Cardiology

Case: RUSH Exam Part 2

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Series 2 of 4, This video represents a comprehensive algorithym for the intergration of bedside ultrasound for patients in shock. By focusing on "Pump, Tank, and the Pipes," clinicians will gain crucial anatomic and physiologic data to better care for these patients.

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- [Voiceover] Welcome back to SoundBytes Ultrasound.
My name is Dr. Phil Perera
and in this video we're going to look further
onto the Rapid Ultrasound in Shock examination
or the RUSH evaluation,
specifically examining part one,
evaluation of the pump or evaluation of cardiac status
in hypotensive patient.
In the last video I showed this table,
which encompasses a lot of information.
However let's focus on line one.
We can see here how evaluation of the pump
can further assess which type of shock our patient has
by seeing characteristic findings of the heart
within the four categories of shock.
Hopefully we'll begin to make more sense of this table
by moving through this first video.
Step one, evaluation of the pump,
encompasses three main elements,
the first of which is to examine the heart
for the presence of a pericardial effusion.
If a pericardial effusion is seen,
to further evaluate the heart
for potential cardiac tamponade
requiring pericardiocentesis.
Step number two would be to evaluate the left ventricle
for contractility as an assessment of how much fluid
this heart can handle.
Part three would be assessment of the heart
for right ventricular strain,
which in the right clinical context
may signify a massive pulmonary embolis
as the etiology for hypotension.
For the evaluation of the pump or cardiac evaluation,
we're going to utilize the three main cardiac windows.
Here we see the first major one, probe position A,
which is the parasternal window onto the heart.
In this window there's two main views,
the parasternal long and short axis views of the heart.
We can also move the probe further inferiorly
to the subxiphoid position that is shown
in probe position B
where we can see the heart from the more inferior aspect.
We can then move the probe more laterally
to probe position C, the apical window onto the heart,
where there's several views that can be used here
to evaluate the heart from a more lateral orientation.
Let's review how to perform the cardiac evaluation
by beginning with the parasternal long axis view
of the heart.
Here we want to use a smaller footprint phased array probe
that can easily fit in between the ribs
to get a good view onto the heart.
We'll generally begin in intercostal space 3 or 4
with the marker dot on the probe
down towards the patient's left elbow.
That's with a caveat that the ultrasound screen indicator
is maintained toward the left of the screen.
Now moving the patient into left lateral decubitus position
may aid in assessment of the heart,
as it moves the heart closer to the chest wall
and may give you a better view
if it's difficult to see the heart initially
with the patient supine.
Here is the anatomy of the heart that we'll see
from the parasternal long axis view.
Notice that the right ventricle
will be the most superficial chamber,
and just deep and to the left of the right ventricle
we'll see the left ventricle.
We also see the left atrium
to the right of the left ventricle,
and the mitral valve in between the two chambers.
Now to the right of the left ventricle
we'll see the aortic valve,
and to the right of the aortic valve
we'll see a small part of the left ventricular
outflow tract.
Here's a video of the parasternal long axis view
of the heart in action.
Again, we'll remember the right ventricle
as the most superficial chamber
and deep to the right ventricle, the left ventricle.
We see here the left atrium
to the right of the left ventricle,
and notice the mitral valve flipping up and down
in between the left atrium and the left ventricle.
We also see the aortic valve there
to the right of the left ventricle,
and another very important structure to look for
on the parasternal long axis of the heart
is the descending aorta,
which would be a cylinder in cross section
just posterior to the left atrium.
That will define the posterior pericardial reflection,
which we can see here with a small indicator arrow.
This is very important when we try to determine
if fluid around the heart is pericardial or pleural,
as we'll go through in some upcoming videos.
This illustration reinforces the difference
between pericardial and pleural effusion
from the parasternal long axis view.
In the image to the left,
I'm first showing the descending aorta,
that cylinder seen in cross section
just posterior to the mitral valve.
Notice the posterior pericardial reflection,
that white line that comes off
just anterior to the descending aorta.
