<p begin="00:00:14.975" end="00:00:16.658" style="s2">- Once we've done the survey,</p>
<p begin="00:00:16.658" end="00:00:18.355" style="s2">we wanna go back and take measurements</p>
<p begin="00:00:18.355" end="00:00:21.843" style="s2">of the aorta in a transverse<br />view in three levels.</p>
<p begin="00:00:21.843" end="00:00:25.948" style="s2">One level is proximal above the<br />level of the renal arteries,</p>
<p begin="00:00:25.948" end="00:00:29.392" style="s2">the second is just at the<br />level of the renal arteries</p>
<p begin="00:00:29.392" end="00:00:33.356" style="s2">and the third is at the<br />level of the bifurcation.</p>
<p begin="00:00:33.356" end="00:00:36.856" style="s2">We're gonna go back to the epigastric area</p>
<p begin="00:00:40.060" end="00:00:42.810" style="s2">and look for our landmarks again.</p>
<p begin="00:00:44.233" end="00:00:48.862" style="s2">In the middle of the screen<br />we have the aorta pulsating</p>
<p begin="00:00:48.862" end="00:00:52.030" style="s2">to the right of the aorta the IVC</p>
<p begin="00:00:52.030" end="00:00:53.604" style="s2">and anterior to the aorta we have</p>
<p begin="00:00:53.604" end="00:00:56.342" style="s2">the superior mesenteric artery.</p>
<p begin="00:00:56.342" end="00:00:59.175" style="s2">I'm going to freeze the image here</p>
<p begin="00:01:02.657" end="00:01:05.074" style="s2">and perform two measurements.</p>
<p begin="00:01:08.369" end="00:01:12.369" style="s2">Measuring from the outside<br />wall to outside wall,</p>
<p begin="00:01:13.805" end="00:01:16.162" style="s2">so I measure the entire size of the aorta</p>
<p begin="00:01:16.162" end="00:01:19.745" style="s2">and just the residual<br />lumen of an aneurysm.</p>
<p begin="00:01:23.223" end="00:01:27.312" style="s2">I will perform two measurements,<br />anterior to posterior,</p>
<p begin="00:01:27.312" end="00:01:29.639" style="s2">and a transverse measurement.</p>
<p begin="00:01:29.639" end="00:01:33.806" style="s2">From there I'm gonna move<br />a little bit more inferior</p>
<p begin="00:01:39.714" end="00:01:41.169" style="s2">optimizing the image so I can see</p>
<p begin="00:01:41.169" end="00:01:43.669" style="s2">the wall of the aorta clearly.</p>
<p begin="00:01:45.635" end="00:01:48.003" style="s2">I will freeze the image.</p>
<p begin="00:01:48.003" end="00:01:50.908" style="s2">Perform my measurements,<br />the same two views again.</p>
<p begin="00:01:50.908" end="00:01:52.658" style="s2">From the outside wall</p>
<p begin="00:01:54.478" end="00:01:56.145" style="s2">to the outside wall,</p>
<p begin="00:02:00.936" end="00:02:05.103" style="s2">that's the AP measurement and<br />the same for the transverse.</p>
<p begin="00:02:12.280" end="00:02:13.345" style="s2">The measurement is displayed on</p>
<p begin="00:02:13.345" end="00:02:14.925" style="s2">the bottom left of the screen and</p>
<p begin="00:02:14.925" end="00:02:17.380" style="s2">in this case our measurement<br />is 1.36 centimeters</p>
<p begin="00:02:17.380" end="00:02:19.402" style="s2">by 1.69 centimeters.</p>
<p begin="00:02:19.402" end="00:02:23.451" style="s2">So we're looking for a value<br />of over three centimeters</p>
<p begin="00:02:23.451" end="00:02:25.784" style="s2">to be considered aneurysmal.</p>
<p begin="00:02:27.528" end="00:02:30.671" style="s2">I'll keep moving down in a transverse view</p>
<p begin="00:02:30.671" end="00:02:32.671" style="s2">towards the bifurcation.</p>
<p begin="00:02:35.173" end="00:02:37.590" style="s2">Here we see the aorta divide.</p>
<p begin="00:02:39.755" end="00:02:42.694" style="s2">So right before it divides, I want to</p>
<p begin="00:02:42.694" end="00:02:45.777" style="s2">perform my measurement at that point.</p>
<p begin="00:02:48.046" end="00:02:50.525" style="s2">So I will freeze and perform the</p>
<p begin="00:02:50.525" end="00:02:52.858" style="s2">same two measurements again.</p>
<p begin="00:03:00.390" end="00:03:01.223" style="s2">Anterior</p>
<p begin="00:03:04.969" end="00:03:06.219" style="s2">and transverse.</p>
<p begin="00:03:07.245" end="00:03:10.438" style="s2">From outside wall to outside wall.</p>
<p begin="00:03:10.438" end="00:03:12.375" style="s2">And that is the completion<br />of the measurements</p>
<p begin="00:03:12.375" end="00:03:16.125" style="s2">you need to do for the<br />abdominal aortic exam.</p>

<p begin="00:00:15.428" end="00:00:16.551" style="s2">- So what I'd like to do now</p>
<p begin="00:00:16.551" end="00:00:19.559" style="s2">is walk you through the<br />abdominal aortic exam.</p>
<p begin="00:00:19.559" end="00:00:21.333" style="s2">We do this exam when we're looking for</p>
<p begin="00:00:21.333" end="00:00:23.500" style="s2">abdominal aortic aneurysm.</p>
<p begin="00:00:26.397" end="00:00:28.351" style="s2">We're gonna use a phased array transducer.</p>
<p begin="00:00:28.351" end="00:00:30.254" style="s2">This is a good all-purpose transducer</p>
<p begin="00:00:30.254" end="00:00:31.606" style="s2">for the emergency department,</p>
<p begin="00:00:31.606" end="00:00:35.197" style="s2">so you can use this for fast<br />exam or abdominal aortic exam.</p>
