Hi, everyone, and, welcome to my webinar with the Webinar vet. This is on ultrasound for veterinary nurses, and, it's all you need to know to get started. There's a two-part series, so there's this one today, and then there's one later on as well, regarding, sort of, we're gonna go through abdominal ultrasound in this first one and the basics of getting started with ultrasound.

And the second one, we're going to venture into sort of thoracic and cardiac ultrasound as well. So, a little bit about me. I qualified in 2018 as a registered veterinary nurse.

I currently work in a small animal hospital in emergency and critical care setting. This involves, doing triages and working throughout the night, so I'm a bit of a vampire in that respect. And I'm a BVAir Council member as well.

I started that in 2019, and that will run until 2022. So that's just being involved in the wider profession. I'm currently studying my Vets Now ECC certificate.

And I also own a dachshund named Harry, as you can see there on the right, and 44 tortoises as well. On social media, I tend to share quite a lot of what we can do as vet nurses. My main niche areas be an ultrasound, which I'm talking to you today about.

But you can find me on Facebook and Instagram, aspi_RVN, and I'm always happy to answer any questions on there as well. Just a quick conflict of interest declaration. I've got no relevant financial interests arrangement or affiliation with any company in relation to the content provided in this presentation.

And just a quick disclaimer, it's just important to know that everything discussed should be performed under the instruction of a veterinary surgeon and in line with the veterinary nurses RCVS Code of Professional conduct as well. Our learning outcomes for this webinar are to know how to prepare a patient for ultrasound scans. To know how to operate the ultrasound machine and the probe, to know how to carry out a pocus scan, which is a point of care ultrasound scan of the abdomen and thorax, and to recognise the basic structures and organs that we commonly see on ultrasound and be able to differentiate what is normal and abnormal with those.

So we're gonna start off with the machine. So, it's quite a lot of buttons on the machine. It can be quite daunting initially.

So, I've popped a little list there of the important buttons that we need to really sort of be focused on and what we need to get our images, really. So, we've got the width, frequency, depth, focus position, the freeze and save button, which is actually quite an important one, believe it or not, the calliper and the presets as well. So just to briefly go through each of those that sort of.

And what they do. The width is, usually a little button that we can twist. That just increases our, our field of view, basically, that what we see.

So, we can either get like a slimline view, or we can get sort of quite a wide view, sort of, obviously, giving you bigger view of the organs. And if you've got a bit larger animal, you're gonna be able to fit more on the screen and see a bit more of what's going on as a total picture, rather than a, a more focused assessment. We've then got the frequency.

So, this one is quite a, a bit of a balancing act as well. So, we'll talk about this a bit later on. But this alters the resolution of the image.

So it, it affects the image quality quite a lot, and also works hand in hand with the depth. The depth will give us a good indication of how deep into the, the animal you want to go. So whether you've got a deep-chested dog or whether you've got a puppy and a kitten.

Puppies and kittens, obviously, they're, they're not very deep at all. So, you sort of don't really need that very high. And the frequency will alter the quality of that image.

So if we've got a higher frequency, it'll give you a poor resolution of the image, so the, the, image quality will be quite poor, but your depth will be quite good. And then vice versa. So, we, we will go into that in a bit more depth sort of later on.

And then we've got a focus position, that just alters which part of the image you are getting the best sort of, The best, quality, sort of along the gradient of the image going deeper into the, into the patient. We've then got the freeze and save button, so that's one that you need to know where they are quite rapidly. If you need to freeze an image, so you've got it, and obviously saving that as well, so you can refer to that later on throughout the scan.

We've then got a calliper, which is very handy to measure organs if we have any that we want to sort of just make sure that they're within a normal size limit, or pockets of free fluid, potentially, that we may come across. And then we've also got our presets which we tend to select when we select what probe we're using. You can have presets that are already, programmed into machines, so we can get cat abdominal scans, or we can get cardiac sort of presets as well.

They just help with having all the correct frequencies already in place before you have to sort of start fiddling with anything. So, onto the probes. Not the most exciting part of scanning at all, but, it's definitely handy to know, cause otherwise, you're not going to get the images that you require.

So, we've got 3 main probes that we tend to see in our practise. The one that we tend to use most is the first one at the top left there, which is our convex or microconvex probe. That's quite an all-round probe, so we use that for our abdominal scans, and we can use it for some sort of thoracic scans as well.

It just doesn't always fit in between the rib spaces very nicely, depending on the size of your patient, but we can use this for cats, dogs, some exotics as well. It's more of a universal probe, really. So, it's an all-round good at everything.

And then moving on to the second probe. So, we've got our phased array probe, just at the top right there. We tend to use this for our cardiac or thoracic scans.

So we won't touch on this too much, on this, webinar, but in part two, we'll, we'll go into more detail with that. But that's a bit more handy for going in between the rib spaces just because of the shape of it and the field of view that it gives you. And our third one is our linear probebe.

So we don't tend to use these massively. It has quite a poor depth, and it gives you a rectangular field of view. We tend to use them for like ligaments or muscles, say, foreign bodies that we might see, like grass seeds that are under the skin.

We can tend to see those as well. And just bear in mind as well, on those images, we have an indicator. So that's that little notch that is pointing out there near.

So, on the top right photo, we have a little notch just pointing near my thumb. That's a very important thing to this note, so we'll go on to that next, in terms of how that correlates with your image on the screen. So the indicator is either a little, little notch that pokes out or a little, button, potentially, or sometimes we have a little light on there as well.

That is what you want to be pointing to the cranial end of the, of the cat or the dog. That will then correlate onto your image on the screen, as what we can see there is the V. So the V on the screen matches up with that notch.

So that's how you want it. So both points into the cranial end. Just so you get that mirror image of what's on the screen, it'll just make your life a lot more easier to understand the anatomy of your patient, where things should be, and just sort of just sort of follow the scan from there, really.

