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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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Case Study Videos

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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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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.

Applications

Cardiology

Media Library Type

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

3D How To: Ultrasound Guided Paracentesis

Read more about 3D How To: Ultrasound Guided Paracentesis

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3D animation demonstrating an ultrasound guided Paracentesis Procedure.

Applications

Cardiology

Media Library Type

How To Videos

Media Library Tag

Subtitles

- [Voiceover] A curved array transducer
with an abdomen exam type
is used to perform an ultrasound guided paracentesis.
It is easier to perform this exam
when the bladder is not filled.
The patient is placed in a supine position.
The abdominal cavity is evaluated in two planes.
Place the transducer in a transverse position
with the orientation marker to the right.
The transducer is placed at the lateral border
of the rectus sheath at the level of the umbilicus.
To evaluate the abdominal cavity for free fluid,
sweep the transducer from an inferior to superior position.
Fluid will appear hypoechoic or anechoic
and accumulate in the lateral gutter
and between loops of bowel.
To obtain a long axis view,
rotate the transducer 90 degrees with the orientation marker
directed to the point of needle entry.
Sweep the transducer across the abdominal cavity
from left to right to evaluate the abdomen for free fluid.
A needle insertion site should be chosen
in the lateral abdominal area
in a dependent area of the fluid collection
which is clear from loops of bowel.
The needle should be inserted lateral to the rectus sheath
in a transverse fashion to avoid the epigastric artery.
Follow the needle entry by slowly sliding the transducer
in the direction of needle advancement.
The needle will appear as a small, bright hypoechoic dot.
When the needle tip appears,
the transducer should be advanced a short distance distally
to follow the tip of the needle trajectory.
The needle is slowly advanced
under direct ultrasound visualization
until the tip is seen to indent
and then puncture the parietal peritoneum.
The transducer should be moved slightly proximally
and distally to confirm location of the needle tip.

Brightcove ID

5508117950001

https://youtube.com/watch?v=LDIo6xQS7Hc

3D How To: Female Pelvis Exam

Read more about 3D How To: Female Pelvis Exam

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3D animation demonstrating a Female Pelvis ultrasound exam.

Publication Date

Thu, 05/05/2016 - 12:00

Media Library Type

How To Videos

Media Library Tag

Subtitles

- [Voiceover] A curved, or phased array transducer,
with a pelvis exam type,
is used to perform the pelvis ultrasound exam.
A full bladder is used as an acoustic window
to view the pelvic organs.
The pelvis is evaluated in two plains.
Place the transducer in a long axis position
with the orientation marker to the patient's head,
at the level of the symphysis pubis.
Angle the transducer inferiorly into the pelvis.
The bladder appears in the near-field of the image,
as a hypoechoic triangular structure.
The uterus is gray in appearance
and located either directly posterior
or superior to the bladder.
The endometrial stripe will appear as
a bright echogenic line from the fundus to the cervix.
The uterus does not always lay directly in the midline
so it may be necessary to slightly rotate the transducer
to view the entire length of the uterus.
Sweep the transducer from side to side
to see the entire uterus.
The ovaries may be seen by sweeping the transducer
to the lateral aspects of the pelvis.
They are almond-shaped and slightly hypoechoic structures.
Follicles may appear as multiple
hypoechoic, cystic structures within the ovaries.
Some follicles may be quite prominent,
depending upon the luteal stage.
To obtain a transverse view of the uterus,
rotate the transducer 90 degrees,
so the orientation marker is to the patient's right.
The bladder appears more rectangular in shape in this view.
Sweep the transducer superiorly
from the level of the cervix to the fundus
to see the entire uterus.
The ovaries will be seen on either side of the uterus
and can vary in location,
from a superior to inferior position.

Brightcove ID

5750473717001

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

Case: Ultrasound Guidance for Paracentesis

Read more about Case: Ultrasound Guidance for Paracentesis

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Using bedside ultrasound imaging when performing paracentesis, identifying ideal candidates for this procedure, mapping the internal jugular vein and ascites to determine an ideal puncture point, needle depth, and needle trajectory.