In this case we see fluid,
but notice that it layers out anterior to
the descending aorta and posterior pericardial reflection,
and therefore it's within the pericardial sac.
That's to be differentiated from the image to the right,
where we again identify the descending aorta
and the posterior pericardial reflection.
Notice here that the fluid is posterior to both,
and therefore within the pleural cavity.
Those are some very important landmarks to identify
when trying to figure out if fluid is pericardial
versus pleural.
Next we'll take a look at a video.
Here again we'll begin by identifying
the posterior pericardial reflection
and the descending aorta.
Notice the descending aorta,
seen just posterior to the left atrium,
and the white line that is the pericardium,
or the posterior pericardial reflection.
I'll identify that with a small indicator arrow,
first tracing the descending aorta
and next the posterior pericardial reflection.
Now we see anechoic or dark fluid around the heart here,
but notice that it's anterior to both the descending aorta
and the posterior pericardial reflection,
and therefore it's within the pericardial sac.
In fact here we can see some fluid anterior to the heart
as well as posterior.
Now let's take a look at another video,
first identifying the descending aorta
and posterior pericardial reflection.
We'll look at those with a small indicator arrow,
again identifying the descending aorta
and the posterior pericardial reflection.
Here we see a large amount of anechoic or dark fluid,
but notice here it's posterior to both the descending aorta
and the posterior pericardial reflection.
In this case this is a pleural effusion
and not pericardial.
Notice we can also see lung moving back and forth
as the patient breathes within the pleural effusion.
Now that we've learned how to determine
if fluid is pericardial versus pleural,
let's look at this video clip.
We'll first identify that descending aorta
and posterior pericardial reflection,
and we see that this fluid is anterior to both
and therefore pericardial.
The next step would be to look at the right side
of the heart, in this case the right ventricle,
for diastolic deflection that could indicate
early tamponade physiology.
We can see here that there's fluid
both anterior and posterior to the heart,
and we notice the serpentine deflection
of the right ventricle
that is worrisome for early tamponade physiology,
and in fact this patient's blood pressure
was noted to be decreasing on serial evaluations.
The next step in pump evaluation or cardiac evaluation
is to determine contractility of the left ventricle.
Here we see the three main chambers
as seen from the parasternal long axis view of the heart,
the right ventricle, left atrium,
and as shown by the small indicator arrow,
the left ventricle.
Notice that during systole,
the endocardial walls of this left ventricle
almost close down completely,
indicating excellent contractility.
We can also see that the anterior leaflet
of the mitral valve flips open
and almost slaps up against the septum with each heartbeat,
indicating again good contractility of the left ventricle.
If this patient was hypotensive,
we could actually give this patient quite a lot of fluid
before putting the patient into pulmonary edema.
We can further investigate contractility
by calculating fractional shortening of the left ventricle.
This is commonly done by using M-mode ultrasound
and placing the cursor across the left ventricle
from the parasternal long axis view.
Here we see the tracings of the right ventricle,
the septum as shown with a small indicator arrow,
and now the posterior wall.
Here we see the chamber size and maximum
of the left ventricle during diastole
and there is systole.
We can calculate end-diastolic diameter,
which is shown here by caliper A
and measured at 2.96 centimeters of the left ventricle.
We can also measure end-systolic diameter
of the left ventricle as shown by caliper B
at 1.0 centimeters.
To calculate fractional shortening,
what we take is a difference between end-diastolic diameter
and end-systolic diameter
over end-diastolic diameter.
That gives us here a fractional shortening of 62%.
Anything above 35% to 40% is considered normal
and in this case we would gauge excellent contractility,
as judged by a calculation of fractional shortening.
Now let's take a look at another patient
who came into the emergency department
with a low blood pressure of 80 over palp.
Here we see the three main chambers
from the parasternal long axis view,
and notice the very poor contractility
of the left ventricle.
We can see that the endocardial walls move little
from diastole through to systole,
and we can further see that there's little motion
of the mitral valve.
This indicates poor blood flow
between the left atrium and left ventricle,
corroborating a low contractility status.
