Basic

Ultasonograph
y
By
By Dr.
Dr. SHASHWATH
SHASHWATH HEGDE
HEGDE
Department
Department of
of Emergency
Emergency Medicine
Medicine
India
India

How is the Image formed on the Monitor?

Strong reflections HYPERDENSE = White dots
Diaphragm, gallstones, bone
Weaker reflections = Grey dots Most solid organs,
thick fluid
No reflections (HYPODENSE)= Black dots Fluid within a
cyst, urine, blood

body and are used to image

superficial structures or organs
close to the skin surface. Short
wave lengths result in a higher
resolution ultrasound image,
meaning that superficial tissue is
seen in greater detail. The scanning
applications for a High Frequency
Transducer include;
Superficial blood vessels
Breasts
Testes
Thyroid
Nerves
Superficial skin lumps
Lung
Low Frequency6 Transducers emit

The most important mode for the ultrasound-beginner

is the B-mode. B-mode stands for brightness mode
and provides structural information utilizing different
shades of gray (or different brightness) in a twodimensional image (Figure 1).

Figure 1: Sample of B-Mode image.

M-mode stands for motion mode. It captures returning
echoes in only one line of the B-mode image but
displays them over a time axis. Movement of
structures positioned in that line can now be visualized.
Often M-mode and B-mode7 are displayed together on

FAST is an acronym for Focused

Assessment with Sonography in Trauma
and has become synonymous with beside
ultrasound in trauma
extended FAST exam (EFAST), evaluating
for pneumo- and hemothorax in addition
to intraperitoneal injuries.(10,11,16)

Learning to perform the FAST exam simply involves

earning how to visualize the heart, diaphragms, liver,
spleen and bladder.
Overall, the FAST exam is about 90% sensitive for
detecting any amount of intraperitoneal free fluid

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The testicle can appear enlarged and hypoechoic

and the parenchyma of the testicle will become less
homogenous when compared with the unaffected
testicle (Figure 5)

Figure 5: Transverse scan of both testicles showing

normal left testicle and right testicular torsion. Note the
hypoechogenicity of the right testicle. (Courtesy of
Michael Blaivas, M.D.)
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Introduction
Physics
Emergency uses
Fast
Doplar USG
Cardiac and aortic
Gynecology and OBstetric
Conclusion

Objectives
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 Hearing Range in different

Animals
kHz Frequancy

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Physics
The first application of
ultrasound as a medical
diagnostic tool was
published in 1942 by Karl
and Friederich Dussik in
Vienna. The Austrian
brothers attempted to
locate brain tumors and
the cerebral ventricles by
measuring ultrasound
transmission through the
skull.

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History
Around 1900 , machine, called
hydrophone, sent and received
ultrasonic signals underwater.
The Titanic disaster in 1912 and World
War I accelerated investigations of
underwater and airborne echoranging systems.
This lead to the beginning of SONAR
(Sound Navigation and Ranging) and
RADAR (Radio Detection and Ranging,
using electromagnetic waves).
The main industrial application of
ultrasonic waves in the 1930s and
1940s became the detection of metal
flaws.

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II. Ultrasound Modes

The most important mode for the ultrasound-beginner is the B-mode. B-mode stands for brightness mode and provides structural information utilizing different
.shades of gray (or different brightness) in a two-dimensional image (Figure 1)

.Figure 1: Sample of B-Mode image

M-mode stands for motion mode. It captures returning echoes in only one line of the B-mode image but displays them over a time axis. Movement of structures
positioned in that line can now be visualized. Often M-mode and B-mode are displayed together on the ultrasound monitor. (Figure 2)

.Figure 2: M-Mode (lower portion of the image) combined with B-Mode image. In this still image the M-mode captures the movement of a particular part of the heart

.The Doppler mode follows very sophisticated and complex laws of physics
It utilizes a phenomenon called Doppler shift, which is a change in frequency from the sent to the returning sound wave. These changes or shifts are generated by
.sound waves reaching moving particles. The change of frequency/amount of shift correlates with the velocity and direction of particle motion
In simplified terms, the Doppler mode examines the characteristics of direction and speed of tissue motion and blood flow and presents it in audible, color or spectral
.displays

Color Doppler ultrasound is also called color-flow ultrasound. It is able to show blood flow or tissue motion in a selected two-dimensional area. Direction and velocity of
.tissue motion and blood flow are color coded and superimposed on the corresponding B-mode image (Figure 3)

.Figure 3: Color Doppler image

Power Doppler: Unlike color Doppler, common power Doppler does not examine flow velocity or the direction of flow. It looks at the amplitudes of the returning
.frequency shifts and is able to detect even states of very low flow (Figure 4). This is of use when examining vascular emergencies such as testicular or ovarian torsion

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Diagnostic ultrasound used for

common medical imaging uses
frequencies between 2 and 20
million Hertz (Megahertz,
MHz).Lower frequencies are able
to penetrate deeper into tissue
but show poorer resolution. In
contrary higher frequency
ultrasound will display more
detail with a higher resolution in
exchange for less depth
penetration. This is a very
important principle when
choosing your probes and
frequencies
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 Image Interpretation:

Anechoic / Echolucent - Complete absence of returning sound

waves, area is black.
Hypoechoic - Structure has very few echoes and appears darker
than surrounding tissue.
Hyperechoic / Echogenic - Opposite of hypoechoic, structure
appears brighter than surrounding tissue.
Image Acquisition / Probe Positions:

Transverse Plane - Also known as an axial plane or cross section,

runs parallel to the ground separating the superior from the
inferior, or, the head from the feet.
Sagittal Plane - Oriented perpendicular to the ground, separating
left from right. The "midsagittal plane" is a sagittal plane that is
exactly in the middle of the body.
Coronal Plane - Also known as the frontal plane, separates the
anterior from the posterior or the front from the back.

