Sonography in the Critical Patient

A medical crisis requiring the diagnosis and documentation of internal injury requires the use of multiple imaging modalities. Computed tomography (CT) and magnetic resonance imaging (MRI) both provide the clinician with images allowing for diagnosis of fluid or blood within the chest and abdomen.  Both modalities require placement of the stable patient into the imaging gantry. In the case of the acutely ill or a trauma, the patient cannot leave the emergency department (ED) or intensive care unit (ICU). The portability of an ultrasound system allows for image acquisition at the patient’s bedside is an aid for diagnosis with minimal patient movement.    There are multiple types of ultrasound exams for emergency care which include focused abdominal sonography for trauma (FAST), the extended FAST (eFAST), rapid ultrasound in shock (RUSH), focused cardiac ultrasound (FOCUS), focus assessed transthoracic echo (FATE), and bedside lung ultrasound in emergency (BLUE) exam. Within this course you will find a high-level summary of the RUSH, FOCUS, FATE, and BLUE exams to provide you with an overview of these protocols. This course focuses on the anatomy, protocols, and sonographic appearance of fluid or blood within the chest and abdomen for FAST and eFAST exams.   Congratulations! You have completed the Sonography in the Critical Patient course. Listed below are the key points presented in this course. Take time to review the material before you try the final assessment.   Download and print a copy of the detailed Course Review.   In this course you have learned to:        Describe imaged anatomy and transducer placement used when assessing the critical patent.        Explain the sonographic appearance of fluid and blood within the abdomen and chest. View these instructions for information on navigating through the self-evaluation tools we call ‘Your Turns’. Click the icon below to start the self-evaluation exercise. Note: This is not part of the final Assessment. Learn how to navigate the Your Turns Learn how to navigate the Your Turns. Instructions:Flash File:HTML5 File:/content/generator/Course_90023134/Navigation_Instructions/index.htmlPDF File: Upon completion of the course you will be able to:      Describe imaged anatomy and transducer placement used when assessing the critical patent.      Explain the sonographic appearance of fluid and blood within the abdomen and chest.  Sonographic views included in protocols for determining the presence of fluid or blood in the critical patient include the lungs, heart chambers, IVC (inferior vena cava), liver, kidneys, spleen, and pelvic organs.  Each has a unique normal sonographic appearance allowing for identification of abnormalities either within or surrounding the targeted anatomy. We begin with a discussion of intraperitoneal and intrathoracic anatomy as seen on the sonographic image.  Ultrasound of the heart helps identify the presence of pericardial fluid, chamber size and global heart function. The views used during a cardiac exam in the critical patient, mirror images obtained in most echocardiographic studies.   Image orientation for echocardiographic has the right side of the heart on the right side of the sector and the left side of the heart on the left side of the image. This corresponds to the heart situs in the body. Explore the links below for a discussion of intracardiac anatomy seen on the sonographic image.  Learn More about Heart Anatomy Learn more about heart anatomy.1 Tab TitleTextApical Four-chamber Anatomy This image of the heart is the apical four-chamber view. The transducer placement on the chest allows for imaging from the apex to the base of the heart showing all four heart chambers. In this image you see the left ventricle (asterisk) and the left atrium (circle) on the right side of the image. The right atrium (triangle) lies superior to the right ventricle which has the linear tendinous cords tricuspid (double arrows) attached to the valve. Subcostal Four-chamberThe subcostal or subxiphoid four-chamber view is part of the FAST, eFAST, and FATE protocols. There are no obstructions, such as the lung or sternum, to hinder imaging making it a relatively easy image to obtain. In this view, fluid collects in the dependent areas of the pericardial sac. If a large amount of fluid compressing the heart restricts the amount of expansion of the right ventricle restricting pulmonary flow and blood oxygen levels. Called tamponade, the decrease in cardiac output which may result in organ failure. The subcostal view allows assessment of the heart chambers and any fluid collections above and below the diaphragm.2 This image shows how the right ventricle lies between the liver (arrow) and left ventricle (circle). The two atria image on the right side of the sector.  The image orientation for this view has the apex of the heart to the left and the base towards the right. The transducer notch angles toward the patient’s left shoulder corresponding to the image icon.  Parasternal Long Axis The parasternal long axis view of the heart begins with obliquely positioning the transducer between the third and fourth rib. Place the transducer on the anterior chest as close to the xiphoid as possible. The orientation notch is towards the patient’s right shoulder. This image shows the right ventricle (circle), left ventricle (double arrows), aortic root (asterisk), left atrium (triangle) and descending aorta (open arrow).   