Potpourri-US

5-minute Ultrasound in Dyspnea
Appendicitis

Echocardiography

Echo in AMI

Ectopic Pregnancy

Musculoskeleteal Ultrasound

RUSH - Rapid Ultrasound for Shock and Hypotension

Ultrasound in ED

Journals

Critical Journal Ultrasound

Links

sinaiem.us

Echo in AMI

Regional wall relationships in Echo (youtube) and another (youtube)

Link summary here at cardiophile.org

Samples:

2 chamber view:

-

5-minute Ultrasound in Dyspnea

Cardiac (2 minutes)

- PLAX:

1. PE: RV dilatation, RV apical wink (McConell's sign)

2. Low EF: if anterior MV leaflet does not reach septum by 7mm = EF <30

IVC (1 minute): check this just adjacent to Hepatic Vein

- better to see in M-mode

Lungs (2 minutes)

1. PTX

2. Anterior lung fields: 3 or more B lines per rib space = Pulmonary Edema

http://www.ultrasoundpodcast.com/podcastgen/?p=episode&name=2011-07-15_eup-dyspnea3.m4v

Appendicitis

1. RLQ, Find the Iliac Artery (or ask patient where's maximal pain)
2. Just beside it is the Appendix (tubular blind-end tube)

>6mm of Appendix diameter

Non-compressible, Sonographic Mcburney's

Periappendiceal fluid

Appendicolith with shadowing

Sn: 72-95%

Sn of CT (92.7%)

http://www.youtube.com/watch?v=bDUM4lOTFDE&NR=1

http://www.ultrasoundpodcast.com/podcastgen/?p=episode&name=2011-07-08_eup-appendix2.m4v

Ectopic Pregnancy

• 15% of the time, ectopic pregnancy is not found even in Transvaginal; a positive pregnancy test plus free fluid is Ruptured EP unless proven otherwise (very unlikely ruptured ovarian cyst). Source, Rob Reardon, HQMEDED.com
• 99.5% specific is Morrison's pouch fluid for EP

Echo

Markers and Position:

• Marker to the right of the screen (opposite of the other U/S)
• PLAX: marker to the right shoulder, probe between nipples, a little to the left and down
• PSAX: rotate, marker to left shoulder; perpendicular to chest (along MV), tilt to heart base (along aortic valve), tilt to heart apex (papillary muscles)
• A4C: PMI, at left and down of left nipple; marker to left posterior axillary, aim the probe towards right shoulder

Routines:

• 
  

Proximal Aorta: <3.8cm (usually 2cm)

RV: if dilated, to know if this is acute RV dysfunction or chronic

- old lung problem (COPD/Asthma) = chronic

- if RV apex is actively contracting = acute, likely acute PE (check for DVT)

Musculoskeletal Ultrasound

http://www.youtube.com/watch?v=lTtONw5nF5w&NR=1

RUSH - Rapid Ultrasound for Shock and Hypotension

HIMAP: Heart, IVC, Morrison's, Aorta, Pneumothorax

IVC: youtube

- Better to use M-mode

IVC	cm	Insp collapse	CVP
Fluid load likely to help	<1.5cm	Complete	<5
FL unlikely to increase CO	<2.5cm	No Collapse	>20

* give fluid if there is >50% IVC collapse with respiration,

or even if collapse is clearly visible without a specific measurement

No IVC collapse = does not mean fluid overload

- it means if you give fluids, cardiac output will not increase

eg. sepsis = negative inotropy = IVC will not collapse

- give inotropic support like calcium or dobutamine/dopamine, cardiac output increases, check IVC again, now it will collapse, then you can give fluids

IVC/Aorta Ratio

- correlates better with BSA, age, sex: more patient specific assessment of volume

IVC/Ao = 1.2 normal

IVC/Ao <1 volume depleted

IVC/Ao >1.5 overload/poor cardiac output

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Source: emcrit.org

Ultrasound in ED

1. AAA youtube
2. FAST youtube
   
3. Thoracic US (Hemothorax, Pneumothorax, Rib Fracture)
   Pneumothorax
   
   • Thoracic US should be included in FAST exam
   • decrease depth to 5 cm (we're not looking on deeper structures)
     
