EDE

Emergency Department Echo

The Essentials of Emergency Department Ultrasound

5th Edition

Dr. Ray Wiss Course Director 2004

Table of contents
Acknowledgements Course Philosophy Introduction Glossary Physics - Nature of U/S waves - Wave properties - Effects of different tissue densities - Tissue interfaces - Modes of transmission - Frequency, Penetration and Resolution - Axial resolution - Probes Understanding EDE Images - Planes of view - Probe placement - Probe orientation - Centering the image - Probe manipulation Image Modulation - Depth - Gain - Time-Gain Compensation - Power - Focus Artifact - Refraction - Shadowing - Enhancement Cardiac EDE - Evaluating Cardiac Activity - Evaluating the Pericardium - Etiologies of acute pericarditis - Emergency pericardiocentesis 4 5 6 7 8 9 9 10 11 11 12 13 15 17 17 18 19 20 20 21 21 22 22 23 23 25 25 27 29 33 36 37 40 41

3 Aortic EDE - The Essential Landmarks - Identifying the Aorta - Technique and Image Interpretation - Transverse vs. Longitudinal Scanning Abdominal EDE - Plane of View - Right Upper Quadrant - Left Upper Quadrant - Upper Quadrant Scanning Technique - Abdominal Traps - Abdominal Tricks - Pelvis Obstetrical EDE - Ectopic Pregnancy Epidemiology - Anatomical Approach Transabdominal Obstetrical EDE The Endometrial Stripe Centering the Area of Interest Transvaginal Obstetrical EDE Preparing the Probe Transvaginal EDE - Contraindication Transvaginal EDE Technique Transvaginal EDE Spatial Orientation Transvaginal EDE Probe Manipulation Diagnosing an IUP Fetal Pole Fetal Cardiac Activity Sources of Error The Empty Uterus Other Possibilities Role of Quantitative -HCG Measuring Crown-Rump Length Obstetrical EDE Algorithm Risk Factors for Ectopic Pregnancy 43 43 44 45 45 49 49 50 53 55 58 59 61 65 66 66 67 69 69 71 72 72 73 75 77 80 81 81 86 89 90 92 92 93 94 95 96 97 98 99

Further Reading Maintenance Quality Assurance Conclusion The 10 Commandments of EDE

Acknowledgements
The focus of the EDE course has always been on the beginner. Over four years, over 150 courses and over 2000 graduates, we have gained ever greater insight into how those who have never used ultrasound learn the technique and what they find difficult to grasp. These insights, while leaving the content essentially the same, have led to numerous modifications which better explain those points we most want to get across. The inclusion of videos is the next logical step in this evolution. This process would not have been possible without a great deal of work on the part of some very special people who gave unstintingly of their time and energy to this project. The fifty or so Emergency Physicians who have become EDE Instructors have all brought great improvements to the course and they all deserve to be recognized. Within the ranks of the Master Instructors, however, there are four who need to be specifically mentioned. Dr. Steve Socransky has been there since the The Early Days, when we used to lug our stuff around in cardboard boxes held together by duct tape. It was the ground work he did that brought ultrasound to Sudbury and gave the EDE course its birthplace. Dr. Ben Ho also remembers The Early Days. And right from those early days, Ben understood better than anyone else what EDE had to be and kept us true to that path. He is the moral compass of the EDE Course. Dr. Lionel Marks de Chabris is one of the finest teachers I have ever known and has made great improvements to the structure and method of EDE training. His influence has made us all better bedside instructors. Dr. Mike Betzner has literally transformed the course with his technological prowess. His video contributions have added more clarity to our explanations than my words ever could. Finally, I would never have gotten anywhere in ED ultrasound if it had not been for the extraordinary generosity of Dr. Mike Lambert, one of the medical worlds true visionaries, who accepted this interested Canadian into his Chicago home. I consider myself incredibly fortunate to have been able to work with a group such as this: great emergency physicians, great teachers, and great friends. They have been my fellow travellers on a completely unexpected journey a journey which has been fascinating, fulfilling and more fun than anyone deserves to have.

Sudbury, January 2005

Course Philosophy
I found the following sentence on the very first page of the very first handout of the very first Emergency Department Ultrasound course I attended. It described the way U/S waves were generated by the piezoelectric effect: In simple terms, the piezoelectric effect is the phenomena whereby a crystalline material with a dipole moment vibrates at a given frequency when an alternating current is applied. In simple terms?!? I was still reeling from that one when they flashed the first U/S image on the screen. It looked like what I imagine a blizzard must look like to someone who is very myopic, looking through a dirty window. For reasons I cant explain, I did not run screaming from the room. Rather, I kept going to courses and training sessions until I achieved independent practitioner status (as per the American College of Emergency Physicians). Along the way I became convinced that it was possible for ED physicians to become rapidly comfortable with U/S techniques if the following pedagogical principles were applied: 1) Focus exclusively on the key indications for this modality. 2) Teach only those elements of U/S physics that are essential to know to get the machine to work and to be able to interpret the images. 3) Precede all U/S images by simple explanatory graphics, to make the snowstorm a little clearer. 4) Omit all extraneous material, especially any reference to the piezoelectric effect. This course is the result of that belief. In ten intense hours, you will become adept at generating and interpreting U/S images that will allow you to rule-in or rule-out common, life-threatening conditions that you have all had to manage. It is essential to read this text before taking the course, so that the didactic sessions can serve as confirmatory exercises only. This allows us to spend a maximum amount of time doing hands-on scanning. I hope you enjoy getting to know Eddie! Dr. Ray Wiss Course Director

Introduction
The purpose of this course is to teach you, in a rapid and simple manner, how to use a basic U/S unit to dramatically alter your management of patients in whom one of five life-threatening conditions is a possibility: non-cardiogenic shock, pericardial tamponade, intra-abdominal hemorrhage, ruptured abdominal aortic aneurysm and ectopic pregnancy. These are universally recognized as the key indications for U/S to be performed by emergency physicians because patient instability sometimes mandates that management decisions based on U/S findings be made in minutes (making consultation with a radiologist impossible). Equally important, but less well-known, is the fact that the ultrasound images generated in these situations are easily interpretable. Youll learn why on the course. To achieve the objective of making you a functional ED sonographer as quickly as possible, all extraneous information has been removed and only the essentials remain. This should not worry you. We already interpret ECGs, X-Rays and CT scans with only a vague idea of how these images were produced. So it is with ultrasound. We could talk for hours about the piezoelectric effect and spatial pulse length, but we wont. During this course, you will only learn exactly what you need to know to get a usable image on the screen and to interpret that image. This concept is so important that it is reflected in the very name of the course. You will not be taught how to do ultrasound examinations. Rather, this course will teach you how to do an Emergency Department Echo (an E.D.E. pronounced Eddie), a completely different creature. Your primary goal when performing an EDE is to be a safe sonographer. You may be surprised to find that the key to this does not lie in accurately calling an EDE positive or negative. Rather it lies in knowing when an EDE is inconclusive. You have gotten along just fine without EDE until now. If EDE enables you to acquire high-quality information about your patient, use it. If the information is of uncertain quality, discard it. In those cases, you must proceed as though the scan was not done at all and manage the patient the same way you would have before EDE. EDE is only an adjunct to your clinical skills, and should in no way take precedence over those skills. This course is not intended to teach you how to be a formal ultrasonographer. This generally requires one to two years of training, most of which has little or no bearing on EM. Nor is this course meant to teach you how to get the most out of your ED ultrasound machine. As EDE continues to evolve, it is possible that certain advanced applications will begin to be widely used. Should you wish to pursue this avenue you are encouraged to take further courses with a more specialized curriculum. As well, the textbooks suggested in the attached reading list can guide the interested student towards other topics. Finally, this course must be seen as only the first step in your development as an ED sonographer. Afterwards, you must do regular scans in the context of an established ED Ultrasound program, in which you will benefit from continual feedback and quality assurance.

Glossary
You cant get away from this. When you learn a new technique in medicine, it comes with a bunch of new terms. I include these basic ones so that you can make sense of what other U/S texts are saying. I have tried to keep the language of this course as simple as possible, often following the sonographic term with a more descriptive or intuitive expression (in brackets).

Echogenic: A material that produces echoes (i.e. U/S waves bounce off). The more
echogenic a substance is, the whiter the image it produces on the screen.

Echolucent: A material that does not produce echoes (i.e. allows U/S waves to pass
through). The more echolucent a substance is, the blacker the image it produces on the screen.

Hyperechoic: More echogenic (therefore whiter/brighter) than surrounding tissue. Hypoechoic: Less echogenic (therefore darker) than surrounding tissue. Isoechoic:
tissue. Just as echogenic as (and therefore indistinguishable from) surrounding

Anechoic:

Producing no echoes at all. The resulting image, therefore, will be completely black.

Near-field: The top half of the U/S screen. Represents that part of the body closest to
the probe.

Far-field: The bottom half of the U/S screen. Represents that part of the body furthest
from the probe.

Formal Ultrasound: A formal for short. A scan done by ultrasound technicians or

radiologists, in the Diagnostic Imaging department, with a machine that costs 5-10 times what an EDE machine costs. Also called a confirmatory study.

Scan: U/S lingo for a sonographic examination. Can cause confusion initially, as people
wonder whether one is referring to an ultrasound exam or a CT scan. In this text, scan always refers to an ultrasound examination. Can be used as a noun (That guy needs a scan), a verb (Weve got to scan that guy) or an adjective (That guy was just not scanable).

Physics
This chapter, as you might well imagine, can be pretty boring. The video below therefore serves two purposes. First, it introduces you to the technique of playing a video inside a text file, something you probably have not had to do before. To do this properly, two pieces of software must be installed on your computer. If you are reading this, then you already have Adobe Acrobat in place (unless you are using a Mac, which can open the text with Preview you must open the text with Adobe). Make sure you also have the DivX video player installed. If you dont, download it now by going to http://www.divx.com/divx/download. After that, it should be effortless. Just place your cursor on the image below. It will become a hand icon with the index extended (a hand with all fingers extended denotes a still). Click on the video. Wait a few seconds (as long as ten seconds, sometimes). Watch it play. Note that ALL the videos have voice-over, so it is essential to read this text using a computer with a sound card (and with the mute function disabled ). Second, it is hoped that a first bolus of humour will help you get through the dryness of the material ahead. Hang in there! There isnt that much physics to learn, but you do need to grasp the basics of it before you get to the fun stuff: the clinical applications (where you will also find 22 other videos which arent as funny, but which are certainly more useful).

Nature of U/S waves

Suppose you were to hit two metal spoons against each other. You would produce sound. How far that sound could be heard would depend on 1) how hard you hit the spoons together and 2) the medium through which the sound waves had to travel. If a listener were on the other side of a thick brick wall, he would not hear you at all. On the other hand, if you and your listener were both underwater, he could hear you at a great distance. And if you were in a canyon or a cathedral, you could hear your own echo, but you might have a difficult time telling where the echo was coming from. You can read whole chapters about the nature of U/S waves, but they behave no differently from any other sound waves. They travel well through some media, worse through others, and can bounce off virtually anything. Keep the above analogy in mind as we discuss the physics involved.

Wave properties Penetration, Attenuation and Reflection

Ultrasound waves, depending on the amount of energy they possess, will pass through (penetrate) a medium to a certain depth. As they do so, they continually lose some of their energy to the tissues through which they pass, a process called attenuation. The energy lost is converted into a negligible amount of heat. The rest of the waves energy is reflected back towards the waves original source. It is this reflected energy, like the echo of sonar on a submarine, which enables the U/S machine to generate the image we see on the screen1. Dont worry about how it does it; just accept that thats how it works. Energy penetrates, and is attenuated.

Some of the energy is reflected back to its source.

Effects of different tissue densities

Ultrasound waves, as was mentioned, are like any other sound waves: they travel well through some media, less well through others and not at all through some. This is a function of the resistance (or impedance) of a particular tissue. In the case of ultrasound, the waves travel very well (low resistance) through liquid (blood/urine), reasonably well
1

Eventually, not enough energy is reflected to produce an echo strong enough for the U/S machine to receive. No echo, no image. So a lot of tissue (usually adipose) between your probe and your target makes EDE difficult, if not impossible.