Fluid seen between the left atrium and descending aorta helps differentiate pericardial fluid from a pleural effusion.  Parasternal Short Axis The parasternal short axis shows images the heart in a cross-section perpendicular or 90-degrees to the long axis.  Angle the transducer marker towards the left shoulder after rotating from the long axis of the heart. Depending on the level, this view shows anatomy from the apex to the base of the heart. Real-time assessment allows observation of heart contraction and any fluid seen in the pericardial sac. The mid-ventricle view, at the level of the papillary muscles, is the most useful in a trauma patient. From the transthoracic approach the right ventricle (asterisk) has an anterior position while the left (circle) ventricle images with thicker walls. A small amount of pericardial fluid (arrow) images posterior to the heart. Learn More with Cardiac Videos Learn more with cardiac videos. Tab TitleTextApical Four-chamberSubcostal Four-chamberParasternal Long AxisParasternal Short Axis Your Turn Your Turn. Instructions:Flash File:HTML5 File:/content/generator/Course_90023134/socp-your-turn-01/index.htmlPDF File: In the patient with either volume depletion or volume overload, the IVC diameter increases or decreases from the normal size. The inferior vena cava has a normal anterior to posterior linear measurement between 1.5 to 2.5 centimeters with inspiration.4 Measure the distance approximately three centimeters inferior to the right atrium on the longitudinal midline.   In this diagram you can see the IVC coursing deep to the liver when imaging from the anterior abdomen. The hepatic veins empty into the upper IVC providing a landmark for measurement for the caval index.3   Explore the link below to learn more about measuring the IVC and calculating the caval index.  Learn More about Measuring the IVC Learn more about measuring the IVC. Tab TitleTextNormal Width Measure the IVC distance on a longitudinal plane approximately three centimeters inferior to the right atrium.4, 5 Place the transducer slightly inferior to the xiphoid with the IVC centered. This image, taken at expiration, shows an IVC measurement of 2.5 centimeters.   Measure the AP IVC diameter perpendicular to the vessel rather than the central ultrasound beam. Caval Index4, 5  When the patient inhales or sniffs, the normal IVC diameter reduces by 50 percent or more in the supine patient.  To calculate the caval index, simply use the following formula:   IVC expiration diameter – IVC inspiration diameter   X 100                      IVC expiration diameter IVC expiration  = 25.2 IVC inspiration = 20.1   CI = (25.2 – 20.1 / 20.1) x 100     = (5.1 / 20.1) x 100     = 0.2536 x 100     = 25.36 or a 25.36 percent collapse M-mode An alternate method to measure the IVC distance is to use the M-mode feature on the ultrasound system.4 The IVC images as an anechoic linear area (arrow) on the M-mode tracing.  Simply measure from the anterior to posterior wall in both inspiration and expiration to obtain measurements to calculate the caval index.   Use anatomical M-mode (AMM) to align the M-line independent of transducer angle and increase temporal resolution. IVC Video The abdominal exam, performed after trauma, includes imaging of four abdominopelvic regions; the epigastric (1), right and left lumbar (2 and 3), and hypogastrium (4). In the post trauma patient, we may see anechoic fluid in one to four areas dependent on both the severity and location of hemorrhage. This diagram shows the location for transducer placement during an exam of the abdomen in the critical patient. 1 – Subxiphoid / subcostal four-chamber / caval view 2 – RUQ (right upper quadrant) 3 – LUQ (left upper quadrant) 4 – Pelvic / low midline Orientation for abdominal images has the transducer notch to the patient’s head with the orientation marker viewed on to the left of the image for sagittal (longitudinal views). Transverse images have the transducer marker to the patient right with the orientation marker on the left side of the image.  Learn More Abdominal Anatomy Learn more abdominal anatomy. Tab TitleTextRUQObtain the right upper quadrant view by placing the transducer at or below the right ribcage. Image on the longitudinal or transverse plane with the patient in the supine position to ensure the fluid moves to the posterior abdomen. Small amounts of fluid or blood in the upper abdomen often move inferior to the diaphragm or into Morison’s pouch found between the liver and right kidney.    The left image shows the kidney with the anterior liver (open arrow).  Morison’s pouch (multiple arrows) is a potential space where anechoic fluid collects. The right image shows the transverse right kidney with the anterior liver and the location of Morison’s pouch (multiple arrows).Abdominal Ascites Ascites (asterisk) in the abdomen has an anechoic appearance inferior to the diaphragm. Fluid outlines the anterior abdominal wall and liver capsule (double arrows).  LUQ In the left upper quadrant, fluid collects under the diaphragm and in the suprarenal space. In the normal patient, this potential space images as a hyperechoic boundary between the organs.  This image shows the left kidney (circle) and spleen (arrow) on a coronal plane. The kidneys share a similar sonographic appearance as do the spleen and liver.  