Aorta

- Hello, my name is Phil Perera
and I'm the emergency ultrasound coordinator
at the New York Presbyterian Hospital in New York City,
and welcome to SoundBytes Cases!
In this SoundBytes module entitled
Part 2 of bedside ultrasound of the aorta,
we'll go further on our discussion
of bedside ultrasonography of the aorta,
and detection of abdominal aortic aneurysms.
We'll begin with a review of the definitions
and the anatomy of the types of
abdominal aortic aneurysms that you
may encounter in the emergency department.
We'll look at a number of ultrasound images
demonstrating triple-A's, and we'll
conclude with a discussion of the
potential pitfalls of bedside imaging
of an abdominal aortic aneurysm.
This illustration shows the types
of abdominal aortic aneurysms that
may be encountered in clinical practice.
The more common type of abdominal aortic aneurysm
is defined as Fusiform, or diffuse dilatation
of the abdominal abdominal aorta.
Remember that a triple-A is defined
as an aortic diameter greater than three centimeters.
Let's start by looking at the picture to the far left.
What we see here is a diffuse dilatation
of the aorta beginning at the level below the renals,
and ending just above bifurcation into the iliac arteries.
Notice the picture towards the middle;
some of these fusiform aneurysms
can extend from the abdominal aorta
all the way down into the iliac artery.
Now the less common type of abdominal aortic aneurysm
is known as Saccular, as shown
in the picture to the far right,
where you have a localized out-pouching
of the abdominal wall.
This next illustration makes the point
that choosing the correct probe orientation
is very important in terms of getting a
correct measurement of the aorta,
due to the cylinder effect.
Let's look at the two long axis views
of the probes along the aorta, as shown
towards the left of the image here.
Beginning in probe position 1,
we see a side slice, in which the probe
is positioned towards the side of the aorta,
and underestimating the true diameter of the aortic lumen.
We can see that positioning the probe
towards the middle of the image,
as shown here in probe position 2,
we'll get a correct diameter, but this can be
difficult to ascertain using the long axis orientation.
A better orientation is to position the probe
in the short axis configuration,
as shown in probe position 3,
one can then get a sense in terms of the true lumen,
and get the best measurements
of the abdominal aortic aneurysm.
In the last illustration we made the point
that it's important to image the
abdominal aortic aneurysm for an accurate dimension
in the short axis configuration.
But it's also very important to include
outer-wall to outer-wall in the measurements
of the abdominal aortic aneurysm.
Here we can see a measurement
of a triple A only including the inner lumen,
and notice that we could vastly underestimate
the true diameter of this very large triple-A.
Here's the correct dimensions
of the abdominal aortic aneurysm,
and notice here, that we're measuring
anterior, posterior, and laterally,
including the thrombus that coats the outer walls
of this abdominal aortic aneurysm,
in addition to the true lumen,
and we get an outstanding number of
eight by eight centimeters on this triple-A.
Here's a short axis view of a
very large abdominal aortic aneurysm
in a patient who presented to the emergency department
with abdominal and back pain,
and with a small indicator arrow
I'm showing in the B mode image towards the left,
the large triple-A, and there's the spine,
which is our landmark for determination of the aorta.
Now we can see the Color Power Doppler image
towards the right, showing pulsations of blood
within this very large triple-A.
Next we're going to measure this
abdominal aortic aneurysm, and notice
we have a short axis configuration
including outer-wall to outer-wall,
that includes the inner lumen, and the outer thrombus,
and we have a measurement of 4.8 by 4.9 centimeters,
making a criteria of a triple-A
greater than three centimeters.
This video clip is another short axis
orientation of a very large triple-A
in a patient who presented the the ED with abdominal pain.
We mark the spine as our landmark,
and anterior to the spine we see a very large triple-A.
Notice the true lumen, and the accumulation of thrombus
that's seen substantially anterior to the true lumen.
Next, we'll measure this triple-A,
and here we've placed our calipers
from outer-wall to outer-wall
in a short axis configuration,
and we come up with an aneurysm
of 6.3 by 5.8 centimeters, again making
the criteria of a very large triple-A
greater than three centimeters.
This video clip shows a very interesting triple-A,
with multiple onion-skin layers of thrombus
surrounding a very small lumen
towards the middle of the triple-A.
And notice again that we could vastly underestimate
the true dimensions of this triple-A,
if all we included was the lumen.
We see here a very large burden of clot
surrounding the lumen circumferentially
in a short axis orientation.
Next, we're going to position the probe
in a long axis orientation, and I'd like
to categorize this as the Subway sandwich sign,
and what we see here is the lumen,
making up the filling of our Subway sandwich,
and notice the anterior and posterior
burden of clot making up the loaves of the bread,
circumferentially surrounding the lumen.
So a very large triple-A and long axis configuration.
Next we're going to measure this triple-A,
and here we're putting the calipers
from anterior, posterior, and laterally,
trying to add that lumen and the
thrombus to our measurements,
and I came up with a measurement
that was 6.3 by 6.16 centimeters,
again making the definition of a triple-A.
This image is a short axis configuration
showing an extremely large triple-A,
in a patient who presented to the ED
with abdominal pain, during a snowstorm
in New York City in January.
Notice the very large triple-A
and the chaotic flow of blood inside.
You can almost see the thrombus deposition
from the swirls of blood in this very large triple-A.
Here's a long axis configuration
of the same triple-A, and again we can
almost take the patient's heartbeat, or pulse,
by measuring the movements of the swirls of blood
within this chaotic flow of blood within the large triple-A,
and we can see the deposition of the thrombus
both on the anterior and posterior walls
of this very large triple-A.
Here we're putting color Power Doppler down,
to again show that this is a vascular structure,
and what's interesting is again we
can see the chaotic flow of blood,
round and round within this triple-A,
that contributes to the substantial burden
of clot formation that occurs on a triple-A.
In the next image, we're going to measure
this gigantic abdominal aortic aneurysm
in the short axis orientation,
and we measure from outer-wall to outer-wall,
we get a measurement of 8.8 by 8.6 centimeters.
So this patient went directly to the operating room,
and had successful placement of a stent.
This is a rare video clip showing a saccular
abdominal aortic aneurysm, in a patient
who presented to the ED with epigastric abdominal pain.
We have the probe positioned in a long axis configuration,
superior to the left, and we see the aorta
running from left to right, and
we see an outpouching of the aorta coming anteriorly there.
That's a saccular aneurysm, and as we measure it,
we come up with a measurement of 4.45 centimeters.
As the patient was symptomatic
with epigastric abdominal pain over this aneurysm,
she went directly to the operating room
for operative repair.
Let's go over some pitfalls and
useful hints for imaging of the abdominal aorta.
At times, the aorta may be difficult to see,
secondary to excess bowel gas.
We may press the transducer more
firmly towards the spine to displace the bowel gas
and get a look at that aorta.
If the patient has a high body mass index,
we can use a lower frequency to
increase penetration, and to get
a better look at the abdominal aorta.
Using Color Doppler can help us to identify vessels,
and be careful because there are times
when the spine may look like a triple-A,
but again close attention to the spine,
and the location of vascular structures anteriorly
will clear that up.
This video clip shows an example
where the spine could be mistaken
as a large abdominal aortic aneurysm.
Notice that it has the appearance
of a dark structure within the abdomen,
and at first glance it could look like
an abdominal aortic aneurysm, however,
we note that there's positile structures
anterior to the spine, we see the aorta to the left,
and the IVC towards the patient's right side.
We could also use color Power Doppler
to differentiate the vascular structures
of the aorta and IVC versus the spine.
This ultrasound image shows another interesting pitfall.
At first glance, we see a very large, dark structure
towards the top of the picture here,
that could be mistaken as a
very large abdominal aortic aneurysm.
But again, close attention to the location
of the spine posteriorly will help us out.
Notice we see the bone table of the spine,
notice just anterior to the spine
we actually can see here the aorta.
This very large structure is actually
a very large mesenteric cyst,
and it failed to have pulsations with power color doppler.
In conclusion, thanks for joining me
for this SoundBytes module going over
Part 2 of bedside ultrasound of the aorta.
Hopefully through this module you
now understand the definition of
and anatomy found on bedside ultrasound imaging
of an abdominal aortic aneurysm,
and now you can use bedside sonography
as a rapid diagnostic tool for picking up a triple-A.
Remember, that if a patient has unstable hemodynamics,
and a large triple-A is seen on bedside sonography,
that patient must be assumed to have a rupturing triple-A.
Using bedside sonography, we can facilitate
timely operative management of these patients
and possibly save a life.
So I hope to see you back in the future,
as SoundBytes continues.

