Case Study Videos

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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- [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

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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

Case: Axillary Vein Cannulation

Read more about Case: Axillary Vein Cannulation

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Discussion on helpful scanning techniques and anatomy landmarks used to perform an ultrasound guided cannulation. Topics: patient and transducer position, identification of structures near the vein, vein depth, & insertion technique.

Applications

Cardiology

Clinical Specialties

Anesthesiology (Regional)

Media Library Type

Case Study Videos

Subtitles

- [Voiceover] Welcome back to SoundBytes Cases.
This is Phil Perera, and in this module we'll discuss
cannulation of the axillary vein using ultrasound guidance.
So why, you might ask, would I want to use
ultrasound to cannulate the axillary vein,
when in effect, the axillary vein is an alternative approach
to cannulation of the subclavian vein on the chest wall?
The axillary vein is a continuation of the brachial vein
onto the chest wall, and becomes a subclavian vein,
as it passes medially under the first rib.
The axillary vein can be well visualized
using ultrasound at this lateral position on the chest wall,
and that's in contrast to the subclavian vein,
where the presence of the bony clavical
makes imaging of the infraclavicular portion
of the subclavian vein difficult.
So in effect, this is a lateral puncture
of the subclavian vein relaying into the axillary vein,
if you're gonna use the right anatomical terminology.
Ultrasound guidance of Axillary Vein cannulation
is now well documented in the medical literature,
although many clinicians remain unaware
that ultrasound can be integrated into this approach.
Two studies document utility
of ultrasound guidance for axillary vein cannulation
with a decreased complication rate,
and the studies are shown below,
the first in 2004 and the more recent in 2012,
both from our colleagues in Great Britain.
In 2011 the CDC came out
with some guidelines for the prevention
of intravascular catheter related infections.
Their recommendations included
using a subclavian vein site, if possible,
rather than internal jugular vein or femoral vein sites,
in adult patients, to minimize the risk of infection,
with a non-tunneled catheter.
They did say to avoid the subclavian site in hemodialysis
and advanced kidney disease patients, to decrease
the risk of subclavian vein stenosis.
They also advocated the use
of ultrasound guidance, if available.
Now let's review the relevant
upper extremity venous anatomy,
that we'll need to know,
to perform successful cannulation of the axillary vein.
Here we see the axillary vein and the axillary artery,
lateral on the patient's chest wall.
Notice here the clavical and the first rib.
As these structures move medially past the first rib,
they become the subclavian vein and artery.
We can see these arteries and veins here,
more medially located on the patient's chest.
Notice also,
we see the internal jugular vein and carotid artery,
moving up and down the patient's neck,
and coming together with the subclavian vessels.
We see the brachiocephalic vein,
which is the confluence of all of these vessels,
as they move down towards the heart,
to become the superior vena cava,
and we remember that, optimally,
we want to place the tip of the catheter,
when performing central venous cannulation,
in the superior vena cava,
and not into the right atrium.
Here's another anatomical image,
showing a perspective from a more lateral orientation
on the patient's chest wall.
Here, we see the axillary vein and axillary artery,
and notice that the normal orientation
of the vein and the artery
is that the artery should be superior to the vein,
although occasionally we have seen some variation,
and it's not unusual for the vein
to be overlapped by the artery, or vice versa.
We see the continuation of the axillary vein and artery,
onto the patient's chest wall, medially,
to become the subclavian vein and artery,
as the vessels pass medial to the first rib.
We also see the internal jugular vein and carotid artery,
and the superior vena cava.
To best image the axillary vein using ultrasound
we'll place the probe on the lateral chest wall.
Here we see the probe applied,
in a longitudinal or long axis orientation
over the top of the axillary vein.
We can image the vessel, using the long axis orientation,
to get a lot of information about the vessel,
but we can look in the short axis orientation,
by turning the probe so the probe indicator
will be towards the patient's right shoulder.
This will cut the vessel in cross section,
making it appear like a circle.
Before performance of the axillary vein cannulation,
we'll want to select the right ultrasound probe for the job.
For this application,
we'll be using a higher frequency 10 MHz linear array probe,
and because we're performing this procedure in a dynamic
or real-time guidance technique,
we'll want to put a sterile sheet or barrier
over the probe, so as to maintain
sterile precautions throughout the procedure.
Note, in some of the upcoming pictures, we don't have
a sterile sheet over the probe, but if we were performing
this in real procedure, we'd want to make sure,
that we have that sterile sheet over the probe.
While someone will run through a pre-procedure checklist,
assessing for relative contraindications
to axillary vein cannulation,
as it's a relatively non-compressible vessel,
coagulopathy is a contraindication
to axillary vein cannulation.
Also, renal disease or need for dialysis
would be relative contraindications to cannulation
of the axillary vein.
We can also run through a more extensive checklist,
known as the 6 point bundle,
which is shown in the upper right,
which emphasizes the use of maximal sterile precautions
for both patient and clinician during the procedure.
Now let's specifically discuss
some of the ultrasound guided approaches
to axillary vein cannulation.
The axillary vein can be visualized
in both short and long axis orientations, using ultrasound.
Imaging of the needle during cannulation of the vein
can then be performed in either orientation,
and there are pluses and minuses of both these orientations,
for cannulation of the vessel.
I generally recommend to start
in the short axis orientation
to introduce the needle,
initially to advance the needle down to the vein.
One may successfully cannulate the vessel in short axis,
however, one thing that can be very helpful
is to flip the probe, once the needle is under the skin,
into the long axis orientation,
to be used to visualize the needle
as it approaches the vessel,
as a long axis orientation shows needle depth
better than the short axis orientation.
So, putting it altogether, here's the probe position
for cannulation of the axillary vein
in the long axis orientation.
Notice here, that the needle would be placed
in an orientation coming in
under the lateral aspect of the probe,
and moving more medially.
Thus we can image the full position of the needle
as it moves down to the axillary vein.
In the next few images,
we'll also show you the placement of the probe
for the short axis cannulation of the axillary vein,
so as to compare both long and short axis imaging.
Here's a few pictures showing the orientation of the probe,
and the placement of the probe
for cannulation of the axillary vein
in a short axis orientation.
Notice here, that we have the probe
in an up and down configuration,
with the indicator dot towards
the patient's right shoulder or superior.
Notice we're placing the needle roughly at about the
midway point underneath the probe.
Now there are some benefits
of starting with the short axis orientation,
namely that it's helpful in orienting the needle,
up or down, superior or inferior,
on the patient's chest wall,
to best aim it towards the axillary vein.
Here are some ultrasound images
of the axillary vein and artery,
taken from the short axis view.
We have the probe marker oriented
towards the patient's head,
thus to the left of the image is superior,
and to the right is inferior.
We notice the axillary artery, the smaller vessel,
superior or towards the left of the image.
We see the larger axillary vein
at about the three centimeter mark,
inferior or towards the right of the image.
Notice towards the back of the image,
we can actually see the lung
sliding up and down as the patient breathes,
at about the five centimeter mark.
Thus it's very important to cannulate the vessel carefully,
and not to pass the needle deep,
past the axillary vein or artery
to cause an inadvertent pneumothorax.
Here's another image of the axillary artery and vein,
taken from a short axis configuration.