High Midline Positioning the transducer on the longitudinal midline plane, just inferior to the xiphoid, images the left lobe of the liver. Bring the diaphragm (yellow) and heart (arrow) into the sector by rocking the transducer towards the patient’s head. Low MidlineIn the supine female patient, fluid collects within the pelvis in the rectouterine pouch (aka, pouch of Douglas). In the male patient, this potential space is directly posterior to the bladder and is the rectovesical pouch.     These images of the female pelvis show the uterus between the bladder (asterisk) and pouch of Douglas (yellow line). The potential space posterior to the uterus and vagina collects fluid, which appears anechoic, similar to the urine within the bladder.  Your Turn Your Turn. Instructions:Flash File:HTML5 File:/content/generator/Course_90023134/socp-your-turn-2/index.htmlPDF File: The use of lung ultrasound helps clinicians determine the need for further testing (i.e., radiographs, CT) in the critical patient. Portable or bedside imaging with an ultrasound system has quickly become a vital tool for monitoring lung disease. The development of evidence-based recommendations for lung ultrasound include systematic approaches to obtaining images. During the lung exam, use a small footprint transducer, convex, or linear which allows intercostal imaging. The frequency range used depends on the area imagined. An example of a transducer used to image the anterior apical areas is a 10L4 or 5V1, however, to image the lung base from a subcostal plane, a 5C1 or the DAX transducer may be a better choice.   This section describes lung-specific findings seen while imaging the lungs. A description of the eFAST protocol can be found later in this course. Pleural effusion lies between the lung pleura and chest wall, and in the absence of loculations and infection, presents as an anechoic rim around the lung.6 The location for this fluid, whether serous or new hemorrhage due to trauma, depends on the patient position. When imaging the pleural line, observe any increases in thickness, both global and focused. Changes in the pleural lining occur with abnormalities such as pneumothorax, pneumonia, and acute respiratory distress syndrome (ARDS).6 An angle of incidence, either greater or less than 90-degrees, decreases the diagnostic accuracy of pleural line thickness.6 Click the icon below to learn more about the importance of the angle of incidence when imaging the pleural lining.  Learn More about Pleural Imaging Learn more about pleural imaging. Tab TitleTextNormal Lung The normal lung images within the pleural cavity with a homogeneous, low-level echo pattern. The ribs (asterisk) create shadows when imaging through the chest wall (double arrows) on a longitudinal plane. The intercostal muscle and pleural interface images as a hyperechoic boundary (arrow) around the lung of measuring approximately two millimeters thick. When imaging the lung, watch for the sliding movement within the chest cavity. Perpendicular An angle of incidence as close to perpendicular (90-degrees) increases the detail7 of the pleural lining (arrow) allowing for determination of normalcy. This image was taken with the transducer oriented on a longitudinal plane at the anterior third and fourth rib space. Asterisk – rib.   Non-perpendicular This image, taken with the linear transducer angled towards the feet, shows a pleural lining (arrows) that appears irregular. To correct this image, simply angle the transducer towards the patient’s feet. Asterisk – rib. Real-time ComparisonThe left image shows a real-time clip of an image using a perpendicular angle of incidence. Compare the pleural line (arrow) to the right image showing a transducer angle towards the head. Asterisk – rib.   Reverberation seen within the chest cavity is due to bouncing of the sound waves between the visceral and parietal surface of the lung.8, 9 This artifact, often called A-lines in lung imaging, remain stationary in relation to imaged anatomy and gradually diminish in brightness and width. This artifact is due to the presence of a strong reflector and may be found in the normal lung, with B-lines, and in the presence of a pneumothorax, pulmonary edema, or a lung contusion as well as many other disease processes. 8, 9, 10 The combination of A-lines and a sliding lung (discussed later) indicate a normal lung only for the area imaged.11 Learn More about A-lines Learn more about A-lines. Tab TitleText2D-mode This image, using a curved linear (CH5-2) transducer, shows multiple reverberation artifacts when imaging the lung.7 Real-time This real-time clip shows the equidistant (arrows) A-line artifact using a phased array transducer (5P1) transducer.   