ITSUS- Self Study Modules

Teaching Ultrasound by Exploring Anatomy

Musculoskeletal Ultrasound - Self-Guided Practice

Objectives

1. Practice interrogating an anatomic region and centering the image by sweeping and sliding

2. Practice adjusting depth and gain to identify anatomic structures and details

3. Practice saving and labeling images

4. Recognize nerves, muscles, blood vessels, tendons, and bone on ultrasound

5. Practice using Color Doppler to identify arteries and veins (advanced)

Pre-scan

1. Press the power button to turn on the ultrasound machine

2. Press the patient button and enter your Med Center username, year, and program into the Last Name field (e.g. DOE01.MS1.TUBEA)

3. Enter the appropriate anatomy in the First Name field (e.g. Median Nerve)

4. Make sure that the linear probe is selected and that the “MSK” preset is selected

   1. If the wrong probe is selected, trace the wire from the linear probe to find its bay and press the button to select it

5. Accept the changes and create the new patient

CARPAL TUNNEL AND FOREARM

BEGINNER – Carpal Tunnel Anatomy

To acquire a view of the carpal tunnel and median nerve:

• Start with the probe halfway down the forearm with the leading edge pointed radially. Locate the median nerve between the muscle bodies of FDS and FDP. Hand should be supinated.

  • Adjust the depth and window until you see the radius

  • Identify the pronator quadratus with its fibers running parallel to the sonographic plane

  • Without sweeping or sliding, fan the probe proximally and distally until you get the sharpest image

  • When you have a good image, save it and label the FDS, FDP, PQ, radius, and median nerve

• Slide the probe radially until you find the radial artery

  • Identify the artery

  • Put some pressure on the vessel—does it collapse or not? 

• Move the probe back medially until the median nerve is once again centered in the image. Sweep the probe distally into the wrist and watch the path of the median nerve as it enters the carpal tunnel.

  • Identify the median nerve at the superficial radial aspect of the carpal tunnel and differentiate it from the tendons of the FDS and FDP

 INTERMEDIATE – Color Doppler

From a view of the radial artery:

• Press COLOR and move the box over radial artery using the trackpad

  • On Color Mode, red means the flow is toward the probe and blue means the flow is away. Fan the probe proximally then distally and observe the color changes

    • If this was a vein, how would the color flow be different?

    • Save and label an image of the radial artery and its surrounding structures

• Find the soft-key corresponding to INVERT and press it while keeping the image on the radial artery

  • How does the Doppler readout change?

ADVANCED – Anisotropy

From a view of the median nerve:

• Rotate the probe 90° and sweep medially until you find a tendon

• Rock the probe so the beam moves proximally and distally

  • Note the changes in the appearance of the tendon. This is anisotropy

• Move the probe back medially until the median nerve is once again centered in the image. Sweep the probe distally into the wrist and watch the path of the median nerve as it enters the carpal tunnel.

  • Identify the median nerve at the superficial radial aspect of the carpal tunnel by fanning the beam distally. The tendons should turn black but the median nerve should remain the same color. This illustrates that muscle tendons have a high degree of anisotropy.

  • Anisotropy is directionally dependent changes in material properties. In ultrasound, this means that changing the angle of incination of the probe can change how a structure appears on the scan. Tendons change color from white to black because when the angle of incination of the probe changes from 90, the sound waves can propagate down the collagen fibrils and be absorbed, rather than be reflected back towards the probe.

FINGER AND HAND

BEGINNER - Finger

• With the probe pointed proximally and acquire a longitudinal section of the palmar side of the finger

  • Slide the probe to center the joint in the field

• Save an image with labels demonstrating an IP joint and flexor tendon

ADVANCED – Radial Artery

From a view of the radial artery:

• Sweep the probe distally over the thenar eminence to follow the radial artery as it travels into the hand

  • Acquire and label an image demonstrating the course of the radial artery into the hand

  • ***NOTE: This may not be visible in every hand***

Saving and Labeling Images

1. When you have an image you like, press freeze

2. To place a text label, press TEXT and use the trackpad to move the text box near the piece of anatomy you’re labeling. Use the keyboard to enter your label. Press TEXT again to save your label and bring up a new text box.

3. To place an arrow, press the button with an arrow on it and move it around with the trackpad.

4. Press SAVE to store your labeled image

After Scanning

1. Press the power button to turn off the machine

2. Remove the sheets from the bed you used and put them in the linens basket. Put new sheets on the bed

3. Wipe off the probes (and yourself/your model) with towels, and put the towels in the linens basket.

4. Unplug the machine and wrap the power cord around the back. Make sure all the other wires are in place. Put the machine back where you found it.

5. Sign-in on the computer in the ultrasound room using the instructions in front of the screen. For the SESSION NAME field, select TUBE-A

Head and Neck Ultrasound - Self-Guided Practice

Objectives

1. Review the anatomy of the carotid sheath, infrahyoid muscles, larynx, and vertebral arteries and relate them to the surface anatomy

2. Practice interrogating an anatomic region and centering the image by sweeping and sliding

3. Practice pivoting and rotating the probe over an anatomic structure

4. Become familiar with the COLOR and DOPPLER tools and their utility in examining blood vessels

5. Become familiar with acquiring and saving video clips

Pre-scan

1. Press the power button to turn on the ultrasound machine

2. Press the patient button and enter your Med Center username, year, and program into the “Last Name” field (e.g. DOE01.MS1.TUBEA)

3. Enter the appropriate anatomy in the “First Name” field (e.g. Carotid Sheath)

4. Make sure that the linear probe is selected and that the “Vascular” preset is selected

   1. If the wrong probe is selected, trace the wire from the linear probe to find its bay and press the button to select it

5. Accept the changes and create the new patient

CAROTID SHEATH

BEGINNER – Carotid Sheath Anatomy

• Point the probe to the patient’s right and aim the beam neutrally

• Find the common carotid artery, internal jugular, and vagus nerve in cross-section, lateral to the thyroid cartilage and just medial to the sternocleidomastoid muscle

  • Center the carotid sheath in the image by sliding medially and laterally

  • Adjust the depth so that the whole sheath is visible without too much penetration below it

• Sweep the probe cephalad, then caudal, to follow the course of the carotid sheath. Try to keep the artery in the center of the screen while you do this.

