Ultrasound

phased array

1.7-4MHz cardiac probe

curved array

2-5 MHz abdominal probe

non-collapsibe pulsatile/color flow brighter, thicker walls

3 characteristics of arteries on us

compressible, nonpulsitile, larger, thinner walls

3 characteristics of veins on us

linear array

4-13 MHz vascular probe

ID free fluid in peritoneal, pericardial or pleural spaces.

FAST exam

focused assessment with sonography for trauma

FAST exam

echogenic, brighter, decreases

Glomerulonephritis, nephrotic syndrome causes renal parenchyma to become more ________ and _______ than the liver and spleen. renal parenchyma usually (increases/decreases) in size with chronic disease

rapid ultrasound for shock and hypotension

RUSH

eFAST plus IVC, R/o AAA, R/O dvt

Rush components

head, anterior, posterior, superior, inferior

Sagittal plane: •Leading edge towards _____ •Top of screen ________ •Bottom of screen _______ •Left of screen _______ •Right of screen _______

testicular torsion

Scrotal US shows decreased or absent testicular doppler signal

acoustic shadowing

US encounters structure that blocks the transmission of sound waves - bowel gas and gallstones

water, brighter , drink water, underneath, brighter

US loves _____ The structure that is deep to it will come back as _______ so before we do US on pregnant patients or anyone on pelvic us, have them _____ _____ bc it helps us identify the bladder but also makes structures _________ it _______. this is an example of acoustic enhancement

epididymitis

US of testicle shows increased blood flow to affected area of testicle. (use opposite side to compare/0

hydrocele

US testicles shows anechoic mass

US aorta

___ ______ is screening study of choice when an asymptomatic pulsatile mass is palpated in the abdomen

depth

_______ adjusts how deep the ultrasound waves are going. structure of interest taking up 80% of the screen.

density

________ of the structure a sound wave hits impacts the resulting image. the ________ the structure, the brighter the returning image

large: acute renal congestion small: poor function, CKD

a large kidney suggests ? a small kidney suggests?

3cm

a normal aorta measures no more than ______ in diameter

heterogenous, hypoechoic, solid masses.

appearance of fibroids on us

hyperechoic

appears brighter than surrounding tissue

mickey mouse, Common hepatic duct, common bile duct, Pancreatic duct

bile ducts: look like two ____ _____ signs •US can evaluate intrahepatic and extrahepatic bile ducts and pancreatic duct •______ ____ ______ should measure no more than 4 mm in diameter and the ______ _____ ______ measures no more than 6 mm in diameter. •______ ______measures < 2mm

blue - away red - toward

blue = ______ red = _______ on color doppler

B mode

brightness

ovaries

chocolate chip cookie appearance

hydronephrosis

dilation of the renal pelvis and calyces due to obstruction from stones

RUSH

eFAST + IVC view for fluid status r/o AAA r/o DVT

fAST + pulmonary

eFAST componetns

gestational sac, yolk sac, viable fetus

ectopic pregnancy is mostly excluded if a _______ ____, ______ ____ or a ____ ____ is seen in the uterin cavity

PID

enlarged ovaries w multiple cysts and inflammation pus filled, dilated fallopian tube fusion of the dilated fallopian tube and ovary multiloculated mass w septations

blood, bile, urine

examples of anechoic structures

eFAST

extended , takes standard fast and adds pulmonary component.

