FOCUS App

The Toronto General Hospital Department of Anesthesia has an app for Cardiac Ultrasound. Their FOCUS (FOcused Cardiac UltraSound) app is also available to download in the App Store.

This app has several different features. Firstly, it gives a great overview on the different ultrasound views of the heart, including how to obtain these views, how to optimize these views and which structures are assessable with each view. Another great feature of this app is that is provides a great overview of the anatomy with the use of educational diagrams with key anatomical structures labelled. The images and diagrams are clear and easy to read.

The FOCUS app also provides an overview and examples of normal and abnormal pericardium, left ventricular funciton, right ventricular function, and volume status. 

This is a great user-friendly and interactive app for anyone who is just starting to learn how to perform bedside cardiac ultrasound, as well as anyone who needs a quick reminder on the essential points. 

Procedure: Pericardiocentesis

This video provides an overview of how to use an ultrasound to perform a pericardiocentesis using the cardiac probe.

As with most ultrasound guided procedures, it's important to visualize the needle on insertion and correctly identify the surrounding anatomy. The video provides a good overview of cardiac anatomy as well as the location of a pericardial effusion on echo.

Clinical case: Cardiac Tamponnade

A 43 year old gentleman presents to the emergency department via ambulance with significant shortness of breath. 

On clinical exam, he is in respiratory distress, and his blood pressure is 80/40 with a heart rate of 114. The JVP is quite elevated on exam, and there is significant pedal edema. Heart sounds are difficult to appreciate on auscultation, and there are crackles bilaterally on lung auscultation. 

You perform a quick bedside ultrasound which reveals the following images:

These images represent a significant pericardial effusion causing cardiac tamponade. Although tamponade is a clinical diagnosis, bedside ultrasonography can aid in the diagnosis (Grade 1C recommendation, Society of Critical Care Medicine 2016).

In these images, both the presence of a significant pericardial effusion as well as right ventricular collapse in diastole support the diagnosis of cardiac tamponade. 

Critical Care Guidelines - Part 2

The second part of the Society of Critical Care Medicine's guidelines regarding bedside ultrasonography have recently been posted on their website. This part of the guidelines, by Levitov et al., focuses on cardiac bedside ultrasonography in the critical care setting.

The link can be found here: SCCM: Cardiac Ultrasonography

This guideline lists several class 1 recommendations for the use of bedside cardiac ultrasonography based on the GRADE system, which demonstrates that there is evidence to support the use of beside cardiac ultrasonography in the evaluation of the critically ill patient.

Clinical Case: Pneumothorax

A 63 year old lady with a history COPD arrives to the emergency department via ambulance acutely short of breath.

She is in respiratory distress with accessory muscle use. Her heart rate is 130, her blood pressure is 90/30, her respiratory rate is 35 and her oxygen saturations are 88% on a 100% non rebreather mask.

You listen to her chest, and you hear decreased breath sounds on the left, and absent breath sounds on the right.

You perform a quick bedside ultrasound of both lungs, starting on the left, that reveals the following images:

 

This is an example of a tension pneumothorax, which requires urgent treatment with needle decompression and chest tube insertion. Bedside ultrasound is a quick diagnostic test to aid in the diagnosis.

The first images are of a normal lung, with pleural sliding seen on 2D images corresponding with respirations. In M-Mode, the seashore sign can be seen, with the appearance of waves in the top half of the image while the bottom half appears like sand.

In a pneumothorax (00:38), however, there is no longer a pleural slide, and there is the more homogenous "barcode sign" in M-Mode.

Although these ultrasound signs can indicate the presence of a pneumothorax, the diagnosis of a tension pneumothorax is based on clinical signs as described above, particularly the respiratory distress and hemodynamic instability.

Procedure: Paracentesis

This video below describes how to use bedside ultrasonography while performing a paracentesis.

With ultrasound, an area with an adequate amount of free fluid can be identified, and the risk of perforating bowel can be decreased. With the use of the abdominal probe, this area can be identified quickly by scanning the abdomen to obtain both transverse and long axis views.

Clinical Case: Empyema

A 47 year old gentleman presents to the emergency department with fevers, shortness of breath and productive cough. He is tachycardic and is requiring supplemental oxygen. You hear crackles and decreased breath sounds at the base of the right lung.

You perform a bedside lung ultrasound which reveals the following image:

This is an example of a loculated pleural fluid which can be detected on ultrasound. These loculations occur in complicated parapneumonic effusions and empyema. Utrasonography plays a key role in both the diagnoses and management of these effusions. Identifying loculations on ultrasound changes management, since a thoracentesis is required in this circumstance. Also, ultrasound-guided thoracentesis allows you to identify a pocket of fluid that is attainable for sampling.