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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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Case Study Videos

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- [Voiceover] Welcome back to Soundbytes Ultrasound
teaching videos.
My name is Dr Phil Perera, and this video sequence
entitled The RUSH Exam Video Part 4,
we're gonna go further on to our exploration
of the Rapid Ultrasound in Shock
in the Critically Ill Patient, ultrasound algorithm.
In this video we'll focus on Part three,
evaluation of the pipes.
I'm also going to include evaluation for right ventricular
dilatation, really part of step one,
evaluation of the pump, that we did not go over earlier
in the video sequence.
Here in table one we see the four classic types
of shock, and the ultrasound findings associated
with each of these conditions.
We've covered step one, evaluation of the pump,
specifically looking for cardiac contractility,
and the presence of a pericardial effusion.
Now looking under the column of obstructive shock,
we see two conditions that we haven't covered prior,
and that we'll go over in this video.
Specifically, looking for, right ventricular strain
or cardiac thrombis, that may signal a massive pulmonary
emobolis, as the etiology for the patient's shock.
Now let's skip down to part three, evaluation of the pipes,
which will really be the main focus of this sequences.
And here, under hypovolemic shock, we're going to asses
both the thoracic and abdominal aorta for pathology,
specifically, dissection or aneurysm with rupture.
Under obstructive shock, if we do see
right ventricular thrombis, or right ventricular strain,
we may wanna switch probes and look for the presence
of a deep veious thrombosis, to correlate or corroborate
obstructive shock as the etiology
for the patient's condition.
Now let's learn how to analyze the relative cardiac
chamber sizes as a means of determining right ventricular
dilatation, and the possibility of a thrombo-embolic cause
for the patient's shock condition.
The normal left ventricular to right ventricular size
ratio should be one to zero point six,
meaning that the left ventricle should generally
be twice the size of the right ventricle.
In cases of acute pulmonary strain,
such as a massive pulmonary embolis,
as seen in the small image to the upper left,
the right ventricle will suddenly dilate,
and may be larger than the left ventricle,
as seen in the image.
In conditions of sudden right ventricular dilatation,
the RV wall will generally be thin,
measuring less than five millimeters,
and this needs to be differentiated from cases of
chronic pulmonary artery hypertension or strain,
where the right ventricle will have time to dilate,
as well as hypertrophy, and the wall will generally
be thicker than five millimeters.
Let's take a look at this video clip taken from
a patient who presented to the ED,
with a blood pressure of 70 over pul,
and a history of a recent hip replacement one week prior.
With a small indicator arrow,
I'm tracing the confines of the left ventricle.
Notice that the LV is relatively small in relation
to the gigantic RV, and there I'm showing the confines
of the RV with the indicator arrow.
This would indicate a massive pulmonary embolism
as a cause of the patient's shock,
and the need for acute therapy to correct this condition.
To put that last video clip into reference,
let's take a look at a normal parasternal long axis view
of the heart.
Here we see that the left ventricle is about twice
the size of the right ventricle,
which would be the normal relation between the two chambers.
Notice in the last video, the relation was almost reversed.
Here's another video clip taken from a hypotensive patient,
who had just gotten off a long plane flight,
and what we see here, is that the LV is very small
in relation to the RV, and notice the deflection
of the septum away from the RV with each heartbeat,
indicating relatively high pressures
within the right ventricle.
So this was an acute pulmonary embolis,
and the treatment here was going to be fibrinolysis.
We can now examine the heart in the parasternal short
axis view, by moving the probe 90 degrees clockwise.
Now we see the heart in cross section,
and notice that the chambers appear as cylinders end on.
We can see the gigantic right ventricle to the top
of the screen, and the much smaller left ventricle
is traced by the small indicator arrow.
Notice here that the septum is flattened,
and bows away from the right ventricle,
due to the relatively high pressures within the RV.
The LV almost takes on the appearance of a D-shaped
chamber, due to the flattening of the septum,
and the high pressures within the right ventricle.
A classic finding in a massive pulmonary embolis.
As we had mentioned earlier, we need to differentiate
right ventricular dilatation in acute causes such
as an acute pulmonary embolis, from a more chronic cause
such as primary pulmonary hypertension.
This was taken from a patient who had long standing
primary pulmonary hypertension,
and with the small indicator arrow,
I'm tracing the confines of the relatively large RV
in relation to the LV, and we can also see the thickening
of the RV wall greater than five millimeters.
This indicates a time for hypertrophy,
that would indicate more of a chronic condition.
We can also see a compensatory hypertrophy
of the papillary muscles within the right ventricle,
tethering the valve that is often seen with
primary pulmonary hypertension.
Now, swiveling the probe to a parasternal short axis view
in the same patient, we also see the findings
of the small LV in relation to the RV,
and the D-shaped chamber finding,
but notice that looking closer at the right ventricle,
we can again see the hypertrophic wall,
greater than five millimeters,
and again, the compensatory thickening of the papillary
muscles within the right ventricle,
often seen with primary pulmonary hypertension.
This video clip was taken from a patient
who presented to the emergency department with
unexplained tachycardia,
associated with periodic chest pain,
and shortness of breath.
This is a subxiphoid view of the heart,
and looking within the right atrium,
it looks like there's jellybeans bouncing around
within the chamber.
In actuality, this is thrombis, moving around
within the right atrium, very very concerning,
that this may pass out through the right ventricle
into the pulmonary system and cause
a massive pulmonary embolism.
While this is an unusual finding
to see a clot within the heart,
we may be able to see this as we look closer and closer
at the heart in patients presenting with unexplained
tachycardia and shock.
This is an apical view from the same patient.
Notice here we see the thrombis bouncing around
in the right atrium.
Notice that it actually passes out through the
right ventricle, into the right ventricle,
through the tricuspid valve, and then is pushed back
into the right atrium, and this was a very interesting case
and that this patient had relatively high pulmonary
arterial pressures, and a large amount of tricuspid
regurgitation, that pushed the thrombis back into
the right atrium.
Let's now move on to specifically look further at
step three of the rapid ultrasound in shock exam,
the evaluation of the pipes.
While in this illustration it looks like there's
many probes on the patient's body,
let's sequentially break this down.
Let's look first at probes positions A and B.
Probe position A is a suprasternal notch view,
in which we may be able to get a look at the
thoracic aorta, and the actual arch of the aorta,
looking specifically for aneurysm or dissection.
Position B is the classic parasternal view,
in which we can also get a glimpse of the thoracic aorta,
looking for dissection or aneurysm.
Probes positions C and D are the classic probe positions
for placement, to look for evaluation of abdominal
aortic aneurysm.
We can also see an intimal flap at times that may signal
a thoracic aortic dissection extending down
into the abdomen.
Now probes position E and F are the classic positions
for the DVT exam, and should be performed
if the patient has right ventricular dilatation
on bedside echo, and one has a high suspicion
for a thrombo-embolic cause of the patient's shock.
In this video clip we see a parasternal long axis view
of the heart.
Recall that we see the three chambers of the heart
from this view, the left atrium, the left ventricle,
and the right ventricle.
We see the aortic valve,
and the left ventricular outflow tract to the right
of the aortic valve.
Notice in this video clip that this aortic root
is relatively widened, and I'm tracing that
with a small indicator arrow.
Now a normal aortic root should measure no greater
than three point eight centimeters,
and a widened aortic root is suspicious for thoracic
aortic dissection, or aneurysm.
Here we're actually measuring the aortic root,
notice that it measures 4.74 centimeters.
And we can see there that this patient
has a thoracic aortic aneurysm.
Now we may be able to see an intimal flap here
within this region, which would indicate
a dissection as the etiology for the patient's shock.
In this video clip, taken from a patient with
Marfan Syndrome, and chest pain radiating to the back,
we see a very widened aortic root taken from the
parasternal long axis view.
This would indicate the possibility of a Stanford Class A
aortic dissection as a cause of the patient's shock.
Notice here, the very very widened aortic root,
and what looks like the possibility of an intimal flap.
Now an intimal flap may not always be seen
on transthoracic echo, but if one is very suspicious,
one can pursue a transesophageal echo or a CT scan
to further confirm this condition.
This patient actually was confirmed to have a
Stanford Class A aortic dissection requiring a stent.
This image of the aortic arch was taken from the
suprasternal notch view.
In this view the probe is placed directly into
the suprasternal notch, with the probe marker
oriented towards the patent's right side.
In relatively thin patients, it can be possible
to move the head to the side and to aim the probe
down into the chest to get a view of the aortic arch.
And here we can see the ascending aorta to the left,
the descending aorta to the right,
and the aortic arch right in the middle.
Notice we also see some of the branching vessels
coming off of the aortic arch, and this would be
normal anatomy, not consistent with dissection.
But occasionally we may be able to pick up an aortic
dissection or aneurysm, from the suprasternal notch view.
This video clip represents the suprasternal notch view
taken from the patient with Marfan syndrome
discussed earlier in the video sequence.
The first thing we notice right away is that this aortic
arch is much more dilated than the normal anatomy
shown prior, and with the small indicator arrow,
I'm showing the confines of the aortic arch.
Let's look closer within the aortic arch,
and right away we can see what looks like an intimal flap
moving around with each heartbeat.
So this patient was diagnosed with a Stanford Class A
aortic dissection, extending from the root,
through the arch, and down into the descending aorta.
The next step in the evaluation of the pipes
is performed through looking at the abdominal aorta.
The probe should be placed in positions C and D
as shown on the patient's abdomen,
with the probe in a short axis configuration.
Generally we'll begin with the probe high,
at position C, and move all the way down to D
to fully examine the aorta.
We're looking for an abdominal aortic aneurysm,
as signaled by a abdominal aorta greater than three
centimeters in diameter.
Now most AAAs will be fusiform in nature,
and also infrarenal.
Some may extend down into the iliac artery.
A minority of triple As will be saccular as shown
in the image over to the right, where we have
