It’s here! SonoDoc: A fun, online game to learn bedside #ultrasound in a case-based way. Learn #POCUS indications, how to’s, integrate into case mgmt, how to use it for next steps/dispo. Play FREE or Stanford CME ($25). HUGE thanks to many folks for authoring cases/beta testing/feedback/support. 5 years in the making, and so happy to share it with you all. Enjoy! http://sonodocgame.com
This post involves a personal experience from a free lance writer who asked me whether we (EM or primary care docs) should/can be doing bedside ultrasound for an assessment of the thyroid when we feel something wrong – even if its for the sole purpose of expediting care and biopsy, or alleviating concerns with a negative study. It was a valid question, and she wrote about her experience below. The thyroid is not a difficult gland to find, nor is it a technically difficult ultrasound to perform – although not a current use for bedside ultrasound, it may start to be given the ease to which nodules can be seen: (for pictures of normal thyroid and abnormal thyroid nodules, see the end of the post – the pics are not her thyroid)
At a regular physical exam, my doctor discovered a small lump in my neck. She said it was on my thyroid, and referred me to an endocrinologist for further evaluation. At only 19 years old, I was scared and extremely uneducated in regards to thyroid health and diagnoses. My endocrinologist ordered a radiology ultrasound to be done at a later time where I had the technician hovering over me. After the doctor declared I had two nodules, I was scheduled to go back yet again for an ultrasound-guided fine needle aspiration (FNA) to help rule out cancer. This persistent waiting from one appointment to another for small amounts of information were frustrating, and I wondered why my own doctor couldn’t just do the initial ultrasound to visualize the nodules, streamlining the process and expediting my work up.
The day finally arrived for the FNA, and the scene couldn’t be more uncomfortable—and comical at the same time. As the technician tried to gain an image of the right spots with the large wand, the endocrinologist struggled to bypass the size of it in order to gain the samples he needed. On top of that, it was nearly four months from the time of my original physical exam before I found out I had benign nodules. I was told I would need to follow up with a radiology ultrasound every few years.
Point-of-care (POC) ultrasounds, units that are small and possibly hand-held that are increasing in popularity among physicians and emergency doctors, can used by primary care doctors with their assessment. Not only are they portable, but they are easier and more comfortable to use for all parties involved. While not widely publicized or used for thyroid nodules yet, there is potential that POC ultrasounds could aid in diagnosis and follow-up for related patients.
Thyroid nodules are areas of abnormal cell growths within the thyroid gland. Depending on their size, nodules may form a visible mass in the neck. Some can also cause a goiter, or enlarged thyroid gland. The majority of thyroid nodules are not cancerous. However, an ultrasound and FNA can rule this out. These nodules may go undetected for years. Others can coexist with other related issues, such as hypothyroidism and hyperthyroidism. Thyroid nodules can also become painful to the touch and when you swallow.
Unless you can feel a lump in your thyroid gland, these types of nodules are first detected through a physical exam of the neck. Conventional radiology ultrasounds are currently used as a follow-up to locate the nodules and rule out any potential problems.
On a larger scale, the increased use of POC ultrasounds can help the health of patients. It can even help save lives: although rare, thyroid cancer can be deadly if not caught early. Most cases of thyroid nodules and masses occur in older patients, some of whom may not be able to make it to radiology offices for a traditional ultrasound. By employing the use of a POC ultrasound, a physician can quicken the diagnosis and make the process more comfortable for patients. The fact is that once patients leave their primary care physicians’ offices, it is up to them to follow up on referrals to ultrasound appointments. Having a POC device handy ensures that a patient won’t miss these crucial diagnoses.
Having an ultrasound for thyroid nodules is easier with POC ultrasounds. Since the area of investigation is small, this approach makes the most sense when considering comfort for both doctor and patient.
Another benefit is the cost. POC ultrasounds cost providers less money, and it may be more affordable to patients. With the rising costs of healthcare, more and more patients are missing out on critical exams. By making thyroid scans more affordable, patients may be less likely to skip out on their appointments. The downside is that POC ultrasounds are not used for thyroid nodules yet. By pushing for their use in all areas of healthcare, POC may ease the ultrasound experience and even save lives.
Author Bio: Kristeen Cherney is a freelance health and lifestyle writer who also has a certificate in nutrition. Her work has been published on numerous health-related websites.
