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Current Role of Emergency US in Patients with Major Trauma¹

¹ From the Department of Clinical Radiology, University Hospital Munich, Nussbaumstr 20, 80336 Munich, Germany. Presented as an education exhibit at the 2006 RSNA Annual Meeting. Received March 16, 2007; revision requested April 11 and received May 29; accepted June 8. All authors have no financial relationships to disclose.

View larger version (38K): [in this window] [in a new window] [Download PPT slide]   Figure 1.  Diagram shows the standard projections routinely obtained in a FAST examination: a transverse view of the subxiphoid region (1), longitudinal views of the right (2) and left (3) upper quadrants, and transverse and longitudinal views of the suprapubic region (4). In addition to these projections, right and left longitudinal thoracic views (*) may be obtained.

 

View larger version (108K): [in this window] [in a new window] [Download PPT slide]   Figure 2a.  US images obtained with FAST examinations in a healthy volunteer (a–d) and a patient with chest trauma (e). (a) Transverse view of the subxiphoid region (1 in Fig 1), obtained with cranial angulation of the transducer, shows a normal pericardium, without effusion. LA = left atrium, LV = left ventricle, RV = right ventricle. (b) Longitudinal view of the right upper quadrant (2 in Fig 1) shows a normal Morison pouch (arrows) with no free fluid. RK = right kidney, RLL = right lobe of liver. (c) Longitudinal view of the left upper quadrant (3 in Fig 1) shows a normal splenorenal fossa (arrows). This is another intraperitoneal recess in which abnormal fluid might collect. LK = left kidney, S = spleen. (d) Longitudinal view of the suprapubic region (4 in Fig 1) shows a normal pouch of Douglas (arrows), the space between the rectum (R) and the urinary bladder (UB). The fluid-distended rectum should not be mistaken for free fluid. (e) Longitudinal view of the left thoracic region (* at right in Fig 1) shows the pleural space, which is not normally visible at US but is so in this case because of a pleural effusion (arrows). CL = collapsed lung, S = spleen.

 

View larger version (110K): [in this window] [in a new window] [Download PPT slide]   Figure 2b.  US images obtained with FAST examinations in a healthy volunteer (a–d) and a patient with chest trauma (e). (a) Transverse view of the subxiphoid region (1 in Fig 1), obtained with cranial angulation of the transducer, shows a normal pericardium, without effusion. LA = left atrium, LV = left ventricle, RV = right ventricle. (b) Longitudinal view of the right upper quadrant (2 in Fig 1) shows a normal Morison pouch (arrows) with no free fluid. RK = right kidney, RLL = right lobe of liver. (c) Longitudinal view of the left upper quadrant (3 in Fig 1) shows a normal splenorenal fossa (arrows). This is another intraperitoneal recess in which abnormal fluid might collect. LK = left kidney, S = spleen. (d) Longitudinal view of the suprapubic region (4 in Fig 1) shows a normal pouch of Douglas (arrows), the space between the rectum (R) and the urinary bladder (UB). The fluid-distended rectum should not be mistaken for free fluid. (e) Longitudinal view of the left thoracic region (* at right in Fig 1) shows the pleural space, which is not normally visible at US but is so in this case because of a pleural effusion (arrows). CL = collapsed lung, S = spleen.

 

View larger version (101K): [in this window] [in a new window] [Download PPT slide]   Figure 2c.  US images obtained with FAST examinations in a healthy volunteer (a–d) and a patient with chest trauma (e). (a) Transverse view of the subxiphoid region (1 in Fig 1), obtained with cranial angulation of the transducer, shows a normal pericardium, without effusion. LA = left atrium, LV = left ventricle, RV = right ventricle. (b) Longitudinal view of the right upper quadrant (2 in Fig 1) shows a normal Morison pouch (arrows) with no free fluid. RK = right kidney, RLL = right lobe of liver. (c) Longitudinal view of the left upper quadrant (3 in Fig 1) shows a normal splenorenal fossa (arrows). This is another intraperitoneal recess in which abnormal fluid might collect. LK = left kidney, S = spleen. (d) Longitudinal view of the suprapubic region (4 in Fig 1) shows a normal pouch of Douglas (arrows), the space between the rectum (R) and the urinary bladder (UB). The fluid-distended rectum should not be mistaken for free fluid. (e) Longitudinal view of the left thoracic region (* at right in Fig 1) shows the pleural space, which is not normally visible at US but is so in this case because of a pleural effusion (arrows). CL = collapsed lung, S = spleen.