Media Library Type

Case Study Videos

Media Library Tag

Subtitles

- Hello, my name is Phil Perera,
and I am the Emergency Ultrasound Coordinator
at the New York Presbyterian Hospital in New York City,
and welcome to Soundbytes.
In today's module we're going to focus in specifically
on the use of bedside ultrasound
for the paracentesis procedure.
Now, the use of bedside ultrasound for paracentesis
can actually lower your complication rate
and allow you to know who is a better candidate
for the actual procedure.
So, step number one, when you're deciding
if a paracentesis procedure is necessary,
is to determine if the patient actually has ascites
and if there's significant areas of fluid pockets
that are amendable to a drainage procedure.
The second step is to best mark the location
for the needle placement, using bedside ultrasound.
And the two techniques that have been used in the past
are the midline linea alba,
or the lateral gutter techniques.
And using bedside ultrasound can allow you to decide,
between the two, where is the best location
for the needle placement.
This illustration shows the preferred positions
for the paracentesis procedure.
The key concept here is, to avoid the epigastric vessels
during the puncture attempt,
note the location of the epigastric vessels,
just lateral to midline on the abdominal wall.
So we wanna use that 3 MHz probe,
and we can place the probe,
as shown in positions one and two,
in the traditional lateral gutter approaches
for the paracentesis procedure.
This would be above the anterior superior iliac crests.
And we can look for fluid within the lateral gutters
and plan for a puncture attempt
in either of these positions.
We can also place the probe in probe position three
as shown in the midline linea alba position.
We'd wanna place the probe below the umbilicus
in the midline, in a relatively avascular
midline linea alba position.
Now, we can also use the 10 MHz higher frequency probe
to get a better look at the abdominal wall
in relation to the bowel and the ascites fluid
prior to our puncture attempt.
In fact, this will give us a more detailed look
into the abdominal cavity, to better plan our approach
for the paracentesis procedure.
Here's the location of the probe to the lateral position
for the paracentesis procedure.
Note the placement of the high-frequency linear array probe
above the anterior superior iliac crests
along the lateral gutters of the patient.
Notice here, the location of the epigastric vessels
in relation to the lateral gutters,
and we want to avoid those epigastrics
during any puncture attempt.
Notice also the location of the bladder,
and we want to make sure that we decompress the bladder
prior to any puncture attempt for a paracentesis.
But we can see here that the probe
is safely lateral to most of these structures,
thus the paracentesis can be safely performed
from this position on the abdominal wall.
This video clip shows a small amount of ascites
as taken with a 3 MHz probe, and we can see here
a small amount of ascites is denoted
by that dark or anechoic fluid collection,
and we can see the intestine with anchoring mesentery
swaying back and forth within the ascites
as the patient breathes.
And this is known as gut sliding,
and it makes the intestine look almost like palm trees
swaying back and forth within the breeze.
So, from this location, it might be unsafe
to perform a paracentesis, as it could be difficult
to get a needle in between the areas of intestine
without puncturing through an area
of intestine or mesentery.
This video shows a moderate amount of ascites,
again taken with a 3 MHz probe.
And we note the intestine with anchoring mesentery
sliding back and forth as the patient breathes,
and we see a large collection of ascites,
that dark or anechoic fluid collection,
anterior to the intestine.
So this might be a good location to perform a paracentesis
as we could place the needle safely into that ascites
without going through into the intestine
or anchoring mesentery.
This video clip emphasizes the point
that using a higher-frequency 10 MHz probe
on the abdominal wall
gives a more detailed exam of the evaluation
of the ascites in relation to the intestine.
And we see the abdominal wall anteriorly,
and we can see the bowel floating within the ascites.
Here we can actually mark down and measure
the safety zone from in which a needle could safely go
through the abdominal wall, into the ascites,
without hitting bowel.
Note here, the safety zone is approximately two centimeters,
as marked out with the centimeter dots
towards the right of the image.
Another benefit of using the higher-frequency probe
prior to a paracentesis procedure
is to investigate the depth of the abdominal wall,
as a thick abdominal wall can frustrate attempts
at a paracentesis procedure.
Here we see the depth of the abdominal wall,
which measures 2.5 centimeters anteriorly,
and we can see the line,
which is the peritoneal lining there,
just deep to the abdominal wall.
Note the presence here of ascites,
the dark fluid collection,
just deep to the peritoneal lining
and we can see the gut sliding,
or bowel moving back and forth, deep within the ascites.
Note the two-centimeter safety zone
for placement of the needle into the ascites fluid,
but note here we'd need to use a longer needle,
a needle longer than 2.5 centimeters,
just to get through the abdominal wall
to get fluid from the abdominal cavity.
In this video clip, we've moved the probe slightly lateral
