Case: Aorta Ultrasound - Aneurysms
Case: Aorta Ultrasound - Aneurysms
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This video details how bedside ultrasound imaging can be used to perform abdominal ultrasound examinations.
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<p begin="00:00:14.109" end="00:00:15.631" style="s2">- Hello, my name is Phil Perera</p>
<p begin="00:00:15.631" end="00:00:17.429" style="s2">and I'm the emergency<br />ultrasound coordinator</p>
<p begin="00:00:17.429" end="00:00:20.193" style="s2">at the New York Presbyterian<br />Hospital in New York City,</p>
<p begin="00:00:20.193" end="00:00:22.860" style="s2">and welcome to SoundBytes Cases!</p>
<p begin="00:00:24.063" end="00:00:25.590" style="s2">In this SoundBytes module entitled</p>
<p begin="00:00:25.590" end="00:00:27.793" style="s2">Part 2 of bedside ultrasound of the aorta,</p>
<p begin="00:00:27.793" end="00:00:29.363" style="s2">we'll go further on our discussion</p>
<p begin="00:00:29.363" end="00:00:31.383" style="s2">of bedside ultrasonography of the aorta,</p>
<p begin="00:00:31.383" end="00:00:33.856" style="s2">and detection of abdominal<br />aortic aneurysms.</p>
<p begin="00:00:33.856" end="00:00:36.134" style="s2">We'll begin with a<br />review of the definitions</p>
<p begin="00:00:36.134" end="00:00:37.766" style="s2">and the anatomy of the types of</p>
<p begin="00:00:37.766" end="00:00:39.440" style="s2">abdominal aortic aneurysms that you</p>
<p begin="00:00:39.440" end="00:00:41.802" style="s2">may encounter in the emergency department.</p>
<p begin="00:00:41.802" end="00:00:43.884" style="s2">We'll look at a number<br />of ultrasound images</p>
<p begin="00:00:43.884" end="00:00:45.680" style="s2">demonstrating triple-A's, and we'll</p>
<p begin="00:00:45.680" end="00:00:47.267" style="s2">conclude with a discussion of the</p>
<p begin="00:00:47.267" end="00:00:48.940" style="s2">potential pitfalls of bedside imaging</p>
<p begin="00:00:48.940" end="00:00:51.607" style="s2">of an abdominal aortic aneurysm.</p>
<p begin="00:00:52.628" end="00:00:54.150" style="s2">This illustration shows the types</p>
<p begin="00:00:54.150" end="00:00:55.652" style="s2">of abdominal aortic aneurysms that</p>
<p begin="00:00:55.652" end="00:00:58.170" style="s2">may be encountered in clinical practice.</p>
<p begin="00:00:58.170" end="00:01:00.761" style="s2">The more common type of<br />abdominal aortic aneurysm</p>
<p begin="00:01:00.761" end="00:01:03.406" style="s2">is defined as Fusiform,<br />or diffuse dilatation</p>
<p begin="00:01:03.406" end="00:01:05.225" style="s2">of the abdominal abdominal aorta.</p>
<p begin="00:01:05.225" end="00:01:06.838" style="s2">Remember that a triple-A is defined</p>
<p begin="00:01:06.838" end="00:01:10.017" style="s2">as an aortic diameter greater<br />than three centimeters.</p>
<p begin="00:01:10.017" end="00:01:12.933" style="s2">Let's start by looking at<br />the picture to the far left.</p>
<p begin="00:01:12.933" end="00:01:14.631" style="s2">What we see here is a diffuse dilatation</p>
<p begin="00:01:14.631" end="00:01:17.177" style="s2">of the aorta beginning at<br />the level below the renals,</p>
<p begin="00:01:17.177" end="00:01:21.199" style="s2">and ending just above bifurcation<br />into the iliac arteries.</p>
<p begin="00:01:21.199" end="00:01:23.264" style="s2">Notice the picture towards the middle;</p>
<p begin="00:01:23.264" end="00:01:25.119" style="s2">some of these fusiform aneurysms</p>
<p begin="00:01:25.119" end="00:01:27.087" style="s2">can extend from the abdominal aorta</p>
<p begin="00:01:27.087" end="00:01:29.541" style="s2">all the way down into the iliac artery.</p>
<p begin="00:01:29.541" end="00:01:32.859" style="s2">Now the less common type of<br />abdominal aortic aneurysm</p>
<p begin="00:01:32.859" end="00:01:34.532" style="s2">is known as Saccular, as shown</p>
<p begin="00:01:34.532" end="00:01:35.912" style="s2">in the picture to the far right,</p>
<p begin="00:01:35.912" end="00:01:37.879" style="s2">where you have a localized out-pouching</p>
<p begin="00:01:37.879" end="00:01:39.019" style="s2">of the abdominal wall.</p>
<p begin="00:01:39.019" end="00:01:41.281" style="s2">This next illustration makes the point</p>
<p begin="00:01:41.281" end="00:01:43.421" style="s2">that choosing the<br />correct probe orientation</p>
<p begin="00:01:43.421" end="00:01:45.272" style="s2">is very important in terms of getting a</p>
<p begin="00:01:45.272" end="00:01:46.746" style="s2">correct measurement of the aorta,</p>
<p begin="00:01:46.746" end="00:01:48.111" style="s2">due to the cylinder effect.</p>
<p begin="00:01:48.111" end="00:01:50.704" style="s2">Let's look at the two long axis views</p>
<p begin="00:01:50.704" end="00:01:52.549" style="s2">of the probes along the aorta, as shown</p>
<p begin="00:01:52.549" end="00:01:54.401" style="s2">towards the left of the image here.</p>
<p begin="00:01:54.401" end="00:01:56.089" style="s2">Beginning in probe position 1,</p>
<p begin="00:01:56.089" end="00:01:58.610" style="s2">we see a side slice, in which the probe</p>
<p begin="00:01:58.610" end="00:02:00.700" style="s2">is positioned towards<br />the side of the aorta,</p>
<p begin="00:02:00.700" end="00:02:03.972" style="s2">and underestimating the true<br />diameter of the aortic lumen.</p>
<p begin="00:02:03.972" end="00:02:05.818" style="s2">We can see that positioning the probe</p>
<p begin="00:02:05.818" end="00:02:07.319" style="s2">towards the middle of the image,</p>
<p begin="00:02:07.319" end="00:02:09.177" style="s2">as shown here in probe position 2,</p>
<p begin="00:02:09.177" end="00:02:11.464" style="s2">we'll get a correct<br />diameter, but this can be</p>
<p begin="00:02:11.464" end="00:02:14.384" style="s2">difficult to ascertain using<br />the long axis orientation.</p>
<p begin="00:02:14.384" end="00:02:17.257" style="s2">A better orientation is<br />to position the probe</p>
<p begin="00:02:17.257" end="00:02:18.928" style="s2">in the short axis configuration,</p>
<p begin="00:02:18.928" end="00:02:20.491" style="s2">as shown in probe position 3,</p>