Brightcove ID

5508128547001

https://youtube.com/watch?v=WKnFD6KeO4c

Case: Aorta Ultrasound - Introduction

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This video details how bedside ultrasound imaging can be used, as well as proper probe placement and how to interpret the ultrasound images seen during abdominal ultrasound examinations.

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- Hello, my name is Phillips Perera
and I'm the Emergency Ultrasound Coordinator
at the New York Presbyterian Hospital in New York City.
Welcome to SoundBytes Cases.
In this SoundBytes Module entitled Part 1
of Beside Ultrasound of the Aorta,
we're going to specifically look
at the Beside Detection of Abdominal Aortic Aneurysms.
Now this application of Point of Care Beside Sonography
is one of the most crucial ones for the Emergency Physician
as Detection of an Abdominal Aortic Aneurysm can be
life saving for your patient at the bedside.
Using Point of Care Sonography to make a rapid
diagnosis of a rupturing Abdominal Aortic Aneurysm
in a patient who has unstable vital signs can facilitate
timely transfer of the patient to the operating theater
without undue delay in the Emergency Department
such as waiting for a CAT Scan.
Because there's a lot of material to cover
on the topic of Bedside Ultrasound of the Aorta,
I've divided this module into Aorta Ultrasound
Parts one and two.
In this module entitled Aorta Ultrasound Part 1
we're gonna begin by reviewing the anatomy of the Aorta,
we'll then move on to learn how to perform the Ultrasound
examination of the Abdominal Aorta, all the way from the top
at the subxiphoid process as the Aorta
exits the thoracic cavity to bifurcation
at the level of the Umbilicus.
We'll then also move on to learn how to understand
the interpretation of the Ultrasound images
that you will obtain using Beside Sonography.
Let's review the position of the probe
for Sonography of the Aorta.
Generally we'll begin by placing the probe in
a short axis configuration.
Begin by placing the probe in probe position one
in the Epigastric region to visual the Aorta
as it enters the Abdominal Cavity and exits
through the Thoracic Cavity via the diaphragm.
The probe should be configured with a marker dot
over towards the patients right side.
Press down to firmly displace bowel gas
and get a glimpse of that Aorta.
Now, we should visualize the spine as our landmark
and on top of the spine we'll visualize the Aorta.
Then we should slide the probe inferiorly to probe position
two here as show in the Super Umbilical region.
This will allow us to visualize the entire part
of the Abdominal Aorta all the way down
to Bifurcation.
We should complete the examination of the Aorta
by looking at the Aorta in a long-axis plane.
We'll begin by placing the probe in probe position one
again in the Epigastric region to visualize the top part
of the Abdominal Aorta.
Have the marker dot superiorily oriented towards the
patient's head.
We can then slide the probe inferiorily
to probe position two
at the region just above the Umbilicus to visualize
the Aorta all the way down to Bifurcation into the
Periceliac.
Now if we're having problems visualizing the Aorta
due to the presence of a lot of bowel gas,
we can also get a glimpse of the Aorta from probe position
three, the Right Hepatic area.
This is going to be about the region where we're
going to look at the trauma fast Right Upper Quadrant
view, but here were going to angle the probe more interior
over the kidney to get a glimpse at the Abdominal Aorta
and long access.
Here's an image showing the Antatomy of the Aorta
that we'll need to know to perform Beside Sonography
of this structure.
Recall that the Inferior Vena Caba and Aorta form
two pair tubular structures that course through
the Abdominal compartment.
The IVC will be towards the patient's right
and the Aorta will be over towards the patient's left-side.
We see here the first major Abdominal branch
of the Aorta which is the Celiac Axis made up
predominantly of the Hepatic Artery
and the Splenic Artery.
The third branch, the left Gastric Artery is not
well seen on Bedside Sonography.
The next major branch that we can see using
Bedside Sonography is the Superior Mesenteric Artery.
This is a very important landmark as the Renal
Artery and Vein come out the Aorta at about this level.
In fact the Left Renal Vein courses right below the
Superior Mesenteric Artery.
We need to pay particular attention to the Infer-Renal
part of the Aorta as this is where the majority of
the Abdominal Aortic Aneurysms will originate.
Now we need to scan all the way down to the Bifurcation
of the Aorta into the Periceliac Arteries
and sometimes we'll catch small aneurysms
at the Distal Aspect of the Aorta that branch
into the Illiac Artery.
This is a Short-Axis configuration taken
of the Abdominal Aorta just below the subxiphoid
process of the Sternum looking through the liver.
Now, our first landmark should be the spine.
Notice that it has a hyperechoic or bright appearance
on Bedside Ultrasound.
Just above the spine we see the Inferior Vena Cava
with it's Respiratory Phasic Pulsations
towards the patient's right and the Aorta
towards the patient's left side.
We can apply Doppler sonography to further differentiate
the two structures and notice here we're doing Colorflow
Doppler and we again recognize the spine as our landmark
for recognizing the Vascular structures of the IVC
and the Aorta on top of the spine
and we see the Phasic Respitory pattern of bloodflow
within the IVC and the steady pulsations of blood
within the Aorta with each heart beat
differentiating the two structures.
Let's now take a closer look at the Celiac Axis,
the first major branch of the Abdominal Aorta
The Celiac Axis has the Ultrasound appearance of
a seagull sign and it's made up of three arteries,
the Hepatic Artery, the Splenic Artery
and the Left Gastric Artery, although the third
is usually not visualized well with Bedside Sonography.
Now, let's take a look at some Ultrasound images
of the Celiac Axis and we see a B-mode or gray scale
image to the upper right.
Notice the IVC to the right and the Aorta to the left.
We see the Celiac Axis coming off the Aorta
having the appearance of a seagull in flight.
Notice that the right wing of the seagull will
be the Hepatic Artery coursing towards the patient's
right side and the Splenic Artery will be branching
over towards the patient's left.
To the bottom we see a Colorflow Doppler image
of the Celiac Axis showing flow within both
the Hepatic and Splenic Arteries.
Here's a video clip of the Celiac Axis in action.
Again, we're in the short-axis configuration with the
probe marker over towards the patient's right side.
We identified the spine as our landmark for identification
of the IVC and Aorta Anterior to the spine
and we see here that the bright bone table
of the spine.
Notice the Inferior Vena Cava towards
the patient's right side and we see the Aorta
towards the patient's left side.
With the seagull sign made up of the Celiac Axis
coming up the Aorta.
Here we have video clip in which we'll look at
Ultrasonic appearance of the Celiac Axis using
Doppler Sonography.
We've again identified the spine by it's
hyperechoic or bright appearance and we see the IVC
over towards the patient's right and the Aorta towards
the patient's left.
As we look closely at the Aorta we see the branch
the Celiac Axis coming up anteriorly from the Aorta.
Again, having that classic appearance of the seagull sign
with the two branches, the Hapatic and Splenic Arteries.
The second major branch of the Abdominal Aorta
is Superior Mesenteric Artery also known as the SMA.
Now, the Superior Mesenteric Artery has a classic
appearance as it has a bright or hyperechoic rim
due to fat wrapped around the Artery.
Remember that it's at this level that the Renal Artery
and veins come up the IVC and Aorta and we must be very
aware of the Aorta at this area because of the presence
of Infer-Renal Aortic Aneurysms.
We see a B-mode or gray scale image over to the right
and we see the IVC and Aorta on top of the spine.
Notice the classic appearance of the Superior Mesenteric
Artery as it arches up the Aorta with it's hyperechoic
or bright rim.
Here we actually catch the Splenic Vein passing Anterior
to the Super Mesenteric Artery.
To the bottom we see a Colorflow Doppler image showing
the Superior Mesentary Artery coming off of the Aorta.
This video clip show the Proximal Abdominal Aorta
in short axis.
We identify the spine and the Aorta on top of
the spine.
There's the Celiac Axis coming up
and there's the Superior Mesenteric Artery
with the Splenic Vein over the top,
so again, Celiac and there's SMA and there's
the Splenic Vein wrapped on top.
Let's freeze down that image and again identify
the Superior Mesenteric Artery
with it's bright or hyperechoic rim
and the Splenic Vein passing anterior
to the SMA.
Here we'll apply Colorflow Doppler to further
examine the Superior Mesenteric Artery
coming up the Aorta.
We identify the Aorta on top of the spine
and we can see the Superior Mesenteric Artery
coming up anterior
from the Aorta.
Notice we can also catch the Splenic Vein wrapped
on top of the Superior Mesenteric Artery.
We'll go ahead and freeze that down.
There's Aorta towards the back of the image,
the Superior Mesenteric Artery anterior to the Aorta
and the Splenic Vein arching on top of SMA.
To complete your examination of the Aorta
it's important to look all the way to Bifurcation.
Here where I identified the spine and on top of that
the Distal Aorta and Short Axis.
As we scan more Distally, down to the level
of the Umbillicus, here we see the Bifurcation
of the Illiac Arteries.
So, we'll watch that again and there we see
Bifurcation bright at that point here.
There's the Periceliac Arteries and we can see
the right and left Illiac Arteries delineated well
on B-mode imaging.
Now we'll apply Colorflow Doppler
to look at the Birfurcation of the Aorta.
Again, we're in the Short Axis configuration
and we see the spine, the IVC to the right
and the Aorta to the left.
Let's put this into video play, now.
What we see here is the pulsations of flow within
the IVC and Aorta and we can see the Aorta
branching right there to the Periceliac Arteries.
Notice the pulsations within the both
of the Periceliac Arteries.
We'll still that down and we can see the right and the left
Illiac Arteries well delineated
with the Colorflow Doppler.
It's always important to look at body structures
in two planes, so now we're going to inspect
the Aorta in a Long Axis view.
The probe is place in the mid-sagittal orientation
with the marker towards the patient's head.
We have Superior to the left and Inferior
to the right.
We can identify the Aorta with it's pulsations and
it's thick muscular wall.
We see the branches of the Aorta, the Celiac Axis
branching more superiorly and the Superior
Mesentaric Artery
arching inferiorly into the intestine.
We can apply Colorflow Doppler
to the Aorta in Long Axis view,
and again, we can see the pulsations of the Aorta
with each heart beat.
We see the liver anteriorly in the mid-sagittal
configuration and notice the Celiac Axis arching here
superiorly and the Superior Mesentaric Artery moving
inferiorly down towards the intestine.
In conclusion, thanks for joining me
for this SoundBytes Module cover Part one
of Beside Ultrasound of the Aorta.
Using Bedside Ultrasound to detect an Abdominal
Aortic Anuerysms remains one of the most crucial
applications of Point of Care Sonography
for the Emergency Physician.
Hopefully by going through the module you now understand
the anatomy of the Abdominal Aorta, how to perform
the Ultrasound Exam of this structure and how
to interpret the images of the Aorta that you will obtain.
I hope to see you back as SoundBytes continues
and as we return in Beside Ultrasound of the Aorta
Part two when we're going to focus entirely on the
detection of Abdominal Aortic Anuerysms.