Again, we have the probe marker indicator
towards the patient's head.
Superior to the left, inferior to the right.
Thus we see the smaller axillery artery
to the left or superior, and the larger axillery vein
inferior toward the right of the image.
Notice that as we apply probe pressure
down onto the patient's chest wall,
we can actually compress the axillary vein ,
and this is one way of telling vein from artery,
as normally the vein should compress,
as long as there's no thrombus inside it,
and the artery will stay open.
We can see the lung sliding
towards the deeper aspect of the image.
In this ultrasound image,
again taken from a short axis configuration,
we'll use Color Flow Doppler to further differentiate
the axillary artery from the axillary vein.
We note again, that superior is to the left,
and inferior is to the right.
We can see the smaller axillery artery,
with pulsations indicating arterial flow within the lumen.
Notice here, we also see phasic respitory flow
within the axillary vein, corresponding to
inhalation and exhalation by the patient.
Thus, another way of differentiating the axillary artery
from the axillary vein.
Here are some images showing the appropriate positioning
of the probe for long axis cannulation of the axillary vein.
Again we notice that we have a high frequency linear array
probe positioned over the lateral chest wall,
directly over the axillary vein.
We have the needle coming in,
under the long axis of the probe.
Now, I like to have the probe positioned
so that the marker on the probe is oriented lateral.
Thus, the needle will come in underneath the indicator
and progress directly underneath the probe
as it courses from the skin down to the axillery vein.
It's important to keep the needle and plane
underneath the probe at all times,
so that it can be visualized as it goes down to the vessel.
Here's a long access ultrasound image of the axillary vein
as it courses from lateral to the left of the image
to medial to the right of the image.
Notice that the axillary vein appears
as a tubular structure, at about the three centimeter mark.
Now let's take a look at the axillery artery
using B-mode or greyscale sonography.
We can see the axillary artery
arching from lateral to medial
across the patient's chest wall,
and we note the pulsations within the lumen,
indicative of an arterial structure.
We can also see the thoracoacromial trunk
coming off medially off the axillery artery.
Next, we'll use Color Flow Doppler
to further differentiate venous structures from arterial.
This will be the axillary vein and we can tell this,
as it does not have that constant arterial pulsations
within the lumen.
Notice that rather,
it has the phasic respitory variation of flow
within its lumen, as indicative of a venous structure.
We can also see the thoracoacromial trunk
coming off medially.
Let's contrast that last ultrasound clip with
this one, showing the axillary artery, using
Color Power Flow Doppler.
Color Power Flow Doppler shows amplitude of flow,
and we can see that fast flow is very yellow,
we can see the faster flow within the inner part of the
lumen of the vessel.
But notice that we have here
the characteristic arterial pulsations,
that differentiate from venous pulsations.
Now let's discuss the micropuncture technique
for central venous cannulation.
The micropuncture technique has a lot of advocates
when talking about cannulation of the axillary vein,
as it utilizes a smaller 21 gauge needle
for the initial puncture of the axillary vein.
This is in contrast to a traditional central line kit,
which uses and 18 gauge needle, a much larger needle,
for that initial vessel cannulation.
One can then use
this smaller 21 gauge needle to cannulate the vessel,
and place a guidewire into the vessel.
A larger catheter can then be inserted
over the guidewire into the vessel.
Using these smaller diameter needles
is potentially safer for deeper puncture
of vessels like the axillary vein
to avoid potential complications.
In this video clip, we'll watch cannulation
of a vessel using a short axis approach.
This is a phantom which simulates the human body
and we can see that as we place the probe
in the short axis orientation,
the vessel appears as circular end-on.
Notice here, that we can see the echogenic tip of the needle
coming down to the vessel, permeating the interior wall,
and entering into the lumen of the vessel.
So the short axis plane allows
better lateral guide of the needle path,
and is a good starting position
for cannulation of an axillary vein.
In this video clip, we'll use the long axis approach
for cannulation of a central vein.
Here we're using some new technology,
known as MBE technology,
that is on a lot of the Sonosite machines.
What we see here is the tip of the needle
is much more echogenic.
We aim the needle towards the dotted line,
which is coming from right to left on the image here.
Now let's watch the needle coming in from left to right,
and we can see that,
as the needle is in plane with the probe
in the long axis approach,
we can see the full extent of the needle
as it travels from superficial down
to permeate the anterior wall of the vessel
and enter into the vessel lumen.
Thus the long access plane allows
a much better guide to needle depth
and allows you to gauge where the tip of the needle is
at all times.
That's why I generally start with a short axis approach
and then flip to long axis.
In this video clip, we'll look at a real-time
axillary vein cannulation in a real patient.
Here we see the needle coming down from left to right,
we're using the long axis view.
Notice that the images are not quite as crisp,
because the probe is slightly off-axis to the vessel.
What we can see here is the tip of the needle
as shown by a small arrow, coming down, pushing down
on that anterior wall of the axillary vein,
and then entering into the vessel lumen.
So in this case we were able to successfully cannulate
the axillary vein, although the images are
not quite as clear as in the phantom,
and this is one pitfall from using the long axis approach,
that you must be completely in plane with the needle
throughout its entire path down to the vessel.
Here's another clip in the long axis orientation,
showing a successful cannulation of an axillary vein.
We can see here the needle pushing down
on that anterior wall, and then entering
into the vessel lumen.
Now one potential pitfall is that, occasionally,
the vessel can be pushed down, the anterior wall can tent
towards the posterior wall, as you push the needle down.
So have patience, and occasionally,
a slight pull-back with the needle
will loosen that tissue, and allow you
to free the needle tip within the vessel lumen.
But again, the teaching point here
is that the long axis view is great
for assessment of needle depth at all times.
Another use of ultrasound and the long axis technique
which I find very helpful,
is to assess that the guidewire
is safely within the position,
within the lumen of the axillary vein.
Here we note the needle coming down from left to right,
and we can see the guidewire passing
through the tip of the needle,
moving down the axillary vein,
down towards the superior vena cava.
This can be very helpful in assessing that the guidewire
is indeed safely within the axillary vein,
prior to placement of the plastic catheter.
While standard practice would dictate
that after placement of a central line,
one would obtain a chest radiograph
to look for the placement of the tip of the catheter
in the superior vena cava.
A quick and easy way of assessing
that the catheter is indeed inside the superior vena cava
is to use a saline flush.
Here we're flushing the saline into the catheter
and we can note the presence of bubbles
within the right side of the heart,
indicating that the catheter is indeed
within the vessel lumen, so a quick and easy way,
right at the bedside, prior to obtaining a chest radiograph.
In conclusion, thanks for joining me
for this SoundBytes module,
going over ultrasound guided approaches
to axillary vein cannulation.
Ultrasound guidance of axillary vein cannulation
is now well supported in the medical literature,
and in fact, the CDC guidelines from 2011
advocate placement of central lines
within the axillary and subclavian veins,
to lower the incidence of bloodstream-associated infections.
As we discussed, the micropuncture technique,
using a smaller needle
for the initial cannulation of the axillary vein,
can be very helpful for this approach.
We can then place a guidewire and larger catheters
into the vessel more safely.
So clinicians should strongly consider
this alternative approach,
using ultrasound guided approaches into the axillary vein,
when determining the location
for central venous catheter placement in their patients.
So, I hope to see you back, as SoundBytes continues.

