POCUS
SESAME, RUSH, FALLS , BLUE PROTOCOL, POCUS CA
PRESENTER: DR MUKUND SAJJAN
MODERATOR: DR NIKHIL KOTHARI
SESAME PROTOCOL
The SESAME protocol provides a structured approach for assessing
patients in severe shock or cardiac arrest using echo
Key Concepts of the SESAME Protocol
1. Sequential Assessment: The protocol guides clinicians to
sequentially evaluate echographic findings.
2. Application in Cardiac Arrest: Originally designed for severe shock,
the SESAME protocol has been adapted for established cardiac arrest
scenarios, allowing for rapid diagnosis and intervention.
Ruling Out Pneumothorax in the
SESAME Protocol
STEP 1
Primary Goal: Rule out pneumothorax in cardiac arrest situations.
• Reason for Lung First:Immediate identification of specific pathology.
• Quick assessment (under 2 seconds).
• Signs to Look For:
• Bat sign (lung surface)
• Seashore sign
• Pneumothorax Detection:
• Typically large and detectable regardless of probe placement.
• .
Technical Considerations
• Probe Placement:
• Anterior chest wall, near the lower BLUE-point.
• Impact of CPR:
• CPR may cause rib fractures, complicating diagnosis.
• Ultrasound scanning should ideally interrupt compressions briefly.
Step 2 - Searching for Pulmonary Embolism
Focus on DVT Detection
• V-Point Assessment:
• Rapid evaluation of the lower femoral vein using a microconvex probe.
Importance of DVT Detection
• Connection to PE:
• ~50% of massive pulmonary embolism cases also present with DVT.
Rapid Identification
• B-Mode Ultrasound Signs:
• Visible clot
• Uncompressible vein
• Doppler Limitations:
• Time-consuming; not included in SESAME protocol.
• Calf Vein Sensitivity:
• Assessing calf veins can improve detection rates (~66%).
• If DVT is Excluded:
• Reduced likelihood of pulmonary embolism.
• Proceed to assess for right ventricular (RV) dilatation.
• Transition to Step 3 for further evaluations.
Step 3 - Diagnosis of Hypovolemic
Cardiac Arrest
Abdominal Ultrasound Assessment
• Probe Movement:
• After femoral vein assessment, move towards the heart.
• Quick check of the abdomen for fluid collections.
STEP 4. RULING OUT PERICARDIAL
TAMPONADE
•Two Hearts Phenomenon
•Pericardial window: Visible when fluid enlarges the mediastinum.
•Tamponade in Cardiac Arrest
•Substantial effusion suggests tamponade with obstructive shock.
•Microconvex Probe Advantage
•Ideal for diagnosing and guiding needle insertion in pericardial tamponade.
•Standard cardiac probes and abdominal/vascular probes are less useful.
•Holistic Ultrasound
•One probe, multiple functions: diagnosis and intervention.
•SESAME-Protocol
STEP 5. THE HEART Transthoracic echocardiography
Considerations for Echocardiography During Cardiac Arrest
1. Mastery of Echocardiography
1. The user must be proficient in echocardiography techniques to interpret results effectively.
2. Unpredictability of Cardiac Window
1. It is uncertain whether a good cardiac window (ultrasound view) will be present in any given
situation.
3. Interruption of Cardiac Compressions
1. Performing TTE typically requires stopping chest compressions, which can delay life-saving
interventions.
4. Adjustment of Depth Settings
1. Heart location: Being a deep organ, TTE requires adjusting the depth from 85 mm to 140
mm before assessing the heart.
Patterns on TTE
1. Asystole
1. Simplest pattern: Absence of cardiac activity (asystole) is easily diagnosed
but usually indicates a poor prognosis.
2. Dilated Right Ventricle (RV)
1. Indicator of Pulmonary Embolism: A dilated RV can suggest the presence
of a pulmonary embolism, a life-threatening condition.
SESAME-PROTOCOL AND TIMING
Ultrasound Timing Breakdown:
• Probe & Contact Gel Ready:
• 7 seconds from switch-on to applying the probe.
• Pneumothorax Detection:
• 5 seconds per lung, 10 seconds total.
• DVT Detection (at V-point):
• 5 seconds per side, 10 seconds total (can be done during compressions).
