Fluid

Case: FAST Exam - LUQ Exam

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The left upper quadrant (LUQ) ultrasound exam can help clinicians more accurately diagnose intra-abdominal injuries. Topics: infra-diaphragmatic and splenorenal spaces, & how to identify free fluid caused by a trauma.

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- 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, we'll continue our journey,
looking at the views of the Trauma FAST exam.
Hopefully you've had a chance to join me prior
for the views of the right upper quadrant,
and in this module,
we're going to look specifically
at the left upper quadrant views of the Trauma FAST exam,
known traditionally by two terms,
the splenorenal, or the perisplenic views.
In an upcoming module,
we'll look specifically at the suprapubic view,
or bladder view, of the Trauma FAST exam.
There's a lot of information we can gain
by looking at the left upper quadrant
in our trauma patients,
and we'll need to know that it's not a mirror image
of the right upper quadrant,
that the spleen offers less of an acoustic window
onto the left upper quadrant than the liver does
on the other side.
Here's a slide reviewing how to perform
the left upper quadrant view of the Trauma FAST exam.
As the spleen offers less of an acoustic window
on the left upper quadrant,
we need to bring the probe in
from a more posterior position.
Thus, the mantra, knuckles to stretcher.
Optimally, we're using a smaller footprint probe
that can get in between the ribs
and get a good view into the left upper quadrant area.
Position the probe in the long axis view
with the probe marker towards the patient's head,
at about the midaxillary line, or posterior axillary line,
with your knuckles almost touching down to the bedside.
We'll concentrate on two areas, most importantly,
the area above the spleen and below the diaphragm,
where fluid will preferentially accumulate,
but rounding out our exam,
we'll look inferior at that spleno-renal space.
Now that we know how to perform
the left upper quadrant view of the Trauma FAST exam,
let's take a look at a normal ultrasound image.
I have the probe oriented towards the patient's head,
so superior chest cavity is towards the left,
inferior abdominal cavity towards the right.
Notice the spleen,
the large organ in the middle of the image here,
and the kidney, the football shaped organ,
as seen inferior and posterior to the spleen.
Notice the curving white line just above the spleen,
which is the diaphragm.
Recall that in the left upper quadrant,
that fluid will accumulate preferentially
in between the spleen and the diaphragm
and will be a dark or anechoic stripe positioned there.
Here's another normal video clip
taken from the left upper quadrant.
In this case, I'm swinging the probe from inferior,
looking at the spleno-renal interface,
to superior, looking at that infra-diaphragmatic space.
And here, as I freeze the image,
we see the spleen right in the middle of the image,
the curving white line making up the diaphragm,
and notice the thoracic cavity
as seen just left, or superior, to the diaphragm.
If the patient had a significant hemothorax,
or fluid collection in the thoracic cavity,
that would be represented by
a dark or anechoic fluid collection
just above the diaphragm in the thoracic cavity.
Now that we've had a chance
to examine several normal video clips
as taken from the left upper quadrant,
let's look at a pictorial here,
showing a positive left upper quadrant FAST exam.
Here we see superior located to the left,
inferior to the right.
We see the spleen in the middle of the image,
the kidney inferiorly to the right.
The thoracic cavity with the diaphragm
to the left of the spleen, or superior.
We see the area of fresh fluid
as demarcated by the orange color,
and notice that it layers out
predominantly below the diaphragm
and above the spleen,
and this is the area where fluid
will preferentially deposit in the left upper quadrant.
There are ligaments that sling
from the diaphragm all the way to the colon
that prevent the flow of fluid
into that area between the spleen and the kidney
until the fluid is relatively large
within the left upper quadrant.
So, now let's take a look at a positive exam
from a trauma patient,
and we see here the spleen in the middle of the image,
the kidney inferiorly located to the spleen,
and notice the large amount of fresh fluid,
that dark or anechoic fluid collection
that layers out above the spleen
in the infra-diaphragmatic location,
and anterior to the spleen.
This indicates a large amount of fresh blood
in the left upper quadrant,
and we also see a blood clot,
that echogenic material waving around
anteriorly to the spleen.
So a positive exam in a trauma patient.
Here's another positive left upper quadrant view.
Notice here, there's a larger amount
of fresh fluid present on this examination.
We see the spleen in the middle of the image,
the kidney inferiorly there to the right,
and all the dark, fresh fluid,
as indicated by the dark, or anechoic, fluid collection,
as seen infra-diaphragmatic and above the spleen.
Notice again that the fluid is not
preferentially layering out in between
the spleen and the kidney, reinforcing the point that
this is not a mirror image of the right upper quadrant.
Here's another positive examination
in a patient who comes in hypotensive
after being hit by a car.
Notice I'm swinging the probe
between the kidney, up superiorly,
to look at the spleen.
Notice the absence of fluid in between the spleen
and the kidney,
but the presence of free fluid
right above the spleen and below the diaphragm
as indicated by that dark stripe.
Here's an interesting video clip from a trauma patient.
Again, we're looking at the left upper quadrant,
and we delineate the spleen and kidney.
Notice the presence here of fresh fluid,
the dark or anechoic fluid stripe
as seen layering out superior, or in anterior,
to the spleen there,
but let's look above the diaphragm here,
which we see as the curving white line
moving up and down as the patient breathes,
and what we notice here is the presence
of a dark fluid collection within the thoracic compartment.
So we're able to diagnose in this patient
an associated hemothorax
in addition to the hemoperitoneum.
So the left upper quadrant view
also helpful for looking into the thoracic compartment
as well as diagnosing interabdominal injury.
One maneuver that can help you
uncover fresh fluid within the left upper quadrant
is to have the patient take a deep breath
and analyze that infra-diaphragmatic space
as the diaphragm moves upward, off of the spleen.
Notice here that we uncovered the amount
of fresh fluid that's present right above the spleen
and below the diaphragm as the patient
takes a deep breath,
and that diaphragm moves superiorly.
So, in conclusion, I'm glad I could share with you
this SoundBytes module, going over the trauma FAST exam,
specifically the left upper quadrant, or perisplenic view.
There's a great deal of information that we can gain
by looking into the left upper quadrant
in our trauma patients,
and it's important to realize that
the left upper quadrant is not a mirror view
of the right upper quadrant,
and that fluid will preferentially layer out
in the area above the spleen and below the diaphragm,
in contrast to the hepatorenal space
on the right upper quadrant.
So, I hope to see you back as SoundBytes continues
and we move on to look at the suprapubic,
or bladder view, of the Trauma FAST exam.

