www.sonocloud.org - lots of clips of abnormal pathology images with user-generated content

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Point of Care Ultrasound Book:

 

Introduction to Bedside Ultrasound iBook, Volume 1: Volume 1 & 2 are great resources assembled by the well-know EM docs behind US podcast

 

Introduction to Bedside Ultrasound iBook, Volume 2: Volume 1 & 2 are great resources assembled by the well-know EM docs behind US podcast

On Twitter follow:

@ReneeDversdal

@Sonointernist

Search hashtags

#IMpocus

#FOAMus

#FOAMed

Websites

 

Society for US in Med Ed Learning Modules: Comprehensive modules covering basics through some organ specific uses

University of S Carolina videos: Brief YouTube videos covering anatomy & physiology

Asynchronous Crowdsourced Education for Clinical Ultrasound: Amazing database of Free Open Access Medical Education for Clinical Ultrasound!

Ultrasound of the Week: “Learn bedside ultrasound, one week at a time”

5 minute Sono:

SonoGuide: “US Guide for Emergency Physicians”

SonoInternist Site: Created by former US fellow at U S Carolina & includes a map of fellow IM US enthusiasts

Cardiovascular Limited Ultrasound Exam Facebook page: Central location for educational videos, most recent summary paper link, etc

ACEP Emergency  Ultrasound Collaborative Resource: Dense but thorough overview of US in EM

AIUM Ultrasound in Medical Ed Portal: “clearinghouse of resources related to facilitating the integration of ultrasound into medical school education

Stanford Echocardiography in ICU: Basic echo overview

Online Echo Modules: First 4 are free

SonoCloud: database with tons of searchable images & clips


Apps

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Ultrasound REsources

Free open access medical education (FOAMed) has been a key component to the development of ultrasound education. Internationally, there has been a relatively large, enthusiastic group of educators who have dedicated themselves to sharing their knowledge of POCUS. You will find a number of these resources here. We understand that learners have their unique styles of learning, so we encourage you to try some of these different resources and let us know what you find useful.


Ultrasoundpodcast.com: Mike, Matt, and Jacob "Making horrible doctors decent and good doctors great."

5 Minute Sono: Jacob Avila and Ben Smith excellent podcast with short clips perfect for just-in-time learning.

Society for US in Med Ed Learning Modules: Comprehensive modules covering basics through some organ specific uses.

Ultrasound leader Chris Fox and UC Irvine's itunes podcast series found here for iPad users.

Ultrasound GEL Podcast - a literature review podcast led by Mike Bratz, Creagh Boulger, and Jacob Avila.

Podcasts/Videos


Abbott Northwestern's IM Residency has an fabulous POCUS training program. Their content is hosted here

Irene Ma, an EM Ultrasound trained Internist/Nephrologist, Internal Medicine POCUS website.

Emergency Ultrasound Teaching has a bunch of pooled lectures, test questions, and images.

UCLA's procedure focused POCUS website, created by Jason Williams.

Philips has published an ibook formatted website with a lot of different ultrasound applications.

123 Sonography first several echo lectures are free. These are high quality.

Ultrasound of the Week frequently published cases where ultrasound saved the day.

SonoGuide: an EM-based, collaborative ultrasound website with great content.

SonoMojo: cheat sheets to help define what you should know at the bedside.

Echocardia is a great resource for all things echo, complete with case of the week, clinical cases, relevant literature.

The Pocus Atlas contains images for review and overview of the literature with an assessment of how to use different POCUS applications.

If you want a great anatomy review for focused cardiac ultrasound, I highly recommend University of Toronto's modules ... these will help you spatially put together cardiac images.

Websites


Point of Care Ultrasound Book, Nilam Soni et al: Most med schools have access to clinicalkey.com where anyone can access the book.

Introduction to Bedside Ultrasound iBook, Volume 1 and Volume 2: Volume 1 & 2 are great resources assembled by the well-know EM docs behind US podcast. 

Books


Ultrasound-users have gravitated to twitter to share great cases. Here are some people worth following and #tags used by the community:

Twitter

 

@jchristianfox

@Yale_EUS

@Benjikmathews

@UTS_Australia

@CreaghB

@5MinSono

#IMpocus,  #POCUS,  #FOAMus,  #FOAMed

@ReneeDversdal

@US_pyro

@Sonointernist

@pdxfutbal

@irenema99

@ultrasoundpod

@ultrasoundjelly

Intern Intensive

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Ambulatory Material

Session #1-Introduction to Point-of-Care Ultrasound(POCUS) and Focused Cardiac Ultrasound (FCU)

Looking for a place to start? Check out this great review of ultrasound knobology by 5 minute sono. Est. time 5 min.

