Powerpoint Presentation - exported from Keynote Mac presentation. Introduction to Cardiac Point of Care U/S. Talk was meant for Emergency Medicine Residents PG1-3 level. Modest tweaks of font and spacing required prior to your own use. Associated PDF file in original Keynote format.

1. Fundamentals of Point of Care
Cardiac Ultrasound For
Emergency Medicine Residents
Frank W Meissner, MD, RDMS, RDCS
FACP, FACC, FCCP, FASNC, CPHIMS, CCDS

2. POC U/S
Hand Held Devices
Excellent 2D imaging
OK quality Color Flow Doppler U/S
Newest System incorporates PW Doppler -
but rare to have this capability- won’t discuss
PW Doppler today

3. No REVIEW of U/S Physics
Although important to understanding of U/S
image production
Not possible given short time given to discussion
Additionally, simplified knob-ology of POC
U/S results in lack of user control of imaging
parameters, thus not vital to understand U/S
physics in order to obtain dx images

4. When & Why
Chest Pain Evaluation
Dyspnea Evaluation
Known LV Dysfunction
Possible SBE or Cardiac Embolization

5. Potential Chest Pain Dx
Chest Pain
Ischemic Dz
Rgnal Wall Motion prior to EKG changes or clinical
symptoms
Unlike current enzyme protocols can detect ischemia rather
than infarct
>80% lesion will result in resting regional wall motion abnmlty

6. Potential Dx
Critical Aortic Valve Stenosis
Aortic Dissection of Root or Arch
Pulmonary Embolism
CFD > mod-large TR Jet with nml sized RA
McConnell Sign (hyperdynamic apex + hypokinetic/Akinetic RV Free Wall)
Pericarditis (small Pericardial Effusion)
R/O Pericardial Tamponade
Mitral Valve Prolapse - Barlow’s Syndrome
Acute cholecystitis vs GB colic
Pleurisy with effusion
Atrial Myxoma

7. Dyspnea
Evidence of Valvular Dysfunction (AoV/MV
Stenosis vs Severe AI/MR )
Evidence of Pulmonary Embolism
Evidence of Systolic vs Diastolic HF
Pleural Effusion, Atelectasis, Pneumonia

8. Cardiac Cycle

9. Systole AV Valves Closed

10. Diastole AV Valves Open

11. Transducer Positions &
Cardiac Views
Parasternal Position
Long Axis
Short Axis
Apical Position
4-, 5-, 2-, 3- chamber Views
Subcostal Position
IVC & hepatic veins, RV/LV inflow view, LV-aorta, RV outflow
Suprasternal Notch (not covered)

12. Transducer Positions

13. Imaging Planes

14. Imaging Windows

15. Parasternal LA View
What is seen?
Mid portion & base of the LV, MV leaflets, non-
coronary & RV leaflets of AoV, Aortic Root, RA,
RV
Imaging plane aligned parallel to the Long Axis of LV
With medial angulation/rotation of transducer
RV/TV/RA brought into view

16. Parasternal LA View

17. Parasternal LAX View

18. Detailed Anatomy -
Parasternal LAX View

19. Detailed Anatomy - PLAX
RV Wall
RV
Interventricular Septum
LV
Posterior Wall
MV
Papillary Muscles
Chordae Tendinae
LA
AoV
Ascending Aorta

20. RV Inflow Tract View

21. Parasternal SAX (AoV Level)
RVOT
TV
PV
PA
AoV
RA
LA
Intra-atrial Septum

22. Parasternal SAX (AoV Level)

23. Parasternal SAX (MV Level)
RV Free Wall
IVS
LV
MV orifice
LVPW
Pericardium

24. RV Free Wall
RV Cavity
IVS
LV Cavity
Papillary Muscles
Posterior LV Wall
Pericardium
Parasternal SAX (Papillary Level)

25. Apical 4-Chamber
LV Apex
RV Cavity
IVS
Intra-atrial Septum
LV Cavity
LV Lateral Wall
MV
TV
Papillary muscles
Chordae Tendinae
Pulmonary Veins
LA
RA
Pu

26. Apical 5-chamber
LV Apex
RV Cavity
IVS
Intra-atrial Septum
LV Cavity
LV Lateral Wall
MV
TV
AoV
LV Outflow Tract
Pulmonary Veins
LA
RA
Pu

27. Apical 2 Chamber
LV Apex
Anterior Wall LV
Inferior Wall LV
LV Cavity
MV
LA
Pulmonary Veins

28. LV Apex
AntSeptal LV
InferiorLat LV
LV Cavity
MV
LA
AoV
LV outflow tract
RV Infundibulum
Apical Long Axis or
3-Chamber View

29. Cardiac Valves

30. Septal Walls - Apical 4Chamber

31. Wall Seg - Coronary Artery
Relationships

32. RUSH Protocol Probe Positions

33. Rush Protocol Probe Positions
Evaluate ‘The Pump’

34. Rush’ed Exam

35. “The Pump”
Severe LV Systolic Dysfunction

36. “The Pump”
Large Pericardial Effusion

37. “The Pump”
Hemorrhagic Tamponade

38. “The Pump”
Acute RV Strain => Pulmonary Embolism

39. “The Pump”
RA Thrombus => Pulmonary Embolism

40. Rush Probe Positions
Evaluate ‘The Tank’

41. ‘The Tank’
Evaluate IVC with Sniff Test

42. ‘The Tank’
Eval IVC with ‘Sniff test’ m-mode

43. ‘The Tank’
Eval IVC with ‘Sniff Test’ in case of High
Filling Pressures

44. ‘The Tank’‘The Tank’
Fast Exam - Fluid in Morrison’s Pouch

45. ‘The Tank’
e-FAST Eval - Pleural Effusion

46. ‘The Tank’
e-FAST eval R/O PTX

47. ‘The Tank’
e-FAST Eval Pulm
Edema

48. RUSH Exam - Probe Sites
‘The Pipes’

49. ‘The Pipes’
Large Abdominal Aortic Aneurysm

50. “The Pipes’
Acute Abdominal Aortic Dissection

51. ‘The Pipes’
Acute Thoracic Arch Dissection

52. ‘The Pipes’
Acute DVT of Femoral Vein

53. Levels of Echo Competence

54. Conclusions
POC U/S is a Wholistic Tool
We have Discussed the Available Cardiac U/S
Views
We have Discussed in Detail the Rush Protocol for
Shock
The Key to Mastery Is To ‘Probe’ Every Patient -
This Requires Discipline in a Busy ED