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Lung US: Upcoming trend in ED - อ.พญ.สุธาพร ล้ำเลิศกุล
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Point of care bedside ultrasound in critical decision making
Suthaporn Lumlertgul M.D.!Emergency unit, King Chulalongkorn Hospital!
WINFOCUS Thailand director
Basics and upcoming trends
Quick history of lung ultrasound
• Pneumothorax!
• Pulmonary Edema!
• Pleural Effusion !
• Pneumonia!
• ARDS
Emergency Thoracic Ultrasound
In the supine patient, fluid will be in the posterior dependent segments while air will be more apparent in the anterior segments.
Air
Pleural effusion
rib shadow
pleural line
• Spontaneous!
• Chest trauma!
• Mechanical ventilation patients!
• Iatrogenic!
• Thoracenteses!
• Central line placements
Pneumothorax
1. Probe
2. Location
3. Orientation
Pneumothorax
Technique
Pneumothorax
DiagnosisSensitivity Limitations
Physical Exam 58% when compared to CXR
CXR 20-75% supine films
CT 98+% cost, radiation, transport, time
Chen SC et al. Hemopneumothorax missed by auscultation in penetrating chest injury. J Trauma. 1997 Jan; 42 (1):86-9
rib shadow
pleural line
MM
Lung Sliding
No Lung
Sliding
M M
A: Stratrophere Sign. B; Gliding of pleura results in Comet tail artifact which produce as Granular pattern in M Mode below pleural line called; Seashore sign
Pleural line
Soft tissueA
B
Pleural line
Soft tissue
Pneumothorax
Lung point
normal lung sliding
Lung
PneumothoraxNormal
LungLung
Lung
Lung slidingno Lung sliding
Lung point
Case
• A 45 years old come in with alteration of conscious
• The diagnosis is intracranial hemorrhage, u design to intubate
• After intubate the patient saturation is 90-92%
• You wonder if your tube is in the right place
Lung Sliding
Lung pulse
M
No Lung
Sliding
M
Seashore sign
• Hyperechoic lines!
• Horizontal !
• Parallel to pleura!
• Regular intervals!
• Normal artifact
A-linesPulmonary Edema
Reverberation
A line
A line
pleural line
• Hyperechoic lines!
• Vertical, radial!
• Originates at pleura!
• Extends to bottom of screen without fading!
• Erases A-lines!
• Sign of interstitial thickening
B-linesPulmonary Edema
sensitivity and specificity of 94 and 92%,
Dry Dyspnea Wet Dyspnea
Dry Dyspnea Wet Dyspnea
In the case of pulmonary edema, with a positive likelihood ratio of 12.4 and a negative likelihood ratio of 0.06
Rapid, noninvasive, inexpensive, reproducible, safe, and accurate way
Ultrasound Enhancedresuscitation; pocket Manual
US does not replace medical history, physical examination, or clinical judgment. It rather serves as a tool to increase or decrease the probability of the disease to a level that could prompt finalizing the diagnosis and streamlining the treatment.
• Pneumothorax!
• Pulmonary Edema!
• Pleural Effusion !
• Pneumonia!
• ARDS
Emergency Thoracic Ultrasound
A line
A
pleural line
Rt Lt
• Pneumothorax!
• Pulmonary Edema!
• Pleural Effusion !
• Pneumonia!
• ARDS
Emergency Thoracic Ultrasound
B5 ?
{7 mm
{3 mm
B7 Interlobular - septa process, Diffuse pulmonary fibrosis!
B3 Interlobular - alveolar process, ARDS/pulmonary edema
B3 VS B7
In the land of blind , the one eye man is king
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