Fundamentals of Ultrasound

Physics and Knobology

PHITIPPINE SOCIETY OF ULTRASOUND IN SURGERY INC.

(Psus)
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INSTITUTE OF DIAGNOSTIC MEDICAL SONOGRAPHY
 Table of Contents

INTRODUCTION 1

History
Definition
SONOGRAPHIC TERM INOLOGY 2

BASIC FORMULAS 2
J

CHARACTER]STICS OF SOU ND 4
GENERATIONS OF SOUND 5

Piezo-electric Effect

Pulse Length (PL)

Pulse Repetition Period (PRP)

Pulse Repetition Frequency {PRF}

GENERATION OF THE ULTRASOUND IMAGE 6

DigitalScan Converter
Grey Scale lnnaging

Beamformer
Scannlng Modes

ULTRASOUND _ TISSUE INTERACTION 7

Attenuation
Gain

Absorption
Reflection

Refraction

Scattering

Acoustic lmpedance

Tissue Echogenicity

PHILIPPINE SOCIEW OF ULTRASOUND IN SURGERY

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IMAGE RESOLUTION 1L
COLOR DOPPLER L3

THE TRANSDUCER 13

Focus

Bandwidth
Frequency

Types of Transducers

KNOBOLOGY - IMAGE OPTIMIZATION 19

. Frequency Selection

Depth / Field of View

Scan Angle

Gain adjustment

Focus position

Dynamic Range

Frame Rate

Compound lmaging
IMAGE PROCESSING ?3
Pre-processing

Post-processing

TRANSDUCER MOVEMENT 25
BASIC SCANNING TECHNIQUES 26
IMAGE ORIENTATION 28
SAFETY OF ULTRASOUND 30
ROUTINE EQUIPM ENT MAINTENANCE 32
LI M ITATIONS OF ULTRASOUND 34

PFIILIPPINE SOCIETY OF ULTRASOUND IN SURGERY

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 rH E t-t tsroEyllf uEBAsou N I
The use of ultrasound as a diagnostic modality is a relatively new practice. The idea
came after Langevin made use of a pulse-echo technique called SONAR {Sound Navigation and
Rangingi in 1916.
Later, in the late thirties, ultrasound was applied in industry by Firestone to detect metal
flaws present in equipment and machinery.
An Australian researcher named Dussik was the first to apply ultrasound to medicine.
He used the metal flaw detector to evaluate the cerebral ventricles for midline displacements
or defects.
ln 1949, Ludwig and Struthers irnproved the pulse-echo technique to detect foreign
bodies in soft tissue. Soon this practice was applied to the gallbladder, in the search for
gallstones.
- Howry and Bliss produced the flnst cross-sectiorral ultrascund innage in 1950. The idea
that this would be useful for imaging of the gravid uterus followed shortly thereafter.
lan Donald, in Scotland, was the first ta obtain sonographic images of evarian cysts and
BPDs in 1958"
ln the 40 years since Dussik's application sf ultrasound to rnedicine, the quallty of
ultrasonic evaluation has improved drarnatically to such a point that it is now considered an
integral part of diagnostic imaging. The relatively low cost, ease of examination, and absence of
significant bio-effects make ultrasound a fuvorable route to take among the many irnaging
rnodalities. As you will see, the ease with which one can master sonography makes this
modality integral to modern rnedical practice.

DEFINING ULTRASOUNS - A. brief iook at how it works

The human ear can hear sound in the frequency range of 20-20,000 Hertz {cycles per
second). Ultrasound is that sound which is at a frequency greater than 2Q&)0 Hertz. Diagnostic
Ultrasound operates in the range cf 1to 18 Megahertz.

Ultrasound travels in the forrn of a longitudinal wave, in which particle motion is along
the same direction as the rffave is traveling. These waves are generated by the ultrasound
transducer. Longitudinal waves transfer energy through the motion of regions of cornpression
and rarefaction within the wave. Because it is in $Jave form, ultrasound physics is governed by
many of the same principles as basic \n ave physics {see attached formulae).

The ability of the ultrasonic wave to travelthrouglr any medium is restricted by

properties of that medium; these properties include the density and elasticity which make up
the acoustical impedance specific to that medium. Transmission is also limited by the
transducer frequency being used; hlgher frequencies have shofter wavelengths and penetrate
less than lower frequencies.

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,t
 As the ultrasound bearn encounters tissues of different acoustic impedance, velocities
are altered such that neturning echoes are received by the transducer at different tirnes and
have different intensities. The differences in time and intensity are adjusted for by the user and
the computer within the systern" This inforrnation, along uvith the values for sound !\rave
velocities in tissues is used by the ultrasound device to generate the diagnostic image on the
rnonitor.

8)N qG AAPH r e TEfiM I N er0.qy

L Acou*tic $hadow - caused by absorption or reflection of sound and results in a lack of

echoes posterior to a structure (partia! "dlrfl1' or complete 'tlean").
2 Anechoic_- completelyvoid of inte rnal echses not necessarily cystic unless through
transmission is noted"
3. Complex - disptraying more than one sonegraphic characteristie; non-hon'logeneous
cornposition.
4. not nece$sarily a true cyst"
Cystic_- describes a fluid-flltred area,
q
Echo free - completely void of internal echoesli*terf;aces {anechoic}.
6. Echogenic - a relative term describing a structure that produces echo*s dependent on
the number of internal interfaces it has.
v. Echoeenicity - refers to the echc-producing ability that a structure has, dependent on
internalcomposition; a structure is associated with an echogenicity, which when altered
is considered abnormal.
6 Echo poor - structure containing very few of lcw-level echoes; not cystic in nature thus
will not exhibit through transmission.
9. Homogeneous - structure that has uniform composition.
10. Hyper reflective - structure displaying more echoes than characteristic of it.
tL. Hypo reflective - structure displaying fewer echoes than is characteristic of it.
L2. lnhcmogeneous - structure without uniform cornposition.
13. lnterface - strang echo that is produced due to a large acoustic irnpedanee rnismatch;
most pronounced when the beam is perpendicular.
1n Mixed Echogenicity - cornplex; displaying more than one sanographic characteristic.
15. Sonogram - an ultrasound examination.
16. Sonograoher - a professionaltrained in ultrasound technology {they are not "techs"}.
L7. Sonolaglst - a physician urho specializes in ultrasound"
18. Sonolucent - ccrnplete ly void of interna I echoesli ntedaces.
10 Texture - the echo pattern within a structure.

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70. Threugh Transrnissian {Acou*ic Enhancement} - caused by a lack of attenuating ability
of a superflcial structure such that distal structures appear to have more echoes due to
more sound passing through.
2L. Transducer * a deviee capable of changing one form of energy to another.
22. Transonicity - refers to a structure's ability to allow sound to pass through it; usually
qualified as good or bad.
23. Ultrasound - sound with a frequrency greater than 20,000 Hertz {cycles per second}.
24. I"lnilocular - comprised of one cavity or compartrnent {i.e,, sirnple or unilocular cyst].

BA$|C FOR[rUti$

Sound is attenuated ldblMHzlcrn

Thdvelocity of sound is assumed to be tr540 nnlsec; the average speed of sound in human
tissues
Velocity (v) is equalto frequency {f} multiplied by wavelength {I}: v = f }u
Acoustic impedance {z} is equalto the density of the medium {d} multiplied by the speed of
sound {c} thru that medium: z = d c

Attenuation Coefficient: dB=10 Log rr{12112}

Snetrl's Law: Sin I V1

Sin r v2

lntensity (l):dB = 10 Log {ed = 20 LoS Ar 0r Power {W}

{Ai}' Ai Area{crn2}

v - velccity {m/s} f - frequency (hertz)

l, - wavelength {meters} z - acoustic impedance (e/cm')
d - density l- intensity
i- incident bearn r- refracted beam
A - amolitude

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Characteristics of Sou nd

Sound is a fsrm of mechanical energy that travels in a straight line through a conducting
mediunr {e.9., body tissue} as a iongitudinal wave pr*ducing alternating cornpression {high
pressr.*re) and rarefaction {low pressr.rre}. Sound propagaticr^r can be represented in a sinusoidal
waveforrn wlth a characteristic amplitude {A}, wavelength {U, frequency (f}, period {T} and
velocity lspeed {c} + directionJ.

