Hello. I'm gonna talk today about a relatively new adaptation of diagnostic ultrasound and equine practise, which is the point of care, examination and the equipment that goes along with it. And I want to thank you for attending and also thank the organisers for inviting me to give this presentation.
I'd also like to thank my collab collaborators, Doctor Chris Novata Solis and my fellow, Doctor Lindsay Deacon who helped acquire some of these images. So exactly what is point of care? Ultrasound, point of care ultrasound.
Is an examination that's performed at the time that you need to provide care to the patient. So it is a myriad of things. It can be an ultrasound examination that is actually performed to clarify findings on physical examination.
For instance, You don't hear any lung sounds in the ventral thorax, and you're concerned about a pleural effusion, you can use this technology to just put the probe on and look and see is there fluid there. It's very useful in an emergency setting and point of care ultrasound has been used quite a Lot in the equine field in the area of colic trying to decide if surgery is indicated and a flash protocol was originally developed, which is a fast examination of the equine abdomen to decide whether or not surgery is indicated, and we'll discuss that. That's the, point of care ultrasound that's been around for the longest period of time.
It can also be used to help you decide about the hemodynamic or cardiovascular status of a patient. Is the patient still really hemo concentrated? Is there a problem with myocardial function?
And then it can help you in diagnostic and therapeutic decision making. So things like where do I perform the thoracocentesis. I have a horse that presented or that I'm seeing with a puncture wound or laceration.
Is there a foreign body there? Is there a fracture associated with that? Is there a synovial structure involvement?
And it can be very useful in looking at fractures in areas where routine radiographs can't assess a fracture. So this is Doctor Lindsay Deacon performing an abdominal sonographic examination with one of the pieces of equipment. This one is known as the butterfly.
There's a number of pieces of equipment on the market. This particular unit uses one transducer to do all the scans. The only, the only missing piece with most of these point of care machines is there's no transrectal, transducer.
So with this particular transducer and, and the machine hooked up either to a tablet or a cell phone. You can scan everything that you would scan in the horse except for the transrectal examination. So, it's actually quite convenient as you can see, being able to see it on your cell phone, and you might initially think that the image isn't big enough on the cellphone to make an assessment and you wanna use the tablet.
And that's what I actually thought initially because I'm getting older and I thought it'd be much easier to read the tablet. But in fact, it's more difficult to sort of juggle the tablet. You need to have somebody else holding the tablet for you.
Whereas with the cell phone, you can make the adjustments in image quality, depth, all those things with your thumb. So it's individual preference. So here you can see in the back is Doctor Novice De Solis.
Doing a scan with a tablet. In the middle is Doctor Deacon doing a scan with the cell phone, and in the front is Doctor Sarah Coler doing a scan with a traditional hospital-based piece of ultrasound equipment. This is another piece of equipment called the Lumify and this particular point of care ultrasound machine, like many others, requires you to purchase several transducers.
So you have to swap the transducers out. It, it also allows you to just adjust the image, so gain depth, time gain compensation curve or TGC and almost all these also have the ability to do M mode, colour Doppler, and to make Measurements. So there's different image qualities between the units.
There's different ease of use between them, but they're all designed for the same purpose to have a small, very portable unit that you can scan multiple different areas with, with or without having, with or without having to make adjustments as far as changing transducers. So the original umA protocol, excuse me, Flash protocol was for a fast localised abdominal sonographic examination of the horse that was admitted for colic. So that's what FAS stands for.
And it's important to realise that it's a localised abdominal examination and not a complete ultrasound examination of the abdomen. So in the flash situation, the idea was to have a very quick exam that individuals of almost any level of experience could put the probe on and in 10 minutes or so make a decision about whether or not it looked like surgical intervention was needed. And basically, in their case study, it was horses that had small intestinal lesions.
So they had a high positive and negative predictive value for detecting the dilated urgent small intestinal loops, indicating that the horse required surgery. So you can see their windows and their little chart about what they are looking at. So they're basically looking for number one, different spots where you're likely to see small intestinal distention.
Number 2 is actually their thoracic imaging window and they're looking there to see if there's any possibility of something like a diaphragmatic hernia. Then on the right, they're looking at a duodenal window and they're also looking at the main large colon window, and on the left, they're looking at the stomach and looking to see is there evidence of a nephrosplenic ligament entrapment. So those are basically the things that you're looking for.
