Cornell
HM-POCUS

Hospital Medicine Point of Care Ultrasonography

General Guidelines:

• Know the standardized terminology used to describe probe movements. 
  • Everyone is expected to use this terminology throughout the course.
    • Handout Reference
    • Video Reference
  • Emphasize that learners make one probe movement at a time.
• Avoid directly handling the ultrasound probes and machines.
  • Guide learners using verbal instructions.
    • Only physically assist the learner if they are absolutely unable to obtain an adequate image. 
  • Utilize a laser pointer.
    • If you don’t have one, we can provide one for you.
  • The learner who is not scanning can assist with adjusting machine knobs. 
• Manage time between learners.
  • Be aware of learners who monopolize the probe. Ensure each learner receives equal probe time.
  • Ensure that learners are able to perform the operations listed and identify anatomy delineated in daily scan lists.
• Manage Interactions between models and learners.
  • Limit nonessential chatter between models and learners.
  • Alert course leaders immediately of any inappropriate behaviors by participants. 

Session Guidelines:

• Teach basic machine operations.
• Teach proper hand position.
• Emphasize probe movement and how those movements relate to changes in the screen image.
  • Utilize the ultrasound beam prop and illustrations provided at the bedside.
• Emphasize orientation.
  • Learner should be able to understand the relationship between screen and probe markers.
  • Learner should be able to relate screen borders to anatomic relationships (e.g., patient’s left versus right, anterior versus posterior, cranially versus caudally, etc.).

Session Approach:

1. Machine Operations
   • Identify and utilize the following operations: Power button, patient selection, preset selection, depth dial, gain dial, and TGC.
   • Alter the following settings so that learners will have to fix them during the scan session: Screen orientation marker, gain, depth, TGC, and probe selection.
2. Bladder
   • Identify the bladder in transverse view, then tilt to identify prostate (or uterus).
     • Ensure that the learner correlates screen and probe markers.
     • Ensure that the learner correlates patient’s sides with the screen.
   • Rotate probe to obtain the sagittal view of the bladder
   • Rock the probe to visualize prostate (or uterus and vaginal stripe).
   • Be sure to identify the rectum in both transverse and sagittal views.
3. Right Kidney
   • Patient should be supine. Learner should begin with the probe at the posterior axillary line at the level of the xiphoid process. 
     • Identify the hepatorenal recess.
       • Correlate borders of the screen to the patient’s head, feet, lateral side, and medial side.
       • Utilize the ultrasound beam prop (with drawing insert) to demonstrate the structures being scanned. Demonstrate using the prop at the machine screen.
   • Learner next slides the probe cranially along the posterior axillary line. Demonstrate movement on the screen. 
     • • • Identify the curtain sign.
   • Learner then slides the probe caudally to return the kidney to the center of the screen. They then rotate the probe 15-30 degrees to the posterior, aligning the probe between the ribs.
     • Demonstrate the right kidney in its long axis.
   • Learner tilts probe posteriorly and anteriorly to scan kidney from posterior to anterior surfaces. Learner rotates probe 90 degrees to the posterior.
     • Demonstrate the right kidney in its short axis.
   • Learner tilts probe caudally and cranially to scan kidney from inferior to superior poles. Rotating the probe to anteriorly by 90 degrees, the learner returns to the long axis. Learner sweeps probe anteriorly to midaxillary line, then tilts posteriorly to visualize the kidney. Learner then sweeps probe to the anterior axillary line and tilts posteriorly to visualize the kidney. 
     • Describe the different anatomy seen from the posterior axillary, midaxillary, and anterior axillary lines.
4. Left Kidney
   • Patient should be supine. Learner should follow the same instructions used above for the right kidney, however, with one exception: The probe is rotated 90 degrees anteriorly to obtain the short axis view.
     • Identify the splenorenal recess
     • Demonstrate the left kidney in its long axis
     • Demonstrate the left kidney in its short axis.
     • Describe the different anatomy seen from the posterior axillary, midaxillary, and anterior axillary liens. 

