Microsoft Word - Troubleshooting

EquipmentPacket:MedicalUltrasoundUMDNS#:14278DateofCreation:November18,2015Creator:CompliedbyCassandraStancoforEngineeringWorldHealth(EWH)EquipmentPacketContents:Thispacketcontainsinformationabouttheoperation,maintenance,andrepairofmedicalultrasound.PartI:ExternalFromthePacket: 1. AnIntroductiontoUltrasound:PowerPointPartII:IncludedinthisPacket: 1. OperationandUse:a. BriefOverviewofUltrasoundDevices(p.3)b. IntroductiontoUltrasound(p.4-18)c. OperationandUseofUltrasoundDevices(p.19-32)2. DiagramsandSchematics:a. Figure1:B-ModeUltrasound(p.34)b. Figure2:MorTMModeUltrasound(p.35)c. Figure3:FetalUltrasound(p.36)3. PreventativeMaintenanceandSafety:a. UltrasoundPreventativeMaintenance(p.38)b. UltrasoundPreventativeMaintenanceTable(p.39)4. TroubleshootingandRepair:a. UltrasoundTroubleshootingFlowchart(p.41-44)b. UltrasoundUserChecklist(p.45)5. ResourcesforMoreInformationa. ResourcesforMoreInformation(p.47)b. Bibliography(p.48)




1.*Operation*and*Use*of*Medical*Ultrasound*****Featured*in*this*Section:****WHO./“Manual/of/Diagnostic/Ultrasound,/Second/Edition.”/WHO,/2011./Retrieved/from:/http://apps.who.int/medicinedocs/documents/s21383en/s21383en.pdf/*WHO./“Scanning/System,/Ultrasonic.”/From/the/publication:/Core(Medical(Equipment./Geneva,/Switzerland,/2011./*Wikipedia./“/Medical/Ultrasound.”/Wikipedia,/pgs/1S15./Retrieved/from:/https://en.wikipedia.org/wiki/Medical_ultrasound/** */* ** *




http://www.who.int/medical_devices/en/index.html
© Copyright ECRI Institute 2011 (not including the GMDN code and device name).


Reproduced with Permission from ECRI Institute’s Healthcare Product Comparison System.


© Copyright GMDN Agency 2011. GMDN codes and device names are reproduced with permission from the GMDN Agency.


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Health problem addressed
These devices are used primarily for abdominal and OB/GYN
scanning. Some systems include additional transducers to
facilitate more specialized diagnostic procedures, such as
cardiac, vascular, endovaginal, endorectal, or small-parts (e.g.,
thyroid, breast, scrotum, prostate) scanning.


Product description
General-purpose ultrasonic scanning systems provide two-
dimensional (2-D) images of most soft tissues without subjecting
patients to ionizing radiation. These systems typically consist of
a beamformer, a central processing unit, a user interface (e.g.,
keyboard, control panel, trackball), several probes (transducers
or scanheads), one or more video displays, some type of
recording device, and a power system.


Principles of operation
Ultrasound refers to sound waves emitted at frequencies
above the range of human hearing. For diagnostic imaging,
frequencies ranging from 2 to 15 megahertz (MHz) are typically
used. Ultrasonic probes contain one or more elements made of
piezoelectric materials (materials that convert electrical energy
into acoustic energy and vice versa). When the ultrasonic
energy emitted from the probe is refl ected from the tissue, the
transducer receives some of these refl ections and reconverts
them into electrical signals. These signals are processed and
converted into an image. Lower sound frequencies provide
decreased resolution but greater tissue penetration, while
higher frequencies improve resolution when deep penetration
is not necessary.


Operating steps
To perform ultrasonic imaging, a probe is either placed on the
skin (after an acoustic coupling gel is applied) or inserted into a
body cavity. Scanned structures can be measured by ultrasound
technicians using digital calipers (i.e., cursors electronically
superimposed over the scanned cross-sectional image that
calculate the size of the scanned structure). The caliper system
can also be used by technicians to plot and measure the area,
circumference, or volume of a structure. A data-entry keyboard
permits information such as patient name, date, and type of
study to be entered and displayed along with the scanned image.


Reported problems
Ultrasound diagnostic imaging appears to be risk-free when used
properly. Ultrasound transducers should be handled carefully
to avoid damage. Electromechanical problems, such as cracks
in piezoelectric elements, can alter beam width and/or spatial
pulse length, thereby affecting lateral and axial resolution. Errors
in distance measurements can cause incorrect calculations.


Use and maintenance
User(s): Ultrasound technician


Maintenance: Medical staff; technician;
biomedical or clinical engineer


Training: Initial training by manufacturer and
manuals


Environment of use
Settings of use: Hospital radiology
departments; private physician offi ces


Requirements: Stable power source


Product specifi cations
Approx. dimensions (mm): 1340x420x630


Approx. weight (kg): 75


Consumables: NA


Price range (USD): 25,000 -220,000


Typical product life time (years): 5


Shelf life (consumables): NA


Types and variations
General-purpose; OB/GYN; small parts;
vascular; cardiology; endocavity


Scanning System, Ultrasonic
UMDNS GMDN
15976 Scanning Systems, Ultrasonic, General-Purpose 40761 General-purpose ultrasound imaging system


Other common names:
Abdominal Ultrasound Scanners; Doppler Devices; General-Purpose Ultrasonic Scanners; Metal Detectors; Metal
Detectors, Ultrasonic; Scanners, Ultrasonic, Dedicated Linear Array; Scanners, Ultrasonic, General-Purpose; Scanners,
Ultrasonic, Pediatric; Ultrasound Scanners, Bladder; Ultrasound Scanners, General-Purpose; Ultrasound Scanners,
Urology; Diagnostic imaging equipment, general use




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1 Diagnostic applications


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CPF FKUGCUG QH VJQUG XGUUGNU


2 From sound to image


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2.2 Receiving the echoes


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2.3 Forming the image


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2.4 Displaying the image


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3 Sound in the body


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6Q IGPGTCVG C &KOCIG VJG WNVTCUQPKE DGCO KU UYGRV
# VTCPUFWEGT OC[ DG UYGRV OGEJCPKECNN[ D[ TQVCVKPI QT
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RTQEGUUGF CPF WUGF VQ EQPUVTWEV VJG KOCIG 6JG KOCIG KU
VJGP C & TGRTGUGPVCVKQP QH VJG UNKEG KPVQ VJG DQF[
& KOCIGU ECP DG IGPGTCVGF D[ CESWKTKPI C UGTKGU QH CF




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KV KU FKឹEWNV VQ OCMG & KOCIGU QH OQXKPI VKUUWGU 4G
EGPVN[ & RJCUGF CTTC[ VTCPUFWEGTU VJCV ECP UYGGR VJG
DGCO KP & JCXG DGGP FGXGNQRGF 6JGUG ECP KOCIG HCUVGT
CPF ECP GXGP DG WUGF VQ OCMG NKXG & KOCIGU QH C DGCVKPI
JGCTV
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OWUENG OQVKQP 6JG FKាGTGPV FGVGEVGF URGGFU CTG TGR
TGUGPVGF KP EQNQT HQT GCUG QH KPVGTRTGVCVKQP HQT GZCORNG
NGCM[ JGCTV XCNXGU VJG NGCM UJQYU WR CU C ីCUJ QH WPKSWG
EQNQT %QNQTU OC[ CNVGTPCVKXGN[ DG WUGF VQ TGRTGUGPV VJG
CORNKVWFGU QH VJG TGEGKXGF GEJQGU


4 Modes of sonography


5GXGTCN OQFGU QH WNVTCUQWPF CTG WUGF KP OGFKECN
KOCIKPI=?=? 6JGUG CTG


• A-mode #OQFG CORNKVWFG OQFG KU VJG UKO
RNGUV V[RG QH WNVTCUQWPF # UKPING VTCPUFWEGT UECPU
C NKPG VJTQWIJ VJG DQF[ YKVJ VJG GEJQGU RNQVVGF QP
UETGGP CU C HWPEVKQP QH FGRVJ 6JGTCRGWVKE WNVTC
UQWPF CKOGF CV C URGEKិE VWOQT QT ECNEWNWU KU CNUQ
#OQFG VQ CNNQY HQT RKPRQKPV CEEWTCVG HQEWU QH VJG
FGUVTWEVKXG YCXG GPGTI[


• B-mode or 2Dmode +P $OQFG DTKIJVPGUUOQFG
WNVTCUQWPF C NKPGCT CTTC[ QH VTCPUFWEGTU UKOWNVCPG
QWUN[ UECPU C RNCPG VJTQWIJ VJG DQF[ VJCV ECP DG
XKGYGF CU C VYQFKOGPUKQPCN KOCIG QP UETGGP /QTG
EQOOQPN[ MPQYP CU & OQFG PQY


• C-mode # %OQFG KOCIG KU HQTOGF KP C RNCPG PQT
OCN VQ C $OQFG KOCIG # ICVG VJCV UGNGEVU FCVC
HTQO C URGEKិE FGRVJ HTQO CP #OQFG NKPG KU WUGF
VJGP VJG VTCPUFWEGT KU OQXGF KP VJG & RNCPG VQ UCO
RNG VJG GPVKTG TGIKQP CV VJKU ិZGF FGRVJ 9JGP VJG
VTCPUFWEGT VTCXGTUGU VJG CTGC KP C URKTCN CP CTGC QH
EO2 ECP DG UECPPGF KP CTQWPF UGEQPFU=?


• M-mode +P /OQFG OQVKQP OQFG WNVTCUQWPF
RWNUGU CTG GOKVVGF KP SWKEM UWEEGUUKQP ཊ GCEJ VKOG
GKVJGT CP #OQFG QT $OQFG KOCIG KU VCMGP 1XGT
VKOG VJKU KU CPCNQIQWU VQ TGEQTFKPI C XKFGQ KP WNVTC
UQWPF #U VJG QTICP DQWPFCTKGU VJCV RTQFWEG TGីGE
VKQPU OQXG TGNCVKXG VQ VJG RTQDG VJKU ECP DG WUGF VQ
FGVGTOKPG VJG XGNQEKV[ QH URGEKិE QTICP UVTWEVWTGU


• Doppler mode 6JKU OQFG OCMGU WUG QH VJG
&QRRNGT GាGEV KP OGCUWTKPI CPF XKUWCNK\KPI DNQQF
ីQY


• Color Doppler 8GNQEKV[ KPHQTOCVKQP KU RTG
UGPVGF CU C EQNQTEQFGF QXGTNC[ QP VQR QH C $
OQFG KOCIG


• Continuous Doppler &QRRNGT KPHQTOCVKQP KU
UCORNGF CNQPI C NKPG VJTQWIJ VJG DQF[ CPF CNN
XGNQEKVKGU FGVGEVGF CV GCEJ VKOG RQKPV CTG RTG
UGPVGF QP C VKOG NKPG


• Pulsed wave (PW) Doppler &QRRNGT KPHQT
OCVKQP KU UCORNGF HTQO QPN[ C UOCNN UCORNG
XQNWOG FGិPGF KP & KOCIG CPF RTGUGPVGF
QP C VKOGNKPG


• Duplex C EQOOQP PCOG HQT VJG UKOWNVCPGQWU
RTGUGPVCVKQP QH & CPF WUWCNN[ 29 &QRRNGT
KPHQTOCVKQP 7UKPI OQFGTP WNVTCUQWPF OC
EJKPGU EQNQT &QRRNGT KU CNOQUV CNYC[U CNUQ
WUGF JGPEG VJG CNVGTPCVKXG PCOG Triplex


• Pulse inversion mode +P VJKU OQFG VYQ UWE
EGUUKXG RWNUGU YKVJ QRRQUKVG UKIP CTG GOKVVGF CPF
VJGP UWDVTCEVGF HTQO GCEJ QVJGT 6JKU KORNKGU VJCV
CP[ NKPGCTN[ TGURQPFKPI EQPUVKVWGPV YKNN FKUCRRGCT
YJKNG ICUGU YKVJ PQPNKPGCT EQORTGUUKDKNKV[ UVCPF
QWV 2WNUG KPXGTUKQP OC[ CNUQ DG WUGF KP C UKOKNCT
OCPPGT CU KP Harmonic mode UGG DGNQY


• Harmonic mode +P VJKU OQFG C FGGR RGPGVTCVKPI
HWPFCOGPVCN HTGSWGPE[ KU GOKVVGF KPVQ VJG DQF[ CPF
C JCTOQPKE QXGTVQPG KU FGVGEVGF 6JKU YC[ PQKUG
CPF CTVKHCEVU FWG VQ TGXGTDGTCVKQP CPF CDGTTCVKQP CTG
ITGCVN[ TGFWEGF 5QOG CNUQ DGNKGXG VJCV RGPGVTCVKQP
FGRVJ ECP DG ICKPGF YKVJ KORTQXGF NCVGTCN TGUQNW
VKQP JQYGXGT VJKU KU PQV YGNN FQEWOGPVGF


5 Expansions


#P CFFKVKQPCN GZRCPUKQP QT CFFKVKQPCN VGEJPKSWG QH WNVTC
UQWPF KU biplanar ultrasound KP YJKEJ VJG RTQDG JCU
VYQ & RNCPGU VJCV CTG RGTRGPFKEWNCT VQ GCEJ QVJGT RTQ
XKFKPI OQTG GឹEKGPV NQECNK\CVKQP CPF FGVGEVKQP=? (WT
VJGTOQTG CP omniplane RTQDG KU QPG VJCV ECP TQVCVG
q VQ QDVCKPOWNVKRNG KOCIGU=? +P & WNVTCUQWPF OCP[
& RNCPGU CTG FKIKVCNN[ CFFGF VQIGVJGT VQ ETGCVG C
FKOGPUKQPCN KOCIG QH VJG QDLGEV


5.1 Doppler ultrasonography


5GG CNUQ &QRRNGT GEJQECTFKQITCRJ[
5QPQITCRJ[ ECP DG GPJCPEGF YKVJ &QRRNGT OGCUWTG
OGPVU YJKEJ GORNQ[ VJG &QRRNGT GាGEV VQ CUUGUU YJGVJGT
UVTWEVWTGU WUWCNN[ DNQQF=? CTG OQXKPI VQYCTFU QT CYC[
HTQO VJG RTQDG CPF KVU TGNCVKXG XGNQEKV[ $[ ECNEWNCVKPI
VJG HTGSWGPE[ UJKHV QH C RCTVKEWNCT UCORNG XQNWOG HQT
GZCORNG ីQY KP CP CTVGT[ QT C LGV QH DNQQF ីQY QXGT C
JGCTV XCNXG KVU URGGF CPF FKTGEVKQP ECP DG FGVGTOKPGF
CPF XKUWCNKUGF 6JKU KU RCTVKEWNCTN[ WUGHWN KP ECTFKQXCUEW
NCT UVWFKGU UQPQITCRJ[ QH VJG XCUEWNCT U[UVGO CPF JGCTV
CPF GUUGPVKCN KP OCP[ CTGCU UWEJ CU FGVGTOKPKPI TGXGTUG
DNQQF ីQY KP VJG NKXGT XCUEWNCVWTG KP RQTVCN J[RGTVGPUKQP
6JG &QRRNGT KPHQTOCVKQP KU FKURNC[GF ITCRJKECNN[ WUKPI




