Ultrasound-Guided Procedures in the

Emergency Department—Diagnostic and

Therapeutic Asset
Alfredo Tirado, MDa,*, Teresa Wu, MDb, Vicki E. Noble, MD
c
,
Calvin Huang, MD, MPHc, Resa E. Lewiss, MDd,
Jennifer A. Martin, MDd, Michael C. Murphy, MDe,
Adam Sivitz, MDf

KEYWORDS
 Ultrasound  Procedures  Pericardiocentesis  Abscess  Lumbar puncture
 Paracentesis  Arthrocentesis  Thoracentesis

KEY POINTS
 Correct orientation of the probe is paramount for procedural ultrasound (ie, aligning the
probe marker with the on-screen logo).
 Ultrasound is a diagnostic modality that can aid in the therapeutic intervention of some
serious conditions such as pericardial tamponade, pleural effusions, and massive ascites.
 It is important for the user to pay close attention to the trajectory of the needle in all
ultrasound-guided procedures. This ensures accuracy and reduces error.

ULTRASOUND-GUIDED PERICARDIOCENTESIS
Background
When patients are suspected of having a life-threatening pericardial effusion and
cardiac tamponade, prompt diagnosis and treatment are imperative to improve chan-
ces of survival. Making the diagnosis of a pericardial effusion is often difficult based on

Disclosure: None.
a
Department of Emergency Medicine, Florida Hospital-East Orlando, 7727 Lake Underhill
Road, Orlando, FL 32822, USA; b EM Residency Program, Department of Emergency Medicine,
Maricopa Medical Center, College of Medicine, University of Arizona, 2601 E. Roosevelt Street,
Phoenix, AZ 85008, USA; c Emergency Ultrasound Division, Department of Emergency Medi-
cine, Massachusetts General Hospital, Harvard University, 55 Fruit Street E00-3-B, Boston, MA
02114–2696, USA; d Emergency Ultrasound Division, Department of Emergency Medicine, St
Luke’s Roosevelt Hospital Center, 1111 Amsterdam Avenue, New York, NY 10025, USA;
e
Department of Emergency Medicine, Harvard Medical School, Mount Auburn Hospital, 330
Mount Auburn Street, Cambridge, MA 02138, USA; f Newark Beth Israel Medical Center and
The Children’s Hospital of New Jersey, Pediatric Emergency Medicine Fellowship, University of
Medicine and Dentistry of New Jersey, 201 Lyons Avenue, Newark, NJ 07112, USA
* Corresponding author.
E-mail address: [email protected]

Emerg Med Clin N Am 31 (2013) 117–149

http://dx.doi.org/10.1016/j.emc.2012.09.009 emed.theclinics.com
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 US Guided procedures in ED 123

Fig. 9. White arrow demonstrates comet tail artifact between the 2 pleural surfaces.

 To maximize the collection of pericardial fluid available for aspiration, gently roll
the patient over toward his or her left side. The pericardial fluid should settle near
the apex of the heart for an ultrasound-guided para-apical pericardiocentesis
attempt.

ULTRASOUND-GUIDED THORACENTESIS AND PARACENTESIS

Background
Thoracentesis and paracentesis are necessary for both diagnostic and therapeutic
reasons. Both procedures are performed at the bedside by the clinician, traditionally
using either physical examination findings or radiology-performed imaging to guide
skin puncture. Point of care ultrasound not only can make the diagnosis of pleural effu-
sions and ascites more accurately than physical examination and portable radio-
graphs but also can help to guide the needle placement and can speak to the
feasibility of the procedure in general. Indeed, there is ample evidence that ultrasound
allows for real-time, accurate guidance and has the ability to decrease
complications.8,9

Indications
Pleural effusions can be either unilateral or bilateral and can stem from multiple
processes including heart failure, malignancy, infection, and hemorrhage. When an
effusion accumulates enough volume, it can cause mass effect on the lung and dia-
phragm, leading to shortness of breath, pleurisy, and sometimes chest pain. Although
chest radiography can demonstrate the presence of an effusion, it does not show the
extent of diaphragm excursion or depth of the fluid pocket and cannot reveal lung/
pleural adhesions—all of which can be seen with bedside ultrasound. In addition,
chest radiography can be misleading if the patient is supine, whereas ultrasound is
very accurate in supine patients. This can be particularly helpful in ventilated
patients.10 Thoracentesis can sample the pleural fluid for analysis, providing a diag-
nosis. Furthermore, removal of a volume of fluid will improve the patient’s ventilatory
mechanics and provide symptomatic relief.
Ascitic fluid is often the result of hepatic disease, which leads to portal hypertension
and a hypoproteinemic state. Malignancy and hemorrhage are 2 other causes of
124 Tirado et al

