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THE ESSENTIALS OF BEDSIDE ULTRASOUND GUIDED PROCEDURES

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Topics/Contents
Click on each title to navigate to the topic

Trauma/Shock GI/GU
1. Rapid Ultrasound for Shock and 25. Paracentesis - P. 76
Hypotension (RUSH) - P. 4 26. Evaluation for Cholecystitis - P. 79
2. eFAST Exam - P. 8 27. Ultrasound Guided Cholecystostomy - P. 83
3. IVC Evaluation for Volume Status - P. 12 28. Percutaneous Gastrostomy Tube Placement/
Replacement/Visualization - P. 86
29. Small Bowel Obstruction - P. 90
Cardiac
30. Testicular/Ovarian Torsion - P. 92
4. Cardiac Examination - P. 15
31. Ultrasound Guided Percutaneous Liver
5. Ultrasound Guided Pericardiocentesis - P. 18
Biopsy - P. 95
6. Ultrasound Guided Swan-Ganz Catheter
32. Bladder Volume Assessment - P. 98
Insertion - P. 22
33. Ruptured Ectopic Pregnancy - P. 100
7. Contrast Ultrasound for Shunting/PFO - P. 26

Soft Tissue/MSK
Pulmonary
34. Necrotizing Soft-Tissue Infections
8. Ultrasound to Evaluate Pneumothorax - P. 29
(NSTI) - P. 102
9. Evaluation of Pulmonary Edema - P. 31
35. Arthrocentesis - P. 104
10. Thoracentesis - P. 33
36. Incision and Drainage of Abscess - P. 107
11. Ultrasound Evaluation of Pleural Drains
37. Ultrasound Guided Single Injection
(Chest Tubes) - P. 36
Peripheral Nerve Blocks - P. 110
12. Evaluation for Pulmonary Emboli - P. 39
13. Diagnosing Alveolar Interstitial Syndrome -
38. Peripheral Nerve Evaluation - P. 113
P. 42
39. Foreign Body Removal - P. 116
40. Ultrasound Diagnosis of Subperiosteal
Abscess - P. 119
Renal 41. Ultrasound Guided Joint Steroid
14. Dialysis Fistula Planning and Injections - P. 121
Assessment - P. 45
15. Renal Stone Evaluation - P. 47

Neuro
16. Ultrasound Guided Lumbar Puncture - P. 50
17. Ophthalmic Artery Doppler - P. 53
18. Ventriculoperitoneal Shunt Assessment - P. 55

Vascular
19. Central Venous Access - P. 58
20. Femoral Venous Access - P. 61
21. Radial Artery Access - P. 64
22. Diagnostic Whole Leg Ultrasound for
Suspected DVT - P. 67
23. Ultrasound Evaluation for Aortic
Dissection - P. 70
24. Carotid Evaluation - P. 73
 THE ESSENTIALS OF BEDSIDE US GUIDED PROCEDURES

Contributors
❖Jacob Wochna ❖Ian Sullivan
❖Dinh-Huy D. Nguyen ❖Jay Gajera
❖Pouya Aghajafari ❖Sydney Rubin
❖Navjit Dullet ❖Suhag Patel
❖Jonathan Friedman ❖Rakesh S. Ahuja
❖Rick Artrip ❖Rajath Rao
❖Sipan Mathevosian ❖Matthew Chiarello
❖Jonathan Barclay ❖Vikrant Bhatnagar
❖Henry Szeto ❖David Kopylov
Editors

❖Dinh-Huy D. Nguyen
❖Sipan Mathevosian
❖Navjit Dullet
❖Kartik Kansagra
❖Rakesh Ahuja
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THE ESSENTIALS OF BEDSIDE US GUIDED PROCEDURES
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Education Committee of the ICU Service Line- Resident and Fellow Section, Society of Interventional Radiology

Procedure: Rapid Ultrasound for Shock and Hypotension (RUSH)

AUTHORS: EDITORS:
HENRY SZETO NAVJIT DULLET
SIPAN MATHEVOSIAN
Rapid Ultrasound for Shock and Hypotension (RUSH)

Indications
1. Undifferentiated shock and/or hypotension

Absolute Contraindications
1. None

Goals
1. Evaluate for cause of hypotension in a patient by
examining three systems:
a. Pump (heart, pericardium)
b. Tank (IVC, lungs, thoracic and peritoneal
cavities)
c. Pipes (abdominal aorta and lower
extremity veins).
This exam may aid in diagnosing the type of shock
(hypovolemic, cardiogenic, obstructive, or distributive).

Preoperative Preparation
1. None

Procedure
1. Obtain a 3.5–5 MHz phased array transducer and a 7.5–10 MHz linear array transducer. The linear array transducer will be used to
evaluate lungs and lower extremity veins. Use the phased array transducer for all other examinations.

Pump (heart):
2. Place the phased array transducer in parasternal long position.
3. Identify the heart and evaluate contractility, right heart strain, and for pericardial effusion.
4. The transducer may also be placed in the apical or subxiphoid position for a more complete evaluation.

Tank (IVC, thoracic and peritoneal cavities, lungs):

IVC:
5. Place the phased array transducer in a sagittal orientation in the subxiphoid position. Identify the liver, right atrium, and IVC.
6. Observe the IVC for respiratory variation.
7. In M-mode, place the scan line approximately 2cm inferior to cavo-atrial junction. Ensure probe is midline of the IVC for accurate
assessment.
8. Record a clip through inhalation and exhalation. Maximum IVC diameter occurs during exhalation and vice versa. Note this
relationship is reversed in ventilated patients.
9. Measure minimum and maximum diameter of IVC. The IVC compressibility index (CI) is the minimum divided by the maximum
diameter. In general, an IVC diameter >2cm or compressibility index <50% indicates a hypervolemic state or low cardiac output. IVC
compressibility has an inverse relationship with CVP measurement.
IVC < 2.1cm, CI > 50% has an estimated CVP of 0-5 mmHg
IVC > 2.1cm, CI < 50% has an estimated CVP of 10-20mmHg

E-FAST (thoracic and peritoneal cavities, lungs)

RUQ:
10. Place the phased array transducer in the intercostal space between ribs 8-11, posterior to mid-axillary line.
11. Identify the liver and kidney interface (Morrison’s pouch) and evaluate the entirety of the space for fluid. Next, slide the probe
cephalad and evaluate for fluid above the diaphragm. The probe may be obliqued parallel to ribs to eliminate rib shadowing.

LUQ:
12. Place the phased array transducer in the intercostal space between ribs 6-9, along the posterior axillary line. Identify the spleen-kidney
interface and evaluate perisplenic and splenorenal spaces for fluid. Next, slide the probe cephalad and evaluate for fluid above the
diaphragm.

Suprapubic:

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 13. Place the phased array transducer immediately superior to the pubic symphysis in a transverse orientation. Fan cephalad and caudad to
evaluate for free fluid posterior to the bladder. In men, free fluid collects in the rectovesical space. In women, free fluid may collect in
the rectouterine or vesico-uterine spaces.
14. Rotate the probe to a sagittal orientation and fan right and left to re-evaluate these spaces.

Anterior Thorax:
15. Place the linear array transducer in a sagittal orientation on the third or fourth intercostal space, along the mid-clavicular line. Evaluate
for lung sliding. Repeat on other side. Absence of lung sliding is strongly suggestive of pneumothorax. In a semi-supine patient, air is
most likely to accumulate anteriorly.
16. Switch to the phased array transducer and place on anterolateral position in the intercostal spaces between ribs 2-5. Evaluate for B-
lines, which would appear as “spotlights” emerging from the pleural line and extending into the far field. This is suggestive of
pulmonary edema.

Pipes (abdominal aorta, femoral and popliteal veins):

Aorta:
17. Place the phased array transducer in transverse orientation on the midline near the epigastrium. Identify the aorta, which is the thicker
walled, pulsatile vessel to the anatomical left of the IVC. If bowel gas obscures vision, apply steady pressure to transducer to displace
bowel gas.
18. Evaluate for aneurysm or dissection. An outer wall-to-outer wall diameter of >3cm is abnormal. Risk of rupture is greatly increased
when aneurysm diameter is >5cm.
19. Re-evaluate in sagittal position to characterize shape of aneurysm.
20. Slide transducer caudal until the iliac bifurcation to evaluate the infrarenal aorta in both transverse and sagittal orientation.
21. If a dissection is identified, evaluate the flow within the true and false lumens with color flow and note the extent of dissection.
Femoral and popliteal veins:
22. Place the linear array transducer in a transverse orientation on the common femoral vein, just below the inguinal ligament. The vein is
medial to the artery and is compressible.
23. Scan inferiorly towards the confluence of the saphenous, superficial, and deep femoral veins. Compress periodically while scanning.
A thrombus will appear as a non-compressible, hyperechoic mass within the lumen of the vein. Repeat on the other leg.
24. Next, place the transducer in a transverse orientation posterior to the knee. Identify the popliteal vein.
25. Begin scanning in the superior part of the popliteal fossa and proceed inferiorly until the trifurcation of the calf veins. Compress
periodically to evaluate for thrombus.

Rush protocol summary:

Figure from Seif, D., et al. Bedside Ultrasound in Resuscitation and the Rapid Ultrasound in Shock Protocol. 2012.

3
Actionability
1. This screening exam rapidly evaluates for potential causes of shock and hypotension to guide treatment of a critically ill patient.

References
1. Weingard, Scott D., Duque, D., and Nelson, B., The Rush Exam: Rapid Ultrasound for Shock and Hypotension. EMcrit 2008.
http://emcrit.org/rush-exam/ Accessed 27 Dec 2018.
2. Perera, P., Mailhot, T., Riley, D., and Mandavia, D. The RUSH Exam: Rapid Ultrasound in SHock in the Evaluation of the Critically
Ill. Emerg Med Clin N Am 28(2010) 29-56. doi:10.1016/j.emc.2009.09.010
3. Seif, D., Perera, P., Mailhot, T., et al. Bedside Ultrasound in Resuscitation and the Rapid Ultrasound in Shock Protocol. Critical Care
Research and Practice 2012;2012, Article ID 503254, 14 pages. doi:10.1155/2012/503254.
4. http://www.mmheme.org/ultrasound-modules/2015/4/15/echocardiography

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THE ESSENTIALS OF BEDSIDE US GUIDED PROCEDURES
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Procedure: eFAST Exam

AUTHORS: EDITORS:
HENRY SZETO DINH-HUY D. NGUYEN
NAVJIT DULLET
eFAST Exam

Goals
1. Evaluate for free fluid in thoracic and peritoneal cavities, hemopericardium, pneumothorax, and fluid status of patient.

Indications
1. Traumatic injury to chest or abdomen

2. Undifferentiated shock and/or hypotension

Absolute Contraindications
1. None

Preoperative Preparation
2. None

Technique
1. Obtain a 2–5 MHz phased array or curvilinear probe.

❖ Pericardium:

2. Place the transducer in subxiphoid position. Identify the heart and evaluate for injury/hemopericardium. If body habitus
prevents good visualization, the transducer may be placed in parasternal long position.

❖ RUQ:

3. Place the transducer in the intercostal space between ribs 8-11, posterior to mid-axillary line. Identify the liver and kidney
interface (Morrison’s pouch) and evaluate the entirety of the space. Next, slide the probe cephalad and evaluate for fluid
above the diaphragm. The probe may be obliqued parallel to ribs to eliminate shadowing.

❖ LUQ:

4. Place the transducer in the intercostal space between ribs 6-9, along the posterior axillary line. Identify the spleen-kidney
interface and evaluate perisplenic and splenorenal spaces. Next, slide the probe cephalad and evaluate for fluid above the
diaphragm.

❖ Suprapubic:

5. Place the transducer immediately superior to the pubic symphysis in a transverse orientation. Fan cephalad and caudad to
evaluate for free fluid posterior to the bladder. In men, free fluid collects in the rectovesical space. In women, free fluid
may collect in the rectouterine or vesico-uterine spaces. Rotate the probe to a sagittal orientation and fan right and left to
re-evaluate these spaces.

❖ Anterior Thorax

6. Place the transducer in a sagittal orientation on the third or fourth intercostal space, along the mid-clavicular line. Evaluate
for lung sliding. Repeat on other side.

❖ IVC

7. Place the transducer in a sagittal orientation in the subxiphoid position. Identify the liver, right atrium, and IVC.

8. In M-mode, place the scan line approximately 2cm inferior to cavo-atrial junction. Ensure probe is midline of the IVC for
accurate assessment.

9. Record a clip through inhalation and exhalation. Maximum IVC diameter occurs during exhalation and vice versa.

10. Measure minimum and maximum diameter of IVC. Divide the minimum by the maximum diameter. This is the IVC
compressibility index. In general, an IVC diameter >2cm or compressibility index <50% indicates a hypervolemic state.
IVC compressibility has an inverse relationship with CVP measurements.

2
Actionability
1. This screening exam can help triage unstable patients for emergent operation or advanced imaging (CT) and stable patients
for advanced imaging (CT), serial eFAST exams, or observation.
2. FAST exam may need to be repeated if there is persistent or new onset hypotension.

Images

Image: RUQ ultrasound view showing hepatic heterogeneity and fluid surrounding the liver after trauma. Image from Richards J,
McGahan J. Focused Assessment with Sonography in Trauma (FAST) in 2017: What Radiologists Can Learn.

Image: LUQ ultrasound view showing splenic laceration and hematoma. Image from Richards J, McGahan J. Focused Assessment
with Sonography in Trauma (FAST) in 2017: What Radiologists Can Learn.

Image: Subxiphoid view showing hemopericardium. Image from Richards J, McGahan J. Focused Assessment with Sonography in
Trauma (FAST) in 2017: What Radiologists Can Learn.

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 Image: pneumothorax visualized, a-lines are far more prominent and numerous than in normal lung, absence of lung sliding will also
be seen. B lines and comet tails are less likely to occur in the presence of pneumothorax. Image from Richards J, McGahan J. Focused
Assessment with Sonography in Trauma (FAST) in 2017: What Radiologists Can Learn.

References
1. Richards, J R and McGahan J P. Focused Assessment with Sonography in Trauma (FAST) in 2017: What Radiologists Can
Learn. Radiology 2017; 283:30-48.
2. Bloom, B A and Gibbons, R C. Focused Assessment with Sonography for Trauma (FAST). StatPearls 2018.
3. Richards JR, McGahan JP. Focused Assessment with Sonography in Trauma (FAST) in 2017: What Radiologists Can
Learn. Radiology. 2017;283(1):30-48.

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THE ESSENTIALS OF BEDSIDE US GUIDED PROCEDURES

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Procedure: IVC Volume Status

AUTHORS: EDITORS:

NAVJIT DULLET NAVJIT DULLET

IVC Volume Status
Indications
1. Assessing and monitoring intravascular volume status in patients, such as treatment of CHF exacerbation or hypovolemic shock. This
study can be used to determine whether a patient should be for their diaries, or whether they are in need of additional fluids. This can
be used as a supplementation, or temporary substitute to more invasive measures, such as CBP monitorization or pulmonary artery
catheterization.

Absolute Contraindications:
1. None

Preoperative Preparation:
1. None

Procedure
1. Position the patient supine, as level as allowable.
2. Select the 5 – 1 MHz transducer cardiac type transducer.
3. Place the transducer and the sub-xyphoid position. Identify the IVC, right atrium, and liver.
4. Use M – mode to measure the diameter of the IVC. Place the single scanline at a point along the IVC, approximately 2 cm inferior to
the right atrium – IVC junction. Also ensure that the probe is at the midline of the IVC to ensure accurate measurement of IVC
diameter.
5. Save the clip through inhalation – exhalation. Maximum diameter occurs in exhalation, minimum diameter occurs in inhalation.
6. Measure the minimum and maximum diameter of the IVC. The IVC compressibility index (IVC – CI) can be calculated using this
number. It can give an indication of intravascular volume status. This is calculated by dividing the minimum diameter by the
maximum diameter.
7. The compressibility index gives an indication of the variability in IVC size throughout the respiratory cycle, which can correlate with
intravascular volume status and cardiac function. In general, IVC diameter > 2cm or a compressibility of <50% indicates a
hypervolemic state. IVC compressibility has an inverse relationship with CVP measurements.
8. Kircher et al. found a correlation between IVC size, percent compressibility, and mmHg CVP, shown in the chart below.
IVC Size (cm) Percent of Collapsibility (%) CVP (mmHg)
<1.5 >50 0-5
1.5-2.5 >50 6-10
1.5-2.5 <50 11-15
>2.5 <50 16-20

Actionability
1. These measurements can provide indication of whether diuresis or fluid replacement is necessary. Values between 15 – 50% have
been found to be diagnostic for heart failure, and variation of 15% or less in IVC diameter has been found to be diagnostic for CHF.

Images

Image: US view showing the inferior vena cava. Photo credit radiopaedia.org

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 Image: M-Mode of the IVC, showing maximal and minimal measurements used for the calculation of IVC-CI. Image credit criticalecho.com.

References
1. Kelly N, Esteve R, Papadimos TJ, et al. Clinician-performed ultrasound in hemodynamic and cardiac assessment: a synopsis of
current indications and limitations. Eur J Trauma Emerg Surg 2015;41(5):469-80.
2. Saha NM, Barbat JJ, Fedson S, et al. Outpatient Use of Focused Cardiac Ultrasound to Assess the Inferior Vena Cava in Patients With
Heart Failure. Am J Cardiol 2015;116(8):1224-8.
3. Stawicki SP, Braslow BM, Panebianco NL, et al. Intensivist use of hand-carried ultrasonography to measure IVC collapsibility in
estimating intravascular volume status: correlations with CVP. J Am Coll Surg 2009;209(1):55-61.
4. Carroll D. Inferior Vena Cava. https://radiopaedia.org/cases/inferior-vena-cava-ultrasound-2?lang=us.
5. Tutorial 6 – Volume status and preload responsiveness assessment. https://criticalecho.com/tutorial-4-volume-status-and-preload-
responsiveness-assessment.

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Procedure: Cardiac Exam

AUTHORS: EDITORS:

NAVJIT DULLET
Cardiac Exam
Indications
1. Focused cardiac ultrasound examination is performed to evaluate cardiac function, pericardial effusion/tamponade, and volume status.
Point-of-care ultrasonography of the heart does not provide as detailed images as proper echocardiographic, so it’s uses are more
limited. Thus, focused point-of-care ultrasound is not the best test for evaluation of the valve function.

Goals
1. to identify LV dimensions and systolic function, right ventricular systolic function, volume status, and pericardial effusion/tamponade
physiology.

Contraindications
1. There are no absolute contraindications for this study

Procedure
1. Obtain a 5 – 1 MHz cardiac transducer point-of-care ultrasound device.
2. Parasternal long axis is performed with the transducer in the 3rd or 4th intercostal space. The notch of the probe must be directed
towards the sternum. The probe should be placed at the left lateral border of the sternum, just at the sternal – costal angle. If you can’t
obtain a good image, then move to the next lower intercostal space. There should be visualization of the right ventricle, left ventricle,
mitral valve, aortic valve, interventricular septum.
3. Apical 4 chamber view is performed with the probe at the apex of the left ventricle, located at the apical impulse. The probe is
oriented towards the right shoulder, with the notch at the 2 or 3 o’clock position. The left ventricle, left atrium, right ventricle, and
right atrium should be visualized.
4. Subcostal views may be the only views available to ventilated patients. Subcostal views can be both short axis and 4 chamber. With
this view, the transducer will be placed under the xyphoid, with the notch at the 3 o’clock position. The probe is oriented towards the
patient’s sternum. In order to get this view, the probe can be placed vertically 3 cm below the xyphoid, then angled upward until the 4
chambers are visualized.
5. Using these views, the area surrounding the ventricles and pericardium can be visualized for fluid, signifying pericardial effusion or
cardiac tamponade.
6. Parasternal long axis view can be used to evaluate left ventricular function and left atrial enlargement. Left atrial enlargement has been
found to be characterized by a maximum end systolic diameter of greater than 4 cm
7. LV dysfunction can be considered when mitral E point separation (see figure below, also known as EPSS) is greater than 7mm. This is
the distance between the mitral valve and the septum in early diastole. EPSS > 7mm correlates with a low EF (~30%).
8. and left ventricular systolic dysfunction can be considered present when mitral valve anterior leaflet “E-point” (point of greatest
amplitude of the anterior leaflet of the mitral valve on M – mode) to septum separation greater than 1 cm in early diastole, which
corresponds to an ejection fraction of less than 55%.

Actionability
1. This exam can indicate whether a patient may have pericardial effusion progressing to tamponade, whether the patient is in heart
failure, or even an indication of volume status for the patient, however and IVC exam would be better suited for this purpose.

Images

Figure: parasternal long axis view. LA (left atrium), MV (mitral valve), ALMV (anterior leaflet, mitral valve), PLMV (posterior leaflet, mitral
valve), LV (left ventricle), IVS (interventricular septum), PWLV (posterior wall, left ventricle), DA (descending aorta), AO (ascending aorta),
AoV (aortic valve), RVOT (right ventricular outflow tract). Photo credit radiopaedia.org

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 Figure: Apical 4 chamber view. LA (left atrium), RA (right atrium), IAS (interatrial septum), MV (mitral valve), TV (tricuspid valve), MVAL
(mitral valve anterior leaflet), MVPL (mitral valve, posterior leaflet), LV (left ventricle), IVS (interventricular septum), TVAL (tricuspid valve
anterior leaflet) TVSL (tricuspid valve anterior leaflet) RSPV (right superior pulmonic vein) LIPV (left inferior pulmonic vein). Photo credit
radiopaedia.org

Figure: M mode showing E wave and A wave. Photo credit: Sief D et al. Bedside Ultrasound in Resuscitation and the Rapid Ultrasound in Shock
Protocol. Critical Care Research and Practice. Oct 2012.