Brightcove ID

5726805223001

https://youtube.com/watch?v=VBHCmw8iHCc

Case: FAST Exam - Suprapubic Views

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This video details how using long-axis and short-axis suprapubic views during a trauma FAST ultrasound examination enables clinicians to identify fluid in a trauma patient's pelvic cavity.

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- Hello, my name is Phil Perera and I'm the Emergency
Ultrasound Coordinator at the New York
Presbyterian Hospital in New York City.
And welcome to Soundbytes Cases.
In this Soundbytes module we'll continue
our journey looking at the Trauma Fast Exam.
I hope you've had a chance to join me prior
for modules looking at the right upper quadrant
and left upper quadrant views of the Trauma Fast Exam.
In this module we will specifically look at
the Suprapubic view, also known as the bladder or pelvic
view of the Trauma Fast Exam.
There is a lot of information we can gain
from looking at the Suprapubic view,
as we can potentially detect a smaller amount of fluid
than is required to make a positive right
upper quadrant or left upper quadrant view.
Literature suggests that only about
100 to 200 ccs of fluid can be detected
accurately on the Suprapubic view.
Here's a slide reviewing how to perform
the Suprapubic view of the Trauma Fast Exam.
In contrast to the upper quadrant views,
where we looked only in the long axis configuration,
the Suprapubic view is made up of two planes.
We want to look in both long and short axis configurations.
We'll begin at long axis with the marker dot
oriented toward the patient's head
and complete our exam by moving the probe
into short axis with the marker dot
toward the patients right side.
This way we can fully scan through the pelvis
and not miss any small amounts of fluid there.
It's optimal to perform the examination
with a full bladder as an optimal
acoustic window, so perform the
exam prior to having the patient
void or placing a foley catheter.
Here's an illustration showing the anatomy
that we'll need to know to perform
the Suprapubic view of the Trauma Fast Exam.
We see the pattern of fluid flow in a female,
to the left here, and a male, to the right.
Let's look closer at the female pelvis,
to the left, and what we see is that fluid will
preferentially develop in the pelvic
Cul de Sac, located behind the uterus.
Now, small amounts of fluid will only be
located in the pelvic Cul de Sac,
but as the amount of fluid enlarges
it will come out and increase so
that it will layer out on top of
the uterus and on top of the dome of the bladder.
But small amounts of fluid will only be found in
that pelvic Cul de Sac posterior to the uterus.
Now let's take a look at the male
pelvis to the right and we see
small amounts of fluid that will only be found
in the Retrovesical Space behind the bladder.
As the amount of fluid enlarges it
will come anterior to settle out
over the top of the dome of the bladder.
But as we emphasized in the female,
small amounts of fluid will only be
found in one place and in the male
it will be in that Retrovesical Space
immediately posterior to the bladder.
Let's begin by looking at some normal
video from the Suprapubic View.
In this case, a long axis view in a female,
superior to the left, inferior to the right.
The first structure we identify is
the bladder, the dark area, anteriorly
and posterior to the bladder we see the uterus.
Now if we look into the potential space,
the Pelvic Cul de Sac, posterior to the
uterus for any dark fluid collections, we see an
absence of any fluid on this normal video clip.
Now let's inspect a video clip from a male.
In this case a short axis view.
We see a large bladder there, anteriorly
and behind the bladder we see two
tubular structures making up the
Seminal Vesicles, a normal finding in a male.
Now if we're looking for free fluid
behind the bladder, we'd be looking
for dark or anechoic fluid collection
layering out behind the bladder.
Notice this is a normal examination.
Here's a positive examination
in a female trauma patient.
We're looking in the long axis view,
superior to the left, inferior to the right.
The first structure we identify is
the bladder, as seen inferior here.
And notice the uterus, the solid organ,
as seen superior to the bladder.
We note the parts of the uterus, the fundus
anteriorly, and the cervix more posteriorly.
Now let's look into the Pelvic Cul de Sac
immediately posterior to the uterus,
and what we see here is the presence of a
dark or anechoic fluid collection just posterior
to the cervix within the pelvic Cul de Sac.
So in the female trauma patient,
this does denote a positive examination
and can be a sign of ongoing bleeding
within the abdominal pelvic cavity.
So let's contrast this clip in which
we see a small amount of fresh
fluid within the pelvic Cul de Sac.
With this one, in which we have a female
trauma patient with a large amount
of bleeding within the pelvic cavity.
We see here, again, a long axis scan superior
to the left, inferior to the right, the bladder
we see as the dark structure inferiorly
and the uterus superior to the bladder.
Notice the fresh fluid as seen posterior
to the uterus within the Cul de Sac,
but note that the amount of fluid
comes anterior to the uterus,
as seen here between the uterus and the bladder.
So this denotes a large amount of blood within
the pelvic cavity in this female trauma patient.
If we now orient the probe to the patient's right side,
we obtain a short axis view of the same patient.
And what we see here is the uterus in the
middle of the image and notice the large amount
of fresh fluid as seen both to the top, or anterior,
to the uterus and posterior to the uterus.
Notice in this case we can see the
broad ligaments of the uterus well outlined
by all the fresh fluid within the pelvis.
So a large amount of fresh fluid, or blood,
in this case, within this female trauma patient.
Here's a positive examination
Suprapubic View, short axis in a male.
Probe is oriented towards the patient's right and
anteriorly we see a large, fluid filled bladder.
Posterior to the bladder, in the retrovesical
space we appreciate the presence of free fluid,
as shown by that dark or anechoic
fluid collection there.
Now this gives a finding known as
the double wall sign, and we see
the wall of the bladder, outlined by
the urine inside the bladder, and the
blood, in this case, outside the bladder
in the area of the retrovesical space.
To further confirm that the last patient
had a positive exam and that we're
not mistaking areas of fluid as seminal vesicles,
we'll re-scan the patient in the long axis plane,
superior to the left, inferior to the right.
We see the large circular bladder,
as seen anteriorly and superior
and posterior to the bladder in the
retrovesical space, we can see
free fluid layering out there.
This confirms that indeed the patient
has a positive exam, with blood
layering out behind the bladder.
And, again, we see the double wall sign,
urine outlining the inner wall of the
bladder, and blood, in this case,
outlining the outer wall of the bladder.
Here we're scanning a male trauma patient with
a long axis configuration and we see a large
amount of free fluid within the pelvis.
We note the bladder inferiorly,
and note all the free fluid layering
out both posterior to the bladder
in the retrovesical space and coming
anteriorly onto the dome of the
bladder as seen to the left here.
So a large amount of free fluid in this male trauma patient.
In conclusion, I'm glad I could
share with you the Soundbytes Module
covering the Suprapubic View of the Trauma Fast Exam.
This view is a very important
one to add onto the exam of your
trauma patient as we can potentially
detect a smaller amount of fluid here,
within the pelvis, than it takes to
make a positive right upper quadrant
or left upper quadrant view.
Remember that this is a two-step exam,
we'll be looking in both short
and long axis configurations to
verify fluid, and also remember
the differences between the female, where we're
looking into the pelvic Cul de Sac for fluid,
and the male, where we're looking into
the retrovesical space for fluid.
So I hope to see you back in the
future as Soundbytes continues.

