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Mourad H Senussi, MD, MS

Sep 22, 2020 • 17 tweets • 14 min read • Read on X

(1/)I've had several people ask me about details on how to use bedside ultrasound to confirm ET tube placement, detect esophageal and mainstem intubations, and adjust positioning.

So here is a step by step guide!

Ref: journals.lww.com/ccejournal/Ful…

(2/)**Overview** this protocol utilizes sequential tracheal and bilateral thoracic lung ultrasound.
1. Tracheal ultrasound to r/o esophageal intubations
2. Right Lung US
3. Left Lung US
4. Adjustment to achieve bilateral lung sliding

(3/)**Tracheal Ultrasound**
This is simple. Place your transducer transversely at the level of the suprasternal notch. Below is an example of the appearance of the trachea with a hyperechoic anterior wall and acoustic shadowing.

(4/) Know your paratracheal structures well! Also familiarize yourself with the appearance using the linear transducer or phased array/abdominal probe. Pay special attention to the left paratracheal region where an often collapsed esophagus can be seen.

(5/) Using a phased array probe you gain depth at the expense of resolution. Find what works for you.

(6/) Real time US of the trachea.

(7/) So now that we have familiarized ourselves with the ultrasonographic appearance of the trachea and adjacent structures.
Step1. Rule out esophageal intubations!!! With the ET tube in the esophagus you will see a double trachea or double tract sig

(8/) ** Double Barrel Trachea ** in esophageal intubation s

(9/) Step 2: Determine Lung sliding on the right. This indicated tracheal or endobronchial intubation. (works best in non-spontaneously breathing patients with delivery of breaths via bagging or the vent)

(10/) Step 3: Determine left lung sliding in a similar fashion. in no lung sliding then likely a right main stem intubation. Retract the ET tube slightly until lung sliding is demonstarted on the left. this indicates bilateral lung ventilation!

(11/) Below is an example of no lung sliding on the left. What you do you see is the "Lung Pulse"! Don't let that shimmering effect fool you. It represents the transmission of the heart pulsations to the pleural line and is pathognomonic for lung collapse. See Lichtenstein et al.

(12/) In equivocal cases Diaphragmatic Ultrasound can be utilized either by looking at diaphragmatic movements from the subcostal view of the area of interest or looking at the PLAPs point for lung curtain sign!

(13/) Caveats
- This protocol depends on the ability to detect bilateral lung vent via lung sliding therefore preexisting conditions that affect the pleural line may limit this. Pre-scan is preferred. Many things can cause a lack lung sliding!

(14/) This protocolized, systematic approach using tracheal and thoracic ultrasonography can be used to confirm endotracheal intubation, detect main stem intubations, and adjust tube positioning in the critically ill.

(15/) This has the potential to be used for routine intensive care, out-of-hospital or resource-poor settings, or situations which require isolation precautions to mitigate the use of CXR. So grab those probes and give it a try.

@Phani_kc

@Phani_kc @pdsalinas @ArgaizR @iceman_ex @ThinkingCC @kyliebaker888 @Pocus101 @IM_POCUS @drmarcogarrone @PulmCrit @BCM_Lung @bcmhouston @CCF_IMCHIEFS @CCF_PCCM @LatifiMani @krveshi @POCUS_Society @pocusfoamed @POCUSAcademy @pocusmeded @PhilipsPOCUS @NephroP @UAB_Sono @PittIMPOCUS

@AIUMultrasound

@AIUMultrasound @HeyDrNik @MaizeandLube @ACEP_EUS @SCUFellowships @UltrasoundJelly @ultrasound @CriticalCareNow @critconcepts @PittCCM @SCCM @IM_Crit_ @critcareexplore @critconcepts @iBookCC @ICS_updates @I_C_N @intensiveblog @siddharth_dugar @msiuba @nsenussiMD @suzanskef

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More from @msenussiMD

Mourad H Senussi, MD, MS

@msenussiMD

Feb 8, 2023

**Hepatic Veins : A window to the heart**
What do you see here?

Clue: look at the rhythm

Hepatic veins can provide a plethora of information on the "right heart apparatus".
1. Tricuspid valve
2. RV function /PA pressures
3. Volume status

Often overlooked but can also glean some info on electrical activity of the atria i.e. atrial dysrhythmias.

