Rupture

- Hello, my name is Phil Perera
and I'm the emergency ultrasound coordinator
at the New York Presbyterian Hospital in New York City,
and welcome to SoundBytes Cases!
In this SoundBytes module entitled
Part 2 of bedside ultrasound of the aorta,
we'll go further on our discussion
of bedside ultrasonography of the aorta,
and detection of abdominal aortic aneurysms.
We'll begin with a review of the definitions
and the anatomy of the types of
abdominal aortic aneurysms that you
may encounter in the emergency department.
We'll look at a number of ultrasound images
demonstrating triple-A's, and we'll
conclude with a discussion of the
potential pitfalls of bedside imaging
of an abdominal aortic aneurysm.
This illustration shows the types
of abdominal aortic aneurysms that
may be encountered in clinical practice.
The more common type of abdominal aortic aneurysm
is defined as Fusiform, or diffuse dilatation
of the abdominal abdominal aorta.
Remember that a triple-A is defined
as an aortic diameter greater than three centimeters.
Let's start by looking at the picture to the far left.
What we see here is a diffuse dilatation
of the aorta beginning at the level below the renals,
and ending just above bifurcation into the iliac arteries.
Notice the picture towards the middle;
some of these fusiform aneurysms
can extend from the abdominal aorta
all the way down into the iliac artery.
Now the less common type of abdominal aortic aneurysm
is known as Saccular, as shown
in the picture to the far right,
where you have a localized out-pouching
of the abdominal wall.
This next illustration makes the point
that choosing the correct probe orientation
is very important in terms of getting a
correct measurement of the aorta,
due to the cylinder effect.
Let's look at the two long axis views
of the probes along the aorta, as shown
towards the left of the image here.
Beginning in probe position 1,
we see a side slice, in which the probe
is positioned towards the side of the aorta,
and underestimating the true diameter of the aortic lumen.
We can see that positioning the probe
towards the middle of the image,
as shown here in probe position 2,
we'll get a correct diameter, but this can be
difficult to ascertain using the long axis orientation.
A better orientation is to position the probe
in the short axis configuration,
as shown in probe position 3,
one can then get a sense in terms of the true lumen,
and get the best measurements
of the abdominal aortic aneurysm.
In the last illustration we made the point
that it's important to image the
abdominal aortic aneurysm for an accurate dimension
in the short axis configuration.
But it's also very important to include
outer-wall to outer-wall in the measurements
of the abdominal aortic aneurysm.
Here we can see a measurement
of a triple A only including the inner lumen,
and notice that we could vastly underestimate
the true diameter of this very large triple-A.
Here's the correct dimensions
of the abdominal aortic aneurysm,
and notice here, that we're measuring
anterior, posterior, and laterally,
including the thrombus that coats the outer walls
of this abdominal aortic aneurysm,
in addition to the true lumen,
and we get an outstanding number of
eight by eight centimeters on this triple-A.
Here's a short axis view of a
very large abdominal aortic aneurysm
in a patient who presented to the emergency department
with abdominal and back pain,
and with a small indicator arrow
I'm showing in the B mode image towards the left,
the large triple-A, and there's the spine,
which is our landmark for determination of the aorta.
Now we can see the Color Power Doppler image
towards the right, showing pulsations of blood
within this very large triple-A.
Next we're going to measure this
abdominal aortic aneurysm, and notice
we have a short axis configuration
including outer-wall to outer-wall,
that includes the inner lumen, and the outer thrombus,
and we have a measurement of 4.8 by 4.9 centimeters,
making a criteria of a triple-A
greater than three centimeters.
This video clip is another short axis
orientation of a very large triple-A
in a patient who presented the the ED with abdominal pain.
We mark the spine as our landmark,
and anterior to the spine we see a very large triple-A.
Notice the true lumen, and the accumulation of thrombus
that's seen substantially anterior to the true lumen.
Next, we'll measure this triple-A,
and here we've placed our calipers
from outer-wall to outer-wall
in a short axis configuration,
and we come up with an aneurysm
of 6.3 by 5.8 centimeters, again making
the criteria of a very large triple-A
greater than three centimeters.
This video clip shows a very interesting triple-A,
with multiple onion-skin layers of thrombus
surrounding a very small lumen
towards the middle of the triple-A.
And notice again that we could vastly underestimate
the true dimensions of this triple-A,
if all we included was the lumen.
We see here a very large burden of clot
surrounding the lumen circumferentially
