Shortness Of Breath

- So, it's actually quite easy to do
an ultrasound examination in the E.D.
to determine if a patient has deep vein thrombosis,
and this is a well established practice of ultrasound.
We're gonna do a modified version of that
for the E.D. exam though.
To set up for this examination you want to tilt
the gurney, so that you're in a reverse trandelenburg.
So this encourages venous extension in the leg,
so it's easier to visualize the veins with ultrasound.
We're going to use a linear transducer for this examination,
and the views that we do for this exam
will just be in a transverse orientation only.
So when you're setting up for this examination
make sure the orientation marker again is to the right.
For this examination technique we're gonna use
a compression technique where we just
slightly compress the vein with some downward motion.
When you set up the exam on the system,
just select the exam key,
then from your menu select the venous exam type,
and hit select.
When you do this you're optimizing the system,
so it's automatically configured
for your best resolution of the veins.
We're gonna use a little bit of ultrasound gel,
and we're gonna assess two areas.
The femoral area and the popliteal area.
I'm gonna start with the femoral area.
We're going to place the ultrasound transducer
at the inguinal crease...
in a transverse view.
When I do this, immediately below the transducer and the
ultrasound image I'm going to see two anechoic structures.
The one that's gonna be more
medial is the common femoral vein.
The one that's more lateral is the common femoral artery.
The way I can landmark this is by looking for
the junction with the saphenous vein,
or the long saphenous vein.
And we see this emptying into the
anterior aspect of the common femoral vein.
And in this image we actually see the
venous valves separating
the long saphenous and common femoral veins.
So at this point what I do, is I just
use my compression technique.
So I just push with the transducer down until I see
both walls of the vein coapt or touch and meet each other.
If I get a complete coapt like this
I know there's nothing between those two walls,
so there's no venous thrombosis in the vein.
So again, just compress down until
you see those two walls meet completely.
You'll see that the artery does not compress,
and is pulsatile beside the vein.
Now that you've identified your landmarks,
you wanna do a thorough evaluation of that area.
So again placing the transducer at the inguinal crease,
we're going to compress the area of the common femoral vein.
We wanna move a few centimeters proximal to this,
so superiorly on the body,
and we'll start a compression technique.
Making sure that those walls collapse completely,
and we just work through this area
compressing every centimeter.
We see our common femoral vein and saphen junction here,
and we can continue compressing
just a few centimeters below this.
On the ultrasound we've seen the division to
superficial femoral artery and profunda artery.
Just lateral to the vein,
and then we should see the vein divide to
femoral vein and profunda vein.
Again, compressing all the way down,
until you see this junction.
From here I'm going to move down to the popliteal region.
Just move the system down towards the knee,
and we're going to actually go behind the knee.
Putting the transducer into the popliteal fossa.
Once you've identified the popliteal artery and vein,
mid-popliteal fossa level,
you wanna evaluate above and below this area
to make sure you evaluate all those areas
for deep vein thrombosis.
So we're going to start mid-level,
and just work our way superiorly in the leg.
To the superior aspect of the popliteal fossa.
Compressing all the way.
We go up a few centimeters,
and then we start to move down the leg
compressing into the inferior aspect of the popliteal fossa.
Again making sure that those vein walls
actually touch and meet each other,
so we know that there's no deep vein thrombosis
that's fresh which would be h-ai-p-oe-c-u-g.
Could be difficult to see if we did not
do this compression technique.
Those are the two steps for assessing the leg
for deep vein thrombosis.
It's just these two evaluation points.
But just make sure that you evaluate each area thoroughly,
and you do your compression technique completely.

Brightcove ID

5508114175001

https://youtube.com/watch?v=FHerMNhCR54

How to: Pneumothorax Evaluation

Read more about How to: Pneumothorax Evaluation

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Learn transthoracic lung ultrasound to rule out pneumothorax.