In this patient we're going to have to be careful
about the amount of fluid loading,
as this patient may easily go into pulmonary edema.
We can calculate the fractional shortening
of this hypocontractile heart
by placing the M-mode cursor across the left ventricle,
and we see A, end-systolic diameter of 3.78.
We can also look at the widest diameter as B,
end-diastolic diameter,
which is calculated at 5.17 centimeters.
Therefore this fractional shortening is much decreased
at 27%.
Let's move on to discuss the parasternal short axis view
of the heart.
A pearl here is not to take the probe off of the chest
once you've obtained the parasternal long axis
view of the heart.
Simply rotate the probe 90 degrees clockwise,
so now the indicator dot on the probe
is down toward the patient's right hip.
That's with the caveat that the ultrasound screen
indicator dot is positioned to the left of the screen.
Again moving the patient into left lateral
decubitus position may help imaging
from this parasternal short axis view.
From the parasternal short axis view of the heart,
we'll be imaging the heart in cross section.
Therefore we'll see the left ventricle in cross section
as a cylinder to the bottom right of the image
and the right ventricle to the upper left.
Let's now look at a video of the parasternal short axis
view of the heart.
We can again see that the left ventricle
would be the prominent chamber, cut in cross section.
Here we can actually see the mitral valve
moving up and down through each heartbeat.
Notice again the good contractility of this left ventricle.
All the walls come in well from diastole through systole.
If this was a patient in shock,
we can go ahead and give plenty of fluids
before starting the patient on pressors.
Next let's take a look at another heart.
Here we see a patient who came into the emergency department
with a blood pressure of 70 over palp
and a fast heart rate.
We can notice that the left ventricle
is very hyperdynamic,
meaning that it's almost completely squeezing down
during systole and also tachycardic.
This is usually seen in a septic or hypovolemic condition,
indicating that this is a heart that's begging for fluids.
The right action would be to fluid load in this patient.
In this video clip we see another finding.
We see behind the left ventricle
an anechoic or dark fluid collection surrounding the heart.
I'll show that with a small indicator arrow.
This is a pericardial effusion
circumferentially surrounding the heart here.
Notice that it layers out behind the left ventricle
and right ventricle.
Let's now take another look at a parasternal short axis view
of the heart in hypotensive patient.
Here we see very poor contractility of the left ventricle,
as shown here with the small indicator walls
by very little endocardial movement
from diastole through to systole.
Also notice the very poor movement or little movements
of the mitral valve during the cardiac cycle.
This is a pump in jeopardy
and one which we want to be careful
about the amount of fluids that we give
during a resuscitation.
We can also put M-mode ultrasound
directly across the left ventricle in short axis,
again looking at the change from end-diastole
through end-systole,
just getting a fractional shortening
and again confirming very poor contractility
or poor function of the cardiac pump.
The next cardiac imaging window that we'll discuss
is the subxiphoid.
Here the probe is placed under the xiphoid tip
of the sternum,
aiming the probe down and up towards the left shoulder.
Now we want to keep the marker dot on the probe
towards the right side of the patient
with the caveat that the ultrasound screen indicator
is positioned to the left of the screen.
From this view, we're looking from an inferior position
up towards the heart,
and we're going to see the liver as our acoustic window
onto the heart,
and the right side of the heart closer to the probe.
We'll see the right ventricle and right atrium
close to the probe,
and further away the left ventricle and left atrium.
We can also see the tricuspid and mitral valves
from this view.
Here's a video clip of a heart
taken from the subxiphoid window.
We recall that the liver is our acoustic window
from this view and we see the right side chambers,
superficial and to the top of the screen.
We see the right ventricle and the right atrium
with the tricuspid valve flipping up and down
in between the two chambers.
We see the left ventricle
and with a small indicator arrow there,
I'm showing the poor contractility of this left ventricle.
Notice the poor percentage change
through from diastole through to systole.
We see the left atrium to the left of the left ventricle
and the mitral valve.
Now with a small indicator arrow,
I'm now tracing the posterior pericardial reflection
around the heart,
and there is the anterior pericardial reflection.
