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P1: PBU 0521688697pre CUFX157/Noble 521 86017 July 19, 2007 23:4 This page intentionally left blank ii P1: PBU 0521688697pre CUFX157/Noble 521 86017 July 19, 2007 23:4 Manual of Emergency and Critical Care Ultrasound The use of ultrasound has revolutionized the way many acute injuries and conditions are managed in emergency departments (ED) and critical care units, with several accrediting agencies mandating that physicians become proficient in the applications and interpretation of ultrasound Today, EDs and critical care units nationwide are outfitted with ultrasound equipment, allowing acute conditions such as ectopic pregnancy or abdominal aortic aneurysm rupture to be diagnosed within critical seconds This book is a practical and concise introduction to bedside emergency ultrasound It covers the full spectrum of conditions diagnosed via this modality and gives useful instruction for using ultrasound to guide commonly performed invasive procedures It introduces the major applications for emergency ultrasound by using focused diagnostic questions and teaching the image acquisition skills needed to answer these questions Images of positive and negative findings for each application (FAST, echocardiography, etc.) are presented, as well as scanning tips for improved image quality Each section also contains a review of the literature supporting each application Dr Vicki E Noble is the director for emergency ultrasound at Massachusetts General Hospital in Boston, MA She received her MD from the University of Pennsylvania in 1999 and completed a fellowship in emergency ultrasound at St Luke’s–Roosevelt Hospital in New York She is a Fellow of the American College of Emergency Physicians and is the Ultrasound Section subcommittee chair for education and practice standards She is also a member of the American Institute of Ultrasound in Medicine and has been a member of the American Registry of Diagnostic Medical Sonographers since 2004 She has been awarded the Society for Academic Emergency Medicine Excellence Award and has been nominated for the Harvard University Medical School Teaching Award and the Brian McGovern Award for Clinical Excellence at Massachusetts General Hospital She has taught extensively in emergency ultrasound both in the United States and internationally Dr Bret Nelson is director of emergency ultrasound for the Department of Emergency Medicine at Mount Sinai School of Medicine in New York He is a member of the American College of Emergency Physicians, the American Institute of Ultrasound in Medicine, and the American Registry of Diagnostic Medical Sonographers He has taught courses on ultrasound throughout Europe and the United States and received the Excellence in Teaching Award at Mount Sinai Dr A Nicholas Sutingco is the director of emergency ultrasound for the Departments of Emergency Medicine at the INOVA Fair Oaks Hospital in northern Virginia He received his MD from the George Washington University School of Medicine and completed his emergency medicine residency training at the Massachusetts General Hospital/Brigham and Women’s Hospital He is a member of the American College of Emergency Physicians and is active in teaching courses in ultrasound in northern Virginia i P1: PBU 0521688697pre CUFX157/Noble 521 86017 July 19, 2007 ii 23:4 P1: PBU 0521688697pre CUFX157/Noble 521 86017 July 19, 2007 23:4 Manual of Emergency and Critical Care Ultrasound Vicki E Noble Massachussetts General Hospital Bret Nelson Mount Sinai School of Medicine A Nicholas Sutingco INOVA Fair Oaks Hospital & The Fauquier Hospital iii CAMBRIDGE UNIVERSITY PRESS Cambridge, New York, Melbourne, Madrid, Cape Town, Singapore, São Paulo Cambridge University Press The Edinburgh Building, Cambridge CB2 8RU, UK Published in the United States of America by Cambridge University Press, New York www.cambridge.org Information on this title: www.cambridge.org/9780521688697 © Vicki E Noble, Bret Nelson, A Nicholas Sutingco 2007 This publication is in copyright Subject to statutory exception and to the provision of relevant collective licensing agreements, no reproduction of any part may take place without the written permission of Cambridge University Press First published in print format 2007 eBook (NetLibrary) ISBN-13 978-0-511-35590-5 ISBN-10 0-511-35590-4 eBook (NetLibrary) paperback ISBN-13 978-0-521-68869-7 paperback ISBN-10 0-521-68869-8 Cambridge University Press has no responsibility for the persistence or accuracy of urls for external or third-party internet websites referred to in this publication, and does not guarantee that any content on such websites is, or will remain, accurate or appropriate Every effort has been made in preparing