Echo - Getting the Views
Parasternal Long View
Start in the ribspace above the nipple line. Right where the V2 sticker would go for an EKG. Indicator goes to the patient's right shoulder IF the dot is on the right side of the screen. Otherwise goes to patient's left hip if the dot is on the left side of the screen. Probe is nearly perpendicular to skin. If you don't see anything it usually means you have to slide down a rib space. If you see the LV but no aorta it means you have to slide more medial or angle the probe toward the right shoulder.
RV Inflow View
From the parasternal long view, fan the probe so it points down toward the right hip. You accomplish this by moving the tail of the probe toward the left shoulder. This is a great view for assessing TV pathologies and calculating PA systolic pressures. It's also a useful view for floating PA-catheters or transvenous pacers from jugular or femoral approach. This view can also assesss positioning of ECMO cannulas.
RV Outflow View
Now fan the probe in the opposite direction - toward the left shoulder. You accomplish this by moving the tail of the probe toward the right hip. This is useful for assessing pulmonic valve pathologies and calculating PA diastolic and PA mean pressures. Sometimes, you can see a saddle pulmonary embolus from this view.
Parasternal Short View - Pulmonary Artery
Rotate the probe 90 degrees from the above view or from the parasternal long view. Fan the probe upward toward the manubrium. Indicator is toward the left shoulder if the dot is on the right side of the screen else it's to the right hip. This is another way to assess the pulmonary valve, calculate pulmonary artery diastolic/mean pressures, and catch saddle embolus.
Parasternal Short View - Aorta
Rock the probe slightly more medially while continue to fan the probe toward the manubrium. This is another view for assessing tricuspid valve abnormalities, pulmonic valve abnormalities, and aortic valve abnormalities.
Parasternal Short View - Basal
Fan the probe down toward the right scapular tip. If the LV looks oval, you may need to rotate the probe until it appears fully circular. Sometimes slightly sliding away from the sternum is necessary. This is a great view for assessing septal interdependence - though this must be interpreted with caution with any bundle branch block - as well as basal LV segmental wall motion abnormalities.
Parasternal Short View - Mid
Fan the probe down further now toward the left scapular tip. Similar to above but now assessing for mid LV segmental wall abnormalities. You can sometimes see the posteromedial papillary muscle rupture in this view.
Parasternal Short View - Apex
Fan the probe down even further now toward the left hip. Similar to above but now assessing for apex LV segmental wall abnormalities.
Apical 4 Chamber
The starting position is drastically different based on patient position and body type. Try to have the patient in left lateral decubitus to bring the heart more left and anterior. Or have the patient sit up and lean forward to bring it more anterior. Feeling for the PMI is a good place to start. Otherwise, one rib space under the left nipple is a reasonable starting point. Rock the probe medially and fan the probe slightly upward toward the right scapular tip. Many adjustments will be necessary to optimize the view. Keep the indicator to the same side of the screen (patient's left if on the right side of the screen and patient's right if on the left side of the screen).
Apical 5 Chamber
From the A4 view, fan the probe upward to the right shoulder by dropping the tail of the probe down toward the left hip. This is a great view for assessing the aortic valve and calculating stroke volume.
Apical 2 Chamber
From the A4 view, rotate the probe 80-90 degrees counterclockwise so the indicator faces up (if the dot is on the right side of the screen) or down (if the dot is on the left).
Apical 3 Chamber
From the A2 view, rotate the probe 30 degrees counterclockwise.