Pulmonary Emboli

- [Voiceover] A phased array transducer
with a cardiac exam type is used to perform
the parasternal short axis view of the heart.
If possible, place the patient in a left lateral
decubitus position to reduce any lung artifact
and to bring the heart closer to the anterior chest wall.
Place the transducer at the third or fourth
intercostal space immediately left of the sternum.
Move between the third and fourth intercostal space
and slide the transducer toward and away from the sternum
to identify the optimal scanning window.
Assuming the short axis of the heart to be positioned
on a plane from the patient's right shoulder
to the left hip.
Rotate the transducer to adjust
for the body habitus of the patient.
The orientation marker will be at approximately
the two o'clock position.
As an alternative approach, this exam may be performed
using an abdomen exam type with an orientation marker
to the patient's left side at approximately
the eight o'clock position.
The myocardium will appear gray
and the blood-filled chambers will appear hypoechoic.
The left ventricle will appear as a doughnut shape
in the center of the image.
The anterior, septal, inferior, and posterior
lateral walls of the ventricle can be identified.
The mitral valve will be seen in cross section.
From this position, the transducer can be tilted upward
to visualize the aortic valve in cross section.
End downward to visualize the myocardium
of the left ventricle.
Note the wall motion of the myocardial segments
and function of the valves.

Brightcove ID

5752141722001

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

3D How To: Parasternal Long Axis View

Read more about 3D How To: Parasternal Long Axis View

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3D animation demonstrating a Parasternal Long Axis view of the heart.

Applications

Cardiology

Clinical Specialties

Anesthesiology (Regional)

Media Library Type

How To Videos

Subtitles

- [Voiceover] A phased array transducer with a cardiac
exam type, is used to perform parasternal long axis
view of the heart.
If possible, place the patient in a left lateral
decubitus position to reduce any lung artifact,
and to bring the heart closer to the anterior chest wall.
Place the transducer at the third, or fourth, intercostal
space immediately left of the sternum.
Move between the third, and fourth intercostal space,
and slide the transducer toward, and away from the sternum
to identify the optimal scanning window.
Assuming the long axis of the heart to be positioned on a
plane from the patients right shoulder to left hip, rotate
the transducer to adjust for the body
habitus of the patient.
The orientation marker, will be at approximately
the 10 o'clock position.
As an alternative approach, this exam may be performed using
an abdomen exam type, with the orientation marker
to the patients right side at approximately
the 4 o'clock position.
They myocardium will appear gray, and the blood filled
chambers will appear hypoechoic.
The descending aorta is seen in cross section as a round
structure posterior to the atrioventricular junction.
This view is used to evaluate the right ventricle, left
ventricle outflow tract, and left ventricle.
Note overall activity of the heart.
Any wall motion abnormality, valve abnormalities,
and the presence of pericardial effusion.

Brightcove ID

5794989686001

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

3D How To: Apical 4-Chamber View

Read more about 3D How To: Apical 4-Chamber View

/sites/default/files/Echocardiography_Apical_Disclaimer_edu00461_thumbnail.jpg

3D animation demonstrating an Apical 4-Chamber view of the heart.

Applications

Cardiology

Clinical Specialties

Anesthesiology (Regional)

Media Library Type

How To Videos

Subtitles

- [Voiceover] A phased array transducer
with a cardiac exam type is used to perform
the apical four chamber view of the heart.
If possible, place the patient
in a left-lateral decubitus position
to reduce any lung artifact and to bring the heart
closer to the anterior chest wall.
Place the transducer at the apex
or point of maximum impulse,
with the orientation marker to the patient's
left side at a three o'clock position.
As an alternative approach, this exam may be
performed using an abdomen exam type,
with the orientation marker to the patient's right side.
Aim to the right shoulder.
The apex of the heart is visualized
closest to the transducer.
The myocardium will appear gray,
and the blood-filled chambers will appear hypoechoic.
The ventricles are in the near field,
and the atria are in the far field of the image.
This view is used to compare the size of the right
and left ventricles and evaluate contractility.
The right side of the heart,
which is located on the left side of the screen,
should be smaller than the left.
Th apical, septal, and lateral walls
of the left ventricle are visualized in this view.

