CULTURAL AND LINGUISTIC COMPETENCY Federal and State Law Regarding Linguistic Access and Services for Limited English Proficient Persons I. Purpose. This document is intended to satisfy the requirements set forth in California Business and Professions code 2190.1. California law requires physicians to obtain training in cultural and linguistic competency as part of their continuing medical education programs. This document and the attachments are intended to provide physicians with an overview of federal and state laws regarding linguistic access and services for limited English proficient (“LEP”) persons. Other federal and state laws not reviewed below also may govern the manner in which physicians and healthcare providers render services for disabled, hearing impaired or other protected categories II. Federal Law – Federal Civil Rights Act of 1964, Executive Order 13166, August 11, 2000, and Department of Health and Human Services (“HHS”) Regulations and LEP Guidance. The Federal Civil Rights Act of 1964, as amended, and HHS regulations require recipients of federal financial assistance (“Recipients”) to take reasonable steps to ensure that LEP persons have meaningful access to federally funded programs and services. Failure to provide LEP individuals with access to federally funded programs and services may constitute national origin discrimination, which may be remedied by federal agency enforcement action. Recipients may include physicians, hospitals, universities and academic medical centers who receive grants, training, equipment, surplus property and other assistance from the federal government. HHS recently issued revised guidance documents for Recipients to ensure that they understand their obligations to provide language assistance services to LEP persons. A copy of HHS’s summary document entitled “Guidance for Federal Financial Assistance Recipients Regarding Title VI and the Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons – Summary” is available at HHS’s website at: http://www.hhs.gov/ocr/lep/ As noted above, Recipients generally must provide meaningful access to their programs and services for LEP persons. The rule, however, is a flexible one and HHS recognizes that “reasonable steps” may differ depending on the Recipient’s size and scope of services. HHS advised that Recipients, in designing an LEP program, should conduct an individualized assessment balancing four factors, including: (i) the number or proportion of LEP persons eligible to be served or likely to be encountered by the Recipient; (ii) the frequency with which LEP individuals come into contact with the Recipient’s program; (iii) the nature and importance of the program, activity or service provided by the Recipient to its beneficiaries; and (iv) the resources available to the Recipient and the costs of interpreting and translation services. Based on the Recipient’s analysis, the Recipient should then design an LEP plan based on five recommended steps, including: (i) identifying LEP individuals who may need assistance; (ii) identifying language assistance measures; (iii) training staff; (iv) providing notice to LEP persons; and (v) monitoring and updating the LEP plan. A Recipient’s LEP plan likely will include translating vital documents and providing either on-site interpreters or telephone interpreter services, or using shared interpreting services with other Recipients. Recipients may take other reasonable steps depending on the emergent or nonemergent needs of the LEP individual, such as hiring bilingual staff who are competent in the skills required for medical translation, hiring staff interpreters, or contracting with outside public or private agencies that provide interpreter services. HHS’s guidance provides detailed examples of the mix of services that a Recipient should consider and implement. HHS’s guidance also establishes a “safe harbor” that
Recipients may elect to follow when determining whether vital documents must be translated into other languages. Compliance with the safe harbor will be strong evidence that the Recipient has satisfied its written translation obligations. In addition to reviewing HHS guidance documents, Recipients may contact HHS’s Office for Civil Rights for technical assistance in establishing a reasonable LEP plan. III. California Law – Dymally-Alatorre Bilingual Services Act. The California legislature enacted the California’s Dymally-Alatorre Bilingual Services Act (Govt. Code 7290 et seq. ) in order to ensure that California residents would appropriately receive services from public agencies regardless of the person’s English language skills. California Government Code section 7291 recites this legislative intent