Soundbytes Cases

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

Brightcove ID

5508128547001

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

Case: Gallbladder Ultrasound - Cholecystitis

Read more about Case: Gallbladder Ultrasound - Cholecystitis

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This video (part 3 of 3) reviews the use of medical ultrasound imaging, the spectrum of findings in acute cholecystitis, as well as primary and secondary diagnostic findings in this disease.

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- Hello, my name is Phil Perera,
and I'm the Emergency Ultrasound Coordinator
at the New York Presbyterian Hospital in New York City.
And welcome to SoundBytes Cases.
In this SoundBytes module entitled,
Part Three of Bedside Ultrasound of the Gallbladder,
we're going to go on further on our discussion
of the pathology found on bedside imaging
of the Right Upper Quadrant.
Hopefully, first you've reviewed Parts One and Two
in the series on bedside ultrasound of the gallbladder
and understand the Right Upper Quadrant exam performance
and normal anatomy, as well as the
ultrasound findings of gallstones.
In this module, part three, we're going to specifically
review the spectrums of findings found in
Acute Cholecystitis, and we'll learn the primary
and secondary diagnostic findings in this disease.
The majority of cases of Acute Cholecystitis that present
to the Emergency Department are going to be calculous
or associated with cholesterol gallstones.
While a calculous cholecystitis does exist,
it's rarely seen in the Emergency Department.
Usually seen in patients who have been hospitalized,
those who have had surgery recently,
or those who have immunocompromised states
such as HIV or diabetes.
Acute Cholecystitis is usually caused by obstruction of
the cystic duct by a gallstone resulting in pathology.
And the list of sequelae include: gallbladder distension,
gallbladder edema, infection, or acute cholecystitis,
ischemia of the gallbladder wall, resulting in
necrosis and perforation of the actual gallbladder.
What are the clinical signs of acute cholecystitis that
we're examining for at the bedside of the patient
with acute Right Upper Quadrant abdominal pain?
Well, the primary diagnostic ultrasound finding
is going to be the presence of gallstones
with a positive sonographic Murphy's sign,
or tenderness over the gallbladder with pressure down
on the ultrasound probe.
These findings have a 92% positive predictive value for
Acute Cholecystitis as found in this article
by Dr. Ralls et al and radiology.
It's an older article from 1985, but one that's often
mentioned on discussion of Acute Cholecystitis.
Now there's multiple secondary signs of cholecystitis
that we should go through, and these include: a distended
gallbladder greater than 10 centimeters in length,
a thickened gallbladder wall that's usually mentioned
as greater than three millimeters in width.
Also, one may be able to see fluid in the gallbladder wall,
or edema within the gallbladder wall, as shown by
a stripe of fluid within the wall.
Also, we can have pericholecystic fluid, or a line of fluid
outside the gallbladder wall as a result of inflammation
or early perforation.
Now the presence of these secondary signs
of Acute Cholecystitis does improve our
diagnostic positive predictive value,
but only increases the yield from 92% to 95%.
So, it's really most important to look for the
primary diagnostic signs of Acute Cholecystitis.
Here's a video clip from a patient who presented with
Right Upper Quadrant pain and fever.
And as we look at the gallbladder, the first thing we see
is the presence of multiple gallstones
within the neck of the gallbladder.
Also, we're going to examine here the
anterior wall of the gallbladder.
And notice with the small indicator arrow,
I'm just pointing out that anterior wall.
Notice that it appears thickened.
Now here I'm just indicating the posterior wall
of the gallbladder, and notice that it's difficult
to measure the posterior wall due to an artifact
known as posterior acoustic enhancement.
The sound waves race through the gallbladder,
making it difficult to measure that
posterior wall as it lights up.
Here we're going to put calipers down on the
anterior gallbladder wall, and notice that we have
a measurement of four millimeters,
indicative of a thickened gallbladder wall
as we defined prior in the last slide
as greater than three millimeters in width.
This is a video showing two views of the gallbladder,
taken from a patient with
Right Upper Quadrant pain and fever.
We see long axis to the left
and short axis view to the right.
This shows that it's important to image the gallbladder
in both long and short axis configurations,
as I think on these two video clips that
the gallbladder wall anteriorly is better seen
on the short axis view to the right.
And we see here a concretion of gallstones
within the gallbladder lumen
and a thickened anterior wall of the gallbladder.
This patient also had a positive sonographic Murphy's sign.
Here I'm going to still that last image down
of the gallbladder in short axis configuration
and we see the anterior wall of the gallbladder
well-delineated here.
Notice the calipers across with the measurement
of nine millimeters, fulfilling the criteria
of a thickened wall.
This video clip shows another finding of Acute Cholecystitis
in addition to the multiple gallstones that we see
within the gallbladder lumen,
we appreciate a thickened anterior gallbladder wall.
And within the wall of the gallbladder, we see a stripe
of black fluid, consistent with gallbladder wall edema.
And here with the small indicator arrow I'm just going to
trace out that area of gallbladder wall edema within
that anterior wall of the gallbladder.
Interestingly enough, that surgery, the gallbladder
was found to be very edematous, inflamed,
and the wall was necrotic.
Let's now inspect another video clip from
an elderly patient with Right Upper Quadrant pain and fever.
And we see here on imaging of the gallbladder,
a distended gallbladder stretching out
across the video clip here.
Notice the large concretion of gallstones packed in
at the neck of the gallbladder.
But let's look closely at the anterior wall
of the gallbladder.
And we notice as shown with a small indicator arrow,
a stripe of fluid that is going to be pericholecystic fluid
outside that anterior wall of the gallbladder.
Now the patient also had a positive sonographic
Murphy's sign with a great deal of tenderness
on pressure down with the probe over this gallbladder.
So, as we mentioned in part one of the ultrasound modules
on gallbladder sonography, it's always important to
look at a different plane on imaging of the gallbladder.
So here's a subcostal view of the same gallbladder.
We see again the multiple concretion of gallstones
within the gallbladder neck as seen inferiorly
towards the image here.
Notice the shadowing off the back of the gallbladder.
And we can see here the large stripe of
pericholecystic fluid that is shown by that
dark area of fluid that wraps around
the anterior wall of the gallbladder.
So, Acute Cholecystitis on bedside sonography.
Let's wrap this module by looking at this video clip
for the multiple signs of Acute Cholecystitis
that are present here.
First of all, we notice the distended gallbladder
with a significant load of gallstones
stretching across the posterior wall of the gallbladder.
Incidentally, the patient had a positive sonographic
Murphy's sign, fulfilling the primary diagnostic signs
of Acute Cholecystitis.
Next, let's take a look at this video clip for some of the
secondary diagnostic signs of Acute Cholecystitis.
As we look at the anterior wall of the gallbladder,
we see here that it's thickened and inflamed.
We also see a stripe of pericholecystic fluid
just outside the anterior wall of the gallbladder.
So we see here some more of the secondary signs
of Acute Cholecystitis.
In conclusion, thanks for tuning in
for this SoundBytes module going over Part Three
of Bedside Ultrasound of the Gallbladder.
Hopefully now you understand the primary diagnostic signs
of Acute Cholecystitis on bedside imaging.
That is the presence of gallstones
and a sonographic Murphy's sign.
Recall that these two findings have a very high yield
for the presence of Acute Cholecystitis.
I hope also that you can identify some of the
secondary diagnostic signs of Acute Cholecystitis.
That is a large gallbladder,
a distended gallbladder greater than 10 centimeters,
with gallbladder wall thickening
greater than three millimeters,
the presence of gallbladder wall edema,
and also, finally, the presence of pericholecystic fluid.
So now, I believe you're ready to evaluate patients
during your next shift for gallbladder disease
and Acute Cholecystitis.
And I look forward to seeing you in the future
as SonoAccess continues.

