Application of interventional ultrasound in emergency medicine conditions

Abstract

Ultrasonography is a modern diagnostic tool both in intensive care and emergency medicine. Small, portable and simple ultrasound devices have been introduced due to technological advances. The image quality, size, and weight of portable ultrasound devices are improving. Prehospital point-of-care ultrasonog-raphy may have an impact on the decision making in prioritizing initial treatment. First aid at the scene of the accident and transporting the patient to the hospital is a key element, which in the case of appropriate diagnostics allows you to fight life-threatening injuries. The intention of using ultrasound protocols is to shorten and simplify the ultrasound examination allowing to eliminate or find complications of an injury as soon as possible. The protocols used include elements of ultrasonography and echocardiography of the lung tissue, abdominal cavity, pelvis, large vessels or the eyeball. The intention of the authors of the article was to present to the reader the basic ultrasound protocols applicable to patients in emergency situations.

Full text

Disaster and Emergency Medicine Journal
2018, Vol. 3, No. 4, 137–147
DOI: 10.5603/DEMJ.2018.0029
Copyright © 2018 Via Medica
ISSN 2451–4691
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Copyright © 2018 Via Medica, ISSN 2451–4691
review articles
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Maciej Dudek, Lazarski University, 43 Swieradowska Str., 02–662 Warsaw, Poland; e-mail: silenthealthcare@gmail.com
APPLICATION OF INTERVENTIONAL ULTRASOUND
IN EMERGENCY MEDICINE CONDITIONS
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1 Lazarski University, Warsaw, Poland
2 Departments of Outcomes Research and General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, United States of America
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E:D& $(+.+F&$-GH) is a modern diagnostic tool both in intensive care and emergency medicine. Small,
portable and simple ultrasound devices have been introduced due to technological advances. The image
quality, size, and weight of portable ultrasound devices are improving. Prehospital point-of-care ultrasonog-
raphy may have an impact on the decision making in prioritizing initial treatment. First aid at the scene of
the accident and transporting the patient to the hospital is a key element, which in the case of appropriate
diagnostics allows you to ght life-threatening injuries. The intention of using ultrasound protocols is to
shorten and simplify the ultrasound examination allowing to eliminate or nd complications of an injury
as soon as possible. The protocols used include elements of ultrasonography and echocardiography of the
lung tissue, abdominal cavity, pelvis, large vessels or the eyeball. The intention of the authors of the article
was to present to the reader the basic ultrasound protocols applicable to patients in emergency situations.
?'H) I+&%(/) point-of-care ultrasonography, emergency medicine, ultrasonography, diagnostic imaging,
review
Disaster Emerg Med J 2018; 3(4): 137–147
J.D&+%E,DJ+.
Ultrasonography gives us the opportunity to ex-
amine the patient without prior preparation and
without any implications of ultrasound [1–3]. It is
the fastest and one of the most accurate diagnos-
tic methods. Such examination can be carried out
anywhere: street, ambulance, victim’s house or the
emergency department.
Point of Care (POC) ultrasound is a fairly young
eld of ultrasound, but the usefulness of protocols
and research in this area is invaluable. In particular,
when we are dealing with an unconscious patient
and gathering an interview is impossible. Interven-
tional ultrasound and Emergency Ultrasonography
is not only for diagnostic purposes.It also allows you
to monitor the condition of the victim by perform-
ing tests such as checking the optic nerve, giving us
information on intracranial pressure [4, 5].
The assumption of POC ultrasound is to perform
tests by medical personnel in order to assess the
current state of the patient and, based on the result
of this examination, undertake medical activities. We
must distinguish these procedures from ordinary
ultrasound examinations. In these studies, we do
not assess the condition of organs, we only check
the absence or presence of pathology that affects
the functioning of the body. We have to treat the
ultrasound like a “Stethoscope” — the rst contact
diagnostic tool. And as you know, the stethoscope
serves all medical staff.