Brightcove ID

5508121223001

https://youtube.com/watch?v=uiTsFtanyzM

How to: Abdominal Aorta Measurements

Read more about How to: Abdominal Aorta Measurements

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Learn to measure the abdominal aorta with ultrasound.

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- Once we've done the survey,
we wanna go back and take measurements
of the aorta in a transverse view in three levels.
One level is proximal above the level of the renal arteries,
the second is just at the level of the renal arteries
and the third is at the level of the bifurcation.
We're gonna go back to the epigastric area
and look for our landmarks again.
In the middle of the screen we have the aorta pulsating
to the right of the aorta the IVC
and anterior to the aorta we have
the superior mesenteric artery.
I'm going to freeze the image here
and perform two measurements.
Measuring from the outside wall to outside wall,
so I measure the entire size of the aorta
and just the residual lumen of an aneurysm.
I will perform two measurements, anterior to posterior,
and a transverse measurement.
From there I'm gonna move a little bit more inferior
optimizing the image so I can see
the wall of the aorta clearly.
I will freeze the image.
Perform my measurements, the same two views again.
From the outside wall
to the outside wall,
that's the AP measurement and the same for the transverse.
The measurement is displayed on
the bottom left of the screen and
in this case our measurement is 1.36 centimeters
by 1.69 centimeters.
So we're looking for a value of over three centimeters
to be considered aneurysmal.
I'll keep moving down in a transverse view
towards the bifurcation.
Here we see the aorta divide.
So right before it divides, I want to
perform my measurement at that point.
So I will freeze and perform the
same two measurements again.
Anterior
and transverse.
From outside wall to outside wall.
And that is the completion of the measurements
you need to do for the abdominal aortic exam.

Brightcove ID

5745409357001

https://youtube.com/watch?v=SHhKyEaW1NM

How to: Abdominal Aorta

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Learn to examine the abdominal aorta with ultrasound.

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- So what I'd like to do now
is walk you through the abdominal aortic exam.
We do this exam when we're looking for
abdominal aortic aneurysm.
We're gonna use a phased array transducer.
This is a good all-purpose transducer
for the emergency department,
so you can use this for fast exam or abdominal aortic exam.
We're gonna start in the transverse view.
I'm going to put some gel on the patient,
from the epigastric area to the area of the umbilicus,
in a straight line.
I'm going to orient the transducer
so the marker is to the patient's right.
And i'm gonna place it straight up and down
in the epigastric area.
The first thing that you're gonna see
on the ultrasound image
is a round, pulsating structure in the middle of the image,
and this will be the aorta.
Immediately posterior to this round, pulsating area
will be the shadow of the spine.
So we just see the anterior surface of the spine
as the white, bright line,
and then behind this, we see a shadow.
That is what we call the spine shadow,
and you can use that as your landmark
to identify the aorta all the way down the body.
So we're gonna start in the epigastric area,
assessing the size of the aorta.
The first landmarks that we want to see,
to know that we are superior enough
above the renal arteries, is the SMA.
This is going to appear as a smaller anechoic circle
just anterior to the aorta.
So just be careful you don't mistake this
actually for the aorta 'cause it is possible
there could be an aneurysm
in the superior mesenteric artery as well.
Immediately anterior to this is the pancreas,
and then, to the right of the patient,
on the left of the screen, we see the IVC
as this hypoechoic structure.
So from this point, we're gonna move down
we're looking for the left renal vein to cross over
as our landmark for the renal level,
and we're gonna continue moving inferiorly.
If you see bowel gas like this,
just wiggle the transducer a little bit
to try to push it out of the way and work around it.
And I'm gonna decrease my depth as I move inferior
because the aorta is gonna move anterior in the body.
So I can decrease my depth to get it into better view.
'Kay, and we're dealing with some bowel gas here.
I just push it away with the transducer,
and here's the aorta, pulsating,
just sitting anterior to the spine,
with the IVC to the right.
I'm going to continue down to the level of the umbilicus,
pushing away the bowel gas,
and here, I see the aorta divide
into right and left iliac arteries.
So now we see two round circles instead of one.
Once we finish the transverse sweep,
we're gonna turn the transducer so the orientation marker
is facing the patient's head.
We'll place it again starting at the epigastric level.
I'm gonna increase the depth here a little bit,
find the aorta, and, at this point,
because I'm in a sagittal view,
it should appear as a long, black tube
moving from the left to the right of the image.
We can see here in the image,
I'm in the very proximal portion of the aorta.
We see the liver anterior to the aorta.
I move up a little bit, I can see the heart beating
just above the diaphragm.
So I know I'm at the very proximal level,
and I'm just gonna start to survey down the aorta.
The branch that I'm seeing here, coming at a shallow angle,
is the superior mesenteric artery.
So I know I'm above the level of the renal arteries
when I see that landmark.
I'm gonna continue down,
following it in a longitudinal view,
and again, I see the shadow of the spine
directly posterior to the aorta.
I keep moving down, working around the bowel gas,
looking for the long, black tube
immediately anterior to the spine.
And again, I do this all the way down
to the level of the umbilicus.
And I will see a left iliac artery
and a right iliac artery.
And again, I can decrease the depth to optimize my image
because it is so anterior
by the time you get to the umbilicus.

