Name: Echocardiographic Assessment Using Subxiphoid-Only Examination for Hypotensive Patients (Video) | JoVE Journal
Uploaded: 2025-04-18T12:50:00.000+00:00
Duration: 8 min 45 s
Description: Learn focused ultrasound techniques for rapid hypotensive patient assessment using subcostal cardiac and IVC imaging. This protocol enhances diagnostic accuracy and improves emergency care outcomes.

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5 minutes

The authors wish to acknowledge the leadership of Albany Medical College for their support of students working under the auspices of the Summer Research Fellowship.

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<li>Nikravan, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((An+echocardiographic+approach+for+the+management+of+shock%3A+The+subcostal+to+apical%2C+respiratory+to+parasternal-cardiac+to+respiratory%2C+aortic+to+stomach+protocol%5BTitle%5D)+AND+%22Semin+Ultrasound+CT+MR%22%5BJournal%5D)">An echocardiographic approach for the management of shock: The subcostal to apical, respiratory to parasternal-cardiac to respiratory, aortic to stomach protocol.</a> Semin Ultrasound CT MR. 45 (1), 74-83 (2024).</li>
<li>Nikravan, S., Song, P., Bughrara, N., Diaz-Gomez, J. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Focused+ultrasonography+for+septic+shock+resuscitation%5BTitle%5D)+AND+%22Curr+Opin+Crit+Care%22%5BJournal%5D)">Focused ultrasonography for septic shock resuscitation.</a> Curr Opin Crit Care. 26 (3), 296-302 (2020).</li>
<li>Bughrara, N., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((1479%3A+Rapid+ultrasound+evaluation+of+patients+with+sepsis-associated+hypotension+using+pattern+recognition%5BTitle%5D)+AND+%22Crit+Care+Med%22%5BJournal%5D)">1479: Rapid ultrasound evaluation of patients with sepsis-associated hypotension using pattern recognition.</a> Crit Care Med. 52 (S), S710(2024).</li>
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</ol>

The authors have no relevant disclosures.

The EASy MAP protocol is just one of several ultrasound protocols that can be clinically useful in the evaluation of a patient with acute hemodynamic instability37,38. Unlike many more complex exams, however, the core of the EASy exam is its brevity and simplicity, which allows the user to rapidly identify many common pathologies at the bedside through pattern recognition18. The pattern recognition emphasis allows for simplified knowledge ...