a small protrusion of the wall, out from the normal aorta.
This video clip demonstrates an abdominal aortic aneurysm,
in a patient who presented to the emergency department
with a hypotensive state and tachycardium.
Here we see a very large abdominal aortic aneurysm
in the short axis view.
Notice here we see a large amount of thrombis
along the walls of the aorta,
and recall that when measuring for an abdominal aortic
aneurysm, we need to measure the thrombis in addition
to the lumin.
That means we're going to measure from outer wall
to outer wall, not just the inner walls of the lumin.
And we can see the swirls of clot or pre-clot
within the lumin of the triple A.
Now to confirm that this is a triple A,
we can further go ahead and put a color power doppler,
or color flow doppler, onto this area,
just to confirm that there's flow within the lumin,
and that this is indeed a vascular structure.
We'll perform that in the next step here,
and by putting color power doppler there,
we can see that this is indeed a turbulent movement
of blood within the large abdominal aortic aneurysm.
So right away we have an etiology for the patient's shock,
and this is a patient who needs to go directly
to the operating room, and bypass the CT scan
in order to live.
This video clip was taken from a patient who presented
to the ED with hypotension accompanied by
chest, back, and abdominal pain.
Here we see a short axis view of the abdominal aorta.
First with the indicator arrow, I'll trace out the spine,
a landmark for the posterior aspect of the abdominal cavity.
Anterior to that, we'll notice the abdominal aorta,
and while it's not terribly large in size,
we see a positive finding in the lumin,
the presence of an intimal flap.
To the right there is the true lumin,
and to the left is the false lumin,
so what we see here is a thoracic dissection
that's extending down into the abdomen.
This actually turned out to be a class A dissection
that was extending from the root all the way down
into the abdominal cavity.
So occasionally we can actually pick up,
in the aortic dissection, on evaluation of the aorta,
on bedside ultrasound.
Here's a long axis view of the same patient,
notice we have the probe marker,
so that superior is to the left, inferior to the right.
Again we see the abdominal aorta stretch out
as a tubular structure across the screen,
and in the middle we see the presence of an intimal flap,
moving around with each heartbeat, again,
pathonomic for an aortic dissection.
The next step in part three, evaluation of the pipes,
once one has evaluated the major arterial circuit,
IE the thoracic and abdominal aorta for pathology,
is to examine the major venous circuit,
IE probes position E and F, looking for a pathology
within the venous circuit such as a massive DVT,
that could be the cause of a thrombo-embolic etiology
for shock.
And now while not every patient will need this examination,
I will go ahead and perform this exam in a patient
with a high pre-test probability for a thrombo-embolic
cause of shock, or right ventricular dilatation
seen on bedside echo.
This illustration shows the lower extremity venous anatomy.
Recall that the common femoral vein bifurcates into
the deep and superficial femoral veins.
Now the superficial femoral vein is the one
that continues on down the thigh,
and into the leg, and in fact has been renamed
the femoral vein of the thigh.
It will continue on into the back of the knee to
become the popliteal vein.
Now we can perform a two point compression examination,
looking for a DVT, by placing the probe into the area
of the small indicator arrow,
scanning from the common femoral vein down
to bifurcation, into the femoral vein of the thigh,
and the deep femoral vein.
We can then proceed all the way down to the popliteal vein,
placing the probe posteriorly, and compressing sequentially
from high within the popliteal fascia,
down to the area of trifurcation into the three calf veins.
Failure to compress would be indicative of a positive DVT.
This video clip illustrates normal compression of the
femoral vein.
At this level, we see the common femoral vein and artery.
We have the high frequency linear array probe
placed on a side to side configuration,
with the probe marker laterally oriented,
or towards the left.
Notice that the femoral vein towards the right or medial,
completely compresses with probe pressure,
indicating the absence of a DVT.
So this would be considered
a completely normal DVT examination, and in fact
we can see a little bit of the saphenous vein coming
off the top of the femoral vein.
Now we can use doppler to help us in identification
of the femoral vessels.
This would be a positive examination,
we can see the femoral artery with pulsations,
laterally or towards the left,
and towards the right or medial,
we actually see the femoral vein,
and notice the swirls of fresh clot
present within the vessel.
Now recall that we must go ahead and compress the vessel
to confirm a DVT, so that will be our next step,
but here again we see absence of flow within the
femoral vein, which is completely clotted off by a DVT.
Next we'll apply gentle probe pressure downwards,
with a high frequency linear array probe.
Notice we see failure of compression of the femoral vein,
and with the small indicator arrow I'm tracing the confines
of the femoral vein, again we can see the
echogenic debris of the DVT,
that's actually the saphenous coming off the top,
also involved with this DVT.
So a failure of compression of the femoral vein,
indicative of a positive DVT,
and in the right clinical scenario,
this could suggest a thrombo-embolic cause
for the patient's shock, especially if the patient
has right ventricular dilatation on bedside echo.
Continuing downwards, we'll look at the popliteal vein.
Now remember that the probe is placed posteriorly
into the popliteal fascia for this exam,
and gentle probe pressure is applied.
We can see that the artery is anterior to the vein,
and that the vein, which is posteriorly located,
completely compresses.
This would be a normal examination,
and we can see that the walls completely come together
with probe pressure.
This video clip illustrates a positive exam
for a popliteal vein thrombosis.
Recall again that the popliteal artery is located
anterior to the vein, and we can see here
that the popliteal vein with what looks like swirls
of echogenic material.
With a small indicator arrow, I'll show the confines
of the popliteal vein, and notice that with probe pressure,
that the vessel does not compress.
And in fact, with the small indicator arrow there
I can see a calf vein that's coming off the popliteal vein,
that's also filled with debris or DVT.
And we know that most DVTs occur within the calf,
and propagate upwards into the popliteal vein.
Now let's put all the information we've learned
in the various RUSH segments, into one unified
RUSH protocol, to help us in determining the etiology
for the patient's shock.
Let's begin by looking at hypovolemic shock.
In step one, evaluation of the pump, often heart will
be small in size and hypercontracting,
with the endocardial walls almost coming together
during sistole.
On evaluation of the tank, the inferior vena cava
may be small in size, with a large percentage change
during inspiration.
The internal jugular veins may also be small in size,
with a low closing column within the neck.
We may see the presence of peritoneal fluid,
or pleural fluid, indicating a hole within the tank.
In step three, evaluation of the pipes, one may see
an abdominal aortic aneurysm, which may be the cause
of hemorrhagic shock, causing the shock etiology
in this patient.
One may also see an intimal flap
indicating aortal dissection,
another cause of hemorrhagic shock within our patient.
Moving on to the next category, cardiogenic shock,
generally the heart will be dilated in size.
With systolic dysfunction,
the heart will be hypocontracting,
with a small percentage change from diastole through
to sistole.
On evaluation of the tank, the inferior vena cava
will often be large in size, greater than two centimeters,
with a small percentage change during inspiration.
The internal jugular vein will be distended as well,
with a high closing column within the neck.
One may see, on evaluation of the lung,
the positive lung rockets that we talked about,
or ultrasonic beelines indicating pulmonary edema.
Pleural effusion and ascites may also be seen
as a sign of tank overload.
On evaluation of the pipes, often this will be normal,
although occasionally a DVT may be seen in this
low flow state.
In obstructive shock, of which the first is,
pericardial effusion with cardiac tamponade,
we'll be looking specifically for a circumferential
pericardial effusion, with diastolic collapse
of the right atrium and or right ventricle,
indicative of cardiac tamponade.
In the other two types of obstructive shock,
a massive PE or a tension pneumothorax,
generally we will see a hypercontracting heart,
and recall that in cases of a massive PE,
we may see right ventricular dilatation,
and we may at times actually see thrombis within
the right atrium, and or right ventricle.
Moving on to the tank, the inferior vena cava
is usually distended in obstructive shock,
with a low percentage change from expiration
through to inspiration.
The internal jugular vein will also be distended,
with a high closing column within the neck.
Now if the patient has a tension pneumothorax,
we may be able to see absent lung sliding and
the absence of vertical comet tails.
Moving on to the evaluation of the pipes
in obstructive shock, we may be able to pick up
a positive DVT within the femoral or popliteal regions,
indicative of a thrombo-embolic etiology of the shock,
and a DVT that may have moved on into the heart
and into the lungs to cause a massive PE.
Last but not least, in distributive shock,
of which sepsis will be the most common,
in early septic shock, the heart is
generally hypercontracting, with the endocardial walls
almost touching during sistole.
Later in sepsis, the heart may fail,
and one can see a hypocontracting heart with
a small percentage change from diastole through to sistole.
On evaluation of the tank, in distributive shock,
generally the IVC will be normal or small,
less than two centimeters, with a high percentage change
during inspiration.
The internal jugular vein may also be normal or small,
with a low closing column within the neck.
In cases of sepsis due to empyema,
we may be able to pick up the presence of a septage
or a complicated pleural effusion.
And in cases of peritonitis, usually due to
spontaneous bacterial peritonitis in a liver patient,
we may see the presence of peritoneal fluid or ascites.
On the evaluation of the pipes in distributive shock,
generally this part can be omitted,
as this usually will be normal.
So in conclusion, the RUSH ultrasound protocol
can quickly help us at the bedside,
stratify a patient into one of the four categories
of shock, and immediately start the correct therapy
for the patient's shock state.
Now continuing on, we can use the RUSH exam
to monitor the patient's response to treatment
over time, and this is very important in cases
of hypovolemic shock or distributive shock,
where one can look at fluid loading at the response
of the inferior vena cava and internal jugular veins.
Hopefully they should become more plump,
and less distensible, with respirations,
as volume resuscitation continues.
This means that the RUSH exam can first identify
the patient's shock state, allowing for appropriate therapy,
and also very importantly can allow us to evaluate
the patient's response to therapy,
by looking at the response to fluid loading,
as we want to push up the central venous pressure
in cases of hypovolemic and distributive shock states.
So, I'm glad you could join me for the Soundbytes Videos,
and I look forward to seeing you in the future,
as Soundbytes continues.

