Emergent Ultrasound Procedures

Chapter 19

• 🧰 Sonography = Powerful & efficient
  It's a super helpful tool for checking what's wrong with patients in the emergency room — fast and effectively!

• 📦➡🩺 Smaller machines = more flexibility
  Thanks to smaller ultrasound equipment and better technology, sonography isn’t just stuck in imaging departments anymore — it’s now common in the ED too!

• 🎓📚 Better training = more use
  Changes in medical training for emergency doctors and specialists have helped make ultrasound a key part of emergency care.

• ⏱⚡ Quick decisions = better outcomes
  In emergencies, the team has to act fast — sonography helps them figure out what’s wrong quickly and accurately.

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🚨 Common Reasons People Visit the ED

• 🚗💥 Trauma (like car accidents)

• ❤🔥 Chest pain

• Trouble breathing

• 🩸 Low blood pressure (hypotension)

• 🤢🤮 Bad nausea & vomiting

• 😵 Passing out (syncope)

• 😖 Belly or pelvic pain

• 🪓 Cuts/lacerations

• 🦴 Broken bones

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🩻 Sonographer’s Role in Emergencies

• 📞 "Call-back" situations
  You might get called in to perform an ultrasound after a quick check by the ED team.

• 🩺 Formal or complete scans
  If doctors need a more detailed look, that’s where you come in with your sonography skills!

• ⚠ Critical conditions sonography can help with:

  • 🤕 Internal bleeding from trauma

  • 👶 Ectopic pregnancy

  • 💓 Fluid around the heart (pericardial tamponade)

  • 💥 A ruptured aortic aneurysm

🏥 Sonography in the Emergency Department (ED)

• 🚑 Blunt abdominal trauma is common
  Doctors often have to check if a patient has internal injuries after a hit or blow to the belly (like from a car crash or fall).

• ❓ Hard to tell just by looking
  Physical signs (like bruising or pain) aren’t always reliable — especially if the patient:

  • Is unconscious

  • 🧠 Has brain or nerve issues

  • 💊 Is on meds that hide symptoms

  • 🤕 Has other serious injuries

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So basically: doctors need extra help (like sonography!) to figure out what’s going on inside the belly because the outside doesn’t always show the full picture. 🧠🔍🩺

Assessment of Abdominal Trauma

• 🕵‍♀️ What is DPL?
  It’s a test that checks for internal bleeding or organ damage in the belly after blunt trauma.

• 🧍‍♂ Who gets it?
  Used for patients when doctors weren’t sure if they needed surgery (exploratory laparotomy).

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🛌 How the Procedure Works

1. 😴 Patient lies flat (supine)

2. 🚽 Bladder is emptied with a catheter

3. 🤢 Stomach is emptied using a nasogastric (NG) tube to avoid pushing on the belly

4. 💉 Skin is numbed (anesthetized)

5. ✂ A small cut is made in the middle or near the belly button

6. 🧵 Doctors go through several layers to reach the peritoneal cavity (inside the belly)

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⚠ Risks of DPL

• 🕒 Takes about 10–15 minutes

• ⚔ Risk of:

  • Bowel injury

  • Bladder puncture

  • Blood vessel cuts

  • Wound problems

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🚫 Why It’s Not Ideal Today

• 🙅‍♂ Too invasive for most patients (especially alert, stable ones)

• 💨💦 It can mess up future ultrasound or CT results by adding air or fluid into the belly

🧪 Diagnostic Peritoneal Lavage (DPL)

• 📏 CT = the go-to imaging test
  It’s still the gold standard for checking injuries in the abdomen.

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🛑 But there are some downsides:

• 🚚 Patient has to be moved — can’t do it at the bedside

• ⏳ Takes time, especially if bowel prep is needed

• 🚫 Not safe for unstable patients (they need faster, on-the-spot options)

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When CT is used:

• 🤔 When doctors really suspect something’s wrong inside

• 🤷‍♀ When the exam isn’t clear but the patient seems stable

• 😣 If there’s ongoing belly pain

• 📉 When hematocrit drops (sign of internal bleeding)

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✅ Why CT is helpful:

• 🔍 It’s very accurate (high sensitivity & specificity)

• 💧 Great at spotting fluid collections (like blood or other fluids)

💻 Computed Tomography (CT)

• 🌍 Started in Europe & Asia in the 1970s

• 🇺🇸 Came to North America & the UK in the 1990s
  (Took a little longer to catch on!)

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🔧 Why it became popular:

• 🧳 Ultrasound machines got smaller & better
  = easier to use in emergency settings!

