The authors wish to acknowledge Dr. Annie Y. Chen and Ms. Linda Salas Mesa for their assistance with photography.

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The patients provided written informed consent for participating in the study. Patient inclusion criteria: any patient with hemodynamic instability or abdominal pain/distension. Patient exclusion criteria: patient refusal.
1. Transducer selection
<ol>
	<li>Select a low-frequency linear transducer (1-5 MHz) (see Table of Materials) to visualize organs deeper than 6 cm in the body1,19.</li>
	<li>If available, select the curvilinear low-frequency probe as its wide footprint maximizes spatial resolution of intra-abdominal organs.</li>
	<li>If the curvilinear probe is not available, select any low-frequency probe such as a sector array probe (aka &#34;phased array probe&#34;, see Table of Materials). 
	NOTE: The sector array probe is sometimes colloquially called the &#34;phased array probe&#34;. However, this latter colloquial term is misleading because all modern ultrasound transducers (including even linear high-frequency transducers) use electronic phasing to steer the ultrasound beam20,21,22, so what distinguishes the sector array from other ultrasound probes is not that it is a &#34;phased array&#34; (all modern transducers are) but that this probe traces out a sector arc. But because many point-of-care ultrasound providers use the term &#34;phased array&#34; to refer to the sector array probe, this manuscript will mention both terms. However, to those interested in the mechanics of how ultrasound machines work, sector array probe is the technically accurate name and is already widely used by ultrasound experts outside of the point-of-care ultrasound world18,23,24,25,26.</li>
	<li>If the e-FAST exam is being performed and is being used to screen for pneumothorax, use a linear high-frequency probe (&#8805; 5 MHz, see Table of Materials) for that application and then resume using a low-frequency probe for the remainder of the FAST/e-FAST exam.</li>
</ol>
2. Machine settings and machine placement
<ol>
	<li>Mode
	<ol>
		<li>Select abdominal mode, which will place the indicator on the left screen and maximize spatial resolution while minimizing temporal resolution. 
		NOTE: In contrast to &#34;abdominal&#34; mode, &#34;cardiac&#34; mode will maximize temporal resolution at the expense of spatial resolution, settings that are optimal for visualizing the fast-moving structures within the heart but unhelpful for visualizing the slow-moving structures in the abdomen or screening for gross fluid in the pericardial sac.</li>
	</ol>
	</li>
	<li>Machine placement
	<ol>
		<li>Place the ultrasound machine on either the patient&#39;s left or right side but ensure that the sonographer has a direct line of sight to both the machine&#39;s screen and to the patient simultaneously so that the operator can manipulate both the ultrasound probe and the ultrasound machine settings concurrently.</li>
	</ol>
	</li>
	<li>Image acquisition preset
	<ol>
		<li>Set the ultrasound machine&#39;s image acquisition technique to prospective collection. If the operator prefers &#34;retrospective collection, &#34; they will need to reverse the order of any paired steps involving fanning the ultrasound probe and click Acquire before image acquisition.</li>
	</ol>
	</li>
</ol>
3. Patient positioning
<ol>
	<li>Position the patient supine with the chest and abdomen exposed1.</li>
	<li>For Right Upper Quadrant (RUQ) and Left Upper Quadrant (LUQ) views, abduct the patient&#39;s arms at least 5 inches away from their body to allow access for the ultrasound probe to reach the patient&#39;s flanks.</li>
</ol>
4. Scanning technique
<ol>
	<li>Apply gel to the ultrasound probe prior to attempting each view.</li>
	<li>Point indicator mark cranially for coronal or sagittal views and toward the patient&#39;s right side for transverse views.</li>
</ol>
5. FAST exam cardiac views
<ol>
	<li>Subxiphoid (aka subcostal) 4-chamber view
	<ol>
		<li>Place the probe on the anterior abdominal wall just caudal to the xiphoid process in the midline or slightly to the patient&#39;s right1.</li>
		<li>Orient the ultrasound beam transversely with the indicator to the patient&#39;s right and the probe nearly flat against the patient&#39;s abdomen and directed towards the patient&#39;s left shoulder1 (Figure 1).</li>
		<li>Adjust probe positioning and screen depth to obtain a view of the four cardiac chambers visualized in the center of the ultrasound image (Figure 2; Video 1).</li>
		<li>Adjust the gain until the intracardiac blood appears uniformly black (anechoic) with just a few specks of grey27.</li>
		<li>Click on Acquire.</li>
		<li>Inspect the circumference of the heart for a similar dark hypoechoic stripe around the myocardium (Figure 2; Video 2).</li>