 

View larger version (91K): [in this window] [in a new window] [Download PPT slide]   Figure 2d.  US images obtained with FAST examinations in a healthy volunteer (a–d) and a patient with chest trauma (e). (a) Transverse view of the subxiphoid region (1 in Fig 1), obtained with cranial angulation of the transducer, shows a normal pericardium, without effusion. LA = left atrium, LV = left ventricle, RV = right ventricle. (b) Longitudinal view of the right upper quadrant (2 in Fig 1) shows a normal Morison pouch (arrows) with no free fluid. RK = right kidney, RLL = right lobe of liver. (c) Longitudinal view of the left upper quadrant (3 in Fig 1) shows a normal splenorenal fossa (arrows). This is another intraperitoneal recess in which abnormal fluid might collect. LK = left kidney, S = spleen. (d) Longitudinal view of the suprapubic region (4 in Fig 1) shows a normal pouch of Douglas (arrows), the space between the rectum (R) and the urinary bladder (UB). The fluid-distended rectum should not be mistaken for free fluid. (e) Longitudinal view of the left thoracic region (* at right in Fig 1) shows the pleural space, which is not normally visible at US but is so in this case because of a pleural effusion (arrows). CL = collapsed lung, S = spleen.

 

View larger version (90K): [in this window] [in a new window] [Download PPT slide]   Figure 2e.  US images obtained with FAST examinations in a healthy volunteer (a–d) and a patient with chest trauma (e). (a) Transverse view of the subxiphoid region (1 in Fig 1), obtained with cranial angulation of the transducer, shows a normal pericardium, without effusion. LA = left atrium, LV = left ventricle, RV = right ventricle. (b) Longitudinal view of the right upper quadrant (2 in Fig 1) shows a normal Morison pouch (arrows) with no free fluid. RK = right kidney, RLL = right lobe of liver. (c) Longitudinal view of the left upper quadrant (3 in Fig 1) shows a normal splenorenal fossa (arrows). This is another intraperitoneal recess in which abnormal fluid might collect. LK = left kidney, S = spleen. (d) Longitudinal view of the suprapubic region (4 in Fig 1) shows a normal pouch of Douglas (arrows), the space between the rectum (R) and the urinary bladder (UB). The fluid-distended rectum should not be mistaken for free fluid. (e) Longitudinal view of the left thoracic region (* at right in Fig 1) shows the pleural space, which is not normally visible at US but is so in this case because of a pleural effusion (arrows). CL = collapsed lung, S = spleen.

 

View larger version (149K): [in this window] [in a new window] [Download PPT slide]   Figure 3a.  US images obtained with FAST examinations in patients with abdominal trauma show accumulations of free fluid. (a) Longitudinal view of the right upper quadrant shows a small amount of free intraperitoneal fluid in the Morison pouch (arrow). RK = right kidney, RLL = right lobe of liver. (b) Longitudinal view of the left upper quadrant shows free fluid in the perisplenic region (white arrow) with signal amplification dorsal to the fluid (black arrows). S = spleen. (c) Longitudinal view of the suprapubic region shows a small amount of free fluid in the pouch of Douglas (arrow). R = rectum, U = uterus, UB = urinary bladder.

 

View larger version (147K): [in this window] [in a new window] [Download PPT slide]   Figure 3b.  US images obtained with FAST examinations in patients with abdominal trauma show accumulations of free fluid. (a) Longitudinal view of the right upper quadrant shows a small amount of free intraperitoneal fluid in the Morison pouch (arrow). RK = right kidney, RLL = right lobe of liver. (b) Longitudinal view of the left upper quadrant shows free fluid in the perisplenic region (white arrow) with signal amplification dorsal to the fluid (black arrows). S = spleen. (c) Longitudinal view of the suprapubic region shows a small amount of free fluid in the pouch of Douglas (arrow). R = rectum, U = uterus, UB = urinary bladder.