In recent years, the increased availability, quality, and portability of ultrasonographic equipment has driven a rapid expansion in the field of point-of-care ultrasound (POCUS). POCUS is defined as an ultrasound exam that is performed for well-defined clinical indications and is interpreted by the patient's primary treating clinician, with the findings immediately incorporated into the treatment plan1,2. This is in contrast to consultative ultrasound, which refers to an ultrasound exam that is requested by a patient's primary treating clinician but performed by a separate specialist team3. Because consultative exams must be transmitted to a reading expert after the acquisition of the images, there may be a significant lag time between the identification of the clinical indication and the availability of the study for clinical decision-making. Given that consultative exams require significant time to acquire all images and require the availability of both a dedicated sonographer and then a reading physician4, such exams cannot always be performed and read on the time scales demanded by acutely unstable patients (often minutes) and are not feasible in all clinical settings, especially during off hours (i.e., evenings, nights, weekends, and holidays). In contrast, portable ultrasound machines can be expediently brought to the bedside by treating clinicians, allowing POCUS exams to provide actionable information for immediate clinical decision-making. For example, POCUS can provide an immediate window into the hemodynamic status of a patient5,6,7, augmenting more traditional clinical tools such as physical examination, clinical gestalt, and other hemodynamic monitoring techniques. While cardiac POCUS uses the same basic ultrasound technology as more comprehensive evaluations by consultative cardiology echocardiographic studies, POCUS exams have their own specific clinical indications and can be obtained in a much wider range of emergency situations (trauma bay, operating room, acute stabilization in the post-anesthesia care unit, etc.) and in a short amount of time8 for immediate clinical decision-making. Fundamentally, POCUS studies are obtained for the purpose of answering a specific clinical question, the answer to which will guide the patient's immediate management.
Significant research has previously been directed towards the use of POCUS for evaluation of volume status; the size and collapsibility of the inferior vena cava (IVC) has often been studied as a proxy for determining the preload of the right heart, which, for some patient populations, is a useful estimator of volume status9,10,11. However, the utility of IVC evaluation alone as a predictor of response to fluid resuscitation is of less certain value in patients with undifferentiated shock, with substantial heterogeneity between studies and patient populations12,13,14,15; many critically ill patients are also receiving positive pressure ventilation, which can confound attempts to estimate central venous pressure via IVC ultrasound alone16. Additionally, given that the venous return comprises just one of many factors necessary for adequate cardiac output and end-organ perfusion, a systematic approach to the patient with acute clinical instability (such as hypotension or respiratory failure) is likely to require a more thorough picture of cardiovascular and respiratory status, necessitating the introduction of additional sonographic views. Patients with sepsis, for example, may exhibit a wide range of cardiac phenotypes17, meaning that an IVC-only approach would miss significant hemodynamic heterogeneity.
Here, we describe a method for rapidly evaluating the acutely hypotensive patient by the acquisition of an abbreviated POCUS exam: the Echocardiographic Assessment using Subxiphoid-only - Mean Arterial Pressure, or EASy MAP exam18. The EASy MAP exam is a concise examination for immediate determination of cardiovascular and cardiorespiratory status, consisting of subcostal views of the heart and IVC plus anterior and posterolateral lung ultrasound views. Within the EASy MAP protocol, IVC assessment is not intended to function in isolation but rather as one element of a broader framework that includes evaluation of cardiac function, lung ultrasound, and clinical context. The resultant images can then be interpreted using simple pattern recognition, with patients generally falling into one of several cardiovascular and pulmonary phenotypes; this information can then be used for the immediate management of the hypotensive patient. This integrated approach seeks to leverage pattern recognition to identify actionable clinical findings while acknowledging the inherent limitations of any single ultrasonographic metric. By simplifying the steps needed to obtain images and extract clinically actionable results, the goal is to broaden the range of clinicians who are able to use POCUS at the bedside and to simplify the knowledge transfer process and time to achieve competency18. These exams are performed with the understanding that quantitative measurements could still be required, triggering follow-up by consultative echocardiographic studies, especially if signs of chronic disease are identified during the EASy MAP exam. There are many circumstances where both EASy MAP evaluation and consultative examinations will be appropriate, with EASy MAP being performed as the most immediate evaluation and closed-loop reassessment of response to therapy.
For purposes of this examination and protocol, we define hypotension as a mean arterial pressure (MAP) less than 65 mmHg19,20,21,22,23, excluding patients in cardiac arrest. We describe a protocol for image acquisition (in accordance with previously established ultrasonographic techniques24,25). We also describe common pitfalls in image acquisition and methods for identification of the relevant anatomy. We also provide a standardized 12-point scoring system for the evaluation of the quality of cardiac images. The goal of this protocol is to allow clinicians to obtain immediate information about the etiology of the patient's hypotension such that the treatment plan can be adjusted to best address the patient's condition.
The viability of the EASy MAP protocol as an entry-level POCUS examination has been previously validated in a number of patient populations in a small cohort study18,26, novice sonographers with a single day of didactic training in a similar EASy protocol were able to acquire a clinically actionable image in 55 out of 63 total exams (87%; Figure 1). In 100 hypotensive patients with sepsis, EASy exam images were of sufficient quality to guide patient management in 75% of cases8, and phenotypes recognized on the EASy exam were associated with significant differences in patient management.
<img alt="Success rate pie chart; 87% successful, 13% unsuccessful, resident-performed exams." class="xfigimg" src="/files/ftp_upload/67531/67531fig01.jpg" data-altupdatedat="1788304762000" data-alt="Figure 1"> 
Figure 1: Success of EASy exams performed by trainees following a 1-day didactic. A total of 63 exams were performed on 14 unique patients over the course of 12 days. This figure has been modified from18. <a href="https://www.jove.com/files/ftp_upload/67531/67531fig01large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>

<table><tbody><tr><td>Phased Array Ultraosund Probe</td><td>Mindray</td><td>P4-2S</td><td>Probe used for all components of exam</td></tr><tr><td>Portable Ultrasound System</td><td>Mindray</td><td>TE7</td><td>Portable/bedside POCUS unit</td></tr><tr><td>Ultrasound Gel</td><td>Aquasonic</td><td>PLI 01-08</td><td>Aqueous sonographic conduction gel</td></tr></tbody></table>

echocardiographic assessment using subxiphoid-only examination for hypotensive patients

Echocardiographic Assessment Using Subxiphoid-Only Examination for Hypotensive Patients

Point-of-care ultrasound, or POCUS, has gathered significant interest as a tool to augment clinical decision-making in the care of acutely ill patients. Patients with hemodynamic instability, in particular, require immediate intervention and are at high risk for further cardiovascular and/or respiratory decompensation. POCUS examination of these patients, therefore, requires a protocol that is sufficient to answer clinicians' questions while still retaining adequate brevity to be feasible in a short period of time at the bedside. Here, we demonstrate a protocol for obtaining such information by the Echocardiographic Assessment using Subxiphoid-Only - Mean Arterial Pressure, or EASy MAP exam, a focused ultrasonographic assessment of the cardiovascular and respiratory systems. The cardiovascular portion of the examination utilizes the subcostal window to obtain views of the heart and inferior vena cava (IVC); this is then supplemented by anterior upper lung and posterolateral diaphragmatic pleural views for the respiratory portion. All six views (cardiac, IVC, left and right anterior upper lung, and left and right posterolateral pleural) are obtained using a low-frequency phased array transducer. We discuss some of the common pitfalls encountered in obtaining these images and the basics of interpreting the most common findings; also described is a 12-point scale for rating the quality of the images obtained from the cardiac view and a small number of supplementary views that may be considered when clinically relevant.

