Bedside echocardiography in the emergency department — as part of a focused approach to the critically ill or shocked patient — is emerging as a key skill for the resuscitationist. The ‘FAST scan’ has moved up to the heart and thorax, and is proving to be an incredibly useful tool in the resus room.
“Every time you see a sick patient, perform bedside ultrasound. Look at the heart, look at the belly. You will save lives.”
— Amal Mattu, quoted in ‘He simply looks sick…‘
Approaches to Bedside Echo in the Critically Ill Patient
One approach is Weingart, Duque and Nelson’s 5-step Rapid Ultrasound for Shock/ Hypotension (RUSH) protocol which can be completed in just 2 minutes and uses the ‘HI-MAP‘ mnemonic:
1. HEART — Parasternal long and then 4 chamber cardiac views, with the general purpose or cardiac probe
2. IVC view with the same probe
3. If not already using it, switch to general purpose abdominal probe and scan MORISON’s and splenorenal views with thorax images and then examine the bladder window.
4. Increase your depth and find the AORTA above and below the renal artery with four views.
5. Scan both sides of the chest for PNEUMOTHORAX. It may be beneficial to switch to a small-parts, high frequency transducer, but the general purpose probe will often supply sufficient views of the pleural interface.
The basic Echo views and how to get them!
But what if don’t know your echocardiogram from your elbow?
Obviously, you need to get some supervised training to get up to speed. However, to get you started, here are some brief but highly informative videos from the 123sonography.com team detailing the key views for performing bedside echocardiography.
The parasternal window
The apical 4-chamber view
The subcostal window
123sonography.com has a comprehensive online echocardiography course that can be accessed with a free trial here.
Also, check out the online UltrasoundVillage.com lecture detailing the Standard Views.
Key abnormalities to look for on Bedside Echo
So, what are we looking for? These videos show the critical diagnoses that we’re trying to hunt down…
Heart — Cardiac standstill and CPR during cardiac arrest
If you see this, things are not going so well:
Heart — Left ventricular dysfunction
No fancy measurements are need to see that this left ventricle is very sick (from HQMEDED.com):
The key questions are:
- How big is the LV?
Normal LV end diastolic diameter is 3 to 5.5 cm
<30% change from systole suggests a hypodynamic heart
>90% change from systole sugest a hyperdynamic heart (e.g. hypovolemia)
- What is the LV systolic function?
Normal fractional shortening is 25 to 44%, and normal ejection fraction is 50 to 65%
Heart — Pericardial tamponade
A flailing heart drowning in a pericardial sea:
The key findings to look for in suspected pericardial tamponade are:
- collapse of the right atrium during diastole (sensitive)
- collapse of the right ventricle during early diastole (specific)
- pericardial fluid (may not be as obvious as in the video above)
This case of a hemopericardium on UltrasoundVillage.com shows that the effusion is not always echo-free.
Heart — Pulmonary embolism
Key findings suggestive of PE on echo include:
- RV wall hypokinesis
- Moderate or severe
- McConnell’s sign — akinesia of the mid free wall but normal motion at the apex (77% sensitivity and 94% specificity for PE)
- RV dilatation
- End-diastolic diameter >30 mm in parastemal view
- RV larger than LV in subcostal or apical view
- Increased tricuspid velocity >26 m/sec
- Paradoxical RV septal systolic motion
- Pulmonary artery hypertension
- Pulmonary artery systolic pressure >30 mmHg
- Dilated IVC with lack of respiratory collapse
You might also want to look at the leg veins:
Test yourself with this case-based Q&A: Bedside Echo in Pulmonary Embolism
This video from Scott Weingart and emcrit.org shows how to visualise the IVC to check for fluid responsiveness:
What to look for:
- An IVC diameter of <1.5 cm with complete inspiratory collapse suggests low CVP (<5) and is likely to be fluid responsive
- an IVC diameter of >2.5 cm with no inspiratory collapse represents a high CVP (> 20) and cardiac output is unlikely to improve with fluid loading.
It is reasonable to give give fluid if there is more than 50% IVC collapse with respiration, or even if collapse is clearly visible without a specific measurement. Have another look once the fluid is in.
This HQMEDED.com video shows an obviously dilated aortic root in the long axis view:
The other views from this case can be found at case presentation — aortic dissection and demonstrate the presence of a flap and a coexistent pericardial effusion.
Key features of aortic dissection to look for on echo:
- dilated aortic root
- aortic flap
- pericardial effusion and evidence of tamponade
Another interesting case of aortic dissection is online at UltrasoundVillage.com
Look for these features:
- loss of the lung sliding sign (in the normal lung it looks like there are ants marching along the pleural interface during respiration)
- loss of comet tails
- appearance of reverberation artefact
- try to identify a contact point (the interface between the pneumothroax and normal lung)
- look for subcutaneous emphysema (“clouds with rain” that you can’t see behind)
Look for a triangle of black at the costophrenic angle. If there are clots or loculations there may be some echogenic matter visible.
A hemothorax is shown at UltrasoundVillage.com
Own the Echo!
Hopefully that’s enough to inspire you to want to ‘own the Echo’. Learn from your patients and teachers, and be sure to take advantage of the amazing resources being shared on the web. Finally, leave a comment if you know of any other free online video resources useful for learning the essentials of echocardiography in the critically ill.
- I have access to the 123sonography.com echocardiography course for review purposes.
- I am a registered user of UltrasoundVillage.com, and have received supervised training from the doctors who run the website and courses.