Cardiac POCUS, pt 2

Question 1

The 6 E’s of Cardiac POCUS

Answer 1

Exertion
Effusion
Exit
-
Equality
Ejection
Entrance

Question 2

How to confirm a true pulseless electrical activity (“Exertion”)

Answer 2

Absence of coordinated myocardial contractions and valve movement
Pooling of blood and echogenic clots in the chambers

Question 3

Features of cardiac tamponade (“Effusion”)

Answer 3

Pericardial effusion
RA systolic collapse
RV diastolic collapse
Lack of IVC respiratory variation

Question 4

Upper limit of normal of the aortic root (“Exit”)

Answer 4

3.5 cm (Ma & Mateer)

The traditionally accepted values for the upper limits of normal diameter for sinus of valsalva (SOV) and the sinotubuar junction (STJ) are 4 cm and 3.6 cm for males and 3.6 cm and 3.2 cm for females respectively (Nagpal et al, 2020)

Question 5

Aortic dissection may be detected by what ultrasound views?

Answer 5

Parasternal long-axis (PLAx)
Suprasternal view
Abdominal vew

Question 6

How to perform suprasternal view

Answer 6

Place te transducer in the sternal notch
With the marker pointed toward the pateint’s left scapula (cardiac preset)
with transducer aimed as far anteriorly as possible

(Head is turned to the left)

Question 7

Structures seen in suprasternal view

Answer 7

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

Question 8

3 branches of the aortic arch

Answer 8

Brachiocephalic artery
Left common carotid artery
Left subclavian artery

Question 9

Ultrasound findings of massive PE (“Equality”)

Answer 9

Massive RV dilatation
*Right-sided heart failure
Small, vigorously contracting LV
McConnell’s sign
Paradoxical septal motion
Septal flatteing or D-sign

* TAPSE <17 mm (A4C view) (Tricuspid Annular Plane Systolic Excursion)

Question 10

Normal right ventricular end-diastolic diameter (RVEDD)

Answer 10

At A4C:
≤3.5 cm at the mid-RV
≤4.0 cm at the base

Question 11

Normal RV free wall thickness

Answer 11

2.0 - 3.0 mm is normal.
≥5.0 mm is hypertrophied
Hypertrophied RV free wall may indicate a more chronic etiology of RV strain rather than an acute event.

Question 12

Discuss EPSS (“Ejection”)

Answer 12

E-point Septal Separation
The first peak is the E-point (passive filling in early diastole)
The second peak is the A-point (caused by atrial contraction)
This double peak is evidence of sinus rhythm
≤6 mm: normal left ventricular function
>7 mm: EF <50%
≥13 mm: EF ≤35%

Do note that visual estimation is the most efficient method for estimating left ventricular ejection fraction

Question 13

optimal method to measure left ventricular ejection fraction

Answer 13

Using the method of discs (modified Simpson’s rule)

Calculation of LV EF by the method of disks will be inaccurate if true apical views are not obtained and foreshortened (oblique) views of the LV are measured.

Question 14

Stroke volume can be measured by obtaining these 2 variables:

Answer 14

(1) the area of the LVOT
(2) the velocity time integral (VTI) of the flow through the aortic valve during systole

Question 15

How to determine left atrial enlargement?

Answer 15

by measuring the end-systolic atrial diameter in the parasternal long-axis view.
>4 cm, or if significantly larger than the aortic root –> LAE

Question 16

This is suggestive of LVH

Answer 16

LV internal chamber diameter >5.5 - 6.0 cm
or wall thickness ≥12 mm,
measured at the end of diastole

Normal LV:
Conoid shape, pointed apex
*Wall thickness 0.6 - 0.9 cm (<1 cm)

Question 17

IVC is measured where? (“Entrance”)

Answer 17

about 3-4 cm distal to its junction with the atrium
or 2 cm distal to the entry of the hepatic veins

Question 18

standard definition of fluid responsiveness

Answer 18

> 15% increase in cardiac output with a fluid bolus (500 - 1000mL)

Question 19

Ultrasound indicators of hypovolemia

Answer 19

Hyperdynamic LV
LV systolic collapse
IVC collapsibility

Question 20

Remarks on IVC assessment

Answer 20

From a practical standpoint, the initial size and respiratory variation in the IVC are not as helpful (except in extremes) as the changes that occur in these parameters in response to a fluid challenge.

Question 21

Heart axes

Answer 21

The long axis of the heart is more horizontal in short obese patients
and more vertical in tall thin patients

Question 22

Often the most useful view for point-of-care cardiac ultrasound

Answer 22

the subcostal views
- does not interfere in resuscitative measures such as thoraxostomy, CPR, subclavian line insertion, or endotracheal intubation

Question 23

What to do if with poor-quality images on subcostal view?

Answer 23

Appropriate amount of utz gel,
Shallow angle to the chest wall,
Moving the transducer to the right to use the left lobe of the liver as a window and to avoid gas-filled stomach
In have patient inspire deeply, or intubated patients, you may increase the tidl volumeand
moving off the xipohoid and over the lower intercostal spaces to image the barrel-chested patient with larger A-P diameter

Question 24

the short-axis view at the level of the papillary muscles is an important view because

Answer 24

it allows identification of the different walls of the left ventricle

Question 25

Structure seen in Mercedez Benz View

Answer 25

Aortic Valve (Mercedes Benz Sign)
Left atrium
Right atrium
TV, RV, PV

Question 26

remarks on doing the apical veiw

Answer 26

whenever possible, place the patient in the left lateral decubitus position to reduce lung artifact and to bring the heart closer to the chest wall

Question 27

the apical view is advantageous for

Answer 27

assessing LV function
and relative chamber sizes

Question 28

The most efficient method for estimating left ventricular ejection fraction

Answer 28

Visual estimation

Question 29

Remarks on measuring the aortic root

Answer 29

Everything on the aortic side of the annulus is measured end-diastole and leading edge to leading edge (L-L) while the aortic annulus and LVOT are measured in mid-systole and inner to inner edge. (Buckland)