12/7/21, 1:23 PM Basic critical care echo: a beginners’ guide - ICU Revisited

Basic critical care echo: a beginners’ guide

 HO

GETTING SHIT DONE

Basic critical care echo: a beginners’

guide
by Bruno Tomazini 3 years ago

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It’s been a while that I’m thinking about writing a beginners’ guide to
Basic
critical critical
care echocare echo:
(CCE), a beginners’
and when I meanguide
beginners I mean those guys who
don’t even know what an ultrasound probe is, like I once did. We’re here for
those guys! We will discuss some technical aspects, how the views are obtained
and a bit of image interpretation. Nothing too fancy, just some words, images
and videos for the working class doctor in the middle of nowhere who doesn’t
have anything better to do because the hospital blocked the Netflix access.


First things f irst

Of course with proper training and dedication we can do amazing thing with
echo, especially show ourselves off to residents and other attendings. But since
this is a beginners’ guide, I advise we all stick to the basics and respect our
limitations.

Like any other image exam or monitoring device, the CCE doesn’t tell us
what to do with our patients, our clinical evaluation and expertise does. The
CCE guides us. How do I interpret the information depends on that clinical
evaluation. Therefore, the main goal of CCE in this early phase of learning is
to answer specif ic and direct questions: why is this patient in shock
(cardiogenic, obstructive, hypovolemic)? Is my patient responding to
treatment? Is there a pericardial effusion? Maybe it’s just me but I don’t see
the point knowing the patient has a mild mitral regurgitation if the patient is
already dead!

This will allow us to perform a focused, fast and longitudinal evaluation of

our patients’ hemodynamic. These goals are COMPLETELY different from
the goals of the echo performed by our fellow friends cardiologists and
radiologists: they talk about Wilkins score, strain, and the IVC, which are all
bullshit for us and for our critically ill patients.

In the end, and these are the most important messages I have to you guys:

—CCE is only useful if the doctor who is performing it knows what to do

with the information he’s getting from the exam.

—A dumb doctor with an ultrasound still is a dumb doctor!

—Do not make assumptions based on things you did not evaluate!

Transducers and Modes

For the CCE we use the phased array transducer. It has a small footprint
(makes easier to scan between the ribs), low frequency (~2.5MHz) and
therefore higher penetration. Once I got my probe in hand I need to choose my
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exam mode (it will tell the machine how to use the probe). Most of the
Basic critical
machines care
have all of echo: a beginners’
the following modes: guide
B-Mode, M-Mode, and Doppler.
The table below summarizes the transducer and modes we use.

Adjustments Tips

Always remember the DAG (depth, axis, and penetration). How do you
expect to obtain a good image without making the proper adjustments on the
machine? And this is one of the most common mistakes I see when someone is
learning CCE. Almost always, the image is overgained and the depth is not
correct. An overgained image can generate artifacts which can confuse the
inexperienced doctor (we all saw that flat in the aorta in the parasternal long
axis view) and hide important information. The same with undergained
images, where you can hardly differentiate the structures. Remember, be
thorough with your adjustments!

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Basic critical care echo: a beginners’ guide

Most of the time once you select the phased array transducer, the machine
goes straight to “cardiac mode” which is a series of presets to improve image
quality. Make sure you’re in cardiac mode while doing CCE.

Hold me tight

The way you hold the probe tells a lot about you, the same the way you
hold… Nevermind. For the CCE the two basic grips are the PEN and the
FINGER. For all cardiac views, except the subcostal, the probe must be held
the way you hold a pen:

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Basic critical care echo: a beginners’ guide

For the subcostal images, remember to put your f inger on top of the
transducer, it will give you more precision and help you when angulating it.

Remember to rest your hypothenar region on the patient, this will greatly
increase your stability. Also use ultrasound gel! LOTS of it! I heard once the
amount the US gel you are using tells how good you are. The fewer, the better!
That’s horsecrap! Use how much gel you want! You gotta use your precious

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time helping the patient, not getting more gel every minute! Don’t waste time,
Basic critical care echo: a beginners’ guide
waste GEL!

