1. Ultrasound : Zonare Knobology Jamie Jenkins MD, RDMS
Regional Ultrasound Director FHS
St Josephs Medical Center

2. Core Applications of Ultrasound

3. Knobology
How to use the machine

4. Medical Legal Aspect
Only 21% of EM physicians personally perform bedside ultrasound
Standard of Care: Central lines
No lawsuits for misreads as of 2007
3 lawsuits for failure to use
2 with AAA
1 with rule out ectopic
Credentialing
Can we hide behind it or with out it?
Our we shielding ourselves by claiming we weren't trained?
Once case that showed that an older physician had a pt with possible AAA but that He didn’t know how to use US well so sent the pt down to get a CT scan. The patient died in the scanner. A suite was filed as the physician could have gotten the other ED physician that was better at US to come and do the scan. Physician won…
There was a similar case with an ectopic
It is in the ACEP definition of our skill set so we should be able to do basic US with some confidence.

5. Knobology: The Basics
M –mode: press to see the motion mode= This allows you to measure an objects rate of motion, (Fetal heart tones or the motion of the pleural line for pnuemothorax)
Optimize: Press this button while the probe is on the patient and the computer will optimize the picture to be the best quality from a brightness perspective
2-D: otherwise known as gain. Turning this knob will allow you to make adjustments to the gain (brightness) of the screen. Just remember brightness will only help so much so be judicial when using this knob.
Freeze: use this button to freeze the image in order to measure something in the image or to save a still image
Store: This will save a 6 second clip / movie
Print: This will save a single image/ Still

6. Changing probes
Press the transducer key and then use the soft keys to select which transducer you need
Please do not change the Transducer plug-ins.
Transducer button : Selecting this will change the screen above the soft keys to allow you to choose which transducer you wish to use
C4-1 is the curvilinear: the probe most commonly used for FAST exams as well as cardiac exams, AAA, GB and Pregnancy
L14-5 is the linear probe: the probe with the flat surface: this is used most commonly for lung exams to evaluate for Pneumothorax as well as appendicitis, soft tissue and vascular access
Pressing on the button just below the designation will allow that transducer to be selected.

7. Exam Type
Exam type: Pressing this button will allow you to change between preset exam types (i.e. OB/ Abd) it will change the screen above the soft keys
You will then see the keys appear as so you can turn the knob to select your desired exam type
This is important as certain measurements are only found under certain exam types (i.e. fetal Biparietal Diameter and Crown Rump length are only found under OB)

8. New patient exam
Press new patient key in upper left hand corner of the keyboard

9. New Patient: Non-credentialed physicians, Training scans at all hospitals
Last name: Training
First name: EDUS
Do not fill out MR number
Operator: Your name
Press exit
On first page, press space bar and type in pt name and MR number
Training scans can be done even if you are a credentialed physician.
Do not place the MR number on the new patient screen. If you do your images will be saved in the patients chart
ON the first screen Type in the pt name and MR number so that you can get credit for the scan.

10. New Patient: Credentialed physicians At St Joes & St Francis
Enter an order in EPIC
Click worklist
Select patients name from list
The screen will self populate
Fill in your name under operator
Press exit and start scanning
At the End of the exam press the end exam key on the keyboard
If you fail to enter the order first then you will need to enter the MR number on your own. In this case please do not enter any leading zeros. Also please still enter an order after you are finished with the scan as, again, if there is no order we will loose the image after 3 months.

11. New Patient: Credentialed physicians at St Anthony & St Clare
Last name: Patients last name
First name: Patients first name
ID: MR number
Operator: Your last name
Press exit and start scanning
Print images and attach to a paper with pts sticker and give to HUC to scan in for HIM
At the End of the exam press the end exam key on the keyboard
If you fail to enter the order first then you will need to enter the MR number on your own. In this case please do not enter any leading zeros.

12. If you manually enter info instead of using worklist: St Josephs & St Francis
If you manually enter the patient information including the MR number
No leading zeros
No dashes
No FIN numbers
Ex: MR number is
Enter
At St Josephs and St Francis you still need to enter an order after you finish the scan
It is preferred that you use the worklist

13. Central Lines Document on central line section of the note
Wire or needle seen in lumen
Image saved to patients permanent record
You must save an image of this.
There is an EPIC smart Phrase under my name (Jamie Jenkins) .eduscentralline
No image saved means we can not bill for it.
At St Francis and St Josephs you still will need to enter an order for the ultrasound scan or again the image will be lost.