in a short axis orientation.
Next, we're going to position the probe
in a long axis orientation, and I'd like
to categorize this as the Subway sandwich sign,
and what we see here is the lumen,
making up the filling of our Subway sandwich,
and notice the anterior and posterior
burden of clot making up the loaves of the bread,
circumferentially surrounding the lumen.
So a very large triple-A and long axis configuration.
Next we're going to measure this triple-A,
and here we're putting the calipers
from anterior, posterior, and laterally,
trying to add that lumen and the
thrombus to our measurements,
and I came up with a measurement
that was 6.3 by 6.16 centimeters,
again making the definition of a triple-A.
This image is a short axis configuration
showing an extremely large triple-A,
in a patient who presented to the ED
with abdominal pain, during a snowstorm
in New York City in January.
Notice the very large triple-A
and the chaotic flow of blood inside.
You can almost see the thrombus deposition
from the swirls of blood in this very large triple-A.
Here's a long axis configuration
of the same triple-A, and again we can
almost take the patient's heartbeat, or pulse,
by measuring the movements of the swirls of blood
within this chaotic flow of blood within the large triple-A,
and we can see the deposition of the thrombus
both on the anterior and posterior walls
of this very large triple-A.
Here we're putting color Power Doppler down,
to again show that this is a vascular structure,
and what's interesting is again we
can see the chaotic flow of blood,
round and round within this triple-A,
that contributes to the substantial burden
of clot formation that occurs on a triple-A.
In the next image, we're going to measure
this gigantic abdominal aortic aneurysm
in the short axis orientation,
and we measure from outer-wall to outer-wall,
we get a measurement of 8.8 by 8.6 centimeters.
So this patient went directly to the operating room,
and had successful placement of a stent.
This is a rare video clip showing a saccular
abdominal aortic aneurysm, in a patient
who presented to the ED with epigastric abdominal pain.
We have the probe positioned in a long axis configuration,
superior to the left, and we see the aorta
running from left to right, and
we see an outpouching of the aorta coming anteriorly there.
That's a saccular aneurysm, and as we measure it,
we come up with a measurement of 4.45 centimeters.
As the patient was symptomatic
with epigastric abdominal pain over this aneurysm,
she went directly to the operating room
for operative repair.
Let's go over some pitfalls and
useful hints for imaging of the abdominal aorta.
At times, the aorta may be difficult to see,
secondary to excess bowel gas.
We may press the transducer more
firmly towards the spine to displace the bowel gas
and get a look at that aorta.
If the patient has a high body mass index,
we can use a lower frequency to
increase penetration, and to get
a better look at the abdominal aorta.
Using Color Doppler can help us to identify vessels,
and be careful because there are times
when the spine may look like a triple-A,
but again close attention to the spine,
and the location of vascular structures anteriorly
will clear that up.
This video clip shows an example
where the spine could be mistaken
as a large abdominal aortic aneurysm.
Notice that it has the appearance
of a dark structure within the abdomen,
and at first glance it could look like
an abdominal aortic aneurysm, however,
we note that there's positile structures
anterior to the spine, we see the aorta to the left,
and the IVC towards the patient's right side.
We could also use color Power Doppler
to differentiate the vascular structures
of the aorta and IVC versus the spine.
This ultrasound image shows another interesting pitfall.
At first glance, we see a very large, dark structure
towards the top of the picture here,
that could be mistaken as a
very large abdominal aortic aneurysm.
But again, close attention to the location
of the spine posteriorly will help us out.
Notice we see the bone table of the spine,
notice just anterior to the spine
we actually can see here the aorta.
This very large structure is actually
a very large mesenteric cyst,
and it failed to have pulsations with power color doppler.
In conclusion, thanks for joining me
for this SoundBytes module going over
Part 2 of bedside ultrasound of the aorta.
Hopefully through this module you
now understand the definition of
and anatomy found on bedside ultrasound imaging
of an abdominal aortic aneurysm,
and now you can use bedside sonography
as a rapid diagnostic tool for picking up a triple-A.
Remember, that if a patient has unstable hemodynamics,
and a large triple-A is seen on bedside sonography,
that patient must be assumed to have a rupturing triple-A.
Using bedside sonography, we can facilitate
timely operative management of these patients
and possibly save a life.
So I hope to see you back in the future,
as SoundBytes continues.

