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An Illustrated

Step-By-Step
Pocket Guide
Perfect for
Beginner &
Expert Users
Critical Care Medicine
Emergency Medicine
Trauma Surgery
Liver
Ao
GB
IVC
Spine
Bowel
Gas
Hepatic
Splenic
Celiac
2-D Image
M-Mode Image
Pleural Line
Chest Wall
No Lung Sliding
M-Mode Cursor
STEPHEN J. LEECH MD RDMS
LIFE-SAVING
POINT-OF-CARE
ULTRASOUND APPLICATIONS
Aorta, Cardiac, FAST/Trauma, Pneumothorax, Pelvic, US-Guided Access
Emergency
Ultrasound
Consultants
Life-Saving Point-Of-Care Ultrasound Applications
A Step-By-Step Pocket Guide
By Stephen J. Leech MD RDMS
Disclaimer
This education material provides a general overview and is not intended to replace formal
training through CME courses or other programs. This material does not constitute
professional medical advice or a complete course of training. You should not perform an
ultrasound examination solely in reliance upon the information in this education material.
Copyright 2008 by Emergency Ultrasound Consultants, LLC
All rights reserved. No part of this publication may be reproduced or distributed in any
form or by any means without the prior written permission of Emergency Ultrasound
Consultants, LLC.
Stephen J. Leech MD RDMS
Director, Emergency Ultrasound, Department of Emergency Medicine
Director, Emergency Ultrasound Fellowship, Department of Emergency Medicine
Orlando Regional Medical Center, Orlando, Florida
Director, Southeast Region, Emergency Ultrasound Consultants, LLC
Acknowledgements
Author would like to thank Paul R. Sierzenski MD RDMS, Michael Blaivas MD
RDMS, L. Connor Nickels MD, Eike Flach MD, SonoSite Inc., and L2Designs.com
for their assistance with the development of this publication.
Emergency Ultrasound Consultants, LLC
EUS Consultants, LLC is the industry leader in point-of-care ultrasound
specializing in education, business practices, risk managment, and billing. Our
faculty are board certifed, fellowship trained physicians who are both nationally
and internationally recognized. They have authored or contributed to major
emergency and bedside ultrasound policy including societal (ACEP, AAEM, SAEM),
national (ABEM, AIUM), international (World Congress) and governmental (CMS
and MEDPAC). We guarantee that all of our ultrasound courses, consultations,
management services and products will be provided by attending physicians who
are fellowship trained and expert diagnostic medical sonographers.
Paul R. Sierzenski MD RDMS
President, Emergency Ultrasound Consultants, LLC
Michael Blaivas MD RDMS
Vice-President, Emergency Ultrasound Consultants, LLC
Learn more about Emergency Ultrasound Consultants by visiting www.eusconsultants.com.
SonoSite, Inc.
SonoSite, Inc., the world leader and specialist in hand-carried ultrasound, is
pleased to provide an unrestricted education grant to Emergency Medicine
Residents Association (EMRA) for the production of this reference guide.
Learn more about SonoSite by visiting www.sonosite.com.
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AORTA
I NDI CAT I ONS
Suspected Abdominal Aortic Aneurysm (AAA)
Suspected Aortic Dissection
AORTA POCKET GUIDE
GE NE R A L P OI NT S
Use either the C60 curved or P21 phased array transducer
Select the Abdominal preset from exam type
Scan the aorta in BOTH transverse and sagittal planes
Aorta should taper and become more anterior moving distally
Aorta can be differentiated from the IVC by:
Location - aorta on patients left, IVC on patients right
Position relative to liver - aorta runs behind liver, IVC runs through liver
Brightness and thickness of walls - aorta has brighter and thicker walls
IVC runs into right atrium
Measure aortic diameter from outer wall to outer wall
Measure proximal (above celiac), mid (at SMA), and distal (just above bifurcation)
sections
AAA is defned as any measurement > 3 cm or any distal segment that is > 50%
larger than the more proximal segment
Ultrasound accurately detects AAAs but does not accurately detect rupture
An intimal fap will appear as an echogenic line within the aortic lumen and suggests
aortic dissection
Bowel gas may limit study
Steady downward pressure should move gas out of the way
Scanning patient from RIGHT fank using the liver as a window may be used as
an option
AORTA T R A NS V E RS E
Transducer in epigastrium, just below xiphoid process
Transducer indicator aimed toward patients RIGHT in transverse plane
Identify the spinal shadow as key landmark
Bright echogenic crescent shaped refection with shadow in far feld
Aorta is just anterior and to the left of the spine
Identify the aorta, IVC, celiac, SMA, left renal vein, splenic vein
Scan down length of aorta through bifurcation into iliac arteries

