Atlas of Emergency Ultrasound Atlas of Emergency Ultrasound Edited by John Christian Fox University of California, Irvine School of Medicine, CA, USA C A M B R I D G E U N I V E R S I T Y P R E S S Cambridge, New York, Melbourne, Madrid, Cape Town, Singapore, São Paulo, Delhi, Tokyo, Mexico City Cambridge University Press The Edinburgh Building, Cambridge CB2 8RU, UK Published in the United States of America by Cambridge University Press, New York www.cambridge.org Information on this title: www.cambridge.org/9780521191685 © J.C. Fox 2011 This publication is in copyright. Subject to statutory exception and to the provisions of relevant collective licensing agreements, no reproduction of any part may take place without the written permission of Cambridge University Press. First published 2011 Printed in the United Kingdom at the University Press, Cambridge A catalog record for this publication is available from the British Library Library of Congress Cataloging-in-Publication Data Atlas of emergency ultrasound / edited by John Christian Fox. p. ; cm. Includes index. ISBN 978-0-521-19168-5 (hbk.) 1. Diagnostic ultrasonic imaging–Atlases. 2. Emergency medicine– Diagnosis–Atlases. I. Fox, J. Christian. [DNLM: 1. Ultrasonography–Atlases. 2. Emergency Treatment– Atlases. WN 17] RC78.7.U4A85 2011 616.070543–dc22 2011008590 ISBN 978-0-521-19168-5 Hardback Cambridge University Press has no responsibility for the persistence or accuracy of URLs for external or third-party internet websites referred to in this publication, and does not guarantee that any content on such websites is, or will remain, accurate or appropriate. Every effort has been made in preparing this book to provide accurate and up-to-date information which is in accord with accepted standards and practice at the time of publication. Although case histories are drawn from actual cases, every effort has been made to disguise the identities of the individuals involved. Nevertheless, the authors, editors, and publishers can make no warranties that the information contained herein is totally free from error, not least because clinical standards are constantly changing through research and regulation. The authors, editors, and publishers therefore disclaim all liability for direct or consequential damages resulting from the use of material contained in this book. Readers are strongly advised to pay careful attention to information provided by the manufacturer of any drugs or equipment that they plan to use. Contents List of contributors vi Preface vii 1. Focused assessment of sonography in trauma 1 Patricia Fermin and John Christian Fox 2. Ocular ultrasound 19 George Mittendorf and John Christian Fox 3. Cardiac ultrasound 26 Shane Summers 4. Ultrasound of the lung 35 Justin Davis and Seric Cusick 5. Right upper quadrant ultrasonography 58 Daniel Gromis and John Christian Fox 6. Intestinal ultrasound 77 Warren Wiechmann and Chase Warren 7. Pelvic ultrasound 88 Cindy Chau and John Christian Fox 8. Genitourinary ultrasound 103 Christina Umber and John Christian Fox 9. Musculoskeletal ultrasound 133 Deborah Shipley Kane and Jennifer McBride 10. Pediatric ultrasound 141 Stephanie Doniger and George Mittendorf 11. Ultrasound-guided procedures 158 Eric J. Chin 12. Arterial ultrasound 175 Sharis Simonian and John Christian Fox 13. Venous ultrasound 185 Kevin Burns and John Christian Fox Index 191 v Contributors Kevin Burns New York University School of Medicine, New York, New York, USA Cindy Chau, MD Resident, OB/GYN, University of California, Irvine Medical Center, Orange, California, USA Eric J. Chin, MD, RDMS, MAJ, USA, MC Associate Program Director, Emergency Ultrasound Fellowship, Staff Emergency Physician, Brooke Army Medical Center, San Antonio Uniformed Services Health Education Consortium, San Antonio, Texas, USA Seric Cusick, MD, RDMS Department of Emergency Medicine, Hoag Hospital, Newport Beach, California, USA Justin Davis Kaiser Oakland Medical Center, Oakland, California, USA Stephanie Doniger, MD, RDMS Director of Emergency Ultrasound, Children’s Hospital and Research Center Oakland, Oakland, California, USA Patricia Fermin, MD Resident, Emergency Medicine, Harbor-UCLA Medical Center, Los Angeles, California, USA John Christian Fox, MD, Clinical RDMS Professor of Emergency Medicine, Director of Instructional Ultrasound, University of California, Irvine Medical Center, Orange, California, USA