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The 2021 RCEM Curriculum PoCUS syllabus details...

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The 2021 RCEM Curriculum PoCUS syllabus details...

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Attached is the official PoCUS syllabus for the 2021 RCEM Curriculum, which I was directly involved in working on and writing. It is now widely available on RCEM website alongside other new curriculum information.

The long and short of it is that trainees are required to start basic PoCUS from ST1 and become advanced by ST6, whilst continually demonstrating maintenance and progressions of incompetence by a variety of evidence. It is deemed no longer acceptable to only aim for a single sign-off/finishing school at the end of training to demonstrate competency as seemed to have been in practice for the 2015 RCEM curriculum.

It is likely that Introductory, level 1/core/equivalent, and refresher courses with more advanced components will continue to support the trainees. However local leads, trainers, including those in anaesthetic, critical care, and acute medicine as trainees rotate around will become much more important to gain competencies from, before returning to EM in HST.

For those in the middle of official training, unless the transition period of 1 year or a bit more depending on individual circumstances apply in which case the 2015 RCEM curriculum model still applies for CCT, the new competency model will need to be followed (this also applies to all the CESR as transition period doesn't apply).

More details will be officially announced by RCEM PoCUS Education and Training Subcommittee in the coming weeks to months. So watch the space.

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To be printed off and brought to the assessment day

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Month 7 (4of4)- How to upload onto PACS 

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Month 7 (4of4)- How to upload onto PACS 

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Governance and administration of ED PoCUS is an important aspect that is overlooked by many. In Leeds ED we have recently made protocols and guidelines for our colleagues to follow to adhere to safe scanning

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There is so much to know about how to do things properly with PoCUs in Ed

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Good Way of remembering how to look after the US machines

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Month 7 (1of4)- Look after the US Machines and Probes 

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Month 7 (1of4)- Look after the US Machines and Probes 

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Do NOT use alcohol based wipes nor tagoderms

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Another excellent Point of Care Ultrasound teaching session for our @MyiED Senior Doctors that was delivered by @draroramohit

& @EveryOneNoOne1 @MedEdLeeds

@LeedsHospitals

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Have you seen someone do something good in a sim?
Give them some feedback here!

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We are back once again

Book either through CEMBook or directly by the following link:

https://leedsededucationbookings.simplybook.it/v2/#book

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How to perform FICB
https://link.springer.com/article/10.1007/s43678-020-00022-6

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Nick Mani founded FOAMed PoCUs Website

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Leeds ED PoCUS Hub as a concept presented by Nick Mani and Mohit Arora

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the best and most up-to-date resource

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Point of Care Ultrasound Learning Made Easy

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Core/Level 1 Finishing School- 1st Session

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Core/Level 1 Finishing School- 1st Session

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26 Aug- Excellent F2F Y&H deanery ultrasound finishing school today for EM Trainees

@draroramohit@EveryOneNoOne1

GilbertP @MyiED@yemus2017

@ButterflyNetInc

Particularly have an exclusive access to the new

@SonoSite @SonoSiteEurope

PX ultrasound machine, which is excellent (Thank You)
As always thank you to

@MedEdLeeds

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Core/Level 1 Finishing School- 2nd Session

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Core/Level 1 Finishing School- 2nd Session

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22 Sep- We ran another successful Yorkshire and Humber Deanery School of EM core/level 1 ultrasound signing off day for our EM trainees led by @yemus2017 @draroramohit (virtual) @EveryOneNoOne1 Gilbert P @MedEdLeeds @MyiED @LeedsHospitals

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The basics of PoCUS Machine is essential. Pay attention to them.

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An extensive collection of PoCUS video modules, spanning over 25 hours of learning.

Brought to you by Doctors.net.uk in partnership with 3D4Medical

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Find out about the benefits of joining Doctors.net.uk, which include free accredited online education, discussion forums, clinical resources, daily medical news and a professional email address. Read more ›

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Find out about the benefits of joining Doctors.net.uk, which include free accredited online education, discussion forums, clinical resources, daily medical news and a professional email address. Read more ›

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EuSEM 2020 Virtual Congress  Ultrasound Poster Presentations 

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EuSEM 2020 Virtual Congress  Ultrasound Poster Presentations 

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Excellent rep & acknowledgement of our hard work on EM PoCUS led by @draroramohit & Gilbert P @vdaga3 at the @EuropSocEM 2020 ConferencePosters by:-
2x @EveryOneNoOne12x
Lydia B
1x @ch5247
@yemus2017 @MyiED
Thanks @MedEdLeeds @LeedsHospitals

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Bigger, Better, Sounder...

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For demo/printing off

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Presenting at the EMTA19 Conference PoCUS Break-out Session

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Presenting at the EMTA19 Conference PoCUS Break-out Session

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Really enjoyed teaching on @UniversityLeeds @LeedsMedHealth Medical Student Ultra Sound Training (MUST) with GilbertP RachelB @jamesnchlsn @MedEdLeeds. Such an excellent idea to have ultrasound in medical school undergrad curriculum.

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Really enjoyed teaching on @UniversityLeeds @LeedsMedHealth Medical Student Ultra Sound Training (MUST) with GilbertP RachelB @jamesnchlsn @MedEdLeeds. Such an excellent idea to have ultrasound in medical school undergrad curriculum.

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How awesome is this femoral nerve ultrasound phantom made from a few chicken breasts, IKEA bags, a wire and some modelling balloons? Simple + cheap, but great fidelity (fascia even pops!) Great idea @draroramohit @EveryOneNoOne1 @yemus2017 @MyiED #POCUS

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How awesome is this femoral nerve ultrasound phantom made from a few chicken breasts, IKEA bags, a wire and some modelling balloons? Simple + cheap, but great fidelity (fascia even pops!) Great idea @draroramohit @EveryOneNoOne1 @yemus2017 @MyiED #POCUS

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How awesome is this femoral nerve ultrasound phantom made from a few chicken breasts, IKEA bags, a wire and some modelling balloons? Simple + cheap, but great fidelity (fascia even pops!) Great idea @draroramohit @EveryOneNoOne1 @yemus2017 @MyiED #POCUS

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How awesome is this femoral nerve ultrasound phantom made from a few chicken breasts, IKEA bags, a wire and some modelling balloons? Simple + cheap, but great fidelity (fascia even pops!) Great idea @draroramohit @EveryOneNoOne1 @yemus2017 @MyiED #POCUS

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Continuing our successful PoCUS sim in collaboration with our sim team at the end of level 1 course

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POCUS teaching today with the Yorkshire ST3’s. turns out they are quite competitive with their quizzes and a bit of Xmas background music. Hoping they will benefit from their free NEW BOOKS :) front row @❤️. @yemus2017 @draroramohit @ch5247 @EveryOneNoOne1 @StuartNuttall1

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POCUS teaching today with the Yorkshire ST3’s. turns out they are quite competitive with their quizzes and a bit of Xmas background music. Hoping they will benefit from their free NEW BOOKS :) front row @❤️. @yemus2017 @draroramohit @ch5247 @EveryOneNoOne1 @StuartNuttall1

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Wk 7- Rapid Ultrasound for Shock and Hypotension (Medical/Surgical/Critical Care/PoCUS) 

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Wk 7- Rapid Ultrasound for Shock and Hypotension (Medical/Surgical/Critical Care/PoCUS) 

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PoCUS for differential of shock

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Wk 7- Rapid Ultrasound for Shock and Hypotension (Medical/Surgical/Critical Care/PoCUS) Poster 

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Wk 7- Rapid Ultrasound for Shock and Hypotension (Medical/Surgical/Critical Care/PoCUS) Poster 

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Month 4- Hypotension ?cause (Is it Tank⛽️/Pipes🥤/Fluid💧🩸)                                   Nov '19

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Month 4- Hypotension ?cause (Is it Tank⛽️/Pipes🥤/Fluid💧🩸)                                   Nov '19

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Situation:
Male in 60s presenting with severe hypotension/Peri-arrest. D&V for few days.
Background:
Multiple comorbidities including CCF/Ventricular shunt for congenital hydrocephalus
Assessment:
Unwell/Peri-arrest. Dehydrated.
A-Intact on 15 Litres NRB FiO2
B-Crackles right side
C-Shutdown peripheral, Central CRT prolonged. HS pure. Lactate 7. IVI ongoing.
D-GCS (E4V1M6) PERL BM normal range
E- SNT Abdo. BS+
Recommendation:
Most likely dehydrated/Septic Shock from chest. Will need to exclude heart pathology (already known CCF/CArdiomyopathy)

Sepsis 6/CXR/ECG (Sinus tachy)/CT head

Critical care/Med Reg review (already had more than 2 litres of fluid, responding but still hypotensive)

RUSH HI-MAP including 2-point DVT scans (https://emcrit.org/rush-exam/)
'Kissing' IVC walls
B-Lines only right chest (CXR haziness of the cardiac and phrenic angle)
LVF hypokinetic

Learning Points:
-PoCUS Hypotension (RUSH HI-MAP)/lung (BLUE) protocols augments clinical assessment
rather than replace it/the other imaging such as CT
-Particularly it can narrow down differentials, as well as help with fluid therapy strategy/monitoring/response to treatment (FALLS protocol)

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1- Scaleane plane block for rib fracture (US Guided)
2- Reduction of distal radius fracture (US Guided)
3- Peripheral Venous Access (US Guided)
4- Same day DVT scanning in ED (2-point proximal veins)

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The AEUS Vimeo is a #FOAMed resource regarding all subjects in point-of-care ultrasound. The Narrated Series is created by some of the world's #POCUS experts

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The AEUS Vimeo is a #FOAMed resource regarding all subjects in point-of-care ultrasound. The Narrated Series is created by some of the world's #POCUS experts

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The AEUS Narrated Lecture Series is a free open-access medical education resource. The project was initiated by Dr. Meghan Kelly Herbst, who serves as the project...

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Guide to level 1 sign off, including logbook and reflection 

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Guide to level 1 sign off, including logbook and reflection 

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Written by Nick Mani & Mohit Arora Oct '19, ED Consultant in Leeds and PoCUS Lead in Yorkshire and Humber Deanery

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Guide to level 1 sign off, including logbook and reflection 

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Guide to level 1 sign off, including logbook and reflection 

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Written by Nick Mani Oct '19, PoCUS Senior Clinical Fellow in Leeds ED and HST in Yorkshire and Humber Deanery

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FALLS-protocol: lung ultrasounding hemodynamic assessment of shock

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FALLS-protocol: lung ultrasounding hemodynamic assessment of shock

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Lichtenstein '13

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Gilbert P & Lydia B @MyiED @yemus2017 Monday Lunch Time Club teaching echo to our ED colleagues. @jamesnchlsn  @ergemeruk as a volunteer. Excellent teaching and learning platform @MyiED @LeedsHospitals

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Gilbert P & Lydia B @MyiED @yemus2017 Monday Lunch Time Club teaching echo to our ED colleagues. @jamesnchlsn  @ergemeruk as a volunteer. Excellent teaching and learning platform @MyiED @LeedsHospitals

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From recent @RCollEM Annual Clinical Conference regarding PoCUS in ED. Food for thought.

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Interesting analysis of PoCUS in EM by @ECRI_Institute

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Interesting analysis of PoCUS in EM by @ECRI_Institute

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However the glass half full though rather than half empty.
Agree with most if not all the points.
"Point-of-care ultrasound scanners are changing the practice of healthcare in many specialties and safety measures have struggled to keep up."

@ECRI_Institute

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Month 3- Peri-Arrest Focused Echo ❤️❤️❤️?signs of PE                            Oct '19  

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Month 3- Peri-Arrest Focused Echo ❤️❤️❤️?signs of PE                            Oct '19  

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Situation:
Pt in 50s presented with collapsed, SOB preceding it.
Background:
Not initially known and limited collateral history (later GP records revealed valve pathology and previous surgery/intervention, Asthma, AF on warfarin,T2DM,HTN, Cholesterol)
Assessment:
Hypotensive, Tachycardic, Tachypnoea with ,
Airway obstructed, see saw breathing, peripheral shut-down (later on noted that both legs becoming mottled/cold/pulseless, PERL BM low on VBG, Focal left side neurology and up-going plantars, Abdo SNT, No bleeding signs
Recommendation:
?Life threatening Asthma/Sepsis
?Massive PE (if arrest lysis and prolonged CPR)
?CVA/low BM
Securing Airway with endotracheal intubation (anaesthetic/critical care colleagues fast bleeped)
Breathing adjunct and maneuvers as well as BVM
Circulation filling and adrenaline (helping ?asthma as well)
Correcting BM, and ABx

Focused bedside Echo by ED Reg/PoCUS Fellow, which demo left but not right enlarged atrium and ventricle with a possible thrombus on the inlet of the mitral valve that was evidently functioning abnormally.

Finally pt had CT scan which demonstrated thrombus in the abdominal aorta and iliac arteries, and pt went to vascular.

Learning Points
-IVC could be assessed for signs of RV strain.
-Right heart strain doesn't equal to massive PE. It might be caused be left ventricle failure, lung conditions such as COPD leading to cor pulmonale.
-Proximal deep veins could be scanned at bedside bilaterally at 2 points for signs of DVT
-It is all in the clinical context, and the decision for lysis and prolonged CPR needs to be balanced against the likelihood and futility.
-Focused bedside echo could be very helpful to add more information to the clinical assessment.

