Kidney

Case: FAST Exam - LUQ Exam

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The left upper quadrant (LUQ) ultrasound exam can help clinicians more accurately diagnose intra-abdominal injuries. Topics: infra-diaphragmatic and splenorenal spaces, & how to identify free fluid caused by a trauma.

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- Hello, my name is Phil Perera,
and I'm the emergency ultrasound coordinator
at the New York Presbyterian Hospital in New York City,
and welcome to SoundBytes Cases.
In this module, we'll continue our journey,
looking at the views of the Trauma FAST exam.
Hopefully you've had a chance to join me prior
for the views of the right upper quadrant,
and in this module,
we're going to look specifically
at the left upper quadrant views of the Trauma FAST exam,
known traditionally by two terms,
the splenorenal, or the perisplenic views.
In an upcoming module,
we'll look specifically at the suprapubic view,
or bladder view, of the Trauma FAST exam.
There's a lot of information we can gain
by looking at the left upper quadrant
in our trauma patients,
and we'll need to know that it's not a mirror image
of the right upper quadrant,
that the spleen offers less of an acoustic window
onto the left upper quadrant than the liver does
on the other side.
Here's a slide reviewing how to perform
the left upper quadrant view of the Trauma FAST exam.
As the spleen offers less of an acoustic window
on the left upper quadrant,
we need to bring the probe in
from a more posterior position.
Thus, the mantra, knuckles to stretcher.
Optimally, we're using a smaller footprint probe
that can get in between the ribs
and get a good view into the left upper quadrant area.
Position the probe in the long axis view
with the probe marker towards the patient's head,
at about the midaxillary line, or posterior axillary line,
with your knuckles almost touching down to the bedside.
We'll concentrate on two areas, most importantly,
the area above the spleen and below the diaphragm,
where fluid will preferentially accumulate,
but rounding out our exam,
we'll look inferior at that spleno-renal space.
Now that we know how to perform
the left upper quadrant view of the Trauma FAST exam,
let's take a look at a normal ultrasound image.
I have the probe oriented towards the patient's head,
so superior chest cavity is towards the left,
inferior abdominal cavity towards the right.
Notice the spleen,
the large organ in the middle of the image here,
and the kidney, the football shaped organ,
as seen inferior and posterior to the spleen.
Notice the curving white line just above the spleen,
which is the diaphragm.
Recall that in the left upper quadrant,
that fluid will accumulate preferentially
in between the spleen and the diaphragm
and will be a dark or anechoic stripe positioned there.
Here's another normal video clip
taken from the left upper quadrant.
In this case, I'm swinging the probe from inferior,
looking at the spleno-renal interface,
to superior, looking at that infra-diaphragmatic space.
And here, as I freeze the image,
we see the spleen right in the middle of the image,
the curving white line making up the diaphragm,
and notice the thoracic cavity
as seen just left, or superior, to the diaphragm.
If the patient had a significant hemothorax,
or fluid collection in the thoracic cavity,
that would be represented by
a dark or anechoic fluid collection
just above the diaphragm in the thoracic cavity.
Now that we've had a chance
to examine several normal video clips
as taken from the left upper quadrant,
let's look at a pictorial here,
showing a positive left upper quadrant FAST exam.
Here we see superior located to the left,
inferior to the right.
We see the spleen in the middle of the image,
the kidney inferiorly to the right.
The thoracic cavity with the diaphragm