$POUSBTU VMUSBTPOPHSBQIZ VMUSBTPVOE DPOUSBTU JNBHJOH


4QFDUSBM %PQQMFS TDBO PG UIF DPNNPO DBSPUJE BSUFSZ


$PMPVS %PQQMFS TDBO PG UIF DPNNPO DBSPUJE BSUFSZ


URGEVTCN &QRRNGT QT CU CP KOCIG WUKPI EQNQT &QRRNGT
FKTGEVKQPCN &QRRNGT QT RQYGT &QRRNGT PQP FKTGEVKQPCN
&QRRNGT 6JKU &QRRNGT UJKHV HCNNU KP VJG CWFKDNG TCPIG
CPF KU QHVGP RTGUGPVGF CWFKDN[ WUKPI UVGTGQ URGCMGTU VJKU
RTQFWEGU C XGT[ FKUVKPEVKXG CNVJQWIJ U[PVJGVKE RWNUCVKPI
UQWPF
#NN OQFGTP WNVTCUQWPF UECPPGTU WUG RWNUGF &QRRNGT VQ
OGCUWTG XGNQEKV[ 2WNUGF YCXG OCEJKPGU VTCPUOKV CPF TG
EGKXG UGTKGU QH RWNUGU 6JG HTGSWGPE[ UJKHV QH GCEJ RWNUG KU
KIPQTGF JQYGXGT VJG TGNCVKXG RJCUG EJCPIGU QH VJG RWNUGU
CTG WUGF VQ QDVCKP VJG HTGSWGPE[ UJKHV UKPEG HTGSWGPE[ KU
VJG TCVG QH EJCPIG QH RJCUG 6JG OCLQT CFXCPVCIGU QH
RWNUGF &QRRNGT QXGT EQPVKPWQWU YCXG KU VJCV FKUVCPEG KP
HQTOCVKQP KU QDVCKPGF VJG VKOG DGVYGGP VJG VTCPUOKVVGF
CPF TGEGKXGF RWNUGU ECP DG EQPXGTVGF KPVQ C FKUVCPEG YKVJ
MPQYNGFIG QH VJG URGGF QH UQWPF CPF ICKP EQTTGEVKQP KU
CRRNKGF 6JG FKUCFXCPVCIG QH RWNUGF &QRRNGT KU VJCV VJG
OGCUWTGOGPVU ECP UWាGT HTQO CNKCUKPI 6JG VGTOKPQNQI[
ན&QRRNGT WNVTCUQWPFཔ QT ན&QRRNGT UQPQITCRJ[པ JCU DGGP
CEEGRVGF VQ CRRN[ VQ DQVJ RWNUGF CPF EQPVKPWQWU &QRRNGT
U[UVGOU FGURKVG VJG FKាGTGPV OGEJCPKUOU D[ YJKEJ VJG
XGNQEKV[ KU OGCUWTGF
+V UJQWNF DG PQVGF JGTG VJCV VJGTG CTG PQ UVCPFCTFU HQT VJG
FKURNC[ QH EQNQT &QRRNGT 5QOG NCDQTCVQTKGU UJQY CTVGT
KGU CU TGF CPF XGKPU CU DNWG CU OGFKECN KNNWUVTCVQTU WUW
CNN[ UJQY VJGO GXGP VJQWIJ UQOG XGUUGNU OC[ JCXG RQT
VKQPU ីQYKPI VQYCTFU CPF RQTVKQPU ីQYKPI CYC[ HTQO VJG


VTCPUFWEGT 6JKU TGUWNVU KP VJG KNNQIKECN CRRGCTCPEG QH C
XGUUGN DGKPI RCTVN[ C XGKP CPF RCTVN[ CP CTVGT[ 1VJGT NCD
QTCVQTKGU WUG TGF VQ KPFKECVG ីQY VQYCTF VJG VTCPUFWEGT
CPF DNWG CYC[ HTQO VJG VTCPUFWEGT 5VKNN QVJGT NCDQTCVQ
TKGU RTGHGT VQ FKURNC[ VJG UQPQITCRJKE &QRRNGT EQNQT OCR
OQTG KP CEEQTF YKVJ VJG RTKQT RWDNKUJGF RJ[UKEU YKVJ VJG
TGF UJKHV TGRTGUGPVKPI NQPIGT YCXGU QH GEJQGU UECVVGTGF
HTQO DNQQF ីQYKPI CYC[ HTQO VJG VTCPUFWEGT CPF YKVJ
DNWG TGRTGUGPVKPI VJG UJQTVGT YCXGU QH GEJQGU TGីGEVKPI
HTQO DNQQF ីQYKPI VQYCTF VJG VTCPUFWEGT $GECWUG QH
VJKU EQPHWUKQP CPF NCEM QH UVCPFCTFU KP VJG XCTKQWU NCDQ
TCVQTKGU VJG UQPQITCRJGT OWUV WPFGTUVCPF VJG WPFGTN[KPI
CEQWUVKE RJ[UKEU QH EQNQT &QRRNGT CPF VJG RJ[UKQNQI[ QH
PQTOCN CPF CDPQTOCN DNQQF ីQY KP VJG JWOCP DQF[ UGG
4GF UJKHV=?=?=?
#NVJQWIJ #PIKQITCRJ[ CPF 8GPQITCRJ[ YJKEJ DQVJ WUG
:TC[ CPF EQPVTCUV KPLGEVKQP OCVGTKCN CTG OQTG CEEW
TCVG VJCP &QRRNGT 5QPQITCRJ[ &QRRNGT 5QPQITCRJ[ OC[
DG EJQUGP DGECWUG KV KU HCUVGT NGUU GZRGPUKXG CPF PQP
KPXCUKXG=?


5.2 Contrast ultrasonography (ultrasound
contrast imaging)


/CKP CTVKENG %QPVTCUVGPJCPEGF WNVTCUQWPF


# EQPVTCUV OGFKWO HQT OGFKECN WNVTCUQPQITCRJ[ KU C HQT
OWNCVKQP QH GPECRUWNCVGF ICUGQWU OKETQDWDDNGU=? VQ KP
ETGCUG GEJQIGPKEKV[ QH DNQQF FKUEQXGTGF D[ &T 4C[
OQPF )TCOKCM KP =? CPF PCOGF EQPVTCUVGPJCPEGF
WNVTCUQWPF 6JKU EQPVTCUV OGFKECN KOCIKPI OQFCNKV[
KU ENKPKECNN[ WUGF VJTQWIJQWV VJG YQTNF=? KP RCTVKEW
NCT HQT GEJQECTFKQITCRJ[ KP VJG 75# CPF HQT WNVTCUQWPF
TCFKQNQI[ KP 'WTQRG CPF #UKC
/KETQDWDDNGUDCUGF EQPVTCUV OGFKC KU CFOKPKUVTCVGF
KPVTCXGPQWUN[ KP RCVKGPV DNQQF UVTGCO FWTKPI VJG OGFK
ECN WNVTCUQPQITCRJ[ GZCOKPCVKQP 6JG OKETQDWDDNGU DG
KPI VQQ NCTIG KP FKCOGVGT VJG[ UVC[ EQPិPGF KP DNQQF
XGUUGNU CPF ECPPQV GZVTCXCUCVG VQYCTFU VJG KPVGTUVKVKCN
ីWKF #P WNVTCUQWPF EQPVTCUV OGFKC KU VJGTGHQTG RWTGN[
KPVTCXCUEWNCT OCMKPI KV CP KFGCN CIGPV VQ KOCIG QTICP
OKETQXCUEWNCTK\CVKQP HQT FKCIPQUVKE RWTRQUGU # V[RKECN
ENKPKECN WUG QH EQPVTCUV WNVTCUQPQITCRJ[ KU FGVGEVKQP QH C
J[RGTXCUEWNCT OGVCUVCVKE VWOQT YJKEJ GZJKDKVU C EQPVTCUV
WRVCMG MKPGVKEU QH OKETQDWDDNGU EQPEGPVTCVKQP KP DNQQF
EKTEWNCVKQP HCUVGT VJCP JGCNVJ[ DKQNQIKECN VKUUWG UWTTQWPF
KPI VJG VWOQT=? 1VJGT ENKPKECN CRRNKECVKQPU WUKPI EQP
VTCUV GZKUV UWEJ CU KP GEJQECTFKQITCRJ[ VQ KORTQXG FGNKP
GCVKQP QH NGHV XGPVTKENG HQT XKUWCNN[ EJGEMKPI EQPVTCEVKDKN
KV[ QH JGCTV CHVGT C O[QECTFKCN KPHCTEVKQP (KPCNN[ CRRNKEC
VKQPU KP SWCPVKVCVKXG RGTHWUKQP=? TGNCVKXG OGCUWTGOGPV
QH DNQQF ីQY =? GOGTIG HQT KFGPVKH[KPI GCTN[ RCVKGPV
TGURQPUG VQ CP CPVKECPEGTQWU FTWI VTGCVOGPV OGVJQFQN
QI[ CPF ENKPKECN UVWF[ D[ &T 0CVJCNKG .CUUCW KP =?
GPCDNKPI VQ FGVGTOKPG VJG DGUV QPEQNQIKECN VJGTCRGWVKE
QRVKQPU=?




&91"/4*0/4


1BSBNFUSJD JNBHJOH PG WBTDVMBS TJHOBUVSFT EJBHSBN


+P QPEQNQIKECN RTCEVKEG QH OGFKECN EQPVTCUV WNVTCUQPQI
TCRJ[ ENKPKEKCPU WUG VJG OGVJQF QH RCTCOGVTKE KOCIKPI
QH XCUEWNCT UKIPCVWTGU=? KPXGPVGF D[ &T 0KEQNCU 4QIPKP
KP =? 6JKU OGVJQF KU EQPEGKXGF CU C ECPEGT CKFGF
FKCIPQUVKE VQQN HCEKNKVCVKPI EJCTCEVGTK\CVKQP QH C UWURK
EKQWU VWOQT OCNKIPCPV XGTUWU DGPKIP KP CP QTICP 6JKU
OGVJQF KU DCUGF QP OGFKECN EQORWVCVKQPCN UEKGPEG =?=?
VQ CPCN[\G C VKOG UGSWGPEG QH WNVTCUQWPF EQPVTCUV KOCIGU
C FKIKVCN XKFGQ TGEQTFGF KP TGCNVKOG FWTKPI RCVKGPV GZ
COKPCVKQP 6YQ EQPUGEWVKXG UKIPCN RTQEGUUKPI UVGRU CTG
CRRNKGF VQ GCEJ RKZGN QH VJG VWOQT


ECNEWNCVKQP QH C XCUEWNCT UKIPCVWTG EQPVTCUV WRVCMG
FKាGTGPEG YKVJ TGURGEV VQ JGCNVJ[ VKUUWG UWTTQWPFKPI
VJG VWOQT


CWVQOCVKE ENCUUKិECVKQP QH VJG XCUEWNCT UKIPCVWTG KPVQ
C WPKSWG RCTCOGVGT VJKU NCUV EQFGF KP QPG QH VJG HQWT
HQNNQYKPI EQNQTU


• ITGGP HQT EQPVKPWQWU J[RGTGPJCPEGOGPV
EQPVTCUV WRVCMG JKIJGT VJCP JGCNVJ[ VKUUWG
QPG


• DNWG HQT EQPVKPWQWU J[RQGPJCPEGOGPV EQP
VTCUV WRVCMG NQYGT VJCP JGCNVJ[ VKUUWG QPG


• TGF HQT HCUV J[RGTGPJCPEGOGPV EQPVTCUV WR
VCMG DGHQTG JGCNVJ[ VKUUWG QPG QT


• [GNNQY HQT HCUV J[RQGPJCPEGOGPV EQPVTCUV
WRVCMG CHVGT JGCNVJ[ VKUUWG QPG


1PEG UKIPCN RTQEGUUKPI KP GCEJ RKZGN EQORNGVGF C EQNQT
URCVKCN OCR QH VJG RCTCOGVGT KU FKURNC[GF QP C EQORWVGT
OQPKVQT UWOOCTK\KPI CNN XCUEWNCT KPHQTOCVKQP QH VJG VW
OQT KP C UKPING KOCIG ECNNGF RCTCOGVTKE KOCIG UGG NCUV
ិIWTG QH RTGUU CTVKENG =? CU ENKPKECN GZCORNGU 6JKU RCTC
OGVTKE KOCIG KU KPVGTRTGVGF D[ ENKPKEKCPU DCUGF QP RTG
FQOKPCPV EQNQTK\CVKQP QH VJG VWOQT TGF KPFKECVGU C UWU
RKEKQP QH OCNKIPCPE[ TKUM QH ECPEGT ITGGP QT [GNNQY ཊ C


JKIJ RTQDCDKNKV[ QH DGPKIPKV[ +P VJG ិTUV ECUG UWURKEKQP
QH OCNKIPCPV VWOQT VJG ENKPKEKCP V[RKECNN[ RTGUETKDGU C
DKQRU[ VQ EQPិTO VJG FKCIPQUVKE QT C %6 UECP GZCOKPC
VKQP CU C UGEQPF QRKPKQP +P VJG UGEQPF ECUG SWCUKEGTVCKP
QH DGPKIP VWOQT QPN[ C HQNNQYWR KU PGGFGF YKVJ C EQP
VTCUV WNVTCUQPQITCRJ[ GZCOKPCVKQP C HGY OQPVJU NCVGT
6JG OCKP ENKPKECN DGPGិVU CTG VQ CXQKF C U[UVGOCVKE DKQRU[
TKUM[ KPXCUKXG RTQEGFWTG QH DGPKIP VWOQTU QT C %6 UECP
GZCOKPCVKQP GZRQUKPI VJG RCVKGPV VQ :TC[ TCFKCVKQP 6JG
RCTCOGVTKE KOCIKPI QH XCUEWNCT UKIPCVWTGU OGVJQF RTQXGF
VQ DG GាGEVKXG KP JWOCPU HQT EJCTCEVGTK\CVKQP QH VWOQTU
KP VJG NKXGT=? +P C ECPEGT UETGGPKPI EQPVGZV VJKU OGVJQF
OKIJV DG RQVGPVKCNN[ CRRNKECDNG VQ QVJGT QTICPU UWEJ CU
DTGCUV=? QT RTQUVCVG


5.3 Molecular ultrasonography (ultra-
sound molecular imaging)


6JG HWVWTG QH EQPVTCUV WNVTCUQPQITCRJ[ KU KP OQNGEWNCT
KOCIKPI YKVJ RQVGPVKCN ENKPKECN CRRNKECVKQPU GZRGEVGF KP
ECPEGT UETGGPKPI VQ FGVGEV OCNKIPCPV VWOQTU CV VJGKT
GCTNKGUV UVCIG QH CRRGCTCPEG /QNGEWNCT WNVTCUQPQITC
RJ[ QT WNVTCUQWPF OQNGEWNCT KOCIKPI WUGU VCTIGVGF OK
ETQDWDDNGU QTKIKPCNN[ FGUKIPGF D[ &T #NGZCPFGT -NKDCPQX
KP =?=? UWEJ VCTIGVGF OKETQDWDDNGU URGEKិECNN[
DKPF QT CFJGTG VQ VWOQTCN OKETQXGUUGNU D[ VCTIGVKPI
DKQOQNGEWNCT ECPEGT GZRTGUUKQP QXGTGZRTGUUKQP QH EGT
VCKP DKQOQNGEWNGU QEEWTU FWTKPI PGQCPIKQIGPGUKU=?=?
QT KPីCOOCVKQP=? RTQEGUUGU KP OCNKIPCPV VWOQTU #U C
TGUWNV C HGY OKPWVGU CHVGT VJGKT KPLGEVKQP KP DNQQF EKT
EWNCVKQP VJG VCTIGVGF OKETQDWDDNGU CEEWOWNCVG KP VJG
OCNKIPCPV VWOQT HCEKNKVCVKPI KVU NQECNK\CVKQP KP C WPKSWG
WNVTCUQWPF EQPVTCUV KOCIG +P VJG XGT[ ិTUV GZ
RNQTCVQT[ ENKPKECN VTKCN KP JWOCPU HQT RTQUVCVG ECPEGT YCU
EQORNGVGF CV #OUVGTFCO KP VJG 0GVJGTNCPFU D[ &T *GUUGN
9KLMUVTC=?


