Keith Killu Scott Dulchavsky Victor Coba 1st Edition Book ICU The Ultrasound Pocket All rights are reserved Except as permitted under the United States Copyright Act of 1976, no part of this publication maybe reproduced or distributed in any form or by any means, or stored in a data base or retrieval system, without the prior written permission of the lead authors and publisher Contact info@medicalimagineering.com Copyright © Keith Killu, Scott Dulchavsky, Victor Coba This work is registered for copyrights at the Library of Congress First Edition 2010 ISBN 978-0-615-35560-3 Print Edition 978-0-615-35533-7 Electronic Edition At the time of publication, every effort has been made to make sure of the accuracy of the information provided The authors, editors and publishers are unable to warrant that the information provided is free from error, since clinical standards change constantly The authors, editors and publishers disclaim all liability for direct or consequential damages resulting from the use of material in this book Art/Design/Photography, Surgical Imagineers at Butler Graphics, Inc 3D Modeling, Butler Graphics/VitalPxl Collaboration Male/Female 3D Model, Zygote Dedication I dedicate this small measure of work to My Mother, for all your sacrifices My Wife, for always being there And All Ultrasound enthusiasts on earth and in space Keith Killu MD, Detroit Dedicated to my wife, who first showed me the value of ultrasound, and to the frontier astronaut and cosmonaut sonographers on the International Space Station who inspired us to expand the indications and education for point of care ultrasound Scott A Dulchavsky MD PhD, Detroit To my sweetheart and family for their love, support and patience throughout the entire project and the inspiration for upcoming future endeavors Victor Coba MD, Detroit Leads Authors Keith Killu MD, FCCP, FACP Karthikeyan Ananthasubramaniam MD, FACC,FASE Associate Professor of Medicine/ Wayne State University School of Medicine Director of Nuclear Cardiology and Echo cardiography Lab/ Dept of cardiology, Henry Ford Hospital Clinical Assistant Professor/ Wayne State University School of Medicine Critical Care medicine/Dept of Surgery, Henry Ford Hospital Scott A Dulchavsky MD,PhD Professor/Wayne State University School of Medicine Chairman/Dept of Surgery, Henry Ford Hospital Victor Coba MD David Amponsah MD Assistant Clinical Professor/Wayne State University School of Medicine Ultrasound Director/ Dept of Emergency Medicine, Henry Ford Hospital J Antonio Bouffard MD Senior Staff Radiologist/ Bone Radiology Division Department of Diagnostic Radiology, Henry Ford Hospital Critical Care Medicine/Emergency Medicine Staff Physician/Dept of Emergency Brian M Craig MD Medicine Ultrasound Section Leader Henry Ford Hospital Dept of Radiology, Henry Ford Hospital Kathleen Garcia FASE, RVT Wyle Integrated Science & Engineering Houston, Texas Patrick R Meyers BS, RDMS,RDCS, RVT Owner Musculoskeletal Ultrasound of Wisconsin Jennifer Milosavljevic MD Staff Physician Dept of OB/GYN, Henry Ford Hospital Luca Neri, MD Professor/USCME Project Director Past President, WINFOCUS Critical Care A O Niguarda Ca’ Granda Hospital Milano, Italy Kathleen O’Connell Medical Student Wayne State University School of Medicine Detroit, Michigan Guillermo Uriarte RN,RDCS,RCVT Technical Director, Lead Echo Sonographer Dept of Noninvasive Cardiology Henry Ford Hospital Gabiele Via, MD Editorial Board/Critical Ultrasound Journal Department of Anesthesia & Intensive Care University of Pavia • Pavia, Italy Contributors Jack Butler Media Specialist, Surgical Imagineer Dept of Surgery/Henry Ford Hospital Butler Graphics, Inc., CEO Ashot Sargsyan, MD Wyle Integrated Science & Engineering Houston, Texas Neil Rudzinski Media Specialist 3D Visualization Dept of Surgery/Henry Ford Hospital