynamic technique). The sonographic appearance of the needle tip on the screen is a hyperechoic structure that casts a narrow shadow called ring-down artifact (Figure 6). Following cannulation of the vein using ultrasound guidance, standard Seldinger technique should be used to place the catheter during which ultrasound is usually not needed. The technique for central venous access of the Femoral Vein (FV) is similar to the above descibed IJ approach. Especially in patients were the femoral vein runs inferior to the artery, ultrasound can guide in a more oblique approach, minimizing the risk of accidential arterial puncture.

Figure 6: Ring-down artifact over left IJ vein.

Peripheral Venous Access Patient is placed in supine position with tourniquet applied to assist in vein engorgement. Transducer is placed on the antecubital fossa in transverse axis and the same technique described above is used to 173

identify and cannulate the peripheral vein of interest. An alternative approach is positioning the transducer in a long or sagittal axis to the vessel of interest. This is very helpful to confirm that an approporiate angle was used to cannulate the vessel.

IV. Pathology Remember that central or peripheral veins can be thrombosed or contain a permanent catheter which makes them unsuitable for cannulation.

V. Pearls and Pitfalls

Failure to identify the needle in the tissue. Remember to look for the ringdown artifact to avoid this. Failure to distinguish between vein and artery. Remember to look for the compressible vessel. Doppler flow can be used if necessary. Angling the transducer towards the entry site of the needle on the skin may help visualize the needle earlier. Avoid advancing the catheter if the needle tip is not visualized. Placing the patient in a supine and Trendelenburg position will help facilitate central venous access. Having the patient perform a Valsalva maneuver will help engorge the internal jugular vein. Ideal positioning of neck should be midline or slightly lateral. Excessive head rotation may cause dangerous overlay of the internal jugular vein over the carotid artery. Use caution when utilizing a long axis approach to central venous cannulation due to the inability to maintain visualization of the carotid artery at all times. Estimate the length of the needle path and choose a catheter with the appropriate length. Failure to use sterile ultrasound gel for line placement. If not available you

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can substitute with a package of surgical lubricant.

VI. Reference 1 Hudson PA, Rose JS. Real-time ultrasound guided internal jugular vein catheterization in the emergency department. Am J Emerg Med.1997;15:79-82. 2 Slama M, Novara A, Safavian A, Ossart M, Safar M, Fagon JY. Improvement of internal jugular vein cannulation using an ultrasoundguided technique. Intensive Care Med.1997;23:916-919. 3 Teichgrber UK, Benter T, Gebel M, Manns MP. A sonographically guided technique for central venous access. AJR.1997;169:731-733. 4 Denys BG, Uretsky BF, Reddy PS. Ultrasound-assisted cannulation of the internal jugular vein. A prospective comparison to the external landmark-guided technique. Circulation.1993;87:1557-1562. 5 Keyes LE, Frazee BW, Snoey ER, Simon BC, Christy D. Ultrasound-guided brachial and basilic vein cannulation in emergency department patients with difficult intravenous access. Ann Emerg Med.1993;34:711-714.

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Chapter 12

Ultrasound Guided Procedures in Emergency Medicine Practice Pericardiocentesis

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Chapter 12: Ultrasound Guided Procedures in Emergency Medicine Practice Pericardiocentesis

II. Pericardiocentesis I. Introduction and Indications The pericardial space usually contains 15-50 ml of fluid, which serves as lubricant between the visceral and parietal layers of the pericardium. Several systemic conditions can cause an increased amount of fluid in this space. Blood can also collect in this space following trauma. Clinical manifestations are highly dependent on the amount and rate of accumulation of this fluid or blood. The worst outcome is ventricular collapse causing a precipitous drop in cardiac output, hypotension and possible cardiac arrest. Using bedside echocardiography allows the emergency physician to rapidly evaluate the pericardium and identify the presence of a pericardial effusion. Identification of a pericardial effusion causing collapse of the right ventricle is diagnostic of pericardial tamponade and mandates immediate pericardiocentesis.(1-3) Indications: Emergent detection of pericardial effusion and visual guidance during drainage. II. Anatomy See cardiac chapter for anatomy details.