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🚑 Why sonography is awesome in emergencies:

• ⚡ Fast — takes less than 4 minutes

• 🎯 Accurate

• 🏃‍♀ Portable — go anywhere the patient is

• 😌 Noninvasive — no needles, no surgery!

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📉 Downsides:

• 💨 Air in the belly (subcutaneous or intra-abdominal) makes images harder to see

• 🍔 Obesity can reduce image quality

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🏅 Still a top choice today!

• 🔁 Can be repeated easily if needed

• 🩻 Helps image many parts of the body — not just the belly!

🌀 Ultrasound for Blunt Abdominal Trauma (BAT)

• 🔍 FAST = quick ultrasound exam
  It’s a focused check of the belly, pelvis, and around the heart to look for free fluid (like blood).

• 🏥 Who performs it?
  Done in the ED by trained and certified staff (very important for accuracy!).

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⚠ Why FAST is so important:

• 💔 Helps spot life-threatening bleeding (hemorrhage)

• 🏃‍♂ Timely diagnosis = fast decisions

  • Should the patient go to surgery?

  • Head to the CT scanner?

  • Go to the angiography suite?

✅ FAST Exam Key Areas:

1. Pericardium (around the heart)

2. Abdomen (look for blood or fluid)

3. 🫃 Pelvis (check for internal bleeding)

🚑 FAST Ultrasound Surve:

• 🌍 FAST Ultrasound Area:

  • Pericardial sac (around the heart)

  • 💧 Urinary bladder

  • 🍗 Perihepatic area (liver and Morison’s pouch)

  • 🍉 Perisplenic region (spleen area & splenorenal recess)

  • 🍴 Paracolic gutters (sides of the intestines)

  • 🏖 Cul-de-sac (area behind the uterus)

• 👀 What’s checked?

  • Visceral organs (organs inside the body) for any irregularities

  • 🔴 Color Doppler may be used to check blood flow if needed

⏱ Why FAST is so Fast and Effective:

• ⚡ Quick to perform — so it’s perfect for trauma situations

• 👨‍⚕ Best when done by trained ultrasound techs who know what they’re doing

• 📍 Onsite testing = fast decision-making!

🚧 Limitations of FAST:

• 👨‍⚕ Operator skill matters — results depend on who’s doing the ultrasound

• 🏋‍♀️ Body size can affect image quality

  • If the patient is larger, it may be harder to see everything clearly

• ❌ CT is still better for some scans (intraperitoneal & retroperitoneal issues), but it’s not available bedside

🚑 Focused Assessment with Sonography for Trauma (FAST)

• ⏱ Fast exam!

  • Takes less than 4 minutes 🕓

  • Done simultaneously with physical check and patient stabilization

  • Looks for free fluid or hemoperitoneum (blood in the abdomen)

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🩺 What’s Checked During the Ultrasound:

• Four quadrants of the abdomen

  • Check the pericardial sac (around the heart) ❤

  • Check the cul-de-sac (pelvic area) 🍑

  • Right and left upper abdomen 🏃‍♀

  • Epigastrium (top part of abdomen) 🥞

  • Retroperitoneal space (behind abdominal organs) 🏙

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📋 How the Ultrasound Is Done:

• Patient position: Usually supine (lying down) 🛏

• Transducer use: Different size transducers based on patient size 🎛

• Bladder check: Filled with 200-300 mL sterile saline to help with pelvic scan 💦

  • Goal: Check for free fluid, organ texture, and heart sac ❤

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🔍 What the Ultrasound Looks For:

1. Free Fluid:

   • Usually hemoperitoneum (blood) 🩸

   • Could also be bowel, urine, bile, or ascitic fluid (fluid build-up) 💧

2. Hypoechoic or Hyperechoic Fluid:

   • Fluid may look dark or bright with scattered echoes, showing blood inside 🩸

3. Where Fluid Collects:

   • Most common area: Subhepatic space (Morison’s pouch) 🧠

   • Next common area: Pelvic cavity 🍑

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⚠ What Happens If Fluid Is Found:

• Small fluid collection:

  • The surgeon might not do immediate surgery 🛑

  • Instead, they’ll monitor with ultrasound or CT 🩻

• Massive fluid collection:

  • Organs float in the fluid 🌊

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🏥 Why It Matters:

• Quick and non-invasive — super helpful in emergencies!

• Helps doctors decide if surgery is needed 🔪

• Gives immediate info on internal bleeding or injury!

🚑 Blunt Trauma Ultrasound Assessment

🩸 Hepatic and Splenic Injury Detection with Ultrasound:

• Liver Injuries:

  • Lacerations or contusions are easily detected with ultrasound.

