Top 10 Ultrasound Techniques That Should Be Acquired by Emergency Physicians
Transcript of Top 10 Ultrasound Techniques That Should Be Acquired by Emergency Physicians
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Top 10 ultrasound techniques that
should be acquired by EPs
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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Outline of Top 10 EUS
1. Airway control
2. Dyspnea
3. Trauma US
4. Shock
5. Vascular access
6. IUP & EP
7. Pneumoperitoneum
8. Obstruction, Biliary
9. Obstruction, GU
10.Obstruction, GI
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Airway control
EUS重點
1. Position
–確認ETT不在食道 (Cardiac arrest)
2. Confirmation
– Lung sliding
3. Complication
– PTX
4. Advanced airway landmark
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TRUE
Tracheal Rapid Ultrasound Exam
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Airway
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Dyspnea
EUS重點 • PTX
– A lines without lung sliding; lung points
– Trauma; Critically dyspnea or shock; Pre-hospital
• Alveolar-interstitial syndrome – B lines (vertical artifacts); Lung rockets
– D/D: COPD with AE or APE
• PLE – Anechoic: simple; Septation: empyema
• Consolidation – Dynamic airbronchogram
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Alveolar-interstitial syndrome
B lines (Lung rockets)
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Consolidation
C line
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Dynamic airbroncogram
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Trauma US
FASTER
Free fluid / PTX
Long bone fracture / Rib fracture
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Trauma US
EUS重點 • Free fluid
– Peritoneal cavity
– Pericardial cavity
– Throax
• Free air – PTX
– Pneumoperitoneum
• Fracture: long bone & rib – Cortical surface interruption
• Solid organ injury – Mosaic echotexture within target organ
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21F with left flak pain
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20M, TA with AMS and
Tachycardia
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92M with right chest pain
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Shock
FAST / Heart / Great vessels
(Aorta/IVC/DVT)
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The RUSH Exam Rapid Ultrasound in SHock
in the Evaluation of the Critically l l l
Step 1: The pump
Step 2: The tank
Step 3: The pipes
Emerg Med Clin N Am 28 (2010) 29–56 19
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RUSH Step 1: Evaluation of the Pump
A. Parasternal views
– Long/ short axis
B. Subxiphoid view
C. Apical view
Emerg Med Clin N Am 28 (2010) 29–56 20
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RUSH Step 1: Evaluation of the Pump
• ‘‘Effusion around the pump’’
– evaluation of the pericardium
• ‘‘Squeeze of the pump’’
– determination of global left
ventricular function
• ‘‘Strain of the pump’’
– assessment of right ventricular
strain
Emerg Med Clin N Am 28 (2010) 29–56 21
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RUSH Step 2: Evaluation of the Tank
A. IVC long axis
B. FAST/RUQ
– Add pleural view
C. FAST/LUQ
– Add pleural view
D. FAST/Pelvis
E. Pneumothorax
Pulmonary edema
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RUSH Step 2: Evaluation of the Tank
• ‘‘Fullness of the tank’’ – evaluation of the inferior cava
and jugular veins for size and collapse with inspiration ,F/U
• ‘‘Leakiness of the tank’’ – FAST exam and pleural fluid
assessment
• ‘‘Tank compromise’’ – pneumothorax
• ‘‘Tank overload’’ – pulmonary edema
Emerg Med Clin N Am 28 (2010) 29–56 23
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RUSH Step 3: Evaluation of the Pipes
A. Suprasternal aorta
B. Parasternal aorta
C. Epigastric aorta
D. Supraumbilical aorta
E. Femoral DVT
F. Popliteal DVT
Emerg Med Clin N Am 28 (2010) 29–56
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RUSH Step 3: Evaluation of the Pipes
• ‘‘Rupture of the pipes’’
– aortic aneurysm and
aortic dissection
• ‘‘Clogging of the
pipes’’
– venous
thromboembolism
Emerg Med Clin N Am 28 (2010) 29–56 Emerg Med Clin N Am 28 (2010) 29–56 25
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Early pregnancy (IUP)
Ectopic pregnancy
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Early pregnancy and Ectopic pregnancy
EUS 重點
• Early pregnancy
–了解早期懷孕的超音波影像
– Double decidual sac sign (DDSS)
• Ectopic pregnancy
–熟悉可能呈現的超音波變化
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US Findings in IUP
• Gestational sac
• Double decidual sac sign (DDSS)
• Yolk sac
• Embryo
• Cardiac activity
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Intradecidual Sign