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III. Scanning Technique and Sonographic Findings Commonly attempted ultrasound views for this procedure are the subxiphoid (SX) and parasternal long axis (PSLA) view. However, the optimal position of the probe depends on multiple factors including patient position and body habitus, and oftentimes good results can be achieved with an apical or apical/PSLA approach. (See also cardiac chapter for more details.) Subxiphoid The probe is placed transversely at the left costal margin at the level of the subxiphoid process with the ultrasound beam aimed at the patients left shoulder.

The structures closest to the probe will appear on top of the screen display with the liver being a landmark. The liver borders the right ventricle of the heart. A pericardial effusion will appear as an anechoic area surrounding the heart.

Figure 1: Subxiphoid view of the heart with pericardial effusion. Parasternal The transducer is placed in the left parasternal area between the 2nd and 4th intercostal spaces.

The indicator should be facing the patients right shoulder Provides good images of left atrium, mitral valve, left ventricle, proximal ascending aorta. Look for anechoic area surrounding the heart. An apical four-chamber view can be utilized as well.

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Figure 2

Video clip 1

Figure 2: Parasternal long axis view with effusion. Video clip 1: Parasternal view of pericardial effusion

IV. Pathology Procedure Technique The chest wall is prepped and draped in standard surgical fashion. The ideal site of skin puncture is where the fluid accumulation is closest to the skin surface (chest wall). A curvilinear or phased array transducer covered in a sterile sheath with frequency ranging from 2.5 3.5 mHz is placed on the left anterior chest wall in the parasternal long axis. Look for the anechoic area on the top of the screen above the right ventricle. The distance from the transducer to the center of the effusion can be measured using the measuring tool on the machine (see video 5). A 16 18 gauge needle attached to a syringe is inserted adjacent to the transducer through the chest wall and into the pericardium. For placement confirmation, it is also recommended to use the activated saline technique. Here the position of the needle is confirmed by injecting agitated saline through the needle, creating a bubble appearance within the pericardial effusion and confirming placement within the fluid-filled pericardial sac.

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Figure 3: Position of the ultrasound probe for parasternal ultrasoundguided pericardiocentesis.

Illustration 1: Schematic view of pericardiocentesis.

There are several advantages to performing this procedure with the transducer on the anterior chest adjacent to the needle as opposed to the transducer positioned in the subxiphoid position distant from the needle entry point. In the subxiphoid view, the heart and hence the effusion you are trying to drain is located perpendicular to the ultrasound beam making it difficult to visualize the needle. Placing the transducer on the chest wall in the parasternal long axis aligns the beam in the same plane as the structure of interest with close proximity to the needle giving you excellent visualization. In addition to being closer to the skin surface and hence the effusion, the parasternal approach steers clear of other vital structures such as the liver and lung. (1-3)

V. Pearls and Pitfalls Confusing the epicardial fat pad with pericardial effusion. Remember the fat pad is an anterior structure and effusions are

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usually circumferential. Overlooking large pericardial effusions because they are clotted. Remember that clotted blood appears less anechoic than fresh blood. Normal pericardium will appear as a single, brightly echogenic stripe next to the myocardium. Add a flexible sheath to permit repeated drainage.

VI. References 1. Tayal VS, Moore CL, Rose GA. Cardiac. In: Ma J OJ, Mateer JR, eds. Emergency Ultrasound. 1st edition,89-127. McGraw-Hill, New York, 2003. 2. Tibbles CD, Porcaro W. Procedural applications of ultrasound. Emerg Med Clin North Am.2004;22(3):797-815. 3. Tayal VS, Kline JA. Emergency echocardiography to detect pericardial effusion in patients in PEA and near-PEA states. Resuscitation.2003;59(3):315-8.

Chapter 13

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Ultrasound Guided Procedures in Emergency Medicine Practice Thoracentesis

Chapter 13: Ultrasound Guided Procedures in Emergency Medicine Practice Thoracentesis

III. Thoracentesis I. Introduction and Indications One of the many etiologies of dyspnea in the emergency department is a pleural effusion. A pleural effusion is an abnormal collection of fluid in the pleural space. Removal of this fluid by needle aspiration is called a thoracentesis. Although Xray can be obtained relatively easily it has been shown to be less sensitive than ultrasound for detecting smaller effusions. In addition, ultrasound can precisely identify the location of the fluid so that the chest wall can be marked in

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preparation for thoracentesis. (1) Thoracentesis can be both diagnostic and therapeutic for the patient. Using ultrasound to guide this procedure can decrease the very high complication rate associated with it. (1-3) Indications:

Therapeutic intervention in symptomatic patient Diagnostic evaluation of pleural fluid Anatomy The pleural space is bordered by the visceral and parietal pleura. Fluid in the pleural space appears anechoic and is readily detected above the brightly echogenic diaphragm when the patient is in a supine position.