Brightcove ID

5508128547001

https://youtube.com/watch?v=WKnFD6KeO4c

Case: FAST Exam - Suprapubic Views

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This video details how using long-axis and short-axis suprapubic views during a trauma FAST ultrasound examination enables clinicians to identify fluid in a trauma patient's pelvic cavity.

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- Hello, my name is Phil Perera and I'm the Emergency
Ultrasound Coordinator at the New York
Presbyterian Hospital in New York City.
And welcome to Soundbytes Cases.
In this Soundbytes module we'll continue
our journey looking at the Trauma Fast Exam.
I hope you've had a chance to join me prior
for modules looking at the right upper quadrant
and left upper quadrant views of the Trauma Fast Exam.
In this module we will specifically look at
the Suprapubic view, also known as the bladder or pelvic
view of the Trauma Fast Exam.
There is a lot of information we can gain
from looking at the Suprapubic view,
as we can potentially detect a smaller amount of fluid
than is required to make a positive right
upper quadrant or left upper quadrant view.
Literature suggests that only about
100 to 200 ccs of fluid can be detected
accurately on the Suprapubic view.
Here's a slide reviewing how to perform
the Suprapubic view of the Trauma Fast Exam.
In contrast to the upper quadrant views,
where we looked only in the long axis configuration,
the Suprapubic view is made up of two planes.
We want to look in both long and short axis configurations.
We'll begin at long axis with the marker dot
oriented toward the patient's head
and complete our exam by moving the probe
into short axis with the marker dot
toward the patients right side.
This way we can fully scan through the pelvis
and not miss any small amounts of fluid there.
It's optimal to perform the examination
with a full bladder as an optimal
acoustic window, so perform the
exam prior to having the patient
void or placing a foley catheter.
Here's an illustration showing the anatomy
that we'll need to know to perform
the Suprapubic view of the Trauma Fast Exam.
We see the pattern of fluid flow in a female,
to the left here, and a male, to the right.
Let's look closer at the female pelvis,
to the left, and what we see is that fluid will
preferentially develop in the pelvic
Cul de Sac, located behind the uterus.
Now, small amounts of fluid will only be
located in the pelvic Cul de Sac,
but as the amount of fluid enlarges
it will come out and increase so
that it will layer out on top of
the uterus and on top of the dome of the bladder.
But small amounts of fluid will only be found in
that pelvic Cul de Sac posterior to the uterus.
Now let's take a look at the male
pelvis to the right and we see
small amounts of fluid that will only be found
in the Retrovesical Space behind the bladder.
As the amount of fluid enlarges it
will come anterior to settle out
over the top of the dome of the bladder.
But as we emphasized in the female,
small amounts of fluid will only be
found in one place and in the male
it will be in that Retrovesical Space
immediately posterior to the bladder.
Let's begin by looking at some normal
video from the Suprapubic View.
In this case, a long axis view in a female,
superior to the left, inferior to the right.
The first structure we identify is
the bladder, the dark area, anteriorly
and posterior to the bladder we see the uterus.
Now if we look into the potential space,
the Pelvic Cul de Sac, posterior to the
uterus for any dark fluid collections, we see an
absence of any fluid on this normal video clip.
Now let's inspect a video clip from a male.
In this case a short axis view.
We see a large bladder there, anteriorly
and behind the bladder we see two
tubular structures making up the
Seminal Vesicles, a normal finding in a male.
Now if we're looking for free fluid
behind the bladder, we'd be looking
for dark or anechoic fluid collection
layering out behind the bladder.
Notice this is a normal examination.
Here's a positive examination
in a female trauma patient.
We're looking in the long axis view,
superior to the left, inferior to the right.
The first structure we identify is
the bladder, as seen inferior here.
And notice the uterus, the solid organ,
as seen superior to the bladder.
We note the parts of the uterus, the fundus
anteriorly, and the cervix more posteriorly.
Now let's look into the Pelvic Cul de Sac
immediately posterior to the uterus,
and what we see here is the presence of a
dark or anechoic fluid collection just posterior
to the cervix within the pelvic Cul de Sac.
So in the female trauma patient,
this does denote a positive examination
and can be a sign of ongoing bleeding
within the abdominal pelvic cavity.
So let's contrast this clip in which
we see a small amount of fresh
fluid within the pelvic Cul de Sac.
With this one, in which we have a female
trauma patient with a large amount
of bleeding within the pelvic cavity.
We see here, again, a long axis scan superior
to the left, inferior to the right, the bladder
we see as the dark structure inferiorly
and the uterus superior to the bladder.
Notice the fresh fluid as seen posterior
to the uterus within the Cul de Sac,
but note that the amount of fluid
comes anterior to the uterus,
as seen here between the uterus and the bladder.
So this denotes a large amount of blood within
the pelvic cavity in this female trauma patient.
If we now orient the probe to the patient's right side,
we obtain a short axis view of the same patient.
And what we see here is the uterus in the
middle of the image and notice the large amount
of fresh fluid as seen both to the top, or anterior,
to the uterus and posterior to the uterus.
Notice in this case we can see the
broad ligaments of the uterus well outlined
by all the fresh fluid within the pelvis.
So a large amount of fresh fluid, or blood,
in this case, within this female trauma patient.
Here's a positive examination
Suprapubic View, short axis in a male.
Probe is oriented towards the patient's right and
anteriorly we see a large, fluid filled bladder.
Posterior to the bladder, in the retrovesical
space we appreciate the presence of free fluid,
as shown by that dark or anechoic
fluid collection there.
Now this gives a finding known as
the double wall sign, and we see
the wall of the bladder, outlined by
the urine inside the bladder, and the
blood, in this case, outside the bladder
in the area of the retrovesical space.
To further confirm that the last patient
had a positive exam and that we're
not mistaking areas of fluid as seminal vesicles,
we'll re-scan the patient in the long axis plane,
superior to the left, inferior to the right.
We see the large circular bladder,
as seen anteriorly and superior
and posterior to the bladder in the
retrovesical space, we can see
free fluid layering out there.
This confirms that indeed the patient
has a positive exam, with blood
layering out behind the bladder.
And, again, we see the double wall sign,
urine outlining the inner wall of the
bladder, and blood, in this case,
outlining the outer wall of the bladder.
Here we're scanning a male trauma patient with
a long axis configuration and we see a large
amount of free fluid within the pelvis.
We note the bladder inferiorly,
and note all the free fluid layering
out both posterior to the bladder
in the retrovesical space and coming
anteriorly onto the dome of the
bladder as seen to the left here.
So a large amount of free fluid in this male trauma patient.
In conclusion, I'm glad I could
share with you the Soundbytes Module
covering the Suprapubic View of the Trauma Fast Exam.
This view is a very important
one to add onto the exam of your
trauma patient as we can potentially
detect a smaller amount of fluid here,
within the pelvis, than it takes to
make a positive right upper quadrant
or left upper quadrant view.
Remember that this is a two-step exam,
we'll be looking in both short
and long axis configurations to
verify fluid, and also remember
the differences between the female, where we're
looking into the pelvic Cul de Sac for fluid,
and the male, where we're looking into
the retrovesical space for fluid.
So I hope to see you back in the
future as Soundbytes continues.

