USG THORAX

1. USG THORAX
BY
Dr NARENDRA TENGLI
2nd year JUNIOR RESIDENT
DEPARTMENT OF PULMONARY MEDICINE

2. LEARNING OBJECTIVES
• Basic terminology in ultrasonography (USG)
• Selection of ultrasound probe for thorax and its
technique and application
• Basic sonography windows of thorax
• Normal lung pattern in ultrasonography
• Abnormal patterns in lung pathology –pleural
effusion, pneumothorax, pneumonia, lung
tumors etc
• USG Lung Algorithm to reach diagnosis
• The use of USG in guiding –thoracocentesis,
biopsy

3. How does ultrasound work
• Ultrasound uses sound waves which when
strike an object, bounces back or echo
• By measuring these echo waves, its
possible to determine how far is the
object, its size ,shape and consistency
• The transducer sends the sound waves and
then receive and records them and a real
time pitcher is created by the computer
and displayed on the moniter
• Doppler US creates graph or colour
pitchres that represent flow of blood
vessels

4. Basic Principal in ultrasound
Impedance is critically important in understanding LUS because the loss of US
energy through tissue greatly determines how well it will form an image.
Most structures that form good images with US have impedance values between
1.5 MRayl (water) and 1.7 MRayl (organs). In contrast, the acoustic impedance of
air is 0.0004 MRayl, and for bone it is 6–8 MRayl. Since air and bone impede US
wave transmission quite differently from water and organs, it is much more
difficult to obtain accurate sonographic information from these structures. This
will have an impact on the attenuation of US energy through these structures,
Resolution of image depends on frequency of Probe used Frequency is thus
directly correlated with image resolution and indirectly correlated with tissue
penetration.

5. Terminology in ultrasound
• Echogenicity – is the capability of tissue producing echo
• These are relative term that refers to the echo returning from
structure
• Hyperechoic- (white on screen)-tissue generate a greater echo
• Hypoechoic –(Gray on the screen)-tissue generating lower echo
• Anechoic –(black on the screen)-tissue that do not generate an echo
• Isoechoic- tissue or structure that produces an echo of the same
strength as that of surrounding structure or tissue.

6. •Acoustic shadow- the shadow produced due failure
of the sound beam to pass through an object- stone, bone

7. Ultrasound Transducer/probe
• It serves to generate as well as
receive ultrasound waves
• Ultrasound machine usually have
• curvilinear (abdominal probe)
• linear (vascular access probe)
• phased array (echo probe), or a
combination.
• A great advantage of lung
ultrasound is that useful images can
be obtained with each of these.
Each probe has pros and cons.

8. Probe Selection- Curvilinear Probe
• This best all round for lung
ultrasound
• low frequency probe (3-5
MHz)
• scans Deeper into the
chest
• Low resolution
• Larger footprint
• can image multiple rib
spaces
• Best probe for evaluating
for pleural fluid, Acute
interstial syndrome ,lung
consolidation

9. Probe Selection- Linear Probe
• High frequency Probe-(8-12)
• improved resolution of the
pleural line
• Best probe for evaluating for
lung sliding and guidance for
thoracocentesis
• The disadvantage is poor
penetration of high-frequency
US hence deeper structures are
poorly imaged.

10. Phased Array (3-4.5)
These probes have a
useful footprint for
getting in between the
ribs. They can be used
to demonstrate all the
signs of Lung
ultrasound but the
clarity of the images is
not as good.
These are mainly built
for cardiac 2D
echography

11. US probe marker and image orientation
Typically ,there is a dot or a cross on the probe ,this correlates with a dot on the left side of the screen
This marker should be towards the patient’s right in the transerverse and head in the longitudnal

12. US imaging modalities
The US machine consists of several modalities that emit
US
Brightness or B-mode is the main modality used for
diagnostic imaging of the lung. It converts the returning
echoes of varying amplitudes into the greyscale visualised
on the screen.
Motion or M-mode depicts the motion of a given
structure in the transducer’s directed plane over time.
The motion (or non motion) of the structure is plotted
along the y-axis, and time in seconds is plotted along the
x-axis. This scanning modality can be used to evaluate the
lung for Pneumothorax and diaphgram movement

