Point of Care Ultrasound for the Hospitalist UCSF Parnassus Campus - - PDF document

SUNDAY – MONDAY

October 20-21, 2019

UCSF Parnassus Campus • San Franciso, CA

Department of Medicine University of California, San Francisco School of Medicine

Point of Care Ultrasound for the Hospitalist

COURSE DIRECTORS

Brandon Boesch, DO Hospitalist, Department of Medicine Division of Inpatient Medicine Alameda Medical Center – Highland Hospital Oakland, California Trevor Jensen, MD, MS Assistant Professor of Medicine, Division of Hospital Medicine University of California, San Francisco San Francisco, California

Department of Medicine, Division of Hospital Medicine University of California, San Francisco School of Medicine

UCSF

Point of Care Ultrasound for the Hospitalist

October 20-21, 2019

UCSF Clinical Skills Center San Francisco, California Course Chairs Brandon Boesch, DO

Chief of Hospital Medicine Internal Medicine Point of Care Ultrasound Director Highland Hospital –A Member of Alameda Health System Oakland, California

Trevor Jensen, MD, MS

Assistant Professor of Medicine, Division of Hospital Medicine University of California, San Francisco San Francisco, California

POCUS for the Hospitalist

OVERVIEW

The UCSF Point-of-Care Ultrasound (POCUS) for the Hospitalist Workshop is a hands-on experience to learn the techniques of bedside ultrasound. Live demonstrations, case review, and didactics will complement hours of hands-on practice sessions. Participants will gain the skills, knowledge, and confidence to integrate bedside ultrasound into clinical practice. The workshop is designed to maximize the participant’s time practicing ultrasound skills on live models. The groups will have a small ratio of participants learning (3:1 at hands on stations) from experienced instructors who utilize POCUS in their hospital medicine practices. The curriculum will be based on practical skills needed for the hospitalized patient with a focus on protocols and cases that underscore how POCUS can be applicable in real world scenarios. Specifically the participant will learn to obtain imaging of the heart, lungs, abdominal organs, and vascular structures with time to practice interpretation of normal and abnormal images and discussion of clinical applicability. Attendees will learn appropriate ultrasound guided technique for procedures such as thoracentesis, central venous access, and paracentesis with time for questions and answers. The workshop ends with a special session on program development and economics of POCUS. This course is an “Approved 2-day POCUS Course” for the SHM POCUS Certificate of Completion https://www.hospitalmedicine.org/clinical-topics/ultrasonography-cert/

OBJECTIVES

At the end of the workshop, a participant will have enhanced skills and strategies to: 1. Apply the fundamental principles of ultrasound technology and perform basic operation of a portable ultrasound machine; 2. Utilize techniques to perform bedside ultrasound for the purpose of procedural guidance (paracentesis, thoracentesis, central venous catheter placement, and lumbar puncture); 3. Utilize techniques to perform focused diagnostic ultrasound examinations at the bedside, including imaging of the heart, lungs, and major abdominal organs; 4. Recognize the indications for basic point of care ultrasound exams and protocols, in light of the clinical utility and limitations of bedside ultrasound imaging; 5. Practice interpretation of normal and abnormal ultrasound images.

ACCREDITATION

The University of California, San Francisco School of Medicine (UCSF) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Physicians: UCSF designates this live activity for a maximum of 13.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Nurses: For the purpose of recertification, the American Nurses Credentialing Center accepts AMA PRA Category 1 Credit™ issued by organizations accredited by the ACCME. Pharmacy: The California Board of Pharmacy accepts as continuing professional education those courses that meet the standard of relevance to pharmacy practice and have been approved for AMA PRA Category 1 Credit™. Physician Assistants: AAPA accepts Category 1 Credit™ from AOACCME. Prescribed credit from AAFP, and AMA PRA Category 1 Credit™ from organizations accredited by the ACCME. This CME activity meets the requirements under California Assembly Bill 1195, continuing education and cultural and linguistic competency. ABIM MOC Credits: American Board of Internal Medicine (ABIM) MOC: Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 13.75 MOC points in the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit. IMPORTANT: The online course evaluation must be completed by the due date specified. Within 45 days after submitting your evaluation, we will report your MOC points.

GENERAL INFORMATION

Attendance Verification/Sign-In Sheet / CME Certificates Please remember to sign-in on the sign-in sheet when you check in at the UCSF Registration Desk on your first day. You only need to sign-in once for the course, when you first check in. After the meeting, you will receive an email with a link to complete your online Course Evaluation / Electronic CME Certificate. Our Qualtrics survey system will send you reminders to complete your survey and claim your credit (until you do) for the period the survey is open. Upon entering your credit claim information, your CME certificate will be automatically generated on screen to print and/or email yourself a copy. If you’re not using a mobile device, you will also receive a copy by email automatically. For smartphone users, you may want to take a photo of your certificate as some settings prevent you from emailing the certificate. The link will be available for 30 days after the last day of the course. However, after that date the link will expire and you will no longer be able to claim your credits online. You must then contact the Office

• f CME at registration@ocme.ucsf.edu to receive your certificate.

