<p begin="00:00:17.902" end="00:00:20.298" style="s2">- Hello, my name is Phil<br />Perera and I'm the Emergency</p>
<p begin="00:00:20.298" end="00:00:23.075" style="s2">Ultrasound Coordinator at the<br />New York Presbyterian Hospital</p>
<p begin="00:00:23.075" end="00:00:27.889" style="s2">in New York City and<br />welcome to SoundBytes Cases.</p>
<p begin="00:00:27.889" end="00:00:29.652" style="s2">- [Voiceover] In this module<br />we're going to focus on</p>
<p begin="00:00:29.652" end="00:00:32.473" style="s2">genitourinary ultrasound.</p>
<p begin="00:00:32.473" end="00:00:34.721" style="s2">So, what are the goals<br />of bedside GU ultrasound</p>
<p begin="00:00:34.721" end="00:00:36.312" style="s2">for the emergency physician?</p>
<p begin="00:00:36.312" end="00:00:38.388" style="s2">Well, first of all, we're<br />going to inspect closely</p>
<p begin="00:00:38.388" end="00:00:41.259" style="s2">the kidney looking for hydronephrosis.</p>
<p begin="00:00:41.259" end="00:00:44.042" style="s2">We may also be able to see<br />kidney stones as stones lodge</p>
<p begin="00:00:44.042" end="00:00:46.162" style="s2">within parenchyma of the kidney</p>
<p begin="00:00:46.162" end="00:00:48.423" style="s2">or at the uretero-pelvic junction.</p>
<p begin="00:00:48.423" end="00:00:50.927" style="s2">We should also include<br />imaging of the bladder</p>
<p begin="00:00:50.927" end="00:00:54.354" style="s2">with our GU ultrasound and we<br />can look for bladder stones,</p>
<p begin="00:00:54.354" end="00:00:55.959" style="s2">stones that have migrated from the kidney</p>
<p begin="00:00:55.959" end="00:01:00.340" style="s2">down to the UVJ and also<br />get a sense of bladder size.</p>
<p begin="00:01:00.340" end="00:01:02.704" style="s2">Hopefully through this<br />module we can look at bedside</p>
<p begin="00:01:02.704" end="00:01:06.177" style="s2">ultrasound as an alternative,<br />non-CAT scan based strategy,</p>
<p begin="00:01:06.177" end="00:01:08.950" style="s2">for the management of<br />uncomplicated kidney stones</p>
<p begin="00:01:08.950" end="00:01:12.862" style="s2">without the associated dose of radiation.</p>
<p begin="00:01:12.862" end="00:01:14.816" style="s2">Let's now review how to perform</p>
<p begin="00:01:14.816" end="00:01:17.182" style="s2">the renal ultrasound examination.</p>
<p begin="00:01:17.182" end="00:01:19.425" style="s2">As shown in the pictorial to the right,</p>
<p begin="00:01:19.425" end="00:01:22.081" style="s2">we want to come in with a probe<br />in a long axis configuration</p>
<p begin="00:01:22.081" end="00:01:24.974" style="s2">with a marker dot superior<br />towards the patient's head.</p>
<p begin="00:01:24.974" end="00:01:27.185" style="s2">It's good to use a smaller<br />footprint probe that can</p>
<p begin="00:01:27.185" end="00:01:29.351" style="s2">easily sit between the ribs.</p>
<p begin="00:01:29.351" end="00:01:31.594" style="s2">For the left kidney scan,<br />we're going to come in</p>
<p begin="00:01:31.594" end="00:01:34.451" style="s2">from a more posterior<br />position as the spleen offers</p>
<p begin="00:01:34.451" end="00:01:37.303" style="s2">less of an acoustic window onto the kidney</p>
<p begin="00:01:37.303" end="00:01:39.436" style="s2">than on the right side<br />where we have the liver,</p>
<p begin="00:01:39.436" end="00:01:42.567" style="s2">which offers a great acoustic<br />window onto the kidney.</p>
<p begin="00:01:42.567" end="00:01:44.937" style="s2">For the left side we want to<br />put the patient in the right</p>
<p begin="00:01:44.937" end="00:01:47.922" style="s2">lateral decubitus position<br />with the left side up</p>
<p begin="00:01:47.922" end="00:01:49.835" style="s2">so we can come in from<br />that posterior position</p>
<p begin="00:01:49.835" end="00:01:51.342" style="s2">and image the kidney.</p>
<p begin="00:01:51.342" end="00:01:53.672" style="s2">On the right side, we can<br />come in from a little bit more</p>
<p begin="00:01:53.672" end="00:01:56.001" style="s2">anterior using the liver<br />as our acoustic window</p>