13. US imaging modalities

14. Colour Doppler
Doppler physics allows the differentiation of
reflected sound waves towards or away from the
probe. Objects moving towards the transducer
produce a higher reflected frequency, whereas
sources moving away from the transducer
produce a lower reflected frequency. These
distinctions can be represented either by colour
changes (colour Doppler) .This means that waves
moving towards the transducer (at the top of the
screen) will appear red, whereas waves moving
away from the transducer (at the bottom of the
screen) will appear blue.

15. Basic Sonographic Windows
• Ideally USG probe should be placed at the
same places in the intercostal spaces
where stethoscope is put for auscultation
• Each hemithorax is divided into Anterior
,lateral and posterior zone/region by
anterior and posterior axillary line
• Each zone is again divided into superior
and inferior.
• Dorsal region of upper lobes cannot be
assessed easily because scapula does not
allow acoustic window. A systematic and
comprehensive approach for assessment
is needed to avoid mistakes

16. • Several different
FTUS(fousced thoraxic US)
protocols and approaches
have been described;
however, no international
specific protocol has been
obtained. Many protocols
divide the thorax into a
number of scanning points,
areas or zones that are
assessed using US, but the
number of zones varies
significantly for each
protocol [4, 9, 12, 13, 31,
37–48].

17. Position of patient
The patient position will affect the position of free air (e.g. PTX) and
free fluid (e.g. simple pleural effusion) in the pleural cavities, and
patient positioning is therefore of importance when assessing the
patient for these two conditions. The supine position is the
recommended position for assessing the presence of
PTX, since the air will tend to be placed anteriorly in the chest cavity, an
area that is easily assessable using FTUS. If the patient is placed in the
sitting position, a small PTX can be missed if the air is located solely at
the apex of the chest cavity, an area that is more difficult to assess
using US. In comparison, patients should be placed in the sitting
position when scanning to detect a pleural effusion, in which case the
fluid will tend to be in the lower posterior zones
Some patients with acute respiratory failure cannot be placed in a
supine position due to severe dyspnea. Anterior, lateral and posterior
surfaces are scanned with the patient in the sitting position.

18. Assessment of the posterior zones is not
always possible (e.g. critically ill patients,
trauma patients). The posterior surfaces can
then be scanned either directly or indirectly.
Direct assessment can be performed with the
patient lying on their side, in a decubitus
position, or alternatively the transducer can be
inserted in between the mattress and the
patient, making it possible to scan at least part
of the posterior surface. The indirect approach
involves use of the liver and spleen as acoustic
windows in order to identify the presence of
the “spine sign” Posterior zones.

19. Normal lung pattern on Ultrasonograph
• The USG probe is placed
longitudinally and perpendicular to
the ribs over intercostal space
• Once pathology us identified , probe
can be placed horizontal for further
view
• using USG gel as coupling medium to
the skin because presence of air in
between can reflect back >99.9% of
the ultrasound beam.

20. Chest wall
Structures such as skin, s.c.
tissue, muscles and connective
tissue are visible just beneath
the transducer. The connective
tissue appears hyperechoic, and
often more hyperechoic
horizontal linear structures can
be seen, representing
connective tissue. The two ribs
aligning the ICS are visible as
two hyperechoic lines with an
underlying shadow
SKIN
S.C FAT
MUSCLE
INTRAMUSCULAR
SEPTUM
PLEURAL
BAND
SKIN
OUTER RIB CORTEXa
OUTER RIB CORTEX

21. This boundary appears as white band (lung/pleural line)
measuring up to 2 mm.
Pleura Placed just below and
between the two ribs, a
hyperechoic horizontal line is
seen presenting the visceral
and parietal pleura. Most
conventional clinical US
machines are not able to
differentiate the two pleural
surfaces from each other.
The combined surfaces are
termed the pleural line
PLEURA

