POCUS

TAKES TIME

Find a reference and stick with it

• Personal:
  • HHCUBOOK.com
  • WesternSono.ca/RapidReview
• Vetted:
  • Western Sono (high quality training)
  • POC_US App (reference for on the ward)
  • ASE Cardiovascular Point-of-Care Imaging for the Medical Student and Novice User (online class)
  • 123sonography (online class)

POCUS becomes intuitive when you visualize the structure in the body then direct the probe

POCUS Basics

• Anatomic landmark
  • You know where the heart is
• Sonographic Landmark
  • The beating structure
• Fine tune your image
  • SLOW movement
  • Optimize gain/depth

Probes

• Curved array / curvilinear

• Phased array /cardiac

Indications

• Cardiac Arrest (is the heart beating?)
• Unexplained Shock/Hypotension
• Dyspnea
• Chest pain
• Thoracic trauma

Cardiac Views

• Parasternal Long Axis (PLAX)
• Parasternal Short Axis (PSAX)
• Apical 4 Chamber (A4C)
• Subcostal (SAX)

Parasternal

Long Axis

Parasternal

Short Axis

Apical 4 Chamber

Sub

Costal

Parasternal Views

1. Assess LV function
2. Valvular Disease
3. RV strain

Parasternal Views

• Advantages
  • Easy (usually)
• Challenges
  • Image generation can be limited by lung, rib spaces

Parasternal Long Axis

• ANATOMIC LANDMARK: left sternal border, 3-4th interspace
• Probe marker to the right shoulder

Parasternal Long Axis

• SONOGRAPHIC LANDMARK: HEART
• Identify:
  • LV, RV, LA, MV, AV
  • Pericardium +/- Pericardial/pleural fluid

Parasternal Short Axis

• ANATOMIC LANDMARK: left sternal border 3-4th interspace
• Probe marker to the left shoulder
• From long axis, fix probe and rotate clockwise 90°

Parasternal Short Axis

• SONOGRAPHIC LANDMARK: HEART
• Identify (tilt probe from right shoulder - left hip):
  • 3 levels: Aortic Valve, Mitral Valve, Pap Muscle
  • Tilt probe from right shoulder - left hip

Parasternal Short Axis

• SONOGRAPHIC LANDMARK: HEART
• Identify (tilt probe from right shoulder - left hip):
  • 3 levels: Aortic Valve, Mitral Valve, Pap Muscle
  • Tilt probe from right shoulder - left hip

Parasternal Short Axis

• SONOGRAPHIC LANDMARK: HEART
• Identify (tilt probe from right shoulder - left hip):
  • 3 levels: Aortic Valve, Mitral Valve, Pap Muscle
  • Tilt probe from right shoulder - left hip

Tips

• Troubleshooting

  • If no view, make large concentric circles

    • Once you see heart, slowly focus in

  • +++GEL

  • Left lateral decubitus position

Apical Views

1. Assess LV function
2. Valvular Disease
3. RV strain

Apical Views

• Advantages
  • Can obtain a lot of information
• Challenges
  • Image generation can be limited by lung, rib spaces
  • Difficult to obtain in beginning (often needs a lot of left lateral decubitus positioning

Apical 4 Chamber

• ANATOMIC LANDMARK: apex (5th interspace, ant ax line)
• Probe marker to the right

Apical 4 Chamber

• SONOGRAPHIC LANDMARK: HEART
• Identify: LV, RV, LA,, RA, MV, TV
  • Pericardium +/- Pericardial fluid

Tips

• Troubleshooting

  • If no view, make large concentric circles

    • Once you see heart, slowly focus in

  • Alternatively, start at parasternal short axis and slide down to the apex keep heart in view

  • +++GEL

  • Left lateral decubitus position***

Subcostal View

1. Is there cardiac contractility (is the heart beating vigorously)? Y/N
2. Is there a pericardial effusion? Y/N

Subcostal View

• Advantages
  • Easy (usually)
  • Out of the way of the trauma team
  • Better for PCE
• Challenges
  • Image generation can be limited by air (bowel gas, lung, subQ), pain, redundant tissue

Subcostal View

• ANATOMIC LANDMARK: just below xiphoid
• Heart is ANTERIOR structure and mostly MIDLINE
• Probe flat, directed toward head, marker to the right
• Downward pressure

Subcostal View

• SONOGRAPHIC LANDMARK: HEART
• Identify: LV, RV, LA, RA, MV, TV
  • Pericardium +/- Pericardial fluid

1. Cardiac Contractility

• Is the heart beating vigorously? Y/N
  • Anything in between is INDETERMINATE at this point

2. Pericardial Effusion PCE

• Is there a PCE present? Y/N
  • Sweep until heart disappears BOTH anteriorly and posteriorly

Tips

• False positives

  • Pleural effusion, free fluid, fat pad

• Troubleshooting

  • Start LOW

  • GEL

  • ↑ Depth

  • Bend knees, hands to sides, deep breath & hold

  • Downward pressure with some upward pressure*

  • Move to patient’s right to use liver as an acoustic window

LV Function

LV Function

LV Function

Valve Regurgitation

Tamponade

• Pericardial Effusion +
  • RV collapse in diastole
  • RA collapse in systole
  • Pulsus paradoxus in TV/MV inflow
  • IVC dilation