Video References
1. https://www.sonosite.com/media-library/3d-how-parasternal-long-axis-view
2. https://www.sonosite.com/media-library/3d-how-apical-4-chamber-view

References
1. Kelly N, Esteve R, Papadimos TJ, et al. Clinician-performed ultrasound in hemodynamic and cardiac assessment: a synopsis of
current indications and limitations. Eur J Trauma Emerg Surg 2015;41(5):469-80.
2. Kimura BJ, Gilcrease GW, 3rd, Showalter BK, et al. Diagnostic performance of a pocket-sized ultrasound device for quick-look
cardiac imaging. Am J Emerg Med 2012;30(1):32-6.
3. Kimura BJ, Yogo N, O'Connell CW, et al. Cardiopulmonary limited ultrasound examination for "quick-look" bedside application. Am
J Cardiol 2011;108(4):586-90.
4. Via G, Hussain A, Wells M, et al. International evidence-based recommendations for focused cardiac ultrasound. J Am Soc
Echocardiogr 2014;27(7):683 e1-83 e33.
5. Parasternal long axis view - normal (transthoracic echocardiography). https://radiopaedia.org/cases/parasternal-long-axis-view-
normal-transthoracic-echocardiography?lang=us.
6. Apical 4 Chamber View. https://radiopaedia.org/cases/apical-4-chamber-view-normal-transthoracic-echocardiography?lang=us.
7. Diastolic Dysfunction (point of care ultrasound). https://radiopaedia.org/articles/diastolic-dysfunction-point-of-care-
ultrasound?lang=us.
8. Left ventricular ejection fraction (echocardiography). https://radiopaedia.org/articles/left-ventricular-ejection-fraction-
echocardiography?lang=us.
9. Kimura BJ, Yogo N, O'Connell CW, et al. Cardiopulmonary limited ultrasound examination for "quick-look" bedside application. Am
J Cardiol 2011;108(4):586-90.

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THE ESSENTIALS OF BEDSIDE US GUIDED PROCEDURES

Brought to you by:

Education Committee of the ICU Service Line- Resident and Fellow Section, Society of Interventional Radiology

Procedure: Ultrasound Guided Pericardiocentesis

AUTHORS: EDITORS:

VIKRANT BHATNAGAR NAVJIT DULLET

SIPAN MATHEVOSIAN
Ultrasound Guided Pericardiocentesis

Goal
1. To use a portable ultrasound to guide pericardiocentesis to aspirate fluid from the pericardial sac

Indications
1. Cardiac tamponade
2. Symptomatic pericardial effusion with hemodynamic compromise. Without hemodynamic compromise, US pericardiocentesis can be
considered in cases refractory to medical management
3. Large pericardial effusion, with size < 2cm
4. Suspicion of infectious pericardial effusion (TB, bacterial, fungal)

Contraindications
1. Aortic dissection
2. Myocardial rupture
3. Traumatic effusion with hemodynamic instability
4. 1-3 warrant immediate surgical intervention rather than US pericardiocentesis. Pericardiocentesis can be considered in a case-by-case
basis if the patient decompensates on the way to surgical intervention.
5. Relative contraindications are uncorrected coagulopathy, thrombocytopenia, and anticoagulant use

Equipment
1. 18 gauge spinal needle OR large bore needle from a central line kit
2. 20 or 30cc syringe
3. Local anesthetic
4. 25 gauge (1.5 inch) needle for anesthetic
5. Sterile supplies: betadine and drape
6. Catheter or trocar needle kit if continued drainage required
7. Type and cross for patient as blood products may be needed in case of complications

Consent
Discuss possible complications/risks including:
1. Bleeding
2. Infection
3. Damage to adjacent structures
4. Local anesthesia
5. Entry site hematoma
6. Arrhythmia
7. Myocardial damage
8. Cardiac perforation
9. Pneumothorax
10. Mortality

Procedure
1. Identify an approach that opens to the largest effusion pocket. Several different methods exist, including apical, parasternal, and
subxiphoid
2. Parasternal carries a risk of pneumothorax and damage to intercostal vessels
3. Apical carries a risk of ventricular puncture and pneumothorax
4. Subxiphoid may not be optimal due to distribution of pericardial effusion, path to reach effusion pocket may be longer, and structures
(i.e. liver) may be inadvertently traversed.
5. Patient should be positioned at 30 degrees, with slight rotation to left side to enhance effusion fluid collection in anterior/inferior part
of chest
6. Sub-Xiphoid Approach
a. Place probe in Sub-Xiphoid area, angled up into chest using liver as window
b. You should first see Right Ventricle (RV)
c. Pericardial effusion will be a black anechoic area above the RV
d. Evaluate the IVC, will be enlarged
e. Use measurement markers on Ultrasound monitor to measure the distance between RV and where needle will be inserted
f. Add local anesthetic with a standard 25g (1.5 inch) needle over the site of planned entry

2
 g. Utilize a 18 gauge 15cm needle for entry to effusion
h. Typical entry point is 1cm inferior to the left xiphocostal angle. Once needle beneath cartilage cage, lower needle angle to
30 degrees to the chest wall. Advance needle towards left mid-clavicle.
i. Needle will appear on screen and should guide advancement
j. Aspirate and advance needle every 1-2 mm until fluid drawn back
k. Once blood aspirated, inject agitated saline (~5mL) to confirm appropriate location under ultrasound
l. If trochar technique used, advance catheter over needle, remove needle. Otherwise, insert guidewire through needle to
pericardial space, and exchange needle for drainage catheter over guidewire using Seldinger technique
m. Utilize sheath needle, j-wire, and drainage catheter for aspiration of pericardial fluid
7. Parasternal Approach
a. Place probe in Left Parasternal position in the 4th or 5th intercostal space
b. You should first visualize anterior part of the right ventricle (RV) first
c. Pericardial effusion will be seen as a black anechoic area above the RV
d. Use measurement markers on Ultrasound monitor to measure the distance between RV and chest wall where needle will be
inserted
e. Add local anesthetic with a standard 25g (1.5 inch) needle over the site of planned entry
f. Utilize a 18 gauge 9cm needle for entry to effusion
g. Needle inserted parallel to probe and directed at 45 degree angle towards effusion
h. Needle will appear on screen and should guide advancement
i. Aspirate and advance needle every 1-2 mm until fluid drawn back
j. Once blood aspirated, inject agitated saline (~5mL) to confirm appropriate location under ultrasound
k. If trochar technique used, advance catheter over needle, remove needle. Otherwise, insert guidewire through needle to
pericardial space, and exchange needle for drainage catheter over guidewire using Seldinger technique
8. Pericardial drain can be left in place for 24-72 hours, which should be a sufficient time to prevent recurrence
9. Limit acute pericardial fluid drainage to less than 500mL to avoid pericardial decompression syndrome.

Image courtesy of FOAMcast

3
Complications
1. Mortality
2. Arrhythmia
3. Cardiac Perforation
4. Pericardial/Epicardial Thrombus
5. Injury to neighboring structures, including arteries/veins, diaphragm, liver
6. Pneumothorax
7. Infection
8. Bleeding
9. Transient hypotension from vagal stimulation
10. Pericardiocentesis catheter occlusion

References
1. Osman A, Wan Chuan T, Ab Rahman J, Via G, Tavazzi G. Ultrasound-guided pericardiocentesis: a novel parasternal approach. Eur J
Emerg Med. 2018;25(5):322-7.
2. Kumar R, Sinha A, Lin MJ, et al. Complications of pericardiocentesis: A clinical synopsis. Int J Crit Illn Inj Sci. 2015;5(3):206-12.
3. Gluer, R., Murdoch, D., Haqqani, H. M., et al. Pericardiocentesis–How to do it. Heart, Lung and Circulation 2015; 24(6): 621-625.
4. Carmody K, et al. Handbook of Critical Care & Emergency Ultrasound. McGraw Hill. 2011
5. Heffner A. Emergency Pericardiocentesis. Up to Date. May 2019. https://www.uptodate.com/contents/emergency-pericardiocentesis.
6. http://foamcast.org/2016/08/08/episode-54-the-pericardium/

4
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Procedure: Ultrasound Guided Swan-Ganz Catheter Insertion

AUTHORS: EDITORS:

VIKRANT BHATNAGAR DINH-HUY D. NGUYEN

Ultrasound Guided Swan-Ganz Catheter Insertion
Goal
1. To use a portable ultrasound to guide swan-ganz catheter insertion in the pulmonary artery

Indications
1. Cardiovascular illnesses such as pulmonary hypertension, cardiogenic shock, mixed shock states, cardiac tamponade, mechanical
complications of STEMI (e.g., RV infarction, ventricular septal rupture, and papillary muscle rupture), evaluation for heart or lung
transplantation.

Contraindications
1. Patients with septic shock, ARDS, acute decompensated heart failure, undergoing high risk surgery, right-sided endocarditis, tumors,
or masses, severe coagulopathy and thrombocytopenia. Relative contraindication is the presence of left bundle branch block.

Equipment
1. 2-D Ultrasound
2. Pulmonary-artery catheter is 110 cm long and 5 to 8 French in diameter
3. This catheter has 4 lumens:
i. Blue lumen/CVP port represent the Right Atrial Lumen - 30 cm from the tip of the catheter and rests within the RA.
ii. White/Clear lumen terminates close to the prior lumen - 31 cm from the tip of the catheter and lies in the RA. This port is used
for infusion.
iii. Yellow lumen is the pulmonary artery (PA) lumen is the distal port at the tip of the catheter. Used for PA pressure
measurement.
iv. Red port is the balloon port. Helps place the tip of the catheter in the PA. Use air to inflate balloon.
v. Thermistor is a red/white connector that contains a temperature-sensitive wire that terminates 4 cm proximal to the tip of the
catheter. Connection of the thermistor port to cardiac output (CO) monitor allows determination of a CO using thermodilution.
4. Electronic pressure monitor, preferably one capable of displaying multiple tracings simultaneously
5. Local anesthetic, 25 gauge (1.5 inch) needle for anesthetic, 10 cc syringe
6. 18-gauge introducer needle
7. Guidewire
8. #11 blade scalpel
9. Introducer sheath with an internal obturator
10. Sutures, a needle driver, scissors, and an antibiotic-impregnated adhesive dressing.
11. Sterile supplies: saline flushes, chlorhexidine, drape, surgical cap, mask with eye shield, gown, gloves
12. CAUTION: catheter tip may induce ventricular arrhythmias, a defibrillator and transvenous pacemaker should be available at all
times.

Procedure:
1. Use high-frequency vascular probe on the ultrasound to identify correct vessel and that no thrombus exists in the vessel.
i. Right Internal Jugular Vein and Left Subclavian Veins are preferred.
2. Prep and drap in usual sterile fashion.
3. Use a sterile ultrasound probe to identify the R-IJV and use the 25-gauge needle to infiltrate the skin and subcutaneous tissue with
lidocaine.
4. Insert the introducer sheath using modified Seldinger technique
5. Advance the 18-gauge needle into the vein while applying negative pressure to the syringe. Use Ultrasound to visualize needle entry.
6. Once dark-red, non-pulsatile blood is aspirated, remove the syringe and insert the guidewire through the needle.
7. Use the scalpel to make a 3-4 mm incision adjacent to the needle, and then remove the needle. While holding the guidewire to ensure
that it remains accessible and does not embolize, insert the sheath over the guidewire until the hub fills the wound.
8. Remove guidewire from the sheath, and then attach a sterile flush to the port to ensure brisk flow.
9. Attach the distal port of the pulmonary-artery catheter to the main pressure monitor.
10. Place the catheter tip level with the patient's heart, and set the pressure to zero.
11. Orient the catheter so that its curvature follows its expected path, and then insert it into the sheath.
12. Advance the catheter to 15 cm (i.e., halfway between the first two thin marks), at which point its tip will lie outside the sheath, and
then inflate the balloon.

2
13. Continue to advance the catheter until a RA pressure waveform is transduced.
14. The distance to the RA is typically 15 to 20 cm from an IJ or subclavian vein
15. Advance the catheter another 5 to 10 cm until a RV pressure waveform is transduced.

16. Advance the catheter another 5 to 10 cm until a PA pressure waveform is transduced

17. Advance the catheter until the waveform indicating pulmonary-capillary wedge pressure is transduced

18. Once measurements have been completed, deflate the balloon and confirm the reappearance of a PA pressure waveform. If this
waveform does not reappear, slowly withdraw the catheter until it does.
19. Aspirate blood from the distal port to measure the mixed venous oxygen or pulmonary-artery saturation.
20. Note the final position of the catheter. Confirm that the balloon has deflated.
21. Fasten the plastic sleeve to the sheath, which will secure the catheter and reduce the risk of infection.
22. Suture the sheath to the skin and apply adhesive dressing.

3
Potential Complications:
1. Infection of the insertion site
2. Ventricular arrhythmias and right bundle-branch block
3. Air embolism
4. Pulmonary-artery perforation
5. Pulmonary infarction
6. Thrombosis

Resources:
1. Kelly CR, Rabbani LE. N Engl J Med 2013;369:e35.
2. Rodriguez Ziccardi M, Khalid N. Pulmonary Artery Catheterization. [Updated 2019 Feb 16]. In: StatPearls [Internet]. Treasure Island
(FL): StatPearls Publishing; 2019 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482170/
3. Swan HJ, Ganz W, Forrester J, Marcus H, Diamond G, Chonette D. Catheterization of the heart in man with use of a flow-directed
balloon-tipped catheter. N. Engl. J. Med. 1970 Aug 27;283(9):447-51.

4
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THE ESSENTIALS OF BEDSIDE US GUIDED PROCEDURES

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Procedure: Contrast Ultrasound for Shunting/PFO

AUTHORS: EDITORS:
RICK ARTRIP DINH-HUY D. NGUYEN
NAVJIT DULLET
Contrast Ultrasound for Shunting/PFO

Goal
1. To use contrast ultrasound for cardiac shunt detection

Indication
1. Contrast ultrasound can be used for shunt detection, to diagnose a persistent left superior vena cava, and to estimate right ventricular
systolic pressure. Contrast echocardiography can improve echocardiographic border delineation of Doppler signal, permit detection of
R to L shunts and assess myocardial perfusion.

Equipment
1. 2-D Echocardiography system
2. Cardiac ultrasound probe
3. Sterile ultrasound gel
4. Alcohol wipes
5. IV catheter
6. Agitated saline
7. Masks, gowns, gloves for medical personnel

Procedure
1. Obtain consent from the patient
2. Secure IV access in the antecubital fossa if available. If not available, the dorsal surface of the hand. Begin injection of the agitated
saline, which allows for enhanced visualization of the atria and ventricles and allows for identification of a shunt.
3. Parasternal long axis is performed with the transducer in the left 3rd or 4th intercostal space. The notch of the probe must be directed
towards the sternum.
a. The probe should be placed at the left lateral border of the sternum, just at the sternal – costal angle. If you can’t obtain a
good image, then move to the next lower intercostal space. There should be visualization of the right ventricle, left
ventricle, mitral valve, aortic valve, interventricular septum.
4. Apical 4 chamber view is performed with the probe at the apex of the left ventricle, located at the apical impulse.
a. The probe is oriented towards the right shoulder, with the notch at the 2 or 3 o’clock position. The left ventricle, left
atrium, right ventricle, and right atrium should be visualized. Apical four chamber view is the most helpful in identifying
shunts.
5. Subcostal views maybe the only views available to ventilated patients. Subcostal views can be both short axis and 4 chamber. With
this view, the transducer will be placed under the xiphoid, with the notch at the 3 o’clock position.
a. The probe is oriented towards the patient’s sternum. In order to get this view, the probe can be placed vertically 3 cm
below the xiphoid, then angled upward until the 4 chambers are visualized.
6. Using these views, the area surrounding the ventricles and pericardium can be visualized for fluid, signifying pericardial effusion or
cardiac tamponade.
7. Parasternal long axis view can be used to evaluate left ventricular function and left atrial enlargement. Left atrial enlargement has been
found to be characterized by a maximum and systolic diameter of greater than 4 cm, and left ventricular systolic dysfunction can be
considered present when mitral valve anterior leaflet “E-point” (point of greatest amplitude of the anterior leaflet of the mitral valve
on M –mode) to septum separation greater than 1 cm in early diastole, corresponding to an ejection fraction of less than 55%.
8. Imaging will show contrast crossing the atrial or ventricular septum during imaging, this helps with the diagnosis of shunt or PFO.

2
Findings

References
1. Kelly N, Esteve R, Papadimos TJ, et al. Clinician-performed ultrasound in hemodynamic and cardiac assessment: a synopsis of
current indications and limitations. Eur J Trauma Emerg Surg 2015;41(5):469-80.
2. Kimura BJ, Gilcrease GW, 3rd, Showalter BK, et al. Diagnostic performance of a pocket-sized ultrasound device for quick-look
cardiac imaging. Am J Emerg Med 2012;30(1):32-6.
3. Kimura BJ, Yogo N, O&#39;Connell CW, et al. Cardiopulmonary limited ultrasound examination for &quot;quick-look&quot;
bedside application. Am J Cardiol 2011;108(4):586-90.
4. Via G, Hussain A, Wells M, et al. International evidence-based recommendations for focused cardiac ultrasound. J Am Soc
Echocardiogr 2014;27(7):683 e1-83 e33.
5. Image: Michael Main, MD (St. Luke’s Mid America Heart Institute, Kansas City, Missouri).

3
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Procedure: Ultrasound to Evaluate Pneumothorax

AUTHORS: EDITORS:

NAVJIT DULLET SIPAN MATHEVOSIAN

Ultrasound Evaluation of Pneumothorax

Indications
1. Rapid evaluation for when pneumothorax may be suspected. Ultrasound has a high sensitivity and specificity for the diagnosis of
pneumothorax. Delay in diagnosis and treatment may lead to progression of pneumothorax and possibly hemodynamic instability

Absolute Contraindications
1. None

Preoperative Preparation
1. None if only evaluating for the presence of pneumothorax. Sterile procedure and chest tube tray if bedside decompression is
anticipated.

Procedure
1. Obtain a cardiac or linear array high frequency ultrasound probe
2. Air will arise to the least dependent area of the chest. Focus initial ultrasound examination at these locations. In a supine patient, this is
between the 2nd and 4th intercostal spaces, mid-clavicular line. In an upright patient, initial examination should focus on the apical-
lateral position.
3. Place the ultrasound with the indicator pointing cephalad. Identify the ribs with posterior shadowing behind them. Exam will focus on
the area between the two ribs. You should be able to see the layers of pleura and lungs sliding
4. Presence of pleural sliding is an indication of normal aerated lung. This is identified as horizontal movement along the pleural line
5. If available, M-Mode can be used. In M-Mode, a ‘waves on sandy beach’ appearance should appear, indicating movement of the
pleura. M-Mode is especially useful in patients with poor respiratory reserve. The ‘waves’, visualized closest to the probe, represent
the static portion of the chest above the pleural line. The ‘sand’ represents the movement/sliding below the pleural line.
6. Negative predictive value of lung sliding is reported as high as 99-100%.
7. Lung sliding may be absent in additional conditions, including ARDS, pulmonary fibrosis, consolidations, atelectasis, phrenic nerve
paralysis
8. An additional notable feature of pneumothorax is an absence of Comet-tail artifact (which is generated by visceral pleura). These are
not visualized when pneumothorax occurs. Additionally, A-Lines (lines that are parallel to the pleura) will be present in
pneumothorax. The presence of A-lines and absence of comet-tail artifact is a clue that a patient may have a pneumothorax.
9. An example of lung sliding can be seen at https://radiopaedia.org/cases/lung-point-sign-of-pneumothorax-on-ultrasound?lang=us.

References
1. Husain, Lubnaf, et al. “Sonographic Diagnosis of Pneumothorax.” Journal of Emergencies, Trauma, and Shock, vol. 5, no. 1, 2012, p.
76., doi:10.4103/0974-2700.93116.
2. Dixon A. Lung point sign of pneumothorax on ultrasound. Radiopaedia. https://radiopaedia.org/cases/lung-point-sign-of-
pneumothorax-on-ultrasound?lang=us.
3. Patel M. Pneumothorax (ultrasound). Radiopaedia. https://radiopaedia.org/cases/pneumothorax-ultrasound?lang=us.
4. Images courtesy of: em.emory.edu (LEFT); rebelem.com (RIGHT)

2
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THE ESSENTIALS OF BEDSIDE US GUIDED PROCEDURES

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Procedure: Evaluation of Pulmonary Edema

AUTHORS: EDITORS:

NAVJIT DULLET
Evaluation of Pulmonary Edema
Indications
1. Pulmonary congestion and pulmonary edema are a major cause of morbidity and mortality. Pulmonary edema may be both due to
cardiac and noncardiac processes. Physical examination is essential in titrating management for patients with pulmonary edema.
Bedside ultrasound examination is a method to quickly evaluate critically ill patients for the presence and progression of pulmonary
edema.

Goals
1. To use portable bedside ultrasound to assist in the evaluation and management of pulmonary edema in acutely ill patients.

Contraindications
1. There are no absolute contraindications to ultrasound evaluation for pulmonary edema

Procedure
1. Obtain a cardiac ultrasound ( such as a 5 – 1 MHz) transducer. Alternatively, a higher frequency linear transducer can also be used.
2. Place the patient in a supine position
3. Start by examining the intercostal space in a longitudinal view. This minimizes the impact of rib shadowing on examination. Scan
medially to laterally, towards the posterior axillary line. Common imaging locations may include the parasternal, mid-clavicular,
anterior axillary, and middle axillary planes. Move inferiorly and superiorly to adjacent intercostal spaces and repeat the examination.
4. Change to a transverse view and repeat the examination.
5. Look for B-lines, which are artifacts that are present in approximately 20% of patients, and typically represent pulmonary congestion
or pulmonary edema in most patients. Finding of 3 or more B-lines in the anterior or lateral fields is always abnormal. B-lines are a
result of reverberation artifact from thickened inter-alveolar septa. B-lines that are 7 mm apart are indicative of interstitial edema
(intralobular edema), while those that are 3 mm apart are more indicative of alveolar edema (interlobular edema). B-lines appear as
lines extending from the transducer to the deepest visualized point on the ultrasound screen.
6. A lines are usually nonpathologic, and they appear as equidistant transverse bands.
7. The severity of pulmonary edema can be evaluated by the number of B-lines. Less than 5 B-lines indicates no edema, 5 – 15 indicates
mild edema, 15 – 30 indicates moderate edema, and > 30 indicates severe edema.
8. Correlation with transthoracic echo may be recommended to differentiate cardiogenic versus non-cardiogenic pulmonary edema.
Noncardiogenic pulmonary edema will typically have more patchy pattern of B-lines while cardiogenic pulmonary edema may have a
more diffuse pattern. BNP is recommended. Additionally, patients may have a combination of cardiogenic and non-cardiogenic
pulmonary edema.
9. Treatment can be monitored by assessing the number and pattern of B-lines.

