Ultrasound in the Critically Ill: A Practical Guide

Preface
Contents
Contributors
1 Physics of Ultrasound
1.1 Introduction
1.2 The Ultrasound Wave
1.3 The Origin of the Ultrasound Image
1.4 Ultrasound Modes
1.4.1 A—Mode
1.4.2 B—Mode
1.4.3 M—Mode
1.4.4 Doppler
1.5 Ultrasound Transducers
1.6 Ultrasound Terminology
1.7 Artefacts
1.7.1 Dorsal Acoustic Shadow
1.7.2 Posterior Enhancement
1.7.3 Lateral Wall Sign
1.7.4 Mirror Artefact (Figs. 1.18 and 1.19)
1.8 Conclusion
2 Preparation and Image Optimisation
2.1 Introduction
2.2 Preparation
2.3 Image Optimisation
2.3.1 Depth (Fig. 2.4)
2.3.2 Gain (Fig. 2.5)
2.3.3 Time Gain Compensation (TGC, Fig. 2.6)
2.3.4 Orientation (Fig. 2.7)
2.4 Conclusion
3 Clinical Governance
3.1 Introduction
3.2 Organisational Ultrasound Governance Board
3.3 Departmental Ultrasound Governance Group
3.4 Individual Practitioner Governance
3.5 Conclusion
4 Airway Ultrasound
4.1 Introduction
4.2 Equipment Needed for Airway Sonography
4.3 Typical Features of Airway Sonography and the Tissue/Air Border
4.4 Normal Airway from the Tongue to the Pleura Is Depicted (Figs. 4.2, 4.3, 4.4, 4.5, 4.6 and 4.7)
4.5 Clinical Application of Airway Ultrasound
4.5.1 Qualifying and Quantifying Airway Pathology and Deviations from Normal Anatomy that Are Relevant to Airway Management
4.5.2 Identification of the Trachea and the Cricothyroid Membrane
4.5.3 Distinguishing Between Oesophageal, Tracheal, and Main-Stem Intubation
4.5.4 Ultrasound Guided Surgical or Percutaneous Dilatational Tracheostomy
4.6 Conclusion
References
5 Basic Lung Ultrasound
5.1 Introduction
5.2 Basic Semiotics of Lung Ultrasound
5.3 Normal Pattern
5.4 Absence of Lung Sliding
5.5 B-Lines
5.6 Lung Consolidations
5.7 Pleural Effusion
5.8 Conclusion
References
6 Advanced Lung Ultrasound
6.1 Introduction
6.2 Monitoring
6.3 Multiorgan Ultrasound
6.4 Conclusion
References
7 Focused Transthoracic Echocardiography
7.1 Introduction
7.2 Standard Views
7.3 Scanning Process
7.4 Diagnostic Algorithm
7.5 Common Pathology
7.5.1 LV Failure
7.5.2 RV Failure
7.5.3 Severe Hypovolaemia
7.6 Advanced Focused Echocardiography
7.6.1 Stroke Volume
7.6.2 Valve Function
7.7 Conclusion
8 Advanced Transthoracic Echocardiography
8.1 Introduction
8.2 Modalities of Echocardiography and Thoracic Ultrasound
8.3 Levels of Expertise and Certification
8.4 Advanced Critical Care Echocardiography: Beyond Basic
8.4.1 Left Ventricular Function
8.4.2 Filling Pressures and Volume Status
8.4.3 Right Ventricular Function
8.5 3D and 4D Imaging
8.6 Strain and Strain Rate Imaging
8.7 Echocardiography for New Critical Care Techniques
8.8 Conclusion
References
9 Transoesophageal Echocardiography
9.1 Introduction
9.2 The TOE Probe
9.3 Probe Insertion and Patient Preparation
9.4 Image Acquisition
9.5 Indications for TOE in ICU
9.6 Contra-indications to Use of TOE
9.7 TOE Examination on the ICU
9.8 Clinical Applications
9.9 Conclusion
References
10 FAST Scanning
10.1 Introduction
10.2 Equipment
10.3 FAST Scan Principles
10.4 FAST Scan Views
10.4.1 Right Upper Quadrant
10.4.2 Left Upper Quadrant
10.4.3 Pelvis
10.4.4 Pericardium
10.4.5 Extended FAST—eFAST
10.4.6 Focussed Assessment for Free Fluid—FAFF
10.5 Conclusion
References
11 Renal Tract Ultrasound
11.1 Introduction
11.2 Equipment
11.3 Sonoanatomy
11.4 Pathology
11.5 Conclusion
12 Abdominal Ultrasound—Liver, Spleen and Biliary Tree
12.1 Introduction
12.2 Artefacts
12.3 Scanning Technique
12.4 Liver
12.4.1 Anatomy
12.4.2 Liver Size
12.4.3 Normal Liver Parenchyma
12.4.4 Abnormal Liver Parenchyma
12.4.5 Inflammatory Conditions
12.4.6 Focal Hepatic Masses
12.5 Haemangiomas
12.5.1 Hepatic Cyst
12.5.2 Malignant Focal Liver Lesions
12.6 Portal Vein Gas
12.7 Portal Vein Occlusion
12.8 Hepatic Venous Congestion
12.9 Hepatic Venus Outflow Obstruction
12.10 Spleen
12.10.1 Anatomy
12.10.2 Splenic Size
12.10.3 Infarcts
12.10.4 Abscess
12.10.5 Cysts
