Ultrasound Notes

Aorta
Biliary
Cardiac
DVT
FAST
Lung / Thoracic
Procedure
Renal
Aorta

Celiac Trunk

Arrowhead = splenic v
Arrow = SMA

Longitudinal Aorta
Emergency bedside ultrasound is highly sensitive for the presence of an AAA but has poor
sensitivity for acute rupture.
Unfortunately, ultrasound does not reliably identify retroperitoneal blood. See an ultrasound of
a retroperitoneal bleed. An AAA rupture occasionally is intraperitoneal, with free fluid readily
identified by ultrasound (Image 3.6 and Movie 3.14). This is a particularly ominous finding
Thrombus within an AAA can be mistaken for the aortic wall, leading to an underestimation of
the true AAA diameter. To avoid this error, adjust the gain so that aortic lumen is black. If
possible, decrease the dynamic range to improve the contrast between vessel wall and lumen.
Be sure to measure outer wall to outer wall.
Another pitfall is to assume an AAA is not ruptured in the absence of free intraperitoneal fluid.
Retroperitoneal bleeding, which is a far more common site of rupture, is NOT reliably detected
by ultrasound
While ultrasound can reliably detect an AAA, it typically gives no information about rupture
Saccular aneurysms can be easily missed unless a thorough scan is performed.
An ectatic aorta may have irregular course
Angled transverse cuts may exaggerate the true aortic diameter. Obtain measurements at 90°
to the vessel. Off-axis (tangential) longitudinal cuts underestimate aortic diameter. Caliper
measurements should be made in a transverse view only
Inexperienced sonographers can mistake the IVC for the aorta, especially in long axis because
both the aorta and IVC are pulsatile
Biliary
Questions:
1. Gallstones
2. Evidence of cholecystitis: wall thickening and pericholecystic fluid
3. CBD
4. Sonographic murphy sign
Indications
1. RUQ Pain
2. N/V
3. Jaundice
Curvilinear probe
 Starting position: Subcostal
 Perform subcostal sweep: probe marker pointing towards the head sweep from
subxiphoid along the subcostal margin
 Place the probe in the right costal margin just right of midline


 If the gallbladder is not visualized you can ask the patient to take and hold a deep
breath  moves the gallbladder inferiorly
 Alternative left later decubitus positioning helps
 Adjust depth so that the structures take up 2/3 of the screen
 To identify the portal triad, and ultimately the CBD, get the GB in sagittal view and the
neck of the gallbladder will point towards the portal triad
 
 CBD should be less than first number of the patients age: 53 yo normal is < 5 mm
 > 1 cm is considered diagnostic of CBD obstruction
Patient positions: left lateral decubitus position
Mickey Mouse sign is best view in the short axis
Use color doppler to differentiate hepatic artery from CBD
Excessive motion can cause artifact in color doppler – maintain transducer as still as possible

scan CBD to locate largest diameter first

CBD is measured inner wall to inner wall
CBD is normally <= 6 mm. add 1 mm for ever decade over 60
s/p cholecystectomy – up to 10 mm is considered normal
Cardiac
Measuring cardiac output:
1. LVOT Area
a. Obtain PSLA

b.

c.

d.
e. Measuring from inner edge to inner edge at the level of the aortic annulus
(attachment of valve leaflets). Get god visualization of the aortic root
f. Measure during mid-systole with maximal separation of the leaflets
g. LVOT area = (pi * (diameter in cm)^2) / 4
2. VTI
a. Using pulse waved doppler to measure the velocity across the LVOT
b. Obtain an apical long axis or 5 chamber view
c.
i. Apical 5 chamber

d.
i. Apical long axis
 ii.
iii. Select PW Doppler mode and place the doppler gate parallel and center
of the LVOT at where you measured the diameter
iv. Produces a waveform tracing the velocities of blood flowing out of the
LVOT with each heartbeat
1. Waveform is negative since the blood is flowing away from the
transducer
v. Next select LVOT VTI through the machine measurement package (found
under CO or Ao in measurement section)
vi. Trace waveform of one ejection fraction period
vii. This calculates VTI by taking area under the curve  reported in cm
viii. Stroke volume = Area of LVOT (cm2) x VTI (cm)
ix. CO = SV * HR
 x.
3. Pitfalls:
a. Any angle between the doppler wave and LVOT can result in underestimation of
VTI and therefor SV
b. Failure to measure the LVOT diameter in mid systole will underestimate LVOT
area and SV
c. Pts with irregular HR require the VTI measurement be obtained 5-10 times and
then averaged
4. Determining if patients with CHF will be fluid responsive with Passive Leg Raise
a. PLR = 250 cc immediately? Or 500cc-1L
b. Initial measurement of SV should be obtained with the patient in the
semirecumbent position or head of the bead at 45 degrees

i.
 c. The patient should then place in recumbent position with legs elevated to 45
degrees for 30-90 seconds (video said 2 minutes). This allows time for blood to
drain into their central circulation
d. SV should be measured while legs are still raised and have been so for at least 90
seconds
i. Consider wedging something underneath to do so
e. A change of SV > 10% after PLR (or CO > 10%)  predictor of fluid
responsiveness
5. EPSS
a. EPSS quick and dirty method to measure LVEF
b. Depends on free movement of mitral valve – inaccurate measurements are due
to disease processes that affect MV – mitral stenosis, calification, significant
aortic insufficiency and dilation of the mitral annulus from dilated
cardiomyopathy
c. Obtain PSLA
d. Place M mode through the tip of the MV
e.

f. Well visualization of the MV

i. If MV is touching the septum on visual inspection the patient’s EF can be
described as normal or greater than 55%
g. If the MV is NOT touching the septum, the distance from the MV during the E-
point and septum should be measured.
i. Distance < 0.7cm is consistent with normal EF
ii. Distance > 1.0 cm is consistent with reduced EF
h. Initiate M mode
i. Identify E and A waves of the MV
j.

k.
l. Measure distance from tip of MV to septum
m. Recent MRI study created an equation that can be used to estimate LVEF based
on EPSS distance
i. LVEF = 75.5 – 2.5 x EPSS
n. EPSS can falsely underestimate the LVEF with
i. Aortic insufficiency – AI regurgitant jet can push down the MV anterior
leaflet in diastole causing EPSS to be elevated despite a normal EF
 ii.
o. Mitral stenosis: moderate to severe MS can cause decreased excursion of the
MV anterior leaflet and thus elevate EPSS
6. Other methods to estimate LVEF – Fractional shortening and Simpson method