The Role of Ultrasound in Emergency Medicine

And you want to make the right decisions with the information that you have at hand, and you want to try and get as much information as you can without too much delay. And ultrasound really fits into this. So with DASH, I come to the greatest pitfall, and that is actually not using ultrasound, when you are looking after the sickest people who present to the hospital. You guys are the ambassadors for the hospital. These patients are looking to you to help them. You know, you need to get this right. A lot of people tell me that, you know, you want to call a friend to get an echo done. Okay. You know, oftentimes this does not pan out. You know, you are better off doing this yourself and learning how to do this yourself. So just going through how you would assess a patient who comes in in shock into resus, you have your monitor, you have your skin perfusion, you have with ultrasound, you can add a lot more information very, very quickly. If you take ultrasound out of the equation here, all you really have is just a monitor and your fingertips. The clinical exam is important, absolutely. I assess patients with shock by putting my hand on their extremities, on the center, to see what the skin temperature is, because that gives you a very quick idea of what your systemic vascular resistance looks like without actually having to go and do really complicated calculations. That is the best indicator of shock with this patient and helps to delineate any information that you get further on. from other assessments. With shock, anybody who comes with shock to the emergency department, okay, I believe that they really need a systematic exam, a focused exam with point of care ultrasound. And this is where the RUSH exam comes in. So the RUSH exam was initially, I suppose, talked about by Scott Weingart back in 2009. There have been a few iterations and a few additions into it, so much so that it's the rushed exam. Okay, so it involves getting views of the HASH, the IVC, Morrison's pouch, eFAST exam, your aorta, your pneumothorax, and then as an addition, looking for an ectopic, looking for DVTs. Now, there are other, obviously, protocols out there. EGLS is more focused on ultrasound of the IVC, lungs, and hash. And having a systematic approach is very important, regardless of whatever approach you decide to take. So in EGLS, it's like, is there a pneumothorax? Is there a tamponade? Is there a hypovolemic or distributive shock? and is there LV dysfunction? And then finally, is there RV strain? The heart is a pretty complex organ. As you can see, it has four chambers, you know, the right side, the left side, all slightly different. If you have right-sided failure, you know, the treatment is very different from left-sided failure. And if you are facile with point-of-care ultrasound, you know, getting a few views of the heart will actually tell you what kind of shock you're dealing with. and how you can actually treat this the best way. So some pro tips for echocardiography. If you're not doing this every day, I appreciate that some of the views can be quite difficult. So how you hold the probe, okay? You need to hold the probe like a pen. Don't hold it like a dead rash or holding it like a sock, a dirty sock that you're trying to put into the washing machine. Hold it with... the probe, hold the probe like a pen, rest your hand on the patient's chest. That gives you a lot more stability and stops you from sliding off the patient's chest as you're trying to get that important view. Use lots of jelly. You know, as you get more experienced, the amount of jelly actually that you use gets less and less and less. But initially try and use lots of jelly to make sure that the probe has good contact with skin. Then exert pressure. Exert pressure where to the point it's slightly uncomfortable. And then when you think you have reached that point, exert a little bit more pressure. It's important that you get good contact with skin. Air is at the enemy of ultrasound, so if you don't use sufficient pressure, you will not get a good image. Remember to use dynamic maneuvers. Use the left lateral position. Get your patient positioned. Even in the ICU, we can get patients who are intubated, ventilated, on dialysis. We usually can get them into a kind of a semi-left lateral position by just propping pillows behind them on the right side. you know, and then you kind of can sit on the bed and, you know, perform the examination. Patients who are able to obey commands, you know, they can, to improve your images, you can actually get them to breath hold, you know, for echo, if you're doing, if you get them to exhale and hold their breath at that point for even for a second or two, you'll be able to get quite good images on the anterior chest wall. So if you... get them to take a big breath in. If you have problems getting a subcostal view, get them to take a big breath in and hold it there. That pushes the heart down. You will be able to get a good view of the subcostal area then. And one last point, don't look at your hand position. Look at what's happening on the screen. Look at how the image actually relates to your probe, your movements of the probe. So we'll just go into this very, very briefly. So this is your sub... subcostal view. Keep your hand on top of the probe. Keep the probe quite shallow. You should get a view like this. You should see four chambers of the harsh. This is a good view for evaluating pericardial effusions, relative LV or RV distension, and your LV function as well. You got a shot of the liver in the near field, right up here. This is your right ventricle here, right atrium here, left atrium here, left ventricle there. You can go do your parasternal long axis, which is the second or third intercostal space, just lateral to the sternal border. This view is best gotten with a patient in a semi-left lateral view that just pushes the heart closer to the skin, moves the lung out of the way, lots of jelly, some pressure. could hold the probe well, you should be able to get a pretty good image. This is what you're going to get. So again, from near field to far field, this is your right ventricular outflow tract. This is your ascending aorta, aortic valve. This is your left ventricle. This is your mitral valve. This is your left atrium. This is your descending thoracic aorta. In this view, what you're looking for is a one is to one. is to one ratio. So the diameters or the measurements of the right ventricle, the ascending aorta and the left atria should all be in a one is to one is to one ratio. So they should all look about the same size. If you have enlargement of the right ventricle, so say maybe you get a two is to one is to one ratio, then what could possibly be happening is that you're getting some RV dilatation. Is that due to RV failure? you know, do you have a big PE? If you get a one is to two is to one ratio, then you got to suspect that there's something going on here. If your patient is shocked, does the patient have an ascending aortic aneurysm? Okay. What's even worse is if you see a one is