Learning Objectives:

  1. Describe the indications and limitations of POC Echo 

  2. Perform standard POC Echo windows (subcostal, parasternal, and apical) and planes (four chamber, long and short axis). 

  3. Identify relevant US anatomy, including the pericardium, cardiac chambers, valves, descending thoracic aorta, and inferior vena cava. 

  4. Evaluate left ventricular function and central venous pressure to guide hemodynamic assessment of patient. 

  5. Identify cardiac arrest, pericardial effusions with or without sonographic evidence of tamponade, and dilation of the aortic root or the descending thoracic aorta.

  6. Advanced evaluation 

    1. Acquire a view of the aortic arch and recognize aortic arch dissection and/or aneurysm.

    2. Identification of right ventricular dysfunction. 

    3. Assessment of cardiac output and fluid responsiveness.

  7. Procedural guidance: ultrasound-guided pericardiocentesis, ultrasound-assisted transvenous pacer placement, and ultrasound-guided central venous catheter placement 

  8. Integrate advanced emergency POC echocardiography into individual patient management and departmental function


Indications:

  • Detection of pericardial effusion with or without sonographic evidence of tamponade

  • Evaluation of intrinsic cardiac activity in the setting of a cardiac arrest

  • Evaluation of global left ventricular systolic function

  • Evaluation of right heart dysfunction

Extended Indications:

  • Evaluation of volume status and cardiac preload.

  • Identification of acute right ventricular dysfunction in the setting of acute chest pain, dyspnea, or hemodynamic instability.

  • Identification of aortic dissection or thoracic aortic aneurysm.

  • Assessment for volume responsiveness and cardiac output measurements

  • Procedural guidance for emergent pericardiocentesis, pacemaker wire placement and capture. 

  • Integration of POC Echo into cardiac arrest management (identifying pseudo-PEA vs true PEA or asystole, identification of the underlying cause of arrest, utilizing echo findings to help prognosticate likelihood of ROSC or survival to admission and/or hospital discharge.)

Required Views:

  • At least 3 views of below:

    • Subxiphoid

    • Parasternal long

    • Parasternal short

    • Apical 4 chamber

    • Apical 5 chamber

  • IVC with measurement if applicable

ANATOMY:

How to Scan:

ACEP Sonoguide: Cardiac Ultrasound

Five Minute Sono: How to Obtain Cardiac Windows

Five Minute Sono: Basic Cardiac Function

Five Minute Sono: Right Heart Assessment 

Five Minute Sono: Pericardial Effusion

Five Minute Sono: Pericardial Effusion

Five Minute Sono: Cardiac Tamponade

Five Minute Sono: US-Guided Pericardiocentesis

POCUS 101: Cardiac Ultrasound Made Easy

Tips/Tricks/Pitfalls:

  • Scan in a systematic pattern to make sure that you visualize every structure every time. 

  • The descending thoracic aorta will help differentiate pericardial effusions (will travel anterior to the aorta) from pleural effusions (will dive posterior to the thoracic aorta)

  • Patients with COPD will often have extremely challenging parasternal views, so start with a subxiphoid view to get a more reliable quick POC echo assessment on a dyspneic patient with known COPD

  • Pericardial fat pads can mimic pericardial effusions. Check for fluid in dependent areas of the heart as well if you are unsure about a finding. 

  • Having a patient lay in left lateral decubitus will often help to optimize views. Make sure your patient can tolerate this.

  • A sustained inspiration will often improve subxiphoid views while “holding” a breath after a complete exhalation will often improve parasternal views.

  • A RWMA (regional wall motion abnormality) will become present within minutes of transmural ischemia, thus POC Echo should be first-line in the evaluation of patients with suspected acute myocardial infarction

  • Approximately fifty percent of congestion heart failure will have a preserved ejection fraction, so consider diastolic dysfunction in patients presenting with signs and symptoms of congestive heart failure but have a preserved ejection fraction.  Most of these patients will have LVH as well as LAE.  Can evaluate with advanced POC echo (transmitral flow and septal tissue doppler measurements) to further elucidate diastolic dysfunction.

Pathology:

  • LV systolic dysfunction

  • Right heart dysfunction

    • Septal flattening (D-Sign)

    • RV dilation

    • McConnel’s Sign 

    • Tricuspid Regurgitation

    • Systolic Notching Pattern (on RV outflow track view)

  • Pericardial effusion +/- sonographic tamponade 

  • Regional wall motion abnormalities 

  • Ventricular hypertrophy

  • Aortic root dilatation

  • Hyperdynamic LV

  • Collapsed IVC (< 1cm, completely collapsing)

  • Plethoric IVC (> 2.1 cm, minimal respirophasic variation)

  • LV  diastolic dysfunction 

  • Valvular disease (stenosis, regurgitation, vegetations…)

Key Literature:

  1. The role of point-of-care ultrasound (POCUS) imaging in clinical outcomes during cardiac arrest: a systematic review.

  2. Cardiac Ultrasound in the Intensive Care Unit: A Review - PMC

  3. Point-of-Care Ultrasound in Early Identification of Tamponade: A Case Series - PMC

  4. Point of Care Ultrasound for Diagnosis and Management in Heart Failure: A Targeted Literature Review - PMC

Additional Resources:

The POCUS Atlas: Echocardiography

US Gel Articles

Author: Niyi Soetan, MD

Peer editing by: David Murray, MD FPD-AEMUS