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MIDS 197 > Ch 11 Subcostal > Flashcards

Ch 11 Subcostal Flashcards

1
Q

List the subcostal imaging planes?

A

-4CH* (5CH, RVOT)
-IVC/Hep vein*
-Abdominal Ao*
-SAX (AoV, MV, PM, apex)
-Bicaval
-Situs

(* = routinely performed)

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2
Q

How should the pt lie for subcostal scanning?

A

In supine with legs bent at knees (to relax abdominal wall musculature)

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3
Q

What should pt’s m/c do with their breathe during subcostal scanning?

A

Breath in + hold m/c improves image

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4
Q

Is this window helpful in FAST exams?

A

Yes! Also helpful with pt’s who have suboptimal parasternal/apical windows

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5
Q

What is the subcostal window used to assess?

A

The heart, pericardium, RV free wall thickness + extracardiac vasculature

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6
Q

What are some reasons a pt may have suboptimal parasternal or apical windows?

A

-Heart sits low in chest
-Too much lung in the way

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7
Q

Where do we put our probe + indicator for subcostal 4CH?

A

-Probe placed on pt’s abdomen, under xiphoid process
-Probe tilted slightly leftward
-Indicator points to pt’s left side at 3 o’clock

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8
Q

Do we need to see the LV apex in our SUB 4CH view?

A

No, it is nice if we can see it but apical views are better to assess the apex

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9
Q

What is the best standard view to quickly assess for pericardial effusion + septal defects?

A

SUB 4CH - b/c septum is perpendicular to the u/s beam

(septal defects: ASDs, VSDs, patent foramen ovale)

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10
Q

What can cause RV + LV hypertrophy?

A

RV: pulmonary hypertension
LV: systemic hypertension

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11
Q

What structures are seen in SUB 4CH?

A

-LA
-MV
-LV
-RA
-TV
-RV
-IVS
-IAS (zoomed in clips allow assessment for PFO + ASD)

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12
Q

The RV free wall when measured at peak of R wave in line with the tip of the anterior TV leaflet when open should be less than how many mm to be considered normal?

A

<5mm = normal

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13
Q

What are 2 other views we can get from SUB 4CH?

A

-5CH (angle anteriorly)
-RVOT (angle even more anteriorly)

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14
Q

How can we acquire the zoomed in IAS from SUB 4CH?

A

-Decrease depth + zoom into IAS
-Acquire a clip + then evaluate same area with CD
-Perform tiny sweeps to ensure we have evaluated entire IAS

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15
Q

Should we increase or decrease our scale when evaluating the IAS?

A

-Decrease it to 30-50 (depending on pt’s HR) to allow for lower flow to be seen
-Higher HR means set a higher scale

(should not see any flow crossing the IAS in a normal pt)

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16
Q

What is the m/c type of ASD?

A

Secundum ASD

(must seek the skinny legend when imaging IAS to ensure we have fully evaluated it)

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17
Q

Do shunts go from left-right or right-left?

A

Left to right b/c they go to an area of less pressure

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18
Q

How can we optimize our SUB 4CH?

A

-Get pt to take big breath in + hold it
-Rotate slightly clockwise or counter-clockwise to see all 4 chambers
-Rock (heel/toe) to center heart
-Move slightly to pt’s right + angle superiorly or inferiorly

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19
Q

For the most part we want a horizontal + flat 4CH, when would we want a more vertical 4CH?

A

-To assess regurgitation
-To doppler b/c we want as parallel to flow as possible
-To mimic apical views b/c maybe those views were suboptimal + could not assess well there

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20
Q

What are we assessing for in the 4CH view?

A

-Pericardial effusion (right sided collapse)
-VSD
-ASD
-LV size + function
-RV size, function + wall thickness
-RA/LA size
-Intra cardiac masses
-Pacer wires

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21
Q

How do we acquire the IVC/Hep view from 4CH view?

A

-Rotate counter clockwise to 12 o’clock
-Angle to pt’s right

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22
Q

What structures are seen in the IVC/Hep view?

A

-Liver
-IVC
-RA
-TV
-HV

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23
Q

Why is the IVC collapsible with inspiration?

A

-B/c veins don’t have thick walls
-Taking a breath in or sniff decreases intra thoracic pressure causing IVC to collapse

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24
Q

What is the IVC collapsing used to signify?

A

Used to signify normal central venous pressure

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25
Q

If the IVC fails to collapse more than 50% during inspiration, what does this indicate?

A

Elevated RA pressure

26
Q

How do we measure the IVC?

A

Inner to inner of IVC at largest diameter + again at smallest diameter just distal to IVC/HV junction

27
Q

Why would a breathe hold not be recommended for visualizing the IVC?

A

B/c it won’t collapse

28
Q

List the RA pressure for normal, normal/abnormal + abnormal?

A

Normal: 3 mmHg
Normal/Abnormal: 8 mmHg
Abnormal: 15 mmHg

29
Q

List the IVC size, % collapse + RAP when considered low/normal?

