990917_急診超音波介紹(ntuh-er)
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EUS (Emergency Ultrasound)
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50M, MVA patient, HR 130bpm, BP 70/40 Internal bleeding ?
85M, sudden onset right flank pain, 8/10 Renal colic or AAA ?
48F, RUQ pain with fever Cholecystitis ?
28F, low abdominal pain with shock, EIA (+) Ectopic pregnancy ?
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Aloka SSD 900 Toshiba Nemio
Troubleshooting Printer ?
Hyperechoic Hypoechoic
Isoechoic Anechoic
Acoustic shadow:
Lateral shadow:
Acoustic enhancement:
(artifacts)
: &
:
Landmarks of the chest wall Lung surface: 1500cm2 Position: as stethoscope 9 areas Anterior zone (1-4) Lateral zone (5,6) Posterior zone (S,M,L)
4 stages 1. anterior 2. lateral 3. portion of posterior 4. posterior
Landmarks of the chest wall Lung surface: 1500cm2 Position: as stethoscope 9 areas Anterior zone (1-4) Lateral zone (5,6) Posterior zone (S,M,L)
4 stages 1. anterior 2. lateral 3. portion of posterior 4. posterior
: 62.310.3 mm : 20.3 5.1 mm : < 2 mm (: 4~7 mm)
: a 40.87.8mm b 30.66.8mm c 83.610.6mm Spleen index a * b > 20 cm2 c * b > 30 cm2
: 25mm 14mm
: :
2 mm
15mm
: 10.2 9.6 cm : 4.2 6.9 cm
: 10.6 9.8 cm : 4.8 6.2 cm
* * * 0.75 Error 15~30 %
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()
Normal Landmark Bat sign
Rib
Pleural line A-line
Normal dynamic lung pattern Lung sliding: all-or-nothing rule Seashore sign
Rule out pneumothorax
ACEP 2008 EUS guidelines
Ann Emerg Med. 2009;53:550-570
EUS (Emergency Ultrasound)Hx & PEimpression EUSYes or No
EUS EUS EUS (Binary thinking)EUS
EUS EUS
(yes-no) EUS
(yes-no)AAA
(FAST)
free fluid
/
DVT
effusion
pericardial tamponade
(FAST)
(AAA)
(Hydronephrosis)
(Cardiac Arrest)
EUSProblem or Symptom-oriented
in the Evaluation of the Critically l l l Step 1: The pump Step 2: The tank Step 3: The pipesEmerg Med Clin N Am 28 (2010) 2956
Rapid Ultrasound in SHock
The RUSH Exam
RUSH Step 1: Evaluation of the PumpA. Parasternal views Long/ short axis
B. Subxiphoid viewC. Apical view
RUSH Step 1: Evaluation of the Pump Effusion around the pump evaluation of the pericardium
Squeeze of the pump determination of global left ventricular function
Strain of the pump assessment of right ventricular strain
Emerg Med Clin N Am 28 (2010) 2956
RUSH Step 2: Evaluation of the TankA. IVC long axis B. FAST/RUQ Add pleural view Add pleural view
C. FAST/LUQD. FAST/Pelvis E. Pneumothorax Pulmonary edema
RUSH Step 2: Evaluation of the Tank Fullness of the tank evaluation of the inferior cava and jugular veins for size and collapse with inspiration
Leakiness of the tank FAST exam and pleural fluid assessment
Tank compromise pneumothorax
Tank overload pulmonary edemaEmerg Med Clin N Am 28 (2010) 2956
RUSH Step 3: Evaluation of the PipesA. B. C. D. E. F. Suprasternal aorta Parasternal aorta Epigastric aorta Supraumbilical aorta Femoral DVT Popliteal DVT
RUSH Step 3: Evaluation of the Pipes Rupture of the pipes aortic aneurysm and aortic dissection
Clogging of the pipes venous thromboembolism
Emerg Med Clin N Am 28 (2010) 2956
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W4 (Hand-on practice)
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SKH-EUS schedule : EUS(1) &
: EUS--(2)(9)
: EUS--(11)(20)
: EUS_Challenging cases & Journal Reading
Hand-on Practice1. Describe 2. Demo 3. Do3
1
2
: 1. 2. 3. 4. 20 (1, 2,3) : :
(A)1. (10 positive exam 10%) 2. (10 positive exam 10%) 3. (FAST) (10 positive exam 20%) 4. (10 positive exam 20%) 5. (10 positive exam for IUP & FHB 20%) 6. (10 positive exam for obstructive uropathy & urinary retension 20%) 7. (10 positive exam 10%) 8.US-assisted paracentesis or thoracentesis ((10 )
(B) 1.Liver tumor 2.Pneumobilia 3.PVT thrombosis 4.Unexplained jaundice 5.Cardiac activity during CPR 6.Global LV systolic function evaluation 7.Intravascular volume status evaluation (IVC) 8.US-assisted pericardiocentesis 9.Evaluation of hematuria 10.Evaluation of acute renal failure 11.Renal cyst and tumor 12.Pneumothorax 13.Solid organ injury 14.GI-tract: target sign or pseudokidney sign 15.GI-tract: bowel obstruction 16.Soft tissue abscess evaluation and drainage 17.Soft tissue foreign bodies evaluation 18.Joint effusion evaluation and drainage 19.US-assisted lumbar puncture 20.Ovarian cyst 21.Myoma uteri 22.
1. 2. 3. ( )
(Basic EUS) 4 : 1:4 Workshop (4) 1. 2. 3. 4.
(Advanced EUS) 16 ; : 1:4Day 1Lecture 1. (40 min) 2. (50 min) 3.( )(50 min) 4. (50 min) 5. (50 min) Day 1Workshop 1.Abdominal US (1 hr) 2.Chest US (1 hr) 3.Echocardiaography (1 hr) 4.Thoraco-abdominal trauma (1 hr) Day 2 Lecture 1. (50 min) 2. (50 min) 3. (50 min) 4. (50 min) 5. (40 min)
Day 2: Workshop 1.Shock screening (1 hr) 2.AAA & DVT assessment (1hr) 3.Peidatric and OB/GYN assessment (1 hr) 4.Clinical applications for procedures (1 hr)
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-Novice
-Emergency Medicine
-Emergency Medicine
-Critical Care
Take Home Message Hx & PEimpression Yes or No
JUICE BAR [email protected]