2 POCUS in Emergency FAST IVC LUNGresidents December 2022

POCUS IN
EMERGENCY
Dr. Asmaa Mohamed Alkafafy
Assistant Professor of emergency medicine
Faculty of medicine Alexandria university
Member of the scientific council at Egyptian fellowship
of emergency medicine
POCUS Instructor at sonoschool Egypt
Agenda / ILOs
• Different applications and protocols
• Basic knobology and proper image
acquisition
• E FAST
• Lung ultrasound
• Utilization of ultrasound in the ED is now becoming
prevalent
• It is considered the emergency physician’s third eye or

new stethoscope
• Point of care lung ultrasound is crucial in emergency room

Applications
• Fluid collection ( intra abdominal- pleural –pericardium)
• Pneumothorax
• Cardiac arrest
• Pulmonary oedema
• IVC diameter
• DVT
• Aortic dissection
• Global systolic function
• Increase ICP
• Ultrasound guided procedures
Different protocols
• FAST
• E FAST
• BLUE
• RUSH
• RUSH VTI
• And many others…..

Ultrasound
Basics
Ultrasound
refers to sound
frequencies
beyond
20,000Hz
Echogenicity
Fat and Bone
AIR
Echogenicity
Hyperechoic / white; are
tissues that give strong
echo such as FAT and
BONE
Anechoic / black; are

tissues that give weak
echo such as fluid and
blood
AIR is very weak

conductor of
ultrasound…… Black,,,,
Reverbation artifacts
Ultrasound modes
• B mode ,,, brightness mode,,, 2D image
• M- Mode ,,,, motion mode

Ultrasound modes
• B mode ,,, brightness mode,,, 2D image
• M- Mode ,,,, motion mode
• Doppler mode,,, color, CW, PW

Ultrasound
Planes
Ultrasound Planes
Transverse plane Sagittal plane
Ultrasound transducers
• The higher the frequency the lesser the penetration
and the more the resolution & v. v.
• High frequency linear transducer (7-12 MHz) is the best for

airway, vascular, superficial structures (superficial 2-3 cm from
the skin)
• The curved low-frequency (2-5 MHZ) transducer is most

suitable for deep organs.
• The micro convex (4-10 MHz) transducer gives a wide view of

the pleura between two ribs.
ULTRASOUND TRANSDUCERS
Convex
Low frequency
Linear
High
frequency
probe
Microconvex
probe
How to obtain proper US image ?
If only one transducer available
USE THE CURVILINEAR/

DEEP / LOW FREQUENCY
PROBE!
Probe Orientation
KNOB
identification
GENEROUS GEL
APPLICATION
Optimize GAIN & DEPTH
Pressure Alignment Rotation Tilting
Remember PART
FAST
What is FAST?
• Focused
• Assessment
• with Sonography for
• Trauma
FAST
eFAST
eFAST Components
1) RUQ
2) Sub-xiphoid
3) LUQ
4) Pelvic
5) Right
6) Left
Pneumothorax
Probe Selection
•Curvilinear
•Phased Arrey
RUQ
• Components:
Abnormal
Tips
• Position the patient supine
• Don’t forget to scan the inferior pole of the kidneys
• Avoid rib shadow by rotating the probe in intercostal
space
• Don’t misdiagnose peri-nephric fat with Free fluid
collection
Double line sign (perinephric fat)
Double line sign
Sub-xiphoid View
Abnormal
Tips
• Ask the patient to bend their knees, it helps relax the
abdominal wall
• Don’t misdiagnose pericardial fat pad with pericardial
effusion
Pericardial fat pad vs Effusion
LUQ
Abnormal
Tips
• Don’t misdiagnose Stomach with Free fluid collection
Supra-Pubic View
Male - LS
MALE LS and TS
Female - LS
Female - TS
Female - TS
Male vs female
Abnormal
Abnormal
Abnormal
Tips
• Females >>> ovulation time
• Males >>> Seminal Vesicles
• Full bladder
• Decrease gain settings in the far field to
compensate for posterior acoustic enhancement

caused by fluid filled bladder.
Lung Views
• Bilateral most apical point of both lungs and assess
for criteria of pneumothorax
Normal Lung
• Sliding of the visceral against parietal pleura
• No pleural collection
• A- lines
Pl. sliding sign (B &M- modes)
Results
The 10 basic signs BLUS
• Bat sign (indicating pleural line),
• Lung sliding (yielding the seashore sign),
• A line (horizontal artifact),
• Quad and sinusoid sign indicating pleural effusion,
• Tissue / Shred sign indicating lung consolidation,
• B line and lung rockets (artifacts indicating interstitial
syndrome),
• Absent lung sliding with the stratosphere sign,
suggesting pneumothorax,
• Lung point, diagnostic for pneumothorax.
Sensitivity and specificity BLUS
ranging from 90 to 100%compared to
the gold standard (CT Scan)
Different ultrasound protocols
• 8 zones protocol
A- lines vs B- lines
• A –lines (Air) : reflection of the pleural line
• Normal or pathological (pnemothorax, pulmonary

embolism, bronchial asthma and COPD)
• B-lines are pathological indicating lung congestion; Heart

Failure, pneumonia,…etc.
A- lines
B-LINES
B-LINES
Pneumothorax
• Criteria to diagnose Pneumothorax:
1.No lung Sliding
2.Barcode sign in M-mode
3.Lung point (most specific)

