Case Study Videos

Case: Central Line Bundle: Improving Patient Safety

Read more about Case: Central Line Bundle: Improving Patient Safety

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Video case study covering the 6-point central line bundle.

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Cardiology

Clinical Specialties

Anesthesiology (Regional)

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Case Study Videos

Subtitles

- [Voiceover] In this Soundbytes module, we'll discuss
how we can improve patient safety through a concept
known as a central line bundle.
Now the central line bundle is a six step checklist
of initiatives that can decrease both the infectious,
and mechanical complications of central line placement.
Let's begin this module by going over some of the
potential patient benefits of central venous access.
Central venous access allows more secure
vascular access in our sickest patients,
and gives us the ability to deliver
high flow infusions in these patients.
Central venous access is also a safer administration route
of vasopressors as opposed to the peripheral route.
A central line allows for better hemodynamic monitoring
of our patients, allowing you to monitor
central venous pressure, or CVP, and also
mixed venous oxygen saturation.
However there are some serious patient risks involved
with placement of a central venous catheter.
The two main groups of complications are the mechanical,
and the infectious.
Those included under mechanical complications are
pneumothorax formation, hemothorax formation,
and inadvertent arterial puncture with hematoma formation.
The second main category are the infectious complications
and central associated bloodstream infections
are increasingly recognized cause of increased
morbidity and mortality in our sickest patients.
Because of these recognized complications of
central line placement, bedside ultrasound has stepped up
to help us lower the complication rate.
Bedside ultrasound dramatically decreases
the mechanical complications of central line placement,
allowing real time guidance of the cannulating needle
into the central vein.
Bedside ultrasound is now recommended by
governmental agencies and multiple medical societies
as an aid in placement of central lines.
And over recent years there's been increasing momentum
in initiatives to decrease
central line associated infections.
Two major initiatives were the IHI 100,000 Lives Campaign
which came out in 2005, with the aim to improve
patient safety in all USA hospitals.
Also in 2006, the Joint Commissions, JCAHO
came out with the Six National Safety Goals,
also with the aim of reducing risk of
health care associated infections.
The Institute for Health Care Improvement, or IHI
recommendations for central venous access include
five major initiatives.
The first is increasing attention to hand hygiene.
Number two, adequate skin antisepsis,
number three, maximal barrier precautions,
number four, catheter site selection,
and number five, daily review of the need
for a central line.
If one adds ultrasound guidance of line placement
to the five point IHI recommendations of hand hygiene,
skin antisepsis, maximal barrier precautions,
catheter site selection, and daily review of the need
for central line, one gets to the central line
six point bundle, the current standard
for decreasing complications of central line placement.
Before performing central venous access,
it's mandatory to perform a checklist prior to the procedure
to decrease the complication rate.
The first thing one should do is to review
the patient charts for those increased procedural risks
to our patients, such as coagulopathy,
thrombocytopenia, the presence of a DVT
within the upper extremity or lower extremity veins,
or a known latex allergy.
One should obtain informed consent from our patients,
also performing a prescan ultrasound to look for a clot
in the targeted veins.
Last but not least, it's optimal and mandatory
to perform a time out procedure together
with the nursing staff.
Going through the IHI guidelines for decreasing
the complication rate for central venous access,
the first step is to wash your hands thoroughly
prior to the procedure.
As an alternative, one can consider application of
alcohol based, waterless hand cleansers which offer
additional disinfection benefit over conventional washing.
The second step for decreasing the complication rate
of central venous access, is adequate attention
to skin antisepsis.
For this initiative, Chlorhexidine is going to be optimal.
Chlorhexidine offers benefits over traditional
Povidine-iodine with regard to skin antisepsis,
and it's best to scrub the Chlorhexidine sponge
vigorously across your patient's skin for 20 seconds,
applying three Chlorhexidine scrubs sequentially
to a wide field area over the patient's skin.
The third step is adequate attention to
maximal barrier precautions during the
central venous placement procedure.
The operator and all assistants should wear a cap,
mask, sterile gown and sterile gloves
throughout the procedure.
It's important to place a wide field barrier
over the patient during the procedure
to decrease the infectious risk to our patient.
The patient should be covered from head to toe
with this wide field barrier, with only a small opening
for the insertion site of the central line.
The fourth main step within the IHI guidelines,
is adequate attention to site selection
for placement of a central venous catheter.
In general, high lines are preferred.
The internal jugular vein and subclavian vein
are associated with a decreased risk of
infectious complications to our patients.
In general, low lines are less preferred,
as placement of a catheter into the femoral vein
is associated with higher risk of infection,
and also a higher risk of DVT in our patients.
Critical actions following placement of a
central venous catheter include using sterile technique
to flush all lines of the catheter, and then putting
sterile catheter caps on all lumens.
We'll then place a sterile dressing,
like the Tegaderm shown in the picture to the upper right
over the access site, and obtain a chest radiograph
after all high lines, to look for placement
of the tip of the catheter,
and also to rule out a pneumothorax.
An optimal approach to facilitate compliance
with the central line bundle, is to create a
dedicated central line bundle cart that moves
to the patient during the actual procedure.
On this dedicated central line bundle cart,
can be included all the supplies essential
to central venous access, to facilitate easy compliance
with the steps.
In the cart can be included the chlorhexidine swabs,
all the sterile barrier supplies for the operator,
such as the cap, gown and sterile gloves,
the wide field barrier for our patient,
sterile caps to go onto the central venous catheter,
and the dressing cover, the Tegaderm to cover the site
after the procedure is completed.
One should also have the ultrasound probe
sterile sheath cover, to facilitate the use of
ultrasound in a sterile manner during the procedure.
A crucial step that's more relevant for the
critical care units, is a daily review of all
central venous lines to see if the line is truly needed.
All unessential lines should be immediately removed
from the patient, if not essential for optimal patient care,
to decrease the risk of infections to our patients.
So in conclusion, the central venous access six point bundle
can potentially decrease the complication rate
for our patients undergoing this procedure.
Remember that we get to the six point bundle
by adding ultrasound guidance of line placement
to the IHI five point recommendations as shown below.
Hand hygiene, skin antisepsis, maximal barrier precautions,
catheter site selection, going for those high lines
over the low lines, and a daily review of the
need for a central line.
Through adherence to the
central venous access six point bundle,
we can potentially make the central venous access procedure
a safer one for our patients.
Remember that, number one, we can potentially
lower the rate of mechanical complications
by using ultrasound guidance throughout the procedure.
And number two, we can potentially lower the rate of
infectious complications of the procedure,
by close adherence to the IHI guidelines.
In conclusion, hopefully we can make hospitalization
a potentially safer experience for the most ill
of our patients who are receiving central venous access,
for their treatments.
So I hope to see you back in the future,
as Soundbytes continues.

Brightcove ID

5508123477001

https://youtube.com/watch?v=hUH-B7qy-fc

Case: Ultrasound for Pneumothorax

Read more about Case: Ultrasound for Pneumothorax

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The video demonstrates how to use long and short axis configurations, as well as M-mode, to detect and diagnose both a complete and partial pheumothorax.