The transducer (probe) marker is always on the right side of the screen in the
cardiac convention.

Observations

The critically ill patients often have poor windows, maybe because you can’t
proper position them, maybe they are in mechanical ventilation and the lungs
keep getting in front of your image, maybe he has subcutaneous emphysema,
abdominal hypertension and so on. However, always make sure to do your
best, especially regarding patient positioning! If the patient can be moved, do
it!

We won’t discuss doppler or any other measurements today!

The Basic views (5) are:

-Parasternal Long Axis (PLAX)

-Parasternal Short Axis (PSAX)

-Apical 4 Chamber (A4C)

-Subcostal (SC)

-IVC

Parasternal Long Axis (PLAX)

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Patient position: Left lateral decubitus (if possible).

Basic critical care echo: a beginners’ guide
Transducer position: Between 2nd and 4th rib-space. Remember to go
window-shopping, alternate between rib spaces to f ind the best view.
Sometimes your window might be a little to the left, maybe lower… Transducer
marker to the patient’s right shoulder (it may vary a bit).

Depth: ~15-18cm (make sure the descending thoracic aorta is visible).

Tips: Make sure the aortic and mitral valve are in the same plane.

Good for: Pericardial x pleural effusion (pericardial effusions cross the

descending aorta, while pleural effusions don’t), left ventricular (LV) function
(normal, hyperdynamic, depressed), ascending aorta, measure left ventricular
outflow tract (LVOT), right ventricle outflow tract (RVOT), interventricular
septum dynamic. Of course, the PLAX is useful for other things like SAM,
EPSS, mitral and aortic valve…But let’s forget about them for today.

These are the structures we see on the PLAX view:

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Basic critical care echo: a beginners’ guide

Normal exam

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Basic critical care echo: a beginners’ guide

00:00 00:06

00:00 00:06

Hyperdynamic heart

Note the anteroseptal and inferolateral wall “kissing”.

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Basic critical care echo: a beginners’ guide

00:00 00:05

Severely reduced function

The LV barely contracts. Also, there is a small pericardial effusion.

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Basic critical care echo: a beginners’ guide

00:00 00:08

Pericardial effusion / Tamponade physiology

The effusion crosses the descending thoracic aorta, which differentiates it

from a pleural effusion, which doesn’t. Also, you can see the RVOT collapsing
in diastole, this is compatible with tamponade physiology, which is different
from cardiac tamponade. The f irst has echocardiography criteria for
tamponade, the second is a clinical syndrome.

Parasternal Short Axis (PSAX) – Papillary muscle level

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Patient position: Left lateral decubitus (if possible).

Basic critical care echo: a beginners’ guide
Transducer position: Between 2nd and 4th rib-space. Transducer marker to
the patient’s left shoulder (it may vary a bit).

Depth: ~15-18cm.

Tips: From the PLAX view, rotate the transducer 90˚ clockwise. The LV
must be round! Careful with off-axis images (the LV will appear elliptical, and
D shaped)! You must see both papillary muscles.

Good for: Outstanding for IV septum dynamic, LV function and RV size.

The PSAX window has in fact 5 different levels (LV apex, papillary muscle,
mitral valve, aortic valve, pulmonary artery), however, we will only discuss the
papillary muscle level.

These are the structures we see on the PSAX view:

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Normal exam
Basic critical care echo: a beginners’ guide

00:00 00:06

00:00 00:04

 
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Severely reduced function

Basic critical care echo: a beginners’ guide
The LV barely contracts.

00:00 00:08

Pericardial effusion

The effusion surrounds the heart.

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Basic critical care echo: a beginners’ guide

00:00 00:06

Right ventricle

The RV is supposed to be smaller than the LV (as seen in the videos above).
In this video, you can see the right ventricle is humongous. During systole, the
IV septum bounces and the LV is D shaped, which is consistent with increased
RV pressure. In fact, this patient had pulmonary hypertension with cor
pulmonale. Also, you can see a small pericardial effusion.