• There are 3 types of imaging used in lung US. Emphasize approaching the 3 separately:
  • Lung parenchyma imaging based on US artifact
  • Anatomic imaging of consolidations/effusions
  • Anatomic imaging of pleura
• In anatomic imaging (PLAPS) continue emphasis on orientation.
  • Learner to understand the relationship between screen and probe markers.
  • Learner to correlate screen borders with anatomical relationships (e.g., patient’s left versus right, anterior versus posterior, cranially versus caudally, etc.).
• Continue emphasis of probe movement relative to the screen.
  • Utilize the ultrasound beam prop for demonstration on model and on US screen.
• Utilize all 3 probes: phased array and curvilinear probes for imaging anatomical structures and lung artifact, and linear probe for imaging the pleura. Discuss advantages and limitations of each, including (but not limited to) the following:
  • All 3 probes are adequate for imaging lung sliding
  • Linear probe is NOT adequate for imaging A- and B-lines
  • Subpleural/pleural pathology requires high resolution linear probe imaging
  • Deeper parenchymal lesions/consolidations/PLEFF should be imaged using with a curved-array transducer
  • Phased-array transducer is adequate for gross evaluation in most circumstances, fits between the ribs, but lacks the spatial resolution of curved-array transducer
• Please do NOT teach M-mode or CD on day 1. These should be reserved for more advanced learners or omitted all together.
• Scan with the patient in both supine and then in the sitting position. Emphasize that the number of zones scanned depends on clinical setting, patient mobility and clinical particulars of the presentation. Examples:
  • An ICU patient on mechanical ventilation may not be easily moved and only anterior and lateral zones may be scanned
  • An ambulatory stable patient should be scanned in the same position they would be examined: sitting up. Evaluation of posterior lung zones is essential.
  • In a stable outpatient with ILD every intercostal space paraspinal, posterior mid-clavicular, posterior axillary, mid-axillary, anterior axillary, anterior mid-clavicular and parasternal lines bilaterally
  • In a patient with severe dyspnea at rest and/or acute respiratory failure a scan limited to just 2 points (upper anterior lung fiends) may be appropriate. Absence of diffuse B-line pattern at these positions makes CHF as a cause of acute respiratory failure substantially less likely.
• It is critical that all lung scanning always starts with the probe placed on the chest wall longitudinally (along the long axis of the body, crossing the ribs) with the probe marker towards the model’s head. If a wider view unobstructed by rib shadows is desired, the probe may then be turned parallel to the ribs with the probe marker in compliance with radiology convention.
• US machines in the class have 2 pulmonary presets “lungs” and “consolidation/effusion”. Discuss the difference in settings.
• Artifact suppression software is employed for anatomic imaging of “consolidation/effusion”. This software is purposefully removed for “lung” imaging. This includes features such as below. Do NOT discuss in any detail (this list is available to those who want it):

• Depth should be set at at 12-15 cm.
• Focal zone should be at the pleural line.
• At home learners may not have access to machines which have a pulmonary preset. Demonstrate settings in abdominal mode with depth and focus as above, harmonics, frame averaging, and multi-beam imaging turned off.
• Please scan in the order outlined below

• Anatomic imaging of PLAPS
  • Use both phase-array and curved array probes during this session
  • Start by locating the right kidney and hepato-renal recess. Demonstrate that in the supine patient both kidneys can usually be imaged (at least partially) by placing the probe at the level of the xiphoid process posterior to the posterior axillary line (“knuckles into the bed”).
  • Mind probe orientation
  • Once the kidney is located, identify the renal capsule and the liver. Discuss how occasionally the renal capsule is misidentified as hemidiaphragm, and liver as a dense PLEFF.
  • Slide cephalad and visualize the hemidiaphragm. Have learners identify the spine. Use the paddle with the PLAPS view to discuss orientation.
  • Demonstrate curtain sign
  • Demonstrate spine sign
  • Attempt to demonstrate mirror artifact. Visualize the diaphragm and curtain sign.
  • Turn the probe into transverse orientation and demonstrate diaphragmatic movement in and out of the field. Discuss implications for thoracentesis and emphasize the importance of the probe being in longitudinal orientation.

