Cardiac ultrasound: Difference between revisions

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==Background==
==Background==
* Only ED US when probe marker will be pointing to the left (parasternal views)
*Important to realize that the cardiac ultrasound preset on some machines reverses the indicator marking with the probe indicator on the right
* Use phased array probe
*With the general ED ultrasound the probe indicator is on the left of the screen
 
==Indications==
*[[Shock]]
*[[Chest pain]]
*[[Shortness of breath]]


==Technique==
==Technique==
*Parasternal Long
#Select probe
**Pointer to the L hip, probe at L 3rd/4th intercostal space adjacent to sternum
#*Phased array probe
**Use to visualize global function and r/o pericardial effusion/tamponade
#Location
***Can evaluate mitral valve, aortic valve, aortic root, LV squeeze
[[File:Cardiac Ultrasound.png|250px]]
 
===Parasternal Long===
*Pointer to right shoulder, probe at left 3rd/4th intercostal space adjacent to sternum
*Use to visualize global function and rule out pericardial effusion/tamponade
**Can evaluate mitral valve, aortic valve, aortic root, LV squeeze
 
===Parasternal Short===
*Pointer to left shoulder, probe at left 3rd/4th intercostal space adjacent to sternum
*Tip: obtain parasternal long view, then rotate probe 90 degrees
*Use to evaluate LV squeeze, right ventricle
**Right heart strain = dilated right ventricle
 
===Apical 4 chamber===
*Pointer to right, usually below nipple
*Use to visualize global function (Left and right ventricle, squeeze)
*Use this view to obtain the Tricuspid Annular Plane Systolic Excursion (TAPSE)<ref>Kaul, S., Tei, C., Hopkins, J. and Shah, P. (1984). Assessment of right ventricular function using two-dimensional echocardiography. American Heart Journal, 107(3), pp.526-531.</ref>
**Represents the distance the tricuspid annulus moves longitudinally toward the apex during systole
**Measurement obtained using M-Mode with the tracer line through the lateral tricuspid annulus
** < 16mm is suggestive of right heart dysfunction<ref>Rudski, L., Lai, W., Afilalo, J., Hua, L., Handschumacher, M., Chandrasekaran, K., Solomon, S., Louie, E. and Schiller, N. (2010). Guidelines for the Echocardiographic Assessment of the Right Heart in Adults: A Report from the American Society of Echocardiography. Journal of the American Society of Echocardiography, 23(7), pp.685-713.</ref>
 
===Subxyphoid===
*Pointer to right, subxyphoid with probe pointed toward head
*Use liver to as acoustic window to visualize heart
 
===Suprasternal (Optional)===
*Pointer at 12 o'clock (cephalad) and place in sternal notch
*Move probe inferior and to the left to visualize aortic arch
*Rotate probe clockwise for further image optimization
**Can evaluate for aortic dissections/aneurysms, coarctation of the aorta, and aortic stenosis/regurgitation
 
===Apical 5 chamber (optional)===
*Start in the Apical 4 chamber view, tilt the probe upwards until the aortic outflow tract is seen
*This view can be used to calculate the velocity time integral (VTI) and subsequently cardiac output to assess fluid responsiveness
 
===Apical 3 chamber (optional)===
 
*Start in the Apical 4 chamber view, rotate the probe until the marker points towards the patient's right shoulder
*This view can be used to calculate the velocity time integral (VTI) and subsequently cardiac output to assess fluid responsiveness (alternate method to the apical 5 chamber view)
 
==Findings==
===Classic Ultrasound Findings For Critically Ill Patients===
{| class="wikitable sortable"
|-
! Disease !! Cardiac !! IVC !! Lung (Phased Array) !! Lung (Linear)
|-
| [[MI]] || Focal WMA<br/>Mod/Poor squeeze || ↑ || NL or B-lines  || Sliding
|-
| [[Pericardial Effusion and Tamponade|Tamponade]] || RA collapse with filling<br/>RV collapse with filling || ↑ || NL || Sliding
|-
| [[pneumothorax]] || NL or Hyperdynamic || ↑ || Lung point<br/>Consolidated lung || Absent lung sliding
|-
| [[Sepsis]] || Hyperdynamic squeeze || ↓ || NL (see pneumonia)  || Sliding
|-
| [[Pneumonia]] || Hyperdynamic squeeze || NL or ↓ || Unilateral B-lines || Sliding
|-
| [[Congestive heart failure|Decompensated HF]] || Mod/Poor squeeze || ↑ || Bilateral B-lines || Sliding
|-
| [[PE]] || RV > LV<br/>McConnell's sign || ↑ || NL or Unilateral B-lines || Sliding
|}
 