Pics from aium.org – NORMAL ADULT THYROID
Pics form ultrasound-images.com :
ADENOMAS
FOLLICULAR ADENOMA
PAPILLARY CARCINOMA
Ok, this is awesome. I know you are likely thinking that i am talking about ultrasound and how it helps with bladder aspiration, and although i do think that is awesome, it’s not that which makes me smile right now. It is that it is highlighted in the New England Journal of Medicine – oh yes, that’s right. You’ll need to be a subscriber to see the video, but you can see the front page of the article here. Hooray for the NEJM on highlighting ultrasound in this important application for our patients!
I am going to say a statement that is going to be shocking to some of you: There has been a decline in CT use by the emergency department over the last 2 decades, according to Raja et al. Can you believe it? I couldnt either. I previously thought, now that CT is so easy to get, of course everyone is ordering them more. There have been several studies showing an increase in ionizing radiation exposure over the last decade, so the results are a bit confusing. Im sure when compared to 20+ years ago, we are ordering more in total, but the trend may be that we are declining in ordering. Well, not only has Raja came to this conclusion, but when seeing how the FAST scan has affected abdominal CT scan orders, then it makes me wonder if point of care ultrasound (POCUS) is one of the main reasons for this trend. Yeah, I know, it’s a stretch, but I cannot imagine it isnt a factor, along with ALARA, and other discussions on radiation exposure.
In a study by Sheng et al – which includes some of my heroes, Drs. Vickie Noble and Andrew Liteplo – they looked at the trend of abdominal CT orders in adult trauma patients at their institution. Could it be that bedside ultrasound has effected CT orders everywhere? Their abstract is below:
Objective. We sought to describe the trend in abdominal CT use in adult trauma patients after a point-of-care emergency ultrasound program was introduced. We hypothesized that abdominal CT use would decrease as FAST use increased. Methods. We performed a retrospective study of 19940 consecutive trauma patients over the age of 18 admitted to our level one trauma center from 2002 through 2011. Data was collected retrospectively and recorded in a trauma registry. We plotted the rate of FAST and abdominal CT utilization over time. Head CT was used as a surrogate for overall CT utilization rates during the study period. Results. Use of FAST increased by an average of 2.3% (95% CI 2.1 to 2.5, P < 0.01) while abdominal CT use decreased by the same rate annually. The percentage of patients who received FAST as the sole imaging modality for the abdomen rose from 2.0% to 21.9% while those who only received an abdominal CT dropped from 21.7% to 2.3%. Conclusions. Abdominal CT use in our cohort declined while FAST utilization grew in the last decade. The rising use of FAST may have played a role in the reduction of abdominal CT performed as decline in CT utilization appears contrary to overall trends.
For those of us who travel, teach, and spread the gospel of ‘sound – we look for resources that may help in knowing the conversation for this topic. AIUM has a page that could help in your needs, as well as see photos of trips that their physicians have undertaken for ultrasound teaching and advancement.
Ive posted on other groups that have gone all over the world, in addition to my own experiences – including TO-theWorld who enhanced maternal education and minimizing MTFT of HIV.
For other resources, that are free for ultrasound in global health:
Here’e a video that discusses ultrasound in global health, with a cameo photo of our own Dr. Jessica Ngo using it during Stanford’s emergency response to Haiti after the disaster with our SEMPER team.
Our newest guest post is by one of the best emergency medicine resident educators I know – of course, you dont want to miss his educational pearls on twitter too – Dr. Jacob Avila. He discusses a case that illustrates how bedside ultrasound can help in your unexplained short of breath patient, and even cancel that triage bias that your attending can do to sway you away from the truth. Let’s give it to Dr. Avila for highlighting (with a great literature review) how ultrasound can help you too. Here it is – enjoy! (note: not all images were of this patient, but were taken from other resources)
“You arrive to the emergency department for your first night shift of the month, and as you place your bag on the desk, the attending walks towards you with a chart in his hand. “Do you mind seeing this patient? It’s a COPD’er with dyspnea. It’s probably just a COPD exacerbation.” You look at the chart and see that it’s a 46 year old female with shortness of breath. As you walk into the room, you notice the patient appears slightly pale, is afebrile, has an O2 saturation of 91% and is tachycardic in the 110’s with a blood pressure of 105/76, temperature of 98.5° and respiratory rate of 26. While taking the history, you note that the patient is a smoker and recently returned from a 12 hour car ride to see relatives. Suspecting that this may be something other than simple COPD exacerbation, you grab your ultrasound machine and start with the cardiac echo (as described in the RADiUS protocol) and are able to get the following image:
This apical 4-chamber view shows severe right heart dilation, defined as a RV:LV ratio >1. However, you remember that the patient has a history of COPD, and chronic pulmonary hypertension can cause chronic right ventricular dilation1. At that moment, the patient becomes hypotensive with a systolic blood pressure in the 70’s and develops severe respiratory distress. What should we do?
