Introduction to ultrasound in emergency department

A&E medical meeting

28/07/2011
Dr. David Tran
(Source: Ultrasound
guide for emergency physician, Beatrice Hoffmann)

www.sonoguide.com

History of ultrasound in medicine

The first application of ultrasound as a medical diagnostic tool was published in 1942 by Karl and Friederich Dussik in Vienna The Austrian brothers attempted to locate brain tumors and the cerebral ventricles by measuring ultrasound transmission through the skull. They concluded that if imaging of the ventricles was possible, the interior of the human body could also be visualized using ultrasound. This marked the beginning of diagnostic ultrasonography in the medical field

Evolution of ultrasound in emergency medicine

The portability of real-time bedside diagnosis has made ultrasound an attractive tool for emergency medicine. More and more emergency physicians have made bedside sonography part of their clinical practice and research activities Implementing this diagnostic test into our daily practice can reduce morbidity and mortality for many medical and surgical emergencies. In addition, emergency ultrasound education has become part of our specialty training

Efficiency and cost-effectiveness

Increased efficiency and cost-effectiveness in the evaluation of the blunt abdominal trauma patient with the use of ultrasound. Arrillaga A, Graham R, York JW, Miller RS. (Am. Surg. 1999, Jan) Over a 9-month period, 331 patients suspected of sustaining blunt abdominal trauma were evaluated at a Level I trauma center by US, CT, and/or DPL. Cost data and time to disposition were determined for analysis. The sensitivity, specificity, and accuracy of US were similar to those reported in previous studies. There was a significant difference in time to disposition with the US group being significantly lower (P = 0.001). The total procedural cost was 2.8 times greater for the CT/DPL group than for the US group. US is not only effective in diagnosing blunt abdominal trauma, but it is also more efficient and cost-effective than is CT/DPL

Basic ultrasound physics

Sound is a mechanical wave, which requires a medium in which to travel. It is a series of pressure waves propagating through a medium. One cycle of the acoustic wave is composed of a complete positive and negative pressure change. The wavelength is the distance traveled during one cycle, the frequency of the wave is measured in cycles per second or Hertz (Cycles/s, Hz).

Speed propagation in differents medium (tissues)

The speed with which an acoustic wave travels through a medium is determined by the density and stiffness of the medium. The greater the stiffness, the faster the wave will travel. This means that sound waves travel faster in solids than liquids or gases. Acoustic waves are calculated to travel through human tissue at body temperature at approximately 1540 m/s (about one mile per second).

Effects between the unhomogeneos border of two different mediums

When traveling through a medium the sound waves' intensity and amplitude decreases. This is called 'attenuation' and is the reason why echoes from deeper structures are weaker than echoes from superficial areas. The major cause of attenuation in soft tissue is absorption, Other mechanisms are reflection, refraction and scatter.

Artifacts in ultrasound: Shadowing

Shadowing: This artifact is caused by partial or total reflection or absorption of the sound energy. A much weaker signal returns from behind a strong reflector (air) or sound-absorbing structure (gallstone, kidney stone, bone).

Posterior enhancement

Posterior Enhancement: In posterior enhancement, the area behind an echoweak or echo-free structure appears brighter (more echogenic) than its surrounding structures. This occurs because neighboring signals had to pass through more attenuating structures and return with weaker echoes

Edge Shadowing

Edge Shadowing: The lateral edge shadow is a thin acoustic shadow that appears behind edges of cystic structures. Sound waves encountering a cystic wall or a curved surface at a tangential angle are scattered and refracted, leading to energy loss and the formation of a shadow

Reverberation

Reverberation: Reverberation occurs when sound encounters two highly reflective layers. The sound is bounced back and forth between the two layers before traveling back. The probe will detect a prolonged traveling time and assume a longer traveling distance and display additional reverberated images in a deeper tissue layer

Different probes (transducers)

Large Convex Probe: Main ED utilization is transabdominal sonography.

Sector Probe: Sector probes are utilized especially for transthoracic sonography. Linear Probe: Main utilization is vascular sonography or evaluation of superficial soft tissue structures.

Ultrasound vocabulary

Anechoic - Complete absence of returning sound waves, area is black.

Hypoechoic - Structure has very few echoes and

appears darker than surrounding tissue.

Hyperechoic / Echogenic - Opposite of hypoechoic,

structure appears brighter than surrounding tissue.

Position of the probe

Axial Plane - Separates the superior from the inferior, or, the head from the feet. Sagittal Plane - Oriented perpendicular to the ground, separating left from right. The "midsagittal plane" is a sagittal plane that is exactly in the middle of the body. Coronal Plane - Also known as the frontal plane, separates the anterior from the posterior or the front from the back. Oblique Plane - The probe is oriented neither parallel to, nor at right angles from, coronal, sagittal or transverse planes.

