Emergent Ultrasound Procedures Flashcards
What problems are the reasons people frequently visit the ER?
- gastrointestinal
- genitourinary
- respiratory
- nervous
- cardiac systems
- ortho conditions
- lacerations
- fractures
What is a “FAST” scan?
- focused assessment with sonography for trauma
- has become an extension of the physical examination of the trauma patient
- limited exam of abdomen or pelvis to evaluate free fluid or pericardial fluid
What does a FAST scan evaluate for?
-the abdomen or pelvis for free fluid or pericardial fluid
How is the FAST exam a decision-making tool?
-in the context of traumatic injury, the timely diagnosis of life-threatening hemorrhage found during this exam helps determine the transfer to the operating room, CT scanner, or angiography
What spaces are assessed in a FAST exam?
- perihepatic/hepatorenal space
- perisplenic
- pelvis–cul-de-sac
- pericardium
Where does fluid collect?
in the most dependable areas of the abdomen and pelvis
How long does the FAST exam usually take?
-about 5 min
What is performed simultaneously with the FAST exam?
-physical assessment, resuscitation, and stabilization of trauma patient
What is the goal of the FAST exam?
-scan four quadrants, pericardial sac, and cul-de-sac for presence of free fluid or hemoperitoneum
What does free fluid usually represent in the trauma setting? What else could it be?
- usually represents hemoperitoneum
- may also represent bowel, urine, bile, or ascitic fluid
How does the fluid look sonographically?
-hypoechoic or hyperechoic, with scattered internal echoes representing the blood, and conforms to the anatomic site it occupies
What is the most common site of fluid accumulation regardless of the site of the injury?
-subhepatic space (*Morison’s pouch)
What is the next most common space for fluid accumulation?
pelvis-pouch of Douglas
*What is one of the most common reasons for emergent surgery?
-*acute appendicitis
What is the best way to scan the appendix?
- linear sequential array (unless pt is obese than convex) due to superficiality
- over right iliac/inguinal region
What is the FAST scan protocol?
- fill urinary bladder
- scan subxiphoid to look for pericardial effusion
- evaluate the RUQ, liver texture for abnormalities, epigastrium, LUQ, RLQ, LLQ
How is the pericardium surveyed in a FAST scan?
-a subcostal approach with the transducer angled in a cephalic direction toward the 4-chamber view of the heart to image the pericardial sac for pericardial effusion
What can extreme shortness of breath be a sign of?
pericardial effusion
What is evaluated in the RUQ during a FAST scan?
-diaphragm, dome of live, subhepatic space (Morison’s pouch), right kidney, and right flank
What is evaluated in the epigastric area during a FAST scan?
pancreas, vessels
What is evaluated in the LUQ of FAST scan?
spleen and left kidney
What is evaluated in the lower quadrants of a FAST scan?
-urinary bladder and uterus
What transducer is best for evaluating for pericardial effusion?
sector array
What is the difference between pleural effusion and ascites?
- pleural effusion is above the diaphragm
- ascites is fluid in the peritoneal cavity
What are normal reasons to see a small amount of fluid in a woman of menstrual age?
-ovulation and menstruation
What causes variances in the sonographic appearance of hepatic and splenic injuries?
-vary according to type and time of injury
What are more easily detected with ultrasound than any other visceral abdominal injury?
liver lacerations or contusions
How do parenchymal injuries appear?
*heterogeneous or hyperechoic
How will hematomas and localized lacerations appear initially?
-hypoechoic with low-level echoes generated from RBCs
How will hematomas and localized lacerations appear as the blood begins to coagulate and after?
-echogenic, which over time will become more anechoic with the on set of hemolysis
What are the pitfalls of abdominal ultrasound?
-failure to show contained solid-organ injuries; injuries to the diaphragm, pancreas, and adrenal gland, and some bowel injuries.
*Why is close clinical observation or CT warranted after a negative ultrasound?
-*because it does not exclude an intraperitoneal injury
What are common emergency conditions?
Cholecystitis and pancreatitis, urolithiasis, and aortic dissection, appendicitis, and paraumbilical hernia
What are the clinical and sonographic findings of cholecystitis?
- Clinical: RUQ pain, fever, nausea, vomiting, leukocytosis
- Sonographic: thickened GB wall, + Murphy’s sign, pericholecystic fluid, dilated GB, an immobile gallstone, sludge
What are the clinical and sonographic findings of pancreatitis?
- Clinical: mid-epigastic pain, radiating to back, fever, leukocytosis (amylase, lipase)
- Sonographic: normal to edematous gland, enlarged and hypoechoic texture, irregular borders, increased vascular flow
*What is the most common cause of acute cholecystitis?
-*a cystic duct obstruction, generally by a gallstone. Stones as small as 0.5mm may be visualized with ultrasound
What are clinical and sonographic findings to urolithiasis?
- Clinical: spasmodic flank pain, pain may radiate into pelvis, leukocytosis, hematuria, and fever
- Sonographic: echogenic foci w/ shadowing, hydronephrosis may be present, and look for ureteral jets in bladder
What are the clinical and sonographic findings of aortic dissection?
- Clinical: sudden onset of severe chest pain with radiation to arms, neck or back; syncope may be present
- Sonographic: aneurysm, look for flap at site of dissection, look for false lumen
What are the sonographic findings in aortic dissection?
- presence of an echogenic membrane (false lumen)
- visualization of the flap at the site of dissection
- decreased or reversed blood flow in the false lumen
What are the causes of aortic dissection?
- hypertension (70-90%)
- Marfan syndrome (16%)
- pregnancy
- acquired or congenital aortic stenosis
- acquired or congenital aortic stenosis
- coarctation of aorta
- trauma
- iatrogenic (cardiac catherization, aortic valve replacement)
Where do the majority of aortic dissections occur? And where do the others occur?
- *approx. 70% of aortic dissections occur in the ascending aorta
- 20% in the abdominal aorta
- 10-20% in the aortic arch
What are the clinical and sonographic findings of appendicitis?
-Clinical: intense RLQ, nausea and vomiting, fever, leukocytosis
Sonographic: distended non-compressible appendix, color flow, McBurney’s sign
What are the clinical and sonographic findings of paraumbilical hernia?
- Clinical: asymptomatic to mild discomfort, palpable mass, Valsalva shows exaggeration of mass, reduce sac with gentle pressure, occurs more often in female adults
- sonographic: lower/mid abdominal mass; look for real time peristalsis of bowel hernia
What must be ruled out for patients presenting with acute pelvic pain?
- tubo-ovarian abscess, ruptured ovarian cyst, or ectopic pregnancy
- ovarian torsion is likewise an emergent situation for severe pelvic pain
What is the ring sign?
gestational sac lying outside the uterine cavity in the fallopian tube (ectopic)
