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How to: Pneumothorax Evaluation

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Learn transthoracic lung ultrasound to rule out pneumothorax.

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- Classically, it's been thought
that the lung cannot be ultrasounded.
In fact, that's not true.
We can use ultrasound very easily
to rule out a pneumothorax.
I'm gonna show you, using two different transducers,
how we can see the lung pleural line
to exclude the presence of a pneumothorax.
We're gonna start with our transducers.
We have two different choices of transducers.
We have our phased array transducer
and a linear array transducer.
If you're doing this as part of the fast exam,
most likely you've already have
a phased array transducer in your hand.
Therefore, I'm gonna go ahead
and show you what the images look like
using a phased array transducer.
The exam type has already been set up
in an abdominal preset,
and so we're ready to start scanning.
Now the area that we're gonna scan
is an area where we're gonna expect air to collect
in the presence of a pneumothorax.
That would be the most anterior aspect of the lung.
So if you look at our model right here,
we would expect air to collect more likely
in the anterior surface than more posteriorly.
Therefore, when I do my scanning,
I'm gonna scan about mid-clavicular line
at the most anterior area of the patient's body.
So we're gonna go ahead and start scanning.
Here's our probe marker right here.
We're gonna aim that toward the patient's head,
and I'm scanning right now in a sagittal fashion.
I'm gonna turn my gain up a little bit,
and first thing you're gonna recognize
that our depth is too deep.
Remember, what we're scanning now is really superficial.
We're looking at the lung's surface.
So I'm gonna decrease our depth
so we can see the lung surface quite easily.
Now what we're looking at here on the screen
is a classic shimmering line
that you see with the pleural surface,
that being the parietal and the visceral pleural surface
rubbing against each other.
So we see a rib here on the left.
We see another rib to the right.
And in the center is a line which is horizontal,
and we see shimmering.
That presence of that shimmering,
as well as very small, tiny comet tails
that are coming from the posterior aspect of that,
excludes the presence of a pneumothorax.
If you have time,
you want to use your linear array transducer.
This transducer does high-frequency imaging,
allows you to do much better imaging
of superficial structures.
So we're gonna get a lot better quality,
high-resolution pictures, of the pleural line.
So here's our transducer that I've chosen.
This is the marker here right now.
And I'm gonna go ahead and put a little gel here.
Now I'm gonna cut sagittally
at the highest point in his chest,
in about the mid-clavicular line,
and I notice to the left of the screen
is a rib right here,
and we see another rib right here.
And in between the two, we see the pleural line.
And as he takes a breath, we see shimmering.
These are the two surfaces of the lung,
the visceral surface and the parietal surface,
rubbing together.
We also see little tiny white lines,
your little comet tail lines,
which also show that both surfaces are touching together.
If you see this pattern,
you have reliably excluded a pneumothorax.
You can see in this model
that we can easily see the rib here anteriorly
and another one more inferiorly,
and we see the pleural line easily here in the middle,
we see shimmering.
Now you may want to document this in a still pattern.
That is very easy to do by just activating the M-mode.
We hit the M-mode key here.
And we put the M-mode marker
through the center of the pleural line
where we see shimmering, and with M-mode again.
And what we see now is a pattern
that's called the seashore sign.
And I'm gonna freeze this.
So now we have a frozen image
of the M-mode through the pleural line,
and we see the shimmering line here,
and we see here a classic seashore sign.
And when you see this,
this is still documentation of exclusion of a pneumothorax.
If you do your exam in the mid-clavicular line
at the most anterior portion of the chest,
and you see a good shimmering line,
then you've ruled out a pneumothorax.
If you don't see any shimmering line,
then you most likely are dealing
with a patient with a pneumothorax.
You can then take your transducer
and move it to the patient's left or to his right
or in more superior and inferior
to get a qualitative size of the pneumothorax
you're dealing with.

Brightcove ID

5741746210001

https://youtube.com/watch?v=D3mm9wwlw7g

3D How To: Lung Examination

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3D animation demonstrating a lung ultrasound exam.

