 Hi, I'm Cern Boyson and he's a critical care specialist. I'm Serge Shaloud and Serge is a small animal internal medicine specialist and we're here today to present our first UCVM, VCDS, video podcast, bringing veterinary education, open access around the world. That's right, we work for the University of Calvary Faculty of Veterinary Medicine and today we'd like to start our podcasts with veterinary point of care ultrasound in small animals. This is a topic very near and dear to my heart, point of care ultrasound, so just to introduce everybody and catch everybody up to speed on what we're talking about, we're going to try and introduce a quick case here and then we're going to go through some of the more common things that we refer to when we talk about point of care ultrasound. Sounds good, let's talk about this case, Cern. Alright, so this is mittens, mittens is a six and a half year old domestic short hair that has been missing for two days and the owner found mittens outside and brought mittens immediately into the emergency clinic. And on our initial treehouse examination we look at mittens and the mucus man names are pale, capillary full time is prolonged, heart rates 142, respiratory rates 44 breaths per minute with increased harsh lung sounds, no obvious murmur, no obvious gallop rhythm when we're listening to the chest, but the lung sounds are harsh and the temperature is 37.4 degrees Celsius. What do you think? You're an internist but I think you can probably figure this one out. Serge, you tell me, is this patient stable or unstable and why? Well, Cern, I would say unstable. Okay, and what was your assessment there to tell you that this patient is unstable? I don't know, I didn't like that heart rate a lot and the capillary full time, even for an internist that sounds pretty prolonged. Good, and then we've got the pale mucus membranes and we've got a weed from oral pulse. So we definitely have signs of cardiovascular and respiratory unstable patient in this situation. We're obviously going to start our resuscitation and how are you going to figure out what's going on? We're going to act pretty quickly. What are your choices? What are you going to be doing here? Well, I think the biggest thing I'd want to see here is abdominal and thoracic redographs. I want to see a lot of x-rays, like 10, 20 different x-rays. You could go do some x-rays, it will give you some information in terms of what's going on in the chest and abdomen, but there's a good chance that you're going to kill this cat on the radiology table. What? If our patient's unstable, it is a concern, one, to take him out of the emergency room and two, to restrain him, increases work of breathing, increases stress. What do you recommend, Serge? So this is where we've started to talk about point of care ultrasound. How long does this take? Less than five minutes, I'll get my scans done. This is done at the cage side. This patient's sitting on the table, I've got a tech put in an IV catheter in, I've got somebody getting the blood pressure, the ECG's been hooked up, maybe we're giving them fluids, maybe we're not, we're giving them oxygen, we're giving them analgesia, well, all this is happening. I'm picking up my ultrasound probe and I'm putting this on that patient and within five minutes I can probably tell you what's going on in that patient. That sounds pretty fantastic. And again, the nice thing about this, if you look at the literature out there, this does not take a lot of extra training. So we're not looking at high-level training in terms of specialists in radiology. This is something that general practitioners, emergency doctors, can easily learn and apply in their patients. It doesn't take that much training, right? Like, even a child pretty much sees. What you're kind of telling me here. That's exactly what I'm telling you. Tell me more about this. Well, the main goal, if we put these ultrasound probes on in that five minutes, there's a few things that we're looking for. We're looking for an underlying cause. An allergy that tells us why, in this case, mittens is unstable. It will hopefully help us then, if we find something, let's say we find some pre-fluid somewhere, one of our main goals in many of these cases, it can then allow us to direct further diagnostics towards obtaining that fluid and figure out what direction we're going into in that patient. What about helping potential next steps? Will they help you with that? Yes, exactly. And that's the other thing. If we put the ultrasound probe on and we find lesions in the lung, we find them in the abdomen, it's going to help us direct therapy and maybe further analgesics. If we get a sample in the patient septic, we know that right away. So as a diagnostic tool, it helps us collect a sample that tells us the underlying problem and therefore we know we need to train that or put them on antibiotics or whatever it is that we need to do. So I'm getting in now. What you're saying is this doesn't replace the physical exam, radiographs or anything else. It complements, has its place, certainly in the early minutes when you're doing everything else with that patient. I would actually say that's a good summary, Dr. Schu. All right, friend, is there a fancy name to this or previous name to this? Does