<p begin="00:00:15.263" end="00:00:16.802" style="s2">- Okay, I'm going to walk<br />you through the steps of</p>
<p begin="00:00:16.802" end="00:00:18.776" style="s2">doing a focused echo exam.</p>
<p begin="00:00:18.776" end="00:00:20.792" style="s2">And, there's a couple of<br />different views that you do</p>
<p begin="00:00:20.792" end="00:00:22.069" style="s2">as part of the focused echo exam.</p>
<p begin="00:00:22.069" end="00:00:23.995" style="s2">I'm going to concentrate<br />first on the parasternal</p>
<p begin="00:00:23.995" end="00:00:26.170" style="s2">long axis, and then we'll<br />walk you through the</p>
<p begin="00:00:26.170" end="00:00:28.259" style="s2">apical four-chamber view as well.</p>
<p begin="00:00:28.259" end="00:00:31.285" style="s2">The parasternal long axis,<br />you can also use as part</p>
<p begin="00:00:31.285" end="00:00:34.932" style="s2">of your FAST examination<br />if you're having trouble</p>
<p begin="00:00:34.932" end="00:00:37.365" style="s2">doing the subcostal or subxiphoid view.</p>
<p begin="00:00:37.365" end="00:00:40.630" style="s2">The parasternal long axis<br />is a great alternative to</p>
<p begin="00:00:40.630" end="00:00:44.913" style="s2">get an overall estimation of<br />function of the left ventricle,</p>
<p begin="00:00:44.913" end="00:00:46.796" style="s2">as part of the FAST exam, and also</p>
<p begin="00:00:46.796" end="00:00:49.629" style="s2">evaluate for pericardial effusion.</p>
<p begin="00:00:50.470" end="00:00:52.396" style="s2">Okay, so the first thing<br />you're going to do with this,</p>
<p begin="00:00:52.396" end="00:00:54.254" style="s2">if you can, is have the patient</p>
<p begin="00:00:54.254" end="00:00:55.936" style="s2">turn over to their left side.</p>
<p begin="00:00:55.936" end="00:00:58.819" style="s2">The reason we like to do this<br />is as you have the patient</p>
<p begin="00:00:58.819" end="00:01:01.378" style="s2">turned to their left, the<br />heart's going to fall forward in</p>
<p begin="00:01:01.378" end="00:01:03.926" style="s2">the chest cavity and bring<br />it a little bit closer to the</p>
<p begin="00:01:03.926" end="00:01:07.756" style="s2">window that you're trying<br />to access, through the ribs.</p>
<p begin="00:01:07.756" end="00:01:10.491" style="s2">So in this case, if we're doing<br />a cardiac examination, with</p>
<p begin="00:01:10.491" end="00:01:14.367" style="s2">a cardiac exam type, we want<br />the orientation marker facing</p>
<p begin="00:01:14.367" end="00:01:17.284" style="s2">up to the patient's right shoulder.</p>
<p begin="00:01:18.903" end="00:01:21.939" style="s2">So once we have the orientation<br />figured out, we're going to</p>
<p begin="00:01:21.939" end="00:01:25.439" style="s2">put a little bit of gel on the transducer.</p>
<p begin="00:01:28.519" end="00:01:32.206" style="s2">And we're going to find where<br />the sternum is, and just move,</p>
<p begin="00:01:32.206" end="00:01:36.375" style="s2">just a little bit left of<br />the sternum, looking for the</p>
<p begin="00:01:36.375" end="00:01:39.208" style="s2">fourth to sixth intercostal space.</p>
<p begin="00:01:44.450" end="00:01:46.748" style="s2">And that should put you at<br />least in the ballpark area for</p>
<p begin="00:01:46.748" end="00:01:49.927" style="s2">where you're going to find<br />the parasternal long axis</p>
<p begin="00:01:49.927" end="00:01:51.427" style="s2">view of the heart.</p>
<p begin="00:01:53.630" end="00:01:57.463" style="s2">So remembering that the<br />heart sits in the body</p>
<p begin="00:01:58.530" end="00:02:00.896" style="s2">at a slight angle, this is going to be the</p>
<p begin="00:02:00.896" end="00:02:03.800" style="s2">long axis view of the heart itself.</p>
<p begin="00:02:03.800" end="00:02:05.963" style="s2">Not long axis of the body,<br />but we'll look at the long</p>
<p begin="00:02:05.963" end="00:02:07.496" style="s2">axis of the heart.</p>
