AORTA

INDICATIONS:

Medical Necessity: Evaluate the aorta for presence or absence of aneurysm
Focused Question: Is there an abdominal aortic aneurysm?

REQUIRED IMAGES: Measure Outer Wall to Outer Wall at each location (clip and still image recommended)

1.) Transverse image at Proximal, Mid, and Distal Aorta

aorta 1 prox.png
aorta 2 mid.png
aorta distal.png

2.) Saggital or Longitudinal image at Distal Aorta and Bifurcation

 
 

RENAL

INDICATIONS:

Medical Necessity: Evaluate for hydronephrosis
Structures studied: Kidneys, including collecting system
Focused Question: Is hydronephrosis present? 

REQUIRED IMAGES:

Add Color Doppler to potential hydronephrosis to ensure it is not a vessel.
Evaluate for ureteral jets if any hydronephrosis seen.

1. Long and Short Axis View of Right and Left Kidney

1. Long and Short Axis View of Right and Left Kidney

2. Transverse and Saggital View of Bladder with Views of Ureteral Jets

2. Transverse and Saggital View of Bladder with Views of Ureteral Jets

 

HOW TO SCAN - RENAL

SCAN BILATERALLY

1.) Obtain video clip fanning through entire portions of both kidneys in both the longitudinal and transverse planes.

LEFT:

RIGHT:

2.) Obtain one static representative image.

STATIC LONGITUDINAL IMAGE OF KIDNEY WITHOUT HYDRONEPHROSIS

STATIC LONGITUDINAL IMAGE OF KIDNEY WITHOUT HYDRONEPHROSIS

 

If hydronephrosis is present (particularly bilaterally), scan the urinary bladder. If the bladder is distended, have the patient empty the bladder and repeat scan after 15 minutes.  

If there is any confusion as to the origin of fluid filled structures seen in the renal pelvis, apply color flow to differentiate vascular spaces from urinary spaces.

 

CARDIAC

INDICATIONS:

Medical Necessity: To assess for the presence or absence of pericardial effusion. To assess for the presence or absence of cardiac activity.
Structures studied: Heart, pericardium.
Focused Question: Is a pericardial effusion present? Is there cardiac activity?

REQUIRED IMAGES:

Parasternal Long Axis (PSTL), Parasternal Short Axis (PSAX), Apical 4 Chamber (AP 4/5), Subxiphoid, and IVC Images

cardiacus.png
 

HOW TO SCAN - CARDIAC

1.) Obtain at a minimum, video clips of the sub-costal and parasternal long axis views of the heart.

Additional views may include parasternal short axis and apical 4 chamber.

2.) Obtain one static representative image.

SUB-COSTAL VIEW STATIC IMAGE WITHOUT PERICARDIAL EFFUSION

SUB-COSTAL VIEW STATIC IMAGE WITHOUT PERICARDIAL EFFUSION

 
 

RUQ

INDICATIONS:

Medical Necessity: Evaluate for gallstones and dilated common bile duct and sonographic signs or cholecystitis, such as “positive sonographic Murphy’s sign,” thickened gall bladder wall, and pericholecystic fluid

Structures studied: Gallbladder (GB), common bile duct

REQUIRED IMAGES:

Short Axis, Long Axis, Common Bile Duct

rug short.png
rug long.png
rug common.png

HOW TO SCAN - RUQ

1.) Obtain a video clip of the GB in it’s entirety, in both the longitudinal and transverse planes.

 

2.) Obtain a static image of the GB in the transverse plane with a measurement of the anterior GB wall.

TRANSVERSE VIEW OF GALLBLADDER

TRANSVERSE VIEW OF GALLBLADDER

ANTERIOR WALL MEASUREMENT IN THE TRANSVERSE PLANE

ANTERIOR WALL MEASUREMENT IN THE TRANSVERSE PLANE

3.) Obtain a static image of the Common bile duct (CBD).

