Focused

Cardiac Ultrasound Views: Subxiphoid

Read more about Cardiac Ultrasound Views: Subxiphoid

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Using bedside cardiac ultrasound and a phased array probe to evaluate cardiac structures and health, the presence of pericardial effusion, and evaluating the left heart chamber size and valves.

Applications

Cardiology

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Case Study Videos

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- Hello, my name is Phil Perera,
and I'm the Emergency Ultrasound Coordinator
at the New York Presbyterian Hospital in New York City,
and welcome to SoundBytes Cases.
In this module, we'll continue our journey
through the cardiac echocardiography examinations,
looking at the four standard views.
In this module, we're specifically going to focus on
probe position B, as shown in the pictorial here,
the subxiphoid view of the heart.
Hopefully you've joined me prior
for the parasternal views, as shown in probe position A,
and in an upcoming module on the apical view,
as shown in probe position C.
The subxiphoid view of the heart
is an excellent way of imaging the patient's heart,
and getting a lot of information directly at the bedside.
Now let's learn how to perform
the subxiphoid view of the heart.
As shown in the pictorial to the right,
the probe is coming from an abdominal position,
placed just inferior to the xiphoid tip of the sternum.
It's important to lay the probe flat
and push down and under the sternum,
aiming towards the patient's left shoulder.
Now the marker dot on the probe
should be over towards the patient's right side,
with a caveat that the ultrasound's screen
indicator dot is over towards the left of the screen.
Now it's very important to put your hands
on top of the probe, and really push down and up
to get the good imaging plane underneath
the sternum, to make the angle to get
a good view of the heart from this plane.
Let's now take a look at the image
that you'll obtain from the subxiphoid view of the heart.
Here's a pictorial to the left, and an
ultrasound image to the right.
The first chamber that we'll encounter
directly below the liver, which is our
acoustic window in this case, on to
the heart will be the right ventricle.
Immediately posterior to the right ventricle
we'll be seeing the left ventricle,
and as shown in this pictorial,
notice that it has more muscular and hypertrophic walls.
From the subxiphoid plane, we'll also
be able to image the right atrium
to the left of the right ventricle,
and the left atrium, just to the left
of the left ventricle.
We can also appreciate the white line
that is the pericardium circumferentially
surrounding the heart.
Now that we know where the chambers are,
let's take a look at a video clip
of a normal heart from the subxiphoid plane.
As we remember, the liver is our
acoustic window onto the heart from this plane,
and so the liver will be seen anteriorly,
just to the top of the screen.
Just below the liver, we appreciate here
the right ventricle, and notice here,
just to the left of the right ventricle,
we can appreciate the right atrium.
Notice the tricuspid valve flipping up and down
in between the right atrium and the right ventricle.
Now let's look posterior to the right ventricle,
and we appreciate the left ventricle.
Notice again, its more muscular and hypertrophic walls.
Just to the left of the left ventricle
we appreciate, in this case, the left atrium,
and we also get a glimpse here of the mitral valve
flipping up and down in between
the left atrium and the left ventricle.
Now let's look at that white line,
both anteriorly above the right ventricle,
and posterior, below the left ventricle,
that is the pericardium.
Note here the absence of any significant
pericardial effusions.
In that last video clip, we noted good
contractility of the left ventricle
from diastole to systole.
Let's contrast that clip to this one
from a patient who presented with shortness
of breath, and advanced cardiomyopathy.
We see the right ventricle just below the liver,
anterior to the left ventricle.
And what we see here is a poorly contracting
and dilated left ventricle, consistent
with a cardiomyopathy heart.
However, note the absence of any significant
dark or anechoic fluid collections
consistent with a pericardial effusion.
Here's a patient who presented with renal failure
and acute shortness of breath.
We're again looking from the subxiphoid plane,
so we see a little strip of the liver anteriorly.
The right ventricle just below the liver,
and the left ventricle seen posteriorly
to the right ventricle.
Notice how hypertrophic the walls of
the left ventricle are in this patient.
We also appreciate a dark fluid collection
both anteriorly, just below the liver
and above the right ventricle,
and posterior below the left ventricle,
consistent with a circumferential,
or large, pericardial effusion.
If we see a large pericardial effusion
on bedside echo, our next move is to
look for signs of cardiac tamponade.
Here's a patient who manifests
all the signs of cardiac tamponade on bedside echo.
Let's look specifically at the right side of the heart.
Notice the very large pericardial effusion,
and note the chaotic movement of the right ventricle
as it struggles to open during diastole.
The compression of the right ventricle
in this patient is consistent with
advanced cardiac tamponade.
The right side of the heart is
preferentially compressed before
the left ventricle, due to its lower pressure circuit.
In conclusion, I'm glad I could share with you
this SoundBytes module going over
the subxiphoid view of the cardiac echo examination.
This is a very important exam to
put into your routine practice
in looking at your patient's heart at the bedside,
and will tell you if the patient
has a pericardial effusion, as well as
giving a sense of left ventricular contractility.
Also, the subxiphoid view of the heart
gives better views of the right side of the heart
than the more superior parasternal views of the heart.
So I hope to see you back as SoundBytes continues,
and as we move on to discuss the other
echo exam planes of the heart.

