Emergency front of neck access—another victory for ultrasound (?)

This is another reference list for a talk on ultrasound for emergency cricothyroidotomy given at the fantastic 2019 Critical Care Symposium conference that occurs in Manchester each year. The talk is at the end of the reference list. We’re updating details about our POCUS fellowships too, but until then, please contact us on

Elliott DSJ, Baker PA, Scott MR, Birch CW, Thompson JMD. Accuracy of surface landmark identification for cannula cricothyroidotomy.
Anaesthesia. 2010 Sep;65(9):889–94. Weblink

Gadd K, Wills K, Harle R, Terblanche N.
Relationship between severe obesity and depth to the cricothyroid membrane in third-trimester non-labouring parturients: a prospective observational study.
British journal of anaesthesia. 2018 May;120(5):1033–9. Weblink

Blaivis M, Sama AE.
Ultrasonography in the detection of the cricoid membrane for needle cricothyrotomy.
Acad Emerg Med 2001;8: 579-80 Weblink

Kristensen MS, Teoh WH, Rudolph SS, Tvede MF, Hesselfeldt R, Børglum J, et al.
Structured approach to ultrasound-guided identification of the cricothyroid membrane: a randomized comparison with the palpation method in the morbidly obese.
British journal of anaesthesia. 2015 Jun;114(6):1003–4. Weblink

Siddiqui N, Yu E, Boulis S, You-Ten KE.
Ultrasound Is Superior to Palpation in Identifying the Cricothyroid Membrane in Subjects with Poorly Defined Neck Landmarks: A Randomized Clinical Trial. Anesthesiology. 2018 Dec;129(6):1132–9. Weblink

Embedded presentation. Alas, no way currently to get the videos to play in this format.

Pushing the Boundaries of POCUS—beyond the heart & lungs

This is a reference list for a talk given at the fantastic 2019 Critical Care Symposium conference that occurs in Manchester each year. The talk is at the end of the reference list. We’re updating details about our POCUS fellowships too, but until then, please contact us on

Hansen HC, Helmke K.
Validation of the optic nerve sheath response to changing cerebrospinal fluid pressure: ultrasound findings during intrathecal infusion tests.
J Neurosurg.; 1997 Jul;87(1):34–40. Weblink

Blaivas M, Theodoro D, Sierzenski PR.
Elevated intracranial pressure detected by bedside emergency ultrasonography of the optic nerve sheath.
Acad Emerg Med. 2003 Apr;10(4):376–81. Weblink

Ultrasonographic optic nerve sheath diameter to detect increased intracranial pressure in adults:a meta-analysis. Acta radiologica 2019 Feb;60(2):221–9. Weblink

Sargsyan AE, Hamilton DR, Melton SL, Amponsah D, Marshall NE, Dulchavsky SA.Ultrasonic evaluation of pupillary light reflex.
Crit Ultrasound J. 2009;1(2):53–7. Webink

Van de Putte P, Perlas A.
Ultrasound assessment of gastric content and volume.British journal of anaesthesia. 2014 Jul;113(1):12–22. Weblink

Not forgetting the fantastic www.gastricultrasound.org as well to learn how to undertake volumetric gastric ultrasound

Ultrasound for Lower Extremity Deep Venous Thrombosis: Multidisciplinary Recommendations From the Society of Radiologists in Ultrasound Consensus Conference.Circulation 2018 Apr 3;137(14):1505–15. Weblink

Ferrari G, De Filippi G, Elia F, Panero F, Volpicelli G, Aprà F. Diaphragm ultrasound as a new index of discontinuation from mechanical ventilation.
Crit Ultrasound J. Springer; 2014;6(1):8. Weblink

A narrative review of diaphragm ultrasound to predict weaning from mechanical ventilation: where are we and where are we heading?Peter Turton, Sondus ALAidarous and Ingeborg Welters
The Ultrasound Journal 2019 11:2 Weblink

Vetrugno L, Guadagnin GM, Barbariol F, Langiano N, Zangrillo A, Bove T. Ultrasound Imaging for Diaphragm Dysfunction: A Narrative Literature Review. J Cardiothorac Vasc Anesth. 2019 Jan 4. Weblink

Regrettably we don’t currently have a way to get the embedded videos to play right now.