Brightcove ID

5733899294001

https://youtube.com/watch?v=Xsj5j2hzjtA

Case: Gallbladder Ultrasound - Introduction

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This video (part 1 of 3) details how bedside medical ultrasound imaging of the gallbladder allows for rapid evaluation of patients presenting with acute abdominal pain.

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- Hello.
My name is Phil Perera and I'm the
emergency ultrasound coordinator at the
New York Presbyterian Hospital in New York City.
And welcome to Soundbytes Cases.
In this Soundbytes module, we're going to focus on
bedside ultrasound of the gallbladder.
I've divided this module up into parts one, two, and three,
and in this module, part one, we're going to focus on the
normal hepatobilliary imaging and ultrasound findings.
Bedside ultrasound of the gallbladder allows rapid
evaluation of patients presenting with acute abdominal pain
to the emergency department and interestingly enough,
gall stone related disease is now more commonly diagnosed
in the emergency department with the increased advent of
bedside scanning.
Gall stone related disease is not only seen in traditional
females population, as described in textbooks.
It's also being seen in men with rapid weight loss or
weight gain changes, and also in the elderly.
So, let's begin this module with a review of the anatomy of
the right upper quadrant, how to perform the exam,
and the ultrasound findings in hepatobilliary imaging.
Let's begin with a review for the positions
for gallbladder sonography.
As shown in probe position one, the first position that's
often used for gallbladder sonography is going to be known
as the high/lateral view, in which we're looking through
the ribs.
It's best to use a smaller footprint probe for this exam
so that we can easily sit the probe between the ribs.
We're going to be coming in in a view that's very similar
to the right upper quadrant view for the trauma FAST Exam,
however, the probe here is angled more anteriorly than for
the FAST Exam to image the gallbladder.
The second position is known as the subcostal view, as shown
in probe position two here, and it's best to roll
the patient into the left lateral decubitus position
so that the gallbladder is closer to the probe.
From the subcostal position, we can push down directly
on the gallbladder to illicit the sonographic murphy's sign.
Now from both of these positions, we should rotate the probe
from long axis, with the probe marker toward the patient's
right shoulder to the short axis configuration, with the
probe marker over towards the right side, to completely
inspect through the gallbladder for any pathology.
Here's an illustration reviewing
the anatomy of the gallbladder and billiary tracts
important to bedside sonography.
Here we see the gallbladder,
shaped as a pear-like structure,
and we see the parts of the gallbladder,
the upper fundus, the intermediate body,
and the neck of the gallbladder toward the top of the image.
Recall that it's impacted stones at the neck of the
gallbladder that often cause symptomatic billiary colic
and can lead to acute cholecystitis.
We also see the cystic duct draining the bile from
the neck of the gallbladder and joining into the
hepatic duct, which is draining the bile from the liver.
The confluence of the cystic duct and hepatic duct forms
the common bile duct and stones lodged within this
area can cause choledocholithiasis.
We also the pancreatic duct joining to the bile duct and
dumping into the duodenum at the second part of the
duodenum, located at the ampulla of vater.
Stones that may lodge here can cause
gall stone pancreatitis.
Now let's take a look at the ultrasound findings of a
normal gallbladder.
We see the liver to the left and the gallbladder just
inferior to the liver to the right.
Notice the areas of the gallbladder.
We see the upper fundus towards
the upper right part of the image,
the body of the gallbladder, the intermediate part,
and the neck of the gallbladder all the way down towards
the left of the image.
As we look closely through this gallbladder,
we see that it has the typical darker or anechoic type
appearance on bedside sonography and that's because of the
fluid within the gallbladder, that is bile.
We see here the absence of any significant stones,
and remember that gall stones would appear as brighter
or hyperechoic foci within the gallbladder lumen.
Here's a normal variant, known as a septated gallbladder
and we see a little septi, that little white line,
going through the middle of the gallbladder.
This can be seen on bedside sonography and is not to be
mistaken as pathology.
Here's an illustration showing
the relation of the gallbladder to the portal vein
known as the exclamation dot sign.
The exclamation would be made up by the gallbladder
and the dot would be the portal vein.
We see a thin white line connecting the gallbladder to
the portal vein, known as
the median lobar fissure of the liver
and this can be a very helpful landmark as one looks
to find the gallbladder in relation to the portal vein.
Also, we see the common bile duct and the hepatic artery
on top of the portal vein, making up the structures of the