Early diagnosis of a pulmonary embolism (PE) is exceedingly important, as two thirds of patients with mortality associated with a PE die within the first hour of their presentation2, and intuitively, those who are treated earlier generally have a better prognosis 3. The definitive diagnosis of a PE requires the use of a CT scanner 4, but in a patient who is unstable, like this one, that isn’t an option. Looking at the right ventricular to left ventricular ratio is a maneuver that can rapidly change your differential diagnosis or confirm what you previously suspected. A recent study by Dresden et al found right ventricular dilatation identified by emergency physicians had a specificity of 98% for a PE. That number is impressive, but when you look at the methodology section of the publication, only 10% of the patients they included had coexisting COPD, and all of the false positives in the study were in patients with COPD5. One technique that may help differentiate between chronic and acute dilation is looking at the RV free wall in the subxiphoid view while in end diastole. A free wall size >0.5 cm is more likely to be chronic RV dilation6i. However, this view is not always possible in all patients. Another echo sign you could look for is the McConnell sign (apical winking of the right ventricle during systole), which previously was reported to have an impressive 94% specificity and 77% sensitivity for an acute PE7l, but a subsequent and larger study found the McConnell sign to be only 70% sensitive and 33% specific for a PE8. Take a look at what the McConnell sign looks like”
Another, less commonly seen finding would be directly seeing the clot in the right atrium (RA) or in the pulmonary arteries.
Clot in RA:
Clot in pulmonary artery:
Of more practical use are two other sonographic findings: Deep venous thrombosis (DVT) and distal pulmonary infarction.
In a study that included 199 examinations, bedside 2-point compression evaluation of the greater saphenous/femoral vein junction and the popliteal veins of patients with suspected DVT was found to be 100% sensitive and 99% specific for DVT 9. However, it is possible for a patient to present with an acute PE and have a negative DVT, and only about 40-50% of patients with DVT’s will end up having a PE10, 11
DVT on one side diagnosed by noncompressible vein:
More recently, lung ultrasound has been explored for the assessment of a suspected PE. A recent systematic review and meta-analysis by Squizzato et al which included 10 studies and a total of 887 patients found lung ultrasound to have a mean sensitivity of 87% and a mean specificity of 82% for acute PE12. What they looked for in the lung was the presence of triangular, wedge or rounded hypoechoic, pleural based lesions. These lesions are thought to be due to embolic occlusions that resulted in either focal atelectasis with extravasation of blood or focal infarction of the lung parenchyma . However, they state in their publication that “Several methodological drawbacks of the primary studies limit any definite conclusion”.
Lung infarction:
Instead of looking at just one specific sonographic finding for the diagnosis of acute PE, a better method may the use of multi-organ sonography. Recently, Nazerian et al. published a study utilizing multi-organ sonography in the diagnosis of PE. This study used echo, lung and DVT ultrasound to diagnose PE and found that when the three ultrasounds were combined, they yielded a sensitivity of 90%, which was significantly higher than each of the exams by themselves13.
Like any physical exam finding, lab reports or other radiographic assessments, the sonographic analysis of a patient with a suspected pulmonary embolism should be used as part of your diagnostic quiver, and not the silver bullet. Any of the above mentioned ultrasound findings of acute PE can potentially be found in other, non-PE causes of dyspnea. DVT’s can just be DVT’s, RV enlargement can be chronic or from an RV infarction, and subpleural fluid collections can be seen in contusions, pneumonia and cancer. This doesn’t mean not to use it though. Just think about all the other tests we use in the emergency department, such as EKG’s, chest x-rays, troponins, BNP, and the d-dimer. All of these can be abnormal in PE and in non-PE entities.