Brightcove ID

5508114789001

https://youtube.com/watch?v=Pa3z9zWNfB8

How to: Female Pelvis: Transvaginal View

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Obtaining a transvaginal view of the female pelvis

Clinical Specialties

EMED

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- If you do a transabdominal examination
of the pelvis for early pregnancy
and you cannot find a definitive
gestational sack inside of the uterus,
the next step you need to do is
an intracavitary examination of the uterus
and cervix and the adnexal area
to determine where the pregnancy is,
whether it's intrauterine or extrauterine.
So what I'm gonna do right now
is walk through the steps on how
you would do that examination
and we're gonna use this Phantom by Blue Phantom,
that will actually demonstrate an ectopic pregnancy.
So the first stage of the prep
for the intracavitary transducer
is that we need to cover it with a sheath.
When you do this, we need to remove
any air gaps that are inside the sheath,
next to the transducer face.
So what we will do is put a little
bit of gel inside the cover,
position that over the tip of the transducer
and then just pull down the covering over the transducer
and pull this down right over the handle,
so you've got good coverage.
And then just make sure that you examine the tip here
and make sure you eliminate any
air bubbles that are covering the transducer face.
So once you've got the air bubbles eliminated,
then you can move on to the next step.
We're going to put a little bit
of gel on the outside of the latex cover now.
And again, your orientation for
this examination is very important.
So for the long ax or sagittal view,
we want the orientation marker up
and then when we go to the coronal view,
we're gonna turn that so it faces the patient's right.
After we've inserted the transducer in a long axis view,
the first thing that we're gonna
see is a long ax of the uterus.
In this Phantom representation of the uterus,
we see an endometrial stripe,
which is represented by the white line.
So if I was doing this as a real pelvic exam,
I would scan to the right of the patient,
all the way through to the right adnexa
and then back over, all the way back through the uterus,
over to the left adnexa.
And the reason I'm doing this
is because I don't see the pregnancy inside the uterus,
so I'm suspecting that it's extrauterine
or an ectopic pregnancy.
I do have some hints here though, using this Phantom.
In the posterior cul de sac region,
I'm seeing a black anechoic area,
which would represent free fluid or blood.
If I scan all the way over to the left adnexa, in this case,
the first structure I come across,
this echogenic area represents the ovary.
If I keep scanning to the left, in the pelvis,
I encounter this other area
and this represents, in this case, our ectopic pregnancy.
When I'm medial, just right beside the uterus,
I see the ovary and I scan out a little bit more
and this represents the ectopic pregnancy.
And this is what you should see,
a round, circular structure like this,
with a bright, echogenic brim.
And it is possible to sometimes
to see a fetal heartbeat inside
the ectopic pregnancy as well.
Now, I'm gonna change the orientation of the transducer,
so I'm in a coronal view.
To do that, I'm gonna turn the transducer counterclockwise.
The uterus will appear circular,
because I'm cutting a cross sectional view of it
and I tilt the handle of the transducer up,
to move inferiorly, down to the region of the cervix
and then bring the transducer handle
down to scan superiorly,
into the area of the fundus of the uterus.
Again, in this case, I can see that
there's no pregnancy inside the uterus itself.
If I scan over to the left of the Phantom,
again, we see the left ovary and then right beside it,
we see our representation of the ectopic pregnancy.
This bright, circular area.
Moving back towards the midline,
the anechoic area just posterior to the uterus
is represented as free fluid or blood, in this case.
So those are the views that you
would need to do a thorough assessment
of the pelvis for early pregnancy.

Brightcove ID

5750481386001

https://youtube.com/watch?v=0CqicUl0hw8

Case: Aorta Ultrasound - Introduction

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This video details how bedside ultrasound imaging can be used, as well as proper probe placement and how to interpret the ultrasound images seen during abdominal ultrasound examinations.

