Transcript A, B, and C

Turan Saul, M.D.
Critical Ultrasound Review
St. Luke’s Roosevelt Hospital Center
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Trachea and
Lungs
Cardiac
E-FAST and
Pelvic
IVC and
Soft Tissue
Lumbar Puncture
And
Peripheral IV
Trachea and
Lungs
Cardiac
E-FAST and
Pelvic
IVC and
Soft Tissue
Lumbar Puncture
And
Peripheral IV
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Thank You
John Cahill, M.D.
Resa E. Lewiss, M.D.
William Bagley, M.D.
Paul Travnicek, M.D.
The above image demonstrates?
A.
B.
C.
D.
E.
Vertebral shadowing
Esophagus
Linear foreign body
Tracheal rings
None of the above
D – Tracheal Rings
• Tracheal rings
• Cricothyroid membrane
• High frequency linear probe
• Sagittal plane
Characteristic sonographic appearance of normal anatomy
SLRUS
Indirect methods to assess the airway after
successful intubation include?
A.
B.
C.
D.
E.
Bilateral, symmetric pleural sliding
Visible comet-tail artifacts
Symmetric diaphragmatic movement
Midline tracheal rings
A, B, and C
E - A, B, and C
A. Bilateral, symmetric pleural sliding
B. Visible comet-tail artifacts
C. Symmetric diaphragmatic movement
• These findings are normal, and do not raise concern for:
- pneumothorax
- right mainstem intubation
- loss of oxygenation
• Confirmation of midline tracheal rings with posterior
shadowing is a direct method of assessment
SLRUS
DAILY
DOUBLE
The following image is concerning for an esophageal intubation because?
A.
B.
C.
D.
E.
The trachea is visible
The esophagus is visible
Impossible to tell from this image
This is a normal image
Need to evaluate in both transverse and sagittal planes.
B – The esophagus is visible
• Esophagus is normally
collapsed and not visible
adjacent to the trachea
• Posterior shadowing
- trachea from cartilaginous rings
- left para-tracheal area: esophagus opened
by the endotracheal tube
SLRUS
The “lung point” is?
A. The name given to the transition point between
expanded and collapsed lung
B. The most sensitive sign of pneumothorax
C. Present in normal, expanded lungs
D. The superior most portion of the chest wall
A. The name given to the transition point between
expanded and collapsed lung
• Lung point
- also known as the “leading edge sign”
- 66% sensitivity for pneumothorax
- not present in large pneumothorax,
where retracted lung does not touch
the wall
- most specific sign of pneumothorax
- data thus far shows never found
in patients without pneumothorax
SLRUS
What is the name of this sign?
What pathology is associated with this sign?
A.
B.
C.
D.
Adult respiratory distress syndrome
Interstitial pneumonia
Pulmonary edema
Thickening of alveolar septa due to interstitial pulmonary
disease
D. Thickening of alveolar septa due to interstitial
pulmonary disease
• “Multiple comet tail artifacts”
- more than 3 in one rib space
- less than 7 millimeters apart
- arise from pleural line
Indicative of any acute interstitial syndrome
• DDx: adult respiratory distress syndrome, cardiogenic
pulmonary edema, bacterial or other pneumonia,
exacerbation of chronic interstitial diseases
SLRUS
This image (sinusoid sign) was obtained with the
ultrasound set on?
A. B – mode
B. M – mode
C. Doppler mode
And it is indicative of?
A. Pneumothorax
B. Pleural effusion
C. Pneumonia
D. Interstitial disease
B - M mode, B - Pleural effusion
• “Sinusoid sign”
- sign of respiratory interpleural variation
- occurs as visceral pleural moves toward
parietal pleural during inspiration when there
is pleural effusion
SLRUS
Mimics of pericardial effusion include?
A.Pericardial fat pad
B.Pleural effusion
C.Intra-peritoneal fluid
D.All of the above
E.None of the above
D - All of the above
These are all mimics of pericardial effusions
- Pericardial fat pad
- Pleural effusions
- Intra-abdominal fluid
SLRUS
A patient presents with muffled heart
tones, hypotension, and JVD. Sonographic
findings expected with this clinical
presentation include?
