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M-Turbo: Femoral Nerve and Artery

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M-Turbo: Femoral Nerve and Artery.

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M-Turbo: Catheter in IJV Short Axis.

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M-Turbo: Catheter in IJV Short Axis.

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FP/GP

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M-Turbo: Catheter in IJV Long Axis

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M-Turbo: Catheter in IJV Long Axis.

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How To: Deep Vein Thrombosis

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Demonstration on how to perform a deep vein thrombosis exam.

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Lower Extremity

Deep Venous Thrombosis

Three-Point Compression

Patency

Mid Thigh

Superficial Femoral Vein

Common Femoral Vein

Subtitles

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

Brightcove ID

5508114175001

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

How To Perform A Saphenous Nerve Block

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Dr. David Auyong reviews scanning techniques and sonographic landmarks for an ultrasound guided nerve block.

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Subtitles

- The saphenous nerve block is useful for
medial knee surgery, medial leg surgery,
and medial ankle and foot surgery.
The saphenous nerve is a continuation
of the femoral nerve below the knee.
This is a good block to do in conjunction
with a popliteal sciatic nerve block to give you
complete anesthesia below the knee.
To perform the saphenous nerve block,
we typically use a linear probe.
The linear probe allows us to get
good resolution and reasonable penetration.
Typical settings for the saphenous nerve block
start between four and six centimeters total depth,
expecting the nerve to be between two and four centimeters.
Now the saphenous nerve is a small nerve,
and we may not see it in everybody.
In fact, most people we don't see it in.
The reason we do a saphenous nerve block
is that we don't take away any quadriceps muscles,
and so the patient will have no quadriceps muscle weakness.
To get a saphenous nerve, you may also do a femoral block,
but by doing a femoral block, you may
or you will take out all your quadriceps.
So this technique I'm going over is a great technique
for outpatient surgery, because their
quadriceps muscle strength will be intact.
This technique I'm using is useful in elderly
and obese patients because we're using muscle landmarks
rather than nerve or other small landmarks.
So we usually start about 10 centimeters above the knee.
Put the probe on the medial side of the leg.
We can abduct the leg a little bit
to give us better visualization here.
Now when we put the probe on here,
we like to start more anterior.
This gives us a view of the femur,
the hyperechoic stripe here, as well as the vastus medialis.
The vastus medialis can pretty much be found in everybody.
We're going to slide the probe posterior next.
The next muscle we'll come across is the sartorius muscle.
Now we see the vastus medialis muscle ending
and see the sartorius muscle in view now.
There are many anatomical differences in patient to patient.
The saphenous nerve can run anterior
to the sartorius muscle, posterior to the
sartorius muscle, and I've even seen it
piercing the sartorius muscle.
So the whole key is, is that we will put
our local anesthetic below the sartorius muscle
in order to get a good saphenous nerve block.
Most of the time we're doing a field type block
where we deposit the local behind the sartorius muscle,
and expect that that local will get to the nerve,
because these nerves can be difficult
to see in obese or elderly patients.
So now, our needle approach is
gonna be using a 10 centimeter needle.
This needle will be inserted a few centimeters
away from the probe in this angle.
We like to see the needle in a shallow plane
and then advance it deeper below the sartorius muscle.
This block can also be performed if the patient is prone,
imagine my needle coming from the other side.
Typical volumes used here are between
five and 20 milliliters of local anesthetic; if a good
nerve is seen, usually represented by a hyperechoic
structure, then I'll just place five milliliters.
Most patients, we do not see the individual
nerve here, and we will place 10 milliliters
as a type of field block in this area.
Here, our needle is advancing through the vastus medialis.
We try to position the tip of the needle
underneath the sartorius muscle,
which is located to the right of the screen.
You can see the hyperechoic areas,
some of which may represent the nerve.
Our needle is now directly below the sartorius muscle,
and you can see the local anesthetic
spreading below the sartorius muscle
to track to the saphenous nerve.

Brightcove ID

5508114742001

https://youtube.com/watch?v=E1tmS9Lv1bU

Body

Dr. David Auyong reviews scanning techniques and sonographic landmarks for an ultrasound guided nerve block.