	</ol>
	</li>
	<li>Parasternal long-axis view (optional) 
	NOTE: In some patients, the subxiphoid window may provide ambiguous findings or inadequate visualization of the pericardium due to abdominal obesity or distended/gas-filled stomach1. In these circumstances, the parasternal window may provide an alternative window to screen for pericardial effusion.
	<ol>
		<li>Place the probe along the left sternal border just caudal to the clavicle with the indicator mark pointing toward the patient&#39;s left hip (Figure 3). 
		NOTE: The transducer indicator mark is pointed toward the patient&#39;s left hip and not toward the right shoulder, as would be done when performing transthoracic cardiac ultrasound because the entire FAST exam is traditionally performed in &#34;abdominal&#34; rather than &#34;cardiac&#34; mode.</li>
		<li>While keeping the probe indicator pointed toward the patient&#39;s left hip, slide (translate) the probe caudally examining each rib interspace until the heart disappears and making a note of which interspaces provided a useful view of the heart.</li>
		<li>Slide (translate) the probe back cranially to the interspace or spaces that provide the best visualization of the heart.</li>
		<li>Adjust probe positioning to obtain a view with the following structures visible: descending thoracic aorta, left atrium, left ventricle, left ventricular outlow tract, right ventricle, and pericardium (Figure 4; Video 3).</li>
		<li>Adjust screen depth so that at least 3-6 cm of depth is visible deep to the descending thoracic aorta (Figure 4; Video 3; Video 4).</li>
		<li>Adjust gain as mentioned in step 5.1.4.</li>
		<li>Click on Acquire.</li>
		<li>Inspect the circumference of the heart for a dark hypoechoic stripe that dissects into the plane between the heart and the descending thoracic aorta (Figure 4).</li>
	</ol>
	</li>
</ol>
6. FAST exam abdominal windows
<ol>
	<li>Right upper quadrant (RUQ) window
	<ol>
		<li>Place the ultrasound probe in the coronal plane on the patient&#39;s right side along the mid-to-posterior axillary line in the 7th to 9th intracoastal space with the probe indicator towards the patient&#39;s head (Figure 5)1,28.</li>
		<li>Adjust the probe positioning to obtain a view containing the following structures: (1) liver; (2) right kidney; (3) hepato-renal interface (a potential space also called Morison&#39;s pouch) (Figure 6; Video 5)1.</li>
		<li>Adjust screen depth so that the hepato-renal interface occupies the middle third of the screen (Figure 6; Video 5).</li>
		<li>Adjust the gain until the liver and kidney appear slightly hyperechoic (tissue echogenicity) but not so dark as completely black and not so bright that they are indistinguishable from their hyperechoic capsules (Figure 6; Video 5). Click on Acquire.</li>
		<li>Fan through the hepato-renal interface anteriorly to posteriorly and back during the video acquisition (Video 6).</li>
		<li>Inspect the hepato-renal recess for a hypoechoic or anechoic stripe between the caudal-most tip of the liver and the inferior pole of the kidney, as this is the most sensitive site for detection of free peritoneal fluid in both the RUQ and usually the entire FAST exam in a supine patient29 (Figure 6; Video 7).</li>
		<li>If the initial view is negative, continue the search for fluid by sliding (translating) the probe caudally into the paracolic gutter and/or cranially to view the hepato-diaphragmatic space between the liver and the diaphragm28,29 (Video 8).
		<ol>
			<li>From the cranial-most RUQ view, visualize the right pleural space cranial to the diaphragm allowing the operator to easily perform this component of the e-FAST exam as a logical extension of the conventional FAST exam1,28,29 (Video 9).</li>
		</ol>
		</li>
	</ol>
	</li>
	<li>Left upper quadrant (LUQ) window
	<ol>
		<li>Place the ultrasound probe in the coronal plane on the patient&#39;s left flank along the mid-to-posterior axillary line in the 5th to 7th intracoastal space with the probe indicator towards the patient&#39;s head1,28(Figure 7).</li>
		<li>Adjust the probe positioning to obtain a view containing the following structures: (1) spleen; (2) diaphragm; and (3) if possible, the spleno-renal interface (Figure 8; Video 10).</li>
		<li>Adjust screen depth so that the spleno-diaphragmatic interface occupies the middle third of the screen (Figure 8; Video 10).</li>
		<li>Adjust gain as indicated in step 6.1.4, but replace liver with spleen in the instructions (Figure 8; Video 10). Click on Acquire.</li>
		<li>Fan through the interface between the spleen and diaphragm anteriorly to posteriorly and back during the video acquisition (Video 11).</li>
		<li>Inspect the interface for a hypoechoic or anechoic stripe between the spleen and diaphragm and between the spleen and left kidney (Figure 8; Video 12).</li>