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How To Videos

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Subtitles

- Classically, it's been thought
that the lung cannot be ultrasounded.
In fact, that's not true.
We can use ultrasound very easily
to rule out a pneumothorax.
I'm gonna show you, using two different transducers,
how we can see the lung pleural line
to exclude the presence of a pneumothorax.
We're gonna start with our transducers.
We have two different choices of transducers.
We have our phased array transducer
and a linear array transducer.
If you're doing this as part of the fast exam,
most likely you've already have
a phased array transducer in your hand.
Therefore, I'm gonna go ahead
and show you what the images look like
using a phased array transducer.
The exam type has already been set up
in an abdominal preset,
and so we're ready to start scanning.
Now the area that we're gonna scan
is an area where we're gonna expect air to collect
in the presence of a pneumothorax.
That would be the most anterior aspect of the lung.
So if you look at our model right here,
we would expect air to collect more likely
in the anterior surface than more posteriorly.
Therefore, when I do my scanning,
I'm gonna scan about mid-clavicular line
at the most anterior area of the patient's body.
So we're gonna go ahead and start scanning.
Here's our probe marker right here.
We're gonna aim that toward the patient's head,
and I'm scanning right now in a sagittal fashion.
I'm gonna turn my gain up a little bit,
and first thing you're gonna recognize
that our depth is too deep.
Remember, what we're scanning now is really superficial.
We're looking at the lung's surface.
So I'm gonna decrease our depth
so we can see the lung surface quite easily.
Now what we're looking at here on the screen
is a classic shimmering line
that you see with the pleural surface,
that being the parietal and the visceral pleural surface
rubbing against each other.
So we see a rib here on the left.
We see another rib to the right.
And in the center is a line which is horizontal,
and we see shimmering.
That presence of that shimmering,
as well as very small, tiny comet tails
that are coming from the posterior aspect of that,
excludes the presence of a pneumothorax.
If you have time,
you want to use your linear array transducer.
This transducer does high-frequency imaging,
allows you to do much better imaging
of superficial structures.
So we're gonna get a lot better quality,
high-resolution pictures, of the pleural line.
So here's our transducer that I've chosen.
This is the marker here right now.
And I'm gonna go ahead and put a little gel here.
Now I'm gonna cut sagittally
at the highest point in his chest,
in about the mid-clavicular line,
and I notice to the left of the screen
is a rib right here,
and we see another rib right here.
And in between the two, we see the pleural line.
And as he takes a breath, we see shimmering.
These are the two surfaces of the lung,
the visceral surface and the parietal surface,
rubbing together.
We also see little tiny white lines,
your little comet tail lines,
which also show that both surfaces are touching together.
If you see this pattern,
you have reliably excluded a pneumothorax.
You can see in this model
that we can easily see the rib here anteriorly
and another one more inferiorly,
and we see the pleural line easily here in the middle,
we see shimmering.
Now you may want to document this in a still pattern.
That is very easy to do by just activating the M-mode.
We hit the M-mode key here.
And we put the M-mode marker
through the center of the pleural line
where we see shimmering, and with M-mode again.
And what we see now is a pattern
that's called the seashore sign.
And I'm gonna freeze this.
So now we have a frozen image
of the M-mode through the pleural line,
and we see the shimmering line here,
and we see here a classic seashore sign.
And when you see this,
this is still documentation of exclusion of a pneumothorax.
If you do your exam in the mid-clavicular line
at the most anterior portion of the chest,
and you see a good shimmering line,
then you've ruled out a pneumothorax.
If you don't see any shimmering line,
then you most likely are dealing
with a patient with a pneumothorax.
You can then take your transducer
and move it to the patient's left or to his right
or in more superior and inferior
to get a qualitative size of the pneumothorax
you're dealing with.

Brightcove ID

5741746210001

https://youtube.com/watch?v=D3mm9wwlw7g

3D How To: Ultrasound Guided Thoracentesis

Read more about 3D How To: Ultrasound Guided Thoracentesis

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3D animation demonstrating an ultrasound guided thoracentesis exam.

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Congested Heart Failure

Infection

Tumors

Increased Blood Pressure

Blocked Blood Vessels

Subtitles

- [Voiceover] A phased array transducer
with an abdomen exam type is used to evaluate
the chest cavity for the presence of fluid.
The procedure is best performed with the subject
in a sitting position, leaning slightly forward,
to allow access to the posterior chest cavity.
The patient is instructed to breathe normally.
And the transducer is placed in a long-axis orientation
over the posterior chest wall
at the eighth or ninth intercostal space,
in the posterior axillary line.
The orientation marker is directed to the patient's head.
The ribs are identified in the near field of the image
as a bright interface with a posterior shadow.
The pleural line is identified as a bright
hyperechoic line between the rib shadows.
The to and fro sliding movement of the visceral pleura
against the parietal pleura, with breathing,
generates the lung sliding sign.
The transducer is moved along the posterior axillary line
to identify the bright, hyperreflective diaphragm.
Fluid will appear as a dark anechoic area
in the dependent area of the chest cavity.
Identify the borders of the fluid collection
and the normal appearing lung.
A needle insertion site should be chosen
in the posterior chest,
in a dependent area of the fluid collection.
Adjust the transducer so it is located between two ribs.
The needle should be inserted just below
the center position of the transducer
to allow the needle to pass just superior
to the lower rib to avoid the neurovascular bundle,
which lies on the inferior surface of the rib.
Follow the needle entry by slowly sliding
the transducer in the direction of needle advancement.
The needle will appear as a small bright hyperechoic dot.
When the needle tip appears,
the transducer should be advanced a short distance distally
to follow the tip of the needle trajectory.
The needle is slowly advanced under direct
ultrasound visualization until the tip is seen
to indent and then puncture the parietal pleura.
The transducer should be moved slightly proximally
and distally to confirm that the needle tip lies
in the fluid collection in the chest cavity.

Brightcove ID

5733273235001

https://youtube.com/watch?v=x1XR4AOi8q0

3D How To: Lung Examination

Read more about 3D How To: Lung Examination

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3D animation demonstrating a lung ultrasound exam.

Applications

Cardiology

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How To Videos

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Subtitles

- [Voiceover] A phased array transducer
with a long exam type is used to evaluate lung sliding.
The anterior, lateral, and posterior zones of the chest wall
should be evaluated.
The transducer is placed in a long-axis orientation
over the anterior chest wall at the third or fourth
intercostal space in the anterior axillary line.
The orientation marker is directed to the patient's head.
A shallow scanning depth is used.
The ribs are identified in the near field of the image
as a bright interface with a posterior shadow.
The pleural line is identified as a bright,
hyperechoic line between the rib shadows.
The to and fro sliding movement of the visceral pleural
against the parietal pleural with breathing
generates the lung sliding sign.
Evaluate the pleural movement for A line and B line
reverberation artifacts.
To evaluate the posterior pleural space,
move the transducer distally to the level
of the seventh intercostal space.
Slide the transducer posteriorly to the midaxillary line.
Increase the scanning depth to view the interface
between the pleural space and diaphragm.
In a normal patient, a mirror image artifact
of the liver or spleen will appear the diaphragm.