it have a specific acronym or name? We're talking mostly about focused assessment and sonography for trauma or more commonly now triage because it encompasses more. But we're essentially talking about fast exams. I like that. It certainly fits with the type of exam you're doing. It's pretty fast under five minutes. Yes, and I will say that. Can you tell me about the different types of techniques here? Is it just like, where are you using it? Classically, focused assessment, sonography for triage exams at the abdomen, A-fast of the thorax, commonly referred to as T-fast. We're also starting to see in the veterinary literature a lot of lung ultrasound. We'll talk about that as well. And there is an ongoing movement now moving towards things including even the heart, the vascular system for volume status and we're looking at some other things too and turning the gallbladder as well. Those are things that we will cover in future podcasts. My head's getting a little dizzy. That sounds like a lot of ultrasound. Are you sure this can be done in five minutes? Has this been validated? So again, a lot of the earlier studies, the A-fast and the T-fast has been demonstrated and validated in the veterinary literature and shown that the average time for a non-specialist to complete these examinations is under five minutes. If you're adding them together, it does take a little bit more time but I would say that this is still something that can be easily completed in under ten minutes and with a good experience. All of these views can be done in under five. I agree. The difference is amazing. Fantastic. So wait, let me get this right. From what I understand, from what I remember when you were training me, your name was on this fast paper. So you're the one who created this. That's pretty awesome. I wouldn't say that. Actually, what I did was I read some human literature and I simply took that protocol and adopted it to veterinary medicine. So we published that out of tough. So Dr. Zansky, Dr. Rush, my mentors as well as a lot of my resident mates, and that was a very team effort, collaborative approach to setting up that first translational study, we'll call it, from human to veterinary medicine. So you're telling me to do veterinary research you don't need to be a genius? I'm saying there's a lot of veterinary geniuses out there, Dr. Salute, that do some amazing research but in my case, I'm going to say you can simply read the human literature and adapt a lot of what they do to veterinary progression. And is it pretty much the same, that human fast versus the veterinary faster or did you do something different here? There's a lot of similarities between the human abdominal fast studies and the abdominal fast studies that we're now doing in veterinary literature. One of the big things we did though, we turned the animal on its side. Okay, I get it now. That is pretty genius. I like that. All right. So talk to me about these sites. Where are you putting the probe here? So we're putting the probe at four different locations. Subziphoid, diaphragmatic hepatic site by putting the probe at the subziphoid. So essentially right here we're going to be putting our probe right here at that subziphoid location and looking at the liver between the liver lobes, between the liver and the diaphragm and let's talk about them later podcasts standing further into the story. So we've got Lily here that's going to act as our model, Lily. Right. Like my daughter's dog acting as our model. Hi, Lily. We want to look at the left perellumbar region. So we're going to be down in this region here. Sort of right behind the ribs looking for that left kidney. And this is also known as the spinal renal site. We're going to look at on the other side of the patient on that right perellumbar region. We're certainly going to have to hepatic and renal site. So the perellumbar site or right sublumbar region. And then we're going to come in sort of midline over the bladder and we're going to assess that area over the bladder in our last view. And that's also known as the cystococcus. So I think I understand that but I've also read about this fifth view which I'm not too clear on that. We have a video here showing essentially that exact. Let's take a look at this video here. You think about where fluid accumulates on your fast examination. It's in the gravity dependent spot. So our fluids actually going to be accumulating down here. Two things to avoid when you're doing your ultrasound on your fast exam. Some people will actually come in at low angle here and they'll push the probe up like this. What that does is it creates a V of skin on either side of the probe. And if you push the probe up like this what you're actually liable to do is move the fluid from that gravity dependent spot to either gutter on the side of the probe. So if you push in heavy like this the fluid tends to accumulate on the two gutters on either side of the probe. Therefore what we're doing if we're just looking for free fluid at this spot it's not about to get a quick flash of the umbilicus. If you think about where the fluid is going to accumulate and you wanted to do an aspiration without ultrasound you would aim it like this to try and catch this pocket down here where my fingertips are. So that's