<p begin="00:00:08.580" end="00:00:10.059" style="s2">- [Voiceover] A phased array transducer</p>
<p begin="00:00:10.059" end="00:00:12.768" style="s2">with an abdomen exam<br />type is used to evaluate</p>
<p begin="00:00:12.768" end="00:00:16.201" style="s2">the chest cavity for<br />the presence of fluid.</p>
<p begin="00:00:16.201" end="00:00:18.749" style="s2">The procedure is best<br />performed with the subject</p>
<p begin="00:00:18.749" end="00:00:21.484" style="s2">in a sitting position,<br />leaning slightly forward,</p>
<p begin="00:00:21.484" end="00:00:25.026" style="s2">to allow access to the<br />posterior chest cavity.</p>
<p begin="00:00:25.026" end="00:00:27.464" style="s2">The patient is instructed<br />to breathe normally.</p>
<p begin="00:00:27.464" end="00:00:30.645" style="s2">And the transducer is placed<br />in a long-axis orientation</p>
<p begin="00:00:30.645" end="00:00:32.742" style="s2">over the posterior chest wall</p>
<p begin="00:00:32.742" end="00:00:35.483" style="s2">at the eighth or ninth intercostal space,</p>
<p begin="00:00:35.483" end="00:00:37.932" style="s2">in the posterior axillary line.</p>
<p begin="00:00:37.932" end="00:00:41.384" style="s2">The orientation marker is<br />directed to the patient's head.</p>
<p begin="00:00:41.384" end="00:00:44.312" style="s2">The ribs are identified in<br />the near field of the image</p>
<p begin="00:00:44.312" end="00:00:47.848" style="s2">as a bright interface<br />with a posterior shadow.</p>
<p begin="00:00:47.848" end="00:00:50.107" style="s2">The pleural line is identified as a bright</p>
<p begin="00:00:50.107" end="00:00:53.002" style="s2">hyperechoic line between the rib shadows.</p>
<p begin="00:00:53.002" end="00:00:55.800" style="s2">The to and fro sliding<br />movement of the visceral pleura</p>
<p begin="00:00:55.800" end="00:00:58.175" style="s2">against the parietal<br />pleura, with breathing,</p>
<p begin="00:00:58.175" end="00:01:00.504" style="s2">generates the lung sliding sign.</p>
<p begin="00:01:00.504" end="00:01:03.640" style="s2">The transducer is moved along<br />the posterior axillary line</p>
<p begin="00:01:03.640" end="00:01:07.426" style="s2">to identify the bright,<br />hyperreflective diaphragm.</p>
<p begin="00:01:07.426" end="00:01:10.018" style="s2">Fluid will appear as a dark anechoic area</p>
<p begin="00:01:10.018" end="00:01:12.559" style="s2">in the dependent area of the chest cavity.</p>
<p begin="00:01:12.559" end="00:01:14.832" style="s2">Identify the borders<br />of the fluid collection</p>
<p begin="00:01:14.832" end="00:01:17.483" style="s2">and the normal appearing lung.</p>
<p begin="00:01:17.483" end="00:01:19.544" style="s2">A needle insertion site should be chosen</p>
<p begin="00:01:19.544" end="00:01:21.134" style="s2">in the posterior chest,</p>
<p begin="00:01:21.134" end="00:01:24.293" style="s2">in a dependent area of<br />the fluid collection.</p>
<p begin="00:01:24.293" end="00:01:28.129" style="s2">Adjust the transducer so it<br />is located between two ribs.</p>
<p begin="00:01:28.129" end="00:01:30.041" style="s2">The needle should be inserted just below</p>
<p begin="00:01:30.041" end="00:01:32.080" style="s2">the center position of the transducer</p>
<p begin="00:01:32.080" end="00:01:34.192" style="s2">to allow the needle to pass just superior</p>
<p begin="00:01:34.192" end="00:01:37.509" style="s2">to the lower rib to avoid<br />the neurovascular bundle,</p>
<p begin="00:01:37.509" end="00:01:40.600" style="s2">which lies on the inferior<br />surface of the rib.</p>
<p begin="00:01:40.600" end="00:01:42.756" style="s2">Follow the needle entry by slowly sliding</p>
<p begin="00:01:42.756" end="00:01:46.096" style="s2">the transducer in the direction<br />of needle advancement.</p>
<p begin="00:01:46.096" end="00:01:49.808" style="s2">The needle will appear as a<br />small bright hyperechoic dot.</p>
<p begin="00:01:49.808" end="00:01:51.769" style="s2">When the needle tip appears,</p>
<p begin="00:01:51.769" end="00:01:55.196" style="s2">the transducer should be advanced<br />a short distance distally</p>
<p begin="00:01:55.196" end="00:01:58.201" style="s2">to follow the tip of<br />the needle trajectory.</p>
<p begin="00:01:58.201" end="00:02:00.488" style="s2">The needle is slowly advanced under direct</p>
<p begin="00:02:00.488" end="00:02:03.408" style="s2">ultrasound visualization<br />until the tip is seen</p>
<p begin="00:02:03.408" end="00:02:07.005" style="s2">to indent and then puncture<br />the parietal pleura.</p>
<p begin="00:02:07.005" end="00:02:09.897" style="s2">The transducer should be<br />moved slightly proximally</p>
<p begin="00:02:09.897" end="00:02:12.849" style="s2">and distally to confirm<br />that the needle tip lies</p>
<p begin="00:02:12.849" end="00:02:16.516" style="s2">in the fluid collection<br />in the chest cavity.</p>

<p begin="00:00:07.217" end="00:00:08.450" style="s2">- [Voiceover] Linear array transducer</p>
