Creative – Western Sono

10 Things I Learned on my POCUS Elective

Derek Wu — Tue, 18 Dec 2018 05:23:13 +0000

“This reflective writing piece was completed by Dr. Aashish Kalani upon completion of his recent CCUS block. For those of you unable to rotate with us, who have rotated but may have forgotten some things or for those who will someday rotate with us, read on – I think you’ll find value here!”

Rob Arntfield, MD, FRCPC, December 2018

1

Not all hyperdynamic hearts warrant IV fluids

The temptation when seeing hyperdynamic LV function is to provide IV fluid which may be a precarious one

The differential for hyperdynamic LV function is broad, including deranged metabolic states, infectious states, inflammatory states, and hypovolemia. Liberally providing IV fluids for hyperdynamic hearts may not correct some of these states and may drive iatrogenic volume overload which can carry a range of complications including lung injury, impaired mobility, and organ dysfunction. Combining the clinical picture, IVC status and lung profile should be combined with determination of hyperdynamic LV function to facilitate decision-making with regards to IV fluids and beyond.

2

More to B-lines than pulmonary edema

Bilateral B-line lung pattern has a large differential

Other than cardiogenic pulmonary edema, bilateral B-line pattern can be compatible with pneumonia, ARDS, interstitial lung disease and other conditions. Assessments of the pleural line, pulmonary parenchyma (including presence or absence of C-pattern), distribution of B-lines, cardiac status, and – of course – clinical status can help narrow down the etiology.

3

Cardiac output assessment is a more useful assessment of LV function compared to LVEF

Cardiac output calculations provide more accurate assessments of systemic perfusion

While more challenging to acquire accurately, cardiac output calculations incorporating LVOT diameter, HR, and LVOT VTI assessments take out complicating factors such as mitral regurgitation which can skew LVEF.

4

More to differentiating pneumonia from atelectasis than dynamic air-bronchograms

Dynamic air bronchograms are not terribly sensitive

Other lung ultrasound findings, such as absence of A-lines, hepatization, and ill-defined margins are some of the other of findings that can help support a diagnosis of pneumonia over atelectasis.

5

Findings to support diagnosis of a complicated pleural effusion

Typically loculations and septations are searched for to help diagnose complicated pleural effusions

Other signs are supportive as well, such as plankton sign (swirling debris in the pleural fluid that appear with respiratory motion). As well, complicated fluid may not always be anechoic but can be hyperechoic as well. Another useful finding is the hematocrit sign (demonstrating settling of fluid with increased echogenicity at the dependent area of the effusion where coagulated cells and other debris gather as a result of gravity)

6

Assessment of LV function should take heart rate into consideration

Increased heart rates can make the inexperienced ultrasonographer overestimate LV function

Slowing down the video clip during image interpretation can reveal underlying sluggish hearts. When slowing down the video clip, subjective assessments in addition to endocardial wall excursion, endocardial thickening and EPSS should be applied.

7

Arntfield’s Law

Quality of parasternal views in any given patient is inversely proportional to quality of subcostal views

Based on the natural axis of how the heart sits in the thoracic cavity, often if easy parasternal views are obtainable, the heart is sitting in a more superior and transverse orientation. This may mean that subcostal views will be more challenging in the same patient. The same goes for more inferior, longitudinally positioned hearts. Some patients of course have a panel of beautiful views but this “law” does help the junior ultrasonographer with trusting the skill development process.

8

Tips to optimize a cardiac image

Rather than adjusting the gain, dropping the dynamic range often provides better contrast of anechoic cavities with hyperechoic cardiac tissue

As well, rather than just adjusting the depth, modulating the sector width to encompass the heart but not entrap it can also help appraise relevant pathology at hand. Also sometimes hearts can be cut off axis which can over- or under-estimate cavitary size – rotating, tilting, and rocking movements as appropriate can help obtain a more comprehensive set of views after which the most accurate picture can be selected.

9

IVC diameter & variability with respiration – not as useful for assessing volume status and volume responsiveness as you may think

The literature for IVC assessment and its relationship to volume responsiveness and overall volume status is scarce and limited

It is especially fraught with peril to use IVC assessments in the spontaneously breathing patients to help make these decisions. Perhaps one applicable area of IVC assessment is in passively ventilated patients – distensibility >18% can support a strategy of volume resuscitation, combined with other parameters of course. Otherwise, IVC diameters at the extremes can be helpful – skinny IVCs with large respiratory variation can support plans for fluid resuscitation and plethoric IVCs with little-no respiratory variation should raise caution.