Ultrasound physics may not be the most exciting topic, but a basic understanding can go a long way to help you understand, interpret and optimize your image. Here is a brief review by Dr. Mike Stone on UltrasoundPodcast.com. Est. time 20 min.

A nice little "how to" from our friends at Sonosite:

1) Parasternal Long Axis Est time 5 min

2) Subcostal/Subxyphoid Est time 2 min

3) IVC. Est. time 2 min. Note: disregard their recommendation on probe orientation and point that probe marker toward the head. Otherwise great review of anatomy.


Session #2 - Cardiovascular Limited Ultrasound Examination (CLUE)

Struggling to determine volume status for your patients? Dr. Mike Wagner teaches us to grab the ultrasound and get a "CLUE". Est time 15 min.

Two great articles from Dr. Kimura regarding his CLUE exam:

1)Limited US Examination for "Quick-Look" Bedside Application

2)Cardiac Limited US Exam Techniques to Augment the Bedside Physical Examinaton

Use of US at the bedside to assess the IVC can be incredibly helpful, but only if we know how to interpret our findings. It's easy to get lost sorting through the IVC literature. Below is a couple of high yield review articles to put it all in perspective. Take home point: Useful to estimate CVP in spontaneously breathing patients, but only in extremes!

1)The efficacy of sonographic measurement of IVC diameter as an estimate of CVP

2) Caval Sonography in Shock


Session #3

*Nice review on Abbott Northwestern's website of evaluation for cardiac tamponade.

*I like this case/paper: “Point-of-Care Diagnosis of Cardiac Tamponade Identified by the Flow Velocity Paradoxus - Shyy - 2017 - Journal of Ultrasound in Medicine - Wiley Online Library.” http://onlinelibrary.wiley.com/doi/10.1002/jum.14251/full.

123sonography with a nice webinar on diastology.

*Did you find other helpful resources? Email me at piro@ohsu.edu so I can keep tabs on the best resources for learners.


Background and Physics

Aim: To learn how to perform basic operation of an ultrasound and to also understand the physics behind ultrasound wave formation and properties and image generation.

Click for background/physics resources

Click for background/physics resources

Basic Background

Please review some of the materials from this link so that you understand the essential background of POCUS, as described in the objectives linked above. Then take the SURVEY by clicking the button below.

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Expert

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THE DATA:

 

 

 

Suggested Background Resources

Review chapter 2-6 in Nilam Soni's, Point-of-care Ultrasound.

Soni, Nilam, Robert Arntfield, and Pierre Kory. Point of Care Ultrasound. Elsevier Saunders, 2015.

Introduction to Bedside Ultrasound

Reading


Please refer to these websites I have compiled to explore on your own.

Websites


Physics Videos

Brief physics primer from Mike Stone, US extraordinaire and current ED physician practicing in the Portland area.

Video, Estimated Time: 18 min.

Mike Stone goes over Doppler if you are interested.

Video, Estimated Time: 23 min.

Dr. Resa Lewiss has a background physics hosted under the "Physics" tab on the EM ultrasound website.

Video, Estimate Time: 18 min


Ultrasound pocket card for reference with the quick and dirty of what you need to know.

US Basics Cheatsheet


Sonosite Edge Operation

Sonosite Edge operational videos, which provide basic instruction on how to adjust image quality and use the different modes.

Video 1, Estimated Time: 7 min.

Video 2, Estimated Time: 9 min.

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ProcEdure Block

Aim: to provide practitioners with basic understanding of how to systematically use ultrasound to guide procedures. At the completion of the procedure block, the practitioner should be able to use ultrasound to aid paracentesis, thoracentesis, lumbar puncture, knee arthrocentesis, and placement of peripheral IVs.

Click for required material

Click for required material

Required

Please complete the following learning exercises prior to 1:1 scanning on Monday morning. Then take the Quiz by clicking the button below.

Click for a bit more to get you up to speed

Click for a bit more to get you up to speed

Added Complexity

More material covering central and arterial lines and more!

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Click for mastery

Expert

Coming Soon

Basic Procedure Pre-Learning

Thoracentesis

* Ultrasound in the diagnosis and management of pleural effusions. Soni N Franco R Velez M Schnobrich D Dancel R Restrepo M Mayo P Journal of hospital medicine 2015 vol: 10 (12) pp: 811-6.