LOW FREQUENCY
A

f = 1Hz

f = cycleslsec.
T

,1 A HIGH FREQUEI{CY

L
f=3Hz
fuurd is a. PrE*E rrE tYave

C
T
R L
tR C R C
t
R C
T
x.

!,
I

T I I I I
TiEE
fr
tri

HffiT: rtl stsdr fu mn1lffiirr ffit rIl rtsdr {m rrn&t+ion

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PHILIPP}NE ST}C}ETY OF ULTRASOUND IN SUBGERY
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The frequency cf an ultrasound wave is above 20,000 l'lz {or 20 KHz} and medical ultrasound
commanly is in the 2.5-X"8 MHz range. Hurnan hearing is in the 20-20,000 Hz range. The speed
of sound varies for different biological media but the average value is assumed to be 1,540
rn/sec (constant) for most human soft tissues. The speed of sound {ci can be calculated by
multiplying wavelength {}r} x frequency {f}. Thus sou*d with a high frequency has a short
wavelength and vice versa. For exarnple, the uravelength of a 2 MHz ultrascund wave = A.77
mm and that of a 15 MHz wave = 0.L0 mm.

MEDIUM SPEED OF SOIJND in meters per second

Air 300
Lung 500
Fat L,450
Brain 1,520
Muscle 1,580
Liver 1,550
Kidney 1,560
Blood 1,560
Soft Tissue 1,540
Bone 4,000

Generation of an Ultrasound Wave

An ultrasound wave is generated when an electric field is applied to an array of piezoelectric

crystals located sn the transducer surface. Electrieal stimulation causes mechanical distortion of
the crystals resulting in vibration and production of sound waves {i.e. mechanical dnergy). The
conversion of electrical to mechanical {scund} energy is called the converse piezoelectric effect
{Gabriel Lippman 1881}.

Each piezoelectric crystal produces an ultrasound

wave. The summation of all waves generated by
the piezoelectric crystals forms the ultrasound
beam. Ultrasound waves are generated in pulses
(intermittent trains of pressure waves) and each
pulse commonly consists of 2 or 3 sound cycles of
the same frequency.

"r., ,,i. i' The pulse length {PL} is the distance traveled per
-1. i
i . r I .
pulse. Waves of short pulse lengths improve axial
nasolution for ultrasound imaging. The PL cannot
be reduced to less than 2 or 3 sound cycles by the
damping materials within the transducer.

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 PRF per time unit {S}

'li Lrf

PL PRP

PRF: Pul*e Flepetition Freque*cy is the number

o{ pulses occuning i* time.

Pulse Repetition Period {PRP} is the time from the start of one pulse to the start of the next
pulse.

Pul$e Bepetition Frequency {PRf} is the rate of pulses emitted by the transducer {number of
pulses per unit time). Ultrasound pulses must be spaced with enough time between pulses to
permit the sound to reach the target of interest and return to the transducer before the next
pulse is generated. The PRF for rnedical imaging ranges from t-10 kHz. For example, if the PRF =
5 kHz and the time between pulses is 0.2 msec., it willtake 0.1 msec to reach the target and 0.L
rnsec to return to the transducer. This means the pulse will travel 15.4 cm before the next pulse
is emitted {1,540 m/sec x 0.1 rnsec = 0.154 nr in S.1 msec = 15.4 cm}.

Generation of an Ultrasound lmage

An ultrasound image is generated wiren the pulse wave emitted frorn the transducer is
transmitted into the body, reflected off the tissue interface and returned to the transducer. The
human body is composed of tissues of varying densities. Tissues of varying densities reflect
echoes of varying intensities. Dense or hand tissues like bones reflect high amplitude {strong)
echoes, softer tissr..les like the liver or kidney reflect lower arnplitude {weaker} echoes, while
fluids do not reflect any echoes at all.

The transducer transforms the echo {rnechanical energy} into an electrical signal. The stronger
the echo, the higher is the amplitude of the electrical signal. Weaker echoes are converted to
lower amplitude electrical signals {see Tissue Echogenicity}. The digital scan converter then
maps these {nange of} signals and assigns a nurnber frem 0 to 255 t255 erey levels}, where 0 is
mapped lplaced in the correct pasition an the pixel board - mapping) as black and 255 is
rnapped as white and all the nunrbers in between represent different shades of grey. This
process is called grey scale irnaging. These shades ef grey are then cornbined and displayed as
an image on the screen. {see also Dynarnic fronge o* page 22}

The position of the dots {shades of gray} on the monitor represents the depth from which the
returning echo was received. When the system hearnformer generates the electrical pulses, it

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also starts the system clock and signals the start of transmission. The system then calculates
how long it takes for the echo to return to the transducer.
By using the following formula: Distanee = Velocity x Time,

Distance

1540 m/s x 58 1/ 2=4"47ere 58 usec

t
4
Crr}
T*.
{Measured delay time}
(Average speed of sound in soft tissue)

where the average ve{ocity of sownd in tissue is assumed constant ot 754A mekrs / second,the
system can now determine the distance between the transducer surface and tissue interface.

The image can be displayed in a number of modes:

1) Amplitude {A} mode

2) Brightness iB) mode
3) Motion {M} mode
4) Doppler {D} mode

Among the 4 mcdes, the B mode is rnost comrnonly used. There are 5 basic components of an
ultrasound scanner that are required for generation, display and storage of an ultrasound
image.

1. Pulser or beamformer - applies high amplitude voltage to energize the crystals

2. Transducer - convetts electrical eilergy to mechanical {ultraseund} energy and vice versa
3. Receiver - detects and an'lplifies weak signals
4. Display - displays ultrasound signals in a variety of modes
5. Memory - stores video display

Ultrasound - Tissue lnteraction

As the ultrasound beam travels thror:gh tissue layers, the amplitude of the original signal
becomes attenuated as the depth af penetration increases. Attenuation {energy loss) is due to:

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l") Abs*rption {conversion of acoustic energy to heat}
2) Retlectian
3) Scattering at interfaces

ln soft tissue, 8A% of the attenuatien of the sound wave is caused by absorption resulting in
heat production. Attenuation is rneasured in decibels per centimeter af tissue and is
represented by the attenuation coefficient af the specific tissr,re type {see table below}. A
reduction of 3 dB corresponds to dirninution of the original intensity by half. The higher the
attenuation coefficient, the mcre attenuated the ultrasound wave is by the specified tissue. For
example, bone with a very high attenuation c*efficient severely lirnits beam transmission.

Body Tissue Attenuation Coefficient {dB/cm at lMHz)

Water 0.002
Blaod s.18
Fat 0.63
Liver 0.5 - 0.94
Kidney 1"0
Muscle 1.3 - 3.3
Bone 5"0

The degree of attenuation also varles directly with the frequency of the ultrasound wave {see
figure below) and the" distance traveled. Generally speaking, a high frequenq wave is
associated with ttigh attenu{rficr: tfius ffmifing fiSsue penetratiar, whereas a low frequency
wave is asscciafed witlt lcw #ssue attenuatian and deep trbsre penetration.

x5

2 10
e .*"*MUSCLE
F
s
5
z
t- -LlvER
F
0
-BLOOD
Z 4 6810

FREQUENCY

To compensate for attenuation, it is possible to amplify the signal intensity of the returning
echo. The degree of receiver amplification is called the Gain. lncreasing the gain will amplifu
only the returning signal {echo} and not the transmit signal" An increase in the averall gain will
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a

increase hrightness of the entire image, including the background noise. Preferably, the time
gain cempensatien tfCCI is adjusted to setectiveiy arnplify tlre weaker signals returning from
deeper structures.

