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Lung and Pleural Ultrasonography - Ultrasound Guided Vascular Access - Goal Directed Echocardiography - Measures of Volume Responsiveness
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Lung and Pleural Ultrasonography - Ultrasound Guided Vascular Access - Goal Directed Echocardiography - Measures of Volume Responsiveness

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Lung and Pleural Ultrasonography

Lung and Pleural Ultrasonography
Ultrasound Guided Vascular Access
Goal Directed Echocardiography
Measures of Volume Responsiveness

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    Lung and Pleural Ultrasonography - Ultrasound Guided Vascular Access - Goal Directed Echocardiography - Measures of Volume Responsiveness Lung and Pleural Ultrasonography - Ultrasound Guided Vascular Access - Goal Directed Echocardiography - Measures of Volume Responsiveness Presentation Transcript

    • Lung and Pleural Ultrasonography Ultrasound Guided Vascular AccessGoal-Directed EchocardiographyMeasures of Volume Responsiveness Fellows Introductory Lecture
      Bassel Ericsoussi, MD
      Pulmonary and Critical Care Fellow
      University of Illinois Medical Center at Chicago
      1
      Bassel Ericsoussi, MD
    • “It is crucial that chest physicians take the lead in advocating for ultrasound to become part of our daily practice, create educational opportunities for members of our societies, and incorporate ultrasound training in our fellowship programs.”
      Dr. David Feller-Kopman
      Bassel Ericsoussi, MD
      2
    • Echogenicity
      • The more ultrasound waves reflected back, the brighter the image
      • Hyperechoic (bright echo)
      • Air
      • Diaphragm
      • Periostium
      • Isoechoic/echogenic
      • Liver
      • Kidney
      • Muscle
      • Hypoechoic (dark echo)
      • Fluid
      • Blood
      • Fat
      Bassel Ericsoussi, MD
      3
    • Bassel Ericsoussi, MD
      4
    • Modes
      B-Mode
      Traditional real-time, cross-sectional scanning mode
      M-Mode
      One dimensional display of motion
      Bassel Ericsoussi, MD
      5
    • Image Artifacts
      Acoustic enhancement
      Increase amplitude caused by intervening structures with low attenuation
      Acoustic shadowing
      Reduced amplitude caused by intervening structures with high attenuation
      Bassel Ericsoussi, MD
      6
    • Artifacts cont.
      A lines
      “Reverberation” artifacts
      Horizontal lines parallel to the pleural line
      Distance between A-lines is equal to, or a multiple of, the distance between the skin to the pleural line
      Seen in normal parenchyma
      A lines w/o lung sliding
      Search for PTX
      Bassel Ericsoussi, MD
      7
    • Bassel Ericsoussi, MD
      8
    • Artifacts cont. B lines/Comet-Tail Artifacts
      • Arise from pleural line, extend to the bottom of the screen
      • Move with lung sliding
      • Efface A lines at their point of intersection
      • Normally seen in the lower lateral lung zones (3-4 lines)
      • lower lung zone interstitial markings are normal
      • Hence, a few Comet Tails in this area are also normal
      • Correlate with the alveolar interstitial pattern (correlate with the presence of extravascular lung water )on CXR or chest/CT
      • 7 mm apart B lines: intra-lobular septa process
      • Diffuse interstitial fibrosis
      • < 3mm apart “closely spaced” B lines: intra-alveolar process
      • Pulmonary edema (smooth pleura) or ARDS (rough pleura)
      Bassel Ericsoussi, MD
      9
    • Bassel Ericsoussi, MD
      10
    • Explanation Of The Formation Of The B-lines (Comet-tail Artifact).
      • When the US beam meets the thickened interstitial area, it reflects resulting in an artifact composed of all the micro-reflections.
      • Each reflection of the beam is displayed on the screen behindthe previous reflection.
      • A distance of about 1 mm separates eachreflection.
      11
      Bassel Ericsoussi, MD
    • Normal Lung
      few Comet Tails in the lower lung zone
      Acute pulmonary edema closely spaced comet-tail artifacts
      Diffuse interstitial fibrosis comet-tail artifacts are 7 mm apart
      Bassel Ericsoussi, MD
      12
    • Artifacts cont.
      E-lines
      Similar to B lines but Arise from the chest wall, not from the pleural line
      Vertical laser-like lines that reach the edge of the screen
      Generated by subcutaneous emphysema
      Bassel Ericsoussi, MD
      13
    • Artifact cont.