<p begin="00:00:35.197" end="00:00:39.071" style="s2">We're gonna start in the transverse view.</p>
<p begin="00:00:39.071" end="00:00:41.882" style="s2">I'm going to put some gel on the patient,</p>
<p begin="00:00:41.882" end="00:00:45.272" style="s2">from the epigastric area to<br />the area of the umbilicus,</p>
<p begin="00:00:45.272" end="00:00:46.855" style="s2">in a straight line.</p>
<p begin="00:00:48.999" end="00:00:50.692" style="s2">I'm going to orient the transducer</p>
<p begin="00:00:50.692" end="00:00:53.762" style="s2">so the marker is to the patient's right.</p>
<p begin="00:00:53.762" end="00:00:57.152" style="s2">And i'm gonna place it<br />straight up and down</p>
<p begin="00:00:57.152" end="00:00:59.122" style="s2">in the epigastric area.</p>
<p begin="00:00:59.122" end="00:01:00.373" style="s2">The first thing that you're gonna see</p>
<p begin="00:01:00.373" end="00:01:01.530" style="s2">on the ultrasound image</p>
<p begin="00:01:01.530" end="00:01:05.264" style="s2">is a round, pulsating structure<br />in the middle of the image,</p>
<p begin="00:01:05.264" end="00:01:07.514" style="s2">and this will be the aorta.</p>
<p begin="00:01:08.676" end="00:01:12.156" style="s2">Immediately posterior to<br />this round, pulsating area</p>
<p begin="00:01:12.156" end="00:01:14.676" style="s2">will be the shadow of the spine.</p>
<p begin="00:01:14.676" end="00:01:16.970" style="s2">So we just see the anterior<br />surface of the spine</p>
<p begin="00:01:16.970" end="00:01:19.064" style="s2">as the white, bright line,</p>
<p begin="00:01:19.064" end="00:01:21.313" style="s2">and then behind this, we see a shadow.</p>
<p begin="00:01:21.313" end="00:01:22.995" style="s2">That is what we call the spine shadow,</p>
<p begin="00:01:22.995" end="00:01:24.780" style="s2">and you can use that as your landmark</p>
<p begin="00:01:24.780" end="00:01:28.327" style="s2">to identify the aorta all<br />the way down the body.</p>
<p begin="00:01:28.327" end="00:01:30.511" style="s2">So we're gonna start<br />in the epigastric area,</p>
<p begin="00:01:30.511" end="00:01:32.259" style="s2">assessing the size of the aorta.</p>
<p begin="00:01:32.259" end="00:01:36.124" style="s2">The first landmarks that we want to see,</p>
<p begin="00:01:36.124" end="00:01:37.960" style="s2">to know that we are superior enough</p>
<p begin="00:01:37.960" end="00:01:41.043" style="s2">above the renal arteries, is the SMA.</p>
<p begin="00:01:44.091" end="00:01:47.604" style="s2">This is going to appear as<br />a smaller anechoic circle</p>
<p begin="00:01:47.604" end="00:01:50.613" style="s2">just anterior to the aorta.</p>
<p begin="00:01:50.613" end="00:01:52.772" style="s2">So just be careful you don't mistake this</p>
<p begin="00:01:52.772" end="00:01:55.051" style="s2">actually for the aorta<br />'cause it is possible</p>
<p begin="00:01:55.051" end="00:01:56.542" style="s2">there could be an aneurysm</p>
<p begin="00:01:56.542" end="00:01:59.536" style="s2">in the superior mesenteric artery as well.</p>
<p begin="00:01:59.536" end="00:02:03.151" style="s2">Immediately anterior to<br />this is the pancreas,</p>
<p begin="00:02:03.151" end="00:02:06.982" style="s2">and then, to the right of the patient,</p>
<p begin="00:02:06.982" end="00:02:09.439" style="s2">on the left of the screen, we see the IVC</p>
<p begin="00:02:09.439" end="00:02:11.856" style="s2">as this hypoechoic structure.</p>
<p begin="00:02:14.107" end="00:02:17.524" style="s2">So from this point, we're gonna move down</p>
<p begin="00:02:19.547" end="00:02:23.515" style="s2">we're looking for the left<br />renal vein to cross over</p>
<p begin="00:02:23.515" end="00:02:26.515" style="s2">as our landmark for the renal level,</p>
<p begin="00:02:28.351" end="00:02:31.934" style="s2">and we're gonna continue<br />moving inferiorly.</p>
<p begin="00:02:33.648" end="00:02:34.893" style="s2">If you see bowel gas like this,</p>
<p begin="00:02:34.893" end="00:02:37.433" style="s2">just wiggle the transducer a little bit</p>
<p begin="00:02:37.433" end="00:02:41.540" style="s2">to try to push it out of<br />the way and work around it.</p>
<p begin="00:02:41.540" end="00:02:46.063" style="s2">And I'm gonna decrease my<br />depth as I move inferior</p>
<p begin="00:02:46.063" end="00:02:50.230" style="s2">because the aorta is gonna<br />move anterior in the body.</p>
<p begin="00:02:51.319" end="00:02:54.673" style="s2">So I can decrease my depth<br />to get it into better view.</p>
<p begin="00:02:54.673" end="00:02:55.829" style="s2">'Kay, and we're dealing<br />with some bowel gas here.</p>
<p begin="00:02:55.829" end="00:02:58.067" style="s2">I just push it away with the transducer,</p>
<p begin="00:02:58.067" end="00:03:00.120" style="s2">and here's the aorta, pulsating,</p>
<p begin="00:03:00.120" end="00:03:02.652" style="s2">just sitting anterior to the spine,</p>
<p begin="00:03:02.652" end="00:03:05.359" style="s2">with the IVC to the right.</p>
<p begin="00:03:05.359" end="00:03:09.502" style="s2">I'm going to continue down to<br />the level of the umbilicus,</p>