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The purpose of the procedure is to detect free u-
id (blood) in the peritoneal cavity and pericardium.
When the patient is showing hemodynamic instabil-
ity with signs of anemization, we can assume that
internal hemorrhage has occurred [6]. The fastest
way to conrm this diagnosis is to perform the FAST
procedure, i.e., Focused Assessment with Sonog-
raphy for Trauma. Thanks to this examination, the
patient can be quickly diagnosed and transported
directly from the ambulance or ED to the operating
theater, where they will be immediately operated,
without unnecessary waste of time, which is critical
for the patient’s health and life. Examination FAST
(extended) is an extended examination of the chest
area and is intended to check if there is uid (blood)
or pneumothorax in the chest [7, 8].
Detection of free uid in the abdominal cavity
in patients after injuries using ultrasound is about
75% (up to 95%). The specicity of the method is
estimated at 98%. While a physical examination is
only 50–60% sensitive.
In the course of the study, it should be remem-
bered that the ultrasound examination in a patient
after an injury is not used to assess the extent of or-
gan trauma. The information from the test is binary
0 — no liquid/air or 1 — liquid/air.
When performing the test, we usually use a Con-
vex type head, i.e., a curved head in Poland com-
monly referred to as the abdominal head. In a situ-
ation where we do not have such a transducer, we
can use a Phased Array type head, which is a head
dened in the sector or cardiology sector in Poland
(Fig. 1).
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The whole procedure consists of 4 positions and
5 head applications within the abdominal cavity,
chest, and pelvis (Fig. 2). To perform the test, we can
use a Convex head or Phased Array head, i.e. a cardi-
ac head with setting for abdominal applications [9].
There are also devices that have dedicated settings
for POC procedures. The patient lies supine on a at
surface so that the uid (blood) ows gravitationally
into the open spaces.
The procedure begins with a sub-bridge projec-
tion in which we assess the heart and the pericardi-
um. We start from this position because if we do not
observe the movement of the heart muscle, it does
not make sense to continue the procedure.
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The position of the head and the space under
examination: under the alveolar process in the trans-
verse plane with the head marker pointing to the
right (right side of the patient). The head is at a large
angle and is directed to the left side of the chest
(Fig. 3). We increase the depth of penetration of
the device so that the image shows the whole heart
and part of the liver, diaphragm, and lungs. When
this projection is obtained, we must use adequate
force for pressure to get a picture of the heart from
under the surface of the ribs. In the absence of
the desired image, we perform delicate fan-shaped
movements, and left-right movements [10]. The ob-
tained image should show the heart, part of the
liver, and lungs. During image analysis, we direct our
attention to the way the heart works, its regularity
of work, and the quality of the ventricles and atrial
contraction. We do not try to assess heart rate under
*JFE&')!S)Differend ultrasononogrphy probes: (A) CONVEX probe; (B) Phassed Array probe

Maciej Dudek et al., Application of interventional ultrasound in emergency medicine conditions
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the account of ow speed or quality of valve work.
However, irregular or non-synchronized heart work
can be an indicator of the appearance of the pericar-
dial sac. Blood in the ultrasound image is presented
in black, just like any liquid.
If you cannot get the heart image from the post-
bridge position because of the patient’s obesity or
extensive trauma, we move the head to the chest
and place it in the left parasternal longitudinal posi-
tion. In this position, we keep the heads in a position
perpendicular to the surface of the skin with a mark
pointing in the cephalic direction.
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The position of the head and the area under
study: periosteal area and hepatorenal space (Mori-
son’s pouch). We try to show the whole kidney, part
of the diaphragm and the right lobe of the liver [11].
We arrange the head in the right axillary line of the
anterior or medial plane in the sagittal and sagittal
plane of the intercostal space from 7 to 9. Head
marker must be directed in the cephalothorax. This
part of the procedure is imperative because by cor-
rectly orienting the head we can precisely determine
the position of free uid (Fig. 4).
The intercostal spaces are not the same in dif-
ferent people, so often the image is signicantly
obscured by the acoustic shadow of the ribs. To by-
pass this problem, we must arrange the head along
them. The ultrasound beam is very narrow because
it is about 1.5 mm, so imaging through the inter-
costal spaces should be a solution to this problem.
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The position of the head and the space under
investigation: the peri-implant space (spleen-renal
cantilever). In this projection, we try to present the
entire left kidney, spleen, and part of the diaphragm
[12]. We arrange the head in the left posterior axil-
lary or axillary line in intercostal spaces from about
ribs 5 to 7 in the sagittal or oblique plane with
the head marker directed in the cephalothorax. We
are proceeding here quite analogously to the RUQ
*JFE&')BS)Ultrasound projections during FAST protocol
*JFE&')"S)Ultrasound subcostal projection
*JFE&')WS)Ultrasound right upper quadrant projection

