Rupture

- [Voiceover] A curved or phased array transducer
with an abdomen exam type is used to perform
an aorta ultrasound exam.
The entire length of the aorta from
the level of the diaphragm
to the bifurcation of the iliac arteries
must be evaluated in two planes.
The examination begins with the transducer
placed transversely in the epigastric mid line,
with the marker directed to the patient's right.
The aorta is seen as a round, pulsatile structure,
anterior to the bright reflection of the vertebrae.
The vena cava is an oval structure
immediately to the left of the aorta on the screen,
which changes in caliber with compression
or deep inspiration.
The abdominal aorta will course gradually,
becoming more superficial as it progresses distally.
The transducer is slowly moved distally
to identify the celiac trunk,
renal arteries,
superior mesenteric artery,
and bifurcation to the iliac arteries.
Note the location of any change in size
of the aorta or iliac arteries,
and measure in long and short axis views
from outer wall to outer wall
to determine the true diameter.
The transducer is returned to the epigastric area
and rotated 90 degrees clockwise,
with the orientation marker to the patient's head.
The transducer is swept side to side
to identify the maximal diameter of the aorta.
The abdominal aorta will have proximal to distal taper.
The transducer is moved distally
to evaluate the walls of the aorta
for any change in the shape or size.
If the aorta is difficult to visualize
due to overlying bowel, gentle downward transducer pressure
may encourage peristalsis of the overlying bowel.
Alternatively, consider moving the patient
into a left lateral decubitus position
to re-position the bowel away from the field of view.

Brightcove ID

5508114778001

https://youtube.com/watch?v=NI-tU5w-gzg

3D How To: Ocular Ultrasound

Read more about 3D How To: Ocular Ultrasound

/sites/default/files/Ocular_Disclaimer_edu00470_thumbnail.jpg

3D animation demonstrating an ocular ultrasound exam, or ultrasound of the eye.

Media Library Type

How To Videos

Media Library Tag

Ocular

Intraccular Structures

Intraoccular Foreign Body

Intercranial Pressure

Membrane Optic Nerve Sheath Measurement

Elevated

Increased Intercranial Pressure

Subtitles

- [Voiceover] A linear array transducer with an ophthalmic
exam type is used to perform an ocular ultrasound exam.
The eye is evaluated in two planes.
Apply a copious amount of ultrasound gel to the closed eye.
Gently place the transducer in the transverse position
with the orientation maker to the patient's right.
The globe of the eye is seen as a round,
dark fluid filled structure.
Several structures are identified in the globe.
The cornea is a thin layer parallel to the eyelid.
The anterior chamber and the lens are anechoic,
separated by the thin, echogenic iris.
The choroid and retina form a thin, light grey layer
at the posterior aspect of the globe.
The optic nerve sheath is hypoechoic, or dark grey,
moving away from the globe.
Angle the transducer from the superior to inferior
aspect of the globe to visualize each structure.
From the transverse position, rotate the transducer
90 degrees so the transducer orientation marker
is directed towards the top of the patient's head.
Angle the transducer from side to side to visualize
the lens, retina, and optic nerve sheath.

Brightcove ID

5508136018001

https://youtube.com/watch?v=weS0JvDRBG4

3D How To: eFAST Pelvis

Read more about 3D How To: eFAST Pelvis

/sites/default/files/EFast_Pelvis_EDU00457_Thumbnail.jpg

3D animation demonstrating the pelvis view while performing an eFAST exam.

Media Library Type

Media Library Tag

Subtitles

- [Voiceover] A phased array transducer
with an abdomen exam type
is used to perform the pelvis view of the fast exam.
Place the transducer in a transverse position
with the orientation marker to the right
at the level of the symphysis pubis.
The pelvis is evaluated in two planes.
It is easier to perform this exam
when the bladder is filled.
The bladder is used as an acoustic window
to view the cul de sac
or retrovesicular space for free fluid.
To visualize the bladder,
angle the transducer inferiorly into the pelvis.
If it is difficult to visualize the bladder,
slide to the left or right of the symphysis pubis
to bring the bladder into view.
To evaluate the pelvis for free fluid,
sweep the transducer from an inferior to superior position.
Fluid will appear hyperechoic or anechoic
and accumulate posterior to the bladder,
posterior to the uterus, and between loops of bowel.
To obtain a long access view,
rotate the transducer 90 degrees
with the orientation marker
pointed toward the patient's head.
Sweep the transducer across the pelvis from left to right
to evaluate the pelvis for free fluid.

Brightcove ID

5508134284001

https://youtube.com/watch?v=pFtpx-yZfe0

Body

3D animation demonstrating the pelvis view while performing an eFAST exam.

Case: Ocular Ultrasound Part 2

Read more about Case: Ocular Ultrasound Part 2

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Part 2 of 2. Ocular ultrasound case study.