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Case Study Videos

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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're going to look specifically
at Ultrasound of the Lung to Evaluate for Pneumothorax.
Interestingly enough,
a classical belief was that the lung was not optimal
for ultrasound imaging.
However newer findings have shown
that actually ultrasound is an excellent modality
for viewing the pleura and for detecting pnemothoraces.
There's been a lot of research looking at this
and what's interesting is that ultrasound
has been found now to be more sensitive than chest X-ray
in the diagnosis of pneumothorax especially
in the supine trauma patient.
And now we're going to add on views of the lungs
looking for pneumothorax as part
of our Extended FAST Exam,
or the E-FAST exam that we'll be performing
in trauma patients.
We can also detect pneumothoraces as well
in our medical patients.
Now let's learn how to perform the ultrasound examination
for the pneumothorax detection.
Here we have the high frequency linear type array probe
positioned on the anterior chest wall
at about the midclavicular line
looking in to about intercostal space three.
Now in most cases of pneumothorax with the patient supine
the air would be predominantly seen in this area.
Note we're looking in a long axis configuration
between the ribs with the marker dot
oriented superiorly towards the patient's head.
Once we've identified both the ribs and the pleura
we can swivel the probe into the short axis configuration
to further look at the pleura
and to detect pneumothorax.
Here we have the probe oriented in a transverse
or short axis orientation between the ribs
looking directly down at the pleura.
Notice in this case the marker dot is located
towards the lateral aspect of the patient.
Using both long and short axis configurations
will allow you to detect a pneumothorax
with a high degree of accuracy.
If no lung is seen on the anterior chest wall
one can size out a pneumothorax
by looking in the lateral positions as shown here.
Notice the probe on the lateral chest wall
in the short axis configuration between the ribs.
If lung is seen here laterally but not anteriorly,
this would tell you it was an incomplete pneumothorax.
We can complement the short axis view
by locating the probe into the long axis configuration
with the marker dot towards the patient's axilla
to further examine into these lateral areas
of the chest wall.
Here's a nice pictorial showing
the normal findings of a lung
in a long axis type configuration.
Superior rib to the left,
inferior rib to the right.
Notice that the ribs cast shadows posteriorly
due to the inability of the soundwaves
to permeate the hard calcifications of the rib.
We see the chest wall anteriorly,
and note here the two layers of the pleura.
And we see here the outer parietal pleura,
and the inner visceral pleura.
Now while I've depicted these as two separate layers,
in reality on ultrasound examination
they're seen as a single shimmering white line
that moves back and forth as the patient breathes.
And as the patient breathes we can see white comet tails,
or linear lines, vertical lines,
coming off the pleura down deep into the lung.
So that will be the normal finding of a lung
on long axis configuration.
Here's a nice ultrasound image
showing a normal lung
and what we see here,
we're in the long axis configuration,
so the superior rib is to the left,
inferior rib to the right.
Chest wall anteriorly,
and we see here the lung sliding
which is the opposition of the outer parietal
and the inner visceral pleura.
And we see the vertical comet tails
coming off the back of the pleura.
Thus this is a completely normal exam.
No pneumothorax.
But note the location of the pleura deep to the ribs,
and that classic shimmering line back and forth
as the patient takes a breath.
Here we see more dramatic comet tails
coming off the shimmering parietal and visceral pleura.
In this patient we see the comet tails
shooting off the back,
telling us that this lung is up and there's no pneumothorax.
So vertical lines coming off the back of the pleura
always mean that the lung is up and are always a good sign
on lung ultrasound sonography.
As we mentioned we should also swivel the probe
into the short axis configuration
to further examine the lung,
and what we see here is a normal lung
in short axis configuration.
Note here we're looking in between the ribs
so all we see is the dome of the lung
and notice that it slides back and forth
as the patient breathes,
and we see the vertical comet tails
coming off the back.
So a completely normal examination in the short axis plane.
Here's another ultrasound image
taken from the short axis configuration.
Note here we see very prominent comet tails
coming off the back of the lung as it slides back and forth.
Again it's that opposition
of the parietal and visceral layers of the pleura
that allow the lung shimmering,
but notice here all the comet tails coming off the back.
In this case this patient had some pulmonary edema
associated with the lung
and these comet tails are more pronounced
due to the presence of water within the pleura.
But notice all these vertical lines coming off the back
telling us this lung is up.
A way to document that the lung is up
to print out for the chart is to put M-Mode,
and generally what we do is locate it so the M-Mode cursor
is down right at the pleura.
And what we see is the classic seashore sign,
or waves on the beach.
If we look anteriorly we'll see the classic waves,
or no motion of the chest wall,
and below that,
deep to the pleura we'll see the positive motion of the lung
making up the beach.
So waves on the beach,
or the seashore sign,
and M-Mode documentation that the lung is up
and that there's no pneumothorax.
Now that we understand what a normal lung looks like
on bedside examination,
let's take a look at a pictorial showing a pneumothorax
in a long axis view.
We see here that the parietal pleura
is now split from the visceral pleura,
which is attached to the lung
by a layer of air shown by the yellow color.
It's the splitting of the parietal and visceral pleura
that now causes a lack of lung sliding.
And instead of the opposed visceral and parietal pleura
sliding back and forth as the patient breathes,
all we see is a single line,
the parietal pleura,
with a lack of vertical comet tails coming off the back.
Here's an ultrasound image taken from a patient
who was stabbed to the left chest
and who had shortness of breath.
What we see here is a long axis view of a pneumothorax.
Let's take a look at the chest wall anteriorly,
and right below that we see the parietal pleura,
the single white line located directly inferior to the ribs.
But notice the classic lack of the lung sliding.
All we see here is a single white line
that fails to slide back and forth as the patient breathes.
Notice also the absence of the vertical comet tails.
Here's another image of a pneumothorax
in a long axis configuration,
and we see here the chest wall anteriorly,
and the single white line which is the parietal pleura.
Now this patient was acutely dyspneic,
so notice that there is some motion of the chest wall
and that the parietal pleura moves up and down,
but notice the failure of horizontal sliding.
Notice also the absence of any vertical comet tails
coming off the back of the pleura.
Now let's inspect a pneumothorax from the short axis view.
We see the chest wall anteriorly,
the parietal pleura as shown as a single,
non-mobile white line in the middle of the image.
Note the failure of movement back and forth,
the lack of vertical comet tails,
and what we see here is repeating horizontal air lines
from the pneumothorax.
To document the absence of lung sliding
and the presence of a pneumothorax,
we'll again turn to M-Mode.
If we put the M-Mode cursor down on the pleura,
what we'll see is a set of linear repeating lines.
This documents no motion of both the chest wall
and of the lung,
making up a finding known as the bar code sign.
Here's a pictorial showing interesting finding.
The signature of an incomplete pneumothorax,
known as lead point.
And what we see is an incomplete pneumothorax
with air collecting to the superior aspect
of the image to the left.
Thus splitting the parietal from the visceral layers
and causing an absence of lung sliding superiorly.
However, as the lung is coming up against the chest wall
to the right or inferiorly,
that's where we'll see the presence
of horizontal lung sliding,
and the presence of the vertical comet tails.
Here's an ultrasound image showing the lead point,
and what we see here is the lung sliding to the right,
the area where the lung touches up against the chest wall,
and to the left the area of absence of lung sliding
telling you there that air has collected
between the visceral and parietal layers.
So the ultrasound equivalent of the image
that we just looked at telling you
that this is an incomplete pneumothorax.
But here we see that lead point,
or transition point,
very well on bedside sonography.
In conclusion I'm glad I could share with you
this ultrasound module going over ultrasound of the lung
to evaluate for pneumothorax.
This is an excellent tool for viewing the pleura
and making the diagnosis of pneumothorax,
and there's been some research showing that it may be
more sensitive than chest X-ray in the diagnosis
of pneumothorax,
allowing rapid diagnosis of pneumo
in both your trauma and medical patient,
thus facilitating more timely management
of these most critical patients.
So I hope to see you back as SoundBytes continues.

Brightcove ID

5508134309001

https://youtube.com/watch?v=Xxdedx1HtHo

Case: Ultrasound Guidance for Thoracentesis

Read more about Case: Ultrasound Guidance for Thoracentesis

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This video details how bedside ultrasound imaging can be used to guide thoracentesis, detect pleural fluid levels, and analyze patient anatomy. It also discusses patient positioning during the thoracentesis and probe placement.

