Trick of the Trade: Ultrasound-guided injection for shoulder dislocation


Who loves relocating shoulder dislocations as much as I do? I know you do.

Often patients undergo procedural sedation in order to achieve adequate pain control and muscle relaxation. Alternatively or adjunctively, you can inject the shoulder joint with an anesthetic. Personally, I have had variable effectiveness with this technique. In cases of inadequate pain control, I always wonder if I was actually in the joint.

How can you improve your success rate in injecting into glenohumeral joint injection?


By |2019-01-28T22:35:26-08:00Nov 8, 2011|Orthopedic, Tricks of the Trade, Ultrasound|

Tricks of the Trade: Underwater ultrasonography


I’ve heard of underwater basketweaving, but underwater ultrasonography?

Bedside ultrasonography is a great tool to help find small foreign bodies. Commonly foreign bodies get lodged superficially in the patient’s extremities. Because superficial structures (<1 cm deep) are difficult to visualize on ultrasound, you should apply a really generous, thick layer of ultrasound gel to create some distance. Alternatively, you can add a step-off pad, such as a bag of saline or fluid-filled glove, to place between the patient’s skin and transducer. What’s a quicker and easier way to create some distance yet preserve image quality?

Trick of the Trade

Submerse both the body part and the ultrasound transducer under water.

ultrasonography water bath

For this “bath water technique”, start by holding the transducer perpendicular to the wound and about 1 cm away from the skin. You can adjust the distance to optimize the image quality.



Thanks to Andy at Emergency Medicine Ireland blog for these 2 ultrasound images! 

This submersion technique has been published in American Journal of EM in 2004 as a painless alternative to gel or a step-off pad, because the transducer does not need to apply any pressure on the patient’s wound.

Blaivas M, Lyon M, Brannam L, Duggal S, Sierzenski P. Water bath evaluation technique for emergency ultrasound of painful superficial structures. Amer J Emerg Med. 2004; 22(7), 589-93 PMID: 15666267

By |2020-04-21T12:30:07-07:00Jul 20, 2011|Tricks of the Trade, Ultrasound|

Paucis Verbis: Cardiac tamponade or just an effusion?

cardiac_tamponadeWhat is a cardiac tamponade? It is a clinical state where pericardial fluid causes hemodynamic compromise. With bedside ultrasonography in most Emergency Departments now, it’s relatively easy to detect a pericardial effusion.

But what we more want to know in the immediate setting is: Is this cardiac tamponade?

You can look for RA systolic or RV diastolic collapse. What if it’s equivocal? How good is the clinical exam and EKG in ruling out a tamponade?


By |2019-01-28T22:41:46-08:00Jul 8, 2011|ALiEM Cards, Cardiovascular, Ultrasound|

Tricks of the Trade: Ultrasound workshop setup


Have you ever been to an ultrasound workshop where each small group of attendees huddles around the small ultrasound display? Personally I think the 3 people closest to the display really see the images well. This tends to exclude the other participants.

Last week, I hosted (my first!) ultrasound workshop for the UCSF Alumni CME Conference where I showed peri-retired UCSF alumni from various specialties about the future of bedside ultrasonography. I equated it to the 21st century stethoscope. Thanks to my star team of ultrasonographers: Dr. Asaravala, Flores, Miss, Lenaghan, and Wilson.


By |2016-11-11T18:54:22-08:00May 11, 2011|Tricks of the Trade, Ultrasound|

Trick of the Trade: Check pupillary constriction with ultrasound

SwollenEyeIn some trauma patients with head and face trauma, you will need to check their pupillary response to light. Severe periorbital and eyelid swelling, however, make this difficult. You want to minimize multiple attempts to retract the eyelids because of the risk of a ruptured globe. What’s a minimally painful and traumatic way to check for pupillary constriction?

By |2019-01-28T22:50:28-08:00Apr 6, 2011|Ophthalmology, Tricks of the Trade, Ultrasound|

Trick of the Trade: Ultrasound-guided supraclavicular central line

SupraclavicularPositionsmEmergency physicians are procedural experts in central venous access. The subclavian vein is the best site for such access, because it has been shown to have the lowest rate of iatrogenic infections and deep venous clots

Bedside ultrasonography has really revolutionized how we obtain vascular access over the past 10 years. Identifying the subclavian vein using ultrasonography, however, is still technically challenging. The vein is located just posterior to the clavicle, which often gets in the way of the linear transducer.

By |2016-11-11T19:00:20-08:00Nov 10, 2010|Tricks of the Trade, Ultrasound|