• Massive Fluid Collections (Abdomen):
• 10–12 seconds (can also be done during compressions).
• Pericardial Fluid Detection:
• 8–10 seconds.
• Total Time to Cardiac Assessment:
• Less than 40 seconds of scanning time
If no cardiac window after 12 seconds, resume compressions and retry later.
•Recent studies: RV enlargement might occur after several minutes of resuscitation,
• but SESAME-protocol performs heart assessment much earlier.
Gel allows for quick transitions and immediate resumption of cardiac compressions after scanning.
RUSH PROTOCOL
PROTOCOL FOR HYPOTENSION
The phased array probe will be the mainstay of the RUSH protocol . If a
DVT examination is indicated, a switch to the linear probe is required.
Remember, using the eFAST or abdominal preset will have the
orientation marker on the left side of the screen instead of the right
side like in the cardiac preset. This will require you to flip your probe
indicator 180 degrees on your probe to obtain the appropriate cardiac
views.
Cardiac assessment
Ejection Fraction Assessment
• Observe the left ventricle throughout the cardiac cycle. Is it hyperdynamic or
hypodynamic? Does it squeeze uniformly?
• Next, note the anterior leaflet of the mitral valve. Does it move freely and
approach the interventricular septum with each diastolic filling? If not, the
heart’s contractile function may be impaired and the patient may be
experiencing an exacerbation of systolic heart failure resulting in hypotension.
• If the heart appears hyperdynamic, the source of hypotension may be related
to hypovolemia or sepsis. This can be determined by continuing to evaluate the
patient using the rest of the RUSH exam.
EPSS distance
Normal vs abnormal EPSS: (a) EPSS
<7 mm, which correlates with
normal EF. (b) EPSS >13 mm which
correlates with severe LV
dysfunction
Fractional shortening
Fractional shortening can be used to estimate EF. This is performed by
placing an M-mode spike through the anterior and posterior walls of the
LV at the mid-LV in the parasternal short axis view. In M-mode, the
diameter of the left ventricular cavity is measured in end-diastole
(LVEDD) and end-systole (LVESD). One can then apply the below
formula to obtain an estimation of EF%:
FS = (LVEDD-LVESD/LVEDD) x 100%
A normal EF is suggested by a percent FS between 25-45%
Fractional shortening
TAPSE
Normal Tapse
• Right ventricular hypokinesia
• T
ricuspid annular plane systolic excursi
on (TAPSE)
<1.6 cm
Mcconels sign:Pulmonary embolism
Mcconels sign
It is defined as a regional pattern of
right ventricular dysfunction, with
akinesia of the mid free wall and hyper
contractility of the apical wall.
Right RV strain
dilatation of the right ventricle
• quantified as a basal diameter >4.2
cm, a mid-cavity diameter >3.5 cm,
and a length exceeding 8.6 cm
• ideally measured in the RV focused
apical 4 chamber view
• right ventricle/ left ventricle end
diastolic basal diameter ratio >1
DVT scan
If any evidence of right heart strain is found, the exam should proceed
directly to the evaluation of the legs to scan for a possible deep vein
thrombosis by looking for a noncompressible vein. Findings of DVT in
the setting of RV strain will greatly increase the chances the patient has
a significant pulmonary embolism
Pocus findings. Cardiac tamponade
Parasternal long cardiac view which
demonstrates large effusion with RV
diastolic collapse
Right ventricular diastolic collapse
viewed in M-mode
Right ventricular diastolic collapse
viewed in M-mode
Flow variations in respiration
when assessing for tamponade, it can be helpful to assess the mitral
and tricuspid inflow variation. In pericardial tamponade, there is
increased interventricular interdependence during filling exaggerating
the respiratory variation flow through the atrioventricular valves. This
can be performed in the apical four chamber view, by placing pulse
wave doppler (PWD) over the area of either the mitral valve or tricuspid
valve. The velocities are then measured during expiration and
inspiration. A mitral valve inflow variation of over 25% or tricuspid
valve inflow variation over 40% is indicative of pulsus paradoxus and
tamponade physiology. Additional findings in tamponade include a
wide, plethoric IVC with minimal variation, as well as collapse of the
right atrium during ventricular systole.
Mitral and tricuspid flow variation in
tamponade
Step2: IVC assessment
• A high CVP suggested by a dilated and noncollapsible IVC may hint
towards an obstructive or cardiogenic etiology.