to two is to one and you see a pericardial effusion. Okay. So a pericardial effusion will be seen here and in the far field in the pericardium. The pericardial effusion will go between the harsh and the descending aorta. And that differentiates it from a pleural effusion, which happens, the pleural effusion will go around the aorta and does not go between each and the harsh. That would be even more, those findings of a pericardial effusion and a dilated aorta. would be obviously very suggestive of a dissection of the ascending aneurysm, ascending thoracic aneurysm. Dilation of the left atria is probably a more chronic process, and I wouldn't worry about it too much. But it would suggest that you have high filling pressures in the left ventricle. And if you're considering that giving fluid or volume to this patient, you want to be a little bit careful if they already have high filling pressures, because any... bit more fluid could actually tip them into pulmonary edema. So that's for your parasternal long axis view. You rotate your probe then 90 degrees from the best position of your parasternal long axis to give you your parasternal short axis view. And with your parasternal short axis, this is the view that you should get. Your left ventricle is here. This is your mid-papillary view. This is your mitral valve. So we're just scanning through all of it. Over here, this structure here is the right ventricle. So it's almost like a donut. the left ventricle, and then across on kind of stuck onto the side of the donut is your right ventricle. Now, the apical four chamber view is, I suppose people find this the more difficult view to get. Your probe should be, you know, big movements initially, just the intercostal space below the nipple in female patients. you know, put it into the inframammary crease, direct the probe towards the right scapula, because that's the plane that the heart will lie in. Move the probe around in big circular motions initially to try and get a view. And then after that, slowly, you know, dial down on where the best view is. Probe marker should be kind of towards the two o'clock to three o'clock position. The view you should get is one of um you know uh the lv should be the center okay this is your rv over here it's your ra this is your la this is your mitral valve tricuspid valve this gives you a good global function you can certainly tell whether there's a pericardial fusion you can tell about lv function you can decide on the the relative interplay between your right ventricle and your left ventricle now After all of that, what are you looking for? So obviously, in your subcostal view, if you see something like this, like a man jumping on someone's right ventricle, you will obviously be quite concerned about tamponade. Pericardial fusions do not have to be large to cause very severe shock. This obviously is not a good sign. So you can see here the left atrium. or sorry, the right atrium is being pushed down in early diastole. The right ventricle is also almost non-existent in this pretty large pericardial fusion. Okay, if this person is shocked, they look clapped out, they're going to need a needle in this space. Okay, this is another interesting one. This is a sonographic, you know, if you wonder what... pulses alternance looks like visually. This is what pulses alternance looks like on your ECG. If you plug it in the ECG properly, you'll see the QRS complexes alternating. So this is also worrying for Tempernard. I think the best way of describing it is, I suppose, John Travolta doing Saturday Night Fever. You can see how the movement of the RV is collapsing. So I suppose no presentation on ultrasound is complete without some stories. So these are all real patients that I've seen over my time using point-of-care ultrasound. So this first lady here was MC. So she was a 73-year-old female. I had a... pretty soft blood pressure, 90 on 50, cat refill time was five, you know, a bit shocked. She was quite shocked. Lactate of five, you know, very nonspecific symptoms, abdominal pain, urinary frequency, chest pain, a little bit of everything. She was diagnosed with urosepsis. Given some volume, blood pressure improved a little bit. She was sent to the ward. We were contacted, the ICU team were contacted. later on to come and review this patient because after she had probably about three liters of fluid, she was not getting any better. In fact, she was getting worse. Her lactate was going up to 12. Her blood pressure had now dropped to 70 on Thursday. Her radial pulse was not palpable. Her carbaryl time was in the order of six or seven. So she was getting worse and worse and worse. The problem was that this diagnosis of sepsis is fraught with premature closure, diagnostic bias, and there are so many cognitive biases here. Because once you say someone has sepsis, they're almost... pushed into a space where they get the fluid, they get their antibiotics, and they are all assumed to get better after that. But nobody actually goes to look at the heart. And when you go to look at the heart, this is what you actually see. So she's got a pericardial fusion here. You can see here that her RV is actually collapsing, almost non-existent in this subcostal view. In the apical four chamber... you can see that the right atrium is actually collapsing in diastole. So this heart is not actually filling on the right side. You know, she needed a needle decompression. So she got, you know, we did an ultrasound guided drain and aspiration probably about 10 to 15 mils. And, you know, her shock status improved remarkably. So don't forget that. The other lady, this is one that I think probably a lot of people are quite familiar with. You know, a young lady at 4 a.m. comes in, has high BMI. She's short of breath, doesn't have chest pain. She has cough productive of phlegm, 38.4 degrees Celsius. You know, she's multiple like SIRS criteria, you know, blood pressure of 80 on 50, lactate of 4. You know, she's been stamped with the respiratory sepsis. put on antibiotics, put on some fluids, hope you get better. But nobody actually looks at a harsh. When you do actually look at a harsh, you can see here in your parasternal long axis, the RV is dilated. You can see it's actually pushing into the LV. When you look at the parasternal short axis, you can see that this is not the donut with the croissant curved over it. This is actually what we call the D sign. So it's suggesting RV overpressure. The pericardium is a fixed space. It's a zero-sum game. If the RV dilates, the LV has to decrease in size. So if you had a shock state, the shock state only gets worse as your RV dilates because your LV is getting smaller. And by convention, your cardiac output will decrease as well because of that. Apical four chamber here, you can see the RV is still pretty dilated. So the conversation, the... The appropriate treatment for this lady was, does she get TPA? So she fulfills the criteria for getting thrombolysis. So she's put on an Actilize Alteplase infusion, and the hemodynamics markedly improve within a couple of hours. Now, in terms of her LV function, in