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Common Pathologies

Bailey Freeman, DNP, CRNA and Angela Mordecai

Quick Facts
Procedure
Confirmation Steps
Documentation Requirements
Scope Guide

Quick Facts

  • Key pathologies identifiable on POCUS include effusion, tamponade, severe dysfunction
  • POCUS findings must be integrated with clinical presentation
  • Findings may guide immediate interventions in critical situations
  • Serial exams can track progression or response to treatment

 

Indications

Cardiac pathology assessment via POCUS is indicated for:

  • Unexplained hypotension or shock
  • Suspicion for pericardial effusion or tamponade
  • Concern for severe cardiac dysfunction
  • Monitoring known cardiac conditions

 

Relative Contraindications

  • Findings should never delay definitive intervention in unstable patients

 

Procedure

 

Pathology Assessment Techniques

PERICARDIAL EFFUSION ASSESSMENT

  1. Examine all cardiac views systematically:
    • Parasternal long axis
    • Parasternal short axis
    • Apical four-chamber
    • Subcostal (often best for effusion)
  2. Look for echo-free space around the heart
  3. Measure largest dimension in diastole if present
  4. Classify effusion size:
    • Small: <1.0 cm
    • Moderate: 1.0-2.0 cm
    • Large: >2.0 cm
  5. Assess for signs of tamponade:
    • Right atrial collapse during diastole
    • Right ventricular diastolic collapse
    • IVC plethora with reduced respiratory variation

 

CARDIOMYOPATHY RECOGNITION

  1. Evaluate chamber sizes and relationships
  2. Assess wall thickness and contractility
  3. Look for distinctive patterns:
    • Dilated: Enlarged chambers with reduced function
    • Hypertrophic: Thickened walls, especially septum
    • Restrictive: Normal size, stiff walls, atrial enlargement
  4. Assess for secondary signs:
    • Valve regurgitation
    • Atrial enlargement
    • IVC changes

 

VALVULAR ABNORMALITY ASSESSMENT

  1. Examine valve structure and motion
  2. Look for abnormal appearances:
    • Thickened or calcified leaflets
    • Restricted opening (stenosis)
    • Incomplete closure (regurgitation)
    • Flail leaflets or prolapse
  3. Assess chamber response to valvular disease:
    • Chamber dilation
    • Wall hypertrophy
    • Secondary functional changes

 

Specific Pathology Details

 

PERICARDIAL EFFUSION

Sonographic Appearance

  • Characteristics:
    • Echo-free (black) space surrounding heart
    • Fluid between pericardium and epicardium
    • May be circumferential or loculated
    • Often most prominent posteriorly in PLAX view
  • Distribution patterns:
    • Circumferential: Surrounds entire heart
    • Loculated: Confined to specific region
    • Posterior: Initially collects behind left ventricle
    • Anterior: Less common, may increase tamponade risk

 

Tamponade Physiology

  • Primary signs:
    • Right atrial collapse (lasting >1/3 of cardiac cycle)
    • Right ventricular diastolic collapse
    • Respiratory variation in chamber sizes
    • IVC plethora (>2.1 cm) with minimal respiratory variation
  • Clinical correlation:
    • Hypotension
    • Tachycardia
    • Pulsus paradoxus
    • Elevated jugular venous pressure

 

CARDIOMYOPATHIES

Dilated Cardiomyopathy

  • Sonographic features:
    • Enlarged LV and RV chambers
    • Reduced contractility (typically diffuse)
    • Normal or thinned walls
    • Often with functional mitral regurgitation
    • Left atrial enlargement
  • Hemodynamic impact:
    • Reduced cardiac output
    • Elevated filling pressures
    • Risk of thrombus formation (blood stasis)

 

Hypertrophic Cardiomyopathy

  • Sonographic features:
    • Thickened LV walls (>1.5 cm)
    • Often asymmetric septal hypertrophy
    • Possible outflow tract obstruction
    • Small LV cavity
    • Hyperdynamic function
  • Distinguishing features:
    • Asymmetric septal hypertrophy
    • Systolic anterior motion of mitral valve (SAM)
    • Dynamic outflow obstruction

 

VALVULAR ABNORMALITIES

Aortic Valve Disease

  • Stenosis features:
    • Thickened, calcified leaflets
    • Restricted opening
    • Left ventricular hypertrophy
    • Post-stenotic dilation of ascending aorta
  • Regurgitation features:
    • Incomplete leaflet coaptation
    • LV dilation
    • Hyperdynamic LV in chronic cases

 

Mitral Valve Disease

  • Stenosis features:
    • Thickened, calcified leaflets
    • Restricted opening (“hockey stick” appearance)
    • Left atrial enlargement
    • Normal LV size in pure stenosis
  • Regurgitation features:
    • Incomplete leaflet coaptation
    • Flail or prolapsed leaflet
    • Left atrial and ventricular enlargement
    • Hyperdynamic LV in chronic cases

 