Electronic Syllabus

In an effort to minimize our carbon footprint, we are distributing an electronic syllabus – doing so saves nearly 400,000 pieces of paper! For the evaluation purposes, please rate the syllabus based on the PowerPoint presentation inside the meeting room. After the conference we will be posting an updated PDF copy of all the presentations on this website:http://www.ucsfcme.com/2020/MDM20P02/slides.html Security The campus sees a lot of foot traffic each day from students, faculty, staff, visitors, patients, and the general community. We urge caution with regard to your personal belongings. Please do not leave any personal belongings unattended in the meeting room or break rooms during lunch, the breaks or

• vernight.

Final Presentations A link to PDF versions of the final presentations will be sent via e-mail approximately 2 weeks post

• course. Only presentations that have been authorized for inclusion by the presenters will be

included.

CULTURAL AND LINGUISTIC COMPETENCY

Federal and State Law Regarding Linguistic Access and Services for Limited English Proficient Persons I. Purpose. This document is intended to satisfy the requirements set forth in California Business and Professions code 2190.1. California law requires physicians to obtain training in cultural and linguistic competency as part of their continuing medical education programs. This document and the attachments are intended to provide physicians with an overview of federal and state laws regarding linguistic access and services for limited English proficient (“LEP”) persons. Other federal and state laws not reviewed below also may govern the manner in which physicians and healthcare providers render services for disabled, hearing impaired or other protected categories II. Federal Law – Federal Civil Rights Act of 1964, Executive Order 13166, August 11, 2000, and Department of Health and Human Services (“HHS”) Regulations and LEP Guidance. The Federal Civil Rights Act of 1964, as amended, and HHS regulations require recipients of federal financial assistance (“Recipients”) to take reasonable steps to ensure that LEP persons have meaningful access to federally funded programs and services. Failure to provide LEP individuals with access to federally funded programs and services may constitute national origin discrimination, which may be remedied by federal agency enforcement action. Recipients may include physicians, hospitals, universities and academic medical centers who receive grants, training, equipment, surplus property and other assistance from the federal government. HHS recently issued revised guidance documents for Recipients to ensure that they understand their

• bligations to provide language assistance services to LEP persons. A copy of HHS’s summary

document entitled “Guidance for Federal Financial Assistance Recipients Regarding Title VI and the Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons – Summary” is available at HHS’s website at: http://www.hhs.gov/ocr/lep/ As noted above, Recipients generally must provide meaningful access to their programs and services for LEP persons. The rule, however, is a flexible one and HHS recognizes that “reasonable steps” may differ depending on the Recipient’s size and scope of services. HHS advised that Recipients, in designing an LEP program, should conduct an individualized assessment balancing four factors, including: (i) the number or proportion of LEP persons eligible to be served or likely to be encountered by the Recipient; (ii) the frequency with which LEP individuals come into contact with the Recipient’s program; (iii) the nature and importance of the program, activity or service provided by the Recipient to its beneficiaries; and (iv) the resources available to the Recipient and the costs of interpreting and translation services. Based on the Recipient’s analysis, the Recipient should then design an LEP plan based on five recommended steps, including: (i) identifying LEP individuals who may need assistance; (ii) identifying language assistance measures; (iii) training staff; (iv) providing notice to LEP persons; and (v) monitoring and updating the LEP plan. A Recipient’s LEP plan likely will include translating vital documents and providing either on-site interpreters or telephone interpreter services, or using shared interpreting services with other

• Recipients. Recipients may take other reasonable steps depending on the emergent or nonemergent

needs of the LEP individual, such as hiring bilingual staff who are competent in the skills required for medical translation, hiring staff interpreters, or contracting with outside public or private agencies that provide interpreter services. HHS’s guidance provides detailed examples of the mix of services that a Recipient should consider and implement. HHS’s guidance also establishes a “safe harbor” that

Recipients may elect to follow when determining whether vital documents must be translated into other

• languages. Compliance with the safe harbor will be strong evidence that the Recipient has satisfied its

written translation obligations. In addition to reviewing HHS guidance documents, Recipients may contact HHS’s Office for Civil Rights for technical assistance in establishing a reasonable LEP plan. III. California Law – Dymally-Alatorre Bilingual Services Act. The California legislature enacted the California’s Dymally-Alatorre Bilingual Services Act (Govt. Code 7290 et seq.) in order to ensure that California residents would appropriately receive services from public agencies regardless of the person’s English language skills. California Government Code section 7291 recites this legislative intent as follows: “The Legislature hereby finds and declares that the effective maintenance and development of a free and democratic society depends on the right and ability of its citizens and residents to communicate with their government and the right and ability of the government to communicate with them. The Legislature further finds and declares that substantial numbers of persons who live, work and pay taxes in this state are unable, either because they do not speak or write English at all, or because their primary language is

• ther than English, effectively to communicate with their government. The

Legislature further finds and declares that state and local agency employees frequently are unable to communicate with persons requiring their services because of this language barrier. As a consequence, substantial numbers of persons presently are being denied rights and benefits to which they would

• therwise be entitled.

