Transthoracic Echo on the Unit: Five Views and Six Patterns

Three in the morning. A patient on the unit is hypotensive, the noradrenaline is going up, and somebody has already given a litre. What is the fastest way to actually know what's wrong? Put a probe on them. This is the first of two foundation episodes on echocardiography — the thing that turns a guess into a diagnosis, at the bedside, in about ninety seconds. Today it's transthoracic echo on the intensive care unit: the views, and the patterns you are looking for in a shocked patient. Next time we take the transoesophageal probe into theatre. We start with accreditation, because Mike's advice is to start early. The routes come in two shapes and it helps to see that first: a mentored portfolio, or an examination. FICE is the portfolio route — an approved basic course, a logbook of fifty studies with at least ten directly supervised, all fifty reviewed with your mentor, and a triggered assessment, with the first and last scans no more than twelve months apart. EDEC is the examination route — a hundred transthoracic and thirty-five transoesophageal cases, a mentor and a supervisor, and a formal exam you can start once you've done thirty and ten. Plus the machine you actually need: a cardiac phased-array probe, 2D and M-mode, colour and spectral Doppler, ECG gating — and proper image archiving, for three reasons most people haven't thought about. Then the five views that will get you a very long way. Parasternal long axis for overall size and function and the mitral and aortic valves. Parasternal short axis — the doughnut — which at papillary muscle level is the single best view for regional wall motion and for the shape of the septum. Apical four-chamber for comparing the ventricles, for TAPSE, and for Doppler through the mitral and tricuspid valves. Subcostal, the one people neglect and the one that works when nothing else does, because it doesn't care about ventilation, chest drains or dressings — and the best view for a pericardial effusion. And the inferior vena cava from there. Then six patterns. Hypovolaemia, with its hyperdynamic ventricle, end-systolic effacement and kissing walls. Low afterload, which can look almost identical — and why that means echo is never read in isolation. Right ventricular failure, usually obvious the moment the probe goes on: a dilated right ventricle squashing a small, underfilled left one. Tamponade, with diastolic collapse of the right atrium and ventricle. Dynamic left ventricular outflow tract obstruction and systolic anterior motion — which looks like a mitral valve problem and is really a haemodynamic one, where the management runs almost exactly opposite to your instincts. And type A dissection: a normal-looking heart with a flap in the root. The case we'd want every new starter to know is the aortic valve replacement done for aortic stenosis. That hypertrophied ventricle now ejects vigorously through a brand-new valve, empties, and becomes profoundly hypovolaemic. The vasopressor requirement climbs, somebody quite reasonably asks for an echo to exclude tamponade — and the scan shows hypovolaemia instead. That is echo earning its keep: not confirming what you suspected, but telling you that you were looking at the wrong thing. We finish on fluid responsiveness, with some honest context about why it matters less than it used to, the real pitfalls of the vena cava, and why lung ultrasound and venous congestion assessment tell you more than any single number. Chapters (00:00) Cold open — 3am, hypotensive, a litre already in (00:40) Why accreditation is worth starting now (01:30) Two shapes of pathway: FICE and EDEC (03:00) The machine you actually need — and why archiving matters (04:00) The five views: parasternal long axis (04:40) Parasternal short axis — the doughnut (05:30) Apical four-chamber (06:00) Subcostal, and the inferior vena cava (06:50) Hypovolaemia: kissing walls and a collapsed cava (07:40) Why low afterload looks the same (08:20) Right ventricular failure (09:00) Tamponade (09:40) Dynamic LVOT obstruction and systolic anterior motion (10:30) Type A dissection (11:00) The classic case: the scan you ordered for tamponade (12:00) Fluid responsiveness, honestly (13:00) Wrap-up Key takeaways Echo turns a guess into a diagnosis at the bedside in about ninety seconds — put the probe on early Start accreditation now: FICE is a mentored portfolio route, EDEC is examination-based, and both take time. Requirements change, so check the current version Your machine needs a cardiac phased-array probe, 2D and M-mode, colour and spectral Doppler, ECG gating — and image archiving, without which you have no logbook, no comparison and no record Five views will take you a long way: parasternal long axis, parasternal short axis, apical four-chamber, subcostal, and the inferior vena cava The parasternal short axis at papillary muscle level is the best single view for regional wall motion and for septal shape The subcostal view is the rescue view — it works when nothing else does, and it's the best view for a pericardial effusion Hypovolaemia is a hyperdynamic ventricle with end-systolic effacement and a small, collapsing cava Low afterload can look almost identical, so read the scan alongside the clinical context and the vasopressor requirement Right ventricular failure is a dilated right ventricle squashing a small underfilled left one, with a displaced septum — usually obvious by eye Tamponade shows diastolic collapse of the right atrium and right ventricle, with normal left ventricular size and function Systolic anterior motion looks like a mitral problem but is haemodynamic — fill them and get the rate/inotropy down After an aortic valve replacement for stenosis, expect the scan you ordered for tamponade to show you hypovolaemia Treat fluid responsiveness with humility: the vena cava has real pitfalls, and lung ultrasound and venous congestion assessment tell you more than any single number References / further reading Intensive Care Society. Focused Intensive Care Echocardiography (FICE) accreditation European Society of Intensive Care Medicine. European Diploma in Advanced Critical Care Echocardiography (EDEC) British Society of Echocardiography. Personal and departmental accreditation Lancellotti P et al. The use of echocardiography in acute cardiovascular care: European Association of Cardiovascular Imaging and Acute Cardiovascular Care Association recommendations Mitchell C et al. Guidelines for performing a comprehensive transthoracic echocardiographic examination in adults: recommendations from the American Society of Echocardiography. J Am Soc Echocardiogr 2019 Vieillard-Baron A et al. A decade of progress in critical care echocardiography: a narrative review. Intensive Care Med 2019 Follow the podcast Bluesky: @cardiacoutput.bsky.social X: @CardiacOutputMC If you've found this useful, a follow or a share genuinely helps other trainees find it — and do get in touch if there's a topic you'd like covered. This podcast is for medical education for healthcare professionals. It is not clinical advice. Accreditation requirements change — always check the current version with the relevant body, and follow your own centre's guidelines.