Actionability
1. Noncardiogenic pulmonary edema benefits from oxygen and positive pressure ventilation, while cardiogenic pulmonary edema
benefits from aggressive preload in afterload management.

Example of B lines (B7 lines), which correlate with thickened interlobular septa. Photo credit Litchenstein et al. A-lines and B-lines: lung
ultrasound as a bedside tool for predicting pulmonary artery occlusion pressure in the critically ill. Chest. Oct 2019

References
1. Blanco PA, Cianciulli TF. Pulmonary Edema Assessed by Ultrasound: Impact in Cardiology and Intensive Care Practice.
Echocardiography 2016;33(5):778-87.
2. Lichtenstein D. Lung ultrasound in the critically ill. Curr Opin Crit Care 2014;20(3):315-22.
3. Litchenstein et al. A-lines and B-lines: lung ultrasound as a bedside tool for predicting pulmonary artery occlusion pressure in the
critically ill. Chest. Oct 2019
4. Miglioranza MH, Gargani L, Sant'Anna RT, et al. Lung ultrasound for the evaluation of pulmonary congestion in outpatients: a
comparison with clinical assessment, natriuretic peptides, and echocardiography. JACC Cardiovasc Imaging 2013;6(11):1141-51.
5. Santos TM, Franci D, Coutinho CM, et al. A simplified ultrasound-based edema score to assess lung injury and clinical severity in
septic patients. Am J Emerg Med 2013;31(12):1656-60.

2
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Procedure: Thoracentesis

AUTHORS: EDITORS:

NAVJIT DULLET
Ultrasound Guided Thoracentesis
Indications
1. Ultrasound-guided thoracentesis can be performed when there is evidence of fluid collection within the pleural space identified on
other imaging modalities. Ultrasound evaluation can also be performed on patients with worsening respiratory status. This procedure
is both diagnostic and/or therapeutic, since fluid can be sent for analysis.

Goals
1. To identify a fluid collection within the pleural space that is amenable to drainage via thoracentesis.

Contraindications
1. Skin infection or subcutaneous tissue infection at the desired side of entry
2. Insufficient volume of fluid (maximum pleural depth > 1 cm)
3. Some studies/recommendations call for an INR > 2.0, or platelets < 50,000, however, a study posted in the American Journal of
Roentgenology found no hemorrhagic complication reported, despite some patients having an INR > 3.0 and plt < 30,000.
4. As with paracentesis, procedure should be used with caution or avoided in patients with severe bleeding diathesis, such as DIC.

Pre-Procedure Preparation
1. If possible, hold NOACs for 24 hours, Plavix for 5 days, and Warfarin for 5 days. Aspirin can be continued
2. NOACs can be resumed 24 hours after procedure
3. Therapeutic Lovenox can be resumed 12 hours after procedure
4. Warfarin can be resumed 12 hours after procedure

Consent
Discuss possible complications/risks including:
1. Bleeding
2. Infection
3. Damage to adjacent structures
4. Local anesthesia
5. Entry site hematoma
6. Pneumothorax
7. Possible need for IR intervention if persistent hemorrhage

Procedure
1. Obtain a convex array 2 – 5 MHz ultrasound probe. Alternatively, a 5 – 1 MHz cardiac probe can also be used.
2. Place the patient in a seated position, with their back facing the operator
3. Start by placing the ultrasound probe on the lateral back of the site of interest. Scan the interspace, and try to identify anatomical
structures, such as the diaphragm and liver or spleen depending on the side selected.
4. Work superiorly, continuing to scan the interspaces. Identify the largest fluid pocket (the deepest fluid area). As a reminder, fluid
appears anechoic, however effusion fluid may be more heterogenous if an empyema is present.
5. Mark the desired site of entry using a pen cap or a marking pen. Make sure to visualize the area through several respiratory cycles to
ensure that lung tissue does not move into the desired path. Additionally, try to make the target site greater than 10 cm away from
midline, since intercostal arteries may be more tortuous near the spine.
6. Measure the distance from the skin surface to the edge of the pleura. A longer needle may be needed if this distance is larger than the
needle present in the thoracentesis kit that is used
7. Proceed with sterile preparation
8. Anesthetize the marked area using lidocaine or an equivalent solution. Advance the needle towards the superior border of the inferior
rib at the intercostal space that is selected. Additionally, aspirate once you believe you are near the fluid collection. Advance the
needle up to the pleural surface, and aspirate as you advance the needle. Once/if you are able to aspirate pleural fluid, pullback the
needle slightly. Inject additional lidocaine, since the pleural surface is the area that is very sensitive to pain.
9. Create a skin nick using a scalpel at the desired side of entry
10. Depending on the method used (direct needle versus catheter placement), the next steps will vary
11. For direct needle thoracentesis, advance the thoracentesis needle while aspirating with the syringe. Continue until pleural fluid is
aspirated). Remove the syringe and attach a three-way stopcock with tubing. Attach a syringe to the open end of the three-way
stopcock. Aspirate pleural fluid, and sent for analysis if needed. Attach the tubing to a collecting container, and start draining pleural
fluid if needed
12. If a catheter is used, advance the catheter with a trocar. The needle should not be advanced further than the distance to pleural fluid as
identified on ultrasound. Once pleural fluid is aspirated, advance the catheter/trochar an additional ~2mm. Then, remove the trocar
while advancing the catheter. Ensure that all drainage holes are within the fluid collection. Attach a three-way stopcock to the catheter
and attach a syringe and a drainage bag to the other 2 ports on the three-way. Aspirate pleural fluid and sent for analysis if needed.
13. Monitor the fluid collection with ultrasound if desired. Once a sufficient quantity of fluid has been removed (no more than 1.5L),
prepare for removal of the needle were catheter. Have a Tegaderm and gauze ready
14. Remove the needle, and quickly place a piece of gauze and pressure over the entry site. Place a Tegaderm over this piece of gauze.
This is important to reduce the likelihood of pneumothorax. Pneumothorax can occur in approximately 12 – 30% of thoracentesis

2
 procedures. If the pneumothorax occurs, it is usually small and resolves spontaneously. Order a chest x-ray to monitor progression if
necessary.
15. Common tests to order on pleural fluid include cell count, protein, LDH, pH, glucose, amylase. If infection is suspected, order Gram
stain and culture. If malignancy is suspected, order cytology.

Complications
1. Pain
2. Cough (stop removing pleural fluid if patient coughs several times)
3. Pneumothorax
4. Hemothorax
5. Arterial laceration
6. Laceration of adjacent structures, including diaphragm, liver, and spleen
7. Empyema
8. Tumor seeding (if malignant effusion)

Actionability
1. Drainage of a pleural effusion can provide symptomatic relief for a patient who may have been having difficulty breathing. In
addition, fluid analysis can guide treatment and therapeutic options.

References
1. Feller-Kopman D. Ultrasound-guided thoracentesis. Chest 2006;129(6):1709-14.
2. Heffner JE, Mayo P. Ultrasound-guided thoracentesis UpToDate2018 [Available from:
https://www.uptodate.com/contents/ultrasound-guided-thoracentesis.
3. Soni NJ, Franco R, Velez MI, et al. Ultrasound in the diagnosis and management of pleural effusions. J Hosp Med 2015;10(12):811-6.
4. Patel MD, Joshi SD. Abnormal preprocedural international normalized ratio and platelet counts are not associated with increased
bleeding complications after ultrasound-guided thoracentesis. AJR Am J Roentgenol. 2011;197(1):W164-8.

3
 *POCUS*
THE ESSENTIALS OF BEDSIDE US GUIDED PROCEDURES
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Procedure: Ultrasound Evaluation of Pleural Drains (Chest Tubes)

AUTHORS: EDITORS:
JONATHAN FRIEDMAN DINH-HUY D. NGUYEN
Ultrasound Evaluation of Pleural Drains
Goals
1. Emergent placement of a pleural drain may be necessary to re-expand or decompress the lung and mediastinum in cases of
pneumothorax or a rapidly expanding effusion. Point of care ultrasound examination and guidance can be used to quickly evaluate the
need for and assist in the placement of a pleural drain while avoiding malpositioning, such as in the subcutaneous, intraabdominal, or
transdiaphragmatic planes. Furthermore, troubleshooting already placed drains may be also possible.

Indications
1. Pneumothorax
2. Hemothorax
3. Chylothorax
4. Empyema
5. Recurrent effusion

Absolute Contraindications
1. Skin infection overlying entry point

Relative Contraindications
1. Coagulopathy
2. Pulmonary adhesions
3. Trauma

Procedure
1. The patient is placed in a position that is appropriate for chest tube insertion, typically with the head partially elevated and the
ipsilateral arm raised over their shoulder. Patient can be placed in a supine position (reclined to 40-45 degree angle) or fully seated
position.
2. A linear probe can be used to evaluate for pneumothorax or pleural fluid collections as described in the pneumothorax POCUS guide.
3. The diaphragm should be identified and the lowest possible site for tube insertion should be chosen while avoiding the diaphragm.
4. Once a suitable site is found, color doppler is used to identify the intercostal artery, typically along the upper third of the intercostal
space.
5. Local anesthesia should be given subcutaneously, superficial to the rib and then work the needle to above the inferior margin of the rib
and apply further anesthetic to deep tissues. Ultrasound can be used to ensure correct depth of anesthetic.
6. The pleural drain is then placed using a surgical or Seldinger technique, depending on the type of tube and requirements for drainage.
7. Ultrasound is then used to confirm correct placement of the drain. A surgical tube or pigtail catheter may not be fully visualized within
the scope of the transducer, but adequate depth can be obtained to see whether the tube correctly inserts into the pleural space and is
oriented away from the subcutaneous tissues, diaphragm or adjacent organs.

Complications
1. Bleeding
2. Infection (i.e. at entry site or empyema)
3. Clogged tube
4. Malposition
5. Re-expansion pulmonary edema
6. Pneumothorax
7. Iatrogenic injury to adjacent organs and structures including diaphragm, liver, lung, heart, aorta, intercostal artery

2
Figures

Figure: Ultrasound schematic showing pleural effusion, lung, and shadow caused by ribs. Caudal position shown to the right. Intercostal artery
location shown below the rib. Image credit: Vetrugno et al. An easier and safe affair, pleural drainage with ultrasound in critical patient: a
technical note.

References
1. Menegozzo, C. A. M., & Utiyama, E. M. (2018). Steering the wheel towards the standard of care: proposal of a step-by-step
ultrasound-guided emergency chest tube drainage and literature review. International Journal of Surgery.
2. Boujaoude, Z., & Shersher, D. (2019). Chest Tube Thoracostomy. Critical Care Medicine: Principles of Diagnosis and Management
in the Adult, Fifth Edition. Elsevier.
3. Vetrugno L, Guadagnin GM, Orso D, Boero E, Bignami E, Bove T. An easier and safe affair, pleural drainage with ultrasound in
critical patient: a technical note. Crit Ultrasound J. 2018;10(1):18.

3
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Procedure: Evaluation for Pulmonary Emboli

AUTHORS: EDITORS:
SIPAN MATHEVOSIAN DINH-HUY D. NGUYEN
Evaluation for Pulmonary Emboli

Goal
1. To learn techniques in bedside assessment of pulmonary emboli by ultrasonography.

Indications
1. In patients for which there is a clinical suspicion for pulmonary embolism but for whom CT pulmonary angiography is unavailable or
contraindicated (e.g. PEA arrest, shock/hypotension with signs of right heart failure, unstable patient, contrast allergy, renal
contraindication, pregnancy)
2. Best with triple POC (lung, echo, DVT) ultrasounds
3. Cannot definitively rule out PE, but with high clinical suspicion and positive ultrasonographic findings, may be beneficial for early
diagnosis and early treatment especially in an emergent setting. Sensitivity and specificity approach that of older single or two row
detector CT, but not that of multi detector CT.

Contraindications
1. No contraindications exist for this procedure.

Technique
1. Obtain a 5 MHz micro-convex ultrasound probe with a small footprint.
2. Position the patient sitting upright, arms raised and behind the head to widen the intercostal spaces and outwardly rotate the scapula.
3. Vertical examination of 6 areas should be performed: paravertebral, midscapular, posterior axillary, midaxillary, anterior axillary, and
midclavicular. Both longitudinal and transverse images should be taken, starting with the area of pain if present.
4. Conversely, in the unstable or dyspneic patient, the BLUE protocol positions can be scanned. Two hands are placed side by side on the
chest, parallel and just inferior to the clavicle with the fingertips at the sternum. The 3 BLUE points are the midpoint of each hand, and
the middle edge of the inferior hand.
5. Findings characteristic of PE are wedge-shaped, triangular, or rounded, pleural-based hypoechoic lesions with or without pleural
effusion.
6. In the dyspneic patient, according to BLUE protocol, an A profile (lung sliding with A-lines at anterior wall = normal anterior profile)
plus a positive DVT study is consistent with pulmonary embolism.

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Figures courtesy of http://famus.org.uk/modules/blue-protocol

7. More likely to detect lower lobe PE given accessibility with ultrasound

8. If infarct is hemorrhagic rather than pale infarct, atelectasis may be visible for only a few hours to a day
9. Evaluation of the right ventricle should also be performed to look for signs of right heart strain (specific, not sensitive. Please see
cardiac echo material for more information. In short, parasternal long axis, parasternal short axis, parasternal RV inflow, apical 4
chamber, and right ventricle focused apical 4 chamber.
10. Right heart dimensions measures at end diastole: base > 42 mm, mid RV > 35 mm, long > 86 mm indicative of right ventricular dilation.
11. Switch to left parasternal short axis to view the right ventricle outflow tract (RVOT) and obtain distal RVOT diameter at end diastole.
RVOT diameter > 27 mm indicative of dilation.
12. Subcostal views of the IVC proximal to hepatic veins should be viewed and measured for inspiratory collapse. IVC > 2.1 cm and <50%
collapse with inspiration is indicative of elevated right atrial pressures.
13. Switch to subcostal 4 chamber view to evaluate for bowing of the inter-ventricular septum into the left ventricle.
14. Next, ultrasonographic evaluation of the lower extremities should be performed to look for DVT. Please see the appropriate section for
details.

Actionability
1. This exam can indicate whether a patient may have a pulmonary embolism in the setting of acute decompensation, or CTPE
unavailability or contraindication.

References
1. Comert SS, Caglayan B, Akturk U, et al. The role of thoracic ultrasonography in the diagnosis of pulmonary embolism. Annals of
Thoracic Medicine 2013. 8(2):99-104. doi:10.4103/1817-1737.109822.
2. Squizzato A, Galli L, Gerdes VEA. Point-of-care ultrasound in the diagnosis of pulmonary embolism. Critical Ultrasound Journal
2015. 7:7. doi:10.1186/s13089-015-0025-5.
3. Koenig S, Chandra S, Alaverdina A. Ultrasound Assessment of Pulmonary Embolism in Patients Receiving CT Pulmonary
Angiography. Chest 2014. 145;1:818-823. https://doi.org/10.1378/chest.13-0797.
4. Gargani L, Volpicelli G. How I do it: lung ultrasound. Cardiovascular Ultrasound 2014. 12:25. https://doi.org/10.1186/1476-7120-12-
25.
5. Rudski L, Lai W, Afilalo J, et al. Guidelines for the echocardiographic assessment of the right heart in adults: a report form the
American Society of Echocardiography. J Am Soc Echocardiogr 2010. 23:685-713. doi:10.1016/j.echo.2010.05.010.
6. http://famus.org.uk/modules/blue-protocol

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Procedure: Diagnosing Alveolar Interstitial Syndrome

AUTHORS: EDITORS:
JACOB WOCHNA DINH-HUY D. NGUYEN
Diagnosing Alveolar Interstitial Syndrome
Goal
1. To utilize ultrasound to diagnose alveolar interstitial syndrome.

Indications
1. Rapid detection of alveolar interstitial syndrome (AIS) with ultrasound may be utilized in the setting of dyspnea. AIS encompasses
both acute and chronic conditions. Acute Respiratory Distress Syndrome (ARDS), interstitial pneumonia, pneumonitis, and pulmonary
edema are among the acute causes of AIS via diffuse involvement of the interstitium. Pulmonary fibrosis is a chronic condition of the
interstitium which causes diffuse impairment of the alveolocapillary exchange capacity.

Absolute Contraindications
1. None.

Procedure
1. Obtain a 1-5 MHz curvilinear transducer and set the initial depth setting to 14cm.
2. Place the patient in the supine position.
3. Divide the chest into right and left anterior and lateral sections. The anterior sections are bounded by the clavicle superiorly,
diaphragm inferiorly, sternum medially, and anterior axillary line laterally. The lateral sections are bounded by the axilla superiorly,
diaphragm inferiorly, anterior axillary line anteriorly, and posterior axillary line posteriorly. Each of these sections are divided into a
superior and inferior area, for a total of eight sections on the chest (Figure 1).
4. Each of the eight sections must be examined to diagnose AIS.
5. Examine an intercostal space in the longitudinal view in each section and assess for artifact. Vertical hyperechoic lines that extend
from the lung-wall interface and spread to the edge of the screen are termed B line (or comet tail) artifacts (Figure 2). These B lines
will move synchronously with lung sliding. This artifact is due to extravascular fluid presence in the interstitium, surrounded by air,
resulting in a high impedance gradient. This is not a normal finding in a healthy lung, outside of the most inferior intercostal space.
6. To diagnose AIS, a minimum of three B line artifacts must be present in each scan, there must be diffuse positivity in more than one
scan per side, and these findings must be identified bilaterally.
7. This constellation of findings guides the differential towards AIS. To determine which disease state is causing the appearance of AIS
on ultrasound, there are qualities that can be detected on the scan. Diffuse parenchymal lung disease, which occurs in pulmonary
fibrosis, will demonstrate an irregular, fragmented pleural line, small hypoechoic subpleural areas, and B lines in a nonhomogeneous
distribution. ARDS can present with sonographic findings of anterior subpleural consolidations, absence or reduction in lung sliding,
spared areas with normal parenchyma, irregular, fragmented, or thickened pleural line, and nonhomogeneous distribution of B lines.

Figure 1: Depiction of the chest wall areas which need to be scanned for the diagnosis of alveolar interstitial syndrome (AIS). Areas 1 and 2:
upper and lower anterior sections, respectively. Areas 3 and 4: upper and lower lateral sections, respectively. These sections will need to be
scanned on the contralateral side of the chest wall for a complete evaluation of AIS. AAL = Anterior axillary line. PAL = Posterior axillary line.
(Figure adapted from Volpicelli et al.).

2
Findings

Figure 2: Appearance of hyperechoic B line artifact (white arrow) extending from the pleural line to the inferior portion of the screen on lung
ultrasound. This image was taken in the setting of acute pulmonary edema. (Figure adapted from Volpicelli et al.).

References:
1. Hasan AA, Makhlouf HA. B-lines: Transthoracic chest ultrasound signs useful in assessment of interstitial lung diseases. Ann
Thorac Med. 2014. doi:10.4103/1817-1737.128856
2. Lichtenstein D, Mézière G, Biderman P, Gepner A, Barré O. The comet-tail artifact: An ultrasound sign of alveolar-interstitial
syndrome. Am J Respir Crit Care Med. 1997. doi:10.1164/ajrccm.156.5.96-07096
3. Piette E, Daoust R, Denault A. Basic concepts in the use of thoracic and lung ultrasound. Curr Opin Anaesthesiol. 2013.
doi:10.1097/ACO.0b013e32835afd40
4. Rippey, J. Lung ultrasound technique – overview. Life in the fast lane website. https://litfl.com/lung-ultrasound-technique-
overview. Updated December 7, 2018. Accessed April 7, 2019.
5. Volpicelli G, Elbarbary M, Blaivas M, et al. International evidence-based recommendations for point-of-care lung ultrasound. In:
Intensive Care Medicine. ; 2012. doi:10.1007/s00134-012-2513-4
6. Volpicelli G, Mussa A, Garofalo G, et al. Bedside lung ultrasound in the assessment of alveolar-interstitial syndrome. Am J
Emerg Med. 2006. doi:10.1016/j.ajem.2006.02.013

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Procedure: Dialysis Fistula Planning and Assessment

AUTHORS: EDITORS:
SIPAN MATHEVOSIAN DINH-HUY D. NGUYEN
Dialysis Fistula Planning and Assessment

Goals
1. To evaluate the vasculature and understand principles of surgical dialysis fistula creation.
2. To evaluate a fistula and assess for inflow, outflow, and conduit problems

Indications
1. Preoperative evaluation and assessment of vasculature prior to surgical fistula creation
2. Assessment of preexisting dialysis fistula for maturation and troubleshooting.

Contraindication
1. None

Procedure:
I: Preoperative assessment
1. Obtain a linear (vascular) transducer probe.
2. Position the patient sitting with outstretched arms; tie a tourniquet around the biceps of the desired arm to dilate the venous system.
3. NOTE: surgical considerations for placement include vascular anatomy, but also include handedness, work/vanity, prior dialysis
fistulas, prior or current indwelling lines/pacers/hardware, prior radiation or surgery to the field, hand/arm pain or swelling, and
history of severe CHF.
4. NOTE: Assessment of the palmar arch for collateral flow with Allen’s test should be performed prior to planning
5. Short axis scans of the radial artery should be performed and the vasculature should be assessed for pulsatility, calcifications, and size.
The radial artery should ideally be > 3mm, pulsatile, and with minimal calcifications to facilitate a surgical anastomosis.
6. Short axis scans of the venous anatomy should be performed, starting from known to unknown. Assess the cephalic and basilic veins
for size and for proximal patency. The vein should ideally be greater than 2.5mm (preferably 3) and have upstream patency.
7. NOTE: in general, the ideal order of anastomoses is distal to proximal as to not occlude or jeopardize potential upstream veins; radial-
cephalic -> brachial-cephalic -> brachial-basilic.
8. 5. Assess the central vein to look for stenosis or occlusion.

II: Maturation assessment and troubleshooting.