Brightcove ID

5752154065001

https://youtube.com/watch?v=ew6uJvZDhmw

Body

Using bedside cardiac ultrasound and a phased array probe to evaluate cardiac structures and health, the presence of pericardial effusion, and evaluating the left heart chamber size and valves.

Case: Cardiac Ultrasound - Apical View

Read more about Case: Cardiac Ultrasound - Apical View

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Using the apical view and a phased array probe during bedside cardiac ultrasound examinations can enable clinicians to evaluate cardiac health, structures, & ventricular contractility. This view is ideal for identifying cardiomyopathy, pericardial effusion, and cardiac tamponade.

Applications

Cardiology

Media Library Type

Case Study Videos

Subtitles

- Hello, my name is Phil Perera
and I'm the emergency ultrasound coordinator
at the New York Presbyterian Hospital in New York City
and welcome to Soundbytes Cases.
In this module we'll continue our journey
down the path of the four cardiac examination views.
Specifically in this module
we're going to look at probe position C,
known as the apical view of the heart.
I hope you've been able to join me prior
looking at probe position A, the parasternal views,
and probe position B the subxiphoid views of the heart.
So the apical view of the heart is an excellent view
and gives a great deal of information
about our patient's heart
as it shows all four chambers of the heart
in relation to one another.
Therefore, the apical view of the heart
is preferred by cardiologists as it shows the synergy
of all of the chambers of the heart to one another.
Now let's take a look at a pictorial
showing how to perform the apical view of the heart.
Preferably, you're going to be using a small footprint
phased array type probe
that can easily get in between the ribs.
Position the probe directly underneath the left nipple
at about the point of maximal impulse of the heart
with the probe indicator
over towards the patient's right side.
Now that's with the caveat
that the ultrasound's screen indicator is positioned
toward the left of the screen.
Now moving the patient
into the left lateral decubitus position
can improve imaging from the apical view of the heart
as it moves the heart closer to the probe
and moves the lung out of the way.
Thus, it's important to consider moving the patient
into this position
when performing the apical view of the heart.
Now let's learn how to interpret the images
that we'll obtain.
We see here a pictorial to the left
and an ultrasound image to the right.
As we're imaging from the apical view of the heart,
we're closest to the ventricles
and in this image we see the left ventricle
to the right of the screen and the right ventricle adjacent.
The atria from the apical view of the heart
will be further away, thus posterior to the ventricles
and we see here the left atrium
just below the left ventricle
and the right atrium below the right ventricle.
We also see the valves, the tricuspid valve to the left
and the mitral valve to the right
in between the left atrium and the left ventricle.
We can also appreciate the white lines
surrounding the heart, which is the pericardium.
Now let's take a look at a video clip
showing the apical view of the heart in action.
This is taken from a medical student triathlete,
so let's take a look at that left ventricle.
We see the left ventricle in its more superficial location
to the right of the screen.
Notice the percentage change from diastole to systole.
Note the walls almost touch with each heartbeat,
indicating a good contractility.
We see the right ventricle to the side of the left ventricle
and the two atria posterior to the ventricles.
Notice the mitral valve in between the left atrium
and left ventricle and the tricuspid valve
to the right side.
Notice here the absence
of any significant pericardial effusion.
Let's contrast that last clip from this patient
who has a dilated cardiomyopathy,
and as we look at that left ventricle
from the apical view of the heart
we see a very poor percentage change
from diastole through systole.
This is indicative of a very poor contractility
of this heart.
We see the right ventricle to the side of the left ventricle
and the two atria posterior.
Notice the sluggish movement of both the mitral value
and the tricuspid valve.
We see a little bit of pericardial effusion,
that little black rim around the heart,
also going together
with this patient's cardiomyopathy status.
Here's an interesting video clip
of a patient who presented with acute shortness of breath.
What we notice here is the right ventricle
and the left ventricle closest to the screen,
but we see here a very large pericardial effusion
circumferentially surrounding the heart.
And notice the heart swinging back and forth
in all the pericardial effusion.
This gives rise to the phenomenon
known as electrical alternans
or different sizes QRSs on the EKG.
Here's a patient who was in bad shape
and presented with acute shortness of breath.
We see a very large pericardial effusion
and let's look specifically at the right ventricle.
Notice that it caves in from diastole
due to the high pressure in the pericardial sac.
Thus this is indicative of advanced cardiac tamponade.
This patient will need a stat pericardiocentesis procedure.
So in conclusion I'm glad I could share with you
this Soundbytes module
going over the apical views of the heart.
This is an often neglected view
but one that gives a great deal of information
about your patients heart
and really should be routinely integrated
into the cardiac echo examination.
It's best to move the patient
into the left lateral decutibus position
to optimize imaging from the apical view of the heart
to see all four chambers of the heart
in relation to one another.
So I hope to see you back as Soundbytes continues.

