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Making Waves - All About Ultrasound BloG

5 Quick Scanning Tips For Carotid Ultrasound

7/16/2020

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Scanning those tortuous Carotid vessels can sometimes be tricky! So here we'll go through 5 quick scanning tips to help you get great carotid images and accurate velocities. 
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1. Do a Quick Scan Survey
Taking a quick look through the entire vessel and bifurcation before you start imaging will help you know of any plaque that might be present and will also help you be aware of the vessel course. This will help you better prepare to angle your Color & Doppler through any stenosis and also if there are tortuous vessels. It is always a good idea to know what you are getting yourself into first. 
2. Be Consistent
Often times your scanning protocol will be determined by the facility you work for. This is helpful with accreditation and standardization to make sure that accurate and consistent exams are performed every time, for every patient. With regard to protocol, it can sometimes be difficult to jump around from one vessel location, like proximal to the distal and then ECA and ICA and then go back to obtain it again for other imaging modes like Color and Spectral Doppler. So if at all possible, it is best to stay consistent, perform all imaging modes (2D, Color and PW Doppler) in that one location and then move on. 
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3. Heel/Toe Will Come in Handy
Using the "Heel/Toe" method to rock and tilt the angle of the transducer will help to line up the vessel to the correct Doppler angle. This is especially useful when there is "deep dive" of the vessel or when there is a tortuous curve. By using your hand to angle the transducer, you can maintain that 60 degree angle and ensure that each Doppler sample is angled correctly. 
4. It's All About the Angle
Remember your Doppler angle should be parallel to blood flow through the vessel (not the vessel wall). This is important when there is a stenosis, because often the flow direction will change due to the shape of the plaque. Also, it's important to remember that the SVU recommends keeping your Doppler angle between 45-60 degrees in order to maintain consistency in reporting velocities. It can be helpful if you are doing a follow up study for a patient with a known stenosis to check the prior ultrasound images (not just the report) and review the Doppler angle used previously and where the stenosis was sampled. This can help to reduce errors between sonographers and ensure that the velocities reported are consistent and only different if there is truly a reduction in vessel lumen since the previous exam. 
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5. Attention to Detail
Sometimes those tortuous vessels and deep vessels can be difficult. Pay attention to your PRF/scale, your wall filter settings and your color box angle. This can help bring in flow in those difficult exams. Often steering your color box straight will help to pick up those deep diving vessels. 

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The Echocardiographer's role in lv diastology assessment

7/9/2020

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​Diastology can often be confusing, as there have many updates to the standards and guidelines regarding how to assess and grade left ventricular diastology in the past few years. So let's dig in to how to assess this and the echocardiographer's role in evaluating diastology based on the updated 
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2016 ASE Guidelines.

So as cardiac sonographers, we should all know the basics... E/A reversal = Diastolic Dysfunction, but there is a little more to it than that. If you're not fully evaluating diastology with additional measures, you're probably missing some positive cases. Also the Intersocietal Accreditation Commission now includes reporting of left ventricular diastolic function as a requirement for echocardiography accreditation. 
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What exactly is diastolic dysfunction? This is a decrease in left ventricular compliance during diastole. While the ejection fraction and left ventricular systolic function are needless to say, pretty important, the diastolic function of the heart is important too. If the heart does not rest properly during diastole, then it cannot fill with the right amount of blood volume needed and eventually this can lead to heart failure and significant clinical implications. So it's important to know the left atrial pressures and end diastolic left ventricular pressures in order to determine the level of severity of the diastolic dysfunction. The updated guidelines break it down like this:

Grade 0 = Normal
Grade  1 = Impaired Relaxation/Diastolic Dysfunction
Grade 2 = Pseudonormalization
Grade 3 = Restrictive Pathophysiology

So how do we get to the diagnosis? Based on the updated standards from the ASE, determination of normal vs diastolic dysfunction is evaluated initially, based on the patient's EF. 

