Case: Cardiac Ultrasound - Parasternal Short Axis
Case: Cardiac Ultrasound - Parasternal Short Axis
<p begin="00:00:15.183" end="00:00:16.903" style="s2">the Emergency Ultrasound Coordinator</p>
<p begin="00:00:16.903" end="00:00:19.168" style="s2">at the New York Presbyterian<br />Hospital in New York</p>
<p begin="00:00:19.168" end="00:00:22.335" style="s2">City, and welcome to SoundBytes Cases!</p>
<p begin="00:00:23.417" end="00:00:25.593" style="s2">In this module, we'll<br />continue our journey looking</p>
<p begin="00:00:25.593" end="00:00:28.509" style="s2">specifically at the cardiac<br />echo views of the heart.</p>
<p begin="00:00:28.509" end="00:00:30.811" style="s2">In this module, we're<br />going to focus entirely</p>
<p begin="00:00:30.811" end="00:00:33.805" style="s2">on the parasternal short<br />axis view of the heart.</p>
<p begin="00:00:33.805" end="00:00:36.010" style="s2">Now we've covered the<br />parasternal long axis</p>
<p begin="00:00:36.010" end="00:00:39.104" style="s2">view of the heart previously<br />in SoundBytes module</p>
<p begin="00:00:39.104" end="00:00:41.050" style="s2">and recall that the<br />probe will be positioned</p>
<p begin="00:00:41.050" end="00:00:43.507" style="s2">for the parasternal views<br />in Position A as shown</p>
<p begin="00:00:43.507" end="00:00:45.883" style="s2">here in the pictorial to the right.</p>
<p begin="00:00:45.883" end="00:00:48.825" style="s2">In upcoming segments, we'll<br />cover the subxiphoid view</p>
<p begin="00:00:48.825" end="00:00:52.108" style="s2">as shown in probe Position<br />B, and finally the apical</p>
<p begin="00:00:52.108" end="00:00:55.946" style="s2">view of the heart as shown<br />here in probe Position C.</p>
<p begin="00:00:55.946" end="00:00:58.404" style="s2">Now the parasternal short<br />axis view of the heart</p>
<p begin="00:00:58.404" end="00:01:00.873" style="s2">can be very helpful in<br />emergency care as it gives</p>
<p begin="00:01:00.873" end="00:01:03.320" style="s2">a great deal of information<br />about the contractility</p>
<p begin="00:01:03.320" end="00:01:05.218" style="s2">of our patient's heart.</p>
<p begin="00:01:05.218" end="00:01:06.955" style="s2">So let's look now further into how</p>
<p begin="00:01:06.955" end="00:01:09.196" style="s2">to perform this examination.</p>
<p begin="00:01:09.196" end="00:01:11.475" style="s2">The probe will be placed<br />just left of the sternum</p>
<p begin="00:01:11.475" end="00:01:14.002" style="s2">at about intercostal space 3 or 4</p>
<p begin="00:01:14.002" end="00:01:16.438" style="s2">as shown in the pictorial<br />here to the right.</p>
<p begin="00:01:16.438" end="00:01:18.741" style="s2">Now in variance to the<br />parasternal long axis</p>
<p begin="00:01:18.741" end="00:01:20.581" style="s2">view of the heart where<br />the probe marker was</p>
<p begin="00:01:20.581" end="00:01:22.923" style="s2">positioned down towards<br />the patient's left elbow</p>
<p begin="00:01:22.923" end="00:01:25.330" style="s2">we'll swivel the probe 90<br />degrees clockwise so now</p>
<p begin="00:01:25.330" end="00:01:28.158" style="s2">the marker is down towards<br />the patient's right hip.</p>
<p begin="00:01:28.158" end="00:01:30.468" style="s2">That's with the caveat<br />that the ultrasound screen</p>
<p begin="00:01:30.468" end="00:01:33.456" style="s2">indicator is positioned<br />towards the left of the screen.</p>
<p begin="00:01:33.456" end="00:01:35.236" style="s2">Now moving the patient into left lateral</p>
<p begin="00:01:35.236" end="00:01:36.952" style="s2">decubitus position may help imaging</p>
<p begin="00:01:36.952" end="00:01:39.425" style="s2">from the parasternal short axis plane.</p>
<p begin="00:01:39.425" end="00:01:41.078" style="s2">Here's what the views from the parasternal</p>
<p begin="00:01:41.078" end="00:01:43.263" style="s2">short axis plane of the<br />heart will look like.</p>
<p begin="00:01:43.263" end="00:01:45.430" style="s2">We see a pictorial here<br />to the left showing</p>
<p begin="00:01:45.430" end="00:01:48.436" style="s2">the left ventricle cut in<br />cross section as a cylinder</p>
<p begin="00:01:48.436" end="00:01:50.601" style="s2">and the right ventricle as a little sliver</p>
<p begin="00:01:50.601" end="00:01:52.846" style="s2">just to the left of the left ventricle.</p>
<p begin="00:01:52.846" end="00:01:55.616" style="s2">We see an ultrasound image<br />corresponding to the right</p>
<p begin="00:01:55.616" end="00:01:58.418" style="s2">and note the left ventricle<br />again, that cylinder</p>
<p begin="00:01:58.418" end="00:02:01.201" style="s2">cut in cross-section<br />and the right ventricle</p>
<p begin="00:02:01.201" end="00:02:04.206" style="s2">above the left ventricle more anteriorally</p>
<p begin="00:02:04.206" end="00:02:05.892" style="s2">and to the left.</p>
<p begin="00:02:05.892" end="00:02:08.084" style="s2">In this way we get a<br />good sense of the overall</p>
<p begin="00:02:08.084" end="00:02:09.459" style="s2">cylinder of the left ventricle</p>
<p begin="00:02:09.459" end="00:02:12.100" style="s2">and can gauge its contractility.</p>
<p begin="00:02:12.100" end="00:02:14.748" style="s2">Here's a video clip<br />showing extra contractility</p>
<p begin="00:02:14.748" end="00:02:16.835" style="s2">of the left ventricle as<br />taken from the parasternal</p>
<p begin="00:02:16.835" end="00:02:19.785" style="s2">short axis plane and note<br />the muscular contractions</p>
<p begin="00:02:19.785" end="00:02:22.506" style="s2">of the left ventricle as<br />a cylinder squeezing in</p>
<p begin="00:02:22.506" end="00:02:24.787" style="s2">dramatically during systole.</p>
<p begin="00:02:24.787" end="00:02:26.472" style="s2">We also note the mitral valve flipping up</p>
<p begin="00:02:26.472" end="00:02:28.760" style="s2">and down within the left<br />ventricle and the right</p>
<p begin="00:02:28.760" end="00:02:32.371" style="s2">ventricle as seen up and<br />above the left ventricle.</p>
<p begin="00:02:32.371" end="00:02:34.485" style="s2">Now let's contrast this video clip showing</p>
<p begin="00:02:34.485" end="00:02:36.992" style="s2">excellent contractility<br />with another patient</p>
<p begin="00:02:36.992" end="00:02:39.723" style="s2">who had an advanced cardiomyopathy.</p>
<p begin="00:02:39.723" end="00:02:41.792" style="s2">Note again the left<br />ventricle and note here</p>
<p begin="00:02:41.792" end="00:02:44.525" style="s2">the poor percentage change<br />from diastole through</p>
<p begin="00:02:44.525" end="00:02:47.644" style="s2">systole, indicating an<br />advanced cardiomyopathy</p>
<p begin="00:02:47.644" end="00:02:49.798" style="s2">with low ejection fraction.</p>
<p begin="00:02:49.798" end="00:02:52.138" style="s2">We can also see the<br />right ventricle anterior</p>
<p begin="00:02:52.138" end="00:02:53.457" style="s2">to the left ventricle.</p>
<p begin="00:02:53.457" end="00:02:55.601" style="s2">For learning purposes,<br />we'll identify the walls</p>
<p begin="00:02:55.601" end="00:02:58.713" style="s2">of the LV, the septum in<br />between the ventricles,</p>
<p begin="00:02:58.713" end="00:03:01.120" style="s2">the anterior wall to<br />the top of the screen,</p>
<p begin="00:03:01.120" end="00:03:03.752" style="s2">posterior wall to the<br />back, and the lateral wall</p>
<p begin="00:03:03.752" end="00:03:06.671" style="s2">as shown here towards the<br />right portion of the screen.</p>
<p begin="00:03:06.671" end="00:03:09.200" style="s2">Now while I show the walls<br />of the left ventricle here,</p>
<p begin="00:03:09.200" end="00:03:11.538" style="s2">it's important to realize<br />that the goal of emergency</p>
<p begin="00:03:11.538" end="00:03:14.675" style="s2">echo at the bedside is<br />to determine overall left</p>
<p begin="00:03:14.675" end="00:03:17.005" style="s2">ventricular contractility<br />rather than looking</p>
<p begin="00:03:17.005" end="00:03:20.165" style="s2">for segmental wall motion abnormalities.</p>
<p begin="00:03:20.165" end="00:03:22.549" style="s2">So in conclusion, the<br />parasternal short axis view</p>
<p begin="00:03:22.549" end="00:03:24.393" style="s2">of the heart gives a<br />great deal of information</p>
<p begin="00:03:24.393" end="00:03:27.321" style="s2">about the contractility<br />of the left ventricle.</p>
<p begin="00:03:27.321" end="00:03:29.731" style="s2">This will allow you to<br />identify patients who may</p>
