<p begin="00:00:07.492" end="00:00:08.958" style="s2">- [Voiceover] A phased array transducer</p>
<p begin="00:00:08.958" end="00:00:10.583" style="s2">with a cardiac exam type,</p>
<p begin="00:00:10.583" end="00:00:12.586" style="s2">is used to perform an ultrasound guided</p>
<p begin="00:00:12.586" end="00:00:16.071" style="s2">trans-thoracic pericardiocentesis.</p>
<p begin="00:00:16.071" end="00:00:17.612" style="s2">The patient is placed in a</p>
<p begin="00:00:17.612" end="00:00:20.505" style="s2">left lateral decubitus<br />position, if possible.</p>
<p begin="00:00:20.505" end="00:00:22.921" style="s2">Place the transducer at the apex or point</p>
<p begin="00:00:22.921" end="00:00:26.163" style="s2">of maximum impulse, with<br />the orientation marker</p>
<p begin="00:00:26.163" end="00:00:30.330" style="s2">to the patients left side,<br />at a three o'clock position.</p>
<p begin="00:00:32.392" end="00:00:34.726" style="s2">The apex of the heart<br />is visualized closest</p>
<p begin="00:00:34.726" end="00:00:36.576" style="s2">to the transducer.</p>
<p begin="00:00:36.576" end="00:00:38.757" style="s2">Move between the apical and parasternal</p>
<p begin="00:00:38.757" end="00:00:41.165" style="s2">long axis views of the<br />heart, to determine the</p>
<p begin="00:00:41.165" end="00:00:44.298" style="s2">most superficial and<br />largest pocket of fluid.</p>
<p begin="00:00:44.298" end="00:00:46.292" style="s2">The myocardium will appear grey,</p>
<p begin="00:00:46.292" end="00:00:49.478" style="s2">and the blood filled chambers<br />will appear hypoechoic.</p>
<p begin="00:00:49.478" end="00:00:51.426" style="s2">The ventricles are in the near field,</p>
<p begin="00:00:51.426" end="00:00:54.539" style="s2">and the atria are in the<br />far field of the image.</p>
<p begin="00:00:54.539" end="00:00:57.285" style="s2">A pericardial effusion will appear as</p>
<p begin="00:00:57.285" end="00:01:00.654" style="s2">a dark anechoic fluid collection<br />surrounding the heart.</p>
<p begin="00:01:00.654" end="00:01:03.974" style="s2">For direct needle guidance,<br />using an in plane technique,</p>
<p begin="00:01:03.974" end="00:01:07.644" style="s2">the transducer is rotated<br />90 degrees counterclockwise.</p>
<p begin="00:01:07.644" end="00:01:11.539" style="s2">So the orientation marker is<br />at the 12 o'clock position.</p>
<p begin="00:01:11.539" end="00:01:13.104" style="s2">This will create a view of the heart</p>
<p begin="00:01:13.104" end="00:01:15.268" style="s2">that is between the apical fore chamber</p>
<p begin="00:01:15.268" end="00:01:17.872" style="s2">and parasternal long axis views.</p>
<p begin="00:01:17.872" end="00:01:19.872" style="s2">Note the absence of the lung,</p>
<p begin="00:01:19.872" end="00:01:22.583" style="s2">to ensure it is not in the needle path.</p>
<p begin="00:01:22.583" end="00:01:24.415" style="s2">The needle is inserted in the skin,</p>
<p begin="00:01:24.415" end="00:01:26.621" style="s2">just proximal to the transducer,</p>
<p begin="00:01:26.621" end="00:01:29.565" style="s2">opposite to the side of<br />the orientation marker.</p>
<p begin="00:01:29.565" end="00:01:31.126" style="s2">The needle is slowly advanced,</p>
<p begin="00:01:31.126" end="00:01:35.123" style="s2">and is seen as a bright<br />hypoechoic linear structure.</p>
<p begin="00:01:35.123" end="00:01:36.799" style="s2">The needle is slowly advanced,</p>
<p begin="00:01:36.799" end="00:01:39.092" style="s2">under direct ultrasound visualization,</p>
<p begin="00:01:39.092" end="00:01:40.941" style="s2">until the tip is seen to puncture the</p>
<p begin="00:01:40.941" end="00:01:42.963" style="s2">pericardial fluid collection.</p>
<p begin="00:01:42.963" end="00:01:45.358" style="s2">The needle should be<br />advanced until the needle tip</p>
<p begin="00:01:45.358" end="00:01:47.122" style="s2">lies within the fluid collection,</p>
<p begin="00:01:47.122" end="00:01:49.171" style="s2">which can then be aspirated.</p>
<p begin="00:01:49.171" end="00:01:51.175" style="s2">Vascular structures to be avoided</p>
<p begin="00:01:51.175" end="00:01:53.344" style="s2">include the internal mammary,</p>
