Bedside Ultrasound in Critical Care Practice

Mazen Kherallah, MD, FCCPInfectious Disease and Critical Care

Medicinemkherallah@msn.com

US Basics

US Basics

Normal Ultrasound Pattern

The pleural line (white arrow) is a roughly horizontal hyperechoic line 0.5 cm below the upper and lower ribs identified by acoustic shadow (R). A single vertical artifact arising from the pleural line and spreading up to the edge of the screen (comet-tails, indicated by asterisk) can be seen in dependant regions in normally aerated lungs

Normal Ultrasound Pattern

'lung sliding' associated with artifactual horizontal A-lines

Rib Fracture

Ultrasound Aspects of Alveolar-Interstitial Syndrome

B-lines 7 mm apart or spaced comet-tail artifacts. The pleural line (white arrow) and the ribs (R) with their acoustic shadow. B-lines arising from the pleural line and spreading up to the edge of the screen correspond to thickened interlobular septa .

Ultrasound Aspects of Alveolar-Interstitial Syndrome

B-lines 7 mm apart or spaced comet-tail artifacts. These artifacts correspond to thickened interlobular septa .

Ultrasound Aspects of Alveolar-Interstitial Syndrome

B-lines 3 mm or less apart. The pleural line (white arrow) and the rib (R) with their acoustic shadow. Contiguous comet-tails arising from the pleural line and spreading up to the edge of screen correspond to ground-glass areas on chest CT scan.

Ultrasound Aspects of Alveolar-Interstitial Syndrome

B-lines 3 mm or less apart. The pleural line (white arrow) and the rib (R) with their acoustic shadow. Contiguous comet-tails arising from the pleural line and spreading up to the edge of screen are present. These artefacts correspond to ground-glass areas on chest CT scan.

Ultrasound Aspect of a Lung Consolidation and Pleural Effusion

Transversal view of consolidated left lower lobe; lung consolidation is seen as a tissular structure (C). In this consolidation, hyperechoic punctiform images (indicated by asterisk) can be seen; these correspond to air bronchograms (air-filled bronchi). Pleural effusion is anechoic (Pl). .

Ultrasound Aspect of Lung Consolidation and Pleural Effusion

Cephalocaudal view of consolidated left lower lobe: lung consolidation with air bronchograms. Ao, descending aorta; D, diaphragm; Pl, pleural effusion..

Ultrasound Aspect of Lung Consolidation and Pleural Effusion

Cephalocaudal view of consolidated left lower lobe: lung consolidation with air bronchograms.

Consolidated Left Lower Lobe with a Peripheral Abscess.

The abscess (A) appears as rounded hypoechoic lesions inside a lung consolidation (C). Ao, descending aorta; D, diaphragm; Pl, pleural effusion..

Consolidated Left Lower Lobe with a Peripheral Abscess.

The abscess (A) appears as rounded hypoechoic lesions inside a lung consolidation (C). Ao, descending aorta; D, diaphragm; Pl, pleural effusion..

Consolidated lung 'floating' in a Massive Pleural Effusion

The pleural effusion (Pl) is abundant enough to be compressive and the lung (C) is seen consolidated and floating in the pleural effusion.

Consolidated Lung and Adjacent Pleural Effusion with Pleural Adherences.

The pleural effusion (Pl) is abundant and the lung is seen consolidated and floating (C) in the pleural effusion with pleural adherences. (A)

Pneumothorax with “Lung Point”

(a) Normal lung and (b) pneumothorax patterns using time-motion mode lung ultrasound. In time motion mode, one must first locate the pleural line (white arrow) and, above it, the motionless parietal structures. Below the pleural line, lung sliding appears as a homogenous granular pattern (a). In the case of pneumothorax and absent lung sliding, horizontal lines only are visualised (b). In a patient examined in the supine position with partial pneumothorax, normal lung sliding and absence of lung sliding may coexist in lateral regions of the chest wall. In this boundary region, called the 'lung point' (P), lung sliding appears (granular pattern) and disappears (strictly horizontal lines) with inspiration when using the time-motion mode

US Sensitivity and Specificity for Pneumothorax

Sensitivity Specificity

CXR 28% 100%

US 87% 97%

Lichtenstein, DA; Meziere, G; Lascols, N; Biderman, P; Courret, JP; Gepner, A; Goldstein, I; Tenoudji-Cohen, M. Ultrasound diagnosis of occult pneumothorax. Crit Care Med. 2005;33:1231–1238.

US Guided Vascular Access

The problem...

