Sonoexams level 1

Read before making Sonoexams:

Sonodynamics fundamentals

Blue text in these guidelines define the actual Sonoexam scanning protocols.
Red links in the guidelines lead to live video samples of the protocols. The videos are large, having diagnostic quality, and in some cases there are low resolution alternatives.

Sonoexam protocols:

Neck

Thyroid

Gallstones, video

Liver, video

Pancreas, video

Spleen

Kidneys, video

Abdominal aorta

Scrotum

Baker cyst

Patellar tendon

Achilles tendon

Ascites or blood (FAST)

Neck:

This Sonoexam aims at covering all lymph node locations.
The neck is basically divided into eight slightly overlapping sectors around the cirkumference, beginning with the left dorsal part and ending with the right dorsal part. The number of sectors may be modified to fit necks and transducers of various sizes, since overlapping of the sector borders is important. A linear array transducer (15L8w) is preferred, but large, heavily attenuating necks may require the higher penetration of a curved array. The patient has the head placed as low as tolerable.

  1. Transverse scan of the entire length of the neck dorsally by the left side of the midline, from skull base to shoulder. Depth to the surface of the vertebral column with a small margin.
  2. 1 is repeated, but with the transducer positioned laterally on the dorsal half of the neck, slightly overlapping to the ventral half of the neck.
  3. Transverse scan of the left lateral aspect of the ventral half of the neck with slight overlapping of 2. The transducer is aimed so that the ventral parts of the deep tissues are preferred over those by the transverse processes of the vertebrae.
  4. Transverse scan ventrally along the left side of the neck, slightly overlapping the midline. The field of view should aim as dorsally as possible, thus avoiding much of the non-information of the air in trachea. It is essential that the areas around the large vessels are well overlapped by scans 3 and 4.
  5. As 4 to 1, but on the right side in reversed order, from the ventral midline to the right dorsal part of the neck.
  6. Oblique scan aiming at the mouth floor, perpendicular to the lower edge of the mandible, from the left mandibular angle to the chin.
  7. Same as 5, but from the chin to the right mandibular angle.
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Thyroid:

A linear array transducer is preferred, but large, heavily attenuating necks may require the addition of the deeper penetration of a curved array. The patient has the head placed as low as tolerable. The Sonoexam aims at seeing the two thyroid lobes from two angles transversally, one longitudinally plus isthmus. Most frequently the isthmus is located between the upper parts of the lobes, giving the thyroid the shape of a “U” turned upside down. However, isthmus can be located at any level, giving the thyroid the shape of an “H” or a “U”.

  1. Transverse Sonoscan of the left lobe from a slightly lateral position, the scan plane pointing about 45 degrees medially.
  2. Transverse Sonoscan of the left lobe from a ventral position, pointing almost in the dorsal direction, with the trachea just visible at the medial edge.
  3. Transverse Sonoscan of the isthmus in the midline.
  4. 2 and 1 are repeated covering the right lobe, respectively.
  5. Longitudinal Sonoscan covering the upper part of the left lobe, isthmus, and the upper part of the right lobe, in a circular motion.
  6. Longitudinal Sonoscan covering the lower part of the left lobe, over trachea and covering the lower part of the right lobe, in a circular motion.
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Gallstones:

The position and size of the normal gallbladder vary between individuals. Especially the neck of the gallbladder may be difficult to visualize. Sonoscans of the lateral segments of the left liver lobe and the head of the pancreas are done for evaluation of the bile ducts.

  1. Supine position, intercostal exam with the transducer aligned along the ribs, one Sonoscan.
  2. Supine position, inspiration, transversal Sonoscan of the gallbladder subcostally.
  3. Supine position, inspiration, longitudinal Sonoscan of the gallbladder subcostally.
  4. Left decubitus position, inspiration, transversal Sonoscan of the gallbladder subcostally.
  5. Left decubitus position, inspiration, longitudinal Sonoscan of the gallbladder subcostally.
  6. Left decubitus position, inspiration, the transducer plane along the upper part of the main bile duct and the portal vein, one Sonoscan covering the liver hilum.
  7. Supine position, inspiration, transversal Sonoscan of liver segments 2, 3 and left part of 4.
  8. Supine position, inspiration, longitudinal Sonoscan of liver segments 2, 3 and left part of 4. Priority of the diaphragm over the caudal border of the liver.
  9. Supine position, inspiration, transversal Sonoscan of the pancreatic head. From above the pancreas and downward passed the horizontal part of duodenum.
  10. Supine position, inspiration, longitudinal Sonoscan of the pancreatic head. From the superior mesenteric vein to the descending part of duodenum.

