ECC VPOCUS

Question 1

Veterinary Point-of-Care Ultrasound (VPOCUS)
- what is it? what do we use it for?

Answer 1

Extension of physical examination, modern visual stethoscope

• Initial screening test: answer specific (Y/N) clinical questions
  > direct stabilization & resuscitation efforts
  > guide diagnostic plans & clinical course
  > monitor progression or resolution

Question 2

Veterinary Point-of-Care Ultrasound (VPOCUS) does not replace what?

Answer 2

DO NOT replace clinical assessment, thoracic auscultation, formal diagnostic imaging (x-rays, ultrasound, CT, echocardiography)

Question 3

Advantages of VPOCUS

Answer 3

• Non-invasive, safe
• Bedside, portable, widely available
• Minimal restraint (unstable patients)
• Rapid, early detection
• expedites timely diagnosis of many conditions
• Inexpensive, serial examinations
• Radiation sparing
• Achievable proficiency, easily-mastered skills
• No clipping, alcohol sufficient

Question 4

avoid what position for VPOCUS

Answer 4

dorsal recumbency

Question 5

what dictates stabilization & order of POCUS

Answer 5

Triage Exam

Question 6

what colour are fluids, soft tissue, air, bone, stones, on US?

Answer 6

anechoic / black = some fluid

hypoechoic / isoechoic / shades of grey
= soft tissue, some fluid

hyperechoic / whites = air, bone, stones, fibrous tissue
()
Air looks like striped lines
fluid looks black
soft tissue is grey
fibrous tissue is white
stones/bones are white with defined border

Question 7

properties of linear array probe
- frequency, depth, resolution

Answer 7

• higher frequency
• less penetration (↓ depth)
• better resolution (details)

Question 8

properties of curvilinear array probe
- frequency, depth, resolution

Answer 8

Curvilinear (microconvex) array
- lower frequency
- greater penetration (↑ depth)
- poorer resolution (details)

Question 9

how do we keep out bearings with US?

Answer 9

reference mark on probe,
- should point to head if longitudinal
- points to patient’s right if transverse

Question 10

what is FAST and what is it used for?

Answer 10

• Focused Assessment with Sonography for Trauma, Triage, Tracking
• 2004 veterinary: free fluid (trauma) > intraabdominal, intrathoracic lesions (beyond trauma) > trending (monitoring)

Question 11

what is included in global FAST

Answer 11

• Abdominal FAST® +/- specific target organs
• Thoracic FAST®
• Vet BLUE®
• Focused ECHO

Question 12

Abdominal FAST® or POCUS - what is included?

Answer 12

• Original AFAST: 4 sites
  > Diaphragmaticohepatic (DH) - Subxiphoid
  > Splenorenal (SR)
  > Cystocolic (CC)
  > Hepatorenal (HR)
• 5-point standardized AFAST: 5 sites
  > NEW: 5th umbilical view
• Free fluid: Y/N
• Specific target organs of interest

Question 13

Abdominal fluid scores (AFS)
- what do they mean?

Answer 13

• # of FAST positive sites: 0-4> if ≤ 5mm (cat) or ≤ 1cm (dog): give score of 0.5
  positive sites: origin of injury?
• Degree of hemorrhage, need for blood transfusions
  > AFS 3-4: big bleeder
  > AFS 1-2: small bleeder
• Serial exams q 4-6 hours: monitor ongoing/resolution
  > n=27, 17% became positive on serial AFAST®
  > time, fluid resuscitation

Question 14

Thoracic FAST® & Evolution of TFAST®
- what is our scanning positions? what views do we take? what are we assessing?

Answer 14

• Scanning position: standing or sternal*
• Original TFAST: 4 views
  > Chest tube sites (CTS) 7th to 9th ICS
  > Pericardial sites (PCS)
• 5-point standardized TFAST: 5 views
  > DH site: window into pleural & pericardial spaces
  > Dogs: heart rests on diaphragm
• Free fluid: Y/N
• Pneumothorax: Y/N

Question 15

Vet BLUE® or PLUS - what are they? what are they for?

Answer 15

• Veterinary Bedside Lung Ultrasound Examination
  > more extensive regionally-based lung scan
  > wet lung (B-lines) vs. dry lung (glide sign and A-lines)
• Pleural space & Lung UltraSound
• Screening evaluation: respiratory distressed / respiratory-compromised
• Pattern-based approach, categorize into probable causes:
  > upper airway vs. lower airway
  > heart failure vs. lung disease vs. respiratory look-a-likes

Question 16

Vet BLUE® Protocol

Answer 16

• 8 sites:
• Caudodorsal lung lobe region (CdLL)
• Perihilar lung lobe region (PhLL)
• Middle lung lobe region (MdLL)
• Cranial lung lobe region (CrLL)

Question 17

Lung Surface Artifacts
- normal? abnormal?