• Sweep cephalad to return to the level of the thyroid cartilage

• Put pressure on the carotid sheath to demonstrate the difference in compressibility of veins and arteries

• Freeze the image and label the carotid artery, IJ, and vagus nerve. Save the image.

  • Press 2D to return to scanning mode and DELETE to clear the labels

INTERMEDIATE – Color Doppler

From a view of the carotid sheath:

• Press COLOR and use the trackpad to move the box over the carotid artery

  • Without leaving the level of the thyroid cartilage, fan the probe so that the beam aims caudally

    • What are you looking into, and which direction is the blood flowing in relation to the beam? Note the color over the artery.

• • Fan the beam so it is aimed cephalad. How does the color change?

  • Suppose you’re scanning a patient and can’t tell if the vessel you’re looking at is a vein or artery. How would you use the color tool to tell the difference?

ADVANCED – Pulse Wave Doppler

From a centered image of the common carotid artery:

• Center the image on the carotid artery and rotate the probe 90° counterclockwise to get a longitudinal section of the artery

• Press DOPPLER and move the indicator into the center of the arterial lumen

  • Rock the beam cephalad and caudally until the artery runs parallel to the line on the Doppler indicator

• Press the soft-keys to change the angle and width of the Doppler gate

  • After pressing each soft-key, you can press SELECT to toggle between moving different parts of the gate

  • Play around with these until you get the gate or the line through the gate parallel to the arterial walls

• Press DOPPLER again to acquire a trace

  • The carotid trace should look like this:

• • If it doesn’t, you can press UPDATE to readjust your probe or Doppler-gate alignment

  • Press UPDATE again to resume tracing

• You can press FREEZE to stop the trace and examine it more closely

• Repeat the process with the IJ to see the difference between an arterial and venous Doppler waveforms. You can make this process easier by lying down the model and lowering the head of the bed.

  • The IJ trace should look like this:

• Press 2D to return to regular scanning

VERTEBRAL ARTERY

ADVANCED

From a longitudinal view of the carotid artery

• Fan the beam medially until a big shadow appears. This shadow is produced by the vertebral body

  • Can you see the vertebral artery running through the vertebral canal?

    • Hint: it will only be visible between the vertebral bodies

• If you find the vertebral artery, save and label an image

VOCAL CORDS

ADVANCED

Change the settings of the probe from vascular to superficial. Point the probe to the patient’s right and aim the beam neutrally. Place the probe over the thyroid cartilage so that you get a cross-sectional view of the larynx

• Ask your model to hum or talk while you sweep the probe cephalad and caudal. Try to see the vocal cords vibrating deep to the thyroid cartilage

  • When you see the vocal cords, stop moving and optimize your image

• Ask your model to hum again, then press CLIP to capture a motion clip. Hold the probe stationary over the vocal cords until the machine beeps.

• Save your clip

Saving and Labeling Images

1. When you have an image you like, press freeze

2. To place a text label, press TEXT and use the trackpad to move the text box near the piece of anatomy you’re labeling. Use the keyboard to enter your label. Press TEXT again to save your label and bring up a new text box.

3. To place an arrow, press the button with an arrow on it and move it around with the trackpad. Press ____ to save the arrow in that position.

4. Put a text box in the lower left corner to describe the body part and the view you have acquired (e.g. R FOREARM CROSS SECTION)

5. Press SAVE to store your labeled image

After Scanning

1. Press the power button to turn off the machine

2. Remove the sheets from the bed you used and put them in the linens basket. Put new sheets on the bed

3. Wipe off the probes (and yourself/your model) with towels, and put the towels in the linens basket.

4. Unplug the machine and wrap the power cord around the back. Make sure all the other wires are in place. Put the machine back where you found it.

5. Sign-in on the computer in the ultrasound room using the instructions in front of the screen. For the SESSION NAME field, select TUBE-A

Cardiothoracic Ultrasound - Self-Guided Practice

Objectives

1. Practice sweeping, sliding, fan, rocking, and rotating the probe

2. Practice using Color Doppler to assess blood flow

3. Learn how to scroll through a series of frozen images

4. Become familiar with pictographic labeling

5. Become familiar with the Dual Window view

6. Learn how to change the orientation of the window to get a standard cardiology view

7. Become familiar with M mode and its utility in assessing pleural movement

Pre-scan

1. Press the power button to turn on the ultrasound machine

2. Press the patient button and enter your Med Center username, year, and program into the “Last Name” field (e.g. DOE01.MS1.TUBEA)

3. Enter the appropriate anatomical structure in the “First Name” field (e.g. Cardiac)

4. Make sure that the phased-array probe is selected

   1. If the wrong probe is selected, trace the wire from the linear probe to find its bay and press the button to select it

5. Accept the changes and create the new patient

PLEURAL VIEW

BEGINNER – Pleural Sliding

Put the probe along the right sternal border, with the leading edge toward the model’s head.

• Identify the white line in the near field. This is the pleura

• Ask your patient to take a deep breath and note the sliding movement of the pleura

ADVANCED – Pleural M-mode Tracing

Press M MODE and have your model breathe normally. The motion trace should look a sandy beach

• Move the probe to your forearm and use M MODE to assess its motion. Compare this to what you got for the lung

• Why are they different? When would the pleura resemble the bar code pattern of the forearm?

