Case: RUSH Exam Part 4
Case: RUSH Exam Part 4
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Series 4 of 4, This video represents a comprehensive algorithym for the intergration of bedside ultrasound for patients in shock. By focusing on "Pump, Tank, and the Pipes," clinicians will gain crucial anatomic and physiologic data to better care for these patients.
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<p begin="00:00:25.215" end="00:00:26.600" style="s2">- [Voiceover] Welcome back<br />to Soundbytes Ultrasound</p>
<p begin="00:00:26.600" end="00:00:28.290" style="s2">teaching videos.</p>
<p begin="00:00:28.290" end="00:00:31.430" style="s2">My name is Dr Phil Perera,<br />and this video sequence</p>
<p begin="00:00:31.430" end="00:00:33.988" style="s2">entitled The RUSH Exam Video Part 4,</p>
<p begin="00:00:33.988" end="00:00:35.852" style="s2">we're gonna go further<br />on to our exploration</p>
<p begin="00:00:35.852" end="00:00:37.007" style="s2">of the Rapid Ultrasound in Shock</p>
<p begin="00:00:37.007" end="00:00:41.358" style="s2">in the Critically Ill<br />Patient, ultrasound algorithm.</p>
<p begin="00:00:41.358" end="00:00:43.387" style="s2">In this video we'll focus on Part three,</p>
<p begin="00:00:43.387" end="00:00:45.376" style="s2">evaluation of the pipes.</p>
<p begin="00:00:45.376" end="00:00:48.556" style="s2">I'm also going to include<br />evaluation for right ventricular</p>
<p begin="00:00:48.556" end="00:00:51.706" style="s2">dilatation, really part of step one,</p>
<p begin="00:00:51.706" end="00:00:54.394" style="s2">evaluation of the pump, that<br />we did not go over earlier</p>
<p begin="00:00:54.394" end="00:00:56.784" style="s2">in the video sequence.</p>
<p begin="00:00:56.784" end="00:00:58.344" style="s2">Here in table one we see<br />the four classic types</p>
<p begin="00:00:58.344" end="00:01:00.157" style="s2">of shock, and the ultrasound<br />findings associated</p>
<p begin="00:01:00.157" end="00:01:02.936" style="s2">with each of these conditions.</p>
<p begin="00:01:02.936" end="00:01:05.827" style="s2">We've covered step one,<br />evaluation of the pump,</p>
<p begin="00:01:05.827" end="00:01:08.688" style="s2">specifically looking for<br />cardiac contractility,</p>
<p begin="00:01:08.688" end="00:01:11.292" style="s2">and the presence of a<br />pericardial effusion.</p>
<p begin="00:01:11.292" end="00:01:14.116" style="s2">Now looking under the<br />column of obstructive shock,</p>
<p begin="00:01:14.116" end="00:01:17.133" style="s2">we see two conditions that<br />we haven't covered prior,</p>
<p begin="00:01:17.133" end="00:01:19.121" style="s2">and that we'll go over in this video.</p>
<p begin="00:01:19.121" end="00:01:21.650" style="s2">Specifically, looking for,<br />right ventricular strain</p>
<p begin="00:01:21.650" end="00:01:25.872" style="s2">or cardiac thrombis, that may<br />signal a massive pulmonary</p>
<p begin="00:01:25.872" end="00:01:29.174" style="s2">emobolis, as the etiology<br />for the patient's shock.</p>
<p begin="00:01:29.174" end="00:01:32.359" style="s2">Now let's skip down to part<br />three, evaluation of the pipes,</p>
<p begin="00:01:32.359" end="00:01:35.468" style="s2">which will really be the<br />main focus of this sequences.</p>
<p begin="00:01:35.468" end="00:01:37.913" style="s2">And here, under hypovolemic<br />shock, we're going to asses</p>
<p begin="00:01:37.913" end="00:01:42.096" style="s2">both the thoracic and<br />abdominal aorta for pathology,</p>
<p begin="00:01:42.096" end="00:01:46.262" style="s2">specifically, dissection<br />or aneurysm with rupture.</p>
<p begin="00:01:46.262" end="00:01:47.960" style="s2">Under obstructive shock, if we do see</p>
<p begin="00:01:47.960" end="00:01:52.160" style="s2">right ventricular thrombis,<br />or right ventricular strain,</p>
<p begin="00:01:52.160" end="00:01:54.142" style="s2">we may wanna switch probes<br />and look for the presence</p>
<p begin="00:01:54.142" end="00:01:57.778" style="s2">of a deep veious thrombosis,<br />to correlate or corroborate</p>
<p begin="00:01:57.778" end="00:01:59.680" style="s2">obstructive shock as the etiology</p>
<p begin="00:01:59.680" end="00:02:02.243" style="s2">for the patient's condition.</p>
<p begin="00:02:02.243" end="00:02:04.025" style="s2">Now let's learn how to<br />analyze the relative cardiac</p>
<p begin="00:02:04.025" end="00:02:07.341" style="s2">chamber sizes as a means of<br />determining right ventricular</p>
<p begin="00:02:07.341" end="00:02:11.038" style="s2">dilatation, and the possibility<br />of a thrombo-embolic cause</p>
<p begin="00:02:11.038" end="00:02:13.640" style="s2">for the patient's shock condition.</p>
<p begin="00:02:13.640" end="00:02:15.873" style="s2">The normal left ventricular<br />to right ventricular size</p>
<p begin="00:02:15.873" end="00:02:19.424" style="s2">ratio should be one to zero point six,</p>
<p begin="00:02:19.424" end="00:02:21.455" style="s2">meaning that the left<br />ventricle should generally</p>
<p begin="00:02:21.455" end="00:02:24.363" style="s2">be twice the size of the right ventricle.</p>
<p begin="00:02:24.363" end="00:02:26.926" style="s2">In cases of acute pulmonary strain,</p>
<p begin="00:02:26.926" end="00:02:28.880" style="s2">such as a massive pulmonary embolis,</p>
<p begin="00:02:28.880" end="00:02:31.237" style="s2">as seen in the small<br />image to the upper left,</p>
<p begin="00:02:31.237" end="00:02:33.434" style="s2">the right ventricle will suddenly dilate,</p>
<p begin="00:02:33.434" end="00:02:36.170" style="s2">and may be larger than the left ventricle,</p>
<p begin="00:02:36.170" end="00:02:38.111" style="s2">as seen in the image.</p>
<p begin="00:02:38.111" end="00:02:41.206" style="s2">In conditions of sudden<br />right ventricular dilatation,</p>
<p begin="00:02:41.206" end="00:02:43.857" style="s2">the RV wall will generally be thin,</p>
<p begin="00:02:43.857" end="00:02:45.800" style="s2">measuring less than five millimeters,</p>
<p begin="00:02:45.800" end="00:02:48.160" style="s2">and this needs to be<br />differentiated from cases of</p>
<p begin="00:02:48.160" end="00:02:51.313" style="s2">chronic pulmonary artery<br />hypertension or strain,</p>
<p begin="00:02:51.313" end="00:02:54.052" style="s2">where the right ventricle<br />will have time to dilate,</p>
<p begin="00:02:54.052" end="00:02:56.743" style="s2">as well as hypertrophy,<br />and the wall will generally</p>
<p begin="00:02:56.743" end="00:03:00.062" style="s2">be thicker than five millimeters.</p>
<p begin="00:03:00.062" end="00:03:01.933" style="s2">Let's take a look at this<br />video clip taken from</p>
<p begin="00:03:01.933" end="00:03:03.549" style="s2">a patient who presented to the ED,</p>
<p begin="00:03:03.549" end="00:03:06.535" style="s2">with a blood pressure of 70 over pul,</p>
<p begin="00:03:06.535" end="00:03:08.637" style="s2">and a history of a recent hip<br />replacement one week prior.</p>
<p begin="00:03:08.637" end="00:03:10.423" style="s2">With a small indicator arrow,</p>
<p begin="00:03:10.423" end="00:03:12.982" style="s2">I'm tracing the confines<br />of the left ventricle.</p>
<p begin="00:03:12.982" end="00:03:16.372" style="s2">Notice that the LV is<br />relatively small in relation</p>
<p begin="00:03:16.372" end="00:03:20.339" style="s2">to the gigantic RV, and there<br />I'm showing the confines</p>
<p begin="00:03:20.339" end="00:03:23.154" style="s2">of the RV with the indicator arrow.</p>
<p begin="00:03:23.154" end="00:03:26.600" style="s2">This would indicate a<br />massive pulmonary embolism</p>
<p begin="00:03:26.600" end="00:03:28.745" style="s2">as a cause of the patient's shock,</p>
<p begin="00:03:28.745" end="00:03:32.917" style="s2">and the need for acute therapy<br />to correct this condition.</p>
<p begin="00:03:32.917" end="00:03:35.392" style="s2">To put that last video<br />clip into reference,</p>
<p begin="00:03:35.392" end="00:03:37.786" style="s2">let's take a look at a normal<br />parasternal long axis view</p>
<p begin="00:03:37.786" end="00:03:39.110" style="s2">of the heart.</p>
<p begin="00:03:39.110" end="00:03:41.631" style="s2">Here we see that the left<br />ventricle is about twice</p>
<p begin="00:03:41.631" end="00:03:43.707" style="s2">the size of the right ventricle,</p>
<p begin="00:03:43.707" end="00:03:47.136" style="s2">which would be the normal<br />relation between the two chambers.</p>
<p begin="00:03:47.136" end="00:03:50.858" style="s2">Notice in the last video, the<br />relation was almost reversed.</p>
<p begin="00:03:50.858" end="00:03:54.458" style="s2">Here's another video clip taken<br />from a hypotensive patient,</p>
<p begin="00:03:54.458" end="00:03:57.060" style="s2">who had just gotten off<br />a long plane flight,</p>
<p begin="00:03:57.060" end="00:04:00.290" style="s2">and what we see here, is<br />that the LV is very small</p>
<p begin="00:04:00.290" end="00:04:03.098" style="s2">in relation to the RV,<br />and notice the deflection</p>
<p begin="00:04:03.098" end="00:04:06.783" style="s2">of the septum away from<br />the RV with each heartbeat,</p>
<p begin="00:04:06.783" end="00:04:08.639" style="s2">indicating relatively high pressures</p>
<p begin="00:04:08.639" end="00:04:10.666" style="s2">within the right ventricle.</p>
<p begin="00:04:10.666" end="00:04:12.826" style="s2">So this was an acute pulmonary embolis,</p>
<p begin="00:04:12.826" end="00:04:17.470" style="s2">and the treatment here was<br />going to be fibrinolysis.</p>
<p begin="00:04:17.470" end="00:04:19.457" style="s2">We can now examine the heart<br />in the parasternal short</p>
<p begin="00:04:19.457" end="00:04:22.601" style="s2">axis view, by moving the<br />probe 90 degrees clockwise.</p>
<p begin="00:04:22.601" end="00:04:25.292" style="s2">Now we see the heart in cross section,</p>
<p begin="00:04:25.292" end="00:04:28.481" style="s2">and notice that the chambers<br />appear as cylinders end on.</p>
<p begin="00:04:28.481" end="00:04:30.340" style="s2">We can see the gigantic<br />right ventricle to the top</p>
<p begin="00:04:30.340" end="00:04:33.892" style="s2">of the screen, and the<br />much smaller left ventricle</p>
<p begin="00:04:33.892" end="00:04:36.245" style="s2">is traced by the small indicator arrow.</p>
<p begin="00:04:36.245" end="00:04:38.727" style="s2">Notice here that the septum is flattened,</p>
<p begin="00:04:38.727" end="00:04:40.553" style="s2">and bows away from the right ventricle,</p>
<p begin="00:04:40.553" end="00:04:43.569" style="s2">due to the relatively high<br />pressures within the RV.</p>
<p begin="00:04:43.569" end="00:04:46.636" style="s2">The LV almost takes on the<br />appearance of a D-shaped</p>
<p begin="00:04:46.636" end="00:04:49.423" style="s2">chamber, due to the<br />flattening of the septum,</p>
<p begin="00:04:49.423" end="00:04:52.003" style="s2">and the high pressures<br />within the right ventricle.</p>
<p begin="00:04:52.003" end="00:04:55.828" style="s2">A classic finding in a<br />massive pulmonary embolis.</p>
<p begin="00:04:55.828" end="00:04:58.204" style="s2">As we had mentioned earlier,<br />we need to differentiate</p>
<p begin="00:04:58.204" end="00:05:01.475" style="s2">right ventricular dilatation<br />in acute causes such</p>
<p begin="00:05:01.475" end="00:05:04.285" style="s2">as an acute pulmonary embolis,<br />from a more chronic cause</p>
<p begin="00:05:04.285" end="00:05:07.017" style="s2">such as primary pulmonary hypertension.</p>
<p begin="00:05:07.017" end="00:05:09.219" style="s2">This was taken from a<br />patient who had long standing</p>
<p begin="00:05:09.219" end="00:05:10.918" style="s2">primary pulmonary hypertension,</p>
<p begin="00:05:10.918" end="00:05:12.705" style="s2">and with the small indicator arrow,</p>
<p begin="00:05:12.705" end="00:05:15.859" style="s2">I'm tracing the confines<br />of the relatively large RV</p>
<p begin="00:05:15.859" end="00:05:19.088" style="s2">in relation to the LV, and we<br />can also see the thickening</p>
<p begin="00:05:19.088" end="00:05:22.144" style="s2">of the RV wall greater<br />than five millimeters.</p>
<p begin="00:05:22.144" end="00:05:25.754" style="s2">This indicates a time for hypertrophy,</p>
<p begin="00:05:25.754" end="00:05:28.028" style="s2">that would indicate more<br />of a chronic condition.</p>
<p begin="00:05:28.028" end="00:05:31.869" style="s2">We can also see a compensatory hypertrophy</p>
<p begin="00:05:31.869" end="00:05:34.183" style="s2">of the papillary muscles<br />within the right ventricle,</p>
<p begin="00:05:34.183" end="00:05:36.497" style="s2">tethering the valve<br />that is often seen with</p>
<p begin="00:05:36.497" end="00:05:38.819" style="s2">primary pulmonary hypertension.</p>
<p begin="00:05:38.819" end="00:05:42.604" style="s2">Now, swiveling the probe to<br />a parasternal short axis view</p>
<p begin="00:05:42.604" end="00:05:44.058" style="s2">in the same patient, we<br />also see the findings</p>
<p begin="00:05:44.058" end="00:05:47.453" style="s2">of the small LV in relation to the RV,</p>
<p begin="00:05:47.453" end="00:05:49.520" style="s2">and the D-shaped chamber finding,</p>
<p begin="00:05:49.520" end="00:05:51.965" style="s2">but notice that looking<br />closer at the right ventricle,</p>
<p begin="00:05:51.965" end="00:05:54.748" style="s2">we can again see the hypertrophic wall,</p>
<p begin="00:05:54.748" end="00:05:56.521" style="s2">greater than five millimeters,</p>
<p begin="00:05:56.521" end="00:05:59.828" style="s2">and again, the compensatory<br />thickening of the papillary</p>
<p begin="00:05:59.828" end="00:06:01.561" style="s2">muscles within the right ventricle,</p>
<p begin="00:06:01.561" end="00:06:04.954" style="s2">often seen with primary<br />pulmonary hypertension.</p>
<p begin="00:06:04.954" end="00:06:07.309" style="s2">This video clip was taken from a patient</p>
<p begin="00:06:07.309" end="00:06:08.883" style="s2">who presented to the<br />emergency department with</p>