Answer 17

Normal:
Gator/bat sign
P-P line
A-lines
Z-lines
Glide sign
Seashore sign
Curtain sign
()
Abnormal:
Barcode sign
Lung point
B-lines
Shred sign
Tissue sign
Nodule sign
Free fluid (quad sign)

Question 18

Gator/Bat Sign
- what is it?

Answer 18

• Normal: intercostal orientation

Question 19

P-P (Pulmonary-Pleural) Line
- what is it?

Answer 19

• Hyperechoic linear continuity between ribs
• Normal: parietal & visceral pleura

Question 20

A-Lines
- what are they?

Answer 20

• Equidistant hyperechoic parallel lines distal to P-P line
• Normal: air reverberation artifacts

Question 21

Glide Sign
- what is it? good or bad? how to enhance?

Answer 21

• Normal: Glide is Good
• Real-time shimmering appearance at P-P line
• Parietal (thoracic wall) & visceral (lung) pleura apposition
• To-and-fro sliding motion at different speed & direction
• Absent = pneumothorax
  ()
  3 tricks to enhance:
  1. reduce gain (brightness)
  2. tilt probe to scan at an angle
  3. slide probe over a rib

Question 22

Seashore vs. Barcode Sign
- what does it mean?

Answer 22

pneumothorax

Question 23

B-Lines (a.k.a. Lung Rockets, Comet Tails)
- what are they? what do they mean?

Answer 23

• Laser-like hyperechoic lines extending from P-P line to the far field
• Obliterates A-lines, oscillate (bold arrows) with respiration
  ()
• Wet lung, alveolar-interstitial syndrome = non-specific, ↓ aeration in lungs
• Patient signalment, history, PE findings, regional lesion distribution pattern:
• Cardiogenic pulmonary edema
• Non-cardiogenic pulmonary edema
• Pulmonary contusions / hemorrhage
• Pneumonia - Atelectasis
• Fibrosis, etc.
  ()
• Rule out pneumothorax

Question 24

The Vet BLUE® B-Line Scoring System

Answer 24

• Normal = infrequent 1-3 B-lines at single site
• ↑↑B-lines∝↑↑severity
  ()
• Sentinels:
• wet lung (interstitial syndrome)
• alveolar flooding (alveolar syndrome) - lung consolidation (shred, tissue signs)

Question 25

Shred Sign - what does this mean?

Answer 25

- Lung consolidation with aeration - Sig. deviation from normal linear continuity of hyperechoic P-P line - Hypoechoic, echo-poor tissue with rough-jagged margins (shredded)

Question 26

Tissue Sign - what does this mean?

Answer 26

- Lung consolidation with no aeration - Ultrasonographic appearance of lung similar to tissue - Tissue (lung) hepatization = looks like liver

Question 27

Nodule Sign - what does this look like?

Answer 27

- Focal, well-marginated, circumscribe hypoechoic structure(s) - Surrounded distally by air-filled lung

Question 28

Free Fluid (Quad Sign) - what does it look like?

Answer 28

Ranges in echogenicity - anechoic (black) > moderate echogenicity (shades of grey) - degree of viscosity & cellularity

Question 29

Limitations of Vet BLUE® or PLUS

Answer 29

- US cannot adequately image through aerated lung (air) - Lung surface pathologies: 3 mm > detect lesions extended to lung periphery > unable to detect centrally (deeper) located pulmonary lesions - DO NOT replace formal diagnostic imaging (x-rays, CT scan) () - Non-specific, pattern-based approach > cannot definitively diagnose lung conditions > similar to interpretation of thoracic x-rays findings

Question 30

Focused ECHO - what is the purpose? not a replacement for what?

Answer 30

- Investigate causes of clinical signs > immediate treatment decisions > pericardial effusion > volume status (hypovolemia), cardiac contractility (systolic dysfunction, DCM) > LA enlargement (L-CHF, volume overload), R-sided enlargement (PH) > cardiac mass(es), thrombus, thickened valves (endocarditis) () - Particularly useful in cats: respiratory distress > +/- murmur, gallop, non-specific radiographic findings > differentiate heart failure from other causes () - DO NOT replace formal echocardiography

Question 31

Focused ECHO scanning position? views?

Answer 31

- Scanning position: standing or sternal* () - R parasternal long-axis view: > Four-chamber view () - R parasternal short-axis view: > LV papillary muscle (mushroom) view > Mitral valve (fish-mouth) view > LA:Ao (Mercedes-Benz) view

Question 32

Focused ECHO - Tips & tricks:

Answer 32

1. rolled towel under cranial thorax - optimize probe maneuverability, better heart base visualization 2. point of maximal intensity (PMI) 3. reference mark towards shoulder/elbow 4. find short-axis (mushroom) view 1st