What materials have a medium level of attenuation?
liver/kidney, fat
What materials have a low level of attenuation?
Air, Bone, Muscle
describe the echogenecity of liver tissue
isoechoic
if one states the gain is too high, the image is _______ (dark/bright) and the gain must be _________ (inc/dec)
bright; dec
if one states the gain is too low, the image is _______ (dark/bright) and the gain must be _________ (inc/dec)
dark; inc
describe the echogenecity of blood
anechoic
describe the echogenecity of bone
hyperechoic
Define attenuation
a reduction in the amount of sound wave transmitted back to the probe due to scattering and absorption of the wave as it travels through the medium (tissue)
What materials have a high level of attenuation?
blood, fluid
T or F: Lung US in fact is more sensitive than a chest radiograph for detection of pleural effusion
True!
how to conduct a full lung scan (checking for pneumonia, pleural effusion, subpleural consolidation)
Use curvilinear probe
Patient seated
indicator towards head
Start posterior, inferior (left, right)
Identify kidney, liver/spleen/lung (ribs, pleura)
Paint strokes (make sure the transducer is at 90 degrees to skin whole time(
Note spine, scapula
Go all the way up to apex
raise pt's arm and go side to front (posterior axillary line to anterior axillary line)
identify the anatomy and pathology in the image
blue arrow: diaphragm
yellow arrow: collapsed lung
green stars: effusion
red bracket: spine sign
what is the "mirror effect" that can be observed in zone 4
The lung has a similar echogenecity to the liver
Name the anatomy that can be identified in zone 4
Liver, kidney, diaphragm, lung
Rib shadows
What area is best to observe a pleural effusion?
Right lateral chest (zone 4 in image)
What pathophysiology may be observed when evaluating lung parenchyma?
Interstitial edema or thickening
Pulmonary edema
Pneumonia
2 or more regions bilaterally that are positive for abnormal B lines is defined as ____________ and indicates ___________.
‘interstitial syndrome’; diffuse pulmonary edema
How many B lines is considered abnormal?
3 or more in one ICS
Identify the A and B lines
A lines (left) and B lines (right)
Describe A lines and B lines
A lines-- normal findings; Horizontal lines – reverberation artifact
B lines -- abnormal findings; Vertical lines – indicating Interstitial fluid or thickening
indicate superior, inferior, anterior, and posterior on this image
anterior (top)
Superior (left) inferior (right)
posterior (bottom)
During the lung scan, the patient should be __________ and the indicator should face towards the patient's __________.
seated; head
In a lung scan, what anatomy is ID under the pleura?
lung parenchyma
If a dark stripe is present separating the pleural line it may indicate...
a pleural effusion
an absence of "ants marching" indicates ...
pneumothorax
"ants marching" describe what phenomenon
parietal and visceral pleura sliding during respiration (normal)
The pleural line will be _________ (above/below) the ribs in a lung scan.
below
when scanning lungs, ___________ cast by ribs are normal to see.
shadows
name the 3 different probes
curvilinear, linear, phased array
name the 4 ways you can move your probe to get a better image
slide, rotate, fan, rock
describe locations to US when evaluating for pneumothorax
anterior chest; ladder pattern (8)
describe the locations to US when looking for consolidation in lungs
describe the findings in the image **
consolidation/pneumonia
similarities and differences of lung scan findings for CHF and pneumonia *need help with answer*
both may observe edema/fluid buildup in lung however CHF would be more diffuse and bilateral anf pneumonia may be unilateral and local. Pneumonia findings may also change with the patient's orientation.
limitations of lung scanning *need help answering*
depth?
describe findings of pneumonia/consolidation
lung appears like liver in echotexture = ‘hepatization’
‘Lobar’ or translobar consolidation is commonly seen with bacterial infection while viral infection tends to cause ‘patchy’ consolidation
White punctiform structures are often seen in consolidated lung (also in atelectasis) – these are air bronchograms (air is white on ultrasound)
Describe physical exam findings of heart failure compared to POCUS findings
PE: pulmonary rales, peripheral edema in LE
POCUS: diffuse pulmonary edema indicated by 2 regions bilaterally of positive B lines (3 or more per ICS = 1 positive region)
what view would you see a saccular aortic aneurysm
long axis (longitudinal)
what are three PE findings of cardiac tamponade
Beck's triad:
muffled heart sounds
JVD
hypotension
pulsus paradoxus (change of >10mm between beats)
POCUS findings on M Mode for pneumothorax
Normal: waves on a sandy beach
Abnormal: Barcode sign
Pericardial effusion tx
pericardial centesis
IV fluid bolus to combat against external pressure
a normal IVC will...
be fluid tolerant
have variations with respirations
collapse with sniff test
a plethoric IVC can be described as...
