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Soft Tissue

Clinical Considerations Ultrasound is an ideal modality to supplement evaluation of the soft tissue. The high–frequency linear transducer produces a detailed image of the area in question. By adding dynamic interrogation, such as manual compression or color flow, we can further characterize the findings to help confirm or rule out many common diagnoses. Soft tissue infections, including cellulitis and abscess, are extremely prevalent, and becoming more…

Peripheral Veins and Arteries

Peripheral Artery Disease Patients may present with acute or chronic lower extremity arterial insufficiency. Chronic lower extremity arterial insufficiency is typically secondary to atherosclerosis. Atherosclerosis is a gradual, degenerative disease where plaque accumulates in the wall of the artery and typically causes gradual, progressive clinical manifestations. However, plaques may become unstable and result in acute ischemic symptoms as well. The two primary risk factors for chronic…

Female Pelvis, Pregnant: Second and Third Trimesters

Anatomy This chapter is different from other chapters, in that there may be a variety of causes and different anatomic regions may be the etiology of pain in later pregnancy. As for anatomic considerations, the main focus of this chapter will be on obstetrical etiologies of pain and/or bleeding. Much of the focus will be on the placenta, cervix, umbilical cord, and amniotic fluid. During the…

Female Pelvis, Pregnant: First Trimester

Normal First-Trimester Ultrasound Appearance Pelvic ultrasound is the key imaging modality in the diagnosis of early pregnancy and its associated complications. Both transabdominal and transvaginal sonography (TVS) techniques are used. Gestational Sac Intradecidual Sign The intradecidual sign refers to an eccentric, extraluminal, rounded, cystic structure located within the endometrium. It is the earliest imaging sign of an intrauterine pregnancy (IUP) on TVS and is observed as…

Female Pelvis, Nonpregnant

Normal Anatomy The uterus is composed of the muscular layer, or myometrium. The body is the main portion of the uterus. The fundus is a more superior portion above the body of the uterus. The areas of the uterus where the fallopian tubes enter are called the cornua . The inferior portion of the uterus is the cervix. Peritoneal reflections are noted both anterior to the…

Male Pelvis

Scrotum Normal Anatomy The surface of the testis is surrounded by the tunica vaginalis, which extends to the inner surface of the scrotal wall in continuity. A trace amount of fluid in between both layers allows a high mobility of the testis. This arrangement is similar to the pleura with the visceral and parietal layers that allow the lung excursion. Adult measurements of the testis are…

Lower Abdomen and Bowel

Bowel Ultrasound Normal Anatomy The small bowel consists of the bowel distal to the stomach and proximal to the colon. It is approximately 5 meters long and includes the duodenum, jejunum, and ileum. The small bowel contains prominent mucosal folds known as plicae circulares or valvular connvinetes . The jejunum has the most developed and highest concentration of these folds, which remain present even in distended…

Abdominal Aorta

Introduction Patients with aortic pathology often present with nonspecific complaints or presentations such as back pain, abdominal pain, myocardial infarction (MI), or even stroke, making the diagnosis difficult. The adage of “abdominal pain plus one other organ system” should prompt the physician to consider aortic pathology as the unifying diagnosis. The level and acuity of pain often is secondary to the etiology of the pain. For…

Kidney and Renal Transplant

Normal Anatomy Kidneys The kidneys are retroperitoneal structures and are surrounded by fascial layers, including Gerota’s fascia. There is direct supply of the renal arteries and veins to the kidney from the abdominal aorta. The right and left renal arteries lie posterior to the renal veins. Their relationship to each other and the surrounding vascularity is shown in Fig. 19.1 . The kidneys consist of the…

Pancreas

Normal Anatomy The pancreas is mostly within the retroperitoneum in the anterior pararenal space. However, the tail of the pancreas is actually an intraperitoneal structure and in close relationship with the splenorenal ligament. To best understand the anatomy of the pancreas, an understanding of embryology is necessary. The pancreas develops from two pancreatic buds: the dorsal bud and the ventral bud. With development, the ventral bud…