Image- Four chambers view with right ventricle enlargement that is on the left upper part of the image, which is bulging into the left ventricle as an example http://www.j-pcs.org/viewimage.asp?img=JPractCardiovascSci_2018_4_2_126_240966_f4.jpg

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Click on the link below and fellow the screen for the available dates. Once booked on, if unable to attend, please cancel ASAP.

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Educational Bookings | Scheduling and Booking Website

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Select your serviceSelect the date and timeSIM NEWS for all our resources and news

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30/9/19 Summary Sheet- FAFF/eFAST/Echo in Life Support

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Practical guide

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Is it worth it or a time waster/distraction?

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BodyWorks Eve is a state-of-the-art ultrasound patient simulator (https://www.intelligentultrasound.com/bodyworks/)
Hopefully we can invest in one for the department in the near future

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Really enjoyed being part of an excellent faculty for the first official Leed Cadaveric Ultrasound Guided Regional/Nerve Block Course for EM & anaesthetic. Absolutely fantastic way to teach/learn/ teamwork @yemus2017 @draroramohit @GilbertP @vdaga3 @KMekala @JennyF-G @UniversityLeeds @LeedsHospitals @MyiED 24/09/2019  

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Really enjoyed being part of an excellent faculty for the first official Leed Cadaveric Ultrasound Guided Regional/Nerve Block Course for EM & anaesthetic. Absolutely fantastic way to teach/learn/ teamwork @yemus2017 @draroramohit @GilbertP @vdaga3 @KMekala @JennyF-G @UniversityLeeds @LeedsHospitals @MyiED 24/09/2019  

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Fascia Iliaca Block Procedure

Academic Life in Emergency Medicine Website

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An 82-year-old woman presents with left hip pain after a mechanical fall while cleaning the kitchen floor. When EMS arrived, the left leg was foreshortened and externally rotated. The paramedics administered 10 mg of IV morphine, but she is still writhing in pain on arrival. The AP pelvic x-ray demonstrates a left femoral neck fracture (arrow). You consider performing a fascia iliaca nerve block for better pain control.

Why do a fascia iliaca nerve block?

Multiple studies have shown decreased in-hospital mortality and complications when regional anesthesia is performed. Specifically for hip fractures, fascia iliaca blocks led to a reduction of postoperative complications from 33% to 20% along with decreased mortality, deep vein thromboses, altered mental status, and pulmonary complications.

Goal of the fascia iliaca nerve block

The goal of this nerve block is to maximize analgesia, while minimizing side effects such as respiratory depression, delirium, hypotension, and nausea/vomiting that may be associated with IV opioid administration. The target of the anesthetic injection is the potential space between the iliacus muscle and the fascia that overlies it (fascia iliaca), within which the femoral nerve and lateral femoral cutaneous nerve (LFCN) course. A large volume injection (40 mL) will lead to appropriate fascial spread and anesthesia of the femoral nerve (88%), LFCN (90%), and sometimes the obturator nerve.

When should I not perform the fascia iliaca block (contraindications)?

Any anticoagulation, besides aspirin and NSAIDs

Overlying cellulitis at the skin puncture site

Ipsilateral fractures at high risk of compartment syndrome, such as tibial plateau fractures

Equipment

Figure 2. A layout of the equipment needed for a fascia iliaca nerve block

The necessary equipment for this nerve block includes the following:

Sterile precautions

Sterile ultrasound probe cover

Sterile gloves

ChloraPrep wipe

Identifying the anatomy

Bedside ultrasound with a linear transducer

Instilling the anesthetic

Lidocaine 1% (2-5 mL) for local wheal of anesthetic

Local long-acting anesthetic (e.g., 40 mL of 0.2% ropivacaine) for nerve block

Sterile saline flush

10 mL syringe

60 mL syringe

Extension tubing

18-gauge needle

25-gauge needle

21-gauge nerve block needle

Figure 3. Syringe and nerve block needle set-up for administration of anesthetic agent

Anesthetic medication options

For a longer period of regional anesthesia, we recommend ropivacaine or bupivacaine. Given the higher cardiac toxicity of bupivacaine due it's highly lipophilic nature compared to other local anesthetics, we suggest 40 mL of 0.2% ropivacaine as the first-line agent. Lidocaine is not preferred given it's shorter duration of action, which is contradictory to the goal of prolonged analgesia.

Local anesthetic agent

Relative potency

Duration of action

Maximum allowable subcutaneous dose (mg/kg)

Figure 4. Local amide-based anesthetic agents and their pharmacokinetic effects, adapted from Goldfrank's Toxicologic Emergencies

Technique

Equipment positioning

Start by setting up an equipment stand on the same side of the bed as the patient's fracture, with the ultrasound machine on the contralateral side of the fracture. You will stand on the side of the fracture facing towards the head of the bed and looking across the patient's body at the ultrasound machine.

Wipe the ipsilateral inguinal area with the ChloraPrep and drape the area.

Fill the 60 mL syringe with 4 mL of 0.2% ropivacaine.

Attach the syringe to the extension tubing and nerve block needle.

Remove air from the tubing and "prime it" with the ropivacaine from the syringe.

Place the sterile ultrasound probe cover on the probe.

Sterile preparation

Position the linear, high-frequency ultrasound probe held in horizontal orientation with the probe marker pointed towards the patient's right side (Figure 5).

Locate the femoral vessels ideally at the level of the common femoral artery and vein.

Slide the probe laterally until you see the iliacus and sartorius muscles (Video 1). The iliacus muscle will be in the same plane as the femoral vessels, and the sartorius will be superior and lateral (Figure 6).

Anatomy identification

Using a 10 mL syringe and 25 gauge needle, deposit a small wheal of local anesthetic (e.g. lidocaine) directly adjacent to the lateral surface of the ultrasound probe.

Switch to the longer 21 gauge nerve block needle, which is affixed to an extension tubing and 60 mL ropivacaine-filled syringe (Figure 3). The primary operator should be sterilely gowned and hold the nerve block needle, while a secondary operator should hold the ropivacaine syringe, being in charge of instilling the anesthetic when needed.

Primary operator: Insert the nerve block needle at a steep 45-60 degree angle through the wheal and advance in a plane through the subcutaneous tissue until you visualize the tip of the needle underneath the fascia iliaca. You will likely feel pop or change in resistance as you pass through the fascia iliaca.

Secondary operator: Once the needle is appropriately positioned by the primary operator, inject a micro-aliquot of anesthetic (0.5 to 1 mL) to see if the fascia iliaca appropriately dissects off the iliacus muscle (Video 2).

Video 2. Ultrasound image of the left hip, showing an in-plane view of the nerve block needle and appropriate dissection of the fascia iliaca from the iliacus muscle with a micro-aliquot injection of anesthetic

If the needle tip is placed inappropriately above (superficial to) the fascia iliaca in the subcutaneous tissue or within the iliacus muscle, make in-plane adjustments of the needle tip and instill additional micro-aliquots until appropriate localization.

Once the needle is appropriately positioned, inject the entire volume of the 40 mL 0.2% ropivacaine. Clear the ropivacaine remaining in the extension tubing with a few mL's of the sterile saline flush after swapping the 60 mL syringe with a sterile saline flush.

Adequate anesthesia can take up to 30-60 minutes as the ropivacaine tracks upwards into the pelvis.

Instillation of anesthetic agent

Alternative Technique

A suprainguinal approach may lead to more proximal spread of anesthetic and more successful pain control; however, the approach relies on adequate visualization of the patient's internal oblique muscle, which is often tiny and hard to see in the elderly. The suprainguinal approach mirrors the above approach to identify the iliacus muscle. Then slide the probe superiorly along the iliacus muscle until the probe is above the inguinal canal. Then rotate the probe marker 90 degrees so that it points towards the umbilicus. The sartorius and internal oblique muscles will form a "bowtie" shape with the iliacus muscle below them. Inject the anesthetic in between the bowtie, aiming just below the fascia iliaca as described in the traditional approach (Figure 8).

Kaufman R. Local Anesthetics. In: Goldfrank L, ed. Goldfrank's Toxicologic Emergencies. New York, NY: McGraw-Hill; 2011:967.

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Fascia iliaca nerve block: A hip fracture best-practice Fascia iliaca nerve block: Best practices for your patient with a hip fracture

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An 82-year-old woman presents with left hip pain after a mechanical fall while cleaning the kitchen floor. When EMS arrived, the left leg was foreshortened and externally rotated. The paramedics administered 10 mg of IV morphine, but she is still writhing in pain on arrival.

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@TeddyDanielz “Must Know Sono-Literature for US Fellows” 

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@TeddyDanielz “Must Know Sono-Literature for US Fellows” 

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Month 2- The theory behind ultrasound guided peripheral venous access

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Month 2- The theory behind ultrasound guided peripheral venous access

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Pythagoras theorem
Hagen-Poiseuille's law
Out-of-plane and in-plane views

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Month 2- Difficult Peripheral Venous Access 💉💉💉   Sep '19 

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Month 2- Difficult Peripheral Venous Access 💉💉💉   Sep '19 

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Situation:
50yr  presented with an open ankle fracture which needed to be manipulated on scene due to vascular compromise.
Background:
ex-IVDU with no fixed address.
Assessment:
No other injuries detected. NVI lower limb but an open fracture to the medial side of the ankle joint, but satisfactory position for casting before XR.  IV morphine/paracetamol/antibiotics required ASAP. Systolic 75 responding to lying flat and straight leg raise of the other leg, appears moderately dehydrated needing IVI.
The nurse and ED Reg couldn't find an obvious peripheral vein for access.
Recommendation:
Ultrasound guided peripheral venous access gained in he left brachial vein by the ED Reg.
Learning points:
-Consider intraosseous /external jugular vein venous access in dire emergencies, and do not attempt ultrasound guided venous access as this will waste precious time.
-Ultrasound guided peripheral venous access is an efficient way of gaining access, it might be temporary until patient hydrated before identifying other peripheral veins.
-Basilic/Brachial veins are the most ideal one for ultrasound guided peripheral venous access.
-Utilise a sleeve of a sterile glove with normal gel on the probe on the inner part, and lube gel on the outer part to perform it as aseptically as possible (See the following photo). Avoid tegaderm. Avoid alcoholic solution/wipes on the probes. Both will eventually break the probe crystal covering.
-Utilise the linear probe as high frequency and will give the best resolution and frame rate.
-Remember Hagen-Poiseuille's law for the size of the cannula (see the following illustration)
-Remember the pythagoras theorem for the distance of the needle tip to the vessel, as this is different to the distance of the probe to the vessel as shown on side of the screen (see the following illustration).
-In-plane/out of plane/alternating between the two views.
-Once flashback of blood is seen, put away the probe and concentrate on advancing the cannula and securing it.

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Make your first attempt your best attempt: IV cannulation with ultrasound

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Needs Editing for trainee name, course/teaching title, signature

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Enjoyed teaching day on wed for our junior clinical fellows @MyiED with @LeedsEDSim @AlexNevard @Mayada70 @ch5247 organising. Amongst other sessions, we did ultrasound guided vascular access and fascia iliaca block with a quiz made on Google @yemus2017. Hope something was learnt!

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Enjoyed teaching day on wed for our junior clinical fellows @MyiED with @LeedsEDSim @AlexNevard @Mayada70 @ch5247 organising. Amongst other sessions, we did ultrasound guided vascular access and fascia iliaca block with a quiz made on Google @yemus2017. Hope something was learnt!

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23 Aug 2019

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It was absolutely fantastic & a joy teaching our juniors doctors @MyiED with my own  🦋 probe @ButterflyNetInc and ipad pro @Apple, and letting them all practice doing ultrasound guided peripheral vascular acess @draroramohit @yemus2017

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It was absolutely fantastic & a joy teaching our juniors doctors @MyiED with my own  🦋 probe @ButterflyNetInc and ipad pro @Apple, and letting them all practice doing ultrasound guided peripheral vascular acess @draroramohit @yemus2017

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29 Aug 2019

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Abstract

Ultrasound (US) use has rapidly entered the field of acute pain medicine and regional anesthesia and interventional pain medicine over the last decade, and it may even become the standard of practice. The advantages of US guidance over conventional techniques include the ability to both view the targeted structure and visualize, in real time, the distribution of the injected medication, and the capacity to control its distribution by readjusting the needle position, if needed. US guidance should plausibly improve the success rate of the procedures, their safety and speed. This article provides basic information on musculoskeletal US techniques, with an emphasis on the principles and practical aspects. We stress that for the best use of US, one should venture beyond the "pattern recognition" mode to the more advanced systematic approach and use US as a tool to visualize structures beyond the skin (sonoanatomy mode). We discuss the sonographic appearance of different tissues, introduce the reader to commonly used US-related terminology, cover basic machine "knobology" and fundamentals of US probe selection and manipulation. At the end, we discuss US-guided needle advancement. We only briefly touch on topics dealing with physics, artifacts, or sonopathology, which are available elsewhere in the medical literature.

