Medmastery POCUS Masterclass Handbook - 0

COURSE
POCUS
TITLE
MASTERCLASS
HANDBOOK
DavidTeacher name
Mackenzie, MD, CM
Table of contents
Airway ultrasound
Recognizing when to use airway ultrasound 4
Confirming endotracheal tube placement 5
Identifying the cricothyroid membrane 6
Lung ultrasound
Moving beyond the basics of lung ultrasound 8
Acquiring lung ultrasound images 9
Diagnosing pneumonia 10
Recognizing viral lung infections 11
Evaluating for other lung pathologies 12
Avoiding potential pitfalls with lung ultrasound 14
Point-of-care echocardiography
Moving beyond the basics of echocardiography 17
Performing echocardiography in cardiac arrest 19
Diagnosing pericardial tamponade 20
Recognizing regional wall motion abnormalities 22
Evaluating right-heart function 23
Estimating pulmonary artery systolic pressure (PASP) 24
Assessing heart valve structure and function 26
Evaluating diastolic function 29
Recognizing endocarditis 32
Gastrointestinal applications
Recognizing when to perform gastrointestinal ultrasound 33
Diagnosing small bowel obstruction 34
Imaging the appendix 36
Evaluating for appendicitis 37
Diagnosing intussuseption 39
Diagnosing pyloric stenosis 41
Assessing the stomach for NPO status 43
Vascular ultrasound
Scanning the great vessels 45
Visualizing the aortic arch 46
Diagnosing a great vessel dissection 48
Identifying a thoracic aortic aneurysm 50
Diagnosing upper extremity deep vein thrombosis (DVT) 52
Confirming central line placement 54
Musculoskeletal imaging
Applying point-of-care ultrasound to musculoskeletal structures 55
Identifying soft tissue structures 56
Visualizing soft tissue structures in the upper limb 58
Visualizing soft tissue structures in the lower limb 61
Diagnosing fractures 63
Identifying tendon injuries 65
Recognizing a shoulder dislocation 67
Detecting joint effusions 69
Evaluating for hip effusion 71
Diagnosing peritonsillar abscess 73
Scrotal ultrasound
Recognizing when to perform scrotal ultrasound 75
Acquiring scrotal images 76
Diagnosing testicular torsion 77
Evaluating for other testicular pathologies 79
Volume status and fluid responsiveness

Evaluating volume status with ultrasound 81
Quantifying the inferior vena cava (IVC) 82
Assessing fluid tolerance 84
Estimating cardiac output 86
Predicting fluid responsiveness 88
Further reading 89
Appendix
Reference list 94
Become an expert by learning the most important clinical skills at www.medmastery.com.
Airway ultrasound
RECOGNIZING WHEN TO USE

AIRWAY ULTRASOUND
Did you know it is possible to use ultrasound to help manage airway emergencies? While airway ultrasound
is not typically needed for all airway management, there are instances when it can be helpful to troubleshoot
difficult situations.
There are two scenarios when we might use airway ultrasound

1. Predicted difficult airway 2. Post intubation hypoxia
Patients who need airway management but have Airway ultrasound can also help you avoid and
potentially difficult airways are an ideal population evaluate post intubation hypoxia by allowing
for airway ultrasound. These may include patients immediate bedside evaluation of endotracheal
who are obese, or who have abnormal landmarks tube positioning.
due to trauma, a history of head and neck surgery,
or radiation.
Specific applications
1. Identify surgical airway landmarks 3. Rapidly evaluate tube position
A surgical airway is an uncommon procedure. It Ultrasound allows rapid assessment of tube

can be difficult to palpate the relevant landmarks, positioning. We can detect evidence of a right
particularly in the stressful setting of a failed mainstem intubation by checking for lung sliding.
intubation. Airway ultrasound allows you to identify
the landmarks for an incision rapidly and accurately. This is faster than waiting for a post-intubation
chest x-ray.
This is a technique that should be used when you
have time to prepare a double setup with attempted
intubation before trying a surgical airway, and not
in a crash situation in which an airway is needed
immediately.
2. Visualize esophageal placement
Airway ultrasound allows an operator to see

esophageal placement of an endotracheal tube
during an intubation attempt. This is performed
as a two operator technique, with one clinician
performing the intubation, and the other monitoring
the attempt with ultrasound. This is most useful if
video laryngoscopy is not used.
4
Airway ultrasound
CONFIRMING
ENDOTRACHEAL TUBE PLACEMENT
Correct endotracheal tube position can be confirmed using POCUS ultrasound
• look for bilateral lung sliding
• use real time guidance to directly visualize the esophagus during an airway attempt
Lung sliding
Patients with a well-positioned tube should show bilateral lung sliding with ventilation. Examine the anterior
chest in the mid-clavicular line as you would to look for a pneumothorax. If pulsatile movement similar
to sliding, but occurring more rapidly than ventilation is observed, this indicates lung pulse. Lung pulse
indicates transmission of the heart beat impulse to the pleura, but no ventilation.
Left lung Right lung Interpretation
Sliding Sliding Correct position
Lung pulse Sliding Right mainstem intubation
Lung pulse Lung pulse Esophageal placement
Real time guidance

You’ll use a linear transducer applied right of midline on the inferior aspect of the neck. If the patient has a
particularly thick or large neck, then the curvilinear transducer may be needed. Then slide the transducer to
the right of midline as shown below.
By observing the esophagus during an intubation, the operator can determine positioning of the tube. The
esophagus will distend with the endotracheal tube if the tube is placed in the esophagus. If the tube is
advanced and there is no distension of the esophagus, the tube should be in the trachea. Secure the tube
and check for bilateral lung sliding.
5
Airway ultrasound
IDENTIFYING THE
CRICOTHYROID MEMBRANE
Why use ultrasound?
Identifying the cricothryoid membrane by palpating landmarks for cricothyrotomy, ensuring a safer
for landmarks can be time consuming and procedure. It is important to remember that this
unreliable. A landmark-based approach may lead technique should be used in preparation for a double
to injury or delay in establishing a surgical airway. setup for a predicted difficult intubation, and not for
Ultrasound allows accurate identification of the immediate cricothyrotomy for a failed airway.
Thyroid cartilage
Cricothyroid muscle
Cricoid cartilage
Placement
To identify the cricothyroid membrane, place a linear transducer in the midline of the neck in long-axis,
with the probe marker pointing towards the patient’s head.
6
Anatomy
Note the linear, hyperechoic line that represents the The cricothyroid membrane is seen in the gap
air-mucosal interface. Superficial to this line, the between the thyroid and cricoid cartilages, the two
tracheal rings are seen as hypoechoic structures. larger hypoechoic structures nearest the head.
Thyroid cartilage
Cricothyroid membrane Cricoid cartilage
Tracheal rings
Air-mucosal interface
Head Feet
NOTE:
Use a marking pen to locate the membrane
as a target for a cricothyrotomy incision.
7
Lung ultrasound
MOVING BEYOND THE BASICS

OF LUNG ULTRASOUND
Core ultrasound applications
Core applications for lung ultrasound include these evaluations
• pneumothorax • pleural effusion • sonographic B lines
In these cases, we are using ultrasound to address a question with a yes or no answer. It is best used in
patients in which you have a specific clinical question to test for.
Advanced lung ultrasound

Advanced lung ultrasound can take a more general approach, and be applied to any patient with dyspnea.
It has the greatest value in patients with abnormal vital signs or critical illness and shock.
Advanced lung ultrasound allows us to diagnose more entities
Pneumonia Viral respiratory Interstitial Acute respiratory Traumatic

infections lung disease distress syndrome pulmonary
(ARDS) contusions
Advanced lung ultrasound does not use a yes or no approach to establishing a diagnosis. Many lung
ultrasound findings can overlap and look similar, despite a very different underlying disease.
Successful use of lung ultrasound requires a user to consider
• Presence of findings • Pre-test probability for a

• Distribution of findings given disease
When performing advanced lung ultrasound, a thorough examination of both lungs, including the posterior
aspect of the chest, is often required. This is a region not typically included in basic lung ultrasound.
8
Lung ultrasound
ACQUIRING LUNG
ULTRASOUND IMAGES
Advanced lung ultrasound often requires an overall examination of the lungs, rather than a focused test for a
single problem such as pneumothorax or pleural effusion.
Probe selection
Use the low frequency curvilinear transducer for an
initial survey of the lungs. Use the high frequency
linear transducer to examine the pleura or in
pediatric patients.
Technique
Examine the eight zones of the anterior chest. You
will also need to examine the posterior lung to
complete a full evaluation for pneumonia and other
pleural abnormalities.
With the transducer in a vertical orientation,

use a mow the lawn approach to ensure you
are thorough.
A good general approach includes:

1. Start deep 3. Switch probes
Acquire initial images with the curvilinear Changing to the linear transducer can allow you to
transducer. Set your depth sufficiently deep (> 10 examine pleural-based abnormalities with
cm) that you can appreciate sonographic B lines, if greater resolution.
present, and that you have an overview of
anatomic relationships.
2. Adjust depth
This allows you to confirm and refine your initial

findings. If you see superficial abnormalities at
the level of the pleura, reduce your depth to better
appreciate their characteristics. If you see potential
sonographic B lines, increase depth to at least 18 cm
to ensure they meet B line criteria.
9
Lung ultrasound
DIAGNOSING PNEUMONIA
Pneumonia can be identified rapidly and without radiation exposure using ultrasound.
Ultrasound has greater sensitivity and specificity than a chest x-ray for the diagnosis of pneumonia.
Most pneumonias develop in small, peripheral airways near the pleura. Consolidation then creates a solid
medium in contact with the pleura that can be visualized with ultrasound.
Normal pleura Pleural irregularity
Pneumonia has a range of appearances. All suspected consolidations, but smaller ones in particular,
must be interpreted in terms of the pre-test probability that the patient has pneumonia. Small, subpleural
consolidations can represent a variety of diseases. Ensure you evaluate the lung for other abnormalities;
multiple consolidations may alter the differential diagnosis.
Shred sign Empyema Subpleural consolidation
If you think the likelihood of pneumonia is moderate to high, but lung ultrasound is non-diagnostic,
obtain a chest x-ray. While lung ultrasound is more sensitive overall, it can miss pneumonias, particularly
interstitial infections that do not contact the pleura.
10
Lung ultrasound
RECOGNIZING VIRAL
LUNG INFECTIONS
The majority of lower respiratory infections result from viral illnesses. Lung ultrasound can be used to
support a clinical impression of a viral infection. This can be useful in pediatric patients, and help avoid the
radiation of a chest x-ray.
Common lung ultrasound findings in viral respiratory infections