Brightcove ID

5745320579001

https://youtube.com/watch?v=AqAHzGijNIo

Edge: Aorta Sagital

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Liver IVC Sagital

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Case: RUSH Exam Part 4

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Series 4 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
teaching videos.
My name is Dr Phil Perera, and this video sequence
entitled The RUSH Exam Video Part 4,
we're gonna go further on to our exploration
of the Rapid Ultrasound in Shock
in the Critically Ill Patient, ultrasound algorithm.
In this video we'll focus on Part three,
evaluation of the pipes.
I'm also going to include evaluation for right ventricular
dilatation, really part of step one,
evaluation of the pump, that we did not go over earlier
in the video sequence.
Here in table one we see the four classic types
of shock, and the ultrasound findings associated
with each of these conditions.
We've covered step one, evaluation of the pump,
specifically looking for cardiac contractility,
and the presence of a pericardial effusion.
Now looking under the column of obstructive shock,
we see two conditions that we haven't covered prior,
and that we'll go over in this video.
Specifically, looking for, right ventricular strain
or cardiac thrombis, that may signal a massive pulmonary
emobolis, as the etiology for the patient's shock.
Now let's skip down to part three, evaluation of the pipes,
which will really be the main focus of this sequences.
And here, under hypovolemic shock, we're going to asses
both the thoracic and abdominal aorta for pathology,
specifically, dissection or aneurysm with rupture.
Under obstructive shock, if we do see
right ventricular thrombis, or right ventricular strain,
we may wanna switch probes and look for the presence
of a deep veious thrombosis, to correlate or corroborate
obstructive shock as the etiology
for the patient's condition.
Now let's learn how to analyze the relative cardiac
chamber sizes as a means of determining right ventricular
dilatation, and the possibility of a thrombo-embolic cause
for the patient's shock condition.
The normal left ventricular to right ventricular size
ratio should be one to zero point six,
meaning that the left ventricle should generally
be twice the size of the right ventricle.
In cases of acute pulmonary strain,
such as a massive pulmonary embolis,
as seen in the small image to the upper left,
the right ventricle will suddenly dilate,
and may be larger than the left ventricle,
as seen in the image.
In conditions of sudden right ventricular dilatation,
the RV wall will generally be thin,
measuring less than five millimeters,
and this needs to be differentiated from cases of
chronic pulmonary artery hypertension or strain,
where the right ventricle will have time to dilate,
as well as hypertrophy, and the wall will generally
be thicker than five millimeters.
Let's take a look at this video clip taken from
a patient who presented to the ED,
with a blood pressure of 70 over pul,
and a history of a recent hip replacement one week prior.
With a small indicator arrow,
I'm tracing the confines of the left ventricle.
Notice that the LV is relatively small in relation
to the gigantic RV, and there I'm showing the confines
of the RV with the indicator arrow.
This would indicate a massive pulmonary embolism
as a cause of the patient's shock,
and the need for acute therapy to correct this condition.
To put that last video clip into reference,
let's take a look at a normal parasternal long axis view
of the heart.
Here we see that the left ventricle is about twice
the size of the right ventricle,
which would be the normal relation between the two chambers.
Notice in the last video, the relation was almost reversed.
Here's another video clip taken from a hypotensive patient,
who had just gotten off a long plane flight,
and what we see here, is that the LV is very small
in relation to the RV, and notice the deflection
of the septum away from the RV with each heartbeat,
indicating relatively high pressures
within the right ventricle.
So this was an acute pulmonary embolis,
and the treatment here was going to be fibrinolysis.
We can now examine the heart in the parasternal short
axis view, by moving the probe 90 degrees clockwise.
Now we see the heart in cross section,
and notice that the chambers appear as cylinders end on.
We can see the gigantic right ventricle to the top
of the screen, and the much smaller left ventricle
is traced by the small indicator arrow.
Notice here that the septum is flattened,
and bows away from the right ventricle,
due to the relatively high pressures within the RV.
The LV almost takes on the appearance of a D-shaped
chamber, due to the flattening of the septum,
and the high pressures within the right ventricle.
A classic finding in a massive pulmonary embolis.
As we had mentioned earlier, we need to differentiate
right ventricular dilatation in acute causes such
as an acute pulmonary embolis, from a more chronic cause
such as primary pulmonary hypertension.
This was taken from a patient who had long standing
primary pulmonary hypertension,
and with the small indicator arrow,
I'm tracing the confines of the relatively large RV
in relation to the LV, and we can also see the thickening
of the RV wall greater than five millimeters.
This indicates a time for hypertrophy,
that would indicate more of a chronic condition.
We can also see a compensatory hypertrophy
of the papillary muscles within the right ventricle,
tethering the valve that is often seen with
primary pulmonary hypertension.
Now, swiveling the probe to a parasternal short axis view
in the same patient, we also see the findings
of the small LV in relation to the RV,
and the D-shaped chamber finding,
but notice that looking closer at the right ventricle,
we can again see the hypertrophic wall,
greater than five millimeters,
and again, the compensatory thickening of the papillary
muscles within the right ventricle,
often seen with primary pulmonary hypertension.
This video clip was taken from a patient
who presented to the emergency department with
unexplained tachycardia,
associated with periodic chest pain,
and shortness of breath.
This is a subxiphoid view of the heart,
and looking within the right atrium,
it looks like there's jellybeans bouncing around
within the chamber.
In actuality, this is thrombis, moving around
within the right atrium, very very concerning,
that this may pass out through the right ventricle
into the pulmonary system and cause
a massive pulmonary embolism.
While this is an unusual finding
to see a clot within the heart,
we may be able to see this as we look closer and closer
at the heart in patients presenting with unexplained
tachycardia and shock.
This is an apical view from the same patient.
Notice here we see the thrombis bouncing around
in the right atrium.
Notice that it actually passes out through the
right ventricle, into the right ventricle,
through the tricuspid valve, and then is pushed back
into the right atrium, and this was a very interesting case
and that this patient had relatively high pulmonary
arterial pressures, and a large amount of tricuspid
regurgitation, that pushed the thrombis back into
the right atrium.
Let's now move on to specifically look further at
step three of the rapid ultrasound in shock exam,
the evaluation of the pipes.
While in this illustration it looks like there's
many probes on the patient's body,
let's sequentially break this down.
Let's look first at probes positions A and B.
Probe position A is a suprasternal notch view,
in which we may be able to get a look at the
thoracic aorta, and the actual arch of the aorta,
looking specifically for aneurysm or dissection.
Position B is the classic parasternal view,
in which we can also get a glimpse of the thoracic aorta,
looking for dissection or aneurysm.
Probes positions C and D are the classic probe positions
for placement, to look for evaluation of abdominal
aortic aneurysm.
We can also see an intimal flap at times that may signal
a thoracic aortic dissection extending down
into the abdomen.
Now probes position E and F are the classic positions
for the DVT exam, and should be performed
if the patient has right ventricular dilatation
on bedside echo, and one has a high suspicion
for a thrombo-embolic cause of the patient's shock.
In this video clip we see a parasternal long axis view
of the heart.
Recall that we see the three chambers of the heart
from this view, the left atrium, the left ventricle,
and the right ventricle.
We see the aortic valve,
and the left ventricular outflow tract to the right
of the aortic valve.
Notice in this video clip that this aortic root
is relatively widened, and I'm tracing that
with a small indicator arrow.
Now a normal aortic root should measure no greater
than three point eight centimeters,
and a widened aortic root is suspicious for thoracic
aortic dissection, or aneurysm.
Here we're actually measuring the aortic root,
notice that it measures 4.74 centimeters.
And we can see there that this patient
has a thoracic aortic aneurysm.
Now we may be able to see an intimal flap here
within this region, which would indicate
a dissection as the etiology for the patient's shock.
In this video clip, taken from a patient with
Marfan Syndrome, and chest pain radiating to the back,
we see a very widened aortic root taken from the
parasternal long axis view.
This would indicate the possibility of a Stanford Class A
aortic dissection as a cause of the patient's shock.
Notice here, the very very widened aortic root,
and what looks like the possibility of an intimal flap.
Now an intimal flap may not always be seen
on transthoracic echo, but if one is very suspicious,
one can pursue a transesophageal echo or a CT scan
to further confirm this condition.
This patient actually was confirmed to have a
Stanford Class A aortic dissection requiring a stent.
This image of the aortic arch was taken from the
suprasternal notch view.
In this view the probe is placed directly into
the suprasternal notch, with the probe marker
oriented towards the patent's right side.
In relatively thin patients, it can be possible
to move the head to the side and to aim the probe
down into the chest to get a view of the aortic arch.
And here we can see the ascending aorta to the left,
the descending aorta to the right,
and the aortic arch right in the middle.
Notice we also see some of the branching vessels
coming off of the aortic arch, and this would be
normal anatomy, not consistent with dissection.
But occasionally we may be able to pick up an aortic
dissection or aneurysm, from the suprasternal notch view.
This video clip represents the suprasternal notch view
taken from the patient with Marfan syndrome
discussed earlier in the video sequence.
The first thing we notice right away is that this aortic
arch is much more dilated than the normal anatomy
shown prior, and with the small indicator arrow,
I'm showing the confines of the aortic arch.
Let's look closer within the aortic arch,
and right away we can see what looks like an intimal flap
moving around with each heartbeat.
So this patient was diagnosed with a Stanford Class A
aortic dissection, extending from the root,
through the arch, and down into the descending aorta.
The next step in the evaluation of the pipes
is performed through looking at the abdominal aorta.
The probe should be placed in positions C and D
as shown on the patient's abdomen,
with the probe in a short axis configuration.
Generally we'll begin with the probe high,
at position C, and move all the way down to D
to fully examine the aorta.
We're looking for an abdominal aortic aneurysm,
as signaled by a abdominal aorta greater than three
centimeters in diameter.
Now most AAAs will be fusiform in nature,
and also infrarenal.
Some may extend down into the iliac artery.
A minority of triple As will be saccular as shown
in the image over to the right, where we have
