Top 10 ultrasound techniques that

should be acquired by EPs

新光醫院急診醫學科
陳國智醫師
中華民國醫用超音波學會指導醫師
Juice119@gmail.com

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 Outline of Top 10 EUS
1. Airway control 6. IUP & EP
2. Dyspnea 7. Pneumoperitoneum
3. Trauma US 8. Obstruction, Biliary
4. Shock 9. Obstruction, GU
5. Vascular access 10.Obstruction, GI

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 Airway control
EUS重點
1. Position
– 確認ETT不在食道 (Cardiac arrest)
2. Confirmation
– Lung sliding
3. Complication
– PTX
4. Advanced airway landmark

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 TRUE
Tracheal Rapid Ultrasound Exam

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Airway

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 Dyspnea
EUS重點
• PTX
– A lines without lung sliding; lung points
– Trauma; Critically dyspnea or shock; Pre-hospital
• Alveolar-interstitial syndrome
– B lines (vertical artifacts); Lung rockets
– D/D: COPD with AE or APE
• PLE
– Anechoic: simple; Septation: empyema
• Consolidation
– Dynamic airbronchogram

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 PTX
A lines

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Alveolar-interstitial syndrome
B lines (Lung rockets)

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PLE

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Consolidation
C line

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Dynamic airbroncogram

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 Trauma US
FASTER
Free fluid / PTX
Long bone fracture / Rib fracture

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 Trauma US
EUS重點
• Free fluid
– Peritoneal cavity
– Pericardial cavity
– Throax
• Free air
– PTX
– Pneumoperitoneum
• Fracture: long bone & rib
– Cortical surface interruption
• Solid organ injury
– Mosaic echotexture within target organ

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21F with left flak pain

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20M, TA with AMS and
Tachycardia

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21F, TA with deformed R thigh

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92M with right chest pain

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 Shock

FAST / Heart / Great vessels

(Aorta/IVC/DVT)

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 The RUSH Exam
Rapid Ultrasound in SHock
in the Evaluation of the Critically l l l

Step 1: The pump

Step 2: The tank
Step 3: The pipes

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Emerg Med Clin N Am 28 (2010) 29–56
RUSH Step 1: Evaluation of the Pump

A. Parasternal views
– Long/ short axis

B. Subxiphoid view

C. Apical view

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Emerg Med Clin N Am 28 (2010) 29–56
RUSH Step 1: Evaluation of the Pump

• ‘‘Effusion around the pump’’

– evaluation of the pericardium
• ‘‘Squeeze of the pump’’
– determination of global left
ventricular function
• ‘‘Strain of the pump’’
– assessment of right ventricular
strain

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Emerg Med Clin N Am 28 (2010) 29–56
RUSH Step 2: Evaluation of the Tank

A. IVC long axis

B. FAST/RUQ
– Add pleural view
C. FAST/LUQ
– Add pleural view
D. FAST/Pelvis
E. Pneumothorax
Pulmonary edema

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Emerg Med Clin N Am 28 (2010) 29–56
RUSH Step 2: Evaluation of the Tank

• ‘‘Fullness of the tank’’

– evaluation of the inferior cava
and jugular veins for size and
collapse with inspiration ，F/U
• ‘‘Leakiness of the tank’’
– FAST exam and pleural fluid
assessment
• ‘‘Tank compromise’’
– pneumothorax
• ‘‘Tank overload’’
– pulmonary edema

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Emerg Med Clin N Am 28 (2010) 29–56
RUSH Step 3: Evaluation of the Pipes

A. Suprasternal aorta
B. Parasternal aorta
C. Epigastric aorta
D. Supraumbilical aorta
E. Femoral DVT
F. Popliteal DVT

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Emerg Med Clin N Am 28 (2010) 29–56
RUSH Step 3: Evaluation of the Pipes

• ‘‘Rupture of the pipes’’

– aortic aneurysm and
aortic dissection
• ‘‘Clogging of the
pipes’’
– venous
thromboembolism

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Emerg Med Clin N Am 28 (2010) 29–56
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Vascular access

Central venous access

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Early pregnancy (IUP)

Ectopic pregnancy

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 Early pregnancy and Ectopic pregnancy
EUS 重點
• Early pregnancy
– 了解早期懷孕的超音波影像
– Double decidual sac sign (DDSS)
• Ectopic pregnancy
– 熟悉可能呈現的超音波變化