terms of function, When you look at LV function, people say it's very difficult to tell. You certainly need a bit of experience with this. So that's why I recommend trying to echo most people that come into the department. If they have a little bit of chest pain or if they are shocked, certainly have a look at their heart. Because you will quickly recognize when the mitral valve is actually moving well or not moving so well. So this is a moderately depressed. LV and this is normal LV. And then if you contrast it with this, so this is a mitral valve that's hardly moving at all. So this is a really severely depressed LV function. We talk about some wall motion abnormalities as well. So this is, if you look at this parasternal short axis, so it's got almost a full house of the wall motion abnormalities. You can see here that this wall here, not moving. This wall here, a little bit hypokinesic. It's not actually thickening very well. And in this case here with systole, the wall, the interventricular septum is actually bowing in the opposite direction. So that is the wall motion abnormalities. Patients who have STEMIs, one thing I'll say is actually, I know once they have a STEMI again, you know... everybody goes right you know we need to get to cath lab we need to get to the cath lab yeah absolutely uh you know they do need to get a cath lab um but always have a look uh you know it only takes you a minute or two to do a high map exam uh you know it'd be pretty silly for them to try and if the low blood pressure has caused you know um these st elevations but in actual fact you know if the uh if the low blood pressure was caused by say a ruptured triple a you know That would be pretty interesting for the cardiologists in the cardiac cath lab. Or if they had a pericardial effusion and you saw a dilated aortic outflow tract, you know, that would certainly be suggested for dissection. And, you know, certainly PCI is not going to fix that problem. You can link your various coronary artery territories to the various walls. You can look this up on Ben Smith's website. He's found on Twitter at Ultrasound Jelly. So we go from the heart to the IVC. So the IVC is often not. It's a pretty sad creature these days. Everybody seems to think that the IVC is a bad thing to look at. I don't think it is. I think everybody looks at it kind of in the wrong way. So this is the view that you are normally taught to look at the IVC. So this is the longitudinal view of the IVC. You can see, you may think that this is a pretty round structure, doesn't really change with very much respiration. But I suppose with... as with most things in radiology, you want to look at things in both angles. So like with this, you know, you may think, you know, this guy is trying to give the finger to the press core, but in actual fact, you know, he's just saying, well, you know, there's three people, three things that we need to look out for. You need to look at the IVC in the short axis because that same structure that we saw earlier on, if you look at this, you can see that it's actually not that round. It's actually. There's a bit of movement in it, okay? And all that is, is just a rotation of the probe in 90-degree fashion. So it depends on how you look at it. Obviously, if you look at it this way, or if your probe is slightly tilted and you're looking in that direction, as you slice it, you know, the diameter looks slightly different. This is kind of an ellipsoid. So this is kind of what we would almost consider euvolemia, or maybe slightly hypovolemic. and contrast that to an IVC that's actually fully dilated in the short axis. So you can see that this is fully, fully round, and this is a truly, truly dilated IVC. Try not to use the IVC to decide on fluid responsiveness. The IVC is good in the extremes of conditions. So if it's really, really small or really, really large, it just tells you whether this patient is able to tolerate fluid. I don't use the IVC to tell me whether this patient is going to improve their hemodynamics by giving them fluid. I'm going to use the IVC to try and figure out whether I'm going to cause the patient any harm by giving them any fluids. If you had a patient with an IVC this size, it would suggest that if you gave them 500 mils of a crystalloid bolus, you're probably not going to do them any harm. If you have a patient who is shocked... and maybe it's a traumatic cause of shock that you've determined, and you are looking at their shock stage and you're wondering why are they still shocked? They've had most of their blood products already at this stage. If you see an empty IVC, you have to consider whether they are still bleeding. If it's full, you have to consider whether they have developed obstructive shock from tamponade or... you know, attention pneumothorax, preventing forward flow of blood from the IVC into the right ventricle. Let's talk about the E-FAST exam. So everybody's brain and buffer is the E-FAST exam in emergency medicine. You know, your right upper quadrant, your pelvic view, your left upper quadrant, and then a subcostal view of the hash. So I tend to... do my fast exam in this way. So I use the right upper quadrant first, followed by the pelvis in the longitudinal view only. And the last view I look at is the left upper quadrant. Because of the paracolic gutter in the right upper quadrant is a little bit lower than the left upper quadrant, blood or free fluid tends to track into the right upper quadrant first. you usually tend to see in the paracolic gutter or the caudal tip of the liver. Even if you had a splenic laceration or a splenic rupture, the free fluid usually tends to appear in the right upper quadrant, funnily enough. So having a look at these images, make sure you scan through the whole organ. If you look at the clip on the left, you may say, hey, look, there's no free fluid. I've imaged Morrison's pouch. And there doesn't seem to be any free fluid at all. But make sure you look lower down. So if you over here, you can see that the free fluid is actually just starting in the caudal tip of the liver coming into the inferior pole of the kidney. Okay. You know, free fluid doesn't tend to occur on the right side above the diaphragm. So this is the space that you want to look at in the right upper quadrant. And then if you look into the paracordic gutter, then you will see free fluid here as well. Okay. So there's caudal tip of the liver, paracordic gutter. Make sure you look in this space before you say that the right upper quadrant is clear. This is the bladder view. So pelvic view. So this is the bladder in long axis, not catheterized yet, but you can see again free fluid in the pelvic view. The left upper quadrant is interesting, so it's rare enough that you actually find this free fluid between the spleen and the kidney. Most of the free fluid, if you find it on the left side, will be actually between the spleen and the diaphragm because the attachment between the spleen and the kidney is usually really tight. And free fluid doesn't usually track in there, usually tends to track above the spleen between