<p begin="00:03:29.731" end="00:03:33.330" style="s2">have a cardiogenic cause<br />for their presentation.</p>
<p begin="00:03:33.330" end="00:03:36.004" style="s2">So I hope to see you back<br />as SoundBytes continues</p>
<p begin="00:03:36.004" end="00:03:38.614" style="s2">and we move on to discuss<br />the subxiphoid views</p>
<p begin="00:03:38.614" end="00:03:41.197" style="s2">and apical views of the heart.</p>
Case: Parasternal Long Axis Pt. 2
Case: Parasternal Long Axis Pt. 2
<p begin="00:00:11.560" end="00:00:13.405" style="s2">and I'm the emergency<br />ultrasound coordinator</p>
<p begin="00:00:13.405" end="00:00:15.261" style="s2">at the New York Presbyterian Hospital</p>
<p begin="00:00:15.261" end="00:00:16.904" style="s2">in New York City.</p>
<p begin="00:00:16.904" end="00:00:19.938" style="s2">Welcome to SoundBytes Cases.</p>
<p begin="00:00:19.938" end="00:00:22.407" style="s2">In this module, entitled<br />Cardiac Echocardiography,</p>
<p begin="00:00:22.407" end="00:00:24.818" style="s2">Parasternal Long Axis View Part Two,</p>
<p begin="00:00:24.818" end="00:00:26.116" style="s2">we're going to look further into</p>
<p begin="00:00:26.116" end="00:00:28.037" style="s2">the uses of the parasternal long axis view</p>
<p begin="00:00:28.037" end="00:00:29.913" style="s2">at the patient's bedside.</p>
<p begin="00:00:29.913" end="00:00:31.651" style="s2">Recall that the parasternal long axis view</p>
<p begin="00:00:31.651" end="00:00:33.215" style="s2">of the heart is going to be obtained</p>
<p begin="00:00:33.215" end="00:00:36.776" style="s2">by placing the probe into<br />position A as shown here.</p>
<p begin="00:00:36.776" end="00:00:37.933" style="s2">That will configure the probe</p>
<p begin="00:00:37.933" end="00:00:41.094" style="s2">just left of the sternum at<br />about intercostal space three</p>
<p begin="00:00:41.094" end="00:00:42.560" style="s2">with the marker dot down towards</p>
<p begin="00:00:42.560" end="00:00:44.739" style="s2">the patient's left elbow.</p>
<p begin="00:00:44.739" end="00:00:47.312" style="s2">Now, the first two goals from<br />the parasternal long axis view</p>
<p begin="00:00:47.312" end="00:00:49.257" style="s2">of the heart are going to be first of all,</p>
<p begin="00:00:49.257" end="00:00:50.863" style="s2">to look for left ventricular</p>
<p begin="00:00:50.863" end="00:00:52.747" style="s2">contractility.</p>
<p begin="00:00:52.747" end="00:00:54.186" style="s2">The second goal is going to be</p>
<p begin="00:00:54.186" end="00:00:57.377" style="s2">to investigate for a pericardial effusion.</p>
<p begin="00:00:57.377" end="00:00:58.989" style="s2">Let's begin by looking at some clips,</p>
<p begin="00:00:58.989" end="00:01:01.855" style="s2">going over left ventricular contractility.</p>
<p begin="00:01:01.855" end="00:01:04.155" style="s2">Here's a video clip, showing<br />excellent contractility</p>
<p begin="00:01:04.155" end="00:01:05.310" style="s2">of the left ventricle as taken</p>
<p begin="00:01:05.310" end="00:01:07.477" style="s2">from a medical student triathlete.</p>
<p begin="00:01:07.477" end="00:01:09.015" style="s2">Recall the chambers of the heart,</p>
<p begin="00:01:09.015" end="00:01:11.093" style="s2">as taken from the<br />parasternal long axis plane,</p>
<p begin="00:01:11.093" end="00:01:14.290" style="s2">the left atrium, as seen<br />in the posterior location;</p>
<p begin="00:01:14.290" end="00:01:16.775" style="s2">the mitral valve, just to<br />the left of the left atrium;</p>
<p begin="00:01:16.775" end="00:01:17.745" style="s2">and the left ventricle,</p>
<p begin="00:01:17.745" end="00:01:20.727" style="s2">as seen with it's hypertrophic walls.</p>
<p begin="00:01:20.727" end="00:01:22.247" style="s2">Notice the strong contractility</p>
<p begin="00:01:22.247" end="00:01:24.849" style="s2">of this left ventricle<br />as the endocardial walls</p>
<p begin="00:01:24.849" end="00:01:27.003" style="s2">almost meet during ossicle.</p>
<p begin="00:01:27.003" end="00:01:28.744" style="s2">We see the aortic valve to the right</p>
<p begin="00:01:28.744" end="00:01:29.729" style="s2">of the left ventricle</p>
<p begin="00:01:29.729" end="00:01:32.197" style="s2">and the right ventricle<br />in a superficial location</p>
<p begin="00:01:32.197" end="00:01:34.151" style="s2">above the left ventricle.</p>
<p begin="00:01:34.151" end="00:01:35.812" style="s2">Recall the descending aorta,</p>
<p begin="00:01:35.812" end="00:01:37.469" style="s2">the cylinder cut and cross section,</p>
<p begin="00:01:37.469" end="00:01:40.008" style="s2">just posterior to the left atrium.</p>
<p begin="00:01:40.008" end="00:01:42.108" style="s2">Note the posterior pericardial reflection</p>
<p begin="00:01:42.108" end="00:01:44.997" style="s2">coming off just anterior<br />to the descending aorta</p>
<p begin="00:01:44.997" end="00:01:47.284" style="s2">and posterior to the left ventricle.</p>
<p begin="00:01:47.284" end="00:01:48.837" style="s2">With the small indicator arrow,</p>
<p begin="00:01:48.837" end="00:01:50.328" style="s2">I'll trace out the posterior</p>
<p begin="00:01:50.328" end="00:01:52.619" style="s2">pericardial reflection.</p>
<p begin="00:01:52.619" end="00:01:54.506" style="s2">Note here the absence of any dark</p>
<p begin="00:01:54.506" end="00:01:57.006" style="s2">or anechoic fluid collections.</p>
<p begin="00:01:57.841" end="00:01:59.936" style="s2">Now let's contrast that last video clip</p>
<p begin="00:01:59.936" end="00:02:01.462" style="s2">with this one taken from a patient</p>
<p begin="00:02:01.462" end="00:02:03.568" style="s2">with an advanced cardiomyopathy.</p>
<p begin="00:02:03.568" end="00:02:04.965" style="s2">We recall the left ventricle</p>
<p begin="00:02:04.965" end="00:02:07.382" style="s2">and the right ventricle<br />in a superficial location</p>
<p begin="00:02:07.382" end="00:02:08.907" style="s2">above the LV.</p>
<p begin="00:02:08.907" end="00:02:10.528" style="s2">Notice the very poor percentage change</p>
<p begin="00:02:10.528" end="00:02:11.798" style="s2">of the endocardio walls</p>
<p begin="00:02:11.798" end="00:02:13.468" style="s2">of the left ventricle during ossicle,</p>
<p begin="00:02:13.468" end="00:02:14.832" style="s2">indicating a very decreased</p>
<p begin="00:02:14.832" end="00:02:16.332" style="s2">ejection fraction.</p>
<p begin="00:02:17.185" end="00:02:18.565" style="s2">Here's a clip taken from a patient</p>
<p begin="00:02:18.565" end="00:02:20.472" style="s2">who presented with a transplanted heart</p>
<p begin="00:02:20.472" end="00:02:22.180" style="s2">and acute shortness of breath.</p>
<p begin="00:02:22.180" end="00:02:24.579" style="s2">We'll begin by identifying<br />the descending aorta</p>
<p begin="00:02:24.579" end="00:02:27.244" style="s2">as shown here to the<br />bottom part of the picture.</p>
<p begin="00:02:27.244" end="00:02:29.098" style="s2">Note the posterior pericardial reflection,</p>
<p begin="00:02:29.098" end="00:02:31.079" style="s2">that white line coming off just anterior</p>
<p begin="00:02:31.079" end="00:02:33.257" style="s2">to the descending aorta.</p>
<p begin="00:02:33.257" end="00:02:34.497" style="s2">But what we see here is the presence</p>
<p begin="00:02:34.497" end="00:02:36.338" style="s2">on a dark, fluid collection,</p>
<p begin="00:02:36.338" end="00:02:39.627" style="s2">a pericardial effusion<br />that layers out posteriorly</p>
<p begin="00:02:39.627" end="00:02:41.966" style="s2">above the posterior pericardial reflection</p>
<p begin="00:02:41.966" end="00:02:45.060" style="s2">and comes anteriorly<br />to surround the heart.</p>
<p begin="00:02:45.060" end="00:02:46.507" style="s2">With a small indicator arrow,</p>
<p begin="00:02:46.507" end="00:02:48.320" style="s2">I'll point to the anterior portion</p>
<p begin="00:02:48.320" end="00:02:51.217" style="s2">of the pericardial effusion<br />and note the chaotic movement</p>
<p begin="00:02:51.217" end="00:02:52.376" style="s2">of the right ventricle</p>
<p begin="00:02:52.376" end="00:02:53.984" style="s2">as shown here.</p>
<p begin="00:02:53.984" end="00:02:56.870" style="s2">This is indicative of early<br />tamponade or high pressures</p>
<p begin="00:02:56.870" end="00:02:59.360" style="s2">within the pericardial sac.</p>
<p begin="00:02:59.360" end="00:03:00.193" style="s2">Here's a video clip</p>
<p begin="00:03:00.193" end="00:03:03.042" style="s2">showing a potential mimic<br />of a pericardial effusion.</p>
