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Arunangshu Chakraborty, Balakrishnan Ashokka - A Practical Guide To Point of Care Ultrasound (POCUS) - Springer (2022)
Arunangshu Chakraborty, Balakrishnan Ashokka - A Practical Guide To Point of Care Ultrasound (POCUS) - Springer (2022)
Point of Care
Ultrasound (POCUS)
Arunangshu Chakraborty
Balakrishnan Ashokka
Editors
123
A Practical Guide to Point of Care
Ultrasound (POCUS)
Arunangshu Chakraborty
Balakrishnan Ashokka
Editors
A Practical Guide
to Point of Care
Ultrasound (POCUS)
Editors
Arunangshu Chakraborty Balakrishnan Ashokka
Department of Anaesthesia Department of Anaesthesia
Critical Care and Pain, Tata National University Hospital
Medical Center Singapore, Singapore
Newtown, Kolkata, West Bengal, India
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature
Singapore Pte Ltd. 2022
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189721, Singapore
I dedicate this work to my better half Ananya, for her
unrelenting support and our children, Anwesh and Agniv for
being my inspiration.
Arunangshu Chakraborty
I dedicate this academic journey to ‘Tanvi Ashokka’, my tween
twinkle, for helping me ‘Focus’ on that matters beyond the
‘POCUS’.
Balakrishnan Ashokka
Foreword
Although the concept of ultrasound is over 200 years old, the history of using
ultrasound as a medical diagnostic tool began only about 70 years ago. Soon,
the principle was also found to be an excellent tool for viewing the heart, and
echocardiography was born. Strictly being in the radiologists’ domain for the
first 50 years, it caught the attention of the intensivists and the emergency
physicians. They found ultrasound to be an excellent tool for inexpensive,
non-invasive and bedside imaging. They started using it for even hitherto
uncharted areas like lung ultrasonography. These physicians were not trained
radiologists, but they needed this valuable imaging tool throughout the day.
So, a term point-of-care ultrasonography was born. It was the use of the ultra-
sound machine to answer some specific questions and assist in some specific
procedures, especially needed in critical care. We are already seeing the
future when an ultrasound transducer attached to our smartphone will replace
the stethoscope for the emergency and critical care physicians.
With this background my former colleague Dr. Arunangshu Chakraborty
along with Dr Ashokka Balakrishnan has written this excellent book on point-
of-care ultrasound. The book is meant for the critical care physician, the
emergency physician and the anaesthesiologist. These physicians will find it
to be comprehensive, yet handy. The book addresses all aspects of critical
care ultrasonography and transthoracic echocardiography, including its use in
the diagnostics and the common bedside procedures. The authors also pro-
vide excellent illustrations to explain the salient points. Each chapter ends
with a set of self-assessment questions. It also comes with some high-quality
videos as an additional feature. This book will teach the beginner and stay
with the regular user of point-of-care ultrasonography as a quick reference. I
foresee a wide acceptance of this book among the critical care physicians.
vii
Preface
ix
Contents
1 Basics
of Point-of-Care Ultrasound������������������������������������������������ 1
Arunangshu Chakraborty and Balakrishnan Ashokka
2 Ultrasound-Guided Vascular Cannulation������������������������������������ 19
Arunangshu Chakraborty, Rakhi Khemka,
Sudhakar Subramani, and Li Jia Fan
3 Point
of Care Ultrasound of the Airway���������������������������������������� 55
Deborah Khoo
4 Point-of-Care
Ultrasound of the Lungs ���������������������������������������� 81
Archit Sharma and Sudhakar Subramani
5 Point-of-Care
Ultrasound of the Heart: Transthoracic
Echocardiogram������������������������������������������������������������������������������ 103
Rohit Vijay Agrawal, Sudipta Mukherjee,
Chang Chuan Melvin Lee, Arunangshu Chakraborty,
and Manojit Lodha
6 Vascular Ultrasound������������������������������������������������������������������������ 121
Sudhakar Subramani, Satoshi Hanada,
and Arunangshu Chakraborty
7 Focused
Assessment with Sonography in Trauma
(FAST) Exam������������������������������������������������������������������������������������ 149
Vishakha Prasad Erasu and Priyadarshini Marathe
8 Miscellaneous
POCUS: Gastric Ultrasound, Urinary
Bladder Ultrasound, Ocular Ultrasound,
Obstetric POCUS ���������������������������������������������������������������������������� 171
Chetan Mehra and Amit Dikshit
9 POCUS:
What does the Future Hold? ������������������������������������������ 189
Rachel Hui Xuan Chia and Balakrishnan Ashokka
Answer Keys ������������������������������������������������������������������������������������������ 199
xi
Basics of Point-of-Care Ultrasound
1
Arunangshu Chakraborty
and Balakrishnan Ashokka
1.1 Basics of Ultrasound: Physics introduction in the early 1960s [1]. It has
and Physiology evolved rapidly through scientific discoveries
and advancement in computing. When ultra-
Sound waves are waves of compression and rar- sound was used for the first time in regional
efaction in a medium such as air. For propagation anesthesia in the 1990s, the ultrasound output
of sound, the most important factors are its fre- was a chart of dots. Now it provides a real-time
quency, wavelength, and the qualities of the image which is easily relatable to the anatomy.
medium it travels through. Ultrasound is safer compared to ionizing radia-
Only a part of the sound waves present in tion and it is portable. The side effects of clini-
nature is audible to human ears, which is known cal ultrasound are negligible. The use of
as the hearing range. Human hearing range is ultrasound by anesthesiologists for the purpose
between 20 and20,000 Hz, although individual of interventions such as vascular cannulations
capabilities may vary. Any sound which has a fre- and regional anesthesia has made those tech-
quency lower than 20 Hz is not audible to most niques safer and more reliable compared to
humans and known as infrasound. On the other landmark-based techniques [2, 3].
hand, sound of frequency greater than 20,000 Hz
is also inaudible to human ears and known as
ultrasound. In the animal kingdom, animals such 1.1.1 Mechanism of Action
as elephants can generate and hear the infrasound
that allows them to communicate over a long dis- Ultrasound is created by the piezoelectric effect
tance, whereas bats and dolphins can generate and (PE) converting electrical energy into mechanical
receive ultrasound which endows them survival vibrations (Fig. 1.1). The word piezo is derived
edge in navigation and spatial orientation. from the Greek word “piezein,” meaning “to
Ultrasound has steadily gained importance press.” It was discovered by Pierre Curie in
and popularity in medical imaging since its 1880 in quartz crystals.
When a varying voltage is applied, the PE
A. Chakraborty (*) material starts to vibrate, with the frequency of
Department of Anaesthesia, Critical Care and Pain, the voltage determining the frequency of the
Tata Medical Center, Newtown, Kolkata, sound waves produced. When placed in contact
West Bengal, India
with skin via an “acoustic coupling” jelly, the
B. Ashokka “transducer” (commonly called “probe”) trans-
Centre for Medical Education (CenMED), National
University Health System, Singapore, Singapore
mits and receives the ultrasound beam.
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022 1
A. Chakraborty, B. Ashokka (eds.), A Practical Guide to Point of Care Ultrasound (POCUS),
https://doi.org/10.1007/978-981-16-7687-1_1
2 A. Chakraborty and B. Ashokka
Application of an
Ultrasound electric current to the crystal causes it
machine to vibrate and thus generate ultrasound
waves
Fig. 1.1 Ultrasound created by piezoelectric effect converting electrical energy into mechanical vibrations
Skin
Like all electromagnetic waves, sound waves media impedances which results in creation of
also exhibit the phenomenon of reflection. The strong echoes.
amount of reflection from a surface depends on Ultrasound is almost totally reflected at the
the angle of incidence and the difference in interface between tissue/liquid and air, producing
impedances between two media. the brightest echo. E.g., the echo produced by
There is an absence of echo/reflection if there pleura in a normal lung.
is no difference in media impedances. However, Refraction is the change of direction of sound
in an interface between lung or bone and soft tis- while crossing the interface between two media.
sues, there is a significant difference between the The radiological significance of this phenomenon
1 Basics of Point-of-Care Ultrasound 5
Z = Density x Velocity
Transducer
Fig. 1.5 Reflection
Transducer
is the creation of artifacts such as those seen the sound energy. Lost energy is absorbed by the
under larger vessels on USG. medium producing heat. The loss of energy, and
thus attenuation is directly related to the fre-
quency of the ultrasound beam.
1.1.3 Transmission Thus, greater the frequency, more the atten-
uation, and lesser is the penetration of the ultra-
Not all waves are reflected when passing through sound wave.
dissimilar media, some are transmitted Attenuation coefficient is a measure of atten-
(Fig. 1.6). The transmitted waves generally pro- uation caused by each tissue as a function of the
duce weaker echo therefore with increasing ultrasound wave frequency. The practical aspect
depth the amplitude and resolution of ultrasound of this, for example, is that tissues such as bones
weaken. have a high attenuation coefficient which greatly
limits the transmission of the ultrasound beam.
Also, this means penetration shall decrease with
1.1.4 Attenuation increasing frequency.
Scattering: This is the redirection of sound
The amplitude of the sound waves decreases with waves in different directions caused due to inter-
increasing depth of penetration in the body. This action with a rough surface or small reflector
is known as attenuation. It happens due to loss of (Fig. 1.7).
6 A. Chakraborty and B. Ashokka
Probe Probe
Beam
Beam
Fig. 1.10 (a) Linear and (b) Curvilinear transducers and their ultrasound beam pattern
5 important
functions
Depth to optimize Frequency
the image
Focusing Doppler
Gain
Fig. 1.14 Gain adjustment: Ultrasound scan of the axillary area with gain adjustment: (a) low gain, (b) high gain, (c)
optimal gain
1 Basics of Point-of-Care Ultrasound 11
Focus: Focus of the ultrasound image is the Pressure: By putting mild pressure with the
narrowest point of the ultrasound beam. It is the probe, subcutaneous fat can be displaced and a
point where the image resolution is best. better image can be obtained.
Modern ultrasound machines have electronic Alignment: Proper alignment of the probe in
focus adjustment capacity. It is best to place the the recommended plane is required to obtain a
focus just at the level of or slightly below the clinically useful image. E.g., The US probe is
object to be viewed for optimum image held transversely for a TAP block, but sagittally
quality. for a SAP block.
The ultrasound machine console (Fig. 1.15) Rotation: The probe may need to be slightly
contains the buttons and sliders for modifying all rotated to align it perfectly with the underlying
the above factors such as frequency, depth, and tissue and the block needle. E.g., For the supra-
focus. One must be well versed with the console clavicular brachial plexus block, the probe needs
to obtain the best image and to be able to store to be slightly externally rotated.
and retrieve images. Tilt: Slight cephalad, caudal, lateral, medial,
or oblique tilt may be necessary for the optimal
Compound Imaging image. Because of the direction of the nerve
It is the technology that combines multiple fibers, some nerves seem different at different
coplanar images (spatial compounding) with angles and a little tilt is required to obtain the per-
images obtained from multiple frequency pendicular cross section and hence the best
spectra (frequency compounding) to form a image. This property of tissues is called anisot-
single image. This decreases artifacts and ropy. E.g., Caudal tilt is required for imaging the
speckles and improves resolution [10] supraclavicular brachial plexus.
(Fig. 1.16).
Needling Techniques
Maneuvering the US Probe: PART The Ultrasound beam travels in a straight line,
Even after optimizing the image setting, an opti- like a thin sheet, perpendicular to the probe. How
mal image may not be obtained. For that, the the intervening needle is visualized depends on
ultrasound probe needs to be held and maneu- how much of its length is in alignment with the
vered (Fig. 1.17). ultrasound beam [11, 12].
12 A. Chakraborty and B. Ashokka
Fig. 1.16 Compound image combines multiple coplanar images with images obtained from multiple frequency spectra
to form a single image
P • Pressure
A • Alignment
R • Rotation
T • Tilt
In-Plane
The needle is placed parallel to the transducer.
The needle shaft and tip are both visible
(Figs. 1.18 and 1.19).
Example: axillary block.
This approach is safe and easy to learn but is
difficult to practice in deeper blocks. The quality Fig. 1.18 In-plane needling technique
1 Basics of Point-of-Care Ultrasound 13
Fig. 1.19 In-plane needling technique. Note that the entire length of the needle and its tip is imaged in real time
Needle tip
IJV
CCA
Fig. 1.20 Out of plane cannulation of internal jugular ultrasound image on the right shows the sonoanatomy and
vein (IJV): Left panel shows the probe holding and needle the tip of the needle being seen as a bright hyperechoic
entering out of plane at a right angle to the probe. The spot. CCA common carotid artery lies medial to the IJV
of needle visualization depends on the angle of tant to observe tissue displacement by the
entry of the needle. The flatter the angle (acute advancing needle tip as often the needle tip may
angle), the better is the image. To reach deeper not be seen.
objects, a more perpendicular angle is required, For superficial procedures such as internal
which makes needle visualization in this tech- jugular vein cannulation, it is a good strategy to
nique difficult. estimate the depth of the target and calculate the
entry point of the needle, angle of inclination,
1.1.5.5 Out of Plane and angle of the ultrasound probe accordingly.
The needle is placed perpendicular to the trans- For deeper structures, hydrodissection with
ducer probe. The tip of the needle may be diffi- 1–2 ml saline can be used to confirm the location
cult to locate accurately in this approach and use of the needle tip.
of echogenic tip needles is advised. It is impor- Example: Vascular cannulations (Fig. 1.20).
14 A. Chakraborty and B. Ashokka
1.1.5.6 Bioeffect and Safety facts such as A lines and B lines are pathogno-
Ultrasound application produces biologic effects monic and useful for the detection of clinical
by thermal and nonthermal mechanisms. Heat is conditions.
generated through absorption of ultrasound by These artifacts are described in detail in text-
tissues and is directly proportional to ultrasound books of point-of-care ultrasound.
intensity, frequency, and duration.
Two standard indices are displayed by an
ultrasound machine (Fig. 1.21). 1.2 Point-of-Care Ultrasound:
Thermal index (TI): It is the transducer Concept and Limitations
acoustic power divided by the estimated power
needed to increase tissue temperature by 1°. Like the five elements of nature, the human body
Mechanical index (MI): It is the peak rar- is also composed of solid tissue (earth), liquid tis-
efactional pressure divided by the square root of sue (water), and gas-filled spaces (air). While
the center frequency of the pulse bandwidth. The imaging with ultrasound, we refer to tissue in
relative likelihood of thermal and mechanical terms of “echogenicity” or “echo signature.”
hazard is indicated by TI and MI, respectively. TI Water offers least resistance to the passage of
or MI >1.0 is dangerous. ultrasound thereby providing the least echo-
Different tissue and examination settings are genicity which is called anechoic. Of all parts in
saved and categorized in modern ultrasound the body, water containing tissues such as blood,
machines to aid in imaging as well as reducing pleural fluid, and amniotic fluid have the least
these bioeffects. For example, the ophthalmic echogenicity, the echogenicity being directly pro-
mode is a low power setting that allows examina- portional to the density of the fluid and it increases
tion of the eyes without causing any tissue injury if there are suspended particles. Thereby, an exu-
to the sensitive ophthalmic tissues such as the dative pleural fluid will have more echogenicity
retina. than a serous fluid. The sludge in the gallbladder
Artifacts: Artifacts are false images produced can be distinguished from normal bile because of
due to highly reflective tissue interfaces. There the suspended particles, which reflect ultrasound
are various types of artifacts, such as comet tail and produce a higher echogenicity.
artifacts and mirror image artifacts. Solid tissues reflect ultrasound based on their
Some of the artifacts are misleading, water content. Thereby, muscles are less echo-
whereas some are useful. Lung ultrasound arti- genic than the adipose tissue and the fibrous sep-
tae that separate them. The nerves being solid,
with lesser water content than muscle can be
MECHANISM identified too, but their echogenicity changes
from their origin to the end. Nerves at their origin
as nerve roots tend to be less echogenic and
appear as hollow circles or “bubbles” in the short
axis (SAX) view, but as the roots unite to form
divisions and the divisions unite to form nerves,
Thermal Non-thermal they gather more and more fatty layers of peri-
neural tissue and the nerves appear as “honey-
comb” in the SAX view.
Bones are the most dense tissue in the body
and they do not allow ultrasound to pass.
Mechanical Cavitation Therefore, the bones appear hyperechoic due to
the reflection of ultrasound by the shiny bony
Fig. 1.21 Bioeffect and safety surface and we see an “acoustic shadow” beneath
1 Basics of Point-of-Care Ultrasound 15
them, like the shadow cast by a solid object under ultrasound almost completely, producing the
the sun. highest hyperechoic image that appears shiny
Air also does not allow the passage of ultra- and glistening.
sound, but the tissue-air interface reflects the
View of ribs and pleura: Note the acoustic shadow cast by Honeycomb appearance of peripheral nerves, note the
the ribs, which are hyperechoic anechoic nature of the blood vessels and the injected
local anesthetic (LA) in contrast to the nerve and the
surrounding tissue
8. Pollard BA, Chan VW. Introductory curriculum for 11. Maecken T, Zenz M, Grau T. Ultrasound character-
ultrasound-guided regional anesthesia. Toronto, ON: istics of needles for regional anesthesia. Reg Anesth
University of Toronto Press Inc.; 2009. Pain Med. 2007;32:440–7.
9. Tsui BC. Atlas of ultrasound and nerve stimulation- 12. Pollard BA. New model for learning ultrasound-
guided regional anesthesia. New York: Springer; guided needle to target localization. Reg Anesth Pain
2007. Med. 2008;33:360–2.
10. Brian DS, Macfarlane AJ, Sites VR, Chan VW, Brull
R, et al. Clinical sonopathology for the regional anes-
thesiologist. Reg Anesth Pain Med. 2010;35:272–89.
Ultrasound-Guided Vascular
Cannulation 2
Arunangshu Chakraborty, Rakhi Khemka,
Sudhakar Subramani, and Li Jia Fan
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022 19
A. Chakraborty, B. Ashokka (eds.), A Practical Guide to Point of Care Ultrasound (POCUS),
https://doi.org/10.1007/978-981-16-7687-1_2
20 A. Chakraborty et al.
a b c
Fig. 2.1 Blood vessels: (a) Radial artery, (b) Cubital vein, (c) Internal jugular vein and common carotid artery
depth
tant to remember to lighten the pressure of the
UST while cannulating the artery (Fig. 2.1). distance = depth
b
2.2.2 Depth, Distance, and Angle
tion. Even superficial but larger targets can be can- • Decide the type and bore of cannula/catheter.
nulated with a needle angle of 45° or more. For • Review relevant past medical history.
superficial and smaller targets a shallower approach
is usually required for cannulation as a steeper angle 2.2.4.2 Positioning/Room Set Up/
may lead the needle to go through the posterior wall Ergonomics
easily causing difficulty in cannulation, hematoma,
and requiring multiple attempts. Superficial vessels Patient
such as radial artery cannulation usually require an • Comfortably lying or sitting.
angle of 30° or less. The distance of the point of • Supine position with Trendelenburg for cen-
entry of the needle needs to be calculated accord- tral venous cannulation of upper extremity.
ingly. Moving the probe up and down and tilting the • Arm well supported; arm board (if available)
probe would help visualizing the needle. with the limb abducted and externally rotated.
• Adequate exposure to clean field.
2.2.4 Preparation
2.3 Central Venous Cannulation
2.2.4.1 Preprocedural Evaluation
• Review indications for cannulation. Although the placement of a central venous cath-
• Decide the technique—Seldinger/catheter- eter (CVC) is a routine procedure in intensive
over-needle. care medicine and in perioperative care, acute
22 A. Chakraborty et al.
severe complications such as inadvertent arterial corresponds with an orientation marker on one
puncture or cannulation, hematoma, hemothorax, side of the US scan sector shown on the US
or pneumothorax occur in a relevant proportion device screen helps to obtain the correct probe
of patients [26]. Traditionally, IJV central cannu- orientation during US examination [30]. It is
lation placement is performed using landmark important to note here that the IJV and the CCA
techniques based on the knowledge of anatomic often have considerable overlapping, starting
structures and palpation of arteries next to the from 20% to even 100% at this level. When the
veins. Unfortunately, these landmark techniques CCA is directly below the IJV, even with the
have their own limitations in detecting anatomic ultrasound guidance there is a considerable risk
variations at the CVC insertion site as well as of inadvertent CCA puncture. Therefore, it is
venous thrombosis that is especially common in prudent to scan up and down the IJV to find out
oncologic and critically ill patients can make the position where the overlapping is minimum
CVC placement impossible or dangerous for the and choose that point for the puncture. Turning
patient [27]. The use of ultrasound has been pro- the head too much to the other side sometimes
posed to increase the safety and quality of CVC increases the overlap. These factors should be
placement by reducing CVC-related complica- considered at the time of positioning. If the
tions [28]. The meta-analysis of over 5000 patient is awake, he/she can be advised to opti-
patients from 35 trials demonstrated a reduced mize the head turn to the optimal level.
total rate of complications by using US compared The distance of the point of entry of the needle
with conventional landmark techniques (4.0% vs from the footprint of the UST should be kept in
13.5%, respectively). In addition, the overall suc- mind while inserting the needle and the angle
cess rate was higher in the US (97.6% vs 87.6%). adjusted accordingly.
The benefits of US-guided CVC placement with Sometimes the needle would push the skin
regard to the total complication rate, overall suc- and subcutaneous tissue in a manner before actu-
cess rate, and number of attempts until success ally piercing that it appears that the needle has
were consistent across experienced and inexperi- gone past the vein. In such a situation the vein
enced operators [29]. appears collapsed under the pressure of the nee-
dle. As soon as the needle enters the vein the
pressure is relieved and the needle tip is seen as a
2.3.1 Internal Jugular Vein bright echogenic point inside the hypoechoic
Cannulation lumen of the IJV.
While positioning the UST, the midpoint
One of the earliest vascular cannulations that is of the UST, which often has a mark, should
performed using ultrasound guidance is the inter- be directly above the midpoint of the vein.
nal jugular vein (IJV) cannulation. The patient- Lateral and medial ends should be identified
awake or under anesthesia/sedation is placed before entering the skin. In case of doubt,
supine, head turned to the other side and table/ remember CCA lies medially and posterior
bed tilted to 10–15° Trendelenburg. The head (below) to the IJV.
down maneuver helps in engorging the vein and US can be used in different ways to facilitate
also prevents inadvertent venous air embolism CVC placement. Using US prior to catheter
(VAE). After antiseptic dressing and draping, the placement only to visualize the IJV to determine
ultrasound probe, covered in a sterile plastic patency and anatomical variants has been
sheet is placed on the neck at the level of the referred to as the US-assisted approach.
cricoid cartilage and slided laterally to image the However, the US-guided approach, which is
IJV and the common carotid artery (CCA). Small, real-time visualization of needle placement and
linear array, high-frequency transducers advancement is generally recommended to pre-
(5–15 MHz) with scanning surface of 2–5 cm are vent or minimize catheter-related complications
best suited for IJV cannulation. An index mark [31]. US guidance during needle advancement
2 Ultrasound-Guided Vascular Cannulation 23
can be performed using: a short-axis (SAX) to learn for physicians not familiar with ultra-
probe orientation and an out-of-plane view of the sound [35]. The advantage of the SAX approach
needle; a long-axis (LAX) probe orientation and allows better visualization of the vein in relation
an in-plane view of the needle or occasionally an to the artery might more sufficiently help to
oblique orientation, a view that is halfway avoid accidental arterial puncture, but the needle
between the short-axis and the long-axis view is only visualized as an echogenic point which is
with the US probe placed at approximately 45° not necessarily the tip of the needle [36]. The
with respect to the target vessel [32, 33]. In addi- entire needle can be visualized in its complete
tion a new anteroposterior SAX but in-plane course with LAX in-plane approach and the
technique that combines the advantage of in- depth of the needle tip is also visualized simulta-
plane technique to track the needle tip and short- neously thereby reducing the risk of penetration
axis view of visualizing nearby anatomical of the posterior vessel wall [37] (Figs. 2.3, 2.4,
structures by placing the probe on the side of the 2.5, and 2.6).
neck, oriented anteroposteriorly, perpendicular
to the long axis of the neck have been described.
This view visualizes IJV and its relationship to 2.3.2 Subclavian Vein Cannulation
the carotid artery in the short axis [34].