When the EASy protocol is used to assess the patient with hypotension, a successful exam is broadly defined as an exam that clarifies the diagnostic picture (in this case, the underlying etiology of hypotension) to a degree that is sufficient to immediately guide patient management. Conversely, an unsuccessful exam is one that is unhelpful in guiding management and does not provide sufficient information to result in actionable recommendations. High-quality imaging is essential for a successful EASy MAP examination, with...

The protocol here provides a rapid, phenotype-based approach for focused ultrasound evaluation of the hypotensive patient, using subcostal images of the inferior vena cava and heart, with additional views of the upper lungs and pleural spaces.

Point-of-care ultrasound, or POCUS, has gathered significant interest as a tool to augment clinical decision-making in the care of acutely ill patients. ...

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Research

JoVE Journal

Medicine

Transthoracic echocardiography offers a noninvasive method for the evaluation of cardiac function in mice. A combination of ultrasound and Doppler imaging modalities can be used to obtain dimensional measurements of the heart and intracardiac blood flow, which together provide an assessment of cardiac systolic and diastolic performance.

Transthoracic Echocardiography in Mice

High frequency Doppler ultrasound is a novel technology for assessing regional myocardial function. This work presents first evidence demonstrating applicability of this versatile imaging platform for the repeated measure of myocardial strain, dp/dt, and mitral regurgitation in the ischemia-reperfused (IR) murine heart.

High-frequency High-resolution Echocardiography: First Evidence on Non-invasive Repeated Measure of Myocardial Strain, Contractility, and Mitral Regurgitation in the Ischemia-reperfused Murine Heart

This video demonstrates use of a rail-mounted high-frequency ultrasound probe to perform echocardiography on an anesthetized mouse.  The methods describe both conventional two-dimensional and M-mode measurements of cardiac function in addition to newer, more powerful tools such as color Doppler, strain analysis, as well as general and targeted contrast imaging.

Murine Echocardiography and Ultrasound Imaging

Structured protocols are necessary to provide answers on research questions in critically ill patients. The Simple Intensive Care Studies (SICS) provides an infrastructure for repeated measurements in critically ill patients including clinical examination, biochemical analysis and ultrasonography. SICS projects have specific focus but the structure is flexible to other investigations.<br...

Observational Study Protocol for Repeated Clinical Examination and Critical Care Ultrasonography Within the Simple Intensive Care Studies

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Ultrasonographic Assessment During Cardiopulmonary Resuscitation

Presented here is a protocol to perform comprehensive neonatal echocardiography by trained neonatologists in the neonatal intensive care unit. The trained individuals provide longitudinal assessments of heart function, systemic and pulmonary hemodynamics in a consultative role. The manuscript also describes the requirements to become a fully trained neonatal hemodynamics specialist.

Hemodynamic Precision in the Neonatal Intensive Care Unit using Targeted Neonatal Echocardiography

Here, we present a protocol that can be applied in the neonatal intensive care unit and the delivery room in relation to three scenarios: cardiac arrest, hemodynamic deterioration, or respiratory decompensation. This protocol can be performed with a state-of-the-art ultrasound machine or an affordable handheld device; an image acquisition protocol is carefully detailed.

A Modified Sonographic Algorithm for Image Acquisition in Life-Threatening Emergencies in the Critically Ill Newborn

This protocol outlines the use of point-of-care ultrasound (POCUS) to monitor patients on peripheral veno-arterial extracorporeal membrane oxygenation (V-A ECMO) without left ventricular venting. It evaluates left ventricular distension, intracardiac or aortic root thrombus, and identifies useful cardiac POCUS parameters for weaning from V-A ECMO.

Point-of-Care Ultrasound for Peripheral Veno-Arterial Extracorporeal Membrane Oxygenation Without Left Ventricular Venting

This article provides a protocol for the echocardiographic assessment of right ventricular size and pulmonary hypertension in mice.  Applications include phenotype determination and serial assessment in transgenic and toxin-induced mouse models of cardiomyopathy and pulmonary vascular disease.

Echocardiographic Assessment of the Right Heart in Mice

Individuals with intermittent claudication exhibit poor balance compared to healthy controls. Computerized dynamic posturography is an objective method for measuring an individual's postural responses to balance disturbances. This provides an objective reflection of the person’s ability to respond to situations under which sensory stimuli are altered and unexpected perturbations occur.

Computerized Dynamic Posturography for Postural Control Assessment in Patients with Intermittent Claudication

Learn focused ultrasound techniques for rapid hypotensive patient assessment using subcostal cardiac and IVC imaging. This protocol enhances diagnostic accuracy and improves emergency care outcomes.

Echocardiographic Assessment Using Subxiphoid-Only Examination for Hypotensive Patients

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