<p begin="00:00:08.450" end="00:00:10.353" style="s2">with a vascular exam type,</p>
<p begin="00:00:10.353" end="00:00:13.051" style="s2">is used to perform an<br />ultrasound guided insertion</p>
<p begin="00:00:13.051" end="00:00:16.639" style="s2">of a radial artery catheter<br />via a transverse approach.</p>
<p begin="00:00:16.639" end="00:00:18.809" style="s2">The patient is in a supine position,</p>
<p begin="00:00:18.809" end="00:00:22.821" style="s2">with the arm abducted 45<br />degrees and externally rotated.</p>
<p begin="00:00:22.821" end="00:00:25.326" style="s2">The wrist is extended<br />by placing a small roll</p>
<p begin="00:00:25.326" end="00:00:26.974" style="s2">beneath the wrist crease.</p>
<p begin="00:00:26.974" end="00:00:29.218" style="s2">The transducer is placed transversely</p>
<p begin="00:00:29.218" end="00:00:31.187" style="s2">just proximal to the wrist crease,</p>
<p begin="00:00:31.187" end="00:00:34.397" style="s2">with the orientation marker<br />directed to the patient's right.</p>
<p begin="00:00:34.397" end="00:00:36.681" style="s2">The radial artery is superficial,</p>
<p begin="00:00:36.681" end="00:00:40.593" style="s2">and is seen as a dark anechoic,<br />round, pulsatile structure</p>
<p begin="00:00:40.593" end="00:00:42.541" style="s2">on the lateral aspect of the wrist,</p>
<p begin="00:00:42.541" end="00:00:46.056" style="s2">seen in the midst of<br />static, echodense material.</p>
<p begin="00:00:46.056" end="00:00:48.006" style="s2">There are often small venous vessels,</p>
<p begin="00:00:48.006" end="00:00:49.852" style="s2">which accompany the radial artery,</p>
<p begin="00:00:49.852" end="00:00:53.165" style="s2">which can be compressed with<br />gentle transducer pressure.</p>
<p begin="00:00:53.165" end="00:00:56.565" style="s2">The radius can be seen as<br />an anechoic, dark structure,</p>
<p begin="00:00:56.565" end="00:00:59.991" style="s2">approximately one centimeter<br />below the radial artery.</p>
<p begin="00:00:59.991" end="00:01:03.399" style="s2">Adjust the transducer so it<br />is centered over the artery.</p>
<p begin="00:01:03.399" end="00:01:06.422" style="s2">Follow the needle entry by<br />slowing sliding the transducer</p>
<p begin="00:01:06.422" end="00:01:08.929" style="s2">in the direction of needle advancement.</p>
<p begin="00:01:08.929" end="00:01:11.892" style="s2">The needle will appear<br />as a small, bright dot.</p>
<p begin="00:01:11.892" end="00:01:13.338" style="s2">When the needle tip appears,</p>
<p begin="00:01:13.338" end="00:01:16.666" style="s2">the transducer should be advanced<br />a short distance distally</p>
<p begin="00:01:16.666" end="00:01:19.079" style="s2">to follow the tip of<br />the needle trajectory,</p>
<p begin="00:01:19.079" end="00:01:21.525" style="s2">and stay in advance of the needle entry.</p>
<p begin="00:01:21.525" end="00:01:22.923" style="s2">The needle is slowly advanced,</p>
<p begin="00:01:22.923" end="00:01:25.176" style="s2">under direct ultrasound visualization,</p>
<p begin="00:01:25.176" end="00:01:28.168" style="s2">until the tip is seen to<br />puncture the radial artery.</p>
<p begin="00:01:28.168" end="00:01:30.016" style="s2">The transducer should be moved slightly</p>
<p begin="00:01:30.016" end="00:01:32.702" style="s2">proximally and distally<br />to confirm the needle tip</p>
<p begin="00:01:32.702" end="00:01:35.869" style="s2">lies in the mid-portion of the artery.</p>

<p begin="00:00:07.889" end="00:00:09.349" style="s2">- [Voiceover] A linear array transducer</p>
<p begin="00:00:09.349" end="00:00:12.631" style="s2">with a nerve exam type is used<br />to perform ultrasound guided</p>
<p begin="00:00:12.631" end="00:00:14.687" style="s2">popliteal nerve block.</p>
<p begin="00:00:14.687" end="00:00:17.850" style="s2">The target depth is<br />approximately 2 to 4 centimeters</p>
<p begin="00:00:17.850" end="00:00:20.373" style="s2">in an 80 kilogram adult.</p>
<p begin="00:00:20.373" end="00:00:23.568" style="s2">The patient is positioned in<br />a lateral decubitus position</p>
<p begin="00:00:23.568" end="00:00:26.091" style="s2">with the hip and knee slightly flexed.</p>
<p begin="00:00:26.091" end="00:00:28.135" style="s2">The transducer is placed transversely</p>
<p begin="00:00:28.135" end="00:00:31.135" style="s2">on the popliteal skin<br />crease with the orientation</p>
<p begin="00:00:31.135" end="00:00:33.388" style="s2">marker directed laterally.</p>
<p begin="00:00:33.388" end="00:00:36.393" style="s2">The transducer should be<br />moved medially and laterally</p>
<p begin="00:00:36.393" end="00:00:40.222" style="s2">to identify the dark round<br />pulsatile popliteal artery.</p>
<p begin="00:00:40.222" end="00:00:43.492" style="s2">The compressible poplital<br />vein can be seen superior</p>
<p begin="00:00:43.492" end="00:00:45.695" style="s2">to the popliteal artery.</p>
<p begin="00:00:45.695" end="00:00:49.145" style="s2">The tibial nerve lies<br />superficial to the popliteal vein</p>