It is the intention of the Legislature in enacting this chapter to provide for effective communication between all levels of government in this state and the people of this state who are precluded from utilizing public services because of language barriers.” The Act generally requires state and local public agencies to provide interpreter and written document translation services in a manner that will ensure that LEP individuals have access to important government services. Agencies may employ bilingual staff, and translate documents into additional languages representing the clientele served by the agency. Public agencies also must conduct a needs assessment survey every two years documenting the items listed in Government Code section 7299.4, and develop an implementation plan every year that documents compliance with the Act. You may access a copy of this law at the following url: http://www.spb.ca.gov/bilingual/dymallyact.htm

PRESENTING FACULTY

COURSE CHAIRS Trevor Jensen, MD, MS Assistant Professor of Medicine, Division of Hospital Medicine University of California, San Francisco San Francisco, California Brandon Boesch, DO Chief of Hospital Medicine Internal Medicine Point of Care Ultrasound Director Highland Hospital –A Member of Alameda Health System Oakland, California COURSE PRESENTERS & TRAINER James E. Anstey, MD Assistant Professor, UCSF Division of Hospital Medicine Carolina Candotti, MD Assistant Professor of Medicine UC Davis Medical Center Sacramento, California Joel B. Cho, MD, RDMS, RDCS Director, Point-of-Care-Ultrasound Department of Hospital Medicine Kaiser San Francisco Internal Medicine Residency Program Senior Physician The Permanente Medical Group, Kaiser San Francisco San Francisco, California Stephanie M. Conner, MD Assistant Professor of Medicine, Division of Hospital Medicine University of California, San Francisco San Francisco, California Aubrey O. Ingraham, MD Hospitalist Kaiser Permanente Oakland Medical Center Oakland, California Andre D. Kumar, MD Clinical Assistant Professor Co-President, Society of Hospital Medicine Bay Area Stanford University School of Medicine Stanford, California Linda M. Kurian, MD, FACP, SFHM Chief, Division of Hospital Medicine Assistant Professor of Medicine Zucker School of Medicine at Hofstra/Northwell New York, New York Marc Kurtzman, MD Hospitalist The Permanente Medical Group, Kaiser San Francisco San Francisco, California

Farhan Lalani, MD Assistant Professor of Clinical Medicine University of California, San Francisco San Francisco, California Charlie LoPresti, MD Director of Point of Care Ultrasound Louis Stokes Cleveland VA Medical Center Associate Professor of Medicine Case Western Reserve University School of Medicine

DISCLOSURES

All of the faculty speakers, trainers, moderators, and planning committee members have disclosed they have no relevant financial relationship or affiliation with any commercial interests who provide products or services relating to their presentation(s) in this continuing medical education activity. This UCSF CME educational activity was planned and developed to: uphold academic standards to ensure balance, independence, objectivity, and scientific rigor; adhere to requirements to protect health information under the Health Insurance Portability and Accountability Act of 1996 (HIPAA); and, include a mechanism to inform learners when unapproved or unlabeled uses of therapeutic products or agents are discussed or referenced. This activity has been reviewed and approved by members of the UCSF CME Governing Board in accordance with UCSF CME accreditation policies. Office of CME staff, planners, reviewers, and all others in control of content have disclosed they have no relevant financial relationships with commercial interests.

COURSE SCHEDULE

SUNDAY – OCTOBER 20, 2019

8:00 am Continental Breakfast and Pre-Test (Room S-118) Registration Open 8:30 Welcome ................................................................................................................................ Chairs 9:00 Focused Cardiac Ultrasound ............................................................................ James Anstey, MD 9:45 Coffee Break 10:00 Scanning Live Models

• 1. Parasternal Long/Short
• 2. Apical 4 Chamber
• 3. Subcostal 4 Chamber and IVC
• 4. Abnormal Image Interpretation

12:00 pm Lunch (Nursing Mezzanine) 1:00 Lung & Thoracentesis ................................................................................ Stephanie Conner, MD 1:30 DVT, Central Venous Access, Skin/Soft Tissue ........................................... Charlie LoPresti, MD 2:00 Coffee Break 2:15 Scanning Live Models

• 1. Lung (BLUE Protocol)
• 2. Cardiac/Shock Protocols
• 3. Leg DVT/Soft Tissue
• 4. Abnormal Image Interpretation

4:15 Competency & Clinical Integration ........................................................... Trevor Jensen, MD, MS . Brandon Boesch, DO 5:00 pm Adjourn

MONDAY, OCTOBER 21, 2019

8:00 am Continental Breakfast 8:30 Abdominal Ultrasound ................................................................................... Brandon Boesch, DO 9:50 Coffee Break 10:00 Scanning Live Models

• 1. Aorta and Branches, Abdominal Wall Vessels
• 2. RUQ and GU
• 3. LUQ and GU
• 4. Abnormal Image Interpretation

12:00 pm Lunch (Nursing Mezzanine) 1:00 POCUS HM Program Management ........................................................... Trevor Jensen, MD, MS 2:00 Coffee Break 2:15 Wrap-up, Post-Test 4:00 Free Scan (with Pathology) Scanning Live Models 4:45 pm Adjourn

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.