<p begin="00:01:56.001" end="00:01:57.550" style="s2">onto the kidney.</p>
<p begin="00:01:57.550" end="00:01:59.635" style="s2">But it's also a good idea to<br />put the patient in the left</p>
<p begin="00:01:59.635" end="00:02:02.246" style="s2">lateral decubitus position<br />with the right side up</p>
<p begin="00:02:02.246" end="00:02:04.573" style="s2">so that we can angle the<br />probe and get good views</p>
<p begin="00:02:04.573" end="00:02:07.226" style="s2">of the kidney from the right side.</p>
<p begin="00:02:07.226" end="00:02:09.474" style="s2">Here's an illustration of<br />the kidney that's important</p>
<p begin="00:02:09.474" end="00:02:11.925" style="s2">for bedside ultrasound of this structure.</p>
<p begin="00:02:11.925" end="00:02:14.825" style="s2">Recall the outer area of<br />the kidney, the cortex,</p>
<p begin="00:02:14.825" end="00:02:18.572" style="s2">and interior to the outer<br />cortex we see the medulla.</p>
<p begin="00:02:18.572" end="00:02:21.474" style="s2">Notice several renal pyramids<br />located within the medullary</p>
<p begin="00:02:21.474" end="00:02:24.744" style="s2">area, and recall that the<br />loops of Henle are going to be</p>
<p begin="00:02:24.744" end="00:02:27.773" style="s2">oriented inside the renal pyramids.</p>
<p begin="00:02:27.773" end="00:02:30.177" style="s2">Now the renal pyramids<br />will be filtering the blood</p>
<p begin="00:02:30.177" end="00:02:33.087" style="s2">and producing urine which will<br />flow into the calyceal area</p>
<p begin="00:02:33.087" end="00:02:34.963" style="s2">interior of the kidney.</p>
<p begin="00:02:34.963" end="00:02:38.319" style="s2">We can see here that the<br />small areas of the calyces</p>
<p begin="00:02:38.319" end="00:02:41.085" style="s2">come together to make the renal pelvis.</p>
<p begin="00:02:41.085" end="00:02:43.530" style="s2">Now the renal pelvis, in<br />turn, will continue on</p>
<p begin="00:02:43.530" end="00:02:47.508" style="s2">as the ureter inferiorly into the bladder.</p>
<p begin="00:02:47.508" end="00:02:50.286" style="s2">Now a classic appearance of<br />the interior of the kidney</p>
<p begin="00:02:50.286" end="00:02:52.706" style="s2">is that it has a bright<br />or hyperechoic appearance</p>
<p begin="00:02:52.706" end="00:02:54.381" style="s2">on bedside sonography.</p>
<p begin="00:02:54.381" end="00:02:56.464" style="s2">And this is because of<br />the abundance of fat</p>
<p begin="00:02:56.464" end="00:02:59.053" style="s2">within the renal sinuses.</p>
<p begin="00:02:59.053" end="00:03:02.242" style="s2">Here's a typical normal<br />kidney on bedside ultrasound.</p>
<p begin="00:03:02.242" end="00:03:04.706" style="s2">I have the probe marker oriented<br />towards the patient's head</p>
<p begin="00:03:04.706" end="00:03:07.152" style="s2">so superior pole of the<br />kidney is to the left,</p>
<p begin="00:03:07.152" end="00:03:08.827" style="s2">inferior to the right.</p>
<p begin="00:03:08.827" end="00:03:12.294" style="s2">We see the outer cortex,<br />that outer rim of kidney to</p>
<p begin="00:03:12.294" end="00:03:13.642" style="s2">the peripheral aspect.</p>
<p begin="00:03:13.642" end="00:03:16.171" style="s2">And we see just interior to the cortex,</p>
<p begin="00:03:16.171" end="00:03:17.881" style="s2">the medullary pyramids.</p>
<p begin="00:03:17.881" end="00:03:19.555" style="s2">Notice that they have a<br />little bit of a darker,</p>
<p begin="00:03:19.555" end="00:03:22.203" style="s2">or hypoechoic, signature<br />due to the presence of fluid</p>
<p begin="00:03:22.203" end="00:03:24.590" style="s2">within the medullary pyramids.</p>
<p begin="00:03:24.590" end="00:03:28.153" style="s2">We see the inner part of the<br />kidney, the calyceal region,</p>
<p begin="00:03:28.153" end="00:03:29.794" style="s2">and notice that it has<br />a hyperechoic, or bright</p>
<p begin="00:03:29.794" end="00:03:31.742" style="s2">appearance on bedside sonography,</p>