<p begin="00:06:08.883" end="00:06:10.579" style="s2">unexplained tachycardia,</p>
<p begin="00:06:10.579" end="00:06:12.573" style="s2">associated with periodic chest pain,</p>
<p begin="00:06:12.573" end="00:06:14.018" style="s2">and shortness of breath.</p>
<p begin="00:06:14.018" end="00:06:16.374" style="s2">This is a subxiphoid view of the heart,</p>
<p begin="00:06:16.374" end="00:06:18.322" style="s2">and looking within the right atrium,</p>
<p begin="00:06:18.322" end="00:06:20.142" style="s2">it looks like there's<br />jellybeans bouncing around</p>
<p begin="00:06:20.142" end="00:06:21.704" style="s2">within the chamber.</p>
<p begin="00:06:21.704" end="00:06:25.384" style="s2">In actuality, this is<br />thrombis, moving around</p>
<p begin="00:06:25.384" end="00:06:28.862" style="s2">within the right atrium,<br />very very concerning,</p>
<p begin="00:06:28.862" end="00:06:30.890" style="s2">that this may pass out<br />through the right ventricle</p>
<p begin="00:06:30.890" end="00:06:33.204" style="s2">into the pulmonary system and cause</p>
<p begin="00:06:33.204" end="00:06:35.560" style="s2">a massive pulmonary embolism.</p>
<p begin="00:06:35.560" end="00:06:37.183" style="s2">While this is an unusual finding</p>
<p begin="00:06:37.183" end="00:06:39.373" style="s2">to see a clot within the heart,</p>
<p begin="00:06:39.373" end="00:06:41.892" style="s2">we may be able to see this<br />as we look closer and closer</p>
<p begin="00:06:41.892" end="00:06:44.454" style="s2">at the heart in patients<br />presenting with unexplained</p>
<p begin="00:06:44.454" end="00:06:46.287" style="s2">tachycardia and shock.</p>
<p begin="00:06:47.807" end="00:06:49.877" style="s2">This is an apical view<br />from the same patient.</p>
<p begin="00:06:49.877" end="00:06:52.658" style="s2">Notice here we see the<br />thrombis bouncing around</p>
<p begin="00:06:52.658" end="00:06:54.396" style="s2">in the right atrium.</p>
<p begin="00:06:54.396" end="00:06:57.301" style="s2">Notice that it actually<br />passes out through the</p>
<p begin="00:06:57.301" end="00:06:59.088" style="s2">right ventricle, into the right ventricle,</p>
<p begin="00:06:59.088" end="00:07:01.453" style="s2">through the tricuspid valve,<br />and then is pushed back</p>
<p begin="00:07:01.453" end="00:07:04.255" style="s2">into the right atrium, and this<br />was a very interesting case</p>
<p begin="00:07:04.255" end="00:07:07.479" style="s2">and that this patient had<br />relatively high pulmonary</p>
<p begin="00:07:07.479" end="00:07:11.169" style="s2">arterial pressures, and a<br />large amount of tricuspid</p>
<p begin="00:07:11.169" end="00:07:13.697" style="s2">regurgitation, that pushed<br />the thrombis back into</p>
<p begin="00:07:13.697" end="00:07:15.114" style="s2">the right atrium.</p>
<p begin="00:07:17.003" end="00:07:19.456" style="s2">Let's now move on to<br />specifically look further at</p>
<p begin="00:07:19.456" end="00:07:21.653" style="s2">step three of the rapid<br />ultrasound in shock exam,</p>
<p begin="00:07:21.653" end="00:07:24.138" style="s2">the evaluation of the pipes.</p>
<p begin="00:07:24.138" end="00:07:26.040" style="s2">While in this illustration<br />it looks like there's</p>
<p begin="00:07:26.040" end="00:07:28.108" style="s2">many probes on the patient's body,</p>
<p begin="00:07:28.108" end="00:07:31.127" style="s2">let's sequentially break this down.</p>
<p begin="00:07:31.127" end="00:07:34.892" style="s2">Let's look first at<br />probes positions A and B.</p>
<p begin="00:07:34.892" end="00:07:37.534" style="s2">Probe position A is a<br />suprasternal notch view,</p>
<p begin="00:07:37.534" end="00:07:38.812" style="s2">in which we may be able<br />to get a look at the</p>
<p begin="00:07:38.812" end="00:07:43.608" style="s2">thoracic aorta, and the<br />actual arch of the aorta,</p>
<p begin="00:07:43.608" end="00:07:46.131" style="s2">looking specifically for<br />aneurysm or dissection.</p>
<p begin="00:07:46.131" end="00:07:49.204" style="s2">Position B is the<br />classic parasternal view,</p>
<p begin="00:07:49.204" end="00:07:52.403" style="s2">in which we can also get a<br />glimpse of the thoracic aorta,</p>
<p begin="00:07:52.403" end="00:07:55.746" style="s2">looking for dissection or aneurysm.</p>
<p begin="00:07:55.746" end="00:07:58.973" style="s2">Probes positions C and D are<br />the classic probe positions</p>
<p begin="00:07:58.973" end="00:08:01.903" style="s2">for placement, to look for<br />evaluation of abdominal</p>
<p begin="00:08:01.903" end="00:08:03.236" style="s2">aortic aneurysm.</p>
<p begin="00:08:04.302" end="00:08:07.614" style="s2">We can also see an intimal<br />flap at times that may signal</p>
<p begin="00:08:07.614" end="00:08:10.268" style="s2">a thoracic aortic<br />dissection extending down</p>
<p begin="00:08:10.268" end="00:08:11.685" style="s2">into the abdomen.</p>
<p begin="00:08:13.661" end="00:08:16.215" style="s2">Now probes position E and<br />F are the classic positions</p>
<p begin="00:08:16.215" end="00:08:19.119" style="s2">for the DVT exam, and should be performed</p>
<p begin="00:08:19.119" end="00:08:22.345" style="s2">if the patient has right<br />ventricular dilatation</p>
<p begin="00:08:22.345" end="00:08:25.905" style="s2">on bedside echo, and<br />one has a high suspicion</p>
<p begin="00:08:25.905" end="00:08:30.580" style="s2">for a thrombo-embolic cause<br />of the patient's shock.</p>
<p begin="00:08:30.580" end="00:08:32.892" style="s2">In this video clip we see a<br />parasternal long axis view</p>
<p begin="00:08:32.892" end="00:08:34.384" style="s2">of the heart.</p>
<p begin="00:08:34.384" end="00:08:36.546" style="s2">Recall that we see the<br />three chambers of the heart</p>
<p begin="00:08:36.546" end="00:08:39.190" style="s2">from this view, the left<br />atrium, the left ventricle,</p>
<p begin="00:08:39.190" end="00:08:40.722" style="s2">and the right ventricle.</p>
<p begin="00:08:40.722" end="00:08:42.622" style="s2">We see the aortic valve,</p>
<p begin="00:08:42.622" end="00:08:45.155" style="s2">and the left ventricular<br />outflow tract to the right</p>
<p begin="00:08:45.155" end="00:08:46.561" style="s2">of the aortic valve.</p>
<p begin="00:08:46.561" end="00:08:49.586" style="s2">Notice in this video clip<br />that this aortic root</p>
<p begin="00:08:49.586" end="00:08:52.118" style="s2">is relatively widened,<br />and I'm tracing that</p>
<p begin="00:08:52.118" end="00:08:54.775" style="s2">with a small indicator arrow.</p>
<p begin="00:08:54.775" end="00:08:57.296" style="s2">Now a normal aortic root<br />should measure no greater</p>
<p begin="00:08:57.296" end="00:08:59.691" style="s2">than three point eight centimeters,</p>
<p begin="00:08:59.691" end="00:09:02.339" style="s2">and a widened aortic root<br />is suspicious for thoracic</p>
<p begin="00:09:02.339" end="00:09:05.665" style="s2">aortic dissection, or aneurysm.</p>
<p begin="00:09:05.665" end="00:09:07.659" style="s2">Here we're actually<br />measuring the aortic root,</p>
<p begin="00:09:07.659" end="00:09:11.453" style="s2">notice that it measures 4.74 centimeters.</p>
<p begin="00:09:11.453" end="00:09:13.112" style="s2">And we can see there that this patient</p>
<p begin="00:09:13.112" end="00:09:15.695" style="s2">has a thoracic aortic aneurysm.</p>
<p begin="00:09:16.627" end="00:09:19.519" style="s2">Now we may be able to<br />see an intimal flap here</p>
<p begin="00:09:19.519" end="00:09:21.586" style="s2">within this region, which would indicate</p>
<p begin="00:09:21.586" end="00:09:25.970" style="s2">a dissection as the etiology<br />for the patient's shock.</p>
<p begin="00:09:25.970" end="00:09:27.665" style="s2">In this video clip,<br />taken from a patient with</p>
<p begin="00:09:27.665" end="00:09:32.141" style="s2">Marfan Syndrome, and chest<br />pain radiating to the back,</p>
<p begin="00:09:32.141" end="00:09:34.500" style="s2">we see a very widened<br />aortic root taken from the</p>
<p begin="00:09:34.500" end="00:09:36.773" style="s2">parasternal long axis view.</p>
<p begin="00:09:36.773" end="00:09:40.121" style="s2">This would indicate the<br />possibility of a Stanford Class A</p>
<p begin="00:09:40.121" end="00:09:43.977" style="s2">aortic dissection as a cause<br />of the patient's shock.</p>
<p begin="00:09:43.977" end="00:09:46.583" style="s2">Notice here, the very<br />very widened aortic root,</p>
<p begin="00:09:46.583" end="00:09:49.395" style="s2">and what looks like the<br />possibility of an intimal flap.</p>
<p begin="00:09:49.395" end="00:09:51.673" style="s2">Now an intimal flap may not always be seen</p>
<p begin="00:09:51.673" end="00:09:55.593" style="s2">on transthoracic echo, but<br />if one is very suspicious,</p>
<p begin="00:09:55.593" end="00:09:58.781" style="s2">one can pursue a transesophageal<br />echo or a CT scan</p>
<p begin="00:09:58.781" end="00:10:01.932" style="s2">to further confirm this condition.</p>
<p begin="00:10:01.932" end="00:10:03.957" style="s2">This patient actually<br />was confirmed to have a</p>
<p begin="00:10:03.957" end="00:10:08.468" style="s2">Stanford Class A aortic<br />dissection requiring a stent.</p>
<p begin="00:10:08.468" end="00:10:10.326" style="s2">This image of the aortic<br />arch was taken from the</p>
<p begin="00:10:10.326" end="00:10:12.440" style="s2">suprasternal notch view.</p>
<p begin="00:10:12.440" end="00:10:14.346" style="s2">In this view the probe<br />is placed directly into</p>
<p begin="00:10:14.346" end="00:10:17.362" style="s2">the suprasternal notch,<br />with the probe marker</p>
<p begin="00:10:17.362" end="00:10:20.254" style="s2">oriented towards the patent's right side.</p>
<p begin="00:10:20.254" end="00:10:23.523" style="s2">In relatively thin<br />patients, it can be possible</p>
<p begin="00:10:23.523" end="00:10:26.006" style="s2">to move the head to the<br />side and to aim the probe</p>
<p begin="00:10:26.006" end="00:10:29.186" style="s2">down into the chest to get<br />a view of the aortic arch.</p>
<p begin="00:10:29.186" end="00:10:32.457" style="s2">And here we can see the<br />ascending aorta to the left,</p>
<p begin="00:10:32.457" end="00:10:34.480" style="s2">the descending aorta to the right,</p>
<p begin="00:10:34.480" end="00:10:36.583" style="s2">and the aortic arch right in the middle.</p>
<p begin="00:10:36.583" end="00:10:38.653" style="s2">Notice we also see some<br />of the branching vessels</p>
<p begin="00:10:38.653" end="00:10:41.338" style="s2">coming off of the aortic<br />arch, and this would be</p>
<p begin="00:10:41.338" end="00:10:44.811" style="s2">normal anatomy, not<br />consistent with dissection.</p>
<p begin="00:10:44.811" end="00:10:47.125" style="s2">But occasionally we may be<br />able to pick up an aortic</p>
<p begin="00:10:47.125" end="00:10:52.009" style="s2">dissection or aneurysm, from<br />the suprasternal notch view.</p>
<p begin="00:10:52.009" end="00:10:54.330" style="s2">This video clip represents<br />the suprasternal notch view</p>
<p begin="00:10:54.330" end="00:10:56.868" style="s2">taken from the patient<br />with Marfan syndrome</p>
<p begin="00:10:56.868" end="00:10:58.655" style="s2">discussed earlier in the video sequence.</p>
<p begin="00:10:58.655" end="00:11:01.563" style="s2">The first thing we notice<br />right away is that this aortic</p>
<p begin="00:11:01.563" end="00:11:04.084" style="s2">arch is much more dilated<br />than the normal anatomy</p>
<p begin="00:11:04.084" end="00:11:06.691" style="s2">shown prior, and with the<br />small indicator arrow,</p>
<p begin="00:11:06.691" end="00:11:09.788" style="s2">I'm showing the confines<br />of the aortic arch.</p>
<p begin="00:11:09.788" end="00:11:11.944" style="s2">Let's look closer within the aortic arch,</p>
<p begin="00:11:11.944" end="00:11:14.132" style="s2">and right away we can see what<br />looks like an intimal flap</p>
<p begin="00:11:14.132" end="00:11:17.032" style="s2">moving around with each heartbeat.</p>
<p begin="00:11:17.032" end="00:11:19.723" style="s2">So this patient was diagnosed<br />with a Stanford Class A</p>
<p begin="00:11:19.723" end="00:11:22.371" style="s2">aortic dissection,<br />extending from the root,</p>
<p begin="00:11:22.371" end="00:11:26.760" style="s2">through the arch, and down<br />into the descending aorta.</p>
<p begin="00:11:26.760" end="00:11:28.164" style="s2">The next step in the<br />evaluation of the pipes</p>
<p begin="00:11:28.164" end="00:11:31.399" style="s2">is performed through looking<br />at the abdominal aorta.</p>
<p begin="00:11:31.399" end="00:11:34.131" style="s2">The probe should be placed<br />in positions C and D</p>
<p begin="00:11:34.131" end="00:11:36.072" style="s2">as shown on the patient's abdomen,</p>
<p begin="00:11:36.072" end="00:11:38.753" style="s2">with the probe in a<br />short axis configuration.</p>
<p begin="00:11:38.753" end="00:11:40.574" style="s2">Generally we'll begin with the probe high,</p>
<p begin="00:11:40.574" end="00:11:43.216" style="s2">at position C, and move<br />all the way down to D</p>
<p begin="00:11:43.216" end="00:11:45.368" style="s2">to fully examine the aorta.</p>
<p begin="00:11:45.368" end="00:11:47.779" style="s2">We're looking for an<br />abdominal aortic aneurysm,</p>
<p begin="00:11:47.779" end="00:11:51.707" style="s2">as signaled by a abdominal<br />aorta greater than three</p>
<p begin="00:11:51.707" end="00:11:54.104" style="s2">centimeters in diameter.</p>
<p begin="00:11:54.104" end="00:11:56.873" style="s2">Now most AAAs will be fusiform in nature,</p>
<p begin="00:11:56.873" end="00:11:58.359" style="s2">and also infrarenal.</p>
<p begin="00:11:58.359" end="00:12:01.683" style="s2">Some may extend down<br />into the iliac artery.</p>
<p begin="00:12:01.683" end="00:12:05.460" style="s2">A minority of triple As<br />will be saccular as shown</p>
<p begin="00:12:05.460" end="00:12:06.827" style="s2">in the image over to<br />the right, where we have</p>