		<li>If the spleno-renal interface was inadequately visualized in steps 6.2.5-6.2.7, slide (translate) the probe caudally until the spleno-renal interface is visualized and repeat steps 6.2.5-6.2.7 but this time focusing on the spleno-renal rather than the spleno-diaphragmatic interface (Video 13).</li>
		<li>To examine the left pleural space (i.e., if performing an e-FAST exam), slide (translate) the probe cranially until the view is centered on the diaphragm1,28 (Video 14).</li>
	</ol>
	</li>
	<li>Suprapubic (pelvic) window 
	NOTE: Since a fluid-filled bladder provides an excellent medium for the transmission of ultrasound waves, imaging the pelvis before insertion of a foley catheter or clamping the foley catheter to allow filling of the bladder can improve image acquisition1,28.
	<ol>
		<li>Transverse suprapubic (pelvic) view
		<ol>
			<li>Position the ultrasound probe in the transverse plane with the indicator mark pointing to the patient&#39;s right side, place the probe just cranial to the pubic symphysis, and angle the ultrasound beam 10-20 degrees caudally into the pelvis1,28 (Figure 9).</li>
			<li>Adjust the probe positioning to obtain a view containing the following sex-specific structures.</li>
			<li>If the patient is female:
			<ol>
				<li>Adjust the probe to visualize the following structures: (1) the bladder in its maximal dimension; (2) the uterus (if present); and (3) the space just posterior to the uterus (rectouterine pouch of Douglas)2&#160;(Figure 10).</li>
				<li>Adjust screen depth so that the uterus occupies the middle third of the screen (Figure 10; Video 15).</li>
				<li>Adjust screen gain so that the urine in the bladder appears relatively anechoic (black) and the space deep into the bladder is distinct from the posterior bladder wall (Figure 10; Video 15).</li>
			</ol>
			</li>
			<li>If the patient is male:
			<ol>
				<li>Adjust the probe to visualize the following structures: (1) the bladder in its maximal dimension and (2) the space just posterior to the bladder (recto-vesical pouch)2 (Figure 11; Video 16).</li>
				<li>Adjust screen depth so that the bladder occupies the middle third of the screen (Figure 11; Video 16).</li>
				<li>Adjust the screen gain so that the urine in the bladder appears relatively anechoic (black) and the space deep into the bladder is distinct from the posterior bladder wall (Figure 11; Video 16).</li>
			</ol>
			</li>
			<li>Click on Acquire. Fan across the pelvis posteriorly to anteriorly during the video acquisition (Video 17).</li>
			<li>Inspect the view for an anechoic stripe in the peri-uterine/rectouterine space if the patient is female (Figure 10B; Video 18) and in the recto-vesical space if the patient is male (Figure 11B; Video 19).</li>
		</ol>
		</li>
		<li>Sagittal suprapubic (pelvic) view
		<ol>
			<li>Starting with the transverse view above (6.3.1.1), rotate the ultrasound probe 90 degrees clockwise until the ultrasound beam is in the sagittal plane with the indicator mark pointing to the patient&#39;s head and keep the ultrasound beam angled 10-20 degrees caudally into the pelvis1,28&#160;(Figure 12).</li>
			<li>Adjust the probe positioning to obtain a view containing the following sex-specific structures.</li>
			<li>If the patient is female:
			<ol>
				<li>Adjust the probe to visualize the following structures: (1) the bladder in its maximal dimension; (2) the uterus (if present); and (3) the space just posterior to the uterus (rectouterine pouch of Douglas)2&#160;(Figure 13; Video 20).</li>
				<li>Adjust screen depth so that the uterus occupies the middle third of the screen (Figure 13; Video 20).</li>
				<li>Adjust screen gain so that the urine in the bladder appears relatively anechoic (black) and the space deep to the bladder is distinct from the posterior bladder wall (Figure 13; Video 20).</li>
			</ol>
			</li>
			<li>If the patient is male:
			<ol>
				<li>Adjust the probe to visualize the following structures: (1) the bladder in its maximal dimension and (2) the space just posterior to the bladder (recto-vesical pouch)2&#160;(Figure 14; Video 21).</li>
				<li>Adjust screen depth so that the bladder occupies the middle third of the screen (Figure 14; Video 21).</li>
				<li>Adjust the screen gain so that the urine in the bladder appears relatively anechoic (black) and the space deep into the bladder is distinct from the posterior bladder wall (Figure 14; Video 21).</li>
			</ol>
			</li>
			<li>Click on Acquire. Fan across the pelvis left-to-right and back during the video acquisition (Video 22).</li>
			<li>Inspect the view for an anechoic stripe in the peri-uterine/rectouterine space if the patient is female (Video 23) and in the recto-vesical space if the patient is male (Video 24).</li>
		</ol>
		</li>
	</ol>
	</li>
</ol>

