Emergency Ultrasound

Mary Ann Edens, M.D.

Assistant Professor, Dept. of
EM
Director of Emergency
Ultrasound

Physics

Sound waves with frequencies

greater than 20 kHz are called
ultrasound
Medical ultrasound waves have
frequencies between 1 20 MHz
Sound waves are mechanical
waves

Created in the transducer by back

and forth displacement

Physics and Knobology

Physics

Ultrasound transducers send out

sound waves and then listen for
returning echoes
Most transducers at this time send
out waves only approximately 1%
of the time

Physics

Acoustic impedance determines

the amount of sound waves
transmitted and reflected by
tissues
Reflection occurs when the
ultrasound beam hits two tissues
(areas) having different acoustic
impedance
Large differences in impedances
inhibit useful information

Terms

Hyperechoic

Structure reflects
most sound waves
Structure appears
white on screen

Terms

Anechoic

Structure allows
most sound waves
through
Structure appears
black on screen

Terms

Echogenic

Tissues in
between
Allow some sound
waves through
and reflect others
Structures appear
in various shades
of gray depending
on amount of
reflection

Terms

Homogeneous

Tissue has uniform texture

Terms

Heterogeneous

Various degrees of echogenicity

present

Terms

Isoechoic

Two tissues with same amt of

echogenicity

Transducers

The higher the frequency, the

better the resolution
The better the resolution, the
better you can distinguish objects
from each other

Transducers

Lower frequency

Transducers

Higher frequency

Transducers

Linear

Gives rectangular image

Generally has higher frequency
Good for looking at a smaller area
and for gauging depth
Gives more of a one dimensional view
Sometimes referred to as the vascular
probe

Transducers

Linear

From Heller & Jehle. Ultrasound in Emergency Medicine. Philadelphia:

W.B. Saunders, 1995, p. 202.

Transducers

Curvilinear

Uses same linear orientation but

arranged on a curved surface
Generally lower frequency
Gives a wider angle of view

Transducers

Curvilinear

Transducers

The footprint refers to the portion

of the transducer that contacts the
patient
Curvilinear transducers come with
different footprints for different
purposes

Transducers

Transducers have a marker that

corresponds to a mark on the
screen
Helps with spatial orientation

Knobology

Power

Controls the strength or intensity of

the sound wave
Use ALARA principle

As low as reasonably acheivable

Knobology

Gain

Degree of amplification of the

returning sound
Increasing the gain, increases the
strength of the returning echoes and
results in a lighter image
Decreasing the gain, does the
opposite

Knobology

Too much gain

Knobology

Too little gain

Knobology

Optimal gain

Knobology

Time gain compensation

Used to equalize the stronger echoes

in the near field with the weaker
echoes in the far field
Should be a gentle curve

Knobology

Focal zone

Where the narrowest portion of the

beam is
Gives the optimal resolution

Knobology

Focal zone off

Focal zone right

Knobology

Depth

Each frequency has a range of depth

of penetration
Decrease the depth to visualize
superficial structures
May need to increase the depth of
penetration to visualize larger organs

Knobology

Zoom

Can place zoom box on a portion of a

frozen image to enlarge that portion
of the image
May lose some resolution because
pixels are enlarged

Basic OB/Gyn Ultrasound

Goals

To perform a focused examination

on patients with complicated first
trimester pregnancies
To rule in an intrauterine
pregnancy (not to rule out an
ectopic)

Scanning Techniques

Transabdominal

Supine position
A full bladder will provide sonographic
window
3.5 MHz curvilinear transducer
Place transducer in the sagittal plane
just above the pubic bone

Scanning Techniques

Transabdominal

Locate the long-axis of uterus and

sweep from side to side
Turn transducer 90 degrees counterclockwise

Scanning Techniques

Transabdominal

Locate the short-axis of the uterus

and angle cephalad and caudad
Goal is to see the entire uterus

Scanning Techniques

Transvaginal

Supine lithotomy position

5.0-7.5 MHz intracavitary transducer
Need to apply gel to the transducer
and transducer cover
Have assistant to chaperone