to the left of the spleen, or superior.
We see the area of fresh fluid
as demarcated by the orange color,
and notice that it layers out
predominantly below the diaphragm
and above the spleen,
and this is the area where fluid
will preferentially deposit in the left upper quadrant.
There are ligaments that sling
from the diaphragm all the way to the colon
that prevent the flow of fluid
into that area between the spleen and the kidney
until the fluid is relatively large
within the left upper quadrant.
So, now let's take a look at a positive exam
from a trauma patient,
and we see here the spleen in the middle of the image,
the kidney inferiorly located to the spleen,
and notice the large amount of fresh fluid,
that dark or anechoic fluid collection
that layers out above the spleen
in the infra-diaphragmatic location,
and anterior to the spleen.
This indicates a large amount of fresh blood
in the left upper quadrant,
and we also see a blood clot,
that echogenic material waving around
anteriorly to the spleen.
So a positive exam in a trauma patient.
Here's another positive left upper quadrant view.
Notice here, there's a larger amount
of fresh fluid present on this examination.
We see the spleen in the middle of the image,
the kidney inferiorly there to the right,
and all the dark, fresh fluid,
as indicated by the dark, or anechoic, fluid collection,
as seen infra-diaphragmatic and above the spleen.
Notice again that the fluid is not
preferentially layering out in between
the spleen and the kidney, reinforcing the point that
this is not a mirror image of the right upper quadrant.
Here's another positive examination
in a patient who comes in hypotensive
after being hit by a car.
Notice I'm swinging the probe
between the kidney, up superiorly,
to look at the spleen.
Notice the absence of fluid in between the spleen
and the kidney,
but the presence of free fluid
right above the spleen and below the diaphragm
as indicated by that dark stripe.
Here's an interesting video clip from a trauma patient.
Again, we're looking at the left upper quadrant,
and we delineate the spleen and kidney.
Notice the presence here of fresh fluid,
the dark or anechoic fluid stripe
as seen layering out superior, or in anterior,
to the spleen there,
but let's look above the diaphragm here,
which we see as the curving white line
moving up and down as the patient breathes,
and what we notice here is the presence
of a dark fluid collection within the thoracic compartment.
So we're able to diagnose in this patient
an associated hemothorax
in addition to the hemoperitoneum.
So the left upper quadrant view
also helpful for looking into the thoracic compartment
as well as diagnosing interabdominal injury.
One maneuver that can help you
uncover fresh fluid within the left upper quadrant
is to have the patient take a deep breath
and analyze that infra-diaphragmatic space
as the diaphragm moves upward, off of the spleen.
Notice here that we uncovered the amount
of fresh fluid that's present right above the spleen
and below the diaphragm as the patient
takes a deep breath,
and that diaphragm moves superiorly.
So, in conclusion, I'm glad I could share with you
this SoundBytes module, going over the trauma FAST exam,
specifically the left upper quadrant, or perisplenic view.
There's a great deal of information that we can gain
by looking into the left upper quadrant
in our trauma patients,
and it's important to realize that
the left upper quadrant is not a mirror view
of the right upper quadrant,
and that fluid will preferentially layer out
in the area above the spleen and below the diaphragm,
in contrast to the hepatorenal space
on the right upper quadrant.
So, I hope to see you back as SoundBytes continues
and we move on to look at the suprapubic,
or bladder view, of the Trauma FAST exam.

