Focused Cardiac Ultrasound

July 29, 2021

ID6843

To CiteDCA Citation Guide

00:04Indications to perform a focused
00:07cardiac ultrasound include assessment
00:09of left ventricular function,
00:11assessment for pericardial effusion,
00:13assessment for relative chamber
00:15size and right heart strain,
00:17and the global assessment of the
00:20inferior vena cava for volume status.
00:25The focus will be done with
00:27a low frequency transducer.
00:28Your best choice will be a phased array
00:30probe as it will allow you to look at
00:33the heart in between the rib spaces.
00:35Alternatively, you may use
00:37a curvilinear probe as well.
00:39A complete focus will consist
00:42of five separate views.
00:43These include the Parish journal,
00:45Long Access, the Parasternal short axis,
00:48the apical four chamber,
00:50a subxiphoid and an inferior vena cava view.
01:12personal assets placing
01:13the transducer in the long axis parallel
01:15to the license at the heart you get an
01:18image that looks something like this.
01:19Again, you can rotate the transducer
01:22to get an image that looks. Like this?
01:33In the left video clip there is a
01:36heart with good symmetric squeeze
01:37of the left ventricle and nice
01:40excursion of the anterior leaflet of
01:42the mitral valve hitting the septum.
01:44In the video clip on the
01:46right, there is severely
01:47depressed function. In a
01:49six week old after a
01:51cardiac arrest event. Note
01:52the poor global squeeze of the
01:54entire left ventricle and the absent
01:56movement. Of the mitral valve.
02:04The left clip again depicts
02:06a normal appearing heart on
02:08the right side of the screen.
02:10There is a circumferential pericardial
02:12effusion with preserved LV function.
02:14Note the arrow points to the effusion.
02:17Collecting to the posterior
02:18aspect of the heart on this view.
02:26You can use the descending aorta to
02:29differentiate whether a large fluid
02:31collection is present within the pericardial
02:33SAC or outside of the pericardium.
02:35In these clips, the descending
02:36aorta is marked by an asterisk.
02:39Note the clip on the left,
02:41a large fluid collection has seemed to
02:43run in front of the descending aorta.
02:46In contrast, on the video clip on the right,
02:49a large fluid collection is present behind
02:51the descending aorta and this represents.
02:53A pleural effusion.
03:03Again, on the left of the screen is a normal
03:06PSA view with the left ventricle being
03:08the largest chamber that can be
03:10seen on the screen. Compare that
03:13to the right sided clip where there
03:15is an enlarged ventricle and a
03:17child with a natural septal defect.
03:19The ASD can be seen to come into view
03:22during the early portion of this clip.
03:24The RV has compensated and
03:26become enlarged due to
03:27the constant left to right
03:29shunt through the ASD.
03:37And finally, in these clips one can
03:40compare the normal cardiac structure that
03:43can be observed on the clip on the left.
03:46The video clip on the right shows severe
03:49diffuse hypertrophic cardiomyopathy.
03:51This particular adolescent presented with
03:53Presyncope during a basketball game,
03:55and he had a normal echocardiogram several
03:58years prior to this point of care study.
04:25Rotating 90 degrees, you get
04:27required personal short access.
04:31And if you slide toward
04:32the apex of the heart.
04:36You see the popular
04:37muscles and keep sliding.
04:38You see the mitral valve slide
04:39keep sliding, keep sliding.
04:40You should be able to see
04:42that you already got flow.
04:49Here are two Paris Journal
04:51short access comparison views.
04:53On the left clip you can see
04:55the normal circular appearance
04:57of the left ventricle at the
04:59papillary muscle level node.
05:01In isometric squeeze,
05:02and no evidence of
05:04pericardial effusion. The clip
05:05on the right shows a large
05:08pericardial effusion,
05:08although the PSA view is not
05:11the best for smaller effusions,
05:13larger effusions can be confirmed on this.
05:16Cardiac window note that the large
05:18fluid collection is seen to run
05:19anterior to the descending aorta,
05:21which can be seen here in
05:23short access as
05:24a course is behind the heart.
05:33Here we can compare the relative
05:35chamber sizes in a PSA view.