<p begin="00:12:06.827" end="00:12:10.593" style="s2">a small protrusion of the wall,<br />out from the normal aorta.</p>
<p begin="00:12:10.593" end="00:12:14.608" style="s2">This video clip demonstrates<br />an abdominal aortic aneurysm,</p>
<p begin="00:12:14.608" end="00:12:16.684" style="s2">in a patient who presented<br />to the emergency department</p>
<p begin="00:12:16.684" end="00:12:20.283" style="s2">with a hypotensive state and tachycardium.</p>
<p begin="00:12:20.283" end="00:12:23.057" style="s2">Here we see a very large<br />abdominal aortic aneurysm</p>
<p begin="00:12:23.057" end="00:12:24.426" style="s2">in the short axis view.</p>
<p begin="00:12:24.426" end="00:12:27.159" style="s2">Notice here we see a<br />large amount of thrombis</p>
<p begin="00:12:27.159" end="00:12:29.016" style="s2">along the walls of the aorta,</p>
<p begin="00:12:29.016" end="00:12:31.956" style="s2">and recall that when measuring<br />for an abdominal aortic</p>
<p begin="00:12:31.956" end="00:12:34.652" style="s2">aneurysm, we need to measure<br />the thrombis in addition</p>
<p begin="00:12:34.652" end="00:12:36.230" style="s2">to the lumin.</p>
<p begin="00:12:36.230" end="00:12:37.891" style="s2">That means we're going to<br />measure from outer wall</p>
<p begin="00:12:37.891" end="00:12:41.458" style="s2">to outer wall, not just the<br />inner walls of the lumin.</p>
<p begin="00:12:41.458" end="00:12:43.897" style="s2">And we can see the swirls<br />of clot or pre-clot</p>
<p begin="00:12:43.897" end="00:12:47.000" style="s2">within the lumin of the triple A.</p>
<p begin="00:12:47.000" end="00:12:49.071" style="s2">Now to confirm that this is a triple A,</p>
<p begin="00:12:49.071" end="00:12:51.725" style="s2">we can further go ahead and<br />put a color power doppler,</p>
<p begin="00:12:51.725" end="00:12:53.874" style="s2">or color flow doppler, onto this area,</p>
<p begin="00:12:53.874" end="00:12:56.311" style="s2">just to confirm that there's<br />flow within the lumin,</p>
<p begin="00:12:56.311" end="00:12:59.037" style="s2">and that this is indeed<br />a vascular structure.</p>
<p begin="00:12:59.037" end="00:13:00.943" style="s2">We'll perform that in the next step here,</p>
<p begin="00:13:00.943" end="00:13:03.425" style="s2">and by putting color power doppler there,</p>
<p begin="00:13:03.425" end="00:13:07.890" style="s2">we can see that this is<br />indeed a turbulent movement</p>
<p begin="00:13:07.890" end="00:13:11.571" style="s2">of blood within the large<br />abdominal aortic aneurysm.</p>
<p begin="00:13:11.571" end="00:13:14.601" style="s2">So right away we have an<br />etiology for the patient's shock,</p>
<p begin="00:13:14.601" end="00:13:16.542" style="s2">and this is a patient<br />who needs to go directly</p>
<p begin="00:13:16.542" end="00:13:19.476" style="s2">to the operating room,<br />and bypass the CT scan</p>
<p begin="00:13:19.476" end="00:13:21.622" style="s2">in order to live.</p>
<p begin="00:13:21.622" end="00:13:23.566" style="s2">This video clip was taken<br />from a patient who presented</p>
<p begin="00:13:23.566" end="00:13:26.170" style="s2">to the ED with hypotension accompanied by</p>
<p begin="00:13:26.170" end="00:13:28.997" style="s2">chest, back, and abdominal pain.</p>
<p begin="00:13:28.997" end="00:13:31.778" style="s2">Here we see a short axis<br />view of the abdominal aorta.</p>
<p begin="00:13:31.778" end="00:13:34.963" style="s2">First with the indicator arrow,<br />I'll trace out the spine,</p>
<p begin="00:13:34.963" end="00:13:38.720" style="s2">a landmark for the posterior<br />aspect of the abdominal cavity.</p>
<p begin="00:13:38.720" end="00:13:41.786" style="s2">Anterior to that, we'll<br />notice the abdominal aorta,</p>
<p begin="00:13:41.786" end="00:13:44.431" style="s2">and while it's not terribly large in size,</p>
<p begin="00:13:44.431" end="00:13:46.288" style="s2">we see a positive finding in the lumin,</p>
<p begin="00:13:46.288" end="00:13:48.273" style="s2">the presence of an intimal flap.</p>
<p begin="00:13:48.273" end="00:13:51.128" style="s2">To the right there is the true lumin,</p>
<p begin="00:13:51.128" end="00:13:53.530" style="s2">and to the left is the false lumin,</p>
<p begin="00:13:53.530" end="00:13:57.388" style="s2">so what we see here is<br />a thoracic dissection</p>
<p begin="00:13:57.388" end="00:13:59.840" style="s2">that's extending down into the abdomen.</p>
<p begin="00:13:59.840" end="00:14:03.447" style="s2">This actually turned out<br />to be a class A dissection</p>
<p begin="00:14:03.447" end="00:14:06.340" style="s2">that was extending from<br />the root all the way down</p>
<p begin="00:14:06.340" end="00:14:09.241" style="s2">into the abdominal cavity.</p>
<p begin="00:14:09.241" end="00:14:11.017" style="s2">So occasionally we can actually pick up,</p>
<p begin="00:14:11.017" end="00:14:14.040" style="s2">in the aortic dissection,<br />on evaluation of the aorta,</p>
<p begin="00:14:14.040" end="00:14:15.950" style="s2">on bedside ultrasound.</p>
<p begin="00:14:15.950" end="00:14:18.529" style="s2">Here's a long axis view<br />of the same patient,</p>
<p begin="00:14:18.529" end="00:14:20.310" style="s2">notice we have the probe marker,</p>
<p begin="00:14:20.310" end="00:14:23.943" style="s2">so that superior is to the<br />left, inferior to the right.</p>
<p begin="00:14:23.943" end="00:14:26.878" style="s2">Again we see the abdominal<br />aorta stretch out</p>
<p begin="00:14:26.878" end="00:14:29.586" style="s2">as a tubular structure across the screen,</p>
<p begin="00:14:29.586" end="00:14:32.600" style="s2">and in the middle we see the<br />presence of an intimal flap,</p>
<p begin="00:14:32.600" end="00:14:35.078" style="s2">moving around with each heartbeat, again,</p>
<p begin="00:14:35.078" end="00:14:37.861" style="s2">pathonomic for an aortic dissection.</p>
<p begin="00:14:37.861" end="00:14:40.341" style="s2">The next step in part three,<br />evaluation of the pipes,</p>
<p begin="00:14:40.341" end="00:14:43.262" style="s2">once one has evaluated the<br />major arterial circuit,</p>
<p begin="00:14:43.262" end="00:14:46.198" style="s2">IE the thoracic and abdominal<br />aorta for pathology,</p>
<p begin="00:14:46.198" end="00:14:48.602" style="s2">is to examine the major venous circuit,</p>
<p begin="00:14:48.602" end="00:14:53.113" style="s2">IE probes position E and<br />F, looking for a pathology</p>
<p begin="00:14:53.113" end="00:14:55.802" style="s2">within the venous circuit<br />such as a massive DVT,</p>
<p begin="00:14:55.802" end="00:14:58.571" style="s2">that could be the cause of<br />a thrombo-embolic etiology</p>
<p begin="00:14:58.571" end="00:14:59.820" style="s2">for shock.</p>
<p begin="00:14:59.820" end="00:15:02.393" style="s2">And now while not every patient<br />will need this examination,</p>
<p begin="00:15:02.393" end="00:15:04.841" style="s2">I will go ahead and perform<br />this exam in a patient</p>
<p begin="00:15:04.841" end="00:15:07.818" style="s2">with a high pre-test probability<br />for a thrombo-embolic</p>
<p begin="00:15:07.818" end="00:15:10.728" style="s2">cause of shock, or right<br />ventricular dilatation</p>
<p begin="00:15:10.728" end="00:15:12.478" style="s2">seen on bedside echo.</p>
<p begin="00:15:13.451" end="00:15:17.518" style="s2">This illustration shows the<br />lower extremity venous anatomy.</p>
<p begin="00:15:17.518" end="00:15:21.973" style="s2">Recall that the common<br />femoral vein bifurcates into</p>
<p begin="00:15:21.973" end="00:15:24.297" style="s2">the deep and superficial femoral veins.</p>
<p begin="00:15:24.297" end="00:15:26.250" style="s2">Now the superficial<br />femoral vein is the one</p>
<p begin="00:15:26.250" end="00:15:28.112" style="s2">that continues on down the thigh,</p>
<p begin="00:15:28.112" end="00:15:31.210" style="s2">and into the leg, and<br />in fact has been renamed</p>
<p begin="00:15:31.210" end="00:15:33.697" style="s2">the femoral vein of the thigh.</p>
<p begin="00:15:33.697" end="00:15:35.558" style="s2">It will continue on into<br />the back of the knee to</p>
<p begin="00:15:35.558" end="00:15:37.839" style="s2">become the popliteal vein.</p>
<p begin="00:15:37.839" end="00:15:40.730" style="s2">Now we can perform a two<br />point compression examination,</p>
<p begin="00:15:40.730" end="00:15:43.800" style="s2">looking for a DVT, by placing<br />the probe into the area</p>
<p begin="00:15:43.800" end="00:15:45.866" style="s2">of the small indicator arrow,</p>
<p begin="00:15:45.866" end="00:15:48.177" style="s2">scanning from the common femoral vein down</p>
<p begin="00:15:48.177" end="00:15:51.661" style="s2">to bifurcation, into the<br />femoral vein of the thigh,</p>
<p begin="00:15:51.661" end="00:15:53.772" style="s2">and the deep femoral vein.</p>
<p begin="00:15:53.772" end="00:15:57.073" style="s2">We can then proceed all the<br />way down to the popliteal vein,</p>
<p begin="00:15:57.073" end="00:15:59.638" style="s2">placing the probe posteriorly,<br />and compressing sequentially</p>
<p begin="00:15:59.638" end="00:16:02.136" style="s2">from high within the popliteal fascia,</p>
<p begin="00:16:02.136" end="00:16:05.777" style="s2">down to the area of trifurcation<br />into the three calf veins.</p>
<p begin="00:16:05.777" end="00:16:10.703" style="s2">Failure to compress would be<br />indicative of a positive DVT.</p>
<p begin="00:16:10.703" end="00:16:12.904" style="s2">This video clip illustrates<br />normal compression of the</p>
<p begin="00:16:12.904" end="00:16:14.396" style="s2">femoral vein.</p>
<p begin="00:16:14.396" end="00:16:17.799" style="s2">At this level, we see the<br />common femoral vein and artery.</p>
<p begin="00:16:17.799" end="00:16:20.934" style="s2">We have the high frequency<br />linear array probe</p>
<p begin="00:16:20.934" end="00:16:22.922" style="s2">placed on a side to side configuration,</p>
<p begin="00:16:22.922" end="00:16:25.030" style="s2">with the probe marker laterally oriented,</p>
<p begin="00:16:25.030" end="00:16:26.434" style="s2">or towards the left.</p>
<p begin="00:16:26.434" end="00:16:29.046" style="s2">Notice that the femoral vein<br />towards the right or medial,</p>
<p begin="00:16:29.046" end="00:16:32.148" style="s2">completely compresses with probe pressure,</p>
<p begin="00:16:32.148" end="00:16:34.847" style="s2">indicating the absence of a DVT.</p>
<p begin="00:16:34.847" end="00:16:36.126" style="s2">So this would be considered</p>
<p begin="00:16:36.126" end="00:16:39.262" style="s2">a completely normal DVT<br />examination, and in fact</p>
<p begin="00:16:39.262" end="00:16:41.627" style="s2">we can see a little bit of<br />the saphenous vein coming</p>
<p begin="00:16:41.627" end="00:16:43.690" style="s2">off the top of the femoral vein.</p>
<p begin="00:16:43.690" end="00:16:46.960" style="s2">Now we can use doppler to<br />help us in identification</p>
<p begin="00:16:46.960" end="00:16:48.737" style="s2">of the femoral vessels.</p>
<p begin="00:16:48.737" end="00:16:50.884" style="s2">This would be a positive examination,</p>
<p begin="00:16:50.884" end="00:16:53.407" style="s2">we can see the femoral<br />artery with pulsations,</p>
<p begin="00:16:53.407" end="00:16:55.151" style="s2">laterally or towards the left,</p>
<p begin="00:16:55.151" end="00:16:56.842" style="s2">and towards the right or medial,</p>
<p begin="00:16:56.842" end="00:16:58.413" style="s2">we actually see the femoral vein,</p>
<p begin="00:16:58.413" end="00:17:00.604" style="s2">and notice the swirls of fresh clot</p>
<p begin="00:17:00.604" end="00:17:03.131" style="s2">present within the vessel.</p>
<p begin="00:17:03.131" end="00:17:06.238" style="s2">Now recall that we must go<br />ahead and compress the vessel</p>
<p begin="00:17:06.238" end="00:17:09.649" style="s2">to confirm a DVT, so that<br />will be our next step,</p>
<p begin="00:17:09.649" end="00:17:11.827" style="s2">but here again we see<br />absence of flow within the</p>
<p begin="00:17:11.827" end="00:17:15.994" style="s2">femoral vein, which is<br />completely clotted off by a DVT.</p>
<p begin="00:17:17.249" end="00:17:19.991" style="s2">Next we'll apply gentle<br />probe pressure downwards,</p>
<p begin="00:17:19.991" end="00:17:22.106" style="s2">with a high frequency linear array probe.</p>
<p begin="00:17:22.106" end="00:17:25.173" style="s2">Notice we see failure of<br />compression of the femoral vein,</p>
<p begin="00:17:25.173" end="00:17:27.648" style="s2">and with the small indicator<br />arrow I'm tracing the confines</p>
<p begin="00:17:27.648" end="00:17:30.043" style="s2">of the femoral vein, again we can see the</p>
<p begin="00:17:30.043" end="00:17:32.324" style="s2">echogenic debris of the DVT,</p>
<p begin="00:17:32.324" end="00:17:34.447" style="s2">that's actually the<br />saphenous coming off the top,</p>
<p begin="00:17:34.447" end="00:17:36.728" style="s2">also involved with this DVT.</p>
<p begin="00:17:36.728" end="00:17:39.535" style="s2">So a failure of compression<br />of the femoral vein,</p>
<p begin="00:17:39.535" end="00:17:42.056" style="s2">indicative of a positive DVT,</p>
<p begin="00:17:42.056" end="00:17:43.603" style="s2">and in the right clinical scenario,</p>
<p begin="00:17:43.603" end="00:17:46.125" style="s2">this could suggest a thrombo-embolic cause</p>
<p begin="00:17:46.125" end="00:17:48.627" style="s2">for the patient's shock,<br />especially if the patient</p>
<p begin="00:17:48.627" end="00:17:53.008" style="s2">has right ventricular<br />dilatation on bedside echo.</p>
<p begin="00:17:53.008" end="00:17:56.289" style="s2">Continuing downwards, we'll<br />look at the popliteal vein.</p>
<p begin="00:17:56.289" end="00:17:58.743" style="s2">Now remember that the<br />probe is placed posteriorly</p>
<p begin="00:17:58.743" end="00:18:01.190" style="s2">into the popliteal fascia for this exam,</p>
<p begin="00:18:01.190" end="00:18:03.552" style="s2">and gentle probe pressure is applied.</p>
<p begin="00:18:03.552" end="00:18:06.329" style="s2">We can see that the artery<br />is anterior to the vein,</p>
