ABCDE OF CRITICAL CARE :

THE ULTRASOUND WAY

Dr. Vinay Gulati

Associate Professor, Medicine
All India Institute of Medical Sciences
New Delhi, India
Why the ultrasound way?
 Ralls PW. Sonography in the 21st century.
J Ultrasound Med. 2001;20:87-88.

 It has been typically described as an

extension of the palpating hand and a
“visual”
visual stethoscope during the
physical examination, providing both
anatomic and functional information
complementary to the routine physical
examination.
examination
 But Why the chain?
A (Airway) kills before B (Breathing)
and
C(Circulation) kills before D(Disability)
so
prioritize order of assessment
with
purpose to treat first that kills first
Emerg Radiol. 2007 July; 14(3): 135–141.
Ultrasound Algorithm
Breathing
g
 Lung ultrasound is largely based on interpretation of
artifacts
tif t created
t d by
b the
th interplay
i t l off airi andd fluid
fl id in
i th
the
lung

 Normally ultrasounds are not transmitted through

anatomical structures filled with air

 Loss of air(consolidation) or pleural effusion lets the

US waves transmit to deeper intra-thoracic
intra thoracic structures
Lung Examination
 Patient Position –Usually
Usually Supine
Transducer Type
o Curvilinear
o For
F d deeper structures
t t
o Linear
o For superficial structures (pleura)

 Always examine both lungs,

transducer should be
perpendicular to the chest wall
 Lung Examination Zones

 Lung Zone 1/L1

2ndd, 3rdd, 4thh intercostal spaces,
anterior chest wall

 Lung Zone 2/L2

5th-8th intercostal spaces,
anterior chest wall

 Lung Zone 3/L3

4th-10th intercostal spaces,
between the anterior &
posterior axillary lines
Structures to be identified

Chest Wall

Pleura

Lung Parenchyma

Diaphragm

Liver & Spleen

Lung Signs
Bat Sign/Normal
g /

• Transducer at L1, with the marker Cephalad

• The sign is formed by shadows of two ribs and the pleural line
(looks like a bat flying towards you)
• Try to obtain this image initially, to avoid artifacts
 Lung Signs (cont.)

Lung Sliding/Normal

Pleural line is found below the chest

wall

Movement of pleura with breathing

will g
generate the “lungg sliding”
g
sign
Lung signs (cont
(cont.))
Lung Sliding (cont.)
(cont )

• Lung sliding can

sometimes be better
evaluated with the M
Mode generating the “Sea
Shore” sign
g

• The presence of the lung

sliding and the sea shore
sign, mostly rules out
pneumothorax
L ng Signs (cont
Lung (cont.))
Absent Sliding
• Can be absent in pneumothorax, atelectasis,
pleurodesis, parietal emphysema or any cause
that interrupts
p normal p pleural movement
Lung Signs (cont
(cont…))
A Lines/Normal
• Can be part of the normal
lung signs
• R
Representst normall artifact
tif t
repetition(s) of the pleural
line
Lung Signs (cont
(cont.))
Comet Tail Artifact/B Lines

• LASER like Vertical lines, extending from the pleural line up to

the edge of screen without fading.

• Synchronized with lung sliding

• When present they will usually overshadow the A -lines

lines

• Represents thickening interlobular septa and extra vascular

lung
g water as in alveolar interstitial disease ( p
pulmonary
y
edema, ARDS…)

• Their presence mostly rules out pneumothorax

Lung Signs (cont
(cont…))
Z Lines
• Represents artifacts
• Originates from pleural line,
f d after
fades ft few
f cms
• Do not exten to the edge of
the screen
• Do not overshadow A line
• Can be part of the normal
lung signs
Pleural Effusion/ Hemothorax
Patient Position
Supine

Pulmonary
P l regions
i
Lung Zones L3, L4

Transducer Type and Placement

• Phased Array or curvilinear
• The footprint is perpendicular to the skin with the marker pointing
cephalad
Pl
Pleural
l Eff
Effusion/
i / Hemothorax
H th
Start at the lower edge of Zone
3 and slide the transducer
cephalad to detect the interface
between the Diaphragm and
Pl
Pleurall space