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Gestational Sac
• Anechoic area within the uterus
surrounded by two bright echogenic rings
– Decidua vera (the outer ring)
– Decidua capsularis (the inner ring)
• This is referred to as the double decidual
sac sign (DDSS)
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Double Decidual Sign
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Yolk Sac
• First embryonic structure that can be
detected sonographically
• Visualized approximately 5-6 weeks after
the last menstrual period
• Bright, ring like structure within the GS
• Should be readily seen when the GS sac
is greater than 10 mm (using EVS)
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Yolk Sac
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Intrauterine embryo & yolk sac
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Ectopic Pregnancy
• 2% of all pregnancies, 7-13% of those who
present with pain or bleeding
• Incidence quadrupled in last 20 years
• 50% were missed before widespread use
of ultrasound
• Still the #1 cause of maternal death in
1st trimester
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Rule-out Ectopic Pregnancy
(saves time and money)
• Find an IUP
• Chance of both IUP and EP is 1/3000
• As high as 1/100 if pt takes fertility agents
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β-hCG Levels
• Correlate roughly with gestational age
• Older algorithms relied on β-hCG
• One level means almost nothing
• Serial levels are helpful
• 40% ectopics have a β-hCG level <1000
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Correlation of Gestational Age, β-hCG, and Pelvic Ultrasound Findings.
Gestational Age β-hCG1,2 mIU/mL Transvaginal US
Findings
Transabdominal US Findings
4-5 weeks < 1000 Intradecidual sac
N/A
5 weeks 1000-2000 Gestational sac (± DDS)
N/A
5-6 weeks >2000 Yolk sac
(± embryo)
Gestational sac (+ DDS)
6 weeks 10,000-20,000 Embryo with cardiac
activity
Yolk sac (+ embryo)
7 weeks >20,000 Embryonic torso/head
Embryo with cardiac activity
1Significant individual variation in β-hCG levels at a given gestational age may occur.
2 In multiple pregnancy (twins, triplets) levels will be much higher at a given gestational age. 42
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Discriminatory Zone
• Def:
– The level of β-hCG at which findings of an
IUP are expected on sonography
• Titinalli
– TVS 1500 mIU/mL; TAS 6000 mIU/mL
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ß-hCG >discriminatory zone and empty
uterus is EP until proven otherwise
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Sonographic Spectrum of EP • Ruptured ectopic pregnancy
• Definite ectopic pregnancy
• Extrauterine empty gestational sac
• Adenexal mass
• Pseudogestational sac
• Empty uterus
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Pneumoperitoneum
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Scanning Method
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Intraperitoneal free air
• Air
– Echogenic areas +
– Posterior reverberation (ring-down)artifacts
– Shifting phenomenon
• Location
– Epigastric region (Supine)
– Left lateral decubitus position
• Others: echogenic fluid
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Pneumoperitoneum
• Echogenic line
• Ring-down artifacts
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Intraperitoneal free air
Moriwaki, Y. et al. Arch Surg 2009;144:137-141. 50
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Effect of position change
Supine position L’t lateral decubitus position
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Effect of respiration
Inspiration Expiration
L: lung;
P: pneumoperitoneum 52
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Scissors Maneuver
J Clin Ultrasound 2004; 32:381-385 Okkes Ibrahim Karahan, JOURNAL OF CLINICAL ULTRASOUND 2004 53
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EPSS Enhancement of the peritoneal stripe sign
Ashwin Asrani Emerg Radiol 2007 54
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Air but not IPFA
• Air in Lung
• Air in GI tract
• Subcutaneous emphysema
• Chilaiditi syndrome
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Sensitivity Specificity PPV NPV accuracy
US 92 53 95 39 88
X-ray 78 53 94 20 76
BJS 2002; 89:351-354 BJS 2002 56
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IPFA by US in Trauma and acute abdomen
Moriwaki, Y. et al. Arch Surg 2009;144:137-141. 57
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Obstruction
Biliary tract (GB & CBD)
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膽囊炎的超音波影像
• 膽結石 – 大多數患者有結石存在
– 如果沒有結石,要考慮acalculous cholecystitis.