<p begin="00:18:06.329" end="00:18:08.980" style="s2">and that the vein, which<br />is posteriorly located,</p>
<p begin="00:18:08.980" end="00:18:10.552" style="s2">completely compresses.</p>
<p begin="00:18:10.552" end="00:18:12.451" style="s2">This would be a normal examination,</p>
<p begin="00:18:12.451" end="00:18:15.182" style="s2">and we can see that the walls<br />completely come together</p>
<p begin="00:18:15.182" end="00:18:16.876" style="s2">with probe pressure.</p>
<p begin="00:18:16.876" end="00:18:19.864" style="s2">This video clip<br />illustrates a positive exam</p>
<p begin="00:18:19.864" end="00:18:21.986" style="s2">for a popliteal vein thrombosis.</p>
<p begin="00:18:21.986" end="00:18:24.347" style="s2">Recall again that the<br />popliteal artery is located</p>
<p begin="00:18:24.347" end="00:18:26.947" style="s2">anterior to the vein, and we can see here</p>
<p begin="00:18:26.947" end="00:18:28.929" style="s2">that the popliteal vein<br />with what looks like swirls</p>
<p begin="00:18:28.929" end="00:18:31.451" style="s2">of echogenic material.</p>
<p begin="00:18:31.451" end="00:18:33.641" style="s2">With a small indicator<br />arrow, I'll show the confines</p>
<p begin="00:18:33.641" end="00:18:36.948" style="s2">of the popliteal vein, and<br />notice that with probe pressure,</p>
<p begin="00:18:36.948" end="00:18:39.719" style="s2">that the vessel does not compress.</p>
<p begin="00:18:39.719" end="00:18:41.500" style="s2">And in fact, with the<br />small indicator arrow there</p>
<p begin="00:18:41.500" end="00:18:45.476" style="s2">I can see a calf vein that's<br />coming off the popliteal vein,</p>
<p begin="00:18:45.476" end="00:18:49.329" style="s2">that's also filled with debris or DVT.</p>
<p begin="00:18:49.329" end="00:18:52.261" style="s2">And we know that most DVTs<br />occur within the calf,</p>
<p begin="00:18:52.261" end="00:18:55.938" style="s2">and propagate upwards<br />into the popliteal vein.</p>
<p begin="00:18:55.938" end="00:18:57.299" style="s2">Now let's put all the<br />information we've learned</p>
<p begin="00:18:57.299" end="00:19:00.150" style="s2">in the various RUSH<br />segments, into one unified</p>
<p begin="00:19:00.150" end="00:19:03.418" style="s2">RUSH protocol, to help us<br />in determining the etiology</p>
<p begin="00:19:03.418" end="00:19:05.322" style="s2">for the patient's shock.</p>
<p begin="00:19:05.322" end="00:19:08.183" style="s2">Let's begin by looking<br />at hypovolemic shock.</p>
<p begin="00:19:08.183" end="00:19:11.372" style="s2">In step one, evaluation of<br />the pump, often heart will</p>
<p begin="00:19:11.372" end="00:19:13.698" style="s2">be small in size and hypercontracting,</p>
<p begin="00:19:13.698" end="00:19:15.942" style="s2">with the endocardial walls<br />almost coming together</p>
<p begin="00:19:15.942" end="00:19:17.192" style="s2">during sistole.</p>
<p begin="00:19:18.308" end="00:19:20.625" style="s2">On evaluation of the tank,<br />the inferior vena cava</p>
<p begin="00:19:20.625" end="00:19:23.312" style="s2">may be small in size, with<br />a large percentage change</p>
<p begin="00:19:23.312" end="00:19:25.632" style="s2">during inspiration.</p>
<p begin="00:19:25.632" end="00:19:28.167" style="s2">The internal jugular veins<br />may also be small in size,</p>
<p begin="00:19:28.167" end="00:19:31.599" style="s2">with a low closing column within the neck.</p>
<p begin="00:19:31.599" end="00:19:33.499" style="s2">We may see the presence<br />of peritoneal fluid,</p>
<p begin="00:19:33.499" end="00:19:37.561" style="s2">or pleural fluid, indicating<br />a hole within the tank.</p>
<p begin="00:19:37.561" end="00:19:41.409" style="s2">In step three, evaluation<br />of the pipes, one may see</p>
<p begin="00:19:41.409" end="00:19:44.135" style="s2">an abdominal aortic aneurysm,<br />which may be the cause</p>
<p begin="00:19:44.135" end="00:19:47.409" style="s2">of hemorrhagic shock,<br />causing the shock etiology</p>
<p begin="00:19:47.409" end="00:19:48.944" style="s2">in this patient.</p>
<p begin="00:19:48.944" end="00:19:50.678" style="s2">One may also see an intimal flap</p>
<p begin="00:19:50.678" end="00:19:52.661" style="s2">indicating aortal dissection,</p>
<p begin="00:19:52.661" end="00:19:56.138" style="s2">another cause of hemorrhagic<br />shock within our patient.</p>
<p begin="00:19:56.138" end="00:19:58.726" style="s2">Moving on to the next<br />category, cardiogenic shock,</p>
<p begin="00:19:58.726" end="00:20:01.077" style="s2">generally the heart<br />will be dilated in size.</p>
<p begin="00:20:01.077" end="00:20:03.427" style="s2">With systolic dysfunction,</p>
<p begin="00:20:03.427" end="00:20:04.918" style="s2">the heart will be hypocontracting,</p>
<p begin="00:20:04.918" end="00:20:07.528" style="s2">with a small percentage<br />change from diastole through</p>
<p begin="00:20:07.528" end="00:20:08.975" style="s2">to sistole.</p>
<p begin="00:20:08.975" end="00:20:10.840" style="s2">On evaluation of the tank,<br />the inferior vena cava</p>
<p begin="00:20:10.840" end="00:20:13.727" style="s2">will often be large in size,<br />greater than two centimeters,</p>
<p begin="00:20:13.727" end="00:20:16.598" style="s2">with a small percentage<br />change during inspiration.</p>
<p begin="00:20:16.598" end="00:20:19.364" style="s2">The internal jugular vein<br />will be distended as well,</p>
<p begin="00:20:19.364" end="00:20:22.181" style="s2">with a high closing<br />column within the neck.</p>
<p begin="00:20:22.181" end="00:20:25.027" style="s2">One may see, on evaluation of the lung,</p>
<p begin="00:20:25.027" end="00:20:27.510" style="s2">the positive lung rockets<br />that we talked about,</p>
<p begin="00:20:27.510" end="00:20:30.583" style="s2">or ultrasonic beelines<br />indicating pulmonary edema.</p>
<p begin="00:20:30.583" end="00:20:34.560" style="s2">Pleural effusion and<br />ascites may also be seen</p>
<p begin="00:20:34.560" end="00:20:36.135" style="s2">as a sign of tank overload.</p>
<p begin="00:20:36.135" end="00:20:39.009" style="s2">On evaluation of the pipes,<br />often this will be normal,</p>
<p begin="00:20:39.009" end="00:20:41.618" style="s2">although occasionally a<br />DVT may be seen in this</p>
<p begin="00:20:41.618" end="00:20:42.868" style="s2">low flow state.</p>
<p begin="00:20:43.987" end="00:20:45.479" style="s2">In obstructive shock,<br />of which the first is,</p>
<p begin="00:20:45.479" end="00:20:49.442" style="s2">pericardial effusion<br />with cardiac tamponade,</p>
<p begin="00:20:49.442" end="00:20:50.974" style="s2">we'll be looking specifically<br />for a circumferential</p>
<p begin="00:20:50.974" end="00:20:53.755" style="s2">pericardial effusion,<br />with diastolic collapse</p>
<p begin="00:20:53.755" end="00:20:56.237" style="s2">of the right atrium<br />and or right ventricle,</p>
<p begin="00:20:56.237" end="00:20:58.059" style="s2">indicative of cardiac tamponade.</p>
<p begin="00:20:58.059" end="00:21:00.332" style="s2">In the other two types<br />of obstructive shock,</p>
<p begin="00:21:00.332" end="00:21:03.582" style="s2">a massive PE or a tension pneumothorax,</p>
<p begin="00:21:05.137" end="00:21:07.377" style="s2">generally we will see a<br />hypercontracting heart,</p>
<p begin="00:21:07.377" end="00:21:10.152" style="s2">and recall that in cases of a massive PE,</p>
<p begin="00:21:10.152" end="00:21:12.594" style="s2">we may see right ventricular dilatation,</p>
<p begin="00:21:12.594" end="00:21:15.124" style="s2">and we may at times<br />actually see thrombis within</p>
<p begin="00:21:15.124" end="00:21:17.940" style="s2">the right atrium, and or right ventricle.</p>
<p begin="00:21:17.940" end="00:21:20.583" style="s2">Moving on to the tank,<br />the inferior vena cava</p>
<p begin="00:21:20.583" end="00:21:23.064" style="s2">is usually distended in obstructive shock,</p>
<p begin="00:21:23.064" end="00:21:26.535" style="s2">with a low percentage<br />change from expiration</p>
<p begin="00:21:26.535" end="00:21:28.517" style="s2">through to inspiration.</p>
<p begin="00:21:28.517" end="00:21:30.876" style="s2">The internal jugular vein<br />will also be distended,</p>
<p begin="00:21:30.876" end="00:21:34.102" style="s2">with a high closing<br />column within the neck.</p>
<p begin="00:21:34.102" end="00:21:36.472" style="s2">Now if the patient has<br />a tension pneumothorax,</p>
<p begin="00:21:36.472" end="00:21:38.994" style="s2">we may be able to see<br />absent lung sliding and</p>
<p begin="00:21:38.994" end="00:21:41.994" style="s2">the absence of vertical comet tails.</p>
<p begin="00:21:42.917" end="00:21:45.412" style="s2">Moving on to the evaluation of the pipes</p>
<p begin="00:21:45.412" end="00:21:47.228" style="s2">in obstructive shock, we<br />may be able to pick up</p>
<p begin="00:21:47.228" end="00:21:50.713" style="s2">a positive DVT within the<br />femoral or popliteal regions,</p>
<p begin="00:21:50.713" end="00:21:54.275" style="s2">indicative of a thrombo-embolic<br />etiology of the shock,</p>
<p begin="00:21:54.275" end="00:21:56.847" style="s2">and a DVT that may have<br />moved on into the heart</p>
<p begin="00:21:56.847" end="00:22:00.156" style="s2">and into the lungs to cause a massive PE.</p>
<p begin="00:22:00.156" end="00:22:02.307" style="s2">Last but not least, in distributive shock,</p>
<p begin="00:22:02.307" end="00:22:04.620" style="s2">of which sepsis will be the most common,</p>
<p begin="00:22:04.620" end="00:22:06.645" style="s2">in early septic shock, the heart is</p>
<p begin="00:22:06.645" end="00:22:09.791" style="s2">generally hypercontracting,<br />with the endocardial walls</p>
<p begin="00:22:09.791" end="00:22:12.374" style="s2">almost touching during sistole.</p>
<p begin="00:22:13.544" end="00:22:15.619" style="s2">Later in sepsis, the heart may fail,</p>
<p begin="00:22:15.619" end="00:22:17.566" style="s2">and one can see a<br />hypocontracting heart with</p>
<p begin="00:22:17.566" end="00:22:21.665" style="s2">a small percentage change from<br />diastole through to sistole.</p>
<p begin="00:22:21.665" end="00:22:24.039" style="s2">On evaluation of the tank,<br />in distributive shock,</p>
<p begin="00:22:24.039" end="00:22:26.939" style="s2">generally the IVC will be normal or small,</p>
<p begin="00:22:26.939" end="00:22:29.876" style="s2">less than two centimeters,<br />with a high percentage change</p>
<p begin="00:22:29.876" end="00:22:31.459" style="s2">during inspiration.</p>
<p begin="00:22:33.027" end="00:22:36.388" style="s2">The internal jugular vein<br />may also be normal or small,</p>
<p begin="00:22:36.388" end="00:22:39.951" style="s2">with a low closing column within the neck.</p>
<p begin="00:22:39.951" end="00:22:42.887" style="s2">In cases of sepsis due to empyema,</p>
<p begin="00:22:42.887" end="00:22:44.669" style="s2">we may be able to pick up<br />the presence of a septage</p>
<p begin="00:22:44.669" end="00:22:47.041" style="s2">or a complicated pleural effusion.</p>
<p begin="00:22:47.041" end="00:22:49.317" style="s2">And in cases of<br />peritonitis, usually due to</p>
<p begin="00:22:49.317" end="00:22:52.784" style="s2">spontaneous bacterial<br />peritonitis in a liver patient,</p>
<p begin="00:22:52.784" end="00:22:55.866" style="s2">we may see the presence of<br />peritoneal fluid or ascites.</p>
<p begin="00:22:55.866" end="00:22:59.653" style="s2">On the evaluation of the<br />pipes in distributive shock,</p>
<p begin="00:22:59.653" end="00:23:01.185" style="s2">generally this part can be omitted,</p>
<p begin="00:23:01.185" end="00:23:03.552" style="s2">as this usually will be normal.</p>
<p begin="00:23:03.552" end="00:23:06.209" style="s2">So in conclusion, the<br />RUSH ultrasound protocol</p>
<p begin="00:23:06.209" end="00:23:08.082" style="s2">can quickly help us at the bedside,</p>
<p begin="00:23:08.082" end="00:23:10.283" style="s2">stratify a patient into<br />one of the four categories</p>
<p begin="00:23:10.283" end="00:23:12.805" style="s2">of shock, and immediately<br />start the correct therapy</p>
<p begin="00:23:12.805" end="00:23:14.928" style="s2">for the patient's shock state.</p>
<p begin="00:23:14.928" end="00:23:18.578" style="s2">Now continuing on, we<br />can use the RUSH exam</p>
<p begin="00:23:18.578" end="00:23:21.393" style="s2">to monitor the patient's<br />response to treatment</p>
<p begin="00:23:21.393" end="00:23:24.462" style="s2">over time, and this is<br />very important in cases</p>
<p begin="00:23:24.462" end="00:23:26.739" style="s2">of hypovolemic shock<br />or distributive shock,</p>
<p begin="00:23:26.739" end="00:23:29.555" style="s2">where one can look at fluid<br />loading at the response</p>
<p begin="00:23:29.555" end="00:23:33.004" style="s2">of the inferior vena cava<br />and internal jugular veins.</p>
<p begin="00:23:33.004" end="00:23:34.907" style="s2">Hopefully they should become more plump,</p>
<p begin="00:23:34.907" end="00:23:37.553" style="s2">and less distensible, with respirations,</p>
<p begin="00:23:37.553" end="00:23:40.862" style="s2">as volume resuscitation continues.</p>
<p begin="00:23:40.862" end="00:23:42.649" style="s2">This means that the RUSH<br />exam can first identify</p>
<p begin="00:23:42.649" end="00:23:46.539" style="s2">the patient's shock state,<br />allowing for appropriate therapy,</p>
<p begin="00:23:46.539" end="00:23:49.193" style="s2">and also very importantly<br />can allow us to evaluate</p>
<p begin="00:23:49.193" end="00:23:50.975" style="s2">the patient's response to therapy,</p>
<p begin="00:23:50.975" end="00:23:53.292" style="s2">by looking at the<br />response to fluid loading,</p>
<p begin="00:23:53.292" end="00:23:55.739" style="s2">as we want to push up the<br />central venous pressure</p>
<p begin="00:23:55.739" end="00:24:00.506" style="s2">in cases of hypovolemic and<br />distributive shock states.</p>
<p begin="00:24:00.506" end="00:24:03.527" style="s2">So, I'm glad you could join<br />me for the Soundbytes Videos,</p>