• Lung parenchymal imaging based in artifact
  • Demonstrate normal lung artifact (A-lines) anywhere on the anterior chest. Mind the probe placement in the longitudinal orientation
  • Optimize machine settings as discussed in the previous section
  • Demonstrate that presence of A-lines is dependent on the insonation beam being perpendicular to the pleura (not to chest wall). Have the learner rock and tilt the probe. Appearance and disappearance of A-lines should be appreciated. Emphasize that both rocking and tilting is always required when scanning lung parenchyma
  • In a supine model, demonstrate 8 zone scanning
  • Demonstrate alternative continuous scanning in parasternal, mid-clavicular, anterior-, mid- and posterior axillary lines. The scanning should 1st be done with the probe in longitudinal orientation (to demonstrate “bat sign”, and then in transverse orientation (to cover most lung parenchyma)
  • In an upright patient demonstrate posterior zone scanning (variably 2 or 3 on each side)
  • Again, demonstrate continuous scanning along posterior mid-clavicular and paraspinal lines. The scanning should 1st be done with the probe in longitudinal orientation (to demonstrate “bat sign”, and then in transverse orientation (to cover most lung parenchyma)

• Anatomic imaging of the pleura
  • Use all 3 transducers
  • Identify “bat sign”
  • Identify all horizontal hyper-echoic lines, including ribs and pleura, which is DEEP to the ribs. The main purpose of this is to not miss subcutaneous emphysema
  • Identify lung sliding
  • Optimize depth and gain (down-gain) to bring out lung sliding
  • Instruct the model to hyperventilate (do not just say “hyperventilate, please”) and demonstrate lung pulse. Note the difference in intensity between right and left hemi-thoracies
  • Find reflection of the pleura over the liver (or the pericardium, etc.). Demonstrate the end of the pleura and discuss how it is different from the “lung point”
  • Note limitations of anterior chest scans on the left

Anatomic Imaging of Lung Parenchyma

Curved array

Preset: Lung –Lung/PLEFF. Discuss the difference from Lung proper preset

Model position: Supine

• • • Locate the R kidney (xiphoid – knuckles into the bed), hepatorenal recess, hemidiaphragm
    • Decrease the depth and demonstrate misidentification of the renal capsule as a diaphragm (liver is mistaken for a complex PLEFF). Then set proper depth
    • Identify rib shadows. Teach to rotate the probe slightly to minimize rib shadows
    • Identify structures (liver, kidney, spine, hemidiaphragm)
    • Ask to identify cephalad and caudad direction on the screen
    • Point to the spine and ask where “this” is in the patient (medial)
    • This usually causes confusion. Use a paddle with a drawing to illustrate the cut. Compare the probe with a knife as opposed to a video camera. US is a tomographic modality. Compare the view to the coronal reconstruction of CT (half of it).
    • Ask what probe movement will bring the diaphragm closer to the screen midline (sliding cephalad)
    • Curtain sign
    • Spine sign – discuss
    • Mirror artifact. Frequently absent when imaging with a curved array but may be more readily seen with a phased array.
    • Switch to phased array

Phased array

Preset: Lung – Lung/PLEFF

Model position: Supine

• • • Locate the LEFT kidney.
    • Identify anatomic structures
    • Discuss the difference between the right and the left side (left is more cephalad and more posterior)
    • Set proper depth
    • Identify structures (spleen, kidney, spine, hemidiaphragm)
    • curtain sign
    • spine sign/mirror artifact. Mirror artifact is usually more prominent with the phased array probe
    • Sweep ventrally and demonstrate “pseudo-PNA” – gastric content.
    • Emphasize importance of posterior lung scanning for loculated effusions

