Ultrasound in the Critically Ill: A Practical Guide

Preface
Contents
Contributors
1 Physics of Ultrasound
	1.1 Introduction
	1.2 The Ultrasound Wave
	1.3 The Origin of the Ultrasound Image
	1.4 Ultrasound Modes
		1.4.1 A—Mode
		1.4.2 B—Mode
		1.4.3 M—Mode
		1.4.4 Doppler
	1.5 Ultrasound Transducers
	1.6 Ultrasound Terminology
	1.7 Artefacts
		1.7.1 Dorsal Acoustic Shadow
		1.7.2 Posterior Enhancement
		1.7.3 Lateral Wall Sign
		1.7.4 Mirror Artefact (Figs. 1.18 and 1.19)
	1.8 Conclusion
2 Preparation and Image Optimisation
	2.1 Introduction
	2.2 Preparation
	2.3 Image Optimisation
		2.3.1 Depth (Fig. 2.4)
		2.3.2 Gain (Fig. 2.5)
		2.3.3 Time Gain Compensation (TGC, Fig. 2.6)
		2.3.4 Orientation (Fig. 2.7)
	2.4 Conclusion
3 Clinical Governance
	3.1 Introduction
	3.2 Organisational Ultrasound Governance Board
	3.3 Departmental Ultrasound Governance Group
	3.4 Individual Practitioner Governance
	3.5 Conclusion
4 Airway Ultrasound
	4.1 Introduction
	4.2 Equipment Needed for Airway Sonography
	4.3 Typical Features of Airway Sonography and the Tissue/Air Border
	4.4 Normal Airway from the Tongue to the Pleura Is Depicted (Figs. 4.2, 4.3, 4.4, 4.5, 4.6 and 4.7)
	4.5 Clinical Application of Airway Ultrasound
		4.5.1 Qualifying and Quantifying Airway Pathology and Deviations from Normal Anatomy that Are Relevant to Airway Management
		4.5.2 Identification of the Trachea and the Cricothyroid Membrane
		4.5.3 Distinguishing Between Oesophageal, Tracheal, and Main-Stem Intubation
		4.5.4 Ultrasound Guided Surgical or Percutaneous Dilatational Tracheostomy
	4.6 Conclusion
	References
5 Basic Lung Ultrasound
	5.1 Introduction
	5.2 Basic Semiotics of Lung Ultrasound
	5.3 Normal Pattern
	5.4 Absence of Lung Sliding
	5.5 B-Lines
	5.6 Lung Consolidations
	5.7 Pleural Effusion
	5.8 Conclusion
	References
6 Advanced Lung Ultrasound
	6.1 Introduction
	6.2 Monitoring
	6.3 Multiorgan Ultrasound
	6.4 Conclusion
	References
7 Focused Transthoracic Echocardiography
	7.1 Introduction
	7.2 Standard Views
	7.3 Scanning Process
	7.4 Diagnostic Algorithm
	7.5 Common Pathology
		7.5.1 LV Failure
		7.5.2 RV Failure
		7.5.3 Severe Hypovolaemia
	7.6 Advanced Focused Echocardiography
		7.6.1 Stroke Volume
		7.6.2 Valve Function
	7.7 Conclusion
8 Advanced Transthoracic Echocardiography
	8.1 Introduction
	8.2 Modalities of Echocardiography and Thoracic Ultrasound
	8.3 Levels of Expertise and Certification
	8.4 Advanced Critical Care Echocardiography: Beyond Basic
		8.4.1 Left Ventricular Function
		8.4.2 Filling Pressures and Volume Status
		8.4.3 Right Ventricular Function
	8.5 3D and 4D Imaging
	8.6 Strain and Strain Rate Imaging
	8.7 Echocardiography for New Critical Care Techniques
	8.8 Conclusion
	References
9 Transoesophageal Echocardiography
	9.1 Introduction
	9.2 The TOE Probe
	9.3 Probe Insertion and Patient Preparation
	9.4 Image Acquisition
	9.5 Indications for TOE in ICU
	9.6 Contra-indications to Use of TOE
	9.7 TOE Examination on the ICU
	9.8 Clinical Applications
	9.9 Conclusion
	References
10 FAST Scanning
	10.1 Introduction
	10.2 Equipment
	10.3 FAST Scan Principles
	10.4 FAST Scan Views
		10.4.1 Right Upper Quadrant
		10.4.2 Left Upper Quadrant
		10.4.3 Pelvis
		10.4.4 Pericardium
		10.4.5 Extended FAST—eFAST
		10.4.6 Focussed Assessment for Free Fluid—FAFF
	10.5 Conclusion
	References
11 Renal Tract Ultrasound
	11.1 Introduction
	11.2 Equipment
	11.3 Sonoanatomy
	11.4 Pathology
	11.5 Conclusion
12 Abdominal Ultrasound—Liver, Spleen and Biliary Tree
	12.1 Introduction
	12.2 Artefacts
	12.3 Scanning Technique
	12.4 Liver
		12.4.1 Anatomy
		12.4.2 Liver Size
		12.4.3 Normal Liver Parenchyma
		12.4.4 Abnormal Liver Parenchyma
		12.4.5 Inflammatory Conditions
		12.4.6 Focal Hepatic Masses
	12.5 Haemangiomas
		12.5.1 Hepatic Cyst
		12.5.2 Malignant Focal Liver Lesions
	12.6 Portal Vein Gas
	12.7 Portal Vein Occlusion
	12.8 Hepatic Venous Congestion
	12.9 Hepatic Venus Outflow Obstruction
	12.10 Spleen
		12.10.1 Anatomy
		12.10.2 Splenic Size
		12.10.3 Infarcts
		12.10.4 Abscess
		12.10.5 Cysts