To improve this image, move the artifact into the central beam by angling towards the patient’s feet. Another form of reverberation artifact, B-lines, extend deep to the echogenic pleural line.6, 8 This finding helps us determine the amount of aeration within the imaged lung. Two or less B-lines are a normal finding and can coexist with A-lines.8 With many disease processes lung density increases along with a loss of aeration. Moderate lung disease shows more than three, well-defined B-lines imaged between the ribs.6, 9    Learn More about B-lines Learn more about B-lines. Tab TitleText2D Image  The left image shows a single B-line (arrow) while imaging through the chest wall. A common finding, B-lines often image during upper abdominal exams. This longitudinal image (right) uses a cephalad transducer angle with anterior wall placement. The B-line (arrow) extends from the echogenic diaphragm into the right lung base. Left image courtesy of Prof. Dirk-Andrè Clevert-LMU Munich, Germany.Real-timePathologyIn the patient with pneumonia, fluid fills the alveoli.6 In the case of localized pneumonia, we see pathologic B-line artifacts around the diseased area. Pulmonary edema, images with multiple evenly spaced B-lines that may extend across intercostal spaces. ARDS can show interspersed normal and abnormal tissue through presentation of areas of extended B-lines and normal lung.8 In the presence of a lung contusion and interstitial bronchopneumonia both focal and multifocal that are either clustered or space image.10 In the patient with a pneumothorax, multiple, vertical comet tail artifacts arise from the echogenic pleural line.6 Called Z-lines, lung comets or I-lines, the artifact fades with depth and have a higher echogenicity than the pleural lining. A common artifact, Z-lines do not move with the lung during respiration nor do they remove A-lines. This artifact images better with a higher frequency, linear transducer and suggest contact between the pleural layers.8 This is a transverse image taken high in the liver with the right lung base shows a Z-Line (arrow) superior to the diaphragm.     Z-lines occur in the normal and abnormal lung restricting the use in diagnosis of lung disease.8   During real-time imaging of the lung we can image the movement of the lung within the pleural cavity. The chest and lung move in opposite directions indicating the presence of a normal lung. The absence of movement raises suspicion for pneumothorax or acute respiratory distress syndrome.9, 10   Anechoic fluid between the parietal and visceral layers of the lung (pleural effusion) changes size with respiration.9 This change, called the sinusoid sign, also images well with ultrasound. Other factors that reduce lung movement within the chest cavity include adhesions due to pneumonia, acute injury, lung hyperventilation, and intubation.8   Use the cineloop function to document the pleural / lung sliding movement. Image the lung from the anterior, lateral, and posterior approaches to rule out a pneumothorax in all locations.12 Learn More about Sliding Lung Learn more about sliding lung.6, 8 Tab TitleTextLung Point This real-time image was taken with a linear transducer (12L3) using the Lung preset. The normal lung tip moves from superior to inferior (left to right) between the ribs.   Missing lung point may be due to a Large pneumothorax Pneumothorax plus adhesion of the pleura ​Chronic disease (i.e., fibrotic lung disease) Sliding Lung An image or video clip can image multiple lung signs. Here you see a      B-line (arrow) move in and out of the image field while the lung slides within the chest cavity. M-mode The use of M-mode also helps document the presence of lung sliding. Called the ‘seashore’ sign, the pleural line displays in the anterior portion of the tracing with the lung sliding creating a pulse-like line. Curtain Sign Imaging the lung base at the costophrenic angle provides a method to assess movement of the lung.  Air in the normal lung effectively obscures or ‘curtains’ the underlying anatomy in the upper abdomen.  Images and video clips show an air artifact appear over the left kidney / spleen, right kidney / liver, and the accompanying diaphragm.  This clip shows the curtain sign (arrow) moving over the right kidney, liver, and right diaphragm. Learn More about Lung Consolidation Learn more about lung consolidation. As disease within the lung progresses, fluid, inflammatory, and cellular infiltrates, replace air within the alveoli. The removal of the acoustic impedance created by air, results in our ability to image the lung. As with many processes, the timing of imaging during the development of consolidation, changes with the severity of the disease. Described as hepatization, the lung images with an echo texture similar to the liver as an irregular mass-like appearance (shred sign).6 Sonographic appearance of lung consolidation8 Early stage - Subpleural defect - Wedge-shaped defect - Irregular areas with hyperechoic borders (normal lung) Late stage - Solid homogenous areas - Hyperechoic, air-filled bronchioles - Hypoechoic regions within homogenous areas (possible lung necrosis or abscess)   Explore the links below for the Glossary, References, and Further Reading opportunities. Glossary Glossary. Tab TitleTextA - IAnechoic – Devoid of echoes.   Aneurysm – Abnormal widening of a vessel.   Echogenic – Brighter structure than surrounding organs.   Echogenicity – General term used to describe sonographic structures.   Echo texture – Characteristic sonographic appearance of an organ or structure.   Hyperechoic – See echogenic.   Hypoechoic – Structure with less brightness than surrounding structures.   Hypotension – Abnormally low blood pressure.   Axillary line (Coronal)– Longitudinal plane dividing the body into front and back portions.   Intraperitoneal – Within the abdominal cavity membrane (peritoneum).   Intrathoracic – Within the thorax.P - TPericardial sac – Fibrous sac surrounding the heart and great vessels. Peritoneal lavage – The introduction of a catheter through the abdominal wall allowing for introduction and draining of saline. The presence of blood in the returned saline suggest the presence of internal injury.   