1. Obtain a linear (vascular) transducer probe.
2. Position the patient sitting with outstretched arm.
3. Palpate the vein for a thrill. Observe the skin for aneurysmal dilation.
4. NOTE: a pulse with no thrill can indicate an occlusion.
5. NOTE: aneurysmal dilatation can be from central venous occlusion (can also be from repeated access).
6. Scan in short access along and find the anastomosis; scan along the venous side and assess for patency, stenosis, occlusions, and size
criteria.
7. NOTE: The mature native dialysis fistula must have a 6 mm vein (dilated from venous hypertension), be < 6mm from the skin (for
access), be 6-10 cm in length (for cannulation), and have >600ml/s flow (used preferably 2-3 months after creation).
8. NOTE: the mature fistula graft does not have these criteria; maturation occurs after scarring down of the surgical site to prevent
hematoma and bleeding during cannulation (usually around 2 weeks post creation)

Actionability
1. This exam assesses for preoperative planning for surgical fistula creation and assesses for maturation postoperatively. The exam is
also used for trouble shooting and evaluation of occlusion and stenosis.

References:
1. Shenoy S, Darcy M. Ultrasound as a Tool for Preoperative Planning, Monitoring, and Interventions in Dialysis Arteriovenous Access.
Am J Roent 2013; 201:4 W539-W543. 10.2214/AJR.13.11277.
2. Davidson I, Gallieni M, Saxena R, et al. A patient centered decision making dialysis access algorithm. J Vasc Access 2007; 8:59–68.
10.1177/112972980700800201.
3. Zamboli P, Fiorini F, D’Amelio A, Fatuzzo P, Granata A. Color Doppler ultrasound and arteriovenous fistulas for
hemodialysis. Journal of Ultrasound. 2014;17(4):253-263. doi:10.1007/s40477-014-0113-6.

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Procedure: Renal Stone Evaluation

AUTHORS: EDITORS:
RICK ARTRIP DINH-HUY D. NGUYEN
Renal Stone Evaluation

Goal
1. To use ultrasound to evaluate for renal stones in the urinary tract

Indication
1. Ultrasound evaluation is useful in patients who have renal insufficiency or cannot tolerate contrast. It is also good at characterizing
radiolucent filling defects that CT detects.

Equipment needed

1) 2-D Echocardiography system

2) Curvilinear probe
3) Sterile ultrasound gel
4) Masks, gowns, gloves for medical personnel

Procedure
1) Place the patient on the exam table in the supine position
2) Expose the left and right lateral back, at the abdominal level, in order adequately to scan both poles of the kidney
3) Place the ultrasound gel and probe in the mid axillary space, with the probe in a longitudinal orientation with indicator toward the
patient’s head
4) Right Kidney:
a) Slide the probe until you find the hepatorenal interface
i) If rib shadow is present, rotate the probe in a counterclockwise fashion for full visualization
5) Left Kidney:
a) The left kidney sits higher than the right kidney because the spleen is not as large, it is recommended to place the probe a
couple rib spaces higher to best visualize the left kidney
6) Scan through the kidney looking for hydronephrosis and calculi - scan anterior to posterior, and superior to inferior

7) Bladder
a) Place the probe in the suprapubic region
b) Scan the bladder superior to inferior
c) Identify the junction of the ureters to the bladder

Findings

1. Hydronephrosis. Image from Em.Rap

2
 2. Kidney stone

Image: example of nephrolithiasis. Echogenic stone visualized within the renal calyx. Image from radiopaedia.org.

References

1. How to Scan the Kidneys Using Ultrasound. (2017, October 4). Retrieved from https://www.youtube.com/watch?v=XaAmKXUAcn0
2. Kidney Ultrasound. (n.d.). Retrieved from
https://www.hopkinsmedicine.org/healthlibrary/test_procedures/urology/kidney_ultrasound_92,p07709
3. Urinary Calculi (Urolithiasis) Imaging: Practice Essentials, Radiography, Computed Tomography. (2018, November 14). Retrieved
from https://emedicine.medscape.com/article/381993-overview#a5
4. A Gallery of High-Resolution, Ultrasound, Color Doppler & 3D Images - Renal calculi. (n.d.). Retrieved from
https://www.ultrasound-images.com/renal-calculi/
5. Patel M. Urethral Calculi. Radiopaedia. https://radiopaedia.org/cases/urethral-calculi-1.
6. Ultrasound of Hydronephrosis. (n.d.). Retrieved from https://www.emrap.org/episode/ultrasoundof4/ultrasoundof

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Procedure: Ultrasound Guided Lumbar Puncture

AUTHORS: EDITORS:

NAVJIT DULLET DINH-HUY D. NGUYEN

SIPAN MATHEVOSIAN
Ultrasound Guided Lumbar Puncture
Goal
1. To use ultrasound visualization to understand anatomy and improve the accuracy of traditional lumbar puncture technique

Indications
1. Obtain CSF for diagnostic and/or therapeutic purposes

Contraindications
1. Ultrasonography for lumbar puncture does not have any absolute contraindications
2. Other contraindications include those for lumbar puncture, including but not limited to signs of infection at the planned access site,
elevated intracranial pressure due to cerebral mass, spinal cord trauma, uncorrected coagulopathy

CONSENT
Discuss possible complications/risks including:
1. Bleeding
2. Infection
3. Damage to adjacent structures
4. Local anesthesia
5. Headache
6. Persistent CSF leak

Coagulopathy/Anticoagulation
1. INR > 1.5, Plt > 50
2. Hold NOACs for 48 hours, Warfarin for 5 days, Plavix for 5 days, therapeutic Lovenox x 24 hours, UFH for at least 6 hours
3. Warfarin can be resumed 12 hours after procedure, NOACS can be resumed 48 hours after procedure

Technique
1. After obtaining consent for procedure, place the patient in a lateral decubitus position, or have them sit upright. Patient will need to be
in lateral decubitus position if opening pressure desired.
2. Obtain a higher frequency (5 – 10 MHz) probe for normal BMI patients, and a lower frequency probe (2 – 4 MHz) for higher than
normal BMI patients.
3. Start by identifying anatomic landmarks on the patient if possible. Position the probe in the transverse position at the level of the iliac
crests. You may be able to visualize the spinous process of L4 as a hypoechoic structure (a ‘bump’) with acoustic shadowing. Move
the probe inferiorly along the spine, and try to identify additional spinous processes and the sacrum. The sacrum can be identified as a
solid fused bone while the spinous processes will have spaces between them (interspinous spaces).
4. Mark the midline position of the vertebral body with a marking pen. This will serve as a reference point.
5. Move the probe along the spine. Mark the next highest and next lowest spinous processes (optional).
6. Switch the probe to a long axis position along the spine. Move the probe along an imaginary line connecting the points that you had
drawn. You should be able to visualize the interspinous spaces as the space between the hypoechoic spinous processes.
7. Identify a target interspinous space.
8. Steps 8 and 9 are optional. Mark the level of the interspinous space on both sides of the probe. 2 marks will be made, one mark just to
the left of the probe, another just to the right. Remove the probe, and draw a line connecting the 2 marks that were just made. Draw
another line connecting the spinous process above and below the airspace that was marked.
9. The intersection of the 2 lines that were just drawn marks the ideal target location for entry of the spinal needle and the midline
approach. If s paramedian approaches taken, the entry point of the spinal needle would be just to the right or left of the intersection.
10. At this point, you can also measure the skin – ligamentum flavum distance, which can help guide how large of a spinal needle will be
needed.
11. Prep the patient for lumbar puncture using sterile technique. Place a sterile ultrasound cover over the ultrasound probe if real time
needle guidance is planned.
12. If real-time ultrasound guidance is used, place the ultrasound probe over the widest interspinous space. Rotate the transducer 45° into
an oblique paramedian view, ensuring that the probe is aligned in a plane from the spinous process of the superior vertebra to the
lamina of the inferior vertebra.
13. Slide the transducer slightly superior and medial, and insert the spinal needle where the probe previously was. Track the needle with
ultrasound visualization as you approach the ligamentum flavum.
14. Once the ligamentum flavum is pierced, check for CSF as you advance the needle 1 – 2 mm at a time.

2
Paramedian sagittal oblique of the lumbar spine: Ligamentum Flavum (LF); Epidural Space (ES); Posterior Dura (PD); Anterior Complex (AC);
Cauda Equina (CE); Intrathecal Space (ITS); Erector Spinae Muscle (ESM); Intervertebral Disc (IVD).

Actionability
1. Ultrasound guidance can improve the accuracy of lumbar puncture technique. Fluid collected from lumbar puncture can be sent for
analysis, or fluid can be trained for therapeutic purposes.

Post Procedure Care

1. Place a bandage over the site of entry. There are no restrictions on activities after LP. Warn patients that they may experience a
headache, which will subside within a day.

Reference Video
https://www.youtube.com/watch?v=ndnZxAcNjdg

References
1. Bentley S. Bedside Ultrasonography for Lumbar Puncture Medscape: Medscape; 2015 [updated Mar 7 2015. Available from:
https://emedicine.medscape.com/article/1458641-overview.
2. Ferre RM, Sweeney TW. Emergency physicians can easily obtain ultrasound images of anatomical landmarks relevant to lumbar
puncture. Am J Emerg Med 2007;25(3):291-6.
3. Soni NJ, Franco-Sadud R, Schnobrich D, et al. Ultrasound guidance for lumbar puncture. Neurol Clin Pract 2016;6(4):358-68.
4. Stiffler KA, Jwayyed S, Wilber ST, et al. The use of ultrasound to identify pertinent landmarks for lumbar puncture. Am J Emerg Med
2007;25(3):331-4.
5. Images courtesy of Nysora: https://www.nysora.com/techniques/neuraxial-and-perineuraxial-techniques/spinal-sonography-and-
applications-of-ultrasound-for-central-neuraxial-blocks/

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Procedure: Ophthalmic Artery Doppler

AUTHORS: EDITORS:
RICK ARTRIP DINH-HUY D. NGUYEN
SIPAN MATHEVOSIAN
Ophthalmic Artery Doppler

Goal
1. To evaluate blood flow in the ophthalmic artery using color doppler.

Indication
1. Ophthalmic artery doppler can be used to assess flow characteristics of the ophthalmic artery and establish a relationship with the
internal and common carotid arteries. Ophthalmic artery doppler can also be used to assess the cerebral effects and the impact of
pharmacotherapy in the management of pre-eclampsia.

Equipment needed

1) 2-D Echocardiography system

2) Linear array high frequency probe
3) Sterile ultrasound gel
4) Masks, gowns, gloves for medical personnel

Procedure
1) Place the patient at a 45˚ angle on the examination table.
2) Have the patient close the eye that is going to be examined.
3) Place ultrasound gel on the probe, using copious amounts of gel will
prevent pressure being applied to the eyeball.
4) Apply the probe to the patient’s eye, with the indicator facing
laterally or superiorly depending if you are taking a horizontal or
vertical approach to examine the retinal artery.

5) Transducer is placed horizontally on the patient’s eye and Doppler

is turned on. Ophthalmic artery is identified by its direction of flow
toward the probe and pulsatility.
6) Pulsed-wave Doppler is applied, sample volume is placed 15 mm
behind optic disc, medial to optic nerve. The sample volume should
be 2 mm in length.
7) Three to five consistent cardiac cycles are obtained.

References
1. How to Case Study: Ocular Ultrasound Part 1. Sonosite. 8 Jul 2011.
https://www.youtube.com/watch?v=nYLDKJfHlSU.
2. Kane SC, Brennecke SP, da Silva Costa F. Ophthalmic artery
Doppler analysis: a window into the cerebrovasculature of women
with pre-eclampsia. Ultrasound Obstet Gynecol. 2017;49(1):15-21

- EDV = end-diastolic volume, FDP = first diastolic

peak velocity, PSV = peak systolic velocity

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Procedure: Peritoneal Shunt Assessment

AUTHORS: EDITORS:
SUHAG PATEL SIPAN MATHEVOSIAN
SIPAN MATHEVOSIAN NAVJIT DULLET
Peritoneal Shunt Assessment

Goals
1. To become familiar with ventriculoperitoneal shunt components: proximal (ventricular) catheter, reservoir, one-way valve, distal
catheter.
2. To evaluate peritoneal components for patency and for potential shunt complications including obstruction, migration, and
disconnection.
3. To evaluate shunt reservoir for potential neurosurgical ventricular tap in critically ill patients with shunt obstruction.
NOTE: This is generally done by palpation similar to port access but ultrasound guidance may be needed in setting of complex cranial
surgeries or uncertain location.
4. To understand that, in general, all malfunctions lead back to neurosurgery for revision.
NOTE: Patients with suspected shunt malfunction should be evaluated with shunt series and non-contrast CT scan of the head. A CT
abdomen may be needed if intraabdominal component is suspected as source of malfunction, and abdominal POCUS can be used for early
problem identification.

Indications
1. Evaluation of patient with suspected shunt malfunction with suspected peritoneal component
malfunction. Patients typically present with nausea, vomiting, altered mental status, or signs of
elevated ICP.
2. Ventricular shunt tap in the critically ill patient with suspected shunt malfunction.
NOTE:: ventriculoatrial and ventriculopleural shunts are not specifically discussed.

Contraindications
1. None for peritoneal ultrasound evaluation.
2. Infection over ventricular site is absolute contraindication to tap. Coagulopathy and lack of shunt
imaging are relative contraindications. Note that increased ICP is not a contraindication.

Procedure
I: Peritoneal component evaluation:
1. Obtain a curvilinear (2-5MHz) transducer.
2. Broadly scan the abdomen until a portion of the catheter is identified (linear echogenicity). Follow the catheter until the tip is
identified.
3. The catheter tip should be evaluated for presence of a peritoneal CSF pseudocyst which will appear as a hypoechoic/anechoic
collection at the shunt tip. Evaluate the collection for internal debris or septations that may suggest an infected pseudocyst which will
guide need for removal.
4. Follow the catheter back in its entirety and evaluate for disconnection, fracture, or migration (will be better evaluated by plain
radiograph).
5. Scan the remainder of the abdomen for fluid collections and include the groins to evaluate for inguinal hernia secondary to decreased
peritoneal resorption; note that the catheter tip may be in an inguinal hernia sac causing obstruction.
II: Ventricular CSF Tap
6. Obtain a linear (vascular) transducer probe.
7. Position the patient supine and scan through the scalp in the region of the reservoir in
both shot and long axes.
8. Patient should be prepped in the usual sterile fashion.
9. Attach/place a 23-25 G butterfly needle into the reservoir under ultrasound guidance
(note caveats made in Goals section). Butterfly needle should be pre-attached to 3-way
stopcock with manometer to evaluate pressure.
10. If there is CSF flow, the obstruction is DISTAL. Repeated slow drainage of CSF fluid
filling the manometer can be performed, with repeat measurements until pressure is less
than 20 cmH20. Do not drain quickly as this can cause subdural hematoma.
11. If there is no CSF flow, the obstruction is proximal and needs operative revision Complex multicystic fluid collection abutting a
emergently. catheter tip (not pictured); case courtesy of Radswiki

Actionability
1. This exam assesses ventriculoperitoneal shunt catheters for post-operative complications including obstruction, migration, and
fracture. This exam is limited in the evaluation of VPS but can be helpful in early problem identification, particularly of distal
obstruction. Neurosurgical ventricular reservoir tap may occasionally require ultrasound guidance.

2
References
1. Roepke C et al. The lowdown on venriculoperitoneal shunts. Annals of Emergency Medicine. 2016. 61(3): 414-416. DOI:
https://doi.org/10.1016/j.annemergmed.2016.01.015.
2. Wallace A et al. Imaging Evaluation of CSF Shunts. American Journal of Roentgenology. 2014;202: 38-53. 10.2214/AJR.12.10270.
3. Goeser CD et al. Diagnostic imaging of ventriculoperitoneal shunt malfunction and complications. Radiographics. 1998. 18:635-651.
https://doi.org/10.1148/radiographics.18.3.9599388
4. Vega RA et al. Sonographic localization of a nonpalpable shunt: Ultrasound-assisted ventricular shunt tap. Surg Neurol Int.
2013;4:101. Published 2013 Aug 6. doi:10.4103/2152-7806.116151.
5. Ghritlaharey RK. Ventriculoperitoneal Shunt Disconnection, Shunt Migration, and Silent Bowel Perforation in a 10-Year-Old Boy. J
Neurosci Rural Pract. 2019;10(2):342–345. doi:10.4103/jnrp.jnrp_329_18
6. Weerakody Y et al. Peritoneal CSF pseudocyst. Radiopaedia. rID 11105.

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Education Committee of the ICU Service Line- Resident and Fellow Section, Society of Interventional Radiology

Procedure: Central Venous Access

AUTHORS: EDITORS:

DINH-HUY D. NGUYEN
Central Venous Access

Goal
1. Used in emergency situations to administer resuscitation fluids and medications (i.e.pressors). Can be used for hemodynamic
monitoring, transvenous pacing, and venous procedures/interventions.

Indications
1. Access for central catheters and ports
2. Access for fluid and medication administration
3. Parenteral nutrition

Absolute Contraindications
1. Severe coagulopathy (plt < 20k, and INR > 3), however,
procedure can be performed after administration of platelets
and FFP
2. Presence of another device at site
3. Bacteremia

Preoperative Preparation
1. Identify appropriate location for access
1. Jugular vein (internal and external) - reliably
accessible with low complication rates
2. Subclavian vein (avoid in coagulopathy)
3. Femoral vein – used for uncooperative patients, emergent access when ultrasound is not available

Consent
1. Discuss possible complications including:
a. Blood loss
b. Hematoma
c. Infection
d. Damage to adjacent structures

Preparation
1. Ideally, patient is in Trendelenburg position, however, in critically ill and obese patients, this is often not an option.
2. Using sterile technique, drape and prepare site and use sterile gown, mask, gloves and cap.
3. Local anesthesia and possibly sedation should be used to ensure comfort and little movement as possible from patient.

Procedure
1. Identify the vein with ultrasound when available (preferred)
2. Infiltrate the skin with local anesthetic
3. Cannulate the vein (needle or angiocatheter) and confirm the intravenous location of the needle
4. Insert the guidewire into the vein through the access needle or angiocatheter
5. Remove the needle or angiocatheter while controlling the guidewire
6. Make a small stab incision in the skin at the puncture site adjacent to the guidewire
7. Advance the dilator over the guidewire into the vein, maintain control of the guidewire and ensure it does not advance with the
catheter, then remove the dilator
8. Thread the catheter over the guidewire, maintain control of the guidewire and ensure it does not advance with the catheter.
9. Remove the guidewire, taking care to control the catheter
10. Sequentially aspirate blood from each access hub and flush with saline to ensure functioning of the catheter
11. Suture the catheter into place and dress the site using sterile technique
12. Confirm the position of the tip of the catheter

Possible Early Complications

1. Bleeding
2. Pain
3. Blood loss

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Possible Late Complications
1. Infection
2. Hematoma
3. Pain
4. Thrombosis
5. Embolism

References

1. Ruesch S, Walder B, Tramèr MR. Complications of central venous catheters: internal jugular versus subclavian access--a systematic
review. Crit Care Med 2002; 30:454.
2. McGee DC, Gould MK. Preventing complications of central venous catheterization. N Engl J Med 2003; 348:1123.
3. American Society of Anesthesiologists Task Force on Central Venous Access, Rupp SM, Apfelbaum JL, et al. Practice guidelines for
central venous access: a report by the American Society of Anesthesiologists Task Force on Central Venous Access. Anesthesiology
2012; 116:539.
4. Freel AC, Shiloach M, Weigelt JA, et al. American College of Surgeons Guidelines Program: a process for using existing guidelines to
generate best practice recommendations for central venous access. J Am Coll Surg 2008; 207:676.

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 *POCUS*
THE ESSENTIALS OF BEDSIDE US GUIDED PROCEDURES

Brought to you by:

Education Committee of the ICU Service Line- Resident and Fellow Section, Society of Interventional Radiology

Procedure: Femoral Venous Access

AUTHORS: EDITORS:

JAY GAJERA DINH-HUY D. NGUYEN

Femoral Vascular Access

Goal
1. Most common method of gaining central venous access in emergency situations is via femoral vein cannulation. The predictable
location of the femoral vein as well as the relative large vessel calibre makes them an easy target for ultrasound guided cannulation as
well as blind technique.

Indications
1. Emergency Venous access during CPR
2. Hypotensive trauma patients
3. Urgent haemodialysis access
4. Provision of irritant medications not suitable for long term peripheral venous administration
5. CVP monitoring

Absolute Contraindications
1. Venous injury at the level of the femoral veins or proximally in the iliac veins or IVC
2. Anatomic abnormality in SVC/lower limb venous drainage
3. Known or suspected venous thrombosis on the proposed side of cannulation
4. Ambulatory patient (risk of catheter displacement)

Relative Contraindications
1. Coagulopathy – innate or acquired (anticoagulation)
2. Previous long term venous catherization
3. Known vasculitic disorder
4. Previous radiation therapy

Anatomy
1. Femoral vein is medial to the Femoral artery in the Femoral triangle
2. Mnemonic = Lateral -> NAVEL (Nerve, Artery, Vein, Empty space, Lymphatics) -> Medial
3. Reminder to remain below inguinal ligament to minimize risk of peritoneal puncture

Technique
1. Patient preparation: obtain informed consent, place patient in a supine position, consider bed height, use protective sheets to prevent a
mess
2. Surveillance: identify surface landmarks of inguinal region, palpate femoral artery and use ultrasound to grossly evaluate region to
identify the femoral vein and its course – ensure collapsibility of femoral vein upon application of pressure – mark the site of
cannulation
3. Sterile technique: don personal protective equipment, commence decontamination of femoral region with chlorhexidine prep and
drape
4. Preparation of equipment: identify all equipment to be used including venepuncture needle, guidewire and dilator, as well as central
line. Prime all lumens of central line using normal saline. Good practice to organize equipment in the order that they will be used for
the procedure.
5. Local Anaesthetic: using a fine gauge needle, infiltrate superficial skin and subcutaneous tissue with 2-5ml of lidocaine
 6. Venepuncture: using ultrasound identify the vein, and advance trochar/needle (attached to a syringe) for initial venepuncture until
flashback is visualized, maintain negative pressure by elevating plunger of the syringe during needle advancement
7. Seldinger technique: insert guidewire through the lumen of the needle and gently advance, if resistance is encountered rotate and
reattempt. Do not force the guidewire against resistance. Ensure the guidewire is grasped at all times through out the procedure to
avoid risk of guidewire embolization, remove the needle while guidewire is firmly held in position
8. Scalpel: create small nick at entry site to permit entry of the dilator + central line
9. Dilator: Railroad the dilator device over the guidewire and use it to create a tract for easy passage of the central line – some force may
be required. Again being mindful of maintaining control of the guidewire at all times. Remove the dilator and apply pressure at the
entry site with gauze as bleeding will occur
10. Central Line insertion: railroad the central line over the guidewire and advance all the way to the hilt. Remove the guidewire. Check
patency of all lumens by aspirating and flushing with normal saline.
11. Suture line in place and apply sterile dressings – site should be examined daily

Complications
1. Infection – superficial or systemic
2. Guidewire embolism
3. Arterial puncture
4. Haematoma
5. Pseudoaneurysm formation
6. Venous thrombosis
7. Peritoneal puncture +/- bowel laceration
8. Bladder puncture
9. Femoral nerve injury

References
1. Saugel B, Scheeren TWL, Teboul JL. Ultrasound-guided central venous catheter placement: a structured review and recommendations
for clinical practice. Crit Care. 2017 Aug 28;21(1):225
 *POCUS*
THE ESSENTIALS OF BEDSIDE US GUIDED PROCEDURES

Brought to you by:

Education Committee of the ICU Service Line- Resident and Fellow Section, Society of Interventional Radiology

Procedure: Radial Artery Access

AUTHORS: EDITORS:

DINH-HUY D. NGUYEN NAVJIT DULLET

Radial Artery Access

Indications
1. When frequent blood gases are necessary
2. For real-time monitoring of blood pressure during shock, major surgery, hypertensive emergency, or vasopressor therapy.

