Wrist

Media Library Type

Media Library Tag

Subtitles

- [Voiceover] A liner array transducer with
a venous exam type is used to preform
an ultrasound guided insertion
of a peripherally inserted central catheter
via a transverse approach.
The patient is in a supine position
with the arm extended 90 degrees at the patient's side
and externally rotated.
The transducer is placed transversely just proximal
to the medial condyle in the bicipital groove
with the orientation marker directed to the patient's right.
The basilic vein is seen as a dark anechoic circular,
compressible structure in the mid-portion of
the ultrasound image, between the biceps and triceps muscle.
Deeper, and slightly to the right of the screen,
the bright hyper-echoic humerus can be seen.
Adjust the transducer so it is
centered over the basilic vein.
Follow the needle entry by slowly sliding
the transducer in the direction of needle advancement.
The needle will appear as a small bright dot.
When the needle tip appears,
the transducer should be advanced a short distance
to follow the tip of the needle trajectory
and stay in advance of the needle entry.
The needle is slowly advanced under
direct ultrasound visualization until the tip
is seen to indent and then puncture the basilic vein.
The transducer should be moved slightly proximally
and distally to confirm that the needle tip
lies in the mid portion of the basilic vein.
This technique can also be used
with the deep brachial or cephalic vein.

Brightcove ID

5741617671001

https://youtube.com/watch?v=rWxN4JFBEJc

3D How To: Median and Ulnar Nerve Block

Read more about 3D How To: Median and Ulnar Nerve Block

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3D animation demonstrating an ultrasound guided median and ulnar nerve block.

Clinical Specialties

Media Library Type

Media Library Tag

Subtitles

- [Voiceover] A linear array transducer
with a nerve exam type is used to perform
a median and ulnar regional nerve block.
The target depth is approximately one to two centimeters
in an 80-kilogram adult.
The patient is placed supine with the arm
externally rotated at the side.
The transducer is placed in a transverse plane
at the wrist crease
with the orientation marker
directed towards the patient's right side.
The hypoechoic pulsatile ulnar artery is identified.
It may be helpful to use color Doppler
if the artery is small.
The ulnar nerve is an oval, or triangular,
bright, hyperechoic structure
that lies immediately medial to the artery.
Trace the nerve up the forearm
following the course of the artery.
The ulnar nerve will start to separate from the artery
approximately 2/3 of the way up the forearm.
The separation allows safe placement of local anesthetic
around the nerve.
Follow the fascial plane medially
to the superficial and deep flexor muscles
to identify the bright, hyperechoic median nerve.
The median nerve appears as an oval, or triangular,
bright, hyperechoic structure between the muscles.
The needle can be advanced
using an in-plane or out-of-plane technique.
For an in-plane approach, the needle is positioned
one to two centimeters lateral to the transducer
and advanced under the transducer.
The initial path for the needle is toward the ulnar nerve
to allow the needle tip
to lie immediately beside the ulnar nerve.
Inject three to five cc of local anesthetic
around the ulnar nerve to perform the block.
The needle is then redirected laterally to the median nerve.
Injection of three to five cc of local anesthetic
around the median nerve
will complete the median nerve block.

Brightcove ID

5508114149001

https://youtube.com/watch?v=6NKkzs9FA5I

How To: Wrist Injection

Read more about How To: Wrist Injection

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Dr. Scott Pollock demonstrates how to perform an ultrasound guided wrist injection.

Clinical Specialties

Physical Med & Rehab

Media Library Type

Media Library Tag

Hand

Wrist

Extensor Tendon

Synovial Prolipheration

Subtitles

- This is a demonstration only for injecting
the Median Nerve, placing steroids into the carpal tunnel.
So, I'm not using sterile technique,
sterile gel or cleansing the area.
This is for demonstration purposes only.
And I am going to be doing an injection in this direction.
Again, I am going to be placing the needle
parallel to the transducer.
Apply some gel here.
By placing the transducer transversely,
I have in the middle of the screen, the Median Nerve.
I can find
the Ulnar Artery on this side.
And you can see it pulsating.
I mark the Ulnar Artery with an indelible pen.
And then move just a little bit to the radial side,
so that the Ulnar Artery is down here.
And place a 25 gauge needle
in this direction, very superficially,
because it's only two millimeters deep.
And bring that needle in from the left side of the screen.
In this image, the Median Nerve is sitting right here.
The Retinaculum is along this surface here.
And the needle is coming in
from the left side of the screen.
This is bone down here.
You'll see the needle advanced superficial to
the nerve and fluid,
which includes steroids and Lidocaine injected.
In the next brief video,
the needle is seen deep to the Median Nerve,
so the nerve is here.
And the needle can be seen underneath it
and again,
injection with Lidocaine and steroid is performed.
The other approach that some people use
is with the transducer longitudinal.
Here's the Median Nerve on the screen.
And you can approach the Median Nerve this way,
so distal to proximal.

