急診超音波於兒科急重症的應用

彰化基督教醫院 急診醫學部 超音波推廣組 教學CR 蔡揚名

超音波檢查的特徵
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隨時可做 非侵入性 即時動態 具移動性 可同時急救 無放射暴露 可協助穿刺

應用範圍


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休克評估與急救 外傷評估 先天性心臟病 新生兒腦內出血 腹部急症 婦科急症 胸腔急症 睪丸急症 其他感染急症 侵入性治療引導

2006 ACEP US-guided procedure

Vascular access -Central vein:包含CVP、FVP等 -Peripheral vein -Arterial line -IO insertion Soft tissue abscess Drainage -Ascites -Pleural effusion -Pericardial effusion -Joint fluid

2006 ACEP US-guided procedure
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Lumbar puncture Soft tissue foreign body localization Fracture reduction Endotracheal tube location confirm Cystofix implantation

準備

Probe -High frequency(7~12 MHz),linear probe Approach -Long axis -Short axis Technique -Static -Real time

Vascular access
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Artery 在超音波下是壓不扁的 Vein是可以壓扁的,除非裡面有血栓 不好打的血管通路都可以靠超音波引導來打上

Femoral vein

Basilic and Cephalic vein

Radial artery cannulation

Prepare

無菌技巧

IO needle

Lumbar puncture

6H6T

Subxiphoid view

Hypovolemia

CVP vs IVC size

When CPR?

Advanced Trauma Life Support

Primary ABCD A:Airway and C-spine B:Breathing (Pneumothorax and Hemothorax) C:Circulation (FAST) D:Dysfunction of CNS

配備基本要求
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Real-time (即時) 2.5-3.5 MHZ Probe Laser printer, VHS Measurement capability Portability (攜帶型)

FAST for trauma

Ocular ultrasound?

IICP?
急診超音波如何判斷IICP 1. 使用high frequency, high resolution的linear probe (7.5-10MHz) 2. 測量眼球後方3mm處的Optic Nerve Sheath Diameter(ONSD) 3. ONSD 大於5mm和IICP有相關性 4. Sensitivity 100%, Sepcificity 63%

Annals of Emergency Medicine Volume 49, No. 4, April, 2007

How to scan?

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2009, 17:34

急診心臟超音波鐵則
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只要會看型態和結構是否有初步異常 Wall motion 會掃兩種以上的View

Parasternal Long Axis

Transducer placement

Desired Image

What the image shows

Parasternal Long Axis

Illustration by Patrick J Lynch www.infomed.yale.edu

Parasternal Short Axis

LA

SA

Parasternal Short Axis

Illustration by Patrick J Lynch www.infomed.yale.edu

Parasternal Short Axis Base

Illustration by Patrick J Lynch www.infomed.yale.edu

Apical 4 Chamber

Apical 4 Chamber

Illustration by Patrick J Lynch www.infomed.yale.edu

Suprasternal Notch View

Suprasternal Notch View

Endocarditis

Vegetations

Ebstein's Anomaly

Tetralogy of Fallot

Patent Ductus Arteriosus

Coronary artery dilatation(KD)

Classification of Peri- and Intraventricular Haemorrhage
Adapted from Volpe (1989):

Grade 1: germinal matrix haemorrhage with no or minimal IVH (<10% of ventricular area on parasagittal view) Grade 2: IVH (10–50% of the ventricular area on parasagittal view without Hydrocephalus)

Grade 3: IVH (>50% of the ventricular area on parasagittal view with Hydrocephalus).

Grade I:

bilateral germinal matrix haemorrhage

Grade II

Grade III:

Acute Abdomen
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腹痛是急診最常見的主訴 急性腹痛是急診醫師最大的挑戰 並須先排除立即需要開刀的急性腹痛 病史詢問與理學檢查永遠是最重要的 『超音波』是急診醫師診斷急性腹痛的第二隻 聽診器,而且往往比你的聽診器更加強大

Acoustic shadow

Comet tail artifact

Pediatric Acute Abdomen

兒童常見急性腹痛原因 –– 口訣

AIM - IH (目標 – 全國大賽)  A : Acute appendicitis  I : Intussusception  M : Malrotation  I : Incarcerated hernia  H : Hollow organ perforation / Hypertrophic
pyloric stenosis

善用兒童評估三角

Appendix

Psoas mucle

appendix

muscle可見肌肉 纖維質地

Landmark of Appendix

Iliac crest Psoas muscle

Acute appendicitis

Acute appendicitis

Acute appendicitis

Mimickers – Mesenteric adenitis

Target sign in RUQ.

