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Scenario
25 y/o female C/O: acute low abdominal pain w/ cold sweating, VAS: 8/10 BP: 60/40 mmHg; HR: 130 bpm Menstruation: 2nd day Your impression ? Next step ?
1st choice for emergency physician Use a lower frequency transducer: 3.5 5 mHz Better penetration, larger field of view It should be the initial imaging window to assess for
Advanced IUP Fibroids/masses Pelvic fluid
Trans-abdominal US
Transvaginal US
Use a higher frequency transducer: 6.0-7.5mHz Provides optimal imaging of:
Endometrium Myometrium Cul-de-sac Ovaries
A full bladder is not necessary for this approach Is usually better tolerated by patients
Trans-Abdominal Scan
US Findings in IUP
Gestational sac Double decidual sac sign (DDSS) Yolk sac Embryo Cardiac activity
Intradecidual Sign
Gestational Sac
Anechoic area within the uterus surrounded by two bright echogenic rings
Decidua vera (the outer ring) Decidua capsularis (the inner ring)
Yolk Sac
First embryonic structure that can be detected sonographically Visualized approximately 5-6 weeks after the last menstrual period Bright, ring like structure within the GS Should be readily seen when the GS sac is greater than 10 mm (using EVS)
Yolk Sac
Ectopic pregnancy
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Ectopic Pregnancy
2% of all pregnancies, 7-13% of those who present with pain or bleeding Incidence quadrupled in last 20 years 50% were missed before widespread use of ultrasound Still the #1 cause of maternal death in 1st trimester
-hCG Levels
Correlate roughly with gestational age Older algorithms relied on -hCG One level means almost nothing Serial levels are helpful 40% ectopics have a -hCG level <1000
Discriminatory Zone
Def:
The level of -hCG at which findings of an IUP are expected on sonography
Rosen
TVS 3000 mIU/mL; TAS 6500 mIU/mL
Sonographic Spectrum of EP
Extrauterine empty gestational sac Adenexal mass Pseudogestational sac Empty uterus
Ectopic Pregnancy
Molar pregnancy
Estimation of GA
Biparietal Diameter
Femur Length
Location of appendix
Determining the etiology of abdominal pain pelvic organs or other etiology Hemorrhagic ovarian cyst Ovarian torsion Ovarian hyperstimulation syndrome (OHSS) Tubo-ovarian abscess Fibroid (Leiomyoma)
OHSS
Pelvic Tumor
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Hematometria
52
Teratoma
53
Alvarado Score
Question
? 1. Blind-ended tubular structure 2. Non-compressible appendix 3. Diameter > 6mm 4. Dome sign 5. Appendicolith
Appendicitis
Diameter > 6mm (Cross section) Non-compressiblity of appendix Localized pain during compression with the transducer Alteration of the periappendiceal fat (echogenic & non-compressible fat) Obstruction of the lumen by an appendicolith Hypervascularizaion in color Doppler of appendix and surrounding fat
Eur Radiol. 2002;12:1748-61
Landmark of Appendix
RLQ
Iliac crest Psoas muscle Iliac vessels Cecum & A-colon
Appendicolith
Landmark
Ruptured appendicits
Ruptured appendicitis
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Ruptured appendicitis
67
Appendicitis
68
Colon
Cecal diverticulitis
70
? 1. Corona sign 2. Target sign 3. Curtain sign 4. Dome sign 5. Veiled Kidney sign
Right-sided diverticulitis in a 32-year-old woman with right lower quadrant pain and fever
A-colon diverticulitis
Cecal diverticulitis
S-colon diverticulitis
81
Ruptured AAA
82
Ketamine-induced cystitis
83
Colovesicular fistula
84
Bladder rupture
85
86
MSK
1. 2. 3. 4. 5.
87
Outlines
US anatomic considerations Skin and soft tissue infection Long Bony fracture evaluation
Skin Subcutaneous tissue Fascial planes Muscles Tendon
Echogenic Hypoechoic Traverse by irregular strands of hyperechoic connective tissue Hyperechoic; regular thickness Striated appearance on long axis scan Fibrillar; echogenic Anechoic (Artery versus Vein) Irregular, circular, echogenic; with hypoechoic rim Echogenic cortices and dense acoustic shadows
(5-10MHz) (depth)(focus) (longitudinal & transverse) & (Split screen)
Stand-off pad Water/gel-filled glove Water bath technique
Water/gel-filled glove
EUS &
&
Cellulitis Subcutaneous abscess
Cobblestone-like appearance Variable appearance Most: hypoechoic; spherical mass Content:
Hyperechoic sediment Septae Gas Isoechoic or hyperechoic Liquefied pus
induced motion of the content
Necrotizing fasciitis
Cellulitis
Nonspecific Indicative of edema Skin Subcutaneous tissue Compare to unaffected side
NTUH experience
diffuse thickening of the SC tissue a layer of fluid accumulation more than 4 mm in depth along the deep fascial layer 66 patients (17,NF) Sensitivity: 88.2% Specificity: 93.3% PPV: 83.3% NPV: 95.4% Accuarcy: 91.9
Yen ZS, et al. AEM. 2002;9:1448-1451
Secondary component
Use of Doppler to evaluate for abnormal flow
No complete compression
1. Presence of a clot 2. Inadequate pressure on the transducer
Femoral vessels
102
FASTER
Rib
Rib fracture
Rib fracture
Normal sternum
Femur
Back carbuncle
115
Neck abscess
116
Lymphadenopathy
117
Perianal abscess
118
50M,
Identify toe FB
119
19M
120
Septic arthritis
121
Find landmark
Recognize patterns
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