It can be one of the most difficult views to obtain. Why? Well, you may need to go through some lung tissue, you dont really know where the apex is, and it’s never where it’s supposed to be…. among others. Well I’m hoping to make it a bit easier for you.
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. Continue reading
There was a case a few years back that got a lot of attention. 56 year old hypotensive and the providers could have sworn that he had a pericardial effusion, and thus tamponade because they saw the image below on their AP4 and PSL views. They called the cath lab and the cardiology fellow who also performed their echo thought the same and set it up for the patient to get a pericardial window as he was… well….”unstabley stable” – as one of my mentors would say.
You get a patient who has gradual onset of shortness of breath with a history of cancer, a patient with sudden severe exertional chest pressure and new orthopnea, a patient with known pericarditis with worse pain or breathing difficulty, or a trauma patient with a penetrating stab wound to the chest and you want to evaluate whether they have a pericardial effusion, signs of tamponade, or poor contractility through a bedside echo, but you just can’t seem to obtain a great subxiphoid (SX) view. The SX view of the heart seems like it would be easy to obtain. I mean, it is right there! – right by the probe, and the patient is alive so you know he has a heart! Well, sometimes it’s not so easy. There are several reasons for this: your probe positioning, not seeing the liver, and the patient’s thoracic cage.