05:37The normal clip on the left.
05:39You can observe the croissant
05:41shaped right ventricle next to
05:42the donut shaped left ventricle.
05:44The left ventricle is the
05:46larger of the two chambers.
05:47The abnormal clip on the right
05:50shows an enlarged right ventricle
05:51and an infant who was eventually
05:53diagnosed with aortic stenosis.
05:55The RV
05:55here is the bigger of the
05:58two chambers. There is also
06:00abnormal squeeze and global depression
06:02of systolic function. On this view. These
06:05next set of clips once again compare
06:08a normal PSA Chamber evaluation
06:10on the left compared to a markedly
06:14abnormal appearance of
06:15the right ventricle
06:16on the right. In this abnormal
06:19clip, there is a dreaded design
06:21with flattening of the
06:23interventricular septum due to a large
06:26pulmonary embolus, which
06:27has caused increased pressures.
06:29In the right ventricle and
06:31subsequent enlargement,
06:32the septal fattening is a non specific
06:34finding and can be caused by any
06:37disease process that elevates pressures
06:39in the right ventricle and therefore
06:42transmits AD shaped appearance
06:43to the left ventricle.
07:07The next we would look at
07:09is something called and
07:10apical, four chamber view,
07:11which again you find the
07:13apex of the heart filled up.
07:16Looking like that.
07:20Again, you want to rotate until
07:22you get the image that you have.
07:24Here again, you can tell the
07:26translation back and forth to make sure
07:29that the ventricular septum
07:30septum lines up with the
07:32vertical axis of the image.
07:40On this comparison, split screen
07:42for the apical four chamber
07:43view. The left clip shows a
07:45heart with good function.
07:47The lateral walls of the left and
07:49right ventricle are both seemed to
07:51squeeze nicely towards the septum.
07:53The clip on the
07:55right shows abnormal function on this
07:57apical four chamber view of a two week old
08:00with the juxta ductal aortic coarctation.
08:02Its newborn presented with hypothermia,
08:04lethargy, and unexplained dyspnea,
08:06but had a normal heart rate and
08:08blood pressure at the time.
08:10This focus was performed,
08:11there appears to be depressed function and
08:14poor squeeze of the ventricular walls.
08:16In addition, you can see air
08:18bubbles coursing through the right
08:20atrium and the right ventricle.
08:22You may experience this finding if.
08:24The focus is performed during
08:26Ivy Fluid administration.
08:27The other interesting finding here is
08:28that there is an occasional air bubble
08:31that escapes into the left atrium.
08:33This finding is caused by a
08:35direct digital communication,
08:36such as would be seen with
08:37a small ASD or PFO.
08:45Here we see comparison views
08:47again of a normal appearing apical
08:49four chamber view on the left.
08:52The video clip on the right is striking
08:54for the large fluid collection
08:56that is encircling the heart.
08:58This large pericardial effusion is starting
09:00to show signs of tamponade Physiology.
09:02The star marks the lateral
09:04wall of the right ventricle.
09:06This degree of fluid accumulation in the
09:08pericardial SAC has now overcome the
09:11pressures within the right ventricle.
09:12This is an important finding to recognize
09:15as in bowing of the lateral wall of
09:17the right ventricle is an ominous
09:20finding that requires prompt recognition.
09:22And preparations for pericardiocentesis.
09:32In this split screen you can see on
09:34the left normal appearing chamber
09:36sizes and the dominant left ventricle,
09:38which is the largest of all
09:40the chambers on the screen.
09:42The abnormal video clip on the right
09:44shows an enlarged right ventricle in an
09:46adolescent with a pulmonary embolus.
09:48There is a greater than one to one
09:50ratio in the size of the right ventricle
09:53compared to the left ventricle.
09:55This is seen in the presence
09:57of right sided heart strain.
09:59Which is typically caused by
10:01pathology that elevates the pressures
10:03in the pulmonary vasculature.
10:05One last caveat to consider on the apical
10:07four chamber view is the importance
10:09of correlating the indicator on the
10:11patient to the indicator on the screen.
10:14A good anatomical Pearl to take away
10:16is that the tricuspid valve will
10:18generally take off closer to the probe
10:20and therefore higher on the screen
10:22when compared to the mitral valve.
