Manual of Emergency and Critical Care Ultrasound Second Edition
Manual of Emergency and Critical Care Ultrasound Second Edition Vicki E. Noble MD, RDMS, FACEP Director, Division of Emergency Ultrasound, Department of Emergency Medicine, Massachusetts General Hospital, and Assistant Professor, Harvard Medical School, Boston, MA, USA Bret P. Nelson MD, RDMS, FACEP Director of Emergency Ultrasound and Associate Professor of Emergency Medicine, Mount Sinai School of Medicine, New York, NY, USA
University Printing House, Cambridge CB2 8BS, United Kingdom Cambridge University Press is part of the University of Cambridge. It furthers the University s mission by disseminating knowledge in the pursuit of education, learning and research at the highest international levels of excellence. Information on this title: /9780521170918 # Vicki E. Noble, Bret P. Nelson 2011 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 published 2007 Second edition published 2011 7th printing 2015 Printed in the United Kingdom by Bell and Bain Ltd, Glasgow A catalog record for this publication is available from the British Library Library of Congress Cataloging in Publication data Noble, Vicki E., 1969 author. Manual of emergency and critical care ultrasound / Vicki E. Noble, Bret P. Nelson. 2nd Edition. p. ; cm. Includes bibliographical references and index. ISBN 978-0-521-17091-8 (Paperback) 1. Diagnostic ultrasonic imaging Handbooks, manuals, etc. 2. Ultrasonic imaging Handbooks, manuals, etc. 3. Emergency medicine Diagnosis Handbooks, manuals, etc. I. Nelson, Bret, 1973 II. Title. [DNLM: 1. Ultrasonography methods. 2. Critical Care methods. 3. Emergencies. 4. Emergency Medical Services methods. 5. Emergency Treatment methods. WN 208] RC78.7.U4N63 2011 616.07 543 dc22 2010046476 ISBN 978-0-521-17091-8 Paperback Cambridge University Press has no responsibility for the persistence or accuracy of URLs for external or third-party internet websites referred to in this publication, and does not guarantee that any content on such websites is, or will remain, accurate or appropriate. Every effort has been made in preparing this book to provide accurate and up-to-date information which is in accord with accepted standards and practice at the time of publication. Although case histories are drawn from actual cases, every effort has been made to disguise the identities of the individuals involved. Nevertheless, the authors, editors and publishers 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 publishers 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 Introduction 1 Basic definitions and physics principles 1 Basic instrumentation 5 Using the transducer/probe 7 Understanding the formed image 11 Adjusting the image 12 Scanning modes 14 Effects and artifacts 16 SECTION 1: DIAGNOSTIC ULTRASOUND 23 2. Focused assessment with sonography in trauma (FAST) 27 Introduction 27 Focused questions for the FAST exam 28 Anatomy 28 Technique 32 Scanning tips 38 Normal images 39 Abnormal images 42 Extended FAST or efast 47 Sample clinical protocol 49 Literature review 50 Detection of pneumothorax 51 New directions 56 References 57 3. Cardiac ultrasound 61 Introduction 61 Focused questions for cardiac ultrasound 61 Anatomy 62 Technique 63 Scanning tips 73 Normal images 74 v
Abnormal images 76 Sample clinical protocols 86 Literature review 87 New directions 88 References 88 4. First trimester ultrasound 91 Introduction 91 Focused questions for first trimester ultrasound 92 Terminology 92 hcg levels 93 Anatomy 93 Technique 94 Scanning tips 101 Normal images in early pregnancy 101 Ectopic pregnancy 106 Abnormal images 107 Sample clinical protocol 109 Literature review 110 New directions 111 References 112 5. Abdominal aorta ultrasound 115 Introduction 115 Focused questions for aorta ultrasound 115 Anatomy 116 Technique 116 Scanning tips 124 Abnormal images 125 Sample clinical protocol 128 Literature review 129 References 130 6. Renal and bladder ultrasound 133 Introduction 133 Focused questions for renal and bladder ultrasound 134 Anatomy 134 Technique 136 Bladder volume estimation 138 vi
