Discover and read the best of Twitter Threads about #POCUS

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What are the key clinical questions about haemodynamics that ultrasound can answer?

@icmteaching, @wilkinsonjonny and I are going to take you through the 10 most importantโ€ฆ

starting with...

Q1. Is stroke volume abnormal?

#FUSIC #echofirst #POCUS #ultrasound #haemodynamics
Despite shock being such an important diagnosis, intensive care clinicians are rubbish at detecting a low or high cardiac output (CO) clinically.

Sensitivity of detecting cardiac index (CI) < 2 clinically in this study was 0!โ€ฆ
From an apical 5- or 3-chamber view we can use PW Doppler to assess the velocity time integral (VTI) in the LVOT to determine blood flow.

Essentially, LVOT VTI is the average distance travelled by ejected blood during one contraction...

It is also known as stroke distance.
Read 12 tweets
Patient with epig pain and multiple ED visits with neg CT and non-specific labs - but persistent pain. What do you do? GI cocktail + famotidine and discharge? How about a little #POCUS first. #FOAMed #FOAMus #Ultrasound #MedTwitter @mtabbut @laurarbrownmd @RJonesSonoEM
And the transverse view. What do you think now? Poll below in thread. #Whatsthedx #EmergencyMedicine @DianeGramer @SLWerner_EM @ClaridgeJeffrey @vanessapho @ladha_prerna
What do you think?
Read 9 tweets
1/How can #POCUS #echofirst help in the evaluation of #hyponatremia?
#Nephrology consulted for low sodium. Pt received diuretic for shortness of breath (which was possibly due to hiatal hernia as shown on CXR).
2 physicians FELT patient was EUVOLEMIC
Small ๐Ÿงตbelow ๐Ÿ‘‡ #MedEd Image
2/Based on the above labs, it does look like euvolemic hyponatremia (Urine Na is high, Uosm >100 but not too high, BUN not high). BP was 150s systolic.
That's it? Give some salt tablets or UreNa etc.?
No; perform PHYSICAL EXAM (= #POCUS)
IVC was small - doesn't tell much ๐Ÿ˜ฌ
3/ Next step? Look at the heart, assess stoke volume.
Recent echo LVEF>50%
LV contraction looks good visually
We measured LVOT VTI (couldn't measure LVOT diameter due to chest deformity precluding good PLAX view but its not a problem; VTI is generally enough)
#POCUS Image
Read 10 tweets
Time to discuss some rationale/evidence behind doing #VExUS #POCUS #Nephrology
A short #tweetorial #MedEd ๐Ÿ‘‡
1/ Is fluid overload harmful?
of course yes. Here is a recent meta-analysis.
2/ Does fluid administration affect renal venous flow in asymptomatic but vulnerable patients (#heartfailure)?
3/ In fact, elevated CVP is associated with reduced GFR.
This ๐Ÿ‘‡is a study in outpatients undergoing right heart cath (N = 2557). In CVP values >6 mm Hg, a steep decrease in GFR was observed.
Read 18 tweets
AKI Consult: ๐Ÿ‘ต โžก๏ธ ED with severe DKA. CT Abdomen and Chest to look for infectious trigger: negative. Tx with IV insulin and balanced crystalloid + 6 L with obvious improvement. Cr was 2.7

Remained oliguric, now in sudden shock with increasing NE dose (0.5 ucg/kg/min) ๐Ÿšจ 1/12
#POCUS Very hyper-dynamic๐Ÿซ€ with increased contractility and no RV dysfunction.

๐Ÿ”Ž Look carefully at color of flow exiting the LV:

Aliasing (green color): This means ultrasound system is trying to image an event that is occurring faster than the sample rate

This means flow is fast. But how fast? Choose the CW doppler setting and find out!

In this case acceleration was almost 6 m/s!

