Fundamentals of Point of Care Cardiac Ultrasound For

Emergency Medicine Residents

Frank W Meissner, MD, RDMS, RDCSFACP, FACC, FCCP, FASNC, CPHIMS, CCDS

POC U/S

Hand Held Devices

Excellent 2D imaging

OK quality Color Flow Doppler U/S

Newest System incorporates PW Doppler - but rare to have this capability- won’t discuss PW Doppler today

No REVIEW of U/S Physics

Although important to understanding of U/S image production

Not possible given short time given to discussion

Additionally, simplified knob-ology of POC U/S results in lack of user control of imaging parameters, thus not vital to understand U/S physics in order to obtain dx images

When & Why

Chest Pain Evaluation

Dyspnea Evaluation

Known LV Dysfunction

Possible SBE or Cardiac Embolization

Potential Chest Pain Dx

Chest Pain

Ischemic Dz

Rgnal Wall Motion prior to EKG changes or clinical symptoms

Unlike current enzyme protocols can detect ischemia rather than infarct

>80% lesion will result in resting regional wall motion abnmlty

Potential Dx

Critical Aortic Valve Stenosis

Aortic Dissection of Root or Arch

Pulmonary Embolism

CFD > mod-large TR Jet with nml sized RA

McConnell Sign (hyperdynamic apex + hypokinetic/Akinetic RV Free Wall)

Pericarditis (small Pericardial Effusion)

R/O Pericardial Tamponade

Mitral Valve Prolapse - Barlow’s Syndrome

Acute cholecystitis vs GB colic

Pleurisy with effusion

Atrial Myxoma

Dyspnea

Evidence of Valvular Dysfunction (AoV/MV Stenosis vs Severe AI/MR )

Evidence of Pulmonary Embolism

Evidence of Systolic vs Diastolic HF

Pleural Effusion, Atelectasis, Pneumonia

Cardiac Cycle

Systole AV Valves Closed

Diastole AV Valves Open

Transducer Positions & Cardiac Views

Parasternal Position

Long Axis

Short Axis

Apical Position

4-, 5-, 2-, 3- chamber Views

Subcostal Position

IVC & hepatic veins, RV/LV inflow view, LV-aorta, RV outflow

Suprasternal Notch (not covered)

Transducer Positions

Imaging Planes

Imaging Windows

Parasternal LA View

What is seen?

Mid portion & base of the LV, MV leaflets, non-coronary & RV leaflets of AoV, Aortic Root, RA, RV

Imaging plane aligned parallel to the Long Axis of LV

With medial angulation/rotation of transducer RV/TV/RA brought into view

Parasternal LA View

Parasternal LAX View

Detailed Anatomy - Parasternal LAX View

Detailed Anatomy - PLAX

RV Wall

RV

Interventricular Septum

LV

Posterior Wall

MV

Papillary Muscles

Chordae Tendinae

LA

AoV

Ascending Aorta

RV Inflow Tract View

Parasternal SAX (AoV Level)

RVOT

TV

PV

PA

AoV

RA

LA

Intra-atrial Septum

Parasternal SAX (AoV Level)

Parasternal SAX (MV Level)

RV Free Wall

IVS

LV

MV orifice

LVPW

Pericardium

RV Free Wall

RV Cavity

IVS

LV Cavity

Papillary Muscles

Posterior LV Wall

Pericardium

Parasternal SAX (Papillary Level)

Apical 4-ChamberLV Apex

RV Cavity

IVS

Intra-atrial Septum

LV Cavity

LV Lateral Wall

MV

TV

Papillary muscles

Chordae Tendinae

Pulmonary Veins

LA

RA

Pu

Apical 5-chamber

LV Apex

RV Cavity

IVS

Intra-atrial Septum

LV Cavity

LV Lateral Wall

MV

TV

AoV

LV Outflow Tract

Pulmonary Veins

LA

RA

Pu

Apical 2 Chamber

LV Apex

Anterior Wall LV

Inferior Wall LV

LV Cavity

MV

LA

Pulmonary Veins

LV Apex

AntSeptal LV

InferiorLat LV

LV Cavity

MV

LA

AoV

LV outflow tract

RV Infundibulum

Apical Long Axis or 3-Chamber View

Cardiac Valves

Septal Walls - Apical 4Chamber

Wall Seg - Coronary Artery Relationships

RUSH Protocol Probe Positions

Rush Protocol Probe Positions

Evaluate ‘The Pump’

Rush’ed Exam

“The Pump”

Severe LV Systolic Dysfunction

“The Pump”

Large Pericardial Effusion

“The Pump”

Hemorrhagic Tamponade

“The Pump”

Acute RV Strain => Pulmonary Embolism

“The Pump”

RA Thrombus => Pulmonary Embolism

Rush Probe Positions

Evaluate ‘The Tank’

‘The Tank’

Evaluate IVC with Sniff Test

‘The Tank’

Eval IVC with ‘Sniff test’ m-mode

‘The Tank’

Eval IVC with ‘Sniff Test’ in case of High Filling Pressures

‘The Tank’‘The Tank’

Fast Exam - Fluid in Morrison’s Pouch

‘The Tank’

e-FAST Eval - Pleural Effusion

‘The Tank’

e-FAST eval R/O PTX

‘The Tank’

e-FAST Eval Pulm Edema

RUSH Exam - Probe Sites

‘The Pipes’

‘The Pipes’

Large Abdominal Aortic Aneurysm

“The Pipes’

Acute Abdominal Aortic Dissection

‘The Pipes’

Acute Thoracic Arch Dissection

‘The Pipes’

Acute DVT of Femoral Vein

Levels of Echo Competence

Conclusions

POC U/S is a Wholistic Tool

We have Discussed the Available Cardiac U/S Views

We have Discussed in Detail the Rush Protocol for Shock

The Key to Mastery Is To ‘Probe’ Every Patient - This Requires Discipline in a Busy ED