Moving on, we have our frequency, which we touched on earlier. So, this should hopefully be just a, a nice easy way for you to, to understand this. So your low frequency is your good depth, but your poor resolution.

And your high frequency, poor depth, but a good image quality. So, the yellow point on the left as well, not the V that we previously spoke about. It's just on the, near the 4, on the right-hand image, and between the 5 and the 10 on the left-hand image.

That is your focus positions. That will give you sort of a gradient of where your, where the most focused sort of ultrasound waves are, are sort of directed at. The image on the left is a cardiac scan.

That you can just see in the top left there that that's on a 5 megahertz, as a frequency. So that's a fairly low frequency. So it's giving you good depth sort of through the chest.

Obviously, the chest isn't always that deep, but it gives you quite a poor res resolution. It is a bit fuzzy, although most ultrasound images can look quite fuzzy and grey. That's sort of not very clear, sort of cut in terms of, like, the, the circular sort of motion in there.

As opposed to the image on the right-hand side, and that's one of our, picture of our liver. That's at 8 megahertz, so that's like quite a, a good sort of middle ground for your ultrasound, really. So, I tend to use 8 quite frequently, and pardon the pun there.

. That gives us a good sort of universal image, sort of frequency to see what we need to see, really. You can adjust that then depending on whether you're looking at organs that are closer to the skin or further deeper into the patient as well. But the best thing to do in that is if you are scanning, have a go at just moving the frequency, see what your dials do, see how that affects your image on the screen.

And what you'll then get to the point of doing is that you'll build up, a sort of a, a memory really of, of how you like to see it. So sometimes if you've got the lights on, that sometimes can't be helped in the practise, the frequency might help you in terms of being able to see what's on the screen a bit easier, if you haven't got a dark room to scan in potentially. Moving on to when we can use it.

So, personally, I think it can be used all the time. I'm a big fan of ultrasound, so, . We've got our pocus scans, which is our point of care ultrasound imaging.

So, we've got abdominal and thoracic scans, as we've previously discussed. So, we can do our abdominal organ assessment. So we can look at things like bladder, the kidneys, our stomach, intestines, spleen or liver.

We can look for any abnormalities. So, we've, got any free fluid, any potential obstructions. And then the same again in our thoracic as well.

So we can do cardiac scans, we can look at our lung fields. Is there anything that's there that shouldn't be there, and various things like that as well. We've then got our post-op monitoring as well.

So, I don't know how many of you do enterectomies or enterotomies in practise, or any gastrointestinal surgery. We can look to make sure that the wound isn't breaking down in internally, so we've got no dehiscences of the intestinal, sutures. We can look at the gastrointestinal motility to make sure that the peristalsis of the guts is nice, and whether we then need to intervene with any prokinetic drugs potentially.

And then we obviously got our organ assessment and observation, which we'll go through later on, whether things look normal, whether they're they're abnormal. We're not necessarily diagnosing as vet nurses, because that's something that we're not allowed to do. But we can see what's normal and what potentially looks abnormal.

So, I tend to refer to that as something along the lines of, if you take a patient's temperature and it's high, you can alert the fact that there's a high temperature, you're not diagnosing anything. You're gathering the information they need to make a further plan of action. Or, pick what further tests they need as well.

Moving on to the basics. So we've got our, basically, we'll go through the, the three different things that we tend to sort of see on not sound scan, is whether it's black. So that is often referred to as anechoic as well.

We've got, also hypoechoic, as for how that is referred to, and that is often either fluid or dense material, or sometimes it can be gas. But there's quite a differentiation between the black and something that's potentially shadowing. So just to talk you through the images on the screen, so you build up your bank of what is normal, so you've got an image bank in your head of what is normal and abnormal, essentially.

Top left there, we have an organ. We've got that solid black circle in the middles, that is fluid. That is our gallbladder, that is contained, so it's not free, free flowing throughout the abdomen.

So that is within a structure. The second image we have, that is a volume of fluid in the abdomen. As you can see, there's not really much of a structure there.

That's sort of free flowing, it's easier if you're doing a hands-on scan and you're there, you'd be able to see that that isn't contained within a structural wall. And then the far right is a bladder. That's contained within a structural wall, so very different to the middle photo.

So, you've got two normal, images there, and one that is abnormal. In terms of, again, when we would bring out the scanner, and when we would find that, if you've got any trauma patient that's come in, so if there's been a, a road traffic accident, a cat that's been hit by a car, a dog that's had any trauma, potentially, or anything that's sort of indicating that there's something not quite right, your ultrasound scan is very non-invasive, it's very quick. It can rule out some things sort of, very rapidly.

And if there is a problem, you can fast track that patient to your, to your veterinary surgeon who's working, and that can. End in sort of something that's potentially seen quicker. And by seeing that quicker, we improve the patient welfare and the care that we give it, rather than it potentially waiting for a vet who may be extremely busy, as we all are in clinic, to get to that patient to scan it.

So, if we, as nurses can gain that skill, we can take the pressure off, and we can use it as a triage skill, along with our history taking and taking our vital parameters as well. Moving on to another basic. So this is our shadowing, or what I sort of sometimes call a bit hazy.

As you can see, that's quite different to the, the sort of the black anechoic that we saw in the previous one. So, that's more like a hazy grey shadow, what I call it, sort of coming through there. That's, in fact, the colon.

So we get quite a lot of gas or dense materials, so faeces. It's quite tricky to differentiate early on the difference between what is shadowing and what's hazy and gas. So when we get shadowing, that will potentially block all of the ultrasound rays.

So where you're getting the sort of little grainy. Grey parts below that, that organ structure at the top of the probe. If that was a foreign body, for instance, that's very, very dense, that is gonna block the sound waves, you would just get a complete blackout beneath it.

So you wouldn't get any of those little grainy parts underneath it. It would just completely block the rays. That's how we tend to differentiate the gas between a foreign body.

