<p begin="00:00:13.400" end="00:00:15.183" style="s2">- Hello, my name is Phil Perera and I'm</p>
<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>

<p begin="00:00:07.459" end="00:00:09.119" style="s2">- [Voiceover] A phased array transducer</p>
<p begin="00:00:09.119" end="00:00:11.852" style="s2">with a cardiac exam<br />type is used to perform</p>
<p begin="00:00:11.852" end="00:00:15.084" style="s2">the parasternal short<br />axis view of the heart.</p>
<p begin="00:00:15.084" end="00:00:18.007" style="s2">If possible, place the<br />patient in a left lateral</p>
<p begin="00:00:18.007" end="00:00:21.500" style="s2">decubitus position to<br />reduce any lung artifact</p>
<p begin="00:00:21.500" end="00:00:24.866" style="s2">and to bring the heart closer<br />to the anterior chest wall.</p>
<p begin="00:00:24.866" end="00:00:27.393" style="s2">Place the transducer<br />at the third or fourth</p>
<p begin="00:00:27.393" end="00:00:31.262" style="s2">intercostal space immediately<br />left of the sternum.</p>
<p begin="00:00:31.262" end="00:00:34.455" style="s2">Move between the third and<br />fourth intercostal space</p>
<p begin="00:00:34.455" end="00:00:38.127" style="s2">and slide the transducer toward<br />and away from the sternum</p>
<p begin="00:00:38.127" end="00:00:40.961" style="s2">to identify the optimal scanning window.</p>
<p begin="00:00:40.961" end="00:00:43.757" style="s2">Assuming the short axis of<br />the heart to be positioned</p>
<p begin="00:00:43.757" end="00:00:45.991" style="s2">on a plane from the<br />patient's right shoulder</p>
<p begin="00:00:45.991" end="00:00:47.457" style="s2">to the left hip.</p>
<p begin="00:00:47.457" end="00:00:49.349" style="s2">Rotate the transducer to adjust</p>
<p begin="00:00:49.349" end="00:00:52.084" style="s2">for the body habitus of the patient.</p>
<p begin="00:00:52.084" end="00:00:54.458" style="s2">The orientation marker<br />will be at approximately</p>
<p begin="00:00:54.458" end="00:00:56.443" style="s2">the two o'clock position.</p>
<p begin="00:00:56.443" end="00:00:59.555" style="s2">As an alternative approach,<br />this exam may be performed</p>
<p begin="00:00:59.555" end="00:01:02.883" style="s2">using an abdomen exam type<br />with an orientation marker</p>
<p begin="00:01:02.883" end="00:01:05.400" style="s2">to the patient's left<br />side at approximately</p>
<p begin="00:01:05.400" end="00:01:07.650" style="s2">the eight o'clock position.</p>
<p begin="00:01:11.625" end="00:01:13.778" style="s2">The myocardium will appear gray</p>
<p begin="00:01:13.778" end="00:01:17.599" style="s2">and the blood-filled chambers<br />will appear hypoechoic.</p>
<p begin="00:01:17.599" end="00:01:20.165" style="s2">The left ventricle will<br />appear as a doughnut shape</p>
<p begin="00:01:20.165" end="00:01:21.924" style="s2">in the center of the image.</p>
<p begin="00:01:21.924" end="00:01:25.905" style="s2">The anterior, septal,<br />inferior, and posterior</p>
<p begin="00:01:25.905" end="00:01:29.304" style="s2">lateral walls of the<br />ventricle can be identified.</p>
<p begin="00:01:29.304" end="00:01:32.414" style="s2">The mitral valve will be<br />seen in cross section.</p>
<p begin="00:01:32.414" end="00:01:35.839" style="s2">From this position, the<br />transducer can be tilted upward</p>
<p begin="00:01:35.839" end="00:01:39.756" style="s2">to visualize the aortic<br />valve in cross section.</p>
<p begin="00:01:41.591" end="00:01:44.146" style="s2">End downward to visualize the myocardium</p>
<p begin="00:01:44.146" end="00:01:45.882" style="s2">of the left ventricle.</p>
<p begin="00:01:45.882" end="00:01:48.959" style="s2">Note the wall motion of<br />the myocardial segments</p>
<p begin="00:01:48.959" end="00:01:51.209" style="s2">and function of the valves.</p>