abdominal free fluid. When much fluid accumulates, it can lead to a mass effect on the
abdominal wall and on the diaphragm. This causes abdominal discomfort and can
also lead to shortness of breath and decreased exercise tolerance. In rare cases,
when abdominal pressures build high enough, right heart filling can be impaired as
a result of compression of the inferior vena cava. Furthermore, ascitic fluid can
become infected as a result of bowel flora translocation, thus leading to spontaneous
bacterial peritonitis. Spontaneous bacterial peritonitis may be suspected when
patients with known ascites present with signs of infection including, fever, leukocy-
tosis, abdominal pain, and altered mental status. Diagnostic paracentesis and analysis
of the fluid are essential to making this diagnosis. Large-volume paracentesis can
provide symptomatic relief for patients. Bedside ultrasound can confirm the presence
or absence of abdominal free fluid and can help to identify a fluid pocket of adequate
depth for sampling. Furthermore, large vessels in the abdominal wall can be visualized
and avoided. Finally, omental and bowel adhesions to the peritoneum can be
identified.

Anatomy and Imaging

The pleural cavity is formed by a continuous membranous lining that surrounds and
adheres to the lung parenchyma (visceral pleura) and the interior of the chest wall
(parietal pleura). Normally, the pleural cavity has a scant lubricating layer of fluid
that is too small to be visualized directly with ultrasound. As the visceral and parietal
layers rub against one another with lung expansion, the surfaces slide against one
another (ie, lung sliding). Furthermore, in normal lungs, there may be a “comet tail arti-
fact,” which is thought to represent reverberation artifact created by small microbub-
bles of fluid between the 2 pleural surfaces (Fig. 10). Pleural fluid can be seen above
the liver or spleen in the mid-axillary line with the patient supine (Fig. 11) and is noted
when there is a loss of the mirror image artifact (normally caused by the reflection of
the diaphragm and the lack of sound reflection from the aerated lung) or when there is
the continuation of the spinal shadow above the diaphragm when there is fluid in the
thoracic cavity that can transmit ultrasound. It is also possible to see fluid in the poste-
rior mid scapular line with the patient upright-seated position, and this is demon-
strated as a black anechoic space separating the visceral and parietal pleura
(Fig. 12). Below each rib runs the intercostal neurovascular bundle; because this is

Fig. 10. Comet trail reverberation artifact artifact demonstrated by arrow.

 US Guided procedures in ED 125

Fig. 11. Pleural fluid in mid-axillary line with patient in supine position.

hidden under the curvature of each rib, it will not normally be visualized
sonographically.
The abdominal contents are covered by a membranous layer that adheres to the
interior of the abdominal wall called the peritoneum. Running just above the peritoneal
layer is the inferior epigastric artery—this should be identified and avoided when ultra-
sound is used to guide needle placement (Fig. 13). Free fluid in the abdomen is gravity
dependent and will accumulate in the recesses between organs, specifically the hep-
atorenal (Morrison), splenorenal, and retrovesicular spaces. A minimum of about 250
mL of fluid can be sonographically visualized.11 As the volume increases, the rest of
the abdomen will fill with fluid and the peritoneum will be lifted off of the bowels.

Fig. 12. Pleural fluid obtain by placing patient in upright position, with anechoic pace
between visceral from parietal pleura.
126 Tirado et al

Fig. 13. Doppler image demonstrating inferior epigastric artery.

The fluid will appear as an anechoic region between the peritoneum and solid organs
(Fig. 14).

Technique
Thoracentesis and paracentesis can be performed by aspirating fluid with a medium-
gauge needle and syringe. More commonly, catheter-introducer kits are used; these
kits will include either a plastic or a metal catheter sheathed over a longer introducer
needle.
Both thoracentesis and paracentesis can be performed with ultrasound imaging,
occurring preprocedurally or in real-time guidance. With either technique, the patient
should be positioned with the ultrasound directly visible in the operator’s line of sight
(Fig. 15). It is important not to change the patient’s position after marking the point of
entry, because this can shift the pocket of fluid and move bowel into the path of the
needle trajectory.

Fig. 14. Fluid appears anechoic (black) between the viscera in the peritoneal cavity.
 US Guided procedures in ED 127

Fig. 15. Ultrasound system position, visible to the operator’s line of sight.