Clinical Specialties

EMED

Media Library Type

Case Study Videos

Media Library Tag

Ocular

Intraccular Structures

Intraoccular Foreign Body

Intercranial Pressure

Membrane Optic Nerve Sheath Measurement

Elevated

Increased Intercranial Pressure

Soundbytes Cases

Subtitles

- Hello, my name is Phil Perera,
and I'm the Emergency Ultrasound Co-Director
at the LA County USC Medical Center
in Los Angeles, California.
And welcome to SoundBytes.
Welcome back to SoundBytes,
Ocular Ultrasound Part 2.
In this module,
we'll further explore ocular ultrasound building
on those concepts introduced
in ocular ultrasound module part one.
We'll learn how to diagnose retinal pathology,
specifically retinal detachment.
We'll also look at vitreous pathology,
a possible mimic of retinal pathology,
such as retinal detachment.
And we'll learn how to differentiate
between the two conditions,
using the kinetic or movement examination.
Now let's take a look at an illustration
showing the anatomy of a retinal detachment.
We note the anterior structures of the eye,
the cornea, anterior chamber, lens, and iris
are all normal in this illustration.
The pathology exists in the posterior aspect of the eye.
In the posterior part of vitreous body.
And we note here that the retina has buckled
away from the choroid,
both medially and laterally.
And this is a very bad thing because the blood supply
to the retina exists through the choroid.
And the lack of opposition of these two layers
will cause ischemia of the retina with time.
Now we remember that the retina is a continuation
of the optic nerve, thus the retina will always be
attached there or tethered down to the optic nerve.
The retina is also going to be attached or tethered down
anterior and laterally at the ora serrata.
And this is important as we start to look at ultrasounds
of retinal detachment.
Now let's return to our patient's ocular ultrasound.
Placing the probe in a side to side
or transverse orientation over the affected eye.
Right away we note that there's pathology within
the posterior aspect of the eye.
And we can see a hyperechoic or bright structure
waving around in the posterior aspect of the eye
that should not be there.
We'll look at the patient's other in the small video
to the right and we note here the normal appearance
of the retinal tacked down to the choroid.
So in the affected eye, this is actually
a detached retina that's moving around
as the patient looks up and down.
And we have the probe position over the patient's eye.
So right away, our diagnosis within immediate orientation
of the probe onto the eye is, retinal detachment.
Here's the ultrasound from another patient
who presented with non traumatic loss of vision.
And again, we note the classic appearance
of a retinal detachment.
We have the probe configured in a side to side orientation,
or transverse orientation over the patient's eye.
With the probe marker oriented lateral.
We can see the optic nerve sheath coming up
from the posterior aspect into the eye.
And we note the detached retina emanating off
from the optic nerve.
Now recalling that the macula lies just lateral
to the optic nerve, we can see here that this detachment
has affected the macula.
That this is classified as a mac off,
or macular off retinal detachment.
Now let's take a look at a retinal detachment
using the kinetic ultrasound examination.
We're having the patient look from side to side
as we place the probe over the closed eyelid.
And we note here a very large posterior detachment
of the retina.
We can see here that it has tethered membrane appearance
as the patient looks from side to side.
Now we note some anterior vitreous material
that swirls around as the patient looks from side to side.
But I want you to look towards that posterior aspect
of the eyeball.
Towards that membrane, the tethered membrane,
that moves back and forth as the patient looks
from side to side.
And that is the classic appearance on kinetic exam
of a detached retina.
Here's another ocular kinetic exam of a retinal detachment.
And we can see the tethered membrane appearance
of the detached retina moving around
as the patient looks from side to side.
But we can see that it has a classic V that tethers in
at the optic nerve sheath right there.
And I'm gonna still that image down.
And again we can see the optic nerve posteriorly
coming up towards the back of the eye.
And the detached retina tethered right there
to form a V coming anteriorly into the vitreous material.
So that's a classic appearance of a retinal detachment
on kinetic examination.
Always tethered at the optic nerve.
Here's another video clip showing the kinetic examination
detailing a retinal detachment.
As the patient looks from side to side,
we can see the serpentine motion, the flicker,
of the retina which moves around as a tethered membrane
in the back portion of the patient's eye.
But notice it has the classic appearance,
that it's tethered there, both posteriorly
at the optic nerve, and anteriolaterally
at the ora serrata.
So another classic appearance of a retinal detachment
on bedside exam.
Here's a bedside ultrasound examination
from another patient who had painless loss of vision.
And looking into the back of the eye,
we see another classic appearance
of a retina detached off the back of the eye.
Notice it has a classic membrane type appearance
that layers out in the back of the eyeball.
Now as I mentioned in the earlier part of this module,
we should always investigate body structures
in two planes and retinal detachments
are no exception to that rule.
Here' we're going to now place the probe in a vertical
up and down orientation.
And what's interesting is,
now I have the patient looking down.
So I can best see the inferior aspect of the eye.
And we note that this retinal detachment
is mainly an inferior detachment.
And we can see here, the detached retina
coming off as a membrane that tethers in at the optic nerve
which we can see that black area coming in
to the back of the eye.
And we can see the detached membrane
is predominantly located inferior to the optic nerve.
Now it's important to realize that there are possible
mimics of retinal detachment both on clinical evaluation
and on bedside ultrasonography.
Vitreous pathology, such as vitreous hemorrhage and
vitreous detachment can be confused with retinal detachment.
And the symptoms can overlap
with that of retinal detachment.
Patients can have both floaters and vision loss.
And while at first glance, the ultrasound may
confuse the two, there are important concepts
with ultrasound in order to discriminate
the two conditions one from another.
This ultrasound was taken from a patient
who's experienced multiple floaters within their right eye.
And what we see here is the classic appearance
on bedside ultrasound of vitreous blood.
And we can see the speckles of the vitreous material
within the vitreous cavity,
the posterior aspect of the eye ball.
Now to best visualize vitreous hemorrhage on bedside
ultrasound, it's important to realize that we may have to
turn the gain up for a high level
for optimal visualization of vitreous hemorrhage.
But again, we see the classic appearance, those little
speckles of vitreous blood within the vitreous body.
This ultrasound was taken from another patient
with painless loss of vision.
And again, looking into the vitreous body,
we see vitreous material present within the posterior
aspect of the eye.
This is the classic appearance of vitreous detachment.
All that vitreous material has accumulated there
within the posterior aspect of the eye.
Leading to vision loss and prominent speckles
or floaters as the patient looked from side to side.
Because vitreous pathology can be confused with
retinal detachment, it's really crucial to employ
the kinetic examination as an aid to best diagnose
retinal detachment versus vitreous pathology.
In this clip, we see vitreous material
that's congealed within the back of the eye
and notice as the patient looks from side to side,
it tumbles around there within the posterior aspect,
the vitreous cavity of the eye ball.
And here again, we'll see the patient looking from
side to side more rapidly and notice the classic
tumbling motion of the vitreous material
within the back of the eye.
This is to be differentiated from a retinal detachment
as the retina will have more of a tethered membrane
appearance as it's going to be attached within
the back of the eye at the optic nerve
and anterolaterally at the ora serrata.
Vitreous material will tumble like clothes
within a dryer as it's not attached
within the posterior aspect of the eye.
Very different than a retinal detachment.
Now that we understand more about vitreous hemorrhage
and vitreous detachment,
in comparison to retinal detachment,
let's take a look at this video clip
from a patient who presented with painless loss of vision.
Note the huge amount of vitreous material
that's accumulated within the vitreous body,
the posterior aspect of the eye.
And notice that it tumbles around as the patient looks
from side to side.
So this was a huge amount of vitreous hemorrhage.
Vitreous material that accumulated within the back
of the eye of this patient who was a diabetic.
And notice a classic clothes dryer tumbling motion
of this vitreous material.
Just to reinforce the difference on bedside ultrasound
from a retinal detachment, in the small box I've put there
the video clip of the retinal detachment.
Notice there, the tethered membrane appearance
as the patient looks from side to side.
Very different than the clothes dryer
tumbling motion of the vitreous material as we see
in the large clip in the middle of the image here.
In conclusion, thanks for tuning in
for this SoundBytes module.
Going over part two of ocular ultrasound.
Now you're ready to use ocular ultrasound as an effective
tool to investigate pathology of the eye.
Opening up that back part of the eye
for better examination than we previously been able to
using the traditional fundoscopic exam.
You'll quickly make the diagnosis of retinal pathology
using bedside ultrasound.
And hopefully now be able to discriminate
that from vitreous disease.
Potentially improving the management of patients
presenting with ocular complaints
to the emergency department.
So I hope to see you back in the future
as SoundBytes continues.