WINFOCUS 2019 – Dubai

Lung ultrasound in clinical practice: one step forward (G Volpicelli)

Lung ultrasound has been the most impactful new diagnostic tool in the modern emergency medicine during the last 15 – 20 years, together with the advent of troponins… with the difference that lung ultrasound has a wide spectrum of application while troponin has only very few specific


Ultrasonic Absorption and Reflection by Lung Tissue – By Dunn and Fry, 1961

Lung ultrasound relies on 3 basic patterns

  1. A lines
  2. B lines
  3. Consolidation

Use and look for additional signs…

Integrate information

  • Contextualisation
    • There is a wide differential diagnosis for B lines BUT with clinical history, the differential can be focussed e.g. localised B-lines in the context of a previously healthy young man who just sustained blunt chest trauma.
  • Monitoring
    • The re-expansion of a previously atelectatic lung.
  • Multiorgan
    • The use of lung ultrasound together with echocardiography

TEE-guided resuscitation (F Teran)



Standardised TEE views/approach

Transesophageal echocardiography during cardiopulmonary arrest in the emergency department.

Focused transesophageal echocardiography for emergency physicians—description and results from simulation training of a structured four-view examination

Why TEE?

US is the standard of care – European Resuscitation Council 2015 Guidelines

Whilst TTE is limited by windows and opportunity to get the images, TEE/TOE –> high quality image, no interference, chest compression continues.

ACEP 2017 Guidelines for the Use of Transesophageal Echocardiography (TEE) in the ED for Cardiac Arrest

Goals of resuscitative TEE

  • Identification of presence/absence of cardiac activity
  • Identification of cardiac rhythm
  • Evaluation of LV function
  • Evaluation of RV function
  • Identification of pericardial effusion/tamponade

How is TEE impacting care?

  • Identify pathology
  • Assess intervention
  • Improve quality of CPR
    • Shorter time off chest
    • Optimisation of area of maximal compression
  • Understand physiology and the haemodynamics

Shorter time of chest (ref full text)

  • TTE – 19s pulse check
  • TEE – 9s pulse check

Multiorgan Ultrasound in Cardiac Arrest (R Breitkreutz)


You will find treatable conditions with FEEL

Interruptions for ultrasound are trainable

Emergency department point-of-care ultrasound in out-of-hospital and in-ED cardiac arrest.

  • Cardiac activity on US was most associated with survival following cardiac arrest
  • US during cardiac arrest identifies interventions outside of the standard ACLS protocol

Focus cardiac ultrasound core curriculum and core syllabus of the European Association of Cardiovascular Imaging 

US-CAB protocol for ultrasonographic evaluation during cardiopulmonary resuscitation: Validation and potential impact.

*Disclaimer – AW does not and would not use ultrasound to confirm ETT position in his practice

Diaphragm ultrasound: research to clinical practice (G Ferrari)

Measurements depend on effort and are reproducibility variable

There is no standardised method to assess but broadly speaking 2 most frequently used are Diaphragm Excursion and Diaphragmatic Thickening (Fraction)

The advantages of using ultrasound to evaluate the diaphragm

  • Lack of ionising radiation
  • Bedside procedure
  • Non invasive
  • Real-time evaluation of diaphragm movement/thickness
  • Fast, easy and reproducible
  • Natural window to the critically ill (pleural effusions, consolidation or atelectasis allow an easier identification of the hemidiaphragms)
  • Method of choice in the investigation of hemidiaphragmatic paralysis

If subcostal views are difficult to obtain, can use lateral approach but no reference values for this approach

Ultrasonographic diagnostic criterion for severe diaphragmatic dysfunction after cardiac surgery.

Diaphragm dysfunction (DD) in ICU

DD can be present at ICU admission, or may develop during ICU stay

There is increasing evidence that DD is already present at ICU admission in a high % of pts

Evolution of diaphragm thickness during mechanical ventilation: impact of inspiratory effort.

Measuring diaphragm thickness with ultrasound in mechanically ventilated patients: feasibility, reproducibility and validity. 

Diaphragmatic ultrasonography for predicting ventilator weaning: A meta-analysis

Can diaphragmatic ultrasonography performed during the T-tube trial predict weaning failure? The role of diaphragmatic rapid shallow breathing index

A new diagnostic approach to heart failure (L Gargani)

Essentially, she means the addition of lung ultrasound to your normal cardiac evaluation. End.