II.

Figure 1: Showing a large pleural effusion, diaphragm and liver.

III. Scanning Technique and Pathology: Procedure Technique: The ideal position for the patient is to sit upright leaning forward. A high frequency linear transducer (7.5 to 10 MHz) is the optimal choice for this procedure and placed on the patients back in the sagittal or transverse position (Figure 2). The lung is seen as an echogenic structure moving with respiration. Look for the deepest pocket of fluid superficial to the lung. The image is frozen and a measurement should be taken to approximate the depth the needle will have to be inserted to reach the maximum amount of fluid (Figure 3). 183

Figure 2: Shows patient in sitting position with ultrasound probe placed over the thoracentesis area.

Figure 3: Muscle, fluid, lung, and measurements.

Illustration 2: Overview of technique.

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Since the ultrasound beam must penetrate the chest wall in order to image the effusion you will see ribs. The edge of the bone is echogenic and gives off a characteristic shadowing (Figure 4). The area should be marked with a pen and then prepped and draped in standard surgical fashion before the procedure is performed. IV. Pathology Complications can include pneumothorax, puncture of lung tissue, cystic masses, empyema or mediastinal structures.

V. Pearls and Pitfalls Failure to identify the deepest pocket of fluid. Failure to identify the diapragm, avoiding intra-abdominal injury. Failure to use this diagnostic tool for all thoracentesis procedures. Not appreciating that the lung is a moving structure. This may change the depth of fluid with in-or expiration.

VI. References 1. Koh DM, Burke S, Davies N, Padley SP. Transthoracic US of the chest: clinical uses and applications. Radiographics.2002;22:e1. 2. Barnes TW, Morgenthaler TI, Olsen EJ, Hesley GK, Decker PA, Ryu JH, Sonographically guided thoracentesis and rate of pneumothorax. J Clin Ultrasound.2005;33(9):442-6. 3. Jones PW, Moyers JP, Rogers JT, Rodriguez RM, Lee YC, Light RW. Ultrasound-guided thoracentesis: is it a safer method? Chest.2003;123:418-23.

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Chapter 14

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Ultrasound Guided Procedures in Emergency Medicine Practice Paracentesis

Chapter 14: Ultrasound Guided Procedures in Emergency Medicine Practice Paracentesis

IV. Paracentesis I. Introduction and Indications Ascites is defined as an abnormal collection of fluid with the peritoneal cavity. The most common cause for ascites in the United States is alcoholic liver cirrhosis. Although small collections of fluid may by asymptomatic, larger amounts may cause abdominal pain, nausea, anorexia and infection. The process of aspirating fluid from the abdomen is called paracentesis and is commonly done by emergency physicians to relieve symptoms in these patients and to retrieve fluid samples for diagnostic testing. This procedure is invasive and presents a risk for complications with high morbidity such as bowel perforation 187

and infection. (1,2) Use ultrasound to localize intra-abdominal fluid and for visual guidance of fluid aspiration whenever possible. It can also be employed in unstable patients with a positive FAST exam. Ultrasound guided paracentesis can help distinguish the identity of fluid in these emergent situation and expedite needed care. (3) Indications:

Diagnostic evaluation of new-onset ascites Therapeutic intervention in symptomatic patients Diagnostic evaluation of free intra-abdominal fluid in unstable patients

II. Anatomy Intrabdominal structures that may impede the successful aspiration of fluid include the bladder, gravid uterus, and bowel. Usually the bladder is tucked into the pelvic recess unless full. Bowel is a moving structure that may float very close to the abdominal wall. Fluid appears anechoic inferior to the echogenic abdominal wall musculature. Bowel is usually echogenic and actively moving within the fluid.

Figure 1

Figure 2

Figure 1 and 2: Large ascites with several bowel loops (Figure 2 courtesy of B. Hoffmann, M.D.).

