急診超音波在 下腹部和骨骼軟組織的應用

陳國智醫師 新光醫院急診醫學科 輔仁大學醫學系 中華民國醫用超音波學會指導醫師
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Lower abdominal echo

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Scenario
25 y/o female C/O: acute low abdominal pain w/ cold sweating, VAS: 8/10 BP: 60/40 mmHg; HR: 130 bpm Menstruation: 2nd day Your impression ? Next step ?

2008 ACEP EUS guidelines
• • • • Describe the relevant local anatomy of pelvic cavity Describe the role of focused US in first-trimester pregnancy pain and bleeding. Understand the role of US and quantitative β-hCG in a clinical algorithm for firsttrimester pregnancy pain and bleeding. Understand the differential diagnosis of early pregnancy including intrauterine pregnancy, embryonic demise, molar pregnancy, ectopic pregnancy, and indeterminate classes. Recognize the relevant focused findings and pitfalls when evaluating for early intrauterine pregnancy and ectopic pregnancy. – Early embryonic structures – Location of embryonic structures in pelvis – Findings of ectopic pregnancy – Pseudogestational sac – Adnexal masses

Role of EUS for OB/GYN
• • • • • • Identify an IUP Establish fetal viability Hemodynamic instability in a female patient Trauma and pregnancy Localization of IUD/foreign body Identify sources of pelvic pain and bleeding in pregnant & non-pregnant patients

1st choice for emergency physician • Use a lower frequency transducer: 3.5 –5 mHz • Better penetration, larger field of view • It should be the initial imaging window to assess for
– Advanced IUP – Fibroids/masses – Pelvic fluid

Trans-abdominal US

• The bladder should be full to provide an acoustic window

Transvaginal US
• Use a higher frequency transducer: 6.0-7.5mHz • Provides optimal imaging of:
– – – – Endometrium Myometrium Cul-de-sac Ovaries

• A full bladder is not necessary for this approach • Is usually better tolerated by patients

Normal Pelvic Anatomy

Trans-Abdominal Scan

Normal Pelvic Scan

TVS: Sagittal View

Pelvic Scan (TVS)

TAS versus TVS

Pelvic Sagittal View

US Findings in IUP
• • • • • Gestational sac Double decidual sac sign (DDSS) Yolk sac Embryo Cardiac activity

Intradecidual Sign

Gestational Sac
• Anechoic area within the uterus surrounded by two bright echogenic rings
– Decidua vera (the outer ring) – Decidua capsularis (the inner ring)

• This is referred to as the double decidual sac sign (DDSS)

Double Decidual Sign

Yolk Sac
• First embryonic structure that can be detected sonographically • Visualized approximately 5-6 weeks after the last menstrual period • Bright, ring like structure within the GS • Should be readily seen when the GS sac is greater than 10 mm (using EVS)

Yolk Sac

Embryo & Yolk Sac

Intrauterine embryo & yolk sac

Intrauterine fetus and yolk sac & amnion

A Fetal Heart Beat
• An important prognostic indicator • The rate of spontaneous abortion is extremely low (2- 4%) after the detection of normal embryonic cardiac activity • The normal fetal heart rate in early pregnancy is 112-136

43F complained low abdominal pain
What do you see ?

Ectopic pregnancy
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Ectopic Pregnancy
• 2% of all pregnancies, 7-13% of those who present with pain or bleeding • Incidence quadrupled in last 20 years • 50% were missed before widespread use of ultrasound • Still the #1 cause of maternal death in 1st trimester

Rule-out Ectopic Pregnancy (saves time and money)
• Find an IUP • Chance of both IUP and EP is 1/8000 • As high as 1/100 if pt takes fertility agents

β-hCG Levels
• • • • • Correlate roughly with gestational age Older algorithms relied on β-hCG One level means almost nothing Serial levels are helpful 40% ectopics have a β-hCG level <1000

Discriminatory Zone
• Def:
– The level of β-hCG at which findings of an IUP are expected on sonography

• Titinalli 7th ed.
– TVS 1500 mIU/mL; TAS 6000 mIU/mL

• Rosen
– TVS 3000 mIU/mL; TAS 6500 mIU/mL

ß-hCG >discriminatory zone and empty uterus is EP until proven otherwise

• Ruptured ectopic pregnancy • Definite ectopic pregnancy

Sonographic Spectrum of EP

• Extrauterine empty gestational sac • Adenexal mass • Pseudogestational sac • Empty uterus

