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Hello, everyone. Thank you for joining us today for this event in the Radiology series. It will be the second part of the ultrasound series and I'm very pleased to have doctor er here to do this seminar and have this lecture. Thank you doctor for joining us so much today and I'll let you have the stage. Thank you and uh thank you for prepo it to a Friday uh Friday night, Friday evening to get this done. Uh Let me share my screen, right? So I welcome all of you to the second part of the ultrasound series. As I tell uh with every session, it is the aim of this whole series is to basically introduce you to this all of these various radiology uh imaging modalities. And I hope by the end of this session, you will have that familiarity towards ultrasound. When you start your clinical practice, you whenever you come across this machine, you will have the curiosity to go and play with the different knobs and maybe uh use it on patients and and use it uh to be a part of your clinical practice because these days ultrasound is rapidly becoming part of uh the clinical practitioner's life and it's not just a radiologist tool. And that is why it's called point of care ultrasound. Specifically, I will be looking at emergency medicine, application of ultrasound scanning because I feel like when you start your medical practice uh internships and such, I feel uh that is where you'll have the biggest application of ultrasound. And then of course, later on, you can choose uh if you want to work more with ultrasound. Uh But let's start with the basics. Uh I hope you do remember a bit about the physics, the, the principle of ultrasound scanning. Uh we will come across a lot of those things again in this session. And uh where necessary. I, I'm happy to explain them again. Uh This is for everybody, some of you might know a lot of uh uh ultrasound, some may not. So I want everybody to be uh equally benefiting from the series. So specifically, I want to look at fast and e fast the rush protocol and just briefly look at ultrasound guided IV axis. I understand that this is not a practical class and there are, there are a lot of limitations for us to explain things, but uh I'll try my best. So starting with fast uh in trauma setting is where we use fast. And what does fast stand for? Uh F stands for focused A stands for assessment using sonography in trauma. So uh when they first started utilizing ultrasound in trauma patients. They used to use four views which was mainly uh you can see two and three are the abdomen, uh right, upper quadrant and left, upper quadrant views. With four being the pelvic or suprapubic view and one being the subcostal or subs view of the heart. But as we started using more and more of ultrasound, nowadays, we follow something called as EFA, which is extended fast where we started looking at the apex of the lungs bilaterally as well. So it became EFA where this abuse started to get in as well. So let's first start uh the abdomen part and let's start looking at the right upper quadrant. Can any of you tell me what probe we will be using when looking at abdominal structures? If you remember from the last class, if not, that's also fine. If you can, that will be good anybody. Uh if you can, if somebody can just voice it out because I can't see the child. If not, we'll just go ahead. So we use the curvilinear low frequency probe for abdomen. The reason being low frequency means lesser dissemination, it goes further into it. And curvilinear probe gives you a fan out view which helps us to visualize the structures inside. So whenever you're doing abdomen, you you're gonna be using a curvilinear probe. Now I'm gonna use a stack of tissues as a probe. Uh Just to explain some parts. Uh Imagine if this part is what you will be facing the tissue or the body part. And imagine if this black line is the the uh probe marker. Now, probe markers are usually on the side you can see here, it is usually raised and it's usually you can feel it with your finger. You don't have to look to find where the probe marker is. It's very important, you know where the pro pro marker is facing. Because the image on the system monitor is going to show you uh a sign to show where the probe marker is. And that is what you you're going to be using to understand or uh look at pathologies and understand where each of things are. So in this case, with right upper quadrant, you are going to be placing the probe at the right side slightly anterior to the midaxillary or at the midaxillary line with the probe marker that is uh facing towards the head end and you will be at the 10th 10th intercostal space uh roughly. And what you will be seeing is just imagine every time you're using the ultrasound, imagine you are shining a torch inside the body. So you know that the torch light goes in as uh fanned out beams, isn't it just like that? Imagine the ultrasound is going and found out? And you can see if this is a torch and the light going in what you will be seeing is, and this is the head end, this is the pelvic and you can see the most prominent structure will be the brown, that is the liver here, the diaphragm lungs on top and bottom, we can see kidney. So how will the image look on the monitor? This will be where the probe is, this is the head end and this is the pelvic end. You can see the liver, you can see the diaphragm, you can see the lungs, you can see the kidney. Now in trauma setting, the most important part for us is the space between the liver and the kidney, which is the morrisons pouch. I mean this hepato renal recess is where the fluid is gonna be. Uh we are going to be looking for fluid in that particular recess where it's going to be the dependent area where fluid is going to come and accumulate. We can also see the right costophrenic uh pleural recess, which should be