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Mourad H Senussi, MD, MS Profile picture
@msenussiMD
Mar 31, 2018 • 9 tweets • 5 min read • Read on X
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Tips & tricks for axillary/subclavian central line
1. Start at midclavicular line -> the deltopectoral groove.
2. Collapsible, thin-walled
3. Continuous Doppler flow!
4. Presence of valves denotes a venous structure
5. BONUS inject fluid via ipsilateral peripheral IV!
Longitudinal view note the alignment of the rib underneath to utilize the PART method
Continuous flow upon Doppler interrogation
Pulsatile flow when tilting cephalad. Big no no
Bonus: try flushing an ipsilateral peripheral IV to confirm
@iceman_ex @MasriAhmadMD @ThinkingCC @UTS_Australia @PulmCrit @ultrasoundpod @UltrasoundJelly @AIUMultrasound @EM_RESUS
@msiuba @jameshorowitzmd @CritCareReviews @precordialthump #FOAMed #pocus #FOAMcc
Simple and safe using the rib for protection. Confirmed with echo... But here's the CXR ;) Image
Extra Bonus: By using color Doppler you can augment flow by squeezing the bicep to also confirm you are looking at the vein. With a combination of any of the above mentioned texhniques... This should be a cinch.

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More from @msenussiMD

Mourad H Senussi, MD, MS Profile picture
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 Profile picture
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 Profile picture
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 Profile picture
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 Profile picture
Sep 22, 2020
(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. Transverse ultrasonographic appearance of the trachea. The t
Read 17 tweets
Mourad H Senussi, MD, MS Profile picture
Jul 7, 2020
(1/24)*De-mystifying Hepatic waveforms*
Welcome to Part 2. Now that we have gone through the basics:(). 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

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