Hi, everyone. Welcome to part two of my webinar series. So this is the Ulso for Veterinary nurses, and all you need to know.

In part two, we're going to go through the thorax, ultrasound scans. So we did go through the abdomen on part one, if you haven't seen it already. We'll just go through a little recap prior to starting on the thorax stuff as well.

So just a little bit about me quickly in case you haven't seen part one. So I qualified in 2018 as a registered veterinary nurse. I work in a small animal hospital in emergency and critical care currently, and I'm soon to go on to, working for vets now as a raven vet nurse.

I'm currently a BA council member that I started in 2019. I'm due to finish that in 2022. I'm also studying for my Vets Now ECC certificate, which I'm due to complete in 2022 or so.

And a little fun fact about me is that I own a Jackson named Harry and about 44 tos currently. And you can also find me on social media as Pi_RVN on Facebook and Instagram. Just a conflict of interest declaration that I have no relevant financial interest arrangement or affiliation with any company or organisation in relation to the content provided in this presentation.

And just a quick important note is that everything discussed should be performed under the instruction and direction of a veterinary surgeon and in line with the RCUS code of professional conduct. So the learning outcomes for this webinar are to know how to prepare a patient for the ultrasound scans that we're gonna be talking about. And we also need to know how to operate the ultrasound machine, the probe, which we previously discussed, but we will just recap.

To know how to carry out a point of care ultrasound scan of the abdomen and thorax, so this is part two, which we'll be looking at the thorax for. We also need to be able to recognise basic structures and organs commonly seen on ultrasound and be able to differentiate what is normal and abnormal. So, just quickly, going on to the machine.

So these are our main buttons that we need to be paying attention to throughout the scan. We've obviously got the first one being the width. So they're usually sort of dials that you can turn and sort of change the width, which is your field of view of the scan that you'll be doing.

We also have a frequency, which is, can be quite complicated. We'll go into a bit more depth, with that a bit later. But that alters the resolution of the image quality that you have on the screen.

And it works as a bit of a balancing act, along with the, with the depth of the image, too. So, then also the depth, which works hand in hand with the frequency that, alters how deep your probe is reaching into your patients. So if you've got a deep chested animal, potentially, you might need a, a bit more depth with your probe.

And that obviously works on side frequency, as we've, we've mentioned already. We've then got focus position, which changes which part of the image has the most focus. The freeze and save button, which the probably the most important buttons, especially in the thorax, ultrasound scans that we do, because we need to be quite rapid in terms of saving those images and getting the, the correct sort of area that we're, we're freezing.

Then we've got the calliper, which is the measurement tool. And then we also have our presets, which, will come in very handy for your, thorax scans. So you can have things like, a cat heart sort of presets, or a, a large dog heart preset and sort of small dogs, as well.

So that'll have all your settings already programmed in, so you'll have the correct frequencies and depth already there for you. And it just helps you to, save some time without having to faff around with, with ultra and then. The settings prior to it.

And just a quick, one to note as well on this one, we do have the . The colour as well. So, a lot of machines usually have the colour if it is programmed in order to do cardiac scans.

That is the colour Doppler, which we can then, use to see sort of the flow of blood as well. So we can see sort of the oxygenated and deoxygenated blood within the heart, and we can discuss that a bit more when it comes in handy later on as well. So quickly, last time we covered the probes, so we've got the convex and microconvex probes, which is the most common, that's the curved one on the top left there.

We then have the phased array, which is just the right of that, which is our most common, commonly used probe, the cardiac scans or thoracic scans. It's just good for getting in between rib spaces, whereas sometimes, depending on sort of what, what size patient you've got, the, microconvex probe can sometimes be blocked by the ribs, to get in between those spaces, but it's definitely worth having a go with both. Just to see which images you can get.

Sometimes I do find that the images I get are better on the microconvex probe, depends on the patient. And also, we have that window as well, going through, looking through the diaphragm into the thorax as well. So, that one, I would tend to use the microconvex for, for that view.

But for the sake of heart stands, and the like, we, we would use the face array just because it has that colour Doppler, settee on it as well, and just to get, get in between those rib spaces as well. We then have our linear, probe, which, does sort of ligaments, muscles. So, very, sort of wide field of view, but it doesn't go very deep into the, the abdomen, or thorax.