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https://youtube.com/watch?v=9UyVHqvGgHE

Case: RUSH Exam Part 3

Read more about Case: RUSH Exam Part 3

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Series 3 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.

Applications

Cardiology

Media Library Type

Case Study Videos

Subtitles

- [Voiceover] Hello and welcome back
to Soundbytes ultrasound teaching videos.
My name is Dr. Phil Perera and in this video segment
termed RUSH Part 3, we're going to look specifically further
at the rapid ultrasound in shock
in the critically ill patient or the RUSH exam
focusing on evaluation of the tank or step two.
Now the RUSH exam is a three part examination
that begins with evaluation of the pump or cardiac status;
continues with part two, evaluation of the tank;
and finishes with part three, evaluation of the pipes.
In this video segment we're specifically gonna focus on
part two, evaluation of the tank.
Now this is a three part evaluation
beginning with part one, evaluation of tank volume;
continuing on to part two, evaluation of tank leakiness;
and concluding with part three, which is evaluation
for tank compromise.
So in this three-part evaluation
the first part, the evaluation of tank fullness
really means evaluation
of the patient's core vascular circuit for volume status
or central venous pressure.
This can be performed
through examination of the inferior vena cava
and alternatively with assessment
of the internal jugular veins.
Part two, evaluation for tank leakiness and overload
is performed through examination of the extended FAST exam
looking for free fluid in the abdominal and pelvic cavities
as well as in the thoracic cavity.
We can also employ lung ultrasound techniques
looking for pulmonary edema or ultrasound B-lines,
which can signify tank overload in the appropriate patient.
Last we'll conclude with evaluation for tank compromise
in which we'll again employ lung ultrasound techniques
to look for the presence of pneumothorax.
In a hypotensive patient with a positive pneumothorax,
this may signify a tension pneumothorax
requiring immediate decompression.
Here's a slide showing the probe positions
for evaluation of the tank.
Let's begin by looking at position A.
This is the best position
to evaluate the inferior vena cava
and we can look at the inferior vena cava
from the subxiphoid position
in both short and long axis views.
Probe positions B, C, and D
represent the appropriate positioning
of the ultrasound probe for investigation
of the extended FAST exam,
in which we can look for free fluid
within the abdominal and pelvic cavities
as well as within the thoracic cavities.
Finally, probe position E is the positioning of the probe
to look anteriorly on the chest for pulmonary edema
or ultrasonic B-lines.
Now let's learn how to evaluate the inferior vena cava
for assessment of central venous pressure.
First I place the probe
in the subxiphoid four chamber position
looking at the heart,
then I rotate the probe more posteriorly
down towards the spine to look at the IVC
as it runs from the right atrium down through the liver.
In this view the IVC will be seen as a cylinder
allowing us to get the full dimensions of the chamber.
The probe can be moved
slightly towards the patient's right side
to best image the IVC as it runs through the liver.
And one would like to follow the IVC
all the way down through the liver
towards the confluence of the hepatic veins
as the IVC should be measured just distal to this position
where the IVC and the hepatic veins join each other.
The next step is to visualize the IVC
in the long axis configuration
to corroborate the findings found on short axis view.
To do this the probe is swiveled with the IVC in sight
from a short axis view with the marker dot
oriented towards the patient's right to the long axis plane
with the probe in an up-and-down configuration
and the marker oriented upwards towards the ceiling.
In this way, the IVC will appear as a tubular structure
running up and down the screen with the superior aspect
towards the left and the inferior aspect
towards the right of the screen.
In this illustration we see a long axis configuration
of the IVC.
To determine the volume of the core vascular circuit
or the central venous pressure,
the IVC needs to be looked at
with regards to two specific variables.
The first is the absolute size of the IVC
and the second is the percentage change
from expiration to inspiration.
The IVC is measured at a point about two centimeters
distal to the confluence of the right atrium
at a point just inferior to the confluence
of the hepatic veins.
A small IVC that measures less than two centimeters
and that collapses greater than 50% with inspiration
or a sniff maneuver generally correlates
to a lower CVP less than 10 centimeters of water.
Conversely, a larger IVC greater than two centimeters
that collapses less than 50%
with inspiration or sniff maneuver
correlates to an elevated CVP above 10 centimeters of water.
In this way we can use analysis of the IVC
to get valuable information
about the patient's central venous pressure.
In this video clip we'll take a look at the IVC
in a short axis configuration
first aiming the probe
to a subxiphoid chamber view right there.
We see a positive pericardial effusion.
Now let's watch the IVC as it moves inferiorly
away from the right atrium through the liver
and we can see there the confluence of the hepatic veins.
Remember we wanna measure the absolute size
and the inspiratory collapse of the IVC
just distal to the hepatic veins.
And we can see there that the IVC is relatively small
and that it has a high percentage change
from expiration to inspiration.
We can use M-Mode ultrasound to graphically show
the changes in the IVC over time.
Here we notice that the IVC is 2.74 centimeters
at its widest diameter during expiration
but that it closes to 0.44 centimeters during inspiration.
And while we talked about the absolute size of the IVC
as being a predictor of CVP,
I actually think the percentage change
during respiratory variation is more important
as a predictor of CVP.
And in this patient we notice a greater than 50% change
indicating a relatively low CVP
less than 10 centimeters of water.
Now we'll swivel the probe to a long axis configuration
with the probe marker up towards the ceiling
and the probe aligned in an up-and-down configuration
across the patient's abdomen.
Superior to the left, inferior to the right
we see the IVC as a tubular structure.
Now noting the inspiratory changes of the IVC
we can see that the walls almost completely collapse
during inspiration
and with a small indicator arrow
I'll show the area where we should generally measure the IVC
that's two centimeters distal to the confluence of the IVC
to the right atrium just inferior
to the confluence of the hepatic veins with the IVC.
So a CVP less than 10 centimeters of water
with inspiratory collapse of the IVC.
We can again put M-Mode ultrasound over the IVC
to further graphically determine the general size
and respiratory dynamics of the IVC
and we can see that this is a smaller IVC
that measures 0.98 at expiration
and that almost completely closes,
in fact does close during inspiration
demonstrating a low CVP less than 10 centimeters of water.
Let's contrast those last video clips with this one.
Beginning with the heart in a subxiphoid four-chamber view
we see that this heart is not beating well.
As we aim the probe more inferiorly
down to image the IVC
as it moves inferiorly down through the liver
from the right atrium we can see that this IVC is very large
and that it has little inspiratory collapse.
In fact, we also see the three hepatic veins
are very engorged.
Notice we can also see little speckles of prethrombus
within the IVC indicating a low flow state.
Now we'll put M-Mode ultrasound directly over the IVC
in the short axis configuration.
Notice this IVC is relatively large at 2.52 centimeters
and then has very little change during inspiration.
We can also see the speckles of prethrombus
within the lumen of the IVC indicating a low flow state.
So this patient has a CVP
that's greater than 10 centimeters of water.
In fact, this tank is pretty full.
Now we'll swivel the probe to the long axis configuration
with the probe marker up towards the ceiling
and the probe aligned up and down on the patient's abdomen.
Superior here is towards the left of the screen
and inferior to the right.
With a small indicator arrow
I was just showing the engorged hepatic vein
entering into the IVC.
Recall that we wanna measure the IVC
just inferior to that point
where the hepatic vein enters into the vessel.
Here we see very little inspiratory collapse of the IVC
as well as a plethoric or dilated IVC
that indicates a high CVP
greater than 10 centimeters of water.
We can put that M-Mode cursor right along the IVC
just inferior to the confluence of the hepatic vein.
Again we see the IVC is dilated
greater than 2.46 centimeters but more importantly
notice here the small respiratory variation of the IVC
from expiration to inspiration
indicating an elevated CVP
greater than 10 centimeters of water.
Let's put all that information into play
in a real clinical case of a hypotensive patient.
This is a four-chamber subxiphoid view.
That's the right atrium, right ventricle, left ventricle,
and left atrium.
Here we see a large circumferential
dark anechoic pericardial effusion surrounding the heart.
So what we'll do is we'll duck the probe inferiorly
down towards the spine looking at the IVC
as it moves away from the right atrium into the liver.
Here we see the IVC as it emerges from the right atrium.
Notice here that this IVC has little respiratory collapse
and that it's relatively large in size
and we can see the dilated hepatic veins
joining into the IVC.
In the presence of a significant pericardial effusion,
this is concerning for potential early tamponade physiology
as one sees an elevation of the CVP as tamponade progresses.
We'll confirm those findings by swiveling the probe
to the long axis configuration superior to the left,
inferior to the right.
Again, we see the heart with a large pericardial effusion.
Notice here we see the IVC that's relatively distended
or plethoric greater than two centimeters
just distal to that hepatic vein
and notice the little respiratory collapse
of the IVC with inspiration
indicating a relatively high CVP
and the potential for early tamponade physiology
in this patient.
There may be times where visualization
of the inferior vena cava can be limited by gas
or fluid-filled intestine or stomach.
In these cases, visualization of the internal jugular veins
can act as an alternate measure
for assessing central venous pressure.
In this examination,
the head of the bed is placed upwards 30 degrees
and a high-frequency linear array probe is placed
tangentially or in a short axis view
across the internal jugular vein.
Here we see a plethoric or distended internal jugular vein
that has little inspiratory collapse
indicating a relatively high CVP.
This ultrasonic assessment of jugular venous distension
or CVP can be confirmed by using the probe
in a long axis configuration with the probe up and down
along the neck in the plane of the internal jugular vein.
I like to have the probe marker upwards
towards the patient's head
and here we can see the internal jugular vein is distended
all the way from low just above the clavicle to high,
all the way just below the mandible
indicating jugular venous distension on ultrasound
or a relatively high central venous pressure.
Now let's take a look at the jugular vein
in a patient who presented
with hypovolemic hypotensive shock.
We see here the probe is in a short axis configuration
across the internal jugular vein
and we notice a very small IJ vein
that almost completely collapses during inspiration
indicating a relatively low CVP
and the need for immediate resuscitation with IV fluids.
We can corroborate those findings
by moving the probe to a long axis configuration
with the probe marker up towards the patient's head.
We see the carotid artery deep to the internal jugular vein
and we see the closing level of the IJ vein
low within the neck.
Again corroborating a low CVP
less than 10 centimeters of water
and the need for immediate resuscitation
with intravenous fluids in this hypovolemic patient.
Step two in the assessment of the tank
is to look for tank leakiness or overload.
This is performed by using the extended FAST exam
putting the probe into positions two, three, and four,
the right upper quadrant, left upper quadrant,
and suprapubic views.
This will determine the presence of free fluid
within the abdominal, pelvic, and thoracic cavities.
While the RUSH exam is not specifically designed
for the evaluation of the trauma patient,
occasionally a patient may present
as a delayed presentation of trauma
or after occult trauma with this positive finding.
In this situation, a surgical consultation
and operative repair for an injury to an internal ogran
may be indicated.
In this view we have a positive right upper quadrant exam
with free fluid in Morison's pouch.
Now in the non-trauma patient, this could indicate
failure of the heart, liver, or kidneys
as contributing pathology
to the patient's physiological state.
Now the patient with a fever on this finding,
this would indicate the possibility
of spontaneous bacterial peritonitis
and the need for paracentesis
to obtain cultures of the fluid.
By angling the ultrasound probe
above the right upper quadrant and left upper quadrant views
we can actually look above the diaphragm
to look for the presence of positive free fluid
within the thoracic cavities.
Here we have a positive examination
from left upper quadrant view,
the small arrow indicating the presence of free fluid
within the left thoracic cavity.
We can see the spleen to the right or inferior
and we can see the lung waiving around superior
or towards the left.
In the non-trauma patient
this could show the possibility
of lung, kidney, or heart failure
as an exacerbating condition to the patient's pathology
and the patient with a presentation of occult trauma
or delayed presentation of trauma,
this could indicate a hemithorax needing urgent treatment.
Lung ultrasound applications
have become increasingly important in the assessment
of the hypotensive patient or the patient with dyspnea.
In this examination, which is still part of part two,
assessment of the tank looking for tank leakiness
or tank overload, we use the three megahertz probe
to examine the pleura by placing the probe
both anteriorly and laterally on the chest.
This would be a normal examination
and we can see the pleural line moving back and forth
towards the top of the screen.
We note here the presence of multiple A-lines,
those horizontal reverberating lines
coming off of the pleura at regular intervals
that are indicative of normal lung.
In contrast, let's take a look at this video clip
taken from a patient
who presented with acute pulmonary edema.
Here we see the pleural line
as taken with a three megahertz lower frequency probe
and instead of those repeating horizontal lines
the A-lines that we saw in normal lung
now we see the development of these vertical lines
known as lung rockets.
And here we see the lung rockets
emanating all the way to the back of the screen
using the three megahertz probe.
Lung rockets are also known as ultrasonic B-lines
and these indicate fluid within the alveoli.
Now, if the B-lines are seen
in multiple areas of the lung bilaterally,
this is more consistent with acute pulmonary edema.
As pulmonary edema progresses,
we can see the development
of more and more ultrasonic B-lines or vertical lung rockets
showing a worsening of the pulmonary edema.
In this situation we almost see a complete lung whiteout
with multiple rays coming off of the pleural line
showing the development of multiple lung rockets
within one ultrasound field.
Now while the presence of ultrasonic B-lines
are indicative of a syndrome
known as alveolar interstitial syndrome or AIS,
which just shows the presence of positive fluid
within the alveoli,
if this is diffuse on both sides of the chest
this is more indicative of pulmonary edema
and the presence of tank overload.
The final step in evaluation of the tank
is to look for tank compromise
or the presence of a tension pneumothorax
requiring emergent decompression.
We see the positive lung findings on the right
with a 10 megahertz probe, we see the lung sliding
as the patient breathes the lung moves back and forth.
We can see the opposed parietal and visceral pleura
with positive vertical comet tails and sliding.
To the left we see a positive pneumothorax
and notice here we see the stationary parietal pleura,
which shows no sliding back and forth.
We also see the absence
of the vertical comet tail artifacts.
In the hypotensive patient
these findings may necessitate emergent decompression
with the needle or chest tube.
So in conclusion, thank you for joining me
for part two, Assessment of the Tank of the RUSH Protocol.
As we described, this is a three-part evaluation
beginning with part one, evaluation of tank fullness,
which as we described is an examination
of the inferior vena cava and internal jugular veins
to assess central venous pressure.
Part two, evaluation for tank leakiness
and overload is performed by the extended FAST exam
to look for free fluid within the abdomen and pelvis
as well as to look for the presence of ultrasonic B-lines
indicative of pulmonary edema.
The last part of the tank assessment
is to look for tank compromise
or the presence of a tension pneumothorax
indicated by the lack of lung sliding
and the lack of positive comet tail artifacts.
Now we can begin to use the RUSH protocol
to assist in the evaluation of the hypotensive patient
to allow us to figure out which type of shock
the patient is suffering from.
Let's take a look at this table
with regard to beginning with hypovolemic shock to the left.
On assessment of the pump,
the heart may be small in size and hypercontracting.
On evaluation of the tank, the inferior vena cava
and internal jugular veins may be small in size
with a large percentage change
from expiration through to inspiration.
In a patient who has an occult trauma
or delayed presentation of trauma
we may actually see positive free fluid
in the peritoneal cavity or within the pleural cavity
indicative of blood.
In the second type of shock, cardiogenic,
we may see a dilated heart which is hypocontracting.
The IVC and internal jugular veins may be distended
with a small percentage change from expiration
through to inspiration.
Also, we may see pulmonary edema
as evidenced by the presence of multiple lung rockets
and it's not uncommon for us to visualize
a pleural effusion or ascites in these patients.
In the presence of obstructive shock
of which we think of the three main categories
being one, cardiac tamponade;
two, massive pulmonary embolus;
and three, tension pneumothorax,
generally on assessment of the pump
we're gonna see a hypercontracting heart.
In the presence of cardiac tamponade
we're gonna look for the presence of pericardial effusion
and diastolic collapse of the right ventricle
and or right atrium.
Now we'll discuss the findings of a large pulmonary embolus
in an upcoming video,
but generally we're looking for dilatation
of the right side of the heart
and we may be able to visualize a cardiac thrombus.
On assessment of the tank
and the different types of obstructive shock
we generally will see a distended
and large inferior vena cava and internal jugular veins
with little respiratory collapse.
In the presence of a tension pneumothorax
we can see absent lung sliding
and absent vertical comet tail artifacts
requiring emergent decompression.
In the last category of shock,
distributive, of which sepsis will be the main cause,
on evaluation of the pump in early sepsis
we'll generally see a hypercontracting heart.
As sepsis continues we may see a component
of cardiac failure and hypocontraction.
On evaluation of the tank,
the IVC and internal jugular veins
will generally be small in size
with the large comparative change
during the respiratory phases.
We may be able to see the presence of peritoneal fluid
indicating a spontaneous bacterial peritonitis,
especially in liver patients,
and we may also be able to see pleural fluid
indicated in empyema
and the appropriate patients requiring drainage.
So, now we can see how we can use
all of the assessment that we've learned
in the evaluation of the pump and the tank
to stratify the different types of shock accordingly
with the ultrasound findings.
So I look forward to seeing you back in the future
as the RUSH series continues with part three
Evaluation of the Pipes.