Now back to our patient. She is a 46 year-old female with COPD that had right heart enlargement, which we learned above can be seen in COPD without the presence of a PE. You were unable to get a good subcostal view of the heart to measure the lateral wall, mostly because the patient did not tolerate being laid flat. You move on to the lungs and in the lower right thorax and there you find two hypoechoic, pleural based lesions. Heparin and a CT scan are ordered, and the CT scan shows a large clot located in the right main pulmonary artery.
Here is the CT scan showing the clot:
To see a recent podcast by Ultrasoundpodcast on multi-organ US for PE, go here.
References:
In a publication in WestJEM by Bramante, Raio and team, they discuss two cases of appendicitis found on trans-vaginal ultrasound. Now, this is something that I have been told can happen, but there are few studies on it. It makes sense. First off, the trans-vaginal probe is high frequency, there is an empty bladder and there is a regional evaluation of the pelvis. The appendix can lie low and be visualized, and diagnosed with acute appendicitis. Raio also published a study on this in Emergency Medicine International. They studied 224 females with right lower quadrant pain suspicious for appendicitis excluding those pregnant or under 16yrs old. They had 27 with a positive ultrasound for gyn pathology and 55 had appendicitis per OR report. Of course they wondered if they should have looked for the appendix too! Other studies have shown that with both a transabdominal and a transvaginal ultrasound, you can improve accuracy in appendicitis diagnoses, but that wasnt necessarily to look for the appendix. The Journal of Ultrasound in Medicine published in 2006 about a case of transvaginal US and appendicitis very nicely too. The OB literature also stated how some of their cases of pelvic pain had appendicitis seen on both transabdominal and transvaginal ultrasound.
Ok, back to the case reports in WestJEM by Bramante et al. The 2 cases showed the evaluation and pretty obvious sonographic images seen with acute appendicitis with transvaginal ultrasound after an equivocal transabdominal ultrasound:
In a meeting of 15 members of the radiology, Ob/Gyn, and emergency medicine communities, new criteria were set that was published in NEJM Oct 2013 so that we dont prematurely state that a pregnancy is non-viable. This is pretty important, and a subject that I posted about earlier as well when discussing the usefulness (…or useless ness) of the beta hCG. Can you imagine what was done, and I remember this algorithm – you have a patient with 1st trimester pain or vaginal bleeding, no IUP seen on US, low beta Hcg, and OB was called and the patient was given methotrexate??? Well, there have been cases where those patients actually had a viable IUP that showed up a week later… and then the lawsuit happens….scary stuff. It’s different now where we dont care too much about the beta hCG, or whether there is not an IUP, but whether we see anything around the ovary….and even then, very close follow up and rechecks may be considered. Below is the Eurekalert and the AuntMinnie articles on it too:
A panel of 15 medical experts from the fields of radiology, obstetrics-gynecology and emergency medicine, convened by the Society of Radiologists in Ultrasound (SRU), has recommended new criteria for use of ultrasonography in determining when a first trimester pregnancy is nonviable (has no chance of progressing and resulting in a live-born baby). These new diagnostic thresholds, published Oct. 10 in the New England Journal of Medicine, would help to avoid the possibility of physicians causing inadvertent harm to a potentially normal pregnancy.
“When a doctor tells a woman that her pregnancy has no chance of proceeding, he or she should be absolutely certain of being correct. Our recommendations are based on the latest medical knowledge with input from a variety of medical specialties. We urge providers to familiarize themselves with these recommendations and factor them into their clinical decision-making,” said Peter M. Doubilet, MD, PhD, of Brigham and Women’s Hospital and Harvard Medical School in Boston, the report’s lead author.
Among the key points made by the expert panel:
The panel also cautioned physicians against taking any action that could damage an intrauterine pregnancy based on a single blood test, if the ultrasound findings are inconclusive and the woman is in stable condition.
Kurt T. Barnhart, MD, MSCE, an obstetrician-gynecologist at the Perelman School of Medicine at the University of Pennsylvania and a member of the SRU Multispecialty Panel, added, “With improvement in ultrasound technology, we are able to detect and visualize pregnancies at a very early age. These guidelines represent a consensus that will balance the use of ultrasound and the time needed to ensure that an early pregnancy is not falsely diagnosed as nonviable. There should be no rush to diagnose a miscarriage; more time and more information will improve accuracy and hopefully eliminate misdiagnosis.”
