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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
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
2
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
Alveolar-interstitial syndrome
B lines (Lung rockets)
8
Consolidation
C line
10
Dynamic airbroncogram
11
Trauma US
FASTER
Free fluid / PTX
Long bone fracture / Rib fracture
12
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
13
21F with left flak pain
14
20M, TA with AMS and
Tachycardia
15
92M with right chest pain
17
Shock
FAST / Heart / Great vessels
(Aorta/IVC/DVT)
18
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
24
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
26
Early pregnancy (IUP)
Ectopic pregnancy
28
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
29
US Findings in IUP
• Gestational sac
• Double decidual sac sign (DDSS)
• Yolk sac
• Embryo
• Cardiac activity
30
Intradecidual Sign
31
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)
32
Double Decidual Sign
33
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)
34
Yolk Sac
35
36
Intrauterine embryo & yolk sac
37
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
39
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
40
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
41
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
43
ß-hCG >discriminatory zone and empty
uterus is EP until proven otherwise
44
Sonographic Spectrum of EP • Ruptured ectopic pregnancy
• Definite ectopic pregnancy
• Extrauterine empty gestational sac
• Adenexal mass
• Pseudogestational sac
• Empty uterus
45
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
55
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
Obstruction
Biliary tract (GB & CBD)
62
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
63
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)
64
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
65
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
66
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
67
Obstruction
GU tract
68
Acute flank pain/
suspected renal colic
EUS重點:
懷疑有obstruction時
排除AAA時
69
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
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
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