Brightcove ID

5508114789001

https://youtube.com/watch?v=Pa3z9zWNfB8

Case: FAST RUQ Exam - Hemorrhage

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This video (part 2 of 2) focuses on positive findings found during right upper quadrant (RUQ) ultrasound examinations; it also includes instructions for performing the trauma FAST RUQ-hepatorenal ultrasound exams

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- 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,
Part Two of the Right Upper Quadrant View
of the Trauma Fast Exam,
we're going to focus entirely on positive findings
from this view.
Hopefully you've had a chance to join me prior
for Part One of the Right Upper Quadrant View
of the Trauma Fast Exam where we focused entirely
on normal findings from the right upper quadrant.
And hopefully have a chance to join me back
as we go through the left upper quadrant
and suprapubic views of the Trauma Fast Exam.
So let's begin this module by going through a
review of how to perform
the right upper quadrant view of the Trauma Fast Exam.
Remember that the probe is positioned in the
long axis configuration with the marker dot superiorally
and that we're going to place the probe in between the ribs
at about the anterior axillary line.
Here we'll want to focus on the three areas
as I emphasized in Part One of this module.
Number one, the infra-diaphragmatic space
looking at that region just below the diaphragm
and above the liver,
and actually looking into the chest cavity for a hemothorax.
Position two, which is the traditional Morison's Pouch
or hepatorenal interface.
And position three, to round out the exam
looking at the caudal liver tip representing the
beginning of the right paracolic gutter.
Here's a nice illustration showing a positive examination
from the right upper quadrant view of the Trauma Fast Exam.
We see the liver smack in the middle of the image
and the kidney slightly posterior and inferior to the liver.
Let's look at the preferential deposition of fluid
as shown here in the orange color,
and we see that it layers out predominantly around
the caudal tip of the liver as shown towards the
inferior edge of the image here.
Notice that it flows from the caudal tip of the liver
into that potential space which is Morison's Pouch
in between the liver and the kidney.
Now this is very important to emphasize as many times,
fresh fluid can only be seen around that
caudal tip of the liver,
and then it would move into that hepatorenal interface
or Morison's Pouch.
Here's a positive ultrasound examination from a patient
who was hit by a car while crossing the street
and we see here the liver
smack in the middle of the image here.
Notice the kidney located inferior and posterior
to the liver.
And in between the liver and the kidney in that
potential space known as Morison's Pouch,
we see a dark or anechoic fluid collection.
Not insignificant,
actually a pretty large stripe in this patient.
This represents the positive examination,
or the presence of fresh fluid,
in this case blood within Morison's Pouch.
And notice that it layers out in between
that liver and kidney.
To emphasize the point that a complete right upper quadrant
view includes looking at the caudal tip of the liver,
let's examine this video clip from another trauma patient.
If we look at the hepatorenal interface there,
we fail to see the presence of any fluid,
but as we move the probe inferiorially,
we see that the caudal tip of the liver as shown right there
is well outlined by fluid.
And here we see the inferior pole of the kidney,
the caudal tip of the liver extending above the kidney,
and notice all the fresh fluid
both anterior and posterior to the caudal tip of the liver.
Making the point that this is a very important area
to look for in the right upper quadrant exam.
Here's a video clip from a patient who was stabbed
with a really big knife to the epigastric region.
And as we look at the right upper quadrant,
we can actually see a linear liver laceration
extending through the medial aspect of the liver.
We also appreciate the presence of a large
amount of fresh fluid.
That dark or anechoic fluid collection
layering out posteriorally there to the liver
and extending into Morison's Pouch,
the hepatorenal interface.
So as this patent had unstable hemodynamics,
the next move was to package for the operating room.
And here we can actually see the caudal tip of the liver
waving around in all the fresh fluid,
in this case blood.
And I obtained this view by moving the probe
one intercostal space inferior from the last view
to well delineate the caudal tip of liver
which we can see here moving around in all the fresh fluid.
In the last few video clips the appearance of fresh fluid
on bedside sonography was darker, anechoic.
However as blood clots it can take on a more echogenic
or lighter appearance.
In this video clip a patient was stabbed
and had a significant down time before being
brought to the Emergency Department.
As we look at the hepatorenal interface,
we see a large amount of clotted blood there
made up by that echogenic
or lighter appearance of the blood there.
Notice that the large amount of blood extends into
the right paracolic gutter as we scan inferiorially.
And here we can see the liver,
the kidney,
and the clotted blood,
that more echogenic or lighter blood in Morison's Pouch.
So in conclusion,
I'm glad I could share with you this Part Two Module
on the Right Upper Quadrant View of the Trauma Fast Exam.
I hope now you have a better understanding
on how to perform a complete exam
looking into the three areas as we discussed.
Infradiaphragmatic,
Morison's Pouch,
and inferior tip of the liver.
And hopefully now you'll be able to discern
the presence of fresh blood versus clotted blood
on bedside sonography.
So I hope to see you back as Sono access continues
and as we move further through the other views of the
Trauma Fast Exam.

