<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="00:00:07.292" 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="00:00:07.010" 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>

<p begin="00:00:07.397" end="00:00:09.087" style="s2">- [Voiceover] A linear array transducer</p>
<p begin="00:00:09.087" end="00:00:10.710" style="s2">with a venous exam type</p>
<p begin="00:00:10.710" end="00:00:13.822" style="s2">is used to perform an<br />ultrasound-guided insertion</p>
<p begin="00:00:13.822" end="00:00:17.827" style="s2">of an internal jugular catheter<br />via a transverse approach.</p>
<p begin="00:00:17.827" end="00:00:19.996" style="s2">The patient is in a supine position</p>
<p begin="00:00:19.996" end="00:00:21.420" style="s2">with the head slightly turned</p>
<p begin="00:00:21.420" end="00:00:23.431" style="s2">toward the contralateral side.</p>
<p begin="00:00:23.431" end="00:00:26.331" style="s2">The operator is positioned<br />at the head of the bed.</p>
<p begin="00:00:26.331" end="00:00:28.712" style="s2">The transducer is placed transversely</p>
<p begin="00:00:28.712" end="00:00:29.970" style="s2">just below the apex</p>
<p begin="00:00:29.970" end="00:00:32.663" style="s2">of the sternocleidomastoid<br />muscle triangle,</p>
<p begin="00:00:32.663" end="00:00:35.671" style="s2">with the orientation marker<br />directed to the patient's left</p>
<p begin="00:00:35.671" end="00:00:37.655" style="s2">at a 9:00 position.</p>
<p begin="00:00:37.655" end="00:00:39.098" style="s2">The most superficial structure</p>
<p begin="00:00:39.098" end="00:00:41.086" style="s2">identified in the ultrasound image</p>
<p begin="00:00:41.086" end="00:00:43.548" style="s2">is the sternocleidomastoid muscle.</p>
<p begin="00:00:43.548" end="00:00:46.077" style="s2">Deeper to this, the internal jugular vein</p>
<p begin="00:00:46.077" end="00:00:49.080" style="s2">will appear as a dark<br />anechoic elliptical shape,</p>
<p begin="00:00:49.080" end="00:00:51.990" style="s2">and is compressible with<br />transducer pressure.</p>
<p begin="00:00:51.990" end="00:00:55.354" style="s2">The artery will be circular and pulsatile.</p>
<p begin="00:00:55.354" end="00:00:58.421" style="s2">The thyroid gland lies<br />medial to these structures,</p>
<p begin="00:00:58.421" end="00:01:01.367" style="s2">and has a light gray echo signature.</p>
<p begin="00:01:01.367" end="00:01:03.420" style="s2">Adjust the transducer so it is centered</p>
<p begin="00:01:03.420" end="00:01:05.804" style="s2">over the internal jugular vein.</p>
<p begin="00:01:05.804" end="00:01:08.867" style="s2">Follow the needle entry by<br />slowly sliding the transducer</p>
<p begin="00:01:08.867" end="00:01:11.272" style="s2">in the direction of needle advancement.</p>
<p begin="00:01:11.272" end="00:01:15.230" style="s2">The needle will appear as a<br />small bright hyperechoic dot.</p>
<p begin="00:01:15.230" end="00:01:16.923" style="s2">When the needle tip appears,</p>
<p begin="00:01:16.923" end="00:01:20.067" style="s2">the transducer should be advanced<br />a short distance distally</p>
<p begin="00:01:20.067" end="00:01:22.537" style="s2">to follow the tip of<br />the needle trajectory,</p>
<p begin="00:01:22.537" end="00:01:25.144" style="s2">and stay in advance of the needle entry.</p>
<p begin="00:01:25.144" end="00:01:26.523" style="s2">The needle is slowly advanced</p>
<p begin="00:01:26.523" end="00:01:28.724" style="s2">under direct ultrasound visualization</p>
<p begin="00:01:28.724" end="00:01:30.616" style="s2">until the tip is seen to indent,</p>