A.Diastolic collapse
B.Dilated IVC without inspiratory variation
C.Circumferential pericardial effusion
D. A “swinging heart”
E. All of the above
E – All of the above
• The patient presents with the classic triad of cardiac
tamponade
• Tamponade includes all of these sonographic features
• As little as 150 mL of pericardial fluid can cause
compression on the heart
• “Scalloping” is diastolic collapse of the RV (or RA),
while a “swinging heart” is counter-clockwise rotational
movement of the heart
SLRUS
The most accurate method of confirming
asystole is?
A.Lack of movement of valves
B.M-mode
C.Visualization of blood stasis
D.Color Doppler
E.Absence of ventricular contractions
B – M-Mode
• Sonographic asystole is defined as absence
of ventricular contraction
• It is difficult to confirm lack of movement
of valves or ventricular contraction simply
by visualization
• M-Mode can objectively assess whether
there is movement at the level of the valves
or ventricular contractions
• This is a tool that may be used to direct
cessation of resuscitative efforts
SLRUS
Estimating left ventricular ejection
fraction?
A.Makes assumptions about the shape of the
left ventricle
B.Has good inter-rater reliability
C.Is most accurate in symmetric ventricles
D.Can be qualitative or quantitative
E.All of the above
E - All of the above
Measuring LV ejection fraction:
- Makes assumptions about the shape of
the left ventricle
- Has good inter-rater reliability
- Is most accurate in symmetric ventricles
- Can be qualitative or quantitative
SLRUS
A dilated right ventricle is seen on
emergency ultrasound of a hypotensive
patient. What may this finding indicate?
A.Portal vein thrombosis
B.Pulmonary embolus
C.Hypovolemia
D.Septic shock
B – Pulmonary embolus
• A dialated right ventricle is a marker of
elevated pulmonary pressures
- pulmonary embolus
- pulmonary hyptertension
SLRUS
All of the following may cause difficulties in
cardiac imaging except?
A.Obesity
B.Hyperinflated lungs in COPD
C.Severe kyphosis
D.Wide inter-costal spaces
E. Pectus excavatum
D – Wide intercostal spaces
• Heart encased in bony thorax, surrounded
by lungs
• Finding an acoustic window can be difficult
• Stay close to left sternal border
• Move patient into left lateral decubitus
SLRUS
True or false?
When evaluating the lungs as part of the
E – FAST, you need to use a high frequency
linear probe to rule out a pneumothorax
FALSE
False
• A low frequency curvilinear probe may be
used
• M-mode or color flow can be used for better
visualization
SLRUS
The most sensitive site for the detection
of hemoperitoneum on your E-FAST is?
The most dependent site of the peritoneal
cavity is?
Morison’s pouch, pelvis
Morison’s pouch, Pelvis
• Inreased sensitivity of Morison’s
pouch view for fluid
- slight trendelenburg, 5º
- inferior pole of right kidney, this is
first site traumatic fluid is visible
SLRUS
A hypotensive patient with a stab wound to the
chest wall has this finding on your E-FAST.
Your next step is?
A. Prepare for a pericardiocentesis
B. Prepare for an open thoracotomy
C. Look for another cause of his hypotension
D. Place bilateral chest tubes
C. Look for another cause of hypotension
• Epicardial fat pad
- can be confused with pericardial effusion
• Effusions collect in the most dependant
portion of the pericardial sac, i.e. posteriorly
• Epicardial fat is seen anterior to the heart
SLRUS
A
B
Identify the following structures:
A.
B.
C.
D.
E.
