FoCUS_Yale_Final (1)

Transcript

• 00:05Indications to perform a focused
• 00:07cardiac ultrasound include
• 00:09assessment of left ventricular function,
• 00:12assessment for pericardial effusion,
• 00:15assessment for relative chamber size
• 00:17and right heart strain,
• 00:19and the global assessment of
• 00:20the inferior vena cava for
• 00:22volume status.
• 00:25A focus will be done
• 00:26with a low frequency transducer.
• 00:28Your best choice will be
• 00:29a phased array probe as
• 00:31it will allow you to
• 00:32look at the heart in
• 00:33between the rib spaces.
• 00:35Alternatively,
• 00:35you may use a curvilinear
• 00:37probe as well.
• 00:39A complete focus will consist
• 00:41of five separate views. These
• 00:43include the parasternal long axis,
• 00:46the parasternal short axis,
• 00:48the apical four chamber,
• 00:50a subxiphoid,
• 00:51and an inferior vena cava
• 00:53view.
• 01:10So we start with the
• 01:11parasternal long axis, placing the
• 01:13transducer in the long axis
• 01:15parallel to the long axis
• 01:16of the heart to get
• 01:17an image that looks something
• 01:18like this.
• 01:19Again, you can rotate the
• 01:21transducer to get an image
• 01:22that looks
• 01:23like
• 01:31this.
• 01:33In the left video clip,
• 01:34there is a heart with
• 01:35good symmetric
• 01:37squeeze of the left ventricle
• 01:39and nice excursion of the
• 01:40anterior leaflet of the mitral
• 01:42valve hitting the septum.
• 01:44In the video clip on
• 01:45the right, there is severely
• 01:46depressed function in a six
• 01:48week old after cardiac arrest
• 01:50event.
• 01:51Note the poor global squeeze
• 01:54of the entire left ventricle
• 01:55and the absent movement of
• 01:57the mitral valve.
• 02:04The left clip again depicts
• 02:06a normal appearing heart.
• 02:08On the right side of
• 02:09the screen, there is a
• 02:10circumferential
• 02:11pericardial effusion
• 02:12with preserved LV function.
• 02:15Note the arrow points to
• 02:16the effusion collecting to the
• 02:18posterior aspect of the heart
• 02:20on this view.
• 02:26You can use the descending
• 02:28aorta to differentiate
• 02:30whether a large fluid collection
• 02:31is present within the pericardial
• 02:33sac or outside of the
• 02:34pericardium.
• 02:35In these clips, the descending
• 02:37aorta is marked by an
• 02:38asterisk.
• 02:39Note the clip on the
• 02:41left, a large fluid collection
• 02:43is seen to run-in front
• 02:44of the descending aorta.
• 02:46In contrast on the video
• 02:47clip on the right, a
• 02:49large fluid collection is present
• 02:50behind the descending aorta, and
• 02:52this represents
• 02:53a pleural diffusion.
• 03:03Again on the left of
• 03:04the screen is a normal
• 03:05PSLA view with the left
• 03:07ventricle being the largest chamber
• 03:09that can be seen on
• 03:10the screen.
• 03:12Compare that to the right
• 03:13sided clip where there is
• 03:14an enlarged right ventricle and
• 03:16a child with an atrial
• 03:17septal defect.
• 03:19The ASD can be seen
• 03:20to come into view during
• 03:22the early portion of this
• 03:23clip.
• 03:24The RV has compensated and
• 03:26become enlarged due to the
• 03:27constant
• 03:28left to right shunt through
• 03:30the ASD.
• 03:36And finally in these clips
• 03:38one can compare the normal
• 03:40cardiac structure that can be
• 03:41observed on the clip on
• 03:42the left.
• 03:44The video clip on the
• 03:45right shows
• 03:46severe
• 03:47diffuse
• 03:48hypertrophic
• 03:49cardiomyopathy.
• 03:50This particular adolescent
• 03:52presented with presyncope during a
• 03:54basketball game,
• 03:56and he had a normal
• 03:57echocardiogram
• 03:58several years prior to this
• 04:00point of care study.