<p begin="00:01:30.616" end="00:01:33.391" style="s2">and then puncture the<br />internal jugular vein.</p>
<p begin="00:01:33.391" end="00:01:34.837" style="s2">The transducer should be moved</p>
<p begin="00:01:34.837" end="00:01:36.859" style="s2">slightly proximally and distally</p>
<p begin="00:01:36.859" end="00:01:38.740" style="s2">to confirm that the needle tip lies</p>
<p begin="00:01:38.740" end="00:01:41.990" style="s2">in the mid-portion of the jugular vein.</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>

<p begin="00:00:07.545" end="00:00:09.217" style="s2">- [Voiceover] A linear array transducer</p>
<p begin="00:00:09.217" end="00:00:11.689" style="s2">with a venous exam type is used to perform</p>
<p begin="00:00:11.689" end="00:00:15.584" style="s2">an ultrasound guided insertion<br />of a femoral vein catheter</p>
<p begin="00:00:15.584" end="00:00:17.953" style="s2">via a transverse approach.</p>
<p begin="00:00:17.953" end="00:00:20.153" style="s2">The patient is in a supine position</p>
<p begin="00:00:20.153" end="00:00:22.616" style="s2">with the operator at the right side.</p>
<p begin="00:00:22.616" end="00:00:24.913" style="s2">The transducer is placed transversely,</p>
<p begin="00:00:24.913" end="00:00:27.362" style="s2">just inferior to the inguinal crease</p>
<p begin="00:00:27.362" end="00:00:30.502" style="s2">with the orientation marker<br />directed to the patient's right</p>
<p begin="00:00:30.502" end="00:00:32.815" style="s2">at a 9 o'clock position.</p>
<p begin="00:00:32.815" end="00:00:35.934" style="s2">The superficial femoral<br />artery is seen as a dark</p>
<p begin="00:00:35.934" end="00:00:38.806" style="s2">anechoic pulsatile circular structure</p>
<p begin="00:00:38.806" end="00:00:41.503" style="s2">in the mid portion of<br />the ultrasound image.</p>
<p begin="00:00:41.503" end="00:00:44.022" style="s2">Deeper and slightly to<br />the right of the image,</p>
<p begin="00:00:44.022" end="00:00:45.838" style="s2">the femoral vein will appear as a</p>
<p begin="00:00:45.838" end="00:00:48.119" style="s2">dark anechoic elliptical shape</p>
<p begin="00:00:48.119" end="00:00:51.470" style="s2">that is compressible<br />with transducer pressure.</p>
<p begin="00:00:51.470" end="00:00:53.632" style="s2">Adjust the transducer so it is centered</p>
<p begin="00:00:53.632" end="00:00:57.199" style="s2">over the femoral vein<br />medial to the artery.</p>
<p begin="00:00:57.199" end="00:01:00.510" style="s2">Follow the needle entry by<br />slowly sliding the transducer</p>
<p begin="00:01:00.510" end="00:01:02.902" style="s2">in the direction of needle advancement.</p>
<p begin="00:01:02.902" end="00:01:06.317" style="s2">The needle will appear<br />as a small bright dot.</p>
<p begin="00:01:06.317" end="00:01:07.849" style="s2">When the needle tip appears,</p>
<p begin="00:01:07.849" end="00:01:11.318" style="s2">the transducer should be advanced<br />a short distance distally</p>
<p begin="00:01:11.318" end="00:01:14.038" style="s2">to follow the tip of<br />the needle trajectory.</p>
<p begin="00:01:14.038" end="00:01:15.838" style="s2">The needle is slowly advanced under</p>
<p begin="00:01:15.838" end="00:01:17.990" style="s2">direct ultrasound visualization</p>
<p begin="00:01:17.990" end="00:01:19.837" style="s2">until the tip is seen to indent</p>
<p begin="00:01:19.837" end="00:01:22.070" style="s2">and then puncture the femoral vein.</p>
<p begin="00:01:22.070" end="00:01:24.942" style="s2">The transducer should be<br />moved slightly proximally</p>