Brightcove ID

5741728173001

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

3D How To: Deep Vein Thrombosis Exam

Read more about 3D How To: Deep Vein Thrombosis Exam

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3D animation demonstrating a Deep Vein Thrombosis ultrasound exam

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How To Videos

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Lower Extremity

Deep Venous Thrombosis

Three-Point Compression

Patency

Mid Thigh

Superficial Femoral Vein

Common Femoral Vein

Subtitles

- [Voiceover] A linear array transducer
with a venus exam type is used to perform
a lower extremity, deep vein thrombosis ultrasound exam.
At least three evaluation sites are necessary.
Common femoral vein, at the saphenofemoral junction,
confluence of the proximal deep femoral vein,
and the superficial femoral vein,
and the popliteal vein.
The patient is in a supine position
with the leg in slight external rotation and flexion.
Place the transducer in a transverse position
with the orientation marker to the patient's right side,
at the level of the inguinal ligament.
The three structures of the femoral triangle are visualized.
The common femoral artery, common femoral vein,
and greater saphenous vein.
The common femoral artery is round and pulsatile,
and the common femoral vein is thin-walled,
oval in shape and collapsible with compression.
The greater saphenous vein confluence
is observed at the anterior aspect
of the common femoral vein.
With the transducer perpendicular to the skin,
apply gentle downward compression
until the vein collapses
and the anterior and posterior walls completely touch.
Slide the transducer distally to the level
of the confluence of
the superficial femoral and proximal deep femoral veins.
Repeat the compression technique,
demonstrating complete collapse of the veins.
Move the transducer to the popliteal fossa.
From this approach, the popliteal vein
will appear anterior to the popliteal artery.
Repeat the compression technique.

Brightcove ID

5508123491001

https://youtube.com/watch?v=khD3dnxEt2o

3D How To: eFAST Lung Sliding Detection (Phased)

Read more about 3D How To: eFAST Lung Sliding Detection (Phased)

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3D animation demonstrating how to detect lung sliding with a phased array transducer while performing the eFAST exam.

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Cardiology

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Cardiology

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Subtitles

- [Voiceover] A phased array transducer is used
to evaluate lung sliding as an extension of the FAST exam.
The orientation marker is positioned
in the direction of the patient's head.
The transducer is placed in a long-axis orientation
over the anterior chest wall at the third
or fourth intercostal space
in the anterior axillary or midclavicular line.
A superficial scanning depth is used.
The ribs are identified in the near field of the image
as a bright interface with a posterior shadow.
The pleural line is identified
as a bright hyperechoic line between the rib shadows.
The normal to and fro sliding movement
of the visceral pleural against the parietal pleural
with breathing generates the lung sliding sign.
If desired, the delineation of the lung sliding interface
may be enhanced by changing to a linear array transducer.

Brightcove ID

5753042634001

https://youtube.com/watch?v=n9J12nmNhUU

How To Detect Lung Sliding with Ultrasound

Read more about How To Detect Lung Sliding with Ultrasound

/sites/default/files/EFast_LungSliding_HR_Linear_EDU00456_Thumnail.jpg

3D animation demonstrating how to detect lung sliding with a linear transducer while performing the eFAST exam.

Applications

Cardiology

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How To Videos

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Subtitles

- [Voiceover] A linear array transducer is used
to evaluate lung sliding as an extension of the FAST exam.
The orientation marker is positioned in the direction
of the patient's head.
The transducer is placed in a long access orientation
over the anterior chest wall
at the third or fourth intercostal space
in the interior axillary to mid-clavicular line.
The ribs are identified in the near field of the image
as bright interface with a posterior shadow.
The plural line is identified
as a bright hyperechoic line between the rib shadows.
The to and fro sliding movement of the visceral plural
against the parietal plural with breathing
generates the lung sliding sign.

Brightcove ID

5741746239001

https://youtube.com/watch?v=26RQyxk5vGc

Body

3D animation demonstrating how to detect lung sliding with a linear transducer while performing the eFAST exam.

Case: DVT Ultrasound Part 2

Read more about Case: DVT Ultrasound Part 2

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Deep-Vein Thrombosis and Ultrasound: Case Study