YB is an Editor on the American Society of Anesthesiologists' Editorial Board on Point-of-Care Ultrasound and Section Editor for POCUS for OpenAnesthesia.org.

Traumatic injuries remain a leading cause of morbidity and mortality in the United States and worldwide. The rapid evaluation of the trauma patient and identification of injuries, including major hemorrhage, is a key component of reducing trauma morbidity. The FAST exam rapidly and non-invasively screens for potential sources of life-threatening hemorrhage. Critical steps to the success of the procedure are obtaining all of the views through the four primary ultrasonographic windows and, if necessary, using the alternati...

The Focused Assessment with Sonography for Trauma (FAST) exam is a diagnostic point-of-care ultrasound (POCUS) exam of the torso designed to rapidly assess potentially life-threatening hemorrhage in trauma patients1. The FAST exam was one of the earliest POCUS techniques to achieve widespread adoption: it was first developed in the 1980s in Europe and spread to the United States in the early 1990s. As POCUS became more commonly utilized in the evaluation of trauma patients, a consensus conference was held in 1997, which standardized the definition of the FAST exam and its role in the care of trauma patients. Over time, some authors have advocated for adding a focused ultrasound exam of the lung to the traditional FAST exam and have termed this multi-organ exam the extended FAST (e-FAST) exam2.
The primary role of both the classical FAST and its newer iteration, e-FAST, is in the initial evaluation of trauma patients3. Hemodynamic instability in traumatically injured patients is commonly caused by a limited number of conditions, including primary hemorrhage, cardiac tamponade, and tension pneumothorax3,4. As a part of the ACBDE steps of the Advanced Trauma Life Support(ATLS) primary survey, the Circulation step looks to identify and treat the life-threatening causes of hemodynamic instability in trauma patients3,5,6. This step includes ruling out cardiac tamponade and intracavitary bleeding in the pleural spaces and peritoneum, among other sources6,7. The FAST exam allows for visualization of free fluid in the pericardium and peritoneum, and with e-FAST views, bilateral pleural spaces3,6,7. In the clinical picture of hemodynamic instability after major trauma, this fluid is presumed to be blood until proven otherwise.
As a point-of-care ultrasound examination, the FAST/e-FAST exam offers several advantages. The exam can be performed using small portable ultrasound machines at the patient&#39;s bedside while other care is ongoing and without requiring the transport of the patient 3. The limited views using B-mode technique means that a complete examination can be obtained rapidly within a few minutes, and the noninvasive nature of the ultrasound exam means that the exam can be easily repeated if the patient&#39;s clinical picture changes3,8,9.
At the same time, the simple nature of the FAST exam has several limitations. Like any ultrasound examination, it is operator dependent to obtain appropriate views and accurate interpretation of the images in real-time9. Various patient factors, including obesity, and subcutaneous emphysema, may limit the ability to acquire adequate images. Additionally, the simplified views of the FAST/e-FAST exams do not look for specific organ injuries but rather screen for free fluid in the various body compartments. In the appropriately selected trauma patient, this free fluid is likely to represent blood from ongoing hemorrhage but may represent other fluid from traumatic or non-traumatic medical conditions.
Given the advantages and limitations of the FAST/e-FAST exams, their primary indication is in evaluating hemodynamically unstable patients who have suffered blunt trauma. For this patient population, the primary goal is to identify traumatic sources of hemodynamic instability, such as cardiac tamponade and intracavitary hemorrhage, which require immediate operative intervention. In this role, it has replaced diagnostic peritoneal lavage (DPL) as the primary modality for diagnosing intraperitoneal hemorrhage and physical examination and challenges the chest X-ray for diagnosing intrapleural hemorrhage and pneumothorax1. With their rapid and noninvasive nature, the FAST/e-FAST exams have been used in other trauma patients, including hemodynamically stable blunt trauma patients and penetrating trauma patients, both stable and unstable. However, the indications for and interpretation of these exams remain less clear.
Outside of the trauma setting, the FAST exam may have value in several different crisis management situations, including but not limited to any of the following: triaging the severity of obstetric hemorrhage10, searching for the location of perioperative bleeding, screening for peri-procedural bladder rupture, and as part of the preoperative assessment of patients with suspected but unconfirmed ascites scheduled for elective surgery11,12,13. In these non-trauma contexts, the providers available to perform the FAST exam are likely to come from specialties like obstetrics, anesthesiology, internal medicine, and critical care, for whom FAST exam training is highly variable in residency/fellowship curricula13,14,15,16. It is these non-trauma specialties that form the target audience of this review. Some of these non-trauma specialties tend to either have existing expertise in lung ultrasound (e.g., intensivists17) or have reasons to perform the abdominal views of the FAST exam in isolation (e.g., anesthesiologists and obstetricians)10. For these reasons and because the lung views of the e-FAST exam are already comprehensively covered in a separate manuscript18, this review will focus primarily on image acquisition for the abdominal views of the FAST exam. Despite this, it is worth emphasizing that, in the trauma setting, sonographic examination of the lung is, in many hospitals, considered a core part of the FAST protocol (i.e., e-FAST is the form of the FAST exam preferred by some trauma providers).