<p begin="00:02:20.491" end="00:02:23.375" style="s2">one can then get a sense<br />in terms of the true lumen,</p>
<p begin="00:02:23.375" end="00:02:24.892" style="s2">and get the best measurements</p>
<p begin="00:02:24.892" end="00:02:26.779" style="s2">of the abdominal aortic aneurysm.</p>
<p begin="00:02:26.779" end="00:02:29.326" style="s2">In the last illustration we made the point</p>
<p begin="00:02:29.326" end="00:02:30.746" style="s2">that it's important to image the</p>
<p begin="00:02:30.746" end="00:02:33.058" style="s2">abdominal aortic aneurysm<br />for an accurate dimension</p>
<p begin="00:02:33.058" end="00:02:34.925" style="s2">in the short axis configuration.</p>
<p begin="00:02:34.925" end="00:02:36.967" style="s2">But it's also very important to include</p>
<p begin="00:02:36.967" end="00:02:39.196" style="s2">outer-wall to outer-wall<br />in the measurements</p>
<p begin="00:02:39.196" end="00:02:41.114" style="s2">of the abdominal aortic aneurysm.</p>
<p begin="00:02:41.114" end="00:02:42.382" style="s2">Here we can see a measurement</p>
<p begin="00:02:42.382" end="00:02:44.910" style="s2">of a triple A only<br />including the inner lumen,</p>
<p begin="00:02:44.910" end="00:02:47.337" style="s2">and notice that we could<br />vastly underestimate</p>
<p begin="00:02:47.337" end="00:02:50.066" style="s2">the true diameter of<br />this very large triple-A.</p>
<p begin="00:02:50.066" end="00:02:52.211" style="s2">Here's the correct dimensions</p>
<p begin="00:02:52.211" end="00:02:53.938" style="s2">of the abdominal aortic aneurysm,</p>
<p begin="00:02:53.938" end="00:02:55.579" style="s2">and notice here, that we're measuring</p>
<p begin="00:02:55.579" end="00:02:57.423" style="s2">anterior, posterior, and laterally,</p>
<p begin="00:02:57.423" end="00:03:00.091" style="s2">including the thrombus<br />that coats the outer walls</p>
<p begin="00:03:00.091" end="00:03:02.095" style="s2">of this abdominal aortic aneurysm,</p>
<p begin="00:03:02.095" end="00:03:03.870" style="s2">in addition to the true lumen,</p>
<p begin="00:03:03.870" end="00:03:05.889" style="s2">and we get an outstanding number of</p>
<p begin="00:03:05.889" end="00:03:08.694" style="s2">eight by eight centimeters<br />on this triple-A.</p>
<p begin="00:03:08.694" end="00:03:10.953" style="s2">Here's a short axis view of a</p>
<p begin="00:03:10.953" end="00:03:13.147" style="s2">very large abdominal aortic aneurysm</p>
<p begin="00:03:13.147" end="00:03:15.218" style="s2">in a patient who presented<br />to the emergency department</p>
<p begin="00:03:15.218" end="00:03:17.395" style="s2">with abdominal and back pain,</p>
<p begin="00:03:17.395" end="00:03:19.007" style="s2">and with a small indicator arrow</p>
<p begin="00:03:19.007" end="00:03:21.342" style="s2">I'm showing in the B mode<br />image towards the left,</p>
<p begin="00:03:21.342" end="00:03:24.035" style="s2">the large triple-A, and there's the spine,</p>
<p begin="00:03:24.035" end="00:03:26.866" style="s2">which is our landmark for<br />determination of the aorta.</p>
<p begin="00:03:26.866" end="00:03:29.250" style="s2">Now we can see the Color<br />Power Doppler image</p>
<p begin="00:03:29.250" end="00:03:31.330" style="s2">towards the right, showing<br />pulsations of blood</p>
<p begin="00:03:31.330" end="00:03:34.415" style="s2">within this very large triple-A.</p>
<p begin="00:03:34.415" end="00:03:35.596" style="s2">Next we're going to measure this</p>
<p begin="00:03:35.596" end="00:03:37.359" style="s2">abdominal aortic aneurysm, and notice</p>
<p begin="00:03:37.359" end="00:03:39.209" style="s2">we have a short axis configuration</p>
<p begin="00:03:39.209" end="00:03:40.960" style="s2">including outer-wall to outer-wall,</p>
<p begin="00:03:40.960" end="00:03:44.130" style="s2">that includes the inner<br />lumen, and the outer thrombus,</p>
<p begin="00:03:44.130" end="00:03:47.483" style="s2">and we have a measurement<br />of 4.8 by 4.9 centimeters,</p>
<p begin="00:03:47.483" end="00:03:49.348" style="s2">making a criteria of a triple-A</p>
<p begin="00:03:49.348" end="00:03:51.308" style="s2">greater than three centimeters.</p>
<p begin="00:03:51.308" end="00:03:53.412" style="s2">This video clip is another short axis</p>
<p begin="00:03:53.412" end="00:03:55.348" style="s2">orientation of a very large triple-A</p>
<p begin="00:03:55.348" end="00:03:57.943" style="s2">in a patient who presented the<br />the ED with abdominal pain.</p>
<p begin="00:03:57.943" end="00:03:59.977" style="s2">We mark the spine as our landmark,</p>
<p begin="00:03:59.977" end="00:04:02.931" style="s2">and anterior to the spine we<br />see a very large triple-A.</p>
<p begin="00:04:02.931" end="00:04:05.948" style="s2">Notice the true lumen, and<br />the accumulation of thrombus</p>
<p begin="00:04:05.948" end="00:04:09.540" style="s2">that's seen substantially<br />anterior to the true lumen.</p>
<p begin="00:04:09.540" end="00:04:11.423" style="s2">Next, we'll measure this triple-A,</p>
<p begin="00:04:11.423" end="00:04:13.153" style="s2">and here we've placed our calipers</p>
<p begin="00:04:13.153" end="00:04:14.748" style="s2">from outer-wall to outer-wall</p>
<p begin="00:04:14.748" end="00:04:16.392" style="s2">in a short axis configuration,</p>
<p begin="00:04:16.392" end="00:04:17.934" style="s2">and we come up with an aneurysm</p>
<p begin="00:04:17.934" end="00:04:21.029" style="s2">of 6.3 by 5.8 centimeters, again making</p>
<p begin="00:04:21.029" end="00:04:23.420" style="s2">the criteria of a very large triple-A</p>
<p begin="00:04:23.420" end="00:04:25.399" style="s2">greater than three centimeters.</p>
<p begin="00:04:25.399" end="00:04:28.201" style="s2">This video clip shows a<br />very interesting triple-A,</p>
<p begin="00:04:28.201" end="00:04:30.888" style="s2">with multiple onion-skin<br />layers of thrombus</p>
<p begin="00:04:30.888" end="00:04:32.500" style="s2">surrounding a very small lumen</p>
<p begin="00:04:32.500" end="00:04:34.266" style="s2">towards the middle of the triple-A.</p>
<p begin="00:04:34.266" end="00:04:36.468" style="s2">And notice again that we<br />could vastly underestimate</p>
<p begin="00:04:36.468" end="00:04:38.543" style="s2">the true dimensions of this triple-A,</p>