from the last position in the same patient.
Again, we note the deep abdominal wall,
at 2.5 centimeters, denoting that a longer needle
will be needed to get the ascites fluid.
But here we see a large collection of ascites,
and note here the absence of gut sliding,
denoting a larger pocket of ascites
and a more favorable position
for the paracentesis procedure.
So this is actually the position
in which we perform the paracentesis,
using a longer lumbar puncture needle
and we're safely able to get a paracentesis done
and get the ascites fluid out for evaluation in the lab.
In this video clip, we'll reemphasize the surface anatomy
for the lateral abdominal position for paracentesis.
Note we're coming with a cap needle
underneath the 10 MHz probe, at the lateral puncture point.
This would be the preferred position
for the lateral approach for paracentesis,
as shown by the black star.
Now, some of the surface anatomy that we can palpate
includes the iliac crest, and note here
we're about four to five centimeters
above the iliac crest there.
We also want to avoid
those all-important epigastric vessels,
which we can see medial to the puncture point
from the lateral paracentesis approach.
Using ultrasound guidance, we can map out
the best position on the abdominal wall
for the paracentesis approach,
and go either right or left-side
depending on the maximal pocket of ascites present.
We also want to ascertain the relative locations
of the liver and spleen, so as to avoid
iatrogenic injury to a solid organ.
And as we emphasized earlier in the video clips,
you want to look for that intestine
with anchoring mesentery,
so as to avoid intestinal puncture during the procedure.
While the lateral gutter approach to paracentesis
is commonly emphasized during medical training,
the midline linea alba position
can be a great location for a paracentesis procedure.
Note here the probe is placed along the midline linea alba
with a marker dot towards the patient's head.
And we see it placed along the midline,
just inferior to the umbilicus.
Here we'll further investigate
the midline linea alba position
for the paracentesis procedure.
Note the high-frequency probe,
placed along the midline linea alba,
and we're coming with a cap needle
at a 45-degree angle underneath the probe
looking for the ring down artifact
onto a suitable pocket of ascites.
Here's a different view point
from the same midline linea alba position.
Again, we're placing that probe along the midline.
And this would be about the appropriate position
for the paracentesis procedure.
And here we just place the needle right there,
directly inferior to the umbilicus.
And I'll indicate that with a black star.
Note here, we'd be coming through
the relatively avascular midline linea alba.
But recall that it's very, very important
from this position to not puncture
through the bladder, and we can see
the relative location of the bladder
in relation to the puncture point.
So we must have the patient void
or place a Foley catheter, prior to attempting
a paracentesis from the midline linea alba position.
Here's a video clip from the midline linea alba,
taken with a 3 MHz probe.
I have the probe oriented towards the patient's head
so the superior aspect is towards the left
and inferior's towards the right.
Note here, we see the bowels superiorly,
moving up and down within the ascites fluid,
which we see in the middle of the image here,
and note the bladder, relatively large,
towards the inferior aspect of the image here.
Now, we can see that this would be a pocket
amendable to paracentesis, but recall again,
to increase the safety of the procedure
from the midline linea alba approach,
we'd want to drain the bladder prior to a puncture attempt.
Here's a video clip taken from the same patient
after having him completely void.
And note now, we have the decompressed bladder,
making the ascites pocket much larger
and more amenable to a paracentesis puncture
from that midline linea alba technique.
And we can see here now, the pocket of ascites
as denoted by the dark or anechoic fluid collection,
between the bowel superior
and the decompressed bladder inferiorly.
In this video clip, we can see
how using the higher-frequency 10 MHz probe
can allow real-time guidance of the needle
down into the ascites pocket,
and we see the detection of the needle
coming in from left to right through the abdominal wall,
with the tip of the needle safely parked
within the ascites fluid.
Notice here that the bowel is distant
to the tip of the needle,
thereby we can minimize any puncture
through the bowel during the paracentesis procedure.
We need to put a sterile sheet over the probe
during this procedure.
So, in conclusion, thanks for tuning in
for ultrasound guidance of paracentesis.
Ultrasound guidance for this procedure
can potentially make the paracentesis procedure
a safer one for our patients, and using a combination
of both the three and 10 MHz probes
can fully evaluate the ascites prior to a procedure.
We can use either one of two techniques.
Either the static technique, we position the patient
and then mark off the puncture spot with ultrasound
prior to a procedure,
or we can actually use a dynamic technique
where we place the probe in a sterile sheet
and watch the needle in real-time
go through the abdominal wall into the ascites fluid.
Either of these techniques
can potentially decrease your complication rate,
so I hope in the future you'll consider
ultrasound guidance for paracentesis
during your next paracentesis procedure.