<p begin="00:03:09.502" end="00:03:12.414" style="s2">pushing away the bowel gas,</p>
<p begin="00:03:12.414" end="00:03:14.768" style="s2">and here, I see the aorta divide</p>
<p begin="00:03:14.768" end="00:03:17.891" style="s2">into right and left iliac arteries.</p>
<p begin="00:03:17.891" end="00:03:21.808" style="s2">So now we see two round<br />circles instead of one.</p>
<p begin="00:03:23.001" end="00:03:24.346" style="s2">Once we finish the transverse sweep,</p>
<p begin="00:03:24.346" end="00:03:26.924" style="s2">we're gonna turn the transducer<br />so the orientation marker</p>
<p begin="00:03:26.924" end="00:03:29.252" style="s2">is facing the patient's head.</p>
<p begin="00:03:29.252" end="00:03:33.419" style="s2">We'll place it again starting<br />at the epigastric level.</p>
<p begin="00:03:37.646" end="00:03:42.312" style="s2">I'm gonna increase the<br />depth here a little bit,</p>
<p begin="00:03:42.312" end="00:03:44.245" style="s2">find the aorta, and, at this point,</p>
<p begin="00:03:44.245" end="00:03:46.460" style="s2">because I'm in a sagittal view,</p>
<p begin="00:03:46.460" end="00:03:48.845" style="s2">it should appear as a long, black tube</p>
<p begin="00:03:48.845" end="00:03:52.762" style="s2">moving from the left to<br />the right of the image.</p>
<p begin="00:03:56.494" end="00:03:57.826" style="s2">We can see here in the image,</p>
<p begin="00:03:57.826" end="00:04:00.044" style="s2">I'm in the very proximal<br />portion of the aorta.</p>
<p begin="00:04:00.044" end="00:04:03.438" style="s2">We see the liver anterior to the aorta.</p>
<p begin="00:04:03.438" end="00:04:05.832" style="s2">I move up a little bit, I<br />can see the heart beating</p>
<p begin="00:04:05.832" end="00:04:07.355" style="s2">just above the diaphragm.</p>
<p begin="00:04:07.355" end="00:04:10.087" style="s2">So I know I'm at the very proximal level,</p>
<p begin="00:04:10.087" end="00:04:13.566" style="s2">and I'm just gonna start<br />to survey down the aorta.</p>
<p begin="00:04:13.566" end="00:04:17.733" style="s2">The branch that I'm seeing<br />here, coming at a shallow angle,</p>
<p begin="00:04:19.307" end="00:04:22.140" style="s2">is the superior mesenteric artery.</p>
<p begin="00:04:28.062" end="00:04:30.554" style="s2">So I know I'm above the<br />level of the renal arteries</p>
<p begin="00:04:30.554" end="00:04:32.411" style="s2">when I see that landmark.</p>
<p begin="00:04:32.411" end="00:04:34.355" style="s2">I'm gonna continue down,</p>
<p begin="00:04:34.355" end="00:04:36.835" style="s2">following it in a longitudinal view,</p>
<p begin="00:04:36.835" end="00:04:40.108" style="s2">and again, I see the shadow of the spine</p>
<p begin="00:04:40.108" end="00:04:42.775" style="s2">directly posterior to the aorta.</p>
<p begin="00:04:45.223" end="00:04:49.306" style="s2">I keep moving down, working<br />around the bowel gas,</p>
<p begin="00:04:51.799" end="00:04:54.466" style="s2">looking for the long, black tube</p>
<p begin="00:04:56.122" end="00:04:59.541" style="s2">immediately anterior to the spine.</p>
<p begin="00:04:59.541" end="00:05:02.624" style="s2">And again, I do this all the way down</p>
<p begin="00:05:05.437" end="00:05:08.150" style="s2">to the level of the umbilicus.</p>
<p begin="00:05:08.150" end="00:05:10.983" style="s2">And I will see a left iliac artery</p>
<p begin="00:05:14.855" end="00:05:16.938" style="s2">and a right iliac artery.</p>
<p begin="00:05:19.921" end="00:05:24.423" style="s2">And again, I can decrease the<br />depth to optimize my image</p>
<p begin="00:05:24.423" end="00:05:26.006" style="s2">because it is so anterior</p>
<p begin="00:05:26.006" end="00:05:29.089" style="s2">by the time you get to the umbilicus.</p>

<p begin="00:00:07.318" end="00:00:09.711" style="s2">- [Voiceover] A curved, or<br />phased array transducer,</p>
<p begin="00:00:09.711" end="00:00:11.431" style="s2">with a pelvis exam type,</p>
<p begin="00:00:11.431" end="00:00:14.568" style="s2">is used to perform the<br />pelvis ultrasound exam.</p>
<p begin="00:00:14.568" end="00:00:16.987" style="s2">A full bladder is used<br />as an acoustic window</p>
<p begin="00:00:16.987" end="00:00:18.989" style="s2">to view the pelvic organs.</p>
<p begin="00:00:18.989" end="00:00:22.579" style="s2">The pelvis is evaluated in two plains.</p>
<p begin="00:00:22.579" end="00:00:25.534" style="s2">Place the transducer<br />in a long axis position</p>
<p begin="00:00:25.534" end="00:00:28.254" style="s2">with the orientation marker<br />to the patient's head,</p>
<p begin="00:00:28.254" end="00:00:31.254" style="s2">at the level of the symphysis pubis.</p>
<p begin="00:00:32.384" end="00:00:36.384" style="s2">Angle the transducer<br />inferiorly into the pelvis.</p>
<p begin="00:00:38.036" end="00:00:40.705" style="s2">The bladder appears in the<br />near-field of the image,</p>
<p begin="00:00:40.705" end="00:00:43.616" style="s2">as a hypoechoic triangular structure.</p>
<p begin="00:00:43.616" end="00:00:45.800" style="s2">The uterus is gray in appearance</p>
