<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>

• Article, VExUS Grading
• LV Diastolic Function
• Echopedia, Diastolic Function
• Hepatic Vascular Pulsatility

• Enter patient information
• Attach EKG leads
• Select phased array transducer
• Choose ST UMMC 1 Echo preset

• 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)

• 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)

• 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

• 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

• 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

• 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

• Linear probe, decrease depth to 5cm
• Measure at HOB 0 degrees and then HOB 90 degrees
• Only need one side