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Cardiology

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- [Voiceover] A phased array transducer
with a long exam type is used to evaluate lung sliding.
The anterior, lateral, and posterior zones of the chest wall
should be evaluated.
The transducer is placed in a long-axis orientation
over the anterior chest wall at the third or fourth
intercostal space in the anterior axillary line.
The orientation marker is directed to the patient's head.
A shallow scanning depth is used.
The ribs are identified in the near field of the image
as a bright interface with a posterior shadow.
The pleural line is identified as a bright,
hyperechoic line between the rib shadows.
The to and fro sliding movement of the visceral pleural
against the parietal pleural with breathing
generates the lung sliding sign.
Evaluate the pleural movement for A line and B line
reverberation artifacts.
To evaluate the posterior pleural space,
move the transducer distally to the level
of the seventh intercostal space.
Slide the transducer posteriorly to the midaxillary line.
Increase the scanning depth to view the interface
between the pleural space and diaphragm.
In a normal patient, a mirror image artifact
of the liver or spleen will appear the diaphragm.

Brightcove ID

5741728173001

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

3D How To: Ocular Ultrasound

Read more about 3D How To: Ocular Ultrasound

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3D animation demonstrating an ocular ultrasound exam, or ultrasound of the eye.

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Ocular

Intraccular Structures

Intraoccular Foreign Body

Intercranial Pressure

Membrane Optic Nerve Sheath Measurement

Elevated

Increased Intercranial Pressure

Subtitles

- [Voiceover] A linear array transducer with an ophthalmic
exam type is used to perform an ocular ultrasound exam.
The eye is evaluated in two planes.
Apply a copious amount of ultrasound gel to the closed eye.
Gently place the transducer in the transverse position
with the orientation maker to the patient's right.
The globe of the eye is seen as a round,
dark fluid filled structure.
Several structures are identified in the globe.
The cornea is a thin layer parallel to the eyelid.
The anterior chamber and the lens are anechoic,
separated by the thin, echogenic iris.
The choroid and retina form a thin, light grey layer
at the posterior aspect of the globe.
The optic nerve sheath is hypoechoic, or dark grey,
moving away from the globe.
Angle the transducer from the superior to inferior
aspect of the globe to visualize each structure.
From the transverse position, rotate the transducer
90 degrees so the transducer orientation marker
is directed towards the top of the patient's head.
Angle the transducer from side to side to visualize
the lens, retina, and optic nerve sheath.

Brightcove ID

5508136018001

https://youtube.com/watch?v=weS0JvDRBG4

3D How To: eFAST Lung Sliding Detection (Phased)

Read more about 3D How To: eFAST Lung Sliding Detection (Phased)

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3D animation demonstrating how to detect lung sliding with a phased array transducer while performing the eFAST exam.

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Cardiology

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Cardiology

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How To Videos

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Subtitles

- [Voiceover] A phased array transducer is used
to evaluate lung sliding as an extension of the FAST exam.
The orientation marker is positioned
in the direction of the patient's head.
The transducer is placed in a long-axis orientation
over the anterior chest wall at the third
or fourth intercostal space
in the anterior axillary or midclavicular line.
A superficial scanning depth is used.
The ribs are identified in the near field of the image
as a bright interface with a posterior shadow.
The pleural line is identified
as a bright hyperechoic line between the rib shadows.
The normal to and fro sliding movement
of the visceral pleural against the parietal pleural
with breathing generates the lung sliding sign.
If desired, the delineation of the lung sliding interface
may be enhanced by changing to a linear array transducer.

Brightcove ID

5753042634001

https://youtube.com/watch?v=n9J12nmNhUU

How To Detect Lung Sliding with Ultrasound

Read more about How To Detect Lung Sliding with Ultrasound

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3D animation demonstrating how to detect lung sliding with a linear transducer while performing the eFAST exam.

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Cardiology

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How To Videos

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Subtitles

- [Voiceover] A linear array transducer is used
to evaluate lung sliding as an extension of the FAST exam.
The orientation marker is positioned in the direction
of the patient's head.
The transducer is placed in a long access orientation
over the anterior chest wall
at the third or fourth intercostal space
in the interior axillary to mid-clavicular line.
The ribs are identified in the near field of the image
as bright interface with a posterior shadow.
The plural line is identified
as a bright hyperechoic line between the rib shadows.
The to and fro sliding movement of the visceral plural
against the parietal plural with breathing
generates the lung sliding sign.

Brightcove ID

5741746239001

https://youtube.com/watch?v=26RQyxk5vGc

Body

3D animation demonstrating how to detect lung sliding with a linear transducer while performing the eFAST exam.