Brightcove ID

5508114740001

https://youtube.com/watch?v=bWxv_a9CkBs

Case: Intrauterine Pregnancy - Part 2

Read more about Case: Intrauterine Pregnancy - Part 2

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This video discusses how to use ultrasound to determine the gestational age of a normal pregnancy, determine a fetal heart rate, and identify markers for an abnormal pregnancy and fetal demise.

Clinical Specialties

Media Library Type

Media Library Tag

Tubal Ectopic Abdominal Ectopic

Ampullary

Ovarian

Pseudogestational Sac

Subtitles

- [Voiceover] Hello, my name is Phil Perera
and I am the emergency ultrasound coordinator
at the New York Presbyterian Hospital in New York City.
Welcome to Soundbytes Cases.
In this module entitled Emergency OB/GYN Ultrasound:
Part 2 of Intrauterine Pregnancy,
we're going to focus on the further assessment
of normal pregnancy.
We'll look at two further things that
are important to assess in your pregnancies.
First of all, learning how to date the gestational age
of the pregnancy, as well as learning
how to determine the fetal heart rate.
Then we'll wrap up the module by examining further findings
in abnormal pregnancies and learning how to differentiate
these findings from a normal intrauterine pregnancy.
The first concept that we'll focus on
is dating fetal gestational age.
In the first trimester, we're going to use an assessment
of the crown rump length.
Interestingly, dating in the first trimester
is actually probably the most accurate during all
phases of pregnancy, as there's a difference in
the growth curve as the fetus develops.
In the second trimester, we'll measure
the skull biparietal diameter.
And the third trimester, the dating is composed
of the biophysical profile, focusing on the femur length,
as well as other biophysical measurements.
This is an image of a first trimester pregnancy,
and we're going to evaluate the gestational age by
measuring the crown rump length.
Here we see the fetal pole stretched across
the gestational sac and we see the crown located
over towards the right and the rump towards the left.
If we put the calipers down from the crown across
to the rump we get a measurement of 1.46cm.
By selecting Crown Rump Length in the software package
on the ultrasound machine, we'll get an assessment
of gestational age which we can see here towards
the bottom left, seven weeks and six days.
As first trimester dating is considered one of the most
accurate during the entire pregnancy, it's nice to print
this image out and give to your patient to take for
their followup visit with their OB/GYN.
In the second trimester, dating of gestational age
focuses on skull circumference or measurement of
the biparietal diameter.
We want to measure the skull at about the level
of the thalamus in an axial orientation with the face down.
As we can see here, replacing the calipers from
the outer skull table proximally to the inner skull
table distally, and we have a measurement of 3.26cm
correlating to a 16 week one day gestational age.
In addition to measuring the gestational age of the fetus,
another very important concept is to get a measurement
of the fetal heart rate.
Normal fetal heart rates will range from 120-160
beats per minute, but lower rates down to 90 beats
per minute can be seen in early pregnancy in
the early parts of the first trimester.
M-Mode is the best method for determining fetal heart rate.
Power Doppler and Contrast gives more ultrasonic energy
to the developing heart, thus M-Mode is the preferred
way of measuring the fetal heart rate at this time.
Here, we're going to use M-Mode to determine
the fetal heart rate.
Notice we have the fetus zoomed up towards the top
of the image and replacing the M-Mode caliper directly
over the fetal heart.
Towards the bottom we see the M-Mode Motion strip
and notice the little waves showing the motion
of the fetal heart.
In this particular ultrasound machine, we need to
measure between each peak, and we see here that
we get a heart rate determination towards the bottom,
