ultrasound 

<guided> 

Procedures

wilma chan, md

03.11.2014
brigham & women's hospital
emergency medicine // ultrasound // HAEMR

 

AIRWAY 
paracentesis 
thoracentesis
SUBCLAVIAN CENTRAL LINE

airway


before

during

after

Airway


<before> surgical preparation

<during> endotracheal intubation

<after> post-tube placement

AIRWAYSURGICAL PREP

AIRWAYSURGICAL PREP


[probe] linear
[preset] superficial
[parts] anterior neck
[position] mid-sagittal
[picture] cricoid & thyroid cartilage


AIRWAYSURGICAL PREP 



Kristensen MS. Ultrasonography in the management of the airway. Acta Anaesthesiol Scand. 2011 Nov;55(10):1155-73.

 















Kristensen MS. Ultrasonography in the management of the airway. Acta Anaesthesiol Scand. 2011 Nov;55(10):1155-73.


AIRWAYSURGICAL PREP 













Kristensen MS. Ultrasonography in the management of the airway. Acta Anaesthesiol Scand. 2011 Nov;55(10):1155-73.










 airwaysurgical prep



AIRWAYSURGICAL PREP???


AIRWAYSURGICAL PREP 










Aslani A et al. Accuracy of identification of the cricothyroid membrane in female subjects using palpation: An observational study. Anesth Analg 2012 May; 114:987.

AIRWAYSURGICAL PREP 


Elliott DS, Baker PA, Scott MR, Birch CW, Thompson JM. Accuracy of surface landmark identification for cannula cricothyroidotomy. Anaesthesia 2010; 65: 889–94.

AIRWAYSURGICAL PREP


anticipate your difficult airway 

identify CTM from cartilage borders

mark your site 


AIRWAYintubation


airwaYintubation


[probe] linear
[preset] superficial
[parts] suprasternal
[position] transverse
[picture] tracheal ring, esophagus

AIRWAYintubation











Kristensen MS. Ultrasonography in the management of the airway. Acta Anaesthesiol Scand. 2011 Nov;55(10):1155-73.









Kristensen MS. Ultrasonography in the management of the airway. Acta Anaesthesiol Scand. 2011 Nov;55(10):1155-73.Kristensen MS. Ultrasonography in the management of the airway. Acta Anaesthesiol Scand. 2011 Nov;55(10):1155-73.





Kristensen MS. Ultrasonography in the management of the airway. Acta Anaesthesiol Scand. 2011 Nov;55(10):1155-73.

 airwayintubation

AIRWAYintubation


TRUE protocol (2011) during emergent intubation
---

93% concordance : wave-capnography

median time: 9sec

---

Chou recommends real-time US to 

confirm airway during CPR in trained hands

AIRWAYINTUBATION



indirect confirmation


real-time observation

use other modalities to corroborate


AIRWAYTUBE PLACEMENT

AIRWAYTUBE PLACEMENT





[probe] linear or curvilinear
[preset] superficial
[parts] left chest
[position] longitudinal
[picture] ribs, pleura

AIRWAYTUBE PLACEMENt 

Lichtenstein DA, Lascols N, Prin S, Mezière G. The "lung pulse": an early
ultrasound sign of complete atelectasis. Intensive Care Med. 2003
Dec;29(12):2187-92.

airwaytube placement


AIRWAYtube placement











https://umem.org/educational_pearls/2315/













AIRWAYTube placement


diagnosis of non-ventilated lung 
(RMS, atelectasis)
---

93% sensitivity
100% specificity
---

no previous pulm disease

AIRWAYsummary


<before> surgical preparation

<during> endotracheal intubation

<after> post-tube placement

 

AIRWAY 
paracentesis 
thoracentesis
SUBCLAVIAN CENTRAL LINE

paraCENTESISprep


[probe] curvilinear (& linear)
[preset] abdominal (& superficial)
[parts]  infraumbilical, lateral abdomen
[position] longitudinal, transverse
[picture] bladder, bowel, epigastric artery

paracentesisprep


Paracentesistechnique


empty the bladder

reclining or lateral decubitus

mark epigastrics

survey area around target entry

measure bowel to wall
 
position & prep

 







PARACENTESISTECHNIQUE


PARACENTESISPREP


PARACENTESISTECHNIQUE

assess distance to bowel

PARACENTESISTECHNIQUE


do NOT move pt after position and US 

sterile prep & drape

z-track needle entry

in-plane view 

visualize needle, catheter


PARACENTESISTECHNIQUE 















Nazeer SR, Dewbre H, Miller AH. Ultrasound-assisted paracentesis performed by emergency physicians vs the traditional technique: a prospective, randomized study. Am J Emerg Med. 2005 May;23(3):363-7.

PARACENTESISpitfalls

distended bowel, bladder, cysts (renal, ovarian)

PARACENTESISpitfalls

distended bowel, bladder, cysts (renal, ovarian)

 

PARACENTESISPITFALLS

distended bowel, bladder, cysts (renal, ovarian)


PARACENTESIStroubleshooting

"I'm stuck..."