  • Appear as heterogeneous (uneven) or hyperechoic (brighter) areas 🩻

  • Hematomas (blood clots) and localized lacerations:

    • Initially hypoechoic (darker) due to red blood cells 🩸

    • Then echogenic as blood clots or coagulates 💥

    • Eventually, they become anechoic (no echo) as blood breaks down over time

• Splenic Injury:

  • Appears as diffusely heterogeneous parenchyma (liver or spleen tissue).

  • Both hyperechoic and hypoechoic regions are seen.

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🚨 Pitfalls of Abdominal Ultrasound:

• Limitations include:

  • Missed injuries to organs like:

    • Diaphragm, pancreas, adrenal glands, and some bowel injuries.

  • Negative ultrasound doesn’t rule out injury; clinical observation or CT is still needed.

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🔍 Types of Parenchymal Injuries in Ultrasound:

• Intraparenchymal Hemorrhage (Bleeding inside the organ):

  • Appears as anechoic (dark) regions within the parenchyma (tissue of the liver or spleen) 🩸

• Global Parenchymal Injury:

  • The normal vascular pattern in the liver is absent and shows widespread disruption of liver tissue.

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🏥 Impact of Early Diagnosis:

• Splenic Injury:

  • If hemoperitoneum (fluid in the abdomen) is seen and there’s a clear splenic injury, surgery may be performed directly.

• Hepatic Injury:

  • Extensive liver injury may need further investigation (like CT or angiography) before surgery 🔬

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🍑 Free Pelvic Fluid in Women:

• Women of reproductive age:

  • Fluid in the cul-de-sac (space in the pelvis) is likely normal (physiologic) and just needs follow-up.

  • Fluid elsewhere in the abdomen might indicate important injury that requires further evaluation.

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🚫 Limitations of Ultrasound in Trauma Assessment:

• Obesity can block proper viewing of internal structures.

• Subcutaneous emphysema (air under the skin from injuries like pneumothorax) may affect imaging.

• Intraperitoneal clots may appear hyperechoic (bright) but sometimes may be isoechoic (same brightness), making it harder to detect.

• Contained parenchymal injuries (like liver or spleen) and bowel injuries may not have visible free fluid and could be missed if only ultrasound is used.

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🔍 Summary:

• Ultrasound is excellent for detecting liver and spleen injuries, but has limitations for identifying injuries to other organs (pancreas, diaphragm, bowel).

• Close monitoring or CT is needed in many cases for better clarity and diagnosis.

Parenchymal Injury Overview with Ultrasound 📉

• Common complaint in the ER: sharp pain in the right upper abdomen 💥

• Can be due to various causes, such as:

  • Diabetes or peptic ulcer disease 🏥

  • Heart attack (MI) 💔

• Important to consider the patient’s history and do a thorough physical exam 👩‍⚕

Right Upper Quadrant Pain

• Female patients with right upper quadrant pain 😖, fever, tenderness, and elevated white blood cells 🦠: likely acute cholecystitis

• Most common cause: Cholelithiasis (gallstones) blocking the cystic duct

Acute Cholecystitis vs. Cholelithiasis

• Irregular, thickened gallbladder wall 🏰 (gallbladder looks inflamed)

• Positive Murphy sign (pain when pressing on the gallbladder area) ⚠

• Sludge (thick, gooey bile) 🛢

• Pericholecystic fluid (fluid around the gallbladder) 💦

• Dilated gallbladder > 5 cm (bigger than usual) 📏

Sonographic Findings of Acute Cholecystitis

• Echogenic foci (bright spots) inside the inflamed gallbladder ✨

• Acoustic shadowing (dark shadow behind the stones) 🌑

  • Make sure the shadow is from the stones, not nearby bowel gas 🍽

• If the stones are small, they can get stuck at the gallbladder neck 😵

• Cholesterol stones:

  • Smaller and less echogenic (don’t show up as bright)

  • Can cause a comet tail artifact (a tail-like appearance) 🚀

Gallstones on Ultrasound

• Common Bile Duct (CBD) is easy to spot on ultrasound 🏞

  • Find the portal vein: The CBD is to the right and anterior (in front) of it 👀

• Hepatic artery is in front and slightly to the left of the portal vein 🩸

• Normal CBD size: Up to 6 mm 📏

  • Can increase to 10 mm with age 🧓

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Looking for Stones in the CBD:

• Check for echogenic foci (bright spots) inside the duct ✨

• These stones will cause acoustic shadowing (a dark spot behind them) 🌑

• Adjust gain on ultrasound to get a clear view 🔧

• Change the patient’s position to avoid interference from bowel gas 🏃‍♀💨

Biliary Dilation

• Pain Location:

  • Midepigastric pain that radiates to the back 🏥💥

  • Classic sign of acute pancreatitis 🔥

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What Happens in Pancreatitis?