Pneumothorax – Air within the pleural cavity.   Posterior – Towards the back of the body.   Potential space – An area where two adjacent organs meet but are not attached.   Protocol – Accepted manner to complete a task.   Pulmonary edema – Excess fluid with the alveoli of the lungs resulting in difficulty in breathing.   Sagittal – A plane dividing the body into right and left sections.   Supine – Lying on the back.   Tamponade – Heart compression due to the accumulation of fluid within the pericardial sac resulting in an abnormal heart rhythm.   Thrombosis – Clot.   Transthoracic – Through the chest wall. References / Further Reading References / Further Reading. Tab TitleText1 - 91. Denault, A.Y., Langevin, S., Lessard, M.R., Courval, J.F., and Desjardins, G. (2018). Transthoracic echocardiographic evaluation of the heart and great vessels. Canadian Journal of Anaesthesia = Journal Canadien D'anesthesie. 65(4): 449-472.   2. Raatz Stephenson, S. (2016). Emergency Ultrasound. In Sanders, R.C. and Hall-Terracciano, B., (Eds.), Clinical Sonoography: A Practical Guide (pp. 841-859). Philadelphia: Wolters Kluwer.   3. Moore, K.L., Dalley, A.F., and Agur, A.M.R. (2015). Abdome. In Moore, K.L., Dalley, A.F., and Agur, A.M.R., (Eds.), Anatomia umana: A orientamento clinico (pp. 197-350). Rozzano: Casa Editrice Ambrosiana.   4. Boyd, J.H., Sirounis, D., Maizel, J., and Slama, M. (2016). Echocardiography as a guide for fluid management. Critical Care. 20(1): 274.   5. Porter, T.R., Shillcutt, S.K., Adams, M.S., Desjardins, G., Glas, K.E., Olson, J.J., and Troughton, R.W. (2015). Guidelines for the use of echocardiography as a monitor for therapeutic intervention in adults: A report from the American Society of Echocardiography. Journal of the American Society of Echocardiography. 28(1): 40-56.   6. Kruisselbrink, R., Chan, V., Cibinel, G.A., Abrahamson, S., and Goffi, A. (2017). I-AIM (Indication, Acquisition, Interpretation, Medical decision-making) framework for point of care lung ultrasound. Anesthesiology: The Journal of the American Society of Anesthesiologists. 127(3): 568-582.   7. Hedrick, W. (2013). Technology for diagnostic sonography. St. Louis, MO: Elsevier. 8. Lee, F.C.Y. (2016). Lung ultrasound-a primary survey of the acutely dyspneic patient. Journal of intensive care. 4(1): 57-57.   9. A, T. and M.C, O.R. (2020). Thoracic and lung ultrasound, StatPearls Publishing: Treasure Island (FL).  10 - 1810. Saraogi, A. (2015). Lung ultrasound: Present and future. Lung India. 32(3): 250-257.   11. Gargani, L. and Volpicelli, G. (2014). How I do it: Lung ultrasound. Cardiovascular ultrasound. 12: 25-25.   12. Brooks, T., Kendall, J.L., and Kendall, L. (2014). Trauma. In Cosby, K.S. and Kendall, J.L., (Eds.), Practical Guide to Emergency Ultrasound (pp. 21-54). Philadelphia: Lippincott Williams & Wilkins, a Wolters Kluwer business.   13. Seif, D., Perera, P., Mailhot, T., Riley, D., and Mandavia, D. (2012). Bedside ultrasound in resuscitation and the rapid ultrasound in shock protocol. Critical care research and practice. 2012: 503254-503254.   14. Labovitz, A.J., Noble, V.E., Bierig, M., Goldstein, S.A., Jones, R., Kort, S., . . . Wei, K. (2010). Focused cardiac ultrasound in the emergent setting: A consensus statement of the American Society of Echocardiography and American College of Emergency Physicians. Journal of the American Society of Echocardiography. 23(12): 1225-1230.   15. Andrus, P. and Dean, A. (2013). Focused cardiac ultrasound. Global Heart. 8(4): 299-303.   16. Nagre, A.S. (2019). Focus-assessed transthoracic echocardiography: Implications in perioperative and intensive care. Annals of Cardiac Anaesthesia. 22: 302.   17. Lichtenstein, D. (2015). BLUE-protocol and FALLS-protocol: Two applications of lung ultrasound in the critically ill. Chest: The Cardiopulmonary and Critical Care Journal (147): 6.   18. Javedani, P.P., Metzger, G.S., Oulton, J.R., and Adhikari, S. (2018). Use of focused assessment with sonography in trauma examination skills in the evaluation of non-trauma patients. Cureus. 10(1): e2076-e2076.19 - 2219. Cattarossi, L. (2013). Lung ultrasound: its role in neonatology and pediatrics. Early Human Development. 89: S17-S19.   20. Saraogi, A. (2015). Lung ultrasound: Present and future. Lung India. 32(3): 250-257. 21. Moore, K.L., Dalley, A.F., and Agur, A.M.R. (2015). Torace. In Moore, K.L., Dalley, A.F., and Agur, A.M.R., (Eds.), Anatomia umana: A orientamento clinico (pp. 79-196). Rozzano: Casa Editrice Ambrosiana.   22. Volpicelli, G., Elbarbary, M., Blaivas, M., Lichtenstein, D., Mathis, G., and Kirkpatrick, A. (2012). International liaison committee on lung ultrasound (ILC-LUS) for International Consensus Conference on Lung Ultrasound (ICC-LUS). International evidence based recommendations for point-of-care lung ultrasound. Intensive Care Med. 38: 557-591.   