BTW, this is the only basic position you need for this. Dipping the tail or lifting the tail then get you inflow and outflow views. This is more advanced. #FUSIC

3/13

Next, the Parasternal short axis (PSAX) – Mitral view

If you’ve lined up the aortic and mitral valves in the centre of the image on PLAX, a simple rotation of the probe through 90 degrees gives you your view🤛👍

4/13

Here it is:

Mitral level – with associated sonoanatomy🤛 The ‘fish mouth’

Now, with the SAX views, you are required to make some probe movements. Essentially dipping or lifting the tail to fan through the heart.

5/13

PSAX aortic level – from the mitral level, dip the tail of the probe down towards the patient’s feet and here is your Classic Mercedes badge of the hopeful fro-leaflet valve. You can see the tricuspid here as well.

6/13

PSAX papillary level – Lift the tail towards the patient’s head and find the papillary muscle heads. This is the papillary level. Great for assessing crude regional wall motion abnormalities
👍 head butting paps could mean hypovolaemia. Miles away, LV failure🤷‍♂️

7/13

Apical 4 Chamber view

Marker to the bed, around the apex beat point. Or at 3 o’clock.

As @sharonmkay says, ‘window shopping’ about with crude probe movements around the area allows the view to flash up. Then make finer movements.

8/13

Here is the apical 4 chamber and sonoanatomy.

Open up the atria and ventricles by dipping the probe tail. If the view goes, it’s a rib in your way. Move up over it or under it to get the window back👍 the LV apex should not move much, if it does, you are foreshortened!

9/13

The apical 5 chamber view

Dip the probe tail to catch the LVOT and aortic valve into your view as your 5th chamber.

It’s the VTi view folks👍

10/13

The subcostal 4 chamber view

The FAST view! Land the probe like a space rocket, around the point the xiphisternum dips down, marker to the patient’s left. Then gently scoop upwards, as if to lift the heart up.

11/13

Here it is with associated sonoanatomy

Look for LV/ RV size discrepancies, crude movements and atrial enlargement. Good for pericardial effusions too👍

12/13

Rotate the probe anti-clockwise so the marker points to 12 o’clock.

This is the IVC view👍

Look for size/collapsibility/thrombi. Do not use 1 view to tell you volume status..you need trending as well as SAX view for this, with others parameters borne in mind!⚠️

13/13

What about Regional wall motion abnormalities then🤷‍♂️

Our PSAX papillary level is fairly good for crude assessment of this. Take a look at the regions shown and stare at it to convince yourself ALL parts thicken nicely. If not, there may be a coronary territory issue.

Happy probing!

You can download all of these here:

https://criticalcarenorthampton.com/basic-image-acquisition/

Also, this too👍

POCUS-grams

To all #POCUS nutters @RubbleEM @kyliebaker888 @avkwong @NephroP @amit_pawa @bhca @POCUSClub @NixLimerick @cianmcdermott @FTeranMD @ThinkingCC @zedunow @UltrasoundMD @cardiacACCP @MJGriksaitis @aroradrn @r_wiersema @parulekar8550 @PARADicmSHIFT @iceman_ex @rosie_hogg @curromir

And a link that works!!!

#FOAMed #POCUS #FOAMcc #echofirst #medtwitter

Basic Image Acquisition

Originally tweeted by Jonny Wilkinson (@Wilkinsonjonny) on March 30, 2021.

LUNG

Today it’s Lung #POCUS for you!

It is:

Easy to perform
Accurate
Sensitive
Repeatable
Negates irradiation or transport elsewhere!

#FOAMed #POCUS #FOAMcc #foamus @icmteaching @ICUltrasonica

Where do we scan then?? Linear/curvilinear or phased probe positions shown👍👇

We don’t tend to use linear for the basal sections, as you need depth for the PLAPS points. To see the pleura clearly, minimise depth and drop gain down, you get a real concept of sliding on the screen.

Here are the normal views for you @GEHealthcare

Now; the Pneumothorax!

Pleural slide disappears as the parietal and visceral pleura separate. So, a static washing line is seen between the rib pillars 👇. The more you see, the more you recognise. Decompress IF your patient is compromised. It’s more sensitive than CXR!

Here is another view with a linear probe. The pleura is visualised better with the high-frequency probe.