portal triad.
Here's an ultrasound image showing the portal vein,
exclamation dot sign.
And we see the gallbladder to the right,
making the exclamation,
and the dot, the portal vein, to the left.
Notice that the dot, the portal vein,
has hyperechoic walls, due to the fact that it's bringing
greasy blood from the intestine to be filtered
by the liver.
We see the white line connecting the gallbladder to the
portal vein that is median lobar fissure and posteriorly
we see the inferior vena cava.
Here's an ultrasound image showing the median lobar fissure
of the liver in greater detail.
Here we see the gallbladder, the pear-like structure,
to the right of the image and the branching portal vein
over towards the left.
As we look in between the two structures we see the
thin white line known as the median lobar fissure
of the liver.
Now the MLF can be a very important landmark as we look
from the portal vein up to the neck of the gallbladder
to inspect the neck of the gallbladder for any small stones
that might be lodged there and causing billiary colic.
Here's another video clip in which we can see the
relation of the portal vein to the gallbladder
in explicit detail.
Notice the gallbladder to the right,
the portal vein, the branching structure with hyperechoic,
or whiter, walls, towards the left,
and we can see the area of the MLF, the
median lobar fissure, connecting to two structures.
And again, this is a very important landmark for
walking your way up to the neck of the gallbladder to
look for any small stones impacted at the neck.
Also, looking for the portal vein can be very helpful in
looking for a contracted gallbladder that can be difficult
to identify on bedside sonography.
Now let's review an image showing the anatomy of the
portal triad.
We see the first the first structure of the portal triad,
the common bile duct, marked in green.
Notice that it connects the gallbladder
down to the duodenum.
While it's located to the left in this picture,
in a real patient it would be located over toward the
patient's right side.
We see the posterior structure of the portal triad,
the portal vein, marked in blue, and we see the
hepatic artery, which would be the third structure of
the portal triad. over towards the right of this image, but
would be located towards the patient's left side on
real-time scanning.
Here's a video clip showing the sonographic appearance
of the portal triad, which we refer to as
the Mickey Mouse Sign.
And here we see the gallbladder over toward the left
of the image and the portal triad, making up
the Mickey Mouse Sign.
The portal vein, making up Mickey's face, and
the ears of Mickey, the common bile duct making up
the left ear of Mickey and the hepatic artery making up
Mickey's right ear.
And this image is best obtained from a subcostal plane
and a transverse axis and a probe marker over towards
the patient's right side.
Now we can place Doppler sonography onto
the Mickey Mouse Sign to further delineate the structures
and we see that the portal vein, making up
Mickey's face, the posterior most structure of the portal
triad, will actually light up with Doppler sonography.
We can also see that Mickey's right ear, the hepatic artery,
also has Doppler flow on Doppler sonography.
However, the common bile duct, Mickey's left ear, fails to
appreciate any Doppler flow due to the sluggish flow within
the common bile duct.
In this video clip, we can appreciate the common bile duct
and portal vein in more of a long axis configuration.
We've turned the probe, so now the probe marker is over
toward the patient's right shoulder
and we see the gallbladder towards the top of the image
and notice here we see two parallel channels towards
the bottom aspect of the image here.
Notice the portal vein with Doppler flow, and on top of
the portal vein, we can appreciate the common bile duct.
As the common bile duct enlarges with obstruction,
it will become as large or larger than
the accompanying portal vein.
Normal dimensions for the common bile duct is that it
should be no more than one millimeter for each decade of
the patient's life.
A common bile duct that measures across in diameter
greater than eight millimeters is universally enlarged.
And when we measure the common bile duct,
we're going to measure from inner wall to inner wall
across the lumen of of the common bile duct.
My conclusion points for this Soundbytes module,
going over part one of gallbladder sonography,
gallbladder ultrasound at the patient's bedside is a
very helpful ultrasound exam in evaluating the
patient presenting to the emergency department with
acute abdominal pain.
And hopefully through looking at this module,
you know how to perform the right upper quadrant
ultrasound examination and understand the anatomy
of the hepatobilliary tract essential to bedside sonography.
And also, by going through the footage, looking at the
ultrasound imaging of the gallbladder and portal triad,
you now know how to interpret the ultrasound images
that you will obtain at the patient's bedside.
So I look forward to seeing you back as
Sono Access continues and we go on to future modules
focusing on gall stones and acute cholecystitis.