Moving on again. So the basics we have here is like a grey, white, hypoechoic, that tends to relate to something that's like soft tissue structure. So we've got our liver there.

If you have something that's quite hypoechoic, so very white, that tends to relate to something that's quite inflammatory. So, whether we've got a pancreas that's very angry, or some lymph nodes that are really angry as well, or any missentry around the intestinal tracts can also come across quite angry. Moving on to our patient preparation.

So the biggest thing here is that if you fail to prepare, then prepare to fail. I think there's, it's so important to take the time to prepare your patient and get a good scanner window. It'll give you much better quality images, and in the end, it'll save you time.

So, then a few minutes at the start of preparing your patient will get you the images you need, rather than trying to scan, getting halfway through, and then realising that you need to actually prepare your patient properly to get what you need. So, clipping the fair or hair will give you a better probe contact. This removes the gas that gets trapped between your hair strands or your fur.

The moment you pop some ultrasound gel on your patient, if they have fur, you're just gonna get an absolute mess, and there'll be too much gas between your probe and the patient, you're not gonna see what you need to see. Following on from clipping the fur, we need to degrease the skin with the skin preparation, depending on your patient, obviously, if they have any allergies, obviously, consult your vet first and see what's best. Tend to go for something like chlorhexidine.

Be careful with the use of spirit, cause that can damage some probes, but we can use clingfilm if we need to in terms of popping that over the probe just to, to protect that slightly. By decreasing the skin, this allows for better contact with the gel. It allows this to then soak into the patient.

You'll find as you carry on your scan and you sort of go for a bit longer, as the gel soaks in and you carry on using the gel, your images sometimes look better and better as the scan progresses. A quiet, a dark room is quite essential. It's not always possible if you're in a busy hospital and you haven't got a, a scan room as such.

But it allows for better vis visualisation of the images on the screen. You won't get the glare on the screen and, and bits and pieces as well. And with it being quiet, your patient's less likely to be reactive.

Sometimes we need sedation for our patients as well. So, that will obviously be the vet's decision in terms of what they'd like to use. We find quite a lot in our clinic that butorhonol can work quite well to obtain the images that we need to.

It just sort of takes the edge off them. It allows them to delay in lateral recumbency if they're within a stable. State to do so.

Obviously, if they're critical, sometimes you may need to do this internal recumbency, which is absolutely fine. Either or can be done. Just take it on a case by case basis, really.

Obviously, lateral currency is the most desired, just because, sort of, you can then go for the gravity side, and it tends to be sort of a lot, the standard sort of how to, how to scan them. We can then work in our sort of routine in terms of getting our fast scan images. We've just got a little video, here just to show you where to clip for an abdominal, point of care ultrasound.

This is my dog, who tends to eat foreign bodies, so he's in and out of the, the practise. Also has pancreatitis flare-ups as well. So, we just want a nice, clean, shaved close to the skin, just so we can reduce all of that, potential air that's getting trapped between the fur and the, our ultrasound probe.

So Anatomy and physiology was my absolute downfall at college. It does help to have a good understanding of roughly where these organs are situated within your patients. Obviously, with exotics and bits and pieces, they can, they can vary hugely.

But with our cat and dog, they're, they're very similar to where they're situated. They might vary, where they're situated in abnormal cases, and the approximate locations are sort of there on the right-hand side of roughly where we'd look to be scanning to find our, our main organs there. So, for our abdominal pocus scans, or you may have heard it referred to as AFAST and TFAST scans, exactly the same thing.

Point of care ultrasound is, is our AFAST and TFAST scans. So, what's on offer when we're scanning these areas? We've got our liver, our gallbladder.

Gallbladder tends to sit within our liver, but we're gonna go through all the individual organs and what, what's normal and what's abnormal through them shortly. We've got the spleen, the kidneys, the bladder, the gastrointestinal tract, and the stomach. You can further your skills as well, and you can start to look for things like adrenal glands or pancreas, your lymph nodes, your sort of, aorta running through the body as well.

However, don't let that put you off picking up the probebe to start scanning initially. You don't need to be able to find, you know, even if you can't find the spleen to start with, you know, if you can start by finding a bladder, you've got the basics of then moving on to, to finding the other organs. Once you then build up your image of what's normal and what's abnormal, you can then start to advance your.

Still set onto looking for other things, looking at cardiac scans, looking at kidneys, following the ureters, or, and various things like that. But don't be put off for the fact that you can't find sort of these adrenal glands and bits and pieces, because they are not easy at all. But just pick it up and have a go, really.

We have 4 main quadrants. When we scan our patients, we can then get a score of 4 when we do this as well in terms of a triage scenario. So, the most times I tend to scan is if we have someone walk in the door that potentially is pale, distended abdomen, recumbent, if I haven't got a vet free, and I get permission from the owner, and also the vet, sort of just through communicating with them, I'll then pop the probe on.

So, we then want to look at these 4 windows. We can get a score of 4 there as well, which relates to if there's free fluid in each of these quadrants. So for every quadrant that there's free fluid in, you'd add 1.

So it'll be out of 4. So, sometimes they're absolutely swimming in fluids, so you'd just get a 4 out of 4. But these different windows tend to see different organ structures through, and, It's important that we cover all of those and get a, a picture of everything that's going on.

So, we've got our diaphragmatic hepatic. So, this is, usually at the base of the zipho sternum. We can see the diaphragm, the liver, and the gallbladder here.

We can also look at the cardiac, assessment through the diaphragm as well. So we can look into the chest through the, through the diaphragm. It's important to note, as I'll show you in a later image, that the diaphragm can cause like a mirror reflection.

It's got a bright white sort of line that goes down there, but we can go further into detail with that on the next slide. We've then got our splenorenal as well. So that's our flank side of the patient, if you remember the image previously, sort of roughly where the spleen would be situated, just along and up the rib cage, sort of towards the dorsal area of the hypoxial muscles.

