1001130_急診基礎超音波 (CV+Chest+MSK)@羅東博愛
Transcript of 1001130_急診基礎超音波 (CV+Chest+MSK)@羅東博愛
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急診超音波簡介
原理、心臟、胸部、骨骼肌肉軟組織
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
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急診超音波的角色為何 ?
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臨床情境
• 50M, MVA patient, HR 130bpm, BP 70/40
– Internal bleeding ?
• 85M, sudden onset right flank pain, 8/10
– Renal colic or AAA ?
• 48F, RUQ pain with fever
– Cholecystitis ?
• 28F, low abdominal pain with shock, EIA (+)
– Ectopic pregnancy ?
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急診超音波三部曲
•操作者
–熟悉超音波的機器
•判讀者
–熟悉超音波影像及解剖學
•決策者
–與臨床工作整合協助決策 4
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Cardiovascular Assessment
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Heart Anatomy
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Thoracic Cavity
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Cardiac Axes
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Transducer consideration
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Classic routes of heart
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Subxiphoid Short-Axis View
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Central Venous Pressure
IVC size for volume assessment
IVC size (cm) Resp. change RA pressure
(cm)
<1.5 Total collapse 0-5
1.5-2.5 >50% collapse 5-10
1.5-2.5 <50% collapse 11-15 (>10)
>2.5 <50% collapse 16-20
>2.5 No change >20
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IVC size assessment
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Parasternal Short-Axis View
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Parasternal Short-Axis View
papillary muscle level
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Parasternal Short-Axis View
mitral valve level
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Parasternal Short-Axis View
aortic valve level
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Mercedes Benz sign
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Primary Indications
• Detection of pericardial effusion and/or
tamponade
• Evaluation of gross cardiac activity during
CPR
• Evaluation of global LV systolic function
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Secondary Indications
• Gross evaluation of intravascular volume
status and cardiac preload
• Indentify acute RV dysfunction and/or
acute pul. HTN for chest pain / dyspnea/or
hemodynamic instability
• Pericardiocentesis guidance
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Limitations for EUS
• Focal wall motion abnormality
• Diastolic dysfunction
• Valvular abnormalities and function
• Intracardiac mass or thrombus, ventricular
aneurysm, septal defect, AD, myocarditis,
HCM, and vegetation
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Technical limitations
• Thorax abnormalities
• Pulmonary hyperinflation
• Obesity
• Patient can’t cooperate
• Subcutaneous emphysema
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Key component
• Evaluation of pericardial effusion – Anechoic or hypoechoic fluid
– Complex echogenicity: inflammation, infection, malignancy, hemorrhage
• Classification – None
– Small, <10 mm in width in dastole, non-circumferential
– Moderate, circumferential, not greater than 10 mm
– Large, 10-20mm in width
– Very large, > 20 mm and/or evidence of tamponade
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Pericardial Effusion
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Pericardial Effusion
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Key component
• Echocardiographic evidence of tamponade
– Diastolic collapse of any chamber in the
presence of moderate or large effusion
– Hemodynamic instability with a moderate or
large pericardial effuion
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Cardiac Tamponade
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US Guided- Pericardiocentesis
• Subcostal approach
– Traditional approach
– Blind
– Increased risk of injury to liver, heart
• Echo-guided
– Left parasternal preferred for needle entry or…
– Largest area of fluid collection adjacent to the chest wall
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Technique
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Pericardial Effusion / Tamponade
• Tamponade
– Clinical diagnosis
– Circulatory collapse due to pericardial effusion
• Subxiphoid approach is the best window
– Effusion location – inferior & posterior
• Echo evidence of tamponade
– Diastolic collapse of the right side of the heart
– Plethoric IVC without inspiratory collapse
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Chest
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Why such a delay for lung
ultrasound to become popular ?
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Principles of Lung Ultrasound
1. Dependent versus Nondependent disorders
2. Lung surface is extensive
3. All lung signs arise from the pleural line
4. Analyze artifacts
5. Dynamic signs
6. Acute disorders contact the thorax surface
7. A simple & 2-D device meets this task
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Earth-Sky Axis
• Fluids want to descent, gases to rise.
• Lung disorders
– Dependent: PLE, consolidation, ….
– Non-dependent: PTX, interstitial syndrome, ….
