2. Emergency Ultrasound of the Aorta Fahad Khan, MD St. Luke’s/Roosevelt Hospital Center Columbia University, New York City April 24, 2009

3. Case  70 y/o male presents after witnessed syncopal episode  Upon awakening, patient complained of feeling weak  Patient walked to bathroom and collapsed

4. Case  Afebrile, 110, 95/50, 18, 98% RA  Appears pale, diaphoretic  Tachycardic, S1S2  CTAB  Abd: soft, periumbilical tenderness, no rebound, no guarding  Otherwise unremarkable exam

5. Abdominal Ultrasound

7. Risk Factors for AAA  Male  Atherosclerosis  Smoking  Hypertension  Age

8. Key Question  Is there an abdominal aortic aneurysm?  Aorta >3cm  Iliac >1.5cm

9. Indications  Suspected AAA  Pulsatile abdominal mass  Unexplained hypotension/ CV collapse  Elderly  Unexplained back/flank pain  Unexplained hematuria

10. Abdominal Aorta Anatomy

11. Minimal Criteria  Transverse  1) Proximal aorta  2) Mid aorta  3) Distal aorta  4) Iliac bifurcation  Sagittal  5) Infra-renal

12. Technique Low Frequency 2-5 MHz

13. Transverse Views

14. Proximal Aorta Transverse Splenic Vein Superior Mesenteric Artery Aorta

15. Proximal Aneurysm

16. Mid Aorta Transverse Aorta IVC Spine

17. Aortic Aneurysm

18. Sagittal Aorta Head Feet

19. Longitudinal Aneurysm

20. Distal Aorta and Bifurcation Transverse

21. Aortic Bifurcation Transverse Right Common Iliac Artery Left Common Iliac Artery Spine

22. Distal Aneurysm

23. Pitfalls  Only true contraindication – delaying immediate surgical intervention  Over-reliance – finding a AAA, does not mean it has ruptured  Error in imaging – parasagittal plane  Patient factors – body habitus, bowel gas

24. Useful clinical information can be obtained from emergency ultrasound of the abdominal aorta quickly, and with accuracy as compared to CT.

25.  Emergency ultrasound of the abdominal aorta is very sensitive and specific  Can guide and expedite urgent vascular consultation  AAA can be effectively excluded by bedside emergency ultrasound regardless of patient’s disposition

26. Questions?