With limited available data unable to predict 2.3.2.1 Anatomy of Subclavian Vessels
superiority of one technique over another one. The subclavian vein is the continuation of the
However, SAX out-of-plane approach is easier axillary vein as it courses beneath the clavicle. At
Fig. 2.3 US image of internal jugular vein in (a) short (out-of-plane view) and (b) long axis(in-plane view)
24 A. Chakraborty et al.
Fig. 2.6 Cannulation of the internal jugular vein (IJV): print to the point of entry of the needle is shorter than the
Left: Note the high-frequency linear UST being held in a depth of the target vessel. Right: the needle tip is seen as a
transverse orientation and the needle entering at an angle bright echogenic object inside the lumen of the IJV. Note
of about 60°. Note that the distance from the UST foot- the overlap of CCA and IJV to more than 30%
2 Ultrasound-Guided Vascular Cannulation 25
the lateral border of the first rib, it travels superi- such as aneurysm, stenosis, or thrombosis of the
orly then under the clavicle travels medially until vessels. Compared to US-guided cannulation of
it joins the internal jugular vein to form the IJV there are limited data on the utilization of US
innominate vein. The subclavian artery runs pos- for SV cannulation. Meta-analysis of over 2000
terior and superior to the subclavian vein. The patients from nine studies showed that the use of
brachial plexus courses superiorly and deep to US resulted in a reduced rate of accidental arte-
the medial portion of the subclavian artery. On rial puncture (0.8% vs 5.9%); and hematoma for-
the left side, the thoracic duct lies close to the mation (1.2% vs 6.6%). However, there was no
subclavian vessels. Most importantly, the lung statistically significant difference between the
and pleural cavity lie inferior and deeper to the use of US and the conventional landmark tech-
subclavian vein and are particularly vulnerable to nique with regard to the total complication rate,
accidental puncture more often on the left chest the overall success rate, the number of attempts
where the apex of the lung can extend just above until success, the time to successful cannulation,
the first rib. Familiarity with anatomical variants and the success rate with the first attempt [38,
of subclavian vessels are essential prior to any 39]. Currently there is no strong evidence of
interventional procedures or cannulation of both using the US for SV cannulation from different
vein and artery. societies (Fig. 2.7).
a b
Fig. 2.7 US image of subclavian vessels. (a) Short axis image with probe in parasagittal orientation, (b) Long axis
image, with the probe in coronal/transverse orientation
26 A. Chakraborty et al.
nique. The clavicle, which lies directly above the After instilling local anesthetic (LA) along the
SCV, precludes ultrasound imaging. SCV being a path of the needle entry, the central venous can-
deeper vein and the subclavian artery lying in nulation needle, fixed with an empty 2 cc (or
close proximity makes the cannulation even more 5 cc) syringe is inserted in-plane from lateral to
challenging. Subclavian vein (SV) can be visual- medial. (Once the needle tip can be imaged inside
ized from infraclavicular (most common) or the SCV, dark venous blood can be aspirated in
supraclavicular approach. High-frequency linear the syringe attached to the needle. The syringe is
probes are commonly used to visualize subcla- then disconnected and the guidewire is intro-
vian vessels and for morbidly obese individuals, duced. The guidewire should be visualized in the
curvilinear probe with better penetration features superior vena cava and not in the SCA or the IJV
is recommended. The UST is positioned perpen- by placing the UST on the neck and tilting the
dicular to the midline, i.e., in a coronal/transverseprobe caudally. If the guidewire is found in the
orientation, medial end of the UST lying on the neck it is to be pulled back and negotiated in
midpoint of the clavicle. A little cephalad tilt of again. Only after confirmation of the guidewire
the UST allows imaging of the SCV and location in the superior vena cava, the needle is
SCA. The artery would be imaged lying posterior withdrawn.
to the vein. Before puncture, one should be sure Proceduralist can stand either at head end or
that both the artery and the vein can be imaged on the ipsilateral side for right subclavian vein
separately. Vein can also be identified by its col- cannulation. Ergonomics need to be ensured as it
lapsibility under pressure and that it expands is a demanding procedure.
upon valsalva maneuver and by a Trendelenberg A short-axis view can be also obtained at this
position. In case of difficulty of visualization, a location by rotating the UST by 90° and an out-
more lateral site may be chosen. of-plane approach for cannulation can be
An infraclavicular approach is a more tradi- performed.
tional approach, although a supraclavicular In either approach, it is mandatory to identify
approach has been described. and image the subclavian artery before beginning
the process of cannulation. Currently no evidence
Infraclavicular Approach of showing one method’s superiority over other
For infraclavicular approach, either SAX out-of- methods however a US-guided infraclavicular
plane or long-axis in-plane techniques have been approach is feasible to visualize SCV in most of
implemented with limitations of each approach the clinical settings (Figs. 2.8 and 2.9).
like in IJV cannulation. Compared to the land-
mark method, cannulation occurs more laterally. Supraclavicular Approach
The UST is held transversely at an angle of
90° to the midline just below the clavicle in a way Ultrasound Assessment of SCV in the Fossa
that the medial side of the ultrasound image Above the Clavicle
shows the clavicle and the shadow cast by it and The SCV runs from lateral to medial under the
the lateral side shows the subclavian vein on a clavicle, just anterior to the subclavian artery
little cephalad tilt of the transducer. The image is (SCA). As it approaches the heart, the SCV is
adjusted for depth, which is typically at 6 cm for joined by the IJV, forming the brachiocephalic
thin individuals. As the transducer is slided later- (innominate) vein. The supraclavicular approach
ally and tilted further cephalad, both subclavian attempts to cannulate the portion of the SCV just
vein and artery can be imaged. The angle of lateral to the clavicular head of the sternocleido-
insonation is important to observe because the mastoid muscle. The right SCV is preferred to the
needle for an in-plane cannulation would travel left since it forms a straighter angle with the IJV,
in the same plane. offering a shorter distance for wire passage into
2 Ultrasound-Guided Vascular Cannulation 27
the superior vena cava, avoiding proximity to the Ultrasound-Guided SCV Cannulation
thoracic duct, which drains into the left Once visualize the SCV, turn the probe in the lon-
SCV. Place a high-frequency linear transducer gitudinal plane prior to needle puncture. Enter
(6–13 MHz) on the lateral neck just above the the SCV from the lateral aspect using in-plane
clavicle to locate the IJV and carotid artery. technique. Probe needs to be tilted more anteri-
Slowly trace the IJV by moving the probe cau- orly (caudally) and stabilized against the clavicle.
dally into the supraclavicular fossa until the This approach has an advantage of placing SCV
probe abuts the clavicle. While visualizing the even during CPR. This approach has several
most caudal aspect of the IJV, angle the probe advantages over landmark technique. SCV can
anteriorly to visualize the confluence of the IJV also be accessed by short axis out-of-plane tech-
and SCV (Fig. 2.11). At this proximal location, nique (Fig. 2.11). However, long-axis approach is
the SCV lies anterior to the SCA, and the opera- preferred to avoid pleural puncture. Ultimately
tor should dynamically fan the probe from a pos- familiarity of SCV anatomy at this location and
terior to anterior position to identify both the operator skill determines the successful
vessels. cannulation.
28 A. Chakraborty et al.
2.3.3 Femoral Vein Cannulation 4. Confirm needle position in the vein, recom-
mended to use LAX to complete the track of
The femoral vein (FV) cannulation is employed the needle inside the vessel and to avoid pos-
for central venous access where the superior terior wall puncture.
extremity central venous access is otherwise 5. Confirm wire position in the vein and track all
ruled out and for temporary intravenous pacing. the way to IJ and SV junction if wire is placed
A high-frequency linear array UST is selected. in IJV to ensure wire enters the innominate
The patient lies supine and the proceduralist vein prior to dilation over the guidewire.
stands on the ipsilateral side. The UST is placed 6. Confirm catheter position in the vein.
transversely, just inferior to the inguinal crease.
The superficial femoral artery can be easily iden- 2.3.3.2 Femoral Vein Cannulation
tified as an anechoic pulsatile structure with the
FV lying medial and inferior to it. The FV appears Limitations of Ultrasound-Guided Central
as an oval-shaped anechoic object which is com- Venous Catheter Placement
pressible by the UST. After adjusting the UST, so Although US is noninvasive and thus does not
that the FV lies in the center of the image, the bear a risk to directly harm the patient, some lim-
block needle is inserted out of the plane. The itations and disadvantages of US during central
UST is slided up and down to follow the needle venous access are worth considering. One might
trajectory till the tip of the needle appears at the argue that the risk of catheter-related bloodstream
upper surface of the vein as a bright dot, appears infections might be higher if US is used for CVC
to indent on the vein wall and then pierces it. placement without applying a strict aseptic
Dark venous blood can be aspirated with the approach. US might give a false sense of security
syringe attached. Guidewire is passed down. and mislead him/her to neglect traditionally
The entire procedure should be performed under taught principles with regard to needle direction
direct ultrasound imaging. The needle is to be especially for inexperienced users. To overcome
advanced only when visualized without any doubt. these problems formal education and training
The same process can be applied for a femoral including simulation with a structured certifica-
artery cannulation. tion of US skills for vascular access and the
development of a consensus standard for these
2.3.3.1 Systematic Approach for USG training programs have been suggested.
Central Venous Catheter Sometimes insertion site-related specific issues
Placement when using US. For example, shorter necks in
Irrespective of cannulation site, for clinical prac- morbid obese individuals might make LAX a
tice, the authors recommend a systematic challenge to visualize the IJV and might need
approach using six steps: curved-array probes even for IJ placement. For
subclavian access, because the angle of cannula-
1. To identify the anatomy of the insertion site tion is usually steeper when using US, it is espe-
and localization of the vein, it is recommended cially important to align and constantly visualize
to perform a baseline scan prior to sterile the needle to avoid pleural injury.
preparation. It also helps to know anatomical
variants.
2. To confirm patency of the vein by using vari- 2.3.4 Confirmation of the Correct
ous US features such as color Doppler, com- Position of the Central Venous
pression US or even spectral Doppler in rare Catheter Tip
occasions.
3. Use real-time US guidance for puncture of the Prevention of central venous catheter tip malpo-
vein, one should be familiar with the depth sition is of paramount importance, as it has been
and angular orientation prior to placing the associated with significant complications, includ-
needle. ing central venous or superior vena cava throm-
2 Ultrasound-Guided Vascular Cannulation 29
bosis, arrhythmias, cardiac tamponade, and ferent echocardiographic views have been tested:
hemodynamic monitoring inaccuracy. Moreover, the apical four-chamber view, the subcostal four
with malposition, appropriate treatment may be chambers view, the subcostal bi-caval view and
delayed with subsequent further related compli- the suprasternal/supraclavicular view. Both of the
cations. In this regard, the intracavitary electro- four chambers views allow only evaluation of the
cardiographic (IC-ECG) method is currently right atrium without visualization of the superior
recommended in international guidelines as vena cava or inferior vena cava. On the contrary,
accurate, well-tolerated, and cost-effective for the subcostal bi-caval view, the most studied
assessing the proper location of the central approach, allows visualization of the superior
venous catheter tip. However, this method is vena cava, cavo-atrial junction, right atrium, and
commonly considered to be applicable only when inferior vena cava. Four groups of researchers
there is a well-defined and identifiable P wave in have studied the suprasternal/supraclavicular
the ECG trace. Although a few studies have view, which allows the identification of the con-
recently suggested that IC-ECG might also be fluence between the two brachiocephalic veins,
used in patients with atrial fibrillation after some the superior vena cava, the right branch of the
appropriate modifications of the basic technique, pulmonary, artery and the aortic arch. These
in patients with a pacemaker or with other structures enable indirect identification of the
arrhythmias, IC-ECG is still considered to be not cavo-atrial junction. Ultrasound-based tip navi-
applicable. As bedside chest radiograph has been gation may be used during the procedure to help
shown to be inaccurate in identifying the catheter the operator in directing the guidewire.
tip location due to the inaccuracy of the radio-
logical landmark for the cavo-atrial junction, 2.3.4.1 The European Society
ultrasound imaging has been proposed as an of Anesthesiologists
alternative technique to IC-ECG and chest radio- Recommends [40]
graph for tip location. Indeed, the application of 1. When an intracardiac electrocardiogram is
ultrasound to vascular access should not be lim- not applicable, using real-time ultrasound to
ited to venepuncture but should be extended to detect and prevent central venous catheter
assist in all steps of the procedure. Specifically, in malposition, as it has been shown to be well-
regard to the prevention of primary malposition, tolerated, feasible, quickly performed, and
ultrasound may play two roles as a “tip location” interpreted at bedside, and more accurate and
and a “tip navigation” technique. Ultrasound- faster than a chest radiograph (1C).
based tip navigation techniques can be used to 2. Combining vascular ultrasound for guidewire
confirm that the catheter or the guidewire is and central venous line tip navigation with
threading towards the cavo-atrial junction by transthoracic echocardiography for tip loca-
sonographic visualization throughout the ipsilat- tion (1C).
eral brachiocephalic vein, ruling out catheter 3. Performing pleural and lung ultrasound
misdirection into the ipsilateral IJV or other (PLUS) to rule out potential pleural-
superior vena cava tributary veins (e.g., the con- pulmonary complications (mainly pneumo-
tralateral brachiocephalic vein). Sonographic tip thorax) soon after the procedure in any
navigation may be performed with the same lin- difficult puncture of the subclavian or axillary
ear probe used for the puncture. As a tip location vein and, particularly, if the patient complains
technique, ultrasound allows direct or indirect of shortness of breath or discomfort that wors-
visualization of the catheter tip or the J-guidewire ens after catheter placement (1B).
at the cavo-atrial junction, upper right atrium, or 4. Using PLUS to monitor the development of a
in the lower superior vena cava by means of confirmed pleural-pulmonary complication or
transthoracic echocardiography. Different for follow-up of treatment (1B).
approaches and different protocols have been 5. Ultrasound for diagnosis and follow-up of
described in the literature on this topic. Four dif- catheter-related thrombosis (1C).
30 A. Chakraborty et al.
learn to be able to complete the task of radial 2.5.4 Arteria Dorsalis Pedis
artery cannulation even after a few missed Cannulation
attempts.
Radial artery is superficial and the diameter Arteria dorsalis pedis (ADP) cannulation is use-
of the lumen is about 3–4 mm. Being a small ful for head and neck surgery with plastic recon-
and superficial target, it is easy to miss. Out-of- struction that would need a radial free flap. It is a
plane approach is generally preferred, in-plane small and superficial target, easy to miss. A short-
approach is possible too! When performing the axis view is to be obtained first to identify the
cannulation out-of-plane, slide the probe up artery. In contrast with most arteries, ADP is a
and down and tilt towards the advancing needle superficial artery which is easily collapsible by
to locate the tip. Once blood appears in the hub the pressure of the UST. Therefore, after identifi-
of the cannula, an attempt should be made to cation, use of color Doppler is warranted to con-
take a long-axis view and insert the cannula a firm the artery. Once confirmed, the UST should
few mm more inside the lumen. Then the cath- be rotated by 90° while keeping it centered on the
eter is slided in, keeping the stylet fixed with artery to obtain the long-axis view (LAX).
the other hand. Careful alignment of the UST is needed to get the
In the catheter-over-needle technique, as is complete LAX view. Colour Doppler is used
most commonly performed, often it happens that again to confirm (Fig. 2.10). In-plane approach
blood appears at the hub indicating that the can- can be taken to cannulate the artery if a good
nula has entered the artery, but upon advance- LAX view can be obtained. Alternatively, an out-
ment of the catheter it gets kinked and it has to be of-plane approach can be performed. When going
taken out and reinserted. The angle of the cannula out of plane, slide the probe up and down and tilt
should be kept acute, less than 30° so that after towards the advancing needle to locate the tip.
entering the artery, a few mm more can be
inserted to avoid kinking of the catheter.
2.5.5 Posterior Tibial Artery
Cannulation
2.5.3 Femoral Artery Cannulation
The posterior tibial artery (PTA) cannulation can
Femoral artery is cannulated for percutaneous be useful for head and neck surgeries and particu-
coronary intervention (PCI) and other intra- larly in children, in whom the radial or the ADP
arterial interventions such as thrombectomy and may be too small to cannulate. It is an important
recanalisation. It is sometimes used in cardiac skill to learn.
anesthesia and cardiothoracic intensive care units Has been used in small children as an alter-
for arterial pressure monitoring and intra-arterial native to the radial artery as the lumen
balloon pump (IABP). (ID>1.1 mm) can generally accommodate a
The process of cannulation is similar to the 20 G arterial cannula [49].
femoral vein cannulation. An out-of-plane
approach and a Seldinger technique is used, i.e., 2.5.5.1 Technique
a needle is inserted in the artery, upon obtaining Site: Midpoint between the medial malleolus and
pulsatile blood flow a guidewire is inserted, the the Achilles tendon.
needle is taken out followed by insertion of the Position: Ankle dorsiflexion and eversion sig-
catheter over the guidewire. For safety precaution nificantly increase the proximity to the skin sur-
against accidental dislodgement of the catheter face. An assistant may be asked to hold the foot
thus inserted, many centers practice suturing the in position for cannulation.
catheter hub with skin before taking the guide- Posterior tibial vessels lie in close proximity
wire out. to the tibial nerve in a neurovascular bundle
34 A. Chakraborty et al.
Fig. 2.10 Cannulation
1. Subclavian vein (SCV) and
of the subclavian vein artery (SCA) are identified
(SCV)—stepwise in the long axis view
approach. The needle
(Arrowheads) enter
lateral to medial.
Subclavian artery (SCA)
lies below the SCV
2. In-plane cannulation is
performed. Note the needle
tip (arrows) in the center of
the vein
3. Guidewire (arrows) is
inserted and imaged with
ultrasound
4. Ultrasound transducer is
placed above the clavicle
and tilted caudally to
observe the guidewire
(arrows) entering the
Superior vena cava (SVC).
The guidewire appears as a
shiny line moving with each
heartbeat.
2 Ultrasound-Guided Vascular Cannulation 35
(Figs. 2.11 and 2.12). Compression with the UST 2.7.2 Positioning the Patient
will collapse the veins, allowing the artery to be for Needle Insertion
identified, which lies flanked on both sides by the and Catheter Placement
veins. Color Doppler should be used to confirm
the artery. Once the PTA is identified a LAX view • Perform central venous access in the neck or
is obtained and in-plane cannulation is performed chest with the patient in the Trendelenburg
(Fig. 2.12). Out-of-plane cannulation can also be position when clinically appropriate and
performed, depending on the experience and feasible.
preference of the proceduralist (Figs. 2.13, 2.14,
2.15, 2.16, 2.17, 2.18, 2.19, and 2.20).
2.7.3 Needle Insertion, Wire
Placement, and Catheter
2.6 Recommendations Placement
for Ultrasound-Guided
Vascular Access [1] • Select catheter size (i.e., outside diameter) and
type based on the clinical situation and skill/
The 2020 practice guidelines from the ASA experience of the operator.
recommends-. • Select the smallest size catheter appropriate
for the clinical situation.
• For the subclavian approach select a thin-wall
2.7 Recommendations needle (i.e., Seldinger) technique vs a catheter-
for Prevention of Mechanical over-the-needle (i.e., modified Seldinger)
Trauma or Injury technique.
• For the jugular or femoral approach, select a
2.7.1 Catheter Insertion Site thin-wall needle or catheter-over-the-needle
Selection technique based on the clinical situation and
the skill/experience of the operator.
• Determine catheter insertion site selection • For accessing the vein before threading a dila-
based on clinical need and practitioner judg- tor or large-bore catheter, base the decision to
ment, experience, and skill. use a thin-wall needle technique or a catheter-
• Select an upper body insertion site when pos- over-the-needle technique at least in part on
sible to minimize the risk of thrombotic com- the method used to confirm that the wire
plications relative to the femoral site. resides in the vein (Fig. 2.21).
36 A. Chakraborty et al.
Fig. 2.12 IJV
cannulation 1. Identify anatomy of the insertion site and localization of the vein
a. Confirm position of
the guidewire inside
the vein.
b. Tilt the probe caudally
to notice the guidewire
entering the superior
vena cava
Femoral vein lies medial to the artery Obtain LAX view by rotating the
probe by 90 degrees
Identify anatomy of the insertion site and localization of the vein
a. The FV can be
punctured in SAX or
LAX view.
b. Image the
needle tip in the center
of the vein (arrows).
Fig. 2.13 (continued)
2 Ultrasound-Guided Vascular Cannulation 39
Fig. 2.13 (continued)
1 Artery is
identified in
SAX
2 LAX view
is obtained,
confirmed
using color
doppler
3 In plane
cannulation
is
performed.
Confirm by
observing
the blood
flashback
as well as
the cannula
images
inside the
artery
Fig. 2.16 Cannulation of the radial artery in 3 steps: 1. real-time imaging (note the blood in the hub and the can-
Identification of the artery in the short-axis view, 2. Long- nula inside the artery—arrows)
axis view with color Doppler, 3. In-plane cannulation with
2 Ultrasound-Guided Vascular Cannulation 41
Fig. 2.17 Cannulation
of the femoral artery
in short-axis view; note
the needle tip
(Arrow) inside the artery
Identification of the ADP in In-plane cannulation of ADP After blood flashback the
LAX with color doppler catheter is advanced in the
artery in-plane
Fig. 2.19 Short-axis
view of the posterior
tibial artery with color
Doppler (note the red
color)
42 A. Chakraborty et al.
Tibial nerve and the posterior Posterior tibial artery in the In-plane cannulation of PTA
tibial vessels in the SAX view LAX with color doppler
YES
DO
YES Slide catheter over needle into vessel
NOT
PROCEED
YES YES
Any question
of difficulty
No
difficulty‡
Confirm venous residence of wire with
ultrasound, TEE, continuous ECG, or
fluoroscopy
YES
Fig. 2.21 Algorithm for central venous insertion and veri- wall needle in the Seldinger technique could move out of
fication. This algorithm compares the thin-wall needle the vein and into the wall of an artery between the manom-
(i.e., Seldinger) technique vs the catheter-over-the needle etry step and the threading of the wire step. ECG, electro-
(i.e., modified Seldinger) technique in critical safety steps cardiography; TEE, transesophageal echocardiography.
to prevent unintentional arterial placement of a dilator or †
For neonates, infants, and children, confirmation of
large-bore catheter. The variation between the two tech- venous placement may take place after the wire is threaded.
niques reflects mitigation steps for the risk that the thin- ‡
Consider confirming venous residence of the wire [1].
2 Ultrasound-Guided Vascular Cannulation 43
–– When feasible, real-time ultrasound may • Verify that the wire has not been retained in
be used when the subclavian or femoral the vascular system at the end of the procedure
vein is selected. by confirming the presence of the removed
• Use static ultrasound imaging before prepping wire in the procedural field.
and draping for prepuncture identification of –– If the complete guidewire is not found in
anatomy to determine vessel localization and the procedural field, order chest radiogra-
patency when the internal jugular vein is phy to determine whether the guidewire
selected for cannulation. has been retained in the patient’s vascular
–– Static ultrasound may also be used when system.
the subclavian or femoral vein is selected.
2.8 Recommendations
2.7.5 Verification of Needle, Wire, for Management of Arterial
and Catheter Placement Trauma or Injury Arising
from Central Venous Access
• After insertion of a catheter that went over the
needle or a thin-wall needle, confirm venous • When unintended cannulation of an arterial
access. vessel with a dilator or large-bore catheter
–– Do not rely on blood color or absence of occurs, leave the dilator or catheter in place
pulsatile flow for confirming that the cath- and immediately consult a general surgeon, a
eter or thin-wall needle resides in the vein. vascular surgeon, or an interventional radiolo-
• When using the thin-wall needle technique, gist regarding surgical or nonsurgical catheter
confirm venous residence of the wire after the removal for adults.
wire is threaded. • For neonates, infants, and children, deter-
–– When using the catheter-over-the-needle mine on a case-by-case basis whether to
technique, confirmation that the wire leave the catheter in place and obtain consul-
resides in the vein may not be needed (1) tation or to remove the catheter
when the catheter enters the vein easily and nonsurgically.
manometry or pressure-waveform mea- • After the injury has been evaluated and a treat-
surement provides unambiguous confirma- ment plan has been executed, confer with the
tion of venous location of the catheter and surgeon regarding relative risks and benefits
(2) when the wire passes through the cath- of proceeding with the elective surgery vs
eter and enters the vein without difficulty. deferring surgery to allow for a period of
–– If there is any uncertainty that the catheter patient observation.
or wire resides in the vein, confirm venous
residence of the wire after the wire is
threaded; insertion of a dilator or large- 2.8.1 Resource Preparation
bore catheter may then proceed.
• After final catheterization and before use, con- • Perform central venous catheterization in an
firm residence of the catheter in the venous environment that permits use of aseptic
system as soon as clinically appropriate. techniques.
• Confirm the final position of the catheter tip as • Ensure that a standardized equipment set is
soon as clinically appropriate. available for central venous access.
–– For central venous catheters placed in the • Use a checklist or protocol for placement and
operating room, perform a chest radiograph maintenance of central venous catheters.
no later than the early postoperative period • Use an assistant during placement of a central
to confirm the position of the catheter tip. venous catheter.