Lung ultrasound has a role in heart failure with regards to –

  • diagnosis
  • monitoring
  • prognostication

Lung ultrasound integrated with clinical assessment for the diagnosis of acute decompensated heart failure in the emergency department: a randomized controlled trial.

  • TheBottomLine has broken this down for you here

2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC)
Recommend the use heart and lung ultrasound assessment early (30-60 mins)

Luna’s 5 Laws

  1. LUS/POCUS saves time
  2. The worse the situation, the more important it is to utilise POCUS
  3. Integrated cardiopulmonary ultrasound assessment
  4. Master all the lung signs
  5. Remember the different types of congestion
Haemodynamic vs pulmonary congestion

Take-home messages

  • LUS can help in the diagnosis, monitoring and prognosis of heart failure
  • It helps saves time
  • It reveals subclinical congestion
  • It differentiates haemodynamic from pulmonary congestion
  • It is better placed as part of ‘multiorgan’ ultrasound approach
  • It doesn’t replace your brain or medical knowledge

Ultrasound and Trauma (S Ianniello & L Zieleskiewicz)

In Dr Ianniello’s department, a radiologists attends in resus for the arrival of major trauma. An extended-FAST is performed for every unstable (SBP<90mmHg).

For the stable trauma patient, no unrecognised diagnosis with a clinical impact was missed due to lack of chest and pelvic x-ray.

Integrating eFAST in the initial management of stable trauma patients: the end of plain film radiography

She recommends

  • Don’t waste time
  • Scan for free fluid and pericardial effusion first
  • Second, look for pneumothorax
  • (if there is time, look for injuries to solid organs)
  • Use eFAST for an overview, not for a definitive diagnosis
  • Move the pt on to CT or OR as quickly as possible

The Future?

Strain analysis for cardiac contusion and to better detect pneumothorax?

Ultrasound-guided pericardiocentesis (Dr A Osman)

Multiple approaches – parasternal, apical and subxiphoid

Go for –

  • largest fluid
  • closest to the probe
  • avoid vital structures

Ultrasound-guided pericardiocentesis: a novel parasternal approach

  • A description of a parasternal, medial to lateral needling approach
  • Main advantages
    • Safe, as all surrounding structures are visualised and thus avoided
    • High-frequency probe allows for detailed visualisation of needle and wire
    • Fast procedural time

Ultrasound guide in tracheostomy (Dr D Govil)

The speaker makes the case that the use of ultrasound completely negates the need for the bronchoscope.

Ultrasound-Guided Percutaneous Dilational Tracheostomy: A Systematic Review of Randomized Controlled Trials and Meta-Analysis.

Comparison of percutaneous tracheostomy methods in intensive care patients: blind, fibreoptic bronchoscopy and fibreoptic bronchoscopy plus ultrasound

Comparison of 3 techniques in percutaneous tracheostomy: Traditional landmark technique; ultrasonography-guided long-axis approach; and short-axis approach – Randomised controlled study.

US use and the estimation of intracranial pressure in emergency (F Rasulo)

Ultrasound is useful because its more readily available compared to more invasive methods.

ICP by itself is probably not useful and a multimodal approach should be adopted in order to ‘personalise’ care and treatment

Consensus summary statement of the International Multidisciplinary Consensus Conference on Multimodality Monitoring in Neurocritical Care

Transcranial Doppler after traumatic brain injury: is there a role?

Neuroultrasound can measure flow (TCD, pulsatility), pressure (ONSD) and midline shift. These can/should be combined.

And coming to you soon – neuropocus competencies….

Integrated approach to aortic rupture (P Nazerian)

Aortic dissection has multiple differentials and hence can be easy to misdiagnosed.

Multiple approaches currently being used

  • Aortic dissection detection risk score
  • Chest x-ray
  • D-dimer
  • Bedside TTE (importantly, the suprasternal views)

All are not perfect.

The ADvISED trial aimed to combine all these techniques.

Diagnostic Accuracy of the Aortic Dissection Detection Risk Score Plus D-Dimer for Acute Aortic Syndromes: The ADvISED Prospective Multicenter Study.

  • RebelEM has broken it down here

WINFOCUS Lung Course 2019


Key referenceInternational evidence-based recommendations for point-of-care lung ultrasound.