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III.

Scanning Technique and Normal Findings Procedure Technique: A low frequency transducer (3.5 MHz) is placed in a sterile sheath. It is then positioned in saggital orientation either in the infra-umbilical or left lower quadrant of the supine patient. The deepest pocket of fluid is identified. The needle is inserted through the abdominal wall under real time ultrasound guidance. The tip of the needle is seen as a hyperechoic structure entering through the abdominal wall into the fluid and steering clear of the moving bowel and the bladder, especially with the infra-umbilical approach.

Illustration 1: Schematic view of paracentesis needle placement.

IV. Pathology Complications can include bowel perforation with infection and sepsis, puncture of bladder or cystic masses. V. Pearls and Pitfalls Failure to visualize the deepest pocket of fluid Insertion of needle in close proximity to bowel Not working with the transducer placed in a sterile sheath

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Mistaking the bladder or cystic masses for ascites

VI. References 1. Nazeer SR, Dewbre H, Miller AH. Ultrasound-assisted paracentesis performed by emergency physicians vs the traditional technique: a prospective, randomized study. Am J Emerg Med.2005;23:363-7. 2. Tibbles CD, Porcaro W. Procedural applications of ultrasound. Emerg Med Clin North Am.2004;22:797-815. 3. Blaivas M. Emergency diagnostic paracentesis to determine intraperitoneal fluid identity discovered on bedside ultrasound of unstable patients. J Emerg Med.2005;29:461-5.

Chapter 15
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Ultrasound Guided Procedures - Foreign Body Localization

Chapter 15: Ultrasound Guided Procedures - Foreign Body Localization

V. Foreign Body Localization I. Introduction and Indications The patient presenting with a wound should always raise concern for a possible retained foreign body. Despite meticulous irrigation and Xray imaging, some foreign bodies are still missed. Although radiopaque foreign bodies will often be seen on standard Xrays, radiolucent objects such as wood are often not visualized. Ultrasound has proven to be a valuable tool for localizing foreign bodies in soft tissue, especially those that are radiolucent. (1,2) Indications

Detection of radiolucent foreign body Assistance and verification of foreign body removal

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II. Anatomy The area of interest will usually be the soft tissue, most often of the feet or hands. Very superficial objects may be very difficult to find since sound is not transmitted nor reflected well in the area immediately near a transducer footprint. IV. Scanning Technique and Sonographic Findings Ultrasound Technique: A high frequency linear transducer (7.5 to 10 MHz) is placed on the structure of interest with or without the use of a standoff pad. Using a stand-off pad can elevate the transducer several millimeters above the structures of interest. This allows better sound transmission and an improved view of the underlying soft tissues. Filling a glove with ultrasound gel can make a standoff pad. Foreign bodies will usually appear hyperechoic to the surrounding soft tissue. Material such as wood or plastic tends to produce shadowing (Figure 1). Metal objects tend to produce reverberation or comet tail artifact (Figure 2). The body part can also be placed in a water bath to enhance visualization of the structure of interest. The area is scanned throughout its entirety in search for a hyperechoic object in both the sagittal and transverse planes. Once found, the depth down from the skin can be measured as well as the size of the object. Survey the area surrounding the object for vessels. Vessels in close proximity to the object may prompt the practitioner to avoid probing the area in the emergency department.

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Figure 1: Superficial located foreign body causing shadowing.

Figure 2: Small metal foreign body in the neck causing a significant comet tail artifact. (image courtesy of B. Hoffmann, M.D.)

IV. Pathology Unsuccessful location and manipulation of the foreign body can lead to increased tissue injury, increased infection risk and wound healing problems.

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V. Pearls and Pitfalls Inadequate knowledge of regional anatomy. Remember, bone and articular surfaces may appear hyperechoic and cast shadows. Failure to realize that scar tissue may appear hyperechoic. Not looking for vascular structures in close proximity to the foreign body this can lead to potential injuring .

VI. References 1. Lyon M, Brannam L, Johnson D, Blaivas M, Duggal S. Detection of soft tissue foreign bodies in the presence of soft tissue gas. J Ultrasound Med. 2004;23:677-81. 2. Crawford R, Matheson AB. Clinical value of ultrasonography in the detection and removal of radiolucent foreign bodies. Injury.1989;20:341-3.

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