Tag Archives: ultrasound

LUQ oblique probe orientation

Improving left upper quadrant view

Many clinicians are challenged when 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

Left renal ultrasound probe position

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.

Rib shadows obscure view of spleen

Rotate the probe slightly towards the patient’s back so the probe is slightly more parallel to the ribs. Do not go fully transverse.
LUQ oblique probe orientation

This exposes more of the probe to the interspace, yielding a larger window through which to view the spleen.
Spleen in the left upper quadrant window

For more tips on viewing the spleen, check out this post.

What The Heck 1

This patient presented with right upper quadrant abdominal pain. There was RUQ tenderness on exam, but no fever, rebound or Murphy sign. A point-of-care ultrasound was performed to assess for signs of cholecystitis and the following image was obtained. This prompted the operator to ask, “What the heck?”

Gallbladder
What structures are visible here? How could you differentiate them? More after the break!

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Ultrasound Zen

ZenStone To image something which moves, you must remain still. To image something which is still, you must move.

If you think on this long enough, the point is self-evident and requires no explanation. Or, just see some examples below.

We are pretty well adapted to seeing three dimensions at a time. Thus when imaging a moving structure like the heart, we hold the probe in a fixed position to obtain standard views. This allows us to focus on the movement, and cardiac presets optimize temporal resolution at the expense of spatial resolution. We are then seeing two spatial dimensions and one temporal dimension (heart moving in time).

D Shaped Left Ventricle from Sinai EM Ultrasound on Vimeo.

It is very difficult to appreciate the anatomy and function of the heart, for example,  when the probe is moving.

In contrast, imaging the right upper quadrant for fluid in Morison’s pouch requires a slow fan through the liver, diaphragm, and kidney. This allows us to appreciate the entire potential space where fluid can collect. Abdominal imaging is optimized for spatial resolution at the expense of temporal resolution, so be sure to move the probe slowly. Fanning through the entire structure of interest will often reveal pathology which was missed with a single-plane scan. Small gallstones, small amounts of peritoneal or pleural fluid, saccular aneurysms, and other maladies can fool a novice sonographer who isn’t thorough. In this case we are seeing three spatial dimensions.

FAST1 RUQ pos from Sinai EM Ultrasound on Vimeo.

So, keep your audience in mind when you are creating scans. Should you fan through the static anatomy, or let the movement of the structures speak for themselves?

Physical exam

Is ultrasound the stethoscope of the future? Is it an extension of the physical examination? Will it replace the physical exam?

No.

Point-of-care ultrasound is a diagnostic test. It is a rapid, bedside, noninvasive, accurate, diagnostic test, but still a diagnostic test. It can certainly augment data obtained through physical examination and medical interviews, and adds to information obtained by blood assays and radiology studies.

It is performed using FDA-approved medical devices by clinicians with specialized training. Images used for medical decision-making may be archived and shared with colleagues from multiple specialties. Quality assurance programs improve clinician accuracy and accountability. These are not physical examination characteristics. These are qualities of good diagnostic tests.

There is and will continue to be debate about this issue. Whether we think about point-of-care ultrasound as a diagnostic test or part of the physical examination has ramifications for training, documentation, archiving, and billing.

We recommend checking the guidelines relevant to your specialty and making up your own mind on this issue. In either camp some things remain constant: train well and use ultrasound to enhance the care you provide your patients.

 

Ultrasound Awareness Month

As a part of Ultrasound Awareness Month we’d like to let providers of all levels know about membership opportunities with national and international organizations.

They offer an enormous amount of information for providers at all levels; from the first time Sonographer to the Ultrasound Director and offer forums and support for all your Ultrasound-related endeavors.

Please visit the following websites for more information and/or follow them on twitter to interact with them in real time. We have included links to student, resident, or fellow membership options where applicable. Be sure to check out special rates, courses, and benefits in all of these organizations designed tom promote inclusion of providers at all levels!