the diaphragm. So the aorta, so quick word about the, let's talk aortic assessment. Okay, so, you know, a lot of people are quite, you know, they feel that they are quite happy with doing aortic examinations, you know, especially on patients in ultrasound courses, because all the models that you get for ultrasound courses are already svelte and thin and they have no body fat. So it's very easy to image the aorta so much so that everybody gets these images when you go to scan at an ultrasound conference or an ultrasound course. But, you know, reality kind of bites in that, you know, a lot of the patients who have aortic disease, they're fast, they have food, they probably eat them before they come in, they're a little bit hairy, and they may have a lot of gas in there as well. So much so that when you try and do an aortic examination, this is what you tend to see. So your teaching, traditional teaching would tell you to start from the epigastrium, work your way down to the bifurcation. But anatomy kind of tells you that doing it in a slightly different way. is actually more intuitive that if you start lower down at the belly button and work your way up or work your way down from there to the belly at the bifurcation that will make a lot more sense because the aorta as you can see over here is a lot more anterior because of your lordosis of your lumbar spine so start at the bifurcation start at your belly button and then move up or down because then you can localize where this is Just a separate word as well about the aorta, instead of looking for this the aorta over here, always look for the vertebral body first because the aorta is always located very close to that. Screen through the aorta as we see here, down to the bifurcation. We can give you this example of diagnostic bias where this patient comes in complaining of loin to groin pain. He says it comes and goes. There's no history of trauma. Those are his vital signs. Someone thought his GP, he had seen his GP about a week ago with this similar pain and has presented late to the department. This is what he looks like. If he went down the route of getting a renal ultrasound, if there was a stone, you may see dilation of the ureter over here, or you may see a stone in the vesicular ureteric junction. But in this case, if you're going to scan this, make sure you have a look at his aorta because in actual fact, the aorta can really screw you up because the symptoms are never, never, never really classical tearing pain. They present with intermittent pain, they can present with right upper quadrant pain. The AAAs that I've diagnosed in the ED with ultrasound, none of them have the classic story that you get from the textbooks. So again, make sure you screen through. So you can see here large AAA. and outer wall measure the outer wall to outer wall okay you can see the vertebral vertebral body at the back here uh again another one another triple a here all right don't measure the lumen okay that's not the that's not the problem it's actually the wall-to-wall diameter that you're looking for um Again, another one. There's quite a lot of wall thrombus here. You can see there's even thrombus going in there. This is in the long axis. You can see here this is all clot or thrombus. So be facile with this. You scan. I think they did a study where you scan the 100. If you scan the 100 aeolus, you're going to save one life at the very least. Last but not least, the pneumothorax. So with pneumothoraces, I think most people use this quite regularly. Lung sliding, no pneumothorax at this point. Over here, you can see no lung sliding, quite highly suggestive of a pneumothorax. If you look for the lung point, this is almost 100% specific for a pneumothorax. This is where the lung is actually starting to collapse away from the rib cage. Some pitfalls here, if you look at this, you may think that there is no pneumothorax because you saw a bit of sliding there. But just be aware of where your pleural line starts, because your pleural line is below a rib. So this is your rib here. This is not the pleural line. This is actually subcutaneous emphysema. So just be aware of that. Now, ectopics, you know, this has to be contextual. You have to take this in context. If you have a patient with abdominal pain, young patient, female, abdominal pain, you know, with a positive HCG, if you scan the bladder and you look at the uterus and you see the uterine stripe, so this is an empty uterus. you know, it'd be very highly suggestive of an ectopic pregnancy. Now, in this clip, you can actually see a gestational sac that is not in the uterus. So this is what we would consider an ectopic pregnancy. All right. But, you know, you didn't need to see this gestational sac to be able to call this as a possible ectopic pregnancy because there's no fetus in the uterus with a positive pregnancy test. DVT scanning is pretty straightforward. Compression, if you apply compression to the veins, you should see that it collapse. If they don't collapse, then you got to be concerned about cloche. And that all figures into the patient, how you would manage patient with shock. You know, if they have RV dilatation and they have a cloche, you know, the conversation then should be, are you going to thrombolyze this patient? Is this patient stable enough to survive a CTPA? So take home points. If the patient presents in shock, you know, they should get an ultrasound as part, you know, they should get a focused high MAP rush exam as part of the examination, as part of the clinical examination, you know, and however, which way you choose to do this protocol, it should, it should be completed on them. The reassessment is the beauty of ultrasound because you can actually always go back to look again. It's not like you have to transport the patient to a CT scanner again to see whether you, what you have given them as initial management, whether that has worked. As you can see here, collapsing IVC, hyperdynamic left ventricle, dry lungs here because you see A-lines and some sliding. You've given them maybe two leases of volume and you know, Maybe they are still shocked. Maybe their oxygen requirements have gone up. Reassess them at ultrasound. This may be what you see, a dilated IVC now. This is B lines here in the lung views. The heart now looks pretty full. Function looks reasonably okay. But at this point here, if they are still shocked, you have to consider whether they actually need vasopressors rather than more volume. It's always good to incorporate, you should always incorporate focus into your clinical examination. And like these guys here on the walker leisure, you know, they're always better together. And that's me. So, oh yeah, wow, well within time. Okay, so if you have any questions you want to ask, you can take them now. If you're shy, you can always email them. to me or direct message me on my Twitter account. This QR code brings you to my YouTube channel where I'll try and put clips up or videos up every now and again. So yeah, thank you. Thank you for having me again. I suppose I'll take any questions that you may have.