Keywords: Hyperechoic, hypoechoic, anechoic, musculoskeletal, ultrasound, regional anesthesia, ultrasound knobology, ultrasound probe selection and manipulation

INTRODUCTION

Ultrasound (US) use has rapidly entered the field of acute pain medicine and regional anesthesia and interventional pain medicine over the last decade, and it may even become the standard of practice.[ 1] US guidance for nerve blocks and interventional pain management techniques may have several potential advantages over conventional landmark-based techniques that assume minimal anatomical variation between persons, or nerve stimulation-assisted techniques that are based on the premise that an appropriate motor response is the perfect surrogate marker for needle proximity to the sensory fibers of a nerve. These assumptions, of course, are not entirely correct, and could potentially be responsible for block failure or block placement difficulties when these conventional techniques are used. The advantages of US guidance include the ability to both view the targeted structure and visualize, in real time, the distribution of the medication throughout and relative to the tissue (e.g., nerve tissue), as well as the capacity to control its distribution by readjusting the needle position, capabilities which should plausibly improve the success rate of the procedures. The ability to visualize the targeted structure and other structures of importance, such as blood vessels, lung, or other organs, should, logically, also improve the speed and safety of the procedures.[ 2]

Compared to the use of fluoroscopy-guided procedures that can only visualize bony tissue, US additionally allows the visualization of soft tissues. US equipment is also more portable and less expensive. Moreover, even regular use of US does not place patients and practitioners at risk of harmful radiation exposure, although this may be a matter of debate.[ 3]

It should be clearly understood from the outset that the ability to "see" the targeted structure with US does not preclude a thorough knowledge of gross or micro-anatomy. Some experts agree that proper utilization of US requires an even better knowledge of applied anatomy than that required for conventional techniques of nerve localization. For the best use of US in acute pain medicine and regional anesthesia, one should venture beyond the "pattern recognition" mode to the more advanced systematic approach and use US as a tool to visualize structures beyond the skin (advanced sonoanatomy mode). 'Pattern recognition' refers to memorization of an US image of a targeted structure (textbook picture) and learning the maneuvers and techniques necessary to acquire the image. This is, however, not sufficient in the presence of anatomical variations or if US is used for diagnostic purposes. It also implies the need for the continuous presence of a teacher to confirm the image obtained and the required maneuver for different block variations (personal observation). To advance beyond the pattern recognition mode, a thorough knowledge of applied anatomy combined with a basic understanding of how a 2-dimensional (2-D) US image represents a 3-dimensional (3-D) anatomical structure is needed; the latter is the goal we wish to accomplish in this paper for the readership.

This article will provide basic information on musculoskeletal US techniques, with an emphasis on the principles and practical aspects. We discuss the sonographic appearance of different tissues, introduce the reader to commonly used US related terminology, cover basic machine "knobology" and fundamentals of manipulation of the US probe and US-guided needle advancement. We will only briefly touch on topics dealing with physics, artifacts, or sonopathology, which are available elsewhere in the medical literature.[ 4- 6] We hope to, in the future, publish an article that will provide an exhaustive review concerning the use of sonoanatomy of the neck above the clavicle.

US images in this paper were taken with a straight array 38-mm, high frequency probe (6-13 MHz), although one image was taken with a curved array 60-mm, low frequency probe (2-5 MHz) on an S-nerve US machine (S-Nerve, Sonosite, Bothell, WA, USA). Use of other equipments, especially curved probes, which have smaller "footprints," will produce different images.

IDENTIFYING DIFFERENT TISSUE TYPES AND UNDERSTANDING ULTRASOUND TERMINOLOGY

Echogenicity

Echogenicity of the tissue refers to the ability to reflect or transmit US waves in the context of surrounding tissues.[ 7- 9] Whenever there is an interface of structures with different echogenicities, a visible difference in contrast will be apparent on the screen. Based on echogenicity, a structure can be characterized as hyperechoic (white on the screen), hypoechoic (gray on the screen) and anechoic (black on the screen) [].

Bone appears black or anechoic on US, with a bright hyperechoic rim [Figures and ]. Because the US beam cannot penetrate bone, it casts an acoustic shadow beyond it. Cartilage appears hypoechoic, and is more penetrable by US than bone. Blood vessels also appear black or anechoic []. Veins are usually easily collapsible upon external pressure by the transducer, while arteries are pulsatile and do not collapse with moderate pressure. Blood vessels have a distinct appearance on color Doppler mode: flow toward the probe appears red, while flow away from the probe appears blue. A useful mnemonic used by radiologists is BART, i.e., Blue Away, Red Toward. Muscles are hypoechoic with striate structure; fat is almost anechoic, while fascia and other connective tissue strands and fascicles appear as hyperechoic lines [Figures and ]. Lymph nodes appear anechoic or hypoechoic. The appearance of nerves is variable, depending on the proximity to the neuraxium. Proximal nerves are hypo-anechoic (approximately similar to blood vessels but neither collapsible nor pulsatile), and distal nerves are hyperechoic, with a stippled ("honeycomb") structure (with hypo-anechoic fascicles on the hyperechoic background of connective tissue surrounding them) []. Ligaments and tendons have a similar appearance to distal nerves (hyperechoic, but not "honeycomb"). If in doubt, one can trace the "target structure" proximally or distally in order to distinguish the nerve from a tendon based on anatomy (the tendon will be traceable to the muscle body). Tendons have characteristic striation in the long-axis view, and are more anisotropic (discussed later) than nerves. The lung has a very distinct appearance []; one can usually visualize a "shimmering", hyperechoic pleura sliding in rhythm with each breath, as well as comet tail artifacts, if US is performed while the patient is breathing; these are images that cannot be appreciated on static pictures. Loss of sliding and shimmering pleura and comet tail artifact may be due to pneumothorax.[ 7- 9]

Scanning planes

Scanning planes are similar to the well-known anatomical planes: axial (transverse), sagittal, parasagittal, and coronal.[ 10] "Oblique" direction can be combined with any standard plane to create, for example, a "parasagittal oblique" or "transverse oblique" scanning plane.

Ultrasound views

All subjects, except cubes and spheres (that are absolutely symmetrical in all directions), have a long axis and a short axis when viewing them from a 2-D approach. Viewing a structure in the long axis will provide a long-axis view, and vice versa; an oblique view is also possible.

Anatomical structures, such as vessels or nerves, are more commonly viewed in the short axis (round shape on the screen) than long axis when the operator loses the lateral-medial perspective. Rotating an US probe to 90° will change a short-axis view into a long-axis view, and vice versa. An oblique view can be appreciated during rotation of the probe between the true short axis view and the long-axis view.

Angle of incidence

The angle at which the US waves encounter the surface of the structure, termed, the angle of incidence, affects the way it is presented on the screen. If the angle is perpendicular, or close to perpendicular, more US waves will be reflected back to the transducer and fewer will be "scattered" away, resulting in a better image. If the US waves are more parallel to the surface of the object (more than a 45° angle of incidence), the image will have less definition. The operator can improve the image of the target by tilting or rotating the probe, thus adjusting the angle of incidence [].

A close-to-perpendicular angle of incidence is also very important for better needle visualization during US-guided needle insertion, and can be achieved by changing the needle approach such that it is advanced more perpendicular to the US waves [].

Anisotropy

Anisotropy in ultrasonography could be defined as a tissue property that is responsible for changes in the US reflection dramatically, even with mild changes in the angle of incidence. It creates the phenomenon known as "now-you-see-me-now-you-don't". Different tissues have varying degrees of anisotropy. Nerves and tendons are notoriously anisotropic and could make US-guided nerve blocks quite challenging. Tendons are slightly more anisotropic than peripheral nerves, a factor that occasionally can be used for differentiating structures that may look similar on US, although tracing the structures more proximally or distally to verify anatomical relationship is still a better way of doing it. US probe maneuvers, such as pressure, tilt, and rotation, are primarily performed to optimize the angle of incidence in order to get the best reflection of the targeted structure.

ULTRASOUND WAVE FREQUENCY, IMAGE RESOLUTION, AND PENETRATION

High frequency probes (10-15 MHz) and midrange frequency probes (5-10 MHz) provide better resolution but have less penetration. High frequency probes are, therefore, preferred for US imaging of superficial structures (2-4 cm), while midrange frequency probes are preferred for slightly deeper structures (5-6 cm). However, when US imaging of deep structures (for example, a proximal sciatic nerve that can be as much as 10 cm deep) is required, a low frequency probe (2-5 MHz) is preferred, although the quality of the image will be substantially poorer. When determining the correct choice between probes with different US frequencies, choose the one that will provide the best resolution for the required depth. Most practitioners have several different probes for more flexibility.

CURVILINEAR VERSUS STRAIGHT PROBE

Curvilinear probes generate a wedge-shaped US beam and a corresponding image on the screen[ 8] [, left image]. The curved image of the anatomical structures which, in reality, are straight may initially look peculiar but, with time, the operator becomes accustomed to the view. The curved probe can easily roll on its scanning surface, thus affecting the direction of the US beam. This ability to roll the probe is occasionally advantageous in allowing us to "look around the corner", but it can also have a disadvantage in that extra efforts are needed to keep the US beam perpendicular to the skin surface while looking straight down.

The curvilinear probe provides a broader view that could be obtained via a smaller acoustic window; the image of deeper structures is wider than the footprint of the probe. This factor of widening of the image with the depth should be also considered during distance measurement. In general, determining the precise depth of the structure and width assessment with a curved probe is tricky. It is necessary to understand that the width of the image is equal to the probe footprint size only at the uppermost part of the image, and the depth marks on the side of the screen are pertinent only for measurement of the depth on the line drawn through the middle of the probe.

The curvilinear probe may be superior to the straight probe in its ability to visualize the needle that advanced in plane at the steep angle because it provides a more favorable angle of incidence.

Straight probes produce a straight US beam and an image with a width equal to the size of the transducer footprint from the surface to the deeper structures [, right image].

ULTRASOUND PROBE FOOTPRINT SIZE

The smaller footprint probe may be advantageous when negotiating the small anatomical convexity and concavity of the body surface, and may provide better contact between the probe and skin, which is especially useful while using US in uneven areas (supraclavicular or infraclavicular, for example), especially for children. When the footprint of the probe is too small, vision becomes "tunneled", although a larger footprint will not only give a "wider picture" but also improve lateral resolution. A small footprint of the probe is occasionally more advantageous for in-plane needle advancement, allowing the operator to place the needle entry closer to the target and thus also shortening the distance to the target.

COLOR DOPPLER FUNCTION

Color Doppler helps to distinguish structures with movement, for example, blood moving within vessels. Because proximal nerves are usually hypo-anechoic and can be confused with blood vessels, this function may be especially helpful []. Color Doppler can also be used to determine the direction of the blood flow when needed.

Compared to 2-D US, Doppler works best when US waves are almost parallel to the direction of the moving object (that is, blood, as in the case of blood vessels). When the angle of incidence is close to 90° and flow is low, there may be no color on the screen, possibly producing a false negative indication of "no flow".[ 5] To increase the sensitivity of vessel recognition, the probe should be tilted out, off the perpendicular angle of incidence. Power Doppler should also be used in these situations because it is more sensitive in recognizing low flow in small blood vessels despite an unfavorable angle of incidence than regular Color Doppler.[ 5]

KNOBOLOGY : GAIN, FOCUS, AND MODE OF SCANNING

Changing the gain will change the amount of white, black, and gray on the monitor. Adjusting the gain of the image may improve the operator's ability to distinguish structures on the screen; the amount of gain to use depends on personal preference. Most US machines have an auto-gain knob, which is commonly used.

Modern US machines have useful "nerve", "angio" or "general" modes. The "focus" function available on these machines may help to improve visualization of the targeted structure, although it is rarely needed for superficial structures if the depth is set correctly.

DEPTH SETTINGS

It is wise to begin with a somewhat higher depth setting in order to first get a "big picture", and then gradually decrease the depth when the targeted structure is found. For US-guided injection, the depth should be set about 1 cm deeper than the target of interest. If another structure of importance, such as a vessel or lung, is situated below the target, the depth should be adjusted accordingly to produce a good view of the field and improve safety.

By knowing the target depth and its position on the screen, the initial angle of needle advancement can be estimated even before visualizing the needle on the screen. (If one uses a 4-cm-wide transducer and an in-plane approach, the initial angle will be close to 45° if the targeted structure is situated in the middle of the screen at the 2-cm depth and the needle is inserted at the edge of the transducer.) This angle should be adjusted as soon as the needle can be viewed on the screen and its trajectory is clear.

PROBE ORIENTATION

Probe orientation is important because the US probe can be easily rotated around (180°) while the position of the monitor remains unchanged, which may create confusion in the direction of probe manipulation and needle advancement and placement. Therefore, it is always useful to confirm which side of the probe corresponds to a particular side of the screen in order to identify the correct orientation of the image. All transducers have an orientation marker that corresponds to the marker on the screen.

PROBE MANIPULATION

When dealing with US probe manipulation, the mnemonic PART (Pressure, Alignment, Rotation and Tilt) is useful []. It is important to understand that by manipulating the US probe, we primarily manipulate the direction of the beam, and, by changing the direction of the beam, slightly different US images of the same structures can be obtained.

Pressure

Correct pressure application can considerably improve the image quality. It affects the echogenicity of the tissue and shortens the distance to the structure of interest. Ordinarily, pressure must be applied evenly to get the correct direction of the scan; however, occasionally, the operator may intentionally need to apply more pressure on one side of the probe in order to direct the US beam in the desired manner (angling the probe). Pressure to the probe is also applied to compress a vein or to push an anatomical structure out of the way of an intended needle pass. Excessive pressure, however, can cause discomfort to the patient. Placing excessive pressure on the transducer may also be responsible for significant depth underestimation to the relatively deep structure if US is used solely for marking and measuring, and if a procedure is done after that without US on a patient who has significant amount of soft tissue, which "springs back" when the probe is removed.

Alignment (sliding)

The main goal of this maneuver is to find the structure of interest and position it optimally on the screen for needle advancement (usually in the middle of the screen for an out-of-plane approach and somewhat on the opposite side of the screen for an in-plane approach). Sliding is also very useful for tracing the potential structure proximally and distally for better verification of pertinent anatomy during a "scout scan".