A) Vagina
A) Bladder
A) Uterus
A) Uterus
A) Uterus
B) Bladder, Transverse plane
B) Uterus, Transverse plane
B) Bladder, Transverse plane
B) Free fluid, Sagittal plane
B) Bladder, Sagittal plane
E - A) Uterus
B) Bladder Sagittal plane
• Trans-abdominal
- sagittal plane
- body of the uterus posterior
and cephalad to the bladder
A
B
• This image demonstrates vaginal strip and cervix
- in trans-vaginal images, bladder on the right side of
the screen and less of the organ system visible
SLRUS
Which is the correct progression of pregnancy as
visualized by pelvic sonography?
A. Intradecidual sign, yolk sac, gestational sac, embryo with cardiac activity
B. Intradecidual sign, gestational sac, yolk sac, embryo with cardiac activity
C. Gestational sac, embryo with cardiac activity, yolk sac, intradecidual sign
D. Gestational sac, intradecidual sign, embryo with cardiac activity, yolk sac
E. Yolk sac, embryo with cardiac activity, gestational sac, intradecidual sign
B - Intradecidual sign, gestational sac,
yolk sac, embryo with cardiac activity
• This marks the normal progression of
changes in the body of the uterus with
implantation of an IUP
• The Emergency Physician may only
confirm an IUP once the yolk-sac is
visualized
SLRUS
DAILY
DOUBLE
A patient presents with a positive urine pregnancy
test and vaginal bleeding in the 1st trimester. She is
hemodynamically stable and a bedside emergency
pelvic ultrasound is indeterminate. The next best
step is?
A. Repeat bedside ultrasound in 30 min
B. Obtain formal ultrasound and OB/Gyn consult
C. Wait for results of the ß-HCG to decide
D. Discharge the patient home with instructions
E. Culdocentesis
B - Obtain formal ultrasound and OB/Gyn consult
• The focused Yes/No question for pelvic ultrasound in
1st trimester pregnancy is:
Is there an intra-uterine pregnancy?
• If the examination is indeterminate
- proceed with specialist consultation and formal
ultrasound
• Ectopic pregnancy is the most life threatening
concern
SLRUS
D
A
B
C
Which letter corresponds to the IVC?
A. A
B. B
C. C
D. D
A - IVC
• A. IVC: thin walled, respiratory variation,
compressible, to the right of aorta, low flow
• B. Aorta: thick echogenic walls, pulsatile, to the
left of the IVC, non compressible, no respiratory
variation, high flow
• C: Vertebral body: Bone - very echogenic,
posterior shadowing, posterior to vessels
• D: Liver: medium echogenicity, heterogeneous,
dense
D
A B
C
SLRUS
An 88 year old woman presents from home with 4
days of fever, lethargy, decreased PO intake and
urinary incontinence. On arrival her vitals are:
HR 128 BP 88/56 RR20. She has dry mucus
membranes and poor skin turgor. You expect on
sonographic exam of her IVC?
A. IVC plethora
B. Greater then 50% collapse on inspiration
C. Less then 50% collapse on inspiration
D. Change only with sniff test
B – Greater than 50% collapse
This scenario describes a pt with urosepsis and
extreme fluid depletion
•
•
•
•
In these cases, expect to see greater then 50%
collapse (even complete collapse) of the IVC
with inspiration
IVC plethora is seen in fluid overload states
< 50 % collapse during inspiration is normal
The “sniff test” is done when there is no
respiratory variation to ensure compliant patent
vessels
SLRUS
Which of the following is NOT a good way of
measuring volume status using ultrasound of
the IVC?
A.
B.
C.
D.
Long axis sub-xyphoid
Cross-section sub-xyphoid
Right anterior axillary line: through the liver
Pelvic: through the bladder
D - Pelvic: through the bladder
• The IVC should not be measured in the
pelvis
• Long axis sub-xyphoid, cross-section subxyphoid, and right anterior axillary line
have been described in the literature
• Measure 3.5cm distal to the right atrium
SLRUS
22 year old male history of IVDA presents with a
hot red swollen painful arm for 3 days. You
choose to ultrasound the area. Which of the
following can not be evaluated using ultrasound?
A.Abscess formation
B.Location of vessels
C.Cellulitis
D.Foreign Body
E. Necrotizing Fasciitis
E – Necrotizing Fasciitis
Necrotizing fasciitis can not be diagnosed with
ultrasound
The others can be easily identified using
ultrasound
SLRUS
What image represents an abscess?