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 US Findings in IUP
• Gestational sac
• Double decidual sac sign (DDSS)
• Yolk sac
• Embryo
• Cardiac activity

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Intradecidual Sign

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 Gestational Sac
• Anechoic area within the uterus
surrounded by two bright echogenic rings
– Decidua vera (the outer ring)
– Decidua capsularis (the inner ring)
• This is referred to as the double decidual
sac sign (DDSS)

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Double Decidual Sign

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 Yolk Sac
• First embryonic structure that can be
detected sonographically
• Visualized approximately 5-6 weeks after
the last menstrual period
• Bright, ring like structure within the GS
• Should be readily seen when the GS sac
is greater than 10 mm (using EVS)

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Yolk Sac

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Intrauterine embryo & yolk sac

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 Intrauterine fetus
and yolk sac & amnion

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 Ectopic Pregnancy
• 2% of all pregnancies, 7-13% of those who
present with pain or bleeding
• Incidence quadrupled in last 20 years
• 50% were missed before widespread use
of ultrasound
• Still the #1 cause of maternal death in
1st trimester

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 Rule-out Ectopic Pregnancy
(saves time and money)
• Find an IUP
• Chance of both IUP and EP is 1/3000
• As high as 1/100 if pt takes fertility agents

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 β-hCG Levels
• Correlate roughly with gestational age
• Older algorithms relied on β-hCG
• One level means almost nothing
• Serial levels are helpful
• 40% ectopics have a β-hCG level <1000

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 Correlation of Gestational Age, β-hCG, and Pelvic Ultrasound Findings.
Transabdominal US Findings
Transvaginal US
Gestational Age β-hCG1,2 mIU/mL
Findings

N/A
4-5 weeks < 1000 Intradecidual sac

N/A
5 weeks 1000-2000 Gestational sac (± DDS)

Gestational sac
(+ DDS)
Yolk sac
5-6 weeks >2000
(± embryo)

Yolk sac
(+ embryo)
Embryo with cardiac
6 weeks 10,000-20,000
activity

Embryo with
cardiac activity
7 weeks >20,000 Embryonic torso/head

1Significant individual variation in β-hCG levels at a given gestational age may occur. 42
2 In multiple pregnancy (twins, triplets) levels will be much higher at a given gestational age.
 Discriminatory Zone
• Def:
– The level of β-hCG at which findings of an
IUP are expected on sonography
• Titinalli
– TVS 1500 mIU/mL; TAS 6000 mIU/mL

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ß-hCG >discriminatory zone and empty
uterus is EP until proven otherwise

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 Sonographic Spectrum of EP
• Ruptured ectopic pregnancy
• Definite ectopic pregnancy
• Extrauterine empty gestational sac
• Adenexal mass
• Pseudogestational sac

• Empty uterus

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Pneumoperitoneum

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Scanning Method

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 Intraperitoneal free air
• Air
– Echogenic areas +
– Posterior reverberation (ring-down)artifacts
– Shifting phenomenon
• Location
– Epigastric region (Supine)
– Left lateral decubitus position
• Others: echogenic fluid

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Pneumoperitoneum

• Echogenic line

• Ring-down artifacts

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Intraperitoneal free air

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Moriwaki, Y. et al. Arch Surg 2009;144:137-141.
 Effect of position change
Supine position L’t lateral decubitus position

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 Effect of respiration
Inspiration Expiration

L: lung;
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P: pneumoperitoneum
Scissors Maneuver

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J Clin Ultrasound
Okkes Ibrahim Karahan, JOURNAL 2004;
OF CLINICAL 32:381-385
ULTRASOUND 2004
 EPSS
Enhancement of the peritoneal stripe sign

Ashwin Asrani
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Emerg Radiol 2007
 Air but not IPFA
• Air in Lung
• Air in GI tract
• Subcutaneous emphysema
• Chilaiditi syndrome

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 Sensitivity Specificity PPV NPV accuracy

US 92 53 95 39 88

X-ray 78 53 94 20 76

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BJS 2002; 89:351-354
BJS 2002
IPFA by US in Trauma and acute abdomen

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Moriwaki, Y. et al. Arch Surg 2009;144:137-141.
18M with severe abdominal pain

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40M with acute abdomen

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78M with abdominal pain

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55M with abdominal pain

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 Obstruction

Biliary tract (GB & CBD)

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 膽囊炎的超音波影像
• 膽結石
– 大多數患者有結石存在
– 如果沒有結石，要考慮acalculous cholecystitis.