 

View larger version (148K): [in this window] [in a new window] [Download PPT slide]   Figure 3c.  US images obtained with FAST examinations in patients with abdominal trauma show accumulations of free fluid. (a) Longitudinal view of the right upper quadrant shows a small amount of free intraperitoneal fluid in the Morison pouch (arrow). RK = right kidney, RLL = right lobe of liver. (b) Longitudinal view of the left upper quadrant shows free fluid in the perisplenic region (white arrow) with signal amplification dorsal to the fluid (black arrows). S = spleen. (c) Longitudinal view of the suprapubic region shows a small amount of free fluid in the pouch of Douglas (arrow). R = rectum, U = uterus, UB = urinary bladder.

 

View larger version (123K): [in this window] [in a new window] [Download PPT slide]   Figure 4a.  Images from a 24-year-old woman who was struck by a car while riding a bicycle. (a) Transverse US view of the subxiphoid region, obtained at an initial FAST examination, shows an area of slight hyperechogenicity in the left lobe of the liver (arrow), a finding suggestive of a laceration. A small collection of free fluid also was visible in the pouch of Douglas. GB = gallbladder, RLL = right lobe of liver. (b) Abdominal CT image shows an area of decreased attenuation (arrow) in the liver, a finding that helped confirm the diagnosis of liver laceration.

 

View larger version (137K): [in this window] [in a new window] [Download PPT slide]   Figure 4b.  Images from a 24-year-old woman who was struck by a car while riding a bicycle. (a) Transverse US view of the subxiphoid region, obtained at an initial FAST examination, shows an area of slight hyperechogenicity in the left lobe of the liver (arrow), a finding suggestive of a laceration. A small collection of free fluid also was visible in the pouch of Douglas. GB = gallbladder, RLL = right lobe of liver. (b) Abdominal CT image shows an area of decreased attenuation (arrow) in the liver, a finding that helped confirm the diagnosis of liver laceration.

 

View larger version (161K): [in this window] [in a new window] [Download PPT slide]   Figure 5a.  Severe abdominal trauma in a 63-year-old man after a motor vehicle collision. Images from the initial FAST examination were reported to be of poor quality and not diagnostically adequate for all regions examined, yet gross injuries were excluded. (a) Contrast-enhanced abdominal CT image, obtained after the FAST examination, shows a grade IV laceration of the right liver lobe (large arrow) with active contrast material extravasation (black arrowheads). A large subcapsular hematoma (small arrows) also is visible. Injuries of that grade of severity require urgent surgical intervention, which would not have been performed on the basis of the initial US findings. The poor quality of images from the FAST examination was retrospectively considered to have been caused by serial rib fractures on the right side, with concomitant pneumothorax and massive cutaneous emphysema in the right flank (white arrowheads). (b) Intraoperative photograph shows the grade IV liver laceration with a massive active hemorrhage.

 

View larger version (123K): [in this window] [in a new window] [Download PPT slide]   Figure 5b.  Severe abdominal trauma in a 63-year-old man after a motor vehicle collision. Images from the initial FAST examination were reported to be of poor quality and not diagnostically adequate for all regions examined, yet gross injuries were excluded. (a) Contrast-enhanced abdominal CT image, obtained after the FAST examination, shows a grade IV laceration of the right liver lobe (large arrow) with active contrast material extravasation (black arrowheads). A large subcapsular hematoma (small arrows) also is visible. Injuries of that grade of severity require urgent surgical intervention, which would not have been performed on the basis of the initial US findings. The poor quality of images from the FAST examination was retrospectively considered to have been caused by serial rib fractures on the right side, with concomitant pneumothorax and massive cutaneous emphysema in the right flank (white arrowheads). (b) Intraoperative photograph shows the grade IV liver laceration with a massive active hemorrhage.

 

View larger version (55K): [in this window] [in a new window] [Download PPT slide]   Figure 6a.  Images from a 68-year-old woman who jumped from a rooftop. (a) Longitudinal (right) and transverse (left) views of the left upper quadrant, obtained at the initial FAST examination, show parenchymal hyperechogenicity (arrowhead) and a small free perisplenic fluid collection (arrow). In the transverse plane, the caudal splenic edge is irregular in contour. The injury was rated grade II by the sonographer. Because other severe injuries to the head, chest, and pelvis were suspected, the patient subsequently underwent whole-body CT. (b) CT image shows a completely shattered spleen with massive active bleeding in the perisplenic and perihepatic regions (arrows) and extravasation of contrast material (arrowhead), findings that resulted in upgrading of the severity of injury to grade V, an indication for immediate surgery. If the diagnosis had been based on US findings alone, the extent of the lesion would have been dramatically underestimated and treatment would have been delayed. The findings were confirmed at laparotomy, and a splenectomy was performed.