uh here, which can also show us the pleural effusion as well. So keep in mind that this this view will help us to see not just peritoneal fluid collection, but also pleural fluid collection as well. Now looking at this particular uh image, this is how uh an image of a normal right upper quad is gonna look like. What you see here is where the probe is going to be here is where the head end is here is where the pelvic end is. You can see the liver here. I don't know if you can remember. We talked about the mirror image artifact. You can see a bit of something looks very similar to liver on this side. So this is the diaphragm. This is the right pleural reces because of the air. You're seeing this mirror image artifact with diaphragm in between. You can see the kidneys here and you can see the space in between. This is the morrisons pouch. These are both perinephric fat. You remember the sound gets scattered within the tissues. And that typical feature for all tissue or that typical scatter for all tissues is gonna give you that appearance that helps us to identify each organ looking at this particular uh ultrasound. This is an abnormal ultrasound whereby you can see this black shadow, which was not here in between the the liver and the kidney and that is the fluid in the Morris spot. So if you look, this will be how an ultrasound is. If you can see and appreciate, you can see the liver, you can see the kidney and you can see the black fluid that is here and here. So this is the free fluid in the Morrison sponge. Now another one where this is the left lobe of liver and you can see the perihepatic fluid collection. So this is how free fluid is gonna be seen in right upper quadrant imaging. Next, let's look at the left upper quadrant similar to the right upper quadrant. Again, we are gonna be placing the probe with the marker towards the head end and this way of holding the probe like a pen with the knuckles on the bed. So it's called a knuckle on bed approach. That means that the probe is gonna be in the posterior axillary line. And the other one, it was mid axillary or slightly anterior to the midaxillary. This one is the posterior axillary line. And what will be seeing? What will you be seeing if you are shining a light inside? You can see the diaphragm and you can see the spleen above you'll see the lung and then you can see the kidney, the perisplenic space in this left upper quad in view will be looking to find fluid in the perisplenic space. Ok. Again, you can see the left side pleural rhesus is visible as well. So you can see pleural fluid in this view as well. Keep that in mind. Now, looking at a normal scan, what you will see is the spleen. You can see the kidney and this is the splenorenal space. And this will be where the perisplenic space is in this particular image. It's not a good quality. But you can see if you can look closely, you can appreciate the fluid in the in the spinor renal space and a little bit in the perisplenic space. So this is the left upper quadrant scan where you can see the spleen and then the anechoic fluid all across. Uh if you, if you remember whenever sound goes through a fluid medium, it passes through much better and thereby whatever is below the fluid is gonna be appearing more brighter, the gain is gonna be more. And you can appreciate that a bit here as well. Even here, if you can see just below the fluid that becomes a slightly brighter when compared to the rest of the field. And that is because of the fluid presence over there. OK. So these are the things I'm just trying to correlate with the things that we learned from the last session in this this practical application of the basic principles. OK. Now, next is the pelvic view. Now pelvic view, we have, we can do it in two planes. One is the longitudinal plane and the other is the transverse plane, you can see longitudinal plane and transverse plane. So how do we do it? So what you're seeing on the image here is a longitudinal plane where you have the probe placed above the pubic symphysis in the midline with the probe marker facing towards the head. And you can see that the operator has slightly tilted the probe in such a way that he is shining the torch into the pelvis. OK. Imagine it's like a torch and you're shining the torch into the pelvis. So this is a longitudinal view and what structures you see will obviously depend upon the gender as well. So males and females is going to be different. So in males, what will you see when you have the probe marker here and then shining the light inside or the sound inside just beneath the pic bone, you will see the bladder and then you can have the prostate here. You will have the seminal vesicle here and the rectum. So in males, you have to understand that the dependent portion where the fluid is going to accumulate. If there is free fluid is going to be in this recto vesicle pouch. Ok. But what about females in females? So if you are keeping the probe here, the sh the sound is coming like this, it will first in uh first come and fall on the bladder and then we have the uterus, the rectum and in between these two, we have the pouch of Douglas of the rectal uterine pouch. Now this if you look at an ultrasound image. So this is a male pelvic ultrasound in the longitudinal view. If you can see this is the bladder, this is the prostate. This will be the rectum and here will be the recto a cycle pouch. Now, this is a normal ultrasound in case of females, this will be the bladder. This will be the uterus here, the rectum beneath and in between will be the pouch of Douglas. Again, this is a normal scan. Now, what is the other view? This transverse view? How do you get your transverse view? So you started with this way where you have the probe marker facing towards the head and on the uh midline above the pic simes facing into the uh pelvis. Now what you will be doing