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

10/9/2019 3

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

10/9/2019 4

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

10/9/2019 5

• 3 Windows
• Parasternal
• Apical
• Subcostal

Sonographic Windows

Slide adapted with permission from Arun Nagdev

Parasternal Long

Parasternal Short Apical 4-Chamber Subcostal

10/9/2019 6

Parasternal Long: Probe + Position Parasternal Long Anatomy

Images obtained from echocardiographer.org

10/9/2019 7

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

10/9/2019 8

Parasternal Long: Normal Parasternal Long: Abnormal

10/9/2019 9

Parasternal Long Tips

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

Parasternal Short: Position

10/9/2019 10

Parasternal Short: Orientation Parasternal Short: Orientation

10/9/2019 11

Parasternal Short: Interpretation

• Utility

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

Parasternal Short: Normal

10/9/2019 12

Parasternal Short: Abnormal Parasternal Short Tips

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

10/9/2019 13

Subcostal View: Position Subcostal View: Orientation

10/9/2019 14

Subcostal View: Interpretation

• Utility

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

Subcostal View: Normal

10/9/2019 15

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

10/9/2019 16

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

10/9/2019 17

Apical 4 Chamber: Normal Apical 4 Chamber: Abnormal

10/9/2019 18

Apical 4 Chamber View

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

toward right scapula

Valvular disease

10/9/2019 19

Right Ventricle Evaluation

IVC: Position

10/9/2019 20

IVC: Orientation IVC: Measurement

10/9/2019 21

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

10/9/2019 22

Fan IVC/Aorta/IVC

• IVC: Abnormal

10/9/2019 23

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

10/9/2019 1

October 20, 2019

Stephanie Conner MD

Point of Care Ultrasound Lung Ultrasound

Objectives

• Basic principles of lung ultrasound
• Key lung ultrasound findings
• Brief overview of thoracentesis windows

10/9/2019 2

Objectives

• Basic principles of lung ultrasound
• Key lung ultrasound findings
• Brief overview of thoracentesis windows

Probe Selection

Linear

• Superficial depth
• High resolution
• Ideal for evaluating the

pleural line, lung sliding

Phased array

• Deeper depth
• Lower resolution
• Ideal for evaluating a-

lines, b-lines, consolidations, and effusions

10/9/2019 3

Patient Position: Ambulatory

• Chest. 2011;140(5):1332-1341. doi:10.1378/chest.11-0348

Hospitalized Patient Technique

10/9/2019 4

Anatomy of Lung Ultrasound

Skin & soft tissue Ribs Pleural line Intercostal space

Key Learning Point

Ultrasound cannot visualize through bone or

• air. Therefore, everything we see in lung

ultrasound is either: Artifact

• r

Abnormal

• A-lines
• Rib shadow
• B-lines
• Consolidation
• Pleural Effusion

10/9/2019 5

Lung scatter & A-lines

Ultrasound scatters in air, so you can’t see through it

Rib shadowing

Rib shadow

Ultrasound cannot penetrate through bone, so you can’t visualize deep to it.

10/9/2019 6

Key Learning Point

Ultrasound cannot visualize through bone or

• air. Therefore, everything we see in lung

ultrasound is either: Artifact

• r

Abnormal

• A-lines
• Rib shadow
• B-lines
• Consolidation
• Pleural Effusion

Objectives

• Basic principles of lung ultrasound
• Key lung ultrasound findings (5)
• Brief overview of thoracentesis windows

10/9/2019 7

A-lines (1 of 5)

Reverberations between the highly reflective pleura and transducer Can be seen in any LZ DDx:

• Normal
• If no lung sliding:

PTX

• If hypoxic/dyspneic:

asthma, COPD, PE

A- vs. B-lines

10/9/2019 8

B-lines (2 of 5)

Propogation of US waves through the lungs 2/2 widening of the interlobular septa Differential diagnosis:

• Pulmonary edema
• Pneumonia
• ILD
• ARDS

>3 b-lines in >2 zones bilaterally = interstitial syndrome.