Brightcove ID

5733888191001

https://youtube.com/watch?v=FY3dBuQV03w

Case: Gallbladder Ultrasound - Gallstones

Read more about Case: Gallbladder Ultrasound - Gallstones

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This video (part 2 of 3) focuses on normal hepatobiliary imaging and anatomy of and near the gallbladder.

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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 SoundBytes module, entitled
Part Two of Bedside Ultrasound of the Gallbladder,
we're gonna go further on
to our discussion of gallbladder sonography.
Hopefully, first of all, you've reviewed
part one in the series
and have a basic understanding of how to perform
the right upper quadrant exam
and also how to interpret the images that you will obtain.
In this module, entitled Part Two of Gallbladder Sonography,
we're going to focus specifically on the spectrum
of gallstone-related disease, beginning
with a deposition of cholesterol crystals
known as gallbladder sludge and microlithiasis,
on to the ultrasound findings with large stone concretions
that may cause biliary colic and acute cholecystitis.
Here's a video clip from a patient who presented with
right upper quadrant pain,
and we see here the gallbladder in the middle of the image.
Let's look towards the neck of the gallbladder,
and we appreciate a fluid level
that's made up of gallbladder sludge.
We see here that the gallbladder sludge
is tucked in there towards the neck of the gallbladder,
but we see crystals moving up towards the fundus
and towards the body of the gallbladder.
I'd like to make a couple points
with regard to gallbladder sludge,
and the first is that occasionally beam artifact
can masquerade as gallbladder sludge.
However, sludge is going to be defined as having
a fluid level that is going to layer out with gravity.
Also, remember that gallbladder sludge can occasionally
cause symptoms of acute biliary colic
and acute cholecystitis in patients,
so it's not a benign finding.
Here's a video clip from a young male presenting with
right upper quadrant pain,
and as we're looking through the gallbladder,
we notice here a finding within the neck of the gallbladder.
We see a concretion of gallbladder sludge and also
tiny gallbladder stones known as microlithiasis.
Notice that the microlithiasis has a posterior
acoustic shadowing, due to the blocking of sound waves
through the concretions of the cholesterol crystals.
So, an interesting finding on
the spectrum of gallbladder disease.
Here's another video clip,
again from a male presenting with right upper quadrant pain,
and what we see here is a gallbladder
in the middle of the image,
and notice the layering out of multiple small stones
on the back wall of the gallbladder.
We see the characteristic appearance of a gallstone here.
Notice it has a hyperechoic, or bright, appearance,
and we can see shadows coming off the back,
as the sound waves can't permeate
the hard cholesterol crystals.
Here's a still image showing the classic appearance of
an impacted stone at the gallbladder neck.
Here, we're looking through the lateral intercostal view,
so we get a nice long axis view of the gallbladder.
We can see here a gallstone that's located
within the neck of the gallbladder.
Notice that it has the classic bright, or hyperechoic,
appearance, and we see the hard shadow,
the blackout of sound waves posterior to the gallstone.
Interestingly enough, as we rolled the patient around
and inspected the gallstone,
the gallstone failed to move, showing that it was impacted
and the cause of the patient's biliary colic.
Here's a video clip showing an impacted stone
at the gallbladder neck, again taken from that lateral
intercostal view that gives us those great long axis
views of the gallbladder.
We see the liver to the top of the image
and the gallbladder inferior to the liver.
Towards the neck of the gallbladder, we see a white,
hyperechoic gallstone, and we see
the classic posterior acoustic shadowing.
As we mentioned in module one, it's always important to
look at the gallbladder in two orientations.
Here we've moved the patient into
the left lateral decubitis position,
and we're looking from the subcostal plane.
Again, we see the gallbladder stretched out inferior
to the liver, and within the neck of the gallbladder,
we see the hyperechoic, bright gallstone,
and notice also the posterior acoustic shadow.
As we pressed down on this gallbladder, the patient
had a lot of pain, confirming a sonographic Murphy sign.
Here we're going to change the orientation of the probe
into a short axis configuration.