Flow acceleration occurs in the setting of obstruction (similar to putting your finger on the hose exit)

So what is causing the obstruction? 3/12
Read 12 tweets
#POCUS #echofirst #MedEd case of the day.
Context: alcoholic liver cirrhosis with suspected #hepatorenal syndrome
Purpose: think about the underlying pathophysiology & seek expert input
1/ PLAX, PSAX, Apical views of the heart. Heart rate ~110-116 bpm
#VExUS images in ๐Ÿงต
2/ overall, looks hyperdynamic. LA looks little enlarged on PLAX, visual TAPSE high on apical.
In cirrhosis, hyperdynamic circulation is expected because of splanchnic vasodilatation and 'relative' arterial under filling.
LV EF #POCUS obtained using @kosmosplatform ๐Ÿ‘‡
3/ Lets calculate stroke volume using LVOT VTI #POCUS
It looks supra-normal
Read 20 tweets
OK #VExUS #POCUS enthusiasts, time for another case discussion.
Somebody asked if I ever recommend IV fluid in a patient with #VExUS 3.
Here is one example where I did.
1/ First, let's see the #physicalexam (#IMPOCUS) findings, then will tell about the case. #MedEd #Nephrology
2/ So, hepatic shows D-only pattern๐Ÿ‘†
If we are doing #VExUS, IVC must be big. Here is the M-mode #POCUS ๐Ÿ‘‡
3/ Renal parenchymal vein #VExUS #POCUS
It also demonstrates D-only pattern ๐Ÿ‘‡
Read 15 tweets
#POCUS quiz of the day:
Easy one. Identify 1, 2 and 3.
POLL in thread ๐Ÿ‘‡ #IMPOCUS #MedEd
PE = pleural effusion
PER = pericardial effusion
Ao = aorta
IVC = inferior vena cava
Rt = right
Lt = left
Correct answer: option 2 -
1. left pleural effusion (note the appearance of collapsed lung; also u can see rib shadows/posterior chest wall = lung area)
2. Right pleural effusion (remember the Boomerang sign on subxiphoid view?)
3. IVC
Read 4 tweets
1/ More 3D #POCUS models for educators + beginners! (๐—ฐ๐—ผ๐—ป๐—ฐ๐—ฒ๐—ฝ๐˜๐˜‚๐—ฎ๐—น๐—ถ๐˜‡๐—ฒ > memorize)

๐—”๐Ÿฐ๐—– and ๐—ฆ๐—– views
Major chambers in these 4C views:
2/ Deconstructing the ๐—”๐Ÿฐ๐—– view:

โ€ข The ๐—ฝ๐—ฟ๐—ผ๐—ฏ๐—ฒ ๐—บ๐—ฎ๐—ฟ๐—ธ๐—ฒ๐—ฟ ๐—ถ๐˜€ ๐—ผ๐—ป ๐˜๐—ต๐—ฒ ๐—ฅ๐—œ๐—š๐—›๐—ง, or oriented toward the LA/LV relative to RA/RVx
โ€ข The top of the screen (๐—”๐—ฝ๐—ฒ๐˜…) ๐—ถ๐˜€ ๐—ฐ๐—น๐—ผ๐˜€๐—ฒ๐˜€๐˜ to the probe and
โ€ข Atria are furthest
3/ With those constraints one can determine general ๐—”๐Ÿฐ๐—– probe location

โ€ข Probe marker ~3 oโ€™clock (๐˜ถ๐˜ด๐˜ถ๐˜ข๐˜ญ๐˜ญ๐˜บ 2:30)
โ€ข ~5rd IC space
โ€ข ~Midclavicular line (๐˜ข๐˜ญ๐˜ต๐˜ฉ๐˜ฐ๐˜ถ๐˜จ๐˜ฉ ๐˜—๐˜”๐˜ ๐˜ข๐˜ฏ๐˜ฅ ๐˜ข๐˜ฑ๐˜ฆ๐˜น ๐˜ข๐˜ณ๐˜ฆ๐˜ฏ'๐˜ต ๐˜ข๐˜ญ๐˜ธ๐˜ข๐˜บ๐˜ด 1:1)
โ€ข Probe tilted to head
Read 9 tweets
Time for a #POCUS #tweetorial on optimization of Doppler. Very important for #VExUS enthusiasts. #MedEd
1/ Unlike greyscale imaging which depends on amplitude of the returned signal, Doppler depends on frequency information. This graphic explains why perpendicular angle is bad.
2/ other way of saying this, in relevance to color Doppler #POCUS
RBC moving away from the probe = Fr<Ft = negative Doppler shift = Blue color
RBC moving towards = Fr>Ft = positive Doppler shift = Red color
Rest of the images/videos from this excellent paper:โ€ฆ
3/ Anatomy (components) of a spectral Doppler waveform (carotid shown)๐Ÿ‘‡
Above baseline is like red on color (towards probe), below = blue. As 0 degree angle is not always possible, <60 is considered OK.
Read 19 tweets
1/ Thought of doing a quick #tweetorial on image acquisition for #POCUS friends starting to do #VExUS
It's kind of "how I do it" guide and not necessarily optimized for research.
1st: Look at the IVC in both long and short axes
If big, do further scans ๐Ÿ‘‡ #MedEd #FOAMed
2/ Lateral approach works best to obtain a straight segment of the portal vein (straight = best Doppler shift) and a nice hepatic vein too.
Place transducer approximately in the anterior axillary line pointing towards sternal notch. Then fan antero-posteriorly.
3/ Forgot what is fanning?
Its also called tilting or some people say, "look" in a particular direction from the same spot.
Read 18 tweets
Today itโ€™s Lung #POCUS for you!

