Clinical Ultrasound A Pocket Manual
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vi Preface
carried around and provide a quick reference for learning on
the job.
Whether you are an emergency medical technician or
senior physician, it is our hope that this manual will ease
some of the intimidation of learning ultrasound. Utilizing
simple bullet point instructions and a vast library of point-of-
care images, this book will be there with you at the bedside to
help with any study you want to complete!
Angela Bray Creditt Richmond, VA
Jordan Tozer Richmond, VA
Michael Vitto Richmond, VA
Michael Joyce Richmond, VA
Lindsay Taylor Richmond, VA
Acknowledgments
Thank you to our VCU Emergency Medicine family for your
persistent support and encouragement. Thank you to those
who have helped contribute to this book including L. Das
Narla M.D., Rashida Woods M.D., Tim Layng D.O., Rohit
Manaktala M.D., Trecia Henriques M.D., Evie Louka, and
Morgan Williams. Lastly, a tremendous thank you to Dr.
Dave Evans, Ultrasound Fellowship Director at VCU, for
educating our medical students, residents, faculty, and other
medical professionals in ultrasound.
vii
Contents
1 Introduction: Basic Ultrasound Principles . . . . . . . . 1
Basic Terminology . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Transducer Selection . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Transducer Position . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Ultrasound Artifact . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
2 Extended Focused Assessment with
Sonography for Trauma . . . . . . . . . . . . . . . . . . . . . . . 19
Clinical Application and Indications . . . . . . . . . . . . 19
Normal EFAST Anatomy . . . . . . . . . . . . . . . . . . . . . 20
Image Acquisition . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
EFAST Pathology . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
3 Cardiac Ultrasound . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Normal Cardiac Anatomy . . . . . . . . . . . . . . . . . . . . . 48
Image Acquisition . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Parasternal Long Axis . . . . . . . . . . . . . . . . . . . . . . . . 49
Parasternal Short Axis . . . . . . . . . . . . . . . . . . . . . . . . 51
Apical Four- and Two-Chamber . . . . . . . . . . . . . . . . 53
Subxiphoid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Inferior Vena Cava . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Measuring Global Left Ventricular
Systolic Function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Cardiomyopathies . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Right Ventricular Dilation . . . . . . . . . . . . . . . . . . . . . 64
Pericardial Effusion and Tamponade . . . . . . . . . . . . 66
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
ix
x Contents
4 Thoracic Ultrasound . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Indications/Clinical Application . . . . . . . . . . . . . . . . 75
Normal Thoracic Anatomy . . . . . . . . . . . . . . . . . . . . . 76
Image Acquisition . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
Image Acquisition . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
Thoracic Pathology . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
5 Head and Neck Ultrasound . . . . . . . . . . . . . . . . . . . . 91
Tonsillar Ultrasound . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Thyroid Ultrasound . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Tracheal Ultrasound . . . . . . . . . . . . . . . . . . . . . . . . . . 100
Carotid Artery Ultrasound . . . . . . . . . . . . . . . . . . . . 104
Salivary Gland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110
6 Musculoskeletal Ultrasound . . . . . . . . . . . . . . . . . . . 113
Clinical Application and Indications . . . . . . . . . . . . 113
Normal Musculoskeletal Anatomy . . . . . . . . . . . . . . 114
Image Acquisition . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
Shoulder Joint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
Tendons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
Knee Joint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
Bone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128
Nerves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
7 Abdominal Aortic Aneurysm Ultrasound . . . . . . . . 135
Clinical Application/Indications . . . . . . . . . . . . . . . . 135
Normal Aortic Anatomy . . . . . . . . . . . . . . . . . . . . . . 136
Image Acquisition . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
Abdominal Aortic Pathology . . . . . . . . . . . . . . . . . . . 142
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
8 Biliary Ultrasound . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
Clinical Application and Indications . . . . . . . . . . . . 149
Normal Biliary Anatomy . . . . . . . . . . . . . . . . . . . . . . 150
Imaging Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
Gallbladder Pathology . . . . . . . . . . . . . . . . . . . . . . . . 156
Contents xi
Common Bile Duct Pathology . . . . . . . . . . . . . . . . . 162
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
9 Renal and Bladder Ultrasound . . . . . . . . . . . . . . . . . 167
Clinical Application and Indications . . . . . . . . . . . . 167
Genitourinary Anatomy . . . . . . . . . . . . . . . . . . . . . . . 168
Image Acquisition . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
Renal Pathology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176