<p begin="00:00:45.800" end="00:00:48.233" style="s2">and located either directly posterior</p>
<p begin="00:00:48.233" end="00:00:50.087" style="s2">or superior to the bladder.</p>
<p begin="00:00:50.087" end="00:00:52.139" style="s2">The endometrial stripe will appear as</p>
<p begin="00:00:52.139" end="00:00:55.945" style="s2">a bright echogenic line from<br />the fundus to the cervix.</p>
<p begin="00:00:55.945" end="00:00:58.877" style="s2">The uterus does not always<br />lay directly in the midline</p>
<p begin="00:00:58.877" end="00:01:02.209" style="s2">so it may be necessary to<br />slightly rotate the transducer</p>
<p begin="00:01:02.209" end="00:01:04.732" style="s2">to view the entire length of the uterus.</p>
<p begin="00:01:04.732" end="00:01:07.015" style="s2">Sweep the transducer from side to side</p>
<p begin="00:01:07.015" end="00:01:09.219" style="s2">to see the entire uterus.</p>
<p begin="00:01:09.219" end="00:01:12.192" style="s2">The ovaries may be seen<br />by sweeping the transducer</p>
<p begin="00:01:12.192" end="00:01:14.615" style="s2">to the lateral aspects of the pelvis.</p>
<p begin="00:01:14.615" end="00:01:18.536" style="s2">They are almond-shaped and<br />slightly hypoechoic structures.</p>
<p begin="00:01:18.536" end="00:01:20.605" style="s2">Follicles may appear as multiple</p>
<p begin="00:01:20.605" end="00:01:24.688" style="s2">hypoechoic, cystic structures<br />within the ovaries.</p>
<p begin="00:01:27.166" end="00:01:29.314" style="s2">Some follicles may be quite prominent,</p>
<p begin="00:01:29.314" end="00:01:31.981" style="s2">depending upon the luteal stage.</p>
<p begin="00:01:34.855" end="00:01:37.375" style="s2">To obtain a transverse view of the uterus,</p>
<p begin="00:01:37.375" end="00:01:39.869" style="s2">rotate the transducer 90 degrees,</p>
<p begin="00:01:39.869" end="00:01:42.788" style="s2">so the orientation marker<br />is to the patient's right.</p>
<p begin="00:01:42.788" end="00:01:46.581" style="s2">The bladder appears more<br />rectangular in shape in this view.</p>
<p begin="00:01:46.581" end="00:01:48.775" style="s2">Sweep the transducer superiorly</p>
<p begin="00:01:48.775" end="00:01:51.181" style="s2">from the level of the cervix to the fundus</p>
<p begin="00:01:51.181" end="00:01:53.284" style="s2">to see the entire uterus.</p>
<p begin="00:01:53.284" end="00:01:56.324" style="s2">The ovaries will be seen on<br />either side of the uterus</p>
<p begin="00:01:56.324" end="00:01:57.941" style="s2">and can vary in location,</p>
<p begin="00:01:57.941" end="00:02:01.024" style="s2">from a superior to inferior position.</p>

<p begin="00:00:15.338" end="00:00:17.481" style="s2">- We're gonna do the FAST exam,</p>
<p begin="00:00:17.481" end="00:00:19.857" style="s2">the pelvic view in a female now.</p>
<p begin="00:00:19.857" end="00:00:22.104" style="s2">Again we have the phase array transducer,</p>
<p begin="00:00:22.104" end="00:00:24.440" style="s2">here's our probe marker right here,</p>
<p begin="00:00:24.440" end="00:00:26.319" style="s2">I'm gonna start off with a sagittal view.</p>
<p begin="00:00:26.319" end="00:00:29.870" style="s2">And ideally, the<br />(slurred) bladder is full.</p>
<p begin="00:00:29.870" end="00:00:32.183" style="s2">So you go just above the symphysis pubis,</p>
<p begin="00:00:32.183" end="00:00:34.754" style="s2">so we're scanning down here sagittaly,</p>
<p begin="00:00:34.754" end="00:00:36.570" style="s2">and some of the anatomic landmarks</p>
<p begin="00:00:36.570" end="00:00:37.842" style="s2">that we're looking at,</p>
<p begin="00:00:37.842" end="00:00:39.802" style="s2">at the very top of the<br />screen is the bladder,</p>
<p begin="00:00:39.802" end="00:00:41.482" style="s2">which is an anechoic structure,</p>
<p begin="00:00:41.482" end="00:00:43.363" style="s2">fluid filled, obviously with urine,</p>
<p begin="00:00:43.363" end="00:00:45.292" style="s2">it's got nice walls around it.</p>
<p begin="00:00:45.292" end="00:00:47.500" style="s2">Just below that is the uterus,</p>
<p begin="00:00:47.500" end="00:00:49.548" style="s2">which is a pear-shaped organ.</p>
<p begin="00:00:49.548" end="00:00:50.908" style="s2">You can see it well visualized</p>
<p begin="00:00:50.908" end="00:00:52.772" style="s2">because the bladder is full.</p>
<p begin="00:00:52.772" end="00:00:53.605" style="s2">And just below that</p>
<p begin="00:00:53.605" end="00:00:55.772" style="s2">is a potential space, the Cul de Sac,</p>
<p begin="00:00:55.772" end="00:00:58.125" style="s2">where we can look for, very carefully,</p>
<p begin="00:00:58.125" end="00:01:01.186" style="s2">small amounts of free fluid.</p>
<p begin="00:01:01.186" end="00:01:02.495" style="s2">When we scan this patient,</p>
<p begin="00:01:02.495" end="00:01:04.192" style="s2">in this view, in the sagittal view,</p>
<p begin="00:01:04.192" end="00:01:06.871" style="s2">from the patient's left<br />to the patient's right.</p>
<p begin="00:01:06.871" end="00:01:09.234" style="s2">And we're slowly slowly scanning to see</p>
<p begin="00:01:09.234" end="00:01:11.808" style="s2">if there's any evidence of free fluid.</p>