<p begin="00:01:24.942" end="00:01:27.510" style="s2">and distally to confirm<br />that the needle tip</p>
<p begin="00:01:27.510" end="00:01:31.177" style="s2">lies in the mid portion<br />of the femoral vein.</p>

<p begin="00:00:07.376" end="00:00:09.578" style="s2">- [Voiceover] A linear array<br />transducer with a nerve</p>
<p begin="00:00:09.578" end="00:00:12.337" style="s2">exam type, is used to<br />perform an ultra sound</p>
<p begin="00:00:12.337" end="00:00:15.428" style="s2">guided axillary regional nerve block.</p>
<p begin="00:00:15.428" end="00:00:17.955" style="s2">The target depth is<br />approximately one to two</p>
<p begin="00:00:17.955" end="00:00:21.374" style="s2">centimeters in an 80 kilogram adult.</p>
<p begin="00:00:21.374" end="00:00:23.840" style="s2">The patient is positioned<br />supine with the arm</p>
<p begin="00:00:23.840" end="00:00:28.657" style="s2">abducted 90 degrees, and<br />the elbow bent 90 degrees.</p>
<p begin="00:00:28.657" end="00:00:32.334" style="s2">The transducer is placed high<br />as possible in the axilla,</p>
<p begin="00:00:32.334" end="00:00:35.847" style="s2">with the orientation marker<br />directed to the patient's head.</p>
<p begin="00:00:35.847" end="00:00:38.894" style="s2">Slowly slide the transducer<br />in a lateral to medial</p>
<p begin="00:00:38.894" end="00:00:42.731" style="s2">direction to identify the axillary artery.</p>
<p begin="00:00:42.731" end="00:00:46.632" style="s2">The axillary artery is a dark,<br />round, pulsitile structure</p>
<p begin="00:00:46.632" end="00:00:48.637" style="s2">with a hyperechoic wall.</p>
<p begin="00:00:48.637" end="00:00:52.303" style="s2">The axilalry veins lie around<br />the periphery of the artery</p>
<p begin="00:00:52.303" end="00:00:54.250" style="s2">and are easily compressed.</p>
<p begin="00:00:54.250" end="00:00:57.051" style="s2">Slide the transducer up<br />the arm to a proximal</p>
<p begin="00:00:57.051" end="00:00:59.521" style="s2">position, so the terrace major muscle,</p>
<p begin="00:00:59.521" end="00:01:01.625" style="s2">which helps control the<br />distribution of local</p>
<p begin="00:01:01.625" end="00:01:04.638" style="s2">anesthetic during<br />injection, is postero-medial</p>
<p begin="00:01:04.638" end="00:01:06.707" style="s2">to the artery and nerves.</p>
<p begin="00:01:06.707" end="00:01:10.199" style="s2">The biceps and coracobrachialis<br />muscles, will appear</p>
<p begin="00:01:10.199" end="00:01:12.011" style="s2">lateral to the artery.</p>
<p begin="00:01:12.011" end="00:01:15.411" style="s2">The median, ulner, and<br />radial nerves appear as</p>
<p begin="00:01:15.411" end="00:01:18.289" style="s2">hyperechoic circles, with<br />a honey comb appearance</p>
<p begin="00:01:18.289" end="00:01:20.013" style="s2">surrounding the artery.</p>
<p begin="00:01:20.013" end="00:01:23.539" style="s2">The nerve positions will<br />vary around the artery.</p>
<p begin="00:01:23.539" end="00:01:26.582" style="s2">The transducer is slowly<br />moved laterally over</p>
<p begin="00:01:26.582" end="00:01:29.902" style="s2">the biceps and corocobrachealis muscles.</p>
<p begin="00:01:29.902" end="00:01:32.847" style="s2">The musculocutaneous<br />nerve can be seen between</p>
<p begin="00:01:32.847" end="00:01:36.500" style="s2">these muscles as a small,<br />bright, hyperechoic circle</p>
<p begin="00:01:36.500" end="00:01:38.241" style="s2">or triangle.</p>
<p begin="00:01:38.241" end="00:01:40.923" style="s2">The needle is positioned<br />one to two centimeters</p>