12.10.6 Focal Masses
12.10.7 Rupture
12.11 Gallbladder and Bile Ducts
12.11.1 Anatomy
12.11.2 Gallbladder Thickening
12.11.3 Stones, Polyps and Sludge
12.11.4 Acute Cholecystitis
12.12 Jaundice: Biliary Dilatation
12.13 Pneumobilia
12.14 Cholangitis
References
13 Abdominal Ultrasound—Bowel and Peritoneum
13.1 Introduction
13.1.1 Anatomy
13.2 The Gut Wall Signature
13.3 Nasogastric Tube Positioning
13.4 Small Bowel Ileus/Obstruction
13.5 Bowel Ischaemia
13.6 Pseudomembranous Colitis
13.7 The Peritoneal Cavity
13.7.1 Anatomy
13.8 Ascites
13.9 Peritonitis
13.10 Abscess
13.11 Percutaneous Aspiration and Drainage
13.12 Pneumoperitoneum
13.13 Conclusion
References
14 Vascular Access
14.1 Introduction
14.2 Equipment
14.3 Sonographic Anatomy
14.4 Performing Venous Access
14.5 Sites of Access
14.5.1 Internal Jugular Vein
14.5.2 Subclavian/Axillary Vein
14.5.3 Femoral Vein
14.6 Complications
14.7 Arterial Access
14.8 Peripheral Access (PICCs/Cannulae)
14.9 Useful Adjuncts
14.10 Conclusion
References
15 Venous Sonography
15.1 Introduction
15.2 Equipment
15.3 Anatomy
15.4 Scanning Process
15.5 Use of Colour Doppler
15.6 What’s ‘Normal’ or Not
References
16 Neuro-ophthalmic Ultrasound
16.1 Introduction
16.2 Ophthalmic Ultrasound
16.2.1 Anatomy of the Optic Nerve Sheath and Pupillary Aperture
16.3 Evidence for Ultrasound of the Optic Nerve Sheath
16.3.1 Advantages and Disadvantages of Optic Nerve Ultrasound
16.4 Technique of Optic Nerve Ultrasound
16.5 Ultrasonic Examination of the Pupillary Reflex
16.5.1 Technique of Ultrasonic Examination of Consensual Pupillary Light Reflex
16.6 Conclusion
References
17 Cranial Doppler
17.1 Introduction
17.2 Transcranial Doppler
17.2.1 The Transcranial Doppler Transducer
17.2.2 Acoustic Windows
17.3 Principles of TCD Scanning
17.4 Pitfalls of TCD Ultrasound
17.4.1 Factors Increasing FV
17.4.2 Factors Decreasing FV
17.5 The Use of Transcranial Doppler as Ancillary Test in Brainstem Death
17.6 Technique of Transcranial Doppler
17.7 Safety Concerns with Ophthalmic and Transcranial Ultrasound
17.8 Conclusion
References
18 Musculoskeletal Ultrasound
18.1 Introduction
18.2 Fractures
18.3 Foreign Body
18.4 Soft Tissue Infection
18.5 Joint Effusion/Haemarthrosis
18.6 Conclusion
References
19 The Haemodynamically Unstable Patient
19.1 Introduction
19.2 Organ Blood Flow
19.3 The Cause of Shock
19.3.1 Hypovolaemic Shock
19.3.2 Cardiogenic Shock
19.3.3 Obstructive Shock
19.3.3.1 Tamponade
19.3.3.2 Pulmonary Embolism
19.3.3.3 Pneumothorax
19.3.3.4 Pleural Effusion
19.3.4 Distributive
19.4 Guiding Management
19.5 Conclusion
References
20 The Polytrauma Patient
20.1 Introduction
20.2 FAST Scanning
20.3 Conclusion
References
21 The Patient with Acute Breathlessness
21.1 Introduction
21.2 Making that Diagnosis
21.3 Step 1—the BLUE Protocol/Focused Lung Ultrasound
21.4 Step 2—Focused Cardiac Ultrasound
21.5 ICU-Specific Problems
21.5.1 Diagnosing The ‘Acute Respiratory Failure’ Referral
21.5.2 Is that a Pleural Effusion?
21.5.3 The Patient ‘Stuck’ on a Ventilator and Not Weaning
21.6 Conclusion
22 The Patient Difficult to Wean from Mechanical Ventilation
22.1 Introduction
22.2 Respiratory Assessment
22.2.1 Lung Aeration
22.2.2 Pleural Effusions
22.2.3 Diaphragmatic Function
22.3 Diaphragmatic Paralysis or Weakness
22.3.1 Cardiac Function
References
23 The Patient with Acute Kidney Injury
23.1 Introduction
23.2 Normal Sonographic Appearances of the Kidney
23.3 Causes of AKI
23.3.1 Pre Renal
23.3.2 Intrinsic
23.3.3 Post Renal
23.4 Urosepsis
23.5 Exclusions
23.6 Conclusion
24 The Patient with Acute Abdominal Pain
24.1 Introduction
24.2 Indications
24.3 Equipment
24.4 Protocols
24.5 A Proposed Approach
24.6 Right Upper Quadrant
24.7 Epigastrium and Peri-umbilical Region
24.8 The Left Upper Quadrant
24.9 The Left Lower Quadrant
24.10 Supra Pubic Region
24.11 Right Lower Quadrant
24.12 Conclusion
References