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

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

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More from @Wilkinsonjonny

3 Apr
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!
Read 23 tweets
30 Mar
1/13

Today’s Tweetorial for you!

We look at basic cardiac #POCUS views👍 🫀

First; the Parasternal Long Axis (PLAX)

#FOAMed #FOAMcc #echofirst

Probe position shown with marker to right shoulder, left Parasternal edge; roughly at intercostal spaces 2-3/3-4🤷‍♂️
2/13

What should you see on ultrasound, and the associated sono anatomy🤔

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🤛👍
Read 16 tweets
29 Mar
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.
Read 7 tweets
25 Mar
So; there are often debates regarding ultrasound probe manoeuvres 🤷‍♂️

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 btw😉

#FOAMed #POCUS #FOAMcc #echofirst 1/7
2/7

SWEEPING

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 ‘window shop’, for structures we can’t see at first. When they snap into view, we can fine-tune movements 👍 Also allows view of larger organs.
3/7

ROCKING

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 ‘swing’ it into view, so it appears more square on the screen. Makes parallel measurements more accurate and things less off-axis🤷‍♂️
Read 9 tweets

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