a small protrusion of the wall, out from the normal aorta.
This video clip demonstrates an abdominal aortic aneurysm,
in a patient who presented to the emergency department
with a hypotensive state and tachycardium.
Here we see a very large abdominal aortic aneurysm
in the short axis view.
Notice here we see a large amount of thrombis
along the walls of the aorta,
and recall that when measuring for an abdominal aortic
aneurysm, we need to measure the thrombis in addition
to the lumin.
That means we're going to measure from outer wall
to outer wall, not just the inner walls of the lumin.
And we can see the swirls of clot or pre-clot
within the lumin of the triple A.
Now to confirm that this is a triple A,
we can further go ahead and put a color power doppler,
or color flow doppler, onto this area,
just to confirm that there's flow within the lumin,
and that this is indeed a vascular structure.
We'll perform that in the next step here,
and by putting color power doppler there,
we can see that this is indeed a turbulent movement
of blood within the large abdominal aortic aneurysm.
So right away we have an etiology for the patient's shock,
and this is a patient who needs to go directly
to the operating room, and bypass the CT scan
in order to live.
This video clip was taken from a patient who presented
to the ED with hypotension accompanied by
chest, back, and abdominal pain.
Here we see a short axis view of the abdominal aorta.
First with the indicator arrow, I'll trace out the spine,
a landmark for the posterior aspect of the abdominal cavity.
Anterior to that, we'll notice the abdominal aorta,
and while it's not terribly large in size,
we see a positive finding in the lumin,
the presence of an intimal flap.
To the right there is the true lumin,
and to the left is the false lumin,
so what we see here is a thoracic dissection
that's extending down into the abdomen.
This actually turned out to be a class A dissection
that was extending from the root all the way down
into the abdominal cavity.
So occasionally we can actually pick up,
in the aortic dissection, on evaluation of the aorta,
on bedside ultrasound.
Here's a long axis view of the same patient,
notice we have the probe marker,
so that superior is to the left, inferior to the right.
Again we see the abdominal aorta stretch out
as a tubular structure across the screen,
and in the middle we see the presence of an intimal flap,
moving around with each heartbeat, again,
pathonomic for an aortic dissection.
The next step in part three, evaluation of the pipes,
once one has evaluated the major arterial circuit,
IE the thoracic and abdominal aorta for pathology,
is to examine the major venous circuit,
IE probes position E and F, looking for a pathology
within the venous circuit such as a massive DVT,
that could be the cause of a thrombo-embolic etiology
for shock.
And now while not every patient will need this examination,
I will go ahead and perform this exam in a patient
with a high pre-test probability for a thrombo-embolic
cause of shock, or right ventricular dilatation
seen on bedside echo.
This illustration shows the lower extremity venous anatomy.
Recall that the common femoral vein bifurcates into
the deep and superficial femoral veins.
Now the superficial femoral vein is the one
that continues on down the thigh,
and into the leg, and in fact has been renamed
the femoral vein of the thigh.
It will continue on into the back of the knee to
become the popliteal vein.
Now we can perform a two point compression examination,
looking for a DVT, by placing the probe into the area
of the small indicator arrow,
scanning from the common femoral vein down
to bifurcation, into the femoral vein of the thigh,
and the deep femoral vein.
We can then proceed all the way down to the popliteal vein,
placing the probe posteriorly, and compressing sequentially
from high within the popliteal fascia,
down to the area of trifurcation into the three calf veins.
Failure to compress would be indicative of a positive DVT.
This video clip illustrates normal compression of the
femoral vein.
At this level, we see the common femoral vein and artery.
We have the high frequency linear array probe
placed on a side to side configuration,
with the probe marker laterally oriented,
or towards the left.
Notice that the femoral vein towards the right or medial,
completely compresses with probe pressure,
indicating the absence of a DVT.
So this would be considered
a completely normal DVT examination, and in fact
we can see a little bit of the saphenous vein coming
off the top of the femoral vein.
Now we can use doppler to help us in identification
of the femoral vessels.
This would be a positive examination,
we can see the femoral artery with pulsations,
laterally or towards the left,
and towards the right or medial,
we actually see the femoral vein,
and notice the swirls of fresh clot
present within the vessel.
Now recall that we must go ahead and compress the vessel
to confirm a DVT, so that will be our next step,
but here again we see absence of flow within the
femoral vein, which is completely clotted off by a DVT.
Next we'll apply gentle probe pressure downwards,
with a high frequency linear array probe.
Notice we see failure of compression of the femoral vein,
and with the small indicator arrow I'm tracing the confines
of the femoral vein, again we can see the
echogenic debris of the DVT,
that's actually the saphenous coming off the top,
also involved with this DVT.
So a failure of compression of the femoral vein,
indicative of a positive DVT,
and in the right clinical scenario,
this could suggest a thrombo-embolic cause
for the patient's shock, especially if the patient
has right ventricular dilatation on bedside echo.
Continuing downwards, we'll look at the popliteal vein.
Now remember that the probe is placed posteriorly
into the popliteal fascia for this exam,
and gentle probe pressure is applied.
We can see that the artery is anterior to the vein,
and that the vein, which is posteriorly located,
completely compresses.
This would be a normal examination,
and we can see that the walls completely come together
with probe pressure.
This video clip illustrates a positive exam
for a popliteal vein thrombosis.
Recall again that the popliteal artery is located
anterior to the vein, and we can see here
that the popliteal vein with what looks like swirls
of echogenic material.
With a small indicator arrow, I'll show the confines
of the popliteal vein, and notice that with probe pressure,
that the vessel does not compress.
And in fact, with the small indicator arrow there
I can see a calf vein that's coming off the popliteal vein,
that's also filled with debris or DVT.
And we know that most DVTs occur within the calf,
and propagate upwards into the popliteal vein.
Now let's put all the information we've learned
in the various RUSH segments, into one unified
RUSH protocol, to help us in determining the etiology
for the patient's shock.
Let's begin by looking at hypovolemic shock.
In step one, evaluation of the pump, often heart will
be small in size and hypercontracting,
with the endocardial walls almost coming together
during sistole.
On evaluation of the tank, the inferior vena cava
may be small in size, with a large percentage change
during inspiration.
The internal jugular veins may also be small in size,
with a low closing column within the neck.
We may see the presence of peritoneal fluid,
or pleural fluid, indicating a hole within the tank.
In step three, evaluation of the pipes, one may see
an abdominal aortic aneurysm, which may be the cause
of hemorrhagic shock, causing the shock etiology
in this patient.
One may also see an intimal flap
indicating aortal dissection,
another cause of hemorrhagic shock within our patient.
Moving on to the next category, cardiogenic shock,
generally the heart will be dilated in size.
With systolic dysfunction,
the heart will be hypocontracting,
with a small percentage change from diastole through
to sistole.
On evaluation of the tank, the inferior vena cava
will often be large in size, greater than two centimeters,
with a small percentage change during inspiration.
The internal jugular vein will be distended as well,
with a high closing column within the neck.
One may see, on evaluation of the lung,
the positive lung rockets that we talked about,
or ultrasonic beelines indicating pulmonary edema.
Pleural effusion and ascites may also be seen
as a sign of tank overload.
On evaluation of the pipes, often this will be normal,
although occasionally a DVT may be seen in this
low flow state.
In obstructive shock, of which the first is,
pericardial effusion with cardiac tamponade,
we'll be looking specifically for a circumferential
pericardial effusion, with diastolic collapse
of the right atrium and or right ventricle,
indicative of cardiac tamponade.
In the other two types of obstructive shock,
a massive PE or a tension pneumothorax,
generally we will see a hypercontracting heart,
and recall that in cases of a massive PE,
we may see right ventricular dilatation,
and we may at times actually see thrombis within
the right atrium, and or right ventricle.
Moving on to the tank, the inferior vena cava
is usually distended in obstructive shock,
with a low percentage change from expiration
through to inspiration.
The internal jugular vein will also be distended,
with a high closing column within the neck.
Now if the patient has a tension pneumothorax,
we may be able to see absent lung sliding and
the absence of vertical comet tails.
Moving on to the evaluation of the pipes
in obstructive shock, we may be able to pick up
a positive DVT within the femoral or popliteal regions,
indicative of a thrombo-embolic etiology of the shock,
and a DVT that may have moved on into the heart
and into the lungs to cause a massive PE.
Last but not least, in distributive shock,
of which sepsis will be the most common,
in early septic shock, the heart is
generally hypercontracting, with the endocardial walls
almost touching during sistole.
Later in sepsis, the heart may fail,
and one can see a hypocontracting heart with
a small percentage change from diastole through to sistole.
On evaluation of the tank, in distributive shock,
generally the IVC will be normal or small,
less than two centimeters, with a high percentage change
during inspiration.
The internal jugular vein may also be normal or small,
with a low closing column within the neck.
In cases of sepsis due to empyema,
we may be able to pick up the presence of a septage
or a complicated pleural effusion.
And in cases of peritonitis, usually due to
spontaneous bacterial peritonitis in a liver patient,
we may see the presence of peritoneal fluid or ascites.
On the evaluation of the pipes in distributive shock,
generally this part can be omitted,
as this usually will be normal.
So in conclusion, the RUSH ultrasound protocol
can quickly help us at the bedside,
stratify a patient into one of the four categories
of shock, and immediately start the correct therapy
for the patient's shock state.
Now continuing on, we can use the RUSH exam
to monitor the patient's response to treatment
over time, and this is very important in cases
of hypovolemic shock or distributive shock,
where one can look at fluid loading at the response
of the inferior vena cava and internal jugular veins.
Hopefully they should become more plump,
and less distensible, with respirations,
as volume resuscitation continues.
This means that the RUSH exam can first identify
the patient's shock state, allowing for appropriate therapy,
and also very importantly can allow us to evaluate
the patient's response to therapy,
by looking at the response to fluid loading,
as we want to push up the central venous pressure
in cases of hypovolemic and distributive shock states.
So, I'm glad you could join me for the Soundbytes Videos,
and I look forward to seeing you in the future,
as Soundbytes continues.

