Conquering Clinical Pivot Points-Ultrasound · • Introduction to ultrasound physics and...

Conquering Clinical Pivot Points with Point-of-Care Ultrasound

Workshop Instructors

Jabraan Pasha, MD, RDMS

Workshop Instructors

Mary Mao, MD

Workshop Instructors

Mark Perdue MHS, PA-C

Workshop Instructors

Bobby Bosse, PA-C

Workshop Instructors

Jacob Murray, MD

Workshop Objectives

Workshop Objectives• Understand the principles of point-of-care

ultrasound

Workshop Objectives• Understand the principles of point-of-care

ultrasound

• Introduction to ultrasound physics and knobology

Workshop Objectives• Understand the principles of point-of-care

ultrasound

• Introduction to ultrasound physics and knobology

• Learn image acquisition and interpretation of pulmonary, renal and cardiac ultrasound

Point-of-Care Ultrasound? What’s That?

Point-of-Care Ultrasound? What’s That?

What it’s not:

Point-of-Care Ultrasound? What’s That?

What it’s not:• A comprehensive radiologic

study

Point-of-Care Ultrasound? What’s That?

What it’s not:• A comprehensive radiologic

study• A general screening test

Point-of-Care Ultrasound? What’s That?

What it is:

Point-of-Care Ultrasound? What’s That?

What it is:• A focused and goal-directed exam

Point-of-Care Ultrasound? What’s That?

What it is:• A focused and goal-directed exam• Quickly performed

Point-of-Care Ultrasound? What’s That?

What it is:• A focused and goal-directed exam• Quickly performed • Performed at patient’s bedside

Ultrasound physics

Ultrasound physics

ProbesPhased Array• Cardiac• Abdominal

ProbesLinear• Soft Tissue• Pulmonary• Lines

ProbesCurvilinear Probe• Abdominal• Chest*

Orientation

• Screen marker on left of screen (except cardiac)

• Probe marker to patients right or patients head

Orientation

Acoustic Windows• Good conductors

• Solid• Flexible

• Liver• Spleen• Kidney• Bladder

Acoustic Windows• Poor conductors

• Air• Not Flexible

• Lung• Bone• Bowel

Acoustic Windows

Acoustic Windows

Acoustic Windows

Acoustic Windows

Echogenicity

Gain

• Affects the brightness of the image

Gain

Depth

• Changes the depth of the beam

• Image should be in the center of the screen

Artifacts

• Mirror image artifact

Artifacts• Post Acoustic Shadowing

Artifacts

• Reverberation

Planes

Case #165 y/o male with h/o COPD and CHF presents to ED with dyspnea on exertion and hypoxia. On exam, there is scattered wheezes and crackles heard at the bases. CXR shows enlarged lung fields and increased vascular congestion

Case #1

COPD exacerbation vs CHF exacerbation

Application #1: Pulmonary Ultrasound

Application #1: Pulmonary Ultrasound

• Clinical Question:

Application#1: Pulmonary Ultrasound

• Clinical Question: Is there significant pulmonary edema?

Application #1: Pulmonary Ultrasound

Patient and Probe Positioning• Patient supine• Abdominal probe in sagittal plane

in mid-clavicular line• Depth set to 12cm

Application #1: Pulmonary Ultrasound

Clinical Question:

Application #1: Pulmonary Ultrasound

Clinical Question: Is there significant pulmonary edema?

Application #1: Pulmonary Ultrasound

Application #1: Pulmonary Ultrasound

Application #1: Pulmonary Ultrasound

• Lung ultrasound study• B-Lines present in100% of patients with

pulmonary edema• Absent In 92% of patients with COPD

exacerbation• Absent in 98.8% of patients with normal

lungs

Bonus Application: Pneumothorax

Bonus application: Pneumothorax

Patient and Probe Positioning• Patient supine• Linear probe in sagittal plane in

mid-clavicular line• Depth set to 4cm

Bonus application: Pneumothorax

Clinical Question: Is there a pneumothorax?

Bonus application: Pneumothorax

Bonus application: Pneumothorax

Bonus application: Pneumothorax

Bonus application: Pneumothorax

Pulmonary Ultrasound Breakout Session

Case #2

65 yo male with h/o BPH and arthritis, seen in clinic for elevated creatinine of 2.6 (baseline 1.1)

Case #2

Extrinsic vs Intrinsic Renal Disease

Application #2: Renal Ultrasound

Application #2: Renal Ultrasound

• Clinical Question:

Application #2: Renal Ultrasound

• Clinical Question: Is there hydronephrosis

Application #2: Renal Ultrasound• Clinical Question: Is there hydronephrosis?

• Patient supine• Curvilinear or phased array probe in coronal

plane at rib 8-12• Depth set to approx. 14cm• Left kidney is often more posterior/superior

Application #2: Renal Ultrasound

Application #2: Renal Ultrasound

Application #2: Renal Ultrasound

Application #2: Renal Ultrasound

Application #2: Renal Ultrasound

Application #2: Renal Ultrasound

Application #2: Renal Ultrasound

Application #2: Renal Ultrasound

Application #2: Renal Ultrasound

Application #2: Renal Ultrasound

Renal Ultrasound Breakout Session

BREAK TIME!

Case #3

75 yo male with h/o CAD and recent worsening dyspnea on exertion

Application #3: Cardiac Ultrasound

• Clinical Question: Is the EF reduced?

Application #3: Cardiac Ultrasound

Application #3: Cardiac Ultrasound

• Clinical Question: Is the EF reduced? • Parasternal Long axis view• Left parasternal between ribs 2 and 5

Application #3: Cardiac Ultrasound• Clinical Question: Is the EF reduced?

• Screen marker on right• Probe marker towards patient’s right

shoulder• Often helpful if patient lying on left side

with left arm behind head

Application #3: Cardiac Ultrasound

Application #3: Cardiac Ultrasound

Application #3: Cardiac Ultrasound

Cardiac Ultrasound Breakout Session

Questions?

Thank You!!