Multiple protocols exist for the critical patient in the ED or ICU. The RUSH, FOCUS, eFAST, FAST, and BLUE protocols share a common goal in a quick evaluation of specific areas in the unstable patient. Indications for the performance of a focused exam include: Blunt and penetrating trauma to the chest or abdomen Hypotension of unknown origin Localization of ascites, pleural or pericardial fluid Blunt trauma to the chest during a car accident  contributes to the risk of developing bleeding  within the pericardium and pleural cavities. RUSH, FOCUS, FATE, and BLUE Protocols Learn more about RUSH, FOCUS, FATE, and BLUE protocols. Tab TitleTextRUSH2, 13 Hemorrhage, regardless of cause, has the potential to place a patient into hypovolemic shock. The rapid ultrasound in shock (RUSH) protocol helps the clinician assess for signs of shock in the heart, vascular system via the IVC and jugular vein (double arrows), and for the presence of fluid in the lungs or peritoneum. Included is a search for aortic abnormalities such as a ruptured aneurysm or intimal tear and / or the presence of DVT (deep vein thrombosis).  The jugular fills and empties (double arrows; collapses) next to the common carotid artery (open arrow). RUSH exam views include: -Parasternal long-axis views for      - Pericardial effusion      - Tamponade      - LV contractility      - RV strain signs -IVC / Jugular volume (collapse with inspiration) -Free fluid in abdomen or chest spaces -Lung pathology (pulmonary edema or tension pneumothorax) -Sequential transverse aortic view for aneurysm and dissection (abdominal and thoracic) -Deep vein thrombosis in the lower extremities. FOCUS2, 14, 15 The American Society of Echocardiography (ASE) supplies guidance for an extension of the FAST exam to include the heart in case of blunt or penetrating trauma to the chest. The focused cardiac ultrasound (FOCUS) protocol includes a chest evaluation for pericardial effusion, global cardiac function, and the size of heart chambers. Additionally, respiratory changes in the inferior vena cava (IVC) allow determination of the cardiac volume status. Ultrasound also aids in the completion of a pericardiocentesis or thoracentesis with the findings of free fluid or hemorrhage.  FOCUS exam views include: -Lung images for pericardial effusion and tamponade -Global cardiac systolic function -Assessment of the right ventricle for enlargement -Right ventricular dysfunction due to pulmonary embolus -Volume Assessment via IVC diameter changes FATE16 The focused assessed transthoracic echo (FATE) protocol centers on heart function using a transthoracic approach to assess ventricular function, volume status, fluid response, and valvular integrity. The advanced FATE adds hemodynamic assessment to aid in cardiac output and pressure calculations via Doppler tracings, diagnosis of diastolic abnormalities, and severity of valve-based heart disease as well as other diagnostic parameters.   Basic FATE views include:  -Subcostal view -Apical four-chamber view -Parasternal long-axis view  -Parasternal short-axis view                    -Pleura imaging Advanced FATE views include basic views and: -Subcostal vena cava view -Apical two-, three- and five-chamber view -Parasternal short-axis view at the mitral valve -Parasternal short-axis view of the aorta   BLUE10, 17 One protocol specific to the lung, BLUE (bedside lung ultrasound in emergency) allows bedside evaluation of acute respiratory failure. This series of images uses the sonographic appearance of the pleura, lung sliding, A-lines, Z-lines, interstitial, and lung point signs to determine the presence of acute disease. The six imaged areas include four anterior locations plus the right and left lung at the posterior axillary line.   BLUE protocol foundations - Air moves superior (position dependent) - Fluid moves inferior (position dependent) - Localize the pleural line. - Identify artifacts (i.e. A-lines) - Lung sliding - Minimize depth to only show anatomy or artifacts Your Turn Your Turn. Instructions:Flash File:HTML5 File:/content/generator/Course_90023134/socp-your-turn-003/index.htmlPDF File: In the past, determining the presence of blood in the abdomen for patient’s presenting with abdominal trauma required a diagnostic peritoneal lavage (DPL). A positive result, blood in the extracted fluid, often resulted in an exploratory laparotomy to find the origin of the injury. Multiple disadvantages to DPL include, not only the risk for infection, but the difficulty in use with some patients due to body habitus and the inability to perform serial procedures. In this case ultrasound becomes the imaging modality of choice as the system can be used in conjunction to adjacent life-saving measures. The ease of use for continued monitoring for development of bleeding is an added benefit to using ultrasound. Hemorrhage, regardless of location, has a characteristic appearance during each phase from acute, consolidating, and reabsorption. In the acute phase, blood appears echo-free (anechoic). However, as areas of hemorrhage begin to solidify, we see intermittent areas of complex fluid to mass-like areas low-level echoes. In the final phase, resolution, the clotted blood begins to liquefy, once again appearing anechoic. The FAST exam protocol includes images of four areas of the abdomen, the pericardial area, the RUQ, LUQ and the rectovesical / pouch of Douglas areas.2, 12 Explore the link below to learn more about obtaining the images.   Note: The imaging techniques described have the patient in the supine position.  Learn More about the FAST Exam Learn more about the FAST exam.2, 12 Tab TitleTextRUQ The RUQ of the Morison’s (hepatorenal) pouch starts with placing the transducer at the right midaxillary line from the ninth to tenth ribs. The large liver is both a landmark and acoustic window to image Morison’s pouch. With the liver centered in the sector, slide, or angle, the transducer towards the patient’s feet until the right kidney moves into view.  