Media Library Type

Media Library Tag

Congested Heart Failure

Infection

Tumors

Increased Blood Pressure

Blocked Blood Vessels

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 SoundBytes module I'd like to begin by discussing
the case of a patient who presented with worsening
shortness of breath
and had a chest X-ray which revealed this finding.
Notice here we have the presence of
an opacified left hemithorax
and notice here that the trachea is pushed away
from the left hemithorax
suggesting the presence of a very large pleural effusion
as the cause of our patient's dyspnea.
Now if in fact this was a large pleural effusion causing
our patient's shortness of breath
a therapeutic thoracentesis would be in order
to relieve her symptoms.
This leads into the topic for this SoundBytes module
which is the use of bedside ultrasound to perform the
thoracentesis procedure.
In this module I'd like to go through how sonography
can potentially make the thoracentesis procedure
a safer one for our patients
with a decrease in the inherent complications of the
procedure, such as pneumothorax or perforation
of the diaphragm.
Before a performance of a thoracentesis procedure
it's mandatory to look with sonography
to make sure that there's enough pleural fluid
amenable for a safe thoracentesis.
Notice here we have the patient positioned in
an upright position
so that the fluid will layer out above the level
of the diaphragm.
Notice here we note the diaphragm as shown by the red line
across the patient's anterior chest wall
Notice here we have the probe positioned along the lateral
aspect of the patient's chest with a marker dot towards
the patient's head.
We can angle the probe above the diaphragm
to look for a dark or anechoic collection of fluid
consistent with a pleural effusion.
This is the ultrasound image that corresponds to the
chest X-ray from the patient as we discussed in
the beginning of the module.
We have the probe positioned across the patient's left
side of the chest,
coming in with a probe marker toward the patient's head.
We can see here, superior towards the left and
inferior towards the right,
We note the spleen and the kidney,
inferior in the abdominal compartment
and we see the white line that is the diaphragm
moving up and down as the patient breathes.
We note above the diaphragm,
superior in the chest cavity,
the presence of a large, dark or anechoic
collection of fluid,
consistent with a very large pleural effusion,
and we fail to appreciate any lung within
this pleural effusion.
Just to emphasize the point that it's very important
to look with sonography, prior to performance of a
thoracentesis procedure,
we know this pleural effusion is taken from the right chest
we see the liver towards the inferior aspect of the patient
towards the right here,
and we note above the diaphragm here,
which is moving up and down as the patient breathes,
the presence of a dark or anechoic fluid collection,
but we also see here lung within the pleural effusion
and an attachment of the lung,
a fibrinous attachment,
that attaches the lung down to the diaphragm.
So this could be potentially a complicated performance
of a thoracentesis as the needle that goes into that
chest cavity could be pushed by that fibrinous attachment
up into the lung causing a pneumothorax.
This is the first traditional position of the patient
for the thoracentesis procedure.
This is the recumbent position in which we have the patient
lying down with the head of the bed elevated.
This will encourage the fluid to layer out above
the diaphragm,
and make it more amenable to a puncture attempt.
Here we see a pleural effusion within the left hemithorax,
note the effusion as denoted by the yellow liquid
around the red lung.
Here the black star indicates the appropriate position
for the needle for the puncture point for the thoracentesis.
When performing a thoracentesis procedure the needle should
be positioned above the level of the rib,
so as to avoid the neurovascular bundle,
which as shown in this illustration lies just below
to the rib.
Here I'm demonstrating the appropriate position of the probe
to investigate for the lateral approach to the thoracentesis
this time on the right chest.
Notice the positioning of the probe,
in this case the 3 MHz probe,
on the lateral chest wall,
right above the level of the diaphragm,
to look for a pleural effusion.
Here I'll indicate the orientation of the ribs
across the lateral chest wall,
and here's about the orientation of the diaphragm.
Now remember that that diaphragm will move up and down
as the patient breathes, so we want to place the probe
above the level of the diaphragm,
to look into the thoracic cavity
for a suitable collection of fluid.
Therefore here we note the position of the needle
for the appropriate positioning of the needle
for the lateral puncture approach
to the thoracentesis procedure.
And we note again that the level of the diaphragm,
on the lateral chest wall is shown by the red line,
and we note the needle above the diaphragm,
so that it can safely enter into the thoracic cavity
and not cause a complication such as puncture the diaphragm
during the thoracentesis procedure.
Here we note the second traditional positioning of
the patient for the thoracentesis procedure,
which is the standard upright position,
in which the needle would come in from a posterior approach.
And we note the patient bending forward over a stand
or a table.
Here we see a pleural effusion within the right chest
and we note here the patient has a puncture point
that would come in, into the pleural effusion,
below the scapula but above the layer of the diaphragm.
In this video clip I'll outline some of the surface anatomy
important for the posterior approach to the
thoracentesis procedure.
Here's about the level of the scapula on the
posterior chest wall,
and this is about the level of the diaphragm,
so the appropriate positioning for the needle for
the thoracentesis procedure
would be about the level of my finger here.
And we'll just freeze that down,
there's the scapula,
and here's about the level of the diaphragm.
Notice my finger safely above the diaphragm,
so as not to puncture through the diaphragm
into the abdominal cavity.
As shown by the black star this would be the appropriate
positioning of the needle for the thoracentesis procedure.
Prior to the thoracentesis procedure
we'll investigate the pleural effusion using a 3 MHz probe.
Notice the 3 MHz probe is placed along the
posterior chest wall,
at first with the probe marker on the long axis trajectory
with the orientation of the marker towards
the patient's head.
We can then swivel the probe into the lateral orientation,
with the probe marker lateral to further investigate
above the diaphragm,
for a suitable collection of pleural effusion amenable
to a thoracentesis procedure.
A clinical pearl that can be very helpful in further
delineating the pleural effusion with regard to the
patient's anatomy is to look further with a
10 MHz high frequency linear array type probe
prior to the thoracentesis puncture.
Notice here we're placing the high frequency probe along the
posterior chest wall in the long axis configuration with the
probe marker swiveled toward the patient's head.
We can also orient the probe in between the patient's ribs
in the lateral orientation as well,
to further investigate the anatomy.
This illustration shows what the anatomy of a pleural
effusion will look like using a high frequency 10 MHz probe.
In this illustration the probe is configured in the
long axis orientation.
So we have superior to the left and inferior to the right.
We see anteriorly the chest wall and we see the
superior rib to the left and the inferior rib to the right.
We know that the parietal pleura,
that white line just deep to the ribs,
and below the parietal pleura we can see the darker
anechoic pleural effusion.
In this illustration we're actually showing here
the visceral pleura, that coats the outside of the lung,
and we can actually see the distance between the pleura
layers, the parietal pleura and the visceral pleura,
which would be the full extent of the pleural effusion.
This would be your safety zone,
or the area in which it would be safe to place a needle.
It would be not safe to place a needle any deeper
than that safety zone,
as a needle could puncture through the visceral pleura
and into the lung, causing a pneumothorax.
Here's an ultrasound image showing a very large pleural
effusion as taken with a high frequency 10 MHz probe.
Superior towards the left, inferior towards the right.
We can see the hyperechoic, or bright bone tables of the rib
both superior and inferior,
which will show us the areas of the rib to avoid
during the thoracentesis procedure.
We'd actually want to come in over the top of the inferior
rib to avoid the neurovascular bundle.
We can see here the white line making up the parietal pleura
and deep to the parietal pleura we note a large amount of
pleural effusion.
We note here the absence of a lung in the pleural effusion
so we can place the needle pretty deeply here
without causing a pneumothorax.
This ultrasound image is again taken with a high frequency
10 MHz probe,
but in this orientation the probe is configured between
the ribs in the lateral orientation.
So, all we see is the chest wall, anteriorly,
we see the parietal pleura, that white line deep to the
chest wall,
and just deep to the parietal pleura we can see the
pleural effusion as made up by the darker anechoic
collection of fluid.
Now, note here that we also see the lungs sliding
back and forth as the patient breathes,
and we can see the full extent of the pleural effusion,
or the safety zone for performance of
the thoracentesis procedure.
In this ultrasound image,
again taken with a 10 MHz high frequency probe,
we can see the diaphragm moving back and forth as
the patient breathes,
defining the lower aspect of the thoracic cavity.
Thus, it would probably be unsafe to perform a
thoracentesis at this level of the chest wall,
because we might go through the diaphragm and into
the spleen with a needle.
So, it's important to look first to ascertain
the level of the diaphragm,
and make sure that the thoracentesis needle is going
safely above the diaphragm so as not to puncture
into the abdominal compartment.
In this video clip we'll first place the
high frequency 10 MHz probe along the posterior
aspect of the chest wall to define the proper
orientation for the puncture for the posterior approach
to thoracentesis procedure.
The needle can then come in directly underneath the probe
as shown here.
Now, I'll show a wide angle shot here and note this is
the proper position for the thoracentesis needle,
as definied by sonography from the posterior approach
to thoracentesis.
In conclusion, thanks for tuning in for this SoundBytes
module going over ultrasound guidance for the
thoracentesis procedure.
Sonography can potentially make the procedure a safer one
for our patients with a decrease in the complication rate,
such as pneumothorax or perforation of the diaphragm.
We'll want to use both the 3 MHz and higher frequency 10 MHz
probes to fully evaluate the effusion in relation to
the patient's anatomy, prior to a puncture attempt.
We can either use the static technique where we position
the patient appropriately and then mark off the
puncture spot with sonography,
prior to the thoracentesis procedure.
Or, we can use a dynamic technique,
where we place the probe in a sterile sheet
and watch the needle in real-time go into the chest cavity.
So, I hope to see you back in the future
as SoundBytes continues.

Brightcove ID

5733895862001

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

Case: Ultrasound Guidance for Paracentesis

Read more about Case: Ultrasound Guidance for Paracentesis

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Using bedside ultrasound imaging when performing paracentesis, identifying ideal candidates for this procedure, mapping the internal jugular vein and ascites to determine an ideal puncture point, needle depth, and needle trajectory.