If a patient has a normal ejection fraction then the algorithm looks at four components to determine whether or not the patient has a degree of diastolic dysfunction:

1. Average E/e’ > 14
2. e' velocity
  -Septal e’ velocity < 7 cm/s 
  -Lateral e’ velocity <10 cm/s
3.TR velocity > 2.8 m/s
4. LA volume index >34ml/m2

If <50% are positive, the patient is considered normal. If >50% are positive, the patient has a degree of diastolic dysfunction. If only 50% are positive, then we are unable to determine whether the patient has diastolic dysfunction. 

If the patient has a compromised ejection fraction, then we can assume that there is a degree of diastolic dysfunction and can grade it based on the E/A ratio. 

When the mitral inflow pattern shows an E/A ratio <0.8 along with a peak E velocity of <50cm/sec, then the mean LAP is either normal or low and this is considered a Grade 1. 

When the mitral inflow pattern shows an E/A ratio of >2, the mean LAP is elevated, consistent with Grade 3 diastolic dysfunction. Keep in mind patients with young or athletic patients may show this ratio in the setting of normal diastolic function. Also, patients in atrial fibrillation may exhibit a reduced or loss of the mitral A wave and may also produce similar findings.

For patients with reduced EF's that do not meet one of those parameters and the mitral inflow shows an E/A Ratio >0.8 AND the peak E velocity is >50 cm/sec OR E/A Ratio >8 but <2, then other parameters are required for determination of diastolic dysfunction.

1. Average E/e’ Ratio - average E/e’ ratio >14 
2. TR Velocity - peak jet velocity >2.8 m/sec
3. LA Volume Index - >34 mL/m2

If 2 of 3 are negative, the patient is considered to have Grade 1 diastolic dysfunction, where if 2 of 3 are positive, then this is considered Grade 2. 

So, are you confused yet? Let's look at the grading parameters a little closer.

​​GRADE 0 - NORMAL DIASTOLOGY

This means that left atrial pressures (LAP) are normal and the diastolic function is not impaired. The left ventricle relaxes normally throughout diastole and allows for complete diastolic filling. The E/A ratio in a normal setting, is between 1 and 2. This gradually reduces with age and E/A ratio >0.75 may be considered normal above 75 years. 
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​​​GRADE 1 - IMPAIRED RELAXATION/DIASTOLIC DYSFUNCTION

Patients that do not have a NORMAL EF, will have a degree of diastolic dysfunction and are evaluated based on filling pressures of the left atrium. Left atrial pressures can be somewhat normal in a patient with Grade 1 diastolic dysfunction, but will increased as this progresses. Patients with Grade 1 diastolic dysfunction will have reduced e' velocities and prolonged deceleration time. 
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​​GRADE 2 - PSEUDONORMALIZATION

One of the biggest factors that our role as sonographers requires, is knowing your patient history. This will often help you know whether or not you're dealing with a normal waveform or pseudonormalization. Granted there are some other key factors but the most obvious is whether or not the patient has previously been diagnosed with diastolic dysfunction. If they have previously had reversal of the E/A waveform and now have a normal waveform pattern, this is a pretty good indicator that the patient is in pseudonormalization. Also, keep in mind some of the other factors associated with increased left atrial pressures, such as blunting or changes to the pulmonary venous waveform, as well as reduced e' velocities. When pseudonormalization is present, the valsalva maneuver can assist to "unload" the ventricle and to reduce filling pressures, causing the E/A reversal to be unmasked. 
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​​GRADE 3 - RESTRICTIVE FILLING PATTERN

Grade 3 diastolic dysfunction involves increased left atrial pressures and increased end diastolic left ventricular pressure. This may result in reversal of the pulmonary venous waveform and is often seen with the presence of left atrial enlargement and left ventricular hypertrophy.
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​ECHO DIASTOLOGY GRADING ANALYSIS TOOLS!