So, I wouldn't tend to use this one for, for any thorax scans, really. And then it's important to note the indicator, which is sort of near the thumb, which is a little notch, that just gives you the orientation of the probe onto the screen. So, it also helps when you're doing your long axis and short axis views, of which way you need to be pointing that probe as well.

So, that is just the indicator that we just previously mentioned, that mirrors your view on the screen. So if the notch or light is pointing towards the cranial under the patient, and the marker is, the cranial, side on the screen as well. So it just mirrors what you're seeing on the screen as to what you're doing with your patient at that time.

And then just a little bit about our frequency. So, frequency is a balancing act, as we previously mentioned, specifically with our sort of thorax scans, you can get some deep, quite deep-chested dogs sometimes, or, if you've obviously got a cat, won't be so deep-chested. So, we just need to remember that with a low frequency, you're going to get good depth from your probe, but your image quality is gonna be quite poor.

And with your high frequency, you're gonna get a poor depth, but your image resolution and quality is gonna be good, so. For instance, if I had a cat, I would probably be using a higher frequency, cause I'm not gonna get as good depth, but the resolution of the image is gonna be quite good. As opposed to a, a deep-chested dog, you're probably gonna have to lower your frequency to get a better depth into the thorax, which will give you, unfortunately, a poorer resolution of the image.

So, I just find that balancing act of getting the correct depth that you need, along with the resolution of the image that you need for it to be sort of, of a diagnostic quality. And then we've got the yellow point on the left there, which is just a little arrow, in between the 5 and the 10. That is your focus position point as well, so that's where you're getting your, your most sort of your best resolution in that image, just going along that curvature of the image there.

So just moving on to where you can use, the ultrasound stands in in the respect of thoracic scans. We tend to use it in the point of care ultrasound, so, triage, so if we've got an emergency that's come through the door. I tend to use that most in terms of if we've got a patient that's presenting with dyspnea.

And we can then use that to rule in or rule out whether that's a cardiac issue. We can have a quick look at the lung fields and see what's going on, and any obvious abnormalities that might be present straight away. The biggest tool that I've learned in terms of doing my thoracic scans, in terms of ultrasound, is being able to get the view of the heart, of the left atrium and the aorta, and to measure that ratio to see whether it is a cardiac, sort of respiratory distress, or whether there's something else that's causing that.

So being able to access that and do it quickly is definitely a skill to master, but it does take time. We can also use it in kennel side sort of scanning, so it's non-invasive, and it gives us quick rapid answers. So, if you've got a patient that's potentially receiving oxygen, specifically with our thorax scans, if they, if they are dissic, then we can sort of do it anywhere, really, in the practise.

It doesn't have to be in a specific room, like an X-ray. So it can be quite, a useful tool to, to do whilst they are receiving treatment, potentially. We also can obviously look at the organ assessments and observations.

So, in the chest, we've got the lungs and the heart. There are some lymph nodes in there as well, which you may sort of discover as you do more of the thoracic sounds, but we're mainly gonna be focused on the lungs and the heart in this one. So, that's why cardiac assessment there, is there as well.

But we'll go through a bit more on a view of the heart in terms of the extent of what, as the veterinary nurses, scanning thorax is, what we really need to be able to look for. And when we need to be able to say that this needs a, a full sort of cardiac workup or needs further sort of investigations. By us doing, as veterinary nurses doing these scans, if you've got a, A patient that's come through the door that is disne potentially, and all your veterinary, surgeons are busy.

If you're able to speak to them to say, are you OK for me to do a, point of care ultrasound on this patient, and along with the owner's consent, this can result in a better and quicker sort of patient outcome, and the care and treatment received. The triage assessment can fast track a patient into needing, sort of, a treatment, sort of more rapidly. As opposed to waiting for someone to be free.

So, the more nurses that can pick up a probe and be able to spot potentially free fluid in the chest, or whether there's a, heart failure, sort of, signalment, then that can really sort of assist our patients that are walking through the door. And really using it on any trauma patient. So, any patient that's potentially been in a road traffic accident, or if they've had any blunt trauma, or if they've been in a fight, potentially, it's always worth just, speaking to your, your vet in charge of the case and just sort of suggesting an ultrasound, potentially.

They'll probably curse me in the future for suggesting that, cause, if everyone starts to do it. But it ultimately will just sort of make sure that there's nothing going on in the chest, and it can also then be monitored in serial scanning, so we can sort of just maintain scanning them sort of maybe twice a day just to check that nothing's getting any worse. So, quickly onto the basics again, like last time.

