<p begin="00:00:07.217" end="00:00:08.450" style="s2">- [Voiceover] Linear array transducer</p>
<p begin="00:00:08.450" end="00:00:10.353" style="s2">with a vascular exam type,</p>
<p begin="00:00:10.353" end="00:00:13.051" style="s2">is used to perform an<br />ultrasound guided insertion</p>
<p begin="00:00:13.051" end="00:00:16.639" style="s2">of a radial artery catheter<br />via a transverse approach.</p>
<p begin="00:00:16.639" end="00:00:18.809" style="s2">The patient is in a supine position,</p>
<p begin="00:00:18.809" end="00:00:22.821" style="s2">with the arm abducted 45<br />degrees and externally rotated.</p>
<p begin="00:00:22.821" end="00:00:25.326" style="s2">The wrist is extended<br />by placing a small roll</p>
<p begin="00:00:25.326" end="00:00:26.974" style="s2">beneath the wrist crease.</p>
<p begin="00:00:26.974" end="00:00:29.218" style="s2">The transducer is placed transversely</p>
<p begin="00:00:29.218" end="00:00:31.187" style="s2">just proximal to the wrist crease,</p>
<p begin="00:00:31.187" end="00:00:34.397" style="s2">with the orientation marker<br />directed to the patient's right.</p>
<p begin="00:00:34.397" end="00:00:36.681" style="s2">The radial artery is superficial,</p>
<p begin="00:00:36.681" end="00:00:40.593" style="s2">and is seen as a dark anechoic,<br />round, pulsatile structure</p>
<p begin="00:00:40.593" end="00:00:42.541" style="s2">on the lateral aspect of the wrist,</p>
<p begin="00:00:42.541" end="00:00:46.056" style="s2">seen in the midst of<br />static, echodense material.</p>
<p begin="00:00:46.056" end="00:00:48.006" style="s2">There are often small venous vessels,</p>
<p begin="00:00:48.006" end="00:00:49.852" style="s2">which accompany the radial artery,</p>
<p begin="00:00:49.852" end="00:00:53.165" style="s2">which can be compressed with<br />gentle transducer pressure.</p>
<p begin="00:00:53.165" end="00:00:56.565" style="s2">The radius can be seen as<br />an anechoic, dark structure,</p>
<p begin="00:00:56.565" end="00:00:59.991" style="s2">approximately one centimeter<br />below the radial artery.</p>
<p begin="00:00:59.991" end="00:01:03.399" style="s2">Adjust the transducer so it<br />is centered over the artery.</p>
<p begin="00:01:03.399" end="00:01:06.422" style="s2">Follow the needle entry by<br />slowing sliding the transducer</p>
<p begin="00:01:06.422" end="00:01:08.929" style="s2">in the direction of needle advancement.</p>
<p begin="00:01:08.929" end="00:01:11.892" style="s2">The needle will appear<br />as a small, bright dot.</p>
<p begin="00:01:11.892" end="00:01:13.338" style="s2">When the needle tip appears,</p>
<p begin="00:01:13.338" end="00:01:16.666" style="s2">the transducer should be advanced<br />a short distance distally</p>
<p begin="00:01:16.666" end="00:01:19.079" style="s2">to follow the tip of<br />the needle trajectory,</p>
<p begin="00:01:19.079" end="00:01:21.525" style="s2">and stay in advance of the needle entry.</p>
<p begin="00:01:21.525" end="00:01:22.923" style="s2">The needle is slowly advanced,</p>
<p begin="00:01:22.923" end="00:01:25.176" style="s2">under direct ultrasound visualization,</p>
<p begin="00:01:25.176" end="00:01:28.168" style="s2">until the tip is seen to<br />puncture the radial artery.</p>
<p begin="00:01:28.168" end="00:01:30.016" style="s2">The transducer should be moved slightly</p>
<p begin="00:01:30.016" end="00:01:32.702" style="s2">proximally and distally<br />to confirm the needle tip</p>
<p begin="00:01:32.702" end="00:01:35.869" style="s2">lies in the mid-portion of the artery.</p>

<p begin="00:00:07.397" end="00:00:09.087" style="s2">- [Voiceover] A linear array transducer</p>
<p begin="00:00:09.087" end="00:00:10.710" style="s2">with a venous exam type</p>
