CARDIAC ECHO
ED Echocardiogram Pearls & Pitfalls
- Positioning: elevate the head of bed slightly, have the patient bend their knees to get a better and less uncomfortable subcostal, view
- Small amounts of pericardial fluid will accumulate posteriorly first under the force of gravity.
- Findings in tamponade include diastolic right ventricular collapse
- Pericardioscentesis: Apex is usually the #1 site, subcostal best in only 12%
- Volume status: Use the sniff test. Visualize the IVC and have the patient make a strong sniff. If there is full collapse if the IVC, the CVP should be less than 5, if there is some collapse it is 5-10 and if there is no collapse the CVP is greater than 10.
- A hypoechoic space seen anterior to the heart with no evidence of posterior fluid is most likely a pericardial fatpad.
- Fluid doesn’t accumulate behind the left atrium because the pericardium is adherent there.
- Pleural fluid can be mistaken for pericardial fluid. If uncertain, try to visualize the post-cardiac aorta; if the fluid is behind that it is likely pleural in origin.
- Proper Positioning: Elevate the head of bed slightly, have the patient bend their knees to get a better and less uncomfortable subcostal/subxiphoid view. Remember to angle the ultrasound beam under the patient’s xiphoid process and towards their left shoulder. To obtain a parasternal ultrasound of the heart, you can achieve great imaging with the parasternal long axis and parasternal short axis approach. Having the patient twist their torso to the left can help bring the heart closer to the chest wall and away from their sternum, therefore improving your parasternal views.
- Pericardial Effusions: Make sure you visualize the posterior pericardium surrounding the heart. Gravity will direct small amounts of pericardial fluid to accumulate in the posterior pericardium in patients who are lying supine. Remember that fluid doesn’t accumulate behind the left atrium because the pericardium is adherent to the myocardium there. A hypoechoic space seen anterior to the heart with no evidence of posterior fluid is most likely a pericardial fat-pad, however, a loculated effusion is possible. Learn how to perform both parasternal and subxiphoid scans so comparison views can be obtained in cases that aren’t cut and dry.
- Pericardial Tamponade: Echocardiographic findings in pericardial tamponade include diastolic right atrial and/ or right ventricular collapse. These finding are usually seen prior to the clinical picture of tamponade (hypotension, tachycardia, jugular venous distension)
- Pericardiocentesis: Use bedside ultrasound to help you determine where the largest collection of fluid has accumulated. The apex is usually the best site to start, but look everywhere to be certain. The traditional subcostal approach is best in only 12% of cases. Scan around the thorax until you find the location where you maximize your chances of tapping into the effusion, meanwhile minimizing the chance of accidentally puncturing an organ.
- Pleural Fluid: Pleural fluid can be mistaken for pericardial fluid. If uncertain, try to visualize the aorta behind the heart. If the fluid is posterior to the aorta it is likely pleural, rather than pericardial, in origin.
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Cardiac Echo
Echo of normal heart – Parasternal View – labeled
Echo of normal heart -Â Apical View – labeled
Normal Heart: Sub-xyphoid veiw
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Dilated Heart from advanced CHF
Cardiac Tamponade: Malingnant
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Pericardial Effusion
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Amyloid Heart
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Pulmonary Embolism causing dilated hypokinetic Right Ventricle
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Pulmonary Embolism causing dilated hypokinetic Right Ventricle
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