<p begin="00:03:31.742" end="00:03:35.498" style="s2">due to fat within the renal sinuses.</p>
<p begin="00:03:35.498" end="00:03:38.275" style="s2">Now let's take look at a<br />picture showing the grading</p>
<p begin="00:03:38.275" end="00:03:41.293" style="s2">of hydronephrosis from<br />normal kidney to the left,</p>
<p begin="00:03:41.293" end="00:03:44.101" style="s2">to a severe hydronephrosis<br />kidney to the right.</p>
<p begin="00:03:44.101" end="00:03:46.633" style="s2">What we see in the normal<br />kidney is a normal architecture</p>
<p begin="00:03:46.633" end="00:03:48.799" style="s2">with the medullary<br />pyramids draining the urine</p>
<p begin="00:03:48.799" end="00:03:51.733" style="s2">into the calyces and<br />then out into the ureter.</p>
<p begin="00:03:51.733" end="00:03:55.035" style="s2">Now if a kidney stone or<br />other obstruction type pattern</p>
<p begin="00:03:55.035" end="00:03:58.049" style="s2">had occurred, we can see<br />that the hydronephrosis would</p>
<p begin="00:03:58.049" end="00:04:01.965" style="s2">be manifested by increasing<br />ballooning out of fluid</p>
<p begin="00:04:01.965" end="00:04:04.663" style="s2">within the calyceal region<br />of the interior part</p>
<p begin="00:04:04.663" end="00:04:06.051" style="s2">of the kidney.</p>
<p begin="00:04:06.051" end="00:04:08.830" style="s2">We can also see dilatation of the ureter.</p>
<p begin="00:04:08.830" end="00:04:12.016" style="s2">Notice in the moderate type<br />picture here to the right</p>
<p begin="00:04:12.016" end="00:04:14.386" style="s2">we can see ballooning out<br />of the medullary pyramids</p>
<p begin="00:04:14.386" end="00:04:16.754" style="s2">in addition to the calyces.</p>
<p begin="00:04:16.754" end="00:04:19.650" style="s2">In a worse case scenario, in<br />the severe hydronephrosis,</p>
<p begin="00:04:19.650" end="00:04:22.957" style="s2">the entire inner part of the<br />kidney is shelled out by fluid</p>
<p begin="00:04:22.957" end="00:04:26.218" style="s2">and all that's left is a<br />little rim of the outer cortex</p>
<p begin="00:04:26.218" end="00:04:29.620" style="s2">around all the fluid within<br />the hydronephrotic kidney.</p>
<p begin="00:04:29.620" end="00:04:32.149" style="s2">Let's begin by taking a look<br />at a patient who presented</p>
<p begin="00:04:32.149" end="00:04:35.981" style="s2">with a very small kidney stone<br />and Grade 1 hydronephrosis.</p>
<p begin="00:04:35.981" end="00:04:38.430" style="s2">Superior pole to the left,<br />inferior pole of the kidney</p>
<p begin="00:04:38.430" end="00:04:39.532" style="s2">to the right.</p>
<p begin="00:04:39.532" end="00:04:41.977" style="s2">As we scan back and forth<br />through the kidney we note</p>
<p begin="00:04:41.977" end="00:04:44.180" style="s2">multiple little dark<br />areas within the interior</p>
<p begin="00:04:44.180" end="00:04:45.326" style="s2">of the kidney.</p>
<p begin="00:04:45.326" end="00:04:47.324" style="s2">These could be construed as cysts.</p>
<p begin="00:04:47.324" end="00:04:49.973" style="s2">However, as we scan up and<br />down, through the kidney,</p>
<p begin="00:04:49.973" end="00:04:54.170" style="s2">we can see that they all<br />coalesce to form dilated calyces,</p>
<p begin="00:04:54.170" end="00:04:57.315" style="s2">the signature of a Grade<br />1 hydronephrosis with mild</p>
<p begin="00:04:57.315" end="00:05:00.129" style="s2">swelling of the interior of the kidney.</p>
<p begin="00:05:00.129" end="00:05:02.656" style="s2">But it's very important<br />to fan anterior posterior</p>
<p begin="00:05:02.656" end="00:05:04.939" style="s2">through the kidney to see<br />that all of these areas</p>
<p begin="00:05:04.939" end="00:05:09.833" style="s2">of hydronephrosis coalesce<br />into the calyceal region.</p>
<p begin="00:05:09.833" end="00:05:11.421" style="s2">Here's an example of a more advanced</p>
<p begin="00:05:11.421" end="00:05:13.627" style="s2">degree of hydronephrosis,<br />known as moderate,</p>