Media Library Type

Case Study Videos

Media Library Tag

Subtitles

- Hello, my name is Phil Perera,
and I am the Emergency Ultrasound Coordinator
at the New York Presbyterian Hospital in New York City,
and welcome to Soundbytes.
In today's module we're going to focus in specifically
on the use of bedside ultrasound
for the paracentesis procedure.
Now, the use of bedside ultrasound for paracentesis
can actually lower your complication rate
and allow you to know who is a better candidate
for the actual procedure.
So, step number one, when you're deciding
if a paracentesis procedure is necessary,
is to determine if the patient actually has ascites
and if there's significant areas of fluid pockets
that are amendable to a drainage procedure.
The second step is to best mark the location
for the needle placement, using bedside ultrasound.
And the two techniques that have been used in the past
are the midline linea alba,
or the lateral gutter techniques.
And using bedside ultrasound can allow you to decide,
between the two, where is the best location
for the needle placement.
This illustration shows the preferred positions
for the paracentesis procedure.
The key concept here is, to avoid the epigastric vessels
during the puncture attempt,
note the location of the epigastric vessels,
just lateral to midline on the abdominal wall.
So we wanna use that 3 MHz probe,
and we can place the probe,
as shown in positions one and two,
in the traditional lateral gutter approaches
for the paracentesis procedure.
This would be above the anterior superior iliac crests.
And we can look for fluid within the lateral gutters
and plan for a puncture attempt
in either of these positions.
We can also place the probe in probe position three
as shown in the midline linea alba position.
We'd wanna place the probe below the umbilicus
in the midline, in a relatively avascular
midline linea alba position.
Now, we can also use the 10 MHz higher frequency probe
to get a better look at the abdominal wall
in relation to the bowel and the ascites fluid
prior to our puncture attempt.
In fact, this will give us a more detailed look
into the abdominal cavity, to better plan our approach
for the paracentesis procedure.
Here's the location of the probe to the lateral position
for the paracentesis procedure.
Note the placement of the high-frequency linear array probe
above the anterior superior iliac crests
along the lateral gutters of the patient.
Notice here, the location of the epigastric vessels
in relation to the lateral gutters,
and we want to avoid those epigastrics
during any puncture attempt.
Notice also the location of the bladder,
and we want to make sure that we decompress the bladder
prior to any puncture attempt for a paracentesis.
But we can see here that the probe
is safely lateral to most of these structures,
thus the paracentesis can be safely performed
from this position on the abdominal wall.
This video clip shows a small amount of ascites
as taken with a 3 MHz probe, and we can see here
a small amount of ascites is denoted
by that dark or anechoic fluid collection,
and we can see the intestine with anchoring mesentery
swaying back and forth within the ascites
as the patient breathes.
And this is known as gut sliding,
and it makes the intestine look almost like palm trees
swaying back and forth within the breeze.
So, from this location, it might be unsafe
to perform a paracentesis, as it could be difficult
to get a needle in between the areas of intestine
without puncturing through an area
of intestine or mesentery.
This video shows a moderate amount of ascites,
again taken with a 3 MHz probe.
And we note the intestine with anchoring mesentery
sliding back and forth as the patient breathes,
and we see a large collection of ascites,
that dark or anechoic fluid collection,
anterior to the intestine.
So this might be a good location to perform a paracentesis
as we could place the needle safely into that ascites
without going through into the intestine
or anchoring mesentery.
This video clip emphasizes the point
that using a higher-frequency 10 MHz probe
on the abdominal wall
gives a more detailed exam of the evaluation
of the ascites in relation to the intestine.
And we see the abdominal wall anteriorly,
and we can see the bowel floating within the ascites.
Here we can actually mark down and measure
the safety zone from in which a needle could safely go
through the abdominal wall, into the ascites,
without hitting bowel.
Note here, the safety zone is approximately two centimeters,
as marked out with the centimeter dots
towards the right of the image.
Another benefit of using the higher-frequency probe
prior to a paracentesis procedure
is to investigate the depth of the abdominal wall,
as a thick abdominal wall can frustrate attempts
at a paracentesis procedure.
Here we see the depth of the abdominal wall,
which measures 2.5 centimeters anteriorly,
and we can see the line,
which is the peritoneal lining there,
just deep to the abdominal wall.
Note the presence here of ascites,
the dark fluid collection,
just deep to the peritoneal lining
and we can see the gut sliding,
or bowel moving back and forth, deep within the ascites.
Note the two-centimeter safety zone
for placement of the needle into the ascites fluid,
but note here we'd need to use a longer needle,
a needle longer than 2.5 centimeters,
just to get through the abdominal wall
to get fluid from the abdominal cavity.
In this video clip, we've moved the probe slightly lateral
from the last position in the same patient.
Again, we note the deep abdominal wall,
at 2.5 centimeters, denoting that a longer needle
will be needed to get the ascites fluid.
But here we see a large collection of ascites,
and note here the absence of gut sliding,
denoting a larger pocket of ascites
and a more favorable position
for the paracentesis procedure.
So this is actually the position
in which we perform the paracentesis,
using a longer lumbar puncture needle
and we're safely able to get a paracentesis done
and get the ascites fluid out for evaluation in the lab.
In this video clip, we'll reemphasize the surface anatomy
for the lateral abdominal position for paracentesis.
Note we're coming with a cap needle
underneath the 10 MHz probe, at the lateral puncture point.
This would be the preferred position
for the lateral approach for paracentesis,
as shown by the black star.
Now, some of the surface anatomy that we can palpate
includes the iliac crest, and note here
we're about four to five centimeters
above the iliac crest there.
We also want to avoid
those all-important epigastric vessels,
which we can see medial to the puncture point
from the lateral paracentesis approach.
Using ultrasound guidance, we can map out
the best position on the abdominal wall
for the paracentesis approach,
and go either right or left-side
depending on the maximal pocket of ascites present.
We also want to ascertain the relative locations
of the liver and spleen, so as to avoid
iatrogenic injury to a solid organ.
And as we emphasized earlier in the video clips,
you want to look for that intestine
with anchoring mesentery,
so as to avoid intestinal puncture during the procedure.
While the lateral gutter approach to paracentesis
is commonly emphasized during medical training,
the midline linea alba position
can be a great location for a paracentesis procedure.
Note here the probe is placed along the midline linea alba
with a marker dot towards the patient's head.
And we see it placed along the midline,
just inferior to the umbilicus.
Here we'll further investigate
the midline linea alba position
for the paracentesis procedure.
Note the high-frequency probe,
placed along the midline linea alba,
and we're coming with a cap needle
at a 45-degree angle underneath the probe
looking for the ring down artifact
onto a suitable pocket of ascites.
Here's a different view point
from the same midline linea alba position.
Again, we're placing that probe along the midline.
And this would be about the appropriate position
for the paracentesis procedure.
And here we just place the needle right there,
directly inferior to the umbilicus.
And I'll indicate that with a black star.
Note here, we'd be coming through
the relatively avascular midline linea alba.
But recall that it's very, very important
from this position to not puncture
through the bladder, and we can see
the relative location of the bladder
in relation to the puncture point.
So we must have the patient void
or place a Foley catheter, prior to attempting
a paracentesis from the midline linea alba position.
Here's a video clip from the midline linea alba,
taken with a 3 MHz probe.
I have the probe oriented towards the patient's head
so the superior aspect is towards the left
and inferior's towards the right.
Note here, we see the bowels superiorly,
moving up and down within the ascites fluid,
which we see in the middle of the image here,
and note the bladder, relatively large,
towards the inferior aspect of the image here.
Now, we can see that this would be a pocket
amendable to paracentesis, but recall again,
to increase the safety of the procedure
from the midline linea alba approach,
we'd want to drain the bladder prior to a puncture attempt.
Here's a video clip taken from the same patient
after having him completely void.
And note now, we have the decompressed bladder,
making the ascites pocket much larger
and more amenable to a paracentesis puncture
from that midline linea alba technique.
And we can see here now, the pocket of ascites
as denoted by the dark or anechoic fluid collection,
between the bowel superior
and the decompressed bladder inferiorly.
In this video clip, we can see
how using the higher-frequency 10 MHz probe
can allow real-time guidance of the needle
down into the ascites pocket,
and we see the detection of the needle
coming in from left to right through the abdominal wall,
with the tip of the needle safely parked
within the ascites fluid.
Notice here that the bowel is distant
to the tip of the needle,
thereby we can minimize any puncture
through the bowel during the paracentesis procedure.
We need to put a sterile sheet over the probe
during this procedure.
So, in conclusion, thanks for tuning in
for ultrasound guidance of paracentesis.
Ultrasound guidance for this procedure
can potentially make the paracentesis procedure
a safer one for our patients, and using a combination
of both the three and 10 MHz probes
can fully evaluate the ascites prior to a procedure.
We can use either one of two techniques.
Either the static technique, we position the patient
and then mark off the puncture spot with ultrasound
prior to a procedure,
or we can actually use a dynamic technique
where we place the probe in a sterile sheet
and watch the needle in real-time
go through the abdominal wall into the ascites fluid.
Either of these techniques
can potentially decrease your complication rate,
so I hope in the future you'll consider
ultrasound guidance for paracentesis
during your next paracentesis procedure.

Brightcove ID

5508114740001

https://youtube.com/watch?v=bWxv_a9CkBs

Case: Detection of Pleural Fluid

Read more about Case: Detection of Pleural Fluid

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This video details the use of bedside ultrasound imaging to detect pleural fluid, grade the amount of fluid in the pleural cavity, and detect loculated pleural effusions.