So we've got the black, which is also referred to as either anechoic or hypoechoic. So that is either fluid or dense material or gas. Tends to be, if it is fluid in a structure, you tend to have, like, that smooth wall.

Whereas if it's free fluids, sort of in an abdomen or a chest, you then tend to get, more of a jagged edge on that fluid in them cavities. So, just the left top photo there is a gallbladder within the liver. So that is an abdominal one.

And then the middle photo is free fluid. And then we've got a bladder on the right-hand side. So you can just tell the difference between the bladder and the gallbladder compared to that free fluid in the middle.

It's not a nice smooth edge. So, that would also go the same for the chest. And we can discuss that a bit further later on in terms of whether there's free fluid or whether there might be something like a pericardial effusion, for instance, and how to differentiate those.

And then, in terms of specifically for the thorax scans, we've got A lines and B lines, which are constantly spoken about. These can get quite confusing sometimes, because you don't really know what they are sometimes, initially when starting out. But they are quite simple, once you've sort of got two grips of what they look like.

And actually, when you pick up a probe and do a scan, and you've seen them for yourself, you'll then get to grips in terms of what they are. So there's just a diagram above there for you which goes through A lines. So the first picture on the left-hand side is a lines which are a horizontal pattern.

So we've got the . The lines going from the left to the right of the screen. And that is a normal appearance of, of long fields, really.

Compared to the bee lines, which we've got, sort of, as the, the next three photos. So, the first photo of the, well, the second photo in, in, on the left, that looks like a sort of a flashlight appearance going straight down the middle of the screen. So, we commonly refer to that as a rocket, or, people call them comet tails or flashlights.

And then as we go on, you've got more appearing. So, we've got the CETA rockets, which there's quite a few of coming out there, and then you've got class rockets. So, they're all classed as beelines.

And they are abnormal on a presentation of a thorax scan. So, they commonly, represent things such as, if the lungs are quite wet, if there's fluid on the lungs, or like, something similar to, like, an aspiration pneumonia, really. So, that pattern is an abnormal pattern.

So it would require potentially further investigation, such as an X-ray, to sort of fit this, jigsaw together. So, Ultrasound in terms of thorax is always a, a part of the jigsaw, basically in putting it together to find out the, the complete picture of what's going on. And then we've got further basics, which is like that grey, white, or hyperchoic, which can be soft tissue structures or inflammatory if it is really hypoechoic.

So, if it is really white, then that can be inflammatory. So, for instance, if we were to have refund the pancreas, the soft tissue can come across quite white, and very bright in terms of being hyper-echoic and inflammatory. And then just a bit about patient preparation, so this is quite important, especially in terms of being able to get diagnostic images that are of decent quality.

So it it's important to take the time to prepare your patient and get a good scanner window. It just gives you obviously the better quality images and ultimately it saves time in the end rather than sort of faffing around trying to get the images you need. So clipping the fur and the hair over the area will give your probe best contact between the probe and the skin of the patient.

If you do leave hair there or fur, the minute you put, potentially ultrasound gel there, you're just gonna create a barrier which will have gas trapped in between, and it's just gonna interfere with your images, and you're not gonna get sort of very good diagnostic quality images. You can sometimes get away with not clipping them in some instances, but you would have to use something like Spirit to dampen down the fare and make sure that you can get a decent enough window, but if you can clip, then just do it, it's completely worth it, worth doing. Just be sure that if you're using Spirit, that your probes are protected, either with clingfilm or something over the top that, you can still get your ultrasound, .

Waves through, just to protect the prey, because some of them can be quite sensitive to spirit. We then need to degrease the skin. So with something like a chlorhexine skin preparation, and that allows for better contact with the gel, and it allows it, the gel to soak in, which you might find then as you're scanning, that the, images improve as you go on, as the gel sort of, soaks into the, the skin, it gives you better contact.

So, it can be worth popping the gel on. Prior to the scan, that's not always possible in thorax scans because they're usually sort of more of an emergency sort of scan and a triage scan, but you also get just good images as long as you prepare the skin, OK. A quiet and dark room is very useful just to prevent any sort of patient sort of movement and ideally someone sort of restraining it, obviously this cat on the table was being very well behaved with just a sandbag.