• Complications– Pneumothorax– Hemothorax– Arterial puncture– Hematoma formation

• Neck, groin, mediastinum

• Failure to obtain access

Complications

McGee DC, Gould MK. Preventing Complications of Central Venous Catheterization. NEJM 2003;348:1123-33

Ultrasound Guided Vascular Access

• Agency for Healthcare Research and Quality– Making Health Care Safer: A Critical Analysis of

Patient Safety Practices• “Use of real-time ultrasound guidance during central

line insertion to prevent complications”

http://www.ahcpr.gov/clinic/ptsafety/chap21.htm

Ultrasound Guided Vascular Access

“In hospitals where US equipment is available and physicians have adequate training, the use of US guidance should be routinely considered for cases in which IJ venous catheterization will be attempted”

McGee DC, Gould MK. Preventing Complications of Central Venous Catheterization. NEJM 2003;348:1123-33

Adult IJ – US vs Landmark

Failed Catheter Placement US Landmark Relative Risk (95% CI)

Mallory ‘90 0/12 6/17 0.11 (0.01-1.73)Nadig ‘98 0/36 13/37 0.04 (0-0.62)Slama ‘97 0/37 10/42 0.05 (0-0.89)Soyer ‘93 0/24 5/23 0.09 (0.01-1.49)Sulek ’00 3/60 5/60 0.6 (0.15-2.4)Teichgraeber ’97 2/50 26/50 0.08 (0.02-0.31)Troianos ’91 0/77 3/83 0.15 (0.01-2.93)Total 5/296 68/312 0.14 (0.06-0.33)

Hind DH, Calvert N, Davidson A, et al. BMJ 2003

Adult IJ

• Denys et al “randomized” patients to IJ- US guided=928, Landmark=302

• Overall success 100% vs 88.1%• First attempt success 78% vs 38%• Skin to vein time 9.8 (2-68) vs 44.5 (2-1000) sec• Carotid puncture 1.7% vs 8.3%

Denys BG, Uretsky BF, Reddy PS. Ultrasound-assisted cannulation of the internal jugular vein – a prospective comparison to the external landmark-guided technique. Circulation 1993;87:1557-62

Vein Versus Artery

• Artery– Thicker walls– Non-compressible– Pulsatile– (color flow)

• Vein– Thinner walls– Compressible– Non-pulsatile– (color flow)

Ultrasound Access Techniques

• “Static”– mapping technique– no sterile technique required for US

• “Dynamic”– views needle entering vein

• freehand• needle guide

– requires sterile technique

Static Technique

• Position patient as you will for procedure• Look at vessels and confirm landmark-

predicted anatomy• Mark location, note depths and angles• Remove ultrasound, prep patient without

moving• Vein cannulated as usual

Dynamic Technique

• Place gel in palm of sterile glove• Place vascular probe in palm, avoid trapped air

bubbles, and wrap free fingers out of way• Sterile KY jelly for glove-skin interface

Dynamic technique

• Center vessel in center of screen• Center of probe overlies center of vessel and

serves as landmark for needle• Needle creates bright echo with ringdown

artifact• Advance needle to vein, which is deformed by

needle pressure and then recoils to original position as vein is cannulated

Vessel specifics

Internal Jugular

MedialLateral

IJ

Carotid

Internal jugular

MedialLateral

Vascular Access

Internal Jugular

MedialLateral

Focused Assessment with Sonography in Trauma (FAST)

Goals of FAST

• Rapid detection of:– Hemoperitoneum– Hemopericardium– Hemothorax

• Advanced/expanded– rapid detection of pneumothorax– identification of solid organ injury

Standard Views

RUQ Morison’s View

LUQ View Pelvic View

RUQ

RUQ

Head Foot

Liver

Upper polekidney

Lower polekidney

Diaphragm

Free Fluid in Morison’s Pouch

Very rough rule of thumb: 0.5 cm fluid stripe = 500 cc, 1 cm fluid stripe = 1 L

Free Fluid in Morison’s Pouch

Free Fluid in Morison’s Pouch

Pleural Fluid Collection

False + RUQ view

IHepatic Vein

IVC

Subxiphoid

Normal Subxiphoid

LV

RV

RA

LA

Liver

Pericardial Effusion

RV

RA

Effusion

Parasternal long

RV

LV

LVOT

LA

Descending aorta

Aortic valve

Posteriorpericardium

Mitral valve

Parasternal long

• The descending aorta is an important landmark• Regardless of how large a pericardial effusion is, it

will always "tuck in" between the aorta and the heart• Pleural effusions will dive down posterior to the

descending aorta• This distinction is important if you are debating doing

a pericardiocentesis vs chest tube!

Parasternal Long

Aorta

Visceralpericardium Pericardial effusion

tucking between aortaand heart

Parietal pericardium

RV

LV

Thickened septum

Parasternal long

Pleural Effusion

RV

LVLVOT

Aorta

Pleural effusiondiving posterior to aorta

LUQ

• Posterior axillary line at 9th-10th interspace• Breath holds to move spleen down• Tougher view b/c spleen is much smaller

acoustic window than liver, so more gas• If kidney seen but no spleen, slide one

interspace cephalad

LUQ

LUQ free fluidHemoperitoneum Normal splenorenal recess

LUQ – free fluid

LUQ free fluid

LUQ - Fractured spleen

Free fluid

Laceration

Normal splenorenalrecess

Diaphragm

LUQ - free fluid

70 y/o driver of car Tboned on driver's side

Pelvic

• Place probe just superior to symphasis• Sagittal midline - aim beam 0-30 degrees into

pelvis with orientation marker towards head• Transverse midline - rotate 90 degrees to R

and fan up and down

Pelvic

Pelvic free fluid

Free fluid

Pelvic Free Fluid

Pelvic free fluid

Lower uterus

Small amountof physiologicfluid

Critical Care is A Promise

يتقنه أن عمال عمل اذا العبد يحب الله ان

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