Rotation

With rotation, one can achieve several goals. First, one can attain a true axial view of the target with its long axis parallel to the surface but not perpendicular to the current US plane. For example, if you image a blood vessel (that is parallel to the surface) in the short-axis view and slide a US probe along the vessel's long axis, you must slightly rotate the probe when the vessel makes a turn in order to maintain true short axis view. Second, one can align the target into a more favorable trajectory for a safe needle pass (away from vessels or pleura, for example).

Rotation will affect the image if it brings the object out of the true axial view. If the long axis of the object remains parallel to the surface and the US probe is gradually rotated relative to the long axis of the structure, the round cross section of the true axial cut (of the normally round vessel or nerve, for example) will be replaced by a more oval shape. By continuous rotation of the probe of 90° from the initial probe position, one can change the view of the structure from its short axis to its long axis, and vice versa.

Tilt

There is no particular recognized terminology to define the direction of the tilt, and confusion can arise from the fact that when the probe is tilted in one direction, the US plane, in fact, sweeps to the opposite direction.

Several goals can be achieved by tilting the probe. First, by sweeping the US beam in the particular direction desired by tilting the probe, one can "preview" the image by sliding the probe in the opposite direction of the tilt []. Second, by tilting the probe, a true short-axis view of the object can be obtained, the long axis of which is not perpendicular to the initial US beam plane [, position 2].

As with rotation, if the US plane cuts the long axis of the target at the angle that is not perpendicular, it will distort the 2-D image [, position 1]. By tilting the probe out of the true axial view of the target, the image will change as follows:

1. The distance from the surface to the target will increase and

2. The shape of the target on the screen will be untrue (oval instead of round, for example).

ULTRASOUND ARTIFACTS

US artifacts are responsible for untrue images when we see on the monitor something that does not exist in reality or we do not see something that is in fact true. Many artifacts from US have been described; some are well understood and related to the physics of US, such as reverberation, mirror image, or acoustic enhancement artifacts, while others are not fully understood. These are outside of the scope of our paper; if detailed information is desired on these topics, the reader is referred to specialized texts.[ 6]

SONOPATHOLOGY

A general description of sonopathology can be found in other articles.[ 11] As a rule of thumb, factors that negatively affect the echogenicity of tissues include the accumultion of extra water in soft tissue, as occurs with edema; loss of muscle mass, as happens with hypotrophy; and accumulation of micro-droplets of fat in the muscle, thereby producing an US image with less sharpness and contrast. Fluid collections could be readily seen by US and this has been used by radiologists for years. Air bubbles in the soft tissue can significantly affect the image to the point that it renders US unproductive. It stands to reason that a great deal of experience in imaging of normal sonoanatomy is needed before an operator can reliably visualize any pathology. Pure anatomical variations, such as unusual location of the nerve or presence of additional nerve or vessel, for example, are not considered pathological, provided these variations are not affecting normal function. Some anatomical variations that are missed on the exam before the nerve block, nevertheless, could be responsible for block failure.

NEEDLE ADVANCEMENT TERMINOLOGY AND TECHNIQUES

In-plane needle placement occurs when the needle can be seen on the US monitor in the long-axis view (long axis of the needle is situated within the US scanning plane). Out-of-plane needle placement occurs when the long axis of the needle is directed across the scanning plane so the needle can be seen in the short-axis view []. Although other approaches can be employed, in-plane needling is commonly used for single injections, while out-of-plane is used for catheter placement.

When performing out-of-plane needle advancement, dynamic tilting or sliding of the transducer when advancing the needle may help track the tip of the needle []. Visualizing the tip of the needle can be challenging, yet is essential. For this purpose, it is common to use tissue movement, or injections of small volumes of dextrose (if nerve stimulation is planned) or normal saline as an indicator (hydrolocation). Use of US, in combination with nerve stimulation, may be especially beneficial for the out-of-plane approach in some instances.

The in-plane mode is usually the preferred approach because it allows one to visualize the entire needle, including its tip. Visualization can be enhanced if a larger or specially designed echogenic needle is used and a more favorable angle of incidence is employed.[ 12]

ERGONOMICS OF ULTRASOUND-GUIDED PROCEDURES

An US machine should be positioned on the contralateral side of the patient, with the operator standing on the ipsilateral side that needs to be blocked or examined. The transducer is usually held in the operator's nondominant hand, with the needle in the dominant hand. The transducer should gently be held quite low on the probe, close to the scanning surface, rather than harshly gripped on the top of the handle. When planning to use the in-plane approach, it is preferable to place the probe directly perpendicular to the skin. (If it is possible to do without sacrificing image quality, try not to tilt the probe, as this will add difficulty with in-plane needle advancement; personal observation).

PROBE MANIPULATION DURING NEEDLE ADVANCEMENT

It is important to stabilize the US probe position after obtaining the desired image. This can be facilitated by gently bracing the hand holding the probe on the patient's body. Subsequently, we recommend taking the operator's attention off the screen and focusing on attaining correct needle alignment with the US probe. Only after some advancement of the needle through the skin has occurred should the probe operator shift his/her attention back to the screen. At that point, if the needle can be visualized on the screen, further advancement and trajectory changes can be made based on feedback from the US screen without averting attention to the probe position and needle. Eye-hand coordination is required for this maneuver, and phantom exercises are very helpful to enhance this particular skill.[ 13]

Operators, particularly at the beginning of training, commonly lose sight of the tip of the needle or the entire needle from view. In these instances, it is perfectly proper to look back at the probe and find the best possible way to realign the needle with the US plane. If only the tip of the needle is "moving out" of view, one can slightly withdraw the needle back and try again with slight trajectory adjustment. Visualization of the needle can also be regained by slight probe manipulations (tilt, rotation, or sliding). It is important to develop a "feel of depth" for needle advancement and have accurate expectations for corresponding changes on the US screen should they occur. The US beam is very thin (about 1 mm wide), so even subtle movements can bring the needle in and out of the viewing field. If the operator does not have this "feel of depth" and corresponding expectation for the tip of the needle position on the screen, and tip of the needle accidently moves out of the US plane, the operator may advance the needle deep, before realizing it.

SUMMARY

Knowledge of the fundamentals of US that were mentioned in this article, combined with understanding of the clinical 3-D anatomy of the area of the interest, will allow practitioners to use musculoskeletal US and US-guided procedures effectively and safely. We hope to publish an article dedicated to sonoanatomy of the neck above the clavicle in the near future.

Footnotes

Source of Support: Nil

Conflict of Interest: None declared

REFERENCES

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Ultrasound: Basic understanding and learning the language

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Ultrasound (US) use has rapidly entered the field of acute pain medicine and regional anesthesia and interventional pain medicine over the last decade, and it may even become the standard of practice. The advantages of US guidance over conventional techniques ...

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Codifying Terms for Effective Teaching

David P. Bahner MD, RDMS

Corresponding Author

E-mail address: david.bahner@osumc.edu

Departments of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio USA.

Address correspondence to David P. Bahner MD, RDMS, Department of Emergency Medicine, The Ohio State University, 750 Prior Hall, 376 W 10th Ave, Columbus, OH 43210 USA. Search for more papers by this author

First published:

Abstract

There is a need for consistent, repetitive, and reliable terminology to describe the basic manipulations of the ultrasound transducer. Previously, 5 basic transducer motions have been defined and used in education. However, even with this effort, there is still a lack of consistency and clarity in describing transducer manipulation and motion. In this technical innovation, we describe an expanded definition of transducer motions, which include movements to change the transducer's angle of insonation to the target as well as the location on the body to optimize the ultrasound image. This new terminology may allow for consistent teaching and improved communication in the process of image acquisition.

Abbreviations

FAST

focused assessment with sonography for trauma

I‐AIM

indication, acquisition, interpretation, and medical decision making

Point‐of‐care ultrasound involves physician acquisition and interpretation of ultrasound images at the bedside to diagnose and direct patient care. 1 This process includes defining the indications for the examination, acquisition and interpretation of images, and using the results of the examination for medical decision making. 2 The rate‐limiting step in the use of focused ultrasound by physicians is often the acquisition of images, as it involves manipulating the transducer and fine‐tuning its position, in multiple directions, to display the ideal image.

There are little consistent data on the key maneuvers used to manipulate a transducer to acquire a high‐quality image. In 1999, the American Institute of Ultrasound in Medicine published a technical bulletin, which described 5 basic movements, including sliding, rocking, tilting, rotating, and compression. 3 This nomenclature has been used; however, there is still a substantial inconsistency and overlap in terminology describing transducer motion. 4 ⁻7 Terms in common usage include move, slide, angle, fan, rock, and heel‐toeing. 4 ⁻7 Other authors have compared transducer motions to aeronautic controls, describing motions as yaw, pitch, and roll. 8

Prescriptive instructions to acquire ideal images are difficult without common terminology and understandable nomenclature. Consequently, transducer placement is illustrated on the body and correlated with an ideal image. 4 ⁻8 Since patient anatomy and conditions vary greatly, the illustrated transducer placement does not always yield the ideal image. This factor is not an issue for experienced physicians, who naturally adjust transducer position to optimize the image. However, novice users are often challenged when the generated image is not as expected and compensate by moving the transducer in multiple planes simultaneously, resulting in repeated display of suboptimal images. This process may necessitate a demonstration of the correct adjustments from the instructor by removing the transducer from the learner's hand or "hand holding" in an attempt to obtain the ideal image. This practice inevitably affects the autonomy of the learners and the valuable aspect of hands‐on learning time.

In this article, we describe a specific codification of terms for consistent, repetitive, and reliable teaching of ultrasound image acquisition. The key aspect of this technical innovation is distinguishing between movements that change the transducer's location on the body from those that affect the angle of insonation. This codification of transducer motions enables educators to instruct without removing the transducer from the learner's hand, subsequently improving the educational experience and enhancing knowledge retention. Prescriptive language further allows for quality improvement instruction from any location between operator and proctor, enabling opportunities for instruction from as near as the bedside to as far as a remote location.

Redefining the Cardinal Transducer Motions

In 1999, the American Institute of Ultrasound in Medicine defined transducer motion, described as sliding, rocking, tilting, rotating, and compression. 3 However, these definitions do not distinguish between movements that change the transducer's location on the body from those that change the angle of insonation. The angle of insonation is defined as the angle of the ultrasound beam relative to the tissue or organ of interest ( Figure 1). For example, a specular reflection produces the strongest echo signal by changing the angle of insonation so that the angle of incidence equals the angle of reflection ( Figure 1).

For optimal imaging, maximizing the amplitude of a target's echo through transducer movement is critical. The amplitude of a target's echo detected by the transducer depends on the orientation of the target relative to the incident beam, the target's size, and its surface characteristics. The optimal image is obtained at a specular reflector, since the target's reflection to the transducer is maximized. A specular reflector is described by a perpendicular beam incident on a large, smooth, and flat interface, resulting in a reflected beam perpendicular to the surface. Although some of the body's tissues behave as specular reflectors (ie, the diaphragm, the endometrial stripe, walls of blood vessels, and many solid organs), most echoes in the body arise from smaller interfaces that are neither perfectly smooth nor flat (diffuse reflectors). 9 ⁻12 Some tissues and organs can act as specular reflectors when imaged at a 90° angle of insonation, resulting in a strong echo and a hyperechoic image. 12 Due to the body's anatomy, these structures are oriented at many oblique angles relative to the skin surface, making visualization as a specular reflector difficult. 10 Approximating a specular reflection to produce the strongest echo signal is obtained by changing the angle of insonation, through transducer manipulation, so that the angle of incidence equals the angle of reflection ( Figure 1). 10 ,12

The redefined transducer motions described here expand on the previously published cardinal movements of the transducer, with a focus toward obtaining ideal images at specular reflectors. These are identified as slide, rock, sweep, fan, pressure/compression, and rotation and are related to the movements of the transducer in space ( Table 1). These movements are primarily defined by the movement of the transducer across the body or by changing the transducer's angle of insonation. This difference is demonstrated in the comparison between the sliding and rocking movements of the transducer. Transducer movement in the long axis across the body with a consistent angle of insonation (90° to the target of interest) is called sliding ( Table 1 and Video 1). This movement is commonly used when performing the focused assessment with sonography for trauma (FAST) scan on the Morison pouch and attempting to visualize the diaphragm by moving (sliding) the transducer cranially along the long axis of the transducer. In contrast, changing only the angle of insonation of the transducer in the long axis, with a fixed body position, is described as rocking ( Table 1 and Video 2). This movement (rocking) is used in the FAST scan when visualizing the long axis of the pelvis with the nonindicator transducer edge held against the pubis and the angle of insonation changed toward the pelvis to visualize the complete bladder in the long axis.

Slide

Motion in the long axis of the probe across the body with a consistent angle of insonation at 90° to the target

Rock

Motion in the long axis of the probe along a fixed point on the body while changing the angle of insonation away from 90°

Sweep

Motion in the short axis of the probe across the body with a consistent angle of insonation at 90° to the target

Fan

Motion in the short axis of the probe along a fixed point on the body while changing the angle of insonation away from 90°

Pressure/compression

Pressure on the probe into the body, compression of the body by applying force on the probe toward the patient's body

Rotation

Movement around the compression axis in a clockwise or counterclockwise direction

The evaluation of the body by moving the transducer in the short axis also has a similar set of descriptors: sweeping and fanning. Transducer movement in the short axis across the body with a consistent angle of insonation (perpendicular) is called sweeping ( Table 1 and Video 3). Transducer movement in the short axis with a fixed position on the body but changing only the angle of insonation is called fanning ( Table 1 and Video 4).

