The extended Focused Assessment with Sonography in Trauma (eFAST) is a valuable diagnostic tool for quickly assessing trauma patients. It helps identify life-threatening conditions such as pneumothorax, cardiac tamponade, and intra-abdominal free fluid, which are common after blunt or penetrating trauma. Using point-of-care ultrasound (POCUS), eFAST allows healthcare providers to make rapid decisions about patient care, especially in the emergency department. What is eFAST? The FAST (Focused Assessment with Sonography in Trauma) exam was one of the earliest applications of POCUS and primarily focused on detecting free fluid in the abdomen. The eFAST exam expands on this by including an evaluation of the lungs to detect pneumothorax or intrathoracic fluid, making it an essential tool for trauma cases. A positive eFAST exam in an unstable patient can prompt immediate surgical intervention to prevent further deterioration. Key indications for eFAST: Pneumothorax: Collapsed lung that may cause breathing difficulties. Intrathoracic fluid: Accumulation of fluid in the chest cavity. Cardiac tamponade: Fluid accumulation around the heart leads to decreased cardiac output. Intra-abdominal free fluid: Blood or other fluid in the abdominal cavity, often indicating internal bleeding. Essential information about eFAST eFAST should be performed as part of the “C” (Circulation and Hemorrhage Control) in the ABC approach to trauma. eFAST can be used for both blunt and penetrating trauma, though the sensitivity in penetrating trauma improves with repeated scanning. A positive eFAST exam can indicate significant internal bleeding or trauma, which may require immediate surgery. Anatomy & fluid collection sites Intraperitoneal fluid tends to accumulate in specific anatomical locations due to gravity. These include: Morrison’s pouch: Between the liver and kidney. Perisplenic space: Around the spleen. Rectovesical pouch (in males) or rectouterine pouch (in females): Located in the pelvis, behind the bladder or uterus. eFAST examination technique  Ultrasound machine setup: Transducer: Curvilinear or […]

Deep venous thrombosis (DVT) is a serious medical condition in which a blood clot forms in the deep veins, typically in the legs. If left untreated, DVT can lead to life-threatening complications like pulmonary embolism (PE). This article presents a case study of a 52-year-old patient with DVT following recent orthopedic surgery. It outlines the steps for diagnosing and managing this condition using point-of-care ultrasound (POCUS) and clinical guidelines. A 52-year-old man presented to the emergency department with swelling and pain in his left leg, worsening over the last three days. Medical History: Recent knee replacement surgery (2 weeks ago) Obesity (BMI 33) Smoking habit (1 pack/day for 20 years) Clinical examination findings: Localized pain and asymmetric edema in the left leg. Reddish-blue skin discoloration over the calf. Mild dyspnea (shortness of breath) and discomfort in the chest, raising concerns about potential pulmonary embolism. Common risk factors for DVT: Recent surgery, especially orthopedic procedures Prolonged immobilization Cardiac conditions Hypercoagulable states (blood clotting disorders) Smoking, obesity, and use of contraceptive medications Diagnostic approach: Using POCUS to detect DVT Position the patient: Start with the patient supine with the leg extended and externally rotated. For popliteal (behind the knee) assessments, position the leg in flexion.     2. Scanning: Start at the inguinal crease with a linear transducer. Scan slowly and assess the compressibility of the vein every 1-2 cm along the femoral and popliteal areas. 3. Key locations for detecting thrombi: Common femoral vein (CFV) Bifurcation of the CFV and saphenous vein Popliteal vein Pay special attention to these regions as they are common sites for clot formation. 4. Confirm DVT: The vein’s non-compressibility is a definitive sign of DVT. In normal cases, applying pressure to the vein with the transducer should collapse it completely. If it remains open, a thrombus […]