===Parasternal Long===
*Assess for pericardial effusion and differentiate from pleural effusions
*Assess ejection fraction using E-point septal separation (EPSS)
**Measures the distance between the maximal opening of the anterior leaflet of the mitral valve during diastole (the E wave) and the septum
**Measured using M mode
**EPSS > 7mm is 100% sensitive for EF < 30%<ref>McKaigney CJ, Krantz MJ, La Rocque CL, et al. E-point septal separation: a bedside tool for emergency physician assessment of left ventricular ejection fraction. Am J Emerg Med. 2014; 32(6):493-497.</ref>
*Fractional shortening for LVEF estimation
**Place M-mode marker perpendicular to LV cavity
**Measure LV end diastolic diameter (LVEDD) and LV end systolic diameter (LVESD)
**Calculate LVEF using %FS = (LVEDD-LVESD)/LVEDD×100%
 
===Parasternal Short===
*Assess for pericaridal effusion
*Assess for squeeze - visual estimate of hyperdynamic, good, moderate, or poor
*Can also assess fractional shortening in short axis at level of papillary muscles (see above for calculation)
 
===Apical 4 chamber===
*Assess RV:LV diameter at the level of the valves
**Normal RV:LV is 0.6:1
**RV strain is >1:1
*Assess for McConnell's sign
*Calculate TAPSE using M-mode
 
===Subxyphoid===
*Assess for pericardial effusion
*If concerns for PE, assess for right ventricular wall diameter in end diastole<ref>Rudski LG, Lai WW, Afilalo J, et al. Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography. J Am Soc Echocardiogr. 2010; 23(7):685-713.</ref>
**Diameter of <5mm is suggestive of acute pulmonary hypertension
**Diameter of >5mm is suggestive of chronic pulmonary hypertension
 
===Suprasternal (Optional)===
*Assess for aortic dissection


*Parasternal Short
===[[IVC ultrasound]]===
**Pointer to L shoulder, probe at L 3rd/4th intercostal space adjacent to sternum
*Tyically included in interpretation
**Tip: obtain parasternal long view, then rotate probe 90 degrees
**Use to evaluate LV squeeze, R ventricle
***R heart strain = dilated R ventricle


*Apical 4 chamber
==Images==
**Pointer to Right, usually below nipple
[[File:Cardiac Subxyphoid.png|300px]]
**Use to visualize global function (Left and right ventricle, squeeze)


*Subxyphoid
==Pearls and Pitfalls==
**Pointer to Right, subxyphoid with probe pointed toward head
**Use liver to as acoustic window to visualize heart


*Suprasternal
**Pointer at 12 o'clock (cephalad) and place in sternal notch
**Move probe inferior and to the left to visualize aortic arch
**Rotate probe clockwise for further image optimization
***Can evaluate for aortic dissections/aneurysms and aortic stenosis/regurg.


==Measurements==  
==Documentation==
Aorta
===Normal Exam===
*Normal aortic root is <3.8 cm (parasternal view w/ dot pointing to Lt arm)
A bedside ultrasound was conducted to assess the heart with clinical indications of SOB. The parasternal long, parasternal short, apical four chamber, subxyphoid, and IVC views were obtained. Normal diameter AOFT, no pericardial or pleural effusions identified, good squeeze, RV<LV, and IVC was not plethoric nor flat. Normal cardiac ultrasound.


