THIS PRESENTATION IS ABOUT ICU ECHOCARDIOGRAPHY.

1. Dr. Santosh Kumar Bhaskar
ICU ECHOCARDIOGRAPHY

3. The five most important things to
know
1.Know your limits
2.ECHO views
3.Eyeball assessment of LV function
4.Diagnosis of pericardial and pleural
effusion
5.Assessment of volume status.

4. Indications for
ECHOCARDIOGRAPHY in critically
ill patients.
 ESTIMATION OF VOLUME STATUS
 CIRCULATORY FAILURE
 Etiology
 Tamponade
 Left ventricle dysfunction
 Severe valvulopathy
 Pulmonary embolism
 Hemodynamic assessment
 Monitoring
 RESPIRATORY DISTRESS
 DISTINCTION BETWEEN CARDIOGENIC AND LESIONAL
PULMONARY EDEMA
 PROBLEMS IN WEANING PATIENTS FROM THE VENTILATOR
 THORACIC TRAUMA
 CHEST PAIN
 CARDIAC ARREST

5. Preparation of the patient
 Patient position
 Lying on the left side with the arm widely abducted.
 Room
 Quiet and dark for better visualization.
 Echographer
 Scanning hand -Use your dominant hand and always scan
in the same position
 Holding 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 device
 Ideally the machine should be infront of you.
 Gel – to improve the contact.

6. 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 probe
 Translation-right to left
 Angulation- up to
down
 Rotation-clockwise-
anticlockwise.

7. TTE
 CHAMBERS EVALUATION
 VALVES EVALUATION
 PERICARDIUM

8. 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 .

9. Plax view

10. Criteria of quality for good plax
view
The septum must be as horizontal as
possible.
You should not visualize the apex of
the left ventricle
You should see the aortic and mitral
valves but the tricuspid valve

11. 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.

12. Apical 4 chamber view
 Probe at the apex of lt
ventricle.
 Probe oriented
towards the rt
shoulder, the notch at
2-3 oclock .

13. Apical 4 chamber view

14. Criteria of quality of the image
 Apex 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.

15. Trouble shooting
 Crux of the heart is tilted towards right—
tranlate your probe laterally.
 Crux of the heart is tilted towards left ---
translate your probe medially.
 Don’t see the mitral and tricuspid valve-----
angle the probe up.
 Don’t 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.

16. 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 .

17. Subcostal /subxiphoid view

18. 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.

19. Subcostal IVC

20. Troubleshooting
 Important 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

21. M- Mode

22. HEMODYNAMICS
 VOLUME STATUS
 TAMPONADE
 RIGHT VENTRICULAR SYSTOLIC PRESSURE
 CARDIAC OUTPUT

23. Volume status

24.  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.

25. How to predict hemodynamic
response to fluid challenge?

26. Severe hypovolumia
Collapsed chambers
Collapsed IVC
LVOT obstruction

27. Tamponade
 Presence of
pericardial effussion
 Collapse of RV free
wall
 Loss of IVC
respiratory variation
 Increeased
interventricular
dependance

29. RA and RV collapse

30. Loss of IVC respiratory variation

31. Increased Ventricular
interdependance

32. Respiratory change in chamber
size

33. Cardiac output

34. Cardiac output

35. Cardiac output

36. RV systolic pressure

37. Thanksfor
patient
hearing

38. Practice questions

39. Practice questions

40. Practice questions

41. Practice questions

42. Practice questions

43. Practice questions

44. Practice questions

45. Practice questions

46. Practice questions

47. Practice questions

48. Practice questions