We can then see the spleen in the left kidneys there, and we can also see peritoneal fluid that might be present in that situation as well. So, if we've got a, a, hemoabdomen, you tend to sort of see the, the fluid swimming around there. We've then got our systocolic quadrant, so that's where we look at the bladder and the colon.

Quite an important one to look at if we've got sort of potential bladder ruptures, or if we've got blocked bladders and cats. We can look at the colon to see sort of whether there's diarrhoea potentially to come or any sort of liquid. That tends to be based in the mid-caudal abdomen.

The bladder's got a nice one to start with as a base, if you want to. It's entirely up to you in terms of how best you want to go for your routine, whether you want to start at the, the sort of cranial end of the dog and go round. Some people start the bladder because it's a nice, easier one to identify and see.

It's just important to know that if you put more pressure on the probe, you can displace or compress the bladder, which can make it sort of seem fuller or, you know, more compressed, that it looks empty. You can also go from the dependent side of the patient. So, if we've got our patient laying in right lateral recumbency, pop your probe, sort of just underneath the patient and just sort of point it up towards the ceiling, We tend to see the dependent side then, cause, like, we know, you say fluid would drop with gravity.

Sometimes, if you scan from the top of the patient, and there's a small quantity of fluid, you will miss it. So it's important to always just check that underneath of the patients to make sure that the, the fluid hasn't dropped as the patient's gone onto their lateral recumbent side. We've then got our hepatorenal, which is similar to the systocolic in terms of going up and under on the dependent side.

So that's when you'll, you'll see if there is any fluid that has fallen. So you want to go, if your patient's in right lateral recumbency, you want to get underneath them, and you want to push up. Sort of heading towards where the right kidney would be based.

So you can see both kidneys, potentially on the same image, or you're just looking to look at the right kidney after already assessing the left whilst there, whilst you're going into sort of for the splenorenal sort of quadrant there. This can be quite painful if they've got things like pancreatitis, or if they've got abdominal pain for whatever reason. So just bear in mind, it can be quite an uncomfortable thing to do.

So, you might be best off turning them over onto the other lateral just to, just to get a view of that kidney. And bearing in mind that kidney is, is usually more cranial as well. So, each of the windows, these are some of the views that we tend to get.

So, we've got our diaphragmatic hepatic window, as we previously discussed, is that the, the ziphoid sternum. The views of the diaphragm, liver and the gallbladder can be obtained. So, the top image, we've got our liver with our gallbladder sitting in, and the bottom is our liver.

We've got a small pocket of free fluid where you can see those dotted lines there, which is our calliper measuring that pocket of fluid. And that bright white light that you've got running down the left-hand side of it is our diaphragm. So sometimes what can happen is that pocket of free fluid you see there would be seen on the left of the diaphragm.

So, it would sometimes potentially make you think that there's fluid in the chest. But that bright white line, which is our diaphragm, can cause a reflection like a mirror, as we've previously just mentioned. So it's important just to assess both.

If you are doing a, an abdominal scan, do a thoracic scan as well. There's no point in, in missing something for the sake of, sort of a few extra minutes of just assessing the, the lung fields and the cardiac, silhouette as well. So, we can also look at the cardiac, assessment through our diaphragm.

So, you want to just sort of point it more cranially, and you will then get the, the heart and view, depending on how deep-chested your patient is, whether it's quite a deep-chested dog, that might be quite difficult. You might be best off going through the rib spaces, with your different probes, potentially. Then we've got our splenorenal, which is our flank side of the patient, heading up towards the hypaxial muscles.

So visualising the spleen here in the left kidney. So, we've got the spleen up there on the top right image. So some people might just think that looks a bit like a, just a grey blur.

I tend to refer to the spleen as like a slug-like appearance run, run along the, the top of the screen there. That is usually more sort of, close to the patient's skin, so you haven't got to go very deep to look for that potentially. We want to visualise, Both of those, make sure that there's nothing that looks abnormal.

We've got our kidney down the bottom right there, which is quite an easy one to identify. So it's quite a nice one as well to, to start off with. We might see perisoneal fluid here, so hemoabdomens, or if there's fluid around the kidney, potentially, so we can get hydronephrosis and it's, and sort of edematous kidneys as well.

Sometimes moving up here depends on how full the stomach is, or whether the patient's eaten recently, or whether there's a lot of gas in their stomach, that can sometimes come into view as you're moving alongside the rib cage. The stomach tends to be sort of just tucked underneath, but it is always handy to, to try and get a view of that as well, just to see if there's anything that looks abnormal, or they've got sort of quite a thickened gastrointestinal tract that's running through. As you go through the splenorennal as well, you, you can get a view of the gastrointestinal tract.

So just below our spleen. So in this area here, we've got, the lumen of the gastrointestinal tract running through there. So try to view as much of the intestinal tract as we can as well.

Then have our systocolic area. So, we've got the bladder and the colon, which we can visualise here. We've got them in the mid cordal abdomen, roughly where you'd expect them to be.

The bladder, you can palpate and put the probe on as well if you're struggling to find it. And then just bear in mind that the pressure on the probe can displace or compress the bladder as well. We can go on the dependent side and use the gravity as well for those just to see whether there's any fluid that might be underneath.

Just see it an all-round picture, really, you just want to cover as much of the area as possible, in case there's anything that's hiding anywhere. Now we've got our hepatorenal quadrant. So, the right side of the patient, so we're going under and up towards the kidney location.

Again, it can be painful, depends on the patient's, status that we've, we've got, whether they are in pain, they might require sedation, potentially, but we get a good view of the right kidney that way. But, again, as I previously mentioned, you might have to just swap them over onto the other lateral recumbency, to get a good view of that. So, there are a lot of images, for the abdominal organs, and going through, we're now gonna go through each of the organs and what is normal and what's abnormal.