Case: Ocular Ultrasound Part 2

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Part 2 of 2. Ocular ultrasound case study.

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EMED

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Ocular

Intraccular Structures

Intraoccular Foreign Body

Intercranial Pressure

Membrane Optic Nerve Sheath Measurement

Elevated

Increased Intercranial Pressure

Soundbytes Cases

Subtitles

- Hello, my name is Phil Perera,
and I'm the Emergency Ultrasound Co-Director
at the LA County USC Medical Center
in Los Angeles, California.
And welcome to SoundBytes.
Welcome back to SoundBytes,
Ocular Ultrasound Part 2.
In this module,
we'll further explore ocular ultrasound building
on those concepts introduced
in ocular ultrasound module part one.
We'll learn how to diagnose retinal pathology,
specifically retinal detachment.
We'll also look at vitreous pathology,
a possible mimic of retinal pathology,
such as retinal detachment.
And we'll learn how to differentiate
between the two conditions,
using the kinetic or movement examination.
Now let's take a look at an illustration
showing the anatomy of a retinal detachment.
We note the anterior structures of the eye,
the cornea, anterior chamber, lens, and iris
are all normal in this illustration.
The pathology exists in the posterior aspect of the eye.
In the posterior part of vitreous body.
And we note here that the retina has buckled
away from the choroid,
both medially and laterally.
And this is a very bad thing because the blood supply
to the retina exists through the choroid.
And the lack of opposition of these two layers
will cause ischemia of the retina with time.
Now we remember that the retina is a continuation
of the optic nerve, thus the retina will always be
attached there or tethered down to the optic nerve.
The retina is also going to be attached or tethered down
anterior and laterally at the ora serrata.
And this is important as we start to look at ultrasounds
of retinal detachment.
Now let's return to our patient's ocular ultrasound.
Placing the probe in a side to side
or transverse orientation over the affected eye.
Right away we note that there's pathology within
the posterior aspect of the eye.
And we can see a hyperechoic or bright structure
waving around in the posterior aspect of the eye
that should not be there.
We'll look at the patient's other in the small video
to the right and we note here the normal appearance
of the retinal tacked down to the choroid.
So in the affected eye, this is actually
a detached retina that's moving around
as the patient looks up and down.
And we have the probe position over the patient's eye.
So right away, our diagnosis within immediate orientation
of the probe onto the eye is, retinal detachment.
Here's the ultrasound from another patient
who presented with non traumatic loss of vision.
And again, we note the classic appearance
of a retinal detachment.
We have the probe configured in a side to side orientation,
or transverse orientation over the patient's eye.
With the probe marker oriented lateral.
We can see the optic nerve sheath coming up
from the posterior aspect into the eye.
And we note the detached retina emanating off
from the optic nerve.
Now recalling that the macula lies just lateral
to the optic nerve, we can see here that this detachment
has affected the macula.
That this is classified as a mac off,
or macular off retinal detachment.
Now let's take a look at a retinal detachment
using the kinetic ultrasound examination.
We're having the patient look from side to side
as we place the probe over the closed eyelid.
And we note here a very large posterior detachment
of the retina.
We can see here that it has tethered membrane appearance
as the patient looks from side to side.
Now we note some anterior vitreous material
that swirls around as the patient looks from side to side.
But I want you to look towards that posterior aspect
of the eyeball.
Towards that membrane, the tethered membrane,
that moves back and forth as the patient looks
from side to side.
And that is the classic appearance on kinetic exam
of a detached retina.
Here's another ocular kinetic exam of a retinal detachment.
And we can see the tethered membrane appearance
of the detached retina moving around
as the patient looks from side to side.
But we can see that it has a classic V that tethers in
at the optic nerve sheath right there.
And I'm gonna still that image down.
And again we can see the optic nerve posteriorly
coming up towards the back of the eye.
And the detached retina tethered right there
to form a V coming anteriorly into the vitreous material.
So that's a classic appearance of a retinal detachment
on kinetic examination.
Always tethered at the optic nerve.
Here's another video clip showing the kinetic examination
detailing a retinal detachment.
As the patient looks from side to side,
we can see the serpentine motion, the flicker,
of the retina which moves around as a tethered membrane
in the back portion of the patient's eye.
But notice it has the classic appearance,
that it's tethered there, both posteriorly
at the optic nerve, and anteriolaterally
at the ora serrata.
So another classic appearance of a retinal detachment
on bedside exam.