Brightcove ID

5508109915001

https://youtube.com/watch?v=Gj5IioG7SyM

How to: Female Pelvis: Transvaginal View

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Obtaining a transvaginal view of the female pelvis

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EMED

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- If you do a transabdominal examination
of the pelvis for early pregnancy
and you cannot find a definitive
gestational sack inside of the uterus,
the next step you need to do is
an intracavitary examination of the uterus
and cervix and the adnexal area
to determine where the pregnancy is,
whether it's intrauterine or extrauterine.
So what I'm gonna do right now
is walk through the steps on how
you would do that examination
and we're gonna use this Phantom by Blue Phantom,
that will actually demonstrate an ectopic pregnancy.
So the first stage of the prep
for the intracavitary transducer
is that we need to cover it with a sheath.
When you do this, we need to remove
any air gaps that are inside the sheath,
next to the transducer face.
So what we will do is put a little
bit of gel inside the cover,
position that over the tip of the transducer
and then just pull down the covering over the transducer
and pull this down right over the handle,
so you've got good coverage.
And then just make sure that you examine the tip here
and make sure you eliminate any
air bubbles that are covering the transducer face.
So once you've got the air bubbles eliminated,
then you can move on to the next step.
We're going to put a little bit
of gel on the outside of the latex cover now.
And again, your orientation for
this examination is very important.
So for the long ax or sagittal view,
we want the orientation marker up
and then when we go to the coronal view,
we're gonna turn that so it faces the patient's right.
After we've inserted the transducer in a long axis view,
the first thing that we're gonna
see is a long ax of the uterus.
In this Phantom representation of the uterus,
we see an endometrial stripe,
which is represented by the white line.
So if I was doing this as a real pelvic exam,
I would scan to the right of the patient,
all the way through to the right adnexa
and then back over, all the way back through the uterus,
over to the left adnexa.
And the reason I'm doing this
is because I don't see the pregnancy inside the uterus,
so I'm suspecting that it's extrauterine
or an ectopic pregnancy.
I do have some hints here though, using this Phantom.
In the posterior cul de sac region,
I'm seeing a black anechoic area,
which would represent free fluid or blood.
If I scan all the way over to the left adnexa, in this case,
the first structure I come across,
this echogenic area represents the ovary.
If I keep scanning to the left, in the pelvis,
I encounter this other area
and this represents, in this case, our ectopic pregnancy.
When I'm medial, just right beside the uterus,
I see the ovary and I scan out a little bit more
and this represents the ectopic pregnancy.
And this is what you should see,
a round, circular structure like this,
with a bright, echogenic brim.
And it is possible to sometimes
to see a fetal heartbeat inside
the ectopic pregnancy as well.
Now, I'm gonna change the orientation of the transducer,
so I'm in a coronal view.
To do that, I'm gonna turn the transducer counterclockwise.
The uterus will appear circular,
because I'm cutting a cross sectional view of it
and I tilt the handle of the transducer up,
to move inferiorly, down to the region of the cervix
and then bring the transducer handle
down to scan superiorly,
into the area of the fundus of the uterus.
Again, in this case, I can see that
there's no pregnancy inside the uterus itself.
If I scan over to the left of the Phantom,
again, we see the left ovary and then right beside it,
we see our representation of the ectopic pregnancy.
This bright, circular area.
Moving back towards the midline,
the anechoic area just posterior to the uterus
is represented as free fluid or blood, in this case.
So those are the views that you
would need to do a thorough assessment
of the pelvis for early pregnancy.

Brightcove ID

5750481386001

https://youtube.com/watch?v=0CqicUl0hw8

Case: FAST RUQ Exam - Normal Exam

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This video (part 1 of 2) details how performing the right upper quadrant (RUQ) ultrasound examination on trauma patients enables clinicians to potentially identify internal injuries.

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- 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 we're going to focus entirely on
the trauma fast exam.
Specifically, we're going to look further into the
right upper quadrant view, also known as
the hepatorenal view.
Now, we're going to cover the two other views of
the trauma fast exam in upcoming modules of SoundBytes.
The left upper quadrant view, also known as
the splenorenal or perisplenic view,
and the suprarpubic view, also known as the bladder view.
There's a tremendous amount of information we can gain by
looking closely into the right upper quadrant area
in our trauma patient.
Traditionally it's been emphasized that the hepatorenal area
or Morison's pouch view, is the primary target for the
right upper quadrant, but it can take up to 600 ccs of fluid
to make a positive exam if only looking into that area.
So I'll show some alternative views in this module that can
help us to possibly improve on that number.
Now let's take a look at a slide showing us how to perform
the right upper quadrant view of the trauma fast exam.
We'll want to place the probe at about the anterior axillary
line and using the liver as an acoustic window aiming
the probe down towards the bedside retroperitoneally to get
a good view of these anatomical structures.
It's best to have a small footprint probe that can easily
sit between the ribs giving a good view on to this area.
Notice that this is a long axis view with a probe marker
position superiorly.
Now our first view from this right upper quadrant area
will be position one as shown here in the
infra-diaphragmatic space just below the diaphragm
and above the liver.
Second, we'll move the probe slightly inferiorly to look in
to the traditional Morison's pouch or hepatorenal interface,
and the last view is the caudal tip of the liver shown here
in position three.
It's very important to look at the caudal tip of the liver,
as this represents the beginning of the right paracolic
gutter and small amounts of fluid will pool here before
moving into Morison's pouch.
Now that we know how to perform the right upper quadrant
view of the trauma fast exam, let's take a look at a normal
image that you might obtain.
Remembering that this is a long axis view,
I have the probe marker here positioned towards
the patient's head.
So towards the left of the clip here is
superior chest cavity and towards the right is
inferior or abdominal cavity.
Notice the first large structure that comes into view
in the middle of the image is the liver and to the right,
or inferior to the liver we see the football shaped kidney.
Now it's that interface between the liver and kidney that
represents a potential space known as Morison's pouch
where we're be looking for dark, anechoic fluid collections.
Note here, we see a thin, white line making up a normal exam
and representing the fat within the capsule
around the kidney.
Notice to the left of the liver we see the white diaphragm
that represents the interface between chest
and abdominal cavities.
Let's take a look at another normal
right upper quadrant examination.
Again the probe marker is towards the patient's head.
This is the superior chest cavity towards the left.
Inferior abdominal cavity towards the right.
We see the liver in the middle of the image,
and notice the diaphragm above the liver moving up and down
as the patient breathes.
We see the kidney inferior to the liver, and notice
the potential space in between the liver and the kidney
that makes up the hepatorenal fossa or pouch of Morison.
Notice in this video clip all we see is a white line
representing the fat within the capsule around the kidney
or Gerota's capsule.
If there was fluid, we would see a dark or anechoic fluid
collection in this potential space.
Let's now look at the diaphragm which we see above the liver
and if we look above the diaphragm this is where we would
look for fluid within the chest cavity or hemothorax
in the trauma patient.
We may have to move the probe several intercostal spaces
on the patient's side to fully investigate
the right upper quadrant for fluid.
Here's a swing view where I'm starting relatively superior
right there looking in the area between the diaphragm
and the liver, going through Morison's pouch, as I'll show
coming up right here the area between the liver
and the kidney and terminating at the inferior
tip of the liver.
Notice here we notice the caudal tip of the liver extending
almost all the way inferiorly down past the inferior pole
of the kidney, and it's important to look at that caudal
tip of the liver, as it represents the beginning
of the right paracolic gutter.
So in conclusion, I'm glad I could share with you part one
of the right upper quadrant view of the trauma fast exam.
Now we know how to recognize a normal examination
looking all the way from the area below the diaphragm
through Morison's pouch and terminating at a view of
the caudal tip of the liver.
So I hope to see you back as SoundBytes continues,
and we look at part two of the right upper quadrant view
focusing on positive examinations.