<p begin="00:01:53.344" end="00:01:55.844" style="s2">and the intercostal arteries.</p>

<p begin="00:00:07.862" end="00:00:09.374" style="s2">- [Voiceover] A curved array transducer</p>
<p begin="00:00:09.374" end="00:00:10.901" style="s2">with an abdomen exam type</p>
<p begin="00:00:10.901" end="00:00:14.038" style="s2">is used to perform an<br />ultrasound guided paracentesis.</p>
<p begin="00:00:14.038" end="00:00:16.119" style="s2">It is easier to perform this exam</p>
<p begin="00:00:16.119" end="00:00:18.248" style="s2">when the bladder is not filled.</p>
<p begin="00:00:18.248" end="00:00:20.735" style="s2">The patient is placed<br />in a supine position.</p>
<p begin="00:00:20.735" end="00:00:24.165" style="s2">The abdominal cavity is<br />evaluated in two planes.</p>
<p begin="00:00:24.165" end="00:00:27.188" style="s2">Place the transducer in<br />a transverse position</p>
<p begin="00:00:27.188" end="00:00:30.032" style="s2">with the orientation marker to the right.</p>
<p begin="00:00:30.032" end="00:00:32.876" style="s2">The transducer is placed<br />at the lateral border</p>
<p begin="00:00:32.876" end="00:00:35.719" style="s2">of the rectus sheath at<br />the level of the umbilicus.</p>
<p begin="00:00:35.719" end="00:00:38.433" style="s2">To evaluate the abdominal<br />cavity for free fluid,</p>
<p begin="00:00:38.433" end="00:00:42.920" style="s2">sweep the transducer from an<br />inferior to superior position.</p>
<p begin="00:00:42.920" end="00:00:45.829" style="s2">Fluid will appear hypoechoic or anechoic</p>
<p begin="00:00:45.829" end="00:00:47.828" style="s2">and accumulate in the lateral gutter</p>
<p begin="00:00:47.828" end="00:00:49.827" style="s2">and between loops of bowel.</p>
<p begin="00:00:49.827" end="00:00:51.762" style="s2">To obtain a long axis view,</p>
<p begin="00:00:51.762" end="00:00:55.516" style="s2">rotate the transducer 90 degrees<br />with the orientation marker</p>
<p begin="00:00:55.516" end="00:00:58.036" style="s2">directed to the point of needle entry.</p>
<p begin="00:00:58.036" end="00:01:00.831" style="s2">Sweep the transducer<br />across the abdominal cavity</p>
<p begin="00:01:00.831" end="00:01:04.651" style="s2">from left to right to evaluate<br />the abdomen for free fluid.</p>
<p begin="00:01:04.651" end="00:01:07.170" style="s2">A needle insertion site should be chosen</p>
<p begin="00:01:07.170" end="00:01:08.991" style="s2">in the lateral abdominal area</p>
<p begin="00:01:08.991" end="00:01:11.364" style="s2">in a dependent area of<br />the fluid collection</p>
<p begin="00:01:11.364" end="00:01:13.867" style="s2">which is clear from loops of bowel.</p>
<p begin="00:01:13.867" end="00:01:16.825" style="s2">The needle should be inserted<br />lateral to the rectus sheath</p>
<p begin="00:01:16.825" end="00:01:20.499" style="s2">in a transverse fashion to<br />avoid the epigastric artery.</p>
<p begin="00:01:20.499" end="00:01:23.571" style="s2">Follow the needle entry by<br />slowly sliding the transducer</p>
<p begin="00:01:23.571" end="00:01:26.204" style="s2">in the direction of needle advancement.</p>
<p begin="00:01:26.204" end="00:01:30.040" style="s2">The needle will appear as a<br />small, bright hypoechoic dot.</p>
<p begin="00:01:30.040" end="00:01:31.828" style="s2">When the needle tip appears,</p>
<p begin="00:01:31.828" end="00:01:35.241" style="s2">the transducer should be advanced<br />a short distance distally</p>
<p begin="00:01:35.241" end="00:01:38.150" style="s2">to follow the tip of<br />the needle trajectory.</p>
<p begin="00:01:38.150" end="00:01:39.792" style="s2">The needle is slowly advanced</p>
<p begin="00:01:39.792" end="00:01:42.035" style="s2">under direct ultrasound visualization</p>
<p begin="00:01:42.035" end="00:01:44.034" style="s2">until the tip is seen to indent</p>
<p begin="00:01:44.034" end="00:01:46.830" style="s2">and then puncture the parietal peritoneum.</p>
<p begin="00:01:46.830" end="00:01:49.758" style="s2">The transducer should be<br />moved slightly proximally</p>
