The Holistic Approach (HOLA) concept of ultrasound
imaging in clinical practice and medical education
Poster No.:
C-1993
Congress:
ECR 2016
Type:
Educational Exhibit
Authors:
G. Petrocheilou , P. ARGYRIOU , C. Gillmann , M. Blaivas , D.
1
4 1
2
3
2
4
3
Karakitsos ; Alimos, Athens/GR, Athens/GR, Erlangen/DE,
4
South Carolina/US
Keywords:
Emergency, Management, Ultrasound, Education, eLearning,
Education and training
DOI:
10.1594/ecr2016/C-1993
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Page 1 of 14
Learning objectives
The aim of this presentation is to analyze the Holistic Approach (HOLA) concept of
ultrasound imaging in clinical practice and medical education.
Background
Ultrasound is a rapid, real-time, hands-on patient imaging modality with excellent safety
profile. The above features have made ultrasound a highly informative component of the
physical examination in most medical disciplines with a tremendously expanding clinical
role over the past 70 years. Still, most medical systems do not take full advantage of the
real-time nature, universality, and versatility of ultrasound imaging.
Findings and procedure details
Sonographic images of adult patients from the Radiology Department and Intensive Care
Unit are retrospectively analysed to present HOLA ultrasound clinical logistics.
The HOLA concept of ultrasound imaging (suggested by Dimitrios Karakitsos and further
refined by Ashot Ernest Sargysan and Michael Blaivas) defines ultrasound as part of the
physical examination by a clinician, to visualize all or any parts of the body, tissue, organs
and systems in their live, anatomically and functionally interconnected state and in the
context of the whole patient's clinical circumstances. The term "holistic" in the HOLA
acronym is used in its original meaning in ancient Greek, to emphasize the importance
of the whole and the interdependence of its parts.
HOLA scanning can be performed from head to toes. HOLA starts from the head
(Fig. 1 on page 3, Fig. 2 on page 4) by accessing temporal and ophthalmic
windows for TCD (Transcranial Doppler), eye and orbit ultrasound. Facial structures can
be also scanned using appropriate machine settings. Neck, supra- and infraclavicular
and upper limb exploration(Fig. 3 on page 5, Fig. 4 on page 6, Fig.
5 on page 7) provides information about the trachea, neurovascular structures,
thyroid and soft tissues. General chest ultrasound comprises lung and pleural space
scanning (subpleural lung parenchyma, diaphragmatic and pleural space pathology)
(Fig. 6 on page 8) and echocardiography (cardiac and pericardial abnormalities and
hemodynamic assessment) (Fig. 7 on page 9). Abdominal scanning integrates the
FAST components for free fluid detection and the aorta ( Fig. 8 on page 10 ), but also
explores the solids organs, the gastrointestinal tract and the urogenital system ( Fig. 9
Page 2 of 14
on page 11 ). Exploration of the inguinal region (common site for vascular access and
corresponding complications) is extended to the lower limbs ( Fig. 10 on page 12 ).
The HOLA concept is adjustable to meet the diagnostic and monitoring specificities
of individual clinical scenarios (e.g., trauma, sepsis etc.), as it can be easily scaled
down to specific application profiles. Although HOLA could be interpreted globally as the
transducer being applicable to all surfaces and tissues, it rather defines the scope of
clinical critical care practice, while creating appropriate referrals that require additional
ultrasound expertise.
Ultrasound-guided procedures and development of complex evaluation protocols (e.g.,
combination of lung, cardiac ultrasound, and vena cava analysis, linked with clinical
and laboratory data to assess volume status) are examples of clinically driven modular
applications of the HOLA ultrasound concept.
Pilot academic programs in North America integrate ultrasound scanning using it for
educational purposes as an adjunct to the physical examination.
Images for this section:
Page 3 of 14
Fig. 1: Anterior (1), middle (2) and posterior (3) temporal windows to perform TCD (a) Bmode transcranial ultrasound showing hydrocephalus. (b) Transcranial Doppler depicting
pulsatility index within normal limits in a brain injured patient.
© Radiology and ICU Department, General Hospital of Gennimatas and 401 Military
General Hospital, Athens, Greece
Page 4 of 14
Fig. 2: Ophthalmic window to perform TCD and ocular ultrasound and scanning of
maxillary sinuses and other facial structures. (a) Ocular ultrasound showing increased
optic nerve sheath diameter (> 0.6 cm) in craniocerebral injury. (b) View through the
submandibular gland showing sialolithiasis - a dilated duct and an intraductal stone
(arrow) with acoustic shadowing.
