Ultrasound Quiz 4: Ace of Hearts

Question 1:

A 58 year old male comes into the ER for dyspnea and chest pain. He's worried he's having a heart attack. With the help of this ultrasound, what can you tell him?

He's having a heart attack The heart is beating normally, but you need to do an ECG to rule out an MI There's a pericardial effusion There's endocarditis The patient has mitral regurgitation

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!

Question 2:

A 20 year old female is being seen in the ER in distress. Her vitals show a HR of 130 and a RR of 29. She is worried because her mother had cardiac tamponade. Once she seems calmer, you perform an US. What is the best next step?

She has a pericardial effusion, and with her clinical presentation we can diagnose cardiac tamponade. She needs pericardiocentesis. Her heart is enlarged and she is at risk of developing heart failure. You should give her diuretics. Her heart seems normal, but you are still worried about an MI so you order an ECG to rule it out. The ultrasound is normal, but you should prescribe her SSRIs to help her with her nerves The ultrasound was done to reassure the patient. You explain to her that she is having a panic attack. You should teach her how to recognize her symptoms and reassure her that it isn't dangerous.

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.

Question 3:

A 37 year old female is coding and you remember that you can use POCUS to check on the heart in between compressions. In this scan of the heart, what can you see?

The patient has endocarditis and needs IV antibiotics immediately You can barely see the heart because of all the fluid around it. The patient needs a pericardiocentesis right away. The patient's heart is beating, although very slowly. Tell them to stop the code and give atropine to speed it up. The patient is in asystole. The ultrasound isn't clear. Tell your colleagues to stop compressions for a bit so you can properly find the heart.

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!