Brightcove ID

5726805223001

https://youtube.com/watch?v=VBHCmw8iHCc

Case: FAST RUQ Exam - Hemorrhage

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This video (part 2 of 2) focuses on positive findings found during right upper quadrant (RUQ) ultrasound examinations; it also includes instructions for performing the trauma FAST RUQ-hepatorenal ultrasound exams

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- Hello, my name is Phil Perera
and I'm the Emergency Ultrasound Coordinator
at the New York Presbyterian Hospital in New York City
and welcome to SoundBytes Cases.
In this module entitled,
Part Two of the Right Upper Quadrant View
of the Trauma Fast Exam,
we're going to focus entirely on positive findings
from this view.
Hopefully you've had a chance to join me prior
for Part One of the Right Upper Quadrant View
of the Trauma Fast Exam where we focused entirely
on normal findings from the right upper quadrant.
And hopefully have a chance to join me back
as we go through the left upper quadrant
and suprapubic views of the Trauma Fast Exam.
So let's begin this module by going through a
review of how to perform
the right upper quadrant view of the Trauma Fast Exam.
Remember that the probe is positioned in the
long axis configuration with the marker dot superiorally
and that we're going to place the probe in between the ribs
at about the anterior axillary line.
Here we'll want to focus on the three areas
as I emphasized in Part One of this module.
Number one, the infra-diaphragmatic space
looking at that region just below the diaphragm
and above the liver,
and actually looking into the chest cavity for a hemothorax.
Position two, which is the traditional Morison's Pouch
or hepatorenal interface.
And position three, to round out the exam
looking at the caudal liver tip representing the
beginning of the right paracolic gutter.
Here's a nice illustration showing a positive examination
from the right upper quadrant view of the Trauma Fast Exam.
We see the liver smack in the middle of the image
and the kidney slightly posterior and inferior to the liver.
Let's look at the preferential deposition of fluid
as shown here in the orange color,
and we see that it layers out predominantly around
the caudal tip of the liver as shown towards the
inferior edge of the image here.
Notice that it flows from the caudal tip of the liver
into that potential space which is Morison's Pouch
in between the liver and the kidney.
Now this is very important to emphasize as many times,
fresh fluid can only be seen around that
caudal tip of the liver,
and then it would move into that hepatorenal interface
or Morison's Pouch.
Here's a positive ultrasound examination from a patient
who was hit by a car while crossing the street
and we see here the liver
smack in the middle of the image here.
Notice the kidney located inferior and posterior
to the liver.
And in between the liver and the kidney in that
potential space known as Morison's Pouch,
we see a dark or anechoic fluid collection.
Not insignificant,
actually a pretty large stripe in this patient.
This represents the positive examination,
or the presence of fresh fluid,
in this case blood within Morison's Pouch.
And notice that it layers out in between
that liver and kidney.
To emphasize the point that a complete right upper quadrant
view includes looking at the caudal tip of the liver,
let's examine this video clip from another trauma patient.
If we look at the hepatorenal interface there,
we fail to see the presence of any fluid,
but as we move the probe inferiorially,
we see that the caudal tip of the liver as shown right there
is well outlined by fluid.
And here we see the inferior pole of the kidney,
the caudal tip of the liver extending above the kidney,
and notice all the fresh fluid
both anterior and posterior to the caudal tip of the liver.
Making the point that this is a very important area
to look for in the right upper quadrant exam.
Here's a video clip from a patient who was stabbed
with a really big knife to the epigastric region.
And as we look at the right upper quadrant,
we can actually see a linear liver laceration
extending through the medial aspect of the liver.
We also appreciate the presence of a large
amount of fresh fluid.
That dark or anechoic fluid collection
layering out posteriorally there to the liver
and extending into Morison's Pouch,
the hepatorenal interface.
So as this patent had unstable hemodynamics,
the next move was to package for the operating room.
And here we can actually see the caudal tip of the liver
waving around in all the fresh fluid,
in this case blood.
And I obtained this view by moving the probe
one intercostal space inferior from the last view
to well delineate the caudal tip of liver
which we can see here moving around in all the fresh fluid.
In the last few video clips the appearance of fresh fluid
on bedside sonography was darker, anechoic.
However as blood clots it can take on a more echogenic
or lighter appearance.
In this video clip a patient was stabbed
and had a significant down time before being
brought to the Emergency Department.
As we look at the hepatorenal interface,
we see a large amount of clotted blood there
made up by that echogenic
or lighter appearance of the blood there.
Notice that the large amount of blood extends into
the right paracolic gutter as we scan inferiorially.
And here we can see the liver,
the kidney,
and the clotted blood,
that more echogenic or lighter blood in Morison's Pouch.
So in conclusion,
I'm glad I could share with you this Part Two Module
on the Right Upper Quadrant View of the Trauma Fast Exam.
I hope now you have a better understanding
on how to perform a complete exam
looking into the three areas as we discussed.
Infradiaphragmatic,
Morison's Pouch,
and inferior tip of the liver.
And hopefully now you'll be able to discern
the presence of fresh blood versus clotted blood
on bedside sonography.
So I hope to see you back as Sono access continues
and as we move further through the other views of the
Trauma Fast Exam.

Brightcove ID

5508109915001

https://youtube.com/watch?v=Gj5IioG7SyM

Case: FAST RUQ Exam - Normal Exam

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This video (part 1 of 2) details how performing the right upper quadrant (RUQ) ultrasound examination on trauma patients enables clinicians to potentially identify internal injuries.