<p begin="00:03:03.042" end="00:03:05.328" style="s2">Let's being by identifying<br />the descending aorta</p>
<p begin="00:03:05.328" end="00:03:07.065" style="s2">as a cylinder cut and cross section</p>
<p begin="00:03:07.065" end="00:03:08.831" style="s2">posterior to the left atrium.</p>
<p begin="00:03:08.831" end="00:03:11.382" style="s2">We identify the posterior<br />pericardium, as shown here,</p>
<p begin="00:03:11.382" end="00:03:15.099" style="s2">coming off just anterior<br />to the descending aorta.</p>
<p begin="00:03:15.099" end="00:03:16.632" style="s2">Note the presence here of a large,</p>
<p begin="00:03:16.632" end="00:03:18.929" style="s2">dark or anechoic fluid collection,</p>
<p begin="00:03:18.929" end="00:03:20.948" style="s2">but note that it layers<br />our posteriorly there</p>
<p begin="00:03:20.948" end="00:03:22.875" style="s2">to the pericardium.</p>
<p begin="00:03:22.875" end="00:03:25.296" style="s2">Thus, this fluid is<br />within the pleural cavity</p>
<p begin="00:03:25.296" end="00:03:27.658" style="s2">and not within the pericardial cavity.</p>
<p begin="00:03:27.658" end="00:03:30.296" style="s2">With a small indicator<br />arrow I'm again reinforcing</p>
<p begin="00:03:30.296" end="00:03:31.708" style="s2">the pericardial reflection</p>
<p begin="00:03:31.708" end="00:03:33.304" style="s2">and the presence of the fluid</p>
<p begin="00:03:33.304" end="00:03:34.951" style="s2">within the thoracic cavity,</p>
<p begin="00:03:34.951" end="00:03:36.534" style="s2">a pleural effusion.</p>
<p begin="00:03:38.006" end="00:03:39.196" style="s2">Next we'll look at a video clip</p>
<p begin="00:03:39.196" end="00:03:40.703" style="s2">from a patient who present with acute</p>
<p begin="00:03:40.703" end="00:03:43.164" style="s2">shortness of breath requiring intubation.</p>
<p begin="00:03:43.164" end="00:03:45.644" style="s2">First, we'll begin by<br />identifying the descending aorta,</p>
<p begin="00:03:45.644" end="00:03:48.541" style="s2">then the posterior pericardial reflection.</p>
<p begin="00:03:48.541" end="00:03:50.072" style="s2">Note here, the presence of fluid,</p>
<p begin="00:03:50.072" end="00:03:52.333" style="s2">both within the pericadial<br />sac, as shown here,</p>
<p begin="00:03:52.333" end="00:03:54.255" style="s2">layering anterior to the pericardium</p>
<p begin="00:03:54.255" end="00:03:57.375" style="s2">and posteriorly within the pleural cavity</p>
<p begin="00:03:57.375" end="00:04:00.277" style="s2">layering out just below<br />the pericardial reflection.</p>
<p begin="00:04:00.277" end="00:04:03.021" style="s2">Why, you might ask, does the<br />patient have all this fluid?</p>
<p begin="00:04:03.021" end="00:04:04.985" style="s2">Well, let's look closely<br />at the mitral valve</p>
<p begin="00:04:04.985" end="00:04:06.933" style="s2">and on the posterior mitral valve leaflet,</p>
<p begin="00:04:06.933" end="00:04:09.307" style="s2">we see a calcified vegetation.</p>
<p begin="00:04:09.307" end="00:04:10.253" style="s2">This patient, in fact,</p>
<p begin="00:04:10.253" end="00:04:12.306" style="s2">had an infected dialysis catheter</p>
<p begin="00:04:12.306" end="00:04:14.481" style="s2">with mitral valve endocarditis</p>
<p begin="00:04:14.481" end="00:04:17.637" style="s2">and had developed wide-open<br />mitral valve regurgitation</p>
<p begin="00:04:17.637" end="00:04:19.055" style="s2">resulting in heart failure</p>
<p begin="00:04:19.055" end="00:04:20.389" style="s2">and all the fluid layering out</p>
<p begin="00:04:20.389" end="00:04:21.708" style="s2">within the pericardium and</p>
<p begin="00:04:21.708" end="00:04:23.961" style="s2">the thoracic cavity.</p>
<p begin="00:04:23.961" end="00:04:26.114" style="s2">In conclusion, the<br />parasternal long axis view</p>
<p begin="00:04:26.114" end="00:04:28.300" style="s2">of the heart gives a<br />great deal of information</p>
<p begin="00:04:28.300" end="00:04:29.681" style="s2">about our patient's condition</p>
<p begin="00:04:29.681" end="00:04:32.597" style="s2">and can be instrumental in emergency care.</p>
<p begin="00:04:32.597" end="00:04:33.430" style="s2">Through this module,</p>
<p begin="00:04:33.430" end="00:04:34.874" style="s2">I hope now that you'll have a better idea</p>
<p begin="00:04:34.874" end="00:04:37.422" style="s2">on how to grade left<br />ventricular contractility</p>
<p begin="00:04:37.422" end="00:04:39.610" style="s2">as good through poor.</p>
<p begin="00:04:39.610" end="00:04:41.511" style="s2">Also, to be able to identify the presence</p>
<p begin="00:04:41.511" end="00:04:44.277" style="s2">of a pericardial effusion.</p>
<p begin="00:04:44.277" end="00:04:46.655" style="s2">I hope to see you back<br />as SoundBytes continues</p>
<p begin="00:04:46.655" end="00:04:47.889" style="s2">and we look further at the</p>
<p begin="00:04:47.889" end="00:04:51.056" style="s2">cardiac echocardiography examinations.</p>
Case: Parasternal Long Axis Pt. 1
Case: Parasternal Long Axis Pt. 1
<p begin="00:00:13.163" end="00:00:15.222" style="s2">and I'm the emergency<br />ultrasound coordinator</p>
<p begin="00:00:15.222" end="00:00:18.094" style="s2">ad the New York Presbyterian<br />Hospital in New York City</p>
<p begin="00:00:18.094" end="00:00:20.984" style="s2">and welcome to SoundBytes Cases.</p>
<p begin="00:00:20.984" end="00:00:23.846" style="s2">Let's begin by reviewing<br />the four standard views</p>
<p begin="00:00:23.846" end="00:00:26.402" style="s2">of the cardiac echo exam.</p>
<p begin="00:00:26.402" end="00:00:28.931" style="s2">The first view, as shown<br />in probe position A</p>
<p begin="00:00:28.931" end="00:00:32.743" style="s2">is the parasternal views both<br />and long and short axis planes</p>
<p begin="00:00:32.743" end="00:00:34.911" style="s2">and this is going to be performed directly</p>
<p begin="00:00:34.911" end="00:00:37.095" style="s2">on the anterior chest wall.</p>
<p begin="00:00:37.095" end="00:00:40.685" style="s2">The second view is where<br />probe position B is shown here</p>
<p begin="00:00:40.685" end="00:00:42.546" style="s2">coming from the abdominal position</p>
<p begin="00:00:42.546" end="00:00:45.234" style="s2">or the subxiphoid view of the heart.</p>
<p begin="00:00:45.234" end="00:00:48.578" style="s2">The last view is going to be<br />shown by probe position C,</p>
<p begin="00:00:48.578" end="00:00:50.235" style="s2">the apical view of the heart at</p>
<p begin="00:00:50.235" end="00:00:52.266" style="s2">the point of maximum impulse.</p>
<p begin="00:00:52.266" end="00:00:54.493" style="s2">This module will specifically focus on</p>
<p begin="00:00:54.493" end="00:00:56.779" style="s2">the parasternal views,<br />specifically looking</p>
<p begin="00:00:56.779" end="00:00:59.352" style="s2">at the long axis plane.</p>
<p begin="00:00:59.352" end="00:01:00.570" style="s2">There's a great deal of information</p>
<p begin="00:01:00.570" end="00:01:02.931" style="s2">we can get from the<br />parasternal long axis planes</p>
<p begin="00:01:02.931" end="00:01:05.907" style="s2">so let's learn how to<br />perform the examination.</p>
<p begin="00:01:05.907" end="00:01:08.654" style="s2">For this examination, it's<br />optimal to use a small footprint</p>
<p begin="00:01:08.654" end="00:01:09.644" style="s2">phase to ray type probe that</p>
<p begin="00:01:09.644" end="00:01:12.510" style="s2">can easily sit between the ribs.</p>
<p begin="00:01:12.510" end="00:01:14.730" style="s2">We're going to place the<br />probe just left of the sternum</p>
<p begin="00:01:14.730" end="00:01:17.143" style="s2">at about intercostal space three or four</p>
<p begin="00:01:17.143" end="00:01:19.222" style="s2">with the marker dot on<br />the probe aimed down</p>
<p begin="00:01:19.222" end="00:01:20.918" style="s2">toward the patient's left elbow,</p>
<p begin="00:01:20.918" end="00:01:23.781" style="s2">if the patient's left<br />elbow is down by the side.</p>
<p begin="00:01:23.781" end="00:01:26.253" style="s2">That's with the caveat that<br />ultrasound screen indicator</p>
<p begin="00:01:26.253" end="00:01:28.943" style="s2">would be over toward<br />the left of the screen.</p>
<p begin="00:01:28.943" end="00:01:32.142" style="s2">This will align the probe in<br />the long axis of the heart.</p>
<p begin="00:01:32.142" end="00:01:34.540" style="s2">Occasionally it can be<br />someone difficult to get</p>
<p begin="00:01:34.540" end="00:01:36.164" style="s2">a good view of the heart from this plane</p>
