Abd

- [Voiceover] A curved, or phased array transducer,
with a pelvis exam type,
is used to perform the pelvis ultrasound exam.
A full bladder is used as an acoustic window
to view the pelvic organs.
The pelvis is evaluated in two plains.
Place the transducer in a long axis position
with the orientation marker to the patient's head,
at the level of the symphysis pubis.
Angle the transducer inferiorly into the pelvis.
The bladder appears in the near-field of the image,
as a hypoechoic triangular structure.
The uterus is gray in appearance
and located either directly posterior
or superior to the bladder.
The endometrial stripe will appear as
a bright echogenic line from the fundus to the cervix.
The uterus does not always lay directly in the midline
so it may be necessary to slightly rotate the transducer
to view the entire length of the uterus.
Sweep the transducer from side to side
to see the entire uterus.
The ovaries may be seen by sweeping the transducer
to the lateral aspects of the pelvis.
They are almond-shaped and slightly hypoechoic structures.
Follicles may appear as multiple
hypoechoic, cystic structures within the ovaries.
Some follicles may be quite prominent,
depending upon the luteal stage.
To obtain a transverse view of the uterus,
rotate the transducer 90 degrees,
so the orientation marker is to the patient's right.
The bladder appears more rectangular in shape in this view.
Sweep the transducer superiorly
from the level of the cervix to the fundus
to see the entire uterus.
The ovaries will be seen on either side of the uterus
and can vary in location,
from a superior to inferior position.

Brightcove ID

5750473717001

https://youtube.com/watch?v=ebpcUlQVmLE

How To: FAST Exam: Female Pelvis

Read more about How To: FAST Exam: Female Pelvis

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Learn to examine the female pelvis for free fluid.

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- We're gonna do the FAST exam,
the pelvic view in a female now.
Again we have the phase array transducer,
here's our probe marker right here,
I'm gonna start off with a sagittal view.
And ideally, the (slurred) bladder is full.
So you go just above the symphysis pubis,
so we're scanning down here sagittaly,
and some of the anatomic landmarks
that we're looking at,
at the very top of the screen is the bladder,
which is an anechoic structure,
fluid filled, obviously with urine,
it's got nice walls around it.
Just below that is the uterus,
which is a pear-shaped organ.
You can see it well visualized
because the bladder is full.
And just below that
is a potential space, the Cul de Sac,
where we can look for, very carefully,
small amounts of free fluid.
When we scan this patient,
in this view, in the sagittal view,
from the patient's left to the patient's right.
And we're slowly slowly scanning to see
if there's any evidence of free fluid.
Once we finish the sagittal view,
we want to go ahead and do a transverse view.
What we're gonna do now
is point the transducer marker toward the patient's right.
So we're gonna rotate that transducer,
toward the patient's right.
Again, we see the bladder in the center of the screen.
We're now gonna scan from inferior,
just below the symphysis, to more superior,
and in between we're also gonna identify the uterus.
So we're going right to the very top of the bladder,
to about mid-bladder,
we can see the uterus here in the center.
A very small amount of free fluid here,
which can be physiological as well.
So we're scanning all the way inferiorly,
to more superiorly, we see the uterus,
we actually see part of the ovary there,
and then we're gonna go all the way more superiorly.

Brightcove ID

5508120185001

https://youtube.com/watch?v=HxQE2gYH3Sk

How to: FAST Exam: LUQ

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Learn to scan the splenorenal recess for fluid collections.

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- The next view I'm going to take you through
is a perisplenic or left upper quadrant view.
This view tends to be a little bit more difficult
because the spleen is smaller and doesn't provide
as large an acoustic window.
We're going to start.
Again, the patient's going to be supine.
This is a probe marker right here.
We're going to go really posterior.
My hand is going to touch the gurney.
You can go about four finger breadths
just above the costal margin.
You can identify the kidney.
That's going to be a pretty identifiable organ,
characteristic bean shape.
Then we can see it here on the screen.
Just above it, we're going to see the spleen.
To the far left of the screen as well
we see the diaphragm.
Once you're in this location,
you want to carefully pan through
the inferior part of the spleen,
and then jump over that rib,
and see the superior part of the spleen,
because fluid often collects just above the spleen
and below the diaphragm.
Once you identify a good view in the left upper quadrant,
you'll want to do a sweep through that area
looking for free fluid.
Again, you see the kidney, you see the spleen.
Find the interface between.
Look for fluid between those two organs.
Then particularly scan above that spleen,
scanning all the way through the organ,
looking for free fluid above the spleen
and below the diaphragm.
Again, when you're scanning through this area,
you want to carefully look above the diaphragm
for evidence of hemothorax.
When you're scanning in this view,
also make sure you scan the full kidney.
Here we see the superior pole to the left of the screen,
and the inferior pole.
You want to make sure you get that full kidney
in view when you examine the left upper quadrant.

Brightcove ID

5508114757001

https://youtube.com/watch?v=IuRklL3cWJU

How To: CBD Measurements

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Learn how to measure the common bile duct.