is you will turn it counter clockwise 90 degrees. So in this case, this will now point towards the right side. So you can see here it's pointing towards the right side midline with uh the probe slightly tilted in such a way that it is shining inside the pelvis. So what will you be seeing the anatomy now will be now imagine if you are seeing here and it will be like cutting across. So you you are kind of visualizing from this end. So you'll start seeing three holes instead. So this will be the transverse view and pelvic. So this is males, bladder prostate and then rectum in females, it will be bladder uterus rectum. This will be the pouch of Douglas. So if you're seeing fluid, in this case, this is the transverse and longitudinal view, abnormal pelvic scans where you can see the bladder uterus and then free fluid here, you can see free fluid accumulating. In this case, this is a female, this is a uterus and beneath, you can see the free fluid. So if you can appreciate in this scan, again, you can see the fluid is very obvious here and you can see the uterus. So they are fanning the the probe to see from right to left. So next option. So we have finished the abdomen. We have looked at the right, right upper quadrant to look at the morrisons pouch, the left upper quadrant, specifically looking at the perisplenic space, the pelvic in females specifically the Douglas pouch and in males, we are looking at the recto vesicle pouch. Now coming to the echo part, I'm gonna briefly look at the whole echo in this session, not just the fast scan, so we can finish it all off in one go. So uh so focus assessment uh of cardiology uh is called as focus. So focus cardiac ultrasound is utilizing ultrasound at point of care to look at the heart. It can be done by a nephrologist, an emergency doctor, a cardiologist, whatever. So we have, we have a separate probe that we use for cardiac. If anybody remembers from the last class, it's called as a phased array probe. Why do we use a phased array probe? Because we had problems using the curvilinear one or the linear one. What were the problems? One of which was there are bones, a lot of bones, the heart is situated beneath the rib cage that means that bone is not going to pass the sound through. We need the footprint to be smaller so it can be fit between the rib spaces. So we have a smaller footprint. Second thing when you reduce the footprint too much, the view, the view that you have is very less. So you need a fanning out kind of uh transmission of sound inside. How do we get that done with a very small footprint of a probe? So we used phased array where each of the crystal is being activated in different time zones. So it ends up sending out uh signals in a phased manner. So, and you end up getting this fan like projection outwards. So you bypass the problem of lung air as well. So that way you're getting a good view of the heart. So that's why we use the face ra probe. Keep that in mind. Now we have four views when we are looking at echo. But before going there, I need to highlight something that is very important. When when coming to probe markers in face array probe, we told that the probe marker is important because it helps us to look at the image and have that orientation as to which is where, which is the head and which is the posterior end, which is anterior and all those things. So in cardiac setting, so when you're using the face probe, you're gonna be shifting to the cardiac setting. Remember in cardiac setting, the marker is going to be on the right side. So when you look at the previous ones, you can see the marker on abdominal scan was on the left hand side. But in this case, it is on the right hand side. So keep that in mind that in cardiac setting, it's going to be on the other part. Now, what are the four views we have parasternal long axis, short axis, apical four chamber view and the Subxiphoid view. Let's look at each of them carefully. I know that when it's, when you see like this, it might seem complicated, but it does not just imagine that you're gonna be shining a light inside the chest to look at the heart. OK. So it all depends on how we are holding the probe, how the light is falling on and where the light is falling on. That's it. So let's start with parasternal long axis. What does it mean? So this green aspect is how you're going to be holding the probe. So it's kind of like like this you're holding in. So this is the sternum. So it is next to the sternum. So it is parasternal where you're gonna be keeping it left to the sternum at about third or fourth intercostal space. And you're going to be having the probe marker facing towards the right shoulder. Ok. So this is the long axis of the body, this is the long axis of the heart. You can see that the long axis of the heart is kind of tilting towards the right shoulder. And when you keep the probe here, we are trying to shine the light along the long axis of the heart that is the aim. So you can see the probe here shining the sound inside and you can see that it is falling on the long axis of the heart. And these are the structures that we will be seeing. So you can see again, this is the probe marker facing the right shoulder, the heart is inside the chest cavity like this. And this part is what you will be seeing you can see on the body. So this is the long axis of the heart and that is where you're shining the light and the probe marker. Sorry, the probe is kept at between the either third or fourth intercostal space with the marker facing to the right shoulder. Keep those things in mind. So what will you be seeing? I mean, remember the indicators on the right side and these are the structures that you will see. You'll see the left atrium, you'll see the mitral valve, the left ventricle, the right ventricle outflow tract, the aorta, the aortic valve and the descending aorta. So this