Phased array

Preset: Lung –Lung proper

Model position: Supine

• • • Place the probe on the anterior chest wall, 2nd ICS. Start with the RIGHT
    • Probe perpendicular to the ribs
    • Set depth at 12-15cm
    • Orient the probe perpendicular to the pleura. Emphasize perpendicularity to the pleura not to the chest wall
      • Make the pleura horizontal by rocking the probe
      • Then tilt the probe back and forth – rock and tilt. demonstrate appearance/disappearance of A-lines
    • Identify all horizontal hyper-echoic structures
      • Fascia
      • Ribs
      • Pleura (deep to the ribs)
    • Bat sign
    • Discuss why initially the probe must be perpendicular to the ribs (pleura vs SQ emphysema)
    • Point out that the focal zone is at the depth of the pleura
    • Show lung zones of the anterior and lateral chest (8-zone scanning)
      • Discuss decision making re: the number of zones.
      • In a pt with ARF 2/2, lack of B-lines in anterior upper lung fields r/o CHF as a cause of ARF (2-zone)
      • In an ICU pt post lung zones may not be readily available for evaluation – 8 zones
      • In a stable outpatient with IPF – continuous scanning along all lines

Preset: Lung –Lung proper

Model position: Sitting up

• • • Scan posterior lung zones (2 or 3 zones).
    • Emphasize necessity for posterior lung scanning (ex.: COVID)
    • Probe perpendicular to the ribs
    • Set depth at 12-15cm
    • Orient the probe perpendicular to the pleura. Emphasize perpendicularity to the pleura not to the chest wall
      • Make the pleura horizontal by rocking the probe
      • Then tilt the probe back and forth – rock and tilt. demonstrate appearance/disappearance of A-lines
    • Identify all horizontal hyper-echoic structures
      • Fascia
      • Ribs
      • Pleura (deep to the ribs)
    • Bat sign
    • Turn the probe parallel to the ribs. Emphasize that should NEVER be done on the 1st approach
    • Apply gel to the skin of the model and scan continuously (or semi-continuously in a female model) in paraspinal, posterior clavicular, post axillary, mid-axillary, ant axillary, and parasternal lines.
    • Discuss that linear probe is not suitable for imaging lung parenchyma (artifact-based)

Curvilinear probe

Preset: Lung – Lung proper

Model position: Supine

• • • Decrease the depth to 4cm or less
    • Identify lung sliding (shimmering, row of ants)
    • Decrease the gain and note the effect on lung sliding
    • Bat sign
    • Turn the probe parallel to the ribs – demonstrate that lung sliding is still present
    • Switch to Phased array Probe

Phased array probe

Preset: Lung –Lung proper

Model position: Supine

• • • Demonstrate the same and discuss the difference in appearance (lower resolution)
    • Switch to linear probe

Linear probe

Preset: Lung – Lung proper

Model position: Supine

• • • Identify structures, as previously
    • Discuss higher resolution
    • Ask if A-lines are present (correct answer is that linear probe cannot be used for that)
    • Hyperventilate the patient (give specific instructions)
    • Demonstrate lung pulse. Right mid axillary line. Then Left mid axillary line. Compare. Discuss significance. Scenario: R main-stem intubation – L lung pulse
    • NO M-MODE, PLEASE. Learners are invited to ask to be shown this during the scan clinic.
    • Identify pleural reflection on either side of the chest.
    • Discuss the difference from lung point (lung point: hyperechoic line, part is moving, part is not; pleural reflection: hyperechoic line terminates, whatever hyperechoic line is seen – in moving)

General Guidelines:

Cardiac scanning occurs Tuesday and Wednesday of the course. 

General Instructions:

• Minimize direct handling of the probe and guide learners using verbal instructions.
• Manage time between learners.
• Tuesday:
  • Obtain each cardiac view.
  • Emphasize how to properly hold the probe.
  • Emphasize making one type of probe movement at a time.
  • Identify relevant anatomy. Utilize the laser pointer.
  • Utilize the ultrasound beam prop and 3D printed hearts.
• Wednesday:
  • Optimize each cardiac view.
  • Watch optimization videos
  • Ask student not scanning to suggest probe movements and explain. 