+P OQNGEWNCT WNVTCUQPQITCRJ[ VJG VGEJPKSWG QH CEQWUVKE
TCFKCVKQP HQTEG CNUQ WUGF HQT UJGCT YCXG GNCUVQITCRJ[ KU
CRRNKGF KP QTFGT VQ NKVGTCNN[ RWUJ VJG VCTIGVGF OKETQDWD
DNGU VQYCTFU OKETQXGUUGNU YCNN ិTUVN[ FGOQPUVTCVGF D[ &T
2CWN &C[VQP KP =? 6JKU CNNQYU VQ OCZKOK\G DKPFKPI
VQ VJG OCNKIPCPV VWOQT VJG VCTIGVGF OKETQDWDDNGU DGKPI
KP OQTG FKTGEV EQPVCEV YKVJ ECPEGTQWU DKQOQNGEWNGU GZ
RTGUUGF CV VJG KPPGT UWTHCEG QH VWOQTCN OKETQXGUUGNU #V
VJG UVCIG QH UEKGPVKិE RTGENKPKECN TGUGCTEJ VJG VGEJPKSWG
QH CEQWUVKE TCFKCVKQP HQTEG YCU KORNGOGPVGF CU C RTQVQ
V[RG KP ENKPKECN WNVTCUQWPF U[UVGOU CPF XCNKFCVGF JO WJWP
KP &=? CPF &=?=? KOCIKPI OQFGU


5.4 Elastography (ultrasound elasticity
imaging)


/CKP CTVKENG 'NCUVQITCRJ[


7NVTCUQWPF KU CNUQ WUGF HQT GNCUVQITCRJ[ YJKEJ KU C TGNC




8FBLOFTTFT


VKXGN[ PGY KOCIKPI OQFCNKV[ VJCV OCRU VJG GNCUVKE RTQRGT
VKGU QH UQHV VKUUWG=?=? 6JKU OQFCNKV[ GOGTIGF KP VJG NCUV
VYQ FGECFGU 'NCUVQITCRJ[ KU WUGHWN KP OGFKECN FKCIPQUGU
CU KV ECP FKUEGTP JGCNVJ[ HTQO WPJGCNVJ[ VKUUWG HQT URGEKិE
QTICPUITQYVJU (QT GZCORNG ECPEGTQWU VWOQTU YKNN QH
VGP DG JCTFGT VJCP VJG UWTTQWPFKPI VKUUWG CPF FKUGCUGF
NKXGTU CTG UVKាGT VJCP JGCNVJ[ QPGU=?=?=?=?


6JGTG CTG OCP[ WNVTCUQWPF GNCUVQITCRJ[ VGEJPKSWGU=?
6JG OQUV RTQOKPGPV CTG 3WCUKUVCVKE 'NCUVQITCRJ[5VTCKP
+OCIKPI 5JGCT 9CXG 'NCUVKEKV[ +OCIKPI 59'+ 5WRGT
UQPKE 5JGCT +OCIKPI 55+ #EQWUVKE 4CFKCVKQP (QTEG +O
RWNUG KOCIKPI #4(+ CPF 6TCPUKGPV 'NCUVQITCRJ[ 6JG
UVGCFKN[ ITQYKPI ENKPKECN WUG QH WNVTCUQWPF GNCUVQITCRJ[
KU C TGUWNV QH VJG KORNGOGPVCVKQP QH VGEJPQNQI[ KP ENKPKECN
WNVTCUQWPF OCEJKPGU %WTTGPVN[ CP KPETGCUG QH CEVKXKVKGU
KP VJG ិGNF QH GNCUVQITCRJ[ KU QDUGTXGF FGOQPUVTCVKPI UWE
EGUUHWN CRRNKECVKQP QH VJG VGEJPQNQI[ KP XCTKQWU CTGCU QH
OGFKECN FKCIPQUVKEU CPF VTGCVOGPV OQPKVQTKPI


5.5 Compression ultrasonography


%QORTGUUKQP WNVTCUQPQITCRJ[ KU C UKORNKិGF VGEJPKSWG
WUGF HQT SWKEM FGGR XGKP VJTQODQUKU FKCIPQUKU 6JG
GZCOKPCVKQP KU NKOKVGF VQ EQOOQP HGOQTCN XGKP CPF
RQRNKVGCN XGKP QPN[ KPUVGCF VQ URGPF VKOG RGTHQTOKPI VJG
HWNN GZCOKPCVKQP NQYGT NKODU XGPQWU WNVTCUQPQITCRJ[ +V
KU RGTHQTOGF WUKPI QPN[ QPG VGUV XGKP EQORTGUUKQP=?


%QORTGUUKQP WNVTCUQPQITCRJ[ JCU DQVJ JKIJ UGPUKVKXKV[
CPF URGEKិEKV[ HQT FGVGEVKPI RTQZKOCN FGGR XGKP VJTQODQ
UKU QPN[ KP U[ORVQOCVKE RCVKGPVU 4GUWNVU CTG PQV TGNKCDNG
YJGP VJG RCVKGPV KU U[ORVQONGUU CPF OWUV DG EJGEMGF
HQT GZCORNG KP JKIJ TKUM RQUVQRGTCVKXG RCVKGPVU OCKPN[ KP
QTVJQRGFKE RCVKGPVU=?=?


6 Attributes


#U YKVJ CNN KOCIKPI OQFCNKVKGU WNVTCUQPQITCRJ[ JCU KVU
NKUV QH RQUKVKXG CPF PGICVKXG CVVTKDWVGU


6.1 Strengths


• +V KOCIGU OWUENG UQHV VKUUWG CPF DQPG UWTHCEGU XGT[
YGNN CPF KU RCTVKEWNCTN[ WUGHWN HQT FGNKPGCVKPI VJG KP
VGTHCEGU DGVYGGP UQNKF CPF ីWKFិNNGF URCEGU


• +V TGPFGTU ནNKXGཔ KOCIGU YJGTG VJG QRGTCVQT ECP F[
PCOKECNN[ UGNGEV VJG OQUV WUGHWN UGEVKQP HQT FKCIPQU
KPI CPF FQEWOGPVKPI EJCPIGU QHVGP GPCDNKPI TCRKF
FKCIPQUGU .KXG KOCIGU CNUQ CNNQY HQT WNVTCUQWPF
IWKFGF DKQRUKGU QT KPLGEVKQPU YJKEJ ECP DG EWODGT
UQOG YKVJ QVJGT KOCIKPI OQFCNKVKGU


• +V UJQYU VJG UVTWEVWTG QH QTICPU


• +V JCU PQ MPQYP NQPIVGTO UKFG GាGEVU CPF TCTGN[
ECWUGU CP[ FKUEQOHQTV VQ VJG RCVKGPV


• 'SWKROGPV KU YKFGN[ CXCKNCDNG CPF EQORCTCVKXGN[
ីGZKDNG


• 5OCNN GCUKN[ ECTTKGF UECPPGTU CTG CXCKNCDNG GZCOK
PCVKQPU ECP DG RGTHQTOGF CV VJG DGFUKFG


• 4GNCVKXGN[ KPGZRGPUKXG EQORCTGF VQ QVJGT OQFGU QH
KPXGUVKICVKQP UWEJ CU EQORWVGF :TC[ VQOQITCRJ[
&':# QT OCIPGVKE TGUQPCPEG KOCIKPI


• 5RCVKCN TGUQNWVKQP KU DGVVGT KP JKIJ HTGSWGPE[ WNVTC
UQWPF VTCPUFWEGTU VJCP KV KU KP OQUV QVJGT KOCIKPI
OQFCNKVKGU


• 6JTQWIJ VJG WUG QH CP7NVTCUQWPF TGUGCTEJ KPVGTHCEG
CP WNVTCUQWPF FGXKEG ECP QាGT C TGNCVKXGN[ KPGZRGP
UKXG TGCNVKOG CPF ីGZKDNG OGVJQF HQT ECRVWTKPI
FCVC TGSWKTGF HQT URGEKCN TGUGCTEJ RWTRQUGU HQT VKU
UWG EJCTCEVGTK\CVKQP CPF FGXGNQROGPV QH PGY KOCIG
RTQEGUUKPI VGEJPKSWGU


6.2 Weaknesses


%PVCMF BPSU BSUJGBDU JO TPOPHSBQIZ EVF UP EJઢFSFODF JO WFMPDJUZ
PG TPVOE XBWFT JO NVTDMF BOE GBU


• 5QPQITCRJKE FGXKEGU JCXG VTQWDNG RGPGVTCVKPI DQPG
(QT GZCORNG UQPQITCRJ[ QH VJG CFWNV DTCKP KU XGT[
NKOKVGF VJQWIJ KORTQXGOGPVU CTG DGKPI OCFG KP
VTCPUETCPKCN WNVTCUQPQITCRJ[


• 5QPQITCRJ[ RGTHQTOU XGT[ RQQTN[ YJGP VJGTG KU C
ICU DGVYGGP VJG VTCPUFWEGT CPF VJG QTICP QH KP
VGTGUV FWG VQ VJG GZVTGOG FKាGTGPEGU KP CEQWUVKE
KORGFCPEG (QT GZCORNG QXGTN[KPI ICU KP VJG ICU
VTQKPVGUVKPCN VTCEV QHVGP OCMGU WNVTCUQWPF UECPPKPI
QH VJG RCPETGCU FKឹEWNV CPF NWPI KOCIKPI KU PQV
RQUUKDNG CRCTV HTQO FGOCTECVKPI RNGWTCN GាWUKQPU


• 'XGP KP VJG CDUGPEG QH DQPG QT CKT VJG FGRVJ RGP
GVTCVKQP QH WNVTCUQWPF OC[ DG NKOKVGF FGRGPFKPI
QP VJG HTGSWGPE[ QH KOCIKPI %QPUGSWGPVN[ VJGTG
OKIJV DG FKឹEWNVKGU KOCIKPI UVTWEVWTGU FGGR KP VJG
DQF[ GURGEKCNN[ KP QDGUG RCVKGPVU




0#45&53*$ 6-53"406/%


• 2J[UKSWG JCU C NCTIG KPីWGPEG QP KOCIG SWCNKV[ +O
CIG SWCNKV[ CPF CEEWTCE[ QH FKCIPQUKU KU NKOKVGF YKVJ
QDGUG RCVKGPVU QXGTN[KPI UWDEWVCPGQWU HCV CVVGPWCVGU
VJG UQWPF DGCO CPF C NQYGT HTGSWGPE[ VTCPUFWEGT KU
TGSWKTGF YKVJ NQYGT TGUQNWVKQP


• 6JG OGVJQF KU QRGTCVQTFGRGPFGPV # JKIJ NGXGN
QH UMKNN CPF GZRGTKGPEG KU PGGFGF VQ CESWKTG IQQF
SWCNKV[ KOCIGU CPF OCMG CEEWTCVG FKCIPQUGU


• 6JGTG KU PQ UEQWV KOCIG CU VJGTG KU YKVJ %6 CPF/4+
1PEG CP KOCIG JCU DGGP CESWKTGF VJGTG KU PQ GZCEV
YC[ VQ VGNN YJKEJ RCTV QH VJG DQF[ YCU KOCIGF


7 Risks and side-effects


7NVTCUQPQITCRJ[ KU IGPGTCNN[ EQPUKFGTGF C UCHG KOCIKPI
OQFCNKV[=?


&KCIPQUVKE WNVTCUQWPF UVWFKGU QH VJG HGVWU CTG IGPGTCNN[
EQPUKFGTGF VQ DG UCHG FWTKPI RTGIPCPE[ 6JKU FKCIPQUVKE
RTQEGFWTG UJQWNF DG RGTHQTOGF QPN[ YJGP VJGTG KU C XCNKF
OGFKECN KPFKECVKQP CPF VJG NQYGUV RQUUKDNG WNVTCUQPKE GZ
RQUWTG UGVVKPI UJQWNF DG WUGF VQ ICKP VJG PGEGUUCT[ FKCI
PQUVKE KPHQTOCVKQP WPFGT VJG ནCU NQY CU TGCUQPCDN[ RTCE
VKECDNGཔ QT #.#42 RTKPEKRNG
9QTNF *GCNVJ 1TICPK\CVKQPU VGEJPKECN TGRQTV UGTKGU
=? UWRRQTVU VJCV WNVTCUQWPF KU JCTONGUU ན&KCI
PQUVKE WNVTCUQWPF KU TGEQIPK\GF CU C UCHG GាGEVKXG CPF
JKIJN[ ីGZKDNG KOCIKPI OQFCNKV[ ECRCDNG QH RTQXKFKPI
ENKPKECNN[ TGNGXCPV KPHQTOCVKQP CDQWV OQUV RCTVU QH VJG
DQF[ KP C TCRKF CPF EQUVGាGEVKXG HCUJKQPཔ #NVJQWIJ
VJGTG KU PQ GXKFGPEG WNVTCUQWPF EQWNF DG JCTOHWN HQT VJG
HGVWU 75 (QQF CPF &TWI #FOKPKUVTCVKQP XKGYU RTQOQ
VKQP UGNNKPI QT NGCUKPI QH WNVTCUQWPF GSWKROGPV HQT OCM
KPI ནMGGRUCMG HGVCN XKFGQUཔ VQ DG CP WPCRRTQXGF WUG QH C
OGFKECN FGXKEG
/GFKECN WNVTCUQPQITCRJ[ UJQWNF PQV DG RGTHQTOGF YKVJ
QWV C OGFKECN KPFKECVKQP VQ RGTHQTO KV 6Q FQ QVJGT
YKUG YQWNF DG VQ RGTHQTO WPPGEGUUCT[ JGCNVJ ECTG VQ RC
VKGPVU YJKEJ DTKPI WPYCTTCPVGF EQUVU CPF OC[ NGCF VQ
QVJGT VGUVKPI 1XGTWUG QH WNVTCUQPQITCRJ[ KU TGRQTVGF
KP VJG 7PKVGF 5VCVGU GURGEKCNN[ CU TQWVKPG UETGGPKPI HQT
FGGR XGKP VJTQODQUKU CHVGT QTVJQRGFKE UWTIGTKGU KP RC
VKGPVU YJQ CTG PQV CV JGKIJVGPGF TKUM HQT JCXKPI VJCV
EQPFKVKQP=?


7.1 Studies on the safety of ultrasound


• # OGVCCPCN[UKU QH UGXGTCN WNVTCUQPQITCRJ[ UVWF
KGU RWDNKUJGF KP HQWPF PQ UVCVKUVKECNN[ UKIPKិ
ECPV JCTOHWN GាGEVU HTQO WNVTCUQPQITCRJ[ DWV OGP
VKQPGF VJCV VJGTG YCU C NCEM QH FCVC QP NQPIVGTO UWD
UVCPVKXG QWVEQOGU UWEJ CU PGWTQFGXGNQROGPV=?


• # UVWF[ CV VJG ;CNG 5EJQQN QH /GFKEKPG RWDNKUJGF
KP HQWPF C UOCNN DWV UKIPKិECPV EQTTGNCVKQP DG


VYGGP RTQNQPIGF CPF HTGSWGPV WUG QH WNVTCUQWPF CPF
CDPQTOCN PGWTQPCN OKITCVKQP KP OKEG=?


• # UVWF[ RGTHQTOGF KP 5YGFGP KP =? JCU UJQYP
VJCV UWDVNG GាGEVU QH PGWTQNQIKECN FCOCIG NKPMGF
VQ WNVTCUQWPF YGTG KORNKECVGF D[ CP KPETGCUGF KP
EKFGPEG KP NGHVJCPFGFPGUU KP DQ[U C OCTMGT HQT
DTCKP RTQDNGOU YJGP PQV JGTGFKVCT[ CPF URGGEJ
FGNC[U=?=?


• 6JG CDQXG ិPFKPIU JQYGXGT YGTG PQV EQP
ិTOGF KP C NCVGT HQNNQYWR UVWF[=?