But you can also use sedation and restraint, obviously, under the veterinary surgeon's direction. Your tonal can work well to obtain the ultrasound images that you need. It's definitely worth considering the sed sedation, in terms of the thorax, if they are stable to do so, just because if you're gonna get, dog, for instance, that's panting heavily, you are gonna get quite a lot of movement blur, which are gonna just sort your images and not give you sort of very good diagnostic quality.

Lateral recumbency and thorax is often, most desirable. Just bear in mind that if you place a sneak or, respiratory distressed patients in lateral recumbency, they might struggle, as it sort of puts pressure on, sort of, on the lungs. So this can be done internal for our respiratory patients, if, if needed.

I tend to sort of do them when they're sitting on a consult table, and just go round either side, so I can do the left side and the right side. We've then got the, use of a cardiac table, which is just there in that photo. So that's a little cut out where you place, sort of, roughly where the heart is, over that area.

So it, the the force of gravity brings that down, and then you place the probe underneath the patient, and it gives you sort of a, a good image there. If you haven't got a cardiac table available, then things like cat castles can work quite nice on their side with that, little cut outlets there works exactly the same. Or sometimes I've seen people sort of make, do sort of makeshift things as well.

So, just getting that gap underneath, to put the probe to see if your gravity helping you sort of with that heart fall into one side. Oh, I'm just gonna go back quickly, regarding patient preparation. For our cardiac scans, obviously, we want to feel for the heart, ideally.

So, where you're feeling that beat, then you're, you're clipping over that area on both sides. So, if we're doing a, a full cardiac scan, we need to clip on both sides. And then also, if we are doing the lung fields as well, we need to clip an area between the most prominent rib space that is sticking out.

So, if we put our patients on lateral recumbency, the part of the ribs that is uppermost. So, if you were to go down to its level, you'd see that part being most prominent sticking to the top. That's the ideal ribs basically that you want to clip a bit of hair in between.

And then we can go through sort of what you're then going to do with that later on. So, what are we looking at on thoracic ultrasounds? Mainly our lung fields and our heart, and also the plural space.

So, the lung fields, we're looking at the quality of the lungs and any signs of abnormality. So, we're looking for those A lines and B lines. Any signs of, a potential pneumothorax, which we'll go through later in terms of how you are assessing whether there is a pneumothorax, which is used in the respect of a glide sign.

We can also look for a pleural fusion. So, we'd have the black anechoic free fluid, would be showing up within that chest. And also the bee lines, which the flashlight appearance, or rockets, or comet tails, whichever you like to call them, can also sort of, indicate something like an aspiration pneumonia, potentially, or pulmon pulmonary contusions.

We're also then looking at, the heart, so we can assess things like the conjunctility, the left atrium, and the aortic ratio, for potential sort of heart failure workups. We can look for pericardial effusions and tamponade. And we can also look for any formations of things like clots or tumours that may be present in the chambers that we have there.

. So just assessing the valves as well, so making sure that the blood flow looks normal, that they're not sort of, flapping around too much how they shouldn't be. So, going back on themselves. But ultimately, we're just sort of doing a, a triage scan to look for, whether there is, an obvious abnormality.

And the plural space. So we can assess that for plural space disease, which would commonly be sort of fluid or tumours. So, again, that black anechoic-free fluid would be sloshing around in there.

Or tumours, you'd probably get sort of something like a soft tissue, appearance where it shouldn't be, which would be. Quite different from your lung fields, but they can be quite difficult to scan a chest, so don't beat yourself up if you find it tricky when you start out doing it. There's not much space to go through the ribs, and so it is, it is a, a skill that you need to practise and be patient with more so than the abdomen.

So, the assessment of the lung fields, we're looking for a good lung movement. Bear in mind, if you have a patient that's been in a lateral recumbency for a little while, you might have, alterations in, in the movement, and sort of how aerrated they are, and bits and pieces from there. .

We want to obviously clip the patch between the ribs and the most prominent area, and then we're looking for things like a glide sign on inspiration and exploration. So the first image to the right there at the top, that is a typical image of, a long field with bee lines. So we've got those flashlights where you can see the bee.

And then what you've got next to it are the two rib spaces. So, the two black lines going down are the rib spaces that are blocking the ultrasound waves from getting through. So that's quite typical and we tend to refer to that as a gate to sign as well, so sometimes people think it looks a bit like an alligator.

But whatever, whatever you want to use to make you remember it is absolutely perfectly fine. And then moving on to the glide sign, which is an important thing to be able to do in a triage point of view. Knowing whether there is a glide sign or not can indicate whether there's potentially a pneumothorax.

