Presenter : Joswita Monteiro

ULTRASOUND Course : M.Sc., MIT (3rd Sem)

PROTOCOL
Moderator : Asst. Prof. Mr. Vashist B.
Mhalsekar
DOP : 27/05/22
 BASIC RULES OF SCANNING
• Orientation of the image

• Contact with the patients skin

• Background of the image

• Distribution of the ultrasound beam

 BASIC RULES OF SCANNING
• Frequency and resolution

• Focus of ultrasound beam

• Sensitivity and gain

• Artifacts

• Quality control
ULTRASOUND PROTOCOLS
 PREPARATION OF PATIENT
• 8hrs fasting

• Prevent dehydration water should be given

• Infants: 3hrs fasting

 CHOICE OF TRANSDUCER
• 3.5MHz transducer – adults

• 5MHz transducer – children/ thin adults

• Curvilinear or sector transducers are preferred

 ABDOMEN AND PELVIS
INDICATIONS:

• Localized abdominal pain with indefinite clinical features

• Suspected intra abdominal abscess
• Nonspecific abdominal mass
• Suspected intra- abdominal fluid (ascites)
• Abdominal trauma
 POSITION OF PATIENT
• Comfortably lie on his/her back

• Head rest on small pillow, if there is abdominal

tenderness a pillow also be placed under patients knee

• Cover abdomen with coupling agent

• Allowed to breath quietly

 SETTING THE CORRECT GAIN
• Start by placing transducer centrally at top of abdomen

• Angle transducer beam towards right side of patient to

image liver

• Adjust gain setting - image has normal homogeneity and

texture
 SCANNING TECHNIQUE
• Slowly move transducer from midline across
abdomen to right- repeat at different levels

• Transducer can be angled in different directions -

more information and better localization
 LIVER

INDICATIONS

• Hepatomegaly
• Suspected liver abscess
• Jaundice
• Abdominal trauma
• Ascites
• Suspected liver mass
• Right upper abdominal pain
 SETTING CORRECT GAIN
• Diaphragm should be clearly seen

• Before scanning specific area, ask patient to

take deep breath and hold it
 SCANNING TECHNIQUE
• Should be in sagittal, transverse and oblique
planes including scans through intercostal and
subcostal spaces

• Done with slow rocking movement of transducer

in all planes
NORMAL LIVER
ABNORMAL LIVER
 PANCREAS
INDICATIONS

• Upper abdominal pain

• Persistent fever
• Suspected malignant disease
• Recurrent chronic pancreatitis
• Pseudocyst or abscess
• Abdominal trauma
POSITION OF PATIENT
 SETTING CORRECT GAIN
• Place transducer centrally at top of abdomen

• Angle beam to right side of patient to image

liver, adjust gain for best images
 SCANNING TECHNIQUE
• Transverse upper abdominal scans moving from
side to side and from costal margin towards
umbilicus

• Longitudinal scans moving up and down across

upper abdomen

• To examine specific area tell patient to take deep

breath and hold it
 TRANSVERSE SCANNING

• Start across abdomen moving downwards

towards feet until splenic vein is seen

• Superior mesenteric artery seen just below vein

• By angling and rocking transducer, head and tail

of pancreas may be seen
 LONGITUDINAL SCANNING
• Start just to right of midline - inferior venacava
with head of pancreas anteriorly, below liver

• Continue scan, moving to left

• Identify aorta and superior mesenteric artery which

will identify body of pancreas
 SPLEEN
INDICATIONS

• Splenomegaly
• Left abdominal mass
• Blunt abdominal trauma
• Ascites
• Suspected malignancy
 SETTING CORRECT GAIN
• Start placing transducer centrally at top of
abdomen

• Angle beam to right side of patient to image

liver; adjust gain to obtain best image
SCANNING TECHNIQUE
NORMAL SPLEEN
ABNORMAL SPLEEN
ABNORMAL SPLEEN
ABNORMAL SPLEEN
 KIDNEYS
INDICATIONS

• Renal or ureteric pain

• Suspended renal mass
• Non-functioning kidney on urography
• Hematuria
• Recurrent urinary infection
 PREPARATION
NO PREPARATION
• If urinary bladder is to be examined, drink
water