14. OB/ IUP OB/ Pregnancy Scan OB mode Transabdominal views of the uterus
Calc button will give you options for fetal dates/ FHT
Transabdominal views of the uterus
transverse and longitudinal
Fetal Heart Tones (m-mode)
Fetal dates
>12weeks BPD
<12weeks crown rump length 
BPD (Inner to outer walls of the skull)
Clips of bilateral adenexa (even if obvious IUP) 
In the OB mode the calcs button will allow you to get to
look for corneal pregnancy, ectopic,
YOLK sac means IUP
Signs suggestive of abnormal embryonic development include a gestational sac greater than 10 mm in diameter without a visible yolk sac a gestational sac greater than 18 mm in diameter without a fetal pole or a collapsed gestational sac. Other signs associated with a poor prognosis include the absence of a fetal heart beat in an embryo with a CRL of at least 5 mm and a fetal heart beat less than 90 beats per minute.  Gestational trophoblastic disease (molar pregnancy) may present with multiple, small, irregular cystic lesions within the endometrium 

15. Fetal Heart Tones Please use M –mode to document FHT.
Press M-mode once and the screen will change,
Align the line with the fetal heart
When you have the image you want press freeze
Press calc, select FHT/ HR and measure the distance between beats.
Please don't doppler the fetal heart, there have been studies that show that the increased thermal index present with doppler can damage developing tissues.  The recommendations from ACEP and AIUM (American Institute for Ultrasound in Medicine) are to use m-mode to determine fetal heart tones.  Please contact me if you have any questions about this.
M –mode measure the rate of an object in motion over time. Therefore it is perfect for assessing fetal heart tones. To do this, ensure you are in Ob mode (upper right hand corner of the screen, find the fetal heart via ultrasound. Press the m-mode button, the screen will change to the view above. Align the fetal heart with the white line on the upper image. When you see the wave form appear on the bottom portion of the screen press freeze. Press the calc button select FHT/HR and a blue line will appear. Use the scroll ball to move the line to a point on the wave form. Press set, another blue line will appear and again use the scroll ball to move the line to the same point on the wave form, the next wave over. When you do this the HR will appear at the bottom right of the screen.

16. Early Pregnancy Ultrasound
Misconception: A very low B-HCG rules out ectopic pregnancy
Truth: 40% of ectopic pregnancies will present with a B-hcg less than 1000 mIU/ml
20% will present with a B-hcg less than 500 mIU/ml
Pts who present with a B-hcg less than 1000 mIU/ml have a higher risk of ectopic pregnancy
Keep in mind with ectopics all you may see is an empty uterus and free fluid in the pelvis.

17. Transabdominal Ultrasound
Uterus Longitudinal
Uterus transverse on right

18. Gallbladder Transverse and longitudinal clips through the gallbladder
Measurement of the anterior wall of the gallbladder
(2-3 mm)
Measurement of the CBD
 (4-8mm)
Look for:
Stones
Wall thickness
Pericholecystic fluid
Sono-murphys
CBD dilation 
Views: Long, Transverse, Left Lateral Decub
Stones , pericholecystic fluid, wall thickening
Nl GB long: cm/transverse 2-3 cm
Nl anterior GB wall: 2-3 mm; CHD 4-8mm