<p begin="00:01:36.164" end="00:01:38.185" style="s2">and moving the patient<br />into the left lateral</p>
<p begin="00:01:38.185" end="00:01:40.086" style="s2">decubitus position can<br />sometimes help imaging</p>
<p begin="00:01:40.086" end="00:01:44.114" style="s2">from the parasternal long<br />axis plane of the heart.</p>
<p begin="00:01:44.114" end="00:01:45.858" style="s2">So now let's take a look at the images</p>
<p begin="00:01:45.858" end="00:01:47.584" style="s2">that we'll obtain by performing</p>
<p begin="00:01:47.584" end="00:01:50.159" style="s2">the parasternal long<br />axis view of the heart.</p>
<p begin="00:01:50.159" end="00:01:52.046" style="s2">Here's a nice pictorial to the left</p>
<p begin="00:01:52.046" end="00:01:53.692" style="s2">and what we see is that<br />the most superficial</p>
<p begin="00:01:53.692" end="00:01:55.847" style="s2">structure will be the right ventricle.</p>
<p begin="00:01:55.847" end="00:01:58.988" style="s2">Notice that the right atrium<br />is not seen from this plane.</p>
<p begin="00:01:58.988" end="00:02:00.759" style="s2">Directly posterior to the right ventricle</p>
<p begin="00:02:00.759" end="00:02:02.869" style="s2">will be the left<br />ventricle and to the right</p>
<p begin="00:02:02.869" end="00:02:06.837" style="s2">of the left ventricle will<br />be seen the left atrium.</p>
<p begin="00:02:06.837" end="00:02:09.043" style="s2">We can also see the<br />mitral valve in between</p>
<p begin="00:02:09.043" end="00:02:10.931" style="s2">the left atrium and the left ventricle</p>
<p begin="00:02:10.931" end="00:02:13.767" style="s2">and a little bit of the<br />aorta above the left atrium.</p>
<p begin="00:02:13.767" end="00:02:16.398" style="s2">Let's look at the ultrasound<br />still image, here, to the right</p>
<p begin="00:02:16.398" end="00:02:18.549" style="s2">and, again, we see the<br />superficial right ventricle,</p>
<p begin="00:02:18.549" end="00:02:20.958" style="s2">posterior we see the left ventricle</p>
<p begin="00:02:20.958" end="00:02:24.262" style="s2">with it's more muscular<br />and hypertrophic walls.</p>
<p begin="00:02:24.262" end="00:02:26.746" style="s2">Notice the left atrium,<br />as seen to the right</p>
<p begin="00:02:26.746" end="00:02:29.014" style="s2">of the left ventricle,<br />and the mitral valve</p>
<p begin="00:02:29.014" end="00:02:31.045" style="s2">in between the two chambers.</p>
<p begin="00:02:31.045" end="00:02:34.626" style="s2">We categorize this as left<br />ventricular inflow tract.</p>
<p begin="00:02:34.626" end="00:02:37.692" style="s2">Note the aortic valve sitting<br />right above the left atrium</p>
<p begin="00:02:37.692" end="00:02:40.466" style="s2">and we see a little bit<br />of the aortic root there.</p>
<p begin="00:02:40.466" end="00:02:45.285" style="s2">This is what we categorize<br />as aortic outflow tract.</p>
<p begin="00:02:45.285" end="00:02:47.085" style="s2">Let's now take a look at the parasternal</p>
<p begin="00:02:47.085" end="00:02:49.614" style="s2">long axis view of the heart in action.</p>
<p begin="00:02:49.614" end="00:02:51.589" style="s2">Remember, again, that the<br />most superficial chamber</p>
<p begin="00:02:51.589" end="00:02:52.966" style="s2">will be the right ventricle</p>
<p begin="00:02:52.966" end="00:02:54.738" style="s2">and the normal dimensions<br />of the right ventricle</p>
<p begin="00:02:54.738" end="00:02:56.569" style="s2">are that it should be about half</p>
<p begin="00:02:56.569" end="00:02:58.292" style="s2">the size of the left ventricle.</p>
<p begin="00:02:58.292" end="00:02:59.787" style="s2">If the right ventricle is the same size</p>
<p begin="00:02:59.787" end="00:03:01.194" style="s2">of the left ventricle,</p>
<p begin="00:03:01.194" end="00:03:03.839" style="s2">that could be a sign of RV strain.</p>
<p begin="00:03:03.839" end="00:03:06.251" style="s2">We see the left ventricle<br />posterior to the right ventricle.</p>
<p begin="00:03:06.251" end="00:03:08.331" style="s2">Note it's hypertrophic walls.</p>
<p begin="00:03:08.331" end="00:03:11.194" style="s2">This patient actually had<br />long standing hypertension.</p>
<p begin="00:03:11.194" end="00:03:12.615" style="s2">Let's look at the percentage change from</p>
<p begin="00:03:12.615" end="00:03:14.824" style="s2">diastole through systole and here we see</p>
<p begin="00:03:14.824" end="00:03:17.581" style="s2">that the walls come in<br />well with each heartbeat</p>
<p begin="00:03:17.581" end="00:03:19.545" style="s2">indicating good contractility.</p>
<p begin="00:03:19.545" end="00:03:22.217" style="s2">We see the left atrium to the<br />right of the left ventricle</p>
<p begin="00:03:22.217" end="00:03:24.661" style="s2">and notice the mitral valve flipping up</p>
<p begin="00:03:24.661" end="00:03:27.302" style="s2">and down in between the left<br />atrium and the left ventricle.</p>
<p begin="00:03:27.302" end="00:03:30.214" style="s2">We see here good movement<br />of the mitral valve</p>
<p begin="00:03:30.214" end="00:03:32.392" style="s2">indicating a good amount of blood flowing</p>
<p begin="00:03:32.392" end="00:03:35.302" style="s2">between the left atrium<br />and the left ventricle.</p>
<p begin="00:03:35.302" end="00:03:36.604" style="s2">Now, just above the left atrium and</p>
<p begin="00:03:36.604" end="00:03:38.767" style="s2">to the right of the left ventricle,</p>
<p begin="00:03:38.767" end="00:03:40.714" style="s2">we see the aortic valve</p>
<p begin="00:03:40.714" end="00:03:43.318" style="s2">and notice there just to the<br />right of the aortic valve,</p>
<p begin="00:03:43.318" end="00:03:46.489" style="s2">a little bit of the<br />diamond shaped aortic root.</p>
<p begin="00:03:46.489" end="00:03:50.110" style="s2">This will be our left<br />ventricular outflow tract.</p>
<p begin="00:03:50.110" end="00:03:52.157" style="s2">Now, another very important<br />structure to identify</p>
<p begin="00:03:52.157" end="00:03:54.888" style="s2">on bedside sonography<br />is the descending aorta</p>
<p begin="00:03:54.888" end="00:03:56.882" style="s2">which is a cylinder cut in cross section</p>
<p begin="00:03:56.882" end="00:03:59.667" style="s2">right below the mitral<br />valve, as seen in this image.</p>
<p begin="00:03:59.667" end="00:04:00.904" style="s2">This is a very important landmark</p>
<p begin="00:04:00.904" end="00:04:02.990" style="s2">because the posterior<br />pericardium reflection,</p>
<p begin="00:04:02.990" end="00:04:06.190" style="s2">that white line seen posterior<br />to the left ventricle,</p>
<p begin="00:04:06.190" end="00:04:09.407" style="s2">comes off anterior to<br />the descending aorta.</p>
<p begin="00:04:09.407" end="00:04:11.243" style="s2">This allows us to tell if the fluid</p>
<p begin="00:04:11.243" end="00:04:15.511" style="s2">that we see there may be<br />pericardial or plural.</p>
<p begin="00:04:15.511" end="00:04:17.390" style="s2">In conclusion, I'm glad<br />I could share with you</p>
<p begin="00:04:17.390" end="00:04:19.098" style="s2">the SoundBytes module going over part one</p>
<p begin="00:04:19.098" end="00:04:22.059" style="s2">of parasternal long<br />axis view of the heart.</p>
<p begin="00:04:22.059" end="00:04:24.410" style="s2">There's a great deal of<br />information that we can gain</p>
<p begin="00:04:24.410" end="00:04:26.731" style="s2">by looking at the<br />parasternal long axis view,</p>
<p begin="00:04:26.731" end="00:04:28.887" style="s2">looking for left<br />ventricular contractility,</p>
<p begin="00:04:28.887" end="00:04:30.787" style="s2">the presence of a pericardial effusion,</p>
<p begin="00:04:30.787" end="00:04:34.883" style="s2">and also the possibility of<br />right ventricular strain.</p>
<p begin="00:04:34.883" end="00:04:36.898" style="s2">So, I hope to see you back in the future</p>
<p begin="00:04:36.898" end="00:04:39.220" style="s2">as we're going to cover further modules</p>
<p begin="00:04:39.220" end="00:04:40.840" style="s2">going over the parasternal views,</p>
<p begin="00:04:40.840" end="00:04:43.450" style="s2">the subxiphoid views, and the apical views</p>
<p begin="00:04:43.450" end="00:04:47.283" style="s2">so I'll see you back as<br />sono access continues.</p>
Cardiac Ultrasound Views: Subxiphoid
Cardiac Ultrasound Views: Subxiphoid
Using bedside cardiac ultrasound and a phased array probe to evaluate cardiac structures and health, the presence of pericardial effusion, and evaluating the left heart chamber size and valves.