POSITION OF PATIENT
• Starts with patient lying on his back
• Cover right upper abdomen liberally with
coupling agent
 SETTING THE CORRECT GAIN
• Transducer over right upper abdomen

• Angle beam as necessary and adjust gain

to obtain best image of renal parenchyma
 SCANNING TECHNIQUE
• Right kidney with patient supine

• Deep suspended inspiration

• Longitudinal scan over right upper abdomen and follow

with transverse scan

• Bowel gas - 3 / 4 glasses of water

 NORMAL KIDNEY
• Length: upto 12cm and not less than 9cm

• Width: 4-6cm
•
• Thickness : upto 3.5cm
 ADRENAL (SUPRARENAL)GLAND
• Not easily seen
• Best scanning position is supine
• Situated above medial to kidneys
ABNORMAL KIDNEYS
CALCULI AND TRAUMA
 URINARY BLADDER
INDICATION

• Dysuria
• Haematuria
• Recurrent infection
• Pelvic mass
• Retention of urine
• Pelvic pain
 PATIENT PREPARATION
• Bladder must be full
• 4 – 5 glasses of fluid
• Examine after 1hr
• Patient in supine and rotated obliquely
• Lubricate lower abdomen with coupling agent
 SCANNING TECHNIQUE
• Transverse scans from pubic symphysis
upwards to umbilicus

• Longitudinal scans, moving from one side

of lower abdomen to other
 NORMAL BLADDER
• Full bladder appears as a large, echo-free area
arising out of pelvis

• Bladder wall less than 4mm thick- well distended

• After scanning, patient need to void – residual

urine
ABNORMAL
URINARY
BLADDER
 GYNAECOLOGY

INDICATIONS

• Pelvic pain, mass

• Abnormal vaginal bleeding
• Diffuse abdominal pain
• Infertility
 PREPARATION OF PATIENT
• Patient in supine, rotate patient after preliminary
scans

• Erect scanning is occasionally needed

 SETTING CORRECT GAIN
• Position transducer longitudinally over full
bladder and adjust gain to produce best image
 SCANNING TECHNIQUE
• Longitudinal scans - midline between
umbilicus and pubic symphysis

• Next scan transversely from pubic symphysis

upwards to umbilicus

• Turn patient obliquely(30-40 degree)- ovaries

 ENDOVAGINAL ULTRASOUND
• Specific transducer with long handle is needed

• Do not use any other transducer or any uncovered transducer

• Bladder must be empty

• Useful for imaging an early pregnancy

• Uterine ,fallopian tube /ovarian masses
• Ectopic pregnancy
NORMAL
ANATOMY
ABNORMAL UTERUS
POSITION OF
UTERUS
OVARIES
NORMAL OVARY
OVARIAN FOLLICLES
ABNORMAL
UTERUS
MALIGNANT
DISEASE
OVARIAN CYST
PELVIC ABCESS
 PERICARDIUM
INDICATION
• Suspected pericardial effusion

PREPARATION OF PATIENT
• No

PATIENT POSITION
• Supine and then sitting
• Apply coupling agent over cardiac area
 SETTING CORRECT GAIN
• Start by placing transducer centrally of
abdomen

• Angle beam to right side of patient to image

liver

• Adjust gain setting to obtain image with

normal homogeneity and texture
 SCANNING TECHNIQUE
• Start from centre in upper abdomen close to edge of ribs

• Angle transducer towards head and patient with deep

breath

• Cardiac chambers vary in size depending on stage of

cardiac cycle
 PERICARDIAL
EFFUSION

• Fluid around heart seen as echo-

free region surrounding heart
muscle
 PLEURA
INDICATION

• Pleural fluid
• Localizing small effusions
• Aspiration
 POSITION OF PATIENT
• Scanned while sitting comfortably

• Apply coupling agent over lower part of

chest on side to be examined
 SCANNING TECHNIQUE
• Transducer centred between ribs and held
perpendicular to skin

• Lung will be highly echogenic because of

contained air

• Alter patient position to see how much fluid

moves
ABNORMAL
PLEURA
 ULTRASOUND GUIDED NEEDLE PUNCTURE

IMPORTANCE:

• To localize abscess

• Aspiration of small effusion

• Biopsy of small tumour

 TECHNIQUE

• Strictly sterile conditions

• Shortest and safest route for needle insertion

• Keep needle in correct plane of ultrasound by fastening it to

transducer

• When needle is correctly positioned, remove transducer,

leaving needle
 WARNING

• Only section of needle within scanning

plane will appear on screen

• Make sure actual tip of needle is seen

 REFERENCES
• Manual of diagnostic ultrasound – edited by P.E.S PALMER
THANK YOU
ULTRASOUND QA
 QUALITY ASSURANCE
• It’s a process of ensuring that all aspects of an ultrasound
service meet and perform to agree standards

• Aim is to maintain standards and seek to improve

performance of all aspects of ultrasound service

• Patients have access to high-quality ultrasound services

 QUALITY ASSURANCE
• Institute of physics and engineering in medicine (IPEM)

• 3 levels of QA testing:

• Acceptance/baseline tests
• User test
• Routine QA test
 BASELINE ACCEPTANCE TESTS

• Carried out with any new machine, new probe,

major hardware or software upgrade is added

• Includes all tests specified for routine QA,

establishes baseline readings for further routine
and user tests can be compared
 USER TESTS

• Frequent intervals(1-4 weeks) by operator

• Significant changes in scanner performance over

time
 ROUTINE QA TESTS

• Performed every 6months but at least every 12

months

• Likely to detect deterioration in performance

 GENERAL MACHINE CLEANLINESS

System power Monitor

switch control

Filter
Main power
switch

Filter Power
switch
FILTERS
 Fans

Controls
 MECHANICAL AND ELECTRICAL

Power cord
Wheel and wheel
locks
TRANSDUCER CHECK
 PERFORMANCE TESTING
• Transducer choice
• System sensitivity
• Photography and gray scale hard copy
• Scan image uniformity
• Distance measurement accuracy
• Spatial resolution tests
 EQUIPMENT REQUIRED FOR IMAGE
PERFORMANCE TESTING

Tissue equivalent (TE) phantoms:

• Mimic tissue

• Sound to travel at speed of 1540m/s

• Attenuation of 0.5-0.8dB/cm/MHz

• Scattering properties similar to echogenicity of soft

tissue
PHANTOMS
 TRANSDUCER CHOICE
• Results of test procedures depend on which
transducer assembly is used

• Choose transducer assembly that will become a

standard for all test procedures
 SYSTEM SENSITIVITY
• Weakest echo signal level that can be
detected and displayed clearly in an image

• Affected by:
• Damaged cables
• Damaged transducer
• Electronic drift
PHOTOGRAPHY AND GRAYSCALE HARD COPY

For quick follow-up testing,

gray-scale bar pattern on
clinical image display can be
used
 SCAN IMAGE UNIFORMITY

• Phantom which is scanned should give

uniform brightness throughout

• Image non uniformity caused by:

• Bad element array
• Loose connection
• Side to side image compensation
 DISTANCE MEASUREMENT
ACCURACY
• Instruments used for measuring structure dimensions, organ sizes, the area should be tested
periodically to obtain accurate distance measurements

• Vertical / axial distance measurement test

• Horizontal distance measurement test

VERTICAL DISTANCE MEASUREMENT
TEST
HORIZONTAL DISTANCE MEASUREMENT
TEST
 SPATIAL RESOLUTION TESTS
• Tests don’t perform routinely
• Done only during equipment acceptance tests
• Common methods are:
• Axial resolution
• Lateral resolution
• Slice thickness
 AXIAL RESOLUTION TEST

Its measure of how close two reflectors can

be to one another along axis of an ultrasound
beam and still be resolved as separate
reflectors
 LATERAL RESOLUTION TEST

Its ability to distinguish structures that are

closely positioned within image plane
along a line perpendicular to beam of major
axis
 SLICE THICKNESS
• Phantom intended for detailed evaluation of
slice thickness

• Part of plane imaged appear as horizontal band

• Axial length of band equals to slice thickness

 SUMMARY
• Test phantoms contain various tissue equivalent materials and comes in variety shape and
size

• Phantoms are utilized for range of QA performance testing

• Guidelines used for QA performance testing

• Guidelines need to be updated periodically as ultrasound technology develops

THANK YOU