Brightcove ID

5754395503001

https://youtube.com/watch?v=oXiIU4mx-H8

Case: RUSH Exam Part 2

Read more about Case: RUSH Exam Part 2

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Series 2 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.

Applications

Cardiology

Clinical Specialties

Cardiology

Media Library Type

Case Study Videos

Subtitles

- [Voiceover] Welcome back to SoundBytes Ultrasound.
My name is Dr. Phil Perera
and in this video we're going to look further
onto the Rapid Ultrasound in Shock examination
or the RUSH evaluation,
specifically examining part one,
evaluation of the pump or evaluation of cardiac status
in hypotensive patient.
In the last video I showed this table,
which encompasses a lot of information.
However let's focus on line one.
We can see here how evaluation of the pump
can further assess which type of shock our patient has
by seeing characteristic findings of the heart
within the four categories of shock.
Hopefully we'll begin to make more sense of this table
by moving through this first video.
Step one, evaluation of the pump,
encompasses three main elements,
the first of which is to examine the heart
for the presence of a pericardial effusion.
If a pericardial effusion is seen,
to further evaluate the heart
for potential cardiac tamponade
requiring pericardiocentesis.
Step number two would be to evaluate the left ventricle
for contractility as an assessment of how much fluid
this heart can handle.
Part three would be assessment of the heart
for right ventricular strain,
which in the right clinical context
may signify a massive pulmonary embolis
as the etiology for hypotension.
For the evaluation of the pump or cardiac evaluation,
we're going to utilize the three main cardiac windows.
Here we see the first major one, probe position A,
which is the parasternal window onto the heart.
In this window there's two main views,
the parasternal long and short axis views of the heart.
We can also move the probe further inferiorly
to the subxiphoid position that is shown
in probe position B
where we can see the heart from the more inferior aspect.
We can then move the probe more laterally
to probe position C, the apical window onto the heart,
where there's several views that can be used here
to evaluate the heart from a more lateral orientation.
Let's review how to perform the cardiac evaluation
by beginning with the parasternal long axis view
of the heart.
Here we want to use a smaller footprint phased array probe
that can easily fit in between the ribs
to get a good view onto the heart.
We'll generally begin in intercostal space 3 or 4
with the marker dot on the probe
down towards the patient's left elbow.
That's with a caveat that the ultrasound screen indicator
is maintained toward the left of the screen.
Now moving the patient into left lateral decubitus position
may aid in assessment of the heart,
as it moves the heart closer to the chest wall
and may give you a better view
if it's difficult to see the heart initially
with the patient supine.
Here is the anatomy of the heart that we'll see
from the parasternal long axis view.
Notice that the right ventricle
will be the most superficial chamber,
and just deep and to the left of the right ventricle
we'll see the left ventricle.
We also see the left atrium
to the right of the left ventricle,
and the mitral valve in between the two chambers.
Now to the right of the left ventricle
we'll see the aortic valve,
and to the right of the aortic valve
we'll see a small part of the left ventricular
outflow tract.
Here's a video of the parasternal long axis view
of the heart in action.
Again, we'll remember the right ventricle
as the most superficial chamber
and deep to the right ventricle, the left ventricle.
We see here the left atrium
to the right of the left ventricle,
and notice the mitral valve flipping up and down
in between the left atrium and the left ventricle.
We also see the aortic valve there
to the right of the left ventricle,
and another very important structure to look for
on the parasternal long axis of the heart
is the descending aorta,
which would be a cylinder in cross section
just posterior to the left atrium.
That will define the posterior pericardial reflection,
which we can see here with a small indicator arrow.
This is very important when we try to determine
if fluid around the heart is pericardial or pleural,
as we'll go through in some upcoming videos.
This illustration reinforces the difference
between pericardial and pleural effusion
from the parasternal long axis view.
In the image to the left,
I'm first showing the descending aorta,
that cylinder seen in cross section
just posterior to the mitral valve.
Notice the posterior pericardial reflection,
that white line that comes off
just anterior to the descending aorta.
In this case we see fluid,
but notice that it layers out anterior to
the descending aorta and posterior pericardial reflection,
and therefore it's within the pericardial sac.
That's to be differentiated from the image to the right,
where we again identify the descending aorta
and the posterior pericardial reflection.
Notice here that the fluid is posterior to both,
and therefore within the pleural cavity.
Those are some very important landmarks to identify
when trying to figure out if fluid is pericardial
versus pleural.
Next we'll take a look at a video.
Here again we'll begin by identifying
the posterior pericardial reflection
and the descending aorta.
Notice the descending aorta,
seen just posterior to the left atrium,
and the white line that is the pericardium,
or the posterior pericardial reflection.
I'll identify that with a small indicator arrow,
first tracing the descending aorta
and next the posterior pericardial reflection.
Now we see anechoic or dark fluid around the heart here,
but notice that it's anterior to both the descending aorta
and the posterior pericardial reflection,
and therefore it's within the pericardial sac.
In fact here we can see some fluid anterior to the heart
as well as posterior.
Now let's take a look at another video,
first identifying the descending aorta
and posterior pericardial reflection.
We'll look at those with a small indicator arrow,
again identifying the descending aorta
and the posterior pericardial reflection.
Here we see a large amount of anechoic or dark fluid,
but notice here it's posterior to both the descending aorta
and the posterior pericardial reflection.
In this case this is a pleural effusion
and not pericardial.
Notice we can also see lung moving back and forth
as the patient breathes within the pleural effusion.
Now that we've learned how to determine
if fluid is pericardial versus pleural,
let's look at this video clip.
We'll first identify that descending aorta
and posterior pericardial reflection,
and we see that this fluid is anterior to both
and therefore pericardial.
The next step would be to look at the right side
of the heart, in this case the right ventricle,
for diastolic deflection that could indicate
early tamponade physiology.
We can see here that there's fluid
both anterior and posterior to the heart,
and we notice the serpentine deflection
of the right ventricle
that is worrisome for early tamponade physiology,
and in fact this patient's blood pressure
was noted to be decreasing on serial evaluations.
The next step in pump evaluation or cardiac evaluation
is to determine contractility of the left ventricle.
Here we see the three main chambers
as seen from the parasternal long axis view of the heart,
the right ventricle, left atrium,
and as shown by the small indicator arrow,
the left ventricle.
Notice that during systole,
the endocardial walls of this left ventricle
almost close down completely,
indicating excellent contractility.
We can also see that the anterior leaflet
of the mitral valve flips open
and almost slaps up against the septum with each heartbeat,
indicating again good contractility of the left ventricle.
If this patient was hypotensive,
we could actually give this patient quite a lot of fluid
before putting the patient into pulmonary edema.
We can further investigate contractility
by calculating fractional shortening of the left ventricle.
This is commonly done by using M-mode ultrasound
and placing the cursor across the left ventricle
from the parasternal long axis view.
Here we see the tracings of the right ventricle,
the septum as shown with a small indicator arrow,
and now the posterior wall.
Here we see the chamber size and maximum
of the left ventricle during diastole
and there is systole.
We can calculate end-diastolic diameter,
which is shown here by caliper A
and measured at 2.96 centimeters of the left ventricle.
We can also measure end-systolic diameter
of the left ventricle as shown by caliper B
at 1.0 centimeters.
To calculate fractional shortening,
what we take is a difference between end-diastolic diameter
and end-systolic diameter
over end-diastolic diameter.
That gives us here a fractional shortening of 62%.
Anything above 35% to 40% is considered normal
and in this case we would gauge excellent contractility,
as judged by a calculation of fractional shortening.
Now let's take a look at another patient
who came into the emergency department
with a low blood pressure of 80 over palp.
Here we see the three main chambers
from the parasternal long axis view,
and notice the very poor contractility
of the left ventricle.
We can see that the endocardial walls move little
from diastole through to systole,
and we can further see that there's little motion
of the mitral valve.
This indicates poor blood flow
between the left atrium and left ventricle,
corroborating a low contractility status.
In this patient we're going to have to be careful
about the amount of fluid loading,
as this patient may easily go into pulmonary edema.
We can calculate the fractional shortening
of this hypocontractile heart
by placing the M-mode cursor across the left ventricle,
and we see A, end-systolic diameter of 3.78.
We can also look at the widest diameter as B,
end-diastolic diameter,
which is calculated at 5.17 centimeters.
Therefore this fractional shortening is much decreased
at 27%.
Let's move on to discuss the parasternal short axis view
of the heart.
A pearl here is not to take the probe off of the chest
once you've obtained the parasternal long axis
view of the heart.
Simply rotate the probe 90 degrees clockwise,
so now the indicator dot on the probe
is down toward the patient's right hip.
That's with the caveat that the ultrasound screen
indicator dot is positioned to the left of the screen.
Again moving the patient into left lateral
decubitus position may help imaging
from this parasternal short axis view.
From the parasternal short axis view of the heart,
we'll be imaging the heart in cross section.
Therefore we'll see the left ventricle in cross section
as a cylinder to the bottom right of the image
and the right ventricle to the upper left.
Let's now look at a video of the parasternal short axis
view of the heart.
We can again see that the left ventricle
would be the prominent chamber, cut in cross section.
Here we can actually see the mitral valve
moving up and down through each heartbeat.
Notice again the good contractility of this left ventricle.
All the walls come in well from diastole through systole.
If this was a patient in shock,
we can go ahead and give plenty of fluids
before starting the patient on pressors.
Next let's take a look at another heart.
Here we see a patient who came into the emergency department
with a blood pressure of 70 over palp
and a fast heart rate.
We can notice that the left ventricle
is very hyperdynamic,
meaning that it's almost completely squeezing down
during systole and also tachycardic.
This is usually seen in a septic or hypovolemic condition,
indicating that this is a heart that's begging for fluids.
The right action would be to fluid load in this patient.
In this video clip we see another finding.
We see behind the left ventricle
an anechoic or dark fluid collection surrounding the heart.
I'll show that with a small indicator arrow.