<p begin="00:04:38.543" end="00:04:40.499" style="s2">if all we included was the lumen.</p>
<p begin="00:04:40.499" end="00:04:42.662" style="s2">We see here a very large burden of clot</p>
<p begin="00:04:42.662" end="00:04:45.627" style="s2">surrounding the lumen circumferentially</p>
<p begin="00:04:45.627" end="00:04:48.467" style="s2">in a short axis orientation.</p>
<p begin="00:04:48.467" end="00:04:49.978" style="s2">Next, we're going to position the probe</p>
<p begin="00:04:49.978" end="00:04:52.143" style="s2">in a long axis orientation, and I'd like</p>
<p begin="00:04:52.143" end="00:04:55.036" style="s2">to categorize this as<br />the Subway sandwich sign,</p>
<p begin="00:04:55.036" end="00:04:57.164" style="s2">and what we see here is the lumen,</p>
<p begin="00:04:57.164" end="00:05:00.139" style="s2">making up the filling<br />of our Subway sandwich,</p>
<p begin="00:05:00.139" end="00:05:02.543" style="s2">and notice the anterior and posterior</p>
<p begin="00:05:02.543" end="00:05:05.271" style="s2">burden of clot making up<br />the loaves of the bread,</p>
<p begin="00:05:05.271" end="00:05:07.440" style="s2">circumferentially surrounding the lumen.</p>
<p begin="00:05:07.440" end="00:05:11.842" style="s2">So a very large triple-A<br />and long axis configuration.</p>
<p begin="00:05:11.842" end="00:05:13.787" style="s2">Next we're going to measure this triple-A,</p>
<p begin="00:05:13.787" end="00:05:15.564" style="s2">and here we're putting the calipers</p>
<p begin="00:05:15.564" end="00:05:17.543" style="s2">from anterior, posterior, and laterally,</p>
<p begin="00:05:17.543" end="00:05:19.696" style="s2">trying to add that lumen and the</p>
<p begin="00:05:19.696" end="00:05:21.587" style="s2">thrombus to our measurements,</p>
<p begin="00:05:21.587" end="00:05:23.349" style="s2">and I came up with a measurement</p>
<p begin="00:05:23.349" end="00:05:25.641" style="s2">that was 6.3 by 6.16 centimeters,</p>
<p begin="00:05:25.641" end="00:05:29.141" style="s2">again making the definition of a triple-A.</p>
<p begin="00:05:30.625" end="00:05:32.456" style="s2">This image is a short axis configuration</p>
<p begin="00:05:32.456" end="00:05:34.116" style="s2">showing an extremely large triple-A,</p>
<p begin="00:05:34.116" end="00:05:35.876" style="s2">in a patient who presented to the ED</p>
<p begin="00:05:35.876" end="00:05:38.117" style="s2">with abdominal pain, during a snowstorm</p>
<p begin="00:05:38.117" end="00:05:40.334" style="s2">in New York City in January.</p>
<p begin="00:05:40.334" end="00:05:42.127" style="s2">Notice the very large triple-A</p>
<p begin="00:05:42.127" end="00:05:44.409" style="s2">and the chaotic flow of blood inside.</p>
<p begin="00:05:44.409" end="00:05:46.255" style="s2">You can almost see the thrombus deposition</p>
<p begin="00:05:46.255" end="00:05:49.785" style="s2">from the swirls of blood in<br />this very large triple-A.</p>
<p begin="00:05:49.785" end="00:05:51.564" style="s2">Here's a long axis configuration</p>
<p begin="00:05:51.564" end="00:05:53.455" style="s2">of the same triple-A, and again we can</p>
<p begin="00:05:53.455" end="00:05:56.123" style="s2">almost take the patient's<br />heartbeat, or pulse,</p>
<p begin="00:05:56.123" end="00:05:59.359" style="s2">by measuring the movements<br />of the swirls of blood</p>
<p begin="00:05:59.359" end="00:06:02.558" style="s2">within this chaotic flow of<br />blood within the large triple-A,</p>
<p begin="00:06:02.558" end="00:06:04.672" style="s2">and we can see the<br />deposition of the thrombus</p>
<p begin="00:06:04.672" end="00:06:06.996" style="s2">both on the anterior and posterior walls</p>
<p begin="00:06:06.996" end="00:06:08.883" style="s2">of this very large triple-A.</p>
<p begin="00:06:08.883" end="00:06:11.428" style="s2">Here we're putting color<br />Power Doppler down,</p>
<p begin="00:06:11.428" end="00:06:14.139" style="s2">to again show that this<br />is a vascular structure,</p>
<p begin="00:06:14.139" end="00:06:16.218" style="s2">and what's interesting is again we</p>
<p begin="00:06:16.218" end="00:06:17.990" style="s2">can see the chaotic flow of blood,</p>
<p begin="00:06:17.990" end="00:06:20.080" style="s2">round and round within this triple-A,</p>
<p begin="00:06:20.080" end="00:06:22.343" style="s2">that contributes to the substantial burden</p>
<p begin="00:06:22.343" end="00:06:25.526" style="s2">of clot formation that<br />occurs on a triple-A.</p>
<p begin="00:06:25.526" end="00:06:27.313" style="s2">In the next image, we're going to measure</p>
<p begin="00:06:27.313" end="00:06:29.491" style="s2">this gigantic abdominal aortic aneurysm</p>
<p begin="00:06:29.491" end="00:06:31.023" style="s2">in the short axis orientation,</p>
<p begin="00:06:31.023" end="00:06:33.289" style="s2">and we measure from<br />outer-wall to outer-wall,</p>
<p begin="00:06:33.289" end="00:06:37.141" style="s2">we get a measurement of<br />8.8 by 8.6 centimeters.</p>
<p begin="00:06:37.141" end="00:06:39.457" style="s2">So this patient went directly<br />to the operating room,</p>
<p begin="00:06:39.457" end="00:06:43.481" style="s2">and had successful placement of a stent.</p>
<p begin="00:06:43.481" end="00:06:45.423" style="s2">This is a rare video<br />clip showing a saccular</p>
<p begin="00:06:45.423" end="00:06:47.299" style="s2">abdominal aortic aneurysm, in a patient</p>
<p begin="00:06:47.299" end="00:06:51.417" style="s2">who presented to the ED with<br />epigastric abdominal pain.</p>
<p begin="00:06:51.417" end="00:06:53.896" style="s2">We have the probe positioned<br />in a long axis configuration,</p>
<p begin="00:06:53.896" end="00:06:56.466" style="s2">superior to the left, and we see the aorta</p>
<p begin="00:06:56.466" end="00:06:58.419" style="s2">running from left to right, and</p>
<p begin="00:06:58.419" end="00:07:01.486" style="s2">we see an outpouching of the<br />aorta coming anteriorly there.</p>
<p begin="00:07:01.486" end="00:07:04.902" style="s2">That's a saccular aneurysm,<br />and as we measure it,</p>
<p begin="00:07:04.902" end="00:07:07.910" style="s2">we come up with a measurement<br />of 4.45 centimeters.</p>
