Soundbyte Cases

Cardiac Ultrasound Views: Subxiphoid

Read more about Cardiac Ultrasound Views: Subxiphoid

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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.

Applications

Cardiology

Media Library Type

Case Study Videos

Subtitles

- Hello, my name is Phil Perera,
and I'm the Emergency Ultrasound Coordinator
at the New York Presbyterian Hospital in New York City,
and welcome to SoundBytes Cases.
In this module, we'll continue our journey
through the cardiac echocardiography examinations,
looking at the four standard views.
In this module, we're specifically going to focus on
probe position B, as shown in the pictorial here,
the subxiphoid view of the heart.
Hopefully you've joined me prior
for the parasternal views, as shown in probe position A,
and in an upcoming module on the apical view,
as shown in probe position C.
The subxiphoid view of the heart
is an excellent way of imaging the patient's heart,
and getting a lot of information directly at the bedside.
Now let's learn how to perform
the subxiphoid view of the heart.
As shown in the pictorial to the right,
the probe is coming from an abdominal position,
placed just inferior to the xiphoid tip of the sternum.
It's important to lay the probe flat
and push down and under the sternum,
aiming towards the patient's left shoulder.
Now the marker dot on the probe
should be over towards the patient's right side,
with a caveat that the ultrasound's screen
indicator dot is over towards the left of the screen.
Now it's very important to put your hands
on top of the probe, and really push down and up
to get the good imaging plane underneath
the sternum, to make the angle to get
a good view of the heart from this plane.
Let's now take a look at the image
that you'll obtain from the subxiphoid view of the heart.
Here's a pictorial to the left, and an
ultrasound image to the right.
The first chamber that we'll encounter
directly below the liver, which is our
acoustic window in this case, on to
the heart will be the right ventricle.
Immediately posterior to the right ventricle
we'll be seeing the left ventricle,
and as shown in this pictorial,
notice that it has more muscular and hypertrophic walls.
From the subxiphoid plane, we'll also
be able to image the right atrium
to the left of the right ventricle,
and the left atrium, just to the left
of the left ventricle.
We can also appreciate the white line
that is the pericardium circumferentially
surrounding the heart.
Now that we know where the chambers are,
let's take a look at a video clip
of a normal heart from the subxiphoid plane.
As we remember, the liver is our
acoustic window onto the heart from this plane,
and so the liver will be seen anteriorly,
just to the top of the screen.
Just below the liver, we appreciate here
the right ventricle, and notice here,
just to the left of the right ventricle,
we can appreciate the right atrium.
Notice the tricuspid valve flipping up and down
in between the right atrium and the right ventricle.
Now let's look posterior to the right ventricle,
and we appreciate the left ventricle.
Notice again, its more muscular and hypertrophic walls.
Just to the left of the left ventricle
we appreciate, in this case, the left atrium,
and we also get a glimpse here of the mitral valve
flipping up and down in between
the left atrium and the left ventricle.
Now let's look at that white line,
both anteriorly above the right ventricle,
and posterior, below the left ventricle,
that is the pericardium.
Note here the absence of any significant
pericardial effusions.
In that last video clip, we noted good
contractility of the left ventricle
from diastole to systole.
Let's contrast that clip to this one
from a patient who presented with shortness
of breath, and advanced cardiomyopathy.
We see the right ventricle just below the liver,
anterior to the left ventricle.
And what we see here is a poorly contracting
and dilated left ventricle, consistent
with a cardiomyopathy heart.
However, note the absence of any significant
dark or anechoic fluid collections
consistent with a pericardial effusion.
Here's a patient who presented with renal failure
and acute shortness of breath.
We're again looking from the subxiphoid plane,
so we see a little strip of the liver anteriorly.
The right ventricle just below the liver,
and the left ventricle seen posteriorly
to the right ventricle.
Notice how hypertrophic the walls of
the left ventricle are in this patient.
We also appreciate a dark fluid collection
both anteriorly, just below the liver
and above the right ventricle,
and posterior below the left ventricle,
consistent with a circumferential,
or large, pericardial effusion.
If we see a large pericardial effusion
on bedside echo, our next move is to
look for signs of cardiac tamponade.
Here's a patient who manifests
all the signs of cardiac tamponade on bedside echo.
Let's look specifically at the right side of the heart.
Notice the very large pericardial effusion,
and note the chaotic movement of the right ventricle
as it struggles to open during diastole.
The compression of the right ventricle
in this patient is consistent with
advanced cardiac tamponade.
The right side of the heart is
preferentially compressed before
the left ventricle, due to its lower pressure circuit.
In conclusion, I'm glad I could share with you
this SoundBytes module going over
the subxiphoid view of the cardiac echo examination.
This is a very important exam to
put into your routine practice
in looking at your patient's heart at the bedside,
and will tell you if the patient
has a pericardial effusion, as well as
giving a sense of left ventricular contractility.
Also, the subxiphoid view of the heart
gives better views of the right side of the heart
than the more superior parasternal views of the heart.
So I hope to see you back as SoundBytes continues,
and as we move on to discuss the other
echo exam planes of the heart.