• Toxic enzymes leak into the pancreas tissue 🧪💣

• This causes inflammation and blockage in the ducts, blood vessels, and fat 🛑

• Peripancreatic tissue (around the pancreas) can also become inflamed 💔

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Clinical Findings 👩‍⚕

• Fever 🌡

• Leukocytosis (high white blood cell count) ⚪

• Elevated enzymes in the blood 🩸

  • Amylase spikes within 24 hours ⏳

  • Lipase spikes after 72 hours and stays higher longer 🕒

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Ultrasound Findings (What We See on the Screen!) 👀

• Pancreas looks normal to swollen (edematous) 📏➡📈

• It may be hypoechoic (darker) compared to normal tissue 🌑

• Irregular borders due to inflammation 🌀

• Increased blood flow around the pancreas (shows as more color on Doppler) 💉

Pancreatitis (Epigastric Pain)

• Symptoms:

  • Abdominal pain that radiates to the back 💥➡🦵

  • Hypotension (low blood pressure) ⬇

  • Pulsatile abdominal mass (can feel a heartbeat-like pulse in the belly) 💓

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What to Look for in the ED? 👩‍⚕🏥

• Sonography helps separate:

  • Aortic dissection (tear in the aorta) 🚨

  • Vague abdominal complaints 🩻

  • Symptoms that might look like kidney stones 💎

• If dissection is suspected, CT with contrast is more specific because it shows the whole aorta clearly 💻

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Ultrasound Findings 📊🔍

• Locate aneurysm near the renal vessels (kidney arteries) 🔄

  • Aneurysms can extend into these vessels if a dissection happens 🚨

• Measure the aorta:

  • Measure the outside wall-to-wall diameter in two planes:

    • Transverse (side-to-side) ↔

    • Longitudinal (top-to-bottom) ⬆⬇

• Most aneurysms occur near the umbilicus (belly button) 🌍

• Aneurysms can grow in:

  • Transverse diameter (side-to-side) ↔

  • Anterior-posterior diameter (front-to-back) ↕

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Challenges & Pitfalls 🧐💥

• Obesity or bowel gas can block a clear view 🏋‍♀️💨

  • Try imaging from lateral abdominal wall (using the liver or spleen as a "window" 🌟)

• Positioning: If needed, the patient can be rolled to a decubitus position (on their side) for a better view 🔄

• Measurement tip: The transducer should be perpendicular to the vessel to avoid inaccurate sizing 📏

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Important Things to Know! ⚠💡

• A small aneurysm can still rupture — it’s important to assess carefully ⚡

• Free fluid in the belly (intraperitoneal fluid) should be checked for, especially in acute cases 💧

• Paraaortic nodes may look like aneurysms but they don’t have blood flow 🚫

Abdominal Aortic Aneurysm (AAA) 🩸💥

• What is it?

  • Fluid builds up in the pericardial sac (the lining around the heart) 🫣💦

• How to Detect?

  • Cardiac ultrasound is used to rule out pericardial effusion or check heart function during emergencies 🚑

• Who’s Affected?

  • Body habitus (how someone’s body is built) and other health conditions can make it harder to see the heart on ultrasound 🏋‍♂️

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Types of Fluid & Appearance 👀

• Normal Fluid:

  • Appears anechoic (black on ultrasound) or hypoechoic (gray) 🖤⚫

• Abnormal Fluid:

  • Fluid with inflammation, cancer, or bleeding can have more complex textures 🩸🦠

• Where does the fluid collect?

  • Fluid usually starts in the lowest part of the heart (depends on gravity) ⬇

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Measuring the Effusion 📏

• Small effusion (<1 cm):

  • Can only be seen posteriorly (back side of the heart) 🔙

• Moderate effusion (1-2 cm):

  • Fluid is circumferential (around the heart) 🌍

• Large effusion (>2 cm):

  • Fluid is extensive and may affect heart function 🚨

• Check in multiple views:

  • Parasternal long axis, short axis, apical four chamber, and subcostal views 🔄

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Distinguishing from Pleural Effusion 🩺

• Pleural effusion (fluid around the lungs) can look similar to pericardial effusion! 🤔

  • Pericardial effusion is anterior (in front of the aorta) 🫣

  • Pleural effusion is posterior (behind the aorta) 🫨

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Cardiac Tamponade & Other Emergencies ⚠

• Cardiac Tamponade:

  • A severe fluid buildup that compresses the heart and can be life-threatening 💔🚨

  • Right heart chamber collapse during diastole (when the heart relaxes) is a key sign 😱

• What to do?

