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1. 1. 45. what 45. are the what are the standard standard windows windows used used for a for a B. suboccipital,...

1. 1. 45. what 45. are the what are the standard standard windows windows used used for a for a B. suboccipital, B. suboccipital, transtemporal, transtemporal, opthalmic opthalmic window window complete transcranial complete transcranial Doppler Doppler exam? exam? THE three THE three standard standard windows windows used used for for aa TCD TCD exam exam A. suboccipital, A. suboccipital, transtemporal transtemporal ar ethe ar ethe suboccipital, suboccipital, B. suboccipital, B. suboccipital, transtemporal, transtemporal, opthalmic opthalmic window window transtemporal transtemporal C. suboccipitla, transtemporal, opthamic window, C. suboccipitla, transtemporal, opthamic window, ophtalmic window ophtalmic window submandibular submandibular the submandibular window is a supplemental D. transtemporal D. transtemporal only, only, other other views views performed performed ifif the submandibular window is a supplemental view used to assesss abnormalities identified abnormalities identified view used to assesss the distal the distal ICA ICA Category Details TCD - Transcranial Doppler - Uses 2 MHz non-imaging probe for Doppler evaluation of cerebral vessels Assumes 0-degree angle of insonation. - Assesses vessel velocity, direction, pulsatility, and turbulence Time-averaged maximum velocity (TAMV} is commonly used for evaluation. - Microbubble contrast can improve exam, requires constant infusion and two transducers. TCCD- Transcranial Color Uses 1.8 - 3.5 MHz phased array for B-mode, color, and Doppler images. Duplex Exam Offers ability for angle correction: PSV measured for diagnosis instead of TAMV. Transcranial Imaging (TQ) is another term for TCCD. Peak systolic velocity (PSV) can also be used for evaluation. Evaluates vertebrobasilar system, Gircle of Willis. bilateral ACA, PCA, MCA. siphon, vertebral, and single basilar vessels. - Detects collateral flow by evaluating flow direction and velocity in orbital/ ophthalmic artery, and basilar artery. Uses 5-10 mm Doppler sample size. Color Doppler setting: Flow toward probe as red, flow away as blue. increase frame rates for better 2D and color Doppler visualization. 2. 2. Which imaging Which imaging plane plane can can produce produce aa c. Coronal c. Coronal longitudinal image longitudinal image of of the the IVC IVC and and the the Aorta on Aorta on e placing placing the the patient patient in in the the decubitus decubitus position position the same image? the same image? and placing and placing the the probe probe a. transverse a. transverse ▪= on on the the lateral lateral aspect aspect ofof the the b. mid b. mid saggital saggital abdomen will demonstrate a abdomen will demonstrate a c. coronal c. coronal longitudinal view longitudinal view of of the the aorta aorta d. coronal d. coronal and and transverse transverse and IVC and IVC side side by by side side on on thethe image. image. ▪= a a transverse transverse view view can can also also demonstrate both great vessels demonstrate both great vessels on the on the same same image image but but will will not not provide a provide a longitudinal longitudinal view view US Of The Aorta Details Feature Description Best anatomic bedmark for abdorninal 1 Anechoic, hallow tube anterior to spine structures Longitudinal Anechoic. Groular structure to the left of the IVC Transverse Can demonstrate bath the sorta and IVC on same image 4 Coronal view Should be obtained of the worta and the proximal fee arteries AP and transverse measurements Obtained in longitudinal plane, from outer wall to outer wall of the vessel AP dimentions Obtained in the transverse plane, froen outer wall to outer wall of the vessel  Width dimensions Should be identified in the normal aorta 8 Gradual distal tapering Hecomes more anterior distally The proximal mid and distal aortic Documented, along with both common iliac arteries seginents 11 The. common ilisc artery Ends at the biturcation into the extemal and internal Hac artenes on between diaphragm oe nd celiac axis/SMA celiac axis/SMA to just below renal artery 2 Avetage Normal Measurements trom below renal arteries