Page Outline

JVP

1 clip

  • Short-axis view of IJ as probe is moved cephalad to demonstrate collapse of the vein at the height of the JVP

    • IJ positioned in the centre of the screen; carotid visible

    • patient positioned so that IJ collapse is visible

    • Height of JVP noted on the clip (text)

IVC

2 clips

  • Long-axis IVC view with RA-caval junction visible, ideally with hepatic vein seen entering IVC. Duration must be at minimum 1 full respiratory cycle to capture respirophasic changes.

    • Visualize maximal diameter of IVC (avoid cylinder effect)

    • Avoid false-positive collapsibility due to translation of the IVC with respiration

  • Short-axis IVC view: duration must be at minimum 1 full respiratory cycle to capture respirophasic changes.

    • Location should be upstream from hepatic vein insertion

  • Alternate locations for LAX and SAX views

    • if not obtainable from the standard subxiphoid position, it is acceptable to obtain both views from either a right mid-axillary view or a right coronal (transhepatic) view.

  • (optional): still images of IVC in long-axis measuring maximal/minimal IVC diameter at 1-2cm distal to the hepatic vein

  • (optional): still M-mode image showing M-mode through IVC, placed 1-2cm distal to hepatic vein, with measurements taken

Lung

12 clips


All clips should be 4-6 seconds in duration and demonstrate respiratory movement of the lungs/pleura (with probe stationary)

  • Full lung assessment: 6 clips per hemithorax (4 acceptable if posterior chest not accessible)

    • Anterior chest wall: 2nd/3rd ICS, mid-clavicular line (R1/L1)

      • Depth 9-13cm

    • Anterior chest wall, 5th/6th ICS, mid-clavicular line (R2/L2)

      • *Note: may be challenging on the left side, particularly in females, due the heart and/or breast tissue

      • Depth 9-13cm

    • Anterior-to-mid axillary line: level of the nipple (R3/L3)

      • Depth typically 10-14cm

      • As high up in the axilla as possible

    • PLAPS (postero-lateral alveolar-pleural syndrome point): most posterior/dependent region (mid-to-posterior axillary line or farther back) at the costophrenic angle (R4/L4)

      • Depth sufficient to allow visualization of entire intra-abdominal organ and the visible diaphragm

      • Must see visualize the boundary between thorax and abdomen (no rib shadows in the way)

      • *Note: if there is dependent pathology, you’re encouraged to take several clips here, in both the mid- and posterior axillary lines

    • Posterior superior chest (R5/L5)

      • If patient is able to sit up/roll over

      • Lateral to scapula, just below the spine of scapula

    • Posterior inferior chest (R6/L6)

      • If patient is able to sit up/roll over

      • Lateral to scapula, at border with diaphragm (goal is to capture posterior dependent pathology)

  • Technique points for all clips:

    • Intercostal space centred on screen

    • Pleura horizontal (if possible); optimize beam angle for pleural resolution

  • Pleural effusion study: complete full lung study as above

    • At least one view (Costo/PLAPS) must include:

    • Demonstrate spine sign

    • Demonstrate fluid that is contiguous and fills angulated spaces eg. costophrenic angle, area between chest wall and lung (to confirm pleural effusion)

    • Visualize consolidated/compressed lung within the pleural effusion

  • Pneumothorax study: complete full lung study as above

    • Images to highlight presence/absence of pleural sliding (decreased depth/gain; linear probe; M-mode)

    • Identify lung point if present

  • **For all lung scans: if pathology is identified, perform additional clips to thoroughly survey the area

    • If pleural pathology is noted, perform additional zoomed clips (+/- linear probe) to better characterize

All clips should be 4-6 seconds in duration, with probe stationary. You are always encouraged to perform all 4 cardiac views plus IVC (and additional views if possible/desired).