<p begin="00:07:07.910" end="00:07:09.748" style="s2">As the patient was symptomatic</p>
<p begin="00:07:09.748" end="00:07:12.671" style="s2">with epigastric abdominal<br />pain over this aneurysm,</p>
<p begin="00:07:12.671" end="00:07:14.501" style="s2">she went directly to the operating room</p>
<p begin="00:07:14.501" end="00:07:15.774" style="s2">for operative repair.</p>
<p begin="00:07:15.774" end="00:07:17.813" style="s2">Let's go over some pitfalls and</p>
<p begin="00:07:17.813" end="00:07:20.480" style="s2">useful hints for imaging<br />of the abdominal aorta.</p>
<p begin="00:07:20.480" end="00:07:23.293" style="s2">At times, the aorta may<br />be difficult to see,</p>
<p begin="00:07:23.293" end="00:07:25.818" style="s2">secondary to excess bowel gas.</p>
<p begin="00:07:25.818" end="00:07:27.537" style="s2">We may press the transducer more</p>
<p begin="00:07:27.537" end="00:07:30.081" style="s2">firmly towards the spine<br />to displace the bowel gas</p>
<p begin="00:07:30.081" end="00:07:31.986" style="s2">and get a look at that aorta.</p>
<p begin="00:07:31.986" end="00:07:34.183" style="s2">If the patient has a high body mass index,</p>
<p begin="00:07:34.183" end="00:07:35.940" style="s2">we can use a lower frequency to</p>
<p begin="00:07:35.940" end="00:07:38.083" style="s2">increase penetration, and to get</p>
<p begin="00:07:38.083" end="00:07:40.709" style="s2">a better look at the abdominal aorta.</p>
<p begin="00:07:40.709" end="00:07:43.498" style="s2">Using Color Doppler can<br />help us to identify vessels,</p>
<p begin="00:07:43.498" end="00:07:45.698" style="s2">and be careful because there are times</p>
<p begin="00:07:45.698" end="00:07:48.562" style="s2">when the spine may look like a triple-A,</p>
<p begin="00:07:48.562" end="00:07:51.202" style="s2">but again close attention to the spine,</p>
<p begin="00:07:51.202" end="00:07:53.696" style="s2">and the location of vascular<br />structures anteriorly</p>
<p begin="00:07:53.696" end="00:07:55.279" style="s2">will clear that up.</p>
<p begin="00:07:56.600" end="00:07:58.356" style="s2">This video clip shows an example</p>
<p begin="00:07:58.356" end="00:07:59.973" style="s2">where the spine could be mistaken</p>
<p begin="00:07:59.973" end="00:08:02.122" style="s2">as a large abdominal aortic aneurysm.</p>
<p begin="00:08:02.122" end="00:08:03.863" style="s2">Notice that it has the appearance</p>
<p begin="00:08:03.863" end="00:08:06.018" style="s2">of a dark structure within the abdomen,</p>
<p begin="00:08:06.018" end="00:08:08.259" style="s2">and at first glance it could look like</p>
<p begin="00:08:08.259" end="00:08:11.035" style="s2">an abdominal aortic aneurysm, however,</p>
<p begin="00:08:11.035" end="00:08:13.087" style="s2">we note that there's positile structures</p>
<p begin="00:08:13.087" end="00:08:15.721" style="s2">anterior to the spine, we<br />see the aorta to the left,</p>
<p begin="00:08:15.721" end="00:08:18.803" style="s2">and the IVC towards the<br />patient's right side.</p>
<p begin="00:08:18.803" end="00:08:21.228" style="s2">We could also use color Power Doppler</p>
<p begin="00:08:21.228" end="00:08:22.919" style="s2">to differentiate the vascular structures</p>
<p begin="00:08:22.919" end="00:08:26.779" style="s2">of the aorta and IVC versus the spine.</p>
<p begin="00:08:26.779" end="00:08:29.852" style="s2">This ultrasound image shows<br />another interesting pitfall.</p>
<p begin="00:08:29.852" end="00:08:32.851" style="s2">At first glance, we see a<br />very large, dark structure</p>
<p begin="00:08:32.851" end="00:08:34.822" style="s2">towards the top of the picture here,</p>
<p begin="00:08:34.822" end="00:08:36.231" style="s2">that could be mistaken as a</p>
<p begin="00:08:36.231" end="00:08:38.478" style="s2">very large abdominal aortic aneurysm.</p>
<p begin="00:08:38.478" end="00:08:40.643" style="s2">But again, close attention to the location</p>
<p begin="00:08:40.643" end="00:08:43.218" style="s2">of the spine posteriorly will help us out.</p>
<p begin="00:08:43.218" end="00:08:45.205" style="s2">Notice we see the bone table of the spine,</p>
<p begin="00:08:45.205" end="00:08:47.141" style="s2">notice just anterior to the spine</p>
<p begin="00:08:47.141" end="00:08:49.850" style="s2">we actually can see here the aorta.</p>
<p begin="00:08:49.850" end="00:08:51.648" style="s2">This very large structure is actually</p>
<p begin="00:08:51.648" end="00:08:53.691" style="s2">a very large mesenteric cyst,</p>
<p begin="00:08:53.691" end="00:08:57.312" style="s2">and it failed to have pulsations<br />with power color doppler.</p>
<p begin="00:08:57.312" end="00:08:59.152" style="s2">In conclusion, thanks for joining me</p>
<p begin="00:08:59.152" end="00:09:00.439" style="s2">for this SoundBytes module going over</p>
<p begin="00:09:00.439" end="00:09:03.371" style="s2">Part 2 of bedside ultrasound of the aorta.</p>
<p begin="00:09:03.371" end="00:09:04.776" style="s2">Hopefully through this module you</p>
<p begin="00:09:04.776" end="00:09:06.189" style="s2">now understand the definition of</p>
<p begin="00:09:06.189" end="00:09:09.031" style="s2">and anatomy found on<br />bedside ultrasound imaging</p>
<p begin="00:09:09.031" end="00:09:11.265" style="s2">of an abdominal aortic aneurysm,</p>
<p begin="00:09:11.265" end="00:09:13.115" style="s2">and now you can use bedside sonography</p>
<p begin="00:09:13.115" end="00:09:16.143" style="s2">as a rapid diagnostic tool<br />for picking up a triple-A.</p>
<p begin="00:09:16.143" end="00:09:19.903" style="s2">Remember, that if a patient<br />has unstable hemodynamics,</p>
<p begin="00:09:19.903" end="00:09:22.877" style="s2">and a large triple-A is<br />seen on bedside sonography,</p>
<p begin="00:09:22.877" end="00:09:26.193" style="s2">that patient must be assumed<br />to have a rupturing triple-A.</p>
<p begin="00:09:26.193" end="00:09:28.409" style="s2">Using bedside sonography,<br />we can facilitate</p>
<p begin="00:09:28.409" end="00:09:30.742" style="s2">timely operative management<br />of these patients</p>
<p begin="00:09:30.742" end="00:09:33.051" style="s2">and possibly save a life.</p>