to Ihise bifurcation Distal 1,1-2.0 emu portion theese: 0.6-1.4 em 3. DURING 3. DURING A A TCD TCD EXAM EXAM the the depth depth is is set set 100 100 mm mm d. basilar, d. basilar, away away from from the the transducer transducer while using while using the the suboccipital suboccipital window. window. what vessel what vessel Instructor Feedback will be will be interrogated interrogated and and what direction will what direction will the the flow flow be moving? be moving? A. basilar, toward A. basilar, toward the the transducer transducer exhibit flow moving away b. carotid b. carotid siphon siphon ,, varies varies with with portion portion of of the the siphon siphon transducer and toward the brain evaulated evaulated c. vertebral, c. vertebral, toward toward the the transducer transducer d. basilar, away from the transducer d. basilar, away from the transducer Intracranial Artery Average Depth Setting Probe Angulation Time Averaged Maximum Velocity Direction of Flow Vertebral 60 - 90 mm Lateral 34 cms t Bom/s Away Basilar 8 - 120 mm Midline 4} cms + 10 cm/s Away PCA Segment Direction of Flow PI Away from the transducer P2 Toward the transducer 4. 43. 4. 43. which of the which of the following following describes describes the the proper proper D. anterior D. anterior angulation angulation with 65 mm with 65 mm depth depth technique for technique evaluating the for evaluating the ACA ACA through through the the e When When using using the the temporal temporal window window temporal window? temporal window? e the the ACA ACA isis evaluated evaluated with with anterior anterior probe probe A. midline A. midline placement placement with 50 mm with 50 mm depth depth B. posterior B. posterior angulation angulation with 65 mm with 65 mm depth depth angulation set angulation set a a 65 65 mm mm depth depth C. anterior C. anterior angulation angulation 50 50 mm mm depth depth Transtemporal Window Details D. anterior angulation with 65 mm D. anterior angulation with 65 mm depth depth Patient Position Supine with head supported Probe Placement Cranium in the temporal area, superior to the zygomatic arch, with the notch toward the patient's nose Structures Evaluated MCA ACA PCA, and terminal ICA Collateral and Stenosis Communicating arteries can be evaluated if stenosis and collateral flow are Evaluation present Landmark for MCA Sphenoid bone Midline Probe Placement Slight anterior angulation shows MCA flow at appropriate depths Transtemporal Window: « Patient in the supine position with head supported * Place probe on cranium in temporal area, superior to the zygomatic arch, with notch toward patient's nose © Used to evaluate the MCA, ACA, PCA and terminal ICA * If stenosis and collateral flow are present, the communicating arteries can also be evaiuated with this window * Sphenoid bone used as landmark for MCA * Midline probe placernent with slight anterior angulation will demonstrate the MCA flow (at appropnate depths! * MCA demonstrates flow toward the transducer « From the MCA, angle more sharply anterior and adjust depth of cursor for the ACA * ACA identified mediat and anterior to the MCA » ACA demonstrates flow away from the transducer © From the MCA, angle posterior and adjust depth to assess P1 and P2 « Cerebral peduncies used as landmark for PCA * P1 demonstrates flow toward the transducer, P2 demonstrates flow away from the transducer » From the MCA, angie inferior to the origin of the MCA to locate the ICA * Foramen lacrum used as landmark for the terminal ICA * Terminal ICA identified slightly inferior to MCA/ACA level * Flow direction in the terminal ICA varies due to varied course of the terminal ICA Transtemporal Window Details Patient Position Supine with head supported Probe Placement Cranium in temporal area, superior to the zygomatic arch, notch towards the patient's nose Evaluated Structures MCA ACA, PCA, and terminal ICA Collateral and Stenosis Communicating arteries can alto be evaluated if stenosis and collateral flow Evaluation are present Landmark for MCA Sphenoid bone Midline Probe Placement Slight anterior angulation shows MCA flow (at appropriate depths) MCA Flow Direction Toward the transducer ACA identification Medial and anterior to the MCA ACA Flow Direction Away frorn the transducer PCA Assessment Angle posterior from the MCA, adjust depth to assess Pt and P2 PCA Landmark Cerebral peduncles P1 Flow Direction Toward the transducer P2 Flow Direction Away from the transducer ICA Location Angle inferior to the origin of the MCA to locate Landmark for Terminal CA Foramen lacerum Terminal ICA identification Slightly inferiar 1o MCA/ACA level Terminal ICA Flow Direction Varies due to the varied course of the terminal ICA 5. 