• Normal lung
• Vertical comet tail artifacts / sonographic B lines
• Irregular, thickened pleura
• Small subpleural consolidations
Distinguishing viral and bacterial infections

In general, the pattern of lung ultrasound findings can help differentiate viral and bacterial infections. Some
findings can overlap; interpret the ultrasound in light of the patient’s condition and the likelihood of
a particular illness.
• Focal abnormality • Diffuse abnormalities

• Single consolidation • Multiple consolidations
• Larger consolidation • Smaller consolidation
• Air bronchogram
Atypical pneumonia
Pneumonia due to atypical organisms such as mycoplasma may demonstrate a diffuse B line pattern.
Influenza virus may also create the appearance of diffuse B lines on ultrasound.
11
Lung ultrasound
EVALUATING FOR OTHER

LUNG PATHOLOGIES
Lung ultrasound can allow you to identify other lung pathologies, such as:
Pulmonary embolism Acute respiratory Pulmonary contusion Influenza

distress syndrome
(ARDS)
Pulmonary embolism
Normal lung appearance is the most common Subpleural consolidations can be seen in patients
finding associated with pulmonary embolism. Seeing with pulmonary embolus. This likely reflects a small
the appearance of normal lung on ultrasound, in a lung infarct. Pay particular attention to points of
patient with dyspnea or hypoxia, raises the concern pleuritic pain.
for pulmonary embolus. Consider integrating the
lung ultrasound with an echocardiogram and a deep
vein thrombosis (DVT) study.
Acute respiratory distress syndrome (ARDS)

Patients with ARDS typically have diffuse sonographic B lines. The presence of other findings helps
differentiate ARDS from cardiogenic pulmonary edema. The following table outlines the likelihood of seeing
each finding in ARDS versus pulmonary edema.
ARDS (%) Pulmonary edema (%)
B lines 100 100
Irregular pleura 100 25
Reduced lung sliding 100 0
Spared areas 100 0
Consolidations 83 0
Pleural effusion 66 95
12
Pulmonary contusion
Chest trauma resulting in a pulmonary contusion produces focal B lines. There may also be an associated
pleural effusion or a thickened pleura.
Influenza
Lung ultrasound findings in influenza may range from normal lung to a diffuse B line profile with subpleural
consolidations. The latter has potential for overlap with ARDS; as always, consider the lung ultrasound
findings in light of the clinical presentation.
13
Lung ultrasound
AVOIDING POTENTIAL PITFALLS

WITH LUNG ULTRASOUND
There are several important potential pitfalls to consider when using lung ultrasound.
Not considering the context

Lung ultrasound findings can be nonspecific; the same findings can occur in different diseases. Interpret
findings in light of the patient’s overall condition and your clinical impression.
Not obtaining more imaging

Chest x-ray and computed tomography (CT) are important complementary tests to lung ultrasound. Don’t
hesitate to obtain more imaging if you haven’t answered your questions with ultrasound.
14
Overdiagnosing the image

As you perform more lung ultrasounds, you will recognize structures or appearances that seem abnormal.
Be wary of making overly specific diagnoses if you are unsure of what you are seeing or its significance, or
before you have completed your study.
Not examining all of the chest

Some lung ultrasound findings can be subtle or localized to a small region of the chest. Complete a thorough
study of both lungs before deciding the ultrasound is negative for any findings.
Stopping the search

Interpreting lung ultrasound accurately depends on an understanding of both the type and distribution
of findings. If you find something – don’t stop looking! Complete your examination of both lungs prior to
making a diagnosis based on the scan.
15
Not adjusting depth

You can lose important information by setting your depth too shallow or too deep. In particular, adjust depth
(or change transducers) to examine a suspected pleural abnormality.
Forgetting the thymus

The thymus is a common source of false positive pneumonias in pediatric patients.
Not considering other clinicians

Your colleagues may not understand or be comfortable with point-of-care lung ultrasound. Share your
findings (and teach them ultrasound!) but obtain other imaging to support them when needed.
16
MOVING BEYOND THE BASICS

OF ECHOCARDIOGRAPHY
Core point-of-care echocardiography applications include assessing for pericardial effusion, and evaluation
of ejection fraction, and right ventricular size.
Advanced point-of-care echocardiography applications:
Cardiac arrest Endocarditis Valve assessment
Right-heart function Cardiac tamponade Diastolic function Wall motion abnormalities
Advanced echo applications are among the most

complex in point-of-care ultrasound.
17
Caveats
1. Many advanced applications will not have a yes or no answer for the operator. Findings may exist on
a spectrum.
2. Consider the pre-test probability of a disease when interpreting your results.
3. Use a targeted approach. Most users will not look for all abnormalities in a given patient.
4. Point-of-care echo findings are typically more specific than sensitive.
5. Point-of-care echo does not replace comprehensive echo. A comprehensive study will often be needed
if a point-of-care echo is inconclusive.
6. Be wary of false positive findings. Inexperienced operators are more likely to over-diagnose a low quality
image or to have false positives.
7. Work collaboratively with cardiologists and other clinicians; if you see a concerning finding, be sure to alert
others involved in the patient care, but get lots of practice and build your reputation for quality studies and
prudent interpretations.
18
PERFORMING ECHOCARDIOGRAPHY
IN CARDIAC ARREST
Point-of-care echo can help guide care in both medical and traumatic cardiac arrest.
Medical cardiac arrest

Consider using echo at a pulse check, but be sure to minimize the time without compressions. Have an
experienced operator obtain subxiphoid or apical views as quickly as possible. Do not delay restarting
compressions. Basic echo findings during arrest include no activity, fibrillation, and organized contraction.
No activity supports the decision to terminate spontaneous circulation, or if there is no pulse

resuscitation if the care team otherwise thinks palpable, pulseless electrical activity (PEA).
further effort is futile. Be aware that you may
observe swirling blood or agonal twitching of the Echo findings in PEA can be integrated with data
myocardium or valve, as a result of the low flow from the monitor or electrocardiogram, to help
state. You can still terminate resuscitation, even narrow down a cause and ultimately a potential
though you may not observe complete cardiac course of treatment. A narrow complex rhythm
standstill. on the monitor with a hyperdynamic left ventricle
may be associated with a mechanical cause
Ventricular fibrillation supports an attempt at (pneumothorax, tamponade, pulmonary embolus)
defibrillating the patient. while a hypokinetic heart or wide complex rhythm
may suggest an underlying mechanical cause of
Organized contraction indicates return of the PEA.
Traumatic cardiac arrest

The presence of a pericardial effusion or organized
cardiac activity supports the decision to proceed
with resuscitative thoracotomy. While all decisions
should be individualized to the patient, the absence
of a pericardial effusion or organized activity
indicates that risk of thoracotomy may exceed the
potential benefit. Hemopericardium in a patient
with trauma may appear echogenic and complex.
Note the example, here, of a complex effusion in a
traumatic arrest.
19
DIAGNOSING
PERICARDIAL TAMPONADE
Cardiac tamponade is a clinical diagnosis, but point-of-care echo findings can provide evidence of early
tamponade. There are two-dimensional (2D) and Doppler findings.
Pericardium
As intrapericardial pressure begins to exceed intracardiac pressure, tamponade develops. Look for
late diastolic collapse of the right atrium and early diastolic collapse of the right ventricle as the pericardial
pressure increases.
Late diastolic Early diastolic
It can be helpful to imagine looking for someone jumping on the trampoline of the right ventricle or atrium to
see this collapse on ultrasound.
Inferior vena cava (IVC)

As obstructive physiology develops in tamponade, right atrial filling pressure increases, and is transmitted to
the IVC. In tamponade, we expect a dilated (> 2 cm) IVC with minimal respiratory variation.
20
Doppler
As tamponade develops, changes in interventricular dependence lead to changes in inflow across the mitral
and tricuspid valve with respiration. This is pulsus paradoxus. A > 25% change with respiration is consistent
with echo tamponade.
21
RECOGNIZING REGIONAL WALL

MOTION ABNORMALITIES
Wall motion abnormalities (WMA) are an early finding in cardiac ischemia. WMA appear as a focal area of
hypokinetic wall movement. Detecting a WMA in a patient with suspected ischemia may help lead to more
aggressive diagnosis and treatment.
Without prior echo data, it is not possible to distinguish between a new or old WMA.
Point-of-care echo divides the heart into large territories for potential WMA. Comprehensive echo further
subdivides these into smaller segments.
Septal
Anterior
Lateral
Posterior
Inferior
To recognize a WMA, it can be helpful to imagine

a dot at the centre of the ventricle and ask if each
segment of the myocardium is moving equally
toward the dot.
22
EVALUATING
RIGHT-HEART FUNCTION
Evaluating left-heart systolic function and right
ventricular size, as a marker of strain, are core
point-of-care echo applications. We can also
evaluate right-heart function to help guide diagnosis
and resuscitation.
The shape and movement of the right ventricle

are different from the left. The major axis for right
ventricular movement will appear as vertical, not
inward.
We can evaluate right ventricular function best using

the apical four chamber view. In this window, the
left ventricle contracts in, while the right ventricle
moves up and down (see right). Reduced movement
indicates decreased right-heart function.
We can quantitatively measure right ventricular

function using the triscuspid annular plane systolic
excursion (TAPSE). Place an M mode cursor through
the free wall of the right ventricle at the level of the
valve and obtain a tracing (see right). Then measure
the displacement of the right ventricle (below).
A TAPSE > 1.7 cm is normal.