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5754400770001

https://youtube.com/watch?v=9UyVHqvGgHE

Case: RUSH Exam Part 3

Read more about Case: RUSH Exam Part 3

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Series 3 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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Case Study Videos

Subtitles

- [Voiceover] Hello and welcome back
to Soundbytes ultrasound teaching videos.
My name is Dr. Phil Perera and in this video segment
termed RUSH Part 3, we're going to look specifically further
at the rapid ultrasound in shock
in the critically ill patient or the RUSH exam
focusing on evaluation of the tank or step two.
Now the RUSH exam is a three part examination
that begins with evaluation of the pump or cardiac status;
continues with part two, evaluation of the tank;
and finishes with part three, evaluation of the pipes.
In this video segment we're specifically gonna focus on
part two, evaluation of the tank.
Now this is a three part evaluation
beginning with part one, evaluation of tank volume;
continuing on to part two, evaluation of tank leakiness;
and concluding with part three, which is evaluation
for tank compromise.
So in this three-part evaluation
the first part, the evaluation of tank fullness
really means evaluation
of the patient's core vascular circuit for volume status
or central venous pressure.
This can be performed
through examination of the inferior vena cava
and alternatively with assessment
of the internal jugular veins.
Part two, evaluation for tank leakiness and overload
is performed through examination of the extended FAST exam
looking for free fluid in the abdominal and pelvic cavities
as well as in the thoracic cavity.
We can also employ lung ultrasound techniques
looking for pulmonary edema or ultrasound B-lines,
which can signify tank overload in the appropriate patient.
Last we'll conclude with evaluation for tank compromise
in which we'll again employ lung ultrasound techniques
to look for the presence of pneumothorax.
In a hypotensive patient with a positive pneumothorax,
this may signify a tension pneumothorax
requiring immediate decompression.
Here's a slide showing the probe positions
for evaluation of the tank.
Let's begin by looking at position A.
This is the best position
to evaluate the inferior vena cava
and we can look at the inferior vena cava
from the subxiphoid position
in both short and long axis views.
Probe positions B, C, and D
represent the appropriate positioning
of the ultrasound probe for investigation
of the extended FAST exam,
in which we can look for free fluid
within the abdominal and pelvic cavities
as well as within the thoracic cavities.
Finally, probe position E is the positioning of the probe
to look anteriorly on the chest for pulmonary edema
or ultrasonic B-lines.
Now let's learn how to evaluate the inferior vena cava
for assessment of central venous pressure.
First I place the probe
in the subxiphoid four chamber position
looking at the heart,
then I rotate the probe more posteriorly
down towards the spine to look at the IVC
as it runs from the right atrium down through the liver.
In this view the IVC will be seen as a cylinder
allowing us to get the full dimensions of the chamber.
The probe can be moved
slightly towards the patient's right side
to best image the IVC as it runs through the liver.
And one would like to follow the IVC
all the way down through the liver
towards the confluence of the hepatic veins
as the IVC should be measured just distal to this position
where the IVC and the hepatic veins join each other.
The next step is to visualize the IVC
in the long axis configuration
to corroborate the findings found on short axis view.
To do this the probe is swiveled with the IVC in sight
from a short axis view with the marker dot
oriented towards the patient's right to the long axis plane
with the probe in an up-and-down configuration
and the marker oriented upwards towards the ceiling.
In this way, the IVC will appear as a tubular structure
running up and down the screen with the superior aspect
towards the left and the inferior aspect
towards the right of the screen.
In this illustration we see a long axis configuration
of the IVC.
To determine the volume of the core vascular circuit
or the central venous pressure,
the IVC needs to be looked at
with regards to two specific variables.
The first is the absolute size of the IVC
and the second is the percentage change
from expiration to inspiration.
The IVC is measured at a point about two centimeters
distal to the confluence of the right atrium
at a point just inferior to the confluence
of the hepatic veins.
A small IVC that measures less than two centimeters
and that collapses greater than 50% with inspiration
or a sniff maneuver generally correlates
to a lower CVP less than 10 centimeters of water.
Conversely, a larger IVC greater than two centimeters
that collapses less than 50%
with inspiration or sniff maneuver
correlates to an elevated CVP above 10 centimeters of water.
In this way we can use analysis of the IVC
to get valuable information
about the patient's central venous pressure.
In this video clip we'll take a look at the IVC
in a short axis configuration
first aiming the probe
to a subxiphoid chamber view right there.
We see a positive pericardial effusion.
Now let's watch the IVC as it moves inferiorly
away from the right atrium through the liver
and we can see there the confluence of the hepatic veins.
Remember we wanna measure the absolute size
and the inspiratory collapse of the IVC
just distal to the hepatic veins.
And we can see there that the IVC is relatively small
and that it has a high percentage change
from expiration to inspiration.
We can use M-Mode ultrasound to graphically show
the changes in the IVC over time.
Here we notice that the IVC is 2.74 centimeters
at its widest diameter during expiration
but that it closes to 0.44 centimeters during inspiration.
And while we talked about the absolute size of the IVC
as being a predictor of CVP,
I actually think the percentage change
during respiratory variation is more important
as a predictor of CVP.
And in this patient we notice a greater than 50% change
indicating a relatively low CVP
less than 10 centimeters of water.
Now we'll swivel the probe to a long axis configuration
with the probe marker up towards the ceiling
and the probe aligned in an up-and-down configuration
across the patient's abdomen.
Superior to the left, inferior to the right
we see the IVC as a tubular structure.
Now noting the inspiratory changes of the IVC
we can see that the walls almost completely collapse
during inspiration
and with a small indicator arrow
I'll show the area where we should generally measure the IVC
that's two centimeters distal to the confluence of the IVC
to the right atrium just inferior
to the confluence of the hepatic veins with the IVC.
So a CVP less than 10 centimeters of water
with inspiratory collapse of the IVC.
We can again put M-Mode ultrasound over the IVC
to further graphically determine the general size
and respiratory dynamics of the IVC
and we can see that this is a smaller IVC
that measures 0.98 at expiration
and that almost completely closes,
in fact does close during inspiration
demonstrating a low CVP less than 10 centimeters of water.
Let's contrast those last video clips with this one.
Beginning with the heart in a subxiphoid four-chamber view
we see that this heart is not beating well.
As we aim the probe more inferiorly
down to image the IVC
as it moves inferiorly down through the liver
from the right atrium we can see that this IVC is very large
and that it has little inspiratory collapse.
In fact, we also see the three hepatic veins
are very engorged.
Notice we can also see little speckles of prethrombus
within the IVC indicating a low flow state.
Now we'll put M-Mode ultrasound directly over the IVC
in the short axis configuration.
Notice this IVC is relatively large at 2.52 centimeters
and then has very little change during inspiration.
We can also see the speckles of prethrombus
within the lumen of the IVC indicating a low flow state.
So this patient has a CVP
that's greater than 10 centimeters of water.
In fact, this tank is pretty full.
Now we'll swivel the probe to the long axis configuration
with the probe marker up towards the ceiling
and the probe aligned up and down on the patient's abdomen.
Superior here is towards the left of the screen
and inferior to the right.
With a small indicator arrow
I was just showing the engorged hepatic vein
entering into the IVC.
Recall that we wanna measure the IVC
just inferior to that point
where the hepatic vein enters into the vessel.
Here we see very little inspiratory collapse of the IVC
as well as a plethoric or dilated IVC
that indicates a high CVP
greater than 10 centimeters of water.
We can put that M-Mode cursor right along the IVC
just inferior to the confluence of the hepatic vein.
Again we see the IVC is dilated
greater than 2.46 centimeters but more importantly
notice here the small respiratory variation of the IVC
from expiration to inspiration
indicating an elevated CVP
greater than 10 centimeters of water.
Let's put all that information into play
in a real clinical case of a hypotensive patient.
This is a four-chamber subxiphoid view.
That's the right atrium, right ventricle, left ventricle,
and left atrium.
Here we see a large circumferential
dark anechoic pericardial effusion surrounding the heart.
So what we'll do is we'll duck the probe inferiorly
down towards the spine looking at the IVC
as it moves away from the right atrium into the liver.
Here we see the IVC as it emerges from the right atrium.
Notice here that this IVC has little respiratory collapse
and that it's relatively large in size
and we can see the dilated hepatic veins
joining into the IVC.
In the presence of a significant pericardial effusion,
this is concerning for potential early tamponade physiology
as one sees an elevation of the CVP as tamponade progresses.
We'll confirm those findings by swiveling the probe
to the long axis configuration superior to the left,
inferior to the right.
Again, we see the heart with a large pericardial effusion.
Notice here we see the IVC that's relatively distended
or plethoric greater than two centimeters
just distal to that hepatic vein
and notice the little respiratory collapse
of the IVC with inspiration