And that will just build up an image bank of, different images for you of what, again, what is normal as an appearance. And then once you get what is normal, you'll then be able to notice if there is an abnormality. Much easier.

So, as long as you know it's abnormal, we only need to know what looks abnormal. We don't need to know why it is or what's going on. We then need to get a vet to come and have a look, potentially fast track that patient in terms of a triage and get it treated sooner.

And it'll just result in either better patient care, quicker patient care. And also, it's, handy for us to use our skills. It's what we're there for.

So. Can then get muscle memory of finding the routine organs on a, on a poker scan as well. So everyone has their own routine of what they start with, what direction they go around in.

And just getting used to the probe movements and sort of the, it's like driving a plane, I think it's, it's very, not that I've ever driven a plane. Very small movements, sort of fanning up and down, just sort of getting used to what those movements do, twisting the probe into sort of a short axis view or a long axis view as well. So, a long axis view, you want to be pointing that notch that we mentioned earlier towards the cranial end of the patient.

And if you are doing a short axis view, so it's like a cross section of what you're looking at, you want to then turn that probe, so they're not just pointing towards the ceiling, if the patient was in, lateral recumbency. Or if they're in, if they're standing, you want to do it, so that notch is pointing to the, towards the cranial sort of end, and then if you want short access view again, you're just pulling that notch, so it's pointing towards you. So, our first organ, this is where I tend to start with my poker scans, is our liver.

So, as previously mentioned, it's the diaphragmatic hepatic window of the Ziffy sternum. So, just right at the bottom of our rib cage is where we want to just feel that and pop the probe, just where the rib cage sternum is, is finishing. It runs alongside the diaphragm, so we've got that hyperechoic bright white line.

That's quite a nice sort of indicator of that that is the liver. One of the biggest questions I tend to get asked is, how do you, differentiate the liver between the spleen? People think they, they look fairly similar, which they do.

They've got that mid-gray appearance. They both can be quite vascular. Although it depends on how you orientate the probe, the liver can look more or less vascular.

We also, as a differentiation between that and the spleen, we have a gallbladder that tends to be quite viewable as well. So you've got that sort of circular, black anechoic circle in there as well. The Gallbladder can, sometimes appear as like a mucousy, what we call it, so we can get gallbladder issues.

They are horrendously painful. So, just bear in mind if you need any analgesia whilst you are scanning the patient, as they might be very reactive. We get quite a mixed ecogenicity, with our liver, so we can get patchiness or free fluid alongside sort of our, Running throughout, we can get distended veins and sludgy gallbladders as well.

And just note that the V, again, on, on those images is where the orientation of the probe is pointing towards our, our cranial end of the dog or the cat. We have our liver abnormalities. So, we've got two images here of both sort of classic liver abnormalities.

Other ones, you might get a different ecogenicity. So we can see sort of like liver tumours, potentially. You might get cavitated appearances, where you've got nodules on the liver.

So if you've got loads of different shades of grey, potentially going through your liver, then that might be sort of signs of neoplasia, potentially. But anything abnormal, take an image of it, take several images of it from all different angles and views. .

If there's any abnormal shapes or or even edges as well as there's an abnormality. So, we only need to be finding those abnormalities and taking an image of them, and then that can be referred to if we need. The top right image, we have a distended vasculature running through the liver.

So, that's quite a distended biliary tree running through. So that could be a biliary tract obstruction, potentially. But again, that's an, an observation that we can make, and we can report that back to the, to the vet.

That we can get incidental findings as well that are irrelevant to what is going on. But it's just important that we take images of everything we do, so we've got them to refer back to. The bottom right image is quite an interesting one.

You can see it says GB halo. So GB is gallbladder. So we're labelled and everything as well.

It's quite difficult to sometimes interpret an image if you don't know roughly where it is, or if it's not imaged, labelled, sorry. Here with the gallbladder, we can get sludge, so sometimes it can look like we've got a grey appearance sort of running through it. We can also get a halo appearance, so you can see sort of like that edematous black, black ring going around the .

Around the gallbladder. This can indicate potential, cardiac issues. It can be due to edoema of the gallbladder, if you've got an obstruction or if it's angry and inflamed.

It can also indicate anaphylaxis as well. So, if they are having a reaction to something, then we can get the halo sign of the gallbladder. So, it's quite an interesting one that can, it's a lot of information if it is present.

That's not to say if it isn't present, that there's no cardiac issues. So again, make sure that we're carrying out our full sort of, pos scans of our abdomen and thorax. We can also get mucous seals in our gallbladder.

I tend to describe those as like a grapefruit appearance, so imagine cutting that in half and sticking a grapefruit in the middle of our gallbladder. It tends to look like that, that's a structure. Then we have our kidneys.

So, they are located in the hypaxial muscle reg region, sort of the retroperistoneal space, in the dorsal edge. So, heading to the spine of the, the patient. They're quite easy to identify as opposed to some of the other organs, but they can be quite tricky to find on occasion, because they are quite mobile.

So don't beat yourself up if you can't find them straight away. They're mixed in the ecogenicity due to the organ structure that we have. So, we've got the renal pelvis, the cortex, and the medulla.

We can measure them as well, just, to get a good. Feel for whether they're, whether you've got a small kidney and a big kidney. And they're usually sort of between a few centimetres to 5 to 6 centimetres, but they can vary between our species and breed.

And the right kidney is more cranial, as we mentioned, than the left. So, you often have to scan them under the rib cage to, to get a good view of that. Here, we're looking to make sure, obviously, the sizes of them, they're not that you've got two very different kidney sizes, but if we've got one that's very large or one that's very small, that can indicate blockages or sort of, you know, kidney damage or kidney failure, potentially.

We're also looking for any, anechoic lines or blocking of the ultrasound waves when we're doing those, to indicate kidney stones or urethral obstructions. Just like this on our kidney abnormalities. So, we have a complete loss of structural detail.