So there are lots of things that you could miss, . Particularly in a horse with chronic colic by just doing a flash. But the flash is a quick, easy way in the acute emergency situation or if you're in the field trying to decide, does this horse need to be sent for surgical intervention.
So in this instance here, you can see that there are multiple distended loops of small intestine as big as 6.5 centimetres in diameter. They're not modal.
They're quite turgid. They have normal wall thickness in the images that you're seeing here, but there's loops and loops and loops that are stacked up. And so there is likely that there's some type of small intestinal obstruction.
And again, this would be an example of a horse that would need to go forward for surgical intervention. If you contrast that with this horse, Who also has distended loops of small intestine, and they are somewhat hypomodal, so the motility is definitely decreased, but they're not amodal, and you can see that they're the surgical, excuse me, the, the loops of small intestine are filled with fluidity ingesta, but you can see those loops of small intestine contract. And so there is motility, they're not turgid.
The wall thickness of these loops also appears normal. You can measure with these programmes. So these would measure normal as well.
So this would be an example of a horse that while there is some small intestinal distension, this horse does not look like a surgical candidate. Another example, this is a a postpartum ma. And during her pregnancy in the latter stage of gestation, she developed two ventral abdominal wall hernias, one on the left side of the midline and one on the right side of the midline, and she's now weaned her full, and this is the the exam before she's gonna have a hernia repair.
And you can see that she's got A fluid-filled area in this region and the subcutaneous tissues, we're looking from ventral to dorsal. You can see some lacy loculations there, which is fibrine. So that's consistent with haemorrhage.
So that indicates that there may be further tearing of the body wall. Here, you have the most superficial layer of her ventral abdominal wall and the deeper layer of the abdominal muscature which kind of ends right about here. You can see a blunted end there and you can see a loop of small intestine that is within that hernia space, .
And this loop of small intestine has thickened walls. It's not turgid, but the walls are definitely thickened compared to this area over here, and this is the same air at the same time. And now you can see other loops of small intestine in the abdomen.
So we're not in the hernia at this time. We're actually in the abdomen. That have normal wall thickness, but again, are those turgid distended loops of small intestine.
This is another 6+ centimetre diameter loop. We're going from ventral to dorsal. So this achoic material that you see here is actually settled ingesta and fluid ingest on on top and this sign of the settled ingesta is another indication that you probably have a surgical lesion because you have enough ileus that any ingestor that's in there just totally settles out to the most ventral portion of that intestinal loop.
You could also look at, to look at the abdomen and other, you know, non-flash situations. So situations where the horse is uncomfortable or maybe mildly colicky or chronically colicky. And you can use the probe in that setting.
And you can see here that there's excess fluid in the abdomen, pretty clear on the right. The spleen has a shaggy coating on the visceral surface of the spleen. So these hypochoic almost seaweed-like shaggy tufts or fibrine that is stuck on the serosal or visceral surface of the spleen.
Dorsal to that are normal small intestinal loops with, you know, slightly decreased motility and they also look a little more fluidy than normal, but they are contracting. You can tell that they're gigunum because they have a really long mesentery. And then above them is colon.
On the left video loop, you can see much more fibrine here on the spleen, and you can also see fibrine tags here on the serosal surface of the large colon. So you definitely have a fibrinous peritonitis with fibrri lining both the gastrointestinal viscera and the, the organs themselves. And here you can actually see that there's increased ecogenicity of the paritin.
Fluid. And these are all obtained with the point of care ultrasound machine. So you can make a decision about, certainly this horse needs an abdominal paracentesis with culture and sensitivity of that fluid.
This turned out to be an actinnobacillus peritonitis in this horse. In chronic colic. And even some acute colics, one of the things you wanna identify is the lateral band of the secum.
That's a good marker to tell you where the secum is located, and you can follow that to identify the secum. Once you've identified the location of the then you can figure out where the right dorsal and right ventral colon is as well. And the other thing that you can do is if there's this, this lateral band of the cecum should always be below the costochondral junction of the rib.
So if you find another colonic Vessel or pair of vessels to be more accurate. That are above the costochondral junction. That's not normal and that's most consistently seen if you have a right dorsal displacement, but you could also see that with a volvulus that's 180 or 420.