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Deep Venous Thrombosis

Superficial Femoral Vein

Three-Point Compression

Thrombosis

Thrombus

Vein

Subtitles

- Hello, my name is Phil Perera,
and I'm the Emergency Ultrasound Co-Director
at the L.A. County U.S.C. Medical Center
in Los Angeles, California.
And welcome to SoundBytes.
Welcome back to SoundBytes Ultrasound
and part two of the bedside DVT ultrasound evaluation.
Hopefully you've had a chance
to complete part one of the module prior,
looking at the normal anatomy of the leg veins
and normal compression examination looking for a DVT.
In this module part two,
we'll specifically examine positive DVT examinations
using the focused exam to look at the femoral
and popliteal veins.
A DVT will be identified by a failure
of venous compression using the high frequency probe.
We'll wrap up the module by looking at some DVT mimics
and alternative findings that you may encounter
on bedside ultrasound examination of the leg.
To reemphasize the positive findings
on lower extremity DVT ultrasound,
a thrombosed vein will not completely compress
with pressure down by the high frequency probe.
We may be able to observe echogenic material
within the vessel lumen consistent with a clot,
but that has to do with the age of a clot.
Fresh clot may be more echogenic or bright in nature,
whereas older clot may be more organized and darker
or hypoechoic on bedside ultrasound examination.
This video clip was taken from a patient
who presented to the emergency department
with a painful and swollen leg.
We're using doppler flow
to first identify the target femoral artery and vein.
We can see here the doppler pulsations
within the femoral artery noted lateral
or towards the left of the image.
We see here the femoral vein towards the right
or towards the medial aspect of the image
and note the lack of doppler flow.
Looking within the vessel, we can see swirls of thrombus
within the femoral vein consistent with clot.
And we note also the saphenous vein
on top of the femoral vein is also thrombosed.
We note here that there's no doppler pulsations
within the femoral vein as the result of blockage
due to the clot.
Now that we've identified the target femoral artery
and vein using doppler flow,
we can switch over to grayscale or B-mode sonography.
Here we're looking at the femoral artery
as it bifurcates into the profundus
and superficialis arteries.
And we note here towards the medial aspect of the artery,
or towards the right, the femoral vein.
Again, looking within the femoral vein,
we see swirls of echogenic clot consistent
with fresh thrombus.
And we note again that the saphenous vein
off the top of the femoral vein appears clotted as well.
So our next move would be to apply compression down
onto the vessels to look for compressibility of the vein.
Here we note we're compressing down
with a high frequency linear array type probe,
and we can see indentation of the femoral arteries
towards the left.
But note here the failure of compression of the femoral vein
due to the presence of thrombus within the lumen.
And we can see the thrombus moving around
as we press down with the probe.
Again, a positive DVT exam based on the fact
of failure of compression of the femoral vein.
Now let's look at another video clip showing a positive DVT
in a patient presenting to the emergency department
with a painful and swollen leg.
We're using doppler flow again
to target the femoral vessels,
and we see the pulsations of the femoral artery
lateral to the femoral vein.
We note here the absence of flow within the femoral vein,
suspicious for a DVT,
but our next move would be to apply compression
down with a probe.
Here we're compressing
with a high frequency linear type array probe
directly onto the femoral vein,
and we note the failure of compression of the vessel.
We can also see a rocking movement of the thrombus
within the lumen of the vessel.
Notice that it rocks back and forth
as we apply pressure down with the probe.
Again, a positive finding for a DVT of the femoral vein.
This video clip was taken from a post-surgical patient
with a painful, swollen leg.
We're applying compression down
to the common femoral vessels,
and we notice right away a positive finding
within the femoral vein.
We see here echogenic swirls of clot
and notice the failure of compression
of the vein with probe pressure.
Here we also see the saphenous vein
towards the anterior part of the image
above the femoral vein, also with clot formation.
And we notice that the saphenous vein fails
to compress down with probe pressure.
Now let's move down the leg and look specifically
at the popliteal vein.
Here are two video clips,
towards the left, the B-mode or grayscale sonography image,
and towards the right, a color-flow doppler.
We identified the popliteal vein
as seen towards the top of the image,
effectively posterior to the popliteal artery.
And we can identify the color-flow flashes,
the pulsations of the popliteal artery,
as seen deep to the image here.
Notice the echogenic swirls of clot
within the popliteal vein,
and to the left here we're compressing down
and we note the popliteal vein fails
to compress secondary to the DVT.
This video clip was taken from a patient
who presented with a painful, swollen calf.
We identified the popliteal vein
as seen to the top of the image,
or posterior in relation to the popliteal artery,
which is seen here anteriorly,
or towards the bottom of the image.
Now, we're pressing down with the probe,
applying pressure to the popliteal vein,
and we notice a positive finding.
The popliteal vein fails to compress
with direct probe pressure.
Now, what's interesting as in contrast to other clips
in this module, we don't really identify the swirls
of echogenic clot within this popliteal vein,
thus this was an older clot
that has been more organized with time,
thus giving a darker appearance more hypoechoic in nature.
Now let's turn to a discussion of some potential pitfalls
within DVT ultrasonography.
In the femoral region, lymph nodes may appear
as a thrombosed vein with a failure to compress
on bedside sonography.
Therefore, it's very important to adequately determine
the location of the femoral artery and vein
and compare that to the location of the lymph node.
The lymph node will be a single structure,
unlike the paired femoral vessels.
Also, the lymph node will usually be seen more superficial
to the vascular structures of the femoral artery and vein.
Here's an example of a femoral lymph node.
Notice that it has the appearance
of what could be construed as a DVT.
We see the node,
and it looks like it has echogenic material within it,
but this is the normal ultrasound finding of a lymph node.
Notice that it's a single structure
and not related to the common femoral artery
as a DVT would be within the common femoral vein.
Here we changed the magnification or the depth
of the ultrasound image to better investigate the lymph node
in its relation to the femoral vessels.
Note the single node, the femoral node seen superficial
to the femoral vessels as seen deep within the image.
Note that the node is single,
in contrast to the paired femoral vessels seen deeper.
As we progress down the leg,
we can encounter another potential pitfall
within the realm of DVT ultrasound,
and that is the alternative finding of a Baker's cyst.
A Baker's cyst can be encountered just behind the knee
within the popliteal region.
This cyst can result from an outpouching
of synovial fluid from the knee joint,
usually in patients with advanced arthritis.
Unfortunately, the Baker's cyst can rupture,
spreading inflammatory joint fluid down the leg,
and can present very similarly to a DVT.
This video clip demonstrates the typical appearance
of an unruptured Baker's cyst.
This Baker's cyst was found in the popliteal region
of a patient who was referred to the emergency department
for a swelling behind the knee.
Here we see the typical appearance of a cyst
that is that of a dark or anechoic fluid collection
on bedside sonography.
In this video clip we're going to change the depth
of the ultrasound image to better interrogate
the Baker's cyst in its relation
to the popliteal artery and vein.
Here we see the single superficial Baker's cyst
to the right in its relation to the popliteal artery
and vein seen deeper on the image and to the left.
And note that they have very different appearances,
that the Baker's cyst is a single structure
in contrast to the paired popliteal vessels.
In this video clip we see a large ruptured Baker's cyst
tracking down the calf
and closely approximating a DVT on clinical examination.
We see a short axis view to the left.
And I'm gonna start with the probe high
within the popliteal fossa right here.
I'm gonna move the probe down the calf,
and we can see that the fluid collection spreads
all the way down the calf.
In the long axis view to the right,
I'm gonna start by showing the superior axis to the left
and inferior to the right.
And we can see the fluid collection
of the ruptured Baker's cyst tracking from superior
all the way inferiorly down the calf.
So thanks for tuning in for this SoundBytes module
going over bedside DVT examination part two.
Now you've learned the focused bedside
DVT ultrasound examination
and can quickly evaluate both the femoral
and popliteal veins for clot.
This can be a very helpful examination
in working up those patients with a swollen and painful leg,
allowing for initiation of timely and appropriate therapy.
This bedside DVT examination can also be used
to look for DVT in cases of suspected pulmonary embolus.
So I hope to see you back in the future
as SoundBytes continues.