So, the absence of a glide sign can indicate pneumothorax. So being able to just assess that and whether that is there or not. So, you should be able to see that glide sign there.

So we'll leave that plane for a little while. So, we've just got the lung movement there, and that is completely normal. That is the glide sign you want to see between those two rib spaces.

So, you can't quite see the rib spaces on that image. There's a slight bit of black, just to the left there. But that is a perfect glide sign that we want to be seeing.

If that was absent, I'd be cautious of a pneumothorax, which can be, Confirmed by X-ray as well. So again, this is just a piece of the jigsaw puzzle and using it hand in hand with our other diagnostic imaging tools that we have available. And then some lung abnormalities that we may come across, we can get free fluid in the pleural cavity.

So that would be pleural space disease, so we can get free fluid and sort of fibrin floating around there. Commonly, that presents with respiratory distress that we see in emergency setting, and rapid diagnosis in terms of doing that, that pocus scan quite quickly, can be, life-saving, really. So, a fast, scan or a pocus scan that gives us information can then result in a therapeutic procedure, potentially being carried out.

So, a thoracocentesis, to drain that fluid off, and it can help in terms of how the patient is breathing. And then resulting in better patient care and treatment ultimately. We've also got the bee lines and the rockets that we can see on our lung abnormalities as well when we're assessing those which we've just discussed and also whether we've got the absence of a glide sign or pneumothorax, so we're just looking for that glide sign as well every time.

And another abnormality that we can see sometimes is the presence of abdominal organs. So this is most commonly seen in our RTAAs. So, any trauma, potentially can cause herniation or rupture of the diaphragm, and that can then cause those abdominal organs to end up in the chest.

And we then commonly see respiratory distress in those cases, as well as if there was sort of fluid or anything in there as well. It's just, making the space available for the lungs to expand a lot smaller and restricted. A couple of videos.

So, this is sort of building up your bank of sort of images and videos as well of what is abnormal. So, this is a lung abnormality. So I'll just play that there.

So, believe it or not, that is the, the plural space there. So, that was a patient that was presented, quite dysneic, on presentation. So, a high res rate, sort of abdominal, shallow breathing.

And sort of really struggling, really. Not very good mucous membrane colour, so quite cyanotic, and pop the probe on, and sort of, within a few seconds, we can see that there's a lot of free fluid in that chest cavity. So, that gives us, a cause for the, the knee that's going on.

It doesn't give us an underlying cause of what's caused it, unless we knew that there was trauma. But you can then alert your surgeon who's working, if they, have approved you to do the, the poker scan there and say that this dog needs seeing, sort of ASAP, really, and it needs sort of treatment. Meanwhile, if you have someone nearby, you can get them to potentially start pre prepping, some stuff to get ready.

And that can just obviously speed up the whole procedure, vastly. For these ones, we've used the face array probe, all the microconvex just to fit between the rib spaces as well. You can also view things like this through the diaphragmatic hepatic window.

So, at the sternum of the animal and putting that into the thorax, we can then tend to see quite a lot of information through there as well, depending on how deep-chested your dog is, or if you've got a cat, they tend to be quite nicely viewed through there as well. And I've got another video for you down here, which is also . Some pleural fluid.

So, I'll just play this several times. So, we've got the diaphragm running down with the liver, and then we've got the heart being up against there. So, that heart is quite close to the diaphragm, initially, but there's also fluid in there.

So everything is sort of, going to be displaced because of the fluid that's sitting there. So that would be a a plural effusion as well. So, the underlying cause from that, is unknown at that point.

But it could be sort of something like a heart-based tumour. It could be trauma again. But yeah, it would be sort of needing further investigations to, to find out what's going on.

Mm And then just to quickly talk about the diaphragm. So, the diaphragm can cause a mirror image. So it's important to remember that when we are, viewing it through that, at the bottom of the sternum, if we're using that probe there.

So, just a quick note on that top right photo, Where that fluid is being measured, there is a possibility that you would see that, and it might look like it was in the thorax. That isn't, so that would just be the diaphragm, causing the mirror image from the abdomen, from that free fluid where the liver is, into the thorax. So, it's important to know if you are seeing that fluid there, that might not necessarily be that it's also in the, the thorax as well.

The diaphragm then looks quite different, if it's been ruptured or torn or herniated in, in the case of a road traffic accident, for instance, for instance. It tends to be quite a bright reflective line, as you can see in the top photo. And then we have a photo on this at the bottom right.