<p begin="00:01:40.923" end="00:01:43.840" style="s2">lateral to the transducer,<br />and advanced using</p>
<p begin="00:01:43.840" end="00:01:45.654" style="s2">an in plane technique.</p>
<p begin="00:01:45.654" end="00:01:48.947" style="s2">The needle path is directed<br />through the biceps muscle,</p>
<p begin="00:01:48.947" end="00:01:51.381" style="s2">toward the musculocutaneous nerve.</p>
<p begin="00:01:51.381" end="00:01:53.924" style="s2">The initial end point for<br />the needle is immediately</p>
<p begin="00:01:53.924" end="00:01:56.682" style="s2">beside the musculocutaneous<br />nerve, where three</p>
<p begin="00:01:56.682" end="00:02:00.299" style="s2">to five CCs of anesthetic<br />should be injected.</p>
<p begin="00:02:00.299" end="00:02:03.252" style="s2">The needle is then advanced<br />to a position immediately</p>
<p begin="00:02:03.252" end="00:02:05.392" style="s2">post-terior to the artery.</p>
<p begin="00:02:05.392" end="00:02:08.968" style="s2">As local anesthetic is<br />injected, the terrace muscle</p>
<p begin="00:02:08.968" end="00:02:11.648" style="s2">is pushed down, and the<br />local anesthetic should</p>
<p begin="00:02:11.648" end="00:02:15.567" style="s2">spread medial and lateral<br />underneath the artery.</p>
<p begin="00:02:15.567" end="00:02:18.450" style="s2">The needle can be advanced<br />through hydrodisection</p>
<p begin="00:02:18.450" end="00:02:21.830" style="s2">to facilitate appropriate<br />spread of local anesthetic.</p>
<p begin="00:02:21.830" end="00:02:25.513" style="s2">Finally, the needle is withdrawn<br />and redirected anterior</p>
<p begin="00:02:25.513" end="00:02:27.297" style="s2">to the artery.</p>
<p begin="00:02:27.297" end="00:02:29.918" style="s2">Local anesthetic should be<br />injected over the artery</p>
<p begin="00:02:29.918" end="00:02:33.249" style="s2">to finish with a circumferential<br />spread of local anesthetic</p>
<p begin="00:02:33.249" end="00:02:34.749" style="s2">around the artery.</p>

<p begin="00:00:07.204" end="00:00:08.813" style="s2">- [Voiceover] A linear array transducer</p>
<p begin="00:00:08.813" end="00:00:11.101" style="s2">with a superficial venous exam type</p>
<p begin="00:00:11.101" end="00:00:13.364" style="s2">is used to perform an ultrasound guided</p>
<p begin="00:00:13.364" end="00:00:15.289" style="s2">drainage of an abscess.</p>
<p begin="00:00:15.289" end="00:00:18.603" style="s2">The transducer is placed<br />in a longitudinal direction</p>
<p begin="00:00:18.603" end="00:00:21.380" style="s2">over the area of tenderness or fluctuance,</p>
<p begin="00:00:21.380" end="00:00:23.098" style="s2">with the orientation marker directed</p>
<p begin="00:00:23.098" end="00:00:24.780" style="s2">toward the patient's head.</p>
<p begin="00:00:24.780" end="00:00:27.090" style="s2">It is helpful to have a<br />generous amount of gel</p>
<p begin="00:00:27.090" end="00:00:30.651" style="s2">on the transducer face, to<br />decrease transducer pressure</p>
<p begin="00:00:30.651" end="00:00:33.171" style="s2">and pain with the examination.</p>
<p begin="00:00:33.171" end="00:00:35.625" style="s2">The depth and extent of the abscess cavity</p>
<p begin="00:00:35.625" end="00:00:37.445" style="s2">is determined by scanning the cavity</p>
<p begin="00:00:37.445" end="00:00:39.281" style="s2">in a left-to-right direction.</p>
<p begin="00:00:39.281" end="00:00:42.033" style="s2">Septation of the abscess<br />cavity should be determined</p>
<p begin="00:00:42.033" end="00:00:43.879" style="s2">as it is important to free these areas</p>