10 through solid organs (liver/spleen) and not at all through bone (high resistance). Gas is a separate issue. The ultrasound waves have no trouble passing through gas but are immediately deflected in all directions. This is called scatter2. The practical implications of this are: 1) Blood is easy to recognize. Like any other liquid, it appears as a completely black area on the screen because U/S waves travel so well through it that there are no echoes reflected back towards the probe. If you see black where it should not be, call a surgeon. 2) Solid organs (and urine in a full bladder) can serve as acoustic windows, allowing the U/S waves to penetrate deep into the body without interference from bowel gas. 3) Bone reflects 100% of the U/S waves that hit it. All of that reflected energy shows up as a bright, white area on the screen. No waves beyond the bone, however, means no image either. The area behind the bone, therefore, is entirely black (anechoic). Bone can be the bane of our existence, as the ribs conspire to get in the way at the most inopportune times. However, it can also be very useful, as when the spine serves as an important landmark. 4) Gas, in our case, is almost always bowel gas (though subcutaneous emphysema and other pathological gas-forming processes can intrude). The deflection of the U/S waves caused by the gas gives the screen a grey snowstorm appearance, from which no useful information can be obtained. Gas can also be a problem outside the body. If there is air between the probe and the skin, the U/S waves will be scattered before even entering the body. Luckily, this problem can be solved through the application of generous amounts of U/S gel, which forms an acoustic connection between the probe and the skin. An important concept to grasp at this point is that the more a substance reflects energy towards the probe, the brighter the image on the screen. The less it reflects, the darker the image. To my mind this is fairly intuitive: energy lights up the screen. No energy? Darkness.

Scatter also refers to the deflection of U/S waves that occurs when the probe head is not at right angles to the surface being interrogated (looked at). This is mostly an issue when scanning the aorta, as you will see on the course.

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Tissue Interfaces
Our ability to distinguish between structures depends not only on their different densities but also, and especially, on the interface between those different densities. The more pronounced the interface3 (e.g. blood against a solid organ, rather than contused splenic tissue against normal splenic tissue), the easier it is to identify the structures or material involved. In all components of this course, the tissue interfaces are very clear: blood between kidney and liver blood between kidney and spleen blood between myocardium and pericardium blood contained in a thick, fibrous aortic wall gestational sac in the uterus.

EDE is not about the distinction between subtle shades of grey. Rather, it is a study in stark contrasts. These contrasts make image recognition very easy. The challenge of this course, as you will see in the practical sessions, is image generation.

Modes of transmission
EDE work is done in B (for Brightness) mode. The other modes are: A (Amplitude) M (Motion) D (Doppler).

Does this matter? No. Only the B mode will be used during this course. Just make sure your machine is on B mode before you use it (if you have a choiceseveral of the machines we can afford only have B mode).

Another way of saying this would be the greater the difference in echogenicity.

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Frequency, Penetration and Resolution

General EDE probes have a frequency in the 2.5-4.0 MHz range, with the majority being 3.5 MHz4. It is important to understand the relationship a probes frequency will have to its performance, specifically with regards to penetration and axial resolution (the ability of the waves to distinguish between two objects at different depths)5.

Frequency and penetration are inversely related, while frequency and resolution are directly related. Therefore:
As frequency increases, penetration decreases As frequency decreases, penetration increases As frequency increases, resolution increases As frequency decreases, resolution decreases

A low frequency probe, therefore, is good for peering deep into the body (into the chest and abdomen) to look at relatively large objects. Smaller objects, like foreign bodies near the surface, are better identified with a high frequency probe. But we wont be dealing with foreign body localization on this course. Everything we will be doing can be done with a single 3.5 MHz probe. So just make sure the probe you are using has 3.5 written somewhere on it, and forget the rest. If you want to spend a bit more money, get a probe that can vary from 2.5 MHz - which would be great in a large-chested patient (i.e. COPD) - to 5.0 MHz - which would be better in children.

The exception is the endovaginal probe, which is usually a 5.0-7.5 MHz probe. A higher frequency is used here because a) the objects of interest are much closer to the probe than they are elsewhere and b) the objects of interest are much smaller.
5

There is also the term lateral resolution, which refers to the ability of the U/S waves to distinguish between two objects at same depth, but separated along a right-to-left axis. This is not an issue of frequency but rather of focus, and will be addressed later.

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Axial Resolution

Poor Axial Resolution

Good Axial Resolution

Axial resolution: The ability of a scan to determine whether a big echogenic blob is actually two smaller echogenic blobs one on top of the other. Improves as frequency increases (compare with lateral resolution). (Note: Get used to the above diagram, which represents the classic pie-wedge-shaped ultrasound screen. Youll be seeing it often.)

On page 12 (facing page, to your right) we present an example of a standard ultrasound screen. As you can see, to the beginners eye it looks like a cloud of grey, devoid of information. Dont worry. Things will become clearer soon.

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Sample ultrasound screen #1

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Probes
Ultrasound probes (also called transducers) suffer from unfortunately confusing nomenclature. We will try to clarify this terminology here. If you get frustrated with these terms, relax. They have little bearing on your ability to obtain a good ultrasound image. The two key terms are FORMAT and ARRAY FORMAT refers to the field of view produced by the probe. There are two formats: linear and sector. Linear format probes produce a rectangular field of view and are used for viewing objects close to the surface. They do not concern us here. Sector probes produce the more familiar pie-wedge-shaped field of view. All of the scans done during this course will be with sector probes. ARRAY refers to the way the crystals (the elements which vibrate, via the piezoelectric effect, to produce the ultrasound waves) are arranged. These can be phased or linear. But this linear has nothing to do with the earlier linear. Got that? Me neither. Linear array probes are further divided into flat linear (which sounds redundant) and curved linear (which sounds like a contradiction). A flat linear array gives you a rectangular field of view, and is used for seeing objects close to the surface. We will not be using flat linear array probes on this course.

Phased Array Probe

Flat Linear Array Probe

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Curved Linear Array Probe

Does any of this matter? No. Cn this course, we will be using only sector format probes. The images you will see, therefore, will always be pie-wedge-shaped. On the course, we will use curved linear array probes with a large probe head, almost exclusively6. These have a greater area over which signals can be received and thus give you better image quality. But the bottom line is that for EDE purposes virtually any phased array or curved linear array probe will be adequate7.

Novice ED sonographers often prefer probe heads that are as small as possible because these can be manoeuvred more easily. But this is a transient advantage. With a bit if training, you will learn how to manipulate the larger probe head effectively and be able to benefit from its better image quality.

All this physics stuff is pretty dry, eh? Heres your reward for actually reading the text attentively. On the day of the course, when the instructor says Lets start! stand up. You can then turn and face any of your colleagues who are still seated and berate them for being less meticulous than you are. We are trying to make this an EDE tradition, so no spilling the beans!

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Understanding EDE Images

Insofar as they are two-dimensional representations of three-dimensional structures, U/S images are not significantly different from X-Ray or CT images. The trick is to generate the image you want. This is one of the key points of this course. Image interpretation in EDE is easy. Image generation can be tricky. To begin with, the ED sonographer must get used to the different orientations in which images appear on the screen. Then, there are a number of things that can be done to electronically modulate the image (knobology in U/S lingo). Both of these will be dealt with in greater detail in the following sections. To become a competent ED sonographer you will have to first develop the ability to visualize internal, three-dimensional structures in two dimensions. This is the cognitive challenge of EDE (well talk about the physical challenge later). This is harder than you might think as the planes of view are often off-kilter and the organs imaged are usually only partly seen. Dont panic! These obstacles can be overcome.

Planes of view
This section has most people scurrying back to their basic anatomy books, because U/S texts like to use the terms that describe certain planes of view more or less interchangeably. For instance, the longitudinal axis is often referred to (technically incorrectly) as the sagittal or the coronal plane. But who cares? What we need to do is agree on two terms, one in which the probe is placed along a line running head-to-toe and one in which it is placed along a line running left-to-right. So, for the purposes of this course: Longitudinal view: Probe placed along the body (i.e. head to toe). Transverse view: Probe placed across the body (i.e. left to right). Of these two, the transverse plane will be the easiest to grasp, as it reproduces a CT image: as you look at the screen, the patients head is away from you, the patients feet are towards you, and the patients right side corresponds to the screens left side and viceversa. The longitudinal view is somewhat less intuitive. It will show a wedge-shaped section of the body, with the left side of the screen corresponding to the cephalad direction (illustrated in the next section). These terms are useful to give you a starting point. Much of our work will be done in views that are not purely longitudinal or purely transverse, but it is easier to start from a known point and modify it (i.e. start in the longitudinal plane and rotate 30 clockwise).

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Probe placement
The first step in generating a high-quality, reproducible image is to be consistent in the way the probe is applied to the body. By convention, this means that when the probe is angled longitudinally (i.e. head-to-toe), the left side of the screen (as you look at it) corresponds to the cephalad side.

Probe in longitudinal view

Left side of screen cephalad H E A D F E E T

When the probe is in a transverse orientation, the left side of the screen (as you look at it) corresponds to the patients right, much like a CT image (the head is behind the screen).

Probe in transverse view

Left side = Patients right L R E I F G T H T

Finally, remember that the part of the body closest to the probe will always be at the top of the screen, no matter what orientation you are in. Beginners often try to interpret what they see in terms of anterior-posterior, with posterior being the bottom of the screen. Get into the habit of thinking in terms of near-field versus far-field.

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Probe Orientation
Orienting the probe is usually easy because most of them have a small knob or bar on one side, which is the side you should orient towards the patients head or towards their right side. This isnt always the case, though. Some probes do not have this handy little knob, so get into the habit of manually confirming that your orientation is correct before you place the probe on the patient. To do this, simply tap (lightly! the probes are fragile) one side of the probe head and watch the screen. You will easily be able to see whether your finger appears on the left or the right side of the screen. This is analogous to the habit many of us have of tapping our stethoscopes to ensure we have not rotated it the wrong way.

Probe Reference Mark

This side doesnt have it.

This side does.

It is interesting to note that, as a sign of their rugged individualism (or just their contrarian nature), echocardiographers orient their probes exactly opposite to the way everybody else does. For them, the indicator points to the patients left, which means that the left side of the screen will show the left side of the patient. There is no logical reason for this, but they get pretty touchy if you question this practice. The result is that some confusion exists in the EM literature. Some sources show the left ventricle on the right, while others show it on the left, depending on whether the emergency physician writing the article was trained by a radiologist or a cardiologist. Does this matter? No. The things we are looking for in Cardiac EDE (global cardiac function and pericardial effusion) are utterly unaffected by the orientation of the probe.

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Centering the Image

As mentioned previously, the probe marker is always oriented towards the patients right or towards the patients head. There is a very good reason for this. In the practical sessions, you will be constantly required to center the Area of Interest, i.e. to bring the image you are most interested in towards the center of the screen. To do this, you will have to move the probe one way or the other. Sounds easy, but its trickier than you might think. If you follow the rule above (probe always to patients right or patients head), then the following directions will also always apply: In the Longitudinal view To move the Area of Interest to the right, move the probe cephalad. To move the Area of Interest to the left, move the probe caudad.

In the Transverse view To move the Area of Interest to the right, move the probe to the patients right. To move the Area of Interest to the left, move the probe to the patients left.

By consistently placing the probe on the patient in the same way every time, you will more rapidly develop the ability to reflexively move the image you see on the screen to center the area of interest.

Probe manipulation
There remains the actual physical skill to be considered, and this is quite important in and of itself. Very small movements of the sonographers hand can result in alterations of the plane being scanned of 10, 20, or even 30 degrees. Since the image you seek may lie in only one plane, it can be surprisingly difficult sometimes to align the probe correctly. The key is slow hand movements. If you go quickly, you can go right through the plane you are looking for without realizing it. This is particularly true in endovaginal ultrasound, where the structures of interest are much smaller. This cannot be emphasized enough. Move your hand sl-o-o-o-o-o-o-w-ly. It is also a good idea to teach yourself to be ambidextrous from the beginning. The ED environment often imposes restrictions on where you can stand. Learn to always hold the probe in the hand which is next to the patient. This leaves your other hand free to manipulate knobs, adjust the screen, reach for more goo, etc.

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Image Modulation
Like a TV set, an EDE machine has various dials and knobs which can be tweaked in an effort to coax out a better image (the above-mentioned knobology). It can seem, at first glance, that there are an unlearnable number of the widgets on the U/S machine. Relax. There are only two you really need to know about.

Depth
The U/S machine receives echoes from various depths in the body. You can regulate how much of that depth is displayed on the screen. You will use maximum depth when trying to find a deep object (e.g. the heart of a barrel-chested COPDer) and minimum depth when looking for a shallow object (the hepatorenal space in a skinny child). The corollary here is that the less the depth, the greater the magnification objects seen at minimum depth will appear larger than when seen at greater depth settings. You can determine the current depth setting at a glance by looking at the centimeter marks on the side of the screen. The more centimeter markings there are, the greater the depth. As a general rule, set the depth to maximum whenever you begin a new scan. Once you have the structure(s) of interest on the screen, you can decrease the depth to achieve greater magnification.