That was a diaphragmatic hernia that was, confirmed on X-ray afterwards. It's quite a jagged line. It's not nice and smooth, following the liver down there.

You've then got that break that's there, which is that black hypoechoic line coming through, that almost looks like a rib space. So that's blocking the, the rays going through there. So that's sort of quite typical of a, a damaged diaphragm.

So, it's quite a, a quick and easy thing to look at as well. And obviously, if you were to be, cautious of a diaphragmatic fracture, you could also scan the abdomen, and you're probably gonna have the absence of quite a few of the, sort of gastrointestinal tracts and the stomach, and various, abdominal organs that may have herniated through into the thorax as well. So, moving on to the heart.

This can be quite a tricky one to master. So, again, be patient. And there's still a lot of, vets out there as well who can get frustrated with standing hearts because they just can't get the view that they need.

But ultimately, it's just about being patient, finding out which little movements of the probe would do what and where it needs to go to get which view. It's quite difficult for me to sit here and tell you where to put the probe on an animal. Sort of it's quite a practical thing that needs to be done.

But what I would advise is sort of, palpating the heart through the skin and placing a probe there to start with. And then, find out what the different orientations of the probe do and which views they give you as well. And just doing tiny little movements to see which difference that makes.

It can be quite frustrating when you're standing, and that you do a movement and you completely lose the image that you've got. That's very easily done on thorax scans, because you've got those rib spaces that you might jump in between the two. So, just have a play around on a patient that's stable enough for you to do so, and just try and To sort of build that bank of images and that experience of being able to pop the pro bono find the image that you need.

Other than that, a cardiac table is quite advantageous, in doing that and adequate restraint can make this much easier and gets you the views to be obtained a lot easier as well. Tend to go through right lateral recumbency, and then placing that over the cut out on the cardiac table. And, so you prepare the patient over the cardiac area as well, so you're just palpating that through the skin, then you can clip them in that area.

And then lateral or sternal recumbency as we've previously mentioned, depends on the patient status that you have as well. You might require sedation restraint. So, various views can be obtained as well.

And you're mainly looking to get a left atrium and aortic ratio measurement from a nurse perspective. And whether there is anything like a pericardial effusion, or whether there's anything bouncing around on one of the chambers that shouldn't be there, And ultimately, you might be able to see whether there's any pleural fluid there as well. We're not having to do sort of, all the extra stuff in terms of what a cardiologist would be looking to do.

We're doing this from a triage point of view in an emergency setting, to sort of get a, a quicker, sort of signalling of what's going on, so that the treatment plan can be initiated a lot quicker. And then, obviously, outpatient outcome is usually gonna be improved from that point of view. So, obvious abnormalities are gonna be things like pericardial effusions, and enlarged left atrium, clots or tumours, or, in the chambers, or potentially tumours in the pericardium as well.

So, basically, is there fluid there? Should it be there? And does it fit with the clinical signs that you're seeing?

It's the main, mainly important thing to, to, you know. And then a few of the views there that we've got, the top left view is the one that's commonly referred to as like a fish mouth view or a mushroom. So when that's going, it does look like a fish mouth that's opening and closing.

That's the short axis view, that we tend to see, sort of, and it's a nice one to start with because it can be sort of one of the easier ones to see, as opposed to trying to get those, left atrium and aortic views. We've also got the right sided parasternal axis view and the right sided short axis view of the left atrium and aorta. So, the, the one on the bottom right is the ideal one that we want in terms to give us information of the left atrium size and whether it, the signalment is cardiac, or whether if they are in respiratory distress is being caused by something like an aspiration pneumonia as opposed to, heart failure along those lines.

And then the perfect view, which some people refer to as like the Carlsberg view or or various things like that, but the perfect view of the, the heart that we want to get is, so we've got that left atrium and the aorta, visible on our scan. You can get them visible on the scan, but what you want to try and aim for, is to get that Mercedes-Benz sign in the aorta. So, if you follow that 5 and do a cross section through the image, you should be able to see that first ha you come to is the aorta.

And there is what looks like a Mercedes-Benz sign sitting in the middle of that. So, hopefully, you can see that. And then That gives you the sort of perfect view in terms of being able to then measure, your left, left atrium and your aorta, and then divide them between themselves.

