Learning Ultrasound – 13 – Scanning Technique For The Apical 4 Chamber View

This post consists of excerpts from the book Point-Of-Care Ultrasound for Emergency Physicians — “The EDE Book”. I purchased the e book two years ago. The e book is only available on Apple devices. The e book is only about $15 and it is simply the best there is on learning  to perform point of care ultrasound (POCUS). You need to buy it now.

There are two skills that need to be developed to become a successful point-of-care ultrasonographer:

  1. The ability to obtain adequate (meaning interpretable) scans. And this is, by far, the most difficult part of learning POCUS. And it is at teaching this critical skill that the book, Point-Of-Care Ultrasound for Emergency Physicians — “The EDE Book”, excels. There is no better ultrasound book for teaching the difficult skill of image acquisiton. The first part of this post is concerned with learning image acquisition.
  2. The ability to interpret ultrasound scans. [This link jumps to the part of this post where cardiac ultrasound interpretation is reviewed if you are already skilled at image acquisition.]

I have posted these Learning Ultrasound series, temporarily, for a friend who does not currently have access to an Apple device.

Here are the excerpts:

So in the picture above the heart is not centered. So you’re going to slide the probe as in the two pictures below to get the heart centered.

In the image below the septum is not vertical which is the way it should be. The septum must be vertical for an ideal A4C view.

So when the septum is not vertical but the heart is centered correctly, which it is in the image above, you’ll want to heel or toe the probe as in the images below.

 

Echocardiography [meaning cardiologists] have taken a different path from all the rest of the sonography world. Cardiologists perform echo with a phased array probe and the cardiac preset activated. The cardiac preset flips the image [so that the parasternal long axis view points in the opposite direction to what we (meaning POCUS scanners) do – See Learning Ultrasound -5- The Parasternal Long Axis Scan]. However, they perform the SC [subcostal] and the A4C [apical 4 chamber] views with the probe indicator pointed to patient left. In effect, this echo equivalent of a “double negative” means they see the same image that we do when performing the SC and 4AC. In contrast, when they perform a PSL (parasternal long axis), they do so with the indicator pointed to the right as we do. But the echo presets have flipped the image. The result is a mirror image PSL of what we see on the screen in [our cardiac ultrasound scans].

All of the above is well discussed in the article Current issues with emergency cardiac ultrasound probe and image conventions [PubMed Abstract] [Full Text HTML] [Full Text PDF].  2008 Mar;15(3):278-84. doi: 10.1111/j.1553-2712.2008.00052.x.


Interpretation Of The Cardiac POCUS scans

YouTube has a number of excellent videos that you can review for examples of normal and of depressed left ventricular dysfunction.

Resources:

(1) Point-Of-Care Ultrasound for Emergency Physicians — “The EDE Book”; “The clearest and most concise approach to emergency ultrasound.” There is an inexpensive ebook available for Apple devices and I strongly recommend you purchase it right away.

(2) Current issues with emergency cardiac ultrasound probe and image conventions [PubMed Abstract] [Full Text HTML] [Full Text PDF].  2008 Mar;15(3):278-84. doi: 10.1111/j.1553-2712.2008.00052.x.

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