COMPONENTS

Critical care ultrasonography may be divided into 5 components (technical, pleuro-pulmonary, abdominal, vascular and cardiac).
Inside each module are treated:
- normal anatomy
- US anatomy (normal and pathological)
- pathological images
- clinical implication of a pathological image
- limitations of ultrasonography
- limitations of the interpretation (ability to render an indeterminate result).

SKILLS AND COMPETENCIES

Each component consists of a set of practical and theoretical knowledge ("skills"). Mastering all the items in a component defines a competency.

TECHNICAL COMPONENT

Skills

Basic course
Ultrasound physics
Basic component of US system
Types of transducer and production of ultrasound
Use of ultrasound controls
Understanding of the frequencies used in medical ultrasound and the effect on image quality and penetration
Interaction of ultrasound with tissue including biological effects
Recognition and explanation of common artifacts
Image recording system
Probe manipulation and orientation
Ultrasound system and probes cleaning and disinfection
Entering patient identification
Archiving images

Advanced course
Doppler modes
Advanced US machine settings

HEART COMPONENT

Skills

Basic course
Acquisition of this five basic views :
- parasternal long axis
- parasternal short axis at the papillary muscles level
- apical 4 chamber view
- subcostal 4 chamber view
- inferior vena cava view
Visual evaluation of LV systolic function 
Evaluation of homogeneous/heterogeneous LV contraction pattern
Evaluation of LV cavity size (index of chronicity of LV dysfunction)
Evaluation of RV/LV ratio (index of RV dysfunction)
Recognition of paradoxical iv septal motion
Evaluation of IVC diameter and respiratory variations
Visual evaluation of pericardial effusions
Quantification of pericardial effusion
Visual evaluation of right cavities compression by pericardial effusion.

Advanced course
Acquisition of 3 additional views :
- parasternal short axis view at the level of the aortic valve
- parasternal short axis view at the level of the apex
- apical 5 chamber view
Evaluation of left and right ventricular systolic function with calculated indices.
Estimation of cardiac output
Estimation of pulmonary artery pressure
Detection of significant LV hypertrophy
Estimation of left atrial size
Evaluation of left atrial pressure/diastolic dysfunction
Study of left ventricle wall kinetics.
Detection of significant left outflow tract obstruction
Identification of significant valvulopathies.

LUNG COMPONENT

Skills

Basic course

Lung
Knowledge of the basic semiology of lung ultrasound
- A lines
- B lines
- sliding lung
- lung point
Identification and characterization of air artifacts suggestive of the normal aeration pattern:
- A lines with sliding lung
Identification and characterization of air artifacts suggestive of alveolar interstitial pattern
- number and location of B lines
- knowledge of the limitations of not visualizing lung sliding / B lines
Identification and characterization of consolidated lung
-  identification of tissue density lung, with or without air bronchograms
Identification and characterization of air artifacts to rule-out pneumothorax
- presence of sliding lung
- presence of B lines
Identification and characterization of findings that rule-in pneumothorax:
- presence of lung point (both by 2D imaging and M-mode)
Diaphragm imaging and motion analysis with 2D mode

Pleura
Identification of a relatively echo free space surrounded by typical anatomic boundaries
- diaphragm
- chest wall
- ribs
- visceral pleura
- normal /consolidated/atelectatic lung
Identification of characteristic dynamic findings of pleural fluid such as
- diaphragmatic motion
- floating lung
- dynamic fluid motion
- respirophasic shape change
Characterization of fluid
- anechoic
- echogenicity (using liver/spleen as reference)
- homogeneous or heterogeneous; presence of strands/debris/septations
Identification of miscellaneous findings such as :
- pleural based masses
- thickening
Performance of semi-quantitative assessment of fluid volume
Recognition of specific limitations of ultrasonography to identify pleural fluid such as
- inadequate image quality due to technical limitations
- subcutaneous emphysema
- echo dense purulent fluid
- mimics of effusion such as mesothelioma or pleural fibrosis
Integration of these elements in a protocol
Pleural puncture under echoguidance

Advanced course
- Distinction between consolidation caused by pneumonia or by passive atelectasia ?
- Estimation of the volume of a pneumothorax ?
- Evaluation of diaphragmatic function ?

 
ABDOMINAL COMPONENT

Skills

Basic course
Identification of abdominal structures and of a relatively echo free space surrounded by typical anatomic boundaries :
- abdominal wall
- diaphragm
- liver (size)
- gallbladder
- spleen (size)
- kidney (size)
- bladder
- bowel
- uterus
- spinal column
- aorta
- inferior vena cava
Identification of characteristic dynamic findings of intra-peritoneal fluid such as
- diaphragmatic motion
- floating bowel
- bowel peristalsis
- dynamic fluid motion
- shape change
- compressibility
Characterization of fluid
- anechoic
- echogenicity (using liver/spleen as reference);
- homogeneous or heterogeneous
- presence of strands/debris/septations
Procedure
- peritoneal puncture under echoguidance
Bladder
- identification of bladder 
- identification urinary catheter
- identification of abnormal bladder contents
- differentiation of distended bladder from ascites
- qualitative assessment of intravesicular volume
- identification of overdistention
- insertion of a suprapubic catheter under echoguidance
Kidneys
- identification of both kidneys
- identification of presence or absence of hydronephrosis
- measurement of kidneys in longitudinal axis
Aorta
- identification and anatomy of abdominal aorta
- identification of abdominal aortic aneurysm
Gallbladder
- Identification of biliary stone
- Identification of the signs evoking a cholecystis

Advanced course
- Biliary tract anatomy and obstruction
- Intestinal anatomy and scanning technique
- Identification of bowel peristalsis/retroperistalsis
- Identification of intraperitoneal air
- Quantification of gastric content
- US classification of acute intestinal injury                    

VASCULAR COMPONENT

Skills

Basic course
Identification of relevant veins and arteries:
- internal jugular vein/carotid artery
- subclavian vein/artery, axillary vein/artery
- brachial vein/artery
- radial artery
- femoral vein/artery
- peripheral veins such as basilic, cephalic, external jugular
Differentiation of vein from artery based on :
- anatomic position
- compressibility
- respirophasic changes
Identification of normal anatomic variability such as
- vascular hypoplasia
- variability of carotid artery position relative to internal jugular
Identification of adjacent non-venous structures such as
- sternocleidomastoid muscle
- mass
- lymph node
Identification of partial or complete venous thrombosis
- visualization of intraluminal thrombus
- compressibility
US guided puncture of arteries and veins
- internal jugular vein
- subclavian vein, axillary vein
- brachial artery
- radial artery
- femoral vein/artery
- peripheral veins such as basilic, cephalic, external jugular
Knowledge of the effects of patient positioning on anatomic topography
- head/lower extremity rotation effects on overlap of the artery by the vein
- effects of Trendelenburg position on vascular distention

Advanced course
- Subclavian and axillary vein US guided puncture