<p begin="00:09:33.051" end="00:09:34.958" style="s2">So I hope to see you back in the future,</p>
<p begin="00:09:34.958" end="00:09:36.958" style="s2">as SoundBytes continues.</p>
<p begin="00:00:15.631" end="00:00:17.429" style="s2">and I'm the emergency<br />ultrasound coordinator</p>
<p begin="00:00:17.429" end="00:00:20.193" style="s2">at the New York Presbyterian<br />Hospital in New York City,</p>
<p begin="00:00:20.193" end="00:00:22.860" style="s2">and welcome to SoundBytes Cases!</p>
<p begin="00:00:24.063" end="00:00:25.590" style="s2">In this SoundBytes module entitled</p>
<p begin="00:00:25.590" end="00:00:27.793" style="s2">Part 2 of bedside ultrasound of the aorta,</p>
<p begin="00:00:27.793" end="00:00:29.363" style="s2">we'll go further on our discussion</p>
<p begin="00:00:29.363" end="00:00:31.383" style="s2">of bedside ultrasonography of the aorta,</p>
<p begin="00:00:31.383" end="00:00:33.856" style="s2">and detection of abdominal<br />aortic aneurysms.</p>
<p begin="00:00:33.856" end="00:00:36.134" style="s2">We'll begin with a<br />review of the definitions</p>
<p begin="00:00:36.134" end="00:00:37.766" style="s2">and the anatomy of the types of</p>
<p begin="00:00:37.766" end="00:00:39.440" style="s2">abdominal aortic aneurysms that you</p>
<p begin="00:00:39.440" end="00:00:41.802" style="s2">may encounter in the emergency department.</p>
<p begin="00:00:41.802" end="00:00:43.884" style="s2">We'll look at a number<br />of ultrasound images</p>
<p begin="00:00:43.884" end="00:00:45.680" style="s2">demonstrating triple-A's, and we'll</p>
<p begin="00:00:45.680" end="00:00:47.267" style="s2">conclude with a discussion of the</p>
<p begin="00:00:47.267" end="00:00:48.940" style="s2">potential pitfalls of bedside imaging</p>
<p begin="00:00:48.940" end="00:00:51.607" style="s2">of an abdominal aortic aneurysm.</p>
<p begin="00:00:52.628" end="00:00:54.150" style="s2">This illustration shows the types</p>
<p begin="00:00:54.150" end="00:00:55.652" style="s2">of abdominal aortic aneurysms that</p>
<p begin="00:00:55.652" end="00:00:58.170" style="s2">may be encountered in clinical practice.</p>
<p begin="00:00:58.170" end="00:01:00.761" style="s2">The more common type of<br />abdominal aortic aneurysm</p>
<p begin="00:01:00.761" end="00:01:03.406" style="s2">is defined as Fusiform,<br />or diffuse dilatation</p>
<p begin="00:01:03.406" end="00:01:05.225" style="s2">of the abdominal abdominal aorta.</p>
<p begin="00:01:05.225" end="00:01:06.838" style="s2">Remember that a triple-A is defined</p>
<p begin="00:01:06.838" end="00:01:10.017" style="s2">as an aortic diameter greater<br />than three centimeters.</p>
<p begin="00:01:10.017" end="00:01:12.933" style="s2">Let's start by looking at<br />the picture to the far left.</p>
<p begin="00:01:12.933" end="00:01:14.631" style="s2">What we see here is a diffuse dilatation</p>
<p begin="00:01:14.631" end="00:01:17.177" style="s2">of the aorta beginning at<br />the level below the renals,</p>
<p begin="00:01:17.177" end="00:01:21.199" style="s2">and ending just above bifurcation<br />into the iliac arteries.</p>
<p begin="00:01:21.199" end="00:01:23.264" style="s2">Notice the picture towards the middle;</p>
<p begin="00:01:23.264" end="00:01:25.119" style="s2">some of these fusiform aneurysms</p>
<p begin="00:01:25.119" end="00:01:27.087" style="s2">can extend from the abdominal aorta</p>
<p begin="00:01:27.087" end="00:01:29.541" style="s2">all the way down into the iliac artery.</p>
<p begin="00:01:29.541" end="00:01:32.859" style="s2">Now the less common type of<br />abdominal aortic aneurysm</p>
<p begin="00:01:32.859" end="00:01:34.532" style="s2">is known as Saccular, as shown</p>
<p begin="00:01:34.532" end="00:01:35.912" style="s2">in the picture to the far right,</p>
<p begin="00:01:35.912" end="00:01:37.879" style="s2">where you have a localized out-pouching</p>
<p begin="00:01:37.879" end="00:01:39.019" style="s2">of the abdominal wall.</p>
<p begin="00:01:39.019" end="00:01:41.281" style="s2">This next illustration makes the point</p>
<p begin="00:01:41.281" end="00:01:43.421" style="s2">that choosing the<br />correct probe orientation</p>
<p begin="00:01:43.421" end="00:01:45.272" style="s2">is very important in terms of getting a</p>
<p begin="00:01:45.272" end="00:01:46.746" style="s2">correct measurement of the aorta,</p>
<p begin="00:01:46.746" end="00:01:48.111" style="s2">due to the cylinder effect.</p>
<p begin="00:01:48.111" end="00:01:50.704" style="s2">Let's look at the two long axis views</p>
<p begin="00:01:50.704" end="00:01:52.549" style="s2">of the probes along the aorta, as shown</p>
<p begin="00:01:52.549" end="00:01:54.401" style="s2">towards the left of the image here.</p>
<p begin="00:01:54.401" end="00:01:56.089" style="s2">Beginning in probe position 1,</p>
<p begin="00:01:56.089" end="00:01:58.610" style="s2">we see a side slice, in which the probe</p>
<p begin="00:01:58.610" end="00:02:00.700" style="s2">is positioned towards<br />the side of the aorta,</p>
<p begin="00:02:00.700" end="00:02:03.972" style="s2">and underestimating the true<br />diameter of the aortic lumen.</p>
<p begin="00:02:03.972" end="00:02:05.818" style="s2">We can see that positioning the probe</p>
<p begin="00:02:05.818" end="00:02:07.319" style="s2">towards the middle of the image,</p>
<p begin="00:02:07.319" end="00:02:09.177" style="s2">as shown here in probe position 2,</p>
<p begin="00:02:09.177" end="00:02:11.464" style="s2">we'll get a correct<br />diameter, but this can be</p>
<p begin="00:02:11.464" end="00:02:14.384" style="s2">difficult to ascertain using<br />the long axis orientation.</p>
<p begin="00:02:14.384" end="00:02:17.257" style="s2">A better orientation is<br />to position the probe</p>
<p begin="00:02:17.257" end="00:02:18.928" style="s2">in the short axis configuration,</p>
<p begin="00:02:18.928" end="00:02:20.491" style="s2">as shown in probe position 3,</p>
<p begin="00:02:20.491" end="00:02:23.375" style="s2">one can then get a sense<br />in terms of the true lumen,</p>
<p begin="00:02:23.375" end="00:02:24.892" style="s2">and get the best measurements</p>
<p begin="00:02:24.892" end="00:02:26.779" style="s2">of the abdominal aortic aneurysm.</p>