PARASTERNAL LONG AXIS

BEGINNER – Parasternal Long Axis and Anatomy

Acquire a parasternal long-axis view

• Rock the beam caudally to bring the apex of the heart into view

• Rock the beam cephalad to bring the base of the heart back into view

• Adjust the probe, depth, and gain until you have an optimal long-axis image.

INTERMEDIATE – Color Doppler

From a standard parasternal long axis view:

• Press COLOR and move the box over the interventricular septum. Verify that your model does not have a VSD and save an image to prove it.

 INTERMEDIATE – Scrolling Through Saved Frames

From a standard parasternal long axis view:

• Press FREEZE to save the image. When you press FREEZE, the ultrasound machine saves several frames acquired before that.

  • Use the trackpad to scroll through these frames and see which one shows the anatomy most clearly

• Press PICTO to bring up the pictographic labels. You can scroll through the available pictographs using the soft-keys. When you find the picto for the long axis view, press SELECT

• Label the visible anatomy and save the image

ADVANCED – Changing Image Orientation

From a standard parasternal long-axis view in B mode:

• Press the soft-key farthest to the right to access the second page of soft-key options

• Press the second soft-key (U/L) to change the orientation of the image. Do this until you have the leading edge indicator on the upper right corner of the window. This is the conventional cardiology view

• Note how the orientation of the anatomy changes as you change the orientation of the screen

• Get a new parasternal long-axis view with your leading edge pointing toward the model’s right shoulder. How does this compare to your original image?

• Press the soft-keys to return to the original image orientation, with the leading edge indicator in the upper left corner

ADVANCED – End-Point Septal Separation

From a standard parasternal long-axis view:

• Rock and slide until you center the mitral valve in the frame

• Adjust the depth to make the mitral valve as large as possible

• Adjust the gain to optimize the image

• Press M-MODE and use the trackpad to put the line through the mitral valve

  • Make sure the line passes through the spot where the valve leaflet hits the interventricular septum

• Press UPDATE to acquire the motion trace

  • In the middle of the trace, you should see a black area with a series of white peaks interrupting it

• Press CALC to pull up the calculation functions

  • Use the trackpad to scroll to the MV sub-menu and press SELECT, then scroll to EPSS and press SELECT again

  • Put the first cursor at the very tip of one of the peaks

  • Put the other cross on the other end of the black space

    • ***In this exercise, you’re measuring how close the mitral valve comes to hitting the septal wall during diastole. This is a rough estimate of ejection fraction. Note that this measurement is very user dependent and being off-axis can result in an inaccurate measurement.***

• Interpret the value that the CALC function gives you

  • __________

PARASTERNAL SHORT AXIS

BEGINNER – Parasternal Short Axis and Anatomy

From a standard parasternal long axis view:

• Rotate the probe 90° clockwise until the leading edge is pointing to the patient’s right hip

  • This is the parasternal short axis view

• Sweep or fan the probe cephalad to get the mediastinal view. Identify the aortic valve, and chambers of the heart.

  • Save and label an image with the relevant anatomy

• Sweep or fan the probe caudally to see the base of the heart. Identify the mitral valve and the chambers of the heart

  • Save and label an image with the relevant anatomy

• Sweep or fan the probe caudally to get the mid-heart view. Identify the papillary muscles, chordae tendinae, and visible chambers of the heart.

  • Save and label an image with the relevant anatomy

ADVANCED – Dual Window

From a standard parasternal long-axis view:

• Press the soft-key for the dual window view. You’ll see the long axis view in the left window

• Press UPDATE to freeze the long axis image in the left window

  • Rotate the probe 90° to get a parasternal short axis view in the right window

• Save and label dual-window short-axis views (with appropriate pictographs) demonsrating the mitral valve, aortic valve, and papillary muscles

  • For each view, place a line or arrow through the left window showing the location of the short axis cut

APICAL 4-CHAMBER

ADVANCED – A4C View and Interpretation

• Ask the patient to lie in the left lateral decubitus position

• Place the probe at the patient’s PMI, with the leading edge toward the right hip

• Fan the probe cephalad so that the beam gives you a coronal section of the heart

• Save and label an image identifying the four chambers, interventricular and inter-atrial septa, and atrioventricular valves

Saving and Labeling Images

1. When you have an image you like, press freeze

2. To place a text label, press TEXT and use the trackpad to move the text box near the piece of anatomy you’re labeling. Use the keyboard to enter your label. Press TEXT again to save your label and bring up a new text box.

3. To place an arrow, press the button with an arrow on it and move it around with the trackpad.

4. Press SAVE to store your labeled image

After Scanning

1. Press the power button to turn off the machine

2. Remove the sheets from the bed you used and put them in the linens basket. Put new sheets on the bed

3. Wipe off the probes (and yourself/your model) with towels, and put the towels in the linens basket.

4. Unplug the machine and wrap the power cord around the back. Make sure all the other wires are in place. Put the machine back where you found it.

5. Sign-in on the computer in the ultrasound room using the instructions in front of the screen. For the SESSION NAME field, select TUBE-A

Aortic Ultrasound - Self-Guided Practice

Objectives

1. Practice sweeping, sliding, fan, rocking, and rotating the curvilinear probe

2. Review the anatomy of the abdominal aorta and its major branches

3. Learn to use pulse-wave Doppler to compare arterial and venous waveforms

Pre-scan

1. Press the power button to turn on the ultrasound machine

2. Press the patient button and enter your Med Center username, year, and program into the “Last Name” field (e.g. DOE01.MS2.TUBEA)

3. Enter the appropriate anatomical structure in the “First Name” field (e.g. Aorta)

4. Make sure that the curvilear probe and the VASCULAR setting are selected

   1. If the wrong probe is selected, trace the wire from the linear probe to find its bay and press the button to select it

5. Accept the changes and create the new patient

BEGINNER – Abdominal Aorta and Branches

Note-  When scanning the aorta, bowel gas can occasionally obstruct your view of the structures. You can try to move the gas out of the way by trying to push the bowel gas out of the way.