Brightcove ID

5508139234001

https://youtube.com/watch?v=zxmkrrq1P3M

Body

Case: Supraclavicular Approach to Subclavian Vein Cannulation

Read more about Case: Supraclavicular Approach to Subclavian Vein Cannulation

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3D animation demonstrating the Ultrasound Guided Insertion of a Subclavian Vein Catheter.

Applications

Cardiology

Clinical Specialties

Anesthesiology (Regional)

Media Library Type

Case Study Videos

Subtitles

- [Voiceover] This is Dr. Phil Perera
and welcome to SoundBytes.
In this module we're gonna go over how to use ultrasound
to guide us for the supraclavicular subclavian
vein cannulation.
The supraclavicular approach to the subclavian vein
is a great alternative to the traditional infraclavicular
approach that's been emphasized over the years
in medical and surgical training.
For this approach, the catheter is placed into the
subclavian vein above the clavicle either very close to,
or at the junction with the internal jugular vein
at the confluence of the brachiocephalic vein.
Advantages of this approach include a relatively short
distance to the vein and less wire kinking than with
the infraclavicular approach.
A nice article that goes over this approach was in
the Western Journal of Emergency Medicine in 2009 by
the authors listed below in the reference.
Let's take a moment to review the upper extremity
venous anatomy that we'll need to know to perform
supraclavicular subclavian cannulation.
The first landmark is the clavicle, and remember,
as the subclavian vein passes lateral to the clavicle
it becomes the axillary vein.
We can see the subclavian artery and vein running
above and below the clavicle.
We can also see the internal jugular vein
and carotid artery going up and down the neck.
We can see the confluence of the internal jugular vein
and the subclavian vein to form the brachiocephalic veins.
In effect, we're aiming at the confluence here,
the brachiocephalic vein for placement of the catheter.
And we can see that the brachiocephalic veins join
to become the superior vena cava
going into the right atrium.
And that's where we want to place the tip of the catheter.
Now let's take a look at the essential anatomy
from a lateral approach.
We again note the clavicle here forming the boundary
between the subclavian artery and vein
and the axillary artery and vein.
We see the subclavian artery and vein arching
above and below the clavicle.
And we see the internal jugular vein and carotid artery
going up and down the neck.
Notice again the confluence of the subclavian vein
and the internal jugular vein at the brachiocephalic vein.
And again, that's where we'll be aiming with our needle.
Notice the brachiocephalic vein joining in the
superior vena cava and down into the heart.
Now let's take a moment to talk about ultrasound guidance
for this approach to the subclavian vein.
Traditionally it's been thought to be difficult to image
this portion of the subclavian vein as it arches
above the clavicle.
However, the supraclavicular portion of the subclavian
vein can be well visualized by placing the ultrasound probe
in a medial position just above the clavicle and angling
it down into the chest.
To visual the subclavian vein just anterior
to the subclavian artery.
In this illustration, we see the probe placed above
the subclavian vein able to image it
in a long axis orientation.
For this application we'll want to use the high frequency
10 megahertz linear array type probe.
And notice that we have the probe angled anterior
to pick up the vein which will be located anterior
to the subclavian artery.
Thus, cannulation of the vessel will be performed
in a long axis approach using ultrasound guidance.
An alternative approach to find the subclavian vein
and the brachiocephalic vein is to follow the internal
jugular vein inferiorly down the neck.
We then will visualize the subclavian vein as it joins
with the internal jugular vein at the confluence
of the brachiocephalic vein.
And we can use color Doppler flow imaging as shown
in the video box to the upper right to differentiate
vein from artery.
Notice the characteristic pulsations of the artery
versus the constant phasic respiratory hum of the vein.
To use ultrasound guidance for the supraclavicular approach
we'll want to place the probe in a long axis orientation
in the supraclavicular fossa.
As noted here in the picture to the upper right,
we can see the probe placed over the top of the clavicle.
There's not a lot of space in the supraclavicular fossa
and that's why it's easier to place the probe in a
long axis orientation rather than a short axis approach.
We'll be using the high frequency linear array type probe
for this application and because we want to use dynamic
or real time guidance, we're going to use a sterile sheath
over the probe.
Now let's go over how to use ultrasound to visualize
the subclavian vein.
We'll begin by running the probe down the neck
to identify the internal jugular vein lateral
to the carotid artery.
We can push down with the probe to differentiate
vein from artery as the vein should completely compress
as long as there's no thrombosis present.
We can also use Doppler flow to differentiate
the two vessels.
After we identify the internal jugular vein within the neck
we'll run the probe even further inferiorly down the neck
and angle it down into the chest.
Now, note here that we're seeing the subclavian artery
and the carotid artery and the confluence
of the two vessels.
And remember that the subclavian artery is going to be
located posterior to the subclavian vein.
Next we're gonna orient the probe even more anteriorly
watching internal jugular vein go down into the chest
and join with the subclavian vein at the confluence
of the brachiocephalic vein.
And we remember that the subclavian vein will be located
more anteriorly than the subclavian artery.
Now let's take a look at some ultrasound images showing
the internal jugular vein running down the neck and joining
with the subclavian vein at the brachiocephalic confluence.
And we can see the subclavian vein arching from the lateral
aspect to the left of the image, here,
and joining with the brachiocephalic vein medially.
Again, we'll be aiming the needle for the confluence
of the subclavian vein down with the brachiocephalic vein.
Now we can that the structure is relatively superficial,
we can see the depth markers over to the right,
and we note that the subclavian vein is only at about
one centimeter depth.
In this ultrasound image we first locate the internal
jugular vein and then we orient the probe a little bit
more anteriorly to pick up that subclavian vein
and the confluence of the brachiocephalic vein.
So all we're doing is a slight tilt anteriorly
with the probe to visualize the subclavian vein
running into the brachiocephalic vein.
And again, we can see the depth markers over to the right
there, and we notice that the subclavian vein is located
at about one to two centimeters.
So again, it's a relatively superficial structure.
In this ultrasound image we see the subclavian vein
coming from lateral to the left of the screen
and joining with the brachiocephalic vein medially.
We can see a valve at the confluence
between the two structures.
Our needle would come in from the lateral aspect