Diaphragm ultrasound is a non-invasive, point-of-care ultrasound (POCUS) technique used to assess diaphragmatic function. This case study explores its application in evaluating diaphragmatic dysfunction in a clinical setting. Case presentation A 60-year-old woman was transferred to the ICU following an elective cardiac surgery. Her medical history included chronic obstructive pulmonary disease (COPD) and hypertension. Postoperative complications included prolonged ventilator dependency and difficulty weaning from mechanical ventilation. Physical examination The patient was alert but exhibited signs of respiratory distress, including shallow breathing and accessory muscle use. Auscultation revealed reduced breath sounds at the lung bases. There was no evidence of overt neuromuscular weakness, but diaphragmatic dysfunction was suspected. Clinical decision Given the suspicion of diaphragmatic dysfunction contributing to the patient’s difficulty in weaning from mechanical ventilation, a diaphragm ultrasound was performed at the bedside to assess the diaphragm’s structure and function. Indications for diaphragm ultrasound Difficulty in weaning from mechanical ventilation Suspected diaphragmatic paralysis or dysfunction Postoperative assessment following high-risk surgeries Evaluation of neuromuscular disorders affecting respiratory function Essential information on diaphragm ultrasound Diaphragm ultrasound provides real-time, dynamic assessment of diaphragm movement and thickness. It is a bedside, non-invasive technique that offers immediate insights into diaphragmatic function. While it complements other imaging modalities, diaphragm ultrasound is particularly useful for trending diaphragm function over time. Ultrasound machine setup Transducer: Curvilinear or phased array SCA; linear for ZOA. Preset: Abdominal Orientation: Transverse for SCA and toward the head for ZOA. Depth: 12-18 cm for SCA; 1.5-3 cm for ZOA Patient Positioning Position the patient supine with both arms at their sides. For better access to the diaphragm, slight lateral decubitus or slight upright positioning may be utilized, though reproducibility may be lower. Landmarks Clavicle: Midclavicular line Axilla: Anterior axillary line Costal Margin: Identify for transducer placement Xiphoid Process: As a reference point for […]

Transcranial Doppler (TCD) ultrasound is a non-invasive tool utilized in point-of-care ultrasound (POCUS) for assessing cerebral blood flow dynamics. This case study explores the application of TCD in detecting intracranial hypertension in a clinical setting. Case presentation: A 45-year-old male presented to the emergency department with severe headache, nausea, and blurred vision. Medical history included hypertension and a recent head trauma from a minor car accident. Physical Examination: The patient was conscious but exhibited signs of increased intracranial pressure (ICP), such as papilledema and bradycardia. Initial neurological assessment showed no focal deficits. Clinical Decision: Given the suspicion of intracranial hypertension, a TCD ultrasound was performed at the bedside to quickly assess cerebral blood flow dynamics and evaluate for raised ICP. Indications for TCD Intracranial hypertension Suspected diagnosis of cerebral circulatory arrest Vasospasm detection Identification of midline shift Essential Information on TCD TCD offers real-time information and can be performed at the bedside. It is not a replacement for CT scans but provides trending capabilities and immediate data. Functional Anatomy and Machine Setup Anatomy: Key structures include the circle of Willis and intracranial arteries. The mesencephalic plane is critical for vascular assessment. Machine Setup: Transducer: Phased array Preset: Transcranial (or cardiac) Orientation: Index marker toward the frontal bone/orbital Depth: 15 cm Patient Positioning: Patient positioned supine with the head of the bed elevated to 30 degrees. Landmarks include the ear and temporomandibular joint. Transducer placed 2-3 cm above the temporomandibular joint at the level of the temporal bone. Scanning Plane: Mesencephalic plane: Visualizes the middle cerebral artery (MCA) with red flow toward the transducer. Use pulsed wave Doppler to measure cerebral blood flow velocities. Assessment Using TCD Pulsatility Index (PI): Calculated using the formula: PI  = (PSV – EDV)/ MFV Where PSV is peak systolic velocity, EDV is end diastolic velocity, and MFV […]