Brightcove ID

5508134322001

https://youtube.com/watch?v=_eHZz-OCc_M

3D How To: Deep Vein Thrombosis Exam

Read more about 3D How To: Deep Vein Thrombosis Exam

/sites/default/files/DeepVeinThrombosis_eduoo469_thumbnail.jpg

3D animation demonstrating a Deep Vein Thrombosis ultrasound exam

Media Library Type

How To Videos

Media Library Tag

Lower Extremity

Deep Venous Thrombosis

Three-Point Compression

Patency

Mid Thigh

Superficial Femoral Vein

Common Femoral Vein

Subtitles

- [Voiceover] A linear array transducer
with a venus exam type is used to perform
a lower extremity, deep vein thrombosis ultrasound exam.
At least three evaluation sites are necessary.
Common femoral vein, at the saphenofemoral junction,
confluence of the proximal deep femoral vein,
and the superficial femoral vein,
and the popliteal vein.
The patient is in a supine position
with the leg in slight external rotation and flexion.
Place the transducer in a transverse position
with the orientation marker to the patient's right side,
at the level of the inguinal ligament.
The three structures of the femoral triangle are visualized.
The common femoral artery, common femoral vein,
and greater saphenous vein.
The common femoral artery is round and pulsatile,
and the common femoral vein is thin-walled,
oval in shape and collapsible with compression.
The greater saphenous vein confluence
is observed at the anterior aspect
of the common femoral vein.
With the transducer perpendicular to the skin,
apply gentle downward compression
until the vein collapses
and the anterior and posterior walls completely touch.
Slide the transducer distally to the level
of the confluence of
the superficial femoral and proximal deep femoral veins.
Repeat the compression technique,
demonstrating complete collapse of the veins.
Move the transducer to the popliteal fossa.
From this approach, the popliteal vein
will appear anterior to the popliteal artery.
Repeat the compression technique.

Brightcove ID

5508123491001

https://youtube.com/watch?v=khD3dnxEt2o

Case: DVT Ultrasound Part 2

Read more about Case: DVT Ultrasound Part 2

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Deep-Vein Thrombosis and Ultrasound: Case Study

