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Introduction to Cardiac POCUS

Bailey Freeman, DNP, CRNA and Angela Mordecai

Quick Facts
Procedure
Confirmation Steps
Documentation Requirements
Scope Guide

Quick Facts

  • Can be performed in 3-5 minutes at the bedside

 

  • Requires minimal equipment: ultrasound machine with cardiac probe

 

  • Provides real-time assessment of cardiac function and hemodynamics

 

  • Complements physical examination and other diagnostic tools

 

Indications

Cardiac Point-of-Care Ultrasound (POCUS) is indicated for:

  • Undifferentiated shock or hypotension
  • Suspected heart failure or volume overload
  • Chest pain evaluation
  • Cardiac arrest or peri-arrest states
  • Pre/post-procedure cardiac assessment
  • Trauma with suspected cardiac injury
  • Dyspnea of uncertain etiology

 

Absolute Contraindications

  • No absolute contraindications for diagnostic ultrasound

 

Relative Contraindications

  • Recent thoracic surgery at probe placement sites
  • Severe chest wall pain limiting patient positioning

Procedure

 

Equipment Needed:

  1. Ultrasound machine with cardiac (phased array) probe
  2. Ultrasound gel
  3. Clean drape or towels
  4. Proper patient positioning (supine or left lateral decubitus)

Universal Procedure Steps

PRE-PROCEDURE

  1. Position patient appropriately (supine or left lateral decubitus)
  2. Prepare ultrasound machine with cardiac presets
  3. Apply ultrasound gel
  4. Orient to cardiac anatomy

SCANNING TECHNIQUE

  1. Overview of the five standard cardiac views
  2. Basic probe handling techniques
  3. Orientation to cardiac anatomy on ultrasound

CONFIRMATION STEPS

  1. Proper machine settings (depth, gain, focus)
  2. Correct probe orientation markers
  3. Adequate acoustic windows

 

Standard Cardiac Views

PARASTERNAL LONG AXIS (PLAX)

PS Long Axis Echo Probe Position and Anatomy. Adapted from “Basic Cardiac Point-of-Care Ultrasound” by Matthew Lipton, MD, licensed under CC BY 4.0

Anatomy

  • Location: 3rd-4th intercostal space, left sternal border
  • Structures visualized:
    • Left ventricle
    • Right ventricle
    • Aortic valve
    • Mitral valve
    • Left atrium

Technical Details

  • Probe position:
    • Indicator toward patient’s right shoulder
    • Slight angulation may be needed

 

PARASTERNAL SHORT AXIS (PSAX)

PS Short Axis Echo Probe Position and Anatomy. Adapted from “Basic Cardiac Point-of-Care Ultrasound” by Matthew Lipton, MD, licensed under CC BY 4.0

Anatomy

  • Location: 3rd-4th intercostal space, left sternal border
  • Structures visualized:
    • Cross-sectional view of left ventricle
    • Right ventricle
    • Mitral valve
    • Papillary muscles

Technical Approach

  • Probe position:
    • From PLAX position, rotate probe 90° clockwise
    • Indicator points toward left shoulder

 

 

APICAL FOUR-CHAMBER

Apical 4-Chamber Echo Probe Position and Anatomy. Adapted from “Basic Cardiac Point-of-Care Ultrasound” by Matthew Lipton, MD, licensed under CC BY 4.0

Anatomy

  • Location: Point of maximal impulse (PMI), typically near apex
  • Structures visualized:
    • All four chambers
    • Mitral and tricuspid valves

Technical Approach

  • Probe position:
    • Indicator toward left axilla
    • Left lateral decubitus position helps

 


SUBCOSTAL

[Insert Image]

Anatomy

  • Location: Below xiphoid process
  • Structures visualized:
    • All four chambers
    • Pericardium

Technical Approach

  • Probe position:
    • Indicator toward patient’s right side
    • Angle under rib cage toward heart

 

 

IVC VIEW

IVC measurement. On the left, IVC measurement. Red arrow head indicating approximate location of the measurement. On the right, estimated RA or CVP based on size and collapsibility of the IVC. Blue arrow indicating low CVP and red indicating high CVP. In short, a >2.1 cm measurement and minimal collapsibility is high CVP, a <2.1cm measurement and major collapsibility is low CVP and anything is between is a CVP of 8mmHg. See collapsibility index chart on the right where estimated CVP is given as the intermediate value and the parenthesis shows the ranges of pressures in mmHg.