73. 5. 73. Which Which of of the the following following describes describes the the d. patients d. patients with with hip hip pain pain can can be be placed placed in in an an recommended protocol recommended protocol forfor an an accurate accurate evaluation evaluation oblique or oblique or prone prone position position to to obtain obtain the the doppler doppler of the lower extremity arteries? of the lower extremity arteries? samples form the popliteal artery samples form the popliteal artery A. place A. place the the ptpt in in the the trendelenburg trendelenburg position position B. Rotate B. Rotate the the leg leg internall internall and and bend bend the the knee knee Patient Positioning for Doppler Evaluation. Positioniny slightly slig htly Scenario m Instructions C. flex C. flex the the foot foot and and roatate roatate thethe ankle ankle when when sat xamination fete sient hese ite clon paren. performing doppler performing doppler evaluation evaluation of of the the distal distal posterior posterior Lag Positioning Rotate the feg externallyand bend the knee stightly for Doppler evaluation Thal H 1 H Foot and Ankle The fo ankle should always be im the neutral position when performing a Doppler tibial and dorsalis pedis arteries tibial and dorsalis pedis arteries Position evaluation of the distal PTA (Posterior Tibial Artery) and DPA (Dorsalis Pedis Artery) d. patients d. patients with with hiphip pain pain can can be be placed placed inin an an Patients with Hip Patients with hip pain can be placed in an oblique or prone position to obtain the Doppier Pain samples from the poptiteal artery. oblique or oblique or prone prone position position to to obtain obtain the the doppler doppler samples form samples form the the popliteal popliteal artery artery 6. 6. which imaging which imaging plane plane can can demonstrate demonstrate the the IVC IVC and and C. CORONAL C. CORONAL AND AND TRANSVERSE TRANSVERSE the aorta the aorta on on the the same same image image in in a a normal normal patient? patient? A. coronal A. coronal only only B. transverse B. transverse onlyonly C. coronal and transverse C. coronal and transverse D. mid D. mid saggital saggital only only View Structures Description Coronal View inferior Vera Cava ed a5 a large vessel returning deoxygenated blood from (ve. rer body Aorta (AO artery carrying oxygenated blood from the heart to the systemic system, Color Doppler Red indicates flow toward the probe: Blue indicates flaw away from the probe Doppler Velocity Blood flow velocities between -38.5 cm/s to +365 cm/s are Range indicated. Transverse inferior Vena Cava Seen as a round vessel, typically located anterior to the spine, right View (ive) of AO. Aorta (AO! Aorta visualized in cross-section, located left and stightly anterior to the IVC 7. 7. 167. when 167. when evaluating evaluating the the GSV GSV for for use use as as a a A. >3 mm A. >3 mm bypass graft bypass graft what is the what is the preferred preferred diameter diameter for for e when evaluating a when evaluating a vein vein for for use use as as a a bypass bypass the vein? the vein? graft, graft, A. >3 A. >3 mm mm > 10mm B. > 10 mm B. e a a3mm diameter or 3 mm diameter or greater greater is is preferred preferred C.