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<br /> Ultrasound<br /> Point-of-care echo<br /> in pulmonary embolism<br /> Philips tutorial<br /> Chris Moore, MD, RDMS, RDCS<br /> Department of Emergency Medicine<br /> Yale University School of Medicine<br /> Contents<br /> POC echo for the detection of pulmonary embolism<br /> 1 Introduction 3<br /> 2 Clinical case 4<br /> 3 PE and cardiac pathophysiology 5<br /> 4 Cardiac A and P review 8<br /> 5 Image orientation 9<br /> 6 Sonographic views and anatomy 18<br /> 7 Doppler for calculation of RVSP 32<br /> 8 Diagnosis of acute PE using<br /> POC echo 35<br /> 9 Clinical case resolution 58<br /> 10 Summary 61<br /> 11 References <a title="Philips_POC_Echo_PulmonaryEmbolismTutorial_FNL (Desktop) page 1" href="http://viewer.zmags.com/publication/3b8dd26d?page=1"> Ultrasound Point-of-care echo in pulmonary embol</a> <a title="Philips_POC_Echo_PulmonaryEmbolismTutorial_FNL (Desktop) page 2" href="http://viewer.zmags.com/publication/3b8dd26d?page=2"> Contents POC echo for the detection of pulmona</a> <a title="Philips_POC_Echo_PulmonaryEmbolismTutorial_FNL (Desktop) page 3" href="http://viewer.zmags.com/publication/3b8dd26d?page=3"> 1 Introduction Pulmonary embolism (PE) is</a> <a title="Philips_POC_Echo_PulmonaryEmbolismTutorial_FNL (Desktop) page 4" href="http://viewer.zmags.com/publication/3b8dd26d?page=4"> 2 Clinical case A 58-year-old woman with br</a> <a title="Philips_POC_Echo_PulmonaryEmbolismTutorial_FNL (Desktop) page 5" href="http://viewer.zmags.com/publication/3b8dd26d?page=5"> 3 PE and cardiac pathophysiology The vast m</a> <a title="Philips_POC_Echo_PulmonaryEmbolismTutorial_FNL (Desktop) page 6" href="http://viewer.zmags.com/publication/3b8dd26d?page=6"> In a patient with diagnosed PE, transthoracic ech</a> <a title="Philips_POC_Echo_PulmonaryEmbolismTutorial_FNL (Desktop) page 7" href="http://viewer.zmags.com/publication/3b8dd26d?page=7"> Table 1: Categorization of PE severity Small (“lo</a> <a title="Philips_POC_Echo_PulmonaryEmbolismTutorial_FNL (Desktop) page 8" href="http://viewer.zmags.com/publication/3b8dd26d?page=8"> 4 Cardiac A and P review The heart can be pi</a> <a title="Philips_POC_Echo_PulmonaryEmbolismTutorial_FNL (Desktop) page 9" href="http://viewer.zmags.com/publication/3b8dd26d?page=9"> 5 Image orientation A review of ultrasound </a> <a title="Philips_POC_Echo_PulmonaryEmbolismTutorial_FNL (Desktop) page 10" href="http://viewer.zmags.com/publication/3b8dd26d?page=10"> The “general” and “cardiology” orientations are i</a> <a title="Philips_POC_Echo_PulmonaryEmbolismTutorial_FNL (Desktop) page 11" href="http://viewer.zmags.com/publication/3b8dd26d?page=11"> A quick visual way to verify orientation is by pl</a> <a title="Philips_POC_Echo_PulmonaryEmbolismTutorial_FNL (Desktop) page 12" href="http://viewer.zmags.com/publication/3b8dd26d?page=12"> General convention Parasternal long-axis </a> <a title="Philips_POC_Echo_PulmonaryEmbolismTutorial_FNL (Desktop) page 13" href="http://viewer.zmags.com/publication/3b8dd26d?page=13"> Cardiology convention Parasternal long-axis </a> <a title="Philips_POC_Echo_PulmonaryEmbolismTutorial_FNL (Desktop) page 