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--- resources:clinical_tools:pocus [2023/09/26 13:18] – created admin
+++ resources:clinical_tools:pocus [2023/10/04 14:03] (current) – [Profiling, Hemodynamic] admin
@@ Line 1: / Line 1: @@
-Setup
+=====Profiling, Hemodynamic=====
-Enter patient information
+<mermaid>
-Attach EKG leads
+  flowchart TD
-Select phased array transducer
+    filter_dys("(1) Bad LVEF OR (2) low CI AND low HR`")
-Choose ST UMMC 1 Echo preset
+    dys_hypoperf_yes["Access SVR"]
+    dys_hypoperf_no["Assess SVI and venous congestion"]
+    filter_dys_svi["Has SVI < 35, VR(+), VC(-)"] -- Yes --> test1
+    filter_dys_svi["Has SVI < 35, VR(+), VC(-)"] -- No --> test2
+    filter_dys -- Yes --> type_dys
+    filter_dys -- No --> B
+    type_dys["**Dysfunctional**"] --> filter_dys_hypoperf["End organ hypoperfusion?"]
+    filter_dys_hypoperf -- Yes and SVR > 1200 --> dys_svr_high["Inotrope +/- vasodilator"]
+    filter_dys_hypoperf -- Yes and SVR < 800 AND MAP < 65 --> dys_svr_low["Inotrope +/- vasoconstrictor"]
+    filter_dys_hypoperf -- No --> dys_hypoperf_no
+</mermaid>
-Parasternal long axis (PLAX)
-Qualitative EF assessment (CLIP)
-LVOT diameter (SAVE)
-PLAX, during end systole
-Inner edge to inner edge of aortic at base of aortic valve
-Normal 1.8-2.4 (~BSA, can use as surrogate if unable to measure)
-Color doppler over MV and AoV to look for regurgitation (CLIP)
-Parasternal short axis (PSAX)
+==== Hepatic Congestion====
-Qualitative EF assessment at each level
+  * [[https://doi.org/10.1159/000526902 | Article, VExUS Grading]]
-Level of papillary muscles (CLIP) - assess RV as well
+  * [[ https://pocus101.b-cdn.net/wp-content/uploads/2020/05/Diastology-Dysfunction-Assesment-POCUS-101-1024x639.png | LV Diastolic Function]]
-Level of mitral valve (CLIP)
+  * [[https://www.echopedia.org/index.php?title=Diastolic_Function | Echopedia, Diastolic Function]]
-Level of aortic valve (CLIP)
+  * [[https://journals.lww.com/kidney360/fulltext/2021/08000/use_of_ultrasound_to_assess_hemodynamics_in.16.aspx | Hepatic Vascular Pulsatility]]
-Color doppler over tricuspid to check for TR (CLIP)
+===== FREE Exam =====
+==== Setup ====
+  * Enter patient information
+  * Attach EKG leads
+  * Select phased array transducer
+  * Choose ST UMMC 1 Echo preset
-Apical four chamber (A4C)
+==== Parasternal long axis (PLAX) ====
-Qualitative assessment of RV and LV size (CLIP)
+  * Qualitative EF assessment (CLIP)
-Color doppler over MV, LA, and LV (CLIP)
+  * LVOT diameter (SAVE)
-Mitral inflow E-a (SAVE)
+  * PLAX, during end systole
-A4C, mitral valve, PW doppler just inside ventricle
+  * Inner edge to inner edge of aortic at base of aortic valve
-Above baseline, measuring flow into the ventricle/towards the probe
+  * Normal 1.8-2.4 (~BSA, can use as surrogate if unable to measure)
-E = early diastolic filling
+  * Color doppler over MV and AoV to look for regurgitation (CLIP)
-A = late atrial kick
-A is just before QRS, E is before A
-E > A in normal and pseudonormal (super abnormal)
-Mitral annulus TDI (SAVE)
-A4C, mitral valve, lateral annulus, TDI -> PW
-A’ is just before QRS, E’ is before A’
-E’ and E occur at the same time point in the cardiac cycle
-Normal E/E’ >10
-Color doppler over TV (CLIP)
-TR Vmax (SAVE)
-A4C, CW doppler
-Can also be done in PSAX, CW doppler, if visible at aortic valve level
-Only if tricuspid regurgitation is present
-Surrogate for RVSP/PASP (TR max PG = RVSP + CVP)
-TAPSE (SAVE)
-A4C, tricuspid valve, lateral annulus, M-mode
-Estimate visually before measuring
-Measure peak to valley
-RV specific, only free wall, no contribution from septum/LV
-Normal >1.7
-Apical five chamber (A5C)
+==== Parasternal short axis (PSAX) ====
-Collar doppler over LVOT and AoV (CLIP)
+  * Qualitative EF assessment at each level
-LVOT VTI (SAVE)
+  * Level of papillary muscles (CLIP) - assess RV as well
-A5C, aortic valve, PW doppler where LVOT diameter was measured
+  * Level of mitral valve (CLIP)
-Quantitative surrogate for stroke volume (SV)
+  * Level of aortic valve (CLIP)
-Trace largest flow away from probe, baseline to baseline
+  * Color doppler over tricuspid to check for TR (CLIP)
-Normal 18-24 in euvolemia (approx. 10x BSA)
-Stroke volume variation (SAVE)