Lung Ultrasound overview

Ultrasound whilst very useful does suffer from ideal vs reality difference. Often images obtained in real-life patients and conditions don’t reflect those seen at courses. BUT it is usually good enough.


  • Bones of thoracic cage
    • 70% of pleura is still visible
  • Air in lung
  • Surface imaging techniques
Lesion surrounded by normal aerated lung often cannot be seen on ultrasound

Recommends scanning in 8 sectors (c.f. Lichtenstein’s BLU protocol which utilises 6 points – ref). It does depend on what you are looking for – if pneumonia, make sure you scan the posterior aspects.


Key point 1 – differentiating between air before or beyond the visceral pleura

Key point 2 – No sliding does not equal pneumothorax necessarily. Differential diagnosis includes:

  • Pleural adhesions
  • Emphysematous bullae
  • Apnoea
  • Selective intubation
  • Atelectasis
  • Pneumonia

Do you see the lung pulse?

Do you see B-lines? If B-lines are present, there is NO pneumothorax

The position of the lung point in the supine patient gives an idea of the size. If above the anterior axillary line, it is small.

Interstitial Syndrome


  • Vertical
  • From the pleural line
  • Spreads without fade
  • Moves synchronously with lung sliding
  • Erases horizontal artifacts

Pathological – at least 3 B-lines in longitudinal scan (or at least 3 closely placed B-lines in transverse scan)

B-line generation

Where do B-lines come from?

Sonographic interstitial syndrome: the sound of lung water.

  • Increase fluid –> increase weight but constant lung volume
  • Lung deflation –> weight constant but lung volume reduces

Focal Interstitial Syndrome

  • Pneumonia
  • Atelectasis
  • Pulmonary contusion
  • Pulmonary infarction
  • Pleural disease
  • Neoplasia

Diffuse Interstitial Syndrome

  • Pulmonary oedema of various causes
  • Interstitial pneumonia
  • Diffuse parenchymal lung disease (pulmonary fibrosis, alveolar proteinosis…)
Lung US vs PA catheter and PICCO
Lung US vs BNP

Lung ultrasound integrated with clinical assessment for the diagnosis of acute decompensated heart failure in the emergency department: a randomized controlled trial

Pulmonary fibrosis

  • Irregular, fragmented pleural line
  • Small echo-poor subpleural areas
  • Irregularly spaced B-lines


  • Anterior sub-pleural consolidation
  • Absence or reduced sliding
  • ‘Spared areas’ of normal parenchyma
  • Pleural line abnormalities (irregular thickened, fragmented pleural line)
  • Non-homogenous distribution of B-lines


Consolidation = fluid-filled lung

  • Subpleural
  • Tissue-like echotexture

It is a dynamic process and therefore, appearance will vary

  1. When initially fluid filled, hepaticisation
  2. Phase of lysis follows –> lentil-shaped air trapping

Pulmonary infarction

  • Early –> hypoechoic, homogeneous subpleural structure
  • Late –> margins serrated, echodence, no blood flow on colour doppler, triangular in shape

Atelectasis – absence of ventilation

  • Compression vs resorption atelectasis

Pleural effusion

CT inferior to LUS in differentiating exudate and transudate

Pleural exudates and transudates: diagnosis with contrast-enhanced CT.

Quantification – many methods exist. The gold standard remains CT.

Usefulness of ultrasonography in predicting pleural effusions > 500 mL in patients receiving mechanical ventilation.

Multiplane ultrasound approach to quantify pleural effusion at the bedside.

Thoracocentesis – Use ultrasound in real-time NOT blind NOT marking

British Thoracic Society Pleural Disease Guideline Group

Evaluation of pleuritic chest pain

Diagnosis of radio-occult pulmonary conditions by real-time chest ultrasonography in patients with pleuritic pain.

  • Ultrasound sensitivity – 94.7%
  • Ultrasound specificity – 96.7%

A comparison of different diagnostic tests in the bedside evaluation of pleuritic pain in the ED.

Chest radiography and blood tests may be inadequate in the diagnostic process of pleuritic pain. In case of silent CXR, LUS is critical for identifying patients with pleural-pulmonary radio-occult conditions at bedside and cannot be safely replaced by other conventional methods.