and be aimed medially towards that confluence
and we can see that it would have to come down about
two centimeters to successfully cannulate the vessel.
In this illustration we'll go over the surface anatomy
for the supraclavicular subclavian vein cannulation.
The needle should be aimed towards the subclavian vein
at the confluence of the internal jugular vein
into the brachiocephalic vein.
Generally we're gonna place the needle up the back
of the clavicular head of the sternocleidomastoid.
The needle should be aimed towards the sternal notch.
And again, it's a relatively superficial stick.
This video reviews the middle triangle of the neck
as framed by the divisions of the
sternocleidomastoid muscle.
Remember that the sternal head will run medial
and the clavicular head will run lateral.
The clavicle will form the inferior boundary of the middle
triangle of the neck.
And we can see the index finger placed
within the middle triangle.
Within this triangle will run the internal jugular vein
and the carotid artery.
And that's where we want to be first locating with the probe
the internal jugular vein as it runs down the neck.
Here are the traditional surface landmarks for cannulation
of the supraclavicular subclavian vein.
We want to identify the clavicular head of the
sternocleidomastoid laterally and that's generally
where we'll be placing our needle.
The needle will be aimed towards the sternal notch medially.
And we can see that the needle will be coming over the top
of the clavicle aimed into the subclavian vein.
And this video clip will simulate the correct placement
of the needle for cannulation of the subclavian vein
above the clavicle.
Here I'm just illustrating where the subclavian vein
should be running from lateral to medial.
And note here, we'll place the needle just lateral
to the clavicular head of the sternocleidomastoid
with an orientation towards the sternal notch
of the sternum.
Next we'll add ultrasound into the mix
and here we're placing the high frequency linear array probe
into the supraclavicular fossa,
just above the subclavian vein.
So we'd be placing the needle on the lateral aspect
of the probe so that we can watch the needle
come down into the vessel.
And again, I'm just emphasizing the standard trajectory
of the needle from that lateral aspect of the clavicular
head of the sternocleidomastoid towards the sternal notch.
Here we get a different perspective for the placement
of the probe in the long axis configuration in the
supraclavicular fossa.
And we see here that that needle should be oriented off
the back of the probe or lateral to the probe.
We'll be placing the needle directly underneath the probe
so we can watch it all times as it goes down to the vessel
to correctly cannulate the subclavian vein.
And the needle should be aimed towards that sternal notch.
Here we're going to successfully cannulate the
subclavian vein using the long axis approach
under ultrasound guidance.
And we can see the needle coming in from lateral to medial
successfully cannulating the subclavian vein.
Notice that the needle has a bright or echogenic
appearance on ultrasound.
Here we'll stop the video clip and we can see the tip
of the needle centered within the subclavian vein.
We'll note the depth markers over to the right
of the ultrasound image, here, and we can see that
the subclavian vein is at about one to two centimeters.
And we need to keep this in mind as the dome of the lung
is relatively close to the subclavian and we want
to keep that tip of the needle relatively superficial.
Once we've had a successful cannulation of the vessel
we can actually guide the guide-wire
using ultrasound guidance.
This is helpful as we want to make sure that the guide-wire
passes without obstruction down into the vessel lumen.
In this video clip we can actually see the guide-wire
advance through the catheter into the subclavian vein
laterally and being pushed down the subclavian vein
into the confluence with the brachiocephalic vein medial
and to the right.
Next we can watch as the guide-wires further advance
down the brachiocephalic vein into the superior vena cava.
And here we can see the echogenic guide-wire coming
from left down the subclavian into the brachiocephalic
and into the superior vena cava.
And remember that we want to position the tip of the
guide-wire and then the resulting catheter within
the superior vena cava so that it doesn't enter into
the right atrium.
To summarize some of the important parts of this module
I want to emphasize that the supraclavicular approach
to subclavian vein is a great alternative to the
traditional infracavicular approach and one in which
ultrasound guidance can be used dynamically or real time
to guide the needle down into the vein,
hopefully to decrease the risk of complications
to our patient during the procedure.
As we discussed, the subclavian vein cannulation
is performed with the ultrasound probe held in the
long axis orientation in the supraclavicular fossa
so that the needle will enter off the back of the probe
laterally and be advanced in a long axis view down
into the vein.
Let's finish here with a discussion of some of the
potential complications of this approach,
the first of which is inadvertent pneumothorax.
Now the subclavian vein is relatively close to the lung,
the dome of the lung, and for that reason,
we'll traditionally go on the right side where the
right side of the lung is a little lower at the dome
than on the left side.
We could actually visualize the dome of the lung
on ultrasound as seen in the video box to the upper right.
We can see the pleural surfaces moving back and forth
as the patient breathes and this is called lung sliding.
So we can visualize the lung and avoid it.
We want to avoid deep punctures with the needle
and keep that needle tip visualized at all times
as we advance it down into the vein.
The second potential complication is inadvertent puncture
of the subclavian artery during the cannulation procedure.
Remember that the subclavian vein lies anterior
to the subclavian artery and we can actually identify
both structures prior to puncture attempts using ultrasound.
We can use color flow Doppler imaging to differentiate
the artery from the vein and as seen in the mini boxes
to the upper part of the video here,
we can see to the left the pulsations within
the subclavian artery and the venous hum to the right,
there, within the subclavian vein.
We want to aim that needle anteriorly at all times to avoid
the subclavian artery so as not to inadvertently puncture
it during the cannulation procedure.
So while it's important to discuss the potential
complications of this approach,
I feel that this is a great line in clinical use
and one that's actually better or safer for our patients
than the traditional blind landmark-based infraclavicular
approach to the subclavian vein.
So I hope it's something that you'll give a try in
the clinical areas using ultrasound guidance.
And I look forward to seeing you back in the future
as SoundBytes continues.

Brightcove ID

5508120186001

https://youtube.com/watch?v=I3Jqbxa1_Ts

Case: Ocular Ultrasound Part 2

Read more about Case: Ocular Ultrasound Part 2

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Part 2 of 2. Ocular ultrasound case study.

