ObjectivesReview common indications for obtaining ultrasoundReview ultrasound machine fundamentalsDiscuss ultrasound imaging artifactspitfallsUS workshop US IndicationsClinical bedsideDiagnostic f ID: 821166
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Clinical Ultrasound ApplicationsKatrina
Clinical Ultrasound ApplicationsKatrina Wogu PAC RDMSCharles T Dotter Department of Interventional RadiologyOHSUObjectivesReview common indicatio
ns for obtaining ultrasoundReview ultras
ns for obtaining ultrasoundReview ultrasound machine fundamentalsDiscuss ultrasound imaging artifacts/pitfallsUS workshopUS IndicationsClinical (
bedside)Diagnostic (formal)Indications
bedside)Diagnostic (formal)Indications for Clinical UltrasoundTraumaQuicker diagnosisAbdomen GB, Kidney, Ao/IVCFASTSmall partsSoft TissueForeign
bodiesVascularMusculoskeletalUSguided pr
bodiesVascularMusculoskeletalUSguided proceduresPrerequisites for Clinical UltrasoundOperator dependentPractice!Comfortable with US interpretatio
nKnow crosssectional anatomyCertified tr
nKnow crosssectional anatomyCertified training programsObtain formal ultrasound if unsureIndications for Diagnostic UltrasoundAbdomenBreastThyroi
dTestesOB/GynVascularCardiacSome foreign
dTestesOB/GynVascularCardiacSome foreign bodiesInfants/PediatricsBiopsyLarge HCCThyroid AdenomaBreast CancerTestes w/ R HydroceleNeonatal Head
ICHPopliteal DVTGlass FragmentsGartne
ICHPopliteal DVTGlass FragmentsGartner’s Duct CystUS Machine FundamentalsPhysicsInstrumentationScanning TechniqueUS Physics & Instrument
ationHertz (Hz) = cycles per second (c/s
ationHertz (Hz) = cycles per second (c/s)US = 215MHzWavelengthLong = low frequencyMore penetrationPoor resolutionShort = high frequencyLess penetr
ationGood resolutionBasic Ultrasound Ma
ationGood resolutionBasic Ultrasound Machine OperationLiver/Kidney InterfaceGallbladderPropagation of SpeedOptimal fluid, soft tissue, organs
Basic Ultrasound Machine Operation36 we
Basic Ultrasound Machine Operation36 weeks14 weeksPropagation of SpeedSuboptimal air, gas, boneBasic Ultrasound Machine OperationInstrumentat
ion2D (Bmode)3D/4DmodeDoppler Pulsed, Co
ion2D (Bmode)3D/4DmodeDoppler Pulsed, Color, PowerHarmonics GainTGC’sDepthFocal zoneBasic Ultrasound Machine OperationTerminologyEchogenicit
ystructure’s ability to produce ech
ystructure’s ability to produce echoes Anechoic: does not reflect echoesIsoechoic: reflects echoes equal to surrounding structuresHypoec
hoic: reflects fewer echoes than surrou
hoic: reflects fewer echoes than surrounding structuresHyperechoic: reflects more echoes than surrounding structures*Terminology is relative t
o surrounding structures (i.e. kidney is
o surrounding structures (i.e. kidney is hypoechoic to liver)Basic Ultrasound Machine OperationTransducer SelectionCurvedLarger footprintFAST,
Abdomen, OB/Gyn, pediatricsSectorSmal
Abdomen, OB/Gyn, pediatricsSectorSmaller footprintLower resolutionCardiac, obese patientsLinearSoft tissue, small parts, FB, pediatrics, cent
ral line placementHighest resolutionEnd
ral line placementHighest resolutionEndovaginalTransrectalBasic Ultrasound Machine OperationTransducer SelectionStand at patient’s rightH
old transducer relative to anatomySAX:
old transducer relative to anatomySAX: notch toward patient’s rightLAX: notch toward patient’s headExceptions: cardiac imagingUse
enough gelFASTFocused Assessment with
enough gelFASTFocused Assessment with Sonography for TraumaFASTLUQ PericardialPelvisFAST (extended): PneumothoraxHemothoraxPleural effusionFA
STRUQNormal RUQFree Fluid in Morrison
STRUQNormal RUQFree Fluid in Morrison’s PouchFASTLUQNormal LUQPerisplenic Fluid CollectionPerisplenic ClotFASTPericardial/Subxiphoi
dNormal 4ChPericardial EffusionFASTPe
dNormal 4ChPericardial EffusionFASTPelvisFree fluidPhysiologicAscitesBloodRuptured OV cystRuptured ectopic pregnancyNormal PelvisRuptured Ect
