Ultrasound Notes

Cardiac
Head and Neck
Gastrointestinal
Lung
MSK
Pelvic
Procedures
Renal and Bladder
Sterile Technique
Vascular Access
Cardiac

 All windows except for PSL, we have

the indicator to the patient’s right
 PSL includes right ventricle
 Mitral valves open during diastole with
two movements of the mitral valve –
early phase second is atrial kick
o During early phase the valve
comes into contact with septum
 indication of good diastolic
function
 Hard to tell if you have fluid in chest vs fluid in the pericardial space
during parasternal long axis
 PSSA
o Aortic valve is Mercedes benz
o Mitral Valve is fish mouth
 Apical 4 chamber – assess centrality, comparison of
left vs right, see both mitral and tricuspid valve
(assess for valvular abnormalities), calculate EF
o Tricuspid valve is close to apex
o Mitral valve is further from apex
o How to make sure you have the orientation
correctly
o Moderator band only present in right
ventricle
o
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PSLA
3/4th ICS
Left of the parasternal border
Index marker point to the patients right shoulder (11 o clock)
Depth: 10-16 cm to see the descending aorta in SAX
Increase depth to 20cm to assess for a left pleural effusion
Optimizing view:
 Place the MV and AV in the center of the image (tilt probe away from the sternum)
 Make the AV cusps appear symmetric (rotate the probe)
 Make the IVS and posterior LV wall appear horizontal (change interspace)
 Not visualize the LV apex (rotate the probe)
Parasternal Short Axis
3/4th ICS L parasternal border
Index marker towards the Left shoulder (2 o clock)
Can also obtain by rotating the probe 90 degrees clockwise from the parasternal LAX view and
tilting the probe downwards
Adjust the depth: 10-16 cm to see entire LV
Optimizing:
 Place LV in the center of the image (rotate probe)
 Make the LV appear round in shape and RV crescent shaped (change interspace)
 Visualize both papillary muscles attached to the LV wall (change interspace)
 Adjust image gain to visualize the pericardium
Apical four chamber
4/5th ICS Midclavicular line or at PMI
Index marker pointing towards Left (3 o’clock)
Depth 14-18 cm to image the atria
Depth 6-10 cm to assess LV apex
Optimize
 Ensure all four cardiac chambers are seen
 If atria are not seen tilt probe anterior
 If ventricles are too spherical, move probe down one interspace
 Make the IVS appear vertical and in the center of the image (move probe laterally)
 Not visualize the AV (if AV is seen the probe is too anterior, tile the probe posterior)
 Adjust gain to visualize the endocardium
Subcostal view:
Push the probe flat and push down with a slight tile to the patient’s right in the subxiphoid
region
Index marker towards the patients left (3 oclock)
16-24cm to image the entire LA and LV
Optimize by:
View all four cardiac chambers
See entire LV including apex (rotate probe)
Not visualize the AV (if AV seen try tilting probe posterior or rotating the probe)
MSK Ultrasound
General principles
 High frequency linear probe
 Hockey Sticks
 When you are so close to the object you want to visualize you should consider using a
stand off bad / water bucket / glove filled with ultrasound gel to get optimal focal point
 Comparative – you can compare to the other extremity for comparison if you are not
sure

Shoulder
Knee
Wrists
Procedures:
 IJ is the most target reach
 Review sterile technique section
 Remember sound comes from the center of probe not the edge so
you have subtract the edge from the distance you desire to place
your needle
 Remember sound comes from the center of probe not the edge so
you have subtract the edge from the distance you desire to place
your needle
 You want your needle to aim at the center of the probe
 Long axis technique
o Problem is you have to keep the needle under the long axis of the probe and
keep the probe over the exact long axis of the blood vessel
o Technically challenging – unless you do this everyday multiple time a day
 Key point is to move the probe until you lose sight of the needle
 Stop as soon as the bright spot has disappeared
Sterile Technique
 IJ is the most target reach
 Use sterile technique –
o Gown and gloved already
o Open sterile packet
o Grab sheath
o Put hand inside
o Poke your fingers into it
o Have nonsterile assistant – put gel on
probe, put probe into your sheath
o With your sterile hand pull sheath off
probe and have assistant bring down
the ultrasound wire for you
o Put rubber band underneath the most
superior aspect of transducer
o Than apply sterile gel on the top of the
transducer
o Remember to always express the air
bubbles out (air is the enemy of
ultrasound
 Peripheral access, nerve blocks are semi
sterile can simple use tegaderm – don’t need
gel between probe and tegaderm – can use sterile
gel on top of derm (on the field) – great for code
situations as well when we don’t have enough time
for sterile technique
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Vascular Access
Technique:
 High frequency transducer
 Linear or microconvex
 Have the indicator towards YOUR LEFT so moving left will have the same effect on the
screen
 Short axis technique
o Locate vein
o Easily compressible
o Center vein on screen
 Tenting:
 Peripheral technique
o Even a small amount of pressure can compress veins
 U/S Guided procedures – key is to always know where the need tip is located
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