Depth Marker Structure partly seen at shallow depth setting

Structure completely seen at increased depth, but magnification reduced

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Gain
The gain dial allows you to modulate the strength of the signal returning to the probe. Remember that as more energy returns to the probe, the image on the screen appears whiter/brighter. Conversely, if less energy is reflected to the probe, the image appears darker. Gain allows you to electronically increase the sensitivity of the probe, which allows you to modify the apparent strength of the return. This makes the entire screen whiter or darker, which enables you to enhance certain structures. If you want to make an echogenic (white) structure stand out, you would increase the gain. If you were most interested in an anechoic (dark) area, you would decrease the gain. Gain is analogous to the squelch dial on a radio. Turn it down and you hear less static, but you might lose the signal you want to receive. Turn it up, and you have no trouble receiving, but there can be a lot of static. As you develop an ultrasound eye, you will find yourself gradually turning the gain down, as you become accustomed to picking out ever more subtle shadings.

There are a bunch of other knobs found on most U/S machines. While these are of virtually no interest to us, the more common ones will be briefly described here so that you can tell the biomedical gang where to set them (before you crazy-glue them in place).

Time-Gain Compensation
Some EDE machines have a more sophisticated version of gain called Time Gain Compensation (TGC). This is a series of sliding knobs that look like this:

Time Gain Compensation

There is nothing complicated about TGC (except maybe the name). It just allows you to fine tune the gain at a specific depth while leaving the rest of the field unaffected. This is of very limited use to the five key questions of EDE. Generally, the settings are placed in a mid-range progression as shown above and left there forever. Only the main gain dial, which controls overall gain, is then used.

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Power
Remember that U/S waves attenuate (lose energy) as they go through any tissue. Increasing the power enables you to push U/S waves through tissue in which you are not interested (usually fat) to get to tissue in which you are interested (like the aorta). This feature is often only found in a limited form (if at all) on the lower-end machines generally available to ED physicians. This is only a problem in the most obese patients. For virtually all patients, a mid-range setting will be adequate.

Focus
Some machines allow you to focus the U/S waves at a particular depth. This enables you to improve the lateral resolution8 at that depth. In other words, you are better able to distinguish that a big echogenic blob is actually two smaller echogenic blobs at the same depth. This is of limited utility in this course, with the possible exception of early twin gestations (and even there it would fall into the nice to know category, rather than the need to know). If your machine has a focus button, turn it off.

Lateral resolution

Poor Lateral Resolution

Good Lateral Resolution

Sometimes called transverse resolution.

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Sample ultrasound screen #2

How about now can you start to make out some of the structures on the screen? Its still early in your training, so again, dont panic if you cant make things out. It will come to you.

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Artifact
As with everything that comes out of Diagnostic Imaging, there is always the question of whether or not the image you are looking at is real or not. There are several ways a U/S machine can try to fool you, but fortunately the things we are looking for are not easily affected. Remember, EDE is a study in stark contrasts. Minor forms of artifact will not confuse us. However, you should be aware of the following three types of artifact:

1) Refraction

2) Shadowing

3) Enhancement

because 1) they are the most common, and 2) the first two can imitate free fluid something in which we are most interested.

Refraction
As the name implies, this occurs when the U/S waves are deflected from their original path by passing close to a large, curved, fluid-filled structure (in our case, usually the bladder or gall bladder). The result is a shadow-like image that seems to project from the edges of the curved structure. Also called edge artifact.

Refraction

Fluidfilled Structure This looks like fluid but it isnt!

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Refraction

Refraction Artifact Fluid-filled Structure

27

Shadowing
When U/S waves hit something that blocks their path (in our case, usually a bone), everything behind the blocking structure appears black. You could be tricked into thinking it was fluid, except that it looks like a shadow (hence the term acoustic shadow).

Shadowing

Bone Acoustic Shadow Not Fluid!

28

Shadowing

Bone Shadowing Artifact

29

Enhancement
The opposite of shadowing. When U/S waves go through an area of low resistance, namely fluid, the tissues on the far side glow more brightly than the tissues beside them. The bladder, the gall bladder and any fluid-filled cystic or vascular structure can do this. The waves go through the fluid without any difficulty and therefore retain nearly all of their energy. Upon entering denser tissue on the far side, this excess energy makes the far-field wall of the fluid-filled structure light up more brightly than adjacent tissues.

Enhancement

Fluid-filled Structure

Enhancement Artifact

30

Enhancement

Fluid-filled Structure Enhancement Artifact

31

A few final tips

It is helpful to darken the room if you can, but this is not essential9. The things we are looking for (except for early gestations) are easily seen, even in well-lit environments. Get comfortable. Whenever possible, bring the patient to a comfortable height so that you can manipulate the probe with a minimum of hand/arm effort. This will make it more likely that you will move your hand slo-o-o-o-o-o-wly and deliberately. And dont hesitate to go from one side of the bed to the other if you cant reach a particular area easily. Ultrasound gel is needed to ensure there is no air between the probe head and the body (remember the scattering effect of air on U/S waves). Use lots of gel. No, use LOTS of gel! You cant have too much gel. Several machines have knobs which control contrast and brilliance. These are analogous to the controls on your television set and completely intuitive. They can be left in a midrange position and ignored, or modified according to personal taste and visual acuity. The first few centimeters of the screen are a dead zone from which no useful information can be obtained. Never try to interpret what you see there.

Dead Zone

It does give the resuscitation effort that cool EDE look, though.

32

Sample ultrasound screen #3

At this point, things should be coming into focus. This screen, for instance, should no longer appear grey. Can you see the structures on the ultrasound screen?

33

Cardiac EDE
The first practical session in this course deals with the heart, as it is the easiest image to generate. Remember, the challenge of this course is not image recognition, it is image generation. Although Cardiac EDE can be done from a number of directions, by far the best approach is the subxiphoid view. This means that you place the probe head below the xiphoid, and aim almost straight up, in a more or less transverse plane.

The subxiphoid view (2 Videos)

This is sometimes called the subcostal view. There are several other views, such as the parasternal (which comes in long and short varieties), the apical and others, but none is as good as the subxiphoid for the purposes of this course. It is technically easier to perform and it enables you to perform your scan while staying out of the way of colleagues who may be intubating, placing chest tubes, performing CPR, etc. (the chest is prime real estate during a resuscitation).

34 If you do not immediately see the heart (a mostly black structure - because it is fluidfilled - within a bright, white envelope), perform an AP sweep (i.e. tilt the probe until it is almost flat on the patients abdomen and then sweep slowly posteriorly). Once you have confidently identified your target, center the heart on the screen (almost always, this will mean having the depth at maximum). In this position, you should be able to appreciate the following structures (from near-field to far-field): liver pericardium RV LV pericardium again

You may even be able to see the valves flapping around.

A Normal Heart

Pericardium RV

Liver

LV

It was mentioned earlier that many beginners have difficulty with the spatial orientation of the image on the screen. In Cardiac EDE, this situation is exacerbated because the probe is pointing UP. The near-field images are therefore inferior structures, while the far-field images are superior. Novices almost always equate the far-field with the posterior part of the body, which leads to much initial confusion.

35 It is then necessary to sweep completely through the heart, passing from anterior to posterior and back again, watching the heart disappear completely at each extreme. This is called sweeping through the area of interest. Get used to this expression, as you will hear it over and over again during this course. Unlike CT or plain radiography, EDE is a dynamic image. It is necessary to pass completely through an area (slo-o-o-o-wly) to ensure that no pathology has been missed. The pericardium, being a tough fibrous structure, provides an excellent interface for U/S waves. As such, it shows up as a bright, white, fairly thick line surrounding the heart. This can be made even more obvious by turning the gain higher than normal. It is essential to confidently identify the pericardium. The rest (e.g. heart chambers) is secondary. Once you are sure you have recognized the pericardium, the thing moving around inside it is the heart. Pretty simple, eh? Once you have done this, you can address the two key questions of Cardiac EDE:

1) Is there vigorous global cardiac activity? 2) Is there a pericardial effusion?

The goal here is to eliminate potentially correctible causes of shock.

Normal Heart Video

36

Evaluating Cardiac Activity

As you will see in the demonstrations on the normal models, recognizing grossly normal cardiac activity is simple. You can easily see the heart contracting at a frequency roughly equal to your own heart rate. Also, you can see fluid-filled structures (fluid is black on the screen) being squeezed, and the black area either diminishing greatly or disappearing altogether. This is the blood being squeezed out of the various chambers. It is not important to be sure whether one chamber is beating more effectively than another. It is only necessary to decide whether, as a unit, the heart is beating normally or not at all. Once you have made this determination, you go down one of two clear paths:

1) Heart not beating

Unless there is a defibrillatable rhythm on the monitor (VF, VT, SVT), this is cardiac standstill. This is not survivable. The patient is dead. Stop whatever you are doing. Consult Pathology. The one major exception to this would be the pediatric hypoxic arrest. Remember that kids arent dead till theyre well-oxygenated and dead. There are rarer exceptions, such as hypothermia. As always, let your clinical judgment take precedence. If your gut tells you to carry on with the resuscitation, proceed!

2) Heart beating vigorously

In the context of unexplained hypotension, this finding suggests that the cause is noncardiogenic and therefore potentially correctable. The readily reversible causes of this condition being hypovolemia, hypovolemia, hypovolemia and tension pneumothorax, this finding should lead you to provide fluids, fluids, fluids and possibly chest tubes (? bilateral). You should also search for heretofore unsuspected blood loss. There is of course the possibility that you will see something in between these two extremes: a heart beating, but in a way that does not seem normal. This would be the case in ischemic hypokinesis and metabolic derangements, among others10. However, these are quite subtle findings and are beyond the scope of this course. In Cardiac EDE, you should be making the determination of vigorous cardiac activity or complete absence thereof. If you are unable to be certain of one these two findings, you must declare the scan to be indeterminate and proceed with the management of the patient without drawing any conclusions from said scan.

10

This condition can also occur with severe acidosis or hyperkalemia, but in these settings the heart will not really be beating normally and you should interpret the scan as being indeterminate. In this case, one may want to consider administering 2 amps of bicarbonate and 2 vials of calcium chloride immediately. With the exception of digoxin toxicity (hyperkalemia in which calcium is contraindicated) there is no down-side to this approach. Other possibilities would include a massive PE or catastrophic valve failure. Unfortunately, neither of these conditions is likely to be survivable in the setting of severe hypotension

37

Evaluating the Pericardium

The goal here is to determine whether or not there is a pericardial effusion (the diagnosis of cardiac tamponade is a clinical one: the presence of hypotension, or at least pulsus paradoxus, is required). While the pericardium normally contains up to 50 cc of lubricating oil (WD 40, I think), this will not be easily appreciable on U/S. With the patient in the supine position, pericardial effusions will become apparent at the following levels: ~ 100 ml: posteriorly, only in systole 100-300 ml: posteriorly, throughout the cardiac cycle >300 ml: anteriorly and posteriorly This will appear as an extra black area inside the pericardium which does not change in shape (or only changes very slightly) during systole. As mentioned above, it is vitally important to scan through the entire heart. If you discover a pericardial effusion, you now have to determine its cause and its effect. In trauma cases, the cause will be apparent, while in medical ones it may take a little digging (see PERICARDITIS mnemonic - pg 38). Judging the effect requires a little clinical judgment. The normal pericardium can only accommodate 100-200 ml of fluid before hemodynamic compromise occurs if it accumulates rapidly. In trauma cases, the patient most likely had a normal pericardium before being shot or run over. It is therefore reasonable to assume that the pericardial effusion is responsible for some, if not all, of the hypotension. This should lead you to perform an emergent pericardiocentesis (described at the end of this section). In medical cases, where the accumulation may have taken place over weeks or months, the pericardium can stretch to accommodate several times more fluid than it can in the acute setting. Tamponade will come on slowly in these patients, and they will initially present with increasing shortness of breath on exertion and fatigue, rather than signs of shock. It is also possible that the pericardial effusion has nothing to do with the patients vital sign abnormalities. For example, the presence of hypotension and pericardial effusion, combined with bradycardia and a temperature of 34.2C, should suggest the diagnosis of myxedema. There are echocardiographic signs of tamponade, ranging from the fairly obvious (decreased chamber volume) to the fairly subtle (my favorite being RV/RA free wall collapse in mid-to-late diastole). However, in EDE it is mandatory to describe pericardial effusions as being present or absent, and not to stray onto thinner ice. As mentioned at the beginning of this section, the diagnosis of tamponade should remain a clinical one. In trauma, the effusion is almost certainly to blame, while in medical cases it is only likely. Having said that, the converse holds true for both trauma and medical cases:

no effusion, no tamponade.