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Affiniti&#160; (including linear high-frequency, curvilinear, and sector array transducers)</td>
			<td>Philips</td>
			<td>n/a</td>
			<td>Used to obtain a subset of the Figures and Videos</td>
		</tr>
		<tr>
			<td>Edge 1 ultrasound machine (including linear high-frequency, curvilinear, and sector array transducers)</td>
			<td>SonoSite</td>
			<td>n/a</td>
			<td>Used to obtain a subset of the Figures and Videos</td>
		</tr>
		<tr>
			<td>M9 (including linear high-frequency, curvilinear, and sector array transducers)</td>
			<td>Mindray</td>
			<td>n/a</td>
			<td>Used to obtain a subset of the Figures and Videos</td>
		</tr>
		<tr>
			<td>Vivid iq&#160; (including linear high-frequency, curvilinear, and sector array transducers)</td>
			<td>GE</td>
			<td>n/a</td>
			<td>Used to obtain a subset of the Figures and Videos</td>
		</tr>
	</tbody>
</table>

focused assessment with sonography for trauma (fast) exam: image acquisition

Over the past twenty years, the Focused Assessment with Sonography for Trauma (FAST) exam has transformed the care of patients presenting with a combination of trauma (blunt or penetrating) and hypotension. In these hemodynamically unstable trauma patients, the FAST exam permits rapid and noninvasive screening for free pericardial or peritoneal fluid, the latter of which implicates intra-abdominal injury as a likely contributor to the hypotension and justifies emergent abdominal surgical exploration. Further, the abdominal portion of the FAST exam can also be used outside of the trauma setting to screen for free peritoneal fluid in patients who become hemodynamically unstable in any context, including after procedures that may inadvertently injure abdominal organs. These "non-trauma" situations of hemodynamic instability are often triaged by providers from specialties other than emergency medicine or trauma surgery who are not familiar with the FAST exam. Therefore, there is a need to promulgate knowledge about the FAST exam to all clinicians caring for critically ill patients. Toward this end, this article describes FAST exam image acquisition: patient positioning, transducer selection, image optimization, and exam limitations. Since the free fluid is likely to be found in specific anatomic locations that are unique for each canonical FAST exam view, this work centers on the unique image acquisition considerations for each window: subcostal, right upper quadrant, left upper quadrant, and pelvis.

Four sonographic windows are typically used to obtain the traditional FAST exam views19. The windows are subcostal 4-chamber (SC4C), right upper quadrant (RUQ), left upper quadrant (LUQ), and suprapubic/pelvic. Although the windows can be imaged in any order, the exam is typically performed in the following order: SC4C, RUQ, LUQ, and then suprapubic/pelvic1,19. This is because pericardial tamponade is usually more rapidly life-threatening ...

Watch this Scientific Journal Video about Focused Assessment with Sonography for Trauma FAST Exam: Image Acquisition at JoVE.com

Focused Assessment with Sonography for Trauma FAST Exam: Image Acquisition

The Focused Assessment with Sonography for Trauma (FAST) exam is a diagnostic point-of-care ultrasound examination used to screen for the presence of free fluid in the pericardium and peritoneum. Indications, techniques, and pitfalls of the procedure are discussed in this article.

Focused Assessment with Sonography for Trauma (FAST) Exam: Image Acquisition

Over the past twenty years, the Focused Assessment with Sonography for Trauma (FAST) exam has transformed the care of patients presenting with a ...

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4.6K Views.  Duke University Hospital. The Focused Assessment with Sonography for Trauma (FAST) exam is a diagnostic point-of-care ultrasound examination used to screen for the presence of free fluid in the pericardium and peritoneum. Indications, techniques, and pitfalls of the procedure are discussed in this article. 

Video: Focused Assessment with Sonography for Trauma FAST Exam: Image Acquisition

A Detailed Protocol for Physiological Parameters Acquisition and Analysis in Neurosurgical Critical Patients

Intracranial pressure (ICP) monitoring is now widely used in neurosurgical critical patients. Besides mean ICP value, the ICP derived parameters such as ICP waveform, amplitude of pulse (AMP), the correlation of ICP amplitude and ICP mean (RAP), pressure reactivity index (PRx), ICP and arterial blood pressure (ABP) wave amplitude correlation (IAAC), and so on, can reflect intracranial status, predict prognosis, and can also be used as guidance of proper treatment. However, most of the clinicians focus only on the mean ICP value while ignoring these parameters because of the limitations of the current devices. We have recently developed a multimodality monitoring system to address these drawbacks. This portable, user-friendly system will use a data collecting and storing device to continuously acquire patients&#39; physiological parameters first, i.e., ABP, ICP, and oxygen saturation, and then analyze these physiological parameters. We hope that the multimodality monitoring system will be accepted as a key measure to monitor physiological parameters, to analyze the current clinical status, and to predict the prognosis of the neurosurgical critical patients.

Recently, we have developed a portable multimodality monitoring system for the monitoring of various physiological parameters in neurosurgical critical patients. Detailed protocols on how to use this multimodality monitoring system are presented here.

Intracranial pressure (ICP) monitoring is now widely used in neurosurgical critical patients. Besides mean ICP value, the ICP derived parameters such as ...