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projection, also important here to check the entire
peripheral area (Fig. 5). In order to do this accu-
rately, we have to move the head in the direction to
and from the center of the axillary line in the middle
and posterior axillary line. Free liquid blood will be
manifested on the screen of the ultrasound as black.
If the patient is conscious and it is known that his
lungs are not damaged (we do eFAST or BLUE pro-
tocol), we can ask him to take a deep breath, which
will greatly facilitate the full depiction of this space.
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Space under study: lower abdominal cavity, and
smaller pelvis. The test is much easier to do when
the patient’s bladder is full. For this reason, we
should do this procedure before assembling the
catheter, you can also clamp the catheter and wait
for the bladder to ll or ll it with saline [13]. As we
wrote in the description of the projection, it consists
of two touchdowns, it does not matter much from
which we start to remember both.
a) Head position: Transverse position — arrange
the head above the pubic symphysis with the
head marker pointing to the right (right side of
the patient), heads lean towards the pelvis. In
the picture, we try to visualize the bladder in the
transverse plane of the Douglas pouch and pelvic
organs (Fig. 6).
b) Head position: Arrow position — position the
head above the pubic symphysis with the mark
of the head directed in the sagittal plane in the
sagittal plane. When moving from the transverse
to the sagittal position, we rotate the head 90°,
during rotation of the head we should keep the
image of the bladder in the eld of view (Fig. 7).
4*$(D)-&+D+,+:
The eFAST (extended) study is an extended ver-
sion of the FAST study [14]. To perform the eFAST
test, add 3 positions of the head to the basic ex-
amination (Fig. 8). These items can be added any-
where in the study, but people with more experience
recommend a method with the order of 1-6-2-3-
4-5-7-8. It is logical because thanks to the similar
positions of the head positioning, we can speed up
the examination [15]. In the course of watching the
lungs, we focus on two important phenomena, on
the symptom of “sliding”, or slipping the pleura,
and viewing artifacts, or articial creatures of the
ultrasound device (Fig. 9). Physiologically, the lungs
are lled with air, so we cannot visualize their esh.
Instead, we observe lines type A, B, C / Consolida-
tion. The heads are placed in the left-collar, clavicu-
lar left and right positions 7–8 in 3–4th intercostal
*JFE&')[S)Ultrasound left upper quadrant projection
*JFE&')\S)Ultrasound pelvis projection — Transverse position *JFE&')#S)Ultrasound pelvis projection — Arrow position

Maciej Dudek et al., Application of interventional ultrasound in emergency medicine conditions
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and positions 6 in 8–9. Pictures are not able to
present the full study. In the pictures above, only
the starting positions are presented, as well as the
structures and organs that we should show [16]. We
remember that the head presents a two-dimension-
al image, and the test space is three-dimensional,
which means that we have to move the head in
specic directions to get full information.
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The BLUE (Bedside Lung Ultrasound in Emergen-
cy) procedure is used to diagnose the acute respira-
tory failure, which is a life-threatening condition
[17, 18]. This procedure can be performed both at
the patient’s home and in the hospital emergency
department. The information we receive relates to
the lungs and their condition: pneumothorax, pul-
monary edema, or pulmonary embolism. The whole
procedure should take up to three minutes. The test
can be performed using any head, i.e., Phased Array,
Convex, MicroConvex or Linear [19]. The recom-
mended head for this procedure is the Microconvex
or Phased Array. In the BLUE procedure, we view
artifacts as in the case of e-FAST. At the same time,
we should choose lung test applications (if we have
this option) or choose an abdominal application and
turn off the options creating cross-linked beams on
the device, because the device will create non-exist-
ent B lines.
During the examination, the ultrasound machine
can display several types of “lines” on the screen
during the procedure:
• Lines A — These are normal artifacts (horizon-
tal, parallel) resulting from the reection of the
pleural line in the air in the lungs, such lines will
repeat at regular intervals - it is important that
the distance between lines A and the pleural line
in the image must be constant otherwise, we
may suspect Line C or Consolidation.
• Lines B — These are abnormal (vertical, perpen-
dicular) artifacts that arise from small quantities of
liquid in the pleural space. Under normal condi-
tions, the uid is hypoechoic (dark, black) on the
ultrasound image, but when it is surrounded by air,
it gives a hyperechoic effect (light, white) through
the effect of signal amplication in the uid space.
Remember that the A lines do not coexist in the
image with lines B.
• C-lines / Consolidations — These are lines creat-
ed in a similar process to Line B, but in this case,
the amount of uid in the pleura is much greater.
At the same time, the images appearing on the
screen of the device do not have to come from
the pleural space, but from the lungs themselves
(Consolidations). We can observe such a picture
when the lung parenchyma becomes visible dur-
ing the examination.
The next and very important symptom observed
on the screen during the lung examination is the
“sliding symptom”. It consists of checking the oc-
*JFE&')KS)Ultrasound projections during eFAST protocol
*JFE&')TS)Ultrasound symptom of “sliding”

