<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="00:00:07.379" end="00:00:09.137" style="s2">- [Voiceover] A linear array transducer</p>
<p begin="00:00:09.137" end="00:00:11.666" style="s2">with a nerve exam type is used to perform</p>
<p begin="00:00:11.666" end="00:00:14.865" style="s2">a median and ulnar regional nerve block.</p>
<p begin="00:00:14.865" end="00:00:18.167" style="s2">The target depth is approximately<br />one to two centimeters</p>
<p begin="00:00:18.167" end="00:00:20.392" style="s2">in an 80-kilogram adult.</p>
<p begin="00:00:20.392" end="00:00:23.105" style="s2">The patient is placed supine with the arm</p>
<p begin="00:00:23.105" end="00:00:25.641" style="s2">externally rotated at the side.</p>
<p begin="00:00:25.641" end="00:00:28.475" style="s2">The transducer is placed<br />in a transverse plane</p>
<p begin="00:00:28.475" end="00:00:29.721" style="s2">at the wrist crease</p>
<p begin="00:00:29.721" end="00:00:31.120" style="s2">with the orientation marker</p>
<p begin="00:00:31.120" end="00:00:33.953" style="s2">directed towards the patient's right side.</p>
<p begin="00:00:33.953" end="00:00:38.214" style="s2">The hypoechoic pulsatile<br />ulnar artery is identified.</p>
<p begin="00:00:38.214" end="00:00:40.485" style="s2">It may be helpful to use color Doppler</p>
<p begin="00:00:40.485" end="00:00:42.265" style="s2">if the artery is small.</p>
<p begin="00:00:42.265" end="00:00:45.357" style="s2">The ulnar nerve is an oval, or triangular,</p>
<p begin="00:00:45.357" end="00:00:47.294" style="s2">bright, hyperechoic structure</p>
<p begin="00:00:47.294" end="00:00:50.318" style="s2">that lies immediately<br />medial to the artery.</p>
<p begin="00:00:50.318" end="00:00:52.141" style="s2">Trace the nerve up the forearm</p>
<p begin="00:00:52.141" end="00:00:54.392" style="s2">following the course of the artery.</p>
<p begin="00:00:54.392" end="00:00:57.527" style="s2">The ulnar nerve will start<br />to separate from the artery</p>
<p begin="00:00:57.527" end="00:01:00.689" style="s2">approximately 2/3 of<br />the way up the forearm.</p>
<p begin="00:01:00.689" end="00:01:03.902" style="s2">The separation allows safe<br />placement of local anesthetic</p>
<p begin="00:01:03.902" end="00:01:05.269" style="s2">around the nerve.</p>
<p begin="00:01:05.269" end="00:01:07.372" style="s2">Follow the fascial plane medially</p>
<p begin="00:01:07.372" end="00:01:10.376" style="s2">to the superficial and deep flexor muscles</p>
<p begin="00:01:10.376" end="00:01:14.030" style="s2">to identify the bright,<br />hyperechoic median nerve.</p>
<p begin="00:01:14.030" end="00:01:17.358" style="s2">The median nerve appears<br />as an oval, or triangular,</p>
<p begin="00:01:17.358" end="00:01:20.735" style="s2">bright, hyperechoic structure<br />between the muscles.</p>
<p begin="00:01:20.735" end="00:01:22.051" style="s2">The needle can be advanced</p>
<p begin="00:01:22.051" end="00:01:25.372" style="s2">using an in-plane or<br />out-of-plane technique.</p>
<p begin="00:01:25.372" end="00:01:28.332" style="s2">For an in-plane approach,<br />the needle is positioned</p>
<p begin="00:01:28.332" end="00:01:31.655" style="s2">one to two centimeters<br />lateral to the transducer</p>
<p begin="00:01:31.655" end="00:01:34.231" style="s2">and advanced under the transducer.</p>
<p begin="00:01:34.231" end="00:01:37.655" style="s2">The initial path for the needle<br />is toward the ulnar nerve</p>
<p begin="00:01:37.655" end="00:01:38.812" style="s2">to allow the needle tip</p>
<p begin="00:01:38.812" end="00:01:41.893" style="s2">to lie immediately beside the ulnar nerve.</p>