22. The two ribs adjoining an
ICS (hyperechoic surface
with posterior shadowing)
and the pleural line
resemble a bat flying
towards the US screen
This is known as “bat sign”

23. Lung sliding is seen as a horizontal movement of the pleural line in synchrony with
the respiratory cycle, indicating a sliding movement of the visceral pleura against
the parietal pleura. Lung sliding is due to the up-and-down movement of the
visceral pleura in synchrony with the piston-like respiratory movement of the
diaphragm.
Several factors may affect the magnitude of lung sliding (e.g. lung zone scanned,
patient tidal volume, underlying disease and intubation). When air separates the
two pleural layers (e.g. pneumothorax (PTX), the movement disappears and cannot
be detected with US. In such cases, the pleural line represents only the parietal
pleura, which is still visible but does not slide since it is fixed to the chest wall.
Apart from PTX, other conditions may also cause absence of lung sliding (e.g.
fibrotic involvement in interstitial lung diseases, prior pleural empyema or sequelae
from a prior intrathoracic operation)
LUNG SLIDING

25. • In time motion mode (M mode), the structures till parietal pleura appear as
horizontal lines and beyond this sandy pattern representing lung sliding.
• The presence of pleural line, lung sliding, A-Lines in 2D and seashore sign in
M mode are characteristic of aerated lung
SEA
SAND

26. A-LINES
• Beyond pleural line in normally aerated lung, artifacts are seen in image.
These are reverberation artifacts, produced by bouncing of echo between
pleural line and probe. These motionless, regularly spaced (equal to the
distance between the skin and the pleural line) and gradually fading
horizontal white lines which resemble pleural line are called A-Lines

27. B-LINES
Sound Waves do not travel well through aerated lung
due to scatter and reflection; they travel much better
through tissue with increased density, such as fluid-
filled or fibrotic lung. This helps to differentiate
among well-aerated (i.e. healthy), fluid-filled (i.e.
pulmonary oedema, pulmonary contusion) and
consolidated (i.e. pneumonia) lung. With a fluid-filled
lung, the fluid within the alveoli will conduct the
wave rather than scatter it. The waves thus become
trapped and are reflected within the alveoli to create
hyperechoic vertical “B-lines” that extend from the
pleural interface to the bottom of the screen and
move with respiration The degree of fluid within the
alveoli or fibrotic lung tissue corresponds to the
number and size of B-lines. B-lines can also coalesce
together and appear as a wide belt(“lung rockets”). In
newborns, wet lung will have this B-line belt
appearance, which disappears when the lungs fill
with air
B-LINES

28. B-lines are defined as discrete laser-like vertical hyperechoic artifacts that
arise from the pleural line and extend to the bottom of the screen without
fading, move synchronously with lung sliding and erase A-lines. They used
to be called “comet tails” and “lung rockets” in the past, and this
terminology is obsolete now. B-line formation is incompletely understood

29. C- lines
• C Lines
• C lines are defined as hypoechoic
subpleural focal images generated
by condensed lung tissue, without
visceral pleural line gap .
• These line may be suggestive of
pneumonia with additional signs
lines (contained within the square). C lines are
defined as hypoechoic subpleural focal images
(generated by condensed lung tissue) without
visceral pleural line gap (arrow)HSP: subpleural
hypoecho genicities; DPL: pleural effusion; LIE: left
lower lobe.

30. • False B lines (E and Z lines)
• False B lines (E and Z lines) are vertical to the pleural line and may be
mistaken for true B lines. However such lines represent different
entities, as follows:
• E lines
• “E” stands for subcutaneous emphysema. E lines are vertical lines
seen when there is gas trapped in the subcutaneous space. These
lines do not arise from the pleural line, but from the subcutaneous
tissue; given the gas does not move, they are not synchronous with
respiratory movements (Figure 5). E lines are well-defined and also
erase A lines, and may therefore be mistaken for true B lines.
•
Z lines
• Z lines are common artifacts seen in more than 80% of the population
and may be mistaken for coalescent B lines described above. Z lines
are vertical, bundle-like shaped lines arising from the pleural line;
however, they are ill-defined, do not erase A lines and are not perfectly
synchronous with respiratory movements.(3)