Brightcove ID

5767048880001

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

Case: Cardiac Ultrasound - Parasternal Short Axis

Read more about Case: Cardiac Ultrasound - Parasternal Short Axis

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This video details the use of bedside ultrasound imaging, specifically the parasternal short-axis view, with a phased array probe to evaluate cardiac health and anatomy, especially when looking at a patient's left ventricular contractility.

Applications

Cardiology

Media Library Type

Case Study Videos

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, we'll continue our journey looking
specifically at the cardiac echo views of the heart.
In this module, we're going to focus entirely
on the parasternal short axis view of the heart.
Now we've covered the parasternal long axis
view of the heart previously in SoundBytes module
and recall that the probe will be positioned
for the parasternal views in Position A as shown
here in the pictorial to the right.
In upcoming segments, we'll cover the subxiphoid view
as shown in probe Position B, and finally the apical
view of the heart as shown here in probe Position C.
Now the parasternal short axis view of the heart
can be very helpful in emergency care as it gives
a great deal of information about the contractility
of our patient's heart.
So let's look now further into how
to perform this examination.
The probe will be placed just left of the sternum
at about intercostal space 3 or 4
as shown in the pictorial here to the right.
Now in variance to the parasternal long axis
view of the heart where the probe marker was
positioned down towards the patient's left elbow
we'll swivel the probe 90 degrees clockwise so now
the marker is down towards the patient's right hip.
That's with the caveat that the ultrasound screen
indicator is positioned towards the left of the screen.
Now moving the patient into left lateral
decubitus position may help imaging
from the parasternal short axis plane.
Here's what the views from the parasternal
short axis plane of the heart will look like.
We see a pictorial here to the left showing
the left ventricle cut in cross section as a cylinder
and the right ventricle as a little sliver
just to the left of the left ventricle.
We see an ultrasound image corresponding to the right
and note the left ventricle again, that cylinder
cut in cross-section and the right ventricle
above the left ventricle more anteriorally
and to the left.
In this way we get a good sense of the overall
cylinder of the left ventricle
and can gauge its contractility.
Here's a video clip showing extra contractility
of the left ventricle as taken from the parasternal
short axis plane and note the muscular contractions
of the left ventricle as a cylinder squeezing in
dramatically during systole.
We also note the mitral valve flipping up
and down within the left ventricle and the right
ventricle as seen up and above the left ventricle.
Now let's contrast this video clip showing
excellent contractility with another patient
who had an advanced cardiomyopathy.
Note again the left ventricle and note here
the poor percentage change from diastole through
systole, indicating an advanced cardiomyopathy
with low ejection fraction.
We can also see the right ventricle anterior
to the left ventricle.
For learning purposes, we'll identify the walls
of the LV, the septum in between the ventricles,
the anterior wall to the top of the screen,
posterior wall to the back, and the lateral wall
as shown here towards the right portion of the screen.
Now while I show the walls of the left ventricle here,
it's important to realize that the goal of emergency
echo at the bedside is to determine overall left
ventricular contractility rather than looking
for segmental wall motion abnormalities.
So in conclusion, the parasternal short axis view
of the heart gives a great deal of information
about the contractility of the left ventricle.
This will allow you to identify patients who may
have a cardiogenic cause for their presentation.
So I hope to see you back as SoundBytes continues
and we move on to discuss the subxiphoid views
and apical views of the heart.

Brightcove ID

5752151759001

https://youtube.com/watch?v=B731sgCuZU4

Case: Parasternal Long Axis Pt. 2

Read more about Case: Parasternal Long Axis Pt. 2

/sites/default/files/Cases_SB_PLAX_Contractability_Thumb.jpg

This video details the use of bedside ultrasound imaging and a phased array probe to evaluate cardiac health and structure, especially when evaluating the left heart chambers and valves, or investigating for paracardial effusion.