  • Doppler to check blood flow changes 🩸

  • Inferior vena cava (big vein) checked for dilation 🧠

• Pulsus tardus:

  • A slow pulse seen in tamponade cases (heart’s having trouble pumping) 🕒

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Trauma & Hemopericardium 🩸🚑

• Hemopericardium (blood in the pericardial space) can occur after trauma 🚗💥

  • Blood will look echogenic (brighter) compared to the heart muscle 🩸🖤

• Fatty tissue around the heart might look like effusion, but it’s just fat 🐮🍔

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Fast-Forming vs. Slow-Forming Effusions ⏳⚡

• Rapidly forming effusion (small) can cause tamponade quickly 🏃‍♀💨

• Large, slow-forming effusion might be tolerated with minimal symptoms 😌

Pericardial Effusion Overview 💧

• Definition:
  A tear in the aorta's lining (intima) causes blood to flow between the layers of the vessel, creating a false lumen (a blood-filled space) 🩸💔

• Where does it happen?

  • 70% in the ascending aorta (part closest to the heart) 💓

  • 10-20% in the aortic arch 🌉

  • 20% in the abdominal aorta (lower part of the aorta) 🌾

• How it spreads?

  • Most dissections spread downward to iliac vessels (lower body), but they can also extend upward ⬆⬇

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Clinical Symptoms (How It Feels) 🚨

• Pain:

  • Sudden, severe chest pain that feels like tearing 💥

  • Pain radiates to the arms, neck, or back 💪🦸‍♀

• Other Signs:

  • Syncope (fainting) in some cases

  • If the carotid artery is involved, it can cause hemiplegia (paralysis on one side) 🧠🚶‍♀

  • Decreased pulses if subclavian or iliac arteries are affected (weak arms/legs) 🙌🦵

• Pain Location Clues:

  • Anterior thorax pain = proximal dissection (close to the heart) 💔

  • Interscapular (between the shoulder blades) pain = distal dissection (farther from the heart) 💥

  • Back pain = distal dissection 🦋

  • Abdominal pain = could indicate visceral artery occlusion (blockage of arteries to organs) 🤕

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Sonographic Findings (What We See on Ultrasound) 👀💻

• Most common area to see it:
  The ascending aorta is where most dissections happen 🚀

• What do we look for?

  • Flap: A moving echogenic intimal membrane (the flap) visible in the aorta or iliac arteries 🌊

  • False lumen: The blood in the false lumen may move freely if both lumens (true and false) are open 💧

• What happens if the flap is thick?

  • The membrane might not move, and the lumen can become thrombosed (clotted) 🩸🛑

• Using Color Doppler:

  • Flow in the false lumen is usually slow or reversed (blood moving in the opposite direction) 🩸🔴

What is Aortic Dissection? ⚡

• What’s a pseudodissection?

  • A blood flow pattern that looks like a dissection but doesn’t have a flap 🙅‍♂❌

  • Hypoechoic thrombus (dark clot) forms near the aorta's outer layer 🖤

  • No intimal flap is seen 👀

Pseudodissection (Fake Dissection!) 😳

• A fancy name for kidney or urinary tract stones 💎.

• Causes flank pain (side of your body, between ribs and hip) 😣.

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🩻 How Doctors Check for Stones

• CT scan (noncontrast helical) = best at finding stones 🔍📸.

• IVU (Intravenous Urography) also good, but uses dye 🧪.

• Ultrasound is used if CT or IVU aren’t safe (like pregnancy 🤰 or allergies 🚫).

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💥 Symptoms to Watch For

• Renal colic = sharp, wave-like spasms of pain 🌀.

• Pain often starts suddenly in the flank 😵.

• May spread to lower abdomen, groin, scrotum, or labia 🧭.

• Needs strong pain meds sometimes 💊💤.

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🧪 Lab Tests

• Urinalysis shows blood in urine (85% of the time) 🩸.

• No blood? It might be a fully blocked ureter 🚫💧.

• Fever, high white blood cells (WBCs) = possible infection 🦠.

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🧿 Ultrasound Findings

• Stones look like bright (echogenic) spots with dark shadows behind them ⚫✨.

• Can see tiny stones, even as small as 0.5 mm!

• If the ureter is blocked → shows hydronephrosis (kidney swelling) 🚰🔄.

• Gas in the bowels can hide the lower ureter 😑💨.

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🎨 Doppler Ultrasound Tricks

• Look for "ureteral jets" – tiny spurts of urine into the bladder 🚿.

• Use color Doppler: Wait 2–3 mins and jets should appear 💦🌈.

• Both right and left ureters should show jets (check both sides!) 👀➡⬅.

• Power Doppler is also great for detecting the jets ⚡🔍.

