Case Study Videos

Case: Aorta Ultrasound - Introduction

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This video details how bedside ultrasound imaging can be used, as well as proper probe placement and how to interpret the ultrasound images seen during abdominal ultrasound examinations.

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- Hello, my name is Phillips Perera
and I'm the Emergency Ultrasound Coordinator
at the New York Presbyterian Hospital in New York City.
Welcome to SoundBytes Cases.
In this SoundBytes Module entitled Part 1
of Beside Ultrasound of the Aorta,
we're going to specifically look
at the Beside Detection of Abdominal Aortic Aneurysms.
Now this application of Point of Care Beside Sonography
is one of the most crucial ones for the Emergency Physician
as Detection of an Abdominal Aortic Aneurysm can be
life saving for your patient at the bedside.
Using Point of Care Sonography to make a rapid
diagnosis of a rupturing Abdominal Aortic Aneurysm
in a patient who has unstable vital signs can facilitate
timely transfer of the patient to the operating theater
without undue delay in the Emergency Department
such as waiting for a CAT Scan.
Because there's a lot of material to cover
on the topic of Bedside Ultrasound of the Aorta,
I've divided this module into Aorta Ultrasound
Parts one and two.
In this module entitled Aorta Ultrasound Part 1
we're gonna begin by reviewing the anatomy of the Aorta,
we'll then move on to learn how to perform the Ultrasound
examination of the Abdominal Aorta, all the way from the top
at the subxiphoid process as the Aorta
exits the thoracic cavity to bifurcation
at the level of the Umbilicus.
We'll then also move on to learn how to understand
the interpretation of the Ultrasound images
that you will obtain using Beside Sonography.
Let's review the position of the probe
for Sonography of the Aorta.
Generally we'll begin by placing the probe in
a short axis configuration.
Begin by placing the probe in probe position one
in the Epigastric region to visual the Aorta
as it enters the Abdominal Cavity and exits
through the Thoracic Cavity via the diaphragm.
The probe should be configured with a marker dot
over towards the patients right side.
Press down to firmly displace bowel gas
and get a glimpse of that Aorta.
Now, we should visualize the spine as our landmark
and on top of the spine we'll visualize the Aorta.
Then we should slide the probe inferiorly to probe position
two here as show in the Super Umbilical region.
This will allow us to visualize the entire part
of the Abdominal Aorta all the way down
to Bifurcation.
We should complete the examination of the Aorta
by looking at the Aorta in a long-axis plane.
We'll begin by placing the probe in probe position one
again in the Epigastric region to visualize the top part
of the Abdominal Aorta.
Have the marker dot superiorily oriented towards the
patient's head.
We can then slide the probe inferiorily
to probe position two
at the region just above the Umbilicus to visualize
the Aorta all the way down to Bifurcation into the
Periceliac.
Now if we're having problems visualizing the Aorta
due to the presence of a lot of bowel gas,
we can also get a glimpse of the Aorta from probe position
three, the Right Hepatic area.
This is going to be about the region where we're
going to look at the trauma fast Right Upper Quadrant
view, but here were going to angle the probe more interior
over the kidney to get a glimpse at the Abdominal Aorta
and long access.
Here's an image showing the Antatomy of the Aorta
that we'll need to know to perform Beside Sonography
of this structure.
Recall that the Inferior Vena Caba and Aorta form
two pair tubular structures that course through
the Abdominal compartment.
The IVC will be towards the patient's right
and the Aorta will be over towards the patient's left-side.
We see here the first major Abdominal branch
of the Aorta which is the Celiac Axis made up
predominantly of the Hepatic Artery
and the Splenic Artery.
The third branch, the left Gastric Artery is not
well seen on Bedside Sonography.
The next major branch that we can see using
Bedside Sonography is the Superior Mesenteric Artery.
This is a very important landmark as the Renal
Artery and Vein come out the Aorta at about this level.
In fact the Left Renal Vein courses right below the
Superior Mesenteric Artery.
We need to pay particular attention to the Infer-Renal
part of the Aorta as this is where the majority of
the Abdominal Aortic Aneurysms will originate.
Now we need to scan all the way down to the Bifurcation
of the Aorta into the Periceliac Arteries
and sometimes we'll catch small aneurysms
at the Distal Aspect of the Aorta that branch
into the Illiac Artery.
This is a Short-Axis configuration taken
of the Abdominal Aorta just below the subxiphoid
process of the Sternum looking through the liver.
Now, our first landmark should be the spine.
Notice that it has a hyperechoic or bright appearance
on Bedside Ultrasound.
Just above the spine we see the Inferior Vena Cava
with it's Respiratory Phasic Pulsations
towards the patient's right and the Aorta
towards the patient's left side.
We can apply Doppler sonography to further differentiate
the two structures and notice here we're doing Colorflow
Doppler and we again recognize the spine as our landmark
for recognizing the Vascular structures of the IVC
and the Aorta on top of the spine
and we see the Phasic Respitory pattern of bloodflow
within the IVC and the steady pulsations of blood
within the Aorta with each heart beat
differentiating the two structures.
Let's now take a closer look at the Celiac Axis,
the first major branch of the Abdominal Aorta
The Celiac Axis has the Ultrasound appearance of
a seagull sign and it's made up of three arteries,
the Hepatic Artery, the Splenic Artery
and the Left Gastric Artery, although the third
is usually not visualized well with Bedside Sonography.
Now, let's take a look at some Ultrasound images