this book to provide accurate and up-to-date information that is in accord with accepted standards and practice at the time of publication Nevertheless, the authors, editors, and publisher can make no warranties that the information contained herein is totally free from error, not least because clinical standards are constantly changing through research and regulation The authors, editors, and publisher therefore disclaim all liability for direct or consequential damages resulting from the use of material contained in this book Readers are strongly advised to pay careful attention to information provided by the manufacturer of any drugs or equipment that they plan to use P1: PBU 0521688697pre CUFX157/Noble 521 86017 July 19, 2007 23:4 Contents Contents Acknowledgments xi 1 Fundamentals Basic Definitions and Physics Principles Basic Instrumentation Using the Transducer/Probe Understanding the Formed Image Adjusting the Image Scanning Modes Effects and Artifacts 10 10 12 14 PART I DIAGNOSTIC ULTRASOUND 19 23 Focused Assessment with Sonography in Trauma (FAST) Introduction Focused Questions of the FAST Exam Anatomy Technique Scanning Tips Normal Images Abnormal Images Extended FAST or eFAST Sample Clinical Protocol Literature Review Detection of Pneumothorax Technique New Directions References 23 24 24 28 33 34 37 42 43 43 45 45 49 49 53 Echocardiography Introduction Focused Questions for Echocardiography Anatomy Technique Scanning Tips Normal Images 53 53 54 55 64 65 Contents v P1: PBU 0521688697pre CUFX157/Noble 521 86017 July 19, 2007 23:4 Contents Abnormal Images Advanced Applications Guidance for Procedures Sample Clinical Protocols Literature Review New Directions References 66 70 76 77 79 80 80 85 First Trimester Ultrasound Introduction Focused Questions for First Trimester Ultrasound Terminology hCG Levels Anatomy Technique Normal Images in Early Pregnancy Ectopic Pregnancy Abnormal Images Sample Clinical Protocol Literature Review New Directions References 85 85 86 87 87 88 92 97 98 100 101 101 102 105 Abdominal Aortic Aneurysm Introduction Focused Questions for Aortic Ultrasound Anatomy Technique Scanning Tips Abnormal Images Sample Clinical Protocol Literature Review References 105 105 106 106 112 113 115 117 118 119 Renal and Bladder Introduction Focused Questions for Renal and Bladder Ultrasound Anatomy Technique Bladder Volume Estimation vi Contents 119 119 119 120 123 P1: PBU 0521688697pre CUFX157/Noble 521 86017 July 19, 2007 23:4 124 124 126 131 132 132 132 135 Gallbladder Introduction Focused Questions for Gallbladder Ultrasound Anatomy Technique Measurements Scanning Tips Normal Images Abnormal Images Sample Clinical Protocol Literature Review References 135 135 135 136 139 140 141 143 149 149 151 153 Deep Vein Thrombosis Introduction Focused Questions for DVT Ultrasound Anatomy Technique Scanning Tips Normal Images Abnormal Images Sample Clinical Protocol Advanced Techniques Literature Review References 153 153 153 155 160 161 162 164 164 166 166 169 Chest Ultrasound Introduction Focused Questions for Lung Ultrasound Anatomy Technique Scanning Tips 169 169 169 171 172 Contents vii Contents Scanning Tips Normal Images Abnormal Images Sample Clinical Protocol Literature Review New Directions References P1: PBU 0521688697pre CUFX157/Noble 521 86017 July 19, 2007 23:4 Contents Images Literature Review New Directions References 172 173 173 173 10 Ocular Ultrasound 175 Introduction Focused Questions for Ocular Ultrasound Anatomy Technique Scanning Tips Normal Images Abnormal Images Literature Review New Directions References 175 175 175 177 177 178 179 180 181 181 11 Fractures 183 Introduction Focused Questions for Bone Ultrasound Anatomy Technique Scanning Tips Normal Images Abnormal Images Literature Review New Directions References 183 183 183 184 184 185 186 187 188 189 PART II PROCEDURAL ULTRASOUND 191 12 Vascular Access 195 Introduction Focused Questions for Vascular Access Anatomy Technique Cannulation of the Subclavian Vein Cannulation of the External Jugular Vein Peripheral Venous Cannulation Scanning Tips Pitfalls 195 195 195 198 205 205 205 206 207 viii Contents ... some other identifier (Figure 1.9) Objects located near the probe marker on the transducer will appear near the probe marker on the screen Objects opposite the probe marker will appear on the other... Hospital & The Fauquier Hospital iii CAMBRIDGE UNIVERSITY PRESS Cambridge, New York, Melbourne, Madrid, Cape Town, Singapore, São Paulo Cambridge University Press The Edinburgh Building, Cambridge. .. side of the screen marker For the most part, bedside ultrasound keeps the screen marker on the lefthand side of the screen However, formal echocardiography is performed with the marker on the right-hand