🧍‍♂ What is Urolithiasis?

• During late pregnancy, it’s common for kidneys to look slightly swollen (hydronephrotic) 🫣.

• This happens because the growing uterus presses on the ureters 🚼➡🧵.

• Right kidney is affected more often because:

  • It sits lower than the left 👇🏽.

  • So it gets more pressure from the uterus .

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🧪✨ How to Tell If It’s a Problem

• Since mild hydronephrosis is normal in pregnancy, how do you check for a stone (obstruction)? 🧐

• Use color Doppler to look for ureteral jets (urine flow into the bladder) 🚿🌈.

• Seeing the jets = ureters are working ✅ = No blockage!

• No jets = possible stone or obstruction 🚫💧.

🤰💧 Hydronephrosis in Pregnancy

• Acute appendicitis = inflamed appendix 😖🔥

• Caused by blockage in the appendix (often poop, infection, or lymph tissue) 🚫🧻

• Leads to swelling, reduced blood flow, and possible bursting (perforation) 💣😬

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👧👦 Who Gets It?

• Most common surgical emergency in kids age 2+ 🧒👦🧑

• Can happen to anyone, any age

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🩹💢 Classic Symptoms

• Pain in the lower right belly ➡⚡️

• Nausea & vomiting 🤢🤮

• Fever 🌡

• High white blood cells (leukocytosis) 🧪

• Rebound tenderness (McBurney's sign) = hurts more when you let go than when pressing 😣👆

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🔍💻 Ultrasound Tips

• Use a high-frequency linear probe 📡🔎

• Be gentle—the area is very tender 👐😖

• Apply gradual pressure to move bowel out of the way and see the appendix

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🧽🌀 What You’ll See on Ultrasound

• Appendix wall > 2 mm thick = likely inflamed 🧱🔥

• Target sign on cross-section 🎯 (hypoechoic center = fluid, bright ring = mucosa, dark outer ring = muscle)

• No peristalsis and non-compressible (unlike normal bowel) 🚫🌀

• If asymmetric wall or fluid nearby → could mean rupture and need to check for abscesses 💧🦠

⚠📍 What is Appendicitis?

• Happens when abdominal wall is weak ➡ organs (viscera) push through

• Paraumbilical hernia = near the belly button 🎯

• More common in women

• Inguinal hernia = in the groin area ⚽

• More common in men 🧔

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🔁 TYPES OF HERNIAS

1. Reducible ➡ contents can go back in ✅

2. Incarcerated ➡ contents are stuck 🚫

3. Strangulated ➡ stuck + blood flow blocked ❌🩸 = emergency!

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🧬 CAUSES OF HERNIA

• Congenital (born with it) 👶

• Weak muscles 🏋‍♂️❌

• High belly pressure (from obesity, pregnancy, ascites, masses) 🧸🤰⚖

• Repeated pregnancies or surgeries 🔁🔪

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⚠ COMPLICATIONS

• Strangulation ➡ cut-off blood flow 🚫🩸

• Rupture in severe ascites 💧💥

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📸 SONOGRAPHIC FINDINGS

• See bowel moving inside the hernia 🌀🩻

• Check during Valsalva maneuver (bear down like pushing 💨) 😤

• Look for:

  1. Anterior wall defect 💢

  2. Bowel loops inside sac 🔄

  3. Sac gets bigger with Valsalva ➕

  4. Contents can return with gentle push 🤲✅

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🔬 WHAT YOU'LL SEE ON SCREEN

• Colon = fluid + gas + movement 🌊💨🌀

• Omentum and fat = very bright (echogenic) ✨

• Use high-frequency linear probe 🎯🔎

• Lower gain to see the layers clearly 📉🔍

• Use color Doppler to check blood flow in sac 🌈🩸

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⚔ INGUINAL HERNIAS

Indirect (🚶‍♂ follows path of spermatic cord)

• Goes through inguinal canal

• Enters at deep inguinal ring

• Found lateral to inferior epigastric vessels

• Usually congenital or injury-related 👶⚠

Direct (📍bulges directly out)

• Pushes through weak fascia

• Found medial to inferior epigastric vessels

• Rarely goes into scrotum ❌🍒

• Common in older men 👴

💥 WHAT IS A HERNIA?

