Intro to Bedside Ultrasound. Cardiac Ultrasound

Transcription

1 Intro to Bedside Ultrasound Cardiac Ultrasound

2 TEACHERS University of California-Irvine School of Medicine Nathan Molina Trevor Plescia Jack Silva

3 Aorta Pulmonary trunk Left ventricle Pericardium Right ventricle

4

5 The 4 Views of Cardiac Ultrasound PARASTERNAL LONG PARASTERNAL SHORT APICAL 4-CHAMBER SUBXIPHOID (SUBCOSTAL)

6 Parasternal Short Parasternal Long Apical 4-Chamber Right Subxiphoid

7 CARDIAC ULTRASOUND TRANSDUCERS Phased Array (P21) Convex (C60) The best transducer for viewing the heart is the phased array P21 The convex C60 can also be used

8 PARASTERNAL LONG - Start with the probe just to the left of the sternum (parasternal), in the 2 nd intercostal space - The indicator should be pointed to the patient s left hip - This will give a view of the heart along its long axis

9

10

11 What is the arrow pointing to? Left Ventricle

12 What is the arrow pointing to? Right Ventricle

13 What is the arrow pointing to? Interventricular septum

14 What is the arrow pointing to? Pericardium

15 What is the arrow pointing to? Aortic Outflow Tract

16 What is the arrow pointing to? Mitral Valve

17 17 Left Atrium

18 Mitral Valve (Anterior Leaflet)

19 Mitral Valve (Anterior Leaflet)

20 LEFT VENTRICULAR FUNCTION - In parasternal long axis, observe movement of mitral valve - Anterior leaflet should slap interventricular septum - Observe left ventricular contraction during systole - Deficiencies indicate poor left ventricular function - Avoid fluid overload

21 HYPERTROPHIC CARDIOMYOPATHY - Normal septum thickness: cm - >1.2 cm HCM - Each tick mark = 1 cm - Useful for estimation - Use calipers to make exact measurement

22 ATHLETE S HEART VS HCM Athlete s Heart (Benign Enlargement) HCM Septum Thickness <15 mm >15 mm Symmetry Yes (for septum and LV wall) No (septum much thicker) Deconditioning Reduction within 3 months None

23 PARASTERNAL SHORT - Start in the parasternal long axis (indicator pointed to patient s left hip) - Then rotate the probe 90 clockwise so that the indicator is pointed to the patient s right hip

24 PARASTERNAL SHORT - Once positioned, use the fanning technique to view different structures: - Initially you will see the mitral valve, which resembles a fish mouth - Fan inferiorly to see the papillary muscles and the apex - You may also see the chordae tendineae - Fan superiorly, to see the aortic valve, which resembles the Mercedes-Benz logo

25 Mitral Valve: Fish Mouth

26 Fan inferiorly to see papillary muscles

27 Fan superiorly to see the aortic valve

28 Aortic Valve: Mercedes-Benz

29 QUESTION From the parasternal short view, how would you manipulate the transducer to visualize the aortic valve? Fan superiorly

30 APICAL 4-CHAMBER - Start with the transducer over the patient s Point of Maximal Impulse or PMI (4 th or 5 th intercostal space, midclavicular or anterior axillary) - Point the indicator to the patient s right

31 APICAL 4-CHAMBER - Fan the probe superiorly toward the base of the heart - Assess the size of the ventricles. The right ventricle should be approximately 2/3 the size of the left ventricle. - The apical 4-chamber view can be hard to find on patients in a supine position - Try the left lateral decubitus position, as it brings the heart closer to the thoracic cage

32

33 APICAL 4-CHAMBER Tricuspid valve RV RA LV LA Mitral valve

34 SUBXIPHOID - Indicator pointed to patient s right

35 SUBXIPHOID VIEW The subxiphoid view is useful clinically for: Diagnosing pericardial effusion The pericardium is a high attenuating structure, and will appear hyperechoic. Fluid will be hypoechoic. Diagnosing cardiac arrest FAST scan

36 SUBXIPHOID TRICK Start at liver edge and follow subcostal margin until heart is seen Aim beam at chin

37 Subxiphoid Tricuspid Valve RV Pericardium RA LV LA Mitral Valve

38 PERICARDIAL EFFUSION - Fluid in the pericardial sac - Increased intrapericardial pressure can disrupt cardiac rhythm and efficiency - Cardiac tamponade

39 SUMMARY Cardiac ultrasound utilizes 4 different views: 1) Parasternal long 2) Parasternal short 3) Apical 4-chamber 4) Subxiphoid The indicator is pointed to the patient s right in all views except for parasternal long, where it is pointed to the patient s left hip

40 SUMMARY Structures visible in each view Parasternal long: interventricular septum, left ventricle, mitral valve, aortic valve, aortic outflow tract, and right ventricle In a normal heart, the mitral valve s anterior leaflet will make contact with the interventricular septum Parasternal short: aortic valve, mitral valve, and papillary muscles Apical 4-chamber: all 4 chambers of the heart Subxiphoid is good for assessing pericardial effusion

41 REFERENCES Atlas of Anatomy, Second Edition, By Gilroy, MacPherson, Ross, Schuenke, Schulte, Schumacher. Thieme Medical Publishers, Select images from the UCISOM Ultrasound in Education Department