<p begin="00:02:07.496" end="00:02:10.047" style="s2">When we look at the ultrasound<br />image, we should quickly</p>
<p begin="00:02:10.047" end="00:02:14.214" style="s2">be able to identify the left<br />ventricle, which we see here.</p>
<p begin="00:02:16.825" end="00:02:19.651" style="s2">And what we're evaluating for is a squeeze</p>
<p begin="00:02:19.651" end="00:02:22.136" style="s2">of this left ventricle.</p>
<p begin="00:02:22.136" end="00:02:25.839" style="s2">So on this image, we<br />have the right ventricle,</p>
<p begin="00:02:25.839" end="00:02:29.422" style="s2">left ventricle, left<br />atrium, and the aorta.</p>
<p begin="00:02:31.028" end="00:02:33.611" style="s2">Mitral valve, and aortic valve.</p>
<p begin="00:02:36.423" end="00:02:38.115" style="s2">Typically, we are doing<br />this examination to</p>
<p begin="00:02:38.115" end="00:02:41.220" style="s2">evaluate for pericardial effusion.</p>
<p begin="00:02:41.220" end="00:02:43.879" style="s2">So we want to identify the pericardium.</p>
<p begin="00:02:43.879" end="00:02:46.645" style="s2">This is going to be<br />this bright, white line</p>
<p begin="00:02:46.645" end="00:02:48.848" style="s2">around the heart.</p>
<p begin="00:02:48.848" end="00:02:50.482" style="s2">What's important in this view is that</p>
<p begin="00:02:50.482" end="00:02:52.683" style="s2">you have it deep enough<br />so that you can identify</p>
<p begin="00:02:52.683" end="00:02:55.682" style="s2">where the descending aorta is.</p>
<p begin="00:02:55.682" end="00:02:57.832" style="s2">The descending aorta is<br />going to appear posterior</p>
<p begin="00:02:57.832" end="00:02:59.452" style="s2">to the left atrium.</p>
<p begin="00:02:59.452" end="00:03:02.362" style="s2">And we're going to see<br />it as a round circle.</p>
<p begin="00:03:02.362" end="00:03:05.279" style="s2">If the fluid is in the pericardium,</p>
<p begin="00:03:06.504" end="00:03:09.935" style="s2">it's going to be above<br />this descending aorta.</p>
<p begin="00:03:09.935" end="00:03:12.793" style="s2">If it's a plural<br />effusion, it's going to be</p>
<p begin="00:03:12.793" end="00:03:14.547" style="s2">behind the descending aorta.</p>
<p begin="00:03:14.547" end="00:03:17.272" style="s2">So this is a very important<br />landmark that you need to</p>
<p begin="00:03:17.272" end="00:03:19.680" style="s2">identify, so you can clearly establish</p>
<p begin="00:03:19.680" end="00:03:22.415" style="s2">where the fluid is present.</p>
<p begin="00:03:22.415" end="00:03:25.090" style="s2">Another important area you<br />have to identify to determine</p>
<p begin="00:03:25.090" end="00:03:28.123" style="s2">exactly where the pericardial<br />effusion is, is the</p>
<p begin="00:03:28.123" end="00:03:30.011" style="s2">anterior aspect of the heart.</p>
<p begin="00:03:30.011" end="00:03:32.620" style="s2">You have to be careful when<br />you evaluate this area,</p>
<p begin="00:03:32.620" end="00:03:34.731" style="s2">because there could be<br />a fat pad in this area</p>
<p begin="00:03:34.731" end="00:03:37.226" style="s2">that appears hypoechoic.</p>
<p begin="00:03:37.226" end="00:03:40.163" style="s2">So for it to be a true<br />pericardial effusion, we want to</p>
<p begin="00:03:40.163" end="00:03:43.192" style="s2">see the fluid wrapping all<br />the way around the heart,</p>
<p begin="00:03:43.192" end="00:03:44.616" style="s2">to the posterior aspect.</p>
<p begin="00:03:44.616" end="00:03:47.104" style="s2">If it's just here, in the anterior aspect,</p>
<p begin="00:03:47.104" end="00:03:49.604" style="s2">it's probably just a fat pad.</p>

<p begin="00:00:07.492" end="00:00:08.958" style="s2">- [Voiceover] A phased array transducer</p>
<p begin="00:00:08.958" end="00:00:10.583" style="s2">with a cardiac exam type,</p>
<p begin="00:00:10.583" end="00:00:12.586" style="s2">is used to perform an ultrasound guided</p>
