Chest ultrasound in emergency
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This document discusses the use of chest ultrasound in emergency settings. It describes how chest ultrasound can demonstrate acute pathological conditions of the pleura, thoracic wall, and lungs. It outlines techniques for focused cardiac ultrasound and assessment of the inferior vena cava. Normal ultrasound appearances are shown along with signs of various conditions like pneumothorax, pleural effusion, pulmonary edema, and more. Advantages include availability at the bedside without radiation, though limitations include skill requirement and inability to fully evaluate certain patients.
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Chest ultrasound in emergency
- 1. CHEST ULTRASOUND IN EMERGENCY Dr. Sandip Giri
- 2. The Principal : When to use !! • Use of the chest ultrasound depends on stability of patients. HIGHLY UNSTABLE with multiogan injuries MUTIORGAN TRAUMA & STABLE NON TRAUMATIC ACUTE THORACIC COMPLAINTS INDETERMINATE RADIOGRAPHIC FINDINGS USG EFASTPORTABLE X RAY CT USG EFAST X-RAY CT USG
- 3. The Principal : Why to use !! • Demonstration of various acute pathological conditions of pleura thoracic wall, lung surface and cardiovascular surfaces including upper abdomen. • Playing pivotal role in decision making.
- 4. The Principal : How do we use !! • Interplay of high acoustic mismatch between: (a) Aerated lung tissues and (b) the pleura and thoracic wall. • Different signs (essentially artefacts occurring due to mismatch)
- 5. The Principal • Two main parts, which are closely related: (a) lung and pleura US and (b) (b) focused cardiac US. In addition, assessment of IVC .
- 6. Techniques
- 7. Technique
- 8. Techniques
- 9. Techniques
- 10. Techniques
- 11. Techniques APICAL FOUR CHAMBER VIEW IVC LONG VIEW
- 12. Algorithm Longitudinal and transverse in intercostal space but may also be oblique avoiding ribs !! For emergency Conditions !! • Abdominal approach at right and left upper quadrant. • Focused ultrasound can be done in subxiphoid, parasternal and apical four chamber view. Zone 1 Zone 2 Zone 3 Zone 4
- 15. Normal Appearances SUBXIPHOID VIEW PARASTERNAL LONG AXIS PARASTERNAL SHORT AXIS
- 16. Normal Appearances Four Chamber View Long IVC
- 18. Artefacts and signs • A line • B line • Z line • Barcode Sign • Seashore sign • Bat wing sign • Lung sliding sign • Lung pulse sign
- 19. A lines Horizontal parallel hyperechoic linear artifacts depicted at regular intervals below the pleural line.
- 20. B – lines (Rockets) B-lines are vertical hyperechoic artifacts originating from the pleural line that extend to the edge of the screen and erase the A-lines.
- 21. Z Lines The Z-lines are short, ill-defined vertical hyperechoic lines arising from the pleural line.
- 23. Barcode sign
- 24. Lung pulse sign Rythmic movement of the pleura in synchrony with the cardiac rhythm Best viewed in the lung adjacent to the heart.
- 25. Sonographic evaluation of acute thoracic conditions Pneumothorax • Lung sliding absent • Bar code sign • Lung point sign • Absence of B lines • Absence of lung pulse in M mode • Multiple A llines
- 26. Lung Point Sign
- 28. Limitation of the study Quantification of the pneumothorax is not possible. Examination is impossible in cases of : Subcutaneous emphysema Restricted in extreme obesity, Adhesive pleural disease Emphysema of the lung
- 29. Pleural Effusion • Anechoic space between the parietal and visceral pleurae • Plankton sign: swirling hyperechoic debris • Jellyfish sign: oscillating movement of the collapsed lung within the effusion • Moving septation within the fluid.
- 30. Fluid color sign: color Doppler signal within pleural fluid (during respiration with heart motion.