AORTA S AGI T TA L
Return the transducer to the epigastrium
Transducer indicator aimed toward patients HEAD in sagittal plane
Identify spine, celiac, and SMA as key landmarks
Scan down length of aorta through bifurcation
RE COMME NDE D I MAGE S T O S AV E
Transverse view above the SMA with measurement of aortic diameter
Transverse view at SMA with measurement of aortic diameter
Transverse view above or at the bifurcation with measurement of aortic diameter
Sagittal view of the proximal aorta with measurement of aortic diameter
Sagittal view of the distal aorta with measurement of aortic diameter
Include any additional views showing pathology
AORTA
POCKET GUIDE AORTA
CARDIAC
CARDIAC POCKET GUIDE
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I NDI CAT I ONS
Determination of Cardiac Activity in Cardiac Arrest
Suspected Pericardial Effusion and Tamponade
Estimation of LV Function
Estimation of Preload and RV Filling Pressure
CARDIAC
POCKET GUIDE CARDIAC
GE NE R A L P OI NT S
Use the P21 phased array transducer
Select the Cardiac preset from exam type
Cardiac orientation orients the image toward patients HEAD or LEFT side
Rolling the patient into the LLD position can help imaging by bringing the heart against
the chest wall
Press Clip button to save video clips instead of saving still images
FIndings suggestive of tamponade include a pericardial effusion with diastolic collapse
of the RA/RV and dilation of the IVC with no respiratory variation
S U BX I P HOI D 4 CH A MBE R ( S U BX 4 C)
Transducer in subxiphoid region
Transducer indicator aimed toward patients LEFT side
Aim US beam toward patients LEFT shoulder at a shallow angle
Identify liver, cardiac silhouette, RV, LV, RA, LA, and pericardial space
Easiest 4 chamber view to obtain, best view during CPR
Shallow angle, lots of depth required for visualization

S U BX I P HOI D I VC ( S U BX I VC)
Transducer in subxiphoid region
Transducer indicator aimed toward
patients HEAD
Sweep into RUQ to fnd IVC running
through liver in a longitudinal plane
Measure IVC diameter just distal to
hepatic veins to estimate CVP

PA R AS T E RNA L L ONG A X I S ( P S L A X )
Transducer perpendicular to chest wall in LEFT 4-6th parasternal space
Transducer indicator aimed toward patients RIGHT shoulder
Identify RV, LV, LA, mitral valve, aortic valve, aortic root, and descending thoracic aorta
behind the LA
Best view for measurement of aortic root diameter (normal < 3.8 cm)
Best view for LV function estimation
Assess LV wall thickening, change in size of LV cavity, force and speed of valve opening

PA R AS T E RNA L S HORT A X I S ( P S S A X )
Transducer perpendicular to chest wall in LEFT 4-6th parasternal space
Transducer indicator aimed toward patients LEFT shoulder
Rotated 90 degrees clockwise from PSLAX
Identify RV, LV, and papillary muscles indenting the LV
Best view for regional LV function (SALPI going clockwise around LV from septum)