<p begin="00:00:43.879" end="00:00:46.948" style="s2">during the drainage procedure<br />for optimal results.</p>
<p begin="00:00:46.948" end="00:00:50.132" style="s2">The superior and inferior<br />extent of the abscess cavity</p>
<p begin="00:00:50.132" end="00:00:52.593" style="s2">can be determined by moving the transducer</p>
<p begin="00:00:52.593" end="00:00:55.357" style="s2">in a superior to inferior direction.</p>
<p begin="00:00:55.357" end="00:00:57.394" style="s2">The drainage incision should be planned</p>
<p begin="00:00:57.394" end="00:01:00.730" style="s2">at an area where the abscess<br />cavity is most superficial</p>
<p begin="00:01:00.730" end="00:01:04.147" style="s2">and likely to promote dependent drainage.</p>

<p begin="00:00:02.881" end="00:00:04.710" style="s2">- Soon as we turn on the function of the</p>
<p begin="00:00:04.710" end="00:00:09.042" style="s2">advanced neo visualization, the<br />image quality stays the same</p>
<p begin="00:00:09.042" end="00:00:13.209" style="s2">and we just see greater echos<br />when we insert the needle.</p>
<p begin="00:00:19.386" end="00:00:21.172" style="s2">So I haven't noted any decrement to the</p>
<p begin="00:00:21.172" end="00:00:23.864" style="s2">image resolution and quality.</p>
<p begin="00:00:23.864" end="00:00:26.957" style="s2">In my practice it's really<br />added increased speed.</p>
<p begin="00:00:26.957" end="00:00:30.492" style="s2">I'm getting to the target<br />more directly with less time.</p>
<p begin="00:00:30.492" end="00:00:33.267" style="s2">Getting in and out, which<br />always makes the patient happier</p>
<p begin="00:00:33.267" end="00:00:35.589" style="s2">and certainly it reduces<br />the amount of pain</p>
<p begin="00:00:35.589" end="00:00:38.063" style="s2">that might be involved in a procedure.</p>
<p begin="00:00:38.063" end="00:00:40.614" style="s2">- So the ability to see the<br />needle going through tissue</p>
<p begin="00:00:40.614" end="00:00:43.197" style="s2">makes their clinical procedures safer,</p>
<p begin="00:00:43.197" end="00:00:46.169" style="s2">makes it faster, obviously<br />better for the patient.</p>
<p begin="00:00:46.169" end="00:00:49.649" style="s2">- It appears maybe two,<br />three, four times brighter.</p>
<p begin="00:00:49.649" end="00:00:52.315" style="s2">Seems to have a better echo<br />during the entire procedure.</p>
<p begin="00:00:52.315" end="00:00:55.471" style="s2">- Basically, the enhanced<br />visualization technology</p>
<p begin="00:00:55.471" end="00:00:58.939" style="s2">is a softer grade, and<br />it's very easy to use.</p>
<p begin="00:00:58.939" end="00:01:01.561" style="s2">There's no extra equipment<br />or specialty needles</p>
<p begin="00:01:01.561" end="00:01:04.168" style="s2">that have to be part of the procedure.</p>
<p begin="00:01:04.168" end="00:01:06.587" style="s2">Hard to close, it works<br />with any needle out there,</p>
<p begin="00:01:06.587" end="00:01:09.099" style="s2">and it's basically available<br />at the push of a button.</p>
<p begin="00:01:09.099" end="00:01:11.309" style="s2">- The beauty of it is that<br />there really is no setup time.</p>
<p begin="00:01:11.309" end="00:01:12.997" style="s2">It actually speeds up the procedure</p>
<p begin="00:01:12.997" end="00:01:14.621" style="s2">'cause it's easier to see the needle.</p>
<p begin="00:01:14.621" end="00:01:17.660" style="s2">So if anything it's a<br />time saving technique.</p>
<p begin="00:01:17.660" end="00:01:20.502" style="s2">I think it really can enhance learning</p>