• 04:25Then if you rotate it
• 04:26ninety degrees, you'll get what
• 04:27we call a parasternal short
• 04:28axis
• 04:30axis. And then if you
• 04:31slide towards the apex of
• 04:33the heart,
• 04:35you should see the papillary
• 04:36muscles.
• 04:38And you keep sliding to
• 04:39see the mitral valve. Just
• 04:40slide, keep sliding. Keep sliding.
• 04:42You should be able to
• 04:42see that your body got
• 04:43below.
• 04:49Here are two parasternal
• 04:51short access comparison views.
• 04:54On the left clip, you
• 04:55can see the normal circular
• 04:56appearance of the left ventricle
• 04:58at the papillary muscle level.
• 05:00Note the nice symmetric squeeze
• 05:01and no evidence of
• 05:03pericardial effusion.
• 05:05The clip on the right
• 05:06shows a large pericardial effusion.
• 05:09Although the PSSA view is
• 05:11not the best for smaller
• 05:12effusions, larger effusions can be
• 05:14confirmed on this cardiac window.
• 05:17Note that the large fluid
• 05:18collection is seen to run
• 05:19anterior to the descending aorta,
• 05:22which can be seen here
• 05:23in short access as it
• 05:24courses behind the
• 05:26heart.
• 05:33Here we can compare the
• 05:34relative chamber sizes in a
• 05:36PSSI view. The normal clip
• 05:38on the left, you can
• 05:39observe the cross on shaped
• 05:40right ventricle
• 05:42next to the doughnut shaped
• 05:43left ventricle.
• 05:44The left ventricle is the
• 05:45larger of the two chambers.
• 05:48The abnormal clip on the
• 05:49right shows an enlarged right
• 05:50ventricle
• 05:51and an infant who was
• 05:52eventually diagnosed with aortic stenosis.
• 05:55The RV here is the
• 05:57bigger of the two chambers.
• 05:59There is also abnormal squeeze
• 06:01and global depression of systolic
• 06:03function on this view.
• 06:05These next set of clips
• 06:06once again compare a normal
• 06:08PSSA
• 06:09chamber evaluation
• 06:10on the left
• 06:12compared to a markedly abnormal
• 06:14appearance of the right ventricle
• 06:16on the right. In this
• 06:18abnormal clip, there is a
• 06:19dreaded d sign with flattening
• 06:22of the intraventricular
• 06:23septum
• 06:24due to a large pulmonary
• 06:25embolus,
• 06:27which has caused increased pressures
• 06:29in the right ventricle and
• 06:30subsequent enlargement.
• 06:32The septal wall flattening is
• 06:34a nonspecific finding and can
• 06:36be caused by any disease
• 06:37process that elevates pressures in
• 06:39the right ventricle and therefore
• 06:41transmits a d shaped appearance
• 06:43to the left ventricle.
• 07:07Next we will look at
• 07:08is something
• 07:09called an apical four chamber
• 07:10view,
• 07:11which again, you find the
• 07:12apex of the heart,
• 07:14tilt up,
• 07:15and give me a little
• 07:16bit more back.
• 07:20Again, you wanna rotate
• 07:22until you get the image
• 07:24that you have here. Again,
• 07:25you can tilt the transducer
• 07:27back and forth
• 07:28to make sure that the
• 07:29ventricular septum, the atrial septum
• 07:31lines up with the vertical
• 07:32axis of the image.
• 07:40On this comparison split screen
• 07:42for the apical four chamber
• 07:43view, the left clip shows
• 07:45a heart with good function.
• 07:47The lateral walls of the
• 07:48left and right ventricle are
• 07:49both seen to squeeze nicely
• 07:51towards the septum.
• 07:53The clip on the right
• 07:55shows abnormal function on this
• 07:57apical four chamber view of
• 07:58a two week old with
• 08:00a juxteductal
• 08:01aortic coarctation.