pulsed wave doppler/spectral doppler

focuses over a specific vessel and shows the return measures speed of return venous more band like arterial more triangular like

compressibility, compress , distort, artery,

for DVT, •Look for __________ of the vein - it should normally ________ when enough pressure is placed to _______ the _______

tubo-ovarian complex

fusion of dilated fallopian tube and ovary in PID

anechoic, echogenoic,

gallbladder in a fasting patient is ____________ with an __________ walll

doppler US

gold standard for DVT; measures quantities of flow

transverse (axial/short axis)

holding the probe horizontally

sagittal (longitudinal/long axis)

holding the probe vertically

acoustical shadowing

if fibroids contain calcium, what may happen on US

decrease it

if someone is rly fat, what should we do to the frequency

anechoic

in the aorta, moving blood appears _________

hypoechoic

less dense than surrounding tissue. appears darker than surrounding tissue

high frequency

linear array is considered a ______ _______ probe

aneurysm

localized dilation of an artery by at least 50% over normal size

zoom

magnifies a portion of the image. ideally should optimize gain and depth before ______

color wave doppler

measures direction of flow blue is away from probe, red is toward (BART) measuring arterial and venous pulsations

M mode

motion -- move line over structure of interest. Could use for pneumothorax - could do for fetal heart tones, cardiac activity.

tubo-ovarian abscess

multiloculated mass with sepations in PID

acoustic shadowing, edge artifact, mirror image artifact, acoustic enhancement, compression artifact,

name examples of artifact (5)

anechoic

no echos. appears jet black. blood, bile and urine

9-12cm, 4-5cm. 8-11th

normal kidneys are ____ long and _____ wide . typically span from _______ ICS

PCOS

numerus >12 ovarian follicles

edge artifact

occurs from reflection and refraction with encountering a round structure

venous - band like arterial - triangular like

on pulsed wave doppler, venous is more _____-______ and arterial is more ________ -___

hydronephrosis, dilated, anechoic, bear claw

on renal ultrasound, typically cannot see stones but can see secondary effect: ________, and renal sinus will have _______ fluid filled ________ renal pelvis. looks like a ____ _____

largest is common bile duct, smallest is pancreatic duct

out of common hepatic duct, common bile duct, and pancreatic duct, which is the largest, and which is the smalles

anechoic, homogeneous, hemorrhagic

ovarian cysts: •Well-defined, thin-walled and _______ with _________ internal fluid density •May have echogenic material if ________

epithelium, cystic, septations

ovarian tumors from _________ most are _____ but have thick irregular walls and internal _______ which are not seen w ovarian cysts

low frequency

phased array and curved array are considered _____ __________

ectopic pregnancy - HCG level >1500 should have visible IUP on transvaginal US.

pt comes in for first trimester US. you draw an HCG level and it is 1600. an ultrasound is performed an there are large amounts of free fluid in teh abdominal cavity. what do you suspect

pyosalpinx

pus filled, dilated fallopian tube in PID

microcavitation, heat, diagnostic US, as low as reasonably achievable

safety of US: •At high intensities, _________ and _______ production can occur but this has not been seen with intensity used with ________ ___ •Use the ALARA principle = ________________

isoechoic

same as surrounding tissue

presence of stones GB thickness >3mm pericholecystic fluid + sonographic murphys sign.

signs of cholecystitis on US

testicular malignancy

solid mass within testicle seen on scrotal US

ping

sound created by a series of pressure waves. a crystal in the transducer sends US waves and waits for echos to return.

surfaces reflect, ideal organs, acoustic windows

sound is not able to travel through certain organs because their _______ _______ the majority of soundwaves. we can work around this by imaging through _____ _______, aka ______ _______

venous duplex

standard to r/o DVT allows for velocity and flow measurement assesses for compression includes common femoral, proximal deep femoral and greater saphenous and poplietal vein

false, greater than 20,000 hertz.

t/f: US has sound waves with frequency less than 20,000 herz

true

t/f: US is best at identifying the presence of a normal IUP; not as good at directly visualizing an ectopic

false, color indicates direction. which is typically correlating with veins and arteries but it can be showing urine entering the bladder

t/f: colors on color doppler indicate veins and arteries

true

t/f: eFAST is equivalent or better to CXR for identifying hemothorax and pneumothorax

true

t/f: endometrial thickness varies by phase of menstrual cycle

true; helps us distinguish between polyp and gallstone because gallstones move.