• 94% sensitivity, 92%

specificity for pulmonary edema

Features of B-lines

• Arise from the

pleural line

• Obliterate a-

lines

• Move with lung

sliding

• Extend >12cm
• Abnormal >3 in
• ne LZ

10/9/2019 9

Clinical Correlation of B-lines

Liteplo et al. Real-time resolution

• f sonographic B-lines in a patient

with pulmonary edema on CPAP. AJEM (2010)

• Case: Hx CHF, ESRD,

dyspnea, orthopnea

• Initial US: Diffuse B-lines
• After CPAP x 3.5hrs: A-lines

Alveolar Consolidation (3 of 5)

• “Hepatization of lung”
• Ddx: PNA vs

atelectasis

• Clinical correlation,
• ther POCUS signs

(shred sign, air bronchograms) needed

* Real world note: probably the most challenging application of lung US

10/9/2019 10

Case: 50 y/o male with cough & fever

Liver

Pleural Effusion (4 of 5)

• Identification of a hypoechoic or echo-free

space surrounded by typical anatomic boundaries

• Costophrenic angles bilaterally (LZ 4)
• Simple vs complex

10/9/2019 11

RUQ/Perihepatic view: Normal

Morison’s Pouch Costophrenic Recess Diaphragm Pleural Effusion

Typical anatomic boundaries:

• Diaphragm (and abdominal
• rgans)
• Chest wall
• Ribs
• Visceral pleura
• Lung

Spine sign

10/9/2019 12

Simple vs complex effusions

Pleural Effusion

US more sensitive than XR or exam:

• Exam > 300mL
• CXR >200mL
• US > 20 mL

Scan dependent zones Fluid is hypoechoic (black) Spine sign Effusion Lung Liver

10/9/2019 13

Lung Findings Summary

• US for B-lines, consolidation, and pleural

effusion = more sensitive than physical exam or CXR

• Faster to acquire than CXR
• Less radiation

Pneumothorax (5 of 5)

10/9/2019 14

Key Principle: Lung Sliding

Movement of visceral pleura against parietal pleura with respiratory motion Linear probe B- and M-mode Findings:

Syndrome Lung sliding? A-lines? B-lines? Normal √ √ Pneumothorax √ Pneumonia ± √

Is Pleural Sliding Present?

10/9/2019 15

Is Pleural Sliding Present?

Pneumothorax

When in doubt… M-mode

Soft Tissue Normal Lung

Beach Ocean

Normal M-mode of Lung

10/9/2019 16

Soft Tissue

Abnormal Lung

Ocean / Barcode

Abnormal M-mode: PNEUMOTHORAX

The Lung Point

Interface of normal lung sliding and absent lung sliding

• Sensitivity: 0.66
• Specificity: 1.00

(Lichtenstein 233 ICU pts vs CT)

10/9/2019 17

Summary: US in pneumothorax

• Outperforms CXR in supine patients
• Much higher sensitivity, similar specificity
• Lower specificity in critically ill ICU patients
• False positives with pleural scarring, TB,

ARDS (specificity 60-91%)

• Lung Point: 100% specificity

Summary of Findings in Dyspnea/Hypoxia

Findings Diagnosis A lines Asthma, COPD, PE Diffuse B lines Cardiogenic pulmonary edema Loss of pleural line, consolidation, focal B lines Pneumonia A lines without pleural sliding, lung point Pneumothorax

10/9/2019 18

Objectives

• Basic principles of lung ultrasound
• Key lung ultrasound findings
• Brief overview of thoracentesis windows

Thoracentesis

10/9/2019 19

US Guidance in Thoracentesis

• Find fluid on ultrasound
• Establish landmarks for safe needle insertion

with adequate depth

• Usually not done under direct US guidance
• Check for lung sliding before AND after the

procedure

10/9/2019 20

Safe for thoracentesis?

Safe for thoracentesis?

10/9/2019 21

10/9/2019 1

October 20-21, 2019

Point of Care Ultrasound UCSF Continuing Medical Education DVT Charlie LoPresti, MD

Disclosure

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

10/9/2019 2

DVT

DVT for the Hospitalist?

• Compression of veins at bedside
• Immediate results
• Available nights and weekends
• Able to repeat the exam
• Accuracy is good

10/9/2019 3

LE DVT US: Anatomy LE DVT US: Probe

10/9/2019 4

2 “points” = 2 Regions, 6 Clips

– Proximal Thigh = From CFV to Middle/Distal SFV (5 Clips) – Popliteal Fossa = Pop Vein 3‐ 4cm above crease (1 Clip)

LE DVT US: Positions

4+

10/9/2019 5

LE DVT US: Compression technique

• Compression is adequate
• Doppler does not improve sensitivity and

specificity but may help identify and confirm vessels

• Visible Thrombus is diagnostic
• Non compressible vein is diagnostic

10/9/2019 6

• 1. Common

Femoral Vein

• 2. Common Femoral

Vein at Greater Saphenous

10/9/2019 7

• 3. Common Femoral Vein

at Lateral Perforator

• 4. Common and Deep

Femoral Veins

10/9/2019 8

4+. (Superficial) Femoral Vein Mid Thigh

• 5. Popliteal Vein

10/9/2019 9

LE DVT US: Pitfalls

• Finding vessels

– Inadequate depth

• False Positives

– Inadequate pressure – Caught on hamstring tendon – Lymph nodes – Overcalling branch of pop artery as pop DVT

View? Side? Abnormality?

