Thread by @Pocus101

Having Problems Getting all those Cardiac (Echo)🫀Views on your Shock⚡️Patients?

1⃣Learn The Common Echo Views
2⃣Learn the IVC View
3⃣Estimate EF and CVP
4⃣Dx Massive PE
5⃣Dx Cardiac Tamponade

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Have your patient in the supine or left lateral decubitus position.

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Use the phased array (Cardiac/echo) probe and make sure you are in the cardiac preset with the indicator orientation marker to the right of the screen.

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Remember the 4 chambers (RA, RV, LA, LV) and 4 valves (mitral, tricuspid, pulmonic, aortic) of the heart as you scan your patient.

Also, the heart is much more medial (towards the sternum) than you may realize.

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For the Parasternal Long Axis view. Point the indicator towards the pt's RIGHT shoulder. Identify RV, LV, LA, Aortic valve, Mitral valve, pericardium, and descending aorta.

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If you are having trouble orienting yourself, just remember “the 3 L‘s“: For the Parasternal Long Axis view, the Left Ventricle is on the Left side of the screen.

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To get the Parasternal SHORT axis view, rotate your probe 90 degrees clockwise so that the indicator is now pointing towards the patient’s left shoulder.

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The three main parasternal short axis levels you will see are the Mid-Papillary, Mitral valve (fish mouth), and Aortic Valve (mercedes benz) levels.

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PSSA Mid-Papillary View

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PSSA Mitral Valve (Fish Mouth) View

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PSSA Aortic Valve (Mercedes Benz) View

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For Apical 4 chamber (A4C) slide the probe down towards the apex while keeping the indicator towards the patient's left. Identify the RV, RA, LV, LA, mitral valve, and tricuspid valve.

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If you are having trouble getting the Apical 4 Chamber view, try placing the patient in the left lateral decubitus position. It will reduce lung artifact and bring the heart more proximal to your ultrasound probe, usually giving you an optimal view.

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Subxiphoid (Subcostal) view:

With the patient’s knees bent, position the probe under the costal arch (beneath the xiphoid process) with the indicator pointing towards the left shoulder.

Identify the RV, LV, RA, LA, tricuspid valve and mitral valve.

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For the subxiphoid view, make sure to use liver as acoustic window. If you are still having trouble getting a clear image, try applying gentle downward pressure on the probe.

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For the IVC view, position the probe in the subxiphoid area and point the indicator towards the patient's feet. Identify the RA and IVC (also sometimes the hepatic vein).

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Evaluate the IVC diameter and collapsibility.

Use the IVC to estimate the CVP.

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Estimate the ejection fraction of your patients.

Ejection fraction (EF) in percentage is defined as: EF(%) = SV/EDV x 100

The more you see the easier it gets!

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Hyperdynamic EF

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Normal EF

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Mildly/Moderately Reduced EF

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Severely Reduced EF

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For pulmonary embolism, you can sometimes directly see a clot in the pulmonary artery or a clot in transit.

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You can also look for indirect signs of PE such as RV stain and the D sign

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Another indirect sign of PE is McConnell's sign showing hypo/akinesis of the RV free wall and preserved function of the RV apex.

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For pericardial effusion. Remember the rate of accumulation is much more important than the absolute size.

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Make sure to identify the descending aorta to differentiate between pericardial and pleural effusion.

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A pericardial fat pad can be a false positive for pericardial effusion. It is usually located anteriorly, echogenic, and appears to move with the heart contractions.

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One of the first signs of echocardiographic tamponade is right atrial systolic collapse.

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The other sign of echocardiographic tamponade is right ventricular diastolic collapse.

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