© Radiology and ICU Department, General Hospital of Gennimatas and 401 Military
General Hospital, Athens, Greece
Page 5 of 14
Fig. 3: Neck scanning zones. (a) Median line transverse view at the level of thyroid gland.
(b) Visualization of a calcified thrombi remnant (arrow) attached to the internal jugular
vein (IJV) wall (SCM= sternocleidomastoid muscle).
© Radiology and ICU Department, General Hospital of Gennimatas and 401 Military
General Hospital, Athens, Greece
Page 6 of 14
Fig. 4: Supraclavicular and infraclavicular approaches extending laterally showing (a)
partial thrombosis of the subclavian vein (SCV), (c) a corresponding image of CT
venography.
© Radiology and ICU Department, General Hospital of Gennimatas and 401 Military
General Hospital, Athens, Greece
Page 7 of 14
Fig. 5: Upper limb exploration. (a) Partial thrombosis in the axillary vein (AXV). (b)
Complete thrombosis of the right brachial arterial (RBA) with monophasic flow in right
ulnar artery (RUA).
© Radiology and ICU Department, General Hospital of Gennimatas and 401 Military
General Hospital, Athens, Greece
Page 8 of 14
Fig. 6: Thoracic wall, Lung and Pleural ultrasound. (a) Sternal fracture (arrow). (b) Pleural
effusion and lung consolidation with air-bronchogram. (c) Lung atelectasis floating within
a pleural effusion.
© Radiology and ICU Department, General Hospital of Gennimatas and 401 Military
General Hospital, Athens, Greece
Page 9 of 14
Fig. 7: Transthoracic echocardiography. (a) Subxiphoid view showing a small
pericardial effusion. (b) Bacterial endocarditis of the aortic valve (transesophageal
echocardiography).
© Radiology and ICU Department, General Hospital of Gennimatas and 401 Military
General Hospital, Athens, Greece
Page 10 of 14
Fig. 8: HOLA abdominal scanning paths: upper abdominal scans; extended intercostal
and right subcostal oblique scans; right and left flank scans; suprapubic and lower pelvic
views; scanning of vessels (midabdominal). (a) and (b) Perihepatic and perisplenic fluid
in a trauma patient is hemoperitoneum. (c) Infrarenal abdominal aortic aneurysm with
mural thrombus (sagittal view). (d) A big stone in the bladder: echogenic mass on the
bladder floor with acoustic shadowing.
© Radiology and ICU Department, General Hospital of Gennimatas and 401 Military
General Hospital, Athens, Greece
Page 11 of 14
Fig. 9: HOLA abdominal scanning paths: scanning of solid organs; scanning of small
and large intestine. (a) Dilated intrahepatic ducts parallel to adjacent portal branches
("double barrel gun appearance"). (b) Cholecystitis. Dilated gallbladder with sludge and
wall thickening. (c) Pyonephrosis: Layering pus (arrow) in a dilated collecting system. (d)
Obstructive ileus: dilated (> 3 cm) small intestinal loops.
© Radiology and ICU Department, General Hospital of Gennimatas and 401 Military
General Hospital, Athens, Greece
Page 12 of 14
Fig. 10: Inguinal area and Lower limb exploration: (a) Superficial femoral artery (SFA)
pseudoaneurysm complicating central venous catheterization of common femoral vein.
Almost complete thrombosis of popliteal vein (POPV). (c) Baker cyst in popliteal fossa.
© Radiology and ICU Department, General Hospital of Gennimatas and 401 Military
General Hospital, Athens, Greece
Page 13 of 14
Conclusion
•
•
•
Radiologists should be aware of the HOLA clinical logistics. Hence, their role
in any in- and out-of- hospital setting can be valuable as pertinent ultrasound
examinations could be tailored to meet the diagnostic and monitoring needs
of individual clinical scenarios (e.g., trauma, sepsis) following expert input.
Although ultrasound routinely deals with acoustic barriers, there should be
no barriers in the way of its implementation in clinical practice.
Ultrasound imaging is a "wave" moving forward, leading us all towards an
era of "visual medicine" in the direction of more vigorous, operationally
responsive and efficient patient care.
Personal information
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