Chapter 14

Chapter 14: Sonographic Examination and Guidelines

Chapter Objectives

Appreciate the importance of a quality assurance program.
Provide the novice with an overview of many of the suggested requirements that are typically included in various routine sonographic examinations.
Appreciate the variations required to standard protocols in the everyday practice of sonography.

Quality Assurance

Quality assurance programs involve:
- Assessment of all ultrasound system components.
- Provision of repairs and preventive maintenance on ultrasound equipment.
- Maintenance of comprehensive records of all assessments.
Primary Goals of Quality Assurance:
- Maintaining high function of equipment: Ensuring that ultrasound systems operate at optimal levels.
- Detecting gradual degradation of images: Spotting any decline in image quality over time.
- Minimizing potential downtime of equipment: Reducing the amount of time equipment is out of service.
- Protecting patients from overexposure: Ensuring patient safety with minimal exposure to ultrasound energy.
Most sonography departments employ engineer specialists to perform analyses using specific instruments.
Important Actions: If transducers show cracks, wiring has visible tears, or images appear degraded, report to management.

As Low As Reasonably Achievable (ALARA) Principle

All sonographic examinations should be conducted with ALARA in mind.
This principle mandates the practice of minimizing exposure to patients to the lowest level reasonable.

Exam Checklist

Pick up Requisition form:
- Ensure understanding of the order and the protocol.
Prepare for Check-up:
- Consider patient preparation, size, mobility, and transportation.
Patient Interaction:
- Introduce yourself and obtain two patient identifiers utilizing AIDETS:
  - Acknowledge - note the patient.
  - Introduce - yourself and your role.
  - Duration - inform of the expected length of the exam.
  - Explanation - explain the examination process to the patient.
  - Thank You - Thank the patient for their cooperation.
Move to Ultrasound Room:
- Take the patient to the ultrasound room appropriately (WC, Ambulatory, or Stretcher).
Explain Exam Type:
- Describe the examination to be performed and its anticipated duration.
Adjust Environment:
- Dim or turn off the lights to create a suitable scanning environment.
Patient Information Entry:
- Enter patient information on the ultrasound machine.
- Ensure to include your own initials.
Select Appropriate Settings:
- Choose the proper preset for the exam and the transducer frequency.
Conduct the Scan:
- Follow protocols while scanning:
  - Observe organ borders and textures.
  - Measure organs using the worksheet on the machine.
  - Look for pathologies.
  - Use color and pulsed Doppler techniques.
  - Print the worksheet.
End of Exam Protocol:
- Clean the transducer (do not spray directly on the machine).
- Adjust the bed/stretcher settings.
- Inform the patient about what’s next.
Fill out the Exam Worksheet:
- Measurements: Include dimensions in centimeters rounded to the nearest tenth.
  - Example: For a measurement of $1.567$ cm, round to $1.6$ cm.
- Include specific measurements (Anteirior-Posterior, L x W x H for organs, and more) for various organs such as the liver, gallbladder, kidneys.
- Measure any pathologies and provide detailed observations on texture, size, location, etc.
Present Images and Documentation:
- Present images and the completed worksheet to the radiologist.
- For simulations, save images to a USB drive for presentation to the supervising physician.
- If approved, give subsequent information to the patient and transition them back to the waiting area.
- Clean the room for the next patient.

Timely Communication of Urgent Findings

Examination findings necessitating immediate communication with the interpreting physician include:
- Ruptured Abdominal Aortic Aneurysm (AAA)
- Arterial Occlusion
- Ectopic Pregnancy / Ruptured Ectopic Pregnancy
- Testicular Torsion
- Deep Vein Thrombosis (DVT)
- Appendicitis / Ruptured Appendicitis
- Pyloric Stenosis
- Ovarian Torsion
It is crucial that results of ultrasound examinations are communicated promptly due to their impact on patient outcomes and typically entail that the patient remains until a discussion occurs with their healthcare provider.

Abdominal and Small Part Sonography Guidelines

Patient Preparation:
- Fasting for 6 to 8 hours is generally required to allow gallbladder distension and reduce bowel gas.
Liver Guidelines:
- Perform imaging in both longitudinal and transverse planes.
- Compare liver imaging to adjacent organs and assess the three major lobes.
Gallbladder and Biliary Tract Guidelines:
- Image in both planes (longitudinal and transverse) while supine.
- Use probe pressure to assess for a painful gallbladder.
- Ensure full imaging of the biliary tree.
Pancreas Guidelines:
- Standard practice is imaging via a transverse plane.
- Identify all portions of the pancreas, and assess for abnormalities and dilatations.
- Evaluate the peripancreatic region for fluid and adenopathy.
Spleen Guidelines:
- Characters of spleen imaging include both longitudinal and transverse scans to compare echogenicity to the left kidney and assess diaphragm for pleural effusion.
Bowel Guidelines:
- Assess for abnormalities like wall thickening, masses, and hyperemia, utilizing at least two viewing planes.
Peritoneal Fluid Guidelines:
- Identify the location and extent of fluid and provide images in appropriate quadrants.
Kidney and Urinary Bladder Guidelines:
- Scan kidneys in longitudinal and transverse planes; evaluate the cortices, renal pelvis, and overall echogenicity.
- Record maximum renal lengths and assess for masses or abnormalities.

Breast Sonography Guidelines

No patient preparation is usually required.
Correlate findings with clinical signs/symptoms and other imaging studies.
Imaging Tips:
- View lesions in two perpendicular projections and record their maximal dimensions in at least two orthogonal planes.
- Label images appropriately and ensure they are complete.
Mass characterization heavily relies on technical factors.

Scrotal Sonography Guidelines

Typically, no patient preparation is needed.
Position patient for simultaneous imaging of both testicles, examining in longitudinal and transverse planes.
Evaluate the size of each testicle and epididymis and examine scrotal wall thickness and palpable masses.
Utilize color spectrometry to assess vascularity in testicles.

Thyroid and Parathyroid Sonography Guidelines

Usually, no patient preparation is needed; the patient should be positioned supine with the neck hyperextended for imaging.
Measure lobes in three dimensions and assess potential neck lesions if examining for adenoma.

Gynecologic Sonography Guidelines

Transabdominal: Requires bladder distension; in emergencies, saline may be used via Foley catheter.
Transvaginal: No preparation needed, evaluate uterus and ovaries in multiple planes.

Obstetric Sonography Guidelines

First Trimester: Transabdominal (bladder distended) / Transvaginal (empty bladder); evaluate for gestational sac and assess for amniotic fluid.
Second/Third Trimesters: Minimal preparation; document fetal details and assess placental health.

Vascular Sonography Protocols

Carotid Sonography: Typically requires no patient preparation and employs Doppler techniques to assess carotid arteries.
Peripheral Venous Sonography: Conducts comprehensive evaluations in both the longitudinal and transverse planes across major veins.
Upper Extremity and Peripheral Arterial Guidelines: Employ grayscale and Doppler imaging, no preparation required.

Conclusion

Sonographic guidelines are critical for specific examinations across various fields such as abdominal, breast, vascular, and obstetrics ensuring clear imaging and accurate diagnosis through establishing standard protocols and best practices.