Ectopic Pregnancy

Empty uterus & free fluid in CDS

Empty Uterus & Complex fluid in CDS

Empty Uterus & Free fluid in CDS & hepatorenal space

Complex adnexal mass

39F_33wk + ABD pain

Molar pregnancy

Estimation of GA

Pregnancy Dating Crown Rump Length (CRL)

Biparietal Diameter

Femur Length

Fetal Heart Rate Determination

Location of appendix

Pregnancy 18wks & 30wks & Appendicitis

• Determining the etiology of abdominal pain pelvic organs or other etiology • Hemorrhagic ovarian cyst • Ovarian torsion • Ovarian hyperstimulation syndrome (OHSS) • Tubo-ovarian abscess • Fibroid (Leiomyoma)

Main Goals in Non-pregnant Patients

Ruptured corpus luteum cyst

16F with low abdominal pain Pregnancy test: negative
What do you see ?

Ruptured ovarian cyst with internal bleeding
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OHSS

18F with low abdominal pain

What do you see ?

Pelvic Tumor
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16F with severe low abdominal pain
What do you see ?

Hematometria
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47F with low abdominal pain
What do you see ?

Teratoma
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39F with fever and low abdominal pain
What do you see ?

TOA & Pyosalpinx
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Graded compression technique

GI tract lesions on sonography
1. 2. 3. 4. 5. 6. 腸胃道壁增厚 (>4mm) 腸胃道壁分層消失 蠕動減少 用超音波探頭壓迫時不變形 病灶通道內容物減少 病灶附近之其他變化(LN, fat, ascites)

Alvarado Score

Question
• 請問下列何者非急性闌尾炎的超音波發現 ? 1. Blind-ended tubular structure 2. Non-compressible appendix 3. Diameter > 6mm 4. Dome sign 5. Appendicolith

Appendicitis
• Diameter > 6mm (Cross section) • Non-compressiblity of appendix • Localized pain during compression with the transducer • Alteration of the periappendiceal fat (echogenic & non-compressible fat) • Obstruction of the lumen by an appendicolith • Hypervascularizaion in color Doppler of appendix and surrounding fat
Eur Radiol. 2002;12:1748-61

Landmark of Appendix
• RLQ
– – – – Iliac crest Psoas muscle Iliac vessels Cecum & A-colon

Cecum, Ileum and Appendicitis

Appendicitis with obvious cecum and ileum

Appendicolith

Appendicitis with appendicolith

學習認Landmark

Ruptured appendicits

10M with low abdominal pain
What do you see ?

Ruptured appendicitis
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14M with low abdominal pain
What do you see ?

Ruptured appendicitis with abscess and ileus
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47M with RLQ and low abdominal pain
What do you see ?

Ruptured appendicitis
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27F, pregnancy at 14 wk RLQ pain
What do you see ?

Appendicitis
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Colon

21M with RLQ pain
What do you see ?

Cecal diverticulitis
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問題
• 請問下列何者為大腸憩室炎的超音波發現 ? 1. Corona sign 2. Target sign 3. Curtain sign 4. Dome sign 5. Veiled Kidney sign

21M with RLQ pain Cecal diverticulitis

Dome sign: acute colonic diverticulitis

J Clin Ultrasound. 2000;28:340-6.

Right-sided diverticulitis in a 32-year-old woman with right lower quadrant pain and fever

O'Malley, M. E. et al. Radiographics 2003;23:59-72

Copyright © Radiological Society of North America, 2003

48M with right abdominal pain

A-colon diverticulitis

18M with RLQ pain

Cecal diverticulitis

25F with LLQ pain

S-colon diverticulitis

26F with RUQ pain

A-T colon junction diverticulitis

32M with RLQ pain

Terminal ileum diverticulitis

39F with LLQ pain
What do you see ?

