POCUS for the Internist: Lungs & Pericardial Effusions
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1 POCUS for the Internist: Lungs & Pericardial Effusions Jeremy S. Boyd, MD, FACEP Asst. Professor of Emergency Medicine Vanderbilt University Medical Illustrations courtesy of Robinson Ferre, MD, FACEP Vanderbilt University
2 No Financial Disclosures
3 One Federal Grant Disclosure
4 Lots of Cognitive Disclosures
5 I think its great, and I m sure for those techies who can use it that it will revolutionize their practice in the right clinical circumstances. That being said, I am extremely doubtful that it will ever come into general use. To do it well takes too much time, and it can be a hassle for both the physician and the patient. -Unknown (or at least to be revealed)
6 POCUS Rule #1: Ultrasound is a tool.
7 POCUS Rule #2: Ultrasound is not a substitute for clinical judgment.
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10 Ultrasound Basics
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13 top = closest to probe t brightness
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15 From Soni et al, Point-of-Care Ultrasound, 1 st edition, 2014
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18 Acoustic Impedance (Tissues Reflect Soundwaves Differently)
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33 POCUS
34 POCUS
35 40yo patient presents to the office with the complaint of post-prandial abdominal pain, especially after eating at her favorite hot chicken establishment (even when ordered mild). Does she have gallstones?
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37 72yo m with COPD, CHF, 1ppd smoker complains of worsened dyspnea with exertion, orthopnea. Breath sounds with faint wheezing and diminished bilaterally, R > L. Does he have a pleural effusion?
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39 Lung Ultrasound
40 The lungs should be seen and not heard. -Keith Wrenn, MD, FACP, FAAEM
41 The lungs should be seen (with soundwaves). -never said by Keith Wrenn, MD, FACP, FAAEM
42 Lung Anatomy
43 Chest Wall Skin Rib Parietal Pleura Intercostal Muscle Slide 43 Visceral Pleura
44 Chest Wall Rib Skin Parietal Pleura Intercostal Muscle Slide 44 Visceral Pleura
45 Costophrenic Angle
46 Costophrenic Angle
47 Probe Placement
48 Depends on the Clinical Question
49 Pneumothorax
50 Pleural Effusion
51 Right Left Pulmonary Edema
52 Understanding Ultrasound Artifacts of the Lung
53 1.Mirror Artifact 2.Comet Tail Artifact
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55 Requires 2 Conditions 1. Smooth surface 2. Doesn t transmit sound Lung Bone Air Filled Structure
56 Slide 56
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58 A-lines A A A
59 Dry Lung A A A
60 Comet Tails
61 water air
62 air H2O H2O air H2O H2O air H2O air air H2O air H2O air
63 many returning echos 1 returning echo air H2O H2O air H2O air air H2O air H2O air air H2O air H2O air H2O H2O H2O H2O H2O air
64 Slide 64
65 Comet Tail Artifact
66 B-lines B B B
67 Wet Lung B B B
68 The B-Line 1. Arises from the pleura 2. Laser Like 3. Reaches the bottom of the ultrasound screen 4. Moves with respiration 5. Erases A-lines
69 Lung Pathology
70 Potential Pathology 1. Pneumothorax = Lung Sliding = Aerated lung is touching the chest wall 2. Interstitial Edema = A lines (Dry Lung) or B Lines (Wet Lung) 3. Consolidation = Fluid/Puss filled Alveoli 4. Pleural Fluid
71 Potential Pathology 1. Pneumothorax = Lung Sliding = Aerated lung is touching the chest wall 2. Interstitial Edema = A lines (Dry Lung) or B Lines (Wet Lung) 3. Consolidation = Fluid/Puss filled Alveoli 4. Pleural Fluid
72 Lung Sliding Parietal Pleura Visceral Pleura
73 Lung Sliding
74 Lung Point
75 Lung Point = Edge of the Pneumothorax Air Slide 75 Lung
76 Lung Air
77 Lung Point
78 Potential Pathology 1. Pneumothorax = Lung Sliding = Aerated lung is touching the chest wall 2. Interstitial Edema = A lines (Dry Lung) or B Lines (Wet Lung) 3. Consolidation = Fluid/Puss filled Alveoli 4. Pleural Fluid
79 A-Lines
80 A Lines with PTX
81 B-Lines
82 B-Lines
83 B-Lines