<p begin="00:00:12.419" end="00:00:14.395" style="s2">and I'm the Emergency<br />Ultrasound Coordinator</p>
<p begin="00:00:14.395" end="00:00:17.231" style="s2">at the New York Presbyterian<br />Hospital in New York City,</p>
<p begin="00:00:17.231" end="00:00:19.898" style="s2">and welcome to SoundBytes Cases.</p>
<p begin="00:00:20.899" end="00:00:22.392" style="s2">In this module, we'll continue our journey</p>
<p begin="00:00:22.392" end="00:00:24.929" style="s2">through the cardiac<br />echocardiography examinations,</p>
<p begin="00:00:24.929" end="00:00:27.067" style="s2">looking at the four standard views.</p>
<p begin="00:00:27.067" end="00:00:29.289" style="s2">In this module, we're<br />specifically going to focus on</p>
<p begin="00:00:29.289" end="00:00:32.134" style="s2">probe position B, as shown<br />in the pictorial here,</p>
<p begin="00:00:32.134" end="00:00:35.565" style="s2">the subxiphoid view of the heart.</p>
<p begin="00:00:35.565" end="00:00:36.914" style="s2">Hopefully you've joined me prior</p>
<p begin="00:00:36.914" end="00:00:40.170" style="s2">for the parasternal views,<br />as shown in probe position A,</p>
<p begin="00:00:40.170" end="00:00:42.603" style="s2">and in an upcoming module<br />on the apical view,</p>
<p begin="00:00:42.603" end="00:00:45.243" style="s2">as shown in probe position C.</p>
<p begin="00:00:45.243" end="00:00:46.703" style="s2">The subxiphoid view of the heart</p>
<p begin="00:00:46.703" end="00:00:49.287" style="s2">is an excellent way of<br />imaging the patient's heart,</p>
<p begin="00:00:49.287" end="00:00:52.725" style="s2">and getting a lot of information<br />directly at the bedside.</p>
<p begin="00:00:52.725" end="00:00:53.843" style="s2">Now let's learn how to perform</p>
<p begin="00:00:53.843" end="00:00:55.698" style="s2">the subxiphoid view of the heart.</p>
<p begin="00:00:55.698" end="00:00:57.399" style="s2">As shown in the pictorial to the right,</p>
<p begin="00:00:57.399" end="00:00:59.388" style="s2">the probe is coming from<br />an abdominal position,</p>
<p begin="00:00:59.388" end="00:01:02.989" style="s2">placed just inferior to the<br />xiphoid tip of the sternum.</p>
<p begin="00:01:02.989" end="00:01:04.921" style="s2">It's important to lay the probe flat</p>
<p begin="00:01:04.921" end="00:01:06.908" style="s2">and push down and under the sternum,</p>
<p begin="00:01:06.908" end="00:01:09.312" style="s2">aiming towards the<br />patient's left shoulder.</p>
<p begin="00:01:09.312" end="00:01:11.008" style="s2">Now the marker dot on the probe</p>
<p begin="00:01:11.008" end="00:01:13.350" style="s2">should be over towards<br />the patient's right side,</p>
<p begin="00:01:13.350" end="00:01:15.537" style="s2">with a caveat that the ultrasound's screen</p>
<p begin="00:01:15.537" end="00:01:19.162" style="s2">indicator dot is over towards<br />the left of the screen.</p>
<p begin="00:01:19.162" end="00:01:20.511" style="s2">Now it's very important to put your hands</p>
<p begin="00:01:20.511" end="00:01:23.783" style="s2">on top of the probe, and<br />really push down and up</p>
<p begin="00:01:23.783" end="00:01:25.682" style="s2">to get the good imaging plane underneath</p>
<p begin="00:01:25.682" end="00:01:27.937" style="s2">the sternum, to make the angle to get</p>
<p begin="00:01:27.937" end="00:01:31.354" style="s2">a good view of the heart from this plane.</p>
<p begin="00:01:32.452" end="00:01:33.787" style="s2">Let's now take a look at the image</p>
<p begin="00:01:33.787" end="00:01:36.911" style="s2">that you'll obtain from the<br />subxiphoid view of the heart.</p>
<p begin="00:01:36.911" end="00:01:38.459" style="s2">Here's a pictorial to the left, and an</p>
<p begin="00:01:38.459" end="00:01:40.922" style="s2">ultrasound image to the right.</p>
<p begin="00:01:40.922" end="00:01:42.583" style="s2">The first chamber that we'll encounter</p>
<p begin="00:01:42.583" end="00:01:44.374" style="s2">directly below the liver, which is our</p>
<p begin="00:01:44.374" end="00:01:46.324" style="s2">acoustic window in this case, on to</p>
<p begin="00:01:46.324" end="00:01:48.603" style="s2">the heart will be the right ventricle.</p>
<p begin="00:01:48.603" end="00:01:51.019" style="s2">Immediately posterior<br />to the right ventricle</p>
<p begin="00:01:51.019" end="00:01:52.700" style="s2">we'll be seeing the left ventricle,</p>
<p begin="00:01:52.700" end="00:01:54.433" style="s2">and as shown in this pictorial,</p>
<p begin="00:01:54.433" end="00:01:58.653" style="s2">notice that it has more<br />muscular and hypertrophic walls.</p>
<p begin="00:01:58.653" end="00:02:00.267" style="s2">From the subxiphoid plane, we'll also</p>
<p begin="00:02:00.267" end="00:02:02.050" style="s2">be able to image the right atrium</p>
<p begin="00:02:02.050" end="00:02:04.023" style="s2">to the left of the right ventricle,</p>
<p begin="00:02:04.023" end="00:02:06.011" style="s2">and the left atrium, just to the left</p>
<p begin="00:02:06.011" end="00:02:07.673" style="s2">of the left ventricle.</p>
<p begin="00:02:07.673" end="00:02:09.401" style="s2">We can also appreciate the white line</p>
<p begin="00:02:09.401" end="00:02:11.432" style="s2">that is the pericardium circumferentially</p>
<p begin="00:02:11.432" end="00:02:13.265" style="s2">surrounding the heart.</p>
<p begin="00:02:15.126" end="00:02:16.452" style="s2">Now that we know where the chambers are,</p>
<p begin="00:02:16.452" end="00:02:17.853" style="s2">let's take a look at a video clip</p>
<p begin="00:02:17.853" end="00:02:21.393" style="s2">of a normal heart from<br />the subxiphoid plane.</p>
<p begin="00:02:21.393" end="00:02:23.160" style="s2">As we remember, the liver is our</p>
<p begin="00:02:23.160" end="00:02:25.579" style="s2">acoustic window onto the<br />heart from this plane,</p>
<p begin="00:02:25.579" end="00:02:27.720" style="s2">and so the liver will be seen anteriorly,</p>
<p begin="00:02:27.720" end="00:02:29.758" style="s2">just to the top of the screen.</p>
<p begin="00:02:29.758" end="00:02:31.454" style="s2">Just below the liver, we appreciate here</p>
<p begin="00:02:31.454" end="00:02:33.783" style="s2">the right ventricle, and notice here,</p>
<p begin="00:02:33.783" end="00:02:35.552" style="s2">just to the left of the right ventricle,</p>
<p begin="00:02:35.552" end="00:02:38.623" style="s2">we can appreciate the right atrium.</p>
<p begin="00:02:38.623" end="00:02:41.075" style="s2">Notice the tricuspid<br />valve flipping up and down</p>
<p begin="00:02:41.075" end="00:02:44.932" style="s2">in between the right atrium<br />and the right ventricle.</p>
<p begin="00:02:44.932" end="00:02:47.172" style="s2">Now let's look posterior<br />to the right ventricle,</p>
<p begin="00:02:47.172" end="00:02:49.136" style="s2">and we appreciate the left ventricle.</p>
<p begin="00:02:49.136" end="00:02:53.968" style="s2">Notice again, its more muscular<br />and hypertrophic walls.</p>
<p begin="00:02:53.968" end="00:02:55.740" style="s2">Just to the left of the left ventricle</p>
<p begin="00:02:55.740" end="00:02:58.326" style="s2">we appreciate, in this<br />case, the left atrium,</p>
<p begin="00:02:58.326" end="00:03:01.084" style="s2">and we also get a glimpse<br />here of the mitral valve</p>
<p begin="00:03:01.084" end="00:03:02.602" style="s2">flipping up and down in between</p>
<p begin="00:03:02.602" end="00:03:05.382" style="s2">the left atrium and the left ventricle.</p>
<p begin="00:03:05.382" end="00:03:06.794" style="s2">Now let's look at that white line,</p>
<p begin="00:03:06.794" end="00:03:09.159" style="s2">both anteriorly above the right ventricle,</p>
<p begin="00:03:09.159" end="00:03:11.112" style="s2">and posterior, below the left ventricle,</p>
<p begin="00:03:11.112" end="00:03:12.710" style="s2">that is the pericardium.</p>
<p begin="00:03:12.710" end="00:03:14.504" style="s2">Note here the absence of any significant</p>
<p begin="00:03:14.504" end="00:03:16.337" style="s2">pericardial effusions.</p>
<p begin="00:03:17.266" end="00:03:18.904" style="s2">In that last video clip, we noted good</p>
<p begin="00:03:18.904" end="00:03:20.604" style="s2">contractility of the left ventricle</p>
<p begin="00:03:20.604" end="00:03:22.739" style="s2">from diastole to systole.</p>
<p begin="00:03:22.739" end="00:03:24.752" style="s2">Let's contrast that clip to this one</p>
<p begin="00:03:24.752" end="00:03:26.269" style="s2">from a patient who<br />presented with shortness</p>
<p begin="00:03:26.269" end="00:03:29.047" style="s2">of breath, and advanced cardiomyopathy.</p>
<p begin="00:03:29.047" end="00:03:31.272" style="s2">We see the right ventricle<br />just below the liver,</p>
<p begin="00:03:31.272" end="00:03:33.392" style="s2">anterior to the left ventricle.</p>
<p begin="00:03:33.392" end="00:03:35.418" style="s2">And what we see here<br />is a poorly contracting</p>
<p begin="00:03:35.418" end="00:03:37.683" style="s2">and dilated left ventricle, consistent</p>
