SonoTip&Trick: “I can’t get a good parasternal long view.” Really? well, try this…

When you have that bad trauma case or that sick patient and you’re trying to assess their cardiac contractility or for pericardial effusion/tamponade, you try the subxiphoid (SX) view first, but despite the tricks outlined in a prior post, you still can’t get it. So, you move to the parasternal long (PSL) view on the left anterior chest, at the 3rd-4th intercostal space:

… and still can’t get a good view, and you think: “What am I doing wrong?!!!” – and then you think of just giving up…. well, let me give you a few tricks that may help. If the patient is able to turn on their left side, then great, if not, it’s ok.

1. Start high and Start medial- If you cannot visualize the heart in SX view despite visualizing the liver to help, it may be that the heart is higher in the thoracic cage. Place your phased array probe, with the indicator toward the patient’s left hip (in abdominal presets – screen dot on your left), just next to the sternum, starting just under the clavicle. If you don’t see the heart there, slide down a rib space. If you still don’t see it, keep sliding down rib spaces until you see the beating (which is your first clue that you’re in the correct spot).

2. Slowly change the angle of your probe (up and down) when you’re assessing each rib space above – this will clue you in on whether you’re getting close. ‘Slowly’ is the key word here. If you’re angling downward too much in a rib space and see the PSL heart, you may need to just hop down one more rib space to visualize it better. If that makes it worse, hop back up.

3. Slowly rotate your probe (clockwise/counterclockwise), once you see the beating heart after doing the above, keeping the angle that worked, to see the true long view of the left sided heart.

4. Slide your probe laterally only if you need to in order to center the aortic and mitral valves on your screen.

5. Ensure adequate depth – in order to visualize for left sided pleural effusion versus pericardial effusion, and also to evaluate the descending thoracic aorta.

Once you’ve assessed for pleural effusion and the descending aorta, you can decrease the depth to focus more on the heart itself:

Here’s a general/traditional teaching of the PSL view by my colleague Dr. Sarah Williams using one of our awesome nurses, Niall, as a model (who has a great Australian accent and wished he could have taught it, as things sound so much more official with it :):

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