A TAPSE < 1.7 cm indicates right
ventricular dysfunction.
23
ESTIMATING PULMONARY ARTERY

SYSTOLIC PRESSURE (PASP)
Elevated pulmonary artery pressure results from pulmonary arterial hypertension, thromboembolic disease,
left-heart disease, or lung disease.
We can measure the pulmonary artery systolic pressure (PASP) with echo, and use this as an estimate of the
mean pulmonary artery pressure. This information allows us to understand hemodynamics in the critically ill
and evaluate patients with dyspnea.
Calculating PASP
To measure the PASP, we need to determine the pressure gradient across the triscuspid valve.
We use the modified Bernoulli equation:
PPASP = 4 x VTR2 + PRA
VTR = velocity of tricuspid regurgitation PRA = right atrial pressure
To measure VTR, identify the tricuspid regurgitation jet with color Doppler, then apply continuous wave
Doppler to measure its peak velocity.
Then measure inferior vena cava (IVC) size and collapsibility with M mode to obtain an estimate for PRA.
24
Inferior vena cava (IVC) % Collapse Estimated right atrial pressure

size (cm) (RAP)
< 1.5 < 1.5 0–5
1.5–2.5 > 50 5–10
1.5–2.5 > 50 10–15
> 2.5 > 50 15–20
The values for VTR and PRA can now be substituted in to the Bernoulli equation.
The result indicates whether elevated pulmonary artery pressure is present.
Normal Mild Moderate Severe

< 25 mm Hg > 40–50 mm Hg > 50 mm Hg > 60 mm Hg
25
ASSESSING HEART VALVE

STRUCTURE AND FUNCTION
A point-of-care assessment of the heart valves can help you understand the cause of circulatory or
respiratory failure, as well as guide a resuscitation strategy or prompt additional testing.
Technique
Point-of-care assessment of the valves includes a two-dimensional (2D) examination and the use of color
Doppler. Point-of-care studies do not replace the need for comprehensive echo. The goal of point-of-care
echo examinations is to identify severe regurgitation. This can be achieved by asking – does the valve
appear structurally normal?
Watch for the movement of the valve leaflets, their coaptation, and the presence of calcifications or masses.
Then apply color Doppler over the valve.
Two-dimensional valve assessment Color Doppler
Mitral regurgitation
In the apical and long-axis windows, use color Doppler to examine for the presence of a regurgitant jet.
No regurgitation Regurgitant jet
26
Severe regurgitation is present if the jet occupies > 40% of, or swirls eccentrically in, the left atrium.
Parasternal long-axis view Apical four-chamber view
Severe regurgitation
Aortic regurgitation
Evaluate the aortic valve in the long-axis and apical
five chamber windows. A regurgitant jet occupying
> 65% of the outflow tract, or an eccentric jet along
the wall of the outflow tract, indicates
severe regurgitation.
Parasternal long-axis view
Apical five-chamber view
27
Tricuspid regurgitation
Some degree of tricuspid regurgitation is common
even in healthy individuals. Increased regurgitation
may be seen in right ventricular pressure overload
(e.g., pulmonary embolus, pulmonary hypertension)
or structural lesions (e.g., endocarditis, Ebstein’s
anomaly).
Valvular stenosis
Evaluation for stenosis is complex, and most appropriate for comprehensive echo examinations. For the
point-of-care operator, a valve that appears structurally normal is unlikely to have significant stenosis. The
presence of restricted valve movement or calcifications increases the likelihood that stenosis is present.
28
EVALUATING DIASTOLIC FUNCTION

Evaluating for diastolic dysfunction may be helpful in patients with suspected heart failure but normal
systolic function, and in patients with unexplained dyspnea.
Diastolic function can be evaluated using a Doppler assessment of the mitral inflow, and tissue Doppler
measurements of the septum or lateral wall.
Mitral inflow
Place a pulse wave Doppler gate in position to measure inflow, and obtain a waveform tracing.
There are basic patterns of mitral inflow that correspond to diastolic function. The E wave indicates passive
filling, and the A wave represents the atrial kick.
29
The E wave is greater than the A wave in all but the delayed relaxation pattern. To help distinguish subtypes,
we use the E:A ratio and examine the effect of having the patient perform a Valsalva maneuver.
Pseudonormal
Performing Valsalva will cause the A wave to grow larger than the E wave for pseudonormal and reversible
restrictive patterns, but not for the irreversible restrictive pattern.
Reversible restrictive
In restrictive patterns, the E:A ratio will be 2:1 or greater. This helps distinguish between pseudonormal and
reversible restrictive patterns.
Irreversible restrictive
30
Tissue Doppler (TDI)

TDI of the septum and lateral wall can also help characterize diastolic function.
TDI patterns can be used with mitral inflow to calculate E/e’ values, and determine the degree of
diastolic dysfunction.
31
RECOGNIZING ENDOCARDITIS
In high-risk patients (intravenous drug use, known valvular disease, recent bacteremia), point-of-care echo
can help diagnose endocarditis.
The sensitivity of transthoracic echocardiography is not adequate to exclude endocarditis. High-risk patients
will need further testing.
Technique
Use all of the parasternal, apical, and subxiphoid windows to increase sensitivity.
Look for
• presence of vegetation on a valve
• abnormal valve coaptation
• regurgitation with color Doppler
Vegetation
Regurgitation
32
RECOGNIZING WHEN TO PERFORM

GASTROINTESTINAL ULTRASOUND
Basic abdominal point-of-care ultrasound applications include evaluation of the aorta and kidneys, and
assessment for free fluid.
Advanced applications include:
Small bowel obstruction Appendicitis Intussusception Pyloric stenosis Stomach contents
Advantages of performing these applications may include
Rapid diagnosis Reduced radiation Facilitate transfer
Caveats
These point-of-care studies work best if they are performed in patients with a high clinical concern for the
disease, and not in all patients with abdominal pain, vomiting, or a gastrointestinal complaint. As with other
advanced applications, there are several precautions to consider.
1. Interpret findings in the context of pre-test probability for a disease.
2. Specificity is typically higher than sensitivity.
3. Follow up imaging, including computed tomography (CT), is often required.
33
DIAGNOSING SMALL
BOWEL OBSTRUCTION
Point-of-care ultrasound is an excellent test for small bowel obstruction (SBO). Test performance is far
better than an abdominal radiograph.
Technique
Point-of-care ultrasound should be used in
patients with moderate to high clinical suspicion
for SBO. Using a low frequency transducer,
perform a systematic examination of the abdomen
using a mow the lawn technique. Use gentle
pressure to displace bowel gas and assess bowel
compressibility.
Findings
There are an array of potential findings
Dilated bowel > 2.5 cm Free fluid between Pneumatosis

(This is the most common!) bowel loops
Noncompressible bowel Back and forth movement Bowel wall > 3 mm Loss of peristalsis
of bowel content
34
Dilated loops of bowel
Wall thickening and free fluid
35
IMAGING THE APPENDIX

Ultrasound is an excellent test for diagnosing appendicitis, but depends on the skill of the operator and
the patient anatomy. Ultrasound does not have perfect sensitivity, and a non-diagnostic scan requires
additional testing.
Technique
The high frequency transducer is the best choice
due to its excellent resolution. The curvilinear
transducer can also be used, but if patient size
requires its additional depth, the likelihood of a
non-diagnostic study increases.
One approach to identify the appendix is to place the

transducer at the point of maximal tenderness, and
identify the relevant anatomy. The appendix appears
as a blind-ending tube arising from the cecum. The appendix arises from the cecum
An alternative approach is to trace the right (ascending) colon from the upper abdomen into the right lower
quandrant. The right colon is typically gas-filled. As the gas dissipates in the right lower quadrant, the probe
will have slid off the cecum, and be in the anticipated region of the appendix.
Anatomy
Typical right lower quadrant anatomy is depicted below. The psoas and iliac vessels typically lie deep to the
appendix. A normal appendix may be difficult to identify.
36
EVALUATING FOR APPENDICITIS
Ultrasound findings in appendicitis

Diagnosing appendicitis relies on multiple findings. Not all will be present, but the defining criterion is a
noncompressible, blind-ending tubular structure.
Noncompressible, Dilated > 6 mm Appendicolith Free fluid Hyperemic with Surrounding

blind-ending structure color Doppler echogenic fat
It is important to realize that some findings of uncomplicated appendicitis—particularly free fluid—can

overlap with ruptured appendicitis. Remember to interpret ultrasound findings in light of the clinical history.
A confirmatory computed tomography (CT) scan may be necessary if ultrasound is non-diagnostic or if
there are other features of the case that suggest rupture.
Examples of appendicitis
In short-axis, the appendix often appears as a
target sign.
In long-axis, the appendix typically appears as a

blind-ending tubular structure. Always image in
both planes.
37
An appendicolith will create an acoustic shadow. Note the dilation of the appendix.
Periappendiceal echogenic fat appears hyperechoic and hazy. Apply color Doppler to evaluate for hyperemia.
Free fluid is consistent with appendicitis, but can also indicate rupture. Note the complex free fluid deep to
the appendix in this patient, which is present in long- and short-axis.
Long-axis view Short-axis view
38
DIAGNOSING INTUSSUSCEPTION
Intussusception is an important consideration in the differential diagnosis of an infant with vomiting,
abdominal pain, or lethargy. Ultrasound is the most common imaging test used to make the diagnosis of
ileocolic intussusception. Sensitivity and specificity are near 100% for experienced operators.
Point-of-care ultrasound can allow rapid diagnosis while a patient is symptomatic, and facilitate
consultation, transfer, and definitive care.
Technique
Use the high frequency linear transducer. Trace An alternative is to use a mow the lawn approach
the path of the colon. Use graded compression to by moving the transducer through all four abdominal
displace bowel gas. quadrants.
Ultrasound findings of intussusception

There are three patterns seen on ultrasound that are consistent with intussusception: target sign,
pseudokidney sign, and pancake sign. These correspond to visualizing the intussusception in a short-,
oblique-, and long-axis, respectively.
Target sign
39
Pseudokidney sign
Pancake sign
40
DIAGNOSING PYLORIC STENOSIS

Pyloric stenosis is a common diagnostic consideration in neonates with vomiting. Ultrasound is the test of
choice to make the diagnosis: it allows direct visualization of the pylorus and can differentiate stenosis from
pylorospasm. It does not require radiation, and is faster and more comfortable than other forms of imaging.
It is also nearly 100% sensitive.
Technique
Use a high frequency linear transducer. In a long-axis orientation, scan medial to the gall bladder. The
stomach will be anterior to the aorta and should appear fluid filled and distended, particularly if the
pylorus is stenotic and impairing gastric emptying. Consider putting the baby in the right lateral decubitus
position to scan.
Anatomy
After identifying the pylorus muscle, measure the length and width of the pylorus.
Pylorus muscle
Stomach
41
Pyloric stenosis
A pyloric width > 3 mm or pyloric length > 14 mm are consistent with pyloric stenosis. To differentiate
pyloric stenosis from pylorospasm, have the child feed, and watch for passage of fluid through the pylorus.
If stenosis is present, fluid will not pass through the pylorus.
Pyloric width > 3 cm
42
ASSESSING THE STOMACH

FOR NPO STATUS
Ultrasound of the stomach can provide more direct visualization of stomach contents. This is more
reliable than a patient’s history of last intake, and can guide an assessment of the risk of aspiration during
a procedure.
Technique
Use the curvilinear transducer in an adult, and the
linear transducer for pediatric patients. Obtain a
long-axis image in the subxiphoid region; fan left
and right to obtain an image of the antrum. Placing
the patient in the right lateral decubitus position
will increase the sensitivity of the test.
Findings
The goal of the examination is to recognize the antrum. It should be collapsed in an empty stomach.
A patient with simple fluid will have a distended, hypoechoic antrum.
43
Patients who have recently consumed solids may have entrained air; they have a characteristic appearance
of shadowing air in the antrum that may preclude visualizing contents of the posterior wall of the stomach.
Patients who have ingested both liquids and solids can show a mixture of both hyper and
hypoechoic contents.
44
Vascular ultrasound
SCANNING THE GREAT VESSELS