Bladder Pathology . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184
10 Abdominal Ultrasound . . . . . . . . . . . . . . . . . . . . . . . . 185
Clinical Application and Indications . . . . . . . . . . . . 185
Normal Abdominal Anatomy . . . . . . . . . . . . . . . . . . 186
Image Acquisition . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186
Abdominal Pathology . . . . . . . . . . . . . . . . . . . . . . . . . 188
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195
11 Gynecologic Ultrasound . . . . . . . . . . . . . . . . . . . . . . . 197
Clinical Application and Indications . . . . . . . . . . . . 197
Normal Gynecologic Anatomy . . . . . . . . . . . . . . . . . 198
Image Acquisition . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199
Gynecologic Pathology . . . . . . . . . . . . . . . . . . . . . . . . 204
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211
12 Obstetric Ultrasound . . . . . . . . . . . . . . . . . . . . . . . . . 213
Clinical Application and Indications . . . . . . . . . . . . 213
Normal Gynecologic Anatomy . . . . . . . . . . . . . . . . . 214
Image Acquisition . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214
Evaluation for Intrauterine Pregnancy . . . . . . . . . . . 220
Obstetric Pathology . . . . . . . . . . . . . . . . . . . . . . . . . . 226
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235
13 Testicular Ultrasound . . . . . . . . . . . . . . . . . . . . . . . . . 237
Clinical Application and Indications . . . . . . . . . . . . 237
Normal Testicular Anatomy . . . . . . . . . . . . . . . . . . . . 238
Image Acquisition . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238
Testicular Pathology . . . . . . . . . . . . . . . . . . . . . . . . . . 241
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252
xii Contents
14 Lower Extremity Venous Ultrasound . . . . . . . . . . . . 253
Clinical Application/Indications . . . . . . . . . . . . . . . . 254
Lower Extremity Venous Anatomy . . . . . . . . . . . . . 254
Image Acquisition . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255
Lower Extremity Venous Pathology . . . . . . . . . . . . . 262
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 266
15 Skin and Soft Tissue Ultrasound . . . . . . . . . . . . . . . . 267
Clinical Application and Indications . . . . . . . . . . . . 267
Normal Skin and Soft Tissue Anatomy . . . . . . . . . . 268
Image Acquisition . . . . . . . . . . . . . . . . . . . . . . . . . . . . 268
Skin and Soft Tissue Pathology . . . . . . . . . . . . . . . . . 270
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277
16 Ocular Ultrasound . . . . . . . . . . . . . . . . . . . . . . . . . . . 279
Clinical Application and Indications . . . . . . . . . . . . 279
Normal Ocular Anatomy . . . . . . . . . . . . . . . . . . . . . . 280
Image Acquisition . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281
Ocular Pathology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 283
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 290
17 Pediatric Ultrasound . . . . . . . . . . . . . . . . . . . . . . . . . . 293
Appendicitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293
Intussusception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 298
Pyloric Stenosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 300
Testicular Torsion . . . . . . . . . . . . . . . . . . . . . . . . . . . . 303
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307
18 Ultrasound-Guided Procedures . . . . . . . . . . . . . . . . 309
Ultrasound-Guided Peripheral
Intravenous Access . . . . . . . . . . . . . . . . . . . . . . . . . . . 309
Central Venous Catheterization . . . . . . . . . . . . . . . . 319
Paracentesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 326
Regional Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . 330
Lumbar Puncture . . . . . . . . . . . . . . . . . . . . . . . . . . . . 339
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 344
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 347
List of Contributors
Drew Clare, M.D. Department of Emergency Medicine,
Virginia Commonwealth University Medical Center,
Richmond, VA, USA
Angela Bray Creditt, D.O. Department of Emergency
Medicine, Virginia Commonwealth University Medical
Center, Richmond, VA, USA
Michael Joyce, M.D., R.D.M.S., R.D.C.S. Department of
Emergency Medicine, Virginia Commonwealth University
Medical Center, Richmond, VA, USA
Lindsay Taylor, M.D., R.D.M.S., R.D.C.S. Department of
Emergency Medicine, Virginia Commonwealth University
Medical Center, Richmond, VA, USA
Jordan Tozer, M.D., M.S., R.D.M.S., R.D.C.S. Department of
Emergency Medicine, Virginia Commonwealth University
Medical Center, Richmond, VA, USA
Michael Vitto, D.O., M.S., R.D.M.S., R.D.C.S. Department
of Emergency Medicine, Virginia Commonwealth University
Medical Center, Richmond, VA, USA
xiii
Chapter 1
Introduction: Basic
Ultrasound Principles
Learning ultrasound can be overwhelming and confusing,
especially for those who are becoming familiar with equip-
ment and images for the first time. This chapter will provide
an overview of basic point-of-care ultrasound physics and
procedures. It will explain ultrasound-specific terminology
for image optimization, transducer types, clinical application
and positioning, and different scanning modes such as bright-
ness mode, motion mode, and Doppler. Lastly, common ultra-
sound artifacts, their characteristics, and how to recognize
them will be described.