is how the scan itself will look like. You can see the right ventricle or tract, the aorta and the left reum, all of this should be on the right side and kind of similar in size. If you can appreciate that aortic valve, mitral valve, you can see the left ventricle, the interven septum on the left ventricle wall. And this is how the light is shining or the sound is falling on the on the heart can appreciate these two structures. So you need to get develop that ability to create the image in your head. To understand how your probe is kept how the the sound is falling on the structures and what you are seeing so that you can imagine that in your head and try to pick up the pathologies. So this is how uh paranal long axis view is going to be, You can see the right ventricle outflow tract aorta, a bit of uh aortic valve. We can appreciate that the left atrium, left ventricle descending aorta. This is the left ventricle wall interventric septum. So what are the abnormalities that you can pick up in paranal long axis view? First and foremost, most important thing will be the pericardial effusion in case of trauma. So, pericardial effusion you can look at to see beneath the left ventricular wall as well as above the right ventricle outflow tract. These are the two spaces where we're looking for to see fluid in paras and a long axis to you. Now, what else can you see? You can also appreciate left ventricle function. So you can measure the left ventricle function by looking at how mo uh if the if the mo the function, the motility of the left ventricle wall is ok. If there is uh if the functioning of the mitral valve is ok or not. So if you can look at this image, what you can appreciate is the pericardial fluid that is seen above and below. That is above the right vicar out for tract and below the left ventricle um base. So this is the scan again, you can see the fluid there here and we can see again another anechoic black shadow here. This is also fluid. What you need to understand is it is below a posterior to the descending aorta. So in this case, it is beneath the diaphragm and it's a pleural fluid that you are seeing. So above the descending aorta, it will be pericardial effusion below will be pleural effusion. Ok. And uh coming to left ventricular function. So if you can appreciate if you can just take a look at the left ventricle uh wall, the mitral valve leaflet, how the leaflet is touching the left ventricle wall in the interven septum, sorry. Uh And on this side, and if you look at this image, you can see that the wall thickness has gone up compared to this. One wall thickness has gone up, the the activity has gone down. And if you look at the mitral valve, it is not completely opening. So it is not touching. If you remember from last class, we talked about this and we did an M mode through here looking at the mitral valve in a normal heart. And this was what we saw. You can see the mitral valve actually touching the interventricular septum of the left ventricular wall on this side. So here it is not completely opening. So if in here, we could have taken an M mode, we could have seen that it's not completely touching the interventricular septum. So this is another application of the parasternal long axis view. I also want to show you the parasternal short axis view. So again, the name says parasternal, so it's the same site. What you end up doing is we had the probe marker which was facing towards the right shoulder, we turn it 90 degrees to have the probe marker focused towards the left shoulder. And this is the heart. This is the probe, you can see the probe marker facing towards the left shoulder and this section is what we will be seeing this section. So let's see. So if this is the probe and this is the section that we are looking at, this is how the image is gonna appear, which will let you see the right ventricle, the left ventricle and the papillary muscles. So this level of parasternal short axis is called a mid papillary level parasternal short axis view. Now, we can use parasternal short axis to see three more sections. And what you will be doing is you're gonna move this towards the sternum or towards the mitral valve. So what do you mean by towards the sternum? You know, this is held like this, this is where the sternum is going to be. So you're moving it slightly this way towards the sternum and you end up on the mitral valve where you'll be seeing the right ventricle, the left ventricle and the mitral valve by cuspid valve inside and it looks like a fish. And when inside the, when you see in the echo, you can see the fish opening and closing its mouth. So it's called as a fish mouth view. If you tilt the probe with the tail end coming towards the base a bit, you end up looking at the aortic valve and aortic valve will appear like the Mercedes Benz logo. OK. So that is a Mercedes Benz view or the aortic valve level. Let's look at each. So this is the mid papillary level. You can see the right ventricle, the left ventricle and the papillary muscles. Now, this is the parasternal short axis view, mid papillary level. Now, when you go slightly towards the sternum or the mitral valve, you end up seeing, seeing the mitral valve like this is the mitral valve by if you can appreciate like a fish opening its and closing its mouth. That is why this is a fish mouth view. If you tilt it slightly, you end up seeing the aortic valve and you can see the Mercedes Benz logo over there. Ok. Now, uh pas next is the epical four chamber view. Now, how do we see the epical four chamber view you place at the apex, apex beat or the point of maximal impulse and then you have the probe marker still facing towards the left shoulder, but you're gonna keep the probe itself facing along the long axis of the heart. OK. So this is where the the probe is going to be. And this is how we will see the image where