<p begin="00:01:11.808" end="00:01:13.816" style="s2">Once we finish the sagittal view,</p>
<p begin="00:01:13.816" end="00:01:16.087" style="s2">we want to go ahead and<br />do a transverse view.</p>
<p begin="00:01:16.087" end="00:01:17.141" style="s2">What we're gonna do now</p>
<p begin="00:01:17.141" end="00:01:20.830" style="s2">is point the transducer marker<br />toward the patient's right.</p>
<p begin="00:01:20.830" end="00:01:23.677" style="s2">So we're gonna rotate that transducer,</p>
<p begin="00:01:23.677" end="00:01:24.941" style="s2">toward the patient's right.</p>
<p begin="00:01:24.941" end="00:01:27.734" style="s2">Again, we see the bladder<br />in the center of the screen.</p>
<p begin="00:01:27.734" end="00:01:30.381" style="s2">We're now gonna scan from inferior,</p>
<p begin="00:01:30.381" end="00:01:34.269" style="s2">just below the symphysis,<br />to more superior,</p>
<p begin="00:01:34.269" end="00:01:38.726" style="s2">and in between we're also<br />gonna identify the uterus.</p>
<p begin="00:01:38.726" end="00:01:41.965" style="s2">So we're going right to the<br />very top of the bladder,</p>
<p begin="00:01:41.965" end="00:01:42.880" style="s2">to about mid-bladder,</p>
<p begin="00:01:42.880" end="00:01:46.769" style="s2">we can see the uterus here in the center.</p>
<p begin="00:01:46.769" end="00:01:49.936" style="s2">A very small amount of free fluid here,</p>
<p begin="00:01:49.936" end="00:01:52.576" style="s2">which can be physiological as well.</p>
<p begin="00:01:52.576" end="00:01:55.993" style="s2">So we're scanning all the way inferiorly,</p>
<p begin="00:01:57.937" end="00:02:00.672" style="s2">to more superiorly, we see the uterus,</p>
<p begin="00:02:00.672" end="00:02:03.792" style="s2">we actually see part of the ovary there,</p>
<p begin="00:02:03.792" end="00:02:07.959" style="s2">and then we're gonna go all<br />the way more superiorly.</p>

<p begin="00:00:15.492" end="00:00:16.763" style="s2">- The next view I'm gonna take you through</p>
<p begin="00:00:16.763" end="00:00:19.343" style="s2">in the FAST exam is the subcoastal view</p>
<p begin="00:00:19.343" end="00:00:21.477" style="s2">of the heart in a four-chamber plane.</p>
<p begin="00:00:21.477" end="00:00:23.708" style="s2">For this, we're gonna put our transducer</p>
<p begin="00:00:23.708" end="00:00:24.958" style="s2">to phased array</p>
<p begin="00:00:25.797" end="00:00:27.248" style="s2">to the subxiphoid area,</p>
<p begin="00:00:27.248" end="00:00:29.577" style="s2">aiming towards the<br />patient's left shoulder.</p>
<p begin="00:00:29.577" end="00:00:30.820" style="s2">Here is the probe marker here,</p>
<p begin="00:00:30.820" end="00:00:32.310" style="s2">which I'm going to angle towards</p>
<p begin="00:00:32.310" end="00:00:33.977" style="s2">the patient's right.</p>
<p begin="00:00:34.826" end="00:00:38.844" style="s2">When I do this exam, I wanna<br />make sure this transducer is</p>
<p begin="00:00:38.844" end="00:00:40.564" style="s2">along the frontal plane</p>
<p begin="00:00:40.564" end="00:00:42.678" style="s2">and aiming toward the chest.</p>
<p begin="00:00:42.678" end="00:00:45.604" style="s2">A common mistake is to go too</p>
<p begin="00:00:45.604" end="00:00:47.052" style="s2">inferior into the abdomen,</p>
<p begin="00:00:47.052" end="00:00:49.209" style="s2">so you want to go deep into the chest.</p>
<p begin="00:00:49.209" end="00:00:50.476" style="s2">When you're in this location,</p>
<p begin="00:00:50.476" end="00:00:52.066" style="s2">the other thing you're gonna need to do</p>
<p begin="00:00:52.066" end="00:00:53.609" style="s2">is increase your depth.</p>
<p begin="00:00:53.609" end="00:00:55.598" style="s2">I'm gonna use my depth key right here</p>
<p begin="00:00:55.598" end="00:00:56.957" style="s2">and I'm gonna increase,</p>
<p begin="00:00:56.957" end="00:00:59.650" style="s2">so I can see the full heart in view</p>
<p begin="00:00:59.650" end="00:01:03.130" style="s2">and now you can see<br />we're at 21 centimeters.</p>
<p begin="00:01:03.130" end="00:01:05.906" style="s2">Some common landmarks<br />that you need to identify,</p>
<p begin="00:01:05.906" end="00:01:07.530" style="s2">the first thing you see<br />is that we see liver</p>
<p begin="00:01:07.530" end="00:01:09.204" style="s2">at the top of the screen.</p>
<p begin="00:01:09.204" end="00:01:12.362" style="s2">That liver is our coustic<br />window into the heart.</p>
<p begin="00:01:12.362" end="00:01:14.562" style="s2">The beating thing in the<br />center is obviously the heart</p>
<p begin="00:01:14.562" end="00:01:16.369" style="s2">and we can identify the entire heart</p>
<p begin="00:01:16.369" end="00:01:19.474" style="s2">and the perimeter of the<br />heart with the pericardium.</p>
<p begin="00:01:19.474" end="00:01:21.725" style="s2">The pericardium is the<br />white line that I'm seeing,</p>
<p begin="00:01:21.725" end="00:01:24.114" style="s2">you can see that's<br />surrounding the full heart.</p>
<p begin="00:01:24.114" end="00:01:25.951" style="s2">Then we can identify the chambers.</p>
