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31
Fig. 3.17 Normal pelvic view as seen in display monitor
Fig. 3.18 Sagittal pelvic view. Colored structures for better visualization
3 Abdominal Views: Technique, Anatomy, Abnormal Images, Scanning Tips, and Tricks
32
Pericardial View: Subcostal and Parasternal
In the E-FAST view, the subcostal window may permit a full four-chamber perspec-
tive of the heart. The pericardium is more hyperechoic than the heart muscle. If fl uid
is present between the parietal and visceral pericardium, this should be identifi ed
with high sensitivity as a black line representing an acute bleed; however, in some
healthy patients, a small amount of fl uid can also be seen in the dependent aspect of
the heart, so clinical correlation is always mandatory. A partial pericardial anterior
anechoic line may correspond to a pericardial fat strip yet if circumferential will in
fact represent pericardial fl uid (Fig. 3.20 ) .
Fig. 3.19 Normal anatomy of sagittal pelvic view
Heplful Tips
Never forget the basics of ultrasonography such as the use of suffi cient amount
of gel to facilitate good ultrasound wave transmission and the proper inclina-
tion of the probe to avoid interference from any bone structures.
Helpful Tips
Be careful with subcutaneous emphysema which can obscure a proper ultra-
sound view. The transducer should be very angled approximately 5–10° or be
fl at to the skin.
F. Ferreira et al.
33
Perihepatic View
The perihepatic or right upper quadrant view allows for a partial view of the liver and
right kidney. This permits good visualization of fl uid in Morison’s pouch, the right
pleural space, and the subphrenic space. If a hemoperitoneum exists , it will appear
as an anechoic area in Morison ’ s pouch and / or the subphrenic space (Fig. 3.21 ).
This free fl uid tends to triangulate as it follows the path of least resistance differing
from visceral edema, which has a more cylindrical appearance. Morison’s pouch
represents a dependent location for blood accumulation. Be aware that the internal
fl uid in the viscera such as the duodenum, colon, gallbladder, and even the vena
cava can be mistaken for free peritoneal fl uid.
Fig. 3.20 Positive pericardial E-FAST
Pericardial fl uid may be obscured by a large hemothorax. It is advisable to
repeat your scan after chest tube placement. If the subxifoid window is not
available try the left parasternal window at 4th or 5th intercostal space.
Helpful Tips
Placing the patient in a Trendenlenburg position will facilitate fl uid accumula-
tion at Morison’s pouch.
3 Abdominal Views: Technique, Anatomy, Abnormal Images, Scanning Tips, and Tricks
34
Perisplenic View
The perisplenic or left upper quadrant view allows for different perspectives of the
spleen, left kidney, and left pleural space. Hemoperitoneum will translate as an
anechoic area in the subphrenic space or in the splenorenal recess (Fig. 3.22 ). The
path of least resistance for the peritoneal fl uid will most likely extend to the sub-
phrenic space , with overfl ow going into the splenorenal fossa and eventually across
to Morison ’ s pouch . Pleural fl uid, in a trauma context, is most likely a hemothorax
being located in the left pleural space and accurately detected on this limited view
as an anechoic region above the left hemidiaphragm.
Be aware that perinephric fat can mimic a hematoma. Perinephric fat is
usually symmetric with the opposite kidney.
Ascites has an identical appearance and can be mistaken for hemoperito-
neum. Liver disease and right heart failure should be considered.
Fig. 3.21 Positive perihepatic E-FAST
F. Ferreira et al.
35
Pelvic View: Transversal and Sagittal
In a female patient, free fl uid appears in the rectouterine pouch with greater amounts
of fl uid extending around the uterus (Figs. 3.23 and 3.24 ). In a male patient, this
fl uid appears in the rectovesical pouch or cephalad to the bladder. In both cases, a
signifi cant amount of perivesical fl uid , most likely blood in trauma cases , will pro-
duce an anechoic medium that accentuates bowel loop underwater undulation .
Fig. 3.22 Positive perisplenic E-FAST
Helpful Tips
Due to gastric distension secondary to opioid medication and hyperventila-
tion, a NG tube placement will permit a better view of the upper left
quadrant.
Placing a towel under the spine board will allow for a better view of the
spleen from a more posterior angle.
Stay posteriorly for a better visualization.
3 Abdominal Views: Technique, Anatomy, Abnormal Images, Scanning Tips, and Tricks
36
Fig. 3.24 Positive pelvic view (sagittal)
Fig. 3.23 Positive pelvic view (transverse)
F. Ferreira et al.
37
Suggested Reading
1. American College of Surgeons Committee on Trauma (2008) ATLS® student course manual,
8th edn. American College of Surgeons, Chicago
2. Boffard KD (2007) Manual of defi nitive surgical trauma care, 2nd edn. Edward Arnold
Publishers Ltd., London
3. Boulanger BR, Brenneman FD, McLellan BA et al (1999) Prospective evidence of the superi-
ority of a sonography-based algorithm in the assessment of blunt abdominal injury. J Trauma
65:632–637
4. Ihnatsenka B, Boezaart AP (2010) Ultrasound: basic understanding and learning the language.
Int J Shoulder Surg 4:55–62
5. Melniker L, Liebner E, McKinney M et al (2006) Randomized clinical trial of point-of-care,
limited ultrasonography for trauma in the emergency department: Sonography Outcomes
Assessment Program (SOAP) -1 trial. Ann Emerg Med 48:227–235
6. Rozycki GS, Ochsner MG, Feliciano DV et al (1998) Early detection of hemoperitoneum by
ultrasound examination of the right upper quadrant: a multicenter study. J Trauma 45:878–880
Helpful Tips
Fluid within a collapsed bladder may appear as free peritoneal fl uid. A full
bladder is essential.