Brightcove ID

5745551911001

https://youtube.com/watch?v=lQo-Nm0Y5m0

Case: Ocular Ultrasound Part 1

Read more about Case: Ocular Ultrasound Part 1

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Part 1 of 2. Ocular ultrasound case study.

Clinical Specialties

EMED

Media Library Type

Case Study Videos

Media Library Tag

Ocular

Intraccular Structures

Intraoccular Foreign Body

Intercranial Pressure

Membrane Optic Nerve Sheath Measurement

Elevated

Increased Intercranial Pressure

Soundbytes Cases

Subtitles

- Hello my name is Phil Perrea
and I'm the emergency ultrasound co-director
at the LA County USC Medical Center
in Los Angeles, California.
And welcome to Soundbytes.
Today's clinical case is entitled
Fourth of July in My Eye.
And our patient today is a 24 year old male
who presents to the emergency department
complaining of painless loss of vision to his right eye.
Initially, he was reading an engineering textbook
in preparation for final exams
when he experienced flashes of lights
into the right eye like fireworks.
And now he notes decreased vision to his right eye
described like a curtain coming in from the side.
So the history taken from our patient
suggest pathology in the posterior aspect
of the patient's eye.
And unfortunately for us,
this has traditionally been a black box area of the eye
as it's very difficult to examine using traditional means.
So that leads us into our clinical question for today,
which is for physicians working in the emergency department
in the year 2011,
what techniques do we currently have
to make the diagnosis of pathology
within the posterior aspect of the eye
and can we do better than our traditional testing.
Traditionally we've used the fundoscopic exam
to examine the posterior aspect of the eye,
and interestingly enough,
we're currently using technology, the opthalmoscope,
which was originally invented in the year 1851
by Von Helmholtz in Germany.
Now this was adapted in 1915 by Welch Allen
into our modern opthalmoscope that we see here
to the upper left,
and we've had a slight improvement
with the fundoscopic gun, as shown here towards the right,
which may give a better view of the retina.
However it's well understood by ophthalmologists
that direct opthalmoscopy gives a limited view of the retina
in comparison to the techniques that they'll use
on examination of the retina,
which is indirect opthalmoscopy
using a mirror and curved lens.
In fact, making the topic of ocular ultrasound
very pertinent for the emergency physician,
is the fact that the eye is actually
the perfect organ for ultrasound examination
and could not have been engineered better.
Fluid throughout the eye
allows for great conduction of sound waves
through the anterior part of the eye
into the posterior aspect of the eye,
and excellent imaging of all parts of the eye.
Many type of pathology can be correctly diagnosed
using bed side ultrasonography.
So what do I need to perform this examination?
Well any standard emergency department
bedside ultrasound machine will do well for this exam.
We'll need to have the high frequency
linear array type probe,
that's the probe that you're already using
for vascular access,
which we'll be using for ocular ultrasound.
We'll need lots of gel,
or preferably surgilube,
as surgilube is less irritating to the closed eyelid.
Now let's watch a video on how to perform
the ocular ultrasound examination.
Here we have the high frequency
linear type array probe in our hand,
and note we've prepared our patient
with a copious amount of sergilube
on the outer part of the closed eyelid.
We're going to gently place the probe
over the patient's closed eyelid,
scanning through the eye,
and note that we're going to orient the probe
both superior and inferior
looking all the way through the eye
from the anterior aspect down through the posterior part.
Now from this orientation, I like to have the probe marker
oriented laterally
towards the outer part of the patient's face
so that I know where the structures
of the posterior part of the eye are oriented.
Now let's take a look at that same
ocular ultrasound approach
from a more anterior position.
Note again that we're placing the probe,
the high frequency linear type array probe,
over the closed eyelid
in a side to side orientation.
Now the probe marker is going to be oriented laterally
towards the outer part of the patient's face.
Now remember that if there's any question of trauma
or globe rupture,
we have to be extremely careful
when applying the probe onto the eyelid.
In fact, we should really be scanning through
a copious amount of gel, known as a gel pillow,
and really not applying any pressure down
to the actual eye.
To complete our examination of the eye
we should also perform ocular ultrasound
from the vertical approach,
having the probe in an up and down configuration.
Note here, we're again scanning through the closed eyelid.
Now we have the probe marker up towards the patient's head.
We want to scan from side to side
to fully investigate the eye
in a second plane
for any signs of pathology.
And here is just a closed in view
showing the probe placed over the closed eyelid.
Here's a more anterior view,
again, showing the vertical approach
to bedside ocular ultrasound.
Note the high frequency probe placed over the closed eyelid
and scanning from side to side
will image all parts of the eye.
Remember that the probe marker for this vertical approach
is going to be oriented superiorly.
And imaging in two planes
will best round out the examination of the eyeball.
Now let's take a moment to review the anatomy of the eye
that we'll see using bedside ocular ultrasound.
Here's a nice pictorial of the eyeball.
Lateral of the eye to the left
and medial aspect of the eye to the right.
Let's start with the most anterior structure, the cornea,
which we see towards the top part of the image.
We can see the lens,
which is located directly below the cornea,
which will have a distinct hyperechoic
or bright appearance on bedside ultrasound.
We note the iris coming in to attach to the lens,
another structure that can be seen
using bedside ultrasound.
Now that region anterior to the iris
is known as the anterior chamber.
And we can also image pathology
within the anterior chamber, really hyphemas.
Now behind the lens is going to live
the vitreous body,
filled with vitreous gel,
which allows the eyeball to keep that rounded configuration.
We see blood vessels arching up into the vitreous body.
Now let's recall the outer parts of the eyeball
and the fibrous coat, the sclera,
is the outermost portion of the eye.
We see the medial aspect of the coats of the eyeball,
the choroid, which is the vascular layer
which supplies the retina with blood,
and then we see the inner neural layer, the retina.
And we note that the optic nerve comes in posteriorly,
another structure which can be seen on bedside ultrasound
to give rise to the retina.
Now we note here,
the indentation, the macula,
which is seen just lateral to the optic nerve.
And we recall that the macula
is the area of the densest composition
of rods and cones.
Here's a typical ultrasound of a normal eye.
This eye is taken in the horizontal
or side to side probe configuration
with the probe marker lateral.
We see the cornea, the anterior most structure of the eye,
and we see below the cornea, the rounded iris.
Note the classic appearance of the lens
just below the iris,
which has a hyperechoic or bright appearance
due to its very hard refractive pattern.
And we can see little refraction waves
coming off the back of the lens.
Note the anterior chamber, the potential space,
just anterior to the iris
and below the cornea.
We see the vitreous body and back of the lens
and note the retina, well seen here,
to the posterior aspect of the vitreous body.
This retina is well tacked down
and in opposition to the posterior aspect of the eye.
That's a normal examination.
Now if we have the probe in a side to side
or transverse orientation, across the eye,
with the probe marker lateral
and we aim the probe a little bit more inferiorly
down towards the patient's foot,
the optic nerve sheath will come into view.
Note the optic nerve has a classic appearance
on bedside ultrasound.
It's dark or hypoechoic.
And we can see it leading right up to the back of the eye.
In conclusion, thanks for tuning in
to part one of ocular ultrasound.
I hope I've been able to score the point through this module
that ocular ultrasound is an easily learned
and very helpful technique for the emergency physician
and in the year 2011,
finally allows excellent imagining
of that black box posterior area of the eye.
I hope to see you back in the future
as Soundbytes continues,
and as we return in ocular ultrasound part two,
focusing on retinal pathology.