B - Abscess
A. Cyst - thin walled, homogenous, fluid filled
B. Abscess - thick walled, heterogenous, irregular
boarders
May demonstrate - septations, hyperechogenicity
posterior shadowing
C. Artery - thick walled, pulsatile,
non-compressible
D. Lymph node – homogenous,
non-compressible
SLRUS
22 year old male with history of IVDA presents
with a hot red swollen painful arm for 3 days.
You choose to ultrasound the area. You want to
image in 2 planes, and identify surrounding
structures. Which probe should you use?
A. 3-5 MHz curvilinear
B. 3-5 MHz phased array
C. 5-10 MHz linear array
D. 8-13 MHz intra-cavitary probe
• The 8-13 intra-cavitary probe has good
surface resolution, but the shape is awkward
and the curved array makes it more difficult
to use for procedural guidance
• The 5-10 MHz linear array has the best
resolution for superficial structures with a
shape convenient for procedural guidance
SLRED
Which of the following
best describes letter a?
A.Ligamentum flavum
B.Dura mater
C.Spinous processes
D.Sub-arachnoid space
E.Transverse processes
C - Spinous processes
a. Spinous process
b. Dura mater/ligamentum
flavum
c. Sub-arachnoid space
SLRUS
Ultrasound can assist in lumbar puncture
by providing information about?
A.The site of needle introduction
B.The angle needed to approach the subarachnoid space
C.The distance needed to obtain CSF
D.All of the above
D – All of the above
A. The site of needle
introduction
B. The angle needed to
approach the subarachnoid space
C. The distance needed
to obtain CSF
SLRUS
Which of the following is not true regarding
ultrasound guided lumbar puncture?
A.A paramedian approach allows for dynamic
guidance
B.It is of little use in a patient with multiple
failed attempts
C.Is most helpful in patients whose surface
landmarks cannot be palpated
D. Should be done using sterile technique
B - It will not be beneficial in a patient with
multiple failed attempts
• Ultrasound guidance can be helpful in
patients with:
–
–
–
–
Obesity
Scoliosis / Arthritis
Anxiety
Failed Attempts
SLRUS
Ultrasound guidance for vascular access?
A.Decreased complication rates
B.Decreases time to venipuncture
C.Results in fewer needle stick attempts
D.Enhances patient comfort
E.All of the above
E – All of the above
• Ultrasound-guidance has been shown in adult and
pediatric populations to decreased complication
rate, decreased procedure time, and reduce needle
stick attempts.
• Overall, patient comfort is more than without
ultrasound-guidance
SLRUS
While performing an ultrasound guided central
line, the most accurate method of distinguishing
artery from vein is?
A.Compression technique: a vein will collapse while
an artery will not
B.Compression technique: an artery will collapse
while a vein will not
C.Visualization of the vessel in long-axis
D.Visualization of the vessel in short-axis
E. None of the above
• Short and long-axis are different ways that
we can see the vessel, in cross-section or
longitudinally respectively
• In addition, one can visualize arterial
pulsations and confirm artery vs. vein with
Color Doppler
SLRUS
Which is the preferred method of performing
ultrasound-guided peripheral IV placement?
A.Static ultrasonography with short-axis vessel
visualization
B.Static ultrasonography with long-axis vessel
visualization
C.Dynamic ultrasonography with short-axis vessel
visualization
D.Dynamic ultrasonography with long-axis vessel
visualization
C - Dynamic ultrasonography with short-axis
vessel visualization
• Real-time ultrasound guidance (dynamic) is
preferred over static ultrasonography since vessels
often roll with placement of the line
• Real-time guidance allows for more accurate
placement and allows for needle redirection
• Short-axis vessel visualization is easier and more
accurate than long-axis
• Under dynamic US, vessel tenting is seen prior to
the catheter entering the vessel and ring-down
artifact from the needle itself
SLRUS