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Point of Care Ultrasound

Point of Care Ultrasound. For Rural Emergency Prepared by Shane Barclay MD. Goals and Objectives. Learn basic terminology and settings on the ultrasound machine. Learn the techniques for: substernal cardiac for detecting pericardial effusion aortic scanning for AAA

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Point of Care Ultrasound

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  1. Point of Care Ultrasound For Rural Emergency Prepared by Shane Barclay MD

  2. Goals and Objectives Learn basic terminology and settings on the ultrasound machine. Learn the techniques for: substernal cardiac for detecting pericardial effusion aortic scanning for AAA detecting free fluid in the abdomen detecting fluid or air in the chest cavity

  3. Why these scans? They form most of the basis of the eFAST exam. These are technically some of the harder scans to perform. Therefore ‘everything’ after this is easy!

  4. What the student needs to learn • Sight recognition • Muscle memory

  5. EDE eFAST RUSH POCUS

  6. EDE: “Emergency Department Echo” Developed by Dr. Ray Wiss EDE 1, IP certification, EDE 2, EDE 3

  7. eFAST: Extended Focused Assessment for Shock Trauma Extended Focused Assessment with Sonography for Trauma

  8. RUSH: Rapid Ultrasound for Shock and Hypotension

  9. Types of ultrasound teaching POCUS – Point of Care Ultrasound Is the general descriptor for Physicians using ‘bed side ultrasound’.

  10. Before you start scanning patients • Demographics on the patient. Know how to enter. • If at all possible save your images. • Tell the patient what you are going to do and what you are NOT going to do. You are not doing a ‘formal ultrasound’.

  11. Now for the boring part!

  12. Terminology Ultrasound produces sound waves that either pass through tissues, or if the tissue is ‘solid’, reflect back to the probe, which in turn ‘makes an image’. As the waves pass through tissue, they lose energy, called attenuation. The energy lost is converted into heat.

  13. Terminology Depth Gain Echogenic Echolucent Hyperechoic Hypoechoic Frequency /penetration/resolution Modes of Transmission Artifact types

  14. Terminology Depth This is the depth, in centimeters, the probe will generate an image, from the skin into the body cavity or organ.

  15. cm markers

  16. Terminology Gain This allows you to change the ‘strength’ of the signal being returned to the probe. Increasing gain makes the image ‘brighter’. Decreasing gain makes the image ‘darker’.

  17. Terminology Depth and Gain These are the 2 things you will manipulate to get a clear image. Third ‘factor’ is gel. So if you can’t see the image:Add more gel, change your gain, change your depth.

  18. Terminology Echogenic Tissues that ‘reflect’ back waves (ie bone) will produce an ‘echo’ which on the screen will appear ‘white’. Echogenic structures are white.

  19. Terminology Echogenic

  20. Terminology Echolucent Structures that don’t reflect back waves, or allow the waves to pass through them, such as fluid, are called ‘Echolucent’. We like echolucent structures to use as an ‘acoustic window’.

  21. Terminology Echolucent

  22. Terminology Echolucent Acoustic ‘windows’ can be: gel between the probe and skin, fluid (urine filled bladder) or solid (structures like the liver)

  23. Terminology

  24. Terminology Hyperechoic Refers to structures that ‘produce more waves’ (ie are more solid) and will therefore appear more ‘white’. Often used interchangeably with ‘Echogenic’.

  25. Terminology Hypoechoic Refers to structures that ‘produce less echo waves’ therefore are ‘darker’. Often used interchangeably with ‘echolucent’.

  26. Terminology Frequency /penetration/resolution Ultrasound probes have different frequencies – range 2.0 – 5.0 MHz. Frequency is what determines the degree and depth of penetration as well as resolution of ultrasound waves.

  27. Terminology Frequency /penetration/resolution Frequency and penetration are inversely related: Higher frequency – lower (shallow) penetration Lower frequency – higher (deeper) penetration Higher frequency – higher resolution Lower frequency – lower resolution

  28. Terminology Probes (Transducers) Most eFAST can be done using a ‘curved array’ probe. These are low frequency which allows for deeper penetration, but at the expense of resolution.

  29. Curved – low frequency, good penetration but lower resolution. Used for abdomen and eFAST Phased – high freq, shallow penetration, good resolution. Mainly for cardiac. Linear – high freq. shallow but good resolution. For superficial structures.

  30. By any other name! Endocavity Transvaginal

  31. By any other name! Do not start using this on a 15 year old male with suspected peritonsillar abscess and call it a ‘transvaginal ultrasound probe’! Call it an ‘endo-cavity probe’.

  32. Terminology ‘Mode’ (Mode of Transmission) B – Brightness. Most common use. M – Motion. D – Doppler. Can be color Doppler or pulsed wave.

  33. Terminology Artifact - any structure in an ultrasound image that does not have a corresponding anatomic tissue structure • Refraction or Edge artifact • Shadowing artifact • Reverberation or ring down artifact • Comet tail artifact • Mirror (image) artifact • Anisotropy • Slide Lobe artifact

  34. Terminology 1. Refraction or Edge artifact – shadow like image when u/s waves are passing by a small walled or large curved structure (ie bladder)

  35. Refraction or edge artifact

  36. Terminology 2. Shadowing artifact – appearance of ‘blackness’ behind solid structures – ie shadow behind bone or stone.

  37. Shadowing artifact

  38. Shadowing artifact

  39. Terminology 3. Reverberation or Ring down artifact – highly reflective interfaces which cause waves to reflect multiple times back to the probe superimposing images on the monitor (i.e. pleura)

  40. Ring down artifact These lines are often called “A” lines.

  41. Terminology 4. Comet Tail artifact – hyperechoic reverberation artifacts arising from the pleural line and spreading down toward the lower edge of the screen and are most frequently normal findings. In the lung when several comet tail artifacts (or B lines) are present they are often called ‘lung rockets’.

  42. Comet tail artifact or lung rockets

  43. Terminology 5. Mirror image artifact – another form of reverberation artifact, occurring when reflective surfaces return multiple echoes back to the probe.

  44. Mirror image artifact Kidney Actual liver ‘Mirror’ image of the liver Here the liver appears to be on the chest cavity side of the diaphragm (bright white line).

  45. Terminology 6. Anisotropy – when u/s waves hit tendons, nerves or ligaments NOT at 90 degrees, they can appear very dark or Echolucent (look like fluid)

  46. Anisotropy artifact

  47. Terminology 7. Side Lobe artifact – u/s beams from the edge of the probe are weak and when they hit a highly reflective object an echo returns to the probe which can be misinterpreted as an object from the center of the probe.

  48. Side lobe artifact

  49. Enough Terminology !

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