<p begin="00:05:13.627" end="00:05:16.114" style="s2">or Grade 2 hydronephrosis.</p>
<p begin="00:05:16.114" end="00:05:18.634" style="s2">And what we see here is that<br />the interior of the kidney,</p>
<p begin="00:05:18.634" end="00:05:22.058" style="s2">the calyceal region, is filled<br />with dark or anechoic fluid.</p>
<p begin="00:05:22.058" end="00:05:24.422" style="s2">We can also see that the<br />medullary pyramids are</p>
<p begin="00:05:24.422" end="00:05:27.101" style="s2">more pronounced due to<br />the coalescence of fluid</p>
<p begin="00:05:27.101" end="00:05:28.652" style="s2">going up from the calyceal region</p>
<p begin="00:05:28.652" end="00:05:30.813" style="s2">into the medullary pyramids.</p>
<p begin="00:05:30.813" end="00:05:33.382" style="s2">And if we look closely<br />we can see the beginning</p>
<p begin="00:05:33.382" end="00:05:36.690" style="s2">of hydroureter, the<br />arching away of the ureter,</p>
<p begin="00:05:36.690" end="00:05:40.108" style="s2">coming down inferiorly away<br />from the calyceal region.</p>
<p begin="00:05:40.108" end="00:05:42.840" style="s2">So a more pronounced<br />degree of hydronephrosis</p>
<p begin="00:05:42.840" end="00:05:46.226" style="s2">on the spectrum of disease<br />seen within the kidney</p>
<p begin="00:05:46.226" end="00:05:49.248" style="s2">due to a larger kidney stone.</p>
<p begin="00:05:49.248" end="00:05:51.621" style="s2">Here's a kidney from another<br />patient with a larger kidney</p>
<p begin="00:05:51.621" end="00:05:53.825" style="s2">stone representing a Grade 2 - 3,</p>
<p begin="00:05:53.825" end="00:05:56.153" style="s2">or moderate to severe, hydronephrosis.</p>
<p begin="00:05:56.153" end="00:05:58.736" style="s2">And again we see the dilated<br />calyceal region filled</p>
<p begin="00:05:58.736" end="00:06:01.758" style="s2">with fluid and in this<br />video clip we see well</p>
<p begin="00:06:01.758" end="00:06:05.148" style="s2">the hydroureter, the dilated<br />ureter arching inferiorly</p>
<p begin="00:06:05.148" end="00:06:08.991" style="s2">away from the kidney down<br />towards the patient's bladder.</p>
<p begin="00:06:08.991" end="00:06:11.768" style="s2">Here's an example of the<br />highest grade hydronephrosis,</p>
<p begin="00:06:11.768" end="00:06:14.220" style="s2">severe, or Grade 3,<br />hydronephrosis in a patient</p>
<p begin="00:06:14.220" end="00:06:17.033" style="s2">who had a 1.5 centimeter kidney stone.</p>
<p begin="00:06:17.033" end="00:06:19.803" style="s2">And as we look through the<br />kidney, scanning back and forth,</p>
<p begin="00:06:19.803" end="00:06:22.208" style="s2">we can see that all the<br />medullary pyramids and the</p>
<p begin="00:06:22.208" end="00:06:24.958" style="s2">calyceal region is<br />completely filled with dark,</p>
<p begin="00:06:24.958" end="00:06:26.350" style="s2">or anechoic, fluid.</p>
<p begin="00:06:26.350" end="00:06:30.522" style="s2">All that's left here is the<br />outer cortex of renal tissue.</p>
<p begin="00:06:30.522" end="00:06:33.106" style="s2">So, unfortunately, this<br />was a patient who had</p>
<p begin="00:06:33.106" end="00:06:35.350" style="s2">a long-standing hydronephrosis<br />and who had lost a lot</p>
<p begin="00:06:35.350" end="00:06:37.717" style="s2">of the kidney function on this side.</p>
<p begin="00:06:37.717" end="00:06:39.964" style="s2">As we still the image down<br />we can see that the dilated</p>
<p begin="00:06:39.964" end="00:06:44.005" style="s2">calyceal region leads to a<br />very dilated hydroureter,</p>
<p begin="00:06:44.005" end="00:06:46.492" style="s2">again confirming hydronephrosis.</p>
<p begin="00:06:46.492" end="00:06:49.023" style="s2">When evaluating a patient<br />with a possible kidney stone,</p>
<p begin="00:06:49.023" end="00:06:51.555" style="s2">when you find hydronephrosis<br />you should also look</p>
<p begin="00:06:51.555" end="00:06:53.600" style="s2">at the bladder and you<br />may be able to visualize</p>
<p begin="00:06:53.600" end="00:06:55.231" style="s2">a stone present at the left</p>