Michael Blaivas, MD, an emergency medicine physician affiliated with the University of South Carolina and one of the panelists, emphasized that “These are critical guidelines and will help all physicians involved in the care of the emergency patient. They represent an up-to-date and accurate scientific compass for navigating the pathway between opposing forces felt by the emergency physician and his/her consultants who are concerned about the potential morbidity and mortality of an untreated ectopic pregnancy in a patient who may be lost to follow-up, but yet must ensure the safety of an unrecognized early normal pregnancy.”
Aunt Minnie article :
“In addition, the authors emphasized that the commonly used “discrimination level” of the pregnancy blood test is not reliable for excluding a viable pregnancy. They also cautioned physicians against taking any action that could damage an intrauterine pregnancy based on a single blood test, if the ultrasound findings are inconclusive and the woman is in stable condition.
“The guidelines presented here, if promulgated widely to practitioners in the various specialties involved in the diagnosis and management of problems in early pregnancy, would improve patient care and reduce the risk of inadvertent harm to potentially normal pregnancies,” the authors wrote.
Not stringent enough
Research over the past two to three years has shown that previously accepted criteria for ruling out a viable pregnancy are not stringent enough to avoid false-positive results, but it has been difficult both to disseminate this information to practitioners and to implement standardized protocols.
The challenge is that physicians from multiple specialties — including radiology, obstetrics and gynecology, emergency medicine, and family medicine — are involved in the diagnosis and management of early-pregnancy complications, according to the authors.
“As a result, there is a patchwork of conflicting, often outdated published recommendations and guidelines from professional societies,” they wrote.
To address the problem, SRU in October 2012 organized the Multispecialty Consensus Conference on Early First Trimester Diagnosis of Miscarriage and Exclusion of a Viable Intrauterine Pregnancy. At the conference, researchers reviewed the diagnosis of nonviability in early intrauterine pregnancy of uncertain viability and, separately, in early pregnancy of unknown location. They focused mainly on the initial or only ultrasound study performed during the pregnancy.
The conference participants developed the following guidelines for transvaginal ultrasound diagnosis of pregnancy failure in a woman with an intrauterine pregnancy of uncertain viability.
Findings diagnostic of pregnancy failure:
Findings suspicious for but not diagnostic of pregnancy failure:
Pregnancy of unknown location
The panel also determined diagnostic and management guidelines related to the possibility of a viable intrauterine pregnancy in a woman with a pregnancy of unknown location.
For the finding of no intrauterine fluid collection and normal (or near-normal) adnexa on ultrasonography, the authors provided the following key points:
If ultrasound had not yet been performed, the researchers offered the following key point: “The hCG levels in women with ectopic pregnancies are highly variable, often < 1,000 mIU/mL, and the hCG level does not predict the likelihood of ectopic pregnancy rupture,” they wrote. “Thus, when the clinical findings are suspicious for ectopic pregnancy, transvaginal ultrasonography is indicated even when the hCG level is low.”
Panel member Dr. Kurt Barnhart, an ob/gyn at Perelman School of Medicine at the University of Pennsylvania, said in a statement that the guidelines represent a consensus that will balance the use of ultrasound and the time needed to ensure that an early pregnancy is not falsely diagnosed as nonviable.
“There should be no rush to diagnose a miscarriage; more time and more information will improve accuracy and hopefully eliminate misdiagnosis,” he said in the statement.
By Viveta Lobo, MD and Laleh Gharahbaghian, MD, FACEP
Our latest insert in the ACEP Ultrasound Section newsletter is below – on the FAST scan – the Suprapubic sections. The prior entries was on the FAST scan: The Cardiac views ( go here) and The Upper Quadrants ( go here. ). The ACEP US Section is the go-to site for everything you want to know about starting an US program, credentialing in ultrasound, the policies and politics, and is the home of SonoGuide – an amazing educational resource for bedside ultrasound, and the EMSONO: Ultrasound Test. It is also where we add our entries for their newsletter that goes over tips and tricks, cases, and all things ultrasound in the news. We recently wrote an article for the ACEP Ultrasound Section Newsletter – which is available for all members of the ACEP US Section – and I highly recommend becoming a member – it’s totally worth it.”
It was a TRUE pleasure to record a podcast recently with Dr. Scott Weingart (aka, my hero) on EMCrit (twitter: EMCrit), and writing this article with our newest ultrasound faculty member, Dr. Viveta Lobo, describes some of what was spoken about.
