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YOUR CART

Emergency medicine ultrasound Guide

Basics & Set Up
PROBES
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GAIN
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M MOde
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Doppler
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KNOBOLOGY
Bryant Allen, MD
Master of Curly Hair
ARTIFACTS

POCUS
CARDIAC
  • Technique
  • Normal Anatomy
  • Pathology
  • Pitfalls
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Tamponade
Picture
​EFAST
  • Technique
  • Anatomy
  • Pathology
  • Pitfalls
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PROBE: Phased Array or Curvilinear
MODE: FAST
STARTING DEPTH: 8 cm
SCANNING:
  1. Use either the phased array or curvilinear probe to evaluate Morrison's pouch (space between the liver and kidney).  Be sure to examine the caudal tip of the liver and inferior pole of the kidney, as this is the area where fluid often accumulates first.
  2. Scan through the retrovesicular space (space between rectum and bladder) in transverse and sagittal planes.
  3. Examine the perisplenic space (between the spleen and the diaphragm).  This view is often slightly more posterior than Morrison's pouch.
  4. Place the probe in the subxiphoid space to obtain a subcostal view of the heart and examine for pericardial effusion.
  5. Place the curvilinear (or switch to the linear probe) to evaluate the lungs for sliding by looking in the second intercostal space bilaterally.
VIEWS:
☐ Morisson's Pouch
☐ Retrovesicular space
     
☐ Sagittal
      
☐ Transverse
☐ Parasplenic
☐ Subcostal Cardiac
☐ Lung sliding
Morrison's Pouch, interface between liver and kidney
Picture
Retrovesicular sagittal view
Picture
Subcostal view
Picture
Parasplenic view, located between spleen and diaphragm
Picture
Retrovesicular transverse view
Picture
Lung Sliding 
Morrison's Pouch, ​free fluid
Picture
Retrovesicular view sagittal, ​free fluid
Picture
Pericardial Effusion
Picture
Parasplenic view, free fluid 
Picture
Retrovesicular view transverse, free fluid
Picture
  • Incomplete view of Morrison's pouch
    • Scan all the wall to the caudal tip of the liver/inferior pole of the kidney
  • Missed free fluid posterior to the bladder
    • Due to posterior acoustic enhancement, fluid behind the bladder may appear isoechoic.  Adjust the TGC to remedy this artifact.
  • ​Difficulty obtaining parasplenic view​
    • Adjust probe to get a more posterior view of the LUQ
OB
  • Technique
  •  Anatomy
  • Pathology
  • Pitfalls
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PROBE: 
 <6 weeks = Enodcavitary
 >6 weeks = Curvilinear 

MODE: EARLY OB                           
STARTING DEPTH: 16 cm
SCANNING :
  1. Scan and obtain clips through the entire uterus in transverse and sagittal planes
  2. Identify IUP, measure FHR, and gestational age
  3. Look for the presence of free fluid
  4. Scan through the adnexa
VIEWS:
☐ Uterus in transverse and sagittal planes
☐  IUP within uterus
     -     GS + yolk sac OR fetal pole in the fundus
​☐ Adnexa
☐​ Cul-de-sac​
MEASUREMENTS:
☐  Fetal HR (M-Mode)
☐ Gestational age (choose one method)
​​
     -     Gestational sac 
     -     CRL (head to bottom)   
     -     BPD (outer to inner, perpendicular to falx)
     -     Femur length
☐ Fetal demise
     -     fetal pole > 7mm without HR, OR
     -     GS >25 mm without fetal pole
Sagittal uterus with endocavitary probe
Transverse uterus with endocavitary probe
Picture
Picture

Sagittal uterus with transabdominal probe
Picture
Transverse uterus with transabdominal probe
Picture

Transverse view of the adnexa
Picture
IUP,  yolk sac within gestational sac in fundus
Picture
Ruptured ectopic pregnancy 
Picture
Intrauterine demise, no fetal pole seen in GS
Picture

Subchorionic hemorrhage
Picture
Molar pregnancy
Picture

Free fluid in the cul-de-sac
Picture
Ovarian Cyst
Picture
Pitfall           ​
Solution
Not able to identify the gestational sac with curvilinear probe           ​
Switch to the endocavitary probe
Difficulty identifying ovaries  ​
Look lateral to the uterus; ovaries typically have a "chocolate chip appearance"
Mistaking ectopic for IUP  ​
IUP = fetal pole/yolk sac within GS in fundus
Missing a heterotopic pregnancy      ​
Even if an IUP is identified, be sure to examine the adnexa
Failing to perform a bedside US because bHCG is below the "discriminatory zone"      
 A beside US should be performed if indicated, regardless of the quantitative bHCG
LuNG
  • Technique
  • Anatomy
  • Pathology
  • Pitfalls
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PROBE: Linear or Curvilinear
MODE: Thoracic/Lung
STARTING DEPTH: 6 cm  
​
SCANNING:
  1. Place the probe with the marker facing towards patient's head on anterior chest wall (2nd-3rd intercostal space) and evaluate for lung sliding 
  2. Look for B-lines, consolidation, pleural effusion
  3. If looking for edema or pneumonia, move probe to evaluate midaxillary line and costophrenic angle bilaterally 
​VIEWS (right and left):
☐ Lung sliding 
☐ Anterior chest
☐ Mid-Axillary line

