Common Mistakes in Point of Care Cardiac Ultrasound (Echocardiography, POCUS)

Point of Care Ultrasound (POCUS) for cardiac imaging is a valuable skill that provides rapid diagnostic insights. However, mastering cardiac POCUS requires practice and awareness of common pitfalls. In this video, Dr. Andre Kumar, a hospitalist at Stanford and an expert in point of care ultrasound, shares troubleshooting tips for optimizing various cardiac ultrasound views.

Parasternal Long-Axis View: Common Mistakes and Tips

• One frequent issue is poor visualization of the heart structures due to excess lung air, which can obscure the cardiac window. To mitigate this, Dr. Kumar suggests having the patient turn onto their left side, which brings the heart closer to the chest wall, enhancing visualization of the left atrium, left ventricle, and aortic outflow tract.
  
  
• For patients with too much lung air, asking them to fully exhale can deflate the lungs and improve cardiac visualization. It's important for the sonographer to hold their breath simultaneously to keep a steady view.
  
  
• Difficulty in visualizing the aortic valve can often result from improper probe positioning. Adjusting the probe angle towards the patient's head or rotating it slightly clockwise can help in getting a clearer view of the aortic valve.

Parasternal Short-Axis View: Common Mistakes and Tips

• A common mistake in acquiring the parasternal short-axis view is placing the probe too close to the sternum. This can result in a black or blank screen due to overlying bone. Slightly sliding the probe laterally helps to achieve the correct view.

• Incorrect probe angle can lead to mixed or hybrid views, showing both the mitral valve and the left ventricular cavity. Correcting the probe’s angle towards the left ventricular apex, rather than straight down, provides a clearer short-axis view.

Apical 4-Chamber View: Common Mistakes and Tips

• The apical 4-chamber view can be challenging due to its dependence on probe position and patient orientation. Dr. Kumar recommends having the patient turn onto their left side to improve visualization.

• Avoiding a foreshortened view is crucial. A foreshortened view shows the left ventricular cavity but fails to capture the atria well. To address this, the sonographer should adjust the depth and ensure the probe is perpendicular to the patient’s chest wall. Sliding the probe one or two rib spaces down can also help in capturing a more comprehensive view of the atria, resulting in the heart appearing more oval-shaped.

Subcostal View: Common Mistakes and Tips

• Visualization in the subcostal view may be obstructed by bowel gas, especially in patients who have recently eaten. Encouraging the patient to take a deep breath can push the heart closer to the abdominal cavity, reducing interference from gas.

• A common error is holding the probe perpendicular to the chest, which can miss the heart’s position. Adjusting the probe to a more parallel angle relative to the patient’s body improves visibility. Using an overhand grip, similar to holding a remote control, facilitates this adjustment.