Different from these definitions are the final movements of the transducer, which are defined by the relationship of the transducer footprint to the body. This relationship can be either a consistent position of the transducer footprint to the body (with application of pressure on the transducer) or a rotation of the transducer footprint in relation to the body. Compression/pressure is defined as pressure being applied on the transducer, with the transducer footprint at a fixed position, causing the transducer to move into the body by applying pressure on the tissue ( Table 1 and Video 5). This maneuver is commonly used to displace bowel gas or remove a contact artifact. It is also used clinically to compress veins, determine elastography, and assess the tissue response to pressure. In contrast, rotation is movement around the axis of the transducer's footprint ( Table 1 and Video 6). A clock face can be used to describe rotation, with the indicator edge directed cephalad, which is designated 12 o'clock. Rotations can be made in the clockwise or counterclockwise direction around the fixed axis. For example, rotation of the transducer 90° clockwise is a motion of turning the leading edge from 12 o'clock to 3 o'clock.

Application of Redefined Cardinal Movements

The act of deliberate scanning means moving the transducer in one direction at a time to achieve certain elements of a high‐quality scan and then progressing to the next movement in response to the generated image. This act is the psychomotor skill that each operator masters to obtain the desired ideal image. Although transducer motion is the primary path to achieving these high‐quality images, a proper and consistent language can assist with pattern recognition, psychomotor skill acquisition, and improved communication between operator and proctor. This ability to acquire high‐quality images occurs through a consistent experience in which the operator is able to recognize the plane of imaging and the correct plane required and then, through consistent feedback from expert operators, learns maneuvers that will allow for the optimal generation of images. For example, pattern recognition and psychomotor scanning can help operators if they realize that after a target is centered on the screen by sliding or rocking, the only motions required for an ideal image to be obtained are sweeping, fanning, and rotating the transducer into the correct plane.

The use of these redefined cardinal movements can allow for a systematic approach to interrogating a space of interest. A cohesive application of these cardinal movements can enhance education by coordinating the intended goal of scanning and clarifies bedside ultrasound teaching, as operator and educator are consistent in their communication.

The use of these redefined cardinal transducer movements has been formalized as part of the I‐AIM (indication, acquisition, interpretation, and medical decision making) educational model used at The Ohio State University. 2 In this training program, image acquisition is optimized through a consistent teaching practice and improved communication. For consistency in our ultrasound training, the displayed images all have the indicator dot on the left. The left side of the image corresponds to the transducer's indicator edge and is referred to as the leading edge, whereas the opposite is the receding edge ( Figure 2). Using this rule of image orientation, the transducer motion of "sliding" brings partially visualized images at the leading or receding edge into full view. Sliding moves the target structure from side to side on the screen. When the operator performs a "rocking" motion, this functions to center structures from the leading to receding edges as tilted images around a fixed focal point. In contrast, "sweeping" functions to interrogate a structure from side to side or end to end by bringing structures into and out of the screen. Similarly, "fanning" can be used to interrogate a structure side to side like sweeping but does so around a fixed focal point and varies the angle of insonation around a specified target. Finally, the transducer can be rotated around a fixed focal point clockwise or counterclockwise to image structures in a 360° fashion, moving from long to short axes and through many oblique axes to optimize the image.

The scanning protocol developed from the I‐AIM model begins with macro movements (defined as >3-5 cm) to survey the area and then continues to finer movements for image optimization after the target is identified. This survey of the area begins by using a short‐axis macro sweep over the area of interest to assess for viable acoustic windows, identify target structures, and observe the returning ultrasound signatures. From these macro sweeps, landmarks are identified, and the operator determines whether the anatomy of interest is fully visualized and in the correct intended plane. If not, the transducer is moved in a long‐axis slide to center the intended anatomy on the screen and bring it into full view. A long‐axis rocking motion is then used to center the anatomy of interest, and the angle of insonation is adjusted in the short axis by micro (<3 cm) fan motions, which optimize the specular reflection. Isolated rotation from this point displays the anatomy of interest in long, short, and many oblique axes without also altering the location of the desired anatomy on the screen or the strength of the echo signal.

Application of these rules, while using consistent language, enables educators to formulate prescriptive instructions to obtain ideal images. For example, learners seeking to visualize the Morison pouch during a FAST examination are instructed to place the patient in the supine position and use a curvilinear transducer with the depth set to about 14 cm. Place the transducer, with the beam oriented parallel to the bed, along the right anterior axillary line at about the eighth or ninth rib space with the indicator edge oriented at 12 o'clock. This position should bring the right lobe of the liver into view. As the transducer is swept posteriorly, the gallbladder, the great vessels, and the right kidney are displayed from anterior to posterior. When the hepatorenal interface is visualized, sweep the transducer to bring this interface into full view and rock to center the hepatorenal space on the screen. Rotate the transducer from the 12‐o'clock to the 10‐o'clock position to eliminate rib shadows, as the 10‐o'clock position (leading edge toward the bed) approximates the angle of the ribs relative to the axillary line. Adjust the depth and gain appropriately to optimize the image, and save a still of the ideal image.

Discussion

Point‐of‐care ultrasound involves acquisition and interpretation of ultrasound images, which are often challenging to obtain for novice users. Providing prescriptive instructions to acquire ideal images is difficult without common terminology, a rationale for optimal transducer placement, and understandable nomenclature used by both learners and educators. Without a clear communication channel, this process often leads to instruction, which involves removing the transducer from the hand of a novice user. It further makes it difficult for novice users to gain the needed framework and skills for troubleshooting suboptimal images.

In this technical innovation, we describe the use of a redefined, clarified set of cardinal transducer manipulations focused on the key aspect of the angle of insonation and how it relates to improved ultrasound image acquisition. Learners gain a framework for transducer adjustment and troubleshooting to optimize a suboptimal image by moving the transducer in clear directions toward obtaining specular images of targeted tissue. Because the transducer never leaves a learner's hand, "scanning muscle memory" may be developed by repeatedly following standard instructions for transducer movement while observing how the image is altered. Because these terms describe movement according to axes of the transducer and not the body, they can be used interchangeably regardless of the transducer used or examination performed.

These transducer motions are those that have been integrated into the I‐AIM educational model at one institution. 2 The use of this method has been successful in teaching multiple diverse learners of the art of point‐of‐care ultrasound. However, it is clear that other methods to codify transducer motions exist. It is our opinion that ambiguity around these terms may delay optimal learning of how to scan effectively. Future studies could determine how current operators codify the various transducer motions to determine a consensus on terminology and descriptors. As more medical schools begin to train undifferentiated future physicians how to use ultrasound, there will need to be a coordination of terms, techniques, and teaching styles. Ultimately, a standard codification could help clarify the acquisition of images and assist in education.

The codification of transducer motions and a standardized technique for description may also assist with point‐of‐care ultrasound in venues outside the hospital setting. The World Health Organization projects that radiography and ultrasound, whether combined or separate, will satisfy two‐thirds of all imaging needs in the developing world. 13 As the use of ultrasound expands to austere environments, assistance with remote instruction of novice users may become an important part of patient care. 14 ⁻17 Clearly, standardized terms and educational methods may assist in remote ultrasound instruction where the operator is fully responsible for moving the transducer in performing the examination.

In conclusion, there is a need for consistent, repetitive, and reliable terminology to describe the basic manipulations of the ultrasound transducer. In this technical innovation, we describe an expanded definition of transducer motions and the application of the redefined cardinal motions for education. This new terminology may allow for consistent teaching and improved communication in the process of image acquisition.

Number of times cited according to CrossRef: 12

Shaun B Pratt, Fernando Martinez-Taboada, Lateral ultrasound-guided axillary RUMM block in cats: a pilot cadaveric study, Journal of Feline Medicine and Surgery, 10.1177/1098612X20948149, (1098612X2094814),

Transducer Manipulation, Atlas of Ultrasound-Guided Regional Anesthesia, 10.1016/B978-0-323-50951-0.00010-4, (22-23),

AIUM Curriculum for Fundamentals of Ultrasound Physics and Instrumentation, Journal of Ultrasound in Medicine, 10.1002/jum.15088, 8, (1933-1935), 38,

Curriculum for the Performance of Ultrasound‐Guided Procedures, Journal of Ultrasound in Medicine, 10.1002/jum.15089, 8, (1951-1969), 38,

Curriculum for Fundamentals of Ultrasound in Clinical Practice, Journal of Ultrasound in Medicine, 10.1002/jum.15090, 8, (1937-1950), 38,

L. C. J. M. Peters, R. Ollearo, R. G. F. A. Verbeek, J. L. P. J. van der Steen, H. B. Akkerman, A. W. F. Volker, P. L. M. J. van Neer, G. H. Gelinck, undefined, 2019 IEEE International Ultrasonics Symposium (IUS), 10.1109/ULTSYM.2019.8926238, (60-63),

William Clark Manson, Meghan Kirksey, Jan Boublik, Christopher L Wu, Stephen C Haskins, Focused assessment with sonography in trauma (FAST) for the regional anesthesiologist and pain specialist, Regional Anesthesia & Pain Medicine, 10.1136/rapm-2018-100312, (rapm-2018-100312),

Steven J. Campbell, Rabih Bechara, Shaheen Islam, Point-of-Care Ultrasound in the Intensive Care Unit, Clinics in Chest Medicine, 10.1016/j.ccm.2017.11.005, 1, (79-97), 39,

Kellie C. Huxel Bliven, Barton E. Anderson, Saskia D. Richter, Inder Raj S. Makin, Educational Technique: Using a Phased Approach to Integrate Diagnostic Ultrasound into Athletic Training Education, Athletic Training Education Journal, 10.4085/1304372, 4, (372-376), 13,

Michael Gottlieb, Hands‐off Ultrasound Technique: Utilizing Simultaneous Modeling to Enhance Ultrasound Training, AEM Education and Training, 10.1002/aet2.10071, 1, (55-56), 2,

Reem S. Abu-Rustum, M. Fouad Ziade, The 3-Sweep Approach: A Standardized Technique for Fetal Anatomic Assessment in the Limited Resource Setting, Journal of Fetal Medicine, 10.1007/s40556-017-0114-6, 1, (25-30), 4,

Brooke Osborne, Kerry Thoirs, Nayana Parange, The effectiveness of simulation training in the teaching of skills required for sonographic fetal assessment in mid‐trimester pregnancy to novices: A pilot study, Australasian Journal of Ultrasound in Medicine, 10.1002/ajum.12020, 4, (147-153), 19,

Abstract

There is a need for consistent, repetitive, and reliable terminology to describe the basic manipulations of the ultrasound transducer. Previously, 5 basic transducer motions have been defined and used in education. However, even with this effort, there is still a lack of consistency and clarity in describing transducer manipulation and motion. In this technical innovation, we describe an expanded definition of transducer motions, which include movements to change the transducer's angle of insonation to the target as well as the location on the body to optimize the ultrasound image. This new terminology may allow for consistent teaching and improved communication in the process of image acquisition.

Abbreviations

FAST

focused assessment with sonography for trauma

I‐AIM

indication, acquisition, interpretation, and medical decision making

Point‐of‐care ultrasound involves physician acquisition and interpretation of ultrasound images at the bedside to diagnose and direct patient care. 1 This process includes defining the indications for the examination, acquisition and interpretation of images, and using the results of the examination for medical decision making. 2 The rate‐limiting step in the use of focused ultrasound by physicians is often the acquisition of images, as it involves manipulating the transducer and fine‐tuning its position, in multiple directions, to display the ideal image.

There are little consistent data on the key maneuvers used to manipulate a transducer to acquire a high‐quality image. In 1999, the American Institute of Ultrasound in Medicine published a technical bulletin, which described 5 basic movements, including sliding, rocking, tilting, rotating, and compression. 3 This nomenclature has been used; however, there is still a substantial inconsistency and overlap in terminology describing transducer motion. 4 ⁻7 Terms in common usage include move, slide, angle, fan, rock, and heel‐toeing. 4 ⁻7 Other authors have compared transducer motions to aeronautic controls, describing motions as yaw, pitch, and roll. 8

Prescriptive instructions to acquire ideal images are difficult without common terminology and understandable nomenclature. Consequently, transducer placement is illustrated on the body and correlated with an ideal image. 4 ⁻8 Since patient anatomy and conditions vary greatly, the illustrated transducer placement does not always yield the ideal image. This factor is not an issue for experienced physicians, who naturally adjust transducer position to optimize the image. However, novice users are often challenged when the generated image is not as expected and compensate by moving the transducer in multiple planes simultaneously, resulting in repeated display of suboptimal images. This process may necessitate a demonstration of the correct adjustments from the instructor by removing the transducer from the learner's hand or "hand holding" in an attempt to obtain the ideal image. This practice inevitably affects the autonomy of the learners and the valuable aspect of hands‐on learning time.

In this article, we describe a specific codification of terms for consistent, repetitive, and reliable teaching of ultrasound image acquisition. The key aspect of this technical innovation is distinguishing between movements that change the transducer's location on the body from those that affect the angle of insonation. This codification of transducer motions enables educators to instruct without removing the transducer from the learner's hand, subsequently improving the educational experience and enhancing knowledge retention. Prescriptive language further allows for quality improvement instruction from any location between operator and proctor, enabling opportunities for instruction from as near as the bedside to as far as a remote location.