<p begin="00:01:25.951" end="00:01:28.377" style="s2">The chambers are<br />relatively easy to identify</p>
<p begin="00:01:28.377" end="00:01:30.019" style="s2">in this view.</p>
<p begin="00:01:30.019" end="00:01:32.203" style="s2">The chambers on the right side</p>
<p begin="00:01:32.203" end="00:01:34.286" style="s2">of the heart are over here</p>
<p begin="00:01:34.286" end="00:01:36.094" style="s2">and the easy way to identify those,</p>
<p begin="00:01:36.094" end="00:01:38.496" style="s2">remember the liver's on<br />the right side of the body,</p>
<p begin="00:01:38.496" end="00:01:41.725" style="s2">so these chambers that are<br />adjacent to the liver would be</p>
<p begin="00:01:41.725" end="00:01:43.475" style="s2">right-sided chambers.</p>
<p begin="00:01:44.344" end="00:01:47.441" style="s2">The large chamber, which<br />is adjacent to the liver</p>
<p begin="00:01:47.441" end="00:01:48.958" style="s2">is the right ventricle,</p>
<p begin="00:01:48.958" end="00:01:51.012" style="s2">on the other side we<br />see the left ventricle</p>
<p begin="00:01:51.012" end="00:01:53.258" style="s2">and we see the two atria.</p>
<p begin="00:01:53.258" end="00:01:55.106" style="s2">Again, our focus</p>
<p begin="00:01:55.106" end="00:01:58.091" style="s2">on this exam is to<br />identify the pericardium</p>
<p begin="00:01:58.091" end="00:02:00.495" style="s2">and to look for free fluid within it.</p>
<p begin="00:02:00.495" end="00:02:01.446" style="s2">What we're gonna look for</p>
<p begin="00:02:01.446" end="00:02:04.309" style="s2">is an anechoic area<br />within that pericardium</p>
<p begin="00:02:04.309" end="00:02:07.044" style="s2">which would be signs of a hemopericadium.</p>
<p begin="00:02:07.044" end="00:02:08.424" style="s2">Now if you can't get this view,</p>
<p begin="00:02:08.424" end="00:02:11.246" style="s2">a great alternate view<br />is the parasternal view</p>
<p begin="00:02:11.246" end="00:02:13.387" style="s2">of the heart in a long axis plane.</p>
<p begin="00:02:13.387" end="00:02:14.778" style="s2">We're gonna take you through that in the</p>
<p begin="00:02:14.778" end="00:02:16.861" style="s2">echocardiography section.</p>

<p begin="00:00:15.546" end="00:00:16.890" style="s2">- The next view I'm<br />going to take you through</p>
<p begin="00:00:16.890" end="00:00:19.221" style="s2">is a perisplenic or left<br />upper quadrant view.</p>
<p begin="00:00:19.221" end="00:00:21.219" style="s2">This view tends to be a<br />little bit more difficult</p>
<p begin="00:00:21.219" end="00:00:23.222" style="s2">because the spleen is<br />smaller and doesn't provide</p>
<p begin="00:00:23.222" end="00:00:25.156" style="s2">as large an acoustic window.</p>
<p begin="00:00:25.156" end="00:00:25.989" style="s2">We're going to start.</p>
<p begin="00:00:25.989" end="00:00:27.762" style="s2">Again, the patient's going to be supine.</p>
<p begin="00:00:27.762" end="00:00:29.700" style="s2">This is a probe marker right here.</p>
<p begin="00:00:29.700" end="00:00:31.184" style="s2">We're going to go really posterior.</p>
<p begin="00:00:31.184" end="00:00:32.939" style="s2">My hand is going to touch the gurney.</p>
<p begin="00:00:32.939" end="00:00:34.428" style="s2">You can go about four finger breadths</p>
<p begin="00:00:34.428" end="00:00:37.158" style="s2">just above the costal margin.</p>
<p begin="00:00:37.158" end="00:00:38.895" style="s2">You can identify the kidney.</p>
<p begin="00:00:38.895" end="00:00:41.275" style="s2">That's going to be a<br />pretty identifiable organ,</p>
<p begin="00:00:41.275" end="00:00:42.830" style="s2">characteristic bean shape.</p>
<p begin="00:00:42.830" end="00:00:44.445" style="s2">Then we can see it here on the screen.</p>
<p begin="00:00:44.445" end="00:00:47.184" style="s2">Just above it, we're<br />going to see the spleen.</p>
<p begin="00:00:47.184" end="00:00:50.328" style="s2">To the far left of the screen as well</p>
<p begin="00:00:50.328" end="00:00:51.609" style="s2">we see the diaphragm.</p>
<p begin="00:00:51.609" end="00:00:53.113" style="s2">Once you're in this location,</p>
<p begin="00:00:53.113" end="00:00:55.301" style="s2">you want to carefully pan through</p>
<p begin="00:00:55.301" end="00:00:56.973" style="s2">the inferior part of the spleen,</p>
<p begin="00:00:56.973" end="00:00:58.803" style="s2">and then jump over that rib,</p>
<p begin="00:00:58.803" end="00:01:01.066" style="s2">and see the superior part of the spleen,</p>
<p begin="00:01:01.066" end="00:01:04.617" style="s2">because fluid often collects<br />just above the spleen</p>
<p begin="00:01:04.617" end="00:01:06.199" style="s2">and below the diaphragm.</p>
<p begin="00:01:06.199" end="00:01:09.079" style="s2">Once you identify a good view<br />in the left upper quadrant,</p>
<p begin="00:01:09.079" end="00:01:10.808" style="s2">you'll want to do a<br />sweep through that area</p>
<p begin="00:01:10.808" end="00:01:12.416" style="s2">looking for free fluid.</p>
<p begin="00:01:12.416" end="00:01:14.762" style="s2">Again, you see the kidney,<br />you see the spleen.</p>