Brightcove ID

5752159405001

https://youtube.com/watch?v=4vBJoWP-zBM

Body

How to: Focused Echo: Apical View

Read more about How to: Focused Echo: Apical View

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Learn to examine the heart using the apical window and four chamber plane.

Applications

Cardiology

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How To Videos

Subtitles

- The other view that you wanna do
as part of the focused echo examination
is the apical four chamber view,
and the orientation marker for this view
is gonna be to the patent's left.
So it actually matches the orientation marker on the screen.
To identify where you need to go, palpate for the PMI,
and then place the transducer at this point.
This is the apical four chamber view.
On this view, we have an overall assessment of the heart.
We can see all chambers of the heart in one view.
On the left side of the screen,
we're gonna see the right side of the heart.
So this is gonna be the right atrium, tricuspid valve,
right ventricle, intraventricular septum,
left ventricle, mitral valve, and left atrium.
And what we're really looking for here is a comparison
of right to left side, size of the left ventricle
to the right ventricle, left atrium to the right atrium.
If you've determined that you need
to do a pericardiocentesis, this is a good view to evaluate
if you can get good access from this point,
because if you can get access from this point,
instead of going through the subxiphoid approach,
you avoid the liver altogether,
and at this point, you're very close to the heart
and can quickly identify where the fluid is
and draw it out.

Brightcove ID

5752153080001

https://youtube.com/watch?v=Ze0s5XRv2gQ

How to: Focused Echo: Parasternal View

Read more about How to: Focused Echo: Parasternal View

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Learn to examine the heart using the parasternal window and the long axis plane.

