Ultrasound - Basic cardiac
To assess and exclude the presence of three specific pathologies:
Right heart failure
Left ventricular dysfunction (global)
Consider in the following presentations:
Contraindications (absolute in bold)
Airway management or resuscitation required
Consent is not required if the patient lacks capacity or is unable to consent
Brief verbal discussion is recommended if the situation allows
Less complex non-emergency procedure with low risk of complications
Failure to obtain adequate views (bone or air artefact, excess tissue)
Failure of image interpretation (false negative or positive)
PPE: non-sterile gloves
Ultrasound machine and gel
Phased array ultrasound probe (orientation described below)
Curvilinear ultrasound probe (may be used for subcostal window)
Positioning (marker descriptions for phased array cardiac probe)
Supine for subcostal view
Left lateral position with arm above head for parasternal and apical view
Subcostal: probe inferior to xiphoid directed towards patient’s left shoulder (marker to the left)
Parasternal long axis: probe at left sternal edge between second and fifth intercostal space (marker to right clavicle)
Parasternal short axis: rotate probe 90 degrees clockwise from long axis view (marker to left shoulder)
Apical four chamber: positioned at maximum apical beat or fifth intercostal space anterior axillary line (marker left)
Subcostal: apply firm downward pressure, angling the probe slowly up from the abdomen into the left chest
Parasternal long axis: drag probe over the chest wall between second and fifth intercostal space searching for the best window
Parasternal short axis: tilt the probe sweeping through the heart from base to apex obtain views at all levels
Apical four chamber: direct towards the patient’s head, dragging probe over chest searching for the best window
Sequence (left ventricular function assessment)
Visualise LV function (myocardial thickening and endocardial excursion) in multiple views
Gross visual assessment only (measurements are not required in the basic cardiac echo)
Define LV function: hyperdynamic, normal, moderately depressed, severely depressed or standstill
Sequence (pericardial effusion assessment)
Visualise the pericardium and any pericardial fluid in multiple views
Estimate the greatest depth of pericardial effusion (measurements are not required in the basic cardiac echo)
Define pericardial effusion: none, small (<0.5cm), moderate (0.5-2.0cm), large (>2cm)
Sequence (right heart dilation)
Visualise LV and RV diameter in multiple view (the usual RV:LV ratio is 0.6:1)
Define RV dilation: none (RV smaller than LV), moderate or more (RV larger than LV)
Clean ultrasound gel from patient
Document estimated LV function, presence of pericardial fluid and right ventricular dilation
Complete clinical assessment combining results with clinical history, exam and other investigations
It is not always possible to obtain all four cardiac views on every patient
The subcostal view is sometimes the only view we can get during resuscitation or CPR
Attempt to obtain all views, however one or more views may answer all three questions of basic echo
Echo all hypotensive patients, and assimilate your finding with the rest of your assessment
By convention the probe marker is on the opposite side of the probe for both the phased array ultrasound probe (cardiac) and the curvilinear ultrasound probe (abdominal). This is relevant for emergency department ultrasound where we use machines incorporating both a phased array ultrasound probe (cardiac) and a curvilinear ultrasound probe (abdominal).
This text describes probe orientation for the phased array cardiac probe. When the curvilinear abdominal probe is used (e.g. in the subxiphoid window) the marker needs to be pointed in the opposite direction (right) to obtain the same view.
When evaluating cardiac motion during CPR, terminal cardiac dysfunction typically progresses through global ventricular hypokinesis, incomplete systolic valve closure, absence of valve motion, absence of ventricular motion, and finally culminating in intracardiac gel-like densities. A lack of mechanical cardiac activity seen on bedside echo has a very poor prognosis, and can assist the decision to terminate resuscitation.
Published investigations demonstrate that emergency physicians with relatively limited training and experience can accurately estimate global cardiac ejection fraction. Left ventricular systolic function is typically graded as normal (EF>50%), moderately depressed (EF 30-50%), or severely depressed (EF<30%).
This guideline has been reviewed and approved by the following expert groups:
Emergency Care Institute
Please direct feedback for this procedure to ACI-ECIs@health.nsw.gov.au.
Roberts JR, Custalow CB, Thomsen TW. Roberts and Hedges’ clinical procedures in emergency medicine and acute care. 7th ed. Philadelphia, PA: Elsevier; 2019.
Dunn RJ, Borland M, O’Brien D (eds.). The emergency medicine manual. Online ed. Tennyson, SA: Venom Publishing; 2019.
Manoj P, et al (2019): In: UpToDate. Waltham (MA): UpToDate.: Emergency ultrasound in adults with abdominal and thoracic trauma
Emergency ultrasound imaging criteria compendium. Ann Emerg Med. 2016;68(1):e11-e48. doi:10.1016/j.annemergmed.2016.04.028
Dawson M, Mallin M. Introduction to bedside ultrasound: volume 1. New York NY: Apple Books; 2013.
Dawson M, Mallin M. Introduction to bedside ultrasound: volume 2. New York NY: Apple Books; 2013.