<p begin="00:00:49.145" end="00:00:52.668" style="s2">and appears as a bright<br />hyperechoic oval structure.</p>
<p begin="00:00:52.668" end="00:00:55.331" style="s2">The transducer should be slowly translated</p>
<p begin="00:00:55.331" end="00:00:57.926" style="s2">up the posterior thigh<br />to identify the point</p>
<p begin="00:00:57.926" end="00:01:00.976" style="s2">where the peroneal and tibial nerves join.</p>
<p begin="00:01:00.976" end="00:01:04.783" style="s2">The ideal point for needle<br />insertion is at or just below</p>
<p begin="00:01:04.783" end="00:01:07.763" style="s2">the split of the tibial<br />and peroneal nerves.</p>
<p begin="00:01:07.763" end="00:01:11.138" style="s2">The needles is advanced<br />using an in-plane technique.</p>
<p begin="00:01:11.138" end="00:01:14.455" style="s2">The needle is positioned<br />1 to 2 centimeters lateral</p>
<p begin="00:01:14.455" end="00:01:18.534" style="s2">to the transducer and<br />advanced under the transducer.</p>
<p begin="00:01:18.534" end="00:01:20.831" style="s2">The initial end point for<br />the needle is immediately</p>
<p begin="00:01:20.831" end="00:01:22.906" style="s2">beside the tibial nerve.</p>
<p begin="00:01:22.906" end="00:01:25.326" style="s2">Local anesthetic should<br />be principally injected</p>
<p begin="00:01:25.326" end="00:01:27.880" style="s2">around the tibial nerve,<br />as it is responsible</p>
<p begin="00:01:27.880" end="00:01:31.963" style="s2">for the majority of the<br />innervation of the foot.</p>

<p begin="00:00:07.465" end="00:00:09.053" style="s2">- [Voiceover] A liner<br />array transducer with</p>
<p begin="00:00:09.053" end="00:00:11.160" style="s2">a venous exam type is used to preform</p>
<p begin="00:00:11.160" end="00:00:13.097" style="s2">an ultrasound guided insertion</p>
<p begin="00:00:13.097" end="00:00:15.733" style="s2">of a peripherally<br />inserted central catheter</p>
<p begin="00:00:15.733" end="00:00:18.144" style="s2">via a transverse approach.</p>
<p begin="00:00:18.144" end="00:00:19.835" style="s2">The patient is in a supine position</p>
<p begin="00:00:19.835" end="00:00:23.522" style="s2">with the arm extended 90<br />degrees at the patient's side</p>
<p begin="00:00:23.522" end="00:00:24.977" style="s2">and externally rotated.</p>
<p begin="00:00:24.977" end="00:00:27.961" style="s2">The transducer is placed<br />transversely just proximal</p>
<p begin="00:00:27.961" end="00:00:30.980" style="s2">to the medial condyle<br />in the bicipital groove</p>
<p begin="00:00:30.980" end="00:00:34.207" style="s2">with the orientation marker<br />directed to the patient's right.</p>
<p begin="00:00:34.207" end="00:00:37.505" style="s2">The basilic vein is seen as<br />a dark anechoic circular,</p>
<p begin="00:00:37.505" end="00:00:40.124" style="s2">compressible structure<br />in the mid-portion of</p>
<p begin="00:00:40.124" end="00:00:43.985" style="s2">the ultrasound image, between<br />the biceps and triceps muscle.</p>
<p begin="00:00:43.985" end="00:00:46.285" style="s2">Deeper, and slightly to<br />the right of the screen,</p>
<p begin="00:00:46.285" end="00:00:49.383" style="s2">the bright hyper-echoic<br />humerus can be seen.</p>
<p begin="00:00:49.383" end="00:00:51.365" style="s2">Adjust the transducer so it is</p>
<p begin="00:00:51.365" end="00:00:53.544" style="s2">centered over the basilic vein.</p>
<p begin="00:00:53.544" end="00:00:55.856" style="s2">Follow the needle entry by slowly sliding</p>
<p begin="00:00:55.856" end="00:00:58.889" style="s2">the transducer in the direction<br />of needle advancement.</p>
<p begin="00:00:58.889" end="00:01:01.720" style="s2">The needle will appear<br />as a small bright dot.</p>
<p begin="00:01:01.720" end="00:01:03.472" style="s2">When the needle tip appears,</p>
<p begin="00:01:03.472" end="00:01:06.443" style="s2">the transducer should be<br />advanced a short distance</p>
<p begin="00:01:06.443" end="00:01:08.519" style="s2">to follow the tip of the needle trajectory</p>
<p begin="00:01:08.519" end="00:01:11.159" style="s2">and stay in advance of the needle entry.</p>
<p begin="00:01:11.159" end="00:01:12.892" style="s2">The needle is slowly advanced under</p>
<p begin="00:01:12.892" end="00:01:15.533" style="s2">direct ultrasound<br />visualization until the tip</p>
<p begin="00:01:15.533" end="00:01:19.306" style="s2">is seen to indent and then<br />puncture the basilic vein.</p>
<p begin="00:01:19.306" end="00:01:21.919" style="s2">The transducer should be<br />moved slightly proximally</p>
<p begin="00:01:21.919" end="00:01:24.040" style="s2">and distally to confirm<br />that the needle tip</p>
<p begin="00:01:24.040" end="00:01:26.679" style="s2">lies in the mid portion<br />of the basilic vein.</p>
<p begin="00:01:26.679" end="00:01:28.592" style="s2">This technique can also be used</p>
<p begin="00:01:28.592" end="00:01:31.925" style="s2">with the deep brachial or cephalic vein.</p>