04.35.14 hrs __[0006225]

10/9/2019 10

Summary

• Learn the anatomy
• 2 region exam (no longer 2 point)
• Compression is key
• Be mindful of pitfalls

10/9/2019 1

October 20-21, 2019

Point of Care Ultrasound UCSF Continuing Medical Education Skin and Soft Tissue and Central Venous Cannulation Charlie LoPresti, MD

Disclosure

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

10/9/2019 2

Skin and Soft Tissue Ultrasound

SSTI Ultrasound

US can differentiate between cellulitis and abscess Reverberation artifact can show air in soft tissue representing necrotizing fasciitis

10/9/2019 3

Transducer

High frequency linear transducer for depth up to 4 cm

• nd. A, brachial artery; B, bone; F, fascia; M, muscle; N, nerve; V,

Soni N., Arntfield R., & Kory P. (2019) Point-of-Care ultrasound. Philadelphia: Elsevier

10/9/2019 4

Cobblestoning

Abscess

Soni N., Arntfield R., & Kory P. (2015) Point-of-Care ultrasound. Philadelphia: Elsevier

10/9/2019 5

Posterior Acoustic Enhancement

Soni N., Arntfield R., & Kory P. (2020) Point-of-Care ultrasound. Philadelphia: Elsevier

Abscess with ?Nec Fasc

10/9/2019 6

Rib Fracture

Soni N., Arntfield R., & Kory P. (2015) Point-of-Care ultrasound. Philadelphia: Elsevier

Anisotropy

Soni N., Arntfield R., & Kory P. (2020) Point-of-Care ultrasound. Philadelphia: Elsevier

10/9/2019 7

Joints

• Ultrasound useful for joint effusions at

multiple joints in the hospitalized patient

Soni N., Arntfield R., & Kory P. (2020) Point-of-Care ultrasound. Philadelphia: Elsevier

Goals for scanning

• Look at the soft tissue planes in the leg
• Identify vessels, bone, muscle, possibly lymph

nodes

• Can look at the abdominal wall to see rectus

and epigastric vessels

• Can look in forearm for tendons, nerves,

arteries, veins, muscle, bone

10/9/2019 8

Central Venous Cannulation

Pre Procedure Technique

Position the machine for easy viewing Check Lung Sliding Look at entire vessel on both sides of the neck Look for compressibility, clot, stenosis

10/9/2019 9

Identify the Vein Not always this obvious

Compression technique Color Doppler

Soni N., Arntfield R., & Kory P. (2015) Point-of- Care ultrasound. Philadelphia: Elsevier

Soni N., Arntfield R., & Kory P. (2015) Point-of-Care ultrasound. Philadelphia: Elsevier

10/9/2019 10

Use Color Doppler

Red means flow towards the probe, not arterial flow To identify the artery, look for pulsatile appearance and disappearance of color Mosaic, continuous flow indicates a vein

Technique

Prepare all materials in order needed for procedure on sterile tray or drape Select best target site Place needle with real time US guidance Visualize wire in vein with US prior to dilation Check lung sliding after procedure

10/9/2019 11

 Out of plane

visualization

Longitudinal Approach Transverse Approach

10/9/2019 12

Visualize the Wire

Scanning Today

• Visualize the right and left IJ, carotid, and

surrounding structures

• Figure out the best location to place a line on

your model and demonstrate with your finger

• At the table IV models, try to follow your

needle tip into the vessel in both transverse and longitudinal

10/9/2019 13

10/9/2019 1 Point of Care Ultrasound UCSF Continuing Medical Education Abdominal Imaging and Procedures Brandon Boesch, DO

Disclosure

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

10/9/2019 2

Areas to Identify

Soni N., Arntfield R., & Kory P. (2015) Point-of-Care ultrasound. Philadelphia: Elsevier

10/9/2019 3

Probe Selection

Curvilinear Phased Array

Probe Position

• Knuckles on the bed
• Adjust probe angle for view between ribs

and take into account the angle of abdominal

• rgans

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Probe position

10/9/2019 5

Normal RUQ View

Soni N., Arntfield R., & Kory P. (2015) Point-of-Care ultrasound. Philadelphia: Elsevier

RUQ/Perihepatic view

Normal Abnormal

10/9/2019 6

RUQ/Perihepatic view

Normal Abnormal

RUQ/Perihepatic view

Normal Abnormal

10/9/2019 7

RUQ/Perihepatic view

Normal Abnormal

RUQ/Perihepatic view

Normal Abnormal

10/9/2019 8

Gallbladder

Can be a very challenging exam False positives are very common in hospitalized patients

Soni N., Arntfield R., & Kory P. (2015) Point-of-Care ultrasound. Philadelphia: Elsevier

Gallbladder

10/9/2019 9

Wall Echo Shadow

Gallbladder or something else?

