Category Archives: education

Brachial veins

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.

NAV-labelsHere’s a plate from Grey’s Anatomy for some perspective:

image413

So how can you tell which is which? Apply pressure slowly and watch for movement.

  1. The veins will collapse
  2. The artery will pulsate
  3. The nerve will do nothing

Brachial vv art median nerve

Organizer Christofer Muhr welcomes participants

SonoSweden 2015

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,

CME-Jim-group

2014 Emergency and Critical Care Ultrasound CME Course

The Mount Sinai Department of Emergency Medicine hosted its annual ultrasound CME conference on April 25. Faculty, fellows, nurses and PAs from a number of institutions and specialties took part in our tenth annual course.

The course was directed by Bret Nelson, MD who introduced ultrasound physics and machine controls, followed by lectures on assessment of  airway and breathing (Jim Tsung, MD, MPH), cardiovascular ultrasound (Jennifer Huang, DO), trauma evaluation (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.

January 23rd NYC RESUS Rounds

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.  She then presented a series of discussion inducing cases.  Carl Kaplan (of Stonybrook not RUSH) presented an interesting case of ONSD ultrasound for hydrocephalus.  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: 22392031
  • Copetti ARDS vs Pulmonary Edema: 18442425
  • NASA MRI Optic Nerve sheath: 22416248
  • Louis Eisen Optic Nerve sheath: 21519957
  • Flawed Pediatric Optic nerve sheath article 19167786 
  • re “reverse” FALLS protocol – Vicki Noble’s on bline resolution at dialysis 19188552

See you next time.

Lung ultrasound goes viral for flu season

Z-linesMore 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-line pattern of normal lung will begin to be replaced by B-lines in the area of affected lung:

Here we’ve highlighted the consolidation from the above video as well:

Pneumonia

In contrast, subpleural consolidations and confluent B-lines are more suggestive of viral pneumonia.
So what do these look like?

Subpleural consolidation:

and another example:

Confluent B-Lines:

occur when multiple B-lines coalesce. In contrast, the next example demonstrates multiple discrete B-lines.

Multiple B-Lines:

And now for something completely different

Z-Lines:  Comet tails that arise from the pleural line 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.

Hepatization versus Pseudo-Hepatization

Counter-intuitively, when insonating the lungs of healthy patients, we don’t “see” lung tissue. Instead we see and interpret artifacts arising from the pleural lines and the diaphragm.  These artifacts change with pulmonary disease processes.  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?

  1. Never use a single image for your diagnosis, scan through area and convince yourself (then save a representative image or clip for QA).
  2. Be systematic and scan down from the lung apices to the diaphragm.
  3. Hunt for the diaphragm and use it as a dividing line between the lung and the abdominal organs.
  4. 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