<p begin="00:01:41.893" end="00:01:45.441" style="s2">Inject three to five<br />cc of local anesthetic</p>
<p begin="00:01:45.441" end="00:01:48.604" style="s2">around the ulnar nerve<br />to perform the block.</p>
<p begin="00:01:48.604" end="00:01:52.681" style="s2">The needle is then redirected<br />laterally to the median nerve.</p>
<p begin="00:01:52.681" end="00:01:56.245" style="s2">Injection of three to five<br />cc of local anesthetic</p>
<p begin="00:01:56.245" end="00:01:57.726" style="s2">around the median nerve</p>
<p begin="00:01:57.726" end="00:02:00.809" style="s2">will complete the median nerve block.</p>

<p begin="00:00:09.277" end="00:00:12.473" style="s2">- Today I will perform<br />an anatomic demonstration</p>
<p begin="00:00:12.473" end="00:00:14.176" style="s2">of the cervical spine utilizing</p>
<p begin="00:00:14.176" end="00:00:16.894" style="s2">the M-Turbo Ultrasound System,</p>
<p begin="00:00:16.894" end="00:00:20.272" style="s2">utilizing the C60 curvilinear probe.</p>
<p begin="00:00:20.272" end="00:00:22.765" style="s2">The point of this<br />exercise is to demonstrate</p>
<p begin="00:00:22.765" end="00:00:25.246" style="s2">the anatomic considerations<br />when performing</p>
<p begin="00:00:25.246" end="00:00:28.005" style="s2">cervical epidural steroid injections</p>
<p begin="00:00:28.005" end="00:00:29.905" style="s2">and cervical facet injections.</p>
<p begin="00:00:29.905" end="00:00:32.402" style="s2">Typical patients may have have<br />a variance in their anatomy</p>
<p begin="00:00:32.402" end="00:00:35.125" style="s2">and the traditional approaches utilizing</p>
<p begin="00:00:35.125" end="00:00:36.739" style="s2">loss of resistance techniques for</p>
<p begin="00:00:36.739" end="00:00:40.204" style="s2">cervical epidural steroids<br />can present come challenges.</p>
<p begin="00:00:40.204" end="00:00:43.271" style="s2">The purpose of utilizing<br />the ultrasound system</p>
<p begin="00:00:43.271" end="00:00:46.105" style="s2">for an anatomic survey<br />is that the patient,</p>
<p begin="00:00:46.105" end="00:00:49.308" style="s2">who normally has a cervical<br />epidural steroid injection</p>
<p begin="00:00:49.308" end="00:00:51.419" style="s2">performed under fluoroscopic technique</p>
<p begin="00:00:51.419" end="00:00:54.799" style="s2">may occasionally encounter<br />false losses of resistance.</p>
<p begin="00:00:54.799" end="00:00:57.909" style="s2">Utilizing this particular<br />tool as a sounding device</p>
<p begin="00:00:57.909" end="00:01:01.742" style="s2">may perhaps improve the<br />accuracy of injection.</p>
<p begin="00:01:02.726" end="00:01:06.584" style="s2">The way this is performed is<br />utilizing again the C60 probe,</p>
<p begin="00:01:06.584" end="00:01:11.234" style="s2">setting the depth to<br />approximately 9.2 centimeters,</p>
<p begin="00:01:11.234" end="00:01:14.283" style="s2">remembering that the average<br />depth to the epidural space</p>
<p begin="00:01:14.283" end="00:01:16.584" style="s2">is appx six centimeters.</p>
<p begin="00:01:16.584" end="00:01:19.283" style="s2">The nerve setting will also be used</p>
<p begin="00:01:19.283" end="00:01:22.646" style="s2">to highlight any neural structures<br />that may be of interest.</p>
<p begin="00:01:22.646" end="00:01:25.938" style="s2">On the patient, initially, I like to mark</p>
<p begin="00:01:25.938" end="00:01:29.605" style="s2">utilizing a Sharpie,<br />the C7 spinous process.</p>
<p begin="00:01:32.137" end="00:01:35.181" style="s2">This is the most easily<br />palpable spinous process,</p>
<p begin="00:01:35.181" end="00:01:37.149" style="s2">and this is facilitated with the patient</p>