You know, you need to get this right. A lot of people tell me that, you know, you want to call a friend to get an echo done. Okay. You know, oftentimes this does not pan out.

You know, you are better off doing this yourself and learning how to do this yourself. So just going through how you would assess a patient who comes in in shock into resus, you have your monitor, you have your skin perfusion, you have with ultrasound, you can add a lot more information very, very quickly. If you take ultrasound out of the equation here, all you really have is just a monitor and your fingertips.

The clinical exam is important, absolutely. I assess patients with shock by putting my hand on their extremities, on the center, to see what the skin temperature is, because that gives you a very quick idea of what your systemic vascular resistance looks like without actually having to go and do really complicated calculations. That is the best indicator of shock with this patient and helps to delineate any information that you get further on. from other assessments. With shock, anybody who comes with shock to the emergency department, okay, I believe that they really need a systematic exam, a focused exam with point of care ultrasound.

And this is where the RUSH exam comes in. So the RUSH exam was initially, I suppose, talked about by Scott Weingart back in 2009. There have been a few iterations and a few additions into it, so much so that it's the rushed exam. Okay, so it involves getting views of the HASH, the IVC, Morrison's pouch, eFAST exam, your aorta, your pneumothorax, and then as an addition, looking for an ectopic, looking for DVTs. Now, there are other, obviously, protocols out there. EGLS is more focused on ultrasound of the IVC, lungs, and hash.

And having a systematic approach is very important, regardless of whatever approach you decide to take. So in EGLS, it's like, is there a pneumothorax? Is there a tamponade?

Is there a hypovolemic or distributive shock? and is there LV dysfunction? And then finally, is there RV strain?

The heart is a pretty complex organ. As you can see, it has four chambers, you know, the right side, the left side, all slightly different. If you have right-sided failure, you know, the treatment is very different from left-sided failure.

And if you are facile with point-of-care ultrasound, you know, getting a few views of the heart will actually tell you what kind of shock you're dealing with. and how you can actually treat this the best way. So some pro tips for echocardiography. If you're not doing this every day, I appreciate that some of the views can be quite difficult. So how you hold the probe, okay?

You need to hold the probe like a pen. Don't hold it like a dead rash or holding it like a sock, a dirty sock that you're trying to put into the washing machine. Hold it with...

the probe, hold the probe like a pen, rest your hand on the patient's chest. That gives you a lot more stability and stops you from sliding off the patient's chest as you're trying to get that important view. Use lots of jelly.

You know, as you get more experienced, the amount of jelly actually that you use gets less and less and less. But initially try and use lots of jelly to make sure that the probe has good contact with skin. Then exert pressure. Exert pressure where to the point it's slightly uncomfortable.

And then when you think you have reached that point, exert a little bit more pressure. It's important that you get good contact with skin. Air is at the enemy of ultrasound, so if you don't use sufficient pressure, you will not get a good image.

Remember to use dynamic maneuvers. Use the left lateral position. Get your patient positioned. Even in the ICU, we can get patients who are intubated, ventilated, on dialysis. We usually can get them into a kind of a semi-left lateral position by just propping pillows behind them on the right side.

you know, and then you kind of can sit on the bed and, you know, perform the examination. Patients who are able to obey commands, you know, they can, to improve your images, you can actually get them to breath hold, you know, for echo, if you're doing, if you get them to exhale and hold their breath at that point for even for a second or two, you'll be able to get quite good images on the anterior chest wall. So if you... get them to take a big breath in. If you have problems getting a subcostal view, get them to take a big breath in and hold it there.

That pushes the heart down. You will be able to get a good view of the subcostal area then. And one last point, don't look at your hand position.

Look at what's happening on the screen. Look at how the image actually relates to your probe, your movements of the probe. So we'll just go into this very, very briefly.

So this is your sub... subcostal view. Keep your hand on top of the probe. Keep the probe quite shallow. You should get a view like this.

You should see four chambers of the harsh. This is a good view for evaluating pericardial effusions, relative LV or RV distension, and your LV function as well. You got a shot of the liver in the near field, right up here.

This is your right ventricle here, right atrium here, left atrium here, left ventricle there. You can go do your parasternal long axis, which is the second or third intercostal space, just lateral to the sternal border. This view is best gotten with a patient in a semi-left lateral view that just pushes the heart closer to the skin, moves the lung out of the way, lots of jelly, some pressure.

could hold the probe well, you should be able to get a pretty good image. This is what you're going to get. So again, from near field to far field, this is your right ventricular outflow tract. This is your ascending aorta, aortic valve. This is your left ventricle.

This is your mitral valve. This is your left atrium. This is your descending thoracic aorta. In this view, what you're looking for is a one is to one.

is to one ratio. So the diameters or the measurements of the right ventricle, the ascending aorta and the left atria should all be in a one is to one is to one ratio. So they should all look about the same size. If you have enlargement of the right ventricle, so say maybe you get a two is to one is to one ratio, then what could possibly be happening is that you're getting some RV dilatation.

Is that due to RV failure? you know, do you have a big PE? If you get a one is to two is to one ratio, then you got to suspect that there's something going on here. If your patient is shocked, does the patient have an ascending aortic aneurysm?

Okay. What's even worse is if you see a one is to two is to one and you see a pericardial effusion. Okay.

So a pericardial effusion will be seen here and in the far field in the pericardium. The pericardial effusion will go between the harsh and the descending aorta. And that differentiates it from a pleural effusion, which happens, the pleural effusion will go around the aorta and does not go between each and the harsh. That would be even more, those findings of a pericardial effusion and a dilated aorta. would be obviously very suggestive of a dissection of the ascending aneurysm, ascending thoracic aneurysm.