==Pericardial Effusion==
===Abnormal Exam===
*For cardiac tamponade, look for bowing of RA or RV wall inward during diastole
A bedside ultrasound was conducted to assess the heart with clinical indications of SOB. The parasternal long, parasternal short, apical four chamber, subxyphoid, and IVC views were obtained. Normal diameter AOFT, EPSS >7mm, no pericardial effusion, bilateral pleural effusions, poor squeeze, RV<LV, and IVC was plethoric. Indicative of systolic heart failure.
*Can be used to identify pocket of fluid for pericardiocentesis
 
==Clips==


==See Also==
==See Also==
*[[Ultrasound (Main)]]
*[[Ultrasound (Main)]]
*[[Formal echocardiography]]
*[[Pericardial Effusion and Tamponade]]
*[[Pericardial Effusion and Tamponade]]


==Source==
==External Links==
Sonosite
[https://www.emra.org/emresident/article/fractional-shortening/ EMRA: Fractional Shortening]
Uptodate
 
[https://www.emra.org/emresident/article/epss/ EMRA: EPSS]
 
===Videos===
{{#widget:YouTube|id= 4qerzEW_ASU}}
 
{{#widget:YouTube|id= EaLuCBXXINg}}
 
{{#widget:YouTube|id= _eHZz-OCc_M}}
 
{{#widget:YouTube|id= 1UJ6RodOSTw}}
 
==References==
<references/>


[[Category: Cards]]
[[Category:Cardiology]]
[[Category: Rads]]
[[Category:Radiology]]
[[Category:Ultrasound]]

Latest revision as of 17:32, 13 September 2023

Background

  • Important to realize that the cardiac ultrasound preset on some machines reverses the indicator marking with the probe indicator on the right
  • With the general ED ultrasound the probe indicator is on the left of the screen

Indications

Technique

  1. Select probe
    • Phased array probe
  2. Location

Cardiac Ultrasound.png

Parasternal Long

  • Pointer to right shoulder, probe at left 3rd/4th intercostal space adjacent to sternum
  • Use to visualize global function and rule out pericardial effusion/tamponade
    • Can evaluate mitral valve, aortic valve, aortic root, LV squeeze

Parasternal Short

  • Pointer to left shoulder, probe at left 3rd/4th intercostal space adjacent to sternum
  • Tip: obtain parasternal long view, then rotate probe 90 degrees
  • Use to evaluate LV squeeze, right ventricle
    • Right heart strain = dilated right ventricle

Apical 4 chamber

  • Pointer to right, usually below nipple
  • Use to visualize global function (Left and right ventricle, squeeze)
  • Use this view to obtain the Tricuspid Annular Plane Systolic Excursion (TAPSE)[1]
    • Represents the distance the tricuspid annulus moves longitudinally toward the apex during systole
    • Measurement obtained using M-Mode with the tracer line through the lateral tricuspid annulus
    • < 16mm is suggestive of right heart dysfunction[2]

Subxyphoid

  • Pointer to right, subxyphoid with probe pointed toward head
  • Use liver to as acoustic window to visualize heart

Suprasternal (Optional)

  • Pointer at 12 o'clock (cephalad) and place in sternal notch
  • Move probe inferior and to the left to visualize aortic arch
  • Rotate probe clockwise for further image optimization
    • Can evaluate for aortic dissections/aneurysms, coarctation of the aorta, and aortic stenosis/regurgitation

Apical 5 chamber (optional)

  • Start in the Apical 4 chamber view, tilt the probe upwards until the aortic outflow tract is seen
  • This view can be used to calculate the velocity time integral (VTI) and subsequently cardiac output to assess fluid responsiveness

Apical 3 chamber (optional)

  • Start in the Apical 4 chamber view, rotate the probe until the marker points towards the patient's right shoulder
  • This view can be used to calculate the velocity time integral (VTI) and subsequently cardiac output to assess fluid responsiveness (alternate method to the apical 5 chamber view)

Findings

Classic Ultrasound Findings For Critically Ill Patients

Disease Cardiac IVC Lung (Phased Array) Lung (Linear)
MI Focal WMA
Mod/Poor squeeze		 ↑ NL or B-lines Sliding
Tamponade RA collapse with filling
RV collapse with filling		 ↑ NL Sliding
pneumothorax NL or Hyperdynamic ↑ Lung point
Consolidated lung		 Absent lung sliding
Sepsis Hyperdynamic squeeze ↓ NL (see pneumonia) Sliding
Pneumonia Hyperdynamic squeeze NL or ↓ Unilateral B-lines Sliding
Decompensated HF Mod/Poor squeeze ↑ Bilateral B-lines Sliding
PE RV > LV
McConnell's sign		 ↑ NL or Unilateral B-lines Sliding