158 beats per minute.
This is something we can print out and place on the chart
to show that at the time we saw the baby there was
an actual heart beat.
While fortunately most pregnancies have a successful
outcome, unfortunately there are going to be some
abnormal pregnancies that we'll see in the emergency
department, consistent with fetal demise.
Some of the measurements we'll use to determine
abnormal pregnancy with fetal demise is a very large
gestational sac greater than 10 millimeters if
no yolk sac is seen.
Once the gestational sac is greater than 18 millimeters,
we should see a fetal pole or else this is an abnormal
pregnancy.
And many times the gestational sac in an abnormal
pregnancy will have an irregular shape with a scallop
type appearance to it.
Here's video from an abnormal pregnancy.
The first thing we notice is a very large
gestational sac without a yolk sac or discernable
fetal pole with heart beat.
We also see the presence of subchorionic hemorrhage
to the superior aspect of the gestational sac.
That's that area of dark or anechoic fluid
surrounding the gestational sac.
This is seen commonly with abnormal pregnancies
or spontaneous miscarriage.
Here, we'll put the calipers down to measure the diameter
of the gestational sac.
Note that it's very large at 2.8 centimeters by
1.6 centimeters, much larger than the one centimeter
mark that we said defined an abnormal pregnancy
if there was no yolk sac or 18 millimeters if no
fetal pole was seen.
Other indicators of an abnormal pregnancy with fetal
demise is a gestation greater than seven weeks,
which is abnormal if no fetal heart beat is seen.
And if the fetal pole is greater than five millimeters
in dimension this is abnormal if no fetal
heartbeat is seen.
This was an unfortunate case in which we see
a large a fetal pole, greater than five millimeters
without a heart beat.
This is indicative of embryonic demise and we also
see a large circular amnion within the gestational sac.
While I do think it's important we're able to pick up
the findings of the abnormal pregnancy, I'm always
going to get a confirmatory ultrasound and/or OB/GYN
consultation before giving the patient the news that
there is a fetal demise.
I'd like to conclude this module with another form
of abnormal pregnancy, which is a molar pregnancy,
which is a form of Gestational Trophoblastic Disease.
Gestational Trophoblastic Disease ranges from
a spectrum from a Benign Hydatidiform Mole to
Invasive Choriocarcinoma, a form of metastatic disease.
The majority of these are derived from paternal
chromosomes; there is no maternal chromosomes in the embryo.
The ultrasound appearance will be a cyst-like bunch
of grapes with a snowstorm-type appearance,
and classically the serum Beta-HCG will be very elevated.
Here's video from a patient who presented with
a Molar Pregnancy.
Her presenting symptoms were uncontrolled hypertension
during the pregnancy, as well as vaginal bleeding, and pain.
What we see here is the presence of a molar pregnancy
within the fundal region of the uterus.
Notice it has a cyst-like type of appearance.
Very different from the normal appearance
of a intrauterine pregnancy.
As we scan back and forth, it almost looks like
a bunch of grapes within the fundus of the uterus.
So a diagnosis of a molar pregnancy and my next move
was to get an OB/GYN consultation stat.
So thanks for tuning in to Part 2 of Emergency OB/GYN
Ultrasound, focusing on intrauterine pregnancy.
Hopefully you now have a better understanding on
how to further assess a normal pregnancy by determining
gestational age and fetal heart rate.
I hope also I've been able to give you some of
the ultrasound findings that you may see in an
abnormal pregnancy to know when you need to get
an OB/GYN consultation in the ED.
I hope to see you back as we move on to Ectopic Pregnancy,
and two modules in which we'll discuss the various
findings of ectopic pregnancies that we may see
in the emergency department.
I'll see you back as Soundbytes continues.