• Place the probe on the patient’s midline in the epigastric area. The leading edge should be pointing to the patient’s right.

  • With the probe in a neutral position, identify the vertebral body and shadow in the far field

  • Identify the abdominal aorta and IVC just anterior to the vertebral column

• Sweep inferiorly, keeping the probe at a neutral angle, until you see celiac artery emerge from the aorta.

  • The celiac trunk looks like a seagull emerging anterior to the aorta at the level of T12 (Note: the celiac trunk can come off at different angles and may not be all visible in a single plane)

  • Identify the common hepatic artery traveling toward the leading edge

  • Identify the splenic artery traveling toward the receding edge

  • Press FREEZE and label the aorta, IVC, vertebral body, celiac trunk, and any visible branches of the celiac artery.

• Continue to sweep inferiorly until you see the SMA in cross-section

  • The SMA is just anterior to the aorta at the level of L1

  • It is surrounded by hypoechoic material giving it a distinct appearance

  • Label and save an image demonstrating the relationship of the SMA to the abdominal aorta

• Continue to sweep inferiorly until you see the bifurcation of the aorta into the common iliac arteries near the umbilicus

  • Label and save an image showing the left and right common iliac arteries.

INTERMEDIATE – Renal Arteries

Begin by finding the SMA as described above.

• Make a small sweep inferiorly to find the renal arteries.

  • The right renal artery (RRA) passes behind the IVC in its course and looks like it is emptying into the IVC

  • The left renal artery (LRA) emerges superior and ventrally to the RRA

• Try to follow the course of the LRA to the left kidney

• Save and label an image demonstrating one of the renal arteries emerging from the abdominal aorta

ADVANCED – Pulse-wave Doppler of Aorta and IVC

Begin by finding the abdominal aorta in cross-section, as described above.

• Rock and slide the probe to center the aorta in the view.

• Rotate the probe 90 degrees so that the leading edge now points toward the patient’s head

  • If necessary, sweep slightly to either side to bring the aorta back into the view

  • This is the longitudinal view of the aorta

• Press DOPPLER and move the indicator into the center of the arterial lumen

  • Rock the beam cephalad and caudally until the artery runs parallel to the line on the Doppler indicator

• Press the soft-keys to change the angle and width of the Doppler gate

  • After pressing each soft-key, you can press SELECT to move different parts of the gate

  • Play around with these until you get the gate or the line through the gate parallel to the arterial walls

• Press DOPPLER again to acquire a trace

  • The aorta trace should look like this:

• • If it doesn’t, you can press UPDATE to readjust your probe or Doppler-gate alignment

  • Press UPDATE again to resume tracing

• You can press FREEZE to stop the trace and examine it more closely

• Repeat the process with the IVC to see the difference between an arterial and venous Doppler waveforms

  • The IVC trace should look like this:

• Press 2D to return to regular scanning

Saving and Labeling Images

1. When you have an image you like, press freeze

2. To place a text label, press TEXT and use the trackpad to move the text box near the piece of anatomy you’re labeling. Use the keyboard to enter your label. Press TEXT again to save your label and bring up a new text box.

3. To place an arrow, press the button with an arrow on it and move it around with the trackpad. Press ____ to save the arrow in that position.

4. Put a text box in the lower left corner to describe the body part and the view you have acquired (e.g. R FOREARM CROSS SECTION)

5. Press SAVE to store your labeled image

After Scanning

1. Press the power button to turn off the machine

2. Remove the sheets from the bed you used and put them in the linens basket. Put new sheets on the bed

3. Wipe off the probes (and yourself/your model) with towels, and put the towels in the linens basket.

4. Unplug the machine and wrap the power cord around the back. Make sure all the other wires are in place. Put the machine back where you found it.

5. Sign-in on the computer in the ultrasound room using the instructions in front of the screen. For the SESSION NAME field, select TUBE-A

Hepatobiliary Ultrasound - Self-Guided Practice

Objectives

1. Review the anatomy of the liver, gallbladder, small bowel, portal system, and hepatic veins and relate them to the surface anatomy

2. Practice interrogating an anatomic region and centering the image by sweeping and sliding

3. Practice pivoting and rotating the probe over an anatomic structure

4. Become familiar with the COLOR, DOPPLER, and CALIPER tools and their utility in examining blood vessels and ducts

5. See peristalsis in the pylorus and small bowel, in real-time

Pre-scan

1. Press the power button to turn on the ultrasound machine

2. Press the patient button and enter your Med Center username, year, and program into the “Last Name” field (e.g. DOE01.MS1.TUBEA)

3. Enter the appropriate anatomic structure in the “First Name” field (e.g. Portal Triad)

4. Make sure that the curvilinear probe is selected and that the ABD preset is selected

   1. If the wrong probe is selected, trace the wire from the linear probe to find its bay and press the button to select it

5. Accept the changes and create the new patient

LIVER AND PORTAL SYSTEM

BEGINNER – Hepatic Veins

• With the leading edge to the patient’s right, place the probe in the subxiphoid region in a neutral position (perpendicular to the patient’s body)

• Fan the beam superiorly to see the hepatic veins draining into the IVC

  • This is called the “antler sign”

• Save an image and label the hepatic veins (right, middle, and left), IVC, and liver

BEGINNER – Portal and Hepatic Veins

• Place the probe in the sagittal plane, along the right costal margin

• Sweep laterally until you can identify the portal vein (with its hyperechoic walls) and hepatic veins