Echo Reflection and Scattering

Attenuation also results from reflection and scattering of the ultrasound urave. The extent of
reflection is determined by the differance in acoustic impedances of the two tissues at the
interface {i"e., the degree of innpedance misrnatch}. Acoustic impedance is the resistance of a
tissue to the pas$age of ultrasound. The higher the degree of impedance rnismatch, the greater
the amount of reflection.

Variation of Acoustie lmpedanee with Bcdy Tissues

6
Body Tissu* Acoustic lmpedance {10 Rayls}
Air 0.0004
Lung 0.18
Fat 1.34
Liver 1.6s
Sloed 1.65
Kidney 1.63
Muscle t.7L
Bone 7.8

The degree of reflection is high for air because air has extremely low acoustic impedance
(0.0004) relative to other body tissues. Bone also produces a strong reflection because its
acoustic impedance is extremely high {7.8} relative to other body tissues. For this reason, it is
clinically irnportant to apply sufffcient conducting gel (an acoustic couptring nnediurn] on the
transducer surfuce to elirninate any air pcckets between the transducer and skin surface.

i-{{
Otherwise much of tlre ultrasound waves will be reflected limiting tissue penetration.

/@ e .:i,

{s} {b} {c} id)

Specular reflection [figures {a} & {b}] occurs at flat, srnooth interfaces where the transmitted
wave is reflected in a single direction depending on the angle of incidence. Examples of
specular reflectors are fasciatr sheaths, the diaphragm and walls of major vessels. Block needles

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are al$o strsng specutrar reflectors. For specular reflection to occur, the wavelength of the
ultrasound wave must be smaller than the reflective strueture.

The angle of the inridance is a major deternrinant of reflection. An ultrasound wave hitting a
smooth mirror like interface {sp*cular reflector} at a 90 degree angle will result in a
perpendicular reflection. An incident wave h;tting the interface at an angtre less than 90 d*grees
will result in the wave being deflected away frann the transducer at an angle equalto the angle
of incidence but in the opposite direction {angle of reflection}. When this happens, the signal of
the returning echo is weakened and a darker innage is displayed. This explains why it is difficult
to visualize a needle inserted at a steep angle {> 45 degrees to the skin surface}.

Reflection in biological tissues is not always specular. Scattering [figures {c} & {d}] or diffuse
reflection occurs when the incident ura\re encounters an interface that is not perfectly smooth
{e.gi, surface of visceral organs}. Echoes frorn diffuse reflectsrs are generally weaker than those
returning from specular reflectors" Scattering [flgure te]] atso oecurs when the wavelength of
the ultrasound wave is larger tlran the dirrrensions of the reflective structure {e.9., red blood
cells). The reflected echo scatters in many different directions resulting in echoes of similar
weak amplitudes. Ultrasonic scaf,tering gives rise to much of the diagnostic information we
observe in rnedical ultrasound imaging.

After reflection and scattering,

REFLECTION ABSORPTION SCATTEHING the rernainder of the incident
bear"n is refracted with a
change in the directien of the
transmitted beam. Refraction
occurs only when the speeds of
*
-hh
q-\,
sound are different on each
side of the tissue interface. The
degree of beam change
{bending} is dependent on the
change in the speed of sound
traveling frern one rnedium on the incide*t side ta another rnediurn on the transnritted side
{Snell's Law}. With medical irnaging, fat c*uses cansiderable refraction and image distortion,
which contributes to sorne of the difficulties encountered in obese patients. Refraction
encountered with bone imaging is eveft rnore significant leading to a major change in the
direction of the incident beam and image distortion.

Tissue Eehogenicity

When an echo returrrs to the transducer, its arnplitude is represented by the degree of
brightness {i.e. echoge*icity} of a dot on the display. Connbination of all the dots fsrms the final
image. Strong specular reflectisns give rise to bright dots {hyperechoic} e.g., diaphragm,

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gallston€, bone, pericardium. Weaker diffuse reflections produce grey dots {hypoechoic} e.g.,
sclid organs. No reflection produces dark dots {a*echoic} e.g., fluid and blaod filled structures
hecause the beam passes easily through these structures without significant reflectlon. Also,
deep structures often appear hypoechoic because attenuation limits beam transmission to
reach the structures, resulting in a weak returning echo"

lmage Resolution

Resolution refers to the ability to discrimlnate between two objects (reflectors or scatterers)
that are close together in space (spatial resoluticn! as separate or two events that occur close
together in tirne {terrporal resolution}.

Spa3ial resolution has two components:

1. Axialresolution
2. Lateral resolution

Axial or Longitudinal resclutian refers to the ability to distinguish two structures that lie along
the axis {i.e. paralfel] of the ultrtsound beam as separate and distinct" Axial resolution is
determined by the pulse length. A high frequency wave with a short pulse length will yield
better axial resolutian than e low frequency wave.

ln the figure A below, a 5 Ml'lz transducer generates ultrasound waves that travel 0.3 mm per
cycle {wavelength = 0.3 mm = speed of sound ,/ frequenry = 1,540 mfsec divided by 5 x 106
cycleslsec). The pulse length is the distance traveled by one echo {3 cycles in this case}. As seen
in figure & a 5 MHz transdueer {wavelength = 0.3 mm and pulse length = 0.9 mm; 3 cycles), the
axial resolution is sufficient to distinguish the 2 target objects as separate beeause the incident
wave hits target # 1 {brown} before hitting target # 2 {gre€n}.

0 A.2 A.4 0.6 0.8 t.O L.Z L.4 1.6 mm

A 0.3 mrn wavelength

0.9 rnm pulse length

ln figure B below, with a 2.5 MHz transducer {wave}ength = 0.6 mrn and pulse length 1.8 mm;
=
3 cycles), the axial resolution is no longer adequate. Because bcth target ff t(brown) and target
# 2 (green) are hit by the same wave, both target objects are seen as one.

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 0 A.2 0.4 0.6 0.8 1.0 L.2 t.4 1.5 mm

0.6 mm wavelength
B
1.8 rnm pulse length

Lateral resolutisn refers to resolution of objects lying side by side {i.e., perpendicular to the
beam axis). Lateral resolution is directly related to the transducer beam width, which in turn is
inversely related to the ultrasound frequency. A hish frequency transducer emits a wave with a
short wavelength and a small beam width. Lateral resoluticn Is pcor when the 2 structures lying
side by side are located within the sarne beam width. Because the returning echoes overlap
with each other side by side, the 2 structures {t and 2 in tigure} will appear as one on the
display. lt is therefore clinically important to chnose the highest frequency transducer possible
tc keep the beam width as narrow as possible in order to prcvide the best possible lateral
resolution. Lateral resslution is also affected by gain settings - the higher the gain, the worse
the lateral resolution. Lateral resolution is typically around 1 mrn.

