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10/9/2019 Point of Care Ultrasound UCSF Continuing Medical Education Cardiac Trevor Jensen, MD, MPH October 20-21, 2019 Disclosure I have no relevant financial relationships with any companies related to the content of this course. 1

10/9/2019 POCUS Cardiac and IVC Cardiac US • Keep it basic • Echocardiography is very complex • We will focus on the fundamentals that will help you care for your patients at the beside • These images will be used with the clinical history to make decisions on your patient 2

10/9/2019 Utility & Protocols • RUSH – Rapid Ultrasound in Shock – Patient is hypotensive or unresponsive • CLUE Protocol – Cardiopulmonary Limited Ultrasound Exam – Patient needs rapid assessment for heart failure • BLUE Protocol – Bedside Lung Ultrasound in Emergency – Patient is in respiratory failure Probe Selection Phased Array Low Frequency Small footprint to image between ribs 3

10/9/2019 How to Hold the Probe • Hold probe like a pencil • Brace hand on the patient • Larger motions that gradually become finer movements to improve image • Sufficient use of ultrasound gel Position of the Patient • Most likely will be supine in the ED/Hospital/ICU • Left Lateral Decubitus will usually result in improved images 4

10/9/2019 Sonographic Windows • 3 Windows • Parasternal • Apical • Subcostal Slide adapted with permission from Arun Nagdev Parasternal Short Parasternal Long Subcostal Apical 4-Chamber 5

10/9/2019 Parasternal Long: Probe + Position Parasternal Long Anatomy Images obtained from echocardiographer.org 6

10/9/2019 Parasternal Long Axis View RV RV LV LV RV RV LV LV Ao Mitral Valve Leaflets DTA Slide adapted with permission from Arun Nagdev Parasternal Long: Interpretation • Utility – Effusion – LV Function • Indices – Movement of mitral valve leaflet tips (EPSS) – Movement of lateral mitral valve annulus – LV Wall Thickening – Change in chamber size • Functional Categories (all views) – Hyperdynamic – Normal – Mildly decreased – Severely decreased 7

10/9/2019 Parasternal Long: Normal Parasternal Long: Abnormal 8

10/9/2019 Parasternal Long Tips • Stay close to sternum • Sonographic windows and axes vary • Difficult in COPD • Look for the Mitral Valve Parasternal Short: Position 9

10/9/2019 Parasternal Short: Orientation Parasternal Short: Orientation 10

10/9/2019 Parasternal Short: Interpretation • Utility – Gross LV systolic function – Assessed at level of papillary muscles – Regional wall motion abnormalities – RV size Parasternal Short: Normal 11

10/9/2019 Parasternal Short: Abnormal Parasternal Short Tips • Stay close to sternum • Sonographic windows and axes vary • Difficult in COPD • Look for the Mitral Valve 12

10/9/2019 Subcostal View: Position Subcostal View: Orientation 13

10/9/2019 Subcostal View: Interpretation • Utility – LV Systolic Function – Pericardial Effusion – Right atrium and ventricle size Subcostal View: Normal 14

10/9/2019 Subcostal View: Abnormal Subcostal 4 Chamber View • Tips: • Firm pressure • Inspiratory hold • Bend the knees • Bowel Gas? Try right of midline • Great for COPD patients 15

10/9/2019 Apical 4 Chamber • Utility – Systolic function – Chamber size – Valvular abnormalities – Doppler measurements • Challenges – most difficult view to obtain – prone to errors in interpretation Apical 4 Chamber: Orientation 16

10/9/2019 Apical 4 Chamber: Normal Apical 4 Chamber: Abnormal 17

10/9/2019 Apical 4 Chamber View • Tips : • Under the breast fold • Left lateral decubitus • End-expiratory hold • Aim sound waves toward right scapula Valvular disease 18

10/9/2019 Right Ventricle Evaluation IVC: Position 19

10/9/2019 IVC: Orientation IVC: Measurement 20

10/9/2019 IVC: Interpretation • Location: • 2‐3 cm caudal to RA or 0‐1 cm caudal to hepatic vein • Metrics • Max diameter: 2.1 cm • Collapsibility: 50% Don’t fall for Aorta! IVC Aorta 21

10/9/2019 Fan IVC/Aorta/IVC • IVC: Abnormal 22

10/9/2019 Summary • Focus on the basic exams + basic interpretations first – Most evidenced based for non‐cardiologists • Even basic exams have broad list of applications – Hypotension – Dyspnea – Volume overload – Unresponsiveness • Build towards more complex exams and protocols 23