Here's a bedside ultrasound examination
from another patient who had painless loss of vision.
And looking into the back of the eye,
we see another classic appearance
of a retina detached off the back of the eye.
Notice it has a classic membrane type appearance
that layers out in the back of the eyeball.
Now as I mentioned in the earlier part of this module,
we should always investigate body structures
in two planes and retinal detachments
are no exception to that rule.
Here' we're going to now place the probe in a vertical
up and down orientation.
And what's interesting is,
now I have the patient looking down.
So I can best see the inferior aspect of the eye.
And we note that this retinal detachment
is mainly an inferior detachment.
And we can see here, the detached retina
coming off as a membrane that tethers in at the optic nerve
which we can see that black area coming in
to the back of the eye.
And we can see the detached membrane
is predominantly located inferior to the optic nerve.
Now it's important to realize that there are possible
mimics of retinal detachment both on clinical evaluation
and on bedside ultrasonography.
Vitreous pathology, such as vitreous hemorrhage and
vitreous detachment can be confused with retinal detachment.
And the symptoms can overlap
with that of retinal detachment.
Patients can have both floaters and vision loss.
And while at first glance, the ultrasound may
confuse the two, there are important concepts
with ultrasound in order to discriminate
the two conditions one from another.
This ultrasound was taken from a patient
who's experienced multiple floaters within their right eye.
And what we see here is the classic appearance
on bedside ultrasound of vitreous blood.
And we can see the speckles of the vitreous material
within the vitreous cavity,
the posterior aspect of the eye ball.
Now to best visualize vitreous hemorrhage on bedside
ultrasound, it's important to realize that we may have to
turn the gain up for a high level
for optimal visualization of vitreous hemorrhage.
But again, we see the classic appearance, those little
speckles of vitreous blood within the vitreous body.
This ultrasound was taken from another patient
with painless loss of vision.
And again, looking into the vitreous body,
we see vitreous material present within the posterior
aspect of the eye.
This is the classic appearance of vitreous detachment.
All that vitreous material has accumulated there
within the posterior aspect of the eye.
Leading to vision loss and prominent speckles
or floaters as the patient looked from side to side.
Because vitreous pathology can be confused with
retinal detachment, it's really crucial to employ
the kinetic examination as an aid to best diagnose
retinal detachment versus vitreous pathology.
In this clip, we see vitreous material
that's congealed within the back of the eye
and notice as the patient looks from side to side,
it tumbles around there within the posterior aspect,
the vitreous cavity of the eye ball.
And here again, we'll see the patient looking from
side to side more rapidly and notice the classic
tumbling motion of the vitreous material
within the back of the eye.
This is to be differentiated from a retinal detachment
as the retina will have more of a tethered membrane
appearance as it's going to be attached within
the back of the eye at the optic nerve
and anterolaterally at the ora serrata.
Vitreous material will tumble like clothes
within a dryer as it's not attached
within the posterior aspect of the eye.
Very different than a retinal detachment.
Now that we understand more about vitreous hemorrhage
and vitreous detachment,
in comparison to retinal detachment,
let's take a look at this video clip
from a patient who presented with painless loss of vision.
Note the huge amount of vitreous material
that's accumulated within the vitreous body,
the posterior aspect of the eye.
And notice that it tumbles around as the patient looks
from side to side.
So this was a huge amount of vitreous hemorrhage.
Vitreous material that accumulated within the back
of the eye of this patient who was a diabetic.
And notice a classic clothes dryer tumbling motion
of this vitreous material.
Just to reinforce the difference on bedside ultrasound
from a retinal detachment, in the small box I've put there
the video clip of the retinal detachment.
Notice there, the tethered membrane appearance
as the patient looks from side to side.
Very different than the clothes dryer
tumbling motion of the vitreous material as we see
in the large clip in the middle of the image here.
In conclusion, thanks for tuning in
for this SoundBytes module.
Going over part two of ocular ultrasound.
Now you're ready to use ocular ultrasound as an effective
tool to investigate pathology of the eye.
Opening up that back part of the eye
for better examination than we previously been able to
using the traditional fundoscopic exam.
You'll quickly make the diagnosis of retinal pathology
using bedside ultrasound.
And hopefully now be able to discriminate
that from vitreous disease.
Potentially improving the management of patients
presenting with ocular complaints
to the emergency department.
So I hope to see you back in the future
as SoundBytes continues.