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- Hello, my name is Phillips Perera
and I'm the Emergency Ultrasound Coordinator
at the New York Presbyterian Hospital in New York City.
Welcome to SoundBytes Cases.
In this SoundBytes Module entitled Part 1
of Beside Ultrasound of the Aorta,
we're going to specifically look
at the Beside Detection of Abdominal Aortic Aneurysms.
Now this application of Point of Care Beside Sonography
is one of the most crucial ones for the Emergency Physician
as Detection of an Abdominal Aortic Aneurysm can be
life saving for your patient at the bedside.
Using Point of Care Sonography to make a rapid
diagnosis of a rupturing Abdominal Aortic Aneurysm
in a patient who has unstable vital signs can facilitate
timely transfer of the patient to the operating theater
without undue delay in the Emergency Department
such as waiting for a CAT Scan.
Because there's a lot of material to cover
on the topic of Bedside Ultrasound of the Aorta,
I've divided this module into Aorta Ultrasound
Parts one and two.
In this module entitled Aorta Ultrasound Part 1
we're gonna begin by reviewing the anatomy of the Aorta,
we'll then move on to learn how to perform the Ultrasound
examination of the Abdominal Aorta, all the way from the top
at the subxiphoid process as the Aorta
exits the thoracic cavity to bifurcation
at the level of the Umbilicus.
We'll then also move on to learn how to understand
the interpretation of the Ultrasound images
that you will obtain using Beside Sonography.
Let's review the position of the probe
for Sonography of the Aorta.
Generally we'll begin by placing the probe in
a short axis configuration.
Begin by placing the probe in probe position one
in the Epigastric region to visual the Aorta
as it enters the Abdominal Cavity and exits
through the Thoracic Cavity via the diaphragm.
The probe should be configured with a marker dot
over towards the patients right side.
Press down to firmly displace bowel gas
and get a glimpse of that Aorta.
Now, we should visualize the spine as our landmark
and on top of the spine we'll visualize the Aorta.
Then we should slide the probe inferiorly to probe position
two here as show in the Super Umbilical region.
This will allow us to visualize the entire part
of the Abdominal Aorta all the way down
to Bifurcation.
We should complete the examination of the Aorta
by looking at the Aorta in a long-axis plane.
We'll begin by placing the probe in probe position one
again in the Epigastric region to visualize the top part
of the Abdominal Aorta.
Have the marker dot superiorily oriented towards the
patient's head.
We can then slide the probe inferiorily
to probe position two
at the region just above the Umbilicus to visualize
the Aorta all the way down to Bifurcation into the
Periceliac.
Now if we're having problems visualizing the Aorta
due to the presence of a lot of bowel gas,
we can also get a glimpse of the Aorta from probe position
three, the Right Hepatic area.
This is going to be about the region where we're
going to look at the trauma fast Right Upper Quadrant
view, but here were going to angle the probe more interior
over the kidney to get a glimpse at the Abdominal Aorta
and long access.
Here's an image showing the Antatomy of the Aorta
that we'll need to know to perform Beside Sonography
of this structure.
Recall that the Inferior Vena Caba and Aorta form
two pair tubular structures that course through
the Abdominal compartment.
The IVC will be towards the patient's right
and the Aorta will be over towards the patient's left-side.
We see here the first major Abdominal branch
of the Aorta which is the Celiac Axis made up
predominantly of the Hepatic Artery
and the Splenic Artery.
The third branch, the left Gastric Artery is not
well seen on Bedside Sonography.
The next major branch that we can see using
Bedside Sonography is the Superior Mesenteric Artery.
This is a very important landmark as the Renal
Artery and Vein come out the Aorta at about this level.
In fact the Left Renal Vein courses right below the
Superior Mesenteric Artery.
We need to pay particular attention to the Infer-Renal
part of the Aorta as this is where the majority of
the Abdominal Aortic Aneurysms will originate.
Now we need to scan all the way down to the Bifurcation
of the Aorta into the Periceliac Arteries
and sometimes we'll catch small aneurysms
at the Distal Aspect of the Aorta that branch
into the Illiac Artery.
This is a Short-Axis configuration taken
of the Abdominal Aorta just below the subxiphoid
process of the Sternum looking through the liver.
Now, our first landmark should be the spine.
Notice that it has a hyperechoic or bright appearance
on Bedside Ultrasound.
Just above the spine we see the Inferior Vena Cava
with it's Respiratory Phasic Pulsations
towards the patient's right and the Aorta
towards the patient's left side.
We can apply Doppler sonography to further differentiate
the two structures and notice here we're doing Colorflow
Doppler and we again recognize the spine as our landmark
for recognizing the Vascular structures of the IVC
and the Aorta on top of the spine
and we see the Phasic Respitory pattern of bloodflow
within the IVC and the steady pulsations of blood
within the Aorta with each heart beat
differentiating the two structures.
Let's now take a closer look at the Celiac Axis,
the first major branch of the Abdominal Aorta
The Celiac Axis has the Ultrasound appearance of
a seagull sign and it's made up of three arteries,
the Hepatic Artery, the Splenic Artery
and the Left Gastric Artery, although the third
is usually not visualized well with Bedside Sonography.
Now, let's take a look at some Ultrasound images
of the Celiac Axis and we see a B-mode or gray scale
image to the upper right.
Notice the IVC to the right and the Aorta to the left.