😖

• Happens often in the middle of the night 🌙🛌

• Patients show up at the ER in serious pain 🚑😩

• Sonographer's job = find the cause fast! ⚡🔍

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🔥 POSSIBLE EMERGENCIES TO LOOK FOR:

• Tubo-ovarian abscess (infection-filled sac) 🦠💥

• Ruptured ovarian cyst 💧💔

• Ectopic pregnancy 👶❌

• Ovarian torsion (twisted ovary) 🔄🛑

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🩻 SONOGRAPHY MODES

1. Transabdominal (TA) – bladder full 💦, gives a big picture 🖼

2. Transvaginal (TV) – bladder empty 🚽, gives close-up detail 🔬

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🏰 UTERUS CHECK

• Should look smooth and even 🎯

• Center line = endometrial canal ➖

• Check from fundus to cervix 🔄

• Look for:

  • Fibroids = pain & bleeding 😖🩸

  • Interstitial pregnancy = near edge of uterus wall 🧱👶 (danger zone!)

  • Normal pregnancy = sac high in cavity 🎈👶

  • Fetal heartbeat = use TV ultrasound ❤👶

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🌊 CUL-DE-SAC (a fluid trap!)

• Small fluid = normal, varies with cycle 🩸📆

• Too much fluid = 😱 Could be:

  • Ruptured ectopic 💥👶

  • Pelvic inflammatory disease (PID) 🦠🔥

  • Ascites or trauma 💧⚠

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🥚 OVARIES

• Best seen with TV ultrasound 🔬

• Look for:

  • Cysts 🎈

  • Ectopic pregnancy 🚫👶

  • Masses or enlargement 🔍

• Torsion signs = big swollen ovary + low/no blood flow 🩸❌

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🧪 FALLOPIAN TUBES

• Also best with TV ultrasound 🎯

• Originate from the cornua of the uterus 🌱

• Watch for:

  • Hydrosalpinx (fluid-filled tube) 💧🧪

  • Tubo-ovarian abscess (infected mess) 🦠💥🔥

ACUTE PELVIC PAIN

🥴

• Ouch! 😖 Painful and swollen scrotum!

• Causes:

  • Car accident 🚗💥

  • Sports injury ⚽🏈

  • Direct hit 🥊

  • Straddle injury 🚲🚫

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🎯 MAIN GOAL OF ULTRASOUND:

• Check for rupture! ⚠🩸

• If caught early (within 72 hours) 🕒➡ 90% can be saved! 🙌

• After 72 hours ➡ only 45% chance 😟

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🩸 TRAUMA COMPLICATIONS:

• Hydrocele = fluid around testicle 💧

• Hematocele = blood around testicle 🩸💥
  (can also show up with bad infections like epididymitis or orchitis) 🦠🔥

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🔍 SONOGRAPHY FINDINGS FOR RUPTURE:

• Weird tissue pattern in the testis 🎨❌

• Broken tunica albuginea (protective layer) 🧱

• Bumpy or irregular testis shape 🤯

• Thickened scrotal wall 📏

• Hematocele present 🩸

🧠 These might look like a tumor or abscess, but with trauma history = likely rupture ⚠

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🔄 TESTICULAR TORSION – Twisted Emergency!

• Caused by abnormal mobility of testis 🕺🌀

• Emergency 🚨—needs FAST diagnosis!

• Common in teens and young adults 👦

• Symptoms = sudden pain + swelling on one side 🌪⚡

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🩻 SONOGRAPHY STAGES OF TORSION:

1. Early (0–6 hrs) ⏰

   • Testis looks normal at first 😇

2. After 4–6 hours 🕓

   • Testis gets swollen + hypoechoic 🥚⬛

   • Lobes become clear due to swelling 🌀

3. After 24 hours ⏳

   • Testis looks heterogeneous (mixed pattern) 🎨

   • Due to bleeding, infarction, necrosis 😵🩸💀

   • Epididymal head = enlarged, dull or patchy 🧠

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🌈 COLOR DOPPLER MAGIC:

• Shows blood flow! 🩸

• ⚠ No flow on painful side + normal flow on other side = TORSION confirmed! ✅🚨

SCROTAL TRAUMA

🦵–

• Common reason: Deep Venous Thrombosis (DVT) 🩸❌

• Other possible causes:

  • Baker's cyst = bulge behind knee that can go down to the calf 🎈🦵

  • Cellulitis = skin infection 🔥

  • Abscess = pus pocket 💥

  • Muscle hematoma = internal bruise 🟣

  • Fasciitis = inflamed connective tissue ⚠

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🧪 2 TYPES OF DVT EVALUATIONS:

1. Compression Test 🤏

   • Gently squeeze veins to see if they collapse

2. Full Ultrasound 💻

   • Uses gray scale, color Doppler, and spectral Doppler to check flow 🟥⬛🔵

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🔍 DVT TYPES:

• Acute = recent clot 🆕

• Chronic = old clot 🧓

• Distal = lower down the leg 👣

• Superficial = close to skin (less dangerous) 🧼

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😣 PATIENT SYMPTOMS:

• Swollen leg 🦵💨

• Tender & painful to touch 😖

• Use gentle compression during scan to avoid hurting them 🧸

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🧠 SONOGRAPHY TIPS:

• Use Color Doppler = sees blood flow 🟥🔵

• Helps tell veins (slow flow) from arteries (fast flow) 🔄

• Avoid false results ❌ by checking flow and compressibility

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⚠ CAUTION IN OBESE PATIENTS:

• Fat may hide deep veins under big superficial ones 🍔🧻

• May lead to missed DVT (false negative!) 👀🙅

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🧫 CLOTS – How Do They Look?