Brightcove ID

5745551911001

https://youtube.com/watch?v=lQo-Nm0Y5m0

Case: Ocular Ultrasound Part 1

Read more about Case: Ocular Ultrasound Part 1

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Part 1 of 2. Ocular ultrasound case study.

Clinical Specialties

EMED

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Case Study Videos

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Ocular

Intraccular Structures

Intraoccular Foreign Body

Intercranial Pressure

Membrane Optic Nerve Sheath Measurement

Elevated

Increased Intercranial Pressure

Soundbytes Cases

Subtitles

- Hello my name is Phil Perrea
and I'm the emergency ultrasound co-director
at the LA County USC Medical Center
in Los Angeles, California.
And welcome to Soundbytes.
Today's clinical case is entitled
Fourth of July in My Eye.
And our patient today is a 24 year old male
who presents to the emergency department
complaining of painless loss of vision to his right eye.
Initially, he was reading an engineering textbook
in preparation for final exams
when he experienced flashes of lights
into the right eye like fireworks.
And now he notes decreased vision to his right eye
described like a curtain coming in from the side.
So the history taken from our patient
suggest pathology in the posterior aspect
of the patient's eye.
And unfortunately for us,
this has traditionally been a black box area of the eye
as it's very difficult to examine using traditional means.
So that leads us into our clinical question for today,
which is for physicians working in the emergency department
in the year 2011,
what techniques do we currently have
to make the diagnosis of pathology
within the posterior aspect of the eye
and can we do better than our traditional testing.
Traditionally we've used the fundoscopic exam
to examine the posterior aspect of the eye,
and interestingly enough,
we're currently using technology, the opthalmoscope,
which was originally invented in the year 1851
by Von Helmholtz in Germany.
Now this was adapted in 1915 by Welch Allen
into our modern opthalmoscope that we see here
to the upper left,
and we've had a slight improvement
with the fundoscopic gun, as shown here towards the right,
which may give a better view of the retina.
However it's well understood by ophthalmologists
that direct opthalmoscopy gives a limited view of the retina
in comparison to the techniques that they'll use
on examination of the retina,
which is indirect opthalmoscopy
using a mirror and curved lens.
In fact, making the topic of ocular ultrasound
very pertinent for the emergency physician,
is the fact that the eye is actually
the perfect organ for ultrasound examination
and could not have been engineered better.
Fluid throughout the eye
allows for great conduction of sound waves
through the anterior part of the eye
into the posterior aspect of the eye,
and excellent imaging of all parts of the eye.
Many type of pathology can be correctly diagnosed
using bed side ultrasonography.
So what do I need to perform this examination?
Well any standard emergency department
bedside ultrasound machine will do well for this exam.
We'll need to have the high frequency
linear array type probe,
that's the probe that you're already using
for vascular access,
which we'll be using for ocular ultrasound.
We'll need lots of gel,
or preferably surgilube,
as surgilube is less irritating to the closed eyelid.
Now let's watch a video on how to perform
the ocular ultrasound examination.
Here we have the high frequency
linear type array probe in our hand,
and note we've prepared our patient
with a copious amount of sergilube
on the outer part of the closed eyelid.
We're going to gently place the probe
over the patient's closed eyelid,
scanning through the eye,
and note that we're going to orient the probe
both superior and inferior
looking all the way through the eye
from the anterior aspect down through the posterior part.
Now from this orientation, I like to have the probe marker
oriented laterally
towards the outer part of the patient's face
so that I know where the structures
of the posterior part of the eye are oriented.
Now let's take a look at that same
ocular ultrasound approach
from a more anterior position.
Note again that we're placing the probe,
the high frequency linear type array probe,
over the closed eyelid
in a side to side orientation.
Now the probe marker is going to be oriented laterally
towards the outer part of the patient's face.
Now remember that if there's any question of trauma
or globe rupture,
we have to be extremely careful
when applying the probe onto the eyelid.