We can call these also near field and far field
pericardial reflections as well.
Notice here that there's no fluid
within the pericardial sac.
In this case we would not have to perform
a pericardiocentesis,
but we notice that the contractility of this left ventricle
is compromised.
Here's another subxiphoid view of the heart
taken from a hypotensive patient.
Right away we notice a positive finding.
We see the right ventricle anterior
and the left ventricle posterior,
and we see here an anechoic or dark fluid collection
layering out around the heart circumferentially.
With a small indicator arrow,
I'm showing the near field pericardium
and fluid directly underneath that
surrounding the heart,
and also around the posterior aspect of the heart
just above the posterior pericardial reflection.
In this case we have a pretty large circumferential
pericardial effusion present.
Once we document a pericardial effusion,
we want to look for the motion of the right side
of the heart to look for diastolic deflection.
Here's normal motion of the heart,
even in the presence of a pericardial effusion.
To the left we see systole with all of the chambers small
and diastole to the right,
and we can see full expansion of both the right atrium
and the right ventricle.
Even though this patient has a pericardial effusion,
we're failing to see secondary signs of cardiac tamponade
as evidenced by either compression of the right atrium
or the right ventricle during diastole.
This illustration demonstrates diastolic compression
of the right ventricle that occurs
during cardiac tamponade physiology.
In the image to the left we see normal systole
with all of the chambers small,
and to the right we see diastolic compression
of the right ventricle,
meaning that the right ventricle never fully expands
during diastole.
Now cardiac tamponade physiology
will first affect the right side of the heart
because of the relatively lower pressure system
as reference to the left side of the heart.
In this video clip taken from a patient
who had declining blood pressures on serial evaluations
in the emergency department,
we first identify a pericardial effusion
from the subxiphoid view.
Looking closer at the right ventricle,
we see a deflection of the RV during diastole.
Now while not completely compressed in,
this early diastolic deflection
is concerning for early tamponade physiology,
and indeed this patient went on to full tamponade physiology
with time requiring a pericardiocentesis.
Again it's going to be a spectrum of findings of the RV
from early diastolic deflection on to full compression.
Here we can see the findings of the right atrium
as it attempts to compensate
during early tamponade physiology.
Notice in this right atrium,
we can see a furious right atrium that's contracting
at a very, very high rate
to push the blood into the right ventricle
and out the pulmonary system
due to the higher pressures
within the right side of the heart.
I've noticed this as a finding that I see
quite frequently in early tamponade physiology,
and I'd like to categorize this as a furious right atrium.
Here's a case of a patient who presented with breast cancer
and increasing shortness of breath,
and came to the emergency department tachycardic,
diaphoretic, and hypotensive.
From the subxiphoid window,
right away we determined that a large
circumferential pericardial effusion is present,
and on closer inspection of the right ventricle
we can see that it's completely compressed in
by the high pressure within the pericardial sac,
indicating full on tamponade physiology.
As we talked about, there is a spectrum
from early diastolic deflection onto this finding
where the RV is completely compressed in.
This patient needed an emergent pericardiocentesis
in the emergency department.
The last window of the heart that I want to discuss
is one of the most important.
That is the apical window of the heart.
Here the probe is placed under the left nipple
at the point of maximal impulse of the heart.
It really helps to have the patient
in the left lateral decubitus position
to bring the heart closer to the chest wall
to get better imaging from this position.
The probe indicator dot will be maintained
towards the patient's right side
with the caveat that the ultrasound screen indicator dot
will be positioned to the left.
This is the cardiac anatomy as seen from the apical window.
Note that the probe is much closer to the ventricles,
therefore the left ventricle will be to the right
of the screen and superficial,
the right ventricle to the left and superficial,
and the atrium further away.
From this view we can also see the mitral
and tricuspid valves.
One of the benefits of the apical view of the heart
is that we see all four chambers of the heart
in relation to one another.
Here's a video clip showing the apical cardiac window.
Notice we have the left ventricle to the upper right,
the right ventricle to the left,
and the atrium further away.
