<p begin="00:00:15.492" end="00:00:16.763" style="s2">- The next view I'm gonna take you through</p>
<p begin="00:00:16.763" end="00:00:19.343" style="s2">in the FAST exam is the subcoastal view</p>
<p begin="00:00:19.343" end="00:00:21.477" style="s2">of the heart in a four-chamber plane.</p>
<p begin="00:00:21.477" end="00:00:23.708" style="s2">For this, we're gonna put our transducer</p>
<p begin="00:00:23.708" end="00:00:24.958" style="s2">to phased array</p>
<p begin="00:00:25.797" end="00:00:27.248" style="s2">to the subxiphoid area,</p>
<p begin="00:00:27.248" end="00:00:29.577" style="s2">aiming towards the<br />patient's left shoulder.</p>
<p begin="00:00:29.577" end="00:00:30.820" style="s2">Here is the probe marker here,</p>
<p begin="00:00:30.820" end="00:00:32.310" style="s2">which I'm going to angle towards</p>
<p begin="00:00:32.310" end="00:00:33.977" style="s2">the patient's right.</p>
<p begin="00:00:34.826" end="00:00:38.844" style="s2">When I do this exam, I wanna<br />make sure this transducer is</p>
<p begin="00:00:38.844" end="00:00:40.564" style="s2">along the frontal plane</p>
<p begin="00:00:40.564" end="00:00:42.678" style="s2">and aiming toward the chest.</p>
<p begin="00:00:42.678" end="00:00:45.604" style="s2">A common mistake is to go too</p>
<p begin="00:00:45.604" end="00:00:47.052" style="s2">inferior into the abdomen,</p>
<p begin="00:00:47.052" end="00:00:49.209" style="s2">so you want to go deep into the chest.</p>
<p begin="00:00:49.209" end="00:00:50.476" style="s2">When you're in this location,</p>
<p begin="00:00:50.476" end="00:00:52.066" style="s2">the other thing you're gonna need to do</p>
<p begin="00:00:52.066" end="00:00:53.609" style="s2">is increase your depth.</p>
<p begin="00:00:53.609" end="00:00:55.598" style="s2">I'm gonna use my depth key right here</p>
<p begin="00:00:55.598" end="00:00:56.957" style="s2">and I'm gonna increase,</p>
<p begin="00:00:56.957" end="00:00:59.650" style="s2">so I can see the full heart in view</p>
<p begin="00:00:59.650" end="00:01:03.130" style="s2">and now you can see<br />we're at 21 centimeters.</p>
<p begin="00:01:03.130" end="00:01:05.906" style="s2">Some common landmarks<br />that you need to identify,</p>
<p begin="00:01:05.906" end="00:01:07.530" style="s2">the first thing you see<br />is that we see liver</p>
<p begin="00:01:07.530" end="00:01:09.204" style="s2">at the top of the screen.</p>
<p begin="00:01:09.204" end="00:01:12.362" style="s2">That liver is our coustic<br />window into the heart.</p>
<p begin="00:01:12.362" end="00:01:14.562" style="s2">The beating thing in the<br />center is obviously the heart</p>
<p begin="00:01:14.562" end="00:01:16.369" style="s2">and we can identify the entire heart</p>
<p begin="00:01:16.369" end="00:01:19.474" style="s2">and the perimeter of the<br />heart with the pericardium.</p>
<p begin="00:01:19.474" end="00:01:21.725" style="s2">The pericardium is the<br />white line that I'm seeing,</p>
<p begin="00:01:21.725" end="00:01:24.114" style="s2">you can see that's<br />surrounding the full heart.</p>
<p begin="00:01:24.114" end="00:01:25.951" style="s2">Then we can identify the chambers.</p>
<p begin="00:01:25.951" end="00:01:28.377" style="s2">The chambers are<br />relatively easy to identify</p>
<p begin="00:01:28.377" end="00:01:30.019" style="s2">in this view.</p>
<p begin="00:01:30.019" end="00:01:32.203" style="s2">The chambers on the right side</p>
<p begin="00:01:32.203" end="00:01:34.286" style="s2">of the heart are over here</p>
<p begin="00:01:34.286" end="00:01:36.094" style="s2">and the easy way to identify those,</p>
<p begin="00:01:36.094" end="00:01:38.496" style="s2">remember the liver's on<br />the right side of the body,</p>
<p begin="00:01:38.496" end="00:01:41.725" style="s2">so these chambers that are<br />adjacent to the liver would be</p>
<p begin="00:01:41.725" end="00:01:43.475" style="s2">right-sided chambers.</p>
<p begin="00:01:44.344" end="00:01:47.441" style="s2">The large chamber, which<br />is adjacent to the liver</p>
<p begin="00:01:47.441" end="00:01:48.958" style="s2">is the right ventricle,</p>
<p begin="00:01:48.958" end="00:01:51.012" style="s2">on the other side we<br />see the left ventricle</p>