 

View larger version (150K): [in this window] [in a new window] [Download PPT slide]   Figure 6b.  Images from a 68-year-old woman who jumped from a rooftop. (a) Longitudinal (right) and transverse (left) views of the left upper quadrant, obtained at the initial FAST examination, show parenchymal hyperechogenicity (arrowhead) and a small free perisplenic fluid collection (arrow). In the transverse plane, the caudal splenic edge is irregular in contour. The injury was rated grade II by the sonographer. Because other severe injuries to the head, chest, and pelvis were suspected, the patient subsequently underwent whole-body CT. (b) CT image shows a completely shattered spleen with massive active bleeding in the perisplenic and perihepatic regions (arrows) and extravasation of contrast material (arrowhead), findings that resulted in upgrading of the severity of injury to grade V, an indication for immediate surgery. If the diagnosis had been based on US findings alone, the extent of the lesion would have been dramatically underestimated and treatment would have been delayed. The findings were confirmed at laparotomy, and a splenectomy was performed.

 

View larger version (129K): [in this window] [in a new window] [Download PPT slide]   Figure 7a.  US images from consecutive examinations in a 29-year-old pregnant woman who was struck by a car. (a) Longitudinal view from an initial FAST examination shows only the cranial pole of the right kidney (arrow); the rest of the organ was obscured by an artifact from a rib (arrowheads). (b) A second longitudinal view from the same examination as a shows the caudal part of the kidney (arrow) as well as a rib artifact (arrowheads). On the basis of these findings, significant injury was excluded. (c) Image from a second US examination performed by an attending radiologist half an hour later shows a small subcapsular hematoma (arrow) that is not obscured by artifact. The lesion was rated grade I.

 

View larger version (137K): [in this window] [in a new window] [Download PPT slide]   Figure 7b.  US images from consecutive examinations in a 29-year-old pregnant woman who was struck by a car. (a) Longitudinal view from an initial FAST examination shows only the cranial pole of the right kidney (arrow); the rest of the organ was obscured by an artifact from a rib (arrowheads). (b) A second longitudinal view from the same examination as a shows the caudal part of the kidney (arrow) as well as a rib artifact (arrowheads). On the basis of these findings, significant injury was excluded. (c) Image from a second US examination performed by an attending radiologist half an hour later shows a small subcapsular hematoma (arrow) that is not obscured by artifact. The lesion was rated grade I.

 

View larger version (116K): [in this window] [in a new window] [Download PPT slide]   Figure 7c.  US images from consecutive examinations in a 29-year-old pregnant woman who was struck by a car. (a) Longitudinal view from an initial FAST examination shows only the cranial pole of the right kidney (arrow); the rest of the organ was obscured by an artifact from a rib (arrowheads). (b) A second longitudinal view from the same examination as a shows the caudal part of the kidney (arrow) as well as a rib artifact (arrowheads). On the basis of these findings, significant injury was excluded. (c) Image from a second US examination performed by an attending radiologist half an hour later shows a small subcapsular hematoma (arrow) that is not obscured by artifact. The lesion was rated grade I.

 

View larger version (108K): [in this window] [in a new window] [Download PPT slide]   Figure 8a.  Images from a 16-year-old male soccer goalkeeper who was struck in the right flank by a field player’s foot. (a) Longitudinal view of the hepatorenal fossa, from an initial FAST examination, shows an intraparenchymal subcapsular area of hyperechogenicity (arrow), a finding indicative of hematoma, as well as a discrete band of free fluid in the Morison pouch (arrowheads). (b) Longitudinal view of the suprapubic region, from the same examination as a, shows a focus of hyperechogenicity (arrow) in the urinary bladder, adjacent to the ureteric ostium. The finding was indicative of macrohematuria. (c) Abdominal CT image helps confirm the renal laceration and perirenal fluid collection (arrowhead). The lesion would have been rated grade III, but the parenchymal rupture seemed to extend into the collecting system (arrow). (d) Delayed phase CT image, obtained 10 minutes after intravenous administration of contrast material, shows extravasation (arrow), a finding indicative of a rupture of the collecting system. The lesion thus was rated grade IV.