So, believe it or not, that is a kidney, as opposed to our previous images. There's quite a size difference there. So, that would be measured, and you would potentially look at the other kidney and see the, see the difference.

We can get tumours that are associated with kidneys, so that can be why they've got lots of detail and loss of shape. We can get blockages in kidney stones, and they can be quite edematous as well. So, you can see a little bit of fluid that is sort of circulating that, that kidney on the outside.

That could be due to it being edematous as well. And right in the middle, we've got that black sort of puddle in the middle. And then below that, we're losing our ultrasound waves.

So, around sort of this area, in the middle, those ultrasound waves are being blocked. Going through there, so that could be an indicative of a, of a kidney stone, potentially. That's just blocking those ultrasound waves reaching all the way through, so that's something to, to note as well.

Moving on to our spleen. So, this is situated in the, like, mid abdomen region, along the rib cage. It's sort of a mid-gray and echogenicity, and this, a slug-like shape is how I refer to it.

So, quite different to our liver. Can be quite small as well sometimes. Obviously, we can get problems with that, which we'll go on to.

And it can be vasculature, but it doesn't look vasculature unless you get a particular view of it. We can view the high list as well, which would sit in the middle, which is our main blood supply, and we can tend to view that as well. So, it's important that we look at the cranial and, and going all the way to sort of the dorsal and the, the caudal edge of the spleen to make sure that we're assessing all of it on the way through.

So you just want to be using small fanning movements as you're moving up and down the spleen, just to make sure that we're not missing anything, potentially. And then we move on to our splenic abnormalities, which I'm sure we're all aware of in practise. They tend to be our hemoabdomens that come in late on a Friday evening, when everyone wants to go home.

So they're, can be mixed in ecogenicity, they can be mottled and cavitated. They might not be necessarily situated where you'd expect them to be, if there is, sort of a bleed, that can cause that, the organs to be sort of displaced throughout. We can obviously, we've got our tumours that are associated with them in terms of hemangiosarcomas.

They can be enlarged, or we can get torsions of spleenss as well. So you might get quite an enlarged spleen as, as that sort of has torsion and sort of fills up with the blood. And then we've got our free fluid, which is quite an indicative sign of a, a splenic abnormality.

The free fluid can be due to many things. It doesn't necessarily have to be a spleen abnormality. We can have asciTS for a number of reasons.

So there, we've got, obviously, our surgery photo. That's just one of my tips, is that if you do manage to do a scan and you see something abnormal, and if it does end up going for something like an exploratory laparotomy, go in on the surgery, because that'll give you your, just gives you your image back of what you're seeing on the screen and what you've, what you see inside. So your 2D image as opposed to your 3D of what's actually going on inside.

And it's important to measure it as well and measure any pockets of free fluid if that's something that we need to do. Measuring free fluid, we can then do serial scanning to make sure it's not getting bigger or that it's reducing. So, if you've flushed an abdomen post-surgery, you can do a post-surgery scan, measure them pockets of free fluid, and then do that again, sort of in 2468 hours' time to make sure that's reducing and not getting bigger.

And then we've got our bladder, which is quite a nice one. So it's situated in the cor abdomen. Again, we can palpate it if we need to.

There is a structural wall surrounding it, unless we've got a, a rupture, potentially. We can also measure this as well. So, if we've got our feline patients that have a potential blocked bladder, or our recumbent patients to make sure that their bladder's not too big, or if it needs expressing or placing a urinary catheter can be quite nice, we can also use the ultrasound.

To assess our length of a urinary catheter if that's been placed, make sure it's not in too far. But it tends to have, obviously, this anechoic fluid and black appearance, and it's quite easily identifiable. However, with everything we do get our abnormalities.

So, we can get our uroliths, which will block our sound waves, like you saw with the kidney. We can get our sediment and sort of crystal urea. Your your abdomen, so you'll have a loss of a structural wall.

You probably won't be able to find the bladder, potentially. We can get our thickened inflamed walls, with cystitis or if we've had a cystootomy and the bladder's quite angry, or if it's quite empty, you can get what looks like a thickened all as well. We can get bladder tumours, which can sometimes look like sludge.

So that top left, image there, that could potentially be a tumour. Obviously, we're not diagnosing at all. But to differentiate whether it is something that's a growth or something abnormal in the bladder, as opposed to sort of sludge and crystals, you can move your dog or you can poke your probe into the bladder a bit more just to see whether that can disturb, or agitate the crystals and see them moving.

If you stand the patient up, then if it is sludge, it'll move. If it's something that's like a tumour, then that will be, that will be in place, it won't move. And we can also get bladder distension as well.

The top right image there is a very inflamed, angry bladder. So that bladder wall, is going around there and we've got the urine in the middle. A good thing to do would be to measure that bladder wall to make sure that it's, we can monitor then whether the, the inflammation, the thickness is reducing as opposed to getting worse, and, make sure there's no leakage from the bladder as well.

And then, again, my dog, problematic, but nurse's dog. That's a video of his bladder with, sediment swirling around in there. So he's got a crystal urea.

Again, you can sort of get that to move just by agitating the, the bladder, potentially, or just giving it a bit of a jiggle, and then you'll see that move around. Then we have our stomach. So, this is situated in our cranial abdomen.

Usually sort of underneath the rib cage, depends on how much they've eaten. We've got a rough sort of situation there where I'd be popping the probe to, to view their stomach. And it tends to have a bit of a mixed appearance, obviously, depending on whether they've eaten, whether they've not eaten.

If there's a foreign body in there, you might get some, quite sort of hypoechoic shadowing, or blocking of the sound waves. We do have a structural wall, which can be inflamed sometimes, whether that's sort of got a gastritis or sort of, hemorrhagic gastroenteritis, potentially, you might see some inflammation. Tends to be located near the spleen and the liver as well.