Lets go over circuitous methods of doing so :)

Note good antegrade flow.

But one can clearly see the f-waves from the atrial flutter!

Read 7 tweets

Mourad H Senussi, MD, MS

@msenussiMD

Feb 7, 2023

***Bloodless central venous cannulation***
1. Preload the needle with your guidewire
2. Use wrap around technique to control the wire
3. Impeccable DYNAMIC ultrasound guidance
4. Rejoice - not a single drop of blood in your field

Alternatively can use the back end of specially designed needles that obviate the need to remove your syringe from the needle. I find it more cumbersome but allows for aspiration of blood!

Important caveats

Must use impeccable dynamic dynamic ultrasound technique and localize the needle tip intraluminally!

Most times when needle tip position is lost is during the syringe removal process. So try out this technique!

Read 4 tweets

Mourad H Senussi, MD, MS

@msenussiMD

Oct 25, 2021

** Bubbles of Truth **

We can gain a tremendous amount of clinical information by observing the flow of bubbles within our vascular system.

Here are a few illustrative examples!

Exhibit A:
Below is a subxiphoid view highlighting markedly distended hepatic veins and IVC. Note the reflux of bubbles into the HV/IVC consistent with high right sided filling pressures.

The bubbles in the above case are arising from rapidly infusing IV fluids through an upper extremity central venous catheter.

Read 14 tweets

Mourad H Senussi, MD, MS

@msenussiMD

Oct 16, 2021

*Hyperdynamic LV: Harbinger of Doom*

This clincial scenario has played out before my eyes on multiple occasions

Echo performed on a pt with undifferentiated shock

"EF > 70%...hyperdynamic.. all good."

A hyperdynamic LV is more sinister than you may think. Lets find out why..

Consider why the LV would be hypercontractile and avoid the knee jerk reflex to assume that it is ONLY due to hypovolemia/hemorrhage i.e decreased RV preload/low mean systemic filling pressure .

Start thinking in terms of LV preload.
1. RV failure
2. Mitral regurgitation
3. VSD
4. Vasodilated state

You need to actively rule out these conditions in the right clinical context.

Read 8 tweets

Mourad H Senussi, MD, MS

@msenussiMD

Jul 7, 2020

https://twitter.com/msenussiMD/status/1278480975643709440

(1/24)*De-mystifying Hepatic waveforms*
Welcome to Part 2. Now that we have gone through the basics:(

https://twitter.com/msenussiMD/status/1278480975643709440

). Time for a deep dive where we can start to decipher the important clinical information we need to apply at the bedside #showmethewaveforms #shocksquad

(2/24)We must acquaint ourselves with the different guises that HV waveforms may appear, they can be
- biphasic and tetrainflectional
- tetraphasic and tetrainflectional
- Increased antegrade flow (S and D magnitude)
- Increased retrograde flow (A-reversal, SR, DR)
See⬇️

(3/24)The fun doesn't stop there! We all know how the atrium augments flow to the ventricle. With atrial relaxation (analogous to x-descent on JVP) that downward deflection helps increase forward flow during systole. With TV closure, you can see a notched S-wave (S1, S2).

Read 26 tweets

Mourad H Senussi, MD, MS

@msenussiMD

Jul 2, 2020

(1/ )There has been an overwhelming interest in the use of hepatic waveforms as a congestive parameter. With social media, somewhat obscure concepts like these are quickly brought to the forefront and implemented in clinical practice. Many are eager to incorporate #VEXUS but...

...a thorough understanding of these waveforms, hemodynamic correlates, and dynamic changes that occur in physiology and disease, is paramount to incorporating this into practice. #shocksquad #tweetorial #VEXUS #showmethewaveform. Here are rules of interpreting hepatic waveforms

(2/13)Rule 1: **Nomenclature, nomenclature, nomenclature! **
That’s right! For us to understand each other we must speak the same language. I have heard these waves being described in a multitude of ways which has brought about considerable confusion and miscommunication.