Redefining the Cardinal Transducer Motions

In 1999, the American Institute of Ultrasound in Medicine defined transducer motion, described as sliding, rocking, tilting, rotating, and compression. 3 However, these definitions do not distinguish between movements that change the transducer's location on the body from those that change the angle of insonation. The angle of insonation is defined as the angle of the ultrasound beam relative to the tissue or organ of interest ( Figure 1). For example, a specular reflection produces the strongest echo signal by changing the angle of insonation so that the angle of incidence equals the angle of reflection ( Figure 1).

For optimal imaging, maximizing the amplitude of a target's echo through transducer movement is critical. The amplitude of a target's echo detected by the transducer depends on the orientation of the target relative to the incident beam, the target's size, and its surface characteristics. The optimal image is obtained at a specular reflector, since the target's reflection to the transducer is maximized. A specular reflector is described by a perpendicular beam incident on a large, smooth, and flat interface, resulting in a reflected beam perpendicular to the surface. Although some of the body's tissues behave as specular reflectors (ie, the diaphragm, the endometrial stripe, walls of blood vessels, and many solid organs), most echoes in the body arise from smaller interfaces that are neither perfectly smooth nor flat (diffuse reflectors). 9 ⁻12 Some tissues and organs can act as specular reflectors when imaged at a 90° angle of insonation, resulting in a strong echo and a hyperechoic image. 12 Due to the body's anatomy, these structures are oriented at many oblique angles relative to the skin surface, making visualization as a specular reflector difficult. 10 Approximating a specular reflection to produce the strongest echo signal is obtained by changing the angle of insonation, through transducer manipulation, so that the angle of incidence equals the angle of reflection ( Figure 1). 10 ,12

The redefined transducer motions described here expand on the previously published cardinal movements of the transducer, with a focus toward obtaining ideal images at specular reflectors. These are identified as slide, rock, sweep, fan, pressure/compression, and rotation and are related to the movements of the transducer in space ( Table 1). These movements are primarily defined by the movement of the transducer across the body or by changing the transducer's angle of insonation. This difference is demonstrated in the comparison between the sliding and rocking movements of the transducer. Transducer movement in the long axis across the body with a consistent angle of insonation (90° to the target of interest) is called sliding ( Table 1 and Video 1). This movement is commonly used when performing the focused assessment with sonography for trauma (FAST) scan on the Morison pouch and attempting to visualize the diaphragm by moving (sliding) the transducer cranially along the long axis of the transducer. In contrast, changing only the angle of insonation of the transducer in the long axis, with a fixed body position, is described as rocking ( Table 1 and Video 2). This movement (rocking) is used in the FAST scan when visualizing the long axis of the pelvis with the nonindicator transducer edge held against the pubis and the angle of insonation changed toward the pelvis to visualize the complete bladder in the long axis.

Slide

Motion in the long axis of the probe across the body with a consistent angle of insonation at 90° to the target

Rock

Motion in the long axis of the probe along a fixed point on the body while changing the angle of insonation away from 90°

Sweep

Motion in the short axis of the probe across the body with a consistent angle of insonation at 90° to the target

Fan

Motion in the short axis of the probe along a fixed point on the body while changing the angle of insonation away from 90°

Pressure/compression

Pressure on the probe into the body, compression of the body by applying force on the probe toward the patient's body

Rotation

Movement around the compression axis in a clockwise or counterclockwise direction

The evaluation of the body by moving the transducer in the short axis also has a similar set of descriptors: sweeping and fanning. Transducer movement in the short axis across the body with a consistent angle of insonation (perpendicular) is called sweeping ( Table 1 and Video 3). Transducer movement in the short axis with a fixed position on the body but changing only the angle of insonation is called fanning ( Table 1 and Video 4).

Different from these definitions are the final movements of the transducer, which are defined by the relationship of the transducer footprint to the body. This relationship can be either a consistent position of the transducer footprint to the body (with application of pressure on the transducer) or a rotation of the transducer footprint in relation to the body. Compression/pressure is defined as pressure being applied on the transducer, with the transducer footprint at a fixed position, causing the transducer to move into the body by applying pressure on the tissue ( Table 1 and Video 5). This maneuver is commonly used to displace bowel gas or remove a contact artifact. It is also used clinically to compress veins, determine elastography, and assess the tissue response to pressure. In contrast, rotation is movement around the axis of the transducer's footprint ( Table 1 and Video 6). A clock face can be used to describe rotation, with the indicator edge directed cephalad, which is designated 12 o'clock. Rotations can be made in the clockwise or counterclockwise direction around the fixed axis. For example, rotation of the transducer 90° clockwise is a motion of turning the leading edge from 12 o'clock to 3 o'clock.

Application of Redefined Cardinal Movements

The act of deliberate scanning means moving the transducer in one direction at a time to achieve certain elements of a high‐quality scan and then progressing to the next movement in response to the generated image. This act is the psychomotor skill that each operator masters to obtain the desired ideal image. Although transducer motion is the primary path to achieving these high‐quality images, a proper and consistent language can assist with pattern recognition, psychomotor skill acquisition, and improved communication between operator and proctor. This ability to acquire high‐quality images occurs through a consistent experience in which the operator is able to recognize the plane of imaging and the correct plane required and then, through consistent feedback from expert operators, learns maneuvers that will allow for the optimal generation of images. For example, pattern recognition and psychomotor scanning can help operators if they realize that after a target is centered on the screen by sliding or rocking, the only motions required for an ideal image to be obtained are sweeping, fanning, and rotating the transducer into the correct plane.

The use of these redefined cardinal movements can allow for a systematic approach to interrogating a space of interest. A cohesive application of these cardinal movements can enhance education by coordinating the intended goal of scanning and clarifies bedside ultrasound teaching, as operator and educator are consistent in their communication.

The use of these redefined cardinal transducer movements has been formalized as part of the I‐AIM (indication, acquisition, interpretation, and medical decision making) educational model used at The Ohio State University. 2 In this training program, image acquisition is optimized through a consistent teaching practice and improved communication. For consistency in our ultrasound training, the displayed images all have the indicator dot on the left. The left side of the image corresponds to the transducer's indicator edge and is referred to as the leading edge, whereas the opposite is the receding edge ( Figure 2). Using this rule of image orientation, the transducer motion of "sliding" brings partially visualized images at the leading or receding edge into full view. Sliding moves the target structure from side to side on the screen. When the operator performs a "rocking" motion, this functions to center structures from the leading to receding edges as tilted images around a fixed focal point. In contrast, "sweeping" functions to interrogate a structure from side to side or end to end by bringing structures into and out of the screen. Similarly, "fanning" can be used to interrogate a structure side to side like sweeping but does so around a fixed focal point and varies the angle of insonation around a specified target. Finally, the transducer can be rotated around a fixed focal point clockwise or counterclockwise to image structures in a 360° fashion, moving from long to short axes and through many oblique axes to optimize the image.

The scanning protocol developed from the I‐AIM model begins with macro movements (defined as >3-5 cm) to survey the area and then continues to finer movements for image optimization after the target is identified. This survey of the area begins by using a short‐axis macro sweep over the area of interest to assess for viable acoustic windows, identify target structures, and observe the returning ultrasound signatures. From these macro sweeps, landmarks are identified, and the operator determines whether the anatomy of interest is fully visualized and in the correct intended plane. If not, the transducer is moved in a long‐axis slide to center the intended anatomy on the screen and bring it into full view. A long‐axis rocking motion is then used to center the anatomy of interest, and the angle of insonation is adjusted in the short axis by micro (<3 cm) fan motions, which optimize the specular reflection. Isolated rotation from this point displays the anatomy of interest in long, short, and many oblique axes without also altering the location of the desired anatomy on the screen or the strength of the echo signal.

Application of these rules, while using consistent language, enables educators to formulate prescriptive instructions to obtain ideal images. For example, learners seeking to visualize the Morison pouch during a FAST examination are instructed to place the patient in the supine position and use a curvilinear transducer with the depth set to about 14 cm. Place the transducer, with the beam oriented parallel to the bed, along the right anterior axillary line at about the eighth or ninth rib space with the indicator edge oriented at 12 o'clock. This position should bring the right lobe of the liver into view. As the transducer is swept posteriorly, the gallbladder, the great vessels, and the right kidney are displayed from anterior to posterior. When the hepatorenal interface is visualized, sweep the transducer to bring this interface into full view and rock to center the hepatorenal space on the screen. Rotate the transducer from the 12‐o'clock to the 10‐o'clock position to eliminate rib shadows, as the 10‐o'clock position (leading edge toward the bed) approximates the angle of the ribs relative to the axillary line. Adjust the depth and gain appropriately to optimize the image, and save a still of the ideal image.

Discussion

Point‐of‐care ultrasound involves acquisition and interpretation of ultrasound images, which are often challenging to obtain for novice users. Providing prescriptive instructions to acquire ideal images is difficult without common terminology, a rationale for optimal transducer placement, and understandable nomenclature used by both learners and educators. Without a clear communication channel, this process often leads to instruction, which involves removing the transducer from the hand of a novice user. It further makes it difficult for novice users to gain the needed framework and skills for troubleshooting suboptimal images.

In this technical innovation, we describe the use of a redefined, clarified set of cardinal transducer manipulations focused on the key aspect of the angle of insonation and how it relates to improved ultrasound image acquisition. Learners gain a framework for transducer adjustment and troubleshooting to optimize a suboptimal image by moving the transducer in clear directions toward obtaining specular images of targeted tissue. Because the transducer never leaves a learner's hand, "scanning muscle memory" may be developed by repeatedly following standard instructions for transducer movement while observing how the image is altered. Because these terms describe movement according to axes of the transducer and not the body, they can be used interchangeably regardless of the transducer used or examination performed.

These transducer motions are those that have been integrated into the I‐AIM educational model at one institution. 2 The use of this method has been successful in teaching multiple diverse learners of the art of point‐of‐care ultrasound. However, it is clear that other methods to codify transducer motions exist. It is our opinion that ambiguity around these terms may delay optimal learning of how to scan effectively. Future studies could determine how current operators codify the various transducer motions to determine a consensus on terminology and descriptors. As more medical schools begin to train undifferentiated future physicians how to use ultrasound, there will need to be a coordination of terms, techniques, and teaching styles. Ultimately, a standard codification could help clarify the acquisition of images and assist in education.

The codification of transducer motions and a standardized technique for description may also assist with point‐of‐care ultrasound in venues outside the hospital setting. The World Health Organization projects that radiography and ultrasound, whether combined or separate, will satisfy two‐thirds of all imaging needs in the developing world. 13 As the use of ultrasound expands to austere environments, assistance with remote instruction of novice users may become an important part of patient care. 14 ⁻17 Clearly, standardized terms and educational methods may assist in remote ultrasound instruction where the operator is fully responsible for moving the transducer in performing the examination.

In conclusion, there is a need for consistent, repetitive, and reliable terminology to describe the basic manipulations of the ultrasound transducer. In this technical innovation, we describe an expanded definition of transducer motions and the application of the redefined cardinal motions for education. This new terminology may allow for consistent teaching and improved communication in the process of image acquisition.

Number of times cited according to CrossRef: 12

Shaun B Pratt, Fernando Martinez-Taboada, Lateral ultrasound-guided axillary RUMM block in cats: a pilot cadaveric study, Journal of Feline Medicine and Surgery, 10.1177/1098612X20948149, (1098612X2094814),

Transducer Manipulation, Atlas of Ultrasound-Guided Regional Anesthesia, 10.1016/B978-0-323-50951-0.00010-4, (22-23),

AIUM Curriculum for Fundamentals of Ultrasound Physics and Instrumentation, Journal of Ultrasound in Medicine, 10.1002/jum.15088, 8, (1933-1935), 38,

Curriculum for the Performance of Ultrasound‐Guided Procedures, Journal of Ultrasound in Medicine, 10.1002/jum.15089, 8, (1951-1969), 38,

Curriculum for Fundamentals of Ultrasound in Clinical Practice, Journal of Ultrasound in Medicine, 10.1002/jum.15090, 8, (1937-1950), 38,

L. C. J. M. Peters, R. Ollearo, R. G. F. A. Verbeek, J. L. P. J. van der Steen, H. B. Akkerman, A. W. F. Volker, P. L. M. J. van Neer, G. H. Gelinck, undefined, 2019 IEEE International Ultrasonics Symposium (IUS), 10.1109/ULTSYM.2019.8926238, (60-63),

William Clark Manson, Meghan Kirksey, Jan Boublik, Christopher L Wu, Stephen C Haskins, Focused assessment with sonography in trauma (FAST) for the regional anesthesiologist and pain specialist, Regional Anesthesia & Pain Medicine, 10.1136/rapm-2018-100312, (rapm-2018-100312),

Steven J. Campbell, Rabih Bechara, Shaheen Islam, Point-of-Care Ultrasound in the Intensive Care Unit, Clinics in Chest Medicine, 10.1016/j.ccm.2017.11.005, 1, (79-97), 39,

Kellie C. Huxel Bliven, Barton E. Anderson, Saskia D. Richter, Inder Raj S. Makin, Educational Technique: Using a Phased Approach to Integrate Diagnostic Ultrasound into Athletic Training Education, Athletic Training Education Journal, 10.4085/1304372, 4, (372-376), 13,

Michael Gottlieb, Hands‐off Ultrasound Technique: Utilizing Simultaneous Modeling to Enhance Ultrasound Training, AEM Education and Training, 10.1002/aet2.10071, 1, (55-56), 2,

Reem S. Abu-Rustum, M. Fouad Ziade, The 3-Sweep Approach: A Standardized Technique for Fetal Anatomic Assessment in the Limited Resource Setting, Journal of Fetal Medicine, 10.1007/s40556-017-0114-6, 1, (25-30), 4,

Brooke Osborne, Kerry Thoirs, Nayana Parange, The effectiveness of simulation training in the teaching of skills required for sonographic fetal assessment in mid‐trimester pregnancy to novices: A pilot study, Australasian Journal of Ultrasound in Medicine, 10.1002/ajum.12020, 4, (147-153), 19,

# data[].attributes.attachment_link.description
David P. Bahner MD, RDMS Corresponding Author E-mail address: david.bahner@osumc.edu Departments of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio USA. Address correspondence to David P. Bahner MD, RDMS, Department of Emergency Medicine, The Ohio State University, 750 Prior Hall, 376 W 10th Ave, Columbus, OH 43210 USA.