So, sort of in between those, and it can sort of look a bit like a grapefruit appearance almost as well. So we've got some images on the next slide that can just give you a bit of a better indication. So, as you can see, that sort of empty stomach gives you the sort of stomach folds that are going in there.

Tends to look a bit like a grapefruit or an orange that's been sliced up in sort of segments. Again, that's what you would sort of see in your gallbladder if you had what we call the muccocele. So just imagine picking it up and that would be sort of it in the liver almost.

And we can get fluid distension of our stomach. We tend to see that quite frequently if there's a duodenal foreign body, potentially. That's just blocking the pyloic outflow.

So, you'll just get this swirling of fluid in the stomach. We tend to see regurgitation with that quite as a clinical sign, or you can get your vomiting in practise as well. It can be quite floculent, so by that I mean, it'll be like black in appearance, but it might look like the crystal urea that you saw.

So there'll be bits sort of floating through it as well. We can get our gas shadowing or our hypoechoic blocking from dense material or foreign material. So that picture on the right is a stomach that's full of, of food.

So you're struggling to get your sound waves through that and get an image of anything further beneath that, because the food is blocking the sound waves from, from moving through. Essentially, that can happen with gas as well. So if you have something like a bloat or a, gastrodilatation volvulus, you might see that that just blocks your sound waves as well.

It's handy as well when doing any ultrasound, if there's abdominal sort of abnormalities, as long as it's not filled with, free fluid, because sometimes that's not very helpful to do an X-ray, as they sort of work sort of hand in hand together. It's a bit of a piece of the puzzle. It's not a, a complete sort of tool, but as great as it is and the information it gives us.

Moving on, we've got the gastrointestinal tract. So this is located all the way through the abdomen. There's not really a, a situation where, where it's in one place or not, unless we've got a diaphragmatic rupture and the intestines are in the chest.

Tends to be quite easily identifiable. We have like a lumen running through, so. Usually looks a bit like a road.

We've got like those, that white line running through the middle, which is our lumen where the food is, is going through. And then we've got the two sort of black, black fluid-filled parts next to it. We can measure our Intestines, so we can make sure they're not thickened, make sure the wall's not thickened.

We can look at our peristalsis, so to make sure that this is moving very nicely, whether prokinetics needs to be added in, we can look at our duodenum, our jujunum, ilium, and the colon. It can be quite difficult to differentiate, and that's usually more on, other organ structures. So, if you're coming out of the stomach, obviously, you've got your duodenum first.

But there is layering techniques that you can use to identify different parts and different, different parts of the intestinal tract. There is a video, it's not the best video of peristalsis, but you can slightly see that there's sort of some movement there of where the food is, is moving through the intestinal tract. If, If there isn't any, and you've sort of got very poor peristalsis and poor gut motility, that'll just be absent and it will just be a standstill.

Potentially, you can also get that where it becomes fluid-filled and you get fluid, sort of sloshing backwards and forwards. That can be due to a foreign body, potentially, or things like mesenteric torsions. So that's definitely important to note that that's a normal appearance of a gastrointestinal tract.

And if you sort of start to get big fluid-filled intestines, then It might require some further investigation and alerting your veterinary surgeon. So, moving on to our abnormalities. So there's 2 here.

So, the top image, we have a loop of intestine that's just swimming in free fluid. That particular one was swimming in free fluid due to a, foreign body that had perforated, and this patient was going septic. And then the bottom image there is an intestinal tumour.

So we've got the bright white, sort of lumen running through here, which is thickened. Unfortunately, it's sort of being, being compressed in the middle there. So, this black, sort of mottled appearance all the way round it is an intestinal tumour, unfortunately.

So that was sort of one that you can trace the intestinal tract, throughout the abdomen. And as you sort of get to that part, it was then quite, quite clear what was going on. Obviously, we've got our poor gut motility, we can have a look for, and lack of peristalsis, and any sort of inflamed layering as well.

And as previously mentioned, any sort of fluid-filled intestines. So, these are 3 images of abnormalities. So we can just talk through what's going on.

So, we'll start with the top left one. That's our gallbladder that is sitting within our liver. That is an abnormality with what is sitting in the gallbladder.

So that, I can't say for sure. So, but it could be something like a tumour, it could be the start of a mucous seal. But there's definitely something that shouldn't be there.

So, if it shouldn't be there, take an image, save it. And then we can refer to that later on, so your, your veterinary surgeon can make a, a plan from there on if they need to do anything about that, or if it's just an incidental finding. It can then be something that's saved and monitored, so we can then re-scan in sort of weeks or months to see if it's changed.

So it's a good thing to refer back to. And then below that, we have our image of a large amount of free fluid. So that's in our abdomen.

So, we've got, that pocket that would be measured. So, again, that's just quite a handy thing to have there. So we can, monitor whether that's getting bigger or smaller.

Your vet can then tap that, so they can take a sample and see whether it's blood or whether it's free fluids, sort of, of a, of a clear type, and assess what they need to do from, from going further with that. In that case, that is something that I would be alerting my vet to very quickly if I found that, you can potentially try and find a cause, but I wouldn't be taking too long, cos it might be something that needs intervention quite rapidly. And then moving on to our image on the bottom right.

That is our classic appearance of a pymetra. So, we've got our uterus that is filled with fluid. That obviously can be a hydrometer, which is full of, sort of this clear fluid and non-infectious, or that can just be a pussy fluid as well.

And this is our case example. So, you've seen that image on the previous one. So, this is a 9 year old, German Shepherd that presented out of hours as a collapsed patient.

Initial vital parameter recordings were, it was collapsed, pale mucous membranes that the pro prolonged capillary refill time. It was tachycardic, tachypenic, and hypertensive on, on presentation. The vets were all busy at this point, dealing with other emergencies as we cover quite a lot of out of hours practises.