Brightcove ID

5750480594001

https://youtube.com/watch?v=4clxpcVLOS0

Case: Intrauterine Pregnancy - Part 1

Read more about Case: Intrauterine Pregnancy - Part 1

/sites/default/files/perera_intrauterine_part1.jpg

This video discusses the use of transvaginal and transabdominal ultrasound for detecting intrauterine pregnancies.

Clinical Specialties

Media Library Type

Media Library Tag

Tubal Ectopic Abdominal Ectopic

Ampullary

Ovarian

Pseudogestational Sac

Subtitles

- 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 module entitled Emergency OB/GYN Ultrasound: Part I,
we're going to focus entirely on the
ultrasound findings of intrauterine pregnancy.
Now patients with early pregnancy and vaginal bleeding
with or without abdominal pain
are frequently seen in the emergency department.
Luckily for us, emergency OB/GYN ultrasound
has evolved to be one of the most helpful
applications of sonography
in a busy emergency medicine practice.
So this module will be focused
primarily on the detection of intrauterine pregnancy
and we'll examine the ultrasound findings that define
a normal pregnancy for an emergency physician sonographer.
Before launching into the sonographic findings
of a normal intrauterine pregnancy,
let's take a moment to quickly review
the OB/GYN anatomy important for this application.
We see the uterus to the left and adnexa to the right.
Notice the areas of the uterus.
We see the lower cervix,
the intermediate body,
and the fundal region towards the top of the uterus.
Now, the fundal region is where we define
an intrauterine pregnancy to be located.
We see the area where the fallopian tube
enters into the uterus,
which is the interstitial region in a normal uterus
and the cornual region in a bicornuate uterus.
And this is where some variants of ectopics can implant.
Notice the areas of the fallopian tube to the right,
which we'll concentrate more on
with regard to ectopic pregnancy.
And we see the broad ligament there encasing
the fallopian tube and the ovary as seen to the right.
When taking care of a patient
who has vaginal bleeding in pregnancy,
there's four main classifications of diagnoses.
The first is a Threatened Abortion,
which is defined as the presence
of an intrauterine pregnancy with bleeding.
The second main classification
encompasses several different terms.
The terms that are commonly used are,
Incomplete Abortion,
Missed Abortion,
Blighted Ovum,
and Fetal Demise.
Basically, all of these mean the presence
of fetal membranes or parts,
without expected fetal growth or cardiac activity.
The third main classification is a Completed Abortion,
in which there is no further presence
of fetal membranes or parts,
and on examination, usually the cervical os will be closed.
The fourth main classification is the most dangerous,
is Ectopic Pregnancy.
Here's a table showing the structures in pregnancy
and about the time that they're seen on transvaginal
versus transabdominal sonography.
As we look in the Embryonic Structure column to the left,
we see the first structure that appears
is a gestational sac, seen on transvaginal sonography
at about 4.5 to 5 weeks,
and about a week later on transabdominal sonography.
The yolk sac is seen at about 5 to 5.5 weeks
on transvaginal sonography
and a week later on transabdominal sonography.
I have this circled in red,
as this is really the way we diagnose
an intrauterine pregnancy.
Then note the fetal pole is seen at about 5.5 to 6 weeks
on transvaginal sonography
and a week later on transabdominal sonography.
The last main finding, which is a fetal heart beat,
is seen at about six weeks on transvaginal sonography
and about at seven weeks on transabdominal sonography.
Another important concept for OB/GYN sonography,
is the correlation of the serum beta HCG
to the findings of a normal pregnancy.
As we see here for transvaginal sonography,
the discriminatory zone at which we will see
findings of an intrauterine pregnancy
are about 1,500 to 2,000 mIU.
For transabdominal sonography,
the discriminatory zone is about 6,500 mIU.
Now, this rule does not apply to ectopic pregnancies,
which secrete beta HCG at atypical levels
and are commonly seen with betas all over the map.
They can be seen with betas lower than 1,000
and as high as 30,000.
The first finding that will occur
during an intrauterine pregnancy
is going to be a gestational sac.
As we see here in the ultrasound picture to the right,
it's a small, round circle that's dark
or hypoechoic in relation to the rest of the uterus.
We actually see a gestational sac below that
that came out of a patient.
Notice that it has a translucent, membrane-type appearance.
Unfortunately, gestational sac
is not diagnostic of an intrauterine pregnancy,
as a pseudogestational sac of ectopic pregnancy
can be seen from hormonal stimulation.
As a general rule of emergency ultrasound,
is that visualization of a gestational sac
is not adequate to call an intrauterine pregnancy.
Here's two video clips showing the gestational sac.
Long Axis to the left,