☐ Costophrenic angle

Normal Lung Anatomy
Picture
Video clip of normal Lung Sliding 
B-Lines
Picture
Consolidation
Picture
Pleural Effusion
Picture
Video clip of pneumothorax with lung point
  • Absence of lung sliding mistaken for pneumothorax
    • ​Absent lung sliding can also be seen in: right maintem intubated patients, patients with bullous disease, severe consolidation
  • Missed pneumothorax 
    • Pneumothorax will only be seen in the scanned area.  Likelihood of identifying pneumothorax is highest when the anterior and apical areas of the chest are scanned.  
  • Mirror artifact mistaken for lung consolidation
    • A mirror artifact duplicate an image by reflection.  Confirm that that what appears to be a consolidation is not actually a reflection of the liver or spleen.
  • Intra-abdominal fluid mistaken for pleural fluid
    • ​Identify the location of fluid in relation to the diaphragm (above or below) to correctly identify intrabdominal vs intrathoracic fluid.
​RENAL
  • Technique
  • Anatomy
  • Pathology
  • Pitfalls
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​SOFT TISSUE
  • Technique
  • Anatomy
  • Pathology
  • Pitfalls
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​​Biliary
  • Technique
  • Anatomy
  • Pathology
  • Pitfalls
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DVT
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>
THORACIC
AORTA

Pediatric POCUS
Appendix
  • Technique
  • Anatomy
  • Pathology
  • Pitfalls
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PROBE: Linear or Curvilinear
MODE: Abdomen or Peds Abdomen          STARTING DEPTH: 4 cm   
  
SCANNING:
  1. Use Graded compression to compress gas
  2. Scan right abdomen from pelvis to liver edge
  3. Trace cecum to appendix 
  4. Visualize appendix in short and long axis 

VIEWS     
☐Psoas Muscle
☐Iliac Vessels
   Appendix 
     
☐Long axis with blind sac connected to cec
​      ☐Short axis with target sign
Measurements:
Diameter < 6mm
Wall thickness < 3mm
Appendix in long axis
Picture
Appendix in short axis
Picture
Appendix in long axis
Picture
The appendix is a blind-ended tubular structure located in the RLQ.  A normal appendix is concentrically layered, mobile, and compressible.  Location of the tip of the appendix is variable, the most common being pelvic and retrocecal.
Appendicitis 
Picture
Picture
Picture
 Diagnostic Criteria
Diameter > 6 mm or
Wall thickness > 3mm
+
Signs of inflammation

Non-compressible
​Aperistaltic
Fat stranding
​Fecalith
​Free Fluid


Picture
Picture

Pitfalls of Appendix US​
  • Appendix obscured by bowel gas 
    • ​Move bowel gas using graded compression
  • Thickened ileum is mistaken for appendix​​
    • ​Identify blind ended pouch and trace to cecum
  • Distal tip appendicitis is overlooked
    • ​Visualize entire length of appendix
  • False Positive interpretation
    • ​A normal appendix can be > 6mm
    • For positive finding, there must be an enlarged appendix + signs of inflammation
  • False Negative interpretation
    • ​A normal appendix must be visualized for a negative study
​
Pylorus
  • Technique
  • Anatomy
  • Pathology
  • Pitfalls
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>
PROBE: LINEAR
MODE: PEDS ABDOMEN                
DEPTH: 4 cm
SCAN:
1. Place patient in comfortable position 
3. Place probe in the epigastrium with marker facing patient's right
4. Use the liver and gallbladder as an acoustic window to visualize the pylorus in its long axis
5. Turn the probe marker towards the patient's head to visualize the pylorus in short axis
VIEWS:
☐ Pylorus in  short axis
☐ Pylorus in long axis
 MEASUREMENTS:
☐ Channel length < 15mmm
☐ Muscle wall < 3mm
Pylorus short axis
Pylorus Transverse 
Pyloric Stenosis in Long Axis
Picture
Pyloric Stenosis in Short Axis
Picture
  • Unable to identify pylorus
    • Increase depth to identify landmarks (liver, gallbladder, stomach).  Once stomach is identified, decrease depth, and follow stomach antrum to pylorus
  • ​Measurements are incorrect
    • Measure only the hypoechoic muscle layer on one side of the channel
  • Pylorospasm
    • Transient muscle spasm that can appear like pyloric stenosis.  Resolves with feeding. ​
Intussusception
  • Technique
  •  Anatomy
  • Pathology
  • Pitfalls
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>
PROBE: LINEAR
MODE: PEDS ABDOMEN                
DEPTH: 6 cm
Picture
SCAN:
1. Place patient in comfortable position and use warm gel to help patient tolerate US
2. Start with the probe marker to the patient's right in the RLQ and scan up to the RUQ.
3. Turn the probe with the marker to the patient's head and scan across the transverse colon.
4. Turn the probe marker back to the patient's right and scan down from LUQ to the LLQ.
VIEWS:
☐ Short axis with target sign
☐ Long axis
 MEASUREMENTS:
☐ Short axis target > 2 cm is positive for intussusception 
RLQ normal anatomy, start scan by identifying these landmarks
Picture
Colon, scalloped, dirty shadowing, poor penetrance
Small bowel, multiple loops seen with peristalsis
Picture
Ileo-colic Intussusception in short axis with target sign
Picture
Ileo-Ilial intussusception, distinguished by size < 2cm and presence of peristalsis
Picture
Ileo-colic Intussusception in long axis with "sandwich sign" 
Picture
  • Intussusception mistaken for a lymph node or kidney.  
    • Intussusception can be distinguished from lymph node by size and presence of concentric circles (loops of bowel).
    • Intussusception can have the appearance of the kidney in long axis.  Identify the kidneys separately to distinguish from intussusception.
CRANIAL 

EMGuideWire

Picture
From the J. Lee Garvey Innovation Studio in the 
Department of Emergency Medicine
Carolinas Medical Center
Charlotte, NC

Picture
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