<p begin="00:03:37.683" end="00:03:40.236" style="s2">with a cardiomyopathy heart.</p>
<p begin="00:03:40.236" end="00:03:42.525" style="s2">However, note the absence<br />of any significant</p>
<p begin="00:03:42.525" end="00:03:44.725" style="s2">dark or anechoic fluid collections</p>
<p begin="00:03:44.725" end="00:03:48.229" style="s2">consistent with a pericardial effusion.</p>
<p begin="00:03:48.229" end="00:03:50.208" style="s2">Here's a patient who<br />presented with renal failure</p>
<p begin="00:03:50.208" end="00:03:51.934" style="s2">and acute shortness of breath.</p>
<p begin="00:03:51.934" end="00:03:54.021" style="s2">We're again looking from<br />the subxiphoid plane,</p>
<p begin="00:03:54.021" end="00:03:56.260" style="s2">so we see a little strip<br />of the liver anteriorly.</p>
<p begin="00:03:56.260" end="00:03:58.413" style="s2">The right ventricle just below the liver,</p>
<p begin="00:03:58.413" end="00:04:00.518" style="s2">and the left ventricle seen posteriorly</p>
<p begin="00:04:00.518" end="00:04:01.885" style="s2">to the right ventricle.</p>
<p begin="00:04:01.885" end="00:04:03.889" style="s2">Notice how hypertrophic the walls of</p>
<p begin="00:04:03.889" end="00:04:06.431" style="s2">the left ventricle are in this patient.</p>
<p begin="00:04:06.431" end="00:04:08.556" style="s2">We also appreciate a dark fluid collection</p>
<p begin="00:04:08.556" end="00:04:10.554" style="s2">both anteriorly, just below the liver</p>
<p begin="00:04:10.554" end="00:04:11.840" style="s2">and above the right ventricle,</p>
<p begin="00:04:11.840" end="00:04:14.000" style="s2">and posterior below the left ventricle,</p>
<p begin="00:04:14.000" end="00:04:15.941" style="s2">consistent with a circumferential,</p>
<p begin="00:04:15.941" end="00:04:19.345" style="s2">or large, pericardial effusion.</p>
<p begin="00:04:19.345" end="00:04:21.142" style="s2">If we see a large pericardial effusion</p>
<p begin="00:04:21.142" end="00:04:22.863" style="s2">on bedside echo, our next move is to</p>
<p begin="00:04:22.863" end="00:04:25.413" style="s2">look for signs of cardiac tamponade.</p>
<p begin="00:04:25.413" end="00:04:26.803" style="s2">Here's a patient who manifests</p>
<p begin="00:04:26.803" end="00:04:30.184" style="s2">all the signs of cardiac<br />tamponade on bedside echo.</p>
<p begin="00:04:30.184" end="00:04:33.384" style="s2">Let's look specifically at<br />the right side of the heart.</p>
<p begin="00:04:33.384" end="00:04:35.779" style="s2">Notice the very large<br />pericardial effusion,</p>
<p begin="00:04:35.779" end="00:04:37.883" style="s2">and note the chaotic movement<br />of the right ventricle</p>
<p begin="00:04:37.883" end="00:04:41.069" style="s2">as it struggles to open during diastole.</p>
<p begin="00:04:41.069" end="00:04:42.618" style="s2">The compression of the right ventricle</p>
<p begin="00:04:42.618" end="00:04:44.288" style="s2">in this patient is consistent with</p>
<p begin="00:04:44.288" end="00:04:46.792" style="s2">advanced cardiac tamponade.</p>
<p begin="00:04:46.792" end="00:04:47.811" style="s2">The right side of the heart is</p>
<p begin="00:04:47.811" end="00:04:49.128" style="s2">preferentially compressed before</p>
<p begin="00:04:49.128" end="00:04:52.766" style="s2">the left ventricle, due to<br />its lower pressure circuit.</p>
<p begin="00:04:52.766" end="00:04:54.311" style="s2">In conclusion, I'm glad<br />I could share with you</p>
<p begin="00:04:54.311" end="00:04:55.677" style="s2">this SoundBytes module going over</p>
<p begin="00:04:55.677" end="00:04:58.896" style="s2">the subxiphoid view of the<br />cardiac echo examination.</p>
<p begin="00:04:58.896" end="00:05:00.207" style="s2">This is a very important exam to</p>
<p begin="00:05:00.207" end="00:05:02.008" style="s2">put into your routine practice</p>
<p begin="00:05:02.008" end="00:05:04.673" style="s2">in looking at your patient's<br />heart at the bedside,</p>
<p begin="00:05:04.673" end="00:05:05.741" style="s2">and will tell you if the patient</p>
<p begin="00:05:05.741" end="00:05:07.575" style="s2">has a pericardial effusion, as well as</p>
<p begin="00:05:07.575" end="00:05:10.793" style="s2">giving a sense of left<br />ventricular contractility.</p>
<p begin="00:05:10.793" end="00:05:12.554" style="s2">Also, the subxiphoid view of the heart</p>
<p begin="00:05:12.554" end="00:05:14.802" style="s2">gives better views of the<br />right side of the heart</p>
<p begin="00:05:14.802" end="00:05:18.837" style="s2">than the more superior<br />parasternal views of the heart.</p>
<p begin="00:05:18.837" end="00:05:21.459" style="s2">So I hope to see you back<br />as SoundBytes continues,</p>
<p begin="00:05:21.459" end="00:05:23.018" style="s2">and as we move on to discuss the other</p>
<p begin="00:05:23.018" end="00:05:25.601" style="s2">echo exam planes of the heart.</p>
Using bedside cardiac ultrasound and a phased array probe to evaluate cardiac structures and health, the presence of pericardial effusion, and evaluating the left heart chamber size and valves.
Case: Cardiac Ultrasound - Apical View
Case: Cardiac Ultrasound - Apical View
Using the apical view and a phased array probe during bedside cardiac ultrasound examinations can enable clinicians to evaluate cardiac health, structures, & ventricular contractility. This view is ideal for identifying cardiomyopathy, pericardial effusion, and cardiac tamponade.
<p begin="00:00:13.140" end="00:00:15.016" style="s2">and I'm the emergency<br />ultrasound coordinator</p>
<p begin="00:00:15.016" end="00:00:17.935" style="s2">at the New York Presbyterian<br />Hospital in New York City</p>
<p begin="00:00:17.935" end="00:00:20.602" style="s2">and welcome to Soundbytes Cases.</p>
<p begin="00:00:21.664" end="00:00:23.207" style="s2">In this module we'll continue our journey</p>
<p begin="00:00:23.207" end="00:00:26.643" style="s2">down the path of the four<br />cardiac examination views.</p>
<p begin="00:00:26.643" end="00:00:28.233" style="s2">Specifically in this module</p>
<p begin="00:00:28.233" end="00:00:30.275" style="s2">we're going to look at probe position C,</p>
<p begin="00:00:30.275" end="00:00:32.752" style="s2">known as the apical view of the heart.</p>
<p begin="00:00:32.752" end="00:00:34.040" style="s2">I hope you've been able to join me prior</p>
<p begin="00:00:34.040" end="00:00:37.314" style="s2">looking at probe position<br />A, the parasternal views,</p>
<p begin="00:00:37.314" end="00:00:41.331" style="s2">and probe position B the<br />subxiphoid views of the heart.</p>
<p begin="00:00:41.331" end="00:00:43.908" style="s2">So the apical view of the<br />heart is an excellent view</p>
<p begin="00:00:43.908" end="00:00:45.693" style="s2">and gives a great deal of information</p>
<p begin="00:00:45.693" end="00:00:47.101" style="s2">about our patient's heart</p>
<p begin="00:00:47.101" end="00:00:49.087" style="s2">as it shows all four chambers of the heart</p>
<p begin="00:00:49.087" end="00:00:50.769" style="s2">in relation to one another.</p>
<p begin="00:00:50.769" end="00:00:52.612" style="s2">Therefore, the apical view of the heart</p>
<p begin="00:00:52.612" end="00:00:55.154" style="s2">is preferred by cardiologists<br />as it shows the synergy</p>
<p begin="00:00:55.154" end="00:00:58.599" style="s2">of all of the chambers of<br />the heart to one another.</p>
<p begin="00:00:58.599" end="00:01:00.386" style="s2">Now let's take a look at a pictorial</p>
<p begin="00:01:00.386" end="00:01:03.571" style="s2">showing how to perform the<br />apical view of the heart.</p>
<p begin="00:01:03.571" end="00:01:05.650" style="s2">Preferably, you're going to<br />be using a small footprint</p>
<p begin="00:01:05.650" end="00:01:07.263" style="s2">phased array type probe</p>
<p begin="00:01:07.263" end="00:01:09.139" style="s2">that can easily get in between the ribs.</p>
<p begin="00:01:09.139" end="00:01:11.667" style="s2">Position the probe directly<br />underneath the left nipple</p>
<p begin="00:01:11.667" end="00:01:14.690" style="s2">at about the point of<br />maximal impulse of the heart</p>
<p begin="00:01:14.690" end="00:01:15.895" style="s2">with the probe indicator</p>
<p begin="00:01:15.895" end="00:01:17.915" style="s2">over towards the patient's right side.</p>
<p begin="00:01:17.915" end="00:01:19.059" style="s2">Now that's with the caveat</p>
<p begin="00:01:19.059" end="00:01:21.312" style="s2">that the ultrasound's screen<br />indicator is positioned</p>
<p begin="00:01:21.312" end="00:01:23.338" style="s2">toward the left of the screen.</p>
<p begin="00:01:23.338" end="00:01:24.419" style="s2">Now moving the patient</p>
<p begin="00:01:24.419" end="00:01:26.503" style="s2">into the left lateral decubitus position</p>
<p begin="00:01:26.503" end="00:01:28.997" style="s2">can improve imaging from<br />the apical view of the heart</p>
<p begin="00:01:28.997" end="00:01:31.166" style="s2">as it moves the heart closer to the probe</p>
<p begin="00:01:31.166" end="00:01:33.539" style="s2">and moves the lung out of the way.</p>