ACEP US Section (US Section President @GeriaSonoMD)

SAEM US Academy (@SAEMAEUS)

AIUM (@AIUM_Ultrasound)

Winfocus (@Winfocus)

Society of Ultrasound in Medical Education (@SUSMEORG)

And of course…SinaiEM.US (@SinaiEMUS)

Ultrasound education at MSSM

The Mount Sinai School of Medicine recently welcomed its incoming first-year class in its traditional White Coat Ceremony. In a day filled with inspirational talks by prominent faculty and medical leaders, students don their new white coats and receive a stethoscope at a special ceremony attended by family, friends and faculty members.

This year, Sinai’s medical students were also introduced to a new curriculum in point-of-care ultrasound:

“First-year medical students traditionally learn about the human body by dissecting the cadavers and eventually by examining the patients, and the examination ranges from inspection and palpation to listening with the help of a stethoscope and interpreting the sounds of the heart, lungs and blood vessels,” says Jagat Narula, MD, PhD, who is the principal investigator of this research study and the director of the cardiovascular imaging program at Mount Sinai School of Medicine. “With handheld ultrasound, our medical students will have the ability to see live images of inside the body projected onto a handheld screen in real time.  It’s an innovative educational concept that can modernize medical education.”

As part of an educational research study, GE Vscan ultrasound machines will be distributed to groups of medical students who will learn to use the technology to image the heart, lungs, and abdomen. Mount Sinai is the first school in New York to initiate such a curriculum.

David Muller, MD, dean of medical education at Mount Sinai School of Medicine, says of the research study, “First-year medical students will learn how to identify and assess the anatomical structures within cardiac, thoracic and abdominal applications. We are excited to incorporate the portable ultrasound in our curriculum as we strive to revolutionize the way medicine is taught.”

The curriculum will augment what is being taught in the Art and Science of Medicine course, which is the students’ introduction to physical examination.

Bret Nelson, MD, RDMS, FACEP, associate professor and director of emergency ultrasound in the department of emergency medicine at Mount Sinai, will be leading the new curriculum with Dr. Narula. Says Dr. Nelson, “Point-of-care ultrasound represents a distinct skill set beyond physical examination. Te increased penetration of sonography through a variety of clinical practice environments means students will need to understand this technology to excel in patient care through their careers.”

FROM LEFT: Jagat Narula, MD, PhD; David Muller, MD; Mike Harsh, Vice President and Chief Technology Officer, GE Healthcare; Dennis S. Charney, MD, Anne and Joel Ehrenkranz Dean, Mount Sinai School of Medicine and Executive Vice President for Academic Affairs, The Mount Sinai Medical Center; Tom Gentile, President and Chief Executive Officer, GE Healthcare; Bret Nelson, MD; and Lisa Kennedy, Director, Strategic Marketing, healthmagination

“Today, we are thrilled to play a part in this important research project by providing Mount Sinai’s first-year medical students with the power of portable ultrasound technology, as they take the first step towards becoming our next generation of doctors,” says Tom Gentile, president and CEO of GE Healthcare Systems. “Tools like Vscan have the ability to help transform the physical exam and today’s announcement reaffirms GE Healthcare’s commitment to research and improving patient care by helping enhance the physician’s ability to quickly and accurately diagnose patients.”

For the full story, please check out the October 1 edition of Inside Mount Sinai.

Ovarian Torsion

Although we tend to suspect torsion only in cases where there is ovarian enlargement, cyst, etc., there are a number of studies that show these are not reliable (sensitive or specific) indicators of torsion. Radiology reports often seem to hedge and note that ovarian torsion is a clinical diagnosis because the test characteristics of ultrasound are not that great even when you include flow, adnexal size, free fluid, and other factors in combination.

Children (<15 years old) are at greater risk of torsing normal ovaries (up to 50% of torsion cases), but even in women of childbearing age 8-19% of cases are associated with normal ovaries. Doppler flow has demonstrated great sensitivity and specificity for torsion by some authors but was much less valuable in this retrospective study.

In this recent study, abnormal ovarian location, abnormal flow and free fluid were the best predictors of torsion; ovarian mass or cyst actually didn’t help rule in or out the diagnosis.

Bottom line: normal ovaries do not rule out torsion. Doppler flow may not be sensitive or specific enough either. So use (dare we say it?) clinical judgement.