The newly updated algorithm for determining diastology and left atrial pressures can be a little overwhelming and difficult to follow, but we make it easy with our Echocardiography Analysis Tools which include our exclusive LV Diastology Assessment Tool! Quickly and easily determine and grade the diastology based on the updated ASE guidelines. Also there are many other parameters that affect diastology and the application of the diagnostic criteria, such as age, athletic hearts and other factors. Learn and review these additional factors and an in depth study of diastolic dysfunction in our MASTERING LV DIASTOLOGY CME COURSE! 
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​CHECK OUT OUR E-LEARNING CME COURSE
MASTERING LV DIASTOLOGY!

APPROVED FOR 1 SDMS CME CREDIT
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​REFERENCE: ASE/EACVI GUIDELINES AND STANDARDS Recommendations for the Evaluation of Left Ventricular Diastolic Function by Echocardiography: An Update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging; Nagueh et al
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Please note: allaboutultrasound.com and iheartecho.com are not endorsed by or affiliated with the American Society of Echocardiography
Re-post from https://www.iheartecho.com/echoblog/the-echocardiographers-role-in-lv-diastology-assessment 
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Constrictive Pericarditis

6/11/2020

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​​​Mastering Echocardiography can be tough, especially when it comes to complex processes like Constrictive Pericarditis. Patients with Constrictive Pericarditis do not present for typical pericarditis symptoms. Instead, they present with symptoms of heart failure and so this can often be a challenge for even very skilled sonographers to identify the subtle differences between Restrictive Cardiomyopathy and Constrictive Pericarditis. These two disease processes can appear very similar on echocardiography. However, there are a few things that clue us into the correct diagnosis.

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Constrictive Pericarditis is seen with a fibrotic, thickened pericardium, which insulates the ventricle and constricts the ventricle from fully relaxing during diastole. Whereas, Restrictive Cardiomyopathy results in a thickened myocardium, which inhibits the ability of the ventricle to relax and also results in abnormal diastolic function. However, that's where the similarities end. ​​
 
​​First of all, we need to evaluate for interdependence of the ventricles. But what does that mean? Ventricular interdependence is when there is a respiratory ventricular septal shift. This then leads to an increase in the volume of one ventricle associated with a decreased volume in the opposite ventricle. This can be tricky to diagnose, so it takes a pretty detailed echo exam and a keen eye of the sonographer and physician. 

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Secondly, when evaluating for constriction, we will need to look at respiratory changes to the Doppler waveform patterns. The respiratory changes in the Mitral inflow pattern will show a variation of greater than 15% when constriction is present. Whereas, with restriction, this waveform pattern will show a restrictive filling pattern with an E/A ratio >2.0 and deceleration time <160ms.
 


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Another key factor in determining constriction vs. restriction is the E/e' ratio and diastolic function. Remember that both disease processes will have a degree of diastolic dysfunction. ​Normal left ventricular function will typically show a lateral e’ greater than septal/medial e' velocities, because the septal wall is somewhat restricted and the lateral wall is more free to move. However, with constriction the pericardium is insulating the ventricular movements and does not allow for full relaxation and movement of the lateral wall. This results in mitral annulus reversus, which is a decreased lateral e' velocity and compensatory increase in tissue velocities in the septal/medial annulus. Restrictive patterns in tissue velocities will show an overall decrease in both the lateral and septal e' velocities.

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Additionally, with constriction, this will result in expiratory hepatic vein reversal. But why does this occur? Remember that air moves from areas of high pressure to low pressure, which allows for air flow into the lungs. During expiration, the volume of air (and the pressure) of the thoracic cavity decreases, causing the intrapulmonary pressure to rise above the atmospheric pressure. However, with constriction, the pericardium is insulating the intracardiac chambers and this keeps them from tracking normally with intrapulmonary pressures. Remember the pulmonary artery and aorta are OUTSIDE of the pericardium. 

​So with constriction the thorax pressure and the  pulmonary venous pressure will drop, but there are phasic filling differences within the heart, because the gradient to fill the left side of the heart is decreased. The heart is no longer able to push outward against the pericardium, so the pressure is forced inward into the cardiac chambers. So during expiration, the pressure in the right atrium causes flow reversal in the hepatic veins. Whereas, with chronic late stages of restriction, there is an inspiratory reversal during diastole, because there is no shifting of septum and the right heart cannot accommodate increased flow which results from chronic diastolic dysfunction and this causes hepatic vein reversal. 