<p begin="00:00:07.862" end="00:00:09.374" style="s2">- [Voiceover] A curved array transducer</p>
<p begin="00:00:09.374" end="00:00:10.901" style="s2">with an abdomen exam type</p>
<p begin="00:00:10.901" end="00:00:14.038" style="s2">is used to perform an<br />ultrasound guided paracentesis.</p>
<p begin="00:00:14.038" end="00:00:16.119" style="s2">It is easier to perform this exam</p>
<p begin="00:00:16.119" end="00:00:18.248" style="s2">when the bladder is not filled.</p>
<p begin="00:00:18.248" end="00:00:20.735" style="s2">The patient is placed<br />in a supine position.</p>
<p begin="00:00:20.735" end="00:00:24.165" style="s2">The abdominal cavity is<br />evaluated in two planes.</p>
<p begin="00:00:24.165" end="00:00:27.188" style="s2">Place the transducer in<br />a transverse position</p>
<p begin="00:00:27.188" end="00:00:30.032" style="s2">with the orientation marker to the right.</p>
<p begin="00:00:30.032" end="00:00:32.876" style="s2">The transducer is placed<br />at the lateral border</p>
<p begin="00:00:32.876" end="00:00:35.719" style="s2">of the rectus sheath at<br />the level of the umbilicus.</p>
<p begin="00:00:35.719" end="00:00:38.433" style="s2">To evaluate the abdominal<br />cavity for free fluid,</p>
<p begin="00:00:38.433" end="00:00:42.920" style="s2">sweep the transducer from an<br />inferior to superior position.</p>
<p begin="00:00:42.920" end="00:00:45.829" style="s2">Fluid will appear hypoechoic or anechoic</p>
<p begin="00:00:45.829" end="00:00:47.828" style="s2">and accumulate in the lateral gutter</p>
<p begin="00:00:47.828" end="00:00:49.827" style="s2">and between loops of bowel.</p>
<p begin="00:00:49.827" end="00:00:51.762" style="s2">To obtain a long axis view,</p>
<p begin="00:00:51.762" end="00:00:55.516" style="s2">rotate the transducer 90 degrees<br />with the orientation marker</p>
<p begin="00:00:55.516" end="00:00:58.036" style="s2">directed to the point of needle entry.</p>
<p begin="00:00:58.036" end="00:01:00.831" style="s2">Sweep the transducer<br />across the abdominal cavity</p>
<p begin="00:01:00.831" end="00:01:04.651" style="s2">from left to right to evaluate<br />the abdomen for free fluid.</p>
<p begin="00:01:04.651" end="00:01:07.170" style="s2">A needle insertion site should be chosen</p>
<p begin="00:01:07.170" end="00:01:08.991" style="s2">in the lateral abdominal area</p>
<p begin="00:01:08.991" end="00:01:11.364" style="s2">in a dependent area of<br />the fluid collection</p>
<p begin="00:01:11.364" end="00:01:13.867" style="s2">which is clear from loops of bowel.</p>
<p begin="00:01:13.867" end="00:01:16.825" style="s2">The needle should be inserted<br />lateral to the rectus sheath</p>
<p begin="00:01:16.825" end="00:01:20.499" style="s2">in a transverse fashion to<br />avoid the epigastric artery.</p>
<p begin="00:01:20.499" end="00:01:23.571" style="s2">Follow the needle entry by<br />slowly sliding the transducer</p>
<p begin="00:01:23.571" end="00:01:26.204" style="s2">in the direction of needle advancement.</p>
<p begin="00:01:26.204" end="00:01:30.040" style="s2">The needle will appear as a<br />small, bright hypoechoic dot.</p>
<p begin="00:01:30.040" end="00:01:31.828" style="s2">When the needle tip appears,</p>
<p begin="00:01:31.828" end="00:01:35.241" style="s2">the transducer should be advanced<br />a short distance distally</p>
<p begin="00:01:35.241" end="00:01:38.150" style="s2">to follow the tip of<br />the needle trajectory.</p>
<p begin="00:01:38.150" end="00:01:39.792" style="s2">The needle is slowly advanced</p>
<p begin="00:01:39.792" end="00:01:42.035" style="s2">under direct ultrasound visualization</p>
<p begin="00:01:42.035" end="00:01:44.034" style="s2">until the tip is seen to indent</p>
<p begin="00:01:44.034" end="00:01:46.830" style="s2">and then puncture the parietal peritoneum.</p>
<p begin="00:01:46.830" end="00:01:49.758" style="s2">The transducer should be<br />moved slightly proximally</p>
<p begin="00:01:49.758" end="00:01:53.925" style="s2">and distally to confirm<br />location of the needle tip.</p>

<p begin="00:00:07.292" end="00:00:09.121" style="s2">- [Voiceover] A linear array transducer</p>
<p begin="00:00:09.121" end="00:00:11.513" style="s2">with a nerve exam type is used to perform</p>
<p begin="00:00:11.513" end="00:00:14.888" style="s2">an ultrasound-guided,<br />interscalene nerve block.</p>
<p begin="00:00:14.888" end="00:00:18.497" style="s2">The target depth is approximately<br />one to three centimeters</p>
<p begin="00:00:18.497" end="00:00:20.715" style="s2">in an 80-kilogram adult.</p>
<p begin="00:00:20.715" end="00:00:24.654" style="s2">The patient is positioned in<br />a 45-degree reclining position</p>
<p begin="00:00:24.654" end="00:00:26.373" style="s2">with a pillow under their head</p>
<p begin="00:00:26.373" end="00:00:29.536" style="s2">and the head turned toward<br />the contralateral side.</p>
<p begin="00:00:29.536" end="00:00:31.900" style="s2">The examination begins by finding</p>