<p begin="00:02:26.779" end="00:02:29.326" style="s2">In the last illustration we made the point</p>
<p begin="00:02:29.326" end="00:02:30.746" style="s2">that it's important to image the</p>
<p begin="00:02:30.746" end="00:02:33.058" style="s2">abdominal aortic aneurysm<br />for an accurate dimension</p>
<p begin="00:02:33.058" end="00:02:34.925" style="s2">in the short axis configuration.</p>
<p begin="00:02:34.925" end="00:02:36.967" style="s2">But it's also very important to include</p>
<p begin="00:02:36.967" end="00:02:39.196" style="s2">outer-wall to outer-wall<br />in the measurements</p>
<p begin="00:02:39.196" end="00:02:41.114" style="s2">of the abdominal aortic aneurysm.</p>
<p begin="00:02:41.114" end="00:02:42.382" style="s2">Here we can see a measurement</p>
<p begin="00:02:42.382" end="00:02:44.910" style="s2">of a triple A only<br />including the inner lumen,</p>
<p begin="00:02:44.910" end="00:02:47.337" style="s2">and notice that we could<br />vastly underestimate</p>
<p begin="00:02:47.337" end="00:02:50.066" style="s2">the true diameter of<br />this very large triple-A.</p>
<p begin="00:02:50.066" end="00:02:52.211" style="s2">Here's the correct dimensions</p>
<p begin="00:02:52.211" end="00:02:53.938" style="s2">of the abdominal aortic aneurysm,</p>
<p begin="00:02:53.938" end="00:02:55.579" style="s2">and notice here, that we're measuring</p>
<p begin="00:02:55.579" end="00:02:57.423" style="s2">anterior, posterior, and laterally,</p>
<p begin="00:02:57.423" end="00:03:00.091" style="s2">including the thrombus<br />that coats the outer walls</p>
<p begin="00:03:00.091" end="00:03:02.095" style="s2">of this abdominal aortic aneurysm,</p>
<p begin="00:03:02.095" end="00:03:03.870" style="s2">in addition to the true lumen,</p>
<p begin="00:03:03.870" end="00:03:05.889" style="s2">and we get an outstanding number of</p>
<p begin="00:03:05.889" end="00:03:08.694" style="s2">eight by eight centimeters<br />on this triple-A.</p>
<p begin="00:03:08.694" end="00:03:10.953" style="s2">Here's a short axis view of a</p>
<p begin="00:03:10.953" end="00:03:13.147" style="s2">very large abdominal aortic aneurysm</p>
<p begin="00:03:13.147" end="00:03:15.218" style="s2">in a patient who presented<br />to the emergency department</p>
<p begin="00:03:15.218" end="00:03:17.395" style="s2">with abdominal and back pain,</p>
<p begin="00:03:17.395" end="00:03:19.007" style="s2">and with a small indicator arrow</p>
<p begin="00:03:19.007" end="00:03:21.342" style="s2">I'm showing in the B mode<br />image towards the left,</p>
<p begin="00:03:21.342" end="00:03:24.035" style="s2">the large triple-A, and there's the spine,</p>
<p begin="00:03:24.035" end="00:03:26.866" style="s2">which is our landmark for<br />determination of the aorta.</p>
<p begin="00:03:26.866" end="00:03:29.250" style="s2">Now we can see the Color<br />Power Doppler image</p>
<p begin="00:03:29.250" end="00:03:31.330" style="s2">towards the right, showing<br />pulsations of blood</p>
<p begin="00:03:31.330" end="00:03:34.415" style="s2">within this very large triple-A.</p>
<p begin="00:03:34.415" end="00:03:35.596" style="s2">Next we're going to measure this</p>
<p begin="00:03:35.596" end="00:03:37.359" style="s2">abdominal aortic aneurysm, and notice</p>
<p begin="00:03:37.359" end="00:03:39.209" style="s2">we have a short axis configuration</p>
<p begin="00:03:39.209" end="00:03:40.960" style="s2">including outer-wall to outer-wall,</p>
<p begin="00:03:40.960" end="00:03:44.130" style="s2">that includes the inner<br />lumen, and the outer thrombus,</p>
<p begin="00:03:44.130" end="00:03:47.483" style="s2">and we have a measurement<br />of 4.8 by 4.9 centimeters,</p>
<p begin="00:03:47.483" end="00:03:49.348" style="s2">making a criteria of a triple-A</p>
<p begin="00:03:49.348" end="00:03:51.308" style="s2">greater than three centimeters.</p>
<p begin="00:03:51.308" end="00:03:53.412" style="s2">This video clip is another short axis</p>
<p begin="00:03:53.412" end="00:03:55.348" style="s2">orientation of a very large triple-A</p>
<p begin="00:03:55.348" end="00:03:57.943" style="s2">in a patient who presented the<br />the ED with abdominal pain.</p>
<p begin="00:03:57.943" end="00:03:59.977" style="s2">We mark the spine as our landmark,</p>
<p begin="00:03:59.977" end="00:04:02.931" style="s2">and anterior to the spine we<br />see a very large triple-A.</p>
<p begin="00:04:02.931" end="00:04:05.948" style="s2">Notice the true lumen, and<br />the accumulation of thrombus</p>
<p begin="00:04:05.948" end="00:04:09.540" style="s2">that's seen substantially<br />anterior to the true lumen.</p>
<p begin="00:04:09.540" end="00:04:11.423" style="s2">Next, we'll measure this triple-A,</p>
<p begin="00:04:11.423" end="00:04:13.153" style="s2">and here we've placed our calipers</p>
<p begin="00:04:13.153" end="00:04:14.748" style="s2">from outer-wall to outer-wall</p>
<p begin="00:04:14.748" end="00:04:16.392" style="s2">in a short axis configuration,</p>
<p begin="00:04:16.392" end="00:04:17.934" style="s2">and we come up with an aneurysm</p>
<p begin="00:04:17.934" end="00:04:21.029" style="s2">of 6.3 by 5.8 centimeters, again making</p>
<p begin="00:04:21.029" end="00:04:23.420" style="s2">the criteria of a very large triple-A</p>
<p begin="00:04:23.420" end="00:04:25.399" style="s2">greater than three centimeters.</p>
<p begin="00:04:25.399" end="00:04:28.201" style="s2">This video clip shows a<br />very interesting triple-A,</p>
<p begin="00:04:28.201" end="00:04:30.888" style="s2">with multiple onion-skin<br />layers of thrombus</p>
<p begin="00:04:30.888" end="00:04:32.500" style="s2">surrounding a very small lumen</p>
<p begin="00:04:32.500" end="00:04:34.266" style="s2">towards the middle of the triple-A.</p>
<p begin="00:04:34.266" end="00:04:36.468" style="s2">And notice again that we<br />could vastly underestimate</p>
<p begin="00:04:36.468" end="00:04:38.543" style="s2">the true dimensions of this triple-A,</p>
<p begin="00:04:38.543" end="00:04:40.499" style="s2">if all we included was the lumen.</p>
<p begin="00:04:40.499" end="00:04:42.662" style="s2">We see here a very large burden of clot</p>