<p begin="00:24:03.527" end="00:24:05.468" style="s2">and I look forward to<br />seeing you in the future,</p>
<p begin="00:24:05.468" end="00:24:07.468" style="s2">as Soundbytes continues.</p>
<p begin="00:00:26.600" end="00:00:28.290" style="s2">teaching videos.</p>
<p begin="00:00:28.290" end="00:00:31.430" style="s2">My name is Dr Phil Perera,<br />and this video sequence</p>
<p begin="00:00:31.430" end="00:00:33.988" style="s2">entitled The RUSH Exam Video Part 4,</p>
<p begin="00:00:33.988" end="00:00:35.852" style="s2">we're gonna go further<br />on to our exploration</p>
<p begin="00:00:35.852" end="00:00:37.007" style="s2">of the Rapid Ultrasound in Shock</p>
<p begin="00:00:37.007" end="00:00:41.358" style="s2">in the Critically Ill<br />Patient, ultrasound algorithm.</p>
<p begin="00:00:41.358" end="00:00:43.387" style="s2">In this video we'll focus on Part three,</p>
<p begin="00:00:43.387" end="00:00:45.376" style="s2">evaluation of the pipes.</p>
<p begin="00:00:45.376" end="00:00:48.556" style="s2">I'm also going to include<br />evaluation for right ventricular</p>
<p begin="00:00:48.556" end="00:00:51.706" style="s2">dilatation, really part of step one,</p>
<p begin="00:00:51.706" end="00:00:54.394" style="s2">evaluation of the pump, that<br />we did not go over earlier</p>
<p begin="00:00:54.394" end="00:00:56.784" style="s2">in the video sequence.</p>
<p begin="00:00:56.784" end="00:00:58.344" style="s2">Here in table one we see<br />the four classic types</p>
<p begin="00:00:58.344" end="00:01:00.157" style="s2">of shock, and the ultrasound<br />findings associated</p>
<p begin="00:01:00.157" end="00:01:02.936" style="s2">with each of these conditions.</p>
<p begin="00:01:02.936" end="00:01:05.827" style="s2">We've covered step one,<br />evaluation of the pump,</p>
<p begin="00:01:05.827" end="00:01:08.688" style="s2">specifically looking for<br />cardiac contractility,</p>
<p begin="00:01:08.688" end="00:01:11.292" style="s2">and the presence of a<br />pericardial effusion.</p>
<p begin="00:01:11.292" end="00:01:14.116" style="s2">Now looking under the<br />column of obstructive shock,</p>
<p begin="00:01:14.116" end="00:01:17.133" style="s2">we see two conditions that<br />we haven't covered prior,</p>
<p begin="00:01:17.133" end="00:01:19.121" style="s2">and that we'll go over in this video.</p>
<p begin="00:01:19.121" end="00:01:21.650" style="s2">Specifically, looking for,<br />right ventricular strain</p>
<p begin="00:01:21.650" end="00:01:25.872" style="s2">or cardiac thrombis, that may<br />signal a massive pulmonary</p>
<p begin="00:01:25.872" end="00:01:29.174" style="s2">emobolis, as the etiology<br />for the patient's shock.</p>
<p begin="00:01:29.174" end="00:01:32.359" style="s2">Now let's skip down to part<br />three, evaluation of the pipes,</p>
<p begin="00:01:32.359" end="00:01:35.468" style="s2">which will really be the<br />main focus of this sequences.</p>
<p begin="00:01:35.468" end="00:01:37.913" style="s2">And here, under hypovolemic<br />shock, we're going to asses</p>
<p begin="00:01:37.913" end="00:01:42.096" style="s2">both the thoracic and<br />abdominal aorta for pathology,</p>
<p begin="00:01:42.096" end="00:01:46.262" style="s2">specifically, dissection<br />or aneurysm with rupture.</p>
<p begin="00:01:46.262" end="00:01:47.960" style="s2">Under obstructive shock, if we do see</p>
<p begin="00:01:47.960" end="00:01:52.160" style="s2">right ventricular thrombis,<br />or right ventricular strain,</p>
<p begin="00:01:52.160" end="00:01:54.142" style="s2">we may wanna switch probes<br />and look for the presence</p>
<p begin="00:01:54.142" end="00:01:57.778" style="s2">of a deep veious thrombosis,<br />to correlate or corroborate</p>
<p begin="00:01:57.778" end="00:01:59.680" style="s2">obstructive shock as the etiology</p>
<p begin="00:01:59.680" end="00:02:02.243" style="s2">for the patient's condition.</p>
<p begin="00:02:02.243" end="00:02:04.025" style="s2">Now let's learn how to<br />analyze the relative cardiac</p>
<p begin="00:02:04.025" end="00:02:07.341" style="s2">chamber sizes as a means of<br />determining right ventricular</p>
<p begin="00:02:07.341" end="00:02:11.038" style="s2">dilatation, and the possibility<br />of a thrombo-embolic cause</p>
<p begin="00:02:11.038" end="00:02:13.640" style="s2">for the patient's shock condition.</p>
<p begin="00:02:13.640" end="00:02:15.873" style="s2">The normal left ventricular<br />to right ventricular size</p>
<p begin="00:02:15.873" end="00:02:19.424" style="s2">ratio should be one to zero point six,</p>
<p begin="00:02:19.424" end="00:02:21.455" style="s2">meaning that the left<br />ventricle should generally</p>
<p begin="00:02:21.455" end="00:02:24.363" style="s2">be twice the size of the right ventricle.</p>
<p begin="00:02:24.363" end="00:02:26.926" style="s2">In cases of acute pulmonary strain,</p>
<p begin="00:02:26.926" end="00:02:28.880" style="s2">such as a massive pulmonary embolis,</p>
<p begin="00:02:28.880" end="00:02:31.237" style="s2">as seen in the small<br />image to the upper left,</p>
<p begin="00:02:31.237" end="00:02:33.434" style="s2">the right ventricle will suddenly dilate,</p>
<p begin="00:02:33.434" end="00:02:36.170" style="s2">and may be larger than the left ventricle,</p>
<p begin="00:02:36.170" end="00:02:38.111" style="s2">as seen in the image.</p>
<p begin="00:02:38.111" end="00:02:41.206" style="s2">In conditions of sudden<br />right ventricular dilatation,</p>
<p begin="00:02:41.206" end="00:02:43.857" style="s2">the RV wall will generally be thin,</p>
<p begin="00:02:43.857" end="00:02:45.800" style="s2">measuring less than five millimeters,</p>
<p begin="00:02:45.800" end="00:02:48.160" style="s2">and this needs to be<br />differentiated from cases of</p>
<p begin="00:02:48.160" end="00:02:51.313" style="s2">chronic pulmonary artery<br />hypertension or strain,</p>
<p begin="00:02:51.313" end="00:02:54.052" style="s2">where the right ventricle<br />will have time to dilate,</p>
<p begin="00:02:54.052" end="00:02:56.743" style="s2">as well as hypertrophy,<br />and the wall will generally</p>
<p begin="00:02:56.743" end="00:03:00.062" style="s2">be thicker than five millimeters.</p>
<p begin="00:03:00.062" end="00:03:01.933" style="s2">Let's take a look at this<br />video clip taken from</p>
<p begin="00:03:01.933" end="00:03:03.549" style="s2">a patient who presented to the ED,</p>
<p begin="00:03:03.549" end="00:03:06.535" style="s2">with a blood pressure of 70 over pul,</p>
<p begin="00:03:06.535" end="00:03:08.637" style="s2">and a history of a recent hip<br />replacement one week prior.</p>
<p begin="00:03:08.637" end="00:03:10.423" style="s2">With a small indicator arrow,</p>
<p begin="00:03:10.423" end="00:03:12.982" style="s2">I'm tracing the confines<br />of the left ventricle.</p>
<p begin="00:03:12.982" end="00:03:16.372" style="s2">Notice that the LV is<br />relatively small in relation</p>
<p begin="00:03:16.372" end="00:03:20.339" style="s2">to the gigantic RV, and there<br />I'm showing the confines</p>
<p begin="00:03:20.339" end="00:03:23.154" style="s2">of the RV with the indicator arrow.</p>
<p begin="00:03:23.154" end="00:03:26.600" style="s2">This would indicate a<br />massive pulmonary embolism</p>
<p begin="00:03:26.600" end="00:03:28.745" style="s2">as a cause of the patient's shock,</p>
<p begin="00:03:28.745" end="00:03:32.917" style="s2">and the need for acute therapy<br />to correct this condition.</p>
<p begin="00:03:32.917" end="00:03:35.392" style="s2">To put that last video<br />clip into reference,</p>
<p begin="00:03:35.392" end="00:03:37.786" style="s2">let's take a look at a normal<br />parasternal long axis view</p>
<p begin="00:03:37.786" end="00:03:39.110" style="s2">of the heart.</p>
<p begin="00:03:39.110" end="00:03:41.631" style="s2">Here we see that the left<br />ventricle is about twice</p>
<p begin="00:03:41.631" end="00:03:43.707" style="s2">the size of the right ventricle,</p>
<p begin="00:03:43.707" end="00:03:47.136" style="s2">which would be the normal<br />relation between the two chambers.</p>
<p begin="00:03:47.136" end="00:03:50.858" style="s2">Notice in the last video, the<br />relation was almost reversed.</p>
<p begin="00:03:50.858" end="00:03:54.458" style="s2">Here's another video clip taken<br />from a hypotensive patient,</p>
<p begin="00:03:54.458" end="00:03:57.060" style="s2">who had just gotten off<br />a long plane flight,</p>
<p begin="00:03:57.060" end="00:04:00.290" style="s2">and what we see here, is<br />that the LV is very small</p>
<p begin="00:04:00.290" end="00:04:03.098" style="s2">in relation to the RV,<br />and notice the deflection</p>
<p begin="00:04:03.098" end="00:04:06.783" style="s2">of the septum away from<br />the RV with each heartbeat,</p>
<p begin="00:04:06.783" end="00:04:08.639" style="s2">indicating relatively high pressures</p>
<p begin="00:04:08.639" end="00:04:10.666" style="s2">within the right ventricle.</p>
<p begin="00:04:10.666" end="00:04:12.826" style="s2">So this was an acute pulmonary embolis,</p>
<p begin="00:04:12.826" end="00:04:17.470" style="s2">and the treatment here was<br />going to be fibrinolysis.</p>
<p begin="00:04:17.470" end="00:04:19.457" style="s2">We can now examine the heart<br />in the parasternal short</p>
<p begin="00:04:19.457" end="00:04:22.601" style="s2">axis view, by moving the<br />probe 90 degrees clockwise.</p>
<p begin="00:04:22.601" end="00:04:25.292" style="s2">Now we see the heart in cross section,</p>
<p begin="00:04:25.292" end="00:04:28.481" style="s2">and notice that the chambers<br />appear as cylinders end on.</p>
<p begin="00:04:28.481" end="00:04:30.340" style="s2">We can see the gigantic<br />right ventricle to the top</p>
<p begin="00:04:30.340" end="00:04:33.892" style="s2">of the screen, and the<br />much smaller left ventricle</p>
<p begin="00:04:33.892" end="00:04:36.245" style="s2">is traced by the small indicator arrow.</p>
<p begin="00:04:36.245" end="00:04:38.727" style="s2">Notice here that the septum is flattened,</p>
<p begin="00:04:38.727" end="00:04:40.553" style="s2">and bows away from the right ventricle,</p>
<p begin="00:04:40.553" end="00:04:43.569" style="s2">due to the relatively high<br />pressures within the RV.</p>
<p begin="00:04:43.569" end="00:04:46.636" style="s2">The LV almost takes on the<br />appearance of a D-shaped</p>
<p begin="00:04:46.636" end="00:04:49.423" style="s2">chamber, due to the<br />flattening of the septum,</p>
<p begin="00:04:49.423" end="00:04:52.003" style="s2">and the high pressures<br />within the right ventricle.</p>
<p begin="00:04:52.003" end="00:04:55.828" style="s2">A classic finding in a<br />massive pulmonary embolis.</p>
<p begin="00:04:55.828" end="00:04:58.204" style="s2">As we had mentioned earlier,<br />we need to differentiate</p>
<p begin="00:04:58.204" end="00:05:01.475" style="s2">right ventricular dilatation<br />in acute causes such</p>
<p begin="00:05:01.475" end="00:05:04.285" style="s2">as an acute pulmonary embolis,<br />from a more chronic cause</p>
<p begin="00:05:04.285" end="00:05:07.017" style="s2">such as primary pulmonary hypertension.</p>
<p begin="00:05:07.017" end="00:05:09.219" style="s2">This was taken from a<br />patient who had long standing</p>
<p begin="00:05:09.219" end="00:05:10.918" style="s2">primary pulmonary hypertension,</p>
<p begin="00:05:10.918" end="00:05:12.705" style="s2">and with the small indicator arrow,</p>
<p begin="00:05:12.705" end="00:05:15.859" style="s2">I'm tracing the confines<br />of the relatively large RV</p>
<p begin="00:05:15.859" end="00:05:19.088" style="s2">in relation to the LV, and we<br />can also see the thickening</p>
<p begin="00:05:19.088" end="00:05:22.144" style="s2">of the RV wall greater<br />than five millimeters.</p>
<p begin="00:05:22.144" end="00:05:25.754" style="s2">This indicates a time for hypertrophy,</p>
<p begin="00:05:25.754" end="00:05:28.028" style="s2">that would indicate more<br />of a chronic condition.</p>
<p begin="00:05:28.028" end="00:05:31.869" style="s2">We can also see a compensatory hypertrophy</p>
<p begin="00:05:31.869" end="00:05:34.183" style="s2">of the papillary muscles<br />within the right ventricle,</p>
<p begin="00:05:34.183" end="00:05:36.497" style="s2">tethering the valve<br />that is often seen with</p>
<p begin="00:05:36.497" end="00:05:38.819" style="s2">primary pulmonary hypertension.</p>
<p begin="00:05:38.819" end="00:05:42.604" style="s2">Now, swiveling the probe to<br />a parasternal short axis view</p>
<p begin="00:05:42.604" end="00:05:44.058" style="s2">in the same patient, we<br />also see the findings</p>
<p begin="00:05:44.058" end="00:05:47.453" style="s2">of the small LV in relation to the RV,</p>
<p begin="00:05:47.453" end="00:05:49.520" style="s2">and the D-shaped chamber finding,</p>
<p begin="00:05:49.520" end="00:05:51.965" style="s2">but notice that looking<br />closer at the right ventricle,</p>
<p begin="00:05:51.965" end="00:05:54.748" style="s2">we can again see the hypertrophic wall,</p>
<p begin="00:05:54.748" end="00:05:56.521" style="s2">greater than five millimeters,</p>
<p begin="00:05:56.521" end="00:05:59.828" style="s2">and again, the compensatory<br />thickening of the papillary</p>
<p begin="00:05:59.828" end="00:06:01.561" style="s2">muscles within the right ventricle,</p>
<p begin="00:06:01.561" end="00:06:04.954" style="s2">often seen with primary<br />pulmonary hypertension.</p>
<p begin="00:06:04.954" end="00:06:07.309" style="s2">This video clip was taken from a patient</p>
<p begin="00:06:07.309" end="00:06:08.883" style="s2">who presented to the<br />emergency department with</p>
<p begin="00:06:08.883" end="00:06:10.579" style="s2">unexplained tachycardia,</p>
<p begin="00:06:10.579" end="00:06:12.573" style="s2">associated with periodic chest pain,</p>
<p begin="00:06:12.573" end="00:06:14.018" style="s2">and shortness of breath.</p>
<p begin="00:06:14.018" end="00:06:16.374" style="s2">This is a subxiphoid view of the heart,</p>