In fact, we should really be scanning through
a copious amount of gel, known as a gel pillow,
and really not applying any pressure down
to the actual eye.
To complete our examination of the eye
we should also perform ocular ultrasound
from the vertical approach,
having the probe in an up and down configuration.
Note here, we're again scanning through the closed eyelid.
Now we have the probe marker up towards the patient's head.
We want to scan from side to side
to fully investigate the eye
in a second plane
for any signs of pathology.
And here is just a closed in view
showing the probe placed over the closed eyelid.
Here's a more anterior view,
again, showing the vertical approach
to bedside ocular ultrasound.
Note the high frequency probe placed over the closed eyelid
and scanning from side to side
will image all parts of the eye.
Remember that the probe marker for this vertical approach
is going to be oriented superiorly.
And imaging in two planes
will best round out the examination of the eyeball.
Now let's take a moment to review the anatomy of the eye
that we'll see using bedside ocular ultrasound.
Here's a nice pictorial of the eyeball.
Lateral of the eye to the left
and medial aspect of the eye to the right.
Let's start with the most anterior structure, the cornea,
which we see towards the top part of the image.
We can see the lens,
which is located directly below the cornea,
which will have a distinct hyperechoic
or bright appearance on bedside ultrasound.
We note the iris coming in to attach to the lens,
another structure that can be seen
using bedside ultrasound.
Now that region anterior to the iris
is known as the anterior chamber.
And we can also image pathology
within the anterior chamber, really hyphemas.
Now behind the lens is going to live
the vitreous body,
filled with vitreous gel,
which allows the eyeball to keep that rounded configuration.
We see blood vessels arching up into the vitreous body.
Now let's recall the outer parts of the eyeball
and the fibrous coat, the sclera,
is the outermost portion of the eye.
We see the medial aspect of the coats of the eyeball,
the choroid, which is the vascular layer
which supplies the retina with blood,
and then we see the inner neural layer, the retina.
And we note that the optic nerve comes in posteriorly,
another structure which can be seen on bedside ultrasound
to give rise to the retina.
Now we note here,
the indentation, the macula,
which is seen just lateral to the optic nerve.
And we recall that the macula
is the area of the densest composition
of rods and cones.
Here's a typical ultrasound of a normal eye.
This eye is taken in the horizontal
or side to side probe configuration
with the probe marker lateral.
We see the cornea, the anterior most structure of the eye,
and we see below the cornea, the rounded iris.
Note the classic appearance of the lens
just below the iris,
which has a hyperechoic or bright appearance
due to its very hard refractive pattern.
And we can see little refraction waves
coming off the back of the lens.
Note the anterior chamber, the potential space,
just anterior to the iris
and below the cornea.
We see the vitreous body and back of the lens
and note the retina, well seen here,
to the posterior aspect of the vitreous body.
This retina is well tacked down
and in opposition to the posterior aspect of the eye.
That's a normal examination.
Now if we have the probe in a side to side
or transverse orientation, across the eye,
with the probe marker lateral
and we aim the probe a little bit more inferiorly
down towards the patient's foot,
the optic nerve sheath will come into view.
Note the optic nerve has a classic appearance
on bedside ultrasound.
It's dark or hypoechoic.
And we can see it leading right up to the back of the eye.
In conclusion, thanks for tuning in
to part one of ocular ultrasound.
I hope I've been able to score the point through this module
that ocular ultrasound is an easily learned
and very helpful technique for the emergency physician
and in the year 2011,
finally allows excellent imagining
of that black box posterior area of the eye.
I hope to see you back in the future
as Soundbytes continues,
and as we return in ocular ultrasound part two,
focusing on retinal pathology.

Brightcove ID

5745552411001

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

Case: Ultrasound for Pneumothorax

Read more about Case: Ultrasound for Pneumothorax

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The video demonstrates how to use long and short axis configurations, as well as M-mode, to detect and diagnose both a complete and partial pheumothorax.