Brightcove ID

5751328524001

https://youtube.com/watch?v=sxNqVWDwmd0

How To: Wrist Exam

Read more about How To: Wrist Exam

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Dr. Scott Pollock demonstrates how to perform a wrist exam.

Clinical Specialties

Media Library Type

Media Library Tag

Rheumatoid Arthritis

Rheumatology

Synovial Prolipheration

Subtitles

- We're going to examine the wrist today,
and the best transducer for this examination
is the L25, the small footprint.
We'll check that the exam type is correct.
We're doing an MSK type of exam.
For orientation, there is a marker here which
corresponds to the turquoise dot on the screen.
Keep this marker proximal when I'm examining longitudinally
and medial when I'm examining transversally.
We'll start the wrist on the dorsal surface
and examine transversally first.
There are six compartments, beginning with
the first compartment at the base of the thumb,
and the sixth compartment near the ulnar styloid.
When we look at the wrist structures,
we're looking not only at tendons and bones,
but we're also looking at a multitude of joints.
If I come over here to a middle portion,
we're looking at carpal bones here.
With the presence of synovitis,
we would have hyperechoic or anechoic fluid
and thickening of synovium at these recesses,
which are the joints.
None of that is present here.
We'll move over to the extensor tendons of the thumb,
where you can sometimes see de Quervain's tenosynovitis,
and here is a nice view of one of
the long tendons of the thumb.
These extensor digitorum tendons here
are normal in appearance on cross-section.
These are the two thumb tendons that you see
right over the distal end of the radius,
which is right here.
This then can be traced distally out toward the thumb,
and these tendons and their peritendinous tissue
can be examined carefully.
On the other side of the wrist toward the ulna,
we have a very nice view of the
extensor carpi ulnaris tendon, which is
one of the largest extensor tendons in the wrist
and easiest to see.
It also is frequently surrounded, in a patient
with an inflammatory process, with fluid
or synovium, and that can be seen as either
anechoic or hyperechoic shadow around the
distinct oval-shaped tendon, which is
hyperechoic, and you can see the fibrillar nature within it.
If we look longitudinally, keeping this dot proximal,
and find that extensor carpi ulnaris tendon,
you can see these parallel lines,
which are going from left to right.
There are areas that are hyperechoic
alternating with hypoechoic.
This is a normal appearance of the tendon,
and also visualize peritendonous tissue.
The retinaculum, which is up here,
in deep to this, this is the distal part of the ulna.
First part of carpal bones,
and triangular ligament is in here.
Next, we look at the volar, or palmer surface of the wrist.
Most of the time, we're going to be
looking at the median nerve in this area.
Again, the transducer marker is placed medially.
This structure here is the median nerve.
We can go toward the radial side and see the artery,
the hyperechoic or anechoic area that has a small pulsation.
Sometimes checking color Doppler signal
or Doppler signal is helpful, and the median nerve, then,
is seen right here in the middle.
On the ulnar surface, going in this direction,
is the ulnar artery, and we can freeze the image
and take a measurement of the median nerve
if it's desired to see whether this is enlarged
using direct correlation between this measurement
and the presence of carpal tunnel syndrome.
So I have placed my calipers on both sides
of the median nerve, just inside the perineurium,
and then I'm going to hit this ellipse button.
Then I can actually take an approximate surface area.
She has a .08 centimeter squared area, which is normal,
and so by ultrasound criteria does not have
carpal tunnel syndrome.

Brightcove ID

5508120239001

https://youtube.com/watch?v=txMGtvWb2XI

How To: Ultrasound Guided Hand Injection

Read more about How To: Ultrasound Guided Hand Injection

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Dr. Scott Pollock demonstrates how to perform an ultrasound guided hand injection.