what we'll do with our probe then. We can put our probe on the umbilicus and we can just aim it down towards that gravity dependent spot and we can search that area again moving the probe cranially we can see the liver coming in here move it ventrally so fan it around and move it without moving it by a great deal from one spot but we'll move back and forth fan and rock the probe and look for the presence of free fluid in that gravity dependent pouch at the umbilicus. Wow. You're convincing me Cern but as an internist as an internist you know me I can't fly by the seat of my pants I need a little more structure are these studies going to be done in left lateral, right lateral tell me a little more. I'm confused. The original studies were in lateral cumminsy however if our patients are unstable and they're resistant to restraint but we're really worried about them particularly if they're dysmic and they're breathing more comfortably in sternal or standing position then absolutely we can scan these patients in standing, sternal, left lateral, right lateral. Alright I like that. The one thing I will say though is you do want to avoid putting patients on their back I know you guys as internal medicine people you like to put your animals on their back when you scan them and shave we'll talk about that shortly but we don't want to put them on their back this is revolutionary alright I like that so one thing though I mean humans I mean we're not that hairy right so you could put a probe on there it's not a big deal but I mean look at even this thing here how do you get the probe to have contact and see things you have to clip okay so that is a misconception in terms of you have to clip so if you don't get a good image quality you certainly can shave the fur alright you know I like using those clippers so not using the clippers oh what about gel you know how much I love using my gel for us on the emergency scanning we will place alcohol so we'll just spray our animals with some alcohol okay and part the fur so that we have good contact between the skin at the level that we want to examine and put the probe there and we will get a good image that tells us what we need to know and all the clips that you're going to see in the future podcast that we have here are done without shaving just using alcohol so what's this combination thing so this is something that I think actually originated on the human side as well but you've got gel based alcohol hand sanitizers and this actually works quite well as a combination of gel and alcohol sanitize your patient at the same time that's fantastic so hold on you were kind of poking in front of me earlier for putting my patients on their back I don't understand what the problem is that why is that such a big issue you get such a nice position on their back you can locate all the organs why not if you put dogs or cats on their back when they're dysmic this will increase your work of breathing it will increase the degree of effort what else though so cardiovascular instability is a little more difficult to understand but if you think about this from a physiologic standpoint when they're in a stern or standing position that weight is on the ventral part of the abdomen we put them in dorsal all the weight of those organs now is compressing on the vena cava for example and that will decrease venous return to the heart and there are certain situations in patients that are cardiovascular stable where that decrease in venous return for example pericardial fusion case could result in the decrease in venous return to the point that they will arrest interesting okay I could totally buy that so we've talked a lot about this fast and that was your first study what are you looking for with abdominal fast scans so it's come a long way and I'm going to say that the basic key point to start is looking for free fluid and that's at those four sites that we mentioned so I think I understand why you think even someone like me can do this because all you're looking for is fluid you're not looking at the spleen specifically or anything else it's fluid so when you're starting out you're going to look for fluid as you get more comfortable with ultrasound you can certainly expand and include other components in your emergency evaluation of your patients but now again as an internist you know I'm really liking this but let me know if something probe can tell you what kind of fluid there is is that the key here so I don't know what you're getting taught but if you're thinking you can detect what the actual fluid is you can see differences in echogenicity the fluid you don't know what the fluid is if you want to know what that fluid is if you want to be dependent on that I would strongly recommend you click the sample of fluid and you'll look at that psychologically or evaluate it chemically fine now what about seeing fluid on one site versus three sites does that make a difference what is that is that anything so there is actually an abdominal fluid scoring system again that was developed by Dr. Luciandro and this basically says how many sites are positive so if I do those four scans and I find this fluid at one site it doesn't matter which site any one of those four that's positive one so that's an AFS score abdominal