Parasternal Long

  • Assess for pericardial effusion and differentiate from pleural effusions
  • Assess ejection fraction using E-point septal separation (EPSS)
    • Measures the distance between the maximal opening of the anterior leaflet of the mitral valve during diastole (the E wave) and the septum
    • Measured using M mode
    • EPSS > 7mm is 100% sensitive for EF < 30%[3]
  • Fractional shortening for LVEF estimation
    • Place M-mode marker perpendicular to LV cavity
    • Measure LV end diastolic diameter (LVEDD) and LV end systolic diameter (LVESD)
    • Calculate LVEF using %FS = (LVEDD-LVESD)/LVEDD×100%

Parasternal Short

  • Assess for pericaridal effusion
  • Assess for squeeze - visual estimate of hyperdynamic, good, moderate, or poor
  • Can also assess fractional shortening in short axis at level of papillary muscles (see above for calculation)

Apical 4 chamber

  • Assess RV:LV diameter at the level of the valves
    • Normal RV:LV is 0.6:1
    • RV strain is >1:1
  • Assess for McConnell's sign
  • Calculate TAPSE using M-mode

Subxyphoid

  • Assess for pericardial effusion
  • If concerns for PE, assess for right ventricular wall diameter in end diastole[4]
    • Diameter of <5mm is suggestive of acute pulmonary hypertension
    • Diameter of >5mm is suggestive of chronic pulmonary hypertension

Suprasternal (Optional)

  • Assess for aortic dissection

IVC ultrasound

  • Tyically included in interpretation

Images

Cardiac Subxyphoid.png

Pearls and Pitfalls

Documentation

Normal Exam

A bedside ultrasound was conducted to assess the heart with clinical indications of SOB. The parasternal long, parasternal short, apical four chamber, subxyphoid, and IVC views were obtained. Normal diameter AOFT, no pericardial or pleural effusions identified, good squeeze, RV<LV, and IVC was not plethoric nor flat. Normal cardiac ultrasound.

Abnormal Exam

A bedside ultrasound was conducted to assess the heart with clinical indications of SOB. The parasternal long, parasternal short, apical four chamber, subxyphoid, and IVC views were obtained. Normal diameter AOFT, EPSS >7mm, no pericardial effusion, bilateral pleural effusions, poor squeeze, RV<LV, and IVC was plethoric. Indicative of systolic heart failure.

Clips

See Also

External Links

EMRA: Fractional Shortening

EMRA: EPSS

Videos

{{#widget:YouTube|id= 4qerzEW_ASU}}

{{#widget:YouTube|id= EaLuCBXXINg}}

{{#widget:YouTube|id= _eHZz-OCc_M}}

{{#widget:YouTube|id= 1UJ6RodOSTw}}

References

  1. ↑ Kaul, S., Tei, C., Hopkins, J. and Shah, P. (1984). Assessment of right ventricular function using two-dimensional echocardiography. American Heart Journal, 107(3), pp.526-531.
  2. ↑ Rudski, L., Lai, W., Afilalo, J., Hua, L., Handschumacher, M., Chandrasekaran, K., Solomon, S., Louie, E. and Schiller, N. (2010). Guidelines for the Echocardiographic Assessment of the Right Heart in Adults: A Report from the American Society of Echocardiography. Journal of the American Society of Echocardiography, 23(7), pp.685-713.
  3. ↑ McKaigney CJ, Krantz MJ, La Rocque CL, et al. E-point septal separation: a bedside tool for emergency physician assessment of left ventricular ejection fraction. Am J Emerg Med. 2014; 32(6):493-497.
  4. ↑ Rudski LG, Lai WW, Afilalo J, et al. Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography. J Am Soc Echocardiogr. 2010; 23(7):685-713.
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