Gallstone protocol (low res) Video showing how each Sonoscan should be presented on the monitor. Small stone in neck of gallbladder and slightly hypertrophic of gall bladder wall..

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Liver:

The liver consists of 8 segments. The goal of the Sonoexam is coverage of the entire liver and definition of the segment where any pathology is located.
All scanning of transversal scan planes is done craniocaudally, and longitudinal scans are scanned from left to right. Together, the transversal scans should cover the entire liver in the cranial-caudal direction with some margin.
In all longitudinal scans except 3 there is priority of diaphragm.
In scan 3 the lower liver edge is the priority.

  1. Supine position, inspiration, transversal Sonoscan of segments 2 and 3.
  2. Supine position, inspiration, longitudinal Sonoscan of segments 2 and 3.
  3. Left decubitus position, inspiration, longitudinal Sonoscan of the caudal part of the entire liver. The depth should reach a few centimeters deeper than to the first branching of the portal vein.
  4. Left decubitus position, inspiration, transversal Sonoscan with the inferior v cava positioned in the deep centre of the field of view. This Sonoscan includes segments 4, 1 and medial parts of segments 7 and 8.
  5. Left decubitus position, inspiration, longitudinal Sonoscan including segments 4, 1, medial parts of 7 and 8, passing the inferior v cava halfway through the Sonoscan.
  6. Left decubitus position, inspiration, transversal Sonoscan below the right costal arch. This Sonoscan includes the lateral parts of segments 7 and 8 and the entire segments 5-6.
  7. Left decubitus position, inspiration, longitudinal Sonoscan below the right costal arch aiming at the lateral parts of segments 8, 7, 6 and 5 respectively. Priority of the diaphragm over caudal parts.

If it is evident that Sonoscans 1-7 have covered the entire liver including the right lateral aspect, we omit Sonoscans 8 and 9. 

  1. Supine position. The right liver lobe is scanned with the transducer plane along the intercostal spaces, one 10 second Sonoscan jumping interstitium by interstitium craniocaudally. Depth setting just passed the portal vein.
  2. Supine position, transversal scan with the transducer positioned subcostally in the right lateral flank for access to the caudal margin of the right liver lobe. The depth is set to cover the medial surface of the accessible liver, but not deeper.
  3. Left decubitus position, inspiration, transversal and longitudinal Sonoscans of the gallbladder subcostally.
  4. Left decubitus position, inspiration, the transducer plane along the upper part of the main bile duct and the portal vein, one Sonoscan covering the liver hilum.

Liver Video showing how each Sonoscan should be presented on the monitor. There is no significant pathology in this exam.

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Pancreas:

The anatomy of the pancreas is complex, especially the correlation to its surroundings. The head is the biggest part of the pancreas, and is positioned slightly to the right of the midline in the supine position. The body and the tail point to the left and slightly cranially to the splenic hilum from the head. The common bile duct runs from the liver hilum down through the right part of the head, and v mesenterica superior enters from the caudal aspect to the left of the head behind the body, where it merges with v lienalis to form v porta, which in turn runs slanted from the pancreas up to the liver hilum. The pancreas Sonoexam aim at coverage of the entire organ including the common bile duct and as much of the pancreatic duct as possible, of the upper part of v mesenterica superior and the extrahepatic part of v porta. Pancreas is sometimes partially or totally inaccessible, due to gas in the ventricle and colon transversum. The tail is the part most often inaccessible. Accessibility can sometimes be achieved by altering deapth of breath or by the sitting or both decubital positions. The pancreas is very mobile sideways, especially in thin patients, which makes the decubital positions even more efficient. Intake of water may also create a window to the pancreas. The patient should always have an empty stomach for the exam. For planned exams, an oral laxative taken the previous day can make a great difference.
Steps 1, 2 and 4 are minimum requirements in abdominal surveys. 
All steps are required in targeted pancreas examinations.