How to: Internal Jugular Vein Needle Insertion

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An overview of ultrasound landmarks and scanning techniques for internal jugular vein access including a demonstration on an ultrasound phantom.

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Subtitles

- Ultrasound guided central lines are rapidly
becoming standard to care.
Ultrasound allows us to do this procedure much safer
than a standard blind landmark approach.
In this segment I'm gonna take you through how we can map
the jugular vein for the procedure of an intrajugular line
using the central approach.
So let me show you how to position our ultrasound.
We have our model here, lying down.
I normally would be at the head of the bed
and if you look at his neck,
you can actually see the two heads
of his general cleidomastoid.
We see a sternal head and the clavicular head
that usually form a triangle.
Normally in a blind landmark approach,
our needle would be going to the apex of the triangle.
We're now gonna use ultrasound to localize the vein.
We're gonna now find the vein
and make the needle insertion so much safer.
We're gonna go ahead and choose our system
which is gonna be placed just to the right of the patient.
We're gonna use a linear transducer.
We're gonna go ahead and set up our examination type.
I'm gonna hit exam, I'm gonna click on venous,
select, and we're gonna be ready to start scanning.
We're going to also use a little trick to put
the transducer marker actually to the patient's left.
The reason I do this is to maintain the orientation
from the head of the bed so the vein and the artery
are in the normal anatomic positions,
so it's not to create more confusion when you're using
ultrasound for guidance of a procedure.
I'm gonna go ahead and put a little bit of gel
on this transducer.
And now let's take a look at his neck in the normal place
that we would normally have put our needle.
So if we're looking at the screen, in the center
of the screen is a very large anechoic structure.
And you can see that it easily collapses.
This is the jugular vein.
Just adjacent to this,
to the left of the screen and below the vein is the artery.
That is what we want to avoid and just a little bit more
to the left of that is the thyroid.
So the ultrasound allows us to easily find the vein.
We can track it along its entire course.
First thing we can identify, is the vein patent?
You might have a patient who has had a previous cannulation
and the vein itself may not be a good candidate.
The second thing, once we've identified the vein,
we can map the skin and actually put marks on the skin,
and we can also look at the side of the ultrasound image
to see how deep the vein is.
And in this case it's about one centimeter deep.
I'm gonna show you how to use ultrasound
to actually guide your needle into the intrajugular vein.
As you can see we have a Blue Phantom here.
We're gonna be able to take a look at the vein,
first with ultrasound,
and then I'm gonna use the ultrasound transducer
to actually guide my needle toward the vein.
I'm gonna go ahead and place a little bit of gel
onto the neck where I expect the jugular vein to lie.
And then I'm gonna use my transducer
to identify this vein.
And you can see on this image,
we can see what is supposed to be a vein here in the center.
And it's compressible; it's about a centimeter deep or so.
So I can use ultrasound guidance.
I can now place this needle into the vein.
Normally this whole setup will be under sterile procedure,
the transducer will be covered with a sterile sheet,
I'll be in full sterile prep, and the needle
and the rest of the equipment all will be sterile.
But for the purposes of this demonstration
I think you'll recognize how I'm placing the needle
and how we're cannulating the vein.
So I put the target in the center of the image,
so this would be the jugular vein in the center
and we know that the jugular vein's about
a centimeter and a half deep in this case.
I'm now gonna show you how you can actually follow
the needle tip as you slowly march toward the vein.
I have the jugular vein centered in the image,
I can see it's compressible, we're sure it's the vein.
Now I take my needle and put it right adjacent
to the transducer in the mid part
and we can see the needle tip,
and I'm gonna slowly advance,
but while I'm advancing I'm angling the transducer
away from the needle and toward the needle tip
so I always have the needle tip in the field of view.
And when I do that I can always keep track
of how far I've gone, and then I do this nice and slow.
And you can see I'm getting closer to the vein now.
And I've actually hit the vein.
And if you can get a close look here, you can actually see
a little bit of blue liquid here,
which demonstrates that I've actually hit the vein.

Brightcove ID

5743128737001

https://youtube.com/watch?v=21w4kuD0_gA

How to: Peripheral Arm Veins for Vascular Access

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An overview of ultrasound landmarks and scanning techniques used for peripheral arm vein access.

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