of the Celiac Axis and we see a B-mode or gray scale
image to the upper right.
Notice the IVC to the right and the Aorta to the left.
We see the Celiac Axis coming off the Aorta
having the appearance of a seagull in flight.
Notice that the right wing of the seagull will
be the Hepatic Artery coursing towards the patient's
right side and the Splenic Artery will be branching
over towards the patient's left.
To the bottom we see a Colorflow Doppler image
of the Celiac Axis showing flow within both
the Hepatic and Splenic Arteries.
Here's a video clip of the Celiac Axis in action.
Again, we're in the short-axis configuration with the
probe marker over towards the patient's right side.
We identified the spine as our landmark for identification
of the IVC and Aorta Anterior to the spine
and we see here that the bright bone table
of the spine.
Notice the Inferior Vena Cava towards
the patient's right side and we see the Aorta
towards the patient's left side.
With the seagull sign made up of the Celiac Axis
coming up the Aorta.
Here we have video clip in which we'll look at
Ultrasonic appearance of the Celiac Axis using
Doppler Sonography.
We've again identified the spine by it's
hyperechoic or bright appearance and we see the IVC
over towards the patient's right and the Aorta towards
the patient's left.
As we look closely at the Aorta we see the branch
the Celiac Axis coming up anteriorly from the Aorta.
Again, having that classic appearance of the seagull sign
with the two branches, the Hapatic and Splenic Arteries.
The second major branch of the Abdominal Aorta
is Superior Mesenteric Artery also known as the SMA.
Now, the Superior Mesenteric Artery has a classic
appearance as it has a bright or hyperechoic rim
due to fat wrapped around the Artery.
Remember that it's at this level that the Renal Artery
and veins come up the IVC and Aorta and we must be very
aware of the Aorta at this area because of the presence
of Infer-Renal Aortic Aneurysms.
We see a B-mode or gray scale image over to the right
and we see the IVC and Aorta on top of the spine.
Notice the classic appearance of the Superior Mesenteric
Artery as it arches up the Aorta with it's hyperechoic
or bright rim.
Here we actually catch the Splenic Vein passing Anterior
to the Super Mesenteric Artery.
To the bottom we see a Colorflow Doppler image showing
the Superior Mesentary Artery coming off of the Aorta.
This video clip show the Proximal Abdominal Aorta
in short axis.
We identify the spine and the Aorta on top of
the spine.
There's the Celiac Axis coming up
and there's the Superior Mesenteric Artery
with the Splenic Vein over the top,
so again, Celiac and there's SMA and there's
the Splenic Vein wrapped on top.
Let's freeze down that image and again identify
the Superior Mesenteric Artery
with it's bright or hyperechoic rim
and the Splenic Vein passing anterior
to the SMA.
Here we'll apply Colorflow Doppler to further
examine the Superior Mesenteric Artery
coming up the Aorta.
We identify the Aorta on top of the spine
and we can see the Superior Mesenteric Artery
coming up anterior
from the Aorta.
Notice we can also catch the Splenic Vein wrapped
on top of the Superior Mesenteric Artery.
We'll go ahead and freeze that down.
There's Aorta towards the back of the image,
the Superior Mesenteric Artery anterior to the Aorta
and the Splenic Vein arching on top of SMA.
To complete your examination of the Aorta
it's important to look all the way to Bifurcation.
Here where I identified the spine and on top of that
the Distal Aorta and Short Axis.
As we scan more Distally, down to the level
of the Umbillicus, here we see the Bifurcation
of the Illiac Arteries.
So, we'll watch that again and there we see
Bifurcation bright at that point here.
There's the Periceliac Arteries and we can see
the right and left Illiac Arteries delineated well
on B-mode imaging.
Now we'll apply Colorflow Doppler
to look at the Birfurcation of the Aorta.
Again, we're in the Short Axis configuration
and we see the spine, the IVC to the right
and the Aorta to the left.
Let's put this into video play, now.
What we see here is the pulsations of flow within
the IVC and Aorta and we can see the Aorta
branching right there to the Periceliac Arteries.
Notice the pulsations within the both
of the Periceliac Arteries.
We'll still that down and we can see the right and the left
Illiac Arteries well delineated
with the Colorflow Doppler.
It's always important to look at body structures
in two planes, so now we're going to inspect
the Aorta in a Long Axis view.
The probe is place in the mid-sagittal orientation
with the marker towards the patient's head.
We have Superior to the left and Inferior
to the right.
We can identify the Aorta with it's pulsations and
it's thick muscular wall.
We see the branches of the Aorta, the Celiac Axis
branching more superiorly and the Superior
Mesentaric Artery
arching inferiorly into the intestine.
We can apply Colorflow Doppler
to the Aorta in Long Axis view,
and again, we can see the pulsations of the Aorta
with each heart beat.
We see the liver anteriorly in the mid-sagittal
configuration and notice the Celiac Axis arching here
superiorly and the Superior Mesentaric Artery moving
inferiorly down towards the intestine.
In conclusion, thanks for joining me
for this SoundBytes Module cover Part one
of Beside Ultrasound of the Aorta.
Using Bedside Ultrasound to detect an Abdominal
Aortic Anuerysms remains one of the most crucial
applications of Point of Care Sonography
for the Emergency Physician.
Hopefully by going through the module you now understand
the anatomy of the Abdominal Aorta, how to perform
the Ultrasound Exam of this structure and how
to interpret the images of the Aorta that you will obtain.
I hope to see you back as SoundBytes continues
and as we return in Beside Ultrasound of the Aorta
Part two when we're going to focus entirely on the
detection of Abdominal Aortic Anuerysms.