38

Pericardial Effusion Video 1

Pericardial Effusion Video 2

39

A Few Final Tips

If you are having trouble bringing the heart into view, there are three things you can do to improve your image. First, you may be experiencing difficulty because the heart is too high in the chest. This is particularly true in the case of broad-chested persons. In these situations it can be very helpful to ask the person to breathe in slowly and to hold their breath. This drops the diaphragm and, by extension, the heart, bringing the target organ closer to the probe. This may not always be possible with an emergency patient, but it can make all the difference in someone who can cooperate. Second, if a patient has a protuberant abdomen (something that has been known to happen in our practice) you can get a slightly better view by flexing the legs (which relaxes the abdominal muscles). Third, some patients have a less-well developed left lobe of the liver (remember the liver is our acoustic window). In these cases, you may have to cheat over to patient right to get a better window. Possible false positives include free fluid in the abdominal and pleural spaces, but you can avoid these pitfalls by using only the subxiphoid approach. As there is no pleural reflection between the xiphoid and the heart, there can be no pleural effusion there either. As for abdominal free fluid, it may be found around the liver but it will not conform to the heart border. As mentioned above, the key structure to identify is the pericardium. This will enable you to be certain whether the fluid you are seeing is intrapericardial or not. A source of false positives that cannot be avoided is the presence of epicardial fat. This strip of tissue is usually quite echolucent and can be remarkably thick. However, the giveaway is that it will appear anteriorly first. As you will recall, effusions appear posteriorly first (due to gravity), and never only anteriorly. It is worth mentioning that epicardial fat pads are quite common and bear no relation to body habitus. Emphysema can also pose a problem by placing air (which scatters the U/S waves) between the probe and the heart. Finally, always remember that you must remain clinicians first and foremost and that EDE gives you information that is frozen in time. If a patients condition deteriorates, redo the EDE to see if a previously absent pericardial effusion has developed in the interim.

40

Possible etiologies of acute pericarditis:

Post-MI (Dressler's syndrome) myxEdema Radiation-induced Infectious Viral (5) Bact (5) Fungal Other: -

"PERICARDITIS"

COXSACKIE, echo, adeno, mono, influenza Cocci (staph, strep, pneumo, meningo), TB (esp. Histoplasma capsulatum) amebiasis, rickettsial

Collagen disease (6) - RA, RF, PAN, SLE, scleroderma, dermatomyositis Amyloid / Anticoagulation (hep & coum) / Aneurysm (dissecting) Renal failure (uremia) Drugs (5)--penicillin, procainamide, phenytoin, pressure (hydralazine), pulmonary (INH) Idiopathic thrombocytopenic purpura Trauma - pericardiotomy, catheters - pacemaker implantation - pressure injection of contrast media Tumours Primary - leiomyofibroma - rhabdomyosarcoma - teratoma - leukemia - lymphoma - lung - La Leche - breast - lying in the sun - melanoma

Metastatic

Infective endocarditis (SBE) w/ valve ring abscess Sarcoid

41

Emergency pericardiocentesis (paraxiphoid approach)

Assemble

- 18-gauge 10-cm spinal needle - stopcock - 20-cc syringe

Attach lead V2 to needle Advance needle towards left scapula tip Aspirate frequently till cavity entered
STOP if 1 - blood obtained (>20 ml aspirated easily = RV) 2 - pulsations felt 3 - ECG changes (ST elevation current of injury)

- leave catheter in place if continuous drainage needed

Note that, although technically tricky, it is possible to watch the pericardiocentesis needle go into the pericardial space on your U/S screen.

42

Sample ultrasound screen #4

Now, with some practical experience under your belt, you can really start to appreciate that this screen is not all just grey mush, cant you? Cant you?

43

Aortic EDE
Scanning the abdominal aorta is both simple and frustrating. The structure you are looking for is not very difficult to identify when you can see it. Unfortunately, our patients rarely take the time to do a proper bowel prep before coming to the Emergency Department. As a result, it is very common for bowel gas to intrude, and for significant scatter to be present. As well, the typical patient in whom you want to eliminate AAA is typically how shall we say this adipose-challenged. This presents the U/S waves with significant resistance and can make scanning impossible simply by placing the aorta out of range. Given the above, this is a good time to re-emphasize that golden rule of EDE only call the ones you are sure of. A significant proportion of your Aortic EDE scans will be inconclusive and you must have the competence and the humility to identify when this is so. Learn to be like the radiologists, and blame the inadequate study on the patient, the equipment, the phase of the moon, etc but dont call it normal if you arent 100% sure.

The Essential Landmarks the heart and the spine

Scanning the aorta must be done from the diaphragm to the iliac bifurcation, entirely in the transverse plane. To ensure you image the entire aorta, place the probe against the xiphoid then angle the probe until it is in a true transverse plane. At the level of the diaphragm, you should see one or two (or more) circular echogenic (white) structures appear, with fluid inside (which appears black). Unfortunately, the abdomen is full of vessels. Since we are only interested in the aorta, it is crucial to first identify the key landmark the spine. This appears as a bright image with a dark acoustic shadow projecting behind. The aorta (and the IVC) will be immediately anterior to the spine, and therefore closer to the probe, and therefore higher up on the screen, thusly:

IVC

Aorta Spine

Acoustic Shadow

44

Identifying the Aorta

The features that definitively identify the aorta are: 1) Thickness of the vessel wall. A little harder to appreciate at first, at least until you have seen a few side-by-side. The aortic wall is clearly thicker than that of the IVC, making it significantly more echogenic (brighter). It is fairly common to see a single large vessel. Eventually, you will come to recognize the aortic wall without needing the IVC for comparison. 2) Non-compressibility. Push the probe into the patient. If the echogenic circle you are looking at flattens and the black fluid disappears, you are pushing on the IVC. The aorta should remain circular. 3) Lack of respiratory variability. The IVC will collapse slightly when the patient inspires, as negative intrathoracic pressure draws blood into the chest, temporarily depleting it. You can exaggerate this by asking the patient to sniff hard. This creates an even greater negative intrathoracic pressure than normal respiration, and should cause the IVC to collapse completely. This is best appreciated high up in the abdomen, as the effect dissipates as one moves further away from the chest. Interestingly, the sniff test will be negative (i.e. the IVC will not collapse) when rightsided pressures are high. It can therefore be used to support the diagnosis of tamponade. Obviously, this will not be appreciable in the patient who is being ventilated and is no longer generating negative intrathoracic pressure. In actual clinical practice, the lack of respiratory variability is rarely used, as the first two criteria suffice.

And dont get fooled by

1) Pulsatility: Make sure you are NOT fooled by a large pulsating vessel. The proximity of the IVC to the aorta can make it pulsate very nicely, and there are several other pulsatile structures in the abdomen. 2) Sidedness: While it is true that the aorta is usually on the patients left (which would be screen right), there are some normal individuals in whom this is not true. Some textbooks say up to 10%, but that seems improbable. Over four years and thousands of scans, the EDE instructor team has found very few examples of this. What is quite common, however, is for the IVC to be undetectable. This is not a problem since, as you can see, the criteria for identifying the aorta can be applied without comparing it to the IVC.

45

Technique and Image Interpretation

Having identified the aorta, you then follow it all the way to the iliac bifurcation, while staying in the transverse plane. At the bifurcation, you should see the single lumen of the aorta become two smaller lumens the iliac vessels. If throughout this entire distance you have noted that the diameter of the aorta is less than 3 cm (echogenic outer wall to echogenic outer wall)11, you are done. Your patient does not have an AAA. If the diameter appears enlarged at any point, the diagnosis of AAA is made. Note that, in this setting, it is not necessary to find the bifurcation. This anatomical landmark is often distorted beyond recognition by the aneurysm. But who cares? If you find a dilated AAA, you have found a critically important image. You must now place that image in the clinical context. Be careful not to be fooled by thrombus or atheroma in the lumen, which can be somewhat echogenic and leave a normal-looking fluid (black) centre. Make sure you identify the echogenic (white!) vessel wall during your (slow!) sweep. It must be noted that while EDE is excellent at identifying dilation of the AAA, it is incapable of identifying rupture of that lesion. This is because most ruptures extend retroperitoneally, an area that EDE is not able to evaluate. As such, there will usually be no free fluid in the abdomen. There are exceptions to this rule, of course, and any positive Aortic EDE should be immediately followed by an Abdominal EDE to look for free fluid. It remains important, therefore, to put the EDE findings in the right clinical context. Take two patients with a 7 cm aorta, abdominal pain and unexplained hypotension. If the first is complaining of back pain and has diminished femoral pulses, call the vascular surgeon. But remember that there are a lot of people walking around with 7 cm aortas. If the second patient has RUQ pain and a temperature of 39.8C, the correct diagnosis would be septic cholecystitis, not ruptured AAA. Again, we see that EDE is merely an adjunct to your clinical skills.

Transverse vs. Longitudinal Scanning

It can be tempting to scan the aorta in the longitudinal plane, as this can be faster. However, this approach increases the risk of missing a proximal aneurysm by not having made certain that the entire aorta was visualized. Also, it is easier for beginners to be fooled by the IVC and to measure Big Blue when you should be measuring Big Red. But the best reason not to scan in the longitudinal plane is that the time spent learning and executing this skill is of no benefit. EDE is binary! If you get the answer you were looking for in the transverse plane (aorta dilated!), youre done! Seeing the extent of the AAA in the longitudinal plane does not change your management of the case in any way. Unstable patient? OR stat! Stable patient, with a good story for ruptured AAA? Consult vascular stat (they will often choose to go to OR without a CT).
11

This describes the vast majority (over 95%) of fusiform AAAs. Sacular aneurysms (which, as the name implies, look like sacs attached to the aorta) are much less common, but equally well seen on EDE.

While were on the subject, have you ever noticed how that over 95% number keeps appearing with regards to AAA? The same number applies to the proportion which are infrarenal, which rupture over 5cm and which rupture into the retroperitoneum.

46

Aortic Scan Video

From the outside and from the inside.

Abdominal Aortic Aneurysm Video

47

A few final tips

Remember what was said about the difficulty of imaging the aorta. Emergency patients almost always come with bellies so full of bowel gas, beer, and baloney that nothing can be done, even by experts with high-end machines, to obtain an ultrasound image of the aorta. Do not be surprised if, after this course, you are only able to see 50% of the aortas that you attempt to image. Do not be surprised if, in a year of doing EDE regularly, you are only able to see 80% of them. Even the techs dont do much better in the unprepared patient. In these cases, CT (with resuscitation gear at hand) or direct-to-OR are your only options for the unstable patient. Before giving up in the face of massive bowel gas, however, you can try to push the probe deeper into the abdomen in the hopes of displacing the gas to either side. Note that this does not always happen immediately. You will often have to push and wait, sometimes for several seconds, to let the picture clear. If this does not work, try moving the probe off-centre to one side or the other. Then angle the probe in to keep the spine centred and proceed with the scan. Sometimes, moving off the midline a few centimetres can dramatically improve your image quality. Because gas is such a problem it is a good idea, in the unstable or at least clinically suspicious patient, to scan once quickly, looking for a true positive. Symptomatic AAAs will usually be so large that they will literally leap off the screen. Realize that it is not necessary to see the entire aorta in this situation. A glimpse of a 7 cm aorta through a cloud of bowel gas confirms that you have a true positive and, in the right clinical setting, is a ticket to the OR. If the quick look is inconclusive, go back up to the top and scan slowly, trying to generate a true negative. If you feel you have located the aorta, it is a good idea to magnify the image by decreasing the depth. This makes it easier to follow the structure. Make sure that the key landmark the spine, with its acoustic shadow remains clearly visible and well-centred. The key area of interest, the vessel wall, is a very echogenic structure (bright, white). Like the pericardium, it is better visualised if the gain is slightly increased. Getting weird artefact just around the bifurcation? Check for belly-button air (if patient is an innie).

48

Sample ultrasound screen #4

You still cant see the ultrasound image on this screen? And youve been reading carefully? You know, this may not be for you. Have you considered psychiatry? They never use ultrasound.