      Z line artifacts
      Similar to B lines arise from the pleural line
      Fade away vertically, do not reach the edge of the screen
      Do not erase the A-lines
      Do not accompany the lung sliding
      Does not have a pathologic meaning
      Lichtenstein et al. The comet tail artifact: an ultrasound sign of alveolar-interstitial syndrome.
      Am J Respir Crit Care Med 1997;156,1640-1646
      Bassel Ericsoussi, MD
      14
    • Artifacts cont.
      Mirror image
      Results from the beam encountering a bright reflector (diaphragm)
      Produces a false object, deep to the mirror that disappears with subtle changes in transducer position
      Bassel Ericsoussi, MD
      15
    • Probes
      Cardiac
      Abdominal
      Endocavity
      Vascular
      Lungs
      2.5-3.5 MHz
      3.5-5.0 MHz
      5.0-7.5 MHz
      7.5-10 MHz
      5 mhz curvilinear probe is ideal (low frequency for deeper tissue)
      Bassel Ericsoussi, MD
      16
    • 7.5-10 MHz
      Superficial structures (vessels)
      1.0-5.0 MHz
      Cardiac
      Lung
      Abdomen
      Bassel Ericsoussi, MD
      17
    • Penetration vs. Resolution
      Higher frequency, less penetration but better resolution
      Good for vessels “vascular/linear probe” 7.5 Mhz
      Lower frequency, better penetration but less resolution
      Good for abdomen, heart, lung “ genera probe” 3.5 Mhz
      Bassel Ericsoussi, MD
      18
    • Knobology
      Patient ID
      Mode
      Depth
      Gain
      THI
      Save
      Annotations
      Bassel Ericsoussi, MD
      19
    • Lung Ultrasonography Compared to Chest Radiography
      Lung ultrasonography is superior to supine portable chest radiographs for detection of
      PTX
      Normal aeration pattern
      Alveolar-interstitial pattern
      Consolidation
      Pleural effusion
      Bassel Ericsoussi, MD
      20
    • Equipment Requirement
      3.5-5.0 MHz transducer
      Cardiac probe is very effective
      Has small footprint to fit into narrow intercostal space
      Bassel Ericsoussi, MD
      21
    • Technique
      Pt supine with arms abducted as needed, lateral decubitus for full examination
      Transducer in longitudinal orientation
      Transducer in intercostal space
      Transducer marker in cephalic position
      Bassel Ericsoussi, MD
      22
    • Ultrasonographic Findings in Normal Lung
      Sliding lung
      Lung pulse
      Pleural Line
      A lines
      B lines/Comet-tails
      Bassel Ericsoussi, MD
      23
    • Sliding Lung Sign
      Represents the movement of visceral against parietal pleura during the respiratory cycle
      Identified as a shimmering white line at the pleural interface
      http://www.sonoguide.com/FAST_Video7.html (Shows normal “lung sliding” in its first part.  The second part of the clip shows an abnormal chest view without lung sliding, suspicious for a pneumothorax)
      Bassel Ericsoussi, MD
      24
    • Pleural Line
      • Located 0.5 cm below the rib line
      • Its visible length between two ribs in the longitudinal scan is approximately 2 cm
      • The upper rib, pleural line, and lower rib (vertical arrows) outline a characteristic pattern called the bat sign
      Bassel Ericsoussi, MD
      25
    • A Lines
      “Reverberation” artifacts
      Horizontal lines parallel to the pleural line.
      Separated by regular intervals that are equal to the distance between the skin and the pleural line.
      Seen in normal aeration pattern
      Predominant A lines plus lung sliding
      Asthma or COPD
      Predominant A lines plus absent lung sliding
      PTX
      Bassel Ericsoussi, MD
      26
    • Bassel Ericsoussi, MD
      27
    • Bassel Ericsoussi, MD
      28
    • B-lines/Comet-Tail ArtifactsLung Rockets
      • Arise from pleural line, extend to the bottom of the screen
      • Move with lung sliding
      • Efface A lines at their point of intersection
      • Normally seen in the lower lateral lung zones (3-4 lines)
      • lower lung zone interstitial markings are normal.