Brightcove ID

5508121223001

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

Case: Renal Ultrasound - Hydronephrosis

Read more about Case: Renal Ultrasound - Hydronephrosis

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A review: the use of ultrasound imaging as an alternative to CT scanning for managing uncomplicated kidney stones. It reviews human anatomy, probe positioning, and scanning techniques.

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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.
- [Voiceover] In this module we're going to focus on
genitourinary ultrasound.
So, what are the goals of bedside GU ultrasound
for the emergency physician?
Well, first of all, we're going to inspect closely
the kidney looking for hydronephrosis.
We may also be able to see kidney stones as stones lodge
within parenchyma of the kidney
or at the uretero-pelvic junction.
We should also include imaging of the bladder
with our GU ultrasound and we can look for bladder stones,
stones that have migrated from the kidney
down to the UVJ and also get a sense of bladder size.
Hopefully through this module we can look at bedside
ultrasound as an alternative, non-CAT scan based strategy,
for the management of uncomplicated kidney stones
without the associated dose of radiation.
Let's now review how to perform
the renal ultrasound examination.
As shown in the pictorial to the right,
we want to come in with a probe in a long axis configuration
with a marker dot superior towards the patient's head.
It's good to use a smaller footprint probe that can
easily sit between the ribs.
For the left kidney scan, we're going to come in
from a more posterior position as the spleen offers
less of an acoustic window onto the kidney
than on the right side where we have the liver,
which offers a great acoustic window onto the kidney.
For the left side we want to put the patient in the right
lateral decubitus position with the left side up
so we can come in from that posterior position
and image the kidney.
On the right side, we can come in from a little bit more
anterior using the liver as our acoustic window
onto the kidney.
But it's also a good idea to put the patient in the left
lateral decubitus position with the right side up
so that we can angle the probe and get good views
of the kidney from the right side.
Here's an illustration of the kidney that's important
for bedside ultrasound of this structure.
Recall the outer area of the kidney, the cortex,
and interior to the outer cortex we see the medulla.
Notice several renal pyramids located within the medullary
area, and recall that the loops of Henle are going to be
oriented inside the renal pyramids.
Now the renal pyramids will be filtering the blood
and producing urine which will flow into the calyceal area
interior of the kidney.
We can see here that the small areas of the calyces
come together to make the renal pelvis.
Now the renal pelvis, in turn, will continue on
as the ureter inferiorly into the bladder.
Now a classic appearance of the interior of the kidney
is that it has a bright or hyperechoic appearance
on bedside sonography.
And this is because of the abundance of fat
within the renal sinuses.
Here's a typical normal kidney on bedside ultrasound.
I have the probe marker oriented towards the patient's head
so superior pole of the kidney is to the left,
inferior to the right.
We see the outer cortex, that outer rim of kidney to
the peripheral aspect.
And we see just interior to the cortex,
the medullary pyramids.
Notice that they have a little bit of a darker,
or hypoechoic, signature due to the presence of fluid
within the medullary pyramids.
We see the inner part of the kidney, the calyceal region,
and notice that it has a hyperechoic, or bright
appearance on bedside sonography,
due to fat within the renal sinuses.
Now let's take look at a picture showing the grading
of hydronephrosis from normal kidney to the left,
to a severe hydronephrosis kidney to the right.
What we see in the normal kidney is a normal architecture
with the medullary pyramids draining the urine
into the calyces and then out into the ureter.
Now if a kidney stone or other obstruction type pattern
had occurred, we can see that the hydronephrosis would
be manifested by increasing ballooning out of fluid
within the calyceal region of the interior part
of the kidney.
We can also see dilatation of the ureter.
Notice in the moderate type picture here to the right
we can see ballooning out of the medullary pyramids
in addition to the calyces.
In a worse case scenario, in the severe hydronephrosis,
the entire inner part of the kidney is shelled out by fluid
and all that's left is a little rim of the outer cortex
around all the fluid within the hydronephrotic kidney.
Let's begin by taking a look at a patient who presented
with a very small kidney stone and Grade 1 hydronephrosis.
Superior pole to the left, inferior pole of the kidney
to the right.
As we scan back and forth through the kidney we note
multiple little dark areas within the interior
of the kidney.
These could be construed as cysts.
However, as we scan up and down, through the kidney,
we can see that they all coalesce to form dilated calyces,
the signature of a Grade 1 hydronephrosis with mild
swelling of the interior of the kidney.
But it's very important to fan anterior posterior
through the kidney to see that all of these areas
of hydronephrosis coalesce into the calyceal region.
Here's an example of a more advanced
degree of hydronephrosis, known as moderate,
or Grade 2 hydronephrosis.
And what we see here is that the interior of the kidney,
the calyceal region, is filled with dark or anechoic fluid.
We can also see that the medullary pyramids are
more pronounced due to the coalescence of fluid
going up from the calyceal region
into the medullary pyramids.
And if we look closely we can see the beginning
of hydroureter, the arching away of the ureter,
coming down inferiorly away from the calyceal region.
So a more pronounced degree of hydronephrosis
on the spectrum of disease seen within the kidney
due to a larger kidney stone.
Here's a kidney from another patient with a larger kidney
stone representing a Grade 2 - 3,
or moderate to severe, hydronephrosis.
And again we see the dilated calyceal region filled
with fluid and in this video clip we see well
the hydroureter, the dilated ureter arching inferiorly
away from the kidney down towards the patient's bladder.
Here's an example of the highest grade hydronephrosis,
severe, or Grade 3, hydronephrosis in a patient
who had a 1.5 centimeter kidney stone.
And as we look through the kidney, scanning back and forth,
we can see that all the medullary pyramids and the
calyceal region is completely filled with dark,
or anechoic, fluid.
All that's left here is the outer cortex of renal tissue.
So, unfortunately, this was a patient who had
a long-standing hydronephrosis and who had lost a lot
of the kidney function on this side.
As we still the image down we can see that the dilated
calyceal region leads to a very dilated hydroureter,
again confirming hydronephrosis.
When evaluating a patient with a possible kidney stone,
when you find hydronephrosis you should also look
at the bladder and you may be able to visualize
a stone present at the left
or right ureterovesicular junction.
Here's a case in which a patient presented with
right flank pain and had right hydronephrosis.
We're looking at the bladder in a short axis configuration
with a marker dot over towards the patient's right side.
What we can see is a hyperechoic large shadowing stone
present at the right UVJ.
If we apply Doppler sonography there we can see the
ureteral jets, the flow of urine coming out through
the UVJ into the bladder, is being blocked by this
one centimeter stone that's plugged at the UVJ.
So, in fact, this patient had to go to the cystoscopy lab
to get the large stone removed and relieving the obstruction
of urine into the bladder.
In conclusion, thanks for joining me for this
SoundBytes module focusing on genitourinary ultrasound.
Our goals, goal number one, hopefully now you know how
to perform ultrasound of the kidney and diagnose
hydronephrosis from mild, or Grade 1,
through moderate to severe, or Grade 3.
Our second goal is to investigate the bladder closely
and we may be able to see stones that have migrated
down to the UVJ on inspection of the bladder.
We can also get a sense of bladder size on bladder
sonography and using Doppler we can look at the
ureteral jets.
Our overriding goal for this module is to use ultrasound
to diagnose kidney stones in a selected group of patients
as an alternative to CAT scanning.
So, I hope to see you back in the future
as SonoA ccess continues.

Brightcove ID

5508121194001

https://youtube.com/watch?v=N750NAEmEso

Case: Cardiac Ultrasound - Parasternal Short Axis

Read more about Case: Cardiac Ultrasound - Parasternal Short Axis

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This video details the use of bedside ultrasound imaging, specifically the parasternal short-axis view, with a phased array probe to evaluate cardiac health and anatomy, especially when looking at a patient's left ventricular contractility.

Applications

Cardiology

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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 module, we'll continue our journey looking
specifically at the cardiac echo views of the heart.
In this module, we're going to focus entirely
on the parasternal short axis view of the heart.
Now we've covered the parasternal long axis
view of the heart previously in SoundBytes module
and recall that the probe will be positioned
for the parasternal views in Position A as shown
here in the pictorial to the right.
In upcoming segments, we'll cover the subxiphoid view
as shown in probe Position B, and finally the apical
view of the heart as shown here in probe Position C.
Now the parasternal short axis view of the heart
can be very helpful in emergency care as it gives
a great deal of information about the contractility
of our patient's heart.
So let's look now further into how
to perform this examination.
The probe will be placed just left of the sternum
at about intercostal space 3 or 4
as shown in the pictorial here to the right.
Now in variance to the parasternal long axis
view of the heart where the probe marker was
positioned down towards the patient's left elbow
we'll swivel the probe 90 degrees clockwise so now
the marker is down towards the patient's right hip.
That's with the caveat that the ultrasound screen
indicator is positioned towards the left of the screen.
Now moving the patient into left lateral
decubitus position may help imaging
from the parasternal short axis plane.
Here's what the views from the parasternal
short axis plane of the heart will look like.
We see a pictorial here to the left showing
the left ventricle cut in cross section as a cylinder
and the right ventricle as a little sliver
just to the left of the left ventricle.
We see an ultrasound image corresponding to the right
and note the left ventricle again, that cylinder
cut in cross-section and the right ventricle
above the left ventricle more anteriorally
and to the left.
In this way we get a good sense of the overall
cylinder of the left ventricle
and can gauge its contractility.
Here's a video clip showing extra contractility
of the left ventricle as taken from the parasternal
short axis plane and note the muscular contractions
of the left ventricle as a cylinder squeezing in
dramatically during systole.
We also note the mitral valve flipping up
and down within the left ventricle and the right
ventricle as seen up and above the left ventricle.
Now let's contrast this video clip showing
excellent contractility with another patient
who had an advanced cardiomyopathy.
Note again the left ventricle and note here
the poor percentage change from diastole through
systole, indicating an advanced cardiomyopathy
with low ejection fraction.
We can also see the right ventricle anterior
to the left ventricle.
For learning purposes, we'll identify the walls
of the LV, the septum in between the ventricles,
the anterior wall to the top of the screen,
posterior wall to the back, and the lateral wall
as shown here towards the right portion of the screen.
Now while I show the walls of the left ventricle here,
it's important to realize that the goal of emergency
echo at the bedside is to determine overall left
ventricular contractility rather than looking
for segmental wall motion abnormalities.
So in conclusion, the parasternal short axis view
of the heart gives a great deal of information
about the contractility of the left ventricle.
This will allow you to identify patients who may
have a cardiogenic cause for their presentation.
So I hope to see you back as SoundBytes continues
and we move on to discuss the subxiphoid views
and apical views of the heart.