Advanced uses of point-of-care ultrasound for vascular structures include
Aortic dissection Thoracic aortic aneurysm Upper extremity deep Confirming central line
venous thrombosis placement
Caveats
The evidence basis for these point-of-care ultrasound applications is less well developed than
core applications.
1. Structures should be imaged in multiple windows, such as short- and long-axis, whenever feasible.
2. Point-of-care ultrasound often has greater specificity than sensitivity
3. Follow up imaging, such as a comprehensive ultrasound or computed tomography (CT) scan, is often
required to confirm point-of-care study findings.
45
Vascular ultrasound
VISUALIZING THE AORTIC ARCH

Point-of-care ultrasound can allow an immediate bedside diagnosis of an aortic dissection. This is
especially helpful in an unstable patient who cannot be transported for other imaging.
In addition to standard transthoracic and abdominal

views of the aorta, images of the aortic arch
and ascending aorta can be obtained using the
suprasternal and right parasternal windows.
Suprasternal window
Position the cardiac transducer in the suprasternal
notch above the sternum and tilt the transducer
anteriorly to obtain an image. Extending the patient’s
neck can improve the image.
Long-axis view Short-axis view
46
Right parasternal window

This window can allow greater visualization of the ascending aorta. It cannot be obtained in all patients. The
transducer is placed to the right of the sternum in a long-axis orientation.
Ascending aorta
Left ventricle
47
Vascular ultrasound
DIAGNOSING A
GREAT VESSEL DISSECTION
Point-of-care ultrasound allows for rapid bedside diagnosis of a dissection of the aorta or other major
arteries. It is specific enough to allow for diagnosis, but not sufficiently sensitive to rule out a dissection.
Identifying a dissection can help in the care of patients too unstable to be transported for other imaging.
Technique
Select a transducer based on the location of the target vessel.
Image suspected dissections in long- and short-axis.
Not all vessels may be visible due to patient habitus, but you can establish the diagnosis by checking for
distal propagation of the dissection flap.
48
Recognizing dissection
Dissections appear as a hyperechoic band passing through a vessel.
Color Doppler can be used to show flow in the true and false lumen of the dissecting vessel.
49
Vascular ultrasound
IDENTIFYING A
THORACIC AORTIC ANEURYSM
Evaluation for abdominal aortic aneurysm is a core point-of-care ultrasound application. We can also
identify thoracic aortic aneurysms. This can be used as a targeted test in a symptomatic patient or in
a patient with an abnormal chest x-ray, or may be detected as an incidental finding during a point-of-
care echo.
Qualitative assessment of the aortic root

In a parasternal long-axis window, the size of the right ventricle, aorta, and left atrium are all approximately
the same. If this 1:1:1 ratio seems abnormal, consider the possibility of a thoracic aortic aneurysm, and
obtain measurements.
Quantitative assessment of the aortic root

The aortic root can be measured at different points, using the parasternal long-axis view.
4 Ascending aorta
3 Sinotubular junction
2 Sinus of valsalva
1 Aortic annulus
The criteria for diagnosing a thoracic aortic aneurysm vary with sex and body size. In general,
measurements > 4 cm are consistent with dilation, and > 4.5 cm is consistent with aneurysm.
50
Measurement technique
Measure the thoracic aorta by using a leading edge to leading edge approach.
Inspect the descending aorta in the parasternal long-axis window; some aneurysms may be isolated to the
descending thoracic aorta.
51
Vascular ultrasound
DIAGNOSING UPPER EXTREMITY

DEEP VEIN THROMBOSIS (DVT)
The incidence of upper extremity deep vein thrombosis (DVT) is increasing. Point-of-care ultrasound can
allow for more timely diagnosis, and is particularly useful in settings where comprehensive ultrasound is not
always available.
Technique
Use a high frequency transducer. Patients should be positioned with their arm abducted and head rotated to
the contralateral side. The goal of an upper extremity DVT study is to evaluate for collapsible deep veins. A
non-collapsible deep vein is consistent with DVT.
Compress each vein in the deep venous system to evaluate for collapsibility.
Internal jugular vein
Subclavian vein
52
Axillary vein
Basilic and brachial veins
Cephalic vein
53
Vascular ultrasound
CONFIRMING CENTRAL LINE

PLACEMENT
Ultrasound allows rapid confirmation of an adequate central line placement, facilitating immediate use
of the line in a critically ill patient.
Technique
• Place the line per standard protocol.
• Obtain an echo window of the heart. The subxiphoid works well for this purpose.
• Instill 5—10 mL saline into the line.
For an internal jugular or subclavian line, visualization of swirling fluid in the right side of the heart
in < 2 seconds indicates the line is well positioned.
< 2 sec
Safety
Check the lungs for evidence of pneumothorax.
If no flush is seen, check the cannulated vessel to ensure the catheter is visible. In addition, check the
contralateral vessels to ensure there is no misplacement of the line.
54
APPLYING POINT-OF-CARE
ULTRASOUND TO
MUSCULOSKELETAL STRUCTURES
Evaluation of soft tissue for abscess or cellulitis is a core point-of-care ultrasound application.
Musculoskeletal (MSK) complaints represent up to 25% of acute care complaints, but MSK topics typically
represent a disproportionately small amount of medical training.
Point-of-care ultrasound can improve the accuracy of physical diagnosis and expedite patient care.
Common applications include assessment for
Fractures Tendon injury Dislocations Effusions
Benefits
MSK ultrasound can help reduce unnecessary radiation, direct the need for further testing, and guide
procedures or the need for immobilization.
Caveats
1. Image in multiple planes.
2. Scan the area of maximal pain.
3. Compare to the unaffected side.
4. Approach the scan with a specific diagnosis in mind.
5. Recognize that MSK ultrasound is more specific than sensitive.
6. Obtain complementary imaging if needed.
55
IDENTIFYING SOFT TISSUE

STRUCTURES
The ability to recognize different types of soft tissues is the foundation of musculoskeletal ultrasound.
Skin
Skin and subcuticular tissue is typically thin. On ultrasound, it is most commonly noted if abnormal.
Normal Edema
Muscle and fascia

Striated muscle appears hypoechoic with
hyperechoic striations. These striations appear
linear in long-axis and dotted in short-axis.
Fascia is hyperechoic and covers striated muscle.
Tendon
Tendons are hyperechoic and have a fibrillar or band-like structure. They have the property of anisotropy
(as observed below, right) and appear most prominent when viewed at a perpendicular angle.
56
Ligament
Ligaments have a hyperechoic, band-like fibrillar
pattern, and will insert on bone at both ends. They
can be difficult to appreciate if uninjured; it helps to
understand the underlying anatomy and expected
location of the tendon, as well as to move the
transducer.
Nerve
Nerves are best seen in short axis. They have a
stippled, honeycomb appearance. Nerves appear
hyperechoic below the clavicle and relatively
hypoechoic above it. Like tendons, they have the
property of anisotropy.
Bone
Bones are hyperechoic and will create shadowing. If
uninjured, they will have a smooth, regular contour.
Blood vessel
Vascular structures are anechoic in their normal
state. They can display flow on color Doppler. Veins
are compressible with low pressure; arteries are
typically noncompressible.
Lymph node
Lymph nodes are hypoechoic with a hyperechoic hilum or stalk. They are most commonly appreciated if
enlarged. They will display flow with Doppler.
57
VISUALIZING SOFT TISSUE

STRUCTURES IN THE UPPER LIMB
Understanding standard views and the ultrasound appearance of the major joints in the upper extremity
allows point-of-care ultrasound users to recognize pathology and perform procedures more effectively.
Shoulder
Place the patient in a seated position, with the elbow flexed to 90 degrees, and the hand resting on the thigh.
Anterior transverse Anterior longitudinal
Deltoid
Biceps tendon
Humerus
Anterior transverse, external rotation Posterior transverse
58
Elbow
For anterior images, have the patient sit, and extend, and supinate the elbow. For lateral images, internally
rotate the shoulder and flex the elbow to 90 degrees. For posterior images, flex the elbow to 90 degrees and
place the hand on the thigh.
Anterior longitudinal, radial aspect Anterior longitudinal, ulnar aspect
Anterior transverse Lateral
Medial Posterior longitudinal
59
Wrist and hand

Place the hand and wrist in a neutral position. Use of a water bath can help evaluate the hand and digits.
Wrist - dorsal longitudinal Wrist – dorsal transverse
Wrist – radial transverse Wrist – ulnar transverse
APL—abductor pollicis longus / EPB—extensor pollicis brevis ECU—extensor carpi ulnaris
Wrist – ulnar longitudinal Wrist – volar transverse
TFC—triangular fibrocartilage / ECU—extensor carpi ulnaris
Interphalangeal – volar longitudinal Interphalangeal – volar transverse
60
VISUALIZING SOFT TISSUE

STRUCTURES IN THE LOWER LIMB
As in the upper extremity, understanding the appearance and standard views of lower extremity
structures on ultrasound is the basis for identifying normal and pathologic findings. Compare findings
to the unaffected side.
Knee
Position the patient seated or supine, with the knee in partial flexion.
Suprapatellar longitudinal Suprapatellar transverse
Infrapatellar longitudinal Infrapatellar transverse
Medial Lateral
MCL—medial collateral ligament LCL—lateral collateral ligament
61
Ankle and foot

Position the patient with the knee flexed and the foot on a table or footstool. For posterior views, place the
patient prone or hang the ankle off the edge of the bed or table.
Anterior longitudinal Anterior transverse
Medial transverse Lateral transverse
Posterior longitudinal Plantar surface
62
DIAGNOSING FRACTURES
While x-rays remain the standard to diagnose most fractures, ultrasound can be a helpful adjunct for some
fractures that are difficult to identify with radiographs, or in low resource settings.
Technique
Use a high frequency, linear transducer. Normal bone should have a regular, continuous cortical surface. The
essential principle of identifying a fracture on ultrasound is to look for a discontinuity of the bone. Be sure
to examine the bone in short- and long-axis, and when feasible, compare to an unaffected side.
• Evaluate for smooth cortex NOTE:

• Look for discontinuity A water bath may be helpful to
• Image in two planes examine digits of the hand or foot.
When to use ultrasound?