Two $lruciures Only one

cg* be structuffi ca*
s*en her* b* s*e* here

However, attenuaticn also increases with frequency thus one must strike a balance between
resolution and attenuation. The beam width can be further reduced by adjusting the focal zone
(FZ). Lateral resolution is the best at the FZ, where the beam is narrowest. lt is therefore
clinically usefu[ to facus the target structure within the focal zone to yield the best possible
lateral resolution. The beam is known to diverge {increased beam width} as it propagates deep
into the far field"

Contrast Resolution {$ee Dyanmic fronge on page 22l

Temporatr resolution, or frame rate, is impcrtant in trying to distinguish events that occur close
together in time. Fname rate depends upon the time taken to eollect allthe data required to
create one irnage, which in turn depends upon the sector width and depth. M-mode irnaging
offers very high sampling rates, typically L800 times per second, because of the very na rrow
field of view {see above}. 2-D echo has a much slower frame rate, typically 20*30 frannes per

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second, because cf the much greater amount of ultrasound dat* that must be collected to
create a single frarrre.

Color Doppler

Color Doppler is an instrurnent to characterize blacd flow" The Doppler Effect occurs when
there is a rnoving source {blood flcw of red blood cells, RBC} and a stationary listener
{ultrasound transducer}. There is an apparent change in the returning echoes due to the
relative motion between the sound source and the receiver. lf the source {RBC} is moving
towards the receiver {transdr.lcer}, the percelved frequency is I-IIGFIER {display in RED} and
when the source {RBC} is moving a},vay fronr the receiver, the perceived fnequency is LOWER
than the actual {display in BLUE}. lt is important to note that Color Dcppler detection of flow
and flow direction is worst when the transducer is perpendicular {90 degreesi to the vesseland
best when the transducer is parallel {0 degrees} to the blood flow.

Power Doppler is useful for differentiating vascular frcm non vascular structures. Power
Doppler is more sensitive than Color Doppler in flow detection but does nct indicate flow
direction.

The Transducer

Each piezoelectric crystal prcduces an ultraseund wave- The sumrnation of allwaves generated
by the piezoelectric crystals forrns the ultrasound beam. The transmitted sound beam has a
shape, a finite width and lenght- The sound is focused eitl"rer by the shape of the transducer, a
lens in front af the transducer, or a complex set of control pulses frorn the ultrasound scanner
machine (Seamformind. This focusing produces an arc-shaped sound wave from the face of
the transducer. The wave travels into the body and comes into focus at a desired depth"

Transducer
i

i tl
\ i!lt Near Zone {Fresnel} - the area between the transducer and the focus
il
;r
i

Focal Zone - the area where the diameter of the sound beam is at a minimum

il
,,lt
lii Far Zone {Fraunhofer} - the area extending beyond the focus

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Transducer characteristics, such as frequency and shape, deterrnine ultrasound image quality
{see lmage Resolution}. The transducer frequencies used f*r peripheral nerve blocks range from
3-L5 MHz Linear and curuilinear {or curved} transducers are most useful for nerve irnaging to
provide high resolution images. Sector phased array transducers are used for 2D-echo or
cardiac sonography.

Modern transducers are broad bandwidth transducers that are designed to generate more
than one frequency. Fcr example, a Linear 5-12 MHz transducer can generate waves ranging in
frequency frorn 5.L2 MHz. With broad bandwidth transducers, the operator can select the
examination frequency to match the target requirernent. The resonance freqt"rency is the one
frequency at which the piezoelectric transducer is most efficient in converting electrical energy
to acoustic energy and vice versa. The resonance frequency is deterrnined by the thickness of
the piezoelectric element.

Take for exarnple the strings on a guitar;

o The diarneters of the strings are different. The smaller strings vibrate faster than the
larger strings, and create higher frequency ssund.
The same principal applies to the elements in a transducer.
I
The figurre below illustrates how the thickness of the crystal irnpacts the frequency of
the sound produced.

The frequency of an imaging transducer is propartional to its resolution capabilities, and

inversely proportiona I to penetration. *

Low Frequency High Frequency

3 MHr 10 MHz

For superficial structr.rres {e.9. vascular, thyroid, breast, extremities}, it is ideal to use high
frequency transducers greater than or equal to 7 MHz. Transducers in the range of 10-15 MHz
are preferred but depth of penetration is often limited to 2-3 cm below the skin surface. For
visualization of deeper struct$res {e.9. in the abdornen; liver, spleen, gall bladder, urinary
hladder), it may be necessary to use a lower frequency transducer {less than or equal to 5 MHz)
because it offers ultrasound penetration of 10 cm or more belornr the skin surface.

However, the image resolution is often inferior to that cbtained with a higher frequency
transducer. Linear transducers less than or equal to 5 crn wide are available for high frequency
L4
PHIilPPINE SOCIETY OF I.'LTRASOUruD IN SI.'R6ERY
ln collaboration rpith
I NSTITUTE OF DIAG NOSTIC MIDICAI SONOGRAPHY NCORPORATID
I
transducers. SrnalNer transducers, i.e., transducer: with srnaller footprints are useful for
detailed scanning where the patient's anatorny prohibits the use cf h'ulkier transducers {e.g.,
the supraelavicular region where there is limited access). Curved transdueers are best suited for
scanning whenever a wide field of view ls required.

*lt is important to remernber that:

liigh frequency = high spatial resolution; high attenuation; shallow penetration

Low frequency = lsuy spatial resolution; low attenuation; deeper penetration

Frequency and lmage Resalution - lt is best to select the highest frequency transducer possible
for the required depth of penetration.
I rlns
A. The use of a Higher Frequency Transducer - A
\ 1 na:l ica 1o r higher frequency transducer (10-12 MHz)
Footprint
\ f; cnn ect rt provides the best image resolution for superficial
structures.

B. The use of a Lower Frequency Transducer - A

lil rar rr { e liei lower frequency transducer (less than 7 MHz) is
lreiiel
required to image deep structures.
al atll{

Types of Transdueers

There are two types of transducers

according to construction: 1) Mechanical
and 2) Electronic Array transducers.
.o')-
Mechanical transducers are also known
as sector or single element transducens;
the latter is because they consist of only
one element {crystal}. The slrap* of the
ultrasound beam from this type of
transducer depends on the physical
(*e
Tran$du.€r
shape and size of the crystal. Scanning rolatros
with a rnechanical transducer is done by
rotating a single elernent (using a motor
inside the transducer housing) through
approximately 90' and the returned Seetsr angle
(n $can ,in5si
echo brightness is plotted along a
succassion of {typically 12S} radiallines.
t5
OI ULTRASOUND IN SURGERY
PHILIPPINE SOCIETY
tn collaboration with
INSTITUTT OF SIAGNOSTIC MEDICAL SONOGRAFHY INCORPORATED
Eleetronic Array Transducers on the other hand are composed of several etrernents or crystals
arranged in an array or beside each other. The elemeftts caft operate individually or in groups
dependi*g on the signals from the $ystem beam{arner. ln electronic array transducers, the
sound is focused by a cornplex set sf control pulses from the ultrasound scanner machine
lheamfarmina). This focusing produces an arc*shaped sound wave from the face of the
transducer. This technology allows the ultrasound machine to change the direction and depth
of the focus. Electronic array transducers are more versatile than mechanical transducers and
they come in many forms.

Below are examples of electronic array transducers.

I
I

I i
I

Linea r Array Transducer Curved Linear or Convex

r
t

,a*

16
PHILIPPINE SOCIETY CIF ULTRASOUhID IN SURGERY
ln collaboration with
I NSTITUTE OF DIAGNOSTIC MEDICAL SONOGRAPilY I NCORPORATED
Another type of etrectronic array transducer is the phased-array transducer. This transducer is
cor*monly used for scanning the heart {2* echo Sonographyi. ln order to generate 2-D
tomographic (sliee) images of the hea*, the ultrasound beam has to be scanned across a
section of the heart" The limited access to the heart afforded by spaces between the ribs and
lungs dictates that cardiac scanners are of the sectar scan type. The transducer is positioned on
the chest manually and held steady, but the ultrasound beam it generates sweeps rapidly to
and fro across a sector of an arc, creating a fan-shaped scan in the sarne way that a lighthouse
beam sweeps across the sea, illuminating abjects in its path. Tlris scanning rnotion is also similar
to that of a rnechanical transducer.

ln order to avoid blurring of the image by the heart's motion, at least 25 images per second are
required. The maximunr attainable irnage franre rate is primarily tha result of a trade-off
between the required image depth, which lirnits the nurnber of pulses transrnitted per second,
and the sector angle and image line density, but other factors such as the display rnode and
imaging processing power of the machine are now involved. lmage frarne rate shown on the
display screen may be as high as 150 s-L or as low as 6 s-1. lt can be improved by reducing
image depth and/or narrowing the scan angle.