Brightcove ID

5508109927001

https://youtube.com/watch?v=Jg0TwINcZqE

Case: DVT Ultrasound Part 1

Read more about Case: DVT Ultrasound Part 1

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Case Study on Deep Vein Thrombosis.

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Case Study Videos

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Lower Extremity

Deep Venous Thrombosis

Three-Point Compression

Patency

Mid Thigh

Superficial Femoral Vein

Common Femoral Vein

Soundbytes Cases

Subtitles

hello my name is Phil Pereira and an emergency ultrasound code
at the LAN
the USC Medical Center in Los Angeles California and welcome to sound bites
welcome back to sound bites ultrasound in this module will learn the focused
ultrasound evaluation of the like four deep venous thrombosis
now divided this module up in two parts one and two
in this module entitled dvt ultrasound part 1
well first of all learn the normal anatomy of the leg veins integral to
performance of the dbt ultrasound examination will then move on to learn
the normal compression exam of the leg veins and how to interpret normal
findings on the bedside dbt examination specifically in this module we're going
to concentrate on the focus dbt examination the focused or limited dbt
exam allows for increased speed in the performance of the examination will
concentrate on to specific areas of the leg
looking at the femoral region and the popliteal region
this limited examination also maintains excellent sensitivity in the detection
of proximal DB tease and in fact most radiology perform dvt examinations
screen only down to the popliteal vessels the cafe an exam is not
routinely performed as part of most radiology perform dvt examinations and
indeed in the focus dvt examinations will skip the examination of the cap
themes that leads us into the concept of the focus dbt exam as being an optimal
means for evaluation for dvt at the bedside and the focus dvt exam will
begin by examining the femoral vein starting high at the level of the
proximal common femoral artery and vein just below the inguinal ligament will
continue the exam of the femoral vein down about four to five sauna meters
through to bifurcation of the vein into the deep and superficial femoral veins
well then turn to examination of the popliteal vein placing the probe hi
within the popliteal fossa will examine the popliteal vein about for sauna
meters within the popliteal fossa continuing the exam of the popliteal
vein down to trifurcation of the vessel into the cap gains
let's now review the lower extremity Venus anatomy integral to performance of
the focus dvt examining
action we begin by identifying the common femoral vein seen here just below
the England ligament notice that the common femoral vein is seen just medial
to the common femoral artery
now the common femoral vein continues down the leg to bifurcate into the deep
and superficial femoral veins
we note here the deep femoral vein coursing to the back of the leg and we
know the adjacent deep femoral artery
we also see here the saphenous vein which joins into the common femoral vein
above the level of bifurcation
now it's important to realize that the superficial femoral vein is the thing
that actually continues down the leg to become the popliteal vein behind the
knee and we note the superficial femoral vein coursing down the leg and
accompanied by the parrot superficial femoral artery behind the knee that
superficial femoral vein will become the popliteal vein and we see the adjacent
popliteal artery
now at the level of traffic ation the popliteal vein will become three
different campaigns and we note here the anterior tibial vain
that's going to course anteriorly on to the CAF the posterior tibial vain seen
post dearly in the CAF and also the perineal vain seem to the lateral aspect
of the cab and it's because these campaigns are so small that it's
difficult to see them on bedside ultrasound ography let's now watch a
video and learn how to perform the ultrasound examination looking for dvt
within the femoral vein system
we begin by placing the high-frequency linear array type probe
it's the same probe that you'll be using for vascular access and a side-to-side
orientation over the common femoral vein and artery just below the inguinal
ligament notice that we're compressing down with the probe and essentially the
dbt exam is a compression exam as a normal vein will completely closed with
pressure down with the probe notice that were sequentially compressing at
different levels along the common femoral vein compressing from the
beginning at the top just below the in Qin ligament all the way down through
bifurcation into the superficial and deep femoral vessels
now a clot will not completely compress with pressure down with the probe and
thus will be identified on bedside examination notice here
its standard to have the marker on the probe going lateral so that we know
where we are with regard to the orientation of the probe versus the
screen
it's best to position our patients slightly up right to distend the femoral
vessels for the DVT exam and as shown in this video we actually had the patient
with a head of the bed up about 30 degrees
we also want to have the legs slightly externally rotated to best orient so
that we can place the probe directly over the common femoral artery and bein
here we see the ultrasound findings that will occur when placing the probe as
shown in the illustration towards the left a note here the probe is placed
with the marker . laterally just inferior to the England ligament over
the common femoral artery and vein as shown in the pictorial towards the right
notice here that the common femoral vein will be seen medial to the common
femoral artery and because we have the marker . oriented laterally or towards
the left of the image the common femoral vein will be seen to the right here
here's a video showing the actual ultrasound findings of the common
femoral artery and vein using color flow Doppler we are in two selves to the
image to the left here showing that the common femoral vein will be seen
medial to the common femoral artery and we know the ultrasound findings to the
right showing pulsatile flow within the common femoral artery
located just lateral to the common femoral vein and we see the basic hum of
the blood flow within the common femoral vein seen medial to the artery here
well it's very nice to have color flow Doppler to differentiate the common
femoral artery from the common femoral vein we can also discern the to using
grayscale or b-mode sonography as shown in the video clip here to the right here
we note the common femoral artery to the left or lateral to the common femoral
vein as shown medially notice that the common femoral artery has more
hypertrophic walls and also pulsatile flow within it
differentiating it from the common femoral vein as seen medially continuing
down the leg as shown in the prone position in the illustration to the left
here we see the following ultrasound findings in the illustration to the
right
we know that the femoral arteries bifurcate at level above the comment
from