Applications

Cardiology

Media Library Type

Case Study Videos

Subtitles

- Hello, my name is Philips Perera
and I'm the emergency ultrasound coordinator
at the New York Presbyterian Hospital
in New York City.
Welcome to SoundBytes Cases.
In this module, entitled Cardiac Echocardiography,
Parasternal Long Axis View Part Two,
we're going to look further into
the uses of the parasternal long axis view
at the patient's bedside.
Recall that the parasternal long axis view
of the heart is going to be obtained
by placing the probe into position A as shown here.
That will configure the probe
just left of the sternum at about intercostal space three
with the marker dot down towards
the patient's left elbow.
Now, the first two goals from the parasternal long axis view
of the heart are going to be first of all,
to look for left ventricular
contractility.
The second goal is going to be
to investigate for a pericardial effusion.
Let's begin by looking at some clips,
going over left ventricular contractility.
Here's a video clip, showing excellent contractility
of the left ventricle as taken
from a medical student triathlete.
Recall the chambers of the heart,
as taken from the parasternal long axis plane,
the left atrium, as seen in the posterior location;
the mitral valve, just to the left of the left atrium;
and the left ventricle,
as seen with it's hypertrophic walls.
Notice the strong contractility
of this left ventricle as the endocardial walls
almost meet during ossicle.
We see the aortic valve to the right
of the left ventricle
and the right ventricle in a superficial location
above the left ventricle.
Recall the descending aorta,
the cylinder cut and cross section,
just posterior to the left atrium.
Note the posterior pericardial reflection
coming off just anterior to the descending aorta
and posterior to the left ventricle.
With the small indicator arrow,
I'll trace out the posterior
pericardial reflection.
Note here the absence of any dark
or anechoic fluid collections.
Now let's contrast that last video clip
with this one taken from a patient
with an advanced cardiomyopathy.
We recall the left ventricle
and the right ventricle in a superficial location
above the LV.
Notice the very poor percentage change
of the endocardio walls
of the left ventricle during ossicle,
indicating a very decreased
ejection fraction.
Here's a clip taken from a patient
who presented with a transplanted heart
and acute shortness of breath.
We'll begin by identifying the descending aorta
as shown here to the bottom part of the picture.
Note the posterior pericardial reflection,
that white line coming off just anterior
to the descending aorta.
But what we see here is the presence
on a dark, fluid collection,
a pericardial effusion that layers out posteriorly
above the posterior pericardial reflection
and comes anteriorly to surround the heart.
With a small indicator arrow,
I'll point to the anterior portion
of the pericardial effusion and note the chaotic movement
of the right ventricle
as shown here.
This is indicative of early tamponade or high pressures
within the pericardial sac.
Here's a video clip
showing a potential mimic of a pericardial effusion.
Let's being by identifying the descending aorta
as a cylinder cut and cross section
posterior to the left atrium.
We identify the posterior pericardium, as shown here,
coming off just anterior to the descending aorta.
Note the presence here of a large,
dark or anechoic fluid collection,
but note that it layers our posteriorly there
to the pericardium.
Thus, this fluid is within the pleural cavity
and not within the pericardial cavity.
With a small indicator arrow I'm again reinforcing
the pericardial reflection
and the presence of the fluid
within the thoracic cavity,
a pleural effusion.
Next we'll look at a video clip
from a patient who present with acute
shortness of breath requiring intubation.
First, we'll begin by identifying the descending aorta,
then the posterior pericardial reflection.
Note here, the presence of fluid,
both within the pericadial sac, as shown here,
layering anterior to the pericardium
and posteriorly within the pleural cavity
layering out just below the pericardial reflection.
Why, you might ask, does the patient have all this fluid?
Well, let's look closely at the mitral valve
and on the posterior mitral valve leaflet,
we see a calcified vegetation.
This patient, in fact,
had an infected dialysis catheter
with mitral valve endocarditis
and had developed wide-open mitral valve regurgitation
resulting in heart failure
and all the fluid layering out
within the pericardium and
the thoracic cavity.
In conclusion, the parasternal long axis view
of the heart gives a great deal of information
about our patient's condition
and can be instrumental in emergency care.
Through this module,
I hope now that you'll have a better idea
on how to grade left ventricular contractility
as good through poor.
Also, to be able to identify the presence
of a pericardial effusion.
I hope to see you back as SoundBytes continues
and we look further at the
cardiac echocardiography examinations.

Brightcove ID

5794989698001

https://youtube.com/watch?v=uciGL4TaoaA

Case: Parasternal Long Axis Pt. 1

Read more about Case: Parasternal Long Axis Pt. 1

/sites/default/files/Cases_SB_PLAX_Exam_Thumb.jpg

Bedside ultrasound imaging and a phased array probe can be used to evaluate cardiac structures and health, the presence of pericardial effusion, and evaluation of the left heart chamber valves and size.

