Bedside Ultrasound for Assessing Patients in Shock

Integrative Volume Status Assessment

“…IVC and aorta are best distinguished by noting the hepatic veins joining the IVC and the intrahepatic course of the IVC [42]. Severe tricuspid regurgitation, tricuspid stenosis, massive pulmonary embolism, cardiac tamponade, restrictive and constrictive cardiomyopathy, pulmonary hypertension, impaired IVC drainage to heart, IVC thrombosis, congestive heart failure, impaired right atrial filling and positive pressure ventilation are commonly encountered scenarios which can lead to a low caval index [49,50]. Changes in intrabdominal pressure, changes in tidal volume on mechanical ventilation, thrombosis of IVC, and presence of an IVC filter are some factors that can affect the IVC diameter and changes seen with inspiration [19].…”

“…FoCUS involves PLAX, a parasternal short axis (PSSA), an A4C, and a subcostal 4 chamber or subxiphoid view [62]. PLAX view is obtained by placing probe along the left sternal border at 2 nd to 4 th intercostal space, perpendicular to the patient's chest with the probe index marker angled toward the patient's right shoulder and PSSA view by rotating the probe 90 degrees with index toward the left shoulder [44,50,63]. PLAX view allows visualization of left atrium (LA), mitral valve (MV), left ventricle (LV), aortic valve, right ventricle (RV), pericardium, and descending aortic root (Figure 4) [44].…”

“…PLAX view allows visualization of left atrium (LA), mitral valve (MV), left ventricle (LV), aortic valve, right ventricle (RV), pericardium, and descending aortic root (Figure 4) [44]. A4C view is obtained with the transducer near the apex of the heart at the point of maximal impulse and directing the index marker toward the patient's left shoulder to obtain a simultaneous view of the LV, the RV, the LA, the RA, the MV, and the tricuspid valve [50]. Subxiphoid or subcostal 4-chamber view is obtained by placing the probe in subxiphoid area as described above during IVC assessment [50].…”

“…Pericardial effusion is seen in several different focused cardiac views, but subxiphoid view provides the clearest and most reliable image [50,62]. In the PLAX and PSSA view, significant effusions are visualized posterior to the LV and anterior to descending aorta and in the A4C view, small effusions are visible lateral to the LV free wall, while moderate to large effusions may be seen around the apex of the heart [62].…”

“…LVEF can be estimated using PLAX view by the MV E-point septal separation method (EPSS) with visual assessment or measurement of smallest distance between anterior MV and the interventricular septum. Movement to within 1 cm of the septum suggests that the LVEF is likely preserved [44,50,62,63,69,70]. In PSSA view, concentric LV squeeze can be observed by estimating the degree of internal chamber collapse in systole versus diastole [62].…”