Cardiac ultrasound: Difference between revisions

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==Background==
==Background==
*Use phased array probe
*Important to realize that the cardiac ultrasound preset on some machines reverses the indicator marking with the probe indicator on the right
*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.
*With the general ED ultrasound the probe indicator is on the left of the screen
 
==Indications==
*[[Shock]]
*[[Chest pain]]
*[[Shortness of breath]]


==Technique==
==Technique==
#Select probe
#*Phased array probe
#Location
[[File:Cardiac Ultrasound.png|250px]]
[[File:Cardiac Ultrasound.png|250px]]
===Parasternal Long===
===Parasternal Long===
*Pointer to the L hip, probe at L 3rd/4th intercostal space adjacent to sternum
*Pointer to right shoulder, probe at left 3rd/4th intercostal space adjacent to sternum
*Use to visualize global function and r/o pericardial effusion/tamponade
*Use to visualize global function and rule out pericardial effusion/tamponade
**Can evaluate mitral valve, aortic valve, aortic root, LV squeeze
**Can evaluate mitral valve, aortic valve, aortic root, LV squeeze


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


===Apical 4 chamber===
===Apical 4 chamber===
*Pointer to Right, usually below nipple
*Pointer to right, usually below nipple
*Use to visualize global function (Left and right ventricle, squeeze)  
*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===
===Subxyphoid===
*Pointer to Right, subxyphoid with probe pointed toward head
*Pointer to right, subxyphoid with probe pointed toward head
*Use liver to as acoustic window to visualize heart
*Use liver to as acoustic window to visualize heart
[[File:Cardiac Subxyphoid.png|300px]]


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


==Measurements==
*Start in the Apical 4 chamber view, rotate the probe until the marker points towards the patient's right shoulder
===Aorta===
*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)
*Normal aortic root is <3.8 cm (parasternal view with dot pointing to Lt arm)


==Findings==
===Classic Ultrasound Findings For Critically Ill Patients===
===Classic Ultrasound Findings For Critically Ill Patients===
{| class="wikitable sortable"
{| class="wikitable sortable"
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| [[Pericardial Effusion and Tamponade|Tamponade]] || RA collapse with filling<br/>RV collapse with filling || ↑ || NL || Sliding
| [[Pericardial Effusion and Tamponade|Tamponade]] || RA collapse with filling<br/>RV collapse with filling || ↑ || NL || Sliding
|-
|-
| [[PTX]] || NL or Hyperdynamic || ↑ || Lung point<br/>Consolidated lung || Absent lung sliding
| [[pneumothorax]] || NL or Hyperdynamic || ↑ || Lung point<br/>Consolidated lung || Absent lung sliding
|-
|-
| [[Sepsis]] || Hyperdynamic squeeze || ↓ || NL (see pneumonia)  || Sliding
| [[Sepsis]] || Hyperdynamic squeeze || ↓ || NL (see pneumonia)  || Sliding
Line 55: Line 73:
|}
|}


==Pericardial Effusion==
===Parasternal Long===
*For cardiac tamponade
*Assess for pericardial effusion and differentiate from pleural effusions
**Pericardial effusion
*Assess ejection fraction using E-point septal separation (EPSS)
***In acute cases, even a relatively small build up of pericardial fluid can lead to hemodynamic compromise
**Measures the distance between the maximal opening of the anterior leaflet of the mitral valve during diastole (the E wave) and the septum
**Diastolic collapse of the right atrium (in atrial diastole)
**Measured using M mode
**Diastolic collapse of the right ventricle
**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>
**Plethoric IVC
*Fractional shortening for LVEF estimation
**Valvular pulsus parodoxus
**Place M-mode marker perpendicular to LV cavity
***Doppler interrogation across the mitral valve will demonstrate exaggerated respiratory variability of transvalvular flow
**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
 
===[[IVC ultrasound]]===
*Tyically included in interpretation
 
==Images==
[[File:Cardiac Subxyphoid.png|300px]]


==Video==
==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==
*[[Ultrasound (Main)]]
*[[Formal echocardiography]]
*[[Pericardial Effusion and Tamponade]]
 
==External Links==
[https://www.emra.org/emresident/article/fractional-shortening/ EMRA: Fractional Shortening]
 
[https://www.emra.org/emresident/article/epss/ EMRA: EPSS]
 
===Videos===
{{#widget:YouTube|id= 4qerzEW_ASU}}
{{#widget:YouTube|id= 4qerzEW_ASU}}


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{{#widget:YouTube|id= 1UJ6RodOSTw}}
{{#widget:YouTube|id= 1UJ6RodOSTw}}
==See Also==
*[[Ultrasound (Main)]]
*[[Pericardial Effusion and Tamponade]]


==References==
==References==
<references/>
<references/>
Sonosite
Uptodate


[[Category:Cardiology]]
[[Category:Cardiology]]
[[Category:Radiology]]
[[Category:Radiology]]
[[Category:Ultrasound]]
[[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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