W​hile diagnosing Constrictive Pericarditis on echocardiography can certainly be a challenge, it can be done with confidence. Paying close attention to the details and recognizing when your patient with heart failure symptoms might actually be more than meets the eye, can help to make the correct diagnosis and ensure adequate treatment for your patient. 
Want more information on the differences between Constrictive Pericarditis and Restrictive Cardiomyopathy, including Strain Imaging methods? See our E-Learning Course Mastering Constrictive Pericarditis and earn 1 SDMS CME credit. ​
Enroll Now For CME
Re-post from: ​https://www.iheartecho.com/echoblog/constrictive-pericarditis

REFERENCES
  • Ling LH, Oh JK, Schaff HV et al. Constrictive pericarditis in the modern era: evolving clinical spectrum and impact on outcome after pericardiectomy. Circulation. 1999;100(13): 1380-6.
  • Myers RB, Spodick DH. Constrictive pericarditis: clinical and pathophysiologic characteristics. Am Heart J. 1999;138(2 Pt 1):219-32.
  • Mehta A, Mehta M, Jain AC. Constrictive pericarditis. Clin Cardiol. 1999;22(5):334-44.
  • Hancock EW. Differential diagnosis of restrictive cardiomyopathy and constrictive pericarditis. Heart. 2001;86(3): 343-9.
  • Ling LH, Oh JK, Tei C, et al. Pericardial thickness measured with transesophageal echocardiography: feasibility and potential clinical usefulness. J Am Coll Cardiol. 1997; 29(6):1317-23.
  • Talreja DR, Edwards WD, Danielson GK, et al. Constrictive pericarditis in 26 patients with histologically normal pericardial thickness. Circulation. 2003;108(15):1852-7.
  • Rajagopalan N, Garcia MJ, Rodriguez L, et al. Comparison of new Doppler echocardiographic methods to differentiate constrictive pericardial heart disease and restrictive cardiomyopathy. Am J Cardiol. 2001;87(1):86-94.
  • Oh JK, Hatle LK, Seward JB, et al. Diagnostic role of Doppler echocardiography in constrictive pericarditis. J Am Coll Cardiol. 1994;23(1):154-62.
  • Hatle LK, Appleton CP, Popp RL. Differentiation of constrictive pericarditis and restrictive cardiomyopathy by Doppler echocardiography. Circulation. 1989;79(2):357-70.
  • Oh JK, Tajik AJ, Appleton CP, et al. Preload reduction to unmask the characteristic Doppler features of constrictive pericarditis. A new observation. Circulation. 1997; 95(4):796-9.
  • Sengupta PP, Mohan JC, Mehta V et al. Accuracy and pitfalls of early diastolic motion of the mitral annulus for diagnosing constrictive pericarditis by tissue Doppler imaging. Am J Cardiol. 2004;93(7):886-90.
  • Ha JW, Ommen SR, Tajik AJ, et al. Differentiation of constrictive pericarditis from restrictive cardiomyopathy using mitral annular velocity by tissue Doppler echocardiography. Am J Cardiol. 2004;94(3):316-9.
  • Garcia MJ, Rodriguez L, Ares M, et al. Differentiation of constrictive pericarditis from restrictive cardiomyopathy: assessment of left ventricular diastolic velocities in longitudinal axis by Doppler tissue imaging. J Am Coll Cardiol. 1996;27(1):108-14.
  • von Bibra H, Schober K, Jenni R, et al. Diagnosis of constrictive pericarditis by pulsed Doppler echocardiography of the hepatic vein. Am J Cardiol. 1989;63(7):483-8.
  • Ha JW, Oh JK, Ling LH, et al. Annulus paradoxus: transmitral flow velocity to mitral annular velocity ratio is inversely proportional to pulmonary capillary wedge pressure in patients with constrictive pericarditis. Circulation. 2001;104(9):976-8.
  • Reuss CS, Wilansky SM, Lester SJ, et al. Using mitral 'annulus reversus' to diagnose constrictive pericarditis. Eur J Echocardiogr. 2009;10(3):372-5.
  • Sengupta PP, Mohan JC, Mehta V et al. Doppler tissue imaging improves assessment of abnormal interventricular septal and posterior wall motion in constrictive pericarditis. J Am Soc Echocardiogr. 2005;18(3):226-30.
  • Sengupta PP, Krishnamoorthy VK, Abhayaratna WP, et al. Disparate patterns of left ventricular mechanics differentiate constrictive pericarditis from restrictive cardiomyopathy. JACC Cardiovasc Imaging. 2008;1(1):29-38.
  • Circ Cardiovasc Imaging. 2014 May;7(3):526-34. doi: 10.1161/CIRCIMAGING.113.001613. Epub 2014 Mar 14.
  • American Society of Echocardiography Clinical Recommendations for Multimodality Cardiovascular Imaging of Patients with Pericardial Disease (J Am Soc Echocardiogr 2013;26:965-1012.)


