Focused/ED/Miscellaneous

Question 1

Focused Cardiac Ultrasound (FCU)

List 4 goals of a focused cardiac ultrasound.

Answer 1

• identify reduced LV systolic function
• determine volume status measured by RAP (more accurate & feasible than physical examination)
• identify marked RV enlargement
• identify significant pericardial effusion

Question 2

Image recording is not mandatory for handheld ultrasound.

True or False ?

Answer 2

True

Image recording is not mandatory

Question 3

Initial evaluation when there is a reasonable suspicion of valvular heart disease scores a 1 on the AUC.

True or False ?

Answer 3

False

*indication #34: initial evaluation when there is a reasonable suspicion of valvular heart disease (AUC score = 9)

Question 4

Sustained or nonsustained atrial fibrillation, SVT, or VT scores a 9 on the AUC.

True or False ?

Answer 4

True

*note:

SVT - Supraventricular tachycardia begins in the upper portion of the heart, usually the atria

VT - Ventricular tachycardia begins in the heart’s lower chambers, the ventricles

Because VTs occur in the ventricles, they make the heart extremely inefficient and are more serious than SVTs.

The symptoms of VTs are usually more severe, and have a much greater tendency to be fatal.

While SVTs are not usually life-threatening, they can cause both emotional and physical problems. It is cause for concern if a patient experiences frequent SVTs or if the episodes are lengthy.

Question 5

List at least 4 things suitable for a handheld ultrasound system.

Answer 5

LV systolic dysfunction

• LA enlargement
• LVH
• aortic root aneurysm
• AV calcification
• MVP/MS
• pulmonary edema
• pleural effusion
• pneumothorax

LV aneurysm

pericardial effusion

isolated RV enlargement

Question 6

The last structural change that can be detected in atherosclerosis is an increase in IMT.

True or False ?

Answer 6

False

*The first structural change that can be detected in atherosclerosis is an increase in IMT

Question 7

A __________________ with level 2 or 3 training performs a limited cardiac echocardiogram.

Answer 7

sonographer

Question 8

FoCUS is done by ＿＿＿＿＿

Answer 8

physician with FCU training

Question 9

“Appropriate Use Criteria” was developed as a result of the over use of echocardiograms.

True and False ?

Answer 9

True

*rational approach to prevent unnecessary use of TTE

Question 10

Atherosclerosis most often develops gradually and slowly, starting from childhood and proceeding into adulthood with varying velocity and susceptibility to complications.

True or False ?

Answer 10

True

Question 11

A limited Echocardiogram has a formal report meeting ________ standards and has a billing code ________.

Answer 11

IAC

93308

Question 12

A handheld ultrasound exam is usually less than ___ minutes.

Answer 12

5

*physician performs imaging during physical examination. Procedure needs short, specific explanation to patient

Question 13

Most Common Indications for TTE in a Clinical Setting is:

Answer 13

Indication #1: Symptoms or conditions potentially related to a cardiac etiology, including but not limited to chest pain, shortness of breath, palpitations, TIA, stroke, or peripheral embolic event (AUC score = 9)

Question 14

Symptoms or conditions potentially related to a cardiac etiology, including but not limited to chest pain, shortness of breath, palpitations, TIA, stroke, or peripheral embolic event AUC score = 9).

True or False?

Answer 14

True

Question 15

Coronary Flow Imaging has a reported specificity of 90%.

True or False ?

Answer 15

True

• Coronary flow imaging has a potential for noninvasive assessment of significant stenosis during routine echocardiography.*
• Indications are reported that there is a 90% specificity*
• *note: specificity -* the percentage of people who test negative for a specific disease among a group of people who do not have the disease

Question 16

_______________ is an important atherosclerotic risk marker.

Answer 16

Intima-media thickness (IMT) is an important atherosclerotic risk marker.

Question 17

Coronary flow imaging has no potential for noninvasive assessment of significant stenosis during routine echocardiography.

True or False ?

Answer 17

False

It has a potential for noninvasive assessment

Question 18

Significant stenosis in the LAD is usually located in the ____ segment of the artery

Answer 18

proximal

Question 19

A FCU as full function: M-mode, 2D, color Doppler, spectral Doppler, TDI, contrast, and is ECG - gated.

True or False?

Answer 19

False

FCU - 2D minimum

limited echo - Full function (M-mode, 2D, color Doppler, spectral Doppler, TDI, contrast), ECG-gated

Question 20

Significant stenosis in the LAD is usually located in the proximal segment of the artery.

True or False?

Answer 20

True

Question 21

Based on the AUC, routine surveillance (< 1 year) of heart failure (systolic or diastolic) when there is no change in clinical status or cardiac examination would be considered ok.

True or False?

Answer 21

False

Indication # 74:** Routine surveillance (< 1 year) of heart failure (systolic or diastolic) when there is no change in clinical status or cardiac examination (**AUC score = 2)

Question 22

List 4 risk factors for carotid intima media thickness.

1.

2.

3.

4.

Answer 22

aging

HLD

HTN

smoking

DM

obesity

sedentary lifestyle

Question 23

A hand held Ultrasound system is the new stethoscope for a physiscian.

True or False?

Answer 23

True

• Physician with a stethoscope – former
• Physician with Hand held ultrasound

Question 24

List 4 limitations of FCU.

1.

2.

3.

4.

