Turan Saul, M.D., RDMS Critical Ultrasound Review St. Luke’s Roosevelt Hospital Center

2. Turan Saul, M.D., RDMS Critical Ultrasound Review St. Luke’s Roosevelt Hospital Center EM JeopardyTM

3. $100 $100 $100 $100 $100 $200 $200 $200 $200 $200 $300 $300 $300 $300 $300 $400 $400 $400 $400 $400 $500 $500 $500 $500 $500 $600 $600 $600 $600 $600

4. Airway and Breathing

5. Cardiac and EFAST

6. Aorta and IVC

7. Venous Access And Soft Tissue

8. Pelvic And DVT

9. Airway and Breathing Cardiac and EFAST Aorta and IVC Vascular Access And Soft Tissue Pelvic and DVT $100 $100 $100 $100 $100 $200 $200 $200 $200 $200 $300 $300 $300 $300 $300 $400 $400 $400 $400 $400 $500 $500 $500 $500 $500 $600 $600 $600 $600 $600

10. Thank You The Dublin College of Physicians and Surgeons Dr. John Cahill ‘ William H. Bagley, M.D. Resa Lewiss, M.D., RDMS Paul Travnicek, M.D.

11. The above image demonstrates? • A. Vertebral shadowing • B. Esophagus • C. Linear foreign body • D. Tracheal rings • E. None of the above

12. D – Tracheal Rings • Tracheal rings • Cricothyroid membrane • High frequency linear probe • Sagittal plane Characteristic sonographic appearance of normal anatomy SLRUS

13. Methods of assessing a successful intubation include visualizing? A. Bilateral, symmetric pleural sliding B. Visible comet-tail artifacts C. Symmetric diaphragmatic movement D. The bar code sign in M-mode E. A, B, and C

14. E - A, B, and C • Bilateral, symmetric pleural sliding • Visible comet-tail artifacts • Symmetric diaphragmatic movement • These findings are normal, and do not raise concern for: • - pneumothorax • - right mainstem intubation • The barcode sign using M-mode occurs when there is a pneumothorax SLRUS

15. DAILY DOUBLE

16. The following image is concerning for an esophageal intubation because? • A. The trachea is visible • B. The esophagus is visible • C. Impossible to tell from this image • D. This is a normal image • E. Need to evaluate in both transverse and sagittal planes.

17. B – The esophagus is visible • Esophagus is normally collapsed and not visible adjacent to the trachea • Posterior shadowing - trachea from cartilaginous rings - left para-tracheal area: esophagus opened by the endotracheal tube SLRUS

18. The batwing pattern represents? A. Viceral pleura, parietal pleura, rib B. Rib, intercostal space, rib C. A pattern of lung sliding and comet tails D. A way to determine if a pneumothorax is present

19. B. Rib, intercostal space, rib SLRUS

20. What two signs are found when viewing normal lung in the 2nd intercostal space? A. Comet tails and a lung pulse B. Lung sliding and comet tails C. Comet tails and “B” lines D. A lung point and lung sliding E. A stratosphere sign and a lung pulse

21. B. Lung sliding and comet tails Comet tail artifacts arise from the interface of the viceral and parietal pleura • Lung sliding is visualized as the normal lung expands and deflates SLRUS

22. The image on the left with M- mode detects? A. Pleural effusion – sinusoid sign B. Normal lung – seashore sign C. Pneumothorax – barcode sign D. Hemothorax – sinusoid sign

23. B - Normal lung, seashore sign • Seashore sign - occurs as ultrasound waves hit normal lung tissue and reflect back SLRUS

24. A 75 year old male with known history of coronary artery disease was found by EMS with no pulse. Upon arrival to the ER the patient is asystolic on the monitor. Which of the following echocardiographic findings might dissuade you from terminating the resuscitation? A) Contraction of mitral valve B) Contraction of the atria C) Contraction of ventricles D) Thickened ventricular wall E) Dilated inferior vena cava

25. C - Contraction of ventricles • Contraction of ventricles with no pulse is PEA • Continue resuscitative efforts SLRUS

26. Pericardial fluid will first be visualized? A. Surrounding the right ventricle B. Surrounding the left ventricle C. Surrounding the right atrium D. In the most dependent part of the pericardial sac

27. D - In the most dependent part of the pericardial sac SLRUS

28. The subxiphoid view is used for evaluation in trauma. All of the following techniques can be used to improve image acquisition EXCEPT: A) Probe angle to the body approximately 5-15 degrees B) Moving the transducer to the patient’s left in the subxiphoid area C) Angling the transducer toward the patients left shoulder D) Asking the patient to take a deep inspiration