Now here, we can see the lung point, where non-sliding meets sliding pleura. Very sensitive for PTX.

If you see this, you can hand on heart diagnose PTX!

Even more lung point action on this scan series.

We have multiple intercostal spaces here, and you see where the PTX appears!

–@GEHealthcare now has the fabulous lung sweep available to do this for you! Fantastic stuff:

If you are unsure if slide is there or not, place m-mode down through the rib window. If you see a seashore appearance, the slide has created the Sandy beach interference.

If there’s no sliding, you get a barcode or stratosphere sign as below. You’ve backed up your diagnosis!

Now; if we intubate the right main bronchus, there is little to no slide on the left🤷‍♂️

But – it’s not a PTX. If we shine m-mode through, we will get a lung pulse.

This is where cardiac pulsation is amplified via opposed intact pleura giving us a blip in unison with the pulse👍

Now, interstitial fluid!

Fluid allows sound waves to travel through. We see this as beams traveling from the pleura right to the bottom of the image. These are b-lines. The more there are, the ‘wetter’ the lungs.

Diuresis can help / fluid restriction. It could be #COVID19 too.

Here is another, but in this one, we see spared areas of normal lung and visible horizontal a-lines.

B-lines are vertical remember.

A = ‘A-cross’

B = to the ‘B-ottom’

Now; in #COVID19 we get pneumonitis. And hence, fluid in the form of B-lines.

Classically, we see jagged and thickened pleura too. So, test positive and this US appearance is typical! So much more sensitive than CXR!

Here’s another #COVID19 view. This patient’s hypoxia was aided by CPAP and diuretics. More B’s = more fluid!

You can often see subtler US changes well before any CXR flags it. And forget the stethoscope when you have US!
B-lines often clear with good diuresis.

What about consolidation?

Eminently detectable with lung #POCUS !

Here we see white shred appearance of consolidation. The shred describes where infected lung interfaces with normal lung.

And some more consolidation. The normal lung is air-filled and appears black.

The more abnormal echogenic specs there are, the more consolidation is forming.

Here’s another example of consolidation in #COVID19, with a small parapnemonic effusion.

We saw a lot of superadded bacterial infections in COVID. You don’t classically see straightforward consolidation with simple viral pneumonitis.

Dynamic air bronchograms appear as basal consolidation worsens.

A great example here is where white echogenic fluid can be seen moving up and down the distal small airways with ventilation.

And some more dynamic air bronchograms. This is Vs those we would describe as static air bronchograms on CXR.

A final air bronchogram series.

Here, the consolidated, poorly aerated lung takes on the sonographic appearance of the liver! This is known as hepatization! Bad news!

We all love to hate finding pleural effusions. A good basal scan can demonstrate black, hypoechoic fluid readily. Here, the lung is squished by pleural fluid and floats around, sometimes like a 🧙‍♀️ hat! Often, CXR doesn’t pick this up but US smacks you in the face with it!

Another massive effusion with a section of tethered lung. This may be chronic, as inflammation has led to fibrosis and tethering to the diaphragm. Drain fluid IF the patient is compromised or for diagnostics. Under US guidance🤛👍

Here is a highly proteinaceous exudative effusion in a cancer patient. You see the echogenic fluid swirling about.

A nastily loculated, large pleural effusion. I would run for the hills Vs putting a drain into this mess!

Put it all together in @DanielLICHTENS1’S BLUE protocol to see how amazingly useful Lung #POCUS is!

Happy scanning. All this and more to come in a book chapter with @LukeFlower1 and some fab stuff with @GEHealthcare soon!

Tagging @zedunow @NephroP @avkwong @amit_pawa @bhca @NixLimerick @aroradrn @cianmcdermott @FTeranMD @cardiacACCP @UltrasoundMD @load_dependent @MJGriksaitis @POCUSClub @ThinkingCC @RubbleEM @rosie_hogg @r_wiersema @iceman_ex @sonophysio @Pocus101 @IMPOCUSFocus @POCUSAcademy

Originally tweeted by Jonny Wilkinson (@Wilkinsonjonny) on April 3, 2021.

DIAPHRAGM

So, remember C3,4,5 keeps you alive?!

Yes, today’s Tweetorial from @icmteaching, @ICUltrasonica and myself is all about the diaphragm!