Crescent sign in LUQ.

Intussusception
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近端腸子套入遠端腸子裡 將近 80% ~90% 為廻腸套入盲腸 (ileo-colic). 好發於3個月大~2歲小孩, 尤其5 ~9個月 超音波診斷率接近百分之百 症狀: Cramping abdominal pain, intermittent vomiting and irritability, strawberry jam stool

Intussusception

Intussusception

US-guided Reduction

Incarcerated hernia

Hypertrophic pyloric stenosis
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剛出生的2~4週會有非膽汁性噴射性的嘔吐 最常造成嬰兒嘔吐手術的原因 幽門周圍環狀肌肉的肥厚, 導致胃出口阻塞

超音波

幽門狹窄診斷標準  長度 ≥ 1.6 cm  腸壁厚 ≥ 0.4 cm  直徑 ≥ 1.4 cm

Hollow organ perforation

Scissors Maneuver

J Clin Ultrasound 2004; 32:381-385

Pancreatitis and pseudocyst

Hydronephrosis

Choledochal Cyst

CBD dilatation

Intrauterine Pregnancy

Ectopic pregnancy

Color Doppler: Ring of Fire

Ovarian torsion

Corpus luteum cyst rupture

過去的誤解
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空氣是超音波的天敵 胸腔超音波只是拿來看肋膜積水的

Lichtenstein的見解
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胸腔超音波不需要功能很複雜的機器 分析肋膜附近的artifact對於鑑別診斷十分重要 分析動態表現(M mode) 探頭需中頻以上,重視解析度而非穿透力

怎麼擺姿勢?

Landmark

Landmark

胸腔疾病於超音波下的分類

Dependent: 肋膜積水、實質化 (Consolidation)…… Non-dependent: 氣胸、肺間質疾病……

Ultrasound Aspects of AlveolarInterstitial Syndrome

B-lines 7 mm apart or spaced comet-tail artifacts. These artifacts correspond to thickened interlobular septa .

Pleural effusion
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Anechoic pattern Static mode: Quad sign or Sharp sign M mode: Sinusoid sign Turbid or with septum: Empyema or malignant PLE

Pneumothorax with “Lung Point”

(a) Normal lung and (b) pneumothorax patterns using time-motion mode lung ultrasound. In time motion mode, one must first locate the pleural line (white arrow) and, above it, the motionless parietal structures. Below the pleural line, lung sliding appears as a homogenous granular pattern (a). In the case of pneumothorax and absent lung sliding, horizontal lines only are visualised (b). In a patient examined in the supine position with partial pneumothorax, normal lung sliding and absence of lung sliding may coexist in lateral regions of the chest wall. In this boundary region, called the 'lung point' (P), lung sliding appears (granular pattern) and disappears (strictly horizontal lines) with inspiration when using the time-motion mode

US Sensitivity and Specificity for Pneumothorax
Sensitivity Specificity

CXR US

28% 87%

100% 97%

Lichtenstein, DA; Meziere, G; Lascols, N; Biderman, P; Courret, JP; Gepner, A; Goldstein, I; Tenoudji-Cohen, M. Ultrasound diagnosis of occult pneumothorax. Crit Care Med. 2005;33:1231–1238.

Lung point 的解釋

Alveolar Consolidation

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Posterolateral alveolar and/or pleural syndrome(PLAPS) Tumor Dynamic air-bronchogram: pneumonia Static air-bronchogram: lung collapse Air-fluid level: lung abscess

Empyema

Lobulated empyema

Lung abscess

Scrotum ultrasound

Testicular torsion

Epididymitis

Parotid abscess / parotitis

Cobblestone appearance

Maxillary Sinusitis

Epiglottitis

Special thanks to~~

新光急診 陳國智醫師 熱心指導

Thanks for your attention !!

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