Please read from "Pleural Ultrasound Examination" through "Pleural Fluid Drainage"

Estimated time: 5 min

* Just-in-time learning video from Sonosite. Estimated time: 2 min

* UC Irvine's has a lecture covering LP, paracentesis, and thoracentesis. Start at the 9 minute point and listen to the end of the lecture for the thoracentesis section.

Start with the phased array probe. I recommend starting with the transducer marker oriented cranially to map out the pleural effusion, and then rotating the marker to the patient's left to identify your puncture site. Consider using the linear transducer to help with needle guidance.


Paracentesis

* The gentleman at Ultrasoundpodcast.com put together this short paracentesis video.

Pearls:

Consider performing FAST exam if you have difficulty finding abdominal free fluid.

Consider using color to identify vasculature at chosen puncture site.

Estimated time: 3 min

* UC Irvine's lecture covering procedures. Listen starting at the 5 minute point to 9 minutes. Estimated time: 4 min


Lumbar Puncture

* UC Irvine's lecture covering procedures. Listen to the first 5 minutes of the video for explanation of how to use US guidance during a LP.


Knee Arthrocentesis


Jacob Avila's ultrasound guided IV placement video

http://5minsono.com/ugiv/

Estimated time: 6 min

IV Placement

Intermediate Procedure Pre-Learning

Central Line Access

Central line placement and confirmation videos courtesy of Jacob Avila.


Arterial Line

Coming Soon


More Procedures

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More Procedures


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Lung Ultrasound

Aim: Lung ultrasound is a powerful tool that can be used to identify artifacts that correlate with abnormal pathology. Lung ultrasound has been shown to have higher sensitivity for consolidations that chest x-ray, be an effective tool to rule out acute heart failure exacerbation, and to accurately identify pleural effusions, among many other applications. At the completion of this module, the internist should be able to identify relevant anatomy, differentiate A-line from B-line pattern, recognize consolidations, and use ultrasound findings to guide their clinical management of patients.

Click to review suggested background material

Click to review suggested background material

Suggested Material

A list of suggested materials can be found here for your review. Please complete the below survey after you complete your review.

Click for a bit more to get you up to speed

Click for a bit more to get you up to speed

Added Complexity

Coming Soon

Click for mastery

Click for mastery

Expert

Coming Soon

THE DATA:

  1. Noble, V. E. et al. Ultrasound Assessment for Extravascular Lung Water in Patients Undergoing Hemodialysis: Time Course for Resolution. Chest 135, 1433–1439 (2009).
  2. Lichtenstein, D. A. & Mezière, G. A. Relevance of Lung Ultrasound in the Diagnosis of Acute Respiratory Failure*: The BLUE Protocol. Chest 134, 117–125 (2008).
  3. Gargani, L. et al. Persistent pulmonary congestion before discharge predicts rehospitalization in heart failure: a lung ultrasound study. Cardiovasc. Ultrasound 13, 40 (2015).
  4. Volpicelli, G. et al. Bedside lung ultrasound in the assessment of alveolar-interstitial syndrome. Am. J. Emerg. Med. 24, 689–696 (2006).
  5. Nazerian, P. et al. Accuracy of lung ultrasound for the diagnosis of consolidations when compared to chest computed tomography. Am. J. Emerg. Med. 33, 620–625 (2015).
  6. Llamas-Álvarez, A. M., Tenza-Lozano, E. M. & Latour-Pérez, J. Accuracy of Lung Ultrasonography in the Diagnosis of Pneumonia in Adults: Systematic Review and Meta-Analysis. Chest 151, 374–382 (2017).
  7. Laursen, C. B. et al. Point-of-care ultrasonography in patients admitted with respiratory symptoms: a single-blind, randomised controlled trial. Lancet Respir. Med. 2, 638–646 (2014).
  8. Soni, N. J. et al. Ultrasound in the Diagnosis & Management of Pleural Effusions. J. Hosp. Med. 10, 811–816 (2015).

 

 

 

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Suggested Lung Exercises

 

Suggested Reading Pathway

Choose 1:

Point-of-Care Ultrasound book, Lung material, pgs. 49-81.

Philips has a chapter on lung ultrasound on an e-book. Requires Adobe Flash Player 10.

Introduction to bedside ultrasound. This is a free ibook that can be obtained from itunes for Appple users (found here).


Basic Review

Jacob Avila's 5 min sono website has several brief, excellent videos that cover the lung examination.