This is a pericardial effusion
circumferentially surrounding the heart here.
Notice that it layers out behind the left ventricle
and right ventricle.
Let's now take another look at a parasternal short axis view
of the heart in hypotensive patient.
Here we see very poor contractility of the left ventricle,
as shown here with the small indicator walls
by very little endocardial movement
from diastole through to systole.
Also notice the very poor movement or little movements
of the mitral valve during the cardiac cycle.
This is a pump in jeopardy
and one which we want to be careful
about the amount of fluids that we give
during a resuscitation.
We can also put M-mode ultrasound
directly across the left ventricle in short axis,
again looking at the change from end-diastole
through end-systole,
just getting a fractional shortening
and again confirming very poor contractility
or poor function of the cardiac pump.
The next cardiac imaging window that we'll discuss
is the subxiphoid.
Here the probe is placed under the xiphoid tip
of the sternum,
aiming the probe down and up towards the left shoulder.
Now we want to keep the marker dot on the probe
towards the right side of the patient
with the caveat that the ultrasound screen indicator
is positioned to the left of the screen.
From this view, we're looking from an inferior position
up towards the heart,
and we're going to see the liver as our acoustic window
onto the heart,
and the right side of the heart closer to the probe.
We'll see the right ventricle and right atrium
close to the probe,
and further away the left ventricle and left atrium.
We can also see the tricuspid and mitral valves
from this view.
Here's a video clip of a heart
taken from the subxiphoid window.
We recall that the liver is our acoustic window
from this view and we see the right side chambers,
superficial and to the top of the screen.
We see the right ventricle and the right atrium
with the tricuspid valve flipping up and down
in between the two chambers.
We see the left ventricle
and with a small indicator arrow there,
I'm showing the poor contractility of this left ventricle.
Notice the poor percentage change
through from diastole through to systole.
We see the left atrium to the left of the left ventricle
and the mitral valve.
Now with a small indicator arrow,
I'm now tracing the posterior pericardial reflection
around the heart,
and there is the anterior pericardial reflection.
We can call these also near field and far field
pericardial reflections as well.
Notice here that there's no fluid
within the pericardial sac.
In this case we would not have to perform
a pericardiocentesis,
but we notice that the contractility of this left ventricle
is compromised.
Here's another subxiphoid view of the heart
taken from a hypotensive patient.
Right away we notice a positive finding.
We see the right ventricle anterior
and the left ventricle posterior,
and we see here an anechoic or dark fluid collection
layering out around the heart circumferentially.
With a small indicator arrow,
I'm showing the near field pericardium
and fluid directly underneath that
surrounding the heart,
and also around the posterior aspect of the heart
just above the posterior pericardial reflection.
In this case we have a pretty large circumferential
pericardial effusion present.
Once we document a pericardial effusion,
we want to look for the motion of the right side
of the heart to look for diastolic deflection.
Here's normal motion of the heart,
even in the presence of a pericardial effusion.
To the left we see systole with all of the chambers small
and diastole to the right,
and we can see full expansion of both the right atrium
and the right ventricle.
Even though this patient has a pericardial effusion,
we're failing to see secondary signs of cardiac tamponade
as evidenced by either compression of the right atrium
or the right ventricle during diastole.
This illustration demonstrates diastolic compression
of the right ventricle that occurs
during cardiac tamponade physiology.
In the image to the left we see normal systole
with all of the chambers small,
and to the right we see diastolic compression
of the right ventricle,
meaning that the right ventricle never fully expands
during diastole.
Now cardiac tamponade physiology
will first affect the right side of the heart
because of the relatively lower pressure system
as reference to the left side of the heart.
In this video clip taken from a patient
who had declining blood pressures on serial evaluations
in the emergency department,
we first identify a pericardial effusion
from the subxiphoid view.
Looking closer at the right ventricle,
we see a deflection of the RV during diastole.
Now while not completely compressed in,
this early diastolic deflection
is concerning for early tamponade physiology,
and indeed this patient went on to full tamponade physiology
with time requiring a pericardiocentesis.
Again it's going to be a spectrum of findings of the RV
from early diastolic deflection on to full compression.
Here we can see the findings of the right atrium
as it attempts to compensate
during early tamponade physiology.
Notice in this right atrium,
we can see a furious right atrium that's contracting
at a very, very high rate
to push the blood into the right ventricle
and out the pulmonary system
due to the higher pressures
within the right side of the heart.
I've noticed this as a finding that I see
quite frequently in early tamponade physiology,
and I'd like to categorize this as a furious right atrium.
Here's a case of a patient who presented with breast cancer
and increasing shortness of breath,
and came to the emergency department tachycardic,
diaphoretic, and hypotensive.
From the subxiphoid window,
right away we determined that a large
circumferential pericardial effusion is present,
and on closer inspection of the right ventricle
we can see that it's completely compressed in
by the high pressure within the pericardial sac,
indicating full on tamponade physiology.
As we talked about, there is a spectrum
from early diastolic deflection onto this finding
where the RV is completely compressed in.
This patient needed an emergent pericardiocentesis
in the emergency department.
The last window of the heart that I want to discuss
is one of the most important.
That is the apical window of the heart.
Here the probe is placed under the left nipple
at the point of maximal impulse of the heart.
It really helps to have the patient
in the left lateral decubitus position
to bring the heart closer to the chest wall
to get better imaging from this position.
The probe indicator dot will be maintained
towards the patient's right side
with the caveat that the ultrasound screen indicator dot
will be positioned to the left.
This is the cardiac anatomy as seen from the apical window.
Note that the probe is much closer to the ventricles,
therefore the left ventricle will be to the right
of the screen and superficial,
the right ventricle to the left and superficial,
and the atrium further away.
From this view we can also see the mitral
and tricuspid valves.
One of the benefits of the apical view of the heart
is that we see all four chambers of the heart
in relation to one another.
Here's a video clip showing the apical cardiac window.
Notice we have the left ventricle to the upper right,
the right ventricle to the left,
and the atrium further away.
Here we see the small indicator arrow
showing the endocardial walls of the left ventricle,
and notice that they have a high percentage change
from diastole through to systole.
This indicates good contractility,
and if this patient was in shock
this heart could take quite a lot of fluid
before going into pulmonary edema.
Good contractility from the apical cardiac window.
Let's contrast that last video clip with this one.
Here we see an apical four chamber view.
Again we see the left ventricle to the right,
the right ventricle to the left.
Here we notice the very poor percentage change
from diastole through to systole of the left ventricle.
Very poor contractility of this left ventricle,
and in this shock patient we'd have to be careful
about the amount of fluids that is given prior to pressors,
as we don't want to throw the patient
into pulmonary edema.
Here's an illustration showing what will happen
with a pericardial effusion and cardiac tamponade
from the apical view of the heart,
look specifically at the right atrium.
To the left we see systole
and we see all chambers compressed in
during the cycle of systole.
To the right we see diastole
and notice the normal change of the chambers
from systole to diastole as they normally expand.
We see the right atrium completely expanded.
Now in this view, that is significant for cardiac tamponade,
we note the right atrium is deflected in during diastole,
showing high relative pressures within the pericardial sac,
pressing in on the right atrium during diastole.
Diastolic collapse of the right atrium
is one of the findings to look for in cardiac tamponade.
Frankly I look for right ventricular collapse first,
and that's a more sensitive finding,
but right atrial collapse during diastole
is another finding that's commonly quoted.
Here we see a very large cardiac effusion
or pericardial effusion as noted from the apical view.
I'm tracing that with the small indicator arrow.
We see the large anechoic fluid stripe
around the right atrium.
Notice this right atrium is again taking on the appearance
of a furious atrium
as it compresses almost completely in during systole
to push the blood into the right ventricle.
I call your attention to the dyssynchronous movements
for the right ventricle and the right atrium.
What we notice here is that there's a little bit
of asynchrony between the two chambers,
indicating early tamponade physiology.
This was manifested by a patient who had
relatively decreasing blood pressures
in the emergency department.
In conclusion the Rapid Ultrasound in Shock or RUSH protocol
was formulated as a noninvasive means using ultrasound
to assess the physiology of the patient in shock.
In this video we've covered step one,
evaluation of the pump or cardiac evaluation,
looking at three main categories.
Step one was examination for pericardial effusion
and potential cardiac tamponade.
We spoke about the fact that we're going to be looking for
diastolic deflection of the right atrium,
or more specifically the right ventricle
as signs of cardiac tamponade.
Step two, evaluation of left ventricular contractility
was seen as a visual calculation of the change
of the endocardial walls from diastole
through to systole.
We also spoke about how we can calculate
using M-mode ultrasound a fractional shortening,
and we reinforced that a normal shortening
should be above 35% to 40%.
Step number three, evaluation of the right ventricle
for dilatation,
we're going to defer to part three,
evaluation of the pipes,
as it best fits in with evaluation
of pulmonary embolis and DVT.
Returning to the table outlining the findings
in the RUSH protocol,
we'll look specifically at step one,
evaluation of the pump.
In hypovolemic shock, the findings that we'll be looking for
are hypercontractile heart with small chamber size.
In cardiogenic shock, we'll be looking for
a hypocontractile heart that may be dilated in size,
especially if there is systolic dysfunction.
With obstructive shock, we'll be looking for
generally a hypercontractile heart
and we may see a pericardial effusion
with signs of cardiac tamponade
as we've talked about in this video.
We'll go further in video number four
to talk about the findings of RV strain
and cardiac thrombus that may be seen
with pulmonary embolis.
In distributive shock, usually sepsis,
we'll see a hypercontractile heart early,
and as sepsis continues we may see a failing heart
with decreased contractility.
I'm glad I could cover part one of the RUSH exam,
evaluation of the pump, in this video module.
I hope to see you back as SoundBytes continues
as we move forward to look specifically at part two,
evaluation of the tank,
and part three, evaluation of the pipes
in the RUSH protocol.

