Parasternal Long Axis (PLAX)

The PLAX view establishes the long axis of the heart but is generally not the optimal view to assess the right ventricle. Nonetheless, comparing the LA, Aortic root and RVOT, which should be roughly the same size, we note the RVOT is more than double the size of the other “chambers”.

Parasternal Short Axis (PSAX)

Chamber size comparison is best assessed with the PSAX view as was done here or the Apical 4 chamber (A4C) view. Here we again find a dilated right ventricle closest to the peaked footprint of the phased array probe. Not only is the RV dilated (greater than LV size), but right sided pressure is flattening the septum, giving the LV a characteristic “D-shaped” appearance. In A4C, TAPSE < 17mm is consistent with pulmonary hypertension.

Any patient with significant acute pulmonary hypertension will have a plethoric IVC. This IVC is > 3cm at the level of the hepatic veins with to and fro venous flow noted.

These findings clearly show pulmonary hypertension — the next step is to decide whether this hypertension is acute or chronic. Certainly factors other than echo findings will be important. What is the patient’s history, is there thrombus on CT, and are there any distinguishing features of their thrombus that suggest acute vs. chronic PE.

On Echo a few factors can be easily assessed:

• Right atrial size – RA > LA size suggests chronic pHTN.
• Right ventricular wall thickness
  • Measure the RV free wall at end-diastole, perpendicular to basal third, just below tricuspid valve. Best subxiphoid.
  • Chronic pHTN > 5 mm
  • Normal / Acute pHTN wall thickness:  $$≤ 5 mm
• More advanced techniques using spectral doppler assessment (TRPG, 60/60) are available as well.

For this patient with PE on CT and acute right ventricular failure, PERT and / or the ICU should see the patient sooner rather than later.

The EMSL now has remote SBIRT resources available. They are open Mon-Sat 10a-8p. They are available to help with any issues including prescribing naltrexone, referring patients, friends, family or yourself, and setting up a health coach.

This course offered this summer by Northwell offers training from combined societies – SHM (the Society of Hospital Medicine) and CHEST (pulm critical care). The directors Linda Kurian and Harald Sautoff are longstanding point of care educators who teach with the national SHM/CHEST courses. I’ve taught with this group and they know how to put on world class ultrasound education. This will definitely be worth it if you are looking for a local course.

The charge nurse should tell the provider to enter the “Ambulatory Referral to the Emergency Department Order” instead of using the expected patient workflow.  There are several benefits to using this order:

1. The sending provider does not have to call the ED – which they hate doing because they usually wait on hold until the charge nurse can pick up the phone. The sending provider can enter whatever information they want into the order (the workup they are requesting, when they want a call back, etc.)
2. Saves the charge nurse from having to pick up the phone and fill out the expected patient workflow – which is not going to get the provider the information that they need anyway.
3. This order generates an OPA that opens as soon as the provider opens the chart and stays in the chart for the whole encounter as a reminder for the provider to contact the PCP when the workup is done. 
4. There is also an icon that appears on a trackboard column that lets the providers know that someone put in this order for the patient.

The Optum docs can enter the order from EpicCareLink – which is what they use in their office.

• Leonard Park 1 Wallace Drive, Mount Kisco, NY
• Fox Senior Center 198 Carpenter Ave, Mount Kisco, NY
• Mount Kisco Public Library 100 Main St, Mount Kisco, NY

Westchester County Community Warming Centers (OPEN 24 HOURS)

• White Plains Samaritan House Shelter (WOMEN ONLY) 33 Church St, White Plains, NY (914)-948-5044
• Open Arms Shelter (MEN ONLY) 86 E Post Rd, White Plains, NY (914) 948-5044
• Yonkers Sharing Community 2 Hudson St, Yonkers, NY (914) 963-2626

For your next difficult access patient, you can review ultrasound guided iv access on the dedicated nwhed.org page.

EDCT Project – When Main CT is down as well

EDCT Project – Communicating with Phelps

Code Stroke – EDCT Project Plan

Code Stroke – No operational CT

Stroke MRI – MR Angio Brain WO IV Contrast (Epic Order, Details )