49

Abdominal EDE
EDE got its start here the evaluation of the abdomen for the presence of free fluid. The value of a positive EDE in this setting is incontrovertible. If you see free fluid in the right clinical context (i.e. trauma and hemodynamic instability), youre done. The patient needs to go to the OR. Otherwise, there are three other possible clinical pathways: 1) EDE positive (free fluid seen), patient stable Generally, a CT will be obtained in these cases. However, if CT is not available (remote area, equipment malfunction) another option is to re-EDE the patient several times to see if the fluid accumulation is increasing. If it is, you should expedite the delivery of the patient towards definitive care, with greater measures for security (e.g. air transfer with packed cells, rather than land transfer without). 2) EDE negative, but patient clinically suspicious Clinical judgement always takes precedence. Never allow a negative EDE to reassure you if there is something worrisome about the patients presentation. You are right. The machine is wrong. Consult your surgical colleagues. If the situation warrants it, go directly to the OR. Otherwise, be prepared to take the patient to CT with full resuscitation gear. Again, you may want to consider the option of redoing the EDE, particularly if other imaging resources are lacking. 3) EDE negative, clinically benign Performing serial EDEs in the stable trauma patient will allow you to detect intraabdominal hemorrhage before any signs of hemodynamic instability become apparent. A clearly negative EDE (one which remains negative over several hours and several repeat scans) is very reassuring.

Plane of View
Abdominal EDE differs from the other two areas we have seen because you will now be scanning in the longitudinal plane. This plane generates images which are somewhat less intuitive than those found in the transverse plane, so it is worthwhile repeating the following two points: 1) Always keep the probe indicator oriented towards the patients head. 2) If you do 1), the left side of the screen will correspond to the cephalad direction (screen right will be caudad). Scans of the abdomen are done in the RUQ, LUQ and Pelvis. While some authors advocate the use of paracolic gutters and other views, these are technically challenging and add little or no sensitivity to the three main views.

50

Right Upper Quadrant

This is the single most important part of the abdominal scan. The RUQ contains the hepatorenal space (aka Morisons pouch), the second lowest part of the supine abdomen. However, since the lowest part - the pelvis - has such little volume, any clinically significant intraperitoneal bleed will quickly overflow into the RUQ via the right paracolic gutter. As for bleeding in the LUQ, it will be diverted directly to the RUQ (i.e. without going via the relatively lower pelvis) by the phrenicolic ligament and the mesentery of the transverse colon. Once in the RUQ the fluid will collect between the kidney and the liver, forming a black stripe between these two solid organs. The excellent tissue interface created here, between the grey organs and the black fluid, makes this easy to see.

All roads lead to. The RUQ*

(Reprinted, with permission, from Ultrasound in Emergency and Ambulatory Medicine, Mosby)

* in the supine patient.

The hepatorenal view alone will detect hemoperitoneum in more than 80% of clinically significant cases. The term clinically significant is obviously quite an important distinction. EDE seems to be able to reliably detect free fluid in the abdomen if the effusions are over 500 cc (in the adult) though some studies find that up to 900 ccs must be present before all operators can detect it. This should not be seen as a limitation. On the contrary, it indicates that the test will detect clinically significant injuries without being overly sensitive. The bottom line is that we should not be quantifying the free fluid seen but rather, as detailed above, declare the EDE to positive or negative and integrate that piece of information into the overall clinical picture.

51 Scans of the upper quadrants will require the greatest technical ability of any EDE scan, so you must be very methodical. Most importantly, you must work in one plane at a time. Use the xiphoid as a landmark, then search for the kidney (which has a distinctive double density) in the posterior-anterior plane. Once the image of the kidney is clear and sharp as possible, move the probe, still in the true longitudinal plane, cephalad or caudad until the interface is clearly seen. If this fails to generate a recognizable image, move cephalad or caudad one or two rib spaces and try the entire sequence again. All of these movements (the AP search for the kidney, the longitudinal search for the interface and the repositioning of the probe) can be done decisively. The only movement that has to be done slowly is the sweep, described on page 53. If you are having a difficult time with this, you are almost certainly placing the probe too anteriorly. The kidney is in the retroperitoneum, not halfway between the spine and the umbilicus. Think posterior axillary line.

RUQ Scan

52

RUQ Scan - Normal

Hepatorenal Interface Kidney

Liver

RUQ Scan - Positive

Free Fluid

53

Left Upper Quadrant

The LUQ is anatomically interesting. Although it lies higher in the supine abdomen than either the pelvis or the RUQ, it is nonetheless essential to scan this area. As mentioned above, the phrenicolic ligament and the mesentery of the transverse colon will eventually divert LUQ fluid to the RUQ (without passing through the pelvis). However, there is enough potential space in the LUQ for a clinically significant bleed to accumulate. Early detection of bleeding from a splenic injury is therefore best accomplished with this scan. The LUQ scan is technically more difficult to do because the spleen is: Smaller than the liver, giving you a smaller target to hit. More mobile than the liver, making it possible for fluid to accumulate on either side of it and not just in the splenorenal space.

Also, the splenorenal interface is higher than the hepatorenal interface, so ribs are even more of an obstacle here than on the right. The first two features also make it more likely that bowel (and the hated bowel gas) will intrude.

LUQ Scan

54

LUQ Scan - Normal

Spleen Kidney

Splenorenal Interface Diaphragm

LUQ Scan - Positive

Free Fluid

55

Upper Quadrant Scanning Technique

The exhortation mentioned above, to make your hand movements slo-o-o-o-o-w, is most important here. The heart and the aorta are fairly large targets that are not influenced by the patients respiration. The RUQ and the LUQ offer smaller targets that can move dramatically with inspiration and expiration. It is possible to scan through a fluid collection in the hepatorenal or splenorenal space very quickly and without realizing you have done so. This would lead to the worst possible scan outcome a false negative. Do not go down that road. To ensure that your technique has been adequate, follow these steps every time: 1) Hold the probe in a true longitudinal position. 2) Find the kidney, which has a distinctive double density, by moving the probe in the AP direction. 3) Find the best possible view of the interface, by moving the probe cephalad or caudad. 4) Sweep through the interface, moving anteriorly, until it disappears. Essentially, this means watching the kidney disappear. Whereas the AP search for the kidney and the longitudinal search for the interface and the repositioning of the probe) can be done decisively 5) Now sweep through the entire interface moving posteriorly. You should be able to watch the interface re-appear, and then disappear again. 6) If your move in the longitudinal plane (Step 3, cephalad-caudad) fails to provide an excellent view of the interface, find the best possible view and tilt the probe approximately 30 (cephalad end towards the bed) to avoid the ribs. This should be done as a last-ditch method, as it reduces the apparent size of the target area (dont try to understand why that is the case, for now). 7) Sometimes the ribs are in exactly the worst possible place and you find yourself able to do only part of the scan through a single rib space. It is perfectly acceptable, in this situation, to move the probe to a neighbouring rib space and attempt to complete the scan from there. If you choose to do this, you must ensure that there is significant overlap in the images seen (i.e. 75% of interface seen from one rib space on anterior sweep, and 50% of interface seen from another rib space on posterior sweep).

56

This is what all that looks like in real life (4 videos). First, find the kidney:

Then, define the interface:

57

Angle, if necessary:

Finally, sweep:

58

Abdominal Traps
First, a source of false positives. Perinephric fat (though usually echogenic) can fool you, as it can be just echolucent (i.e. black) enough to look like free fluid. Always compare the two sides. Perinephric fat deposits are often bilateral and roughly symmetrical, so if you are getting the exact same image on both sides, your patient needs a dietician, not a surgeon12. In contradistinction to epicardial fat, there appears to be a more-or-less direct relationship between body habitus and perinephric fat. Second, imitators of free fluid. Ascites, CAPD fluid, fluid from a ruptured ovarian cyst and urine from a ruptured bladder all look identical to free blood. Your history and physical will give you clues as to the presence of the first three13. The last (urine) could give you real problems in the setting of trauma, but only if there was so much urine that it made it look like intra-abdominal hemorrhage had taken place. If the patient had no other injuries, you would then be confronted with a stable patient and a worrisome scan. Fortunately, this is a rare occurrence, and one in which we already know what to do: follow your clinical instincts and ignore the scan. Pursue further work-up (almost always a CT). This will fail to show any intra-abdominal lesion, though it will be positive for free fluid. The patient can then be safely observed and the worrisome image will resolve over time. Intraluminal bowel fluid can also fool you, as it also can look exactly like free fluid. Unlike the other sources of false positives, this is a common occurrence, but fortunately peristalsis and the echogenic bowel wall usually gives this away. Finally, the ones you have to watch out for, the sources of false negatives: 1) Adhesions from prior surgeries can be so extensive that the free fluid will loculate in unknown (and unknowable) locations in the abdomen. Scars on the belly? Never trust a negative in this setting. 2) Delayed presentations. In the unusual event that a patient arrived 12-24 hours after having bled internally, it is possible for the blood to have clotted. This will appear as an echogenic (i.e. grey/white) area that can be missed. Of course, if they are still alive the day after their bleed, they are less likely to need an emergency operation. 3) LUQ variability. Because of the spleens afore-mentioned qualities (smaller, more mobile), LUQ free fluid can sometimes accumulate medial and/or superior (i.e. cephalad) to it and not only in the splenorenal interface. It is therefore important to always image a significant portion of the diaphragm before declaring an LUQ scan to be negative. Although only a few millimetres thick, the diaphragms density and position relative to the beam makes it stand out as a bright echogenic line, generally curving upwards from the 6 oclock position to 9 oclock or better (see page 52).

12

As a rule, obese patients are poor EDE subjects. However, this tends to be less of a problem in the RUQ and LUQ than elsewhere as all but the most obese tend to have much less adipose tissue on their sides than on their front. Stigmata of liver disease, presence of CAPD catheter, history of sudden unilateral pelvic pain.

13

59

Abdominal Tricks
A few tips to get the most out of your upper quadrant scans. 1) Make sure you start your scan in a true longitudinal plane and at maximum depth. This greatly facilitates proper orientation. 2) Placing the patient in 5-10 of Trendelenburg position for 15-20 minutes can help deliver free fluid to the RUQ and LUQ. This manoeuvre can decrease by one third the amount of free fluid needed for the ED sonographer to be able to detect it. 3) If the patient is stable enough, they can assist you by holding their breath, either at end-expiration or end-inspiration. The interface moves with respiration (which changes its position relative to the ribs) and can often be seen better at one end or the other of the respiratory cycle. 4) As mentioned before: When in doubt, Rescan. This is extremely important in the abdominal trauma scans where, contrary to all other areas interrogated with EDE, the pathology is often not apparent when the patient first arrives in the ED due to the quantity of free fluid necessary to produce a positive image. Patients who will not be CT scanned should, at a minimum, receive a second EDE before discharge. Fortunately, the ease of EDE makes this a simple thing to do.

Abdominal Free Fluid Video

60

Sample ultrasound screen #5

The screen is still grey, eh? Oh well, youve gotten this far, might as well read the last chapter

61

Pelvis
Several centres consider the RUQ/LUQ scans to be sufficient to rule out significant intraabdominal hemorrhage. The scan of the pelvis is advocated because: 1) Although not as easy as the UQ scans, it is not very technically difficult to do. 2) It can detect minor bleeds more quickly, particularly if they originate in the pelvic area. The pelvic scan aims to visualize the rectovesicular pouch in men and the rectouterine pouch (aka Pouch of Douglas) in women. A single transverse view immediately above the symphysis pubis (starting at 0 and angling 30 caudally) is sufficient.

First, place the probe transversely

then sweep to 30 caudad.

The pelvic view can be quite frustrating, until you realize that radiologists fill the bladder to look there, so you can too. If the patient has no contraindications to the placement of a urinary catheter14 then you can go ahead and instill 250 cc of NS into the bladder and clamp the catheter. This gives you a perfect acoustic window through which to peer deep into the pelvis. The bladder will appear as a black mass at the top of the screen. Anything else black should be cause for concern. You will recall that, when looking for the pericardium (a white structure) you were told to increase the gain. Here in the pelvis, you are looking for free fluid (small black structures), so it is wise to decrease the gain. This is particularly true since you are scanning through a full bladder, as there is likely to be considerable enhancement (see Artifact).

14

High riding or absent prostate, blood at the meatus, scrotal hematoma, perineal ecchymoses, or an unstable pelvic fracture.