Longitudinal Plane - The longitudinal plane is perpendicular to the transverse plane an can be either the coronal plane or sagittal plane.

FAST: Focused Assessment with Sonographic in Trauma patients

Many trauma patients have injuries that are not apparent on the initial physical exam. Patients can present with distracting injuries or altered mental status. Significant bleeding into the peritoneal, pleural, or pericardial spaces may occur without obvious warning signs. The purpose of bedside ultrasound in trauma is to rapidly identify free fluid (usually blood) in the peritoneal, pericardial, or pleural spaces.
Recently, research studies have shown that bedside ultrasound is equivalent to, or better than, chest radiography for identifying a hemothorax or pneumothorax in trauma patients. For this reason some trauma centers have begun performing an extended FAST exam (EFAST), evaluating for pneumo- and hemothorax in addition to intraperitoneal injuries

Concept of FAST
The concept behind the FAST exam is that many lifethreatening injuries cause bleeding. Although ultrasound is not 100% sensitive for identifying all bleeding, it is nearly perfect for recognizing intraperitoneal bleeding in hypotensive patients who need an emergent laparotomy and for diagnosing cardiac injuries from penetrating trauma

four transducer positions (1) pericardial area (2) right upper quadrant (3) left upper quadrant (4) pelvis.

It is important to recognize the imperfect nature of such exams, but sonographers who master this challenge, will find it an invaluable tool in the care of trauma patients.

Right coronal view

Right Coronal and Intercostal Oblique Views: The easiest abdominal view to obtain is the view of Morisons pouch. To obtain this view place the probe in the mid-axillary line at about the 8th to 11th intercostal space with the marker-dot pointed cephalad (Figure 4). This gives a coronal view of the interface between the liver and kidney

Fluid in Morisons pouch

Free fluid is usually seen in Morisons pouch or along the lower edge of the liver and around the lower tip of the liver Rib shadows may be prominent when the marker-dot is pointed directly cephalad. Shadows can be minimized by rotating the probe very slightly counterclockwise, so the marker-dot is pointed toward the posterior axilla and giving an intercostal oblique view.

Left upper quadrant

Place the probe in the posterioraxillary line at about the 6th to 9th intercostal space with the marker-dot pointed cephalad, producing a coronal view. From this position the interface between the spleen and left kidney can be found. Free fluid is rarely seen between the spleen and the kidney but rather surrounding all other parts of the spleen or between spleen and diaphragm.
To get rid of rib shadows, and to get a better view of the spleen, slide the probe cephalad and rotate it very slightly clockwise, producing an intercostal oblique view, so that the spleen (not the kidney) is seen

Pelvis view

Since the pelvis is the most dependent part of the peritoneal space, it is the most likely place to see abdominal free fluid. It is easy to obtain both longitudinal and transverse views of the pelvis. If the longitudinal view is performed first, it is often easier to understand the anatomy and obtain good images. Place the probe in the midline just cephalad to the pubic bone with the marker-dot pointed cephalad.

Normal longitudinal view of bladder and uterus

Fluid in the Douglas Pouch (male)

In a male, the Douglas pouch is just behind the bladder. Blood can be seen just posterior to the bladder. If the bladder is empty, it is very difficult to recognize pelvic free fluid in a male. In a female, the pouch of Douglas may still be identifiable, even when the bladder is empty.

Fluid in the Douglas pouch (female)

In a female, the body of the uterus sits in the intraperitoneal space just posterior to the bladder, so free fluid will be seen just posterior to the uterus. This space is often called the pouch of Douglas and sometimes just small amounts can be detected.
Free fluid may also be seen completely surrounding the edges of the uterus.

Litterature review about FAST

Arrillaga A, Graham R, York JW, Miller RS. Increased efficiency and costeffectiveness in the evaluation of the blunt abdominal trauma patient with the use of ultrasound. The American Surgeon 1999; 65:31-5. Boulanger BR, McLellan BA, Brenneman FD, Ochoa J, Kirkpatrick AW. Prospective evidence of the superiority of a sonography-based algorithm in the assessment of blunt abdominal injury. Journal of Trauma 1999; 47:632-7. Melniker LA, Leibner E, McKenney MG, Lopez P, Briggs WM, Mancuso CA. al. Randomized controlled clinical trial of point-of-care, limited ultrasonography in the emergency department: the First Sonography Outcomes Assessment Program Trial. Academic Emergency Medicine 2006; 48:227-35.

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