we can see all four chambers, the right and left ventricle, right and left atria and the two valves, the tricuspid and mitral valve in between the atrium and the ventricle. So this is how the image is going to be if you can appreciate. This is where the probe is going to be the probe marker. You can see there the left ventricle, right ventricle, interventricular septum, the two valves, right and left atrium and the inter atrial septum. So this is how the image is gonna appear in this in the monitor when you look through for the epical four chamber view. OK. So you can see the four chambers, the tricuspid mitral valves. Now coming to the Subxyphoid or subcostal view. Subxiphoid means you're gonna be placing underneath the cypho, we have the probe marker facing towards the the left side, not left shoulder, left side, but the probe is going to be slightly pointing towards the left. But what's important is because the heart is quite superficial when uh we we have to keep the probe almost flat to the surface. That's most important. You, you can see how the uh person is holding the probe, it's, it's held like this quite flat to the surface of the skin. And we have the gastric shadow here. So we'll be using the left lobe of liver as an acoustic window to get this sound inside. And what will be seeing you again, see all four chambers, you can see all four chambers and the two tricuspid and mitral valves. Uh just the, the, the orientation at which you're looking at this were different in apical. You'll be looking from here in uh sub, you'll be looking from this side. You can appreciate the right ventricle, right atrium, left ventricle, left atrium, the tricuspid and mitral valves and the left lobe of liver through which you are looking. So you can see the left lobe of liver, the right ventricle, right atrium, left atrium, left ventricle in fast scans, we usually perform either the subxiphoid or the parasternal, either of which is uh preferred for fast scan in uh and you know that fast scan is a trauma setting. So we are specifically looking for fluid pericardial fluid and that you can see like this in subs view, you can see that the there's fluid underneath the pericardium and the heart can be visualized in the subs view. So another thing that is important is IVC, uh how do we look at IVC? So what we do is we have a probe marker that is facing towards the foot. You can see the probe marker is facing towards the foot. And you are kind of looking at the liver specifically trying to find out the, the IOTA in sorry, the uh the uh in the IVC inside the liver, once you get the IVC, you turn it with the probe marker coming towards the right side and you get this view where you get the long axis view of the inferior vena cava and the right atrium. So this is how you initially see. And then you turn it, you end up seeing the long axis view. Can you see is initially short axis and then it's turned to form the long axis. So initially, if this is a probe, it goes like this, then it's turned to get the long axis and you can see uh the right atrium on here as well. So looking at inside the liver to find the the biggest vessel in the lower most part is going to be there, you see, OK, you can see why do we look at it? We look at it to see if we can look at the collapsibility of the inferior vena. Basically looking at if the patient is uh responsive to fluids, the hypotension or if there is low BP, if you can give fluids and get the BP up. So if it is more than 50% collapsible, that means that we can give fluids for this patient. Ok. So this is the collapsibility of the inferior vena cava with respiration. Another thing that we use uh the echo for is to see if there is uh clot. So this is called a clot in transit where this, if you see something like this, this is uh imprinting pulmonary embolism because this is going to go into the lungs. So that is another thing that you can see in uh echo. So with that, I think we can wind up echo in fast and echo in general. The next and the last thing in fast is the lung view. So lung views, you can see where they have kept. Again, the probe marker is towards the head. They have placed it on the second intercostal space in the midclavicular line with the hands if possible kept like this, which will help you to expand the intercostal spaces and get a better visualization inside. And you first thing is when you have this view, we are looking for something called as a back wing sign. Basically, if you have the two ribs on both sides, and then if you are sending the sound between these two rib spaces, the ribs are going to appear as black because they are not going to be sending the sound through. And you can see uh the portion of lungs in between. So and then the soft tissues above the ribs. So this is what you will be ending up seeing. So it's like uh this is the batwing sign that they are explaining and this is the pleura, the ribs and pleura is a very bright white line here and these are the rib shadows. So this is a pathway sign. So this helps you to understand that you're looking in between the ribs and you're seeing some part of the lungs there. Next thing, what you will be looking for is the A line. Now, I already described the a line last time, it is basically a reverberation artifact. What does it mean? So you have the probe here and then it is hitting the uh pleura coming back, some of it will uh bounce to, to and fro in between or like bounce around in this space and then go back to the probe. So the probe will think that there is an equidistant line, be below the plural line and it will show tho those lines there. So most important thing is a line is horizontal line, equidistant from each other. And this is a reverberation artifact and it is a normal finding that you see in the lungs. So first thing back to wing sign, you can see the a line. 3rd, 3rd thing that you need