• Fresh clots = isoechoic or slightly dark (hypoechoic) 🔘

• Hard to see on low-end machines 😓💻

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💣 HIGH-RISK VEINS for DANGEROUS CLOTS (can travel to lungs 😬):

• Common femoral vein 🦵

• Superficial femoral vein (yes, it’s deep!) 🚫🌊

• Popliteal vein (behind the knee) 🎯

❗The deep femoral vein = usually safe from emboli = not always checked ❌

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🩻 HOW TO DO THE EXAM:

• Use a high-frequency linear probe 📡

• Apply pressure right over the vein

• Normal = walls touch completely 🤝

• Abnormal = vein won’t compress 😵🛑

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❗LOOK OUT: LYMPH NODES

• Sometimes confused with clots 😬

• Enlarged nodes = dark with a bright center 🌓

• Do not compress — different from vein clots 🚷

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🧭 CHECK BEYOND THE LEG:

• Look at IVC and iliac veins too! 🛣

• These may be the source of clots causing pain/swelling ⚠🩸

EXTREMITY SWELLING & PAIN

🩺 Emergency Ultrasound Basics (FAST & More)

• 🧪 DPL (Diagnostic Peritoneal Lavage) used to be the go-to method for checking abdominal trauma — now it's mostly replaced.

• 🧍‍♂➡🧍‍♀ FAST scan is the new superhero! It's a quick ultrasound used right in the ER to check for internal bleeding.

• FAST scan checks the:

  • ❤ Pericardium (around the heart)

  • 🍔 Perihepatic space (near the liver, like Morison’s pouch)

  • 🍇 Perisplenic space (near the spleen)

  • 🚽 Bladder

  • 🌊 Paracolic gutters & cul-de-sac (fluid check zones!)

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💥 Trauma & Pain Detection with Ultrasound

• 💔 Liver injuries (lacerations or bruises) are easier to find than injuries to other organs.

• ⚠ BUT, ultrasound might miss injuries to:

  • 🫃 Diaphragm

  • 🥞 Pancreas

  • ☄ Adrenal glands

  • 🥣 Some bowel issues

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⚡ Pain Locations & What They Might Mean

• 🔥 RUQ (Right Upper Quadrant) pain = possible gallbladder issues

• 🔙 Midepigastric pain radiating to the back = classic acute pancreatitis

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💣 Aneurysms & Dissections

• 💥 Aneurysms often show up at the belly button level (🩻 where the aorta splits into iliac arteries)

  • They can grow both sideways and front to back!

• 🪓 Aortic Dissection = layers of the aorta split apart = emergency!

  • Happens in 3 spots:

    1. At the root of the aorta 🌱 (can spread everywhere!)

    2. Near the left subclavian artery 💪

    3. Just the ascending aorta ⬆

• 😖 Feels like sharp, tearing chest pain that can go to the arms, neck, or back.

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😬 Other Common Emergencies

• 💦 Flank pain = could be kidney stones (urolithiasis)

• 🍽 Appendicitis = blocked appendix → inflammation → pain → often surgery

  • Most common emergency surgery in kids over 2⃣!

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🧱 Other Causes of Abdominal Pain

• 🧷 Hernias = rare but can cause blockage and pain

• 💃 Pelvic pain in women could mean:

  • 🦠 Tubo-ovarian abscess

  • 💣 Ruptured cyst

  • 🚨 Ectopic pregnancy

  • 🔄 Ovarian torsion (twisting — urgent!)

• 🩳 Scrotal trauma = may lead to:

  • 💧 Hydrocele (fluid)

  • 🩸 Hematocele (blood)

• ⚠ Testicular torsion = spermatic cord twist = emergency surgery needed ASAP!

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🦵 Swelling & Pain in the Limbs

• 🩻 Can be due to venous issues (acute, chronic, distal, or superficial)

• Other possible causes:

  • 🥣 Baker cyst (behind the knee)

  • 🔥 Cellulitis

  • 💥 Abscess

  • 🩹 Muscle hematoma

  • 🧱 Fasciitis (infection of connective tissue)

KEY PEARLS