- 31. Sinusoidal sign: dynamic sonographic sign, present when respiratory variation decreases the distance between the parietal and visceral pleura, when separated by a pleural effusion.
- 32. Empyema thoracis • Complex loculation with internal septa • Highly hyperechoic pleural fluid • Pleural thickening
- 33. Empyema with svereal cavities
- 34. Hemothorax Highly hyperechoic collection within the pleural cavity, along the dependent part of the thorax
- 35. Pericardial effusion Hypoechoic area within the pericardial space Diastolic RA or RV collapse with distended IVC with Loss of normal respiratory variation of IVC diameter(Indicative of tamponade )
- 37. Acute Alveolar-Interstitial Syndrome : Pulmonary oedema and ARDS Pulmonary Oedema : • Multiple B-lines (at least six B-lines with linear transducer or at least three B- lines with microconvex transducer) • Diffuse homogeneous distribution • Pleural effusion • Distention of the inferior vena cava with loss of respiratory collapse, and impaired cardiac contractility
- 38. ARDS: • Multiple B-lines with an inhomogeneous distribution • Small subpleural consolidations with posterior and basal lung predominance • Punctate hyperechoic foci of air bronchograms within the consolidations
- 39. Pulmonary embolism and infarction • Multifocal subpleural wedge- shaped consolidations predominantly in lower Lobes • Localized effusion • RV strain pattern, McConnell sign: (akinesia of Midportion of the RV free wall but normal motion at the RV apex)
- 41. Volume status Volume depletion : IVC diameter < 1.5 cm with >50% inspiratory collapse Volume overload : IVC diameter > 2.5 cm with <50% inspiratory collapse
- 42. Rib Fracture • Rib fractures may be seen as a break in the anterior cortex • local hematoma and soft-tissue swelling
- 43. Indirect identification of non displaced fracture Chimney sign : Reverberation artifacts occurring At the fracture margins.
- 44. Subcutaneous Emphysema US image shows E-lines (arrows), which are multiple comet-tail artifacts arising superficial to and obscuring the pleural line.
- 45. Advantages • availability • relatively low cost • lack of ionizing radiation • bedside modality • its easy repeatability • the lack of contraindications.
- 46. Limitation of sonographic study • Dependence on the skills of the examiner • Pulmonary lesions can only be detected if they are pleura based • Artifacts due to skin emphysema can limit or impair the validity of the procedure. • Artifacts are affected by machine factors such as focal zone, frequency, and gain settings • Patients with a large body habitus, no accessible areas for scanning, and inability to cooperate • Time constraints
- 47. Future use , sensitivity and accuracy ?? • Advanced ultrasound machines?? • Requirement of research??? • Understimation of ultrasound use. • Neglected by radiologists?? • Non uniform data regarding sensitivity and specificity ?? • Studies are done by non radiologists than radiologist ??
- 48. The take on history and current scenario on domain of Lung Ultrasound of Critically Ill “We have never designed who had to hold the probe. It was more important to show what was possible to see; for example, the lung. The historical experts (the radiologists) had a major opportunity, which they did not take advantage of in time. This is a pity because, knowing the basis, they could transmit the method immediately. These times are passed, and now the tool is in the hands of clinicians.”
- 49. We hope that LUCI will be used by all physicians dealing with the lung. This means, as an utmost priority, intensivists, pediatricians (neonatologists, PICUs, etc.), and pre-hospital doctors. Next is anesthesiology, emergency medicine, pulmonology, cardiology, and many others. This change will impact a number of unexpected disciplines.” Lichtenstein D. INTENSEVIST, University Hospital Ambroise-Paré in Paris.