<p begin="00:01:49.758" end="00:01:53.925" style="s2">and distally to confirm<br />location of the needle tip.</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="00:00:07.385" end="00:00:09.473" style="s2">- [Voiceover] A curved or<br />phased array transducer</p>
<p begin="00:00:09.473" end="00:00:12.170" style="s2">with an abdomen exam<br />type is used to perform</p>
<p begin="00:00:12.170" end="00:00:14.744" style="s2">an aorta ultrasound exam.</p>
<p begin="00:00:14.744" end="00:00:16.791" style="s2">The entire length of the aorta from</p>
<p begin="00:00:16.791" end="00:00:18.015" style="s2">the level of the diaphragm</p>
<p begin="00:00:18.015" end="00:00:20.748" style="s2">to the bifurcation of the iliac arteries</p>
<p begin="00:00:20.748" end="00:00:23.480" style="s2">must be evaluated in two planes.</p>
<p begin="00:00:23.480" end="00:00:26.126" style="s2">The examination begins with the transducer</p>
<p begin="00:00:26.126" end="00:00:29.631" style="s2">placed transversely in<br />the epigastric mid line,</p>
<p begin="00:00:29.631" end="00:00:33.631" style="s2">with the marker directed<br />to the patient's right.</p>
<p begin="00:00:34.682" end="00:00:37.901" style="s2">The aorta is seen as a<br />round, pulsatile structure,</p>
<p begin="00:00:37.901" end="00:00:41.184" style="s2">anterior to the bright<br />reflection of the vertebrae.</p>
<p begin="00:00:41.184" end="00:00:43.074" style="s2">The vena cava is an oval structure</p>
<p begin="00:00:43.074" end="00:00:46.359" style="s2">immediately to the left of<br />the aorta on the screen,</p>
<p begin="00:00:46.359" end="00:00:48.639" style="s2">which changes in caliber with compression</p>
<p begin="00:00:48.639" end="00:00:50.751" style="s2">or deep inspiration.</p>
<p begin="00:00:50.751" end="00:00:53.234" style="s2">The abdominal aorta will course gradually,</p>
<p begin="00:00:53.234" end="00:00:56.523" style="s2">becoming more superficial<br />as it progresses distally.</p>
<p begin="00:00:56.523" end="00:00:58.935" style="s2">The transducer is slowly moved distally</p>
<p begin="00:00:58.935" end="00:01:01.352" style="s2">to identify the celiac trunk,</p>
<p begin="00:01:02.313" end="00:01:03.563" style="s2">renal arteries,</p>
<p begin="00:01:06.503" end="00:01:08.753" style="s2">superior mesenteric artery,</p>
<p begin="00:01:12.713" end="00:01:15.718" style="s2">and bifurcation to the iliac arteries.</p>
<p begin="00:01:15.718" end="00:01:18.027" style="s2">Note the location of any change in size</p>
<p begin="00:01:18.027" end="00:01:20.307" style="s2">of the aorta or iliac arteries,</p>
<p begin="00:01:20.307" end="00:01:23.021" style="s2">and measure in long and short axis views</p>
<p begin="00:01:23.021" end="00:01:25.054" style="s2">from outer wall to outer wall</p>
<p begin="00:01:25.054" end="00:01:27.444" style="s2">to determine the true diameter.</p>
<p begin="00:01:27.444" end="00:01:30.347" style="s2">The transducer is returned<br />to the epigastric area</p>
<p begin="00:01:30.347" end="00:01:32.963" style="s2">and rotated 90 degrees clockwise,</p>
<p begin="00:01:32.963" end="00:01:36.205" style="s2">with the orientation marker<br />to the patient's head.</p>
<p begin="00:01:36.205" end="00:01:38.466" style="s2">The transducer is swept side to side</p>
<p begin="00:01:38.466" end="00:01:41.870" style="s2">to identify the maximal<br />diameter of the aorta.</p>
<p begin="00:01:41.870" end="00:01:45.463" style="s2">The abdominal aorta will have<br />proximal to distal taper.</p>
<p begin="00:01:45.463" end="00:01:47.712" style="s2">The transducer is moved distally</p>
<p begin="00:01:47.712" end="00:01:49.767" style="s2">to evaluate the walls of the aorta</p>
<p begin="00:01:49.767" end="00:01:52.767" style="s2">for any change in the shape or size.</p>
<p begin="00:01:55.622" end="00:01:57.555" style="s2">If the aorta is difficult to visualize</p>
<p begin="00:01:57.555" end="00:02:01.245" style="s2">due to overlying bowel, gentle<br />downward transducer pressure</p>
<p begin="00:02:01.245" end="00:02:04.715" style="s2">may encourage peristalsis<br />of the overlying bowel.</p>
<p begin="00:02:04.715" end="00:02:06.950" style="s2">Alternatively, consider moving the patient</p>