So the normal clonic vessels are on the Axial side of the intestine. And so there has to be some rotation of the colon for you to be able to visualise those vessels. So this is an image.
Of the lateral cecal band. There's also lymphoid tissue here in the lateral cecal band. So if there's Enlargement of those lymph nodes, so if you can see them prominently, you know, you have some situation that's causing a lymphadenopathy.
You can also see here that there is some thickening of the wall of the secum here where it measures up to almost 0.5 centimetre to 1 centimetre. And a loop of small intestine here that you can see well enough that you can actually see the normal wall layering that loop of small intestine has normal motility and normal looking ingesta within it.
OK, let's advance. All righty, who seem to be frozen here, there we go. OK.
Other things, these are just other examples. The gastric window, that's a really important one that can help you decide about how severe the gastric distension is. Is nasogastric intubation indicated if you're managing a chronic colic and the acute colic, certainly doing a nasogastric intubation and reflexing the horse is gonna be standard protocol.
But if you're unable to get some reflux, you can come over on the left side and quickly check that gastric er window to see if there's fluid in the stomach that you're just unable to get out. So the left two images are demonstrated very enlarged stomach. How do you know that's systemic?
Well, this is the splenic vein and here's the spleen. And the stomach is immediately adjacent to the spleen. There's a gastrosplenic ligament there, so it's this semi-circular organ here.
It has to be the stomach cause that splenic vein is a marker for where the stomach should be located. On occasion, If there's no distention of the stomach, you may see small intestinal echoes in that space between the stomach and the spleen, and that could be totally normal, but when the stomach is distended like this, sorry, you're not gonna see that. And then, on the right, you can see that there's thickening of the wall of the right dorsal colon.
It's thickened up to 1.2 centimetres and the normal thickness of the right dorsal colon should be like 3 or 3.5 centimetres.
The best place to measure and evaluate for the right dorsal colon is on the right side between the 10th and the 15th intercostal space and most consistently in a normal horse, you'll see the right dorsal colon in like 1112, 13, and 14. If there's severe right dorsal colitis and a lot of thickening of the wall of the right dorsal colon, you can often see the right dorsal colon in several spaces that are more cranial. So you might be able to image it in 98.
8th intercostal space, sometimes even the 7th, although that's quite unusual. But that's only if the right dorsal colon is really abnormal and thickened. So, You can look quite close with the point of care ultrasound machine and you can improve the resolution of the Unit to some extent.
So this is just comparing the point of care ultrasound machine and a yearling with Lawsonia and the high-end hospital unit, looking at the same area pretty much of the colon. So this co Appearance here that we're seeing in both of these images is normal to see in the colon. And then you can see that it's quite hypoechoic.
You can tell that it's quite thicken, you know, here's our centimetre marker here. So you can tell that, you know, this is at least 6 to 8 millimetres in thickness. It looks pretty hypoechoic.
The detail of this is certainly better on the very high-end machine. But you can still diagnose that there's thickened colon or small intestine and come to a most likely diagnosis with the point of care machine. And there are definitely are situations where referral to a hospital that has a high-end ultrasound machine.
For further evaluation of lesions that you might pick up on the scan are indicated. But in the field, this gives you an immediate idea of what's going on and is the finding consistent with Lawsonia in this example. This is a horse that wasn't doing well and had loss of appetite and The search for neoplasia was on.
And so we were evaluating the entire thorax and abdomen. And it was actually while we were scanning the thorax cause we always go distal past the diaphragm. That we saw these lesions in the spleen on the left side, but we were, we were planning to do a whole abdominal exam anyway.
And you can see there's multiple punctate anechoic lesions with hypoechoicochoic material in the centre which probably represents necrotic tissue and or clot, . And Since it's in the spleen, one of the things that you would think about possibly is a hemangiosarcoma. But it could be a multitude of different neoplasias that cause, multiple, metastatic lesions, and this turned out to be an adrenal cortical carcinoma in this horse, but only with biopsying the spleen would we have been able to determine that antemortem.
