Cardiac POCUS, pt 1

Question 1

Questions answered by FoCUS (Focused Cardiac UltraSound)

Answer 1

1. EQUALITY - Is there a morphologically normal heart? Is there RV dilatation?
2. EJECTION - Is there LV systolic dysfunction?
3. EFFUSION - Is there pericardial effusion? Is there tamponade?
4. EXIT - Is there dilatation of the aortic root?
5. ENTRANCE - Is the patient fluid responsive?

Question 2

How to perform Parasternal Long-axis (PLAX) view

Answer 2

probe is on the 4th or 5th ICS
prober marker directed to the right shoulder (cardiac preset)

Question 3

remarks on mercedez benz sign

Answer 3

it’s the aortic valve, seen via PSAX view

other structures viewed:
artoic valve
left atrium
right atrium
tricuspid valve
right ventricle
pulmonary valve

Question 4

remarks on the left ventricle (LV)

Answer 4

conoid shape, pointed apex
Wall thickness 0.6- 0.9 cm (<1 cm)

Question 5

remarks on the right ventricle (RV)

Answer 5

Triangular / crescent shape
diameter <3 cm,
RVEDA <2/3 of LVEDA
wall thickness <0.5cm

normal right ventricular end-diastolic (RVEDD) diameter in A4C is ≤3.5 cm at the mid-right ventricule at ≤4.0 cm at the base (Ma & Mateer)

normal thickness of RV free wall is 0.2 to 0.3 cm
≥0.5 cm is hypertrophied (Ma & Mateer)

Question 6

signs of RV dilatation or RV strain

Answer 6

RV is smaler than LV:
ratio is 0.6:1.0

1. PLAX: RV is bigger than aorta and LA
2. PSAX: D sign
3. A4C: RV ≥ LV
4. A4C: McConnell’s sign

Question 7

What is the McConnell’s sign?

Answer 7

Right ventricular free wall hypokinesia with normal function of RV apex (apical sparing)
suggestive of pulmonary embolism

Question 8

remarks on bedside echo in detecting pulmonary embolism

Answer 8

bedside echo is 60-70% sensitive in detecting pulmonary embolism

Question 9

values for ejection fraction

Answer 9

normal: >55%

LV dysfunction
mild: 45-55%
moderate: 30-44%
severe: <30%

Question 10

eyeballing of a heart with normal ejection fraction

Answer 10

1. ventricular myocardium thickens twice its baseline,
2. contracts in a concentric mannner
3. leaflets of mitral valve swing widely open, almost touching the IV septum

Question 11

eyeballing of EF <30%

Answer 11

1. LV myocardium doesn’t thicken when it contracts
2. MV doesn’t swing open widely

Question 12

Ultrasound findings of tamponade (“Effusion”)

Answer 12

1. RV free wall inversion during ventricular diastole (MV is open)
2. Right atrial inversion during ventricular systole
3. dilated IVC
4. decreased caval respirophasic variation

Question 13

Structure that delineates pericardial effusion from pleural effusion

Answer 13

descending thoracic aorta (on PLAX)

Question 14

Earliest ultrasound finding in cardiac tamponade

Answer 14

RA systolic collapse

Question 15

What is the rule of 3rds? (“Equality” and “Exit”)

Answer 15

On PSAX:
Left atrium = Aortic root = Right ventricle
A relatively larger chamber compared to the rest is abnormal.
- left atrial dilatation (such as in HF from RHD)
- aortic root dissection / aneurysm
- RV strain in massive pulmonary embolism

Question 16

Discuss “Entrance”

Answer 16

The IVC is the “Entrance”
IVC assessment helps us determine fluid responsiveness

Collapsibility index (CI)
= [max (exp) diameter - min (insp) diamter ] / max diameter
normal: >50%

For intubated patients, we use Distensiblity index (DI)
Normal: >12%

Question 17

How to perform the suprasternal view

Answer 17

probe is placed on the suprasternal notch
probe is angled about 30 degress
head is turned ot the left
Marker towards the left scapula; probe directed as anteriorly as possible (Ma & Mateer)

Question 18

structures seen in suprasternal view

Answer 18

Aortic arch
Right pulmonary artery
Left brachiocephalic vein
Left common carotid artery