<p begin="00:01:37.149" end="00:01:40.496" style="s2">in the prone position, a<br />bolster under the thorax,</p>
<p begin="00:01:40.496" end="00:01:42.913" style="s2">and the head slightly flexed.</p>
<p begin="00:01:43.954" end="00:01:45.925" style="s2">I place a copious amount of gel</p>
<p begin="00:01:45.925" end="00:01:49.821" style="s2">across the patient's C7 spinous process,</p>
<p begin="00:01:49.821" end="00:01:53.738" style="s2">and then utilizing the<br />probe in the transverse,</p>
<p begin="00:01:54.573" end="00:01:56.570" style="s2">that is the left-to-right positioning,</p>
<p begin="00:01:56.570" end="00:02:00.366" style="s2">I place contact on the<br />skin, and clearly visible</p>
<p begin="00:02:00.366" end="00:02:03.366" style="s2">is the patient's C7 spinous process.</p>
<p begin="00:02:04.461" end="00:02:07.097" style="s2">In this particular view you<br />can also see the lamina,</p>
<p begin="00:02:07.097" end="00:02:10.930" style="s2">and the transverse<br />processes of T1 just below.</p>
<p begin="00:02:12.973" end="00:02:14.856" style="s2">And in the center of the screen,</p>
<p begin="00:02:14.856" end="00:02:18.064" style="s2">under the shadow of the spinous<br />process is a white line.</p>
<p begin="00:02:18.064" end="00:02:21.897" style="s2">This white line, and I<br />will highlight it here,</p>
<p begin="00:02:24.556" end="00:02:29.129" style="s2">demonstrates the actual<br />location of the epidural space.</p>
<p begin="00:02:29.129" end="00:02:32.904" style="s2">So looking off to the right of the screen,</p>
<p begin="00:02:32.904" end="00:02:35.199" style="s2">we can see that the depth is approximately</p>
<p begin="00:02:35.199" end="00:02:38.866" style="s2">five centimeters in<br />this particular patient.</p>
<p begin="00:02:40.790" end="00:02:43.256" style="s2">Other potential views include</p>
<p begin="00:02:43.256" end="00:02:48.086" style="s2">the cranial carotid<br />orientation, or sagittal plane</p>
<p begin="00:02:48.086" end="00:02:51.910" style="s2">of the probe, and placed along the neck,</p>
<p begin="00:02:51.910" end="00:02:53.993" style="s2">and slightly off midline,</p>
<p begin="00:02:54.938" end="00:02:57.649" style="s2">again now can be seen newer structures.</p>
<p begin="00:02:57.649" end="00:03:01.164" style="s2">In this particular case<br />the facet joint line</p>
<p begin="00:03:01.164" end="00:03:05.238" style="s2">is very clearly indicated<br />at these locations.</p>
<p begin="00:03:05.238" end="00:03:08.513" style="s2">The actual location for<br />a medial branch block</p>
<p begin="00:03:08.513" end="00:03:11.513" style="s2">would be on these superior surfaces.</p>
<p begin="00:03:12.556" end="00:03:14.499" style="s2">On the lateral mass.</p>
<p begin="00:03:14.499" end="00:03:18.690" style="s2">If the probe is then rotated further out,</p>
<p begin="00:03:18.690" end="00:03:21.440" style="s2">and a more oblique view obtained,</p>
<p begin="00:03:22.365" end="00:03:25.371" style="s2">the actual foramen of the nerve roots</p>
<p begin="00:03:25.371" end="00:03:27.451" style="s2">can thus be discerned.</p>
<p begin="00:03:27.451" end="00:03:30.118" style="s2">And as we move further cephalad,</p>
<p begin="00:03:33.346" end="00:03:37.513" style="s2">it is possible to view the<br />vertebral artery pulsations.</p>
<p begin="00:03:43.765" end="00:03:44.930" style="s2">And this obviously is a structure</p>
<p begin="00:03:44.930" end="00:03:48.905" style="s2">that would want to be<br />avoided at all costs.</p>
<p begin="00:03:48.905" end="00:03:51.318" style="s2">This concludes the<br />successful anatomical survey</p>
<p begin="00:03:51.318" end="00:03:55.401" style="s2">utilizing ultrasonography<br />of the cervical spine.</p>