• Save an image and label the portal vein, hepatic veins, and liver

INTERMEDIATE – Portal System Anatomy

• Begin from a neutral subxiphoid position

• Fan the beam cephalad (not as far as you would to see the antler sign) and look for the portal system

  • The portal veins are recognizable for their thick, hyperechoic borders

• Once you find the portal system, fan slightly cephalad and caudal to see and define the main portal vein and its main tributaries

  • From this view, this area looks like a “recumbent H”—an “H” lying on its side—with the MPV forming the middle section

• Save images demonstrating the recumbent H and label each branch of the MPV properly

  • You will probably need multiple images at slightly different angles to see all four branches

ADVANCED – Pulse-wave Doppler of the Portal Vein

• Find the main portal vein and its main tributaries (the recumbent H) as described above

• Press DOPPLER and move the indicator into the center of the MPV (middle of the H)

• Press the soft-keys to change the angle and width of the Doppler gate

  • After pressing each soft-key, you can press SELECT to toggle between moving different parts of the gate

  • Play around with these until you get the gate or the small, white line through the gate parallel to the venous walls

• Press DOPPLER again to acquire a trace of venous flow

  • The trace should look like this:

• • If it doesn’t, you can press UPDATE to readjust your probe or Doppler-gate alignment

  • Press UPDATE again to resume tracing

• Press 2D to return to regular scanning mode (aka B-mode)

GALLBLADDER

BEGINNER – Basic Approach to Gallbladder

• Place the probe in the mid-sagittal plane at a neutral angle (90 degrees)

• Find the IVC in the far field—this will be your reference point

• Slide inferiorly until you reach the costal margin

• Sweep toward the patient’s right, following the costal margin

  • The liver should come into view

• Continue sweeping until you see the gallbladder

  • It should be an anechoic, elliptical structure surrounded by liver

• Rotate the probe clockwise until you visualize the gallbladder in its longest axis

• Save and label an image with the relevant anatomy (gallbladder fundus, body, and neck)

BEGINNER – Costal Approach to Gallbladder

• Place the probe in the mid-sagittal plane at a neutral angle

• Find the IVC in the far field—this will be your reference point

• Sweep to the patient’s right, going over the ribs

  • Use the intercostal spaces and the liver as a window

• Continue sweeping until you see the gallbladder

  • It should be an anechoic, elliptical structure surrounded by liver

• Save and label a long axis image with the relevant anatomy

INTERMEDIATE – Hepatorenal Approach to Gallbladder

• Place on the patient’s right posterior axillary line, in a neutral position with the leading edge toward the head

  • This is the FAST 6 view

  • Find the kidney as a reference point

• From the view of the kidney, sweep anteriorly, keeping the probe perpendicular to the patient

  • Use the intercostal spaces and liver as a window

• Continue sweeping until you see the gallbladder (usually in the anterior axillary line)

  • Rotate the probe until you can visualize the gallbladder in its longest axis

• Save and label an image with the relevant anatomy

INTERMEDIATE – Neck of the Gallbladder

• Find the gallbladder by your approach of choice

• It should appear as an anechoic, elliptical structure

  • This means that you’re looking at it in an oblique plane

• Rotate the probe counterclockwise over the gallbladder until you get it in the long axis

  • If you lose the view of the gallbladder in the process, follow-up with a microsweep to find it again

  • In long axis, you should be able to see the neck of the gallbladder

• Save and label an image with particular attention to the gallbladder, the neck of the gallbladder, and the portal veins

PORTAL TRIAD

ADVANCED – Portal Triad Flows

• Begin with the probe at a neutral angle, with the leading edge toward the patient’s right, along the costal border

  • Your model should be supine for this

• Identify the vertebrae and IVC in the far field of the image

• Locate the portal vein, in cross-section, anterior to the IVC

  • Anterior to the portal vein, you should see two small vessels

  • With the portal vein in short axis, the portal triad looks like a silhouette of Mickey Mouse (large circle- PV with two smaller anterior circles as “ears” – hepatic artery, bile duct)

  • This is the portal triad, which is made up of the portal vein, hepatic artery, and bile duct

• Use Color Doppler to identify the bile duct and hepatic artery

  • Press ZOOM and move the box over the triad; press ZOOM again to apply it and enlarge the image

  • Press COLOR and use the trackpad to move the color box over the portal triad

    • If you see no flow anywhere, remember that the angle of insonation has to be less than 60 degrees

    • If there is still no flow after angling the probe, use soft key buttons to increase sensitivity of detection of flow (i.e. change FILTERS from medium to low, SCALE from high to medium to low)

  • Determine which structure has no flow—this is the bile duct. Confirm its sonographic appearance with the location you’ve learned in anatomy lab

ADVANCED – Common Bile Duct Diameter

• Find the portal triad in cross-section, as described above

• Locate the bile duct in the triad

• Rotate the probe counterclockwise over the portal triad to get it in longitudinal section

  • When rotating, you may inadvertently move off of the triad. If this happens, follow up with a microsweep to get it back into view

• Press CALIPER to bring up the built-in measuring tool. You will use this to measure the diameter of the bile duct

  • Place one cross on one wall of the bile duct and press SELECT to lock it in that location

  • Place the other cross on the opposite wall and press SELECT again

  • Measure the bile duct from inner wall to inner wall using caliper button

• Save and label an image containing the caliper indicators and reading. Make sure to identify the anatomy in your saved image.

  • Save image with appropriate body pattern

DUODENUM AND PYLORUS

BEGINNER – Duodenal Anatomy

·       Place probe in sagittal plane (indicator pointing cephalaud) below xiphoid.

·       Sweep probe laterally observing liver in near field.

