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

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

normal right ventricular end-diastolic diameter (RVEDD)
At A4C view:
≤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%

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

The most efficient method for estimating left ventricular ejection fraction

Answer 14

Visual estimation

Question 15

Stroke volume can be measured by obtaining these 2 variables:

Answer 15

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

Question 16

How to determine left atrial enlargement?

Answer 16

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 17

This is suggestive of LVH

Answer 17

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 18

IVC is measured where? (“Entrance”)

Answer 18

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

Question 19

standard definition of fluid responsiveness

Answer 19

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

Question 20

Ultrasound indicators of hypovolemia

Answer 20

Hyperdynamic LV
LV systolic collapse
IVC collapsibility

Question 21

Remarks on IVC assessment

Answer 21

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 22

Heart axes

Answer 22

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

Question 23

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

Answer 23

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

Question 24

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

Answer 24

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 25

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

Answer 25

it allows identification of the different walls of the left ventricle

Question 26

Structure seen in Mercedez Benz View

Answer 26

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

Question 27

remarks on doing the apical veiw

Answer 27

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 28

the apical view is advantageous for

Answer 28

assessing LV function
and relative chamber sizes