<p begin="00:06:55.231" end="00:06:58.084" style="s2">or right ureterovesicular junction.</p>
<p begin="00:06:58.084" end="00:06:59.753" style="s2">Here's a case in which<br />a patient presented with</p>
<p begin="00:06:59.753" end="00:07:02.528" style="s2">right flank pain and had<br />right hydronephrosis.</p>
<p begin="00:07:02.528" end="00:07:05.386" style="s2">We're looking at the bladder<br />in a short axis configuration</p>
<p begin="00:07:05.386" end="00:07:08.490" style="s2">with a marker dot over towards<br />the patient's right side.</p>
<p begin="00:07:08.490" end="00:07:11.674" style="s2">What we can see is a hyperechoic<br />large shadowing stone</p>
<p begin="00:07:11.674" end="00:07:14.083" style="s2">present at the right UVJ.</p>
<p begin="00:07:14.083" end="00:07:17.059" style="s2">If we apply Doppler sonography<br />there we can see the</p>
<p begin="00:07:17.059" end="00:07:20.249" style="s2">ureteral jets, the flow of<br />urine coming out through</p>
<p begin="00:07:20.249" end="00:07:22.942" style="s2">the UVJ into the bladder,<br />is being blocked by this</p>
<p begin="00:07:22.942" end="00:07:26.898" style="s2">one centimeter stone<br />that's plugged at the UVJ.</p>
<p begin="00:07:26.898" end="00:07:29.505" style="s2">So, in fact, this patient had<br />to go to the cystoscopy lab</p>
<p begin="00:07:29.505" end="00:07:32.602" style="s2">to get the large stone removed<br />and relieving the obstruction</p>
<p begin="00:07:32.602" end="00:07:34.804" style="s2">of urine into the bladder.</p>
<p begin="00:07:34.804" end="00:07:36.517" style="s2">In conclusion, thanks<br />for joining me for this</p>
<p begin="00:07:36.517" end="00:07:40.072" style="s2">SoundBytes module focusing<br />on genitourinary ultrasound.</p>
<p begin="00:07:40.072" end="00:07:43.237" style="s2">Our goals, goal number one,<br />hopefully now you know how</p>
<p begin="00:07:43.237" end="00:07:45.597" style="s2">to perform ultrasound of<br />the kidney and diagnose</p>
<p begin="00:07:45.597" end="00:07:48.494" style="s2">hydronephrosis from mild, or Grade 1,</p>
<p begin="00:07:48.494" end="00:07:51.595" style="s2">through moderate to severe, or Grade 3.</p>
<p begin="00:07:51.595" end="00:07:54.450" style="s2">Our second goal is to<br />investigate the bladder closely</p>
<p begin="00:07:54.450" end="00:07:56.371" style="s2">and we may be able to see<br />stones that have migrated</p>
<p begin="00:07:56.371" end="00:07:59.812" style="s2">down to the UVJ on<br />inspection of the bladder.</p>
<p begin="00:07:59.812" end="00:08:02.137" style="s2">We can also get a sense<br />of bladder size on bladder</p>
<p begin="00:08:02.137" end="00:08:04.710" style="s2">sonography and using<br />Doppler we can look at the</p>
<p begin="00:08:04.710" end="00:08:06.643" style="s2">ureteral jets.</p>
<p begin="00:08:06.643" end="00:08:09.470" style="s2">Our overriding goal for this<br />module is to use ultrasound</p>
<p begin="00:08:09.470" end="00:08:12.440" style="s2">to diagnose kidney stones in<br />a selected group of patients</p>
<p begin="00:08:12.440" end="00:08:14.813" style="s2">as an alternative to CAT scanning.</p>
<p begin="00:08:14.813" end="00:08:16.656" style="s2">So, I hope to see you back in the future</p>
<p begin="00:08:16.656" end="00:08:18.739" style="s2">as SonoA ccess continues.</p>

<p begin="00:00:15.330" end="00:00:17.664" style="s2">- Another examination<br />you could do in the ED</p>
<p begin="00:00:17.664" end="00:00:21.020" style="s2">is the evaluation of<br />kidney for nephrolithiasis.</p>
<p begin="00:00:21.020" end="00:00:24.749" style="s2">And this is a relatively<br />easy examination to do.</p>
<p begin="00:00:24.749" end="00:00:27.004" style="s2">We're gonna do, again, using<br />the (mumbles) transducer,</p>
<p begin="00:00:27.004" end="00:00:29.274" style="s2">your all-purpose ED transducer,</p>
<p begin="00:00:29.274" end="00:00:32.166" style="s2">and the first view that<br />we're going to look at</p>