Clinical Specialties

Physical Med & Rehab

Media Library Type

Media Library Tag

Hand

Wrist

Extensor Tendon

Subtitles

- So I'm going to show a technique for injection of fingers,
and we'll do on the Dorsal surface or Extensor surface,
a simulation of injection of either a PIP or MCP joint
and then turn the hand around on the Palmar surface,
and show you an injection approach for Flexor tendons.
I'm gonna use the L25 transducer.
Normally we would be dealing with a sterile field,
and a sterile gel, and most likely a transducer cover,
which is also sterile, but for the purposes of this,
we're just showing you an approach.
If the joint is swollen and has Synovitis,
or a joint diffusion, it's quite easy to see the space
that you're aiming for.
This particular exam, we don't have that finding.
Normally for an injection into a small joint like this,
I like to approach the joint with the transducer placed
transversely, in this type of a plane, and then have
the needle in the same direction parallel, or in plane
with the transducer, so my needle and my transducer are
parallel, and I'm going as superficial as possible,
with a very small needle so it doesn't hurt,
and trying to place the needle into the skin,
and in the one millimeter ultrasound beam,
into the target this way.
On the other side, we'll be looking at a Flexor tendon,
which travels in this direction.
I will place the transducer longitudinally,
and approach with the needle in this direction.
If you keep the needle parallel to the surface
of the transducer, it shows up the best.
The insertion point can be quite close
to the transducer's edge, especially if you're going
very superficially; in a small area like a finger,
or a tendon around here, you don't have a lot of space
and so you have to go very close, and can insert
the needle very flat and superficially.
Because there's very little space between the skin surface
and the tendon, and here it's probably
about two or three millimeters.
And watch exactly where the tip of the needle
and the bevel goes.

Brightcove ID

5751328215001

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

How To: Hand Exam

Read more about How To: Hand Exam

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Dr. Scott Pollock demonstrates how to perform a hand exam.

Clinical Specialties

Physical Med & Rehab

Media Library Type

Media Library Tag

Hand

Wrist

Extensor Tendon

Synovial Prolipheration

Subtitles

- I'm going to examine the MCM and PIP joints now.
We'll be looking at the dorsal, or extensor, surfaces,
as well as the palmar surface of the MCPs
and just take a brief look at the PIP.
The best transducer for this exam is the L25,
which has a small footprint and it allows you
to retain contact with the skin's surface.
There is a marker on the transducer, which represents
this turquoise dot, so in keeping your orientation straight,
you always want to keep this proximal, so this is held
that way for longitudinal images, and medial,
so this marker should be on the outside.
As a rheumatologist, we're going to be looking for
boney detail tendon anatomy, and the presence
or absence of synovitis and erosions.
I'll look, today at the second and third MCPs,
both in the transverse and longitudinal planes,
and we'll take a brief look at the PIP
and then the palmar surface of the second MCP.
We'll look longitudinally over the second MCP first
and see the skin surface on the top.
The bones, this is proximal, so this is
the end of the 2nd Metacarpal.
Here's the Articular Surface, and then here is
the proximal portion of the 1st Phalanx.
The black anechoic surface, here, is Cartilage,
and there's some cartilage here,
and this is a normal joint structure at the second MCP.
There is frequently a small articular cortical defect
on the dorsal surface of this metacarpal.
That is not an erosion.
An erosion would appear elsewhere
with this type of an appearance.
We can also see the Extensor Tendon superficially
right under the surface of the skin.
Could you move your finger just up a little bit,
and you can see that tendon moving and the joint moving.
We'll then take a transverse image and see
a transverse oval image of that Extensor Tendon.
We're going to look for hyperechoic
or anechoic fluid or synovium around it.
In this case, none of that is present.
We can also now look at the third MCP.
Here, again, we see the extensor tendon, the joint
is V-shaped structure.
This is anechoic where the cartilage is and hypoechoic
where the actual joint material is within the capsule.
The joint extends from approximately here
all the way over to here.
That's quite normal.
We'll look at the PIP.
This is the distal end of the 1st Phalanx.
The Joint is this space, here, and she happens
to have a small amount of osteoarthritis, here,
with some Irregularity of this Cortical surface.
I can slip my finger in here and show you where
this is actually moving and you can see
that joint flexing and extending.
We'll look at the flexor surface of the second MCP.
These tendons are quite a bit bigger.
We see the Flexor Tendon moving very nicely
as she flexes and extends her finger, and you can see
the superficial border between the tendon and the
Subcutaneous Tissues, and you can see
the Joint very nicely, here.
This Hypoechoic area is the A1 pulley,
which is just proximal to this joint.

Brightcove ID

5751328211001

https://youtube.com/watch?v=vjkspg2Esq0

Case: Peripheral Venous Access - Part 2

Read more about Case: Peripheral Venous Access - Part 2

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Use ultrasound imaging to identify anatomy prior to intravenous catheter needle punctures, verify needle depth, and use dynamic techniques for attaining optimal needle guidance during deep vein cannulation & IV placement.