 

View larger version (148K): [in this window] [in a new window] [Download PPT slide]   Figure 8b.  Images from a 16-year-old male soccer goalkeeper who was struck in the right flank by a field player’s foot. (a) Longitudinal view of the hepatorenal fossa, from an initial FAST examination, shows an intraparenchymal subcapsular area of hyperechogenicity (arrow), a finding indicative of hematoma, as well as a discrete band of free fluid in the Morison pouch (arrowheads). (b) Longitudinal view of the suprapubic region, from the same examination as a, shows a focus of hyperechogenicity (arrow) in the urinary bladder, adjacent to the ureteric ostium. The finding was indicative of macrohematuria. (c) Abdominal CT image helps confirm the renal laceration and perirenal fluid collection (arrowhead). The lesion would have been rated grade III, but the parenchymal rupture seemed to extend into the collecting system (arrow). (d) Delayed phase CT image, obtained 10 minutes after intravenous administration of contrast material, shows extravasation (arrow), a finding indicative of a rupture of the collecting system. The lesion thus was rated grade IV.

 

View larger version (136K): [in this window] [in a new window] [Download PPT slide]   Figure 8c.  Images from a 16-year-old male soccer goalkeeper who was struck in the right flank by a field player’s foot. (a) Longitudinal view of the hepatorenal fossa, from an initial FAST examination, shows an intraparenchymal subcapsular area of hyperechogenicity (arrow), a finding indicative of hematoma, as well as a discrete band of free fluid in the Morison pouch (arrowheads). (b) Longitudinal view of the suprapubic region, from the same examination as a, shows a focus of hyperechogenicity (arrow) in the urinary bladder, adjacent to the ureteric ostium. The finding was indicative of macrohematuria. (c) Abdominal CT image helps confirm the renal laceration and perirenal fluid collection (arrowhead). The lesion would have been rated grade III, but the parenchymal rupture seemed to extend into the collecting system (arrow). (d) Delayed phase CT image, obtained 10 minutes after intravenous administration of contrast material, shows extravasation (arrow), a finding indicative of a rupture of the collecting system. The lesion thus was rated grade IV.

 

View larger version (96K): [in this window] [in a new window] [Download PPT slide]   Figure 8d.  Images from a 16-year-old male soccer goalkeeper who was struck in the right flank by a field player’s foot. (a) Longitudinal view of the hepatorenal fossa, from an initial FAST examination, shows an intraparenchymal subcapsular area of hyperechogenicity (arrow), a finding indicative of hematoma, as well as a discrete band of free fluid in the Morison pouch (arrowheads). (b) Longitudinal view of the suprapubic region, from the same examination as a, shows a focus of hyperechogenicity (arrow) in the urinary bladder, adjacent to the ureteric ostium. The finding was indicative of macrohematuria. (c) Abdominal CT image helps confirm the renal laceration and perirenal fluid collection (arrowhead). The lesion would have been rated grade III, but the parenchymal rupture seemed to extend into the collecting system (arrow). (d) Delayed phase CT image, obtained 10 minutes after intravenous administration of contrast material, shows extravasation (arrow), a finding indicative of a rupture of the collecting system. The lesion thus was rated grade IV.

 

View larger version (127K): [in this window] [in a new window] [Download PPT slide]   Figure 9a.  Images from a 26-year-old man who was involved in a motor vehicle collision while riding a motorcycle. (a) Transverse US view of the subxiphoid region shows a normal pancreatic head and corpus (arrows). D = duodenum, RLL = right lobe of liver. (b) CT image shows an area of edema (arrows) in the pancreatic parenchyma, a finding indicative of a grade II pancreatic contusion. Laboratory test results showed highly elevated amylase and lipase values that were indicative of pancreatic injury.

 

View larger version (155K): [in this window] [in a new window] [Download PPT slide]   Figure 9b.  Images from a 26-year-old man who was involved in a motor vehicle collision while riding a motorcycle. (a) Transverse US view of the subxiphoid region shows a normal pancreatic head and corpus (arrows). D = duodenum, RLL = right lobe of liver. (b) CT image shows an area of edema (arrows) in the pancreatic parenchyma, a finding indicative of a grade II pancreatic contusion. Laboratory test results showed highly elevated amylase and lipase values that were indicative of pancreatic injury.