84 The Meaning of B-lines B-lines are not necessarily pathologic 3 or more is abnormal Scanning protocols help to understand significance probe placement matters
85 Pathology (3 or More B-Lines) Increased Lung Water ARDS/ALI Cardiogenic Pulmonary Edema Infection PNA (viral or bacterial) Pneumonitis (i.e. HAPE) Contusion Pulmonary Fibrosis
86 Location & Number
87 1 or 2 here can be normal Zone 1 Zone 2 Zone 3
88 B-Lines = Lung Water
89 Scanning Protocols: Volpicelli
90 Scanning Protocols: Lichtenstein Ant Pos Lat Ant
91 Potential Pathology 1. Pneumothorax = Lung Sliding = Aerated lung is touching the chest wall 2. Interstitial Edema = A lines (Dry Lung) or B Lines (Wet Lung) 3. Consolidation = Fluid/Puss filled Alveoli 4. Pleural Fluid
92 Consolidation
93 Consolidation
94 Consolidation
95 Consolidation
96 Potential Pathology 1. Pneumothorax = Lung Sliding = Aerated lung is touching the chest wall 2. Interstitial Edema = A lines (Dry Lung) or B Lines (Wet Lung) 3. Consolidation = Fluid/Puss filled Alveoli 4. Pleural Fluid
97 Normal CPA
98 Pleural Effusion Spine Sign
99 Pleural Fluid Normal
100 Pleural Effusion
101 Pleural Effusion with Consolidation
102 Pleural Effusion
103 Clinical Application
104 Included in systematic review History and physical: n=31 ECG: n=11 CXR: n=18 BNP/NT-proBNP*: n=41 Bedside echo: n=4 Lung ultrasound: n=8 Bioimpedance: n=4
105 SENS SPEC
106 +Test -Test
107 Pericardial Effusion
108 Anatomy Pericardium Wraps around heart ends at major vessels Pericardial fluid Normal = cc Best Windows Sitting = Subcostal Supine = PSLA
109 Top 5 Causes 1. Malignancy 30% 2. Idiopathic 15% 3. Acute MI / Post cath 15% 4. Infectious 15% 5. Uremia 10%
110 No Pericardial Effusion
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112 Small Pericardial Effusion
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114 Large Pericardial Effusion
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116 Pericardial Effusion Size < 1 cm = Small 1-2 cm = Moderate > 2 cm = Large
117 Pericardial Effusion Size Measure in Diastole = when the effusion is the smallest
118 If the heart is surrounded by fluid how do I tell if it is pleural or pericardial fluid?
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123 Tamponade?
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125 5 Sonographic Signs 1. Pericardial effusion 2. Enlarged and plethoric IVC 3. Right atrial systolic collapse 4. RV Diastolic Collapse 5. All chambers underfilled & hyperdynamic
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127 Tale of Two IVCs
128 5 Sonographic Signs 1. Pericardial effusion 2. Enlarged and plethoric IVC 3. Right atrial systolic collapse 4. RV Diastolic Collapse 5. All chambers underfilled & hyperdynamic
129 Pulsus Paradoxus?
130 LR+ = 5.9 LR- = 0.03 Roy et al, JAMA 2007
131 (Remember Rule #1)
132 I think its great, and I m sure for those techies who can use it that it will revolutionize their practice in the right clinical circumstances. That being said, I am extremely doubtful that it will ever come into general use. To do it well takes too much time, and it can be a hassle for both the physician and the patient. -Unknown (or at least to be revealed)
133 " I have no doubt whatever, from my own experience of its value, that it will be acknowledged to be one of the greatest discoveries in medicine by all those who are of a temper, and in circumstances, that will enable them to give it a fair trial. That it will ever come into general use, notwithstanding its value, I am extremely doubtful; because its beneficial application requires much time, and gives a good deal of trouble both to the patient and the practitioner -John Forbes, FRCP, FRS
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135 Ultrasound is a tool.
136 Ultrasound is a tool. Use it wisely.
137 Thank you.
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146 E-FAST Exam
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173 But wait. There s more
174 Vascular Access
175 Vascular Access
176 Vascular Access
177 Vascular Access
178 Cardiac Arrest
179 Intubation
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