14" href="http://viewer.zmags.com/publication/3b8dd26d?page=14"> In order to minimize confusion about indicator-to</a> <a title="Philips_POC_Echo_PulmonaryEmbolismTutorial_FNL (Desktop) page 15" href="http://viewer.zmags.com/publication/3b8dd26d?page=15"> If a view that appears like the “cardiology” conv</a> <a title="Philips_POC_Echo_PulmonaryEmbolismTutorial_FNL (Desktop) page 16" href="http://viewer.zmags.com/publication/3b8dd26d?page=16"> NOTE OF CAUTION: If the right ventricle is enlarg</a> <a title="Philips_POC_Echo_PulmonaryEmbolismTutorial_FNL (Desktop) page 17" href="http://viewer.zmags.com/publication/3b8dd26d?page=17"> In summary, as long as the cardiac structures on </a> <a title="Philips_POC_Echo_PulmonaryEmbolismTutorial_FNL (Desktop) page 18" href="http://viewer.zmags.com/publication/3b8dd26d?page=18"> 6 Sonographic views and anatomy Equipment consi</a> <a title="Philips_POC_Echo_PulmonaryEmbolismTutorial_FNL (Desktop) page 19" href="http://viewer.zmags.com/publication/3b8dd26d?page=19"> Sonographic views and anatomy The typical point-o</a> <a title="Philips_POC_Echo_PulmonaryEmbolismTutorial_FNL (Desktop) page 20" href="http://viewer.zmags.com/publication/3b8dd26d?page=20"> Parasternal long-axis (PSLA) view The parasternal</a> <a title="Philips_POC_Echo_PulmonaryEmbolismTutorial_FNL (Desktop) page 21" href="http://viewer.zmags.com/publication/3b8dd26d?page=21"> [ Video 1] Video of the </a> <a title="Philips_POC_Echo_PulmonaryEmbolismTutorial_FNL (Desktop) page 22" href="http://viewer.zmags.com/publication/3b8dd26d?page=22"> The PSLA view includes the right ventricle anteri</a> <a title="Philips_POC_Echo_PulmonaryEmbolismTutorial_FNL (Desktop) page 23" href="http://viewer.zmags.com/publication/3b8dd26d?page=23"> [ Video 2a] This video d</a> <a title="Philips_POC_Echo_PulmonaryEmbolismTutorial_FNL (Desktop) page 24" href="http://viewer.zmags.com/publication/3b8dd26d?page=24"> [ Video 2b ] This video</a> <a title="Philips_POC_Echo_PulmonaryEmbolismTutorial_FNL (Desktop) page 25" href="http://viewer.zmags.com/publication/3b8dd26d?page=25"> Parasternal short-axis (PSSA) view The parasterna</a> <a title="Philips_POC_Echo_PulmonaryEmbolismTutorial_FNL (Desktop) page 26" href="http://viewer.zmags.com/publication/3b8dd26d?page=26"> Apical four-chamber (A4C) view The apical four-ch</a> <a title="Philips_POC_Echo_PulmonaryEmbolismTutorial_FNL (Desktop) page 27" href="http://viewer.zmags.com/publication/3b8dd26d?page=27"> When correctly obtained, the A4C view should incl</a> <a title="Philips_POC_Echo_PulmonaryEmbolismTutorial_FNL (Desktop) page 28" href="http://viewer.zmags.com/publication/3b8dd26d?page=28"> [Figure 6a] Apical four-chamber view. Right ventr</a> <a title="Philips_POC_Echo_PulmonaryEmbolismTutorial_FNL (Desktop) page 29" href="http://viewer.zmags.com/publication/3b8dd26d?page=29"> Subxiphoid (SX) view The subxiphoid (SX) view is </a> <a title="Philips_POC_Echo_PulmonaryEmbolismTutorial_FNL (Desktop) page 30" href="http://viewer.zmags.com/publication/3b8dd26d?page=30"> [Figure 7] Subxiphoid view. Right ventricle (RV),</a> <a title="Philips_POC_Echo_PulmonaryEmbolismTutorial_FNL (Desktop) page 31" href="http://viewer.zmags.com/publication/3b8dd26d?page=31"> The