Applications

Media Library Type

Media Library Tag

Congested Heart Failure

Infection

Tumors

Increased Blood Pressure

Blocked Blood Vessels

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 SoundBytes module,
we're going to look specifically at the
use of Bedside Ultrasound to detect Pleural Fluid.
Interestingly enough, Ultrasound has been found
to detect as little as 20 ccs of fluid
within the Pleural Space.
In contrast, a Chest X-Ray will not reliably
pick up less than 100 to 150 ccs of fluid
on an AP Film.
Now this problem is only compounded
in the Supine Trauma Patient,
where a Chest X-ray may miss a significant amount of fluid
as a Hemothorax will layer out Posteriorly
and can be very difficult to detect on this film.
For these reasons,
Bedside Ultrasound may offer a more accurate way
of diagnosing Pleural Fluid.
Here's a slide reviewing how to
perform the Ultrasound examination
for detection of Pleural Effusions.
Optimally you'll have a three megahertz probe
with a small footprint that can easily sit between the ribs
as we'll be looking into the Right Upper Quadrant
and Left Upper Quadrant areas.
In position one, we'll be coming into the
standard Right Upper Quadrant Trauma FAST exam
and position the probe into that area
just above the Liver and below the Diaphragm.
We can then angle the probe upwards into the Thoracic Cavity
to look for a Dark or Anechoic Fluid Collection
signifying Thoracic Fluid.
We can repeat the exam in the left side
as shown in probe position two.
Placing the probe into that area
of the Left Upper Quadrant Trauma FAST view.
Look first into the area above the Spleen
and below the Diaphragm
and then angle the probe upwards into
the left Thoracic Cavity.
If fluid is seen with in the Thoracic Cavity,
we can then move the probe upwards
to investigate the extent of the Effusion.
Here's a video going over how to perform the examination.
Notice here, we have a probe placed
into the Right Upper Quadrant Trauma FAST area.
Notice that we're angling the probe upwards
into the Thoracic Cavity to fully investigate
for a Pleural Effusion.
Here, I'm just superimposing
about the level of the Diaphragm
as shown in the red marker.
And notice here that the probe
is positioned coming into that area
just above the Diaphragm into the Thoracic Cavity.
Traditionally, the probe should be
in a long-axis configuration
with the marker dot towards the patient's head.
Again, if a Fluid Collection is seen,
one can then move the probe upwards
to fully investigate how big the Effusion is.
To optimize your examination,
place the patient with the head slightly upwards,
so that the fluid will layer out above the Diaphragm
allowing earlier detection of smaller amounts of fluid.
Now that we know how to perform
the Ultrasound examination for Pleural Fluid,
let's take a look at a normal Right Upper Quadrant
Pleural Examination.
The probe is configured at a long-axis type orientation
with the marker towards the patient's head.
So, we see Superior to the left, Inferior to the right.
The Liver is in the middle of the image.
And let's look above the liver.
Here we see the Diaphragm, that curving, white line
which is moving up and down as the patient breathes.
And to the left or Superior to the Diaphragm
is the Thoracic Cavity.
Now, while looking at the Thoracic Cavity here,
what we see is something called Mirror Artifact.
This occurs as a result of the sound waves
coming through the Diaphragm
and reproducing what looks like a mirror image
of the Liver within the chest.
This is a normal appearance of the Thoracic Cavity
and Mirror Artifact is something that
will be seen commonly on Bedside Sonography.
Notice, however, the absence of a Dark
or Anechoic Fluid Collection within the right chest.
Now, let's take a look at a normal
Left Upper Quadrant Pleural Exam.
Again, we're in a long-axis configuration,
so Superior to the left, Inferior to the right.
We see the Spleen in the middle of the image
and we see the Diaphragm moving up and down
as the patient breathes.
Let's look above the Diaphragm into the Thoracic Cavity.
And, again, we see that Mirror Artifact.
What it looks like is almost like
reproduction of the Spleen within the Thoracic Cavity.
So, this is a normal finding.
And one that is not to be confused with fluid.
Fluid will appear very differently
and will have the appearance of a Dark or Anechoic stripe
right above the Diaphragm.
Here's an illustration showing a positive examination
from the Right Upper Quadrant view
with a Pleural Effusion above the Diaphragm.
We're in that long-axis configuration,
so Superior to the left, Inferior to the right.
We see the Liver in the middle of the image here.
And the Diaphragm, the white line as seen
right above the Liver.
Notice in this image we have a Pleural Effusion
as represented by the Dark area of fluid,
which is immediately Superior to the Diaphragm
and tucks in there right above the Diaphragm
going up into the Thoracic Cavity.
So, this will the signature finding of a Pleural Effusion
as taken from the Trauma FAST Views,
from the Right Upper Quadrant.
And the Left Upper Quadrant will also have a similar view,
although we're just looking above the Spleen
in that orientation.
Here's a video clip showing a Small Pleural Effusion
as taken from the Left Upper Quadrant view.
Here, we see the Spleen in the middle of the image,
the Kidney Inferior to the Spleen.
And the Diaphragm, the curving white line
that's moving up and down as the patient breathes
right above the Spleen.
As we look into that area above the Diaphragm,
we actually appreciate here, the presence
of a Dark or Anechoic Fluid Collection
above the Diaphragm.
This represents a positive Pleural Effusion.
Notice that the amount of fluid is relatively small
and we can actually see the Lung moving up and down
to the left of the image here.
Here's a Moderate Plural Effusion
as taken from the Right Upper Quadrant View.
We see the Liver to the Inferior Aspect or to the right.
The curving white line making up the Diaphragm
in the middle of the image.
And fluid representing a Pleural Effusion
Superior to the Diaphragm.
Interestingly enough, we see the Lung moving around
and all the fluid compressed down
by the fluid within the chest cavity
taking on what appears to like a Liver within the chest.
And something called Hepatization of the Lung.
And this is commonly seen with a Pleural Effusion,
as it pushes in on the Lung
making it more of a solid-type organ.
Here's a Large Pleural Effusion as taken
from the Right Upper Quadrant View.
And what we see here, is the Liver Inferiorly,
the Diaphragm right above the Liver
there in the middle of the image.
And we see a large Dark or Anechoic Collection
immediately Superior to the Diaphragm.
This represents a Large Pleural Effusion.
And in the midst of the Pleural Effusion,
we can see the Lung waving around
and compressed down by all
the fluid within the Thoracic Cavity.
Again, demonstrating that Hepatization
of the Lung as it's compressed down by the Pleural Fluid.
So, this would be a Large Plural Effusion,
as there's a large amount of fluid
both Inferiorly between the Lung and the Diaphragm.
And both Anterior and Posterior to the Lung itself here.
Unfortunately, not all Plural Effusions
will be free-flowing or uncomplicated.
There are occasions where our patients
can have repeated Pleural Effusion
that can be Loculated or Complicated.
Here we see an example of a Loculated Pleural Effusion.
Notice this Lung here has an attachment
with a Fibrin area that attaches it
or glues it onto the Diaphragm Inferiorly.
Therefore, we have two Loculated areas Effusion,
both Anterior to the top of the screen and Posterior.
As the Lung is trapped within the Thoracic Cavity
by this Fibrinous Attachment to the Diaphragm,
it may be dangerous to perform an invasive procedure
like a Thoracentesis or a Chest Tube Placement.
The needle or the Chest Tube could be guided
up into the Lung causing a Pneumothorax
by the Fibrinous Attachment to the Diaphragm.
So, in conclusion, I'm glad I could share with you
this SoundBytes module going over the
Ultrasound Examination for the detection of Pleural Fluid.
As we've discussed earlier in the module,
Ultrasound may be more accurate
in detection of Pleural Fluid than a Chest X-ray.
And Ultrasound allows easy grading
of the amount of fluid within the Pleural Cavity.
It can also detect Complicated Pleural Effusions
that may be Loculated and can help determine
which patients may benefit from a Drainage Procedure
such as a Thoracentesis or a Tube Thoracostomy.
So, I hope to see you back as SoundBytes continues
and in further modules,
we'll actually look closer at
the Thoracentesis Procedure under Ultrasound guidance.

Brightcove ID

5729244712001

https://youtube.com/watch?v=X1E7OgOLzw0

Case: Large Shoulder Tear

Read more about Case: Large Shoulder Tear

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This video details: how bedside medical ultrasound imaging of the shoulder enables clinicians to rapidly and effectively identify and evaluate soft tissue tears, the anatomy of the shoulder, and scanning techniques.