• 08:03This newborn presented with hypothermia,
• 08:05lethargy, and unexplained dyspnea,
• 08:07but had a normal heart
• 08:09rate and blood pressure at
• 08:10the time this focus was
• 08:11performed. There appears to be
• 08:13depressed function and poor squeeze
• 08:15of the ventricular walls.
• 08:17In addition, you could see
• 08:18air bubbles coursing through the
• 08:19right atrium and the right
• 08:20ventricle.
• 08:21You may experience this finding
• 08:23if, the focus is performed
• 08:25during IV fluid administration.
• 08:27The other interesting finding here
• 08:29is that there is an
• 08:29occasional air bubble that escapes
• 08:31into the left atrium.
• 08:33This finding is caused by
• 08:34a direct atrial communication
• 08:36such as would be seen
• 08:37with a small ASD or
• 08:38a PFO.
• 08:46Here we see comparison views
• 08:47again of a normal appearing
• 08:49typical four chamber view on
• 08:50the left.
• 08:52The video clip on the
• 08:53right is striking for the
• 08:54large fluid collection that is
• 08:56encircling the heart. This large
• 08:58pericardial effusion is starting to
• 09:00show signs of tamponade physiology.
• 09:03The star marks the lateral
• 09:04wall of the right ventricle.
• 09:06This degree of fluid accumulation
• 09:08in the pericardial sac has
• 09:10now overcome the pressures within
• 09:11the right ventricle.
• 09:13This is an important finding
• 09:14to recognize
• 09:15as in bowing of the
• 09:16lateral wall of the right
• 09:18ventricle is an ominous finding
• 09:20that requires prompt recognition
• 09:22and preparations for pericardiocentesis.
• 09:32In this split screen, you
• 09:33can see on the left
• 09:34normal appearing
• 09:36chamber sizes
• 09:38and the dominant left ventricle,
• 09:40which is the largest of
• 09:41all the chambers on the
• 09:42screen.
• 09:43The abnormal video clip on
• 09:44the right shows an enlarged
• 09:46right ventricle in an adolescent
• 09:47with a pulmonary embolus.
• 09:49There is a greater than
• 09:50one to one ratio in
• 09:52the size of the right
• 09:53ventricle compared to the left
• 09:54ventricle.
• 09:55This is seen in the
• 09:56presence of right sided heart
• 09:58strain, which is typically caused
• 10:00by pathology that elevates the
• 10:02pressures in the pulmonary vasculature.
• 10:05One last caveat to consider
• 10:06on the apical four chamber
• 10:08view is the importance of
• 10:10correlating the indicator on the
• 10:11patient to the indicator on
• 10:13the screen.
• 10:14A good anatomical pearl to
• 10:16take away is that the
• 10:17tricuspid valve will generally take
• 10:20off closer to the probe
• 10:21and therefore higher on the
• 10:22screen when compared to the
• 10:24mitral valve.
• 10:25On first glance, the video
• 10:26clip on the right would
• 10:28appear to be that of
• 10:29an abnormally enlarged right ventricle.
• 10:31This clip is actually a
• 10:33result of an operator error.
• 10:35Instead of having the indicator
• 10:36towards the patient
• 10:44screen
• 10:45by a hundred eighty degrees,
• 10:47giving off a false impression
• 10:49of enlarged right sided structures.
• 10:52Since the mitral valve takeoff
• 10:53is lower than that of
• 10:54the tricuspid valve, you can
• 10:56detect that this is likely
• 10:58due to a flipped probe
• 11:00and not due to true
• 11:02right ventricular hypertrophy.
• 11:27And you're putting the transducer
• 11:29in the subdividend,
• 11:30aiming up. Sometimes it's easier
• 11:32to put the hand on
• 11:33top of the transducer
• 11:34and then aim up. And
• 11:35then Antonio is gonna help
• 11:36me change the depth so
• 11:37that
• 11:39it fills the heart.
• 11:43Again, you might find this
• 11:44difficult in a skinny patient.