indicating a relatively high CVP
and the potential for early tamponade physiology
in this patient.
There may be times where visualization
of the inferior vena cava can be limited by gas
or fluid-filled intestine or stomach.
In these cases, visualization of the internal jugular veins
can act as an alternate measure
for assessing central venous pressure.
In this examination,
the head of the bed is placed upwards 30 degrees
and a high-frequency linear array probe is placed
tangentially or in a short axis view
across the internal jugular vein.
Here we see a plethoric or distended internal jugular vein
that has little inspiratory collapse
indicating a relatively high CVP.
This ultrasonic assessment of jugular venous distension
or CVP can be confirmed by using the probe
in a long axis configuration with the probe up and down
along the neck in the plane of the internal jugular vein.
I like to have the probe marker upwards
towards the patient's head
and here we can see the internal jugular vein is distended
all the way from low just above the clavicle to high,
all the way just below the mandible
indicating jugular venous distension on ultrasound
or a relatively high central venous pressure.
Now let's take a look at the jugular vein
in a patient who presented
with hypovolemic hypotensive shock.
We see here the probe is in a short axis configuration
across the internal jugular vein
and we notice a very small IJ vein
that almost completely collapses during inspiration
indicating a relatively low CVP
and the need for immediate resuscitation with IV fluids.
We can corroborate those findings
by moving the probe to a long axis configuration
with the probe marker up towards the patient's head.
We see the carotid artery deep to the internal jugular vein
and we see the closing level of the IJ vein
low within the neck.
Again corroborating a low CVP
less than 10 centimeters of water
and the need for immediate resuscitation
with intravenous fluids in this hypovolemic patient.
Step two in the assessment of the tank
is to look for tank leakiness or overload.
This is performed by using the extended FAST exam
putting the probe into positions two, three, and four,
the right upper quadrant, left upper quadrant,
and suprapubic views.
This will determine the presence of free fluid
within the abdominal, pelvic, and thoracic cavities.
While the RUSH exam is not specifically designed
for the evaluation of the trauma patient,
occasionally a patient may present
as a delayed presentation of trauma
or after occult trauma with this positive finding.
In this situation, a surgical consultation
and operative repair for an injury to an internal ogran
may be indicated.
In this view we have a positive right upper quadrant exam
with free fluid in Morison's pouch.
Now in the non-trauma patient, this could indicate
failure of the heart, liver, or kidneys
as contributing pathology
to the patient's physiological state.
Now the patient with a fever on this finding,
this would indicate the possibility
of spontaneous bacterial peritonitis
and the need for paracentesis
to obtain cultures of the fluid.
By angling the ultrasound probe
above the right upper quadrant and left upper quadrant views
we can actually look above the diaphragm
to look for the presence of positive free fluid
within the thoracic cavities.
Here we have a positive examination
from left upper quadrant view,
the small arrow indicating the presence of free fluid
within the left thoracic cavity.
We can see the spleen to the right or inferior
and we can see the lung waiving around superior
or towards the left.
In the non-trauma patient
this could show the possibility
of lung, kidney, or heart failure
as an exacerbating condition to the patient's pathology
and the patient with a presentation of occult trauma
or delayed presentation of trauma,
this could indicate a hemithorax needing urgent treatment.
Lung ultrasound applications
have become increasingly important in the assessment
of the hypotensive patient or the patient with dyspnea.
In this examination, which is still part of part two,
assessment of the tank looking for tank leakiness
or tank overload, we use the three megahertz probe
to examine the pleura by placing the probe
both anteriorly and laterally on the chest.
This would be a normal examination
and we can see the pleural line moving back and forth
towards the top of the screen.
We note here the presence of multiple A-lines,
those horizontal reverberating lines
coming off of the pleura at regular intervals
that are indicative of normal lung.
In contrast, let's take a look at this video clip
taken from a patient
who presented with acute pulmonary edema.
Here we see the pleural line
as taken with a three megahertz lower frequency probe
and instead of those repeating horizontal lines
the A-lines that we saw in normal lung
now we see the development of these vertical lines
known as lung rockets.
And here we see the lung rockets
emanating all the way to the back of the screen
using the three megahertz probe.
Lung rockets are also known as ultrasonic B-lines
and these indicate fluid within the alveoli.
Now, if the B-lines are seen
in multiple areas of the lung bilaterally,
this is more consistent with acute pulmonary edema.
As pulmonary edema progresses,
we can see the development
of more and more ultrasonic B-lines or vertical lung rockets
showing a worsening of the pulmonary edema.
In this situation we almost see a complete lung whiteout
with multiple rays coming off of the pleural line
showing the development of multiple lung rockets
within one ultrasound field.
Now while the presence of ultrasonic B-lines
are indicative of a syndrome
known as alveolar interstitial syndrome or AIS,
which just shows the presence of positive fluid
within the alveoli,
if this is diffuse on both sides of the chest
this is more indicative of pulmonary edema
and the presence of tank overload.
The final step in evaluation of the tank
is to look for tank compromise
or the presence of a tension pneumothorax
requiring emergent decompression.
We see the positive lung findings on the right
with a 10 megahertz probe, we see the lung sliding
as the patient breathes the lung moves back and forth.
We can see the opposed parietal and visceral pleura
with positive vertical comet tails and sliding.
To the left we see a positive pneumothorax
and notice here we see the stationary parietal pleura,
which shows no sliding back and forth.
We also see the absence
of the vertical comet tail artifacts.
In the hypotensive patient
these findings may necessitate emergent decompression
with the needle or chest tube.
So in conclusion, thank you for joining me
for part two, Assessment of the Tank of the RUSH Protocol.
As we described, this is a three-part evaluation
beginning with part one, evaluation of tank fullness,
which as we described is an examination
of the inferior vena cava and internal jugular veins
to assess central venous pressure.
Part two, evaluation for tank leakiness
and overload is performed by the extended FAST exam
to look for free fluid within the abdomen and pelvis
as well as to look for the presence of ultrasonic B-lines
indicative of pulmonary edema.
The last part of the tank assessment
is to look for tank compromise
or the presence of a tension pneumothorax
indicated by the lack of lung sliding
and the lack of positive comet tail artifacts.
Now we can begin to use the RUSH protocol
to assist in the evaluation of the hypotensive patient
to allow us to figure out which type of shock
the patient is suffering from.
Let's take a look at this table
with regard to beginning with hypovolemic shock to the left.
On assessment of the pump,
the heart may be small in size and hypercontracting.
On evaluation of the tank, the inferior vena cava
and internal jugular veins may be small in size
with a large percentage change
from expiration through to inspiration.
In a patient who has an occult trauma
or delayed presentation of trauma
we may actually see positive free fluid
in the peritoneal cavity or within the pleural cavity
indicative of blood.
In the second type of shock, cardiogenic,
we may see a dilated heart which is hypocontracting.
The IVC and internal jugular veins may be distended
with a small percentage change from expiration
through to inspiration.
Also, we may see pulmonary edema
as evidenced by the presence of multiple lung rockets
and it's not uncommon for us to visualize
a pleural effusion or ascites in these patients.
In the presence of obstructive shock
of which we think of the three main categories
being one, cardiac tamponade;
two, massive pulmonary embolus;
and three, tension pneumothorax,
generally on assessment of the pump
we're gonna see a hypercontracting heart.
In the presence of cardiac tamponade
we're gonna look for the presence of pericardial effusion
and diastolic collapse of the right ventricle
and or right atrium.
Now we'll discuss the findings of a large pulmonary embolus
in an upcoming video,
but generally we're looking for dilatation
of the right side of the heart
and we may be able to visualize a cardiac thrombus.
On assessment of the tank
and the different types of obstructive shock
we generally will see a distended
and large inferior vena cava and internal jugular veins
with little respiratory collapse.
In the presence of a tension pneumothorax
we can see absent lung sliding
and absent vertical comet tail artifacts
requiring emergent decompression.
In the last category of shock,
distributive, of which sepsis will be the main cause,
on evaluation of the pump in early sepsis
we'll generally see a hypercontracting heart.
As sepsis continues we may see a component
of cardiac failure and hypocontraction.
On evaluation of the tank,
the IVC and internal jugular veins
will generally be small in size
with the large comparative change
during the respiratory phases.
We may be able to see the presence of peritoneal fluid
indicating a spontaneous bacterial peritonitis,
especially in liver patients,
and we may also be able to see pleural fluid
indicated in empyema
and the appropriate patients requiring drainage.
So, now we can see how we can use
all of the assessment that we've learned
in the evaluation of the pump and the tank
to stratify the different types of shock accordingly
with the ultrasound findings.
So I look forward to seeing you back in the future
as the RUSH series continues with part three
Evaluation of the Pipes.

