Smorgasbord of Sonographic Sumptuousness Aaron Osborne, MD, PhD, PGY-3 Emergency Medicine Ultrasound and Administration Rotation Grand Rounds Presentation 2/17/10 Wednesday, February 17, 2010
Overview Liver, Gallbladder, and Biliary Tree FAST Exam Cardiac Early Pregnancy Renal
Wednesday, February 17, 2010
Liver, Gallbladder, and Biliary Tree
Wednesday, February 17, 2010
Gallbladder Imaging • Required Images • GB Long Axis - measure anterior wall • GB Short Axis - measure anterior wall • Portal Triad • CBD Long/Short Axis - lumen diameter Wednesday, February 17, 2010
Biliary Tract Anatomy
Wednesday, February 17, 2010
Biliary Tract Anatomy
Wednesday, February 17, 2010
Portal Triad
Wednesday, February 17, 2010
Gallbladder
Wednesday, February 17, 2010
Mickey Mouse Sign
Wednesday, February 17, 2010
Exclamation Point Sign
Wednesday, February 17, 2010
CBD Short Axis
Wednesday, February 17, 2010
CBD Long Axis
Wednesday, February 17, 2010
Pericholecystic Fluid
Wednesday, February 17, 2010
Cholecystitis
Wednesday, February 17, 2010
GB Wall Edema
Wednesday, February 17, 2010
Sludge and Stones
Wednesday, February 17, 2010
Sludge and Stones
Wednesday, February 17, 2010
Anatomic Variant
Wednesday, February 17, 2010
GB Wall Inflammation
Wednesday, February 17, 2010
GB Wall Inflammation
Wednesday, February 17, 2010
Gallbladder Pitfalls 1. Failure to visualize entire gallbladder 2. Failure to visualize gallbladder in 2-dimensions 3. Over-reading artifact and shadows 4. Lack of GB wall edema or PC fluid does not ruleout cholecystitis in setting of fever, leukocytosis, illappearance, RUQ pain, and gallstones 5. Failure to accurately identify common bile duct
Wednesday, February 17, 2010
FAST Examination
Wednesday, February 17, 2010
FAST Examination • Should be performed when free fluid suspected in peritoneal cavity
• Rapid exam but needs to be performed with due diligence
• Sensitivity for detecting free fluid is high in experienced hands
Wednesday, February 17, 2010
RUQ FAST Technique
Wednesday, February 17, 2010
RUQ FAST Anatomy
Wednesday, February 17, 2010
RUQ FAST
Wednesday, February 17, 2010
RUQ FAST
Wednesday, February 17, 2010
RUQ Positive FAST
Wednesday, February 17, 2010
RUQ Positive FAST
Wednesday, February 17, 2010
RUQ Positive FAST
Wednesday, February 17, 2010
RUQ Positive FAST
Wednesday, February 17, 2010
RUQ Positive FAST
Wednesday, February 17, 2010
RUQ Positive FAST
Wednesday, February 17, 2010
RUQ Positive FAST
Wednesday, February 17, 2010
RUQ FAST Exam Pitfalls 1. Perinephric fat confused for clotted blood 2. Fluid filled bowel or GB mistaken for hemorrhage 3. Failure to image from above diaphragm to liver tip 4. “Static Imaging”
Wednesday, February 17, 2010
LUQ FAST Technique
Wednesday, February 17, 2010
LUQ FAST Anatomy
Wednesday, February 17, 2010
LUQ FAST
Wednesday, February 17, 2010
LUQ Negative FAST
Wednesday, February 17, 2010
LUQ Positive FAST
Wednesday, February 17, 2010
LUQ Positive FAST
Wednesday, February 17, 2010
LUQ Positive FAST
Wednesday, February 17, 2010
LUQ Positive FAST
Wednesday, February 17, 2010
LUQ FAST Exam Pitfalls 1. Poor positioning of U/S transducer (not post./sup. enough) 2. Failure to image from above diaphragm to liver tip 3. Mistaking the stomach for free-fluid 4. “Static Imaging”
Wednesday, February 17, 2010
Pelvis FAST Technique
Wednesday, February 17, 2010
Pelvis FAST Anatomy
Wednesday, February 17, 2010
Pelvis FAST
Wednesday, February 17, 2010
Pelvis FAST
Wednesday, February 17, 2010
Pelvis Positive FAST
Wednesday, February 17, 2010
Pelvis Positive FAST
Wednesday, February 17, 2010
Pelvis Positive FAST Loop of bowel
Wednesday, February 17, 2010
Pelvis FAST Exam Pitfalls 1. Too much gain - acoustic enhancement by fluid in bladder 2. Prostate and seminal vessicles mistaken for hemorrhage 3. Failure to scan in axial and sagital planes 4. “Static Imaging”
Wednesday, February 17, 2010