and Short Axis to the right.
We see here a very small diameter gestational sac
in both of these orientations.
Unfortunately, this can be seen with a
pseudogestational sac of ectopic pregnancy.
So a small gestational sac, like this,
is in no way diagnostic of an intrauterine pregnancy
for the emergency physician sonographer.
Remember that the gestational sac is seen
at about 4.5 to 5 weeks on transvaginal sonography,
and about a week later on transabdominal sonography.
Here are the findings that we define
as indicative of an intrauterine pregnancy
for an emergency physician sonographer,
and that is the presence of a gestational sac
with a yolk sac inside.
As we see in the picture to the right,
the yolk sac has a circular-type appearance
that we call the Positive Cheerio Sign.
Let's just remember, gestational sac plus yolk sac
is indicative of intrauterine pregnancy.
However, bonus points are given
if you see a fetal pole with a heart beat
for confirmation of intrauterine pregnancy.
Here's a video clip showing a definitive
intrauterine pregnancy.
What we see here is a larger gestational sac
and as we look inside the gestational sac,
we see the positive yolk sac or Cheerio Sign.
Notice the circular yolk sac is seen
towards the inferior aspect of this gestational sac.
This would be diagnostic of an intrauterine pregnancy,
effectively ruling out an ectopic pregnancy
in the vast majority of patients.
Remember that the yolk sac is seen
at about 5 to 5.5 weeks on transvaginal sonography,
and about a week later on transabdominal sonography.
Here we see a pregnancy that is a bit further advanced.
Note we have a larger gestational sac,
that darker or hypoechoic area,
within the fundal region of the uterus,
and as we look inside the gestational sac,
we see the positive yolk sac or the Cheerio,
and looking just to the left of the yolk sac,
we see a tiny little fetal pole there.
Interestingly enough, as we zoomed up on that fetal pole,
we could make out the flicker of a heart beat.
So, a definitive intrauterine pregnancy.
Recall that the fetal pole is seen
at about 5.5 to 6 weeks on transvaginal sonography,
and about a week later on transabdominal sonography.
Here's a transvaginal short axis view
of a seven week intrautertine pregnancy.
We see the gestational sac here.
Notice that the gestational sac
is located in the center of the uterus
as seen here in short axis,
and there's a good amount of myometrial mantle
surrounding the gestational sac,
signifying a fundal location.
We see the positive Cheerio sign, or yolk sac,
to the upper right aspect of the gestational sac,
and right below, we see the fetal pole stretched out.
Notice the positive cardiac activity
as we scan back and forth through the fetal pole.
Here's another intrauterine pregnancy at about seven weeks,
again in the transvaginal short axis view.
We note the good amount of uterus
surrounding the gestational sac,
signifying the fundal location.
We see here the yolk sac or Cheerio sign,
and the fetal pole is stretched out below the yolk sac.
Notice the positive cardiac activity
within the fetal pole.
Now we see another very important finding here
on this ultrasound,
which is the amniotic membrane,
billowing out from around the fetal pole.
Eventually the amniotic membrane
will plaster down on the margins of the gestational sac
to form the amniotic cavity,
in which further growth of the fetus will occur.
Here's an interesting video clip
showing a twin pregnancy.
What we see here are two gestational sacs
signifying dichorionic twins,
and within each of the gestational sacs
we can see little fetal poles
with a flicker of heart beats.
Recall that fetal heart activity
is seen at about six weeks on transvaginal sonography
and about seven weeks on transabdominal sonography.
Here's an early second trimester pregnancy.
What we see here is the next Oscar De La Hoya.
Note the mean right hook on the baby here.
The important finding here is that
this is an intrauterine pregnancy
as we can define a good mantle of uterus
surrounding the pregnancy.
That's very important as there are some ectopics
that can grow to an advanced stage,
but they're discerned by a lack of uterus
around the pregnancy.
Here's another second trimester baby
and as I work in Northern Manhattan,
I refer to this baby as the Merengue baby.
Note the baby moving around fluidly within the amniotic sac.
A sure sign that this kid will grow up to be a slick dancer.
In conclusion, I'm glad I could share with you
this SoundBytes module
going over Emergency OB/GYN Ultrasound: Part I
of intrauterine pregnancy.
Emergency OB/GYN ultrasound is definitely
one of the most helpful sonographic applications
in a busy emergency medicine practice
and hopefully by going through the module
you now have an understanding
of the ultrasound findings diagnostic of a normal pregnancy.
I hope to see you back as we return
in OB/GYN Ultrasound Pregnancy Part 2,
focusing on further assessment of normal pregnancy
as well as looking further into
the ultrasound findings of an abnormal pregnancy.