vain and here we see these superficial and deep femoral arteries in a location
just lateral to the common femoral vein
we also see a very important landmark the saphenous vein joining in to the
common femoral vein at this level it's very important to visualize the south in
this vein as it's really the only superficial vein in the body that we
worry about clot formation within as it goes directly into the common femoral
vein and can propagate up into the IVC and into the heart
here we see a video clip using color flow Doppler demonstrating the
bifurcation of the femoral artery into the superficial and deep family arteries
and here we see that bifurcation point right there
notice that the femoral arteries are located laterally or towards the left of
the common femoral vein which we see located neatly or towards the right of
the image in this video clip will note the bifurcation of the common femoral
artery into superficial and Profundis femoral arteries using grayscale or
b-mode sonography we know the common femoral vein is shown towards the medial
aspect of the image or towards the right and here again we see that bifurcation
point of the common femoral artery into the superficial and profundus femoral
arteries is labeled there and we just remember that . that the artery
generally bifurcates at a level higher than the femoral vein in this video clip
we're able to get a good look at the saphenous vein joining in to the common
femoral vein and we see the common femoral vein located medial to the
common femoral artery
note that the saphenous vein has the look often of a little hat on top of the
common femoral vein and we note here also the turbulent flow of blood here
within the common femoral vein as this was taken in the hypotensive patient
now let's turn our attention to the anatomy of the popliteal fossa
we note here the popliteal vein and the popliteal artery
remember that the popliteal vein is going to be in an orientation
located more posterior to the popliteal artery which will be located more
anterior
here's how to perform the focus dvt ultrasound exam looking into the
popliteal fossa
it's best to have the patient sitting up to further to stand the popliteal vein
and I like to have the patient sitting up with the leg dangling over the bed
I can then pull up a chair and move anterior to the page
agent will place the high-frequency linear array probe
hi within the popliteal fossa sequentially compressing it levels down
all the way down to trifurcation notice that we're using our other hand to
stabilize the anterior knee as we press with the probe post dearly
so again we'll start high within that Papa teal fossa compressing sequentially
all the way through the levels of the popliteal artery and vein down inferior
they're all the way down to trifurcation here's the anatomy with that will see
with the probe placed as shown in the illustration to the left
notice that the probe is placed into the posterior aspect of the knee behind the
popliteal fossa
again with the marker . oriented laterally thus will see the following
images as shown in the illustration to the right note that the popliteal vein
will be located closer to the probe or posterior to the popliteal artery which
will be further away from the probe or more anteriorly located as shown in this
image in this image will use color flow Doppler to further differentiate the
popliteal artery from the popliteal vein and in the video clip here to the right
we can see the pulsatile flow of blood within the popliteal artery has seen and
ear or further away from the probe then the popliteal vein which has seen more
posterior than the artery here
notice that we see a little bit of phasic flow of blood within the
popliteal vein
this video clip employees be mode or grayscale sonography to show the
popliteal vein and popliteal artery
again we can see the popliteal artery located more anterior than the popliteal
vein and we can see the pulsatile movements of the popliteal artery
differentiating it from the vein and in fact we can see a little bit of
turbulent flow of blood within the popliteal vein here and located more
posterior Lee than the popliteal artery
when performing the focus lower extremity dvt ultrasound examination we
want to first identify the femoral and popliteal arteries and veins using be
mode or grayscale sonography now colorflow doppler ultrasound can be
helpful in differentiating the artery from the vessel and also making sure
that you're looking at vascular structures but is not essential most of
our information will actually come from b-mode sonography want to apply
compression to the vein pressing down with the probe
in the short axis or transverse orientation in a normal examination the
walls of the vein will completely touch together
conversely if a dbt is present the walls of the vein will not completely touch
together as a thrombus within the lumen of the vein will prevent the walls from
completely collapsing
here we see normal compression of the common femoral vein and we see here the
common femoral vein to the right of the common femoral artery which we see to
the left
no we're looking in the short axis or transverse orientation pressing down
with the probe and note with pressure down on the probe that the common
femoral vein completely collapses and that the walls the anterior wall and
posterior wall of the vessel meet
we also see compression of the saphenous main that little cap on the top of the
common femoral vein so a completely normal exam of the common femoral vein
at the level just below the England ligament here we're looking a little bit
more distally at the common femoral vein at the level of the bifurcation of the
common femoral artery into superficial and profundus femoral arteries and we
note here complete compression of the vein as we push down with the probe and
note again that the anterior and posterior wall is completely meet
together
now let's move down the leg to look at the normal compression exam of the
popliteal vein recall that the popliteal vein is going to be seen towards the
posterior aspect of the image or closer to the top of the image here then the
popliteal artery as we press down we know complete compression of the
popliteal vein and we see here that the artery still stays open
so again this would be a normal compression exam of the popliteal vein
with the anterior and posterior walls of the vessel completely touching down with
pro pressure
in conclusion thank you for joining me for the sound bites module going over
bedside dvt examination part 1
hopefully now you understand the focus dbt exam which allows for increased
speed with excellent accuracy in the exam performance in this module part 1
we focused on the basic anatomy and the normal examination for the DVT
evaluation for a normal examination we hope that the femoral and popliteal
veins will completely compress down with pro pressure
unfortunately a venous thrombosis will prevent
vane from closing and so we're turn in part to going over the positive
examination and those findings that you might encounter on the focus bedside dbt
examination
so I hope to see in the future as sound bites continues