Video 1, Technical Perfomance of lung examination, Estimated time: 9 min

Video 2, B-lines, Estimated time: 6 min

Video 3, Pleural Effusion, Estimated time: 6 min

Video 4, Pneumonia, Estimated time: 5 min

Video 5, Pneumothorax, Estimated time: 5 min

Deeper Dive

The Ultrasound Podcast guys' fantastic lecture series about lung ultrasound. Well worth a slightly deeper dive.

Video 1, Estimated time: 30 min

Video 2, Estimated time: 25 min

Suggested Video Pathway



Websites

Abbott NW lung material is found here.


BLUE Protocol

The Blue Protocol shows how (figure 8 only!) to see how you can utilize the information you obtain from lung ultrasound to help formulate your thinking.

Estimated time: 3 min


CLUE Protocol

After the completion of the Cardiac Modules, you should understand how lung ultrasound fits into the CLUE protocol. Included here are the steps included in the CLUE protocol.

Focused CardiaC Ultrasound

Part 1: Basic

Aim: Focused cardiac ultrasound (FCU) is the most challenging, but arguably the most useful tool in the sonologist's clinical toolbag. Several methods have been studied to simplify the interpretation of a basic echocardiography and help the bedside physician identify heart failure with reduced ejection fraction, left atrial enlargement, pericardial effusion, and other pathology. At the completion of this module, the bedside physician should be able to perform cardiac imaging from the parasternal long axis (PLAX) and subcostal window, and integrate these views with lung ultrasound to complete the Cardiovascular Limited Ultrasound Examination (CLUE). A complete understanding of cardiac anatomy is critical to cardiac ultrasound and it is recommended that you review normal anatomy in relationship to each window obtained in FCU. The physician should be able to describe E-point septal separation indications, uses, and pitfalls and use the "eyeball test" to recognize left atrial enlargement and pericardial effusions. The subcostal view should be used to compare the LV to the RV and additionally confirm findings from the PLAX view. Finally, a determination of preload should be made by looking at the IVC and understanding its limitations to use.

Click for basic material

Click for basic material

Beginner

Please complete the following learning exercises prior to scanning with your assigned group. Then take the Quiz by clicking the button below.

Click for a bit more to get you up to speed

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Intermediate

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Expert

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For the Basic Cardiac module, focus on PLAX and subcostal applications. Apical 4 chamber and parasternal short axis will be covered in advanced cardiac.

For the Basic Cardiac module, focus on PLAX and subcostal applications. Apical 4 chamber and parasternal short axis will be covered in advanced cardiac.

Basic Cardiac Material

Reading Pathway

POCUS by Nilam Soni

  • Chapter 13, 14, 15, 17, 18 with specific attention paid to PLAX, subcostal, and subcostal-IVC windows

Deeper Dive

  • Dr. Kimura's paper detailing the indications and pitfalls of CLUE, as well as the evidence supporting the use of technique, est time 30 min.
  • Use of the IVC can be very useful, but one must know the indications before interpretting. [Here][5] is a great review article. Est time 20 min.

Video Pathway

Scanning Technique

  • University of South Carolina with short videos on the PLAX and subcostal views of the heart. Est time 2 min each.
  • Dr. Kimura of Scripps Mercy in San Diego walking you through CLUE in a short video, est time 2 min.

Pathology

Deeper Dive

  • 1 hour of Bruce Kimura explaining the CLUE - well worth the time.

Extra Practice

* Please email Dr. Piro if you would like to use the simulator at the CLSB. This is great for low stakes scanning practice and anatomy review.


Banner Picture.jpg

Focused CardiaC Ultrasound

Part 2: Advanced

Aim: Focused cardiac ultrasound (FCU) is the most challenging, but arguably the most useful tool in the sonologist's clinical toolbag. Several methods have been studied to simplify the interpretation of basic echocardiography and help the bedside physician identify heart failure with reduced ejection fraction, left atrial enlargement, pericardial effusion, and other pathology. At the completion of this module, the bedside physician should be able to perform the advanced views of the heart, including the apical four chamber and parasternal short axis, in addition to the PLAX and subcostal views covered in the basic cardiac module. A complete understanding of cardiac anatomy is critical to cardiac ultrasound and it is recommended that you review normal anatomy in relationship to each window obtained in FCU. The physician should be able to compare relative chamber size, describe wall thickness, and globally assess ventricular function. These views should be used to augment the basic cardiac exam and confirm findings that you see in your cardiac assessment.