Anything over 1.6 is usually classed as sort of a cardiac signalment, so if it's in heart, heart failure, potentially, . So, again, just getting the measurements, and you're basically going from, you're getting the diameter of the aorta and basically the length of that, left atrium that's sitting there, which is quite enlarged in respect to that.

So. Is it sort of 1.5 times bigger, and you can quite see, quite clearly see there it is.

So I think that almost 2.1 centimetres off the top of my head as a, as a ratio, which is quite enlarged. We can also use the, the valve assessment there as well, you'll be able to see some of the valves opening and closing, so seeing whether they're meeting nicely, seeing whether they're sort of flapping around a bit more than what they should be and causing sort of regurgitation of oxygenated and deoxygenated blood.

And then you've also got the, the colour Doppler you can put on there as well. So, if you were to put the colour Doppler on over the valves, you'd then see the red and blue of the oxygenated and deoxygenated blood. And if you're getting sort of any regurgitation or mixing of those, you tend to see what is like a green colour.

So it can be quite, handy just to have a little play around with those. You can also use that on the main aorta that runs through the abdomen, just to get a feel of what it looks like as well. And then moving on to cardiac abnormalities.

So again, we just mentioned the left atrium or aortic ratio over 1.6, is a good indication of heart failure. We can also see heart-based tumours, pericardial effusions, poor contractility and sort of the presence of clots as well.

Or potentially tumours that are sitting there. So these are videos, so we'll just go through them. So, the first video we have here is a large clot that is bouncing around in the chamber.

I think large clot is an understatement, that is taking up a considerable amount of that chamber. If that was to escape the heart, then it would probably cause, like, a thromboembolism. But it is rather large, so whether that would ever get out of the heart, who knows.

But that's a bit of a ticking time bomb. So, you can quite obviously see that that shouldn't be there. That's quite a worry to see as well, on our sun scan.

So yeah, I'll just play that for you again. Whilst that's bobbing around there. Whether that's a tumour or a, a clot is, difficult to say exactly.

But in this instance, you just know that that's abnormal and that you can alert your vet that this is what's going on. We can take videos, we can take images, so we've got them to refer back to as well, and that you can show them, so you don't have to then carry out the scan all over again. And then in our second video, we have, this is our short axis view, so that mushroom sort of view that I spoke about earlier.

Hopefully you can see that there. And that's just sort of contracting there, so it looks like a mushroom or a fish mouth. We've also got what we call a, A pericardial effusion going around that, so there is a slight, so where you've got that bright white line sort of going round round the heart, you've then got some black there as well, so there's some fluid inside of that.

That's not the nicest example, you will see them a lot clearer than that as well, so. And then, on our 3rd video, we've got a heart here, and that has got extremely poor contractility. And the left atrium is quite large.

So, you would be measuring the aorta and the left atrium there, just to get you a ratio. Particularly in cats, if we see this, it can be related to hyperthyroidism, so it's definitely worth then suggesting whether a hyperthyroid test should be carried out. So doing a T4, either in-house or sending that out as well, can be quite valuable.

And then on our 4th video. We've got a clot again bouncing around, a clot or a tuber bouncing around in, in one of those chambers, so very similar to that first image, just of a, a slightly different size, that's bouncing around there. So some further abnormalities, so .

Building up your sort of knowledge of what looks normal, as soon as you then see something that is abnormal, you're going to, you're going to recognise it. The presence of potential sort of heart-based tumours are more visible when, an effusion is present. So, if you've got a pericardial effusion, you'll likely see any heart-based tumours that might be on the pericardium, a lot easier cause they'll sort of be highlighted, through that, through that black fluid that we have.

We can also see things like tamponade, which is where the pericardial effusion is so large that it causes sort of a restriction to the heart being able to contract. So if that pericardial effusion is of a certain size, it's going to cause poor poor contractility. So here we have the heart beating.

We've then got a pericardial effusion around that, which is the black fluid. And then just to the left of where the heart is beating, you can see that there's sort of a soft tissue structure there, which is also impeding onto the heart as it contracts, which is likely sort of something to do with. Like a pericardial tumour, or a heart-based tumour along those lines.

So, again, abnormality, take a picture of it, take an image, take a video so you can refer to it afterwards, so you haven't got to re-scan these patients, that are potentially sort of decompensated already. And also the contractility of the heart there was quite poor, due to the sort of the, the amount of fluid that is sitting around it, so that's going to be affecting our patient quite considerably as well. And moving on again.