t/f: gallstones usually fall to most dependent part of gallbladder and will cause acoustic shadowing

false, decrease the frequency

t/f: if you have to examine a deep structure, you should increase the frequency on the probe to get a better picture

false, as long as you use ALARA principle should not be an issue

t/f: microcavitation and heat production is a valid concern when using diagnostic US

false, theyre not visible

t/f: normal intrahepatic bile ducts are visible

true, because we want GB to be filled w fluid. if pt has just eaten, the gall bladder will be emptied and we wont see it

t/f: pt should be fasting when a hepatobiliary US is performed

true

t/f: ultrasound gel is an example of an acoustic window between the skin and the transducer

false, symptoms ABOVE the knee is most sensitive.

t/f: venous duplex is most sensitive in symptomatic pts who have symptoms below the knee

false, this is not true if we are trying to examine deeper structures, because the US waves will spread out since high frequency waves are shorter.

t/f: we should always use the highest frequency possible because the image will be better quality

cine loop

take video of teh past 200+ frames which allows for review of image

freeze

takes image of screen.

brighter

the denser the object, the _______ the returning image

shorter

the higher the frequency, the ________ the wavelength

depth/time

the markers on the right side of the screen indicate this

gray, bright gray/white

the myometrium of the uterus appears ________ and the endometrium appears _______ _____/_____

depth

this control changes _____ pictured on screen structure of interest in cetner of screen 80/20 rule

full bladder

transabdominal US of uterus requires what?

indicator, probe, plane, indicator

transducers need you: •The machine does not know where the probe is in space •The user needs to look for the _______ on ________ and properly orient the probe depending on the ______ being used •This __________ correlates with a "dot" on the US screen

right, left, right, anterior, posterior

transverse plane: •Leading edge towards patient's _____ •Right of screen is patient's _____ •Left of screen is patient's ______ •Top of screen is _______ •Bottom of screen is ________

duplex US

used in vascular studies, combo of traditional and doppler US visualizes structures and flow within a vessel (traditional + color wave) and quantitates flow (using spectral doppler)

lava lamp. will not cause acoustic shadowing

what does biliary sludge look like on US? will it cause acoustic shadowing like gallstones?

takes one line from US and measuring motion in this area over time

what does m mode do?

you want the structure to take up 80% of the screen

what is 80/20 rule in regards to depth

liver, fluid filled bladder

what is an example of an organ that can be used as an acoustic window

live embryo outside the uterus

what is diagnostic for ectopic pregnancy

Y axis = tissue relative to transducer X axis = time

what is y axis in M mode? what is X axis?

spleen, pancreas, gallbladder, kidney

what organs cannot be seen d/t reflection and require an acoustic windo

US w doppler flow

what test will we do to eval ovarian torsion

is there trauma/bleeding around the heart what is the global function of the heart is there any abnormal enlagement of teh ventricles

what three questions do we focus for POCUS of the heart

linear array, its high frequency

what type of probe should be used for vascular exam and could really only be used on thin patients for other purposes

curved because its lower frequency so we can see deeper structures

what type of probe should we use for abdominal US and why

phased array because it is lower frequency

what type of probe should we use for cardiac US and why

elevations in flow velocity when >50% narrowing

what would we expect to occur on US in carotid stenosis?

echogenic

when doing an abdominal US of aorta, may see a thrombus which appears __________

nonpregnant, first trimester

when is transvaginal preferred

if you hear a bruit, if pt has TIA or stroke, see if there is an occlusion.

when might we use carotid US other than for assessment of atherosclerotic disease?