62 You should be aware that there are a couple of sex-specific false positives in the pelvis. 1) Women often have small amounts of physiologic fluid in the rectouterine pouch. 2) The prostate can be quite hypoechoic (i.e. black). If in doubt, confirm that what you are looking at is the prostate by having someone do a simultaneous rectal exam. Ask them to push on the prostate and if the area you are wondering about moves, its the prostate. Note that if you are unable to fill the bladder, it is not worthwhile to attempt a pelvic EDE.

Normal Pelvis (Female)

Bladder

Uterus
Whats this? (hint: key Aortic EDE feature)

63

Normal Female Pelvis Video

Normal Male Pelvis Video

64

Free Fluid in Pelvis

Male Bladder Free Fluid

Free Fluid

Free Fluid

Rectum
Remember that the rectum is retroperitoneal in males, so fluid can ONLY appear anterior to the rectum in the Mickey Mouse Ears.

Female Bladder Free Fluid Free Fluid Free Fluid

Free Fluid

Uterus

Free Fluid

The uterus is free-floating in the pelvis, so free fluid can appear in BOTH Mickeys ears as well as around his Bow Tie (the pouch of Douglas).

65

Obstetrical EDE
Introduction
Obstetrical EDE differs from all the other indications previously discussed because it seeks to rule-in a benign condition - intrauterine pregnancy (IUP) - rather than rule-out a malignant one ectopic pregnancy15. By its very presence, an IUP dramatically decreases the probability of ectopic pregnancy. While the detection of ectopic pregnancy by ultrasound is quite difficult, the detection of an IUP is quite straightforward, making it an appropriate goal for EDE. The diagnosis of ectopic pregnancy is one that, as emergency physicians, we would like to make more accurately. Current data suggests that over 40% of women with this condition are misdiagnosed at first contact. You will recall how previous chapters have stressed the primacy of clinical skills and their superiority over labs and imaging. Ectopic pregnancy is the exception to this rule. We all know how unreliable history is for date of LMP and pregnancy symptoms, and the classic triad of delayed menses, vaginal bleeding and pain is incomplete in up to a quarter of ectopic pregnancies. As for physical exam the most skilful gynecologists are unable to detect more than half of ectopic pregnancy masses on physical exam, even under general anaesthesia16. Luckily, in this area where our primary tools are unreliable, we have a lab test - -HCG that is extraordinarily sensitive and specific, and an imaging modality - EDE - that is readily available and highly accurate.

15

The word malignant is particularly apt here. Ectopic pregnancy remains the second-leading cause of maternal death (after hemorrhage), accounting for 10% of all such mortality. In fact, when an adnexal mass is felt, it is often the corpus luteum of pregnancy. Not infrequently, this mass is not on the same side as the ectopic.

16

66

Ectopic Pregnancy General Approach and Epidemiology

A good rule to follow in Emergency Medicine is to assume that every premenopausal woman who comes to your department with a pelvic or abdominal complaint has an ectopic pregnancy until proven otherwise. The -HCG will rule this out in most cases. For the remainder who have a positive -HCG, obstetrical EDE can greatly improve our diagnostic accuracy and accelerate disposition by detecting the presence of an IUP. While the rate of ectopic pregnancy for all comers is around 1 in 80, the rate of heterotopic pregnancy (a twin gestation where one embryo is in the uterus and the other one is elsewhere) is 1 in 30,00017. By detecting an IUP, therefore, the risk of ectopic pregnancy is vastly reduced. Risk factors for ectopic pregnancy are summarized at the end of this chapter.

Anatomical Approach
There are two anatomical approaches by which Obstetrical EDE can be performed: transabdominal (TA) and transvaginal (TV). TA Obstetrical EDE is done with the same 3.5 MHz probe as for the other indications we have seen. The bladder must be full for this scan to be performed, which can be inconvenient (and uncomfortable!). As well, the advantage of the TA approach - easier spatial orientation of the uterus relative to the adnexae - is negated in EDE because we are looking exclusively at the uterine contents (the adnexae are of no interest in Obstetrical EDE). The TV probe allows for earlier detection of an IUP, which can represent a significant clinical advantage. As well, it is performed with the bladder empty. On the other hand, a TV probe will add roughly $10,000 to the purchase price of your EDE machine. In these days of political correctness, it is worth mentioning that when women who have been scanned via both approaches are asked which one they preferred, the responses are overwhelmingly in favour of the TV approach. Modesty seems to go out the window when someone is pushing on an overfilled bladder.

It is worth noting that both these numbers are trending downwards as chlamydia and fertility treatments become more widespread. In some areas with endemic chlamydia, the heterotopic rate is already 1:4,000. For women who have undergone some kind of fertility enhancement (e.g. clomiphene, IVF), the heterotopic rate can be as high as 1%.

17

67

Transabdominal Obstetrical EDE

Proper visualisation of the uterus by TA EDE requires the acoustic window provided by the full bladder. This can be accomplished by the IV or Foley route, depending on the urgency of the situation18. Begin the scan as per the pelvis in trauma: place the probe in the transverse plane immediately superior (cephalad) to the symphysis pubis and scan from true transverse to 30 caudal (see illustration in Pelvis section of Abdominal chapter). The scan is then continued by placing the probe in the midline longitudinally and sweeping from 45 left to 45 right. Note that the longitudinal sweep will sometimes have to be done with 10-20 of caudal angulation. Although the textbooks tell you that the uterus is a pelvic organ until 12 weeks gestation, the uterus is so mobile that it can be found almost anywhere.

Transabdominal Longitudinal View

In the longitudinal view the uterus will look like an elongated pear, while on the transverse view it will look like a circle. It is a homogenous structure that, in terms of echogenicity, resembles the liver and the spleen. In both cases, it should appear below the bladder (the black structure which is at the top of the screen). Note that the degree of anteflexion or retroflexion of the uterus can dramatically alter the plane in which the organ lies.

18

The bladder can also be filled by the PO route, but this is not the wisest course of action if ectopic pregnancy, and therefore surgery, is a possibility. Better to keep the patient NPO until you are certain they will not need to be anesthetized.

68

Longitudinal View

Bladder Uterus

Uterus in usual position

Uterus in extreme anteflexion

Transverse View Bladder Uterus

Note that, regardless of the view, it is essential to identify the bladder with certainty before making any decisions about the uterine contents. Many novices have been fooled by the urine-filled bladder masquerading as something else.

69

The Endometrial Stripe

In the centre of the non-gravid uterus is the endometrial stripe, which shows up as an echogenic (white) line. Although sometimes poorly appreciated, this structure is the Area of Interest and should be visualized in its entirety, from left to right in the longitudinal view and from the cervix to the fundus in the transverse view, because this is where an IUP will appear.

Longitudinal View

Transverse View

Endometrial Stripe

Centering the Area of Interest

Remember that in the longitudinal view, the left side of the screen corresponds to the cephalic direction on the patient while, in the transverse view, the left side of the screen corresponds to the right side of the patient. Centering the Area of Interest, therefore, is done in the same manner as we have seen in the transverse and longitudinal planes in the abdomen: In the Longitudinal view To move the Area of Interest to the right, move the probe cephalad. To move the Area of Interest to the left, move the probe caudad.

In the Transverse view To move the Area of Interest to the right, move the probe to the patients right. To move the Area of Interest to the left, move the probe to the patients left.

70

Transabdominal approach Transverse View (Video)

Transabdominal approach Longitudinal View (Video)

71

Transvaginal Obstetrical EDE

Transvaginal EDE is performed with a special probe. Properly called an endocavitary probe19, this device will be of a higher frequency than the standard EDE probe, usually 5.0-7.5 MHz. You will recall that as frequency increases, penetration decreases. This is not a problem, as the endocavitary probe can be placed directly against the structure of interest. No resistance problems, no need for acoustic windows. The higher frequency therefore provides greater axial resolution at no real cost in terms of penetration.

An Endocavitary Probe

In exact contradistinction to TA EDE, the patient must first void or have her bladder emptied by catheterisation. Optimally, the patient is then placed in stirrups in a proper obstetrical stretcher. Alternately, a pelvic pillow may be acquired.

A Pelvic Pillow

If neither of the above options is available, or if patient instability precludes movement to the GYN room, an adequate McGiver20 is to place pillows or an upside down bedpan under the patients hips. This is essential, as it will be difficult, if not impossible, to perform the scan without dropping the handle of the probe beneath the level of the patient.
19

The same probe is also used for transrectal U/S, mostly to image the prostate.

20

For those of you without a thorough grounding in popular North American culture, a McGiver is an ingenious improvised solution using common materials readily at hand. From the eponymous television show of the same name.

72

Preparing the probe

The next step is to prepare the probe, with an eye to a) patient safety and b) making sure the U/S waves get to where they need to go (optimising acoustic transmission in ultrasound lingo). First, apply a layer of ultrasound gel to the probe. Then cover the probe with a latex condom (if the patient is not allergic). The condom is then securely fastened to the probe by use of an elastic or a built-in retaining bar. Particular care must be taken immediately after the condom has been placed over the gel to ensure that no small air bubbles have been trapped. If any are seen, they should be gently pushed off to the side as air will distort the passage of the U/S waves, leaving part of the screen black. Finally, it has been reported that a small number of women find the ultrasound gel irritating to the vaginal mucosa and that infection transmission via ultrasound gel is possible. It is therefore recommended that the outer layer of gel be Muko or some other kind of lubricant intended for internal exams. So:

Goo

Condom

Muko.

Transvaginal EDE Contraindication

The only contraindication to TV EDE is recent gynecological surgery, a rather rare occurrence in the first trimester.

73

Transvaginal EDE - Technique

As with all other probes, an endocavitary probe will have a tactile reference mark to enable the user to orient the instrument in the dark.

Endocavitary Probe Reference Mark

The scan is begun by placing the probe with the reference mark towards the ceiling and inserting it 4-5 cm into the vagina21. This places the probe in a true sagittal orientation (body divided into left and right mirror images). As with TA EDE, the endometrial stripe is the key Area of Interest. Once it has been identified, a slo-o-o-o-ow sweep is performed to the left until the beam passes entirely out of the uterus. The scan is then repeated to the right, again until the uterus disappears. The probe is then brought back to center and turned 90 CCW. This places the probe in a true coronal plane, dividing the body into anterior and posterior halves. The same procedure is repeated the probe is swept anteriorly and posteriorly until the uterus disappears, always passing through (and returning to) the endometrial stripe. Although the uterus looks roughly the same in either view, the coronal image is more consistently circular (mimicking the image seen in the transabdominal transverse view) while the sagittal image is roughly oval or pear-shaped (like the longitudinal transabdominal). Compare page 66 to page 70.

21

Some women, particularly if they have had TV U/S before, may prefer to insert the probe themselves.

74

Transvaginal Approach - Sagittal View Bladder Cervix

Fundus

Endometrial Stripe

Transvaginal Approach - Coronal View

Uterus

Endometrial Stripe

As mentioned earlier, it is important to locate and identify the bladder to ensure that it is not confused with the gestational sac. The bladder will appear at the top left of the screen in the sagittal view and across the entire top of the screen in the coronal view. Note that, in either view, one locates the bladder (if not immediately seen) by moving the probe handle down. For now, dont worry about why this always works. Just accept that it does.

75

Transvaginal EDE- Spatial Orientation

Spatial orientation is more difficult in TV EDE than anywhere else in this course. The diagrams on the next four pages will take you through the basic concepts, but it takes a while to really integrate this. Dont panic! You dont actually need to understand this to do TV EDE, but you may want to come back and read this section in a year or so to make more sense of what you are seeing. Remember that the probe head will be placed directly against the uterus, which will therefore appear as a near-field structure.

The probe head is placed against the cervix Probe Head Uterus

Patients Feet

Patients Head therefore it follows that

near field is always caudad

while far-field is cephalad.

But this is far from obvious when you try to picture where the structures lie in the pelvis!