Cardiac FAST Technique
Wednesday, February 17, 2010
Cardiac FAST Anatomy
Wednesday, February 17, 2010
Cardiac FAST
Wednesday, February 17, 2010
Subxyphoid FAST
Wednesday, February 17, 2010
Subxyphoid FAST
Wednesday, February 17, 2010
General FAST Exam Pitfalls 1. Body habitus 2. Prior abdominal surgeries 3. Other peritoneal fluid assumed to be hemorrhage 4. “Static Imaging” - failure to scan through areas of interest
Wednesday, February 17, 2010
Cardiac ECHO
Wednesday, February 17, 2010
ECHO
Wednesday, February 17, 2010
ECHO - PSLA
Wednesday, February 17, 2010
ECHO - PSLA
Wednesday, February 17, 2010
ECHO - PSLA
What is this structure??? Wednesday, February 17, 2010
ECHO - PSLA
Wednesday, February 17, 2010
ECHO - PSLA
Wednesday, February 17, 2010
ECHO - PSLA Intrauterine
Wednesday, February 17, 2010
ECHO - PSSA
Wednesday, February 17, 2010
ECHO - PSSA
Wednesday, February 17, 2010
ECHO - PSSA
Wednesday, February 17, 2010
ECHO - PSSA
Wednesday, February 17, 2010
ECHO - A4C
Wednesday, February 17, 2010
ECHO - A4C
Wednesday, February 17, 2010
ECHO - A4C
Wednesday, February 17, 2010
ECHO - A4C
Wednesday, February 17, 2010
ECHO - A4C
Wednesday, February 17, 2010
ECHO - A4C
LV & LA Dilated Cardiomyopathy
Wednesday, February 17, 2010
ECHO - A4C
Mitral Regurgitation - LA Dilatation
Wednesday, February 17, 2010
ECHO - A4C
Wednesday, February 17, 2010
ECHO - A4C Intrauterine
Wednesday, February 17, 2010
Subxyphoid ECHO Left Ventricular Hypertrophy
Wednesday, February 17, 2010
Cardiac ECHO Pitfalls 1. Over-reading your scan 2. Failure to assess for pericardial fluid with 2 views 3. Mistaking pleural fluid for pericardial fluid 4. Failure to assess long and short axes when assessing for left ventricular systolic function 5. Assessing RV strain/dilatation only by subxyphoid view
Wednesday, February 17, 2010
Early Pregnancy
Wednesday, February 17, 2010
Early Pregnancy
Wednesday, February 17, 2010
Early Pregnancy From the Emergency Physician’s perspective...
Wednesday, February 17, 2010
Early Pregnancy From the Emergency Physician’s perspective... “Is there an IUP?”
Wednesday, February 17, 2010
Early Pregnancy From the Emergency Physician’s perspective... “Is there an IUP?” Cannot rule out ectopic pregnancy by Ultrasonography...
Wednesday, February 17, 2010
Early Pregnancy From the Emergency Physician’s perspective... “Is there an IUP?” Cannot rule out ectopic pregnancy by Ultrasonography... ...can only rule in an IUP!!!
Wednesday, February 17, 2010
Early Pregnancy
Wednesday, February 17, 2010
Early Pregnancy
Wednesday, February 17, 2010
Early Pregnancy
Wednesday, February 17, 2010
Pitfalls to Ruling-in IUP 1. Diagnosing IUP with only a gestational sac 2. Not measuring a definitive 5mm rim of myometrium around entire GS 3. Ignoring possibility of heterotopic pregnancy (1:4000 to 1:1000) 4. Assuming IUP present b/c FHT noted 5. Assuming that an empty uterus implies a completed spontaneous abortion. Wednesday, February 17, 2010
Cannot Rule in IUP
Wednesday, February 17, 2010
Renal
Wednesday, February 17, 2010
Renal Technique
Wednesday, February 17, 2010
Renal Anatomy
Wednesday, February 17, 2010
Renal
Wednesday, February 17, 2010
Renal
Wednesday, February 17, 2010
Renal
Wednesday, February 17, 2010
Renal
Wednesday, February 17, 2010
Renal
Wednesday, February 17, 2010
Renal
Wednesday, February 17, 2010
Renal Pitfalls 1. Normal scan early in course of disease process 2. Dehydration 3. Failure to assess both kidneys 4. Severe hydronephrosis may not be acute 5. Hydronephrosis on U/S does not exclude other pathology (appendicitis, diverticulitis, AAA)
Wednesday, February 17, 2010
References 1. www.sonosite.com 2. Cosby and Kendall, Practical Guide to Emergency Ultrasound, 2006, Lippincott Williams & Wilkins
Wednesday, February 17, 2010
Resources www.sonosite.com
Wednesday, February 17, 2010
I Drank the Kool-Aid
DERRTOWN Wednesday, February 17, 2010
