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resources:clinical_tools:pocus
Table of Contents
Profiling, Hemodynamic
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
Hepatic Congestion
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
resources/clinical_tools/pocus.txt · Last modified: 2023/10/04 14:03 by admin
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