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50M, MVA patient, HR 130bpm, BP 70/40
Internal bleeding ?
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
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1. Subcostal four chamber view 2. Subcostal longitudinal view 3. Parasternal four chamber view 4. Parasternal two chamber view 5. Apical four chamber view
8
Heart Anatomy
Thoracic Cavity
Cardiac Axes
Transducer consideration
Primary Indications
Detection of pericardial effusion and/or tamponade Evaluation of gross cardiac activity during CPR
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
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
Classification
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
Echo-guided
Left parasternal preferred for needle entry or Largest area of fluid collection adjacent to the chest wall
Technique
Chest
37
?
1. 2. Echo 3. Echo 4. Echo 5. (Lung sliding sign)
38
Earth-Sky Axis
Fluids want to descent, gases to rise. Lung disorders
Dependent: PLE, consolidation, . Non-dependent: PTX, interstitial syndrome, .
Patient position
4 stages
1. anterior 2. lateral 3. portion of posterior 4. posterior
4 stages
1. anterior 2. lateral 3. portion of posterior 4. posterior
Ultrasound pattern
A lines & Lung sliding (-) A lines & Lung sliding (+) B3 lines Hepatization & air bronchograms (++) Hepatization & air bronchograms (-) Anechoic collection
?
1. 2. 3. 4. 5. Lung sliding B line Comet-tail artifacts A line Lung point
46
Rib
Normal dynamic lung pattern Lung sliding: all-or-nothing rule Seashore sign
B-line
51
Comet-tail artifact
E-line
Parietal emphysema
Pneumothorax
Pneumothorax
Lung point
Pneumothorax
Lichtenstein DA, et al. Inten Care Med 2000;26:1434-1440
Lung point
Pneumothorax
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
60
Abdomen
61
1. 2. 3. 4. 5. Supine Xray
62
: 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
: :
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 %
()
()
MSK
80
MSK
1. 2. 3. 4. 5.
81
Outlines
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
(5-10MHz) (depth)(focus) (longitudinal & transverse) & (Split screen)
Stand-off pad Water/gel-filled glove Water bath technique
Water/gel-filled glove
EUS &
&
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
Cellulitis
Nonspecific Indicative of edema Skin Subcutaneous tissue Compare to unaffected side
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
FASTER
Rib
Rib fracture
Rib fracture
Normal sternum
Femur
101