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7 Study Tips to Pass your Ultrasound Registry Exam

1/9/2019

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Studying for that ARDMS or CCI ultrasound registry exam can be brutal!
So we've covered this topic a few times before, but it is always helpful to revisit some of these study tips. Passing your ARDMS or CCI Ultrasound Registry exam is easier than you think.... There's no need to worry!

Don't stress over it... just study. Mastering ultrasound physics or any other ultrasound specialty can be so overwhelming and often it can you make you want to give up. Don't give up! You've got this! Keep on studying and use these simple tips to study and PASS your ultrasound registry! 
  • ​1. Get Organized. Make a plan and a schedule for your study time. It helps if you are a new grad to begin while you are still in school. Know what you need to prepare in order to apply (that alone can be a daunting task). Also check out the ARDMS website and review the content outline for the exam you are taking. Then make studying a priority. Find the best time and schedule that works for and stick to it, no matter what! No procrastinating! (I'm preaching to the choir on this one).
  • 2. Don't multitask! Our lives are so hectic and most of the time, our lives require multitasking, but surprisingly studies have shown that multitasking is physically impossible. Multitasking actually keeps you from focusing on what you need to master. So, master the basics and stay focused on one thing at a time.
  • 3. Split it up! Studying usually isn't fun and forcing your way through a long study marathon will only make it worse. The saying "you eat an elephant one bite a time",  applies here. Divide your work into manageable chunks. Take one section and master that! Reward yourself when you finish each accomplishment to keep it fun and less stressful! 
  • 4. Sleep - Sleep is so important! Getting those eight hours of zzz's every night will keep your focus sharp and improve your working memory. Don't skip your sleep - get your rest! (again preaching to the choir here)
  • 5. Take notes - Taking notes will not only keep you more engaged during class or any review courses, but will also help you narrow down what you need to study when exam time rolls around. Also, take notes in pencil.... the tactile engagement of the pencil will help you remember the content when you need it! 
  • 6. Work with what you have - Engage as many senses in studying as you can... read, write and speak the content. Have someone else read the content back to you and quiz yourself. This will help you remember the content on the big day!
  • 7. Study! Obvious, right? There's a right and a wrong way to study... get it right! Review the material several days ahead of time. Look over it in small chunks, and in different ways (for example, write flashcards one day and take practice tests the next).  And.... Don't cram. Give yourself time!

Hope these tips help you pass your ultrasound registry. For more help and tools to pass - check out our ultrasound registry reviews with quizzes and tools to help you master the ARDMS and CCI registries! Sign up for a FREE TRIAL (no credit card needed) of our Ultrasound Physics SPI Registry Review Course that includes our PASS GUARANTEE and pass with us!