Dilation of the left atria is probably a more chronic process, and I wouldn't worry about it too much. But it would suggest that you have high filling pressures in the left ventricle. And if you're considering that giving fluid or volume to this patient, you want to be a little bit careful if they already have high filling pressures, because any...

bit more fluid could actually tip them into pulmonary edema. So that's for your parasternal long axis view. You rotate your probe then 90 degrees from the best position of your parasternal long axis to give you your parasternal short axis view. And with your parasternal short axis, this is the view that you should get. Your left ventricle is here.

This is your mid-papillary view. This is your mitral valve. So we're just scanning through all of it.

Over here, this structure here is the right ventricle. So it's almost like a donut. the left ventricle, and then across on kind of stuck onto the side of the donut is your right ventricle.

Now, the apical four chamber view is, I suppose people find this the more difficult view to get. Your probe should be, you know, big movements initially, just the intercostal space below the nipple in female patients. you know, put it into the inframammary crease, direct the probe towards the right scapula, because that's the plane that the heart will lie in.

Move the probe around in big circular motions initially to try and get a view. And then after that, slowly, you know, dial down on where the best view is. Probe marker should be kind of towards the two o'clock to three o'clock position. The view you should get is one of um you know uh the lv should be the center okay this is your rv over here it's your ra this is your la this is your mitral valve tricuspid valve this gives you a good global function you can certainly tell whether there's a pericardial fusion you can tell about lv function you can decide on the the relative interplay between your right ventricle and your left ventricle now After all of that, what are you looking for? So obviously, in your subcostal view, if you see something like this, like a man jumping on someone's right ventricle, you will obviously be quite concerned about tamponade.

Pericardial fusions do not have to be large to cause very severe shock. This obviously is not a good sign. So you can see here the left atrium. or sorry, the right atrium is being pushed down in early diastole. The right ventricle is also almost non-existent in this pretty large pericardial fusion.

Okay, if this person is shocked, they look clapped out, they're going to need a needle in this space. Okay, this is another interesting one. This is a sonographic, you know, if you wonder what... pulses alternance looks like visually. This is what pulses alternance looks like on your ECG.

If you plug it in the ECG properly, you'll see the QRS complexes alternating. So this is also worrying for Tempernard. I think the best way of describing it is, I suppose, John Travolta doing Saturday Night Fever. You can see how the movement of the RV is collapsing. So I suppose no presentation on ultrasound is complete without some stories.

So these are all real patients that I've seen over my time using point-of-care ultrasound. So this first lady here was MC. So she was a 73-year-old female. I had a... pretty soft blood pressure, 90 on 50, cat refill time was five, you know, a bit shocked.

She was quite shocked. Lactate of five, you know, very nonspecific symptoms, abdominal pain, urinary frequency, chest pain, a little bit of everything. She was diagnosed with urosepsis.

Given some volume, blood pressure improved a little bit. She was sent to the ward. We were contacted, the ICU team were contacted. later on to come and review this patient because after she had probably about three liters of fluid, she was not getting any better.

In fact, she was getting worse. Her lactate was going up to 12. Her blood pressure had now dropped to 70 on Thursday. Her radial pulse was not palpable.

Her carbaryl time was in the order of six or seven. So she was getting worse and worse and worse. The problem was that this diagnosis of sepsis is fraught with premature closure, diagnostic bias, and there are so many cognitive biases here.

Because once you say someone has sepsis, they're almost... pushed into a space where they get the fluid, they get their antibiotics, and they are all assumed to get better after that. But nobody actually goes to look at the heart.

And when you go to look at the heart, this is what you actually see. So she's got a pericardial fusion here. You can see here that her RV is actually collapsing, almost non-existent in this subcostal view.

In the apical four chamber... you can see that the right atrium is actually collapsing in diastole. So this heart is not actually filling on the right side. You know, she needed a needle decompression. So she got, you know, we did an ultrasound guided drain and aspiration probably about 10 to 15 mils.

And, you know, her shock status improved remarkably. So don't forget that. The other lady, this is one that I think probably a lot of people are quite familiar with. You know, a young lady at 4 a.m. comes in, has high BMI.

She's short of breath, doesn't have chest pain. She has cough productive of phlegm, 38.4 degrees Celsius. You know, she's multiple like SIRS criteria, you know, blood pressure of 80 on 50, lactate of 4. You know, she's been stamped with the respiratory sepsis.

put on antibiotics, put on some fluids, hope you get better. But nobody actually looks at a harsh. When you do actually look at a harsh, you can see here in your parasternal long axis, the RV is dilated. You can see it's actually pushing into the LV.

When you look at the parasternal short axis, you can see that this is not the donut with the croissant curved over it. This is actually what we call the D sign. So it's suggesting RV overpressure.

The pericardium is a fixed space. It's a zero-sum game. If the RV dilates, the LV has to decrease in size. So if you had a shock state, the shock state only gets worse as your RV dilates because your LV is getting smaller.

And by convention, your cardiac output will decrease as well because of that. Apical four chamber here, you can see the RV is still pretty dilated. So the conversation, the...

The appropriate treatment for this lady was, does she get TPA? So she fulfills the criteria for getting thrombolysis. So she's put on an Actilize Alteplase infusion, and the hemodynamics markedly improve within a couple of hours. Now, in terms of her LV function, in terms of function, When you look at LV function, people say it's very difficult to tell.

You certainly need a bit of experience with this. So that's why I recommend trying to echo most people that come into the department. If they have a little bit of chest pain or if they are shocked, certainly have a look at their heart. Because you will quickly recognize when the mitral valve is actually moving well or not moving so well. So this is a moderately depressed.

