Liver

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

S Series: Subxiphoid View

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S Series: Subxiphoid View

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Cardiology

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Image

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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: Parasternal Long Axis Pt. 1

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Bedside ultrasound imaging and a phased array probe can be used to evaluate cardiac structures and health, the presence of pericardial effusion, and evaluation of the left heart chamber valves and size.

Applications

Cardiology

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Case Study Videos

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- Hello, my name is Phil Perera
and I'm the emergency ultrasound coordinator
ad the New York Presbyterian Hospital in New York City
and welcome to SoundBytes Cases.
Let's begin by reviewing the four standard views
of the cardiac echo exam.
The first view, as shown in probe position A
is the parasternal views both and long and short axis planes
and this is going to be performed directly
on the anterior chest wall.
The second view is where probe position B is shown here
coming from the abdominal position
or the subxiphoid view of the heart.
The last view is going to be shown by probe position C,
the apical view of the heart at
the point of maximum impulse.
This module will specifically focus on
the parasternal views, specifically looking
at the long axis plane.
There's a great deal of information
we can get from the parasternal long axis planes
so let's learn how to perform the examination.
For this examination, it's optimal to use a small footprint
phase to ray type probe that
can easily sit between the ribs.
We're going to place the probe just left of the sternum
at about intercostal space three or four
with the marker dot on the probe aimed down
toward the patient's left elbow,
if the patient's left elbow is down by the side.
That's with the caveat that ultrasound screen indicator
would be over toward the left of the screen.
This will align the probe in the long axis of the heart.
Occasionally it can be someone difficult to get
a good view of the heart from this plane
and moving the patient into the left lateral
decubitus position can sometimes help imaging
from the parasternal long axis plane of the heart.
So now let's take a look at the images
that we'll obtain by performing
the parasternal long axis view of the heart.
Here's a nice pictorial to the left
and what we see is that the most superficial
structure will be the right ventricle.
Notice that the right atrium is not seen from this plane.
Directly posterior to the right ventricle
will be the left ventricle and to the right
of the left ventricle will be seen the left atrium.
We can also see the mitral valve in between
the left atrium and the left ventricle
and a little bit of the aorta above the left atrium.
Let's look at the ultrasound still image, here, to the right
and, again, we see the superficial right ventricle,
posterior we see the left ventricle
with it's more muscular and hypertrophic walls.
Notice the left atrium, as seen to the right
of the left ventricle, and the mitral valve
in between the two chambers.
We categorize this as left ventricular inflow tract.
Note the aortic valve sitting right above the left atrium
and we see a little bit of the aortic root there.
This is what we categorize as aortic outflow tract.
Let's now take a look at the parasternal
long axis view of the heart in action.
Remember, again, that the most superficial chamber
will be the right ventricle
and the normal dimensions of the right ventricle
are that it should be about half
the size of the left ventricle.
If the right ventricle is the same size
of the left ventricle,
that could be a sign of RV strain.
We see the left ventricle posterior to the right ventricle.
Note it's hypertrophic walls.
This patient actually had long standing hypertension.
Let's look at the percentage change from
diastole through systole and here we see
that the walls come in well with each heartbeat
indicating good contractility.
We see the left atrium to the right of the left ventricle
and notice the mitral valve flipping up
and down in between the left atrium and the left ventricle.
We see here good movement of the mitral valve
indicating a good amount of blood flowing
between the left atrium and the left ventricle.
Now, just above the left atrium and
to the right of the left ventricle,
we see the aortic valve
and notice there just to the right of the aortic valve,
a little bit of the diamond shaped aortic root.
This will be our left ventricular outflow tract.
Now, another very important structure to identify
on bedside sonography is the descending aorta
which is a cylinder cut in cross section
right below the mitral valve, as seen in this image.
This is a very important landmark
because the posterior pericardium reflection,
that white line seen posterior to the left ventricle,
comes off anterior to the descending aorta.
This allows us to tell if the fluid
that we see there may be pericardial or plural.
In conclusion, I'm glad I could share with you
the SoundBytes module going over part one
of parasternal long axis view of the heart.
There's a great deal of information that we can gain
by looking at the parasternal long axis view,
looking for left ventricular contractility,
the presence of a pericardial effusion,
and also the possibility of right ventricular strain.
So, I hope to see you back in the future
as we're going to cover further modules
going over the parasternal views,
the subxiphoid views, and the apical views
so I'll see you back as sono access continues.

Brightcove ID

5794981632001

https://youtube.com/watch?v=H_3V9xlDMA0

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