Patient Positioning Makes a Difference

73 yo male was evaluated by our team in the MICU and noted to have new onset hypotension. Good cardiac images were extremely difficult to obtain during initial scan with patient in semi-fowler position (Image A). Several hours later, patient was rescanned in a left lateral decubitus position. Image quality was noted to be drastically improved and an enlarged aortic root was seen in the parasternal long axis (Image B). The aortic root was measured to be 3.95 cm in diameter (Image C). Normal proximal ascending aorta is 3.0 cm +/- 0.4 cm. Upon further ultrasonographic assessment, the aortic valve was noted to be somewhat calcified (Image D). Given these findings and a concurrent history of hypotension and widened pulse pressure, a formal echocardiogram was ordered to further evaluate the patients cardiac function.

Patient positioning was found to be critical in optimizing ultrasonographic image acquisition in the above case. When possible, patients should be scanned in the following positions in order to insure good ultrasonographic visualization of cardiovascular structures:

Cardiac:
– Subxiphoid: supine
– Parasternal long axis: left lateral decubitus, left arm up
– Parasternal short axis: left lateral decubitus, left arm up
– Apical 4 chamber: left lateral decubitus, left arm up

Vascular:
– IVC: supine
– Thoracic aorta: supine, neck extended, towel roll in between shoulder blades
– DVT: reverse Trendelenburg or head of bed elevated, hip externally rotated, knee flexed

-Filipp Chesnokov

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