Emergency Ultrasound Course · 2019. 10. 31. · Emergency Ultrasound Course Huntington Beach, CA...
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Emergency Ultrasound Course Huntington Beach, CA November 8-10, 2019
Transcript of Emergency Ultrasound Course · 2019. 10. 31. · Emergency Ultrasound Course Huntington Beach, CA...
Emergency Ultrasound Course
Huntington Beach, CA November 8-10, 2019
BasicCardiac Ultrasound
Vi Dinh, MD RDMS RDCSAssociate ProfessorEmergency Medicine
Internal Medicine, Critical CareLoma Linda University Medical Center
Obtain 4 Cardiac Views
GOAL
Parasternal Long Axis
Parasternal Short Axis
Apical 4 Chamber
Subxiphoid
ProbeSelection
PRESET
Supine
Patient Position
Left Lateral Decubitus
Which Way does the INDICATOR GO??
Indicator Location?
Standard Cardiology
Standard
Parasternal Long View:Indicator towards LEFT HIP
Cardiology
Parasternal Long View:Indicator towards RIGHT SHOULDER
LEFT ventricleLEFT side of screen
parasternal LONG axis
3 L’s to successPSLA
LV
LV is on RIGHT
Side of Screen
LV
Rotate probe1800
Systematic Protocol
Parasternal Long Axis
Parasternal Short Axis
Apical 4-Chamber
Subxiphoid
1234
CARDIOLOGY Views
Parasternal LONG Axis
1
Parasternal LONG Axis
1. Indicator to R shoulder
4. Keep probe perpendicular and move up and down sternum
2. NEXT to sternum
3.Nipple line/4th Intercostal space
HUG the Sternum
LEFT Ventricle = “CONE”
Apex
Apex
Base
Base
Ant
Inferior
Ant
Inferior
APEX
BASE
Anterior
Posterior
PSLA
APEX
BASE
Anterior
Posterior
PSLA
RV
LVLVOT
LA
DA
Parasternal Long Axis
PSLA
APEX
BASE
Anterior
Posterior
RV
LV
LVOT
LA
DA
PSLA
APEX
BASE
Anterior
Posterior
Parasternal SHORT Axis
2
rotate CLOCKWISE 90 degrees
Indicator LEFT Shoulder
Probe Orientation?
Parasternal SHORT Axis
Mid-Papillary View
Mid-Papillary View
RIGHT
LEFT
Anterior
Posterior
LV
Papillary Muscles
RVIVS
Mid-Papillary View
RIGHT
LEFT
Anterior
Posterior
Mid-Papillary View
RIGHT
LEFT
Anterior
Posterior
LV
Papillary Muscles
RV
LV
Papillary Muscles
RV
Mitral Valve“Fish Mouth”
Mitral Valve“Fish Mouth”
RIGHT
LEFT
Anterior
Posterior
MV
RV
Aortic Valve“Mercedes Benz”
AVRA
RV
LA
RVOT
Aortic Valve“Mercedes Benz”
RIGHT
LEFT
Anterior
Posterior
LA
RA AVRVOT
RV
LA
RA RVOT
RV
AV
Apical 4-Chamber
3
Apical 4 Chamber
APEX
BASE
Finding the APEX
Apical ViewRIGHT
LEFT
APEX
BASE
A4
Apical View
LVRV
RALA
Mitral ValveTricuspid Valve
RIGHT
LEFT
APEX
BASE
A4
SUBXIPHOID“SUBHEPATIC”
4
Subxiphoid View
B ASE
APEX
RIGHT
LEFT
RV
LV
RA
LA
LIVER
B ASE
APEX
RIGHT
LEFT
RV
LVRA
LA
LIVER
B ASE
APEX
RIGHT
LEFT
SX
Sub XIPHOID
Sub “HEPATIC”
Start RIGHT and sweep in
Putting it All Together!
1st ViewParasternal LONG axis
Indicator towards RIGHT Shoulder
2nd ViewParasternal SHORT axis
Rotate 900 Clockwise Indicator towards LEFT Shoulder
3rd ViewApical 4-Chamber
SLIDE probe to the apex and TILT
4th ViewSubxiphoid View
Place hand OVER probeBring to below xiphoid
1 PSLA2 PSSA3 A4C4 Subxiphoid
Summary
3 L’s
SYSTEMATIC Protocol
Let the views GUIDE you
Inferior Vena Cava
CVP
IVCat RA junction
Caval Index CVP (mm Hg)
<1.5cm >50% 0-5
1.5-2.5cm >50% 5-10
1.5-2.5cm <50% 10-15
>2.5cm little change 15-20
Start Short AxisRotate Clockwise 900
IdentifyIVC
AORTA
Use Cursor!