<p begin="00:00:12.586" end="00:00:16.071" style="s2">trans-thoracic pericardiocentesis.</p>
<p begin="00:00:16.071" end="00:00:17.612" style="s2">The patient is placed in a</p>
<p begin="00:00:17.612" end="00:00:20.505" style="s2">left lateral decubitus<br />position, if possible.</p>
<p begin="00:00:20.505" end="00:00:22.921" style="s2">Place the transducer at the apex or point</p>
<p begin="00:00:22.921" end="00:00:26.163" style="s2">of maximum impulse, with<br />the orientation marker</p>
<p begin="00:00:26.163" end="00:00:30.330" style="s2">to the patients left side,<br />at a three o'clock position.</p>
<p begin="00:00:32.392" end="00:00:34.726" style="s2">The apex of the heart<br />is visualized closest</p>
<p begin="00:00:34.726" end="00:00:36.576" style="s2">to the transducer.</p>
<p begin="00:00:36.576" end="00:00:38.757" style="s2">Move between the apical and parasternal</p>
<p begin="00:00:38.757" end="00:00:41.165" style="s2">long axis views of the<br />heart, to determine the</p>
<p begin="00:00:41.165" end="00:00:44.298" style="s2">most superficial and<br />largest pocket of fluid.</p>
<p begin="00:00:44.298" end="00:00:46.292" style="s2">The myocardium will appear grey,</p>
<p begin="00:00:46.292" end="00:00:49.478" style="s2">and the blood filled chambers<br />will appear hypoechoic.</p>
<p begin="00:00:49.478" end="00:00:51.426" style="s2">The ventricles are in the near field,</p>
<p begin="00:00:51.426" end="00:00:54.539" style="s2">and the atria are in the<br />far field of the image.</p>
<p begin="00:00:54.539" end="00:00:57.285" style="s2">A pericardial effusion will appear as</p>
<p begin="00:00:57.285" end="00:01:00.654" style="s2">a dark anechoic fluid collection<br />surrounding the heart.</p>
<p begin="00:01:00.654" end="00:01:03.974" style="s2">For direct needle guidance,<br />using an in plane technique,</p>
<p begin="00:01:03.974" end="00:01:07.644" style="s2">the transducer is rotated<br />90 degrees counterclockwise.</p>
<p begin="00:01:07.644" end="00:01:11.539" style="s2">So the orientation marker is<br />at the 12 o'clock position.</p>
<p begin="00:01:11.539" end="00:01:13.104" style="s2">This will create a view of the heart</p>
<p begin="00:01:13.104" end="00:01:15.268" style="s2">that is between the apical fore chamber</p>
<p begin="00:01:15.268" end="00:01:17.872" style="s2">and parasternal long axis views.</p>
<p begin="00:01:17.872" end="00:01:19.872" style="s2">Note the absence of the lung,</p>
<p begin="00:01:19.872" end="00:01:22.583" style="s2">to ensure it is not in the needle path.</p>
<p begin="00:01:22.583" end="00:01:24.415" style="s2">The needle is inserted in the skin,</p>
<p begin="00:01:24.415" end="00:01:26.621" style="s2">just proximal to the transducer,</p>
<p begin="00:01:26.621" end="00:01:29.565" style="s2">opposite to the side of<br />the orientation marker.</p>
<p begin="00:01:29.565" end="00:01:31.126" style="s2">The needle is slowly advanced,</p>
<p begin="00:01:31.126" end="00:01:35.123" style="s2">and is seen as a bright<br />hypoechoic linear structure.</p>
<p begin="00:01:35.123" end="00:01:36.799" style="s2">The needle is slowly advanced,</p>
<p begin="00:01:36.799" end="00:01:39.092" style="s2">under direct ultrasound visualization,</p>
<p begin="00:01:39.092" end="00:01:40.941" style="s2">until the tip is seen to puncture the</p>
<p begin="00:01:40.941" end="00:01:42.963" style="s2">pericardial fluid collection.</p>
<p begin="00:01:42.963" end="00:01:45.358" style="s2">The needle should be<br />advanced until the needle tip</p>
<p begin="00:01:45.358" end="00:01:47.122" style="s2">lies within the fluid collection,</p>
<p begin="00:01:47.122" end="00:01:49.171" style="s2">which can then be aspirated.</p>
<p begin="00:01:49.171" end="00:01:51.175" style="s2">Vascular structures to be avoided</p>
<p begin="00:01:51.175" end="00:01:53.344" style="s2">include the internal mammary,</p>
<p begin="00:01:53.344" end="00:01:55.844" style="s2">and the intercostal arteries.</p>