So, this, is also a tamponade. So we've got that restrictive heartbeat through the, through the size of the pericardial, effusion. So, the treatment plan for this would often be pericardiocentesis, to strain that sack of fluid around the heart and allow it to then sort of, sort of those chambers to fill up and, and empty adequately to sort of supply the rest of the body with the oxygenated blood that it needs to survive.

And then, and just a quick one from the abdomen, part one that we've done. Just remember that if you see a halo around your gallbladder, situated around the liver. That it can often be, either anaphylaxis.

So it could be sort of like a snake bite or something that, it's had an allergic reaction to. But it can also be related to cardiac abnormalities. So, if we are seeing those halo signs, please just put the probe on the chest as well, just to rule out.

But there's no cardiac abnormalities. It might not be related to cardiac. Obviously, it could be anaphylaxis, but it's just not worth it if you've already got the scanner out and your patient in front of you, and you're able to, to put the probe on the chest, then abdomen and thoracic sounds go hand in hand, just to make sure we're getting a full picture of everything.

And then just to recap on the thoracic ultrasound, so, coming towards the end of this webinar, it's important to sort of build up your normal image bank. So, whether that's watching, other people do some thoracic scans first, making, out what sort of is going on on the screen, and asking questions of what's going on the screen. So, where the heart appearance is normal.

And sort of whether the lung feels like normal as well. Once you find out what's normal, your abnormalities are gonna become obvious to you, and they often fit with clinical signs as well, especially with thoracs, you tend to get sort of you just need patients that are coming through. And always carry out both your abdominal and thoracic scans which we previously just mentioned, just to get the full picture of what is going on there.

And then just a few, top tips, very much the same as the abdomen. So, just practise as much as possible. So, post-op patients can be a good one as well.

So if they've had any sort of potential thorax surgeries, and they've got a clip patch, then you can practise on those when they're recovering if they're stable. And then mainly learning what the probe does. So, these small movements, and turning of the probe in different angles.

There's more than one way to do it, so I won't sit here and tell you how to hold your probe or how to put it on the chest and where to put it. That's very much a thing that you'll get to grips with as you, as you do more of them. So, but the small movements, especially in thorax scans for your cardiac, images are gonna do so much and give you so many different images as well.

So, just have a go and pick it up and, and literally just sort of have a go and see what different images you can get. Make sure you're preparing your patient, because otherwise it's gonna get very frustrating for you, and you're probably just gonna end up giving up. The images you obtain will be better and you won't get as much sort of blur coming through the screen.

And this builds up your image library. So if you've seen something that you're not sure of, take a picture of it, see if you can find out or find someone who might know what it is. It's handy to have sort of anatomical landmarks around that as well.

If you are taking images, it can be difficult to interpret an image if you don't know where it roughly is or what it's near, or also the sort of clinical signs of the animal as well. There can be incidental findings that you find sometimes that might just not be relevant. And also, the main thing is, be patient.

I see a lot of people do these heart scans, and they, they just can't get images, and they just give up in the end, because they can't get it. And they sort of hand, tend to hand over to a more experienced sonographer, which is absolutely fine. But the only way to learn is by, by doing it in the end.

But just know when the time and the place to learn is, if you've got a stable patient, as opposed to a patient that maybe needs a more rapid, image being taken. And ask questions as well, when someone's scanning, there's nothing worse than not knowing what's going on on the screen. So just don't be afraid to ask questions, if appropriate, obviously, and you'll find it far more interesting in terms of what you're then seeing when you're carrying out your ultrasounds.

And then just one of my favourite approach is that you don't need to be able to find a pancreas or adrenal gland to start doing ultrasound scans. So, a lot of people are put off because they can't get that perfect heart view straight away, and they can't sort of see what they need to, straight away. But that's not what it's about initially.

It's about picking up the, the probe, being able to find some free fluid in the chest, seeing The left atrium looks enlarged, or whether there's not a glide sign, is gonna give your patients a far quicker and more rapid outcome than, than you, you not having a go and picking it up to start with. And, thank you all very much for listening. I'm happy to answer any questions, whether that's via email, which is on the screen there, or through my social media.

Thanks, on Instagram and Facebook. And thanks very much to Webinar vet for allowing me to present this to you. And also, if there is any more further resources that you'd like, the BSABA manual of diagnostic imaging is quite a handy one to have.

And there are others out there, but I'm more than happy to engage with you on social media and answer any questions you may have in the future. Thank you.