• 膽囊橫徑 > 4-5 cm
• GB wall thickness (正常 < 3mm) > 4-5 mm (anterior wall)
– Averages 5 mm in acute cholecystitis
– Averages 9 mm in chronic cholecystitis
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膽囊炎: 其他超音波發現
• Decreased echogeneity of the entire wall
• Sonographic Murphy’s sign
• Pericholecystic fluid
• Diffuse, homogeneous echogeneity with GB
lumen (pus in lumen or GB empyema)
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Sonographic Murphy’s Sign
• 將探頭直接放在膽囊上並施壓
• 若這技巧重覆患者的症狀,高度指向有症狀的膽結石或急性膽囊炎
• 尋找其他指向阻塞或發炎的發現:
– Gallbladder wall thickening
– Increased transverse diameter of GB
– Pericholecystic fluid
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造成膽囊壁增厚的原因
• Present in many non-inflammatory conditions
– Post-prandial most common
– Congestive heart failure
– Starvation/hypoproteinemic states
– Ascites
– HIV
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CBD 掃描技巧Scanning Tips
• 請患者左側躺45度
• 掃描時,探頭和肋緣垂直
• 尋找portal vein最長的部份
• CBD應該就在portal vein的前方(螢幕上方)
• CBD和portal vein先交叉後平行
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Obstruction
GU tract
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Acute flank pain/
suspected renal colic
EUS重點:
懷疑有obstruction時
排除AAA時
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71F with left abdominal pain
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Bladder
• 解尿解不出來,要不要立刻導尿呢?
– Acute urine retension
• 小朋友要導尿留U/C,會不會failure ?
– Bladder size evaluation
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Acute renal failure
重點:
找有無post-renal obstruction
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Complicated UTI
(APN & renal abscess)
EUS應用重點時機
1. Risk factors
2. Treatment failure
3. Severe sepsis/septic shock
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Obstruction
GI tract
(BAM/ Intussusception / Appendicitis)
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Graded compression technique
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GI tract lesions on sonography
1. 腸胃道壁增厚 (>4mm)
2. 腸胃道壁分層消失
3. 蠕動減少
4. 用超音波探頭壓迫時不變形
5. 病灶通道內容物減少
6. 病灶附近之其他變化(LN, fat, ascites)
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Alvarado Score
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Acute appendicitis
The order of occurrence of the symptoms
1. Pain, usually epigastric or umbilical
2. Anorexia, nausea, or vomiting
3. Tenderness-somwhere in the abdomen or
pelvis
4. Fever
5. Leukocytosis
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Appendicitis
Eur Radiol. 2002;12:1748-61 79
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Appendicitis
Pregnancy @ 14 weeks
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Bisection Approximation Method
for GI obstruction
1 2
3
4
5
Hepatogastroenterology. 2006;53:547-51. 82
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Bisection Approximation Method
Location of US examination (From 1 – 5) Possible lesion site
1. A-C 2. D-C 3. Rectum 4. IC region 5. Gastric outlet or duodenum
Dilated Collapsed From 1-2
Dilated Dilated Collapsed From 2-3
Collapsed - - Dilated From 1-4
Collapsed - - Collapsed Dilated From 4-5
Collapsed - - Collapsed Collapsed Above 5 83
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Acute intestinal obstruction
Keyboard sign
Fold of Kerckring
Eur Radiol. 2002;12:1748-61 84
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Intussusception
Target sign
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Intussusception
Lymphoma
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Ileitis with bowel obstruction
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Adhesion ileus with SBO
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Outline of Top 10 EUS
1. Airway control
2. Dyspnea
3. Trauma US
4. Shock
5. Vascular access
6. IUP & EP
7. Pneumoperitoneum
8. Obstruction, Biliary
9. Obstruction, GU
10.Obstruction, GI
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