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

<p begin="00:00:07.459" end="00:00:09.119" style="s2">- [Voiceover] A phased array transducer</p>
<p begin="00:00:09.119" end="00:00:11.852" style="s2">with a cardiac exam<br />type is used to perform</p>
<p begin="00:00:11.852" end="00:00:15.084" style="s2">the parasternal short<br />axis view of the heart.</p>
<p begin="00:00:15.084" end="00:00:18.007" style="s2">If possible, place the<br />patient in a left lateral</p>
<p begin="00:00:18.007" end="00:00:21.500" style="s2">decubitus position to<br />reduce any lung artifact</p>
<p begin="00:00:21.500" end="00:00:24.866" style="s2">and to bring the heart closer<br />to the anterior chest wall.</p>
<p begin="00:00:24.866" end="00:00:27.393" style="s2">Place the transducer<br />at the third or fourth</p>
<p begin="00:00:27.393" end="00:00:31.262" style="s2">intercostal space immediately<br />left of the sternum.</p>
<p begin="00:00:31.262" end="00:00:34.455" style="s2">Move between the third and<br />fourth intercostal space</p>
<p begin="00:00:34.455" end="00:00:38.127" style="s2">and slide the transducer toward<br />and away from the sternum</p>
<p begin="00:00:38.127" end="00:00:40.961" style="s2">to identify the optimal scanning window.</p>
<p begin="00:00:40.961" end="00:00:43.757" style="s2">Assuming the short axis of<br />the heart to be positioned</p>
<p begin="00:00:43.757" end="00:00:45.991" style="s2">on a plane from the<br />patient's right shoulder</p>
<p begin="00:00:45.991" end="00:00:47.457" style="s2">to the left hip.</p>
<p begin="00:00:47.457" end="00:00:49.349" style="s2">Rotate the transducer to adjust</p>
<p begin="00:00:49.349" end="00:00:52.084" style="s2">for the body habitus of the patient.</p>
<p begin="00:00:52.084" end="00:00:54.458" style="s2">The orientation marker<br />will be at approximately</p>
<p begin="00:00:54.458" end="00:00:56.443" style="s2">the two o'clock position.</p>
<p begin="00:00:56.443" end="00:00:59.555" style="s2">As an alternative approach,<br />this exam may be performed</p>
<p begin="00:00:59.555" end="00:01:02.883" style="s2">using an abdomen exam type<br />with an orientation marker</p>
<p begin="00:01:02.883" end="00:01:05.400" style="s2">to the patient's left<br />side at approximately</p>
<p begin="00:01:05.400" end="00:01:07.650" style="s2">the eight o'clock position.</p>
<p begin="00:01:11.625" end="00:01:13.778" style="s2">The myocardium will appear gray</p>
<p begin="00:01:13.778" end="00:01:17.599" style="s2">and the blood-filled chambers<br />will appear hypoechoic.</p>
<p begin="00:01:17.599" end="00:01:20.165" style="s2">The left ventricle will<br />appear as a doughnut shape</p>
<p begin="00:01:20.165" end="00:01:21.924" style="s2">in the center of the image.</p>
<p begin="00:01:21.924" end="00:01:25.905" style="s2">The anterior, septal,<br />inferior, and posterior</p>
<p begin="00:01:25.905" end="00:01:29.304" style="s2">lateral walls of the<br />ventricle can be identified.</p>
<p begin="00:01:29.304" end="00:01:32.414" style="s2">The mitral valve will be<br />seen in cross section.</p>
<p begin="00:01:32.414" end="00:01:35.839" style="s2">From this position, the<br />transducer can be tilted upward</p>
<p begin="00:01:35.839" end="00:01:39.756" style="s2">to visualize the aortic<br />valve in cross section.</p>
<p begin="00:01:41.591" end="00:01:44.146" style="s2">End downward to visualize the myocardium</p>
<p begin="00:01:44.146" end="00:01:45.882" style="s2">of the left ventricle.</p>
<p begin="00:01:45.882" end="00:01:48.959" style="s2">Note the wall motion of<br />the myocardial segments</p>
<p begin="00:01:48.959" end="00:01:51.209" style="s2">and function of the valves.</p>