When assessing patients with difficult peripheral venous access it is often helpful to look in the medial upper arm. Here, the brachial artery (A) and veins (V) are predictably located between the biceps and brachialis muscles. The median nerve (N) resides there as well.
Here’s a plate from Grey’s Anatomy for some perspective:
So how can you tell which is which? Apply pressure slowly and watch for movement.
- The veins will collapse
- The artery will pulsate
- The nerve will do nothing
Lots of inspiring speakers at today’s academic retreat. I had ten minutes to give my opinion on how to give a great talk, and referred to a few great books to help:
My opinion? Craft a powerful message and find the best tools at your disposal to convey it. Easy!
Bret Nelson and Felipe Teran took part in an incredible conference just outside of Stockholm, Sweden. Over one hundred participants and twenty faculty attended this sold-out conference at the Hasseludden Yasuragi Japanese spa . Among the luminaries were Matt Dawson and Mike Mallin (from the Ultrasound Podcast), lung ultrasound queen Vicki Noble, Mike Lambert and Joe Wood (directors of the first ultrasound program in the United States), and many, many others.
Videos from the conference are available here. Besides excellent lectures, there were hands-on sessions recorded. An incredible amount of practical information is conveyed during these hands-on sessions, so it is worth checking out some of these videos as well as the lectures. Bret Nelson’s session on aorta scanning is here,
Felipe Teran and Bret Nelson
Matt Dawson and Mike Mallin
Organizer Christofer Muhr welcomes participants
Participant getting a bit of light reading done on the flight to Stockholm
The Mount SinaiÂ DepartmentÂ of Emergency Medicine hosted its annual ultrasound CME conference on April 25.Â Faculty, fellows, nurses and PAs from a number of institutions and specialties took part in our tenth annualÂ course.
The course was directed by Bret Nelson, MD who introducedÂ ultrasound physics and machine controls, followed by lectures on assessment ofÂ airway and breathing (Jim Tsung, MD, MPH), cardiovascular ultrasoundÂ (JenniferÂ Huang, DO), trauma evaluationÂ (Phil Andrus, MD) and procedure guidance (Amy Sanghvi, MD).
After lunch an intensive hands-on session with live models, task simulators and sim cases rounded out the experience.
Spectacular rounds this week lead by Sahar Ahmad of Stonybrook and hosted by Pierre at BI.
Sahar gave a great presentation on her didactic program for the critical care fellows at Stonybrook. Â She then presented a series of discussion inducing cases. Â Carl Kaplan (of Stonybrook not RUSH) presented an interesting case of ONSD ultrasound for hydrocephalus. Â Sam Parnia gave a presentation on the cardiopulmonary resuscitation research being done at Stonybrook on cerebral oximetry.
Some of the articles (with pmid and link) that came up in discussion were:
- The Lung US Consensus Recommendations:Â 22392031
- Copetti ARDS vs Pulmonary Edema:Â 18442425
- NASA MRI Optic Nerve sheath: 22416248
- Louis Eisen Optic Nerve sheath: 21519957
- Flawed Pediatric Optic nerve sheath article 19167786Â
- re “reverse” FALLS protocol – Vicki Noble’s on bline resolution at dialysisÂ 19188552
See you next time.
More lung ultrasound tips and examples from Drs. Jim Tsung and Brittany Pardue Jones!
Bacterial pneumonia will manifest as lung consolidation with air bronchograms. The A-lineÂ patternÂ of normal lung will begin to be replaced by B-lines in the area ofÂ affectedÂ lung:
Here we’ve highlighted the consolidation from the above video as well:
In contrast, subpleural consolidations and confluent B-lines are more suggestive ofÂ viral pneumonia.
So what do these look like?
andÂ anotherÂ example:
occur when multiple B-lines coalesce. In contrast, theÂ next example demonstrates multiple discrete B-lines.
And now for something completely different
Z-Lines:Â Comet tails thatÂ arise from the pleural lineÂ but DO NOT make it to the bottom of the ultrasound screen. These are not B-lines. These artifacts have not been associated with any pathology, and they do not obliterate A-lines.
For more details on the sonographic appearance of viral lung pathology, check out this article by Jim Tsung.
Counter-intuitively, when insonating the lungs of healthy patients, we donâ€™t â€œseeâ€ lung tissue. Instead we see and interpret artifacts arising from the pleural lines and the diaphragm. Â These artifacts change with pulmonary disease processes. Â In pneumonia, the airway spaces become inspissated with bacterial byproducts and consequently the sonographic appearance of lung tissue changes.
The transformation of lung tissue is termed hepatization: the lung tissue now appears similar to liver tissue.
This can be confusing in the lower lung fields, especially adjacent to the diaphragm because we use the mirror image artifact of the liver and spleen to indicate that lung tissue is normal. This mirrored, artifactual splenic or liver appearance could then be called pseudo-hepatization.
So, how do we differentiate hepatized lung versus pseudo-hepatized lung?
- Never use a single image for your diagnosis, scan through area and convince yourself (then save a representative image or clip for QA).
- Be systematic and scan down from the lung apices to the diaphragm.
- Hunt for the diaphragm and use it as a dividing line between the lung and the abdominal organs.
- Hepatized lung will often have a rim of fluid around it.
Image 1: Normal lung with visible diaphragm
Ultrasound of lung and spleen from Sinai EM Ultrasound on Vimeo.
Image 2: Normal lung with obscured diaphragm
Lung and Spleen Interface on ultrasound from Sinai EM Ultrasound on Vimeo.
Image 3: Hepatized lung at the lower lung field