Brightcove ID

5752151759001

https://youtube.com/watch?v=B731sgCuZU4

Case: Parasternal Long Axis Pt. 2

Read more about Case: Parasternal Long Axis Pt. 2

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This video details the use of bedside ultrasound imaging and a phased array probe to evaluate cardiac health and structure, especially when evaluating the left heart chambers and valves, or investigating for paracardial effusion.

Applications

Cardiology

Media Library Type

Case Study Videos

Subtitles

- Hello, my name is Philips Perera
and I'm the emergency ultrasound coordinator
at the New York Presbyterian Hospital
in New York City.
Welcome to SoundBytes Cases.
In this module, entitled Cardiac Echocardiography,
Parasternal Long Axis View Part Two,
we're going to look further into
the uses of the parasternal long axis view
at the patient's bedside.
Recall that the parasternal long axis view
of the heart is going to be obtained
by placing the probe into position A as shown here.
That will configure the probe
just left of the sternum at about intercostal space three
with the marker dot down towards
the patient's left elbow.
Now, the first two goals from the parasternal long axis view
of the heart are going to be first of all,
to look for left ventricular
contractility.
The second goal is going to be
to investigate for a pericardial effusion.
Let's begin by looking at some clips,
going over left ventricular contractility.
Here's a video clip, showing excellent contractility
of the left ventricle as taken
from a medical student triathlete.
Recall the chambers of the heart,
as taken from the parasternal long axis plane,
the left atrium, as seen in the posterior location;
the mitral valve, just to the left of the left atrium;
and the left ventricle,
as seen with it's hypertrophic walls.
Notice the strong contractility
of this left ventricle as the endocardial walls
almost meet during ossicle.
We see the aortic valve to the right
of the left ventricle
and the right ventricle in a superficial location
above the left ventricle.
Recall the descending aorta,
the cylinder cut and cross section,
just posterior to the left atrium.
Note the posterior pericardial reflection
coming off just anterior to the descending aorta
and posterior to the left ventricle.
With the small indicator arrow,
I'll trace out the posterior
pericardial reflection.
Note here the absence of any dark
or anechoic fluid collections.
Now let's contrast that last video clip
with this one taken from a patient
with an advanced cardiomyopathy.
We recall the left ventricle
and the right ventricle in a superficial location
above the LV.
Notice the very poor percentage change
of the endocardio walls
of the left ventricle during ossicle,
indicating a very decreased
ejection fraction.
Here's a clip taken from a patient
who presented with a transplanted heart
and acute shortness of breath.
We'll begin by identifying the descending aorta
as shown here to the bottom part of the picture.
Note the posterior pericardial reflection,
that white line coming off just anterior
to the descending aorta.
But what we see here is the presence
on a dark, fluid collection,
a pericardial effusion that layers out posteriorly
above the posterior pericardial reflection
and comes anteriorly to surround the heart.
With a small indicator arrow,
I'll point to the anterior portion
of the pericardial effusion and note the chaotic movement
of the right ventricle
as shown here.
This is indicative of early tamponade or high pressures
within the pericardial sac.
Here's a video clip
showing a potential mimic of a pericardial effusion.
Let's being by identifying the descending aorta
as a cylinder cut and cross section
posterior to the left atrium.
We identify the posterior pericardium, as shown here,
coming off just anterior to the descending aorta.
Note the presence here of a large,
dark or anechoic fluid collection,
but note that it layers our posteriorly there
to the pericardium.
Thus, this fluid is within the pleural cavity
and not within the pericardial cavity.
With a small indicator arrow I'm again reinforcing
the pericardial reflection
and the presence of the fluid
within the thoracic cavity,
a pleural effusion.
Next we'll look at a video clip
from a patient who present with acute
shortness of breath requiring intubation.
First, we'll begin by identifying the descending aorta,
then the posterior pericardial reflection.
Note here, the presence of fluid,
both within the pericadial sac, as shown here,
layering anterior to the pericardium
and posteriorly within the pleural cavity
layering out just below the pericardial reflection.
Why, you might ask, does the patient have all this fluid?
Well, let's look closely at the mitral valve
and on the posterior mitral valve leaflet,
we see a calcified vegetation.
This patient, in fact,
had an infected dialysis catheter
with mitral valve endocarditis
and had developed wide-open mitral valve regurgitation
resulting in heart failure
and all the fluid layering out
within the pericardium and
the thoracic cavity.
In conclusion, the parasternal long axis view
of the heart gives a great deal of information
about our patient's condition
and can be instrumental in emergency care.
Through this module,
I hope now that you'll have a better idea
on how to grade left ventricular contractility
as good through poor.
Also, to be able to identify the presence
of a pericardial effusion.
I hope to see you back as SoundBytes continues
and we look further at the
cardiac echocardiography examinations.

Brightcove ID

5794989698001

https://youtube.com/watch?v=uciGL4TaoaA

Case: Parasternal Long Axis Pt. 1

Read more about Case: Parasternal Long Axis Pt. 1

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Bedside ultrasound imaging and a phased array probe can be used to evaluate cardiac structures and health, the presence of pericardial effusion, and evaluation of the left heart chamber valves and size.

Applications

Cardiology

Media Library Type

Case Study Videos

Subtitles

- Hello, my name is Phil Perera
and I'm the emergency ultrasound coordinator
ad the New York Presbyterian Hospital in New York City
and welcome to SoundBytes Cases.
Let's begin by reviewing the four standard views
of the cardiac echo exam.
The first view, as shown in probe position A
is the parasternal views both and long and short axis planes
and this is going to be performed directly
on the anterior chest wall.
The second view is where probe position B is shown here
coming from the abdominal position
or the subxiphoid view of the heart.
The last view is going to be shown by probe position C,
the apical view of the heart at
the point of maximum impulse.
This module will specifically focus on
the parasternal views, specifically looking
at the long axis plane.
There's a great deal of information
we can get from the parasternal long axis planes
so let's learn how to perform the examination.
For this examination, it's optimal to use a small footprint
phase to ray type probe that
can easily sit between the ribs.
We're going to place the probe just left of the sternum
at about intercostal space three or four
with the marker dot on the probe aimed down
toward the patient's left elbow,
if the patient's left elbow is down by the side.
That's with the caveat that ultrasound screen indicator
would be over toward the left of the screen.
This will align the probe in the long axis of the heart.
Occasionally it can be someone difficult to get
a good view of the heart from this plane
and moving the patient into the left lateral
decubitus position can sometimes help imaging
from the parasternal long axis plane of the heart.
So now let's take a look at the images
that we'll obtain by performing
the parasternal long axis view of the heart.
Here's a nice pictorial to the left
and what we see is that the most superficial
structure will be the right ventricle.
Notice that the right atrium is not seen from this plane.
Directly posterior to the right ventricle
will be the left ventricle and to the right
of the left ventricle will be seen the left atrium.
We can also see the mitral valve in between
the left atrium and the left ventricle
and a little bit of the aorta above the left atrium.
Let's look at the ultrasound still image, here, to the right
and, again, we see the superficial right ventricle,
posterior we see the left ventricle
with it's more muscular and hypertrophic walls.
Notice the left atrium, as seen to the right
of the left ventricle, and the mitral valve
in between the two chambers.
We categorize this as left ventricular inflow tract.
Note the aortic valve sitting right above the left atrium
and we see a little bit of the aortic root there.
This is what we categorize as aortic outflow tract.
Let's now take a look at the parasternal
long axis view of the heart in action.
Remember, again, that the most superficial chamber
will be the right ventricle
and the normal dimensions of the right ventricle
are that it should be about half
the size of the left ventricle.
If the right ventricle is the same size
of the left ventricle,
that could be a sign of RV strain.
We see the left ventricle posterior to the right ventricle.
Note it's hypertrophic walls.
This patient actually had long standing hypertension.
Let's look at the percentage change from
diastole through systole and here we see
that the walls come in well with each heartbeat
indicating good contractility.
We see the left atrium to the right of the left ventricle
and notice the mitral valve flipping up
and down in between the left atrium and the left ventricle.
We see here good movement of the mitral valve
indicating a good amount of blood flowing
between the left atrium and the left ventricle.
Now, just above the left atrium and
to the right of the left ventricle,
we see the aortic valve
and notice there just to the right of the aortic valve,
a little bit of the diamond shaped aortic root.
This will be our left ventricular outflow tract.
Now, another very important structure to identify
on bedside sonography is the descending aorta
which is a cylinder cut in cross section
right below the mitral valve, as seen in this image.
This is a very important landmark
because the posterior pericardium reflection,
that white line seen posterior to the left ventricle,
comes off anterior to the descending aorta.
This allows us to tell if the fluid
that we see there may be pericardial or plural.
In conclusion, I'm glad I could share with you
the SoundBytes module going over part one
of parasternal long axis view of the heart.
There's a great deal of information that we can gain
by looking at the parasternal long axis view,
looking for left ventricular contractility,
the presence of a pericardial effusion,
and also the possibility of right ventricular strain.
So, I hope to see you back in the future
as we're going to cover further modules
going over the parasternal views,
the subxiphoid views, and the apical views
so I'll see you back as sono access continues.