Basic Terminology
(a) Brightness Mode (B-mode)
• The standard ultrasound mode for all clinical imaging
• Converts ultrasound waves into a grayscale image [1]
• Figure 1.1—B-mode imaging
• Video 1.1—B-mode imaging
(b) Motion Mode (M-mode)
• Evaluates the movement of structures within the body [2]
Electronic Supplementary Material The online version of this chapter
(doi:10.1007/978-3-319-68634-9_1) contains supplementary material,
which is available to authorized users.
© Springer International Publishing AG 2018 1
A. Creditt et al., Clinical Ultrasound,
https://doi.org/10.1007/978-3-319-68634-9_1
2 Chapter 1. Introduction: Basic Ultrasound Principles
Figure 1.1
B-mode imaging:
Brightness mode
imaging of the
heart. Brightness
mode or B-mode is
the standard ultra-
sound mode for all
clinical imaging
• Records movement of a structure over time
–– A vertical line is placed through the structure of
interest.
–– The machine then converts ultrasound echoes mea-
sured at this line onto the vertical axis of a graph
with time on the horizontal axis [2].
• Figure 1.2—M-mode imaging
(c) Frequency
• The number of sound waves per unit time.
• For clinical imaging, this typically ranges from 2 mega-
hertz (MHz) to 15 MHz [1].
• Higher-frequency transducers have less tissue pene-
tration but provide more detailed image resolution.
• Lower-frequency transducers have greater tissue pen-
etration but sacrifice image resolution.
(d) Gain
• Controls amplification of returning ultrasound
waves [2].
• This translates to brightness of the ultrasound
image [2].
• Gain can be manually controlled by the sonographer
and should be optimized for image clarity.
–– If the gain is too high, the image will be bright.
Figure 1.3—High gain
Basic Terminology 3
Figure 1.2 M-mode imaging: Motion mode imaging of the heart.
Motion mode or M-mode cardiac evaluates the movement of struc-
tures within the body. This image demonstrates the utilization of
M-mode to evaluate movement of the left ventricle over time
Figure 1.3 High gain: This image demonstrates the parasternal long
view of a heart with high gain. Gain is related to brightness of the
image. When the gain is too high, the image will be bright and details
are lost
4 Chapter 1. Introduction: Basic Ultrasound Principles
Figure 1.4 Low
gain: This image
demonstrates the
parasternal long
view of a heart
with low gain. Gain
is related to bright-
ness of the image.
When the gain is
too low, the image
will be dark and
details are lost
–– If the gain is too low, the image will be dark.
Figure 1.4—Low gain
(e) Depth
• Refers to how far sound travels prior to returning to
the transducer, typically reported in centimeters.
–– If depth is increased, the ultrasound machine listens
for returning echoes for a longer period of time to
collect data [2] necessary to create an image.
–– If depth is decreased, the machine will listen for a
shorter period of time.
• This can be manually controlled by the sonographer.