Image Acquisition using Portable Sonography for Emergency Airway Management

With its increasing popularity and accessibility, portable ultrasonography has been rapidly adapted not only to improve the perioperative care of patients, but also to address the potential benefits of employing ultrasound in airway management. The benefits of point of care ultrasound (POCUS) include its portability, the speed at which it can be utilized, and its lack of invasiveness or exposure of the patient to radiation of other imaging modalities.
Two primary indications for airway POCUS include confirmation of endotracheal intubation and identification of the cricothyroid membrane in the event a surgical airway is required. In this article, the technique of using ultrasound to confirm endotracheal intubation and the relevant anatomy is described, along with the associated ultrasonographic images. In addition, identification of the anatomy of the cricothyroid membrane and the ultrasonographic acquisition of appropriate images to perform this procedure are reviewed.
Future advances include utilizing airway POCUS to identify patient characteristics that might indicate difficult airway management. Traditional bedside clinical exams have, at best, fair predictive values. The addition of ultrasonographic airway assessment has the potential to improve this predictive accuracy. This article describes the use of POCUS for airway management, and initial evidence suggests that this has improved the diagnostic accuracy of predicting a difficult airway. Given that one of the limitations of airway POCUS is that it requires a skilled sonographer, and image analysis can be operator dependent, this paper will provide recommendations to standardize the technical aspects of airway ultrasonography and promote further research utilizing sonography in airway management. The goal of this protocol is to educate researchers and medical health professionals and to advance the research in the field of airway POCUS.

Point of care ultrasound (POCUS) is increasingly being utilized in airway management. Presented here are some clinical utilities of POCUS, including differentiating endotracheal and esophageal intubation, identification of the cricothyroid membrane in the event a surgical airway is required, and measuring anterior neck soft tissue to predict difficult airway management.

With its increasing popularity and accessibility, portable ultrasonography has been rapidly adapted not only to improve the perioperative care of ...

Image Acquisition Method for the Sonographic Assessment of the Inferior Vena Cava

Over the past several decades, clinicians have incorporated several applications of diagnostic point-of-care ultrasound (POCUS) into medical decision-making. Among the applications of POCUS, imaging the inferior vena cava (IVC) is practiced by a wide variety of specialties, such as nephrology, emergency medicine, internal medicine, critical care, anesthesiology, pulmonology, and cardiology. Although each specialty uses IVC data in slightly different ways, most medical specialties, at minimum, attempt to use IVC data to make predictions about intravascular volume status. While the relationship between IVC sonographic data and intravascular volume status is complex and highly context-dependent, all clinicians should collect the sonographic data in standardized ways to ensure repeatability. This paper describes standardized IVC image acquisition including patient positioning, transducer selection, probe placement, image optimization, and the pitfalls and limitations of IVC sonographic imaging.&#160;This paper also describes the commonly performed anterior IVC long-axis view and three other views of the IVC that can each provide helpful diagnostic information when the anterior long-axis view is difficult to obtain or interpret.

Point-of-care ultrasound evaluation of the inferior vena cava (IVC) is commonly utilized to identify, among other things, the volume status. Imaging should be performed systematically to ensure repeatability. This manuscript reviews the methods and pitfalls of sonographic IVC examination.

Over the past several decades, clinicians have incorporated several applications of diagnostic point-of-care ultrasound (POCUS) into medical ...

Troubleshooting FoCUS Image Acquisition: Patient Positioning, Transducer Manipulation, and Image Optimization

Focused cardiac ultrasound (FoCUS) is a limited, clinician-performed application of echocardiography to add real-time information to patient care. These bedside exams are problem oriented, rapidly and repeatedly performed, and largely qualitative in nature. Competency in FoCUS includes mastery of the stereotactic and psychomotor skills required for transducer manipulation and image acquisition. Competency also requires the ability to optimize the setup, troubleshoot image acquisition, and understand the sonographic limitations because of complex clinical environments and patient pathology. This article presents concepts for successful, high-quality two-dimensional (B-mode) image acquisition in FoCUS.
Concepts of high-quality image acquisition can be applied to all established sonographic windows of the FoCUS exam: the parasternal long-axis (PLAX), parasternal short-axis (PSAX), apical four chamber (A4C), subcostal fourchamber (SC4C), and the inferior vena cava (IVC). The apical five-chamber (A5C) and subcostal short-axis (SCSA) views are mentioned, but are not discussed in-depth. A pragmatic figure illustrating the movements of the phased array transducer is also provided to serve as a cognitive aid during FoCUS image acquisition.

Here, we present a protocol to allow providers to perform focused cardiac ultrasound (FoCUS) in the clinical environment. We describe methods of transducer manipulation, review common pitfalls of transducer movements, and suggest tips to optimize phased array transducer use.

Focused cardiac ultrasound (FoCUS) is a limited, clinician-performed application of echocardiography to add real-time information to patient care. These ...