opic w/ FF in CDSFASTLung & Pleural Sp
opic w/ FF in CDSFASTLung & Pleural SpacePneumothoraxFASTLung & Pleural SpaceHemothoraxPleural EffusionIVC & AortaIVC vs. AortaIVCIVCAort
aRight sideIntrahepaticVaries with respi
aRight sideIntrahepaticVaries with respiration and volume statusConnects to RA/HVLeft sideExtrahepaticPulsatileSeagull signPossibly atheroscleroti
cIVC vs. AortaIVCTransverseIVCAortaRi
cIVC vs. AortaIVCTransverseIVCAortaRight sideIntrahepaticVaries with respiration and volume statusConnects to RA/HVLeft sideExtrahepaticPulsati
leSeagull signPossibly atheroscleroticI
leSeagull signPossibly atheroscleroticIVCIndicationsVolume statusPE/DVTPostthrombotic syndromeIVCSubxiphoid or R intercostal approachTransducer
marker toward head (sagittal) or R flank
marker toward head (sagittal) or R flank/side (TRV)2cm TRV diameter = NormalInspiratory collapse consider hypovolemia&#x-0.7;&#x 000;2cm = clinica
l correlationPressure or volume overload
l correlationPressure or volume overloadAthleteSag Prox IVCTRV IVC @ HV’sSag Prox/Mid IVCIVCSubxiphoid or R intercostal approachTransduce
r marker toward head (sagittal) or R fla
r marker toward head (sagittal) or R flank/side (TRV)2cm TRV diameter = NormalInspiratory collapse consider hypovolemia&#x-0.7;&#x 000;2cm = clini
cal correlationPressure or volume overlo
cal correlationPressure or volume overloadAthleteNo respiratory variationCongestion, obstructionIVCRespiratory variationNormal, euvolemicStanfor
d University. Echocardiography in ICUIV
d University. Echocardiography in ICUIVCCaval ThrombusBlood clots higher risk of propagationTumor extrinsic compressionPostthrombotic syndromeIV
CIVC FiltersMultiple designsPermanent ve
CIVC FiltersMultiple designsPermanent versus RetrievableTypically infrarenalEvaluation2v XR Abd (AP & lat)CT w/ delayed venous phaseMany more!!I
VCIVC FiltersMultiple designsPermanent v
VCIVC FiltersMultiple designsPermanent versus RetrievableTypically infrarenalEvaluation2v XR Abd (AP & lat)CT w/ delayed venous phaseCTV thrombus
w/in filterXR normal GTAortaAortaIndi
w/in filterXR normal GTAortaAortaIndicationsPulsatile massKnown AAA, new symptomsAAA surveillanceAortaProximal: subxiphoid or R intercostal
approachMid/distal to iliacs: mid abdo
approachMid/distal to iliacs: mid abdomen to umbilicusTransducer marker toward head (sagittal) or R flank/side (TRV)3cm TRV diameter = NormalM
easure outer to outerProximal AoMid Ao
easure outer to outerProximal AoMid AoAortaAneurysmsTrue aneurysmIntima, media, adventitia intactFusiform or saccularPseudoaneurysmTraumaRecent
interventionInfrarenal vs suprarenalCour
interventionInfrarenal vs suprarenalCourtesy: radiopaedia.orgAortaSag AAATRV AAACourtesy: ultrasoundcases.infoAneurysmsTrue aneurysmIntima, medi
a, adventitia intactFusiform or saccular
a, adventitia intactFusiform or saccularPseudoaneurysmTraumaRecent interventionInfrarenal vs suprarenalAortaFusiform AAA with turbulent flowCour
tesy: Medscape, UC Davis AneurysmsTrue a
tesy: Medscape, UC Davis AneurysmsTrue aneurysmIntima, media, adventitia intactFusiform or saccularPseudoaneurysmTraumaRecent interventionInfraren
al vs suprarenalAortaDissectionAortic r
al vs suprarenalAortaDissectionAortic root � 4cmPLAXmeasure diam @ end diastole Presence of intimal flapCourtesy: ultrasoundcases.info; th
epocusatlas.comAortic root dilatationAb
epocusatlas.comAortic root dilatationAbdominal aortic dissectionGallbladderGallbladderIndicationsRUQ pain, fever, leukocytosisSuspect cholecyst
itisGallbladderR subcostal/intercostal
itisGallbladderR subcostal/intercostal approachSupine or LLD positioningTransducer marker toward head (sagittal) or R flank/side (TRV)Normal size
5cm TRVNormal wall thickness 3mmAnechoi
5cm TRVNormal wall thickness 3mmAnechoicSagittalTransverseGallbladderGallstonesSingle or multipleRound or jaggedMobile?Impacted in neck?Wall e
