<p begin="00:00:07.639" end="00:00:09.351" style="s2">- [Voiceover] A linear array transducer</p>
<p begin="00:00:09.351" end="00:00:11.510" style="s2">with a musculoskeletal exam type</p>
<p begin="00:00:11.510" end="00:00:14.415" style="s2">is used to perform an<br />ultrasound guided aspiration</p>
<p begin="00:00:14.415" end="00:00:16.039" style="s2">of a Baker's cyst.</p>
<p begin="00:00:16.039" end="00:00:18.528" style="s2">The patient is in a supine position.</p>
<p begin="00:00:18.528" end="00:00:20.870" style="s2">The transducer is placed transversely</p>
<p begin="00:00:20.870" end="00:00:22.752" style="s2">over the popliteal fossa,</p>
<p begin="00:00:22.752" end="00:00:26.088" style="s2">with the orientation marker<br />directed to the patient's right.</p>
<p begin="00:00:26.088" end="00:00:28.820" style="s2">The most common location<br />for a Baker's cyst</p>
<p begin="00:00:28.820" end="00:00:31.767" style="s2">is at the crossing of the<br />semimembranosus muscle</p>
<p begin="00:00:31.767" end="00:00:32.839" style="s2">and the medial head</p>
<p begin="00:00:32.839" end="00:00:36.367" style="s2">of the gastrocnemius muscle<br />above the femoral condyle.</p>
<p begin="00:00:36.367" end="00:00:38.343" style="s2">The femoral condyle is seen as a</p>
<p begin="00:00:38.343" end="00:00:41.719" style="s2">bright hyperechoic structure<br />on the left of the screen.</p>
<p begin="00:00:41.719" end="00:00:43.494" style="s2">The speckled pattern of the tendon</p>
<p begin="00:00:43.494" end="00:00:45.454" style="s2">of the semimembranosus muscle,</p>
<p begin="00:00:45.454" end="00:00:47.718" style="s2">and the starry night<br />appearance of the medial head</p>
<p begin="00:00:47.718" end="00:00:50.591" style="s2">of the gastrocnemius can<br />be seen as the transducer</p>
<p begin="00:00:50.591" end="00:00:52.535" style="s2">is moved more distally.</p>
<p begin="00:00:52.535" end="00:00:54.071" style="s2">A Baker's cyst appears as a</p>
<p begin="00:00:54.071" end="00:00:58.903" style="s2">C-shaped, darker hypoechoic<br />or anechoic cystic structure,</p>
<p begin="00:00:58.903" end="00:01:01.746" style="s2">with a superficial and deep component.</p>
<p begin="00:01:01.746" end="00:01:04.871" style="s2">The transducer is rotated<br />90-degrees clockwise,</p>
<p begin="00:01:04.871" end="00:01:06.143" style="s2">with the orientation marker</p>
<p begin="00:01:06.143" end="00:01:08.472" style="s2">directed toward the patient's head.</p>
<p begin="00:01:08.472" end="00:01:11.095" style="s2">The extent and depth of the Baker's cyst</p>
<p begin="00:01:11.095" end="00:01:12.946" style="s2">should be confirmed by scanning</p>
<p begin="00:01:12.946" end="00:01:15.839" style="s2">the cyst proximally and distally.</p>
<p begin="00:01:15.839" end="00:01:17.806" style="s2">The needle is inserted in the skin</p>
<p begin="00:01:17.806" end="00:01:20.287" style="s2">just proximal to the transducer.</p>
<p begin="00:01:20.287" end="00:01:22.913" style="s2">The needle is slowly<br />advanced to lie in plane</p>
<p begin="00:01:22.913" end="00:01:24.358" style="s2">to the transducer beam,</p>
<p begin="00:01:24.358" end="00:01:28.447" style="s2">and is seen as a bright,<br />hyperechoic linear structure.</p>
<p begin="00:01:28.447" end="00:01:30.041" style="s2">The needle is slowly advanced</p>
<p begin="00:01:30.041" end="00:01:32.262" style="s2">under direct ultrasound visualization,</p>
<p begin="00:01:32.262" end="00:01:33.623" style="s2">until the tip is seen to lie</p>
<p begin="00:01:33.623" end="00:01:35.022" style="s2">within the Baker's cyst,</p>
<p begin="00:01:35.022" end="00:01:37.647" style="s2">where an aspiration can be done.</p>
<p begin="00:01:37.647" end="00:01:39.415" style="s2">After the procedure is finished,</p>
<p begin="00:01:39.415" end="00:01:40.700" style="s2">the area should be scanned</p>
<p begin="00:01:40.700" end="00:01:42.782" style="s2">to ensure that there is<br />no evidence of bleeding</p>
<p begin="00:01:42.782" end="00:01:43.865" style="s2">in this area.</p>

<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="00:00:07.379" end="00:00:09.137" style="s2">- [Voiceover] A linear array transducer</p>
<p begin="00:00:09.137" end="00:00:11.666" style="s2">with a nerve exam type is used to perform</p>