Scanning Techniques

Transvaginal

With locator anterior, scan the longaxis of the uterus

Transducer does not need to be
inserted all the way to the cervix

Scanning Techniques

Transvaginal

Turn transducer 90 degrees counterclockwise to scan the short-axis of the

uterus
Goal is to see the entire uterus

Sonographic Findings
Nonpregnant Uterus

May see endometrial stripe

Sonographic Findings
Normal Intrauterine
Pregnancy

Gestational sac

First indication of pregnancy but not a

reliable sign of an IUP
Transabdominal scanning

5.5 6 weeks gestation

B-HCG of 6500

Sonographic Findings
Normal Intrauterine
Pregnancy

Gestational sac

Transvaginal scanning

4.5 5 weeks gestation

B-HCG of 1000-2000

Sonographic Findings
Normal Intrauterine
Pregnancy

Gestational sac

Features of normal sac

Round or oval in shape

Central position in uterus
Smooth contour

Sonographic Findings
Normal Intrauterine
Pregnancy

Yolk sac

First reliable sign of an intrauterine

pregnancy
Should be seen by 5 6 weeks
gestation

Sonographic Findings
Normal Intrauterine
Pregnancy

Fetal pole

Should be seen by TV when mean

gestational sac diameter is > 16 mm
Cardiac activity usually detected by
TV by 6 weeks gestation

Use M-mode to confirm activity

Sonographic Findings
Ectopic Pregnancy

Detection of ectopic pregnancy

outside uterus < 20%
Suggestive findings

No IUP with high B-HCG

Pseudogestational sac
Complex adnexal mass
Free fluid in cul-de-sac

Basic Trauma Ultrasound

The FAST Scan

Goals

Bedside screening test for the

detection of hemopericardium and
hemoperitoneum
Not a formal study to detect
pathology

Scanning Techniques

Four standard views

Pericardial

Subxiphoid (parasternal if cannot obtain

subxiphoid view)

Perihepatic
Perisplenic
Pelvic

3.5 MHz curvilinear transducer

Scanning Techniques

Pericardial views

Subxiphoid view

Place transducer in midline and aim

towards the patients left shoulder

Scanning Techniques

Pericardial views

Parasternal view

Place transducer oriented between ribs

on the patients left

Scanning Techniques

Perihepatic view

Place the transducer on the patients

right in the midaxillary line between
the 8th and 11th intercostal spaces

Scanning Techniques

Perisplenic view

Place the transducer on the patients

left in the midaxillary line between
the 8th and 11th intercostal spaces

Scanning Techniques

Pelvic view

Place the transducer in midline just

above the pubic symphysis

Sonographic Findings
Pericardial Views

Subxiphoid view

Four chamber view

The visceral and parietal pericardium
are adherent

Sonographic Findings
Pericardial Views

Subxiphoid view

Pericardial fluid will show as a dark

layer in between the visceral and
parietal pericardial layers
Tamponade is diagnosed by
circumferential fluid collection with
diastolic collapse of the right atrium
or ventricle

Sonographic Findings
Perihepatic View

Normal view

The kidney and liver will be adjacent

to each other
Morrisons pouch will not be visible

Morrisons pouch is the space between

the liver and the right kidney

Sonographic Findings
Perihepatic View

Abnormal view

Intraperitoneal fluid will appear as

anechoic area in Morrisons pouch
Be careful not to misinterpret a fluid
filled structure (i.e. gallbladder, colon,
duodenum) as free fluid

Sonographic Findings
Perisplenic View

Normal view

The left kidney and spleen are

normally adjacent to each other

Sonographic Findings
Perisplenic View

Abnormal view

Intraperitoneal fluid will appear as

anechoic area in the subphrenic
space or splenorenal fossa
Be careful not to misinterpret a fluid
filled structure (i.e. stomach, colon)
as free fluid

Sonographic Findings
Pelvic View

In female patients, intraperitoneal

fluid will appear in the pouch of
Douglas just posterior to the uterus
In male patients, intraperitoneal
fluid will appear in the
retrovesicular pouch or cephalad
to the bladder

Interpretation of FAST

Positive pericardial view

Patient should go to the OR

Positive perihepatic, perisplenic or

pelvic view

The stable patient should go to CT to

further define injuries
The unstable patient should go to the
OR

Basic Abdominal
Ultrasound

Gallbladder
Goals

Evaluation of RUQ abdominal pain

for diagnosis of

Cholelithiasis
Cholecystitis

Gallbladder
Scanning Technique

Supine or left lateral decubitus

position
Ideally patient should be NPO for
4-6 hours
3.5-5.0 MHz curvilinear transducer
Start with transducer in sagittal
plane in the midclavicular line at
the lower costal margin

Gallbladder
Scanning Technique

Slide and angle through liver to

find gallbladder

Look for main lobar fissure to lead to

the gallbladder
Having patient take a deep breath
may help

Once gallbladder is visualized, turn

transducer slightly to find long-axis
of the gallbladder

Gallbladder
Scanning Technique

Sweep from side to side to

evaluate for stones
Turn the transducer 90 degrees
counterclockwise to find short-axis
of the gallbladder
Angle the transducer to evaluate
the entire gallbladder

