Manual of Emergency and Critical Care Ultrasound The use of ultrasound has revolutionized the way many acute injuries and conditions are managed in emergency departments (ED) and critical care units, with several accrediting agencies mandating that physicians become proficient in the applications and interpretation of ultrasound. Today, EDs and critical care units nationwide are outfitted with ultrasound equipment, allowing acute conditions such as ectopic pregnancy or abdominal aortic aneurysm rupture to be diagnosed within critical seconds. This book is a practical and concise introduction to bedside emergency ultrasound. It covers the full spectrum of conditions diagnosed via this modality and gives useful instruction for using ultrasound to guide commonly performed invasive procedures. It introduces the major applications for emergency ultrasound by using focused diagnostic questions and teaching the image acquisition skills needed to answer these questions. Images of positive and negative findings for each application (FAST, echocardiography, etc.) are presented, as well as scanning tips for improved image quality. Each section also contains a review of the literature supporting each application. Dr. Vicki E. Noble is the director for emergency ultrasound at Massachusetts General Hospital in Boston, MA. She received her MD from the University of Pennsylvania in 1999 and completed a fellowship in emergency ultrasound at St. Luke s Roosevelt Hospital in New York. She is a Fellow of the American College of Emergency Physicians and is the Ultrasound Section subcommittee chair for education and practice standards. She is also a member of the American Institute of Ultrasound in Medicine and has been a member of the American Registry of Diagnostic Medical Sonographers since 2004. She has been awarded the Society for Academic Emergency Medicine Excellence Award and has been nominated for the Harvard University Medical School Teaching Award and the Brian McGovern Award for Clinical Excellence at Massachusetts General Hospital. She has taught extensively in emergency ultrasound both in the United States and internationally. Dr. Bret Nelson is director of emergency ultrasound for the Department of Emergency Medicine at Mount Sinai School of Medicine in New York. He is a member of the American College of Emergency Physicians, the American Institute of Ultrasound in Medicine, and the American Registry of Diagnostic Medical Sonographers. He has taught courses on ultrasound throughout Europe and the United States and received the Excellence in Teaching Award at Mount Sinai. Dr. A. Nicholas Sutingco is the director of emergency ultrasound for the Departments of Emergency Medicine at the INOVA Fair Oaks Hospital in northern Virginia. He received his MD from the George Washington University School of Medicine and completed his emergency medicine residency training at the Massachusetts General Hospital/Brigham and Women s Hospital. He is a member of the American College of Emergency Physicians and is active in teaching courses in ultrasound in northern Virginia.
Manual of Emergency and Critical Care Ultrasound Vicki E. Noble Massachussetts General Hospital Bret Nelson Mount Sinai School of Medicine A. Nicholas Sutingco INOVA Fair Oaks Hospital & The Fauquier Hospital
CAMBRIDGE UNIVERSITY PRESS Cambridge, New York, Melbourne, Madrid, Cape Town, Singapore, São Paulo, Delhi Cambridge University Press 32 Avenue of the Americas, New York, NY 10013-2473, USA Information on this title: /9780521688697 C Vicki E. Noble, Bret Nelson, A. Nicholas Sutingco 2007 This publication is in copyright. Subject to statutory exception and to the provisions of relevant collective licensing agreements, no reproduction of any part may take place without the written permission of Cambridge University Press. First edition 2007 Printed in the United States of America A catalog record for this publication is available from the British Library. Library of Congress Cataloging in Publication Data Noble, Vicki E., 1969- Manual of emergency and critical care ultrasound / Vicki E. Noble, Bret Nelson, A. Nicholas Sutingco. p.;cm. Includes bibliographical references and index. ISBN 978-0-521-68869-7 (hardback) 1. Diagnosis, Ultrasonic Handbooks, manuals, etc. 2. Ultrasonic imaging Handbooks, manuals, etc. 3. Emergency medicine Diagnosis Handbooks, manuals, etc. I. Sutingco, Nicholas, 1974- II. Nelson, Bret, 1973- III. Title. [DNLM: 1. Ultrasonography methods. 2. Emergencies. 3. Emergency Medical Services methods. WN 208 N752m 2007] RC78.7.U4N63 2007 616.07 543 dc22 2007008551 Cambridge University Press has no responsibility for the persistence or accuracy of URLs for external or third-party Internet Web sites referred to in this publication and does not guarantee that any content on such Web sites is, or will remain, accurate or approriate. Every effort has been made in preparing this book to provide accurate and up-to-date information that is in accord with accepted standards and practice at the time of publication. Nevertheless, the authors, editors, and publisher can make no warranties that the information contained herein is totally free from error, not least because clinical standards are constantly changing through research and regulation. The authors, editors, and publisher therefore disclaim all liability for direct or consequential damages resulting from the use of material contained in this book. Readers are strongly advised to pay careful attention to information provided by the manufacturer of any drugs or equipment that they plan to use.