44 A. Chakraborty et al.
attempt, reduce the number of overall attempts, tion of small hematomas was observed in 6% of
improve patient’s satisfaction and reduce overall cases [62, 63]. Similar findings were reported
procedure-related complications [50–54]. while subclavian venous cannulation under US
US aid leads to increased success rates of guidance in patients with deranged coagulation
catheter placement in the first attempt, both in parameters [64].
central venous catheters [55] and arterial cathe- US is useful in patients who are obese, edema-
ters, in adults and children [56]. Shiloh et al. [57] tous, have hematomas from previous attempts, or
reported an increase of 71% in the success rate of have weak or missing arterial pulsations. During
radial artery catheterizations. cardiopulmonary resuscitation, US can visualize
Estimates of the complication rate of central the vascular anatomy without relying on an arte-
venous catheterization without the use of US rial pulsation [65]. In patients with nonpulsatile
range between 5% and 19% [58, 59]. Us-guided ventricular assist device in situ, the peripheral
vascular punctures lead to reduced complications pulses are weak or absent and most of them are
associated with traditional techniques, such as anticoagulated, inadvertent arterial puncture dur-
failure of catheter placements, arterial puncture, ing central venous cannulation may lead to seri-
hematoma formation, hemothorax, and pneumo- ous complications [66].
thorax. Hind et al. [55] in a meta-analysis com- In addition, US can be used to screen for ves-
pared central venous catheterization using sel patency, vascular abnormalities, and anatomi-
US-guided puncture with those carried out by cal variations, which can be useful in patients
traditional methods. They reported a reduction of having variations in the relationship between the
86% in relative risk of catheter placement fail- internal jugular vein and carotid artery [67, 68].
ures using ultrasonography, 57% reduction was There are very few alternatives to using US
seen in relative risk of mechanical complications and obtaining visual feedback during vessel can-
(p = 0.02). nulation. Most of them, such as fluoroscopy, are
In another systematic review, which included not as readily available, require specialized train-
cannulation of various central venous structures, ing and certification, and cost.
it was reported that US aid leads to reduction of
82% of relative risk of failure of catheterization
and significantly less occurrence of arterial punc- 2.11 Concerns and Limitations
tures, local hematomas, pneumothorax, and of us-Guided Vascular Access
hemothorax had a reduction of relative risk of
75%, 70%, 79%, and 90%, respectively [60]. US itself is noninvasive and does not cause any
US-guided cannulations lead to cost saving. harm to the patient directly, but it guides an inva-
Calvert et al. estimated a saving of 2000 pounds sive procedure (needle/catheter insertion into a
for each thousand venous central catheterization vessel), and, thus, may result in complications.
guided by ultrasonography compared with those The following concerns can be identified while
guided by anatomic parameters [61]. Reduction using US for vascular puncture/cannulation.
in the average time spent in the procedure is also The operator is usually busy looking at the US
reported as fewer attempts are needed to success- screen searching for the needle, which is always
fully puncture the vessel [56]. not clearly visible especially during the out-of-
US is found to be useful in patients with bleed- plane approach, which can lead to inadvertent
ing diathesis or coagulopathies. Using the tradi- carotid puncture. The needle also may exit the
tional method, Fisher et al. [57] reported a rate of posterior wall of the jugular vein and enter the
9% of minor complications (hematoma forma- carotid artery [69]. The long-axis approach may
tion and bleeding on puncture site) in patients not prevent this complication as the carotid artery
with abnormal platelet count or coagulation is not visualized side by side, and a slight oblique
parameters. In another study, no major complica- needle orientation may not allow proper needle
tions were reported in 133 patients with deranged visualization. Therefore, the incidence of carotid
coagulation. Bleeding on puncture site or forma- puncture during right IJV cannulation can be as
46 A. Chakraborty et al.
high as 4% [70] despite using US [71–73]. better safety profile, ultrasound (US)-assisted
Similarly during subclavian vein cannulation, vascular cannulation is being preferred over clas-
inadvertent puncture of the pleura may result in a sic landmark-based techniques. Literature regard-
pneumothorax. ing training, supervision, and competence needed
In patients with shorter neck anatomy, the regarding central venous access device (CVAD)
long-axis US view of the internal jugular vein insertion is scarce and not fully standardized. No
may be difficult to obtain. The use of US to punc- standard didactic or simulation training is
ture the subclavian vein results in a puncture site required before CVAD insertions by clinicians in
that is usually more lateral compared to the land- training, neither the role, experience, or compe-
mark puncture technique. The close proximity of tence of the supervisor is specified [77].
the vessels and the pleura must be kept in mind Ultrasound guidance CVAD insertion needs
because the angle of cannulation is usually education and training to ensure patient safety
steeper when using US, it is especially important and avoid major complications with the insertion
to align and constantly visualize the needle to of CVAD [78–82].
avoid pleural injury [74]. Understanding of basic anatomy, ultrasound
US guidance does not necessarily mean cor- physics and imaging, and infection prevention
rect placement of the guidewire in the vascular strategies are necessary [45, 83].
lumen, rather the visualization of the guidewire Multiple training techniques have been
in the venous lumen via peripheral ultrasonogra- described to aid the use of ultrasound for central
phy can be misleading as the wire may have venous cannulation [45, 84]. All forms of training
punctured the posterior wall and entered the should lay importance on developing proficiency
carotid artery [75]. in both cognitive and psychomotor skill sets and
Other concerns of US-guided vascular access must include image acquisition, interpretation,
are infections if a proper aseptic technique is not real-time use of ultrasound for vessel puncture
applied, procedural delays due to nonavailability and cannulation, and an experienced instructor
of the equipment, and the costs involved with the who demonstrates to the trainee how to translate
buying and maintaining the US equipment [76]. 2D imaging to perform a 3D task [85].
Routine US use may result in a “de-skilling” In 2013, an international evidence-based con-
of the landmark-based techniques as they are less sensus task force was established through the
taught and practiced nowadays, which might World Congress of Vascular Access (WoCoVA)
result in higher complication rates when US is to provide definitions and recommendations for
not available [76]. training and insertion of CVADs.
To achieve adequate skills for using US skills The task force proposed 16 recommendations.
high-quality care, formal education and training
(including simulation) with a structured certifica- 1. Anatomy and physiology of relevant body
tion of US skills for vascular access and the system.
development of a consensus standard for these 2. Ultrasound for insertion and assessment.
training programs have been suggested. 3. Central venous device tip location.
4. Infection control and sterile technique.
5. Device selection and indications.
2.12 Training 6. Insertion procedures, complication preven-
tion, evaluation, and management.
2.12.1 Training for Ultrasound- 7. Care and maintenance practices.
Guided Vascular Cannulations 8. Qualification and competency.
9. Simulation training.
Vascular cannulation is an important aspect of 10. Anatomical models.
patient care for the administration of fluids and 11. Objective grading and proficiency.
medications and for monitoring purposes. Due to 12. Examination and competency.
2 Ultrasound-Guided Vascular Cannulation 47
B. Internal jugular vein can be seen joining A. LAX in-plane approach is preferred as
the subclavian vein above the clavicle the depth of the needle tip can be seen
C. Pleura can be seen inferior to the subcla- and hence reducing the risk of arterial
vian vein puncture
D. Subclavian artery lies posterior to the B. LAX in-plane approach allows the entire
subclavian vein needle to be visualized and hence suc-
E. All of the above cess rate is higher
16. Difficult cannulation is expected for an obese C. SAX out-of-plane approach allows better
individual who requires CVL placement. visualization of vein in relation to the
Which of the following should be considered artery and helps to avoid accidental arte-
during the preparation? rial puncture
A. High-frequency linear transducer with a D. SAX out-of-plane approach allows the
large footprint entire needle to be visualized and hence
B. Low-frequency curvilinear probe with a reducing the risk of arterial puncture
large footprint E. SAX out-of-plane approach allows nee-
C. Hockey stick transducer with a small dle tip to be visualized and can help to
footprint minimize the risk of posterior wall
D. High-frequency linear transducer with a puncture
small footprint 20. Which of the following statement is true with
E. None of the above regard to limitations of US-guided CVL
17. When cannulating the femoral for CVL
insertion
placement, which of the following statement A. Arterial puncture is not possible if CVL
is true with regard to the anatomical relations is inserted under US guidance
of the femoral vein? B. Central line infection rate is higher when
A. Femoral artery is the most medial US is used for CVL insertion
structure C. In obese patients with short neck, the use
B. Femoral vein lies lateral to the femoral of linear probe and long-axis view is nec-
artery essary in order to increase change of suc-
C. Femoral vein lies medial to the femoral cessful puncture
artery D. When using US in CVL insertion, an
D. Femoral vein lies next to the femoral inexperienced user might focus on the
nerve US images and neglect traditional prin-
E. None of the above ciples with regard to needle direction
18. Which of the following options can accu- E. None of the above
rately assess IJV CVL position tip?
I. Chest radiography
II. Vascular ultrasound imaging References
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Point of Care Ultrasound
of the Airway 3
Deborah Khoo
Abbreviations
(d) Front of neck access—cricothyroidotomy,
percutaneous dilatational tracheostomy
CTM Cricothyroid membrane (PDT).
DLT Double lumen tube
(e) Airway nerve blocks—superior laryngeal
ETT Endotracheal tube nerve block.
FONA Front of neck access (f)
Extubation—leak test, predicting post-
PDT Percutaneous dilatational tracheostomy extubation stridor, successful extubation.
SGA Supraglottic airway
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022 55
A. Chakraborty, B. Ashokka (eds.), A Practical Guide to Point of Care Ultrasound (POCUS),
https://doi.org/10.1007/978-981-16-7687-1_3
56 D. Khoo
Air-Mucosa Interface:
Bright hyperechoic line
Carotid
Thyroid gland Artery Esophagus
Reverberation artefact
(posterior acoustic shadowing)
D.
(continued)
58 D. Khoo
Table 3.1 (continued)
Level of airway Appropriate manner of
that probe beam holding ultrasound to obtain
will be traversing view Normal ultrasound appearance Application
Larynx— The thyroid cartilage
Thyroid is pyramidal in shape
cartilage and and is the largest carti-
vocal cords laginous structure in
the airway ultrasound
exam. May be more
prominent in males
and calcified in the
elderly
The vocal cords can
also be seen at this
Transverse view of the airway at the level of
level. Look for vocal
the thyroid cartilage: AC = anterior
cord asymmetry
commissure; PC = posterior commissure;
(indicating vocal cord
VC = vocal cords; SHM = sternohyoid
palsy), lesions, and
muscle; STM = sternothyroid muscle;
cysts
ArC = arytenoid cartilage; TC = thyroid
Extubation—Air
cartilage
column width
difference at the level
of the vocal cords
before and after ETT
cuff deflation helps to
establish the presence
of air leak and
minimize the risk of
post-extubation stridor
Larynx—Cri- The cricothyroid
cothyroid membrane (CTM) is
membrane seen as a bright
hyperechoic line
(green arrow).
Locating and marking
out of the CTM can be
done rapidly and with
more accuracy than by
the palpation method,
especially in patients
who are obese or have
impalpable structures
Pre-procedural or
real-time ultrasound
guidance for
cricothyroidotomy is
also useful for
avoidance of
unintended airway
injury. Look out for
vessels (e.g., thyroid
artery) crossing the
intended puncture site
3 Point of Care Ultrasound of the Airway 59
Table 3.1 (continued)
Level of airway Appropriate manner of
that probe beam holding ultrasound to obtain
will be traversing view Normal ultrasound appearance Application
Larynx—Cri- The airway at the
coid cartilage level of the cricoid
cartilage is the
narrowest part of the
larynx in pediatric
patients. In both
adults and paediatric
patients, measurement
of the diameter of
airway (orange arrow)
can be used to assist
endotracheal tube
(ETT) sizing
according to the
external diameter of
the ETT
Air creates a bright
white air-mucosa
interface with a
posterior acoustic
shadow
The thyroid gland and
thyroid isthmus may
be seen here or at the
level of the tracheal
rings
Trachea Tracheal rings are less
rings—Trans- prominent and less
verse view superficial compared
to the cricoid cartilage
Use of color doppler
at this level is useful
to check for vascular
structures (e.g., a
high-riding
innominate artery)
that may be crossing
the intended site of a
tracheostomy, as well
as to assess the
optimal site and
spacing between
tracheal rings for a
tracheostomy
Suprasternal Correlates to sizing of
notch double lumen tubes.
Blood vessels may
also be seen in this
area
(continued)
60 D. Khoo
Table 3.1 (continued)
Level of airway Appropriate manner of
that probe beam holding ultrasound to obtain
will be traversing view Normal ultrasound appearance Application
Trachea— Longitudinal midline
Longitudinal ultrasound view of the
view trachea
The hypoechoic
tracheal rings give the
classic “string of
pearls” appearance.
The CTM can again
be identified between
the thyroid and cricoid
cartilage
ble track” appearance parallel to the air-mucosa airflow. The ratio of the air column width
interface (Figs. 3.5 and 3.6) [6]. (Fig. 3.7) pre-extubation (with cuff deflated) to
the air column width immediately post-intuba-
3.3.1.1 Extubation tion, is a potential predictor of post-extubation
Post-extubation stridor (PES) is a concern in stridor. A ratio of <0.8 is predictive of post-
patients who have been intubated for an extended extubation stridor [8, 9]. If the immediate
period, or who may have airway edema for vari- post-intubation air column width is not available,
ous reasons. Cuff-leak tests are widely used to the difference in the air column width with the
predict if the patient may be successfully extu- cuff inflated and deflated may be a possible pre-
bated, and have good specificity, but low sensitiv- dictor, although cut-off values in adults have not
ity, as well as inter-individual variability. This yet been established [10].
means that even if a leak is present, the patient
must be closely monitored for PES post-
extubation [7, 8]. PES often results in reintuba- 3.3.2 Supraglottic Airway (SGA)
tions, prolonged intubation, and its associated
comorbidities. Supraglottic airways may be visualized in the
Pre-extubation ultrasound can allow for transverse orientation, at the submental level.
assessment of the vocal cords, larynx, and ease of Appearance may differ depending on the make
and model of the SGA, but generally would have
a rounded, spade-like shape. Ultrasound may
help in troubleshooting a mispositioned
SGA. Ultrasound may also be used to confirm
intraesophageal position of a gastric tube inserted
via the gastric port of second-generation SGAs
(Fig. 3.8).
Fig. 3.6 Double track lines (blue arrows) can also help to confirm endotracheal ETT placement
62 D. Khoo
a b
Fig. 3.8 (a) Central, well-positioned SGA (blue arrow), seen in the transverse view at the submentum level. (b) SGA
tip folded and off-midline (orange arrow)
Fig. 3.9 Ultrasound appearance of a double lumen tube (blue arrows) in the trachea
3 Point of Care Ultrasound of the Airway 63
Direction of
Direction of needle needle entry
Thyrohyoid
membrane
entry and spread of
Hyoid bone local anaesthetic
Thyrohyoid
muscle
Superior Thyroid
laryngeal cartilage
nerve Superior
Superior
laryngeal
Greater cornu nerve laryngeal
laryngeal shadow
artery
Fig. 3.10 Ultrasound visualization and techniques for superior laryngeal nerve blocks
3.4 Airway Nerve Block • Identify and mark out the CTM—in prepara-
tion for emergency front of neck access if it
The superior laryngeal nerve (SLN) block is a use- becomes necessary. Recommended to do
ful adjunct to facilitate awake intubations or rigid before undertaking potentially difficult air-
bronchoscopy. The internal branch of the SLN ways such as awake intubations, trauma, or
runs beneath or lateral to the greater horn of the obese airways [1, 14, 15].
hyoid, before penetrating the thyrohyoid mem- • Identify the location of airway structures in
brane to provide innervation to the larynx. patients who may have tracheal deviation or lim-
Ultrasound-guided superior laryngeal nerve blocks ited neck mobility, e.g., previous radiotherapy or
allow for target visualization, as well as ensuring surgery to the neck, cervical spine contractures,
spread of local anesthetic and avoidance of vascu- neck masses, and thoracic and spine deformities.
lar (e.g., the superior laryngeal artery) and other • Right-sizing of airway device and selection of
anterior neck structures (Fig. 3.10) [12, 13]. a safe tracheal interspace or location of CTM
for front of neck access.
3.5.1 Focused Rapid Ultrasound 1. Identify the mentum and sternal notch as the
Review of the Upper Airway cephalad and caudal ends of the airway,
respectively.
3.5.1.1 Goals 2. Holding the ultrasound probe in a transverse
manner, begin from the mentum and move the
• To inform of obstructions to securing the air- ultrasound probe in a caudal direction.
way in potentially difficult airways. 3. Identify the thin, bright line of the hyoid bone,
• To check for injuries to the airway, especially looking for continuity of the bone and pres-
in patients who have sustained trauma. ence of soft tissue swelling.
64 D. Khoo
4. Move the probe in a caudal direction and 9. To obtain the longitudinal midline view of the
identify the triangular thyroid cartilage and trachea, slide the ultrasound probe laterally
vocal folds. In a spontaneously breathing until medial edge of the probe is positioned
patient, look for symmetry of vocal cord such that only half of the trachea is in view at
shape and movement. If trauma is suspected, the edge of the ultrasound screen. Rotate the
look for discontinuity on the external surface ultrasound probe so that the lateral edge is
of the cartilage as well as soft tissue now cephalad in the sagittal plane. Identify
swelling. the thyroid and cricoid cartilages, and the
5. Sliding the probe caudally, identify the CTM in between. Mark out the CTM as well
bright white line that denotes the air-mucosa as the midline of the airway.
interface of the cricothyroid membrane
(CTM).
6. Confirm the position of the CTM by continu- 3.5.2 Potential Ultrasound
ing to slide the probe caudally in a transverse Predictors of Laryngoscopy
orientation, seeing the change to the homoge-
neously hypoechoic cricoid cartilage. Airway ultrasound is being increasingly used to
7. Return the probe to the level of the CTM and identify potentially difficult airways, alongside
mark its position, as well as that of the mid- clinical examination and patient history [2]. It is
line, on the patient. important to note that no single criteria predict
8. Continue to scan caudally, observing the airway difficulty in totality, and greater accuracy
change from the cricoid cartilage to the tra- can be achieved with combination of predictors
cheal rings until it reaches the suprasternal and tailoring to the patient’s history and anatomy.
notch. Observe for pulsatile arterial structures Figure 3.11 and Table 3.2 summarize the param-
in this area. eters [4, 16–19].
Sternum
3 Point of Care Ultrasound of the Airway 65
Table 3.2 Summary of ultrasound airway parameters that may predict a difficult airway
Tongue width:
How to obtain image: Linear probe
in transverse orientation at
submental level
Interpretation: A width of >28 mm
corresponds to a higher probability
of obstructive sleep apnoea and
difficult laryngoscopy
(continued)
66 D. Khoo
Table 3.2 (continued)
Skin to epiglottis (SE) distance:
How to obtain image: Linear probe
in transverse orientation just below
level of hyoid bone
Interpretation: An SE distance of
>24 mm may indicate a difficult
airway
Questions Answers
1. A pre-scan prior to performance of a cricothy- Answer: A. The cricothyroid membrane (CTM) appears as a
roidotomy reveals the following structures bright white line due to the air-mucosa interface, with a
Which of the following accurately labels reverberation artifact posteriorly. The CTM is 13–15 mm
structures 1, 2, and 3? long in adults. In the transverse orientation, scanning from
the thyroid cartilage, then to the CTM, followed by the
cricoid, and finally back to the CTM helps to visualize the
transition and ascertain the identity of the CTM [23]
1 2 3
A Cricothyroid Reverberation Sternohyoid
membrane artifact muscle
B Cricoid Reverberation Thyroid gland
cartilage artifact
C Thyroid Endotracheal Sternocleido-
cartilage tube mastoid
muscle
D Cricothyroid Endotracheal Sternothyroid
membrane tube muscle
2. A patient who has sustained a penetrating head Answer: D. Subcutaneous emphysema indicates discontinu-
and neck trauma develops difficulty breathing ity in the airway or aerodigestive tract. Nonintervention may
and is desaturating. Ultrasound of his airway miss the window of opportunity for management before the
reveals subcutaneous emphysema. Appropriate patient becomes more unstable. Positive pressure ventilation
management includes should be minimized until the airway is secured. Careful
A. Monitor the patient closely but do not ultrasound examination of the airway is useful to rapidly
manipulate the airway at this point as it may delineate distorted anatomy and formulate the safest location
worsen the situation to secure the patient’s airway, whether by intubation or front
B. Support the patient with bag-mask ventila- of neck access. Bronchoscopy evaluation is indicated as well
tion where possible. Cervical spine immobility is likely to add to
C. Intubate the patient via the oral or nasal route the complexity
D. Identify the level of injury and proceed to
secure the airway
68 D. Khoo
Questions Answers
3. After a difficult intubation, this image is seen on Answer: B. This ultrasound image shows an oesophageal
ultrasound of the airway. Appropriate immediate intubation. The air column in the ETT produces a “drop-out”
management should include: dark area below the air-ETT interface. Stylets or bougies may
produce the same, albeit smaller, effect. Monitoring of an
intubation in real time using ultrasound allows for immediate
identification of esophageal intubation
Questions Answers
5. In a preoperative assessment for an elective Answer: C. There is a vocal cord cyst at the anterior
surgery, you note that your patient has a hoarse commissure. On the ultrasound, posterior acoustic enhance-
voice. Ultrasound examination reveals the ment of the area below the fluid cyst hints at its nature.
following Careful documentation and preoperative evaluation, as well
as counselling of patient for potential worsening of voice
hoarseness is indicated. The vocal cords are abducted hence
vocal cord paralysis is unlikely. Depending on how
time-sensitive the surgery is, investigation into the cause of
the patient’s hoarse voice is useful but should not prohibit
urgent surgery from proceeding
Questions Answers
8. In a patient with known right recurrent Answer: C. The recurrent laryngeal nerve (RLN) branches
laryngeal nerve palsy, you would expect to see from the vagus nerve and supplies all the intrinsic muscles of
the following on ultrasound in the transverse the larynx, except the cricothyroid muscles. Complete paraly-
orientation at the level of the thyroid cartilage sis of the RLN results in a partially adducted vocal cord,
during inspiration: while partial paralysis results in a fully adducted vocal cord
Right vocal Left vocal cord
cord
A Abducted Abducted
B Abducted Adducted
C Adducted Abducted
D Adducted Adducted
9. A victim of a road traffic accident where the Answer: D. This unfortunate patient will have all the
vehicle caught fire was brought into the attendant issues of trauma and smoke inhalation, not to
emergency department with severe burns to his mention burns and injuries to his face and upper airway
face, although his neck is relatively unscathed.
The potential airway issues include:
A. Lower airway edema
B. Potential cervical spine instability
C. Upper airway injury
D. All of the above
10. Advantages of a cricothyroidotomy over a Answer: D. In an emergency situation, a cricothyroidotomy
tracheostomy in an emergency front of neck offers the fastest and least complicated means of front of
access include: neck airway access. However, it is thought to be associated
A. Relatively avascular structure with an increased risk of subglottic stenosis, and hence
B. More superficial and palpable cricothyroid creation of a formal tracheostomy is often performed within
membrane compared to the deeper tracheal 72 h of an emergency cricothyroidotomy
rings
C. Shorter insertion time required
D. All of the above
11. Postsurgical tracheostomy creation, a ward Answer: A. Fluid, such as blood, appears anechoic on
nurse notices swelling around the tracheos- ultrasound and will cast posterior acoustic enhancement
tomy site. Ultrasound evaluation reveals (bright area). Air will cause posterior shadowing (dark area).
anechoic areas in the subcutaneous and Ultrasound of the airway is a useful bedside examination that
peri-muscular planes is portable, can be done rapidly and noninvasively, and gives
The cause of the swelling is likely to be: immediate information which can be critical to preventing
A. Blood adverse patient outcomes
B. Subcutaneous emphysema
C. Soft tissue swelling
D. An overly tight tracheostomy strap
12. Structures that may overlie the cricothyroid Answer: C. All the other structures may be found in variable
membrane (CTM) DO NOT include: positions overlying cricothyroid membrane and care should
A. The cricothyroid artery and vein (in the be taken in the event a cricothyroidotomy needs to be
upper 1/3) performed
B. The pyramidal lobe of the thyroid gland
C. Recurrent laryngeal nerve
D. Lymph nodes
3 Point of Care Ultrasound of the Airway 71
Questions Answers
13. Differences between the ultrasound appear- Answer: B. The narrowest part of the pediatric airway is at
ance of the pediatric airway compared to that the level of the cricoid cartilage, and airway measurement
of an adult include all EXCEPT: should take place here. Ultrasound sizing of the airway is
A. A cartilaginous and hypoechoic hyoid bone more accurate compared to age-based and height-based
B. Measurement of the tracheal diameter for formulas in estimating ETT size (outer diameter) for
endotracheal tube sizing at the level of the pediatric patients [25, 26]
thyroid cartilage
C. Thinner and less echogenic cricothyroid
membrane
D. An elliptical rather than circular subglottic
airway
14. A 12-year-old child with cerebral palsy and Answer: B. This patient is an airway challenge because of his
severe scoliosis requires a spine operation to limited range of motion. Ultrasound will be difficult because
improve his respiratory function. He has very of his inability to extend his neck, and such patients are
limited cervical extension. Which of the generally small for their age. Ultrasound is a reliable tool to
following ultrasound techniques may help in predict ETT size for pediatric patients with thoracic or
this situation? lumbar scoliosis. However, pediatric patients with cervical
lateral bending will need an ETT smaller than the size
predicted by ultrasonography [27]. Real-time imaging of the
airway during intubation can also help to ensure that the ETT
is placed at an appropriate depth, but this requires a second
operator
Questions Answers
16. A 45-year-old patient attempted suicide by Answer C: The patient likely has upper airway edema and is
drinking a large volume of corrosive fluid and agitated from a combination of intoxication and hypoxia. He
alcohol. He presents to the emergency is in respiratory distress and his airway needs to be secured.
department. He is extremely agitated, trashing, He is likely to be difficult to manage without sedation but
and has pulled out his intravenous cannulas. should be kept spontaneously ventilating where possible. He
His breathing is stridorous and his pulse will not be able to cooperate with an awake intubation
oximetry reading is 88%. What is the most Rapid focused ultrasound assessment of the airway should be
reasonable plan of action? done to identify the cricothyroid membrane as well as to
evaluate airway edema and soft tissue swelling. Serial
ultrasounds can also be used to monitor progress
Questions Answers
18. A patient presents with the following lesion on Answer: A. This patient has a large retropharyngeal abscess.
CT scan and is being brought to the operating Airway anatomy may be distorted, and ultrasound can help
theatre for intubation and emergency surgery especially with ensuring accurate endotracheal tube sizing, as
well as with the identification of critical airway structures
19. The best level to measure the airway diameter Answer: C. The suprasternal notch provides an easily
to select a left-sided double lumen endotra- visualized and measured point of the airway for the purposes
cheal tube size is at the: of sizing of a double lumen endotracheal tube, according to
A. Hyoid its outer diameter
B. Thyroid cartilage
C. Suprasternal notch
D. Cricoid cartilage
20. Which of the following ultrasound features Answer: D. The skin to tracheal distance at the suprasternal
may predict a difficult airway? notch is not proven to be a marker of airway difficulty,
A. Skin to tracheal distance of 23 mm at the although a larger distance would probably correspond to a
suprasternal notch prominent chest which may interfere with the handle of a
B. Tongue width of 27 mm standard laryngoscope
C. Skin to epiglottis distance of 22 mm It is important to remember that no single parameter can
D. Mentohyoid distance of 42 mm predict airway difficulty well. Multiple ultrasound airway
parameters, together with clinical assessment, can help to
increase the rate of identification of difficult airways and
enable management by informing the clinician of the level at
which they are most likely to encounter difficulty
74 D. Khoo
30. Dankle SK, Schuller DE, McClead RE. Risk factors epiglottitis in the emergency department: a prelimi-
for neonatal acquired subglottic stenosis. Ann Otol nary study. J Ultrasound Med. 2012;31(1):19–22.