A P I CA L 4 CH A MBE R ( A 4 C)
Transducer at PMI
Transducer indicator aimed toward patients LEFT axilla
Aim US beam toward patients RIGHT shoulder at a shallow angle
Identify LV, mitral valve, LA, RV, tricuspid valve, and RA
Best view for RV dilation (normal RV : LV ratio is < 0.6 : 1 measured at valve leafets)
RE COMME NDE D I MAGE S T O S AV E
Save AT LEAST 3 of the above views
Include any additional views showing pathology
IVC Size Respiratory Change Estimated CVP
< 1.5 cm Total Collapse 0 - 5 mm Hg
1.5 - 2.5 cm > 50% Collapse 5 - 10 mm Hg
1.5 - 2.5 cm < 50% Collapse 11 - 15 mm Hg
> 2.5 cm < 50% Collapse 16 - 20 mm Hg
> 2.5 cm No Change > 20 mm Hg
FAST / TRAUMA
FAST / TRAUMA POCKET REFERENCE GUIDE
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I NDI CAT I ONS
Identifcation of Free Fluid in the setting of:
Blunt Trauma
Penetrating Trauma
Unexplained Hypotension
Trauma in Pregnancy
FAST / TRAUMA
POCKET REFERENCE GUIDE FAST / TRAUMA
GE NE R A L P OI NT S
Use either the C60 curved or P21 phased array transducer
Select the Abdominal preset from exam type
CARDI AC VI EWS ( CHOOSE ONE VI EW FROM BELOW)
SUBXIPHOID 4 CHAMBER (SUBX 4C)
Transducer in subxiphoid region
Transducer indicator aimed toward patients RIGHT side
Aim US beam toward patients LEFT shoulder at a shallow angle
Identify liver, cardiac silhouette, RV, LV, RA, LA, and pericardial space
Look for free fuid in pericardial space
Shallow angle, lots of depth required for visualization
PARASTERNAL LONG AXIS (PSLAX) (NOT PICTURED - SEE CARDIAC GUIDE)
Transducer perpendicular to chest wall in LEFT 4-6th parasternal space
Transducer indicator aimed toward patients RIGHT shoulder
Identify RV, LV, LA, mitral valve, aortic valve, and aortic root
Look for free fuid in pericardial space

RU Q V I E W
Transducer on patients RIGHT fank, mid-axillary line, 10-12th rib space
Transducer indicator aimed toward patients HEAD in coronal plane
Identify liver, kidney, and diaphragm
Sweep transducer anterior and posterior to visualize all potential spaces
Look for free fuid above diaphragm, in Morisons pouch between liver and kidney,
and in the pericolic gutter at the inferior pole of the kidney

L U Q V I E W
Transducer on patients LEFT fank, posterior axillary line, 10-12th rib space
Transducer indicator aimed toward patients HEAD in coronal plane
Identify spleen, kidney, and diaphragm
Sweep transducer anterior and posterior to visualize all potential spaces
Look for free fuid above diaphragm, between diaphragm and spleen, between
spleen and kidney and in the pericolic gutter at the inferior pole of the kidney
Gas shadow means transducer placement is too anterior or inferior
P E LV I S V I E WS ( P E RF ORM BOT H V I E WS BE L OW)
SAGITTAL
Transducer just above the pubic symphysis
Start in a sagittal plane, transducer indicator aimed towards patients HEAD
Identify the bladder and sweep through pelvis from side to side
Look for free fuid anterior, posterior, or lateral to the bladder
TRANSVERSE
Rotate transducer indicator to the patients RIGHT
Sweep through pelvis from superior to inferior
Look for free fuid superior, inferior, or lateral to the bladder
RE COMME NDE D I MAGE S T O S AV E
Cardiac showing all 4 chambers and view of pericardial space
RUQ showing liver, kidney, diaphragm, and potential spaces
LUQ showing spleen, kidney, diaphragm, and potential spaces
Pelvis in sagittal and transverse planes showing bladder and potential spaces
Include any additional views showing pathology
PNEUMOTHORAX
PNEUMOTHORAX POCKET GUIDE
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I NDI CAT I ONS


Suspected Pneumothorax
Confrmation of Endotracheal Tube Placement
PNEUMOTHORAX
POCKET GUIDE PNEUMOTHORAX
GE NE R A L P OI NT S
Use either the L38 linear, C60 curved or P21 phased array transducer
Select the Small Parts (L38) or Abdominal (C60, P21) preset from exam type
T HOR ACI C S AGI T TA L
Transducer on upper chest, 2nd to 3rd rib space, mid-clavicular line
Sampling additional sites along thorax will increase sensitivity, specifcity, and
allow for determination of size if a PTX is present
Transducer indicator aimed toward patients HEAD in sagittal plane
Identify the ribs and rib shadows the key landmarks
Identify the PLEURAL LINE just below ribs
Echogenic line formed by visceral and parietal pleura
Watch the pleural line for LUNG SLIDING
Horizontal sliding motion will be seen if the pleural surfaces are opposed
Identify COMET TAIL artifacts if present
Vertical reverberation artifacts arising from pleural line
When a PTX is present, air trapped between the pleural surfaces will scatter US waves
and lead to a LOSS of lung sliding and comet tail artifacts