- 50. LUCI • TOOLS AND 7 PRINCIPLES • NEW LUNG ZONES AND LAND MARKS • DEVELOPMENT OF NEW TERMINOLOGY : PLAPS POINT AND PLAPS • PLAPS : At the PLAPS point, the detection of an alveolar, pleural, mixed or even ill-defined but otherwise structural image is called a PLAPS. • BIRTH OF TWO PROTCOL BASED ON PRINCIPLE AND TOOLS OF LUCI: • BLUE AND FALLS PROTOCOL
- 51. Techniques
- 52. Profiles of lung echopattern • A-profile: anterior lung-sliding with A-lines • A'-profile: A-profile with abolished lung sliding with a lines • B-profile: anterior lung-sliding with lung rockets • B'-profile: B-profile with abolished lung sliding • A/B-profile (C) : unilateral B lines, contralateral A-lines
- 53. BLUE PROTCOL
- 54. OTHER FOCUSED PROTOCOL • FALLS • RUSH (Cardiac) • FATE(Cardiac) • RADiUS(The Rapid Assessment of Dyspnea with Ultrasound)
- 55. Algorithm of RADiUS Begin Ultrasound Examination 1. Focused cardiac evaluation 2. IVC assessment of fluid status 3. Pleural effusion evaluation 4. Evaluation of pleura for PTX, interstitial syndrome, PNA, etc.
- 56. THANK YOU
- 58. Techniques 1 .Second intercostal space at midclavicular line (anterior chest wall) 2. Fourth or fifth intercostal space at the midaxillary line (anterolateral chest wall) 3. Posterior part of the lung and pleura may be scanned with patient in upright position
- 59. Common differential diagnosis of Usg Findings USG FINDINS COMMON DIFFERENTIALS A lines Normal findings Asthma and Copd Pneumothorax B lines Normal findings Pulmonary edema ARDS Pulmonary Fibrosis Lung contusion E lines Subcutaneous Emphysema Absent lung sliding Pneumothorax One-lung entubation Total atelectasis Pleuroparenchymal adhesions Subpleural blebs or bullae
Editor's Notes
- Chest radiography is the mainstay imaging modality used in both traumatic and nontraumatic settings. Although computed tomography (CT) is definitive in most acute conditions, attention has recently turned to ultrasonography (US) because of its wide availability, lower cost, the ability to perform the test at the patient’s bedside, real-time evaluation, and lack of radiation exposure. In acute trauma patients who are in unstable condition and those with multiorgan injuries, thoracic US is performed predominantly to help diagnose pneumothorax and hemothorax. This examination follows a routine interrogation with the extended part of the focused assessment with sonography for trauma. For evaluation of patients with isolated thoracic trauma in whom the primary suspicion is for pleural and chest wall injuries, US is performed to help diagnose hemothorax, pneumothorax, and fractures. In patients with acute dyspnea or chest pain, lung and pleura US and focused cardiac US are often combined with US of the inferior vena cava and compression US of the groin areas.
- Presenting COMPLAINT with chest pain dyspnea trauma and pulmonary infection. Etiologies can range from benign causes to life-threatening causes requiring immediate attention and may vary from pathologic conditions of the respiratory tract, cardiovascular system, and thoracic wall to abdominal diseases. US interrogations of IVC for volume assessment and deep venous thrombosis for thrombosis.
- High acoustic mismatch between (a) aerated lung tissues and (b) the pleura and thoracic wall casts a total reflection of the sound wave; therefore, only the superficial portion of the aerated lungs underneath the interface is seen, along with the thoracic wall structures and pleural cavity. When air content within the lungs decreases or fluid content increases secondary to blood or exudative or transudative fluid, the acoustic mismatch is lowered, and the ultrasound wave can partly demonstrate the deeper pulmonary parenchymal structures. It is important to note that many signs at lung US represent artifacts occurring naturally because of acoustic mismatch of tissues reflecting sound waves. ARTEFACTS THAT PLAY ROLE ARE REVERBATION AND ACOUSTIC SHADOWING
- In addition, assessment of IVC and lower limb veins.