Tuesday Morning & Wednesday Morning (Optimization)

Session Guidelines:

Model should begin in the supine position (but may be turned to left lateral decubitus, if needed). Learner should begin with the probe directed towards model’s right shoulder. Learner should start high in the chest, translating the probe caudally along the left sternal border until cardiac structures are seen. Learner should adjust gain such that blood in all chambers is anechoic. Learner should begin with a depth which allows visualization of the descending aorta in the far field before reducing depth to focus on cardiac structures.

• Tuesday:
  • Obtain an image in which the mitral and aortic valves are seen and relatively centered, but cardiac apex is not. 
  • Utilize the ultrasound beam prop with PLAX insert to demonstrate the plane of cut is from the perspective of the model’s head.
  • Correlate screen borders with anatomical borders (e.g., LV apex at screen left).
  • Identify relevant structures: RVOT, LV, MV, LVOT, AV, LA, and aorta
• Wednesday (Optimization)
  • Optimize PLAX view.
  • Evaluate EPSS using M-mode.

Learner to place color Doppler box over the MV. Adjust size of box. Note color scale. Adjust gain such that color does not bleed into tissues.

• • Evaluate MV function using color Doppler.

Tuesday Morning & Wednesday Morning (Optimization)

Session Guidelines: 

From the parasternal long axis view, learner rotates probe 90 degrees such that probe marker is directed toward the model’s left shoulder. Learner may utilize nondominant hand to assist with probe rotation. Learner to adjust gain to ensure anechoic chambers.

• Tuesday:
  • Obtain an image at the level of papillary muscles in which the LV is perfectly round.
  • Utilize ultrasound beam prop with PSAX inserts to demonstrate the plane of cut.
  • Correlate screen borders with anatomical borders.
  • Identify relevant structures: RV, LV, pericardium, anterolateral papillary muscle, and posteromedial papillary muscle. 

Learner tilts probe towards model’s right shoulder to visualize mitral valve and aortic valve levels. Learner tilts probe toward model’s left hip to visualize apical level. Learner may need to translate probe into a superior or inferior rib space in order to visualize all levels.

• • Identify anatomical structures at the other PSAX levels. (Optional)
• Wednesday (Optimization)
  • Optimize PSAX view.
    • Focus on papillary muscle level. All other levels are optional. 
  • Visually estimate EF utilizing fractional shortening and myocardial thickening. 

Tuesday Afternoon & Wednesday Afternoon (Optimization)

Session Guidelines:

Model should begin in the supine position (but may be turned to left lateral decubitus, if needed). Learners should be exposed to the 3 methods of achieving the apical 4 chamber view.

1. PMI: Find PMI by palpation or sonographically. Direct probe marker between model’s left axilla and 3 o’clock. The probe handle is dropped down (i.e., beam is directed anteriorly) and slightly laterally (i.e., beam is directed medially) to find the apical 4 chamber view.
2. Transition from PSAX: Learner can transition from the PSAX by sweeping to apex and then tilting beam anteriorly.
3. Visualization from PLAX: Learner first finds PLAX. A line is visualized from the PLAX to the 5th ICS. The probe is removed from the model’s chest and placed at the end of the imagined line.

• Tuesday:
  • Obtain an adequate view which includes both atria, both ventricles, MV, and TV.
    • There should be limited foreshortening, and ideally the RV and LV free walls are seen.
  • Identify relevant structures: :A, MV, LV, RA, TV, RV, moderator band, interventricular septum, interatrial septum, and descending aorta. 
  • Understand how rocking and sliding affect the septum (i.e., the former changes the angle of the septum, and the latter moves the septum laterally/medially).
    • Utilize the ultrasound beam prop with A4C insert.
  • Understand how rotation affects the apical 4 chamber view.
    • Clockwise rotation to assess that the RV is “fully open.”
    • Counterclockwise rotation to first achieve apical 2 chamber view, then continue rotation to emulate PLAX view.
  • Understand how tilting affects the apical 4 chamber view.
    • Tilt anteriorly to demonstrate the apical 5 chamber view.
    • Tilt posteriorly to demonstrate the coronary sinus view.
  • Wednesday:
    • Continue to practice and optimize the apical 4 chamber view.
    • Use M-mode to measure TAPSE to assess for RV function.
      • TAPSE: normal  >16mm; abnormal <16mm.
    • Use color Doppler to assess MV and TV function.

