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STEPHEN J. LEECH MD RDMS
LIFE-SAVING
POINT-OF-CARE
ULTRASOUND APPLICATIONS
Aorta, Cardiac, FAST/Trauma, Pneumothorax, Pelvic, US-Guided Access
Emergency
Ultrasound
Consultants
Life-Saving Point-Of-Care Ultrasound Applications
A Step-By-Step Pocket Guide
By Stephen J. Leech MD RDMS
Disclaimer
This education material provides a general overview and is not intended to replace formal
training through CME courses or other programs. This material does not constitute
professional medical advice or a complete course of training. You should not perform an
ultrasound examination solely in reliance upon the information in this education material.
Copyright 2008 by Emergency Ultrasound Consultants, LLC
All rights reserved. No part of this publication may be reproduced or distributed in any
form or by any means without the prior written permission of Emergency Ultrasound
Consultants, LLC.
Stephen J. Leech MD RDMS
Director, Emergency Ultrasound, Department of Emergency Medicine
Director, Emergency Ultrasound Fellowship, Department of Emergency Medicine
Orlando Regional Medical Center, Orlando, Florida
Director, Southeast Region, Emergency Ultrasound Consultants, LLC
Acknowledgements
Author would like to thank Paul R. Sierzenski MD RDMS, Michael Blaivas MD
RDMS, L. Connor Nickels MD, Eike Flach MD, SonoSite Inc., and L2Designs.com
for their assistance with the development of this publication.
Emergency Ultrasound Consultants, LLC
EUS Consultants, LLC is the industry leader in point-of-care ultrasound
specializing in education, business practices, risk managment, and billing. Our
faculty are board certifed, fellowship trained physicians who are both nationally
and internationally recognized. They have authored or contributed to major
emergency and bedside ultrasound policy including societal (ACEP, AAEM, SAEM),
national (ABEM, AIUM), international (World Congress) and governmental (CMS
and MEDPAC). We guarantee that all of our ultrasound courses, consultations,
management services and products will be provided by attending physicians who
are fellowship trained and expert diagnostic medical sonographers.
Paul R. Sierzenski MD RDMS
President, Emergency Ultrasound Consultants, LLC
Michael Blaivas MD RDMS
Vice-President, Emergency Ultrasound Consultants, LLC
Learn more about Emergency Ultrasound Consultants by visiting www.eusconsultants.com.
SonoSite, Inc.
SonoSite, Inc., the world leader and specialist in hand-carried ultrasound, is
pleased to provide an unrestricted education grant to Emergency Medicine
Residents Association (EMRA) for the production of this reference guide.
Learn more about SonoSite by visiting www.sonosite.com.
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AORTA
I NDI CAT I ONS
Suspected Abdominal Aortic Aneurysm (AAA)
Suspected Aortic Dissection
AORTA POCKET GUIDE
GE NE R A L P OI NT S
Use either the C60 curved or P21 phased array transducer
Select the Abdominal preset from exam type
Scan the aorta in BOTH transverse and sagittal planes
Aorta should taper and become more anterior moving distally
Aorta can be differentiated from the IVC by:
Location - aorta on patients left, IVC on patients right
Position relative to liver - aorta runs behind liver, IVC runs through liver
Brightness and thickness of walls - aorta has brighter and thicker walls
IVC runs into right atrium
Measure aortic diameter from outer wall to outer wall
Measure proximal (above celiac), mid (at SMA), and distal (just above bifurcation)
sections
AAA is defned as any measurement > 3 cm or any distal segment that is > 50%
larger than the more proximal segment
Ultrasound accurately detects AAAs but does not accurately detect rupture
An intimal fap will appear as an echogenic line within the aortic lumen and suggests
aortic dissection
Bowel gas may limit study
Steady downward pressure should move gas out of the way
Scanning patient from RIGHT fank using the liver as a window may be used as
an option
AORTA T R A NS V E RS E
Transducer in epigastrium, just below xiphoid process
Transducer indicator aimed toward patients RIGHT in transverse plane
Identify the spinal shadow as key landmark
Bright echogenic crescent shaped refection with shadow in far feld
Aorta is just anterior and to the left of the spine
Identify the aorta, IVC, celiac, SMA, left renal vein, splenic vein
Scan down length of aorta through bifurcation into iliac arteries
AORTA S AGI T TA L
Return the transducer to the epigastrium
Transducer indicator aimed toward patients HEAD in sagittal plane
Identify spine, celiac, and SMA as key landmarks
Scan down length of aorta through bifurcation
RE COMME NDE D I MAGE S T O S AV E
Transverse view above the SMA with measurement of aortic diameter
Transverse view at SMA with measurement of aortic diameter
Transverse view above or at the bifurcation with measurement of aortic diameter
Sagittal view of the proximal aorta with measurement of aortic diameter
Sagittal view of the distal aorta with measurement of aortic diameter
Include any additional views showing pathology
AORTA
POCKET GUIDE AORTA
CARDIAC
CARDIAC POCKET GUIDE
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I NDI CAT I ONS
Determination of Cardiac Activity in Cardiac Arrest
Suspected Pericardial Effusion and Tamponade
Estimation of LV Function
Estimation of Preload and RV Filling Pressure
CARDIAC
POCKET GUIDE CARDIAC
GE NE R A L P OI NT S
Use the P21 phased array transducer