Absolute Contraindications
1. None

Preoperative Preparation
1. Locate palpable arterial pulse
2. Perform Allen Test (alternatively use ultrasound) to ensure ulnar collateral patency

Consent
1. Discuss possible complications including:
a. Blood loss
b. Hematoma
c. Infection
d. Damage to adjacent structures

Procedure
1. Once radial artery is identified, ensure site is properly prepped with sterile technique.
2. Integral-guidewire technique:
a. Non-dominant hand finds the artery using ultrasound while the dominant hand inserts needle-guidewire-catheter unit at a
30-45 degree angle until pulsatile blood flow returns.
b. The unit is then stabilized and the guidewire is advanced through the needle and catheter into the artery.
c. The needle-guidewire unit is then stabilized and the catheter is then advanced into the artery over the wire.
d. The needle-guidewire unit is then removed.
e. The catheter is then hooked up to a “zeroed” arterial bag for pressure monitoring.
3. Separate guidewire technique (guidewire and needle-catheter unit are separate)
a. *Preferred for arteries with deeper access
b. Non-dominant hand palpates artery and then locates artery via ultrasound.
c. Dominant hand holds needle- syringe unit at a 30-45 degrees to arm and is advanced over identified artery until pulsatile
blood return is seen
d. Stabilize needle with non-dominant hand while dominant hand removes syringe from needle
i. Once syringe is removed, if blood return continues, continue to advancement of guidewire
ii. Once syringe is removed, if blood return STOPS, adjust needle until blood returns before inserting guidewire.
e. Stabilize needle with non-dominant hand and with dominant hand insert guidewire into back end of needle.
i. Advance slowly and note any resistance in guidewire. Advance until guidewire is in the vessel well beyond the
tip/length of the needle.
ii. If resistance is felt, DO NOT pull back on guidewire independently. The tip of the needle could cut the
guidewire and it could be lost in the needle.
iii. If adjustments to needle and guidewire are necessary, move both needle and guidewire together as a unit.
f. To remove the needle, stabilize the guidewire with a pinch and pull the needle towards the end of the guidewire. DO NOT
let go of guidewire from back end of needle until guidewire obtained from site of insertion.
g. Once needle is removed from overtop guidewire, place catheter into artery using over-the-wire technique.
4. Attached arterial line bag to catheter making sure line was zeroed and observe for good waveform.

Possible Early Complications

1. Bleeding
2. Pain
3. Blood loss

Possible Late Complications

1. Infection
2. Hematoma
3. Pain

2
 4. Thrombosis
5. Embolism

References:
1. McGee WT, Horswell JL, Calderon J, et al. Validation of a continuous, arterial pressure-based cardiac output measurement: a
multicenter, prospective clinical trial. Crit Care 2007; 11:R105.
2. Shiloh AL, Eisen LA. Ultrasound-guided arterial catheterization: a narrative review. Intensive Care Med 2010; 36:214.
3. Maher JJ, Dougherty JM. Radial artery cannulation guided by Doppler ultrasound. Am J Emerg Med 1989; 7:260.
4. Levin PD, Sheinin O, Gozal Y. Use of ultrasound guidance in the insertion of radial artery catheters. Crit Care Med 2003; 31:481.

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 *POCUS*
THE ESSENTIALS OF BEDSIDE US GUIDED PROCEDURES
Brought to you by:
Education Committee of the ICU Service Line- Resident and Fellow Section, Society of Interventional Radiology

Procedure: Diagnostic Whole Leg Ultrasound for Suspected DVT

AUTHORS: EDITORS:
JONATHAN BARCLAY DINH-HUY D. NGUYEN
SIPAN MATHEVOSIAN
Diagnostic Whole Leg Ultrasound for Suspected DVT
Goal
1. To evaluate for acute deep vein thrombosis in the lower extremities.

Indications
1. Patients with clinical manifestations of lower extremity DVT with or without risk factors for thrombus.
2. Patients with suspected DVT and moderate or high probability of DVT based on the gestalt and/or Wells criteria
3. Patients with suspected DVT and low probability of DVT based on gestalt and/or Wells criteria, but elevated D-dimer (eg, >500
ng/mL)

Absolute Contraindications
1. None

Procedure Preparation
1. Position the patient;
a. Expose the leg of interest up to the groin
b. The patients leg should be slightly bent, with the hip rotated so the knee points laterally.
2. Make sure to have enough ultrasound gel prior to starting

Consent
1. A complete leg ultrasound is an extremely low risk procedure. The most common side effect is pain or discomfort with compression.

Procedure
1. With the probe in axial orientation, begin at the mid-inguinal point and find the femoral vessels.
2. Beginning with the common femoral vein (above the entry point of the long saphenous vein), apply gentle pressure to compress the
vein. Acquire dual images, one with the patent vein and one with compression.
a. A vein containing thrombus will not be fully compressible, and may contain echogenic material.
3. Move the probe distally, regularly compressing the vein and watching for any echogenic material within the lumen. Acquire dual
images of the proximal superficial femoral vein, and its first branch, the deep femoral vein. Continue pressure along the SFV until the
mid thigh.
4. Turn the probe 90 degrees into longitudinal orientation and enable color doppler and pulse wave doppler to visualize flow within the
SFV.
a. Normal venous flow should exhibit a response to Valsalva. To demonstrate this, ask the patient to inhale, hold, and exhale.
Flow should decrease during inhalation and holding, then increase with exhalation. Acquire images of the pulse wave
response.
5. Return the probe to axial/transverse orientation and continue down the distal SFV, acquiring dual images, until its insertion into the
adductor canal.
6. Place the probe, in axial position, behind the knee joint in order to visualize the popliteal vein as it exits the adductor canal. Acquire
dual images.
7. Rotate the probe into longitudinal orientation and enable color doppler to better visualize the distal SFV as it becomes the popliteal
vein. Acquire spectral doppler images as described previously.
8. Moving distally, place the probe lateral to the tibial tuberosity while in axial orientation in order to find the anterior tibial vessels.
Acquire dual images as above.
a. If possible, you may want to reposition the patient with their leg hanging off the side of the bed for easier imaging.
However, the images can be required while sitting down.
9. Move medial to the tibial tuberosity to find the posterior tibial and peroneal vessels, acquire dual images.
a. Here, you may the probe longitudinally and enable color doppler to show patency. Squeezing the patients leg distal to the
probe while imaging should provide augmented flow visible on the color doppler.
10. Continue to image distally moving down the posterior tibial and peroneal vessels, before returning to the anterior tibial vein and
imaging distally.
a. Moving distally in transverse, the veins may be difficult to visualize. You may demonstrate flow by using color dopplar
and augmenting flow by squeezing the leg distal to the probe as described previously.
11. Be sure to image any additional symptomatic areas of the leg.
12. You may also image the contralateral CFV with spectral doppler to evaluate symmetry.

Interpretation
1. Positive: A positive DVT study is determined by non-compressibility of any imaged vein.
a. Lack of compressibility is >95% sensitive and specific for DVT
2. Negative: A negative study is one that demonstrates compressibility of all imaged veins
3. Nondiagnostic: When there is uncertainty about whether a DVT is present or absent, typically due to three main reasons:
a. Difficulty visualizing veins (possibly due to morbid obesity or severe edema)
b. Small veins or atypical appearing abnormalities of uncertain significance.
c. Patients with previous DVT who may have a recurrent DVT vs. chronic scarring of the vein.
i. Thrombus is normally soft and deformable with probe pressure, and demonstrates a smooth surface and
enlarged vein.

2
 ii. Post-thrombotic change/scarring is typically rigid and nondeformable with probe pressure. The surface may be
irregular with calcifications and the vein may be normal or decreased in size.
iii. Best indication for recurrent DVT is an abnormality in a previously normal segment of vein.

Limitations
1. Suspected iliac or IVC thrombosis cannot typically be assessed by vein compression. If there is concern for lesions proximal to the
CFV such as an iliocaval DVT, pelvic venous CT or MR venography are suggested.

Figures

References
1. Christopher Bang DO. Lower and upper Extremity deep venous thrombosis evaluation. In: Dogra V &Rubens D, ed. Ultrasound
Secrets. 1st ed. Philadelphia, 2004.
2. Rumack CM, Wilson SR, Charboneau JW. Diagnostic Ultrasound. 2nd ed. Mosby Yearbook Inc., St. Louis, MO. 1998.
3. McGahan JP, Goldberg BB. Diagnostic Ultrasound: A logical approach. Lippincott-Raven Pubs. Phila., PA. 1998.
4. Needleman L, Cronan J, Lilly M, Merli G, Adhikari S, Hertzberg B, DeJong M, Streiff M, Meissner M. Ultrasound for Lower
Extremity Deep Venous Thrombosis. Circulation, 137(14), pp.1505-1515. 2018.
5. http://www.emergencyultrasoundteaching.com/galleries/image_galleries/dvt_images/index.php
6. https://radiologykey.com/ultrasonography-for-deep-venous-thrombosis/

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THE ESSENTIALS OF BEDSIDE US GUIDED PROCEDURES

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Education Committee of the ICU Service Line- Resident and Fellow Section, Society of Interventional Radiology

Procedure: Ultrasound Evaluation for Aortic Dissection

AUTHORS: EDITORS:

VIKRANT BHATNAGAR NAVJIT DULLET

SIPAN MATHEVOSIAN
Transthoracic Ultrasound for Aortic Dissection

Goal
1. To use transthoracic echocardiogram/ultrasound to assess for aortic dissection

Indication
1. TTE can provide evaluation of portions of the ascending aorta, aortic arch, and proximal descending aorta in the event of suspected
aortic dissection (back pain, syncope, significant hypertension ect.)

Procedure
TTE
1. Proximal ascending aorta is visualized in the parasternal long axis view. More superior portion of ascending aorta can be visualized by
scanning superior intercostal spaces or tilting the ultrasound probe more cranially.
2. Imaged portions of the aorta should be examined for dilation, dissection, or intramural thrombus
3. Place a cardiac probe in the left parasternal view, and obtain a long axis view of the heart (see POCUS guide on cardiac exam)
4. Observed the LVOT and proximal aorta for dissection flaps. The absence of a dissection flap on TTE does not exclude the presence of
proximal dissection.
5. The aortic arch and descending aorta can be visualized posterior to the long and short axis cardiac views on TTE.
6. In the parasternal long axis view, descending aorta can be visualized in cross section at the location of the posterior AV groove
7. In the parasternal short axis view, a longitudinal view of the aorta can be seen.
8. The aortic arch can be visualized from the suprasternal notch.
9. Aorta can be imaged in the abdomen using trans-abdominal approach with an abdominal probe.
10. TTE is most accurate at detecting proximal dissections (notable for visible intimal flap)
TEE
1. Sedate the patient or Anesthetize the oropharynx with a topical local anesthetic
2. Insert a bite block
3. Place patient in a left lateral decubitus position
4. Slowly insert the transducer past the oropharynx
5. Ask the patient to swallow if not sedated
6. Insert two fingers into the mouth guiding the probe and depressing the tongue
7. Advance the probe in a neutral position transducer into the esophagus or stomach
8. Proximal Ascending Aorta in long axis view: mid-esophageal angle with transducer angle between 120-140°; ante-flex probe to
maneuver for better imaging
9. Mid-ascending Aorta in long axis view: upper-esophageal angle with transducer angle between 90-110°; withdraw probe from the
prior angle
10. Mid-ascending Aorta in short axis view: upper-esophageal angle with transducer angle between 0-30°; rotate probe clockwise from
the prior angle
11. Descending Aorta in short axis view: transgastric to mid-esophageal angle with transducer angle between 0-10°; slightly flex the probe
12. Descending Aorta in long axis view: transgastric to mid-esophageal angle with transducer angle between 90-100°; slightly flex the
probe
13. Aortic Aorta in long axis view: upper-esophageal angle with transducer angle between 0-10°; withdraw probe from the previous angle
14. Aortic Aorta in short axis view: upper-esophageal angle with transducer angle between 70-90°

2
Complications
1. No complications for TTE examination
2. TEE complications include:
a. Respiratory depression
b. Arrhythmias
c. Bronchospasm
d. Death
e. Damage to adjacent structures (i.e. esophageal perforation)

Actionability
1. Allows for evaluation of aortic dissection. If a type B dissection identified, medical management can be started. If a type A dissection
identified, patient can be prepared for surgery

References
1. Sobczyk D, Nycz K. Feasibility and accuracy of bedside transthoracic echocardiography in diagnosis of acute proximal aortic
dissection. Cardiovasc Ultrasound. 2015;13:15.
2. Schiller N. Echocardiographic evaluation of the thoracic and proximal abdominal aorta. Up to Date. Jan 2018.
https://www.uptodate.com/contents/echocardiographic-evaluation-of-the-thoracic-and-proximal-abdominal-aorta.
3. Hahn RT, Abraham T, Adams MS, et al. Guidelines for Performing a Comprehensive Transesophageal Echocardiographic
Examination: Recommendations from the American Society of Echocardiography and the Society of Cardiovascular
Anesthesiologists. Journal of the American Society of Echocardiography. 2013;26(9):921-964. doi:10.1016/j.echo.2013.07.009
4. Prabhu M, Raju D, Pauli H. Transesophageal echocardiography: Instrumentation and system controls. Ann Card Anaesth
2012;15:144-55
5. Images courtesy of (LEFT) Assaad et al. The Dual Modality Use of Epiaortic Ultrasound and Transesophageal Echocardiography in
the Diagnosis of Intraoperative Iatrogenic Type-A Aortic Dissection. Journal of Cariothoracic and Vascular Anesthesia. 2013. PMID:
22129791; (RIGHT) Venezia et al. Aortic Dissection - Use of this imaging modality at bedside provides a rapid and noninvasive study
with a high specificity for detection of aortic dissection as well as other potential life-threatening emergencies. Emergency Medicine.
2014 November;46(11):506-511.

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THE ESSENTIALS OF BEDSIDE US GUIDED PROCEDURES

Brought to you by:

Education Committee of the ICU Service Line- Resident and Fellow Section, Society of Interventional Radiology

Procedure: Carotid Evaluation

AUTHORS: EDITORS:

RAJATH RAO NAVJIT DULLET

SIPAN MATHEVOSIAN
Carotid Evaluation

Goals
1. To detect a narrowing/blockage due to plaques, or clots within the carotid vasculature in order to explain any present neurologic
symptoms, as well as to prevent any future manifestations of arterial disease, trauma, or malformations in the carotid arteries.

Indications
1. Focal neurological signs (i.e TIA, stroke, amaurosis fugax)
2. Carotid bruit
3. Pulsatile neck mass
4. Follow-up exam on patients with known carotid disease
5. Unexplained non-hemispheric neurologic symptoms
6. Suspected subclavian steal syndrome
7. Suspected carotid artery dissection, AV fistula, or pseudoaneurysm
8. Syncope, seizures, dizziness
9. Screening for high risk patients with a history of atherosclerosis, head and neck radiation, vasculitis, fibromuscular dysplasia
10. Neck trauma
11. Hollenhorst plaque on retinal exam

Absolute Contraindications
1. There are no absolute contraindications to carotid ultrasound

Procedure
1. Patient should be supine, with mandible lifted, and extended inferior neck muscles
2. High frequency linear array probe set at 7 Mhz or higher
3. Blood flow to US signal should be between 45 and 60 degrees
4. For normal carotid arteries, color velocity scale should be set between 30-40 cm/sec.
5. Caution with displaying the color velocity scale. If the color velocity scale is set
below the mean velocity of blood flow, it may be difficult to identify a high velocity
turbulent jet in stenosis. If the color velocity scale is set higher than mean velocity
of blood flow, stenosis may be missed.
6. Caution with near occlusion, blood flow may be lower than color velocity
thresholds, giving a false positive appearance of total occlusion. In this situation,
evaluate the region using low color velocity settings (<15cm/sec).
7. Short-axis view of blood vessels (transverse image): the patient is observed from the
caudal side (the foot side), and the patient’s right side is presented on the left side of
the image obtained
a. SA view to be made in at least two directions, i.e., anterior and lateral (posterior) directions, so that inadequate depiction in
one direction may be made up for by depiction in another direction
8. Long-axis view of blood vessels (longitudinal image): the direction is presented on the image obtained.
9. When checking for atherosclerotic lesions, maximum intima-media thickness (max IMT) of the common carotid artery, bulbus and
internal carotid artery on the right and left side is an indispensable parameter, and mean intima media thickness (mean IMT) of the
common carotid artery may be measured as an optional parameter
10. Use short-axis view to measure Percent stenosis, the primary parameter in Carotid artery disease
a. If PSV (peak systolic velocity) of the stenotic area is > 1.5 m/s, NASCET % stenosis is estimated to be 50% or higher. If
PSV is > 2.0 m/s, NASCET % stenosis is estimated to be 70% or higher
11. Society of Radiologists in Ultrasound (SRU) Consensus for grading stenosis is below (Table 3):

Actionability
1. Presence of a plaques/clots in the carotid vasculature leading to stenosis or aneurysm may be in indication for open endarterectomy,
endovascular intervention, and/or adjustment of medical therapy.

2
References
1. Weerakkody, Y. Ultrasound assessment of carotid arterial atherosclerotic disease. Radiopaedia.
https://radiopaedia.org/articles/ultrasound-assessment-of-carotid-arterial-atherosclerotic-disease?lang=us.
2. Ultrasound Examination of the Extracranial Cerebrovascular System. American Institute of Ultrasound in Medicine.
https://www.aium.org/resources/guidelines/extracranial.pdf.
3. Tahmasebpour HR, Buckley AR, Cooperberg PL, Fix CH. Sonographic examination of the carotid arteries. Radiographics.
2005;25(6):1561-75.
4. https://www.sru.org/Education-Content/US-Consensus-Statements

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THE ESSENTIALS OF BEDSIDE US GUIDED PROCEDURES

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Procedure: Paracentesis

AUTHORS: EDITORS:

RAKESH S. AHUJA NAVJIT DULLET

SIPAN MATHEVOSIAN
Paracentesis

Indications
1. Performed in all patients with new-onset or worsening ascites of unknown etiology for diagnostic or therapeutic purposes, or in
patients with recurrent symptomatic ascites of known etiology for therapeutic purposes.

Absolute Contraindications
1. Disseminated intravascular coagulation

Preoperative Preparation
1. Clinical evaluation: Detailed medical and surgical
history, physical examination (in particular, if performing
large volume paracentesis, determine if etiology of
ascites is cirrhotic versus non-cirrhotic).
2. Review imaging: If not apparent on clinical examination
and no prior imaging is available, consider performing
ultrasonography to determine volume of ascites, location
of adjacent bowel/organs. Color flow imaging may be
beneficial in detecting subcutaneous varices as well as
mapping the course of the inferior epigastric arteries.
3. Hold clopidogrel 5 days before procedure. Hold one dose
of LMWH before procedure. No need to hold ASA.

Consent
1. Discuss possible complications/risks including:
A. Bleeding
B. Infection
C. Damage to adjacent structures
D. Local anesthesia
E. Entry site hematoma
F. Persistent leakage of ascitic fluid
G. Paracentesis-induced circulatory dysfunction (PICD

Procedure
1. Obtain pre-procedural laboratory testing including INR (if receiving warfarin anticoagulation or known suspected liver disease. Per
SIR guidelines, correct INR <2.0 with FFP, Vitamin K); aPTT (if receiving intravenous unfractionated heparin: no consensus on
management); Platelets: check if warranted by clinical history, replete if < 50,000/μl.
2. Position patient supine, head slightly elevated.
3. Using ultrasound guidance, mark access site (preferentially right or left paracolic gutters).
4. Perform sterile prep of abdominal entry site.
5. Administer local anesthetic (typically 1% or 2% lidocaine) - start with skin wheal then anesthetize entry tract through the peritoneum.
6. Perform skin incision at entry site. (5 Fr paracentesis needle is typically used from commercial pre-packaged paracentesis kits.
Traditionally, these kits include a 6 Fr or 8 Fr drainage catheter introduced into the peritoneum by an obturator which becomes blunt
upon entering the abdominal cavity, preventing damage to the viscera). Consider "Z-track technique" to minimize post-procedure
ascitic leak. With this technique, the skin and subcutaneous tissues are held taut while the catheter is advanced, and then released upon
entry into the peritoneum.
7. Ascitic fluid should enter syringe upon entering peritoneum. Remove syringe and inner stylet to form pigtail, confirming positioning
with ultrasound guidance. If diagnostic paracentesis, obtain 60 mL of ascites and obtain appropriate laboratory testing.
8. Attach tubing to pigtail catheter; opposite end can be attached to three-way stopcock and drainage bag, or vacuum bottle.
9. Once fluid stops freely flowing, attempt to slightly reposition catheter and apply slight manual pressure on abdomen to get more fluid.
10. Remove catheter and apply manual compression for hemostasis. Apply sterile occlusive dressing and/or suture incision, particularly if
persistent ascitic leak.

