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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

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10/9/2019 1

October 20-21, 2019

Point of Care Ultrasound UCSF Continuing Medical Education Cardiac Trevor Jensen, MD, MPH

Disclosure

I have no relevant financial relationships with any companies related to the content of this course.

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10/9/2019 2

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

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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

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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

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  • 3 Windows
  • Parasternal
  • Apical
  • Subcostal

Sonographic Windows

Slide adapted with permission from Arun Nagdev

Parasternal Long

Parasternal Short Apical 4-Chamber Subcostal

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Parasternal Long: Probe + Position Parasternal Long Anatomy

Images obtained from echocardiographer.org

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LV LV

RV RV

Parasternal Long Axis View

LV LV

RV RV Ao

DTA

Mitral Valve Leaflets

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

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Parasternal Long: Normal Parasternal Long: Abnormal

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Parasternal Long Tips

  • Stay close to sternum
  • Sonographic windows and axes vary
  • Difficult in COPD
  • Look for the Mitral Valve

Parasternal Short: Position

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Parasternal Short: Orientation Parasternal Short: Orientation

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Parasternal Short: Interpretation

  • Utility

– Gross LV systolic function – Assessed at level of papillary muscles – Regional wall motion abnormalities – RV size

Parasternal Short: Normal

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Parasternal Short: Abnormal Parasternal Short Tips

  • Stay close to sternum
  • Sonographic windows and axes vary
  • Difficult in COPD
  • Look for the Mitral Valve
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Subcostal View: Position Subcostal View: Orientation

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Subcostal View: Interpretation

  • Utility

– LV Systolic Function – Pericardial Effusion – Right atrium and ventricle size

Subcostal View: Normal

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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
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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

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Apical 4 Chamber: Normal Apical 4 Chamber: Abnormal

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Apical 4 Chamber View

  • Tips:
  • Under the breast fold
  • Left lateral decubitus
  • End-expiratory hold
  • Aim sound waves

toward right scapula

Valvular disease

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Right Ventricle Evaluation

IVC: Position

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IVC: Orientation IVC: Measurement

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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

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Fan IVC/Aorta/IVC

  • IVC: Abnormal
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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