<p begin="00:01:51.012" end="00:01:53.258" style="s2">and we see the two atria.</p>
<p begin="00:01:53.258" end="00:01:55.106" style="s2">Again, our focus</p>
<p begin="00:01:55.106" end="00:01:58.091" style="s2">on this exam is to<br />identify the pericardium</p>
<p begin="00:01:58.091" end="00:02:00.495" style="s2">and to look for free fluid within it.</p>
<p begin="00:02:00.495" end="00:02:01.446" style="s2">What we're gonna look for</p>
<p begin="00:02:01.446" end="00:02:04.309" style="s2">is an anechoic area<br />within that pericardium</p>
<p begin="00:02:04.309" end="00:02:07.044" style="s2">which would be signs of a hemopericadium.</p>
<p begin="00:02:07.044" end="00:02:08.424" style="s2">Now if you can't get this view,</p>
<p begin="00:02:08.424" end="00:02:11.246" style="s2">a great alternate view<br />is the parasternal view</p>
<p begin="00:02:11.246" end="00:02:13.387" style="s2">of the heart in a long axis plane.</p>
<p begin="00:02:13.387" end="00:02:14.778" style="s2">We're gonna take you through that in the</p>
<p begin="00:02:14.778" end="00:02:16.861" style="s2">echocardiography section.</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>

<p begin="00:00:07.527" end="00:00:09.159" style="s2">- [Voiceover] A phased-array transducer</p>
<p begin="00:00:09.159" end="00:00:12.039" style="s2">with a cardiac exam<br />type is used to perform</p>
<p begin="00:00:12.039" end="00:00:15.543" style="s2">the subxiphoid, or<br />subcostal view of the heart.</p>
<p begin="00:00:15.543" end="00:00:18.575" style="s2">Place the transducer in<br />the subxiphoid position,</p>
<p begin="00:00:18.575" end="00:00:20.781" style="s2">with the transducer orientation marker</p>
<p begin="00:00:20.781" end="00:00:24.301" style="s2">to the patient's left side<br />at a three o'clock position.</p>
<p begin="00:00:24.301" end="00:00:26.077" style="s2">As an alternative approach,</p>
<p begin="00:00:26.077" end="00:00:29.477" style="s2">this exam may be performed<br />using an abdomen exam type,</p>
<p begin="00:00:29.477" end="00:00:32.365" style="s2">with the orientation marker<br />to the patient's right side,</p>
<p begin="00:00:32.365" end="00:00:34.485" style="s2">at the nine o'clock position.</p>
<p begin="00:00:34.485" end="00:00:37.293" style="s2">This view uses the liver<br />as an acoustic window</p>
<p begin="00:00:37.293" end="00:00:39.949" style="s2">to visualize the four<br />chambers of the heart.</p>
<p begin="00:00:39.949" end="00:00:43.398" style="s2">Aim the transducer slightly<br />toward the left shoulder,</p>
<p begin="00:00:43.398" end="00:00:47.572" style="s2">with approximately a 15-degree<br />angle to the chest wall.</p>
<p begin="00:00:47.572" end="00:00:50.692" style="s2">In some cases, the<br />transducer is almost flat</p>
<p begin="00:00:50.692" end="00:00:53.532" style="s2">to the abdominal wall,<br />so the ultrasound beam</p>
<p begin="00:00:53.532" end="00:00:56.820" style="s2">is directed toward the left chest cavity.</p>
<p begin="00:00:56.820" end="00:00:59.364" style="s2">A considerable amount of ultrasound gel</p>
<p begin="00:00:59.364" end="00:01:01.580" style="s2">and downward pressure may be required</p>
<p begin="00:01:01.580" end="00:01:04.340" style="s2">to maintain contact of the transducer face</p>
<p begin="00:01:04.340" end="00:01:06.132" style="s2">with the abdominal wall.</p>
<p begin="00:01:06.132" end="00:01:07.884" style="s2">Having the patient bend their knees</p>
<p begin="00:01:07.884" end="00:01:10.108" style="s2">helps relax the abdominal wall muscles</p>
<p begin="00:01:10.108" end="00:01:12.541" style="s2">for better transducer positioning.</p>
<p begin="00:01:12.541" end="00:01:15.348" style="s2">The first structure seen<br />closest to the transducer</p>
<p begin="00:01:15.348" end="00:01:16.558" style="s2">is the liver.</p>
<p begin="00:01:16.558" end="00:01:18.684" style="s2">The right side of the<br />heart will appear closer</p>
<p begin="00:01:18.684" end="00:01:21.076" style="s2">to the transducer than<br />the left side of the heart</p>
<p begin="00:01:21.076" end="00:01:23.034" style="s2">on the ultrasound image.</p>
<p begin="00:01:23.034" end="00:01:25.118" style="s2">The myocardium will appear grey,</p>