Tuesday Afternoon & Wednesday Afternoon (Optimization)

Session Guidelines:

Model should be in the supine position with his/her knees bent to relax abdominal musculature. Learner to place probe just right of the subxiphoid region with the probe marker at 3 O’clock. The probe handle is somewhat parallel to the model’s abdomen. Learner’s hand compresses the probe handle and directs the beam slightly leftward and anteriorly.

• Tuesday:
  • Obtain an adequate view which demonstrates the liver and all four chambers of the heart.
  • Utilize the ultrasound beam prop with SC4 insert to demonstrate why the liver is anterior.
    • Correlate screen borders with anatomical borders.
    • Demonstrate homology between subcostal 4 chamber view and apical 4 chamber views using the A4C insert.
  • Identify relevant structures: liver, LA, MV, LV, RA, TV, RV, and pericardium.
  • Understand how rotation affects the subcostal view.
    • Demonstrate the atria/ventricles disappear and how to create a PSAX-like view.

From subcostal 4 chamber view, learner should rock probe to center the RA. The probe is then rotated counterclockwise to 12 o’clock and tilted slightly toward the model’s right and posteriorly to visualize the IVC. Learner to tilt probe slightly to the left to find aorta for confirmation. Tilt back to model’s right to visualize IVC, then reduce depth and find maximal diameter.

• Tuesday:
  • Identify relevant structures: liver, RA, IVC, hepatic vein, and aorta.
  • Practice other methods of visualizing the IVC:
    • Learner to place probe 2-3cm right from the subxiphoid process with probe marker at 12 o’clock. As confirmation, visualize aorta by tilting probe beam toward model’s left.
    • Learner to place probe midline at xiphoid with probe marker at 12 o’clock. Visualize the aorta, then tilt to model’s right to find the IVC. Ensure that IVC diameter and alignment is optimized.
    • Learner to place probe at right anterior axillary line with probe marker directed toward model’s head. IVC will be viewed trans-hepatically in the coronal plane. Ensure that the IVC diameter and alignment is optimized.
• Wednesday:
  • Optimize subcostal 4 chamber view.
  • Optimize subcostal and transhepatic IVC views.
  • Utilize remaining time, if any, to review other cardiac views.

Session Guidelines:

1. Abdominal Aorta

Model should be in the supine position. Learner should select curvilinear transducer. Learner locates the xiphoid process and places the probe in the midline just inferior to it. The probe marker should be oriented toward the model’s right.

• Locate the celiac trunk and identify the following structures: hepatic artery, splenic artery, IVC, aorta, and vertebral shadow.

Instructor to use ultrasound beam prop with celiac trunk insert to demonstrate anatomy. Learner then sweeps inferiorly to SMA level.

• Identify the following structures: SMA, aorta, IVC, left renal vein, splenic vein, portal confluence, pancreas, and vertebral shadow.

Instructor to use ultrasound beam prop with SMA insert to demonstrate anatomy. Learner then sweeps inferiorly until the bifurcation into the common iliac arteries is seen.

• Identify the common iliac arteries and veins.
• Examine the different ways to displace bowel gas:
  • Apply steady downward pressure. (Need to wait for bowel peristalsis.)
  • With model’s abdomen relaxed, wiggle probe to displace bowel gas.
  • Move the transducer laterally and image the vessels from an oblique angle.

Switch learners and repeat the above evaluation of the abdominal aorta in the transverse plane. The learner then rotates the probe such that the probe marker is directed toward the model’s head. Learner to locate then confirm aorta by tilting to the model’s right to visualize the IVC.