fluid score one out of four because you got four sites dick with me bear with me you're sorry so you got four sites he gets positive any one that's one out of four gotcha positive any two would be two out of four positive any three three out of four and positive in all four sites bad four out of four the higher the score the more likely you are to need a blood transfusion so it's that follow up that's really more yeah now bring this into the serial exams you want to see if that fluid is getting worse over time or decreasing over time but we don't tend to use the abdominal fluid score to help us predict whether we need to go to surgery or not even on the human side they don't really have a clear score system that tells you surgery or not so I mean we've talked a lot about the abdomen here and that so let's move on to the thorax I mean you know patients are hit by cars I mean there's a lot of thoracic trauma can you use this for the chest Dr. Salou you most certainly can evaluate the thorax with fast scanning as well this leads to thoracic focus assessment snoggers for triage trauma or triage again known as T-Fast and essentially the urgent studies on this they looked at chest tube site sort of the ninth intercostal space in the caudal dorsal area on one side over the heart so in that fourth to sixth intercostal space more ventrally over the each in the heart per cardinal site they do that on both sides so that's four views and they also include a sub-ziphoid view where you angle the probe same site as that site we talked about when we did the abdomen scanning but to tip the probe more cranially and increase the depth so that you can actually assess can plural per card exactly so you're looking at the thorax through the sub-ziphoid site there's regional lung scans now and there's a few of them out there yeah there's a few of them out there so I'll just test based on those real quick we realized particularly at this chest tube site of the T-Fast examination that we were bitten lung development but we weren't covering the cells now that are looking at regional lung interesting so there is an eight point scan called vet blue and it looks at the chest tube site perihylar and then areas cranial and cauga essentially to the heart on both sides there's another study out there that was done in Italy this is by Dr. Arminese and he's looking at more extensive lung and he's got a nine point scan on either side so 18 points in total where you're moving cranial three sites in the dorsal region there and then going ventricle and looking at three sites and then there's a sliding protocol that's also developed where you move up and down between the ribs so can you kind of summarize what the indications are trauma is a big indication you get any patient that comes in with trauma you should be putting a probe on that patient for sure what clinical findings are you talking about what things are you looking for in your physical exam and your initial data to tell you this is definitely worthwhile those are patients that might have cardiovascular instability or dyspnea so we're going to do that in case they have low hematocrit low total solids high lactates high heart rates external injuries exactly okay I got you okay are there limitations though I mean it sounds like pretty awesome but are there anything any limitations when it comes to trauma so as I said trauma I would put the probe on anything out of trauma put the probe on blunt trauma more likely to result in fluid accumulations or lesions we're going to detect in the thorax such as contusions to the lung low sensitivity so we can miss injuries if we've got penetrating trauma and what else you will also find that it's not very sensitive on the human side or probably on the ventricide we're extrapolating here but retroperitone injury again that said if you do the scan and it's positive you know it's positive you can act on that so it's still worth doing so a negative fast rules that injury not an accurate statement we were doing well together there for a bit there do but you just fell off the wagon so as we talked about a negative result again it's a focused exam we're not looking at the entire abdomen our patient comes in with acute abdomen maybe it's got an ulcer we're not going to pick that on a fast exam unless it perforates and gets set to the abdomen or other diagnostic tests that would further complement so maybe a formal ultrasound of the full abdomen by a radiologist or somebody with that experience and trainee to find those lesions that we're not looking for as an internist trauma's all nice and that's your thing that's great trauma who sounds very ER critical care but I'm an internist what's the use of this for me because I don't see a lot of trauma we actually have a student that graduated with us that did a study while they were a student here at the UCVM and that person is doctor Jean-Ted McMurray she's now a vet she was in our third class to graduate she's been out there and she's done a few studies on an ultrasound the doctor McMurray is actually somebody that probably could speak more to this than I can because it was her study earlier look at that doctor he's here so doctor McMurray welcome to our first UCVM veterinary podcast thank you it's very kind of you to invite me