<p begin="00:04:42.662" end="00:04:45.627" style="s2">surrounding the lumen circumferentially</p>
<p begin="00:04:45.627" end="00:04:48.467" style="s2">in a short axis orientation.</p>
<p begin="00:04:48.467" end="00:04:49.978" style="s2">Next, we're going to position the probe</p>
<p begin="00:04:49.978" end="00:04:52.143" style="s2">in a long axis orientation, and I'd like</p>
<p begin="00:04:52.143" end="00:04:55.036" style="s2">to categorize this as<br />the Subway sandwich sign,</p>
<p begin="00:04:55.036" end="00:04:57.164" style="s2">and what we see here is the lumen,</p>
<p begin="00:04:57.164" end="00:05:00.139" style="s2">making up the filling<br />of our Subway sandwich,</p>
<p begin="00:05:00.139" end="00:05:02.543" style="s2">and notice the anterior and posterior</p>
<p begin="00:05:02.543" end="00:05:05.271" style="s2">burden of clot making up<br />the loaves of the bread,</p>
<p begin="00:05:05.271" end="00:05:07.440" style="s2">circumferentially surrounding the lumen.</p>
<p begin="00:05:07.440" end="00:05:11.842" style="s2">So a very large triple-A<br />and long axis configuration.</p>
<p begin="00:05:11.842" end="00:05:13.787" style="s2">Next we're going to measure this triple-A,</p>
<p begin="00:05:13.787" end="00:05:15.564" style="s2">and here we're putting the calipers</p>
<p begin="00:05:15.564" end="00:05:17.543" style="s2">from anterior, posterior, and laterally,</p>
<p begin="00:05:17.543" end="00:05:19.696" style="s2">trying to add that lumen and the</p>
<p begin="00:05:19.696" end="00:05:21.587" style="s2">thrombus to our measurements,</p>
<p begin="00:05:21.587" end="00:05:23.349" style="s2">and I came up with a measurement</p>
<p begin="00:05:23.349" end="00:05:25.641" style="s2">that was 6.3 by 6.16 centimeters,</p>
<p begin="00:05:25.641" end="00:05:29.141" style="s2">again making the definition of a triple-A.</p>
<p begin="00:05:30.625" end="00:05:32.456" style="s2">This image is a short axis configuration</p>
<p begin="00:05:32.456" end="00:05:34.116" style="s2">showing an extremely large triple-A,</p>
<p begin="00:05:34.116" end="00:05:35.876" style="s2">in a patient who presented to the ED</p>
<p begin="00:05:35.876" end="00:05:38.117" style="s2">with abdominal pain, during a snowstorm</p>
<p begin="00:05:38.117" end="00:05:40.334" style="s2">in New York City in January.</p>
<p begin="00:05:40.334" end="00:05:42.127" style="s2">Notice the very large triple-A</p>
<p begin="00:05:42.127" end="00:05:44.409" style="s2">and the chaotic flow of blood inside.</p>
<p begin="00:05:44.409" end="00:05:46.255" style="s2">You can almost see the thrombus deposition</p>
<p begin="00:05:46.255" end="00:05:49.785" style="s2">from the swirls of blood in<br />this very large triple-A.</p>
<p begin="00:05:49.785" end="00:05:51.564" style="s2">Here's a long axis configuration</p>
<p begin="00:05:51.564" end="00:05:53.455" style="s2">of the same triple-A, and again we can</p>
<p begin="00:05:53.455" end="00:05:56.123" style="s2">almost take the patient's<br />heartbeat, or pulse,</p>
<p begin="00:05:56.123" end="00:05:59.359" style="s2">by measuring the movements<br />of the swirls of blood</p>
<p begin="00:05:59.359" end="00:06:02.558" style="s2">within this chaotic flow of<br />blood within the large triple-A,</p>
<p begin="00:06:02.558" end="00:06:04.672" style="s2">and we can see the<br />deposition of the thrombus</p>
<p begin="00:06:04.672" end="00:06:06.996" style="s2">both on the anterior and posterior walls</p>
<p begin="00:06:06.996" end="00:06:08.883" style="s2">of this very large triple-A.</p>
<p begin="00:06:08.883" end="00:06:11.428" style="s2">Here we're putting color<br />Power Doppler down,</p>
<p begin="00:06:11.428" end="00:06:14.139" style="s2">to again show that this<br />is a vascular structure,</p>
<p begin="00:06:14.139" end="00:06:16.218" style="s2">and what's interesting is again we</p>
<p begin="00:06:16.218" end="00:06:17.990" style="s2">can see the chaotic flow of blood,</p>
<p begin="00:06:17.990" end="00:06:20.080" style="s2">round and round within this triple-A,</p>
<p begin="00:06:20.080" end="00:06:22.343" style="s2">that contributes to the substantial burden</p>
<p begin="00:06:22.343" end="00:06:25.526" style="s2">of clot formation that<br />occurs on a triple-A.</p>
<p begin="00:06:25.526" end="00:06:27.313" style="s2">In the next image, we're going to measure</p>
<p begin="00:06:27.313" end="00:06:29.491" style="s2">this gigantic abdominal aortic aneurysm</p>
<p begin="00:06:29.491" end="00:06:31.023" style="s2">in the short axis orientation,</p>
<p begin="00:06:31.023" end="00:06:33.289" style="s2">and we measure from<br />outer-wall to outer-wall,</p>
<p begin="00:06:33.289" end="00:06:37.141" style="s2">we get a measurement of<br />8.8 by 8.6 centimeters.</p>
<p begin="00:06:37.141" end="00:06:39.457" style="s2">So this patient went directly<br />to the operating room,</p>
<p begin="00:06:39.457" end="00:06:43.481" style="s2">and had successful placement of a stent.</p>
<p begin="00:06:43.481" end="00:06:45.423" style="s2">This is a rare video<br />clip showing a saccular</p>
<p begin="00:06:45.423" end="00:06:47.299" style="s2">abdominal aortic aneurysm, in a patient</p>
<p begin="00:06:47.299" end="00:06:51.417" style="s2">who presented to the ED with<br />epigastric abdominal pain.</p>
<p begin="00:06:51.417" end="00:06:53.896" style="s2">We have the probe positioned<br />in a long axis configuration,</p>
<p begin="00:06:53.896" end="00:06:56.466" style="s2">superior to the left, and we see the aorta</p>
<p begin="00:06:56.466" end="00:06:58.419" style="s2">running from left to right, and</p>
<p begin="00:06:58.419" end="00:07:01.486" style="s2">we see an outpouching of the<br />aorta coming anteriorly there.</p>
<p begin="00:07:01.486" end="00:07:04.902" style="s2">That's a saccular aneurysm,<br />and as we measure it,</p>
<p begin="00:07:04.902" end="00:07:07.910" style="s2">we come up with a measurement<br />of 4.45 centimeters.</p>
<p begin="00:07:07.910" end="00:07:09.748" style="s2">As the patient was symptomatic</p>
<p begin="00:07:09.748" end="00:07:12.671" style="s2">with epigastric abdominal<br />pain over this aneurysm,</p>