Diaphragm Movement!
M-mode
2cm pastHepatic Vein
M-modewith Sniffing
Incorrect M-mode Cursor
Caval Index
IVCe IVCi
Caval Index
IVCe IVCi
IVCe - IVCiIVCe
IVCe IVCi
Max - MinMax
>50%
IVCDiameter
Collapsibility CVP (mm Hg)
<2.1cm >50%Normal
0-5
<2.1cm <50%Indeterminate
5-10
>2.1cm >50%Indeterminate
5-10
>2.1cm <50%High10-20
J Am Soc Echocardiogr 2010;23:685-713
IVCDiameter
Collapsibility CVP (mm Hg)
<2.1cm >50%Normal
0-5
<2.1cm <50%Indeterminate
5-10
>2.1cm >50%Indeterminate
5-10
>2.1cm <50%High10-20
J Am Soc Echocardiogr 2010;23:685-713
CARDIACPATHOLOGY
MUST know Diagnoses
Cardiac Standstill
Pericardial Effusion/Tamponade
Right Ventricular Strain
Ejection Fraction
CARDIAC STANDSTILL
Cardiac Standstill
SX
B ASE
APEX
RIGHT
LEFT
Minimal Activity
SX
B ASE
APEX
RIGHT
LEFT
Minimal Activity
SX
B ASE
APEX
RIGHT
LEFT
Pericardial Effusionand
Tamponade
use ALL VIEWS
PSLA
APEX
BASE
Anterior
Posterior
Normal Heart
DescendingAorta
PSLA
APEX
BASE
Anterior
Posterior
Normal Heart
Pericardial EffusionAND
Pleural Effusion
DescendingAorta
PSLA
APEX
BASE
Anterior
Posterior
PSLA
APEX
BASE
Anterior
Posterior
PericardialEffusion
Pericardial EffusionAND
ASCITES
SX
B ASE
APEX
RIGHT
LEFT
TAMPONADE
RIGHT VENTRICULAR DIASTOLIC COLLAPSE
Tamponade
SX
B ASE
APEX
RIGHT
LEFT
Tamponade
PSLA
APEX
BASE
Anterior
Posterior
TAMPONADE
RIGHT ATRIAL SYSTOLIC COLLAPSE
MASSIVE Pulmonary Embolism
Right Ventricular Strain
Normal RV 2/3 size of LV
PSLA
APEX
BASE
Anterior
Posterior
Right VentricularStrain
RV
APEX
BASE
Anterior
Posterior
PSLA
Compared toNormal Heart
RV
Mcconnell’s Sign
A4
RIGHT
LEFT
APEX
BASE
apex hyperkinetic
RV
D Sign
RIGHT
LEFT
Anterior
Posterior
ParasternalSHORT
RV
LVD
Estimating Ventricular Function
PSLA
Normal Heart
LV
MV
APEX
BASE
Anterior
Posterior
A4
RIGHT
LEFT
APEX
BASE
DEPRESSED Activity
LV
MV
PSLA
APEX
BASE
Anterior
Posterior
SEVERELYDEPRESSED
Activity
LV
MV
E point Septal Separation
QuantitativeMITRAL VALVE Assessment
M-MODE
RV
IVS
Ant MV
Post MV
LV
Slide 17
E-POINT SEPTAL SEPARATION
Ventricular Filling
Diastole Systole
Anterior Leaflet
E wave A wave
MEASURE HERE
Normal EF Reduced EF
<8mm >55%(Normal)
8 -18mm30 - 50%
(Moderately Reduced)
>18mm <30%(Severely Reduced)
EPSS Ejection Fraction
Formula
EF = 75 - EPSS (2.5)
*EPSS in mm
Formula
EF = 75 - EPSS (2.5)
*EPSS in mm
Formula
EF = 75 - 6 (2.5)
Formula
EF = 75 - 15.6 = 59%
Limitations of EPSS
Mitral Stenosis
Mitral Valve Surgery
Aortic Regurgitation
MUST know DiagnosesCardiac Standstill
Pericardial Effusion/Tamponade
Right Ventricular Strain
MUST know Hemodynamics Ventricular Function Assessment
IVC Assessment