as follows: “The Legislature hereby finds and declares that the effective maintenance and development of a free and democratic society depends on the right and ability of its citizens and residents to communicate with their government and the right and ability of the government to communicate with them. The Legislature further finds and declares that substantial numbers of persons who live, work and pay taxes in this state are unable, either because they do not speak or write English at all, or because their primary language is other than English, effectively to communicate with their government. The Legislature further finds and declares that state and local agency employees frequently are unable to communicate with persons requiring their services because of this language barrier. As a consequence, substantial numbers of persons presently are being denied rights and benefits to which they would otherwise be entitled. It is the intention of the Legislature in enacting this chapter to provide for effective communication between all levels of government in this state and the people of this state who are precluded from utilizing public services because of language barriers.” The Act generally requires state and local public agencies to provide interpreter and written document translation services in a manner that will ensure that LEP individuals have access to important government services. Agencies may employ bilingual staff, and translate documents into additional languages representing the clientele served by the agency. Public agencies also must conduct a needs assessment survey every two years documenting the items listed in Government Code section 7299.4, and develop an implementation plan every year that documents compliance with the Act. You may access a copy of this law at the following url: http://www.spb.ca.gov/bilingual/dymallyact.htm
PRESENTING FACULTY COURSE CHAIRS Trevor Jensen, MD, MS Brandon Boesch, DO Assistant Professor of Medicine, Division of Hospital Chief of Hospital Medicine Medicine Internal Medicine Point of Care Ultrasound Director University of California, San Francisco Highland Hospital –A Member of Alameda Health System San Francisco, California Oakland, California COURSE PRESENTERS & TRAINER James E. Anstey, MD Assistant Professor, UCSF Division of Hospital Medicine Carolina Candotti, MD Assistant Professor of Medicine UC Davis Medical Center Sacramento, California Joel B. Cho, MD, RDMS, RDCS Director, Point-of-Care-Ultrasound Department of Hospital Medicine Kaiser San Francisco Internal Medicine Residency Program Senior Physician The Permanente Medical Group, Kaiser San Francisco San Francisco, California Stephanie M. Conner, MD Assistant Professor of Medicine, Division of Hospital Medicine University of California, San Francisco San Francisco, California Aubrey O. Ingraham, MD Hospitalist Kaiser Permanente Oakland Medical Center Oakland, California Andre D. Kumar, MD Clinical Assistant Professor Co-President, Society of Hospital Medicine Bay Area Stanford University School of Medicine Stanford, California Linda M. Kurian, MD, FACP, SFHM Chief, Division of Hospital Medicine Assistant Professor of Medicine Zucker School of Medicine at Hofstra/Northwell New York, New York Marc Kurtzman, MD Hospitalist The Permanente Medical Group, Kaiser San Francisco San Francisco, California
Farhan Lalani, MD Assistant Professor of Clinical Medicine University of California, San Francisco San Francisco, California Charlie LoPresti, MD Director of Point of Care Ultrasound Louis Stokes Cleveland VA Medical Center Associate Professor of Medicine Case Western Reserve University School of Medicine DISCLOSURES All of the faculty speakers, trainers, moderators, and planning committee members have disclosed they have no relevant financial relationship or affiliation with any commercial interests who provide products or services relating to their presentation(s) in this continuing medical education activity. This UCSF CME educational activity was planned and developed to: uphold academic standards to ensure balance, independence, objectivity, and scientific rigor; adhere to requirements to protect health information under the Health Insurance Portability and Accountability Act of 1996 (HIPAA); and, include a mechanism to inform learners when unapproved or unlabeled uses of therapeutic products or agents are discussed or referenced. This activity has been reviewed and approved by members of the UCSF CME Governing Board in accordance with UCSF CME accreditation policies. Office of CME staff, planners, reviewers, and all others in control of content have disclosed they have no relevant financial relationships with commercial interests.