The probe is located in the subcostal plane
with a marker over towards the patient's right.
Thereby we're cutting the gallbladder into cross sections,
so the gallbladder will appear as a circle
on the ultrasound screen.
We see here a gallstone, that hyperechoic area within
the gallbladder lumen, and again the posterior acoustic
shadowing confirming the presence of a gallstone.
Here's a video clip taken from a elderly patient
with acute right upper quadrant pain.
We're scanning back and forth through the gallbladder.
This view is taken from that lateral intercostal view.
And we see here the presence of multiple shadowing
gallstones within the lumen of the gallbladder.
So the end result of cholesterol deposition within
the gallbladder, forming multiple stones
within the gallbladder lumen.
And we can see here, as we scan back and forth,
the multiple hyperechoic foci
with a posterior acoustic shadow.
Here's an interesting video clip from another patient
with acute right upper quadrant pain.
And we see a distended gallbladder,
stretching across the screen here,
the fundus located towards the right,
and the neck over towards the left.
Within the lumen of the gallbladder, we see multiple
gallstones layering across the back wall of the gallbladder.
And notice that they have almost
like a small pea-like type appearance.
And we can see also the posterior acoustic shadowing
as we scan back and forth through the gallstones.
So, multiple gallstones within a distended gallbladder.
A sonographic finding that can be seen with
a gallbladder that's completely filled with stones
and in a contracted state is the wall echo sign.
And here we see an example of the wall echo sign,
long axis to the left and short axis view to the right.
What we see here is the gallbladder filled with stones,
and all we see is the anterior wall of the gallbladder,
the echo from the concretion of stones,
and the shadow off the back of the stones
making the sign.
Thus the wall echo sign pathognomonic for a gallbladder
completely packed with stones in a contracted state.
And it can be occasionally difficult to find the gallbladder
when all you see is the wall echo sign.
One potential pitfall in performance of
right upper quadrant sonography
is that occasionally a loop of bowel may come
right up against the wall of the gallbladder
and be mistaken for a gallstone.
Let's take a look at two video clips
that show the difference between these two appearances.
In the video clip to the left,
we see a loop of bowel that's right up against
the posterior wall of the gallbladder.
Notice that it has a bright, or hyperechoic, appearance
that could be mistaken for a gallstone.
However, the loop of bowel is clearly
outside the gallbladder wall and not inside,
as a gallstone would be.
Also, let's look at the shadows that come off
the back of the air-filled bowel.
What we see is that there are dirty shadows,
as I characterize, that are not completely dark
as those that would be seen off of a gallstone.
Notice that there's areas of white
within the dark areas, characterizing a dirty shadow.
Let's take a look at the video clip to the right,
and what we see here is an impacted gallstone
at the neck of the gallbladder.
Notice that it has a hyperechoic appearance that shadows
and that the gallstone is clearly within
the lumen of the gallbladder.
And we see the shadow that comes off the back
is a clean shadow, completely dark without
those light areas that characterize air shadows.
My conclusion points for this SoundBytes module, going over
part two of Bedside Ultrasound of the Gallbladder.
Hopefully, through this module you now understand
the ultrasound imaging findings in the
spectrum of gallstone disease that may be seen
in patients presenting to the emergency department
with abdominal pain.
I hope also that you can identify the presence of
biliary sludge, or microlithiasis, that can be seen
as the first finding of deposition
of cholesterol crystals,
on to the identification of large gallstone concretions.
And last, I look forward to seeing you back
as SoundBytes continues,
and as we go on to Gallbladder Sonography, part three,
that'll focus entirely on the ultrasound findings
in acute cholecystitis.

Brightcove ID

5733895942001

https://youtube.com/watch?v=L3e-YdQRa-A

Case: FAST Exam - LUQ Exam

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The left upper quadrant (LUQ) ultrasound exam can help clinicians more accurately diagnose intra-abdominal injuries. Topics: infra-diaphragmatic and splenorenal spaces, & how to identify free fluid caused by a trauma.