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Case Study Videos

Media Library Tag

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're going to look specifically
at Ultrasound of the Lung to Evaluate for Pneumothorax.
Interestingly enough,
a classical belief was that the lung was not optimal
for ultrasound imaging.
However newer findings have shown
that actually ultrasound is an excellent modality
for viewing the pleura and for detecting pnemothoraces.
There's been a lot of research looking at this
and what's interesting is that ultrasound
has been found now to be more sensitive than chest X-ray
in the diagnosis of pneumothorax especially
in the supine trauma patient.
And now we're going to add on views of the lungs
looking for pneumothorax as part
of our Extended FAST Exam,
or the E-FAST exam that we'll be performing
in trauma patients.
We can also detect pneumothoraces as well
in our medical patients.
Now let's learn how to perform the ultrasound examination
for the pneumothorax detection.
Here we have the high frequency linear type array probe
positioned on the anterior chest wall
at about the midclavicular line
looking in to about intercostal space three.
Now in most cases of pneumothorax with the patient supine
the air would be predominantly seen in this area.
Note we're looking in a long axis configuration
between the ribs with the marker dot
oriented superiorly towards the patient's head.
Once we've identified both the ribs and the pleura
we can swivel the probe into the short axis configuration
to further look at the pleura
and to detect pneumothorax.
Here we have the probe oriented in a transverse
or short axis orientation between the ribs
looking directly down at the pleura.
Notice in this case the marker dot is located
towards the lateral aspect of the patient.
Using both long and short axis configurations
will allow you to detect a pneumothorax
with a high degree of accuracy.
If no lung is seen on the anterior chest wall
one can size out a pneumothorax
by looking in the lateral positions as shown here.
Notice the probe on the lateral chest wall
in the short axis configuration between the ribs.
If lung is seen here laterally but not anteriorly,
this would tell you it was an incomplete pneumothorax.
We can complement the short axis view
by locating the probe into the long axis configuration
with the marker dot towards the patient's axilla
to further examine into these lateral areas
of the chest wall.
Here's a nice pictorial showing
the normal findings of a lung
in a long axis type configuration.
Superior rib to the left,
inferior rib to the right.
Notice that the ribs cast shadows posteriorly
due to the inability of the soundwaves
to permeate the hard calcifications of the rib.
We see the chest wall anteriorly,
and note here the two layers of the pleura.
And we see here the outer parietal pleura,
and the inner visceral pleura.
Now while I've depicted these as two separate layers,
in reality on ultrasound examination
they're seen as a single shimmering white line
that moves back and forth as the patient breathes.
And as the patient breathes we can see white comet tails,
or linear lines, vertical lines,
coming off the pleura down deep into the lung.
So that will be the normal finding of a lung
on long axis configuration.
Here's a nice ultrasound image
showing a normal lung
and what we see here,
we're in the long axis configuration,
so the superior rib is to the left,
inferior rib to the right.
Chest wall anteriorly,
and we see here the lung sliding
which is the opposition of the outer parietal
and the inner visceral pleura.
And we see the vertical comet tails
coming off the back of the pleura.
Thus this is a completely normal exam.
No pneumothorax.
But note the location of the pleura deep to the ribs,
and that classic shimmering line back and forth
as the patient takes a breath.
Here we see more dramatic comet tails
coming off the shimmering parietal and visceral pleura.
In this patient we see the comet tails
shooting off the back,
telling us that this lung is up and there's no pneumothorax.
So vertical lines coming off the back of the pleura
always mean that the lung is up and are always a good sign
on lung ultrasound sonography.
As we mentioned we should also swivel the probe
into the short axis configuration
to further examine the lung,
and what we see here is a normal lung
in short axis configuration.
Note here we're looking in between the ribs
so all we see is the dome of the lung
and notice that it slides back and forth
as the patient breathes,
and we see the vertical comet tails
coming off the back.
So a completely normal examination in the short axis plane.
Here's another ultrasound image
taken from the short axis configuration.
Note here we see very prominent comet tails
coming off the back of the lung as it slides back and forth.
Again it's that opposition
of the parietal and visceral layers of the pleura
that allow the lung shimmering,
but notice here all the comet tails coming off the back.
In this case this patient had some pulmonary edema
associated with the lung
and these comet tails are more pronounced
due to the presence of water within the pleura.
