In those patients the pelvic view especially

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quadrant until a significant amount of fluid is present. In those patients, the pelvic view (especially longitudinal) may be more helpful. For a variety of normal and abnormal FAST exam images, refer to Chapter 2 . Aorta As discussed in Chapter 5 , leaking abdominal aortic aneurysms can have profound hemodynamic consequences. Thus, a rapid assessment of the aorta caliber can be useful in the evaluation of the acutely hypotensive patient. Although an aorta diameter greater than 3 cm (and iliac vessel diameter greater than 1.5 cm) is considered aneurysmal, the actual diameter must be placed into the proper clinical context. Figure 14.7 demonstrates an aneurysmal aorta. Diagnostic ultrasound 261 Ultrasound in shock
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Pleura and lung Pneumothorax is a common complication of trauma, medical illness such as chronic obstructive pulmonary disease (COPD) and asthma, and iatrogenic complications of mechanical ventilation, central line placement,and other critical care interventions. Thus, evaluation for pneumothorax (as detailed in Chapter 2 ) should be a standard part of the evaluation of the hypotensive patient. Some clinicians prefer to assess for pneumothorax using the same curvilinear, micro- convex, or phased-array probe used for the rest of the hypotension evaluation. Othersswitchtoahigh-frequencylinear probefor amore detailedexaminationof the pleural interface. The latter approach is likely to be more accurate. Figure 14.8 demonstrates the M-mode appearance of normal lung and pneumothorax. In addition, using the appearance or disappearance of B-lines when evaluat- ing the dyspneic or hypotensive patient can help assess cardiac function and can point to whether a patient is becoming fluid-overloaded or diuresing well. Because lung ultrasound is more dynamic than chest x-ray, patient monitoring with ultrasound can help guide clinical management more minutely. This is true not only with fluid overload but also with changes in the appearance of lung parenchyma with acute respiratory distress syndrome (ARDS), pneumonia, and other interstitial lung processes. Lung ultrasound is discussed in more detail in Chapter 9 . Increasing clinician familiarity with lung imaging techniques has the potential to change how pulmonary function is monitored in critical patients. Figure 14.7 Aortic aneurysm, over 8 cm in diameter. Figure 14.8 M-mode appearance of normal lung ( left ) and pneumothorax ( right ). Pleura (*) is visible in the middle of the screen. 262 Diagnostic ultrasound Ultrasound in shock
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Sample clinical protocol Figure 14.9 demonstrates common probe positions for the evaluation of hypotension causes, using the rapid ultrasound in shock/hypotension (RUSH) protocol. Table 14.2 summarizes these views as well as common pathology and clinical actions to consider. 4 3 5 2 8 7 1 6 Figure 14.9 Probe positions for rapid ultrasound in shock/ hypotension (RUSH): (1) heart, (2) IVC, (3, 4, 5) Morison’s pouch and the FAST exam, (6) aorta, and (7, 8) pneumothorax.
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