<p begin="00:00:15.760" end="00:00:16.929" style="s2">- Classically, it's been thought</p>
<p begin="00:00:16.929" end="00:00:18.876" style="s2">that the lung cannot be ultrasounded.</p>
<p begin="00:00:18.876" end="00:00:20.125" style="s2">In fact, that's not true.</p>
<p begin="00:00:20.125" end="00:00:22.426" style="s2">We can use ultrasound very easily</p>
<p begin="00:00:22.426" end="00:00:23.976" style="s2">to rule out a pneumothorax.</p>
<p begin="00:00:23.976" end="00:00:26.864" style="s2">I'm gonna show you, using<br />two different transducers,</p>
<p begin="00:00:26.864" end="00:00:30.038" style="s2">how we can see the lung pleural line</p>
<p begin="00:00:30.038" end="00:00:33.602" style="s2">to exclude the presence of a pneumothorax.</p>
<p begin="00:00:33.602" end="00:00:36.392" style="s2">We're gonna start with our transducers.</p>
<p begin="00:00:36.392" end="00:00:38.271" style="s2">We have two different<br />choices of transducers.</p>
<p begin="00:00:38.271" end="00:00:40.046" style="s2">We have our phased array transducer</p>
<p begin="00:00:40.046" end="00:00:41.883" style="s2">and a linear array transducer.</p>
<p begin="00:00:41.883" end="00:00:43.819" style="s2">If you're doing this as<br />part of the fast exam,</p>
<p begin="00:00:43.819" end="00:00:45.618" style="s2">most likely you've already have</p>
<p begin="00:00:45.618" end="00:00:47.784" style="s2">a phased array transducer in your hand.</p>
<p begin="00:00:47.784" end="00:00:48.718" style="s2">Therefore, I'm gonna go ahead</p>
<p begin="00:00:48.718" end="00:00:50.871" style="s2">and show you what the images look like</p>
<p begin="00:00:50.871" end="00:00:53.538" style="s2">using a phased array transducer.</p>
<p begin="00:00:55.725" end="00:00:57.638" style="s2">The exam type has already been set up</p>
<p begin="00:00:57.638" end="00:00:59.566" style="s2">in an abdominal preset,</p>
<p begin="00:00:59.566" end="00:01:01.906" style="s2">and so we're ready to start scanning.</p>
<p begin="00:01:01.906" end="00:01:03.571" style="s2">Now the area that we're gonna scan</p>
<p begin="00:01:03.571" end="00:01:06.932" style="s2">is an area where we're<br />gonna expect air to collect</p>
<p begin="00:01:06.932" end="00:01:08.677" style="s2">in the presence of a pneumothorax.</p>
<p begin="00:01:08.677" end="00:01:12.052" style="s2">That would be the most<br />anterior aspect of the lung.</p>
<p begin="00:01:12.052" end="00:01:14.107" style="s2">So if you look at our model right here,</p>
<p begin="00:01:14.107" end="00:01:17.519" style="s2">we would expect air to collect more likely</p>
<p begin="00:01:17.519" end="00:01:20.588" style="s2">in the anterior surface<br />than more posteriorly.</p>
<p begin="00:01:20.588" end="00:01:22.616" style="s2">Therefore, when I do my scanning,</p>
<p begin="00:01:22.616" end="00:01:25.240" style="s2">I'm gonna scan about mid-clavicular line</p>
<p begin="00:01:25.240" end="00:01:29.419" style="s2">at the most anterior area<br />of the patient's body.</p>
<p begin="00:01:29.419" end="00:01:30.911" style="s2">So we're gonna go ahead<br />and start scanning.</p>
<p begin="00:01:30.911" end="00:01:34.225" style="s2">Here's our probe marker right here.</p>
<p begin="00:01:34.225" end="00:01:36.239" style="s2">We're gonna aim that<br />toward the patient's head,</p>
<p begin="00:01:36.239" end="00:01:40.095" style="s2">and I'm scanning right<br />now in a sagittal fashion.</p>
<p begin="00:01:40.095" end="00:01:42.403" style="s2">I'm gonna turn my gain up a little bit,</p>
<p begin="00:01:42.403" end="00:01:44.084" style="s2">and first thing you're gonna recognize</p>
<p begin="00:01:44.084" end="00:01:46.148" style="s2">that our depth is too deep.</p>