• Identify celiac trunk and SMA in longitudinal axis.

Learner then slides inferiorly to the bifurcation of the common iliac arteries. Learner rotates the transducer to align with one of the common iliac arteries then back to midline.

• Identify the bifurcation into the common iliac arteries. Compare its appearance to off axis imaging of the common iliac artery.
• Image the distal aorta obliquely to visualize both left and right common iliac arteries.

Switch learners and repeat the above evaluation of the abdominal aorta in the longitudinal plane. 

2. Hepatobiliary

Models should start supine, with knees flexed to soften the abdomen if necessary.  

If bowel gas limits imaging, can try left lateral decubitus positioning, or firm probe compression.

If rib shadow limits imaging, have the models perform inspiratory breath hold.

• Demonstrate following scanning approaches:
  • Subcostal sweep – indicator towards model’s head, start at xiphoid, sweep along costal margin
  • Flattened probe approach – indicator toward model’s right, place probe under costal margin, flatten against abdomen by tilting.
  • Approach from the R kidney – indicator toward model’s head, place probe at R mid-axillary line. Find R kidney, then sweep anteriorly until gallbladder is found.
  • X-7 – indicator towards model’s head, place probe down 7 cm to the right of the xiphoid process
• Once gallbladder is located, orient the probe to image the gallbladder in long-axis.  This may require a combination of several probe movements, which should be done one at a time.
  • Demonstrate exclamation mark sign – identify gallbladder, portal vein, main lobar fissure
  • Tilt probe to scan through gallbladder in long-axis, and evaluate for:
    • Wall thickness at proximal wall (outer wall to outer wall)
    • Pericholecystic fluid
    • Stone/Sludge
    • Polyps
• Evaluate portal triad (can be done before or after evaluation of gallbladder). 
  • Identify the Mickey Mouse sign – PV, CBD and HA
  • Use color to demonstrate differentiate CBD from HA
  • Center the CBD and rotate to image it in the long-axis.  Measure CBD diameter from inner wall to inner wall.
• Identify neighboring structures – liver, kidney, duodenum, pancreas, IVC, etc.
• Identify relevant artifacts:
  • Posterior acoustic enhancement
  • Edge artifact

​

Instructions on Lower Extremity Leg Vein Scanning 

• Probe marker should always be pointed toward the patient’s right.
• Demonstrate compression without displacement of the tissue
• Demonstrate 2 techniques for popliteal scanning:
  • Supine with knee externally rotated.
  • Supine with knee flexed.

Session Guidelines:

Model should be in the supine position. Learner should select the linear transducer. The transducer should be placed on the anterior abdominal wall in the transverse plane. The probe marker should be directed to model’s right.

• Identify the following structures in the transverse plane: dermis, subcutaneous fat, fascial plane, muscle, and bone.

Learner then rotates the probe such that the probe marker is now directed toward the model’s head.

• Identify the same structures in the longitudinal plane.

Switch learners. Place probe on the anterior thigh.

• Identify the following structures in both the transverse and longitudinal plane: dermis, subcutaneous layer, fascial plane, muscle, and bone.

Learner should now roll a towel and place it under the model’s knee. The knee should be in  20-30 degree flexion. Learner places the probe on the distal anterior thigh in the longitudinal axis with the probe marker directed toward the model’s head.

• Identify the quadriceps tendon, femur, and patella.

Learner should sweep to the left and to the right. Learner then slides the probe distally across the patella to the tibia.

• Identify the patellar ligament and the tibia (tibial tuberosity).
• Demonstrate anisotropy by tilting. Compress the area of anisotropy.

Switch learners. Place probe on the distal anterior thigh with the probe marker directed to the model’s right.

• While sweeping distally, identify the  following structures: quadriceps tendon, patella, patellar ligament, and the tibia (tibial tuberosity).
• Identify the lateral femoral condyle, medial femoral condyle, and the hyaline cartilage overlying the trochlear groove.

Use the remainder of the scanning session for review material from previous days.