·       Identify duodenum by the classic appearance of bowel (hypo- to anechoic rim of muscularis with hyperechoic mucosa in center)

·       Once identified, center the structure using sliding and rocking.

·       Save image with appropriate labels (liver, duodenum)

INTERMEDIATE - Peristalsis

·       Rotate the probe clockwise to identify the long axis of the 1st part of duodenum as it connects to the stomach and pylorus.

·       Use zoom to enlarge the image

·       If possible, drink a glass of water and identify water entering the stomach

·       Watch peristalsis as fluid moves through stomach and enters the duodenum through the pylorus

Saving and Labeling Images

1. When you have an image you like, press freeze

2. To place a text label, press TEXT and use the trackpad to move the text box near the piece of anatomy you’re labeling. Use the keyboard to enter your label. Press TEXT again to save your label and bring up a new text box.

3. To place an arrow, press the button with an arrow on it and move it around with the trackpad.

4. Press SAVE to store your labeled image

After Scanning

1. Press the power button to turn off the machine

2. Remove the sheets from the bed you used and put them in the linens basket. Put new sheets on the bed

3. Wipe off the probes (and yourself/your model) with towels, and put the towels in the linens basket.

4. Unplug the machine and wrap the power cord around the back. Make sure all the other wires are in place. Put the machine back where you found it.

5. Sign-in on the computer in the ultrasound room using the instructions in front of the screen. For the SESSION NAME field, select TUBE-A

Renal Ultrasound - Self-Guided Practice

Objectives

1. Review the anatomy of the kidneys, liver, spleen, and bladder and relate them to the surface anatomy

2. Practice rotating and fanning the probe over an anatomic structure to interrogate the area

3. Learn to use the DUAL SCREEN tool to compare two different views of the same structure

4. Become familiar with the COLOR DOPPLER, POWER DOPPLER and CALIPER tools and their utility in assessing urinary flow and volume

5. Practice saving and labeling images of genitourinary anatomy

Pre-scan

1. Press the power button to turn on the ultrasound machine

2. Press the patient button and enter your Med Center username, year, and program into the “Last Name” field (e.g. DOE01.MS2.TUBEA)

3. Enter the appropriate anatomy in the “First Name” field (e.g. Hepatorenal)

4. Make sure that the curvilinear probe is selected and that the “ABD” preset is selected

   1. If the wrong probe is selected, trace the wire from the linear probe to find its bay and press the button to select it

5. Accept the changes and create the new patient

KIDNEYS

BEGINNER - HEPATORENAL

• Place the probe on the patient’s right mid-axillary line, aimed neutrally with the leading edge toward the head

  • Your probe should be at the level of the epigastric area

• Sweep posteriorly until you arrive at the posterior axillary line, keeping the probe parallel to the bed the whole time

  • You should see the kidney inferior and posterior to the liver

• Rotate the probe counterclockwise to eliminate the rib shadows

• Identify the cortex and calyces in the kidney

  • Rotate the probe until you see cortex surrounding the entire calyceal system—when you see this, it means you have a long axis view of the kidney

• Press FREEZE and label the renal cortex, calyces, the liver, diaphragm, and psoas major. Save the image

• Return to the hepatorenal view and press 2D. Ask the patient to take a deep breath and look for the curtain sign

  • Curtain sign: when the patient inspires deeply, the diaphragm moves into the field. If the lungs are aerated, a black “curtain” will pass over the field and you won’t see anything

  • Mirror Sign: The diaphragm is a curved hyperechoic structure that has air behind it. Because of this, some sound waves can bounce off of the diaphragm multiple times

  • Spine Sign

BEGINNER - SPLENORENAL

• Place the probe on the patient’s mid-axillary line, aimed neutrally with the leading edge toward the head

  • The probe should be at the level of the epigastric area

• Sweep posteriorly until you arrive at the posterior axillary line, keeping the probe parallel to the bed the whole time

  • You should see the kidney inferior to the spleen, which looks like liver (starry sky appearance)

• Rotate the probe counterclockwise to eliminate the rib shadows

• Identify the cortex and calyces in the kidney

  • Rotate the probe until you see cortex surrounding the entire calyceal system—when you see this, it means you have a long axis view of the kidney

• Press FREEZE and label the renal cortex, calyces, the spleen, diaphragm, and psoas major. Save the image

• Return to the splenorenal view and press 2D. Check for the curtain sign, mirror sign, and spine signs:

  • Curtain Sign:

  • Mirror sign:

  • Spine Sign:

INTERMEDIATE – POWER DOPPLER

• Find the kidney in either the hepatorenal or splenorenal view, as described above

• Press COLOR to witch to Color Doppler mode

• Press the first soft-key until you are in Power Doppler mode

  • Power Doppler mode shows magnitude of flow, but no direction. You use it to assess the flow rate in a structure when you don’t need to know the direction the fluid is moving.

• Press SELECT to change the size of the Power Doppler box. Make it large enough to fit over the entire kidney.

• Press SELECT again to save the box size

• Using the trackpad, move the box over the kidney

  • Observe the flow in the calyceal system

  • Label and save an image demonstrating that your patient’s kidneys are in fact working

BLADDER

BEGINNER – TRANSVERSE VIEW OF BLADDER

• Place the probe as close to the pubic symphysis as your patient is comfortable with, with the leading edge to the patient’s right and the beam aimed neutrally

• Fan the beam inferiorly until you see the bladder

  • The bladder is a round, fluid-filled structure that will appear in the middle of the field

• If your patient is a male, perform micro-fan maneuvers and try to find the prostate

  • The prostate will be an elliptical, hypoechoic structure inferior and posterior to the bladder (it will be in the far field relative to the bladder)

• In a male patient, you may also be able to see the seminal vesicles superior to the prostate

  • They are small, round, black structures in the far field relative to the baldder

• Freeze the image and label the bladder. If visible, label the seminal vesicles and prostate

INTERMEDIATE – BLADDER VOLUME

• Get the transverse view of the bladder as described above. Fan the probe inferiorly and superiorly until you find the largest transverse view you can get

• Keeping the probe stationary, press the soft-key for Dual Screen (____), then press UPDATE to save your transverse view in one pane

• Rotate the probe 90 degrees clockwise (so the leading edge is toward the head) to get a sagittal view of the bladder

  • Press UPDATE again to save the second pane

• From the dual screen view, press the CALIPER button to bring up the measuring tool

  • Stretch the caliper from the long axis of the bladder on the transverse view (left pane). Write down the value.