Click to review suggested background material

Click to review suggested background material

Beginner

A list of suggested materials can be found here for your review. Please complete the below survey after you complete your review.

Click for a bit more to get you up to speed

Click for a bit more to get you up to speed

Intermediate

Coming Soon

Click for mastery

Click for mastery

Expert

Coming Soon

For the Advanced Cardiac module, focus on the apical 4 chamber and parasternal short axis views. We will cover valvular pathology in this module and using color flow Doppler.

For the Advanced Cardiac module, focus on the apical 4 chamber and parasternal short axis views. We will cover valvular pathology in this module and using color flow Doppler.

Advanced Cardiac Material

Reading Pathway

Review chapter 13-18 in Nilam Soni's, Point-of-care Ultrasound with specific attention paid to the A4C and the PSAX windows.


Video Pathway

Scanning Technique

  • University of South Carolina with short videos on the PSAX and apical 4 chamber views of the heart. Est time 2 min each.

Pathology

Deeper Dive

  • Valvular assessment in detail from US Podcast and Rob Artfield

Extras

*123sonography has 4 free echo videos. Lesson 1 covers a lot of basic principles of echo, with a deeper dive in lessons 2, 3, and 4. Each of these is between 30-40 min long.


Deeper Dive Advanced Cardiac

Valvular Disease

* Great 2 part lecture by Rob Arntfield covering valve assessment at the point-of-care. Part 1 and Part 2.


Diastology

* 123sonography with a nice webinar on diastology.


Pericardial Tamponade

*Nice review on Abbott Northwestern's website of evaluation for cardiac tamponade.

*I like this case/paper: “Point-of-Care Diagnosis of Cardiac Tamponade Identified by the Flow Velocity Paradoxus - Shyy - 2017 - Journal of Ultrasound in Medicine - Wiley Online Library.” http://onlinelibrary.wiley.com/doi/10.1002/jum.14251/full.

*Did you find other helpful resources? Email me at piro@ohsu.edu so I can keep tabs on the best resources for learners.


Focused CardiaC Ultrasound

Part 1: Basic

Aim: Cardiopulmonary ultrasound forms the meat of applications that the general internist will use POCUS for. It can be used to aid diagnosis of heart failure, respiratory failure, prognosticate rehospitalization, and aid volume examinations, among numerous other applications. A primary goal of our curriculum is completing a competent, thorough POCUS cardiopulmonary assessment and developing a comfort in using findings from the exam within the context of patients' clinical history and other presenting data.

 

 

 

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Banner Picture.jpg

Kidney and Bladder

Aim: Ultrasound of the genitourinary system can greatly aid in diagnostic workup of acute kidney injury, urinary retention, and other important diagnoses. Current recommendations in the evaluation of AKI, suggest treating medically before ordering formal ultrasonography to assess for obstructive uropathy in the absence of clear history suggestive of renal obstruction to avoid unnecessary cost. However, bedside physicians can accurately rule out urinary obstruction in AKI in 2-3 minutes, potentially streamlining patient care and reducing hospital length of stay. Furthermore, bladder ultrasound can be used to confirm Foley placement and to assess post-void residual. US of the GU system is a critical component of the internist's bedside tool set.

Click to review suggested background material

Click to review suggested background material

Beginner

A list of suggested materials can be found here for your review. Please complete the below survey after you complete your review.

Click for a bit more to get you up to speed

Click for a bit more to get you up to speed

Intermediate

Coming Soon

Click for mastery

Click for mastery

Expert

Coming Soon

THE DATA:

  1. Noble, V. E. & Brown, D. F. M. Renal ultrasound. Ultrasound Emerg. Med. 22, 641–659 (2004).
  2. Ellenbogen, P., Scheible, F., Talner, L. & Leopold, G. Sensitivity of gray scale ultrasound in detecting urinary tract obstruction. Am. J. Roentgenol. 130, 731–733 (1978).
  3. Dalziel, P. J. & Noble, V. E. Bedside ultrasound and the assessment of renal colic: a review. Emerg Med J 30, 3–8 (2013).
  4. Smith-Bindman, R. et al. Ultrasonography versus Computed Tomography for Suspected Nephrolithiasis. N. Engl. J. Med. 371, 1100–1110 (2014).
  5. Podoll, A., Walther, C. & Finkel, K. Clinical utility of gray scale renal ultrasound in acute kidney injury. BMC Nephrol. 14, 188–188 (2013).
  6. Mandavia, D. P., Aragona, J., Chan, L., Chan, D. & Henderson, S. O. Ultrasound Training for Emergency Physicians— A Prospective Study. Acad. Emerg. Med. 7, 1008–1014 (2000).
  7. Chan, H. Noninvasive Bladder Volume Measurement. J. Neurosci. Nurs. 25, (1993).
  8. Novaes, A. K. B. et al. Point of care kidney ultrasonography and its role in the diagnosis of urinary obstruction: a case report. J. Bras. Nefrol. 39, 220–223 (2017).