Rhinol Laryngol. 1986;95(6 Pt 1):626–30. 35. Senussi MH, Kantamneni PC, Latifi M, Omranian AP,
31. Nicolli EA, Carey RM, Farquhar D, Haft S, Alfonso Krveshi L, Barakat AF, et al. Protocolized tracheal
KP, Mirza N. Risk factors for adult acquired subglot- and thoracic ultrasound for confirmation of endotra-
tic stenosis. J Laryngol Otol. 2017;131(3):264–7. cheal intubation and positioning: a multicenter obser-
32. El Amrousy D, Elkashlan M, Elshmaa N, Ragab vational study. Crit Care Explor. 2020;2(9):e0225.
A. Ultrasound-guided laryngeal air column width dif- 36. Isaiah A, Mezrich R, Wolf J. Ultrasonographic detec-
ference as a new predictor for postextubation stridor tion of airway obstruction in a model of obstructive
in children. Crit Care Med. 2018;46(6):e496–501. sleep apnea. Ultrasound Int Open. 2017;3(1):E34–e42.
33. Hung TY, Li S, Chen PS, Wu LT, Yang YJ, Tseng LM, 37. De Jong A, Molinari N, Pouzeratte Y, Verzilli D,
et al. Bedside ultrasonography as a safe and effective Chanques G, Jung B, et al. Difficult intubation in
tool to diagnose acute epiglottitis. Am J Emerg Med. obese patients: incidence, risk factors, and compli-
2011;29(3):359.e1–3. cations in the operating theatre and in intensive care
34. Ko DR, Chung YE, Park I, Lee HJ, Park JW, You JS, units. Br J Anaesth. 2015;114(2):297–306.
et al. Use of bedside sonography for diagnosing acute
Point-of-Care Ultrasound
of the Lungs 4
Archit Sharma and Sudhakar Subramani
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022 81
A. Chakraborty, B. Ashokka (eds.), A Practical Guide to Point of Care Ultrasound (POCUS),
https://doi.org/10.1007/978-981-16-7687-1_4
82 A. Sharma and S. Subramani
4.1.1 Ultrasound Properties of Lung Overall, LUS images are based on the relative
amounts of air and fluid in the lung. If the lung is
Acoustic impedance (Z), a measure of the resis- highly fluid-filled, then it can be directly visual-
tance of particles in a medium to mechanical ized, whereas in case of pneumothorax, due to air
vibrations determines the appearance of LUS. If being present below the parietal pleura, one is
the density of the given medium and propagation unable to visualize the lung tissue directly.
velocity of US in the medium increases, the over- Although in the past significant attenuation of US
all resistance to sound signal increases. In the signals had discouraged clinicians to utilize US for
thoracic region, there are mediums with different the assessment of lung, in the current day and age,
impedances that cause some of the sounds to be a better understanding of physical properties and
transmitted and some to be reflected as an echo. new and improved ultrasound probes have played
The amount of reflection is based on the differ- a significant role in expanding the use of LUS.
ences in acoustic impedance: fluid appears as
black due to constant Z resulting in no echo, and
soft tissues have a minimal reflection. Majority of 4.1.2 Types of Ultrasound
the reflection happens between soft tissue and air Transducers for LUS
reflect 99.9% rendering this interface virtually
impenetrable to the US. This leads to inability to Table 4.1 shows properties, usefulness, and limi-
visualize normal aerated lung beneath the pleura tations of three commonly used probes for LUS
and only artifacts can be seen [6]. (Fig. 4.1).
Intercostal spaces
Intercostal spaces
5th
3rd 4th
2nd 2nd
9 5 1 17 20 23
26
Anterior axillary line 13
12 3rd
11 6 2 18
21
10 14
10 24 27
9 4th
Mid-axillary line 19
3 22
7 25
16 15 11
5th 28
15 4
14 8
16 12
13
Parasternal lines Mid-clavicular Anterior axillary
line line
28 - point method
8 - point method
6 - point method
& 4 - point method
4.1.4 Blue Protocol (Four-Point Other least commonly used methods are six-
Method) point, eight-point, and 28 points. A six-point
method consists of two blue points and an addi-
Blue protocol is based on a four-points assess- tional scanning site on the fifth intercostal space at
ment, which is basically upper and lower ante- mid-axillary line [9]. In the eight-point method,
rior points, on both sides of the chest wall. A two anterior points between the sternum and the
positive point is defined as the presence of at anterior axillary line, and two lateral points
least three B-lines. For positive examination, between the anterior and the posterior axillary line
for certain acute respiratory disorders, at least are the scanning sites [10]. In the 28-points
three B-lines on each scanning site must be method, scanning sites are at 16 points on the right
present [8]. side and 12 points on the left as shown in Fig. 4.3
4 Point-of-Care Ultrasound of the Lungs 85
Subcutaneous
Tissue
Pleural Line
The lung sliding and lung pulse are the two The key LUS findings associated with pneumo-
dynamic findings found in a normal lung ultra- thorax are the absence of lung sliding, absent
sound. These two features are caused by the B-lines, lung pulse, and presence of the lung
movement of the lung surface (visceral pleura) point. In supine patients, air, being nondependent
in relation to the innermost chest wall (parietal tends to collect anteriorly. In order to exclude or
pleura). The lung sliding represents air move- to diagnose pneumothorax, it is recommended to
ment during respiration and lung pulse indicates place the probe on the highest point of the ante-
the transmission of cardiac contractions through rior chest to demonstrate lung sliding. Absence of
the lung. Turning the probe transversely will lung sliding has a 95% sensitivity and 100% neg-
abolish the rib shadows so more of the pleural ative predictive value in predicting a pneumotho-
line can be seen. The danger of this is that an rax [12]. M-mode imaging will be helpful in
inexperienced user may interpret a rib as the certain challenging patients to diagnose pneumo-
pleural line and incorrectly diagnose absent thorax. It demonstrates only horizontal lines
lung sliding. M-mode imaging will be helpful to without sandy appearance, normal appears in
exclude pneumothorax as it shows seashore near field termed as “stratosphere sign” or bar-
sign, one of the characteristic features of lung code sign (Fig. 4.7) However, one should be
sliding. The horizontal line represents subcuta- aware of other conditions causing absence lung
neous tissue above the pleural line while the sliding such as pleural effusion or if both pleurae
movement of lung sliding appears as sand in far fused together due to underlying pneumonia,
field (Fig. 4.6). pleurodesis, or ARDS. Moreover, the lung sliding
Lung
Sliding No
Yes B Lines No
Yes
Lung
point Yes
NO PNEUMOTHORAX PNEUMOTHORAX
No
Lung
Yes No
pulse
The appearance of LUS depends on the relative as the “shred sign.” Air within the consolidated
aeration of alveoli. Pneumonia is an inflamma- area may remain in small aerated patches of lung,
tory, and infectious process involving the lungs. or more commonly air remains within small bron-
Typically, the alveoli in intensely inflamed areas chi. The echogenic appearance of small air bub-
fill with inflammatory fluid or pus, and this is bles all lined up within a bronchus is known as the
known as consolidation. The changes may be sonographic air bronchogram.
widespread, patchy, or lobar. Ultrasound can
detect the pulmonary changes associated with
pneumonia as long as the process involves some 4.1.12 Atelectasis
of the pleural surface. Pneumonia progresses
through stages, and the ultrasound changes vary Subpleural echo-poor region or tissue-like
depending on the degree and extent of consolida- echotexture is seen in compression or obstructive
tion. In the appropriate clinical setting, a local- atelectasis. This appearance is due to the absence
ized patch of numerous B-lines, often with tiny of peripheral lung expansion. Compression atel-
areas of subpleural consolidation, suggests early ectasis caused by massive pleural effusion is seen
pneumonia. as floating wedge-shaped tissue-like structure, as
As the disease progresses, inflammatory and is demonstrated in Fig. 4.14 [21]. The absence of
purulent fluid fills the alveoli and the lung appears dynamic air/fluid in this tissue like echotexture
solid, with a homogenous relatively fine echotex- helps in differentiating it from pneumonia. Loss
ture similar to liver. The sonographic appearance of aeration in lung at various stages due to
of frank consolidation looks remarkably liver-like gradually increasing pleural effusion can be seen
and is also termed hepatization. More commonly as compression atelectasis develops. Compression
there are smaller areas of consolidation, as dem- or resorptive atelectasis shows early and late
onstrated in Fig. 4.13. Where these abut the pleu- signs along with tissue-like echotexture. Early
ral surface, they are linear, but their deeper borders signs are abolished lung sliding with lung pulse,
usually demonstrate an irregular interface with standstill cupola. Residual trapped air with static
underlying aerated lung. This irregular junction air bronchogram is a late sign. Air is completely
between consolidated and aerated lung is known absorbed subsequently.
4 Point-of-Care Ultrasound of the Lungs 91
Fig. 4.14 Pleural effusion along with atelectatic lung The BLUE protocol has been proposed to help
floating in the pleural fluid in the diagnosis of various lung conditions, as
described before [26, 27]. Each region or zone is
4.1.13 Asthma/Chronic Obstructive then sonographically characterized. Integration
Pulmonary Disease of various LUS findings in all regions/zones
gives sonographic diagnosis. Finally, interpreta-
The presence of pleural line, lung sliding, tion of sonographic diagnosis is done in context
A-Lines in 2D, and seashore sign in M-mode in with history, clinical assessment, other investiga-
both lungs as characteristic LUS picture of aer- tions, and laboratory data. One algorithm is sug-
ated lung have been mentioned above. In condi- gested in Fig. 4.16. Table 4.2 summarizes the
tions like COPD, asthma and pulmonary major LUS findings in different pathological
embolism subpleural aeration are usually not states.
affected. Lung sliding may be reduced by hyper-
inflation [24]. These conditions usually present
with a similar LUS picture of aerated lung, as 4.1.15 Lung Ultrasound in COVID-19
shown in Fig. 4.15. The BLUE protocol has
described this LUS picture as A-profile and sug- POCUS has found its wide application in emer-
gested a decision tree to differentiate these gency and critical care medicine [2]. Many stud-
chronic conditions [25]. ies have shown that ultrasound imaging is more
sensitive than chest X-ray examination in the
diagnosis of ventilator-associated pneumonia
4.1.14 Pulmonary Embolism [28] and community-acquired pneumonia
(CAP) [29–31]. It can also make a sensitive
In the case of a pulmonary embolism, usually an diagnosis of viral pneumonia such as H1-N1 or
A-profile or A-pattern is seen in LUS. The BLUE H7-N9 earlier than chest X-ray examination
protocol suggests searching for venous thrombo- [32] and thus has been recommended as an
sis if A-profile is present. If venous thrombosis is alternative screening method for such pneumo-
present, diagnosis of pulmonary embolism is nia in endemic areas [33, 34]. However, ultra-
considered in patients with acute respiratory fail- sound identification between viral pneumonia
ure. Peripheral pulmonary embolism is seen as and bacterial pneumonia remains a huge chal-
multiple hypoechoic subpleural wedge-shaped lenge. Use of LUS is feasible in the diagnosis of
tissue-like echotexture. There can be local or COVID-19, and the ultrasound images are
basal pleural effusion also [26]. mainly manifested as B-line artifacts, rocket
92 A. Sharma and S. Subramani
The
BLUE
(upper and lower BLUE-points) protocol
Lung Sliding
Table 4.2 (continued)
Lung pathology USG features Distribution
Pulmonary edema Ribs and rib shadows: Present Both lungs
Hyperechoic pleural line and lung sliding: Homogeneous
Present Dependent areas
Pleural line and subpleural abnormalities:
Absent
A-lines: Present
B-lines: Significant and ≥2 bilateral regions +
ALI/ARDS Ribs and rib shadows: Present Both lungs
Pleural line: Present Inhomogeneous
Lung sliding: Present/may be ↓ Spared areas of normal
Pleural and subpleural abnormalities: Present Appearance seen
Anterior subpleural tissue like echo may be
seen
A-lines: Present
B-lines: Significant but irregularly spaced
Pulmonary fibrosis Ribs and rib shadows: Present Affected lung may be bilateral
Pleural line and lung sliding: Present or unilateral
Lung sliding: Normal/may be ↓ Focal/multifocal
Pleural line and subpleural abnormalities: Inhomogeneous
Present
A-lines: Present
B-lines: Significant and spaced
Lung contusion Ribs and rib shadows: Present In affected lung
Pleural line and lung sliding: Present May be bilateral or unilateral
Lung sliding: Normal/may be ↓ Focal/multifocal
Pleural line and subpleural abnormalities: Inhomogeneous
Present
A-lines: Present
B-lines: Significant and spaced/crowded
Interstitial/ Ribs and rib shadows: Present In affected lung
broncho-pneumonia Plural line and lung sliding: Present May be bilateral or unilateral
Lung sliding: Normal/may be ↓ Focal/multifocal
Pleural line and subpleural abnormalities: Inhomogeneous
Present
A-lines: Present
B-lines: Significant and spaced/crowded
Pneumonia consolidation Ribs and rib shadows: Present In affected lung
Pleural line and lung sliding: Absent May be unilateral or bilateral
Tissue like echotexture of consolidated lung Focal/multifocal
Dynamic air/fluid bronchogram: Present Inhomogeneous
Shred sign: Present
Atelectasis Ribs and rib shadows: Present In affected lung
Pleural line and lung sliding: Absent
Tissue like echotexture of atelectatic lung
Dynamic air/fluid bronchogram: Absent
Shred sign: Absent
Attendant signs of atelectasis: Present
Evolving atelectasis
Image characteristics depend on aeration
COPD chronic obstructive pulmonary disease, USG use of ultrasonography
* Correlate USG image with history, clinical examination, and clinical presentation
94 A. Sharma and S. Subramani
extrapleural extension can be evaluated in part by exam. Exceptional cases provide difficult inter-
sonography. The use of color Doppler is funda- pretation, even for experts. Is lung ultrasound
mental for evaluating the vessels of this region. easy? Some experiences show high interob-
The complications commonly associated with server agreement [8]. A burgeoning literature,
interventional procedures involving the chest, up to a consensus conference, seems to confirm
regardless of the type of guidance used, are this accessibility [2]. A scientific assessment of
pneumo- and hemothorax, hemoptysis, vasovagal the learning curve remains to be done, not in
reactions, and if a malignant lesion is being biop- volunteers (creating a selection bias), but in
sied, neoplastic seeding along the needle tract. unselected physicians. Care should be taken to
When interventional procedures are performed confide training to experts choosing simplicity,
under ultrasound guidance, the rate of complica- although one can practice lung ultrasound with
tions is around 1% [40], which is lower than the any machine, any probe, and any teaching
rates reported for CT-guided procedures [41]. approach.
In conclusion, the scope of LUS in emer-
gency and critical care settings has expanded
4.1.17 Advantages of LUS extensively. This imaging modality is easily
available at bedside, real time, and free of
All intensivists prefer the least invasive tool, all else radiation hazards in comparison to conven-
being equal. Ultrasound is an answer to the long- tional imaging modalities of lung, in critically
standing dilemma: “Radiography or CT in the ill patients. It can be used easily at the bedside
ICU?” Radiography is a familiar tool that lacks to assess initial lung morphology in severely
sensitivity [42]: about 60–70% [43]. CT has high hypoxemic patients and can be easily repeated,
accuracy but severe drawbacks: cost, transportation allowing the effects of therapy to be moni-
of critically ill patients, delay between CT and the tored. Its use in the diagnosis of lung diseases
resulting therapy, renal issues, anaphylactic shock, is real but with some practical limitations.
and mainly high irradiation [44]. Ultrasound has Importance of history taking and clinical
quite similar performances to CT [12, 45] being on examination cannot be undermined, and one
occasion superior: better detection of pleural septa- should not jump to the conclusion using just
tions, necrotic areas, real-time measurement allow- the LUS findings.
ing assessment of dynamic signs: lung sliding, air
bronchogram [46], and diaphragm [47]. Ultrasound
should be considered as reasonable, bedside “gold elf-Assessment Questions: Select
S
standard.” For all assessed disorders, it provides the Best Answer
quantitative data. Pleural effusions can be quanti-
fied [48]. Lung consolidation can be monitored, 1. The maximum reflection of ultrasound sig-
which is useful for those who want to increase end- nals during thoracic ultrasound happens at
expiratory pressure [49]. The volume and progres- A. Skin and subcutaneous
sion of a pneumothorax are monitored using the B. Subcutaneous and muscle layer
lung point location [50]. Lung ultrasound will favor C. Soft tissue and pleura
programs allowing decrease in bedside radiographs D. Pleura and lung parenchyma
and CTs in the next decades. 2. Following are the features of using a linear
ultrasound probe in LUS except
A. Deeper penetration
4.1.18 Limitations B. Has narrow sector width
C. Large footprint
Dressings and subcutaneous emphysema create D. Not recommended for rapidly moving
limitations to performing a good ultrasound structures
96 A. Sharma and S. Subramani
3. For better image quality using color Doppler 7. Following are advantages of using curvilin-
all are recommended except ear probe in LUS except
A. Using wall filter for rapidly moving A. Smaller footprint
structures B. Higher penetration
B. High scale velocity C. Ideal for assessment of diaphragm
C. Adjust color gain to get “snowstorm” D. Lower frequency
appearance 8. Blue protocol is one of the commonly
D. Doppler angle must be less than 60° employed methods for comprehensive
4. The structure highlighted in the following assessment of lung using ultrasound. A posi-
image represents tive blue point represents
A. Presence of two B-lines
B. Presence of one B-line
C. Presence of three B-lines
D. Presence of four B-lines
9. Absence of lung sliding is one of the essen-
tial features of LUS to diagnose pneumo-
thorax. Presence of the following
respiratory condition will cause false lung
sliding due to vigorous intercostal muscle
contraction
A. Emphysema
B. Chronic bronchitis
C. Acute respiratory distress syndrome
D. Bronchial asthma
10. The highlighted structure/artifact in the fol-
lowing ultrasound image represents
A. Pleural line
B. B-line
C. A-line
D. Z-line
5. The most appropriate technique to avoid
acoustic shadowing from ribs is
A. Using curvilinear probe
B. Scanning in sagittal plane
C. Phased array probe parallel to rib
D. Using linear probe A. A-line
6. A-lines are one of the common artifacts B. Pleural line
observed in LUS. The true statement about C. T-line
A-line is D. B-line
A. Reflection from bony surface 11. You have high peak ventilation pressures
B. Refraction from pleural surface after intubating a patient with advanced
C. Reverberation from pleural line COPD. You find bilateral anterior B-lines but
D. Refraction from fascial plane cannot find lung sliding over the right ante-
4 Point-of-Care Ultrasound of the Lungs 97
A. Pleural effusion
B. Pulmonary contusions
C. Pericardial effusion
D. Pneumothorax
13. A 50-year-old patient presents with a week-
long history of dyspnea. Fever, and cough.
His blood pressure is 90/50 and he is requir-
ing four liters of oxygen to maintain his satu-
ration. The attached picture represents the A. Pleural effusion
ultrasound exam with the probe held in place B. Pneumonia
at the base of the lung. What is the most C. Pericardial effusion
likely diagnosis? D. Pneumothorax
98 A. Sharma and S. Subramani
What is the most accurate statement? ated and fluid-filled parts of the lung
A. Patient does not have pneumothorax tissue
B. Patient does not have pneumothorax, at B. B-lines are evenly spaced horizontal
that point. A more comprehensive lung lines at integer multiples of the distance
exam is required from the skin to the pleural line
C. Patient needs an emergent chest tube C. B-lines indicate well-aerated lung
D. Patient has a hemothorax that needs to be D. B-lines are diagnostic with for
drained pneumothorax
17. Which one of the following statements about 18. Absence of pleural lung sliding can occur in
B-lines is TRUE? all of the following situations except
A. B-lines are reverberation artifacts arising A. Pneumothorax
from volumetric variations between aer- B. Apnea
4 Point-of-Care Ultrasound of the Lungs 99
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Point-of-Care Ultrasound
of the Heart: Transthoracic 5
Echocardiogram
Rohit Vijay Agrawal, Sudipta Mukherjee,
Chang Chuan Melvin Lee,
Arunangshu Chakraborty, and Manojit Lodha
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022 103
A. Chakraborty, B. Ashokka (eds.), A Practical Guide to Point of Care Ultrasound (POCUS),
https://doi.org/10.1007/978-981-16-7687-1_5
104 R. V. Agrawal et al.
It is also important to understand the limita- ducers are required, but these are beyond the
tions of point-of-care echocardiography. Unlike a scope of this book.
comprehensive echocardiographic study, the Transducer orientation. All transducers have
point-of-care echocardiography does not acquire a marker on one side of the probe which corre-
images from all possible windows and views, it is sponds with the orientation marker on the image
mainly a qualitative assessment, just sufficient to produced on the ultrasound screen [4]. This is
answer the specific clinical query by detecting relevant as the transducer orientation marker is
pathological states relevant to the clinical setting. important in view acquisition during echocar-
Furthermore, the impact of inter-individual varia- diography. In addition, the operator may notice
tion cannot be discounted as the study is inter- that, by convention, the transducer orientation
preted by providers with a wide range of expertise marker on the ultrasound screen is on the left of
and skill levels. Lastly, the study shows a single the image, while this is reversed for echocardiog-
snapshot in the course of a patient’s care and raphy (i.e., on the right of the screen).
repeated reassessment to evaluate the effective- Spectral Doppler. Spectral Doppler imaging
ness of treatment or clinical trajectory may be is important in echocardiography, as it allows for
required. At present, most hemodynamic calcula- the measurement of blood flow velocity to calcu-
tions, such as stroke volume and ejection frac- late pressure gradients and flow. Two forms of
tion, require manual operator measurement or spectral doppler exist—pulsed wave Doppler
assessment, and thus if continuous cardiovascu- (PW) which uses short bursts of ultrasound, or
lar and hemodynamic assessment is required, it is range gating to measure velocities in a specific
not the optimal tool for monitoring. area or depth (sample volume). However, at high
velocities above the Nyquist limit range ambigu-
5.1.1.1 Sonography Principles ity, or aliasing occurs, precluding measurement
and Instrumentation by PW, which is the main disadvantage of
The fundamentals of knobology and ultrasound PW. The Nyquist limit, defined as (Nyquist
physics have been covered elsewhere in this limit = pulse repetition frequency/2), is the maxi-
book, and this section will briefly cover 3 areas mum velocity that can be measured by PW. This
which are particularly relevant to bedside can be increased by adjusting the baseline shift
echocardiography. and scale. Continuous wave Doppler (CW) in
Phased array transducers. Echocardiogra- contrast, utilizes continuously emitting and
phy probes, unlike most other PoCUS methods, receiving crystals to measure velocities across
utilizes phased array transducers with adjustable the entire scan line. Generally speaking, CW dis-
focus and steering. These transducers have mul- plays the highest velocity along the scan line.
tiple piezoelectric elements which are electroni- While this allows it to have no maximum veloc-
cally separate [2]. In newer pocket-sized handheld ity, the signal is not gated, and localization of the
devices, the piezoelectric elements are replaced signal is not possible.
by a novel ultrasound-on-chip technology which
generates a voltage through a membrane that 5.1.1.2 Normal Transthoracic
generates ultrasound waves [3]. Individual ele- Echocardiography (TTE)
ments are fired sequentially to steer the ultra- The American Society of Echocardiography
sound beam by creating a radially propagating (ASE) divides transthoracic echocardiography
scan line. This allows a probe with a small foot- (TTE) into different categories—the ultrasound-
print to allow imaging of a wider field of view assisted physician examination, cardiac PoCUS,
which is essential in cardiac imaging. The small critical care echocardiography, limited echocar-
square footprint also helps to be accommodated diography, and comprehensive echocardiography
within intercostal space and to avoid obstruction [5]. The focused TTE is incorporated as part of
by the ribs. In order to produce three-dimensional several protocols such as the Rapid Ultrasound
echocardiography, specialized matrix array trans- for Shock and Hypotension (RUSH) and
5 Point-of-Care Ultrasound of the Heart: Transthoracic Echocardiogram 105
a b
Fig. 5.1 (a) Probe positioning for the parasternal long- (lower half of the image) to the right ventricle, and the
axis view, with the transducer orientation marker pointing mitral and aortic valves can be seen towards the right of
towards the patient’s left shoulder. (b) The parasternal the image
long-axis view, with the left ventricle shown posterior
patient’s left shoulder. The PSAX view demon- illary muscles. This view is attractive to PoCUS
strates different structures at different levels, of providers as it allows visual estimation of left
which there are five different scan planes. ventricular systolic function, myocardial thicken-
Generally, most PoCUS providers will focus on ing, and movement of all six wall segments at this
the mid-ventricular SAX view (Fig. 5.3a, b) level, as well as LV filling. From this view,
where LV is seen in cross-section with the 2 pap- M-Mode sonography can be aligned perpendicu-
a b
c d
Fig. 5.3 (a) Probe positioning for the parasternal short- (c) The parasternal short-axis view at the basal level,
axis view, with the transducer orientation marker point- demonstrating the “fish mouth” appearance of the mitral
ing towards the patient’s left shoulder. (b) The parasternal valve. (d) The aortic valve short-axis view. (e) The para-
mid-ventricular short-axis view, with the left ventricle sternal short-axis view at the level of the cardiac apex
shown in cross-section with the two papillary muscles.