In the presence of fluid, an anechoic rim appears around the right kidney or inferior to the right diaphragm.   Using a coronal approach is another method to obtain the RUQ view with the kidney liver and right costophrenic angle Use the cineloop function to obtain a sweep of the RUQ. LUQ Transducer placement to image the left upper quadrant requires movement laterally on the chest imaging between the ninth and eleventh ribs. In this imaging plane, you may need to move the transducer posterior and rest against the gurney. Rock the transducer towards the patient’s head and feet while imaging on the longitudinal plane to image the LUQ (perisplenic) organs. Free fluid in this quadrant appears inferior to the left diaphragm (subphrenic space) and spleen as an anechoic rim. Align the transducer on a coronal plane with the orientation notch towards the patient’s head. Keep an eye out for new bleeding within the splenic capsule which appears as hypoechoic areas within or surrounding the spleen.   High Midline The high midline view, also called a subxiphoid or subcostal, begins with placement of the transducer on the upper mid abdomen. Multiple protocols use this location to obtain images. This is an excellent view to obtain an IVC diameter (inspiration / expiration), check for pericardial fluid, and rule out tamponade developed from compression on the right ventricle. This image shows the angle used to obtain the subcostal four-chamber view of the heart when pointing the transducer to the patient’s left shoulder. To help relax the abdominal muscles, bend the patient’s knees.   Low Midline Fluid collects in the dependent area of the abdomen, which, in the supine patient, is in the rectovesical (male) or rectouterine (female) space. To obtain images of this area, place the transducer superior to the symphysis pubis and angle into the pelvis (towards the feet). The full urinary bladder is an acoustic window; however, critical patients often have a Foley catheter in place. In this instance, the inflated catheter balloon acts as a landmark. Retrograde filling of the bladder may be possible in some cases. This image shows the transducer position to obtain a transverse view of the pelvis. Always obtain images on two orthogonal planes to rule out artifactual findings. Differentials for fluid in the pelvis of a woman within reproductive age include a ruptured ectopic, corpus luteum or functional ovarian cyst.18 Your Turn Your Turn. Instructions:Flash File:HTML5 File:/content/generator/Course_90023134/socp-your-turn-004/index.htmlPDF File: The eFAST exam protocol is a procedure used to examine the lung with the aid of ultrasound.  Often used in conjunction with the FAST exam, eFAST helps with monitoring of trauma and disease related processes within the chest cavity.  Learn more about the eFAST exam. Learn more about the eFAST exam. Tab TitleTextIndications19, 20 - Suspected pleural effusions - Trauma - Lung crackles (rales) - Respiratory distress syndrome (chronic / acute) - Hemo- or pneumothorax due to rib fractures - Chest pain - Dyspnea - Fever - Hypoxia - Foreign body localizationLung Anatomy21 Each lung has multiple lobes separated by fissures. The right lung has three lobes resulting in a larger size than the two-lobed left lung. The mediastinum, which holds the heart, trachea, and aorta, separate the two lungs. The pleura surrounds both lungs within the thorax.   The smallest part of the lungs is the alveolar sacs. These small structures hold the alveoli where the oxygen / carbon dioxide gas exchange occurs.  A systematic mapping of the lung starts at the lung apex to the base of the lung. Image both lungs from the anterior chest to the posterior axillary line of the chest wall. The lung regions on the chest is divided into up to twelve zones for a complete ultrasound examination. The upper and lower anterior chest, and the upper and lower lateral chest. Dependent regions and certain pleural effusions may require posterior chest evaluations as clinically indicated.22   The number and location of lung views varies with each patient situation. Always follow your facilities protocols for both the FAST and eFAST exams.   Evaluation of up to twelve zones during the lung exam allows for the following:9 - Pleural sliding, thickness, and uniform thickness - Changes in echogenicity in subpleural areas - Focal versus diffuse A-lines - Presence of B-lines - Lung consolidation Learn More about Lung Zones Learn more about lung zones. Each of the twelve lung zones allow determination of lung sliding, pleura thickness, echogenicity changes, and the presence or absence of diagnostic findings (i.e. consolidation, A-lines, B-lines, focal versus diffuse disease).    If possible, image zones close to the diaphragm (anterior 2, 4, 6, 8; two posterior low basal) with the patient in the semi recumbent to upright position. This allows fluid to collect in the dependent portions. In the presence of a pneumothorax, air rises into the apex (zones 1, 5 and two infrascapular).  