As discussed in our last entry, the FAST exam is undoubtedly the most widely used bedside ultrasound application used in emergency medicine. Its incorporation in the ATLS revised protocol, the RUSH exam, and several other published protocols, makes it an invaluable screening tool for intra abdominal injury causing hemoperitoneum, cardiac injury with pericardial effusion, and unexplained hypotension.(1,2)
We will continue our discussion of the FAST scan by reviewing the pelvis views, and relay some tips and tricks. Refer to the March 2013 Newsletter for our article reviewing tips for scanning the right upper quadrant (RUQ) and left upper quadrants (LUQ), and the June 2013 newsletter for our article reviewing the tips for the cardiac views.
The Suprapubic View
The suprapubic view on the FAST exam is generally the last of the four views performed.
Theoretically, given its dependent anatomical position, one might logically conclude that it should in fact be the most sensitive view to visualize free fluid; unfortunately, the literature has negated this theory – and in fact this can often be the least sensitive view, largely in part of human error, and especially in pelvic fractures.(1,2,4) Anatomically, when we scan the suprapubic area in both transverse and longitudinal planes, there’s a lot that we see –the bladder, bowel, pelvic bones, pelvic organs, and rectum to name a few. This might make it harder for us to visualize free fluid, and separate it out from these other structures. But here’s a few tips to help overcome these limitations. Begin by placing your phased array or curvilinear probe just above the pubic symphysis, aiming inferiorly/caudad into the pelvis.
Tips for the Suprapubic View:
1. Look through a full bladder. A full bladder – The suprapubic view is visualized using a filled bladder as the acoustic window. Not all trauma patients come in with a full bladder and we will not likely go back to the days when a foley catheter used to be placed in order to fill the bladder for visualization. While we are sure our patients appreciate us not doing this anymore – its important to note, that if your patient has an empty bladder, it is best to hydrate them up with the fluids, and repeat the scan when the bladder is more full.(5) With an empty bladder your ability to adequately discern free fluid is very limited. Mostly due to gas scatter from bowel, inadequate depth adjustments, and inability to discern bowel fluid from free fluid. Click Here for a Video of A Normal Female.
2. Adjust your depth – More often than not, when it is time to scan the suprapubic area, your depth is set too deep from scanning the upper quadrants or cardiac views. We often find that a depth of about 13cm to 16cm optimizes your view. The goal is to have your bladder centered on the screen, to easily visualize the areas surrounding the bladder
3. Adjust your gain – The bladder is a fluid filled structure, and as mentioned before, fluid is the “lover” of ultrasound, allowing structures deep to it to be well visualized, however this often creates an artifact called “posterior acoustic enhancement” that produces a hyperechoic and bright area deep to the bladder. This makes it hard to visualize anechoic or black free fluid. One of the biggest pitfalls is not decreasing your gain to accommodate for this, and limiting your ability to pick up anechoic free fluid.
A good rule of thumb, is to ensure that you can easily visualize pelvic organs. If you are able to identify a uterus or a prostate easily, that usually means you have adjusted your gain appropriately. Click Here for a Video of Posterior Acoustic Enhancement.
4. Look everywhere – Unlike in your upper quadrants, free fluid in the pelvic cavity can in fact collect anywhere – anterior, lateral, and posterior to the bladder as well as anterior, lateral, and posterior to the uterus in female patients. This often is dictated by your patient’s position, the lay of the uterus, how full the bladder is, and the size of the prostate to name a few. We suggest looking in four areas –
a. Look anterior and cephalad to the bladder. Click Here for Video of Free Fluid Anterior to the Bladder. This is especially true if the bladder is empty. At times, free fluid will be mistaken for the bladder and thought to be a septated bladder, when in fact it is free fluid cephalad to the bladder. Click Here for Video of Free Fluid Easily Mistaken for Bladder.
b. Look adjacent/lateral to your bladder; free fluid will collect into a “wedge” shape or triangular shape in between bowel folds which will be most evident with appropriate fanning through the region. Click Here for Video of Wedge of Free Fluid.
c. Look deep/posterior to the bladder between it and your pelvic organs. Click Here for Free Fluid Posterior to the Bladder. Especially in females, you can see a collection of free fluid between the bladder and the uterus. This often looks like boxed shaped anechoic structures that as you fan through will appreciate it not being a “contained” structure.
d. Look posterior to your pelvic organs. Free fluid can collect deep to your uterus or prostate. Click Here for Video of Free Fluid Posterior to the Uterus.