Clinical Specialties

Physical Med & Rehab

Media Library Type

Case Study Videos

Media Library Tag

Msk Ultrasound

Musculoskeletal Ultrasound

Shoulder Ultrasound

Rotator Cuff Ultrasound

Rotator Cuff Interval

Coracohumeral Ligament

Subacromial-Subdeltoid Bursitis

Partial Thickness Tear

Bursal Surface Tear

Articular Surface Tear

Intrasubstance Tear

Rotator Cuff Tendon

Supraspinatus Retraction

Calcific Enthesopathy

Cortical Irregularity

Cortical Defects

Subtitles

Invalid Credentials

Brightcove ID

5746974975001

https://youtube.com/watch?v=xBDDlzoV5rM

Case: Arthritic Hand MCP & PIP Pathology

Read more about Case: Arthritic Hand MCP & PIP Pathology

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This introductory video details how bedside medical ultrasound imaging of an arthritic hand allows for rapid and effective evaluation of patients with rheumatoid arthritis and osteoarthritis. It discusses the anatomy of the finger, probe placement, and scanning techniques. It also includes clinical images of the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints. This video is of particular interest to rheumatologists and primary care clinicians.

Clinical Specialties

Physical Med & Rehab

Media Library Type

Case Study Videos

Subtitles

- [Voiceover] The following is an introduction
to the arthritic hand.
Scanning technique is of particular importance
while scanning the metacarpal phalangeal joints
or the proximal interphalangeal joints due to
the slight transducer pressure and its capability
of compressing useful synovial tissues.
Begin with copious gel heeping over the area of interest.
First, utilize the index finger as a primary palpation point
as well as a stabilizer for the ultrasound transducer.
Also, use the thumb as a stopping point
for the transducer's depth over the gel heep.
Try first to observe this gel heep and the position
of the fingers before looking at the screen.
Our first observation highlighted here in white
is the distal metacarpal head, and highlighted in purple,
the normal anatomical metacarpal notch.
The next highlighted bone is the middle phalanx.
Note the joint space here in the normal image
also reveals a normal-appearing hyaline cartilage,
highlighted here in dark blue.
The light blue indicates the normal physiologic amount
of synovial fluid.
The yellow layer indicates the normal synovial membrane.
Observe its attachment point into the metacarpal notch.
In red, we see highlighted here a normal-appearing
areolar connective tissue layer.
In green, highlighted is the extensor tendon
as it passes over the joint.
The purple layer is simply a subcutaneous fat layer,
followed by the orange layer, which is the actual
cutaneous layer or skin.
In this video clip, I will demonstrate the sensitivity
to probe pressure on the synovial capsule.
Observe the simple fluid displacing while the
transducer is depressed,
upon letting up on the probe pressure we see
the simple fluid emerging from the joint highlighted here.
The following study demonstrates severe synovial thickening
in early rheumatoid arthritis.
Here we have highlighted the normal-appearing
distal metacarpal head and metacarpal notch with no erosion.
Here is the proximal phalanx
followed by the normal amount of physiologic fluid,
and our severely inflamed synovial membrane
as it inserts to the metacarpal notch.
Highlighted in red is the areolar connective tissue layer
followed by the common extensor tendon
which appears distended due to the
thickened structures beneath it.
In purple is the subcutaneous layer followed by
the orange layer, which is the cutaneous layer.
And also the very important gel heep
keeping this structures from being compressed.
Confirm inflammatory conditions with power doppler.
Pulsed wave doppler is a tool that measures
the velocity of blood flow.
We will now look at a similar joint,
the proximal interphalangeal joint, or the PIP joint,
which is distal to the metacarpal phalangeal joint
and more commonly affected by osteoarthritis
than rheumatoid arthritis.
It has very similar construction to the MCP joint.
Highlighted here is the proximal phalanx followed by
the middle phalanx and the normal physiologic fluid,
followed by the synovial capsule highlighted here in yellow.
And the extensor tendon, highlighted here in green.
The subcutaneous layer in purple
and the orange cutaneous layer.
When evaluating osteoarthritis, the primary changes
are observed in the cortical surface rather than
the synovial lining.
These cortical growths make the joint almost impossible
to see on a static image.
In yellow is the synovial lining
which appears normal in thickness.
Here we have a little excess joint effusion
and the extensor tendon appears fairly normal,
as do the subcutaneous and cutaneous layers.
So that we see the full extent of this growth
and its effects on the soft tissue,
always remember to use a gel heep.

Brightcove ID

5751328535001

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

Case: Intrauterine Pregnancy - Part 2

Read more about Case: Intrauterine Pregnancy - Part 2

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This video discusses how to use ultrasound to determine the gestational age of a normal pregnancy, determine a fetal heart rate, and identify markers for an abnormal pregnancy and fetal demise.

Clinical Specialties

Media Library Type

Media Library Tag

Tubal Ectopic Abdominal Ectopic

Ampullary

Ovarian

Pseudogestational Sac

Subtitles

- [Voiceover] Hello, my name is Phil Perera
and I am the emergency ultrasound coordinator
at the New York Presbyterian Hospital in New York City.
Welcome to Soundbytes Cases.
In this module entitled Emergency OB/GYN Ultrasound:
Part 2 of Intrauterine Pregnancy,
we're going to focus on the further assessment
of normal pregnancy.
We'll look at two further things that
are important to assess in your pregnancies.
First of all, learning how to date the gestational age
of the pregnancy, as well as learning
how to determine the fetal heart rate.
Then we'll wrap up the module by examining further findings
in abnormal pregnancies and learning how to differentiate
these findings from a normal intrauterine pregnancy.
The first concept that we'll focus on
is dating fetal gestational age.
In the first trimester, we're going to use an assessment
of the crown rump length.
Interestingly, dating in the first trimester
is actually probably the most accurate during all
phases of pregnancy, as there's a difference in
the growth curve as the fetus develops.
In the second trimester, we'll measure
the skull biparietal diameter.
And the third trimester, the dating is composed
of the biophysical profile, focusing on the femur length,
as well as other biophysical measurements.
This is an image of a first trimester pregnancy,
and we're going to evaluate the gestational age by
measuring the crown rump length.
Here we see the fetal pole stretched across
the gestational sac and we see the crown located
over towards the right and the rump towards the left.
If we put the calipers down from the crown across
to the rump we get a measurement of 1.46cm.
By selecting Crown Rump Length in the software package
on the ultrasound machine, we'll get an assessment
of gestational age which we can see here towards
the bottom left, seven weeks and six days.
As first trimester dating is considered one of the most
accurate during the entire pregnancy, it's nice to print
this image out and give to your patient to take for
their followup visit with their OB/GYN.
In the second trimester, dating of gestational age
focuses on skull circumference or measurement of
the biparietal diameter.
We want to measure the skull at about the level
of the thalamus in an axial orientation with the face down.
As we can see here, replacing the calipers from
the outer skull table proximally to the inner skull
table distally, and we have a measurement of 3.26cm
correlating to a 16 week one day gestational age.
In addition to measuring the gestational age of the fetus,
another very important concept is to get a measurement
of the fetal heart rate.
Normal fetal heart rates will range from 120-160
beats per minute, but lower rates down to 90 beats
per minute can be seen in early pregnancy in
the early parts of the first trimester.
M-Mode is the best method for determining fetal heart rate.
Power Doppler and Contrast gives more ultrasonic energy
to the developing heart, thus M-Mode is the preferred
way of measuring the fetal heart rate at this time.
Here, we're going to use M-Mode to determine
the fetal heart rate.
Notice we have the fetus zoomed up towards the top
of the image and replacing the M-Mode caliper directly
over the fetal heart.
Towards the bottom we see the M-Mode Motion strip
and notice the little waves showing the motion
of the fetal heart.
In this particular ultrasound machine, we need to
measure between each peak, and we see here that
we get a heart rate determination towards the bottom,
158 beats per minute.
This is something we can print out and place on the chart
to show that at the time we saw the baby there was
an actual heart beat.
While fortunately most pregnancies have a successful
outcome, unfortunately there are going to be some
abnormal pregnancies that we'll see in the emergency
department, consistent with fetal demise.
Some of the measurements we'll use to determine
abnormal pregnancy with fetal demise is a very large
gestational sac greater than 10 millimeters if
no yolk sac is seen.
Once the gestational sac is greater than 18 millimeters,
we should see a fetal pole or else this is an abnormal
pregnancy.
And many times the gestational sac in an abnormal
pregnancy will have an irregular shape with a scallop
type appearance to it.
Here's video from an abnormal pregnancy.
The first thing we notice is a very large
gestational sac without a yolk sac or discernable
fetal pole with heart beat.
We also see the presence of subchorionic hemorrhage
to the superior aspect of the gestational sac.
That's that area of dark or anechoic fluid
surrounding the gestational sac.
This is seen commonly with abnormal pregnancies
or spontaneous miscarriage.
Here, we'll put the calipers down to measure the diameter
of the gestational sac.
Note that it's very large at 2.8 centimeters by
1.6 centimeters, much larger than the one centimeter
mark that we said defined an abnormal pregnancy
if there was no yolk sac or 18 millimeters if no
fetal pole was seen.
Other indicators of an abnormal pregnancy with fetal
demise is a gestation greater than seven weeks,
which is abnormal if no fetal heart beat is seen.
And if the fetal pole is greater than five millimeters
in dimension this is abnormal if no fetal
heartbeat is seen.
This was an unfortunate case in which we see
a large a fetal pole, greater than five millimeters
without a heart beat.
This is indicative of embryonic demise and we also
see a large circular amnion within the gestational sac.
While I do think it's important we're able to pick up
the findings of the abnormal pregnancy, I'm always
going to get a confirmatory ultrasound and/or OB/GYN
consultation before giving the patient the news that
there is a fetal demise.
I'd like to conclude this module with another form
of abnormal pregnancy, which is a molar pregnancy,
which is a form of Gestational Trophoblastic Disease.
Gestational Trophoblastic Disease ranges from
a spectrum from a Benign Hydatidiform Mole to
Invasive Choriocarcinoma, a form of metastatic disease.
The majority of these are derived from paternal
chromosomes; there is no maternal chromosomes in the embryo.
The ultrasound appearance will be a cyst-like bunch
of grapes with a snowstorm-type appearance,
and classically the serum Beta-HCG will be very elevated.
Here's video from a patient who presented with
a Molar Pregnancy.
Her presenting symptoms were uncontrolled hypertension
during the pregnancy, as well as vaginal bleeding, and pain.
What we see here is the presence of a molar pregnancy
within the fundal region of the uterus.
Notice it has a cyst-like type of appearance.
Very different from the normal appearance
of a intrauterine pregnancy.
As we scan back and forth, it almost looks like
a bunch of grapes within the fundus of the uterus.
So a diagnosis of a molar pregnancy and my next move
was to get an OB/GYN consultation stat.
So thanks for tuning in to Part 2 of Emergency OB/GYN
Ultrasound, focusing on intrauterine pregnancy.
Hopefully you now have a better understanding on
how to further assess a normal pregnancy by determining
gestational age and fetal heart rate.
I hope also I've been able to give you some of
the ultrasound findings that you may see in an
abnormal pregnancy to know when you need to get
an OB/GYN consultation in the ED.
I hope to see you back as we move on to Ectopic Pregnancy,
and two modules in which we'll discuss the various
findings of ectopic pregnancies that we may see
in the emergency department.
I'll see you back as Soundbytes continues.

