24-03: Pericardial (Subxiphoid View)

Technique

• Direct the transducer indicator to the patient’s right (in abdominal or general preset). Note that the E-FAST exam is traditionally performed with abdominal preset settings, but the subxiphoid view is often performed with cardiac preset settings as part of a full focused cardiac ultrasound exam. When this is the case, the marker dot is typically on the opposite side of the screen and the indicator is oriented to the patient’s left.

• With the transducer indicator pointing to the patient’s right, the transducer is directed under the xiphoid process toward the left shoulder in a horizontal or near-coronal plane (Fig. 24.8).

• Pivot, sweep, and tilt the transducer as necessary to view all four cardiac chambers and pericardium.

• Identify the liver (if in view), heart, four cardiac chambers, and surrounding pericardium (Fig. 24.9).

Abnormal Findings

• Hemopericardium (pericardial effusion): Pericardial fluid will appear as an anechoic (black) region noted between the pericardium and the right ventricle. As more fluid collects, the fluid will be seen completely surrounding all four chambers of the heart. Occasionally, internal echoes representing fibrin, clot, or cardiac tissue may be present within the pericardial space (Fig. 24.10).

• Asystole: No cardiac activity present.

• Hyperdynamic cardiac activity: Extensive cardiac contraction with near-total or complete collapse of the cardiac chambers, often associated with tachycardia and hypovolemia.

Pearls

1. When the view is obscured by gas, slide the transducer slightly to the patient’s right subcostal region, and use the right lobe of the liver as the sonographic window.

2. If unable to view the heart in the true subxiphoid or subcostal window, move to a parasternal long-axis view (see “Focused Cardiac Ultrasound” later in this chapter).

3. A frequent mistake in imaging is to direct the transducer posterior toward ...