Pneumothorax
Absent pleural sliding
• Pleural adhesions
• Bullae
• Lung disease
• Surgical emphysema
• Right main bronchus intubation

Lung point
Tips
• In assisted ventilated patient look for lung sliding
while giving breath .
• Decrease the depth while using curvilinear or deep
probe
Shred sign
Hemothorax
• Get space or two above the RUQ on right side and
LUQ on left side
1. Absence of mirror image
2. Spine Sign
Curtain Sign
Hemothorax
Spine sign
Spine sign
A- B- C lung profiles
Dr. Mahmoud Maher
Assistant Lecturer of Emergency Medicine ,
Emergency Medicine Department, Faculty of
Medicine Alexandria University
• Bedside US is a valuable tool in the management of patients
with undifferentiated shock.
• US provides a direct view into the cardiovascular system
and allows the emergency physician to make determinations
about the hemodynamic status of a patient.
• Central venous pressures (CVP) and right atrial pressures
can be estimated by US evaluation of the inferior vena cava
(IVC) and the internal jugular veins, respectively.
• An IVC diameter of 1.5 to 2 cm is considered normal

• A small IVC is a reliable indicator of low central venous
pressure and volume depletion.
• Normal patients may have an IVC that collapses
completely with inhalation or sniffing, but an IVC that
remains small throughout the respiratory cycle is a sign
of significant volume loss.
•A dilated (>2 cm) and fixed (no change with
respirations) IVC and dilated hepatic veins are
consistent with an elevated central venous pressure;
however, these findings do not necessarily mean that a
patient is acutely volume overloaded because patients
with preexisting heart disease or pulmonary
hypertension will have these findings at baseline
• It should be understood that IVC size and collapsibility
provide some basic information about volume status,
especially at the extremes, but they are not good
indicators of the need for fluid in most patients. Using a
combination of IVC, cardiac, and pulmonary findings is
much more accurate.
M-mode
Technique
• Place the probe in the subxiphoid space, perpendicular to
the patient’s abdominal wall and with the marker aimed
toward the patient’s head
• The longitudinal IVC will appear posteriorly, beneath the
liver and the bowel, as a long black cylinder.
• It is important to distinguish the IVC from the aorta.
The aorta lies on the patient’s left side, is more “pipe-
like” in appearance, is noncompressible when pressure
is applied by the US probe, and has a recognizable
pulsatility.
• The IVC is compressible when pressure is applied by
the US probe and varies in diameter with respiration
• It may be beneficial to start in the transverse plane in which both
the IVC and the aorta are visualized
• Starting with the transverse view, rotate the US probe 90°,
maintaining the IVC in the center of the screen to obtain the
longitudinal view
• Measurements of the IVC proximal to its entrance into the right
atrium just beyond the point where the hepatic veins drain into the
IVC allows for a noninvasive estimate of CVP. The negative
pressure generated in the chest by inspiration draws blood
cephalad and decreases the diameter of the IVC
• Normal dimensions for the IVC include a diameter of 1.5 to 2.0 cm
and an inspiratory collapse of 50%.
• A smaller diameter and greater inspiratory collapse are indicative
of a low CVP.
• A larger diameter and lesser inspiratory collapse reflect a high
CVP
IVC measurement technique
The IVC collapsibility and distensibilty
indices
• IVC collapsibility index = [maximum diameter on
expiration – (minimum diameter on inspiration/maximum
diameter on expiration)].
• In mechanically ventilated patients IVC distensibility index

= [(maximum diameter on inspiration–minimum diameter
on expiration)/minimum diameter on expiration].
Limitations for e FAST
Can not visualize retroperitoneum, clotted blood or
distinguish solid organ injury
• Technical difficulties e.g. Morbid obesity , massive
subcutaneous emphysema, limited movement
• Operator dependent
Summary
• POCUS is essential tool for all emergency physicians
• Try complete your clinical ex. By POCUS
• Be aware of proper image acquistion and limitations
• Scan as much as you can and build up your own protocol

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POCUS IN

• It is considered the emergency physician’s third eye or

• Point of care lung ultrasound is crucial in emergency room

• And many others…..

Fat and Bone

Anechoic / black; are

AIR is very weak

• M- Mode ,,,, motion mode

• M- Mode ,,,, motion mode

• Doppler mode,,, color, CW, PW

• High frequency linear transducer (7-12 MHz) is the best for

• The curved low-frequency (2-5 MHZ) transducer is most

• The micro convex (4-10 MHz) transducer gives a wide view of

USE THE CURVILINEAR/

• Don’t forget to scan the inferior pole of the kidneys

• Avoid rib shadow by rotating the probe in intercostal

• Don’t misdiagnose peri-nephric fat with Free fluid

• Don’t misdiagnose pericardial fat pad with pericardial

• Males >>> Seminal Vesicles

• Decrease gain settings in the far field to

compensate for posterior acoustic enhancement

• Normal or pathological (pnemothorax, pulmonary

• B-lines are pathological indicating lung congestion; Heart

1.No lung Sliding

2.Barcode sign in M-mode

3.Lung point (most specific)

• Right main bronchus intubation

while giving breath .

• Decrease the depth while using curvilinear or deep

• An IVC diameter of 1.5 to 2 cm is considered normal

• In mechanically ventilated patients IVC distensibility index

• Technical difficulties e.g. Morbid obesity , massive

subcutaneous emphysema, limited movement

• Try complete your clinical ex. By POCUS

• Be aware of proper image acquistion and limitations

• Scan as much as you can and build up your own protocol

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