Cardiac Ultrasound
Indications
Hypotension
Heart failure
Cardiac arrest
Cardiac trauma
Hypotension
Suspected pulmonary embolism
Dyspnea
Chest pain (angina)
Acquisition
Views
Subxiphoid (SUX)
Long Axis Parasternal (PLAX)
Short Axis Parasternal (PSAX)
Apical 4/5 Chamber (A4C)
Patient
Supine or Left Lateral Decubitus
Probe
Phased Array (or Curvilinear)
Subxiphoid (SUX)
Palpate for the subxiphoid process
Nestle the probe directly below the subxiphoid process with the probe marker pointed towards the patient’s right (if indicator is on the left) or left (if indicator is on the right)
Use an overhand grip on your probe!
Angle your probe so that it is almost lying parallel to the patient’s body
Rock toward the left shoulder until heart motions are visualized
Identify your landmarks
Parasternal Long Axis (PLAX)
Place the probe on the patient’s left chest with the probe marker pointing towards the patients left hip (if indicator is on the left) or right shoulder (if indicator is on the right)
Typically, the optimal window is found between the 3-4th intercostal space
Identify your landmarks
Short Axis (SAX)
After you have obtained your parasternal long axis view, rotate the probe 90 degrees until your probe marker is pointed towards the patient’s right hip (if indicator is on the left) or left shoulder (if indicator is on the right)
Identify your landmarks
SAX at the Aortic Valve
SAX at the Mitral Valve
SAX at the Papillary Muscles
Apical 4 Chamber
Palpate for the point of maximal impulse
Place the probe over the point of maximal impulse with the probe marker pointed towards the patient’s right (if indicator is on the left) or patient’s left (if indicator is on the right)
Identify your landmarks
Slide or rock your probe so that the apex of the heart is pointed directly upwards and the septum is centered on your screen.
Interpretation + Medical Decision Making
Effusion- Yes/No ( if yes is there tamponade)
Ejection- normal, depressed, severely depressed
Equality- is the rv in the a4c smaller than the lv
Entrance- is the ivc fully collapsed, no collapse, or some
Exit- is the aortic root dilated (> 4cm) or disecting Yes/No
Pathology
Vegetation on the Tricuspid Valve in SUX
Depressed ejection fraction
Severe aortic stenosis
Case 1 - Shortness of Breath
35 yo female with stage IV breast cancer presents to the ED with exertional dyspnea. Your attending asks you to get a cardiac ultrasound. What do you see and what would you do next?
Case 1: Click to see answer
There is evidence of pericardial effusion without tamponade, as the RV is not collapsing. This pathology is likely chronic.
Thus, there is no indication for urgent pericardiocentesis. Consider other causes of SOB.
Case 2 - Syncope
A 24 yo female presents to your ED after an episode of syncope. You ultrasound her heart. What treatments would you initiate:
A: Pressors
B: Lytics
C: Intubation
Case 2: Click to see answer
This is a PE. Begin lytics.
Starting pressors/intubation may be harmful as this increases intrathoracic pressure and afterload.
Ultrasound G.E.L. Podcast
Want to learn more? Take a listen to a review of the literature!
