Transthoracic Echocardiography

OVERVIEW

  • Increasing useful bedside test with increasing role in critical care
  • position marker on right

SCANNING PLANES

(1) Parasternal Long Axis (PLAX)
(2) Parasternal Short Axis (PSAX)
(3) Apical 4 Chamber
(4) Subcostal

Parasternal Long Axis (PLAX)

  • position marker to right shoulder
  • transducer @ 2nd and 4th ICS to left of sternum
  • best view and gives most information

Parasternal Short Axis (PSAX)

  • keep transducer in same position on chest
  • rotate 90 degrees so that position marker is towards left shoulder
  • you will need to slow fan to apex of heart

Apical 4 Chamber View

  • move transducer to apex
  • keep position maker towards left shoulder
  • helpful if patient can role 30 degrees to left

Subcostal

  • place transducer below xiphoid process in transverse orientation
  • push down
  • a modified 4 chamber view can be seen

CLINICAL APPLICATIONS

Cardiac Arrest

  • organised activity= good, no activity = bad
  • use PALX: observe organised activity among valves and LV
  • tamponade: fluid in pericardium
  • PE: large RV
  • hypovolaemia: empty LV
  • confirmation of ventricular standstill assists in decision to stop CPR

Pericardial Effusion

  • < 1cm posterior = small
  • 1cm circumferential = large

Pericardial Tamponade

  • diastolic collapse of RV
  • LV collapse (late)
  • IVC dilatation due to increased venous pressure

Shock

  • hypovolaemic: small LV, hyperdynamic
  • obstructive: dilated RV in PE, RV collapse in tamponade, IVC dilation
  • distributive: hyperdynamic LV though good LV size
  • cardiogenic: dilated LV, hypokinetic, IVC dilated

CVP Measurement

  • view IVC as it passes diaphragm through liver
  • sniff-test
    -> if > 50% collapse then CVP < 10mmHg -> if < 50% collapse then CVP > 10mmHg
    -> if IVC does not collapse then the IVC pressure is significantly elevated

Undifferentiated Hypotensive Examination

  • looks for readily reversible causes of hypotension that can be detected on U/S
  • 3 limited views: limited ECHO, RUQ for haemoperitoneum, short axis of aorta

CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

One comment

  1. Hi Chris!!
    met you at Reanimate 3, seems like forever ago.
    keep up the excellent amazing work.
    Tom Fiero, merced California

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