COMMON BILE DUCT MEASUREMENT

COMMON BILE DUCT MEASUREMENT

 

CRITICAL MEASUREMENTS

COMMON BILE DUCT

  • <5mm-normal in patients up to age 50 (Add 1 mm for every decade of life thereafter)

  •  5-7mm equivocal

  •  >7mm-dilated

GALLBLADDER WALL

  •  <3mm-normal

  •  3-4mm-equivocal

  •  >4mm-dilated

Note: The left lateral decubitis, in addition to the supine position, is generally superior for the GB and CBD visualization.


FAST

INDICATIONS:

Medical Necessity: Evaluate for intraperitoneal or pericardial fluid
Structures studied: Hepatorenal space, splenorenal recess, pericardial space, and pelvic views.

REQUIRED IMAGES:

3 Components to a FAST Exam (include each as clinically indicated) : Abdomen, Cardiac, Thoracic

1.) Abdomen

  • RUQ - include hepatorenal space, sub-diaphragmatic space, and inferior edge of the liver

  • LUQ -  include splenorenal space, sub-diaphragmatic space, left paracolic gutter

  • Pelvis - transverse and sagittal views

fast 3.jpg
 

2.) Cardiac

  • Obtain any one of the Parasternal Long Axis, Apical 4 Chamber, or Subxiphoid Views

 

3.) Thoracic

  • Anterior Chest - Right and Left

  • Lateral Inferior Chest, Coronal View - Right and Left

    • Visualize Diaphragm and Spine.  These can be obtained concurrent with abdominal RUQ and LUQ views

 

HOW TO SCAN - FAST

1.) Video in the longitudinal plane, fanning through Morrison’s pouch (hepatorenal space) to include the inferior tip of the liver/inferior pole of right kidney.

2.) Video clip fanning through the bladder in both the longitudinal and transverse planes. 

3.) Video clip in the longitudinal plane scanning through the spleen and kidney. Must include diaghram, spleno-renal space, and inferior tip of the spleen/lower pole of left kidney.

4.) Video clip of the subxiphoid cardiac view in the transverse plane.

5.) If subxiphoid view is techniquely inadequate, a video clip of the parasternal long axis will suffice. 

6.) Obtain one static representative image.

HEPATORENAL SPACE STATIC IMAGE ON FAST EXAMINATION

HEPATORENAL SPACE STATIC IMAGE ON FAST EXAMINATION

 

EARLY PREGNANCY

Click here for the Early Pregnancy Ultrasound Algorithm

INDICATIONS:

Medical Necessity: Confirm intrauterine pregnancy (IUP) and evaluate for signs of ectopic pregnancy.
Structures studied: Uterus and its contents, vesicouterine space, and rectouterine space (Pouch of Douglas).

REQUIRED IMAGES: Transabdominal and Transvaginal Views

Transabdominal Views - Transverse and Sagittal Views of the Uterus

preg transabd.png
 

Transvaginal Views - Transverse and Sagittal Views of the Uterus

preg transvag.png
 

If Intrauterine Pregnancy Visualized, Document FHR and Crown Rump Length

preg - iup.png

HOW TO SCAN - EARLY PREGNANCY

BEGIN TRANSABDOMINALLY

1.) Obtain a video clip fanning through the uterus in its entirety in the longitudinal and transverse planes. Assess for uterine lie, presence or absence of free fluid and evidence of an IUP.

 

IF THE TRANSABDOMINAL SCAN IS NON-DIAGNOSTIC FOR AN IUP, PERFORM A TRANSVAGINAL SCAN. 

1.) Obtain a video clip fanning through the uterus in both the longitudinal and transverse (coronal) planes.

2.) Obtain one static representative image. 