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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'll continue our journey,
looking at the views of the Trauma FAST exam.
Hopefully you've had a chance to join me prior
for the views of the right upper quadrant,
and in this module,
we're going to look specifically
at the left upper quadrant views of the Trauma FAST exam,
known traditionally by two terms,
the splenorenal, or the perisplenic views.
In an upcoming module,
we'll look specifically at the suprapubic view,
or bladder view, of the Trauma FAST exam.
There's a lot of information we can gain
by looking at the left upper quadrant
in our trauma patients,
and we'll need to know that it's not a mirror image
of the right upper quadrant,
that the spleen offers less of an acoustic window
onto the left upper quadrant than the liver does
on the other side.
Here's a slide reviewing how to perform
the left upper quadrant view of the Trauma FAST exam.
As the spleen offers less of an acoustic window
on the left upper quadrant,
we need to bring the probe in
from a more posterior position.
Thus, the mantra, knuckles to stretcher.
Optimally, we're using a smaller footprint probe
that can get in between the ribs
and get a good view into the left upper quadrant area.
Position the probe in the long axis view
with the probe marker towards the patient's head,
at about the midaxillary line, or posterior axillary line,
with your knuckles almost touching down to the bedside.
We'll concentrate on two areas, most importantly,
the area above the spleen and below the diaphragm,
where fluid will preferentially accumulate,
but rounding out our exam,
we'll look inferior at that spleno-renal space.
Now that we know how to perform
the left upper quadrant view of the Trauma FAST exam,
let's take a look at a normal ultrasound image.
I have the probe oriented towards the patient's head,
so superior chest cavity is towards the left,
inferior abdominal cavity towards the right.
Notice the spleen,
the large organ in the middle of the image here,
and the kidney, the football shaped organ,
as seen inferior and posterior to the spleen.
Notice the curving white line just above the spleen,
which is the diaphragm.
Recall that in the left upper quadrant,
that fluid will accumulate preferentially
in between the spleen and the diaphragm
and will be a dark or anechoic stripe positioned there.
Here's another normal video clip
taken from the left upper quadrant.
In this case, I'm swinging the probe from inferior,
looking at the spleno-renal interface,
to superior, looking at that infra-diaphragmatic space.
And here, as I freeze the image,
we see the spleen right in the middle of the image,
the curving white line making up the diaphragm,
and notice the thoracic cavity
as seen just left, or superior, to the diaphragm.
If the patient had a significant hemothorax,
or fluid collection in the thoracic cavity,
that would be represented by
a dark or anechoic fluid collection
just above the diaphragm in the thoracic cavity.
Now that we've had a chance
to examine several normal video clips
as taken from the left upper quadrant,
let's look at a pictorial here,
showing a positive left upper quadrant FAST exam.
Here we see superior located to the left,
inferior to the right.
We see the spleen in the middle of the image,
the kidney inferiorly to the right.
The thoracic cavity with the diaphragm
to the left of the spleen, or superior.
We see the area of fresh fluid
as demarcated by the orange color,
and notice that it layers out
predominantly below the diaphragm
and above the spleen,
and this is the area where fluid
will preferentially deposit in the left upper quadrant.
There are ligaments that sling
from the diaphragm all the way to the colon
that prevent the flow of fluid
into that area between the spleen and the kidney
until the fluid is relatively large
within the left upper quadrant.
So, now let's take a look at a positive exam
from a trauma patient,
and we see here the spleen in the middle of the image,
the kidney inferiorly located to the spleen,
and notice the large amount of fresh fluid,
that dark or anechoic fluid collection
that layers out above the spleen
in the infra-diaphragmatic location,
and anterior to the spleen.
This indicates a large amount of fresh blood
in the left upper quadrant,
and we also see a blood clot,
that echogenic material waving around
anteriorly to the spleen.
So a positive exam in a trauma patient.
Here's another positive left upper quadrant view.
Notice here, there's a larger amount
of fresh fluid present on this examination.
We see the spleen in the middle of the image,
the kidney inferiorly there to the right,
and all the dark, fresh fluid,
as indicated by the dark, or anechoic, fluid collection,
as seen infra-diaphragmatic and above the spleen.
Notice again that the fluid is not
preferentially layering out in between
the spleen and the kidney, reinforcing the point that
this is not a mirror image of the right upper quadrant.
Here's another positive examination
in a patient who comes in hypotensive
after being hit by a car.
Notice I'm swinging the probe
between the kidney, up superiorly,
to look at the spleen.
Notice the absence of fluid in between the spleen
and the kidney,
but the presence of free fluid
right above the spleen and below the diaphragm
as indicated by that dark stripe.
Here's an interesting video clip from a trauma patient.
Again, we're looking at the left upper quadrant,
and we delineate the spleen and kidney.
Notice the presence here of fresh fluid,
the dark or anechoic fluid stripe
as seen layering out superior, or in anterior,
to the spleen there,
but let's look above the diaphragm here,
which we see as the curving white line
moving up and down as the patient breathes,
and what we notice here is the presence
of a dark fluid collection within the thoracic compartment.
So we're able to diagnose in this patient
an associated hemothorax
in addition to the hemoperitoneum.
So the left upper quadrant view
also helpful for looking into the thoracic compartment
as well as diagnosing interabdominal injury.
One maneuver that can help you
uncover fresh fluid within the left upper quadrant
is to have the patient take a deep breath
and analyze that infra-diaphragmatic space
as the diaphragm moves upward, off of the spleen.
Notice here that we uncovered the amount
of fresh fluid that's present right above the spleen
and below the diaphragm as the patient
takes a deep breath,
and that diaphragm moves superiorly.
So, in conclusion, I'm glad I could share with you
this SoundBytes module, going over the trauma FAST exam,
specifically the left upper quadrant, or perisplenic view.
There's a great deal of information that we can gain
by looking into the left upper quadrant
in our trauma patients,
and it's important to realize that
the left upper quadrant is not a mirror view
of the right upper quadrant,
and that fluid will preferentially layer out
in the area above the spleen and below the diaphragm,
in contrast to the hepatorenal space
on the right upper quadrant.
So, I hope to see you back as SoundBytes continues
and we move on to look at the suprapubic,
or bladder view, of the Trauma FAST exam.