<p begin="00:01:33.539" end="00:01:35.851" style="s2">Thus, it's important to<br />consider moving the patient</p>
<p begin="00:01:35.851" end="00:01:37.040" style="s2">into this position</p>
<p begin="00:01:37.040" end="00:01:40.097" style="s2">when performing the<br />apical view of the heart.</p>
<p begin="00:01:40.097" end="00:01:42.009" style="s2">Now let's learn how to<br />interpret the images</p>
<p begin="00:01:42.009" end="00:01:43.284" style="s2">that we'll obtain.</p>
<p begin="00:01:43.284" end="00:01:45.033" style="s2">We see here a pictorial to the left</p>
<p begin="00:01:45.033" end="00:01:46.962" style="s2">and an ultrasound image to the right.</p>
<p begin="00:01:46.962" end="00:01:49.543" style="s2">As we're imaging from the<br />apical view of the heart,</p>
<p begin="00:01:49.543" end="00:01:51.009" style="s2">we're closest to the ventricles</p>
<p begin="00:01:51.009" end="00:01:52.654" style="s2">and in this image we<br />see the left ventricle</p>
<p begin="00:01:52.654" end="00:01:55.486" style="s2">to the right of the screen and<br />the right ventricle adjacent.</p>
<p begin="00:01:55.486" end="00:01:58.346" style="s2">The atria from the<br />apical view of the heart</p>
<p begin="00:01:58.346" end="00:02:01.831" style="s2">will be further away, thus<br />posterior to the ventricles</p>
<p begin="00:02:01.831" end="00:02:03.499" style="s2">and we see here the left atrium</p>
<p begin="00:02:03.499" end="00:02:05.104" style="s2">just below the left ventricle</p>
<p begin="00:02:05.104" end="00:02:08.321" style="s2">and the right atrium<br />below the right ventricle.</p>
<p begin="00:02:08.321" end="00:02:11.325" style="s2">We also see the valves, the<br />tricuspid valve to the left</p>
<p begin="00:02:11.325" end="00:02:13.252" style="s2">and the mitral valve to the right</p>
<p begin="00:02:13.252" end="00:02:15.888" style="s2">in between the left atrium<br />and the left ventricle.</p>
<p begin="00:02:15.888" end="00:02:17.729" style="s2">We can also appreciate the white lines</p>
<p begin="00:02:17.729" end="00:02:20.608" style="s2">surrounding the heart,<br />which is the pericardium.</p>
<p begin="00:02:20.608" end="00:02:22.202" style="s2">Now let's take a look at a video clip</p>
<p begin="00:02:22.202" end="00:02:24.960" style="s2">showing the apical view<br />of the heart in action.</p>
<p begin="00:02:24.960" end="00:02:26.815" style="s2">This is taken from a<br />medical student triathlete,</p>
<p begin="00:02:26.815" end="00:02:29.167" style="s2">so let's take a look<br />at that left ventricle.</p>
<p begin="00:02:29.167" end="00:02:32.312" style="s2">We see the left ventricle in<br />its more superficial location</p>
<p begin="00:02:32.312" end="00:02:34.173" style="s2">to the right of the screen.</p>
<p begin="00:02:34.173" end="00:02:37.441" style="s2">Notice the percentage change<br />from diastole to systole.</p>
<p begin="00:02:37.441" end="00:02:39.918" style="s2">Note the walls almost<br />touch with each heartbeat,</p>
<p begin="00:02:39.918" end="00:02:42.198" style="s2">indicating a good contractility.</p>
<p begin="00:02:42.198" end="00:02:44.781" style="s2">We see the right ventricle to<br />the side of the left ventricle</p>
<p begin="00:02:44.781" end="00:02:48.247" style="s2">and the two atria posterior<br />to the ventricles.</p>
<p begin="00:02:48.247" end="00:02:50.848" style="s2">Notice the mitral valve<br />in between the left atrium</p>
<p begin="00:02:50.848" end="00:02:52.928" style="s2">and left ventricle and the tricuspid valve</p>
<p begin="00:02:52.928" end="00:02:54.242" style="s2">to the right side.</p>
<p begin="00:02:54.242" end="00:02:55.459" style="s2">Notice here the absence</p>
<p begin="00:02:55.459" end="00:02:58.792" style="s2">of any significant pericardial effusion.</p>
<p begin="00:03:00.251" end="00:03:02.942" style="s2">Let's contrast that last<br />clip from this patient</p>
<p begin="00:03:02.942" end="00:03:05.753" style="s2">who has a dilated cardiomyopathy,</p>
<p begin="00:03:05.753" end="00:03:07.113" style="s2">and as we look at that left ventricle</p>
<p begin="00:03:07.113" end="00:03:09.111" style="s2">from the apical view of the heart</p>
<p begin="00:03:09.111" end="00:03:10.826" style="s2">we see a very poor percentage change</p>
<p begin="00:03:10.826" end="00:03:13.001" style="s2">from diastole through systole.</p>
<p begin="00:03:13.001" end="00:03:15.653" style="s2">This is indicative of a<br />very poor contractility</p>
<p begin="00:03:15.653" end="00:03:17.093" style="s2">of this heart.</p>
<p begin="00:03:17.093" end="00:03:19.773" style="s2">We see the right ventricle to<br />the side of the left ventricle</p>
<p begin="00:03:19.773" end="00:03:21.909" style="s2">and the two atria posterior.</p>
<p begin="00:03:21.909" end="00:03:24.244" style="s2">Notice the sluggish movement<br />of both the mitral value</p>
<p begin="00:03:24.244" end="00:03:26.987" style="s2">and the tricuspid valve.</p>
<p begin="00:03:26.987" end="00:03:29.091" style="s2">We see a little bit of<br />pericardial effusion,</p>
<p begin="00:03:29.091" end="00:03:31.418" style="s2">that little black rim around the heart,</p>
<p begin="00:03:31.418" end="00:03:32.785" style="s2">also going together</p>
<p begin="00:03:32.785" end="00:03:35.774" style="s2">with this patient's cardiomyopathy status.</p>
<p begin="00:03:35.774" end="00:03:37.137" style="s2">Here's an interesting video clip</p>
<p begin="00:03:37.137" end="00:03:39.516" style="s2">of a patient who presented<br />with acute shortness of breath.</p>
<p begin="00:03:39.516" end="00:03:41.328" style="s2">What we notice here is the right ventricle</p>
<p begin="00:03:41.328" end="00:03:44.311" style="s2">and the left ventricle<br />closest to the screen,</p>
<p begin="00:03:44.311" end="00:03:47.199" style="s2">but we see here a very<br />large pericardial effusion</p>
<p begin="00:03:47.199" end="00:03:49.426" style="s2">circumferentially surrounding the heart.</p>
<p begin="00:03:49.426" end="00:03:51.444" style="s2">And notice the heart<br />swinging back and forth</p>
<p begin="00:03:51.444" end="00:03:53.151" style="s2">in all the pericardial effusion.</p>
<p begin="00:03:53.151" end="00:03:55.029" style="s2">This gives rise to the phenomenon</p>
<p begin="00:03:55.029" end="00:03:56.569" style="s2">known as electrical alternans</p>
<p begin="00:03:56.569" end="00:04:00.298" style="s2">or different sizes QRSs on the EKG.</p>
<p begin="00:04:00.298" end="00:04:02.505" style="s2">Here's a patient who was in bad shape</p>
<p begin="00:04:02.505" end="00:04:04.682" style="s2">and presented with acute<br />shortness of breath.</p>
<p begin="00:04:04.682" end="00:04:07.056" style="s2">We see a very large pericardial effusion</p>
<p begin="00:04:07.056" end="00:04:09.578" style="s2">and let's look specifically<br />at the right ventricle.</p>
<p begin="00:04:09.578" end="00:04:12.535" style="s2">Notice that it caves in from diastole</p>
<p begin="00:04:12.535" end="00:04:15.382" style="s2">due to the high pressure<br />in the pericardial sac.</p>
<p begin="00:04:15.382" end="00:04:18.592" style="s2">Thus this is indicative of<br />advanced cardiac tamponade.</p>
<p begin="00:04:18.592" end="00:04:22.759" style="s2">This patient will need a stat<br />pericardiocentesis procedure.</p>
<p begin="00:04:25.040" end="00:04:26.718" style="s2">So in conclusion I'm glad<br />I could share with you</p>
<p begin="00:04:26.718" end="00:04:27.770" style="s2">this Soundbytes module</p>
<p begin="00:04:27.770" end="00:04:30.041" style="s2">going over the apical views of the heart.</p>
<p begin="00:04:30.041" end="00:04:31.377" style="s2">This is an often neglected view</p>
<p begin="00:04:31.377" end="00:04:33.227" style="s2">but one that gives a<br />great deal of information</p>
<p begin="00:04:33.227" end="00:04:34.776" style="s2">about your patients heart</p>
<p begin="00:04:34.776" end="00:04:36.529" style="s2">and really should be routinely integrated</p>
<p begin="00:04:36.529" end="00:04:38.969" style="s2">into the cardiac echo examination.</p>
<p begin="00:04:38.969" end="00:04:40.100" style="s2">It's best to move the patient</p>
<p begin="00:04:40.100" end="00:04:42.153" style="s2">into the left lateral decutibus position</p>
<p begin="00:04:42.153" end="00:04:44.930" style="s2">to optimize imaging from<br />the apical view of the heart</p>
<p begin="00:04:44.930" end="00:04:46.698" style="s2">to see all four chambers of the heart</p>
<p begin="00:04:46.698" end="00:04:49.021" style="s2">in relation to one another.</p>
<p begin="00:04:49.021" end="00:04:53.188" style="s2">So I hope to see you back<br />as Soundbytes continues.</p>
Using the apical view and a phased array probe during bedside cardiac ultrasound examinations can enable clinicians to evaluate cardiac health, structures, & ventricular contractility. This view is ideal for identifying cardiomyopathy, pericardial effusion, and cardiac tamponade.