Enrico Storti, MD USCME Project Codirector, WINFOCUS Critical Care A O Niguarda Ca’ Granda Hospital Milano, Italy Volunteers Peter Altshuler Alexandria Dulchavsky Caitlin Reddy Michael Nowak Table of Contents Foreward / Preface Lung Exam 159 Getting Started / Equipment, Terminology and Knobology 10 Optic Nerve Exam 182 Cardiac Exam 23 OB/GYN 190 FAST, Extended FAST/Abdominal Exam 70 Soft Tissue & DVT 200 Evaluation of the Aorta 116 Procedures 214 Vascular 126 YES NO Clinical Protocols 234 Abbreviations AO Aorta Inn Innominate PW AV Aortic Valve IVC Inferior Vena Cava RA CCA Common Carotid Artery IVS Interventricular Septum CBD Common Bile Duct CCW Counterclockwise LLQ Color Flow LUQ Left Upper Quadrant RV CF LA Right Atrium RAP Right Atrial pressure Left Atrium RLQ Right Lower Quadrant Left Lower Quadrant RUQ Right Upper Quadrant Common Femoral Artery CFV Common Femoral Vein LVOT CHD Common Hepatic Duct MV Mitral Valve ON Optic Nerve SCV Subclavian Vein Optic Nerve Sheath Diameter SFA Superficial Femoral Artery Pulmonary Artery Pressure SFV Superficial Femoral Vein Pulmonary Embolus SVC Superior Vena Cava CW Clockwise Dilated Cardiomyopathy DFV Deep Femoral Vein ONSD PAP ET Endotracheal PE FV Femoral Vein PEA GB Gallbladder PFA Left Ventricle Left Ventricular Outflow Tract Right Ventricular Inflow Tract Right Ventricular Outflow Tract TV Tricuspid Valve Profunda Femoris Artery US Ultrasound Greater Saphenous Vein PI Pulmonary Incompetence HOMC Hypertrophic Obstructive Cardiomyopathy PR Pulmonary Regurgitation PV Pulmonary Valve Internal Jugular Vein RVOT Pulseless Electrical Activity GSV IJV RVIT Right Ventricle CFA DCM LV Pulsed Wave Doppler Preface & Foreword PREFACE FOREWORD GETTING STARTED CARDIAC ABDOMINAL AORTA VASCULAR LUNG OPTIC NERVE OB/GYN SOFT TISSUE BONE & DVT PROCEDURES PROTOCOLS PREFACE FOREWORD GETTING STARTED CARDIAC ABDOMINAL AORTA VASCULAR LUNG OPTIC NERVE OB/GYN SOFT TISSUE BONE & DVT PROCEDURES PROTOCOLS Preface The ICU Ultrasound pocket book is far and above the most concise, targeted reference source to enable the novice or advanced emergency or ICU clinician to incorporate point of care ultrasound into their practice This book effectively teams internationally recognized sonologists with NASA researchers developing just in time ultrasound training methods for astronauts on the International Space Station, to provide a rapid ultrasound diagnostic and procedural guide for the ICU The comprehensive sections included in this book cover the ever expanding array of clinical indications for non-radiologist performed ultrasound and provide a novel addition to this field Scott A Dulchavsky MD PhD Detroit 2010 Foreword Bedside intensivist-performed ultrasonography easily qualifies as one of the most, if not the most important paradigm shifting technology developed in critical care in recent years The availability of less expensive, smaller machines with better resolution has made bedside examination by the intensivist feasible What is it about bedside ultrasonography that is so compelling for the ICU physician? Ultrasonography permits the “ultimate” physical examination It allows immediate assessment of vital cardiopulmonary, abdominal, renal, and vascular structural and functional elements in the unstable patient Considerably less diagnostic guess work results in a more precise workup, with less unnecessary, and potentially hazardous, transports to radiology Furthermore it replaces “blind” or landmark guided procedures with defined anatomic visualization that translates into safer, faster, and less painful procedures Critical Care physicians have been slower than their Emergency Medicine colleagues to adopt this technology, but this is changing rapidly There is an expanding literature on the use of ultrasonography in critically ill patients Recent consensus