      • Hence, a few Comet Tails in this area are also normal
      • Correlate with the alveolar interstitial pattern (correlate with the presence of extravascular lung water )on CXR or chest/CT
      • 7 mm apart B lines: intra-lobular septa process
      • Diffuse interstitial fibrosis
      • < 3mm apart “closely spaced” B lines: intra-alveolar process
      • Pulmonary edema (smooth pleura) or ARDS (rough pleura)
      Bassel Ericsoussi, MD
      29
    • Normal Lung
      few Comet Tails in the lower lung zone
      Acute pulmonary edema closely spaced comet-tail artifacts
      Diffuse interstitial fibrosis comet-tail artifacts are 7 mm apart
      Bassel Ericsoussi, MD
      30
    • E-lines
      Generated by subcutaneous emphysema
      Vertical laser-like lines that reach the edge of the screen
      Similar to B lines but Arise from the chest wall, not from the pleural line
      Bassel Ericsoussi, MD
      31
    • Using Ultrasound to Evaluate for a Pneumothorax
      Probe placement
      On the anterior chest in the 3-4th intercostal space and midclavicular line
      Air rises to the anterior chest wall
      It is possible to examine the anterior chest very rapidly to promptly exclude PTX
      In a longitudinal position with the marker-dot pointed cephalad
      Bassel Ericsoussi, MD
      32
    • Bassel Ericsoussi, MD
      33
    • Using Ultrasound to Evaluate for a Pneumothorax
      A high frequency vascular probe but a curvilinear abdominal probe will also work well
      Decrease the depth setting, so that the ultrasound image shows a maximum depth of about 4 cm. 
      Bassel Ericsoussi, MD
      34
    • Using Ultrasound to Evaluate for a Pneumothorax
      http://www.sonoguide.com/FAST_Video7.html (Shows normal “lung sliding” in its first part.  The second part of the clip shows an abnormal chest view without lung sliding, suspicious for a pneumothorax)
      Bassel Ericsoussi, MD
      35
    • Using Ultrasound to Evaluate for a Pneumothorax
      The presence of sliding lung rules out PTX with 100% certainty at the site of the transducer
      However the lack of sliding lung indicates the possibility of PTX
      PTX
      Apnea
      Pleural adhesions
      Mainstem intubation
      Mainstem occlusion
      Very severe parenchymal lung (infiltrates/contusion/ARDS/Atelectasis)
      Bassel Ericsoussi, MD
      36
    • Using Ultrasound to Evaluate for a PneumothoraxB-mode vs. M-modeNormal Lung
      • B-mode: sliding lung
      • M-mode: Seashore Sign
      • Horizontal lines (“waves”) representing the static chest wall
      • granular pattern (“sand”) representing the dynamic artifacts beyond the pleural line
      Bassel Ericsoussi, MD
      37
    • Bassel Ericsoussi, MD
      38
    • SEASHORE SIGN
      Bassel Ericsoussi, MD
      39
    • Using Ultrasound to Evaluate for a PneumothoraxB-mode vs. M-modePTX
      B-mode: Lack of sliding lung
      M-mode: Stratosphere or Barcode Sign
      The granular pattern disappear. The seashore sign turn to barcode sign
      Bassel Ericsoussi, MD
      40
    • Bassel Ericsoussi, MD
      41
    • STRATOSPHERE SIGN
      Bassel Ericsoussi, MD
      42
    • Using Ultrasound to Evaluate for a PneumothoraxB-mode vs. M-modeLung Point
      M-mode: Lung Point Sign
      appear at the precise line where the seashore sign switch to Stratosphere /barcode sign
      It is a very specific sign for PTX
      Bassel Ericsoussi, MD
      43
    • Using Ultrasound to Evaluate for a Pneumothorax
      Identifying the lung point is 100% diagnostic for PTX
      Found at the area where the lung reaches the chest wall
      http://www.sonoguide.com/FAST_Video8.html (Visceral and parietal pleural movement shows the lung point of a pneumothorax)
      Bassel Ericsoussi, MD
      44
    • Using Ultrasound to Evaluate for a Pneumothorax
      Identifying the lung point is 100% diagnostic for PTX
      Absence of lung sliding on B-mode, or stratosphere/barcode sign on M-mode (indicates the possibility of PTX)
      PTX
      Apnea
      Pleural adhesions
      Mainstem intubation
      Mainstem occlusion
      Very severe parenchymal lung (infiltrates/contusion/ARDS/Atelectasis)
      A-lines with no B-lines/comet-tails is suggestive of PTX
      Bassel Ericsoussi, MD
      45
    • Using Ultrasound to Evaluate for a Pneumothorax
      American Academy of Emergency Medicine : Chan SSW et al Acad Emerg Med Jan 2003 Vol.10 1.