Post-Procedure Care
1. Although controversial, the use of albumin has been suggested in large volume paracentesis (defined as > 5 liters). General consensus
is 6-8 g of IV albumin for every liter removed, administered at the end of the procedure
2. Other studies have suggested that 3 mg of terlipressin may be equally beneficial in preventing PICD and less expensive than IV
albumin.

2
Possible Early Complications
1. Abdominal wall hematoma
2. Persistent Ascitic Leak
3. Hypotension

Possible Late Complications

Paracentesis-Induced Circulatory Dysfunction (PICD):
1. After large volume paracentesis, hypovolemia triggers activation of the renin
2. angiotensin-aldosterone (RAA) system; if albumin is not replaced, can develop impaired renal function and rapid recurrence of
ascites. Severe cases can lead to hepatorenal syndrome and/or death.
3. Associated with hypotension, hyponatremia, elevated plasma catecholamine
4. and renin levels
5. PICD is estimated to occur in 80% of cases of large volume paracentesis without albumin substitution; this drops to 15-35% when
volume expanders are used.

References
1. Runyon BA. Introduction to the revised American Association for the Study of Liver Diseases Practice Guideline management of
adult patients with ascites due to cirrhosis 2012. Hepatology. 2013;57(4):1651-3.
2. Ginès P, Cárdenas A, Arroyo V, Rodés J. Management of cirrhosis and ascites. N Engl J Med. 2004;350(16):1646-54.
3. Thomsen TW, Shaffer RW, White B, Setnik GS. Videos in clinical medicine. Paracentesis. N Engl J Med. 2006;355(19):e21.
4. Lindsay AJ, Burton J, Ray CE. Paracentesis-induced circulatory dysfunction: a primer for the interventional radiologist. Semin
Intervent Radiol. 2014;31(3):276-8.
5. Images courtesy of: https://proceduralist.org/paracentesis/paracentesis-kit-supplies/

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THE ESSENTIALS OF BEDSIDE US GUIDED PROCEDURES

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Procedure: Evaluation for Cholecystitis

AUTHORS: EDITORS:

IAN SULLIVAN DINH-HUY D. NGUYEN

NAVJIT DULLET
Evaluation for Cholecystitis

Goals

1. Visualize the gallbladder

2. Measure the gallbladder wall width
3. Characterize the gallbladder as distended vs non-distended
4. Assess for the presence of pericholecystic fluid
5. Identify gallstones and assess for obstructing stones in the gallbladder neck or cystic duct
6. Attempt to illicit a sonographic Murphy's sign
7. Assess for signs of gallbladder wall rupture or impending rupture, such as wall disruption and ulceration/focal bulging respectively
8. Evaluate the common bile duct, intrahepatic and pancreatic ducts for more proximal or distal obstruction

Indications

1. Right upper quadrant ultrasound is indicated as the initial imaging step in all cases of pain where a biliary etiology is suspected.

Contraindications

1. None.

Procedure/Interpretation

1. Equipment: A 3 to 5-MHz sector transducer is used to evaluate the right upper quadrant.
a. Use subcostal and intercostal approaches
i. Deep inspiration is helpful in subcostal approach
ii. During the intercostal approach, the liver can be used as a window
2. Positioning: Obtain scans in a variety of positions including left posterior oblique, left lateral decubitus, prone and upright
a. This allows assessment of mobility of intraluminal structures and their differentiation from non-mobile mural structures
3. Gallbladder: Assessment
a. Wall thickening
i. Over 3mm is abnormal
b. Distension
i. Subjective in assessment
c. Pericholecystic fluid
d. Impacted stones
i. Gallbladder neck
ii. Cystic duct
e. Murphy's sign
i. Cessation of inspiration during deep palpation of the right upper quadrant
f. Pitfall: A gallstone filled gallbladder may be mistaken for gas-filled bowel
i. Stones produce a 'clean' shadow vs the 'dirty' shadow of bowel gas
ii. The "wall-echo-shadow" complex identifies the gallbladder
1. Three lines corresponding to the wall, echoic stones and shadow
4. Gallstones: Assess for gallstone, which appear as mobile echogenic intraluminal structures with acoustic shadowing.
a. Smaller stones may not show shadowing initially
i. A higher frequency transducer can elicit shadowing in small stones
1. The patient can be repositioned to clump stones together
a. These will shadow in aggregate
b. Gallstones located in the gallbladder neck may be impacted
c. Gallstones in the cystic or common bile ducts may cause obstruction
i. Biliary ductal dilatation may be seen in conjunction with obstructing stones or as a secondary sign for non-
visulized obstructing stones or other obstructive causes such as mass lesions

Emphysematous Cholecystitis

1. Emphysematous cholecystitis manifests on ultrasound as intramural nondependent hyperechogenicity that demonstrates dirty shadow
and ring down artifact

2
Incidentals

1. Consider evaluation for intrahepatic or pancreatic duct dilatation. Consider evaluation for right hydronephrosis.

Labs

1. Consider correlation with labs including WBC, bilirubin, alkaline phosphatase, AST and ALT. Amylase and lipase may be useful
when concurrent pancreatitis is suspected.

Actionability

1. Positive: Urgent surgery is treatment of choice in patients presenting acutely. Antibiotics and supportive care may be successful in
downgrading to elective. Percutaneous cholecystectomy is useful in patients who are not well enough for surgery or as a bridge to
surgery.
2. Negative: Consider HIDA scan

Images

Image: Acute cholecystitis with gallbladder wall thickening to 3.5mm. Image from Radiopaedia.org.

Image: Emphysematous cholecystitis. Ill defined wall and dirty shadowing noted. Image from Radiopaedia.org

Resources

1. Yarmish GM, Smith MP, Rosen MP, Baker ME, Blake MA, Cash BD, Hindman NM, Kamel IR, Kaur H, Nelson RC, Piorkowski RJ.
ACR appropriateness criteria right upper quadrant pain. Journal of the American College of Radiology. 2014 Mar 1;11(3):316-22.
2. Singer AJ, McCracken G, Henry MC, Thode Jr HC, Cabahug CJ. Correlation among clinical, laboratory, and hepatobiliary scanning
findings in patients with suspected acute cholecystitis. Annals of emergency medicine. 1996 Sep 1;28(3):267-72.
3. Hertzberg BS, Middleton WD. Ultrasound: the requisites. Elsevier Health Sciences; 2015 Jun 25.Chapter 2: Gallbladder; p.28-48.

3
4. American College of Emergency Physicians. Emergency ultrasound imaging criteria compendium; 2014.
5. Acute Calculous Cholecystitis. https://radiopaedia.org/cases/acute-calculous-cholecystitis-4?lang=us.
6. Emphysematous Cholecystitis. https://radiopaedia.org/cases/emphysematous-cholecystitis?lang=us.

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Procedure: Ultrasound Guided Cholecystostomy

AUTHORS: EDITORS:
NAVJIT DULLET SIPAN MATHEVOSIAN
Ultrasound Guided Cholecystostomy

Goals
1. Use ultrasound guidance to perform percutaneous cholecystostomy.

Indications
1. Percutaneous cholecystostomy is indicated in poor surgical candidates in treatment/management of acute cholecystitis (calculous,
acalculous). Risk factors for acalculous cholecystitis include trauma, recent surgery, shock, burn injury, sepsis, intensive care unit
admission, total parenteral nutrition (TPN), and prolonged fasting.
2. Alternative/secondary decompression of the biliary system (e.g. due to biliary strictures).
3. Alternative treatment for acute cholangitis when endoscopic intervention is not an option.

Contraindications
1. Interposition of bowels over the path to the gallbladder.
2. Coagulopathy is a relative contraindication to cholecystostomy.
3. Traditionally, an INR < 1.5 and platelets < 50,000 are preferred, however, a study by Dewhurst et al. found no difference in
complications between patients with normal coagulation and patients who were coagulopathic.
4. Ascites – though patients can be treated with paracentesis before percutaneous cholecystostomy.

Pre-procedure Preparation
1. Patient should be fasting for 6 hours
2. Appropriate pre-procedure imaging – ultrasound, HIDA, or CT scan
3. Appropriate blood tests (LFT’s, basic electrolytes ect.)
4. Prophylactic antibiotics should be given 12-24 hours before intervention

Consent
1. Discuss possible complications/risks including:
a. Bleeding
b. Infection
c. Damage to adjacent structures
d. Local anesthesia
e. Entry site hematoma
f. Peritonitis
g. Sepsis
h. Pneumothorax
i. Bowel perforation

Procedure/Interpretation
1. Equipment: A 3 to 5-MHz convex transducer is used to evaluate the right upper quadrant..
2. There are two approaches that can be used – transhepatic and transperitoneal.
3. The transhepatic approach provides more catheter stability, reduces bile leakage, and results in faster tract formation (see image). It
may result in more bleeding than the trans-peritoneal approach.
4. The transperitoneal approach is preferred in diffuse liver disease (i.e. metastasis).
5. Evaluate anatomy surrounding the gallbladder using the convex transducer.
6. Perform sterile preparation of the desired entry site.
7. Anesthetize the skin in the area of the desired entry point (lidocaine, etc.)
8. Two techniques may be used: modified Seldinger technique and the Trochar technique.
9. Seldinger Technique
a. Insert a fine 18-gauge needle into the gallbladder.
b. Use a 0.35” guidewire to secure access.
c. Dilators are then used to dilate the tract to 1Fr size higher than the desired drainage catheter.
d. Place the drainage catheter into the formed tract.
e. Once the catheter is within the gallbladder, advance the catheter over the inner stiffener.
f. Remove the guidewire and lock the drainage catheter in place.
10. Trochar Technique
a. Advance the trochar (needle + catheter) into the gallbladder. Once the needle/catheter are within the gallbladder lumen,
advance the catheter over the trochar needle.
11. Attach the catheter to a drainage (usually a bulb drain).

2
 12. Drain should be maintained in place for at least 4 weeks, or until tract formation (ascites, steroid use, uncontrolled diabetes may delay
tract formation).
13. Catheter should be flushed with saline 1-2x/day.

Transhepatic needle approach into an inflamed gallbladder

Complications
1. Hemorrhage
2. Catheter dislodgement
3. Sepsis
4. Bile peritonitis
5. Pneumothorax
6. Recurrent cholecystitis

Resources
1. Blanco PA, Do Pico JJ. Ultrasound-guided percutaneous cholecystostomy in acute cholecystitis: case vignette and review of the
technique. J Ultrasound. 2015;18(4):311-5.
2. Dewhurst C, Kane RA, Mhuircheartaigh JN, Brook O, Sun M, Siewert B. Complication rate of ultrasound-guided percutaneous
cholecystostomy in patients with coagulopathy. AJR Am J Roentgenol. 2012;199(6):W753-60.
3. Gulaya K, Desai SS, Sato K. Percutaneous Cholecystostomy: Evidence-Based Current Clinical Practice. Semin Intervent Radiol.
2016;33(4):291-6.
4. Images courtesy of Dr. Thomas Snow, Radiopaedia ID 37090

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THE ESSENTIALS OF BEDSIDE US GUIDED PROCEDURES
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Procedure: Percutaneous Gastrostomy Tube Placement/Replacement/Visualization

AUTHORS: EDITORS:
SYDNEY RUBIN DINH-HUY D. NGUYEN
NAVJIT DULLET
Percutaneous Gastrostomy Tube Placement/Replacement/Visualization
Goal
1. To use ultrasound to guide and evaluate gastrostomy tube placement.
2. To confirm the location of gastronomy tube

Indications
1. Provide nutritional support for patients with functional gastrointestinal systems and disorders that interfere with oral intake.
2. Access for nutritional supplement, fluid and medication administration.

Contraindications
1. Uncorrectable coagulopathy
2. Unsatisfactory percutaneous access to the stomach
3. Active peritonitis
4. Abdominal wall infection at site of tube insertion
5. History of gastrectomy
6. Lack of informed consent

CONSENT
1. Discuss possible complications/risks including:
2. Bleeding
3. Infection
4. Damage to adjacent structures
5. Local anesthesia
6. Entry site hematoma
7. Peritonitis
8. Bowel perforation

Equipment
1. Ultrasound system with curved ultrasound probe
2. Sterile ultrasound gel
3. Nasogastric or orogastric tube
4. Cope gastrointestinal suture anchor set
5. Hydrophilic guide wire
6. Puncture needle preloaded with an anchor
7. Gastrostomy tube (size dependent on patient body habitus)

Preparation
1. Ideally, patient is placed in supine position.
2. Using sterile technique, drape and prepare site. Use sterile gown, mask, gloves and cap.
3. Local anesthesia and possibly sedation should be used to ensure comfort and little movement as possible from patient.

Procedure for Placement

1. Use a curved ultrasound probe to identify abdominal structures including, the stomach, colon, small bowel, and medial edge of the
liver.
2. Pass orogastric or nasogastric tube.
3. Observe gastric distension with ultrasound while instilling warm saline to fill the stomach.
4. Identify puncture site, junction of the upper two thirds and lower third of the stomach and halfway between the greater and lesser
curvatures.
5. Fasten stomach to the anterior abdominal wall using two or more gastric T-fasteners.
6. Under ultrasound guidance and with stomach still in apposition to abdominal wall, insert introducer needle into the gastric lumen
between the T-fasteners.
7. Advance a guide wire into the gastric lumen through the needle and confirm placement.
8. Withdraw the introducer needle, keeping the wire in place.
9. Create a small skin incision next to the guide wire.
10. Advance the dilator over the wire and into the stomach using ultrasound guidance.
11. Measure the tract length and select appropriate gastrostomy tube.
12. Place a tube through the dilator and advance into the stomach.
13. Inflate the balloon and use ultrasound to confirm tube has been placed in gastric lumen and not intramurally.
14. Remove wire and dilator.
15. Secure the T-fasteners and gastrostomy tube.

2
Procedure for Replacement/Verification of Location
1. Caution with this procedure as there is limited data. The study where this technique was described was limited to 10 patients and used
verification with pH of aspirate and contrast radiographs.
2. Use ultrasound to visualize anatomy, including the stomach, rectus abdominus musculature, and if possible, the fistula tract
3. Obtain a longitudinal view of the stomach, which will enable visualization of the G-Tube as it passes through the stomach wall, into
the stomach. A smaller G tube than the originally sized G tube may need to be used
4. Slide the ultrasound probe distal to the G tube, and turn the probe to an oblique angle, which should produce a cross sectional view of
the G tube within the stomach lumen if replacement is successful
5. Apply color doppler over the tip of the G-Tube and oscillate the G tube. This should produce colorflow within the lumen of the
stomach if placement is successful.

Possible Complications
1. Peritonitis
2. Bleeding/hemorrhage
3. Deep stomal infection
4. Aspiration pneumonia
5. Tube displacement requiring repeat procedure
6. Sepsis
7. Internal organ injury
8. Superficial stomal infection
9. Minor periostomal leakage
10. Tube dislodgement/Burried Bumper Syndrome

Images

Image: G Tube passing through original tract and into the stomach. Image from Wu et al. Ultrasound can accurately guide gastrostomy tube
replacement and confirm proper tube placement at the bedside. J Emerg Med.

Image: Cross sectional view of stomach, showing tip of G Tube in stomach lumen. Image from Wu et al. Ultrasound can accurately guide
gastrostomy tube replacement and confirm proper tube placement at the bedside. J Emerg Med.

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References
1. Church, J.T., Speck, K.E., & Jarboe, M.D. (2017). Ultrasound-guided gastrostomy tube placement: A case series. Journal of Pediatric
Surgery,52(7), 1210-1214.
2. Panzer, S., Harris, M., Berg, W., Ravich, W., & Kalloo, A. (1995). Endoscopic ultrasound in the placement of a percutaneous
endoscopic gastrostomy tube in the non-transilluminated abdominal wall. Gastrointestinal Endoscopy,42(1), 88-90.
3. Haber ZM, Charles HW, Gross JS, Pflager D, Deipolyi AR. Percutaneous radiologically guided gastrostomy tube placement:
comparison of antegrade transoral and retrograde transabdominal approaches. Diagn Interv Radiol. 2016;23(1):55–60.
4. Rahnemai-Azar AA, Rahnemaiazar AA, Naghshizadian R, Kurtz A, Farkas DT. Percutaneous endoscopic gastrostomy: indications,
technique, complications and management. World J Gastroenterol. 2014;20(24):7739–7751.
5. Wu TS, Leech SJ, Rosenberg M, Huggins C, Papa L. Ultrasound can accurately guide gastrostomy tube replacement and confirm proper
tube placement at the bedside. J Emerg Med. 2009;36(3):280-4.

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THE ESSENTIALS OF BEDSIDE US GUIDED PROCEDURES

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Procedure: Small Bowel Obstruction

AUTHORS: EDITORS:

NAVJIT DULLET
Small Bowel Obstruction
Indications
1. To evaluate for small bowel obstruction in the setting of abdominal pain, decreased voiding, decreased bowel sounds, or decreased
caloric intake. Ultrasound examination may be performed more rapidly, with less radiation, compared with x-ray.

Goals
2. To use multiple sonographic views of the abdomen to measure small bowel diameter, and evaluate for the presence of small bowel
obstruction

Contraindications
1. There are no absolute contraindications to ultrasound examination for SBO

Procedure
1. Obtain an abdominal ultrasound transducer (curvilinear 2.5-5MHz or 3.5-5MHz).
2. Place the patient in a supine position.
3. Examine the following regions using sonography: the bilateral colic gutters, epigastric, and suprapubic regions.
4. Scan the bowel as a sweep from the epigastrum, across the mid abdomen, down to the pelvis.
5. The presence of fluid-filled dilated bowel, measuring greater than 2.5 cm with a collapsed distal bowel segment indicates a possible
obstruction. However, a distal bowel segment may not be visualized. Additional findings of small bowel obstruction may be decreased
or absent bowel peristalsis. Other criteria are multiple fluid filled non compressible bowel loops (adjacent to collapsed bowel
segment), localized edema of bowel wall with increased thickness, or free fluid between dilated bowel loops.
6. The jejunum can be distinguished from the ilium by the presence of valvulae conniventes.
7. Bowel wall thickening greater than 3 mm on ultrasonography may indicate bowel ischemia or infarction as a result of SBO,
warranting more aggressive management.

Actionability
1. Diagnosis of SBO in a timely fashion can assist in appropriate management. If SBO is diagnosed, and nasogastric tube can be placed
for decompression. The presence of bowel wall thickening indicates the need for additional imaging, and possible surgical
intervention. Once SBO is diagnosed, referrals can be made to appropriate clinical services.

Images

Image showing dilated loop of small bowel with a diameter consistent with SBO. Photo from Pourmand et al. The Accuracy of Point-of-Care
Ultrasound in Detecting Small Bowel Obstruction in Emergency Department. Emerg Med Int.

References
1. Chao A, Gharahbaghian L. Tips and Tricks: Clinical Ultrasound for Small Bowel Obstruction – A Better Diagnostic Tool? American
College of Emergency Physicians [Available from: https://www.acep.org/Content.aspx?id=100218.
2. Jang TB, Schindler D, Kaji AH. Bedside ultrasonography for the detection of small bowel obstruction in the emergency department.
Emerg Med J 2011;28(8):676-8.
3. Silva AC, Pimenta M, Guimaraes LS. Small bowel obstruction: what to look for. Radiographics 2009;29(2):423-39.
4. Pourmand A, Dimbil U, Drake A, Shokoohi H. The Accuracy of Point-of-Care Ultrasound in Detecting Small Bowel Obstruction in
Emergency Department. Emerg Med Int. 2018;2018:3684081.

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Procedure: Testicular/Ovarian Torsion

AUTHORS: EDITORS:
MATTHEW CHIARELLO NAVJIT DULLET
SIPAN MATHEVOSIAN
Ultrasound of Testicular and Ovarian Torsion
Indications
1. Testicular Ultrasound- All male patients with acute scrotal pain with/without swelling should undergo a scrotal/testicular ultrasound.
Scrotal swelling, asymmetry or enlargement.
2. Female Pelvic Ultrasound of Ovarian Torsion- Assessing a female with acute pelvic/lower abdominal pain

Goals
1. Visualize the testicles/ovaries, evaluate blood flow/vascularity (compared to the contralateral site is very important in evaluation),
location/orientation, hydrocele, testicular edema/infarction. Visualize spermatic cord and evaluate for twisting of the cord.
2. Size of ovary, peripheralization of follicles, edema, presence of an ovarian mass/cyst (lead point for torsion)

Contraindications
1. No absolute contraindications to scrotal ultrasound/transabdominal probe in females.
2. Transvaginal ultrasound may be contraindicated depending on the virginial status of the patient, in pediatric patients and may be
refused depending on patient preference.

Procedure/Interpretation
Testicular Ultrasound
1. Position the patient prone, with the scrotum supported by a towel (placed between the thighs. Use warm gel to minimize
pressure/contraction of scrotal skin. Use a high frequency, linear transducer (at least 8-5 MHz).
2. Start with a midline trans grayscale image to visualize both testicles at the same time.
○ Compare echogenicity of the testicles, should be very smooth and symmetric. Heterogeneity, hypoechoic testicle- are signs
of edema/torsion.
○ Compare orientation. Is the long axis of one oriented vertically and the other horizontally? That would be suspicious for
torsion.
○ Compare scrotal skin to evaluate for asymmetric thickness/scrotal edema.
3. Midline trans color Doppler
○ Compare relative vascularity. Be mindful of scale (as always with color). Is one testicle increased or is the opposite side
decreased in vascularity?
4. Evaluate each individual side.
○ Measure each testicle in 3 dimensions. Unilateral enlarged testicle may be edematous/torsed, or undergoing torsion/de-
torsion.
○ Scan through entire tesiticle to evaluate echogenicity and echotexture with grayscale. Turn on color doppler, select vessel
for spectral analysis- get both arterial and venous flow. Evaluate for presence of a hydrocele.
○ Scan through the spermatic cord, evaluate for a twisting.
○ Evaluate epididymis (epididymitis/orchitis may present similarly to torsion).