Brightcove ID

5726805223001

https://youtube.com/watch?v=VBHCmw8iHCc

Case: FAST Exam - Suprapubic Views

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

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

Brightcove ID

5508114789001

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

Case: FAST RUQ Exam - Hemorrhage

Read more about Case: FAST RUQ Exam - Hemorrhage

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This video (part 2 of 2) focuses on positive findings found during right upper quadrant (RUQ) ultrasound examinations; it also includes instructions for performing the trauma FAST RUQ-hepatorenal ultrasound exams

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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 entitled,
Part Two of the Right Upper Quadrant View
of the Trauma Fast Exam,
we're going to focus entirely on positive findings
from this view.
Hopefully you've had a chance to join me prior
for Part One of the Right Upper Quadrant View
of the Trauma Fast Exam where we focused entirely
on normal findings from the right upper quadrant.
And hopefully have a chance to join me back
as we go through the left upper quadrant
and suprapubic views of the Trauma Fast Exam.
So let's begin this module by going through a
review of how to perform
the right upper quadrant view of the Trauma Fast Exam.
Remember that the probe is positioned in the
long axis configuration with the marker dot superiorally
and that we're going to place the probe in between the ribs
at about the anterior axillary line.
Here we'll want to focus on the three areas
as I emphasized in Part One of this module.
Number one, the infra-diaphragmatic space
looking at that region just below the diaphragm
and above the liver,
and actually looking into the chest cavity for a hemothorax.
Position two, which is the traditional Morison's Pouch
or hepatorenal interface.
And position three, to round out the exam
looking at the caudal liver tip representing the
beginning of the right paracolic gutter.
Here's a nice illustration showing a positive examination
from the right upper quadrant view of the Trauma Fast Exam.
We see the liver smack in the middle of the image
and the kidney slightly posterior and inferior to the liver.
Let's look at the preferential deposition of fluid
as shown here in the orange color,
and we see that it layers out predominantly around
the caudal tip of the liver as shown towards the
inferior edge of the image here.
Notice that it flows from the caudal tip of the liver
into that potential space which is Morison's Pouch
in between the liver and the kidney.
Now this is very important to emphasize as many times,
fresh fluid can only be seen around that
caudal tip of the liver,
and then it would move into that hepatorenal interface
or Morison's Pouch.
Here's a positive ultrasound examination from a patient
who was hit by a car while crossing the street
and we see here the liver
smack in the middle of the image here.
Notice the kidney located inferior and posterior
to the liver.
And in between the liver and the kidney in that
potential space known as Morison's Pouch,
we see a dark or anechoic fluid collection.
Not insignificant,
actually a pretty large stripe in this patient.
This represents the positive examination,
or the presence of fresh fluid,
in this case blood within Morison's Pouch.
And notice that it layers out in between
that liver and kidney.
To emphasize the point that a complete right upper quadrant
view includes looking at the caudal tip of the liver,
let's examine this video clip from another trauma patient.
If we look at the hepatorenal interface there,
we fail to see the presence of any fluid,
but as we move the probe inferiorially,
we see that the caudal tip of the liver as shown right there
is well outlined by fluid.
And here we see the inferior pole of the kidney,
the caudal tip of the liver extending above the kidney,
and notice all the fresh fluid
both anterior and posterior to the caudal tip of the liver.
Making the point that this is a very important area
to look for in the right upper quadrant exam.
Here's a video clip from a patient who was stabbed
with a really big knife to the epigastric region.
And as we look at the right upper quadrant,
we can actually see a linear liver laceration
extending through the medial aspect of the liver.
We also appreciate the presence of a large
amount of fresh fluid.
That dark or anechoic fluid collection
layering out posteriorally there to the liver
and extending into Morison's Pouch,
the hepatorenal interface.
So as this patent had unstable hemodynamics,
the next move was to package for the operating room.
And here we can actually see the caudal tip of the liver
waving around in all the fresh fluid,
in this case blood.
And I obtained this view by moving the probe
one intercostal space inferior from the last view
to well delineate the caudal tip of liver
which we can see here moving around in all the fresh fluid.
In the last few video clips the appearance of fresh fluid
on bedside sonography was darker, anechoic.
However as blood clots it can take on a more echogenic
or lighter appearance.
In this video clip a patient was stabbed
and had a significant down time before being
brought to the Emergency Department.
As we look at the hepatorenal interface,
we see a large amount of clotted blood there
made up by that echogenic
or lighter appearance of the blood there.
Notice that the large amount of blood extends into
the right paracolic gutter as we scan inferiorially.
And here we can see the liver,
the kidney,
and the clotted blood,
that more echogenic or lighter blood in Morison's Pouch.
So in conclusion,
I'm glad I could share with you this Part Two Module
on the Right Upper Quadrant View of the Trauma Fast Exam.
I hope now you have a better understanding
on how to perform a complete exam
looking into the three areas as we discussed.
Infradiaphragmatic,
Morison's Pouch,
and inferior tip of the liver.
And hopefully now you'll be able to discern
the presence of fresh blood versus clotted blood
on bedside sonography.
So I hope to see you back as Sono access continues
and as we move further through the other views of the
Trauma Fast Exam.