This horse had chronic colic, fever and icru, and that often can be seen with obstructive cholangio hepatitis. And you can see that this liver is quite a cox, so there's loss of many of the normal. Vascular markings in this liver, and if we start on the left image, you can see what's called the parallel channel sign that's gonna come in to be right there.
So the vessels in the liver and the bile ducts run side by side. So normally you don't visualise the biliary tree in the horse, and so if you're able to see a parallel channel sign like that, that indicates biliary distension. And most likely, you have some obstruction of the biliary tree, so you have to think about obstructive cholangio hepatitis.
You can see here on the left that we see this achoic material in the biliary tree that's actually casting a weak acoustic shadow, and you can see some of that material extending out in that loop into the bile ducts, . And it, it almost looks like a V there. So there's a lot of sludge and like gritty concretions that are in that, those two bile ducts that are then obstructing.
Biliary flow, and on the right is a frozen image of one of those concretions. If the concretion is really heavily mineralized, we should see the shadow from the surface of the concretion that's closest to the ultrasound transducer. And in this case, it's coming from the far edge of this concretion.
So that suggests that it's more crumbly proteinaceous material. You can look at both kidneys with these point of care, ultrasound machines, and on the left is the hospital machine. On the right here is a point of care ultrasound machine.
This is a horse that had had rapid weight loss for the past Few weeks prior to presentation, again, another hunt for neoplasia. And you can see this abnormal area in the cranial dorsal pole of the kidney that looks like a mass. You can see that here as well, although it's not quite as crisp and clear.
One of the things that I would like to mention is that you can fiddle around with the settings on these point of care machines and improve the image quality, and there are different settings that you can choose from that vary from the machine, so you can see this one is called abdomen Deep. But then within that programme, you can increase or decrease the frequency, change the gain. Move the time gain compensation curve, change the depth so you can make adjustments.
And this would prompt you, since this is, This here is the right kidney. The only way to really further evaluate this would be to do a, a biopsy or you could look at blood flow with the colour Doppler, options on the machine to see if the blood, you know, you had an accurate blood flow pattern like you would expect in the normal or more normal kidney or did you have some Blood flow that was more consistent with a tumour. This turned out to be a lot of fibrotic renal cysts, so it's a very abnormal area of the kidney, but it was not neoplastic.
You can also see other things. These are both point of care images, that are, you know, somewhat subtle, but you can see that there's an increased ecogenicity here between the cortex of the kidney and the medullary portion of the kidney. And this is what's called a medullary rim sign.
And initially when the medullary rim sign was first reported, it was found in a lot of animals, both small animals, humans and horses, that had neoplasia like lymphosarcoma or other things, but it's also been reported in normal individuals, so it's considered. A non-specific finding and that it doesn't really tell you what else is going on with your patient and it's even possible that your patient could be normal. And then we can look at high-risk pregnancies.
So this is a huge plus for the point of care ultrasound machine cause you've got a small little unit that is either a tablet or your phone with a pro 1 or 2. Probes that you're gonna use. One probe that can do everything, or two probes, one that'll do the utero placental unit and one that'll do foetal heart rate and, and look at the foetus.
So here we're looking at the utero placental unit. Which, the foetus is here. Hopefully you can see the foetus.
And then this is the alantokorion here. This anechoic fluid is allantoic fluid. The the mom's or mayor's body wall is here.
This is a uterine blood vessel, and this is all uterus. And then here you can see an anechoic area of separation between the uterus and the latokorion. So there's premature placental separation that's occurring here.
And if we look further, We can see that there's a large area here of echoic material within the uterus that is between the uterus and the illanticorion, and it's in the cranial portion. Of the abdomen and the cranial portion of the uterus, which is consistent with a specific fungal placenitis, which is the nocardia placecentitis. So, In, in this particular mare, if you scanned her transrectally and measured the combined thickness of the uterus and the placenta, it would likely be normal and you would have to do this transabdominal scan to actually identify this area of uteroplantal.
Separation and this very echoic fluid consistent with Nardia. So you can monitor utero placental thickness in your patients with placenitis as you go through treating them. And you can also monitor the foetus looking for signs of foetal distress.
And one of those things that you wanna look for is foetal heart rate, and foetal heart rate is actually quite easy to obtain. All you need is to get an image of the cranial thorax, which is the small triangular part that you can see right here and see something beating in real time. You don't have to have any standard echocardiographic view whatsoever.