<p begin="00:00:31.900" end="00:00:34.916" style="s2">the supraclavicular region<br />of the brachial plexus</p>
<p begin="00:00:34.916" end="00:00:36.709" style="s2">as a landmark technique.</p>
<p begin="00:00:36.709" end="00:00:39.039" style="s2">The transducer is placed posterior</p>
<p begin="00:00:39.039" end="00:00:41.013" style="s2">to the midpoint of the clavicle</p>
<p begin="00:00:41.013" end="00:00:42.373" style="s2">with the orientation marker</p>
<p begin="00:00:42.373" end="00:00:46.540" style="s2">directed to the patient's right<br />at a three-o'clock position.</p>
<p begin="00:00:49.085" end="00:00:51.056" style="s2">The subclavian artery is seen</p>
<p begin="00:00:51.056" end="00:00:53.399" style="s2">as a round, pulsatile structure</p>
<p begin="00:00:53.399" end="00:00:56.778" style="s2">superior to the bright<br />reflection of the first rib.</p>
<p begin="00:00:56.778" end="00:01:00.337" style="s2">The pleura is seen as a<br />bright, hyperechoic reflection</p>
<p begin="00:01:00.337" end="00:01:03.590" style="s2">deep to or at the same<br />depth as the first rib.</p>
<p begin="00:01:03.590" end="00:01:07.432" style="s2">The nerves of the brachial<br />plexus are posterior or superior</p>
<p begin="00:01:07.432" end="00:01:09.681" style="s2">to the subclavian artery.</p>
<p begin="00:01:09.681" end="00:01:12.728" style="s2">The nerves appear as<br />hypoechoic dark circles</p>
<p begin="00:01:12.728" end="00:01:14.814" style="s2">within the bright hyperechoic fascia</p>
<p begin="00:01:14.814" end="00:01:17.115" style="s2">surrounding the brachial plexus.</p>
<p begin="00:01:17.115" end="00:01:21.158" style="s2">To identify the interscalene<br />region of the brachial plexus,</p>
<p begin="00:01:21.158" end="00:01:23.987" style="s2">slowly slide the transducer up the neck.</p>
<p begin="00:01:23.987" end="00:01:26.568" style="s2">The interscalene muscles<br />will frame the nerves</p>
<p begin="00:01:26.568" end="00:01:29.020" style="s2">within the interscalene groove.</p>
<p begin="00:01:29.020" end="00:01:30.848" style="s2">The nerves will change in shape</p>
<p begin="00:01:30.848" end="00:01:34.236" style="s2">from a grape-like cluster in<br />the supraclavicular region</p>
<p begin="00:01:34.236" end="00:01:37.710" style="s2">to a chain-link appearance<br />in the interscalene groove.</p>
<p begin="00:01:37.710" end="00:01:42.445" style="s2">The C5 and C6 nerve roots<br />appear as three circles.</p>
<p begin="00:01:42.445" end="00:01:45.348" style="s2">The hypoechoic pulsatile carotid artery</p>
<p begin="00:01:45.348" end="00:01:48.969" style="s2">will appear medial to the<br />anterior scalene muscle.</p>
<p begin="00:01:48.969" end="00:01:50.345" style="s2">The needle can be advanced</p>
<p begin="00:01:50.345" end="00:01:53.771" style="s2">using an in-plane or<br />out-of-plane technique.</p>
<p begin="00:01:53.771" end="00:01:55.547" style="s2">For an in-plane technique,</p>
<p begin="00:01:55.547" end="00:01:58.220" style="s2">the needle is positioned<br />one to two centimeters</p>
<p begin="00:01:58.220" end="00:02:02.344" style="s2">lateral to the transducer and<br />advanced under the transducer</p>
<p begin="00:02:02.344" end="00:02:05.776" style="s2">until the tip is just<br />posterior to or between</p>
<p begin="00:02:05.776" end="00:02:07.943" style="s2">the C5 and C6 nerve roots.</p>
<p begin="00:02:08.909" end="00:02:11.627" style="s2">The local anesthetic is<br />injected incrementally</p>
<p begin="00:02:11.627" end="00:02:13.691" style="s2">close to the nerve roots.</p>
<p begin="00:02:13.691" end="00:02:15.098" style="s2">The needle can be redirected</p>
<p begin="00:02:15.098" end="00:02:18.749" style="s2">if the spread of local anesthetic<br />is not deemed adequate.</p>
<p begin="00:02:18.749" end="00:02:21.425" style="s2">It is not necessary to<br />have local anesthetic</p>
<p begin="00:02:21.425" end="00:02:24.665" style="s2">anterior and posterior to the nerve roots.</p>
<p begin="00:02:24.665" end="00:02:28.832" style="s2">Posterior spread only of<br />local anesthetic is effective.</p>

<p begin="00:00:07.354" end="00:00:09.128" style="s2">- [Voiceover] A linear array transducer</p>
<p begin="00:00:09.128" end="00:00:11.643" style="s2">with a nerve exam type is used to perform</p>
<p begin="00:00:11.643" end="00:00:15.694" style="s2">an ultrasound-guided,<br />infraclavicular regional nerve block.</p>
<p begin="00:00:15.694" end="00:00:19.134" style="s2">The target depth is approximately<br />three to four centmeters</p>
<p begin="00:00:19.134" end="00:00:21.341" style="s2">in an 80 kilogram adult.</p>
<p begin="00:00:21.341" end="00:00:23.542" style="s2">The patient is positioned supine</p>
<p begin="00:00:23.542" end="00:00:25.523" style="s2">with the arm abducted 90 degrees</p>
<p begin="00:00:25.523" end="00:00:27.616" style="s2">and the elbow bent 90 degrees</p>
<p begin="00:00:27.616" end="00:00:29.525" style="s2">to move the clavicle posterior,</p>