<p begin="00:00:32.166" end="00:00:35.413" style="s2">is a sagittal view of the kidney.</p>
<p begin="00:00:35.413" end="00:00:36.891" style="s2">So I'm gonna start on the right side</p>
<p begin="00:00:36.891" end="00:00:39.904" style="s2">but I will do both sides<br />to show you how to do</p>
<p begin="00:00:39.904" end="00:00:42.286" style="s2">an evaluation on both sides.</p>
<p begin="00:00:42.286" end="00:00:44.036" style="s2">And we're gonna go in</p>
<p begin="00:00:44.875" end="00:00:48.201" style="s2">with the orientation marker<br />pointing to the patient's head.</p>
<p begin="00:00:48.201" end="00:00:50.701" style="s2">So this'll be a sagittal view.</p>
<p begin="00:00:51.539" end="00:00:54.572" style="s2">And then I'm gonna go in fairly laterally.</p>
<p begin="00:00:54.572" end="00:00:55.446" style="s2">With this starting point,</p>
<p begin="00:00:55.446" end="00:00:59.739" style="s2">I can quickly identify<br />where the kidney is.</p>
<p begin="00:00:59.739" end="00:01:03.390" style="s2">In the anterior aspect of<br />the image, you see the liver.</p>
<p begin="00:01:03.390" end="00:01:05.128" style="s2">And immediately posterior to that,</p>
<p begin="00:01:05.128" end="00:01:09.295" style="s2">you see a crescent-shaped<br />organ which is the kidney.</p>
<p begin="00:01:10.160" end="00:01:13.036" style="s2">And so what I want to do<br />evaluate in a long view</p>
<p begin="00:01:13.036" end="00:01:15.703" style="s2">sweeping medially and laterally,</p>
<p begin="00:01:18.193" end="00:01:19.899" style="s2">looking at the cortex to determine</p>
<p begin="00:01:19.899" end="00:01:24.871" style="s2">if there's any echogenic<br />or bright shadowing stones.</p>
<p begin="00:01:24.871" end="00:01:27.871" style="s2">So I can evaluate the superior pole,</p>
<p begin="00:01:29.948" end="00:01:31.948" style="s2">sweep from side to side,</p>
<p begin="00:01:35.476" end="00:01:37.892" style="s2">and kind of look at the inferior pole,</p>
<p begin="00:01:37.892" end="00:01:39.892" style="s2">sweep from side to side,</p>
<p begin="00:01:42.314" end="00:01:43.897" style="s2">and look in the mid</p>
<p begin="00:01:46.293" end="00:01:47.853" style="s2">pelvis area of the kidney</p>
<p begin="00:01:47.853" end="00:01:50.819" style="s2">to determine if there's hydronephrosis,</p>
<p begin="00:01:50.819" end="00:01:54.306" style="s2">an indirect sign of nephrolithiasis.</p>
<p begin="00:01:54.306" end="00:01:56.374" style="s2">Once I've finished the sagittal sweep,</p>
<p begin="00:01:56.374" end="00:01:57.928" style="s2">I'm gonna turn the transducer</p>
<p begin="00:01:57.928" end="00:02:00.555" style="s2">so it's in a transverse<br />view with the marker</p>
<p begin="00:02:00.555" end="00:02:01.977" style="s2">to the patient's right.</p>
<p begin="00:02:01.977" end="00:02:06.144" style="s2">And using the same window as<br />I did for the sagittal view,</p>
<p begin="00:02:07.234" end="00:02:08.201" style="s2">identify the kidney.</p>
<p begin="00:02:08.201" end="00:02:12.184" style="s2">It will now appear as a horseshoe shape.</p>
<p begin="00:02:12.184" end="00:02:14.523" style="s2">And we can see the renal vein</p>
<p begin="00:02:14.523" end="00:02:17.606" style="s2">coming into the pelvis of the kidney.</p>
<p begin="00:02:20.606" end="00:02:24.571" style="s2">And I'm gonna sweep<br />superiorly until I move pass</p>
<p begin="00:02:24.571" end="00:02:27.654" style="s2">the superior aspect of the upper pole</p>
<p begin="00:02:28.799" end="00:02:32.228" style="s2">and then sweep back down inferiorly.</p>
<p begin="00:02:32.228" end="00:02:34.987" style="s2">See the mid-level of the kidney,</p>
<p begin="00:02:34.987" end="00:02:35.904" style="s2">renal vein,</p>
<p begin="00:02:37.883" end="00:02:39.925" style="s2">moving down a rib space,</p>
<p begin="00:02:39.925" end="00:02:42.383" style="s2">and into the inferior pole of the kidney.</p>
<p begin="00:02:42.383" end="00:02:44.200" style="s2">And I continue until I do not see</p>