Brightcove ID

5745552411001

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

Case: Intrauterine Pregnancy - Part 2

Read more about Case: Intrauterine Pregnancy - Part 2

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This video discusses how to use ultrasound to determine the gestational age of a normal pregnancy, determine a fetal heart rate, and identify markers for an abnormal pregnancy and fetal demise.

Clinical Specialties

Media Library Type

Media Library Tag

Tubal Ectopic Abdominal Ectopic

Ampullary

Ovarian

Pseudogestational Sac

Subtitles

- [Voiceover] Hello, my name is Phil Perera
and I am the emergency ultrasound coordinator
at the New York Presbyterian Hospital in New York City.
Welcome to Soundbytes Cases.
In this module entitled Emergency OB/GYN Ultrasound:
Part 2 of Intrauterine Pregnancy,
we're going to focus on the further assessment
of normal pregnancy.
We'll look at two further things that
are important to assess in your pregnancies.
First of all, learning how to date the gestational age
of the pregnancy, as well as learning
how to determine the fetal heart rate.
Then we'll wrap up the module by examining further findings
in abnormal pregnancies and learning how to differentiate
these findings from a normal intrauterine pregnancy.
The first concept that we'll focus on
is dating fetal gestational age.
In the first trimester, we're going to use an assessment
of the crown rump length.
Interestingly, dating in the first trimester
is actually probably the most accurate during all
phases of pregnancy, as there's a difference in
the growth curve as the fetus develops.
In the second trimester, we'll measure
the skull biparietal diameter.
And the third trimester, the dating is composed
of the biophysical profile, focusing on the femur length,
as well as other biophysical measurements.
This is an image of a first trimester pregnancy,
and we're going to evaluate the gestational age by
measuring the crown rump length.
Here we see the fetal pole stretched across
the gestational sac and we see the crown located
over towards the right and the rump towards the left.
If we put the calipers down from the crown across
to the rump we get a measurement of 1.46cm.
By selecting Crown Rump Length in the software package
on the ultrasound machine, we'll get an assessment
of gestational age which we can see here towards
the bottom left, seven weeks and six days.
As first trimester dating is considered one of the most
accurate during the entire pregnancy, it's nice to print
this image out and give to your patient to take for
their followup visit with their OB/GYN.
In the second trimester, dating of gestational age
focuses on skull circumference or measurement of
the biparietal diameter.
We want to measure the skull at about the level
of the thalamus in an axial orientation with the face down.
As we can see here, replacing the calipers from
the outer skull table proximally to the inner skull
table distally, and we have a measurement of 3.26cm
correlating to a 16 week one day gestational age.
In addition to measuring the gestational age of the fetus,
another very important concept is to get a measurement
of the fetal heart rate.
Normal fetal heart rates will range from 120-160
beats per minute, but lower rates down to 90 beats
per minute can be seen in early pregnancy in
the early parts of the first trimester.
M-Mode is the best method for determining fetal heart rate.
Power Doppler and Contrast gives more ultrasonic energy
to the developing heart, thus M-Mode is the preferred
way of measuring the fetal heart rate at this time.
Here, we're going to use M-Mode to determine
the fetal heart rate.
Notice we have the fetus zoomed up towards the top
of the image and replacing the M-Mode caliper directly
over the fetal heart.
Towards the bottom we see the M-Mode Motion strip
and notice the little waves showing the motion
of the fetal heart.
In this particular ultrasound machine, we need to
measure between each peak, and we see here that
we get a heart rate determination towards the bottom,
158 beats per minute.
This is something we can print out and place on the chart
to show that at the time we saw the baby there was
an actual heart beat.
While fortunately most pregnancies have a successful
outcome, unfortunately there are going to be some
abnormal pregnancies that we'll see in the emergency
department, consistent with fetal demise.
Some of the measurements we'll use to determine
abnormal pregnancy with fetal demise is a very large
gestational sac greater than 10 millimeters if
no yolk sac is seen.
Once the gestational sac is greater than 18 millimeters,
we should see a fetal pole or else this is an abnormal
pregnancy.
And many times the gestational sac in an abnormal
pregnancy will have an irregular shape with a scallop
type appearance to it.
Here's video from an abnormal pregnancy.
The first thing we notice is a very large
gestational sac without a yolk sac or discernable
fetal pole with heart beat.
We also see the presence of subchorionic hemorrhage
to the superior aspect of the gestational sac.
That's that area of dark or anechoic fluid
surrounding the gestational sac.
This is seen commonly with abnormal pregnancies
or spontaneous miscarriage.
Here, we'll put the calipers down to measure the diameter
of the gestational sac.
Note that it's very large at 2.8 centimeters by
1.6 centimeters, much larger than the one centimeter
mark that we said defined an abnormal pregnancy
if there was no yolk sac or 18 millimeters if no
fetal pole was seen.
Other indicators of an abnormal pregnancy with fetal
demise is a gestation greater than seven weeks,
which is abnormal if no fetal heart beat is seen.
And if the fetal pole is greater than five millimeters
in dimension this is abnormal if no fetal
heartbeat is seen.
This was an unfortunate case in which we see
a large a fetal pole, greater than five millimeters
without a heart beat.
This is indicative of embryonic demise and we also
see a large circular amnion within the gestational sac.
While I do think it's important we're able to pick up
the findings of the abnormal pregnancy, I'm always
going to get a confirmatory ultrasound and/or OB/GYN
consultation before giving the patient the news that
there is a fetal demise.
I'd like to conclude this module with another form
of abnormal pregnancy, which is a molar pregnancy,
which is a form of Gestational Trophoblastic Disease.
Gestational Trophoblastic Disease ranges from
a spectrum from a Benign Hydatidiform Mole to
Invasive Choriocarcinoma, a form of metastatic disease.
The majority of these are derived from paternal
chromosomes; there is no maternal chromosomes in the embryo.
The ultrasound appearance will be a cyst-like bunch
of grapes with a snowstorm-type appearance,
and classically the serum Beta-HCG will be very elevated.
Here's video from a patient who presented with
a Molar Pregnancy.
Her presenting symptoms were uncontrolled hypertension
during the pregnancy, as well as vaginal bleeding, and pain.
What we see here is the presence of a molar pregnancy
within the fundal region of the uterus.
Notice it has a cyst-like type of appearance.
Very different from the normal appearance
of a intrauterine pregnancy.
As we scan back and forth, it almost looks like
a bunch of grapes within the fundus of the uterus.
So a diagnosis of a molar pregnancy and my next move
was to get an OB/GYN consultation stat.
So thanks for tuning in to Part 2 of Emergency OB/GYN
Ultrasound, focusing on intrauterine pregnancy.
Hopefully you now have a better understanding on
how to further assess a normal pregnancy by determining
gestational age and fetal heart rate.
I hope also I've been able to give you some of
the ultrasound findings that you may see in an
abnormal pregnancy to know when you need to get
an OB/GYN consultation in the ED.
I hope to see you back as we move on to Ectopic Pregnancy,
and two modules in which we'll discuss the various
findings of ectopic pregnancies that we may see
in the emergency department.
I'll see you back as Soundbytes continues.

Brightcove ID

5750480594001

https://youtube.com/watch?v=4clxpcVLOS0

Case: Intrauterine Pregnancy - Part 1

Read more about Case: Intrauterine Pregnancy - Part 1

/sites/default/files/perera_intrauterine_part1.jpg

This video discusses the use of transvaginal and transabdominal ultrasound for detecting intrauterine pregnancies.