Applications

Cardiology

Clinical Specialties

Media Library Type

Case Study Videos

Media Library Tag

Subtitles

- Hello, my name is Phil Perera
and I'm the emergency ultra sound coordinator
at the New York Presbyterian hospital in New York City
and welcome to SoundBytes Cases.
In this SoundBytes module, entitled Ultrasound Guided
Cannulation of Arm Veins Part 2,
we'll look further into the techniques needed
to use ultrasonography to guide a IV into
one of the deep arm veins.
As we discussed in part one of this module,
we first want to map out the vein using both short
and long axis views and we'll employ a dynamic technique
for optimal guidance for the catheter down to the vein.
Want to use a longer angiocath for the procedure,
preferably 1.88 inch or longer
as we need a good amount of plastic catheter in the vein
to avoid extravasation of fluids or meds
during resuscitation of the patient.
This recent published study showed that it's crucial
to select the correct target vessel when deciding
to cannulate a deep arm IV.
169 patients were enrolled in the study
and it was determined that the size of the vessel
directly correlated with the success rate
of the cannulation procedure.
A vessel with a diameter less than three millimeters
correlated to a success rate of only 56%.
While a diameter greater than 6 millimeters correlated
to success rate of 92%.
That's showing that the diameter was directly correlating
to the success rate of placement of a deep arm IV.
Also the depth of the vessel was very important
as no vessel that was deeper than 1.6 centimeters
was successful cannulated.
A very nice study by Dr. Panebianco et al.
A academic emergency medicine, 2009.
Armed with the knowledge of the last study,
here we're going to measure the diameter of a brachial vein
prior to a puncture attempt.
Notice here, we've selected a brachial vain
and we're measure the diameter at 3.7 millimeters
by 4.3 millimeters.
Thus, this would correlate with a low likelihood
of success rate during a cannulation attempt.
Notice also we're measuring the depth of the vessel
and while the depth of the vessel is six millimeters
less than the 1.6 centimeters that correlated
to no successful outcomes of peripheral IV cannulation,
the diameter of the vessel would be very difficult
to cannulate.
Now let's take a look at a better target.
This is a basilic vessel and we can see here
that the diameter is much larger than the last
brachial vein and we measure it at 6.5 millimeters
by 6.7 millimeters.
Thus, this would have a very high success rate
in terms of cannulation with a ultrasound guided IV.
We can also see that the vessel depth is relatively
superficial, again making it more amenable
to a cannulation attempt.
Once we have selected a favorable target vessel
for cannulation, we can place the probe in a short axis
of side to side orientation.
Here we're using a q-tip coming in underneath the probe
at 45 degree angle to look for the ring down artificat
for guidance for placement of the IV in a side to side
or lateral orientation on the patients arm.
We can look for a finding know as the ring down artifact
on the ultrasound screen as shown here.
Notice we have a nice plump basilic vein in the middle
of the field here and we can see a dark mark
emanating from the surface directly down.
Which is the ring down artifact caused by pressure
from the q-tip.
Thus this would be the appropriate poke point
on the side to side orientation on the patients arm
for placement of the IV.
We can also localize a vessel using the long axis technique.
Notice here we have the probe oriented
in an up and down configuration on the patients arm
and are placing the q-tip underneath the distal aspect
again at a 45 degree angle
to look for that ring down artifact onto the vessel.
To increase the accuracy of an ultrasound guided IV,
it's important to know the course of the vessel
as it runs up and down the arm.
Here we see in the picture to the left
that we're localizing the vessel at one point
on the patients arm but it's not enough
to know only one point.
We need to know the course of the vessel
as it runs up and down the arm as show in the picture
here to the right.
Notice we're marking two points on the vessel.
We have the distal poke point as noted by the blue x
towards the outer part of the patients arm
and then we're moving the probe more up the arm
more proximally to mark a second point on the vessel.
A line drawn between these marks would identify
the trajectory that the IV should follow
once it comes in at the the distal poke point
to successfully cannulate the vessel.
This longer angiocath at 1.88 inches would be more
optimal for cannulation of a deep arm vein
using ultrasound guidance.
This schematic shows the reason
that we need a longer angiocath when cannulating
a deeper arm vein.
While the vein my only be one centimeter deep to the skin.
Notice that the needle is not going directly down,
it comes in at about a 45 degree angle
to cannulate the vessel.
So we need a longer aspect of the needle just
to make it down to the target vein.
Plus we also need an ample amount of catheter
to be within the vessel lumen
to avoid extravasation of fluids or medications.
For this reason, 1.88 inch or longer is essential
for cannulation of a deep arm vein.
Now we're ready to cannulate a vessel
using ultrasound guidance.
We'll begin using the short axis or side to side orientation
of the probe with the probe maker
orientated towards the left
as we stand in front of the patient.
This will correlate with the ultrasound screen indicator
dot which is towards the left of the screen.