>7mm C. >7 mm oon Pre-Procedure Vein Mapping D. > 5 mm D. > 5 mm Purpose Confirns presence, location, and adequacy of graft for coronary artery bypass or extremity arterial bypass Comp dity assessed Vein Diameter > 3mm diameter preferred; veins < 2mm cannot be used Wall Confirm thin walls with flexibility for expansion under arterial pressure as a graft Characteristics Common Veins GSV, SSV, Cephalic veins, or Basilic veins commonly mapped for harvesting Used Vessel Suitability Chronic occlusion and valvular incompetence obviate vessel use Patient Instruct the patient to avoid body lotions or powders, as these can inhibit skin marking Instructions Positioning Place the extremity in a dependent position: Leg: Reverse Trendelenburg for GSV, decubitus for SSV > Arms: Supine with arms extended at side, level lower than the heart, or seated position with hand on lap: tourniquets may be applied for small veins al. Step Details Exam Room ~ Keep the roorn warm to limit vasoconstriction, Preparation ~ Cover the rest of the patient and the foot/hand to keep warm: Equipment Use a 10-15MiHz linear transducer: Cover the transducer with a nonsterile probe cover to prevent staining from the marker. Gol Usage Use limited get to allow easier skin marking. Marking the Skin ~ Use a permanent marker or carbot fuchsin tain (used in radiation therapy) to create the markings. ~ Keep the transducer pespendicular to the skin surtace with light pressure. Vein Appearance ~ Vein should appear circular in transverse wew and should fill the screen frorn right to left in sagittal view, - Avoid excessive transducer pressure. Mark Placement ~ Peace a small mark in front of the transducer. - Move the transducer slightly distally while marking every 2-3 on. - Use'a straw to make indents in the skin connecting them with ines using a permanent marker, Vein Diameter Write the diameter of the vein on the arm/leg at the location it was measured. Notation Lower Extremity Start at the groin at the saphenofemoral junction Specifics Continue to the ankle. ~ Mark all cutateous tributaries and perforating veins. Procedure Details Lower Extremity Begins at the groin at the saphenofemoral junction ~ Continued to the level of the ankle. Must mark all cutaneous tributaries. Must mark all perforating veins if the vein will be used as an in situ graft or an AV fistula. Astenial flow will move from the graft through the perforator into the deep venous system. Upper Extremity Begins at the axilla or shoulder, Evaluate the full length of the basilic or cephaic vein Use the same marking techniques and documentation procedures as for the GSV. 8. 11. 8. 11. the the diagnosis diagnosis of of AAA AAA is is made made once once the the aorta aorta B. 3.0 B. 3.0 cm cm AP or AP or width width dimension dimension exceeds exceeds _______ ◦© the the diagnosis diagnosis of of AAA is made AAA is made once once A. 2.5 A. 2.5 cm cm the aorta the aorta AP AP B. 3.0 B. 3.0 cm cm ◦o or or width width dimension dimension exceeds exceeds 3.0 3.0 cm C.3.5 C. cm 3.5 cm D. 4.0 cm D. 4.0 cm 9. 17. 9. 17. which of the which of the following describes aa positive following describes positive d. loss d. loss of of the the radial radial artery artery pulse pulse result from result from the the Adson Adson maneuver? maneuver? e the the Adson's Adson's maneuver maneuver isis patient patient position position A. increased hydrostatic pressure A. increased hydrostatic pressure used to used to evaulate evaulate thoracic thoracic outlet outlet syndrome syndrome B. pain B. pain inin the the foot foot with with quick quick dorsiflexion dorsiflexion ▪« ifif the the radial radial pulse pulse diinishes diinishes or or c. loss c. loss of of pedal pedal pulses pulses ▪= disappears disappears completely completely during during d. loss d. loss of of the the radial radial artery artery pulse pulse the maneuver, the maneuver, ▪= TOS TOS is is diagnosed diagnosed TOS Maneuvers Details 1, Resting neutral position Hand on lap 2. Arm at 90-degree angle to body Arm positioned at a 90-degree angie relative to the body 3. Arm at 180-degree angle to body Arm positioned at a 180-deqree angle relative to the body 4, Adson's maneuver Specific maneuver to assess for TOS 5, Exaggerated military posture (costoclavicular) Posture used to assess TOS &. Neutral position with head left/head right Head movernent maneuvers to assess for TOS maneuver 7. Any position that the patient experiences Any position that reproduces the patient's symptoms symptoms Note: Inspiration/Expiration used with change of position in some maneuvers Adson’s Maneuver Steps 1, Palpate the radial pulse On the affected side with the elbow fully extended. 