10:24On first glance,
10:25the video clip on the right
10:27would appear to be that of an
10:29abnormally enlarged right ventricle.
10:31This clip is actually a result
10:33of an operator error.
10:35Instead of having the indicator
10:37towards the patient right,
10:38the probe was flipped 180 degrees and the
10:40indicator was towards the patients left.
10:43As you can see,
10:44this also flips the image on the
10:46screen by 180 degrees given off
10:48a false impression of enlarged
10:50right sided structures.
10:52Since the mitral valve takeoff is
10:54lower than that of the tricuspid valve,
10:56you can detect that this is likely
10:58due to a flipped probe and not due to
11:02true right ventricular hypertrophy.
11:27Again, you're putting the chance
11:29user supplied for region aiming up.
11:30Sometimes it's easier to put the
11:32hand on top of the transducer.
11:35And then Antonio is going to help me
11:37change of death so that it shows the heart.
11:43Again, that you might find this
11:44difficult in a skinny patient.
11:51Here we find comparison views of
11:53the subxiphoid window on the left
11:54you see the normal positioning
11:56of the heart behind the liver.
11:58As we would expect to see
11:59on a fast examination,
12:01deliver here is used as an acoustic
12:03window to get a good view of the
12:05cardiac chambers on the abnormal
12:07image on the right of the screen,
12:09you see a large pericardial effusion
12:11with collapse of the lateral
12:12wall of the right ventricle.
12:14Although this large effusion
12:15appears to be circumferential,
12:17the most sensitive place to check
12:19for pericardial effusion on the
12:21subxiphoid window is between the
12:23liver and the right ventricle.
12:31This is an example of a
12:33small pericardial effusion,
12:34as seen on subsequent view
12:36found anteriorly between the
12:38liver and the right ventricle.
13:12We can look at the intravascular status into
13:15vascular volume status by looking at the
13:17inferior vena cava.
13:18You put the transducer right in
13:20the midline supply for
13:21process and tilting up.
13:23CIBC we should be able to see
13:25the ABC follow if we deliver
13:27all the way into the radio.
13:29Alternatively, you can trim it
13:30for free so longitudinally again
13:32following the interior cable.
13:40But you can try to open it up by
13:43rotating back and forth until you see
13:46it entering right. You can see the
13:58So the IVC has been studied
14:00in many different manners
14:02and many different contexts.
14:03To see if it can be used as a reliable
14:07tool to assess for volume status.
14:09To some degree.
14:10This is nuanced research that falls beyond
14:12the scope of this learning tutorial.
14:14However, you can find information
14:16you gather from the IVC to be
14:18a useful piece of the puzzle,
14:21especially when you combine this
14:22information with the other cardiac.
14:24Views that you have obtained.
14:26Here we find 3 different calibers of
14:28the IVC and long access on the left
14:31most video clip you see a flat IVC
14:34which seems to collapse completely
14:37suggestive of hypovolemia or dehydration.
14:39In the middle of the screen you see a
14:42full IBC with some proximal collapse.
14:44Clinical correlation is necessary
14:46with particular attention paid to
14:48the patients respiratory dynamics.
14:49The clip on the right shows a
14:52plump IBC without much collapse,
14:54seen during inspiration.
14:55In the right clinical context,
14:57this is suggestive of heart failure
14:59and myocardial pump dysfunction.
15:04A5 year old girl presents with
15:07weight loss, cough and difficulty
15:09sleeping for several days
15:10on physical exam there is an
15:12elevated respiratory rate,
15:14hepatomegaly, and a loud murmur.
15:16Electrocardiogram reveals
15:17left Axis deviation.
15:18Vital signs are as shown, how
15:21would you interpret the
15:23following focus images?
16:03boy presents with intermittent
16:04vomiting and cough for several weeks.
16:06He is afebrile, but the
16:08pediatrician suspects dehydration.
16:10On physical exam, he appears
16:11agitated and is unable to lay flat.
16:13You not hear a murmur or
16:15any abnormal lung sounds.
16:17Vital signs are as shown.
16:19How would you interpret the following focus