31. • The diaphragm can appear as a hypoechoic line (muscle) sandwiched
between two hyperechoic lines [peritoneum and pleura]. It is best
visualized by subcostal placement of probe and using liver and spleen as
acoustic window. Right hemi-diaphragm is seen easily because liver
provides bigger acoustic window

32. Normal excursion of diaphragm with respiratory movement . The lung base descends
during inspiration
Here is a patient of idiopathic phrenic nerve palsy with paradoxical movement ,seen
as a slight cranial displacement of the diaphragm during inspiration

33. Liver and right kidney
In healthy persons, the liver
can be visualized when
scanning the lower part of the
thorax on the right side.
Excellent images of the liver
can generally be obtained
when scanning in the
midaxillary line. The liver is
seen as a large, hyperechoic
solid structure. When
breathing in and out, the
motion of the diaphragm
causes displacement of the
liver. Just below the liver, the
right kidney can be visualized
Liver cirrhosis

34. a)Liver cyst;
b) liver
calcification;
c)hepatic
haemangioma (*)
d) focal nodular
hyperplasia (*);
e and f)
hypoechoic liver
metastasis

35. USG characteristics in Pleural pathologies
1. Pneumothorax
2. Pleural effusion
3. Pneumonia
4. Interstial syndrome
5. Pulmonary embolism
6. Lung tumor

36. PNEUMOTHORAX
 Pneumothorax (PTX) is common after blunt chest
injury, and failure to diagnose and rapidly treat an
enlarging PTX may cause patient death.
 CT scans and chest x ray both of these diagnostic tools
are not readily available for the patient, include a
radiation hazard, and have a time delay between
ordering and obtaining results.
 TUS is a harmless point-of-care examination to
accurately diagnose PTX. With the appropriate
training, all clinicians can perform US examinations to
detect PTX, which suggests that this technique should
be used as a diagnostic adjunct to the clinical
examination of patients with respiratory distress.
Pneumothorax
The key sonographic signs
used to diagnose
pneumothorax
Absent lung slide
Loss of comet-tail artifacts-

37. USG characteristics in Pleural pathologies-
PNEUMOTHORAX

38. Barcode/stratosphere sign-
On M mode pattern of only uninterrupted horizontal lines only -
Lack of lung areation

39. Lung point sign/ lead point
Highly specific ultrasound sign
of incomplete pneumothorax
It involves visualizing the point
where the visceral pleural lung
begins to separate from the
parietal pleural

40. PLEURAL EFFUSION
Pleural effusions represent a significant disease burden globally. TUS,
performed by both
radiologists and physicians, has increasingly become an essential tool in
the evaluation and management of pleural effusions.
 It detects pleural effusions with higher sensitivity and specificity than CXR,
and provides valuable information about the size and depth of the pleural
effusion, the echogenicity of the fluid, the presence of spetated or
loculated fluid, pleural thickening and nodularity, and the presence of any
contralateral pleural effusion.
TUS can provide information on diaphragm position and movement with
respiration, and can assess the presence of lung sliding and the accessibility
of pockets of fluid in loculated pleural effusions, thereby improving the
success rate and safety of pleural procedures.

41. Pleural effusion
• The appearance of effusion between parietal and visceral pleura in ultrasound image depends on its nature
of effusion.
• Most transudates and some exudates appear as anechoic space between pleura because at pleura–effusion
boundary negligible echo is produced .
• The presence of internal echoes in this anechoic space is suggestive of exudate or hemorrhage which can be
confirmed by thoracentesis .
• Vertebral bodies (*) visible behind the window of the liver. Normally, air above the diaphragm (D) blocks
their visualisation above the diaphragm. However, when fluid is present above the diaphragm, the fluid acts
as a window to allow visualisation of the vertebral bodies- spine sign

42. Minimal pleural
effusion is delineated
during expiration
between parietal pleura
and lung in 2D echo and
M mode; this is called as
quad sign.
The posterior axillary
line above diaphragm is
the optimal site for
detection of non-
loculated pleural
effusion.

