Ultrasound Quiz 4: Ace of Hearts

Welcome to another iteration of Musig Mondays! Enjoy the quiz!

If you get an answer wrong, don't worry! There's a detailed explanation for each question (and if it's too much reading, just look at the words in bold).

Excellent! You noticed the fluid surrounding the heart in the pericardium! Remember you can't diagnose cardiac tamponade on ultrasound since it's a clinical diagnosis. 
There's a pericardial effusion here.

First things first, orient yourself! Here, we can see the heart and its chambers as well as the hyperechoic (white) pericardium. In order to make sure you can see the apex of the heart, you should be able to see the "lucky 7 sign" which just the number 7 formed by the hyperechoic (white) lines. This "lucky 7" is formed by the outer ventricular wall and the interventricular septum.
In this scan, there is a hypoechoic (black) substance between the outer walls of the myocardium and the surrounding pericardium. This is a pericardial effusion! Some effusions are much smaller than this one and can be easy to miss! Make sure to fan through the entire heart when ruling out a pericardial effusion, and pay particular attention to the most dependent part of the organ.
Don't be fooled by a pericardial fat pad, which is typically found on the anterior surface of the heart. Because fat is hypodense, it also appears hypoechoic! 
Great job! This is a normal view of the heart from the subxiphoid view.
Here we have a subxiphoid view of the heart.  

Remember that cardiac tamponade is a clinical diagnosis and cannot be made on ultrasound alone. However, an ultrasound scan can help us find an effusion which can help us make the diagnosis.
This scan is that of a normal heart. We don’t see any pericardial effusion. Indeed, we see the lucky 7 sign which represents the lateral wall of the ventricle and the interventricular septum. Afterwards, the heart is fanned through on both sides until it disappears, with no fluid showing up around the heart.
Therefore we can rule out pericardial effusion.
In this case, the patient’s symptoms are not concordant with that of an MI but they do seem to match that of a panic attack. Usually to treat a panic attack in the ER you want to focus on educating the patient on what it is and reassure them that it isn’t dangerous, that way they can learn to manage it on their own, without needing to rush to an ER every time they have a panic attack.

Yes, good job! This is asystole, the heart is not contracting.
In this scan, we see the heart and its chambers, but we cannot appreciate any movement or contractions., This is asystole. Remember, you don't want to stop compressions!