COURSE SCHEDULE SUNDAY – OCTOBER 20, 2019 8:00 am Continental Breakfast and Pre-Test ( Room S-118 ) Registration Open 8:30 Welcome ................................................................................................................................ Chairs 9:00 Focused Cardiac Ultrasound ............................................................................ James Anstey, MD 9:45 Coffee Break 10:00 Scanning Live Models 1. Parasternal Long/Short 2. Apical 4 Chamber 3. Subcostal 4 Chamber and IVC 4. Abnormal Image Interpretation 12:00 pm Lunch ( Nursing Mezzanine ) 1:00 Lung & Thoracentesis ................................................................................ Stephanie Conner, MD 1:30 DVT, Central Venous Access, Skin/Soft Tissue ........................................... Charlie LoPresti, MD 2:00 Coffee Break 2:15 Scanning Live Models 1. Lung (BLUE Protocol) 2. Cardiac/Shock Protocols 3. Leg DVT/Soft Tissue 4. Abnormal Image Interpretation 4:15 Competency & Clinical Integration ........................................................... Trevor Jensen, MD, MS . Brandon Boesch, DO 5:00 pm Adjourn
MONDAY, OCTOBER 21, 2019 8:00 am Continental Breakfast 8:30 Abdominal Ultrasound ................................................................................... Brandon Boesch, DO 9:50 Coffee Break 10:00 Scanning Live Models 1. Aorta and Branches, Abdominal Wall Vessels 2. RUQ and GU 3. LUQ and GU 4. Abnormal Image Interpretation 12:00 pm Lunch ( Nursing Mezzanine) 1:00 POCUS HM Program Management ........................................................... Trevor Jensen, MD, MS 2:00 Coffee Break 2:15 Wrap-up, Post-Test 4:00 Free Scan (with Pathology) Scanning Live Models 4:45 pm Adjourn
10/9/2019 Point of Care Ultrasound UCSF Continuing Medical Education Cardiac Trevor Jensen, MD, MPH October 20-21, 2019 Disclosure I have no relevant financial relationships with any companies related to the content of this course. 1
10/9/2019 POCUS Cardiac and IVC Cardiac US • Keep it basic • Echocardiography is very complex • We will focus on the fundamentals that will help you care for your patients at the beside • These images will be used with the clinical history to make decisions on your patient 2
10/9/2019 Utility & Protocols • RUSH – Rapid Ultrasound in Shock – Patient is hypotensive or unresponsive • CLUE Protocol – Cardiopulmonary Limited Ultrasound Exam – Patient needs rapid assessment for heart failure • BLUE Protocol – Bedside Lung Ultrasound in Emergency – Patient is in respiratory failure Probe Selection Phased Array Low Frequency Small footprint to image between ribs 3
10/9/2019 How to Hold the Probe • Hold probe like a pencil • Brace hand on the patient • Larger motions that gradually become finer movements to improve image • Sufficient use of ultrasound gel Position of the Patient • Most likely will be supine in the ED/Hospital/ICU • Left Lateral Decubitus will usually result in improved images 4
10/9/2019 Sonographic Windows • 3 Windows • Parasternal • Apical • Subcostal Slide adapted with permission from Arun Nagdev Parasternal Short Parasternal Long Subcostal Apical 4-Chamber 5
10/9/2019 Parasternal Long: Probe + Position Parasternal Long Anatomy Images obtained from echocardiographer.org 6
10/9/2019 Parasternal Long Axis View RV RV LV LV RV RV LV LV Ao Mitral Valve Leaflets DTA Slide adapted with permission from Arun Nagdev Parasternal Long: Interpretation • Utility – Effusion – LV Function • Indices – Movement of mitral valve leaflet tips (EPSS) – Movement of lateral mitral valve annulus – LV Wall Thickening – Change in chamber size • Functional Categories (all views) – Hyperdynamic – Normal – Mildly decreased – Severely decreased 7
10/9/2019 Parasternal Long: Normal Parasternal Long: Abnormal 8
10/9/2019 Parasternal Long Tips • Stay close to sternum • Sonographic windows and axes vary • Difficult in COPD • Look for the Mitral Valve Parasternal Short: Position 9