5. Seminal vesicles are also anechoic/black – In males, don’t be fooled by the seminal vesicles. These lie immediately posterior to the bladder, and often appear like a anechoic “bow-tie” shape, with contained fluid and equal on each side.
They will always appear in the same location, and you should fan slowly and carefully through the region to ensure that this is a contained structure and not mistake it for free fluid.
6. Physiological free fluid in females – In menstruating females you can appreciate some physiological free fluid that may be normal. This is hard to differentiate truly from traumatic free fluid, and you will need to consider the clinical picture – Is there any abdominal pain? Is there abdominal or pelvic trauma? Are her vital signs abnormal? Also, the amount and location of free fluid can help – physiological free fluid is found deep to the uterus, and along its border – it should not be greater than 1/3 the length of the border, anything greater than 1/3 should be considered pathological.
7. Fan slowly – While fanning is always important in evaluating any region by ultrasound – we cannot stress it enough when evaluating the suprapubic area. It is impressive and often surprising just how much free fluid can “hide” behind and around the many structures present in this region, and not be visualized unless you dedicatedly fan through the area. It is strongly encouraged to view the suprapubic area in 2 planes – horizontally and longitudinally and fan through each section slowly to make sure you don’t miss any free fluid!(3)
8. Quick Pregnancy Test– In female patients of reproductive age, while performing the pelvic view, take a quick look inside the uterus. You just may quickly get your answer to whether she is pregnant or not but visualizing a gestational sac with fetal pole or yolks sac. However, if you only see a gestational sac and you are performing a FAST scan for unexplained hypotension or shock, this could be an identifier for a pseudosac of an ectopic pregnancy.
Look out for the next and last entry on the FAST scan – the Lung Views in the next newsletter.
References
In the study published in feb 2014 on ambulatory patients and those with prior heart failure, an obvious indirect message is given: do bedside US in ambulatory patients and you will be able to identify disease processes for which your exam or chest Xray may have limited value. Another message is how the heart relates to the presence of B lines on Lung US. This is correlating to another study that compared lung US to BNP value, cliical assessment and echo.
For a quick review of what B lines look like – see below: Using the phased array or curvilinear probe, place the probe over 8 different zones of the chest wall (4 on each side – 2 anterior and 2 lateral) and if you see these bright “rockets” coming down from the pleural line to the end of the screen when you are at 16cm depth, that is a B line. More than 2 B lines in more than 2 zones, bilaterally, from a thin pleural line is consistent with pulmonary edema. Using your cardiac echo to confirm contractility issues helps confirm the findings. To see more of the tutorial, go here.
See the abstract below:
“Lung ultrasound (LUS) represents a novel, noninvasive method in the assessment of extravascular lung water. We investigated the utility of LUS in ambulatory subjects with dyspnea or prior heart failure (HF).
We studied 81 ambulatory subjects with HF history or dyspnea who underwent transthoracic echocardiography (TTE) with LUS of 8 zones. Subjects with heart transplantation or pulmonary conditions known to interfere with LUS were excluded. A reviewer blinded to the clinical data performed echocardiographic measurements and quantified B-lines (reverberation artifacts arising from the pleural line).
Of 81 subjects, 74 (91%) (median age 66 years, 39% men, median left ventricular ejection fraction [LVEF] 54%, 39% with prior HF) had adequate LUS images of all 8 zones and were included in the analysis. The number of B-lines ranged from 0-12 (median 2). Increased B-lines, analyzed by tertiles, were associated with larger left ventricular (LV) end-diastolic (P = 0.036) and end-systolic diameters (P = 0.026), septal wall thickness (P = 0.009), LV mass index (P = 0.001), left atrial (LA) volume index (P = 0.005), tricuspid regurgitation (TR) velocity (P = 0.005) and estimated pulmonary artery systolic pressure (PASP) (P = 0.003). In a secondary analysis associations between B-lines (not grouped by tertiles) and LV mass index, LA volume index, TR velocity and PASP remained stable after adjustment for age, gender, BMI and HF history.
Sonographic B-lines from LUS are related to measures of LV and LA structure and right ventricular pressure in ambulatory patients with dyspnea or prior HF. The added clinical and prognostic utility of this imaging modality in ambulatory patients warrants further investigation.”
SonoSpot: Topics in Bedside Ultrasound 