Female Pelvic Ultrasound

1. Trans abdominal probe is used to assessing ovary location, ovaries are usually better evaluated on the transvaginal probe
○ A cine clip starting midline sagittal (long) at the bladder, and scanning laterally may be useful in identifying abnormal
position/orientation of the ovary; for instance ovary located superior to the bladder would be suspicious
2. Transvaginal probe (or this may be done with a transabdominal probe in applicable)
○ Measure each ovary in 3 dimensions, evaluate echogenicity and echotexture with grayscale. Turn on color doppler, select
vessel for spectral analysis- get both arterial and venous flow. Attempt to identify vascular pedicle and evaluate for a twist.
○ Evaluate for the presence of a cyst/mass (lead point for torsion), peripheralization of normal ovarian follicles, presence of
pelvic free fluid is nonspecific but can be very helpful- especially complex fluid
○ IMPORTANT: B-mode is the most important modality and used to evaluate asymmetric SIZE/EDEMA and
PERIPHERAL FOLLICLES (due to edema). A torsed ovary can have arterial flow as venous supply is first compromised.

Summary/Take-away:
1. Presence of arterial flow does not rule out testicular/ovarian torsion, high arterial pressure may allow detectable arterial flow during
torsion.
2. Use location, orientation, unilateral increased size, decreased echogenicity, heterogeneous echotexture, spermatic cord/vascular
pedicle twist
3. In females, evaluate for asymmetric ovary size/edema, peripheralization of follicles, and free fluid. Flow does not exclude diagnosis.

2
Images

RIGHT - US of bilateral scrotum showing normal color flow on right testes with absent color flow on left testes. L hydrocele also noted.
LEFT - Edematous ovary with peripheralization of the follicles. Images from Radiopaedia.org

References
1. AIUM Practice Parameter for the Performance of Scrotal Ultrasound Examinations; Parameter developed in collaboration with the
American College of Radiology, the Society for Pediatric Radiology, and the Society of Radiologists in Ultrasound. Updated 2015, by
American Institute of Ultrasound in Medicine
2. AIUM Practice Parameter for the Performance of Ultrasound of the Female Pelvis; Parameter developed in collaboration with the
American College of Radiology (ACR), the American College of Obstetricians and Gynecologists (ACOG), the Society for Pediatric
Radiology (SPR), and the Society of Radiologists in Ultrasound (SRU); Updated 2014, by American Institute of Ultrasound in
Medicine
3. Gray-Scale and Color Doppler Sonography of Scrotal Disorders in Children: An Update; Celestino A. RadioGraphics; 25(5).
Published online 2005, RSNA Education Exhibits
4. Pearls and Pitfalls in Diagnosis of Ovarian Torsion; Chang H. RadioGraphics 2008; 28:1355–1368 • Published online
10.1148/rg.285075130
5. Knipe H. Testicular Torsion. Radiopaedia. https://radiopaedia.org/cases/testicular-torsion-8?lang=us.

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THE ESSENTIALS OF BEDSIDE US GUIDED PROCEDURES

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Procedure: US-Guided Percutaneous Liver Biopsy

AUTHORS: EDITORS:

DAVID KOPYLOV DINH-HUY D. NGUYEN

US-Guided Percutaneous Liver Biopsy

Goal
1. Obtain a tissue sample from a specific hepatic lesion or a random sample of liver tissue.

Indications
1. Random Liver Biopsy
a. Acute liver injury
b. Chronic liver disease
c. Graft versus host disease
d. Liver transplant rejection
2. Target liver biopsy
a. Differentiate between a benign or malignant liver lesion in which imaging is equivocal
b. Differentiate between primary or secondary malignant liver lesion.

Absolute Contraindications
1. Uncorrectable coagulopathy*

Relative Contraindications
1. Massive ascites
• A transjugular approach is often preferred in patients with severe coagulopathy or massive ascites.
2. Uncooperative patient
3. Portosystemic gradient measurement required
4. Avoid biopsy of known vascular lesions

Procedure Preparation
1. Hold NOACs for 48 hrs prior to procedure
2. Hold Plavix for 5 days prior to procedure
3. Hold warfarin for 5 days prior to procedure
4. Anti-platelet agents can be resumed 48-72 hours
5. Warfarin can be resumed the day after the procedure

Procedure
1. Perform a planning ultrasound evaluation of the target area to determine the safest percutaneous route to the target area.
a. A 3 to 5 MHz multiarray transducer is preferred. For subcapsular lesions, a high frequency linear probe can be used.
b. Approaches:
i. Intercostal
ii. Subcostal
iii. Xyphoid
2. Give local anesthetic with a standard 25G needle at the site of planned entry.
3. Make a small nick at the site so that the biopsy needle can pass more easily through the skin.
4. The percutaneous biopsy can be performed using a single needle or coaxial technique.
a. Single needle (often used for a random liver biopsy):
i. Set the appropriate throw distance on the core biopsy gun.
ii. Spring load the core biopsy gun.
iii. Place the core biopsy gun through the skin nick and direct it into the liver using ultrasound guidance.
iv. Press the button to fire the core biopsy gun.
v. Remove the core biopsy gun. The specimen will be exposed in needle notch, which can be subsequently
collected on a glass slide or in a specimen container.
1. Pros – samples multiple areas of the liver to decrease the risk of a false negative
2. Cons – repeated punctures of the liver capsule
b. Coaxial (often used for a targeted liver biopsy):
i. Insert a 17-19G outer guide needle into the nick and direct it into the area of interest in the liver using
ultrasound guidance.
ii. Place a spring-loaded core biopsy gun into the guide needle.
iii. Press the button to fire the core biopsy gun.
iv. Remove the core biopsy gun from the guide needle. The specimen will be exposed in needle notch, which can
be subsequently collected on a glass slide or specimen container.
1. Pros – obtaining multiple samples without having to re-access the lesion each time, reduced risk of
tumor seeding
2. Cons – decreased ability to sample different areas of a lesion
5. Consider q15 minute vital checks for the hour following procedure

2
Complications:
1. Major:
a. Hemorrhage requiring intervention
b. Pneumothorax
c. Malignant track seeding
d. Gallbladder/bowel perforation

2. Minor/More common:
a. Hemorrhage not requiring intervention
b. Abdominal pain

References:
1. Shaw C, Shamimi-Noori S. Ultrasound and CT-directed liver biopsy. Clinical Liver Disease. 2014; 4(5): 124-127.
2. Vijayaraghavan GR, David S, Bermudez-Allende M, Sarwat H. Imaging-guided parenchymal liver biopsy: how we do it. J Clin
Imaging Sci. 2011; 1(30).
3. Rockey DC, Caldwell SH, Goodman ZD, Nelson RC, Smith AD, American Association for the Study of Liver D. Liver biopsy.
Hepatology. 2009;49(3):1017-44.

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Procedure: Bladder Volume Assessment

AUTHORS: EDITORS:

NAVJIT DULLET DINH-HUY D. NGUYEN

SIPAN MATHEVOSIAN
Bladder Volume Assessment

Indications
1. Volume analysis by portable ultrasound can be used to help determine the etiology of decreased urinary output as a result of outlet
obstruction, postoperative urinary retention, neurogenic bladder, stroke, neurogenic injury among other pathologies. Ultrasound can
also help classify a urinary problem as a storage disorder, voiding disorder, or both.

Goals
1. To use a portable ultrasound to determine whether there is urinary retention or incontinence. The scan results should be correlated
with other clinical measures, such as urinary analysis and CBC.

Contraindications
1. There are no absolute contraindications to bladder ultrasound

Procedure
1. Obtain a low-frequency (5 – 1 MHz) ultrasound transducer
2. If a measurement of PVR is desired, have the patient void completely prior to examination
3. Place the ultrasound transducer approximately 1 inch above the pubic synthesis, and angle the probe inferiorly. The bladder should be
visualized as a medium to large sized anechoic region.
4. Turn on color flow, and see whether the ureteral jets can be visualized posteriorly
5. Assess for bladder stones, masses, or irregular wall thickening.
6. 3 dimensions need to be measured for bladder volume assessment: length, width, height. From these measurements, the prolate
ellipsoid equation can be used to calculate volume. The equation is as follows: volume = length x width x depth x 0.52.
7. Other studies have looked at using a single dimension for volume assessment. Daurat et al. found that a largest transverse diameter of
< 9.7cm was found to exclude a bladder volume of > 600 mL

Image courtesy of RadiologyAssitant.nl

Actionability
1. Measurement of water volume can help determine the etiology for urinary retention or urinary incontinence. Excessive postvoid
residual volumes may require single catheterization, or placement of a Foley catheter or suprapubic catheter if there is continued
urinary retention.

References
1. Daurat A, Choquet O, Bringuier S, et al. Diagnosis of Postoperative Urinary Retention Using a Simplified Ultrasound Bladder
Measurement. Anesth Analg 2015;120(5):1033-8.
2. Dicuio M, Pomara G, Menchini Fabris F, et al. Measurements of urinary bladder volume: comparison of five ultrasound calculation
methods in volunteers. Arch Ital Urol Androl 2005;77(1):60-2.
3. Kelly CE. Evaluation of voiding dysfunction and measurement of bladder volume. Rev Urol 2004;6 Suppl 1:S32-7.
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Procedure: Ruptured Ectopic Pregnancy

AUTHORS: EDITORS:
MATTHEW CHIARELLO NAVJIT DULLET
Ruptured Ectopic Pregnancy

Background/Indications
1. Acute pelvic pain and/or vaginal bleeding in a female with a positive bHCG.

Goals
1. To visualize either an intra-uterine or an extra-uterine pregnancy. Determine location (tubal [95%], interstitial, cornual, cervical, intra-
abdominal, scar, heterotopic), and if ruptured, unruptured, or live

Contraindications
1. No absolute contraindications

Procedure/Interpretation
1. It is very helpful to have bHCG levels at the time of interpretation of the pelvic ultrasound.
2. For bHCG <2000- it may be too early to visualize an intra-uterine pregnancy sonographically. bHCG level should normally double
every 2 days .
3. (+) bHCG and no gestational sac identified- pregnancy of unknown location; differential includes ectopic vs early intrauterine
pregnancy vs completed miscarriage.
a. bHCG should be trended, and pelvis US should be repeated.

4. Trans-abdominal probe is useful for a wide overview of anatomy and look for free fluid. Trans-vaginal probe will provide much more
detail and diagnostic sensitivity.
5. Scan through the uterus to identify an intra-uterine gestational sac, fluid in the endometrial cavity may be misinterpreted as a
gestational sac (pseudo gestational sac).
a. Double-decidual sign- confirms fluid is actually the gestational sac.
b. Presence of a yolk sac- also confirms this is the gestational sac.
c. If an endometrial gestational sac is present, ectopic is extremely unlikely (heterotopic- both an intrauterine and an
extrauterine pregnancy).
6. Scan towards each adnexa, identify adnexal mass- usually complex cystic but may be simple cyst or less likely solid.
a. Attempt to separate mass from ovary (ovarian ectopic can occur, but quite rare). Apply pressure with US probe, while
recording a cine clip to separated out the mass from the normal ovarian tissue.
b. Color flow may demonstrate a “ring of fire” around the ectopic, but this may also be seen with a corpus luteum (which will
be located intraovarian).
c. Tubal ring sign- echogenic ring around ectopic- confirms tubal location.
7. Once the ectopic pregnancy is identified, attempt to identify a fetal/cardiac motion (live).
8. Signs of rupture look for pelvic free fluid, complex free fluid/hemoperitoneum and hematosalphinx. Use the trans-abdominal probe to
look up in upper abdomen/Morrison’s pouch for free fluid.
a. Pelvic hemorrhage and positive bHCG: PPV 86-93%.

9. Special Circumstance: Interstitial Ectopic

a. Ectopic located within the intramyometrial tube, gestational sac will be eccentrically located, and surrounded by thin
(<5mm) myometrium.
b. Uterine line sign- thin echogenic line in myometrium, is the interstitial tube, borders gestational sac.
i. Ruptured interstitial ectopic high mortality-uterine artery proximity.

Actionability
1. Briefly, treatment separated into medical vs surgical management.
a. Medical Management usually with orally administered methotrexate, methotrexate or KCl may be directly injected into
gestational sac. Recommend also discussing case with Ob/Gyn service.
i. Relative contraindications: Rupture, mass >3.5cm, live (fetal cardiac activity), bHCG >6000.
b. Consult Ob/Gyn for surgical management.

References
1. Lin EP, Diagnostic Clues to Ectopic Pregnancy, Radiographics, Vol 28(6), published online Oct 1, 2008
2. Shah C. Sonoworld, Obstetrics: First Trimester: Rupturing Ectopic Pregnancy.
https://sonoworld.com/CaseDetails/Rupturing_ectopic_pregnancy.aspx?ModuleCategoryId=262; Date accessed: Jul 18, 2018.

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THE ESSENTIALS OF BEDSIDE US GUIDED PROCEDURES

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Procedure: Necrotizing Soft Tissue Infections.

AUTHORS: EDITORS:

NAVJIT DULLET
Necrotizing Soft-Tissue Infections (NSTI)
Indications
1. Assessing a wound, skin color or texture change, and ruling out necrotizing fasciitis, since necrotizing fasciitis may have a similar
appearance to cellulitis in some instances.

Absolute Contraindications
1. None

Procedure
1. Obtain a linear array transducer for both longitudinal and transverse imaging.
2. Prepare examination area, and place ultrasound probe on suspected area of necrotizing fasciitis.
3. Diagnostic features of necrotizing fasciitis include changes in subcutaneous fat, changes in underlying fascia, changes in underlying
muscle. Other findings include fascial and subcutaneous tissue thickening, abnormal fluid accumulation in deep fascial layer, and
occasionally, subcutaneous air. A key distinguishing factor between cellulitis and necrotizing fasciitis is the appearance of turbid fluid
between fascial planes.
4. Subcutaneous emphysema may be seen, however, it may be a finding late in the course of a NSTI. Gas will be very echogenic.
5. Some studies have suggested NSTI can be suggested by deep fascial thickening, thickening of overlying fatty tissue, or a fluid layer >
4mm thick overlying deep fascia. Fluid spaces tracking along deep fascia are not seen in cellulitis
6. Within the muscle, ill-defined hypoechogenicity may be found secondary to inflammatory process, however, hypoechogenicity may
also be found, representing muscle swelling.

Cautions
1. Sensitivity of ultrasound for detecting necrotizing fasciitis varies depending on the location and extent of tissue involvement.
Consequently, ultrasound should not be used to rule out the diagnosis of necrotizing fasciitis. Correlate imaging with clinical picture
and labs, utilizing scores such as the LRINC score. US cannot be definitively be used to exclude a diagnosis of NSTI.

Actionability
1. Ultrasound can aid in the diagnosis of suspected necrotizing fasciitis; however, it should not be used to exclude the diagnosis.

Images

Image: Example of subcutaneous gas represented by echogenic foci with acoustic shadowing. Photo from Russell F, Duncan T. Case Report:
Diabetic Pain. ACEP.

References
1. Castleberg E, Jenson N, Dinh VA. Diagnosis of necrotizing faciitis with bedside ultrasound: the STAFF Exam. West J Emerg Med
2014;15(1):111-3.
2. Jaovisidha S, Leerodjanaprapa P, Chitrapazt N, et al. Emergency ultrasonography in patients with clinically suspected soft tissue
infection of the legs. Singapore Med J 2012;53(4):277-82.
3. Wong CH, Khin LW, Heng KS, et al. The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: a tool for
distinguishing necrotizing fasciitis from other soft tissue infections. Crit Care Med 2004;32(7):1535-41.
4. Yen ZS. Ultrasonographic Screening of Clinically-suspected Necrotizing Fasciitis. Academic Emergency Medicine 2002;9(12):1448-
51.
5. Russell F, Duncan T. Case Report: Diabetic Pain. ACEP. https://www.acep.org/how-we-serve/sections/emergency-
ultrasound/news/september-2015/case-report-diabetic-pain/.

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Procedure: Arthrocentesis

AUTHORS: EDITORS:
POUYA AGHAJAFARI DINH-HUY D. NGUYEN
NAVJIT DULLET
SIPAN MATHEVOSIAN
Arthrocentesis

Goal
1. Ultrasound guided arthrocentesis allows the interventional radiologist to identify target structure for aspiration with improved
accuracy compared to non-guided procedures.

Indications
1. Lack of surface anatomical landmarks due to body habitus
2. Proximity to neurovascular structures
3. A bleeding diathesis
4. Aberrant anatomy
5. Deeper structures
6. Need to avoid radiation

Contraindications
1. Overlying infection
2. Inaccessible joint space
3. Bacteremia
4. Adjacent osteomyelitis
5. Uncontrolled coagulopathy
6. Joint prosthesis

Consent
1. Bleeding - Warfarin or DOACs do not need to be held prior to procedure, however a smaller needle size (22 gauge) is preferred
2. Infection
3. Damage to adjacent structures
4. Local anesthesia
5. Entry site hematoma

Procedure
1. Perform a preliminary scan which will identify relevant structures that are to be avoided during procedure. For thin patients a higher-
frequency (6-13 MHz) linear probe can be used. For patients with a muscular build or higher BMI, a lower frequency probe can be
used. Bony landmarks should be used, which appear very hypoechoic with echogenic rim. Use color to find hyperemic areas/synovitis.
2. Appropriately position the patient for the aspiration. For knees, flex the knee to 15-20 degrees.
3. Mark the overlying skin and prepare in usual sterile fashion.
4. Anesthetize the skin with small gauge needle.
5. Under ultrasound guidance, advance the needle into skin 1cm medial or lateral to the upper 1/3 of the patella, with the needle directed
towards the intercondylar notch. The needle should be directed 45 degrees inferiorly, and 45 degrees posteriorly.
6. Use an 18-20 gauge with a 5mL syringe. If the effusion is large, can use a 20mL syringe.
7. Aspirate as you advance the needle under ultrasound guidance.
8. Once aspiration is complete, send fluid for appropriate analysis (i.e. cell counts, crystal analysis), and place a band-aid over the entry
point.
9. Other joints include carpal, wrist, elbow, shoulder, hip joints; also include subacromial or trochanteric bursa. Please see UptoDate
article in references for approaches.

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Actionability
1. This exam will allow more accurate aspiration for diagnostic and therapeutic purposes.

Possible Early Complications

1. Hemarthrosis
2. Superficial bleeding
3. Tendon rupture
4. Neurovascular damage/damage to adjacent structure

Possible Late Complications

1. Septic Joint
2. Hemarthrosis
3. Septic Bursitis

References
1. Malanga, G.A., & Mautner, K.R. (2014). Atlas of ultrasound-guided musculoskeletal injections. New york: McGraw-Hill Education
Medical.
2. Zuber T. Knee Joint Aspiration and Injection. Am Fam Physician. 2002 Oct 15;66(8):1497-1501.
3. Roberts N. Joint aspiration or injection in adults: Technique and indications. 13 Oct 2017. https://www.uptodate.com/contents/joint-
aspiration-or-injection-in-adults-technique-and-indications.
4. Image courtesy of ACEP: https://www.acepnow.com/article/how-to-perform-ultrasound-guided-knee-arthrocentesis/2/

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Procedure: Incision and Drainage of Abscess

AUTHORS: EDITORS:

NAVJIT DULLET DINH-HUY D. NGUYEN

Incision and Drainage of Abscesses
Goal

1. To identify a superficial abscess that can be treated with incision and drainage or needle guided aspiration.

Indications

1. Ultrasound guidance can be used to determine whether superficial or deep infection/infectious process is an abscess amenable to
incision and drainage, or whether it is a process more amenable to antibiotic treatment, such as cellulitis.

Contraindications

1. No abscess identified on ultrasound examination

2. No clear target for incision and drainage, such as a deep abscess
3. Overlying vascular or nervous structures

Consent
Discuss possible complications/risks including:
A. Bleeding
B. Infection
C. Damage to adjacent structures
D. Local anesthesia
E. Need to enlarge area of I&D due to larger than expected abscess

Additional Preparation
1. Patients at risk of bacterial endocarditis (rheumatic heart, central lines in place etc.) should be given antibiotic prophylaxis with strep
coverage antibiotics prior to I&D.
2. Sterile prep
3. Gauze
4. 25-30 gauge needle
5. Culture swab
6. Scalpel or blade
7. Saline syringe
8. Forceps

Technique

1. Obtain a high-frequency linear probe if one is available. A lower frequency probe may also be used, however, resolution may not be
optimal. If a linear transducer is not available, a curvilinear transducer may also be used.
2. Scan over the area of interest, adjusting depth as necessary. This area may be identified by swelling, color changes, warmth, or pain.
3. The characteristic appearance of an abscess is a hypoechoic or anechoic region, with variable amounts of hyperechoic debris within
abscess cavity. The depth may need to be changed depending on the location of the abscess.
4. Once an area of interest is identified, manipulate the transducer to visualize the entire abscess cavity in one plane. Then rotate the
probe by 90°, and try to visualize the entire cavity. Large abscesses (>5cm by palpation or ultrasound) may be more amenable to
surgical intervention.
5. Slide the transducer to the midpoint of the abscess cavity (the area of maximal fluctuance)
6. Using a marking pen, make a circle around the abscess cavity.
7. Prep the area of interest with sterilization procedure and anesthetize the region.
8. Proceed with the incision and drainage, either making an elliptical area around the cavity, or a linear incision. Probe the cavity with
forceps to break loculations, and irrigate with saline.
9. If the abscess cavity is deeper, it may be more amenable to needle aspiration. Once the area of interest is prepped, ultrasound needle
localization can be used to gain access to the abscess cavity. As you are advancing the needle, hold suction on a syringe. Once the
abscess cavity is entered, paralytic material should be visualized within the syringe.
10. Send fluid or specimen for culture, initiate empirical antibiotics per practice preferences.
11. Place bandage or dressing over needle insertion site after cleaning the region. It is recommended to let I&D abscesses close by
secondary intention
12. Patient may need to have a more thorough I&D performed depending on size of abscess and complexity of the collection

Complications
1. Inadequate drainage may lead to recurrence of abscess, or increased size of abscess, or other infection (osteomyelitis, tenosynovitis,
etc).
2. Aggressive I&D may lead to bacteremia

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Actionability

1. Once a superficial abscess is identified, the region can be marked, and then incision and drainage or needle guided aspiration and be
performed to drain the abscess cavity, and potentially alleviate patient pain.