Accurate evaluation of fluid status in intubated, critically ill patients is crucial for effective patient management. Both hypovolemia and fluid overload can lead to adverse outcomes. Assessing fluid responsiveness—identifying patients who will benefit from volume administration—is essential in these settings. Carotid ultrasound has emerged as a novel, noninvasive method for predicting fluid responsiveness. This systematic review aims to update the literature on carotid ultrasound’s accuracy in predicting fluid responsiveness in mechanically ventilated patients. Carotid ultrasound, also known as carotid duplex ultrasound, is a noninvasive imaging technique used primarily to evaluate the structure and function of the carotid arteries. These arteries, located on either side of the neck, are vital as they supply blood to the brain,neck, and face. Carotid ultrasound combines traditional ultrasound with Doppler ultrasound to visualize the carotid arteries and assess blood flow. In recent years, carotid ultrasound has emerged as a novel tool for assessing fluid responsiveness in critically ill patients. Fluid responsiveness refers to the ability of a patient’s cardiovascular system to respond to fluid administration with a significant increase in stroke volume. This is particularly important in the management of patients in intensive care units (ICUs) or undergoing major surgery. Mechanism Carotid Doppler Peak Velocity (CDPV): Measures the peak velocity of blood flow through the carotid artery. Changes in CDPV can indicate changes in cardiac output and stroke volume in response to fluid administration. Corrected Flow Time (FTc): Assesses the time taken for blood to flow through the carotid artery, corrected for heart rate. FTc can provide insights into the filling status of the heart and fluid responsiveness. META-ANALYSIS OF CURRENT LITERATURE Carotid Ultrasound Parameters and Outcomes Common Parameters: Corrected Flow Time (FTc) Change in Carotid Doppler Peak Velocity (∆CDPV) Change in Carotid Artery Velocity-Time Integral (∆CAVTI) Common Cardiac Output Measures: Transthoracic Echocardiography (TTE) PiCCO […]

A recent meta-analysis underscores the importance of gastric ultrasound in anesthetic practice, particularly for assessing the risk of pulmonary aspiration due to gastric contents. This study aims to establish a reliable upper limit for normal gastric antral area and volume in fasting adults, providing crucial benchmarks for safer anesthesia management. The study analyzed data from 12 primary studies conducted between January 2009 and December 2020, encompassing 1,203 subjects. It determined that the 95th percentile for antral cross-sectional area (CSA) is 9.9 cm², and for gastric volume, it is 2.3 mL/kg. These values provide a critical benchmark for identifying patients at risk of aspiration. Distribution of values of the cross-sectional area measured in the right lateral decubitus position (left) and the gastric volume (right) for all patients. The blue line indicates the median and the red line indicates the 95th percentile value based on the Harrell-Davis method and bootstrap method, respectively. CSA, cross-sectional area. Historically, the threshold for high aspiration risk was set at a gastric volume of 0.8 mL/kg, based on animal studies. However, this meta-analysis reveals that this threshold is overly conservative. The findings suggest that the median gastric volume in fasting adults is approximately 0.6 mL/kg, with the 95th percentile reaching 2.3 mL/kg. The study’s results are significant for clinical practice. They suggest that a gastric antral area of 10 cm² in the right lateral decubitus position can serve as a practical upper limit for fasting patients. Furthermore, the data indicate that an antral grade of 0 or 1 (indicating an empty or nearly empty stomach) correlates with a 98% probability of having a gastric volume below the 95th percentile, thus significantly reducing aspiration risk. This research underscores the utility of gastric ultrasound as a non-invasive tool for evaluating gastric content at the bedside, especially when a patient’s […]