76

Orientation of the beam

If you were to look into the vagina (along the probe), you would see:

Probe in Sagittal View Patient Anterior Probe Head

P L A N E O F

Patient Right Sweep Left Uterus

Patient Left Sweep Right

B E A M

Patient Posterior

Probe in Coronal View Patient Anterior Probe Head

Sweep PLANE Sweep

Anterior OF BEAM Posterior Patient Left

Patient Right

Patient Posterior

77

Transvaginal EDE - Probe Manipulation

Dont be dismayed if the diagrams on the preceding pages leave you scratching your head. Remember that with EDE complicated things either dont matter or can be circumvented. In this case, it will suffice (at first) to get the uterus on the screen and then to center the Area of Interest. The instructions below are meant to simplify things by telling you how to move the probe to center the image on the screen. Note that the movements refer to the direction you move the probe handle. The probe head, therefore, will move in the opposite direction inside the patients vagina. Lets try to see how this works. You know, from the illustration on the preceding page, that the beam in the sagittal view runs anterior-posterior. You also know that the probe reference mark is pointed up, or towards the anterior side and that, by convention, the probe marker appears on the left of the screen. So, if you want to move an Area of Interest more to the right of the screen, thusly:

Area of Interest

Direction of Desired Movement (to Center)

You would have to move the beam anteriorly. The probe head, therefore, has to move up. This can only be done by dropping the probe handle. In the coronal view, you can see that the plane of the beam runs left-to-right. Also, you know that the probe marker is oriented towards the patients right side, which will be the side which appears on the left of the screen (think of the coronal view as a transverse view, lying completely flat). It follows, then, that to move an Area of Interest more towards the right of the screen, you would have to move the beam more towards the right of the patient. The only way to do this is to move the probe handle towards your right, which will move the head of the probe (and thus the beam) towards the patients right.

78 This concept gives a lot of people a hard time. It might be better if, for now, you just memorize the following directions:

In the Sagittal view

The beam divides the body into two symmetrical halves, left and right. The scan is done by sweeping to one side and then to the other.

To move an Area of Interest to the right, move the probe handle down. To move an Area of Interest to the left, move the probe handle up. Sweeping is done Left to Right

Note: The uterus is NOT always in the midline. In fact, it can be quite far off to one side.
As well, it can be quite retroverted in some patients. If your first left-to-right sweep (performed after you have brought the bladder onto the screen) fails to detect uterine tissue, raise the probe handle a bit and repeat the sweep. Still cant see the uterus? Raise the probe a bit more, sweep again. Continue till you find the uterus. Sometimes, it feels as if you are pointing the probe almost straight down before you find it. And dont be surprised if the uterus appears off the midline!

In the Coronal view

The beam divides the body into anterior and posterior halves. The scan is done by sweeping anteriorly and posteriorly.

To move an Area of Interest to the right, move the probe handle to your right. To move an Area of Interest to the left, move the probe handle to your left. Sweeping is done Anterior-Posterior

Note: The uterus is NOT always in the midline. In fact, it can be quite far off to one side.
As well, it can be quite retroverted in some patients (sound familiar?). If your first anteriorposterior sweep (performed after you have brought the bladder onto the screen) fails to detect uterine tissue, move the probe handle a bit to one side and repeat the sweep. Still cant see the uterus? Move the probe a bit more, sweep again. When your hand touches the patients thigh, repeat the process on the other side. Continue till you find the uterus. Sometimes, it feels as if you are pointing the probe almost completely to one side before you find it. And dont be surprised if the uterus appears off the midline!

79 Even with all those explanations, the above probably still seems quite confusing. Hopefully, the two videos below will clarify things somewhat.

Transvaginal Sagittal View

Transvaginal Coronal View

80

Diagnosing an IUP
The aim of this exercise, whether in TA or TV, is to follow the endometrial stripe along its entire course, looking for evidence of pregnancy. Because of the potentially devastating consequences of a false negative in this setting, the criteria for diagnosing pregnancy by EDE are quite strict. No fewer than three structures must be identified:

1) Decidual reaction
Around the 14th post-fertilisation day, the endometrium begins to undergo the decidual reaction. This will lead to the formation of a strongly echogenic (white) lining22.

2) Gestational sac
What we are looking for is an anechoic (black) area contained in the decidual reaction. This is the growing pocket of amniotic fluid wherein the fetus will reside. Unfortunately, some sources use the term gestational sac when they are really referring to the amnion, which leads to no end of confusion. The amnion is a thin echogenic sac contained in the gestational sac (see illustration on pg. 77). It divides the gestational sac into two cavities the amniotic and the chorionic - and fuses with the deciduas between the 12th and 14th week. While it is possible to visualize it as a separate structure until that point, in reality this is a) quite difficult and b) not clinically useful. If you see fluid (black) inside the uterus, proceed with your EDE.

The real challenge of Obstetrical EDE is to detect the 3) Yolk sac

This is another thick echogenic layer found within the gestational sac, but almost always much smaller than said sac. The double ring sign of the yolk sac within the gestational sac is the earliest sign of a definitive IUP. It becomes visible when the gestational sac is 10 mm by TV and 20 mm by TA. It can be detected as early as 5 weeks gestation by TV EDE and 6-7 weeks gestation by TA EDE.

Therefore, to confirm the presence of an IUP, you must visualize: a strongly echogenic layer, which is white (the decidual reaction), within which you find a black area (the gestational sac), in which you must find another white layer (the yolk sac)

These three structures form the double ring sign.

The decidua is made up of the decidua capsularis and the decidua vera, which can form separate echogenic layers, sometimes partially separated by a further layer of fluid. Regrettably, this is sometimes referred to as a double decidual reaction which is often confused with the double ring sign. Examples of both are provided further.

22

81 With the above findings confirmed, the probability of ectopic pregnancy is greatly reduced, as detailed in Epidemiology. The EDE is documented in the chart as an intrauterine pregnancy (IUP). Any other result is documented as No definitive intrauterine pregnancy (NDIUP) and the work-up proceeds as detailed in the algorithm at the end of this chapter.

Fetal Pole
Embryologically, the fetal pole begins to develop roughly at the same time as the yolk sac. Realistically, EDE can only pick it up approximately one week later (i.e. at six weeks gestation for TV and seven to eight weeks for TA). While not essential to the diagnosis of an IUP, it is useful to know that fetal cardiac activity should always be detectable if the fetal pole exceeds 5 mm by TV or 10 mm by TA. Absence of cardiac activity beyond this length is likely to result in a miscarriage. Obviously, the presence of a fetal pole trumps the aforementioned three criteria and confirms the presence of an IUP beyond any doubt.

Fetal Cardiac Activity

Proof positive of a live IUP (LIUP), but harder to detect. It can be reliably detected from approximately the sixth week onwards by TV EDE, and roughly a week or two later by TA EDE. The heart rate must be above 100 to be consistent with good fetal outcome. Cardiac activity must never be tested by Doppler (possible risk of later malformation) but can be tested by M (Movement) mode. Make sure the rhythmic activity you are watching is within the gestational sac. It is surprisingly easy to be fooled by blood vessels coursing through the highly vascular decidual reaction. Dont call something fetal cardiac activity unless it is well away from the uterine wall. If fetal cardiac activity is detected, the probability of miscarriage falls dramatically. Towards the end of the first trimester this may be as low as 2%, though it is obviously higher earlier. The important point here is that the detection of an LIUP ends our workup of these patients. Ectopic has been ruled out (unless there was compelling evidence in favour of a heterotopic ectopic) and miscarriage is unlikely. The patient should still be given advice to return if bleeding persists or increases but, barring this eventuality, she can be followed by her primary-care physician. Be that as it may, always bear in mind that the fact that an IUP is actually an LIUP (Live IUP) falls into the nice-to-know category, rather than need-to-know. Even an IUP which is determined to have expired reduces the risk of ectopic pregnancy to 1:30,000 (the risk of heterotopic ectopic pregnancy).

82

Normal IUP

Decidual Reaction

Gestational Sac*

Amniotic Cavity Fetal pole

Amnion (often not seen)

Chorionic Cavity Yolk sac

IUP Double Ring Sign

* The gestational sac is made up of the chorionic cavity and the amniotic cavity. As mentioned above, it is common to be unable to visualize the amnion. The yolk sac is found in the chorionic cavity and is obliterated after the twelfth week, when the above-mentioned amnion fuses with the chorion (the inner lining of the decidual reaction).

83

IUP Double Ring Sign

Decidual Reaction

Gestational Sac

Yolk Sac

IUP Fetal Pole

Rump Crown

84

NDIUP - Double Decidual Sac, NO Yolk Sac

D. Vera

D. Capsularis

IUP Fetal Pole, Yolk Sac, and Amnion

Yolk Sac Crown

Rump Amnion

85

IUP Video 1

IUP Video 2

86

Sources of Error
A dangerous error in obstetrical EDE would be to conclude that an empty gestational sac within a decidual reaction represents an early pregnancy. While this is certainly possible, it is also found in ectopic pregnancy, where it is termed the pseudogestational sac. Provoked by the natural increase in pregnancy hormones that accompanies the growth of the ectopic pregnancy, the pseudogestational sac is identical to the gestational sac but it contains no yolk sac. It can be tempting, especially early in pregnancy with a stable patient, to assume that the yolk sac is merely poorly seen. Statistically, you are likely to be right. But this is like playing Russian Roulette. When things do go wrong, the result can be catastrophic. Unless all three criteria are present, the patient must be referred for a formal ultrasound at the earliest opportunity. An uncommon but far more dangerous source of error is the visible extrauterine pregnancy, sometimes complete with fetal cardiac activity. For the experienced EDE practitioner, these can often be identified by their off-center position. For the novice, the key skill to develop is the ability to recognize uterine tissue. The Obstetrical EDE is then performed with the goal of finding the white endometrial stripe more or less in the centre of the uterus. This will prevent the beginners eye from being drawn to the ectopic which, being mostly fluid, will be black.

Extrauterine Pregnancy (TV Sag view)

Pseudogestational Sac Bladder Fetal Pole

Ectopic Mass Uterus

Be VERY careful with an image like this one. It almost looks like there are two uteri, and the one on the right has a fetal pole (with, in this case, a beating fetal heart). Obviously, it could be disastrous to call this an IUP. Learn to recognize uterine tissue! The structure to the left is more homogenous and it is next to the bladder where the uterus should be. The other structure, though it certainly draws the eye (particularly with a heart beat inside it) is in the wrong place and just doesnt look right.

87

Extrauterine Pregnancy Video

88 The best way to ensure that you are looking at uterine tissue is to confirm that the uterus and the bladder are found right next to each other. This is often easier to ascertain by the transabdominal approach since spatial relationships are easier to determine in this view than they are transvaginally. The recommended practice, therefore, is to scan the uterus transabdominally first, to ensure that there are no other uterine-like masses (solid-organ tissue density) in the pelvis, as in the image on the previous page. If an IUP is clearly seen, you can stop there. If not, proceed with the TV scan. A common scenario has the operator seeing what appears to be an intrauterine gestational sac on TA EDE, but being unable to tell if it contains a yolk sac or a fetal heart. In these cases, it is wise to measure the gestational sac seen on TA and compare it to the size seen on TV. Obviously, these should be identical.

Confirming IUP on TV

89

The Empty Uterus

In the case of the unstable patient, the finding of an empty uterus (normal endometrial stripe) in a patient with a positive -HCG completes the workup. The patient must go directly to the OR, the diagnosis of ectopic pregnancy being essentially confirmed. An abdominal EDE can be performed to detect the presence of free fluid in the abdomen, which would make the presumptive diagnosis even more likely. If the patient is stable, an abdominal EDE should again be performed to look for free fluid. If the abdominal EDE is positive, gynecological consultation should be obtained promptly. If there is no intra-abdominal free fluid, obtain a formal ultrasound within the next several hours (waiting from 0100 till morning, say, would be acceptable) to attempt to identify the location of the pregnancy. However, one must realize that the most common formal ultrasound report in the setting of ectopic pregnancy, even when done by experienced U/S techs using expensive machines is uterus empty, normal adnexae. But whatever the result, gynecological consultation should be obtained, so that close follow-up (or possibly immediate medical management with methotrexate) can be organized.

90

Other Possibilities
Abortion: If the abortion is incomplete, virtually anything can be seen on the screen, ranging from debris remnants all the way to a normal-looking embryo whose cardiac activity is undetectable. This is a good time to re-emphasize the importance of your clinical skills the sine qua non of incomplete abortion is the open os, confirmed on speculum exam. If you find this, the diagnosis of incomplete abortion can be made with confidence23. The presence of abnormal uterine contents on EDE merely confirms the diagnosis. A complete abortion (total evacuation of the uterine contents) has the same sonographic appearance as an ectopic pregnancy (empty uterus), a positive -HCG and, if enough time had passed, a closed os. The patient would obviously be stable in this case, leaving the diagnosis to be confirmed by a formal U/S and serial quantitative -HCG testing. If the history is strongly suggestive of this diagnosis24, these tests can safely be delayed 24-48 hours. Blighted Ovum: In these cases, the -HCG level can be extremely high (i.e. at a level where uterine contents would certainly be visualized) and yet there is nothing to be seen in the gestational sac. A blighted ovum, therefore, gives you the same image as a pseudogestational sac, but the sac is much bigger. The length of the gestational sac is the key element which will enable you to differentiate between these two entities. If it is over 20 mm without a yolk sac visible a blighted ovum should be suspected. If it is over 25 mm without a yolk sac visible a blighted ovum is virtually certain. While this diagnosis should be confirmed by a formal within 1-2 days, the finding of such a large (>25 mm) gestational sac eliminates the diagnosis of ectopic as effectively as any other IUP.