Gallbladder
Sonographic Findings

Normal gallbladder

Anechoic
Wall thickness < 3 mm
Transverse diameter < 4 cm
May see folds or valves within the
gallbladder

Gallbladder
Sonographic Findings

Abnormal gallbladder cholelithiasis

Stones > 3mm in size will cause

shadowing

Smaller stones and sludge will not

May see wall-echo sign in a

gallbladder full of stones
Evaluate neck of gallbladder carefully
for an impacted stone

Gallbladder
Sonographic Findings

Abnormal gallbladder cholecystitis

Wall thickening > 3 mm

Gallbladder enlargement
Pericholecystic fluid
Sonographic Murphys sign

Pressing with transducer directly over the

gallbladder elicits pain

Renal
Goals

Detection of obstructive uropathy

(i.e. hydronephrosis) in patients
with

Suspected renal colic

Acute renal failure

Renal
Scanning Techniques

Left lateral decubitus or right

lateral decubitus for each
respective kidney
3.55.0 MHz curvilinear transducer
Use intercostal oblique technique
described for the FAST scan
May also use subcostal approach in
the sagittal plane at the
midclavicular line

Renal
Scanning Techniques

Once kidney is found turn

transducer slightly to find long-axis
Scan through entire kidney
Then turn transducer 90 degrees
counterclockwise to find the shortaxis
Scan through entire kidney

Renal
Sonographic Findings

Normal kidney

The renal pelvis appears echogenic

The surrounding renal cortex is
hypoechoic
The size is ~ 9-13 cm in length

Renal
Sonographic Findings

Abnormal kidney - hydronephrosis

Appears as anechoic dilatation of the

renal pelvis
Marked thinning of the cortex implies
long- standing hydronephrosis
The degree of hydronephrosis does
not correspond with the degree of
obstruction
May be present uni- or bilaterally

Renal
Sonographic Findings

Abnormal kidney renal cysts

Appears as anechoic areas within the

cortex with a normal renal pelvis

Aorta
Goals

Evaluation of abdominal or back

pain to rule out AAA

Aorta
Scanning Technique

Supine position
2.5-5.0 MHz curvilinear transducer
Start with transducer in sagittal
plane in the midline just below the
xiphoid process
Angle the transducer slightly to the
patients left to locate the aorta

Aorta
Scanning Technique

Slide and rock the transducer

caudally down the abdomen to
follow the aorta all the way to the
bifurcation
Then move the transducer back to
the subxiphoid space and relocate
the aorta
Turn the transducer 90 degrees
counterclockwise to visualize the
short-axis of the aorta (transverse

Aorta
Scanning Technique

Again slide the transducer caudally

down the abdomen to follow the
aorta all the way to the bifurcation
Any measurements of the aorta
should be taken in this transverse
view
Pressure may be placed to
distinguish the aorta from the IVC

The IVC will collapse, the aorta will

not

Aorta
Sonographic Findings

Normal aorta

Diameter no greater than 3 cm at any

point

Be careful not to measure obliquely

Should taper distally

Lumen should appear anechoic

Aorta
Sonographic Findings

Abnormal aorta - aneurysm

Diameter greater than 3 cm at any

point

Be careful not to measure obliquely

Most aneurysms are found

infrarenally
Mural thrombus may be seen as areas
of low to medium echogenicity within
the wall

Aorta
Sonographic Findings

Abnormal aorta - dissection

Aorta may be greater than 3 cm, but

not always
Diagnosed when an intimal flap is
visualized within the vessel lumen

Ascites
Goals

Evaluation of the patient with liver

failure
May be helpful in deciding the
most appropriate needle
placement for paracentesis

Ascites
Scanning Techniques

Same general technique as

described with FAST scan

Ascites
Sonographic Findings

Same general findings as

described with FAST scan

Basic Cardiac Ultrasound

Goals

To evaluate the patient with

cardiac failure for

Pericardial fluid/tamponade
Cardiac activity

Scanning Technique

Same general technique as

described with FAST scan
Best way to document the
presence of cardiac activity is with
the M-mode

Sonographic Findings

Pericardial fluid as described with

FAST scan
M-mode shows good movement
with normal cardiac activity

Sonographic Findings

In cardiac arrest, four-chamber

view may be difficult to see

M-mode shows no movement in area

of heart

Central Line Placement

US can be used for placement

Easiest line to use for is IJ
Place patient in Trendelenberg
position if able
Place linear probe on neck