  • Basic POCUS cardiac exam: 4 clips 

    • PLAX: parasternal long axis

      • Depth adequate to see 1-2cm deep to the descending thoracic aorta

      • Clear visualization of LA, LV, mitral valve, aortic valve, LVOT/aorta, and RVOT

      • Mitral valve leaflets centered in screen

      • LV captured in its widest dimension (no cylinder effect) and elongated (no foreshortening), with walls as close to horizontal as possible. The LV apex should NOT be visualized. If possible, exclude papillary muscles and chordae.

      • Clear opening of the mitral valve visualized

      • Ideally, LV is pitched horizontally on the screen; rather than pitched obliquely (which will occur if view is taken in a lower rib space)

    • PSAX: parasternal short axis

      • Level of papillary muscles (mid-ventricular level)

      • Ensure adequate rotation to avoid off-axis views and a falsely flattened septum or oval appearance to heart - pap muscle should appear symmetrical with no MV in view

    • A4C: apical 4-chamber

      • LV, RV, LA, RA visualized, with mitral and tricuspid valves opening

      • Avoid 5-chamber view (aortic valve/LVOT in view) if possible

      • Heart vertically oriented

      • LV apex centered with LV chamber size maximized

      • Avoid foreshortening RV (globular/ovoid appearance) by scanning too high on the chest

      • Optimize visualization of myocardium

    • SX: subxiphoid

      • LA, LV, RA, RV visualized, with mitral and tricuspid valves. Optimize chamber size of LV/RV

      • Heart lying horizontal/obliquely

  • Isolated exam for LV systolic function: 3 clips

    • At least 2 of the above views; with optimized visualization of the endocardium

    • M-mode demonstrating EPSS

      • Taken in PLAX with M-mode cursor placed through the tip of the anterior leaflet of the mitral valve (not chordae)

      • Caliper measurements demonstrating EPSS (measure from top of E-wave to interventricular septum)

  • Isolated exam for pericardial effusion: 3 clips

    • 2+ cardiac clips (one of which must be PLAX or SX

      • Optimize visualization of RV free wall and RA

      • *Note: with cardiac clips for effusion, ensure that you have fanned through the heart to capture the largest pocket of effusion. The clip may then be taken with the probe stationary.

    • PLAX: depth at least 2cm below descending thoracic aorta (must be visualized)

      • Still image of effusion with caliper measurements to document size of effusion (measured in diastole; measure largest fluid pocket)

    • PSAX, A4C or SX: depth at least 2cm below inferior LV wall, or deep enough to visualize entire effusion

      • Still image with caliper measurements to document size (measured in diastole; measure largest fluid pocket)

    • 1 clip of IVC in long-axis (see above)

    • Additional images (optional)

      • M-mode in PLAX demonstrating movement of RV free wall compared to IVS

      • M-mode in SX demonstrating movement of RV compared to IVS

      • Doppler images documenting changes in mitral/tricuspid inflows (advanced)

  • RV-focused exam

    • **clinical use of POCUS for RV pathology is a skill that requires further focused training

    • All basic cardiac clips above, plus:

      • RV-focused A4C view; with care to avoid foreshortening. Optimize RV diameter while maintaining maximal LV diameter (rotation).

      • TAPSE done in RV-focused A4C view; measurement taken with M-mode through lateral TV annulus

      • Special attention to septal kinetics in PSAX

      • Screen for TR with colour Doppler (see below); optional TR maxPG/RVSP

      • (optional): zoomed SX with caliper measurement for RV hypertrophy; exclude trabeculae. Measure at tips of TV in diastole.