Clinical Specialties

Media Library Type

Media Library Tag

Tubal Ectopic Abdominal Ectopic

Ampullary

Ovarian

Pseudogestational Sac

Subtitles

- 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 module entitled Emergency OB/GYN Ultrasound: Part I,
we're going to focus entirely on the
ultrasound findings of intrauterine pregnancy.
Now patients with early pregnancy and vaginal bleeding
with or without abdominal pain
are frequently seen in the emergency department.
Luckily for us, emergency OB/GYN ultrasound
has evolved to be one of the most helpful
applications of sonography
in a busy emergency medicine practice.
So this module will be focused
primarily on the detection of intrauterine pregnancy
and we'll examine the ultrasound findings that define
a normal pregnancy for an emergency physician sonographer.
Before launching into the sonographic findings
of a normal intrauterine pregnancy,
let's take a moment to quickly review
the OB/GYN anatomy important for this application.
We see the uterus to the left and adnexa to the right.
Notice the areas of the uterus.
We see the lower cervix,
the intermediate body,
and the fundal region towards the top of the uterus.
Now, the fundal region is where we define
an intrauterine pregnancy to be located.
We see the area where the fallopian tube
enters into the uterus,
which is the interstitial region in a normal uterus
and the cornual region in a bicornuate uterus.
And this is where some variants of ectopics can implant.
Notice the areas of the fallopian tube to the right,
which we'll concentrate more on
with regard to ectopic pregnancy.
And we see the broad ligament there encasing
the fallopian tube and the ovary as seen to the right.
When taking care of a patient
who has vaginal bleeding in pregnancy,
there's four main classifications of diagnoses.
The first is a Threatened Abortion,
which is defined as the presence
of an intrauterine pregnancy with bleeding.
The second main classification
encompasses several different terms.
The terms that are commonly used are,
Incomplete Abortion,
Missed Abortion,
Blighted Ovum,
and Fetal Demise.
Basically, all of these mean the presence
of fetal membranes or parts,
without expected fetal growth or cardiac activity.
The third main classification is a Completed Abortion,
in which there is no further presence
of fetal membranes or parts,
and on examination, usually the cervical os will be closed.
The fourth main classification is the most dangerous,
is Ectopic Pregnancy.
Here's a table showing the structures in pregnancy
and about the time that they're seen on transvaginal
versus transabdominal sonography.
As we look in the Embryonic Structure column to the left,
we see the first structure that appears
is a gestational sac, seen on transvaginal sonography
at about 4.5 to 5 weeks,
and about a week later on transabdominal sonography.
The yolk sac is seen at about 5 to 5.5 weeks
on transvaginal sonography
and a week later on transabdominal sonography.
I have this circled in red,
as this is really the way we diagnose
an intrauterine pregnancy.
Then note the fetal pole is seen at about 5.5 to 6 weeks
on transvaginal sonography
and a week later on transabdominal sonography.
The last main finding, which is a fetal heart beat,
is seen at about six weeks on transvaginal sonography
and about at seven weeks on transabdominal sonography.
Another important concept for OB/GYN sonography,
is the correlation of the serum beta HCG
to the findings of a normal pregnancy.
As we see here for transvaginal sonography,
the discriminatory zone at which we will see
findings of an intrauterine pregnancy
are about 1,500 to 2,000 mIU.
For transabdominal sonography,
the discriminatory zone is about 6,500 mIU.
Now, this rule does not apply to ectopic pregnancies,
which secrete beta HCG at atypical levels
and are commonly seen with betas all over the map.
They can be seen with betas lower than 1,000
and as high as 30,000.
The first finding that will occur
during an intrauterine pregnancy
is going to be a gestational sac.
As we see here in the ultrasound picture to the right,
it's a small, round circle that's dark
or hypoechoic in relation to the rest of the uterus.
We actually see a gestational sac below that
that came out of a patient.
Notice that it has a translucent, membrane-type appearance.
Unfortunately, gestational sac
is not diagnostic of an intrauterine pregnancy,
as a pseudogestational sac of ectopic pregnancy
can be seen from hormonal stimulation.
As a general rule of emergency ultrasound,
is that visualization of a gestational sac
is not adequate to call an intrauterine pregnancy.
Here's two video clips showing the gestational sac.
Long Axis to the left,
and Short Axis to the right.
We see here a very small diameter gestational sac
in both of these orientations.
Unfortunately, this can be seen with a
pseudogestational sac of ectopic pregnancy.