- The four chest areas per side considered for complete eight zone lung ultrasound examination. These areas are used to evaluate for the presence of interstitial syndrome. Areas 1 and 2 denote the upper anterior and lower anterior chest areas, respectively. Areas 3 and 4 denote the upper lateral and basal lateral chest areas, respectively. PSL parasternal line, AAL anterior axillary line, PAL posterior axillary line Source : International evidence-based recommendations for point-of-care lung ultrasound. 2012.
- Abdominal approach RUQ AND LUQ VIEW
- Scanning zones using a 14-zone approach. The numbers of the zones denote the optimal scanning sequence. When scanning the lateral and posterior surfaces of the thorax, the examination should begin in the most caudal zones (e.g. zones 3 and 5) to ensure accurate identification of the border (diaphragm) between the chest and upper abdomen. Thoracic Ultrasound Edited by Christian B. Laursen, Najib M. Rahman and Giovanni Volpicelli Editor in Chief Robert Bals 2018
- Lung ultrasound how we do it ??? Biomed central article
- Supine position; subxiphoid view: place the transducer obliquely over the epigastrium, and point it toward the patient’s left shoulder; PSLA view: place the transducer to the left of the sternal border within the second, third, or fourth intercostal space and parallel to the long axis of the heart; PSSA view: after obtaining the PSLA view, turn the transducer 908, and move the transducer from the cardiac base to the apex; Source: Emergency thoracic us rsna. Radius 9–12-MHz lineararray transducer, turn off imagesmoothing algorithms
- Apical four-chamber view: place the transducer at the fifth intercostal space in the left midclavicular line (cardiac apex), pointing it toward the patient’s right shoulder 3.5–5.0-MHz phased-array or curvilinear-array transducer Supine position, B-mode or Mmode, place the transducer sagittally at the epigastrium, angle it until the IVC is depicted in a longitudinal plane as it enters the RA, measure the IVC diameter at 2–3 cm below the IVC-RA junction during quiet respiration 3.5–5.0-MHz curvilinear-array transducer Source Rsna and thoracic ultrasound book
- (Rumark)
- Bat sign (B-mode): a curvilinear hyperechoic interface with posterior acoustic shadowing from the two adjacent ribs; in the intercostal space about 1–1.5 cm deep to the anterior rib surface is a hyperechoic pleural interface, or pleural line; lung sliding (B-mode): normal gliding movement between the parietal and visceral pleurae synchronous with respiration; seashore sign (M-mode): a combination of a superficial layer of horizontal lines from the static chest wall and a deep layer of granular appearance from the lung movement. a = subcutaneous fat, b = muscles, c = ribs. Merlin’s space is defined in a longitudinal scan as the surface delimited by the pleural line, the shadow of the ribs and the bottom of the screen. Sagittal M-mode US image shows the seashore sign. d = static thoracic wall, e = granular pattern of the lung. Sagittal power Doppler US image shows the power slide sign Normal rib at US appears as a smooth continuous hyperechoic line with posterior acoustic shadowing, representing the anterior cortex. The posterior cortex is generally not depicted
- A longitudinal image through the liver shows the diaphragm( arrowhead as a curving bright echogenic line which can be observed to move with respiration. Because the lung above the diaphragm is air filled and the pleural space is normal, a mirror-image reflection of the liver is displayed above the diaphragm. The mirror image even reproduces the hepatic veins(HV). The longitudinal through image through spleen shows a five line appearance of diaphragm. The muscle of the diaphragm is seen as a thin hypoechoic lines sandwiched between two echogenic lines representing the membranous coverings of the diaphragm,which reproduces the hypoechoic line of muscle of the diaphragm and its echogenic coverings and the spleen.The presence of mirro-image artifact on scan of the thorax obtained from an abdominal approach is evidence of normal pleural space and normal air filled base of the lung.