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Mastering Doppler Principles and Hemodynamics

12/19/2018

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It is so easy to get caught up with our patients who need our immediate attention for things that aren't even ultrasound related and even seasoned sonographers can ignore physics altogether, but when we take it back to the basics, this is where image optimization begins. So, let's take a step back and look at the basics again.....  Doppler principles and hemodynamics... I know, I know, for some just saying the words brings tears to their eyes as they recall sleepless nights studying for the Ultrasound Physics registry! But no need to fear! Doppler is simple when you break it down. So the Doppler Effect is quite simply either a positive shift which is a compression in the wavelength (a higher frequency)  or a negative shift, which results in an elongated wavelength, (a lower frequency) and this is of course all relative to the observer. 
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So what does this have to do with Doppler ultrasound? I'm glad you asked.
​Doppler frequency shifts come from moving red blood cells and give us the spectral display that we see in Continuous Wave and Pulse Wave Doppler. The velocities obtained from these frequency shifts can also be displayed in Color Doppler, superimposed on top of the 2D ultrasound image.  This is a method of displaying the mean or average velocity, while the spectral Doppler display can quantify specific velocities, like the peak systolic and end diastolic velocities, at a point in time. 

Because the Doppler frequency shift is relative to the position of the observer, this is important when placing the Doppler sample and angle of insonation. The Doppler sample volume is the "observer" and the frequency shift created by the moving red blood cell is what we are evaluating on the spectral display. But what happens if the observer changes position? The velocity observed will be different.  This is extremely important for Doppler Angle. The Society for Vascular Ultrasound recommends that scanning angle be maintained between 45-60 degrees.  While we know that the closer to 0 degrees, the more accurate the velocity result because of the math and the cosine of the angle, try getting that on a your average carotid Doppler. It is often not attainable and so for reporting and to maintain consistency in the lab, it is best to stay within the range of what can be easily obtained on most exams. 
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So as you can see from the image, as the angle of insonation is moved, the velocity result is SIGNIFICANTLY impacted. This can be a very big factor in following up serial ultrasound studies if the same Doppler angle is not used for follow up exams. This is why it is so important to look at the previous study images, especially if there is disease. So when you're scanning don't forget these very basic settings and factors that can have a large impact on your patient's results. 
Studying for your SPI ULTRASOUND PHYSICS REGISTRY?
​We have you covered with our SPI Ultrasound Physics Registry Review course and FREE TRIAL available!

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Want more info on Doppler Principles and Hemodynamics? Need CME's?
​See our Mastering Doppler Principles and Hemodynamics E-Learning CME Course!

Approved for 1 SDMS CME Credit Hour

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Mastering Upper Extremity Duplex

2/19/2018

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Master the concepts of Upper Extremity Duplex, including Hemodialysis Access and More! Our new CME Opportunity with E-Learning On Demand. This E-Learning course has been approved for 2 SDMS CME Credit Hours. Register today! CLICK HERE
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Register Now!
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Pediatric Echo Registry Review

1/1/2018

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It is application time again for the ARDMS® Pediatric Echo Registry. The next time to apply is January 3, 2018-March 6, 2018​. Apply for your registry and study with us today! Our Pediatric Echo Ultrasound Registry Review Quiz starts at just $9.99 and can help you prepare for that dreaded registry exam. No need to be intimidated. With over 200 questions in our unlimited quiz, our Test & Learn format will help you learn as you go, testing your knowledge and teaching too! Our test responses are based on your answers and questions are designed to help you learn as you go. Don't be overwhelmed by ultrasound physics or any other ultrasound specialty registry exam.... we have the tools to help you master the content and pass your ARDMS/CCI registries. Simple. Easy. Done! ​
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Step by Step Guide to Mesenteric Abdominal Duplex

7/29/2017

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Mesenteric Abdominal Duplex – it sounds complicated right? In reality though, as long as your patient is prepped, there’s not much to it. I say that with caution though – we’ve all had those patients that just really need another modality of testing. Let's be real... we all know that our ultrasound transducer is NOT a magic wand! 