We see the Celiac Axis coming off the Aorta
having the appearance of a seagull in flight.
Notice that the right wing of the seagull will
be the Hepatic Artery coursing towards the patient's
right side and the Splenic Artery will be branching
over towards the patient's left.
To the bottom we see a Colorflow Doppler image
of the Celiac Axis showing flow within both
the Hepatic and Splenic Arteries.
Here's a video clip of the Celiac Axis in action.
Again, we're in the short-axis configuration with the
probe marker over towards the patient's right side.
We identified the spine as our landmark for identification
of the IVC and Aorta Anterior to the spine
and we see here that the bright bone table
of the spine.
Notice the Inferior Vena Cava towards
the patient's right side and we see the Aorta
towards the patient's left side.
With the seagull sign made up of the Celiac Axis
coming up the Aorta.
Here we have video clip in which we'll look at
Ultrasonic appearance of the Celiac Axis using
Doppler Sonography.
We've again identified the spine by it's
hyperechoic or bright appearance and we see the IVC
over towards the patient's right and the Aorta towards
the patient's left.
As we look closely at the Aorta we see the branch
the Celiac Axis coming up anteriorly from the Aorta.
Again, having that classic appearance of the seagull sign
with the two branches, the Hapatic and Splenic Arteries.
The second major branch of the Abdominal Aorta
is Superior Mesenteric Artery also known as the SMA.
Now, the Superior Mesenteric Artery has a classic
appearance as it has a bright or hyperechoic rim
due to fat wrapped around the Artery.
Remember that it's at this level that the Renal Artery
and veins come up the IVC and Aorta and we must be very
aware of the Aorta at this area because of the presence
of Infer-Renal Aortic Aneurysms.
We see a B-mode or gray scale image over to the right
and we see the IVC and Aorta on top of the spine.
Notice the classic appearance of the Superior Mesenteric
Artery as it arches up the Aorta with it's hyperechoic
or bright rim.
Here we actually catch the Splenic Vein passing Anterior
to the Super Mesenteric Artery.
To the bottom we see a Colorflow Doppler image showing
the Superior Mesentary Artery coming off of the Aorta.
This video clip show the Proximal Abdominal Aorta
in short axis.
We identify the spine and the Aorta on top of
the spine.
There's the Celiac Axis coming up
and there's the Superior Mesenteric Artery
with the Splenic Vein over the top,
so again, Celiac and there's SMA and there's
the Splenic Vein wrapped on top.
Let's freeze down that image and again identify
the Superior Mesenteric Artery
with it's bright or hyperechoic rim
and the Splenic Vein passing anterior
to the SMA.
Here we'll apply Colorflow Doppler to further
examine the Superior Mesenteric Artery
coming up the Aorta.
We identify the Aorta on top of the spine
and we can see the Superior Mesenteric Artery
coming up anterior
from the Aorta.
Notice we can also catch the Splenic Vein wrapped
on top of the Superior Mesenteric Artery.
We'll go ahead and freeze that down.
There's Aorta towards the back of the image,
the Superior Mesenteric Artery anterior to the Aorta
and the Splenic Vein arching on top of SMA.
To complete your examination of the Aorta
it's important to look all the way to Bifurcation.
Here where I identified the spine and on top of that
the Distal Aorta and Short Axis.
As we scan more Distally, down to the level
of the Umbillicus, here we see the Bifurcation
of the Illiac Arteries.
So, we'll watch that again and there we see
Bifurcation bright at that point here.
There's the Periceliac Arteries and we can see
the right and left Illiac Arteries delineated well
on B-mode imaging.
Now we'll apply Colorflow Doppler
to look at the Birfurcation of the Aorta.
Again, we're in the Short Axis configuration
and we see the spine, the IVC to the right
and the Aorta to the left.
Let's put this into video play, now.
What we see here is the pulsations of flow within
the IVC and Aorta and we can see the Aorta
branching right there to the Periceliac Arteries.
Notice the pulsations within the both
of the Periceliac Arteries.
We'll still that down and we can see the right and the left
Illiac Arteries well delineated
with the Colorflow Doppler.
It's always important to look at body structures
in two planes, so now we're going to inspect
the Aorta in a Long Axis view.
The probe is place in the mid-sagittal orientation
with the marker towards the patient's head.
We have Superior to the left and Inferior
to the right.
We can identify the Aorta with it's pulsations and
it's thick muscular wall.
We see the branches of the Aorta, the Celiac Axis
branching more superiorly and the Superior
Mesentaric Artery
arching inferiorly into the intestine.
We can apply Colorflow Doppler
to the Aorta in Long Axis view,
and again, we can see the pulsations of the Aorta
with each heart beat.
We see the liver anteriorly in the mid-sagittal
configuration and notice the Celiac Axis arching here
superiorly and the Superior Mesentaric Artery moving
inferiorly down towards the intestine.
In conclusion, thanks for joining me
for this SoundBytes Module cover Part one
of Beside Ultrasound of the Aorta.
Using Bedside Ultrasound to detect an Abdominal
Aortic Anuerysms remains one of the most crucial
applications of Point of Care Sonography
for the Emergency Physician.
Hopefully by going through the module you now understand
the anatomy of the Abdominal Aorta, how to perform
the Ultrasound Exam of this structure and how
to interpret the images of the Aorta that you will obtain.
I hope to see you back as SoundBytes continues
and as we return in Beside Ultrasound of the Aorta
Part two when we're going to focus entirely on the
detection of Abdominal Aortic Anuerysms.

