you're not going up at ultra sound that's not an excuse to punish your patients with radiation get out there ultrasounds parts lungs my VC's let us know how you feel about it he's slightly intoxicated you know God is wrist pain by finding over-aggressive survives to his buddy's pericardial tamponade cases time Before we jump into that though just a couple quick housekeeping things both volumes of introduction of it's a touchdown one and two have been updated in iTunes recently so if you have those be sure an update there are some fixes also if you're using the iBook on your computer or other device through inkling comm volume 2 is now out it's been a bit of a process getting it converted over but it's now available for those of you don't have an iPad or just prefer to have the book on your computer or iPhone or whatever and remember to apply for the fo med scholarship that the funds from the sale of the books go to support speaking of iBooks if you guys haven't heard a SEP came out an iBook on trauma ultrasound recently which is pretty awesome now obviously we're excited to try it out we love you books and we think it's definitely the future we can't really see a future where we have big hulking books to describe procedures and disseminate information when the same information a thousand times over can fit in your pocket so we're pumped when people embrace this future of Education and put the information in our pockets especially when such illustrious people as those that produce this ebook are doing it so we got a hold of it as soon as we could and decided to do a book review for you here on the podcast because like we said well we love books I think one day I might actually read one now some may think that because we also have an iBook there would be some competition here but that's crazy my love for books is too strong in fact there's nothing that Earth's me more than people who burn books I've never understood that until I read this book yeah I gotta say my favorite part about this book was when I took a break to go take a dump that the book is free and after reading it it's actually pretty clear to me that it's extremely overpriced I can't think of a number big enough they'd have to pay me to read this thing again yeah actually you know I was trying to read this book while I was driving to work one time and I literally took my seatbelt off hoping I'd get in a car accident and die just to be clear the fact that we have any book in no way produces our opinions but a few times while I was reading this I wasn't sure if the authors were high on bath salts or if they just through a Mac in the reading psych room and ask the patient to start typing I mean no offense to the psych patients I am in no way prejudiced by the fact that I have my own iBook but one gripe that I did have about this iBook is that when I opened it there was a naked picture of Mike stone on the inside cover yeah you know I mean I wasn't sure if their title fast was about the scam they're attempting to teach or how quickly you should delete this from your phone if your three-year-old actually downloads it I mean seriously guys Miley Cyrus is the fast pelvic model I honestly lost all respect for Apple for approving this it's several rungs down the ladder of respectability from the 15 to 20 fart apps that I have on my phone and you know one specific gripe about iBooks in general but specifically this one is that a big disadvantage of the iBooks format is that the multiple gesture touch actions just don't leave two hands free to give it a good double flip off obviously we're joking here we devoured that book and loved it and it really is free you should download it and tell everyone you know about it even if you already have our book this is completely different it's very focused on trauma ultrasound specifically it's beautifully designed and really goes into trauma ultrasound much more deeply than we do an introduction to bedside ultrasound so kudos to Bob Jones Mike stone Rob Blankenship and company who produced this thing we both have it and we're going to encourage every medical student and resident we know of to download it great job guys this should be used as a model to others who want to improve the world of medical education with fomat and mike stone sorry dude we could resist so case number one Mike you got a 38 year old female here with a history of diabetes chronic kidney disease on dialysis also and she became acutely disliked and hypotensive during douses today and she was sent down to the IDI from the dialysis clinic so obviously they've just taken off too much fluid right that's why she's hypotensive you see her vitals here a little bit hypotensive a little tachycardic no fever satting borderline what do you think what do you want to do Mike how do you want to evaluate this lady I think I'd probably give her two liters of fluid and innovator we're going to take care of her a little more nuanced fashion let's take a look at her heart so all right she has pericardial effusion I think you can see that Mike what do you think tamponade yes or no because that's what matters doesn't matter how big they see she's done Alyce's she's probably got a chronic effusion we don't know if this is new or not our question is is it causing problems for does she have tampon out here yes or no based on what we learned last podcast let's see so you told me her blood pressure wasn't really that low I mean it was kind of low saggy but looking at this echo there's a pretty big effusion and it looks like there's a little man jumping up and down on top of the trampoline of the right ventricle so I agree early tamponade you can see it there that right ventricle the effect that that effusion is having and if we want to confirm get a little more information because again this is slightly complex she's got a chronic confusion we'll take a look at her IVC also see what's going on because our question was first that she maybe get too much flu taking off in dialysis so we look at our IVC you ever we see big distended not collapsing and also this kind of confirms the fact that she probably has obstructive shock early tamponade so what really probably happened in this lady is she had some she get some flu taking off she already has an effusion there and with that effusion there they decreased her preload just enough to actually cause that pericardial pressure to be higher than the pressure in her right ventricle so you're getting a little bit of tamponade so I really like this case too because it illustrates a point you look at her IVC if you just look here obviously an isolation here weren't thinking about anything