		12.10.6 Focal Masses
		12.10.7 Rupture
	12.11 Gallbladder and Bile Ducts
		12.11.1 Anatomy
		12.11.2 Gallbladder Thickening
		12.11.3 Stones, Polyps and Sludge
		12.11.4 Acute Cholecystitis
	12.12 Jaundice: Biliary Dilatation
	12.13 Pneumobilia
	12.14 Cholangitis
	References
13 Abdominal Ultrasound—Bowel and Peritoneum
	13.1 Introduction
		13.1.1 Anatomy
	13.2 The Gut Wall Signature
	13.3 Nasogastric Tube Positioning
	13.4 Small Bowel Ileus/Obstruction
	13.5 Bowel Ischaemia
	13.6 Pseudomembranous Colitis
	13.7 The Peritoneal Cavity
		13.7.1 Anatomy
	13.8 Ascites
	13.9 Peritonitis
	13.10 Abscess
	13.11 Percutaneous Aspiration and Drainage
	13.12 Pneumoperitoneum
	13.13 Conclusion
	References
14 Vascular Access
	14.1 Introduction
	14.2 Equipment
	14.3 Sonographic Anatomy
	14.4 Performing Venous Access
	14.5 Sites of Access
		14.5.1 Internal Jugular Vein
		14.5.2 Subclavian/Axillary Vein
		14.5.3 Femoral Vein
	14.6 Complications
	14.7 Arterial Access
	14.8 Peripheral Access (PICCs/Cannulae)
	14.9 Useful Adjuncts
	14.10 Conclusion
	References
15 Venous Sonography
	15.1 Introduction
	15.2 Equipment
	15.3 Anatomy
	15.4 Scanning Process
	15.5 Use of Colour Doppler
	15.6 What’s ‘Normal’ or Not
	References
16 Neuro-ophthalmic Ultrasound
	16.1 Introduction
	16.2 Ophthalmic Ultrasound
		16.2.1 Anatomy of the Optic Nerve Sheath and Pupillary Aperture
	16.3 Evidence for Ultrasound of the Optic Nerve Sheath
		16.3.1 Advantages and Disadvantages of Optic Nerve Ultrasound
	16.4 Technique of Optic Nerve Ultrasound
	16.5 Ultrasonic Examination of the Pupillary Reflex
		16.5.1 Technique of Ultrasonic Examination of Consensual Pupillary Light Reflex
	16.6 Conclusion
	References
17 Cranial Doppler
	17.1 Introduction
	17.2 Transcranial Doppler
		17.2.1 The Transcranial Doppler Transducer
		17.2.2 Acoustic Windows
	17.3 Principles of TCD Scanning
	17.4 Pitfalls of TCD Ultrasound
		17.4.1 Factors Increasing FV
		17.4.2 Factors Decreasing FV
	17.5 The Use of Transcranial Doppler as Ancillary Test in Brainstem Death
	17.6 Technique of Transcranial Doppler
	17.7 Safety Concerns with Ophthalmic and Transcranial Ultrasound
	17.8 Conclusion
	References
18 Musculoskeletal Ultrasound
	18.1 Introduction
	18.2 Fractures
	18.3 Foreign Body
	18.4 Soft Tissue Infection
	18.5 Joint Effusion/Haemarthrosis
	18.6 Conclusion
	References
19 The Haemodynamically Unstable Patient
	19.1 Introduction
	19.2 Organ Blood Flow
	19.3 The Cause of Shock
		19.3.1 Hypovolaemic Shock
		19.3.2 Cardiogenic Shock
		19.3.3 Obstructive Shock
			19.3.3.1 Tamponade
			19.3.3.2 Pulmonary Embolism
			19.3.3.3 Pneumothorax
			19.3.3.4 Pleural Effusion
		19.3.4 Distributive
	19.4 Guiding Management
	19.5 Conclusion
	References
20 The Polytrauma Patient
	20.1 Introduction
	20.2 FAST Scanning
	20.3 Conclusion
	References
21 The Patient with Acute Breathlessness
	21.1 Introduction
	21.2 Making that Diagnosis
	21.3 Step 1—the BLUE Protocol/Focused Lung Ultrasound
	21.4 Step 2—Focused Cardiac Ultrasound
	21.5 ICU-Specific Problems
		21.5.1 Diagnosing The ‘Acute Respiratory Failure’ Referral
		21.5.2 Is that a Pleural Effusion?
		21.5.3 The Patient ‘Stuck’ on a Ventilator and Not Weaning
	21.6 Conclusion
22 The Patient Difficult to Wean from Mechanical Ventilation
	22.1 Introduction
	22.2 Respiratory Assessment
		22.2.1 Lung Aeration
		22.2.2 Pleural Effusions
		22.2.3 Diaphragmatic Function
	22.3 Diaphragmatic Paralysis or Weakness
		22.3.1 Cardiac Function
	References
23 The Patient with Acute Kidney Injury
	23.1 Introduction
	23.2 Normal Sonographic Appearances of the Kidney
	23.3 Causes of AKI
		23.3.1 Pre Renal
		23.3.2 Intrinsic
		23.3.3 Post Renal
	23.4 Urosepsis
	23.5 Exclusions
	23.6 Conclusion
24 The Patient with Acute Abdominal Pain
	24.1 Introduction
	24.2 Indications
	24.3 Equipment
	24.4 Protocols
	24.5 A Proposed Approach
	24.6 Right Upper Quadrant
	24.7 Epigastrium and Peri-umbilical Region
	24.8 The Left Upper Quadrant
	24.9 The Left Lower Quadrant
	24.10 Supra Pubic Region
	24.11 Right Lower Quadrant
	24.12 Conclusion
	References