It’s a pretty vital muscle, and is often forgotten. It’s no wonder why, when it’s weak, your patients won’t liberate from the ventilator!

So, does #POCUS have a role in assessing it. Of course it does!🤷‍♂️😂

We use 3 probe positions:

1) Mid axillary/RUQ point – marker 12 O’clock
2) Mid clavicular/Subcostal – marker 12 O’clock
3) Mid clavicular/subcostal – marker 3 O’clock

Here’s MidAx/RUQ position:

The lung curtain does get in the way here, so run M-mode low down to catch the diaphragm.

We use the vital organ (liver or spleen) as our scan window and discriminator between chest cavity and abdominal cavity👍

Speaking of M-mode, it is sensitive for movement / gaging distance. So after you get the B-mode view, run it through the diaphragm👍

⭐️ We can measure the diaphragm’s EXCURSION.

>1cm indicates good spontaneous effort and should mean ‘weanability’, from the ventilator.

Next, position 2:

Place the probe mid clav/SC/marker to 12 O’clock.

Here, we see the muscle bulk to the diaphragm and can appreciate its layers + thickening.

Inspiration -> it thickens
Expiration -> it thins

⭐️ This is diaphragm thickening index or Tdi:

Thin/thick x 100

Run your m-mode through now, we can really appreciate this.

Here we see this respiratory muscle thicken on a spont breath in and thin down on passive recoil expiration.

Tdi >30% = no sonographic diaphragmatic dysfunction. It is 71% specific for extubation success 👏

Finally, position 3:

Probe mid ax/SC /marker to 9 O’clock.

Just another view and not a million miles from a cardiac subcostal. We can see the heart, part of the IVC and there’s minimal lung curtain interference.

Yup, run that M-mode through to appreciate movement and measure it again.

Happy probing!

#FOAMed #FOAMcc #foamus #echofirst #foamem

The evidence to support its usage.

There aren’t heaps of outcome data, but assessment to note extreme wasting, poor excursion and poor Tdi certainly predict success or failure of SBT and liberation from the vent!

https://pubmed.ncbi.nlm.nih.gov/29435329/

More here too

https://thorax.bmj.com/content/69/5/431

A cracking review article

https://theultrasoundjournal.springeropen.com/articles/10.1186/s13089-019-0117-8

Click to access 1806-3756-jbpneu-46-06-e20200064.pdf

Download the full graphic here

https://criticalcarenorthampton.com/pocusgrams/

Tagging @PARADicmSHIFT @r_wiersema @sonophysio @SimonOrlob @iceman_ex @ThinkingCC @amit_pawa @Manoj_Wickram @dr_rajgupta @load_dependent @khaycock2 @zedunow @POCUSAcademy @IMPOCUSFocus @POCUSClub @kyliebaker888

Tagging @PracticalPOCUS @POCUSEcho @pocuseducation @POCUS_Society @TaotePOCUS @Pocus101 @hepocus @POCUSJournal @NephroP @pocusfoamed @POCUSbot @drzaf_pic @Nadia_Hdz_MD @shaskinsMD @elboghdadly @UltrasoundMD @NixLimerick @cianmcdermott @bhca @MJGriksaitis @rosie_hogg

Originally tweeted by Jonny Wilkinson (@Wilkinsonjonny) on April 17, 2021.

LIVER

It’s time for another Tweetorial:

#FOAMed #POCUS #FOAMcc #FOAMus #medtwitter

The Liver!

It is arbitrarily divided into 3 lobes:

1) R
2) L
3) Caudate

A crude line drawn between the GB, the main lobar fissure (MLF) and the IVC divides L and R!

Of course, in anatomy, it gets a little more complex! 🥴

There are further divisions:

R = Anterior + posterior
L = Medial + lateral
Caudate lobe – the IVC = posterior border, the fissure of ligamentum venosum = anterior border

Veins:

3 majors – run INTER segmental + INTER lobar course

1) R hepatic – runs in R intersegmental fissure. It divides R lobe into ant. and post. segments
2) Middle hepatic – separates R ant. from L medial lobe.
3) L hepatic – divides L lobe into medial and lateral segments

Another view of the echo-bright fissure from the ligamentum venosum

Portal Veins:

Main portal takes blood from intestines, spleen, pancreas and GB.

1) Main = L and R
2) L = medial and lateral
3) R = ant. and post.