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Double Barrel Shotgun Sign

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- The more advanced area that you may want to look at
is actually measuring the bile duct.
That's a pretty straight forward procedure.
First thing you do is again find that exclamation sign.
And again we see it here with the gallbladder in length
we see the portal vein,
and just above the portal vein lies the bile duct.
So when we carefully scan you can see an area.
Just above the portal vein which is anechoic.
I'm going to freeze this here in a moment.
And you should be able to see a very tiny duct.
If you are squinting at the screen like I am
trying to see where the duct is.
You are dealing with a patient with a normal duct.
Usually if the duct is enlarged it will be quite evident,
and it can be as large as the portal vein itself.
So I'm going to freeze this here.
So on the screen right now I have a reasonably good image
of the portal vein,
and the associated structures around it.
Right above it we see a very tiny anechoic stripe,
that is the bile duct.
In addition, we also note a very small area which is the
hepatic artery which I'll point out in a moment.
So what we are going to do now is go ahead
and do the measurement of the bile duct.
A normal bile duct measurement is about four millimeters
or less or about one millimeter per decade of life.
So I'm going to go ahead and hit caliper.
And I'm going to drag one end of this to the inter aspect
of the bile duct.
Once I have found that I'm going to hit select,
and I'm going to drag this down.
Just adjacent to it and you can see we are getting
a measurement here of .14 centimeters or 1.4 millimeters,
so well within the normal limits.
Okay I'm going to illustrate to you where
the hepatic artery is.
We can see first this is the portal vein right here.
Right above it is that little anechoic stripe,
which is very tiny and difficult to see,
because this bile duct is normal.
This is the common bile duct.
But right adjacent to here is another anechoic structure,
which is an hepatic artery.
If there is ever any confusion of what you're measuring
you can easily turn the color flow on
to differentiate the two.

Brightcove ID

5733871281001

https://youtube.com/watch?v=S72PbzqihrI

How to: Gallbladder

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Learn the basic approach to scanning the right upper quadrant for biliary tract pathology.

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- Okay, I'm gonna take you through the gallbladder exam.
So in the emergency department you may have
a patient with abdominal pain.
The question is, who are you gonna do a gallbladder exam on?
The patients that you suspect
cholecystitis or biliary colic
are the ones that we're gonna primarily be
doing this exam on.
The exam setup is very straightforward,
let me take you through it.
We have our M-Turbo system here,
it's already powered up and on.
We have a selection of two different transducers.
Most of you may already have this transducer,
this is a phased array transducer,
this is the same transducer you're gonna use
for the FAST exam and echocardiography.
The other transducer that you may also have
is a curvilinear transducer.
This is an excellent transducer,
though you'll sometimes have problems with rib shadows.
So you can use either one,
but for today's demonstration
I'm gonna take you through the phased array.
So once you've chosen the transducer,
the next step is to choose the exam type on the machine.
To choose the examination configuration,
it's very straightforward.
We hit the Exam key right here,
and with the selected transducer right now
we can choose between abdominal, OB, and cardiac.
And for this exam we're gonna choose abdomen,
so I'm gonna hit Select,
and we're gonna be ready to start scanning.
So I had the patient turn to
the left lateral decubitus position,
and I like to have their elbow up as well.
The next thing I do is I draw an imaginary line
along the costal margin,
and we have an imaginary perpendicular line
along the line of the shoulder.
So then I'm gonna put my transducer
right about in this area,
and I should have a very long axis of the gallbladder.
So here's our transducer marker right here.
Again, I'm at the costal margin
pointing toward the shoulder,
and I'll try to find the gallbladder.
So when you're scanning the right upper quadrant,
sometimes you'll have to have
the patient take a deep breath.
And what'll happen is the liver will be pushed down
and the gallbladder will come easier into view.
So that's a little trick that you can use
to see organs in the upper quadrant
that you may not be able to identify easily.
And what we see here on the screen
is what we term the exclamation sign.
The exclamation sign is
the long part of the gallbladder here, and a dot.
And that dot is the portal vein.
They're together, that is a very important landmark.
I'll be scanning through the entire gallbladder
in a long axis fashion,
and then I'll turn the transducer
just a little bit to the right,
and I'll start scanning up to down in a short axis plane.
Things that you can do to optimize that image,
first thing you can do is change your depth.
So in this gentleman I may decrease the depth just slightly
to just sort of bring the gallbladder
better into mod-center field of view.
The other things that I can do
is adjust the gain slightly.
So I can try playing with my gain slightly higher,
and you can see the image gets brighter,
or slightly lower.
You want to optimize these settings
so you have good contrast of the fluid-filled structure,
which is the gallbladder in the center,
and you can also notice any artifacts.
So once you've identified the gallbladder,
and you're happy that you can see
the gallbladder in a nice long view,
you have to carefully look for signs of a gallstone.
Once you see the gallstone,
you're gonna then press gently into the right upper quadrant
and see if they have signs of a sonographic Murphy.
Now, we're all familiar, as physicians,
with what a Murphy sign is,
and that's palpation of the right upper quadrant,
and looking for gallbladder tenderness.
A sonographic Murphy is much more specific,
so we're gonna press on the transducer gently,
and to see if that elicits pain.
The next things you're gonna look for
are signs of inflammation of the gallbladder,
such as fluid around the gallbladder,
that's being pericholecystic fluid,
and also gallbladder wall thickening.
So we're gonna look particularly
at the anterior wall of the gallbladder
and see that this is enlarged.
And anything above four millimeters or so
would be a sign of gallbladder inflammation.
So when you're scanning,
you're gonna be carefully looking for signs of a gallstone.
A gallstone will have a hyper-echoic appearance,
meaning it's gonna be brighter in nature,
and it's gonna cast a shadow.
A key point here is make sure
that the hyper-echoic area that you're noticing
actually lies within the gallbladder.
A common mistake would be to identify an area
outside the gallbladder
that would look just like a gallstone,
and that would be a bowel shadow.

Brightcove ID

5508136034001

https://youtube.com/watch?v=Xz-M6pL8Kfw