Brightcove ID

5508109915001

https://youtube.com/watch?v=Gj5IioG7SyM

M-Turbo: Axillary Nerve Post Injection

Read more about M-Turbo: Axillary Nerve Post Injection

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M-Turbo: Axillary Nerve Post Injection.

Clinical Specialties

Anesthesiology (Regional)

Media Library Type

Image

Case: FAST RUQ Exam - Normal Exam

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This video (part 1 of 2) details how performing the right upper quadrant (RUQ) ultrasound examination on trauma patients enables clinicians to potentially identify internal injuries.

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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 focus entirely on
the trauma fast exam.
Specifically, we're going to look further into the
right upper quadrant view, also known as
the hepatorenal view.
Now, we're going to cover the two other views of
the trauma fast exam in upcoming modules of SoundBytes.
The left upper quadrant view, also known as
the splenorenal or perisplenic view,
and the suprarpubic view, also known as the bladder view.
There's a tremendous amount of information we can gain by
looking closely into the right upper quadrant area
in our trauma patient.
Traditionally it's been emphasized that the hepatorenal area
or Morison's pouch view, is the primary target for the
right upper quadrant, but it can take up to 600 ccs of fluid
to make a positive exam if only looking into that area.
So I'll show some alternative views in this module that can
help us to possibly improve on that number.
Now let's take a look at a slide showing us how to perform
the right upper quadrant view of the trauma fast exam.
We'll want to place the probe at about the anterior axillary
line and using the liver as an acoustic window aiming
the probe down towards the bedside retroperitoneally to get
a good view of these anatomical structures.
It's best to have a small footprint probe that can easily
sit between the ribs giving a good view on to this area.
Notice that this is a long axis view with a probe marker
position superiorly.
Now our first view from this right upper quadrant area
will be position one as shown here in the
infra-diaphragmatic space just below the diaphragm
and above the liver.
Second, we'll move the probe slightly inferiorly to look in
to the traditional Morison's pouch or hepatorenal interface,
and the last view is the caudal tip of the liver shown here
in position three.
It's very important to look at the caudal tip of the liver,
as this represents the beginning of the right paracolic
gutter and small amounts of fluid will pool here before
moving into Morison's pouch.
Now that we know how to perform the right upper quadrant
view of the trauma fast exam, let's take a look at a normal
image that you might obtain.
Remembering that this is a long axis view,
I have the probe marker here positioned towards
the patient's head.
So towards the left of the clip here is
superior chest cavity and towards the right is
inferior or abdominal cavity.
Notice the first large structure that comes into view
in the middle of the image is the liver and to the right,
or inferior to the liver we see the football shaped kidney.
Now it's that interface between the liver and kidney that
represents a potential space known as Morison's pouch
where we're be looking for dark, anechoic fluid collections.
Note here, we see a thin, white line making up a normal exam
and representing the fat within the capsule
around the kidney.
Notice to the left of the liver we see the white diaphragm
that represents the interface between chest
and abdominal cavities.
Let's take a look at another normal
right upper quadrant examination.
Again the probe marker is towards the patient's head.
This is the superior chest cavity towards the left.
Inferior abdominal cavity towards the right.
We see the liver in the middle of the image,
and notice the diaphragm above the liver moving up and down
as the patient breathes.
We see the kidney inferior to the liver, and notice
the potential space in between the liver and the kidney
that makes up the hepatorenal fossa or pouch of Morison.
Notice in this video clip all we see is a white line
representing the fat within the capsule around the kidney
or Gerota's capsule.
If there was fluid, we would see a dark or anechoic fluid
collection in this potential space.
Let's now look at the diaphragm which we see above the liver
and if we look above the diaphragm this is where we would
look for fluid within the chest cavity or hemothorax
in the trauma patient.
We may have to move the probe several intercostal spaces
on the patient's side to fully investigate
the right upper quadrant for fluid.
Here's a swing view where I'm starting relatively superior
right there looking in the area between the diaphragm
and the liver, going through Morison's pouch, as I'll show
coming up right here the area between the liver
and the kidney and terminating at the inferior
tip of the liver.
Notice here we notice the caudal tip of the liver extending
almost all the way inferiorly down past the inferior pole
of the kidney, and it's important to look at that caudal
tip of the liver, as it represents the beginning
of the right paracolic gutter.
So in conclusion, I'm glad I could share with you part one
of the right upper quadrant view of the trauma fast exam.
Now we know how to recognize a normal examination
looking all the way from the area below the diaphragm
through Morison's pouch and terminating at a view of
the caudal tip of the liver.
So I hope to see you back as SoundBytes continues,
and we look at part two of the right upper quadrant view
focusing on positive examinations.

Brightcove ID

5767048880001

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

Case: Aorta Ultrasound - Introduction

Read more about Case: Aorta Ultrasound - Introduction

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

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Subtitles

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

Brightcove ID

5508121223001

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

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