Brightcove ID

5794981632001

https://youtube.com/watch?v=H_3V9xlDMA0

Cardiac Ultrasound Views: Subxiphoid

Read more about Cardiac Ultrasound Views: Subxiphoid

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Using bedside cardiac ultrasound and a phased array probe to evaluate cardiac structures and health, the presence of pericardial effusion, and evaluating the left heart chamber size and valves.

Applications

Cardiology

Media Library Type

Case Study Videos

Subtitles

- 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 module, we'll continue our journey
through the cardiac echocardiography examinations,
looking at the four standard views.
In this module, we're specifically going to focus on
probe position B, as shown in the pictorial here,
the subxiphoid view of the heart.
Hopefully you've joined me prior
for the parasternal views, as shown in probe position A,
and in an upcoming module on the apical view,
as shown in probe position C.
The subxiphoid view of the heart
is an excellent way of imaging the patient's heart,
and getting a lot of information directly at the bedside.
Now let's learn how to perform
the subxiphoid view of the heart.
As shown in the pictorial to the right,
the probe is coming from an abdominal position,
placed just inferior to the xiphoid tip of the sternum.
It's important to lay the probe flat
and push down and under the sternum,
aiming towards the patient's left shoulder.
Now the marker dot on the probe
should be over towards the patient's right side,
with a caveat that the ultrasound's screen
indicator dot is over towards the left of the screen.
Now it's very important to put your hands
on top of the probe, and really push down and up
to get the good imaging plane underneath
the sternum, to make the angle to get
a good view of the heart from this plane.
Let's now take a look at the image
that you'll obtain from the subxiphoid view of the heart.
Here's a pictorial to the left, and an
ultrasound image to the right.
The first chamber that we'll encounter
directly below the liver, which is our
acoustic window in this case, on to
the heart will be the right ventricle.
Immediately posterior to the right ventricle
we'll be seeing the left ventricle,
and as shown in this pictorial,
notice that it has more muscular and hypertrophic walls.
From the subxiphoid plane, we'll also
be able to image the right atrium
to the left of the right ventricle,
and the left atrium, just to the left
of the left ventricle.
We can also appreciate the white line
that is the pericardium circumferentially
surrounding the heart.
Now that we know where the chambers are,
let's take a look at a video clip
of a normal heart from the subxiphoid plane.
As we remember, the liver is our
acoustic window onto the heart from this plane,
and so the liver will be seen anteriorly,
just to the top of the screen.
Just below the liver, we appreciate here
the right ventricle, and notice here,
just to the left of the right ventricle,
we can appreciate the right atrium.
Notice the tricuspid valve flipping up and down
in between the right atrium and the right ventricle.
Now let's look posterior to the right ventricle,
and we appreciate the left ventricle.
Notice again, its more muscular and hypertrophic walls.
Just to the left of the left ventricle
we appreciate, in this case, the left atrium,
and we also get a glimpse here of the mitral valve
flipping up and down in between
the left atrium and the left ventricle.
Now let's look at that white line,
both anteriorly above the right ventricle,
and posterior, below the left ventricle,
that is the pericardium.
Note here the absence of any significant
pericardial effusions.
In that last video clip, we noted good
contractility of the left ventricle
from diastole to systole.
Let's contrast that clip to this one
from a patient who presented with shortness
of breath, and advanced cardiomyopathy.
We see the right ventricle just below the liver,
anterior to the left ventricle.
And what we see here is a poorly contracting
and dilated left ventricle, consistent
with a cardiomyopathy heart.
However, note the absence of any significant
dark or anechoic fluid collections
consistent with a pericardial effusion.
Here's a patient who presented with renal failure
and acute shortness of breath.
We're again looking from the subxiphoid plane,
so we see a little strip of the liver anteriorly.
The right ventricle just below the liver,
and the left ventricle seen posteriorly
to the right ventricle.
Notice how hypertrophic the walls of
the left ventricle are in this patient.
We also appreciate a dark fluid collection
both anteriorly, just below the liver
and above the right ventricle,
and posterior below the left ventricle,
consistent with a circumferential,
or large, pericardial effusion.
If we see a large pericardial effusion
on bedside echo, our next move is to
look for signs of cardiac tamponade.
Here's a patient who manifests
all the signs of cardiac tamponade on bedside echo.
Let's look specifically at the right side of the heart.
Notice the very large pericardial effusion,
and note the chaotic movement of the right ventricle
as it struggles to open during diastole.
The compression of the right ventricle
in this patient is consistent with
advanced cardiac tamponade.
The right side of the heart is
preferentially compressed before
the left ventricle, due to its lower pressure circuit.
In conclusion, I'm glad I could share with you
this SoundBytes module going over
the subxiphoid view of the cardiac echo examination.
This is a very important exam to
put into your routine practice
in looking at your patient's heart at the bedside,
and will tell you if the patient
has a pericardial effusion, as well as
giving a sense of left ventricular contractility.
Also, the subxiphoid view of the heart
gives better views of the right side of the heart
than the more superior parasternal views of the heart.
So I hope to see you back as SoundBytes continues,
and as we move on to discuss the other
echo exam planes of the heart.

Brightcove ID

5752154065001

https://youtube.com/watch?v=ew6uJvZDhmw

Body

Using bedside cardiac ultrasound and a phased array probe to evaluate cardiac structures and health, the presence of pericardial effusion, and evaluating the left heart chamber size and valves.