2. Rotate head Have the patient rotate their head to the side being tested and extend the neck 3. Abduct, extend, and laterally rotate Move the shoulder into abduction, extension, and tateral rotation. the shoulder 4. Deep breath and hold From this position, have the patient take a deep breath and hold it 5. Assess the pulse response Evaluate changes in the radial pulse 6. Positive test Ap tive test is indicated by a decrease in pulse vigor from the starting position to the final position. 10. 35. 10. 35. which which of of the the following following is is used used to to determine determine the the D. transcutaneous D. transcutaneous oximetry oximetry capability of capability of healing healing aa wound wound or or identify identify a a site site for for ◦°o evaulates evaulates oxygen oxygen supply supply and and amputation amputation consumption in consumption in the the tissues tissues A. photoplethysmography A. photoplethysmography surrounding a surrounding a wound wound B. Sclerotherapy B. Sclerotherapy ◦© the the partial partial pressure pressure of of the the oxygen oxygen is is C. ascending C. ascending venogrpahy venogrpahy recordd in recordd in the the tissues tissues around around the the D. transcutaneous oximetry D. transcutaneous oximetry wound. wound. ◦°o 70-80 70-80 mmHg mmHg indicates indicates normal normal pressure pressure ◦o < 0.5 sec toward the feet e 0.5 0.5 sec sec toward toward ° reflux is diagnosed when flow reversal the feet the feet exceeds 0.5sec exceeds 0.5sec >3 >3 sec sec flow flow reversal reversal is C: Augmentation C: Augmentation causes causes increased increased flow toward flow toward is ◦© considered considered severe severe venous venous reflux reflux feet followed by flow reversal > 0.5 sec toward the feet followed by flow reversal > 0.5 sec toward the heart heart e the the best best answer answer is is augmentation augmentation causes causes D: Augmentation D: Augmentation causes causes increased increased flow toward flow toward ▪= increased increased flow flow toward toward heart heart feet followed feet followed by by at at least least 33 seconds seconds of of flow reversal flow reversal followed by followed by flow flow reversal reversal >0.5 >0.5 toward the feet toward the feet sec sec ▪= toward toward the the feet feet Information Details Normal Flow 3 sec flow reversal is considered severe venous reflux. Reflux Best Answer Augmentation causes increased flow toward the heart followed by flow reversal >0,5 sec toward the feet. © Responses verw: Hrommar to ins Augmentanon Hort Normal; incrense in flow toward the heart with no retroynide flow before tow normatites flow toward the heart. then retrograde Now cocurning townrd tve teet voto the Bevery Dewp Veins > 1.0 seconds rafux Superficiat Veins > 0.8 seconds rettux Perfonttors > 0.5 seconds refsx © Pronimal eugmeniaton maneuvers are performed dunng 3 PY Doppler portion for an insufficiency exam © Vivisatee maneuver can be used to perform promal augmentation can be lied to asses rethie BUT if the valle at the saphenotamone junction is competent, raf Is not able to be demonstrated in wor portions of the GSV if t is present © Manual compression for proximal augmantation - squeazing the leg or pressing cn the vain abave the arna bung evatuated wrth tho transducer + Response in Veins Distal to the Augmentation Point Normal; Venous flow ceases at onset of Valsalva manguyer oF compression with no flow reversal Abnormal: Venous flow roversat occurs at the onset of the Valsatva maneuver or compression Duration of the reflux denotes the severity Category Details Response in Veins Proximal Normal ncrease in flow toward the heart with no retrograde flow before flow normalizes Abnormal nerease in flow toward the heart, then retrograde flow occurring toward the feet Reflux Duration Duration of the reflux denotes the seventy Deep Veins Superficial Veins Perforators >0.5 seconds reflux Proximal Augmentation Performed during a PW Doppler portion for an insufficeency exam Maneuvers Valsalva Maneuver Can be used to assess reflux; reflux not demonstrable if the saphenofemoral junction valve is competent Manual Compression Squeezing the Jeg or pressing on the vein above the area being evaluated with the transducer Response in Veins Distal Normal Venous flow ceases at the onset of Valsalva maneuver or compression with no flow reversal Abnormal Venous flow reversal occurs at