Point of Care Ultrasound UCSF Continuing Medical Education Cardiac Trevor Jensen, MD, MPH October 21-22, 2018
Disclosure I have no relevant financial relationships with any companies related to the content of this course.
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
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
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
Sonographic Windows • 3 Windows • Parasternal • Apical • Subcostal Slide adapted with permission from Arun Nagdev
Parasternal Long Parasternal Short Subcostal Apical 4-Chamber
Parasternal Long: Probe + Position
Parasternal Long Anatomy Images obtained from echocardiographer.org
Parasternal Long Axis View RV LV RV 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
Parasternal Long: Normal
Parasternal Long: Abnormal
Parasternal Long Tips • Stay close to sternum • Sonographic windows and axes vary • Difficult in COPD • Look for the Mitral Valve
Parasternal Short: Position
Parasternal Short: Orientation
Parasternal Short: Orientation
Parasternal Short: Interpretation • Utility – Gross LV systolic function – Assessed at level of papillary muscles – Regional wall motion abnormalities – RV size
Parasternal Short: Normal
Parasternal Short: Abnormal
Parasternal Short Tips • Stay close to sternum • Sonographic windows and axes vary • Difficult in COPD • Look for the Mitral Valve
Subcostal View: Position
Subcostal View: Orientation
Subcostal View: Interpretation • Utility – LV Systolic Function – Pericardial Effusion – Right atrium and ventricle size
Subcostal View: Normal
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
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
Apical 4 Chamber: Normal
Apical 4 Chamber: Abnormal
Apical 4 Chamber • Tips : • Under the breast fold • Left lateral decubitus • End-expiratory hold • Aim sound waves toward right scapula
IVC: Position
IVC: Orientation
IVC: Measurement
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
Fan IVC/Aorta/IVC •
IVC: Abnormal
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
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