  1. Supine, inspiration, transverse scan in the epigastrium, of the head and body through the horizontal part of the duodenum.
  2. Supine, inspiration, longitudinal scan, from the tail through the body and head, and the horizontal and descending parts of the duodenum.
  3. Supine, inspiration, transverse scan below the left costal arch, body and tail.
  4. Supine, breath according to access, along suitable intercostal in the left flank, from upper ventral aspect of the kidney well past splenic hilum, through tail.
  5. Left decubitus, inspiration, transversally along lower part of common bile duct, slowly from v mes sup through common bile duct, papilla Vateri into descending part of duodenum.
  6. Left decubitus, inspiration, longitudinally through the head with concentration on common bile duct, pancreatic duct and papilla Vateri, through duodenum.

Pancreas (low res) Video showing how each Sonoscan should be presented on the monitor. There is no significant pathology in this exam.

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Spleen:

The supine position is usually the best, but sometimes the right decubitus position has advantages. The patient can usually breathe at liberty, but in some cases inhalation improves access. Transducer 4C1 (curved abdominal). The objective is coverage of the full volume of the splenic parenchyma. This is achieved by tilting the longitudinal Sonoscans along the intercostal spaces, thus avoiding lines of rib shadows across the scans, and by overlapping several consecutive scans space by space intercostally The most difficult part to cover is the cranial surface of the spleen due to gas interference from the pulmonary sinus. Eventual transversal scans are performed with the 4V1 (vector) transducer at a perpendicular angle to the longitudinal scans.

  1. Position the transducer along the most dorsal intercostal space where the spleen can be seen, and scan at an ordinary slow pace in a ventral-cranial direction as far as the ribs allow access to the spleen.
  2. Move the transducer to the next ventral intercostal space, and repeat the scanning technique in 1 with as large an overlap as possible with the previous Sonoloop.
  3. Repeat 2 until the entire spleen has been covered.
  4. Change to transducer 4V1 and position it at an angle perpendicular to the longitudinal Sonoloops. Repeat 1-3, but scan in a ventral-caudal direction covering the entire spleen through each intercostal space.
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Kidneys:

The best positions of the transducer are highly variable between individuals. It is important to scan both kidneys both longitudinally and transversally in both the supine and decubitus positions since pathology may show in one position but not the other. Obstruction of visibility by the colon must be avoided. The following guidelines represent the minimum requirements for acceptable Sonoexams of the kidneys. Regarding the kidneys the basic scanning rule "transverse first" is deliberately violated due to the fact that the kidneys are initially most naturally approached longitudinally. When already in this position the longitudinal scan becomes the first scan in order to save time.
In Sonoexams of the kidneys of small children it is often beneficial to exchange the supine position for prone position, scanning the kidneys from the back. It is important to remember the scanning directions and body marker positions described in Sonodynamics fundamentals.
For measurement of renal size, the longitudinal measurement is made bedside and kept as a still image.

  1. Supine position, intercostal scan plane longitudinally along the left kidney, one Sonoscan.
  2. Supine position, scan plane transversal or almost transversal to the left kidney, one Sonoscan.
  3. Right decubitus position, most often inspiration, scan plane longitudinally along the left kidney, one Sonoscan,
  4. Right decubitus position, most often inspiration, scan plane transversal or almost transversal to the left kidney, one Sonoscan.
  5. Repeat 1-4 on the right kidney.
  6. Transversal Sonoscan of urinary bladder.
  7. Longitudinal Sonoscan of urinary bladder.

Kidneys/bladder (low res) Video showing how each scan should be presented on the monitor. There is no significant pathology in this exam.

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Abdominal aorta:

Access is often easy below the level of the pancreas, while the upper 1/3 is sometimes hidden. Accessibility problems can often be solved by inspiration, the left decubitus position or compression. As a last resort the upper abdominal aorta may be accessed through the liver (beware not to confuse the inferior vena cava for the aorta) or the left flank. Obstructing intestine may sometimes be pressed upward or downward, and angling the transducer can sometimes give access behind a gassy intestine. The initial position to try is the supine position.
For measurements it is important to keep the scan plane perpendicular to the aorta on transverse scans or the measurements will be exaggerated.

  1. One transversal Sonoscan of the upper abdominal aorta starting as cranially as possible and ending well below the superior mesenteric artery.
  2. One transversal Sonoscan of the lower abdominal aorta from the superior mesenteric artery passed the aortic bifurcation.
  3. Three longitudinal Sonoscans; one including the diaphragm, one centred on the middle of the abdominal aorta and one including the aortic bifurcation.
  4. One transversal and one longitudinal Sonoscan of each common iliac artery.
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Scrotum:

One practical way of fixation asking the patient to hold the penis cranially. It is also favourable to ask the patient to tighten the skin of the scrotum by placing his fingers on the ventras part of the scrotal skin and pulling cranially. The machine is set at “Detail 1” using the 15L8w (linear) transducer.

