Competence In Critical Care Echocardiography

There’s a growing shift in how echocardiography is used in intensive care. Traditionally seen as a cardiologist’s domain, echo is now increasingly performed by intensivists, not to diagnose cardiac diseases, but to better understand the rapidly changing physiological status of ICU patients.

 

In critical care, timely decisions are crucial. Echo becomes a powerful point-of-care tool, allowing bedside assessments to guide treatment in real-time, especially in patients with shock or hemodynamic instability. Since cardiologists aren't always available at the bedside, intensivists need to be equipped to perform and interpret basic echo findings themselves.

 

This isn't about mastering all aspects of Cardiology; rather, it's about using focused cardiac ultrasound to answer specific, practical questions: Is the heart pumping well? Is there fluid overload or hypovolemia? Can I give fluids or vasopressors? These quick assessments can significantly impact immediate clinical decisions.

 

Despite challenges, like patient position, ventilators, or lung interference, modern ultrasound machines offer rapid, non-invasive insights. Techniques like 2D imaging, M-Mode, and Doppler are commonly used, with color flow mapping (BART principle: Blue Away, Red Towards) helping visualize blood movement.

 

Evidence strongly supports this practice. Studies show transthoracic echocardiography (TTE) is diagnostic in up to 90% of ICU cases, and with training, can influence management in more than 50% of patients. Echocardiography in the ICU is no longer optional. It’s becoming a standard part of Critical Care Medicine.

 

This article aims to be a starting point, a motivation to explore and practice critical care echo. Mastery doesn’t come in an hour, but every intensivist can begin the journey.

 

Mastering Probe Handling in ICU Echocardiography

 

In ICU settings, adaptability is key. While most doctors prefer sitting on the right side during an echocardiography scan, the actual position often depends on practical limitations, like machine placement or patient setup. Flexibility and familiarity with the equipment are essential.

 

If you have access to a machine, daily hands-on practice is highly recommended. This not only builds comfort with the phased array cardiac probe (used in ICU due to its small footprint) but also helps you understand the interface, monitor alignment, and probe mechanics.

 

Once you understand the machine and probe, the next step is learning how to manipulate the probe to visualize the heart and surrounding structures effectively. There are four fundamental probe movements:

 

• Sliding – Moving the probe across the chest to scan various anatomical structures.
• Rocking – Forward and backward motion to align body orientation with the monitor.
• Rotating – Turning the probe like a dial to change between long axis and short axis views.
• Tilting – Angling the probe up or down to visualize structures at different depths.

 

Each of these probe maneuvers alters the path of ultrasound waves and provides new diagnostic information, making them essential skills for any intensivist performing bedside echocardiography.

 

To get comfortable with echocardiography, start by practicing probe movements - sliding, rocking, rotating, and tilting. These help you understand how the heart structures appear on screen with each adjustment.

 

In echocardiography, two main views are used: long axis and short axis. The short axis (2 o’clock probe position) slices the heart horizontally, like slicing a banana. The long axis cuts vertically, from superior to inferior, offering a full view of the chambers and valves.

 

Key probe positions include parasternal, apical, subcostal, and suprasternal notch. For the parasternal long axis view (PLAX), place the probe in the 3rd or 4th intercostal space near the sternum, with the pointer toward the patient’s right shoulder. In PLAX, you’ll see the right ventricle (RV), interventricular septum, left ventricle (LV), mitral valve, left atrium (LA), aortic valve, and aortic root.

 

M-mode captures motion over time along a selected line, useful for analyzing valve function and calculating metrics like the velocity time index. Color Doppler adds flow direction, red toward the probe, blue away, helpful in spotting regurgitations.

 

For the short axis view, rotate the probe 90° from PLAX. Tilting it changes the image depth, from the base to the apex of the heart.

 

When performing echocardiography, the probe's position and tilt determine the structures you visualize. Rotating the probe towards the left shoulder shows the right ventricular outlet, pulmonary valves, aortic valves, and atria. Tilting towards the apex or base of the heart alters the view to focus on different chambers and structures, like the aortic root.

 

In the apical four-chamber view, the probe is placed at the apex, showing all four chambers: right and left ventricles (RV, LV) and right and left atria (RA, LA). A five-chamber view adds the chaotic outlet of the LV, with pulse wave Doppler assessing valve function. The two-chamber view is a rotated version of the four-chamber view, showing just the LV and LA.

 

The subcostal view, placed below the xiphoid process, is particularly useful in critically ill or ventilated patients, helping to visualize pericardial effusions, chamber sizes, and IVC. For IVC assessment, the probe is rotated perpendicular to the patient to view the IVC and differentiate it from the aorta, checking its entry into the RA. This view aids in evaluating fluid conditions and shock assessment.

 

Assessing Shock and Cardiac Function with Echo

 

The lecture covers various aspects of cardiac function assessment in shock, focusing on left and right ventricular function. Left ventricular systolic function is crucial for diagnosing left ventricular failure and cardiogenic shock, while right ventricular systolic function is vital for pulmonary embolism and pulmonary hypertension. The pericardium is assessed for effusion or tamponade, and valvular issues are considered.

 

When assessing shock, it’s important to identify its type, whether hypovolemic, cardiogenic, or a combination. Shock is not just low blood pressure but a condition that impairs oxygen delivery to cells. Echo can provide valuable insights into stroke volume, ejection fraction, and valve pathologies, helping to determine the cause.

 

Key echo parameters include velocity time index (VTI) and stroke volume. The ejection fraction is a significant prognostic marker for heart failure. These assessments guide treatment decisions, such as the use of vasopressors or fluid administration. For hypovolemic shock, intravascular volume assessment is crucial to determine the need for fluid therapy.

 

Echo provides critical information for managing these shock types and monitoring the heart’s response.

 

Upskilling for the Evolving Landscape of Critical Care

 

As ICU practices evolve, so does the scope of skills expected from intensivists. Echocardiography is no longer just a diagnostic tool for cardiologists, it’s a dynamic, point-of-care asset in the hands of a trained critical care specialist. Mastering echo techniques is crucial to effectively manage shock, monitor cardiac function, and make informed bedside decisions.

 

To stay ahead in this rapidly advancing field, healthcare professionals must prioritize continuous learning and hands-on skill development. Medvarsity offers specialized programs designed to bridge this gap.

 

Medvarsity’s Certificate Course in Critical Care Medicine is an ideal starting point for those looking to build a strong foundation in managing acutely ill patients. While it covers a wide spectrum of ICU practices, it also emphasizes the role of bedside diagnostics, including echocardiography.

 

For a deeper dive into imaging, the Certificate Course in Clinical Imaging helps clinicians understand the principles of ultrasound, Doppler techniques, and cardiac imaging, equipping them to apply echo more confidently in real-time scenarios.

 

As critical care becomes more multidisciplinary, building competence in bedside echocardiography isn’t just an added advantage; it’s becoming a standard of care. Whether you're an intensivist, emergency physician, or internal medicine specialist, these upskilling programs empower you to deliver high-quality care with speed and precision in the ICU.

 

In today’s ICU, real-time decision-making can mean the difference between life and death, and echocardiography provides a vital lens into the heart’s condition during those moments. As technology becomes more accessible and training more structured, critical care echocardiography is no longer an optional skill; it’s essential.

 

Whether you're aiming to refine your echo skills or broaden your diagnostic capabilities, investing in clinical education is the way forward. Medvarsity’s robust training programs in Critical Care, imaging, and Gastroenterology offer the right blend of theory and practice to help you lead with confidence in the ICU and beyond.