 

 

 

GU Objectives.PNG

Genitourinary Ultrasound

Reading Pathway

Review chapter 20-21 in Nilam Soni's, Point-of-care Ultrasound.


Video Pathway

Point of Care Ultrasound Geek has a nice review on genitourinary ultrasound.


Extras

5 min sono videos on hydronephrosis and measuring bladder volume.

My recommended algorithm for evaluating for hydronephrosis.


Focused CardiaC Ultrasound

Part 2

Aim: Focused cardiac ultrasound (FCU) is the most challenging, but arguably the most useful tool in the sonologist's clinical toolbag. Several methods have been studied to simplify the interpretation of a basic echocardiography and help the bedside physician identify heart failure with reduced ejection fraction, left atrial enlargement, pericardial effusion, and other pathology. In this module, we will focus on learning to evaluate the heart from the subcostal window. At the completion of this module, the bedside physician should be able to describe how to perform subcostal imaging of the heart and identify relevant anatomy with subsequent discrimination of relative normal chamber size and of the existence of pericardial effusion. The physician should be able to describe how to image the IVC and apply its appearance to assess volume in both spontaneously breathing and ventilated patients.

Click for required material

Click for required material

Required

Please complete the following learning exercises prior to scanning with your assigned group. Then take the Quiz by clicking the button below.

Click for a bit more to get you up to speed

Click for a bit more to get you up to speed

Added Complexity

Coming Soon

Click for mastery

Click for mastery

Expert

Coming Soon

THE DATA:

 

 

 

***

Aim: ***

Click for required material

Click for required material

Required

Please complete the following learning exercises prior to scanning with your assigned group. Then take the Quiz by clicking the button below.

Click for a bit more to get you up to speed

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Added Complexity

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THE DATA:

 

 

 

Required * Material


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Quisque congue porttitor ullamcorper. Suspendisse nec congue purus. Vivamus sit amet semper lacus, in mollis libero. Mauris egestas at nibh nec finibus. Nullam sit amet nisi condimentum erat iaculis auctor. Suspendisse nec congue purus.*



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Quisque congue porttitor ullamcorper. Suspendisse nec congue purus. Vivamus sit amet semper lacus, in mollis libero. Mauris egestas at nibh nec finibus. Nullam sit amet nisi condimentum erat iaculis auctor. Suspendisse nec congue purus.



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Ultrasound Question Bank

 
 

It all started when...

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Point OF Care Ultrasound Faculty

Feature 1

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Feature 2

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Feature 3

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US Case Bank

 
 

Using the Case Bank

Periodically, there will be cases published here to test your POCUS knowledge and your ability to interpret POCUS findings and integrate them into patient care. Each case will have a stem, along with a collection of images. Commit to an interpretation of the images and a plan of action by writing in your clinical impression. Then click through for the case resolution.

 
 

Historical Cases

POCUS Report

 
 

Dyspnea

An 87 y/o woman with hx of rheumatoid arthritis presented to the ED with SOB and fever x 2 days. She was found by EMS to have a pulse ox 78% on room air. Pt also was altered with increased work of breathing. Pt also described myalgias, rhinorrhea. She takes methylprednisolone for RA.

POCUS of her Right Lung is shown below.

Her left lung showed lung sliding and A-line pattern in all 4 Volpicelli Zones and no pleural effusion.

 
 

Image Interpretation and Next Steps

Case Resolution

 
 

Dyspnea

An 87 y/o woman with hx of rheumatoid arthritis presented to the ED with SOB and fever x 2 days. She was found by EMS to have a pulse ox 78% on room air. Pt also was altered with increased work of breathing. Pt also described myalgias, rhinorrhea. She takes methylprednisolone for RA.

 
 

Image Interpretation

POCUS of right lung shows B-lines in Volpicelli Zone 1 and 2 (more B-lines in V2 suggesting relative increase in density), and a consolidation with a pleural effusion in Volpicelli Zone 4 as indicated by the small anechoic fluid collection with associated spine sign. When B-lines are present this confirms visceral and parietal pleural apposition, as this refraction artifact needs increased density (eg. not air from pneumothorax) to be present to be visualized. The left lung (images not shown) showed A-line pattern with lung sliding, which can be seen when their is aerated lung (eg normal lung, COPD, asthma).