So a small gestational sac, like this,
is in no way diagnostic of an intrauterine pregnancy
for the emergency physician sonographer.
Remember that the gestational sac is seen
at about 4.5 to 5 weeks on transvaginal sonography,
and about a week later on transabdominal sonography.
Here are the findings that we define
as indicative of an intrauterine pregnancy
for an emergency physician sonographer,
and that is the presence of a gestational sac
with a yolk sac inside.
As we see in the picture to the right,
the yolk sac has a circular-type appearance
that we call the Positive Cheerio Sign.
Let's just remember, gestational sac plus yolk sac
is indicative of intrauterine pregnancy.
However, bonus points are given
if you see a fetal pole with a heart beat
for confirmation of intrauterine pregnancy.
Here's a video clip showing a definitive
intrauterine pregnancy.
What we see here is a larger gestational sac
and as we look inside the gestational sac,
we see the positive yolk sac or Cheerio Sign.
Notice the circular yolk sac is seen
towards the inferior aspect of this gestational sac.
This would be diagnostic of an intrauterine pregnancy,
effectively ruling out an ectopic pregnancy
in the vast majority of patients.
Remember that the yolk sac is seen
at about 5 to 5.5 weeks on transvaginal sonography,
and about a week later on transabdominal sonography.
Here we see a pregnancy that is a bit further advanced.
Note we have a larger gestational sac,
that darker or hypoechoic area,
within the fundal region of the uterus,
and as we look inside the gestational sac,
we see the positive yolk sac or the Cheerio,
and looking just to the left of the yolk sac,
we see a tiny little fetal pole there.
Interestingly enough, as we zoomed up on that fetal pole,
we could make out the flicker of a heart beat.
So, a definitive intrauterine pregnancy.
Recall that the fetal pole is seen
at about 5.5 to 6 weeks on transvaginal sonography,
and about a week later on transabdominal sonography.
Here's a transvaginal short axis view
of a seven week intrautertine pregnancy.
We see the gestational sac here.
Notice that the gestational sac
is located in the center of the uterus
as seen here in short axis,
and there's a good amount of myometrial mantle
surrounding the gestational sac,
signifying a fundal location.
We see the positive Cheerio sign, or yolk sac,
to the upper right aspect of the gestational sac,
and right below, we see the fetal pole stretched out.
Notice the positive cardiac activity
as we scan back and forth through the fetal pole.
Here's another intrauterine pregnancy at about seven weeks,
again in the transvaginal short axis view.
We note the good amount of uterus
surrounding the gestational sac,
signifying the fundal location.
We see here the yolk sac or Cheerio sign,
and the fetal pole is stretched out below the yolk sac.
Notice the positive cardiac activity
within the fetal pole.
Now we see another very important finding here
on this ultrasound,
which is the amniotic membrane,
billowing out from around the fetal pole.
Eventually the amniotic membrane
will plaster down on the margins of the gestational sac
to form the amniotic cavity,
in which further growth of the fetus will occur.
Here's an interesting video clip
showing a twin pregnancy.
What we see here are two gestational sacs
signifying dichorionic twins,
and within each of the gestational sacs
we can see little fetal poles
with a flicker of heart beats.
Recall that fetal heart activity
is seen at about six weeks on transvaginal sonography
and about seven weeks on transabdominal sonography.
Here's an early second trimester pregnancy.
What we see here is the next Oscar De La Hoya.
Note the mean right hook on the baby here.
The important finding here is that
this is an intrauterine pregnancy
as we can define a good mantle of uterus
surrounding the pregnancy.
That's very important as there are some ectopics
that can grow to an advanced stage,
but they're discerned by a lack of uterus
around the pregnancy.
Here's another second trimester baby
and as I work in Northern Manhattan,
I refer to this baby as the Merengue baby.
Note the baby moving around fluidly within the amniotic sac.
A sure sign that this kid will grow up to be a slick dancer.
In conclusion, I'm glad I could share with you
this SoundBytes module
going over Emergency OB/GYN Ultrasound: Part I
of intrauterine pregnancy.
Emergency OB/GYN ultrasound is definitely
one of the most helpful sonographic applications
in a busy emergency medicine practice
and hopefully by going through the module
you now have an understanding
of the ultrasound findings diagnostic of a normal pregnancy.
I hope to see you back as we return
in OB/GYN Ultrasound Pregnancy Part 2,
focusing on further assessment of normal pregnancy
as well as looking further into
the ultrasound findings of an abnormal pregnancy.