Select the Cardiac preset from exam type
Cardiac orientation orients the image toward patients HEAD or LEFT side
Rolling the patient into the LLD position can help imaging by bringing the heart against
the chest wall
Press Clip button to save video clips instead of saving still images
FIndings suggestive of tamponade include a pericardial effusion with diastolic collapse
of the RA/RV and dilation of the IVC with no respiratory variation
S U BX I P HOI D 4 CH A MBE R ( S U BX 4 C)
Transducer in subxiphoid region
Transducer indicator aimed toward patients LEFT side
Aim US beam toward patients LEFT shoulder at a shallow angle
Identify liver, cardiac silhouette, RV, LV, RA, LA, and pericardial space
Easiest 4 chamber view to obtain, best view during CPR
Shallow angle, lots of depth required for visualization
S U BX I P HOI D I VC ( S U BX I VC)
Transducer in subxiphoid region
Transducer indicator aimed toward
patients HEAD
Sweep into RUQ to fnd IVC running
through liver in a longitudinal plane
Measure IVC diameter just distal to
hepatic veins to estimate CVP
PA R AS T E RNA L L ONG A X I S ( P S L A X )
Transducer perpendicular to chest wall in LEFT 4-6th parasternal space
Transducer indicator aimed toward patients RIGHT shoulder
Identify RV, LV, LA, mitral valve, aortic valve, aortic root, and descending thoracic aorta
behind the LA
Best view for measurement of aortic root diameter (normal < 3.8 cm)
Best view for LV function estimation
Assess LV wall thickening, change in size of LV cavity, force and speed of valve opening
PA R AS T E RNA L S HORT A X I S ( P S S A X )
Transducer perpendicular to chest wall in LEFT 4-6th parasternal space
Transducer indicator aimed toward patients LEFT shoulder
Rotated 90 degrees clockwise from PSLAX
Identify RV, LV, and papillary muscles indenting the LV
Best view for regional LV function (SALPI going clockwise around LV from septum)
A P I CA L 4 CH A MBE R ( A 4 C)
Transducer at PMI
Transducer indicator aimed toward patients LEFT axilla
Aim US beam toward patients RIGHT shoulder at a shallow angle
Identify LV, mitral valve, LA, RV, tricuspid valve, and RA
Best view for RV dilation (normal RV : LV ratio is < 0.6 : 1 measured at valve leafets)
RE COMME NDE D I MAGE S T O S AV E
Save AT LEAST 3 of the above views
Include any additional views showing pathology
IVC Size Respiratory Change Estimated CVP
< 1.5 cm Total Collapse 0 - 5 mm Hg
1.5 - 2.5 cm > 50% Collapse 5 - 10 mm Hg
1.5 - 2.5 cm < 50% Collapse 11 - 15 mm Hg
> 2.5 cm < 50% Collapse 16 - 20 mm Hg
> 2.5 cm No Change > 20 mm Hg
FAST / TRAUMA
FAST / TRAUMA POCKET REFERENCE GUIDE
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Identifcation of Free Fluid in the setting of:
Blunt Trauma
Penetrating Trauma
Unexplained Hypotension
Trauma in Pregnancy
FAST / TRAUMA
POCKET REFERENCE GUIDE FAST / TRAUMA
GE NE R A L P OI NT S
Use either the C60 curved or P21 phased array transducer
Select the Abdominal preset from exam type
CARDI AC VI EWS ( CHOOSE ONE VI EW FROM BELOW)
SUBXIPHOID 4 CHAMBER (SUBX 4C)
Transducer in subxiphoid region
Transducer indicator aimed toward patients RIGHT side
Aim US beam toward patients LEFT shoulder at a shallow angle
Identify liver, cardiac silhouette, RV, LV, RA, LA, and pericardial space
Look for free fuid in pericardial space
Shallow angle, lots of depth required for visualization
PARASTERNAL LONG AXIS (PSLAX) (NOT PICTURED - SEE CARDIAC GUIDE)
Transducer perpendicular to chest wall in LEFT 4-6th parasternal space
Transducer indicator aimed toward patients RIGHT shoulder
Identify RV, LV, LA, mitral valve, aortic valve, and aortic root
Look for free fuid in pericardial space
RU Q V I E W
Transducer on patients RIGHT fank, mid-axillary line, 10-12th rib space
Transducer indicator aimed toward patients HEAD in coronal plane
Identify liver, kidney, and diaphragm
Sweep transducer anterior and posterior to visualize all potential spaces
Look for free fuid above diaphragm, in Morisons pouch between liver and kidney,
and in the pericolic gutter at the inferior pole of the kidney
L U Q V I E W
Transducer on patients LEFT fank, posterior axillary line, 10-12th rib space
Transducer indicator aimed toward patients HEAD in coronal plane
Identify spleen, kidney, and diaphragm
Sweep transducer anterior and posterior to visualize all potential spaces
Look for free fuid above diaphragm, between diaphragm and spleen, between
spleen and kidney and in the pericolic gutter at the inferior pole of the kidney
Gas shadow means transducer placement is too anterior or inferior
P E LV I S V I E WS ( P E RF ORM BOT H V I E WS BE L OW)
SAGITTAL
Transducer just above the pubic symphysis
Start in a sagittal plane, transducer indicator aimed towards patients HEAD
Identify the bladder and sweep through pelvis from side to side
Look for free fuid anterior, posterior, or lateral to the bladder
TRANSVERSE
Rotate transducer indicator to the patients RIGHT
Sweep through pelvis from superior to inferior
Look for free fuid superior, inferior, or lateral to the bladder
RE COMME NDE D I MAGE S T O S AV E
Cardiac showing all 4 chambers and view of pericardial space
RUQ showing liver, kidney, diaphragm, and potential spaces
LUQ showing spleen, kidney, diaphragm, and potential spaces
Pelvis in sagittal and transverse planes showing bladder and potential spaces
Include any additional views showing pathology
PNEUMOTHORAX
PNEUMOTHORAX POCKET GUIDE
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