Ultrasound can be especially helpful to diagnose the following fractures
ribs sternum digits
63
Recognizing fractures
Fractures can be recognized by a disruption of the regular surface of hyperechoic bone.
Sternum: long-axis view Sternum: short-axis view Proximal phalanx
Procedural guidance
Ultrasound can be used to guide the needle for a hematoma block, and to provide intra-procedure
visualization of fracture reduction.
64
IDENTIFYING TENDON INJURIES

Why use ultrasound for tendon injuries?
Ultrasound identification of a tendon injury increases the specificity of a clinical diagnosis, provides patients
with a visual depiction of their injury, and may reduce unnecessary radiographs.
Technique
Use a high frequency linear transducer. Examine the site of pain in long- and short-axis, and in comparison
to the unaffected side.
Anatomy
Normal tendons have an organized fibrillar pattern. Movement of the tendon can be visualized to evaluate for
tendon integrity.
65
Tendon injury
Complete disruption of a tendon produces a disruption of the fibrillar pattern. Hypoechoic material
represents blood or edema. Tendon rupture can be complete or partial.
Unaffected Affected
Tendonitis is common and can be seen on ultrasound as fluid surrounding the tendon. Ultrasound cannot be
used to distinguish the etiology of the tendonitis.
66
RECOGNIZING A
SHOULDER DISLOCATION
Point-of-care ultrasound can aid in the management of shoulder dislocations by allowing rapid confirmation
of a clinical diagnosis, guiding delivery of an intra-articular anesthetic, and providing a method to confirm
reduction at the bedside.
Technique
A low frequency curvilinear transducer will be best
for most patients. In pediatric or small patients a
high frequency linear transducer may be sufficient.
Place the transducer on the posterior aspect of the

shoulder along the spine of the scapula.
Anatomy
In patients with a well-located shoulder, the humeral
head and scapular spine should appear parallel.
Dislocation
Patients with an anterior shoulder dislocation will
have the humeral head displaced into the far field of
the ultrasound image.
67
In a posterior dislocation, the humeral head will

appear displaced towards the near field of the
ultrasound image.
68
DETECTING JOINT EFFUSIONS

Why use ultrasound?
All joints contain synovial fluid; it can be challenging to determine if an effusion is present using physical
exam alone, particularly if the patient is obese or has poor landmarks.
Ultrasound allows direct visualization of intra-articular fluid that has swollen beyond the boundary of the
joint capsule.
Normal Effusion
Transducer selection
For superficial joints, such as the digits, or in smaller patients, a high frequency transducer will be sufficient.
Larger patients or deeper joints will often require a low frequency transducer.
If uncertain whether an effusion is present, compare to an unaffected joint.
Joint effusions
Effusions distend the boundaries of a joint capsule, and typically the joint contents rise above the bony
landmarks defining the joint space.
No effusion Knee effusion
69
Familiarity with the underlying joint anatomy is helpful, as pattern recognition helps a user recognize
abnormalities. Here is an example of an elbow effusion.
No effusion Elbow effusion
Complex effusions may contain hyperechoic material.
Hemorrhagic knee effusion
70
EVALUATING FOR HIP EFFUSION

The ability to diagnose a hip effusion in a limping patient can help guide their workup. This is particularly
valuable for children with possible septic arthritis; the presence of a hip effusion may indicate the need
for arthrocentesis.
Technique
Use the high frequency linear transducer for pediatric or slender patients; others often require the low
frequency curvilinear transducer.
Orient the transducer to be angled in line with the femoral neck. Keep the transducer perpendicular to the
skin to avoid anisotropy, which can produce a false positive.
Compare both the affected and unaffected side.
Anatomy
Important landmarks include recognition of the iliopsoas muscle and the femoral neck. In children,
the growth plate has a hypoechoic appearance. Look for effusions in the joint capsule space.
Normal hip
71
Hip effusion
Examine the joint capsule space for fluid. This is most commonly anechoic, but complex fluid might contain
hyperechoic material.
Measure all suspected effusions, as it is normal for joints to contain synovial fluid. The criteria for a hip
effusion is one of two possibilities.
1. Effusion > 5 mm
2. More than 2 mm larger than the unaffected side
72
DIAGNOSING PERITONSILLAR
ABSCESS
Sore throat is a common acute care complaint, and peritonsillar abscess (PTA) is an important
diagnostic consideration.
Point-of-care ultrasound is a radiation free way to help determine if a drainable PTA is present. Ultrasound
can also help identify the important vascular structures near a PTA and guide plans for incision and
drainage.
jugular vein
carotid artery
peritonsilar abscess
Technique
An intraoral or a transcutaneous approach can be used to evaluate for a PTA.
Intraoral
Insert an intracavitary transducer, covered in a glove or probe sheath, toward the peritonsillar space.
Examine the unaffected then the affected side. Fan through the space in a head to toe plane.
A normal tonsil is relatively hypoechoic with a hyperechoic hilum. The carotid can be seen deep to the tonsil
with color Doppler.
73
A PTA will have mixed echogenicity, with anechoic areas indicating liquid, and purulent content.
Transcutaneous
In patients with severe trismus or those unable to tolerate an intraoral probe, consider a transcutaneous or
submandibular approach. Using a high frequency transducer placed inferior to the mandible, aim the probe
towards the peritonsillar space.
A normal tonsil will appear hypoechoic with a hyperechoic hilum.
A PTA will again show anechoic regions indicating fluid or purulence.
74
Scrotal ultrasound
RECOGNIZING WHEN TO PERFORM

SCROTAL ULTRASOUND
Scrotal and testicular complaints are a common reason for males to present for care.
The primary role of scrotal point-of-care ultrasound is to evaluate for testicular torsion. Torsion is a
time-sensitive diagnosis, and in the absence of comprehensive imaging, point-of-care ultrasound can
support a clinical impression of torsion.
Testicular torsion
The most common symptoms in torsion are swelling and pain. Patients may also have nausea, vomiting,
or abdominal pain.
Other findings associated with more common scrotal pathologies may also be noted during a scan:
Epididymitis Orchitis Hydrocele Incarcerated hernia
75
Scrotal ultrasound
ACQUIRING SCROTAL IMAGES

Technique
Use a high frequency linear transducer. Place the
patient supine, with scrotal support and the penis
directed to the head. Obtain images of both testicles
in short- and long-axis. A spectacle or buddy view
of both testes in short-axis in the same image
allows simultaneous comparison. Fan through the
entirety of both testicles.
Anatomy
Normal testicles have a uniform echotexture with
no disruption to the testicular architecture. The
testicles are bounded by a hyperechoic capsule.
No fluid is typically seen in the scrotum.
Color Dopper allows an assessment of flow to the testicle. Power Doppler is more sensitive to detect flow.
Color Doppler Power Doppler
76
Scrotal ultrasound
DIAGNOSING TESTICULAR TORSION

Testicular torsion is a clinical diagnosis. Ultrasound is the most common imaging test used to support the
clinical impression.
Ultrasound findings of torsion

Absence of flow on color or power Doppler is a defining ultrasound feature of torsion. Compare both sides.
An enlarged testicle is common in torsion,

but is not a specific finding.
Reactive edema can be present around the

affected testicle.
Late presenting torsion may show an irregular

echotexture.
77
Caveats
1. The sensitivity of ultrasound for torsion is not 100%, and is likely lower for a point-of-care study.
2. Obtain follow up imaging or consultation for patients with a high clinical concern for torsion but a
non-diagnostic study.
78
Scrotal ultrasound
EVALUATING FOR OTHER

TESTICULAR PATHOLOGIES
While the primary role of scrotal ultrasound is to evaluate for testicular torsion, alternative diagnoses may be
identified, since other causes of testicular pain or swelling are more common than torsion.
Hydrocele
Simple, anechoic fluid is seen around the testicle in patients with a hydrocele.
Short-axis view Long-axis view
Varicocele
Varicocele results from a dilation of the pampiniform
plexus in the spermatic cord. It appears as a cluster
of hypoechoic globules. Flow is present on color
Doppler.
Epididymitis
The normal epididymis head is hypoechoic and can
be seen at the superior pole of the testicle. The body
and tail may not be visible in asymptomatic patients.
79
In epididymitis, the epididymis becomes enlarged

and the echotexture can become irregular. It may be
hyperemic with color Doppler. A reactive hydrocele
may also be noted.
Orchitis
The ultrasound features of orchitis can include an
enlarged testicle, irregular echotexture, hyperemia
on color Doppler, and a hydrocele, which may be
complex.
80
EVALUATING VOLUME STATUS

WITH ULTRASOUND
The goal of administering intravenous (IV) fluid in hemodynamically unstable patients is to increase cardiac
output by increasing preload and stroke volume. Patients who can increase their stroke volume with IV fluid
are said to be volume or fluid responsive.
About 50% of unstable patients are not volume responsive. Clinical examination does not allow accurate
prediction of who will be responsive to IV fluid. Unnecessary IV fluid is harmful to the critically ill.
The Frank-Starling curve illustrates the relationship between stroke volume and preload. The curve can be
shifted left or right with changes in contractile function of the heart. A patient on the steep portion of the
curve (green dot) has the potential to respond to IV fluid. A patient on the plateau of the curve (red dot) will
not increase stroke volume in response to fluid.
Stroke volume
Preload
Ultrasound allows a noninvasive assessment of volume status and can be used to predict whether a patient
will be fluid responsive.
81
QUANTIFYING THE INFERIOR

VENA CAVA (IVC)
Ultrasound of the inferior vena cava (IVC) can be used as a part of volume status evaluation. IVC ultrasound
is an unreliable predictor of fluid responsiveness in spontaneously breathing patients.
Technique
Images of the IVC are obtained in long-axis with a curvilinear or cardiac transducer. It is important to
remember that the IVC changes diameter with respiration.
Inspiration Expiration
Spontaneous
breathing
Inspiration Expiration
Positive
pressure
ventilation
Change in the IVC diameter is measured with M mode, 2–3 cm distal to the junction of the hepatic vein
and IVC.
The IVC collapsibility index (CI) can be calculated as:
82
Limitations
Technical issues can affect the reproducibility of IVC measurements.
The IVC may be insonated on an oblique angle, introducing error into the diameter measurement.
Respirophasic movement of the IVC or inaccurate caliper placement can also affect the accuracy of CI
calculation.
Uses
IVC collapsibility and size does not reliably predict fluid responsiveness. In general, a narrow caliber IVC
(< 1.5 cm) with greater than 50% collapse suggests that a patient will tolerate IV fluid (i.e., their condition
will not worsen with fluid administration). Patients with a dilated IVC (> 2 cm) with < 50% collapse are
less likely to respond to fluid, but may still benefit. Results of the IVC scan should be integrated with lung
ultrasound and echo to assess the risk of pulmonary edema.
83
ASSESSING FLUID TOLERANCE