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- Hello, my name is Phil Perera and I'm the emergency
ultrasound coordinator at the New York Presbyterian Hospital
in New York City, and welcome to SoundBytes Cases.
In this module we're going to focus entirely on
the trauma fast exam.
Specifically, we're going to look further into the
right upper quadrant view, also known as
the hepatorenal view.
Now, we're going to cover the two other views of
the trauma fast exam in upcoming modules of SoundBytes.
The left upper quadrant view, also known as
the splenorenal or perisplenic view,
and the suprarpubic view, also known as the bladder view.
There's a tremendous amount of information we can gain by
looking closely into the right upper quadrant area
in our trauma patient.
Traditionally it's been emphasized that the hepatorenal area
or Morison's pouch view, is the primary target for the
right upper quadrant, but it can take up to 600 ccs of fluid
to make a positive exam if only looking into that area.
So I'll show some alternative views in this module that can
help us to possibly improve on that number.
Now let's take a look at a slide showing us how to perform
the right upper quadrant view of the trauma fast exam.
We'll want to place the probe at about the anterior axillary
line and using the liver as an acoustic window aiming
the probe down towards the bedside retroperitoneally to get
a good view of these anatomical structures.
It's best to have a small footprint probe that can easily
sit between the ribs giving a good view on to this area.
Notice that this is a long axis view with a probe marker
position superiorly.
Now our first view from this right upper quadrant area
will be position one as shown here in the
infra-diaphragmatic space just below the diaphragm
and above the liver.
Second, we'll move the probe slightly inferiorly to look in
to the traditional Morison's pouch or hepatorenal interface,
and the last view is the caudal tip of the liver shown here
in position three.
It's very important to look at the caudal tip of the liver,
as this represents the beginning of the right paracolic
gutter and small amounts of fluid will pool here before
moving into Morison's pouch.
Now that we know how to perform the right upper quadrant
view of the trauma fast exam, let's take a look at a normal
image that you might obtain.
Remembering that this is a long axis view,
I have the probe marker here positioned towards
the patient's head.
So towards the left of the clip here is
superior chest cavity and towards the right is
inferior or abdominal cavity.
Notice the first large structure that comes into view
in the middle of the image is the liver and to the right,
or inferior to the liver we see the football shaped kidney.
Now it's that interface between the liver and kidney that
represents a potential space known as Morison's pouch
where we're be looking for dark, anechoic fluid collections.
Note here, we see a thin, white line making up a normal exam
and representing the fat within the capsule
around the kidney.
Notice to the left of the liver we see the white diaphragm
that represents the interface between chest
and abdominal cavities.
Let's take a look at another normal
right upper quadrant examination.
Again the probe marker is towards the patient's head.
This is the superior chest cavity towards the left.
Inferior abdominal cavity towards the right.
We see the liver in the middle of the image,
and notice the diaphragm above the liver moving up and down
as the patient breathes.
We see the kidney inferior to the liver, and notice
the potential space in between the liver and the kidney
that makes up the hepatorenal fossa or pouch of Morison.
Notice in this video clip all we see is a white line
representing the fat within the capsule around the kidney
or Gerota's capsule.
If there was fluid, we would see a dark or anechoic fluid
collection in this potential space.
Let's now look at the diaphragm which we see above the liver
and if we look above the diaphragm this is where we would
look for fluid within the chest cavity or hemothorax
in the trauma patient.
We may have to move the probe several intercostal spaces
on the patient's side to fully investigate
the right upper quadrant for fluid.
Here's a swing view where I'm starting relatively superior
right there looking in the area between the diaphragm
and the liver, going through Morison's pouch, as I'll show
coming up right here the area between the liver
and the kidney and terminating at the inferior
tip of the liver.
Notice here we notice the caudal tip of the liver extending
almost all the way inferiorly down past the inferior pole
of the kidney, and it's important to look at that caudal
tip of the liver, as it represents the beginning
of the right paracolic gutter.
So in conclusion, I'm glad I could share with you part one
of the right upper quadrant view of the trauma fast exam.
Now we know how to recognize a normal examination
looking all the way from the area below the diaphragm
through Morison's pouch and terminating at a view of
the caudal tip of the liver.
So I hope to see you back as SoundBytes continues,
and we look at part two of the right upper quadrant view
focusing on positive examinations.

Brightcove ID

5767048880001

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

Case: Renal Ultrasound - Hydronephrosis

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A review: the use of ultrasound imaging as an alternative to CT scanning for managing uncomplicated kidney stones. It reviews human anatomy, probe positioning, and scanning techniques.