• 11:51Here we find comparison views
• 11:53of the subxiphoid window. On
• 11:55the left, you see the
• 11:56normal positioning of the heart
• 11:57behind the liver as we
• 11:58would expect to see on
• 12:00a fast examination.
• 12:01The liver here is used
• 12:02as an acoustic window to
• 12:03get a good view of
• 12:04the cardiac chambers.
• 12:06On the abnormal image on
• 12:07the right of the screen,
• 12:08you see a large pericardial
• 12:10effusion with collapse of the
• 12:12lateral wall of the right
• 12:13ventricle.
• 12:14Although this large effusion appears
• 12:16to be circumferential,
• 12:17the most sensitive place to
• 12:19check for pericardial effusion on
• 12:20the subxiphoid window is between
• 12:22the liver
• 12:23and the right ventricle.
• 12:30This is an example of
• 12:32a small pericardial effusion as
• 12:34seen on subsyphoid view found
• 12:36anteriorly between the liver and
• 12:38the right ventricle.
• 13:12We're gonna look at intravascular
• 13:13status, intravascular
• 13:15volume status by looking at
• 13:16the inferior vena cava. You
• 13:18put the transducer right in
• 13:19the midline, subside flow process
• 13:22tilting up.
• 13:23You should be able to
• 13:24see the IVC follow it
• 13:25through the liver, all the
• 13:26way and tranclar right away.
• 13:28Alternatively, you can turn the
• 13:30transducer longitudinally,
• 13:31and then following the inferior
• 13:33vena cava.
• 13:40And you can try to
• 13:40open it up by rotating
• 13:42back and forth until you
• 13:43see
• 13:43it entering
• 13:45and ready to go.
• 13:47You can see the respiratory
• 13:48evaluation.
• 13:50And the beautiful anatomy.
• 13:58So the IVC has been
• 14:00studied in many different manners
• 14:02and many different contexts to
• 14:04see if it can be
• 14:05used as a reliable tool
• 14:06to assess for volume status.
• 14:09To some degree, this is
• 14:10nuanced research that falls beyond
• 14:12the scope of this learning
• 14:14tutorial.
• 14:15However, you can find information
• 14:17you gather from the IVC
• 14:18to be a useful piece
• 14:20of the puzzle,
• 14:21especially when you combine this
• 14:22information with the other cardiac
• 14:24views that you have obtained.
• 14:26Here we find three different
• 14:27calibers of the IVC and
• 14:29long axis.
• 14:31On the left most video
• 14:32clip, you see a flat
• 14:33IVC, which seems to collapse
• 14:35completely,
• 14:36suggestive of hypovolemia
• 14:38or dehydration.
• 14:39In the middle of the
• 14:40screen, you see a full
• 14:41IVC with some proximal collapse.
• 14:44Clinical correlation is necessary
• 14:46with particular attention paid to
• 14:48the patient's respiratory dynamics. The
• 14:50clip on the right shows
• 14:51a plump IVC without much
• 14:53collapse seen during inspiration.
• 14:55In the right clinical context,
• 14:57this is suggestive of heart
• 14:58failure and myocardial
• 14:59pump dysfunction.
• 15:04A five year old girl
• 15:05presents with weight loss, cough,
• 15:07and difficulty sleeping for several
• 15:09days.
• 15:10On physical exam, there is
• 15:11an elevated respiratory rate, hepatomegaly,
• 15:14and a loud murmur.
• 15:15Electrocardiogram
• 15:16reveals left axis deviation.
• 15:18Vital signs are as shown.
• 15:21How would you interpret the
• 15:22following focus images?
• 16:01A four year old boy
• 16:02presents with intermittent vomiting and
• 16:04cough for several weeks. He
• 16:06is afebrile, but the pediatrician
• 16:08suspects dehydration.
• 16:10On physical exam, he appears
• 16:11agitated and is unable to
• 16:12lay flat.
• 16:14You do not hear a
• 16:14murmur or any abnormal lung
• 16:16sounds.
• 16:17Vital signs are as shown.
• 16:19How would you interpret the
• 16:20following focus images?