<p begin="00:01:46.148" end="00:01:49.043" style="s2">Remember, what we're scanning<br />now is really superficial.</p>
<p begin="00:01:49.043" end="00:01:50.784" style="s2">We're looking at the lung's surface.</p>
<p begin="00:01:50.784" end="00:01:52.728" style="s2">So I'm gonna decrease our depth</p>
<p begin="00:01:52.728" end="00:01:55.742" style="s2">so we can see the lung<br />surface quite easily.</p>
<p begin="00:01:55.742" end="00:01:58.562" style="s2">Now what we're looking<br />at here on the screen</p>
<p begin="00:01:58.562" end="00:02:00.794" style="s2">is a classic shimmering line</p>
<p begin="00:02:00.794" end="00:02:03.904" style="s2">that you see with the pleural surface,</p>
<p begin="00:02:03.904" end="00:02:07.465" style="s2">that being the parietal and<br />the visceral pleural surface</p>
<p begin="00:02:07.465" end="00:02:08.954" style="s2">rubbing against each other.</p>
<p begin="00:02:08.954" end="00:02:11.407" style="s2">So we see a rib here on the left.</p>
<p begin="00:02:11.407" end="00:02:13.756" style="s2">We see another rib to the right.</p>
<p begin="00:02:13.756" end="00:02:16.687" style="s2">And in the center is a<br />line which is horizontal,</p>
<p begin="00:02:16.687" end="00:02:18.021" style="s2">and we see shimmering.</p>
<p begin="00:02:18.021" end="00:02:20.332" style="s2">That presence of that shimmering,</p>
<p begin="00:02:20.332" end="00:02:22.422" style="s2">as well as very small, tiny comet tails</p>
<p begin="00:02:22.422" end="00:02:25.173" style="s2">that are coming from the<br />posterior aspect of that,</p>
<p begin="00:02:25.173" end="00:02:28.506" style="s2">excludes the presence of a pneumothorax.</p>
<p begin="00:02:29.398" end="00:02:30.252" style="s2">If you have time,</p>
<p begin="00:02:30.252" end="00:02:32.436" style="s2">you want to use your<br />linear array transducer.</p>
<p begin="00:02:32.436" end="00:02:34.980" style="s2">This transducer does<br />high-frequency imaging,</p>
<p begin="00:02:34.980" end="00:02:37.225" style="s2">allows you to do much better imaging</p>
<p begin="00:02:37.225" end="00:02:38.536" style="s2">of superficial structures.</p>
<p begin="00:02:38.536" end="00:02:41.001" style="s2">So we're gonna get a lot better quality,</p>
<p begin="00:02:41.001" end="00:02:44.450" style="s2">high-resolution pictures,<br />of the pleural line.</p>
<p begin="00:02:44.450" end="00:02:46.634" style="s2">So here's our transducer that I've chosen.</p>
<p begin="00:02:46.634" end="00:02:48.786" style="s2">This is the marker here right now.</p>
<p begin="00:02:48.786" end="00:02:52.900" style="s2">And I'm gonna go ahead<br />and put a little gel here.</p>
<p begin="00:02:52.900" end="00:02:54.715" style="s2">Now I'm gonna cut sagittally</p>
<p begin="00:02:54.715" end="00:02:56.885" style="s2">at the highest point in his chest,</p>
<p begin="00:02:56.885" end="00:02:59.813" style="s2">in about the mid-clavicular line,</p>
<p begin="00:02:59.813" end="00:03:02.071" style="s2">and I notice to the left of the screen</p>
<p begin="00:03:02.071" end="00:03:03.738" style="s2">is a rib right here,</p>
<p begin="00:03:04.596" end="00:03:06.966" style="s2">and we see another rib right here.</p>
<p begin="00:03:06.966" end="00:03:09.559" style="s2">And in between the two,<br />we see the pleural line.</p>
<p begin="00:03:09.559" end="00:03:12.638" style="s2">And as he takes a breath,<br />we see shimmering.</p>
<p begin="00:03:12.638" end="00:03:14.714" style="s2">These are the two surfaces of the lung,</p>
<p begin="00:03:14.714" end="00:03:17.300" style="s2">the visceral surface and<br />the parietal surface,</p>
<p begin="00:03:17.300" end="00:03:18.468" style="s2">rubbing together.</p>