Portals = echogenic walls run INTRA segmental course only

Hepatica = hypoechoic (like tree trunks) and run INTER INTER course

Finally the Couinaud classification!

Divides the liver into 8 segments around the blood vessels – each has a portal vein, a hepatic artery and a bile duct (a portal triad).

Hepatic veins divide it into 4 segments.

A line through the main portal veins splits the 4 into 8

Segments:

1) = the caudate lobe
2+3) superior and inferior lateral segments of L
4a+4b) medial segment of L
5+6) inferior segments of R
7+8) superior segments of R

Happy probing! Tagging @NephroP @avkwong @amit_pawa @bhca @NixLimerick @aroradrn @cianmcdermott @POCUSClub @cardiacACCP @Manoj_Wickram @UltrasoundMD @load_dependent @MJGriksaitis @ThinkingCC @RubbleEM @kyliebaker888 @r_wiersema @rosie_hogg @iceman_ex @sonophysio @Nadia_Hdz_MD

All of this is forthcoming in a book chapter by myself, @icmteaching and @ICUltrasonica with @LukeFlower1

@IMPOCUSFocus @POCUSAcademy @Pocus101 @PracticalPOCUS @hepocus @POCUS_Society @POCUSbot @BCPoCUS @POCUSJournal @pocusfoamed @GlobalPocus @GEHealthcare @ButterflyNetInc

Get Ready GIF

Originally tweeted by Jonny Wilkinson (@Wilkinsonjonny) on April 14, 2021.

GASTRIC

Today’s Tweetorial is Gastric ultrasound!

A potentially rewarding #POCUS skill to learn.

Great 📄 from my good friends @shaskinsMD and @JanBoublikMDPhD #FOAMed #FOAMcc #foamus

https://rapm.bmj.com/content/43/7/689

👍 to assess NPO status and minimise post-op pulmonary complication risk

Where do we scan?

Supine patient, curvilinear probe, marker to 12 O’clock, just under the xiphisternum.

The antrum of the stomach is what we are interested in; it is readily viewable (most of the time). Note, this view is similar to the view we obtain for biliary ultrasound👍

Sometimes we can’t catch that antrum, as it’s tucked away. Placing the patient right lateral decubitus (RLD) helps.

My daughter’s hand acts as the liver and we demonstrate how the antrum (gold squishy), drops and displays in RLD. Never say empty until you check this position!

Here I am filling my antrum up with a mouthful of water. It doesn’t take long for the fluid to enter!

Clear fluids distend, swirl and transit out rapidly. Hence the safety of pre-op water a couple of hours before a case; should be cleared👍

AORTA

1/7

Here is a quick Tweetorial on Abdominal Aorta #POCUS for you all!

It’s a RULE IN study! Not a rule out ⚠️

Images from a forthcoming book chapter with @LukeFlower1 @icmteaching + @ICUltrasonica !

#FOAMed #FOAMcc #echofirst

#medtwitter

Hopefully, we won’t see these?!

2/7

Apply careful firm pressure to displace pesky bowel gas. I start at the umbilicus; you can find the vertebral body easily here. You can then move up or down, tracing the vessel. The aim is to see as much of the vessel as you can. Marker – right (SAX) or to the head (LAX).

3/7

High Subxiphoid SAX

Find that vertebral body shadow again, you will see the aorta and IVC just above this. We are looking for the classic ‘seagull’ sign –

Hepatic artery and splenic artery = wings.

Coeliac trunk = body.

4/7

Upper Transverse View

Move caudally from the last view to get this one. Look for the vertebral body shadow. The aorta lies to the left and the IVC at 10 o’clock to this. The SMA is visible as a small pulsating shape at 11/12 o’clock. Note the left renal vein hugs the aorta.

5/7

The Longitudinal View

2 major branches are apparent. The most cranial = coeliac trunk. Below this = SMA.

The renal arteries branch off below the SMA; not always visible. Right = posterior to the IVC. Other branches are subtle. Hence, CT is best for I.D’ing prior to surgery.

6/7

Bifurcation View (LAX / SAX)

Travelling further caudally, we get this view. We see the bifurcation into the common iliac arteries. IVC and spine lie posteriorly.

Diameter of the iliacs = 1.5cm in men; 1.2cm in women.