# data[].attributes.body
An interesting paper on PoCUS on NEJM

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# data[].attributes.headline
Month 2- How to keep the probe aseptic for procedures? 

# data[].attributes.subject
Month 2- How to keep the probe aseptic for procedures? 

# data[].attributes.body
A surgical gloves will do as shown below. Sleep the probe into the sleeve with some gel. Add aseptic gel to the other side of the glove.  Alternatively the orange sterile bag in the sterile pack. there are formal ultrasound probe sheath, but expensive and cost adds on over time.

# data[].attributes.body
It started with stethoscope like devices and currently it is at portable ultrasounds such as Butterfly iQ/Philips Lumify/SoniSite iViz models

# data[].attributes.attachment_link.title
Ultrasound history Past, Present and future

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demonstrated with Butterfly iQ

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Make your first attempt your best attempt: IV cannulation with ultrasound

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We are back with an exciting new programme courtesy of Lydia

# data[].attributes.subject
We are back with an exciting new programme courtesy of Lydia

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Sign up now via https://leedsededucationbookings.simplybook.it/v2/​

# data[].attributes.body
Myo 2019

# data[].attributes.headline
Month 1- Abdominal Aorta with a graft in-situ PoCUS  

# data[].attributes.subject
Month 1- Abdominal Aorta with a graft in-situ PoCUS  

# data[].attributes.body
Endoleak (blood flow in aneurysm sack) might be demonstrated with a doppler which is beyond competency of ED level 1. CT Angio is recommended and discussion with vascular before deciding to transfer to a tertiary centre. It effect 15-25% of patients with a EVAR graft in-situ.

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Policy Statement 2016

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The Canadian Association of Emergency Physicians 

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The Canadian Association of Emergency Physicians 

# data[].attributes.body
PoCUS Position Statment 2019

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PoCUS resources

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You have the highest standards when it comes to your clinical ultrasound program

Demonstrate to your patients, your institution and your payers that you have a quality program that meets ACEP's high standards for point-of-care ultrasound.

No need to try to fit your practice into some other discipline's criteria.

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Demonstrate to your patients, your institution and your payers that you have a quality program that meets ACEP's high standards for point-of-care ultrasound. No need to try to fit your practice into some other discipline's criteria.

# data[].attributes.body
Leeds ED General Journal Club Padlet

# data[].attributes.body
Leeds ED QIP Padlet

# data[].attributes.headline
World Federation for Ultrasound in Medicine and Biology (WFUMB)

# data[].attributes.subject
World Federation for Ultrasound in Medicine and Biology (WFUMB)

# data[].attributes.body
WFUMB position statment 2017 on PoCUS

# data[].attributes.body
CAR Position Statement 2019 on PoCUS

# data[].attributes.body
Junior Clinical Fellow Access and FIB Quiz- 21 August '19

# data[].attributes.body
Outlines level 1-3 competencies

# data[].attributes.body
Outlines guideline on utilising images for teaching and training

# data[].attributes.body
Founded in 2019 by Nick Mani (@EveryOneNoOne1) to improve training and patient care/safety in Leeds ED and beyond

Mission Statement

To promote emergency PoCUS education for ED Doctors and medical students.

To promote and foster collaboration in emergency PoCUS research

To assist in the development of Emergency PoCUS competency assessment tools and pathways for ongoing
commence maintenance

To provide a networking forum for ED Doctors interested in emergency PoCUS

To collaborate with other PoCUS groups, both nationally and internationally

Disclaimers
The contents are not the opinions of Leeds ED/Hospital/Trust/Y&H Deanery/RCEM. The contents of this webpage are only for local training and education purposes and all the materials will be referenced as much as possible.

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Month 1- Pulsatile Mass in the Abdomen 💓💓💓         August '19  

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Month 1- Pulsatile Mass in the Abdomen 💓💓💓         August '19  

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Situation:
A lady in her early 60s presenting with 1/7 abdo and back pain (new onset), vomit 1x (no blood). Sx still ongoing.
Background-:
HTN/Smoker/Borderline T2DM/High Cholesterol
Assessment:
Obs stable, but hypertensive.
Seen ED Junior Dr, felt a large pulsatile mass in the abdo and asked ED Reg.
Recommendation:
The ED Reg did abdo aorta PoCUS, demonstrating a 6-7cm AAA. Moved to resus, 2x large venous access and cross-match bloods, VBG normal. vascular team urgently called at the same time. CT angiogram confirmed the aneurysm, no leak/rupture/dissection.
Pt went to theatre urgently for a repair.

Learning Point:
- PoCUS is usually a rule-in test, can't demo leak/rupture until at least 150-200ml of blood in abdo cavity (but retroperitoneal aorta most likely tamponade itself)
- Do not mistake the spinous process of the vertebrae for AAA.
- Do a quick swipe down the abdo aorta first before doing the specific measurements. This is done to save time if there is a AAA, in which case not all views are required.
-Need 4x AP measure (Proximal, Mid, Distal for abdo aorta, and Proximal for common iliac arteries) and 1-2x longitudinal (to look for dissection flap/saccular aneurysm)
- Measure from inner to inner lumen, from outer of the thrombus if one present.
- When performing longitudinal view, don't mistake IVC for abdo aorta (tip- fan the prob to the right and identify IVC and then to the left to locate aorta)
- Label you images with at least performer, full name and DOB of pt, the sections scanne. Currently these are printed and attached to pt notes. Soon will be able to upload onto PACS.
- Write a basic report, including indications for the scan, findings, outcome. Need to include competency of the performer (accredited/unaccredited)
- Move pt to resus and call vascular urgently. 2x large bore cannula and take cross-match/group specific depending on the urgency. Could also activate the majot haemorrhage protocol.
- If pt haemodynamic unstable, aim for systolic of 80/conscious pt (permissive hypotension)
- 95% of AAA are infrarenal, can be repaired endo-vasular (EVAR)/surgery. If at renal level or higher, then it makes it extremely complicated, and might require FEVAR.
- Risk of Rupture of Aneurysm depends mostly on the size.
https://www.researchgate.net/profile/Jason_Chuen/publication/239732234/figure/tbl2/AS:392838480187394@1470671400110/12-month-AAA-rupture-risk-by-diameter.png
- If ruptured at presentation, 50/50 chance of survival.

Resources/Links:
See the relevant section on this webpage for guidelines/videos for performing abdominal aorta PoCUS.

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3D How to: Abdominal Aorta Ultrasound - SonoSite Ultrasound

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Framework for reporting/sorting

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Butterfly Network

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Clinical images and short video tutorials for everyone, anywhere. Ultrasound has never looked so good, see why.

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Butterfly Gallery

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Disrupting an entire industry comes with a learning curve. We've designed Butterfly Education to make this learning curve seamless. The Butterfly Education platform is a diverse video library of ultrasound education taught by experts. Learn how to evaluate dyspnea, diagnose sepsis, or perform upper extremity vein access - and so much more.
Browse

You probably know the fundamentals. Now, let's master your interpretation skills.

For you, speed is everything. Learn the ins and outs of the Butterfly iQ so you can assess confidently in seconds.

Get the basics down pat so you can thrive, as practice becomes your practice.

Your iQ membership grants you access to this evolving and ever-growing platform designed to educate, one video at a time.

Image acquisition.

While the iQ's simplicity is refreshing, its features run deep and making the most of this depth requires some knowledge. Don't worry, our image acquisition videos can teach you everything you need to know.

Image interpretation.

Our image interpretation videos will help you understand exactly what you're looking at and will instill the confidence to make decisions based on what you are capturing.

Learn more

Not a Butterfly user ... yet?

Buy now

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Disrupting an entire industry comes with a learning curve. We've designed Butterfly Education to make this learning curve seamless. The Butterfly Education platform is a diverse video library of ultrasound education taught by experts. Learn how to evaluate dyspnea, diagnose sepsis, or perform upper extremity vein access - and so much more.

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Clinical Images and Videos Library

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Clinical Ultrasound Images and Videos | US | Sonosite

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Browse ultrasound images and videos organized by practice and system in Sonosite's comprehensive Clinical Media Gallery.

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Making a massive difference in the developing world

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Rodgers Ssekawoko Muhumuza, left, checked Owamani Bruce for pneumonia with a portable ultrasound scanner in the Kabale district in western Uganda.

Global health

A hand-held device brings medical imaging to remote communities, often for the first time.

Rodgers Ssekawoko Muhumuza, left, checked Owamani Bruce for pneumonia with a portable ultrasound scanner in the Kabale district in western Uganda. Credit...

BUSHORO, Uganda - Lying on a church pew with his arm over his head, 6-year-old Gordon Andindagaye whimpered a bit - in fear, not pain - as Dr. William A. Cherniak slowly swept a small ultrasound scanner up and down his chest.

Dr. Cherniak and Rodgers Ssekawoko Muhumuza, the Ugandan clinical officer he was training, stared at the iPhone into which the scanner was plugged, watching Gordon's lung expand and contract.

"O.K.," Dr. Cherniak finally said. "What do you recommend?"

Gordon had a persistent cough and swollen lymph nodes, and looked tired and unwell. As other boys ran around outside, kicking a soccer ball made of rags and twine, he clung weakly to his mother. The scan on the iPhone's screen suggested his lungs had fluid in them.

As Dr. Cherniak nodded approval, Mr. Muhumuza prescribed an antibiotic, and ordered blood tests to rule out tuberculosis, malaria and H.I.V. He arranged for Gordon and his mother to get a ride to a local clinic for an X-ray and a night of observation.

Dr. Cherniak, an emergency medicine specialist from Canada, said he would upload the scan that evening so an ultrasound specialist in Toronto could double-check the diagnosis: early-stage pneumonia.
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The diagnosis was made possible by a new invention that Dr. Cherniak hopes will revolutionize front-line global medicine: a hand-held ultrasound scanner called the Butterfly iQ.

The Butterfly is about the size of an electric shaver. It is battery-powered and contains microchips rather than piezoelectric crystals, so it usually won't break if dropped. (That was accidentally tested a few times during a week that a reporter spent in rural Uganda with Dr. Cherniak's team.)

For Butterfly Network, the Connecticut company that makes it, the profitable target customers are doctors and nurses who can afford a $2,000 device that fits in a coat pocket and is as portable as a stethoscope.

Image

Dr. William Cherniak with a patient and other health workers. Dr. Cherniak founded Bridge to Health, a Canadian charity, which is testing the scanners in remote areas.

But the scanner also has huge potential in rural Africa, Asia and Latin America, where the nearest X-ray machine may be hours away and the only CT and MRI scanners may be in the nation's capital.

"That was my real motivation for making it," said Jonathan Rothberg, Butterfly's founder, who initially pursued the goal because one of his daughters had a disease that caused kidney cysts needing regular scans.

"Two-thirds of the world's population gets no imaging at all," he added. "When you put something on a chip, the price goes down and you democratize it."

The Bill and Melinda Gates Foundation is one of his backers, as are the investment arms of other family philanthropies.

"My team is engineers and computer scientists," he said. "We'd love to be able to save lives the way doctors do, but we can't - so every tweet from Africa about the Butterfly is an incredible adrenaline shot for us."

He has donated scanners to medical charities working in 13 low-income countries, seven of them in Africa. Several went to Bridge to Health, a Canadian charity that Dr. Cherniak founded six years ago; it works closely with Kihefo, a medical charity based in western Uganda.

For now, the scanners are primarily used to check for pneumonia, which is a major killer of children in poor countries and is frequently misdiagnosed. But Dr. Cherniak's team has found other fascinating uses for the devices - which they deployed under conditions almost as stark and dusty as those found in battlefield medicine.

Kihefo runs what might be described as a traveling medical circus. Each day at dawn, its roustabouts drive a truck loaded with collapsible tents into a different village and erect them on whatever flat ground they find - perhaps a patch of goat-gnawed grass between the school and the church.

To improvise examination tables, they borrow the wooden school desks and church pews, pad them with yoga mats and screen them with thin purple curtains.

An hour later, the Canadian-Ugandan "brigade" rolls in - vans full of doctors, nurses, dentists, chiropractors, gynecologists, ophthalmologists and pharmacists, accompanied by local clinical officers and medical students, all toting huge bags of equipment. (Yes, hockey bags - it's a Canadian charity.)

While the dental team fills cavities and the ophthalmologists check eyes, the medical team sees one patient after another, from newborns to nonagenarians.

On a recent visit to this village, the doctors used their Butterflies not just to screen for pneumonia, but to scan other organs.

Checking a large goiter on the neck of a 42-year-old woman, they learned that it was pressing on her windpipe, meaning she would soon need surgery, even though she had no breathing problems yet.