Applications

Cardiology

Media Library Type

How To Videos

Subtitles

- Okay, I'm going to walk you through the steps of
doing a focused echo exam.
And, there's a couple of different views that you do
as part of the focused echo exam.
I'm going to concentrate first on the parasternal
long axis, and then we'll walk you through the
apical four-chamber view as well.
The parasternal long axis, you can also use as part
of your FAST examination if you're having trouble
doing the subcostal or subxiphoid view.
The parasternal long axis is a great alternative to
get an overall estimation of function of the left ventricle,
as part of the FAST exam, and also
evaluate for pericardial effusion.
Okay, so the first thing you're going to do with this,
if you can, is have the patient
turn over to their left side.
The reason we like to do this is as you have the patient
turned to their left, the heart's going to fall forward in
the chest cavity and bring it a little bit closer to the
window that you're trying to access, through the ribs.
So in this case, if we're doing a cardiac examination, with
a cardiac exam type, we want the orientation marker facing
up to the patient's right shoulder.
So once we have the orientation figured out, we're going to
put a little bit of gel on the transducer.
And we're going to find where the sternum is, and just move,
just a little bit left of the sternum, looking for the
fourth to sixth intercostal space.
And that should put you at least in the ballpark area for
where you're going to find the parasternal long axis
view of the heart.
So remembering that the heart sits in the body
at a slight angle, this is going to be the
long axis view of the heart itself.
Not long axis of the body, but we'll look at the long
axis of the heart.
When we look at the ultrasound image, we should quickly
be able to identify the left ventricle, which we see here.
And what we're evaluating for is a squeeze
of this left ventricle.
So on this image, we have the right ventricle,
left ventricle, left atrium, and the aorta.
Mitral valve, and aortic valve.
Typically, we are doing this examination to
evaluate for pericardial effusion.
So we want to identify the pericardium.
This is going to be this bright, white line
around the heart.
What's important in this view is that
you have it deep enough so that you can identify
where the descending aorta is.
The descending aorta is going to appear posterior
to the left atrium.
And we're going to see it as a round circle.
If the fluid is in the pericardium,
it's going to be above this descending aorta.
If it's a plural effusion, it's going to be
behind the descending aorta.
So this is a very important landmark that you need to
identify, so you can clearly establish
where the fluid is present.
Another important area you have to identify to determine
exactly where the pericardial effusion is, is the
anterior aspect of the heart.
You have to be careful when you evaluate this area,
because there could be a fat pad in this area
that appears hypoechoic.
So for it to be a true pericardial effusion, we want to
see the fluid wrapping all the way around the heart,
to the posterior aspect.
If it's just here, in the anterior aspect,
it's probably just a fat pad.

Brightcove ID

5752164354001

https://youtube.com/watch?v=ZzizANi2bJQ

How to: Abdominal Aorta Measurements

Read more about How to: Abdominal Aorta Measurements

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Learn to measure the abdominal aorta with ultrasound.

Applications

Cardiology

Media Library Type

How To Videos

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Subtitles

- Once we've done the survey,
we wanna go back and take measurements
of the aorta in a transverse view in three levels.
One level is proximal above the level of the renal arteries,
the second is just at the level of the renal arteries
and the third is at the level of the bifurcation.
We're gonna go back to the epigastric area
and look for our landmarks again.
In the middle of the screen we have the aorta pulsating
to the right of the aorta the IVC
and anterior to the aorta we have
the superior mesenteric artery.
I'm going to freeze the image here
and perform two measurements.
Measuring from the outside wall to outside wall,
so I measure the entire size of the aorta
and just the residual lumen of an aneurysm.
I will perform two measurements, anterior to posterior,
and a transverse measurement.
From there I'm gonna move a little bit more inferior
optimizing the image so I can see
the wall of the aorta clearly.
I will freeze the image.
Perform my measurements, the same two views again.
From the outside wall
to the outside wall,
that's the AP measurement and the same for the transverse.
The measurement is displayed on
the bottom left of the screen and
in this case our measurement is 1.36 centimeters
by 1.69 centimeters.
So we're looking for a value of over three centimeters
to be considered aneurysmal.
I'll keep moving down in a transverse view
towards the bifurcation.
Here we see the aorta divide.
So right before it divides, I want to
perform my measurement at that point.
So I will freeze and perform the
same two measurements again.
Anterior
and transverse.
From outside wall to outside wall.
And that is the completion of the measurements
you need to do for the abdominal aortic exam.

Brightcove ID

5745409357001

https://youtube.com/watch?v=SHhKyEaW1NM

How to: Abdominal Aorta

Read more about How to: Abdominal Aorta

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Learn to examine the abdominal aorta with ultrasound.