LV and this is normal LV. And then if you contrast it with this, so this is a mitral valve that's hardly moving at all. So this is a really severely depressed LV function. We talk about some wall motion abnormalities as well. So this is, if you look at this parasternal short axis, so it's got almost a full house of the wall motion abnormalities.

You can see here that this wall here, not moving. This wall here, a little bit hypokinesic. It's not actually thickening very well. And in this case here with systole, the wall, the interventricular septum is actually bowing in the opposite direction.

So that is the wall motion abnormalities. Patients who have STEMIs, one thing I'll say is actually, I know once they have a STEMI again, you know... everybody goes right you know we need to get to cath lab we need to get to the cath lab yeah absolutely uh you know they do need to get a cath lab um but always have a look uh you know it only takes you a minute or two to do a high map exam uh you know it'd be pretty silly for them to try and if the low blood pressure has caused you know um these st elevations but in actual fact you know if the uh if the low blood pressure was caused by say a ruptured triple a you know That would be pretty interesting for the cardiologists in the cardiac cath lab.

Or if they had a pericardial effusion and you saw a dilated aortic outflow tract, you know, that would certainly be suggested for dissection. And, you know, certainly PCI is not going to fix that problem. You can link your various coronary artery territories to the various walls.

You can look this up on Ben Smith's website. He's found on Twitter at Ultrasound Jelly. So we go from the heart to the IVC. So the IVC is often not. It's a pretty sad creature these days.

Everybody seems to think that the IVC is a bad thing to look at. I don't think it is. I think everybody looks at it kind of in the wrong way.

So this is the view that you are normally taught to look at the IVC. So this is the longitudinal view of the IVC. You can see, you may think that this is a pretty round structure, doesn't really change with very much respiration.

But I suppose with... as with most things in radiology, you want to look at things in both angles. So like with this, you know, you may think, you know, this guy is trying to give the finger to the press core, but in actual fact, you know, he's just saying, well, you know, there's three people, three things that we need to look out for. You need to look at the IVC in the short axis because that same structure that we saw earlier on, if you look at this, you can see that it's actually not that round.

It's actually. There's a bit of movement in it, okay? And all that is, is just a rotation of the probe in 90-degree fashion. So it depends on how you look at it.

Obviously, if you look at it this way, or if your probe is slightly tilted and you're looking in that direction, as you slice it, you know, the diameter looks slightly different. This is kind of an ellipsoid. So this is kind of what we would almost consider euvolemia, or maybe slightly hypovolemic.

and contrast that to an IVC that's actually fully dilated in the short axis. So you can see that this is fully, fully round, and this is a truly, truly dilated IVC. Try not to use the IVC to decide on fluid responsiveness.

The IVC is good in the extremes of conditions. So if it's really, really small or really, really large, it just tells you whether this patient is able to tolerate fluid. I don't use the IVC to tell me whether this patient is going to improve their hemodynamics by giving them fluid. I'm going to use the IVC to try and figure out whether I'm going to cause the patient any harm by giving them any fluids.

If you had a patient with an IVC this size, it would suggest that if you gave them 500 mils of a crystalloid bolus, you're probably not going to do them any harm. If you have a patient who is shocked... and maybe it's a traumatic cause of shock that you've determined, and you are looking at their shock stage and you're wondering why are they still shocked? They've had most of their blood products already at this stage. If you see an empty IVC, you have to consider whether they are still bleeding.

If it's full, you have to consider whether they have developed obstructive shock from tamponade or... you know, attention pneumothorax, preventing forward flow of blood from the IVC into the right ventricle. Let's talk about the E-FAST exam. So everybody's brain and buffer is the E-FAST exam in emergency medicine.

You know, your right upper quadrant, your pelvic view, your left upper quadrant, and then a subcostal view of the hash. So I tend to... do my fast exam in this way.

So I use the right upper quadrant first, followed by the pelvis in the longitudinal view only. And the last view I look at is the left upper quadrant. Because of the paracolic gutter in the right upper quadrant is a little bit lower than the left upper quadrant, blood or free fluid tends to track into the right upper quadrant first. you usually tend to see in the paracolic gutter or the caudal tip of the liver. Even if you had a splenic laceration or a splenic rupture, the free fluid usually tends to appear in the right upper quadrant, funnily enough.

So having a look at these images, make sure you scan through the whole organ. If you look at the clip on the left, you may say, hey, look, there's no free fluid. I've imaged Morrison's pouch.

And there doesn't seem to be any free fluid at all. But make sure you look lower down. So if you over here, you can see that the free fluid is actually just starting in the caudal tip of the liver coming into the inferior pole of the kidney. Okay.

You know, free fluid doesn't tend to occur on the right side above the diaphragm. So this is the space that you want to look at in the right upper quadrant. And then if you look into the paracordic gutter, then you will see free fluid here as well. Okay. So there's caudal tip of the liver, paracordic gutter.

Make sure you look in this space before you say that the right upper quadrant is clear. This is the bladder view. So pelvic view. So this is the bladder in long axis, not catheterized yet, but you can see again free fluid in the pelvic view.

The left upper quadrant is interesting, so it's rare enough that you actually find this free fluid between the spleen and the kidney. Most of the free fluid, if you find it on the left side, will be actually between the spleen and the diaphragm because the attachment between the spleen and the kidney is usually really tight. And free fluid doesn't usually track in there, usually tends to track above the spleen between the diaphragm.