When performing thoracentesis, first review relevant cell counts and coagulation
factors and any prior imaging. The patient should ideally be placed in a seated posi-
tion. This position will allow the gravity-dependent fluid to accumulate caudally and
will also increase the distance between the pleural lining and the lung. Furthermore,
large effusions tend to cause orthopnea, and as such, some patients may be unable
to tolerate a supine or prone position. A high-frequency linear probe or a low-
frequency curvilinear probe can be used for this procedure depending on operator
preference and patient body habitus. As with any ultrasound application, the high-
frequency linear probe will provide superior picture quality of the superficial structures
but may be insufficient to visualize the lung parenchyma. The effusion and the dia-
phragm should be visualized and the skin marked. After sterile prep and drape, the
skin should be anesthetized. The needle should be directed toward the rib, orthogonal
to the skin surface, and the soft tissue should be infiltrated as the needle is passed. To
ensure that the intercostal neurovascular bundle inferior to the rib is not injured, the tip
of the needle should first touch the rib periosteum and then should be directed slightly
cephalad until the rib is passed. This will ensure the track is immediately superior to
the rib. After the pleural space is entered, the anesthetic needle can be withdrawn.
A small skin incision is then made with a scalpel so that the larger introducer needle
can be passed. While holding suction with the dominant hand, pass through the
soft tissue along the same track. Once pleural fluid is expressed, advance the catheter
off of the introducer needle, taking care to not advance the needle any farther into the
body cavity. Once the catheter is within the effusion, the needle can be withdrawn
completely and fluid can be removed. After the sampling is complete, the catheter
can be withdrawn. Having the patient perform the Valsalva movement during this
time will increase the intrathoracic pressure and reduce the chance of
pneuomothorax.
128 Tirado et al

When performing paracentesis, first review relevant laboratory data, including

platelet count and coagulation factors. The patient can be placed in a right or left
lateral decubitus position to maximize the fluid pocket. Begin by looking at the lower
quadrants and identify the largest collection. The omentum and bowel loops should be
visible in the far field. Next, scan the overlying abdominal wall for the epigastric
vessels. Depending on body habitus, it may be helpful to switch to a high frequency
(5–10 MHz) linear probe for vessel identification. The skin can then be marked for
puncture, taking care to select an area away from the vessels. Sterilely prep and drape
the skin. Perform soft tissue anesthesia with a smaller-gauge needle. Following this,
a small skin incision can be made to help pass the larger introducer needle. In patients
with tense ascites, it is often prudent to ensure that the puncture to the peritoneal
cavity and the skin puncture not be in parallel, to prevent fistula formation. Holding
suction with the dominant hand, pass the introducer needle through the soft tissue.
Once fluid is expressed, thread the catheter into the peritoneum, taking care to not
advance the needle any farther. Once the catheter is in place, the needle can be with-
drawn and the fluid sampled.

Pitfalls
 When performing paracentesis, be sure to scan in multiple orientations when
identifying the inferior epigastric arteries. If the probe axis is parallel to the vessel,
the vessel may have similar appearance to a soft tissue plane. Additionally, if
color Doppler is being used to identify vascular structures and if the probe is
exactly perpendicular to the vessel, no color signal will be generated.
 When performing thoracentesis or paracentesis, the parietal pleura/peritoneal
layer has the most innervation and may be the greatest source of discomfort
when passing the catheter. When anesthetizing with the smaller-gauge needle
after the fluid pocket is entered, consider withdrawing the needle slightly so
that it is in close proximity to the membranous layer and depositing several milli-
liters of anesthetic agent.
 When performing skin puncture with the catheter-introducer needle for paracent-
esis, the nondominant hand can be used to hold skin tension orthogonal to the
puncture site. This will create a “z-track,” which will decrease postprocedural
leaking.
 Both procedures have “traditional” landmarks and positioning, which do not
necessarily apply when ultrasound is used. A large pleural effusion can be ac-
cessed with the patient recumbent if visualized in real-time. Abdominal free fluid
can also be tapped with a patient supine as opposed to in a decubitus position.
 The lung and diaphragm are dynamic structures. Make sure you observe the full
extent of excursion with the respiratory cycle.
 The intercostal neurovascular bundle is typically hidden inferior and proximal to
the rib and usually cannot be visualized. The typical approach of needle insertion
just cephalad to the rib will avoid vessel injury. However, anatomy can vary and
thus it is important to examine the planned procedural site closely for anomalous
vessels.
 Removal of large volumes may cause fluid shifts that can lead to patient insta-
bility. The traditional recommendation is to use caution when draining more
than 1 L via thoracentesis, because this may lead to reexpansion pulmonary
edema. However, there are recent studies that do not show an increased
risk.12,13 Removal of 8 L via paracentesis is considered large volume and this
may lead to tachycardia and hypotension. Intravascular replacement with crys-
talloid and/or colloid is advisable.14