guidelines outlining specific elements of knowledge that define competency in critical care ultrasound have been published Training guidelines and examinations designed to demonstrate proficiency in critical care ultrasonography are the next steps to fully establishing intensivist-performed ultrasound This book succeeds outstandingly in one important part of that process: the creation of educational materials designed to be used at the ICU bedside to guide image acquisition, image interpretation, and procedural ultrasound As such “The ICU Ultrasound Pocket Book” is a valuable resource for medical students, nurses, physician extenders, residents, and fellows, as well as practicing intensivists PREFACE FOREWORD John M Oropello, MD, FCCM, FCCP, FACP Program Director, Critical Care Medicine Professor of Surgery & Medicine Mount Sinai School of Medicine New York, N.Y GETTING STARTED CARDIAC ABDOMINAL AORTA VASCULAR LUNG OPTIC NERVE OB/GYN SOFT TISSUE BONE & DVT PROCEDURES PROTOCOLS PREFACE FOREWORD GETTING STARTED CARDIAC ABDOMINAL AORTA VASCULAR LUNG OPTIC NERVE OB/GYN SOFT TISSUE BONE & DVT PROCEDURES PROTOCOLS Getting Started Equipment, Knobology & Terminology Ashot Sargsyan, MD Kathleen Garcia, FASE, RVT Advantages of Ultrasound Contents Transducers 11 Ultrasound Machine 12 Definitions 13 Modes 14 Controls 16 Image Orientation 18 Terminology 20 Transducer Orientation 21 Getting Started 22 • Noninvasive • Highly feasible • Rapid, versatile & repeatable • Time saving Be familiar with your ultrasound machine Knobology may be presented differently by different machines, but the principle is the same Setting the machine initially to obtain the best sonographic picture is of ultimate importance The learning curve is usually steep 10 PREFACE FOREWORD GETTING STARTED CARDIAC ABDOMINAL AORTA VASCULAR LUNG OPTIC NERVE OB/GYN SOFT TISSUE BONE & DVT PROCEDURES PROTOCOLS Tracheostomy & Endotracheal ( ET) Intubation Tracheal Ring Procedure and Views Tracheostomy Procedure to be performed following the standard technique Thyroid Gland Pre procedure ultrasound will help • Identify tracheal and paratracheal tissue and blood vessels • Identify the depth of the trachea • Choose best incision site US can be used during the procedure for guidance Trachea Carotid Artery ET intubation US can be used post intubation to confirm the ET tube inside the trachea Trachea/Short Axis 232 Tracheostomy & Endotracheal ( ET) Intubation Procedure and Views (cont.) Inflated cuff • Find the cuff by angling the transducer inferiorly • Appears more echogenic • Acoustic shadowing can be seen • Inflating and deflating the balloon will create a sliding motion Tracheal Cartilage ET tube balloon ET Tube Acoustic shadowing ET Tube/Short Axis ET Tube/Long Axis PREFACE FOREWORD GETTING STARTED CARDIAC ABDOMINAL AORTA VASCULAR LUNG OPTIC NERVE OB/GYN SOFT TISSUE BONE & DVT PROCEDURES PROTOCOLS 233 PREFACE FOREWORD GETTING STARTED CARDIAC ABDOMINAL AORTA VASCULAR LUNG OPTIC NERVE OB/GYN Clinical Protocols Luca Neri, MD Enrico Storti, MD Gabriele Via, MD Thanks to Daniel Lichtenstein for his guidance and inspiration YES NO Contents Table Table A Table B Table B.1 Table B.2 Table B.3 Table B.3 Table C Table C Table C1 Ultrasound Life Support WINFOCUS Pathways Airway Focused Ultrasound Breathing Focused Ultrasound Breathing Focused Ultrasound Breathing Focused Ultrasound Dyspnea Multi-focused Ultrasound Dyspnea Multi-focused Ultrasound (cont.) Shock Focused Echocardiography Shock Focused Echocardiography (cont.) Shock Multi-focused Ultrasound 235 236 237 238 239 240 241 242 243 244 SOFT TISSUE BONE & DVT PROCEDURES PROTOCOLS 234 Table - Ultrasound Life Support WINFOCUS Pathways ABCDE: Multi-focused Ultrasound A B C D E Airway Breathing Circulation Disability Expose, Exclude Extend to Head-to-toes Cervical US Lung US Echo Ocular US