<p begin="00:01:14.762" end="00:01:16.427" style="s2">Find the interface between.</p>
<p begin="00:01:16.427" end="00:01:18.594" style="s2">Look for fluid between those two organs.</p>
<p begin="00:01:18.594" end="00:01:21.864" style="s2">Then particularly scan above that spleen,</p>
<p begin="00:01:21.864" end="00:01:24.144" style="s2">scanning all the way through the organ,</p>
<p begin="00:01:24.144" end="00:01:26.408" style="s2">looking for free fluid above the spleen</p>
<p begin="00:01:26.408" end="00:01:27.960" style="s2">and below the diaphragm.</p>
<p begin="00:01:27.960" end="00:01:30.249" style="s2">Again, when you're<br />scanning through this area,</p>
<p begin="00:01:30.249" end="00:01:32.431" style="s2">you want to carefully<br />look above the diaphragm</p>
<p begin="00:01:32.431" end="00:01:35.170" style="s2">for evidence of hemothorax.</p>
<p begin="00:01:35.170" end="00:01:36.260" style="s2">When you're scanning in this view,</p>
<p begin="00:01:36.260" end="00:01:38.846" style="s2">also make sure you scan the full kidney.</p>
<p begin="00:01:38.846" end="00:01:43.581" style="s2">Here we see the superior pole<br />to the left of the screen,</p>
<p begin="00:01:43.581" end="00:01:45.337" style="s2">and the inferior pole.</p>
<p begin="00:01:45.337" end="00:01:47.178" style="s2">You want to make sure<br />you get that full kidney</p>
<p begin="00:01:47.178" end="00:01:51.261" style="s2">in view when you examine<br />the left upper quadrant.</p>

<p begin="00:00:15.825" end="00:00:18.169" style="s2">- So the patient's gonna<br />arrive in a supine position,</p>
<p begin="00:00:18.169" end="00:00:20.784" style="s2">they'll often be on a backboard<br />as full spinal precaution,</p>
<p begin="00:00:20.784" end="00:00:23.903" style="s2">so motion of the patient<br />will be impossible.</p>
<p begin="00:00:23.903" end="00:00:25.651" style="s2">We're gonna choose our transducer.</p>
<p begin="00:00:25.651" end="00:00:28.435" style="s2">We have chosen the<br />phased array transducer,</p>
<p begin="00:00:28.435" end="00:00:31.935" style="s2">we're gonna put a little gel on top of it.</p>
<p begin="00:00:34.817" end="00:00:37.465" style="s2">And I like to put the probe marker</p>
<p begin="00:00:37.465" end="00:00:40.010" style="s2">toward the patient's<br />head, toward the axilla,</p>
<p begin="00:00:40.010" end="00:00:43.825" style="s2">at about the midaxillaral<br />line, 10 to 11th ribs.</p>
<p begin="00:00:43.825" end="00:00:46.410" style="s2">Another easy tip to find out the location</p>
<p begin="00:00:46.410" end="00:00:48.017" style="s2">is get to the costal margin,</p>
<p begin="00:00:48.017" end="00:00:50.137" style="s2">go about three finger-breadths above it,</p>
<p begin="00:00:50.137" end="00:00:52.570" style="s2">and you should be able to find the kidney</p>
<p begin="00:00:52.570" end="00:00:54.690" style="s2">and see the adjacent liver.</p>
<p begin="00:00:54.690" end="00:00:56.842" style="s2">I'm just adjusting my gain here.</p>
<p begin="00:00:56.842" end="00:00:59.050" style="s2">And already I can see the interface</p>
<p begin="00:00:59.050" end="00:01:02.671" style="s2">between the kidney and the<br />liver, which is Morison's pouch.</p>
<p begin="00:01:02.671" end="00:01:05.082" style="s2">So what we see here, on the bottom,</p>
<p begin="00:01:05.082" end="00:01:08.970" style="s2">this crescent shaped organ, is the kidney.</p>
<p begin="00:01:08.970" end="00:01:10.642" style="s2">Above it we see the liver,</p>
<p begin="00:01:10.642" end="00:01:12.866" style="s2">and just to the left side of the screen</p>
<p begin="00:01:12.866" end="00:01:14.602" style="s2">we see the diaphragm.</p>
<p begin="00:01:14.602" end="00:01:16.773" style="s2">So when I'm examining this area,</p>
<p begin="00:01:16.773" end="00:01:19.161" style="s2">I'm gonna carefully scan through</p>
<p begin="00:01:19.161" end="00:01:21.954" style="s2">the entire area of Morison's pouch,</p>
<p begin="00:01:21.954" end="00:01:23.903" style="s2">including at the liver tip.</p>
<p begin="00:01:23.903" end="00:01:25.866" style="s2">So we see this whole area here</p>
<p begin="00:01:25.866" end="00:01:28.178" style="s2">looking for an anechoic stripe.</p>
<p begin="00:01:28.178" end="00:01:31.730" style="s2">An anechoic stripe would be<br />indicative of free fluid.</p>
<p begin="00:01:31.730" end="00:01:33.770" style="s2">I'm also identifying the diaphragm,</p>
<p begin="00:01:33.770" end="00:01:35.680" style="s2">so when I look at the diaphragm,</p>
<p begin="00:01:35.680" end="00:01:37.577" style="s2">this is the hypoechoic or white line</p>
<p begin="00:01:37.577" end="00:01:39.321" style="s2">to the left side of the screen,</p>
<p begin="00:01:39.321" end="00:01:41.673" style="s2">and I should be able to<br />see that pretty easily</p>
<p begin="00:01:41.673" end="00:01:43.385" style="s2">and you can see what appears to be</p>
<p begin="00:01:43.385" end="00:01:45.593" style="s2">liver on both sides of the diaphragm,</p>
<p begin="00:01:45.593" end="00:01:47.849" style="s2">on the bottom far left of the screen.</p>