• # NCVGT UVWF[ JQYGXGT RGTHQTOGF QP C NCTIGT
UCORNG QH EJKNFTGP JCU GUVCDNKUJGF C
UVCVKUVKECNN[ UKIPKិECPV CNDGKV YGCM CUUQEK
CVKQP QH WNVTCUQPQITCRJ[ GZRQUWTG CPF DG
KPI PQPTKIJV JCPFGF NCVGT KP NKHG=? 5GG
*CPFGFPGUU7NVTCUQWPF


8 Obstetric ultrasound


/CKP CTVKENG 1DUVGVTKE WNVTCUQPQITCRJ[


1DUVGVTKE WNVTCUQWPF ECP DG WUGF VQ KFGPVKH[ OCP[ EQPFK
VKQPU VJCV YQWNF DG JCTOHWN VQ VJG OQVJGT CPF VJG DCD[
/CP[ JGCNVJ ECTG RTQHGUUKQPCNU EQPUKFGT VJG TKUM QH NGCX
KPI VJGUG EQPFKVKQPU WPFKCIPQUGF VQ DG OWEJ ITGCVGT VJCP
VJG XGT[ UOCNN TKUM KH CP[ CUUQEKCVGF YKVJ WPFGTIQKPI CP
WNVTCUQWPF UECP
5QPQITCRJ[ KU WUGF TQWVKPGN[ KP QDUVGVTKE CRRQKPVOGPVU
FWTKPI RTGIPCPE[ DWV VJG (&# FKUEQWTCIGU KVU WUG HQT
PQPOGFKECN RWTRQUGU UWEJ CU HGVCN MGGRUCMG XKFGQU CPF
RJQVQU GXGP VJQWIJ KV KU VJG UCOG VGEJPQNQI[ WUGF KP
JQURKVCNU=?


1DUVGVTKE WNVTCUQWPF KU RTKOCTKN[ WUGF VQ


• &CVG VJG RTGIPCPE[ IGUVCVKQPCN CIG


• %QPិTO HGVCN XKCDKNKV[


• &GVGTOKPG NQECVKQP QH HGVWU KPVTCWVGTKPG XU GEVQRKE


• %JGEM VJG NQECVKQP QH VJG RNCEGPVC KP TGNCVKQP VQ VJG
EGTXKZ


• %JGEM HQT VJG PWODGT QH HGVWUGU OWNVKRNG RTGI
PCPE[


• %JGEM HQT OCLQT RJ[UKECN CDPQTOCNKVKGU


• #UUGUU HGVCN ITQYVJ HQT GXKFGPEG QH KPVTCWVGTKPG
ITQYVJ TGUVTKEVKQP +7)4


• %JGEM HQT HGVCN OQXGOGPV CPF JGCTVDGCV


• &GVGTOKPG VJG UGZ QH VJG DCD[




+VU TGUWNVU CTG QEECUKQPCNN[ KPEQTTGEV RTQFWEKPI C HCNUG
RQUKVKXG VJG %QEJTCPG %QNNCDQTCVKQP KU C TGNGXCPV GាQTV
VQ KORTQXG VJG TGNKCDKNKV[ QH JGCNVJ ECTG VTKCNU (CNUG FG
VGEVKQP OC[ TGUWNV KP RCVKGPVU DGKPI YCTPGF QH DKTVJ FG
HGEVU YJGP PQ UWEJ FGHGEV GZKUVU 5GZ FGVGTOKPCVKQP KU
QPN[ CEEWTCVG CHVGT YGGMU IGUVCVKQP 9JGP DCNCPE
KPI TKUM CPF TGYCTF VJGTG CTG TGEQOOGPFCVKQPU VQ CXQKF
VJG WUG QH TQWVKPG WNVTCUQWPF HQT NQY TKUM RTGIPCPEKGU +P
OCP[ EQWPVTKGU WNVTCUQWPF KU WUGF TQWVKPGN[ KP VJG OCP
CIGOGPV QH CNN RTGIPCPEKGU
#EEQTFKPI VQ VJG 'WTQRGCP %QOOKVVGG QH /GFKECN 7NVTC
UQWPF 5CHGV[ '%/75=?


7NVTCUQPKE GZCOKPCVKQPU UJQWNF QPN[ DG
RGTHQTOGF D[ EQORGVGPV RGTUQPPGN YJQ CTG
VTCKPGF CPF WRFCVGF KP UCHGV[ OCVVGTU 7NVTC
UQWPF RTQFWEGU JGCVKPI RTGUUWTG EJCPIGU CPF
OGEJCPKECN FKUVWTDCPEGU KP VKUUWG &KCIPQUVKE
NGXGNU QH WNVTCUQWPF ECP RTQFWEG VGORGTCVWTG
TKUGU VJCV CTG JC\CTFQWU VQ UGPUKVKXG QTICPU CPF
VJG GODT[QHGVWU $KQNQIKECN GាGEVU QH PQP
VJGTOCN QTKIKP JCXG DGGP TGRQTVGF KP CPKOCNU
DWV VQ FCVG PQ UWEJ GាGEVU JCXG DGGP FGOQP
UVTCVGF KP JWOCPU GZEGRV YJGP C OKETQDWDDNG
EQPVTCUV CIGPV KU RTGUGPV


0QPGVJGNGUU ECTG UJQWNF DG VCMGP VQ WUG NQY RQYGT UGV
VKPIU CPF CXQKF RWNUGF YCXG UECPPKPI QH VJG HGVCN DTCKP
WPNGUU URGEKិECNN[ KPFKECVGF KP JKIJ TKUM RTGIPCPEKGU
7NVTCUQWPF UECPPGTU JCXG FKាGTGPV &QRRNGTVGEJPKSWGU
VQ XKUWCNK\G CTVGTKGU CPF XGKPU 6JG OQUV EQOOQP KU
EQNQWT FQRRNGT QT RQYGT FQRRNGT DWV CNUQ QVJGT VGEJ
PKSWGU NKMG DីQY CTG WUGF VQ UJQY DNQQFីQY KP CP QT
ICP $[ WUKPI RWNUGF YCXG FQRRNGT QT EQPVKPWQWU YCXG
FQRRNGT DNQQFីQY XGNQEKVKGU ECP DG ECNEWNCVGF
(KIWTGU TGNGCUGF HQT VJG RGTKQF ཊ D[ VJG 7-
)QXGTPOGPV &GRCTVOGPV QH *GCNVJ UJQY VJCV PQP
QDUVGVTKE WNVTCUQWPF GZCOKPCVKQPU EQPUVKVWVGF OQTG VJCP
QH VJG VQVCN PWODGT QH WNVTCUQWPF UECPU EQPFWEVGF


8.1 Society and Culture


4GEGPV UVWFKGU JCXG UVTGUUGF VJG KORQTVCPEG QH HTCO
KPI ནTGRTQFWEVKXG JGCNVJ OCVVGTU ETQUUEWNVWTCNN[པ RCT
VKEWNCTN[ YJGP WPFGTUVCPFKPI VJG ནPGY RJGPQOGPQPཔ QH
ནVJG RTQNKHGTCVKQP QH WNVTCUQWPF KOCIKPIཔ KP FGXGNQRKPI
EQWPVTKGU=? +P 6KPG )COOGNVQHV KPVGTXKGYGF
YQOGP KP *CPQKཐU 1DUVGVTKEU CPF )[PGEQNQI[ *QURKVCN
GCEJ ནJCF CP CXGTCIG QH UECPU FWTKPI JGT RTGIPCPE[པ
OWEJ JKIJGT VJCP ិXG [GCTU CIQ YJGP ནC RTGIPCPV YQOCP
OKIJV QT OKIJV PQV JCXG JCF C UKPING UECP FWTKPI JGT RTGI
PCPE[པ KP 8KGVPCO=? )COOGNVQHV GZRNCKPU VJCV ནOCP[
#UKCP EQWPVTKGUཔ UGG ནVJG HQGVWU CU CP CODKIWQWU DG
KPIཔ WPNKMG KP 9GUVGTP OGFKEKPG YJGTG KV KU EQOOQP VQ
VJKPM QH VJG HQGVWU CU ནOCVGTKCNN[ UVCDNGཔ=? 6JGTGHQTG
CNVJQWIJ YQOGP RCTVKEWNCTN[ KP #UKCP EQWPVTKGU ནGZRTGUU


KPVGPUG WPEGTVCKPVKGU TGICTFKPI VJG UCHGV[ CPF ETGFKDKN
KV[ QH VJKU VGEJPQNQI[པ KV KU QXGTWUGF HQT KVU ནKOOGFKCVG
TGCUUWTCPEGཔ=?


9 Regulation


&KCIPQUVKE CPF VJGTCRGWVKE WNVTCUQWPF GSWKROGPV KU TGI
WNCVGF KP VJG 75# D[ VJG (QQF CPF &TWI #FOKPKUVTCVKQP
CPF YQTNFYKFG D[ QVJGT PCVKQPCN TGIWNCVQT[ CIGPEKGU 6JG
(&# NKOKVU CEQWUVKE QWVRWV WUKPI UGXGTCN OGVTKEU IGP
GTCNN[ QVJGT CIGPEKGU CEEGRV VJG (&#GUVCDNKUJGF IWKFG
NKPGU
%WTTGPVN[ 0GY /GZKEQ KU VJG QPN[ 75 UVCVG YJKEJ TGIW
NCVGU FKCIPQUVKE OGFKECN UQPQITCRJGTU %GTVKិECVKQP GZ
COKPCVKQPU HQT UQPQITCRJGTU CTG CXCKNCDNG KP VJG 75 HTQO
VJTGG QTICPK\CVKQPU VJG #OGTKECP 4GIKUVT[ HQT &KCI
PQUVKE /GFKECN 5QPQITCRJ[ %CTFKQXCUEWNCT %TGFGPVKCN
KPI +PVGTPCVKQPCN CPF VJG #OGTKECP 4GIKUVT[ QH 4CFKQ
NQIKE 6GEJPQNQIKUVU
6JG RTKOCT[ TGIWNCVGF OGVTKEU CTG /GEJCPKECN +PFGZ
/+ C OGVTKE CUUQEKCVGF YKVJ VJG ECXKVCVKQP DKQGាGEV
CPF 6JGTOCN +PFGZ 6+ C OGVTKE CUUQEKCVGF YKVJ VJG VKU
UWG JGCVKPI DKQGាGEV 6JG (&# TGSWKTGU VJCV VJG OC
EJKPG PQV GZEGGF GUVCDNKUJGF NKOKVU YJKEJ CTG TGCUQPCDN[
EQPUGTXCVKXG UQ CU VQ OCKPVCKP FKCIPQUVKE WNVTCUQWPF CU C
UCHG KOCIKPI OQFCNKV[ 6JKU TGSWKTGU UGNHTGIWNCVKQP QP
VJG RCTV QH VJG OCPWHCEVWTGT KP VGTOU QH VJG OCEJKPGཐU
ECNKDTCVKQP=?


7NVTCUQWPFDCUGF RTGPCVCN ECTG CPF UGZ UETGGPKPI VGEJ
PQNQIKGU YGTG NCWPEJGF KP +PFKC KP VJG U 9KVJ EQP
EGTPU CDQWV KVU OKUWUG HQT UGZUGNGEVKXG CDQTVKQP VJG )QX
GTPOGPV QH +PFKC RCUUGF VJG 2TGPCVCN &KCIPQUVKE 6GEJ
PKSWGU #EV 20&6 KP VQ TGIWNCVG NGICN CPF KNNG
ICN WUGU QH WNVTCUQWPF GSWKROGPV=? 6JG NCY YCU HWT
VJGT COGPFGF KPVQ VJG 2TG%QPEGRVKQP CPF 2TGPCVCN &K
CIPQUVKE 6GEJPKSWGU 4GIWNCVKQP CPF 2TGXGPVKQP QH /KU
WUG 2%20&6 #EV KP VQ FGVGT CPF RWPKUJ RTGPCVCN
UGZ UETGGPKPI CPF UGZ UGNGEVKXG CDQTVKQP=? +V KU EWTTGPVN[
KNNGICN CPF C RWPKUJCDNG ETKOG KP +PFKC VQ FGVGTOKPG QT FKU
ENQUG VJG UGZ QH C HGVWU WUKPI WNVTCUQWPF GSWKROGPV=?


10 History


7NVTCUQPKE GPGTI[ YCU ិTUV CRRNKGF VQ VJG JWOCP DQF[
HQT OGFKECN RWTRQUGU D[ &T )GQTIG .WFYKI CV VJG
0CXCN /GFKECN 4GUGCTEJ +PUVKVWVG $GVJGUFC /CT[NCPF KP
VJG NCVG U=?=? 'PINKUJDQTP RJ[UKEKUV ,QJP 9KNF
ཊ ិTUV WUGF WNVTCUQWPF VQ CUUGUU VJG VJKEM
PGUU QH DQYGN VKUUWG CU GCTN[ CU JG JCU DGGP FG
UETKDGF CU VJG ནHCVJGT QH OGFKECN WNVTCUQWPFཔ=? 5WDUG
SWGPV CFXCPEGU KP VJG ិGNF VQQM RNCEG EQPEWTTGPVN[ KP UGX
GTCN EQWPVTKGU




3&'&3&/$&4


10.1 France


+P JKU DQQM ན.KPXGUVKICVKQP XCUEWNCKTG RCT WNVTCUQPQ
ITCRJKG &QRRNGTཔ 'F /CUUQP =? &T %NCWFG
(TCPEGUEJK NCKF FQYP VJG &QRRNGT 7NVTCUQWPF HWPFCOGP
VCNU QH VJG JGOQF[PCOKEU UGOKQVKEU YJKEJ CTG UVKNN KP WUG
KP EWTTGPV &QRRNGT CTVGTKCN CPF XGPQWU &WRNGZ 7NVTCUQWPF
KPXGUVKICVKQPU


10.2 Scotland


2CTCNNGN FGXGNQROGPVU KP )NCUIQY 5EQVNCPF D[ 2TQHGU
UQT +CP &QPCNF CPF EQNNGCIWGU CV VJG )NCUIQY 4Q[CN /C
VGTPKV[ *QURKVCN )4/* NGF VQ VJG ិTUV FKCIPQUVKE CR
RNKECVKQPU QH VJG VGEJPKSWG &QPCNF YCU CP QDUVGVTKEKCP
YKVJ C UGNHEQPHGUUGF ནEJKNFKUJ KPVGTGUV KP OCEJKPGU GNGE
VTQPKE CPF QVJGTYKUGཔ YJQ JCXKPI VTGCVGF VJG YKHG QH QPG
QH VJG EQORCP[ཐU FKTGEVQTU YCU KPXKVGF VQ XKUKV VJG 4G
UGCTEJ &GRCTVOGPV QH DQKNGTOCMGTU $CDEQEM9KNEQZ CV
4GPHTGY YJGTG JG WUGF VJGKT KPFWUVTKCN WNVTCUQWPF GSWKR
OGPV VQ EQPFWEV GZRGTKOGPVU QP XCTKQWU OQTDKF CPCVQO
KECN URGEKOGPU CPF CUUGUU VJGKT WNVTCUQPKE EJCTCEVGTKUVKEU
6QIGVJGT YKVJ VJG OGFKECN RJ[UKEKUV 6QO $TQYP CPF HGN
NQY QDUVGVTKEKCP &T ,QJP /CE8KECT &QPCNF TGិPGF VJG
GSWKROGPV VQ GPCDNG FKាGTGPVKCVKQP QH RCVJQNQI[ KP NKXG
XQNWPVGGT RCVKGPVU 6JGUG ិPFKPIU YGTG TGRQTVGF KP 5IF
-BODFU QP ,WPG =? CU ན+PXGUVKICVKQP QH #DFQOKPCN
/CUUGU D[ 2WNUGF 7NVTCUQWPFཔ ཊ RQUUKDN[ QPG QH VJG OQUV
KORQTVCPV RCRGTU GXGT RWDNKUJGF KP VJG ិGNF QH FKCIPQUVKE
OGFKECN KOCIKPI
#V )4/* 2TQHGUUQT &QPCNF CPF &T ,COGU 9KNNQEMU
VJGP TGិPGF VJGKT VGEJPKSWGU VQ QDUVGVTKE CRRNKECVKQPU KP
ENWFKPI HGVCN JGCF OGCUWTGOGPV VQ CUUGUU VJG UK\G CPF
ITQYVJ QH VJG HGVWU 9KVJ VJG QRGPKPI QH VJG PGY 3WGGP
/QVJGTཐU *QURKVCN KP ;QTMJKNN KP KV DGECOG RQUUKDNG
VQ KORTQXG VJGUG OGVJQFU GXGP HWTVJGT &T 5VWCTV %COR
DGNNU RKQPGGTKPI YQTM QP HGVCN EGRJCNQOGVT[ NGF VQ KV CE
SWKTKPI NQPIVGTO UVCVWU CU VJG FGិPKVKXG OGVJQF QH UVWF[
QH HQGVCN ITQYVJ #U VJG VGEJPKECN SWCNKV[ QH VJG UECPU YCU
HWTVJGT FGXGNQRGF KV UQQP DGECOG RQUUKDNG VQ UVWF[ RTGI
PCPE[ HTQO UVCTV VQ ិPKUJ CPF FKCIPQUG KVU OCP[ EQORNK
ECVKQPU UWEJ CU OWNVKRNG RTGIPCPE[ HGVCN CDPQTOCNKV[ CPF
QMBDFOUB QSBFWJB &KCIPQUVKE WNVTCUQWPF JCU UKPEG DGGP
KORQTVGF KPVQ RTCEVKECNN[ GXGT[ QVJGT CTGC QH OGFKEKPG