5 Point-of-Care Ultrasound of the Heart: Transthoracic Echocardiogram 107
lar to the inferior wall passing through the center tation marker pointing towards the patient’s left
of the LV cavity allow assessment of LV end- shoulder (Fig. 5.4a). The probe is directed towards
diastolic and end-systolic diameter, which can the patient’s right shoulder and then moved later-
also be used to calculate fractional shortening ally until the cardiac apex is visualized in the
and estimate ejection fraction based on geometric middle of the upper part of the screen. The probe
formulae such as Teicholz’s formula or the modi- should then be tilted until the interventricular sep-
fied Quinone’s equation [12–14]. This is covered tum runs down the middle of the image. This view
further later in this chapter. shows all 4 cardiac chambers and allows the oper-
From the mid-ventricular view, the probe can ator to estimate the relative sizes of the right- and
be angled cephalad towards the base of the heart left-sided chambers, and visualize both atrioven-
and first produces the “fish mouth” appearance of tricular valves (Fig. 5.4b). Application of color
the mitral valve (Fig. 5.3c). The anterior and pos- flow Doppler allows the detection of mitral and/or
terior mitral valve leaflets can be visualized in tricuspid regurgitation, or turbulent flow sugges-
this view, with the anterior leaflet of the mitral tive of stenosis. Furthermore, this view allows for
valve towards the top of the screen (anteriorly) good alignment for continuous wave Doppler
and the posterior leaflet below. The anterior and interrogation of a tricuspid regurgitation jet for
posterior mitral valve leaflets are each divided estimation of right ventricular systolic pressure.
into three scallops (A1–A3 and P1–P3). A1 and Both left and right ventricular systolic function
P1 are on the right of the image and the A3 and can be estimated or measured in this view.
P3 scallops are on the left. This view is of limited Tricuspid annulus peak systolic excursion
clinical utility in the context of PoCUS. (TAPSE) (Fig. 5.4c), a surrogate measure of right
The probe is further directed cephalad to ventricular systolic function, can be measured in
obtain the aortic valve short-axis view (Fig. 5.3d), this view by aligning M-Mode ultrasound to the
in which the three cusps of the aortic valve appear lateral tricuspid annulus. In this view, the antero-
symmetrical. The tricuspid valve can be seen to lateral and inferoseptal walls of the left ventricle
the left of this image, and the pulmonary valve can be seen. The presence of any pericardial col-
anterior to the aortic valve. The anatomy of the lection can also be seen from this view.
aortic valve can be assessed in this view, as well A cephalad and leftward redirection of the probe
as the presence of any tricuspid regurgitation. from the A4C view produces the apical 5-chamber
Doppler interrogation of the tricuspid valve can view which allows for visualization of the left ven-
be performed in this view. Further cephalad tricular outflow tract and aortic valve, from which
direction of the probe from the aortic valve short- Doppler measurements can be performed.
axis view brings the main pulmonary artery into The A4C view is important as it forms the
view, although this is of limited clinical utility, basis from which additional views such as the
except in the rare case of a massive acute pulmo- apical 2-chamber, apical 3-chamber, and apical
nary embolism, in which a thrombus may be vis- 5-chambers views can be obtained, although
ible in the main pulmonary artery. these are generally not part of PoCUS protocol,
Caudal direction of the probe allows assess- but necessary for advanced measurements and
ment of the cardiac apex (Fig. 5.3e) for wall assessment of global left ventricular function.
motion abnormalities and ballooning, of which Apical 2-chamber (A2C). A 90° counter-
the latter may indicate Takotsubo cardiomyopa- clockwise rotation of the probe from the A4C view
thy. Otherwise, this view does not yield much generates the A2C view (pic), which allows assess-
clinical information for PoCUS providers. ment of the anterior and posterior walls of the left
Apical 4-chamber view (A4C). The A4C is ventricle for wall motion abnormalities, as well as
obtained at the cardiac apex—which can vary sig- left ventricular function. Furthermore, biplane
nificantly between individuals. This view is usu- measurements of left ventricular systolic function,
ally obtained by starting just inferolaterally to the such as Simpson’s biplane, require tracing end-
left nipple or left breast, with the transducer orien- diastolic and end-systolic endocardial borders of
108 R. V. Agrawal et al.
a b
Fig. 5.4 (a) Probe positioning for the apical 4-chamber tricuspid valve peak systolic excursion (TAPSE), mea-
view, with the transducer orientation marker pointing sured by M-Mode echocardiography aligned to the lateral
towards the patient’s left. (b) The apical 4-chamber view tricuspid annulus
with the right ventricle on the left of the screen. (c) The
the left ventricle in orthogonal views; thus, mea- supine position and legs bent at the knees to relax
surements performed in the A4C view will need to abdominal muscles. Subcostal window is particu-
be complemented by measurements in the A2C larly important in those patients where apical and
view. Further counterclockwise rotation of the parasternal windows are difficult to obtain, like
probe from the A2C position generates the apical the patients on ventilator and COPD patients.
3-chamber (A3C) or apical long-axis view, analo- From this window, a 4-chamber view can be
gous to the PLAX view. In this view, the antero- obtained to visualize any pericardial collections
septal and inferolateral walls of the left ventricle, and allow gross estimation of chamber sizes, ven-
as well as the left ventricular outflow tract and aor- tricular filling, and systolic function (Fig. 5.5b).
tic valve can be visualized, and unlike the paraster- Alignment also usually does not allow for ade-
nal long axis, allows for alignment of a Doppler quate alignment for quantitative techniques
beam for pulsed wave and continuous-wave mea- which use pulsed wave or continuous wave
surements of flow across the left ventricular out- Doppler. The apex is also typically not well visu-
flow tract and aortic valve. Unlike the PLAX view, alized, only the septal and lateral walls of the left
the A3C view usually allows for visualization of ventricle, precluding assessment of regional wall
the apex of the left ventricle. motion abnormalities, and limiting the utility of
Subcostal window. The subcostal window this view to visual estimates of function.
can be accessed by placing the transducer in the Nonetheless, application of color flow Doppler in
subxiphoid space (Fig. 5.5a) with patient in this view can still allow for visualization of gross
5 Point-of-Care Ultrasound of the Heart: Transthoracic Echocardiogram 109
a b
Fig. 5.5 (a) Probe positioning for the subcostal view, screen), and the left ventricle and atrium seem posterior.
with the transducer orientation marker pointing to the The liver and inferior vena cava can be seen on the left of
patient’s left. (b) The subcostal 4-chamber view. The right the screen
ventricle and atrium and anterior (upper half of the
Table 5.1 The 11 basic views which constitute a basic perioperative transesophageal echocardiographic examination
Structures visualized and acquisition from previous
View Approximate depth and angle view (if any maneuvers required)
ME 4-chamber view ME, 30–40 cm Both atria and ventricles, atrioventricular valves
0–10° (mitral and tricuspid) interatrial septum, and
interventricular septum
Inferoseptal and anterolateral walls of the LV
Right-sided chambers are seen on the right side of
the image
ME 2-chamber view ME, 30–40 cm Left atrium and ventricle, left atrial appendage, and
00–100° mitral valve
Anterior and posterior walls of the LV are seen
ME long-axis view ME, 40–50 cm Left atrium and ventricle, mitral valve, aortic valve,
120–140° and left ventricular outflow tract
Aortic root and proximal ascending aorta
Anteroseptal and inferolateral walls of the LV
Right ventricle and right ventricular outflow tract in
the far field of the image
ME ascending aortic ME, 30–40 cm Transducer withdrawn slightly from the ME
long-axis view 90–110° long-axis view
The mid-ascending portion of the aorta and right
pulmonary artery is seen
ME ascending aortic ME, 30–40 cm The mid-ascending portion of the aorta and main
short-axis view 20° pulmonary artery and its bifurcation, as well as the
superior vena cava. The left pulmonary artery is not
well visualized
ME aortic valve short-axis ME, 30–40 cm Probe advanced from the ME ascending aortic
view 0–30° short-axis view
Aortic valve, interatrial septum, left main coronary
artery, both atria, pulmonary valve, and the right
ventricular outflow tract can be seen
ME RV inflow-outflow view Me, 30–40 cm Aortic valve, interatrial septum, both atria,
60–80° pulmonary and tricuspid valves, and the right
ventricular outflow tract are visualized
ME bicaval view ME, 30–40 cm Left and right atria, interatrial septum, superior and
90–110° inferior vena cavae on the right and left of the
screen, respectively. The tricuspid valve may be seen
in the far field with increasing angles
TG mid-papillary short-axis TG, 40–45 cm Probe advanced from the mid-oesophageal views
view 0–20° The LV, papillary muscles, and all six walls at the
mid-ventricular level. Part of the RV may be seen
Descending aortic short-axis ME to TG, 30–40 cm The probe is withdrawn to a ME to TG level
view 0° The descending thoracic aorta and left hemithorax is
seen
Descending aortic long-axis ME to TG, 30—40 cm The descending thoracic aorta and left hemithorax is
view 90° seen
Abbreviations: ME midesophageal, RV right ventricle, TG transgastric, LV left ventricle
allows the calculation of LV end-diastolic and ening is a unidimensional assessment and is not
end-systolic dimensions (Fig. 5.8). Its normal clinically appropriate in the presence of regional
value is >30%. Usually, ejection fraction (EF) is wall motion abnormalities or septal dyskinesia.
considered to be double of FS. Fractional short- Fractional area change (FAC) can be measured in
112 R. V. Agrawal et al.
the PSAX view (mid-papillary segment). This is Simpson’s biplane method of disks (from tracing
a two-dimensional assessment of left ventricular endocardial borders). Both Teicholz’s formula
area change during end-systole and end-diastole, and the modified Quinone’s equation have their
the end-systolic area (ESA) and end-diastolic limitations as linear measurements which make
area (EDA), respectively. Normally it is 35–65%, assumptions regarding the shape of the left ven-
and is calculated by FAC = (EDA − ESA) × 100/ tricle and thus may be inaccurate in situations
EDA. Ejection fraction, the difference between where there is asymmetrical left ventricular con-
end-diastolic volume and end-systolic volume of traction such as ischemic heart disease. An alter-
the left ventricle can be calculated by geometric native is to use Simpson’s biplane method of
formulae (Table 5.2), such as the Teicholz’s equa- disks, which requires tracing of LV endocardial
tion or the modified Quinone’s equation (from borders in orthogonal views (i.e., 4-chamber and
M-Mode echocardiography) or the modified 2-chamber views) in both end-diastole and end-
systole. This method divides the LV cavity into
an a priori defined number of disks (usually 20),
and the volume of each disk is calculated based
on the tracing of the LV cavity [12–14, 20, 21].
Another semiquantitative measure of left ven-
tricular systolic function easily obtained by echo-
cardiography is the E-point septal separation
(EPSS) which is the minimum distance between
the tip of the anterior mitral valve leaflet endo-
cardial border of the interventricular septum.
The normal value of the EPSS is <7 mm, which
corresponds with a normal ejection fraction
[10, 11]. Based on magnetic resonance imaging
studies, ejection fraction may be estimated
Fig. 5.8 M-Mode echocardiography demonstrating the
left ventricular cavity. From this view, left ventricular end- from EPSS using the equation ejection
diastolic and end-systolic dimensions can be measured, fraction = 75.5 – (2.5 × EPSS).
and calculations of fractional shortening or ejection frac- Apart from the estimate of ejection fraction,
tion performed the operator should also consider wall motion
Table 5.2 Teicholz’s formula and the modified Quinone’s equation [12–15]
Formula Description
Teicholz’s formula:
Vol = 7D3/(2.4 + D), where D is the LV diameter (mm) Calculates LV volume using only LV diameter (D), and
LVEF = (EDV − ESV)/EDV thus its accuracy is based on geometric assumptions
regarding the shape of the LV
Measurements are performed in end-diastole and
end-systole in order to calculate the EDV and ESV,
respectively
Modified Quinone’s equation:
%ΔD2 = (LVEDD2 − LVESD2)/LVEDD2 Calculates LVEF without planimetry by performing 8
LVEF = (%ΔD2) + [(1 − %ΔD2)(%ΔL)] averaged measurements of the LV internal diameter at
Where LVEDD is the averaged LV end-diastolic different levels in the parasternal long-axis, apical 4
dimension (mm), and LVESD is the averaged LV chamber, and long-axis views at end-diastole (LVEDD)
end-systolic dimension (mm) and end-systole (LVESD). The formula further corrects
%ΔL: Correction for apical contraction for apical contraction visualized in the long axis (%ΔL)
+15% Normal apex as with Teicholz’s formula, the modified Quinone’s
+5% Hypokinetic apex equation is a linear measurement based on geometric
+0% Akinetic apex assumptions, which may be inaccurate in the context of
−5% Slightly dyskinetic apex LV distortion (e.g., asymmetrical wall motion
−15% Frankly dyskinetic apex abnormalities, focal aneurysms)
5 Point-of-Care Ultrasound of the Heart: Transthoracic Echocardiogram 113
Apical view:
17 17 17
14 15 13 14
16 16
11
12 10 Perfusion of segments:
7 8
9 1 – LAD
5 2 – LAD
4 2 3 – RCA
3 6 1
4 – RCA
5 – Cx or RCA
4-chamber 2-chamber 3-chamber 6 – Cx or LAD
7 – LAD
8 – LAD
9 – RCA & LAD
Parasternal short axis (psax): 10 – RCA
11 – Cx or RCA
1 7
13 12 – Cx or RCA
6 8 12 13 – LAD
14 – LAD
2 15 – LAD
14 16
16 – Cx or LAD
3 17 – LAD
9 11
5 15
4 10
Base Mid-vantricular Apex
Fig. 5.9 The 17-segment model and its correspondence model and coronary arterial anatomy using contrast-
to perfusion by coronary arteries depicts the fundamental enhanced cardiac magnetic resonance imaging.
methodological approach. Ortiz-Pérez JT, Rodríguez J, Cardiovasc Imaging. 2008; 1:282–93 [23]
Meyers SN, et al. Correspondence between the 17-segment
abnormalities. The wall segments of the left changes and rise in cardiac markers, but the
ventricle should exhibit symmetrical systolic characteristic ECHO finding of apical balloon-
excursion towards the center of the cavity, and ing is distinctive. Regional wall motion abnor-
the myocardium should increase in thickness by malities may be briefly evaluated with the PSAX
>30% during systole. These findings are easily view at the apical, mid-ventricular, and basal
assessed from the PSAX view, as all six seg- levels. However, a comprehensive evaluation
ments are visible. Evaluation for the presence of also requires assessment with the A4C, A2C,
regional wall motion abnormalities (RWMA) is A3C, and PLAX views. Depending on the
important for the diagnosis of acute coronary occluded vessel (left anterior descending, right
syndrome. Rise in cardiac biomarkers is delayed coronary, or left circumflex artery), different
and time is the key in critically ill patients. areas of the left ventricular wall may show
Furthermore cardiac biomarkers, such as hypokinesia, dyskinesia, or akinesia (Fig. 5.9;
Troponin I can be elevated from other causes Table 5.2) [22, 23].
such as acute kidney injury, pulmonary embo-
lism, and sepsis which need to be distinguished 5.1.1.5 Left Ventricular Diastolic
from acute coronary syndrome. ECG changes Function
can also be a delayed finding, that makes echo- When considering left ventricular function, far
cardiography important for early evaluation of more attention is paid to systolic function com-
acute coronary syndrome. The presence of pared to diastolic function. In diastolic dysfunc-
RWMAs may necessitate early coronary angi- tion, there is impaired relaxation and
ography and intervention. In critically ill noncompliance of the left ventricle (lusitropy).
patients stress cardiomyopathy can be similar to The long-standing consequence is an elevated left
the presentation as ACS with similar ECG ventricular filling pressure, left atrial pressure,
114 R. V. Agrawal et al.
and left atrial dilatation. Measurement of diastolic This results in atrial systole contributing more to
dysfunction can be easily performed by using ventricular filling and a consequently larger A
pulsed wave Doppler to measure mitral inflow wave. The E/A ratio is reversed and E is < A
velocities. The sample volume is placed at the (E/A < 0.75). The deceleration time is prolonged
coaptation point on an A4C view. This generates (>240 ms) congruent with the impaired lusitropy
an E wave which corresponds to opening of the [24–27].
mitral valve and filling of the LV from the left In grade II diastolic dysfunction, pseudonor-
atrium down a pressure gradient [24]. Diastasis malization is seen as a result of elevated left atrial
then occurs as the left ventricular and atrial pres- pressures. The increased left atrial pressure
sures equilibrate. Atrial systole then generates the results in a pressure gradient that reestablishes
A wave due to reacceleration of transmitral flow flow once the mitral valve opens and the E wave
[24]. Identification of the E and A waves can be is larger due to this increased blood flow. This
done by either observing the relative position to restores a “normal” E/A ratio of >1.0 [24–27].
an ECG trace on the sonography platform (if Grade II diastolic dysfunction should be sus-
applied) or the systolic wave on pulsed wave pected in patients with unexplained dilated LA
Doppler. The A wave occurs after the P wave on and can be unmasked by valsalva maneuver or
the ECG and precedes the systolic wave on pulsed during tissue Doppler interrogation.
wave Doppler. Measurement of time interval from Further diastolic dysfunction results in restric-
the peak of the E wave to its extrapolated return to tive ventricular filling. Due to the elevated left
baseline is known as the deceleration time and is atrial pressures filling a stiff, noncompliant ven-
representative of the time required for left ven- tricle, a high inflow velocity is seen with diastasis
tricular and atrial pressures to equalize [24]. achieved rapidly. Atrial contraction contributes
In normal diastole, the mitral E wave is usu- little to ventricular filling against the elevated left
ally slightly higher than the A wave with a resul- ventricular pressures. The E wave is usually
tant ratio of the E and A waves exceeding 1.0 twice the peak velocity of the A wave (E/A > 2)
(E/A 1–1.5). A normal deceleration time of 180– and the deceleration time is short (<140 ms),
220 ms is seen [24–27]. reflecting the rapid pressure equilibrium and
In grade I diastolic dysfunction or impaired diastasis [24–27] (Table 5.3).
relaxation, the active process of ventricular relax- Grade IV Diastolic dysfunction is restrictive
ation is slowed, with a reduction in the E velocity. cardiomyopathy, which is sonologically the same
as Grade III, the only difference being it is not However, tracing of endocardial borders
reversible with Valsalva maneuver. may not be practical at the bedside with porta-
ble sonography platforms. During systole, the
5.1.1.6 Right Ventricular Function right ventricular free wall contracts towards
Assessment the apex.
Generally, the left ventricle (LV) receives much Contractility of the right ventricular free wall
more attention during echocardiographic evalu- contributes minimally (15%) to the cardiac out-
ation, particularly the systolic function of the put. It is the vertical annular movement that is the
LV. However, the importance of the right ven- most important contributor of RV systolic func-
tricle (RV) and its assessment has garnered tion. Tricuspid Annular Plane Systolic Excursion
increased recognition. Right ventricular dys- (TAPSE) can be measured by M-Mode echocar-
function has important physiologic and prog- diography with the cursor aligned to the base of
nostic implications [28]. Conditions that may the lateral tricuspid valve annulus. Normal
result in RV dysfunction include primary RV TAPSE value is 16 mm or more. A TAPSE value
failure (e.g., myocardial infarction, severe sep- less than that indicates RV systolic dysfunction
sis) or increased RV afterload (e.g., Pulmonary [29, 30].
hypertension, pulmonary embolism, acute
respiratory distress syndrome). Assessment of 5.1.1.7 Pulmonary Artery Pressures
RV size can guide fluid resuscitation, and is Systolic, mean, and end-diastolic pulmonary
important, as further fluid loading in the con- artery pressures can be estimated by echocar-
text of RV dysfunction can further worsen RV diography.
function, create interventricular septal bowing Right ventricular systolic pressure (RVSP) is
that compromises LV filling, and worsen used as a surrogate measure of pulmonary artery
hemodynamics. systolic pressure (PASP). This is calculated by
Furthermore, certain causes of RV dysfunc- sum of the estimated or measured right atrial
tion necessitate specific therapy. Pulmonary pressure (RAP) and peak gradient (PPG) of the
emboli may require anticoagulation or thrombol- tricuspid regurgitation (TR) jet, expressed as
ysis, and massive saddle embolism with severe RVSP = TR PPG + RAP. The peak TR gradient
obstructive shock may require surgical is obtained by aligning a continuous wave (CW)
embolectomy. In patients with pulmonary hyper- Doppler beam to the TR jet to measure the peak
tension, specific physiological and pharmacolog- velocity (TR Vmax) and hence gradient by
ical strategies may be required in addition to Bernoulli’s equation, across the tricuspid valve.
treating the underlying etiology—these may Thus, RVSP = 4(TR Vmax)2 + RAP [31].
include inhaled nitric oxide (iNO), inodilator Similarly, mean Pulmonary artery = Mean TR
administration (e.g., Milrinone, Dobutamine), or gradient (obtained by tracing the TR jet in
pulmonary vasodilator therapy. CW) + RAP. If there is insufficient TR to obtain
Fractional area change (FAC) is a commonly a complete CW Doppler envelope, RVSP(and
employed measure of RV systolic function. End- hence PASP) and mean PAP cannot be
diastolic area (EDA) and end-systolic area (ESA) estimated.
can be measured by tracing the endocardial bor- Diastolic PA pressure can be estimated by
ders of the right ventricle, allowing calculation of measuring the end-diastolic velocity of PR (Vpr).
FAC by the formula FAC = (EDA − ESA) × 100/ Diastolic PAP = 4(Vpr)2 + RAP.
EDA. Values of FAC correlate well with RV ejec- In the absence of adequate TR to estimate
tion fraction obtained by cardiac magnetic reso- RVSP, the acceleration time across the pulmonary
nance imaging (CMR) measurements, which are valve can help predict the likelihood of pulmonary
regarded as the gold standard in the quantifica- hypertension, and estimate mean pulmonary artery
tion of RV systolic function. Fractional area systolic pressure (MPAP) by Mahan’s equation. A
change values of <35% indicate RV systolic dys- short pulmonary acceleration time (<92 ms) is
function [29, 30]. suggestive of elevated MPAP.
116 R. V. Agrawal et al.
Doppler assessment. Stroke volume variation scan line, which will occur at the aortic valve
may be used to predict fluid responsiveness. In (and not the LVOT) thus leading to overestima-
one of its more primitive forms, this is visualized tion of SV. Once SV is calculated, a simple prod-
as variation or “swing” in the peak of an arterial uct against heart rate will yield the estimated
waveform that varies with the respiratory cycle. cardiac output.
Stroke volume can be quantified using pulsed
wave Doppler, with the sample volume placed in
the left ventricular outflow tract (LVOT) on the
apical 5-chamber or apical long-axis views.