43. Various ultrasound-guided approaches
have been suggested for assessment
of volume of pleural effusion.
• Interpleural distance of ≥ 50 mm
between posterior chest wall and
lung is predictive of pleural
effusion(PLD) ≥ 500 mL
• PLD>45mm right , PLD> 50mm left .
800ml
• PLD >10mm volume in ml=20xPLD.

44. Categorisation of effusion based on US appearance is generally
described as follows:
1. anechoic
2. complex septated/non septated
3. homogeneous sepated/nonseptated.

45. Floating debris within a pleural effusion
appears as internal echoes that move with
respiration or cardiac motion on dynamic
chest ultrasound. This has been described
as the ‘plankton sign’ and occurs with
exudative pleural effusions or hemothorax
There is moderate-to-large-sized
pleural effusion with multiple
septations/loculations associated
with underlying consolidation

46. PLEURAL THICKNING
• The normal pleura is only 0.2–0.4
mm thick The pleural pathology
manifests either as exudation of
effusion or pleural swelling .
• Several benign and malignant
processes can be seen by TUS. In
addition, TUS can guide the
process of sampling abnormal
pleura in cases of suspected
malignancy or for microbiological
evaluation of non resolving or
tuberculous infection.
• Pleural thickening nodularity and
calcification are among the
sonographic features of pleural
disease.
Longitudinal US image showing gross pleural thickening (1.4 cm;
indicated by crosses). Note the
pleura is hyperechoic; the echogenicity of malignant pleural
thickening is variable and ranges from low
through intermediate to hyperechoic.

47. Nodule noted on the diaphragmatic pleura
(arrow). This effusion proved to be due to
metastatic
adenocarcinoma. Significant parietal pleural thickening
(arrow) in a patient with chronic
rheumatoid pleuritis. A
catheter is seen inside the pleura
(arrowhead). The pleural cavity is
indicated by crosses joined by dotted
lines.

48. Interstitial syndrome
B-lines are probably the most “revolutionary” sign of LUS and can be
used for the evaluation of interstitial syndrome.
Assessment of B-lines can thus be applied to many different diseases,
such as heart failure, end-stage renal disease, acute lung injury,
interstitial lung disease . To differentiate these conditions, a thorough
integration with the clinical picture is absolutely association with other
LUS signs.
The clinical usefulness of B-lines has been demonstrated not only for
diagnosis but also for monitoring and prognosis.

49. pulmonary edema
• The presence of bilateral,
widespread comet-tail
artifacts called B- lines .
Regularly spaced B lines
suggest septal or interstitial
oedema.
• Crowded or coalescent B
lines are suggestive of
alveolar oedema.

50. a)B-lines (arrow) with a regular, thin pleural line in a patient
with acute heart failure.
b) B-lines with an irregular, fragmented pleural line (arrow) in a
patient with acute lung injury

51. LUS has useful prognostic value in assessment of extravascular lung
water in patients with dyspnea and/or chest pain.It has shown role in
volume assessment in patients with kidney disease requiring
hemodialysis

52. PNEUMONIA
Several studies suggest that LUS could be useful for the diagnosis of
pneumonia. The characteristic sonographic signs of pneumonia are a
hypoechoic liver- or tissue-like subpleural consolidation and a marked
dynamic broncho-aerogram. The borders are blurred and serrated,
often accompanied by comet tail artefacts. A parapneumonic effusion
can be detected . Abscess formations are better seen in LUS than in
CXR.
They can be treated under US guidance.
LUS cannot rule out pneumonia.