else would you think about that as far as your management we think about a patient being volume responsive if their IVC is collapsing and there's no collapsing there so you're thinking just IVC in isolation no fluid for this patient but actually she's preload dependent she needs that extra preload to overcome that pressure and a pericardial sac so giving her a little bit of fluid here actually be good with temporize her and probably get her pressure to come back up and then she can have this effusion drained in a more controlled environment not in the emergency department even though there was a little bit of tamponade the right answer here is probably some fluid first and then call CT surgery to take care of this so I was right about the two liters of fluid and intubate I don't know about two liters you're right about fluid but I'm not sure about two liters in this patient probably would have been fine but probably better deaath information beforehand that takes how long how long does it take to get a quick quick parasternal look and quick IVC look less than 60 seconds probably less time than would have taken to hang the IV fluids case number two 53 year old guy history of irregular rhythm had an ablation four days ago now I was pruning with shortness of breath and chest pain with movement a lot of signs look a little familiar slightly saggy little tachycardic at 1:13 no fever static 91% Mike what do you think and just off the bat here it's guy had an ablation four days ago was ablation probably didn't work so we probably need to get an EKG all right killing me so what I wanted you to say was this is a complication of ablation pericardial effusion and tamponade acutely from the ablation a nickel or something get some bleeding they get an effusion and tamponade so here's what we see look at this guy's heart definitely has an effusion the question is not a fusion though it's is it tamponade around what do you think Mike oh it's tough because there's a really big effusion there so if size mattered I'd be pretty worried but I guess you know I can't see the right ventricular free wall that well but I can see the right atrium pretty well and that doesn't really look like it's collapsing to me I would agree and remember we said before the right atrium actually collapses before the right ventricle does so as big as this effusion is I doubt this is acute if this was a cute there would probably be some physiologic changes from it so the ablation thing is kind of a red herring but we really want some more information because really we are worried about this being acute now does this patient have tamponade we don't think so from this image but let's get another image no reason to just get one image if there are others available so here we see the effusion again pretty big effusion Mike what do you think about this view so again a pretty big effusion it's definitely pericardial because it's pointing anterior to the descending thoracic aorta looks like the LVS nice and big and filling pretty well and maybe a little hyper dynamic but not too bad and then I guess the RV free wall is the next thing to talk about doesn't really look like it's collapsing to me looks perfect to me so this confirms what we saw in the last you no signs of obstructive shock from this effusion not tamponade just for fun we'll take a look the IVC as well and what do you see right there Mike definite collapse the IVC yeah complete collapse and as Mike mentioned before one study not a huge study be pretty difficult to actually have obstructive shock and this completely collapsing IVC pretty much impossible so more confirmation of what we thought we feel even better at this point this patients mild hypotension is not from obstructive shock or tamponade ks3 72 year old female history of chest pain for the last seven days the radiates to her back she complains of a tearing chest and back pain that feels like she's being ripped into that sound like anything specific like probably GERD GERD or aortic dissection you probably want to make that diagnosis I mean this is a medical student question the being ripped into tearing chest and back pain they order dissection right I don't know if you all have seen a case of tamponade from a or dissection but I've actually seen a couple now it's one of the first cases that I ever saw they're really going to be passionate about best out of something like I don't think you've ever heard the story but yeah you could probably tell as well as I am and I told her on the podcast before but it was a guy that came in no idea what's going on with him he was just confused hypotensive we looked at his heart he had tamponade we're getting ready to do a pericardiocentesis and then we looked at his aorta and he had a dissection so he's dissecting up around as they order so we're able to give him fluids instead of doing the pericardiocentesis and send him to the CT surgery to the or and he survived but barely actually coded when they're moving him over onto the table but they open his chest repaired the lesion and he did okay and the guy would not have survived if we hadn't had books on there's one of the cases that really was a formative case for me they got me passionate about ultrasound but it sounds very similar to this case except he actually didn't have those complaints but this lady does so we're already thinking the aortic dissection she's hypotensive little tachycardic we take a look at her heart and what do you see here Mike I see a big effusion and there's definitely a heart that's moving a lot in the effusion I I can't really tell you much else so we see the right ventricle I can't really tell if that's collapsing or not it's just not a wonderful image so I want better information better images one thing I could do is increase the depth to try to look at that right atrium as we've already talked about that's going to collapse sooner than the right ventricle and what do you see here slightly different view what do you see Mike yeah so still apical window where I guess where we've got increased depth and I can see the atria now and it looks like that right atrium might be collapsing I would agree it looks like as you described the little man is punching up on that right atrial free wall looking at systolic collapse so we look at the IVC a little more information and what does this look like big dilated IVC dilated hepatic vein pretty clearly not not changing with respiration okay so it looks like it fits at least with obstructive shock and we've seen the right atrium which is collapsing in systole so this patient has tamponade and it's from knowing that it's from the aortic