<p begin="00:06:16.374" end="00:06:18.322" style="s2">and looking within the right atrium,</p>
<p begin="00:06:18.322" end="00:06:20.142" style="s2">it looks like there's<br />jellybeans bouncing around</p>
<p begin="00:06:20.142" end="00:06:21.704" style="s2">within the chamber.</p>
<p begin="00:06:21.704" end="00:06:25.384" style="s2">In actuality, this is<br />thrombis, moving around</p>
<p begin="00:06:25.384" end="00:06:28.862" style="s2">within the right atrium,<br />very very concerning,</p>
<p begin="00:06:28.862" end="00:06:30.890" style="s2">that this may pass out<br />through the right ventricle</p>
<p begin="00:06:30.890" end="00:06:33.204" style="s2">into the pulmonary system and cause</p>
<p begin="00:06:33.204" end="00:06:35.560" style="s2">a massive pulmonary embolism.</p>
<p begin="00:06:35.560" end="00:06:37.183" style="s2">While this is an unusual finding</p>
<p begin="00:06:37.183" end="00:06:39.373" style="s2">to see a clot within the heart,</p>
<p begin="00:06:39.373" end="00:06:41.892" style="s2">we may be able to see this<br />as we look closer and closer</p>
<p begin="00:06:41.892" end="00:06:44.454" style="s2">at the heart in patients<br />presenting with unexplained</p>
<p begin="00:06:44.454" end="00:06:46.287" style="s2">tachycardia and shock.</p>
<p begin="00:06:47.807" end="00:06:49.877" style="s2">This is an apical view<br />from the same patient.</p>
<p begin="00:06:49.877" end="00:06:52.658" style="s2">Notice here we see the<br />thrombis bouncing around</p>
<p begin="00:06:52.658" end="00:06:54.396" style="s2">in the right atrium.</p>
<p begin="00:06:54.396" end="00:06:57.301" style="s2">Notice that it actually<br />passes out through the</p>
<p begin="00:06:57.301" end="00:06:59.088" style="s2">right ventricle, into the right ventricle,</p>
<p begin="00:06:59.088" end="00:07:01.453" style="s2">through the tricuspid valve,<br />and then is pushed back</p>
<p begin="00:07:01.453" end="00:07:04.255" style="s2">into the right atrium, and this<br />was a very interesting case</p>
<p begin="00:07:04.255" end="00:07:07.479" style="s2">and that this patient had<br />relatively high pulmonary</p>
<p begin="00:07:07.479" end="00:07:11.169" style="s2">arterial pressures, and a<br />large amount of tricuspid</p>
<p begin="00:07:11.169" end="00:07:13.697" style="s2">regurgitation, that pushed<br />the thrombis back into</p>
<p begin="00:07:13.697" end="00:07:15.114" style="s2">the right atrium.</p>
<p begin="00:07:17.003" end="00:07:19.456" style="s2">Let's now move on to<br />specifically look further at</p>
<p begin="00:07:19.456" end="00:07:21.653" style="s2">step three of the rapid<br />ultrasound in shock exam,</p>
<p begin="00:07:21.653" end="00:07:24.138" style="s2">the evaluation of the pipes.</p>
<p begin="00:07:24.138" end="00:07:26.040" style="s2">While in this illustration<br />it looks like there's</p>
<p begin="00:07:26.040" end="00:07:28.108" style="s2">many probes on the patient's body,</p>
<p begin="00:07:28.108" end="00:07:31.127" style="s2">let's sequentially break this down.</p>
<p begin="00:07:31.127" end="00:07:34.892" style="s2">Let's look first at<br />probes positions A and B.</p>
<p begin="00:07:34.892" end="00:07:37.534" style="s2">Probe position A is a<br />suprasternal notch view,</p>
<p begin="00:07:37.534" end="00:07:38.812" style="s2">in which we may be able<br />to get a look at the</p>
<p begin="00:07:38.812" end="00:07:43.608" style="s2">thoracic aorta, and the<br />actual arch of the aorta,</p>
<p begin="00:07:43.608" end="00:07:46.131" style="s2">looking specifically for<br />aneurysm or dissection.</p>
<p begin="00:07:46.131" end="00:07:49.204" style="s2">Position B is the<br />classic parasternal view,</p>
<p begin="00:07:49.204" end="00:07:52.403" style="s2">in which we can also get a<br />glimpse of the thoracic aorta,</p>
<p begin="00:07:52.403" end="00:07:55.746" style="s2">looking for dissection or aneurysm.</p>
<p begin="00:07:55.746" end="00:07:58.973" style="s2">Probes positions C and D are<br />the classic probe positions</p>
<p begin="00:07:58.973" end="00:08:01.903" style="s2">for placement, to look for<br />evaluation of abdominal</p>
<p begin="00:08:01.903" end="00:08:03.236" style="s2">aortic aneurysm.</p>
<p begin="00:08:04.302" end="00:08:07.614" style="s2">We can also see an intimal<br />flap at times that may signal</p>
<p begin="00:08:07.614" end="00:08:10.268" style="s2">a thoracic aortic<br />dissection extending down</p>
<p begin="00:08:10.268" end="00:08:11.685" style="s2">into the abdomen.</p>
<p begin="00:08:13.661" end="00:08:16.215" style="s2">Now probes position E and<br />F are the classic positions</p>
<p begin="00:08:16.215" end="00:08:19.119" style="s2">for the DVT exam, and should be performed</p>
<p begin="00:08:19.119" end="00:08:22.345" style="s2">if the patient has right<br />ventricular dilatation</p>
<p begin="00:08:22.345" end="00:08:25.905" style="s2">on bedside echo, and<br />one has a high suspicion</p>
<p begin="00:08:25.905" end="00:08:30.580" style="s2">for a thrombo-embolic cause<br />of the patient's shock.</p>
<p begin="00:08:30.580" end="00:08:32.892" style="s2">In this video clip we see a<br />parasternal long axis view</p>
<p begin="00:08:32.892" end="00:08:34.384" style="s2">of the heart.</p>
<p begin="00:08:34.384" end="00:08:36.546" style="s2">Recall that we see the<br />three chambers of the heart</p>
<p begin="00:08:36.546" end="00:08:39.190" style="s2">from this view, the left<br />atrium, the left ventricle,</p>
<p begin="00:08:39.190" end="00:08:40.722" style="s2">and the right ventricle.</p>
<p begin="00:08:40.722" end="00:08:42.622" style="s2">We see the aortic valve,</p>
<p begin="00:08:42.622" end="00:08:45.155" style="s2">and the left ventricular<br />outflow tract to the right</p>
<p begin="00:08:45.155" end="00:08:46.561" style="s2">of the aortic valve.</p>
<p begin="00:08:46.561" end="00:08:49.586" style="s2">Notice in this video clip<br />that this aortic root</p>
<p begin="00:08:49.586" end="00:08:52.118" style="s2">is relatively widened,<br />and I'm tracing that</p>
<p begin="00:08:52.118" end="00:08:54.775" style="s2">with a small indicator arrow.</p>
<p begin="00:08:54.775" end="00:08:57.296" style="s2">Now a normal aortic root<br />should measure no greater</p>
<p begin="00:08:57.296" end="00:08:59.691" style="s2">than three point eight centimeters,</p>
<p begin="00:08:59.691" end="00:09:02.339" style="s2">and a widened aortic root<br />is suspicious for thoracic</p>
<p begin="00:09:02.339" end="00:09:05.665" style="s2">aortic dissection, or aneurysm.</p>
<p begin="00:09:05.665" end="00:09:07.659" style="s2">Here we're actually<br />measuring the aortic root,</p>
<p begin="00:09:07.659" end="00:09:11.453" style="s2">notice that it measures 4.74 centimeters.</p>
<p begin="00:09:11.453" end="00:09:13.112" style="s2">And we can see there that this patient</p>
<p begin="00:09:13.112" end="00:09:15.695" style="s2">has a thoracic aortic aneurysm.</p>
<p begin="00:09:16.627" end="00:09:19.519" style="s2">Now we may be able to<br />see an intimal flap here</p>
<p begin="00:09:19.519" end="00:09:21.586" style="s2">within this region, which would indicate</p>
<p begin="00:09:21.586" end="00:09:25.970" style="s2">a dissection as the etiology<br />for the patient's shock.</p>
<p begin="00:09:25.970" end="00:09:27.665" style="s2">In this video clip,<br />taken from a patient with</p>
<p begin="00:09:27.665" end="00:09:32.141" style="s2">Marfan Syndrome, and chest<br />pain radiating to the back,</p>
<p begin="00:09:32.141" end="00:09:34.500" style="s2">we see a very widened<br />aortic root taken from the</p>
<p begin="00:09:34.500" end="00:09:36.773" style="s2">parasternal long axis view.</p>
<p begin="00:09:36.773" end="00:09:40.121" style="s2">This would indicate the<br />possibility of a Stanford Class A</p>
<p begin="00:09:40.121" end="00:09:43.977" style="s2">aortic dissection as a cause<br />of the patient's shock.</p>
<p begin="00:09:43.977" end="00:09:46.583" style="s2">Notice here, the very<br />very widened aortic root,</p>
<p begin="00:09:46.583" end="00:09:49.395" style="s2">and what looks like the<br />possibility of an intimal flap.</p>
<p begin="00:09:49.395" end="00:09:51.673" style="s2">Now an intimal flap may not always be seen</p>
<p begin="00:09:51.673" end="00:09:55.593" style="s2">on transthoracic echo, but<br />if one is very suspicious,</p>
<p begin="00:09:55.593" end="00:09:58.781" style="s2">one can pursue a transesophageal<br />echo or a CT scan</p>
<p begin="00:09:58.781" end="00:10:01.932" style="s2">to further confirm this condition.</p>
<p begin="00:10:01.932" end="00:10:03.957" style="s2">This patient actually<br />was confirmed to have a</p>
<p begin="00:10:03.957" end="00:10:08.468" style="s2">Stanford Class A aortic<br />dissection requiring a stent.</p>
<p begin="00:10:08.468" end="00:10:10.326" style="s2">This image of the aortic<br />arch was taken from the</p>
<p begin="00:10:10.326" end="00:10:12.440" style="s2">suprasternal notch view.</p>
<p begin="00:10:12.440" end="00:10:14.346" style="s2">In this view the probe<br />is placed directly into</p>
<p begin="00:10:14.346" end="00:10:17.362" style="s2">the suprasternal notch,<br />with the probe marker</p>
<p begin="00:10:17.362" end="00:10:20.254" style="s2">oriented towards the patent's right side.</p>
<p begin="00:10:20.254" end="00:10:23.523" style="s2">In relatively thin<br />patients, it can be possible</p>
<p begin="00:10:23.523" end="00:10:26.006" style="s2">to move the head to the<br />side and to aim the probe</p>
<p begin="00:10:26.006" end="00:10:29.186" style="s2">down into the chest to get<br />a view of the aortic arch.</p>
<p begin="00:10:29.186" end="00:10:32.457" style="s2">And here we can see the<br />ascending aorta to the left,</p>
<p begin="00:10:32.457" end="00:10:34.480" style="s2">the descending aorta to the right,</p>
<p begin="00:10:34.480" end="00:10:36.583" style="s2">and the aortic arch right in the middle.</p>
<p begin="00:10:36.583" end="00:10:38.653" style="s2">Notice we also see some<br />of the branching vessels</p>
<p begin="00:10:38.653" end="00:10:41.338" style="s2">coming off of the aortic<br />arch, and this would be</p>
<p begin="00:10:41.338" end="00:10:44.811" style="s2">normal anatomy, not<br />consistent with dissection.</p>
<p begin="00:10:44.811" end="00:10:47.125" style="s2">But occasionally we may be<br />able to pick up an aortic</p>
<p begin="00:10:47.125" end="00:10:52.009" style="s2">dissection or aneurysm, from<br />the suprasternal notch view.</p>
<p begin="00:10:52.009" end="00:10:54.330" style="s2">This video clip represents<br />the suprasternal notch view</p>
<p begin="00:10:54.330" end="00:10:56.868" style="s2">taken from the patient<br />with Marfan syndrome</p>
<p begin="00:10:56.868" end="00:10:58.655" style="s2">discussed earlier in the video sequence.</p>
<p begin="00:10:58.655" end="00:11:01.563" style="s2">The first thing we notice<br />right away is that this aortic</p>
<p begin="00:11:01.563" end="00:11:04.084" style="s2">arch is much more dilated<br />than the normal anatomy</p>
<p begin="00:11:04.084" end="00:11:06.691" style="s2">shown prior, and with the<br />small indicator arrow,</p>
<p begin="00:11:06.691" end="00:11:09.788" style="s2">I'm showing the confines<br />of the aortic arch.</p>
<p begin="00:11:09.788" end="00:11:11.944" style="s2">Let's look closer within the aortic arch,</p>
<p begin="00:11:11.944" end="00:11:14.132" style="s2">and right away we can see what<br />looks like an intimal flap</p>
<p begin="00:11:14.132" end="00:11:17.032" style="s2">moving around with each heartbeat.</p>
<p begin="00:11:17.032" end="00:11:19.723" style="s2">So this patient was diagnosed<br />with a Stanford Class A</p>
<p begin="00:11:19.723" end="00:11:22.371" style="s2">aortic dissection,<br />extending from the root,</p>
<p begin="00:11:22.371" end="00:11:26.760" style="s2">through the arch, and down<br />into the descending aorta.</p>
<p begin="00:11:26.760" end="00:11:28.164" style="s2">The next step in the<br />evaluation of the pipes</p>
<p begin="00:11:28.164" end="00:11:31.399" style="s2">is performed through looking<br />at the abdominal aorta.</p>
<p begin="00:11:31.399" end="00:11:34.131" style="s2">The probe should be placed<br />in positions C and D</p>
<p begin="00:11:34.131" end="00:11:36.072" style="s2">as shown on the patient's abdomen,</p>
<p begin="00:11:36.072" end="00:11:38.753" style="s2">with the probe in a<br />short axis configuration.</p>
<p begin="00:11:38.753" end="00:11:40.574" style="s2">Generally we'll begin with the probe high,</p>
<p begin="00:11:40.574" end="00:11:43.216" style="s2">at position C, and move<br />all the way down to D</p>
<p begin="00:11:43.216" end="00:11:45.368" style="s2">to fully examine the aorta.</p>
<p begin="00:11:45.368" end="00:11:47.779" style="s2">We're looking for an<br />abdominal aortic aneurysm,</p>
<p begin="00:11:47.779" end="00:11:51.707" style="s2">as signaled by a abdominal<br />aorta greater than three</p>
<p begin="00:11:51.707" end="00:11:54.104" style="s2">centimeters in diameter.</p>
<p begin="00:11:54.104" end="00:11:56.873" style="s2">Now most AAAs will be fusiform in nature,</p>
<p begin="00:11:56.873" end="00:11:58.359" style="s2">and also infrarenal.</p>
<p begin="00:11:58.359" end="00:12:01.683" style="s2">Some may extend down<br />into the iliac artery.</p>
<p begin="00:12:01.683" end="00:12:05.460" style="s2">A minority of triple As<br />will be saccular as shown</p>
<p begin="00:12:05.460" end="00:12:06.827" style="s2">in the image over to<br />the right, where we have</p>
<p begin="00:12:06.827" end="00:12:10.593" style="s2">a small protrusion of the wall,<br />out from the normal aorta.</p>
<p begin="00:12:10.593" end="00:12:14.608" style="s2">This video clip demonstrates<br />an abdominal aortic aneurysm,</p>
<p begin="00:12:14.608" end="00:12:16.684" style="s2">in a patient who presented<br />to the emergency department</p>