53. 1. Liver- or tissue-like in the early stage
2. Lentil-shaped air trappings
3. Broncho aerogram
4. Fluid bronchogram
5. Blurred or serrated margins
6. Reverberation echoes at the margin
7. Hypoechoic to anechoic in the presence of
abscess
8. Regular vascularistion in colour Doppler
Sonomorphology of pneumonia

54. • Pneumonia
• The appearance in LUS depends on the relative aeration of alveoli.
• Subpleural echo-poor region or tissue(HEPATIC) like echo texture is seen in
alveolar consolidations which reach up to pleura.
• Alveolar consolidation margins are irregular, serrated and blurred in depth (shred
line; shred sign). Dynamic air and fluid bronchogram(s) along with shred line are
characteristic of lung consolidation caused by pneumonia.

55. A 68-year-old severely ill man with clinical signs of acute
pneumonia.
In the upper lobe of the
lung on the left side, there is a liver-like consolidation with a
bronchoaerogram.

56. Follow-up in a patient with pneumonia. LUS shows the regression better than CXR. Day 1: a)
CXR, b) LUS with brochoaerograph, and c) LUS with regular vascularisation. Day 6: d) CXR
with rest shadowing, and e and f ) LUS with reventilation according to the clinical course.

57. Lung abscess
Pulmonary abscesses have a highly characteristic
sonomorphology: round or oval and largely anechoic lesions .
Depending on whether a capsule is formed, the margin
is smooth, echodense and white. Blurred internal echoes are
indicative of high cell content
or viscous pus rich in protein
Lung abscess with persistent fever. Sonography-guided
needle aspiration was successful. The patient went
into complete remission.
If antibiotic therapy does not yield the desired result,
LUS examination and US-guided transthoracic
aspiration are useful and safe diagnostic procedures for
the collection of specimens that enable the accurate
diagnosis of lung abscesses

58. The diagnosis of pulmonary embolism is often a complex process that starts
from clinical suspicion and is guided by risk stratification in selected
populations.
LUS may have a role in this process, as it is a valid technique that is highly
specific for diagnosing typical peripheral lung infarctions and highly
sensitive in ruling out alternative pulmonary diagnoses to pulmonary
embolism.
point-of-care LUS discussed the evidence on the usefulness of LUS for
pulmonary embolism . The results confirmed the
usefulness of LUS as a valid alternative to CT when the latter cannot be
used.
LUS in pulmonary embolism

59. flow chart for the diagnostic work-up in suspected pulmonary
embolism, based on the integration of venous US and LUS with
clinical scoring and D-dimer results

60. Two examples of typical infarcts detected by LUS in two cases of confirmed
pulmonary embolism.
The typical consolidations are hypoechoic images of size >5 mm, wedge or round
shaped, pleural based and without air bronchogram or vascularisation

61. Lung tumours
The diagnostic value of TUS of lung tumours,
especially bronchial carcinomas, is limited and
dependent on the localisation of the tumour.
Different US-based procedures, such as
transcutaneous US, EUS and EBUS are used for
distinct approaches to lung tumours.
B-mode imaging, colour Doppler sonography,
CEUS(contrast enhanced US) and US-controlled
interventions are the sonographic modalities
used in daily clinical practice

62. Patient with lung mass and
histologically proven nonsmall cell
lung cancer. a) CXR shows
a left-sided central lung
consolidation. b) CT shows a left-
sided central tumour with suspected
obstructive
atelectasis. c) B-mode US shows a
homogeneous hypoechoic lung
consolidation without
airbronchogram.
The central tumour cannot be
distinguished from the atelectatic
tissue.
d) CEUS shows reduced
enhancement of the central tumour
in the parenchymal phase, in
comparison to atelectasis.

63. Patient with pain in the left shoulder and
histologically proven nonsmall cell lung cancer
(Pancoast tumour). a) CXR shows a left-sided
apical opafication suggestive of Pancoast
tumour. b) CT shows a left-sided apical tumour
which infiltrates the thoracic wall (arrow). c) B-
mode US shows a left-sided apical echoic
consolidation which infiltrates and destroys the
rib (arrow). d) CEUS shows an inhomogeneous
enhancement of the tumour with areas of no
enhancement due to necrosis (arrow). e) US-
guided tumour biopsy was performed using vital
tissue. The arrow indicates needle reflexion