cho shadow (WES) sign+/Sonographic Murph
cho shadow (WES) sign+/Sonographic Murphy’s signWES signStone in Phrygian capGallbladderWall Thickening�3 mmMeasure perpendicular t
o GBCourtesy: Ultrasoundcases.infoGall
o GBCourtesy: Ultrasoundcases.infoGallbladderAdenomyomatosis“Comettail artifact”Cholesterol deposits in RokitanskyAschoff sinuses Chro
nic inflammationTypically asymptomaticG
nic inflammationTypically asymptomaticGallbladderAcute cholecystitisCalculous vs acalculous (10%)Wall thickening+Sonographic Murphy’sPericho
lecystic fluidAcute acalculous cholecys
lecystic fluidAcute acalculous cholecystitisAcute calculous cholecystitisGallbladderSludgeLayeringPositionalAbsence of Doppler flowSludge with
stone in neckTumefactive sludgeGallbl
stone in neckTumefactive sludgeGallbladderGB carcinoma with lymph mets and stonesTumorPresence of Doppler flowHeterogenousSimilar appearance
to sludgeGuided ProceduresCentral Line
to sludgeGuided ProceduresCentral Line PlacementChest Tube PlacementJoint InjectionAbscess/cyst AspirationAlways visualize needle tipCentral Lin
e PlacementChest Tube PlacementJoint I
e PlacementChest Tube PlacementJoint Injectionshttps://www.youtube.com/watch?v=TLpNsmwBGS4Abscess/Cyst DrainageDiverticulitis w/ abscessArti
facts & PitfallsArtifactsRefractionReve
facts & PitfallsArtifactsRefractionReverberationComettailRingdownScatterShadowingPosteriorLateral edgeEnhancementArtifactsMirror ImageHighly ref
lective surface in path of primary beam
lective surface in path of primary beamPitfallsNormal gas & fluidfilled bowelRight adnexal abscessNormal bowel versus Intraabdominal abscessPer
istalsisContrastenhanced CTPhlegmon vs d
istalsisContrastenhanced CTPhlegmon vs drainable?AccessibilityClinically stabilityConsult IRPitfallsComplex appendicitisPostsplenectomy subdiap
hragmatic intraabdominal abscessNormal b
hragmatic intraabdominal abscessNormal bowel versus Intraabdominal abscessPeristalsisContrastenhanced CTPhlegmon vs drainable?AccessibilityClinica
lly stabilityConsult IRPitfallsNormal
lly stabilityConsult IRPitfallsNormal bowel versus Intraabdominal abscessPeristalsisContrastenhanced CTPhlegmon vs drainable?AccessibilityClinic
ally stabilityConsult IRPitfallsAscites
ally stabilityConsult IRPitfallsAscites vs bladderIdentify bladder jetsHave patient voidPresence of Foley?Bladder Jet via Color DopplerFree Flu
id Superior to BladderNormal Bladder (m
id Superior to BladderNormal Bladder (male)ReferencesAnderson. Echocardiography: The Normal Examination and Echocardiographic Measurements. 3rd
Ed. 2017Acute cholecystitis. https://www
Ed. 2017Acute cholecystitis. https://www.uptodate.com/contents/acutecholecystitispathogenesisclinicalfeaturesanddiagnosis#H3Basics of US machine:
https://www.youtube.com/watch?v=JqVGgq5b
https://www.youtube.com/watch?v=JqVGgq5bEEchopedia.orgEmergencyultrasoundteaching.comFedullo P, Roberts A. Placement of vena cava filters and thei
r complications. UpToDateICM teaching. h
r complications. UpToDateICM teaching. http://www.icmteaching.com/ultrasound/echocardiography/practical/subcostal/Jim J, Thompson R. Management of
symptomatic (nonruptured) and ruptured
symptomatic (nonruptured) and ruptured abdominal aortic aneurysm. UpToDateKandarpa K, Machan L, Durham J. Handbook of Interventional Radiologic P
rocedures. 5th ed. 2016Kaufman J, Lee M.
rocedures. 5th ed. 2016Kaufman J, Lee M. Vascular and Interventional Radiology: The Requisites. 2nd ed. 2014Kremkau F. Diagnostic Ultrasound: Prin
ciples & instruments. 6th ed. 2002Levito
ciples & instruments. 6th ed. 2002Levitov A, Dallas A, Slonim A. Bedside Ultrasonography in Clinical Medicine. 1st ed. 2011Mehta M. AML vegetation
(5). Infective Endocarditis.https://you
(5). Infective Endocarditis.https://youtu.be/3VLT_pZaASM?list=PLVoIwhtJ0D1NeAY3dXdXG53qq3aN2IhjF 7/26Radiopaedia.orgThePOCUSAtlas.comUltrasoundca