Ultrasound can help guide a plan for intravenous (IV) fluid resuscitation in the critically ill.
An integrated approach is most effective, with serial scans of the heart, lungs, and inferior vena cava (IVC).
Heart
Evaluate systolic function to assess the ability of the
left heart to use more preload. Patients with reduced
ejection fraction may benefit from IV fluid, but be less
tolerant of high-volume resuscitation. Examine the right
heart to assess its ability to tolerate fluid. Patients with
right ventricular overload (e.g., in massive pulmonary
embolus) may develop worsening hypotension with IV
fluid.
Lungs
Perform lung ultrasound to check for B lines, pleural
effusion, or consolidation. Serial scans can show the
development of pulmonary edema if B lines develop
with fluid administration.
IVC
Assess the IVC diameter and collapsibility. A small
(< 1.5 cm), collapsible IVC suggests fluid tolerance.
Consider the IVC results in light of the echo findings;
a patient with an obstructive cause of shock (e.g.,
pericardial effusion, pulmonary embolus) should
have pressure transmitted to the IVC, with increased
diameter and decreased collapse.
Practical approach
Perform point-of-care ultrasound for patients with suspected shock or critical illness on arrival in order to
obtain diagnostic information, and to shape your impression of volume status prior to resuscitation. Patients
with normal cardiac function, no B lines, and a small IVC should be fluid tolerant.
84
Limitations
Technical issues can affect the reproducibility of IVC measurements.
The IVC may be insonated on an oblique angle, introducing error into the diameter measurement.
Respirophasic movement of the IVC or inaccurate caliper placement can also affect the accuracy of CI
calculation.
Uses
IVC collapsibility and size does not reliably predict fluid responsiveness. In general, a narrow caliber IVC
(< 1.5 cm) with greater than 50% collapse suggests that a patient will tolerate IV fluid (i.e., their condition
will not worsen with fluid administration). Patients with a dilated IVC (> 2 cm) with < 50% collapse are
less likely to respond to fluid, but may still benefit. Results of the IVC scan should be integrated with lung
ultrasound and echo to assess the risk of pulmonary edema.
85
ESTIMATING CARDIAC OUTPUT

Cardiac output is the product of heart rate and stroke volume.
Stroke volume can be estimated by treating the left ventricular outflow tract (LVOT) as a cylinder, and
calculating the volume of blood ejected through the LVOT with each heartbeat. The cylinder base is the LVOT
diameter and the stroke distance that blood travels is the velocity-time integral (VTI).
LVOT
LVOT
diameter
Stroke distance
(VTI = velocity-time integral)
First, obtain a parasternal long-axis view of the heart

to measure the LVOT diameter.
Then obtain an apical five-chamber view of the

heart. Start from a four-chamber view, then tilt the
transducer anteriorly towards the chest wall. Place a
pulse wave Doppler sample gate in the LVOT.
86
Obtain a Doppler tracing. Use the ultrasound system

software to calculate the area under the curve of the
flow; this is the VTI. A typical VTI is 18–22 cm. Use
the average of several waveforms.
Calculate stroke volume,
((LVOT diameter)2 x 3.14)

Stroke volume = x VTI
4
Now you can calculate cardiac output,
Cardiac output = stroke volume x heart rate
87
PREDICTING FLUID RESPONSIVENESS

Point-of-care echocardiography can be used to predict whether a patient will increase cardiac output in
response to intravenous (IV) fluid administration.
A passive leg raise (PLR) allows a reversible autobolus that mobilizes volume from the legs and increases
preload (~300 mL).
Stroke volume
Fluid responsiveness can be predicted by measuring stroke volume before and after a PLR.
By treating the left ventricular outflow tract diameter as fixed, the calculation can be simplified to a
comparison of velocity-time integral (VTI) before and after PLR.
Perform a passive leg raise by taking a reclining patient to a supine position, and elevating their legs for 30
seconds.
A change in VTI of more than 15% after PLR predicts that a patient will be fluid responsive.
Aortic blood flow velocity