Point-of-Care Lung Ultrasound in Adults: Image Acquisition

Consultative ultrasound performed by radiologists has traditionally not been used for imaging the lungs, as the lungs&#39; air-filled nature normally prevents direct visualization of the lung parenchyma. When showing the lung parenchyma, ultrasound typically generates a number of non-anatomic artifacts. However, over the past several decades, these artifacts have been studied by diagnostic point-of-care ultrasound (POCUS) practitioners, who have identified findings that have value in narrowing the differential diagnoses of cardiopulmonary dysfunction. For instance, in patients presenting with dyspnea, lung POCUS is superior to chest radiography (CXR) for the diagnosis of pneumothorax, pulmonary edema, lung consolidations, and pleural effusions. Despite its known diagnostic value, the utilization of lung POCUS in clinical medicine remains variable, in part because training in this modality across hospitals remains inconsistent. To address this educational gap, this narrative review describes lung POCUS image acquisition in adults, including patient positioning, transducer selection, probe placement, acquisition sequence, and image optimization.

Point-of-care ultrasound (POCUS) of the lungs provides quick answers in rapidly changing clinical scenarios. We present an efficient and informative protocol for image acquisition for use in acute care settings.

Consultative ultrasound performed by radiologists has traditionally not been used for imaging the lungs, as the lungs&#39; air-filled nature normally ...

A Modified Sonographic Algorithm for Image Acquisition in Life-Threatening Emergencies in the Critically Ill Newborn

The use of routine point-of-care ultrasound (POCUS) is increasing in neonatal intensive care units (NICUs), with several centers advocating for 24 h equipment availability. In 2018, the sonographic algorithm for life-threatening emergencies (SAFE) protocol was published, which allows the assessment of neonates with sudden decompensation to identify abnormal contractility, tamponade, pneumothorax, and pleural effusion. In the study unit (with a consulting neonatal hemodynamics and POCUS service), the algorithm was adapted by including consolidated core steps to support at-risk newborns, aiding clinicians in managing cardiac arrest, and adding views to verify correct intubation. This paper presents a protocol that can be applied in the NICU and the delivery room (DR) in relation to three scenarios: cardiac arrest, hemodynamic deterioration, or respiratory decompensation. 
This protocol can be performed with a state-of-the-art ultrasound machine or an affordable handheld device; the image acquisition protocol is carefully detailed. This method was designed to be learned as a general competence to obtain the timely diagnosis of life-threatening scenarios; the method aims to save time but does not represent a substitute for comprehensive and standardized hemodynamic and radiological analyses by a multidisciplinary team, which might not universally be on call but needs to be involved in the process. From January 2019 to July 2022, in our center, 1,045 hemodynamic consultation/POCUS consults were performed with 25 patients requiring the modified SAFE protocol (2.3%), and a total of 19 procedures were performed. In five cases, trained fellows on call resolved life-threatening situations. Clinical examples are provided that show the importance of including this technique in the care of critical newborns.

Here, we present a protocol that can be applied in the neonatal intensive care unit and the delivery room in relation to three scenarios: cardiac arrest, hemodynamic deterioration, or respiratory decompensation. This protocol can be performed with a state-of-the-art ultrasound machine or an affordable handheld device; an image acquisition protocol is carefully detailed.

The use of routine point-of-care ultrasound (POCUS) is increasing in neonatal intensive care units (NICUs), with several centers advocating for 24 h ...

Exploring Quantitative Autofluorescence in Age-Related Macular Degeneration

A Workflow to Quantitatively Determine Age-Related Macular Degeneration Lesion-Specific Variations in Fundus Autofluorescence

Fundus autofluorescence (FAF) imaging allows the noninvasive mapping of intrinsic fluorophores of the ocular fundus, particularly the retinal pigment epithelium (RPE), now quantifiable with the advent of confocal scanning laser ophthalmoscopy-based quantitative autofluorescence (QAF). QAF has been shown to be generally decreased at the posterior pole in age-related macular degeneration (AMD). The relationship between QAF and various AMD lesions (drusen, subretinal drusenoid deposits) is still unclear.
This paper describes a workflow to determine lesion-specific QAF in AMD. A multimodal in vivo imaging approach is used, including but not limited to spectral domain optical coherence tomography (SD-OCT) macular volume scanning and QAF. Using customized FIJI plug-ins, the corresponding QAF image is aligned with the near-infrared image from the SD-OCT scan (characteristic landmarks; i.e., vessel bifurcations). The foveola and the edge of the optic nerve head are marked in the OCT images (and transferred to the registered QAF image) for accurate positioning of the analysis grids.
AMD-specific lesions can then be marked on individual OCT BScans or the QAF image itself. Normative QAF maps are created to account for the varying mean and standard deviation of QAF values throughout the fundus (QAF images from a representative AMD group were averaged to build normative standard retinal QAF AMD maps). The plug-ins record the X and Y coordinates, z-score (a numerical measurement that describes the QAF value in relation to the mean of AF maps in terms of standard deviation from the mean), mean intensity value, standard deviation, and number of pixels marked. The tools also determine z-scores from the border zone of marked lesions.&#160;This workflow and the analysis tools will improve the understanding of the pathophysiology and clinical AF image interpretation in AMD.