They scanned the lungs of a frighteningly emaciated baby to see if she had tuberculosis. They scanned the swollen testicle of a 54-year-old man and determined that he probably had cancer rather than their first tentative diagnosis - fluid draining from worm-infested lymph glands.

Scanning the abdomen of a child with a penis birth defect, they learned that his urine was backing up, threatening him with kidney damage - a problem that a simple operation could correct. They scanned a lump in the chest of a 96-year-old man and concluded that it was probably not cancerous because it lacked blood vessels.

Particularly challenging was the case of a 51-year-old woman with a lump on her neck. In part because she described a long history of what sounded like tuberculosis, they initially suspected scrofula.

(Scrofula - once called "the King's Evil" because medieval monarchs claimed to cure it by touch - is caused by TB bacteria clumping under the skin. )

"I went to a healer who stabbed me with fire," the woman said, describing a traditional method for draining an abscess: heating a knife in a fire and plunging it into the lump. It hurt a lot and healed nothing, she said.

Scanning the lump, Dr. Cherniak saw that it had veins, meaning it was not an abscess and appeared to be attached to a blood vessel.

"See it pulsing away?" he said to his trainee as they looked at his phone. "You don't want to go anywhere near that. If I did a biopsy, it could bleed a lot. Now I know not to muck around with it and get her to a surgeon."

Some cases remained mysterious. A knotty lump in a 70-year-old woman's thigh seemed to be neither a tumor, cyst, abscess nor fat deposit. Dr. Cherniak's best guess was that it was the broken-off tip of a stick she said she had been stabbed with decades earlier.

Through a translator, he explained that he could remove it surgically, but the procedure would be painful and the wound might get infected.

"It's like a bullet you leave if it's safer to not remove it," he said.

She decided to live with it.

Even more mystifying was a woman who appeared to be over 70 but whose belly was so swollen that she looked pregnant.

Doctor after doctor tried scanning her; the gallons of fluid in her abdomen had shoved her organs far from their customary places. Surprisingly, her liver seemed normal - doctors initially had guessed the swelling resulted from alcoholic cirrhosis.

But no one could find her spleen. "What if it's ALL spleen?" Dr. Cherniak mused. "Could it really get that big?"

Various theories - a blocked liver vein, lesions from a sand-fly parasite, a mucus-emitting tumor - were discussed. Finally, all agreed that she needed further scans that only a hospital could do.

The Butterfly's diagnostic potential is enormous, Kihefo's founder, Dr. Geoffrey Anguyo, said enthusiastically: "But the question is, how much training is adequate?"

Learning to interpret the fuzzy black-and-white images on a cellphone screen and recognize all the organs, blood vessels, valves and whatnot inside the body - and to do it well enough to spot tumors and other anomalies - is a skill that can take months to learn.

The Gates Foundation, Dr. Rothberg said, is writing software intended to guide untrained users as they scan. For now, Bridge to Health is focusing on teaching Kihefo's clinical officers, who get up to four years medical training but are not physicians, to diagnose pneumonia.

Success will be achieved, Dr. Anguyo and Dr. Cherniak agreed, when the officers' diagnoses agree with those of the ultrasound specialists in Toronto at least 80 percent of the time.

That's where another aspect of the Butterfly comes in handy: iPhones make it easy to upload scans to the internet.

In Gordon's case, a Canadian reviewer confirmed the diagnosis but said Mr. Muhumuza needed to improve his technique by holding the scanner at a sharper angle and setting it to project sound waves deeper.

Five years ago, Bridge to Health and Kihefo jointly pioneered another imaginative use for ultrasound.

Knowing how hard it is to convince rural women to visit doctors early in their pregnancies, they acquired some portable briefcase-sized scanners and then aired radio ads announcing where Kihefo would set up next the next morning.

" You will be able to see your unborn baby," they promised.

Attendance at their antenatal clinics shot up sixfold, and women who had previously seen only traditional healers began coming in.

That was important because doctors could offer many kinds of care. Problems that can kill a mother or baby can be detected and prevented early in pregnancy, including H.I.V., syphilis, vitamin deficiencies and high blood pressure.

The success of that program "was how we were able to get support from U.S.A.I.D.," said Dr. Anguyo, referring to the United States Agency for International Development.

"U.S.A.I.D. was looking for unique ways to check women aged 15 to 30 for H.I.V., and we had a very good 'trap' for catching those women," he said.

Now, with American grants for the war on AIDS shrinking, Kihefo is hunting for new ways to raise money.

One new project, Dr. Anguyo said, helps local farmers switch from raising chickens to raising rabbits. Rabbits eat grass, which costs nothing, so the profit margin is greater than for chickens, which need corn.

Kihefo encourages its farmers to eat some rabbits for protein and sell the rest to pay their national health insurance premiums.

Better pneumonia diagnosis can also slow the overprescription of antibiotics, which hastens the rise of antibiotic-resistant strains of bacteria.

Of the 91 children with fevers and coughs the team scanned in a week, only one in the village - Gordon - had confirmed pneumonia.

That, Dr. Cherniak surmised, was probably because modern vaccines against pneumonia-causing bacteria are working well.

All the children got antibiotics anyway, because Ugandan national medical protocols require a prescription for every child with high fever and cough. That's common in poor countries, where it is often impossible to get confirmatory X-rays.

(Kihefo's only X-ray machine, for example, is closed down because the charity cannot afford to build lead walls around it.)

Eventually, if ultrasound gains acceptance, the national protocols should change. "If a clinical officer can say, 'It's viral, you can go home,'" Dr. Cherniak said, "you can decrease those wrong prescriptions."

For Gordon, the prompt diagnosis worked out: a visit to the Kihefo clinic 24 hours after he started his antibiotics found him sitting up in bed, smiling and feeling much better.

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In African Villages, These Phones Become Ultrasound Scanners

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Global health A hand-held device brings medical imaging to remote communities, often for the first time. Rodgers Ssekawoko Muhumuza, left, checked Owamani Bruce for pneumonia with a portable ultrasound scanner in the Kabale district in western Uganda. Credit...

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Jonny Wilkinson well know for his love of PoCUS and has great resources on the website

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Hopefully...all that you need for critical care echo / scanning!

Please take a browse through our all new sections, consistently updated on all we think you need to know about critical care ultrasound #POCUS.

Click on the POCUS menu and take a look at each system. I have carefully selected videos and created playlists so you can basically learn the lot from other experts in the field. When you go into each playlist, click on the top left arrow to see what else is in there.

Then.....go get yourself scanning!

JW

Also check out:
Fabulous resource headed by Dr Ashley Miller Nice tutorial based site to take you through all that is POCUS! Amazing Stuff...all in 5 minutes!!
Please click here...don't know what to do with all your scans, store them and have them reviewed here!!

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Hopefully...all that you need for critical care echo / scanning! Please take a browse through our all new sections, consistently updated on all we think you need to know about critical care ultrasound #POCUS. Click on the POCUS menu and take a look at each system.

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Useful website for various techniques, including nerve blocks

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Highland EM Ultrasound Fueled pain management

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Excited to be testing out two different new SoniSare PoCUS for the next two weeks at Leeds ED.

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Excited to be testing out two different new SoniSite PoCUS for the next two weeks at Leeds ED.

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Excellent short lectures on different ED PoCUS modalities

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Clinical assessment of critically ill patients by whole-body PoCUS

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Clinical assessment of critically ill patients by whole-body PoCUS

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Comparing different studies

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focused cardiac ultrasound sound (FoCUS) in shock patients

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Abdominal and Cardiac Evaluation with Sonographyin Shock (ACES)

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Abdominal and Cardiac Evaluation with Sonographyin Shock (ACES)

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PoCUS for differential of shock

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CP/SOB/Hypotension in ED

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29/07/2019 Summary Sheet- FAFF/eFAST/Vascular access

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'Seagull' sign for coeliac axis and 'snowman' sign for the Superior Mesenteric Artery (SMA)

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The teaching and training feedback form

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Google Forms - create and analyze surveys, for free.

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For the first time, along with our wonderful sim team, we piloted sim scenarios in our level 1 course. It was very well ran and received by the candidates with excellent feedback.

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Fascia Iliaca Block Procedure-anatomical vs. ultra-sound guided!

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Fascia Iliaca Block Procedure-anatomical vs. ultra-sound guided!

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Are you dealing with a NOF#? Look no further than this excellent document.

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Fascia Iliaca Block - The two ultra-sound guided approaches!

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Fascia Iliaca Block - The two ultra-sound guided approaches!

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Traditional inguinal vs modern infra-inguinal methods

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Annually, more than 300,000 adults older than age 65 are hospitalized for hip fractures, which frequently result from ground-level falls. ¹ Emergency medical professionals are tasked with providing care and analgesia for patients with femoral neck fractures. Monotherapy with intravenous opioids can often lead to undesired complications (eg, delirium, diminished respiratory drive, and nausea). ²⁻⁴ The ultrasound-guided femoral nerve block (USGFNB) and ultrasound-guided fascia iliaca compartment block (USGFICB) offer improved pain control as well as reduced side effects in comparison with monotherapy with intravenous opioids. 4,5

Even though USGFNB has been described extensively in the emergency medicine literature, its use has not become commonplace. The perceived technical difficulty of the USGFNB may contribute to its current underutilization in acute traumatic femoral neck fractures. 6,7 However, the USGFICB may be a potentially easier technique for the novice sonographer. Evidence supporting this theory includes the technique's proven efficacy in the hands of a variety of clinicians, including resident physicians, nurses, and paramedics. ⁸⁻¹⁰

Anatomy

Sensory innervation of the femoral neck is primarily provided by articular branches of the femoral nerve with minor contributions from the obturator nerve and the superior and inferior gluteal nerves. The femoral nerve (L2-L4) and the obturator nerve (L2-L4) both transverse a compartment that spans the lower abdomen and anterior thigh and is confined anteriorly by the fascia iliaca (ie, fascia iliaca compartment). While both the femoral and obturator nerves course through the same compartment, deposition of large volumes of local anesthesia under the fascia iliaca (as with USGFICB) seldom successfully blocks the obturator nerve. ¹¹ That said, available evidence also suggests that the obturator nerve minimally contributes to distal sensory innervation. ¹²

To perform a USGFICB, two approaches exist. Both have the goal of injecting local anesthetic into the compartment lateral to the femoral nerve, which lies lateral and adjacent to the vascular bundle (see Figure 1). The two approaches are the infrainguinal (see Figure 2A) and the suprainguinal (see Figure 2B).

Supplies

1. High-frequency linear transducer (6-10 MHz) with sterile lubricant

2. 0.5% ropivacaine (5 mg/mL): dilute 30 mL 0.5% ropivacaine into 30 mL 0.9% normal saline

1. Max dose is commonly considered 3 mg/kg.

2. Ropivacaine is the preferred local anesthetic due to its long-acting duration with a greater safety profile than bupivacaine.¹³

3. Mixing of local anesthetics is not currently advised due to less predictable onset, duration, and potency.¹³

3. 22-gauge blunt-tipped echogenic needle (Whitacre and Sprotte needles are blunt-tipped needles, which provide better tactile feedback when "popping through" the fascia lata and fascia iliaca.)

4. IV tubing connected to a 30 or 60 mL syringe

5. Chlorhexidine scrub or alcohol prep sponge

6. Local anesthetic for cutaneous anesthesia (eg, 12% lidocaine without epinephrine)

7. Personal protection equipment including sterile gloves

8. Second provider present for assistance

9. Airway supplies and 20% lipid emulsion available

​With​ ​the above​ ​supplies​ ​prepared​ ​and​ ​on​ ​standby,​ ​perform​ ​a​ ​preprocedure​ ​scan​ ​to determine​ ​the patient's​ ​specific​ ​anatomy. ​Prepare ​the​ ​​selected​ ​injection​ site with chlorhexidine or isopropyl alcohol​​. A skin marker may help maintain proper orientation to the injection site. Next, flush the premixed 30​ ​mL​ ​of​ ​ropivacaine​ ​and​ ​normal saline​​ ​through​ the line and echogenic needle.

Preprocedural Nerve Block

As with any proximal nerve block, several steps should be addressed prior to beginning the procedure. First, a thorough neurological exam should be performed. Discussion with the orthopedic service at your institution is recommended before US-guided nerve blocks for hip fractures are performed. A detailed lower extremity neurovascular examination must be performed and documented. Patients should be placed on continuous cardiac monitoring and pulse oximetry to monitor for local anesthetic systemic toxicity. The risk of local anesthetic systemic toxicity (both neurological and cardiovascular) is highest in cases of unintentional intravascular injection. In addition to supportive, anti-seizure, and cardiac resuscitation measures, early administration of lipid emulsion antidote is recommended with prolonged seizure and/or any cardiac arrhythmia. Providers should be aware of Intralipid (20% lipid emulsion) availability and dosing prior to injecting large volumes of local anesthetic. ¹⁴ Lipid emulsion effectively creates a "lipid sink" where the local anesthetic is soluble with, and bound by, the lipid molecules.

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Control Hip Fracture Pain Without Opioids Using Ultrasound-Guided Fascia Iliaca Compartment Block - ACEP Now

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ACEP Now offers real-time clinical news, news from the American College of Emergency Physicians, and news on practice trends and health care reform for the emergency medicine physician. ACEP Now is an official publication of the American College of Emergency Physicians.

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International Federation of Emergency Medicine

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International Federation of Emergency Medicine

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The PoCUS curriculum in line with RCEM

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Training and Teaching Summary and consent for photograph

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The recommended book for studying and referencing