But notice all these vertical lines coming off the back
telling us this lung is up.
A way to document that the lung is up
to print out for the chart is to put M-Mode,
and generally what we do is locate it so the M-Mode cursor
is down right at the pleura.
And what we see is the classic seashore sign,
or waves on the beach.
If we look anteriorly we'll see the classic waves,
or no motion of the chest wall,
and below that,
deep to the pleura we'll see the positive motion of the lung
making up the beach.
So waves on the beach,
or the seashore sign,
and M-Mode documentation that the lung is up
and that there's no pneumothorax.
Now that we understand what a normal lung looks like
on bedside examination,
let's take a look at a pictorial showing a pneumothorax
in a long axis view.
We see here that the parietal pleura
is now split from the visceral pleura,
which is attached to the lung
by a layer of air shown by the yellow color.
It's the splitting of the parietal and visceral pleura
that now causes a lack of lung sliding.
And instead of the opposed visceral and parietal pleura
sliding back and forth as the patient breathes,
all we see is a single line,
the parietal pleura,
with a lack of vertical comet tails coming off the back.
Here's an ultrasound image taken from a patient
who was stabbed to the left chest
and who had shortness of breath.
What we see here is a long axis view of a pneumothorax.
Let's take a look at the chest wall anteriorly,
and right below that we see the parietal pleura,
the single white line located directly inferior to the ribs.
But notice the classic lack of the lung sliding.
All we see here is a single white line
that fails to slide back and forth as the patient breathes.
Notice also the absence of the vertical comet tails.
Here's another image of a pneumothorax
in a long axis configuration,
and we see here the chest wall anteriorly,
and the single white line which is the parietal pleura.
Now this patient was acutely dyspneic,
so notice that there is some motion of the chest wall
and that the parietal pleura moves up and down,
but notice the failure of horizontal sliding.
Notice also the absence of any vertical comet tails
coming off the back of the pleura.
Now let's inspect a pneumothorax from the short axis view.
We see the chest wall anteriorly,
the parietal pleura as shown as a single,
non-mobile white line in the middle of the image.
Note the failure of movement back and forth,
the lack of vertical comet tails,
and what we see here is repeating horizontal air lines
from the pneumothorax.
To document the absence of lung sliding
and the presence of a pneumothorax,
we'll again turn to M-Mode.
If we put the M-Mode cursor down on the pleura,
what we'll see is a set of linear repeating lines.
This documents no motion of both the chest wall
and of the lung,
making up a finding known as the bar code sign.
Here's a pictorial showing interesting finding.
The signature of an incomplete pneumothorax,
known as lead point.
And what we see is an incomplete pneumothorax
with air collecting to the superior aspect
of the image to the left.
Thus splitting the parietal from the visceral layers
and causing an absence of lung sliding superiorly.
However, as the lung is coming up against the chest wall
to the right or inferiorly,
that's where we'll see the presence
of horizontal lung sliding,
and the presence of the vertical comet tails.
Here's an ultrasound image showing the lead point,
and what we see here is the lung sliding to the right,
the area where the lung touches up against the chest wall,
and to the left the area of absence of lung sliding
telling you there that air has collected
between the visceral and parietal layers.
So the ultrasound equivalent of the image
that we just looked at telling you
that this is an incomplete pneumothorax.
But here we see that lead point,
or transition point,
very well on bedside sonography.
In conclusion I'm glad I could share with you
this ultrasound module going over ultrasound of the lung
to evaluate for pneumothorax.
This is an excellent tool for viewing the pleura
and making the diagnosis of pneumothorax,
and there's been some research showing that it may be
more sensitive than chest X-ray in the diagnosis
of pneumothorax,
allowing rapid diagnosis of pneumo
in both your trauma and medical patient,
thus facilitating more timely management
of these most critical patients.
So I hope to see you back as SoundBytes continues.

Brightcove ID

5508134309001

https://youtube.com/watch?v=Xxdedx1HtHo

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How to: Pneumothorax Evaluation

How to: Pneumothorax Evaluation

3D How To: Lung Examination

3D How To: Lung Examination

3D How To: Ocular Ultrasound

3D How To: Ocular Ultrasound

3D How To: eFAST Lung Sliding Detection (Phased)

3D How To: eFAST Lung Sliding Detection (Phased)

How To Detect Lung Sliding with Ultrasound

How To Detect Lung Sliding with Ultrasound

Case: Ocular Ultrasound Part 2

Case: Ocular Ultrasound Part 2

Case: Ocular Ultrasound Part 1

Case: Ocular Ultrasound Part 1

Case: Ultrasound for Pneumothorax

Case: Ultrasound for Pneumothorax

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