Brightcove ID

5754394219001

https://www.youtube.com/watch?v=IjmF-132sHA

Case: RUSH Exam Part 1

Read more about Case: RUSH Exam Part 1

/sites/default/files/201409_RUSH_Exam_Part_1_EDU00997_sonoaccess_thumbnail.jpg

Series 1 of 4, This video represents a comprehensive algorithm for the integration 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.

Applications

Cardiology

Media Library Type

Case Study Videos

Subtitles

- [Phil] Hello, and welcome back to Soundbytes Ultrasound.
My name is Dr. Phil Perera and in this video module
we're going to cover an advanced application of ultrasound.
That of the RUSH Exam which stands for Rapid Ultrasound
in Shock in the Critically Ill Patient.
This module will be video part one,
and will cover how the RUSH exam,
a series of ultrasound applications,
can be combined into one whole protocol
for the assessment of the patient in shock.
Let's begin with a clinical case
that outlines the power of the RUSH exam.
Here we have a 67 year old male presenting via paramedics
for acute shortness of breath for several hours.
The medics phone ahead with the vital signs,
and they have a blood pressure of 90 over palp,
a heart rate of 120, and a respiratory rate of 32.
They're calling ahead for notification because the patient
appears to be in severe respiratory distress.
The patient has a significant past medical history
significant for COPD, congestive heart failure,
and hypertension on multiple medications.
He states that his baseline blood pressure
runs about 160 to 170 systolic
and that he has been compliant
with his blood pressure medications
making the blood pressure of 90 over palp
a big change from his baseline.
As the patient arrives into the emergency department
he's immediately placed into the resuscitation area
and the vital signs are reconfirmed
showing significant hypotension
as well as a low grade fever and hypoxia.
The patient is talking to you,
but does appear to be in respiratory distress.
On lung exam he has diffuse expiratory wheezing
and inspiratory rales at the bases,
and edema is present in the lower extremities.
So the question for you
is how best to proceed at this point?
Well most of us would order a portable chest x-ray,
an EKG, and some baseline labs.
Here's the patients chest x-ray and it's read as
no acute infiltrate, effusion, no pneumothorax,
the heart size was seen as normal, and notice here
there's no real evidence here for pulmonary edema,
i.e. no real infiltrate or sephilization.
The patient's vital signs clearly indicate
an advanced type of shock
and the clinical question here is what type of shock
is this patient suffering from
and what is the best treatment option for the patient?
Could he have: A. Distributive shock
of which sepsis would be the most common
B. Cardiogenic shock
C. Hypovolemic or hemmorhagic shock,
or D. An obstructive kind of shock
of which the three main causes,
cardiac tamponade, pulmonary embolus,
or tension pneumothorax must be considered.
Thus in the resuscitation area it's a little unclear
as to which type of shock our patient is suffering from
as he has elements in his physical exam and his evaluation
that overlap between the four different types of shock
as detailed here.
In the past it would have been relatively easier
to figure out which type of shock
this patient was suffering from by placement
of an invasive pulmonary artery catheter
or a Swan-Ganz catheter.
This was commonly done when I was training
in internal medicine back in the 90s
and gave an amazing amount of physiological detail
with regard to the patient's state.
Unfortunately multiple studies looking at these PA catheters
found an increased rate of complications
and no improvement in overall morbidity or mortality
of these patients.
Thus their use has drastically declined in the recent past
setting the stage for the use of noninvasive measures
of shock assessment.
The RUSH exam was initially written to fit the void
for non invasive evaluation of physiology
in this case using bedside ultrasound.
The RUSH exam, a series of ultrasound elements
that was combined into a protocol, was initially published
in Emergency Medicine Clinics of North America in 2010
and then republished several more times in 2012.
The RUSH exam was therefore written as a three part
ultrasound evaluation of the patient in shock.
The first step was evaluation of the pump.
Here we were looking for three main things.
First of all assessing the heart for the presence
of a pericardial effusion or cardiac tamponade.
Number two, evaluating the left ventricle for contractility.
And number three, evaluating the right ventricle for strain
or dilatation that could indicate a large pulmonary embolus
in the crack clinical scenario.
Number two was the evaluation of the tank
or inter vascular volume.
The first assessment here was how full is the tank
and this was performed by an evaluation
of the inferior vena cava or internal jugular veins.
The second part was to evaluate
if the tank was leaking or compromised
and this involved elements of the Extended-FAST exam,
an also lung ultrasonography
looking for the presence of pneumothorax
or ultra sonic B Lines.
The third part of the RUSH exam was the evaluation
of the pipes first looking at the arterial circuit
for problems such as abdominal aortic aneurysm
or thoracic aortic aneurysm
which could be the cause of the patient's shock.
Second was the evaluation for the major venous circuit
mainly focusing on the legs for assessment for
deep venous thrombosis.
And this part would be included
especially if the echo showed right ventricular strain
to confirm the presence of a possible pulmonary embolus.
The RUSH exam is therefore an easily remembered
ultrasound protocol for the assessment
of the patient in shock that utilizes
the mnemonic of pump, tank, and pipes
to incorporate many ultrasound elements into an evaluation.
Here's a table that encompasses
many of the major resuscitation shock protocols
that have been published to date,
and we see them across the top of the table.
Let's look specifically
at the RUSH pump, tank, pipes protocol.
To the left we can see the protocol ultrasound elements
that have been combined
into many of these resuscitation protocols.
And we can see that the RUSH exam
combines many of the protocols to date,
starting with Cardiac and IVC exam,
and continuing on through the FAST exam,
the Aorta exam, Lung ultrasound,
and finally the DVT examination.
In a series of upcoming videos we'll go over
how to use the RUSH exam
i.e., how to evaluate the pump, the tank, and the pipes
to figure out exactly what type of shock
the patient is suffering from and how best to treat
the patient in the resuscitation area.
And hopefully by the time we go through all these videos
this table will make a lot more sense.
We'll be able to use the RUSH exam
to figure out the specific type of shock
that the patient is suffering from.
Is it hypovolemic, cardiogenic,
obstructive, or distributive?
And we can see how the different findings
within the pump, tank, and pipe categories
can help us in determining this etiology for the shock.
So I look forward to seeing you back
as Soundbytes continues and as we further explore
the RUSH Exam in the upcoming series of videos.