First and foremost - Patient Prep! Your patient prep is one of the most important factors when performing Mesenteric Duplex Ultrasound. Your patient needs to be NPO for at least 6-8 hours before scanning. A test done without the right prep, might as well have not been done at all.  This is for a number of reasons:
1. You can't see squat with air and gas in the way!
2. The mesenteric arterial system should be scanned both pre and post prandial for evaluation of stenosis and arterial ischemic response. ​

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​So where to begin and what protocol? I've got that covered for you! A mesenteric duplex protocol should include, at a minimum...  Transverse and Longitudinal approach with 2D, Longitudinal approach with Color and PW Doppler (Record PSV and EDV) at each of the following locations:                                                                                                                                                       
•Proximal Aorta
•Celiac Artery/Trunk
•Branching of Common Hepatic Artery and Splenic Artery from the Celiac Artery
•SMA origin, proximal, mid, distal
•IMA origin, proximal and as distal as possible
•IVC 

​A few things can help you improve your imaging and will also help you evaluate patient pathology.
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1. Patient position is an important factor to remember. You should position your patient in a slightly elevated/supine position. This allows for a better view with less pressure on the diaphragm. Another trick is to have your patient lay supine and bend their knees. This also reduces pressure and tension on the diaphragm and allows for better visualization of the structures near the xyphoid process (ie. proximal aorta, celiac trunk, SMA). Having the patient sit erect can also help with evaluation of median arcuate ligament compression and if images are limited otherwise.
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​2. Using patient respirations to control the movement of structures and improve image quality (especially for Doppler waveforms). Respirations also help to evaluate for median arcuate ligament compression is sometimes a major factor in diagnosing this condition. Patient's with median arcuate ligament compression will have mildly elevated flow in the Celiac Artery with inspiration (this is normal). However, with expiration, the artery will be compressed by the median arcuate ligament and will cause an extrinsic obstruction due to compression and a marked increase in flow velocity. Using patient respirations to assess for this is a major factor of the Mesenteric Duplex exam. 

​3. Use Power Doppler - on those difficult patients, power Doppler can be your savior! This can also be used to visualize the Celiac Branches, the IMA and other smaller vessels.
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Okay, so now that we have the basics out of the way... you're probably wondering, what should the waveforms look like and what is normal/abnormal? So here's a quick guide:

​Celiac Artery
​

Remember that the Celiac Artery supplies the liver, spleen and stomach, which are low resistance vascular beds. Normal Doppler waveforms will show increased diastolic flow because of the organs supplied. Flow may also increase with inspiration. ​

Don't forget to evaluate the branches! This is best done in a transverse plane. 

≥70% Celiac Artery Stenosis will show a peak systolic velocity of  ≥200 cm/s.

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​Superior Mesenteric Artery
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​Remember that the SMA supplies the jejunum, ileum, and both the right and transverse colon. Because of this, waveform characteristics will vary based on state (ie. NPO, post-prandial). Diastolic flow will increase as needed for digestion, post-prandially.

In the normal vessel, post-prandial evaluation should show increased peak systolic flow velocities. If PSV flow does not increase, this is suggestive of a hemodynamically significant stenosis. Also keep in mind that inspiration will show an increase in peak systolic velocities.

≥70% SMA stenosis will show a peak systolic velocity of  ≥275cm/s or absence of color flow in the SMA. End diastolic flow velocities of ≥45cm/s are also an indication of ≥70% SMA stenosis. 

​Also keep in mind that you can find pathology based on the angle of the SMA  takeoff from the aorta. If the angle is markedly increased, it may indicate the presence of adenopathy. The SMA should course parallel to the aorta. 


Inferior Mesenteric Artery

​The IMA supplies the distal 1/3 of the transverse colon, splenic flexure, descending colon, sigmoid colon and rectum. It's waveform characteristics are similar to the SMA and will vary based on state (ie. NPO, post-prandial). Diastolic flow will increase as needed for digestion, post-prandially.

≥70% IMA stenosis will show a peak systolic velocity of  ≥275cm/s or absence of color flow in the IMA.