to be looking at is lung sliding, lung, sliding basically is the pleura has two layers, the visceral and parietal pleura. The vessel pleura will be moving along the parietal pleura. And this movement is appreciated with each respiration on the ultrasound. So you can see ants like uh like ants line uh walking in a, on a line, you can see the structure moving up and down. This is a plural line walking on, going up and down. Uh which shows that the vessel pleura is adjacent to the parietal pleura. And it's a normal finding that we see or uh expect in a lung ultrasound. So another way of looking at this lung sliding is you can use the motion mode im mode that we described earlier. And you can, you can look at it at that same spot where you saw the lung sliding. And what you can see is this characteristic appearance of structures like lines like this and then dots below. So if you have this artistic thinking, you can, you can think that this is like a beach, sandy appearance of the beach and this could be the ocean. This is called as sir see show sign. So again another normal sign. So it will be back wing a lines we are looking for the lung sliding and in M mode, we can see the, see show sign. Now, if there is pneumothorax or if the lung sliding is absent, we have to think about pneumothorax in a trauma setting. But if lung sliding is absent, what does it mean? It means that uh the visceral pleura is not running along with the pleura, the parietal pleura. So it could be because of a lung collapse as a result of a pneumothorax. It could also be because of a severe consolidation. It could be also be other things like inflammation, infection. A lot of causes absent lung sliding should not mean that it's there is pneumothorax, but that is a pathological finding that. So, lung sliding is a normal finding. If you don't see absent l sliding, there is something wrong. So now we need to differentiate if there is a pneumothorax or not, if you can find that point where there is lung sliding and then there is no lung sliding. It is called as the lung point. This transition point between the normal lung sliding and no lung sliding. This will be the point where there is lung collapse and then normal lung. So that is a sign of pneumothorax. So if you can appreciate here, this one is moving here. But this area, if you look, this is not moving, this is called as a lung point. Lung point can point to a pneumothorax. It's almost specific for a pneumothorax. Now, another thing that you can do is if you see like absent lung sliding, you can use an M mode there. Earlier, we described something called as a seo sign. This was a se show sign. You can see the, you can see the, the sand like appearance of the beach and the ocean. But if you look at here, we have lost that sound like appearance. It's just uniform horizontal lines that you see almost like a bar code. This is called as a bar code sign where there is absent lung sliding. Again, if you can find that point where there is seo appearance and barcode sign adjacent to each other, you can confirm uh that there is it could be pneumothorax. There another pathological feature I will stop you just for a second. I see there is a question in the chat from. So how can global and strain be training? Echoing of severe aortic stenosis patient predict subclinical cardiac contractile dysfunction and guide when left ventricular ejection fraction is over 50 or 60%. Kind of a long question. Yeah, see. OK. First of all, uh I want to say that this seems to be very much into echo. Uh I don't think this is within the preview of this particular session. Uh uh What I can do for you is if you want, I can have a private uh uh email chat with you. Will that be better? Because if I if you go into echo in such detail, we'll never finish. We are looking specifically for fast scanning and maybe a bit of rush protocol. Uh In this case, you're talking about severe aortic stenosis patient, but we are talking about mostly trauma patient. I hope you understand where I'm coming from, but I I'm happy to have a chat with you afterwards. Is that OK? Uh Miss Doctor Addy, I don't see a reply. We did. Thank you. Yes, we will have a chat after this. OK. Well, I'll, uh if you can, uh I'll, I'll put my email at the end so you can email me and then we'll have a chat because this, you, you're talking about echo and chronic cardiac patients, which I don't think is what we are discussing about today. OK. Right. So coming to B LINES, uh so B lines, again, this is another pathological feature that you can see in lung, ultrasound. What you see is imagine if there is fluid like in the interstitial spaces, you're going to be seeing a vertical line. So what's the difference between a line and B line? Alines were horizontal lines? If you can remember, let me just pull that up. So this is airlines, you can see that airlines are horizontal lines that you see as a result of reverberation art effect. But if you look at B line, what you see is this this light like projection that is going underneath like a, like a, like a ray of light like a vertical ray of light that you see and that is connected to a pleura. And you can see there is still that lung sliding and this light is kind of moving with that lung sliding. And this is called as A B line is usually seen in interstitial edema like uh like pulmonary edema, for example. So this is another uh pathological sign that you see in lung. Now, I want to make it absolutely uh clear that there are so many things that I've left out in ultrasound. So many things I've left out in abdominal ultrasound in cases of echo and I am leaving out in lung ultrasound because this is an introductory series. We don't want to be going in depth and I am not a radiologist by profession, it's not fair for me to start explaining everything. It will take longer and forever to finish. So my point is for