1. EMERGENCY DEPARTMENT ULTRASOUND BASICS CCRMC - June 2009

2. Fundamentals Image created by high frequency sound waves Image created by high frequency sound waves Time for reflection indicates depth of structures Time for reflection indicates depth of structures Perfect reflectors appear white (hyperechoic) Perfect reflectors appear white (hyperechoic) Perfect transmitters appear black (anechoic) Perfect transmitters appear black (anechoic) Low frequency waves: poor resolution, good penetration (penetrate subcutaneous fat) Low frequency waves: poor resolution, good penetration (penetrate subcutaneous fat) High frequency waves: good resolution, poor penetration (better image if penetration not an issue) High frequency waves: good resolution, poor penetration (better image if penetration not an issue)

3. INDICATIONS & KEY FINDINGS Trauma Evaluation Trauma Evaluation Hemoperitoneum, hemopericardium Hemoperitoneum, hemopericardium Cardiac Evaluation Cardiac Evaluation Cardiac activity, pericardial effusion/tamponade, fluid status Cardiac activity, pericardial effusion/tamponade, fluid status Abdominal Aortic Aneurysms / Dissection Abdominal Aortic Aneurysms / Dissection Diameter > 3 cm, intimal flap, hemoperitoneum Diameter > 3 cm, intimal flap, hemoperitoneum Hydronephrosis Hydronephrosis Suspected stone, bladder outlet obstruction Suspected stone, bladder outlet obstruction Cauda Equina, Urinary Retention Cauda Equina, Urinary Retention Post-void residual Post-void residual

4. INDICATIONS & KEY FINDINGS Gallbladder Disease Gallbladder Disease Gallstones, wall thickening, pericholecystic fluid, sonographic Murphy’s Gallstones, wall thickening, pericholecystic fluid, sonographic Murphy’s Sudden Loss of Vision Sudden Loss of Vision Retinal detachment Retinal detachment First Trimester Pregnancy First Trimester Pregnancy Intrauterine pregnancy, free fluid Intrauterine pregnancy, free fluid Procedures Procedures Thora/para/pericardiocentesis, line placement, bladder catheterization Thora/para/pericardiocentesis, line placement, bladder catheterization

5. ORIENTATION Probe marker corresponds to images on left side of monitor Probe marker corresponds to images on left side of monitor Transverse planes: marker oriented towards patients right Transverse planes: marker oriented towards patients right Saggital planes: marker oriented towards patients head Saggital planes: marker oriented towards patients head

6. Acoustic Shadowing Ultrasound waves blocked by echogenic structures create an anechoic area distal to the obstruction. Acoustic shadowing. Ultrasound waves blocked by echogenic structures create an anechoic area distal to the obstruction. Acoustic shadowing.

7. FAST EXAMINATION Focused Abdominal Sonography for Trauma Focused Abdominal Sonography for Trauma Advantages: Advantages: Speed Speed Noninvasive Noninvasive No preparation required No preparation required No exposure to radiation No exposure to radiation Accuracy equal to DPL in detecting hemoperitoneum (Sensitivity 90% Specificity99%) Accuracy equal to DPL in detecting hemoperitoneum (Sensitivity 90% Specificity99%)

8. Intraperitoneal Fluid Distribution

9. FAST - Standard Views Four Standard Views Four Standard Views Subxiphoid Subxiphoid Right upper quadrant Right upper quadrant Left upper quadrant Left upper quadrant Pelvic Pelvic

10. FAST - Right Upper Quadrant Morrison’s pouch a potential space between Gerota’s facia and Glison’s capsule. Morrison’s pouch a potential space between Gerota’s facia and Glison’s capsule. Image area of lower rib cage anterior to midaxillary line marker pointed cephalad. Image area of lower rib cage anterior to midaxillary line marker pointed cephalad. Fluid appears as anechoic stripe and is a positive finding Fluid appears as anechoic stripe and is a positive finding

11. FAST - RUQ (Morrison’s Pouch) Normal Hepato-Renal Recess Fluid in Morrison’s Pouch Perihepatic Fluid + FAST

12. FAST - Left Upper Quadrant Potential space between spleen and kidney Potential space between spleen and kidney Probe oriented mid to posterior axillary line over lower left costal margin Probe oriented mid to posterior axillary line over lower left costal margin Fluid appears as anechoic stripe between spleen ad kidney Fluid appears as anechoic stripe between spleen ad kidney LUQ and RUQ views have capability of detecting hemothorax (anechoic fluid above diaphragm) LUQ and RUQ views have capability of detecting hemothorax (anechoic fluid above diaphragm)

13. FAST - LUQ (Spleenorenal Space) Normal Spleno-Renal Recess Spleno-Renal Free Fluid NB: Remember to also check Spleno-Diaphragmatic Space + FAST

14. FAST - Pelvic View Potential space between rectum and uterus (pouch of Douglas) Potential space between rectum and uterus (pouch of Douglas) Potential space between rectum and bladder (rectovesicular space) Potential space between rectum and bladder (rectovesicular space) Fluid anechoic stripe with well defined borders Fluid anechoic stripe with well defined borders Accentuated by full bladder - check PRIOR to Foley placement Accentuated by full bladder - check PRIOR to Foley placement