A

Size: < 2.1 cm
Collapse: > 50%
RAP: 3 mmHg

30
Q

List the IVC size, % collapse + RAP when considered high/abnormal?

A

Size: > 2.1 cm
Collapse: < 50%
RAP: 15 mmHg

31
Q

List the IVC size, % collapse + RAP when considered intermediate?

A

Size: < 2.1 cm (normal) or > 2.1 cm (abnormal)
Collapse: < 50% (abnormal) or > 50% (normal)
RAP: 8 mmHg

32
Q

How can we optimize our IVC/Hep view?

A

-Rotate to visualize IVC opening into RA
-Rock to center image
-Angle slightly lateral to visualize HV alongside IVC

33
Q

What are we assessing for in IVC/Hep view?

A

-IVC diameter + collapsibility
-HV size

34
Q

How should we put CD over the IVC/Hep view?

A

-Either place box over both structures or optimize for each structure separately
-Possibly decrease scale to allow for vessel filling

35
Q

CD flow should be primarily what color in the IVC/HV?

A

Blue - b/c venous return flows from IVC/Hep into RA

36
Q

Why do we sometimes see red flow in IVC/Hep, even in a normal pt?

A

B/c it is a pulsatile vascular structure, the vein stops/starts to the beat of the heart

37
Q

How can we obtain the abdominal Ao view from the IVC/Hep view?

A

Angle towards pt’s left side

38
Q

What structures are seen in the abdominal Ao view?

A

-Liver
-Abdominal Ao

39
Q

How can we optimize for the abdominal Ao view?

A

-Rock to center image
-Ask pt to breath in + hold it
-Rotate slightly counter clockwise to open up + elongate vessel

40
Q

How can we differentiate the AO from the IVC?

A

-Use CD
-Structure of walls
-Location of anatomy (Ao should not connect to right side of heart)

41
Q

What are we assessing for in the abdominal Ao view?

A

-Size + structure
-Aneurysms + dissection
-Diastolic flow reversal in presence of Ao regurg

42
Q

How can we optimize our image when applying CD to the abdominal Ao?

A

-Angle Ao more vertically to allow for better color visualization
-Place CD box over Ao + make as big as possible, while maintaining FR
-Increase scale

43
Q

What color should CD flow in the abdominal Ao be?

A

Red antegrade flow

44
Q

Are we able to visualize a subcostal short axis?

A

Yes, similar to PSAX:

-AoV + RVOT
-MV
-PM
-Apex (not always possible)

45
Q

What can we assess in the SUB short axis views?

A

Can potentially assess valves, ventricular size, function, wall motion, etc.

46
Q

If the SUB short axis views are so wonderful, why don’t we always use them?

A

B/c the parasternal views are usually more optimal since we are closer to the heart

47
Q

How can we obtain the SSAX AoV view?

A

-Angle medially (to pt’s left) from IVC/Hep view
-Rotate to open up structures + round out the LV

48
Q

How can we obtain the SSAX MV + PM levels?

A

From each level continue to angle leftward through the LV scan plane to shift from AoV level, to MV, to PM, + possibly even apex

49
Q

How can we optimize our SSAX views?

A

-Zoom in
-Rock to center
-Get pt to breath in + hold it
-Rotate clockwise or counter clockwise to visualize all structures in each imaging plane

50
Q

How can we apply CD to our SSAX views?

A

-Apply all the same options of utilizing color that we would apply to PSAX here
-Breath in helps

(often a helpful window in TDS with pt’s who have lung issues)

51
Q

How can we obtain the bicaval view from the IVC/Hep view?

A

-Sweep probe towards pt’s right mid clavicular region, to the right + cephalad/superior
-Increase sector + depth to accommodate for SVC coming into view

52
Q

What is the bicaval view?

A

We see the IVC + SVC both coming + draining into the RA

53
Q

Where should we put our CD box when imaging the bicaval view?

A

-Place box over IVC, RA + SVC to assess venous return into RA
-Place box over IAS to assess for ASDs again

54
Q

Color flowing into RA from IVC in bicaval view will be what color?

A

Blue

55
Q

Color flowing into RA from SVC in bicaval view will be what color?

A

Red

56
Q

How can we obtain the situs view from SUB 4CH?

A

Angle very posteriorly

(probe will be essentially perpendicular to abdominal wall)

57
Q

Abnormal situs has a high correlation to what?

A

Cardiac abnormalities

58
Q

What is situs solitus?

A

Normal orientation: liver primarily on pt’s right side with stomach + Ao to the left of spine

59
Q

What is situs inversus?

A

Flipped orientation: liver primarily on pt’s left side with stomach + Ao to the right of spine

60
Q

What is situs ambiguous?

A

-When position of vessels + liver can not be reliably determined
-High association with congenital cardiac defects

(image shows liver in center with Ao on pt’s right + IVC on pt’s left)

61
Q

How can applying CD to our situs view help us?

A

Can help us differentiate b/w which vessel we are seeing:

Ao = red flow
IVC = blue flow

MIDS 197 (15 decks)

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