- RV: closer to the chest wall on PSLA and PSSA views and deeper to the liver on the subxiphoid view, smaller chamber and thinner myocardium than the LV, crescent shape on PSSA view, free wall moving toward the interventricular septum during systole and outward during diastole; LV: located deeper or further away from the chest wall on PSLA and PSSA views compared with RV, larger chamber and thicker myocardium than the RV, round shape on PSSA view, all walls moving toward the LV cavity during systole, the cavity is not completely obliterated in systole
- Absolute IVC diameter of 1.5–2.5 cm with an inspiratory collapse of <50% Normal US of the inferior vena cava. Sagittal M-mode US image through the liver parenchyma (a) shows the intrahepatic inferior vena cava (b) entering the heart and depicts the respiratory variation of the inferior vena cava diameter (between the calipers).
- Normal IVC. The IVC diameter is measured 2 cm below the cavoatrial junction (arrows) on this parasagittal view.
- ARTEFACTS FROM RSNA AND ADVANCEMENT IN ULTRASOUND
- US image shows multiple A-lines (arrowheads), which are horizontal parallel hyperechoic linear artifacts depicted at regular intervals below the pleural line (arrows). A lines are the repetitive horizontal artifacts arising from the pleural line generated by subpleural air, which, either intraalveolar (normal) or abnormal (pneumothorax), blocks ultrasound waves. A lines represent reverberation artifacts and appear as horizontal, parallel lines equidistant from each. These lines are commonly seen in healthy individuals and may be erased by B lines or enhanced in the presence of pneumothorax.
- B-lines are vertical hyperechoic artifacts originating from the pleural line (arrow) that extend to the edge of the screen and erase the A-lines. B lines represent interlobular septa and appear as small, well-defined vertical comet-tail artifacts perpendicular to and arising from the pleural line. These lines move with the pleural line during respiration and may erase A lines. One or two of these lines may be seen per intercostal space in 30% of healthy individuals, particularly in dependent portions of the lung. B lines indicate filling of intralobular or interlobular septa and are often seen in pulmonary edema and interstitial lung diseases.(1,3) Thickened B lines may fuse together to form coalescent B lines representing peripheral lung ground glass opacities seen in high resolution computed tomography
- The Z-lines are short, ill-defined vertical hyperechoic lines arising from the pleural line (white arrow). They do not reach the edge of the screen, erase the A-lines, or follow the lung sliding. 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.
- US image clearly shows multiple B-lines (arrowheads) and the pleural line (arrows). At real-time imaging, B-lines move synchronously with lung sliding. RSNA. Lung sliding corresponds to the to-and-fro movement of the visceral pleura on the parietal pleura that occurs with respiration.
- M-mode US image shows a bar code sign, or stratosphere sign, a finding that indicates the absence of lung sliding. RSNa
- Loss of lung sliding secondary to pneumothorax in a 41-year-old man who presented with acute chest pain. (a) B-mode US image shows multiple A-lines (arrowheads) and the pleural line (arrows). (b) M-mode US image shows a bar code sign, or stratosphere sign, a finding that indicates the absence of lung sliding. The major criterion to detect a pneumothorax sonographically is the absence of respiratory lung movement during dynamic examination, the so-called lung sliding sign. Adding power color Doppler imaging improves this examination [10] . Further diagnostic criteria are absence of B-lines, absence of lung pulse (in M-mode or power color Doppler) and finally the detection of a lung point. Of note, the results obtained have to be compared with the contralateral site. In seropneumothorax, the mobile airwater level and gas bubbles in the effusion can be visualized.
- Lung point. (a) M-mode US image of a 60-year-old man who sustained blunt thoracic trauma shows an alternating presence and absence of lung sliding. The area between the heads of the double-headed arrow represents a bar code sign, or stratosphere sign. (b) Drawings explain the presence of lung sliding during inspiration (top) but absence of lung sliding during expiration (bottom) because of the different degrees of expansion of the pneumothorax With the patient in the supine position, the area of interest corresponds to the anterior part of the chest on both sides of the thorax, approximately the 3rd–4th intercostal space between the parasternal and the midclavicular lines.