Brightcove ID

5750480594001

https://youtube.com/watch?v=4clxpcVLOS0

Case: Intrauterine Pregnancy - Part 1

Read more about Case: Intrauterine Pregnancy - Part 1

/sites/default/files/perera_intrauterine_part1.jpg

This video discusses the use of transvaginal and transabdominal ultrasound for detecting intrauterine pregnancies.

Clinical Specialties

Media Library Type

Media Library Tag

Tubal Ectopic Abdominal Ectopic

Ampullary

Ovarian

Pseudogestational Sac

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 entitled Emergency OB/GYN Ultrasound: Part I,
we're going to focus entirely on the
ultrasound findings of intrauterine pregnancy.
Now patients with early pregnancy and vaginal bleeding
with or without abdominal pain
are frequently seen in the emergency department.
Luckily for us, emergency OB/GYN ultrasound
has evolved to be one of the most helpful
applications of sonography
in a busy emergency medicine practice.
So this module will be focused
primarily on the detection of intrauterine pregnancy
and we'll examine the ultrasound findings that define
a normal pregnancy for an emergency physician sonographer.
Before launching into the sonographic findings
of a normal intrauterine pregnancy,
let's take a moment to quickly review
the OB/GYN anatomy important for this application.
We see the uterus to the left and adnexa to the right.
Notice the areas of the uterus.
We see the lower cervix,
the intermediate body,
and the fundal region towards the top of the uterus.
Now, the fundal region is where we define
an intrauterine pregnancy to be located.
We see the area where the fallopian tube
enters into the uterus,
which is the interstitial region in a normal uterus
and the cornual region in a bicornuate uterus.
And this is where some variants of ectopics can implant.
Notice the areas of the fallopian tube to the right,
which we'll concentrate more on
with regard to ectopic pregnancy.
And we see the broad ligament there encasing
the fallopian tube and the ovary as seen to the right.
When taking care of a patient
who has vaginal bleeding in pregnancy,
there's four main classifications of diagnoses.
The first is a Threatened Abortion,
which is defined as the presence
of an intrauterine pregnancy with bleeding.
The second main classification
encompasses several different terms.
The terms that are commonly used are,
Incomplete Abortion,
Missed Abortion,
Blighted Ovum,
and Fetal Demise.
Basically, all of these mean the presence
of fetal membranes or parts,
without expected fetal growth or cardiac activity.
The third main classification is a Completed Abortion,
in which there is no further presence
of fetal membranes or parts,
and on examination, usually the cervical os will be closed.
The fourth main classification is the most dangerous,
is Ectopic Pregnancy.
Here's a table showing the structures in pregnancy
and about the time that they're seen on transvaginal
versus transabdominal sonography.
As we look in the Embryonic Structure column to the left,
we see the first structure that appears
is a gestational sac, seen on transvaginal sonography
at about 4.5 to 5 weeks,
and about a week later on transabdominal sonography.
The yolk sac is seen at about 5 to 5.5 weeks
on transvaginal sonography
and a week later on transabdominal sonography.
I have this circled in red,
as this is really the way we diagnose
an intrauterine pregnancy.
Then note the fetal pole is seen at about 5.5 to 6 weeks
on transvaginal sonography
and a week later on transabdominal sonography.
The last main finding, which is a fetal heart beat,
is seen at about six weeks on transvaginal sonography
and about at seven weeks on transabdominal sonography.
Another important concept for OB/GYN sonography,
is the correlation of the serum beta HCG
to the findings of a normal pregnancy.
As we see here for transvaginal sonography,
the discriminatory zone at which we will see
findings of an intrauterine pregnancy
are about 1,500 to 2,000 mIU.
For transabdominal sonography,
the discriminatory zone is about 6,500 mIU.
Now, this rule does not apply to ectopic pregnancies,
which secrete beta HCG at atypical levels
and are commonly seen with betas all over the map.
They can be seen with betas lower than 1,000
and as high as 30,000.
The first finding that will occur
during an intrauterine pregnancy
is going to be a gestational sac.
As we see here in the ultrasound picture to the right,
it's a small, round circle that's dark
or hypoechoic in relation to the rest of the uterus.
We actually see a gestational sac below that
that came out of a patient.
Notice that it has a translucent, membrane-type appearance.
Unfortunately, gestational sac
is not diagnostic of an intrauterine pregnancy,
as a pseudogestational sac of ectopic pregnancy
can be seen from hormonal stimulation.
As a general rule of emergency ultrasound,
is that visualization of a gestational sac
is not adequate to call an intrauterine pregnancy.
Here's two video clips showing the gestational sac.
Long Axis to the left,
and Short Axis to the right.
We see here a very small diameter gestational sac
in both of these orientations.
Unfortunately, this can be seen with a
pseudogestational sac of ectopic pregnancy.
So a small gestational sac, like this,
is in no way diagnostic of an intrauterine pregnancy
for the emergency physician sonographer.
Remember that the gestational sac is seen
at about 4.5 to 5 weeks on transvaginal sonography,
and about a week later on transabdominal sonography.
Here are the findings that we define
as indicative of an intrauterine pregnancy
for an emergency physician sonographer,
and that is the presence of a gestational sac
with a yolk sac inside.
As we see in the picture to the right,
the yolk sac has a circular-type appearance
that we call the Positive Cheerio Sign.
Let's just remember, gestational sac plus yolk sac
is indicative of intrauterine pregnancy.
However, bonus points are given
if you see a fetal pole with a heart beat
for confirmation of intrauterine pregnancy.
Here's a video clip showing a definitive
intrauterine pregnancy.
What we see here is a larger gestational sac
and as we look inside the gestational sac,
we see the positive yolk sac or Cheerio Sign.
Notice the circular yolk sac is seen
towards the inferior aspect of this gestational sac.
This would be diagnostic of an intrauterine pregnancy,
effectively ruling out an ectopic pregnancy
in the vast majority of patients.
Remember that the yolk sac is seen
at about 5 to 5.5 weeks on transvaginal sonography,
and about a week later on transabdominal sonography.
Here we see a pregnancy that is a bit further advanced.
Note we have a larger gestational sac,
that darker or hypoechoic area,
within the fundal region of the uterus,
and as we look inside the gestational sac,
we see the positive yolk sac or the Cheerio,
and looking just to the left of the yolk sac,
we see a tiny little fetal pole there.
Interestingly enough, as we zoomed up on that fetal pole,
we could make out the flicker of a heart beat.
So, a definitive intrauterine pregnancy.
Recall that the fetal pole is seen
at about 5.5 to 6 weeks on transvaginal sonography,
and about a week later on transabdominal sonography.
Here's a transvaginal short axis view
of a seven week intrautertine pregnancy.
We see the gestational sac here.
Notice that the gestational sac
is located in the center of the uterus
as seen here in short axis,
and there's a good amount of myometrial mantle
surrounding the gestational sac,
signifying a fundal location.
We see the positive Cheerio sign, or yolk sac,
to the upper right aspect of the gestational sac,
and right below, we see the fetal pole stretched out.
Notice the positive cardiac activity
as we scan back and forth through the fetal pole.
Here's another intrauterine pregnancy at about seven weeks,
again in the transvaginal short axis view.
We note the good amount of uterus
surrounding the gestational sac,
signifying the fundal location.
We see here the yolk sac or Cheerio sign,
and the fetal pole is stretched out below the yolk sac.
Notice the positive cardiac activity
within the fetal pole.
Now we see another very important finding here
on this ultrasound,
which is the amniotic membrane,
billowing out from around the fetal pole.
Eventually the amniotic membrane
will plaster down on the margins of the gestational sac
to form the amniotic cavity,
in which further growth of the fetus will occur.
Here's an interesting video clip
showing a twin pregnancy.
What we see here are two gestational sacs
signifying dichorionic twins,
and within each of the gestational sacs
we can see little fetal poles
with a flicker of heart beats.
Recall that fetal heart activity
is seen at about six weeks on transvaginal sonography
and about seven weeks on transabdominal sonography.
Here's an early second trimester pregnancy.
What we see here is the next Oscar De La Hoya.
Note the mean right hook on the baby here.
The important finding here is that
this is an intrauterine pregnancy
as we can define a good mantle of uterus
surrounding the pregnancy.
That's very important as there are some ectopics
that can grow to an advanced stage,
but they're discerned by a lack of uterus
around the pregnancy.
Here's another second trimester baby
and as I work in Northern Manhattan,
I refer to this baby as the Merengue baby.
Note the baby moving around fluidly within the amniotic sac.
A sure sign that this kid will grow up to be a slick dancer.
In conclusion, I'm glad I could share with you
this SoundBytes module
going over Emergency OB/GYN Ultrasound: Part I
of intrauterine pregnancy.
Emergency OB/GYN ultrasound is definitely
one of the most helpful sonographic applications
in a busy emergency medicine practice
and hopefully by going through the module
you now have an understanding
of the ultrasound findings diagnostic of a normal pregnancy.
I hope to see you back as we return
in OB/GYN Ultrasound Pregnancy Part 2,
focusing on further assessment of normal pregnancy
as well as looking further into
the ultrasound findings of an abnormal pregnancy.