Brightcove ID

5508123523001

https://youtube.com/watch?v=Sh5cL72kgnU

Case: Ultrasound for Pneumothorax

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The video demonstrates how to use long and short axis configurations, as well as M-mode, to detect and diagnose both a complete and partial pheumothorax.

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Case Study Videos

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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 module we're going to look specifically
at Ultrasound of the Lung to Evaluate for Pneumothorax.
Interestingly enough,
a classical belief was that the lung was not optimal
for ultrasound imaging.
However newer findings have shown
that actually ultrasound is an excellent modality
for viewing the pleura and for detecting pnemothoraces.
There's been a lot of research looking at this
and what's interesting is that ultrasound
has been found now to be more sensitive than chest X-ray
in the diagnosis of pneumothorax especially
in the supine trauma patient.
And now we're going to add on views of the lungs
looking for pneumothorax as part
of our Extended FAST Exam,
or the E-FAST exam that we'll be performing
in trauma patients.
We can also detect pneumothoraces as well
in our medical patients.
Now let's learn how to perform the ultrasound examination
for the pneumothorax detection.
Here we have the high frequency linear type array probe
positioned on the anterior chest wall
at about the midclavicular line
looking in to about intercostal space three.
Now in most cases of pneumothorax with the patient supine
the air would be predominantly seen in this area.
Note we're looking in a long axis configuration
between the ribs with the marker dot
oriented superiorly towards the patient's head.
Once we've identified both the ribs and the pleura
we can swivel the probe into the short axis configuration
to further look at the pleura
and to detect pneumothorax.
Here we have the probe oriented in a transverse
or short axis orientation between the ribs
looking directly down at the pleura.
Notice in this case the marker dot is located
towards the lateral aspect of the patient.
Using both long and short axis configurations
will allow you to detect a pneumothorax
with a high degree of accuracy.
If no lung is seen on the anterior chest wall
one can size out a pneumothorax
by looking in the lateral positions as shown here.
Notice the probe on the lateral chest wall
in the short axis configuration between the ribs.
If lung is seen here laterally but not anteriorly,
this would tell you it was an incomplete pneumothorax.
We can complement the short axis view
by locating the probe into the long axis configuration
with the marker dot towards the patient's axilla
to further examine into these lateral areas
of the chest wall.
Here's a nice pictorial showing
the normal findings of a lung
in a long axis type configuration.
Superior rib to the left,
inferior rib to the right.
Notice that the ribs cast shadows posteriorly
due to the inability of the soundwaves
to permeate the hard calcifications of the rib.
We see the chest wall anteriorly,
and note here the two layers of the pleura.
And we see here the outer parietal pleura,
and the inner visceral pleura.
Now while I've depicted these as two separate layers,
in reality on ultrasound examination
they're seen as a single shimmering white line
that moves back and forth as the patient breathes.
And as the patient breathes we can see white comet tails,
or linear lines, vertical lines,
coming off the pleura down deep into the lung.
So that will be the normal finding of a lung
on long axis configuration.
Here's a nice ultrasound image
showing a normal lung
and what we see here,
we're in the long axis configuration,
so the superior rib is to the left,
inferior rib to the right.
Chest wall anteriorly,
and we see here the lung sliding
which is the opposition of the outer parietal
and the inner visceral pleura.
And we see the vertical comet tails
coming off the back of the pleura.
Thus this is a completely normal exam.
No pneumothorax.
But note the location of the pleura deep to the ribs,
and that classic shimmering line back and forth
as the patient takes a breath.
Here we see more dramatic comet tails
coming off the shimmering parietal and visceral pleura.
In this patient we see the comet tails
shooting off the back,
telling us that this lung is up and there's no pneumothorax.
So vertical lines coming off the back of the pleura
always mean that the lung is up and are always a good sign
on lung ultrasound sonography.
As we mentioned we should also swivel the probe
into the short axis configuration
to further examine the lung,
and what we see here is a normal lung
in short axis configuration.
Note here we're looking in between the ribs
so all we see is the dome of the lung
and notice that it slides back and forth
as the patient breathes,
and we see the vertical comet tails
coming off the back.
So a completely normal examination in the short axis plane.
Here's another ultrasound image