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Vascular Ultrasound
6
Sudhakar Subramani, Satoshi Hanada,
and Arunangshu Chakraborty
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022 121
A. Chakraborty, B. Ashokka (eds.), A Practical Guide to Point of Care Ultrasound (POCUS),
https://doi.org/10.1007/978-981-16-7687-1_6
122 S. Subramani et al.
R Common carotid A
R Subclavian A
R Brachiocephalic A L Subclavian A
Arch of
aorta
aort ing
Descending aorta
end
a
Asc
6.2.2 Ultrasound Assessment Fig. 6.2 Course of common carotid artery and IJV
of Carotid Artery
and Doppler US can be used for the evaluation of
Ultrasound of carotid artery (CA) remains a long- extracranial segments of the CA, with the com-
standing and reliable tool in the current arma- plexity of these two methods commonly being
mentarium of diagnostic modalities used to referred to as duplex ultrasound (DUS). The 2D
assess vascular morbidity, especially in an early US helps predominantly for the assessment of
stage. Both grayscale (two-dimensional—2D) morphology including size, variations in carotid
6 Vascular Ultrasound 123
bifurcation, anomaly, and of vascular wall ath- peri-operative and critical care aspects, knowing
erosclerotic changes (Figs. 6.3a, b and 6.4 nor- variations in CA is essential to minimize inadver-
mal carotid artery sax and lax). From the tent arterial cannulation while placing a central
venous cannula in the internal jugular vein
(Fig. 6.5 variations in carotid artery). Although
a Anterior the 2D US could differentiate between calcified
and noncalcified portions of the plaque, the
SCM advancement of technology using
three-dimensional (3D) methods makes such dif-
Medial Lateral
ferentiation much easier and more precise. The
IJV determination of noncalcified and hypoechoic
CA
portions of the plaques carries an independent
risk factor for stroke. 2D along with 3D ultra-
sound can determine the intima media thickness
Anterior (IMT) aiding in the detection of preclinical ath-
b
erosclerotic disease, and subsequent assessment
of risk stratification based on the grade of ather-
oma [3] (Fig. 6.6 atheroma).
IJV
ICA
BULB CCA
ICA
Cranial Caudal
5mm
CCA
BULB
ICA
5mm
a b
Fig. 6.5 Variants in the course of carotid artery and internal jugular vein
a b
Fig. 6.6 US image of carotid artery in short and long axis with atheromatous plaque
a
b
Fig. 6.8 (a) Spectral doppler of carotid artery (normal) in the longitudinal plane. (b) Spectral doppler of carotid artery
with low systolic and diastolic velocity
higher velocities in females. Moreover, DUS is the vagus nerve posteriorly (Fig. 6.9). It generally
restricted to the cervical portion of the ICA with lies just lateral and anterior to the internal and
the option of obtaining added information from common carotid arteries; in rare situation it lies
transcranial Doppler studies recommended in entirely medial to the carotid artery. The IJV
certain challenging situations. Factors such as combines with the subclavian vein to form the
severe tortuosity of an artery, high carotid bifur- brachiocephalic or innominate vein at the junc-
cation, obesity, or extensive calcification of the tion of the neck and thorax. The left internal jug-
vasculature might reduce the accuracy of estima- ular vein is slightly smaller than the right internal
tion [5]. In spite of these limitations, Duplex jugular vein. Both veins contain valves located a
ultrasound has many advantages of safety, afford- few centimeters before the vessels drain into the
ability, and the ability to directly visualize mor- subclavian vein. Due to a relatively straighter
phology and measure flow compared to other course, right IJV is preferred over left IJV for
imaging modalities. It is also relatively inexpen- central venous cannulation. Familiarity with sur-
sive, readily performed at the bedside with no face anatomy of IJV is essential for both diagnos-
radiation or need for contrast. tic assessment of various disorders and for
cannulation.
Fig. 6.9 Relationship between IJV and carotid artery. (a) IJV anterior to CA, (b) IJV anterolateral to CA and (c) IJV
lateral to CA
IJV
Lateral
Carotid A
lar to caval index in inferior vena cava, and can abnormal extracranial venous flow in a variety of
estimate the jugular venous pulse and right atrial central nervous system disorders, such as multiple
pressure [6]. Despite potential inaccuracies, the sclerosis, migraine, Parkinson’s disorders, Meniere
DS observation of the IJV pulsatility remains an syndrome, and obstructive sleep apnea [9–12]. An
acceptable method of central venous pressure accurate and reproducible DS venous blood flow
monitoring in various clinical settings [7]. It also volume (BFV) method is essential to diagnose
helps to predict fluid responsiveness in mechani- those conditions.
cally ventilated patients after cardiac surgeries
similar to IVC variability [8]. In addition to regular 6.3.2.1 Anatomy of Subclavian Vessels
assessment of IJV for cannulation and fluid status, The subclavian vein is the continuation of the
Spectral DS analysis of the IJVs is an emerging axillary vein as it courses beneath the clavicle. At
new concept in examining their physiological the lateral border of the first rib, it travels superi-
hemodynamic ranges. Many studies have shown orly then under the clavicle travels medially until
6 Vascular Ultrasound 127
IJV
Medial CA
a b
Fig. 6.13 US image of subclavian vessels (infraclavicular approach—short axis and long axis)
changes decrease the diameter of the IVC during 6.4.2 Assessment of IVC
inspiration relative to expiration. These observa- with Ultrasound
tions are reversed with positive pressure ventila-
tion in which IVC diameter increases during Various acoustic windows to visualize the IVC
inspiration. In extremely hypovolemic status, and it depends on the clinician’s ability to acquire
IVC nearly collapses completely with inspiration those views. Most commonly subcostal-
during spontaneous breathing. Generally, respi- subxiphoid site is used to view the IVC, espe-
ratory phasic changes are easily appreciable in cially from intra-hepatic part to IVC—right atrial
relatively hypovolemic status compared to high junction. This view is the part of point-of-care
intravascular volume status. cardiac ultrasound (POCUS) described in detail
Traditionally, central venous pressure (CVP) in trans thoracic echocardiography chapter. Other
and volume status in the acute care setting have views to visualize IVC are from transabdominal
been measured by placing a central line. Central short axis and right lateral transabdominal coro-
lines are invasive, time-consuming to insert, and nal long axis commonly referred to as “rescue
may cause significant complications. US of IVC view.” Short-axis view was obtained by placing
is a relatively inexpensive bedside tool. Clinicians US in the mid-epigastric region with the orienta-
can perform serial IVC measurements on a criti- tion marker towards the patient’s right. By gently
cally ill patient to guide their decision in provid- fanning the probe up and down, one can visualize
ing more intravenous fluids or to administer more IVC and the aorta anterior to the central shadow-
aggressive medication therapy [16]. ing from the vertebral body (Fig. 6.14a, b). By
Cranial
Anterior
b
Aorta
Lateral
IVC
Fig. 6.14 (a) Trans abdominal SAX approach for IVC ( probe position pointer towards right). (b) Trans abdominal
SAX approach for IVC
130 S. Subramani et al.
fanning further cranially towards the chest, by using color flow or spectral Doppler. Pulsatility
hepatic veins joining the IVC come into view. is not a great way to differentiate between IVC
Longitudinal view of IVC is typically obtained and aorta because IVC frequently demonstrates
from subcostal view however in certain clinical transmitted pulsations. Moreover, in moderate to
situations due to surgical dressings, distended severe tricuspid regurgitation, IVC can be very
abdomen, etc., longitudinal view of the IVC is pulsatile mimicking the aorta. Irrespective of the
acquired through the right lateral transabdominal approach, a phased-array (frequency of 2.0–
coronal approach, also known as the “rescue 4.0 MHz) or curvilinear probe (frequency of 3.5–
view.” The probe is placed in the right anterior to 5.0 MHz) should be used to visualize IVC. These
midaxillary line similar to the placement for eval- relatively low-frequency probes provide better
uating pleural effusion with the orientation penetration and visualization of deep structures.
marker towards cranially (Video 6.3). By scan- Literature favors B-mode, subxiphoid Lax view
ning more anteriorly, the IVC can be visualized as the most reliable means of IVC acquisition.
running adjacent to the liver and crossing the dia- IVC measurement is less reliable in M-mode
phragm and joining the right atrium (Fig. 6.15a, when compared to B-mode. This discrepancy is
b). Aorta is often seen parallel to it and it is essen- augmented when calculating IVC collapsibility
tial to differentiate between these two structures index to determine fluid responsiveness [17, 18].
a Cranial
Pointer
towards head
Anterior
b
Cranial
IVC
Aorta
Fig. 6.15 (a) Right lateral trans-abdominal coronal approach (rescue view) probe position pointer towards head. (b)
Right lateral trans-abdominal coronal approach (rescue view) with color flow doppler
6 Vascular Ultrasound 131
a
Diaphragm
Coeliac trunk
Left renal
Superior artery
mesenteric
Infrarenal aorta
artery
Inferior
mesenteric
Right common artery Anterior
iliac artery b
Right external Left internal
iliac artery Abdominal
iliac artery
Aorta
Anterior
Cranial
Celiac A
Superior
mesenteric A
Aorta
Fig. 6.18 US abdominal aorta shows origin of celiac trunk and superior mesenteric artery with color flow doppler
Cephalic
Subscapular
Brachial
Basilic
Median cubital
Cephalic
Radial
Median
antebrachial Basilic
Ulnar
Anterior
Lateral
CV
Brachial
veins BA
Fig. 6.21 US at the mid arm medial aspect showing brachial vessels and basilic vein. BA brachial artery, CV Cephalic
vein
Femoral Artery
Medial
Circumflex
Femoral Artery
Profunda
Femoris
Artery
tered on the transverse view’s image, the probe is view of the PV is visualized. In this view, the PV
moved distally 1–2 cm to reach the saphenofem- is posterior to the accompanying artery (the PV is
oral junction where the GSV joins the CFV closer to the skin, and the accompanying artery is
(Fig. 6.26). By further moving the probe 1–2 cm located deep in the vein) (Fig. 6.28). By further
distally, then the bifurcation of the CFV into the moving the probe distally to the level of the calf,
deep femoral vein and FV is observed (Fig. 6.27). the trifurcation is observed where the PV gives
The deep femoral vein dives deeper into the thigh rise to three tributaries (Fig. 6.29).
after the bifurcation, whereas the FV travels
along with the femoral artery through the adduc-
tor canal in the distal thigh and emerges as the PV 6.6.5 Role of Ultrasound
at the popliteal fossa. By placing the probe along in the Evaluation for Deep
the posterior crease of the knee, the transverse Vein Thrombosis
Anterior
GSV
lateral CFA
CFV
PV
lateral
PA
Anterior
Fig. 6.28 US of the popliteal vein in transverse view. PA
popliteal artery, PV popliteal vein
Anterior
CFA
lateral
FV Lateral
V V
V
DFV
PA
and tenderness by physical examination. lower extremities, the deep venous system should
However, individuals with DVT can also be be scanned routinely from the level just above the
asymptomatic. Nevertheless, unrecognized DVT inguinal ligament to at least the level of the pop-
could cause a life-threatening condition, such as liteal fossa. There has been a controversy on the
pulmonary embolism; therefore, early detection role of the routine evaluation of the three tributar-
and treatment are of utmost importance. ies of the PV at the level of the calf because iso-
Ultrasonography is the most appropriate initial lated thrombus in the tributaries often
diagnostic tool for detecting DVT. Although it spontaneously resolves, and the risk of the anti-
requires knowledge of the vascular anatomy and thrombotic therapy may exceed the risk of pul-
experience with scanning technique, ultrasonog- monary embolism [29]. In addition, evaluating
raphy has numerous advantages compared with the calf veins increases the complexity and time
the other imaging modalities, such as contrast required to perform ultrasonography. Of note,
venography, CT, and MRI. These advantages although the GSV is not a deep vein, investigat-
include portability, low cost, noninvasiveness, ing thrombus in the proximal GSV adjacent to
and avoidance of radiation or nephrotoxic con- the saphenofemoral junction is necessary because
trast exposure. When DVT is suspected at the of the high risk of thrombus dislodgement into
the deep venous system and may warrant antico-
Anterior
agulation therapy [30].
During an ultrasonographic examination,
direct visualization of thrombus is a promising
way to detect DVT. It can be clearly observed
when the thrombus is echogenic (Fig. 6.30).
However, the presence of a thrombus is often
FA ambiguous under direct visualization. For exam-
ple, anechoic or hypoechoic thrombus may not
Lateral
FV be apparent. In contrast, slowly flowing blood or
blood stasis inside a vein mimics the image of a
thrombus. Therefore, direct visualization is not
sufficient enough to detect or rule out
DVT. Applying color flow Doppler ultrasonogra-
phy aids to identify thrombus as color flow inside
the vein is reduced or lost when the vein is par-
tially or completely occluded with thrombus
Fig. 6.30 Direct visualization of the DVT hyperechoic
material is seen in the common femoral vein (Fig. 6.31). Furthermore, the compressibility of
Lateral
Fig. 6.31 Complete and partial occlusion of femoral vein due to thrombosis
6 Vascular Ultrasound 139
the venous segment should be routinely tested on the contrary, venous occlusion is likely if there is
the target vein as it provides high sensitivity and no increase in the venous flow. Of note, venous
specificity to diagnose DVT. Inability to com- compression must be carefully performed as
press a vein while applying pressure by the probe there is a potential risk of dislodging thrombus
is the hallmark finding of thrombus in the venous and causing a catastrophic complication.
segment (Fig. 6.32). On the other hand, the com-
plete collapse of a vein rules out thrombus in that
region (Fig. 6.33). This compression technique 6.6.6 Ultrasound Evaluation
provides only regional information; thus, it may of Chronic Venous
need to apply every 2–3 cm on a targeted vein. Insufficiency
Lastly, the patency of a vein can be examined by
squeezing the distal part of the vein, often by per- Clinical symptoms of venous insufficiency are
forming calf compression. Augmented flow dur- similar to those of DVT. The symptoms include
ing the maneuver is observed by color and pulse leg pain, swelling, and skin manifestations such
Doppler ultrasonography in the normal vein. On as discoloration, induration, and ulceration.
Anterior
Lateral
FA FA
FV with
thrombus insitu
Fig. 6.32 DVT in the common femoral vein noncompressible thrombosed vein in short axis
Anterior
Medial
A
V
Compressed FV
Anterior anterior
A
A
1
FV 2 lateral
cranial V2
V1
V1
FV 1 2
Fig. 6.36 Duplicated femoral vein—Color Doppler Fig. 6.37 DVT in the duplicated femoral vein noncom-
ultrasonography in longitudinal view pressible thrombosed vein (V1) in transverse view
causes of a false-negative result for DVT diagno- can also be mistaken as DVT, especially in a
sis as an occluded duplicated vein can be over- patient with excess weight or enlarged superfi-
looked (Figs. 6.36 and 6.37) [31]. The cial veins. One of the key things that differenti-
femoral-popliteal venous system is a common ate DVT from the other abnormalities is
site of venous duplication, and it should be sus- identifying the adjacent artery as deep veins are
pected when a vein is smaller than normal or almost always accompanied by an artery. In
when the location is unusual. Experience and addition, unlike many other abnormal tissues,
careful attention to the anatomical variant could veins are often circular in the transverse view
prevent the false-negative result. One should be and tubular in the longitudinal view. Lastly, the
aware that various other abnormalities at the differentiation between acute and chronic DVT
lower extremities can be easily mistaken for by ultrasonography can be challenging, although
DVT because clinical symptoms are similar and the differentiation is clinically relevant as the
many of the images resemble noncompressible treatment of the two conditions often differs. As
vessels. These abnormalities include Baker’s thrombus ages, it tends to be more echogenic;
cyst (a fluid-filled cyst behind the knee), pseu- however, the age of thrombus cannot be pre-
doaneurysms, hematomas, cellulitis, muscle cisely determined by the echogenicity alone as
tears, soft tissue tumors, enlarged lymph nodes, significant variation is observed. Therefore,
chronic venous insufficiency, and superficial attention needs to be paid to some other observa-
thrombophlebitis. Thrombus in a superficial vein tions that may help in the differentiation. For
142 S. Subramani et al.
Cranial Questions
3 POINT DVT 1. The most commonly utilized duplex ultra-
CFV sound feature in the diagnosis of carotid
Medial artery stenosis is
Fem A. End diastolic velocity
B. Carotid index
C. Peak systolic velocity
Pop D. Continuous wave Doppler
2. The role of ultrasound in the assessment of
internal jugular vein includes all except
A. Assessing patency of IJV
Fig. 6.40 US of deep veins- three point scan B. To determine its relationship with carotid
artery
whole-leg/complete ultrasonography for diag- C. To identify vagus nerve
nosing suspected symptomatic DVT [33]. D. To estimate central venous pressure based
Several studies favor the use of 3-point limited on change in the cross-sectional area
ultrasonographic examination by adding the FV 3. The following is true based on the ultrasound
to the 2-point limited examination (Fig. 6.40), image
which may increase the sensitivity for DVT
diagnosis [34, 35]. The advantage of limited Anterior
ultrasonographic examination is a significant
reduction of the time required for the examina-
tion. In addition, it requires less technical exper-
tise and can be easily performed at the bedside
by front-line healthcare professionals with mini-
mum training. On the other hand, whole-leg/
complete ultrasonography requires more techni- Lateral
cal expertise as well as time to perform and is
often conducted by an experienced sonographer
(often by a vascular technologist) and interpreted
by a radiologist. It involves scanning the entire
lower extremities, including the calf veins with
color Doppler, pulse wave Doppler, and com-
pression examination at every 2 cm interval.
Although it is ideal, the complete examination
may not be readily performed within a clinically
acceptable time frame in many institutions, and
it could result in suboptimal patient outcomes as
a prompt DVT diagnosis at the bedside may
decrease morbidity and mortality. An under-
standing of lower extremity venous anatomy and A. It denotes ultrasound assessment of right
its common variations is essential for the perfor- IJV and carotid artery
mance of duplex ultrasound, interpretation of the B. The highlighted structure represents left
images, decision for surgery, and, ultimately, the common carotid artery
execution of radiofrequency ablation. In recent C. The highlighted structure represents right
years, the nomenclature of the lower extremity subclavian vein
venous system has been modified to eliminate D. It denotes supraclavicular approach of
confusion. subclavian vessels
144 S. Subramani et al.
Anterior
Lateral
A. Subxiphoid view for IVC assessment
B. Transabdominal longitudinal view for IVC
C. Transabdominal short-axis view of IVC
and aorta
D. Transabdominal longitudinal view of
hepatic vein
6 Vascular Ultrasound 145
11. The deep venous system of the lower extrem- 16. All the following potentially leads to false-
ity consists of the following veins except positive or false-negative results for DVT
A. Common femoral vein except
B. Great saphenous vein A. Improperly high gain setting
C. Deep femoral vein B. Color artifact generated by improper
D. Femoral vein high color scale
E. Popliteal vein C. Inadequate venous compression while
12. The following veins are generally accompa- testing the venous compressibility
nied by an artery except D. None of the above
A. Common femoral vein E. All of the above
B. Great saphenous vein 17. Clinical symptoms and/or ultrasonographic
C. Deep femoral vein images of DVT can be similar to those of
D. Femoral vein A. Baker’s cyst
E. Popliteal vein B. Cellulitis
13. When evaluating the deep veins of the lower C. Enlarged lymph node
extremity, the better image quality of ultraso- D. Superficial thrombophlebitis
nography can be achieved by E. All of the above
A. The head elevated at 30 degrees in a 18. All of the following statements are true
reverse Trendelenburg position except
B. External rotation of the examining leg A. Most of the deep veins are accompanied
with slight knee flexion by an artery
C. A linear ultrasound probe with a high- B. The age of thrombus can be easily deter-
resolution 5–12 MHz mined by the echogenicity alone
D. All of the above C. A free-floating thrombus poses a high
14. The ultrasonographic findings of thrombus risk of pulmonary embolism
in the venous segment include D. Acute DVT often dilates the affected
A. Inability to compress the vein while vein
applying pressure by the probe E. Chronic DVT usually diminishes the
B. Complete collapse of the vein while venous size
applying pressure by the probe 19. The limitations of ultrasonography for DVT
C. Augmented venous flow by squeezing diagnosis include
the distal part of the vein A. Dependency on the sonographies’ skill
D. None of the above B. Limited visualization of the pelvic veins
E. All of the above and calf veins
15. All of the following statements are true
C. Technical difficulties in a patient with
expect excess weight or marked soft tissue
A. Clinical symptoms of venous insuffi- edema
ciency are similar to those of DVT D. None of the above
B. Venous insufficiency can be triggered E. All of the above
and worsened by existing venous obstruc- 20. Compared with whole-leg/complete ultraso-
tion caused by DVT or congestive heart nography, a limited ultrasonographic exami-
failure nation requires
C. Venous blood flow from a superficial A. More time
venous system is normally directed B. More technical expertise
towards the deep venous system C. Scanning the popliteal vein and its
D. The deep veins are more vulnerable to tributaries
the elevated venous pressure compared D. None of the above
with the superficial veins E. All of the above
146 S. Subramani et al.
28. Read H, Holdgate A, Watkins S. Simple external 33. Bernardi E, Camporese G, Buller HR, Siragusa S,
rotation of the leg increases the size and accessi- Imberti D, Berchio A, et al. Serial 2-point ultraso-
bility of the femoral vein. Emerg Med Australas. nography plus D-dimer vs whole-leg color-coded
2012;24(4):408–13. Doppler ultrasonography for diagnosing suspected
29. Robert-Ebadi H, Righini M. Should we diagnose and symptomatic deep vein thrombosis: a randomized
treat distal deep vein thrombosis? Hematology Am controlled trial. JAMA. 2008;300(14):1653–9.
Soc Hematol Educ Program. 2017;2017(1):231–6. 34. Zuker-Herman R, Ayalon Dangur I, Berant R, Sitt
30. Scott G, Mahdi AJ, Alikhan R. Superficial vein EC, Baskin L, Shaya Y, et al. Comparison between
thrombosis: a current approach to management. Br J two-point and three-point compression ultrasound
Haematol. 2015;168(5):639–45. for the diagnosis of deep vein thrombosis. J Thromb
31. Screaton NJ, Gillard JH, Berman LH, Kemp Thrombolysis. 2018;45(1):99–105.
PM. Duplicated superficial femoral veins: a source 35. Pedraza Garcia J, Valle Alonso J, Ceballos
of error in the sonographic investigation of deep vein Garcia P, Rico Rodriguez F, Aguayo Lopez MA,
thrombosis. Radiology. 1998;206(2):397–401. Munoz-Villanueva MDC. Comparison of the
32. Bhatt M, Braun C, Patel P, Patel P, Begum H, accuracy of emergency department-performed point-
Wiercioch W, et al. Diagnosis of deep vein throm- of-
care-ultrasound (POCUS) in the diagnosis of
bosis of the lower extremity: a systematic review lower-extremity deep vein thrombosis. J Emerg Med.
and meta-analysis of test accuracy. Blood Adv. 2018;54(5):656–64.
2020;4(7):1250–64.