NO  GESTATIONAL SAC,  NO  INTRAUTERINE PREGNANCY

NO GESTATIONAL SAC, NO INTRAUTERINE PREGNANCY

GESTATIONAL SAC + YOLK SAC + SURROUNDED BY MYOMETRIUM* = IUP

GESTATIONAL SAC + YOLK SAC + SURROUNDED BY MYOMETRIUM* = IUP

GESTATIONAL SAC BUT NO EVIDENCE OF YOLK SAC OR FETAL POLE = NO IUP

GESTATIONAL SAC BUT NO EVIDENCE OF YOLK SAC OR FETAL POLE = NO IUP

GESTATIONAL SAC + YOLK SAC + FETAL POLE + SURROUNDED BY MYOMETRIUM* = IUP

GESTATIONAL SAC + YOLK SAC + FETAL POLE + SURROUNDED BY MYOMETRIUM* = IUP

To be diagnostic for an IUP, the uterus must be scanned in it’s entirety in 2 orthogonal planes showing a minimum of a gestational sac (GS) containing a yolk sac. The sac must be confirmed to be located within the endometrial cavity. This is best determined by demonstrating continuity between the endometrial cavity containing the gestational sac and the endocervical canal.  Assessment for myometrial mantle all around the sac in 2 orthogonal planes must be confirmed. *If the myometrium is <6 mm, this is concern for a corneal/interstitial or ectopic pregnancy.


BLADDER

bladder+transverse.png
bladder+saggital.png

LUNG

If evaluating only for pneumothorax bilateral anterior chest clips are sufficient. M-mode can also be utilized.

If evaluating only for pleural effusion bilateral lateral inferior chest views that demonstrate the diaphragm are sufficient.

If evaluating for parenchymal disease 10 zones should be assessed: Right and left anterior superior, anterior inferior, lateral superior, posterior inferior, lateral inferior.

Lung+zones.png
lung Lateral+Inferior.png

LOWER EXTREMITY VENOUS

Obtain clips demonstrating compression of the vein. Another option is to utilize dual mode and obtain side-by-side still images of each site uncompressed and compressed.

le+dvt.png

List of Acceptable Confirmatory Studies For Educational POC Ultrasound Examinations

**Any of these educational examinations can be performed with a credentialed faculty without obtaining confirmatory studies

Superficial

  • Consultative soft tissue ultrasound

  • X-ray of the body region being examined

  • CT of the body region being examined

  • MRI of the body region being examined

Level 1 Cardiac

  • Consultative Echocardiogram

  • CT of the chest

  • MRI of the chest

Advanced Cardiac

  • Consultative Echocardiogram

  • CT of the chest

  • MRI of the chest

DVT

  • Consultative DVT ultrasound

  • MRI of the lower extremity

  • CT venogram of the lower extremity

Gallbladder

  • Consultative RUQ ultrasound

  • CT of the abdomen

  • MRI of the abdomen

Abdominal

  • Consultative abdominal ultrasound

  • Abdominal CT

  • Abdominal MRI

Scrotal

  • Consultative scrotal ultrasound

  • CT of the scrotum/pelvis

  • MRI of the scrotum/pelvis

Non-pregnancy pelvic

  • Consultative pelvic ultrasound

  • MRI of the pelvis

  • CT of the pelvis

FAST

  • Consultative abdominal ultrasound

  • CT of the abdomen

  • MRI of the abdomen

Aorta

  • Consultative abdominal ultrasound

  • CT of the abdomen

  • MRI of the abdomen

  • Aortic angiography

Renal

  • Consultative renal ultrasound

  • CT of the abdomen

  • MRI of the abdomen

Obstetric

  • Consultative Obstetric ultrasound

Thoracic

  • Chest x-ray

  • CT of the chest

  • MRI of the chest

Musculoskeletal

  • X-ray of the body region being examined

  • CT of the body region being examined

  • MRI of the body region being examined

Ocular

  • CT of the orbits

  • MRI of the head/eye

Vascular

  • Vascular lab-performed consultative ultrasound

  • CT angiogram

  • Traditional angiography