CR

2006 ACEP US-guided procedure

Vascular access -Central veinCVPFVP -Peripheral vein -Arterial line -IO insertion Soft tissue abscess Drainage -Ascites -Pleural effusion -Pericardial effusion -Joint fluid

2006 ACEP US-guided procedure

Lumbar puncture Soft tissue foreign body localization Fracture reduction Endotracheal tube location confirm Cystofix implantation

Probe -High frequency(7~12 MHz)linear probe Approach -Long axis -Short axis Technique -Static -Real time

Vascular access

Artery Vein

Femoral vein

Basilic and Cephalic vein

Radial artery cannulation

Prepare

IO needle

Lumbar puncture

6H6T

Subxiphoid view

Hypovolemia

CVP vs IVC size

When CPR?

Advanced Trauma Life Support

Primary ABCD AAirway and C-spine BBreathing (Pneumothorax and Hemothorax) CCirculation (FAST) DDysfunction of CNS

Real-time () 2.5-3.5 MHZ Probe Laser printer, VHS Measurement capability Portability ()

FAST for trauma

Ocular ultrasound?

IICP?IICP 1. high frequency, high resolutionlinear probe (7.5-10MHz) 2. 3mmOptic Nerve Sheath Diameter(ONSD) 3. ONSD 5mmIICP 4. Sensitivity 100%, Sepcificity 63%Annals of Emergency Medicine Volume 49, No. 4, April, 2007

How to scan?

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2009, 17:34

Wall motion View

Parasternal Long Axis

Transducer placement

Desired Image

What the image shows

Parasternal Long Axis

Illustration by Patrick J Lynch www.infomed.yale.edu

Parasternal Short Axis

LA

SA

Parasternal Short Axis

Illustration by Patrick J Lynch www.infomed.yale.edu

Parasternal Short Axis Base

Illustration by Patrick J Lynch www.infomed.yale.edu

Apical 4 Chamber

Apical 4 Chamber

Illustration by Patrick J Lynch www.infomed.yale.edu

Suprasternal Notch View

Suprasternal Notch View

Endocarditis

Vegetations

Ebstein's Anomaly

Tetralogy of Fallot

Patent Ductus Arteriosus

Coronary artery dilatation(KD)

Classification of Peri- and Intraventricular HaemorrhageAdapted from Volpe (1989):

Grade 1: germinal matrix haemorrhage with no or minimal IVH (50% of the ventricular area on parasagittal view with Hydrocephalus).

Grade I:

bilateral germinal matrix haemorrhage

Grade II

Grade III:

Acute Abdomen

Acoustic shadow

Comet tail artifact

Pediatric Acute Abdomen

AIM - IH A : Acute appendicitis I : Intussusception M : Malrotation I : Incarcerated hernia H : Hollow organ perforation / Hypertrophicpyloric stenosis

Appendix

Psoas mucle

appendix

muscle

Landmark of Appendix

Iliac crest Psoas muscle

Acute appendicitis

Acute appendicitis

Acute appendicitis

Mimickers Mesenteric adenitis

Target sign in RUQ.

Crescent sign in LUQ.

Intussusception

80% ~90% (ileo-colic). 3~2, 5 ~9 : Cramping abdominal pain, intermittent vomiting and irritability, strawberry jam stool

Intussusception

Intussusception

US-guided Reduction

Incarcerated hernia

Hypertrophic pyloric stenosis

2~4 ,

1.6 cm 0.4 cm 1.4 cm

Hollow organ perforation

Scissors Maneuver

J Clin Ultrasound 2004; 32:381-385

Pancreatitis and pseudocyst

Hydronephrosis

Choledochal Cyst

CBD dilatation

Intrauterine Pregnancy

Ectopic pregnancy

Color Doppler: Ring of Fire

Ovarian torsion

Corpus luteum cyst rupture

Lichtenstein

artifact (M mode)

?

Landmark

Landmark

Dependent: (Consolidation) Non-dependent:

Ultrasound Aspects of AlveolarInterstitial Syndrome

B-lines 7 mm apart or spaced comet-tail artifacts. These artifacts correspond to thickened interlobular septa .

Pleural effusion

Anechoic pattern Static mode: Quad sign or Sharp sign M mode: Sinusoid sign Turbid or with septum: Empyema or malignant PLE

Pneumothorax with Lung Point

(a) Normal lung and (b) pneumothorax patterns using time-motion mode lung ultrasound. In time motion mode, one must first locate the pleural line (white arrow) and, above it, the motionless parietal structures. Below the pleural line, lung sliding appears as a homogenous granular pattern (a). In the case of pneumothorax and absent lung sliding, horizontal lines only are visualised (b). In a patient examined in the supine position with partial pneumothorax, normal lung sliding and absence of lung sliding may coexist in lateral regions of the chest wall. In this boundary region, called the 'lung point' (P), lung sliding appears (granular pattern) and disappears (strictly horizontal lines) with inspiration when using the time-motion mode

US Sensitivity and Specificity for PneumothoraxSensitivity Specificity

CXR US

28% 87%

100% 97%

Lichtenstein, DA; Meziere, G; Lascols, N; Biderman, P; Courret, JP; Gepner, A; Goldstein, I; Tenoudji-Cohen, M. Ultrasound diagnosis of occult pneumothorax. Crit Care Med. 2005;33:12311238.

Lung point

Alveolar Consolidation

Posterolateral alveolar and/or pleural syndrome(PLAPS) Tumor Dynamic air-bronchogram: pneumonia Static air-bronchogram: lung collapse Air-fluid level: lung abscess

Empyema

Lobulated empyema

Lung abscess

Scrotum ultrasound

Testicular torsion

Epididymitis

Parotid abscess / parotitis

Cobblestone appearance

Maxillary Sinusitis

Epiglottitis

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