Acknowledgments xi 1 Fundamentals 1 Basic Definitions and Physics Principles 1 Basic Instrumentation 5 Using the Transducer/Probe 6 Understanding the Formed Image 10 Adjusting the Image 10 Scanning Modes 12 Effects and Artifacts 14 PART I. DIAGNOSTIC ULTRASOUND 19 2 Focused Assessment with Sonography in Trauma (FAST) 23 Introduction 23 Focused Questions of the FAST Exam 24 Anatomy 24 Technique 28 Scanning Tips 33 Normal Images 34 Abnormal Images 37 Extended FAST or efast 42 Sample Clinical Protocol 43 Literature Review 43 Detection of Pneumothorax 45 Technique 45 New Directions 49 References 49 3 Echocardiography 53 Introduction 53 Focused Questions for Echocardiography 53 Anatomy 54 Technique 55 Scanning Tips 64 Normal Images 65 v
Abnormal Images 66 Advanced Applications 70 Guidance for Procedures 76 Sample Clinical Protocols 77 Literature Review 79 New Directions 80 References 80 4 First Trimester Ultrasound 85 Introduction 85 Focused Questions for First Trimester Ultrasound 85 Terminology 86 hcg Levels 87 Anatomy 87 Technique 88 Normal Images in Early Pregnancy 92 Ectopic Pregnancy 97 Abnormal Images 98 Sample Clinical Protocol 100 Literature Review 101 New Directions 101 References 102 5 Abdominal Aortic Aneurysm 105 Introduction 105 Focused Questions for Aortic Ultrasound 105 Anatomy 106 Technique 106 Scanning Tips 112 Abnormal Images 113 Sample Clinical Protocol 115 Literature Review 117 References 118 6 Renal and Bladder 119 Introduction 119 Focused Questions for Renal and Bladder Ultrasound 119 Anatomy 119 Technique 120 Bladder Volume Estimation 123 vi
Scanning Tips 124 Normal Images 124 Abnormal Images 126 Sample Clinical Protocol 131 Literature Review 132 New Directions 132 References 132 7 Gallbladder 135 Introduction 135 Focused Questions for Gallbladder Ultrasound 135 Anatomy 135 Technique 136 Measurements 139 Scanning Tips 140 Normal Images 141 Abnormal Images 143 Sample Clinical Protocol 149 Literature Review 149 References 151 8 Deep Vein Thrombosis 153 Introduction 153 Focused Questions for DVT Ultrasound 153 Anatomy 153 Technique 155 Scanning Tips 160 Normal Images 161 Abnormal Images 162 Sample Clinical Protocol 164 Advanced Techniques 164 Literature Review 166 References 166 9 Chest Ultrasound 169 Introduction 169 Focused Questions for Lung Ultrasound 169 Anatomy 169 Technique 171 Scanning Tips 172 vii
Images 172 Literature Review 173 New Directions 173 References 173 10 Ocular Ultrasound 175 Introduction 175 Focused Questions for Ocular Ultrasound 175 Anatomy 175 Technique 177 Scanning Tips 177 Normal Images 178 Abnormal Images 179 Literature Review 180 New Directions 181 References 181 11 Fractures 183 Introduction 183 Focused Questions for Bone Ultrasound 183 Anatomy 183 Technique 184 Scanning Tips 184 Normal Images 185 Abnormal Images 186 Literature Review 187 New Directions 188 References 189 PART II. PROCEDURAL ULTRASOUND 191 12 Vascular Access 195 Introduction 195 Focused Questions for Vascular Access 195 Anatomy 195 Technique 198 Cannulation of the Subclavian Vein 205 Cannulation of the External Jugular Vein 205 Peripheral Venous Cannulation 205 Scanning Tips 206 Pitfalls 207 viii
Literature Review 207 References 208 13 Ultrasound for Procedure Guidance 209 Cannulation of the Brachial and Cephalic Veins of the Upper Extremity 209 Focused Question 209 Anatomy 209 Technique 209 Tips 210 Pitfalls 212 Literature Review 212 References 212 Pleural Effusion and Thoracentesis 212 Focused Questions 213 Anatomy 213 Technique 213 Tips 215 Pitfalls 215 Literature Review 215 References 216 Ascites and Paracentesis 216 Focused Questions 216 Anatomy 216 Technique 217 Tips 218 Pitfalls 218 Literature Review 218 References 219 Joint Effusions and Arthrocentesis 219 Focused Questions 219 Anatomy 219 Technique 220 Knee 221 Ankle 221 Shoulder 222 Tips 223 Pitfalls 223 Literature Review 223 References 223 Foreign Body Identification/Localization 224 Focused Questions 224 Anatomy 224 Technique 225 Tips 229 ix
Pitfalls 229 Literature Review 229 References 230 Abscess Identification 230 Focused Questions 230 Anatomy 230 Technique 230 Peritonsillar Abscesses 233 Literature Review 233 References 234 Lumbar Puncture 234 Focused Questions 235 Anatomy 235 Technique 235 Tips 236 Pitfalls 237 Literature Review 237 References 237 Index 239 x
Acknowledgments I would never have learned the possibilities of bedside ultrasound without the friendship and support of Drs. Betty Chang, Greg Press, and Manuel Colon, all of whom are the best colleagues a person could ever hope for. In addition, this book is the result of Nick s initiative as a fourth-year resident and Bret s invaluable help in getting it to completion. I am eternally grateful for their patience and knowledge. And of course, every day I am reminded how lucky I am to work with the residents, nurses, administrative support team, and faculty at Massachusetts General Hospital. VEN Acknowledgments My life is richer because of my wife, Susan, and everything I do is made better through her love and support. I also thank Nick, whose idea for a student handbook has grown into this work, and Vicki, whose tenacity and attention to detail made this book a reality. Thanks as well to my residents and students, who drive me to improve with every shift. BPN This book is dedicated to the devoted frontline providers at the Massachusetts General Hospital and the Brigham and Women s Hospital Emergency Departments, who taught me how to practice emergency medicine amidst all the noise and haste. Special thanks to Dr. Vicki Noble, who constantly reminded me to keep faith in my career and sparked my interest in emergency ultrasound. Finally, thank you to my family and my wife, Lisle. Thank you for reminding me daily how beautiful the world is even after a disenchanting day at the office. ANS The authors thank Dr. Manny Colon for contributing many of the illustrations found in this book, and Dr. Thomas Wu for providing photographs of proper patient positioning. Acknowledgments xi