<p begin="00:03:18.468" end="00:03:20.682" style="s2">We also see little tiny white lines,</p>
<p begin="00:03:20.682" end="00:03:22.258" style="s2">your little comet tail lines,</p>
<p begin="00:03:22.258" end="00:03:25.725" style="s2">which also show that both<br />surfaces are touching together.</p>
<p begin="00:03:25.725" end="00:03:27.855" style="s2">If you see this pattern,</p>
<p begin="00:03:27.855" end="00:03:30.808" style="s2">you have reliably excluded a pneumothorax.</p>
<p begin="00:03:30.808" end="00:03:32.319" style="s2">You can see in this model</p>
<p begin="00:03:32.319" end="00:03:36.681" style="s2">that we can easily see<br />the rib here anteriorly</p>
<p begin="00:03:36.681" end="00:03:38.906" style="s2">and another one more inferiorly,</p>
<p begin="00:03:38.906" end="00:03:41.372" style="s2">and we see the pleural line<br />easily here in the middle,</p>
<p begin="00:03:41.372" end="00:03:42.361" style="s2">we see shimmering.</p>
<p begin="00:03:42.361" end="00:03:46.086" style="s2">Now you may want to document<br />this in a still pattern.</p>
<p begin="00:03:46.086" end="00:03:49.955" style="s2">That is very easy to do by<br />just activating the M-mode.</p>
<p begin="00:03:49.955" end="00:03:52.743" style="s2">We hit the M-mode key here.</p>
<p begin="00:03:52.743" end="00:03:55.276" style="s2">And we put the M-mode marker</p>
<p begin="00:03:55.276" end="00:03:57.194" style="s2">through the center of the pleural line</p>
<p begin="00:03:57.194" end="00:04:00.960" style="s2">where we see shimmering,<br />and with M-mode again.</p>
<p begin="00:04:00.960" end="00:04:03.313" style="s2">And what we see now is a pattern</p>
<p begin="00:04:03.313" end="00:04:05.663" style="s2">that's called the seashore sign.</p>
<p begin="00:04:05.663" end="00:04:07.449" style="s2">And I'm gonna freeze this.</p>
<p begin="00:04:07.449" end="00:04:09.113" style="s2">So now we have a frozen image</p>
<p begin="00:04:09.113" end="00:04:11.697" style="s2">of the M-mode through the pleural line,</p>
<p begin="00:04:11.697" end="00:04:14.209" style="s2">and we see the shimmering line here,</p>
<p begin="00:04:14.209" end="00:04:17.364" style="s2">and we see here a classic seashore sign.</p>
<p begin="00:04:17.364" end="00:04:18.749" style="s2">And when you see this,</p>
<p begin="00:04:18.749" end="00:04:22.916" style="s2">this is still documentation of<br />exclusion of a pneumothorax.</p>
<p begin="00:04:23.896" end="00:04:25.888" style="s2">If you do your exam in<br />the mid-clavicular line</p>
<p begin="00:04:25.888" end="00:04:28.912" style="s2">at the most anterior portion of the chest,</p>
<p begin="00:04:28.912" end="00:04:30.731" style="s2">and you see a good shimmering line,</p>
<p begin="00:04:30.731" end="00:04:32.663" style="s2">then you've ruled out a pneumothorax.</p>
<p begin="00:04:32.663" end="00:04:34.641" style="s2">If you don't see any shimmering line,</p>
<p begin="00:04:34.641" end="00:04:36.313" style="s2">then you most likely are dealing</p>
<p begin="00:04:36.313" end="00:04:37.976" style="s2">with a patient with a pneumothorax.</p>
<p begin="00:04:37.976" end="00:04:39.687" style="s2">You can then take your transducer</p>
<p begin="00:04:39.687" end="00:04:42.810" style="s2">and move it to the patient's<br />left or to his right</p>
<p begin="00:04:42.810" end="00:04:44.667" style="s2">or in more superior and inferior</p>
<p begin="00:04:44.667" end="00:04:47.783" style="s2">to get a qualitative<br />size of the pneumothorax</p>
<p begin="00:04:47.783" end="00:04:49.450" style="s2">you're dealing with.</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="00:00:07.010" end="00:00:09.026" style="s2">- [Voiceover] A linear array transducer</p>