10/9/2019 Parasternal Short: Orientation Parasternal Short: Orientation 10
10/9/2019 Parasternal Short: Interpretation • Utility – Gross LV systolic function – Assessed at level of papillary muscles – Regional wall motion abnormalities – RV size Parasternal Short: Normal 11
10/9/2019 Parasternal Short: Abnormal Parasternal Short Tips • Stay close to sternum • Sonographic windows and axes vary • Difficult in COPD • Look for the Mitral Valve 12
10/9/2019 Subcostal View: Position Subcostal View: Orientation 13
10/9/2019 Subcostal View: Interpretation • Utility – LV Systolic Function – Pericardial Effusion – Right atrium and ventricle size Subcostal View: Normal 14
10/9/2019 Subcostal View: Abnormal Subcostal 4 Chamber View • Tips: • Firm pressure • Inspiratory hold • Bend the knees • Bowel Gas? Try right of midline • Great for COPD patients 15
10/9/2019 Apical 4 Chamber • Utility – Systolic function – Chamber size – Valvular abnormalities – Doppler measurements • Challenges – most difficult view to obtain – prone to errors in interpretation Apical 4 Chamber: Orientation 16
10/9/2019 Apical 4 Chamber: Normal Apical 4 Chamber: Abnormal 17
10/9/2019 Apical 4 Chamber View • Tips : • Under the breast fold • Left lateral decubitus • End-expiratory hold • Aim sound waves toward right scapula Valvular disease 18
10/9/2019 Right Ventricle Evaluation IVC: Position 19
10/9/2019 IVC: Orientation IVC: Measurement 20
10/9/2019 IVC: Interpretation • Location: • 2‐3 cm caudal to RA or 0‐1 cm caudal to hepatic vein • Metrics • Max diameter: 2.1 cm • Collapsibility: 50% Don’t fall for Aorta! IVC Aorta 21
10/9/2019 Fan IVC/Aorta/IVC • IVC: Abnormal 22
10/9/2019 Summary • Focus on the basic exams + basic interpretations first – Most evidenced based for non‐cardiologists • Even basic exams have broad list of applications – Hypotension – Dyspnea – Volume overload – Unresponsiveness • Build towards more complex exams and protocols 23
10/9/2019 Point of Care Ultrasound Lung Ultrasound Stephanie Conner MD October 20, 2019 Objectives • Basic principles of lung ultrasound • Key lung ultrasound findings • Brief overview of thoracentesis windows 2 1
10/9/2019 Objectives • Basic principles of lung ultrasound • Key lung ultrasound findings • Brief overview of thoracentesis windows 3 Probe Selection Linear Phased array • Superficial depth • Deeper depth • High resolution • Lower resolution • Ideal for evaluating the • Ideal for evaluating a- pleural line, lung sliding lines, b-lines, consolidations, and effusions 4 2
10/9/2019 Patient Position: Ambulatory Chest. 2011;140(5):1332-1341. doi:10.1378/chest.11-0348 5 Hospitalized Patient Technique 3
10/9/2019 Anatomy of Lung Ultrasound Skin & soft tissue Ribs Pleural line Intercostal space Key Learning Point Ultrasound cannot visualize through bone or air. Therefore, everything we see in lung ultrasound is either: Artifact or Abnormal - A-lines - B-lines - Consolidation - Rib shadow - Pleural Effusion 4
10/9/2019 Lung scatter & A-lines Ultrasound scatters in air, so you can’t see through it Rib shadowing Rib shadow Ultrasound cannot penetrate through bone, so you can’t visualize deep to it. 5
10/9/2019 Key Learning Point Ultrasound cannot visualize through bone or air. Therefore, everything we see in lung ultrasound is either: Artifact or Abnormal - A-lines - B-lines - Consolidation - Rib shadow - Pleural Effusion Objectives • Basic principles of lung ultrasound • Key lung ultrasound findings (5) • Brief overview of thoracentesis windows 12 6
10/9/2019 A-lines (1 of 5) Reverberations between the highly reflective pleura and transducer Can be seen in any LZ DDx: • Normal • If no lung sliding: PTX • If hypoxic/dyspneic: asthma, COPD, PE 13 A- vs. B-lines 14 7