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Subtitles

- Hello, my name is Phil Perera,
and I'm the Emergency Ultrasound Co-Director
at the LA County USC Medical Center
in Los Angeles, California.
And welcome to SoundBytes.
Welcome back to SoundBytes,
Ocular Ultrasound Part 2.
In this module,
we'll further explore ocular ultrasound building
on those concepts introduced
in ocular ultrasound module part one.
We'll learn how to diagnose retinal pathology,
specifically retinal detachment.
We'll also look at vitreous pathology,
a possible mimic of retinal pathology,
such as retinal detachment.
And we'll learn how to differentiate
between the two conditions,
using the kinetic or movement examination.
Now let's take a look at an illustration
showing the anatomy of a retinal detachment.
We note the anterior structures of the eye,
the cornea, anterior chamber, lens, and iris
are all normal in this illustration.
The pathology exists in the posterior aspect of the eye.
In the posterior part of vitreous body.
And we note here that the retina has buckled
away from the choroid,
both medially and laterally.
And this is a very bad thing because the blood supply
to the retina exists through the choroid.
And the lack of opposition of these two layers
will cause ischemia of the retina with time.
Now we remember that the retina is a continuation
of the optic nerve, thus the retina will always be
attached there or tethered down to the optic nerve.
The retina is also going to be attached or tethered down
anterior and laterally at the ora serrata.
And this is important as we start to look at ultrasounds
of retinal detachment.
Now let's return to our patient's ocular ultrasound.
Placing the probe in a side to side
or transverse orientation over the affected eye.
Right away we note that there's pathology within
the posterior aspect of the eye.
And we can see a hyperechoic or bright structure
waving around in the posterior aspect of the eye
that should not be there.
We'll look at the patient's other in the small video
to the right and we note here the normal appearance
of the retinal tacked down to the choroid.
So in the affected eye, this is actually
a detached retina that's moving around
as the patient looks up and down.
And we have the probe position over the patient's eye.
So right away, our diagnosis within immediate orientation
of the probe onto the eye is, retinal detachment.
Here's the ultrasound from another patient
who presented with non traumatic loss of vision.
And again, we note the classic appearance
of a retinal detachment.
We have the probe configured in a side to side orientation,
or transverse orientation over the patient's eye.
With the probe marker oriented lateral.
We can see the optic nerve sheath coming up
from the posterior aspect into the eye.
And we note the detached retina emanating off
from the optic nerve.
Now recalling that the macula lies just lateral
to the optic nerve, we can see here that this detachment
has affected the macula.
That this is classified as a mac off,
or macular off retinal detachment.
Now let's take a look at a retinal detachment
using the kinetic ultrasound examination.
We're having the patient look from side to side
as we place the probe over the closed eyelid.
And we note here a very large posterior detachment
of the retina.
We can see here that it has tethered membrane appearance
as the patient looks from side to side.
Now we note some anterior vitreous material
that swirls around as the patient looks from side to side.
But I want you to look towards that posterior aspect
of the eyeball.
Towards that membrane, the tethered membrane,
that moves back and forth as the patient looks
from side to side.
And that is the classic appearance on kinetic exam
of a detached retina.
Here's another ocular kinetic exam of a retinal detachment.
And we can see the tethered membrane appearance
of the detached retina moving around
as the patient looks from side to side.
But we can see that it has a classic V that tethers in
at the optic nerve sheath right there.
And I'm gonna still that image down.
And again we can see the optic nerve posteriorly
coming up towards the back of the eye.
And the detached retina tethered right there
to form a V coming anteriorly into the vitreous material.
So that's a classic appearance of a retinal detachment
on kinetic examination.
Always tethered at the optic nerve.
Here's another video clip showing the kinetic examination
detailing a retinal detachment.
As the patient looks from side to side,
we can see the serpentine motion, the flicker,
of the retina which moves around as a tethered membrane
in the back portion of the patient's eye.
But notice it has the classic appearance,
that it's tethered there, both posteriorly
at the optic nerve, and anteriolaterally
at the ora serrata.
So another classic appearance of a retinal detachment
on bedside exam.
Here's a bedside ultrasound examination
from another patient who had painless loss of vision.
And looking into the back of the eye,
we see another classic appearance
of a retina detached off the back of the eye.
Notice it has a classic membrane type appearance
that layers out in the back of the eyeball.
Now as I mentioned in the earlier part of this module,
we should always investigate body structures
in two planes and retinal detachments
are no exception to that rule.
Here' we're going to now place the probe in a vertical
up and down orientation.
And what's interesting is,
now I have the patient looking down.
So I can best see the inferior aspect of the eye.
And we note that this retinal detachment
is mainly an inferior detachment.
And we can see here, the detached retina
coming off as a membrane that tethers in at the optic nerve
which we can see that black area coming in
to the back of the eye.
And we can see the detached membrane
is predominantly located inferior to the optic nerve.
Now it's important to realize that there are possible
mimics of retinal detachment both on clinical evaluation
and on bedside ultrasonography.
Vitreous pathology, such as vitreous hemorrhage and
vitreous detachment can be confused with retinal detachment.
And the symptoms can overlap
with that of retinal detachment.
Patients can have both floaters and vision loss.
And while at first glance, the ultrasound may
confuse the two, there are important concepts
with ultrasound in order to discriminate
the two conditions one from another.
This ultrasound was taken from a patient
who's experienced multiple floaters within their right eye.
And what we see here is the classic appearance
on bedside ultrasound of vitreous blood.
And we can see the speckles of the vitreous material
within the vitreous cavity,
the posterior aspect of the eye ball.
Now to best visualize vitreous hemorrhage on bedside
ultrasound, it's important to realize that we may have to
turn the gain up for a high level
for optimal visualization of vitreous hemorrhage.
But again, we see the classic appearance, those little
speckles of vitreous blood within the vitreous body.
This ultrasound was taken from another patient
with painless loss of vision.
And again, looking into the vitreous body,
we see vitreous material present within the posterior
aspect of the eye.
This is the classic appearance of vitreous detachment.
All that vitreous material has accumulated there
within the posterior aspect of the eye.
Leading to vision loss and prominent speckles
or floaters as the patient looked from side to side.
Because vitreous pathology can be confused with
retinal detachment, it's really crucial to employ
the kinetic examination as an aid to best diagnose
retinal detachment versus vitreous pathology.
In this clip, we see vitreous material
that's congealed within the back of the eye
and notice as the patient looks from side to side,
it tumbles around there within the posterior aspect,
the vitreous cavity of the eye ball.
And here again, we'll see the patient looking from
side to side more rapidly and notice the classic
tumbling motion of the vitreous material
within the back of the eye.
This is to be differentiated from a retinal detachment
as the retina will have more of a tethered membrane
appearance as it's going to be attached within
the back of the eye at the optic nerve
and anterolaterally at the ora serrata.
Vitreous material will tumble like clothes
within a dryer as it's not attached
within the posterior aspect of the eye.
Very different than a retinal detachment.
Now that we understand more about vitreous hemorrhage
and vitreous detachment,
in comparison to retinal detachment,
let's take a look at this video clip
from a patient who presented with painless loss of vision.
Note the huge amount of vitreous material
that's accumulated within the vitreous body,
the posterior aspect of the eye.
And notice that it tumbles around as the patient looks
from side to side.
So this was a huge amount of vitreous hemorrhage.
Vitreous material that accumulated within the back
of the eye of this patient who was a diabetic.
And notice a classic clothes dryer tumbling motion
of this vitreous material.
Just to reinforce the difference on bedside ultrasound
from a retinal detachment, in the small box I've put there
the video clip of the retinal detachment.
Notice there, the tethered membrane appearance
as the patient looks from side to side.
Very different than the clothes dryer
tumbling motion of the vitreous material as we see
in the large clip in the middle of the image here.
In conclusion, thanks for tuning in
for this SoundBytes module.
Going over part two of ocular ultrasound.
Now you're ready to use ocular ultrasound as an effective
tool to investigate pathology of the eye.
Opening up that back part of the eye
for better examination than we previously been able to
using the traditional fundoscopic exam.
You'll quickly make the diagnosis of retinal pathology
using bedside ultrasound.
And hopefully now be able to discriminate
that from vitreous disease.
Potentially improving the management of patients
presenting with ocular complaints
to the emergency department.
So I hope to see you back in the future
as SoundBytes continues.