taken from the short axis configuration.
Note here we see very prominent comet tails
coming off the back of the lung as it slides back and forth.
Again it's that opposition
of the parietal and visceral layers of the pleura
that allow the lung shimmering,
but notice here all the comet tails coming off the back.
In this case this patient had some pulmonary edema
associated with the lung
and these comet tails are more pronounced
due to the presence of water within the pleura.
But notice all these vertical lines coming off the back
telling us this lung is up.
A way to document that the lung is up
to print out for the chart is to put M-Mode,
and generally what we do is locate it so the M-Mode cursor
is down right at the pleura.
And what we see is the classic seashore sign,
or waves on the beach.
If we look anteriorly we'll see the classic waves,
or no motion of the chest wall,
and below that,
deep to the pleura we'll see the positive motion of the lung
making up the beach.
So waves on the beach,
or the seashore sign,
and M-Mode documentation that the lung is up
and that there's no pneumothorax.
Now that we understand what a normal lung looks like
on bedside examination,
let's take a look at a pictorial showing a pneumothorax
in a long axis view.
We see here that the parietal pleura
is now split from the visceral pleura,
which is attached to the lung
by a layer of air shown by the yellow color.
It's the splitting of the parietal and visceral pleura
that now causes a lack of lung sliding.
And instead of the opposed visceral and parietal pleura
sliding back and forth as the patient breathes,
all we see is a single line,
the parietal pleura,
with a lack of vertical comet tails coming off the back.
Here's an ultrasound image taken from a patient
who was stabbed to the left chest
and who had shortness of breath.
What we see here is a long axis view of a pneumothorax.
Let's take a look at the chest wall anteriorly,
and right below that we see the parietal pleura,
the single white line located directly inferior to the ribs.
But notice the classic lack of the lung sliding.
All we see here is a single white line
that fails to slide back and forth as the patient breathes.
Notice also the absence of the vertical comet tails.
Here's another image of a pneumothorax
in a long axis configuration,
and we see here the chest wall anteriorly,
and the single white line which is the parietal pleura.
Now this patient was acutely dyspneic,
so notice that there is some motion of the chest wall
and that the parietal pleura moves up and down,
but notice the failure of horizontal sliding.
Notice also the absence of any vertical comet tails
coming off the back of the pleura.
Now let's inspect a pneumothorax from the short axis view.
We see the chest wall anteriorly,
the parietal pleura as shown as a single,
non-mobile white line in the middle of the image.
Note the failure of movement back and forth,
the lack of vertical comet tails,
and what we see here is repeating horizontal air lines
from the pneumothorax.
To document the absence of lung sliding
and the presence of a pneumothorax,
we'll again turn to M-Mode.
If we put the M-Mode cursor down on the pleura,
what we'll see is a set of linear repeating lines.
This documents no motion of both the chest wall
and of the lung,
making up a finding known as the bar code sign.
Here's a pictorial showing interesting finding.
The signature of an incomplete pneumothorax,
known as lead point.
And what we see is an incomplete pneumothorax
with air collecting to the superior aspect
of the image to the left.
Thus splitting the parietal from the visceral layers
and causing an absence of lung sliding superiorly.
However, as the lung is coming up against the chest wall
to the right or inferiorly,
that's where we'll see the presence
of horizontal lung sliding,
and the presence of the vertical comet tails.
Here's an ultrasound image showing the lead point,
and what we see here is the lung sliding to the right,
the area where the lung touches up against the chest wall,
and to the left the area of absence of lung sliding
telling you there that air has collected
between the visceral and parietal layers.
So the ultrasound equivalent of the image
that we just looked at telling you
that this is an incomplete pneumothorax.
But here we see that lead point,
or transition point,
very well on bedside sonography.
In conclusion I'm glad I could share with you
this ultrasound module going over ultrasound of the lung
to evaluate for pneumothorax.
This is an excellent tool for viewing the pleura
and making the diagnosis of pneumothorax,
and there's been some research showing that it may be
more sensitive than chest X-ray in the diagnosis
of pneumothorax,
allowing rapid diagnosis of pneumo
in both your trauma and medical patient,
thus facilitating more timely management
of these most critical patients.
So I hope to see you back as SoundBytes continues.

Brightcove ID

5508134309001

https://youtube.com/watch?v=Xxdedx1HtHo

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