subxiphoid view may also help define RV geome</a> <a title="Philips_POC_Echo_PulmonaryEmbolismTutorial_FNL (Desktop) page 32" href="http://viewer.zmags.com/publication/3b8dd26d?page=32"> 7 Doppler for calculation of RVSP Doppler can </a> <a title="Philips_POC_Echo_PulmonaryEmbolismTutorial_FNL (Desktop) page 33" href="http://viewer.zmags.com/publication/3b8dd26d?page=33"> [Figure 8] CW Doppler demonstrating TR. Note the </a> <a title="Philips_POC_Echo_PulmonaryEmbolismTutorial_FNL (Desktop) page 34" href="http://viewer.zmags.com/publication/3b8dd26d?page=34"> Several cardiac cycles should be measured to ensu</a> <a title="Philips_POC_Echo_PulmonaryEmbolismTutorial_FNL (Desktop) page 35" href="http://viewer.zmags.com/publication/3b8dd26d?page=35"> 8 Diagnosis of acute PE using POC echo S</a> <a title="Philips_POC_Echo_PulmonaryEmbolismTutorial_FNL (Desktop) page 36" href="http://viewer.zmags.com/publication/3b8dd26d?page=36"> As discussed previously, not all PEs are large en</a> <a title="Philips_POC_Echo_PulmonaryEmbolismTutorial_FNL (Desktop) page 37" href="http://viewer.zmags.com/publication/3b8dd26d?page=37"> Acute PE RV LV cavity cavity </a> <a title="Philips_POC_Echo_PulmonaryEmbolismTutorial_FNL (Desktop) page 38" href="http://viewer.zmags.com/publication/3b8dd26d?page=38"> [ Video 3 ] Video demo</a> <a title="Philips_POC_Echo_PulmonaryEmbolismTutorial_FNL (Desktop) page 39" href="http://viewer.zmags.com/publication/3b8dd26d?page=39"> The normal ratio of the maximal diameter of the R</a> <a title="Philips_POC_Echo_PulmonaryEmbolismTutorial_FNL (Desktop) page 40" href="http://viewer.zmags.com/publication/3b8dd26d?page=40"> McConnell’s sign While RV hypokinesis may be glob</a> <a title="Philips_POC_Echo_PulmonaryEmbolismTutorial_FNL (Desktop) page 41" href="http://viewer.zmags.com/publication/3b8dd26d?page=41"> [ Video 4 ] Video demo</a> <a title="Philips_POC_Echo_PulmonaryEmbolismTutorial_FNL (Desktop) page 42" href="http://viewer.zmags.com/publication/3b8dd26d?page=42"> Paradoxical septal motion and D-shaped septum RV </a> <a title="Philips_POC_Echo_PulmonaryEmbolismTutorial_FNL (Desktop) page 43" href="http://viewer.zmags.com/publication/3b8dd26d?page=43"> [ Video 5 ] Two examples</a> <a title="Philips_POC_Echo_PulmonaryEmbolismTutorial_FNL (Desktop) page 44" href="http://viewer.zmags.com/publication/3b8dd26d?page=44"> Tricuspid regurgitation Elevations in RV pressure</a> <a title="Philips_POC_Echo_PulmonaryEmbolismTutorial_FNL (Desktop) page 45" href="http://viewer.zmags.com/publication/3b8dd26d?page=45"> [ Video 6 ] Four examp</a> <a title="Philips_POC_Echo_PulmonaryEmbolismTutorial_FNL (Desktop) page 46" href="http://viewer.zmags.com/publication/3b8dd26d?page=46"> [ Video 7 ] Video demo</a> <a title="Philips_POC_Echo_PulmonaryEmbolismTutorial_FNL (Desktop) page 47" href="http://viewer.zmags.com/publication/3b8dd26d?page=47"> In order to quantitatively estimate RV systolic p</a> <a title="Philips_POC_Echo_PulmonaryEmbolismTutorial_FNL (Desktop) page 48" href="http://viewer.zmags.com/publication/3b8dd26d?page=48"> Elevated RV systolic pressure The ultrasound syst</a> <a title="Philips_POC_Echo_PulmonaryEmbolismTutorial_FNL (Desktop) page 49" href="http://viewer.zmags.com/publication/3b8dd26d?page=49"> [ Video 8 ] Video of c</a> <a title="Philips_POC_Echo_PulmonaryEmbolismTutorial_FNL (Desktop) page 50" href="http://viewer.zmags.com/publication/3b8dd26d?page=50"> Chronic RV strain As mentioned before, RV strain </a> <a title="Philips_POC_Echo_PulmonaryEmbolismTutorial_FNL (Desktop) page 51" href="http://viewer.zmags.com/publication/3b8dd26d?page=51"> [ Video 9a ] A4C view </a> <a title="Philips_POC_Echo_PulmonaryEmbolismTutorial_FNL (Desktop) page 52" href="http://viewer.zmags.com/publication/3b8dd26d?page=52"> [ Video 9b ] Subxiphoi</a> <a title="Philips_POC_Echo_PulmonaryEmbolismTutorial_FNL (Desktop) page 53" href="http://viewer.zmags.com/publication/3b8dd26d?page=53"> TAPSE Another way to determine the degree of righ</a> <a title="Philips_POC_Echo_PulmonaryEmbolismTutorial_FNL (Desktop) page 54" href="http://viewer.zmags.com/publication/3b8dd26d?page=54"> [Figure 11a] Mode tracing demonstrating a normal </a> <a title="Philips_POC_Echo_PulmonaryEmbolismTutorial_FNL (Desktop) page 55" href="http://viewer.zmags.com/publication/3b8dd26d?page=55"> [ Video 10 ] This vide</a> <a title="Philips_POC_Echo_PulmonaryEmbolismTutorial_FNL (Desktop) page 56" href="http://viewer.zmags.com/publication/3b8dd26d?page=56"> Direct visualization of thrombus and ancillary DV</a> <a title="Philips_POC_Echo_PulmonaryEmbolismTutorial_FNL (Desktop) page 57" href="http://viewer.zmags.com/publication/3b8dd26d?page=57"> [ Video 11 ] This vide</a> <a title="Philips_POC_Echo_PulmonaryEmbolismTutorial_FNL (Desktop) page 58" href="http://viewer.zmags.com/publication/3b8dd26d?page=58"> 9 Clinical case resolution In the clinical c</a> <a title="Philips_POC_Echo_PulmonaryEmbolismTutorial_FNL (Desktop) page 59" href="http://viewer.zmags.com/publication/3b8dd26d?page=59"> [ Video 12 ] This some</a> <a title="Philips_POC_Echo_PulmonaryEmbolismTutorial_FNL (Desktop) page 60" href="http://viewer.zmags.com/publication/3b8dd26d?page=60"> [ Video 13 ] Approxima</a> <a title="Philips_POC_Echo_PulmonaryEmbolismTutorial_FNL (Desktop) page 61" href="http://viewer.zmags.com/publication/3b8dd26d?page=61"> 10 Summary Integration of bedside ultrasound i</a> <a title="Philips_POC_Echo_PulmonaryEmbolismTutorial_FNL (Desktop) page 62" href="http://viewer.zmags.com/publication/3b8dd26d?page=62"> In patients with PE that are stable, RV strain ma</a> <a title="Philips_POC_Echo_PulmonaryEmbolismTutorial_FNL (Desktop) page 63" href="http://viewer.zmags.com/publication/3b8dd26d?page=63"> Whichever therapy is chosen, the presence of RV s</a> <a title="Philips_POC_Echo_PulmonaryEmbolismTutorial_FNL (Desktop) page 64" href="http://viewer.zmags.com/publication/3b8dd26d?page=64"> 11 References 1. Tapson VF. Acute pulmon</a> <a title="Philips_POC_Echo_PulmonaryEmbolismTutorial_FNL (Desktop) page 65" href="http://viewer.zmags.com/publication/3b8dd26d?page=65"> Additional resources For additional resources</a> <a title="Philips_POC_Echo_PulmonaryEmbolismTutorial_FNL (Desktop) page 66" href="http://viewer.zmags.com/publication/3b8dd26d?page=66"> This paper reflects the opinion of the author, no</a>