<p begin="00:00:10.710" end="00:00:13.822" style="s2">is used to perform an<br />ultrasound-guided insertion</p>
<p begin="00:00:13.822" end="00:00:17.827" style="s2">of an internal jugular catheter<br />via a transverse approach.</p>
<p begin="00:00:17.827" end="00:00:19.996" style="s2">The patient is in a supine position</p>
<p begin="00:00:19.996" end="00:00:21.420" style="s2">with the head slightly turned</p>
<p begin="00:00:21.420" end="00:00:23.431" style="s2">toward the contralateral side.</p>
<p begin="00:00:23.431" end="00:00:26.331" style="s2">The operator is positioned<br />at the head of the bed.</p>
<p begin="00:00:26.331" end="00:00:28.712" style="s2">The transducer is placed transversely</p>
<p begin="00:00:28.712" end="00:00:29.970" style="s2">just below the apex</p>
<p begin="00:00:29.970" end="00:00:32.663" style="s2">of the sternocleidomastoid<br />muscle triangle,</p>
<p begin="00:00:32.663" end="00:00:35.671" style="s2">with the orientation marker<br />directed to the patient's left</p>
<p begin="00:00:35.671" end="00:00:37.655" style="s2">at a 9:00 position.</p>
<p begin="00:00:37.655" end="00:00:39.098" style="s2">The most superficial structure</p>
<p begin="00:00:39.098" end="00:00:41.086" style="s2">identified in the ultrasound image</p>
<p begin="00:00:41.086" end="00:00:43.548" style="s2">is the sternocleidomastoid muscle.</p>
<p begin="00:00:43.548" end="00:00:46.077" style="s2">Deeper to this, the internal jugular vein</p>
<p begin="00:00:46.077" end="00:00:49.080" style="s2">will appear as a dark<br />anechoic elliptical shape,</p>
<p begin="00:00:49.080" end="00:00:51.990" style="s2">and is compressible with<br />transducer pressure.</p>
<p begin="00:00:51.990" end="00:00:55.354" style="s2">The artery will be circular and pulsatile.</p>
<p begin="00:00:55.354" end="00:00:58.421" style="s2">The thyroid gland lies<br />medial to these structures,</p>
<p begin="00:00:58.421" end="00:01:01.367" style="s2">and has a light gray echo signature.</p>
<p begin="00:01:01.367" end="00:01:03.420" style="s2">Adjust the transducer so it is centered</p>
<p begin="00:01:03.420" end="00:01:05.804" style="s2">over the internal jugular vein.</p>
<p begin="00:01:05.804" end="00:01:08.867" style="s2">Follow the needle entry by<br />slowly sliding the transducer</p>
<p begin="00:01:08.867" end="00:01:11.272" style="s2">in the direction of needle advancement.</p>
<p begin="00:01:11.272" end="00:01:15.230" style="s2">The needle will appear as a<br />small bright hyperechoic dot.</p>
<p begin="00:01:15.230" end="00:01:16.923" style="s2">When the needle tip appears,</p>
<p begin="00:01:16.923" end="00:01:20.067" style="s2">the transducer should be advanced<br />a short distance distally</p>
<p begin="00:01:20.067" end="00:01:22.537" style="s2">to follow the tip of<br />the needle trajectory,</p>
<p begin="00:01:22.537" end="00:01:25.144" style="s2">and stay in advance of the needle entry.</p>
<p begin="00:01:25.144" end="00:01:26.523" style="s2">The needle is slowly advanced</p>
<p begin="00:01:26.523" end="00:01:28.724" style="s2">under direct ultrasound visualization</p>
<p begin="00:01:28.724" end="00:01:30.616" style="s2">until the tip is seen to indent,</p>
<p begin="00:01:30.616" end="00:01:33.391" style="s2">and then puncture the<br />internal jugular vein.</p>
<p begin="00:01:33.391" end="00:01:34.837" style="s2">The transducer should be moved</p>
<p begin="00:01:34.837" end="00:01:36.859" style="s2">slightly proximally and distally</p>
<p begin="00:01:36.859" end="00:01:38.740" style="s2">to confirm that the needle tip lies</p>
<p begin="00:01:38.740" end="00:01:41.990" style="s2">in the mid-portion of the jugular vein.</p>