COL OR P OWE R DOP P L E R S L I DE ( CP D)
Color Power Doppler can be used to accentuate lung sliding and save still images
Select Color from scan modes in right lower portion of keyboard
Toggle to CPD from Color mode using soft keys
Straddle the CPD box across pleural line
In normal cases, the chest wall will remain stationary while the lung slides below the
pleural line, leading to CPD slide artifact in the portion of the box below the pleural line
When a PTX is present, no CPD slide artifact will be present below the pleural line
M- MODE
M-Mode can be used to accentuate lung sliding and save still images
Select M-Mode from scan modes in right lower portion of keyboard
Use track pad to toggle the M-Mode cursor across the pleural line between ribs
Push Update or the M-Mode key a second time to enter M-Mode
In normal cases, the chest wall will remain stationary while the lung slides below the
pleural line, leading to the SEASHORE sign
When a PTX is present, no motion will be seen below the pleural line, leading to the
STRATOSPHERE sign
RE COMME NDE D I MAGE S T O S AV E
Video clip of lung sliding and comets tails if present
Color Power Doppler slide if present
M-Mode image showing SEASHORE or STRATOSPHERE sign
Include any additional views showing pathology
PELVIC
PELVIC POCKET GUIDE
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I NDI CAT I ONS
Identifcation of an Intrauterine Pregnancy
Suspected Ectopic Pregnancy
Suspected Ovarian Cyst and Ovarian Torsion
GE NE R A L P OI NT S
Use either the ICT (EV), C60 curved or P21 phased array (TA) transducers
Select the OB preset if HCG positive, GYN preset if HCG negative from exam type
EV approach allows earlier visualization of fndings of pregnancy by about 1 week
Order of appearance of pregnancy fndings:
Double decidual sign, gestational sac, yolk sac (earliest reliable sign of IUP),
fetal pole, fetal cardiac activity
E NDOVAGI NA L ( E V )
Introduce the ICT transducer into the vagina in a sagittal plane
Transducer indicator aimed toward CEILING
Identify bladder, uterus, endometrial stripe in uterus, and cervix
Sweep transducer from side to side through lateral boundaries of uterus
Rotate the transducer 90 degrees counterclockwise to coronal plane
Transducer indicator aimed toward patients RIGHT
Sweep transducer anterior and posterior though uterus
Look for any free fuid in anterior and posterior cul-de-sacs
Scan any intrauterine contents ONLY AFTER sweeping through uterus in both planes
Take any appropriate fetal measurements (GS diameter, CRL, M-Mode FHR)
Scan laterally into the adnexa in a sagittal plane
Identify iliac vessels as key anatomic landmark
Ovaries usually lie adjacent to iliac vessels
Scan through ovaries in both planes
Use CPD and spectral Doppler to assess ovarian fow

T R A NS A BDOMI NA L ( TA)
Start in a in a sagittal plane just above the pubic symphysis
Transducer indicator aimed toward patients HEAD
Identify bladder, vaginal stripe, cervix, and uterus superior to bladder
Sweep transducer from side to side through lateral boundaries of uterus
Rotate the transducer 90 degrees counterclockwise to transverse plane
Transducer indicator aimed toward patients RIGHT
Sweep transducer anterior and posterior though uterus
Look for any free fuid in anterior and posterior cul-de-sacs
Scan any intrauterine contents ONLY AFTER sweeping through uterus in both planes
Take any appropriate fetal measurements (GS diameter, CRL, M-Mode FHR)
Scan laterally into the adnexa in a sagittal plane
Identify iliac vessels as key anatomic landmark
Ovaries usually lie adjacent to iliac vessels
Scan through ovaries in both planes
Use CPD and spectral Doppler to assess ovarian fow
RE COMME NDE D I MAGE S T O S AV E
Endovaginal
Sagittal view showing uterus, endometrium, cervix, and cul-de-sacs
Coronal view showing uterus, endometrium, and cul-de-sacs
Include any additional views showing fndings related to IUP and pathology
Transabdominal
Sagittal view showing bladder, vaginal stripe, cervix, and uterus and cul-de-sacs
Transverse view showing uterus, endometrium, and cul-de-sacs
Include any additional views showing fndings related to IUP and pathology
PELVIC
POCKET GUIDE PELVIC
US-GUIDED VASCULAR ACCESS
US-GUIDED VASCULAR ACCESS POCKET GUIDE
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Ultrasound-Guided Central Venous Access
Ultrasound-Guided Peripheral Venous Access
Ultrasound-Guided Peripheral Arterial Access
US-GUIDED VASCULAR ACCESS
POCKET GUIDE US-GUIDED VASCULAR ACCESS
GE NE R A L P OI NT S
Use either the L38 or L25 linear array transducer
Select the Vascular preset from exam type
Real-time dynamic guidance has higher success rates, lower complication rates, and
shorter time to access compared to static guidance
Needle location is identifed in real time by:
Ring-down artifact - reverberation artifact causing bright refection with
posterior echoes
Soft tissue movement
Arteries and veins can be differentiated by location, compression, and by Doppler
Deep veins are paired with arteries, peripheral veins run alone
Principles of central and peripheral access are similar
Long axis approach allows better visualization of needle and needle tip throughout
the procedure and is a technically simpler approach
Short axis approach allows better visualization of surrounding structures but makes
visualization of the needle and needle tip more diffcult

