Continuity equation The continuity equation states that the amount of blood flow through one cardiac chamber or valve orifice is the same as the blood flow through the other chambers and orifices Fig. It is based on the principle of conservation of mass. The continuity equation most commonly is applied to calculation of the aortic valve area AVA in aortic stenosis. Flow at the level of the valvular stenosis obtained with continuous wave CW Doppler and that of the LVOT, just below the valve orifice are generally used Fig. The three variables on the right side of the equation in Fig.

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Illustration 2: Drawing illustrating sonographic capture of a long axis parasternal view. Illustration 4: Diagram outlining the wall segments of the left ventricle. Figure 6b: The image displays the aortic root Ao in systole. Figure 6c: A parasternal short axis view is shown at the level of the apex with some visible papillary muscles PM. Video clip 3: Subxiphoid view of the heart.

Figure This is a split screen image of a B-mode and corresponding M-mode ultrasound. Video clip 5: Shows hyperdynamic cardiac activity. David P. Bahner, M. Introduction and Indications Cardiac ultrasound is a valuable skill set for medical professionals in multiple clinical scenarios including trauma, hypotension and cardiac arrest. The proper techniques to image the heart can be mastered with practice and familiarity with the ultrasound machine. As technology continues to improve, the education of future clinical providers becomes the rate-limiting step to fully implement the true potential of ultrasound.

Is tamponade present? What is the cardiac contractility? What is the intravascular volume status of my patient? This chapter will attempt to guide an emergency department medical provider in the necessary skills to acquire and interpret sonographic images of the heart and great vessels in the emergency medicine setting. Anatomy The appearance of cardiac anatomy on ultrasound can sometimes be confusing. It is difficult to derive a three-dimensional mental construct utilizing 2 dimensional images.

The best way to learn anatomy is by reviewing the sonographic shapes and patterns displayed in 2 dimensions and continuously relate that to the 3 dimensional configuration. It is important to find sonographic landmarks to provide spatial orientation when viewing the heart from multiple planes. Echocardiography is a dynamic assessment and it is important to examine structures through the entire cardiac cycle.

The cardiac apex points anterior inferior and about 60 degrees to the left. The heart consists of two thicker walled ventricles, two thinner walled atria and four valves that separate flow between the chambers.

Blood flows between the anterior and posterior leaflets of the mitral valve into the thick walled left ventricle. The left ventricle LV is thicker walled and is the largest of the four chambers in the normal heart. The LV is by far the main focus in echocardiography and learning nuances of its appearance aids the experienced sonographer.

In the longitudinal long parasternal LPS view the cardiac apex is on the left side of the screen while the apex is on the right side of the screen in the subxiphoid SUX view. From the LV, blood flows into the tubular ascending aorta and into the systemic circulation. The aortic valve can be seen in this plane as two of the three aortic leaflets typically the non coronary cusp and right coronary cusp mark diastole closed and systole open.

Occasionally the left coronary cusp is seen in this imaging plane. In the short axis parasternal view, tilting the probe cephalad can image the aortic valve in cross section.

Superior and inferior vena cava drain into the right atrium and can help orient the sonographer. These structures lead the operator to the right side of the heart. From there, blood flows through the tricuspid valve into the triangular shaped right ventricle.

The right ventricle size is determined by forces influencing preload e. It can assume many shapes depending on the disease state. The pulmonary arteries are difficult to see yet can be visualized in the short axis parasternal view.

The right heart normally carries deoxygenated blood to the lungs and is separated from the left heart by the interatrial septum and the thick walled interventricular septum. A variety of congenital cardiac malformations are common and should be considered when normal patterns deviate. Cardiac anomalies have varying prevalence among differing populations. The normal heart will change morphology and function with age and comorbid conditions.

Imaging in adults requires the use of lower frequencies typically MHz. Curvilinear probes can be used to image the heart, especially in the subxiphoid view. However, rib shadows impede the use of these larger footprint probes with transthoracic imaging. Traditional imaging planes for anatomic structures are transverse short axis and sagittal long axis planes. Structures closest to the transducer are displayed at the top of the image deemed the near field.

The deeper structures are displayed at the bottom of the screen in the far field. The focal zone is that area of greatest resolution usually marked with a carat that indicates the transition from the near to far field.

All probes have an indicator that demarcates the leading edge of the beam that corresponds to a mark on the monitor. This orientation in cardiac imaging has created much controversy on how to position the probe on the chest wall to obtain the necessary standard images of the heart. Other methods have been described such as rotating the probe degrees and reversing the image on the monitor so the indicator is on the left side of the image standard for abdominal presets.

The confusion in the cardiac display is best explained and clarified at the bedside by touching one side of the probe and watching the resultant image on the display. Standard display of cardiac anatomy in the long and short axis, subxiphoid and apical views are the goal for cardiac imaging. The chest can be imaged from a series of acoustic windows and tissue planes. First of all, make sure to document the right patient and medical record number. Cardiac settings enhance the image for optimal motion detection.

Apply generous amount of warm gel and position the patient in left lateral decubitus if tolerated. The heart sits in the chest at an angle and can be approached through the intercostal muscles. These intercostals and structures such as the liver gray or black structures in the near field act as acoustic windows to allow sound waves to penetrate to the underlying heart and chest cavity.

Comparatively, strong reflectors such as ribs or gas in the stomach obscure visualization into the far field. The ribs obscure the beam from penetrating, therefore it is important to rotate the cardiac probe to align the beam parallel to the ribs in the space and eliminate rib shadows.

Long Axis Parasternal: The heart sits obliquely in the left chest with the apex pointing toward the left hip. To obtain the long parasternal view, begin to sweep the probe across the parasternal area in the third or fourth intercostal space.

If the mark on the monitor is on the left, than point the probe to the left hip, if the mark on the monitor is on the right, point the probe to the right shoulder. Either way the image is displayed in the same manner for convenience with the curved apex on the left side of the monitor See Illustration 1,2, and 3 and Figures 1 and 2. Look for the landmark mitral valve and rotate the probe to image the aortic and mitral valve in the same long axis plane.


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