References

1. Chau CL, Griffith JF. Musculoskeletal infections: ultrasound appearances. Clin Radiol 2005;60(2):149-59.
2. Euerle B. Introduction and Indications for Abscess Evaluation ACEP: ACEP; 2008 [Available from:
https://www.acep.org/sonoguide/abscess.html#ab12018.
3. Squire BT, Fox JC, Anderson C. ABSCESS: applied bedside sonography for convenient evaluation of superficial soft tissue
infections. Acad Emerg Med 2005;12(7):601-6.
4. Technique of incision and drainage for skin abscess. https://www.uptodate.com/contents/technique-of-incision-and-drainage-for-skin-
abscess.

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Procedure: Ultrasound Guided Single Injection Peripheral Nerve Blocks

AUTHORS: EDITORS:
JONATHAN BARCLAY NAVJIT DULLET
Ultrasound Guided Single Injection Peripheral Nerve Blocks

Goal
1. To provide localized anesthesia to patients in patients via administration of anesthetics directly to the nerve.

Indications
1. In general, used to avoid side effects and complications of general anesthesia (particularly respiratory) and provide analgesia while
minimizing opioid use.
a. Patients at risk for respiratory depression from general anesthesia
b. Difficult airway
c. High risk postoperative nausea and vomiting
d. Patients who wish to remain conscious or avoid systemic meds
e. Outpatient interventions
f. Patients with severe acute localized pain poorly managed with systemic meds

Relative Contraindications
1. Active infection at the site of injection
2. Antithrombotic agents or coagulopathy
3. Pre-existing neural deficit at the site of the block

Absolute Contraindications:
1. Patient inability to cooperate or refusal
2. Allergy to local anesthetics
3. Lack of knowledge of adjacent anatomy

Consent
1. Patient should be made familiar with the precautions and care needed during the recovery of the block.
a. Time to resolution of the block is extremely variable between block location, patient, and anesthetic.
i. Lidocaine may last anywhere from 3 to 8 hours, while bupivacaine may last 6 to 30 hours.
b. Care should be made to avoid injury to the anesthetized limb and avoid falls
i. Equipment such as protective padding, slings, crutches, or wheelchairs may be necessary.
2. Patients should be warned of potential complications:
a. Nerve injury
b. Hematoma
c. Local anesthetic systemic toxicity
d. Allergic reaction
e. Infection
f. Myotoxicity
g. Secondary injury

Procedure Preparation
1. Directed medical history should be obtained with a focus on any conditions that may impact the decision to perform a block (such as
coagulopathy, respiratory compromise, allergies, etc.).
2. Patients should follow normal fasting guidelines for surgery in the case that deep sedation or general anesthesia is needed.
3. Obtain intravenous access and have resuscitation equipment available prior to the procedure.
4. Some patients may benefit from light sedation to improve comfort during the placement of a block.
a. Doses are titrated to optimize patient comfort while maintaining consciousness for communication and cooperation.
b. Typical doses for healthy adults include IV midazolam 1-2mg and fentanyl 25-100mcg.
5. Throughout the procedure, pulse oximetry, ECG, and blood pressure should be monitored.
6. Make sure to gather materials, such as a sterile ultrasound kit, appropriate length and size needles and syringes, as well as anesthetic
of choice.

Procedure
1. Begin by taking surveillance images with the ultrasound to localize the nerve of interest, marking the location of optimal visualization
on the patient’s body. Be sure to identify associated anatomic structures such as nearby nerves, vessels, and bony/soft tissue structures.
2. Prep the procedure site in the usual sterile fashion and place the ultrasound probe in a sterile plastic sheath.
3. Using sterile ultrasound gel, again locate the target nerve and associated structures.

2
 a. The target nerve can be imaged in either the short axis or long axis view, and the optimal view may change based on
operator preference or the anatomical site. Color doppler is helpful to recognize blood vessels.
b. Remember to acquire surveillance images for documentation.
4. When the optimal view is obtained, hold the probe immobile and gather the needle used for the block. Common needles used are 1.5
inch 25 or 27 gauge needles, and common anesthetic is 1% lidocaine. 2-5mL may need to be used.
5. Plan your needle path to the target nerve.
a. Ideally, you should approach the nerve tangentially, projecting the needle so that its tip will land adjacent to the nerve, not
aiming for its center.
6. Using the “in-plane” approach, position the needle parallel to the long side of the transducer and within the field of view of the
ultrasound. Beginning at the skin surface, slowly inject lidocaine to anesthetize the needle track as you advance.
a. The “in-plane” approach should always allow you to visualize the needle tip and body, allowing for safer insertion.
b. The bevel of the needle tip should face up towards the transducer in order to better see the tip.
c. Do NOT advance the needle without seeing the tip.
d. If you lose the tip from view, small injections of lidocaine or saline may help you localize it again.
7. Once the needle tip is positioned accurately near the target nerve, gently aspirate to ensure negative intravascular placement.
8. Inject the local anesthetic of choice in small aliquots, observing for pain or high-pressure during injection.
a. You should visualize a spread of fluid at the needle tip during injection.
b. Anesthetic should spread circumferentially and longitudinally around the nerve for a proper block.
c. For nerves enclosed in fascia, aim to fill the fascial confines with anesthetic.
d. For single nerves in extremities, aim to create a donut of anesthetic around the nerve.
9. Remove the needle then clean and bandage the procedure site appropriately.

Complications
1. Nerve injury
2. Hematoma
3. Local anesthetic systemic toxicity
4. Allergic reaction
5. Infection
6. Myotoxicity
7. Secondary injury

References
1. Neal JM. Ultrasound-Guided Regional Anesthesia and Patient Safety. Regional Anesthesia and Pain Medicine 2016;41(2):195–204.
2. Ultrasound Guided Regional Anesthesia. Oxford Medicine Online 2016.
3. Orebaugh SL, Kirkham KR. Introduction to Ultrasound-Guided Regional Anesthesia. NYSORA Online 2017.
4. Gray AT: Ultrasound-guided regional anesthesia. Anesthesiology 2006; 104:368–373.
5. Nwawka OK, Miller TT. Ultrasound-Guided Peripheral Nerve Injection Techniques. AJR Am J Roentgenol. 2016;207(3):507-16.

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THE ESSENTIALS OF BEDSIDE US GUIDED PROCEDURES

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Procedure: Peripheral Nerve Evaluation

AUTHORS: EDITORS:

NAVJIT DULLET
Peripheral Nerve Evaluation

Indications
1. Ultrasound examination of peripheral nerves allows for dynamic imaging of neurological structures, which may be useful in the
evaluation of peripheral nerve disease, entrapment, trauma, tumor, or infection. Ultrasound examination can typically be performed
faster than MRI evaluation. Additionally, ultrasound examination of peripheral nerves can provide visualization for targets of nerve
blocks

Goals
1. To visualize peripheral nerves and evaluate for trauma, tumors, mass effect, entrapment, or procedures.

Contraindications
1. There are no absolute contraindications to this procedure.

Procedure
1. Obtain a high-frequency linear transducer. Superficial nerves can be scanned with a 17 – 5 MHz transducer or a 18 – 8 MHz
transducer.
2. Using anatomical landmarks, proceed with scanning areas that nerves may be located. Start with the short axis at an easy to identify
anatomical landmarks (such as the ulnar nerve passing just posterior to the brachial artery), and follow the nerve up or down the
extremity.
3. In short axis, the nerve may appear as hypoechoic bundles with hyperechoic material in between (honeycomb pattern). The
hyperechoic connective tissue in college and surrounding the hypoechoic nerve fascicles is usually more hyperechoic than surrounding
muscle and tendons. Peripheral nerves can be seen in the fat or fascial planes superficial to muscles.
4. Long axis view can also be utilized. In the long axis, the hypoechogenic nerve can be distinguished from the more echogenic
tendons/muscles.
5. Some of the imaging findings you may encounter include nerve transection, visualization of a tumor adjacent to the nerve (appears as
a soft tissue mass), understanding anatomy (such as if an intervention is planned in proximity to a peripheral nerve), visualization of
entrapment syndromes.
6. Nerve entrapment or compression may be seen as proximal dilation/enlargement of a nerve structure, decreased echogenicity, or
increased vascularity
7. Proceed with nerve block procedure if it is planned, advancing the anesthetic needle under ultrasound guidance towards the nerve,
however, do not hit the nerve with the needle. Injecting anesthetic posterior to the desired nerve may be enough.

Actionability
1. The visualization of peripheral nerve structures can be used to evaluate for nerve injury, entrapment, mass effect, and help guide
procedures. Information can then be used to guide referral to appropriate clinicians.

Possible Complications of Nerve Block

1. Hematoma formation
2. Damage to adjacent structures
3. Local infection
4. Pneumothorax (depending on nerve location)

Images

Image: example of visualization of the median nerve in carpal tunnel syndrome. Note proximal enlargement. Image from radiopaedia.org.

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 Image: example of short axis view of the median nerve. Nerve appears as a hypoechogenic structure, while tendons are echogenic. Image from
radiopaedia.org.

References
1. Brown JM, Yablon CM, Morag Y, et al. US of the Peripheral Nerves of the Upper Extremity: A Landmark Approach. Radiographics
2016;36(2):452-63.
2. Suk JI, Walker FO, Cartwright MS. Ultrasonography of peripheral nerves. Curr Neurol Neurosci Rep 2013;13(2):328.
3. Gaillard F. Carpal Tunnel Syndrome. Radiopaedia. https://radiopaedia.org/cases/carpal-tunnel-syndrome-4?lang=us.
4. Patel M. Carpal Tunnel Syndrome. Radiopaedia. https://radiopaedia.org/cases/carpal-tunnel-syndrome-1?lang=us.

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THE ESSENTIALS OF BEDSIDE US GUIDED PROCEDURES

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Procedure: Foreign Body Removal

AUTHORS: EDITORS:
JONATHAN BARCLAY DINH-HUY D. NGUYEN
Foreign Body Removal

Goal
1. To remove soft-tissue foreign bodies under local anesthesia and ultrasound guidance.

Indications
1. Patients with suspected or diagnosed soft tissue foreign bodies.
a. Foreign bodies are typically the results of accidents in the home or workplace and consist of wood, metal, or glass.
b. Beware standard x-rays may not detect organic or plastic foreign bodies.
2. Removal of foreign bodies with small entry holes, where the risks of surgical removal outweigh the benefits.

Relative Contraindications
1. Longstanding foreign body – surgery is indicated in order to deal with potential supervening complications.
2. Open wounds
3. Associated lesions to neurovascular structures or tendons requiring surgical repair

Absolute Contraindications
1. Patient refusal or inability to consent or cooperate.

Consent
1. US guided FB removal is minimally invasive and carries a low risk of complications, steps are taken to minimize these risks. Patients
should be informed of potential complications including:
a. Infection
b. Injury to surrounding tissues
c. Bleeding
d. scarring
2. Failure to remove a foreign body with ultrasound guidance does not preclude traditional surgical removal.

Procedure Preparation
1. Begin with diagnostic ultrasound to establish the exact location of the foreign body.
a. Identify any nearby structures (vessels, nerves, tendons).
b. Plan out a potential safe and feasible approach to the foreign body, avoiding nearby structures.
c. Acquire diagnostic images.
2. Gather materials for procedure:
a. Sterile ultrasound kit
b. 22- or 25-G needle syringe
c. Lidocaine or other preferred local anesthetic
d. Scalpel
e. Surgical forceps
f. Steri-Strips and/or sutures, sterile dressing
3. Position the patient to allow easy access to the suspected foreign body based on the diagnostic scan.

Procedure
1. Prep the patients skin under sterile conditions.
2. Visualize the foreign body once again using ultrasound.
3. Inject a small amount of local anesthetic subcutaneously to numb the planned needle insertion site.
4. Using an “in-plane” approach, insert the needle to the foreign body, following your planned path to avoid any vulnerable surrounding
structures.
5. Inject a small amount of local anesthetic (e.g., 2-3mL lidocaine) close to the foreign body.
a. In many cases, injecting the anesthetic next to the foreign body will help separate it from surrounding tissues, and make
removal easier.
6. Slowly retract the needle while continuing to inject local anesthetic in order to numb the path prior to removal.
7. Under constant ultrasound guidance, make a small incision at the needle insertion site using the scalpel.
a. The incision should be just large enough for the surgical forceps to be inserted into, or in the case of a larger foreign body,
wide enough for the foreign body to pass through.
b. The scalpel should be inserted until its tip reaches the foreign body in order to create a path between the foreign body and
the skin surface.
8. While maintaining ultrasound guidance, use your dominant hand to insert the surgical forceps through the incision.

2
 9. Use arms of the forceps to displace the tissues surrounding the foreign body and grip it.
10. Slowly remove the forceps and foreign body
11. Use ultrasound to ensure there are no remaining foreign body fragments.
12. Disinfect the skin area once again and close the incision with either steri-strips or sutures depending on its size.
13. Prescribe antibiotic prophylaxis to prevent any iatrogenic septic complications caused by manipulation of the foreign body (e.g.,
Augmentin 1g bid for 7 days).

Image: Forceps being used to grasp and remove foreign body under ultrasound guidance. Image from Callegari et al. Ultrasound-guided removal
of foreign bodies: personal experience.

References
1. Callegari, L., Leonardi, A., Bini, A. et al. Ultrasound-guided removal of foreign bodies: personal experience. Eur Radiol (2009)
19: 1273.
2. Blankstein A, Cohen I, Heiman Z, et al. Ultrasonography as a diagnostic modality and therapeutic adjuvant in the management
of soft tissue foreign bodies in the lower extremities. Isr Med Assoc J. 2001;3(6):411-3.
3. Shiels WE, Babcock DS, Wilson JL, Burch RA. Localization and guided removal of soft-tissue foreign bodies with sonography.
AJR Am J Roentgenol. 1990;155(6):1277-81.

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 *POCUS*
THE ESSENTIALS OF BEDSIDE US GUIDED PROCEDURES

Brought to you by:

Education Committee of the ICU Service Line- Resident and Fellow Section, Society of Interventional Radiology

Procedure: Ultrasound Diagnosis of Subperiosteal Abscess

AUTHORS: EDITORS:

NAVJIT DULLET
Ultrasound Diagnosis of Subperiosteal Abscess
Indications
1. Subperiosteal abscess can be a complication of osteomyelitis. Common sites of involvement include the metaphysis and the orbit,
secondary to proximity to sinuses. Subperiosteal abscess may require surgical draining, as delay may result in bone necrosis.
Subperiosteal abscesses are more frequently found in pediatric patients compared with adult patients

Goals
1. To identify a subperiosteal fluid collection in the setting of infection to aid management and/or referral for drainage

Contraindications
1. There are no absolute contraindications to ultrasound examination of suspected subperiosteal abscess

Procedure
1. Identify an area of interest based on patient symptoms (pain, redness) or alternative imaging (such as a prior x-ray).
2. Obtain a linear transducer (13 – 6 or 15 – 6 MHz).
3. Scan over the region of interest in both the transverse and longitudinal planes. The cortex of normal bone appears as a dense
echogenic band. Muscle layers appear hypoechoic with linear bands running across.
4. If a subperiosteal abscess or fluid collection is present, there will be subtle cortical changes. There will be a raised periosteum, which
may appear as a thin echogenic band that appears more proximal to the dense echogenic band representing the cortex. The raised
periosteum may not be clearly visible. In between these 2 echogenic regions, there will be a hypoechoic/anechoic region, representing
the fluid collection. If the raised periosteum is not clearly visible, a subperiosteal abscess may appear as a hypoechoic/anechoic
collection lying adjacent to the echogenic band of the cortex.
5. This fluid collection can either be drained with needle aspiration, through surgical intervention, or treated with antibiotics.

Actionability
1. This exam may show the presence of a hypoechoic region adjacent to the cortex, representing a subperiosteal abscess. Correlation
with other clinical markers, such as CRP, WBC can guide management decisions. The treatment options for subperiosteal abscess
include needle drainage, surgical removal, or medical management with antibiotics.

Image

Image: Subperiosteal Abscess. Image from Weenders et al. Subperiosteal abscess in a child. Trueta’s osteomyelitis hypothesis undermined?

References
1. Emmett Hurley P, Harris GJ. Subperiosteal abscess of the orbit: duration of intravenous antibiotic therapy in nonsurgical cases.
Ophthal Plast Reconstr Surg 2012;28(1):22-6.
2. Kaiser S, Rosenborg M. Early detection of subperiosteal abscesses by ultrasonography. A means for further successful treatment in
pediatric osteomyelitis. Pediatr Radiol 1994;24(5):336-9.
3. Kayhan FT, Sayin I, Yazici ZM, et al. Management of orbital subperiosteal abscess. J Craniofac Surg 2010;21(4):1114-7.
4. Liao JC, Harris GJ. Subperiosteal abscess of the orbit: evolving pathogens and the therapeutic protocol. Ophthalmology
2015;122(3):639-47.
5. Mantsopoulos K, Wurm J, Iro H, et al. Role of ultrasonography in the detection of a subperiosteal abscess secondary to mastoiditis in
pediatric patients. Ultrasound Med Biol 2015;41(6):1612-5.
6. Vial J, Chiavassa-Gandois H. Limb infections in children and adults. Diagn Interv Imaging 2012;93(6):530-46.
7. Weenders SG, Janssen NE, Landman GW, et al. Subperiosteal abscess in a child. Trueta's osteomyelitis hypothesis undermined?
Orthop Traumatol Surg Res 2015;101(6):763-5.

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 *POCUS*
THE ESSENTIALS OF BEDSIDE US GUIDED PROCEDURES

Brought to you by:

Education Committee of the ICU Service Line- Resident and Fellow Section, Society of Interventional Radiology

Procedure: Ultrasound Guided Joint Steroid Injections

AUTHORS: EDITORS:

NAVJIT DULLET
Ultrasound Guided Joint Steroid Injections

Indications
1. Pain secondary to inflammatory joint conditions, such as osteoarthritis, bursitis, rheumatoid arthritis, tendinitis, muscle strain among
others
2. Pain secondary to joint condition that requires excessive amounts of oral or IV pain medications, or pain that is not adequately
controlled by oral or IV pain medication

Goals
1. Utilize ultrasound imaging to guide steroid injections of joints, tendons, or other soft tissue structures

Contraindications
1. Caution should be used if a patient is on anticoagulation. For deeper injections, goal INR should be below 1.5. For superficial
injections, INR can be between 2 and 3.
2. Infection in proximity to the targeted area of interest (osteomyelitis, cellulitis, etc).

Preoperative Preparation
1. Anesthetic and steroid solutions
2. 25-30 gauge needle for anesthetic injection
3. 22-25 gauge needle and 1-10mL needle for injection

Procedure
1. Obtain an ultrasound probe with a frequency suitable for the desired injection location. For shoulders in thinner individuals, a higher-
frequency (6 – 13 MHz or similar) linear probe can be used. For patients with a higher BMI or those with a muscular build, a lower
frequency probe can be used.
2. Place the patient in a supine or prone position depending on the target structure. The patient should not be sitting up for steroid
injection.
3. Identify the area of interest (joint space, tendon, etc.), and scan to understand anatomy. Tendons appear as echogenic fibrillar
structures with parallel lines in the longitudinal plane, and multiple dots in the transverse plane. A joint space may appear as a
hypoechoic region due to fluid.
4. Approaches for different anatomical structures
a. Knee: the medial or lateral aspect of the knee, inferior to the patella, is safe for injection. Identify the medial or lateral
margin of the patella, and advance the needle under the patella
b. Hip: use a lower frequency probe to identify the femoral head as well as the femoral vessels. Advance the needle lateral to
the femoral vessels towards the visualized joint space. Use color flow to identify additional vasculature, such as the
circumflex femoral vessels. Direct the needle towards the lower aspect of the joint capsule, while keeping the femoral neck
and joint space and long axis
c. Wrist: utilize a high-frequency probe (around 15 MHz, hockey-stick probe).
d. Shoulder: Place a high-frequency probe in the bicipital groove, halfway between the clavicle and the anterior axillary fold.
Long head of the biceps tendon can be visualized. Move the probe more easily in order to visualize the subacromial bursa
and supraspinatus muscle.
e. AC Joint: Place US probe in a coronal plane over the AC joint. The anechoic joint space can be visualized in contrast to the
echogenic clavicle and acromion. Needle injection can be made from lateral to medial, directed towards the lateral margin
of the clavicle. Subacromial joint space is approximately 4mm below the capsule.
f. Other joint spaces that can be treated are the GH joint space, Subacromial/Subdeltoid bursa, common flexor tendon, ulnar
collateral ligament, lateral epicondyle, wrist/radioulnar joint, and more. Applications for joint injection can be seen in The
Atlas of Ultrasound Guided Musculoskeletal Injections
5. Sterilize the region of interest. Place ultrasound probe cover on ultrasound probe. Advance a needle (25gauge) while aspirating. Once
the area of interest is reached, inject an anesthetic solution. This is then followed by a steroid solution. Caution with mixing steroid
injection and anesthetic as this may result in clumping.
6. Medication dosing:
a. Hydrocortisone: 10-25mg for small joints, 50mg for large joints
b. Methylprednisolone: 2-10mg for soft tissue, 10-80mg for large joints
c. Decadron: 0.5mg-3mg for soft tissue and small joints. 2-4mg for large joints

Actionability
1. This exam allows for more accurate steroid injection for inflammatory pain relief
Complications
1. Infection
2. Bleeding
3. Hemarthrosis
4. Tendinopathy
5. Local tissue atrophy
6. Local tissue necrosis
7. Skin atrophy/depigmentation

References
1. Guerini H, Ayral X, Vuillemin V, et al. Ultrasound-guided injection in osteoarticular pathologies: general principles and precautions.
Diagn Interv Imaging 2012;93(9):674-79.
2. Messina C, Banfi G, Orlandi D, et al. Ultrasound-guided interventional procedures around the shoulder. Br J Radiol
2016;89(1057):20150372.
3. Parra DA. Technical tips to perform safe and effective ultrasound guided steroid joint injections in children. Pediatr Rheumatol Online
J 2015;13:2.
4. Rastogi AK, Davis KW, Ross A, Rosas HG. Fundamentals of Joint Injection. AJR Am J Roentgenol. 2016;207(3):484-94.