And then you put this dotted line, which is your cursor. Through the heart, and this is in the high-end ultrasound machine. And you hit M mode, excuse me, I'm gonna go back.
You hit M mode. And you get these two multiple bumps, you know, that you can see, and as long as you can see two structures that look like moving heart that are moving towards each other, you can make a heart rate measurement from there. So, in this case, you can see the heart rate was 64.
This is not the same patient, unfortunately. But you can see this bear has a heart rate of 64. Her foetus does rather.
And over here, different patients were also going through the heart, the cranial partial, the thorax, and you see that there's all these multiple contractions here that are rhythmic. And so this was measured here which gave a heart rate of just under 92 beats per minute. So you can all, all the systems have MO that allow you to monitor foetal heart rate.
So monitoring the foetus is a really important application of point of care ultrasound. And the thoracic ultrasound is another really important application. In this instance, we're looking at the cranial mestinum in a horse and you can see that there is fluid in the cranial mediastinum on both sides.
This is the mediastinal septum in the centre that's sort of flopping back and forth. And then if we look more dorsally on the right here, you can see lung. So this is the cranial ventralmost portion of the right lung in the third intercostal space, and you can see that it's at least aerated, but there are multiple comet tail radiating artefacts which are now called bee lines or lung rockets.
Indicating that there's some irregular aeration of the periphery there. As the pathology in the lung gets more severe, you'll see compression atleticis, which is what we're visualising on the left and that that tip of the lung is compressed and it's just floating in that relatively anechoic pleural fluid. And you can see that as the horse breathes in, there are multiple radiating comet tail artefacts, but at least in that intercostal space, you do not see any evidence of consolidation.
The undulating structure that you see here in the bottom left is the pericardial diaphragmatic ligament. And you can distinguish that from fibrine because fibrine usually is filmy and filamentous or maybe a mat, a sheet like you saw on the spleen and the colon. And the horse with actinobacillus peritonitis.
So this is a normal structure that you will always see if you take sterile saline and put it in a horse's chest, you will see that structure start to undulate. In the middle image, we're up very close to the heart. As you can see here, that's coronary arteries there.
And you can see that there's a larger area of consolidation, so the lung is less compressed here. And as we look slightly dorsal to the tip, there's a large anechoic cavitated space that we can see right here. When the horse breathed in, you could see it was difficult to see that cause the air And the overlying less affected lung covers it up for a minute right there.
But we can see that anechoic space with hypercoic speckles in it. Those hypercoic speckles are gas. So you have a necrotic area of lung.
It looks a little gelatinous. There's gas in it. So you've got to assume that there's anaerobic infection there.
Even though the pleural fluid is nice and anechoic, so it doesn't look like there's much of a fibrinous component to this pleural pneumonia, but there's a very severe anechoic, anaerobic necrotic area in this lung and you can see this is a, a different inner space because here we have liver instead of heart. And you can see this cavitated lesion that's extending caudal. You can also see the more axial side of the lung, which is down here, also looks cavitated with hyperchoic areas and it consistent with gas.
So again, anaerobic infection. When the infection gets more severe, you'll see things like this. So on the left, this was the course with the aspiration pneumonia.
This little piece here is some air in a, a more aerated portion of the lung. This is A large hypoechoic area of consolidated lung. There's gas lining the whole visceral pleural surface of the lung, which is that hyperchoic rim.
Gas loves to stick. On the Long surface, if there's fibrine. So anywhere there's fibrine, gas likes to stick on it.
And the first place that you might see evidence of gas in the thorax might be on this fibrine. And as we look at this area here, I think we have two things that are actually going on. Some is some lung that's more aerated and some also looks like there's a dorsal gas cap and there's some free gas in the lung, which is a little difficult to differentiate, but If I go back, sorry.
And play this again. There is some air that doesn't move, this right here that looks stuck, and then there's some air that's moving back and forth. There with the fluid as the horse breathes, that's, that area is most likely some dorsal pneumothorax in this case cause it's got again a severe necrotizing pneumonia.
Here we have this air bronchogram, that long linear gas echo, but then there's a circular gaseous structure that looks like an anaerobic abscess. And then in this horse, oops, it's not gonna play. We've got this very echoic jiggly fluid.