10/9/2019 10

Normal LUQ

Soni N., Arntfield R., & Kory P. (2015) Point-of-Care ultrasound. Philadelphia: Elsevier

LUQ Positioning

10/9/2019 11

LUQ/Perisplenic view

Abnormal Normal

Soni N., Arntfield R., & Kory P. (2015) Point-of-Care ultrasound. Philadelphia: Elsevier

10/9/2019 12

LUQ/Perisplenic view

Abnormal Normal

Soni N., Arntfield R., & Kory P. (2015) Point-of-Care ultrasound. Philadelphia: Elsevier

Goals for Scanning Stations

• Identify all the structures in RUQ and LUQ
• Look for the large vessels and spine deep on

the image

• Practice scanning the gallbladder. Find and

name structures that you do know.

10/9/2019 13

Kidney Anatomy

 2 Anatomical Sections ➔ Sonographic

“Double Density”

 Renal Parenchyma = Cortex + Medulla  Renal Sinus = Fatty tissue + Calyces +

Vessels

Image Acquisition

From Point-of-Care Ultrasound, 1st edition, 2014

10/9/2019 14

Normal Kidneys

• 1. Perinephric fat + Gerona's fascia =

hyperechoic

• 2. Renal cortex = hypoechoic
• 3. Medullary pyramids = hypo-/anechoic
• 4. Renal sinus = hyperechoic with small

pockets of urine (not contiguous) and vessels

• 5. Ureter normally obscured by bowel

gas

Normal

10/9/2019 15

Renal Pathologies

 Atrophy  Hydronephrosis  Stone  Cysts  Mass

Atrophic Kidney

10/9/2019 16

Hydronephrosis

 Mild = central dilation with preservation of

renal pyramids

 Moderate = blunting of renal pyramids,

rounding of calices, “bear-claw” appearance, preservation of cortex

 Severe = cortical thinning, calyceal

ballooning, distortion of architecture

Mild Hydronephrosis

From Point-of-Care Ultrasound, 1st edition, 2014

10/9/2019 17

Severe Hydronephrosis

From Point-of-Care Ultrasound, 1st edition, 2014

Bladder

 Indications

 Estimate bladder volume  Confirm catheter placement  Ureteral obstruction (ureteral

jets)

 Detect stones  Work-up for renal failure

10/9/2019 18

Bladder Anatomy

 Posterior and

inferior to symphysis pubis (tilt US beam into pelvis)

 Ureters enter

trigone on postero-inferior wall

 Prostate normally

<5cm transversely

From Point-of-Care Ultrasound, 1st edition, 2014

Image Acquisition

Longitudinal View Transverse View

10/9/2019 19 Normal Male Bladder

Transverse View

Foley + Decompressed Bladder

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Distended Bladder + Foley + Enlarged Prostate

Bladder Volume Estimation

Volume (ml) = 0.75 x width x length x height

Longitudinal View Transverse View

10/9/2019 21

Anatomy of Aorta

From Point-of-Care Ultrasound, 1st edition, 2014

Image Acquisition

Transverse Longitudinal

10/9/2019 22

Transverse Longitudinal

Complete Exam of Aorta

From Point-of-Care Ultrasound, 1st edition, 2014

10/9/2019 23

Celiac Trunk SMA

From Point-of-Care Ultrasound, 1st edition, 2014

Celiac Trunk – “Seagull Sign”

Celiac Trunk

Splenic Artery Common Hepatic Artery

10/9/2019 24

Celiac Trunk – “Seagull Sign”

Celiac Trunk

Splenic Artery Common Hepatic Artery

Splenic Vein Celiac Trunk Aorta SMA

Proximal Aorta

From Point-of-Care Ultrasound, 1st edition, 2014

10/9/2019 25

Proximal Aorta

From Point-of-Care Ultrasound, 1st edition, 2014

Ao SMA Renal Arteries IVC Splenic Vein Vertebr al Body

From Point-of-Care Ultrasound, 1st edition, 2014

Mid-Abdominal Aorta

10/9/2019 26

Proximal Aorta Distal Aorta

Right and Left Common Iliac Arteries

From Point-of-Care Ultrasound, 1st edition, 2014

10/9/2019 27

Distal Aorta

From Point-of-Care Ultrasound, 1st edition, 2014

Abdominal Aortic Aneurysm?

10/9/2019 28

Abdominal Aortic Aneurysm?

Measurement of Aortic Diameter

• Measure outer wall to
• uter wall in both

transverse and longitudinal views

• Normal < 3cm

proximally (<2cm distally)

• Diameter >4.5cm

referral to vascular surgery

10/9/2019 29

AAA?

From Point-of-Care Ultrasound, 1st edition, 2014

AAA?