Oblique Plane- The probe is oriented neither parallel to, nor at

right angles from, coronal, sagittal or transverse planes.

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IV. Probes
Several different types of probes are commonly used in emergency departments. These transducers
consist of the active element (the piezoelectric crystal), damping material and a matching layer. Different
arrangements and forms of activation of the active element have lead to a variance of probes. The most
:common transducers utilized in the emergency department are listed below

:Large Convex Probe

.Main ED utilization is transabdominal sonography
Produces a sector shaped image with a large curved top
.The active element is arranged in a large curved line, also called large curved probe or transducer

:Microconvex Probe
.Utilized for transabdominal or transthoracic sonography
.Produces a sector shaped image with a small curved top
The active element is arranged in a small curved or convex line, the probe can be called small curved
.transducer

:Linear Probe
.Main utilization is vascular sonography or evaluation of superficial soft tissue structures
.It produces a rectangular image. The active element is arranged in a straight line

:Intracavity Probe
.Basically a microconvex probe on a large handle, its main utilization is endovaginal ultrasound

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What happens
to sound
through media

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Doppler ultrasound is based upon the Doppler

. Effect
When the object reflecting the ultrasound
, waves is moving
It changes the frequency of the echoes,
creating a higher frequency if it is moving
toward the probe and a lower frequency if it
. is moving away from the probe
Doppler ultrasound has been used mostly to
measure the rate of blood flow through the
.
heart and major arteries

Doppler Ultrasound
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xiphoid Four-Chamber View: Place the

probe in the subxiphoid region with the
marker-dot toward the patients right side
or right shoulder. Angle the probe toward
the left shoulder (Figure 1). This view
shows the right ventricle immediately
adjacent to the left lobe of the liver
(Figures 2, video clip 1). A pericardial
effusion will be easily recognized between
the liver and the heart

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Figure 1: Position of the ultrasound probe for the

subxiphoid view.
Figure 2: Subxiphoid view. Video clip 1: Subxiphoid
view.
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Parasternal Long-Axis View: Place the probe

just to the left of the sternum in about the
4th or 5th intercostal space, directly over
the center of the heart, with the marker-dot
toward the 4 oclock position (Figure 3). This
view shows the anterior and the posterior
pericardium (Video clip 3). Sliding the probe
toward the cardiac apex (toward the 4
oclock position) provides a good look at the
apex. This view requires less depth and is
easier to obtain in uncooperative patients.

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Right Coronal and Intercostal Oblique Views

:
The easiest abdominal view to
obtain is the view of Morisons
pouch.
To obtain this view place the probe
in the mid-axillary line at about the
8th to 11th intercostal space with
the marker-dot pointed cephalad .
This gives a coronal view

Right Coronal and

Intercostal Oblique Views

Abdominal and lower thoracic views

Figure 4: Shows probe position. Figure 5 and 6:

Morisons pouch view with focus on the liver tip (6).

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Right upper abdominal view with fluid in Morisons

pouch.

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Probe position lt sided pleural evaluation

Pleural fluid

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Positive FAST scan with

fluid between superior
aspect of liver and
diaphragm

Left Coronal and Intercostal Oblique Views:

This is often the most difficult abdominal view to
obtain.
Place the probe in the posterior-axillary line at
about the 6th to 9th intercostal space with the
marker-dot pointed cephalad, producing a coronal
view.
Free fluid is seen surrounding all parts of the
spleen or between spleen and diaphragm.
To get rid of rib shadows, and to get a better view
of the spleen, slide the probe cephalad and rotate
it very slightly clockwise, producing an intercostal
oblique view
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Fluid surrounding the spleen

Probe position for LUQ FAST

Normal perisplenic view

Pelvic Views:
Since the pelvis is the most dependent part of the peritoneal
space, it is the most likely place to see abdominal free fluid
Obtain both longitudinal and transverse views of the pelvis.
Place the probe in the midline just cephalad to the pubic bone
with the marker-dot pointed cephalad.
Make sure the probe position is correct by actually placing the
probe on the pubic bone and noting a bone shadow on the
image.
A full bladder will be triangular in shape.
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Pelvic view

Small amount of free

fluid in pouch of Douglas
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Large amount of free fluid

(black) surrounding the
uterus.

Longitudinal-oblique view of a normal lower

aorta and bifurcation.
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Stones of the Gall Bladder

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Dilated ureter seen below

bladder
transverse view
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kidney stones
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Pearls and Pitfalls

If the initial FAST exam is negative and clinical suspicion remains
high, consider a repeat FAST exam after a short time period.
Trendelenburg position may be required to visualize free fluid
during perihepatic and perisplenic examination.
Consider reverse Trendelenburg position while evaluating for
hemothorax or pelvic free fluid.
It is important to visualize as much perihepatic and perisplenic
area as possible, not just one quick view.

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Gas Subcutaneous emphysema may obscure visualization

of underlying structures.
The hypoechoic stripe of a pericardial effusion usually
wraps around the apex of the heart.
Perinephric fat, especially in obese patients, may be
misinterpreted as intraperitoneal free fluid.
Free fluid isnt always blood;
Not all abdominal injuries produce free fluid.

Clotted blood can generate various degrees of echogenicity and may

be mistaken for normal surrounding soft tissue.
The pelvic view should be completed prior to placement of a Foley
catheter.
Chest ultrasound can only detect a pneumothorax which is directly
under the probe, so consider looking in several sites on the anterior
chest.
Lack of pleural sliding may indicate a pneumothorax, mainstem
intubation or just poor ventilation.
Dimming the lights in the exam room may provide the examiner with
an improved display of ultrasound findings.