<p begin="00:12:16.684" end="00:12:20.283" style="s2">with a hypotensive state and tachycardium.</p>
<p begin="00:12:20.283" end="00:12:23.057" style="s2">Here we see a very large<br />abdominal aortic aneurysm</p>
<p begin="00:12:23.057" end="00:12:24.426" style="s2">in the short axis view.</p>
<p begin="00:12:24.426" end="00:12:27.159" style="s2">Notice here we see a<br />large amount of thrombis</p>
<p begin="00:12:27.159" end="00:12:29.016" style="s2">along the walls of the aorta,</p>
<p begin="00:12:29.016" end="00:12:31.956" style="s2">and recall that when measuring<br />for an abdominal aortic</p>
<p begin="00:12:31.956" end="00:12:34.652" style="s2">aneurysm, we need to measure<br />the thrombis in addition</p>
<p begin="00:12:34.652" end="00:12:36.230" style="s2">to the lumin.</p>
<p begin="00:12:36.230" end="00:12:37.891" style="s2">That means we're going to<br />measure from outer wall</p>
<p begin="00:12:37.891" end="00:12:41.458" style="s2">to outer wall, not just the<br />inner walls of the lumin.</p>
<p begin="00:12:41.458" end="00:12:43.897" style="s2">And we can see the swirls<br />of clot or pre-clot</p>
<p begin="00:12:43.897" end="00:12:47.000" style="s2">within the lumin of the triple A.</p>
<p begin="00:12:47.000" end="00:12:49.071" style="s2">Now to confirm that this is a triple A,</p>
<p begin="00:12:49.071" end="00:12:51.725" style="s2">we can further go ahead and<br />put a color power doppler,</p>
<p begin="00:12:51.725" end="00:12:53.874" style="s2">or color flow doppler, onto this area,</p>
<p begin="00:12:53.874" end="00:12:56.311" style="s2">just to confirm that there's<br />flow within the lumin,</p>
<p begin="00:12:56.311" end="00:12:59.037" style="s2">and that this is indeed<br />a vascular structure.</p>
<p begin="00:12:59.037" end="00:13:00.943" style="s2">We'll perform that in the next step here,</p>
<p begin="00:13:00.943" end="00:13:03.425" style="s2">and by putting color power doppler there,</p>
<p begin="00:13:03.425" end="00:13:07.890" style="s2">we can see that this is<br />indeed a turbulent movement</p>
<p begin="00:13:07.890" end="00:13:11.571" style="s2">of blood within the large<br />abdominal aortic aneurysm.</p>
<p begin="00:13:11.571" end="00:13:14.601" style="s2">So right away we have an<br />etiology for the patient's shock,</p>
<p begin="00:13:14.601" end="00:13:16.542" style="s2">and this is a patient<br />who needs to go directly</p>
<p begin="00:13:16.542" end="00:13:19.476" style="s2">to the operating room,<br />and bypass the CT scan</p>
<p begin="00:13:19.476" end="00:13:21.622" style="s2">in order to live.</p>
<p begin="00:13:21.622" end="00:13:23.566" style="s2">This video clip was taken<br />from a patient who presented</p>
<p begin="00:13:23.566" end="00:13:26.170" style="s2">to the ED with hypotension accompanied by</p>
<p begin="00:13:26.170" end="00:13:28.997" style="s2">chest, back, and abdominal pain.</p>
<p begin="00:13:28.997" end="00:13:31.778" style="s2">Here we see a short axis<br />view of the abdominal aorta.</p>
<p begin="00:13:31.778" end="00:13:34.963" style="s2">First with the indicator arrow,<br />I'll trace out the spine,</p>
<p begin="00:13:34.963" end="00:13:38.720" style="s2">a landmark for the posterior<br />aspect of the abdominal cavity.</p>
<p begin="00:13:38.720" end="00:13:41.786" style="s2">Anterior to that, we'll<br />notice the abdominal aorta,</p>
<p begin="00:13:41.786" end="00:13:44.431" style="s2">and while it's not terribly large in size,</p>
<p begin="00:13:44.431" end="00:13:46.288" style="s2">we see a positive finding in the lumin,</p>
<p begin="00:13:46.288" end="00:13:48.273" style="s2">the presence of an intimal flap.</p>
<p begin="00:13:48.273" end="00:13:51.128" style="s2">To the right there is the true lumin,</p>
<p begin="00:13:51.128" end="00:13:53.530" style="s2">and to the left is the false lumin,</p>
<p begin="00:13:53.530" end="00:13:57.388" style="s2">so what we see here is<br />a thoracic dissection</p>
<p begin="00:13:57.388" end="00:13:59.840" style="s2">that's extending down into the abdomen.</p>
<p begin="00:13:59.840" end="00:14:03.447" style="s2">This actually turned out<br />to be a class A dissection</p>
<p begin="00:14:03.447" end="00:14:06.340" style="s2">that was extending from<br />the root all the way down</p>
<p begin="00:14:06.340" end="00:14:09.241" style="s2">into the abdominal cavity.</p>
<p begin="00:14:09.241" end="00:14:11.017" style="s2">So occasionally we can actually pick up,</p>
<p begin="00:14:11.017" end="00:14:14.040" style="s2">in the aortic dissection,<br />on evaluation of the aorta,</p>
<p begin="00:14:14.040" end="00:14:15.950" style="s2">on bedside ultrasound.</p>
<p begin="00:14:15.950" end="00:14:18.529" style="s2">Here's a long axis view<br />of the same patient,</p>
<p begin="00:14:18.529" end="00:14:20.310" style="s2">notice we have the probe marker,</p>
<p begin="00:14:20.310" end="00:14:23.943" style="s2">so that superior is to the<br />left, inferior to the right.</p>
<p begin="00:14:23.943" end="00:14:26.878" style="s2">Again we see the abdominal<br />aorta stretch out</p>
<p begin="00:14:26.878" end="00:14:29.586" style="s2">as a tubular structure across the screen,</p>
<p begin="00:14:29.586" end="00:14:32.600" style="s2">and in the middle we see the<br />presence of an intimal flap,</p>
<p begin="00:14:32.600" end="00:14:35.078" style="s2">moving around with each heartbeat, again,</p>
<p begin="00:14:35.078" end="00:14:37.861" style="s2">pathonomic for an aortic dissection.</p>
<p begin="00:14:37.861" end="00:14:40.341" style="s2">The next step in part three,<br />evaluation of the pipes,</p>
<p begin="00:14:40.341" end="00:14:43.262" style="s2">once one has evaluated the<br />major arterial circuit,</p>
<p begin="00:14:43.262" end="00:14:46.198" style="s2">IE the thoracic and abdominal<br />aorta for pathology,</p>
<p begin="00:14:46.198" end="00:14:48.602" style="s2">is to examine the major venous circuit,</p>
<p begin="00:14:48.602" end="00:14:53.113" style="s2">IE probes position E and<br />F, looking for a pathology</p>
<p begin="00:14:53.113" end="00:14:55.802" style="s2">within the venous circuit<br />such as a massive DVT,</p>
<p begin="00:14:55.802" end="00:14:58.571" style="s2">that could be the cause of<br />a thrombo-embolic etiology</p>
<p begin="00:14:58.571" end="00:14:59.820" style="s2">for shock.</p>
<p begin="00:14:59.820" end="00:15:02.393" style="s2">And now while not every patient<br />will need this examination,</p>
<p begin="00:15:02.393" end="00:15:04.841" style="s2">I will go ahead and perform<br />this exam in a patient</p>
<p begin="00:15:04.841" end="00:15:07.818" style="s2">with a high pre-test probability<br />for a thrombo-embolic</p>
<p begin="00:15:07.818" end="00:15:10.728" style="s2">cause of shock, or right<br />ventricular dilatation</p>
<p begin="00:15:10.728" end="00:15:12.478" style="s2">seen on bedside echo.</p>
<p begin="00:15:13.451" end="00:15:17.518" style="s2">This illustration shows the<br />lower extremity venous anatomy.</p>
<p begin="00:15:17.518" end="00:15:21.973" style="s2">Recall that the common<br />femoral vein bifurcates into</p>
<p begin="00:15:21.973" end="00:15:24.297" style="s2">the deep and superficial femoral veins.</p>
<p begin="00:15:24.297" end="00:15:26.250" style="s2">Now the superficial<br />femoral vein is the one</p>
<p begin="00:15:26.250" end="00:15:28.112" style="s2">that continues on down the thigh,</p>
<p begin="00:15:28.112" end="00:15:31.210" style="s2">and into the leg, and<br />in fact has been renamed</p>
<p begin="00:15:31.210" end="00:15:33.697" style="s2">the femoral vein of the thigh.</p>
<p begin="00:15:33.697" end="00:15:35.558" style="s2">It will continue on into<br />the back of the knee to</p>
<p begin="00:15:35.558" end="00:15:37.839" style="s2">become the popliteal vein.</p>
<p begin="00:15:37.839" end="00:15:40.730" style="s2">Now we can perform a two<br />point compression examination,</p>
<p begin="00:15:40.730" end="00:15:43.800" style="s2">looking for a DVT, by placing<br />the probe into the area</p>
<p begin="00:15:43.800" end="00:15:45.866" style="s2">of the small indicator arrow,</p>
<p begin="00:15:45.866" end="00:15:48.177" style="s2">scanning from the common femoral vein down</p>
<p begin="00:15:48.177" end="00:15:51.661" style="s2">to bifurcation, into the<br />femoral vein of the thigh,</p>
<p begin="00:15:51.661" end="00:15:53.772" style="s2">and the deep femoral vein.</p>
<p begin="00:15:53.772" end="00:15:57.073" style="s2">We can then proceed all the<br />way down to the popliteal vein,</p>
<p begin="00:15:57.073" end="00:15:59.638" style="s2">placing the probe posteriorly,<br />and compressing sequentially</p>
<p begin="00:15:59.638" end="00:16:02.136" style="s2">from high within the popliteal fascia,</p>
<p begin="00:16:02.136" end="00:16:05.777" style="s2">down to the area of trifurcation<br />into the three calf veins.</p>
<p begin="00:16:05.777" end="00:16:10.703" style="s2">Failure to compress would be<br />indicative of a positive DVT.</p>
<p begin="00:16:10.703" end="00:16:12.904" style="s2">This video clip illustrates<br />normal compression of the</p>
<p begin="00:16:12.904" end="00:16:14.396" style="s2">femoral vein.</p>
<p begin="00:16:14.396" end="00:16:17.799" style="s2">At this level, we see the<br />common femoral vein and artery.</p>
<p begin="00:16:17.799" end="00:16:20.934" style="s2">We have the high frequency<br />linear array probe</p>
<p begin="00:16:20.934" end="00:16:22.922" style="s2">placed on a side to side configuration,</p>
<p begin="00:16:22.922" end="00:16:25.030" style="s2">with the probe marker laterally oriented,</p>
<p begin="00:16:25.030" end="00:16:26.434" style="s2">or towards the left.</p>
<p begin="00:16:26.434" end="00:16:29.046" style="s2">Notice that the femoral vein<br />towards the right or medial,</p>
<p begin="00:16:29.046" end="00:16:32.148" style="s2">completely compresses with probe pressure,</p>
<p begin="00:16:32.148" end="00:16:34.847" style="s2">indicating the absence of a DVT.</p>
<p begin="00:16:34.847" end="00:16:36.126" style="s2">So this would be considered</p>
<p begin="00:16:36.126" end="00:16:39.262" style="s2">a completely normal DVT<br />examination, and in fact</p>
<p begin="00:16:39.262" end="00:16:41.627" style="s2">we can see a little bit of<br />the saphenous vein coming</p>
<p begin="00:16:41.627" end="00:16:43.690" style="s2">off the top of the femoral vein.</p>
<p begin="00:16:43.690" end="00:16:46.960" style="s2">Now we can use doppler to<br />help us in identification</p>
<p begin="00:16:46.960" end="00:16:48.737" style="s2">of the femoral vessels.</p>
<p begin="00:16:48.737" end="00:16:50.884" style="s2">This would be a positive examination,</p>
<p begin="00:16:50.884" end="00:16:53.407" style="s2">we can see the femoral<br />artery with pulsations,</p>
<p begin="00:16:53.407" end="00:16:55.151" style="s2">laterally or towards the left,</p>
<p begin="00:16:55.151" end="00:16:56.842" style="s2">and towards the right or medial,</p>
<p begin="00:16:56.842" end="00:16:58.413" style="s2">we actually see the femoral vein,</p>
<p begin="00:16:58.413" end="00:17:00.604" style="s2">and notice the swirls of fresh clot</p>
<p begin="00:17:00.604" end="00:17:03.131" style="s2">present within the vessel.</p>
<p begin="00:17:03.131" end="00:17:06.238" style="s2">Now recall that we must go<br />ahead and compress the vessel</p>
<p begin="00:17:06.238" end="00:17:09.649" style="s2">to confirm a DVT, so that<br />will be our next step,</p>
<p begin="00:17:09.649" end="00:17:11.827" style="s2">but here again we see<br />absence of flow within the</p>
<p begin="00:17:11.827" end="00:17:15.994" style="s2">femoral vein, which is<br />completely clotted off by a DVT.</p>
<p begin="00:17:17.249" end="00:17:19.991" style="s2">Next we'll apply gentle<br />probe pressure downwards,</p>
<p begin="00:17:19.991" end="00:17:22.106" style="s2">with a high frequency linear array probe.</p>
<p begin="00:17:22.106" end="00:17:25.173" style="s2">Notice we see failure of<br />compression of the femoral vein,</p>
<p begin="00:17:25.173" end="00:17:27.648" style="s2">and with the small indicator<br />arrow I'm tracing the confines</p>
<p begin="00:17:27.648" end="00:17:30.043" style="s2">of the femoral vein, again we can see the</p>
<p begin="00:17:30.043" end="00:17:32.324" style="s2">echogenic debris of the DVT,</p>
<p begin="00:17:32.324" end="00:17:34.447" style="s2">that's actually the<br />saphenous coming off the top,</p>
<p begin="00:17:34.447" end="00:17:36.728" style="s2">also involved with this DVT.</p>
<p begin="00:17:36.728" end="00:17:39.535" style="s2">So a failure of compression<br />of the femoral vein,</p>
<p begin="00:17:39.535" end="00:17:42.056" style="s2">indicative of a positive DVT,</p>
<p begin="00:17:42.056" end="00:17:43.603" style="s2">and in the right clinical scenario,</p>
<p begin="00:17:43.603" end="00:17:46.125" style="s2">this could suggest a thrombo-embolic cause</p>
<p begin="00:17:46.125" end="00:17:48.627" style="s2">for the patient's shock,<br />especially if the patient</p>
<p begin="00:17:48.627" end="00:17:53.008" style="s2">has right ventricular<br />dilatation on bedside echo.</p>
<p begin="00:17:53.008" end="00:17:56.289" style="s2">Continuing downwards, we'll<br />look at the popliteal vein.</p>
<p begin="00:17:56.289" end="00:17:58.743" style="s2">Now remember that the<br />probe is placed posteriorly</p>
<p begin="00:17:58.743" end="00:18:01.190" style="s2">into the popliteal fascia for this exam,</p>
<p begin="00:18:01.190" end="00:18:03.552" style="s2">and gentle probe pressure is applied.</p>
<p begin="00:18:03.552" end="00:18:06.329" style="s2">We can see that the artery<br />is anterior to the vein,</p>
<p begin="00:18:06.329" end="00:18:08.980" style="s2">and that the vein, which<br />is posteriorly located,</p>
<p begin="00:18:08.980" end="00:18:10.552" style="s2">completely compresses.</p>
<p begin="00:18:10.552" end="00:18:12.451" style="s2">This would be a normal examination,</p>
