Point of Care Ultrasound UCSF Continuing Medical Education Cardiac - PowerPoint PPT Presentation

Point of Care Ultrasound UCSF Continuing Medical Education Cardiac Trevor Jensen, MD, MPH October 21-22, 2018

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

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

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

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

Sonographic Windows • 3 Windows • Parasternal • Apical • Subcostal Slide adapted with permission from Arun Nagdev

Parasternal Long Parasternal Short Subcostal Apical 4-Chamber

Parasternal Long: Probe + Position

Parasternal Long Anatomy Images obtained from echocardiographer.org

Parasternal Long Axis View RV LV RV 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

Parasternal Long: Normal

Parasternal Long: Abnormal

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

Parasternal Short: Position

Parasternal Short: Orientation

Parasternal Short: Orientation

Parasternal Short: Interpretation • Utility – Gross LV systolic function – Assessed at level of papillary muscles – Regional wall motion abnormalities – RV size

Parasternal Short: Normal

Parasternal Short: Abnormal

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

Subcostal View: Position

Subcostal View: Orientation

Subcostal View: Interpretation • Utility – LV Systolic Function – Pericardial Effusion – Right atrium and ventricle size

Subcostal View: Normal

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

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

Apical 4 Chamber: Normal

Apical 4 Chamber: Abnormal

Apical 4 Chamber • Tips : • Under the breast fold • Left lateral decubitus • End-expiratory hold • Aim sound waves 
 toward right scapula

IVC: Position

IVC: Orientation

IVC: Measurement

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

Fan IVC/Aorta/IVC •

IVC: Abnormal

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