10.3 Sweden


/GFKECN WNVTCUQPQITCRJ[ YCU WUGF KP CV .WPF 7PK
XGTUKV[ D[ ECTFKQNQIKUV +PIG 'FNGT CPF %CTN *GNNOWVJ
*GTV\ VJG UQP QH )WUVCX .WFYKI *GTV\ YJQ YCU C ITCF
WCVG UVWFGPV CV VJG FGRCTVOGPV QH PWENGCT RJ[UKEU
'FNGT JCF CUMGF *GTV\ KH KV YCU RQUUKDNG VQ WUG TCFCT VQ
NQQM KPVQ VJG DQF[ DWV *GTV\ UCKF VJKU YCU KORQUUKDNG
*QYGXGT JG UCKF KV OKIJV DG RQUUKDNG VQ WUG WNVTCUQPQI
TCRJ[ *GTV\ YCU HCOKNKCT YKVJ WUKPI WNVTCUQPKE TGីGEVQ
UEQRGU HQT PQPFGUVTWEVKXG OCVGTKCNU VGUVKPI CPF VQIGVJGT


VJG[ FGXGNQRGF VJG KFGC QH WUKPI VJKU OGVJQF KP OGFKEKPG
6JG ិTUV UWEEGUUHWN OGCUWTGOGPV QH JGCTV CEVKXKV[ YCU
OCFG QP 1EVQDGT WUKPI C FGXKEG DQTTQYGF
HTQO VJG UJKR EQPUVTWEVKQP EQORCP[ -QEMWOU KP /CNO·
1P &GEGODGT VJG UCOG [GCT VJG OGVJQF YCU WUGF
VQ IGPGTCVG CP GEJQGPEGRJCNQITCO WNVTCUQPKE RTQDG QH
VJG DTCKP 'FNGT CPF *GTV\ RWDNKUJGF VJGKT ិPFKPIU KP
=?


10.4 United States


+P CHVGT CDQWV VYQ [GCTU QH YQTM ,QUGRJ *QNOGU
9KNNKCO9TKIJV CPF 4CNRJ/G[GTFKTM FGXGNQRGF VJG ិTUV
EQORQWPF EQPVCEV $OQFG UECPPGT 6JGKT YQTM JCF
DGGP UWRRQTVGF D[ 75 2WDNKE *GCNVJ 5GTXKEGU CPF VJG
7PKXGTUKV[ QH %QNQTCFQ 9TKIJV CPF /G[GTFKTM NGHV VJG
7PKXGTUKV[ VQ HQTO 2J[UKQPKE 'PIKPGGTKPI +PE YJKEJ
NCWPEJGF VJG ិTUV EQOOGTEKCN JCPFJGNF CTVKEWNCVGF CTO
EQORQWPF EQPVCEV $OQFG UECPPGT KP 6JKU YCU
VJG UVCTV QH VJG OQUV RQRWNCT FGUKIP KP VJG JKUVQT[ QH WN
VTCUQWPF UECPPGTU=?


+P VJG NCVG U &T )GPG 5VTCPFPGUU CPF VJG DKQ
GPIKPGGTKPI ITQWR CV VJG 7PKXGTUKV[ QH 9CUJKPIVQP EQP
FWEVGF TGUGCTEJ QP &QRRNGT WNVTCUQWPF CU C FKCIPQUVKE
VQQN HQT XCUEWNCT FKUGCUG 'XGPVWCNN[ VJG[ FGXGNQRGF
VGEJPQNQIKGU VQ WUG FWRNGZ KOCIKPI QT &QRRNGT KP EQP
LWPEVKQP YKVJ $OQFG UECPPKPI VQ XKGY XCUEWNCT UVTWE
VWTGU KP TGCNVKOG YJKNG CNUQ RTQXKFKPI JGOQF[PCOKE
KPHQTOCVKQP=?


6JG ិTUV FGOQPUVTCVKQP QH EQNQT &QRRNGT YCU D[ )GQា
5VGXGPUQP YJQ YCU KPXQNXGF KP VJG GCTN[ FGXGNQROGPVU
CPF OGFKECN WUG QH &QRRNGT UJKHVGF WNVTCUQPKE GPGTI[=?


11 See also


• &QRRNGT HGVCN OQPKVQT


• 2QN[DKQITCRJ[


• 4CFKQITCRJGT


• 7NVTCUQWPF VTCPUOKUUKQP VQOQITCRJ[


12 References


=? &WDQUG 6 , ན(GVCN $KQOGVT[ 8GTVKECN
%CNXCTKCN &KCOGVGT CPF %CNXCTKCN 8QNWOGཔ +PVS
OBM PG %JBHOPTUJD .FEJDBM 4POPHSBQIZ 1
FQK


=? ན& $2& %QTTGEVKQPཔ ,WN[ 4GVTKGXGF


=? 2CXNKP %JCTNGU (QUVGT ( 5VWCTV 6MUSBTPVOE
#JPNJDSPTDPQZ PG UIF &ZF 5RTKPIGT +5$0






=? *GTVJ ( , ( 'DGTJCTFV 4 8KNOCPP 2 -TCUPKM
/ 'TPUV # ན4GCNVKOG GPFQDTQPEJKCN WNVTC
UQWPF IWKFGF VTCPUDTQPEJKCN PGGFNG CURKTCVKQP HQT UCO
RNKPI OGFKCUVKPCN N[ORJ PQFGUཔ 5IPSBY 61 ཊ
FQKVJZ 2/% 2/+&


=? 2KNQPK 8KVVQTKQ .WKIK 5RC\\CHWOQ .KCPC ,WPG
ན5QPQITCRJ[ QH VJG HGOCNG RGNXKE HNQQTENKPKECN KPFKEC
VKQPU CPF VGEJPKSWGUཔ 1FMWJQFSJOFPMPHZ 26 ཊ


=? #TGPF %( 7NVTCUQWPF QH VJG 5JQWNFGT 2QTVQ #NG
ITG /CUVGT /GFKECN $QQMU (TGG CEEGUU CV
5JQWNFGT75EQO


=? 6JG )CNG 'PE[ENQRGFKC QH /GFKEKPG PF 'FKVKQP 8QN
#$ R


=? %QDDQNF 4KEJCTF 5 % 'PVOEBUJPOT PG #JPNFE
JDBM 6MUSBTPVOE 1ZHQTF 7PKXGTUKV[ 2TGUU RR ཊ
+5$0


=? 2CIG RCTV ++ 6YQFKOGPUKQPCN 'EJQECTFKQITCRJ[
KP 4GXGU , ) 'UVCHCPQWU (CY\[ ) $CTCUJ 2CWN )
$BSEJBD BOFTUIFTJB QSJODJQMFT BOE DMJOJDBM QSBD
UJDF *CIGTUVYQP /& .KRRKPEQVV 9KNNKCOU 9KNMKPU
+5$0


=? %NCWFG (TCPEGUEJK -*OWFTUJHBUJPO WBTDVMBJSF QBS
VMUSBTPOPHSBQIJF EPQQMFS /CUUQP +5$0


=? 'NNKU )GQTIG (4 9KNNKCOU 4WVJ / 'MBU BOE
$VSWFE 4QBDF5JNFT PF GF 1ZHQTF 7PKXGTUKV[ 2TGUU
+5$0


=? &W$QUG 6 , $CMGT # . ན%QPHWUKQP CPF
&KTGEVKQP KP &KCIPQUVKE &QRRNGT 5QPQITCRJ[པ +PVS
OBM PG %JBHOPTUJD .FEJDBM 4POPHSBQIZ 25 ཊ
FQK


=? ན&QRRNGT 7NVTCUQWPF *KUVQT[པ 4GVTKGXGF ,CPWCT[


=? ན+PHQTOCVKQP CPF 4GUQWTEGU &QRRNGT 7NVTCUQWPFཔ 4G
VTKGXGF ,WN[


=? 5EJPGKFGT /KEJGN ན%JCTCEVGTKUVKEU QH
5QPQ8WGရ &DIPDBSEJPHSBQIZ 16 2V ཊ
FQKLVDZ 2/+&


=? )TCOKCM 4C[OQPF 5JCJ 2TCXKP / ན'EJQECT
FKQITCRJ[ QH VJG #QTVKE 4QQVཔ *OWFTUJHBUJWF 3BEJPMPHZ 3
ཊ FQK
2/+&


=? ན%'75 #TQWPF VJG 9QTNF ཊ 6JG +PVGTPCVKQPCN %QPVTCUV
7NVTCUQWPF 5QEKGV[ +%75 2&( 1EVQDGT 4G
VTKGXGF


=? %NCWFQP /KEJGN &KGVTKEJ %JTKUVQRJ ( %JQK $[WPI
+JP %QUITQXG &CXKF 1 -WFQ /CUCVQUJK 0QN
U¹G %JTKUVKCP 2 2KUECINKC (CDKQ 9KNUQP 5VGRJCPKG
4 $CTT 4KEJCTF ) %JCOOCU /CTKC % %JCWDCN
0KVKP ) %JGP /KP*WC %NGXGTV &KTM #PFTG %QT
TGCU ,GCP /KEJGN &KPI *QPI (QTUDGTI (NGOOKPI
(QYNMGU , $TKCP )KDUQP 4QDGTV 0 )QNFDGTI $CTT[
$ .CUUCW 0CVJCNKG .GGP 'FYCTF .5 /CVVTG[


4QDGTV ( /QTK[CUW (WOKPQTK 5QNDKCVK .WKIK 9GUMQVV
*CPU2GVGT :W *WK:KQPI 9QTNF (GFGTCVKQP HQT 7N
VTCUQWPF KP /GFKEKPG 'WTQRGCP (GFGTCVKQP QH 5QEK
GVKGU HQT 7NVTCUQWPF ན)WKFGNKPGU CPF )QQF
%NKPKECN 2TCEVKEG 4GEQOOGPFCVKQPU HQT %QPVTCUV 'P
JCPEGF 7NVTCUQWPF %'75 KP VJG .KXGT ཊ 7RFCVG
པ 6MUSBTPVOE JO .FEJDJOF #JPMPHZ 39 ཊ
FQKLWNVTCUOGFDKQ 2/+&


=? 2KUECINKC ( 0QNU¹G % &KGVTKEJ % %QUITQXG &
)KNLC 1 $CEJOCPP 0KGNUGP / #NDTGEJV 6 $CTQ\\K
. $GTVQNQVVQ / %CVCNCPQ 1 %NCWFQP / %NGX
GTV & %QTTGCU , F1PQHTKQ / &TWFK ( '[FKPI
, )KQXCPPKPK / *QEMG / +IPGG # ,WPI '
-NCWUGT # .CUUCW 0 .GGP ' /CVJKU ) 5CHVQKW
# 5GKFGN ) 5KFJW 2 6GT *CCT ) 6KOOGTOCP &
9GUMQVV * ན6JG '(57/$ )WKFGNKPGU CPF 4GE
QOOGPFCVKQPU QP VJG %NKPKECN 2TCEVKEG QH %QPVTCUV 'P
JCPEGF 7NVTCUQWPF %'75 7RFCVG QP PQPJGRCVKE
CRRNKECVKQPUཔ 6MUSBTDIBMM JO EFS .FEJ[JO 33 ཊ
FQKU 2/+&


=? 6CPI / : /WNXCPC * )CWVJKGT 6 .KO # -
2 %QUITQXG & 1 'EMGTUNG[ 4 , 5VTKFG '
ན3WCPVKVCVKXG EQPVTCUVGPJCPEGF WNVTCUQWPF KOCIKPI #
TGXKGY QH UQWTEGU QH XCTKCDKNKV[པ *OUFSGBDF 'PDVT 1
ཊ FQKTUHU 2/%
2/+&


=? .CUUCW 0 -QUEKGNP[ 5 %JCOK . %JGDKN /
$GPCVUQW $ 4QEJG # &WETGWZ / /CNMC &
$QKIG 8 ན#FXCPEGF *GRCVQEGNNWNCT %CTEKPQOC
'CTN[ 'XCNWCVKQP QH 4GURQPUG VQ $GXCEK\WOCD 6JGTCR[
CV &[PCOKE %QPVTCUVGPJCPEGF 75 YKVJ 3WCPVKិECVKQPཋ
2TGNKOKPCT[ 4GUWNVUཔ 3BEJPMPHZ 258 ཊ
FQKTCFKQN 2/+&


=? 5WIKOQVQ -CVUWVQUJK /QTK[CUW (WOKPQTK 5CKVQ
-C\WJKTQ 4QIPKP 0KEQNCU -COK[COC 0CQJKUC (W
TWKEJK ;QUJKJKTQ +OCK ;CUWJCTW ན*GRCVQEGNNW
NCT ECTEKPQOC VTGCVGF YKVJ UQTCHGPKD 'CTN[ FGVGEVKQP QH
VTGCVOGPV TGURQPUG CPF OCLQT CFXGTUG GXGPVU D[ EQPVTCUV
GPJCPEGF 75པ -JWFS *OUFSOBUJPOBM 33 ཊ
FQKNKX 2/+&


=? 4QIPKP 0 ) #TFKVK / /GTEKGT . (TKPMKPI 2 ,
# 5EJPGKFGT / 2GTTGPQWF ) #PC[G # /GWYN[
, 6TCPSWCTV ( ན2CTCOGVTKE KOCIKPI HQT EJCT
CEVGTK\KPI HQECN NKXGT NGUKQPU KP EQPVTCUVGPJCPEGF WN
VTCUQWPFཔ *&&& 5SBOTBDUJPOT PO 6MUSBTPOJDT 'FSSP
FMFDUSJDT BOE 'SFRVFODZ $POUSPM 57 ཊ
FQK67((% 2/+&


=? 4QIPKP 0 GV CN ན2CTCOGVTKE KOCIGU DCUGF QP
F[PCOKE DGJCXKQT QXGT VKOGཔ *OUFSOBUJPOBM 1BUFOU 9QTNF
+PVGNNGEVWCN 2TQRGTV[ 1TICPK\CVKQP 9+21 RR ཊ