19. Gallbladder
Common Bile Duct

20. Gallbladder Literature
Indications: Signs and symptoms of Cholecystitis
Most sensitive signs: Stones and sono-murphys sign
Very specific signs: Wall thickness, pericholecystic fluid
Wall thickness and pericholecystic fluid can only be assessed in those pts without ascities and without a contracted GB. `
 Gallstones/Sludge:  Gallstones are evident in % of acute cholecystitis and likely play a role in the development of gallbladder cancers as well.  They are demonstrated on ultrasound with a thin, echogenic rim with pronounced shadowing obscuring the tissues behind.  Small gallstones may not shadow.  In such cases, increasing the frequency will improve resolution and shadowing may become apparent.  Most often, gallstones are mobile and will “roll” to the most dependant portion of the gallbladder.  This phenomenon may be demonstrated on ultrasound by maintaining a view of the gallbladder while a patient is rolled to a new position such as left lateral decubitus.  Note the location of the gallstones in relation to the neck of the gallbladder.  Stones in the neck of the gallbladder may be more likely to cause cholecystitis. Gallstones come in many shapes and sizes.  Some will be only a couple of millimeters in diameter while others will grow to larger than 2 centimeters.  Sometimes only a single gallstone will be present, while other patients will have multiple stones (Video 12-18).
2. Sonographic Murphy’s Sign:  The sonographic Murphy’s sign differs from Murphy’s sign identified on physical exam (arrest of inspiration on deep palpation of the right upper quadrant).  Sonographic Murphy’s sign is positive when the point of maximal tenderness is identified in the right upper quadrant while the gallbladder is identified on the ultrasound monitor.  Multiple points in the epigastrium and right upper quadrant must be tested with the ultrasound probe when the gallbladder is not demonstrated in order to properly evaluate this sign.  The sensitivity of the sonographic Murphy’s sign is reported from % with a positive predictive value of 92 % when combined with the finding of gallstones.(15,17)
3.  Gallbladder Wall Thickness:  The normal gallbladder wall measures less than 4 mm.  As detailed above, the gallbladder wall is measured at the most narrow point of the anterior wall in the short-axis.  Care must be taken to not measure the wall at an oblique angle (Video 21). The gallbladder wall may be thickened in many disease states.  Acute cholecystis is the most common of these. Ascites and congestive heart failure are the second and third most common cause of gallbladder wall thickening.  Hepatitis may also cause gallbladder wall edema. Gallbladder wall cancers may show a thickened and/or calcified gallbladder wall.
4.  Pericholecystic Fluid:  Pericholecystic fluid (PCCF) is generally found in wedges around the acutely inflamed gallbladder wall.  It is most often seen posterior to the gallbladder at the around the neck, but may also be seen layering on the anterior wall.  Ascites makes evaluation of pericholecystic fluid due to gallbladder inflammation impossible, as the patient will have free fluid throughout their abdomen, including around their gallbladder (Video 22).
5.  Dilated Common Bile Duct:  The CBD may dilate when obstructed by a stone, a mass, or a stricture.  The normal width of the CBD is 4 mm.  Older patients may have a normally dilated duct up to 1mm for every decade past the age of 40.  The CBD may be dilated up to 1cm normally after cholecystectomy (Video 23 & 24). 

21. FAST Clips of Depth: enough to see posterior surface of heart
RUQ
LUQ
Suprapubic
Cardiac 
Depth: enough to see posterior surface of heart
Pericardial vs Pleural effusion
Parasternal long if unable to get Subxiphoid view
depth needs to be enough to see the posterior aspect of the heart so you can rule out a pericardial effusion
  -To differentiate between a pericardial effusion and a pleural effusion note weather or not the effusion goes between the heart and the Aorta (posterior to the heart) and also look for tamponade (RV collapse in diastole).

22. Aorta
Transverse View
epigastric and infra-renal
Measure the outer to outer wall of the Aorta
Nl <3cm
longitudinal views of the aorta in the epigastric region
Bifurcation of the iliacs
outer to outer wall of the Aorta (so as to not miss a mural thrombus)
longitudinal views of the aorta in the epigastric region (to rule out sacular aneurysms) 
Also try to get a view of the bifurcation of the iliacs if possible although not required.
The current indications by the American College of Emergency Physicians (ACEP) for obtaining an emergency medicine based ultrasound to detect an AAA include “the presence of syncope, shock, hypotension, abdominal pain, abdominal mass, flank pain, or back pain especially in the older population. (10)

23. Renal Bilateral Kidney’s
Two views of each: transverse and longitudinal
Bladder (2 views)
Please label your views

24. Credentialing
50 scans to remain credentialed in all areas of ultrasound over 2 years
CME is required as well
This lecture
Scanning shifts with me
Ultrasound courses/lectures at conferences

25. Questions??????
If there are any questions please feel free to me.
If there are any questions please feel free to or call me