Suprapubic

Case: FAST Exam - Suprapubic Views

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

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

Brightcove ID

5508114789001

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

How To: Female Pelvis: Transabdominal View

Read more about How To: Female Pelvis: Transabdominal View

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Learn the basics of female transabdominal pelvic scanning.

Clinical Specialties

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

Brightcove ID

5750473717001

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

How To: FAST Exam: Female Pelvis

Read more about How To: FAST Exam: Female Pelvis

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Learn to examine the female pelvis for free fluid.

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

Brightcove ID

5508120185001

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

How to: FAST Exam: Male Pelvis

Read more about How to: FAST Exam: Male Pelvis

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Learn the suprapubic view of the trauma FAST exam in males.

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- We're going to go ahead and do the suprapubic view
of the FAST exam.
We're going to put a little gel on this transducer
and we're going to go just above the symphysis pubis
and we're going to start initially sagittally
and then we're going to scan transversely.
We have our marker right here.
That's going to be aiming toward the patient's head
and we're going to put this transducer
just above the symphysis pubis
and we're going to see the bladder.
We can see a pretty large bladder here.
The first thing I'll take a look at when I see the image
is that we need to adjust our depth,
so I'm changing the depth here
to make this bladder into a better size
that is going to fit better within the image.
The next thing I notice that I do need to adjust
is the gain.
This is a very important knob to be adjusting
because in this view particularly
you can have a lot of acoustic enhancement
posterior to the bladder
and we don't want to miss small amounts of fluid.
The far gain, which is this knob here,
may need to be adjusted additionally.
Once you identify the bladder,
which we see as an anechoic structure
with nice circumscribed walls,
you want to then scan from left
to right,
looking particularly for evidence of fluid
outside of that circumscribed bladder.
We're looking for free fluid within the pelvis.
Once we're satisfied that we can see the full bladder
in a sagittal fashion,
we're then going to turn the transducer marker here
toward the patient's right,
and we're going to scan again.
Now we're in a transverse view
and were scanning from very inferiorly
to superiorly,
again looking for free fluid outside of the bladder.
As you're scanning through the bladder,
again you're looking for free fluid,
remember free fluid is anechoic or black on ultrasounds
so that's what you're going to be looking for
outside of the bladder.

Brightcove ID

5508104675001

https://youtube.com/watch?v=6Srf0briZSU

3D How To: eFAST Pelvis

Read more about 3D How To: eFAST Pelvis

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

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

Brightcove ID

5508134284001

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

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

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Case: FAST Exam - Suprapubic Views

Case: FAST Exam - Suprapubic Views

How To: Female Pelvis: Transabdominal View

How To: Female Pelvis: Transabdominal View

How To: FAST Exam: Female Pelvis

How To: FAST Exam: Female Pelvis

How to: FAST Exam: Male Pelvis

How to: FAST Exam: Male Pelvis

3D How To: eFAST Pelvis

3D How To: eFAST Pelvis

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