APEX POCUS

What are the 3 standard cardiac POCUS imaging windows?

1. Parasternal → PLAX, PSAX

2. Apical → A4CH

3. Subcostal → Subcostal 4CH, IVC

What are the 5 core cardiac POCUS views?

• Parasternal long-axis (PLAX)

• Parasternal short-axis (PSAX)

• Apical 4-chamber (A4CH)

• Subcostal 4-chamber

• Subcostal IVC

Parasternal Long-Axis (PLAX)

• Identify this view. What structures are visible?

• View: Parasternal Long-Axis (PLAX)

• Structures: LA, LV, RV, mitral valve, aortic valve, aorta, pericardium

• Evaluates: LV function/hypertrophy, mitral and aortic valve lesions, pericardial effusion

• TEE equivalent: Midesophageal Long-Axis (ME LAX)

• Where do you position the probe for PLAX?

• In which direction does the orientation marker point?

• Window: Parasternal

• Position: Left sternal border, 3rd–4th intercostal space

• Marker: Toward patient's right shoulder

• Patient: Left lateral decubitus preferred

Parasternal Short-Axis (PSAX)

• How to get the PSAX view from the PLAX?

Window: Parasternal

• Rotate probe 90° clockwise from PLAX.

• Orientation marker: Patient's left shoulder.

• TEE equivalent: Transgastric short-axis (TG SAX).

Identify this view. What structures are visible?

• View: Parasternal Short-Axis (PSAX)

• Structures: LV, RV, pericardium.

• Evaluates: LV/RV function and pericardial effusion.

• Visual clue: LV appears circular in cross-section, with the RV adjacent to it.

How do you obtain the Apical 4-Chamber view?

• Window: Apical

• Position: Left lateral decubitus

• Probe: Point of maximum impulse (PMI)

• Orientation marker: Patient's left side

• Ultrasound beam: Toward patient's right shoulder

Identify this cardiac POCUS view.

Apical 4-Chamber (A4CH)

• Structures: RA, RV, LA, LV, AV valves, pericardium

• Evaluates: LV/RV function, AV valve lesions, pericardial effusion

• TEE equivalent: Midesophageal 4-chamber (ME 4C)

How do you obtain the Apical 4-Chamber (A4CH) view?

• Window: Apical

• Patient position: Left lateral decubitus

• Probe placement: Point of maximum impulse (PMI)

  • Men: Just inferolateral to the left nipple

  • Women: Under the inferolateral quadrant of the left breast

• Orientation marker: Toward patient's left side

• Ultrasound beam: Toward patient's right shoulder

How do you obtain the Subcostal 4-Chamber view?

Window: Subcostal

Patient position: Supine

Probe placement: Midline, just inferior to the xiphoid process

Orientation marker: Toward patient's left side

If visualization is difficult:

• Bend patient's knees to relax abdominal muscles.

• Apply additional probe pressure as needed.

• Slide probe to patient's right to use the liver as an acoustic window if bowel gas interferes.

Identify this cardiac POCUS view.

Subcostal 4-Chamber (Subcostal 4CH)

• Structures: RA, RV, LA, LV, AV valves, pericardial space

• Evaluates: RV function and pericardial effusion

• TEE equivalent: Midesophageal 4-Chamber (ME 4C)

• Visual clue: Liver appears in the near field, with the four cardiac chambers deeper in the image.

Subcostal IVC

• How do you obtain the subcostal IVC view?

  
  

• Window: Subcostal

• Starting position: Subcostal 4CH

• Probe movement: Rotate transducer 90°

• Beam direction: Tilt posteriorly

Identify this cardiac POCUS view.

Subcostal IVC

Structures: IVC, RA, liver

• Evaluates: Volume status

• Key finding: IVC collapse suggests hypovolemia

• TEE equivalent: Bicaval view

• Visual clue: IVC appears as a long tubular structure entering the RA, with the liver nearby.

Name this view

Parasternal long axis

Name this view

parasternal short axis

Name this view

apical 4 chamber

Name this image

Subcostal 4 chamber

Name this view

Subcostal IVC

Identify this lung ultrasound sign and its structures.

Bat Sign

Wings: 2nd and 3rd ribs

Body: Hyperechoic pleural line between the ribs

• Acoustic shadows: Dark regions deep to the ribs

• Key concept: Ribs strongly attenuate ultrasound, producing posterior shadowing.

• Memory trick: Ribs = wings; pleural line = body.

What is lung sliding, and what does its absence suggest?

Lung sliding: Shimmering movement of the pleural line during respiration.

Indicates: Visceral and parietal pleura remain in contact.

• Absent lung sliding: May suggest pneumothorax or endobronchial intubation.

• Important: Absence alone does not confirm pneumothorax.

Original APEX image without labels. Identify the artifact.

• A-lines = horizontal, parallel to pleura

• Caused by reverberation artifact

• Usually associated with aerated lung

• Memory trick: A = Across / Air

Identify the artifact.

• B-lines = vertical, extend from pleura to bottom

• Erase A-lines

• Multiple B-lines may suggest pulmonary edema

• Memory trick: B = Bottom

• B BERTICAL (look like the aliens are coming)

How do you perform gastric POCUS?

Patient position: Right lateral decubitus (RLD)

Probe: Curvilinear transducer

• Placement: Midline, just inferior to the xiphoid process

• Orientation marker: Cephalad (toward the head)

• Primary structure: Gastric antrum

Memory trick: Gastric = RIGHT side, BELOW xiphoid, marker UP.

Why is the gastric antrum evaluated in the right lateral decubitus position?

• Gravity moves gastric contents toward the pylorus and antrum.

• Air rises toward the upper portion of the stomach.

• The antrum fills with gastric contents, improving assessment.

• Supine positioning may underestimate gastric volume.

• Gastric POCUS helps guide decisions about RSI and aspiration risk.

Identify the gastric finding.

Empty Stomach — Bull's Eye Sign

Appearance: Flat or small oval antrum resembling a bull's eye.

• Anechoic border: Muscularis propria, NOT fluid.

• Anatomical location: Antrum just below the liver.

• Pancreas: Deep to the stomach.

• Aorta: Deep to the pancreas.

• SMA: Sometimes visible.

_{Quick visual memory trick}

_{Empty stomach = Small bull's eye.}

_{Fluid-filled stomach = Distended antrum.}

Identify the gastric finding.

Clear Fluid in the Gastric Antrum

• Appearance: Round, distended antrum.

• Contents: Anechoic (black).

• Why: Clear fluid produces very few internal echoes.

• Clinical relevance: Gastric fluid volume helps assess aspiration risk.

• »Clear fluid = Big black circle

Identify the gastric finding.

Particulate Matter — Non-clear Liquid or Solid Contents

• Appearance: Round, distended gastric antrum.

• Non-clear liquids (e.g., milk): Hyperechoic.

• Solid food: Bright particulate echoes within the antrum.

• Clinical significance: Suggests gastric contents that may increase aspiration risk.

» Particulate = Bright speckles

How do you calculate clear gastric fluid volume using POCUS?

Gastric volume: (mL) = 27 + 14.6(CSA) - 1.28 (age)

Position: Right lateral decubitus (RLD)

• Measurement: Gastric antrum CSA at the level of the aorta

• Accuracy: Average 3 CSA measurements

CSA = cross-sectional area in cm²; age in years.

Gastric Grading

• Grade 0 = Empty

• Grade 1 = Clear fluid below 1.5 mL/kg

• Grade 2 = Clear fluid above 1.5 mL/kg

• Particulate matter = High risk

APEX - Q - What cardiac view is this

subcostal 4- chamber

• bc it shows you the liver