Case: Cardiac Ultrasound - Apical View

Read more about Case: Cardiac Ultrasound - Apical View

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Using the apical view and a phased array probe during bedside cardiac ultrasound examinations can enable clinicians to evaluate cardiac health, structures, & ventricular contractility. This view is ideal for identifying cardiomyopathy, pericardial effusion, and cardiac tamponade.

Applications

Cardiology

Media Library Type

Case Study Videos

Subtitles

- 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 module we'll continue our journey
down the path of the four cardiac examination views.
Specifically in this module
we're going to look at probe position C,
known as the apical view of the heart.
I hope you've been able to join me prior
looking at probe position A, the parasternal views,
and probe position B the subxiphoid views of the heart.
So the apical view of the heart is an excellent view
and gives a great deal of information
about our patient's heart
as it shows all four chambers of the heart
in relation to one another.
Therefore, the apical view of the heart
is preferred by cardiologists as it shows the synergy
of all of the chambers of the heart to one another.
Now let's take a look at a pictorial
showing how to perform the apical view of the heart.
Preferably, you're going to be using a small footprint
phased array type probe
that can easily get in between the ribs.
Position the probe directly underneath the left nipple
at about the point of maximal impulse of the heart
with the probe indicator
over towards the patient's right side.
Now that's with the caveat
that the ultrasound's screen indicator is positioned
toward the left of the screen.
Now moving the patient
into the left lateral decubitus position
can improve imaging from the apical view of the heart
as it moves the heart closer to the probe
and moves the lung out of the way.
Thus, it's important to consider moving the patient
into this position
when performing the apical view of the heart.
Now let's learn how to interpret the images
that we'll obtain.
We see here a pictorial to the left
and an ultrasound image to the right.
As we're imaging from the apical view of the heart,
we're closest to the ventricles
and in this image we see the left ventricle
to the right of the screen and the right ventricle adjacent.
The atria from the apical view of the heart
will be further away, thus posterior to the ventricles
and we see here the left atrium
just below the left ventricle
and the right atrium below the right ventricle.
We also see the valves, the tricuspid valve to the left
and the mitral valve to the right
in between the left atrium and the left ventricle.
We can also appreciate the white lines
surrounding the heart, which is the pericardium.
Now let's take a look at a video clip
showing the apical view of the heart in action.
This is taken from a medical student triathlete,
so let's take a look at that left ventricle.
We see the left ventricle in its more superficial location
to the right of the screen.
Notice the percentage change from diastole to systole.
Note the walls almost touch with each heartbeat,
indicating a good contractility.
We see the right ventricle to the side of the left ventricle
and the two atria posterior to the ventricles.
Notice the mitral valve in between the left atrium
and left ventricle and the tricuspid valve
to the right side.
Notice here the absence
of any significant pericardial effusion.
Let's contrast that last clip from this patient
who has a dilated cardiomyopathy,
and as we look at that left ventricle
from the apical view of the heart
we see a very poor percentage change
from diastole through systole.
This is indicative of a very poor contractility
of this heart.
We see the right ventricle to the side of the left ventricle
and the two atria posterior.
Notice the sluggish movement of both the mitral value
and the tricuspid valve.
We see a little bit of pericardial effusion,
that little black rim around the heart,
also going together
with this patient's cardiomyopathy status.
Here's an interesting video clip
of a patient who presented with acute shortness of breath.
What we notice here is the right ventricle
and the left ventricle closest to the screen,
but we see here a very large pericardial effusion
circumferentially surrounding the heart.
And notice the heart swinging back and forth
in all the pericardial effusion.
This gives rise to the phenomenon
known as electrical alternans
or different sizes QRSs on the EKG.
Here's a patient who was in bad shape
and presented with acute shortness of breath.
We see a very large pericardial effusion
and let's look specifically at the right ventricle.
Notice that it caves in from diastole
due to the high pressure in the pericardial sac.
Thus this is indicative of advanced cardiac tamponade.
This patient will need a stat pericardiocentesis procedure.
So in conclusion I'm glad I could share with you
this Soundbytes module
going over the apical views of the heart.
This is an often neglected view
but one that gives a great deal of information
about your patients heart
and really should be routinely integrated
into the cardiac echo examination.
It's best to move the patient
into the left lateral decutibus position
to optimize imaging from the apical view of the heart
to see all four chambers of the heart
in relation to one another.
So I hope to see you back as Soundbytes continues.

Brightcove ID

5752159405001

https://youtube.com/watch?v=4vBJoWP-zBM

Body

Team Radio Shack Doctor Uses Sonosite Ultrasound

Read more about Team Radio Shack Doctor Uses Sonosite Ultrasound

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Media Library Type

Case Study Videos

Subtitles

(wind howling)

(intense music)

(light guitar music)

-As I was an athlet, when 
I had problems with my body

and I met doctors where now I think

the treatment was really bad.

my goal was always, to do it better 
to bring them back in short time

back on the track 
on the pitch,

on the tennis field or back 
on the road as a cyclist.

(light music)

I work for an American cycling 
team called RadioShack.

This is really impressive when you see

how high-class the pictures are.

And even on big ultrasound 
scanners in practice

or in clinics, sometimes you 
don't get pictures like this.

It was for me really 
interesting how much you can see

with an ultrasonic scanner, 
especially on shoulders,

because that's the only way 
to do a dynamic examination.

There's no fluid inside, 
this shoulder's really okay.

You get really good pictures, 
and you get a really quick

first idea what is going on in a muscle,

in a tendon, in a joint.

I have it all the time, I 
have it with me in the bus.

If there is any kind of 
problem where I can use

an ultrasonic scanner, I use it.

Around the race, it's a perfect help.

- [Voiceover] The start of 
the Amgen Tour of California.

We still have eight days of racing.

- Every case is like an emergency case,

even if they just have 
like a tendon problem,

'cause for each rider, it 
wants to cycle next day again,

and so you can do a quick 
check on abdomen scan

after a crash, on tendon 
scans when they have problems

after long stages, so it makes 
the whole job much easier.

And I myself feel much 
safer when I have done

an ultrasonic scan and can say, 
okay, doesn't look that bad.

About three years ago, we had 
a case at the Tour de France

where one rider crashed, 
and it was a mountain stage

you can say in the middle of 
nowhere, so the next hospital

was about 150 k's away, 
just mountain roads,

so that means just one way 
probably about 2 1/2 hours ride,

and he crashed on his elbow.

Elbow was swollen, it 
was painful on touchings.

And I scanned his radial 
head, you almost could see

the whole radial head, 
they're all surrounding,

and it was all okay, so I 
said, "There's no fracture.

"Treat him over the night 
and we'll see next morning."

And next morning, he could 
ride again, and he felt well.

So that was probably one case 
where we really saved time,

saved energy, the rider was happy,

the team director was happy.

It's the future to use 
mobile ultrasound systems

more and more, it really 
give me advantage,

it gives me more security in my treatment.

(light music)

Brightcove ID

5508105699001

https://youtube.com/watch?v=2QTFEyZZAGo

Endovag Uterus: LUS Sagital

Read more about Endovag Uterus: LUS Sagital

Media Library Type

Media Library Tag

Compatible Products

How To: Axillary Vein Cannulation

Read more about How To: Axillary Vein Cannulation

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Discussion on helpful scanning techniques and anatomy landmarks used to perform an ultrasound guided cannulation. Topics: patient and transducer position, identification of structures near the vein, vein depth, & insertion technique.".