- Coronal US image of a 77-year-old man with congestive heart failure shows a large anechoic right pleural effusion (a). Image obtained in an intercostal space using a linear array transducer shows a pleural effusion as an anechoic space between the parietal pleura covering intercostal muscle and the visceral pleura. Source rumark 3rd rsna
- Small effusion in the costophrenic angle The color Doppler signals in the effusion originate from the pulse- and respiration-synchronous shifting of the fluid and characterize the not completely echo-free formation as an effusion Effusions as little as 5 ml can be identified without problem sonographically laterodorsal in the angle between the chest wall and the diaphragm with patients in either a standing or sitting position. X ray 150ml. Interpleural distance of ≥ 50 mm between posterior chest wall and lung is predictive of pleural effusion ≥ 500 mL Source chest sonography book
- Transverse US image of a 48-year-old woman with tuberculous pleural empyema shows a complex-appearing left pleural effusion (b) with multiple septa and hyperechoic contents. Note the collapsed lung tissues (*). Empyema thoracis is the presence of pus in the pleural space.
- Pleural empyema with several cavities (K). The aspirate from different cavities was sometimes purulent, sometimes serous (R artifact)
- The US appearance of hemothorax is highly variable; it can be anechoic, hypoechoic, or hyperechoic. Hemothorax tends to locate along the dependent portion, mostly in the posterior costophrenic sulcus in supine patients Transverse US image of a 20-year-old man who sustained blunt thoracic trauma shows the heterogeneous echogenicity of a large left pleural effusion (c) secondary to hemothorax. Note the collapsed lung tissues (*). rsna
- Four-chamber view of the heart demonstrates moderate-size pericardial effusion (arrow). Fluid in the posterior pericardial space may be difficult to distinguish from fluid in the posteromedial pleural cavity. Distinction can be made by visualizing the descending thoracic aorta, as pericardial fluid is present anterior to the aorta whereas pleural fluid is posterior. Physiologically, the pleural cavities normally contain approximately 15 mL of serous fluid Pericardial effusions occur when excess fluid collects in the pericardial space (a normal pericardial sac contains approximately 30-50 mL of fluid). Cardiac tamponade is the result of an accumulation of fluid, pus, blood, gas, or benign or malignant neoplastic tissue within the pericardial cavity, which can occur either rapidly or gradually over time, but eventually, results in impaired cardiac output.
- Parasternal long-axis view showing a pericardial effusion. Notice how the pericardial effusion separates the heart from the descending aorta. DA, descending aorta; LA, left atrium; LV, left ventricle; RV, right ventricle. Subxiphoid view showing a pericardial effusion between the liver and right ventricle (RV). The collapse of the RV during diastole indicates tamponade physiology. LA, left atrium; LV, left ventricle; RA, right atrium. Small effusions exist when separation between the heart and parietal pericardium is less than 0.5 cm. Moderate effusions are 0.5 cm to 2 cm, and large effusion are greater than 2 cm.1 RADIUS
- B lines more than 4 abnormal. lines are normally 7 mm apart. that is spacing of interlobular space. Alveolar oedema 3mm spacing of confluence. Spacing of alveoli = ground glass. Blines multiple anterior or lateral position. Kerley b lines = B lines
- Transverse US image of the left lower lung shows a focal subpleural consolidation (*). Parasternal short-axis (c) focused cardiac US images show dilatation of the right ventricle (RV)
- Hypovolemia and volume overload in two different patients. (a) B-mode US images of the inferior vena cava of a 79-year-old woman with upper gastrointestinal bleeding show a small-caliber inferior vena cava (between arrows) and almost total collapse (“kissing” inferior vena cava) on the inspiratory image, findings suggestive of hypovolemia. (b) M-mode US image of a 77-year-old man with congestive heart failure shows no change of the inferior vena cava diameter (between arrowheads) during respiration, a finding consistent with volume overload.