Brightcove ID

5508121223001

https://youtube.com/watch?v=uiTsFtanyzM

How to: Abdominal Aorta Measurements

Read more about How to: Abdominal Aorta Measurements

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Learn to measure the abdominal aorta with ultrasound.

Applications

Cardiology

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How To Videos

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Subtitles

- Once we've done the survey,
we wanna go back and take measurements
of the aorta in a transverse view in three levels.
One level is proximal above the level of the renal arteries,
the second is just at the level of the renal arteries
and the third is at the level of the bifurcation.
We're gonna go back to the epigastric area
and look for our landmarks again.
In the middle of the screen we have the aorta pulsating
to the right of the aorta the IVC
and anterior to the aorta we have
the superior mesenteric artery.
I'm going to freeze the image here
and perform two measurements.
Measuring from the outside wall to outside wall,
so I measure the entire size of the aorta
and just the residual lumen of an aneurysm.
I will perform two measurements, anterior to posterior,
and a transverse measurement.
From there I'm gonna move a little bit more inferior
optimizing the image so I can see
the wall of the aorta clearly.
I will freeze the image.
Perform my measurements, the same two views again.
From the outside wall
to the outside wall,
that's the AP measurement and the same for the transverse.
The measurement is displayed on
the bottom left of the screen and
in this case our measurement is 1.36 centimeters
by 1.69 centimeters.
So we're looking for a value of over three centimeters
to be considered aneurysmal.
I'll keep moving down in a transverse view
towards the bifurcation.
Here we see the aorta divide.
So right before it divides, I want to
perform my measurement at that point.
So I will freeze and perform the
same two measurements again.
Anterior
and transverse.
From outside wall to outside wall.
And that is the completion of the measurements
you need to do for the abdominal aortic exam.

Brightcove ID

5745409357001

https://youtube.com/watch?v=SHhKyEaW1NM

How to: Abdominal Aorta

Read more about How to: Abdominal Aorta

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Learn to examine the abdominal aorta with ultrasound.

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Subtitles

- So what I'd like to do now
is walk you through the abdominal aortic exam.
We do this exam when we're looking for
abdominal aortic aneurysm.
We're gonna use a phased array transducer.
This is a good all-purpose transducer
for the emergency department,
so you can use this for fast exam or abdominal aortic exam.
We're gonna start in the transverse view.
I'm going to put some gel on the patient,
from the epigastric area to the area of the umbilicus,
in a straight line.
I'm going to orient the transducer
so the marker is to the patient's right.
And i'm gonna place it straight up and down
in the epigastric area.
The first thing that you're gonna see
on the ultrasound image
is a round, pulsating structure in the middle of the image,
and this will be the aorta.
Immediately posterior to this round, pulsating area
will be the shadow of the spine.
So we just see the anterior surface of the spine
as the white, bright line,
and then behind this, we see a shadow.
That is what we call the spine shadow,
and you can use that as your landmark
to identify the aorta all the way down the body.
So we're gonna start in the epigastric area,
assessing the size of the aorta.
The first landmarks that we want to see,
to know that we are superior enough
above the renal arteries, is the SMA.
This is going to appear as a smaller anechoic circle
just anterior to the aorta.
So just be careful you don't mistake this
actually for the aorta 'cause it is possible
there could be an aneurysm
in the superior mesenteric artery as well.
Immediately anterior to this is the pancreas,
and then, to the right of the patient,
on the left of the screen, we see the IVC
as this hypoechoic structure.
So from this point, we're gonna move down
we're looking for the left renal vein to cross over
as our landmark for the renal level,
and we're gonna continue moving inferiorly.
If you see bowel gas like this,
just wiggle the transducer a little bit
to try to push it out of the way and work around it.
And I'm gonna decrease my depth as I move inferior
because the aorta is gonna move anterior in the body.
So I can decrease my depth to get it into better view.
'Kay, and we're dealing with some bowel gas here.
I just push it away with the transducer,
and here's the aorta, pulsating,
just sitting anterior to the spine,
with the IVC to the right.
I'm going to continue down to the level of the umbilicus,
pushing away the bowel gas,
and here, I see the aorta divide
into right and left iliac arteries.
So now we see two round circles instead of one.
Once we finish the transverse sweep,
we're gonna turn the transducer so the orientation marker
is facing the patient's head.
We'll place it again starting at the epigastric level.
I'm gonna increase the depth here a little bit,
find the aorta, and, at this point,
because I'm in a sagittal view,
it should appear as a long, black tube
moving from the left to the right of the image.
We can see here in the image,
I'm in the very proximal portion of the aorta.
We see the liver anterior to the aorta.
I move up a little bit, I can see the heart beating
just above the diaphragm.
So I know I'm at the very proximal level,
and I'm just gonna start to survey down the aorta.
The branch that I'm seeing here, coming at a shallow angle,
is the superior mesenteric artery.
So I know I'm above the level of the renal arteries
when I see that landmark.
I'm gonna continue down,
following it in a longitudinal view,
and again, I see the shadow of the spine
directly posterior to the aorta.
I keep moving down, working around the bowel gas,
looking for the long, black tube
immediately anterior to the spine.
And again, I do this all the way down
to the level of the umbilicus.
And I will see a left iliac artery
and a right iliac artery.
And again, I can decrease the depth to optimize my image
because it is so anterior
by the time you get to the umbilicus.

