Figure 215 probe positioning for the transverse

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Figure 2.15 Probe positioning for the transverse suprapubic view (green arrow pointing to patient’s right) and longitudinal suprapubic view (green arrow pointing to patient’s head). 36 Diagnostic ultrasound Focused assessment with sonography in trauma (FAST)
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difficulty visualizing the bladder is a probe position that is too superior. Remember that the bladder is a pelvic organ and only emerges from above the symphysis pubis as it becomes distended. Examine for fluid posterior to the bladder, posterior to the uterus, and between loops of bowel. It is import- ant to look in both transverse and longitudinal planes for fluid behind the bladder, as the sagittal or longitudinal view is more sensitive for small amounts of fluid. Once the bladder is identified transversely, rotate the probe 90 degrees for the longitudinal view. The longitudinal view is more sensitive for free fluid, because free fluid outside the posterior bladder wall is easier to identify in this plane. Moreover, occasionally if the bladder is very full the transverse view is obtained higher in the peritoneal cavity and so the most dependent part of the pelvis (the rectovesicular space) is missed. Finally, it is important to fan anterior to posterior in the transverse view and side to side in the longitudinal view in order to fully interrogate this space. Subxiphoid Cardiac views are reviewed in more detail in Chapter 3 . For the FAST subxiphoid view, position the probe almost flat on the abdomen with the marker to the patient’s right and angle the probe to the patient’s left shoulder ( Figure 2.17 ). If the patient can bend his or her knees, sometimes this helps relax the abdominal wall muscles. It is also important to remember to bring the depth out to its maximal level for this view, because often the distance from the subxiphoid to the heart is at least 6 cm. With shallow depth settings, the heart will not be visualized. In addition, sometimes a stomach full of air can scatter the ultrasound beams before they reach the heart in the left chest. If this is a problem, slide the probe to the patient’s right and shoot through the left lobe of the liver (as detailed in Chapter 3 ). The liver will act as a better acoustic window than the stomach, and the heart will be easier to visualize ( Figure 2.18 ). Bladder Rectum Figure 2.16 Normal transverse view of the pelvis. Diagnostic ultrasound 37 Focused assessment with sonography in trauma (FAST)
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Scanning tips Trouble with the RUQ view Rib shadow in the way ? ± Try angling the probe obliquely to sneak in between the ribs. ± Have the patient take a deep breath to lower the diaphragm and bring Morison’s pouch lower in the abdomen below the ribs. Can’t see the diaphragm? ± Try bringing the probe lower on the abdominal wall (toward the stretcher in a more posterior coronal plane).
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