Applications

Cardiology

Clinical Specialties

Anesthesiology (Regional)

Media Library Type

Case Study Videos

Media Library Tag

Axillary Vain

Axillary Vein Cannulation

Cannulation

Insertion

Vein

Subtitles

- [Voiceover] Welcome back to SoundBytes Cases.
This is Phil Perera, and in this module we'll discuss
cannulation of the axillary vein using ultrasound guidance.
So why, you might ask, would I want to use
ultrasound to cannulate the axillary vein,
when in effect, the axillary vein is an alternative approach
to cannulation of the subclavian vein on the chest wall?
The axillary vein is a continuation of the brachial vein
onto the chest wall, and becomes a subclavian vein,
as it passes medially under the first rib.
The axillary vein can be well visualized
using ultrasound at this lateral position on the chest wall,
and that's in contrast to the subclavian vein,
where the presence of the bony clavical
makes imaging of the infraclavicular portion
of the subclavian vein difficult.
So in effect, this is a lateral puncture
of the subclavian vein relaying into the axillary vein,
if you're gonna use the right anatomical terminology.
Ultrasound guidance of Axillary Vein cannulation
is now well documented in the medical literature,
although many clinicians remain unaware
that ultrasound can be integrated into this approach.
Two studies document utility
of ultrasound guidance for axillary vein cannulation
with a decreased complication rate,
and the studies are shown below,
the first in 2004 and the more recent in 2012,
both from our colleagues in Great Britain.
In 2011 the CDC came out
with some guidelines for the prevention
of intravascular catheter related infections.
Their recommendations included
using a subclavian vein site, if possible,
rather than internal jugular vein or femoral vein sites,
in adult patients, to minimize the risk of infection,
with a non-tunneled catheter.
They did say to avoid the subclavian site in hemodialysis
and advanced kidney disease patients, to decrease
the risk of subclavian vein stenosis.
They also advocated the use
of ultrasound guidance, if available.
Now let's review the relevant
upper extremity venous anatomy,
that we'll need to know,
to perform successful cannulation of the axillary vein.
Here we see the axillary vein and the axillary artery,
lateral on the patient's chest wall.
Notice here the clavical and the first rib.
As these structures move medially past the first rib,
they become the subclavian vein and artery.
We can see these arteries and veins here,
more medially located on the patient's chest.
Notice also,
we see the internal jugular vein and carotid artery,
moving up and down the patient's neck,
and coming together with the subclavian vessels.
We see the brachiocephalic vein,
which is the confluence of all of these vessels,
as they move down towards the heart,
to become the superior vena cava,
and we remember that, optimally,
we want to place the tip of the catheter,
when performing central venous cannulation,
in the superior vena cava,
and not into the right atrium.
Here's another anatomical image,
showing a perspective from a more lateral orientation
on the patient's chest wall.
Here, we see the axillary vein and axillary artery,
and notice that the normal orientation
of the vein and the artery
is that the artery should be superior to the vein,
although occasionally we have seen some variation,
and it's not unusual for the vein
to be overlapped by the artery, or vice versa.
We see the continuation of the axillary vein and artery,
onto the patient's chest wall, medially,
to become the subclavian vein and artery,
as the vessels pass medial to the first rib.
We also see the internal jugular vein and carotid artery,
and the superior vena cava.
To best image the axillary vein using ultrasound
we'll place the probe on the lateral chest wall.
Here we see the probe applied,
in a longitudinal or long axis orientation
over the top of the axillary vein.
We can image the vessel, using the long axis orientation,
to get a lot of information about the vessel,
but we can look in the short axis orientation,
by turning the probe so the probe indicator
will be towards the patient's right shoulder.
This will cut the vessel in cross section,
making it appear like a circle.
Before performance of the axillary vein cannulation,
we'll want to select the right ultrasound probe for the job.
For this application,
we'll be using a higher frequency 10 MHz linear array probe,
and because we're performing this procedure in a dynamic
or real-time guidance technique,
we'll want to put a sterile sheet or barrier
over the probe, so as to maintain
sterile precautions throughout the procedure.
Note, in some of the upcoming pictures, we don't have
a sterile sheet over the probe, but if we were performing
this in real procedure, we'd want to make sure,
that we have that sterile sheet over the probe.
While someone will run through a pre-procedure checklist,
assessing for relative contraindications
to axillary vein cannulation,
as it's a relatively non-compressible vessel,
coagulopathy is a contraindication
to axillary vein cannulation.
Also, renal disease or need for dialysis
would be relative contraindications to cannulation
of the axillary vein.
We can also run through a more extensive checklist,
known as the 6 point bundle,
which is shown in the upper right,
which emphasizes the use of maximal sterile precautions
for both patient and clinician during the procedure.
Now let's specifically discuss
some of the ultrasound guided approaches
to axillary vein cannulation.
The axillary vein can be visualized
in both short and long axis orientations, using ultrasound.
Imaging of the needle during cannulation of the vein
can then be performed in either orientation,
and there are pluses and minuses of both these orientations,
for cannulation of the vessel.
I generally recommend to start
in the short axis orientation
to introduce the needle,
initially to advance the needle down to the vein.
One may successfully cannulate the vessel in short axis,
however, one thing that can be very helpful
is to flip the probe, once the needle is under the skin,
into the long axis orientation,
to be used to visualize the needle
as it approaches the vessel,
as a long axis orientation shows needle depth
better than the short axis orientation.
So, putting it altogether, here's the probe position
for cannulation of the axillary vein
in the long axis orientation.
Notice here, that the needle would be placed
in an orientation coming in
under the lateral aspect of the probe,
and moving more medially.
Thus we can image the full position of the needle
as it moves down to the axillary vein.
In the next few images,
we'll also show you the placement of the probe
for the short axis cannulation of the axillary vein,
so as to compare both long and short axis imaging.
Here's a few pictures showing the orientation of the probe,
and the placement of the probe
for cannulation of the axillary vein
in a short axis orientation.
Notice here, that we have the probe
in an up and down configuration,
with the indicator dot towards
the patient's right shoulder or superior.
Notice we're placing the needle roughly at about the
midway point underneath the probe.
Now there are some benefits
of starting with the short axis orientation,
namely that it's helpful in orienting the needle,
up or down, superior or inferior,
on the patient's chest wall,
to best aim it towards the axillary vein.
Here are some ultrasound images
of the axillary vein and artery,
taken from the short axis view.
We have the probe marker oriented
towards the patient's head,
thus to the left of the image is superior,
and to the right is inferior.
We notice the axillary artery, the smaller vessel,
superior or towards the left of the image.
We see the larger axillary vein
at about the three centimeter mark,
inferior or towards the right of the image.
Notice towards the back of the image,
we can actually see the lung
sliding up and down as the patient breathes,
at about the five centimeter mark.
Thus it's very important to cannulate the vessel carefully,
and not to pass the needle deep,
past the axillary vein or artery
to cause an inadvertent pneumothorax.
Here's another image of the axillary artery and vein,
taken from a short axis configuration.
Again, we have the probe marker indicator
towards the patient's head.
Superior to the left, inferior to the right.
Thus we see the smaller axillery artery
to the left or superior, and the larger axillery vein
inferior toward the right of the image.
Notice that as we apply probe pressure
down onto the patient's chest wall,