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- Hello, my name is Phil Perera and I'm the Emergency
Ultrasound Coordinator at the New York Presbyterian Hospital
in New York City and welcome to SoundBytes Cases.
- [Voiceover] In this module we're going to focus on
genitourinary ultrasound.
So, what are the goals of bedside GU ultrasound
for the emergency physician?
Well, first of all, we're going to inspect closely
the kidney looking for hydronephrosis.
We may also be able to see kidney stones as stones lodge
within parenchyma of the kidney
or at the uretero-pelvic junction.
We should also include imaging of the bladder
with our GU ultrasound and we can look for bladder stones,
stones that have migrated from the kidney
down to the UVJ and also get a sense of bladder size.
Hopefully through this module we can look at bedside
ultrasound as an alternative, non-CAT scan based strategy,
for the management of uncomplicated kidney stones
without the associated dose of radiation.
Let's now review how to perform
the renal ultrasound examination.
As shown in the pictorial to the right,
we want to come in with a probe in a long axis configuration
with a marker dot superior towards the patient's head.
It's good to use a smaller footprint probe that can
easily sit between the ribs.
For the left kidney scan, we're going to come in
from a more posterior position as the spleen offers
less of an acoustic window onto the kidney
than on the right side where we have the liver,
which offers a great acoustic window onto the kidney.
For the left side we want to put the patient in the right
lateral decubitus position with the left side up
so we can come in from that posterior position
and image the kidney.
On the right side, we can come in from a little bit more
anterior using the liver as our acoustic window
onto the kidney.
But it's also a good idea to put the patient in the left
lateral decubitus position with the right side up
so that we can angle the probe and get good views
of the kidney from the right side.
Here's an illustration of the kidney that's important
for bedside ultrasound of this structure.
Recall the outer area of the kidney, the cortex,
and interior to the outer cortex we see the medulla.
Notice several renal pyramids located within the medullary
area, and recall that the loops of Henle are going to be
oriented inside the renal pyramids.
Now the renal pyramids will be filtering the blood
and producing urine which will flow into the calyceal area
interior of the kidney.
We can see here that the small areas of the calyces
come together to make the renal pelvis.
Now the renal pelvis, in turn, will continue on
as the ureter inferiorly into the bladder.
Now a classic appearance of the interior of the kidney
is that it has a bright or hyperechoic appearance
on bedside sonography.
And this is because of the abundance of fat
within the renal sinuses.
Here's a typical normal kidney on bedside ultrasound.
I have the probe marker oriented towards the patient's head
so superior pole of the kidney is to the left,
inferior to the right.
We see the outer cortex, that outer rim of kidney to
the peripheral aspect.
And we see just interior to the cortex,
the medullary pyramids.
Notice that they have a little bit of a darker,
or hypoechoic, signature due to the presence of fluid
within the medullary pyramids.
We see the inner part of the kidney, the calyceal region,
and notice that it has a hyperechoic, or bright
appearance on bedside sonography,
due to fat within the renal sinuses.
Now let's take look at a picture showing the grading
of hydronephrosis from normal kidney to the left,
to a severe hydronephrosis kidney to the right.
What we see in the normal kidney is a normal architecture
with the medullary pyramids draining the urine
into the calyces and then out into the ureter.
Now if a kidney stone or other obstruction type pattern
had occurred, we can see that the hydronephrosis would
be manifested by increasing ballooning out of fluid
within the calyceal region of the interior part
of the kidney.
We can also see dilatation of the ureter.
Notice in the moderate type picture here to the right
we can see ballooning out of the medullary pyramids