From Point-of-Care Ultrasound, 1st edition, 2014

10/9/2019 30

Aorta Pearls

• Bowel gas limits visualization

– NPO – Firm pressure or sweep transducer

• Types of AAA

– Fusiform – Saccular – (Pseudoaneurysm)

• Measure in transverse and longitudinal planes

Ultrasound for paracentesis

10/9/2019 31

Paracentesis: Probe + position

+

Paracentesis: Orientation + US

Soni N., Arntfield R., & Kory P. (2015) Point-of-Care ultrasound. Philadelphia: Elsevier

10/9/2019 32

Paracentesis: Vessels

Safe for Para?

10/9/2019 33

Safe for Para?

Soni N., Arntfield R., & Kory P. (2015) Point-of-Care ultrasound. Philadelphia: Elsevier

Goals for Scanning Stations

• Can look for epigastric vessels on models
• Can follow needle insertion on table trainers

10/9/2019 34

Ultrasound-guided Lumbar Puncture

Anatomy

Lumbar Spine

• Spinal cord ends

at L1-L2 in adults

• Lumbar puncture

can be safely performed below L2

L1 L2 L3 L4 L5

L1 L2 L3 L4 L5

10/9/2019 35

Lumbar Spine

Transverse Plane Longitudinal Plane

Spinous Process Spinous Process Spinous Process Interspino us Space

Lumbar Puncture Mapping

Transverse Plane

10/9/2019 36

Midline Shadow = Spinous Process

L3 – L4

Transverse Plane

Lumbar Puncture Site Mapping

Longitudinal Plane

10/9/2019 37

Lumbar Puncture Mapping

L5 = Deep and Small

10/9/2019 38

Lumbar Puncture Mapping

 Mark 2 widest interspinous spaces  Patient must remain in position  Higher success in sitting position

Lumbar Spine

10/9/2019 39

Lumbar Spine

Paramedian View

PITFALL:

• Lamina / articular

processes can be mistaken for spinous processes

• No muscle should

be seen superficial to spinous processes

Lamina / articular processes Erector spinae muscles

Lumbar Spine

10/9/2019 40

Lumbar Spine

Paramedian View

MDM20P02: POCUS for HM

10/9/2019 University of California San Francisco City, State Name

Registrant List

UCSF OCME Page 1 of 2 1 MD San Francisco, CA Anstey James 2 PA Arvada, CO Asztalos Maria 3 DO Oakland, CA Boesch Brandon 4 MD Durango, CO Brown Sarah 5 MD Santa Monica, CA Bueno Mauricio Eduardo 6 MD Sacramento, CA Candotti Carolina 7 MD Oalkand, CA Chalaby Shahad Al 8 Calgary, AB, Canada Chan Philip 9 MD Denver, CO Chin George 10 MD, RDMS, RDC San Francisco, CA Cho Joel 11 MD San Francisco, CA Conner Stephanie M. 12 Houston, TX Etchegaray Mikel 13 MD San Diego, CA Farkhondehpour Ali 14 MD Winston-Salem, NC Ferdous Chiwdhury Sakera 15 MD Phoenix, AZ Gulati Samridhi 16 MD Berkeley, CA Ingraham Aubrey O. 17 MD Danville, CA Jancarik John P. 18 MD, MS San Francisco, CA Jensen Trevor Prosch 19 Dublin, CA Jia Xiaolin 20 MD Loma Linda, CA Kim Richard 21 CNP Hastings, MN Kosec Angela 22 MD Stanford, CA Kumar Andre D. 23 MD, FACP, SFH New Hyde Park, NY Kurian Linda M. 24 MD San Francisco, CA Kurtzman Marc 25 DO Cardiff, CA Kviatkovsky Milla 26 MD San Francisco, CA Lalani Farhan 27 San Francisco, CA Lee Brian 28 Honolulu, HI Lee Peter 29 MD Berkeley, CA Levy Tamsin 30 MD Honolulu, HI Lew Henry 31 MD Cleveland, OH Lopresti Charlie 32 MD San Jose, CA Nagaraju Vidya 33 MD Belmont, CA Namburi Divya 34 MD, MPH Oakland, CA Packard Jin M. 35 PA-C Oakland, CA Patlove Silas 36 MD San Diego, CA Patterson Scott 37 Greensboro, NC Powell

• A. Caldwell

38 MD Portland, OR Rankin Alan

City, State Name

Registrant List

UCSF OCME Page 2 of 2 39 MD Mead, WA Reed William 40 MD Minot, ND Routray Chittaranjan 41 DO, PharmD Sauk Rapids, MN Severnak Todd 42 MD Silvis, IL Shah Muhammad Kum 43 MD Seattle, WA Siebert David 44 MD Granger, IN Singh Emily-Rae 45 DNP Byron, MN Solberg Amanda Rene 46 MD Hercules, CA Tamrakar Lina 47 San Diego, CA Vuong Nhan 48 Montrose, CO Wendling Jhana 49 DO Bay Point, CA Yu Katherine 49 Total Number of Attendees for MDM20P02:

cme.ucsf.edu