Brightcove ID

5752154065001

https://youtube.com/watch?v=ew6uJvZDhmw

Body

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.

Heart PLAX Zoomed

Read more about Heart PLAX Zoomed

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Applications

Cardiology

Media Library Type

Image

Heart - PLAX View

Read more about Heart - PLAX View

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Applications

Cardiology

Media Library Type

Image

Heart - PLAX Mitral Regurg

Read more about Heart - PLAX Mitral Regurg

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Applications

Cardiology

Media Library Type

Image

Case: Detection of Pleural Fluid

Read more about Case: Detection of Pleural Fluid

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This video details the use of bedside ultrasound imaging to detect pleural fluid, grade the amount of fluid in the pleural cavity, and detect loculated pleural effusions.

Applications

Media Library Type

Media Library Tag

Congested Heart Failure

Infection

Tumors

Increased Blood Pressure

Blocked Blood Vessels

Subtitles

- Hello, my name is Phil Perera
and I'm the Emergency Ultrasound Coordinator
at the New York Presbyterian Hospital in New York City.
And welcome to SoundBytes Cases.
In this SoundBytes module,
we're going to look specifically at the
use of Bedside Ultrasound to detect Pleural Fluid.
Interestingly enough, Ultrasound has been found
to detect as little as 20 ccs of fluid
within the Pleural Space.
In contrast, a Chest X-Ray will not reliably
pick up less than 100 to 150 ccs of fluid
on an AP Film.
Now this problem is only compounded
in the Supine Trauma Patient,
where a Chest X-ray may miss a significant amount of fluid
as a Hemothorax will layer out Posteriorly
and can be very difficult to detect on this film.
For these reasons,
Bedside Ultrasound may offer a more accurate way
of diagnosing Pleural Fluid.
Here's a slide reviewing how to
perform the Ultrasound examination
for detection of Pleural Effusions.
Optimally you'll have a three megahertz probe
with a small footprint that can easily sit between the ribs
as we'll be looking into the Right Upper Quadrant
and Left Upper Quadrant areas.
In position one, we'll be coming into the
standard Right Upper Quadrant Trauma FAST exam
and position the probe into that area
just above the Liver and below the Diaphragm.
We can then angle the probe upwards into the Thoracic Cavity
to look for a Dark or Anechoic Fluid Collection
signifying Thoracic Fluid.
We can repeat the exam in the left side
as shown in probe position two.
Placing the probe into that area
of the Left Upper Quadrant Trauma FAST view.
Look first into the area above the Spleen
and below the Diaphragm
and then angle the probe upwards into
the left Thoracic Cavity.
If fluid is seen with in the Thoracic Cavity,
we can then move the probe upwards
to investigate the extent of the Effusion.
Here's a video going over how to perform the examination.
Notice here, we have a probe placed
into the Right Upper Quadrant Trauma FAST area.
Notice that we're angling the probe upwards
into the Thoracic Cavity to fully investigate
for a Pleural Effusion.
Here, I'm just superimposing
about the level of the Diaphragm
as shown in the red marker.
And notice here that the probe
is positioned coming into that area
just above the Diaphragm into the Thoracic Cavity.
Traditionally, the probe should be
in a long-axis configuration
with the marker dot towards the patient's head.
Again, if a Fluid Collection is seen,
one can then move the probe upwards
to fully investigate how big the Effusion is.
To optimize your examination,
place the patient with the head slightly upwards,
so that the fluid will layer out above the Diaphragm
allowing earlier detection of smaller amounts of fluid.
Now that we know how to perform
the Ultrasound examination for Pleural Fluid,
let's take a look at a normal Right Upper Quadrant
Pleural Examination.
The probe is configured at a long-axis type orientation
with the marker towards the patient's head.
So, we see Superior to the left, Inferior to the right.
The Liver is in the middle of the image.
And let's look above the liver.
Here we see the Diaphragm, that curving, white line
which is moving up and down as the patient breathes.
And to the left or Superior to the Diaphragm
is the Thoracic Cavity.
Now, while looking at the Thoracic Cavity here,
what we see is something called Mirror Artifact.
This occurs as a result of the sound waves
coming through the Diaphragm
and reproducing what looks like a mirror image
of the Liver within the chest.
This is a normal appearance of the Thoracic Cavity
and Mirror Artifact is something that
will be seen commonly on Bedside Sonography.
Notice, however, the absence of a Dark
or Anechoic Fluid Collection within the right chest.
Now, let's take a look at a normal
Left Upper Quadrant Pleural Exam.
Again, we're in a long-axis configuration,
so Superior to the left, Inferior to the right.
We see the Spleen in the middle of the image
and we see the Diaphragm moving up and down
as the patient breathes.