Daniel Gromis, MD Resident, Emergency Medicine, Advocate Christ Hospital and Medical Center, Chicago, Illinois, USA Jennifer McBride, MD Resident, Emergency Medicine, Georgetown University, Washington, DC, USA George Mittendorf, MD Resident, Emergency Medicine, UCSF – Fresno, Fresno, California, USA Deborah Shipley Kane, MD, RDMS Clinical Instructor, Ultrasound Director, Washington University of St. Louis, St. Louis, Missouri, USA Sharis Simonian, MD Resident, Emergency Medicine, University of California, Irvine, Orange, California, USA Shane Summers, MD, RDMS Program Director, Emergency Ultrasound Fellowship, Assistant Professor of Military and Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, San Antonio, Texas, USA Christina Umber, MD Resident, Emergency Medicine, UCSF – Fresno, Fresno, California, USA Chase Warren University of California, Irvine, Orange, California, USA Warren Wiechmann, MD, RDMS Assistant Professor of Emergency Medicine, UCSF – Fresno, Fresno, California, USA vi Preface When a physician examines a patient at the bedside using the physical exam alone they are forced to rely on their “mind’s eye” to imagine what organs or tissue below the skin that could be the culprit of their patient’s ailment. With the advent of portable bedside ultra- sound, physicians are now able to image the organs and tissue directly at the point-of-care, creating an immediate impact on patient care. Harnessing this technology transforms the doctor–patient relationship from the time of Hippocrates to the modern day. Physician-performed imaging results in greater clinical self-reliance, reducing unnecessary CT scans, thereby causing less radiation exposure. The Atlas of Emergency Ultrasound is designed to give the busy practicing clinician a reference tool of positives. Each organ is represented with common and not so common pathological entities one encounters when practicing emergency ultrasound. This path- ology is clearly outlined by line-art, with detailed captions drawing the reader to salient points. This is not meant to be an exhaustive didactic reference, or evenanintroduction toobtainingultrasoundwindows. This book picks up where introductory coursework ends. There already exist plenty of references designed to teach the basics of image acquisition and ultrasound physics. This book assumes the reader has already begun to incorporate ultrasound into practice, and is now ready to take those skills further by focusing on pathology. While the focus is on emergency ultrasound, there are other specialties that would likely benefit from the pathology found in this text. Physicians who practice primary care will likely find many relevant images to learn from especially with regards to the gallbladder, pelvis, and vasculature, while physicians in the ICU setting will find the cardiac, DVT, and lung chapters of particular interest. Furthermore, surgeons looking for pathology related to the hepato-biliary system, soft tissue, and vasculature will find information relevant to their practice. Finally, as medical students are expected to perform more and more ultrasound at the bedside of their patients onrotations inthe emergency department, theICU,surgery,andObst/Gyn,theytoowillfindhelpful images to help them perform well on these clerkships. Ultimately, Hippocrates would be proud of the physician who can utilize any simple bedside tool to elaborate on the physical exam, but only if that tool would result in “first do no harm.” vii Chapter 1 Focusedassessmentofsonographyintrauma Patricia Fermin and John Christian Fox Epicardial fat pad When imaging the heart, careful attention must be made in identifying any surrounding fluid. The pres- ence of epicardial fat should be ruled out to have a clear determination of the presence of fluid. Hemopericardium An examination of the heart is crucial during trauma to the chest, such as a stabbing, gunshot wound, or motor vehicle collision. The identification of blood surrounding the heart is critical in order to prevent or Atlas of Emergency Ultrasound, ed. John Christian Fox. Published by Cambridge University Press. © J.C. Fox 2011. Epicardial fat pad: In this subxiphoid view, the four chambers of the heart (H) are difficult to visualize. However, a layer of fat (arrows) surrounding the heart may be seen. It is important to distinguish epicardial fat from hemopericardium, which is more echolucent. 1