Brightcove ID

5754395503001

https://youtube.com/watch?v=oXiIU4mx-H8

Case: RUSH Exam Part 2

Read more about 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.

Applications

Cardiology

Clinical Specialties

Cardiology

Media Library Type

Case Study Videos

Subtitles

- [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.

Brightcove ID

5754394219001

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

Case: RUSH Exam Part 1

Read more about Case: RUSH Exam Part 1

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Series 1 of 4, This video represents a comprehensive algorithm for the integration 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.

Applications

Cardiology

Media Library Type

Case Study Videos

Subtitles

- [Phil] Hello, and welcome back to Soundbytes Ultrasound.
My name is Dr. Phil Perera and in this video module
we're going to cover an advanced application of ultrasound.
That of the RUSH Exam which stands for Rapid Ultrasound
in Shock in the Critically Ill Patient.
This module will be video part one,
and will cover how the RUSH exam,
a series of ultrasound applications,
can be combined into one whole protocol
for the assessment of the patient in shock.
Let's begin with a clinical case
that outlines the power of the RUSH exam.
Here we have a 67 year old male presenting via paramedics
for acute shortness of breath for several hours.
The medics phone ahead with the vital signs,
and they have a blood pressure of 90 over palp,
a heart rate of 120, and a respiratory rate of 32.
They're calling ahead for notification because the patient
appears to be in severe respiratory distress.
The patient has a significant past medical history
significant for COPD, congestive heart failure,
and hypertension on multiple medications.
He states that his baseline blood pressure
runs about 160 to 170 systolic
and that he has been compliant
with his blood pressure medications
making the blood pressure of 90 over palp
a big change from his baseline.
As the patient arrives into the emergency department
he's immediately placed into the resuscitation area
and the vital signs are reconfirmed
showing significant hypotension
as well as a low grade fever and hypoxia.
The patient is talking to you,
but does appear to be in respiratory distress.
On lung exam he has diffuse expiratory wheezing
and inspiratory rales at the bases,
and edema is present in the lower extremities.
So the question for you
is how best to proceed at this point?
Well most of us would order a portable chest x-ray,
an EKG, and some baseline labs.
Here's the patients chest x-ray and it's read as
no acute infiltrate, effusion, no pneumothorax,
the heart size was seen as normal, and notice here
there's no real evidence here for pulmonary edema,
i.e. no real infiltrate or sephilization.
The patient's vital signs clearly indicate
an advanced type of shock
and the clinical question here is what type of shock
is this patient suffering from
and what is the best treatment option for the patient?
Could he have: A. Distributive shock
of which sepsis would be the most common
B. Cardiogenic shock
C. Hypovolemic or hemmorhagic shock,
or D. An obstructive kind of shock
of which the three main causes,
cardiac tamponade, pulmonary embolus,
or tension pneumothorax must be considered.
Thus in the resuscitation area it's a little unclear
as to which type of shock our patient is suffering from
as he has elements in his physical exam and his evaluation
that overlap between the four different types of shock
as detailed here.
In the past it would have been relatively easier
to figure out which type of shock
this patient was suffering from by placement
of an invasive pulmonary artery catheter
or a Swan-Ganz catheter.
This was commonly done when I was training
in internal medicine back in the 90s
and gave an amazing amount of physiological detail
with regard to the patient's state.
Unfortunately multiple studies looking at these PA catheters
found an increased rate of complications
and no improvement in overall morbidity or mortality
of these patients.
Thus their use has drastically declined in the recent past
setting the stage for the use of noninvasive measures
of shock assessment.
The RUSH exam was initially written to fit the void
for non invasive evaluation of physiology
in this case using bedside ultrasound.
The RUSH exam, a series of ultrasound elements
that was combined into a protocol, was initially published
in Emergency Medicine Clinics of North America in 2010
and then republished several more times in 2012.
The RUSH exam was therefore written as a three part
ultrasound evaluation of the patient in shock.
The first step was evaluation of the pump.
Here we were looking for three main things.
First of all assessing the heart for the presence
of a pericardial effusion or cardiac tamponade.
Number two, evaluating the left ventricle for contractility.
And number three, evaluating the right ventricle for strain
or dilatation that could indicate a large pulmonary embolus
in the crack clinical scenario.
Number two was the evaluation of the tank
or inter vascular volume.
The first assessment here was how full is the tank
and this was performed by an evaluation
of the inferior vena cava or internal jugular veins.
The second part was to evaluate
if the tank was leaking or compromised
and this involved elements of the Extended-FAST exam,
an also lung ultrasonography
looking for the presence of pneumothorax
or ultra sonic B Lines.
The third part of the RUSH exam was the evaluation
of the pipes first looking at the arterial circuit
for problems such as abdominal aortic aneurysm
or thoracic aortic aneurysm
which could be the cause of the patient's shock.
Second was the evaluation for the major venous circuit
mainly focusing on the legs for assessment for
deep venous thrombosis.
And this part would be included
especially if the echo showed right ventricular strain
to confirm the presence of a possible pulmonary embolus.
The RUSH exam is therefore an easily remembered
ultrasound protocol for the assessment
of the patient in shock that utilizes
the mnemonic of pump, tank, and pipes
to incorporate many ultrasound elements into an evaluation.
Here's a table that encompasses
many of the major resuscitation shock protocols
that have been published to date,
and we see them across the top of the table.
Let's look specifically
at the RUSH pump, tank, pipes protocol.
To the left we can see the protocol ultrasound elements
that have been combined
into many of these resuscitation protocols.
And we can see that the RUSH exam
combines many of the protocols to date,
starting with Cardiac and IVC exam,
and continuing on through the FAST exam,
the Aorta exam, Lung ultrasound,
and finally the DVT examination.
In a series of upcoming videos we'll go over
how to use the RUSH exam
i.e., how to evaluate the pump, the tank, and the pipes
to figure out exactly what type of shock
the patient is suffering from and how best to treat
the patient in the resuscitation area.
And hopefully by the time we go through all these videos
this table will make a lot more sense.
We'll be able to use the RUSH exam
to figure out the specific type of shock
that the patient is suffering from.
Is it hypovolemic, cardiogenic,
obstructive, or distributive?
And we can see how the different findings
within the pump, tank, and pipe categories
can help us in determining this etiology for the shock.
So I look forward to seeing you back
as Soundbytes continues and as we further explore
the RUSH Exam in the upcoming series of videos.

Brightcove ID

5754395461001

https://youtube.com/watch?v=tqBdKIdKqOc

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