Slide 1
Dr. Santosh Kumar BhaskarICU ECHOCARDIOGRAPHY
The five most important things to know1.Know your limits2.ECHO
views3.Eyeball assessment of LV function4.Diagnosis of pericardial
and pleural effusion5.Assessment of volume status.
Indications for ECHOCARDIOGRAPHY in critically ill
patients.ESTIMATION OF VOLUME STATUSCIRCULATORY
FAILUREEtiologyTamponadeLeft ventricle dysfunctionSevere
valvulopathyPulmonary embolismHemodynamic assessmentMonitoring
RESPIRATORY DISTRESSDISTINCTION BETWEEN CARDIOGENIC AND LESIONAL
PULMONARY EDEMAPROBLEMS IN WEANING PATIENTS FROM THE
VENTILATORTHORACIC TRAUMACHEST PAINCARDIAC ARREST
Preparation of the patientPatient positionLying on the left side
with the arm widely abducted.RoomQuiet and dark for better
visualization.Echographer Scanning hand -Use your dominant hand and
always scan in the same positionHolding the probe-hold the probe
between your thumb and your 2nd and 3rd fingers. Rest your wrist on
the patients chest to steady your position without
sliding.Echocardiographic deviceIdeally the machine should be
infront of you.Gel to improve the contact.
The probe
Echo probe frequency range -3.5 -5 MHz.There is a notch or a dot
on one side of the probe.Direction of ultrasound beam.Corresponds
to the dot on screen.Movement of the probeTranslation-right to
leftAngulation- up to downRotation-clockwise- anticlockwise.
TTECHAMBERS EVALUATION
VALVES EVALUATION
PERICARDIUM
How to get the plax view
The plax window is located next to sternum between 3rd and 5th
intercostal spaces.The notch on the probe must be directed toward
the sternum at 9-10 oclock .
Plax view
Criteria of quality for good plax viewThe septum must be as
horizontal as possible.You should not visualize the apex of the
left ventricleYou should see the aortic and mitral valves but the
tricuspid valve
How to improve your image ?If you see the tricuspid valve
--------- angle your probe upwards.If you see the apex of the left
ventricle ---- rotate your probe a few degrees clockwise.If you
lose the image -----come back closer to the sternum ,you may be
sliding on the chest.
Apical 4 chamber view
Probe at the apex of lt ventricle.Probe oriented towards the rt
shoulder, the notch at 2-3 oclock .
Apical 4 chamber view
Criteria of quality of the imageApex of the left ventricle
should be close to the probe and the lines of crux should be
vertical and horizontal,the intersection point at the middle of the
image.Be careful not to shorten the apex which would appear round
shaped and hyperkinetic.
Trouble shootingCrux of the heart is tilted towards
righttranlate your probe laterally.Crux of the heart is tilted
towards left --- translate your probe medially.Dont see the mitral
and tricuspid valve-----angle the probe up.Dont see the lv apex try
to scan one or two intercostal space lower.If you see big and round
shaped rt ventricle you are too medial and too high.
Subcostal view
Patient lying flat with knees bend to relax the abdominal
muscles.Probe is oriented toward the patients sternum with the
notch at 3 o clock .
Subcostal /subxiphoid view
How to get the subcostal 4 chamber view?Begin 3-4 cm below the
xiphoid,then angle upwards till you see the 4 chambers.If not
getting image because of any reason try to move your probe toward
the rt flank under the liver keeping the direction of probe toward
the lt. shoulder of the patient.
Subcostal IVC
TroubleshootingImportant to visulize the merging of the IVC with
RA.Measurement of IVC diameter and its respiratory variation is the
corner stone for the evaluation of patients volume status.Measure
IVC 2-3 cm before its merging in the RA.Use M-Mode to determine the
respirophasic variation.
M- Mode
HEMODYNAMICSVOLUME STATUS
TAMPONADE
RIGHT VENTRICULAR SYSTOLIC PRESSURE
CARDIAC OUTPUT
Volume status
How to assess hemodynamic response to fluid challenge?
Clinical parameters like heart rate ,blood pressure and urine
output are neither specific nor sensitive.More than 15% change is
CARDIAC OUTPUT is considered positive fluid response.How to predict
hemodynamic response to fluid challenge?
Passive leg raising test.Patient on mechanical ventilation with
no spontaneous breathing activity.
How to predict hemodynamic response to fluid challenge?
Severe hypovolumiaCollapsed chambers
Collapsed IVC
LVOT obstruction
Tamponade Presence of pericardial effussion
Collapse of RV free wall
Loss of IVC respiratory variation
Increeased interventricular dependance
RA and RV collapse
Loss of IVC respiratory variation
Increased Ventricular interdependance
Respiratory change in chamber size
Cardiac output
Cardiac output
Cardiac output
RV systolic pressure
Thanks for patient hearing
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