L ONG A X I S ( I N P L A NE )
Obtain a long axis view of target vessel
Transducer indicator aimed towards patients HEAD or toward operator
Align vessel, transducer, and needle
Use center of the probe as an aiming point
Needle enters from LEFT side of screen
Watch for soft tissue movement and ring-down artifact
Try to keep needle tip and shaft in view
S HORT A X I S ( OU T OF P L A NE )
Obtain a short axis view of target vessel
Internal Jugular
Transducer indicator aimed toward patients LEFT side
This allows the operator standing at the head of the bed to correctly
move the needle medially and laterally
Carotid is deep, medial, round, non-compressible
IJ is superfcial, lateral, oblong, and compressible
Femoral (Not Pictured)
Transducer indicator aimed toward patients RIGHT side
This allows the operator standing at the foot of the bed to correctly
move the needle medially and laterally
NAVEL - relationship of structures from lateral to medial
CFA is superfcial, lateral, round, non-compressible
CFV is deep, lateral, oblong, and compressible
Peripheral
Transducer indicator aimed toward patients RIGHT side
This allows the operator standing at the foot of the bed to correctly move the
needle medially and laterally
Center the probe over target vessel
Use center of the probe as an aiming point
Needle enters top of screen in center of feld
Watch for soft tissue movement and ring-down artifact to identify needle location
Try to keep needle tip in view by fanning, sweeping, and rocking transducer
RE COMME NDE D I MAGE S T O S AV E
Needle entering vein
Passage of guide wire
AORTA AORTA
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Other Products and Services
On-site ultrasound educational courses
Program oversight through our Virtual Ultrasound Director program (peer
and QA review of ultrasound images)
Distance learning tools including CD-ROMS, DVDS and internet based
training with AMA Category 1 CME
Business education, quality assurance, and billing
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Risk management case review and root cause analysis
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Emergency
Ultrasound
Consultants
This guidebook is a just the facts reference covering
life-saving and point-of-care ultrasound applications.
It summarizes these critical applications in a compact,
simple, easy to use, pocket reference guide.
PERFECT FOR BEGINNER & EXPERT USERS
critical care medicine emergency medicine trauma surgery
Aorta
Cardiac
FAST/Trauma
Pneumothorax
Pelvic
Ultrasound-Guided Vascular Access
Transducer and preset choices
Transducer placement and angle
Key anatomic landmarks
Scanning technique
Normal fndings
Where to look for pathology
Pearls and pitfalls
Recommended images to save
STEP-BY-STEP
ILLUSTRATED GUIDE
APPLICATIONS
COVERED
Emergency
Ultrasound
Consultants
EDU00120
An Illustrated
Step-By-Step
Pocket Guide
Perfect for
Beginner &
Expert Users
Critical Care Medicine
Emergency Medicine
Trauma Surgery
Liver
Ao
GB
IVC
Spine
Bowel
Gas
Hepatic Splenic
Celiac
2-D Image
M-Mode Image
Pleural Line
Chest Wall
No Lung Sliding
M-Mode Cursor
STEPHEN J. LEECH MD RDMS
LIFE-SAVING
POINT-OF-CARE
ULTRASOUND APPLICATIONS
Aorta, Cardiac, FAST/Trauma, Pneumothorax, Pelvic, US-Guided Access
Emergency
Ultrasound
Consultants