 

AIRWAY 
paracentesis 
thoracentesis
SUBCLAVIAN CENTRAL LINE

THORACENTESISprep


[probe] curvilinear
[preset] lung or abdominal
[parts]  dorsal, subscapular
[position] longitudinal
[picture] ribs, diaphragm, lung tissue

THORACENTESISTECHNIQUE

THORACENTESISTECHNIQUE


patient position(s)

survey target area 

ID diaphragm & lung, ID spleen/liver

zone of safety

THORACENTESIStechnique


THORACENTESISTECHNIQUE


THORACENTESISTECHNIQUE


THORACENTESISTECHNIQUE












Ma OJ, Mateer JR, Blaivas M. Emergency Ultrasound 2nd ed. 2008.

THORACENTESISTECHNIQUE


THORACENTESISTECHNIQUE 



Grogan DR, et al. Complications associated with thoracentesis. A prospective, randomized study comparing three different methods. Arch Intern Med. 1990 Apr;150(4):873-7.

Adjusted hospital los by adverse events








Mercaldi CJ, Lanes SF. Ultrasound guidance decreases complications and
improves the cost of care among patients undergoing thoracentesis and
paracentesis. Chest. 2013 Feb 1;143(2):532-8.

Adjusted hospital cost by adverse event

Mercaldi CJ, Lanes SF. Ultrasound guidance decreases complications and
improves the cost of care among patients undergoing thoracentesis and
paracentesis. Chest. 2013 Feb 1;143(2):532-8.

THORACENTESISpitfalls


US guided vs assisted

avoiding neurovascular bundle

anatomical changes w breathing/ moving

obese pts or subQ emphysema 

reexpansion edema




 

AIRWAY 
paracentesis 
thoracentesis
SUBCLAVIAN CENTRAL LINE

Subclavian Linesanatomy

a



     
   

rob swatski

SUBCLAVIAN LINESanatomy


Subclavian linesprep


[probe] linear
[preset] vascular
[parts] clavicle, 1st rib
[position] infraclavicular, supraclavicular
[picture] SC artery, SC vein, pleura, IJ, ---| |---

SUBCLAVIAN LINESTECHNIQUE

about ---| |---


***

SUBCLAVIAN LINESTECHNIQUE

***
about ---||---

SUBCLAVIAN LINESTECHNIQUE

INFRACLAVICULARapproach

infraclaviculartechnique


laterally @ shoulder in sagittal

    ID  axillary artery, axillary vein in short 
           

    slide medial w clavicle as home base

    ID pleural movement

infraclavicularTECHNIQUE


www.bluephantom.com
www.bluephantom.com

INFRACLAVICULARTECHNIQUE



INFRACLAVICULARTECHNIQUE


infraclavicularTECHNIQUE


track SCV rotate to long view (30deg) @ 1st rib

             ---| |--- to confirm venous flow (valsalva)

                            visualize needle, wire, catheter 

                                                 check IJ for misplacement
   
                                                        check for PTX

SUBCLAVIAN LINESANATOMY

SUBCLAVIAN LINESSTATs  

Fragou M, et al. Real-time ultrasound-guided subclavian vein cannulation versus the landmark method in critical care patients: a prospective randomized study. Crit Care Med.  2011 Jul;39(7):1607-12.

 Outcome measures in US vs LM

 











Fragou, M. et al. Real-time ultrasound-guided subclavian vein cannulation versus the landmark method in critical care patients: a prospective randomized study. Crit Care Med. 2011 Jul;39(7):1607-12.

subclavian linesstats

Success rates US vs Landmark


SUBCLAVIAN LINESstats 

Gualtieri E, Deppe SA, Sipperly ME, Thompson DR. Subclavian venous
catheterization: greater success rate for less experienced operators using
ultrasound guidance. Crit Care Med. 1995 Apr;23(4):692-7..

supraCLAVICULARapproach




              

SUBCLAVIAN LINESANATOMY


SupraCLAVICULARtechnique


IJ --> sternoclavicular junction

                 ID brachiocephalic vein (BCV)

                          slide slightly laterally 

                                     ID junction of SCV to BCV

                                                aim anteriorly (@ sternum)

SupraclavicularTECHNIQUE


SUBCLAVIAN LINESpitfalls


THINK coagulopathies

contralateral PTX

mistaking SCA for SCV

practice anatomy, in-plane ONLY






SUBCLAVIAN LINESpractice

next week @ STRATUS!!

Limitations


airway
paracentesis
thoracentesis
subclavian lines

Thanks

mike stone & josh rempell
&   division of emergency ultrasound

Questions??

get this presentation @
http://goo.gl/oWMA7f

<REferences>

Dawson M, Mallin M. Introduction to Bedside Ultrasound, Volumes 1 &2; Lexington, KY: Emergency Ultrasound Solutions.
Runyon BA. Paracentesis of ascitic fluid. A safe procedure. Arch Intern Med. 1986 Nov;146(11):2259-61.
Ma OJ, Mateer JR, Blaivas M. Emergency Ultrasound 2nd ed. 2008.