Clinicians are better able to assess patient conditions when they use cardiac imaging at the point of care. With this information garnered from the ultrasound, they can set a comprehensive treatment plan. Clinicians can understand the cardiac function and ensure that the patient receives the best possible care, leading to better outcomes.
Cardiac exams for point-of-care patients are essential, and in this article, we discuss the variety of exams that are performed bedside on cardiac patients.
Goal Directed Echo
In this setting, the application of a goal-directed echo is different from the standard exploratory diagnostic comprehensive echo. This is because in an urgent critical care setting – where goal-direct echo is often used – this approach is practical. The aim of goal-directed echo is to identify and find the different causes of acute cardiac failure or the causes of hemodynamic instability. It’s an approach that is consistently evolving but is becoming widely accepted as a beneficial way to manage a patient.
Parasternal Long Axis View
It’s essential to be able to identify the anatomy in the parasternal long axis window. You need to be able to see that the correct plane of cut. The PLAX view should have ascending aorta, mitral valve, left ventricle, left ventricle outflow tract, aortic valve, interventricular septum, right ventricular outflow tract, and descending aorta.
For hand positioning, you should put the transducer indicator dot toward the right shoulder in the 3rd to 5th intercostal space. You want to be as close to the sternum as you can for an optimal and clear view.
Parasternal Short Axis Views
These consist of multiple views obtained at different planes of cut through the heart. A clear view of the left ventricle, right ventricle, interventricular septum, mitral valve, aortic valve, aortic root, and pulmonic valve are seen in the different views obtained at the specific planes of cut. By directing the probe toward the right shoulder, clinicians can evaluate the mitral valve as well as the aortic valve. When the probe is directed toward the left hip, the apical region of the left ventricular cavity can be clearly visualized.
For hand positioning, the probe indicator should be pointed toward the left shoulder. This makes the plane 90 degrees clockwise from the optimal PLAX view in the exact location.
Apical 4 Chamber View
This view is the most important view of the heart and is great to assess all four chambers of the heart and also do a comparison of the left and right heart. The interventricular septum and the interatrial septum are seen as well as the two atrio-ventricular valves. This view is also optimal to determine blood flow within the heart through the heart valves and flow hemodynamics can be adequately assessed using Doppler.
The transducer should be placed on the apical PMI, which is located in the 4th or 5th intercostal space in the left midclavicular plane. The probe indicator notch should point towards the left axilla.
IVC Collapsibility Volume Status to Determine Fluid Responsiveness
It’s vital to assess fluid responsiveness in patients who are in shock. Patients who are identified to be fluid responsive enables a clinician to increase intravascular fluid volume rapidly to help stabilize the patient. Not every patient will benefit from rapid infusion if they are in shock, and in some cases, it can be harmful. Thus, it is important to determine IVC collapsibility before infusing large amounts of IV fluids.
RUSH Exam
Patients who present with shock or hypotension often have higher mortality rates. The traditional physical exam techniques can often be misleading. That is why the prompt and accurate diagnosis is important. POCUS is a critical initial step to evaluate a patient who presents with shock. Resuscitative ultrasound is a new category of ultrasound that allows direct visualization of pathology and the differentiation of various causes of shock. First developed in 2006, the RUSH protocol was created to be a fast and streamlined way to perform a quick evaluation of a patient in shock. Emergency physicians must be able to perform this ultrasound quickly for the fastest and appropriate management of a patient presenting with shock.
For RUSH protocol, the Heart, Inferior vena cava, Morrison’s pouch, aorta, both costophrenic angles, lower extremities, bladder, lower extremities (for DVT) and chest are examined.
Trans-Esophageal Echocardiography for Shock & Cardiac Arrest
One of the most challenging patient presentations that clinicians in an emergency setting must cope with is cardiac arrest. Emergency care providers do their best but without echocardiography, they cannot get the right picture to be able to manage their patients adequately. Treatment guidance for the critically ill shows that transesophageal echocardiography has more advantages than transthoracic echocardiography, especially in a cardiac arrest situation.
When transesophageal echocardiography is implemented, the right techniques are required to assist the emergency physician to manage the patient correctly. Currently, the focus of transesophageal echocardiography is on the patients presenting with cardiac arrest in the emergency department or in a critical care unit. The idea is that it can be also implemented in other patients who require help during resuscitation. It could be a worthy alternative to transthoracic echocardiography in fluid responsivity assessment, and patient monitoring during resuscitation.
In patients who are exhibiting signs of atrial fibrillation, transesophageal echocardiography could give the physician a better chance to examine the left atrial appendage. If no thrombus is found, cardioversion can follow.
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