Next Steps

A patient with fever and a unilateral consolidation found by POCUS is consistent with pneumonia. The patient was started on ceftriaxone and azithromycin and admitted to the MICU with hypoxemic respiratory failure. Of note, her x-ray did show a consolidation, but did not demonstrate a pleural effusion. She rapidly improved on antibiotics and was discharged on hospital day #4 on oral antibiotics.

Sound Reasoning

  • POCUS is more accurate than CXR at identifying consolidation when compared to consolidations identified by CT
    • POCUS: Sensitivity 83%, Specificity 95%
    • Nazerian, Peiman, Giovanni Volpicelli, Simone Vanni, Chiara Gigli, Laura Betti, Maurizio Bartolucci, Maurizio Zanobetti, Francesca Romana Ermini, Cristina Iannello, and Stefano Grifoni. “Accuracy of Lung Ultrasound for the Diagnosis of Consolidations When Compared to Chest Computed Tomography.” The American Journal of Emergency Medicine 33, no. 5 (May 2015): 620–25. https://doi.org/10.1016/j.ajem.2015.01.035.
  • Consolidations on POCUS are defined as "tissue-like or anechoic pattern and blurred, irregular margins. The consolidations due to pneumonia usually contain dynamic air bronchograms (branching echogenic structures with centrifuge movement with breathing) or multiple hyperechogenic lentil-sized spots, due to air trapped in the small airways, with associated focal B-lines.
  • Supine CXR can detect pleural effusions of > 200-300 mL, PA/Lateral can detect pleural effusions of > 75 mL, POCUS can detect effusion of > 5-20 mL.

POCUS Report

 
 

Dyspnea

Case shared by Dr. Miles Grovenburg, images shared are his own.

Somewhere in Botswana ...

A 62 y/o man with hx of hypertension and HFrEF presented to the ED with several days of orthopnea/PND, peripheral edema and chest discomfort.

He was found to have a BP 88/60, HR 54 and SpO2 86% on room air. Physical exam was notable for cold extremities, increased capillary refill and bibasilar crackles. No murmurs, rubs or gallops were appreciated on cardiac auscultation and patient was mentating appropriately.

His ambulatory medications include furosemide and lisinopril.

Cardiac POCUS is shown below.

 
 

Image Interpretation and Next Steps

Case Resolution

 
 

Dyspnea

A 62 y/o man with hx of hypertension and HFrEF presented to the ED with several days of orthopnea/PND, peripheral edema and chest discomfort.

He was found to have a BP 88/60, HR 54 and SpO2 86% on room air. Physical exam was notable for cold extremities, increased capillary refill and bibasilar crackles. No murmurs, rubs or gallops were appreciated on cardiac auscultation and patient was mentating appropriately.

His ambulatory medications include furosemide and lisinopril.

 
 

Images and Interpretation

Image #1: Te PLAX view is obtained here showing the aortic valve at the center of the picture. The AV appears to be coapting normally, however their is a flap in the aortic root that is indicative of an aortic dissection. The aortic root appears to be slightly enlarged (usually > 4.0 cm is concerning for enlargement, where > 4.5 cm indicates aortic aneurysm) in comparison to RV and LA (using rule of a thirds). If their is concern for aortic root pathology, a measurement can be very helpful here (I usually make mine at the sinotubular junction). We are unable to comment on the LV function as that was not the point of interest in the picture. There is no obvious pericardial effusion (relevant in a dissection!), but reducing the gain would help us better evaluate the pericardium.

Two other interesting points of note in this image:

First, the descending thoracic aorta (DTA) is labeled in the far field and does not appear to be enlarged, thus the pathology likely a type A aortic dissection involving the ascending aorta and unlikely to be involving the abdominal aorta.

Second, Dr. Grovenburg images the right side of the heart at the end of the clip by fanning the beam towards his patient's right hip and shows a nice image of the RV, TV, and RA moving from the near field to the far field.