Almost all commercial echo machines use "phased array'' technology to scan the ultrasound
beam. Using sophisticated equiprnent derived from that used to cut silicon for manufacturing
electronic "chips," a single piezoelectrie crystal is striced into as many as 255 very thin strips,
each connected individually to the electrle pulse generator, which activates them in a very rapid
and very precisely cantrolled sequence, as shown in the Fig. 1.

The wavelets from e'ach

crystal element merge to
form a compound
ultrasound wave. By
varying the electrical
activation sequence, the
direction of the compound
wave can be changed and a
i:il
-"--
:

series of pulses generated

? r 1 em crystalcut intq f-1,i:liii:a;
to form a sector scan thinslice, each "' :: ,-'1,, L;
-: i i l, ::.
configuration. For a sector connected separately tc *
angle of 90" and working pube generator
iJ
depth of 1"5 cm, each image 1

comprises about 200 scan ,';.-1 rlir:.j : j: :.ii-r,l :r'ri,'

lines and takes about 40 ..l .ri;:, : :,r,,,,.i:r :.r-r,l.tii.; l,_a i.r;,:: lr,- i: .i :,'\,,j::;,rl
,i,: ,-:lirtirirr. I :, i ., .:1,.,r:
milli-seconds {mess or ms}.
':i.t:i a.i'l -': :'. I' il:,: t';;,.1r

Figure 1

L7
PHILIPPINE SOCIETYOF ULTRASOUND IN SURGERY
in collabaration with
I NSTITUTE OF DIAG NOSTIC MEDICAL SONOG RAPFIY I NCSRPORATED
Steering the Phased-Array Transducer

All elements in a phased array transducer are fired for each scan line" The timing of the
excitation af the crystal elements deterrnines the direction of the bearn. A) When elements on
the right side of the transducer are fired first the bearn is directed to the left. B) When elements
on the left side of the transducer are fired first ttre beam is dlrected to the right" C) When fired
simultaneously the beam is directed straight ahead. D) Minor variations in the timing of crystal
excitatisn focus the bearn.

!!.!
tA) lrt
{B} il
tc} {D}

-{ ++,+4.+ ili;l ii
I i
I-J.
LIU i.jtj
illttt:
J- ,l
iiii
iiji ll
$$F++t lll:l
il
llrii
ii
il
i1
I1:ll .tt
itt
itli
irlll :i

ffiit** rllll
illtl
fril*ilil
tl
A+, i1
\"Jr&r\J\.J \.rrrj
\*.H^*H_H_KJ

ff #
k &

BELOW ARE DIFFTRTNT TRAN$DUCER F*OTPRINTs

Li*ear An*ular Phased Co*v*x Surved V*ctcr

Lir*ear
L8
PHILIPPINT SOCIETYOF ULTRASOUND IN SUR6ERY
In collaboration with
I NSTITUTE OF DIAGNOSTIC MEDICAL SONOG RAPI.IY I NCORPORATED
KN9BOL _oGY - GEryFRflL BULE$LF0R SqA!{NtNg

The ultrassund beam should be directed perpendicular to the object of interest

for optimal visualization (this can be quite challenging with a maving target!)

The user must choose a fransd*mr which has the highest frequency allowable
for the penetration required,

Scan all objects of interest in two planes 90 degrees to each ather {i.e., scan
each structure in its long and short axisi.

Optimizing lmage Quality

Visualization of organs with ultrasound depends on the operator's ability to properly:

1. Locate the organ

2. Handle the transducer {see Transducer Moveme*t}
3. Maximize the ultrasound machine capability by mastering the following controls

- Transducer frequency selection

- Proper adjustment of depth
- Gain {overall gain and Time Gain Compensation - TGC)
- Focus position
- Dynamic range
- Use of compound imaging and other irnage optimization mntrcls (if available)

The TRANSDUCER FREQUENSY is related to the longitudina! or axial resolution

which is the ability to distinguish two structures thal lie along the axis {i"e" parallel) of the
ultrasound beam as separate and distinct. The higher the frequency. the higher is the
axial resolution.

It is important to remember that:

High frequency = high spatiai r-esoiution; high attenuation; shaiiow penetration

Low frequ*flcy = low spatial resolution; lcw atterruation. deeper penetraticn

High freguency transducers have greater abitityto resolye minute structure$, butthe userrs limited
by decreased depth af penetration.

Application:
'Lower frequency probes are used fcr abdominal scanning, third trirnester
pregnancy, and obese patients.
'Higher frequency proks are for superficial exams such as breast, thyroid, and
testicles.
19
PHILIPPINT SCICISTYOF ULTRASOUND ISI SURGERY
ln collaboratian with
I N STITUTE OF DIAGNOSTIC MEDICAL SONOGRAPHY I NCORPORATED
 -3.5 or 5.0 MHz prabes are generally adequate for abdorninal, 1st and 2nd
trimester 0B studies

lVofe; lt is best to select the highest frequency transducer possible for the required
depth of penetration.

The DEPTH setting determines how far the ultrasound beam 'looks' into the patient and
is an important deterrninant of frame rate. The greater the depth setting, the Ionger the
transducer will have to wait for the ultrasound pulse to make lts round trip before
repeating the pulse, and so the lower the fi"anne rate. The depth setting should be
shosen so that the whole area of interest can be seen, but not so deeply that it includes
inelevant structures beyond the region of interest.

lLe.tI
at lA.
a2 a*4.
,E tr{
#
*8" .4.&
t.
alr0B
rl{t
gtc{
u f
ltle
.

t*vae rEEl
tlrt
rlt*i llr:.
ilaa3r rrl.t aro:
lsaar rtffi
*tmr
ltt,, ri**
Ftd I
X?rt lrt
fk
BL.
tr tr
\". {xt

S;
Too shallow Sptimal Too deep

Sector width or scan angle determines the tield of view across which the ultrasound
beam sweeps. As with depth, sector width is an irnportant determinant of frame rate
and should be optimized for each view to include the region of interest. With the scan
angle constant, increasing the depth of the image reduces the frame rate. With the
depth setting constant, increasing the scan angle will also reduce the frame rate.

Narrow FOV = higher frame rate Wide FOV= lowerframe rate

20
PHITIPHNE SOCIETY OF ULTRASOUND IN SLIRGERY
ln csllaboration with
I NSTITUTE OF DIAGNOSTIC MEDICAL SSNOGRAPHY I NCORPORATED
The GAIN function compens&tes for attenuaticn (a reduction in sound amplitude) as
sound travels deep into the body. The intensity of the returning signatrs can ba amplified
by the receiver upon arrival so that the displayed image is brighter and more visible on
the screen.

Gain can be adjusted for the whole image {overall gain} or for part of the image (see
tirne-gain con'lper'rsation {TGG} belovr}. While a high gain setting can he useful for
detectlng weaker signals that rnight otheruvise not be visible" it r*duces lateral resofrtion
and also increases noise. Excessive increase in GAIN will add'*r'loise" to the irnage.

