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.
Many clinicians are challenged whenÂ evaluating patients for perisplenic fluid as part of the FAST or RUSH examination. Here are some common problems and how to fix them.
Fix probe location
Make sure you are holding the probe in a longitudinal view, probe marker towards the patient’s head. Place the probe just above the costal margin, in the posterior axillary line. The knuckles of your probe hand should be touching the stretcher
Start too high (too cephalad)
Starting with the very posterior probe position described above, slide towards the patient’s head until you clearly see pleura and rib shadows. Once you’ve established clear evidence you are over the thorax, slide the probe toward the patient’s feet along the same posterior axillary line until the pleura ends. Now you have found the diaphragm! Scan just caudal to the end of the pleura and you should see the diaphragm and spleen.
Another way to simplify this- If you see pleura, slide towards the feet. If you see bowel gas (or “nothing”), slide towards the head.
Use a slightly oblique approach
When rib shadows obscure the view, use the “sonographic rib spreader” technique.
Rotate the probe slightly towards the patient’s back so the probe is slightly more parallel to the ribs. Do not go fully transverse.
This exposes more of the probe to the interspace, yielding a larger window through which to view the spleen.
For more tips on viewing the spleen, check out this post.
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,
The Third Annual World Congress on Ultrasound in Medical Education was hosted at the Oregon Health and Science University in Portland. Co-sponsored by SUSME and WINFOCUS, the conference highlights research and innovation in ultrasound for education. Over 500 students, residents, and educators from all specialties around the world were in attendance.
Bret Nelson presented research on Mount Sinai’s experience with an integrated ultrasound curriculum for medical students.Â Scores of other schools described their experiences as well, including South Carolina, UC Irvine, Wayne State, Ohio State, A.T. Still University, and many more.
An incredibly passionate and eloquent group of medical students really made this congress special. They were integral to many hands-on training sessions, described research on ultrasound education throughout the U.S. and abroad, and gave plenary talks on the impact of ultrasound on their educational experience.
Thought leaders from around the globe shared their experiences in education and inspired attendees to return to their own institutions and build their own programs. The Ultrasound Podcast guys, Mike Mallin and Matt Dawson, hosted an Ultrasound World Cup whose production values rivaled any televised sporting event.