15. FAST - Pelvic View Normal - no free fluid Free Fluid => + FAST

16. Cardiac Evaluation Indications: Indications: Pulseless electrical activity Pulseless electrical activity Pericardial tamponade Pericardial tamponade Cardiac trauma Cardiac trauma Key Findings: Key Findings: Myocardial wall motion Myocardial wall motion Pericardial effusion Pericardial effusion Apperance:Effusions echo free areas within pericardial sac Apperance:Effusions echo free areas within pericardial sac Small effusions < 100 ml dependent positions Small effusions < 100 ml dependent positions Effusions > 300 ml visualized both anteriorly and posteriorly Effusions > 300 ml visualized both anteriorly and posteriorly

17. Subxyphoid View Without Pericardial EffusionWith Pericardial Effusion

18. Abdominal Aortic Aneurysm Ultrasonography as accurate as CT when measuring aortic diameter Ultrasonography as accurate as CT when measuring aortic diameter Vertebral spine is landmark Vertebral spine is landmark Scan from diaphragm to distal bifurcation Scan from diaphragm to distal bifurcation Measure from outside wall to outside wall Measure from outside wall to outside wall Diameter >3 cm is abnormal Diameter >3 cm is abnormal IVC to right, thinner walls, compresses with probe pressure IVC to right, thinner walls, compresses with probe pressure Image in both transverse and saggital planes Image in both transverse and saggital planes

19. AAA IVC at liver border just superficial to spine and Aorta adjacent. Aorta at level of the celiac artery showing hepato- splenic branching. Common iliacs adjacent to the IVC just distal to branch point.

20. Urinary Obstruction Kidney contains two distinct sonographic regions Kidney contains two distinct sonographic regions Renal Sinus: center of kidney - hyperechoic area Renal Sinus: center of kidney - hyperechoic area Renal Cortex: periphery - much less echogenic Renal Cortex: periphery - much less echogenic Hydronephrosis - anechoic area w/in renal sinus Hydronephrosis - anechoic area w/in renal sinus Renal Cysts: round thin-walled anecohic structures located in renal cortex Renal Cysts: round thin-walled anecohic structures located in renal cortex Ureteral calculi not well visualized (19% of all documented stones, CT 94%) Ureteral calculi not well visualized (19% of all documented stones, CT 94%) Urinary Retention - post-void residual >200ml Urinary Retention - post-void residual >200ml

21. Normal Renal Image

22. Hydronephrosis

23. Gallbladder Disease Imaging modality of choice Imaging modality of choice Primary sonographic finding gallstones Primary sonographic finding gallstones Appear as echolucent structures within gallbladder that move with position change Appear as echolucent structures within gallbladder that move with position change Positive sonographic Murphy's sign: Positive sonographic Murphy's sign: When point of maximal tenderness to transducer pressure is directly over sonographically located gallbladder. (92% positive predictive value) When point of maximal tenderness to transducer pressure is directly over sonographically located gallbladder. (92% positive predictive value) Gallbladder wall thickening: >3 mm (occurs 50- 75% with acute cholecystitis) Gallbladder wall thickening: >3 mm (occurs 50- 75% with acute cholecystitis)

24. Gallbladder Acalculous Gallbladder Gallbladder Calculi - note acoustic shadows

25. Cholecystitis NOTE: Stone shadowing & gallbladder wall thickening

26. Sudden Loss of Vision Unaffected eye is used for comparison

27. First Trimester Pregnancy All first trimester pregnant patients presenting with abdominal/pelvic pain or vaginal bleeding require ultrasound to locate pregnancy. All first trimester pregnant patients presenting with abdominal/pelvic pain or vaginal bleeding require ultrasound to locate pregnancy. Gestational sac, round or oval anechoic area surrounded by two concentric echogenic rings (double decidual sign) earliest sonographic finding suggestive of IUP Gestational sac, round or oval anechoic area surrounded by two concentric echogenic rings (double decidual sign) earliest sonographic finding suggestive of IUP CONCLUSIVE evidence - yolk sac, fetal pole, or FHT CONCLUSIVE evidence - yolk sac, fetal pole, or FHT Endovaginal: detection as early as 4.5 weeks after LMP beta-HCG >2000 mIU/ml (discriminatory zone) Endovaginal: detection as early as 4.5 weeks after LMP beta-HCG >2000 mIU/ml (discriminatory zone) Transabdominal: detection 5.5-6 weeks post LMP Transabdominal: detection 5.5-6 weeks post LMP Patients without CONCLUSIVE evidence of IUP regardless of beta-HCG level Patients without CONCLUSIVE evidence of IUP regardless of beta-HCG level Stable with minimal discomfort - home w/close follow-up Stable with minimal discomfort - home w/close follow-up Unstable vitals or significant pain - Immediate GYN consult Unstable vitals or significant pain - Immediate GYN consult

28. First Trimester Pregnancy

29. Additional Applications Guidance in performing para/thoracentesis and placement of central lines Guidance in performing para/thoracentesis and placement of central lines Detection of foreign bodies (wood,glass,metal and plastic) Detection of foreign bodies (wood,glass,metal and plastic) Determination of fluid status Determination of fluid status Detection of joint effusions & abscesses Detection of joint effusions & abscesses Determine bladder volume prior to cath Determine bladder volume prior to cath