 

View larger version (100K): [in this window] [in a new window] [Download PPT slide]   Figure 10a.  Images from a 64-year-old man with major trauma to the pelvis and chest after being struck by the trunk of a falling tree. (a) Longitudinal US view of the suprapubic region shows a large collection of free fluid in the pouch of Douglas (arrow). Note the bowel loop (BL) "swimming" in the fluid. An emergency laparotomy was performed. UB = urinary bladder. (b) Anteroposterior pelvic radiograph, obtained after filling of the urinary bladder with contrast material, shows the extravasation of contrast material into the abdominal cavity (arrows). Note the massive fractures on both sides of the pelvic girdle.

 

View larger version (110K): [in this window] [in a new window] [Download PPT slide]   Figure 10b.  Images from a 64-year-old man with major trauma to the pelvis and chest after being struck by the trunk of a falling tree. (a) Longitudinal US view of the suprapubic region shows a large collection of free fluid in the pouch of Douglas (arrow). Note the bowel loop (BL) "swimming" in the fluid. An emergency laparotomy was performed. UB = urinary bladder. (b) Anteroposterior pelvic radiograph, obtained after filling of the urinary bladder with contrast material, shows the extravasation of contrast material into the abdominal cavity (arrows). Note the massive fractures on both sides of the pelvic girdle.

 

View larger version (114K): [in this window] [in a new window] [Download PPT slide]   Figure 11a.  Images from a 78-year-old woman with severe thoracic trauma after an automobile collision. (a) Transverse US view of the subxiphoid region, obtained during the initial FAST examination with cranial angulation of the transducer, shows a large pericardial effusion (arrow) with nearly total compression of the right ventricle (arrowheads). LV = left ventricle, RA = right atrium. (b) Transverse US view obtained after an emergency thoracotomy and decompression, during which approximately 500 mL of blood was removed from a hematoma, shows refilling of the right ventricle. A small pericardial effusion is still present (arrow). LA = left atrium, RA = right atrium, RV = right ventricle.

 

View larger version (109K): [in this window] [in a new window] [Download PPT slide]   Figure 11b.  Images from a 78-year-old woman with severe thoracic trauma after an automobile collision. (a) Transverse US view of the subxiphoid region, obtained during the initial FAST examination with cranial angulation of the transducer, shows a large pericardial effusion (arrow) with nearly total compression of the right ventricle (arrowheads). LV = left ventricle, RA = right atrium. (b) Transverse US view obtained after an emergency thoracotomy and decompression, during which approximately 500 mL of blood was removed from a hematoma, shows refilling of the right ventricle. A small pericardial effusion is still present (arrow). LA = left atrium, RA = right atrium, RV = right ventricle.

 

View larger version (57K): [in this window] [in a new window] [Download PPT slide]   Figure 12a.  Normal physiologic ventilation at thoracic US. (a) Longitudinal view shows vertical comet-tail artifacts (arrowheads), which derive from movement of the various pleural layers during respiration. The arrow points to the interface between the pleura and the thoracic wall. (b) Duplex US image shows the lung-sliding sign, which is caused by the movement of the lung along the pleural surface during respiration. The absence of the comet-tail artifact, the lung-sliding sign, or both is indirectly indicative of pneumothorax.

 

View larger version (121K): [in this window] [in a new window] [Download PPT slide]   Figure 12b.  Normal physiologic ventilation at thoracic US. (a) Longitudinal view shows vertical comet-tail artifacts (arrowheads), which derive from movement of the various pleural layers during respiration. The arrow points to the interface between the pleura and the thoracic wall. (b) Duplex US image shows the lung-sliding sign, which is caused by the movement of the lung along the pleural surface during respiration. The absence of the comet-tail artifact, the lung-sliding sign, or both is indirectly indicative of pneumothorax.

 

View larger version (152K): [in this window] [in a new window] [Download PPT slide]   Figure 13a.  Diaphragmatic motion at abdominal US. (a) M-mode image in a patient with normal ventilation shows regular movement of the diaphragm during exhalation (arrows). (b) M-mode image in a patient with apnea shows no diaphragmatic motion (arrows).

 

View larger version (118K): [in this window] [in a new window] [Download PPT slide]   Figure 13b.  Diaphragmatic motion at abdominal US. (a) M-mode image in a patient with normal ventilation shows regular movement of the diaphragm during exhalation (arrows). (b) M-mode image in a patient with apnea shows no diaphragmatic motion (arrows).

 

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