<p begin="00:02:44.200" end="00:02:47.589" style="s2">any tissue of the kidney anymore.</p>
<p begin="00:02:47.589" end="00:02:49.489" style="s2">An important part of a kidney evaluation</p>
<p begin="00:02:49.489" end="00:02:52.600" style="s2">is a bilateral comparison<br />between the right and left kidney</p>
<p begin="00:02:52.600" end="00:02:54.265" style="s2">to determine if there's hydronephrosis</p>
<p begin="00:02:54.265" end="00:02:56.290" style="s2">present on one side versus the other.</p>
<p begin="00:02:56.290" end="00:02:59.226" style="s2">So we'll go ahead and do<br />the left side as well.</p>
<p begin="00:02:59.226" end="00:03:00.757" style="s2">So an easy landmark here</p>
<p begin="00:03:00.757" end="00:03:02.588" style="s2">is just to identify the costal margin</p>
<p begin="00:03:02.588" end="00:03:04.500" style="s2">and then move up one hands width</p>
<p begin="00:03:04.500" end="00:03:08.667" style="s2">and bring your transducer<br />in at the mid-axillary line.</p>
<p begin="00:03:10.297" end="00:03:12.079" style="s2">This should get us right in the area</p>
<p begin="00:03:12.079" end="00:03:14.496" style="s2">of the spleen and the kidney.</p>
<p begin="00:03:16.299" end="00:03:18.816" style="s2">You may need to move<br />up a rib space or two,</p>
<p begin="00:03:18.816" end="00:03:22.540" style="s2">determining on how high<br />and how small the spleen is</p>
<p begin="00:03:22.540" end="00:03:24.784" style="s2">'cause you're using the<br />spleen as your window</p>
<p begin="00:03:24.784" end="00:03:26.701" style="s2">to evaluate the kidney.</p>
<p begin="00:03:29.691" end="00:03:31.059" style="s2">So if I move up a little bit,</p>
<p begin="00:03:31.059" end="00:03:33.387" style="s2">I can see the superior part of the kidney</p>
<p begin="00:03:33.387" end="00:03:35.736" style="s2">on this ultrasound image,</p>
<p begin="00:03:35.736" end="00:03:38.903" style="s2">and I'll just sweep from side to side.</p>
<p begin="00:03:42.656" end="00:03:46.239" style="s2">Again, looking at the<br />cortex of the kidney,</p>
<p begin="00:03:47.914" end="00:03:49.442" style="s2">looking at the renal pyramids,</p>
<p begin="00:03:49.442" end="00:03:50.999" style="s2">and also trying to determine</p>
<p begin="00:03:50.999" end="00:03:53.916" style="s2">if there is hydronephrosis present.</p>
<p begin="00:03:55.420" end="00:03:58.240" style="s2">And then I'm gonna move<br />down one rib space,</p>
<p begin="00:03:58.240" end="00:04:01.281" style="s2">evaluate the lower pole of the kidney,</p>
<p begin="00:04:01.281" end="00:04:03.941" style="s2">and sweep medial to lateral</p>
<p begin="00:04:03.941" end="00:04:07.182" style="s2">to make sure that I've<br />looked at all of the tissue</p>
<p begin="00:04:07.182" end="00:04:09.151" style="s2">'cause these stones can be quite small.</p>
<p begin="00:04:09.151" end="00:04:12.297" style="s2">So you have to do a very<br />thorough evaluation.</p>
<p begin="00:04:12.297" end="00:04:13.987" style="s2">Once I've completed this view,</p>
<p begin="00:04:13.987" end="00:04:17.219" style="s2">I'm gonna turn the transducer<br />to a transverse view.</p>
<p begin="00:04:17.219" end="00:04:21.533" style="s2">So I'm gonna turn the<br />transducer counterclockwise</p>
<p begin="00:04:21.533" end="00:04:26.175" style="s2">and the marker, again, will<br />face the patient's right.</p>
<p begin="00:04:26.175" end="00:04:27.991" style="s2">This will give me that<br />horseshoe-shaped appearance</p>
<p begin="00:04:27.991" end="00:04:29.524" style="s2">of the kidney.</p>
<p begin="00:04:29.524" end="00:04:32.107" style="s2">And if I start it in mid-level,</p>
<p begin="00:04:35.431" end="00:04:39.907" style="s2">I will see the renal vein<br />entering the pelvis of the kidney.</p>
<p begin="00:04:39.907" end="00:04:41.677" style="s2">And from here, this is my mid-point,</p>
<p begin="00:04:41.677" end="00:04:43.760" style="s2">I'm gonna sweep superior.</p>
<p begin="00:04:44.883" end="00:04:48.613" style="s2">I might have to go up<br />a rib space to find it,</p>