10/9/2019 B-lines (2 of 5) Propogation of US waves through the lungs 2/2 widening of the interlobular septa Differential diagnosis: • Pulmonary edema • Pneumonia • ILD • ARDS >3 b-lines in >2 zones bilaterally = interstitial syndrome . • 94% sensitivity, 92% specificity for pulmonary edema Features of B-lines • Arise from the pleural line • Obliterate a- lines • Move with lung sliding • Extend >12cm • Abnormal >3 in one LZ 8
10/9/2019 Clinical Correlation of B-lines Liteplo et al. Real-time resolution of sonographic B-lines in a patient with pulmonary edema on CPAP. AJEM (2010) • Case: Hx CHF, ESRD, dyspnea, orthopnea • Initial US: Diffuse B-lines • After CPAP x 3.5hrs: A-lines 17 Alveolar Consolidation (3 of 5) • “Hepatization of lung” • Ddx: PNA vs atelectasis • Clinical correlation, other POCUS signs (shred sign, air bronchograms) needed * Real world note: probably the most challenging application of lung US 18 9
10/9/2019 Case: 50 y/o male with cough & fever Liver 19 Pleural Effusion (4 of 5) • Identification of a hypoechoic or echo-free space surrounded by typical anatomic boundaries • Costophrenic angles bilaterally (LZ 4) • Simple vs complex 10
10/9/2019 RUQ/Perihepatic view: Normal Morison’s Pouch Diaphragm Costophrenic Recess 21 Typical anatomic boundaries: • Diaphragm (and abdominal organs) • Chest wall • Ribs • Visceral pleura • Lung Spine sign Pleural Effusion 11
10/9/2019 Simple vs complex effusions Pleural Effusion US more sensitive than XR or exam: • Exam > 300mL • CXR >200mL Liver • US > 20 mL Effusion Scan dependent zones Fluid is hypoechoic (black) Lung Spine sign 24 12
10/9/2019 Lung Findings Summary • US for B-lines, consolidation, and pleural effusion = more sensitive than physical exam or CXR • Faster to acquire than CXR • Less radiation 25 Pneumothorax (5 of 5) 26 13
10/9/2019 Key Principle: Lung Sliding Movement of visceral pleura against parietal pleura with respiratory motion Linear probe B- and M-mode Findings: Syndrome Lung sliding? A-lines? B-lines? Normal √ √ Pneumothorax √ Pneumonia ± √ Is Pleural Sliding Present? 28 14
10/9/2019 Pneumothorax Is Pleural Sliding Present? When in doubt… M-mode 29 Normal M-mode of Lung Soft Ocean Tissue Normal Beach Lung 30 15
10/9/2019 Abnormal M-mode: PNEUMOTHORAX Soft Tissue Ocean / Barcode Abnormal Lung 31 The Lung Point Interface of normal lung sliding and absent lung sliding • Sensitivity: 0.66 • Specificity: 1.00 (Lichtenstein 233 ICU pts vs CT) 32 16
10/9/2019 Summary: US in pneumothorax • Outperforms CXR in supine patients • Much higher sensitivity, similar specificity • Lower specificity in critically ill ICU patients • False positives with pleural scarring, TB, ARDS (specificity 60-91%) • Lung Point: 100% specificity 33 Summary of Findings in Dyspnea/Hypoxia Findings Diagnosis A lines Asthma, COPD, PE Cardiogenic Diffuse B lines pulmonary edema Loss of pleural line, Pneumonia consolidation, focal B lines A lines without pleural Pneumothorax sliding, lung point 17
10/9/2019 Objectives • Basic principles of lung ultrasound • Key lung ultrasound findings • Brief overview of thoracentesis windows 35 Thoracentesis 36 18
10/9/2019 37 US Guidance in Thoracentesis • Find fluid on ultrasound • Establish landmarks for safe needle insertion with adequate depth • Usually not done under direct US guidance • Check for lung sliding before AND after the procedure 38 19
10/9/2019 Safe for thoracentesis? 39 Safe for thoracentesis? 40 20
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10/9/2019 Point of Care Ultrasound UCSF Continuing Medical Education DVT Charlie LoPresti, MD October 20-21, 2019 Disclosure I have no relevant financial relationships with any companies related to the content of this course. 1
10/9/2019 DVT 3 DVT for the Hospitalist? • Compression of veins at bedside • Immediate results • Available nights and weekends • Able to repeat the exam • Accuracy is good 2
10/9/2019 LE DVT US: Anatomy LE DVT US: Probe 3
10/9/2019 2 “points” = 2 Regions, 6 Clips – Proximal Thigh = From CFV to Middle/Distal SFV (5 Clips) – Popliteal Fossa = Pop Vein 3‐ 4cm above crease (1 Clip) LE DVT US: Positions 4+ 4