<p begin="00:01:25.118" end="00:01:28.638" style="s2">and the blood filled chambers<br />will appear hypoechoic.</p>
<p begin="00:01:28.638" end="00:01:30.286" style="s2">The bright white pericardium</p>
<p begin="00:01:30.286" end="00:01:32.217" style="s2">is seen surrounding the heart adjacent</p>
<p begin="00:01:32.217" end="00:01:34.598" style="s2">to the grey myocardium.</p>
<p begin="00:01:34.598" end="00:01:37.614" style="s2">Evaluate the function of all chambers.</p>
<p begin="00:01:37.614" end="00:01:38.766" style="s2">Compare the size of the</p>
<p begin="00:01:38.766" end="00:01:41.479" style="s2">right and left ventricular cavities.</p>
<p begin="00:01:41.479" end="00:01:43.983" style="s2">Note any wall motion abnormality,</p>
<p begin="00:01:43.983" end="00:01:48.150" style="s2">and the presence or absence<br />of pericardial effusion.</p>

<p begin="00:00:07.250" end="00:00:09.115" style="s2">- [Voiceover] A phased array transducer,</p>
<p begin="00:00:09.115" end="00:00:10.741" style="s2">with an abdomen exam type,</p>
<p begin="00:00:10.741" end="00:00:13.992" style="s2">is used to perform the<br />subxiphoid or subcostal view</p>
<p begin="00:00:13.992" end="00:00:17.168" style="s2">of the heart in the fast exam.</p>
<p begin="00:00:17.168" end="00:00:20.499" style="s2">Place the transducer in<br />the subxiphoid position</p>
<p begin="00:00:20.499" end="00:00:21.997" style="s2">with the orientation marker</p>
<p begin="00:00:21.997" end="00:00:26.164" style="s2">to the patient's right side<br />at a nine o'clock position.</p>
<p begin="00:00:27.550" end="00:00:30.109" style="s2">This view uses the liver<br />as an acoustic window</p>
<p begin="00:00:30.109" end="00:00:33.113" style="s2">to visualize the four<br />chambers of the heart.</p>
<p begin="00:00:33.113" end="00:00:36.080" style="s2">Aim the transducer slightly<br />toward the left shoulder</p>
<p begin="00:00:36.080" end="00:00:39.125" style="s2">at a 15 degree angle to the chest wall.</p>
<p begin="00:00:39.125" end="00:00:40.225" style="s2">In some cases,</p>
<p begin="00:00:40.225" end="00:00:43.595" style="s2">the transducer is almost<br />flat to the abdominal wall,</p>
<p begin="00:00:43.595" end="00:00:45.582" style="s2">so the ultrasound beam is directed toward</p>
<p begin="00:00:45.582" end="00:00:47.656" style="s2">the left chest cavity.</p>
<p begin="00:00:47.656" end="00:00:49.893" style="s2">A considerable amount of ultrasound gel</p>
<p begin="00:00:49.893" end="00:00:51.884" style="s2">and downward pressure may be needed</p>
<p begin="00:00:51.884" end="00:00:54.480" style="s2">to maintain contact of the transducer face</p>
<p begin="00:00:54.480" end="00:00:56.480" style="s2">with the abdominal wall.</p>
<p begin="00:00:59.524" end="00:01:00.907" style="s2">Increase scanning depth</p>
<p begin="00:01:00.907" end="00:01:03.245" style="s2">to visualize all chambers of the heart.</p>
<p begin="00:01:03.245" end="00:01:04.989" style="s2">The first structure seen closest</p>
<p begin="00:01:04.989" end="00:01:07.593" style="s2">to the transducer is the liver.</p>
<p begin="00:01:07.593" end="00:01:09.660" style="s2">The right side of the<br />heart will appear closer</p>
<p begin="00:01:09.660" end="00:01:12.137" style="s2">to the transducer than<br />the left side of the heart</p>
<p begin="00:01:12.137" end="00:01:14.123" style="s2">on the ultrasound image.</p>
<p begin="00:01:14.123" end="00:01:16.109" style="s2">The myocardium will appear grey,</p>
<p begin="00:01:16.109" end="00:01:17.651" style="s2">and the blood-filled chambers</p>
<p begin="00:01:17.651" end="00:01:19.684" style="s2">will appear hypoechoic.</p>
<p begin="00:01:19.684" end="00:01:21.996" style="s2">The bright white pericardium<br />is seen surrounding</p>
<p begin="00:01:21.996" end="00:01:25.326" style="s2">the heart adjacent to the grey myocardium.</p>
<p begin="00:01:25.326" end="00:01:27.964" style="s2">Evaluate the function of all chambers.</p>
<p begin="00:01:27.964" end="00:01:31.741" style="s2">Compare the size of the right<br />and left ventricular cavities.</p>
<p begin="00:01:31.741" end="00:01:34.300" style="s2">Note any wall motion abnormality,</p>
<p begin="00:01:34.300" end="00:01:38.467" style="s2">and the presence or absence<br />of pericardial effusion.</p>