=? 6TCPSWCTV ( /GTEKGT . (TKPMKPI 2 )CWF '
#TFKVK / ན2GTHWUKQP 3WCPVKិECVKQP KP %QPVTCUV
'PJCPEGF 7NVTCUQWPF %'75 ཊ 4GCF[ HQT 4GUGCTEJ
2TQLGEVU CPF 4QWVKPG %NKPKECN 7UGཔ 6MUSBTDIBMM JO
EFS .FEJ[JO 33 5ཊ FQKU
2/+&




3&'&3&/$&4


=? #PIGNGNNK 2CQNQ 0[NWPF -KO )KNLC 1FF *GNIG
*CWUGT *GNYKI ན+PVGTCEVKXG XKUWCN CPCN[UKU QH
EQPVTCUVGPJCPEGF WNVTCUQWPF FCVC DCUGF QP UOCNN PGKIJ
DQTJQQF UVCVKUVKEUཔ $PNQVUFST (SBQIJDT 35
FQKLECI


=? $CTPGU ' %QPVTCUV 75 RTQEGUUKPI VQQN UJQYU OCNKIPCPV
NKXGT NGUKQPU #WPV/KPPKGEQO


=? #PC[G # 2GTTGPQWF ) 4QIPKP 0 #TFKVK /
/GTEKGT . (TKPMKPI 2 4WឹGWZ % 2GGVTQPU 2
/GWNK 4 /GWYN[ ,; ན&KាGTGPVKCVKQP QH
(QECN .KXGT .GUKQPU 7UGHWNPGUU QH 2CTCOGVTKE +OCIKPI
YKVJ %QPVTCUVGPJCPEGF 75པ 3BEJPMPHZ 261 ཊ
FQKTCFKQN 2/+&


=? ;WCP <JCPI 3WCP ,KCPI ;WPZKCQ <JCPI ,KCP %JGP
<JW *G .KRKPI )QPI ན&KCIPQUVKE 8CNWG QH
%QPVTCUV'PJCPEGF 7NVTCUQWPF 2CTCOGVTKE +OCIKPI KP
$TGCUV 6WOQTUཔ +PVSOBM PG #SFBTU $BODFS 16 ཊ
FQKLDE 2/%
2/+&


=? -NKDCPQX # . *WIJGU / 5 /CTUJ , 0 *CNN % 5
/KNNGT , ) 9KNDNG , * $TCPFGPDWTIGT ) *
ན6CTIGVKPI QH WNVTCUQWPF EQPVTCUV OCVGTKCN #P KP XKVTQ
HGCUKDKNKV[ UVWF[པ "DUB 3BEJPMPHJDB 4VQQMFNFOUVN 412
ཊ 2/+&


=? -NKDCPQX # ན6CTIGVGF FGNKXGT[ QH ICUិNNGF
OKETQURJGTGU EQPVTCUV CIGPVU HQT WNVTCUQWPF KOCIKPIཔ
"EWBODFE %SVH %FMJWFSZ 3FWJFXT 37 ཊ ཊ
FQK5: 2/+&


=? 2QEJQP 5 6CTF[ + $WUUCV 2 $GVVKPIGT 6 $TQ
EJQV , 8QP 9TQPUMK / 2CUUCPVKPQ . 5EJPGKFGT
/ ན$4 # NKRQRGRVKFGDCUGF 8')(4
VCTIGVGF WNVTCUQWPF EQPVTCUV CIGPV HQT OQNGEWNCT KOCIKPI
QH CPIKQIGPGUKUཔ *OWFTUJHBUJWF SBEJPMPHZ 45 ཊ
FQK4.+DGEE 2/+&


=? 9KNNOCPP , - -KOWTC 4 * &GUJRCPFG 0
.WV\ # / %QEJTCP , 4 )CODJKT 5 5
ན6CTIGVGF %QPVTCUV'PJCPEGF 7NVTCUQWPF +OCIKPI
QH 6WOQT #PIKQIGPGUKU YKVJ %QPVTCUV /KETQDWD
DNGU %QPLWICVGF VQ +PVGITKP$KPFKPI -PQVVKP 2GR
VKFGUཔ +PVSOBM PG /VDMFBS .FEJDJOF 51 ཊ
FQKLPWOGF 2/+&


=? .KPFPGT ,4 ན/QNGEWNCT KOCIKPI YKVJ EQP
VTCUV WNVTCUQWPF CPF VCTIGVGF OKETQDWDDNGUཔ +PVSOBM PG
OVDMFBS DBSEJPMPHZ PથDJBM QVCMJDBUJPO PG UIF "NFS
JDBO 4PDJFUZ PG /VDMFBS $BSEJPMPHZ 11 ཊ
FQKLPWENECTF 2/+&


=? %NKPKECN VTKCN PWODGT /$5 HQT ན$4 KP
2TQUVCVG %CPEGT CP 'ZRNQTCVQT[ %NKPKECN 6TKCNཔ CV
%NKPKECN6TKCNUIQX


=? &C[VQP 2CWN -NKDCPQX #NGZCPFGT $TCPFGPDWTIGT
)CT[ (GTTCTC -CVJ[ ན#EQWUVKE TCFKCVKQP HQTEG
KP XKXQ # OGEJCPKUO VQ CUUKUV VCTIGVKPI QH OKETQDWD
DNGUཔ 6MUSBTPVOE JO .FEJDJOF #JPMPHZ 25
FQK5


=? (TKPMKPI 2GVGT ,# 6CTF[ +UCDGNNG 6JªTCWNC\ /CT
VKPG #TFKVK /CTEGN 2QYGTU ,GាT[ 2QEJQP 5KD[NNG
6TCPSWCTV (TCP¨QKU ན'ាGEVU QH #EQWUVKE 4C
FKCVKQP (QTEG QP VJG $KPFKPI 'ឹEKGPE[ QH $4 C
8')(45RGEKិE 7NVTCUQWPF %QPVTCUV #IGPVཔ 6M
USBTPVOE JO .FEJDJOF #JPMPHZ 38 ཊ
FQKLWNVTCUOGFDKQ 2/+&


=? )GUUPGT 4[CP % 5VTGGVGT ,CUQP ' -QVJCFKC
4QUJPK (GKPIQNF 5VGXGP &C[VQP 2CWN #
ན#P +P 8KXQ 8CNKFCVKQP QH VJG #RRNKECVKQP QH #EQWU
VKE 4CFKCVKQP (QTEG VQ 'PJCPEG VJG &KCIPQUVKE 7VKN
KV[ QH /QNGEWNCT +OCIKPI 7UKPI & 7NVTCUQWPFཔ
6MUSBTPVOE JO .FEJDJOF #JPMPHZ 38 ཊ
FQKLWNVTCUOGFDKQ 2/+&


=? 4QIPKP 0 GV CN ན/QNGEWNCT 7NVTCUQWPF +OCI
KPI 'PJCPEGOGPV D[ 8QNWOKE #EQWUVKE 4CFKCVKQP (QTEG
8#4( 2TGENKPKECN KP XKXQ 8CNKFCVKQP KP C /WTKPG 6W
OQT /QFGNཔ 8PSME .PMFDVMBS *NBHJOH $POHSFTT 4BWBO
OBI (" 64"


=? 9GNNU 2 0 6 ,WPG /GFKECN WNVTCUQWPF KOCIKPI
QH UQHV VKUUWG UVTCKP CPF GNCUVKEKV[ ,QWTPCN QH VJG 4Q[CN
5QEKGV[ +PVGTHCEG ཊ FQKTUKH


=? 5CTXC\[CP # *CNN 6, 7TDCP /9 (CVGOK / #IN[COQX
54 )CTTC $5 1XGTXKGY QH GNCUVQITCRJ[ཊCP GOGTIKPI
DTCPEJ QH OGFKECN KOCIKPI %WTTGPV /GFKECN +OCIKPI 4G
XKGYU


=? 1RJKT , %ªURKFGU + 2QPPGMCPVK * .K : #RTKN
'NCUVQITCRJ[ # SWCPVKVCVKXG OGVJQF HQT KOCIKPI
VJG GNCUVKEKV[ QH DKQNQIKECN VKUUWGU 7NVTCUQPKE +OCIKPI
ཊ FQK 9


=? 2CTMGT - , &Q[NG[ / / 4WDGPU & , (GDTWCT[
+OCIKPI VJG GNCUVKE RTQRGTVKGU QH VKUUWG VJG [GCT RGT
URGEVKXG 2J[UKEU KP /GFKEKPG CPF $KQNQI[
FQK


=? %QIQ # .GPUKPI # 9 # -QQROCP / / 9
2KQXGNNC ( 5KTCIWUC 5 9GNNU 2 5 8KNNCNVC 5
$½NNGT * 4 6WTRKG # ) ) 2TCPFQPK 2
ན%QORTGUUKQP WNVTCUQPQITCRJ[ HQT FKCIPQUVKE OCPCIG
OGPV QH RCVKGPVU YKVJ ENKPKECNN[ UWURGEVGF FGGR XGKP
VJTQODQUKU 2TQURGEVKXG EQJQTV UVWF[པ #.+ 316
ཊ FQKDOL 2/%
2/+&


=? -GCTQP %NKXG ,WNKCP ,# 0GYOCP 6' )KPUDGTI ,5
ན0QPKPXCUKXG &KCIPQUKU QH &GGR 8GPQWU 6JTQO
DQUKUཔ "OOBMT PG *OUFSOBM .FEJDJOF 128 ཊ
FQK
2/+&


=? ,QPIDNQGVU .// -QQROCP //9 $½NNGT *4
6GP %CVG ,9 .GPUKPI #9# ན.KOKVCVKQPU
QH EQORTGUUKQP WNVTCUQWPF HQT VJG FGVGEVKQP QH U[ORVQO
NGUU RQUVQRGTCVKXG FGGR XGKP VJTQODQUKUཔ 5IF -BODFU 343
ཊ FQK5
2/+&






=? /GTTKVV %4 ན7NVTCUQWPF UCHGV[ 9JCV
CTG VJG KUUWGU! 3BEJPMPHZ 173 ཊ
FQKTCFKQNQI[ 2/+&


=? ན6TCKPKPI KP &KCIPQUVKE 7NVTCUQWPF GUUGPVKCNU RTKPEKRNGU
CPF UVCPFCTFUཔ 2&( 9*1 R


=? #OGTKECP #ECFGO[ QH 1TVJQRCGFKE 5WTIGQPU (GDTWCT[
ན(KXG 6JKPIU 2J[UKEKCPU CPF 2CVKGPVU 5JQWNF 3WGU
VKQPཔ $IPPTJOH 8JTFMZ BO JOJUJBUJWF PG UIF "#*. 'PVOEB
UJPO #OGTKECP #ECFGO[ QH 1TVJQRCGFKE 5WTIGQPU TG
VTKGXGF /C[ YJKEJ EKVGU


• /GODGTU QH CPF ##15 )WKFGNKPG &G
XGNQROGPV 9QTM )TQWRU QP 2'86'& 2TQRJ[
NCZKU /QPV / ,CEQDU , .KGDGTOCP , 2CTXK\K
, .CEJKGYKE\ 2 ,QJCPUQP 0 9CVVGTU 9 #RT
ན2TGXGPVKPI XGPQWU VJTQODQGODQNKE
FKUGCUG KP RCVKGPVU WPFGTIQKPI GNGEVKXG VQVCN JKR
CPF MPGG CTVJTQRNCUV[པ 5IF +PVSOBM PG CPOF BOE
KPJOU TVSHFSZ "NFSJDBO WPMVNF 94 ཊ
FQK,$,5GFKV 2/%
2/+&


=? $TKEMGT . )CTEKC , *GPFGTUQP , /WIHQTF / 0GKN
UQP , 4QDGTVU 6 /CTVKP /# ན7NVTCUQWPF
UETGGPKPI KP RTGIPCPE[ # U[UVGOCVKE TGXKGY QH VJG ENKP
KECN GាGEVKXGPGUU EQUVGាGEVKXGPGUU CPF YQOGPཐU XKGYUཔ
)FBMUI UFDIOPMPHZ BTTFTTNFOU 4 KཊXK ཊ 2/+&


=? #PI ' 5 $ % )NWPEKE 8 &WSWG # 5EJCHGT
/ ' 4CMKE 2 ན2TGPCVCN GZRQUWTG VQ WN
VTCUQWPF YCXGU KORCEVU PGWTQPCN OKITCVKQP KP OKEGཔ
1SPDFFEJOHT PG UIF /BUJPOBM "DBEFNZ PG 4DJFODFT 103
ཊ $KDEQFG20#5#
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14 Text and image sources, contributors, and licenses


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14.3 Content license
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2
Examination technique: general
rules and recommendations
Range of application
All body regions that are not situated behind expanses of bone or air-containing
tissue, such as the lungs, are accessible to transcutaneous ultrasound. Bone surfaces
(fractures, osteolytic lesions) and the surfaces of the lungs or air-void parts can also be
demonstrated. Examinations through thin, flat bones are possible at lower frequencies.
It is also possible to bypass obstacles with endoprobes (endoscopic sonography).
Thus, transcutaneous ultrasound is used mainly for evaluating:


■ neck: thyroid gland, lymph nodes, abscesses, vessels (angiology);
■ chest: wall, pleura, peripherally situated disorders of the lung, mediastinal tumours


and the heart (echocardiography);
■ abdomen, retroperitoneum and small pelvis: parenchymatous organs, fluid-


containing structures, gastrointestinal tract, great vessels and lymph nodes,
tumours and abnormal fluid collections; and


■ extremities (joints, muscles and connective tissue, vessels).


General indications (B-scan and duplex techniques)
The general indications are:


■ presence, position, size and shape of organs;
■ stasis, concretions and dysfunction of hollow organs and structures;
■ tumour diagnosis and differentiation of focal lesions;
■ inflammatory diseases;
■ metabolic diseases causing macroscopic alterations of organs;
■ abnormal fluid collection in body cavities or organs, including ultrasound-guided


diagnostic and therapeutic interventions;
■ evaluating transplants;
■ diagnosis of congenital defects and malformations.


Additionally, ultrasound is particularly suitable for checks in the management of
chronic diseases and for screening, because it is risk-free, comfortable for patients and
cheaper than other imaging modalities. 29




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Preparation
In general, no preparation is needed for an ultrasound examination; however, for
certain examinations of the abdomen, a period of fasting is useful or necessary. To avoid
problems due to meteorism, dietary restrictions (no gas-producing foods), physical
exercise (walking before the examination) and even premedication (antifoaming agents)
are recommended. Special preparation is only necessary for certain examinations and
these are discussed in the relevant chapters of this manual.


Positioning
The ultrasound examination is usually carried out with the patient in the supine
position. As further described in the specific chapters, it is often useful to turn the
patient in an oblique position or to scan from the back in a prone position, e.g. when
scanning the kidneys. Ultrasound also allows examination of the patient in a sitting
or standing position, which may help in certain situations to diagnose stones or fluid
collection (e.g. pleural effusion).


Coupling agents
A coupling agent is necessary to ensure good contact between the transducer and the
skin and to avoid artefacts caused by the presence of air between them. The best coupling
agents are water-soluble gels, which are commercially available. Water is suitable for
very short examinations. Disinfectant fluids can also be used for short coupling of the
transducer during guided punctures. Oil has the disadvantage of dissolving rubber or
plastic parts of the transducer.


The composition of a common coupling gel is as follows:
■ 1 0.0 g carbomer
■ 0.25 g ethylenediaminetetraacetic acid (EDTA)
■ 75.0 g propylene glycol
■ 1 2.5 g trolamine and up to 500 ml demineralized water.


Dissolve the EDTA in 40 0 ml of water. When the EDTA has dissolved, add the
propylene glycol. Then add the carbomer to the solution and stir, if possible with a
high-speed stirrer, until the mixture forms a gel without bubbles. Add up to 50 0 ml of
demineralized water to the gel.


