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50EMT ?
1. 2. 3. 4.
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Patient position
Ultrasound areas
4 stages
1. anterior 2. lateral 3. portion of posterior 4. posterior
4 stages
1. anterior 2. lateral 3. portion of posterior 4. posterior
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Earth-Sky Axis
Fluids want to descent, gases to rise. Lung disorders
Dependent: PLE, consolidation, . Non-dependent: PTX, interstitial syndrome, .
Ultrasound pattern
A lines & Lung sliding (-) A lines & Lung sliding (+) B3 lines Hepatization & air bronchograms (++) Hepatization & air bronchograms (-) Anechoic collection
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?
1. 2. 3. 4.
Interstitial syndrome
?
1. 2. 3. 4. Bat sign A line B line C line
M?
1. 2. 3. 4. Bat sign Lung rocket Shred sign C line
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Rib
Interstitialline B syndrome
Comet-tail artifact
C line
1. 2. 3. 4.
Pneumothorax
1. 2. 3. 4.
Pleural Effusion
1. Anechoic pattern 2. Static: Sharp sign 3. Dynamic: Sinusoid sign
Discrepant results
transudate exudate pleural effusion ?
1. 2. 3. 4. Fibrin Septation Echogenic fluid Anechoic fluid
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48M, thrombocytopenia
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Pneumothorax
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1. 2. 3. 4. McConnellss sign Lung point Comet-tail artifact Lung pulse
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1. 2. 3. 4. lung sliding comet-tail artifact lung point lung pulse
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Normal dynamic lung pattern Lung sliding: all-or-nothing rule Seashore sign
Setting: MICU Patients: Intervention: supine analysis of anterior chest wall Results:
Feasibility Sensitivity Specificity NPV 98.1% 95.3% 91.1% 100% PTX: 43 Control: 68
Pneumothorax
Lung point
Pneumothorax
Lichtenstein DA, et al. Inten Care Med 2000;26:1434-1440
Lung point
Pneumothorax
Lichtenstein DA, et al. Inten Care Med 2000;26:1434-1440
Pneumothorax Control Group 43 of 43 65 of 302 41 of 43 16 of 302 34 of 43 0 of 302 Sensitivity, % Specificity, % 100 78 95 94 79 100
Lichtenstein DA, et al. CCM 2005;33:1231-1238
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Pneumothorax
1. Lung point(s) (+) 2. Lung sliding (-) 3. B-lines (-) 4. Lung pulse (-)
Interstitial Syndrome
3 B-lines in a longitudinal plane between 2 ribs Thickening of interlobular septa (B7 lines) Ground-glass areas (B3 lines)
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B versus b line
Lung rockets
B-line
Rule out pneumothorax Indicate interstitial syndrome D/D APE & COPD with AE (Sen 100%/Spe 92%)
Positive exam:
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: Comet-tail artifacts
lung edema?
B-line
Z-line
Comet-tail artifact
E-line
Parietal emphysema
73
74
75
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77
Aurora sign
Be careful
81
82
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Alveolar Consolidation
98.5% of cases abut the pleura Sensitivity 90%/ Specificity 98%
C line
Locate in the thorax Arise from the pleural line or associated PLE Tissue-like pattern Static
Irregular deep boundary
Alveolar consolidation
Air bronchogram
Dynamic
pneumonia
Static
Atelectasis Lung pulse
Dynamic
Absence of any sinusoidal component
Lichtenstein D. A., Mezire G. A. Chest 2008;134:117-125 PLAPS: PosteroLateral Alveolar and/or Pleural Syndrome
2008 by American College of Chest Physicians
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Ultrasound profiles
Normal PV demo
Combined Results
Normal Profile, and A Profile Without PLAPS 0 751 109 1 3
B Profile 621 3 0 0 6
B Profile 0 0 0 0 9
C Profile 0 1 10 0 18 0 0 0 0
A/B Profile 0 0 0 8 0
Lung Point
Pulmonary embolism
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89 (74/83)
97 (172/177)
93 (74/79)
95 (172/181)
81 (17/21)
99 (238/239)
94 (17/18)
98 (238/242)
Pneumothorax Pneumonia
88 (8/9)
100 (251/251)
100 (8/8)
99 (251/252)
11 (9/83) Predominant anterior B+ lines on one side, predominant anterior A lines on the other (A/B profile)
100 (177/177)
100 (9/9)
70 (177/251)
14.5 (12/83) Anterior alveolar consolidation (C profile) A profile plus PLAPS A profile plus PLAPS, B, A/B or C profile
Lichtenstein D. A., Mezire G. A. Chest 2008;134:117-125 BLUE: Bedside Lung Ultrasound in Emergency
2008 by American College of Chest Physicians
Airway Control
Tracheal rapid ultrasound exam (T.R.U.E.) for confirming ET placement during emergency intubation Chou HC, el. Resuscitation 2011 Ultrasonographic lung sliding sign in confirming proper endotracheal intubation during emergency Intubation Sim SS. el. Resuscitation 2012
Others
Comet-tail artifact
E-line
Parietal emphysema
Sternal fracture
Rib fracture
Lung Contusion
Pulmonary embolism
Chest. 2005;128:1531-1538
Clinical consideration
Lung US: answer to the traditional quandary of radiography or CT in the ICU Approach to a dyspneic patient A field to be defined: For whom ? A field to be defined: By whom ? Lung US: a space for simplicity Versatility: an access to the neighboring organs Hamlessness, Cost savings Limitations of lung US Training in lung US
Clinical applications
Pleural effusion Pneumothorax Interstitial syndrome Alveolar consolidation Airway control Others
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