C

which has best gain

decreases time to dx and tx no transportation needed less radiation less expensive improves patient satisfaction

why do a US?

a fluid filled bladder pushes away air filled intestines so we can see reproductive organs.

why do we make ppl drink before an ultrasound?

pelvic mass, pelvic pain in females

why mgiht we do pelvic US

extrahepatic will dilate first

with CBD obstruction, what dilates first? extrahepatic or intrahepatic?

ascites

•Abnormal accumulation of fluid in the peritoneal cavity •Ultrasound is used to identify best location to perform a paracentesis to remove the fluid and avoid any organs

GAIN

•Adjusts strength of returning echoes •Changes brightness/darkness of image •Want uniform ____ from top to bottom

point compression, two point compression

•Bedside US utilizes _____ __________ for DVT •Most commonly with ______ ______ ____________ - saphenofemoral junction and popliteal vein

second and third trimester US

•Estimate amniotic fluid volume •Detect fetal anomalies •Determine placental and fetal positioning •Guidance for invasive studies to determine likelihood of fetal viability if birth is premature

first trimester US

•Exclude an ectopic pregnancy •Estimate age of pregnancy •Determine fetal viability •Determine if multiple fetuses are present

< 6 mm, compresses, 6 mm, noncompressible, tender, fecalith

•Normal appendix may not be visualized on US. •Normal diameter ________ •When visible, the normal appendix _________ with pressure from the transducer •In acute appendicitis, the diameter will be ______ or more, and will be __________ and _____ when palpated with the probe •A fecalith may be present

leiomyomas/fibroids

•Often asymptomatic but can cause pain, infertility, menorrhagia, and urinary or bowel symptoms •US is imaging study of choice •Heterogeneous, hypoechoic, solid masses - may show areas with many echoes and others with few •May produce acoustical shadowing, especially if they contain calcium

acoustic enhancement

•Since sound travels well through liquid, there will be increased echoes deep to structures that transmit sounds well

carotid US

•Study of choice for noninvasive assessment of atherosclerotic disease

hepatobiliary US

•Study of first choice for abnormalities of the biliary system •Ultrasound initial test for RUQ pain, jaundice •CT helpful in detecting masses, assessing difficult or unusual anatomy, or to determine the extent of disease already diagnosed, but CT is less sensitive than US in detecting gallstones

FAST exam

•The best initial screening modality in trauma •Purpose: rapidly ID free fluid in the peritoneal, pericardial or pleural spaces •Can ID about 200 mL of fluid •Per the Advanced Trauma Life Support (ATLS) protocol, ____ is performed immediately after the primary ATLS survey •Not sensitive for retroperitoneal injury, visceral or parenchymal injury •False negatives with abdominal injury without hematoperitoneum

mirror image artifact

•The primary beam reflects from a highly reflective surface but instead of directly being received by the transducer, it encounters another structure in its path and is reflected back to the highly reflective surface before coming back •Machine assumes that the returning echo only was reflected once

hyperechoic, grown glass, peripherally , darker, liver, spleen, more, hyperechoic, hypoechoic

•The renal cortex with a ______ ______ appearance, located ________ to the medulla. the renal cortex should be be just slightly (ligher/darker?) than the ______ and ________ The renal pelvis is (more/less?) hyperechoic than the cortex and is located centrally. Kidney parencyma is usually __________ compared to the liver and spleen

artifact

•Things seen on US image that do not exist in reality •Can be helpful to interpret the image or hinder the interpretation •Can also modify behavior/technique in anticipation of _______

compression artifact

•Too much pressure on the transducer makes it appear that a structure is not present

ovarian cysts

•Well-defined, thin-walled and anechoic with homogeneous internal fluid density •May have echogenic material if hemorrhagic

likely miscarriage

•What if HCG is < 1,500 and no IUP seen on US?

biliary sludge

•can cause stasis and produce symptoms similar to cholecystitis. contains crystals, bilirubin and glycoproteins will be visible w a lava lamp appearance on US

echo

•combines structural information with Doppler to evaluate blood flow, chamber function, valvular function and cardiac shunts •Can be combined with stress testing to assess ischemia by wall motion analysis of LV function •Can be performed using transesophageal technique if necessary (TEE)