​You may need to get your magic wand out for this one! 
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Diagnostic Criteria Reference: Moneta, et al

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5 Best Practice Tips to Ob-Gyn Ultrasound

7/20/2017

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1. That Bladder! We have all seen the pregnant pee pee dance… While sometimes uncomfortable for our patients, this is the key to the first trimester transabdominal approach and also to 2nd trimester cervical measurements. Sometimes it just can’t be avoided, your patient is going to dance! However, in the 2nd trimester, it can be helpful for your patient to get what you need with the bladder full and to let them empty it out before completing the rest of your study. Often this can also improve the position of the fetus and help you to get better images with a relaxed mama and a relaxed baby!
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2. Scanning and trying to find those ovaries can prove to be a challenge with a pregnant uterus! Even though it is not our focus, we can’t forget those ovaries! Making sure to image those along with the uterus and fetal images will ensure that you’re not missing potential pathology, but it can definitely be tough with that pregnant uterus in the way. Best methods are to bring the transducer laterally to the patient’s side and to scan in a transverse plane along the lateral side of the uterus, starting pretty high up and moving down toward the patient’s cervix. That transverse plane will give you an increased field of view and will allow you to identify structures more easily.

3. Outflow tracts… the sound of that might scare some sonographers who are not used to looking at the fetal heart or evaluating this on a regular basis, but it’s much easier than you might think. Remember there are two main blood vessels that exit the heart – the aorta and the pulmonary artery. That’s it… just two. So how do you tell which is which? Most of the time (unless in a case of transposition of the great arteries or double outlet right ventricle), the aorta exits the left ventricle and the pulmonary artery exits the right ventricle. It’s important to note that the aorta will arch around after it leaves the heart and extend into the thoracic/abdominal aorta. The pulmonary artery will typically split into two branches.

​Yes, there are many variations that can happen with cardiac pathology and unless you specialize in maternal fetal medicine or fetal echocardiography, you may not know the specifics of every congenital heart disease you might encounter, but if you know the basics and what that looks like, you should be able to know when it’s just not right and alert your reading physician. If you’re not scanning this on a regular basis, it would be a good idea to add this to your daily protocol.
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4. Amniotic Fluid Index – how do you know your measurements are accurate? Many sonographers are not aware of how to properly measure fluid for an AFI. One key tip is to scan with color Doppler flow on – this allows you to identify umbilical cord that might be floating within the pocket of fluid. Another best practice tip and proper way to perform AFI measurements is to be sure your patient is lying flat on the table and keep the probe/ultrasound beam perpendicular to the floor. Also, keep your measurements perpendicular as well. This helps to ensure that the fluid pocket is not falsely enlarged.
5. Gender! We’ve all been there, where it seems that everyone is there for the show. While somehow you ended up being the entertainment for the expectant parents, don’t forget how exciting it can be to know how to plan for your little one. Yes, it’s often a pain with the dad, grandma, grandpa, sister, brother, niece, nephew, the mailman, the neighbor, the sister’s boyfriend’s mother-in-law and everyone else trying to squeeze into the room to catch a glance of the precious cargo and whatever package the baby might be sporting… so take a deep breath, don’t lose it on grandma and remember to SMILE 😊. Oh and scanning, well you know how that goes…​ get those pesky diagnostic measurements and anatomy evaluations out of the way and  then... turtle or hamburger… take your pick!
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Mastering Venous Reflux - Live Scanning Workshop

6/2/2017

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Don't miss our next LIVE SCANNING Event! In Sunny, Fort Lauderdale - July 15th 8:30am-12:30pm.

Together with the professionals from CardioServ, LLC we are hosting this amazing opportunity to learn venous insufficiency ultrasound. This course is for sonographers and physicians interested in learning correct techniques for performing and interpreting venous reflux.
  • Lecture and live scanning
  • Review normal and abnormal anatomy and pathology
  • Learn proper techniques and pitfalls to avoid
  • Diagnostic Criteria and intertpretation
  • Pre and Post ablation techniques
  • Instructors are credentialed experienced sonographers with real-life experience to teach and guide you
You will leave with tips to implement into your daily practice to improve the quality of your scanning and interpretation. Our goal is inspiring excellence in imaging. Let us inspire you to improve your venous reflux knowledge! Seating is Limited - Register Today!
Register Now
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