Generally I want to go and place the IV at a 45 degree angle
underneath the patients skin and then I'll place
the probe over the area of the IV to guide the IV
directly into the vein.
This phantom shows why using the short axis technique
can be an excellent starting point for guiding
the IV directly down to the vein under ultrasound guidance.
Here we can see a target vessel and note we see
the echogenic tip of the needle going
through the anterior wall of the vessel
and permeating into the vessel lumen.
So the short axis technique is optimal
for viewing lateral needle orientation
across the patients arm and guiding the IV directly
down into the venous lumen.
When using the short axis technique,
one must keep in mind the effect of probe slice
on visualization of the needle.
Note here, the probe is position more proximally
along the course of the needle and even though the needle
tip is securely within the vessel lumen,
we're only visualizing the needle to be above the vessel.
Notice the schematic view here towards the left
and we can see the probe is more proximal along
the course of the needle and the ultrasound view
towards the right and even thought the tip of the needle
is securely within the lumen of the vessel,
we're only visualizing the needle above the vein
and may get a false determination of where the tip
of the needle is.
Therefore, when using the short axis technique
when cannulating a deep arm vessel,
it's important to move the probe along the course
of the vessel to stay in plane with the tip
of the needle as you advance the needle under the skin
and into the vessel lumen.
Here we see we've moved the probe more distally along
the course of the vessel and now we're more
in plane with the tip of the needle.
We see the schematic view to left
and the ultrasound view towards the right
showing successful cannulation of the vessel
and the tip of the needle right within the vein lumen.
This video clip shows successful cannulation
of a brachial vein using the short axis technique.
Notice here we see the vessel and notice
we see the echogenic tip of the needle coming down
from the surface and permeating the anterior wall
of the vessel
and there we can see the echogenic tip of the needle
right within the vessel lumen.
We can also use the long axis configuration
for cannulation of a deep arm IV.
Optimally, you want to place the probe in the configuration
of the vessel as it runs up and down the patients arm.
By tradition, we want to have the probe marker oriented
distal so that the distal aspect of the probe
will line up to the left of the ultrasound screen,
as shown here.
So distal on the screen will be to the left
and proximal to the right.
The IV would then enter underneath the probe
at that 45 degree angle.
While the short axis configuration gives
a lot of information about side to side
or lateral orientation of the needle,
the long axis configuration gives a lot of information
with regard to vertical needle depth.
Here we see a needle coming from the left
and permeating into the vein lumen.
Notice here we can get an accurate determination
of the optimal depth of the needle
in relation to the venous lumen for cannulation
of the vessel.
Here's a real cannulation of a brachial vein
in a long axis configuration.
We see the vein stretching out in a long axis configuration
as a tubular structure running from left to right
along the screen and we see the needle coming
in from the left to the right moving up and down
and cannulating within the venous lumen.
So at this point, we're ready to thread the catheter.
This video clip captures a long axis cannualtion
of a deep arm vein and we can see the needle coming
in from left to right and we can see the needle tip
permeating through the vessel lumen.
Now we can see the actual threading of the plastic catheter.
So again we'll look at the needle coming in from left
to right and now we'll go ahead and freeze it
so we can see the actual plastic catheter
securely within the lumen of the vessel
and it's nice to visualize the catheter
within the vessel lumen to ensure
that there's enough catheter there to give a good amount
of medications and fluids with extravasation
of either of these liquids into the patients arm.
In conclusion, thanks for tuning in to this SoundBytes
module going over part 2 of ultrasound guided
cannulation of arm veins.
Ultrasound guidance for peripheral IV insertion
is an extremely helpful technique
and optimally you want to choose a target vessel
greater than six millimeter in diameter
and at a depth of less than 1.6 centimeters
to optimize our cannulation success.
We want also pick a longer catheter so we have
enough needle and plastic catheter to get into
these deep arm vessels.
We use a combination of short and long axis views
to dynamically guide the angiocath into the vein
and just bear with it because there is a steep learning
curve for these ultrasound guided IVs.
So you'll get it with time so don't give up
and practice practice practice.
So I hope to see you back in the future
as we SoundBytes continues.

Brightcove ID

5508134289001

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

Case: Peripheral Venous Access - Part 1

Read more about Case: Peripheral Venous Access - Part 1

/sites/default/files/Cases_SB_Aorta2_EDU00186_Thumb.jpg

Use ultrasound imaging to help identify deep and nonpalpable veins that can accommodate the placement of an IV catheter. Doppler color flow is used to differentiate the brachial artery from other anatomical structures.

Applications

Cardiology

Clinical Specialties