<p begin="00:04:48.613" end="00:04:53.225" style="s2">go all the way through<br />the kidney, superior pole,</p>
<p begin="00:04:53.225" end="00:04:56.267" style="s2">and then start to move<br />inferiorly to mid-level,</p>
<p begin="00:04:56.267" end="00:04:59.150" style="s2">continue on down, inferior again,</p>
<p begin="00:04:59.150" end="00:05:01.559" style="s2">to the lower pole of the kidney,</p>
<p begin="00:05:01.559" end="00:05:03.226" style="s2">and all the way out.</p>
<p begin="00:05:04.355" end="00:05:07.688" style="s2">So that completes the kidney evaluation.</p>

<p begin="00:00:07.000" end="00:00:09.879" style="s2">- [Voiceover] A curved or<br />phased array transducer with an</p>
<p begin="00:00:09.879" end="00:00:12.611" style="s2">abdomen exam type is used to perform a</p>
<p begin="00:00:12.611" end="00:00:14.407" style="s2">renal ultrasound exam.</p>
<p begin="00:00:14.407" end="00:00:17.740" style="s2">The kidney should be<br />evaluated in two planes.</p>
<p begin="00:00:17.740" end="00:00:21.151" style="s2">The transducer is placed in<br />a long access orientation</p>
<p begin="00:00:21.151" end="00:00:23.459" style="s2">along the right midaxillary line,</p>
<p begin="00:00:23.459" end="00:00:24.913" style="s2">at the costal margin,</p>
<p begin="00:00:24.913" end="00:00:27.233" style="s2">with the orientation<br />marker directed toward the</p>
<p begin="00:00:27.233" end="00:00:28.487" style="s2">patient's head.</p>
<p begin="00:00:28.487" end="00:00:30.913" style="s2">If it is difficult to<br />visualize the kidney,</p>
<p begin="00:00:30.913" end="00:00:33.981" style="s2">a deep inspiration will move<br />the kidney below the ribs,</p>
<p begin="00:00:33.981" end="00:00:36.044" style="s2">for easier access.</p>
<p begin="00:00:36.044" end="00:00:39.524" style="s2">It may also be necessary to<br />move the transducer proximally</p>
<p begin="00:00:39.524" end="00:00:42.725" style="s2">along the midaxillary line,<br />to visualize the kidneys,</p>
<p begin="00:00:42.725" end="00:00:44.939" style="s2">using an intercostal approach.</p>
<p begin="00:00:44.939" end="00:00:48.233" style="s2">Using this approach will<br />result in rib shadow artifacts</p>
<p begin="00:00:48.233" end="00:00:50.609" style="s2">overlying the ultrasound image.</p>
<p begin="00:00:50.609" end="00:00:53.963" style="s2">Once the kidney is identified,<br />the transducer is slightly</p>
<p begin="00:00:53.963" end="00:00:58.130" style="s2">rotated to adjust for the oblique<br />orientation of the kidney.</p>
<p begin="00:01:04.713" end="00:01:08.435" style="s2">The transducer is swept<br />from anterior to posterior</p>
<p begin="00:01:08.435" end="00:01:10.457" style="s2">to image the kidney parenchyma,</p>
<p begin="00:01:10.457" end="00:01:14.119" style="s2">which will appear hypoechoic<br />when compared to the liver.</p>
<p begin="00:01:14.119" end="00:01:16.892" style="s2">The renal pyramids are<br />triangular in shape,</p>
<p begin="00:01:16.892" end="00:01:19.550" style="s2">and darker than the renal cortex.</p>
<p begin="00:01:19.550" end="00:01:23.140" style="s2">The renal pelvis will appear<br />as bright, hyperechoic echoes</p>
<p begin="00:01:23.140" end="00:01:24.546" style="s2">within the kidney.</p>
<p begin="00:01:24.546" end="00:01:27.247" style="s2">To obtain a transverse access view,</p>
<p begin="00:01:27.247" end="00:01:29.659" style="s2">rotate the transducer 90 degrees,</p>
<p begin="00:01:29.659" end="00:01:31.652" style="s2">from the long access position.</p>
<p begin="00:01:31.652" end="00:01:34.098" style="s2">The kidney appear as a circular structure,</p>
<p begin="00:01:34.098" end="00:01:35.311" style="s2">with a horseshoe shape,</p>
<p begin="00:01:35.311" end="00:01:37.249" style="s2">at the level of the renal pelvis.</p>
<p begin="00:01:37.249" end="00:01:40.994" style="s2">The transducer is swept from<br />the superior to inferior poles,</p>
<p begin="00:01:40.994" end="00:01:43.494" style="s2">to evaluate the entire kidney.</p>