Brightcove ID

5745551911001

https://youtube.com/watch?v=lQo-Nm0Y5m0

Case: Ocular Ultrasound Part 1

Read more about Case: Ocular Ultrasound Part 1

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Part 1 of 2. Ocular ultrasound case study.

Clinical Specialties

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Ocular

Intraccular Structures

Intraoccular Foreign Body

Intercranial Pressure

Membrane Optic Nerve Sheath Measurement

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Soundbytes Cases

Subtitles

- Hello my name is Phil Perrea
and I'm the emergency ultrasound co-director
at the LA County USC Medical Center
in Los Angeles, California.
And welcome to Soundbytes.
Today's clinical case is entitled
Fourth of July in My Eye.
And our patient today is a 24 year old male
who presents to the emergency department
complaining of painless loss of vision to his right eye.
Initially, he was reading an engineering textbook
in preparation for final exams
when he experienced flashes of lights
into the right eye like fireworks.
And now he notes decreased vision to his right eye
described like a curtain coming in from the side.
So the history taken from our patient
suggest pathology in the posterior aspect
of the patient's eye.
And unfortunately for us,
this has traditionally been a black box area of the eye
as it's very difficult to examine using traditional means.
So that leads us into our clinical question for today,
which is for physicians working in the emergency department
in the year 2011,
what techniques do we currently have
to make the diagnosis of pathology
within the posterior aspect of the eye
and can we do better than our traditional testing.
Traditionally we've used the fundoscopic exam
to examine the posterior aspect of the eye,
and interestingly enough,
we're currently using technology, the opthalmoscope,
which was originally invented in the year 1851
by Von Helmholtz in Germany.
Now this was adapted in 1915 by Welch Allen
into our modern opthalmoscope that we see here
to the upper left,
and we've had a slight improvement
with the fundoscopic gun, as shown here towards the right,
which may give a better view of the retina.
However it's well understood by ophthalmologists
that direct opthalmoscopy gives a limited view of the retina
in comparison to the techniques that they'll use
on examination of the retina,
which is indirect opthalmoscopy
using a mirror and curved lens.
In fact, making the topic of ocular ultrasound
very pertinent for the emergency physician,
is the fact that the eye is actually
the perfect organ for ultrasound examination
and could not have been engineered better.
Fluid throughout the eye
allows for great conduction of sound waves
through the anterior part of the eye
into the posterior aspect of the eye,
and excellent imaging of all parts of the eye.
Many type of pathology can be correctly diagnosed
using bed side ultrasonography.
So what do I need to perform this examination?
Well any standard emergency department
bedside ultrasound machine will do well for this exam.
We'll need to have the high frequency
linear array type probe,
that's the probe that you're already using
for vascular access,
which we'll be using for ocular ultrasound.
We'll need lots of gel,
or preferably surgilube,
as surgilube is less irritating to the closed eyelid.
Now let's watch a video on how to perform
the ocular ultrasound examination.
Here we have the high frequency
linear type array probe in our hand,
and note we've prepared our patient
with a copious amount of sergilube
on the outer part of the closed eyelid.
We're going to gently place the probe
over the patient's closed eyelid,
scanning through the eye,
and note that we're going to orient the probe
both superior and inferior
looking all the way through the eye
from the anterior aspect down through the posterior part.
Now from this orientation, I like to have the probe marker
oriented laterally
towards the outer part of the patient's face
so that I know where the structures
of the posterior part of the eye are oriented.
Now let's take a look at that same
ocular ultrasound approach
from a more anterior position.
Note again that we're placing the probe,
the high frequency linear type array probe,
over the closed eyelid
in a side to side orientation.
Now the probe marker is going to be oriented laterally
towards the outer part of the patient's face.
Now remember that if there's any question of trauma
or globe rupture,
we have to be extremely careful
when applying the probe onto the eyelid.
In fact, we should really be scanning through
a copious amount of gel, known as a gel pillow,
and really not applying any pressure down
to the actual eye.
To complete our examination of the eye
we should also perform ocular ultrasound
from the vertical approach,
having the probe in an up and down configuration.
Note here, we're again scanning through the closed eyelid.
Now we have the probe marker up towards the patient's head.
We want to scan from side to side
to fully investigate the eye
in a second plane
for any signs of pathology.
And here is just a closed in view
showing the probe placed over the closed eyelid.
Here's a more anterior view,
again, showing the vertical approach
to bedside ocular ultrasound.
Note the high frequency probe placed over the closed eyelid
and scanning from side to side
will image all parts of the eye.
Remember that the probe marker for this vertical approach
is going to be oriented superiorly.
And imaging in two planes
will best round out the examination of the eyeball.
Now let's take a moment to review the anatomy of the eye
that we'll see using bedside ocular ultrasound.
Here's a nice pictorial of the eyeball.
Lateral of the eye to the left
and medial aspect of the eye to the right.
Let's start with the most anterior structure, the cornea,
which we see towards the top part of the image.
We can see the lens,
which is located directly below the cornea,
which will have a distinct hyperechoic
or bright appearance on bedside ultrasound.
We note the iris coming in to attach to the lens,
another structure that can be seen
using bedside ultrasound.
Now that region anterior to the iris
is known as the anterior chamber.
And we can also image pathology
within the anterior chamber, really hyphemas.
Now behind the lens is going to live
the vitreous body,
filled with vitreous gel,
which allows the eyeball to keep that rounded configuration.
We see blood vessels arching up into the vitreous body.
Now let's recall the outer parts of the eyeball
and the fibrous coat, the sclera,
is the outermost portion of the eye.
We see the medial aspect of the coats of the eyeball,
the choroid, which is the vascular layer
which supplies the retina with blood,
and then we see the inner neural layer, the retina.
And we note that the optic nerve comes in posteriorly,
another structure which can be seen on bedside ultrasound
to give rise to the retina.
Now we note here,
the indentation, the macula,
which is seen just lateral to the optic nerve.
And we recall that the macula
is the area of the densest composition
of rods and cones.
Here's a typical ultrasound of a normal eye.
This eye is taken in the horizontal
or side to side probe configuration
with the probe marker lateral.
We see the cornea, the anterior most structure of the eye,
and we see below the cornea, the rounded iris.
Note the classic appearance of the lens
just below the iris,
which has a hyperechoic or bright appearance
due to its very hard refractive pattern.
And we can see little refraction waves
coming off the back of the lens.
Note the anterior chamber, the potential space,
just anterior to the iris
and below the cornea.
We see the vitreous body and back of the lens
and note the retina, well seen here,
to the posterior aspect of the vitreous body.
This retina is well tacked down
and in opposition to the posterior aspect of the eye.
That's a normal examination.
Now if we have the probe in a side to side
or transverse orientation, across the eye,
with the probe marker lateral
and we aim the probe a little bit more inferiorly
down towards the patient's foot,
the optic nerve sheath will come into view.
Note the optic nerve has a classic appearance
on bedside ultrasound.
It's dark or hypoechoic.
And we can see it leading right up to the back of the eye.
In conclusion, thanks for tuning in
to part one of ocular ultrasound.
I hope I've been able to score the point through this module
that ocular ultrasound is an easily learned
and very helpful technique for the emergency physician
and in the year 2011,
finally allows excellent imagining
of that black box posterior area of the eye.
I hope to see you back in the future
as Soundbytes continues,
and as we return in ocular ultrasound part two,
focusing on retinal pathology.