    • This is the width of the bladder

  • Move the caliper so that it stretches across the short axis of the bladder on the transverse view. Write down the value.

    • This is the length of the bladder

  • Move the caliper so that it stretches from the leading edge side of the bladder to the receding edge side on the sagittal view. Write down the value

    • This is the height of the bladder

• To get the bladder volume use the following formula: V = w * h* l * 0.52

ADVANCED – URETERAL JETS AT THE TRIGONE

• Get a transverse view of the bladder as described above. Make the probe as flat against the body as possible without losing the bladder

  • When you do this, you are looking at the dome of the bladder

• Fan the beam inferiorly until you see the trigone of the bladder

  • The trigone looks like a small notch in the posterior wall of the bladder

  • In a male patient, you will see the prostate just superior to the trigone

• Press COLOR and use the first soft-key to make sure that you’re on Color Doppler mode

• Move the box over the trigone and leave it there until you see one or two red jets come out toward the anterior wall of the bladder

  • These are the ureteral jets formed when urine enters the bladder from the ureters

  • It may take up to a minute to see a jet, so be patient

Saving and Labeling Images

1. When you have an image you like, press freeze

2. To place a text label, press TEXT and use the trackpad to move the text box near the piece of anatomy you’re labeling. Use the keyboard to enter your label. Press TEXT again to save your label and bring up a new text box.

3. To place an arrow, press the button with an arrow on it and move it around with the trackpad. Press ____ to save the arrow in that position.

4. Put a text box in the lower left corner to describe the body part and the view you have acquired (e.g. HEPATORENAL)

5. Press SAVE to store your labeled image

After Scanning

1. Press the power button to turn off the machine

2. Remove the sheets from the bed you used and put them in the linens basket. Put new sheets on the bed

3. Wipe off the probes (and yourself/your model) with towels, and put the towels in the linens basket.

4. Unplug the machine and wrap the power cord around the back. Make sure all the other wires are in place. Put the machine back where you found it.

5. Sign-in on the computer in the ultrasound room using the instructions in front of the screen. For the SESSION NAME field, select TUBE-A

Thyroid Ultrasound - Self-Guided Practice

Objectives

1. Review the anatomy of the thyroid gland and larynx

2. Practice sweeping and fanning the ultrasound probe to interrogate an anatomic region

3. Learn to use the CALIPER tool to measure the width of a gland

4. Become familiar with the COLOR DOPPLER tool to identify blood flow in a fluid-filled space

5. Practice saving and labeling images of thyroid and laryngeal anatomy

Pre-scan

1. Press the power button to turn on the ultrasound machine

2. Press the patient button and enter your Med Center username, year, and program into the “Last Name” field (e.g. DOE01.MS2.TUBEA)

3. Enter the appropriate anatomy in the “First Name” field (e.g. Thyroid)

4. Make sure that the linear probe is selected and that the “Vascular” preset is selected

   1. If the wrong probe is selected, trace the wire from the linear probe to find its bay and press the button to select it

5. Accept the changes and create the new patient

THYROID

BEGINNER – Thyroid Anatomy

• Place the probe on the patient’s thyroid cartilage, aimed neutrally with the leading edge toward the patient’s right

• Sweep inferiorly until you see the thyroid gland come into view

  • The thyroid gland will be a hypoechoic structure anterior to the larynx

• Make small sweeping motions until the isthmus is visible in the midline

• Slide the probe to the patient’s right to observe the right lobe of the thyroid

  • Repeat to examine the left lobe of the thyroid

• Press FREEZE and label the isthmus, right lobe, and left lobe of the thyroid cartilage?. Save the image

INTERMEDIATE – Width of the Thyroid Lobes

• Follow the directions above to locate and identify the thyroid gland

• Center the image on the right lobe of the thyroid gland by sliding and rocking to the patient’s right

• Once centered, sweep cranially and caudally until you find the widest portion, laterally to medially, of the right lobe

  • Press FREEZE once you have it on the screen

• Press CALIPER and use the trackpad to put the first cursor on the medial border of the right lobe of the thyroid. Press SELECT to save its location

• Use the trackpad to move the second cursor to the lateral border of the thyroid so that the largest medial to lateral distance is covered by the line. Read and record the measurement displayed on the screen

• Repeat the steps above to measure the width of the left lobe

INTERMEDIATE – Superior Thyroid Artery

• Place the probe over the patient’s thyroid cartilage, with leading edge to their right, and sweep inferiorly to find the thyroid gland

• Sweep inferiorly and superiorly to interrogate the thyroid gland for the superior thyroid artery

  • The STA will be a narrow black circle running through the superior portion of the thyroid gland

• Hold the probe steady over the STA and press COLOR

  • Fan the probe inferiorly and superiorly to examine the direction of blood flow in the structure. Does it fit the expected blood flow in the STA?

