CARDIAC ANES

CL-Only Protocol

One Window, Both Answers, Under 30 Seconds

Start subxiphoid. Don't move. Get EF + volume status from the same position.

THE CL PROTOCOL CURVILINEAR OPTIMIZED

1

Subcostal 4-Chamber → Eyeball EF ⚡ ~10 sec

Probe flat under xiphoid, indicator to patient's LEFT, aim toward left shoulder. You'll see all 4 chambers. Eyeball: does the LV squeeze?

↔ Supine⏸ End-ExpCL StrengthAll States

Walls squeeze, cavity shrinks = normal Sluggish walls = reduced Barely moves, globular = severe

↓Don't move — just rotate the probe

2

IVC → Volume Status ⚡ ~15 sec

From subcostal 4C, flatten the probe toward skin and rotate clockwise ~90° to pick up the IVC running into RA. Measure max/min diameter.

↔ SupineSpontaneous → cIVCPPV → dIVC

↓Only if Step 1 is unclear

3

Fallback: PLAX Attempt → EPSS / FS 🔢 ~30+ sec

Only if subcostal EF assessment is equivocal (mild reduction you can't categorize). Move to parasternal, tilt probe on edge. This is your backup, not your primary.

↔ Supine + left tilt⏸ End-Exp⚠ CL Limitation

Step 1 — Probe Placement

Subcostal 4-Chamber View

Probe Position

Anatomy Cross-Section

Sub 4C — Labeled

Sub 4C — Self-Test

Step 1 — Assessment

Eyeball EF — Visual Estimation

Studies show trained providers categorize EF within ±5% of formal Simpson's. You're triaging, not writing an echo report. Ask: "How much does the LV cavity shrink from diastole to systole?"

Normal

≥55%

Walls squeeze vigorously
Cavity nearly obliterates
MV opens briskly

Mild ↓

40–54%

Walls move but sluggish
Cavity shrinks some
Subtle ↓ thickening

Moderate ↓

30–39%

Walls barely converge
LV looks dilated
Minimal size change

Severe ↓

<30%

Walls nearly motionless
Globular, dilated LV
Almost no size change

What to Look For — Quick Checklist

💪

Wall thickening: Do the walls get THICKER during systole? Normal myocardium thickens >40% — you can see this.

📏

Cavity size change: How much does the LV cavity shrink? Dramatic = normal. Minimal = bad.

🚪

MV excursion: Does the mitral valve open wide and briskly? Poor opening = poor filling OR poor function.

🔵

LV shape: Normal = bullet-shaped. Severe ↓ = round/globular. Globular LV = bad sign.

⚖️

RV vs LV size: RV should be smaller than LV. RV ≥ LV = RV dilation (PE? RV failure?)

⚠ Eyeball EF Limitations

Eyeball EF is a categorical estimate (normal / mild / mod / severe) — not a precise number. It's excellent for triaging but don't chart "EF 42% by eyeball." Chart "grossly normal" or "appears moderately reduced." If you need a number, fall back to PLAX for EPSS/FS. Under GA, volatile agents ↓ contractility 5–10% — account for this visually.

Step 2 — Volume Status

IVC — Slide From Subcostal 4C

You're already in position. Flatten the probe and rotate clockwise ~90° to pick up the IVC. Measure 2–3cm from RA-IVC junction.

IVC Probe Position

IVC — Labeled (HV, IVC, RA)

IVC — Self-Test

⚠ Pitfall: Aorta (not IVC!)

2D: End-Expiration — IVC 1.24cm (MAX)

2D: End-Inspiration — IVC 0.76cm (MIN)

M-Mode: End-Exp — IVC 2.08cm

M-Mode: End-Insp — IVC 1.78cm

IVC → CVP Reference

⚠ Don't Confuse IVC with Aorta

IVC vs Aorta Identification

IVC: Thin-walled, compressible, collapses with sniff, connects to RA, hepatic veins drain into it
Aorta: Thick-walled, pulsatile, NOT compressible, vertebral shadowing deep to it, celiac trunk branches off
IVC is to patient's RIGHT of the spine, aorta is LEFT
If you see vertebral shadowing and a thick bright wall — you're on the aorta, slide RIGHT
If you see hepatic veins draining in — you're on the IVC ✓

Transition from Sub4C → IVC

The Slide Maneuver

Start: You're in subcostal 4C (indicator → patient's left)
Flatten the probe even more toward skin
Rotate clockwise ~90° so indicator points cephalad (toward head)
Slide slightly to patient's right of midline
You should see the IVC running longitudinally into the RA
Measure 2–3cm from the RA-IVC junction

IVC Decision

BREATHING MODE?

SPONTANEOUS

cIVC
÷ IVC max (exp)
Max at end-exp
Min during sniff

→ Calculator

PPV / VENT

dIVC
÷ IVC min (exp)
Max during vent breath
Min at end-exp

→ Calculator

Spontaneous Breathing

cIVC — Collapsibility Calculator

↔ SupineSpontaneous Only

cIVC (%) = (IVC max − IVC min) / IVC max × 100

Enter IVC Diameters

IVC maxcm (end-exp)

IVC mincm (sniff)

— %

Collapsibility

—

Est. RAP

IVC Diameter	Collapse	Est. CVP	Fluid Responsive?
≤ 2.1 cm	>50%	0–5 mmHg	Likely — consider bolus
≤ 2.1 cm	<50%	5–10 mmHg	Indeterminate
> 2.1 cm	>50%	5–10 mmHg	Indeterminate
> 2.1 cm	<50%	10–20 mmHg	Unlikely — volume overloaded

cIVC >12% may predict fluid responsiveness in spontaneously breathing patients

Positive Pressure Ventilation

dIVC — Distensibility Calculator

↔ SupinePPV OnlyPassive, Vt ≥8

dIVC (%) = (IVC max − IVC min) / IVC min × 100

Denominator = MIN — physiology is reversed under PPV

Enter IVC Diameters (On Vent)