<p begin="00:07:12.671" end="00:07:14.501" style="s2">she went directly to the operating room</p>
<p begin="00:07:14.501" end="00:07:15.774" style="s2">for operative repair.</p>
<p begin="00:07:15.774" end="00:07:17.813" style="s2">Let's go over some pitfalls and</p>
<p begin="00:07:17.813" end="00:07:20.480" style="s2">useful hints for imaging<br />of the abdominal aorta.</p>
<p begin="00:07:20.480" end="00:07:23.293" style="s2">At times, the aorta may<br />be difficult to see,</p>
<p begin="00:07:23.293" end="00:07:25.818" style="s2">secondary to excess bowel gas.</p>
<p begin="00:07:25.818" end="00:07:27.537" style="s2">We may press the transducer more</p>
<p begin="00:07:27.537" end="00:07:30.081" style="s2">firmly towards the spine<br />to displace the bowel gas</p>
<p begin="00:07:30.081" end="00:07:31.986" style="s2">and get a look at that aorta.</p>
<p begin="00:07:31.986" end="00:07:34.183" style="s2">If the patient has a high body mass index,</p>
<p begin="00:07:34.183" end="00:07:35.940" style="s2">we can use a lower frequency to</p>
<p begin="00:07:35.940" end="00:07:38.083" style="s2">increase penetration, and to get</p>
<p begin="00:07:38.083" end="00:07:40.709" style="s2">a better look at the abdominal aorta.</p>
<p begin="00:07:40.709" end="00:07:43.498" style="s2">Using Color Doppler can<br />help us to identify vessels,</p>
<p begin="00:07:43.498" end="00:07:45.698" style="s2">and be careful because there are times</p>
<p begin="00:07:45.698" end="00:07:48.562" style="s2">when the spine may look like a triple-A,</p>
<p begin="00:07:48.562" end="00:07:51.202" style="s2">but again close attention to the spine,</p>
<p begin="00:07:51.202" end="00:07:53.696" style="s2">and the location of vascular<br />structures anteriorly</p>
<p begin="00:07:53.696" end="00:07:55.279" style="s2">will clear that up.</p>
<p begin="00:07:56.600" end="00:07:58.356" style="s2">This video clip shows an example</p>
<p begin="00:07:58.356" end="00:07:59.973" style="s2">where the spine could be mistaken</p>
<p begin="00:07:59.973" end="00:08:02.122" style="s2">as a large abdominal aortic aneurysm.</p>
<p begin="00:08:02.122" end="00:08:03.863" style="s2">Notice that it has the appearance</p>
<p begin="00:08:03.863" end="00:08:06.018" style="s2">of a dark structure within the abdomen,</p>
<p begin="00:08:06.018" end="00:08:08.259" style="s2">and at first glance it could look like</p>
<p begin="00:08:08.259" end="00:08:11.035" style="s2">an abdominal aortic aneurysm, however,</p>
<p begin="00:08:11.035" end="00:08:13.087" style="s2">we note that there's positile structures</p>
<p begin="00:08:13.087" end="00:08:15.721" style="s2">anterior to the spine, we<br />see the aorta to the left,</p>
<p begin="00:08:15.721" end="00:08:18.803" style="s2">and the IVC towards the<br />patient's right side.</p>
<p begin="00:08:18.803" end="00:08:21.228" style="s2">We could also use color Power Doppler</p>
<p begin="00:08:21.228" end="00:08:22.919" style="s2">to differentiate the vascular structures</p>
<p begin="00:08:22.919" end="00:08:26.779" style="s2">of the aorta and IVC versus the spine.</p>
<p begin="00:08:26.779" end="00:08:29.852" style="s2">This ultrasound image shows<br />another interesting pitfall.</p>
<p begin="00:08:29.852" end="00:08:32.851" style="s2">At first glance, we see a<br />very large, dark structure</p>
<p begin="00:08:32.851" end="00:08:34.822" style="s2">towards the top of the picture here,</p>
<p begin="00:08:34.822" end="00:08:36.231" style="s2">that could be mistaken as a</p>
<p begin="00:08:36.231" end="00:08:38.478" style="s2">very large abdominal aortic aneurysm.</p>
<p begin="00:08:38.478" end="00:08:40.643" style="s2">But again, close attention to the location</p>
<p begin="00:08:40.643" end="00:08:43.218" style="s2">of the spine posteriorly will help us out.</p>
<p begin="00:08:43.218" end="00:08:45.205" style="s2">Notice we see the bone table of the spine,</p>
<p begin="00:08:45.205" end="00:08:47.141" style="s2">notice just anterior to the spine</p>
<p begin="00:08:47.141" end="00:08:49.850" style="s2">we actually can see here the aorta.</p>
<p begin="00:08:49.850" end="00:08:51.648" style="s2">This very large structure is actually</p>
<p begin="00:08:51.648" end="00:08:53.691" style="s2">a very large mesenteric cyst,</p>
<p begin="00:08:53.691" end="00:08:57.312" style="s2">and it failed to have pulsations<br />with power color doppler.</p>
<p begin="00:08:57.312" end="00:08:59.152" style="s2">In conclusion, thanks for joining me</p>
<p begin="00:08:59.152" end="00:09:00.439" style="s2">for this SoundBytes module going over</p>
<p begin="00:09:00.439" end="00:09:03.371" style="s2">Part 2 of bedside ultrasound of the aorta.</p>
<p begin="00:09:03.371" end="00:09:04.776" style="s2">Hopefully through this module you</p>
<p begin="00:09:04.776" end="00:09:06.189" style="s2">now understand the definition of</p>
<p begin="00:09:06.189" end="00:09:09.031" style="s2">and anatomy found on<br />bedside ultrasound imaging</p>
<p begin="00:09:09.031" end="00:09:11.265" style="s2">of an abdominal aortic aneurysm,</p>
<p begin="00:09:11.265" end="00:09:13.115" style="s2">and now you can use bedside sonography</p>
<p begin="00:09:13.115" end="00:09:16.143" style="s2">as a rapid diagnostic tool<br />for picking up a triple-A.</p>
<p begin="00:09:16.143" end="00:09:19.903" style="s2">Remember, that if a patient<br />has unstable hemodynamics,</p>
<p begin="00:09:19.903" end="00:09:22.877" style="s2">and a large triple-A is<br />seen on bedside sonography,</p>
<p begin="00:09:22.877" end="00:09:26.193" style="s2">that patient must be assumed<br />to have a rupturing triple-A.</p>
<p begin="00:09:26.193" end="00:09:28.409" style="s2">Using bedside sonography,<br />we can facilitate</p>
<p begin="00:09:28.409" end="00:09:30.742" style="s2">timely operative management<br />of these patients</p>
<p begin="00:09:30.742" end="00:09:33.051" style="s2">and possibly save a life.</p>
<p begin="00:09:33.051" end="00:09:34.958" style="s2">So I hope to see you back in the future,</p>
<p begin="00:09:34.958" end="00:09:36.958" style="s2">as SoundBytes continues.</p>
Brightcove ID
5508128547001
https://youtube.com/watch?v=WKnFD6KeO4c