So, I spoke to them and asked them if they were happy for me to perform an abdominal ultrasound. Spoke with the owner just to give them their expectations that we'd have to clip someur from their patient. And then, performed the, the ultrasound.

We then found, a hemoabdomen. Well, there, there were 3 fluids. When it was eventually tapped, it was, blood, so we've got a hemo abdomen there.

But in this case, all the veterinary team was busy. So, myself as a nurse could carry out this abdominal scan to gain further information. I obtained the still images.

I then was able to sort of track where the fluid potentially coming from, which just gave us a huge benefit of that. The patient care and welfare is drastically improved because there was someone else who could do it, rather than waiting for one of those veterinary surgeons to become free. And whilst they're waiting, they could potentially be decompensating and deteriorating as well.

So, potentially, in some cases, this is, can be life-saving, cause it can cause a rapid treatment plan, and diagnosis by a veterinary surgeon as well. So, if you have got that skill, just pick up the probe and have a go. Sort of, if you can notice that a bladder has fluid in it, you'll notice if there's free fluid in the abdomen.

So don't be afraid of having a go. And just to recap on our abdominal scans, so, it's just so, I sort of try to bombard you with photos there, really, of, to, build up your image bank of what looks normal. And then if you see some abnormalities because you know it looks normal, it'll just become quite obvious to you.

Mainly we're looking for a free fluid or dilated vessels, urinary bladder, sediment, abnormal organ shape or tumours. We're making observations, we're not diagnosing. As we can't as veterinary nurses anyway, but we can utilise our skills in order to make them observations to provide that better patient care.

We can find incidental findings, as with anything. So, if you were to take an X-ray, you might notice there's some arthritis that you didn't necessarily know that was there. But it's important just to note them anyway, cause it could be relevant or it could not be.

So, definitely note down any finds you find, make sure the images are saved, and you can refer back to them. And, yeah, just build up your Your images, your image bank, really, and take photos of them. I'm more than happy to have a look at photos of people's scans if they want to sort of, just run them by me and see what I think it might be.

I can't say for definite, but it's good to sort of, just have that sort of support, really. If you are scanner with a sonographer as well, ask what's on the screen. It's so much easier to sort of then build up your knowledge bank of what is going on, as opposed to, to not having a clue and just sort of seeing some shades of grey and getting quite boring.

I'd never thought that ultrasound would be my area of interest, but here we are now. And, just some top tips here as well, just to help get you started if you're thinking about ultrasounds in practise. Obviously, speak to your veterinary team and tell them why it can benefit them.

It can take the pressure off from bits and pieces. So practise as much as possible, it's difficult to get started because if you have got a veterinary team, you're like, well, we're, we haven't got much time, I haven't got time to teach you. Or if you can't get the images I need, sort of thing.

So, post-op patients is a great one to start with. So, they're recumbent, if they're comfortable and in a stable condition, and if you've got a mobile scanner in the practise, then you can just take that to the bedside. You haven't necessarily got to take them away.

We can then do serial scanning on them post-op patients to make sure that they're recovering OK, and there's no breakdown of the wounds inside. And then from that, you can learn what the probe does, the small movements, the turning of the probe, the different angles, and that there's more than one way to do it. So, I'm not gonna sit here and tell you how to hold the probe, whether you want to hold it like a pencil, whether you want to sort of hold it like a remote.

It's entirely up to you however you feel most comfortable. Preparing your patient is a very important one. So, as I said before, if you, fail to prepare, then prepare to fail, you'll just get the better, better views.

And if you were to try without preparing a patient, you're not gonna get very good views. You're probably gonna then get frustrated cause you can't see what you need to, and you'll probably end up just giving up. Build up your image libraries to take photos, like I said before, just, even if you just then get to the point where you know what a normal liver looks like, and you can literally look at a screen and be like, that's a liver, that's a spleen, that's a kidney, that's a bladder.

Once you've got that, you can then start to further develop your skills, and you can use those as anatomical landmarks for yourself to then, work towards other sort of abdominal structures as well. Be patient. Rome wasn't built in a day.

You're not gonna be able to necessarily carry out a full abdominal scan from the off, just from sort of watching a few scans. It's definitely something that takes time. And then, again, if you have sort of an experienced stenographer in practise, ask them questions, ask them to talk them through how they got there, see if you can do like a, like a show me tell me thing.

So, get them to show you how they got there, and then ask if you can have a go to sort of find that same image, potentially as well. And then there's just a quote that I had from a recent CPD I went to. It's just discussed an ultrasound, and it just said that you don't need to be able to find a pancreas or an adrenal gland to start doing an ultrasound scan.

I hear so many veterinary surgeons or nurses as well who've said to me. Well, no, I won't scan because I can't find the adrenal gland or I can't find a pancreas, or so and so can find a pancreas better than I can. You don't need to be able to find the pancreas or adrenal gland to start, to start doing it in a triage and a pocus scan, that's not what we need to necessarily see.

If there is a problem with the pancreas or adrenal gland that's so bad, you're probably gonna see it anyway, cause it's gonna be so abnormal and it's gonna stick out like a sore thumb. But in terms of trying to find a pancreas, 9 times out of 10, you can't find them if they're, they're normal anyway. And if they are abnormal, you'll, you'll notice there are abnormalities around that area anyway.

So whether there's edoema, or whether there's fluids, whether it's really angry and hyperrechoic, then they're gonna become apparent. But don't let that put you off starting in the first place. And, yeah, so that's it.

I'm happy to take any questions. My email is on there, and also my Instagram and Facebook, I'm contacts all through. And if you want any further resources, the BSAVA manual of diagnostic imaging is quite a handy one.

So, yeah, I'm more than happy to take questions at any point. And, be contacted through those, through those relevant channels. And I hope you can all join us for part two on the 23rd of November, which will be going further into the thoracic and the chest, point of care ultrasound scans.

Thank you very much.