<p begin="00:01:20.502" end="00:01:23.453" style="s2">and becoming competent<br />in performing aspirations</p>
<p begin="00:01:23.453" end="00:01:24.979" style="s2">and biopsies and a variety of different</p>
<p begin="00:01:24.979" end="00:01:26.977" style="s2">needle localization techniques</p>
<p begin="00:01:26.977" end="00:01:29.690" style="s2">in a much quicker, safer fashion.</p>
<p begin="00:01:29.690" end="00:01:31.370" style="s2">- There's really no<br />other competitor that has</p>
<p begin="00:01:31.370" end="00:01:33.840" style="s2">anything quite like what we're doing.</p>
<p begin="00:01:33.840" end="00:01:35.199" style="s2">There's a few technologies out there</p>
<p begin="00:01:35.199" end="00:01:37.569" style="s2">that try to help see the needle tip.</p>
<p begin="00:01:37.569" end="00:01:39.070" style="s2">The bigger issue I see with those</p>
<p begin="00:01:39.070" end="00:01:41.149" style="s2">is that they take a long time to set up,</p>
<p begin="00:01:41.149" end="00:01:42.569" style="s2">and they're also expensive.</p>
<p begin="00:01:42.569" end="00:01:44.094" style="s2">There's hardware involved.</p>
<p begin="00:01:44.094" end="00:01:46.232" style="s2">This was a proprietary software algorithm</p>
<p begin="00:01:46.232" end="00:01:49.735" style="s2">that we can upgrade any turbo<br />or S system on the market.</p>
<p begin="00:01:49.735" end="00:01:51.977" style="s2">- You get all the visualization<br />that you really need</p>
<p begin="00:01:51.977" end="00:01:53.971" style="s2">and you don't need to<br />use any special needles,</p>
<p begin="00:01:53.971" end="00:01:56.041" style="s2">you don't need to use a larger needle.</p>
<p begin="00:01:56.041" end="00:01:57.848" style="s2">The larger the caliber of the needle,</p>
<p begin="00:01:57.848" end="00:02:00.593" style="s2">the more painful and the more<br />potential for complications</p>
<p begin="00:02:00.593" end="00:02:04.488" style="s2">so I get great visualization<br />with a 25 gauge needle.</p>
<p begin="00:02:04.488" end="00:02:07.485" style="s2">- The reason we're excited<br />is because now we can</p>
<p begin="00:02:07.485" end="00:02:10.264" style="s2">for the first time say<br />that stick needle angles</p>
<p begin="00:02:10.264" end="00:02:13.201" style="s2">are no longer a problem<br />for ultrasound imaging.</p>
<p begin="00:02:13.201" end="00:02:14.587" style="s2">- I think it's one of our biggest</p>
<p begin="00:02:14.587" end="00:02:16.362" style="s2">breakthroughs in a long time,</p>
<p begin="00:02:16.362" end="00:02:17.843" style="s2">and again it meets the criteria.</p>
<p begin="00:02:17.843" end="00:02:19.925" style="s2">It addresses a real<br />problem that our customers</p>
<p begin="00:02:19.925" end="00:02:22.706" style="s2">and our clinicians are<br />dealing with every day.</p>
<p begin="00:02:22.706" end="00:02:26.026" style="s2">It's inexpensive, it's<br />simple, and it works.</p>
<p begin="00:02:26.026" end="00:02:28.350" style="s2">- It is a game changer in the market</p>
<p begin="00:02:28.350" end="00:02:31.017" style="s2">of ultrasound guided procedures.</p>
<p begin="00:02:31.886" end="00:02:34.553" style="s2">It's the speed, the ease of use,</p>
<p begin="00:02:35.700" end="00:02:39.602" style="s2">the reduction of time to<br />completion of the procedure,</p>
<p begin="00:02:39.602" end="00:02:42.084" style="s2">the safety features, all of those are</p>
<p begin="00:02:42.084" end="00:02:46.167" style="s2">a win-win situation for<br />doctor and patient alike.</p>