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=====Profiling, Hemodynamic=====
<mermaid>
  flowchart TD
    filter_dys("(1) Bad LVEF OR (2) low CI AND low HR`")
        
    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>


==== Hepatic Congestion====
  * [[https://doi.org/10.1159/000526902 | Article, VExUS Grading]]
  * [[ https://pocus101.b-cdn.net/wp-content/uploads/2020/05/Diastology-Dysfunction-Assesment-POCUS-101-1024x639.png | LV Diastolic Function]]
  * [[https://www.echopedia.org/index.php?title=Diastolic_Function | Echopedia, Diastolic Function]]
  * [[https://journals.lww.com/kidney360/fulltext/2021/08000/use_of_ultrasound_to_assess_hemodynamics_in.16.aspx | Hepatic Vascular Pulsatility]]
===== FREE Exam =====
==== Setup ====
  * Enter patient information
  * Attach EKG leads
  * Select phased array transducer
  * Choose ST UMMC 1 Echo preset

==== 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) ====
  * Qualitative EF assessment at each level
  * Level of papillary muscles (CLIP) - assess RV as well
  * Level of mitral valve (CLIP)
  * Level of aortic valve (CLIP)
  * Color doppler over tricuspid to check for TR (CLIP)

==== Apical four chamber (A4C)====
  * Qualitative assessment of RV and LV size (CLIP)
  * Color doppler over MV, LA, and LV (CLIP)
  * Mitral inflow E-a (SAVE)
    * A4C, mitral valve, PW doppler just inside ventricle
    * Above baseline, measuring flow into the ventricle/towards the probe
    * E = early diastolic filling
    * 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)====
  * Collar doppler over LVOT and AoV (CLIP)
  * LVOT VTI (SAVE)
    * 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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