Brightcove ID

5745552411001

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

Case: DVT Ultrasound Part 2

Read more about Case: DVT Ultrasound Part 2

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Deep-Vein Thrombosis and Ultrasound: Case Study

Media Library Type

Media Library Tag

Deep Venous Thrombosis

Superficial Femoral Vein

Three-Point Compression

Thrombosis

Thrombus

Vein

Subtitles

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

Brightcove ID

5508109927001

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

Case: DVT Ultrasound Part 1

Read more about Case: DVT Ultrasound Part 1

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Case Study on Deep Vein Thrombosis.

Media Library Type

Case Study Videos

Media Library Tag

Lower Extremity

Deep Venous Thrombosis

Three-Point Compression

Patency

Mid Thigh

Superficial Femoral Vein

Common Femoral Vein

Soundbytes Cases

Subtitles

hello my name is Phil Pereira and an emergency ultrasound code
at the LAN
the USC Medical Center in Los Angeles California and welcome to sound bites
welcome back to sound bites ultrasound in this module will learn the focused
ultrasound evaluation of the like four deep venous thrombosis
now divided this module up in two parts one and two
in this module entitled dvt ultrasound part 1
well first of all learn the normal anatomy of the leg veins integral to
performance of the dbt ultrasound examination will then move on to learn
the normal compression exam of the leg veins and how to interpret normal
findings on the bedside dbt examination specifically in this module we're going
to concentrate on the focus dbt examination the focused or limited dbt
exam allows for increased speed in the performance of the examination will
concentrate on to specific areas of the leg
looking at the femoral region and the popliteal region
this limited examination also maintains excellent sensitivity in the detection
of proximal DB tease and in fact most radiology perform dvt examinations
screen only down to the popliteal vessels the cafe an exam is not
routinely performed as part of most radiology perform dvt examinations and
indeed in the focus dvt examinations will skip the examination of the cap
themes that leads us into the concept of the focus dbt exam as being an optimal
means for evaluation for dvt at the bedside and the focus dvt exam will
begin by examining the femoral vein starting high at the level of the
proximal common femoral artery and vein just below the inguinal ligament will
continue the exam of the femoral vein down about four to five sauna meters
through to bifurcation of the vein into the deep and superficial femoral veins
well then turn to examination of the popliteal vein placing the probe hi
within the popliteal fossa will examine the popliteal vein about for sauna
meters within the popliteal fossa continuing the exam of the popliteal
vein down to trifurcation of the vessel into the cap gains
let's now review the lower extremity Venus anatomy integral to performance of
the focus dvt examining
action we begin by identifying the common femoral vein seen here just below
the England ligament notice that the common femoral vein is seen just medial
to the common femoral artery
now the common femoral vein continues down the leg to bifurcate into the deep
and superficial femoral veins
we note here the deep femoral vein coursing to the back of the leg and we
know the adjacent deep femoral artery
we also see here the saphenous vein which joins into the common femoral vein
above the level of bifurcation
now it's important to realize that the superficial femoral vein is the thing
that actually continues down the leg to become the popliteal vein behind the
knee and we note the superficial femoral vein coursing down the leg and
accompanied by the parrot superficial femoral artery behind the knee that
superficial femoral vein will become the popliteal vein and we see the adjacent
popliteal artery
now at the level of traffic ation the popliteal vein will become three
different campaigns and we note here the anterior tibial vain
that's going to course anteriorly on to the CAF the posterior tibial vain seen
post dearly in the CAF and also the perineal vain seem to the lateral aspect
of the cab and it's because these campaigns are so small that it's
difficult to see them on bedside ultrasound ography let's now watch a
video and learn how to perform the ultrasound examination looking for dvt
within the femoral vein system
we begin by placing the high-frequency linear array type probe
it's the same probe that you'll be using for vascular access and a side-to-side
orientation over the common femoral vein and artery just below the inguinal
ligament notice that we're compressing down with the probe and essentially the
dbt exam is a compression exam as a normal vein will completely closed with
pressure down with the probe notice that were sequentially compressing at
different levels along the common femoral vein compressing from the
beginning at the top just below the in Qin ligament all the way down through
bifurcation into the superficial and deep femoral vessels
now a clot will not completely compress with pressure down with the probe and
thus will be identified on bedside examination notice here
its standard to have the marker on the probe going lateral so that we know
where we are with regard to the orientation of the probe versus the
screen
it's best to position our patients slightly up right to distend the femoral
vessels for the DVT exam and as shown in this video we actually had the patient
with a head of the bed up about 30 degrees
we also want to have the legs slightly externally rotated to best orient so
that we can place the probe directly over the common femoral artery and bein
here we see the ultrasound findings that will occur when placing the probe as
shown in the illustration towards the left a note here the probe is placed
with the marker . laterally just inferior to the England ligament over
the common femoral artery and vein as shown in the pictorial towards the right
notice here that the common femoral vein will be seen medial to the common
femoral artery and because we have the marker . oriented laterally or towards
the left of the image the common femoral vein will be seen to the right here
here's a video showing the actual ultrasound findings of the common
femoral artery and vein using color flow Doppler we are in two selves to the
image to the left here showing that the common femoral vein will be seen
medial to the common femoral artery and we know the ultrasound findings to the
right showing pulsatile flow within the common femoral artery
located just lateral to the common femoral vein and we see the basic hum of
the blood flow within the common femoral vein seen medial to the artery here
well it's very nice to have color flow Doppler to differentiate the common
femoral artery from the common femoral vein we can also discern the to using
grayscale or b-mode sonography as shown in the video clip here to the right here
we note the common femoral artery to the left or lateral to the common femoral
vein as shown medially notice that the common femoral artery has more
hypertrophic walls and also pulsatile flow within it
differentiating it from the common femoral vein as seen medially continuing
down the leg as shown in the prone position in the illustration to the left