you guys to be able to be introduced to the scan. And next time you see something you can pick up, if even if you pick up one slight thing, you'll have this confidence to know that this is not something that is that difficult. I can actually start looking into it, start using it. That is it OK. So with that, I think we have finished the fast. So I want to tell you just the order of fast EFA scan, we started with right upper, left, upper pelvic, looked at the heart and then we looked at the lungs. So this is the order which we usually go for e fast. It should be rapid if possible, uh repeated as well. So you can pick up something later on that you've missed the first time. Next protocol that I want to talk about is the rush protocol. Now rush again R US H stands for rapid ultrasound for sepsis or hypotensive patients. OK. So in that case, we are looking at specifically three things. So it's a rapid assessment, looking at three things, we are looking at pump tank and pipes. What does it mean? So pump is obviously the heart tank is the ability of uh the the amount of intravascular fluid. That is what we're looking at with the tank. And then the pipes are obviously the blood vessels that carry specifically the major blood vessels, the abdominal aorta and the femoral vein and the PPI vein. Let's just briefly look into it. I'm not going to be going into detail for rush either because we have discussed with a lot of these things earlier. I'm just gonna quickly run through just so you are familiar with Rush protocol because these are the two important things in an emergency setting and that is what we are discussing today. Ok. So first thing is the pump we have, you know, the parasternal long axis view, the parasternal short axis, the apical and the subcostal views, the parasternal long axis view. You will help us to look at the pericardium. You know, we talked about earlier about the pericardial effusion. All pericardial effusions are not tampons, tampons occurs when the pericardial effusion is significant enough that the cardiac walls are not able to pump appropriately. Ok. Now, para short axis view again, the left ventricular size can be appreciated what you're looking for as you know, the mid papillary, the papillary views that we looked at earlier. So in the papillary views, you can see the left ventricle wall. Now, if the right ventricle pressure goes up too much, what happens is there's something called as ad sign where this won't be the circular, this will become flattened here because of the increased pressure on the right ventricle. And also when the fluid is too low, there can be, these two will appear to be kissing each other. That is because it's the left ventricle collapse. Ok. So that is one thing uh that will help you to see in the paranal short axis view. Coming back to rush Protocol, we have the apical view. Again, looking at the right ventricular size to see for any right ventricular failure. And if the pressure is too much, it could indicate a right, it could indicate a pulmonary embolism and causing a pulmonary hypertension against subcostal abuse. Once you look at the heart, you look at the tank tank specifically, you start with IVC. You already described about IVC. We're looking at the contractility. If the contractility is more than 50% that means that you can give them fluids if it is too much, then that means that there is a fluid overload uh problem. So next thing is you look at the lung where you're looking to see if the tonus compromised because of things like pneumothorax or pulmonary uh edema or again, pulmonary embolism. So these are things that we can look at in lungs. Uh sorry, effusion, my bad So, edema, effusion and pneumothorax, which will compromise the the hemodynamic system and then in the abdomen, the right left and uh pelvic views, we're looking to see if there is free fluid. So like if it is an abdominal aortic aneurysm rupture, there can be bleeding and many other causes that can cause free fluid or bleeding, which can also affect the BP which will end up causing hypotension or shock. So, remember Rush Protocol, we are trying to find out if there is a cause which you can get with ultrasound. So we are looking at causes, we looked at the heart, we looked at the tank and we look at the pipes. I am not going to go into detail for again, abdominal aorta and also for DVT because I feel like it's, I think there's a lot of around 70 slides which I don't want to make it bigger. So if anybody is interested in uh going for abdominal aorta, I would strongly suggest if you can look into it. We briefly described last time about how to measure the abdominal aortic diameter. And you have to remember that when you're holding the probe, uh if you can see this is where you're gonna be holding the probe initially, always measure the aorta and you know, procedure not transversely because when the ultrasound hits to the sides and goes, there can be deflection which will not give us a clear uh view of the borders laterally. So the transverse borders are better visualized than the lateral borders. OK. So that is a rush protocol. Now coming to uh a brief discussion about ultrasound guided IV access. Again, this is not a practical session. So it is not difficult for it is it is very difficult for me to make you understand what is going on or what you should be doing. Let's want to introduce you to this. So that tomorrow, when you see the machine, when you look at somebody's arm, you should have that confidence to understand what you're seeing. And maybe with the uh with the guidance of a supervisor or a senior colleague, you can actually try and do these procedures in uh in emergency. Specifically, we do procedures like ultrasound, guided cannulation and F blocks. Uh But let's just talk about ultrasound, guided cannulation. So we usually use it in the upper limb but other vessels