-Using doppler saved for LVOT VTI, need at least 10 beats
-Decrease sweep speed (25-35 mm/sec) to see multiple beats
-Measure SV maximum and minimum flow
-Cannot do in arrhythmia, not validated in low EF
-AoV Vmax
-A5C, aortic valve, CW doppler
-If AS, SVV measurement is invalidated
-Normal <200
-Subcostal (SC)
+==== Apical four chamber (A4C)====
-Evaluate for pericardial effusion (CLIP)
+  * Qualitative assessment of RV and LV size (CLIP)
-Oblique view with IVC (CLIP)
+  * Color doppler over MV, LA, and LV (CLIP)
-IVC collapsibility (SAVE)
+  * Mitral inflow E-a (SAVE)
-SC oblique, M-mode
+    * A4C, mitral valve, PW doppler just inside ventricle
-If variability, measure max and min
+    * Above baseline, measuring flow into the ventricle/towards the probe
-Hepatic vein
+    * E = early diastolic filling
-IVC view, PW doppler
+    * A = late atrial kick
-Drains right atrium/IVC, transduces the pressures of the right side
+    * A is just before QRS, E is before A
-Occurs between two QRS complexes
+    * E > A in normal and pseudonormal (super abnormal)
-S = ventricular systole, actually seeing atrial diastole
+  * Mitral annulus TDI (SAVE)
-D = ventricular diastole, actually seeing atrial systole
+    * A4C, mitral valve, lateral annulus, TDI -> PW
-A = atrial kick, causes small reversal in pressure
+    * A’ is just before QRS, E’ is before A’
-Portal vein
+    * E’ and E occur at the same time point in the cardiac cycle
-IVC view, PW doppler
+    * Normal E/E’ >10
-Normal vein, should have continuous flow
+  * Color doppler over TV (CLIP)
-“Pulsatility” or “to and fro” pattern = volume intolerance
+  * TR Vmax (SAVE)
+    * A4C, CW doppler
+    * Can also be done in PSAX, CW doppler, if visible at aortic valve level
+    * Only if tricuspid regurgitation is present
+    * Surrogate for RVSP/PASP (TR max PG = RVSP + CVP)
-Pulmonary
+  * TAPSE (SAVE)
-Gen Abdomen preset
+    * A4C, tricuspid valve, lateral annulus, M-mode
-locations - upper, mid, and lower on left and right (CLIP x6)
+    * Estimate visually before measuring
-Evaluation for B lines
+    * Measure peak to valley
-Rating - (0) = absent, (1 zone) = scattered, (>2 zones) = diffuse
+    * RV specific, only free wall, no contribution from septum/LV
+    * Normal >1.7
-Internal Jugular veins (IJ)
+==== Apical five chamber (A5C)====
-Linear probe, decrease depth to 5cm
+  * Collar doppler over LVOT and AoV (CLIP)
-Measure at HOB 0 degrees and then HOB 90 degrees
+  * LVOT VTI (SAVE)
-Only need one side
+    * A5C, aortic valve, PW doppler where LVOT diameter was measured
+    * Quantitative surrogate for stroke volume (SV)
+    * Trace largest flow away from probe, baseline to baseline
+    * Normal 18-24 in euvolemia (approx. 10x BSA)
+  * Stroke volume variation (SAVE)
+    * Using doppler saved for LVOT VTI, need at least 10 beats
+    * Decrease sweep speed (25-35 mm/sec) to see multiple beats
+    * Measure SV maximum and minimum flow
+    * Cannot do in arrhythmia, not validated in low EF
+  * AoV Vmax
+    * A5C, aortic valve, CW doppler
+    * If AS, SVV measurement is invalidated
+    * Normal <200
+==== Subcostal (SC) ====
+  * Evaluate for pericardial effusion (CLIP)
+  * Oblique view with IVC (CLIP)
+  * IVC collapsibility (SAVE)
+    * SC oblique, M-mode
+    * If variability, measure max and min
+  * Hepatic vein
+    * IVC view, PW doppler
+    * Drains right atrium/IVC, transduces the pressures of the right side
+    * Occurs between two QRS complexes
+    * S = ventricular systole, actually seeing atrial diastole
+    * D = ventricular diastole, actually seeing atrial systole
+    * A = atrial kick, causes small reversal in pressure
+  * Portal vein
+    * IVC view, PW doppler
+    * Normal vein, should have continuous flow
+    * “Pulsatility” or “to and fro” pattern = volume intolerance
+==== Pulmonary ====
+  * Gen Abdomen preset
+  * 6 locations - upper, mid, and lower on left and right (CLIP x6)
+  * Evaluation for B lines
+  * Rating - (0) = absent, (1 zone) = scattered, (>2 zones) = diffuse
+==== Internal Jugular veins (IJ) ====
+  * Linear probe, decrease depth to 5cm
+  * Measure at HOB 0 degrees and then HOB 90 degrees
+  * Only need one side

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