Improving Your Echo Game

    NextPrevious

    Improving Your Echo Game

    Clinical Question – What’s a systematic approach you can use to improve your Echo?

    Case – 66 M with IDDM, HTN, and obesity presents to Resus in septic shock. He is intubated for hypoxemic respiratory failure, and remains persistently hypotensive despite a fluid-challenge and 15 mcgs of levophed. You slap on the probe to evaluate his EF. Here’s the best image you can get:

    This view (e.g. Mush) is not an uncommon view on a mechanically ventilated patient. You continue to flap the probe around but are unsuccessful in improving your echo. What should you do in order to improve your windows?

     

    Strategies:

    1. General Strategies – use more gel, push the probe harder, and do a spiral pattern around the chest to locate the heart. Some patients can benefit from L lateral decube but this is impractical for the mechanically ventilated patient.
    2. Parasternal Long – Start as you normally do around the 3rd-4th ICS near the sternal border. 
      1. Global View – Spiral around the chest to locate the heart.
      2. Fine-Tune the View – After you’ve found the heart, there are 3 fine motor movements you can do with the probe in order to get a crisper image. 
        1. Twist – clockwise/counterclockwise
        2. Tilt – tilt the probe toward and away from you, and left to right 
        3. Translate – move the probe up and down the chest to bring more of the heart onto the screen.
      3. Put it Together – Position probe at the 3rd/4th ICS at the sternal border. Do big sweeping spirals until you find what looks like the classic PSL. Twist/tilt/translate to perfect your view.
    3. Apical 4-Chamber – The best windows for the apical 4 chamber exist between the rib spaces. One way is to place the probe at the PMI for a normal Apical 4. If this fails, consider the alternative approach – start at the posterior axillary line at the 5th ICS and go midsternal to see if you can identify a 4-chamber view. If this fails, go up an additional rib space. This takes about 10-15 seconds. If you have no window, move on to the subcostal view.

    1. Subcostal – if you can’t get good parasternal windows, you may have an inferior shift of the heart. They may have excellent subcostal windows as a result.
      1. Technique – flatten the probe at the xiphoid process as much as possible to get the best view. You may need to tilt the probe toward the R shoulder to improve your view. Angle up or down to improve view. Ask the patient to take a big breath to bring the heart closer to the probe.
      2. Subcostal Short – substitutes for parasternal short. Turn probe 90 degrees counterclockwise (index toward patient’s head).
    2. Note – you shouldn’t make conclusions above ventricular/valve function based on one view. Confirm with an additional view.

    Thanks Eric Chao and Neil Dubs for inspiring this post!

    Resources – 5MinSono Optimizing Cardiac Views, Rob Arntfeld (Former SinaiEM US fellow!) – Echo Image Acquisition

    • Welcome! This is the website for the Mount Sinai Emergency Ultrasound Division. It serves as an information resource for residents, fellows, medical students and others seeking information about point-of-care ultrasound. There is a lot ofRead more

    • Central Line Wizardry

      I was scrolling through twitter this morning when I came across a quick video from @CriticalCareNow for an awesome central line trick. And then I went to his feed and found some more. They areRead more

    • Let’s wait for the “official urinalysis”….?

      Chances are you order a urine dip or urinalysis on a good number of your patients each shift. But how good are these tests at helping us diagnose a urinary tract infection? The short answer:Read more

    • National Physician Suicide Awareness Day

      This past Tuesday (September 17th) was the first annual National Physician Suicide Awareness Day. CORD, ACEP, SAEM and a number of other EM organizations paired with organization from other specialties to raise awareness of theRead more

    • M is for morphine

      Remember MONA (morphine, oxygen, nitro, aspirin) from med school? Well, she may be just “A” now…. Over the years, all of these treatments (except for good old aspirin) have become somewhat controversial in the treatmentRead more

    • Meningitis Prophylaxis

      Have you ever taken care of really critical, undifferentiated patient, only later to find out that they were diagnosed with a serious, contagious illness? We are exposed to innumerable pathogens each day in the ED,Read more

    • The Betel Nut: an oral carcinogen

      Ever walk up to a stable, comfortable appearing patient at Elmhurst and their mouth/teeth are completely RED? Or maybe like a dark brownish/black color? Like this?? It really scared me the first I saw itRead more

    • The Fascia Iliaca compartment block: as magical as it sounds!

      In case you haven’t gotten to this month’s EM:RAP, there’s a really great segment on an important ED procedure that we definitely don’t do enough of in the ED: the nerve block. The section discussesRead more

    • Hurry Up & RUSH!

      You’re working in RESUS, and you get a notification for hypotension. He’s a 65 year old male noted to be hypotensive to 70/40 by EMS. On arrival, he’s altered and unable to provide any history,Read more

    NextPrevious