IVC maxcm (during insp)

IVC mincm (during exp)

— %

Distensibility

dIVC	Fluid Responsive?	Action
> 18%	YES	Fluid bolus
12–18%	GRAY ZONE	PLR, PPV, SVV
< 12%	NO	Pressors / inotropes

⚠ dIVC Invalid If

Spontaneous effort • Vt <8 mL/kg • Open chest • Arrhythmia • Pneumoperitoneum • PEEP ≥15 • RV failure

Backup Only

PLAX Fallback — When Subcostal EF is Equivocal

Only if your eyeball EF is borderline (you can't decide between mild and moderate). Try PLAX for EPSS or FS.

PLAX Probe Position

PLAX — Labeled

PLAX — Self-Test

CL PLAX Tips ⚠ DIFFICULT

Making PLAX Work on the Curvilinear

📐

Tilt on edge: Don't place the probe flat. Stand it up so only the center of the curved face contacts skin in the intercostal space. You're using ~20% of the array.

💧

Excessive gel: The tilted angle creates air gaps. Fill generously.

⬇️

Go lower: Try 4th–5th ICS instead of 3rd–4th. Wider spaces lower down.

↰

Left tilt: Under GA, 15° left table tilt. Awake, ask them to roll slightly left.

🎯

If you get a window: EPSS is fastest (M-mode through MV tip, measure E to septum). <7mm normal, >13mm severe.

EPSS: <7mm = Normal | 7–13mm = Reduced | >13mm = Severe

M-Mode MV — Anatomy

M-Mode EPSS — Measurement Example

📏

EPSS (E-Point Septal Separation): Place M-mode cursor through the tip of the anterior mitral leaflet. Measure the distance from the E-point (maximum opening) to the IVS. The E-point is the tall peak; the A-point is the smaller peak after it.

⚡

Why it works: In a healthy heart, the MV anterior leaflet swings wide and nearly touches the septum (small EPSS). In a failing heart, the LV is dilated and hypokinetic — the leaflet doesn't reach the septum (large EPSS).

⚠️

Pitfalls: EPSS is unreliable with significant AR, MS, or aortic root dilation — all push the leaflet away from the septum independent of EF.

EPSS Calculator (if you get a PLAX window)

EPSSmm

—

EPSS (mm)

—

Est. EF

Shock Recognition & Resuscitation

RUSH Protocol — HI-MAP Approach

Shock is a physiological emergency, not just low BP. Normal BP ≠ no shock. POCUS identifies life-threatening causes in seconds — treat while you diagnose.

Learning Objectives

✔️

Understand SHOCK as a physiological emergency — not just low BP.

✔️

Apply the RUSH Protocol using the HI-MAP approach: Heart → IVC → Morrison's → Aorta → Pneumothorax.

✔️

Use POCUS to identify life-threatening causes in seconds.

✔️

Apply ABCDE resuscitation with ultrasound integration.

✔️

Avoid deadly mistakes in early shock management.

HI-MAP — The 5-Window Sweep

H — Heart

🫀

Pump? Effusion? RV strain?

I — IVC

💧

Tank — volume status

M — Morrison's

🩸

FAST — free fluid

A — Aorta

🫁

AAA / dissection

P — Pneumo

🚫

Lung sliding?

Differentiate the 4 Shock Types

🔴 Cardiogenic — Failing Pump

POCUS: Poor LV contractility, dilated LV, B-lines (pulmonary edema), plethoric IVC.

Treat: Inotropes, afterload reduction, avoid aggressive fluids.

🔵 Hypovolemic — Empty Tank

POCUS: Collapsed/flat IVC, hyperdynamic "kissing" LV, free fluid (if hemorrhagic).

Treat: Volume — crystalloid / blood products, source control.

🟡 Obstructive — Blocked Flow

POCUS: Pericardial effusion/tamponade, RV dilation (massive PE), absent lung sliding (tension PTX), plethoric IVC.

Treat: Decompress — pericardiocentesis, needle thoracostomy, thrombolytics.

🟢 Distributive — Vasodilation

POCUS: Hyperdynamic LV, variable IVC, clear lungs (early), possible source (abscess, cholecystitis).

Treat: Vasopressors (norepi), early antibiotics if septic, source control.

Key Ultrasound Findings — Pattern Recognition

🫀

Poor LV contractility → cardiogenic shock

💧

Collapsed IVC → hypovolemia

🫁

B-lines → pulmonary edema

🩸

Free fluid (FAST+) → internal bleeding

🚫

Absent lung sliding → pneumothorax

⚠ Avoid Deadly Mistakes in Early Shock

Anchoring on a normal BP. Giving fluids to a failing pump. Missing tamponade or tension PTX because you didn't look. Delaying pressors while chasing a diagnosis. Treat while you diagnose.

🧠 💥 High-Yield Teaching Pearls (Exam Gold)

🔑

Normal BP ≠ No shock. Compensated shock kills — look at lactate, mentation, cap refill, urine output.

🔑

Lactate = tissue hypoxia marker. Trend it — a falling lactate means your resuscitation is working.

🔑

IVC = your circulatory "dipstick". Quick, bedside, repeatable — but respect its limits (PEEP, pneumoperitoneum).

🔑

Treat while you diagnose — DO NOT WAIT. Pressors, blood, decompression happen in parallel with the scan.

🔑

RUSH = physiology-driven decision making, not memorization. Ask: pump, tank, pipes — what's broken?

Anesthetic Adjustments

Drug Effects on Your Assessment