      Bassel Ericsoussi, MD
      46
    • Using Ultrasound to Evaluate for a Pneumothorax
      http://www.youtube.com/watch?v=fntJ7GLjCSU&feature=PlayList&p=B9E542E5A7E42CD3
      Bassel Ericsoussi, MD
      47
    • Ultrasound Guided Vascular Access
      Why not identify the target vessel with ultrasonography, instead of using landmark
      Bassel Ericsoussi, MD
      48
    • General Reference
      Bassel Ericsoussi, MD
      49
    • Common Arguments Against US Guidance
      I don’t need it
      It complicates my set-up routine
      I will lose skill at land mark technique
      My house officers won’t develop landmark skills
      I will become dependent on a machine
      Bassel Ericsoussi, MD
      50
    • The Evidence
      US guidance increases success rate and reduces complication rate
      Time saving
      Comfort of the patient
      Reduction in infection
      Standard of care
      Bassel Ericsoussi, MD
      51
    • Anatomic Variation in IJ
      Significant anatomic variation in IJ position and size is common
      Real time US-guidance for vascular access should be applied all the time
      Bassel Ericsoussi, MD
      52
    • Bassel Ericsoussi, MD
      53
    • Equipments
      • Higher frequency, less penetration but better resolution
      • Good for vessels “vascular/linear probe” 7.5 Mhz
      • Color doppler is desirable but not required
      Bassel Ericsoussi, MD
      54
      7.5-10 MHz
      Superficial structures (vessels)
    • Some Suggestions
      Always use a sterile transducer cover
      Chlorhexidine is an excellent US coupling medium
      Position the screen so that it is easily visible to the operator without head turning
      Bassel Ericsoussi, MD
      55
    • Real Time vs. Marking
      Why use anything but real-time guidance?
      Real-time guidance is superior to “mark and stick” technique
      Bassel Ericsoussi, MD
      56
    • Technique: IJ Position
      • Pre-scan to plan approach:
      • Check sliding lung for later comparison post insertion
      • Prepare the pt as per routine with sterile transducer cover and properly positioned machine
      • Obtain transverse view of the IJ
      • Examine the entire vessel: size, visible clot, stenosis, compressibility
      Bassel Ericsoussi, MD
      57
    • Technique: IJ Position
      • Identify best site
      • Hold transducer perpendicular in transverse section
      • Vessel localized to exact center of the transducer
      • Needle insertion 0.5-1.0 cm from transducer at appropriate angle
      • Advance needle watching for tissue movement, needle identification and vessel compression by the needle
      Bassel Ericsoussi, MD
      58
    • Problems
      Avoid site of insertion that places the carotid deep to IJ
      Avoid pressure that will collapse vessel
      Needle tip may be difficult to visualize
      Bassel Ericsoussi, MD
      59
    • Transverse view:
      The IJ vein anterior and lateral to the carotid artery
      Significant overlap of the artery
      Transverse view:
      Less contralateral head rotation
      less overlap of the artery
      Longitudinal view of the IJ vein
      Bassel Ericsoussi, MD
      60
    • For the Safety Conscious
      Visualize the wire in longitudinal view before dilatation
      Check for sliding lung post-procedure in order to rule out PTX
      Bassel Ericsoussi, MD
      61
    • Subclavian Venous Access
      • Ignore all previous landmark experience
      • Go lateral and stay away from the clavicle
      • Locate sc vein in transverse plane
      • Rotate the transducer to longitudinal view of the vein
      • Advance needle along midline long axis of the transducer
      • Do not proceed unless the needle is clearly in US imaging plane!