Let's look above the Diaphragm into the Thoracic Cavity.
And, again, we see that Mirror Artifact.
What it looks like is almost like
reproduction of the Spleen within the Thoracic Cavity.
So, this is a normal finding.
And one that is not to be confused with fluid.
Fluid will appear very differently
and will have the appearance of a Dark or Anechoic stripe
right above the Diaphragm.
Here's an illustration showing a positive examination
from the Right Upper Quadrant view
with a Pleural Effusion above the Diaphragm.
We're in that long-axis configuration,
so Superior to the left, Inferior to the right.
We see the Liver in the middle of the image here.
And the Diaphragm, the white line as seen
right above the Liver.
Notice in this image we have a Pleural Effusion
as represented by the Dark area of fluid,
which is immediately Superior to the Diaphragm
and tucks in there right above the Diaphragm
going up into the Thoracic Cavity.
So, this will the signature finding of a Pleural Effusion
as taken from the Trauma FAST Views,
from the Right Upper Quadrant.
And the Left Upper Quadrant will also have a similar view,
although we're just looking above the Spleen
in that orientation.
Here's a video clip showing a Small Pleural Effusion
as taken from the Left Upper Quadrant view.
Here, we see the Spleen in the middle of the image,
the Kidney Inferior to the Spleen.
And the Diaphragm, the curving white line
that's moving up and down as the patient breathes
right above the Spleen.
As we look into that area above the Diaphragm,
we actually appreciate here, the presence
of a Dark or Anechoic Fluid Collection
above the Diaphragm.
This represents a positive Pleural Effusion.
Notice that the amount of fluid is relatively small
and we can actually see the Lung moving up and down
to the left of the image here.
Here's a Moderate Plural Effusion
as taken from the Right Upper Quadrant View.
We see the Liver to the Inferior Aspect or to the right.
The curving white line making up the Diaphragm
in the middle of the image.
And fluid representing a Pleural Effusion
Superior to the Diaphragm.
Interestingly enough, we see the Lung moving around
and all the fluid compressed down
by the fluid within the chest cavity
taking on what appears to like a Liver within the chest.
And something called Hepatization of the Lung.
And this is commonly seen with a Pleural Effusion,
as it pushes in on the Lung
making it more of a solid-type organ.
Here's a Large Pleural Effusion as taken
from the Right Upper Quadrant View.
And what we see here, is the Liver Inferiorly,
the Diaphragm right above the Liver
there in the middle of the image.
And we see a large Dark or Anechoic Collection
immediately Superior to the Diaphragm.
This represents a Large Pleural Effusion.
And in the midst of the Pleural Effusion,
we can see the Lung waving around
and compressed down by all
the fluid within the Thoracic Cavity.
Again, demonstrating that Hepatization
of the Lung as it's compressed down by the Pleural Fluid.
So, this would be a Large Plural Effusion,
as there's a large amount of fluid
both Inferiorly between the Lung and the Diaphragm.
And both Anterior and Posterior to the Lung itself here.
Unfortunately, not all Plural Effusions
will be free-flowing or uncomplicated.
There are occasions where our patients
can have repeated Pleural Effusion
that can be Loculated or Complicated.
Here we see an example of a Loculated Pleural Effusion.
Notice this Lung here has an attachment
with a Fibrin area that attaches it
or glues it onto the Diaphragm Inferiorly.
Therefore, we have two Loculated areas Effusion,
both Anterior to the top of the screen and Posterior.
As the Lung is trapped within the Thoracic Cavity
by this Fibrinous Attachment to the Diaphragm,
it may be dangerous to perform an invasive procedure
like a Thoracentesis or a Chest Tube Placement.
The needle or the Chest Tube could be guided
up into the Lung causing a Pneumothorax
by the Fibrinous Attachment to the Diaphragm.
So, in conclusion, I'm glad I could share with you
this SoundBytes module going over the
Ultrasound Examination for the detection of Pleural Fluid.
As we've discussed earlier in the module,
Ultrasound may be more accurate
in detection of Pleural Fluid than a Chest X-ray.
And Ultrasound allows easy grading
of the amount of fluid within the Pleural Cavity.
It can also detect Complicated Pleural Effusions
that may be Loculated and can help determine
which patients may benefit from a Drainage Procedure
such as a Thoracentesis or a Tube Thoracostomy.
So, I hope to see you back as SoundBytes continues
and in further modules,
we'll actually look closer at
the Thoracentesis Procedure under Ultrasound guidance.

Brightcove ID

5729244712001

https://youtube.com/watch?v=X1E7OgOLzw0

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Cardiac Ultrasound Views: Subxiphoid

Cardiac Ultrasound Views: Subxiphoid

Heart PLAX Zoomed

Heart PLAX Zoomed

Heart - PLAX View

Heart - PLAX View

Heart - PLAX Mitral Regurg

Heart - PLAX Mitral Regurg

Case: Detection of Pleural Fluid

Case: Detection of Pleural Fluid

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