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Subtitles

- So what I'd like to do now
is walk you through the abdominal aortic exam.
We do this exam when we're looking for
abdominal aortic aneurysm.
We're gonna use a phased array transducer.
This is a good all-purpose transducer
for the emergency department,
so you can use this for fast exam or abdominal aortic exam.
We're gonna start in the transverse view.
I'm going to put some gel on the patient,
from the epigastric area to the area of the umbilicus,
in a straight line.
I'm going to orient the transducer
so the marker is to the patient's right.
And i'm gonna place it straight up and down
in the epigastric area.
The first thing that you're gonna see
on the ultrasound image
is a round, pulsating structure in the middle of the image,
and this will be the aorta.
Immediately posterior to this round, pulsating area
will be the shadow of the spine.
So we just see the anterior surface of the spine
as the white, bright line,
and then behind this, we see a shadow.
That is what we call the spine shadow,
and you can use that as your landmark
to identify the aorta all the way down the body.
So we're gonna start in the epigastric area,
assessing the size of the aorta.
The first landmarks that we want to see,
to know that we are superior enough
above the renal arteries, is the SMA.
This is going to appear as a smaller anechoic circle
just anterior to the aorta.
So just be careful you don't mistake this
actually for the aorta 'cause it is possible
there could be an aneurysm
in the superior mesenteric artery as well.
Immediately anterior to this is the pancreas,
and then, to the right of the patient,
on the left of the screen, we see the IVC
as this hypoechoic structure.
So from this point, we're gonna move down
we're looking for the left renal vein to cross over
as our landmark for the renal level,
and we're gonna continue moving inferiorly.
If you see bowel gas like this,
just wiggle the transducer a little bit
to try to push it out of the way and work around it.
And I'm gonna decrease my depth as I move inferior
because the aorta is gonna move anterior in the body.
So I can decrease my depth to get it into better view.
'Kay, and we're dealing with some bowel gas here.
I just push it away with the transducer,
and here's the aorta, pulsating,
just sitting anterior to the spine,
with the IVC to the right.
I'm going to continue down to the level of the umbilicus,
pushing away the bowel gas,
and here, I see the aorta divide
into right and left iliac arteries.
So now we see two round circles instead of one.
Once we finish the transverse sweep,
we're gonna turn the transducer so the orientation marker
is facing the patient's head.
We'll place it again starting at the epigastric level.
I'm gonna increase the depth here a little bit,
find the aorta, and, at this point,
because I'm in a sagittal view,
it should appear as a long, black tube
moving from the left to the right of the image.
We can see here in the image,
I'm in the very proximal portion of the aorta.
We see the liver anterior to the aorta.
I move up a little bit, I can see the heart beating
just above the diaphragm.
So I know I'm at the very proximal level,
and I'm just gonna start to survey down the aorta.
The branch that I'm seeing here, coming at a shallow angle,
is the superior mesenteric artery.
So I know I'm above the level of the renal arteries
when I see that landmark.
I'm gonna continue down,
following it in a longitudinal view,
and again, I see the shadow of the spine
directly posterior to the aorta.
I keep moving down, working around the bowel gas,
looking for the long, black tube
immediately anterior to the spine.
And again, I do this all the way down
to the level of the umbilicus.
And I will see a left iliac artery
and a right iliac artery.
And again, I can decrease the depth to optimize my image
because it is so anterior
by the time you get to the umbilicus.

Brightcove ID

5745320579001

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

How To: Female Pelvis: Transabdominal View

Read more about How To: Female Pelvis: Transabdominal View

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Learn the basics of female transabdominal pelvic scanning.

Clinical Specialties

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- [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

Read more about 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: FAST Exam: RUQ

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Learn to examine Morison's pouch in the right upper quadrant for fluid collections.

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- So the patient's gonna arrive in a supine position,
they'll often be on a backboard as full spinal precaution,
so motion of the patient will be impossible.
We're gonna choose our transducer.
We have chosen the phased array transducer,
we're gonna put a little gel on top of it.
And I like to put the probe marker
toward the patient's head, toward the axilla,
at about the midaxillaral line, 10 to 11th ribs.
Another easy tip to find out the location
is get to the costal margin,
go about three finger-breadths above it,
and you should be able to find the kidney
and see the adjacent liver.
I'm just adjusting my gain here.
And already I can see the interface
between the kidney and the liver, which is Morison's pouch.
So what we see here, on the bottom,
this crescent shaped organ, is the kidney.
Above it we see the liver,
and just to the left side of the screen
we see the diaphragm.
So when I'm examining this area,
I'm gonna carefully scan through
the entire area of Morison's pouch,
including at the liver tip.
So we see this whole area here
looking for an anechoic stripe.
An anechoic stripe would be indicative of free fluid.
I'm also identifying the diaphragm,
so when I look at the diaphragm,
this is the hypoechoic or white line
to the left side of the screen,
and I should be able to see that pretty easily
and you can see what appears to be
liver on both sides of the diaphragm,
on the bottom far left of the screen.
That is mirror artifact and is a normal finding.
If the patient had a pleural fluid collection after trauma
that would be a hemothorax,
we would see an anechoic or black area in this location.

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https://youtube.com/watch?v=0VTRm_DNW8s

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