Molar pregnancies: A molar pregnancy (or hydatidiform mole) is a grossly abnormal pregnancy. Bizarrely, the ultrasonographic appearance has traditionally been described as a snowstorm, which is completely misleading. A molar pregnancy is actually a mass of small cysts. What you see on U/S is a fairly homogenous mass inside the uterus full of small, fluid-filled (black) holes. To my eye, this looks more like an anthill in cross-section, or possibly a cut through a particularly holy piece of Swiss cheese. Remember that patients with molar pregnancies will present with: Astronomical -HCG levels, Hyperemesis and signs of hyperthyroidism (caused by the -HCG), A uterus which is larger than expected, and Anemia.

As well, it is extremely rare for a normal pregnancy to co-exist with a mole. There should therefore not be any detectable fetal cardiac activity.
23

An ectopic pregnancy will present with bleeding and abnormal uterine contents but almost never an open os. Bleeding before pain, significant bleeding now tapering off and passage of tissue.

24

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NDIUP no yolk sac (Early IUP or Ectopic)

Gestational Sac (?Pseudogestational)

Abnormal gestational sac

Bladder

Gestational Sac

This gestational sac is over 35 mm in diameter, yet no yolk sac is visible. This almost certainly represents a blighted ovum.

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Role of Quantitative -HCG Testing

The role of quantitative -HCG testing is often misunderstood. It is generally recognized that it will be impossible to see an IUP if the -HCG level is below 1500 mIU/ml by the TV approach or below 3000 mIU/ml by the TA approach. However, it does NOT follow that EDE should be deferred until such time as the -HCG level reaches these thresholds. ANY positive -HCG combined with a finding of NDIUP on EDE should be treated as an ectopic - stat referral to Ob/Gyn if unstable, formal ultrasound at the earliest opportunity if stable. Having identified NDIUP (again, assuming the patient is stable), it is useful to do a quantitative -HCG while awaiting the formal to allow the Ob/Gyn to better interpret the results, once a second test is done. When you begin to do EDE you will quickly realize just how variable those ranges for HCG values can be. The numbers listed above (1500 and 3000) are an inferior limit, below which you cannot see an IUP. It does not follow that beyond those numbers you must see an IUP. Rather, these are the thresholds at which it becomes possible.

Measuring Crown-Rump Length

While not one of the formal objectives of EDE, measuring crown-rump length (CRL the distance from the top of the skull to the base of the pelvis) can enable you to prognosticate more accurately: a CRL of greater than 5 mm without a visible fetal heart is unlikely to proceed to viability. Most U/S machines with transvaginal capability allow the physician to automatically convert CRL into gestational age. However, this is of no clinical interest to EDE, other than as a friendly service to our patients. This can be tricky to do, though, and should not be attempted until one has gained considerable facility with the technique.

One Last Little Hint

As good as transvaginal scanning is, it is always a good idea to take a quick look transabdominally first. This will help you to correctly identify the uterus (as described on page 81) and will protect you from those patients who are wildly off the mark with regards to their LMP. Towards the end of the first trimester, the uterus exits the pelvis and an IUP can actually be out of range of the TV probe. Scanning transvaginally at this point will give the operator the impression that the uterus is empty, since only the most caudal part of the uterus is seen. There is no danger in this error, as it forces the operator to obtain a formal study. But there is nothing more embarrassing than having a radiologist inform you that they have found a 10-week pregnancy, which is extremely easy to see via the transabdominal route, where you saw nothing because you looked only transvaginally. There is no need to do this with a full bladder. Beyond 8-9 weeks, the uterus has grown so much that it provides its own acoustic window by pushing the bowel out of the way itself.

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Obstetrical EDE Algorithm

Woman of childbearing age presents with any one of: Pelvic pain Abdominal pain Vaginal bleeding
-HCG at triage (QUAL) POS.

Unexplained hypotension
NEG.

Ectopic excluded

Hx/Px
Appropriate stat workup or resuscitation

All 3 Criteria?

EDE
2 Criteria or fewer?

IUP
Ectopic excluded

NDIUP
Unstable Stable

Stat Ob/Gyn Crossmatch 4U PRBC Continue resuscitation Await O.R.

Free Fluid!

Abdominal EDE Neg. Quant -HCG Obtain Formal Consult Ob/Gyn (after Formal)

Urgent OB/Gyn Crossmatch 2U PRBC Request Formal

Note: it is not necessary for the patient to c/o delayed menses.

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Risk Factors for Ectopic Pregnancy

Ectopic? Think PID (PID is single greatest risk factor) Endometriosis Tumour PID (sevenfold increased risk) Previous ectopic Previous pelvic surgery Previous induced abortions Infertility DES exposure in utero

Note: IUDs do not increase the risk of ectopic per se. However, should a woman become pregnant with an IUD in place, the probability that the pregnancy is ectopic is much higher than it would otherwise be. This is because the IUD effectively reduces the probability of intrauterine pregnancy, but not of extrauterine events.

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Further Reading
Ultrasound in Emergency and Ambulatory Medicine, by Barry Simon and Eric Snoey Emergency Ultrasound, by John Ma and James Mateer Ultrasound in Emergency Medicine, by Michael Heller and Dietrich Jehle

The editors of these texts (and their chapter contributors) are Emergency Physicians, and it shows. Their approach, while detailed enough to keep you going in ED ultrasound for years, is still focused on the non-radiologist. The works are well-written and copiously illustrated. The descriptions of more advanced applications are clear and concise, making them easily accessible. For those of you with a hard-science bent, you can even read all about the piezoelectric effect25! For those who prefer original articles, an extensive review of the literature is available on the web site of the Canadian Emergency Ultrasound Society at www.ceus.ca.

25

If you do, give me call and explain it to me!

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Maintenance
The Emergency Department is a hostile environment for an EDE machine. Rather than being ensconced in a dark corner of the radiology department from whence it shall never budge, the EDE machine is constantly being moved around, sometimes at a high rate of speed. When one then considers the physical layout of the Emergency Department, with all its angles, turns, nooks and crannies as well as the sharp edges one finds along stretchers, crash carts and other resuscitation-area paraphernalia, it is not surprising that EDE machines quickly acquire a goodly number of battle scars. There is little one can do to minimize this other than to urge all Emergency Department personnel to be as cautious as possible when driving the EDE machine around. The most important aspect of maintenance is preventative. It must be clearly understood that 99% of the cost of each probe lies in the crystals directly behind the plastic head cover. When probes are dropped they invariably fall head first into the ground. The clear ping that you hear when the probe hits the ground is the sound of those crystals shattering and of ten thousand dollars flying out the window. It must be an absolute rule that a probe is never left unattended. It must be in its holster or in someones hand26 at all times. Maintenance of the actual probes is quite straightforward. In spite of this, it is remarkable how many emergency departments EDE probes are in a rather shabby state. The ultrasound gel, while not particularly corrosive, certainly can gum up the works if not cleaned off promptly. After each patient contact the gel should be wiped off with a soft, smooth cloth (the corner of the patients bed sheet does very nicely). After this the probe must be cleansed with a non-corrosive disinfectant. Alcohol and other corrosive substances should be avoided, as they will gradually erode the delicate covering at the probe head.

26

Not the patients!

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Quality Assurance
To encourage the implementation of high standards for the use of ED Ultrasound, the Canadian Emergency Ultrasound Society (CEUS) was formed in 2002. Founded by emergency physicians who were heavily involved in teaching this technique, the Society now has several hundred members, as well as the support of specialists in all fields touched by ED Ultrasound. All graduates of the EDE course are urged to visit the Societys website at www.ceus.ca. A detailed explanation of the Societys position is provided, as well as other resources such as a literature review, information on courses, pertinent bulletins and an email-based discussion group. All interested parties are encouraged to join. Its free, and it demonstrates that ED Ultrasound has the support of the EM community. More importantly, it also shows support for the Societys exacting standards.

CEUS Executive
Dr. Michel Garner (Emergency Physician, Qubec) Qubec Representative Dr. Claude Gervais (Pediatrician, Quebec) Secretary-Treasurer Dr. Ben Ho (Emergency Physician, British Columbia) Literature and Standards Dr. Louise Rang (Emergentologist, Ontario) Advanced Applications Dr. Harold Shim (Emergency Physician, British Columbia) Pedagogy Dr. Ray Wiss, (Emergency Physician, Ontario) Public Relations

CEUS Advisory Board

Dr. Ron Baigrie (Cardiologist, Ontario) Dr. Rob Chen, (Anaesthetist-Intensivist, Ontario) Dr. ric Dupras (Vascular Surgeon, Qubec) Dr. Dave Easton (Emergentologist/Intensivist, Manitoba) Dr. John Fenton (Vascular Surgeon, Ontario) Dr. Pascale Gaudet (Ob/Gyn, Qubec) Dr. Roxanne Righi (Ob/Gyn, Ontario) Dr. Peter Ross, (Emergency Physician, New Brusnwick) Dr. John Snider (General Surgeon, Ontario) Dr. Claude Topping (Emergency Physician, Qubec) LCol Carl Walker, Division Surgeon, Canadian Forces

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Conclusion
Emergency Department Echo seeks to rule-in or rule-out conditions which can have an immediate impact on patient survival: non-cardiogenic shock, pericardial tamponade, intra-abdominal hemorrhage, ruptured abdominal aortic aneurysm and ectopic pregnancy. But the impact of EDE is not limited to those cases where it helps to make a life threatening diagnosis in seconds and leads to a dramatic, life-saving change in management. There are also the far more numerous times when it is able to reassure the clinician that such a condition does not exist. This is where EDEs impact is most significant: the ability to rule out significant pathology and, by doing so, enhance patient safety while reducing the stress involved in dealing with such cases. It is the essentially perfect availability of EDE which allows this situation to occur. We no longer have to seek approval for our studies, nor wait for the arrival of the operator. This dramatically drops the threshold at which one obtains an ultrasound study. Used correctly, EDE should become an extension of your physical exam. If EDE is to be a success in this country, we must use it as it was intended. Our scope of practice must remain limited, for now, to those things that we can do well: the five key indications. We must also commit ourselves to having 100% sensitivity NO FALSE NEGATIVES! We must also remember that we remain clinicians first and foremost. EDE is just an image, and must never be allowed to replace our clinical skills. History beats physical, history and physical beats labs and imaging. This has always been the case and all of our modern technology, including EDE, has not changed this. Never let EDE make a diagnosis for you. Always integrate the image you have generated into your diagnostic algorithm. If your index of suspicion is high and your EDE image is negative trust your instincts. Soon, EDE will be broadly recognized by the Canadian medical community as an important addition to the practice of Emergency Medicine, both for its dramatic pick-ups and for its safe (no false negatives!) use. It is likely that, if EDE is properly managed, we will follow in the footsteps our American cousins and see (in 3 to 5 years) the introduction of a wider scope of practice for this modality. This will most likely include renal ultrasound for obstructive hydronephrosis, hepatic ultrasound for gall bladder disease and, with the purchase of a 10-megahertz probe, near surface ultrasound for the detection of foreign bodies, vascular access and DVT. Lets plan on getting together towards the end of the decade for EDE 2! The day is not far when EDE will be considered as essential a part of the Emergency Physicians armamentarium as his stethoscope. On that day, the goal of this course will have been accomplished.

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The 10 Commandments of

EDE
1) Nothing shall replace the primacy of your clinical skills. 2) Thou shalt only call a study negative when it is incontrovertibly so. 3) Thou shalt not hesitate to call a study inconclusive. 4) Thou shalt only use EDE in the appropriate clinical situations. 5) Thou shalt re-EDE patients whose initial scan is negative, should your clinical suspicion deem it necessary. 6) Thou shalt move your hand slowly and deliberately. 7) Thou shalt always be methodical in your approach to the EDE scan. 8) Thou shalt not drop the probe! 9) Thou shalt communicate effectively with your patients, ensuring they understand the limitations of your EDE scan. 10) Nothing shall replace the primacy of your clinical skills. Did I mention that already? Well, its worth repeating.