in addition to the calyces.
In a worse case scenario, in the severe hydronephrosis,
the entire inner part of the kidney is shelled out by fluid
and all that's left is a little rim of the outer cortex
around all the fluid within the hydronephrotic kidney.
Let's begin by taking a look at a patient who presented
with a very small kidney stone and Grade 1 hydronephrosis.
Superior pole to the left, inferior pole of the kidney
to the right.
As we scan back and forth through the kidney we note
multiple little dark areas within the interior
of the kidney.
These could be construed as cysts.
However, as we scan up and down, through the kidney,
we can see that they all coalesce to form dilated calyces,
the signature of a Grade 1 hydronephrosis with mild
swelling of the interior of the kidney.
But it's very important to fan anterior posterior
through the kidney to see that all of these areas
of hydronephrosis coalesce into the calyceal region.
Here's an example of a more advanced
degree of hydronephrosis, known as moderate,
or Grade 2 hydronephrosis.
And what we see here is that the interior of the kidney,
the calyceal region, is filled with dark or anechoic fluid.
We can also see that the medullary pyramids are
more pronounced due to the coalescence of fluid
going up from the calyceal region
into the medullary pyramids.
And if we look closely we can see the beginning
of hydroureter, the arching away of the ureter,
coming down inferiorly away from the calyceal region.
So a more pronounced degree of hydronephrosis
on the spectrum of disease seen within the kidney
due to a larger kidney stone.
Here's a kidney from another patient with a larger kidney
stone representing a Grade 2 - 3,
or moderate to severe, hydronephrosis.
And again we see the dilated calyceal region filled
with fluid and in this video clip we see well
the hydroureter, the dilated ureter arching inferiorly
away from the kidney down towards the patient's bladder.
Here's an example of the highest grade hydronephrosis,
severe, or Grade 3, hydronephrosis in a patient
who had a 1.5 centimeter kidney stone.
And as we look through the kidney, scanning back and forth,
we can see that all the medullary pyramids and the
calyceal region is completely filled with dark,
or anechoic, fluid.
All that's left here is the outer cortex of renal tissue.
So, unfortunately, this was a patient who had
a long-standing hydronephrosis and who had lost a lot
of the kidney function on this side.
As we still the image down we can see that the dilated
calyceal region leads to a very dilated hydroureter,
again confirming hydronephrosis.
When evaluating a patient with a possible kidney stone,
when you find hydronephrosis you should also look
at the bladder and you may be able to visualize
a stone present at the left
or right ureterovesicular junction.
Here's a case in which a patient presented with
right flank pain and had right hydronephrosis.
We're looking at the bladder in a short axis configuration
with a marker dot over towards the patient's right side.
What we can see is a hyperechoic large shadowing stone
present at the right UVJ.
If we apply Doppler sonography there we can see the
ureteral jets, the flow of urine coming out through
the UVJ into the bladder, is being blocked by this
one centimeter stone that's plugged at the UVJ.
So, in fact, this patient had to go to the cystoscopy lab
to get the large stone removed and relieving the obstruction
of urine into the bladder.
In conclusion, thanks for joining me for this
SoundBytes module focusing on genitourinary ultrasound.
Our goals, goal number one, hopefully now you know how
to perform ultrasound of the kidney and diagnose
hydronephrosis from mild, or Grade 1,
through moderate to severe, or Grade 3.
Our second goal is to investigate the bladder closely
and we may be able to see stones that have migrated
down to the UVJ on inspection of the bladder.
We can also get a sense of bladder size on bladder
sonography and using Doppler we can look at the
ureteral jets.
Our overriding goal for this module is to use ultrasound
to diagnose kidney stones in a selected group of patients
as an alternative to CAT scanning.
So, I hope to see you back in the future
as SonoA ccess continues.