<p begin="00:00:09.026" end="00:00:11.485" style="s2">with a venous exam<br />type, is used to perform</p>
<p begin="00:00:11.485" end="00:00:14.424" style="s2">an ultrasound guided<br />insertion of a subclavian</p>
<p begin="00:00:14.424" end="00:00:17.250" style="s2">vein catheter via an transverse approach.</p>
<p begin="00:00:17.250" end="00:00:19.487" style="s2">The patient is in a supine position</p>
<p begin="00:00:19.487" end="00:00:21.144" style="s2">with the head neutral.</p>
<p begin="00:00:21.144" end="00:00:24.198" style="s2">The operator should stand<br />to the patient's right side.</p>
<p begin="00:00:24.198" end="00:00:26.531" style="s2">The transducer is placed transversely</p>
<p begin="00:00:26.531" end="00:00:29.380" style="s2">just inferior to the mid<br />portion of the clavicle,</p>
<p begin="00:00:29.380" end="00:00:31.338" style="s2">with the orientation marker directed</p>
<p begin="00:00:31.338" end="00:00:34.428" style="s2">to the patient's head at<br />a 12 o'clock position.</p>
<p begin="00:00:34.428" end="00:00:36.407" style="s2">The hyperechoic clavicle can be seen</p>
<p begin="00:00:36.407" end="00:00:39.304" style="s2">in the superior portion<br />of the ultrasound image.</p>
<p begin="00:00:39.304" end="00:00:41.387" style="s2">The vein is dark, and anechoic,</p>
<p begin="00:00:41.387" end="00:00:43.977" style="s2">just inferior and deep to the clavicle.</p>
<p begin="00:00:43.977" end="00:00:47.219" style="s2">The transducer should be<br />slowly moved one to two inches</p>
<p begin="00:00:47.219" end="00:00:49.877" style="s2">toward the shoulder, with<br />the face of the transducer</p>
<p begin="00:00:49.877" end="00:00:52.685" style="s2">staying below the clavicle<br />to obtain the best view</p>
<p begin="00:00:52.685" end="00:00:55.397" style="s2">of the subclavian or axillary vein.</p>
<p begin="00:00:55.397" end="00:00:58.063" style="s2">It is important to note<br />that the lung lies directly</p>
<p begin="00:00:58.063" end="00:00:59.861" style="s2">posterior to the vessel.</p>
<p begin="00:00:59.861" end="00:01:02.691" style="s2">So, posterior wall puncture<br />of the axillary vein</p>
<p begin="00:01:02.691" end="00:01:04.214" style="s2">should be avoided.</p>
<p begin="00:01:04.214" end="00:01:07.472" style="s2">Adjust the transducer so it<br />is centered over the vein.</p>
<p begin="00:01:07.472" end="00:01:10.469" style="s2">Follow the needle entry by<br />slowly sliding the transducer</p>
<p begin="00:01:10.469" end="00:01:12.943" style="s2">in the direction of needle advancement.</p>
<p begin="00:01:12.943" end="00:01:16.832" style="s2">The needle will appear as a<br />small, bright, hyperechoic dot.</p>
<p begin="00:01:16.832" end="00:01:19.415" style="s2">When the needle tip<br />appears, the transducer</p>
<p begin="00:01:19.415" end="00:01:21.964" style="s2">should be advanced a<br />short distance distally</p>
<p begin="00:01:21.964" end="00:01:24.265" style="s2">to follow the tip of<br />the needle trajectory,</p>
<p begin="00:01:24.265" end="00:01:26.819" style="s2">and stay in advance of the needle entry.</p>
<p begin="00:01:26.819" end="00:01:28.455" style="s2">The needle is slowly advanced</p>
<p begin="00:01:28.455" end="00:01:30.590" style="s2">under direct ultrasound visualization</p>
<p begin="00:01:30.590" end="00:01:34.266" style="s2">until the tip is seen to<br />puncture the subclavian vein.</p>
<p begin="00:01:34.266" end="00:01:37.399" style="s2">The probe should be moved<br />slightly proximally and distally</p>
<p begin="00:01:37.399" end="00:01:39.357" style="s2">to confirm that the needle tip lies</p>
<p begin="00:01:39.357" end="00:01:41.940" style="s2">in the mid portion of the vein.</p>