TGC or Time Gain compensation is also known as depth gain compensation, and
corrects for the attenuation of the ultrasound signal that accurs with increasing distance
from the transducer. TGC boosts the gain of the signals returning from the far field to
ensure an even 'echo brightness' acrCIss the whole deptFr of the image, The TGC
conlrols can be fine-tuned by the sonographer using slider-bars.

Applicatia*:
Bane appea{s fo Se white an the ultrasound image Semuse if is fiyper reftective.
Blood or fluids appear to be black on the image because tfiey are anechaic.
Soff fiss$e appears as grey {satt and Wpper} an the image &ecairse ff is of medium
echagenicity.

General Rule:
Use plenty of gel ta remave the air interface befween the tran#ucer and the
skin. The physical properties af air do nof allaw passage of the ultrasaund heam even
thouglt the acoustic impedance has a low value.

ffi
\ I it'
Focus can be fine*tuned with phased-array transducers and should be
adjusted for each view so that the beam is focused on the region of
\iii interest.

lmage quality {lateral resolution} and beam focus is best at the focal
i
zone. Most moder"n electronically steered transducers provide electronic
i
focusing adjustable for depth. lt is important to place the Focus at or
slightly below the level of the target structure of interest.

Application:
Since mosf madern equipmenf rs focus variable, cfiange the posifion of the
focus as you scan different anatomicaf regfons in order ta maximize resalution.

21.
PHILIPPINE SOCIETY OF TJLTRASCIUNS IN SURGERY
ln collaboration with
I NSTITUTE OF DIAG hIOSTIC MTDICAL SONOGRAPHY I NICORPORATED
BYNAMIC RANGE

Grey scale compression (dynamic range) adjusts the number of shades of grey that
are displayed in the image. This allows the sonographer to choose the degree of
contrast in the image. More shades of gray resu[t in befier contrast resclution, or the
ability to visualize very subtle differences in tissue signatures.

lncreasing the dynarnic range increases the amount of gray scale displayed so that the
weaker signals are inciuded and the image is softened.

Dynamic R.ange Gontrast Resolution lmage Gontrast Sample

lncrease (High) lncrease (High) Decrease ilow)

Decrease (Low) Decrease (Low) lncrease (High)

Frame Rate

One complete sweep CIr scan wi{l produce one ultrasound image CIr one frame. Frame
Rafe is the number of frarnes dlsplayed on the monitor per second.

The function of the ultrasound machine frame rate is similar to that of a video camera.
To capture a clear picture of maving subject, you'll need a higher frame rate. When
scanning moving organs,; i.e. the heart, you'll need a higher frame rate.

Compound lrnaging is a broad bandwidth technotogy that combines multiple co-planar

images captured from different beam angles and frorn multiple ultrasound frequency
spectra to farm a single irnage in real time. Spatial compounding reduces speckle
artifacts and improves contrast resclution.

22
PHILIPPINT SOCITTY OF ULTRASOUND IN SURGERY
ln collabaration with
I N STITUTE OF DIAG NOSTIC MEDICAL SONOG RAPHY I NCORPORATED
lqaqe P"nocJrsqinq

Digital manipulation of the ultrasound image can irnprove both image quality and
the diagnostic capability.

The user can alter the appearance of the image to enhance sonographic
findings.
{a} Pre-processing

Fre*processing r*fers to compnession of the various amplitudes into number

values. These numbers are used in the digitat *reaticn *f the ultrasonic irnage.

This allows preferential enhancement of certain tissue types and better

characterization of the intemal structure of organs.

Pre-processing is performed before or while scannlng iin real-time) and the

changeable options are persistence, edge enhancement, and cornpression.

Persistence subtle tissue differences

Edge Enhancement vessel and organ boundaries
Compression grey scale available fon irnage formation

(b) Fost-processing

Post-processing takes the numbers assigned by pre-processing and in turn

assigns them tc grey shades available on the video monitor.

Fost-processing is perfarmed after the image is frozen" lt can be used to give

more or less display brightness to weaker echoes.

Once the echo information is stored within the computer, it may be altered to suit the
user's needs through manlpulation of the image processing controls.

Pre- and Post -processing, which were described earlier, affect the assignment of binary
numbers and grey shades to tha retuming echoes.

For general sonograms, to maintain a smooth image, have a medium contrast level,
with pre and post-processing eurves which allow even distribution of numbers and grey
shades among all tissues displayed.

During special procedures sueh as echocardiography, hcwever, it is tc advantageous to

be able to alter the processing curves in such a rnanner as to selectively dispiay the
bright echoes from the cardiac wails as elearly different from the biood-filled cavities.

1a
LJ

PHILIPPINE SOCITTYOF ULTRASOUruD IN SURGERY

ln collaboration with
INSTITUTE OF DIA€NOSTIC MEDICAL SONOGRAPHY INCORPORATED
Pre-pracessing is generally a real-time functian, while post-processing is performed
after the image is frozen.

(al Grey Scale compression

Ultrasound intensity is related ta brightness displayed on the screen. This can be

changed to suit the user. tt is the arnount of "colof in the irnage" The image will
be either very grey and subtle, or very black and white.

(b) Persistence

Persistence is the amount of smoothing done to the image to make it

aesthetically pleasing.

Lower levels of persistence make it possible to visualize motion of very minute

structures and rnay be employed during real-time rnonitoring of an aetive fetus, or
for cardiac examination.

Persistence enhances tissue differentiation to altow visualization of subtle tissue

movement and changes.

{c} Edge Enhancement

Edge enhancement provides enhancement of tissue and vessel boundaries

Used to clearly mark or target an object for needle guidance or mass
measurement. .

td) Measurement

Calipers for measurement are standard equipment on modern ultrasound

scanners

Joy sticks or roller balls are used to move the calipers about a structure which is
to be measured.

The caliper cross hairs should be placed exactly on the edge of the structure for
greatest accuracy.

Calipers can also be u*ed to measure the distance from the transducer to a
target during amniocentesis ol'PUBS. This ensures acsur&te needle placement.

(el Magnilication

Modern ultrasound devices possess the abitity ts "blow up" the entire image, or a
pre-selected porticn of it for cl*ser examinatlon.

24
PHiLIPPINE SOCIETY OF ULTRASOUND IN SURGERY
ln eollaboration with
I NSTITUTE OF DIAG NOSTIC MEDICAL SS$O6RAPI{Y' NCORPORATED
 h{agnitication may allaw yor.r to visualize a small structure, but it generally
affects resslution negatively. A magnification s:ntrol witl blow up the entire field
of view.

Zoom controls will allow you tc blow up a specific area of the image. You will be
able to select the area you wish to enlarge, and rnay scan in this enlarged forrnat.

Transducer Movement

It is best to gently rest the arm holding the transducer on the patienfs body or bed to
maintain hand steadiness and avoid fatigue during scanning.

There are three Bas!c Transdueer lvlovements

1) Sliding; with the transducer in the upright pasition, slide the transducer longitudinally
2) Rotation; rotating the transducer {clockwise I counter-clockwise}
3) Tilting; tilting or angling the transducer

Alignment refers to the task of sliding the transducer longitudinally to follow the course
of the target e.9., a nerve or a needle. This first transducer movernent is also most
useful in locating the block needle.

When the transducer {ultrasound beam} and the needle are perpendicular to each other
(out of plane approach), it is irnpcrtant to slide the transducer along the shaft of the
needle (alignmenti to identify the needle tip. Both the needle tip and shaft in cross
section appear as a hyper-echsic white dot on the screen.

ln-plane Cut-af-piane
:

:::?j1,. :)ii;4.:::;:

:*

Transducer and Needle Alignment - Rctating the transducer is most useful for aligning
the ultrasound beam with the needle {in plane approach} so that the enilre length of the
needle (both shaft and tip) can be clearly seen.