Applications

Cardiology

Media Library Type

Case Study Videos

Subtitles

- Hello, my name is Phil Perera
and I'm the emergency ultrasound coordinator
ad the New York Presbyterian Hospital in New York City
and welcome to SoundBytes Cases.
Let's begin by reviewing the four standard views
of the cardiac echo exam.
The first view, as shown in probe position A
is the parasternal views both and long and short axis planes
and this is going to be performed directly
on the anterior chest wall.
The second view is where probe position B is shown here
coming from the abdominal position
or the subxiphoid view of the heart.
The last view is going to be shown by probe position C,
the apical view of the heart at
the point of maximum impulse.
This module will specifically focus on
the parasternal views, specifically looking
at the long axis plane.
There's a great deal of information
we can get from the parasternal long axis planes
so let's learn how to perform the examination.
For this examination, it's optimal to use a small footprint
phase to ray type probe that
can easily sit between the ribs.
We're going to place the probe just left of the sternum
at about intercostal space three or four
with the marker dot on the probe aimed down
toward the patient's left elbow,
if the patient's left elbow is down by the side.
That's with the caveat that ultrasound screen indicator
would be over toward the left of the screen.
This will align the probe in the long axis of the heart.
Occasionally it can be someone difficult to get
a good view of the heart from this plane
and moving the patient into the left lateral
decubitus position can sometimes help imaging
from the parasternal long axis plane of the heart.
So now let's take a look at the images
that we'll obtain by performing
the parasternal long axis view of the heart.
Here's a nice pictorial to the left
and what we see is that the most superficial
structure will be the right ventricle.
Notice that the right atrium is not seen from this plane.
Directly posterior to the right ventricle
will be the left ventricle and to the right
of the left ventricle will be seen the left atrium.
We can also see the mitral valve in between
the left atrium and the left ventricle
and a little bit of the aorta above the left atrium.
Let's look at the ultrasound still image, here, to the right
and, again, we see the superficial right ventricle,
posterior we see the left ventricle
with it's more muscular and hypertrophic walls.
Notice the left atrium, as seen to the right
of the left ventricle, and the mitral valve
in between the two chambers.
We categorize this as left ventricular inflow tract.
Note the aortic valve sitting right above the left atrium
and we see a little bit of the aortic root there.
This is what we categorize as aortic outflow tract.
Let's now take a look at the parasternal
long axis view of the heart in action.
Remember, again, that the most superficial chamber
will be the right ventricle
and the normal dimensions of the right ventricle
are that it should be about half
the size of the left ventricle.
If the right ventricle is the same size
of the left ventricle,
that could be a sign of RV strain.
We see the left ventricle posterior to the right ventricle.
Note it's hypertrophic walls.
This patient actually had long standing hypertension.
Let's look at the percentage change from
diastole through systole and here we see
that the walls come in well with each heartbeat
indicating good contractility.
We see 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 see here good movement of the mitral valve
indicating a good amount of blood flowing
between the left atrium and the left ventricle.
Now, just above the left atrium and
to the right of the left ventricle,
we see the aortic valve
and notice there just to the right of the aortic valve,
a little bit of the diamond shaped aortic root.
This will be our left ventricular outflow tract.
Now, another very important structure to identify
on bedside sonography is the descending aorta
which is a cylinder cut in cross section
right below the mitral valve, as seen in this image.
This is a very important landmark
because the posterior pericardium reflection,
that white line seen posterior to the left ventricle,
comes off anterior to the descending aorta.
This allows us to tell if the fluid
that we see there may be pericardial or plural.
In conclusion, I'm glad I could share with you
the SoundBytes module going over part one
of parasternal long axis view of the heart.
There's a great deal of information that we can gain
by looking at the parasternal long axis view,
looking for left ventricular contractility,
the presence of a pericardial effusion,
and also the possibility of right ventricular strain.
So, I hope to see you back in the future
as we're going to cover further modules
going over the parasternal views,
the subxiphoid views, and the apical views
so I'll see you back as sono access continues.

Brightcove ID

5794981632001

https://youtube.com/watch?v=H_3V9xlDMA0

Cardiac Ultrasound Views: Subxiphoid

Read more about Cardiac Ultrasound Views: Subxiphoid

/sites/default/files/Cases_SB_Subxiphoid_Echo_EDU00178_Thumb.jpg

Using bedside cardiac ultrasound and a phased array probe to evaluate cardiac structures and health, the presence of pericardial effusion, and evaluating the left heart chamber size and valves.

Applications

Cardiology

Media Library Type

Case Study Videos

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, we'll continue our journey
through the cardiac echocardiography examinations,
looking at the four standard views.
In this module, we're specifically going to focus on
probe position B, as shown in the pictorial here,
the subxiphoid view of the heart.
Hopefully you've joined me prior
for the parasternal views, as shown in probe position A,
and in an upcoming module on the apical view,
as shown in probe position C.
The subxiphoid view of the heart
is an excellent way of imaging the patient's heart,
and getting a lot of information directly at the bedside.
Now let's learn how to perform
the subxiphoid view of the heart.
As shown in the pictorial to the right,
the probe is coming from an abdominal position,
placed just inferior to the xiphoid tip of the sternum.
It's important to lay the probe flat
and push down and under the sternum,
aiming towards the patient's left shoulder.
Now the marker dot on the probe
should be over towards the patient's right side,
with a caveat that the ultrasound's screen
indicator dot is over towards the left of the screen.
Now it's very important to put your hands
on top of the probe, and really push down and up
to get the good imaging plane underneath
the sternum, to make the angle to get
a good view of the heart from this plane.
Let's now take a look at the image
that you'll obtain from the subxiphoid view of the heart.
Here's a pictorial to the left, and an
ultrasound image to the right.
The first chamber that we'll encounter
directly below the liver, which is our
acoustic window in this case, on to
the heart will be the right ventricle.
Immediately posterior to the right ventricle
we'll be seeing the left ventricle,
and as shown in this pictorial,
notice that it has more muscular and hypertrophic walls.
From the subxiphoid plane, we'll also
be able to image the right atrium
to the left of the right ventricle,
and the left atrium, just to the left
of the left ventricle.
We can also appreciate the white line
that is the pericardium circumferentially
surrounding the heart.
Now that we know where the chambers are,
let's take a look at a video clip
of a normal heart from the subxiphoid plane.
As we remember, the liver is our
acoustic window onto the heart from this plane,
and so the liver will be seen anteriorly,
just to the top of the screen.
Just below the liver, we appreciate here
the right ventricle, and notice here,
just to the left of the right ventricle,
we can appreciate the right atrium.
Notice the tricuspid valve flipping up and down
in between the right atrium and the right ventricle.
Now let's look posterior to the right ventricle,
and we appreciate the left ventricle.
Notice again, its more muscular and hypertrophic walls.
Just to the left of the left ventricle
we appreciate, in this case, the left atrium,
and we also get a glimpse here of the mitral valve
flipping up and down in between
the left atrium and the left ventricle.
Now let's look at that white line,
both anteriorly above the right ventricle,
and posterior, below the left ventricle,
that is the pericardium.
Note here the absence of any significant
pericardial effusions.
In that last video clip, we noted good
contractility of the left ventricle
from diastole to systole.
Let's contrast that clip to this one
from a patient who presented with shortness
of breath, and advanced cardiomyopathy.
We see the right ventricle just below the liver,
anterior to the left ventricle.
And what we see here is a poorly contracting
and dilated left ventricle, consistent
with a cardiomyopathy heart.
However, note the absence of any significant
dark or anechoic fluid collections
consistent with a pericardial effusion.
Here's a patient who presented with renal failure
and acute shortness of breath.
We're again looking from the subxiphoid plane,
so we see a little strip of the liver anteriorly.
The right ventricle just below the liver,
and the left ventricle seen posteriorly
to the right ventricle.
Notice how hypertrophic the walls of
the left ventricle are in this patient.
We also appreciate a dark fluid collection
both anteriorly, just below the liver
and above the right ventricle,
and posterior below the left ventricle,
consistent with a circumferential,
or large, pericardial effusion.
If we see a large pericardial effusion
on bedside echo, our next move is to
look for signs of cardiac tamponade.
Here's a patient who manifests
all the signs of cardiac tamponade on bedside echo.
Let's look specifically at the right side of the heart.
Notice the very large pericardial effusion,
and note the chaotic movement of the right ventricle
as it struggles to open during diastole.
The compression of the right ventricle
in this patient is consistent with
advanced cardiac tamponade.
The right side of the heart is
preferentially compressed before
the left ventricle, due to its lower pressure circuit.
In conclusion, I'm glad I could share with you
this SoundBytes module going over
the subxiphoid view of the cardiac echo examination.
This is a very important exam to
put into your routine practice
in looking at your patient's heart at the bedside,
and will tell you if the patient
has a pericardial effusion, as well as
giving a sense of left ventricular contractility.
Also, the subxiphoid view of the heart
gives better views of the right side of the heart
than the more superior parasternal views of the heart.
So I hope to see you back as SoundBytes continues,
and as we move on to discuss the other
echo exam planes of the heart.