I figured I'd just roll on in here so tell us a little bit about this focused assessment of sonography for non trauma what's the rationale behind that and what did you do with the study so basically we just wanted to see what the potential value of point of care ultrasound would be in a non trauma patient population so we looked at 100 dogs and cats that came in from the agency department for non trauma related reasons and did an abdominal scan and a thoracic scan we found that in patients that were stable on presentation about 10% of them had free fluid in the abdomen, pleural space or pericardium so not a lot of patients that come in stable are going to have free fluid or lesions you can detect on the A-Past and T-Past not very many but the number wasn't zero either so there were certainly some cases where we did pick up findings on ultrasound that ended up guiding our approach with those patients even more still worth doing still worth doing especially I think if you have a high index of suspicion for certain disorders or certain pathologies okay what are the odds if it's unstable this is where the study got really exciting in unstable patients we actually found that more than 75% of them had free fluid in one or more of those body cavities so this can be applied to both species right so we found no significant difference in the prevalence of free fluid between dogs and cats including both stable and unstable and you did this as a fourth year vet or student yeah I was a fourth year vet student I had about three hours of lecture time on these topics and then three hours of hands-on practice and some supervision for the first few cases but for the most part doing this study as a student really emphasized to me that you don't need a lot of experience with this you don't need to be someone with ultrasound a lot to gain a lot of value from one care ultrasound and if you had to summarize this what's your take home message then when you're applying ultrasound to these patients that come in to the emergency service in general my take home message would be that vets in general practice can and should be doing these procedures and that patients that have serious pathology will have findings that you can detect with ultrasound excellent thank you very much for joining us on our first official we'll see you again in the future alright I'm out I guess I got a little dizzy there when you threw me inside there but I'm kind of getting the point of this if you were to find fluid and you were to remove some of that fluid I know in fast I take it it was mostly blood that you would be pulling out right in the original trauma studies more often than not your blood but you might have a rupture gallbladder you could have a rupture urinary bladder in there you can't say for sure you need to get sample of that fluid in there if you're known from cases you see free fluid now you think about the number of cases that you've eventually diagnosed over the years that have pathology that results in fluid accumulation it could be a pylothorax in the chest chylothorax you could have a hemoabdomen you could have a uroabdomen you could have pylperonitis so anything you name it if it's fluid could you just do anything so you need to do synthesis pretty much all the time I got you and what about if that patient comes in dehydrated does that make a difference when we talk about fast scans? you have pathology somewhere for example inflammation in the abdomen as you resuscitate them it's a good chance you're going to lose fluid into that site that's affected and therefore over time your fast exams will become positive so roughly every two to four hours is needed it's really what it comes down to is that right? general rule of thumb I'd say every two to four hours but as needed depending on the response to your patient assess your patient you can't overemphasize the value of physical exam if your patient isn't responding that patient's not responding so you're seeing or we actually agree on something two to four hours is a good time frame two to four hours general is a good time frame but if 30 minutes after I start resuscitation he's not doing what I want him to do I'm re-scanning him so can we just re-emphasize what the key points of fast are? alright so we'll wrap up our podcast here with a summary the key points in the fast we do this during resuscitation this is done on the cage side well everything else is going on and it takes five minutes really a five minutes which is awesome minimal experience? you don't need to be a specialist and it takes minimal training and it's repeatable? that's the whole serial fast exam there's no radiation associated with it so it's safe you don't have to radiate your patients you can simply scan them alright no x-rays during those early early minutes there I'm saying x-rays have their value they have their value but when they're unstable they're sick I get it there's better ways you don't have to clip them you don't even have to use gel if you don't need you don't want to there's no traumatic portion to this nope well I'm pretty sold on here Dr. B I think this is pretty good and that concludes our first veterinary ucvm vcds video podcast thank you so much for joining us and also tolerating us we'll see you next time buh-bye