Head & Other Subcutaneous emphysema hematomas Atelectasis Pulmonary edema Pneumonia, Contusion Cardiac function Pericardial fluid Pulmonary embolism Procedures ONSD, Pupillary reflexes, Emphysema, Retinal Detachment Ocular, skull, cervical, pelvis, limbs Procedures & Monitor Trachea patency, placement & lesions ET Device patency & placement Pleural US Vascular US Cranial US Thorax US Sq emphysema Pneumothorax Pleural fluid Procedures IVC , AAA, DVT, Access Trans-cranial Doppler Midline shift Fractures Advanced ECHO, lung, mediastinum, Procedures & Monitor MSK US Hematomas, Fractures Lung US Echo/Vascular US Abdominal US Diaphragm US Abdominal US Subcutaneous emphysema Dynamic lung artifacts Cardiac function, DVT FAST, Hematomas Paralysis/Paresis [Cervical lesion] Visceral & parenchymal organs, Retro-peritoneum, Procedures PREFACE FOREWORD GETTING STARTED CARDIAC Diaphragm US OB/GYN US Paralysis, Injuries Ectopic, Hematomas ABDOMINAL AORTA VASCULAR LUNG OPTIC NERVE OB/GYN SOFT TISSUE BONE & DVT PROCEDURES PROTOCOLS 235 PREFACE FOREWORD GETTING STARTED CARDIAC ABDOMINAL AORTA VASCULAR LUNG OPTIC NERVE OB/GYN SOFT TISSUE BONE & DVT PROCEDURES PROTOCOLS Table A - Airway Focused Ultrasound PERFORMANCE GOAL CLINICAL QUESTION ULTRASOUND APPROACH Tracheal integrity Tracheal imaging Midline position Tracheal imaging ET Tube US signs* ET Tube inside trachea Airway ETT* Position ET tube above the carina Airway patent RESULTS INTERPRETATIONS¶ ULTRASOUND FINDINGS Regular profiles No tracheal displacement or injury No E-Lines ET tube in correct position ET tube above carina Yes/Bilateral Thoracoabdominal US Lung & Pleural Profiles A Profile= anterior A lines with lung sliding A’ Profile= A lines with no lung sliding B Profile= bilateral anterior B lines with lung sliding B’ Profile= bilateral B lines with no lung sliding A/B Profile= B lines on one side, A lines on the other side C Profile= alveolar consolidation Yes Ventilatory US signs** No/Unilateral No/Bilateral Lung pulse B or C profile Lung pulse B or C profile Contra-lateral main stem intubation Ipsi-lateral atelectasis adhesion No Ipsi-lateral pneumothorax [Lung point to confirm] Yes Upper airway obstruction ET Tube misplaced apnea Bilateral atelectasis adhesions No Bilateral pneumothorax [Lung point to confirm] * ET Tube US Signs: Hyperechoic round artifact, reverberations, tilting artifacts ** Thoraco-abdominal Ventilatory US Signs: Lung sliding, Dynamic air bronchogram, B/C lines or Consolidation movements, Fluid movements ¶ Likely diagnosis Prefer and continue with the corresponding protocol Always confirm results clinically 236 Table B Breathing Focused Ultrasound PERFORMANCE CLINICAL ULTRASOUND GOAL QUESTION APPROACH Pleural & lung US Breathing ULTRASOUND FINDINGS Low Fluid/Air ratio ‘Artifacts’ Table B1 High Fluid/Air ratio ‘Solids’ Table B2 Dyspnea/ Hypoxia Diaphragm & Chest Wall US PREFACE FOREWORD GETTING STARTED CARDIAC ABDOMINAL AORTA VASCULAR LUNG OPTIC NERVE OB/GYN SOFT TISSUE BONE & DVT PROCEDURES PROTOCOLS 237 PREFACE FOREWORD GETTING STARTED CARDIAC ABDOMINAL AORTA VASCULAR LUNG OPTIC NERVE OB/GYN SOFT TISSUE BONE & DVT PROCEDURES PROTOCOLS Table B.1 - Breathing Focused Ultrasound PERFORMANCE CLINICAL ULTRASOUND GOAL QUESTION APPROACH Yes [Seashore] Low Fluid/Air ratio ‘Artifacts’ Breathing Dyspnea/ Hypoxia RESULTS INTERPRETATIONS¶ ULTRASOUND FINDINGS Pleural & lung US B-Lines Diffuse bilateral [B Pattern] Focal [B Pattern] Sliding sign None or scattered [A Pattern] No [Stratosphere] Lung Pulse B-Lines or consolidations Lung Point No lung pulse, no lung point ¶ Likely diagnosis Refer and continue with the corresponding protocol Always confirm results clinically No Pneumothorax in the explored region Pulmonary Edema, ARDS, other interstitial lesions Pneumonia, contusions, other interstitial lesions Normal, COPD, asthma, pulmonary