Media Library Type

Media Library Tag

Deep Venous Thrombosis

Superficial Femoral Vein

Three-Point Compression

Thrombosis

Thrombus

Vein

Subtitles

- Hello, my name is Phil Perera,
and I'm the Emergency Ultrasound Co-Director
at the L.A. County U.S.C. Medical Center
in Los Angeles, California.
And welcome to SoundBytes.
Welcome back to SoundBytes Ultrasound
and part two of the bedside DVT ultrasound evaluation.
Hopefully you've had a chance
to complete part one of the module prior,
looking at the normal anatomy of the leg veins
and normal compression examination looking for a DVT.
In this module part two,
we'll specifically examine positive DVT examinations
using the focused exam to look at the femoral
and popliteal veins.
A DVT will be identified by a failure
of venous compression using the high frequency probe.
We'll wrap up the module by looking at some DVT mimics
and alternative findings that you may encounter
on bedside ultrasound examination of the leg.
To reemphasize the positive findings
on lower extremity DVT ultrasound,
a thrombosed vein will not completely compress
with pressure down by the high frequency probe.
We may be able to observe echogenic material
within the vessel lumen consistent with a clot,
but that has to do with the age of a clot.
Fresh clot may be more echogenic or bright in nature,
whereas older clot may be more organized and darker
or hypoechoic on bedside ultrasound examination.
This video clip was taken from a patient
who presented to the emergency department
with a painful and swollen leg.
We're using doppler flow
to first identify the target femoral artery and vein.
We can see here the doppler pulsations
within the femoral artery noted lateral
or towards the left of the image.
We see here the femoral vein towards the right
or towards the medial aspect of the image
and note the lack of doppler flow.
Looking within the vessel, we can see swirls of thrombus
within the femoral vein consistent with clot.
And we note also the saphenous vein
on top of the femoral vein is also thrombosed.
We note here that there's no doppler pulsations
within the femoral vein as the result of blockage
due to the clot.
Now that we've identified the target femoral artery
and vein using doppler flow,
we can switch over to grayscale or B-mode sonography.
Here we're looking at the femoral artery
as it bifurcates into the profundus
and superficialis arteries.
And we note here towards the medial aspect of the artery,
or towards the right, the femoral vein.
Again, looking within the femoral vein,
we see swirls of echogenic clot consistent
with fresh thrombus.
And we note again that the saphenous vein
off the top of the femoral vein appears clotted as well.
So our next move would be to apply compression down
onto the vessels to look for compressibility of the vein.
Here we note we're compressing down
with a high frequency linear array type probe,
and we can see indentation of the femoral arteries
towards the left.
But note here the failure of compression of the femoral vein
due to the presence of thrombus within the lumen.
And we can see the thrombus moving around
as we press down with the probe.
Again, a positive DVT exam based on the fact
of failure of compression of the femoral vein.
Now let's look at another video clip showing a positive DVT
in a patient presenting to the emergency department
with a painful and swollen leg.
We're using doppler flow again
to target the femoral vessels,
and we see the pulsations of the femoral artery
lateral to the femoral vein.
We note here the absence of flow within the femoral vein,
suspicious for a DVT,
but our next move would be to apply compression
down with a probe.
Here we're compressing
with a high frequency linear type array probe
directly onto the femoral vein,
and we note the failure of compression of the vessel.
We can also see a rocking movement of the thrombus
within the lumen of the vessel.
Notice that it rocks back and forth
as we apply pressure down with the probe.
Again, a positive finding for a DVT of the femoral vein.
This video clip was taken from a post-surgical patient
with a painful, swollen leg.
We're applying compression down
to the common femoral vessels,
and we notice right away a positive finding
within the femoral vein.
We see here echogenic swirls of clot
and notice the failure of compression
of the vein with probe pressure.
Here we also see the saphenous vein
towards the anterior part of the image
above the femoral vein, also with clot formation.
And we notice that the saphenous vein fails
to compress down with probe pressure.
Now let's move down the leg and look specifically
at the popliteal vein.
Here are two video clips,
towards the left, the B-mode or grayscale sonography image,
and towards the right, a color-flow doppler.
We identified the popliteal vein
as seen towards the top of the image,
effectively posterior to the popliteal artery.
And we can identify the color-flow flashes,
the pulsations of the popliteal artery,
as seen deep to the image here.
Notice the echogenic swirls of clot
within the popliteal vein,
and to the left here we're compressing down
and we note the popliteal vein fails
to compress secondary to the DVT.
This video clip was taken from a patient
who presented with a painful, swollen calf.
We identified the popliteal vein
as seen to the top of the image,
or posterior in relation to the popliteal artery,
which is seen here anteriorly,
or towards the bottom of the image.
Now, we're pressing down with the probe,
applying pressure to the popliteal vein,
and we notice a positive finding.
The popliteal vein fails to compress
with direct probe pressure.
Now, what's interesting as in contrast to other clips
in this module, we don't really identify the swirls
of echogenic clot within this popliteal vein,
thus this was an older clot
that has been more organized with time,
thus giving a darker appearance more hypoechoic in nature.
Now let's turn to a discussion of some potential pitfalls
within DVT ultrasonography.
In the femoral region, lymph nodes may appear
as a thrombosed vein with a failure to compress
on bedside sonography.
Therefore, it's very important to adequately determine
the location of the femoral artery and vein
and compare that to the location of the lymph node.
The lymph node will be a single structure,
unlike the paired femoral vessels.
Also, the lymph node will usually be seen more superficial
to the vascular structures of the femoral artery and vein.
Here's an example of a femoral lymph node.
Notice that it has the appearance
of what could be construed as a DVT.
We see the node,
and it looks like it has echogenic material within it,
but this is the normal ultrasound finding of a lymph node.
Notice that it's a single structure
and not related to the common femoral artery
as a DVT would be within the common femoral vein.
Here we changed the magnification or the depth
of the ultrasound image to better investigate the lymph node
in its relation to the femoral vessels.
Note the single node, the femoral node seen superficial
to the femoral vessels as seen deep within the image.
Note that the node is single,
in contrast to the paired femoral vessels seen deeper.
As we progress down the leg,
we can encounter another potential pitfall
within the realm of DVT ultrasound,
and that is the alternative finding of a Baker's cyst.
A Baker's cyst can be encountered just behind the knee
within the popliteal region.
This cyst can result from an outpouching
of synovial fluid from the knee joint,
usually in patients with advanced arthritis.
Unfortunately, the Baker's cyst can rupture,
spreading inflammatory joint fluid down the leg,
and can present very similarly to a DVT.
This video clip demonstrates the typical appearance
of an unruptured Baker's cyst.
This Baker's cyst was found in the popliteal region
of a patient who was referred to the emergency department
for a swelling behind the knee.
Here we see the typical appearance of a cyst
that is that of a dark or anechoic fluid collection
on bedside sonography.
In this video clip we're going to change the depth
of the ultrasound image to better interrogate
the Baker's cyst in its relation
to the popliteal artery and vein.
Here we see the single superficial Baker's cyst
to the right in its relation to the popliteal artery
and vein seen deeper on the image and to the left.
And note that they have very different appearances,
that the Baker's cyst is a single structure
in contrast to the paired popliteal vessels.
In this video clip we see a large ruptured Baker's cyst
tracking down the calf
and closely approximating a DVT on clinical examination.
We see a short axis view to the left.
And I'm gonna start with the probe high
within the popliteal fossa right here.
I'm gonna move the probe down the calf,
and we can see that the fluid collection spreads
all the way down the calf.
In the long axis view to the right,
I'm gonna start by showing the superior axis to the left
and inferior to the right.
And we can see the fluid collection
of the ruptured Baker's cyst tracking from superior
all the way inferiorly down the calf.
So thanks for tuning in for this SoundBytes module
going over bedside DVT examination part two.
Now you've learned the focused bedside
DVT ultrasound examination
and can quickly evaluate both the femoral
and popliteal veins for clot.
This can be a very helpful examination
in working up those patients with a swollen and painful leg,
allowing for initiation of timely and appropriate therapy.
This bedside DVT examination can also be used
to look for DVT in cases of suspected pulmonary embolus.
So I hope to see you back in the future
as SoundBytes continues.

Brightcove ID

5508109927001

https://youtube.com/watch?v=Jg0TwINcZqE

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Mitral Regurg Color

Mitral Regurg Color

Mitral Valves

Mitral Valves

Heart - PSAX View

Heart - PSAX View

Heart - PLAX View

Heart - PLAX View

Heart - PLAX Mitral Regurg

Heart - PLAX Mitral Regurg

3D How To: Parasternal Short Axis View

3D How To: Parasternal Short Axis View

3D How To: Parasternal Long Axis View

3D How To: Parasternal Long Axis View

3D How To: Apical 4-Chamber View

3D How To: Apical 4-Chamber View

3D How To: Deep Vein Thrombosis Exam

3D How To: Deep Vein Thrombosis Exam

Case: DVT Ultrasound Part 2

Case: DVT Ultrasound Part 2

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