<p begin="00:00:29.525" end="00:00:32.434" style="s2">and permit a shallow<br />angle of needle insertion.</p>
<p begin="00:00:32.434" end="00:00:34.126" style="s2">The patient's head should be rotated</p>
<p begin="00:00:34.126" end="00:00:36.427" style="s2">toward the contralateral side.</p>
<p begin="00:00:36.427" end="00:00:40.380" style="s2">The transducer is placed on the<br />chest in a paramedian plane,</p>
<p begin="00:00:40.380" end="00:00:42.936" style="s2">inferior to the midpoint of the clavicle</p>
<p begin="00:00:42.936" end="00:00:46.372" style="s2">with the orientation marker<br />directed to the patient's head.</p>
<p begin="00:00:46.372" end="00:00:48.368" style="s2">The axillary artery is seen as</p>
<p begin="00:00:48.368" end="00:00:52.247" style="s2">a dark, round pulsatile<br />structure with a hyperechoic wall</p>
<p begin="00:00:52.247" end="00:00:56.144" style="s2">inferior to the pectoralis<br />major and minor muscles.</p>
<p begin="00:00:56.144" end="00:00:59.668" style="s2">The axillary vein lies<br />beside the axillary artery</p>
<p begin="00:00:59.668" end="00:01:01.751" style="s2">and collapses with compression.</p>
<p begin="00:01:01.751" end="00:01:04.801" style="s2">The nerve cords appear<br />as hyperechoic circles</p>
<p begin="00:01:04.801" end="00:01:06.193" style="s2">with a honeycomb appearance</p>
<p begin="00:01:06.193" end="00:01:10.370" style="s2">within the bright hyperechoic<br />fascia of the brachial plexus.</p>
<p begin="00:01:10.370" end="00:01:13.618" style="s2">The transducer is slowly<br />moved in a lateral direction,</p>
<p begin="00:01:13.618" end="00:01:16.454" style="s2">following the course<br />of the axillary artery.</p>
<p begin="00:01:16.454" end="00:01:18.722" style="s2">The nerves will split into a lateral,</p>
<p begin="00:01:18.722" end="00:01:21.793" style="s2">medial, and posterior cord.</p>
<p begin="00:01:21.793" end="00:01:24.069" style="s2">The optimum position of the transducer</p>
<p begin="00:01:24.069" end="00:01:26.136" style="s2">for the infraclavicular nerve block</p>
<p begin="00:01:26.136" end="00:01:28.306" style="s2">is as lateral as possible.</p>
<p begin="00:01:28.306" end="00:01:31.280" style="s2">The needle is positioned<br />two centimeters cephalad</p>
<p begin="00:01:31.280" end="00:01:35.432" style="s2">to the transducer and advanced<br />using an in-plane technique.</p>
<p begin="00:01:35.432" end="00:01:37.913" style="s2">The needle path is<br />directed over the clavicle</p>
<p begin="00:01:37.913" end="00:01:40.181" style="s2">and through the pectoral muscles.</p>
<p begin="00:01:40.181" end="00:01:42.143" style="s2">The initial endpoint for the needle is</p>
<p begin="00:01:42.143" end="00:01:45.627" style="s2">immediately posterior to<br />the midpoint of the artery.</p>
<p begin="00:01:45.627" end="00:01:48.770" style="s2">The spread of local<br />anesthetic should be observed.</p>
<p begin="00:01:48.770" end="00:01:52.364" style="s2">Supplemental injections can<br />be made anterior to the artery</p>
<p begin="00:01:52.364" end="00:01:53.954" style="s2">to deposit local anesthetic</p>
<p begin="00:01:53.954" end="00:01:57.954" style="s2">around the lateral and<br />medial cords if required.</p>

<p begin="00:00:07.549" end="00:00:09.196" style="s2">- [Voiceover] A linear array transducer</p>
<p begin="00:00:09.196" end="00:00:11.475" style="s2">with a nerve exam type is used to perform</p>
<p begin="00:00:11.475" end="00:00:13.828" style="s2">an ultrasound guided ilioinguinal</p>
<p begin="00:00:13.828" end="00:00:16.351" style="s2">and iliohypogastric nerve block.</p>
<p begin="00:00:16.351" end="00:00:19.067" style="s2">The target depth is<br />approximately three centimeters</p>
<p begin="00:00:19.067" end="00:00:21.384" style="s2">in an 80 kilogram adult.</p>
<p begin="00:00:21.384" end="00:00:24.528" style="s2">The patient is positioned<br />in a supine position.</p>
<p begin="00:00:24.528" end="00:00:27.639" style="s2">The transducer is placed<br />over the bony prominence</p>
<p begin="00:00:27.639" end="00:00:30.408" style="s2">of the anterior superior iliac spine</p>
<p begin="00:00:30.408" end="00:00:33.991" style="s2">with the orientation marker<br />directed to the patient's right.</p>
<p begin="00:00:33.991" end="00:00:37.495" style="s2">The transducer is rotated<br />slightly counterclockwise</p>
<p begin="00:00:37.495" end="00:00:41.199" style="s2">so one side rests on the<br />anterior superior iliac spine</p>
<p begin="00:00:41.199" end="00:00:43.968" style="s2">and the other side<br />points at the umbilicus.</p>
<p begin="00:00:43.968" end="00:00:47.696" style="s2">The medial side of the transducer<br />is slowly swept superiorly</p>
<p begin="00:00:47.696" end="00:00:51.231" style="s2">and inferiorly while<br />maintaining the bony iliac crest</p>
<p begin="00:00:51.231" end="00:00:53.956" style="s2">in the lateral part of<br />the ultrasound image.</p>