Brightcove ID

5508114751001

https://youtube.com/watch?v=gv4q8ZB25JM

Case: Ectopic Pregnancy - Part 2

Read more about Case: Ectopic Pregnancy - Part 2

/sites/default/files/youtube_ANhOwzbKe6Y_0.jpg

This video details how bedside ultrasound can help emergency medicine professionals visualize and diagnose various presentations of ectopic pregnancy, as well as differentiate between an ovarian cyst and an ectopic pregnancy.

Clinical Specialties

Media Library Type

Media Library Tag

Tubal Ectopic Abdominal Ectopic

Subtitles

- 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.
This module is ectopic pregnancy part two,
where we'll go over the multiple
ultrasound presentation of ectopic pregnancies.
Ectopic pregnancy is one of those
conditions that we'll not infrequently
encounter in a busy EM practice.
The most common presentation of
an ectopic pregnancy will be an empty uterus,
with or without free fluid within the pelvic cul de sac
or surrounding the uterus.
We may be actually able to visualize
the ectopic as a Bagel sign,
which constitutes a thickened Fallopian tube.
Other presentations of ectopics
include a complex pelvic mass
with a ring of fire on Doppler sonography,
hemosalpinx or blood within the Fallopian tube
or we may be actually able to visualize
the live ectopic in the adnexa,
with a fetal pole and/or heartbeat.
Here's a transvaginal long axis ultrasound
for a woman who presented with lower abdominal pain
and a positive pregnancy test.
Notice the uterus, as shown in the long axis view,
without an appreciable intrauterine pregnancy
and notice that it's surrounded
by a large amount of free fluid.
That dark or anechoic area surrounding
the uterus both anteriorly to the left,
posteriorly in the cul de sac to the right.
That is the presence of fresh blood.
Notice also the presence of blood clots
anteriorly or to the left, that more echogenic area.
So, given the absence of an intrauterine pregnancy,
we decided to scan out to the adnexa
and notice here, the presence of
a Bagel sign of a tubal ectopic pregnancy.
We see fresh fluid here, above the Bagel,
to the right, blood clot to the left
and the more hyperechoic
or lighter Bagel sign in the middle of the image.
Occasionally it can be difficult to discern
the Bagel sign of a Fallopian tube ectopic
from an ovarian cyst, as show here to the right.
But lets look closer at the two video clips
and notice that the Bagel sign
has a more hyperechoic or bright appearance,
with the single hole more in the middle.
Notice that the ovarian cyst has a different appearance,
with multiple small follicular cysts
to the outer portion of the ovary
and a single midline corpus luteum cyst.
Very different than the Bagel sign.
Here's another patient with an ectopic pregnancy
in a different presentation of ectopic.
We're scanning here from the more midline uterus,
as show there to the left, out to the right adnexa
and notice as we scan out to the right adnexa,
we notice the presence of a complex, pelvic mass.
Notice also the relatively low
serum B-HCG in this case, at 478.
So, a complex pelvic mass with
an absence of intrauterine pregnancy.
Very suspicious for an ectopic pregnancy.
And what's interesting is,
as we put Doppler flow on that complex pelvic mass,
we notice the presence of the ring of fire,
very suggestive of an ectopic pregnancy
and the reasons for the ring of fire
is that the ectopic pregnancy pulls
a huge amount of vascularity towards it
and using the Doppler,
we can see the separate ectopic from the ovary above it.
Here's another presentation of an ectopic pregnancy.
Again, we're scanning at a short axis plane
and we see there the uterus to the left
and outside the uterus, a separate structure.
We note here the presence of a thickened Fallopian tube
and inside the thickened Fallopian tube,
we see here a fetal pole with a heart beat,
consistent with a live ampullary ectopic pregnancy.
Unfortunately in this case,
the presence of a fetal pole with
a heart beat is a contraindication of methotrexate therapy
and this patient will need to undergo surgery.
We mentioned earlier that there are
a variance of ectopic pregnancies
that implant outside the fundal region of the uterus,
in an aberrant location.
This is a good example.
This patient actually has a bicornuate uterus
and as we scan at a short axis plane up the uterus,
we notice that the two limbs of endometrium
that make up the two distinct cornua.
As we go up the left cornua,
we notice here the presence of a cornual ectopic pregnancy
and we see the that it's located off to the side,
way out to the left cornua,
with a very thin myometrial mantle.
If we actually put the calipers down
and measure the endo-myometrial mantle,
we find it's very thin, at three millimeters,
defining an abnormal pregnancy.
A normal pregnancy should have
a myometrial mantle greater than eight millimeters.
Now this is a bicornuate uterus,
so this is a cornual pregnancy.
In a normal uterus,
this would be known as an interstitial pregnancy.
So in conclusion, I'm glad I could share with you
this module on ectopic pregnancy part two,
looking at the varied presentations of ectopic pregnancy.
Hopefully now you better understand
what we're searching for on bedside sonography
when we're working up a patient
with possible ectopic pregnancy.
While visualization of the adnexa
and the Fallopian tubes is an advanced technique,
but it is well within the scope
of a busy emergency medicine practice.
As a final caveat, ectopic pregnancies can
be seen at Beta-HCG levels ranging from very low,
less than 100, to very high, above 20,000
and thus we cannot use a Single Beta-HCG
level to rule out ectopic pregnancy.
It's really better to look at trends
in the hormone level over time.
With an intrauterine pregnancy,
the levels should double in 48 hours,
whereas in most ectopic pregnancy,
it will not climb to the same degree.
So, I hope that now you have a
better understanding of how to
work up the pregnant patient with
a possible ectopic pregnancy.

Brightcove ID

5750496732001

https://youtube.com/watch?v=ANhOwzbKe6Y

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