Respiratory variation of more than 12%, measured with pulse wave Doppler in an apical five-chamber view,
also indicates that a patient is likely to be fluid responsive.
88
FURTHER READING
Chapter 1
Chou, HC, Chong, KM, Sim, SS, et al. 2013. Real-time tracheal ultrasonography for confirmation of endotracheal
tube placement during cardiopulmonary resuscitation. Resuscitation. 84: 1708–1712.
Chou, HC, Tseng, WP, Wang, CH, et al. 2011. Tracheal rapid ultrasound exam (T.R.U.E.) for diagnosing endotracheal
tube placement during emergency intubation. Resuscitation. 82: 1279–1284.
Das, SK, Choupoo, NS, Haldar, R, et al. 2015. Transtracheal ultrasound for verification of endotracheal tube
placement: a systematic review and meta-analysis. Can J Anesth. 62: 413–423.
Siddiqui, N, Arzola, C, Friedman, Z, et al. 2015. Ultrasound improves cricothyrotomy success in cadavers with
poorly defined neck anatomy: a randomized controlled trial. Anesthesiology. 123: 1033–1041.
Sim, SS, Lien, WC, Chou, HC, et al. 2012. Ultrasonographic lung sliding sign in confirming proper endotracheal
intubation during emergency intubation. Resuscitation. 83: 307–312.
Tessaro, MO, Arroyo, AC, Haines, LE, et al. 2015. Inflating the endotracheal tube cuff with saline to confirm correct
depth using bedside ultrasonography. CJEM. 17: 94–98.
Tessaro, MO, Salant, EP, Arroyo, AC, et al. 2015. Tracheal rapid ultrasound saline test (T.R.U.S.T.) for confirming
correct endotracheal tube depth in children. Resuscitation. 89: 8–12.
Werner, SL, Smith, CE, Goldstein, JR, et al. 2007. Pilot study to evaluate the accuracy of ultrasonography in
confirming endotracheal tube placement. Ann Emerg Med. 49: 75–80.
Chapter 2
Corradi, F, Brusasco, C, and Pelosi, P. 2014. Chest ultrasound in acute respiratory distress syndrome.
Curr Opin Crit Care. 20: 98–103.
Nazerian, P, Volpicelli, G, Vanni, S, et al. 2015. Accuracy of lung ultrasound for the diagnosis of consolidations when
compared to chest computed tomography. Am J Emerg Med. 33: 620–625.
Pereda, MA, Chavez, MA, Hooper-Miele, CC, et al. 2015. Lung ultrasound for the diagnosis of pneumonia in
children: a meta-analysis. Pediatrics. 135: 714–722.
Reissig, A and Copetti, R. 2014. Lung ultrasound in community-acquired pneumonia and in interstitial lung
disease. Respiration. 87: 179–189.
Reissig, A, Copetti, R, Mathis, G, et al. 2012. Lung ultrasound in the diagnosis and follow-up of community-
acquired pneumonia: a prospective, multicenter, diagnostic accuracy study. Chest. 142: 965–972.
Tsung, JW, Kessler, DO, and Shah, VP. 2012. Prospective application of clinician-performed lung ultrasonography
during the 2009 H1N1 influenza A pandemic: distinguishing viral from bacterial pneumonia. Crit Ultrasound J.
4: 16.
89
Chapter 3
Adhikari, S, Fiorello, A, Stolz, L, et al. 2014. Ability of emergency physicians with advanced echocardiographic
experience at a single center to identify complex echocardiographic abnormalities. Am J Emerg Med. 32: 363-366.
Ehrman, RR, Russell, FM, Ansari, AH, et al. 2015. Can emergency physicians diagnose and correctly classify
diastolic dysfunction using bedside echocardiography? Am J Emerg Med. 33: 1178–1183.
Gaspari, R, Weekes, A, Adhikari, S, et al. 2016. Emergency department point-of-care ultrasound in out-of-hospital
and in-ED cardiac arrest. Resuscitation. 109: 33–39.
Gaspari, R, Weekes, A, Adhikari, S, et al. 2017. A retrospective study of pulseless electrical activity, bedside
ultrasound identifies interventions during resuscitation associated with improved survival to hospital admission. A
REASON study. Resuscitation. 120: 103–107.
Mallin, M and Dawson, M. 2013. Introduction to Bedside Ultrasound: Volume 2. First edition. I-Books: Emergency
Ultrasound Solutions.
Paulus, WJ, Tschöpe, C, Sanderson, JE, et al. 2007. How to diagnose diastolic heart failure: a consensus
statement on the diagnosis of heart failure with normal left ventricular ejection fraction by the Heart Failure and
Echocardiography Associations of the European Society of Cardiology. Eur Heart J. 28: 2539–2550.
Rudski, LG, Lai, WW, Afilalo, J, et al. 2010. Guidelines for the echocardiographic assessment of the right heart
in adults: a report from the American Society of Echocardiography endorsed by the European Assocation of
Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of
Echocardiography. J Am Soc Echocardiogr. 23: 685–713.
Chapter 4
Fields, MJ, Davis, J, Alsup, C, et al. 2017. Accuracy of point-of-care ultrasonography for diagnosing acute
appendicitis: a systematic review and meta-analysis. Acad Emerg Med. 24: 1124–1136.
Guttman, J, Stone, MB, Kimberly, HH, et al. 2015. Point-of-care ultrasonography for the diagnosis of small bowel
obstruction in the emergency department. CJEM. 17: 206–209.
Jang, TB, Schindler, D, and Kaji, AH. 2011. Bedside ultrasonography for the detection of small bowel obstruction in
the emergency department. Emerg Med J. 28: 676–678.
Mallin, M, Craven, P, Ockerse, P, et al. 2015. Diagnosis of appendicitis by bedside ultrasound in the ED. Am J Emerg
Med. 33: 430–432.
Riera, A, Hsiao, AL, Langhan, ML, et al. 2012. Diagnosis of intussusception by physician novice sonographers in the
emergency department. Ann Emerg Med. 60: 264–268.
Sivitz, AB, Cohen, SG, Tejani, C. 2014. Evaluation of acute appendicitis by pediatric emergency physician
sonography. Ann Emerg Med. 64: 358–364.
Sivitz, AB, Tejani, C, Cohen, SG. 2013. Evaluation of hypertrophic pyloric stenosis by pediatric emergency physician
sonography. Acad Emerg Med. 20: 646–651.
Taylor, MR and Lalani, N. 2013. Adult small bowel obstruction. Acad Emerg Med. 20: 528–544.
90
Chapter 5
Ablordeppey, EA, Drewry, AM, Beyer, AB, et al. 2017. Diagnostic accuracy of central venous catheter confirmation
by bedside ultrasound versus chest radiography in critically ill patients: a systematic review and meta-analysis.
Crit Care Med. 45: 715–724.
Fox, JC and Bertoglio, KC. 2011. Emergency physician performed ultrasound for DVT evaluation. Thrombosis.
2011: 938709.
Kinnaman, KA, Kimberly, HH, Pivetta, E, et al. 2016. Evaluation of the aortic arch from the suprasternal notch view
using focused cardiac ultrasound. J Emerg Med. 50: 643–650.
Nazerian, P, Vanni, S, Castelli, M, et al. 2014. Diagnostic performance of emergency transthoracic focus cardiac
ultrasound in suspected type A aortic dissection. Intern Emerg Med. 9: 665–670.
Nazerian, P, Vanni, S, Morello, F, et al. 2015. Diagnostic performance of focused cardiac ultrasound performed by
emergency physicians for the assessment of ascending aorta dilation and aneurysm. Acad Emerg Med.
22: 536–541.
Taylor, RA, Oliva, I, Van Tonder, R, et al. 2012. Point-of-care focused cardiac ultrasound for the assessment of
thoracic aorta dimensions, dilation, and aneurysmal disease. Acad Emerg Med. 19: 244–247.
Weekes, AJ, Johnson, DA, Keller, SM, et al. 2014. Central vascular catheter placement using saline flush and
bedside echocardiography. Acad Emerg Med. 21: 65–72.
Chapter 6
Adhikari, S and Blaivas, M. 2010. Utility of bedside sonography to distinguish soft tissue abnormalities from joint
effusions in the emergency department. J Ultrasound Med. 29: 519–526.
Chartier, LE, Bosco, L, Lapointe-Shaw, L, et al. 2017. Use of point-of-care ultrasound in long bone fractures:
a systematic review and meta-analysis. CJEM. 19: 131–142.
Kozaci, N, Ay, MO, Akcimen, M, et al. 2015. The effectiveness of bedside point-of-care ultrasonography in the
diagnosis and management of metacarpal fractures. Am J Emerg Med. 33: 1468–1472.
Marshburn, TH, Legome, E, Sargsyan, A, et al. 2004. Goal-directed ultrasound in the detection of long-bone
fractures. J Trauma. 57: 329–332.
Patel, DD, Blumberg, SM, and Crain, EF. 2009. The utility of bedside ultrasonography in identifying fractures and
guiding fracture reduction in children. Pediatr Emerg Care. 25: 221–225.
Vieira, RL and Levy, JA. 2010. Bedside ultrasonography to identify hip effusions in pediatric patients.
Ann Emerg Med. 55: 284–289.
Wu, TS, Roque, PJ, Green, J, et al. 2012. Bedside ultrasound evaluation of tendon injuries. Am J Emerg Med.
30: 1617–1621.
91
Chapter 7
American Institute of Ultrasound in Medicine. 2011. AIUM Practice Guideline for the Performance of Scrotal
Ultrasound Examinations. J Ultrasound Med. 30: 151–155.
Blaivas, M and Brannam, L. 2004. Testicular ultrasound. Emerg Med Clin North Am. 22: 723–748.
Dawson, M and Mallin, M. 2013. Introduction to Bedside Ultrasound: Volume 1. First edition. I-Books: Emergency
Ultrasound Solutions.
Keener, TS, Winter, TC, Nghiem, HV, et al. 1997. Normal adult epididymis: evaluation with color Doppler US.
Radiology. 202: 712–714.
Waldert, M, Klatte, T, Schmidbauer, J, et al. 2010. Color Doppler sonography reliably identifies testicular torsion in
boys. Urology. 75: 1170–1174.
Chapter 8
Barbier, C, Loubières, Y, Schmit, C, et al. 2004. Respiratory changes in inferior vena cava diameter are helpful in
predicting fluid responsiveness in ventilated septic patients. Intensive Care Med. 30: 1740–1746.
Cherpanath, TG, Hirsch, A, Geerts, BF, et al. 2016. Predicting fluid responsiveness by passive leg raising: a
systematic review and meta-analysis of 23 clinical trials. Crit Care Med. 44: 981–991.
Dinh, VA, Ko, HS, Rao, R, et al. 2012. Measuring cardiac index with a focused cardiac ultrasound examination in the
ED. Am J Emerg Med. 30: 1845–1851.
Feissel, M, Michard, F, Mangin, I, et al. 2001. Respiratory changes in aortic blood velocity as an indicator of fluid
responsiveness in ventilated patients with septic shock. Chest. 119: 867–873.
Jones, AE, Tayal, VS, Sullivan, DM, et al. 2004. Randomized, controlled trial of immediate versus delayed goal-
directed ultrasound to identify the cause of nontraumatic hypotension in the emergency department.
Crit Care Med. 39: 1703–1708.
Kanji, HD, McCallum, J, Sirounis, D, et al. 2014. Limited echocardiography-guided therapy in subacute shock is
associated with change in management and improved outcomes. J Crit Care. 29: 700–705.
Maizel, J, Airapetian, N, Lorne, E, et al. 2007. Diagnosis of central hypovolemia by using passive leg raising.
Intensive Care Med. 33: 1133–1138.
Nagdev, AD, Merchant, RC, Tirado-Gonzalez, A, et al. 2010. Emergency department bedside ultrasonographic
measurement of the caval index for noninvasive determination of low central venous pressure.
Ann Emerg Med. 55: 290–295.
92
COURSE
TITLE
APPENDIX
Teacher name
www.medmastery.com
Reference list
Ablordeppey, EA, Drewry, AM, Beyer, AB, et al. 2017. Diagnostic Accuracy of Central Venous Catheter Confir-
mation by Bedside Ultrasound Versus Chest Radiography in Critically Ill Patients: A Systematic Review and
Meta-Analysis. Crit Care Med. 45: 715–724. PMID: 27922877
Adhikari, S and Blaivas, M. 2010. Utility of bedside sonography to distinguish soft tissue abnormalities from
joint effusions in the emergency department. J Ultrasound Med. 29: 519–526. PMID: 20375371
Adhikari, S, Fiorello, A, Stolz, L, et al. 2014. Ability of emergency physicians with advanced echocardiograph-
ic experience at a single center to identify complex echocardiographic abnormalities. Am J Emerg Med. 32:
363-366. PMID: 24428984
American Institute of Ultrasound in Medicine. 2011. AIUM Practice Guideline for the Performance of Scrotal
Ultrasound Examinations. J Ultrasound Med. 30: 151–155. PMID: 21193719
Barbier, C, Loubières, Y, Schmit, C, et al. 2004. Respiratory changes in inferior vena cava diameter are help-
ful in predicting fluid responsiveness in ventilated septic patients. Intensive Care Med. 30: 1740–1746.
PMID: 15034650
Blaivas, M and Brannam, L. 2004. Testicular ultrasound. Emerg Med Clin North Am. 22: 723–748
PMID: 15301848
Chartier, LB, Bosco, L, Lapointe-Shaw, L, et al. 2017. Use of point-of-care ultrasound in long bone fractures: a
systematic review and meta-analysis. CJEM. 19: 131–142. PMID: 27916021
Cherpanath, TG, Hirsch, A, Geerts, BF, et al. 2016. Predicting Fluid Responsiveness by Passive Leg Raising: A
Systematic Review and Meta-Analysis of 23 Clinical Trials. Crit Care Med. 44: 981–991. PMID: 26741579
Chou, HC, Chong, KM, Sim, SS, et al. 2013. Real-time tracheal ultrasonography for confirmation of endotra-
cheal tube placement during cardiopulmonary resuscitation. Resuscitation. 84: 1708–1712. PMID: 23851048
Chou, HC, Tseng, WP, Wang, CH, et al. 2011. Tracheal rapid ultrasound exam (T.R.U.E.) for confirming endo-
tracheal tube placement during emergency intubation. Resuscitation. 82: 1279–1284. PMID: 21684668
Corradi, F, Brusasco, C and Pelosi, P. 2014. Chest ultrasound in acute respiratory distress syndrome. Curr
Opin Crit Care. 20: 98–103. PMID: 24247614
Das, SK, Choupoo, NS, Haldar, R, et al. 2015. Transtracheal ultrasound for verification of endotracheal tube
placement: a systematic review and meta-analysis. Can J Anesth. 62: 413–423. PMID: 25537734
94
Dawson, M and Mallin, M. 2013. Introduction to Bedside Ultrasound: Volume 1. 1st edition. I-Books: Emergen-
cy Ultrasound Solutions. https://books.apple.com/us/book/introduction-to-bedside-ultrasound-volume-1/
id554196012
Dinh, VA, Ko, HS, Rao, R, et al. 2012. Measuring cardiac index with a focused cardiac ultrasound examination in
the ED. Am J Emerg Med. 30: 1845–1851. PMID: 22795411
Ehrman, RR, Russell, FM, Ansari, AH, et al. 2015. Can emergency physicians diagnose and correctly classify dia-
stolic dysfunction using bedside echocardiography? Am J Emerg Med. 33: 1178–1183. PMID: 26058890
Feissel, M, Michard, F, Mangin, I, et al. 2001. Respiratory changes in aortic blood velocity as an indicator of fluid
responsiveness in ventilated patients with septic shock. Chest. 119: 867–873. PMID: 11243970
Fields, JM, Davis, J, Alsup, C, et al. 2017. Accuracy of Point-of-care Ultrasonography for Diagnosing Acute Ap-
pendicitis: A Systematic Review and Meta-analysis. Acad Emerg Med. 24: 1124–1136. PMID: 28464459
Fox, JC and Bertoglio, KC. 2011. Emergency Physician Performed Ultrasound for DVT Evaluation. Thrombosis.
2011: 938709. PMID: 22084671
Gaspari, R, Weekes, A, Adhikari, S, et al. 2016. Emergency department point-of-care ultrasound in out-of-hospi-
tal and in-ED cardiac arrest. Resuscitation. 109: 33–39. PMID: 27693280
Gaspari, R, Weekes, A, Adhikari, S, et al. 2017. A retrospective study of pulseless electrical activity, bedside ul-
trasound identifies interventions during resuscitation associated with improved survival to hospital admission.
A REASON study. Resuscitation. 120: 103–107. PMID: 28916478
Guttman, J, Stone, MB, Kimberly, HH, et al. 2015. Point-of-care ultrasonography for the diagnosis of small bow-
el obstruction in the emergency department. CJEM. 17: 206–209. PMID: 25927264
Jang, TB, Schindler, D and Kaji, AH. 2011. Bedside ultrasonography for the detection of small bowel obstruction
in the emergency department. Emerg Med J. 28: 676–678. PMID: 20732861
Jones, AE, Tayal, VS, Sullivan, DM, et al. 2004. Randomized, controlled trial of immediate versus delayed
goal-directed ultrasound to identify the cause of nontraumatic hypotension in the emergency department. Crit
Care Med. 32: 1703–1708. PMID: 15286547
Kanji, HD, McCallum, J, Sirounis, D, et al. 2014. Limited echocardiography-guided therapy in subacute shock is
associated with change in management and improved outcomes. J Crit Care. 29: 700–705. PMID: 24857642
Keener, TS, Winter, TC, Nghiem, HV, et al. 1997. Normal adult epididymis: evaluation with color Doppler US. Ra-
diology. 202: 712–714. PMID: 9051022
95
Kinnaman, KA, Kimberly, HH, Pivetta, E, et al. 2016. Evaluation of the Aortic Arch from the Suprasternal Notch
View Using Focused Cardiac Ultrasound. J Emerg Med. 50: 643–650. PMID: 26830361
Kozaci, N, Ay, MO, Akcimen, M, et al. 2015. The effectiveness of bedside point-of-care ultrasonography in the di-
agnosis and management of metacarpal fractures. Am J Emerg Med. 33: 1468–1472. PMID: 26175338
Maizel, J, Airapetian, N, Lorne, E, et al. 2007. Diagnosis of central hypovolemia by using passive leg raising. In-
tensive Care Med. 33: 1133–1138. PMID: 17508202
Mallin, M, Craven, P, Ockerse, P, et al. 2015. Diagnosis of appendicitis by bedside ultrasound in the ED. Am J
Emerg Med. 33: 430–432. PMID: 25559314
Mallin, M and Dawson, M. 2013. Introduction to Bedside Ultrasound: Volume 2. 1st edition. I-Books: Emergen-
cy Ultrasound Solutions. https://books.apple.com/us/book/introduction-to-bedside-ultrasound-volume-2/
id647356692
Marshburn, TH, Legome, E, Sargsyan, A, et al. 2004. Goal-directed ultrasound in the detection of long-bone
fractures. J Trauma. 57: 329–332. PMID: 15345981
Nagdev, AD, Merchant, RC, Tirado-Gonzalez, A, et al. 2010. Emergency department bedside ultrasonographic
measurement of the caval index for noninvasive determination of low central venous pressure. Ann Emerg Med.
55: 290–295. PMID: 19556029
Nazerian, P, Vanni, S, Castelli, M, et al. 2014. Diagnostic performance of emergency transthoracic focus cardiac
ultrasound in suspected type A aortic dissection. Intern Emerg Med. 9: 665–670. PMID: 24871637
Nazerian, P, Vanni, S, Morello, F, et al. 2015. Diagnostic performance of focused cardiac ultrasound performed
by emergency physicians for the assessment of ascending aorta dilation and aneurysm. Acad Emerg Med. 22:
536–541. PMID: 25899650
Nazerian, P, Volpicelli, G, Vanni, S, et al. 2015. Accuracy of lung ultrasound for the diagnosis of consolidations
when compared to chest computed tomography. Am J Emerg Med. 33: 620–625. PMID: 25758182
Patel, DD, Blumberg, SM and Crain, EF. 2009. The utility of bedside ultrasonography in identifying fractures and
guiding fracture reduction in children. Pediatr Emerg Care. 25: 221–225. PMID: 19382318
Paulus, WJ, Tschöpe, C, Sanderson, JE, et al. 2007. How to diagnose diastolic heart failure: a consensus
statement on the diagnosis of heart failure with normal left ventricular ejection fraction by the Heart Fail-
ure and Echocardiography Associations of the European Society of Cardiology. Eur Heart J. 28: 2539–2550.
PMID: 17428822
Pereda, MA, Chavez, MA, Hooper-Miele, CC, et al. 2015. Lung ultrasound for the diagnosis of pneumonia in chil-
dren: a meta-analysis. Pediatrics. 135: 714–722. PMID: 25780071
96
Reissig, A and Copetti, R. 2014. Lung ultrasound in community-acquired pneumonia and in interstitial lung dis-
ease. Respiration. 87: 179–189. PMID: 24481027
Reissig, A, Copetti, R, Mathis, G, et al. 2012. Lung ultrasound in the diagnosis and follow-up of commu-
nity-acquired pneumonia: a prospective, multicenter, diagnostic accuracy study. Chest. 142: 965–972.
PMID: 22700780
Riera, A, Hsiao, AL, Langhan, ML, et al. 2012. Diagnosis of intussusception by physician novice sonographers in
the emergency department. Ann Emerg Med. 60: 264–268. PMID: 22424652
Rudski, LG, Lai, WW, Afilalo, J, et al. 2010. Guidelines for the echocardiographic assessment of the right heart
in adults: a report from the American Society of Echocardiography endorsed by the European Association of
Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of
Echocardiography. J Am Soc Echocardiogr. 23: 685–713. PMID: 20620859
Siddiqui, N, Arzola, C, Friedman, Z, et al. 2015. Ultrasound Improves Cricothyrotomy Success in Cadav-
ers with Poorly Defined Neck Anatomy: A Randomized Controlled Trial. Anesthesiology. 123: 1033–1041.
PMID: 26352376
Sim, SS, Lien, WC, Chou, HC, et al. 2012. Ultrasonographic lung sliding sign in confirming proper endotracheal
intubation during emergency intubation. Resuscitation. 83: 307–312. PMID: 22138058
Sivitz, AB, Cohen, SG and Tejani, C. 2014. Evaluation of acute appendicitis by pediatric emergency physician so-
nography. Ann Emerg Med. 64: 358–364. PMID: 24882665
Sivitz, AB, Tejani, C and Cohen, SG. 2013. Evaluation of hypertrophic pyloric stenosis by pediatric emergency
physician sonography. Acad Emerg Med. 20: 646–651. PMID: 23781883
Taylor, MR and Lalani, N. 2013. Adult small bowel obstruction. Acad Emerg Med. 20: 528–544. PMID: 23758299
Taylor, RA, Oliva, I, Van Tonder, R, et al. 2012. Point-of-care focused cardiac ultrasound for the assessment of
thoracic aorta dimensions, dilation, and aneurysmal disease. Acad Emerg Med. 19: 244–247. PMID: 22288871
Tessaro, MO, Arroyo, AC, Haines, LE, et al. 2015. Inflating the endotracheal tube cuff with saline to confirm cor-
rect depth using bedside ultrasonography. CJEM. 17: 94–98. PMID: 25781388
Tessaro, MO, Salant, EP, Arroyo, AC, et al. 2015. Tracheal rapid ultrasound saline test (T.R.U.S.T.) for confirming
correct endotracheal tube depth in children. Resuscitation. 89: 8–12. PMID: 25238740
Tsung, JW, Kessler, DO and Shah, VP. 2012. Prospective application of clinician-performed lung ultrasonog-
raphy during the 2009 H1N1 influenza A pandemic: distinguishing viral from bacterial pneumonia. Crit Ultra-
sound J. 4: 16.PMID: 22862998
97
Vieira, RL and Levy, JA. 2010. Bedside ultrasonography to identify hip effusions in pediatric patients. Ann Emerg
Med. 55: 284–289. PMID: 19695738
Waldert, M, Klatte, T, Schmidbauer, J, et al. 2010. Color Doppler sonography reliably identifies testicular torsion
in boys. Urology. 75: 1170–1174. PMID: 19913882
Weekes, AJ, Johnson, DA, Keller, SM, et al. 2014. Central vascular catheter placement using saline flush and
bedside echocardiography. Acad Emerg Med. 21: 65–72. PMID: 24552526
Werner, SL, Smith, CE, Goldstein, JR, et al. 2007. Pilot study to evaluate the accuracy of ultrasonography in con-
firming endotracheal tube placement. Ann Emerg Med. 49: 75–80. PMID: 17014927
Wu, TS, Roque, PJ, Green, J, et al. 2012. Bedside ultrasound evaluation of tendon injuries. Am J Emerg Med. 30:
1617–1621. PMID: 22244220
98

