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ACEP 2008 EUS guidelines

Ann Emerg Med. 2009;53:550-570

50M, MVA patient, HR 130bpm, BP 70/40
Internal bleeding ?

85M, sudden onset right flank pain, 8/10

Renal colic or AAA ?

48F, RUQ pain with fever

Cholecystitis ?

28F, low abdominal pain with shock, EIA (+)

Ectopic pregnancy ?

Cardiovascular Assessment

1. 2. 3. 4. 5. Subcostal four chamber view Subcostal longitudinal view Parasternal four chamber view Parasternal two chamber view Apical four chamber view

1. Subcostal four chamber view 2. Subcostal longitudinal view 3. Parasternal four chamber view 4. Parasternal two chamber view 5. Apical four chamber view

Heart Anatomy

Thoracic Cavity

Cardiac Axes

Transducer consideration

Classic routes of heart

Subxiphoid Four-Chamber View

Subxiphoid Long-Axis View (IVC view)

Central Venous Pressure

IVC size for volume assessment IVC size (cm) <1.5 1.5-2.5 1.5-2.5 >2.5 >2.5 Resp. change Total collapse >50% collapse <50% collapse <50% collapse No change RA pressure (cm) 0-5 5-10 11-15 (>10) 16-20 >20

IVC size assessment

Parasternal Long-Axis View

Parasternal Short-Axis View

Parasternal Short-Axis View papillary muscle level

Parasternal Short-Axis View mitral valve level

Parasternal Short-Axis View aortic valve level

Mercedes Benz sign

Apical Four-Chamber View

Primary Indications
Detection of pericardial effusion and/or tamponade Evaluation of gross cardiac activity during CPR

Evaluation of global LV systolic function

Secondary Indications
Gross evaluation of intravascular volume status and cardiac preload Indentify acute RV dysfunction and/or acute pul. HTN for chest pain / dyspnea/or

hemodynamic instability
Pericardiocentesis guidance

Limitations for EUS

Focal wall motion abnormality Diastolic dysfunction Valvular abnormalities and function Intracardiac mass or thrombus, ventricular aneurysm, septal defect, AD, myocarditis, HCM, and vegetation

Technical limitations
Thorax abnormalities Pulmonary hyperinflation Obesity Patient cant cooperate Subcutaneous emphysema

Key component
Evaluation of pericardial effusion
Anechoic or hypoechoic fluid Complex echogenicity: inflammation, infection, malignancy, hemorrhage

None Small, <10 mm in width in dastole, noncircumferential Moderate, circumferential, not greater than 10 mm Large, 10-20mm in width Very large, > 20 mm and/or evidence of tamponade

Pericardial Effusion

Pericardial Effusion

Key component
Echocardiographic evidence of tamponade
Diastolic collapse of any chamber in the presence of moderate or large effusion Hemodynamic instability with a moderate or large pericardial effuion

Cardiac Tamponade

US Guided- Pericardiocentesis
Subcostal approach
Traditional approach Blind Increased risk of injury to liver, heart

Left parasternal preferred for needle entry or Largest area of fluid collection adjacent to the chest wall


Pericardial Effusion / Tamponade

Clinical diagnosis Circulatory collapse due to pericardial effusion

Subxiphoid approach is the best window

Effusion location inferior & posterior

Echo evidence of tamponade

Diastolic collapse of the right side of the heart Plethoric IVC without inspiratory collapse



1. 2. Echo 3. Echo 4. Echo 5. (Lung sliding sign)

Why such a delay for lung ultrasound to become popular ?

Principles of Lung Ultrasound

1. 2. 3. 4. 5. 6. 7. Dependent versus Nondependent disorders Lung surface is extensive All lung signs arise from the pleural line Analyze artifacts Dynamic signs Acute disorders contact the thorax surface A simple & 2-D device meets this task

Earth-Sky Axis
Fluids want to descent, gases to rise. Lung disorders
Dependent: PLE, consolidation, . Non-dependent: PTX, interstitial syndrome, .