Disaster anD emergency meDicine Journal 2018, Vol. 3, No. 4
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currence of pleural “slipping” movements [20].
We observe the presence of a symptom in each
of the touchdowns, this is the correct symptom.
Sliding we can observe both in the presentation B
— Brightness and the presentation of M — Motion.
In the B presentation, we obtain a position called
“Bat Sign”, which shows the image of the correct
lung, and two adjacent intrapleural and shadows
that they form. In this position, we also see visible
pleural movement.
In the M presentation, we observe the “See
Shore” Symptom — so-called the symptom of the
beach, which similarly shows the correct image of
the lungs, through the parallel arrangement of the
lines that are the reection of the pleura.
The test consists of three appendages on each
side of the chest, the upper front point, the lower
front point, and the PLAPS:
• The rst point (front top) is between the third
and fourth nger of the upper hand at their base
• The second front lower point is located at the
height of the lower hand
• PLAPS point “posterior and/or lateral alveolar
and/or pleural syndrome” — an intersection of
the posterior axillary line and diaphragmatic/me-
dial transverse line [21].
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The FATE (Focus Assessment Transthoracic in
Emergency) protocol was created for the rapid as-
sessment of hemodynamic disorders. It consists in
the implementation of 4 touchdowns, of which 3 are
closely related to cardiac imaging, sub-vertebral, api-
cal and parasternal projection, and pleural projections
in the middle axillary lines on both sides of the chest.
This study will allow us to assess the condition of the
pericardium: the presence of exudate, cardiac tam-
ponade, cardiac assessment in patients with cardiac
arrest, and the evaluation of the left ventricle systolic
function [22, 23].
As in previous procedures, its execution time
should not exceed 3 minutes. We do not have the
ease of using any head for this protocol, we should
use a Phased Array head because our projections are
strictly echocardiographic [24]. As a last resort, we
may try to use a Microconvex type head, but getting
the correct image will be much more difcult.
• Substernal projection — this position offers ex-
cellent access to the heart in patients lying on
the back. The head should be placed almost par-
allel to the patient’s skin just under the sternum
towards the heart. From this position, we have
a four-chamber view. By turning the head, you
can get a short axis view. This is an important
projection for monitoring pericardial effusions.
• The apical projection — the transducer is placed
over the apex of the heart and directed parallel
to the long axis of the heart, we get a four-cham-
ber apical view. If we have a problem with the
placement of the head, we can use the palpation
technique to locate the apex of the heart (palpa-
ble heartbeats in the intercostal space). From the
four-chamber view, we go to the two-chamber
view. For this purpose, the transducer is rotated
counter-clockwise. Two-cavity projection is used
to assess the left and front walls of the left ven-
tricle. Further rotation of the head gives the view
of the long axis.
• Parasternal projection — the head is placed par-
adigmatic on the line connecting the apex of the
heart with the center of the right clavicle at the
left edge of the sternum. From this position, we
get a black/ve-pointed view. By turning the head
(directing the marker to the right arm) we obtain
a short axis. Image quality can be improved by
turning the patient to the left side. A parasternal
position is often called classic because in it we
check the basic dimensions of the heart.
• Projection of the pleura — this projection is per-
formed in the middle axillary lines. The head
marker is directed to the patient’s head. In this
projection, we use the same principles that we
apply to the BLUE procedure [25].
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The RUSH protocol (Rapid Ultrasound in Shock
and Hypotension) was created in 2009 by Dr. Wein-
gart. The protocol is intended for the assessment of
patients in shock and hypovolemia. The ultrasound
schema was based on the HI-MAP abbreviation,
according to which the projection sequence is per-
formed. For this test, we use Phased Array or Convex
head, as well as abdominal or FAST applications [26,
27]. In RUSH protocol we distinguish the follow-
ing projecttions:
• H — Heart (heart),
• I — Inferior vena cava (main lower vein),
• M — Morison’s pouch,
• A — Aorta,
• P — Pneumothorax (pneumothorax).