      • (optional, advanced): S’

  • Screening exam for severe regurgitation

    • **clinical use of POCUS for RV pathology is a skill that requires further focused training

    • Colour Doppler over aortic, tricuspid, and mitral valves in all accessible views to screen for severe regurgitation

      • Colour box optimized to include the valve and the entire receiving chamber of interest

      • Fan through valve to capture maximal jet

      • Look in as many views as possible; and aim to optimize flow of blood to be parallel to the probe (A4C view)

Cardiac

4+ clips



  • Ascites/free fluid exam: 1 clip demonstrating fluid in a dependent region

    • Clip in sagittal plane, lateral to the rectus sheath, demonstrating the largest fluid pocket, with fanning (lateral/medial) to demonstrate the borders of the pocket

    • Fluid should be contiguous and fill angulated spaces to confirm free-flowing nature

    • Fluid should be present in dependent regions

      • RUQ

        • Morrison’s pouch (hepato-renal interface)

        • Inferior tip of liver

        • Inferior pole of R kidney (R paracolic gutter)

      • LUQ

        • Subdiaphragmatic space (above spleen, below diaphragm)

        • Spleno-renal pouch

        • Inferior pole of L kidney (L paracolic gutter)

      • Pelvis: posterior to bladder (recto-vesicular pouch/recto-uterine pouch)

        • demonstrate bladder and fluid wrapping around bladder

    • Negative free fluid exam (FAST) should demonstrate absence of fluid in all of the above 7 points

  • Hydronephrosis: 6 clips

    • Each side: long-axis and short-axis clips of each kidney, fanning through the kidney to identify abnormalities

    • Colour Doppler over renal pelvis to distinguish normal renal vasculature from dilated renal pelvis

    • Bladder: 1 clip (transverse)

Abdomen

1+ clips

Thoracentesis

  • Confirmation of free fluid (r/o contained fluid)

    • Static clip with low frequency transducer that shows fluid is gravity dependent and forms irregular, angulated borders (rather than geometric forms)

    • Can be demonstrated in either lateral (patient supine) or posterior (patient sitting) costophrenic angles

    • Must include:

      • Intra-abdominal organ (spleen or liver) and diaphragm

      • Atelectatic lung/thoracic structures

      • Fluid forming angulated border with the costophrenic angle, with spine extending above the level of the diaphragm (spine sign)

  • Static clip at needle insertion site with low-frequency (curvilinear) probe in saggital/coronal plane to demonstrate planned trajectory of needle

    •   Demonstrate the pleural surface at the superficial border of fluid space, and lung or other thoracic structure at the deep border of the fluid space

    • Demonstrate rib shadows: the superior surface of inferior rib of chosen intercostal space should be positioned in the middle of the screen (this is the rib you will hit and glide over)

  • Dynamic clip (fanning) at insertion site (low frequency probe, saggital/coronal plane)

    • Must demonstrate that insertion site is free from obstacles (ie diaphragm, lung)

    • Include the pleural surface at the superficial border of fluid space, and lung or other thoracic structure at the deep border of the fluid space

  • Colour Power Doppler (CPD) with linear probe to demonstrate an absence of overlying vessels at insertion site

    • Most of the screen should be occupied by the chest wall with fluid found at the deep aspect of the image

    • CPD box covering the deep ½ of the chest wall, pleura, and small amount of fluid at the deep border

    • Focus should be on the superior aspect of the chosen rib (as this is where you will hit the rib and glide over the rib)

4 clips

  • Confirmation of ascites as per Abdomen criteria above (1 clip)

    • Either RUQ, LUQ, or pelvis/bladder region

    • Images should have enough depth to visualize spine

  • Static clip at needle insertion site with low-frequency (curvilinear) probe in saggital/coronal plane

    • Include peritoneal surface (superficial borer of fluid space) and bowel (deep border of fluid space)

  • Dynamic clip (fanning) at insertion site (low frequency probe, saggital/coronal plane)

    • Must demonstrate that insertion site is free from obstacles (ie bowel adhesions)

    • Include peritoneal surface (superficial borer of fluid space) and bowel (deep border of fluid space)

  • Colour Power Doppler (CPD) with linear probe to demonstrate an absence of overlying vessels at insertion site

    • Most of the screen should be occupied by the abdominal wall with fluid found at the deep aspect of the image

    • CPD box covering the deep ½ of the abdominal wall, peritoneum and small amount of fluid at the deep border

PARACENTESIs

4 clips