II. Indications

  1. FAST Exam
  2. Best view for Pericardial Effusion detection
  3. Best view in COPD and Asthma (heart pushed down towards diaphragm)
  4. Overall four chamber heart view
    1. Subcostal view is an oblique cut through the heart (between transverse and longitudinal)
    2. Apical view is preferred four chamber view as more exactly transverse heart view (perpendicular to longitudinal view)
  5. Start position for inferior vena cava view (when difficult to identify in volume low patients)
    1. First obtain four chamber view in subcostal view
    2. Next, rotate the probe 90 degrees into longitudinal subcostal view

III. Technique

  1. Pearls to improve view window
    1. Liver provides best window to heart
      1. Consider starting this view longitudinally with indicator at 12:00 to identify left lobe of liver and angle through heart
    2. View improves with the patient taking a deep inspiration
    3. View improves when significant pressure is applied
    4. View worsens in Obesity
    5. Imagine the probe as a spoon used to scoop out the heart (anology attributed to Cliff Reid, MD)
    6. Increase the depth to maximum initially while obtaining best view of heart
    7. Maneuvers to improve view
      1. Deep breathing
      2. Upright Posture and left lateral decubitus position (difficult in Trauma patients)
  2. Transducer orientation
    1. Hold transducer over the top (more at the base of probe) to allow for a more shallow angle to abdominal wall (15 degrees)
    2. Push the transducer down (posteriorly) to drop below (deep) to the xiphoid process
    3. Transducer placed sub-xiphoid (by 1-2 cm) in superior epigastrium
    4. Transducer with energy toward left Shoulder (indicator aimed at right flank)
      1. Regardless of screen indicator (left or right), probe indicator should match the direction of screen indicator
      2. Screen indicator on right (Cardiac preset, standard Echocardiogram)
        1. Transducer indicator pointing towards patient's left (3:00 position)
      3. Screen indicator on left (FAST)
        1. Transducer indicator pointing towards patient's right (9:00 position)
  3. Images
    1. UltrasoundHeartSubXiphoid.jpg
    2. ultrasoundProbePositionEchoSubXiphoid.jpg
    3. ultrasoundBMP_cvSubXiphoid.jpg
  4. Landmarks
    1. Four chamber heart view
    2. Increase angle of approach (aiming more posterior) if aorta is seen in the four chamber view
    3. Apex of the heart points to screen right when probe and screen marker are oriented correctly

IV. Interpretation

  1. Pericardial Effusion
  2. Systolic Dysfunction
  3. Wall motion abnormalities

V. Resources

  1. FAST Exam Subcostal (Dr. Mandavia, Sonosite)
    1. http://www.youtube.com/watch?v=Mkc6tUVRgKo
  2. Sub-xiphoid View Video (SonoSite)
    1. http://www.youtube.com/watch?v=1UJ6RodOSTw
  3. Echocardiographer
    1. http://echocardiographer.org/

VI. References

  1. Mateer and Jorgensen (2012) Introduction and Advanced Emergency Medicine Ultrasound Conference, GulfCoast Ultrasound, St. Pete's Beach
  2. Noble (2011) Emergency and Critical Care Ultrasound, Cambridge University Press, New York, p. 61-88
  3. Orman, Dawson and Mallin in Majoewsky (2013) EM:Rap 13(1): 4-6
  4. Reardon (2011) Pocket Atlas Emergency Ultrasound, McGraw Hill, New York, p. 61-106

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