Anatomy

  • Location: From subcostal position, angle toward IVC
  • Structures visualized:
    • Inferior vena cava
    • Right atrium junction

 

Confirmation Methods

PROPER IMAGE ACQUISITION

  1. Adequate depth settings
  2. Appropriate gain adjustment
  3. Proper focus placement
  4. Clear visualization of relevant structures

VIEW ASSESSMENT

  • Key landmarks for each view:
    • PLAX: LV, RV, mitral valve, aortic valve, LA
    • PSAX: Circular LV with papillary muscles
    • Apical: All four chambers visible
    • Subcostal: Four chambers and pericardium
    • IVC: Vessel entering right atrium

 

Documentation Requirements

  • Views obtained
  • Qualitative assessment findings
  • Integration with clinical presentation
  • Limitations encountered
  • Significant pathology identified


SCOPE GUIDE

Strategies & Clinical Optimization

Patient Positioning

  • Patient position is critical for image acquisition
    • Left lateral decubitus improves parasternal and apical windows
    • Semi-recumbent or supine for subcostal views
  • Machine settings
    • Adjust depth to visualize all relevant structures
    • Optimize gain for clear tissue differentiation
    • Set focus at area of interest
  • Approach
    • Start with an organized approach to all five views
    • Use consistent probe orientation techniques
    • Begin with machine presets for cardiac imaging

Respiratory Maneuvers

  • Brief breath-holding can improve image quality
  • Respiratory variation assessment for IVC
  • Deep inspiration may bring heart closer for subcostal views

Technical Optimization

  • Fan through structures to ensure complete visualization
  • Adjust patient position if windows are suboptimal
  • Try alternative acoustic windows when primary views limited

 

Pearls

  • Cardiac POCUS is a skill that improves with deliberate practice
  • Start with easier views (PLAX, subcostal) before attempting more challenging ones
  • Remember POCUS findings always need clinical correlation
  • Use “heel-toe” motion to optimize image acquisition
  • Apply gentle, steady pressure for better contact
  • In difficult cases, try multiple intercostal spaces

View-Specific Tips

  • PLAX/PSAX:
    • Try different intercostal spaces
    • Adjust probe angle slightly
    • Maintain firm contact with chest wall
  • Apical:
    • Palpate PMI before probe placement
    • Full left lateral position may help
    • Try during expiration
  • Subcostal:
    • Have patient flex knees to relax abdomen
    • Try during deep inspiration
    • Apply firm but gentle pressure

Quick Resources

Key Measurements

  • Normal LV function: 55-70% EF
  • Normal IVC diameter: 1.5-2.1cm
  • IVC collapse >50% with inspiration suggests normal/low right atrial pressure
  • Rule of thirds: 1/3 LA, 1/3 aortic root, 1/3 RV in PLAX

Key Images/Diagrams

Labeled view on heart anatomy in Parasternal Long Axis View during Echocadiography. Adapted from “POCUS Cases 3: LV Systolic Dysfunction” by EM Cases is licensed under CC BY 4.0

 

IVC
RV
TV
Right atrium
IVC view probe position. The probe is placed 2-3 cm below the xiphoid process. Marker directed towards the sternal notch. RV, Right ventricle; IVC, Inferior vena cava; TV, Tricuspid valve. Clips created with the use of Z-anatomy.

 

This patient’s IVC is dilated >2.1cm and does not collapse when performing sniff test.

 

Small IVC <2.1cm with more than 50% collapsability

References

1. American College of Emergency Physicians. ACEP Policy Statement: Emergency Ultrasound Imaging Criteria Compendium

Media Attributions

License

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The Scope Copyright © by Bailey Freeman, DNP, CRNA and Angela Mordecai is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, except where otherwise noted.

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