Brightcove ID

5745320579001

https://youtube.com/watch?v=AqAHzGijNIo

How To: Female Pelvis: Transabdominal View

Read more about How To: Female Pelvis: Transabdominal View

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Learn the basics of female transabdominal pelvic scanning.

Clinical Specialties

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- [Voiceover] A curved, or phased array transducer,
with a pelvis exam type,
is used to perform the pelvis ultrasound exam.
A full bladder is used as an acoustic window
to view the pelvic organs.
The pelvis is evaluated in two plains.
Place the transducer in a long axis position
with the orientation marker to the patient's head,
at the level of the symphysis pubis.
Angle the transducer inferiorly into the pelvis.
The bladder appears in the near-field of the image,
as a hypoechoic triangular structure.
The uterus is gray in appearance
and located either directly posterior
or superior to the bladder.
The endometrial stripe will appear as
a bright echogenic line from the fundus to the cervix.
The uterus does not always lay directly in the midline
so it may be necessary to slightly rotate the transducer
to view the entire length of the uterus.
Sweep the transducer from side to side
to see the entire uterus.
The ovaries may be seen by sweeping the transducer
to the lateral aspects of the pelvis.
They are almond-shaped and slightly hypoechoic structures.
Follicles may appear as multiple
hypoechoic, cystic structures within the ovaries.
Some follicles may be quite prominent,
depending upon the luteal stage.
To obtain a transverse view of the uterus,
rotate the transducer 90 degrees,
so the orientation marker is to the patient's right.
The bladder appears more rectangular in shape in this view.
Sweep the transducer superiorly
from the level of the cervix to the fundus
to see the entire uterus.
The ovaries will be seen on either side of the uterus
and can vary in location,
from a superior to inferior position.

Brightcove ID

5750473717001

https://youtube.com/watch?v=ebpcUlQVmLE

How To: FAST Exam: Female Pelvis

Read more about How To: FAST Exam: Female Pelvis

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Learn to examine the female pelvis for free fluid.

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Subtitles

- We're gonna do the FAST exam,
the pelvic view in a female now.
Again we have the phase array transducer,
here's our probe marker right here,
I'm gonna start off with a sagittal view.
And ideally, the (slurred) bladder is full.
So you go just above the symphysis pubis,
so we're scanning down here sagittaly,
and some of the anatomic landmarks
that we're looking at,
at the very top of the screen is the bladder,
which is an anechoic structure,
fluid filled, obviously with urine,
it's got nice walls around it.
Just below that is the uterus,
which is a pear-shaped organ.
You can see it well visualized
because the bladder is full.
And just below that
is a potential space, the Cul de Sac,
where we can look for, very carefully,
small amounts of free fluid.
When we scan this patient,
in this view, in the sagittal view,
from the patient's left to the patient's right.
And we're slowly slowly scanning to see
if there's any evidence of free fluid.
Once we finish the sagittal view,
we want to go ahead and do a transverse view.
What we're gonna do now
is point the transducer marker toward the patient's right.
So we're gonna rotate that transducer,
toward the patient's right.
Again, we see the bladder in the center of the screen.
We're now gonna scan from inferior,
just below the symphysis, to more superior,
and in between we're also gonna identify the uterus.
So we're going right to the very top of the bladder,
to about mid-bladder,
we can see the uterus here in the center.
A very small amount of free fluid here,
which can be physiological as well.
So we're scanning all the way inferiorly,
to more superiorly, we see the uterus,
we actually see part of the ovary there,
and then we're gonna go all the way more superiorly.

Brightcove ID

5508120185001

https://youtube.com/watch?v=HxQE2gYH3Sk