dissection if we actually had a picture of that aortic dissection this would be a case where you wouldn't want to do a quick pericardiocentesis this patient needs preload to keep their keep their blood flowing forward and then CT surgery to open up and repair this lesion it's going to keep filling if you just put a needle in and just try to take the fluid off if it from its roof it's from a dissection case for last one this complicated 69 year old male COPD CHF diabetes on dialysis presents with worsening shortness of breath and a cough over the last three days it's had dis me on walking as to sit up in bed to sleep to get a known prior ejection fraction of less than 30% with a deep pacemaker defibrillator in place mild weight gain over the last few days protective sputum and feels wheezy so what's your differential diagnosis on this one like pretty much everything bad that can happen to someone yeah I mean he's wheezy so it could just be a bad COPD exacerbation together has a sit up in bed to sleep could just be a congestive heart failure exacerbation as EF could be down is gain that weight we've also got productive sputum could this be sepsis from pneumonia you see these little hypotensive and tachycardic so it could be pretty much anything a huge differential diagnosis so let's narrow it down we're going to start at the heart because we get so much information from a quick view of the heart and what do you think about this view Michael this is a really interesting view so it's kind of an apical window but your over the right ventricle and the RV is bigger than the LV it's not squeezing very well it looks really thick the septum is sort of pushing into the left ventricle during systole hold on a second is there an effusion here first uh-oh oh yeah I guess there's an effusion weird okay so there's an effusion now what were you saying you're saying RV much bigger than the LV over here thick what you can see here what else do you see the septum is pushing into the left ventricle so I guess the pressure is in the RV or bigger than the LV okay so this patient has an effusion or question throughout this has been is there tamponade or not here and we've talked about looking at the right ventricle to see if it's compressing see if there's free wall collapse and this is not a great image but I don't really see any collapse at all but this is such a big RV so thick from this chronic elevated right side pressure right-sided pressures remember this is the COPD patient I don't know how much pressure is going to take to collapse that RV but I think it's going to take quite a bit so we may actually not see tamponade here until very late I wish there was just some other way to evaluate for tamponade does anybody remember think back last podcast like anything man it'd be great if we could measure the velocities into the right ventricle and the left ventricle and see if they change with respiration luckily you can because we taught you how on the last podcast before you do that you take a look at the IVC because we can just get more information on this patient too to put the picture together and see a big dilated obviously no collapse so maybe an obstructive process maybe tamponade but at the same time this patient has congestive heart failure maybe they're just volume overloaded is why they have a big dilated IVC not super helpful probably not sepsis is the primary cause though because it's not collapsing at all so we've taken the difference should I go sit down a little bit a little bit more information for us now we use the mitral valve in flow velocities so we have an apical for chamber view we see the effusion here we put the pulse wave Doppler through the mitral valve and we're looking during respiration at the variation of these peak flow old velocities and anybody remember the percentage change that's normal we're looking at 25% so we look at a peak here we trace that dot across 180 centimeters per second we look at this is probably about the lowest peak around here tracing this dot across it's 120 180 minus 120 is 60 60 divided by 180 that's a change of 33 percent it's 33 greater than 25 Mike no it's a difficult question the actual answer was yes sir all right so let me get this straight so first off I'm going to look at the heart and see if the right ventricle or the right atrium are collapsing if I see either one of those then I think it's probably collapse I'm going to look at the IVC and it's not really going to tell me that there definitely is tamponade but it can kind of confirm my suspicions right so if it's collapsing it's not tamponade if it's big and dilated not changed with respiration then it might be tamponade but I got to have some other some other finding that pushes me towards tamponade and then if all else fails and I still think there might be tamponade but things are just confusing because the heart's got a weird maybe the RV's big and the LV small and maybe there's some weird pathology going on then I can use mitral valve inflow to sort of confirm or refute my initial interpretation absolutely yeah we're not giving you a lot of hard and fast rules we're teaching you techniques giving you tools here to be able to apply and then put the picture together you get to be a doctor you get to take care of the patient in front of you hopefully these things just help you more accurately and efficiently do that so let us know what you think go out there start taking some needles and some pericardial sacks and get back to us thanks everyone ok a couple things before we go first off medical students we announced the medical student scholarship for Casa fest last episode and that's full now we had no idea that are going to be so many of you who listened and would want to come so as much as we love being able to support some medical students here we can't feel the whole castle with you guys or anything a castle and flying in the best Ultron teacher in the world isn't cheap so we're excited about meeting our scholarship medical students we're officially full of med students now we do have one more of the resident scholarships we can come for free if you have an attending register with you and going to announce that it's full on the next podcast but it will be considered as the pre announcement of that as of next podcast it's full pretty sure I'll have seen a few regret emails by then med students can't wait to see residents can't wait to see it and everybody else kind of looking forward to seeing you too you're not going up at ultrasound that's not an excuse to punish your patients with radiation get out there ultrasounds parts along some ivc's let us know how you feel