Focused Assessment
with Sonography in Trauma (FAST) 7
Exam
Vishakha Prasad Erasu and Priyadarshini Marathe
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022 149
A. Chakraborty, B. Ashokka (eds.), A Practical Guide to Point of Care Ultrasound (POCUS),
https://doi.org/10.1007/978-981-16-7687-1_7
150 V. P. Erasu and P. Marathe
Table 7.1 Comparison of DPL vs. FAST exam vs. CT scan. This table compares the salient features of the FAST exam,
DPL, and CT scan in the trauma patient
Feature DPL FAST exam CT scan
Bedside test Yes Yes No
Needs transport No No Yes
Ease of performing test in an Can be done Can be done Not without risk of
unstable patient transfer and time
Performed simultaneously with Yes Yes No
clinical assessment
Invasive procedure Yes No No
Radiation exposure No No Yes
Ease of a repeat test Cumbersome Easily done Increases radiation
risk
Operator dependent Yes Yes No
Affected by previous surgery Yes (if altered anatomy like Yes (if altered No
adhesions, etc.) anatomy)
Time to perform test Time to instill lavage fluid and Few minutes 10–15 min excluding
aspirate—Average of 10–15 min transfer times
Cost of test Low Low Higher
and the site of bleeding. As these patients are usu- male and female patient. In the female patient,
ally positioned supine, the dependent regions the bladder lies anterior to the uterus, with the
become the hepatorenal recess, splenorenal rectum lying most posteriorly. The vescicovagi-
recess, and pelvis within the peritoneal cavity. In nal or Douglas pouch is the dependent region
the pleural cavity, the fluid settles posteriorly and formed between the fascia overlying the bladder
inferiorly within each pleural space. If the patient and uterus. In the male patient, the rectovescical
assumes a sitting posture, free fluid would collect pouch is the space between the bladder and rec-
in the pelvis as this would become the most tum. The vescicovaginal and rectovescical
dependent area of the peritoneal cavity. The pouches, form the most dependent pockets for
FAST exam takes advantage of this phenomenon fluid collection in the female and male pelvis,
to rapidly detect fluid (i.e., blood, urine, or faecal respectively.
matter) in these dependent spaces by only focus- The site of injury and hence the location of the
ing on these regions. The FAST exam can detect bleeding point influences the collection of blood
a minimum of 200–250 mls of fluid in the perito- in the dependent regions of the peritoneal cavity.
neal cavity. Injury in the right upper quadrant will cause
The hepatorenal recess is the potential space blood to collect in Morrison’s pouch and then
in the right upper quadrant of the peritoneal cav- flow into the subdiaphragmatic and pelvic spaces.
ity. It lies between the liver and the right kidney The left upper quadrant differs from the right
and in physiological conditions appears as a upper quadrant as blood tends to collect in the
hyperechoic line on ultrasound where the fascial subdiaphragmatic space more often than in the
layers adjoin each other. The splenorenal recess splenorenal space. Injury to the pelvic region will
is the potential space in the left upper quadrant of cause blood to collect in the pelvis but large pel-
the peritoneal cavity and lies between the spleen vic bleeds can cause blood to flow into the
and the left kidney. In physiological situations Morrison’s pouch as well.
when there is no fluid or blood in this space, it In the pleural cavity, fluid or blood in the
appears as a hyperechoic line on ultrasound rep- supine patient tends to collect in the dependent
resenting the adjoining fascia of the spleen and regions. In each hemithorax fluid will collect in
left kidney. The anatomy of the pelvis varies in the posterior and inferior parts with the lung
7 Focused Assessment with Sonography in Trauma (FAST) Exam 151
floating in the free fluid. Air does the opposite by 7.3 Focused Question in FAST
rising to occupy the nondependent regions and Exam
will collect above the respective lung. In the
upright patient, this will be the upper part of the The objective of the FAST exam is to answer the
hemithorax while in the supine patient this will question—“is there fluid?” within the pericar-
correspond to the anterior most part of the dial, pleural, and peritoneal spaces by obtaining
hemithorax. the right upper quadrant, left upper quadrant,
The pericardial space lies within the two lay- pelvic and subcostal views using a low-fre-
ers of the pericardium, creating a potential space quency probe.
for fluid to collect around the heart. This potential
FAST scan pearls
space has a much smaller capacity than the pleu-
1. ONE Question—Is there free fluid?
ral and peritoneal cavities and fluid here tends to
2. TWO Possible answers—Yes or no (if unclear view
surround the heart forming a thin film and then then cannot determine)
expanding as more fluid collects. 3. THREE Body cavities—Pericardium, peritoneum
and pleural
4. FOUR Views—RUQ, LUQ, pelvic, and subcostal
7.2.3 Diagnostic Peritoneal Lavage 5. FIVE MHz or less- frequency of probe
Morison’s pouch
7.10.2 Left Upper Quadrant View Characteristic features of this view (Fig. 7.6):
The probe is placed in the 7–9th intercostal • The lung is difficult to visualize in this view. It
space in the posterior axillary line with the may be seen as a curtain that comes across the
operator’s hand almost resting on the surface screen as the patient breathes.
that the patient is lying on (Fig. 7.5). The probe • The diaphragm is visualized as a hyperechoic
marker is towards the patient’s head and the semilunar structure and the space between the
probe tilted to look slightly anteriorly towards diaphragm and spleen is a common site for
the vertebral column with a depth selection of blood to collect in case of splenic lacera-
more than 20 cm, adjusting later to get the opti- tions (Fig. 7.7).
mum image. The spleen has a similar echotex- • The splenorenal recess and left kidney should be
ture to the liver but is located more posteriorly, visualized in entirety, fanning the probe to look
hidden under the ribs. The structures visualized for fluid. Fluid will appear as an anechoic black
in this view are: stripe between the spleen and the left kidney.
• The psoas muscle is located posterior to the
Lung kidney and fluid can collect anterior to it in
Diaphragm some instances.
Spleen • Rib shadows can cause hindrance in visualiz-
Splenorenal recess ing structures and the tips given above (right
Left kidney (both upper and lower poles) upper quadrant view) can be used to mitigate
Left psoas major muscle
these.
156 V. P. Erasu and P. Marathe
Lung
Diaphragm
Spleen
Splenorenal recess
Fig. 7.6 The left upper quadrant view showing the diaphragm, a section of the spleen, and the left kidney. There is no
pathological fluid seen in this image
7.10.3 Pelvic Cavity: Sagittal female patient. Rotate the probe 90° clockwise so
and Transverse Views that the probe marker is now pointing towards the
patient’s head, maintaining the tilt to look into
The pelvic cavity is assessed in both transverse the pelvic cavity (Fig. 7.8). Now fan or slide the
and longitudinal sections. Begin with the probe probe from side to side to look for fluid in the
in the suprapubic region with the probe marker to pelvis. The structures visualized in this view are:
the right of the patient. Slide the probe caudally
Female patient:
to almost touch the pubic symphysis and then
Urinary bladder
angle the probe away from the patient’s feet, to
Vesicouterine pouch/pouch of Douglas
look into the pelvic cavity with a depth selection Uterus
of 15 cm. Fan the probe, cranio-caudally to look Rectouterine space
for fluid that appears as an anechoic black line Rectum
behind the bladder or behind the uterus in a
7 Focused Assessment with Sonography in Trauma (FAST) Exam 157
Female patient:
Urinary bladder
Uterus
Rectouterine space
Rectum
Male patient:
Urinary bladder
Rectovesical space
Rectum
Fig. 7.9 The transverse view of the pelvis showing a well-filled urinary bladder. There is no pathological fluid in this
image
linear probe or the phased array probe. The when using this probe as the images will be mir-
marker on the screen for the phased array probe rored accordingly. Alternatively, newer machines
is conventionally placed to the right of the screen will have an abdominal preset option with the
in the cardiac preset. If the probe marker is to the cardiac probe which can be selected for the sub-
right of the patient in cardiac preset, the struc- costal views of the FAST exam.
tures on the patient’s right will appear on the left Before placing the probe on the patient, the
of the screen and vice versa. The probe marker depth should be increased to 20 cm as the struc-
may be placed to the left of the patient if the oper- tures to be visualized are situated at a considerable
ator would like to obtain images with the right distance from the probe. Place the probe in the epi-
side of the patient corresponding to the right side gastrium of the patient and slide up to almost touch
of the screen while using the phased array probe the xiphisternum. Now tilt the probe to aim the
in cardiac preset. This should be kept in mind probe towards the patient’s left shoulder, attempt-
160 V. P. Erasu and P. Marathe
Subcostal view:
Liver
Heart
Parasternal long-axis view:
Heart
Descending aorta
Heart
Heart
Descending aorta
• While attempting to look for the heart beneath • In the parasternal long-axis view the descend-
the ribs the probe is placed tangentially on the ing aorta is posterior to the heart. This is used
skin. Care must be exercised to keep the probe as a landmark to differentiate whether the
in contact with the patient’s skin at all times to anechoic black shadow seen posterior to the
avoid compromising on the image quality. A heart is a pericardial or pleural collection. A
generous amount of ultrasound gel will help pericardial collection (Fig. 7.17) will be situ-
maintain good probe-to-skin contact. ated anterior to the aorta whereas pleural fluid
• Occasionally the subcostal view may not pro- is located posterior to the descending aorta. If
vide a clear image due to a barrel chest or any fluid is detected in the subcostal view it is
abdominal viscera obstructing or a tender recommended to confirm it on a parasternal
abdomen. In such instances, the parasternal long-axis view because the subcostal view
long-axis view (Fig. 7.16) can be obtained and may mistake pleural fluid for pericardial fluid.
the depth setting should be decreased to • Other views that can be used to supplement
10–15 cm before proceeding with this view. imaging of the heart for fluid in the pericardial
Fig. 7.16 The
parasternal long-axis
(PLAX) view showing
the heart
cavity are the parasternal short-axis view and pointing towards the patient’s head. The struc-
the apical four-chamber view (please refer to tures towards the head end of the patient will
chapter on ECHO for this). appear on the left side of the screen. Once a cer-
• When performing a FAST scan, the operator tain rib space is examined in both 2D mode and
must be aware of the features of cardiac M-mode, the probe is moved caudally to cover
tamponade to differentiate it from a pericar- most of the rib spaces, repeating the assessment
dial effusion sans tamponade. Identification of for features of a pneumothorax bilaterally. The
the features of cardiac tamponade in the structures visualized in this view are:
hemodynamically unstable trauma patient
Skin
necessitates immediate emergency manage-
Subcutaneous tissues
ment. The features on ultrasound that indicate
Adjoining ribs with intercostal muscles
cardiac tamponade are pericardial effusion Parietal pleura and lung sliding
plus: Superficial lung parenchyma
• Right ventricular (RV) collapse in diastole.
• Right atrial (RA) collapse in systole. Characteristic features of this view:
• Plethoric IVC with minimal respiratory
variation. • The focus of the image obtained is the bright
pleural line in the middle of the screen with
The collapse of the RA/RV due to cardiac the two adjoining ribs and their shadows on
tamponade appears as a wavy seesaw on ultra- either side.
sound and it has been referred to as the “little • Lung sliding is the gliding of the parietal
man jumping on the trampoline” sign. pleura on the visceral pleura during breathing
and is appreciated as “ants marching” on the
white pleural line. This movement has to be
7.11 Extended FAST or e-FAST appreciated in real time and is absent when
Scan there is air between the two pleural surfaces as
in a pneumothorax.
The extended FAST exam was first proposed in • Occasionally a lung point is appreciated at the
2004 and included bilateral chest ultrasound junction of the pneumothorax and normal
exams to detect the presence of a pneumothorax lung where lung sliding abruptly ends. The
in addition to the four views of the FAST exam. normal lung parenchyma may show a few B
Ideally, the high-frequency linear probe is used lines or comet tails which may also end
for assessing the chest for features of a pneumo- abruptly at the lung point.
thorax as the pleura is a superficial structure. If • The M-mode is then used to complement the
this probe is not available the scan can be per- findings of the 2D mode. The line of the
formed with the low-frequency probes. In the M-mode is placed over the pleural line and the
supine trauma, patient air collects in the anterior- obtained image is analyzed. If the upper half
most part of the thorax, whereas in an upright of the image shows horizontal lines with a
trauma patient the air will collect in the apical grainy bottom half, the appearance is called a
regions of the thorax. The anterior-most rib space sandy beach sign and indicates a normal lung.
is different for each patient and is usually between If the entire image shows lines throughout,
the fourth to sixth intercostal spaces. The opera- without the sandy granular appearance, it is
tor may face difficulty in obtaining a good view if known as the barcode or stratosphere sign and
the patient’s breast tissue interferes with the is characteristic of a pneumothorax.
imaging. • It is important to look in multiple intercostal
The exam is performed by placing the probe in spaces for a pneumothorax.
the second intercostal space in the mid-clavicular • The presence of subcutaneous emphysema
line in a linear fashion with the probe marker hinders the use of ultrasound to assess for a
164 V. P. Erasu and P. Marathe
pneumothorax (air is a poor conductor of void in the service that can be delivered in
sound) and in such instances other imaging such cases.
modalities should be used. 7. Training—As with the availability of equip-
(Also see chapter on lung for more ment the access to training may limit the use
information) of the FAST scan in some parts of the world.
The availability of virtual learning platforms
can help overcome this problem.
7.12 Limitations of FAST Scan
POCUS FAST
(Focused Assessment by Sonography in Trauma)
OPERATOR SUPERVISOR OBSERVER
DATE: TIME: LOCATION:
Before scan:
What is the indication for this scan?
Patient consent obtained?
Procedure explained?
Comment on clarity
of views obtained
Free fluid seen?
Please use Any other
FAST scan location Please say
C=clear comments?
YES or NO
P=Partial
N=not seen
RIGHT UPPER QUADRANT VIEWS
Right Hemithorax
Right side of diaphragm
Liver
Morrisons space
Tip of the liver
Upper pole of right
kidney
Lower pole of right
kidney
Right psoas muscle
LEFT UPPER QUADRANT VIEWS
Left Hemithorax
Left side of the
diaphragm
Spleen
Splenorenal space
Upper pole of left
kidney
Lower pole of left
kidney
Left psoas muscle
PELVIC VIEWS
Transverse
Longitudinal
PERICARDIAL VIEWS
View used?
After scan:
Images saved?
Patient informed of scan findings?
POCUS machine cleaned and plugged in safely at designated area?
STABLE UNSTABLE
Remains
unstable
YES Resuscitate as per ATLS;
If history or other injury
(pelvic/spinal) indicates perform FAST exam
need for CT
NO
No Free fluid
FAST exam
Stabilises
CT scan
Free Fluid
Theatre;
Based on clinical
Consider repeat FAST CT scan to define situation and resources –
exam at regular intervals; can have CT scan on
No further investigations route to theatre
if stable and FAST
remains negative.
If becomes unstable
move to Unstable* arm
of flowchart
Fig. 7.18 This flowchart shows possible clinical pathways for the trauma patient with an abdominal injury based on
the patient’s hemodynamic stability and FAST exam results
7 Focused Assessment with Sonography in Trauma (FAST) Exam 167
7.15 FAST Scan vs. US Abdomen simultaneously during the clinical examination
as a bedside test and can be repeated as needed. A
A FAST exam is clearly different from an ultra- FAST scan should never delay or interrupt resus-
sound abdomen exam with regards to the purpose citation measures.
and procedure of the scan. A FAST exam is per-
formed in trauma and focuses on the question of
whether there is fluid in the peritoneal cavity elf-Assessment Questions: Chose
S
(along with pleural and pericardial spaces). It the Single Best Answer
does not comment on any of the internal organs
while an ultrasound abdomen assesses all abdom- 1. The FAST scan includes all of the following
inal structures looking for pathology that can views EXCEPT:
explain the presenting symptoms. A FAST scan A. Right upper quadrant
is easier to learn and recommended as part of B. Left upper quadrant
training for emergency physicians, critical care C. Pelvic
physicians, and prehospital medical personnel. D. Longitudinal view of the aorta
2. You are going to begin your FAST scan with
the abdominal exam. The probe that can be
7.16 Caution used for this exam is:
A. The curvilinear probe with abdominal/
Do NOT delay resuscitation to perform a FAST exam. FAST preset
Always report the FAST scan for a particular time in
the patient’s journey.
B. The cardiac probe with abdominal preset
Always use the FAST exam as a rule-in test and not to C. Both of the above
rule out pathology. D. Only the linear probe
Do NOT clear a region as negative for fluid unless all 3. You are going to perform the extended FAST
areas are clearly visualized. scan. Which probe is best suited for visual-
izing the pleura and why?
A. Linear probe because of its high
frequency
7.17 Summary B. Linear probe because of its low
frequency
The FAST exam is a useful tool in unstable C. Phased array probe because of its low
trauma patient and should be used as part of the frequency
primary survey when available. A clear under- D. None of the above
standing of the physiology of pathological fluid 4. The Morison’s pouch is the most dependent
collection within potential body spaces and the area in the abdomen of the supine patient.
effect of gravity on the location of this fluid is This lies between the:
necessary before attempting the FAST scan. The A. Spleen and left kidney
FAST exam is performed with a low-frequency B. Liver and right kidney
probe and attempts to answer the question of C. Urinary bladder and rectum
whether there is any fluid within the three body D. Urinary bladder and uterus
spaces. These are the peritoneal, pleural, and 5. All of the following are expected to be visu-
pericardial spaces and are examined in four alized on the left upper quadrant view
views, namely the right upper quadrant, left EXCEPT:
upper quadrant, pelvic, and cardiac. It is abso- A. Heart
lutely vital to visualize the four views clearly B. Diaphragm
before reporting a negative scan. A useful advan- C. Spleen
tage of the FAST scan is that it can be performed D. Left kidney
168 V. P. Erasu and P. Marathe
Chetan Mehra and Amit Dikshit
Supplementary Information The online version con- • Suspected delay in gastric emptying:
tains supplementary material available at [https://doi. –– Pregnancy.
org/10.1007/978-981-16-7687-1_8].
• Suspected gastro-paresis.
–– Diabetes Mellitus.
C. Mehra (*) –– Chronic hepatic/renal dysfunction.
Department of Anaesthesiology, Critical Care and –– Neuromuscular disorders.
Pain, Indraprastha Apollo Hospital, New Delhi, India
• Lack of adherence to fasting instructions:
A. Dikshit –– Emergency/urgent procedure.
Ruby Hall Clinic and Hospital, Pune, India
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022 171
A. Chakraborty, B. Ashokka (eds.), A Practical Guide to Point of Care Ultrasound (POCUS),
https://doi.org/10.1007/978-981-16-7687-1_8
172 C. Mehra and A. Dikshit
Fig. 8.1 Probe placement in supine and right lateral decubitus position
8 Miscellaneous POCUS: Gastric Ultrasound, Urinary Bladder Ultrasound, Ocular Ultrasound, Obstetric… 173
Fig. 8.2 Gastric Antrum ultrasound image with sche- mesenteric branches, orange—liver, yellow—pancreatic
matic representation of anatomic structures (Black—ver- body, green—flat empty antrum). *left side of image is
tebral column, dark red—aorta with celiac and superior cranial and right side of image is caudal end
8.2.6.2 Solid Early Stage • Antrum will appear larger in RLD position
• Antrum appears distended with thin walls. compared to supine position (Fig. 8.4).
• The content is of high or mixed echogenicity.
• Specific pattern: “Frosted-glass” pattern (usually 8.2.6.5 Fluid with Air Bubbles
shortly after a solid meal). It is due to a mix of air • Starry night pattern (multiple air bubbles on a
and solid along the anterior wall, blurring the hypoechoic background) usually seen shortly
posterior wall and deeper structures (Fig. 8.3). after ingestion of clear fluids or effervescent
drinks.
8.2.6.3 Solid Late Stage
• Heterogeneous, particulate content (usually
after 1–2 h following a solid meal). 8.2.7 Gastric Volume Assessment
• Homogeneous hyperechoic content: charac- (Clear Fluids)
teristic of dairy products or particulate fluids.
• Volume assessment can differentiate a low
8.2.6.4 Clear Fluid (normal) quantity of baseline gastric secre-
• Antrum appears round and distended with thin tions from a higher (non-fasting) volume.
walls. • Cross-sectional area of the antrum (CSA) has
• The content appears anechoic or hypoechoic. a linear correlation with the gastric volume
• The size of antrum is proportional to gastric (Figs. 8.3 and 8.4: marked by yellow dotted
volume. lines).
174 C. Mehra and A. Dikshit
Fig. 8.3 Gastric antrum image acquired 150 min after meal. (a) Supine and (b) Right lateral decubitus position
a b
Fig. 8.4 Gastric antrum image acquired 15 min after Image (c) Image acquired 2 h after water intake
drinking clear water. Image (a) Patient in supine position; (Measurements: A—area, C—circumference, D1 and
Image (b) Patient in right lateral decubitus position; D2—diameters in two perpendicular planes)
8 Miscellaneous POCUS: Gastric Ultrasound, Urinary Bladder Ultrasound, Ocular Ultrasound, Obstetric… 175
Fig. 8.4 (continued)
Fig. 8.5 Urinary bladder with foley’s catheter in situ (Longitudinal and transverse probe orientation) left image depicts
longitudinall scan and right image depicts transverse scan
8.3.1 Introduction
8.3.2 Indications
8.3.3 Following Topics Will 2. The probe marker should point cranially in
Be Covered in this Description order to obtain a sagittal view of the
bladder.
Use Point-of-Care Bladder ultrasound to: 3. Sweep the probe on either side to examine the
lateral borders of the bladder.
1. Perform Bladder Ultrasound in a Step-by- 4 . As the bladder is directly posterior to the
Step Fashion. pubic symphysis, the ultrasound beam should
2. Measure Bladder Volume. be directed towards the pelvis, so as to iden-
3. Recognize Common Bladder Ultrasound tify the bladder underneath the bone.
Pathology. 5. Transverse view: Rotate the probe 90° to
obtain a transverse view and sweep it superior
to inferior, so as to image the bladder com-
8.3.4 Patient Position pletely (Fig. 8.7).
6. The shape of the bladder varies depending on
Patient placed in supine position with suprapubic anatomical differences and filled-up status of
area exposed. Knees can be flexed to soften the bladder. Its shape can be thought of as spheri-
anterior abdominal wall. cal, a triangular prism, cylinder (ellipsoid), or
cuboid.
7. Surrounding structures including the pubic
8.3.5 Ultrasound Probe Selection
bone, abdominal cavity, rectum (or bowel
gas), uterus (in females), and prostate (in
Curvilinear Ultrasound Probe with abdominal or
males) are important ultrasound landmarks
renal preset: With its wider footprint, it allows
for the identification and assessment of blad-
full visualization of the bladder.
der volume.
a b
Fig. 8.7 Bladder ultrasound. (a) Transverse probe orientation and (b) Transverse probe orientation
178 C. Mehra and A. Dikshit
a b
Fig. 8.8 Bladder ultrasound. (a) Transverse and (b) Longitudinal Views with transverse, longitudinal, and vertical
lengths measurements
1. The factor (0.7) in the formula refers to the 8.4 Point-of-Care Ultrasound
correction coefficient, that varies with the pro- Examination of Eye
posed shape of bladder (unknown–0.72, trian-
gular prism–0.66, ellipsoid–0.81, 8.4.1 Optic Nerve Sheath Diameter
cuboid–0.89, spherical–0.52). (ONSD)
2. Width and Depth of the bladder are measured
in the transverse view (Fig. 8.8). 8.4.1.1 Introduction
3. Height (vertical dimension) is measured in the 1. An elevation of intracranial pressure (ICP)
longitudinal view. secondary to cerebral edema is a major con-
4. Both pre- and post-void measurements should tributor to morbidity and mortality in trauma,
be taken to diagnose urinary retention. neurosurgical patients, and acute liver failure
Point-of-care ultrasound can detect foley’s (ALF) [9].
catheter, bladder mass, bladder calcu- 2. Geriatric surgical populations with multi-
lus, enlarged prostate, or hematoma. ple comorbidities undergo robotic surgeries
Kinking of foley’s catheter can cause with steep Trendelenburg position.
falsely low urine output which can be Impaired cerebral autoregulation may be
easily ruled out using bedside bladder compounded by alterations in cerebral
ultrasound. homeostasis in this population, due to pro-
Use of color Doppler interrogation at the longed duration of surgery in steep head
base of the urinary bladder can show low positioning.
ureteric jets of urine. In the author’s 3. ONSD measurement can be a valuable surro-
opinion, this technique can also be uti- gate for invasive monitoring for assessment of
lized in the differential diagnosis of an ICP in such patients who present with coagu-
oliguric patient. lopathy and high ICP [9, 10].
This technique is beneficial in the postop- 4. Perioperative ICP monitoring may be benefi-
erative assessment of renal transplant cial for guiding the administration of targeted
recipient patients. therapy (i.e., mannitol, hypertonic saline,
8 Miscellaneous POCUS: Gastric Ultrasound, Urinary Bladder Ultrasound, Ocular Ultrasound, Obstetric… 179
Fig. 8.9 (a) Preparation of eye (tegaderm and jelly application) and probe placement for Ocular Ultrasound. (b)
Tegaderm application over eye and position of probe
Fig. 8.10 Ultrasound
appearance of Ocular
structures
CORNEA
IRIS
VITREOUS CHAMBER
OPTIC DISC
OPTIC NERVE
OPTIC NERVE SHEATH
8 Miscellaneous POCUS: Gastric Ultrasound, Urinary Bladder Ultrasound, Ocular Ultrasound, Obstetric… 181
a b
Papilledema
Fig. 8.11 (a) Measurement of Optic Nerve Sheath Diameter (0.27 cm in the above figure). (b) Papilledema bulging
into retina with grossly dilated optic nerve sheath diameter
Use of ocular ultrasound can also detect globe The enlarging uterus will displace the normal
rupture and intraocular foreign body which is position of surrounding structures and this can
beyond the scope of this book. affect the ultrasound appearance of intra-
abdominal pathology (Fig. 8.14).
Point-of-care ultrasound (POCUS) is used to pro- Obstetric POCUS can aid in assessing the follow-
vide an accurate assessment of gestational age, ing conditions:
fetal number, presence or absence of cardiac
activity, and placental location. 1. Fetal lie and presentation.
184 C. Mehra and A. Dikshit
36 wk Xiphisternum
40 wk
32 wk
28 wk
24 wk
Umbilicus
20 wk
16 wk
Public symphysis
(Uterus becomes an
abdominal organ
after 12 weeks)
8.5.6 Applications
8.5.7 Limitations
Questions
Fig. 8.22 Multiple cords around fetus’s neck using color Doppler
8 Miscellaneous POCUS: Gastric Ultrasound, Urinary Bladder Ultrasound, Ocular Ultrasound, Obstetric… 187
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2014;113(1):12–22.