7/7

Measurement of the aorta at the umbilicus:

1.5-2cm – Normal
<3cm – discharge
3-4cm – annual scan
4-5cm – 3monthly scans
>5cm – refer to surgeon
>7cm – critical rupture risk!

Do LAX and SAX measurements – inner to the inner wall, as per MASS study👍

https://pubmed.ncbi.nlm.nih.gov/12443589/

Originally tweeted by Jonny Wilkinson (@Wilkinsonjonny) on March 29, 2021.

DVT

Today’s Tweetorial is on DVT!

@icmteaching and @ICUltrasonica take you through it.

-5-10% of ICU patients will have a silent one.
-Accounts for 12% of ICU deaths
-It is detectable and preventable!

Use #POCUS to your advantage👍

#FOAMed #FOAMcc #foamus #echofirst #FUSIC

-Clinical examination
*60-96% sensitivity
*20-72% specificity

Wells score 👎validity in the critically ill, as by remit that’s a risk factor itself 🤯

Contrast venography = Standard, but you need to be off the unit for that!

Limited US protocol almost as good as triplex

Pop the patient’s leg into the 🐸 leg position.

Scan systematically down the leg, compressing every 2-4cm down the course of the veins. Veins should be squashed shut, reopening on compression release IF patent,

The route shown will pick up most major lower limb DVT’s🤷‍♂️👍

We describe a ‘Triplex scan’ =
1) 2D ultrasound
2) Colour flow doppler
3) Pulsed wave doppler

Colour discerns artery from vein (pulsatility Vs non)

PWD demonstrates flow pattern, or none🤷‍♂️😩

My @sono4you_graz talk on DVT is here

https://fb.watch/8SOGDwG7Yo/

Sml Bowser Junior GIF

Originally tweeted by Jonny Wilkinson (@Wilkinsonjonny) on October 25, 2021.

Today’s Tweetorial is on DVT!

DVT

@icmteaching and @ICUltrasonica take you through it.

-5-10% of ICU patients will have a silent one.
-Accounts for 12% of ICU deaths
-It is detectable and preventable!

Use #POCUS to your advantage👍

#FOAMed #FOAMcc #foamus #echofirst #FUSIC

-Clinical examination
*60-96% sensitivity
*20-72% specificity

Wells score 👎validity in the critically ill, as by remit that’s a risk factor itself 🤯

Contrast venography = Standard, but you need to be off the unit for that!

Limited US protocol almost as good as triplex

Pop the patient’s leg into the 🐸 leg position.

Scan systematically down the leg, compressing every 2-4cm down the course of the veins. Veins should be squashed shut, reopening on compression release IF patent,

The route shown will pick up most major lower limb DVT’s🤷‍♂️👍

We describe a ‘Triplex scan’ =
1) 2D ultrasound
2) Colour flow doppler
3) Pulsed wave doppler

Colour discerns artery from vein (pulsatility Vs non)

PWD demonstrates flow pattern or none🤷‍♂️😩

My @sono4you_graz talk on DVT is here

Sml Bowser Junior GIF

Let’s look at the venous anatomy of the lower limb.

Here we demonstrate the upper portion of the leg, down to the distal femur. There are a few main veins to focus upon.

👍 to @3D4Medical for the anatomical builds I have made throughout this series.

And now, the portion below the knee.

Some stop scanning above the knee…don’t; scan down, behind and below so as not to miss anything!

We SHOULD start right up top, where the first large vein is seen!

The IVC – lies to the right of the aorta, bifurcating alongside its arterial counterpart (iliac veins and iliac arteries).

We don’t often compress here though!!!

Here’s the classic US image we see

Scan Point 1 – the saphenofemoral junction. Shown here.

And here is one of our classically described US signs! 🐭

You can see how he is formed. People forget this starting point…don’t just start at the femoral level, go above🤟

Scan point 2 – the femoral vein.

People use this for vascath access and it’s easy to see why. Large chunky vein near the artery. Runs down midline + anterior, terminating behind the knee.

Remember from lateral to medial N-A-V-Y:
Nerve
Artery
Vein
Y-fronts (underpants)😂

Scan point 3 – the more medial saphenous vein.

This one runs right down the leg, to become the great saphenous vein, terminating above the medial malleolus. Another we sometimes forget to follow down.

Scan point 4 – the popliteal vein.

