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Introduction to Emergency
Ultrasound -FAST and Heart
Diane Hallinen, MD
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Sliding
Moving the probe to a
new window
Requires plenty of gel.
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Rocking
Centers the image in the middle of the screen
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Tilting
Perpendicular to rocking. Allows other planes in the
same axis to come into view
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Rotation
Allows the evaluation of the short and
long axis of a structure
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Compression
• Pressing the probe into the patient.
• This can be uncomfortable.
• Useful for squishing bowel gas out of the way and
for the evaluation of blood vessels.
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Choose your Probe
• Higher Frequency – decreased depth of
field, but better image.
• Lower Frequency – penetrates deeper, but
blurry
• Intracavitary- high frequency
– For transvaginal exams
– Peritonsillar abscess
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FAST Exam
• The goal is to determine if there is free fluid
in the abdominal cavity or around the heart.
• It stands for Focused Assessment for the
Sonographic examination of the Trauma
patient or Focused Abdominal Sonography
for Trauma
• It really is fast, usually takes less than 1
minute if the exam is positive. If it is
negative it takes 2 - 5 minutes.
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Technique
• Most importantly it should be done
simultaneously with the rest of the exam and
resuscitation during the secondary
survey.
• Should be done by a second physician if
possible.
• Repeat exam in 15 minutes increases
sensitivity.
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FAST
• Heart
• RUQ
• LUQ
• Bladder
Also pay attention to
the diaphragms and
gutters.
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Heart
• The primary goal is
to look for
hemopericardium.
• Pericardial
tamponade is evident
by collapse of the
right ventricle and
atrium.
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Pericardial Fluid
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Standard Subcostal
View
• Place the probe just
inferior to the xiphoid,
hand on top.
• Press down to get
under the sternum.
• Point slightly towards
the left nipple.
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Standard Subcostal View
• Ideal view for pericardial effusions since there are no
pleural reflections between the liver and the heart.
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While you are there - go check out the
hepatic veins - Rabbit sign
• The rabbit’s head is the vena cava, the ears
are the middle and left hepatic veins.
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Limitations of the Subxiphoid
View
• Difficult to look at the heart when the
stomach is full of air from bagging or from
a prehospital esophogeal intubation.
• People with a beer belly can be difficult to
image.
• Pregnant women in the third trimester also
can be difficult to image.
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Alternative views
are available, and
may provide a way
to confirm an
effusion, or give
you a better view
of the chambers
and valves. More
on this topic later.
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Hemoperitoneum
• Free fluid is black, and it collects in the
dependant portions of the torso.
• An abdomen with more that 500 cc free
fluid can usually be detected in less than a
minute.
• For children the most dependant portion of
the abdomen is the bladder.
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FAST
• Heart
• RUQ
• LUQ
• Bladder
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Normal Bladder Exam
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Bladder
• The bladder
must be
distended to do
an adequate
exam.
• The foley can be
clamped or
filled with
saline.
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Free Fluid is Black
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Bladder-Loop of Bowel
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FAST
• Heart
• RUQ
• LUQ
• Bladder
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RUQAnechoic (black)
fluid between the
liver and kidney.
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RUQ
Morison’s
pouch is the
most common
area for blood
to accumulate,
in adults,
regardless of
the organ
injured.
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FAST
• Heart
• RUQ
• LUQ
• Bladder
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LUQ
Kidney-spleen interface
can be hard to see, and
blood doesn’t always
settle there. In fact it is
more common to see it
between the spleen and
diaphragm.
If there is fluid in the left
upper quadrant it is
probably from the spleen
or diaphragm.
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LUQ
• PF is pleural
fluid seen above
the diaphragm
D. FF is seen
between the
spleen and
kidney.
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Introduction - Vascular Exam
• Aorta
• Femoral artery and vein
• Subclavian artery and vein
• Internal jugular and carotids
Goal today is to find the vessels,
differentiate the artery from the vein and
explore doppler.
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Aorta - Longitudinal
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Aorta Transverse
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Femoral Artery and Vein
• A deep vein thrombosis can be diagnosed
on the basis of incompressibility of the
femoral vein.
• The femoral vein is an idea access point for
a large bore line.
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Carotid Artery Jugular Vein
The internal jugular vein is an excellent
access point for placing an internal pacer.
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Peripheral IV Access
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Why look at a the heart?
• In arrest -
– Cardiac activity
– Pericardial effusion
– Dilated right ventricle (massive PE)
– Empty heart - hypovolemia
• Many other uses ....hypotension, chest pain,
pericardiocentesis. Don’t worry, you will
get additional lectures.
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Echo Probe Placement
• Traditionally the probe marker is to the
patient’s left, and the monitor indicator is on
the right side of the screen, which is
opposite from abdomen/pelvis scanning.
• Don’t worry about it today…work on
getting the images and figure out the
anatomy. Don’t memorize stuff, deduce it.
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The major views
are the parasternal
long and short,
apical, and sub-
costal.
My favorite view
is the parasternal
long.
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Parasternal Long
• The image is through the long axis of the
heart. The probe is placed between the 2nd
and 4th intercostal space. You might have
to SLIDE the probe to different interspace
to find the best “window.”
• The probe should be snuggled up right next
to the sternum.
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Parasternal Long
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Parasternal Long Axis
• Focus on the mitral
valve. Move the probe
so that you see the
anterior and posterior
leaflets opening and
closing.
• Usually you can see
the aorta in cross
section distal to the
inferior wall.Yale Atlas of Echo
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Parasternal Long
Million dollar question…is this systole or
diastole?
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Parasternal Long with
Tamponade
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Parasternal short
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Parasternal Short
• Rotate the probe 90
degrees while looking at
the aortic valve. Tilt the
probe to scan through the
mitral and ventricle levels.
• Used for wall motion
examination, check for 3
leaflets in the aortic valve,
etc.
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Parasternal Short
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Apical View
• Place the transducer on the point of
maximum impulse, between the ribs.
• Be sure to rotate, slide, and tilt.
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Apical Four Chamber View
• Get a nice view of the
right heart, useful for
tamponade
evaluations.
• Wall motion views,
can see the apex.
• Used for evaluating
valve function via
doppler.
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Apical Four Chamber View
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Tamponade?
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Dilated Cardiomyopathy