<p begin="00:00:11.666" end="00:00:14.865" style="s2">a median and ulnar regional nerve block.</p>
<p begin="00:00:14.865" end="00:00:18.167" style="s2">The target depth is approximately<br />one to two centimeters</p>
<p begin="00:00:18.167" end="00:00:20.392" style="s2">in an 80-kilogram adult.</p>
<p begin="00:00:20.392" end="00:00:23.105" style="s2">The patient is placed supine with the arm</p>
<p begin="00:00:23.105" end="00:00:25.641" style="s2">externally rotated at the side.</p>
<p begin="00:00:25.641" end="00:00:28.475" style="s2">The transducer is placed<br />in a transverse plane</p>
<p begin="00:00:28.475" end="00:00:29.721" style="s2">at the wrist crease</p>
<p begin="00:00:29.721" end="00:00:31.120" style="s2">with the orientation marker</p>
<p begin="00:00:31.120" end="00:00:33.953" style="s2">directed towards the patient's right side.</p>
<p begin="00:00:33.953" end="00:00:38.214" style="s2">The hypoechoic pulsatile<br />ulnar artery is identified.</p>
<p begin="00:00:38.214" end="00:00:40.485" style="s2">It may be helpful to use color Doppler</p>
<p begin="00:00:40.485" end="00:00:42.265" style="s2">if the artery is small.</p>
<p begin="00:00:42.265" end="00:00:45.357" style="s2">The ulnar nerve is an oval, or triangular,</p>
<p begin="00:00:45.357" end="00:00:47.294" style="s2">bright, hyperechoic structure</p>
<p begin="00:00:47.294" end="00:00:50.318" style="s2">that lies immediately<br />medial to the artery.</p>
<p begin="00:00:50.318" end="00:00:52.141" style="s2">Trace the nerve up the forearm</p>
<p begin="00:00:52.141" end="00:00:54.392" style="s2">following the course of the artery.</p>
<p begin="00:00:54.392" end="00:00:57.527" style="s2">The ulnar nerve will start<br />to separate from the artery</p>
<p begin="00:00:57.527" end="00:01:00.689" style="s2">approximately 2/3 of<br />the way up the forearm.</p>
<p begin="00:01:00.689" end="00:01:03.902" style="s2">The separation allows safe<br />placement of local anesthetic</p>
<p begin="00:01:03.902" end="00:01:05.269" style="s2">around the nerve.</p>
<p begin="00:01:05.269" end="00:01:07.372" style="s2">Follow the fascial plane medially</p>
<p begin="00:01:07.372" end="00:01:10.376" style="s2">to the superficial and deep flexor muscles</p>
<p begin="00:01:10.376" end="00:01:14.030" style="s2">to identify the bright,<br />hyperechoic median nerve.</p>
<p begin="00:01:14.030" end="00:01:17.358" style="s2">The median nerve appears<br />as an oval, or triangular,</p>
<p begin="00:01:17.358" end="00:01:20.735" style="s2">bright, hyperechoic structure<br />between the muscles.</p>
<p begin="00:01:20.735" end="00:01:22.051" style="s2">The needle can be advanced</p>
<p begin="00:01:22.051" end="00:01:25.372" style="s2">using an in-plane or<br />out-of-plane technique.</p>
<p begin="00:01:25.372" end="00:01:28.332" style="s2">For an in-plane approach,<br />the needle is positioned</p>
<p begin="00:01:28.332" end="00:01:31.655" style="s2">one to two centimeters<br />lateral to the transducer</p>
<p begin="00:01:31.655" end="00:01:34.231" style="s2">and advanced under the transducer.</p>
<p begin="00:01:34.231" end="00:01:37.655" style="s2">The initial path for the needle<br />is toward the ulnar nerve</p>
<p begin="00:01:37.655" end="00:01:38.812" style="s2">to allow the needle tip</p>
<p begin="00:01:38.812" end="00:01:41.893" style="s2">to lie immediately beside the ulnar nerve.</p>
<p begin="00:01:41.893" end="00:01:45.441" style="s2">Inject three to five<br />cc of local anesthetic</p>
<p begin="00:01:45.441" end="00:01:48.604" style="s2">around the ulnar nerve<br />to perform the block.</p>
<p begin="00:01:48.604" end="00:01:52.681" style="s2">The needle is then redirected<br />laterally to the median nerve.</p>
<p begin="00:01:52.681" end="00:01:56.245" style="s2">Injection of three to five<br />cc of local anesthetic</p>
<p begin="00:01:56.245" end="00:01:57.726" style="s2">around the median nerve</p>
<p begin="00:01:57.726" end="00:02:00.809" style="s2">will complete the median nerve block.</p>

<p begin="00:00:07.227" end="00:00:08.945" style="s2">- [Voiceover] A linear array transducer</p>
<p begin="00:00:08.945" end="00:00:11.605" style="s2">with a superficial exam<br />type is used to perform</p>
<p begin="00:00:11.605" end="00:00:14.437" style="s2">an ultrasound guided lumbar puncture.</p>