Lung consolidation remains stable regardless of position.9     Eight of the twelve zones used to image the lungs. Always document findings on two orthogonal planes. eFAST Protocol Learn more about imaging the lung using an eFAST protocol. Tab TitleTextAnterior Apical Views6, 9  The two views taken from the upper chest help determine the presence of a pneumothorax and document lung sliding. Place the transducer over the third and fourth rib, aligned with the mid axillary and clavicular line, with the orientation notch towards the patient’s head. Tilt the transducer to align the pleural line at a 90-degree angle of incidence. Use a shallow depth to acquire images and cineloop captures documenting for A-lines, B-lines and lung sliding. This chest radiograph shows the location for anterior views (zones 1 and 5) of both the right and left lung.  BasalViews9  Increase the depth to image the base of the lungs to include the liver and kidney on the right and the spleen and kidney on the left. In both the supine and erect position, fluid collects above the diaphragm within the lateral and posterior costophrenic angles.2    When imaging on this midaxillary line, angle the transducer posteriorly and rotate to remove rib shadows. Rock the transducer lengthwise to move the diaphragm to the center or the image. If possible, ask the patient to inhale deeply to assess for both diaphragm movement and effusion. With the finding of either lung consolidation or pleural effusion, perform and anterior to posterior cineloop sweep to document the quantity of fluid. Angle cranially, to assess the amount of fluid present.   When imaging zones 4 and 8 for the costophrenic angles, place the transducer at the midaxillary line (coronal plane) with the transducer orientation notch towards the patient’s head. Place the image orientation marker on the left of the image.  MirrorArtifact7While imaging the normal basal lung from below the diaphragm, you may see a mirror artifact. The diaphragm is a strong reflector which refracts or bends the ultrasound beam.  As a result, the returning signal has a different path than the transmit beam. The ultrasound system then places the echoes within the chest rather than the abdomen.    To determine the presence of a mirror artifact, compare echoes above and below the diaphragm. If they appear the same such as this vascular structure (arrows) in the liver, we can identify the echoes within the lung as artifacts.  Anterior Lower Views  Imaging of zones two and six occurs below the fourth rib, and depending on body habitus, allows imaging of the middle lobe of the left lung and lower lobe of the right lung.8, 21 Fluid accumulates in the costophrenic recess at this level.   This chest radiograph shows the position for zones two (right lung base) and zone six (left lung base). Upper AxillaryViews To obtain views of the upper lung on the axillary line, place the transducer at the forth rib on the posterior axillary line.8 Anatomy seen in zones three and eight include the upper lobes of the lung and portions of the lower lobes.21 On the left side, zone eight includes most of the lower lobe of the lung.8   This chest radiograph shows transducer locations for zones four (right lung) and zone eight (left lung).   PosteriorViews  To obtain posterior of the lungs the patient must be able to sit or roll allowing access to the dorsal chest.11 To obtain images of the right and left posterior basal area, place the transducer at the level of the diaphragm.6 Usually at approximately the 11th and 12th rib space,21 the locations vary due to patient position and body habitus.     The posterior upper location is at the inferior angle of the scapula located at approximately the eight spinous process or between the 7th and 8th intercostal space.   The reproduction, transmission or distribution of this training or its contents is not permitted without express written authority. Offenders will be liable for damages.   All names and data of patients, parameters and configuration dependent designations are fictional and examples only.   All rights, including rights created by patent grant or registration of a utility model or design, are reserved.   Please note that the learning material is for training purposes only!   For the proper use of the software or hardware, please always use the Operator Manual or Instructions for Use (hereinafter collectively “Operator Manual”) issued by Siemens Healthineers. This material is to be used as training material only and shall by no means substitute the Operator Manual. Any material used in this training will not be updated on a regular basis and does not necessarily reflect the latest version of the software and hardware available at the time of the training.   The Operator Manual shall be used as your main reference, in particular for relevant safety information like warnings and cautions. Note: Some functions shown in this material are optional and might not be part of your system. The information in this material contains general technical descriptions of specifications and options as well as standard and optional features that do not always have to be present in individual cases.   Certain products, product related claims or functionalities described in the material (hereinafter collectively “Functionality”) may not (yet) be commercially available in your country. Due to regulatory requirements, the future availability of said Functionalities in any specific country is not guaranteed. Please contact your local Siemens Healthineers sales representative for the most current information.   Copyright © Siemens Healthcare GmbH, 2020