• A low CVP suggested by a small and collapsible IVC may hint towards a
distributive or hypovolemic etiology.
The IVC measurement is mostly used to assess fluid tolerance rather
than fluid responsiveness. Using the IVC collapsibility Index (below), the
diameter and collapsibility during inspiration or with a sniff test can be
used to estimate CVP. Limitations include body habitus, increased
intraabdominal pressure, etc.
Step [Link] pouch Peritoneum
free fluid
Free Fluid at the Caudal Tip of the
Liver
Free Fluid in Morrison’s Pouch and
Suprahepatic Space
Pleural effusion
Thoracic spine sign
In the presence of a pleural fluid
collection, the transmission of
ultrasound waves is enhanced,
allowing us to visualize the presence
of the vertebral bodies; which are
seen as a continuous hyperechoic
line extending both above and below
the diaphragm
Step4: Aorta
Abdominal aortic aneurysm
A normal aorta is usually ~2.0cm in
diameter. An abdominal aortic aneurysm is
defined as
• ≥ 3cm diameter for the abdominal
aorta or a > 50% increase in the aortic
diameter.
• ≥ 1.5cm diameter for the iliac arteries.
• Anytime a patient presents with a AAA of
>/= 5cm and hypotension, assume a
rupture until proven otherwise.
• Be sure to measure Outer wall to Outer
wall for accurate aorta measurements.
Aortic dissection
An aortic dissection may present as
a free flap in the aortic lumen of
either the descending abdominal
aorta, ascending aorta, and/or the
aortic arch. Aortic dissections in the
ascending aorta can also cause
aortic regurgitation and a diastolic
murmur.
Step 5 :Lung USG pleural lines
Lung sliding
• A dynamic sign perceived as
shimmering of the parietal and
visceral pleura in contact is referred
to as lung sliding and is part of the
normal aeration pattern.
Z lines Lung USG
Z lines are common artifacts seen in
more than 80% of the population
and may be mistaken for coalescent
B lines . Z lines are vertical, bundle-
like shaped lines arising from the
pleural line; however, they are ill-
defined, do not erase A lines and are
not perfectly synchronous with
respiratory movements.
B lines
B-lines B-lines, also referred to
as comet tails, are vertical artifacts
that appear as echogenic lines and
extend from the pleural line into the
lung parenchyma. They are created
by discreet short path reverberation
artifacts due to interstitial edema,
increased fluid, or fibrosis in the
interlobular septae.
Absent lung point
Visualizing the junction between
sliding lung and absent sliding is
known as the lung point sign and is
near 100% specific for
pneumothorax.
FALLS Protocol
The FALLS-protocol (Fluid Administration Limited by Lung Sonography) follows
Weil’s classification of shocks. Firstly, it searches for pericardial fluid, then right heart
enlargment, lastly abolished lung sliding
BLUE Protocol
POCUS -CA Protocol
POCUS CA( Pocus after Cardiac arrest )
FEER protocol(Focussed Echocardiographic evaluation in
periresuscittation)
FEEL protocol(Focussed Echocardiographic evaluation in Life support
and Periresuscitation)
POCUS-CA
The evaluation of the images is not carried out during
direct visualization, since this may delay the restart of the
compressions, that means that the recording will be
carried out for 10 s as indicated in the international
resuscitation guidelines
When the compressions are restarted, the clinician will
evaluate the recording obtained to determine diagnostic
findings, the findings are communicated and joint
decision-making with the CPR team is carried out
,The window used for assessing the patient with arrest during
resuscitation is the subxiphoid window as the first option and
the apical four chambers as the second option since they do not
intervene with compressions .
During the pause for pulse taking and rhythm evaluation, the
other windows available for diagnosis can be visualized, for a
limit of 10 s, which are the pulmonary window in the assessment
of pleural glide, the 4-chamber apical cardiac window,
parasternal short axis, and as the last option the parasternal
long axis.
Windows can be used to evaluate pleural effusion, hemothorax,
and free intra-abdominal fluid, described in the Extended
Focused Assessment with Sonography in Trauma (FAST-E)
protocol , which does not require synchronization with the CPR,
and allow obtaining additional information on the patient's
diagnosis.
FEEL protocol
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