ultrasound
<guided>
Procedures
HUP Critical Care Course
dept of emergency medicine // division of emergency ultrasound
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
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
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
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
AIRWAYtube Placement
AIRWAYtube placement
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
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
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, et al. Textbook of US**
THORACENTESISTECHNIQUE
THORACENTESISTECHNIQUE
Adjusted hospital los by adverse events
Adjusted hospital cost by adverse event
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
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.
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
Limitations
airway
paracentesis
thoracentesis
subclavian lines
Thanks
mike stone & josh rempell
& division of emergency ultrasound
Questions??
get this presentation @
slides: http://goo.gl/KUSIGE
notes: https://goo.gl/6RVQju
<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.