POCUS Quick Guides
POCUS Echocardiography

Basic Echo

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General notes —

  • Must include at minimum 2 views (PSL, PSX, AP4, Subxiphoid and IVC), although more is always better.

  • Certain information can be gleaned better from certain views (right heart strain, etc.).

  • If unable to obtain all views — “limited” POCUS study, but in almost all patients at least two views should be obtainable if not all.

  • Limitations include: tachycardia, irregular rhythms, limited windows.

  • Always make sure the heart is within 2/3rd of the screen, dynamically adjust depth and gain.

  • Must be in cardiac setting – increases contrast, improves refresh rate, and improves factors that lead to better picture.

  • The EM orientation is preferred, although cardiology orientation will be accepted if sufficient views are obtained.

  • If you are not sure can use guess words – “probably normal.” If something is not visualized, do not guess.

Parasternal Long

  • Effusion — is there one? (must show DAo).

    • How big? Measure largest pocket in end diastole.

      • No significant

      • Trace

      • Small: 0-1cm

      • Medium 1-2cm

      • Large: >2cm

    • Do not confuse pericardial and pleural effusions.

  • Ejection —

    • Qualitative evaluation (eyeball), can use EPSS or Fractional Shortening (understanding limitations).

    • Normal — (55-70%)

    • Hypodynamic — CHF, MI, cardiomyopathies, toxins etc.

    • Hyperdynamic — LV walls almost touching eg, from hypovolemia/vasodilatory shock.

  • Exit — aortic root – measure, normal size <4cm.

  • Not as good:

    • Equality — RV size – can see dilated RV but not best view.

Parasternal Short

Must be at the papillary muscle view for basic POCUS echo.

  • Ejection — normal, hypodynamic, hyperdynamic

  • Effusion — present (Y/N)? Size (see PSL).

  • Equality — dilated RV? D-sign? Paradoxical septal motion?

Apical 4 Chamber

  • Equality – dilated RV?

    • Normal RV should be <2/3rd size of LV

    • McConnell’s?

    • Abnormal septal displacement?

    • Advanced: TAPSE?

    • See October 2023 SonoProps and dedicated chapter for more discussion about signs of right heart strain.

  • Ejection – normal, hypodynamic, hyperdynamic.

  • Effusion - Present (Y/N)? Size?

    • This view may be useful to see some signs of tamponade.

    • Tamponade is a clinical diagnosis.

    • Signs of tamponade include RA systolic collapse, RV diastolic collapse, MV inflow variation >25%, plethoric IVC.

Subxiphoid

Limited in patients with obesity, epigastric pain.

Potentially great in patients with COPD/hyperinflated lungs.

Techniques to optimize — have patient take a deep breath in. Bend patient’s knees to allow abdominal muscles to relax.

  • Effusion – best view for this. Present (Y/N?). Size?

  • Should be able to see the other E’s as well but not the best view. If only view there are multiple subcostal views obtainable but more advanced: subcostal short, subcostal long etc.

Inferior Vena Cava

  • Entrance – size and respiratory variation.

    • Normal — <1.5cm

    • Plethoric — >2cm; lack of respiratory variability means increased CVP.

    • Flat — touching walls; eg, hypovolemia, vasodilatory shock.

  • Measure size 2cm from IVC/RA junction or 1cm from IVC/hepatic vein junction.

  • Sniff test — have patient take a quick deep breath in to evaluate IVC collapsibility.

  • Do not confuse aorta for IVC.

IVCAorta
Thin-walledThick-walled, peri-aortic fat
Usually towards the right (liver)Left/center
Usually collapsible unless plethoric / increased RA pressureNon-collapsible
Demonstrates respiratory variationPulsatile
Drains into the RAContinues to thoracic aorta
Thin hepatic veins draining into IVCCeliac trunk anterior branches