Brightcove ID

5508114751001

https://youtube.com/watch?v=gv4q8ZB25JM

Case: Ectopic Pregnancy - Part 2

Read more about Case: Ectopic Pregnancy - Part 2

/sites/default/files/youtube_ANhOwzbKe6Y_0.jpg

This video details how bedside ultrasound can help emergency medicine professionals visualize and diagnose various presentations of ectopic pregnancy, as well as differentiate between an ovarian cyst and an ectopic pregnancy.

Clinical Specialties

Media Library Type

Media Library Tag

Tubal Ectopic Abdominal Ectopic

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.
This module is ectopic pregnancy part two,
where we'll go over the multiple
ultrasound presentation of ectopic pregnancies.
Ectopic pregnancy is one of those
conditions that we'll not infrequently
encounter in a busy EM practice.
The most common presentation of
an ectopic pregnancy will be an empty uterus,
with or without free fluid within the pelvic cul de sac
or surrounding the uterus.
We may be actually able to visualize
the ectopic as a Bagel sign,
which constitutes a thickened Fallopian tube.
Other presentations of ectopics
include a complex pelvic mass
with a ring of fire on Doppler sonography,
hemosalpinx or blood within the Fallopian tube
or we may be actually able to visualize
the live ectopic in the adnexa,
with a fetal pole and/or heartbeat.
Here's a transvaginal long axis ultrasound
for a woman who presented with lower abdominal pain
and a positive pregnancy test.
Notice the uterus, as shown in the long axis view,
without an appreciable intrauterine pregnancy
and notice that it's surrounded
by a large amount of free fluid.
That dark or anechoic area surrounding
the uterus both anteriorly to the left,
posteriorly in the cul de sac to the right.
That is the presence of fresh blood.
Notice also the presence of blood clots
anteriorly or to the left, that more echogenic area.
So, given the absence of an intrauterine pregnancy,
we decided to scan out to the adnexa
and notice here, the presence of
a Bagel sign of a tubal ectopic pregnancy.
We see fresh fluid here, above the Bagel,
to the right, blood clot to the left
and the more hyperechoic
or lighter Bagel sign in the middle of the image.
Occasionally it can be difficult to discern
the Bagel sign of a Fallopian tube ectopic
from an ovarian cyst, as show here to the right.
But lets look closer at the two video clips
and notice that the Bagel sign
has a more hyperechoic or bright appearance,
with the single hole more in the middle.
Notice that the ovarian cyst has a different appearance,
with multiple small follicular cysts
to the outer portion of the ovary
and a single midline corpus luteum cyst.
Very different than the Bagel sign.
Here's another patient with an ectopic pregnancy
in a different presentation of ectopic.
We're scanning here from the more midline uterus,
as show there to the left, out to the right adnexa
and notice as we scan out to the right adnexa,
we notice the presence of a complex, pelvic mass.
Notice also the relatively low
serum B-HCG in this case, at 478.
So, a complex pelvic mass with
an absence of intrauterine pregnancy.
Very suspicious for an ectopic pregnancy.
And what's interesting is,
as we put Doppler flow on that complex pelvic mass,
we notice the presence of the ring of fire,
very suggestive of an ectopic pregnancy
and the reasons for the ring of fire
is that the ectopic pregnancy pulls
a huge amount of vascularity towards it
and using the Doppler,
we can see the separate ectopic from the ovary above it.
Here's another presentation of an ectopic pregnancy.
Again, we're scanning at a short axis plane
and we see there the uterus to the left
and outside the uterus, a separate structure.
We note here the presence of a thickened Fallopian tube
and inside the thickened Fallopian tube,
we see here a fetal pole with a heart beat,
consistent with a live ampullary ectopic pregnancy.
Unfortunately in this case,
the presence of a fetal pole with
a heart beat is a contraindication of methotrexate therapy
and this patient will need to undergo surgery.
We mentioned earlier that there are
a variance of ectopic pregnancies
that implant outside the fundal region of the uterus,
in an aberrant location.
This is a good example.
This patient actually has a bicornuate uterus
and as we scan at a short axis plane up the uterus,
we notice that the two limbs of endometrium
that make up the two distinct cornua.
As we go up the left cornua,
we notice here the presence of a cornual ectopic pregnancy
and we see the that it's located off to the side,
way out to the left cornua,
with a very thin myometrial mantle.
If we actually put the calipers down
and measure the endo-myometrial mantle,
we find it's very thin, at three millimeters,
defining an abnormal pregnancy.
A normal pregnancy should have
a myometrial mantle greater than eight millimeters.
Now this is a bicornuate uterus,
so this is a cornual pregnancy.
In a normal uterus,
this would be known as an interstitial pregnancy.
So in conclusion, I'm glad I could share with you
this module on ectopic pregnancy part two,
looking at the varied presentations of ectopic pregnancy.
Hopefully now you better understand
what we're searching for on bedside sonography
when we're working up a patient
with possible ectopic pregnancy.
While visualization of the adnexa
and the Fallopian tubes is an advanced technique,
but it is well within the scope
of a busy emergency medicine practice.
As a final caveat, ectopic pregnancies can
be seen at Beta-HCG levels ranging from very low,
less than 100, to very high, above 20,000
and thus we cannot use a Single Beta-HCG
level to rule out ectopic pregnancy.
It's really better to look at trends
in the hormone level over time.
With an intrauterine pregnancy,
the levels should double in 48 hours,
whereas in most ectopic pregnancy,
it will not climb to the same degree.
So, I hope that now you have a
better understanding of how to
work up the pregnant patient with
a possible ectopic pregnancy.

Brightcove ID

5750496732001

https://youtube.com/watch?v=ANhOwzbKe6Y

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