Seminal vesicles may be incorrectly identifi ed as free fl uid in a transverse
view. Use a sagittal view and sweep slightly lateral to differentiate.
Premenopausal females may normally have a small amount of free fl uid in
the Pouch of Douglas.
3 Abdominal Views: Technique, Anatomy, Abnormal Images, Scanning Tips, and Tricks
39
M. Zago (ed.), Essential US for Trauma: E-FAST, Ultrasound for Acute Care Surgeons,
DOI 10.1007/978-88-470-5274-1_4, © Springer-Verlag Italia 2014
4.1 Introduction
The idea behind chest ultrasound is not a recent one.
The fi rst published paper on the diagnosis of pneumothorax dates back to the
1986 (Rantanen).
In the last 15 years, several papers showed the effi cacy of chest ultrasound in
detecting both pneumothorax (PTX) and hemothorax.
Some authors say that US is faster than the fastest of X-rays, and indeed, it can
buy you some time just when time is of the essence.
In this chapter, you’ll learn how to perform a correct chest ultrasound examina-
tion to detect two life-threatening conditions, such as pneumothorax and
hemothorax.
You will learn to recognize the normal sonographic anatomy of the chest wall as
well as normal and pathological US patterns.
At the end of this chapter, you’ll be able to answer the same old question (“Is
there free fl uid?”) and a new one (“Is there free air?”).
A. A. Casamassima , MD (*)
Emergency Department , Istituto Clinico Città Studi , Milano , Italy
e-mail:
casamax@gmail.com
M. Zago , MD
General Surgery Department , Minimally Invasive Surgery Unit,
Policlinico San Pietro , Bergamo , Italy
e-mail:
maurozago.md@gmail.com
4
Thoracic Views: Anatomy, Techniques,
Scanning Tips and Tricks, Abnormal
Images
Andrea A. Casamassima and Mauro Zago
Chest US is useful in prehospital and in emergency room but also in intensive
care units, to detect PTX and hemothorax earlier than using X-ray and with-
out moving the patient!
40
4.2 Scanning Technique and Semeiotics
As we said before, there are two main severe conditions possibly affecting a chest
trauma patient that can be detected with US: hemothorax and pneumothorax.
Let’s talk about hemothorax fi rst as the technique is a natural extension of the
abdominal views.
You have learned to explore the abdomen in the previous chapter and you
may recall the upper right and left quadrant views. Starting from those views, you
simply have to pan the probe headward a few inches, along midaxillary/posterior
axillary line. That way you will switch from the abdominal to the chest cavity. On
the monitor you will see the liver, a bright curved line which is the diaphragm and
on the left side of the screen you will have the chest cavity.
What you see depends on the condition of the patient.
A bright curtain moving synchronously with the breathing cycle stands for a
normal fi nding (Fig.
4.1 ). The white artifact is the lung (see below): so, if the lung
is detectable on mid-/posterior axillary line without any black strip interposition,
there is no clinically relevant fl uid in the thorax!
Another normal fi nding is the “mirror effect,” an US artifact. Due to the curved
surface of the diaphragm, you will happen to see the same texture of the liver above
(i.e., on the left side) the diaphragm bright line (Fig. 4.2 ).
Fig. 4.1 Normal right upper quadrant view. On the left side of the fi gure, there is the “white
curtain” of the lung, descending to cover the texture of the liver
A.A. Casamassima and M. Zago
41
On left side of the patient, the technique will be the same: upper left abdominal
quadrant view, pan headward 1 or 2 in. You will see the spleen, a bright white line
(the diaphragm), and the white curtain moving in and out of the screen with the
patient’s breathing.
In patients affected by hemothorax, you will see the liver or the spleen, according
to the side you’re probing, the bright line of the diaphragm and on the left side of the
screen, there will be a sort of black triangle or black strip, which is fl uid (Figs. 4.3,
4.4, 4.5, and 4.6 ).
As you may recall from the abdominal views, fl uid is (almost) always black on
the screen.
That simple.
Since these views can be considered an extension of the abdominal examination,
you will use the curved array.
Now we can explore the chest to detect PTX.
In order to obtain a correct chest exam, we need to set our US machine to let us
see artifacts (i.e., you have to switch off any artifact reduction algorithm that US
machine manufacturers are proud of).
You may explore the chest using almost any kind of probe, but it’s advisable to
use the linear array, because higher resolution helps to tell the very artifacts we’re
looking for. When you will become skilled, you will use phased array or curved
probes too.
Fig. 4.2 Mirror effect. On both sides of the diaphragm, you can see the same texture. That indi-
rectly rules out pleural effusion
4 Thoracic Views: Anatomy, Techniques, Scanning Tips and Tricks, Abnormal Images