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Basic critical care echo: a beginners’ guide

00:00 00:08

Apical 4 Chamber (A4C)

Patient position: Left lateral decubitus (if possible).

Transducer position: Cardiac apex (~5th intercostal space, between

midclavicular and anterior axially line). Transducer marker to 3 o’clock. Point
the transducer (not the marker) towards the right shoulder (you’ll have to tilt
it).

Depth: ~20cm.

Tips: Move up or down between rib spaces to f ind the best view. Most
challenging view in critically ill patients. If you tilt it down a bit more from
the A4C you’ll see the LVOT (apical 5 chambers) which will allow you to
measure the VTI (used for cardiac output and other calculations).

Good for: RV and LV function, atrial size, compare LV and RV size,

tamponade evaluation.

These are the structures we see on the A4C view:

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Basic critical care echo: a beginners’ guide

Normal exam

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Basic critical care echo: a beginners’ guide

00:00 00:05

00:00 00:06

Severely reduced function

The LV barely contracts and its increased in size.

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Basic critical care echo: a beginners’ guide

00:00 00:06

Pericardial effusion / Tamponade physiology

You can see the hypoechoic fluid around the heart. Also, right atrial systolic
collapse is seen. Remember tamponade physiology is different from cardiac
tamponade.

00:00 00:06

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Basic critical care echo: a beginners’ guide
Left atrium thrombus

A patient with mitral stenosis and huge left atrium with mobile thrombus
inside. It looks like an asteroid or a pinball ball!

00:00 00:08

Subcostal (SC)
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Patient position: Supine. If possible flex the patient’s knees.

Basic critical care echo: a beginners’ guide
Transducer position: Subxyphoid. Transducer marker to 3 o’clock. Point the
transducer towards the left shoulder (you’ll have to tilt it).

Depth: >15cm

Tips: Remember to change the probe holding (f inger).

Good for: Sometimes is the only view in critical patients. One of the
windows of FAST. RV and LV size and function, IV septum dynamic,
pericardial effusion/tamponade.

These are the structures we see on the SC view:

Normal exam

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Basic critical care echo: a beginners’ guide

00:00 00:05

00:00 00:05

Catheter in the right atrium

You can see a hyperechoic moving linear structure inside the right atrium.
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Basic critical care echo: a beginners’ guide

00:00 00:06

Inferior vena cava longitudinal (IVC)

Patient position: Supine.

Transducer position: Subxyphoid. Transducer marker to 12 o’clock.

Transducer perpendicular to the skin. Small angulation to the right.

Depth: >10cm.

Tips: From the SC view, just rotate the transducer 90˚ counterclockwise.

Good for: Well, in some situations, like tamponade, PE, tricuspid

regurgitation the IVC might be useful. However, I can tell you for sure for
what the IVC is NOT useful: and it is to evaluate fluid responsiveness!

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Basic critical care echo: a beginners’ guide

00:00 00:06

Final thoughts

—Remember that artifacts disappear as you change your window!

—Do not make assumptions based on things you did not evaluate!

—Always correlate the echo f indings with the patient’s history and clinical
impression.

—Practice, practice, practice!

When I was a young padawan we had a patient that arrested, after ROSC
while the other guys were monitoring him I decided to perform an echo, and
look what I found:

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Basic critical care echo: a beginners’ guide

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Basic critical care echo: a beginners’ guide

00:00 00:08

I always thought: How in the hell someone get an echo of a VFib. Well, by
chance I think. Nobody was expecting the patient go into VFib while was
being monitored. I froze!

I know everything might be boring in the beginning, and we all love to do

some fancy doppler measurements and evaluate heart-lung interactions. But
this is a start. I promise we’ll have more fun in the future!

See ya!

Photo Credit

–memegenerator

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