Brightcove ID

5754395461001

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

3D How To: Ultrasound Guided Thoracentesis

Read more about 3D How To: Ultrasound Guided Thoracentesis

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3D animation demonstrating an ultrasound guided thoracentesis exam.

Media Library Type

Media Library Tag

Congested Heart Failure

Infection

Tumors

Increased Blood Pressure

Blocked Blood Vessels

Subtitles

- [Voiceover] A phased array transducer
with an abdomen exam type is used to evaluate
the chest cavity for the presence of fluid.
The procedure is best performed with the subject
in a sitting position, leaning slightly forward,
to allow access to the posterior chest cavity.
The patient is instructed to breathe normally.
And the transducer is placed in a long-axis orientation
over the posterior chest wall
at the eighth or ninth intercostal space,
in the posterior axillary line.
The orientation marker is directed to the patient's head.
The ribs are identified in the near field of the image
as a bright interface with a posterior shadow.
The pleural line is identified as a bright
hyperechoic line between the rib shadows.
The to and fro sliding movement of the visceral pleura
against the parietal pleura, with breathing,
generates the lung sliding sign.
The transducer is moved along the posterior axillary line
to identify the bright, hyperreflective diaphragm.
Fluid will appear as a dark anechoic area
in the dependent area of the chest cavity.
Identify the borders of the fluid collection
and the normal appearing lung.
A needle insertion site should be chosen
in the posterior chest,
in a dependent area of the fluid collection.
Adjust the transducer so it is located between two ribs.
The needle should be inserted just below
the center position of the transducer
to allow the needle to pass just superior
to the lower rib to avoid the neurovascular bundle,
which lies on the inferior surface of the rib.
Follow the needle entry by slowly sliding
the transducer in the direction of needle advancement.
The needle will appear as a small bright hyperechoic dot.
When the needle tip appears,
the transducer should be advanced a short distance distally
to follow the tip of the needle trajectory.
The needle is slowly advanced under direct
ultrasound visualization until the tip is seen
to indent and then puncture the parietal pleura.
The transducer should be moved slightly proximally
and distally to confirm that the needle tip lies
in the fluid collection in the chest cavity.

Brightcove ID

5733273235001

https://youtube.com/watch?v=x1XR4AOi8q0

Case: Ultrasound Guidance for Thoracentesis

Read more about Case: Ultrasound Guidance for Thoracentesis

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This video details how bedside ultrasound imaging can be used to guide thoracentesis, detect pleural fluid levels, and analyze patient anatomy. It also discusses patient positioning during the thoracentesis and probe placement.

Media Library Type

Media Library Tag

Congested Heart Failure

Infection

Tumors

Increased Blood Pressure

Blocked Blood Vessels

Subtitles

- Hello, my name is Phil Perera and I'm the emergency
ultrasound coordinator at the New York Presbyterian Hospital
in New York City and welcome to SoundBytes Cases.
In this SoundBytes module I'd like to begin by discussing
the case of a patient who presented with worsening
shortness of breath
and had a chest X-ray which revealed this finding.
Notice here we have the presence of
an opacified left hemithorax
and notice here that the trachea is pushed away
from the left hemithorax
suggesting the presence of a very large pleural effusion
as the cause of our patient's dyspnea.
Now if in fact this was a large pleural effusion causing
our patient's shortness of breath
a therapeutic thoracentesis would be in order
to relieve her symptoms.
This leads into the topic for this SoundBytes module
which is the use of bedside ultrasound to perform the
thoracentesis procedure.
In this module I'd like to go through how sonography
can potentially make the thoracentesis procedure
a safer one for our patients
with a decrease in the inherent complications of the
procedure, such as pneumothorax or perforation
of the diaphragm.
Before a performance of a thoracentesis procedure
it's mandatory to look with sonography
to make sure that there's enough pleural fluid
amenable for a safe thoracentesis.
Notice here we have the patient positioned in
an upright position
so that the fluid will layer out above the level
of the diaphragm.
Notice here we note the diaphragm as shown by the red line
across the patient's anterior chest wall
Notice here we have the probe positioned along the lateral
aspect of the patient's chest with a marker dot towards
the patient's head.
We can angle the probe above the diaphragm
to look for a dark or anechoic collection of fluid
consistent with a pleural effusion.
This is the ultrasound image that corresponds to the
chest X-ray from the patient as we discussed in
the beginning of the module.
We have the probe positioned across the patient's left
side of the chest,
coming in with a probe marker toward the patient's head.
We can see here, superior towards the left and
inferior towards the right,
We note the spleen and the kidney,
inferior in the abdominal compartment
and we see the white line that is the diaphragm
moving up and down as the patient breathes.
We note above the diaphragm,
superior in the chest cavity,
the presence of a large, dark or anechoic
collection of fluid,
consistent with a very large pleural effusion,
and we fail to appreciate any lung within
this pleural effusion.
Just to emphasize the point that it's very important
to look with sonography, prior to performance of a
thoracentesis procedure,
we know this pleural effusion is taken from the right chest
we see the liver towards the inferior aspect of the patient
towards the right here,
and we note above the diaphragm here,
which is moving up and down as the patient breathes,
the presence of a dark or anechoic fluid collection,
but we also see here lung within the pleural effusion
and an attachment of the lung,
a fibrinous attachment,
that attaches the lung down to the diaphragm.
So this could be potentially a complicated performance
of a thoracentesis as the needle that goes into that
chest cavity could be pushed by that fibrinous attachment
up into the lung causing a pneumothorax.
This is the first traditional position of the patient
for the thoracentesis procedure.
This is the recumbent position in which we have the patient
lying down with the head of the bed elevated.
This will encourage the fluid to layer out above
the diaphragm,
and make it more amenable to a puncture attempt.
Here we see a pleural effusion within the left hemithorax,
note the effusion as denoted by the yellow liquid
around the red lung.
Here the black star indicates the appropriate position
for the needle for the puncture point for the thoracentesis.
When performing a thoracentesis procedure the needle should
be positioned above the level of the rib,
so as to avoid the neurovascular bundle,
which as shown in this illustration lies just below
to the rib.
Here I'm demonstrating the appropriate position of the probe
to investigate for the lateral approach to the thoracentesis
this time on the right chest.
Notice the positioning of the probe,
in this case the 3 MHz probe,
on the lateral chest wall,
right above the level of the diaphragm,
to look for a pleural effusion.
Here I'll indicate the orientation of the ribs
across the lateral chest wall,
and here's about the orientation of the diaphragm.
Now remember that that diaphragm will move up and down
as the patient breathes, so we want to place the probe
above the level of the diaphragm,
to look into the thoracic cavity
for a suitable collection of fluid.
Therefore here we note the position of the needle
for the appropriate positioning of the needle
for the lateral puncture approach
to the thoracentesis procedure.
And we note again that the level of the diaphragm,
on the lateral chest wall is shown by the red line,
and we note the needle above the diaphragm,
so that it can safely enter into the thoracic cavity
and not cause a complication such as puncture the diaphragm
during the thoracentesis procedure.
Here we note the second traditional positioning of
the patient for the thoracentesis procedure,
which is the standard upright position,
in which the needle would come in from a posterior approach.
And we note the patient bending forward over a stand
or a table.
Here we see a pleural effusion within the right chest
and we note here the patient has a puncture point
that would come in, into the pleural effusion,
below the scapula but above the layer of the diaphragm.
In this video clip I'll outline some of the surface anatomy
important for the posterior approach to the
thoracentesis procedure.
Here's about the level of the scapula on the
posterior chest wall,
and this is about the level of the diaphragm,
so the appropriate positioning for the needle for
the thoracentesis procedure
would be about the level of my finger here.
And we'll just freeze that down,
there's the scapula,
and here's about the level of the diaphragm.
Notice my finger safely above the diaphragm,
so as not to puncture through the diaphragm
into the abdominal cavity.
As shown by the black star this would be the appropriate
positioning of the needle for the thoracentesis procedure.
Prior to the thoracentesis procedure
we'll investigate the pleural effusion using a 3 MHz probe.
Notice the 3 MHz probe is placed along the
posterior chest wall,
at first with the probe marker on the long axis trajectory
with the orientation of the marker towards
the patient's head.
We can then swivel the probe into the lateral orientation,
with the probe marker lateral to further investigate
above the diaphragm,
for a suitable collection of pleural effusion amenable
to a thoracentesis procedure.
A clinical pearl that can be very helpful in further
delineating the pleural effusion with regard to the
patient's anatomy is to look further with a
10 MHz high frequency linear array type probe
prior to the thoracentesis puncture.
Notice here we're placing the high frequency probe along the
posterior chest wall in the long axis configuration with the
probe marker swiveled toward the patient's head.
We can also orient the probe in between the patient's ribs
in the lateral orientation as well,
to further investigate the anatomy.
This illustration shows what the anatomy of a pleural
effusion will look like using a high frequency 10 MHz probe.
In this illustration the probe is configured in the
long axis orientation.
So we have superior to the left and inferior to the right.
We see anteriorly the chest wall and we see the
superior rib to the left and the inferior rib to the right.
We know that the parietal pleura,
that white line just deep to the ribs,
and below the parietal pleura we can see the darker
anechoic pleural effusion.
In this illustration we're actually showing here
the visceral pleura, that coats the outside of the lung,
and we can actually see the distance between the pleura
layers, the parietal pleura and the visceral pleura,
which would be the full extent of the pleural effusion.
This would be your safety zone,
or the area in which it would be safe to place a needle.
It would be not safe to place a needle any deeper
than that safety zone,
as a needle could puncture through the visceral pleura
and into the lung, causing a pneumothorax.
Here's an ultrasound image showing a very large pleural
effusion as taken with a high frequency 10 MHz probe.
Superior towards the left, inferior towards the right.
We can see the hyperechoic, or bright bone tables of the rib
both superior and inferior,
which will show us the areas of the rib to avoid
during the thoracentesis procedure.
We'd actually want to come in over the top of the inferior
rib to avoid the neurovascular bundle.
We can see here the white line making up the parietal pleura
and deep to the parietal pleura we note a large amount of
pleural effusion.
We note here the absence of a lung in the pleural effusion
so we can place the needle pretty deeply here
without causing a pneumothorax.
This ultrasound image is again taken with a high frequency
10 MHz probe,
but in this orientation the probe is configured between
the ribs in the lateral orientation.
So, all we see is the chest wall, anteriorly,
we see the parietal pleura, that white line deep to the
chest wall,
and just deep to the parietal pleura we can see the
pleural effusion as made up by the darker anechoic
collection of fluid.
Now, note here that we also see the lungs sliding
back and forth as the patient breathes,
and we can see the full extent of the pleural effusion,
or the safety zone for performance of
the thoracentesis procedure.
In this ultrasound image,
again taken with a 10 MHz high frequency probe,
we can see the diaphragm moving back and forth as
the patient breathes,
defining the lower aspect of the thoracic cavity.
Thus, it would probably be unsafe to perform a
thoracentesis at this level of the chest wall,
because we might go through the diaphragm and into
the spleen with a needle.
So, it's important to look first to ascertain
the level of the diaphragm,
and make sure that the thoracentesis needle is going
safely above the diaphragm so as not to puncture
into the abdominal compartment.
In this video clip we'll first place the
high frequency 10 MHz probe along the posterior
aspect of the chest wall to define the proper
orientation for the puncture for the posterior approach
to thoracentesis procedure.
The needle can then come in directly underneath the probe
as shown here.
Now, I'll show a wide angle shot here and note this is
the proper position for the thoracentesis needle,
as definied by sonography from the posterior approach
to thoracentesis.
In conclusion, thanks for tuning in for this SoundBytes
module going over ultrasound guidance for the
thoracentesis procedure.
Sonography can potentially make the procedure a safer one
for our patients with a decrease in the complication rate,
such as pneumothorax or perforation of the diaphragm.
We'll want to use both the 3 MHz and higher frequency 10 MHz
probes to fully evaluate the effusion in relation to
the patient's anatomy, prior to a puncture attempt.
We can either use the static technique where we position
the patient appropriately and then mark off the
puncture spot with sonography,
prior to the thoracentesis procedure.
Or, we can use a dynamic technique,
where we place the probe in a sterile sheet
and watch the needle in real-time go into the chest cavity.
So, I hope to see you back in the future
as SoundBytes continues.