      Bassel Ericsoussi, MD
      62
    • Bassel Ericsoussi, MD
      63
    • Bassel Ericsoussi, MD
      64
    • Ultrasound Guided Central Venous Catheter Placement
      Bassel Ericsoussi, MD
      65
      http://www.youtube.com/watch?v=Ahz1SPKTiBU
    • Placement of an Arterial Line
      The placement of arterial lines is an important skill for physicians to master as they treat critically ill patients
      Bassel Ericsoussi, MD
      66
    • Placement of an Arterial LineIndications
      Patients with hemodynamic instability
      Patients on vasoactive medications
      Patients undergoing/recovering from major surgery
      Patients requiring frequent ABG’s
      Continuous monitoring of blood pressure allows for better assessment and management of the critically ill patient
      Bassel Ericsoussi, MD
      68
    • Placement of an Arterial Line Contraindications
      Coagulopathy
      Infection of the insertion site
      Scar tissue in the insertion site
      Trauma proximal to the insertion site
      Poor collateral circulation
      Advanced atherosclerosis
      Raynaud’s phenomenon
      Thromboangiitis obliterans
      Bassel Ericsoussi, MD
      69
    • Placement of an Arterial Line Selecting the Site
      Bassel Ericsoussi, MD
      70
    • How to Verify a Collateral Circulation to the Hand: “Allen Test”
      • Somewhat controversial
      • It may give some qualitative assessment of collateral perfusion
      • Allen Test
      • Apply pressure on both the ulnar and radial arteries, while the patient tightly making a fist
      • The hand then is opened
      • Release pressure from one of the arteries
      • Circulation should return to the extremity within 5 sec
      • Any delay suggests poor collateral circulation
      Bassel Ericsoussi, MD
      71
    • Placement of an Arterial Line
      • Equipment
      • Sterile prep and field
      • Needle, catheter and wire
      • 1 % Lidocaine (without epinephrine) with 12 gauge needle and syringe
      • Scalpel or large bore needle
      • Suture and needle drive
      • Wrist board or roll
      • Transduction system for monitoring
      Bassel Ericsoussi, MD
      72
    • Placement of an Arterial Line
      • Techniques
      • Over the wire technique
      • Over the needle technique
      • Modified Seldinger technique
      • Hand Positioning
      • Hand should be positioned on the wrist board
      • Moderate dorsiflexion, roll placed under the wrist (brings the artery closer to the skin)
      Bassel Ericsoussi, MD
      73
    • Placement of an Arterial Line
      The radial artery
      Palpated 1 to 2 cm from the wrist
      Between the bony head of the distal radius and the Flexor Carpi Radialis Tendon
      Bassel Ericsoussi, MD
      74
    • Over-the-wire Technique
      • Enter the needle at a 30-to-45-degree angle to the skin
      • Once a flash of blood is seen in the hub of the catheter
      • Advance the catheter slowly
      • Pull the needle slowly
      • Until pulsatile blood flow is observed
      • Advanced the wire into the vessel
      • Remove the needle
      • Advance the catheter over the wire
      • Remove the wire (Apply pressure over the artery proximal to the catheter before removing the wire)
      • Connect the catheter to a transduction system
      Bassel Ericsoussi, MD
      75
    • Over-the-needle Technique
      The initial approach is the same
      Once pulsatile blood return is seen in the catheter
      Lower The catheter angle should then be lowered toe catheter angle to 10-15 degree
      Advance the catheter over the needle into the vessel
      Bassel Ericsoussi, MD
      76
    • Placement of an Arterial Line
      • The catheter should be secured in place
      • Suturing (the preferred method)
      • Taping
      • Assessment of hand perfusion
      • Before and after placement of the arterial line
      • Frequent intervals while the line is in use
      • check color, temp, capillary refill, and sensation in the hand.
      • Removal of the arterial line
      • Any sign of vascular compromise
      • it is no longer needed
      Bassel Ericsoussi, MD
      77
    • Placement of an Arterial LineTroubleshooting
      • Over the needle technique:
      • Unable to advance the catheter , catheter hung up on the skin
      • Make a skin nick using larger bore needle
      • No blood return is obtained after the initial flush of blood
      • Advance the catheter through the vessel
      • Then switch to over the wire technique
      • Free flow of blood is observed but the catheter will not pass easily
      • Advance the needle slightly farther, the catheter can enter the artery
      Bassel Ericsoussi, MD
      78
    • Placement of an Arterial LineArtery Spasm
      Due to multiple attempts of cannulation
      Nearly impossible to cannulate
      A new site should be chosen
      Bassel Ericsoussi, MD
      79
    • Placement of an Arterial LineTips and Pointers
      If the catheter is in the radial artery, don’t hyperextend the wrist…it can cause nerve damage
      Don’t deliver meds via an arterial line
      Keep pressure bag at 300 mm Hg to maintain a continuous flow of 2-3 ml/hr of flush solution
      Bassel Ericsoussi, MD
      80
    • Placement of an Arterial Line Complications/Hazards
      • Infection
      • Hemorrhage
      • Can lose blood at a rate of 500 ml/min with disconnection
      • Hidden bleeding can occur if the catheter tip punctures the posterior wall of the artery
      • Thrombus
      • Embolism (air or thrombus)
      • Decreased distal blood flow
      • Nerve damage
      Bassel Ericsoussi, MD
      81
    • Placement of an Arterial Line The Waveforms
      Bassel Ericsoussi, MD
      82
    • Placement of an Arterial Line The Normal Waveform
      Bassel Ericsoussi, MD
      83
      Dicrotic limb
      Aanacrotic limb
      rapid ejection of blood from the ventricle
      Aortic valve closes causing some retrograde blood flow.