10/9/2019 LE DVT US: Compression technique • Compression is adequate • Doppler does not improve sensitivity and specificity but may help identify and confirm vessels • Visible Thrombus is diagnostic • Non compressible vein is diagnostic 5
10/9/2019 1. Common Femoral Vein 2. Common Femoral Vein at Greater Saphenous 6
10/9/2019 3. Common Femoral Vein at Lateral Perforator 4. Common and Deep Femoral Veins 7
10/9/2019 4+. (Superficial) Femoral Vein Mid Thigh 5. Popliteal Vein 8
10/9/2019 LE DVT US: Pitfalls • Finding vessels – Inadequate depth • False Positives – Inadequate pressure – Caught on hamstring tendon – Lymph nodes – Overcalling branch of pop artery as pop DVT View? Side? Abnormality? 04.35.14 hrs __[0006225] 9
10/9/2019 Summary • Learn the anatomy • 2 region exam (no longer 2 point) • Compression is key • Be mindful of pitfalls 10
10/9/2019 Point of Care Ultrasound UCSF Continuing Medical Education Skin and Soft Tissue and Central Venous Cannulation Charlie LoPresti, MD October 20-21, 2019 Disclosure I have no relevant financial relationships with any companies related to the content of this course. 1
10/9/2019 Skin and Soft Tissue Ultrasound SSTI Ultrasound US can differentiate between cellulitis and abscess Reverberation artifact can show air in soft tissue representing necrotizing fasciitis 4 2
10/9/2019 Transducer High frequency linear transducer for depth up to 4 cm 5 nd. A, brachial artery; B, bone; F, fascia; M, muscle; N, nerve; V, Soni N., Arntfield R., & Kory P. (2019) Point-of-Care ultrasound. Philadelphia: Elsevier 6 3
10/9/2019 Cobblestoning 7 Abscess Soni N., Arntfield R., & Kory P. (2015) Point-of-Care ultrasound. Philadelphia: Elsevier 8 4
10/9/2019 Posterior Acoustic Enhancement Soni N., Arntfield R., & Kory P. (2020) Point-of-Care ultrasound. Philadelphia: Elsevier 9 Abscess with ?Nec Fasc 10 5
10/9/2019 Rib Fracture Soni N., Arntfield R., & Kory P. (2015) Point-of-Care ultrasound. Philadelphia: Elsevier 11 Anisotropy Soni N., Arntfield R., & Kory P. (2020) Point-of-Care ultrasound. Philadelphia: Elsevier 12 6
10/9/2019 Joints - Ultrasound useful for joint effusions at multiple joints in the hospitalized patient Soni N., Arntfield R., & Kory P. (2020) Point-of-Care ultrasound. Philadelphia: Elsevier 13 Goals for scanning - Look at the soft tissue planes in the leg - Identify vessels, bone, muscle, possibly lymph nodes - Can look at the abdominal wall to see rectus and epigastric vessels - Can look in forearm for tendons, nerves, arteries, veins, muscle, bone 14 7
10/9/2019 Central Venous Cannulation 15 Pre Procedure Technique Position the machine for easy viewing Check Lung Sliding Look at entire vessel on both sides of the neck Look for compressibility, clot, stenosis 16 8
10/9/2019 Identify the Vein Not always this obvious Compression technique Color Doppler Soni N., Arntfield R., & Kory P. (2015) Point-of- Care ultrasound. Philadelphia: Elsevier 17 Soni N., Arntfield R., & Kory P. (2015) Point-of-Care ultrasound. Philadelphia: Elsevier 18 9
10/9/2019 Use Color Doppler Red means flow towards the probe, not arterial flow To identify the artery, look for pulsatile appearance and disappearance of color Mosaic, continuous flow indicates a vein 19 Technique Prepare all materials in order needed for procedure on sterile tray or drape Select best target site Place needle with real time US guidance Visualize wire in vein with US prior to dilation Check lung sliding after procedure 20 10
10/9/2019 Out of plane visualization Longitudinal Approach Transverse Approach 21 22 Soni N., Arntfield R., & Kory P. (2015) Point-of-Care ultrasound. Philadelphia: Elsevier 11
10/9/2019 Visualize the Wire 23 Scanning Today - Visualize the right and left IJ, carotid, and surrounding structures - Figure out the best location to place a line on your model and demonstrate with your finger - At the table IV models, try to follow your needle tip into the vessel in both transverse and longitudinal 24 12
