Measurement

How to: Abdominal Aorta Measurements

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Learn to measure the abdominal aorta with ultrasound.

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Cardiology

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- Once we've done the survey,
we wanna go back and take measurements
of the aorta in a transverse view in three levels.
One level is proximal above the level of the renal arteries,
the second is just at the level of the renal arteries
and the third is at the level of the bifurcation.
We're gonna go back to the epigastric area
and look for our landmarks again.
In the middle of the screen we have the aorta pulsating
to the right of the aorta the IVC
and anterior to the aorta we have
the superior mesenteric artery.
I'm going to freeze the image here
and perform two measurements.
Measuring from the outside wall to outside wall,
so I measure the entire size of the aorta
and just the residual lumen of an aneurysm.
I will perform two measurements, anterior to posterior,
and a transverse measurement.
From there I'm gonna move a little bit more inferior
optimizing the image so I can see
the wall of the aorta clearly.
I will freeze the image.
Perform my measurements, the same two views again.
From the outside wall
to the outside wall,
that's the AP measurement and the same for the transverse.
The measurement is displayed on
the bottom left of the screen and
in this case our measurement is 1.36 centimeters
by 1.69 centimeters.
So we're looking for a value of over three centimeters
to be considered aneurysmal.
I'll keep moving down in a transverse view
towards the bifurcation.
Here we see the aorta divide.
So right before it divides, I want to
perform my measurement at that point.
So I will freeze and perform the
same two measurements again.
Anterior
and transverse.
From outside wall to outside wall.
And that is the completion of the measurements
you need to do for the abdominal aortic exam.

Brightcove ID

5745409357001

https://youtube.com/watch?v=SHhKyEaW1NM

Fetal Heart

Read more about Fetal Heart

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Endovag Uterus: Endometrium Measurement

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3D How To: Ultrasound Guided Abscess Drainage

Read more about 3D How To: Ultrasound Guided Abscess Drainage

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3D animation demonstrating an ultrasound guided abscess drainage procedure.

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- [Voiceover] A linear array transducer
with a superficial venous exam type
is used to perform an ultrasound guided
drainage of an abscess.
The transducer is placed in a longitudinal direction
over the area of tenderness or fluctuance,
with the orientation marker directed
toward the patient's head.
It is helpful to have a generous amount of gel
on the transducer face, to decrease transducer pressure
and pain with the examination.
The depth and extent of the abscess cavity
is determined by scanning the cavity
in a left-to-right direction.
Septation of the abscess cavity should be determined
as it is important to free these areas
during the drainage procedure for optimal results.
The superior and inferior extent of the abscess cavity
can be determined by moving the transducer
in a superior to inferior direction.
The drainage incision should be planned
at an area where the abscess cavity is most superficial
and likely to promote dependent drainage.

Brightcove ID

5508104678001

https://youtube.com/watch?v=7M26wTrphmA

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

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Increased Intercranial Pressure

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- [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

Case: Ocular Ultrasound Part 2

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Part 2 of 2. Ocular ultrasound case study.

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- 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

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How to: Abdominal Aorta Measurements

How to: Abdominal Aorta Measurements

Fetal Heart

Fetal Heart

Endovag Uterus: Endometrium Measurement

Endovag Uterus: Endometrium Measurement

3D How To: Ultrasound Guided Abscess Drainage

3D How To: Ultrasound Guided Abscess Drainage

3D How To: Ocular Ultrasound

3D How To: Ocular Ultrasound

Case: Ocular Ultrasound Part 2

Case: Ocular Ultrasound Part 2

Case: Ocular Ultrasound Part 1

Case: Ocular Ultrasound Part 1

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