Gallbladder and Biliary

The Gallbladder Normal Anatomy The normal anatomy of the gallbladder, biliary tract, and surrounding organs is presented in Fig. 17.1 . The gallbladder is connected via the cystic duct to the common hepatic duct, forming the common bile duct (CBD) that drains into the duodenum through the head of the pancreas. In most situations, the hepatic artery lies between the CBD and the more posteriorly located…

Liver and Spleen

The Liver Normal Liver Normal Anatomy The cephalad portion of the liver is bounded by the diaphragm. The caudal extent of the liver is in close proximity to the stomach, the duodenum, and the large bowel and lies just cephalad to the pancreas. Using the Couinaud classification of liver anatomy, the liver is divided into eight segments. Segment 1 is the caudate lobe. The caudate’s boundary…

FAST of the Abdomen – Beyond the Basics: False Positives, Limitations, and Approach to the Unstable Patient

Introduction The development of focused assessment with sonography for trauma (FAST) over 30 years ago enabled clinicians to rapidly screen for injury at the bedside of patients, especially those hemodynamically unstable for transport to the computed tomography (CT) suite. The identification of free fluid within the peritoneal cavity, pericardium, and pleural spaces can be accomplished with point-of-care ultrasound (US) immediately upon patient arrival to the hospital.…

Ultrasound-Guided Resuscitation

Use of Ultrasound in the Undifferentiated Hypotensive Patient Care of the undifferentiated hypotensive patient is a challenge for clinicians, and identifying life-threatening conditions that are readily reversible is a priority. Point-of-care ultrasound (POCUS) has had a prominent role over the past 20 years in the care of these patients. Focus on conditions that require emergent intervention, such as pneumothorax, intraabdominal hemorrhage, and pericardial effusion, has been…

Approach to the Patient with Chest Pain

Introduction Undifferentiated chest pain presents a diagnostic dilemma because there are many potential causes, with some etiologies being imminently life threatening. These diagnoses often cannot be determined by history or physical examination alone. Patients may be hypotensive or deteriorate quickly, requiring emergent procedures. For these reasons, point-of-care ultrasound (POCUS) is used to evaluate chest pain. The most urgent systems to evaluate are cardiac, aortic, and pulmonary,…

Approach to the Patient with Shortness of Breath

Introduction Patients presenting with undifferentiated shortness of breath can be challenging because their presentations can have many potential etiologies: pulmonary, cardiac, mixed cardiopulmonary, gastrointestinal, neurologic, or other noncardiopulmonary reasons. It is important to evaluate all organ systems potentially involved using a standardized, structured fashion to reach helpful conclusions rapidly at the bedside. Preceding chapters have explored and discussed organ-based evaluations utilizing ultrasound. This chapter will focus…

Focused Transesophageal Echocardiography

Introduction Long considered to be a vital diagnostic tool utilized exclusively within the realm of cardiology, transesophageal echocardiography (TEE) is being used safely and effectively within the perioperative, critical care, and emergency room settings. Of particular importance is the ability to diagnose a vast array of diverse pathologies causing hemodynamic instability. In this capacity, a focused TEE examination has been proven to serve as an important…

Transthoracic Echocardiography

Basic Echocardiography Clinical Correlation Point-of-care cardiac ultrasound is indicated for a wide variety of clinical presentations, including cardiac trauma, cardiac arrest, tachycardia, hypotension, shortness of breath, chest pain, and syncope. It requires a minimum of two views of the heart and may also require visualization of the inferior vena cava (IVC) and pulmonary ultrasound to assess for intravascular volume status, associated lung abnormalities, and correlation with…

Lung

Clinical Correlation Patients who present with undifferentiated shortness of breath can be challenging due to the broad differential diagnosis, which encompasses pulmonary, cardiac, mixed cardiopulmonary, and noncardiopulmonary etiologies. Lung ultrasound has revolutionized the approach to the undifferentiated dyspneic patient. What makes lung ultrasound somewhat unique is that whereas other ultrasound applications use traditional grayscale images of the patient’s anatomy to answer focused questions, lung ultrasound looks…