How to: Focused Echo: Apical View
How to: Focused Echo: Apical View
<p begin="00:00:16.432" end="00:00:18.109" style="s2">as part of the focused echo examination</p>
<p begin="00:00:18.109" end="00:00:20.329" style="s2">is the apical four chamber view,</p>
<p begin="00:00:20.329" end="00:00:22.596" style="s2">and the orientation marker for this view</p>
<p begin="00:00:22.596" end="00:00:24.144" style="s2">is gonna be to the patent's left.</p>
<p begin="00:00:24.144" end="00:00:29.121" style="s2">So it actually matches the<br />orientation marker on the screen.</p>
<p begin="00:00:29.121" end="00:00:32.910" style="s2">To identify where you need<br />to go, palpate for the PMI,</p>
<p begin="00:00:32.910" end="00:00:36.577" style="s2">and then place the<br />transducer at this point.</p>
<p begin="00:00:38.037" end="00:00:40.311" style="s2">This is the apical four chamber view.</p>
<p begin="00:00:40.311" end="00:00:43.042" style="s2">On this view, we have an<br />overall assessment of the heart.</p>
<p begin="00:00:43.042" end="00:00:47.352" style="s2">We can see all chambers<br />of the heart in one view.</p>
<p begin="00:00:47.352" end="00:00:48.540" style="s2">On the left side of the screen,</p>
<p begin="00:00:48.540" end="00:00:50.652" style="s2">we're gonna see the<br />right side of the heart.</p>
<p begin="00:00:50.652" end="00:00:54.198" style="s2">So this is gonna be the right<br />atrium, tricuspid valve,</p>
<p begin="00:00:54.198" end="00:00:57.990" style="s2">right ventricle, intraventricular septum,</p>
<p begin="00:00:57.990" end="00:01:01.823" style="s2">left ventricle, mitral<br />valve, and left atrium.</p>
<p begin="00:01:03.021" end="00:01:05.872" style="s2">And what we're really looking<br />for here is a comparison</p>
<p begin="00:01:05.872" end="00:01:09.553" style="s2">of right to left side,<br />size of the left ventricle</p>
<p begin="00:01:09.553" end="00:01:13.720" style="s2">to the right ventricle, left<br />atrium to the right atrium.</p>
<p begin="00:01:15.915" end="00:01:16.968" style="s2">If you've determined that you need</p>
<p begin="00:01:16.968" end="00:01:20.506" style="s2">to do a pericardiocentesis,<br />this is a good view to evaluate</p>
<p begin="00:01:20.506" end="00:01:23.141" style="s2">if you can get good<br />access from this point,</p>
<p begin="00:01:23.141" end="00:01:25.273" style="s2">because if you can get<br />access from this point,</p>
<p begin="00:01:25.273" end="00:01:27.316" style="s2">instead of going through<br />the subxiphoid approach,</p>
<p begin="00:01:27.316" end="00:01:29.117" style="s2">you avoid the liver altogether,</p>
<p begin="00:01:29.117" end="00:01:31.554" style="s2">and at this point, you're<br />very close to the heart</p>
<p begin="00:01:31.554" end="00:01:34.541" style="s2">and can quickly identify<br />where the fluid is</p>
<p begin="00:01:34.541" end="00:01:35.874" style="s2">and draw it out.</p>
How to: Focused Echo: Parasternal View
How to: Focused Echo: Parasternal View
<p begin="00:00:16.802" end="00:00:18.776" style="s2">doing a focused echo exam.</p>
<p begin="00:00:18.776" end="00:00:20.792" style="s2">And, there's a couple of<br />different views that you do</p>
<p begin="00:00:20.792" end="00:00:22.069" style="s2">as part of the focused echo exam.</p>
<p begin="00:00:22.069" end="00:00:23.995" style="s2">I'm going to concentrate<br />first on the parasternal</p>
<p begin="00:00:23.995" end="00:00:26.170" style="s2">long axis, and then we'll<br />walk you through the</p>
<p begin="00:00:26.170" end="00:00:28.259" style="s2">apical four-chamber view as well.</p>
<p begin="00:00:28.259" end="00:00:31.285" style="s2">The parasternal long axis,<br />you can also use as part</p>
<p begin="00:00:31.285" end="00:00:34.932" style="s2">of your FAST examination<br />if you're having trouble</p>
<p begin="00:00:34.932" end="00:00:37.365" style="s2">doing the subcostal or subxiphoid view.</p>
<p begin="00:00:37.365" end="00:00:40.630" style="s2">The parasternal long axis<br />is a great alternative to</p>
<p begin="00:00:40.630" end="00:00:44.913" style="s2">get an overall estimation of<br />function of the left ventricle,</p>
<p begin="00:00:44.913" end="00:00:46.796" style="s2">as part of the FAST exam, and also</p>
<p begin="00:00:46.796" end="00:00:49.629" style="s2">evaluate for pericardial effusion.</p>
<p begin="00:00:50.470" end="00:00:52.396" style="s2">Okay, so the first thing<br />you're going to do with this,</p>
<p begin="00:00:52.396" end="00:00:54.254" style="s2">if you can, is have the patient</p>
<p begin="00:00:54.254" end="00:00:55.936" style="s2">turn over to their left side.</p>
<p begin="00:00:55.936" end="00:00:58.819" style="s2">The reason we like to do this<br />is as you have the patient</p>
<p begin="00:00:58.819" end="00:01:01.378" style="s2">turned to their left, the<br />heart's going to fall forward in</p>
<p begin="00:01:01.378" end="00:01:03.926" style="s2">the chest cavity and bring<br />it a little bit closer to the</p>
<p begin="00:01:03.926" end="00:01:07.756" style="s2">window that you're trying<br />to access, through the ribs.</p>
<p begin="00:01:07.756" end="00:01:10.491" style="s2">So in this case, if we're doing<br />a cardiac examination, with</p>
<p begin="00:01:10.491" end="00:01:14.367" style="s2">a cardiac exam type, we want<br />the orientation marker facing</p>
<p begin="00:01:14.367" end="00:01:17.284" style="s2">up to the patient's right shoulder.</p>
<p begin="00:01:18.903" end="00:01:21.939" style="s2">So once we have the orientation<br />figured out, we're going to</p>
<p begin="00:01:21.939" end="00:01:25.439" style="s2">put a little bit of gel on the transducer.</p>
<p begin="00:01:28.519" end="00:01:32.206" style="s2">And we're going to find where<br />the sternum is, and just move,</p>
<p begin="00:01:32.206" end="00:01:36.375" style="s2">just a little bit left of<br />the sternum, looking for the</p>
<p begin="00:01:36.375" end="00:01:39.208" style="s2">fourth to sixth intercostal space.</p>
<p begin="00:01:44.450" end="00:01:46.748" style="s2">And that should put you at<br />least in the ballpark area for</p>
<p begin="00:01:46.748" end="00:01:49.927" style="s2">where you're going to find<br />the parasternal long axis</p>
<p begin="00:01:49.927" end="00:01:51.427" style="s2">view of the heart.</p>
<p begin="00:01:53.630" end="00:01:57.463" style="s2">So remembering that the<br />heart sits in the body</p>
<p begin="00:01:58.530" end="00:02:00.896" style="s2">at a slight angle, this is going to be the</p>
<p begin="00:02:00.896" end="00:02:03.800" style="s2">long axis view of the heart itself.</p>
<p begin="00:02:03.800" end="00:02:05.963" style="s2">Not long axis of the body,<br />but we'll look at the long</p>
<p begin="00:02:05.963" end="00:02:07.496" style="s2">axis of the heart.</p>
<p begin="00:02:07.496" end="00:02:10.047" style="s2">When we look at the ultrasound<br />image, we should quickly</p>
<p begin="00:02:10.047" end="00:02:14.214" style="s2">be able to identify the left<br />ventricle, which we see here.</p>
<p begin="00:02:16.825" end="00:02:19.651" style="s2">And what we're evaluating for is a squeeze</p>
<p begin="00:02:19.651" end="00:02:22.136" style="s2">of this left ventricle.</p>
<p begin="00:02:22.136" end="00:02:25.839" style="s2">So on this image, we<br />have the right ventricle,</p>
<p begin="00:02:25.839" end="00:02:29.422" style="s2">left ventricle, left<br />atrium, and the aorta.</p>
<p begin="00:02:31.028" end="00:02:33.611" style="s2">Mitral valve, and aortic valve.</p>
<p begin="00:02:36.423" end="00:02:38.115" style="s2">Typically, we are doing<br />this examination to</p>
<p begin="00:02:38.115" end="00:02:41.220" style="s2">evaluate for pericardial effusion.</p>
<p begin="00:02:41.220" end="00:02:43.879" style="s2">So we want to identify the pericardium.</p>
<p begin="00:02:43.879" end="00:02:46.645" style="s2">This is going to be<br />this bright, white line</p>
<p begin="00:02:46.645" end="00:02:48.848" style="s2">around the heart.</p>
<p begin="00:02:48.848" end="00:02:50.482" style="s2">What's important in this view is that</p>
<p begin="00:02:50.482" end="00:02:52.683" style="s2">you have it deep enough<br />so that you can identify</p>
<p begin="00:02:52.683" end="00:02:55.682" style="s2">where the descending aorta is.</p>
<p begin="00:02:55.682" end="00:02:57.832" style="s2">The descending aorta is<br />going to appear posterior</p>
<p begin="00:02:57.832" end="00:02:59.452" style="s2">to the left atrium.</p>
<p begin="00:02:59.452" end="00:03:02.362" style="s2">And we're going to see<br />it as a round circle.</p>
<p begin="00:03:02.362" end="00:03:05.279" style="s2">If the fluid is in the pericardium,</p>
<p begin="00:03:06.504" end="00:03:09.935" style="s2">it's going to be above<br />this descending aorta.</p>
<p begin="00:03:09.935" end="00:03:12.793" style="s2">If it's a plural<br />effusion, it's going to be</p>
<p begin="00:03:12.793" end="00:03:14.547" style="s2">behind the descending aorta.</p>
<p begin="00:03:14.547" end="00:03:17.272" style="s2">So this is a very important<br />landmark that you need to</p>
<p begin="00:03:17.272" end="00:03:19.680" style="s2">identify, so you can clearly establish</p>
<p begin="00:03:19.680" end="00:03:22.415" style="s2">where the fluid is present.</p>
<p begin="00:03:22.415" end="00:03:25.090" style="s2">Another important area you<br />have to identify to determine</p>
<p begin="00:03:25.090" end="00:03:28.123" style="s2">exactly where the pericardial<br />effusion is, is the</p>
<p begin="00:03:28.123" end="00:03:30.011" style="s2">anterior aspect of the heart.</p>
<p begin="00:03:30.011" end="00:03:32.620" style="s2">You have to be careful when<br />you evaluate this area,</p>
<p begin="00:03:32.620" end="00:03:34.731" style="s2">because there could be<br />a fat pad in this area</p>
<p begin="00:03:34.731" end="00:03:37.226" style="s2">that appears hypoechoic.</p>
<p begin="00:03:37.226" end="00:03:40.163" style="s2">So for it to be a true<br />pericardial effusion, we want to</p>
<p begin="00:03:40.163" end="00:03:43.192" style="s2">see the fluid wrapping all<br />the way around the heart,</p>
<p begin="00:03:43.192" end="00:03:44.616" style="s2">to the posterior aspect.</p>
<p begin="00:03:44.616" end="00:03:47.104" style="s2">If it's just here, in the anterior aspect,</p>
<p begin="00:03:47.104" end="00:03:49.604" style="s2">it's probably just a fat pad.</p>