Brightcove ID

5508114751001

https://youtube.com/watch?v=gv4q8ZB25JM

Case: Ectopic Pregnancy - Part 2

Read more about Case: Ectopic Pregnancy - Part 2

/sites/default/files/youtube_ANhOwzbKe6Y_0.jpg

This video details how bedside ultrasound can help emergency medicine professionals visualize and diagnose various presentations of ectopic pregnancy, as well as differentiate between an ovarian cyst and an ectopic pregnancy.

Clinical Specialties

Media Library Type

Media Library Tag

Tubal Ectopic Abdominal Ectopic

Subtitles

- 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.
This module is ectopic pregnancy part two,
where we'll go over the multiple
ultrasound presentation of ectopic pregnancies.
Ectopic pregnancy is one of those
conditions that we'll not infrequently
encounter in a busy EM practice.
The most common presentation of
an ectopic pregnancy will be an empty uterus,
with or without free fluid within the pelvic cul de sac
or surrounding the uterus.
We may be actually able to visualize
the ectopic as a Bagel sign,
which constitutes a thickened Fallopian tube.
Other presentations of ectopics
include a complex pelvic mass
with a ring of fire on Doppler sonography,
hemosalpinx or blood within the Fallopian tube
or we may be actually able to visualize
the live ectopic in the adnexa,
with a fetal pole and/or heartbeat.
Here's a transvaginal long axis ultrasound
for a woman who presented with lower abdominal pain
and a positive pregnancy test.
Notice the uterus, as shown in the long axis view,
without an appreciable intrauterine pregnancy
and notice that it's surrounded
by a large amount of free fluid.
That dark or anechoic area surrounding
the uterus both anteriorly to the left,
posteriorly in the cul de sac to the right.
That is the presence of fresh blood.
Notice also the presence of blood clots
anteriorly or to the left, that more echogenic area.
So, given the absence of an intrauterine pregnancy,
we decided to scan out to the adnexa
and notice here, the presence of
a Bagel sign of a tubal ectopic pregnancy.
We see fresh fluid here, above the Bagel,
to the right, blood clot to the left
and the more hyperechoic
or lighter Bagel sign in the middle of the image.
Occasionally it can be difficult to discern
the Bagel sign of a Fallopian tube ectopic
from an ovarian cyst, as show here to the right.
But lets look closer at the two video clips
and notice that the Bagel sign
has a more hyperechoic or bright appearance,
with the single hole more in the middle.
Notice that the ovarian cyst has a different appearance,
with multiple small follicular cysts
to the outer portion of the ovary
and a single midline corpus luteum cyst.
Very different than the Bagel sign.
Here's another patient with an ectopic pregnancy
in a different presentation of ectopic.
We're scanning here from the more midline uterus,
as show there to the left, out to the right adnexa
and notice as we scan out to the right adnexa,
we notice the presence of a complex, pelvic mass.
Notice also the relatively low
serum B-HCG in this case, at 478.
So, a complex pelvic mass with
an absence of intrauterine pregnancy.
Very suspicious for an ectopic pregnancy.
And what's interesting is,
as we put Doppler flow on that complex pelvic mass,
we notice the presence of the ring of fire,
very suggestive of an ectopic pregnancy
and the reasons for the ring of fire
is that the ectopic pregnancy pulls
a huge amount of vascularity towards it
and using the Doppler,
we can see the separate ectopic from the ovary above it.
Here's another presentation of an ectopic pregnancy.
Again, we're scanning at a short axis plane
and we see there the uterus to the left
and outside the uterus, a separate structure.
We note here the presence of a thickened Fallopian tube
and inside the thickened Fallopian tube,
we see here a fetal pole with a heart beat,
consistent with a live ampullary ectopic pregnancy.
Unfortunately in this case,
the presence of a fetal pole with
a heart beat is a contraindication of methotrexate therapy
and this patient will need to undergo surgery.
We mentioned earlier that there are
a variance of ectopic pregnancies
that implant outside the fundal region of the uterus,
in an aberrant location.
This is a good example.
This patient actually has a bicornuate uterus
and as we scan at a short axis plane up the uterus,
we notice that the two limbs of endometrium
that make up the two distinct cornua.
As we go up the left cornua,
we notice here the presence of a cornual ectopic pregnancy
and we see the that it's located off to the side,
way out to the left cornua,
with a very thin myometrial mantle.
If we actually put the calipers down
and measure the endo-myometrial mantle,
we find it's very thin, at three millimeters,
defining an abnormal pregnancy.
A normal pregnancy should have
a myometrial mantle greater than eight millimeters.
Now this is a bicornuate uterus,
so this is a cornual pregnancy.
In a normal uterus,
this would be known as an interstitial pregnancy.
So in conclusion, I'm glad I could share with you
this module on ectopic pregnancy part two,
looking at the varied presentations of ectopic pregnancy.
Hopefully now you better understand
what we're searching for on bedside sonography
when we're working up a patient
with possible ectopic pregnancy.
While visualization of the adnexa
and the Fallopian tubes is an advanced technique,
but it is well within the scope
of a busy emergency medicine practice.
As a final caveat, ectopic pregnancies can
be seen at Beta-HCG levels ranging from very low,
less than 100, to very high, above 20,000
and thus we cannot use a Single Beta-HCG
level to rule out ectopic pregnancy.
It's really better to look at trends
in the hormone level over time.
With an intrauterine pregnancy,
the levels should double in 48 hours,
whereas in most ectopic pregnancy,
it will not climb to the same degree.
So, I hope that now you have a
better understanding of how to
work up the pregnant patient with
a possible ectopic pregnancy.