   • 3rd, 4th ICS, MCL
     
   • lack of sliding sign youtube
   • move the probe:
     1) estimate the size
     2) look for the LUNG POINT sign: where the lung is intimately attached to chest wall
     - very specific for pneumothorax, whereas lack of sliding is non specific, also in:
     1) Pleural adhesion
     2) pulmonary infiltrate/contusion
     3) ARDS
     4) Atelectasis
     5) mainstem intubation
     
     
   Sonosite training: Pneumothorax
   1) Lack of Pleural Sliding (Sliding sign): Parietal pleura slides vs visceral pleura
   
   2) Lack Comet Tail or B lines: echogenic reverberation artifacts tapering from pleura down to far field
   3) No evidence of motion in M mode or Color doppler
   SEASHORE SIGN: granular apperance from distinct linear appearance of chest wall
   - no pneumothorax
   STRATOSPHERE SIGN: same laminar linear appearance
   - pneumothorax
   
   
   
   
4. Echocardiography youtube
   -use convex or phased array probe
   -limited ED Echo: pericardial effusion, EF, cardiac standstill
   -also: Ascending aortic dissection
   
   1. Subxiphoid/Subcostal: indicator to the Right
      - aimed at the center of chest, pressure, almost coronal plane
      - may need to increase depth
      
      
      
   2. Parasternal Long: indicator to the Right shoulder
      - Left sternal border, 3rdd-5th ICS, parallel to the heart axis (R shoulder to L hip)
      - the marker is always opposite of the LV (radiologist marker is on the right, therefore LV is on the left; this is opposite of the cardiologists)
      
      
      
      
   3. Parasternal Short: turn the probe counterclockwise about 90 degrees, indicator to R hip
      - cross sectional of the cardiac chambers
      
      
      
   4. Apical 4-chamber: indicator to inferior tip of R scapula
      - at the PMI; small probe movement and adjustment
      - best in L lateral decubitus
      
   5. Proximal IVC
      - sagittal plane, probe at subcostal plane, marker towards feet
      - 2-3cm distal to RA
      - AP diameter should collapse more than 50% during sniffing or forceful inspiration
      - if less than 50%: Right sided filling pressure and CVP are elevated (eg tamponade)
      
      
   PATHOLOGIES:
   
   1. Pericardial effusion
      - hypoechoic signals (DDx: pericardial fat anteriorly and pleural effusion posteriorly)
      - pericardial fat: not too anechoic, only hypoechoid; has shadowing; does not show on entire cardiac cycle/show, hides
      - pericardial effusion should be between descending aorta and heart
      
      
   2. low EF: hypokinetic heart
      
   3. Cardiac standstill
      - no cardiac activity after 20 minutes of ACLS: mortality is 100%
      
   4. ascending aorta dissection
      
   5. IVC collapse: Hypovolemia
   6. IVC less than 50% collapse: high CVP, fluid overload, cardiac tamponade
      
   
   
5. DVT youtube
   
   • loss of compressibility
   • altered blood flow patterns
   • visualization of echogenic material in the vein
6. Gallbladder youtube |
   - make sure gallbladder is visualised and not bowel or cyst, by following connection to bile duct
   - either supine or left lateral decubitus
   - at Morrison's pouch or 7th/8th intercostals (cannot elicit murphy's, ribs might obscure)
   
   • Stone
     
     • hyperechoic structure with significant shadowing
     • if not impacted at the neck, having patient move will also move the stone
     • polyps or valves of Heister might misidentify as stone
     • stones impacted in the neck may be missed
       
   • Cholecystitis
     
     • thickened anterior wall >4mm
     • pericholecystic fluid
     • transverse diameter >5 cm
     • Sonographic murphy's sign: pushing the probe while gallbladder is center in view elicits more pain
     • Bile sludge: common but not specific
   • Obstruction
     
     • Duct >0.6cm if patient is 60 yo; (if post ERCP; duct size is not indicative of pathology)

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VIDEO LINKS

• Left Atrium Clot TEE
  
• Aortic Dissection TEE
  
• Aortic Dissection 2 (Ascending) TEE
  
• Various Echo findings (TEE)
  
• Loculated Pericardial Effusion
• Rib Fracture
• Guide in Reduction of Distal Radial fracture
• Peripheral IV access (each dot is 1 cm)
• CVP insertion