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Ultrasound stuff(1)
 

Ultrasound stuff(1)

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Ultrasound stuff(1) Ultrasound stuff(1) Presentation Transcript

  • ABDOMINALULTRASONOGRAPHY IN CRITICAL CARE Pierre Kory, MPA, MDAssistant Professor, Albert Einstein College of Medicine Beth Israel Medical Center, New York
  • General Abdominal Ultrasonography• Complex anatomical structures with numerous variants • Not necessary to become fully competent in Abdominal Ultrasonography • Goal-Directed abdominal ultrasound is practical and achievable • keep clinical questions few and simple
  • Clinical Questions in Critical Illness • Free Fluid? - FAST exam • Perforated Bowel? - Free Air - lack of gut sliding, A line pattern • Urinary Tract Obstruction? - Hydronephrosis, bladder obstruction • Abdominal Aortic Aneurysm? - dilated aorta • Ischemic bowel? - peristalsis vs. ileus, dilated loops • Colitis? - thick walled, fluid filled loops of bowel • Hepatic Abscess? - anechoic intrahepatic space• Guide Diagnostic/therapeutic interventions
  • Remember:• Use “Abdominal” exam setting• 3.5 to 5.0 MHz transducer• orientation marker on left of screen• Doppler not needed• Can use transverse and longitudinal scans
  • ABDOMINAL FREE FLUID• US detects small amounts of free fluid• FAST exam saves lives in trauma• Real-time analysis of fluid • No tattoo mark needed!• Fluid usually black (anechoic), but may not be……
  • DIAGNOSTIC AREAS• Areas to search - start with ID of diaphragm and scan below! • Hepatorenal recess, “Morrison’s pouch” • Splenorenal recess • Pelvic region • Remember the bladder! • Perihepatic and perisplenic regions
  • PARACENTESIS• Allows safe ‘point of care’ diagnosis/ treatment • Avoids delay/transport for “mark” placement • Avoids danger of subsequent fluid/organ shift • Ultrasound characteristics of fluid can give diagnostic clues • Septations due to infectious etiology or malignancy, echogenic mass - hematoma?
  • PITFALLS • Compression artifact when needle enters abdomen (estimate safe margin with ultrasound) • Dilated, fluid filled bowel can be mistaken for pocket of free fluid! • I.D bowel wall and shape, peristalsis, air admixed with fluid, haustra • Free peritoneal effusion changes shape under manual pressure, bowel ‘floats’ in ascites • Ascites is usually echo free• Is that fluid pocket a massively distended bladder? • Typical shape, Foley catheter
  • ABDOMINAL FREE AIR• “Gut Sliding” sign similar to “lung sliding” sign for PTX • Air outside visceral peritoneum blocks US beam • Gut sliding sign- can “see” visceral and parietal peritoneum sliding against each other • When “free” air interposed between them - cannot SEE SLIDING, only see a “quiet” a line pattern • Careful of confusing “free” air and “bowel air”- bowel air also causes an A line pattern (gut sliding is preserved) • Presence of gut sliding rules out abdominal free air in that locatio
  • ABDOMINAL FREE AIR• Where to look • Non-dependent areas of abdomen! (Air FLoats) • Probe on top of liver, under diaphragm, in semi- recumbent patient (xiphoid) • Absence of gut sliding is not specific for free air • May have peritoneal symphysis • Poor visualization due to body habitus• “Splanchnogram” - if splanchnic organs seen, NO AIR
  • TOXIC MEGACOLON - AIR WITHIN BOWEL
  • GUT SLIDING
  • • Once again……. • The presence of sliding gut and/or a splanchnogram rules out free air • Their absence is highly suggestive in the correct clinical circumstance
  • URINARY TRACT OBSTRUCTION • Acute renal failure and oliguric/anuric patients should have prompt US evaluation • Assessment of kidneys and bladder • Size, echo texture, central echogenic space • Hydronephrosis is recognized with a dilated renal pelvis and calices. • Differentiate between renal cysts and hydronephrosis
  • • KIDNEY DIAGNRAM
  • NORMAL KIDNEY
  • MILD HYDRONEPHROSIS
  • HYDRONEPHROSIS• May take time to appear• Always scan the bladder
  • BLOCKED FOLEY
  • BLADDER COLLAPSED AROUND FOLEY
  • SEE HYDRO? CHECK BLADDER
  • PITFALL - Renal Cysts• Common - can be confused with hydronephrosis
  • ISCHEMIC BOWEL• Peritonitis and Ischemic Bowel • Evidence of peristalsis virtually rules out these disorders • Scan for peristalsis; may take time ~minute • Acute disorders usually affect the whole bowel so unimportant to be precise with anatomy• Important: Absence of peristalsis does not rule in peritonitis and/or ischemic bowel• Clinical context very important
  • DILATED, FLUID FILLED, ILEUS.... ISCHEMIC?
  • PERISTALSIS (bowel is not sick)
  • ABDOMINAL AORTIC ANEURYSM• Clinical relevance • Abdominal pain, hemodynamic instability, prior surgery• How to locate • Transverse scan sub-costal, left paramedian, transducer marker to right of patient • Tubular, anechoic structure • Rotate 90 degrees clockwise for longitudinal view • Size, Atherosclerosis, thrombosis
  • AORTIC ANEURYSM WITH MURAL THROMBUS
  • STOMACH ULTRASOUND• Main Application: Pre-Intubation Scan! • If stomach filled/distended with fluid or blood: • drain promptly to avoid massive emesis during inutbation! • Can be life-saving in unconscious patients • Highly Effective in Patients with GI bleed Koenig S. J Int Care Med, 2011
  • MASSIVE CLOT FILLING STOMACH
  • “SWAMP WATER” FILLING STOMACH
  • Miscellaneous Applications• Liver, spleen, and kidney • Size, echo texture • Gross abnormalities: Abscess, tumor• Advanced US • Hepatobiliary system. Retroperitoneal space,Vascular disease• Competence obtainable but requires additional training