Scanning tips 138 Normal images 140 Abnormal images 141 Sample clinical protocol 147 Literature review 148 New directions 148 References 149 7. Gallbladder ultrasound 151 Introduction 151 Focused questions for gallbladder ultrasound 151 Anatomy 151 Technique 152 Measurements 156 Scanning tips 158 Normal images 159 Abnormal images 160 Mimics 167 Sample clinical protocol 168 Literature review 169 References 171 8. Ultrasound of the deep venous system 173 Introduction 173 Focused questions for DVT ultrasound 173 Anatomy 173 Technique 175 Scanning tips 180 Normal images 181 Abnormal images 182 Sample clinical protocol 185 Advanced techniques 186 Literature review 187 New directions 188 References 189 9. Respiratory ultrasound 191 Introduction 191 Focused questions for respiratory ultrasound 191 Anatomy 192 vii
Technique 195 Scanning tips 197 Normal images 198 Abnormal images 198 Literature review 199 New directions 200 References 200 10. Ocular ultrasound 203 Introduction 203 Focused questions for ocular ultrasound 203 Anatomy 204 Technique 205 Scanning tips 206 Normal images 206 Abnormal images 207 Literature review 209 New directions 210 References 210 11. Soft tissue and musculoskeletal ultrasound 213 Introduction 213 Focused questions for soft tissue and musculoskeletal ultrasound 214 Anatomy 214 Technique 215 Scanning tips 219 Normal images 219 Abnormal images 221 Literature review 224 New directions 224 References 225 12. Gastrointestinal ultrasound 227 Introduction 227 Focused questions for gastrointestinal ultrasound 232 Anatomy 232 Technique 233 Scanning tips 235 Normal images 236 viii
Abnormal images 236 Literature review 238 New directions 239 References 239 13. Pediatric ultrasound 241 Introduction 241 Focused questions for pediatric ultrasound 246 Anatomy 247 Technique 248 Scanning tips 249 Normal images 249 Abnormal images 251 Literature review 253 New directions 253 References 253 14. Ultrasound in shock 255 Introduction 255 General approach to the patient in shock 255 Cardiac ultrasound 255 Inferior vena cava 258 The FAST exam 261 Aorta 261 Pleura and lung 262 Sample clinical protocol 263 Literature review 265 References 266 SECTION 2: PROCEDURAL ULTRASOUND 269 15. Vascular access 273 Introduction 273 Focused questions for vascular access 273 Anatomy 273 Technique 277 Scanning tips 288 Pitfalls 288 Cannulation of the subclavian vein 289 Cannulation of the external jugular vein 289 ix
Peripheral venous cannulation 289 Literature review 294 References 295 16. Ultrasound for procedure guidance 297 Introduction 297 Pleural effusion and thoracentesis 297 Ascites and paracentesis 301 Joint effusions and arthrocentesis 304 Foreign body identification/localization 308 Abscess drainage 315 Lumbar puncture 319 Pericardiocentesis 323 Detection of pacing capture 323 Bladder aspiration 323 Regional nerve blocks 327 References 334 Index 337 x
Acknowledgments Many many thanks to the nurses, doctors, residents, and support staff in the emergency department at Massachusetts General Hospital. They make me a better doctor, keep me honest, and make it fun to come to work on most days. Thanks as well to Bret for his patience with both editions of this book and for being such a strong advocate for the field of point-of-care ultrasound. He never says no even if he probaby should and thanks to Susan for letting him say yes. Finally a million thanks to Dr. Andrew Liteplo for being such a fabulous colleague his enthusiasm for ultrasound knows no bounds, and many of the images in the book are from his collection. It is invaluable to have a colleague who shares my enthusiasm for the potential in point-of-care ultrasound and who works tirelessly supporting the education, research, and administrative efforts behind the advancement of the field. I am very lucky and grateful. VEN Acknowledgments My wife Susan and son Holden give me the strength to work and the reason to come home. This book could not have been completed without their love and support. I am also grateful for Vicki s tireless dedication to this book and the advancement of point-of-care ultrasound. Over the years I have been inspired by my colleagues, residents, and students to improve. Someday I just might. BPN Acknowledgments xi