So the aorta, so quick word about the, let's talk aortic assessment. Okay, so, you know, a lot of people are quite, you know, they feel that they are quite happy with doing aortic examinations, you know, especially on patients in ultrasound courses, because all the models that you get for ultrasound courses are already svelte and thin and they have no body fat. So it's very easy to image the aorta so much so that everybody gets these images when you go to scan at an ultrasound conference or an ultrasound course. But, you know, reality kind of bites in that, you know, a lot of the patients who have aortic disease, they're fast, they have food, they probably eat them before they come in, they're a little bit hairy, and they may have a lot of gas in there as well. So much so that when you try and do an aortic examination, this is what you tend to see.

So your teaching, traditional teaching would tell you to start from the epigastrium, work your way down to the bifurcation. But anatomy kind of tells you that doing it in a slightly different way. is actually more intuitive that if you start lower down at the belly button and work your way up or work your way down from there to the belly at the bifurcation that will make a lot more sense because the aorta as you can see over here is a lot more anterior because of your lordosis of your lumbar spine so start at the bifurcation start at your belly button and then move up or down because then you can localize where this is Just a separate word as well about the aorta, instead of looking for this the aorta over here, always look for the vertebral body first because the aorta is always located very close to that. Screen through the aorta as we see here, down to the bifurcation.

We can give you this example of diagnostic bias where this patient comes in complaining of loin to groin pain. He says it comes and goes. There's no history of trauma. Those are his vital signs.

Someone thought his GP, he had seen his GP about a week ago with this similar pain and has presented late to the department. This is what he looks like. If he went down the route of getting a renal ultrasound, if there was a stone, you may see dilation of the ureter over here, or you may see a stone in the vesicular ureteric junction. But in this case, if you're going to scan this, make sure you have a look at his aorta because in actual fact, the aorta can really screw you up because the symptoms are never, never, never really classical tearing pain. They present with intermittent pain, they can present with right upper quadrant pain.

The AAAs that I've diagnosed in the ED with ultrasound, none of them have the classic story that you get from the textbooks. So again, make sure you screen through. So you can see here large AAA.

and outer wall measure the outer wall to outer wall okay you can see the vertebral vertebral body at the back here uh again another one another triple a here all right don't measure the lumen okay that's not the that's not the problem it's actually the wall-to-wall diameter that you're looking for um Again, another one. There's quite a lot of wall thrombus here. You can see there's even thrombus going in there. This is in the long axis. You can see here this is all clot or thrombus.

So be facile with this. You scan. I think they did a study where you scan the 100. If you scan the 100 aeolus, you're going to save one life at the very least. Last but not least, the pneumothorax. So with pneumothoraces, I think most people use this quite regularly.

Lung sliding, no pneumothorax at this point. Over here, you can see no lung sliding, quite highly suggestive of a pneumothorax. If you look for the lung point, this is almost 100% specific for a pneumothorax.

This is where the lung is actually starting to collapse away from the rib cage. Some pitfalls here, if you look at this, you may think that there is no pneumothorax because you saw a bit of sliding there. But just be aware of where your pleural line starts, because your pleural line is below a rib. So this is your rib here. This is not the pleural line.

This is actually subcutaneous emphysema. So just be aware of that. Now, ectopics, you know, this has to be contextual.

You have to take this in context. If you have a patient with abdominal pain, young patient, female, abdominal pain, you know, with a positive HCG, if you scan the bladder and you look at the uterus and you see the uterine stripe, so this is an empty uterus. you know, it'd be very highly suggestive of an ectopic pregnancy.

Now, in this clip, you can actually see a gestational sac that is not in the uterus. So this is what we would consider an ectopic pregnancy. All right. But, you know, you didn't need to see this gestational sac to be able to call this as a possible ectopic pregnancy because there's no fetus in the uterus with a positive pregnancy test.

DVT scanning is pretty straightforward. Compression, if you apply compression to the veins, you should see that it collapse. If they don't collapse, then you got to be concerned about cloche. And that all figures into the patient, how you would manage patient with shock. You know, if they have RV dilatation and they have a cloche, you know, the conversation then should be, are you going to thrombolyze this patient?

Is this patient stable enough to survive a CTPA? So take home points. If the patient presents in shock, you know, they should get an ultrasound as part, you know, they should get a focused high MAP rush exam as part of the examination, as part of the clinical examination, you know, and however, which way you choose to do this protocol, it should, it should be completed on them.

The reassessment is the beauty of ultrasound because you can actually always go back to look again. It's not like you have to transport the patient to a CT scanner again to see whether you, what you have given them as initial management, whether that has worked. As you can see here, collapsing IVC, hyperdynamic left ventricle, dry lungs here because you see A-lines and some sliding.

You've given them maybe two leases of volume and you know, Maybe they are still shocked. Maybe their oxygen requirements have gone up. Reassess them at ultrasound.

This may be what you see, a dilated IVC now. This is B lines here in the lung views. The heart now looks pretty full. Function looks reasonably okay.

But at this point here, if they are still shocked, you have to consider whether they actually need vasopressors rather than more volume. It's always good to incorporate, you should always incorporate focus into your clinical examination. And like these guys here on the walker leisure, you know, they're always better together.

And that's me. So, oh yeah, wow, well within time. Okay, so if you have any questions you want to ask, you can take them now.

If you're shy, you can always email them. to me or direct message me on my Twitter account. This QR code brings you to my YouTube channel where I'll try and put clips up or videos up every now and again.

So yeah, thank you. Thank you for having me again. I suppose I'll take any questions that you may have.

Transcript for:The Role of Ultrasound in Emergency Medicine

Transcript for:
The Role of Ultrasound in Emergency Medicine