Here we see the small indicator arrow
showing the endocardial walls of the left ventricle,
and notice that they have a high percentage change
from diastole through to systole.
This indicates good contractility,
and if this patient was in shock
this heart could take quite a lot of fluid
before going into pulmonary edema.
Good contractility from the apical cardiac window.
Let's contrast that last video clip with this one.
Here we see an apical four chamber view.
Again we see the left ventricle to the right,
the right ventricle to the left.
Here we notice the very poor percentage change
from diastole through to systole of the left ventricle.
Very poor contractility of this left ventricle,
and in this shock patient we'd have to be careful
about the amount of fluids that is given prior to pressors,
as we don't want to throw the patient
into pulmonary edema.
Here's an illustration showing what will happen
with a pericardial effusion and cardiac tamponade
from the apical view of the heart,
look specifically at the right atrium.
To the left we see systole
and we see all chambers compressed in
during the cycle of systole.
To the right we see diastole
and notice the normal change of the chambers
from systole to diastole as they normally expand.
We see the right atrium completely expanded.
Now in this view, that is significant for cardiac tamponade,
we note the right atrium is deflected in during diastole,
showing high relative pressures within the pericardial sac,
pressing in on the right atrium during diastole.
Diastolic collapse of the right atrium
is one of the findings to look for in cardiac tamponade.
Frankly I look for right ventricular collapse first,
and that's a more sensitive finding,
but right atrial collapse during diastole
is another finding that's commonly quoted.
Here we see a very large cardiac effusion
or pericardial effusion as noted from the apical view.
I'm tracing that with the small indicator arrow.
We see the large anechoic fluid stripe
around the right atrium.
Notice this right atrium is again taking on the appearance
of a furious atrium
as it compresses almost completely in during systole
to push the blood into the right ventricle.
I call your attention to the dyssynchronous movements
for the right ventricle and the right atrium.
What we notice here is that there's a little bit
of asynchrony between the two chambers,
indicating early tamponade physiology.
This was manifested by a patient who had
relatively decreasing blood pressures
in the emergency department.
In conclusion the Rapid Ultrasound in Shock or RUSH protocol
was formulated as a noninvasive means using ultrasound
to assess the physiology of the patient in shock.
In this video we've covered step one,
evaluation of the pump or cardiac evaluation,
looking at three main categories.
Step one was examination for pericardial effusion
and potential cardiac tamponade.
We spoke about the fact that we're going to be looking for
diastolic deflection of the right atrium,
or more specifically the right ventricle
as signs of cardiac tamponade.
Step two, evaluation of left ventricular contractility
was seen as a visual calculation of the change
of the endocardial walls from diastole
through to systole.
We also spoke about how we can calculate
using M-mode ultrasound a fractional shortening,
and we reinforced that a normal shortening
should be above 35% to 40%.
Step number three, evaluation of the right ventricle
for dilatation,
we're going to defer to part three,
evaluation of the pipes,
as it best fits in with evaluation
of pulmonary embolis and DVT.
Returning to the table outlining the findings
in the RUSH protocol,
we'll look specifically at step one,
evaluation of the pump.
In hypovolemic shock, the findings that we'll be looking for
are hypercontractile heart with small chamber size.
In cardiogenic shock, we'll be looking for
a hypocontractile heart that may be dilated in size,
especially if there is systolic dysfunction.
With obstructive shock, we'll be looking for
generally a hypercontractile heart
and we may see a pericardial effusion
with signs of cardiac tamponade
as we've talked about in this video.
We'll go further in video number four
to talk about the findings of RV strain
and cardiac thrombus that may be seen
with pulmonary embolis.
In distributive shock, usually sepsis,
we'll see a hypercontractile heart early,
and as sepsis continues we may see a failing heart
with decreased contractility.
I'm glad I could cover part one of the RUSH exam,
evaluation of the pump, in this video module.
I hope to see you back as SoundBytes continues
as we move forward to look specifically at part two,
evaluation of the tank,
and part three, evaluation of the pipes
in the RUSH protocol.

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https://www.youtube.com/watch?v=IjmF-132sHA

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