• Depth should be optimized so that the structure of
interest is imaged within the center of the screen.
–– Figure 1.5—High depth
–– Figure 1.6—Shallow depth
–– Figure 1.7—Ideal depth
(f) Doppler
• Measures frequency shift
–Doppler
– shift is defined as a change in frequency that
occurs when sound reflects off a moving structure [2].
• Calculates blood velocity
–– An increase in velocity causes an increase in
Doppler shift.
Basic Terminology 5
Figure 1.5 High
depth: This image
demonstrates the
parasternal long
view of a heart
with the depth set
too deep. The
structure of inter-
est should be cen-
tered in the screen
Figure 1.6 Shallow
depth: This image
demonstrates the
parasternal long
view of a heart with
the depth set too
low. The structure
of interest should
be centered in the
screen
Figure 1.7 Ideal
depth: This image
demonstrates the
parasternal long
view of a heart with
ideal depth and gain
settings to properly
vision the entire
structure of interest
as well as the appro-
priate level of detail
6 Chapter 1. Introduction: Basic Ultrasound Principles
• Color Doppler
–– Shifts in velocity are color coded according to
direction of flow in relationship to the transducer.
Flow away from the transducer will appear blue.
Flow toward the transducer will appear red.
This can be remembered as “BART,” Blue Away
Red Toward.
–– Figure 1.8—Color Doppler
–– Video 1.2—Color Doppler
• Power Doppler
–– Displays a signal in color if there is any motion
detected at all
Does not indicate velocity or direction
–– Higher sensitivity than color Doppler allowing for
imaging slower flow [2]
Figure 1.8 Color Doppler: Color Doppler measures shifts in veloc-
ity which are color coded according to direction of flow in relation-
ship to the transducer; flow away from the transducer will appear
blue, and flow toward the transducer will appear red. Note that it
does not relate to venous and arterial flow. In this image, the testi-
cles are being assessed for vascular flow with color Doppler
Basic Terminology 7
–– Good for low-flow applications such as the testicle
and ovary
–– Figure 1.9—Power Doppler
–– Video 1.3—Power Doppler
(g) Transducer
• Contains piezoelectric crystals that have the unique
ability to translate electrical signal into sound
waves.
–– Sound waves are sent to tissues then reflected back
to the transducer.
–– Reflected sound waves are translated into electric
signals by the same piezoelectric crystals.
• Computer software processes these signals into an
ultrasound image.
(h) ALARA
• “As low as reasonably achievable” [1, 2]
• Ultrasound principle to use the least amount of ultra-
sound possible on each patient
Figure 1.9 Power Doppler: Power Doppler will display a signal in
color if there is any motion at all. It does not indicate velocity or
direction. In this image, the testicles are being assessed for vascular
flow with power Doppler
8 Chapter 1. Introduction: Basic Ultrasound Principles
Transducer Selection
• Curvilinear Transducer
–– Low frequency with a wide field of view.
–– Greater tissue penetration allows for imaging of deeper
structures.
–– Ideal for abdominal imaging.
–– Typical frequency range is 2–5 MHz [3].
Figure 1.10—Curvilinear transducer
• Phased Array Transducer
–– Smaller flat footprint.
–– Uses electronic beam steering to produce a pie-shaped
field of view.
–– Allows for imaging through small areas such as between
ribs.
–– Most commonly used for cardiac imaging.
–– Typical frequency range is 2–7 MHz [4].
Figure 1.11—Phased array transducer
• Linear Array Transducer
–– Produces a rectangular image.
–– High frequency makes this transducer ideal for imaging
superficial structures including soft tissue, muscles,
nerves, arteries, and veins.
–– Often used for procedural guidance.
–– Typical frequency range is 5–10 MHz [2].
Figure 1.12—Linear transducer
Figure 1.10
Curvilinear trans-
ducer: Curvilinear
transducers exhibit
low frequency and
a wide field of
view
Transducer Selection 9
Figure 1.11 Phased array transducer:
Phased array transducers have smaller
flat footprints and exhibit a pie-shaped
field of view
Figure 1.12 Linear transducer: Linear
transducers produce rectangular images
using high frequency