Brightcove ID

5733895862001

https://youtube.com/watch?v=6ThpUpgjSiM

Case: Detection of Pleural Fluid

Read more about Case: Detection of Pleural Fluid

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This video details the use of bedside ultrasound imaging to detect pleural fluid, grade the amount of fluid in the pleural cavity, and detect loculated pleural effusions.

Applications

Media Library Type

Media Library Tag

Congested Heart Failure

Infection

Tumors

Increased Blood Pressure

Blocked Blood Vessels

Subtitles

- Hello, my name is Phil Perera
and I'm the Emergency Ultrasound Coordinator
at the New York Presbyterian Hospital in New York City.
And welcome to SoundBytes Cases.
In this SoundBytes module,
we're going to look specifically at the
use of Bedside Ultrasound to detect Pleural Fluid.
Interestingly enough, Ultrasound has been found
to detect as little as 20 ccs of fluid
within the Pleural Space.
In contrast, a Chest X-Ray will not reliably
pick up less than 100 to 150 ccs of fluid
on an AP Film.
Now this problem is only compounded
in the Supine Trauma Patient,
where a Chest X-ray may miss a significant amount of fluid
as a Hemothorax will layer out Posteriorly
and can be very difficult to detect on this film.
For these reasons,
Bedside Ultrasound may offer a more accurate way
of diagnosing Pleural Fluid.
Here's a slide reviewing how to
perform the Ultrasound examination
for detection of Pleural Effusions.
Optimally you'll have a three megahertz probe
with a small footprint that can easily sit between the ribs
as we'll be looking into the Right Upper Quadrant
and Left Upper Quadrant areas.
In position one, we'll be coming into the
standard Right Upper Quadrant Trauma FAST exam
and position the probe into that area
just above the Liver and below the Diaphragm.
We can then angle the probe upwards into the Thoracic Cavity
to look for a Dark or Anechoic Fluid Collection
signifying Thoracic Fluid.
We can repeat the exam in the left side
as shown in probe position two.
Placing the probe into that area
of the Left Upper Quadrant Trauma FAST view.
Look first into the area above the Spleen
and below the Diaphragm
and then angle the probe upwards into
the left Thoracic Cavity.
If fluid is seen with in the Thoracic Cavity,
we can then move the probe upwards
to investigate the extent of the Effusion.
Here's a video going over how to perform the examination.
Notice here, we have a probe placed
into the Right Upper Quadrant Trauma FAST area.
Notice that we're angling the probe upwards
into the Thoracic Cavity to fully investigate
for a Pleural Effusion.
Here, I'm just superimposing
about the level of the Diaphragm
as shown in the red marker.
And notice here that the probe
is positioned coming into that area
just above the Diaphragm into the Thoracic Cavity.
Traditionally, the probe should be
in a long-axis configuration
with the marker dot towards the patient's head.
Again, if a Fluid Collection is seen,
one can then move the probe upwards
to fully investigate how big the Effusion is.
To optimize your examination,
place the patient with the head slightly upwards,
so that the fluid will layer out above the Diaphragm
allowing earlier detection of smaller amounts of fluid.
Now that we know how to perform
the Ultrasound examination for Pleural Fluid,
let's take a look at a normal Right Upper Quadrant
Pleural Examination.
The probe is configured at a long-axis type orientation
with the marker towards the patient's head.
So, we see Superior to the left, Inferior to the right.
The Liver is in the middle of the image.
And let's look above the liver.
Here we see the Diaphragm, that curving, white line
which is moving up and down as the patient breathes.
And to the left or Superior to the Diaphragm
is the Thoracic Cavity.
Now, while looking at the Thoracic Cavity here,
what we see is something called Mirror Artifact.
This occurs as a result of the sound waves
coming through the Diaphragm
and reproducing what looks like a mirror image
of the Liver within the chest.
This is a normal appearance of the Thoracic Cavity
and Mirror Artifact is something that
will be seen commonly on Bedside Sonography.
Notice, however, the absence of a Dark
or Anechoic Fluid Collection within the right chest.
Now, let's take a look at a normal
Left Upper Quadrant Pleural Exam.
Again, we're in a long-axis configuration,
so Superior to the left, Inferior to the right.
We see the Spleen in the middle of the image
and we see the Diaphragm moving up and down
as the patient breathes.
Let's look above the Diaphragm into the Thoracic Cavity.
And, again, we see that Mirror Artifact.
What it looks like is almost like
reproduction of the Spleen within the Thoracic Cavity.
So, this is a normal finding.
And one that is not to be confused with fluid.
Fluid will appear very differently
and will have the appearance of a Dark or Anechoic stripe
right above the Diaphragm.
Here's an illustration showing a positive examination
from the Right Upper Quadrant view
with a Pleural Effusion above the Diaphragm.
We're in that long-axis configuration,
so Superior to the left, Inferior to the right.
We see the Liver in the middle of the image here.
And the Diaphragm, the white line as seen
right above the Liver.
Notice in this image we have a Pleural Effusion
as represented by the Dark area of fluid,
which is immediately Superior to the Diaphragm
and tucks in there right above the Diaphragm
going up into the Thoracic Cavity.
So, this will the signature finding of a Pleural Effusion
as taken from the Trauma FAST Views,
from the Right Upper Quadrant.
And the Left Upper Quadrant will also have a similar view,
although we're just looking above the Spleen
in that orientation.
Here's a video clip showing a Small Pleural Effusion
as taken from the Left Upper Quadrant view.
Here, we see the Spleen in the middle of the image,
the Kidney Inferior to the Spleen.
And the Diaphragm, the curving white line
that's moving up and down as the patient breathes
right above the Spleen.
As we look into that area above the Diaphragm,
we actually appreciate here, the presence
of a Dark or Anechoic Fluid Collection
above the Diaphragm.
This represents a positive Pleural Effusion.
Notice that the amount of fluid is relatively small
and we can actually see the Lung moving up and down
to the left of the image here.
Here's a Moderate Plural Effusion
as taken from the Right Upper Quadrant View.
We see the Liver to the Inferior Aspect or to the right.
The curving white line making up the Diaphragm
in the middle of the image.
And fluid representing a Pleural Effusion
Superior to the Diaphragm.
Interestingly enough, we see the Lung moving around
and all the fluid compressed down
by the fluid within the chest cavity
taking on what appears to like a Liver within the chest.
And something called Hepatization of the Lung.
And this is commonly seen with a Pleural Effusion,
as it pushes in on the Lung
making it more of a solid-type organ.
Here's a Large Pleural Effusion as taken
from the Right Upper Quadrant View.
And what we see here, is the Liver Inferiorly,
the Diaphragm right above the Liver
there in the middle of the image.
And we see a large Dark or Anechoic Collection
immediately Superior to the Diaphragm.
This represents a Large Pleural Effusion.
And in the midst of the Pleural Effusion,
we can see the Lung waving around
and compressed down by all
the fluid within the Thoracic Cavity.
Again, demonstrating that Hepatization
of the Lung as it's compressed down by the Pleural Fluid.
So, this would be a Large Plural Effusion,
as there's a large amount of fluid
both Inferiorly between the Lung and the Diaphragm.
And both Anterior and Posterior to the Lung itself here.
Unfortunately, not all Plural Effusions
will be free-flowing or uncomplicated.
There are occasions where our patients
can have repeated Pleural Effusion
that can be Loculated or Complicated.
Here we see an example of a Loculated Pleural Effusion.
Notice this Lung here has an attachment
with a Fibrin area that attaches it
or glues it onto the Diaphragm Inferiorly.
Therefore, we have two Loculated areas Effusion,
both Anterior to the top of the screen and Posterior.
As the Lung is trapped within the Thoracic Cavity
by this Fibrinous Attachment to the Diaphragm,
it may be dangerous to perform an invasive procedure
like a Thoracentesis or a Chest Tube Placement.
The needle or the Chest Tube could be guided
up into the Lung causing a Pneumothorax
by the Fibrinous Attachment to the Diaphragm.
So, in conclusion, I'm glad I could share with you
this SoundBytes module going over the
Ultrasound Examination for the detection of Pleural Fluid.
As we've discussed earlier in the module,
Ultrasound may be more accurate
in detection of Pleural Fluid than a Chest X-ray.
And Ultrasound allows easy grading
of the amount of fluid within the Pleural Cavity.
It can also detect Complicated Pleural Effusions
that may be Loculated and can help determine
which patients may benefit from a Drainage Procedure
such as a Thoracentesis or a Tube Thoracostomy.
So, I hope to see you back as SoundBytes continues
and in further modules,
we'll actually look closer at
the Thoracentesis Procedure under Ultrasound guidance.

Brightcove ID

5729244712001

https://youtube.com/watch?v=X1E7OgOLzw0

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