Thread by @Manoj_Wickram

Echo is one of the more skilled ultrasound exams you can do. Having learnt it and now teaching it, I see the same mistakes being made over and over again. I have put together thread on beginner mistakes in echo. #tweetorial #POCUS #FUSIC #askpocus

Before the specifics, the basics (which I won't go into too much detail about):
- Optimise depth and gain
- Position your patient if possible
- Hold the probe low and rest some part of your hand on the patient for stability
- If in doubt more jelly and press a little harder

This is the commonest mistake on PLAX I see. People struggle to revert to a PLAX from this RV inflow view (which in itself is useful beyond basic echo). An RV inflow view is obtained by tilting the tail up from the PLAX point. So, to get back to PLAX just do the reverse motion.

Another common mistake with the PLAX view is not being able to see the left atrium. A small clockwise or anticlockwise movement should open up this left atrium.

The short axis should show a nice round shaped LV. If you are seeing an oval shaped LV then this means you are slicing the LV at a strange angle and happens when you are too low down on the chest. To correct this, come up a rib space or two whilst keeping the short axis view.

Apical 4 chamber is arguably the most difficult view. Often, an apical 4 chamber can be obtained but it is off axis. By this I mean that the heart is not centred on the screen and is to one side (ideally you want the IV septum smack bang in the middle of your screen).

The way to manipulate the heart from one side of the screen to another is simply to rock your probe (notice you are not sliding the probe to a different position, simply rocking the probe)

In fact, this rocking motion can be used to manipulate an off axis heart in all the views. PLAX...

PSAX...

Another apical 4 chamber mistake is to get a foreshortened view. Slicing the heart at an incorrect angle makes it look more circular and difficult to interpret. This is due to being high up on the chest and often coming down a rib space and moving lateral corrects this.

A final mistake for the apical 4 chamber is just seeing the ventricles and wondering whether those pesky atria are! To get the atria into view flatten your probe (not too much though, unless you want an apical 5 chamber!).

For the subcostal view the commonest mistake I see is hand positioning. Unlike the other views, you have to go very flat with the subcostal view and therefore need to alter your grip so that there are no fingers underneath allowing you to go flat and point towards the heart.

I am sure anyone who has learnt echo has made all these mistakes. Being aware of these, and more importantly how to correct them, will make you learn faster and become a better scanner!

*No animals were harmed in the making of this post

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