the onset of the Valsalva maneuver or compression Reflux Duration Duration of the reflux denotes the severity 15. The 15. The most most accurate accurate Doppler Doppler predictor predictor of of ICA ICA D. the D. the end end diastolic diastolic velocity velocity stenosis is: stenosis is: e the the most most accurate accurate Dopper Dopper predictor predictor of of ICA ICA A. the systolic ratio A. the systolic ratio (ICAs/CCAs) (ICAs/CCAs) stenosis stenosis B. the B. the diastolic diastolic ratio ratio (ICAd/CCAd) (ICAd/CCAd) ◦o is is the the end end diastolic diastolic velocity velocity C. the C. the peak peak systolic systolic velocity velocity D. the D. the end end diastolic diastolic velocity velocity Doppler Predictor of ICA Stenosis Study Findings Details Most Accurate Predictor 16. 16. 187. SCLEROTHERAPY: 187. SCLEROTHERAPY: D. INVOLVES D. INVOLVES THE THE INJECTION INJECTION OF OF SALINE SALINE INTO INTO A. is used to A. is used to treat treat incompetent incompetent deep deep veins veins SUPERIFICAL VARICOSITIES SUPERIFICAL VARICOSITIES B. refers B. refers to to the the treatment treatment ofof veins veins using using aa Procedure Description Sderotherapy — involv jection of saline or other sclerosing agents that damage the ves and cause radiofrequency catheter radiofrequency catheter C. refers C. refers to to the the treatment treatment ofof deep deep venous venous reflux reflux Ablation al intervention in sore cases; catheter-based radiofrequency application can with compression stockings with compression stockings D. involves D. involves the the injection injection of of saline saline into into superficial superficial e sclerotherapy sclerotherapy refers refers to to the the injection injection of of saline saline varicosities varicosities or other or other sclerosing sclerosing agent agent ▪= that that damages damages the the vein vein ▪= causes causes fibrosis fibrosis to to occur occur ▪= ablation ablation can can be be used used to to avoid avoid surgical intervention in some surgical intervention in some cases cases ▪= catheter catheter based based radiofrequency radiofrequency application can application can occlude occlude the the vessels leading to overal vessels leading to overal atrophy of atrophy of the the vessels 17. 17. IfIf an an abnormal abnormal transcutaneous transcutaneous oximetry oximetry reading reading is is B) move B) move the the sensor sensor proximally proximally obtained, what obtained, should you what should you do do next? next? e TCPO2 TCPO2 isis performed performed to to assess assess tissues tissues to to determine the determine the A) move the A) move the sensor sensor distally distally ◦°o necessary necessary level level of of amputation amputation B) move B) move thethe sensor sensor proximally proximally ◦o the the amputation amputation must must be be done done at at an an C) turn C) turn up up the the oxygen oxygen level level entering entering the the patient's patient's mask mask area of tissue that has normal healing area of tissue that has normal healing D) report D) report the the reading reading location location and and end end the the exam exam capabilites capabilites ◦o ifif abnormal abnormal reading reading is is obtained obtained in in transcutaneous oximetery transcutaneous oximetery ◦o the the sensor sensor should should be be moved moved proximally proximally ◦o keep keep moving moving the the sensor sensor proximally proximally until aa normal until normal reading reading is is obtained obtained ◦© record record the the location location Aspect Details Procedure Name TCPO2 (Transcutaneous Oximetry) Purpose To assess tissue viability and determine the necessary level of amputation. Amputation Requirement Must be performed at an area where tissue shows normal healing capabilities. Action for Abnormal Move the sensor proximally (towards the body}. Reading Procedure Steps 1, Obtain an initial reading, 2 If the reading is abnormal, move the sensor proximally. 3. Continue moving the sensor until a narmal reading is obtained. Final Step Record the location where the normal reading is found. Correct Response: a) Instructor Feedback erformed to assess tissues to determi y ler e ion. The amputation mu be done normal healing capabilities, If an senso