      Opening of the aortic Valve
      SQUARE WAVE TEST:
      1.5-2 oscillations
      before returning to baseline
    • Placement of an Arterial LineOverdamping
      • Air bubbles in the system
      • Too many stopcocks
      • Kink in the catheter
      • kink in the tubing
      • Blood on the transducer
      • Clot in the catheter
      • Empty flush bag
      • Aortic stenosis
      • Vasodilation
      • Low cardiac output
      Bassel Ericsoussi, MD
      84
      • SQUARE WAVE TEST: <1 oscillation
      • Smooth waveform that loses the dicrotic notch
      • SBP falsely low
      • DBP may be high
      • False narrowing of pulse pressure
    • Placement of an Arterial Line Underdamping
      • Excessive tubing
      • Excessive catheter movement
      • Atherosclerosis
      • Vasoconstriction
      • Aortic regurgitation
      • Hyperdynamic states
      • Hypertension
      Bassel Ericsoussi, MD
      85
      • SQUARE WAVE TEST: >3 oscillations
      • Sharp exaggerated waveform with overshoot of the systolic pressure and undershoot of the diastolic
      • False wide pulse pressure
    • Placement of an Arterial Line Variable Amplitude
      Bassel Ericsoussi, MD
      86
      • Regular rhythm
      • PulsusParadoxus: amplitude decreases during inspiration and increases during expiration
      • Irregular rhythm
      • Atrial Fibrillation
    • Placement of an Arterial Line
      Bassel Ericsoussi, MD
      87
      Video
    • Goal Directed Echocardiography in Shock
      Using a goal-directed echocardiographic approach combined with clinical context, you can reliably diagnose causes of shock
      Easy to learn
      Rapid to perform
      Changes management 60-70% of time in ICU (DEBATED)
      Bassel Ericsoussi, MD
      88
    • Goal Directed Echocardiography Training
      80% sensitivity for “clinically important findings”
      IM residents
      20 hr course
      20 goal directed studies
      Bassel Ericsoussi, MD
      89
    • Bassel Ericsoussi, MD
      90
    • Bassel Ericsoussi, MD
      91
    • Parasternal Long Axis View
      Probe position
      Left of the sternum
      3rd-4th intercostal space
      Marker toward the pt’s right shoulder
      Bassel Ericsoussi, MD
      92
    • Parasternal Long Axis View
      Bassel Ericsoussi, MD
      93
    • Parasternal Long Axis View
      Bassel Ericsoussi, MD
      94
    • Parasternal Short Axis View
      Probe position
      Rotate the probe 90 degree from the PSLA view
      The marker toward the pt’s left shoulder
      3 views (tilting the probe toward the base or toward the apex)
      At the level of mitral valve
      At the level of papillary muscles
      At the level of the aortic valve
      Bassel Ericsoussi, MD
      95
    • Parasternal Short Axis View
      Bassel Ericsoussi, MD
      96
    • Parasternal Short Axis ViewAt the Level of the Mitral Valve
      Bassel Ericsoussi, MD
      97
    • Parasternal Short Axis ViewAt the Level of the Papillary Muscles
      Bassel Ericsoussi, MD
      98
    • Parasternal Short Axis ViewAt the level of aortic valve
      Bassel Ericsoussi, MD
      99
    • Apical 4 Chambers View
      Probe position
      Point of Maximal Impulse (PMI)
      The probe’s marker toward the pt’s left posterior axillae
      Bassel Ericsoussi, MD
      100
    • Apical 4 Chambers View
      Bassel Ericsoussi, MD
      101
    • Apical 4 Chambers View
      Bassel Ericsoussi, MD
      102
    • Subcostal View
      The easiest to be obtained in an ICU pt
      Probe location
      Subcostal area
      Marker toward the pt’s left side
      Acute angle toward the pt’s left shoulder
      Bassel Ericsoussi, MD
      103
    • Subcostal View
      Bassel Ericsoussi, MD
      104
    • Subcostal View
      Bassel Ericsoussi, MD
      105
    • Goal Directed Echocardiography in Shock
      • Cardiogenic shock
      • Severe ventricular failure
      • Severe LV dysfunction (EF<25%)
      • Decreased LV contractility
      • Severe LV hypokinesis
      • Wall motion abnormality
      • Cardiorespiratory arrest
      • During CPR in a pulseless pt
      • Lack of mechanical cardiac activity: very poor prognosis
      Bassel Ericsoussi, MD
      106
    • Goal Directed Echocardiography in Shock