Define the scanning situation

Patient position

Landmarks of the chest wall

Lung surface: 1500cm2 Position: as stethoscope 9 areas
Anterior zone (1-4) Lateral zone (5,6) Posterior zone (S,M,L)

4 stages
1. anterior 2. lateral 3. portion of posterior 4. posterior

Landmarks of the chest wall

Lung surface: 1500cm2 Position: as stethoscope 9 areas
Anterior zone (1-4) Lateral zone (5,6) Posterior zone (S,M,L)

4 stages
1. anterior 2. lateral 3. portion of posterior 4. posterior

Degree of aeration and US signs Key concepts: Air versus Water

Degree Pathologic disorder
100% 98% 95% 80% 10% 5% 0% Pneumothorax Normal lung Ground-glass areas Alveolar consolidation Atelectasis Pleural effusion

Ultrasound pattern
A lines & Lung sliding (-) A lines & Lung sliding (+) B3 lines Hepatization & air bronchograms (++) Hepatization & air bronchograms (-) Anechoic collection

Thickening of the interlobular septa B7 lines

1. 2. 3. 4. 5. Lung sliding B line Comet-tail artifacts A line Lung point


Normal Landmark Bat sign


Pleural line A-line

Normal dynamic lung pattern Lung sliding: all-or-nothing rule Seashore sign

Rule out pneumothorax

Normal static lung pattern A line & B line

A lines and B lines cannot be visible at the same location

Comet-tail artifact Lung rockets


Rule out pneumothorax Indicate interstitial syndrome

88F with respiratory failure


Normal versus APE

Comet-tail artifact


Parietal emphysema


Rule out pneumothorax all-or-nothing rule

Stratosphere sign (Barcode Sign)

Lung sliding (-) Sensitivity 100% Specificity 78% A line sign (No B line) Sensitivity 100% Specificity 60%


Sensitivity 66% Specificity 100%

Lung point

Lichtenstein DA, et al. Inten Care Med 2000;26:1434-1440

Explanation of lung point

Sensitivity 66% Specificity 100%

Lung point

Lichtenstein DA, et al. Inten Care Med 2000;26:1434-1440

Signs of PTX
No lung sliding No B line No lung pulse Presence of lung point




1. 2. 3. 4. 5. Supine Xray


: 62.310.3 mm : 20.3 5.1 mm : < 2 mm (: 4~7 mm)

: a 40.87.8mm b 30.66.8mm c 83.610.6mm Spleen index a * b > 20 cm2 c * b > 30 cm2

: 25mm 14mm 15mm

: :

2 mm

: 10.2 9.6 cm : 4.2 6.9 cm

: 10.6 9.8 cm : 4.8 6.2 cm

* * * 0.75 Error 15~30 %





1. 2. 3. 4. 5.


US anatomic considerations Skin and soft tissue infection Long Bony fracture evaluation

Skin Subcutaneous tissue Fascial planes Muscles Tendon
Echogenic Hypoechoic Traverse by irregular strands of hyperechoic connective tissue Hyperechoic; regular thickness Striated appearance on long axis scan Fibrillar; echogenic Anechoic (Artery versus Vein) Irregular, circular, echogenic; with hypoechoic rim Echogenic cortices and dense acoustic shadows

Vascular structures Lymph nodes Bones

(5-10MHz) (depth)(focus) (longitudinal & transverse) & (Split screen)
Stand-off pad Water/gel-filled glove Water bath technique

Water/gel-filled glove


Cellulitis Subcutaneous abscess
Cobblestone-like appearance Variable appearance Most: hypoechoic; spherical mass Content:
Hyperechoic sediment Septae Gas Isoechoic or hyperechoic Liquefied pus
induced motion of the content

Necrotizing fasciitis

Marked thickened of SC layer A layer of anechoic fluid, Subcuatneous gas

greater than 4 mm adjacent to deep fascia Acoustic shadow Reverberation artifact

Nonspecific Indicative of edema Skin Subcutaneous tissue Compare to unaffected side

Normal v.s. Cellulitis

EUS improves accuracy of superficial abscess detection

Squire BT, et al. AEM. 2005;12:601-606

NTUH experience
diffuse thickening of the SC tissue a layer of fluid accumulation more than 4 mm in depth along the deep fascial layer 66 patients (17,NF) Sensitivity: 88.2% Specificity: 93.3% PPV: 83.3% NPV: 95.4% Accuarcy: 91.9
Yen ZS, et al. AEM. 2002;9:1448-1451



Rib fracture

Rib fracture

Normal sternum

Sternal body fracture


Femoral shaft fracture