Whenever you are performing an E-FAST exam on your trauma patient or a thoracic US in those with unexplained shock or shortness of breath, your sphincter tightens when you see fluid in the belly or when there is no lung sliding. Ever placed your probe on the left anterior chest wall and have been surprised after noticing there is no lung sliding? Or, that you see this weird movement of “the lung” on the left side, which surely isn’t normal and definitely deeper than the pleural line and you think, “There’s a left pneumothorax!” Well, guess what guys and gals, it just could be the heart. Continue reading
Given this memorial day weekend, and the sacrifice of our troops, lets discuss something that the military has used for years – and for good reason. US-guided nerve blocks are becoming more and more utilized in our EDs. Especially when we have the elderly patient who is in severe pain from a humeral fracture or a femoral neck fracture, and you’d rather not have to watch (and chase) their blood pressure after giving systemic opiates. It is also a great resource in resource-poor areas, like the aftermath of the disaster of the Haiti earthquake. This is all clearly discussed in the article in Annals of Emergency Medicine this month by Drs. Suzanne Lippert, Arun Nagdev, Mike Stone, Andrew Herring, and Robert Norris. Continue reading
You get a patient who has gradual onset of shortness of breath with a history of cancer, a patient with sudden severe exertional chest pressure and new orthopnea, a patient with known pericarditis with worse pain or breathing difficulty, or a trauma patient with a penetrating stab wound to the chest and you want to evaluate whether they have a pericardial effusion, signs of tamponade, or poor contractility through a bedside echo, but you just can’t seem to obtain a great subxiphoid (SX) view. The SX view of the heart seems like it would be easy to obtain. I mean, it is right there! – right by the probe, and the patient is alive so you know he has a heart! Well, sometimes it’s not so easy. There are several reasons for this: your probe positioning, not seeing the liver, and the patient’s thoracic cage.
If the XR tech is busy with the traumas, its the overnight shift where resources are limited, and you just intubated someone who didnt have great breath sounds or O2 sat to begin with – and want to assess if the ETT is in the trachea – cool way to do it. Linear probe. transverse over the trachea at the jugular notch. You will see the the trachea as an arched hyperechoic (bright linear) structure with tracheal rings coming down from it. With the ETT in the trachea, a shadow of the tube over the trachea will be seen, but that may be tough to see at times, so you can put the color doppler box over it and do a little – wiggle wiggle wiggle wiggle wiggle, yeah – of the ETT – a color ray will spike down from the trachea.
THIS is truly my fav when it come to US applications. If you ever show this to any group of students or other learners, the entre room responds with , “Oooooooh, Awwwww.” You can see pupillary constriction by angling the probe upward to get a coronal view of the eye and shining a light on the eye – or the opposite eye. Or, you can decrease your depth and have the linear probe directly on the eyelid in transverse view while the patient looks upward. You will see the linear muscle layers which will constrict when a light is shined in the opposite eye (as seen below) … Pretty cool stuff, I tell ya….
I call it “Da Spine Sign” (insert any accent here – trust me, its funny). So, fluid is the lover of ultrasound, right? And air is the enemy. Typically you will not see the spine passed the diaphragm when looking at your RUQ view for your FAST scan in normal patients, but oh when you do, BAM! You know there’s fluid in the thorax. Here’s an image showing exactly that, as well as a little somethin’ somethin’ in the intraperitoneal space… so, don’t forget to look above the diaphragm in your FAST scan views! By the way – it’s also called the V-Line - I like my name better :)