Next to some very abnormal lung, and this is what's called polymicrobullous fluid. So it's very cellular fluid that's also contains gas. Again, indicative of an anaerobic infection.
Which is typical of what you might see with aspiration pneumonia. And this is the kind of thing that you can see with Pleural pneumonia that occurs following shipping. So again, this is a very severe pneumonia with gas.
All those hyperchoic things are gas, but in addition, you can see that there's lots of fibrine. So there's loculations that we can see here over the, on the right. Some of them have gas.
Some of these fibrine areas. Have gas in them. There's some lung, which we can outline right here is the lung.
It's much more difficult in this frozen image to outline the lung, but it's this area here. And then there's a lot of gas, and then there's this mat of fibrine, some of which also contains gas. And that's basically what we're seeing.
Here, this jiggly gaseous material stuck on fibrine, a mat of fibrine that we can see there. And more gas in this sort of web of fibrine. So again, an anaerobic pleural pneumonia.
With fibrous, loculations and mats, that you can see. So again, a severe necrotizing pneumonia. It ultrasound is quite good at differentiating a pneumothorax from lung.
And so recently in the human literature, they've published about Using M-mode ultrasound to help you diagnose pneumothorax. So on the left is a small hypochoic area of lung with some gas in the centre. There's multiple areas like this, and the clinicians were concerned about EMPF, equine, multinodular pulmonary fibrosis or possibly fungal pneumonia.
So they did a lung biopsy and then you can look with the point of care ultrasound after the lung biopsy. You can use it to find areas you want to biopsy and then afterwards, you can use it to see is there any haemorrhage from the biopsy or pneumothorax. So this area right here.
Is a focal area of pneumothorax. The lung is actually, excuse me, right here. So this hyperchoic echo that you see here with all these reverberation artefacts is air.
And as the horse breathe, you don't see much movement of the air here at all. If lung was there, you should be able to see the lung movement with that hyperchoic echo. But if you use the M mode, And you get a sign that looks like a barcode.
So this area here. With the MO it looks like a barcode. That is consistent with the pneumothorax.
And if there's actually lung moving, you get a picture like this. So here's the lung surface. And you get all these grey reverberating areas that look like sand, and so this is called the seashore sign.
So as you can see, it's quite clear that people who do a lot of ultrasound have a vivid imagination, but you can see clearly, I think that this whole area looks just like a barcode. And this with a lot of imagination, maybe looks like the seashore and the sand. So what about using it to detect the hemodynamic status in your patients.
And here's another place where this can be quite useful in the emergency settings. So, you, you think your, your volumepled the patient, but it's still really tachycardic. It's PCV and total protein may have returned to normal or near normal.
You put the probe on and you can see this horse is quite tachycardic, OK? The diameter of the left ventricular cavity is smaller than normal. You can actually measure that on the 2D or the M mode, and then the thickness of the interventricular septum and left ventricular freewa are also increased.
And the relative wall thickness is just uses the thickness of the inventricular septum and the left ventricular free wall divided by the internal diameter of the left ventricle to give you a relative wall thickness. So, an increased relative wall thickness is consistent with hypohydration. So that's information that's really helpful in the emergency setting because that helps with, why is this horse still tachycardic?
It's not, it's still not volume replete. And then if you look on the M mode, you can also see in addition to being able to measure the thickness of these chambers, and you could just change the depth here of this M mode image to get the whole left ventricular free wall. But you can see that the rhythm is not regular here and that the horse is having premature complexes, so that would prompt you to obtain an echocardiogram.
And you can differentiate that horse who's hypohydrated and you can see that these were actually images done in emergency settings, so they didn't take the time to really adjust the time gain compensation curve and improve the quality of the image in the far field because they could see enough to make their assessment. So you can see that this is a hypo excuse me, hypokinetic. Left ventricle.
So it's not contracting very vigorously. You can put the M mode transducer through the left ventricle and the short axis view, which is ideal, but you could also do it in the long axis for chamber view. And you can see actually that in contrast to that other horse, there's very poor thickening of the left ventricular free wall here.
And this decreased left ventricular systolic function is something that you can see with an endotoxic shower. So this horse was still tachycardic. It looked toxic, and you can see that actually the endotoxemia is affecting myocardial function, and that's an important piece of information to have in the emergency care of the patient.