Medmastery POCUS Masterclass Handbook - 0

Uploaded by

Copyright:

Available Formats

Medmastery POCUS Masterclass Handbook - 0

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Medmastery POCUS Masterclass Handbook - 0

Uploaded by

Copyright:

Available Formats

COURSE

Volume status and fluid responsiveness

RECOGNIZING WHEN TO USE

There are two scenarios when we might use airway ultrasound

A surgical airway is an uncommon procedure. It Ultrasound allows rapid assessment of tube

2. Visualize esophageal placement

Airway ultrasound allows an operator to see

Left lung Right lung Interpretation

Sliding Sliding Correct position

Lung pulse Sliding Right mainstem intubation

Lung pulse Lung pulse Esophageal placement

Real time guidance

Cricothyroid membrane Cricoid cartilage

MOVING BEYOND THE BASICS

• pneumothorax • pleural effusion • sonographic B lines

Advanced lung ultrasound

Advanced lung ultrasound allows us to diagnose more entities

Pneumonia Viral respiratory Interstitial Acute respiratory Traumatic

Successful use of lung ultrasound requires a user to consider

• Presence of findings • Pre-test probability for a

With the transducer in a vertical orientation,

A good general approach includes:

This allows you to confirm and refine your initial

Normal pleura Pleural irregularity

Shred sign Empyema Subpleural consolidation

Common lung ultrasound findings in viral respiratory infections

Distinguishing viral and bacterial infections

• Focal abnormality • Diffuse abnormalities

EVALUATING FOR OTHER

Pulmonary embolism Acute respiratory Pulmonary contusion Influenza

Acute respiratory distress syndrome (ARDS)

ARDS (%) Pulmonary edema (%)

B lines 100 100

Irregular pleura 100 25

Reduced lung sliding 100 0

Spared areas 100 0

AVOIDING POTENTIAL PITFALLS

Not considering the context

Not obtaining more imaging

Overdiagnosing the image

Not examining all of the chest

Stopping the search

Not adjusting depth

Forgetting the thymus

Not considering other clinicians

MOVING BEYOND THE BASICS

Advanced point-of-care echocardiography applications:

Cardiac arrest Endocarditis Valve assessment

Right-heart function Cardiac tamponade Diastolic function Wall motion abnormalities

Advanced echo applications are among the most

2. Consider the pre-test probability of a disease when interpreting your results.

4. Point-of-care echo findings are typically more specific than sensitive.

Medical cardiac arrest

No activity supports the decision to terminate spontaneous circulation, or if there is no pulse

Traumatic cardiac arrest

Late diastolic Early diastolic

Inferior vena cava (IVC)

RECOGNIZING REGIONAL WALL

To recognize a WMA, it can be helpful to imagine