Top 10 Ultrasound Techniques That Should Be Acquired by Emergency Physicians

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

1

Outline of Top 10 EUS

1. Airway control

2. Dyspnea

3. Trauma US

4. Shock

5. Vascular access

6. IUP & EP

7. Pneumoperitoneum

8. Obstruction, Biliary

9. Obstruction, GU

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

3

TRUE

Tracheal Rapid Ultrasound Exam

4

Airway

5

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

6

PTX

A lines

7

Alveolar-interstitial syndrome

B lines (Lung rockets)

8

PLE

9

Consolidation

C line

10

Dynamic airbroncogram

11

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

14

20M, TA with AMS and

Tachycardia

15

21F, TA with deformed R thigh

16

92M with right chest pain

17

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

Emerg Med Clin N Am 28 (2010) 29–56 19

RUSH Step 1: Evaluation of the Pump

A. Parasternal views

– Long/ short axis

B. Subxiphoid view

C. Apical view

Emerg Med Clin N Am 28 (2010) 29–56 20

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

Emerg Med Clin N Am 28 (2010) 29–56 21

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

Emerg Med Clin N Am 28 (2010) 29–56 22

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

Emerg Med Clin N Am 28 (2010) 29–56 23

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

Emerg Med Clin N Am 28 (2010) 29–56

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RUSH Step 3: Evaluation of the Pipes

• ‘‘Rupture of the pipes’’

– aortic aneurysm and

aortic dissection

• ‘‘Clogging of the

pipes’’

– venous

thromboembolism

Emerg Med Clin N Am 28 (2010) 29–56 Emerg Med Clin N Am 28 (2010) 29–56 25

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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

35

36

Intrauterine embryo & yolk sac

37

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.

Gestational Age β-hCG1,2 mIU/mL Transvaginal US

Findings

Transabdominal US Findings

4-5 weeks < 1000 Intradecidual sac

N/A

5 weeks 1000-2000 Gestational sac (± DDS)

N/A

5-6 weeks >2000 Yolk sac

(± embryo)

Gestational sac (+ DDS)

6 weeks 10,000-20,000 Embryo with cardiac

activity

Yolk sac (+ embryo)

7 weeks >20,000 Embryonic torso/head

Embryo with cardiac activity

1Significant individual variation in β-hCG levels at a given gestational age may occur.

2 In multiple pregnancy (twins, triplets) levels will be much higher at a given gestational age. 42

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

46

Scanning Method

47

Intraperitoneal free air

• Air

– Echogenic areas +

– Posterior reverberation (ring-down)artifacts

– Shifting phenomenon

• Location

– Epigastric region (Supine)

– Left lateral decubitus position

• Others: echogenic fluid

48

Pneumoperitoneum

• Echogenic line

• Ring-down artifacts

49

Intraperitoneal free air

Moriwaki, Y. et al. Arch Surg 2009;144:137-141. 50

Effect of position change

Supine position L’t lateral decubitus position

51

Effect of respiration

Inspiration Expiration

L: lung;

P: pneumoperitoneum 52

Scissors Maneuver

J Clin Ultrasound 2004; 32:381-385 Okkes Ibrahim Karahan, JOURNAL OF CLINICAL ULTRASOUND 2004 53

EPSS Enhancement of the peritoneal stripe sign

Ashwin Asrani Emerg Radiol 2007 54

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

BJS 2002; 89:351-354 BJS 2002 56

IPFA by US in Trauma and acute abdomen

Moriwaki, Y. et al. Arch Surg 2009;144:137-141. 57

18M with severe abdominal pain

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40M with acute abdomen

59

78M with abdominal pain

60

55M with abdominal pain

61

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

68

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

70

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

71

Acute renal failure

重點:

找有無post-renal obstruction

72

Complicated UTI

(APN & renal abscess)

EUS應用重點時機

1. Risk factors

2. Treatment failure

3. Severe sepsis/septic shock

73

Obstruction

GI tract

(BAM/ Intussusception / Appendicitis)

74

Graded compression technique

75

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)

76

Alvarado Score

77

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

78

Appendicitis

Eur Radiol. 2002;12:1748-61 79

Acute appendicitis

80

Appendicitis

Pregnancy @ 14 weeks

81

Bisection Approximation Method

for GI obstruction

1 2

3

4

5

Hepatogastroenterology. 2006;53:547-51. 82

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 83

Acute intestinal obstruction

Keyboard sign

Fold of Kerckring

Eur Radiol. 2002;12:1748-61 84

Intussusception

Target sign

85

Intussusception

Lymphoma

86

Ileitis with bowel obstruction

87

Adhesion ileus with SBO

88

Gallstone ileus

89

Outline of Top 10 EUS

1. Airway control

2. Dyspnea

3. Trauma US

4. Shock

5. Vascular access

6. IUP & EP

7. Pneumoperitoneum

8. Obstruction, Biliary

9. Obstruction, GU

10.Obstruction, GI

90