Maciej Dudek et al., Application of interventional ultrasound in emergency medicine conditions
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The protocol starts with a heart projection (1,2)
(H-Heart), we obtain parasternal and apical projec-
tions to assess the pericardial sac (uid presence)
and the function of both chambers. Next, we pres-
ent the lower main vein (3) (I-inferior vena cava) in
the substernal space with the head marker direct-
ed to the patient’s head. The next projection (4,5)
(M-Morison’s Instruction) in this case means that we
are looking at the spaces on both sides of the pa-
tient, both Morison’s pouch and the kidney-spleen
resection. While watching these spaces, we can
move the head slightly in a cephalic way to visual-
ize the basis of the lungs. The next projection (6,7)
(A-Aorta) is a combination of two projections. We
start at the bladder with the marker pointing to the
left and see the pelvic space to exclude free uid in
the peritoneal cavity, and then move towards the
patient’s head, nding the aorta and assessing its
condition up to the sternum. The last protocol point
(8,9) (P-Pneumothorax) involves lung imaging to
rule out pneumothorax, items as in the e-FAST study.
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The optic nerve is relatively easy to assess for the
part of the nervous system that connects directly to
the brain [28, 29]. The optic nerve is the second crani-
al nerve, it means it is surrounded by the same tires as
the brain [30]. When the intracranial pressure increas-
es, the cerebrospinal uid ows into the subarach-
noid space, causing the pressure of the optic nerve to
increase (in diameter). Knowing this relationship, we
can indirectly determine intracranial pressure (ICP).
The measurement is carried out using an 8–11 MHz
high-frequency linear head [31, 32]. The structure of
the eye is well-translucent for ultrasounds, so the test
can be done with great accuracy every time. We per-
form the measurement when the patient has closed
eyelids. The test time should not exceed one minute.
We measure the diameter of the optic nerve
3mm behind the eyeball (Fig. 10). If we have a prob-
lem with nding a nerve, we can use a colored
Doppler [33]. Anatomically, the artery and vein of
the retina run inside the optic nerve, information
marked with color will allow us to precisely deter-
mine the position of the nerve. The correct diameter
of the optic nerve for an adult does not exceed
5 mm, for a child 4.5 mm, and for an infant 4 mm.
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A simple ultrasound procedure can also be used
to assess the degree of lling of a vascular bed [34].
To determine its degree, we use the upper main
vein, and more specically its diameter (IVC; Fig. 11),
which we compare with the width of the abdominal
aorta (Ao; Fig. 12). This ratio is called the IVC/Ao
index [35, 36].
For this measurement, we use a Convex type
head. We position it in an anterior sagittal and axil-
lary position with a marker directed to the patient’s
head. As the rst we measure IVC at the height of
the intrahepatic section, then we measure the aorta
about 10 mm above the visceral trunk.
After obtaining the results, we substitute them
for a simple IVC/Ao pattern where the standard
deviation is SD = 1.2 +/- 0.2.
*JFE&')!YS)Optic nerve sheath diameter *JFE&')!!S)IVC width measurement