A 52-year-old male patient with a long-standing history of chronic shoulder dislocations presented for elective arthroscopic shoulder surgery. Given his history of recurrent shoulder instability, the surgical team anticipated significant postoperative pain, leading them to plan an interscalene brachial plexus block for postoperative analgesia. This type of block, frequently used for shoulder surgery, is known for its effective pain relief by anesthetizing the nerves that supply the shoulder. However, a common side effect of the interscalene block is phrenic nerve paresis, which can result in diaphragmatic dysfunction or paralysis. Understanding phrenic nerve paresis The phrenic nerve is responsible for innervating the diaphragm, the main muscle involved in breathing. Because of the close anatomical relationship between the phrenic nerve and the interscalene space, there is a significant risk that the nerve could be affected during the block, resulting in diaphragmatic paralysis. This complication, while typically temporary, can reduce the patient’s respiratory capacity and lead to discomfort, especially in patients with pre-existing lung conditions or obesity. In this case, to proactively manage the risk of respiratory complications, point-of-care ultrasound (POCUS) was used to monitor the patient’s diaphragm function before and after the block. Preoperative diaphragm assessment Before the block was administered, the anesthesia team used diaphragm ultrasound to assess the baseline function of the diaphragm. The subcostal view was selected as the primary scanning window, which allows for clear visualization of the diaphragmatic excursion (the movement of the diaphragm during the respiratory cycle).  Baseline observation: Pre-block, excursions of 1 cm were measured during shallow breathing, indicating that the patient’s diaphragm was functioning properly. This baseline measurement is crucial for comparison with postoperative function to identify any potential changes. Postoperative diaphragm monitoring  Following the administration of the interscalene block and the successful completion of surgery, POCUS was again utilized to assess any changes in diaphragmatic […]

Diaphragm dysfunction can arise from several causes, but for regional anesthesia practitioners, one of the most well-known is the interscalene block. This block, commonly used for shoulder surgeries, may inadvertently affect the diaphragm, leading to dysfunction on the blocked side. Immediate, non-invasive assessment of diaphragm function is vital for ensuring optimal patient care in these cases. We are excited to announce the launch of our newest course in the Point-of-Care Ultrasound (POCUS) app: Diaphragm Ultrasound. This course is designed to empower healthcare providers with the skills to evaluate diaphragm function at the bedside quickly and accurately. Course highlights: 30+ Original illustrations and animations: Each lesson contains high-quality visuals, enhancing understanding of diaphragm ultrasound techniques. Practical learning approach: Step-by-step guides, from machine setup to interpretation, ensure a hands-on experience in diaphragm assessment. Non-invasive techniques: Learn non-invasive approaches immediately applicable in clinical settings for evaluating diaphragm function. This course delivers essential background information alongside practical skills to fully grasp diaphragm anatomy, functionality, and its importance in medical practice. Whether you’re preparing for surgery, monitoring postoperative patients, or managing ventilator weaning in the ICU, this course covers it all. Why is diaphragm assessment important? Diaphragm ultrasound is becoming increasingly relevant in various clinical settings due to its non-invasive nature, ease of use, and accuracy. It plays a critical role in: Preoperative assessment of patients at risk for phrenic nerve damage. Postoperative monitoring after high-risk surgeries, such as cardiothoracic or upper abdominal procedures. Critical care, particularly in ventilatory weaning to evaluate diaphragm atrophy or predict difficult weaning. Assessing neuromuscular disorders or respiratory diseases that may impact diaphragm function. Learning objectives By the end of this course, learners will be able to: Understand the anatomy and physiology of the diaphragm. Identify key structures in the diaphragm via ultrasound. Perform dynamic assessments of diaphragmatic function. Recognize […]

A 72-year-old patient was admitted to the Intensive Care Unit (ICU) for monitoring after traumatic brain injury. The patient is fully sedated, ventilated and requires norepinephrine for maintaining adequate cerebral perfusion pressures. He has no severe comorbidities and focused cardiac ultrasound showed normal biventricular function and valves. The patient is rather hypotensive and you are in doubt whether you should administer IV fluids.  Here’s how POCUS can be used to assess the fluid status: Obtain a clear view of the inferior vena cava (IVC) using the IVC view. Use the M-mode 2 cm distal to its junction with the right atrium or 1 cm distal to the hepatic vein. First, assess the diameter of the IVC. The size is between 1.5 and 2.5 cm.  Secondly, assess the minimal diameter and the maximum diameter with M-mode. Calculate the distensibility index: (max. diameter (Dmax) – min. diameter (Dmin))/min. diameter (Dmin) If it is >18%, this patient could benefit from fluid administration. Transform your practice with the power of POCUS using NYSORA’s POCUS App. Enhance your skills, broaden your diagnostic capabilities, and provide outstanding patient care. Experience the difference today – Download the app HERE.