Left UVJ stone
80

Left UVJ stone

81

59M, left flank pain & hematuria

Ruptured AAA

82

21F with painful voiding

Ketamine-induced cystitis

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69M, diffuse low abdominal pain
Difficult voiding and defecation for two weeks

Colovesicular fistula
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95M, abdominal pain with bloody ascites

Bladder rupture

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Soft tissue & MSK echo

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請問超音波在MSK的應用不包含下 列何者
1. 2. 3. 4. 5. 診斷蜂窩性組織炎 辨識肢體腫脹是否為深部靜脈栓塞所致 尋找異物 診斷關節處骨折 辨識是否有軟組織膿瘍

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Outlines
• US anatomic considerations • Skin and soft tissue infection • Long Bony fracture evaluation

正常組織超音波影像
• • • • • • • • Skin Subcutaneous tissue Fascial planes Muscles Tendon
– Echogenic – Hypoechoic – Traverse by irregular strands of hyperechoic connective tissue – Hyperechoic; regular thickness – Striated appearance on long axis scan – Fibrillar; echogenic – Anechoic (Artery versus Vein) – Irregular, circular, echogenic; with hypoechoic rim – Echogenic cortices and dense acoustic shadows

Vascular structures Lymph nodes Bones

掃描注意事項
高解析線形探頭 (5-10MHz)為第一首選 注意深度(depth)和焦點(focus)的設定 適當應用探頭施壓 至少掃描兩個介面 (longitudinal & transverse) 考慮和對側比較 & 呈現在同一畫面 (Split screen) • 如何改善掃描品質 • • • • •
– Stand-off pad – Water/gel-filled glove – Water bath technique

Water/gel-filled glove

EUS在皮膚 & 軟組織感染的應用
• 須熟悉正常超音波軟 組織影像 • 認識週遭組織及結構 • 協助設定最佳切除及 引流路徑 • 正確診斷不明顯膿瘍  診斷 • 正確定位不明顯膿瘍  定位 • 協助膿瘍引流  處置

皮膚 & 軟組織感染
• • Cellulitis Subcutaneous abscess
– Cobblestone-like appearance – Variable appearance – Most: hypoechoic; spherical mass – Content:
• • • • • Hyperechoic sediment Septae Gas Isoechoic or hyperechoic Liquefied pus
– induced motion of the content

Necrotizing fasciitis

– Marked thickened of SC layer – A layer of anechoic fluid, – Subcuatneous gas
• greater than 4 mm • adjacent to deep fascia • Acoustic shadow • Reverberation artifact

Cellulitis
• Nonspecific • Indicative of edema • Skin • Subcutaneous tissue • Compare to unaffected side

Normal v.s. Cellulitis

EUS improves accuracy of superficial abscess detection

Squire BT, et al. AEM. 2005;12:601-606

NTUH experience
• diffuse thickening of the SC tissue • a layer of fluid accumulation more than 4 mm in depth along the deep fascial layer • 66 patients (17,NF) • Sensitivity: 88.2% • Specificity: 93.3% • PPV: 83.3% • NPV: 95.4% • Accuarcy: 91.9
Yen ZS, et al. AEM. 2002;9:1448-1451

EUS for DVT survey
• Primary component
– Visualize the venous structures – Detect gray-scale compressibility – Lack of compressibility  DVT

• Secondary component
– Use of Doppler to evaluate for abnormal flow

No complete compression
1. Presence of a clot 2. Inadequate pressure on the transducer

Position for femoral area

Femoral vessels

72F with fever and left leg pain

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骨折評估
• • • • • • • 肋骨骨折 胸骨骨折 長骨骨折 堅困環境骨折 骨折復位 脫位復位

FASTER

骨折評估
• • • • 骨表面產生不連續線條 骨折周圍低回音血腫 掃描時注意最痛點 至少進行兩個介面掃描

Rib

Rib fracture

Rib fracture

Normal sternum

Sternal body fracture

Femur

Femoral shaft fracture

Tibial shaft fracture

50M with abdominal pain
What do you see ?

Urachal cyst abscess
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42F, low abdominal pain
What do you see ?

Abdominal wall hematoma
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54F with fever and painful back mass
What do you see ?

Back carbuncle
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58M s/p thyroidectomy

Neck abscess
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56M with left thigh pain
What do you see ?

Lymphadenopathy
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75M with anal pain and fever
What do you see ?

Perianal abscess
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50M, 釘槍打入腳趾

Identify toe FB

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19M,打橄欖球受傷

Shoulder dislocation and reduction

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78F with fever and right hip pain

Septic arthritis
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Take Home Message
• Know anatomy

• Find landmark

• Recognize patterns

謝謝聆聽
歡迎指教及給予回饋 Juice119.pixnet.net Juice119@gmail.com
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