Answer 24

1. transducer quality/selection
2. devices used to image: smaller screens, fewer imaging modes, less image processing
3. lack of ECG gating
4. typically not quantitative
5. imaging protocols from limited windows
6. limited experience of user - obtaining images/interpreting images

Question 25

***A focused cardiac ultrasound does not have a defined scope of practice and can be performed anywhere, anytime.*** ***True or False?***

Answer 25

False FCU: location of imaging - defined scope of practice \*Scope of practice is broadly defined as **healthcare services that a physician or other healthcare practitioner is authorized to perform**. Responsibilities are based on education, training, experience, and demonstrated clinical competency.

Question 26

***Intima-media thickness values of more than ___ (ESC) or over the 75th percentile (ASE) should be considered abnormal.***

Answer 26

* Intima-media thickness values of more than **0.9 mm** (**ESC**) or over the **75th percentile** (**ASE)** should be considered abnormal.* * \*note: ESC - The European Society of Cardiology*

Question 27

***A ____________ with FCU training typically is the person performing a FCU.***

Answer 27

**physician** FCU acquisition: Physician with FCU training FCU interpretation: Physician with FCU training defined, limited scope

Question 28

***When the need for clinical evaluation is emergent or urgent and echocardiography is not immediately available, FCU may be used. List 4 pathologies that might be assessed in the ED or at the seen of trauma.***

Answer 28

hemodynamic instability or **shock** **chest trauma** clinical suspicion of **pericardial tamponade** **cardiac arrest** **acute heart failure**

Question 29

What is FOCUS ?

Answer 29

Focused cardiac ultrasound (FOCUS) refers to **the use of ultrasound to evaluate cardiac pathophysiology at the point of care, by providers actively managing a patient**. \*limited exam

Question 30

_Limited Echocardiogram vs. Focused Cardiac US_ * image protocol? * equipment (function)? * measurement? * acquisition by? * interpretation by? * image storage? * documentation? * billing?

Answer 30

Question 31

_Hand Held Ultrasound_ functions (4)

Answer 31

***Basic 2D imaging** – measurements* ***Color Doppler – lesions*** ***High Frequency** – atherosclerosis* ***Assess diastolic filling patterns***

Question 32

_Hand Held Ultrasound Technique_ patient position? gel application? risk? study interpretation? documentation?

Answer 32

* Patient is supine or in semi-Fowler position* * Minimize gel reapplications, preferably use only a single dollop* * Device drop, misplacement, and contamination risks* * Study interpreted on the spot, while imaging* * Document subjective findings, preferably as a component of physical examination* * Recharge device battery every 1-2 days*

Question 33

_Applications of Focused Cardiac Ultrasound_

Answer 33

Question 34

_Most Common Indications for TTE in a Clinical Setting_ ## Footnote ***Indication #2:** Prior testing that is concerning for heart disease or structural abnormality, including but not limited to chest X-ray, baseline scout images for stress echocardiogram, ECG, or cardiac biomarkers (AUC score ?)*

Answer 34

9

Question 35

_Most Common Indications for TTE in a Clinical Setting_ ## Footnote ***Indication #9:** Syncope when there are no other signs of cardiovascular disease (AUC score = ? )*

Answer 35

7

Question 36

_Most Common Indications for TTE in a Clinical Setting_ ## Footnote ***Indication #58:** Suspected cardiovascular source of embolus (AUC score = ?)*

Answer 36

9

Question 37

_Most Common Indications for TTE in a Clinical Setting_ ## Footnote ***Indication #71:** Re-evaluation of known HF (systolic or diastolic) with a change in clinical status or* *cardiac exam without a clear precipitating change in medication or diet (AUC score = ? )*

Answer 37

8

Question 38

_Most Common Indications for TTE in a Clinical Setting_ ## Footnote ***Indication #73:** Re-evaluation of known HF (systolic or diastolic) to guide therapy (AUC score = ? )*

Answer 38

9

Question 39

_Most Common Indications for TTE in a Clinical Setting_ ## Footnote ***Indication #1:** Symptoms or conditions potentially related to a cardiac etiology, including but not limited to chest pain, shortness of breath, palpitations, TIA, stroke, or peripheral embolic event (AUC score = ?)*

Answer 39

9

Question 40

_Most Common Indications for TTE in a Clinical Setting_ ## Footnote ***Indication #5:** Sustained or nonsustained atrial fibrillation, SVT, or VT (AUC score = ?)*

Answer 40

9

Question 41

_Most Common Indications for TTE in a Clinical Setting_ ## Footnote ***Indication #34:** Initial evaluation when there is a reasonable suspicion of valvular heart disease (AUC score = ?)*

Answer 41

9

Question 42

“Rarely Appropriate” indications for TTE

Answer 42

Question 43

* Intima-media thickness is an important atherosclerotic risk marker. However, this increase is not synonymous with subclinical atherosclerosis, but is related to it. Indeed, increase in IMT is also the result of nonatherosclerotic processes.* * T or F ?*

Answer 43

T

Question 44

*The \_\_\_\_\_\_\_\_\_\_\_\_\_\_is a measure used to diagnose the extent of carotid atherosclerotic vascular disease. The test measures the thickness of the inner two layers of the carotid artery—the intima and media—and alerts physicians to any thickening when patients are still asymptomatic.*

Answer 44

*carotid intima-media thickness test (CIMT)*

Question 45

_Coronary Flow Imaging_

Answer 45

Question 46

PoCUS is the test of choice in the ED for... (2)

Answer 46

cardiac arrest and emergency triage

Question 47

UAPE stands for?

Answer 47

ultrasound augmented physical examination