we can actually compress the axillary vein ,
and this is one way of telling vein from artery,
as normally the vein should compress,
as long as there's no thrombus inside it,
and the artery will stay open.
We can see the lung sliding
towards the deeper aspect of the image.
In this ultrasound image,
again taken from a short axis configuration,
we'll use Color Flow Doppler to further differentiate
the axillary artery from the axillary vein.
We note again, that superior is to the left,
and inferior is to the right.
We can see the smaller axillery artery,
with pulsations indicating arterial flow within the lumen.
Notice here, we also see phasic respitory flow
within the axillary vein, corresponding to
inhalation and exhalation by the patient.
Thus, another way of differentiating the axillary artery
from the axillary vein.
Here are some images showing the appropriate positioning
of the probe for long axis cannulation of the axillary vein.
Again we notice that we have a high frequency linear array
probe positioned over the lateral chest wall,
directly over the axillary vein.
We have the needle coming in,
under the long axis of the probe.
Now, I like to have the probe positioned
so that the marker on the probe is oriented lateral.
Thus, the needle will come in underneath the indicator
and progress directly underneath the probe
as it courses from the skin down to the axillery vein.
It's important to keep the needle and plane
underneath the probe at all times,
so that it can be visualized as it goes down to the vessel.
Here's a long access ultrasound image of the axillary vein
as it courses from lateral to the left of the image
to medial to the right of the image.
Notice that the axillary vein appears
as a tubular structure, at about the three centimeter mark.
Now let's take a look at the axillery artery
using B-mode or greyscale sonography.
We can see the axillary artery
arching from lateral to medial
across the patient's chest wall,
and we note the pulsations within the lumen,
indicative of an arterial structure.
We can also see the thoracoacromial trunk
coming off medially off the axillery artery.
Next, we'll use Color Flow Doppler
to further differentiate venous structures from arterial.
This will be the axillary vein and we can tell this,
as it does not have that constant arterial pulsations
within the lumen.
Notice that rather,
it has the phasic respitory variation of flow
within its lumen, as indicative of a venous structure.
We can also see the thoracoacromial trunk
coming off medially.
Let's contrast that last ultrasound clip with
this one, showing the axillary artery, using
Color Power Flow Doppler.
Color Power Flow Doppler shows amplitude of flow,
and we can see that fast flow is very yellow,
we can see the faster flow within the inner part of the
lumen of the vessel.
But notice that we have here
the characteristic arterial pulsations,
that differentiate from venous pulsations.
Now let's discuss the micropuncture technique
for central venous cannulation.
The micropuncture technique has a lot of advocates
when talking about cannulation of the axillary vein,
as it utilizes a smaller 21 gauge needle
for the initial puncture of the axillary vein.
This is in contrast to a traditional central line kit,
which uses and 18 gauge needle, a much larger needle,
for that initial vessel cannulation.
One can then use
this smaller 21 gauge needle to cannulate the vessel,
and place a guidewire into the vessel.
A larger catheter can then be inserted
over the guidewire into the vessel.
Using these smaller diameter needles
is potentially safer for deeper puncture
of vessels like the axillary vein
to avoid potential complications.
In this video clip, we'll watch cannulation
of a vessel using a short axis approach.
This is a phantom which simulates the human body
and we can see that as we place the probe
in the short axis orientation,
the vessel appears as circular end-on.
Notice here, that we can see the echogenic tip of the needle
coming down to the vessel, permeating the interior wall,
and entering into the lumen of the vessel.
So the short axis plane allows
better lateral guide of the needle path,
and is a good starting position
for cannulation of an axillary vein.
In this video clip, we'll use the long axis approach
for cannulation of a central vein.
Here we're using some new technology,
known as MBE technology,
that is on a lot of the Sonosite machines.
What we see here is the tip of the needle
is much more echogenic.
We aim the needle towards the dotted line,
which is coming from right to left on the image here.
Now let's watch the needle coming in from left to right,
and we can see that,
as the needle is in plane with the probe
in the long axis approach,
we can see the full extent of the needle
as it travels from superficial down
to permeate the anterior wall of the vessel
and enter into the vessel lumen.
Thus the long access plane allows
a much better guide to needle depth
and allows you to gauge where the tip of the needle is
at all times.
That's why I generally start with a short axis approach
and then flip to long axis.
In this video clip, we'll look at a real-time
axillary vein cannulation in a real patient.
Here we see the needle coming down from left to right,
we're using the long axis view.
Notice that the images are not quite as crisp,
because the probe is slightly off-axis to the vessel.
What we can see here is the tip of the needle
as shown by a small arrow, coming down, pushing down
on that anterior wall of the axillary vein,
and then entering into the vessel lumen.
So in this case we were able to successfully cannulate
the axillary vein, although the images are
not quite as clear as in the phantom,
and this is one pitfall from using the long axis approach,
that you must be completely in plane with the needle
throughout its entire path down to the vessel.
Here's another clip in the long axis orientation,
showing a successful cannulation of an axillary vein.
We can see here the needle pushing down
on that anterior wall, and then entering
into the vessel lumen.
Now one potential pitfall is that, occasionally,
the vessel can be pushed down, the anterior wall can tent
towards the posterior wall, as you push the needle down.
So have patience, and occasionally,
a slight pull-back with the needle
will loosen that tissue, and allow you
to free the needle tip within the vessel lumen.
But again, the teaching point here
is that the long axis view is great
for assessment of needle depth at all times.
Another use of ultrasound and the long axis technique
which I find very helpful,
is to assess that the guidewire
is safely within the position,
within the lumen of the axillary vein.
Here we note the needle coming down from left to right,
and we can see the guidewire passing
through the tip of the needle,
moving down the axillary vein,
down towards the superior vena cava.
This can be very helpful in assessing that the guidewire
is indeed safely within the axillary vein,
prior to placement of the plastic catheter.
While standard practice would dictate
that after placement of a central line,
one would obtain a chest radiograph
to look for the placement of the tip of the catheter
in the superior vena cava.
A quick and easy way of assessing
that the catheter is indeed inside the superior vena cava
is to use a saline flush.
Here we're flushing the saline into the catheter
and we can note the presence of bubbles
within the right side of the heart,
indicating that the catheter is indeed
within the vessel lumen, so a quick and easy way,
right at the bedside, prior to obtaining a chest radiograph.
In conclusion, thanks for joining me
for this SoundBytes module,
going over ultrasound guided approaches
to axillary vein cannulation.
Ultrasound guidance of axillary vein cannulation
is now well supported in the medical literature,
and in fact, the CDC guidelines from 2011
advocate placement of central lines
within the axillary and subclavian veins,
to lower the incidence of bloodstream-associated infections.
As we discussed, the micropuncture technique,
using a smaller needle
for the initial cannulation of the axillary vein,
can be very helpful for this approach.
We can then place a guidewire and larger catheters
into the vessel more safely.
So clinicians should strongly consider
this alternative approach,
using ultrasound guided approaches into the axillary vein,
when determining the location
for central venous catheter placement in their patients.
So, I hope to see you back, as SoundBytes continues.

Brightcove ID

5508139234001

https://youtube.com/watch?v=zxmkrrq1P3M

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