Disaster anD emergency meDicine Journal 2018, Vol. 3, No. 4
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*'':)-&+D+,+:
The most important POC protocol dedicated to
the management of cardiac arrest is FEEL (Focused
Echocardiographic Evaluation in Life Support). This
protocol was introduced by Breitkreutz in 2007 [37].
We perform this test using a Phased Array type
head, and the procedure consists of 4 positions of
the head: substernal, apical and parasternal in two
axes [38, 39]. We must remember that each of the
POC procedures is used only to detect an abnor-
mal assessment of organs, therefore we only have
10 seconds to perform the assessment of the heart.
Teamwork is very important during the conduct of
the procedure.
This procedure consists of 10 points thanks to
which the resuscitation team and the person per-
forming ultrasound imaging will be able to use the
most efcient time:
1) The team starts BLS and ALS resuscitation proce-
dures — at least 5 full cycles.
2) The investigator informs the team that he starts
the preparation of the ultrasound scanner.
3) Preparing the ultrasound for performing the
procedure. We check whether the device is
working properly, check whether the right head
and application are selected. Also, if we have
the appropriate depth of imaging, and whether
the gel is on the head.
4) Adapting to the situation. The idea is to prepare
yourself and the patient for the procedure. We
set the device in the right place (to see the pic-
ture), if the patient has clothes, we take them off.
5) We tell the resuscitation team to start counting
from 10 to 1 (in seconds — at the end of the
cycle) and then began to measure the pulse.
6) We inform the team to interrupt the compres-
sions after the end of the cycle to perform echo-
cardiography. During the ultrasound procedure,
the ventilation is maintained.
7) We apply the head to the patient in the subster-
nal position while we are compressing and look
for the right image with a fan-shaped motion.
If this position is not possible to obtain (injury,
obesity), we use intercostal spaces and paraster-
nal positions in the long axis.
8) When the team is nished counting from 10 to
1, the compression is interrupted, and the ultra-
sound scan begins. We have 3 seconds to nd
the heart and 3 seconds to evaluate it. If we
do not nd the heart, or we do not observe its
movements, we inform the team about return-
ing to full resuscitation for 5 subsequent cycles,
after which we return with the head in the next
position. Compressions cannot be interrupted
for more than 10 seconds.
9) We inform the team about returning to resusci-
tation activities.
10) After the team returns to resuscitation, we in-
form the others about the conclusions we no-
ticed during the test:
• Wall movement present / absent
• Pericardium tamponade
• Presence of PEA (pulseless electrical activity) /
alleged PEA
• Poor image / no visibility
• etc.
This procedure gives us the opportunity to truly
evaluate the performance of myocardium and the
quality of its work and the effectiveness of resusci-
tation [40, 41].
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We perform a test for the presence of deep vein
thrombosis in a patient with swelling and/or pain in
the calf area. A properly constructed vein collapses
during compression, unlike arteries. When the ve-
nous vessel is destroyed, the walls become hardy
and the functioning of the venous valves is impaired
[42]. We will look for the rst of these two symp-
toms during the procedure. The study is optimally
performed using two heads: Convex type transducer
for examination of iliac veins and Linear head for
evaluation of the rest of the venous system of the
lower limb. There are different methods of per-
forming this test, but I think that the most accurate
*JFE&')!BS)Aorta width measurement

Maciej Dudek et al., Application of interventional ultrasound in emergency medicine conditions
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and the fastest method is the 3-point compression
method [43].
To perform this procedure, we lay the patient
in a supine position and rotate the examined limb,
about 10–15 ° outside. For the assessment of the
popliteal segment, we can put the patient on the
side and bend his leg in the knee joint by 12–30°.
The heads are applied transversely to the course
of the vessel with the marker pointing to the left,
i.e. to the right side of the patient. During each
position, we must compress the venous vessel and
assess its susceptibility to compression. If necessary,
we should document our activities.
The procedure starts with the groin in which we
are looking for the so-called “Mickey Mouse” image,
i.e. the saphenofemoral runoff (Fig. 13). This is the
rst position. Then we go along the femoral vein
to the next section, where I repeat the procedure.
Next, we move to the height of the popliteal vein
and perform a pressure test [44]. The whole process
is repeated on the other limb.
(E00$&H
As presented in the above article, intervention-
al ultrasonography and emergency procedures can
help diagnose and implement treatment in patients
with many disease entities that we will not be able
to recognize during an interview or physical exami-
nation [45, 46]. The ultrasound machine gives us the
possibility of a quick and non-invasive view of the
problem directly, with the simultaneous possibility
of indicating the cause of the ill condition of the
patient without any doubts — especially in uncon-
scious patients. The ultrasound machine is a small
device that can be carried even in a pocket. Access
to such devices for emergency medical services will
not only increase the effectiveness in the diagnosis
of injuries, but also enable continuous monitoring of
the patient’s condition, either in the ambulance or
on the emergency department.
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