#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 🧵
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 👇
3/ Lets calculate stroke volume using LVOT VTI #POCUS
It looks supra-normal
4/ Another reading...also LVOT diameter in PLAX = 2.29 cm
With these numbers, LVOT area would be ~4.15 m2
Stroke volume = 115 ml
CO = ~13 L 😳taking heart rate as 110 bpm
5/ Tricuspid tissue Doppler
High S'/Tricuspid annular plane systolic velocity (TAPSV). In general, TAPSV less than 10 cm/sec is said to indicate low RV ejection fraction.
6/ Transmitral flow #POCUS
Peak E velocity ~1 m/s
E-A fusion seen due to tachycardia I assume.
7/ Mitral annular tissue Doppler #POCUS:
Lateral e' as high as 20 cm/s
With E-A fusion, is it still possible to say LA filling pressures are normal based on E/e'? experts?
8/ Also did RVOT VTI. Just to practice the technique. I understand minor errors in outflow tract diameter lead to significant discrepancy in volume estimation.
VTI ~18 cm, d = 3.1 cm; estimated CO = 14.9 L 😳
Irrespective of error, we can now definitely say its high output state.
9/ How about downstream? IVC #POCUS was difficult to visualize due to abdominal distension. On lateral approach, it appears to be small.
14/ Renal resistive index ~0.74
Difficult to comment if its elevated or not. If you take normal as <0.7, maybe elevated. Its a soft call! #POCUS
15/ Renal parenchymal vein #VExUS
Normal. Unlikely raised intra-abdominal pressure leading to small IVC
16/ Lungs show scattered B-lines with spared areas. Patient had COVID-19 last year. Could be residual changes.
OK, now questions for experts. In this patient with ⬆️serum creatinine, what would you do & what is the rationale?
17/ Albumin? (CO is already very high), octerotide/midodrine? (BP 118/64 at the time of scan) - what's the goal? or transfer to ICU & give Norepinephrine/Terlipressin?
Likely has a component of cholemic/bile case nephropathy (ATN) also based on urine microscopy.
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 pattern👆
If we are doing #VExUS, IVC must be big. Here is the M-mode #POCUS 👇
3/ Renal parenchymal vein #VExUS#POCUS
It also demonstrates D-only pattern 👇
#POCUS quiz of the day:
Easy one. Identify 1, 2 and 3.
POLL in thread 👇 #IMPOCUS#MedEd
👆#POCUS
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
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: pubs.rsna.org/doi/10.1148/rg… 3/ Anatomy (components) of a spectral Doppler waveform (carotid shown)👇
Above baseline is like red on color (towards probe), below = blue. As 0 degree angle is not always possible, <60 is considered OK.
@khaycock2@ArgaizR@katiewiskar@ThinkingCC
Any comments on this portal vein pulsatility obtained from a pt with cirrhosis? (Why prox is more pulsatile?)
No cardiac issue that I know of; was reviewing rad-performed images 🤔
Splenic seems to be fine, looks more like that of distal portal.
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 👇 #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. #POCUS#VExUS
3/ Forgot what is fanning?
Its also called tilting or some people say, "look" in a particular direction from the same spot. #POCUS
#Nephrology#POCUS case of the day:
What do you think is this anechoic structure adjacent to liver?
See thread 👇 for the answer and more images. #MedEd#IMPOCUS
Let's start with a poll before seeing other images: ☝️? #POCUS
The answer is right renal cyst. Note how the kidney appears with fanning the probe. #POCUS
Is rest of the kidney normal? doesn't appear to be...🤔