Author Spotlight: Understanding Age-Related Macular Degeneration Pathophysiology with QAF Workflow 

This research describes a workflow to determine and compare autofluorescence levels from individual regions of interest (e.g., drusen and subretinal drusenoid deposits in age-related macular degeneration [AMD]) while accounting for varying autofluorescence levels throughout the fundus.

Fundus autofluorescence (FAF) imaging allows the noninvasive mapping of intrinsic fluorophores of the ocular fundus, particularly the retinal pigment ...

Optic Nerve Sheath Point of Care Ultrasound: Image Acquisition

The goal of this protocol is to develop a standardized method for acquiring images of the optic nerve sheath and measuring the optic nerve sheath diameter (ONSD). Diagnostic ultrasound of the ONSD to detect intracranial hypertension has traditionally faced many problems because of methodologic discrepancies. Due to inconsistencies in the measuring techniques, the potential for ONSD to become a non-invasive bedside monitoring tool for ICP has been hampered. However, establishing a transparent, consistent methodology for measuring the ONSD would support its use as a valid and reliable method of identifying intracranial hypertension. This is important as it has both high sensitivity and specificity in acute care settings. This narrative review describes ONSD POCUS image acquisition, including patient positioning, transducer selection, probe placement, the acquisition sequence, and image optimization. Further, visual aids are provided to assist in real-time during image acquisition. This method should be considered for patients for whom there are concerns regarding intracranial hypertension but who do not have an intracranial monitor in place.

Point-of-care ultrasound (POCUS) of the optic nerve sheath diameter (ONSD) has been shown to be useful in identifying patients with increased intracranial pressure (ICP). However, the non-standardized technique for this POCUS has hampered its use. We present a standardized image acquisition protocol for use in the acute care setting.

The goal of this protocol is to develop a standardized method for acquiring images of the optic nerve sheath and measuring the optic nerve sheath diameter ...

Gastric Ultrasound Technique for Mitigating Peri-Procedural Aspiration Risk

Gastric Point of Care Ultrasound in Adults: Image Acquisition and Interpretation

Over the past two decades, diagnostic point-of-care ultrasound (POCUS) has emerged as a rapid and non-invasive bedside tool for addressing clinical inquiries related to gastric content. One emerging concern pertains to patients about to undergo sedation and/or endotracheal intubation: the elevated risk of aspiration from the patient&#39;s stomach contents. Aspiration of gastric contents into the lungs poses a serious and potentially life-threatening complication. This occurs more frequently when the stomach is considered &#34;full&#34; and can be affected by the techniques employed for airway management, making it potentially preventable. To mitigate the risk of peri-procedural aspiration, two distinct medical specialties (anesthesiology and critical care medicine) have independently developed techniques to utilize ultrasonography for identifying patients requiring &#34;full stomach&#34; precautions. Due to these separate specialties, the work of each group remains relatively unfamiliar outside its respective field. This article presents descriptions of both techniques for gastric ultrasound. Furthermore, it explains how these approaches can complement each other when one of them falls short. Regarding image acquisition, the article covers the following topics: indications and contraindications, selection of the appropriate probe, patient positioning, and troubleshooting. The article also delves into image interpretation, complete with example images. Additionally, it demonstrates how one of the two techniques can be employed to estimate gastric fluid volume. Lastly, the article briefly discusses medical decision-making based on the findings of this examination.

Author Spotlight: Point-of-Care Ultrasound for Gastric Content Assessment and Risk Stratification in Perioperative Care 

This protocol introduces two methods for image acquisition in gastric ultrasonography. Additionally, tips are provided for interpreting this information to assist in medical decision-making.

Over the past two decades, diagnostic point-of-care ultrasound (POCUS) has emerged as a rapid and non-invasive bedside tool for addressing clinical ...

Quantitative Autofluorescence (QAF) Image Acquisition

To begin, get the participant seated comfortably in front of the quantitative autofluorescence, or qAF device to ensure accurate image acquisition. Have the participant's chin and forehead pressed against the chin and headrest. Adjust the height of the chin rest until the lateral eyelid angle is at the same height as the red marking.Then rotate the wheel on the recording device until the small vessels are in focus to ensure the image is focused in the near infrared modus. Zoom in on the eye by moving the camera forward until the image corners are evenly illuminated. As a rule of thumb, adjust the focus to the spherical equivalent.Reduce the focus before qAF imaging by one or two diopters as blue QAF uses a shorter wavelength, and switch to the modus of the qAF device from the near infrared to the qAF mode. Readjust and upscale the illumination and fine-tune the focus of the image until the small vessels closest to the fovea are in focus and the image is brightly illuminated without red dots. To bleach the photoreceptor pigment in the field of view of the camera, wait for at least 30 seconds in the qAF mode before image acquisition.To capture images, press Image Acquisition on the touchpad of the imaging device. Capture more than one qAF image in case of blinking or sudden eye movements during acquisition.