This document provides an overview of ultrasound applications in the intensive care unit and emergency department. It discusses using ultrasound at the bedside for lung imaging as an alternative to radiography. It describes the signs of pneumothorax, pulmonary edema, pulmonary embolism, and lung consolidation seen on ultrasound. The document also reviews using ultrasound to evaluate the inferior vena cava, heart, and pericardial space. Protocols for lung ultrasound and applications in critically ill patients are presented.

1. Ultrasound in ICU
and Emergency
Gamal Agmy, MD, FCCP
Professor of chest Diseases, Assiut university, Assiut, Egypt

3. Bedside Chest Radiography in the
Critically ill Patients
At the bedside, chest radiography remains the
reference for lung imaging in critically ill patients.
However, radiographical images are often of limited
quality

4. Risk of transportation
Lung Computed Tomography in
the Critically ill
02 09 2012

5. Transthoracic
Sonography

7. (Daniel A. Lichtenstein , MD , FCCP, CHEST
2015; 147 ( 6 ): 1659 - 1670

8. THE BAT VIEW
Chest wall
Pleural line

11. Normal lung surface

12. A lines = default normal
 Horizontal echo
reflection at exact
multiples of intervals
from surface to
bright reflector.
 Dry lung OR PNTX
 Decay with depth
 Obliterated by B
pleura A
A
A
A
A
A

20. the "seashore sign" (Fig.3).

21. • Absent lung sliding
• Exaggerated horizontal artifacts
• Loss of comet-tail artifacts
• Broadening of the pleural line to a band
• Lung point
• Loss of lung impulse
The key sonographic signs of
Pneumothorax

29. Confluent B lines = Bad Bad
 ‘White’ or ‘shining’
lung
 Means increased
severity
 Probably indicates
thicker fluid in alveoli
eg protein or
inflammatory cells
 % space / 10

31. B x 3 x 2 x 2 = CCF
Makes assumption that ‘globally’ wet
lungs are most likely to be CCF
12

32. INTERSTITIAL SYNDROME

33. INTERSTITIAL SYNDROME

38. PULMONARY EMBOLISM

39. PULMONARY EMBOLISM

40. Schematic representation of the parenchymal, pleural and vascular
features associated with pulmonary embolism.(Angelika Reissig, Claus
Kroegel. Respiration 2003;70:441-452)

42. PE DIAGNOSTIC ACCURACY
LUS for diagnosis of PE
Metaanalysis:
- Sens.: 80% (75-83%)
- Spec.: 93% (89-96%)
Niemann T et al. Transthoracic sonography for the detection of pulmonary embolism–a meta-analysis.
Ultraschall Med 2009 30:150–156

43. Ultrasound profiles.
Lichtenstein D A , Mezière G A Chest 2008;134:117-125

45. Tissue pattern representative of Alveolar
Consolidation
Presence of hyperechoic punctiform
imagesrepresentative of air bronchograms
Pleural
effusion
Lower lobe

46. FLUS: IS PRESENT? YES/NO
Normal pattern IS pattern
Cardiogenic pulm. edema:
Excluded – COPD exa?
Cardiogenic pulm. edema:
Suspected

49. BLUE-Protocol and FALLS-Protocol
Two Applications of Lung Ultrasound
in the Critically Ill
(Daniel A. Lichtenstein , MD , FCCP, CHEST
2015; 147 ( 6 ): 1659 - 1670

52. IVC Sonography

53. INDICATIONS
IVC Ultrasound
Spontaneously
Breathing
Mechanical
Ventilation
Volume Status / CVP Fluid Responsiveness

54. Respiratory variation
Expands w/ expiration
Contracts w/ inspiration
Due to changing intrathoracic pressures.

55. PROCEDURE
Probe Selection
1 Low frequency 2-5 MHz
2 Curvalinear probe

56. Where to put the probe…
 Supine position
 Subxiphoid
 Orientate probe in
longitudinal plane with
probe indicator to
patient’s head
 Slightly to right of
midline

57. PROCEDURE
Xiphoid View

58. IVC Longitudinal

59. PROCEDURE
Anterior -Mid-Axillary View

60. IVC Anterior Mid-Axillary View

61. Inspiratory (Minimal) IVC
Diameter

62. Maximum (Expiratory) IVC
Diameter

63. M-Mode IVC Diameters

64. CAVAL INDEX (CI)
CI =
minimal (inspiratory)
diameter
maximum (expiratory)
diameter
maximum (expiratory)
diameter

65. CAVAL INDEX (CI)
Volume
Depletion
Volume
Overload
0% 100%

66. IVC v CVP
Correlation Between IVC Diameter Plus CI and
CVP
IVC Max Diameter
(cm)
CI CVP
(mmHg)
< 1.5
100%
(total collapse)
0-5
1.5-2.5 > 50% 6-10
1.5-2.5 < 50% 11-15
> 2.5 < 50% 16-20
> 2.5
0%
(no collapse)
>20

67. Echocardiography

68. Parasternal long axis
 Transducer at left sternal
edge between 2nd -4th
intercostal space
 Probe marker pointing to
patients R shoulder
 Probe aligned along the
long axis: from R shoulder
to cardiac apex.
 Useful view to assess
contractility

69. Apical 4 chamber
 Transducer at 4th-6th intercostal
space in the midclavicular to
anterior-axillary line.
 Probe directed towards patient’s
right shoulder with the marker
directed towards the left
shoulder.
 Important view to give relative
dimensions of L and R ventricle.
 Normal ventricular diameter
ratio of R ventricle to L ventricle
is <0.7.

71. PericardialTamponade
 Remember tamponade is a clinical diagnosis based on
patient’s haemodynamics and clinical picture.
 Ultrasound may demonstrate early warning signs of
tamponade before the patient becomes haemodynamically
unstable.
 Haemodynamic effects
 Its PRESSURE NOT SIZE THAT COUNTS!
 Rate of formation affects pressure-volume relationship and
is therefore more important than volume of fluid.

72. Tamponade using ultrasound
 A moderate-large effusion.
 Right atrial collapse
 Atrial contraction normal in atrial systole
 Collapse throughout diastole or inversion is abnormal.
 RV collapse during diastole when meant to be filling
(‘scalloping’ seen)