embolism Airway obstruction, apnea, atelectasis, adhesion No Pneumothorax Pneumonia, contusions, ARDS, other lesions No Pneumothorax Pneumothorax Possible pneumothorax with full collapse 238 Table B.2 - Breathing Focused Ultrasound PERFORMANCE CLINICAL ULTRASOUND GOAL QUESTION APPROACH RESULTS INTERPRETATIONS¶ ULTRASOUND FINDINGS Prevalent fluid pattern* Breathing Dyspnea/ Hypoxia Pleural & lung US Dynamic air bronchogram ± fluid bronchogram Homogeneous High Fluid/Air ratio ‘Solids’ * Fluid Pattern US Findings: Hypo/anechoic pattern, fluctuation & sinusoid sign, regular border & Quad sign Prevalent tissue pattern** Heterogeneous ** Tissue Pattern US Findings: Resembling liver paranchyma, solid, irregular borders, shred sign & air/fluid bronchograms ¶ Likely diagnosis Refer and continue with the corresponding protocol Always confirm results clinically PREFACE FOREWORD GETTING STARTED CARDIAC ABDOMINAL AORTA Pleural effusion from any cause Static air bronchogram ± fluid bromchogram LUNG OPTIC NERVE OB/GYN Possible atelectasis, apnea, airway obstruction, or adhesions atelectasis or effusions No air or fluid bronchogram Liver & Spleen images Intrapleural imaging Septated effusions possible hemothorax, tumors Parietal or parenchymal imaging VASCULAR pneumonia, contusion, PE, ARDS SOFT TISSUE BONE & DVT Possible abscesses, lacerations, hematomas, tumors, lymph nodes PROCEDURES PROTOCOLS 239 PREFACE FOREWORD GETTING STARTED CARDIAC ABDOMINAL AORTA VASCULAR LUNG OPTIC NERVE OB/GYN SOFT TISSUE BONE & DVT PROCEDURES PROTOCOLS Table B.3 Dyspnea Multi-focused Ultrasound Pneumothorax Pulmonary Edema Lung Contusion RV dilated, hypokinetic, paradoxical IVS RV small, hyperkinetic +/- LV dilated, LV hypokinetic ± valvular dysfunction Variable Variable Fixed & distended Fixed & distended Fixed & distended Variable Lung Focal B or B’, ±Shred sign, ± dynamic air bronchogram, ± pleural effusion A Profile Lung pulse, ± Consolidation A’ Profile ± Lung Point ±E Lines B Profile Lung pulse, ± Pleural Fluid Focal B or B’, Shred sign, ± dynamic air bronchogram, ± pleural fluid Others ± Reduced diaphragm movement ±Vein thrombosis, Distended hepatic veins ±Tracheal displacement, distended hepatic veins ±Distended hepatic veins ±Pleural or peritoneal fluid Dyspnea Patterns Pneumonia Heart ± Pericardial Fluid IVC Pulmonary Embolism 240 Table B.3 Dyspnea Multi-focused Ultrasound (cont.) COPD Asthma Heart Variable RV dilated & hypertrophic Variable Variable RV dilated & hypertrophic Variable RV dilated & hypokinetic Variable IVC Variable Variable Variable Variable Variable Lung A Profile lung pulse, ± Sliding A Profile lung pulse, ± Sliding B Profile lung pulse ± Sliding Dyspnea Patterns Others PREFACE FOREWORD GETTING STARTED - CARDIAC Chronic Interstitial Disease - ABDOMINAL AORTA ARDS B/C Profile, lung pulse, ± Sliding, ± dynamic air bronchogram ± fluid - VASCULAR LUNG OPTIC NERVE - OB/GYN SOFT TISSUE BONE & DVT Upper Airway Obstruction Atelectasis ETT Displacement Bi/Uni-lateral A Profile, lung pulse, ± Sliding, ± static air bronchogram Diaphragm movement ± esophageal ETT placement PROCEDURES PROTOCOLS 241 PREFACE FOREWORD GETTING STARTED CARDIAC ABDOMINAL AORTA VASCULAR LUNG OPTIC NERVE OB/GYN SOFT TISSUE BONE & DVT PROCEDURES PROTOCOLS Table C Shock Focused Echocardiography Shock State Pre Existing Cardiac Disease Focused Echo Findings Potential Clinical Diagnosis I LV and LA dilatation Yes Dilated Cardiomyopathy II LV hypertrophy Yes Hypertrophic Obstructive Cardiomyopathy, Aortic Stenosis, Hypertensive Cardiomyopathy… III RV dilatation ± hypertrophy Yes Chronic Cor Pulmonale IVC < cm & Inspiratory collapse >50% during spontaneous breathing < 1-1.5 cm & Inspiratory distention >20% during passive mechanical ventilation Hypovolemia 1.5-2.5 cm with respiratory variation Inspiratory collapse