that you can access. This is a spa and the basilic veins are there. If you don't get the cephalic or basilic vein only, then we go for the deep brachial veins. There are superficial veins like the medial cubital vein. But again, it is at the elbow, which means that if you bend, if the patient bends the elbow, it's gonna block the axis. So it is again, not that preferred. Uh But most important thing is before you start, you select the vein that you want, you look map the vein. So that you can see if there is any uh bifurcations or anything else that might obstruct or that might later on. Once you start, you won't be able to finish putting the can in. So make sure you map the area that you want to see and once you uh get an image, so this is a short axis view of the vessels. What is, what is important for me to is to ask if anybody can tell me the difference between an artery and a vein that you can see in the ultrasound or how to differentiate between artery and vein in uh using an ultrasound, you can compress the vein like very good. So veins are compressible. Arteries are not compressible, collapsibility. Yes. Anything else? So if you look at the walls of the artery and vein, the arterial walls will be generally thicker when compared to venous walls. Pulsatility. Yes, absolutely. Right. So, arteries will be pulsatile when compared to veins. So these are the three things that you can quickly do. Of course, there is Doppler that you can do. But these are the big things that you can do to understand the difference and it's important that you do not put it into an artery uh and also vary of other structures nearby like veins, uh sorry, like nerves which shouldn't be uh damaging while you try to get the access in. Now, there are two ways you can do the ultrasound guided axis. One is if you hold the probe in the, along the long axis of the vein, so it will be held like this and you'll be seeing the vein like this way or you can do the short axis way, uh you'll be holding it in a perpendicular weight. And this is how you will be seeing the way what is shown inside is the needle. So you can actually appreciate the vein better. Even here, you can see the needle inside, you can so you can appreciate the the vessel better. So we use a creep method to actually insert it, just, just want to briefly tell you again, as I said, unless you do it, you will not understand uh we have the probe here and you have the needle here. So you, you hold the needle about uh 2 to 3 millimeters before where you keep the probe and you angle it about 30 to 45 degrees, depending on how deep your vessel is, your target vessel is. And once you go in, you, you find the uh tip of the needle and then you visualize it till you reach the the vessel. And then you can see that it starts making an intent on that vessel lumen. So this is called a stenting. So you can see on the long, the long axis view, you can see how the tending is going to be seen. And in this is the vessel. By the way, you can see the tending here. This is a short axis view. So once you get the tending you insert and you can see this red flash coming and then with always, you should have your eyes on the tip of the needle and you get it to the middle and then slowly enter it until you have full length inside and then fix it. OK. Now, I know that this is the not going to be making you confident in doing an ultrasound guided cannulation. But I want you to understand it just fairly easy. And next time you have a chance with the supervisor or a senior colleague, uh you should get it done so that you have this uh confidence in doing it. When you, when you start working, you'll see a lot of patients uh who will have difficult cannulation. The nurses won't be able to do it and that if you have this uh knowledge, it will make your life and the patient's life way easier. So take home points at the end will be whenever you do fast cancer, you fast cancer in trauma. Remember it is a rule in test, not a rule out test. If you don't see free fluid in the abdomen, that doesn't mean it's a normal scan and the patient is fine. It could be that you haven't seen it or it could mean that later on you might as it gets bigger, you might actually pick it up. So always rapidly and repeatedly do scans so that you don't miss out things. So at the end of the day, a CT scan is the rule out technique. OK. And always with an elderly patient coming with hypotension tachycardia, you should also keep in mind that it could be an abdominal aortic aneurysm dissection. So try to involve the A RL scan as well. I know we haven't discussed it today, but uh it, it has too much more explanation. I don't want to go into it today, but keep that in mind as well because we haven't discussed it. Don't forget it. That's also very important. Ok. So I'm gonna give my email there for that uh uh Doctor Andy so that he can email me and I'm happy to have a discussion uh within the limits of course, of my knowledge. Uh I hope you did you, did you see the email? II? Hope you did. I'll write it down in the chart just in case if you don't mind. Of course. All right. And thank you very much for the amazing lecture. It was really great. I think I would just, we will stay for just like one or two minutes if anyone has questions in the chat and of course, thank you everyone for joining us today. Um Yes, there is a recording of the previous session. You can find it on the youtube channel of UI MS. And if you wanna receive a certificate for today's lecture. You will receive an email where you can um answer our feedback form and you will receive a certificate. So we will just stay a couple of more minutes if you have any questions. Well, looks like there aren't any questions, which is great. Thank you so much again for joining us today, doctor and thank you for the amazing lecture. Goodbye. Everyone. Have a nice weekend. Bye guys.