<p begin="00:01:47.849" end="00:01:50.921" style="s2">That is mirror artifact<br />and is a normal finding.</p>
<p begin="00:01:50.921" end="00:01:53.945" style="s2">If the patient had a pleural<br />fluid collection after trauma</p>
<p begin="00:01:53.945" end="00:01:55.457" style="s2">that would be a hemothorax,</p>
<p begin="00:01:55.457" end="00:01:59.624" style="s2">we would see an anechoic or<br />black area in this location.</p>

<p begin="00:00:15.596" end="00:00:17.684" style="s2">- We're going to go ahead<br />and do the suprapubic view</p>
<p begin="00:00:17.684" end="00:00:19.123" style="s2">of the FAST exam.</p>
<p begin="00:00:19.123" end="00:00:22.650" style="s2">We're going to put a little<br />gel on this transducer</p>
<p begin="00:00:22.650" end="00:00:25.395" style="s2">and we're going to go just<br />above the symphysis pubis</p>
<p begin="00:00:25.395" end="00:00:27.855" style="s2">and we're going to start<br />initially sagittally</p>
<p begin="00:00:27.855" end="00:00:30.312" style="s2">and then we're going to scan transversely.</p>
<p begin="00:00:30.312" end="00:00:32.689" style="s2">We have our marker right here.</p>
<p begin="00:00:32.689" end="00:00:35.183" style="s2">That's going to be aiming<br />toward the patient's head</p>
<p begin="00:00:35.183" end="00:00:36.739" style="s2">and we're going to put this transducer</p>
<p begin="00:00:36.739" end="00:00:38.298" style="s2">just above the symphysis pubis</p>
<p begin="00:00:38.298" end="00:00:39.775" style="s2">and we're going to see the bladder.</p>
<p begin="00:00:39.775" end="00:00:41.416" style="s2">We can see a pretty large bladder here.</p>
<p begin="00:00:41.416" end="00:00:43.463" style="s2">The first thing I'll take a<br />look at when I see the image</p>
<p begin="00:00:43.463" end="00:00:45.353" style="s2">is that we need to adjust our depth,</p>
<p begin="00:00:45.353" end="00:00:46.950" style="s2">so I'm changing the depth here</p>
<p begin="00:00:46.950" end="00:00:49.164" style="s2">to make this bladder into a better size</p>
<p begin="00:00:49.164" end="00:00:51.411" style="s2">that is going to fit<br />better within the image.</p>
<p begin="00:00:51.411" end="00:00:53.469" style="s2">The next thing I notice<br />that I do need to adjust</p>
<p begin="00:00:53.469" end="00:00:54.414" style="s2">is the gain.</p>
<p begin="00:00:54.414" end="00:00:58.027" style="s2">This is a very important<br />knob to be adjusting</p>
<p begin="00:00:58.027" end="00:01:00.316" style="s2">because in this view particularly</p>
<p begin="00:01:00.316" end="00:01:02.243" style="s2">you can have a lot of acoustic enhancement</p>
<p begin="00:01:02.243" end="00:01:03.634" style="s2">posterior to the bladder</p>
<p begin="00:01:03.634" end="00:01:06.338" style="s2">and we don't want to miss<br />small amounts of fluid.</p>
<p begin="00:01:06.338" end="00:01:09.210" style="s2">The far gain, which is this knob here,</p>
<p begin="00:01:09.210" end="00:01:11.960" style="s2">may need to be adjusted additionally.</p>
<p begin="00:01:11.960" end="00:01:14.215" style="s2">Once you identify the bladder,</p>
<p begin="00:01:14.215" end="00:01:16.633" style="s2">which we see as an anechoic structure</p>
<p begin="00:01:16.633" end="00:01:19.869" style="s2">with nice circumscribed walls,</p>
<p begin="00:01:19.869" end="00:01:22.452" style="s2">you want to then scan from left</p>
<p begin="00:01:23.385" end="00:01:24.218" style="s2">to right,</p>
<p begin="00:01:27.338" end="00:01:30.578" style="s2">looking particularly for evidence of fluid</p>
<p begin="00:01:30.578" end="00:01:33.322" style="s2">outside of that circumscribed bladder.</p>
<p begin="00:01:33.322" end="00:01:37.013" style="s2">We're looking for free<br />fluid within the pelvis.</p>
<p begin="00:01:37.013" end="00:01:39.720" style="s2">Once we're satisfied that<br />we can see the full bladder</p>
<p begin="00:01:39.720" end="00:01:41.647" style="s2">in a sagittal fashion,</p>
<p begin="00:01:41.647" end="00:01:45.008" style="s2">we're then going to turn<br />the transducer marker here</p>
<p begin="00:01:45.008" end="00:01:47.016" style="s2">toward the patient's right,</p>
<p begin="00:01:47.016" end="00:01:48.317" style="s2">and we're going to scan again.</p>
<p begin="00:01:48.317" end="00:01:50.003" style="s2">Now we're in a transverse view</p>
<p begin="00:01:50.003" end="00:01:53.898" style="s2">and were scanning from very inferiorly</p>
<p begin="00:01:53.898" end="00:01:55.444" style="s2">to superiorly,</p>
<p begin="00:01:55.444" end="00:01:59.611" style="s2">again looking for free fluid<br />outside of the bladder.</p>
<p begin="00:02:01.110" end="00:02:02.759" style="s2">As you're scanning through the bladder,</p>
<p begin="00:02:02.759" end="00:02:04.565" style="s2">again you're looking for free fluid,</p>
<p begin="00:02:04.565" end="00:02:08.168" style="s2">remember free fluid is anechoic<br />or black on ultrasounds</p>
<p begin="00:02:08.168" end="00:02:09.773" style="s2">so that's what you're<br />going to be looking for</p>
<p begin="00:02:09.773" end="00:02:11.690" style="s2">outside of the bladder.</p>