25
PHILIPPINE SOCIETY OF ULTRASOUfiID IN SURGERY
ln collaboration with
I NSTITUTE OF DIAGNOSTIC MEDICAL SONOGRAFHY I NCORPOfiATED
Transdulcer, Needle and Nerve Alignrnent - Rotating the transducer is also required to
accurately align the transducer {u}trasound beami. the needle and the nerve al} in one
plane. This allaws visualization of hoth the ner*r{e and needle in the long axis.

Tilting the transducer can improve irnage quality by aligning the ultrasound beam
perpendicular to the target (nerve or needle). The angle of the incidence is also a
majcr determinant of reflection. An ultrasound wave hitting a smooth mirror like interface
at a 90 degree angle will result in a perpendicular reflection. An incident wave hitting the
interlace at an angle less thar: 90 degrees will result in the wave being deflected away
from the transducer at an angle equal to the angle of incidence but in the appesite
direction iangle of reflection). Vdhen this happens. the signal of the returning eche is
weakened and a darl<er image is displayed" This explains why it is difficult to visualize a
needle inserted at a steep arrgle {t 45 degrees to the skin surface}.

mffi

EA$IC SCANNING TECHNIQUE$

It is much easier to perforrn an ultrasound examination andlor localization if basic

preparatory measures are taken to assure accuracy and safety. Be sure that both the
patient and the ultrasound scanner are ready for examination before you stafi to
manipulate the scanner.

Patient P repa ration and Pasitian i ng

r The patient is usually positioned on an examination table.

r A clear gel is applied to the patient's body in the area to be examined, to help the
transducer make secure contaet ta the skin. The sound waves produced by the
transducer cannot penetrate air, so the gel helps eliminate air pcckets between
the transducer and the skin.
o The sonologist or technologist presses the transducer firmly against the skin and
sweeps it back and forth te ircage the area of interest"
r When the exarnination is cornplete, the patient may be asked to dress and wait
while ultrasound images are reviewed, either on film or on a TV rronitor.

26
PHILIPPINE SOCIETY OF ULTRASOI"'ND IN SURGERY
ln callaboration with
I NSTITUTE OF DIAGNOSTIC M EDICAN- SONOGRAPHY INCORPORATTD
Freparing the ultrasound scanner

r The ultrasound canner should be turned on and allowed to warm up for at least 5
minutes before scanning commenses.
. Any image recording devices which will be used should also be ttirned on at this
time.
. Transducers should be cleansed and placed within easy reach before starting the
exam.
. Power settings and techniques should be checked to insure adequate imaging.

Transducer selection

Depending upon the patient's body size, weight and habitus, the proper transducer must
be Selected. Different applications reqr*ire different types of transducers so select the
proper transducer for the required examination.

For example, a 3.5 MHz or 5.S MHz sonvex transducer with a variable focus is
adequate in most abdominal scans while a higher frequency linear transducer is needed
for vascular, breast and other superficial scans.

After selecting a transducer, perform a quick initial scan to evaluate image orientation,
depth and penetration capabilities, and processing needs.

Image polarity

The irnage should be presented as a series of white dots placed on a black background.

Polarity can be reversed {black image on white background), but the standard is white
on black.
Black areas on the screen are hypaeehoic regions such as ftuid;
White regrbns are hyperechoic structures such as bone.

Scanning Planes

There are three nrajor scanning planes referred to in sonographic terminology:

r Longitudinal (or sagittal)

r Transverse
o Coronal

ln actual practice, however, ultrasound is unique in that any desired plane of

examination is attainable through manipulation of the transducer. Therefore, the
scanning places described below are used as constant references.

27
PHILIPPINE SOCITTY OF ULTRASOUND IN SURCERY
ln collaboration with
1 NSTITUTE OF DIAC NOSTIC MESICAL SONOGRAPHY I NCORPORATED
ta) Longitudinal plane

The longitudinal or sagittal scanning plane is that which runs frorn the head to the
foot and would divide the patient into right and ieft halves

{b} Transverce plane

Transverse scanning is usefulto image body structures which lie transversely

within the body such as the pancreas or a fetus in a transverse lie. The
transverse plane divides the bcdy into upper and lower portions and e:rrtends
from side to side.

{c} Coronal plane

The coronal plane divides the patient i*to anterior and posterior halves. This
plane is en'lplayed during evaluation of the adult kidneys sr other laterally placed
structures within the body.

The abave-mentianed terms are importafifu understand, but wfien yau are actually
scanning ff is mosf irnpofta*t that the scanning pla*e yau chaa$e, or variati*n cf it,
a//ows the beam ta reach fhe fargef at a perpendicular incidence" I*rs fl?eans that yaur
emplayed plane will continually change thraughout the exarn, depeMing upan the
posifion af the target argarr. flhfs is further complicated by the fact that yaur target rnay
bea

lmage Orientation

The sonographic image must be properly oriented in order to obtain correct anatomic
information. You must determine if you are correctly oriented before starting to scan.

ll. li.tt I i .l i ,.'il,,', '. .

iti ilr,1i.l'
I
I
I

. i.l:l! li
"riF* "--"?

posterior
I
ffi

?8
PHILIPPINE SOCIE TY OF UTTRASOIjND IN SURGERY
ln collaboration with
I NSTITUTE OF DIAGNOSTIC M EDICAL SONOGRAPHY I NCORPORATED
 When scanning in a lonqiludlnal plane:

the apex of the image is the patient's anterior

the bottom of the image is the patient's posterior
the left of the image is superior
the right of the image is inferior

When scanning in the treLsvefsqlllane isimilar to a CT scan).

i;.ilr';,, t;,r.1!,. 1i',.'. 1:

iii ll;;l '1rr ,1aiLi.!-t

' iili ii
{* t' ,
i --{.
ieft

I
posteriQf

'the apex of the image is the patient's anterior

'the bottsm of the image is the patient's posterior
'the teft of the irnage is the patient's right
'the right of the image is the patient's left

lf you are scanning in the transverse plane, and you angle the transducer toward the
patient's right hand side, information pertaining to the right should appear on the left
side of the screen.

29
PHILIPPINE SOCIETY OF ULTRASOUND IN SURGERY
In collaboration with
I NSTITUTE OF DIAGNOSTIC MESICAL SONO6 RAPHY I NCORPORATED
rEsr rg A$sFs$ tMAcE QUALiTY
You want your examination to offer the mast diagnostic information possible. Therefore,
you should adjust and set ali image parameters before starting scan.

After choosing a transducer and any preset technique settings, and after your have
confirmed that you are scannlng in the right direction (carrect irnage orientation], yot-r
are ready to perform a quick test to asse$s the image quality.

take a quick image of something in your field of view. FREEZE this image.
Iook carefully at the dlsptrayed image. ,{re there:

- too many eehoes in the near field {top of image}?

- too many echses in the far field (b*ttcm of image)?
- too few echses in near field? too few echoes in far field?

Using TGC (time gain conrpensationi gain pods or dials, correct areas noted above
Once entire image, top to bottom, is uniform then assess the overafi image quality:

- too few echoes overall {image very dark}?

- too many echoes overall {image very white}?

lJsing the OVERALL gain control (pod or dial), correct image gain

Safetv of ultrasound

Ultrasound involves the delivery cf externai energy to body tissues and so it is rmportant
to ccnsider the potentiai adver"se biclogical effects ihat this could entaii. The irrtensity of
exposure to uitrassund is expressed a* power per ilnit of area (wattsl*mZ) expressed
as the rnaximum intensity within the ultrasound beam (the spatial pear) averaged over
the duration of *xposLire {ternporal average), the spatlal peak temporal average
{SPTA). There are two main biologieal effects af exposure to ultrasound energy: thermal
{heating) and mechanical {e,g" cavitation).