• 膽囊橫徑 > 4-5 cm

• GB wall thickness (正常 < 3mm)

> 4-5 mm (anterior wall)
– Averages 5 mm in acute cholecystitis
– Averages 9 mm in chronic cholecystitis

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 膽囊炎: 其他超音波發現

• Decreased echogeneity of the entire wall

• Sonographic Murphy’s sign
• Pericholecystic fluid
• Diffuse, homogeneous echogeneity with GB
lumen (pus in lumen or GB empyema)

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 Sonographic Murphy’s Sign
• 將探頭直接放在膽囊上並施壓
• 若這技巧重覆患者的症狀，高度指向有症
狀的膽結石或急性膽囊炎
• 尋找其他指向阻塞或發炎的發現:
– Gallbladder wall thickening
– Increased transverse diameter of GB
– Pericholecystic fluid

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 造成膽囊壁增厚的原因
• Present in many non-inflammatory conditions
– Post-prandial most common
– Congestive heart failure
– Starvation/hypoproteinemic states
– Ascites
– HIV

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 CBD 掃描技巧Scanning Tips
• 請患者左側躺45度

• 掃描時，探頭和肋緣垂直

• 尋找portal vein最長的部份

• CBD應該就在portal vein的前方(螢幕上方)

• CBD和portal vein先交叉後平行

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Obstruction

GU tract

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 Acute flank pain/
suspected renal colic
EUS重點:
懷疑有obstruction時
排除AAA時

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71F with left abdominal pain

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 Bladder
• 解尿解不出來，要不要立刻導尿呢?
– Acute urine retension

• 小朋友要導尿留U/C，會不會failure ?
– Bladder size evaluation

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 Acute renal failure

重點:
找有無post-renal obstruction

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 Complicated UTI
(APN & renal abscess)
EUS應用重點時機
1. Risk factors
2. Treatment failure
3. Severe sepsis/septic shock
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 Obstruction

GI tract
(BAM/ Intussusception / Appendicitis)

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Graded compression technique

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GI tract lesions on sonography

1. 腸胃道壁增厚 (>4mm)
2. 腸胃道壁分層消失
3. 蠕動減少
4. 用超音波探頭壓迫時不變形
5. 病灶通道內容物減少
6. 病灶附近之其他變化(LN, fat, ascites)

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Alvarado Score

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 Acute appendicitis

The order of occurrence of the symptoms

1. Pain, usually epigastric or umbilical
2. Anorexia, nausea, or vomiting
3. Tenderness-somwhere in the abdomen or
pelvis
4. Fever
5. Leukocytosis

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Appendicitis

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Eur Radiol. 2002;12:1748-61
Acute appendicitis

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 Appendicitis
Pregnancy @ 14 weeks

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Bisection Approximation Method
for GI obstruction

1 2

4
3

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Hepatogastroenterology. 2006;53:547-51.
 Bisection Approximation Method
Location of US examination (From 1 – 5) Possible
lesion site
1. A-C 2. D-C 3. Rectum 4. IC region 5. Gastric
outlet or
duodenum
Dilated Collapsed From 1-2

Dilated Dilated Collapsed From 2-3

Collapsed - - Dilated From 1-4

Collapsed - - Collapsed Dilated From 4-5

Collapsed - - Collapsed Collapsed Above 5

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Acute intestinal obstruction
Keyboard sign

Fold of Kerckring
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Eur Radiol. 2002;12:1748-61
Intussusception
Target sign

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Intussusception
Lymphoma

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Ileitis with bowel obstruction

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Adhesion ileus with SBO

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Gallstone ileus

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 Outline of Top 10 EUS
1. Airway control 6. IUP & EP
2. Dyspnea 7. Pneumoperitoneum
3. Trauma US 8. Obstruction, Biliary
4. Shock 9. Obstruction, GU
5. Vascular access 10.Obstruction, GI

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