Structures to be identified
Chest wall
Diaphragm
Lung
Pleural Effusion
Liver or spleen
 US detects as little as 50 ml fluid

 100% sensitivity
y for effusions > 100ml

 Loculated effusions/ plural fibrosis/ thickening……

 Nature of fluid…. “Plankton sign” (floating web like

structures of fibrinous septae) in complex effusions/
empyemas
 Hemothorax
 Collection of blood in pleural cavity
 Most common cause of hemothorax is
chest
h trauma
 Large hemothorax is often a cause of
shock in trauma victims
Hemothorax
M mode
M-mode
Pleural Effusion
Fluid Volume
Measure the fluid depth at the lung base or the level of the 5th
Measure
intercostal space
Measurement starts 3 cms from the inferior pole of the lung to the
chest wall
>5cm fluid thickness indicates pleural effusion >500 ml
Measurement at end expiration/ end inspiration
Less reliable on left side
N accurate enough
Not h to quantify
f small
ll ((<500ml)
500 l) and
d very llarge
(>1000ml)

Another approach: Height x transversal area at halfway between

upper and lower limits
Pneumothorax
In a critical ill supine patient, air tends to accumulate in the anterior
portion of the thorax

The diagnosis is made by detecting the absence of the lung tissue

movement beneath the pleural line

Patient Position
Supine
p

Transducer

Linear 7-13 MHz, for pleural interface

Phased Array 2.5 -5 MHz or
Curvilinear 2-5 MHz for deeper structures
 Pneumothorax

Transducer Placement
Perpendicular to the skin in Zones L1, L2 and L3

Structures to be identified
Pleura, Ling and Ribs

Sonographic Findings
Lung sliding is absent, 100% sensitivity
• No lung sliding on B Mode
• Seashore sign on M Mode is replaced by Stratosphere sign (no sand, all sea)
L ng Signs (cont
Lung (cont.))
Absent Sliding

• Presence of sliding rules out Pneumothorax with 100%

sensitivity
y
• Specificity of Absent Lung Sliding for Dx of pneumo 60%
• Can be absent in pneumothorax, atelectasis, pleurodesis,
parietal emphysema, severe consolidation, phrenic nerve palsy,
HF ventilation
l or any cause that
h interrupts normall pleural
l l
movement
• Lung tissue replaced by pleural air, hence artifacts by parietal
pleura always form A lines
• Presence of B line rules out pneumothorax
Absent Lung Sliding Sign
Stratosphere Sign
Pneumothorax

 Lung Point
•A localized transition point from intrapleural air (pneumothorax)
artifacts to the interparanchymal air is 100% specific for
pneumothorax
• The transition from the seashore sign to the stratosphere sign on
the M-mode
M mode
L
Lung P
Point
i t
Video
Curtain Sign
Videos of Heart Point Sign
Acute Interstitial syndrome
y ((AIS))
Lung contusion
B Line
B-Line
Lung Consolidation
Pneumonia
C Pattern
Video
Dynamic Bronchogram
Atelectasis
•Lung g sliding
g will be absent
•Lung pulse ( transmission of heart beat to the pleural
line)
•No dynamic movement of the air bronchogram
Video
Diaphragm
 Patient Position - Supine
 Transducer
T d
Curvilinear 2-5 MHz
Phased Array 2.5 -5 MHz
Transducer Placement
L3, marker pointing cephalad
5th to 8th ICS Mid-Posterior
axillary line.
Examine both sides
Strucures to be identified
Lung, Diaphragm, Liver or spleen
 Continued
Sonographic
So og ap c Findings
d gs
Inspiratory amplitude in normal spontaneously
breathing patient is usually > 10mm-20mm
Dyphragm Dysfunction
 Presence of pleural effusion does not usually
affect this amplitude
 Amplitude < 5mm is pathological
 There will be a diminished lung sliding and
paradoxical movement
 M-Mode
M M d can be b used d to detect
d and
d measure the
h
diaphragmatic movement
Video
Diaphragmatic rupture
Sternal Fracture
Protocol & Worksheet

Breathing Protocol

Breathing Worksheet
 The BLUE Protocol

Daniel A et al (CHEST 2008; 134:117–125)

 ATLS WITH AUTLS
Together We Can And Together We Will
Keep this beating……
beating