It is:

Easy to perform
Negates irradiation or transport elsewhere!

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

Where do we scan then?? Linear/curvilinear or phased probe positions shown๐Ÿ‘๐Ÿ‘‡
We donโ€™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 ๐Ÿ‘‡. The more you see, the more you recognise. Decompress IF your patient is compromised. Itโ€™s more sensitive than CXR!
Read 23 tweets

Todayโ€™s Tweetorial for you!

We look at basic cardiac #POCUS views๐Ÿ‘ ๐Ÿซ€

First; the Parasternal Long Axis (PLAX)

#FOAMed #FOAMcc #echofirst

Probe position shown with marker to right shoulder, left Parasternal edge; roughly at intercostal spaces 2-3/3-4๐Ÿคทโ€โ™‚๏ธ

What should you see on ultrasound, and the associated sono anatomy๐Ÿค”

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

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

If youโ€™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 view๐Ÿค›๐Ÿ‘
Read 16 tweets

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

Itโ€™s a RULE IN study! Not a rule out โš ๏ธ

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

#FOAMed #FOAMcc #echofirst


Hopefully we wonโ€™t see these?!

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).

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 โ€˜seagullโ€™ sign -

Hepatic artery and splenic artery = wings.

Coeliac trunk = body.
Read 7 tweets
So; there are often debates regarding ultrasound probe manoeuvres ๐Ÿคทโ€โ™‚๏ธ

Here we go with a graphical Tweetorial, courtesy of myself, @ICUltrasonica and @icmteaching

Hope this helps (you may see these soon in a forthcoming book btw๐Ÿ˜‰

#FOAMed #POCUS #FOAMcc #echofirst 1/7


Here we slide the probe along a slug trail of gel, quite crudely, across a wide area of the body. This is often used to โ€˜window shopโ€™, for structures we canโ€™t see at first. When they snap into view, we can fine-tune movements ๐Ÿ‘ Also allows view of larger organs.


Classic example here is when we get an apical view of the heart. At first, the heart may not be in line with the scan field. We can โ€˜swingโ€™ it into view, so it appears more square on the screen. Makes parallel measurements more accurate and things less off-axis๐Ÿคทโ€โ™‚๏ธ
Read 9 tweets

Patient with left flank pain, pelvic pain, hematuria and gonadal varices

Your only imaging modality is vascular U/S....Lets find out!

A Mohan #Tweetorial

#RPVI #cardiotwitter #irad #vascular @HadyLichaaMD @t_intheleadcoat @TheNarulaSeries
2/ Whatโ€™s going on here?? First name your structures #RPVI

SMA- superior mesenteric artery
AO- Descending Aorta
Lt renal VN- left renal vein

@CHICKVIR @Jonathan_PaulMD @iRadRock @keithppereira @Vascupedia_com @DrYanLiu
3/ Save this- transverse slice at the level of the renals! So much anatomy in such a confined space

#RPVI #cardiotwitter #IRAD #Vascular #foamed #cardioed #cardiology #ultrasound #pocus
Read 11 tweets
Did you adequately numb the peritoneum for your paracentesis?

If it looks like this then yes! Yes, you did. Congratulations. Your patient thanks you (and may ask for you by name next time!)