Precaution: Be careful not to transmit infectious material from one patient to the
next via the transducer or the coupling gel. The transducer and any other parts that
come into direct contact with the patient must be cleaned after each examination. The
minimum requirements are to wipe the transducer after each examination and to clean
it with a suitable disinfectant every day and after the examination of any patient who
may be infectious.


A suitable method for infectious patients, e.g. those infected with human
immunodeficiency virus (HIV) and with open wounds or other skin lesions, is to slip
a disposable glove over the transducer and to smear some jelly onto the active surface
of the transducer.




31


Equipment
Generally, modern ultrasound equipment consists of ‘all-round scanners’. Two
transducers, usually a curved array for the range 3–5 MHz and a linear array for the range
greater than 5 MHz to 10 MHz, as a ‘small-part scanner’ can be used as ‘general-purpose
scanners’ for examination of all body regions with the B-scan technique (Fig.  2.1).


Examinations of the skin and eyes and the use of endoprobes require special
transducers and more expensive equipment to enable the use of higher frequencies.
For echocardiography, di fferent transducers, i.e. electronic sector scanners (phased
array technique) are required.


An integrated Doppler technique is necessary for echocardiography and angiology,
and is also useful for most other applications. Special so ftware is needed for the use of
contrast agents.


Adjustment of the equipment
Correct adjustment of an ultrasound scanner is not di fficult, as the instruments offer a wide
range of possible settings. Most instruments have a standard setting for each transducer
and each body region. This standard can be adapted to the needs of each operator.


When starting with these standards, only slight adaptation to the individual
patient is necessary.


■ The choice of frequency (and transducer) depends on the penetration depth
needed. For examination of the abdomen, it may be useful to start with a lower
frequency (curved array, 3.5 MHz) and to use a higher frequency if the region of
interest is close to the transducer, e.g. the bowel (Fig. 2.1, Fig. 11.26).


■ Adaptation to the penetration depth needed: the whole screen should be used for
the region of interest (Fig. 2.2).


■ The mechanical index should be as low as possible (< 0.7 in adults).


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Fig. 2.1. Ch oice of transdu ce r and freque nc y. G e ne rally, supe rficial stru ctu re s are ex am ine d
at 7.5 MH z; h oweve r, th is freque nc y is not in ge ne ra l su itable for ab do m inal w or k
and is l im ite d to ex am ination of supe rficial str u ctu re s. ( a) A t 7.5 MH z, only the
ve ntra l su rface of t he l ive r can be dis pl aye d. (b) The l ive r and the adj ace nt stru ctu re s
can be ex am in e d co mple tely at 3.5 MH z


a b




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■ The time gain compensation (TGC) setting must compensate for attenuation, e.g.
depending on the abdominal wall, to obtain a homogeneous image. It is useful to
find a good TGC setting when scanning a homogeneous section of the tissue, e.g.
the right liver lobe in the abdomen, before moving the transducer to the region of
interest (Fig. 2.3, Fig. 2.4, Fig. 2.5).


■ The focus, or zone of best resolution, should always be adjusted to the point of interest.


Fig. 2.2. U se of t he scree n. ( a) I ncorre ct adap tation of the scree n: the re gion of inte re st fi ll s
only a sm all p art of the scree n. (b) C orre ct adap tation of the scree n


a b


Fig. 2.3. ( a) Ope rating conso le of an ul trasou nd m ach ine. C ontrol k nob s mu st be ad ju ste d for
e ach p atie nt. R ( range), pe ne tration dep th; F ( focu s), re gion of be st re so lu tion; TGC,
time ( dep th) gain compe nsation ( see F ig. 2.4 ); Z (z oom), e nl arge s re gions of inte re st;
G, D opple r gain; V, D opple r vel ocit y (pul se repe tition freque nc y ) . ( b ) B - im ag e ( not
the same equ ipme nt as in ( a)), sh ow s corre ct (h om oge ne ou s p atte rn of nor m a l
l ive r tissue), TGC cu r ve ( arrow) and focu s z one, wh ich sh oul d be sl igh tly d eepe r
and level w it h the foca l nodul ar hype r pl asia le sion. The the r m al index ( TIS) and the
me ch anical ind ex ( MI) are indicate d. N ote t h at the se indice s are conside ra bly h ighe r
in the col ou r D opple r i m age ( B - scan 0.6 and 0.5, re spe ctively, ve rs u s D opple r 2.3 and
0.8). ( c) The D opple r vel ocit y and the D opple r w indow are corre ctly ad ju ste d to the
size of the le sion and t he expe cte d vel ocit y range in the ve ssel s


a b


c




33


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Fig. 2.4. T ime gain co mpe nsation ( TGC ). The TGC is alw ay s ad ju ste d according to e ach
p atie nt ’ s circ um stance s. ( a) A n ove rall gain in compe nsation ( B - m ode: gain) and
gradu al re gul ation are p ossi ble. (b) The l oss of inte nsit y, or d e cl ine in the e ch oe s
at a gre ate r distance, is compe nsate d for by the TGC, as sh ow n in the diagra m
and ( c) the ul trasou nd im age w it h the dis pl aye d TGC l ine ( arrow) for 3.5 MH z. Th is
compe nsation is not su fficie nt for 7 MH z ( see F ig. 2.1 )


a b


c


Fig. 2.5. TGC adju stme nt. Tw o ex ample s of incorre ct adju stme nt: ( a) The l owe r p art of the
ul trasou nd i m age is too dar k be cau s e the TGC ad ju stme nt is too we ak , whe re as
in (b) the adju stme nt for the m idd le p art is too h igh, cau sing an inh om og e ne ou s
im age of the l ive r w ith a z one th at is too b righ t in the m iddle p art


a b




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3 4


■ The zoom should be used mainly for the final investigation of detail and for
preparing the documentation.


■ If there are problems, use of the image optimizer knob and returning to the stan-
dard settings may help.


Guidelines for the examination
■ Know the patient’s problem and medical history. An advantage of ultrasound is


that the patient’s doctor can carry out the examination, and this provides a good
opportunity to talk to the patient about his or her problem.


■ Make sure that the settings of the equipment and the orientation of the transducer
are correct in relation to the image. This will avoid misinterpretations due to inho-
mogeneous images with areas that are too dark or too bright and with artefacts.


■ Conduct a systematic and complete examination of the whole body region, even if
there is an obvious palpable mass or a localized point of pain.


■ Start with an anatomically constant area and move to the more variable area (e.g.
from the liver to the region of the pancreas or the intestine).


■ Move the transducer in a slow constant pattern, while maintaining the de fined
scanning plane. Hold the transducer motionless when the patient moves, e.g.
during respiration. It is possible to move a transducer in many directions by tilting
it in the scanning plane and moving it perpendicularly, but with a combination of
all these movements the less experienced operator will lose the orientation of the
image (Fig. 2.6, Fig. 2.7).


■ Use anatomically constant, easily visualize d structures for orientation (e.g. liver,
aorta or fluid-filled bladder) and normal structures for comparison (e.g. right and
left kidney or kidney and liver).


■ Examine each organ, structure or tumour in at least two planes. In this way, one
can avoid missing small lesions or misinterpreting artefacts as real alterations.


■ Use palpation to displace fluid or gas from the bowel, to test the consistency of
tumours and organs and to localize points of pain.


■ Continue the entire examination even if pathological conditions are found. Only
a complete examination will avoid that only a less important alteration (e.g. gall-
stones) is found but the main diagnosis (e.g. pancreatic cancer) is missed.


■ In clinically difficult situations or when the findings are doubtful, repeat the exami-
nation a short time later. Such repeat examinations can be carried out even at the
bedside. This is particularly useful with trauma patients and patients in intensive care.




35


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Fig. 2.6. Moveme nts of a transdu ce r. The transdu ce r can be m ove d in its scanning pl ane in a
l ongitu dinal dire ction ( a), t u rne d ab ou t its el f (b), or til te d in the scanning pl ane ( c) or
in a pe r pe ndic ul ar dire ction ( d)


a b


c d


Fig. 2.7. I m aging of the righ t l i ve r l obe and t he righ t k idney ob taine d by til ting the
transdu ce r in diffe re nt dire ctions (I and II)




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36


Documentation
As a rule, both a written report and pictorial documentation should be prepared for
each ultrasound examination.


The written report should include:
■ a description of the problem that led to the examination;
■ a list of the organs (region) examined (generally, it is not necessary to describe


normal findings but to note measurements only);
■ a description of pathological findings (the descriptions should be concise and clear,


but without over-interpretation.); and
■ the diagnosis or decision.


Pictorial documentation of pathological findings in two planes is necessary, but
documentation of a normal finding (one representative scan of the organ or body
region examined) is also useful, e.g. for later check-up examinations.


Interpretation of the ultrasound image
Organs, structures within organs, vessels, tumours and fluid collections are evaluated
by B-scan in terms of their:


■ presence (aplasia?);
■ position (displaced?);
■ outer contour or border (which gives information about the surface of an organ or


tumour as well as about its relation to the adjacent structures);
■ mobility (fixed?);
■ consistency (palpation under ultrasonic observation);
■ echo pattern; and
■ attenuation.


Evaluation of the presence , position and size of an organ is based on the known
normal anatomy. A simple determination of organ diameter is sufficient for most
routine evaluations, provided the shape is normal. The volume (V) of round- or oval-
shaped organs is calculated on the basis of their three perpendicular diameters a, b and
c, following the formula for an ellipsoid:


V a b c= ⋅ ⋅ ⋅0 5 . (2.1)


Formulas for special problems, e.g. pleural e ffusion, are discussed in specific
chapters of this book. The volume of organs and structures with complicated shapes
can be calculated by the 3D technique.


Evaluation of the contour of an organ, and particularly of a neoplastic lesion,
should give information about both the smooth or irregular surface and any sharp or
blurred (ill-defined) demarcation lines (Fig.   2.8, Fig.   2.9, Fig.   2.10). The latter should
include the relation to the surrounding tissue, e.g. any overlap with a natural border,
such as a capsule, or infiltration into adjacent structures. The possibilities of contour
evaluation are limited by the imaging geometry of ultrasound. The fine surface
irregularities of a cirrhotic liver, for example, can be shown, especially since the surface




37


is approximately perpendicular to the ultrasound beam (Fig.   2.11). The contour of an
organ such as the pancreas, however, may appear to be irregular, particularly on the
sides, as a result of the coarse boundary echoes.


Evaluation of the echo pattern (also known as echo structure, echo texture,
echogenicity) of an organ, tissue or tumour is based on an analysis of the intensity
and distribution of the internal echoes that are not due to discernible anatomical
structures, such as vessels, septa or ducts. Single echoes are either weak, average or
strong (Fig.   2.12).


The echo pattern is analysed on the basis of the number and strength of the echoes
and their distribution (Fig.   2.13):


■ echo free – echo poor (hypoechogenic) – average – echo rich (hyperechogenic); and
■ homogeneous or inhomogeneous.


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Fig. 2.8. Ev alu ation of the m argin or conto u r of a le sion (e. g. in the l ive r). The m argin of
b oth le sions is sh ar p. The c y st ( a) is e ch o free, t he h aem angiom a (b) sh ow s a
h om oge ne ou s e ch o - rich p atte rn


a b


Fig. 2.9. Ev alu ation of the conto u r (m argin) of t w o e ch o -p oor l ive r le sions. ( a ) The e ch o -p oor
me tastasis h as a blu rre d ou tl ine, p artic ul ar l y at the cranial side ( arrow), whe re as the
m al ignant lymph o m a (b) sh ow s a p artial ( dorsa l side), rathe r sh ar p bu t al tog e the r
irre gul ar ou tl ine. Sl igh t e ch o e nh anceme nt is see n beh ind the lymph om a


a b




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38


Echo free : no (real) echoes within a lesion, e.g. a cyst (Fig.   2.8, Fig.   2.13). This
diagnosis requires the correct gain and the identification of artefacts (see section on
Artifacts in Chapter   1). Furthermore, only fluid in the strict physical sense is really
echo free. Other types of fluid (e.g. blood, abscesses or exudates) contain small particles
(e.g. blood cells, fibrin) and cause weak echoes (Fig.   2.12).


Echo poor : an echo pattern consisting of only a few weak echoes (see Fig.   2.9).
An echo pattern appears to be echo rich if the tissue causes many weak echoes or


a few strong echoes. In both situations, this region appears ‘bright’ on the screen. For
the first type of echo-rich pattern, the term ‘echo dense’ is occasionally used. Generally,
none of these types of echo-rich pattern is differentiated (Fig.   2.8, Fig.   2.9, Fig.   2.10,
Fig.   2.11, Fig.   2.12, Fig.   2.13, Fig.   2.14).


Fig. 2.10. C ontou r sign . ( a) The le sion in t he l ive r h as a sm ooth ou tl ine and a tange ntial
arte fact ( see F ig. 1.24), bu t is neve rthele ss a hep atocellul ar carcinom a (HCC ),
p rob ably w ith a cap sule. The p atte rn is ave rage, sim il ar to th at of the su rrou nding
l ive r tiss ue. (b) The me tastasis in the ab dom inal w all sh ow s an irre gul ar sh ape and
an e ch o -p oor p atte rn


a b


Fig. 2.11. Su rface of t he l ive r. ( a) The nor m al he al thy l ive r h as a sm ooth su rface. The e ch o
stru ctu re of the nor m al l ive r is h om oge ne o u s and of nor m al b righ tne ss. (b) The
cirr h otic l ive r h as an irre gul ar su rface. ( The e ch o p atte rn of the cirr h otic l ive r is
sl igh tly in h o m oge ne ou s ( coarse ne d)


a b




39


Increased attenuation of ultrasound in an organ may indicate pathological
alterations, such as fibrosis; however, experience is needed to recognize this sonographic
symptom, as no objective parameters exist (Fig.   2.14).


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Fig. 2.12. Q u al it y of e ch oe s. The e ch oe s in t he uppe r p art of the le ft le sion are we ak , wh ile
th ose of the l i ve r are ave rage. I n t he righ t le sion, strong e ch oe s cau se d by gas are
see n. B oth le sions ( ab sce ss e s) sh ow an in h om oge ne ou s p atte rn; the one on the
le ft is e ch o p oor and t he othe r p artia lly e ch o rich . B e h ind the rig h t-h and le sion, a
tange ntial arte fact is see n


Fig. 2.13. E ch o stru ctu re (e ch o p atte rn ). ( a) The ul trasonic stru ctu re of the l ive r and the
p are nchym a of the k idney are e ch o p oor and h om og e ne ou s; the p atte rn in the
ce ntre of t he k idn ey is e ch o rich. A sm all c y st ( arrow) is e ch o free. (b) The l ive r sh ow s
an inh om oge ne ou s e ch o - rich str u ctu re cau se d by e ch o - rich me tastase s


a b




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4 0


Duplex technique
In interpreting Doppler information in an ultrasound image, account should be taken
of the principal problems and limitations of the Doppler technique: angle dependency
and aliasing.


A suitable angle (<  6 0 °) must be found for the ultrasound beam to reach the vessel
of interest, especially if measurements (spectral Doppler) are to be made. The angle
is less problematic for colour Doppler imaging, but colour pixels may be missed if
the angle is close to 90 ° (see Fig.   1. 32). Power Doppler images are not a ffected by this
problem but give no information about the flow direction.