Brightcove ID

5508121194001

https://youtube.com/watch?v=N750NAEmEso

How to: Kidneys

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Learn to examine the kidneys with ultrasound.

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- Another examination you could do in the ED
is the evaluation of kidney for nephrolithiasis.
And this is a relatively easy examination to do.
We're gonna do, again, using the (mumbles) transducer,
your all-purpose ED transducer,
and the first view that we're going to look at
is a sagittal view of the kidney.
So I'm gonna start on the right side
but I will do both sides to show you how to do
an evaluation on both sides.
And we're gonna go in
with the orientation marker pointing to the patient's head.
So this'll be a sagittal view.
And then I'm gonna go in fairly laterally.
With this starting point,
I can quickly identify where the kidney is.
In the anterior aspect of the image, you see the liver.
And immediately posterior to that,
you see a crescent-shaped organ which is the kidney.
And so what I want to do evaluate in a long view
sweeping medially and laterally,
looking at the cortex to determine
if there's any echogenic or bright shadowing stones.
So I can evaluate the superior pole,
sweep from side to side,
and kind of look at the inferior pole,
sweep from side to side,
and look in the mid
pelvis area of the kidney
to determine if there's hydronephrosis,
an indirect sign of nephrolithiasis.
Once I've finished the sagittal sweep,
I'm gonna turn the transducer
so it's in a transverse view with the marker
to the patient's right.
And using the same window as I did for the sagittal view,
identify the kidney.
It will now appear as a horseshoe shape.
And we can see the renal vein
coming into the pelvis of the kidney.
And I'm gonna sweep superiorly until I move pass
the superior aspect of the upper pole
and then sweep back down inferiorly.
See the mid-level of the kidney,
renal vein,
moving down a rib space,
and into the inferior pole of the kidney.
And I continue until I do not see
any tissue of the kidney anymore.
An important part of a kidney evaluation
is a bilateral comparison between the right and left kidney
to determine if there's hydronephrosis
present on one side versus the other.
So we'll go ahead and do the left side as well.
So an easy landmark here
is just to identify the costal margin
and then move up one hands width
and bring your transducer in at the mid-axillary line.
This should get us right in the area
of the spleen and the kidney.
You may need to move up a rib space or two,
determining on how high and how small the spleen is
'cause you're using the spleen as your window
to evaluate the kidney.
So if I move up a little bit,
I can see the superior part of the kidney
on this ultrasound image,
and I'll just sweep from side to side.
Again, looking at the cortex of the kidney,
looking at the renal pyramids,
and also trying to determine
if there is hydronephrosis present.
And then I'm gonna move down one rib space,
evaluate the lower pole of the kidney,
and sweep medial to lateral
to make sure that I've looked at all of the tissue
'cause these stones can be quite small.
So you have to do a very thorough evaluation.
Once I've completed this view,
I'm gonna turn the transducer to a transverse view.
So I'm gonna turn the transducer counterclockwise
and the marker, again, will face the patient's right.
This will give me that horseshoe-shaped appearance
of the kidney.
And if I start it in mid-level,
I will see the renal vein entering the pelvis of the kidney.
And from here, this is my mid-point,
I'm gonna sweep superior.
I might have to go up a rib space to find it,
go all the way through the kidney, superior pole,
and then start to move inferiorly to mid-level,
continue on down, inferior again,
to the lower pole of the kidney,
and all the way out.
So that completes the kidney evaluation.

Brightcove ID

5508114769001

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

How to: FAST Exam: LUQ

Read more about How to: FAST Exam: LUQ

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Learn to scan the splenorenal recess for fluid collections.

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- The next view I'm going to take you through
is a perisplenic or left upper quadrant view.
This view tends to be a little bit more difficult
because the spleen is smaller and doesn't provide
as large an acoustic window.
We're going to start.
Again, the patient's going to be supine.
This is a probe marker right here.
We're going to go really posterior.
My hand is going to touch the gurney.
You can go about four finger breadths
just above the costal margin.
You can identify the kidney.
That's going to be a pretty identifiable organ,
characteristic bean shape.
Then we can see it here on the screen.
Just above it, we're going to see the spleen.
To the far left of the screen as well
we see the diaphragm.
Once you're in this location,
you want to carefully pan through
the inferior part of the spleen,
and then jump over that rib,
and see the superior part of the spleen,
because fluid often collects just above the spleen
and below the diaphragm.
Once you identify a good view in the left upper quadrant,
you'll want to do a sweep through that area
looking for free fluid.
Again, you see the kidney, you see the spleen.
Find the interface between.
Look for fluid between those two organs.
Then particularly scan above that spleen,
scanning all the way through the organ,
looking for free fluid above the spleen
and below the diaphragm.
Again, when you're scanning through this area,
you want to carefully look above the diaphragm
for evidence of hemothorax.
When you're scanning in this view,
also make sure you scan the full kidney.
Here we see the superior pole to the left of the screen,
and the inferior pole.
You want to make sure you get that full kidney
in view when you examine the left upper quadrant.

Brightcove ID

5508114757001

https://youtube.com/watch?v=IuRklL3cWJU

How to: FAST Exam: RUQ

Read more about How to: FAST Exam: RUQ

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

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

Brightcove ID

5508114130001

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