>2mm in diameter proximal to hepatic artery
no respiratory variation
no collapse with sniff test
ways to differentiate a blood vessel from an abscess
blood is anechoic; purulent abscess material is hypoechoic
abscess has a (+) swirl sign
veins and superficial abscesses are collapsible
arteries pulsate
doppeler will show you flow on vessels but not abscesses
POCUS findings with acute cholecystitis
biliary sludge
cholelithiasis
wall thickening >3mm
+ sonographic Murphy sign
pericholecystic fluid
A ________ sign suggests the presence of an abscess
swirl sign
lymphedema may present on POCUS as...
cobblestoning
typical cellulitis finding on POCUS and clinically
POCUS: cobblestoning
Clinical: redness, warmth, and tenderness
fluid in Morison's pouch would be seen...
on RUQ scan between the liver and kidney
how can you improve the apical 4 chamber cardiac view
have the patient roll into LLDQ with arm up and go very lateral
how to estimate LV function
see if the mitral valve leaflet approximates the septum
check for LV global kinesis
which way should the indicator point in apical cardiac
L shoulder
what probe would you use to evaluate for carpal tunnel syndrome
linear
True or false: The inferior pole of the kidney is the most common place for fluid to gather
true, then morison's pouch, suprahepatic,
what is the lung point and what does it tell you
the point where we see the moving pleura stop moving; it tells you where the pneumothorax begins
where is the most important place to check on LUQ eFast scan
suprasplenic
where is the pouch of Douglas
behind the uterus
Where is the probe placed for a pelvic US
just above the pubic symphysis and scan with the indicator facing towards the patient's head
3 most common places to find fluid in RUQ
morison's pouch, caudal tip of liver/inferior pole of kidney, suprahepatic
what does the eFast exam tell you? where are you looking
fluid in free spaces
morrison's pouch (liver and kidney)
pouch of douglas (under uterus)
splenorenal recess
around lungs, heart, bladder
what probe should you use for eFast
curvilinear or phased array
what is the treatment for a severe pneumothorax
needle decompress then chest tube
if you find a pericardial effusion on a stable patient what is the next step? on an unstable patient?
stable--> CT
unstable --> surgery
what nerve is affected by carpal tunnel syndrome?
median nerve
describe the difference between cellulitis, abscesses and tenosynovitis POCUS findings **
cellulitis: cobblestoning
abscesses: swirl sign, purulent material in hypoechoic space
tenosynovitis: deeper hypoechoic line
identify the abnormal hand POCUS image and describe the findings and suspected pathology
bottom left is normal; top and bottom right are abnormal-- fluid around tendon (hypoechoic line) --> flexor tenosynovitis
Describe the signs visible in the picture and possible pathology
resting flexed posture, fusiform swelling of the whole finger, old cut on flexor aspect of finger, warm, red; flexor tenosynovitis
what do kanavel signs indicate?
flexor tenosynovitis
What are the kanavel signs?
1. an exquisite tenderness over the course of the sheath and limited to the sheath
2. the finger sits in a resting flexed posture
3. an exquisite pain on extending the finger, more marked at the proximal end
4. a fusiform swelling of the whole finger.
what is the purpose of a standoff pad
enables you to see the desired structures better by providing some space between the transducer and the structure
Better focus
Better resolution
Can facilitate dynamic exam
In order to POCUS a hand/finger, what must we create? what are common techniques?
Standoff pad; waterbath, glove willed with water, IV bag with air removed
what 3 structures make up the Portal triad on a gallbladder/RUQ US?
portal vein
hepatic artery
common bile duct
*aorta images on D2L*
how would you confirm and treat a PE
confirm: CTA chest
treat: (catheter directed) thrombolysis if stable
if the ratio of RV:LV is 1:1 what may that indicate
dilated right heart from possible PE!
5 E's of cardiac POCUS
ejection fraction (LV)
effusion (pericardial)
exit (aortic root diameter)
entry (IVC diameter)
equality (RV:LV should be 0.6:1)
what are the POCUS findings for cardiac tamponade
pericardial effusion
plethoric IVC
early: collapse of RA in systole
mid: collapse of RV in diastole
late: LV collapse
what are three historical complaints of a patient with cardiac tamponade
shortness of breath
chest pain
syncope
T or F: when measuring the aorta, measure from the inner wall to inner wall
FALSE! outer wall to outer wall
if you're looking at a short axis view of the aorta and see a white line in the middle of the circle (lumen) it is called the _________ and suggests __________.
intimal flap; dissection
what probe to use for soft tissue
linear
what probe is used to visualize the abdominal aorta
curvilinear
List the branches of the abdominal aorta in order
celiac (splits into hepatic and splenic)
superior mesenteric
R and L renal
inferior mesenteric
how far down do you scan the abdominal aorta?
until the bifurcation into the iliac arteries
which 2 cardiac views would allow you to see the thoracic aorta
parasternal long axis and apical (subxiphoid you can too but not great)
what view would you see a fusiform aortic aneurysm
short axis (transverse)
Normal size of abdominal aorta
<3mm
Normal size of thoracic aorta
<4mm
US guided central line placement can be used at which two veins?