64. Patient with histologically proven nonsmall cell lung cancer and
pleural effusion. a) CXR shows a left-sided basal opafication
suggestive of pleural effusion. b) CT shows a left-sided pleural
effusion with pleural nodules. c) B-mode US shows a left-sided
Anechoic pleural effusion with echoic nodular pleural
lesions. d) CEUS shows an enhancement of the pleural lesions
suggestive of pleural carcinosis. Cytologicalexamination of the
pleural fluid shows tumour cells

65. Subcutaneous emphysema
• Subcutaneous emphysema It poses
limitation to LUS and has characteristic
presence of E lines. It is a comet tail like
artifact like B lines which arises from air
collection in subcutaneous tissue. E lines
are laser like vertical hyperechoic
reverberation artifact arising from
subcutaneous tissue and extending up to
bottom of screen Pleural line and bat
sign is not seen because subcutaneous
air prevents imaging beyond it

66. The BLUE and BLUE-plus protocols have been proposed to
help in diagnosis of various lung conditions. One protocol
suggests systematic LUS approach starting with identification
of landmarks before identification of LUS pattern. Each
region or zone is then sonographically characterized.
Integration of various LUS findings in all regions/zones gives
sonographic diagnosis.
Finally interpretation of sonographic
diagnosis is done in context with history, clinical assessment,
other investigations and laboratory data.One algorithm is
suggested . History and clinical assessment are
integrated with sequential interpretation of characteristic
LUS findings
BLUE PROTOCOL

68. POCUS
• What is "Point-of-Care Ultrasound"
(POCUS?)
• Point-of-care ultrasound refers to the
practise of trained medical professionals
using ultrasound to diagnose problems
wherever a patient is being treated, whether
that's in a modern hospital, an ambulance,
or a remote village.it enabled clinicians to
treat patients faster, more accurately, and in
a non-invasive way at the point of care,
without relying on trips to the Radiology
department.

69. FAST- Focused assessment with sonography in
trauma
• Focused assessment with sonography in trauma (commonly abbreviated as
FAST) is a rapid bedside ultrasound examination performed by surgeons,
emergency physicians, and certain paramedics as a screening test for blood
around the heart (pericardial effusion) or abdominal organs
(hemoperitoneum) after trauma.[1]
• The four classic areas that are examined for free fluid are the perihepatic
space (including Morison's pouch or the hepatorenal recess), perisplenic
space, pericardium, and the pelvis. With this technique it is possible to
identify the presence of intraperitoneal or pericardial free fluid. In the
context of traumatic injury, this fluid will usually be due to bleeding.

70. eFAST- Extended-Focused assessment with
sonography in trauma -
• Extended FAST
• The extended FAST (eFAST) allows for the
examination of both lungs by adding
bilateral anterior thoracic sonography to the
FAST exam. This allows for the detection of a
pneumothorax with the absence of normal
‘lung-sliding’ and ‘comet-tail’ artifact (seen
on the ultrasound screen). Compared with
supine chest radiography, with CT or clinical
course as the gold standard, bedside
sonography has superior sensitivity (49–99%
versus 27–75%), similar specificity (95–
100%), and can be performed in under a
minute

71. USG guided and assisted
thoracocentesis
The practitioner must decide whether to
perform a procedure using TUS in “real
time” (i.e. under continuous direct
sonographic vision) or as an “US-assisted”
intervention (i.e. marking a safe site as
identified by TUS immediately prior to
intervention). This choice is likely to
depend on factors including operator
expertise with either technique, and the
size or complexity of the pleural collection
being accessed

72. USG guided Thoracocentesis

74. REFERENCE
• ERS-Thoracic Ultrasound Edited by Christian B. Laursen, Najib M.
Rahman and Giovanni Volpicelli
• Review article from LUNG INDIA Lung ultrasound: Present and future -
Ashish Saraogi Department of Anaesthesiology, National Institute of
Medical Sciences and Research, Jaipur, Rajasthan, India
• GOOGLE IMAGES
• YOUTUBE VIDEOS

75. THANK YOU