Volpicelli et al., 2012

Ultrasound and the airway

Check ETT position – oesophageal intubation and selective intubation

Tracheal rapid ultrasound exam (TRUE) for confirming endotracheal tube placement during emergency intubation

Auscultation versus Point-of-care Ultrasound to Determine Endotracheal versus Bronchial Intubation: A Diagnostic Accuracy Study.

Upper airway anatomy identification

Structured approach to ultrasound-guided identification of the cricothyroid membrane: a randomized comparison with the palpation method in the morbidly obese.

Predict difficult airway

Ultrasound evaluation of the airway in the ED: a feasibility study

Sublingual ultrasound as an assessment method for predicting difficult intubation: a pilot study

Ultrasound-Assisted Evaluation of the Airway in Clinical Anesthesia Practice: Past, Present and Future

Guide percutaneous tracheostomy

Putting it all together

BLUE-protocol and FALLS-protocol: two applications of lung ultrasound in the critically ill.

Advanced level

Complex Pneumothorax


  • False lung point – normal folds of pleura e.g. around the heart
  • Lung pulse cause by mammary vessels
  • Double lung point – link
  • Septated pneumothorax

Unusual new signs of pneumothorax at lung ultrasound

Using Thoracic Ultrasonography to Accurately Assess Pneumothorax Progression During Positive Pressure Ventilation

Ultrasound evaluation of diaphragm function

Sonographic evaluation of the diaphragm in critically ill patients. Technique and clinical applications.


  • Excursion –> curvilinear probe
  • Thickness –> liner probe

Besides excursion, M-mode allows for measurement of inspiratory time, expiratory time and speed of contraction

Diaphragm excursion – inter and intra observer agreement 90-95% (lower agreement on the left)

Diaphragm thickness – need to identify 3 layers (pleura, diaphragm, peritoneum)

Consolidation and differential diagnosis

Sonomorphology of pneumonia

  • Similar to liver
  • Lentil-shaped air trappings
  • Air bronchogram(s)
  • Fluid bronchogram
  • Blurred/serrated margins

Lung ultrasound in the diagnosis and follow-up of community-acquired pneumonia: a prospective, multicenter, diagnostic accuracy study.

  • Sensitivity 94%, specificity 98%
  • With auscultation findings, increase sensitivity
  • CXR missed or was inconclusive in 7% of LUS +
  • LUS missed 8% of CAP

Ultrasound for “Lung Monitoring” of Ventilated Patients

Acute respiratory failure: BLUE protocol

Relevance of Lung Ultrasound in the Diagnosis of Acute Respiratory Failure*

Monitoring alveolar recruitment

Lung sonography is highly sensitive to variations of the pulmonary content and balance between air and fluids, like a real lung densitometer

Volpicelli. J Ultrasound 2013; 32: 165-171

When the lung decreases in air content, US shows an image with increased density

  • Acute cardiac failure – increase density, increase weight of the lung
  • Atelectasis – increase density, constant weight

Ultrasound assessment of lung aeration loss during a successful weaning trial predicts postextubation distress*.

  • Lung ultrasound score calculation
    • All intercostal space
    • Most severe US pattern characterizes that region
    • LUS is calculated from the addition of the 12 examined region

Using sonography to assess lung recruitment in patients with acute respiratory distress syndrome.

Anaesthesia-induced atelectasis

  • Well known condition observed in 68-100% of adult and pediatric pts undergoing general anaesthesia
  • Appear when lung is collapsed, more frequently in the most dependent lung zones
  • This side effect of general anaesthesia can be found in all types of interventions
  • Could be associated with postoperative pulmonary complications

Monitoring pulmonary congestion and haemodynamics

Sadly nothing on portal and venous doppler studies etc. I would refer you to the excellent www.thinkingcriticalcare.com

Take home messages from the speaker

  • LUS provide a simple, semiquantitative index of extravascular lung water (EVLW) accumulation
  • LUS strongly correlates with chest x-ray, CT scan and gravimetric studies in the evaluation of EVLW
  • LUS is an earlier index of EVLW increase in comparison to PaO2/FiO2
  • Correlation among LUS, PiCCO and Swan-Ganz vary according to different clinical features

Integrating US lung-heart-veins: pulmonary embolism

Accuracy of point-of-care multiorgan ultrasonography for the diagnosis of pulmonary embolism.

Diagnostic accuracy of lung ultrasound for pulmonary embolism: a systematic review and meta-analysis.