A 58-year-old male patient with acute dyspnea is assessed in the emergency department using the BLUE protocol. The scan reveals no significant lung pathology (A-profile) but prompts the consideration of deep vein thrombosis (DVT). This rapid assessment aids in detecting DVT to prevent potential complications like pulmonary embolism. Here’s how you perform a DVT POCUS scan:  Position the patient supine with the leg in extension and exorotation. Start scanning at the level of the inguinal crease with a linear transducer. For the popliteal position, the leg is flexed to allow scanning of the fossa.  Slowly scan distally and assess compressibility every 1-2 cm.  It is impossible to compress a thrombosed vein.  4. Pay special attention to 5 visualization key points since these are more likely for visualizing clots.  Common femoral vein. Bifurcation of the common femoral vein and the saphenous vein. Bifurcation of the common femoral vein and the lateral perforator vein.  Bifurcation of the superficial femoral vein and the deep femoral vein. Popliteal vein.  5 key scanning points for DVT visualization. CFV, common femoral vein; GSV, great saphenous vein; SFA, superficial femoral artery; DFA, deep femoral artery; SFV, superficial femoral vein; DFV, deep femoral vein; PA, popliteal artery; PV, popliteal vein.  Transform your practice with the power of POCUS using NYSORA’s POCUS App. Enhance your skills, broaden your diagnostic capabilities, and provide outstanding patient care. Experience the difference today – Download the app HERE.

A 68-year-old woman presented at the emergency department with acute respiratory failure and fever. Lung ultrasound showed a B-profile in all four BLUE points, suggesting pulmonary edema. This prompted us to do a cardiac ultrasound.  Consecutively, a focused cardiac ultrasound was performed. The parasternal long-axis view showed a lesion suggestive of endocarditis which was then confirmed by an official cardiologist ultrasound.  Endocarditis is a serious medical condition that affects the inner lining of the heart and the valves. The causal pathogen may be bacterial but occasionally fungal or viral. Endocarditis is often diagnosed by the formation of vegetations on the heart valves or other endocardial surfaces. These vegetations can interfere with the normal function of the heart, leading to complications such as severe regurgitation, cardiac failure, stroke, or systemic infections if bacteria from the heart enter the bloodstream. Endocarditis requires prompt diagnosis and treatment with antibiotics or, in severe cases, surgery to repair or replace damaged valves. Point-of-care ultrasound (POCUS) is a valuable tool in assessing endocarditis, offering real-time imaging capabilities that aid in detecting vegetations, abscesses, and valvular abnormalities.  When evaluating endocarditis through ultrasound, distinctive pathology characteristics to observe include: Mobile lesion Hyperechoic density Endocarditis is often accompanied by regurgitation Parasternal long-axis view revealing endocarditis. LV, left ventricle; AV, aortic valve; LA, left atrium; MV, mitral valve.  Transform your practice with the power of POCUS using NYSORA’s POCUS App. Enhance your skills, broaden your diagnostic capabilities, and provide outstanding patient care. Experience the difference today – Download the app HERE.

Subclavian vein cannulation is an essential medical procedure used to access central veins for various clinical purposes. The incorporation of point-of-care ultrasound (POCUS) has significantly enhanced the precision and safety of this technique. POCUS allows healthcare providers to visualize and navigate the subclavian vein with accuracy, reducing complications and improving the overall success of the procedure. When it comes to subclavian vein cannulation, these expert tips can make a significant difference: Always identify the vein, artery, pleura and ribs before starting the procedure.  Subclavian vein cannulation carries the least risk for catheter-related infections, while femoral vein cannulation has a higher risk. In cases involving small or flat veins in intubated patients, techniques like the Valsalva maneuver or positive end-expiratory pressure (PEEP) can enhance vein distention, simplifying the cannulation procedure. Always augment your ultrasound-guided subclavian vein cannulation with a lung ultrasound together with a quick cardiac ultrasound to check for the rapid atrial swirl sign (RASS). This will allow you to rule out pneumothorax and confirm the position of the catheter insertion. Transform your practice with the power of POCUS using NYSORA’s POCUS App. Enhance your skills, broaden your diagnostic capabilities, and provide outstanding patient care. Experience the difference today – Download the app HERE.