10

If someone offers you coffee, just take it!

Seriously!

Praesent Et Urna Turpis

robert.arntfield — Tue, 31 Jul 2012 17:26:20 +0000

Quisque ligulas ipsum, euismod atras vulputate iltricies etri elit. Class aptent taciti sociosqu ad litora torquent per conubia nostra, per inceptos himenaeos. Nulla nunc dui, tristique in semper vel, congue sed ligula. Nam dolor ligula, faucibus id sodales in, auctor fringilla libero. Pellentesque pellentesque tempor tellus eget hendrerit. Morbi id aliquam ligula. Aliquam id dui sem. Proin rhoncus consequat nisl, eu ornare mauris tincidunt vitae.

Vestibulum sodales ante a purus volutpat euismod. Proin sodales quam nec ante sollicitudin lacinia. Ut egestas bibendum tempor. Morbi non nibh sit amet ligula blandit ullamcorper in nec risus. Pellentesque fringilla diam faucibus tortor bibendum vulputate. Etiam turpis urna, rhoncus et mattis ut, dapibus eu nunc. Nunc sed aliquet nisi. Nullam ut magna non lacus adipiscing volutpat. Aenean odio mauris, consectetur quis consequat quis, blandit a nunc. Sed orci erat, placerat ac interdum ut, suscipit eu augue. Nunc vitae mi tortor. Ut vel justo quis lectus elementum ullamcorper volutpat vel libero.

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Ut porttitor euismod cursus. Mauris suscipit, turpis ut dapibus rhoncus, odio erat egestas orci, in sollicitudin enim erat id est. Sed auctor gravida arcu, nec fringilla orci aliquet ut. Nullam eu pretium purus. Maecenas fermentum posuere sem vel posuere. Lorem ipsum dolor sit amet, consectetur adipiscing elit. Morbi ornare convallis lectus a faucibus. Praesent et urna turpis. Fusce tincidunt augue in velit tincidunt sed tempor felis porta. Nunc sodales, metus ut vestibulum ornare, est magna laoreet lectus, ut adipiscing massa odio sed turpis. In nec lorem porttitor urna consequat sagittis. Nullam eget elit ante. Pellentesque justo urna, semper nec faucibus sit amet, aliquam at mi. Maecenas eget diam nec mi dignissim pharetra.

Donec At Mauris Enims

robert.arntfield — Tue, 31 Jul 2012 17:25:18 +0000

Lorem ipsum dolor sit amet, consectetuer adipiscing elit, sed diam nonummy nibh euismod tincidunt ut laoreet dolore magna aliquam erat volutpat. Ut wisi enim ad minim veniam, quis nostrud exercitation.

Class Aptent Taciti Soci Ad Litora

robert.arntfield — Tue, 31 Jul 2012 17:24:55 +0000

Lorem ipsum dolor sit amet, consectetuer adipiscing elit, sed diam nonummy nibh euismod tincidunt ut laoreet dolore magna aliquam erat volutpat. Ut wisi enim ad minim veniam, quis nostrud exercitation.

Nullam Vitae Nibh Un Odiosters

robert.arntfield — Tue, 31 Jul 2012 17:23:43 +0000

Proin Sodales Quam Nec Sollicit

robert.arntfield — Tue, 31 Jul 2012 17:23:05 +0000

Quisque ligula ipsum, euismod aturesit vulputate a, ultricies et elit. Class aptent taciti sociosqu ad litora torquent per conubia nostra, per inceptos himenaeos. Nulla nunc dui, tristique in semper vel, congue sed ligula. Nam dolor ligula, faucibus id sodales in, auctor fringilla libero. Pellentesque pellentesque tempor tellus eget hendrerit. Morbi id aliquam ligula. Aliquam id dui sem. Proin rhoncus consequat nisl, eu ornare mauris tincidunt vitae.

Nunc Tincidunt Elit Cursus

robert.arntfield — Tue, 31 Jul 2012 17:22:22 +0000

Quisque ligula ipsum, euismod a vulputate a, ultricies et elit. Class aptent taciti sociosqu ad litora torquent per conubia nostra, per inceptos himenaeos. Nulla nunc dui, tristique in semper vel, congue sed ligula. Nam dolor ligula, faucibus id sodales in, auctor fringilla libero. Pellentesque pellentesque tempor tellus eget hendrerit. Morbi id aliquam ligula. Aliquam id dui sem. Proin rhoncus consequat nisl, eu ornare mauris tincidunt vitae.