<p begin="00:18:12.451" end="00:18:15.182" style="s2">and we can see that the walls<br />completely come together</p>
<p begin="00:18:15.182" end="00:18:16.876" style="s2">with probe pressure.</p>
<p begin="00:18:16.876" end="00:18:19.864" style="s2">This video clip<br />illustrates a positive exam</p>
<p begin="00:18:19.864" end="00:18:21.986" style="s2">for a popliteal vein thrombosis.</p>
<p begin="00:18:21.986" end="00:18:24.347" style="s2">Recall again that the<br />popliteal artery is located</p>
<p begin="00:18:24.347" end="00:18:26.947" style="s2">anterior to the vein, and we can see here</p>
<p begin="00:18:26.947" end="00:18:28.929" style="s2">that the popliteal vein<br />with what looks like swirls</p>
<p begin="00:18:28.929" end="00:18:31.451" style="s2">of echogenic material.</p>
<p begin="00:18:31.451" end="00:18:33.641" style="s2">With a small indicator<br />arrow, I'll show the confines</p>
<p begin="00:18:33.641" end="00:18:36.948" style="s2">of the popliteal vein, and<br />notice that with probe pressure,</p>
<p begin="00:18:36.948" end="00:18:39.719" style="s2">that the vessel does not compress.</p>
<p begin="00:18:39.719" end="00:18:41.500" style="s2">And in fact, with the<br />small indicator arrow there</p>
<p begin="00:18:41.500" end="00:18:45.476" style="s2">I can see a calf vein that's<br />coming off the popliteal vein,</p>
<p begin="00:18:45.476" end="00:18:49.329" style="s2">that's also filled with debris or DVT.</p>
<p begin="00:18:49.329" end="00:18:52.261" style="s2">And we know that most DVTs<br />occur within the calf,</p>
<p begin="00:18:52.261" end="00:18:55.938" style="s2">and propagate upwards<br />into the popliteal vein.</p>
<p begin="00:18:55.938" end="00:18:57.299" style="s2">Now let's put all the<br />information we've learned</p>
<p begin="00:18:57.299" end="00:19:00.150" style="s2">in the various RUSH<br />segments, into one unified</p>
<p begin="00:19:00.150" end="00:19:03.418" style="s2">RUSH protocol, to help us<br />in determining the etiology</p>
<p begin="00:19:03.418" end="00:19:05.322" style="s2">for the patient's shock.</p>
<p begin="00:19:05.322" end="00:19:08.183" style="s2">Let's begin by looking<br />at hypovolemic shock.</p>
<p begin="00:19:08.183" end="00:19:11.372" style="s2">In step one, evaluation of<br />the pump, often heart will</p>
<p begin="00:19:11.372" end="00:19:13.698" style="s2">be small in size and hypercontracting,</p>
<p begin="00:19:13.698" end="00:19:15.942" style="s2">with the endocardial walls<br />almost coming together</p>
<p begin="00:19:15.942" end="00:19:17.192" style="s2">during sistole.</p>
<p begin="00:19:18.308" end="00:19:20.625" style="s2">On evaluation of the tank,<br />the inferior vena cava</p>
<p begin="00:19:20.625" end="00:19:23.312" style="s2">may be small in size, with<br />a large percentage change</p>
<p begin="00:19:23.312" end="00:19:25.632" style="s2">during inspiration.</p>
<p begin="00:19:25.632" end="00:19:28.167" style="s2">The internal jugular veins<br />may also be small in size,</p>
<p begin="00:19:28.167" end="00:19:31.599" style="s2">with a low closing column within the neck.</p>
<p begin="00:19:31.599" end="00:19:33.499" style="s2">We may see the presence<br />of peritoneal fluid,</p>
<p begin="00:19:33.499" end="00:19:37.561" style="s2">or pleural fluid, indicating<br />a hole within the tank.</p>
<p begin="00:19:37.561" end="00:19:41.409" style="s2">In step three, evaluation<br />of the pipes, one may see</p>
<p begin="00:19:41.409" end="00:19:44.135" style="s2">an abdominal aortic aneurysm,<br />which may be the cause</p>
<p begin="00:19:44.135" end="00:19:47.409" style="s2">of hemorrhagic shock,<br />causing the shock etiology</p>
<p begin="00:19:47.409" end="00:19:48.944" style="s2">in this patient.</p>
<p begin="00:19:48.944" end="00:19:50.678" style="s2">One may also see an intimal flap</p>
<p begin="00:19:50.678" end="00:19:52.661" style="s2">indicating aortal dissection,</p>
<p begin="00:19:52.661" end="00:19:56.138" style="s2">another cause of hemorrhagic<br />shock within our patient.</p>
<p begin="00:19:56.138" end="00:19:58.726" style="s2">Moving on to the next<br />category, cardiogenic shock,</p>
<p begin="00:19:58.726" end="00:20:01.077" style="s2">generally the heart<br />will be dilated in size.</p>
<p begin="00:20:01.077" end="00:20:03.427" style="s2">With systolic dysfunction,</p>
<p begin="00:20:03.427" end="00:20:04.918" style="s2">the heart will be hypocontracting,</p>
<p begin="00:20:04.918" end="00:20:07.528" style="s2">with a small percentage<br />change from diastole through</p>
<p begin="00:20:07.528" end="00:20:08.975" style="s2">to sistole.</p>
<p begin="00:20:08.975" end="00:20:10.840" style="s2">On evaluation of the tank,<br />the inferior vena cava</p>
<p begin="00:20:10.840" end="00:20:13.727" style="s2">will often be large in size,<br />greater than two centimeters,</p>
<p begin="00:20:13.727" end="00:20:16.598" style="s2">with a small percentage<br />change during inspiration.</p>
<p begin="00:20:16.598" end="00:20:19.364" style="s2">The internal jugular vein<br />will be distended as well,</p>
<p begin="00:20:19.364" end="00:20:22.181" style="s2">with a high closing<br />column within the neck.</p>
<p begin="00:20:22.181" end="00:20:25.027" style="s2">One may see, on evaluation of the lung,</p>
<p begin="00:20:25.027" end="00:20:27.510" style="s2">the positive lung rockets<br />that we talked about,</p>
<p begin="00:20:27.510" end="00:20:30.583" style="s2">or ultrasonic beelines<br />indicating pulmonary edema.</p>
<p begin="00:20:30.583" end="00:20:34.560" style="s2">Pleural effusion and<br />ascites may also be seen</p>
<p begin="00:20:34.560" end="00:20:36.135" style="s2">as a sign of tank overload.</p>
<p begin="00:20:36.135" end="00:20:39.009" style="s2">On evaluation of the pipes,<br />often this will be normal,</p>
<p begin="00:20:39.009" end="00:20:41.618" style="s2">although occasionally a<br />DVT may be seen in this</p>
<p begin="00:20:41.618" end="00:20:42.868" style="s2">low flow state.</p>
<p begin="00:20:43.987" end="00:20:45.479" style="s2">In obstructive shock,<br />of which the first is,</p>
<p begin="00:20:45.479" end="00:20:49.442" style="s2">pericardial effusion<br />with cardiac tamponade,</p>
<p begin="00:20:49.442" end="00:20:50.974" style="s2">we'll be looking specifically<br />for a circumferential</p>
<p begin="00:20:50.974" end="00:20:53.755" style="s2">pericardial effusion,<br />with diastolic collapse</p>
<p begin="00:20:53.755" end="00:20:56.237" style="s2">of the right atrium<br />and or right ventricle,</p>
<p begin="00:20:56.237" end="00:20:58.059" style="s2">indicative of cardiac tamponade.</p>
<p begin="00:20:58.059" end="00:21:00.332" style="s2">In the other two types<br />of obstructive shock,</p>
<p begin="00:21:00.332" end="00:21:03.582" style="s2">a massive PE or a tension pneumothorax,</p>
<p begin="00:21:05.137" end="00:21:07.377" style="s2">generally we will see a<br />hypercontracting heart,</p>
<p begin="00:21:07.377" end="00:21:10.152" style="s2">and recall that in cases of a massive PE,</p>
<p begin="00:21:10.152" end="00:21:12.594" style="s2">we may see right ventricular dilatation,</p>
<p begin="00:21:12.594" end="00:21:15.124" style="s2">and we may at times<br />actually see thrombis within</p>
<p begin="00:21:15.124" end="00:21:17.940" style="s2">the right atrium, and or right ventricle.</p>
<p begin="00:21:17.940" end="00:21:20.583" style="s2">Moving on to the tank,<br />the inferior vena cava</p>
<p begin="00:21:20.583" end="00:21:23.064" style="s2">is usually distended in obstructive shock,</p>
<p begin="00:21:23.064" end="00:21:26.535" style="s2">with a low percentage<br />change from expiration</p>
<p begin="00:21:26.535" end="00:21:28.517" style="s2">through to inspiration.</p>
<p begin="00:21:28.517" end="00:21:30.876" style="s2">The internal jugular vein<br />will also be distended,</p>
<p begin="00:21:30.876" end="00:21:34.102" style="s2">with a high closing<br />column within the neck.</p>
<p begin="00:21:34.102" end="00:21:36.472" style="s2">Now if the patient has<br />a tension pneumothorax,</p>
<p begin="00:21:36.472" end="00:21:38.994" style="s2">we may be able to see<br />absent lung sliding and</p>
<p begin="00:21:38.994" end="00:21:41.994" style="s2">the absence of vertical comet tails.</p>
<p begin="00:21:42.917" end="00:21:45.412" style="s2">Moving on to the evaluation of the pipes</p>
<p begin="00:21:45.412" end="00:21:47.228" style="s2">in obstructive shock, we<br />may be able to pick up</p>
<p begin="00:21:47.228" end="00:21:50.713" style="s2">a positive DVT within the<br />femoral or popliteal regions,</p>
<p begin="00:21:50.713" end="00:21:54.275" style="s2">indicative of a thrombo-embolic<br />etiology of the shock,</p>
<p begin="00:21:54.275" end="00:21:56.847" style="s2">and a DVT that may have<br />moved on into the heart</p>
<p begin="00:21:56.847" end="00:22:00.156" style="s2">and into the lungs to cause a massive PE.</p>
<p begin="00:22:00.156" end="00:22:02.307" style="s2">Last but not least, in distributive shock,</p>
<p begin="00:22:02.307" end="00:22:04.620" style="s2">of which sepsis will be the most common,</p>
<p begin="00:22:04.620" end="00:22:06.645" style="s2">in early septic shock, the heart is</p>
<p begin="00:22:06.645" end="00:22:09.791" style="s2">generally hypercontracting,<br />with the endocardial walls</p>
<p begin="00:22:09.791" end="00:22:12.374" style="s2">almost touching during sistole.</p>
<p begin="00:22:13.544" end="00:22:15.619" style="s2">Later in sepsis, the heart may fail,</p>
<p begin="00:22:15.619" end="00:22:17.566" style="s2">and one can see a<br />hypocontracting heart with</p>
<p begin="00:22:17.566" end="00:22:21.665" style="s2">a small percentage change from<br />diastole through to sistole.</p>
<p begin="00:22:21.665" end="00:22:24.039" style="s2">On evaluation of the tank,<br />in distributive shock,</p>
<p begin="00:22:24.039" end="00:22:26.939" style="s2">generally the IVC will be normal or small,</p>
<p begin="00:22:26.939" end="00:22:29.876" style="s2">less than two centimeters,<br />with a high percentage change</p>
<p begin="00:22:29.876" end="00:22:31.459" style="s2">during inspiration.</p>
<p begin="00:22:33.027" end="00:22:36.388" style="s2">The internal jugular vein<br />may also be normal or small,</p>
<p begin="00:22:36.388" end="00:22:39.951" style="s2">with a low closing column within the neck.</p>
<p begin="00:22:39.951" end="00:22:42.887" style="s2">In cases of sepsis due to empyema,</p>
<p begin="00:22:42.887" end="00:22:44.669" style="s2">we may be able to pick up<br />the presence of a septage</p>
<p begin="00:22:44.669" end="00:22:47.041" style="s2">or a complicated pleural effusion.</p>
<p begin="00:22:47.041" end="00:22:49.317" style="s2">And in cases of<br />peritonitis, usually due to</p>
<p begin="00:22:49.317" end="00:22:52.784" style="s2">spontaneous bacterial<br />peritonitis in a liver patient,</p>
<p begin="00:22:52.784" end="00:22:55.866" style="s2">we may see the presence of<br />peritoneal fluid or ascites.</p>
<p begin="00:22:55.866" end="00:22:59.653" style="s2">On the evaluation of the<br />pipes in distributive shock,</p>
<p begin="00:22:59.653" end="00:23:01.185" style="s2">generally this part can be omitted,</p>
<p begin="00:23:01.185" end="00:23:03.552" style="s2">as this usually will be normal.</p>
<p begin="00:23:03.552" end="00:23:06.209" style="s2">So in conclusion, the<br />RUSH ultrasound protocol</p>
<p begin="00:23:06.209" end="00:23:08.082" style="s2">can quickly help us at the bedside,</p>
<p begin="00:23:08.082" end="00:23:10.283" style="s2">stratify a patient into<br />one of the four categories</p>
<p begin="00:23:10.283" end="00:23:12.805" style="s2">of shock, and immediately<br />start the correct therapy</p>
<p begin="00:23:12.805" end="00:23:14.928" style="s2">for the patient's shock state.</p>
<p begin="00:23:14.928" end="00:23:18.578" style="s2">Now continuing on, we<br />can use the RUSH exam</p>
<p begin="00:23:18.578" end="00:23:21.393" style="s2">to monitor the patient's<br />response to treatment</p>
<p begin="00:23:21.393" end="00:23:24.462" style="s2">over time, and this is<br />very important in cases</p>
<p begin="00:23:24.462" end="00:23:26.739" style="s2">of hypovolemic shock<br />or distributive shock,</p>
<p begin="00:23:26.739" end="00:23:29.555" style="s2">where one can look at fluid<br />loading at the response</p>
<p begin="00:23:29.555" end="00:23:33.004" style="s2">of the inferior vena cava<br />and internal jugular veins.</p>
<p begin="00:23:33.004" end="00:23:34.907" style="s2">Hopefully they should become more plump,</p>
<p begin="00:23:34.907" end="00:23:37.553" style="s2">and less distensible, with respirations,</p>
<p begin="00:23:37.553" end="00:23:40.862" style="s2">as volume resuscitation continues.</p>
<p begin="00:23:40.862" end="00:23:42.649" style="s2">This means that the RUSH<br />exam can first identify</p>
<p begin="00:23:42.649" end="00:23:46.539" style="s2">the patient's shock state,<br />allowing for appropriate therapy,</p>
<p begin="00:23:46.539" end="00:23:49.193" style="s2">and also very importantly<br />can allow us to evaluate</p>
<p begin="00:23:49.193" end="00:23:50.975" style="s2">the patient's response to therapy,</p>
<p begin="00:23:50.975" end="00:23:53.292" style="s2">by looking at the<br />response to fluid loading,</p>
<p begin="00:23:53.292" end="00:23:55.739" style="s2">as we want to push up the<br />central venous pressure</p>
<p begin="00:23:55.739" end="00:24:00.506" style="s2">in cases of hypovolemic and<br />distributive shock states.</p>
<p begin="00:24:00.506" end="00:24:03.527" style="s2">So, I'm glad you could join<br />me for the Soundbytes Videos,</p>
<p begin="00:24:03.527" end="00:24:05.468" style="s2">and I look forward to<br />seeing you in the future,</p>
<p begin="00:24:05.468" end="00:24:07.468" style="s2">as Soundbytes continues.</p>
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https://youtube.com/watch?v=9UyVHqvGgHE