<p begin="00:00:53.956" end="00:00:56.495" style="s2">The structures of the<br />anterior abdominal wall</p>
<p begin="00:00:56.495" end="00:00:59.425" style="s2">should be identified<br />from superficial to deep,</p>
<p begin="00:00:59.425" end="00:01:03.104" style="s2">including adipose tissue,<br />external oblique muscle,</p>
<p begin="00:01:03.104" end="00:01:04.727" style="s2">internal oblique muscle,</p>
<p begin="00:01:04.727" end="00:01:07.759" style="s2">and the transversus abdominis muscle.</p>
<p begin="00:01:07.759" end="00:01:10.688" style="s2">A fourth muscle, the<br />iliacus, may occasionally</p>
<p begin="00:01:10.688" end="00:01:14.527" style="s2">be visualized underneath<br />the transversus abdominis.</p>
<p begin="00:01:14.527" end="00:01:17.271" style="s2">The nerves are located<br />between the internal oblique</p>
<p begin="00:01:17.271" end="00:01:20.056" style="s2">and the transversus<br />abdominis muscle layers.</p>
<p begin="00:01:20.056" end="00:01:22.816" style="s2">They may appear only as<br />hyperechoic thickness</p>
<p begin="00:01:22.816" end="00:01:25.738" style="s2">between these two muscles<br />or as dark hypoechoic</p>
<p begin="00:01:25.738" end="00:01:29.166" style="s2">oval structures with the<br />bright hyperechoic covering.</p>
<p begin="00:01:29.166" end="00:01:32.752" style="s2">The nerves are very closely<br />related to the iliac crest.</p>
<p begin="00:01:32.752" end="00:01:35.150" style="s2">The needle is advanced using an in-plane</p>
<p begin="00:01:35.150" end="00:01:37.031" style="s2">or out-of-plane technique.</p>
<p begin="00:01:37.031" end="00:01:39.007" style="s2">If using an in-plane technique,</p>
<p begin="00:01:39.007" end="00:01:41.607" style="s2">the needle is positioned<br />one to two centimeters</p>
<p begin="00:01:41.607" end="00:01:45.855" style="s2">medial to the transducer and<br />advanced under the transducer.</p>
<p begin="00:01:45.855" end="00:01:47.343" style="s2">The end point for the needle is</p>
<p begin="00:01:47.343" end="00:01:50.999" style="s2">between internal oblique<br />and transversus abdominis.</p>
<p begin="00:01:50.999" end="00:01:53.689" style="s2">The local anesthetic is<br />injected incrementally</p>
<p begin="00:01:53.689" end="00:01:55.439" style="s2">close to the nerves.</p>

<p begin="00:00:07.596" end="00:00:09.143" style="s2">- [Voiceover] A curved array transducer</p>
<p begin="00:00:09.143" end="00:00:11.456" style="s2">with a nerve exam type is used to perform</p>
<p begin="00:00:11.456" end="00:00:14.407" style="s2">a ultrasound guided sciatic nerve block.</p>
<p begin="00:00:14.407" end="00:00:17.696" style="s2">The target depth is approximately<br />four to six centimeters</p>
<p begin="00:00:17.696" end="00:00:20.063" style="s2">in an 80 kilogram adult.</p>
<p begin="00:00:20.063" end="00:00:23.396" style="s2">The patient is positioned in<br />a lateral decubitus position</p>
<p begin="00:00:23.396" end="00:00:25.591" style="s2">with the hip and knee flexed.</p>
<p begin="00:00:25.591" end="00:00:28.711" style="s2">The transducer is placed<br />between the greater trochanter</p>
<p begin="00:00:28.711" end="00:00:31.763" style="s2">and the ischial tuberosity<br />in a transverse position</p>
<p begin="00:00:31.763" end="00:00:34.303" style="s2">just proximal to the gluteal fold</p>
<p begin="00:00:34.303" end="00:00:37.479" style="s2">with the orientation<br />marker directed laterally.</p>
<p begin="00:00:37.479" end="00:00:39.056" style="s2">The bony landmarks will appear</p>
<p begin="00:00:39.056" end="00:00:43.374" style="s2">as bright hyperechoic crescents<br />with posterior shadowing.</p>
<p begin="00:00:43.374" end="00:00:44.886" style="s2">There are several layers of tissue</p>
<p begin="00:00:44.886" end="00:00:47.454" style="s2">between the bony landmarks,<br />which should be identified</p>
<p begin="00:00:47.454" end="00:00:51.249" style="s2">from superficial to deep,<br />including adipose tissue,</p>
<p begin="00:00:51.249" end="00:00:55.303" style="s2">the gluteus maximus muscle<br />and quadratus femoris muscle.</p>
<p begin="00:00:55.303" end="00:00:58.156" style="s2">The sciatic nerve lies<br />deep to the gluteus maximus</p>
<p begin="00:00:58.156" end="00:01:01.744" style="s2">and superficial to the<br />quadratus femoris muscle.</p>
<p begin="00:01:01.744" end="00:01:04.321" style="s2">It appears as a bright hyperechoic oval</p>
<p begin="00:01:04.321" end="00:01:06.888" style="s2">or triangular shaped density.</p>
<p begin="00:01:06.888" end="00:01:10.176" style="s2">The transducer should be<br />moved slightly cranially</p>
<p begin="00:01:10.176" end="00:01:12.296" style="s2">or caudally from the initial position</p>
<p begin="00:01:12.296" end="00:01:14.357" style="s2">by slightly rocking the transducer</p>
<p begin="00:01:14.357" end="00:01:16.596" style="s2">so the beam is perpendicular to the nerve</p>
<p begin="00:01:16.596" end="00:01:20.739" style="s2">for the best echo reflection<br />if it is difficult to identify.</p>