<p begin="00:00:14.437" end="00:00:16.616" style="s2">The patient is placed<br />in a sitting position</p>
<p begin="00:00:16.616" end="00:00:18.991" style="s2">with the spine maximally flexed.</p>
<p begin="00:00:18.991" end="00:00:22.142" style="s2">The transducer is placed<br />in a transverse direction</p>
<p begin="00:00:22.142" end="00:00:24.333" style="s2">with the orientation<br />marker directed toward</p>
<p begin="00:00:24.333" end="00:00:26.758" style="s2">the patient's left side<br />in the middle of the back</p>
<p begin="00:00:26.758" end="00:00:29.416" style="s2">at the level of the iliac crests.</p>
<p begin="00:00:29.416" end="00:00:32.008" style="s2">The spinous processes<br />will appear as distinct</p>
<p begin="00:00:32.008" end="00:00:35.181" style="s2">hyperechoic peaks with<br />acoustic shadowing below</p>
<p begin="00:00:35.181" end="00:00:37.632" style="s2">and define the midline of the spine.</p>
<p begin="00:00:37.632" end="00:00:40.818" style="s2">The transducer is slowly moved superiorly</p>
<p begin="00:00:40.818" end="00:00:43.706" style="s2">until the next spinous<br />process is identified.</p>
<p begin="00:00:43.706" end="00:00:46.199" style="s2">The transducer is rotated 90 degrees</p>
<p begin="00:00:46.199" end="00:00:48.242" style="s2">with the orientation<br />marker directed toward</p>
<p begin="00:00:48.242" end="00:00:49.707" style="s2">the patient's head.</p>
<p begin="00:00:49.707" end="00:00:52.646" style="s2">The two previously<br />identified spinous processes</p>
<p begin="00:00:52.646" end="00:00:55.552" style="s2">will now appear as<br />crescent-shaped, concave,</p>
<p begin="00:00:55.552" end="00:00:57.792" style="s2">hyperechoic structures.</p>
<p begin="00:00:57.792" end="00:01:00.857" style="s2">The gap between the bright<br />hyperechoic convexities</p>
<p begin="00:01:00.857" end="00:01:03.796" style="s2">is the inner spinous<br />space and defines the area</p>
<p begin="00:01:03.796" end="00:01:07.879" style="s2">in which the lumbar puncture<br />should be performed.</p>

<p begin="00:00:07.204" end="00:00:08.813" style="s2">- [Voiceover] A linear array transducer</p>
<p begin="00:00:08.813" end="00:00:11.101" style="s2">with a superficial venous exam type</p>
<p begin="00:00:11.101" end="00:00:13.364" style="s2">is used to perform an ultrasound guided</p>
<p begin="00:00:13.364" end="00:00:15.289" style="s2">drainage of an abscess.</p>
<p begin="00:00:15.289" end="00:00:18.603" style="s2">The transducer is placed<br />in a longitudinal direction</p>
<p begin="00:00:18.603" end="00:00:21.380" style="s2">over the area of tenderness or fluctuance,</p>
<p begin="00:00:21.380" end="00:00:23.098" style="s2">with the orientation marker directed</p>
<p begin="00:00:23.098" end="00:00:24.780" style="s2">toward the patient's head.</p>
<p begin="00:00:24.780" end="00:00:27.090" style="s2">It is helpful to have a<br />generous amount of gel</p>
<p begin="00:00:27.090" end="00:00:30.651" style="s2">on the transducer face, to<br />decrease transducer pressure</p>
<p begin="00:00:30.651" end="00:00:33.171" style="s2">and pain with the examination.</p>
<p begin="00:00:33.171" end="00:00:35.625" style="s2">The depth and extent of the abscess cavity</p>
<p begin="00:00:35.625" end="00:00:37.445" style="s2">is determined by scanning the cavity</p>
<p begin="00:00:37.445" end="00:00:39.281" style="s2">in a left-to-right direction.</p>
<p begin="00:00:39.281" end="00:00:42.033" style="s2">Septation of the abscess<br />cavity should be determined</p>
<p begin="00:00:42.033" end="00:00:43.879" style="s2">as it is important to free these areas</p>
<p begin="00:00:43.879" end="00:00:46.948" style="s2">during the drainage procedure<br />for optimal results.</p>
<p begin="00:00:46.948" end="00:00:50.132" style="s2">The superior and inferior<br />extent of the abscess cavity</p>
<p begin="00:00:50.132" end="00:00:52.593" style="s2">can be determined by moving the transducer</p>
<p begin="00:00:52.593" end="00:00:55.357" style="s2">in a superior to inferior direction.</p>
<p begin="00:00:55.357" end="00:00:57.394" style="s2">The drainage incision should be planned</p>
<p begin="00:00:57.394" end="00:01:00.730" style="s2">at an area where the abscess<br />cavity is most superficial</p>
<p begin="00:01:00.730" end="00:01:04.147" style="s2">and likely to promote dependent drainage.</p>