Confirmation Steps

MULTI-VIEW CONFIRMATION

  • Pericardial effusion:
    • Confirm in at least two views
    • Differentiate from pleural effusion
    • Verify location (circumferential vs. loculated)
  • Cardiomyopathies:
    • Assess in multiple views for comprehensive evaluation
    • Measure chamber dimensions when possible
    • Evaluate both structure and function
  • Valvular disease:
    • Assess valve in multiple views
    • Look for chamber remodeling responses
    • Correlate findings between views

 

CLINICAL CORRELATION

  • Critical integration:
    • Combine POCUS findings with clinical presentation
    • Assess hemodynamic impact
    • Consider pre-existing conditions
  • Intervention guidance:
    • Identify findings requiring immediate action
    • Determine severity and urgency
    • Guide specific therapeutic approaches
  • Follow-up considerations:
    • Recommend formal echocardiography when appropriate
    • Consider serial POCUS examinations
    • Monitor response to interventions

 

Documentation Requirements

  • Specific pathologic findings documented with images
  • Measurements where applicable
  • Integration with clinical context
  • Presence and severity of key pathologies
  • Views in which abnormalities were identified
  • Hemodynamic impact assessment
  • Recommendations for further evaluation


SCOPE GUIDE

Strategies & Clinical Optimization

Pericardial Effusion Assessment

  • View optimization
    • Examine all views as distribution may be variable
    • Subcostal view often best for anterior effusions
    • Adjust depth to visualize entire pericardium
  • Tamponade recognition
    • Look specifically for chamber collapse and IVC plethora
    • RA collapse most sensitive (earliest sign)
    • RV collapse more specific
  • Effusion characteristics
    • May first appear posteriorly in PLAX view
    • Circumferential effusions more likely significant
    • Dark, echo-free space suggests simple fluid
    • Echogenic effusions suggest blood, exudate, or infection

Cardiomyopathy Recognition

  • Dilated cardiomyopathy approach
    • Measure chamber dimensions when possible
    • Assess for spherical remodeling
    • Evaluate for secondary mitral regurgitation
  • Hypertrophic cardiomyopathy approach
    • Measure septal and posterior wall thickness
    • Look for systolic anterior motion of mitral valve
    • Assess for dynamic outflow obstruction
  • Restrictive patterns
    • Normal-sized ventricles with biatrial enlargement
    • Evaluate for pericardial thickening
    • IVC dilation with reduced respiratory variation

Valvular Assessment Optimization

  • Aortic valve approach
    • PLAX and PSAX views most useful
    • Assess leaflet thickness and mobility
    • Evaluate for secondary chamber changes
  • Mitral valve approach
    • PLAX and apical views most useful
    • Assess for leaflet thickening, restriction, or prolapse
    • Evaluate LA and LV size responses
  • Right-sided valves
    • Apical and subcostal views most useful
    • Assess for tricuspid regurgitation signs
    • Look for RV and RA size responses

 

Pearls

  • Not all effusions cause tamponade; clinical correlation is essential
  • Small, loculated effusions can cause tamponade if rapid accumulation
  • In tension pneumothorax, look for mediastinal shift and RV compression
  • Cardiac findings should not be interpreted in isolation from clinical context
  • Serial examinations provide valuable trending information

Pathology-Specific Tips

  • Pericardial effusion pearls:
    • Effusion is seen anterior to descending aorta (vs. pleural effusion)
    • Small effusions may be physiologic (women, post-surgery)
    • Tamponade is a clinical diagnosis supported by POCUS
  • Cardiomyopathy pearls:
    • Regional wall motion abnormalities suggest ischemia
    • Global dysfunction suggests non-ischemic etiology
    • LV thrombus risk increases with severe dysfunction
  • Valvular pearls:
    • Combined stenosis and regurgitation are common
    • Acute regurgitation has different appearance than chronic
    • Functional regurgitation results from chamber dilation

Quick Resources

Effusion Size Classification

(diagram)

Key Measurements

  • Effusion size classification:
    • Small: <1.0 cm
    • Moderate: 1.0-2.0 cm
    • Large: >2.0 cm
  • LV hypertrophy: Wall thickness >1.1 cm
  • Dilated LV: End-diastolic diameter >5.6 cm
  • Dilated LA: Diameter >4.0 cm

 

Key Images/Diagrams

Aortic valve stenosis on the parasternal long axis view. Heavily calcified (hyperechoic) aortic valve leaflets with restriction to flow on systole.

Pathology Recognition

  • Effusion localization patterns
  • Tamponade physiology illustration
  • Cardiomyopathy comparison chart
  • Valvular disease patterns

 

Management Guidance

  • Tamponade recognition checklist
  • Cardiomyopathy pattern reference
  • Valvular pathology decision tree
  • Emergency intervention indicators

 

Reference Materials

  • Effusion vs. pleural fluid differentiation
  • Tamponade demonstration images
  • Cardiomyopathy comparison examples
  • Valvular abnormality reference images

References

1. International consensus guidelines on cardiac POCUS
2. American Society of Echocardiography guidelines for chamber quantification
3. 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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