• Press 2D and make sure you still have the STA visible in the image. Press FREEZE and label the lobes and isthmus of the thyroid and the STA running through the gland. Save the image

ADVANCED – Vocal Cords

• Place the probe over the thyroid cartilage, with the leading edge pointing to the patient’s right

• Ask your patient to hum or speak and sweep the probe superiorly and inferiorly over the thyroid cartilage

  • Look for bilateral, thin, hyperechoic structures vibrating posterior to the thyroid cartilage. These are the vocal cords.

• Once you have located the vocal cords, hold the probe steady and ask your patient to hum until you tell them to stop. Press CLIP to acquire a video clip of their vibrating vocal cords

  • The machine is done recording once you hear a beep (several seconds after pressing CLIP). Once you hear this, you can tell your patient to stop humming.

Saving and Labeling Images

1. When you have an image you like, press freeze

2. To place a text label, press TEXT and use the trackpad to move the text box near the piece of anatomy you’re labeling. Use the keyboard to enter your label. Press TEXT again to save your label and bring up a new text box.

3. To place an arrow, press the button with an arrow on it and move it around with the trackpad. Press SELECT to save the arrow in that position.

4. Put a text box in the lower left corner to describe the body part and the view you have acquired (e.g. THYROID)

5. Press SAVE to store your labeled image

After Scanning

1. Press the power button to turn off the machine

2. Remove the sheets from the bed you used and put them in the linens basket. Put new sheets on the bed

3. Wipe off the probes (and yourself/your model) with towels, and put the towels in the linens basket.

4. Unplug the machine and wrap the power cord around the back. Make sure all the other wires are in place. Put the machine back where you found it.

5. Sign-in on the computer in the ultrasound room using the instructions in front of the screen. For the SESSION NAME field, select TUBE-A

Pelvic Ultrasound - Self-Guided Practice

Objectives

1. Practice sweeping, sliding, fan, rocking, and rotating the endoluminal probe

2. Review the anatomy of the female reproductive tract

3. Learn to calculate the volume of an ovary

4. Learn to use pre-programmed calculation functions

5. Learn to estimate fetal age based on size on ultrasound.

Pre-scan

1. Press the power button to turn on the ultrasound machine

2. Press the patient button and enter your Med Center username, year, and program into the “Last Name” field (e.g. DOE01.MS2.TUBEA)

3. Enter the appropriate anatomical structure in the “First Name” field (e.g. Repro)

4. Make sure that the endoluminal probe is selected

   1. If the wrong probe is selected, trace the wire from the linear probe to find its bay and press the button to select it

5. Accept the changes and create the new patient

UTERUS

BEGINNER – Sagittal Uterus

Place the endoluminal probe into the vagina, with the leading edge along the ventral surface. The leading edge is on the same side of the probe as your thumb.

• Identify the bladder anterior to the uterus (on the leading edge)

  • The bladder is anechoic

• Rock and slide inferiorly (away from yourself) to find the inferior pole of the bladder, then continue until you visualize the cervix

  • Note that the inferior pole of the bladder points toward the cervix

• Rock and slide superiorly to identify the fundus of the uterus

  • Press FREEZE, then save and label an image demonstrating a sagittal view of the uterus and endometrial stripe

• Prove that the uterus is encased in myometrium by sweeping left and right until the endometrial stripe disappears.

INTERMEDIATE – Coronal View of the Ovary

Acquire a sagittal view of the fundus of the uterus, with the endometrial stripe visible

• Rotate the probe 90 degrees so that the leading edge is on the patient’s right

• Slide the probe to the left and to the right to visualize the ovaries

• Save and label an image of an entire ovary

ADVANCED – Ovarian Volume

Begin from a coronal view of the uterus

• Slide to the left or right to center an ovary in the field

• Sweep anteriorly and posteriorly to find the largest diameter of the ovary in the coronal plane

  • Use the soft keys to switch to dual screen mode

  • Press FREEZE to save the coronal view of the ovary

  • Press UPDATE to activate the second dual-screen window

• Rotate the probe 90 degrees back to the sagittal view of the ovary, and find the largest diameter in this view

• Press CALIPER to open the measuring tool

  • Measure two perpendicular axes on the coronal view and one axis on the sagittal view

  • Use these to calculate the approximate volume of the ovary.

GESTATIONAL SAC

ADVANCED – Estimate Gestational Age

Begin with a sagittal view of the uterus

• Sweep to the left and right until you find the gestational sac in the uterus

• Find the view of the gestational sac with the longest crown-rump length

  • Press FREEZE

• Press CALC to bring up the calculation functions. Use the track-pad to find CRL among the OB calculations and press SELECT to calculate the gestational age

  • Place the first cursor on the head of the fetus and press UPDATE

  • Place the second cursor at the other end of the gestational sac

  • Read the calculated gestational age on the bottom of the screen

• Press FREEZE, then save and label the image of the gestational sac with the calculated gestational age

Saving and Labeling Images

1. When you have an image you like, press freeze

2. To place a text label, press TEXT and use the trackpad to move the text box near the piece of anatomy you’re labeling. Use the keyboard to enter your label. Press TEXT again to save your label and bring up a new text box.

3. To place an arrow, press the button with an arrow on it and move it around with the trackpad. Press ____ to save the arrow in that position.

4. Put a text box in the lower left corner to describe the body part and the view you have acquired (e.g. R FOREARM CROSS SECTION)

5. Press SAVE to store your labeled image

After Scanning

1. Press the power button to turn off the machine

2. Remove the sheets from the bed you used and put them in the linens basket. Put new sheets on the bed

3. Wipe off the probes (and yourself/your model) with towels, and put the towels in the linens basket.

4. Unplug the machine and wrap the power cord around the back. Make sure all the other wires are in place. Put the machine back where you found it.

5. Sign-in on the computer in the ultrasound room using the instructions in front of the screen. For the SESSION NAME field, select TUBE-A