internal jugular and femoral
LE vein anatomy (from proximal to distal)
external iliac artery
deep vein of thigh
femoral vein
popliteal vein
fibular vein
posterior tibial
anterior tibial vein
DVT definition by US
Non-compressibility of a deep vein (in the setting of arterial wall deformation
identify the structures on the abdominal US
1. splenic vein
2. superior mesenteric artery
3. aorta
4. celiac trunk
identify the structures in the aortic US
1. superior mesenteric artery
2. aorta
3. portal vein
4. IVC
5. VB?
identify the structures in the aortic US
1. splenic artery
2. celiac trunk
3. aorta
4. hepatic artery
5. IVC
name the pathology
*need good image*
pericardial effusion
name the pathology
*need good image*
Right heart dilation
ID the anatomy in this RUQ scan
indications for cardiac ultrasound
Significant EKG changes
Assessing Left ventricular Function
Chest Pain/Palpitations
Dizziness
Shortness of Breath
Hypotension
New Heart Murmurs
Cardiac Arrest (assess for cardiac standstill)
where should you place the probe to achieve an apical view
at apex/PMI
just below the nipple line in men
inframammary fold in women
ID the anatomy in this apical view *need good picture*
RA, RV
LA, LV
TV, MV
Compare R & LV
ID the anatomy in a parasternal short axis view
*need a picture*
LV
RV
MV (ant & post leaflets)
Papillary muscles of LV
Aortic valve (Mercedes Benz sign)
what is the D sign and what does it indicate?
when RV pushes on septum, compressing LV in PSSA view; right ventricular dilation
what are the three levels of the parasternal short axis view
1. Mid-papillary level
2. Mitral Valve Level (fish mouth view)
3. Aortic Valve Level (Mercedes Benz view)
ID the anatomy in this parasternal long axis view
1. RV
2. LV
3. Aortic valve
4. left atrium
5. pericardium
6. mitral valve
7. descending aorta
what are the 3 L's of the parasternal long axis view
Long axis
Left ventricle
Left side of screen
ID the anatomy on this subxiphoid image
1. RA
2. RV
3. LA
4. LV
5. Liver
6. Pericardium
what probe is best for cardiac POCUS
phased array
describe how to conduct the subxiphoid cardiac evaluation
Depth: 21-25 cm
Start right & rotate to midline (left)
Flatten transducer (drop tail)
Push down
what are the four cardiac POCUS views
subxiphoid
Parasternal long axis
Parasternal short axis
Apical
what are the 3 cardiac findings that can be definitely confirmed by POCUS?
1. global left ventricular hypokinesis
2. Pericardial effusion
3. Right heart dilation
How to check for ICP in an ocular pocus
identify the optic nerve and measure diameter
3mm down and 5 across
ways to differentiate between retinal and vitreous detachment
retinal = defined, anchor points
vitreous = swirls, weblike
what can you have the patient do to discern between a retinal and vitreous detachment? what will you see?
have patient look right/left
vitreous will swirl
name the pathology
vitreous detachment
name the pathology in this image
retinal detachment
what would a globe rupture look like on POCUS
loss of globe structure/size
loss of anterior chamber
name the pathology in this image
lens dislocation
ID the anatomy in the image
a: anterior chamber
cb: ciliary body
l: lens
p: vitreous
r: retina
on: optic nerve
why is lots of gel used for ocular POCUS
we want to avoid putting ANY pressure on the eye
Where do you place the probe for a LUQ US?
7th and 8th ICS on left side, indicator facing pt's head, quite posterior (knuckles to bed)
which structure in the portal triad will not light up using the doppeler?
CBD
Label the image
1. CBD
2. Hepatic artery
3. portal vein
4. MLF
5. Gallbladder
ID the anatomy of the RUQ scan
yellow: MLF
red: Gallbladder
blue: portal vein
What sign is seen in this abdominal US image? ID the anatomy
exclamation point sign
which was is the indicator facing to see an "exclamation point sign"?
rotate the probe clockwise so the indicator faces the pt's left shoulder
what is the "exclamation point sign"?
The gallbladder is the line of the exclamation and the portal triad is the point. Main Lobar fissure connects the two.
what is the "mickey mouse sign"?
the visualization of the portal triad (portal vein, hepatic artery, common bile duct) in a short axis GB US
what probe is used for abdominal US
curvilinear
Is there pathology in this gallbladder US? If yes, identify it.
acute cholecystitis
Is there pathology in this gallbladder US? If yes, identify it.
acute cholangitis
Is there pathology in this gallbladder US? If yes, identify it.
cholelithiasis
Is there pathology in this gallbladder US? If yes, identify it.
normal
describe the clinical signs of acute cholecystitis
may be febrile or tachycardic, persistent RUQ pain, N/V
describe the clinical signs and POCUS findings of acute cholangitis