Brightcove ID

5750496732001

https://youtube.com/watch?v=ANhOwzbKe6Y

Case: Ectopic Pregnancy - Part 1

Read more about Case: Ectopic Pregnancy - Part 1

/sites/default/files/youtube_iui0HF95XAw_0.jpg

This video details how bedside transvaginal ultrasound can help emergency medicine professionals evaluate OB/GYN anatomy to diagnose possible ectopic pregnancies.

Clinical Specialties

Media Library Type

Media Library Tag

Pseudogestational Sac

Tubal Ectopic Abdominal Ectopic

Subtitles

- Hello, my name is Phil Perrera,
and I'm the emergency ultrasound coordinator
at the New York Presbyterian Hospital in New York City,
and welcome to SoundBytes Cases.
Today's module is going to focus on ectopic pregnancy.
Ectopic pregnancies constitute
about 2% of all total pregnancies,
although they're commonly seen in the emergency department.
Ectopic pregnancy is more commonly seen in women
with a history of tubal ligation
who are using interuterine devices for contraception
or have a history of sexually transmitted diseases,
such as pelvic inflammatory disease
with scarring of the tubes.
Ectopic pregnancy is also commonly seen in women
using fertility agents,
which accounts for the increasing rate of ectopic pregnancy
over all.
As a golden rule, we must consider ectopic pregnancy
in all women with abdominal pain
and/or vaginal bleeding and a positive pregnancy test,
until ruled out by sonography.
Let's begin by reviewing the OB/GYN anatomy
that we'll need to know to perform bedside ultrasound
of the uterus and the adnexa.
We'll begin by locating the lower cervical region
of the uterus.
The portion above that, the body, and the fundal region
of the uterus above the body,
which is where we define an inter-uterine pregnancy
to be located.
Notice the intersticial region of the uterus,
that region of the uterus that abuts the fallopian tube.
In a cornual uterus this is known as cornual region.
Here we also see the portions of the fallopian tube,
the proximal isthmal region,
the distal infindibulum,
and notice the ampullary region
which comprises the majority of the fallopian tube.
We also see here, the broad ligament which encases
the fallopian tube and ovary in the lateral region
of the adnexa.
Remember that the ovary is relatively mobile
within the broad ligament.
Now let's review a transvaginal long axis scan
from a women who presented with a positive pregnancy test,
who had lower abdominal pain and vaginal bleeding.
Notice the fundus, as shown here to the left,
the cervix to the right.
We see here the presence of a thickened white
endometrial stripe in the midline of the uterus.
Notice the pelvic cul de sac that potential space
posterior to the uterus.
Notice here the absence of an inter-uterine pregnancy.
Now, confirm the absence of an IUP by scanning
in the transvaginal short axis plane.
Here we have the probe marker
oriented towards the patient's right,
and we're cutting the uterus in cross section.
Notice again the thickened endometrial stripe
in the midline of the uterus,
and the pelvic cul de sac posteriorly.
Again, we see the absence of an IUP,
and also note the absence of free fluid,
dark anechoic fluid collections
within the pelvic cul de sac.
So, given these findings we're now concerned
about the presence of an ectopic pregnancy.
So, lets begin our discussion of ectopic pregnancies
by reviewing the locations that we commonly see
ectopic pregnancies to be found.
We see here a normal uterus to the left,
and a bicornuate uterus to the right.
We remember that a fundal location is the definition
of an inter-uterine pregnancy as shown smack in the middle
of the normal uterus to the left.
However, we can have variants of ectopic pregnancies
within the uterus as shown in the interstitial location
in the normal uterus to the left,
and in the cornual region in the bicornuate uterus
to the right.
We can also have implantations low
within the cervical region of the uterus,
as shown in the normal uterus to the left.
Now, most ectopic pregnancies will be located
within the fallopian tube and of those
the majority will be found in the ampullary region
as that comprises the majority of the fallopian tube.
But we can have implantations more proximal,
within the isthmal region
or distal within the infindibular region.
Now, tough ectopics to diagnose are those that implant
within the ovary,
within the abdominal cavity,
or within the peritoneal lining.
These can be very, very hard to diagnose
and commonly grow to an advanced stage before diagnosis.
So, returning to our case, given the presence of a positive
pregnancy test and the absence of an IUP
on bedside ultrasound, we were very concerned about
ectopic pregnancy and decided to scan out
to the left adnexa.
Here, notice we're scanning out to the left adnexa,
and we have a positive finding.
What we see here is a thickened fallopian tube,
comprising what is known as the bagel sign.
Notice within the thickened fallopian tube,
we have another positive finding.
That is the presence of a fetal pole.
So, in this patient we were able to diagnose
an ampullary ectopic pregnancy and our next move
was to call OB/GYN stat for a consultation.
So, in conclusion, ectopic pregnancies constitute
the greatest cause, overall, of maternal mortality.
We must consider an ectopic pregnancy in all women
with a positive pregnancy test
where an inter-uterine pregnancy is not visualized
within the fundal part of the uterus.
Most ectopic pregnancies are going to be located
in the fallopian tube,
and we may actually visualize the ectopic
with ultrasound evaluation of the adnexa
as shown in this module.
So, we'll return with ectopic pregnancy part two
which goes over the varied manifestations
of ectopics.

Brightcove ID

5750491404001

https://youtube.com/watch?v=iui0HF95XAw