POCUS: What does the Future
Hold? 9
Rachel Hui Xuan Chia and Balakrishnan Ashokka
The invention of the stethoscope revolutionized Imagine a world where the expertise of a doctor
the practice of medicine in the 1800s. Fast for- could be supported by the power of computer-
ward two centuries later, the era of “Point-of-Care assisted decision-making. The combined efforts
Ultrasound” (POCUS) arrived, heralding a great of multiple experts in the field of computer sci-
milestone in the practice of medicine. POCUS is ence, medicine, robotics, and more have made
well-established in the field of emergency medi- this a reality. There is a plethora of reasons why
cine and trauma management. It is emerging as a traditional technologies in healthcare should
valuable tool in a wide range of applications embrace artificial intelligence (AI). In the field of
including procedural guidance for general and imaging technology, AI has an extraordinary
regional anesthesia, vascular access, decision- ability to not only make sense of images but also
making in intensive care, perioperative care, goal- reveal to the clinician, potentially hidden patterns
directed management, and therapeutics. Now, that would evade even the most highly trained
real-time ultrasound-guided assessment of inpa- human eye. In other words, AI is training the
tients in the wards is within reach for many clini- computer to see what the human eye cannot.
cians. Medical schools are also including
ultrasound interpretation skills in their curricu-
lum. In the next decade, it would be unsurprising 9.2.1 Deep Learning
to see POCUS become the new standard of care.
As advances in imaging technology develop fur- The demand for greater accuracy and more objec-
ther in parallel with the continued upgrading of tive imaging assessments have led to the incorpo-
ultrasound skills of clinicians, the future of ration of deep learning technology into the field
POCUS could bring about enhancements in visu- of ultrasonography. Deep learning is a machine
alization and accuracy, while minimizing the cog- learning technique where artificial neural net-
nitive load on the operator. The future of POCUS works, inspired by the human brain, are able to
can be simply summarized in a few words: “What make sense of data themselves. As one of the top
is advanced today, may be basic tomorrow.” ten breakthrough technologies of 2013 [1], deep
learning has solidified its position as the leading
R. H. X. Chia (*) · B. Ashokka machine learning tool in imaging analysis [2]. In
Department of Anaesthesia, National University 2020, the US Food and Drug Administration
Health System, Singapore, Singapore
approved the first cardiac ultrasound automated
e-mail: [email protected]
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022 189
A. Chakraborty, B. Ashokka (eds.), A Practical Guide to Point of Care Ultrasound (POCUS),
https://doi.org/10.1007/978-981-16-7687-1_9
190 R. H. X. Chia and B. Ashokka
software [3], which uses deep learning technol- its capabilities in detecting lesions is warranted to
ogy to guide the operator to acquire images of prevent overdiagnosis and wastage of resources
diagnostic quality. It accomplishes this via real- and man-hours.
time prescriptive guidance of the user’s hand
motions and transducer positions to obtain the
desired image [4]. Once this image is captured, 9.3 Handheld Ultrasound (HHU)
the ejection fraction can be automatically calcu-
lated. With this novel technology, even novice In the field of POCUS-enabled healthcare
operators with no formal training in ultrasound advancements, the demand for “pocket sized”
will be able to obtain high-quality cardiac images, devices is increasing [11]. The hallmark of HHU
allowing rapid assessment and decision-making. is its accessibility, making it readily available to
Automated software has also been deployed in virtually every patient in the hospital that is lim-
other ultrasound applications such as to identify ited by the need for large bulky equipment and
and track endocardial structures to calculate indi- perpetually busy qualified ultrasound technolo-
ces of myocardial function in commercially gists. This complements and enhances any point-
available platforms (HeartModelA.I., Philips of-care ultrasound assessment. A variety of
Healthcare) [5, 6]. In the field of regional anes- handheld devices with different characteristics
thesia, identification of nerves can be considered are currently available in the market. Some prod-
one of the more challenging tasks for the novice ucts have single or multiple probes, while some
provider and image recognition technology could have the ability to stream images onto a mobile
potentially be incorporated into ultrasound- device. A few devices have incorporated AI sys-
guided regional nerve blocks. A machine learn- tems, aiding the novice operator to obtain high-
ing model has been employed in ultrasound quality images and estimate certain measurements
images of the femoral nerve and brachial plexus of interest, such as ejection fraction in echocar-
[7, 8]. Besides nerve identification, AI-powered diography [12].
systems in ultrasound have also been deployed to Traditionally, the piezoelectric effect is the
increase the accuracy of spinal landmark identifi- cornerstone of ultrasound, which is common-
cation for complex anatomical presentations in place in the transducers of heavier cart-based
neuraxial anesthesia (uSINE™) [9]. Indeed, AI ultrasound machines. Few disadvantages of
allows clinicians to look forward to exciting piezoelectric technology include high cost of
future applications in clinical use, as well as in production and need for separate probes for the
regional anesthesia training. analysis of high and low frequencies [13]. The
Despite its unique capabilities in refining inherent limitations of piezoelectric technology
diagnostic accuracy and sensitivity in medical have inspired the development of a novel
imaging, users of AI-powered systems need to be ultrasound-on-chip technology. Known as
cognizant of certain potential perils. A study on Capacitive Micromachined Ultrasound
screening mammograms showed that deep learn- Transducers (CMUT), piezoelectric crystals are
ing is no more sensitive than radiologists in replaced with a single silicon chip, which con-
detecting cancer, but was consistently less spe- verts electrical currents into ultrasound waves
cific, i.e., higher false-positive rates [10]. The [12]. The advantage of using an ultrasound chip
powerful ability of AI to detect minor changes in is its lower cost of production and ability to ana-
images may potentially be a double-edged sword, lyze a wider range of frequencies without the use
as increased sensitivity leads to overdiagnosis of of multiple probes. In addition, images can be
subclinical diseases with minimal impact on displayed on a mobile device, further enhancing
morbidity and mortality. Undoubtedly, portability (Butterfly iQ) [13].
AI-powered systems have promising clinical Image quality in HHU has been an area of
applications with the potential to improve public concern as some historical evidence suggests that
health. However, more research into finetuning of they are slightly inferior to traditional standalone
9 POCUS: What does the Future Hold? 191
devices [12, 14–16]. HHUs classically utilize 2D The authors found that the HHU accurately
and color Doppler imaging and lack the capabil- estimated the epidural depth, with a mean dif-
ity to visualize all abnormalities. Indeed, image ference of −0.61 cm [95% CI, −0.79 to −0.44]
quality in HHU may be inadequate in performing compared to needle depth, and furthermore
a comprehensive ultrasound examination; how- showed a high first pass rate of 87% with HHU-
ever, users need to understand that the use of guided identification of the lumbar interspace.
POCUS is to function as an adjunct to physical In fact, the Accuro HHU has also shown that it
examination in order to answer a focused clinical is comparable to a console ultrasound machine
question. In a systematic review comparing hand- in estimating epidural depth [25].
held ultrasound with high-end ultrasound sys-
tems, the authors showed that there was a good
overall correlation when the use of HHU is lim- 9.4 Contrast-Enhanced
ited to a distinct focused clinical question [16]. Ultrasound (CEUS)
This consensus is supported by several studies
that have also found HHU to be a valuable tool in The development of Contrast-Enhanced
the various settings, displaying images of suffi- Ultrasound (CEUS) could be a major paradigm
cient quality to detect ascites, hydronephrosis shift in the field of imaging. CEUS was first
and even screening for abdominal aorta aneu- introduced in the 1960s, where the injection of
rysms and measuring aortic diameters [17–22]. agitated saline bubbles produced a detectable sig-
In the field of obstetric anesthesia, the nal change on ultrasound [25]. Decades of
placement of epidural catheters for labor anal- research have culminated in the discovery of
gesia traditionally relies on the palpation of novel ultrasound contrast agents (UCA), which
body surface landmarks. First pass success are microbubbles of perfluorocarbon, nitrogen
rates with palpation alone have been reported gas, or sulfur hexafluoride stabilized in a phos-
to be as low as 20% [23]. In the first study of pholipid membrane [26]. The backscatter of
its kind, Seligman et al. studied the accuracy ultrasound waves is enhanced when UCA micro-
of a HHU device (Accuro, Rivanna Medical, bubbles are injected into the vasculature, which
Charlottesville, VA) (Fig. 9.1) in estimating provides information on microvascular blood
depth to epidural space compared to using the flow and tissue perfusion. The analysis of micro-
conventional method of Tuohy epidural needle vasculature therefore confers a benefit when
depth (depth to loss of resistance to saline) [24]. compared to Doppler ultrasound [27, 28].
With contrast agents no longer restricted to valves, and patients with acute respiratory dis-
computed tomography (CT), magnetic resonance tress syndrome [32].
imaging (MRI), and angiography, the application CEUS has been widely used in abdominal
of CEUS in various clinical settings could benefit and cardiac imaging for decades throughout Asia
patients significantly. Major advantages of CEUS and Europe. Yet, it was only in recent years, its
include its low cost, radiation sparing effects, use was approved by the US Food and Drug
bedside accessibility, lack of need for sedation, Administration for diagnostic liver imaging in
and lack of nephrotoxicity. In addition, its lack of adults and children [33]. The characterization of
iodine content, which is present in other contrast liver lesions has been one of the most well-
media avoids the risk of thyroid function impair- established clinical applications of CEUS, with
ment [29]. Contrast agents are foreign materials several published reports claiming its success
and although it has a good safety profile, hyper- [34–36] (Fig. 9.2). Various studies have shown
sensitivity reactions have been reported in about that CEUS has an excellent accuracy in detecting
0.002% of abdominal studies [30, 31]. The inci- liver lesions, with a reported 87–91% sensitivity
dence of hypersensitivity in CEUS is lower than [37]. Contrast-enhanced imaging of liver lesions
the use of iodine contrast in CT and comparable were found to be related to phagocytosis of the
to the use of Gadolinium contrast in MRI [31]. UCA microbubbles [38]. CEUS is highly accu-
The main contraindications for the use of CEUS rate in differentiating benign and malignant liver
include patients with known coronary artery dis- lesions as well, with a sensitivity of 96–97.2%
ease, severe arrhythmias, right-to-left shunts, and a negative predictive value (NPV) of 94.1–
severe pulmonary hypertension, prosthetic 98.5% [39]. With such remarkable results in
Fig. 9.2 “File:Ultrasonography of a dysplastic nodule.jpg” by R. Badea and Simona Ioanitescu, CC BY 3.0
9 POCUS: What does the Future Hold? 193
liver imaging, CEUS has found its way into a world. Tele-medicine offers healthcare providers
wide variety of non-hepatic imaging applica- a unique opportunity to provide remote consults,
tions, examples of which are the detection and and at the same time increase the opportunity for
differentiation of kidney lesions, clearer delinea- patients globally to receive proper assessments
tion of pancreatic cancer and the adjacent ves- and diagnoses. As data transmission technology
sels, evaluation of aortic or other vascular in healthcare grows in parallel with the miniatur-
abnormalities, and the evaluation solid organ ization of ultrasound devices, this has spurred the
injuries in blunt abdominal trauma [29]. A novel development of the tele-ultrasound practice.
territory within the field of POCUS, CEUS has Tele-ultrasound could potentially eliminate a
gained popularity in the trauma setting, where it major limitation of traditional ultrasound, as with
was able to detect avascular laceration planes as the aid of a remote expert interpreter, the lack of
well as pseudoaneurysms and active bleeding image interpretation skills may no longer pose a
[40, 41]. The expansion of the use of CEUS in problem [43].
emergency medicine has recently garnered the The bulk of the tele-ultrasound application
interest of intensivists caring for critically ill can be found in the field of obstetric and fetal
COVID-19 patients. A case report by Yusuf et al. medicine, majority of which relates to the confir-
proved CEUS to be a useful tool in point-of-care mation of pregnancy, assessing for pregnancy-
lung ultrasound. With its well-known ability to related complications, and monitoring fetal
distinguish perfused from avascular tissues, growth [44]. In recent years, the scope of tele-
CEUS was able to identify microvascular lung ultrasound has reached various clinical applica-
infarcts classically seen in COVID-19 patients tions involving echocardiography to imaging of
with immune-mediated thrombotic events. The trauma patients as well as guided procedures [45,
authors also showed that the degree of lung 46]. The assessment of trauma patients relies
infarction correlated with clinical status, provid- heavily on physical examination supplemented
ing relevant prognostic and diagnostic informa- by the use of ultrasound for rapid diagnosis and
tion to guide management [42]. decision-making. The Focused Assessment with
CEUS is emerging as a promising imaging Sonography for Trauma (FAST) scan is tradition-
technique for POCUS applications and more ally performed by emergency medicine physi-
research into its diagnostic accuracy, healthcare cians to rapidly diagnose life-threatening injuries
costs, and patient safety profile is warranted to requiring immediate management. Recently, sys-
prove its value in various clinical settings. These tems have been developed to enable ultrasound-
techniques when developed into critical care pro- novice paramedics to perform prehospital
tocols can help in early diagnosis, timely initia- ultrasound scans in trauma victims and obtain
tion of definitive management, and more FAST images under the remote direction of emer-
importantly minimize transfer of critical ill venti- gency medicine physicians, allowing the medical
lated patients to radiology suites. Where dissemi- team to obtain an early diagnosis and prepare for
nation of infective pathogens is a concern, the use any emergency procedures [47].
of these techniques help to prevent the occur- In the most extreme example of a remote loca-
rences of super spreader events from patient tran- tion, astronauts aboard the International Space
sit within the hospital. Station (ISS) with limited ultrasound training
were guided by remote experts in the Mission
Control Center (MCC) to aid the diagnosis of
9.5 Tele-Ultrasound several medical ailments commonly occurring in
crew members [48]. Examples of which are mus-
Tele-medicine has been on the rise in the past few culoskeletal pain secondary to joint contusions or
decades, but the recent COVID-19 pandemic has effusions, trauma injuries when crew members
given it a major boost in popularity, as healthcare engage in heavy-duty tasks, and even ocular inju-
systems become overwhelmed throughout the ries. Eye foreign bodies are a common problem
194 R. H. X. Chia and B. Ashokka
as small particles float freely in space. It was Self-Test MCQ (20 Questions)
reported that an untrained astronaut had used
ultrasound to perform an eye examination with 1. Fluid appears _____ on the ultrasound screen
remote guidance from the MCC, and was capable A. White
of visualizing the anatomical structures of the B. Black
globe, iris, and pupil [49]. C. Grey
As telecommunication systems and data trans- D. Not seen
mission technologies improve, tele-ultrasound 2. The linear probe has a range of frequency of
could potentially be ubiquitous around the globe. A. 2–5 MHz
The remote interpretation of ultrasound images B. 4–7 MHz
requires software, hardware, and video- C. 5–10 MHz
conferencing platforms which are costly and D. 10–15 MHz
could be a major barrier in implementing tele- 3. If the image on the monitor screen is too dark,
ultrasound in developing countries [50]. While you should
video streaming might require higher Internet A. Increase depth
streaming capacities, short video clips and popu- B. Use more ultrasound gel
lar 1 min social media and networking platforms C. Decrease gain
could help in rapid transmission of video content D. Increase gain
and timely interpretation by the experts. In low 4. Which of the following is a piezoelectric
resource settings and remote hospitals, there has material?
been some evidence of its clinical feasibility in A. Nickel
emergency medicine however more rigorous B. Tourmaline
research is needed to evaluate its diagnostic accu- C. Iron
racy and effectiveness before tele-ultrasound can D. None of the above
be fully utilized with confidence [51]. 5. Speed of ultrasound is the fastest when travel-
ing through
A. Bone
9.6 Conclusion B. Air
C. Water
The introduction of POCUS has revolutionized D. Muscle
the process of bringing diagnostic imaging possi- 6. Properties of sound waves include
bilities and clinical interpretation is possible in a A. Amplitude
more time-sensitive manner. The advances in B. Frequency
technology and data processing have helped in the C. Wavelength
development of pattern recognition software that D. All of the above
enhance the accuracy of decision-making through 7. The main factor affecting attenuation is
large data points from machine learning. Applying A. Scattering
these could enhance the safety of healthcare, min- B. Divergence
imizing errors and potentially reducing healthcare C. Absorption
costs. Bulkier imaging equipment and long wait D. Reflection
in obtaining specialist and expert opinions can 8. Which of the following are not reported ben-
now be supplemented with portable, hand help efits of using artificial intelligence (AI) in
and modern technology. With the advent of ultrasonography?
enhanced connectivity help is now available rap- A. Improved survival rates
idly. These advances in ultrasound technology B. Enhanced diagnostic accuracy
and the application of POCUS are a welcome C. Wide clinical applications
promise of the near future with scope for reduc- D. Image capture assistance
tion in patient morbidity and mortality.
9 POCUS: What does the Future Hold? 195
9. Which of the following statements regarding 15. Which of the following statements regarding
artificial intelligence (AI) is FALSE? contrast-enhanced ultrasound (CEUS) is
A. Deep learning technology is one of the FALSE?
machine learning techniques used in AI A. The US was the first country to approve
B. AI-powered systems may lower false- the use of CEUS
positive rates in cancer detection B. CEUS may be used in pediatric patients
C. Untrained operators may obtain diagnos- C. POCUS lung ultrasound may benefit
tic quality imaging from CEUS in detecting lung infarcts
D. AI allows automated calculation of car- D. CEUS is highly accurate in differentiat-
diac ejection fraction ing benign and malignant lesions
10. Which of the following statements regarding 16. The gold standard for diagnosis of hepato-
handheld ultrasound is FALSE? cellular carcinoma (HCC) is
A. Piezoelectric crystals have a lower cost A. Computed tomography (CT) perfusion
of production compared to Capacitive B. Liver biopsy
Micromachined Ultrasound Transducers C. Contrast-enhanced ultrasound (CEUS)
(CMUT) D. Magnetic resonance imaging (MRI)
B. Devices may use single or multiple 17. In contrast-enhanced ultrasound of the liver,
probes microbubbles are taken up by
C. 2D imaging is classically used A. Sinusoid cells
D. Epidural depth is one of the parameters B. Kupffer cells
that can be measured C. Stellate cells
11. Which of the following is not a benefit of D. Hepatocytes
handheld ultrasound compared to traditional 18. Which of the following regarding POCUS
cart-based ultrasound? lung ultrasound is FALSE?
A. Low cost A. B-lines are artifacts caused by acoustic
B. Improved image quality impedance due to the underlying lung
C. Portable B. Loss of lung sliding is sensitive to
D. Reduced examination time pneumothorax
12. Current ultrasound contrast agents in the
C. In M-mode, the “barcode” sign suggests
market consist of a pneumothorax
A. Hydrofluorocarbons D. “Lung point” is the most specific sign of
B. Agarose gel pneumothorax
C. Galactose and air 19. Which of the following regarding the FAST
D. Sulfur hexafluoride exam is true?
13. The incidence of hypersensitivity reactions A. It leads to few diagnostic peritoneal lavages
with the use of contrast-enhanced ultrasound B. FAST can be repeated for serial
(CEUS) is reported to be examinations
A. 2% C. It is safe for use in pregnant and pediatric
B. 0.2% patients
C. 0.002% D. All of the above
D. 0.0002% 20. Regarding the FAST exam
14. Which of the following is not a contraindica- A. FAST is more sensitive in obese patients
tion of contrast-enhanced ultrasound (CEUS) B. Solid organ injuries are easily identified
A. Coronary artery disease C. Peritoneal free fluid will not be detected
B. Acute respiratory distress syndrome until more than 500 ml is present
C. Acute kidney injury D. Diagnostic accuracy differs significantly
D. Arrhythmias between radiologists and non-
radiologists
196 R. H. X. Chia and B. Ashokka
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Answer Keys
Chapter 1 Chapter 7
Answers: 1C, 2D, 3A, 4C, 5D, 6B, 7C, 8B, 9D, Answers: 1D, 2C, 3A, 4B, 5A, 6C, 7B, 8C, 9D,
10B 10B, 11C, 12B, 13A, 14D, 15B, 16A, 17D, 18D,
19A, 20B
Chapter 2
Chapter 8
Answers: 1E, 2B, 3E, 4E, 5D, 6E, 7E, 8E, 9A,
10D, 11E, 12A, 13B, 14A, 15E, 16B, 17C, 18D, Answers: 1B. Lateral resolution is determined
19C, 20D primarily by the width of the ultrasound beam.
The focal zone, or narrowest portion of the ultra-
sound beam, is where the highest lateral resolu-
Chapter 3 tion is obtained. Ideally, the target structure(s)
should be positioned within the focal zone to
Answers: 1A, 2D, 3B, 4C, 5C, 6A, 7D, 8C, 9D, maximize resolution.
10D, 11A, 12C, 13B, 14B, 15A, 16C, 17A, 18A, 2C. Linear transducers produce the highest
19C, 20D resolution images of superficial structures
(<6 cm) as they transmit high-frequency ultra-
sound waves in a parallel orientation. Linear
Chapter 4 transducers are used to image any superficial
structures, including blood vessels, skin/soft tis-
Answers: 1C, 2A, 3B, 4C, 5C, 6C, 7A, 8C, 9C, sues, joints, eyes, testicles, thyroid, lymph nodes,
10D, 11C, 12D, 13B, 14A, 15D, 16B, 17A, 18F, and nerves.
19D, 20A 3B. Only the anterior portion of the bladder is
visualized. Increasing the depth will allow visu-
alization of the entire bladder, including the pos-
Chapter 6 terior wall.
4C. Fluid-filled structures serve as acoustic
Answers: 1C, 2C, 3C, 4D, 5D, 6B, 7D, 8B, 9B, windows for sound waves to travel into the
10C, 11B, 12B, 13D, 14A, 15D, 16E, 17E, 18B, abdomino-pelvic cavity to generate ultrasound
19E, 20D images. The blood-filled liver and spleen serve as
acoustic windows in the right and left upper
quadrants. Similarly, a urine-filled bladder is an
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature
Singapore Pte Ltd. 2022
A. Chakraborty, B. Ashokka (eds.), A Practical Guide to Point of Care Ultrasound (POCUS), 199
https://doi.org/10.1007/978-981-16-7687-1
200 Answer Keys
ideal acoustic window for the visualization of 10C. The differential diagnosis for traumatic
pelvic structures. Gas-filled loops of the bowel vision loss includes corneal abrasion, hyphema,
scatter sound waves and prevent visualization of traumatic iritis, lens dislocation, foreign body,
deep structures in the abdomen and pelvis. retinal detachment, vitreous hemorrhage, trau-
Subcutaneous emphysema and asplenia also limit matic optic neuropathy, acute maculopathy, and
ultrasound imaging of the abdomino-pelvic globe rupture. Ocular ultrasound serves as a use-
cavity. ful tool in the setting of trauma to assess pupil-
5B. A small amount of physiologic free fluid lary function, extraocular muscle function, lens
may be detected with point-of-care ultrasound in position, and globe abnormalities, and to evaluate
the pelvic cavity of women. However, in women for evidence of increased intracranial pressure.
with a positive pregnancy test and abdominal All of the conditions listed above can be diag-
pain, the presence of abdomino-pelvic free fluid nosed by ocular ultrasound, except corneal
is an ectopic pregnancy until proven otherwise. abrasion.
6D. Acoustic enhancement, or posterior 11C. The subarachnoid space in the optic
acoustic enhancement, is an artifact that is seen nerve sheath does not dilate uniformly. The most
deep in fluid-filled structures. Due to the low pronounced response to increased fluid in the
acoustic impedance of a fluid-filled body, such as subarachnoid space due to increased intracranial
the bladder, a disproportionately high number of pressure occurs 3 mm posterior to the optic
echoes return to the transducer from tissues deep nerve—retina junction. The optic nerve sheath
into the fluid-filled body, resulting in these tis- diameter should be measured in transverse and
sues appearing hyperechoic, or brighter, than sagittal planes and compared to measurements
usual. obtained on the contralateral side. An optic nerve
7D. Power Doppler is particularly well suited sheath diameter greater than 5 mm is considered
for low-flow states, such as ureteral jets. The ure- abnormal in patients with clinical concern for
teral jets appear as bright yellow-orange emis- elevated intracranial pressure.
sions streaming from the base of the bladder 12D. It is true that transducers that have only
towards its center. Power Doppler does not dis- been in contact with intact skin can be cleaned
play directional information, like color flow with a nonabrasive soap or with low- or interme-
Doppler. None of the other imaging modalities diate-level disinfectant wipes. Statements A
listed is used for the detection of ureteral jets. through C are false. Use of disposable sterile
8D. Past research has demonstrated a close transducer covers followed by cleaning with a
correlation between the estimated bladder vol- nonabrasive soap and high-level disinfection is
ume using the formula above (bladder vol- recommended for endocavitary transducers that
ume = 0.75 × width × length × height) compared have been in contact with mucous membranes.
to the actual catheterized volume (correlation Transducers exposed to patients with Clostridium
factor = 0.983). It is noteworthy that bladder difficile infection should be cleaned with a hypo-
shape has a considerable impact on the accuracy chlorite-based or hydrogen peroxide-based solu-
of US estimation of bladder volume. Though tion to kill the bacterial spores. Ultrasound
applying the corresponding correction coefficient transducers should never be autoclaved or sub-
to volume calculations will improve the accuracy jected to high heat, electricity, or pressure
of the estimation, the correction factor 0.75 yields because the piezoelectric elements can be
the closest approximation regardless of bladder damaged.
shape. 13D. The transducer is placed in the parasagit-
9A. The prostate sits deep in the bladder and tal plane of the epigastric region to obtain general
normally encircles the bladder neck. Normally, qualitative observations of the gastric antrum and
the prostate measures less than 5 cm in transverse body, the stomach cavity, and the stomach con-
diameter. tents. It is scanned curving from right to left. The
Answer Keys 201