You can also use it to look at specific valves if you're looking for endocarditis or you're just looking to see you've got a murmur, and you're looking to just confirm that the horse has regurgitation. And then you could advise the client about taking it in for a specialty examination. In this case, we have a horse with a grade 3 out of 6 holodiastolic decrescendo murmur over the aortic valve.
We're very suspicious that the horse probably has aortic regurgitation. You can see that there is a, this double parallel white echo there is thickening of the left coronary cusp of the aortic valve, which is a typical degenerative change. That you can see in middle age to older horses with aortic regurgitation.
You can actually look at the aortic valve from both sides of the chest, so this image is taken from the left side of the chest. So you would want to look at it from both sides of the chest and on the right side in a short axis view as well, to evaluate all three leaflets of the aortic valve, and then you can turn the colour on. And see is there or is is there regurgitation.
And so in this case, you can see that there's this orange yellow jet that's coming back in diastole into the left ventricular alpha tract. Confirming that you've got aortic regurgitation. And then you could send this horse on to a specialist for a more complete examination.
And exercising ECG. This horse has a loud murmur that you could hear on the left side, so any loud systolic murmur on the left side is mitral regurgitation until proven otherwise. When you put the probe on this horse and this image over here is taken from the right.
So this is a typical four-chamber view, right atrium, right ventricle, left atrium. Left ventricle. You can see enlarged pulmonary veins.
Mitral valve is here, left atrium clearly a lot bigger than the right atrium. Very exaggerated motion of the inner ventricular septum, consistent with the left ventricular volume overload, and a large enddiastolic diameter of the left ventricle. You can measure that with your M mode again, confirming that you've got left ventricular volume overload.
And in this case, because you have pulmonary venous distention, you'd also wanna look at the pulmonary artery to see if you have evidence of pulmonary hypertension. And you can easily put the probe on the lungs to see is there evidence of pulmonary edoema. And with pulmonary edoema, you will see these radiating comet tail artefacts, beelines, lung rockets, whatever you wanna call them, in multiple areas, in both lung fields.
So confirming that you have pulmonary edoema. And again, it's a quick tool to diagnose pulmonary edoema. And you can also see some of the abnormalities of the valve.
So this particular horse has a flail caudal accessory leaflet of the mitral valve, which is this leaflet down here. So as you watch it, you can see that sometimes it reverts or flips up into the left atrium. So sometimes it's just bulging right there, it just flipped up into the left atrium.
In order to do that, there has to be a ruptured cor I tendinny. So the area of the valve that's Abnormal is this free edge right there, and there it just flipped up into the left atrium. That happens to be this leaflet here in your short axis view, and that portion that's flail is this area that's flapping around right there on this image.
You can look at, use it to look at any swelling. So jugular vein swelling, such as in this horse here and Here you can see the jugular vein. To scan the jugular vein, if it's not completely thrombos, you need to have someone or you yourself hold off the jugular vein to distend it.
And then you can see this heterochothrombus here on the luminal surface of the jugular vein. This is with a high-end hospital machine comparison with the point of care ultrasound machine. So image quality clearly much better, but you can still clearly see the thrombus here.
You can use it to look at the eye. This is my colleague, Doctor Olgaseko, and she loves ocular ultrasound. And ocular ultrasound is fun.
It's usually quick. And it can give you a lot of information when you can't see to the back of the globe. So you can see here that this is the lens, this is the anterior chamber here.
The interior chamber actually looks like it's maybe a little larger than it should be. These are the, this is the iris here. This is the retina, this wavy structure that's attached here.
So this is the optic disc. And then this wavy structure here, it goes all the way back to the or errata. So this is called a seagull sign.
So here's a seagull sign, different, horse actually. But this seagull sign is consistent with a complete retinal detachment. So easy thing to use a point of care ultrasound for, for, excuse me.
And then there's your full, so you can use it to look at GI viscera in the fall, look for The thickening of the bowel with gas in the bowel wall, which is pneumatosis intestinalis. Look at umbilical structures or in this case, look at the bladder. So this is a fall that was not seen to urinate normally a male male or a colt.