Image #2:

Image Interpretation

POCUS of right lung shows B-lines in Volpicelli Zone 1 and 2 (more B-lines in V2 suggesting relative increase in density), and a consolidation with a pleural effusion in Volpicelli Zone 4 as indicated by the small anechoic fluid collection with associated spine sign. When B-lines are present this confirms visceral and parietal pleural apposition, as this refraction artifact needs increased density (eg. not air from pneumothorax) to be present to be visualized. The left lung (images not shown) showed A-line pattern with lung sliding, which can be seen when their is aerated lung (eg normal lung, COPD, asthma).

Next Steps

A patient with fever and a unilateral consolidation found by POCUS is consistent with pneumonia. The patient was started on ceftriaxone and azithromycin and admitted to the MICU with hypoxemic respiratory failure. Of note, her x-ray did show a consolidation, but did not demonstrate a pleural effusion. She rapidly improved on antibiotics and was discharged on hospital day #4 on oral antibiotics.

Sound Reasoning

  • POCUS is more accurate than CXR at identifying consolidation when compared to consolidations identified by CT
    • POCUS: Sensitivity 83%, Specificity 95%
    • Nazerian, Peiman, Giovanni Volpicelli, Simone Vanni, Chiara Gigli, Laura Betti, Maurizio Bartolucci, Maurizio Zanobetti, Francesca Romana Ermini, Cristina Iannello, and Stefano Grifoni. “Accuracy of Lung Ultrasound for the Diagnosis of Consolidations When Compared to Chest Computed Tomography.” The American Journal of Emergency Medicine 33, no. 5 (May 2015): 620–25. https://doi.org/10.1016/j.ajem.2015.01.035.
  • Consolidations on POCUS are defined as "tissue-like or anechoic pattern and blurred, irregular margins. The consolidations due to pneumonia usually contain dynamic air bronchograms (branching echogenic structures with centrifuge movement with breathing) or multiple hyperechogenic lentil-sized spots, due to air trapped in the small airways, with associated focal B-lines.
  • Supine CXR can detect pleural effusions of > 200-300 mL, PA/Lateral can detect pleural effusions of > 75 mL, POCUS can detect effusion of > 5-20 mL.

Image #2: Parasternal short axis at the level of the aortic valve. This image is usually obtained by first obtaining the PLAX, then rotating the transducer clockwise by 90 degrees so the transducer marker is roughly pointed towards the patient's left shoulder. Next, the scanner then fans the beam towards the base of the heart to bring the aorta into view. Here, the AV is seen at the middle of the screen (remember, it comes out anterior to the LV!) and a flap is seen in the middle of the screen. Of note, this image is reversed compared to our usual convention, but the pathology is seen clearly nonetheless. An excellent image, and the scanner can say with confidence there is an aortic dissection.

POCUS Report

 
 

Murmur

A 62 y/o with hx of iron deficiency anemia and hip pain was hospitalized for aspiration pneumonia and MSSA bacteremia. A murmur was heard on physical examination.

POCUS of her heart is shown below.

Image captured by Dr. Lindquist.

 
 

Image Interpretation

Case Resolution

 
 

Murmur

A 62 y/o with hx of iron deficiency anemia and hip pain was hospitalized for aspiration pneumonia and MSSA bacteremia. A murmur was heard on physical examination.

 
 

Image Interpretation

This clips shows an apical 4 chamber view of the heart. Color Doppler is being used to assess the tricuspid valve.

Proper use of color Doppler of a valve to assess for regurgitation should put the top of the box just past the valve leaflets (in the RV here) and include chamber which the regurgitant jet is being assessed (the RA here).

Mild TR is demonstrated as a narrow "blue" jet travelling to the bottom of the screen. Remember, flow away from the probe appears blue (it is getting "colder"!).

Sound Reasoning

A still image is shown below of the clip. The arrow points the tricuspid regurgitation jet. The TR was classified as "mild" on formal TTE. Mild TR is found in up to 70% of people, and thus is a normal finding. In fact, the interesting part about TR is that it is critical in the evaluation of PA pressures by echo. The velocity of the TR jet is a key component of the measurement and factors into Bernoulli Principle to measure pressure on the right side of the heart. Thus if no TR, you cannot measure the PA pressure by echo!

Two other quick learning principles.

If you are in the apical 4 chamber view, two key features distinguish the RV from the LV

  • the RV contains the moderator band, labelled "MB" on the annotated image below
  • the RV "inserts" into the LV at the apex, thus the LV extends further to the apex (and closer to the probe) in the A4C view (outlined in red)

Lastly, this patient did not have a vegetation, by POCUS, TTE, or TEE. Remember, TTE has low sensitivity for vegetations, thus by extension, POCUS should be used for "rule in" only of endocarditis.