ECHO AND FOCUSED ECHO IN LIFE SUPPORT

Focused echo in life support (FELS) or basic focused cardiac ultrasound (FCU) utilises basic bedside echo views looking for important qualitative cardiac findings. These findings can be integrated with other PoCUS findings, and the patient clinical picture, in order to aid diagnosis, guide investigation, and improve targeted management. In general the focus of the examination should be answering a few specific binary questions:

  1. Is there a pericardial effusion and the size (+/- Tamponade)

  2. Qualitative LV and RV size and function

  3. Determining fluid status (at extremes)

As well as qualitative echo, with appropriate training, some simple quantitative measures can be undertaken to help guide your cardiac assessment, and help define particular patterns of pathology.

AIMS

  • Understand the anatomy

  • Attain standard echo views

    • PLAX- parasternal long axis

    • PSAX- parasternal short axis

    • A4CH (extension views - A5CH/A2CH )

    • SUBCOSTAL and IVC

    • SUPRASTERNAL

  • Identify normal qualitative echo findings

  • Identify cardiac activity during CPR and in cardiac arrest

  • Recognise and interpret potential abnormal findings and physiology

    • Qualitative assessment of structure and chamber sizes

    • Qualitative assessment of LV - size, function, contraction

    • Qualitative assessment of RV size and function

    • Identify a pericardial effusion and signs of tamponade

    • IVC assessment - size and variability

  • Recognise Limitations of your focused cardiac assessment

  • Appreciate some potential characteristic echo findings of different pathologies

    • Pericardial effusion and tamponade

    • Acute PE with RV strain

    • Impaired systolic LV cardiac function

    • Sepsis

    • Appreciate abnormal valve appearance (not function)

    • Help differentiate causes of shock

  • Understand simple quantitative measures and limitations

    • LV systolic function - MV EPSS (end point septal separation), FS (fractional shortening)

    • RV systolic function- TAPSE (tricuspid annular plane systolic excursion)

    • IVC size and variation

  • Integrate findings with clinical picture

indications

Introduction to Focused Cardiac Ultrasound (A/Prof Sam Orde - Nepean)

Basic focused cardiac ultrasound should focus on limited binary questions. The user should recognised their limitations in experience and the interpretation of images obtained. More detailed examination and interpretation of echo findings should be only carried out with appropriate supervision and credentialed training. Always discuss and show your images to a credentialed supervisor if there is clinical concern, or any abnormal or unexpected findings. Formal investigation/imaging should always be sought if there is any clinical concern.

Some general clinical indications:

  • Cardiac arrest - assessment for cardiac activity

  • Assess gross LV and RV size and function

  • Assess for pericardial fluid and tamponade

  • Help in the determination of volume assessment

  • As part of a shock examination/determination of shock

  • Help guide vasopressor and inotrope therapies

  • Signs of RV strain in PE

LIMITATIONS

  • This is not a formal or quantitative echo !

  • Cardiac windows, positioning, body habitus and clinical condition

cardiac ultrasound probe and ORIeNtATION

The phased array/cardiac probe should be used for your cardiac ultrasound as it has the ideal parameters for attaining the desired views.

phased array PROBE

  • Small foot print enabling positioning between intercostal spaces

  • Wide field of view at depth and narrow superficially allowing interrogation of deep cardiac structures via a small ultrasound window.

  • Medium to low frequency transducer for adequate penetration depth

PRESET AND ORIENTATION

A cardiac preset should be used, with the screen orientation marker being at the top right of the screen image.

BASIC CARDIAC VIEWS AND positioning

There are 5 basic cardiac views that should be obtained. Often one or more of these views may be difficult to obtain in different patients and scenarios.

Parasternal Long axis view (PLAX)

Parasternal Short axis view (PSAX)

Apical 4 Chamber view (A4CH)

Subcostal view (SUB)

Subcostal IVC view

The apical 4 chamber view can be extended to:

  • Apical 5 chamber view (by tilting the probe cephalad) revealing the aortic outflow tract and aortic valve

  • Apical 2 chamber view (by probe rotation anticlockwise approximately 90 degrees) providing a view of the LA and LV chamber with anterior and inferior walls

A sixth cardiac view is the suprasternal window which reveals the ascending and arch of the aorta.

Patient positioning

Positioning will depend on the patients ability tolerate movement and their ability to be placed more supine.

For parasternal and apical views ideally a patient should be positioned rolled towards their left side (left lateral decubitus), right arm by the side, and left hand placed on their head. The patient does not need to be completely supine.

Source : POCUS 101(modified)

For subcostal view the patient is spine ideally with their knees flexed up.

Source: sah.org.au

BASIC CARDIAC VIEW ACQUISITION


parasternal long axis view (plax)

At a parasternal location position the probe in the 3-4th intercostal space with the probe marker aimed at the patient’s right shoulder.

  • Slide the probe within the intercostal space to attain a clean window

  • Tilting the probe within the space to attain the view and avoid rib shadowing

  • Align the probe marker with the patients right shoulder - rotate to gain an elongated view of the LV (usually the apex will be slightly obscured)

Source: Kwaktalk.org