And you can see, these are the umbilical arteries. You can see that they suspend the urinary bladder. Many people will start the scan on a deep setting, and even on the deep setting, you wanna, you should be able to find this structure in any fold that's got fluid in the abdomen, and you just have to go very caudal, so you're just in front of the pubis because the bladder is completely collapsed if it's ruptured, and so it's not gonna extend forward much into the abdominal cavity.
A high resolution image here, the point of care ultrasound images here. You can still make a diagnosis of a ruptured bladder. And even with the high end.
Ultrasound machines, you rarely see the location of the rupture, but in this case, you can see the rupture is right there. There's a piece of tissue flapping. The bladder gets very thin.
So that's actually where the dorsal bladder wall rupture is. But if you don't see it and you just see this folded empty bladder, you can diagnose ruptured bladder and your peritoneum. And with the urop peritoneum, you'll see this excess amount of fluid and ginum is usually just floating around in all this fluid cause the ginum is normal, and it's just, there's a lot of extra fluid in the abdominal cavity.
And then lastly, you can use it in some musculoskeletal areas and you can use it to look at an acute superficial digital flexor tendon lesion if you're in the field and maybe there's only one ultrasound machine in your practise, but you have this, you can put the probe on. So, high resolution exam on the left, point of care exam on the right, but you can clearly see there's an anechoic lesion. And the orientation of these two images is flipped.
I apologise for that, and you can clearly see a lesion going from the proximal superficial down to just past the suspensory bifurcation. So easy to diagnose that you've got a core lesion in the superficial digital flexor tendon. And you can look at more complex structures.
So there's a horse with a swelling of his hack. Turns out most of the swelling is in the calcaneal bursa. And in the calcaneal bursa, you can see anechoic fluid here.
This is the inner tendinous bursa right here. This is subcutaneous bursa. And this is part of the gastrocnemius bursa.
And in this case, you can see that there is a, as you go distal, there's this lesion in the dorsal aspect of the superficial digital flexor tendon. Very unusual lesion. This is a horse that's like 4 degrees lame, has a fever, elevated serum amyloid A and fibrinogen, and actually has a septic calcineal bursitis and superficial digital flexor tendinitis.
End up going to surgery. Had arthroscopic evaluation to bri of the tendon, antibiotics systemically and regionally with limb profusion and did actually quite well. And then another example of a horse with a swelling, in the shoulder region, large anechoic area, the point of care machines on the left.
You can see fibrine or tags of muscle. You can clearly see a disruption in this muscle belly here as you scan back and forth in a deeper pocket. So you can sample this pocket, look at the fluid.
The fluid here on the high resolution machine actually looks more echoic. And this was probably initially trauma, muscle fibre rupture, haemorrhage, and now with this more achoic fluid here, it looks like it's secondarily affected, which it was. And then lastly, I just want to also point out some other things that pocus is good for.
So teaching students, it's just like revolutionising the teaching of med schools and in schools where they've adopted giving a pocus unit to like every student when they get their white coat. And so it helps them understand abnormalities that they find on physical examination. If there's a lesions in their patient, they can monitor them on a daily basis or multiple times a day, record their images, get feedback on them, .
They can learn the necessary skills to actually do the ultrasound exams. So how do they get a good image, how to interpret the image? How, you know, how to adjust the, the machine, so it gives them the opportunity to actually play with a point of care machine.
And play with it is probably the wrong term, but experiment with it and learn how to use it, so by the time they're graduate veterinarian, they're actually comfortable in ultrasound technology. And all these pocus units also have the ability to do telemedicine. So if you're the veterinarian in the field and you find something particularly challenging, you could have a relationship with specialists.
And could actually contact them and have them, take a look at your image in real time, or you could then schedule a particular difficult case where you're way far away from any specialty centre and have somebody Come in on that exam and help you with the interpretation of that case. So there's a lot of exciting things in the future. We've been playing around with, and again, we're not playing around it.
We've given each of our students in internal medicine and emergency and critical care when they're in the rotation, a butterfly transducer and Software, so they can actually do the things that we've discussed here, and our students have found it to be a very valuable educational tool, as I think you could imagine. So, thank you very much for listening. If you have any questions, please feel free to reach out to me.
You have my email at the beginning of the presentation. And again, thank you very much for inviting me to give this talk.