The window for the Doppler examination should be as small as possible, as its width
and length determine the time needed for the construction of one image and, therefore,
the image frequency (Fig.  1.19, Fig. 1.20, Fig.  1.21). The distal border of the window, or
the penetration depth for the Doppler ultrasound, limits the pulse repetition frequency
because a second pulse can be emitted only if the echoes of the adjusted depth have
reached the transducer. The pulse repetition frequency limits the flow velocity, which
can be depicted without aliasing (see section on Doppler techniques in Chapter   1).
Initially, it is useful to adjust the settings to a relatively low velocity (17–2 4 cm/s) to
depict the slow flow velocities in the veins. For the same reason, the filter should be
low to avoid suppressing slow flow signals with those caused by the movement of the
wall. For the examination of veins and arteries, the wall filter should be adjusted to
50 –10 0 Hz and 20 0 Hz, respectively. If aliasing (see section on Doppler techniques
in Chapter   1) occurs in the arteries, the pulse repetition frequency can gradually be
adapted to higher velocities. The baseline can also be shifted to avoid aliasing in the
arteries (Fig.  2.15) because the velocity in the veins in the opposite direction is slow.


The gain of the Doppler signals should be high so that single colour pixels are seen
in the tissue, especially if thrombosis is suspected. If no colour-coded signals are seen
in a vessel, the angle and adjustment, particularly of the pulse repetition frequency,
should be checked. If they are correct, spectral Doppler should also be used to obtain
a definite diagnosis.


Fig. 2.14. A tte nu ation. ( a) The fatt y l ive r sh ow s a t yp ical h o m oge ne ou s e ch o - rich p atte rn.
(b) The e c h o stru ctu re of t he le ft l ive r is e ch o rich ne ar the ve ntra l su rface, bu t the
dorsa l p arts appe ar m ore e ch o p oor. P rov id e d the adju stme nt of the TGC is corre ct,
th is indicate s h ighe r t h an ave rage atte nu ation of the ul trasou nd, as see n in fib rosis


a b




41


In an artery, the colour Doppler technique will yield high systolic flow and give
a good signal. In diastole, however, the flow may become very slow or even reverse
(high-resistance flow), resulting in a weak signal and an unsatisfactory image of the
vessel. With persistence, it is possible to extend the peak flow to get a better colour
Doppler image (Fig.  2.16).


B-scan provides information about the anatomy of vessels, including diagnoses of
dilatation, aneurysms and alterations of the wall and stenosis. Thrombosis in a vessel
can also be demonstrated.


The colour Doppler technique permits detection of small vessels and gives
information about flow and direction. Power Doppler is more sensitive for examining
small vessels and slow flow but does not provide information about the direction of
flow. In particular, it is used to estimate the vascularity of a structure or a mass.


Estimation of flow velocity from the brightness of colour pixels is rather
approximate. Even turbulent flow, caused by stenosis, is not reliable.


Use of spectral Doppler (triplex technique) is needed for a more accurate analysis
of the flow, e.g. direction, velocity and dynamic course. A condition required for an
exact analysis is a Doppler angle of <  6 0 ° (best, ~3 0 °), which may be di fficult to achieve
in the abdomen. Each measurement should be made a least three times, and the average
finding should be used. Attention should be paid to specific conditions, such as a
change in flow, which depend on the activity of the region or tissues it supplies.


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Fig. 2.15. Al iasing. ( a) The spe ctral D opple r dep iction ( duplex te ch nique) of the flow in the
aorta sh ow s al iasing. The pe ak vel ocit y signal s, 80–120 cm/ s, are sh ow n bel ow the
b asel ine ( arrow). (b) C orre ct dep iction as a re sul t of sh ifting the b as el ine ( arrow)


a b




42


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Fig. 2.16. C ol ou r D opple r and spe ctral D opple r of the ab dom inal aorta . ( a) The col ou r D opple r
im age sh ow s re d (he re b righ t) signa l s, be cau se it is m ad e in sy stole, whe re as the
im age in (b) sh ow s blue signal s (he re dar k), indicating reve rse flow in e ar ly diastole.
B oth ph ase s are indicate d in the spe ctral D opple r ( c)


a b


c




*2.*Diagrams*and*Schematics*of*Medical*Ultrasound****Featured*in*this*Section:*****Bruce/Blaus./“Fetal/Ultrasound.”/Wikipedia(Commons,/November/9,/2015./Retrieved/from:/https://commons.wikimedia.org/wiki/File:Fetal_Ultrasound.png/**WHO./“Manual/of/Diagnostic/Ultrasound,/Second/Edition.”/WHO,/2011./Retrieved/from:/http://apps.who.int/medicinedocs/documents/s21383en/s21383en.pdf/* *










3.*Preventative*Maintenance*of*Medical*Ultrasound*****Featured*in*this*Section:******Cooper,/Justin/and/Alex/Dahinten/for/EWH./“Ultrasound/Preventative/Maintenance.”/From/the/publication://Medical(Equipment(Troubleshooting(Flowchart(Handbook./Durham,/NC:/Engineering/World/Health,/2013./*Strengthening/Specialised/Clinical/Services/in/the/Pacific./User(Care(of(Medical(Equipment:(A(first(line(maintenance(guide(for(end(users./(2015)./ * *




Ultrasound+Preventative+Maintenance+!Preventive(Maintenance((
• After!every!use,!clean!the!probe!and!cable!with!a!damp!cloth!to!ensure!that!it!• is!free!of!gel.!• Replace!the!internal!battery!to!protect!internal!memory!if!necessary!o when!replacing!• read!the!manual!to!tell!you!what!to!do!• Clean!the!controls!by!wiping!them!with!a!damp!cloth!or!tissue!after!every!!• working!day.!• Change!the!dust!filter!every!3!to!6!months.!!• Ultrasound!Proper!Usage!o Ensure!proper!mains!voltage!range.!o When!changing!the!dust!filter,!if!the!original!filter!paper!cannot!be!found,!a!!• piece!of!double!gauze!may!be!used.!o Ensure!there!is!no!air!between!the!probe!and!the!patient!by!having!enough!!• ultrasonic!gel!to!ensure!a!quality!image.!!o Do!not!soak!the!cable!with!gel.!o Do!not!turn!off!and!on!the!machine!quickly.!Leave!two!minutes!between!each!!• to!retain!internal!memory!of!the!device.!Also,!leave!the!machine!running!for!!• at!least!15!minutes!every!time.!o To!adjust!the!greyscale!during!a!session,!use!dynamic!controls!on!the!!• machine!not!those!controls!on!the!monitor.!Otherwise!use!the!grey!wedge!on!!• the!monitor.!o The!ultrasound!may!freeze!if!the!information!is!typed!in!too!quickly.!If!the!!• machine!freezes,!turn!the!machine!off!and!wait!two!minutes!before!!• restarting.!o Do!not!spill!liquids!on!the!machine.!o Do!not!hang!anything!for!the!controls!of!the!machine.!• 10.If!the!mains!voltage!varies!more!than!the!tolerance!of!the!machine!specified!!• by!the!manufacturer!(usually!around!+!10%),!a!voltage!stabilizer!is!required.!• 11.Ventilation!holes!of!the!ultrasound!must!not!be!covered!by!papers,!forms,!or!!• tissue!• 12.When!troubleshooting!the!electronics!of!the!device,!start!replacing!fuses!if!!• necessary!and!checking!the!highly!stressed!circuit!that!powers!the!pulse!!• generator.!(




User Care of Medical Equipment – First line maintenance for end users


71


User Care Checklist – Ultrasound machines


Daily

Cleaning



9 Wipe dust off exterior and cover equipment after checks

9 Remove any tape, paper or foreign body from equipment

9 Wipe probe with alcohol-free tissue or cloth



Visual checks



9 Check all fittings and accessories are mounted correctly

9 Check cables are not twisted and probe is safely stored




Function
checks



9 If in use that day, run a brief function check before clinic





Weekly

Cleaning



9 Unplug, clean outside / wheels / rear with damp cloth, dry off

9 Remove, clean and dry external filter if present




Visual checks



9 Check mains plug screws are tight

9 Check mains cable has no bare wire and is not damaged




Function
checks



9 If machine has not been in use, run and test briefly




Every six months
Biomedical Technician check required





*4.*Troubleshooting*and*Repair*of*Medical*Ultrasound*** **Featured*in*this*Section:*****Cooper,/Justin/and/Alex/Dahinten/for/EWH./“Ultrasound/Troubleshooting/Flowchart.”/From/the/publication://Medical(Equipment(Troubleshooting(Flowchart(Handbook./Durham,/NC:/Engineering/World/Health,/2013./**Strengthening/Specialised/Clinical/Services/in/the/Pacific./User(Care(of(Medical(Equipment:(A(first(line(maintenance(guide(for(end(users./(2015)./ *///////////** ****




Ultrasound+Repair+and+Troubleshooting+!!!Flowchart! !! !




Description!1. Begin Ultrasound Flow Chart Begin Ultrasound Flow Chart 2. Does it turn on? Does it turn on? 3. Troubleshoot Power Supply See power supply flowchart 4. Does the screen turn on? Does the screen turn on?
5. Check circuit components Troubleshoot the circuit (see troubleshooting guide) 6. Does the probe work? Does the machine show an image? 7. Check gel. Is there enough of the proper gel.
8. Check probe. Ensure that the probe is properly connected and undamaged.
9. Repair or replace probe. Solder the broken connections or replace the probe.
10. Do the dials work? Do the dials properly control the machine? 11. Replace dials or use anticorrosive contact spray on dials. Replace or use anticorrosive contact spray on dials.
12. Is there a flickery or partial image Does the image on the screen have missing sections? Does the screen flicker?
13. Check probe.


Gently pull on the cable at different points to see when the image flickers. This is where the cable is broken. For composite probes wave a pencil across the transducer. If not seen, this is where the transducer is not




connected.
14. Repair or replace probe. Solder the broken connections or replace the probe. 15. Go to begin. Go to begin.
16. Is there a noisy signal? Is there distortion in the produced image?
17. Replace motor or bearings Replace the motor or bearings if they are broken or damaged. 18. Is there major image deterioration? Is the image severely deteriorated?
19. Are there air bubbles in the probe? Does the oil in the probe have air bubbles in it? 20. Replace oil. Replace oil. 21. Is there a sudden worsening quality of the image? Does the image have sudden changes in quality? 22. Check the preamplifier. Check the preamplifier. 23. Check the mains voltage range. Check the outlet voltage range. 24. Check that the probe is connected securely. Check that the probe is connected securely. 25. Is there a random change in greyscale quality? Is there a random change in greyscale quality? 26. Check the monitor and the preprocessing unit. Check the monitor and the preprocessing unit. 27. Can you change programs or make measurements on the machine? Can you change programs or make measurements on the machine?




28. Check the digital processor. Check the digital processor. 29. Is there a partial image despite an intact probe? Is there a partial image despite an intact probe? 30. Check the digital memory and the microprocessor. Check the digital memory and the microprocessor. 31. Is the image wavy? Is the image wavy? 32. Is the machine calibrated correctly? Is the machine calibrated correctly? 33. Go to begin. Got to begin. 34. Calibrate the machine. Calibrate the machine. 35. End End !




User Care of Medical Equipment – First line maintenance for end users


70


Troubleshooting – Ultrasound Machines




Fault Possible Cause Solution


1.



Equipment is not running



No power from mains socket







Electrical cable fault





Check power switch is on.
Replace fuse with correct voltage
and current if blown.
Check mains power is present at
socket using equipment known to
be working. Contact electrician
for rewiring if power not present.

Try cable on another piece of
equipment. Contact electrician
for repair if required.



2.



Fuse keeps blowing



Power supply or cable fault



Refer to electrician



3.



Probe head damaged or noisy



Possible internal fault



Exchange probe
Send for testing and repair



4.



Image quality poor



Gel insufficient

Controls set incorrectly



Mains voltage is too low

Probe / display problem



Use more ultrasound gel

Check controls for correct
positioning and operation
(refer to user manual)

Use voltage stabiliser

Refer to biomedical technician



5.



Display / computer error



Software fault



Turn machine off and restart.
If problem persists, refer to
biomedical technician



6.



Electrical shocks



Wiring fault



Refer to electrician





*5.*Resources*for*More*Information*about*Medical*Ultrasound****Featured*in*this*Section:******WHO./“Manual/of/Diagnostic/Ultrasound,/Second/Edition.”/WHO,/2011./Retrieved/from:/http://apps.who.int/medicinedocs/documents/s21383en/s21383en.pdf///WHO./“Manual/of/Diagnostic/Ultrasound,/Volume/2.”/WHO,/2013./Retrieved/from:/http://apps.who.int/medicinedocs/en/m/abstract/Js21384en////WHO./“Ultrasound/Equipment:/Basic/Principles.”/Maintenance(and(Repair(of(Laboratory,(Diagnostic(Imaging,(and(Hospital/Equipment((WHO:/1996).*/ *//// /**////* *////




**Resources*for*More*Information:/*/**Internal*Resources*at*library.ewh.org:*For*more*information*about*medical*ultrasound,*please*see*this*resource*in*the*BMET*Library!*/ 1. WHO./“Ultrasound/Equipment:/Basic/Principles.”/Maintenance(and(Repair(of(Laboratory,(Diagnostic(Imaging,(and(Hospital/Equipment((WHO:/1996).*//External*Resources:** 2. This/2Spart/WHO/manual/covers/the/basic/types/of/ultrasound/equipment,/operation/and/use/of/ultrasound,/and/applications/of/ultrasound.//Volume/1/discusses/the/basics/of/ultrasound/and/topics/such/as/ultrasound/use/on/the/neck,/abdomen,/and/kidneys./Volume/2/covers/the/use/of/ultrasound/in/obstetrics/and/gynecology.// a. Volume*1:*WHO./“Manual/of/Diagnostic/Ultrasound,/Volume/1.”/WHO,/2011./Retrieved/from:/http://apps.who.int/medicinedocs/documents/s21383en/s21383en.pdf// b. Volume*2:*WHO./“Manual/of/Diagnostic/Ultrasound,/Volume/2.”/WHO,/2013./Retrieved/from:/http://apps.who.int/medicinedocs/en/m/abstract/Js21384en//*/




Ultrasound*Bibliography:////Bruce/Blaus./“Fetal/Ultrasound.”/Wikipedia(Commons,/November/9,/2015./Retrieved/from:/https://commons.wikimedia.org/wiki/File:Fetal_Ultrasound.png///Cooper,/Justin/and/Alex/Dahinten/for/EWH./“Ultrasound/Preventative/Maintenance.”/From/the/publication://Medical(Equipment(Troubleshooting(Flowchart(Handbook./Durham,/NC:/Engineering/World/Health,/2013.///Cooper,/Justin/and/Alex/Dahinten/for/EWH./“Ultrasound/Repair/and/Troubleshooting.”/From/the/publication:/Medical(Equipment(Troubleshooting(Flowchart(Handbook./Durham,/NC:/Engineering/World/Health,/2013.///Skeet,/Muriel/and/David/Fear./“Theatre/Equipment:/Operating/Table.”/Care(and(Safe(Use(of(Medical(Equipment./VSO/Books,/1995,/p./118S125./// Strengthening/Specialised/Clinical/Services/in/the/Pacific./User(Care(of(Medical(Equipment:(A(first(line(maintenance(guide(for(end(users./(2015).///WHO./“Ultrasound/Equipment:/Basic/Principles.”/Maintenance(and(Repair(of(Laboratory,(Diagnostic(Imaging,(and(Hospital/Equipment((WHO:/1996).*//WHO./“Manual/of/Diagnostic/Ultrasound,/Second/Edition.”/WHO,/2011./Retrieved/from:/http://apps.who.int/medicinedocs/documents/s21383en/s21383en.pdf///WHO./“Manual/of/Diagnostic/Ultrasound,/Volume/2.”/WHO,/2013./Retrieved/from:/http://apps.who.int/medicinedocs/en/m/abstract/Js21384en//*/WHO./“Scanning/System,/Ultrasonic.”/From/the/publication:/Core(Medical(Equipment./Geneva,/Switzerland,/2011./ *Wikipedia./“/Medical/Ultrasound.”/Wikipedia,/pgs/1S15./Retrieved/from:/https://en.wikipedia.org/wiki/Medical_ultrasound/*




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