#ultrasound #irad #MedTwitter #MedEd #POCUS
For any intra abdominal needle passage, pain crossing the skin and peritoneum (sometimes muscles too) are worst. The 25G lido needle isn't too bad, but if you try to pass a 5 French without good local anesthesia, they're going to feel it.
Paracentesis is a great procedure for learning US/needle skills. Make sure you ๐Ÿ‘€your needle tip OVERLYING the deepest, echogenic, anterior abdominal wall layer and numb, numb, numb. If that layer pushes away from you, chase it with your needle!
Read 6 tweets
Goal and benefit of POCUS is to rapidly narrow the differential diagnosis through asking and answering defined clinical questions.
POCUS will narrow the differential more rapidly
Read 18 tweets
Patient with hx ESRD on dialysis and multiple previous central catheters. Needs central line. #POCUS as shown. Go ahead and place the line? Poll in thread. #FOAMed #FOAMus #MedTwitter #EmergencyMedicine @mtabbut @RJonesSonoEM @SLWerner_EM @NephroP @siddharth_dugar
Place the line here?
Answer: This patient with chronic thrombus at the shown location. Best to look for a different location.
Read 4 tweets
So what does a #POCUS guided fluid assessment look like? #tweetorial #askpocus @IMPOCUSFocus @DRsonosRD @KalagaraHari @SonoSerious @tsquaredmd @jaffa_md @nick_wroe @EM_RESUS @coreultrasound @kyliebaker888
Letโ€™s start of the with the lungs! Normal dry lungs are represented by an A line profile. These are horizontal lines that are equidistant from each other and are reverberations artefacts of the pleural line.
B lines are vertical artefacts arising from the pleural propagating all the way down. When widespread and bilateral can be an indication of interstitial/alveolar oedema.
Read 21 tweets
Sometimes you stumble across a case that challenges everyone-even those who with super skills...but even more--a case ripe for diagnostic bias. This is one of them (written consent obtained to share these images:forewarning-->no ECG gating). A thread. @UAlberta_ICU #POCUS
A colleague was looking after a 30-ish yo female who was several wks postpartum. She had been SOB; an early comprehensive echo demonstrated an impaired LV function (EF ~30%). She was admitted to ICU and placed furosemide for CHF, requiring NIPPV. Transitioed to prongs PAD #1.
Read 21 tweets
Let's make #POCUS documentation is a quick tweetorial on how to document safely AND capture billing! We will use a bedside focused cardiac ultrasound as an example! [1/10]

@ACEP_EUS @POCUS_Society @Pocus101 @KalagaraHari @ResaELewiss @DRsonosRD
Component 1: What type of exam are you performing?

Include the LIMITED nature of your exam; anatomic location (including laterality) is necessary for soft tissue/msk or procedural ultrasound.

Documentation example -> Limited transthoracic echo

[2/10] Image
Component 2: Why are you performing the exam?

List the INDICATION for the exam. Putting the proper indication down is important as it may help get the study reimbursed.

Documentation example -> Indication: Shortness of breath

[3/10] Image
Read 10 tweets
A thread about #POCUS guided procedures.
Paracentesis with ultrasound: 49083
Paracentesis without ultrasound: 49082

With #POCUS is safer for patients and less likely to be a failed procedure. Also, billing is higher for ultrasound guidance.โ€ฆ
#POCUS guided procedures, continued
Thoracentesis with #POCUS guidance CPT: 32555
Thoracentesis without #POCUS guidance CPT: 32554

Again, using ultrasound makes for a safer and more successful procedure.โ€ฆ
#POCUS guided procedures, continued
Lumbar puncture CPT: 62270
Ultrasound guidance for needle placement CPT: 76942โ€ฆ
Read 8 tweets
1/2 #POCUS guided femoral nerve block: Femoral nerve is deep to fascia iliaca. Injection superficial to fascia iliaca = failed block. In this patient, initial spread noted in incorrect plane: (additionally note large circumflex iliac branch of femoral artery)
2/2 Needle advanced and now correct spread noted on #POCUS - deep to fascia iliaca, pushing the femoral nerve down. Block worked beautifully!
@threadreaderapp unroll please
Read 3 tweets

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