<p begin="00:01:20.739" end="00:01:23.307" style="s2">When the transducer is<br />moved distally in the thigh,</p>
<p begin="00:01:23.307" end="00:01:26.138" style="s2">the sciatic nerve becomes<br />more oval in shape</p>
<p begin="00:01:26.138" end="00:01:29.267" style="s2">and is found more superficially<br />between the biceps femoris</p>
<p begin="00:01:29.267" end="00:01:31.675" style="s2">and abductor magnus muscles.</p>
<p begin="00:01:31.675" end="00:01:34.922" style="s2">The needle is advanced<br />using an in plane technique.</p>
<p begin="00:01:34.922" end="00:01:38.036" style="s2">The needle is positioned one<br />to two centimeters lateral</p>
<p begin="00:01:38.036" end="00:01:42.219" style="s2">to the transducer and advanced<br />slowly under the transducer.</p>
<p begin="00:01:42.219" end="00:01:43.828" style="s2">The initial end point for the needle</p>
<p begin="00:01:43.828" end="00:01:46.907" style="s2">is just lateral and deep to the nerve.</p>
<p begin="00:01:46.907" end="00:01:49.538" style="s2">The local anesthetic is<br />injected incrementally</p>
<p begin="00:01:49.538" end="00:01:51.011" style="s2">close to the nerve.</p>
<p begin="00:01:51.011" end="00:01:53.355" style="s2">For a successful block, a spread of locals</p>
<p begin="00:01:53.355" end="00:01:55.500" style="s2">should be observed around the medial side</p>
<p begin="00:01:55.500" end="00:01:58.250" style="s2">or tibial component of the nerve.</p>

<p begin="00:00:07.378" end="00:00:09.000" style="s2">- [Voiceover] A linear array transducer</p>
<p begin="00:00:09.000" end="00:00:11.275" style="s2">with a nerve exam type is used to perform</p>
<p begin="00:00:11.275" end="00:00:14.181" style="s2">an ultrasound-guided femoral nerve block.</p>
<p begin="00:00:14.181" end="00:00:17.382" style="s2">The target depth is approximately<br />one to three centimeters</p>
<p begin="00:00:17.382" end="00:00:19.631" style="s2">in an 80 kilogram adult.</p>
<p begin="00:00:19.631" end="00:00:22.367" style="s2">The patient is placed<br />in a supine position.</p>
<p begin="00:00:22.367" end="00:00:24.579" style="s2">The transducer is placed just superior</p>
<p begin="00:00:24.579" end="00:00:26.294" style="s2">to the inguinal skin crease</p>
<p begin="00:00:26.294" end="00:00:30.461" style="s2">with the orientation marker<br />directed to the patient's right.</p>
<p begin="00:00:31.318" end="00:00:33.157" style="s2">The common femoral artery is seen</p>
<p begin="00:00:33.157" end="00:00:35.893" style="s2">as a round, pulsatile structure.</p>
<p begin="00:00:35.893" end="00:00:38.069" style="s2">The transducer should be moved laterally</p>
<p begin="00:00:38.069" end="00:00:41.966" style="s2">one to two centimeters to<br />identify the femoral nerve.</p>
<p begin="00:00:41.966" end="00:00:44.927" style="s2">The nerve lies deep to the fascia iliaca</p>
<p begin="00:00:44.927" end="00:00:48.332" style="s2">and appears as an oblong,<br />bright hyperechoic structure</p>
<p begin="00:00:48.332" end="00:00:50.561" style="s2">lying on the iliacus muscle.</p>
<p begin="00:00:50.561" end="00:00:53.344" style="s2">It may contain dark hyperechoic circles</p>
<p begin="00:00:53.344" end="00:00:55.686" style="s2">that represent the nerve fascicles.</p>
<p begin="00:00:55.686" end="00:00:58.920" style="s2">The nerve always lies<br />deep to the fascia iliaca</p>
<p begin="00:00:58.920" end="00:01:00.135" style="s2">and should not be confused</p>
<p begin="00:01:00.135" end="00:01:03.340" style="s2">with the bright hyperechoic<br />tissue lying above the fascia,</p>
<p begin="00:01:03.340" end="00:01:05.481" style="s2">which is lymphatic tissue.</p>
<p begin="00:01:05.481" end="00:01:08.793" style="s2">The needle is advanced<br />using an in-plane technique.</p>
<p begin="00:01:08.793" end="00:01:11.734" style="s2">The needle is positioned one<br />to two centimeters lateral</p>
<p begin="00:01:11.734" end="00:01:15.563" style="s2">to the transducer and<br />advanced under the transducer.</p>
<p begin="00:01:15.563" end="00:01:17.219" style="s2">The initial end point for the needle</p>
<p begin="00:01:17.219" end="00:01:21.762" style="s2">is just lateral to the nerve<br />and deep to the fascia iliaca.</p>
<p begin="00:01:21.762" end="00:01:24.475" style="s2">The local anesthetic is<br />injected incrementally,</p>
<p begin="00:01:24.475" end="00:01:25.860" style="s2">close to the nerve.</p>
<p begin="00:01:25.860" end="00:01:28.643" style="s2">For a successful block, a spread of local</p>
<p begin="00:01:28.643" end="00:01:31.367" style="s2">should be observed behind<br />the femoral artery.</p>
<p begin="00:01:31.367" end="00:01:34.771" style="s2">If local anesthetic is identified<br />anterior to the artery,</p>
<p begin="00:01:34.771" end="00:01:38.097" style="s2">then the needle is superficial<br />to the fascia iliaca</p>
<p begin="00:01:38.097" end="00:01:42.014" style="s2">and the needle needs to<br />be repositioned deeper.</p>