here we see the following ultrasound findings in the illustration to the
right
we know that the femoral arteries bifurcate at level above the comment
from
vain and here we see these superficial and deep femoral arteries in a location
just lateral to the common femoral vein
we also see a very important landmark the saphenous vein joining in to the
common femoral vein at this level it's very important to visualize the south in
this vein as it's really the only superficial vein in the body that we
worry about clot formation within as it goes directly into the common femoral
vein and can propagate up into the IVC and into the heart
here we see a video clip using color flow Doppler demonstrating the
bifurcation of the femoral artery into the superficial and deep family arteries
and here we see that bifurcation point right there
notice that the femoral arteries are located laterally or towards the left of
the common femoral vein which we see located neatly or towards the right of
the image in this video clip will note the bifurcation of the common femoral
artery into superficial and Profundis femoral arteries using grayscale or
b-mode sonography we know the common femoral vein is shown towards the medial
aspect of the image or towards the right and here again we see that bifurcation
point of the common femoral artery into the superficial and profundus femoral
arteries is labeled there and we just remember that . that the artery
generally bifurcates at a level higher than the femoral vein in this video clip
we're able to get a good look at the saphenous vein joining in to the common
femoral vein and we see the common femoral vein located medial to the
common femoral artery
note that the saphenous vein has the look often of a little hat on top of the
common femoral vein and we note here also the turbulent flow of blood here
within the common femoral vein as this was taken in the hypotensive patient
now let's turn our attention to the anatomy of the popliteal fossa
we note here the popliteal vein and the popliteal artery
remember that the popliteal vein is going to be in an orientation
located more posterior to the popliteal artery which will be located more
anterior
here's how to perform the focus dvt ultrasound exam looking into the
popliteal fossa
it's best to have the patient sitting up to further to stand the popliteal vein
and I like to have the patient sitting up with the leg dangling over the bed
I can then pull up a chair and move anterior to the page
agent will place the high-frequency linear array probe
hi within the popliteal fossa sequentially compressing it levels down
all the way down to trifurcation notice that we're using our other hand to
stabilize the anterior knee as we press with the probe post dearly
so again we'll start high within that Papa teal fossa compressing sequentially
all the way through the levels of the popliteal artery and vein down inferior
they're all the way down to trifurcation here's the anatomy with that will see
with the probe placed as shown in the illustration to the left
notice that the probe is placed into the posterior aspect of the knee behind the
popliteal fossa
again with the marker . oriented laterally thus will see the following
images as shown in the illustration to the right note that the popliteal vein
will be located closer to the probe or posterior to the popliteal artery which
will be further away from the probe or more anteriorly located as shown in this
image in this image will use color flow Doppler to further differentiate the
popliteal artery from the popliteal vein and in the video clip here to the right
we can see the pulsatile flow of blood within the popliteal artery has seen and
ear or further away from the probe then the popliteal vein which has seen more
posterior than the artery here
notice that we see a little bit of phasic flow of blood within the
popliteal vein
this video clip employees be mode or grayscale sonography to show the
popliteal vein and popliteal artery
again we can see the popliteal artery located more anterior than the popliteal
vein and we can see the pulsatile movements of the popliteal artery
differentiating it from the vein and in fact we can see a little bit of
turbulent flow of blood within the popliteal vein here and located more
posterior Lee than the popliteal artery
when performing the focus lower extremity dvt ultrasound examination we
want to first identify the femoral and popliteal arteries and veins using be
mode or grayscale sonography now colorflow doppler ultrasound can be
helpful in differentiating the artery from the vessel and also making sure
that you're looking at vascular structures but is not essential most of
our information will actually come from b-mode sonography want to apply
compression to the vein pressing down with the probe
in the short axis or transverse orientation in a normal examination the
walls of the vein will completely touch together
conversely if a dbt is present the walls of the vein will not completely touch
together as a thrombus within the lumen of the vein will prevent the walls from
completely collapsing
here we see normal compression of the common femoral vein and we see here the
common femoral vein to the right of the common femoral artery which we see to
the left
no we're looking in the short axis or transverse orientation pressing down
with the probe and note with pressure down on the probe that the common
femoral vein completely collapses and that the walls the anterior wall and
posterior wall of the vessel meet
we also see compression of the saphenous main that little cap on the top of the
common femoral vein so a completely normal exam of the common femoral vein
at the level just below the England ligament here we're looking a little bit
more distally at the common femoral vein at the level of the bifurcation of the
common femoral artery into superficial and profundus femoral arteries and we
note here complete compression of the vein as we push down with the probe and
note again that the anterior and posterior wall is completely meet
together
now let's move down the leg to look at the normal compression exam of the
popliteal vein recall that the popliteal vein is going to be seen towards the
posterior aspect of the image or closer to the top of the image here then the
popliteal artery as we press down we know complete compression of the
popliteal vein and we see here that the artery still stays open
so again this would be a normal compression exam of the popliteal vein
with the anterior and posterior walls of the vessel completely touching down with
pro pressure
in conclusion thank you for joining me for the sound bites module going over
bedside dvt examination part 1
hopefully now you understand the focus dbt exam which allows for increased
speed with excellent accuracy in the exam performance in this module part 1
we focused on the basic anatomy and the normal examination for the DVT
evaluation for a normal examination we hope that the femoral and popliteal
veins will completely compress down with pro pressure
unfortunately a venous thrombosis will prevent
vane from closing and so we're turn in part to going over the positive
examination and those findings that you might encounter on the focus bedside dbt
examination
so I hope to see in the future as sound bites continues

Brightcove ID

5508123523001

https://youtube.com/watch?v=Sh5cL72kgnU

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