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10/9/2019 Point of Care Ultrasound UCSF Continuing Medical Education Abdominal Imaging and Procedures Brandon Boesch, DO Disclosure I have no relevant financial relationships with any companies related to the content of this course. 1
10/9/2019 3 Soni N., Arntfield R., & Kory P. (2015) Point-of-Care ultrasound. Philadelphia: Elsevier Areas to Identify Soni N., Arntfield R., & Kory P. (2015) Point-of-Care ultrasound. Philadelphia: Elsevier 4 2
10/9/2019 Probe Selection Phased Array Curvilinear 5 Probe Position - Knuckles on the bed - Adjust probe angle for view between ribs and take into account the angle of abdominal organs 6 3
10/9/2019 Probe position 7 8 4
10/9/2019 Normal RUQ View Soni N., Arntfield R., & Kory P. (2015) Point-of-Care ultrasound. Philadelphia: Elsevier 9 RUQ/Perihepatic view Normal Abnormal 10 5
10/9/2019 RUQ/Perihepatic view Normal Abnormal 11 RUQ/Perihepatic view Normal Abnormal 12 6
10/9/2019 RUQ/Perihepatic view Normal Abnormal 13 RUQ/Perihepatic view Normal Abnormal 14 7
10/9/2019 Gallbladder Can be a very challenging exam False positives are very common in hospitalized patients Soni N., Arntfield R., & Kory P. (2015) Point-of-Care ultrasound. Philadelphia: Elsevier 15 Gallbladder 16 8
10/9/2019 Wall Echo Shadow 17 Gallbladder or something else? 18 9
10/9/2019 Normal LUQ Soni N., Arntfield R., & Kory P. (2015) Point-of-Care ultrasound. Philadelphia: Elsevier 19 LUQ Positioning 20 10
10/9/2019 21 LUQ/Perisplenic view Normal Abnormal Soni N., Arntfield R., & Kory P. (2015) Point-of-Care ultrasound. Philadelphia: Elsevier 22 11
10/9/2019 LUQ/Perisplenic view Normal Abnormal Soni N., Arntfield R., & Kory P. (2015) Point-of-Care ultrasound. Philadelphia: Elsevier 23 Goals for Scanning Stations - Identify all the structures in RUQ and LUQ - Look for the large vessels and spine deep on the image - Practice scanning the gallbladder. Find and name structures that you do know. 24 12
10/9/2019 Kidney Anatomy 2 Anatomical Sections ➔ Sonographic “Double Density” Renal Parenchyma = Cortex + Medulla Renal Sinus = Fatty tissue + Calyces + Vessels Image Acquisition From Point-of-Care Ultrasound, 1 st edition, 2014 13
10/9/2019 Normal Kidneys 1. Perinephric fat + Gerona's fascia = hyperechoic 2. Renal cortex = hypoechoic 3. Medullary pyramids = hypo-/anechoic 4. Renal sinus = hyperechoic with small pockets of urine (not contiguous) and vessels 5. Ureter normally obscured by bowel gas Normal 14
10/9/2019 Renal Pathologies Atrophy Hydronephrosis Stone Cysts Mass Atrophic Kidney 15
10/9/2019 Hydronephrosis Mild = central dilation with preservation of renal pyramids Moderate = blunting of renal pyramids, rounding of calices, “bear-claw” appearance, preservation of cortex Severe = cortical thinning, calyceal ballooning, distortion of architecture Mild Hydronephrosis From Point-of-Care Ultrasound, 1 st edition, 2014 16
10/9/2019 Severe Hydronephrosis From Point-of-Care Ultrasound, 1 st edition, 2014 Bladder Indications Estimate bladder volume Confirm catheter placement Ureteral obstruction (ureteral jets) Detect stones Work-up for renal failure 17
10/9/2019 Bladder Anatomy Posterior and inferior to symphysis pubis (tilt US beam into pelvis) Ureters enter trigone on postero-inferior From Point-of-Care Ultrasound, 1 st edition, 2014 wall Prostate normally <5cm transversely Image Acquisition Transverse View Longitudinal View 18
10/9/2019 Normal Male Bladder Transverse View Foley + Decompressed Bladder 19
10/9/2019 Distended Bladder + Foley + Enlarged Prostate Bladder Volume Estimation Volume (ml) = 0.75 x width x length x height Transverse View Longitudinal View 20
10/9/2019 Anatomy of Aorta From Point-of-Care Ultrasound, 1 st edition, 2014 Image Acquisition Transverse Longitudinal 21
10/9/2019 Transverse Longitudinal Complete Exam of Aorta From Point-of-Care Ultrasound, 1 st edition, 2014 22
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