29. B - Moving the transducer to the patient’s left in the subxiphoid area • Move probe to patient’s right • - uses liver as acoustic window • - moving to left, air in stomach and colon • - angle towards left shoulder SLRUS

30. The following ultrasound image is seen in a patient with blunt abdominal trauma. What is the best course of action? • Put patient in Trendelenburg and scan again • Repeat the exam in 20 minutes • Call the trauma surgeons • Perform a DPL

31. C - Call the trauma surgeons Fluid in Morison’s Pouch SLRUS

32. A hypotensive patient with a stab wound to the chest wall has this finding on your E-FAST. Your next step is? A. Prepare for a pericardiocentesis B. Prepare for an open thoracotomy C. Look for another cause of his hypotension D. Place bilateral chest tubes

33. C. Look for another cause of hypotension • Effusions collect in the most dependant portion of the pericardial sac, i.e. posteriorly • Epicardial fat is seen anterior to the heart SLRUS

34. You are scanning a patient in the right mid-axillary line and you see the following. What does the image represent? • Pleural fluid • Pericardial fluid • Peritoneal fluid • Pelvic fluid

35. A - Pleural fluid SLRUS Peritoneal Fluid Pleural Fluid

36. D A B C Which letter corresponds to the Aorta? A. A B. B C. C D. D

37. B - Aorta A. IVC: thin walled, respiratory variation, compressible, to the right of aorta B. Aorta: thick echogenic walls, pulsatile, to the left of the IVC, non compressible, no respiratory variation C: Vertebral body: Bone - very echogenic, posterior to vessels D: Liver: medium echogenicity, heterogeneous, dense D A B C SLRUS

38. The main indication for emergency sonography of the aorta is? A) Identify aortic aneurysm B) Identify free fluid in the abdomen C) Identify a retroperitoneal hemorrhage D) Measure the size of the bladder.

39. A - Identify aortic aneurysm • Yes or no question asked in aortic ultrasound is – is there an AAA SLRUS

40. The measurement for the abdominal aorta concerning for aneurysm is ? A) > 2 cm B) > 3cm C) > 4cm D) > 5cm E) > 6cm

41. B - > 3cm >3 cm is concerning for aneurysm in the abdominal aorta >1.5 cm is concerning for aneurysm in the iliac arteries SLRUS

42. Which letter corresponds to the IVC? A. A B. B C. C D. D D A B C

43. A. IVC: thin walled, respiratory variation, compressible, to the right of aorta, low flow B. Aorta: thick echogenic walls, pulsatile, to the left of the IVC, non compressible, no respiratory variation, high flow C: Vertebral body: Bone - very echogenic, posterior shadowing, posterior to vessels D: Liver: medium echogenicity, heterogeneous, dense A - IVC D A B C SLRUS

44. An 88 year old woman presents from home with 4 days of fever, lethargy, decreased PO intake and urinary incontinence. On arrival her vitals are: HR 128 BP 88/56 RR20. She has dry mucus membranes and poor skin turgor. You expect on sonographic exam of her IVC? A. IVC plethora B. Greater then 50% collapse on inspiration C. Less then 50% collapse on inspiration D. Change only with sniff test

45. B – Greater than 50% collapse This scenario describes a pt with urosepsis and extreme fluid depletion • In these cases, expect to see greater then 50% collapse of the IVC with inspiration • Large IVC is seen in fluid overload states • < 50 % collapse during inspiration is normal SLRUS

46. Which of the following is NOT a good way of measuring volume status using ultrasound of the IVC? A. Long axis sub-xyphoid B. Cross-section sub-xyphoid C. Right anterior axillary line: through the liver D. Pelvic: through the bladder

47. D - Pelvic: through the bladder • The IVC should not be measured in the pelvis • Long axis sub-xyphoid, cross-section sub-xyphoid, and right anterior axillary line have been described in the literature • Measure 2 cm distal to the right atrium SLRUS

48. Ultrasound guidance for vascular access? • Decreased complication rates • Decreases time to venipuncture • Results in fewer needle stick attempts • Enhances patient comfort • All of the above

49. E – All of the above • Ultrasound-guidance has been shown in adult and pediatric populations to decreased complication rate, decreased procedure time, and reduce needle stick attempts. • Overall, patient comfort is more than without ultrasound-guidance SLRUS

50. While performing an ultrasound guided central line, the most accurate method of distinguishing artery from vein is? • Compression technique: a vein will collapse while an artery will not • Compression technique: an artery will collapse while a vein will not • Visualization of the vessel in long-axis • Visualization of the vessel in short-axis • None of the above