The femoral terminates behind the knee, becoming the pop. vein.

It is often neglected; therefore silent DVT’s are missed here. Always scan behind the knee – push from the back, supporting the knee from the front.

This one trifurcates.

Here’s the whole lot for you. The 4 points below the IVC, if scanned clearly, give you a fighting chance to rule in / out a lower limb DVT with some certainty.

Sensitivity 90-100%
Specificity 75-99% 👍🍺

I wanted to demonstrate ‘Augmentation’

This is where an assistant squeezes the leg at points BELOW the point being scanned. IF the vein is patent, a ‘whoosh’ of colour or PWD trace/sound can be observed as blood freely flows back towards the probe. Seen here👇

Here is a femoral DVT. ☠️

We see a mere blinking of colour on the outside of the vein, around the obstructing clot. The artery can be seen clearly.

Another view of a common femoral vein DVT. It is subtle, but there is a more echogenic, textured mass within the vein, seen a little more clearly with compression.

Don’t over-compress a DVT, or repeatedly do so when you are excited you’ve found one!!! 🤦‍♂️

Here’s a popliteal DVT.

The clot becomes far more obvious on compression. The artery is again the star of the show here!

By the way, veins should compress to obliteration point..if not, why not?!

Now; mimics!

Here is a Baker’s Cyst. Hypoechoic throughout and compressible too. NOT a DVT!

Little to see on colour flow or PWD.

And a lymph node. Looks very similar in echogenicity to a DVT BUT..put power or colour doppler on – swirling starry colours seen as the lymph runs a swirl. Also, normally more superficial and NO flow on PWD!

So:

– It is highly sensitive and specific
– Start at the SFJ and work down, compressing @2cm intervals
– Pop on colour and pulsed wave to make it a triplex series.

You could prevent a PE or worse, death!

Just Do It Shia La Beouf GIF

No one wants to see this when it COULD have been prevented with a basic scan series!

Happy scanning to you all!

@sonophysio @SimonOrlob @iceman_ex @Manoj_Wickram @dr_rajgupta @load_dependent @khaycock2 @POCUSAcademy @IMPOCUSFocus @POCUSClub @kyliebaker888 @GEHealthcare

McConnels sign, PE and large clot in the RA + RV!

@PracticalPOCUS @POCUSEcho @pocuseducation @POCUS_Society @TaotePOCUS @Pocus101 @hepocus @POCUSJournal @NephroP @pocusfoamed @POCUSbot @drzaf_pic @Nadia_Hdz_MD @shaskinsMD @elboghdadly @UltrasoundMD @NixLimerick @cianmcdermott @bhca @MJGriksaitis @rosie_hogg

@RubbleEM @avkwong @amit_pawa @bhca @POCUSClub @NixLimerick @FTeranMD @ThinkingCC @zedunow @UltrasoundMD @cardiacACCP @aroradrn @r_wiersema @parulekar8550 @PARADicmSHIFT @curromir @ICS_updates

Originally tweeted by Jonny Wilkinson (@Wilkinsonjonny) on October 25, 2021.

AIRWAY

Today’s Tweetorial focuses on Airway #POCUS

No one wants to have to perform emergency front of neck access (eFONA) in their career!

So, why not be prepared?!

Let’s talk it through..
#FOAMed #FOAMcc #ultrasound #FOAMus #medtwitter #echofirst #airway

Ultrasound of the airway can certainly help you out👍

It aids the identification of vital parts of the airway you might struggle to find in the heat of the moment!

I’ve had x2 FONA situations in my career! Could have been slicker with #POCUS!🤷‍♂️🤦‍♂️

As easy as 1-2-3-4!! #FOAMed #FOAMcc #difficultairway

So what are we looking for?

Place the linear probe (marker to the right), onto the Adam’s apple. Work down, there are 5 vital structures, shown below:

1) Thyroid cartilage ‘V’
2) Cricothyroid membrane👈👍
3) Cricoid cartilage
4) Thyroid gland
5) Tracheal rings

👇live scan, working from the thyroid cartilage (Adam’s apple), downwards, to above the sternal notch.

1) Inverted ‘v’ = thyroid cart.
2) Reverberation artefact (like A lines in lung), = CTM
3) Continuous ring = cricoid
4) Bow tie = Thyroid
5) Black rings = tracheal rings