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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5836_Библиотеки_им_академика_М_И_Перельмана.pdf
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helps keep the proper orientation as referred. One can also assure this by pressing
on the surface of the probe’s marker just to guarantee its correct position by viewing
movement on the left side of the monitor. All obtained ultrasound images should be
correlated with the clinical situation. Please remember that this type of ultrasound
is more focused on a clinical basis rather than the traditional anatomically oriented
ultrasound that is performed in the radiology unit.
3.2.2 Normal Anatomy
The order of the E-FAST views is not standardized although many surgeons argue
that in cases of thoracic trauma, one should begin with a pericardial view. The peri-
hepatic view may fi rst be performed in abdominal trauma since it is where blood
primarily deposits in the peritoneum .
Fig. 3.1 The four scanning windows of the E-FAST abdominal examination
3 Abdominal Views: Technique, Anatomy, Abnormal Images, Scanning Tips, and Tricks
22
Pericardial View
The subcostal view is also known as subxiphoid; this permits the visualization of the
heart as well as part of the liver and diaphragm. Usually, a very small amount of
physiological fl uid exists between the parietal and visceral pericardium that is non-
circumferential and that is rarely seen. The probe should be placed with the pointer
directed toward the patient’s right. The convex surface of ultrasound probe should
be placed in the midline, angled slightly upward toward the left shoulder, and insin-
uated under the ribcage to minimize thoracic ribcage shadow, until a view of the
heart and left lobe of the liver is obtained (Fig. 3.4 ). Normal pericardium is seen as
a hyperechoic ( white ) line surrounding the heart below the left lobe of the liver
(Figs. 3.5 and 3.6 ). To enhance imaging ask the patient to bend his knees and hold
his breath or make an end - inspiratory pause if on mechanical ventilation. The inter-
costal or parasternal view is also a valid option if the subcostal view is not adequate
owing to obesity, protuberant abdomen, abdominal tenderness, and gas or epigastric
lesions.
Fig. 3.2 The ultrasound transverse caudal to cranial view
F. Ferreira et al.
23
Fig. 3.3 Green marker pointing toward the patient’s head in coronal view
Fig. 3.4 Position for pericardial subxiphoid view
3 Abdominal Views: Technique, Anatomy, Abnormal Images, Scanning Tips, and Tricks
24
Figs. 3.5 and 3.6 Normal subcostal echocardiographic view
F. Ferreira et al.
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Perihepatic View
The perihepatic or right upper quadrant view permits the surgeon to acquire a
partial image of the liver, the right kidney, the subphrenic space, and the right
pleural space. The right subcostal technique is obtained with the probe at the
right infracostal margin , just lateral to the midclavicular line (Fig. 3.7 ). Angle
the probe until the hepatorenal space (Morison’s pouch) is seen. In a normal view,
the liver and kidney are closely aligned separated by a brightly echogenic surface
(Gerota’s fascia) (Figs. 3.8 and 3.9 ). To better visualize the subphrenic space , one
should gradually move the probe in a more cranial direction and laterally closer
to the posterior clavicular line allowing for a more coronal perspective . Right
intercostal oblique or transverse views can be obtained rotating the probe counter-
clockwise (Fig. 3.10 ). This allows a better visualization of the right pleural space,
Morison’s pouch, and right paracolic gutter. As mentioned, to enhance imaging ,
have the patient hold his breath or make an end - inspiratory pause if on mechanical
ventilation .
Perisplenic View
The perisplenic or left upper quadrant view may be considered more challeng-
ing since the spleen is smaller and located more posteriorly than the liver. This
approach requires that the placement of the probe be intercostal and as close to the
posterior axillary line as possible between the 10th and 11th ribs angled to achieve
Fig. 3.7 Position for perihepatic E-FAST view
3 Abdominal Views: Technique, Anatomy, Abnormal Images, Scanning Tips, and Tricks
26
a view of the spleen , the left kidney , the subphrenic space , and the left pleural space
(Figs. 3.11 , 3.12 , and 3.13 ). The spleen has a homogeneous cortex that is more
echogenic than the left kidney cortex. To better visualize the subphrenic space , one
should position the probe marker upward pointing toward the left posterior axilla
Figs. 3.8 and 3.9 Normal view of hepatorenal interface
F. Ferreira et al.
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and gradually move the probe in a more cranial direction laterally closer to the
posterior clavicular line allowing for a more coronal perspective .
One should enhance the view of the left diaphragm and spleen by having the
patient hold his breath or making an end-inspiratory pause if on mechanical ventila-
tion. This will cause the diaphragm to move into the necessary plane. For a better
view of the spleen and lower pole of the kidney, have the patient exhale or make an
end-expiratory pause if on mechanical ventilation, thus minimizing interference
from the stomach.
Fig. 3.10 Probe rotation for intercostal view
Fig. 3.11 Position for perisplenic view
3 Abdominal Views: Technique, Anatomy, Abnormal Images, Scanning Tips, and Tricks
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Fig. 3.12 Normal anatomy of splenorenal space with colored spleen and kidney
Fig. 3.13 Anatomy and view of splenorenal space
F. Ferreira et al.
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Pelvic View
The pelvic view should be evaluated in both transverse and sagittal planes. The
probe must be placed transversely in the abdominal midline 2 – 4 cm superior to the
symphysis pubis with the probe marker pointing to the patient ’ s right , angled down
until the prostate or vaginal stripe is identifi ed (Fig. 3.14 ). The probe is then rotated
90° placing the probe marker in a cranial direction and slightly tilting the probe, to
avoid interference from the pubic rami, providing a sagittal view of pelvic struc-
tures (Fig. 3.15 ). A full bladder is essential for an adequate scan . The best oppor-
tunity to acquire a good sonographic view is before the placement of a urinary
Foley. If it has already been placed, one may inject saline into the bladder in a ret-
rograde manner or wait until it fi lls normally not forgetting to clamp the tube. The
pelvic view permits the visualization of the bladder that serves as an acoustic win-
dow . In the female it allows for visualization of uterus and the rectouterine pouch
and in the male the seminal vesicles, prostate, and rectovesical recess (Figs. 3.16 ,
3.17 , 3.18 , and 3.19 ).
3.2.3 Basic Abnormal Findings (What to Search)
and the Clinical Meaning
In the same order as previously presented, we shall review the abnormal fi ndings
and the clinical meaning that one should keep in mind when performing an E-FAST
examination.
Fig. 3.14 Position for pelvic transverse view
3 Abdominal Views: Technique, Anatomy, Abnormal Images, Scanning Tips, and Tricks
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Fig. 3.16 Normal pelvic transverse view colored for better identifi cation
Fig. 3.15 Position for pelvic sagittal view
F. Ferreira et al.