Vascular emergencies & Appendicitis 新光醫院急診醫學 科 陳國智醫師 中華民國醫用超音波學會指導醫師
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Vascular emergencies &
Appendicitis
新光醫院急診醫學科
陳國智醫師 中華民國醫用超音波學會指導醫師
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Vascular emergencies
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Question
• 請問腹主動脈瘤診斷標準,直徑需為多少 ?
1. 大於2公分
2.
大於3
公分
3. 大於4公分
4. 大於5公分
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Anatomy and Probe position
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Transverse View
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Transverse View
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Longitudinal View
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Coronal View
傳統view 看不見時的輔助介面
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ObstaclesBowel gas
Obesity
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The cylinder tangent effect
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Question
• 請問急診超音波在主動脈急症的應用最重 要的目的為何 ?
1.
診斷有無胸部主動脈瘤
2. 診斷有無腹部主動脈瘤
3. 診斷有無主動脈瘤破裂
4. 診斷有無主動脈剝離
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59M with hematuria and flank pain
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SKHER AAA protocol
• Any patient: age >= 50 y/o
– Syncope / hypotension/dizziness and/or
– Abdominal / back / flank / groin pain
• EUS – Abdominal aorta evaluation
– Subxiphoid area, longitudinal & transverse
– From just below diaphragm to bifurcation
– Epigastrium, SMA, and 3cm above bifurcation
– AAA: diameter more than 3cm (>=5cm, high risk)
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59M with hematuria and flank pain
AAA
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76M with abdominal pain
AAA, impending rupture
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65F with mid-abdominal pain
Aortic dissection with flap
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78M with AAA s/p grafting, Abdominal pain
Ruptured AAA
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69M with chest pain and shock
• 請問此患者最可能是 那種型態的休克 ?
1. Hypovolemic shock
2. Obstructive shock
3. Cardiogenic shock
4. Septic shock
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69M with chest pain and shockHemopericardium by aortic dissection
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84F IHCA during ERCPHemopericardium by aortic dissection
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91F with right thigh swelling for 3 d
• 請問造成左圖大腿病灶最可能的原因為何 ?
1. Abscess
2. Pseudo-aneurysm
3. DVT
4. Tumor
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91F with right thigh swelling for 3 d
Pseudo-aneurysm
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81F with left thigh ecchymosis
AV fistula
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59M with right arm painful swelling
Pseudo-aneurysm
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DVT 臨床表徵
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Clinical assessment model:
Wells criteria
Active cancer (treatment ongoing or within previous 6 months or palliative) 1
Paralysis, paresis or recent plaste, or immobilization of lower limbs 1
Recently bedridden for 3 days or more, or major surgery < 4 weeks 1
Localized tenderness along the DV system distribution 1
Entire leg swollen 1
Calf swelling > 3cm compared with asymptomatic leg (10cm below the tuberosity) 1
Pitting edema 1
Collateral superficial veins (nonvaricose) 1
Previously documented DVT 1
Alternative diagnosis as likely or greater than DVT -2
Low probability 0
Moderate probability 1-2
High probability 3
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Question
• 請問診斷深部靜脈栓塞的最主要依據為何?
1. 掃描部位的靜脈若能完全壓遍即可排除
2.
掃描部位的靜脈是否在Doppler
下有血流
3. 掃描部位的靜脈是否有看到栓塞(thrombus)
4. 必需使用具備Doppler 功能的儀器才能在臨床上應用
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EUS for DVT
• Non-compression of the vessel
– Inability to completely compress the vessels
–With proper pressure
– After ensuring good position
• FYI:
–
–
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Landmark for DVT Scan
• Mid-point of inguinal ligment – Vessels: CFV & CFA
– Until CFV splits into DFV & SFV (Mid-thigh)
• Popliteal fossa
– Vessels: PV & PA – The last 2 cm of PV and end just distal to the trifurcation
– “ the vein comes to the top in the pop”
• Contralateral leg scanning – Optional
• Documentation – Dual-image feature: w/ & w/o compression
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No complete compression
1. Presence of a clot
2. Inadequate pressure on thetransducer
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Methods to extend veins
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Ideal transducer
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Scanning technique
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Position for femoral area
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Effect of Compression
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Popliteal area
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DVT
• EUS
– Can tell you the presence or absence of
proximal DVT
– Can’t tell you• the presence or absence of distal DVT
• the cause of the pain if the US is normal
•Two point compression approach
• Look for
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Question: 請問有無DVT ?
有 (1)無 (2)
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72F with left leg swelling and pain
for 2 days; BT: 38.5℃
Q ti 有無DVT ?
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Question: 有無DVT ?
有(1)
無(2)
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DVT
• Criteria:
1. Non-compressible vein
2. Echogenic thrombus
Question:有無DVT ?
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Question: 有無DVT ? 有 (1) 無 (2)
Mid-thigh DVT
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59M, right leg swelling for 3 days
DVT
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Question: 請問那邊有DVT ?
64F with left leg pain and swelling DVT ??
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64F with left leg pain and swelling, DVT ??
是 (1) 否 (2)
Lymphadenopathy
83M with left leg pain DVT ??
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83M with left leg pain, DVT ?? 是 (1) 否 (2)
Baker’s cyst rupture
66M ith i ht lli
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66M with right arm swelling
Subclavian vein thrombosis
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88F with abdominal pain
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Volvulus ( Whirlpool sign)
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77F with refractory abdominal pain
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SMA occlusion
53F i h i ith bd i l i
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53F, cirrhosis with abdominal pain
SMV thrombosis
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Appendicitis
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Graded compression technique
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GI tract lesions on sonography
1. 腸胃道壁增厚 (>4mm)
2. 腸胃道壁分層消失
3. 蠕動減少
4. 用超音波探頭壓迫時不變形
5. 病灶通道內容物減少
6. 病灶附近之其他變化(LN, fat, ascites)
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Alvarado Score
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Question
• 請問下列何者非急性闌尾炎的超音波發現 ?
1. Blind-ended tubular structure
2. Non-compressible appendix
3. Diameter > 6mm
4. Dome sign
5. Appendicolith
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Appendicitis
Eur Radiol. 2002;12:1748-61
• Diameter > 6mm (Cross section)
• Non-compressiblity of appendix
• Localized pain during compressionwith the transducer
• Alteration of the periappendiceal fat
(echogenic & non-compressible fat)
•
Obstruction of the lumen by anappendicolith
• Hypervascularizaion in color Doppler of appendix and
surrounding fat
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Landmark of Appendix
• RLQ
– Iliac crest
– Psoas muscle
–
Iliac vessels – Cecum & A-colon
A di l t di t f
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Appendiceal outer diameter for
appendiceal mucocele VS appendicitis
Lien WC, AJEM (2006) 24, 801 –805
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Cases
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Cecum, Ileum and Appendicitis
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Appendicolith
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11M with appendicitis
27F Pregnancy 14wks
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27F, Pregnancy 14wks,
Appendicitis
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Lateral appendicits
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學習認 Landmark
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Ruptured appendicits
10M with peritonitis
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10M with peritonitis
Ruptured appendicitis
14M with peritonitis
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14M with peritonitis
Ruptured appendicitis
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45F with RLQ pain
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Ruptured retrocecal appendicitis
*
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47M with RLQ pain
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Ruptured appendicitis
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66M with RLQ pain
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Appendiceal mucocele
57F with mid-abdominal pain
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57F with mid abdominal pain
Appendicitis around umbilicus
*
*
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謝謝聆聽
歡迎指教及給予回饋