Thermal effects are caused by conversion of the mechanical energy of the ultrasound
into heat energy as it passes though the tissues. The amount of heating Is hard to
predict but relates tc several factors including transducer frequency, transmit power,
focus and depth. Heat may be generated not just by the ultrasound but also directly by
the probe itself. lt is prudent to keep imaging time to a rninimum and to ensure that the
probe is repasitioned regularly, and to manitor the temperature of the prabe.

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PHILIPPINE SOCIETY OF ULTRASOUND IN SURGTRY
ln collaboration with
I NSTITUTE OF DIAGNOSTIC MEDICAL SONOGRAPFTY INCORPORATED
Mechanica! affeets include cavitation, in which gas bubbles sre *reated as ultrasound
pas$es through the tissues. lt is net thought tc he a problem during standard trans-
thoracic studies, but is important when bubble contrast agents are used as it can cause
resonance and even disruption of the bubbles. Mechanical effects of riltrassund can
also be measured hy rnechanical index {Ml), which is the peak negative {rarefactional)
presslire divlded by the square root of the transducer frequency. An Ml of <1 is
considered safe.

Although diagnostic ultrasound has an excellent safety record, it is nevertheless prudent

to minimize risk by:

r only performing echo for appropriate clinical indications

r keeping the power output as low as possible
r keeping the exposure time to a rninimum.
h/l-mode and 2-D echa have the lowest utrtrasound intensity, and pulsed-wave Doppler
has the highest intensity {with color Doppler having an intermediate valuei. Ensuring
safety also requires an awareness cf more general hazards such as:

r risk of electrical shock from darnaged or poorly maintained equipment

r risk of injury from trips and falls, particularly when transferring or moving the patient
r risk of infection from inadequate infection control measures
The American lnstitute of Ultrasound in Medicine {AIUM) reparts as of 1985, "no
confirmed adverse biologic effects on patients resulting from [diagnostic ultrasound]
L,rsage have ever been reported."

At much higher po\Mer levels, heat formation and cavitation have been demonstrated

Prudent application of diagnostic ultrasound shot-ild follow the "ALARA" (As Low As
Reasonably Achievable) principle for pCIwer settings

This is similar to the principles of safety used by radiographers

Statement on Mammalian in Vivo Ultrasonic Bio-effects Reaffirmed O*tober 1gg2

ln the low rnegahertz frequency range there have been no independently confirmed
significant biological effects in marnmalian tissues exposed to intensities" below 100
MW/cm'. Furtherrnore, for ultrasonic exposure times* less than 50CI seconds and
greater than 1 second, such effects have not been dernonstrated even at higher
when the product of intensity* and exposure time*" is less than SCI
oul

*Spatial Peak Ternporal Average

as rneasured in a free field of water.
**Total time; this includes off{ime
as well as on-time for a repeated pulse regime.
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PHILIPPINE SOCIETY CIF ULTRASOUND IN SURGERY
ln collaboration with
I NSTITUTE OF DIAGNOST|C MTDICAL SCINOGRAPHY I NCORPORATED
$taternent on Clinisal Safe :
No confirmed aciverse eflects on patients or instrurnent operators cai;sed by exposure
at intensities and exposure conditions typical of present diagnostic irrstrument and
examination practices have ever been reported. Experlence fronr normal diagnostic
practiee may or rnay not be relevant t* extended exposure tinnes and altered exposure
conditions. At this time no hazard has been identified that wouid preclude the use of
diagnostic ultrasound in educaticn and research.

Diagnostic Ultrasound has been in use for over 25 years. Given its known benefits and
recognized efficacy for medical diagnosis, including its use during human pregnancy,
the American lnstitute of Ultrasound in Medicine herein addresses the clinical safety of
such use.

No^confirnred biologic effects on patients or instrument operators caused by exposures

at intensities typical of present diagnostic instruments have ever been reported.

Although the possibility exists that such biological effects may be identified in the future,
cunent data indicate that the benefits to patients of the prudent use of diagnostic
ultrasound outweigh the risks, if any, to the patient.

PaUgnt J User Safety

a DO NOT drop or mishandle the transducers. Transducers are very expensive to

replace. Cracked housings are an electrical threat to the user. Report any
damage to a transducer immediat*ly.

a Freeze the image when you are not actively scanning.

o [Jse power settings which atre "as low as reasonably achievable" {ALARA} yet still
provide diagnostic nfonnation.
i

a Clean transducers with damp cloth before and after each examination.

o Perform quick reference scan before beginning the examination to assure proper
image orientation and transducer selection.

Routine Maintenance

Froper care and maintenance af ultrasound equipment ensures safety and pr^olongs
equipment life and reduces mashine downtime. tselaw are general procedures in srder
tc keep scanning quality at a maxirnum. ALWAyS REFER TG TftE ltlACl{/rVE'S USEE
fvIANUAL for user maintenance procedures"

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PHILIPPINE SOCIETY SF ULTRASOUND IN SURGERY
ln collaboration with
INSTITUTE OF DIAGNOSTIC MEDICAL SONOGRAPHY INCORPORATED
Ctrean and store ultrasound transducers when not in use.
Clean probe with suitable solution {e.g. cutasept} after each patient.
Clean the unit with a damp cloth at the end of the day.
.Do not hang or drape transducers around the device" Flace transducers i":pright in
specially designed transducer holders. USE THE Df$IGNATED HANGHRS FOR THE
TRAN$DUCER CABLES,

Do not put straight bleach directly on transducer head.

.Do not allow transducer to ssak in Cidex for more than one hour
{Cidex or bleach will
destroy the aeoustic rnernbrane on the transducer face). Always follow the length ot
submerging time specified in the n:anufacturer's instructions. The solution must satisfy
the-CDC {Center for Disease Controt) "SterilanUDisinfectant' requirernents.

'Never gas or autoclave a transducer, these processes will destroy the transducer
crystals.

'Use acoustic coupling gel specified by the manufacturer of the scanner. Do not use
mineral oil.

Clean or vacuum air filters on back of scanner once a month

ULTFASOUND VS, X-RAY

Ultrasound exarnination and lecalization is favorabie as compared with x-ray in that:

o Ultrasound is less expensive, widely available and easy to use.

r Ultrasound uses no ionizing radiation, and is the prefened image modality for
diagnosis and monitorinrg of pregnant women and their unborn infants.
o Ultrasound provides real-time imaging, making it a good tool for guiding
minimally invasive procedures such as needle biopsies.
. There is no need fsr oral or injected contrast media.
o Almost any anatornic structure can be visualized from a variety of different
reference points.
r Boundaries of organs and masses are clearly displayed permitting accurate
measurement-
. Tissue characteristics can be assessed.
LIMITATION$ OF GENERAL ULTRA$OUND
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PHII-IPPINE SOCIETY OF UI-TRASOUND IN SURGERY
ln csllaboration with
I NSTITUTE OF DIAGFIOSTIC MEDICAL SONOGRAPHY I NCORPORATED
Ultrasound has difficutrty penetrating bone and therefore can only see the outer surface
of bony structures and not what lies lvithin.

For visualization of bcne, other imaging modalities, such as x-rays, CT scanners or

rnagnetic ressnance imaging (ivlRl), may be selectsd.

Ultrasound waves do not pass through air; therefore, an evaluation of the stomach,
small intestine and large intestine rnay be limlted. lntestinal gas may also prevent
visualizaticn of deeper structures such as the pancreas and aorta.

Patients suffering from obesity are more diflicult to image * this is because fat causes
considerable refractian and image distorticn.

-0-

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PHIUPPINE SOCIETYOF ULTRASOUND IN SURGERV
ln collaboration rarith
I NSTITUTE OF DIAGNOSTIC M EDICAL SONOGRAPHY I NCORPORATE D