  1. One transversal Sonoscan craniocaudally of the left testicle from a lateroventral approach.
  2. One transversal Sonoscan craniocaudally of the left testicle from a medioventral approach.
  3. One longitudinal Sonoscan of the left testicle from left to right. If the entire testicle does not fit into the field of view, the Sonoscan is divided into one cranial and one caudal longitudinal Sonoloop.
  4. 1-3 are repeated on the right testicle.
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Baker cyst:

A linear array transducer is preferred, but large, heavily attenuating knees may require the higher penetration of a curved array. The patient lies in the prone position, or may eventually stand up. The Sonoexam aims at capturing the posterior medial, the intermediary and the posterior lateral aspects of the rear of the knee, with about ten cm margin up and down from the joint level. The Sonoscans are made according to the basic rule of up-down and toward the examiner. This means that one begins with the lateral aspect of the right knee, but with the medial aspect of the left knee, and the sides of the knees are referred to as left and right in the protocol. The body marker is positioned with the sides “as seen” from behind the patient.

  1. Transverse scan of the left aspect of the knee, including the left surface of the muscles and the adjacent subcutaneous fat.
  2. Transverse scan of the knees midline, with a depth that just reaches the femur and tibia.
  3. 1 is repeated, but from the right aspect.
  4. Longitudinal scan of the rear circumference of the knee from left to right (toward the examiner), slightly above the joint level.
  5. 4 is repeated at the joint level.
  6. 4 is repeated slightly below the joint level.
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Patellar tendon:

The patient bends the knees. Transducer 15L8w (linear), “Detail 1” setting. The depth setting to about 2 cm behind the tendon.

  1. One transversal Sonoscan directed to the left part of the tendon, from the patella to the tibia.
  2. As 1, but with the tendon in the middle of the field of view.
  3. As 1, but directed to the right part of the tendon.
  4. One longitudinal Sonoscan from left to right with the tenopatellar junction in the upper margin of the field of view.
  5. One longitudinal Sonoscan from left to right of the middle of the tendon.
  6. One longitudinal Sonoscan from left to right with the tenofibular junction in the lower margin of the field of view.
  7. As 2, but of the opposite side tendon for comparison of thickness.
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Achilles tendon:

The patient in the prone position with the feet hanging out over the “caudal” short end of the bed, bending the foot cranially for tension of the tendon. Depth to about 2 cm passed the tendon.

  1. One transversal Sonoscan from about 15 cm above “floor level” (the plantar surface of the heel)
  2. One longitudinal Sonoscan pointing at the tendon from a left posterior oblique angle, including the tenocalcaneus junction.
  3. One longitudinal Sonoscan pointing at the tendon from a strictly dorsal aspect, including the tenocalcaneus junction.
  4. One longitudinal Sonoscan pointing at the tendon from a right posterior oblique angle, including the tenocalcaneus junction.
  5. As 2-4, but at a more cranial position slightly overlapping Sonoscans 2-4.
  6. As 3, very slow scan, with colour Doppler at the “Low flow” setting.
  7. 1 and 3 on the opposing side tendon, 3 being repeated at a more cranial position slightly overlapping the previous Sonoscan.
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Ascites, free blood (FAST):

The supine position. Depth reaching behind and above the liver and spleen respectively, as well as behind the rectum in the Fossa Douglasii.

  1. One transversal Sonoscan covering the heart chamber level from the epigastrium. This scan is included for completion of the FAST protocol.
  2. Intercostal Sonoscan (one or two Sonoloops through the liver for access above and behind it).
  3. Intercostal Sonoscan in the left flank, visualizing the subdiaphragmal space above and behind the spleen.
  4. Transversal Sonoscan from a laterocaudal approach of the paracolic gutter of the right flank, from subcostally to the pelvic crista, with a depth setting to about 7 cm passed the abdominal wall.
  5. As 4, but on the left side.
  6. Transversally through the urinary bladder with about 7 cm margin behind it for visualization of the Fossa Douglasii.
  7. As 6, but longitudinally.
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