<p begin="00:02:06.950" end="00:02:09.314" style="s2">into a left lateral decubitus position</p>
<p begin="00:02:09.314" end="00:02:13.481" style="s2">to re-position the bowel<br />away from the field of view.</p>

<p begin="00:00:07.527" end="00:00:09.159" style="s2">- [Voiceover] A phased-array transducer</p>
<p begin="00:00:09.159" end="00:00:12.039" style="s2">with a cardiac exam<br />type is used to perform</p>
<p begin="00:00:12.039" end="00:00:15.543" style="s2">the subxiphoid, or<br />subcostal view of the heart.</p>
<p begin="00:00:15.543" end="00:00:18.575" style="s2">Place the transducer in<br />the subxiphoid position,</p>
<p begin="00:00:18.575" end="00:00:20.781" style="s2">with the transducer orientation marker</p>
<p begin="00:00:20.781" end="00:00:24.301" style="s2">to the patient's left side<br />at a three o'clock position.</p>
<p begin="00:00:24.301" end="00:00:26.077" style="s2">As an alternative approach,</p>
<p begin="00:00:26.077" end="00:00:29.477" style="s2">this exam may be performed<br />using an abdomen exam type,</p>
<p begin="00:00:29.477" end="00:00:32.365" style="s2">with the orientation marker<br />to the patient's right side,</p>
<p begin="00:00:32.365" end="00:00:34.485" style="s2">at the nine o'clock position.</p>
<p begin="00:00:34.485" end="00:00:37.293" style="s2">This view uses the liver<br />as an acoustic window</p>
<p begin="00:00:37.293" end="00:00:39.949" style="s2">to visualize the four<br />chambers of the heart.</p>
<p begin="00:00:39.949" end="00:00:43.398" style="s2">Aim the transducer slightly<br />toward the left shoulder,</p>
<p begin="00:00:43.398" end="00:00:47.572" style="s2">with approximately a 15-degree<br />angle to the chest wall.</p>
<p begin="00:00:47.572" end="00:00:50.692" style="s2">In some cases, the<br />transducer is almost flat</p>
<p begin="00:00:50.692" end="00:00:53.532" style="s2">to the abdominal wall,<br />so the ultrasound beam</p>
<p begin="00:00:53.532" end="00:00:56.820" style="s2">is directed toward the left chest cavity.</p>
<p begin="00:00:56.820" end="00:00:59.364" style="s2">A considerable amount of ultrasound gel</p>
<p begin="00:00:59.364" end="00:01:01.580" style="s2">and downward pressure may be required</p>
<p begin="00:01:01.580" end="00:01:04.340" style="s2">to maintain contact of the transducer face</p>
<p begin="00:01:04.340" end="00:01:06.132" style="s2">with the abdominal wall.</p>
<p begin="00:01:06.132" end="00:01:07.884" style="s2">Having the patient bend their knees</p>
<p begin="00:01:07.884" end="00:01:10.108" style="s2">helps relax the abdominal wall muscles</p>
<p begin="00:01:10.108" end="00:01:12.541" style="s2">for better transducer positioning.</p>
<p begin="00:01:12.541" end="00:01:15.348" style="s2">The first structure seen<br />closest to the transducer</p>
<p begin="00:01:15.348" end="00:01:16.558" style="s2">is the liver.</p>
<p begin="00:01:16.558" end="00:01:18.684" style="s2">The right side of the<br />heart will appear closer</p>
<p begin="00:01:18.684" end="00:01:21.076" style="s2">to the transducer than<br />the left side of the heart</p>
<p begin="00:01:21.076" end="00:01:23.034" style="s2">on the ultrasound image.</p>
<p begin="00:01:23.034" end="00:01:25.118" style="s2">The myocardium will appear grey,</p>
<p begin="00:01:25.118" end="00:01:28.638" style="s2">and the blood filled chambers<br />will appear hypoechoic.</p>
<p begin="00:01:28.638" end="00:01:30.286" style="s2">The bright white pericardium</p>
<p begin="00:01:30.286" end="00:01:32.217" style="s2">is seen surrounding the heart adjacent</p>
<p begin="00:01:32.217" end="00:01:34.598" style="s2">to the grey myocardium.</p>
<p begin="00:01:34.598" end="00:01:37.614" style="s2">Evaluate the function of all chambers.</p>
<p begin="00:01:37.614" end="00:01:38.766" style="s2">Compare the size of the</p>
<p begin="00:01:38.766" end="00:01:41.479" style="s2">right and left ventricular cavities.</p>
<p begin="00:01:41.479" end="00:01:43.983" style="s2">Note any wall motion abnormality,</p>
<p begin="00:01:43.983" end="00:01:48.150" style="s2">and the presence or absence<br />of pericardial effusion.</p>