      Hypovolemic Shock
      Severe underfilling of LV
      Small and hyperdynamic LV
      Systolic obliteration of LV cavity
      Small IVC with respiratory variability
      Bassel Ericsoussi, MD
      107
    • Goal Directed Echocardiography in Shock
      • Acute Cor Pulmonaly
      • PE
      • ARDS (High PEEP, increased pulmonary vascular resistance)
      • RV infarct
      • Air/fat embolism
      • Severe RV Dilation: RV size > LV size (normal RV size = 60% of LV)
      • Severe RV dysfunction
      • Apex formed by RV
      • Paradoxical septal movement
      • RA dilation
      • Dilated and invariable IVC
      • Small and Hyperdynamic LV
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      • RV pressure overload with septal flattening causes D sign
      • EchoJournal: Echocardiography Videos and Discussions - RV pressure overload causes D sign
      • McConnell’s Sign: Regional wall motion abnormalities that spare the right ventricular apex
      • http://www.echojournal.org/video/132/McConnells-Sign-RV-dysfunction-in-pulmonary-embolus
      • RV dilation (RV > LV), apex formed by RV, Tricuspid regurgitation (RV failure in acute pulmonary embolus )
      • http://www.echojournal.org/video/133/Huge-Tricuspid-Regurg-Jet
      • http://www.echojournal.org/video/79/Classic-appearance-of-RV-failure-in-acute-pulmonary-embolus-1-of-2
      • http://www.echojournal.org/video/80/Classic-appearance-of-RV-failure-in-acute-pulmonary-embolus-2-of-2
      Bassel Ericsoussi, MD
      Pulmonary and Critical Care Fellow
    • Goal Directed Echocardiography in Shock
      Tamponade
      Pericardial effusion (PSLA view is best for differentiating pleural from pericardial effusion)
      Diastolic collapse of RV and RA
      IVC Dilated without respiratory variation
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    • Diastolic Collapse of RV
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    • Assessment of Fluid Status and Measures of Volume Responsiveness
      When to do volume challenge and volume rescusetation?
      Pulse pressure variation (needs arterial line)
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    • Assessment of Fluid Status and Measures of Volume Responsiveness
      IVC variation
      In subcostal view measure IVC 3 cm from RA
      Max D – min D / average D > 12%
      Max D - min D / min D > 18%
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    • Assessment of Fluid Status and Measures of Volume Responsiveness
      Limitations of IVC and pulse pressure variations, all patients must be
      Sinus rhythm
      Passive on ventilator (AC)
      Off pressors
      Absence of increased abdominal pressure
      Good luck finding these patient
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    • IVC Evaluation
      • Probe position
      • Subcostal
      • Longitudinal
      • The probe’s marker toward the pt’s feet
      • Measure proximal IVC AP diameter 3 cm from the RA
      • With sniffing or forceful inhalation
      • Collapses > 50 %: normal
      • Collapses < 50 %: elevated CVP and right sided pressures
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    • IVC Evaluation
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    • IVC Evaluation
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    • > 50 % collapse with inhalation: normal
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    • < 50 % collapse with inhalation:elevated CVP and right sided pressures
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    • Assessment of Fluid Status and Measures of Volume Responsiveness
      • Straight leg raising test: Can be done on any patient
      • Sinus or irregular rhythm
      • Spontaneous breathing or on ventilator
      • On pressors or off pressors
      • Use apical 5 chamber view and measure the aortic blood flow (stroke volume)
      • Raise legs to 45 degree (you have just given a “blood bolus” 500 ml blood in legs returned to the heart)
      • Wait 30-60-90 sec (highest values within 90 sec)
      • Recheck the stroke volume
      • SVV > 12%
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    • Goal Directed Echocardiography in Shock
      Video
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