• Define the scanning situation
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Patient position
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Landmarks of the chest wall
• Lung surface: 1500cm2
• Position: as stethoscope
• 9 areas – Anterior zone (1-4)
– Lateral zone (5,6)
– Posterior zone (S,M,L)
• 4 stages – 1. anterior
– 2. lateral
– 3. portion of posterior
– 4. posterior
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Landmarks of the chest wall
• Lung surface: 1500cm2
• Position: as stethoscope
• 9 areas – Anterior zone (1-4)
– Lateral zone (5,6)
– Posterior zone (S,M,L)
• 4 stages – 1. anterior
– 2. lateral
– 3. portion of posterior
– 4. posterior
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Degree of aeration and US signs
Degree Pathologic disorder Ultrasound pattern
100% Pneumothorax A lines & Lung sliding (-)
98% Normal lung A lines & Lung sliding (+)
95% Thickening of the interlobular septa B7 lines
80% Ground-glass areas B3 lines
10% Alveolar consolidation Hepatization & air bronchograms (++)
5% Atelectasis Hepatization & air bronchograms (-)
0% Pleural effusion Anechoic collection
Key concepts: Air versus Water
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Normal Landmark
Bat sign
Rib
Pleural line
A-line
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Normal dynamic lung pattern
Lung sliding: all-or-nothing rule
”Seashore sign”
Rule out pneumothorax
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Normal static lung pattern
A line & B line
A lines and B lines cannot be visible at the same location
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Comet-tail artifact
”Lung rockets”
B-line
Rule out pneumothorax Indicate interstitial syndrome
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88F with respiratory failure
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Normal versus APE
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Comet-tail artifact
E-line
Parietal emphysema
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Pneumothorax
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Stratosphere sign (Barcode Sign)
Pneumothorax
Lung sliding (-) Sensitivity 100% Specificity 78% A line sign (No B line) Sensitivity 100% Specificity 60%
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Lung point Sensitivity 66% Specificity 100%
Lichtenstein DA, et al. Inten Care Med 2000;26:1434-1440
Pneumothorax
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Explanation of lung point
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Lung point Sensitivity 66% Specificity 100%
Lichtenstein DA, et al. Inten Care Med 2000;26:1434-1440
Pneumothorax
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Signs of PTX
• No lung sliding
• No B line
• No lung pulse
• Presence of lung point
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MSK
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Outlines
• US anatomic considerations
• Skin and soft tissue infection
• Long Bony fracture evaluation
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正常組織超音波影像 • Skin
– Echogenic
• Subcutaneous tissue – Hypoechoic
– Traverse by irregular strands of hyperechoic connective tissue
• Fascial planes – Hyperechoic; regular thickness
• Muscles – Striated appearance on long axis scan
• Tendon – Fibrillar; echogenic
• Vascular structures – Anechoic (Artery versus Vein)
• Lymph nodes – Irregular, circular, echogenic; with hypoechoic rim
• Bones – Echogenic cortices and dense acoustic shadows
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掃描注意事項
• 高解析線形探頭 (5-10MHz)為第一首選
• 注意深度(depth)和焦點(focus)的設定
• 適當應用探頭施壓
• 至少掃描兩個介面 (longitudinal & transverse)
• 考慮和對側比較 & 呈現在同一畫面 (Split screen)
• 如何改善掃描品質 – Stand-off pad
– Water/gel-filled glove
– Water bath technique
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Water/gel-filled glove
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EUS在皮膚 & 軟組織感染的應用
• 須熟悉正常超音波軟組織影像
• 認識週遭組織及結構
• 協助設定最佳切除及引流路徑
• 正確診斷不明顯膿瘍
診斷
• 正確定位不明顯膿瘍
定位
• 協助膿瘍引流
處置
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皮膚 & 軟組織感染
• Cellulitis – Cobblestone-like appearance
• Subcutaneous abscess – Variable appearance
– Most: hypoechoic; spherical mass
– Content: • Hyperechoic sediment
• Septae
• Gas
• Isoechoic or hyperechoic
• Liquefied pus – induced motion of the
content
• Necrotizing fasciitis – Marked thickened of SC layer
– A layer of anechoic fluid, • greater than 4 mm
• adjacent to deep fascia
– Subcuatneous gas • Acoustic shadow
• Reverberation artifact
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Cellulitis
• Nonspecific
• Indicative of edema
• Skin
• Subcutaneous tissue
• Compare to unaffected side
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Normal v.s. Cellulitis
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EUS improves accuracy of superficial
abscess detection
Squire BT, et al. AEM. 2005;12:601-606
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NTUH experience
• diffuse thickening of the SC tissue
• a layer of fluid accumulation more than 4 mm in depth along the deep fascial layer
• 66 patients (17,NF)
• Sensitivity: 88.2%
• Specificity: 93.3%
• PPV: 83.3%
• NPV: 95.4%
• Accuarcy: 91.9
Yen ZS, et al. AEM. 2002;9:1448-1451
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骨折評估
• 肋骨骨折
• 胸骨骨折
• 長骨骨折
• 堅困環境骨折
• 骨折復位
• 脫位復位
• FASTER
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骨折評估
• 骨表面產生不連續線條
• 骨折周圍低回音血腫
• 掃描時注意最痛點
• 至少進行兩個介面掃描
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Rib
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Rib fracture
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Normal sternum
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Sternal body fracture
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Femur
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Tibial shaft fracture