Brightcove ID

5752154065001

https://youtube.com/watch?v=ew6uJvZDhmw

Body

Using bedside cardiac ultrasound and a phased array probe to evaluate cardiac structures and health, the presence of pericardial effusion, and evaluating the left heart chamber size and valves.

Case: Cardiac Ultrasound - Apical View

Read more about Case: Cardiac Ultrasound - Apical View

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Using the apical view and a phased array probe during bedside cardiac ultrasound examinations can enable clinicians to evaluate cardiac health, structures, & ventricular contractility. This view is ideal for identifying cardiomyopathy, pericardial effusion, and cardiac tamponade.

Applications

Cardiology

Media Library Type

Case Study Videos

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 we'll continue our journey
down the path of the four cardiac examination views.
Specifically in this module
we're going to look at probe position C,
known as the apical view of the heart.
I hope you've been able to join me prior
looking at probe position A, the parasternal views,
and probe position B the subxiphoid views of the heart.
So the apical view of the heart is an excellent view
and gives a great deal of information
about our patient's heart
as it shows all four chambers of the heart
in relation to one another.
Therefore, the apical view of the heart
is preferred by cardiologists as it shows the synergy
of all of the chambers of the heart to one another.
Now let's take a look at a pictorial
showing how to perform the apical view of the heart.
Preferably, you're going to be using a small footprint
phased array type probe
that can easily get in between the ribs.
Position the probe directly underneath the left nipple
at about the point of maximal impulse of the heart
with the probe indicator
over towards the patient's right side.
Now that's with the caveat
that the ultrasound's screen indicator is positioned
toward the left of the screen.
Now moving the patient
into the left lateral decubitus position
can improve imaging from the apical view of the heart
as it moves the heart closer to the probe
and moves the lung out of the way.
Thus, it's important to consider moving the patient
into this position
when performing the apical view of the heart.
Now let's learn how to interpret the images
that we'll obtain.
We see here a pictorial to the left
and an ultrasound image to the right.
As we're imaging from the apical view of the heart,
we're closest to the ventricles
and in this image we see the left ventricle
to the right of the screen and the right ventricle adjacent.
The atria from the apical view of the heart
will be further away, thus posterior to the ventricles
and we see here the left atrium
just below the left ventricle
and the right atrium below the right ventricle.
We also see the valves, the tricuspid valve to the left
and the mitral valve to the right
in between the left atrium and the left ventricle.
We can also appreciate the white lines
surrounding the heart, which is the pericardium.
Now let's take a look at a video clip
showing the apical view of the heart in action.
This is taken from a medical student triathlete,
so let's take a look at that left ventricle.
We see the left ventricle in its more superficial location
to the right of the screen.
Notice the percentage change from diastole to systole.
Note the walls almost touch with each heartbeat,
indicating a good contractility.
We see the right ventricle to the side of the left ventricle
and the two atria posterior to the ventricles.
Notice the mitral valve in between the left atrium
and left ventricle and the tricuspid valve
to the right side.
Notice here the absence
of any significant pericardial effusion.
Let's contrast that last clip from this patient
who has a dilated cardiomyopathy,
and as we look at that left ventricle
from the apical view of the heart
we see a very poor percentage change
from diastole through systole.
This is indicative of a very poor contractility
of this heart.
We see the right ventricle to the side of the left ventricle
and the two atria posterior.
Notice the sluggish movement of both the mitral value
and the tricuspid valve.
We see a little bit of pericardial effusion,
that little black rim around the heart,
also going together
with this patient's cardiomyopathy status.
Here's an interesting video clip
of a patient who presented with acute shortness of breath.
What we notice here is the right ventricle
and the left ventricle closest to the screen,
but we see here a very large pericardial effusion
circumferentially surrounding the heart.
And notice the heart swinging back and forth
in all the pericardial effusion.
This gives rise to the phenomenon
known as electrical alternans
or different sizes QRSs on the EKG.
Here's a patient who was in bad shape
and presented with acute shortness of breath.
We see a very large pericardial effusion
and let's look specifically at the right ventricle.
Notice that it caves in from diastole
due to the high pressure in the pericardial sac.
Thus this is indicative of advanced cardiac tamponade.
This patient will need a stat pericardiocentesis procedure.
So in conclusion I'm glad I could share with you
this Soundbytes module
going over the apical views of the heart.
This is an often neglected view
but one that gives a great deal of information
about your patients heart
and really should be routinely integrated
into the cardiac echo examination.
It's best to move the patient
into the left lateral decutibus position
to optimize imaging from the apical view of the heart
to see all four chambers of the heart
in relation to one another.
So I hope to see you back as Soundbytes continues.

Brightcove ID

5752159405001

https://youtube.com/watch?v=4vBJoWP-zBM

Body

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