Introduction

Focused echocardiography, also known as basic critical care echocardiography (BCCE), is a vital tool in the armamentarium of the critical care practitioner. The following images demonstrate five key windows of BCCE. From these views, we can interrogate the pericardium, atrial/ ventricular structures and valves for life-threatening pathology and potentially reversible causes of cardio-pulmonary deterioration. It is imperative that one achieves mastery level of acquiring these 5 key windows before other views are attempted. Additional windows are included in advanced CCE (ACCE) to complement the comprehensive examination.

ParASTERNAL LONG AXIS (PLAX)

This view can be acquired by placing the probe on the 3rd/4th intercostal space, left parasternal window with the probe marker facing the right shoulder. Ensure depth initially set to 20 cm to visualize pleural and/or pericardial space, then adjusted to ~10-16 cm to optimize viewing window. Ideally, a non-foreshortened PLAX will display the maximal volume of the LV and left ventricular outflow tract. 

PARASTERNAL SHORT AXIS (PSAX)

This view can be acquired by placing the probe on the 3rd/4th intercostal space, left parasternal window with the probe marker facing the left shoulder. Often acquired by first obtaining PLAX and then rotating the probe 90 degrees clockwise. The ideal depth is ~8-12 cm, but should be adjusted to visualize the entire left ventricle and pericardial space. This view is helpful to interrogate LV function and further examine the pericardial/pleural space.

APICAL 4-CHAMBER (A4C)

This view can be acquired by placing the probe at the 4th/5th intercostal space, left mid-clavicular line or point of maximal impulse with the probe marker facing the bed (patient left or 3 o' clock position). This window is best seen with patient in lateral decubitus position, but may be obtained in the supine position in selected patients. This is often the most challenging view to obtain and also the most susceptible to errors in foreshortening.

Subcostal 4-chamber (S4C)

This view can be acquired by placing the probe immediately sub-xyphoid, with the probe marker facing the patients' left (3 o' clock position). The probe handle must be tilted nearly flat against the patients abdomen and depressed to visualize beneath the sternum. Optimal depth varies ~16-22 cm. Also called the "sub-xyhphoid" or "sub-costal long axis".

Inferior vena cava (IVC)

This view can be acquired by placing the probe immediately sub-xyphoid, with the probe marker facing cephalad. The probe handle may be upright or with the tail angled caudad to see the RA-IVC junction. The IVC lies to the right of midline vs the abdominal aorta on the contralateral side.