- US interrogations may be performed of the inferior vena cava for volume assessment and of the groin areas for deep venous thrombosis. Focused cardiac and inferior vena cava US can provide information about the cardiac function and volume status of the patients. Volume depletion IVC diameter < 1.5 cm with >50% inspiratory collapse Volume overload IVC diameter > 2.5 cm with <50% inspiratory collapse Rsna two articles need to know. Normal cvp 10 to 12 science direct article
- Rib fractures in a 61-year-old man who sustained blunt thoracic trauma. Longitudinal US images of two adjacent ribs show a curved hyperechoic interface underneath the thoracic wall muscles with posterior acoustic shadowing, a finding that represents the anterior cortex of the ribs. (a) US image shows a minimally displaced rib fracture (arrow). (b) US image shows a displaced rib fracture (arrows) and an adjacent hematoma Rib fracture is the most common thoracic injury, accounting for more than half of thoracic injuries from blunt thoracic trauma. Most rib fractures are non–life-threatening fractures, but they can become clinically important when multiple fractures occur. US mimics of rib fractures include (a) a normal gap at the costochondral junction and (b) an old deformity of the ribs such as acute angulation or partial callus formation. The hyperechoic pleural interface (“pleural line”) may also be mistaken for an anterior rib cortex. Comparison with adjacent or contralateral ribs and correlation with the site of tenderness should easily allow these mimics to be distinguished from a true fracture.
- A nondisplaced fracture may be indirectly identified by reverberation artifacts occurring at the fracture margins, a finding known as the chimney Phenomenon.
- US image shows E-lines (arrows), which are multiple comet-tail artifacts arising superficial to and obscuring the pleural line. The E-lines represent faint hyperechoic artifacts that extend to the edge of the screen. “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 welldefined and also erase A lines, and may therefore be mistaken for true B lines.
- Novel approaches to ultrasonography of the lung and pleural space: where are we now? By Daniel A Lichtenstein posterolateral alveolar and/or pleural syndrome BLUE-Protocol and FALLS-Protocol by Daniel A Lichtenstein Lung ultrasound in the critically ill by Daniel A Lichtenstein
- The BLUE points. The BLUE points respect LUCI principles 3 and 7. They have been made simple for expediting protocols without loss of information. a) The upper BLUE hand (here the hand of the operator, who has checked that the patient’s hand is approximately the same size; if not, rough adaptations are performed) is applied just below the clavicle and parallel to it, the tips of fingers touching the midline. The upper BLUE point is defined at the middle of the upper BLUE hand. The lower BLUE hand is applied just below. The lower BLUE point is defined at the middle of the palm of the lower BLUE hand. The heart is usually avoided using this way. The lung usually stops at the lower finger. b) The PLAPS point is defined by drawing a transverse line from the lower BLUE point until the posterior axillar line is reached (or better, as posterior as possible). Note that the insertion of the probe between the (supine, ventilated) patient and bed sometimes makes perfect acquisition difficult but this makes the posterior lung of such patients accessible to ultrasound.
- Bedside lung ultrasound in emergency (BLUE) is a basic point-of-care ultrasound (POCUS) examination performed for undifferentiated respiratory failure at the bedside, immediately after the physical examination, and before echocardiography. The protocol is simple and dichotomous, and takes fewer than 3 minutes to complete. It analyzes three standardized points on each hemithorax in patients with acute respiratory failure, seeking to establish the presence or absence of: lung sliding anterior lung rockets posterior and/or lateral alveolar and/or pleural syndrome (PLAPS) a noncompressible deep vein Blue and false protocol radiopedia lichestein.
- new ultrasonographic protocol as the rapid assessment of dyspnea with ultrasonography
- Supine position, start at the anterior and anterolateral chest wall (second intercostal space at midclavicular line and at fourth or fifth intercostal space at the midaxillary line), posterior part of the lung and pleura may be scanned with patient in upright position, sagittal plane provides bat sign, longitudinal scan is used for fracture detection.
- Source: RSNA